Sociology of health and illness

From Wikipedia, the free encyclopedia

The sociology of health and illness, alternatively the sociology of health and wellness (or simply health sociology), examines the interaction between society and health. The objective of this topic is to see how social life affects morbidity and mortality rate, and vice versa. This aspect of sociology differs from medical sociology in that this branch of sociology discusses health and illness in relation to social institutions such as family, employment, and school. The sociology of medicine limits its concern to the patient-practitioner relationship and the role of health professionals in society. The sociology of health and illness covers sociological pathology (causes of disease and illness), reasons for seeking particular types of medical aid, and patient compliance or noncompliance with medical regimes.

 

Health, or lack of health, was once merely attributed to biological or natural conditions. Sociologists have demonstrated that the spread of diseases is heavily influenced by the socioeconomic status of individuals, ethnic traditions or beliefs, and other cultural factors. Where medical research might gather statistics on a disease, a sociological perspective on an illness would provide insight on what external factors caused the demographics who contracted the disease to become ill.

This topic requires a global approach of analysis because the influence of societal factors varies throughout the world. This will be demonstrated through discussion of the major diseases of each continent. These diseases are sociologically examined and compared based on the traditional medicine, economics, religion, and culture that is specific to each region. HIV/AIDS serves as a common basis of comparison among regions. While it is extremely problematic in certain areas, in others it has affected a relatively small percentage of the population. Sociological factors can help to explain why these discrepancies exist.

There are obvious differences in patterns of health and illness across societies, over time, and within particular society types. There has historically been a long-term decline in mortality within industrialized societies, and on average, life-expectancies are considerably higher in developed, rather than developing or undeveloped, societies. Patterns of global change in health care systems make it more imperative than ever to research and comprehend the sociology of health and illness. Continuous changes in economy, therapy, technology and insurance can affect the way individual communities view and respond to the medical care available. These rapid fluctuations cause the issue of health and illness within social life to be very dynamic in definition. Advancing information is vital because as patterns evolve, the study of the sociology of health and illness constantly needs to be updated.

Historical background

Wall painting found in the tomb of an Egyptian official known as the physicians tomb

Humans have long sought advice from those with knowledge or skill in healing. Paleopathology and other historical records, allow an examination of how ancient societies dealt with illness and outbreak. Rulers in Ancient Egypt sponsored physicians that were specialists in specific diseases. Imhotep was the first medical doctor known by name. An Egyptian who lived around 2650 B.C., he was an adviser to King Zoser at a time when Egyptians were making progress in medicine. Among his contributions to medicine was a textbook on the treatment of wounds, broken bones, and even tumors.

Stopping the spread of infectious disease was of utmost importance for maintaining a healthy society. The outbreak of disease during the Peloponnesian War was recorded by Thucydides who survived the epidemic. From his account it is shown how factors outside the disease itself can affect society. The Athenians were under siege and concentrated within the city. Major city centers were the hardest hit. This made the outbreak even more deadly and with probable food shortages the fate of Athens was inevitable. Approximately 25% of the population died of the disease. Thucydides stated that the epidemic "carried away all alike". The disease attacked people of different ages, sexes and nationalities.

Physician in Ancient Greece treating a patient 480–470 BC

Ancient medical systems stressed the importance of reducing illness through divination and ritual. Other codes of behavior and dietary protocols were widespread in the ancient world. During the Zhou Dynasty in China, doctors suggested exercise, meditation and temperance to preserve one's health. The Chinese closely link health with spiritual well-being. Health regimes in ancient India focused on oral health as the best method for a healthy life. The Talmudic code created rules for health which stressed ritual cleanliness, connected disease with certain animals and created diets. Other examples include the Mosaic Code and Roman baths and aqueducts.

Those that were most concerned with health, sanitation and illness in the ancient world were those in the elite class. Good health was thought to reduce the risk of spiritual defilement and therefore enhanced the social status of the ruling class who saw themselves as the beacon of civilization. During the late Roman Period, sanitation for the lower classes was a concern for the leisured class. Those that had the means would donate to charities that focused on the health of non-elites. After the decline of the Roman Empire, physicians and concern with public health disappeared except in the largest cities. Health and public doctors remained in the Byzantine Empire. Focusing on preventing the spread of diseases such as small pox lead to a smaller mortality rate in much of the western world. Other factors that allowed the modern rise in population include: better nutrition and environmental reforms (such as getting clean water supplies).

The present day sense of health being a public concern for the state began in the Middle Ages. A few state interventions include maintaining clean towns, enforcing quarantines during epidemics and supervising sewer systems. Private corporations also played a role in public health. The funding for research and the institutions for them to work were funded by governments and private firms. Epidemics were the cause of most government interventions. The early goal of public health was reactionary whereas the modern goal is to prevent disease before it becomes a problem. Despite the overall improvement of world health, there still has not been any decrease in the health gap between the affluent and the impoverished. Today, society is more likely to blame health issues on the individual rather than society as a whole. This was the prevailing view in the late 20th century. In the 1980s the Black Report, published in the United Kingdom, went against this view and argued that the true root of the problem was material deprivation. This report proposed a comprehensive anti-poverty strategy to address these issues. Since this did not parallel the views of the Conservative government, it did not go into action immediately. The Conservative government was criticized by the Labour Party for not implementing the suggestions that the Black Report listed. This criticism gave the Black Report the exposure it needed and its arguments were considered a valid explanation for health inequality. There is also a debate over whether poverty causes ill-health or if ill-health causes poverty. Arguments by the National Health Service gave considerable emphasis to poverty and lack of access to health care. It has also been found that heredity has more of a bearing on health than social environment, but research has also proved that there is indeed a positive correlation between socioeconomic inequalities and illness.

Methodology

The Sociology of Health and Illness looks at three areas: the conceptualization, the study of measurement and social distribution, and the justification of patterns in health and illness. By looking at these things researchers can look at different diseases through a sociological lens. The prevalence and response to different diseases varies by culture. By looking at bad health, researchers can see if health affects different social regulations or controls. When measuring the distribution of health and illness, it is useful to look at official statistics and community surveys. Official statistics make it possible to look at people who have been treated. It shows that they are both willing and able to use health services. It also sheds light on the infected person's view of their illness. On the other hand, community surveys look at people's rating of their health. Then looking at the relation of clinically defined illness and self reports and find that there is often a discrepancy. 

A great deal of the time, mortality statistics take the place of the morbidity statistics because in many developed societies where people typically die from degenerative conditions, the age in which they die sheds more light on their life-time health. This produces many limitations when looking at the pattern of sickness, but sociologists try to look at various data to analyze the distribution better. Normally, developing societies have lower life expectancies in comparison to developed countries. They have also found correlations between mortality and sex and age. Very young and old people are more susceptible to sickness and death. On average women typically live longer than men, although women are more likely to have bad health.

>80   77.5–80   75–77.5   72.5–75   70–72.5

67.5–70   65–67.5   60–65   55–60   50–55

Life expectancy by region in 2015

Disparities in health were also found between people in different social classes and ethnicities within the same society, even though in the medical profession they put more importance in “health related behaviors” such as alcohol consumption, smoking, diet, and exercise. There is a great deal of data supporting the conclusion that these behaviors affect health more significantly than other factors. Sociologists think that it is more helpful to look at health and illness through a broad lens. Sociologists agree that alcohol consumption, smoking, diet, and exercise are important issues, but they also see the importance of analyzing the cultural factors that affect these patterns. Sociologists also look at the effects that the productive process has on health and illness. While also looking at things such as industrial pollution, environmental pollution, accidents at work, and stress-related diseases.

Social factors play a significant role in developing health and illness. Studies of epidemiology show that autonomy and control in the workplace are vital factors in the etiology of heart disease. One cause is an effort-reward imbalance. Decreasing career advancement opportunities and major imbalances in control over work have been coupled with various negative health costs. Various studies have shown that pension rights may shed light on mortality differences between retired men and women of different socioeconomic statuses. These studies show that there are outside factors that influence health and illness.

International perspective

Africa

Estimation of the number of adults in Africa who are infected with HIV or AIDS. Note that levels of infection are much higher in sub-Saharan Africa.

HIV/AIDS is the leading epidemic that affects the social welfare of Africa. Human Immunodeficiency virus (HIV) can cause AIDS which is an acronym for Acquired Immunodeficiency Syndrome (AIDS), a condition in humans in which the immune system begins to fail, leading to life-threatening infections. Two-thirds of the worlds HIV population is located in Sub-Saharan Africa. Since the epidemic started more than 15 million Africans have died by complications with HIV/AIDS.

People apart of religious sub-groups of Sub-Saharan Africa and those who actively and frequently participate in religious activities are more likely to be at a lower risk of contracting HIV/AIDS. On the opposite end, there are many beliefs that an infected male can be cured of the infection by having sex with a virgin. These beliefs increase the number of people with the virus and also increase the number of rapes against women.

Herbal treatment is one of the primary medicines used to treat HIV in Africa. It is used more than standard treatment because it is more affordable. Herbal treatment is more affordable but is not researched and is poorly regulated . This lack of research on whether the herbal medicines work and what the medicines consist of is a major flaw in the healing cycle of HIV in Africa.

Economically, HIV has a significant negative effect. The labor force in Africa is slowly diminishing, due to HIV-related deaths and illness. In response, government income declines and so does tax revenue. The government has to spend more money than it is making, in order to care for those affected with HIV/AIDS.

AIDS orphans in Malawi

A major social problem in Africa in regards to HIV is the orphan epidemic. The orphan epidemic in Africa is a regional problem. In most cases, both of the parents are affected with HIV. Due to this, the children are usually raised by their grandmothers and in extreme cases they are raised by themselves. In order to care for the sick parents, the children have to take on more responsibility by working to produce an income. Not only do the children lose their parents but they also lose their childhood as well. Having to provide care for their parents, the children also miss out on an education which increases the risk of teen pregnancy and people affected with HIV. The most efficient way to diminish the orphan epidemic is prevention: preventing children from acquiring HIV from their mothers at birth, as well as educating them on the disease as they grow older. Also, educating adults about HIV and caring for the infected people adequately will lower the orphan population.

The HIV/AIDS epidemic is reducing the average life expectancy of people in Africa by twenty years. The age range with the highest death rates, due to HIV, are those between the ages of 20 and 49 years. The fact that this age range is when adults acquire most of their income they cannot afford to send their children to school, due to the high medication costs. It also removes the people who could help aid in responding to the epidemic.

Asia

Asian countries have wide variations of population, wealth, technology and health care, causing attitudes towards health and illness to differ. Japan, for example, has the third highest life expectancy (82 years old), while Afghanistan has the 11th worst (44 years old). Key issues in Asian health include childbirth and maternal health, HIV and AIDS, mental health, and aging and the elderly. These problems are influenced by the sociological factors of religion or belief systems, attempts to reconcile traditional medicinal practices with modern professionalism, and the economic status of the inhabitants of Asia. 

People living with HIV/AIDS

Like the rest of the world, Asia is threatened by a possible pandemic of HIV and AIDS. Vietnam is a good example of how society is shaping Asian HIV/AIDS awareness and attitudes towards this disease. Vietnam is a country with feudal, traditional roots, which, due to invasion, wars, technology and travel is becoming increasingly globalized. Globalization has altered traditional viewpoints and values. It is also responsible for the spread of HIV and AIDS in Vietnam. Even early globalization has added to this problem – Chinese influence made Vietnam a Confucian society, in which women are of less importance than men. Men in their superiority have no need to be sexually responsible, and women, generally not well educated, are often unaware of the risk, perpetuating the spread of HIV and AIDS as well as other STIs.

Confucianism has had a strong influence on the belief system in Asia for centuries, particularly in China, Japan, and Korea, and its influence can be seen in the way people chose to seek, or not seek, medical care. An important issue in Asia is societal effect on the ability of disabled individuals to adjust to a disability. Cultural beliefs shape attitudes towards physical and mental disabilities. China exemplifies this problem. According to Chinese Confucian tradition (which is also applicable in other countries where Confucianism has been spread), people should always pursue good health in their lives, with an emphasis on health promotion and disease prevention. To the Chinese, having a disability signifies that one has not led a proper lifestyle and therefore there is a lack of opportunities for disabled individuals to explore better ways to accept or adapt to their disability.

Indigenous healing practices are extremely diverse throughout Asia but often follow certain patterns and are still prevalent today. Many traditional healing practices include shamanism and herbal medicines, and may have been passed down orally in small groups or even institutionalized and professionalized. In many developing countries the only health care available until a few decades ago were those based on traditional medicine and spiritual healing. Now governments must be careful to create health policies that strike a balance between modernity and tradition. Organizations, like the World Health Organization, try to create policies that respect tradition without trying to replace it with modern science, instead regulating it to ensure safety but keeping it accessible. India in particular tries to make traditional medicines safe but still available to as many people as possible, adapting tradition to match modernization while still considering the economic positions and culture of its citizens.

Flag of World Health Organization

Mental health issues are gaining an increasing amount of attention in the Asian countries. Many of these countries have a preoccupation with modernizing and developing their economies, resulting in cultural changes. In order to reconcile modern techniques with traditional practices, social psychologists in India are in the process of “indigenizing psychology”. Indigenous psychology is that which is derived from the laws, theories, principals, and ideas of a culture and unique to each society.

In many Asian countries, childbirth is still treated by traditional means and is thought of with regional attitudes. For example, in Pakistan, decisions concerning pregnancy and antenatal care (ANC) are usually made by older women, often the pregnant woman's mother-in-law, while the mother and father to be are distanced from the process. They may or may not receive professional ANC depending on their education, class, and financial situation. Generally in Asia, childbirth is still a woman's area and male obstetricians are rare. Female midwives and healers are still the norm in most places. Western methods are overtaking the traditional in an attempt to improve maternal health and increase the number of live births.

Asian countries, which are mostly developing nations, are aging rapidly even as they are attempting to build their economies. Even wealthy Asian nations, such as Japan, Singapore, and Taiwan, also have very elderly populations and thus have to try to sustain their economies and society with small younger generations while caring for their elderly citizens. The elderly have been traditionally well respected and well cared for in most Asian cultures; experts predict that younger generations in the future are less likely to be concerned and involved in the health care of their older relatives due to various factors such as women joining the workforce more, the separation of families because of urbanization or migration, and the proliferation of Western ideals such as individualism.

Australia

The health patterns found on the continent of Australia which includes the Pacific Islands, have been very much influenced by European colonization. While indigenous medicinal beliefs are not significantly prevalent in Australia, traditional ideas are still influential in the health care problems in many of the islands of the Pacific. The rapid urbanization of Australia led to epidemics of typhoid fever and the Bubonic plague. Because of this, public health was professionalized beginning in the late 1870s in an effort to control these and other diseases. Since then Australia's health system has evolved similarly to Western countries and the main cultural influence affecting health care are the political ideologies of the parties in control of the government.

Old heroin bottle

Australia has had treatment facilities for 'problem drinkers' since the 1870s. In the 1960s and 1970s it was recognized that Australia had several hundred thousand alcoholics and prevention became a priority over cures, as there was a societal consensus that treatments are generally ineffective. The government began passing laws attempting to curb alcohol consumption but consistently met opposition from the wine-making regions of southern Australia. The government has also waged a war on illegal drugs, particularly heroin, which in the 1950s became widely used as a pain reliever.

Experts believe that many of the health problems in the Pacific Islands can be traced back to European colonization and the subsequent globalization and modernization of island communities. European colonization and late independence meant modernization but also slow economic growth, which had an enormous effect on health care, particularly on nutrition in the Pacific Islands. The end of colonization meant a loss of medical resources, and the fledgling independent governments could not afford to continue the health policies put in place by the colonial governments. Nutrition was changed radically, contributing to various other health problems. While more prosperous, urban areas could afford food, they chose poor diets, causing 'overnourishment', and leading to extremely high levels of obesity, type 2 diabetes, and cardiovascular diseases. Poorer rural communities, on the other hand, continue to suffer from malnutrition and malaria.

Traditional diets in the Pacific are very low in fat, but since World War II there has been a significant increase in fat and protein in Pacific diets. Native attitudes towards weight contribute to the obesity problem. Tongan natives see obesity as a positive thing, especially in men. They also believe that women should do as little physical work as possible while the men provide for them, meaning they get very little exercise.

Europe

The largest endeavors to improve health across Europe is the World Health Organization European Region. The goal is to improve the health of poor and disadvantaged populations by promoting healthy lifestyles including environmental, economic, social and providing health care. Overall health in Europe is very high compared to the rest of the world. The average life expectancy is around 78 in EU countries but there is a wide gap between Western and Eastern Europe. It is as low as 67 in Russia and 73 in the Balkan states. Europe is seeing an increase in the spread of HIV/AIDS in Eastern Europe because of a worsening socioeconomic situation. Cardiovascular disease, cancer and diabetes mellitus are more prevalent is Eastern Europe. The WHO claims that poverty is the most important factor bringing on ill health across Europe. Those at low socioeconomic status levels and many young people are also at risk because of their increased tobacco, alcohol and drug abuse. Health and illness prevention in Europe is largely funded by the governmental services including: regulating health care, insurance and social programs. The role of religion and traditional medicine, however, is often left unexamined in such reports. 

The study of hypertension within the United Kingdom has turned to examining the role that beliefs play in its diagnosis and treatment. Hypertension is an essential topic for study since it is linked to increased risk of stroke and coronary heart disease. The most common treatment for hypertension is medication but compliance for this treatment plan is low. A study conducted in the UK examined the differences between 'white' patients and first generation immigrants from the West Indies. There were differing reasons for non-compliance that involve the patients' perception and beliefs about the diagnosis. Patients commonly believe that high levels of anxiety when first diagnosed are the major cause and think that when stress levels decline so too will their hypertension. Other respondents in this UK based study had varying beliefs concerning the necessity of medication while others still argued that it was the side effects of medication that made them end their prescribed regimen. West Indian respondents whose lay culture teaches them to reject long-term drug therapy opted instead for folk remedies in higher numbers than the 'white' respondents. What can be seen here is that some people will choose to ignore a doctor's expert advice and will employ 'lay consultation' instead.

Regions of the WHO

Before people seek medical help they try to interpret the symptoms themselves and often consult people in their lives or use 'self-help' measures. A study of 'everyday illness' in Finland including: influenza, infections and musculo-skeletal problems focused on reasons for consulting medical experts and explanations of illness. These common illness were examined not because of their seriousness but because of their frequency. The researchers explain five possible triggers that people seek medical aid: 1- the occurrence of an interpersonal crisis 2- perceived interference with social and personal relations 3- perceived interference with vocational & physical activity 4- sanctioning by other people 5- sufferers ideas about how long certain complaints should last. These kind of explanatory models are part of the process that people use to construct medical culture. They give meaning to illness and health, answer questions about personal responsibility about health and most importantly are part of the dialogue between patients' and professionals' illness explanations. It can help explore why some patients will follow a doctors instructions to the letter and others ignore them completely. A patient's explanation or understanding of their illness can be much broader than a physician's and this dynamic has become a major criticism of modern medical practice since it normally excludes the "social, psychological and experiential dimensions of illness."

The Finnish study examined 127 patients and the results have been different from findings in other countries where there is more 'lay consultation'. Half of the respondents did not have any lay consultation before coming to the doctors office. One-third did not try any self-treatment and three-quarters of the sample consulted the doctor within three days of symptoms developing. Possible explanations are that in Finland there is an aspect "over-protectiveness" within their health care system. Many might conclude that the Finnish people are dependent and helpless but the researchers of this study found that people chose to consult professionals because they trusted them over some lay explanation. These results echo similar studies in Ireland that explain this phenomenon as being based in a strong work ethic. Illness in these countries will affect their work and Finnish people will quickly get treatment so they can return to work. This research out of Finland also describes that this relationship between patient and doctor is based on:

• National and municipal administrative bureaucracies that demand more output and more satisfied patients;
• The public demanding better care;
• Nurses criticizing physicians for not taking a holistic view of patients;
• Hospital specialists wanting better/earlier screening for serious illnesses (e.g. cancer).

The conflict between medical and lay worlds is prominent. On one hand many patients believe they are the expert of their own body and view the Doctor-patient relationship as authoritarian. These people will often use knowledge outside the medical field to deal with health and illness. Others see the doctor as the expert and are shy about describing their symptoms and therefore rely on the doctor for diagnosis and treatment.

North America

Compares figures in the population of OECD countries and the percentage of total population (aged 15 and above) with a body mass index greater than 30. Data was collected between 1996 and 2003.

North America is a fairly recent settled continent, made up of the United States, Canada, Mexico, Central America, and the Caribbean. It was built by an amalgamation of wealth, ideas, culture, and practices. North America is highly advanced intellectually, technologically, and traditionally. This advantageous character of North American nations has caused a high average life expectancy of 75 years for males and 80 years for females. This leads to the conclusion that North America has cultivated a comparatively healthy society. As North America contains several core nations, the growing economies in those nations are able to maintain and develop medical institutions. This subsequently provides more access to health care for American citizens but health care is not universal. North America is known for being a leading nation in regards to industrialization and modernization, but the United States lacks federal laws regarding health care as a basic human right. This lag of health care security causes subsequent issues with pharmaceutical competition, lack of care for the elderly, and little attention to alternative medicine. Health care and education are plentiful at a price and illness still persists for many reasons. A main reason is that a lower- and middle-class population still exists in plentiful numbers, maintaining a group that is highly vulnerable to physical ailment. 

World map showing alcohol consumption around the world

 

North America's primary risk factors for illness are currently alcohol abuse, malnutrition, obesity, tobacco use, and water sanitation. Obesity is a recent epidemic in North America. The 1990s brought a rise in the average Body Mass Index, or BMI. From the beginning and to the end of the decade, the median percent of adults who were obese rose from 12% to 20%. Alcoholism is the addiction of over-consumption of alcohol and is highly prevalent in the US. There are high incidence rates in many other world regions. Roughly 61% of American adults drank in 2007, and 21% of current drinkers consumed five or more drinks at one point in the last year. There have also been 22,073 alcohol induced deaths in the United States in the past year, about 13,000 of which were related to liver disease. Alcoholism has many risk factors ingrained in North American culture, such as heredity, stress from competition or availability. 

The Swine Flu (also known as (H1N1) epidemic is a recent disease emerging in the early 21st century. In April 2009, during the early days of the outbreak, a molecular biologist named Dr. Henry Miller wrote in the Wall Street Journal about New York City high-school students. These students apparently brought the virus back from Mexico and infected their classmates. All six cases so far reported in Canada were connected directly or indirectly with travel to Mexico as well. Flu viruses can be directly transmitted (via droplets from sneezing or coughing) from pigs to people, and vice versa. These cross-species infections occur most commonly when people are close to large numbers of pigs, such as in barns, livestock exhibits at fairs, and slaughterhouses. The flu is transmissible from human to human, either directly or via contaminated surfaces."

South America

There are many diseases that affect South America, but two major conditions are malaria and Hepatitis D. Malaria affects every country in South America except Uruguay, Chile, and The Falkland Islands. Elevation is a major factor in the areas where malaria is found. The disease is spread from person to person via mosquito bites. People are typically bitten by mosquitoes at dusk and dawn. Symptoms of this disorder are: high fever, chills, sweating, headaches, body aches, weakness, vomiting and diarrhea. If left untreated, new symptoms can occur; people that are infected may experience seizures, delirium and coma. Severe cases may end in death. Malaria can be cured, but the symptoms may not become noticeable until months later. There are three forms of medication that can cure Malaria. An infected person's accessibility to these drugs is dependent upon their access to medical care and their financial situation. Literature about Malaria treatment typically is focused toward people who are tourists. Most sources are not written with the native in mind.

Malaria

The first sign of Hepatitis D was detected in 1978 when a strange and unrecognizable internuclear antigen was discovered during a liver biopsy of several Italians who suffered HBV infection. Scientists initially thought that it was an antigenic specificity of HBV, but they soon found that it was a protein from another disease altogether. They called it "Hepatitis Delta Virus" (HDV). This new virus was found to be defective. HDV needed HBV to act as a helper function in order for it to be detected. Normally Hepatitis B is transmitted through blood or any type of blood product. In South America Hepatitis D was found to be fatal. Scientists are still unsure in what way this disease was being transmitted throughout certain South American countries. Sexual contact and drug use are the most common means of transmission. HDV is still considered an unusual form of hepatitis. Agents of this virus resemble that of plant viroids. It is still hard to tell how many stereotypes exist because HDV is under the umbrella of HBV. HDV causes very high titers in the blood of people who are infected. Incubation of Hepatitis D typically lasts for thirty five days. Most often Hepatitis D is a co-infection with Hepatitis B or a super-infection with chronic hepatitis. In terms of super infections there are high mortality rates, ranging seventy to eighty percent; in contrast with co-infections which have a one to three percent mortality rate. There is little information with the ecology of Hepatitis D. Epidemics have been found in Venezuela, Peru, Columbia, and Brazil. People who are treated for Hepatitis B have been able to control Hepatitis D. People who have chronic HDB will continue to get HDV.

Another disease that affects South America is HIV and AIDS. In 2008 roughly two million people had HIV and AIDS. By the end of 2008 one hundred and seventy thousand people were infected with AIDS and HIV. Seventy seven thousand people died from this disease by the end of that year. Brazil has the most people that are affected with AIDS and HIV in South America. Forty-three percent of people in Brazil have HIV. In Brazil sixty percent of the inhabitants use drugs, are HIV positive, and are HIV positive because of their drug use. Usually this disease is transmitted by either drug use involving needles or unprotected sex. Sharing needles and being infected with HIV and AIDS is most common in Paraguay and Uruguay. South America is trying to get treatment to the thousands of people infected by this disease. Brazil is offering generic AIDS prescriptions that are much less expensive than the name brand drugs. One hundred and eighty-one thousand inhabitants in Brazil who were infected are being treated. That accounts for eighty percent of those who needed immediate help. This aid from the government has had positive results. Statistics show that there was a fifty percent decrease in mortality rates, approximately sixty to eighty percent decrease in morbidity rates and a seventy percent decrease in hospitalization of infected people.

In very remote areas of South America, traditional healers are the only forms of health care people have. In north Aymara and south Mapuche, where the indigenous groups have the strongest voices, they still heavily use traditional medicine. The government in Chile has implemented an Indigenous Health System to help strengthen the health care system. Even with Chile's indigenous groups, Chile still has the best public health services in South America. They also have the lowest mortality rates in the area. Their health care policies are centered around family and community well-being by focusing on the strategies for prevention health strategies. Reports have shown an increase in mental health issues, diabetes, and cardiovascular diseases.

South America's economy is developing rapidly and has a great deal of industries. The major industry in South America are agriculture. Other industries are fishing, handicrafts, and natural resources. Its trade and import-export market is continually thriving. In the past South American countries moved slowly in regards to economic development. South America began to build its economy ever since World War II. South America's largest economies are Brazil, Chile, Argentina, and Columbia. Venezuela, Peru, and Argentina's economy are growing very rapidly.

Pharmaceutical marketing

From Wikipedia, the free encyclopedia

Many countries have measures in place to limit advertising by pharmaceutical companies.

 

Pharmaceutical company spending on marketing far exceeds that of its research budget. In Canada, $1.7 billion was spent in 2004 to market drugs to physicians; in the United States, $21 billion was spent in 2002. In 2005, money spent on pharmaceutical marketing in the United States was estimated at $29.9 billion with one estimate as high as $57 billion. When the U.S. numbers are broken down, 56% was free samples, 25% was pharmaceutical sales representative "detailing" (promoting drugs directly to) physicians, 12.5% was direct to user advertising, 4% on detailing to hospitals, and 2% on journal ads. There is some evidence that marketing practices can negatively affect both patients and the health care profession.

To health care providers

Marketing to health-care providers takes three main forms: activity by pharmaceutical sales representatives, provision of drug samples, and sponsoring continuing medical education (CME). The use of gifts, including pens and coffee mugs embossed with pharmaceutical product names, has been prohibited by PHRMA ethics guidelines since 2008. Of the 237,000 medical sites representing 680,000 physicians surveyed in SK&A's 2010 Physician Access survey, half said they prefer or require an appointment to see a rep (up from 38.5% preferring or requiring an appointment in 2008), while 23% won't see reps at all, according to the survey data. Practices owned by hospitals or health systems are tougher to get into than private practices, since appointments have to go through headquarters, the survey found. 13.3% of offices with just one or two doctors won't see representatives, compared with a no-see rate of 42% at offices with 10 or more doctors. The most accessible physicians for promotional purposes are allergists/immunologists – only 4.2% won't see reps at all – followed by orthopedic specialists (5.1%) and diabetes specialists (7.6%). Diagnostic radiologists are the most rigid about allowing details – 92.1% won't see reps – followed by pathologists and neuroradiologists, at 92.1% and 91.8%, respectively.

E-detailing is widely used to reach "no see physicians"; approximately 23% of primary care physicians and 28% of specialists prefer computer-based edetailing, according to survey findings reported in the 25 April 2011, edition of American Medical News (AMNews), published by the American Medical Association (AMA).

PhRMA Code

The Pharmaceutical Research and Manufacturers of America (PhRMA) released updates to its voluntary Code on Interactions with Healthcare Professionals on 10 July 2008. The new guidelines took effect in January 2009."

In addition to prohibiting small gifts and reminder items such as pens, notepads, staplers, clipboards, paperweights, pill boxes, etc., the revised Code:

• Prohibits company sales representatives providing restaurant meals to healthcare professionals, but allows them to provide occasional modest meals in healthcare professionals’ offices in conjunction with informational presentations"
• Includes new provisions requiring companies to ensure their representatives are sufficiently trained about applicable laws, regulations, and industry codes of practice and ethics.
• Provides that each company will state its intentions to abide by the Code and that company CEOs and compliance officers will certify each year that they have processes in place to comply.
• Includes more detailed standards regarding the independence of continuing medical education.
• Provides additional guidance and restrictions for speaking and consulting arrangements with healthcare professionals.

Free samples

Free samples have been shown to affect physician prescribing behavior. Physicians with access to free samples are more likely to prescribe brand name medication over equivalent generic medications. Other studies found that free samples decreased the likelihood that physicians would follow standard of care practices.

Receiving pharmaceutical samples does not reduce prescription costs. Even after receiving samples, sample recipients remain disproportionately burdened by prescription costs.

It is argued that a benefit to free samples is the “try it before you buy it” approach. Free samples give immediate access to the medication and the patient can begin treatment right away. Also, it saves time from going to a pharmacy to get it filled before treatment begins. Since not all medications work for everyone, and many do not work the same way for each person, free samples allow patients to find which dose and brand of medication works best before having to spend money on a filled prescription at a pharmacy.

Continuing medical education

Hours spent by physicians in industry-supported continuing medical education (CME) is greater than that from either medical schools or professional societies.

Pharmaceutical representatives

Currently, there are approximately 81,000 pharmaceutical sales representatives in the United States pursuing some 830,000 pharmaceutical prescribers. A pharmaceutical representative will often try to see a given physician every few weeks. Representatives often have a call list of about 200-300 physicians with 120-180 targets that should be visited in 1-2 or 3 week cycle. 

Because of the large size of the pharmaceutical sales force, the organization, management, and measurement of effectiveness of the sales force are significant business challenges. Management tasks are usually broken down into the areas of physician targeting, sales force size and structure, sales force optimization, call planning, and sales forces effectiveness. A few pharmaceutical companies have realized that training sales representatives on high science alone is not enough, especially when most products are similar in quality. Thus, training sales representatives on relationship selling techniques in addition to medical science and product knowledge, can make a difference in sales force effectiveness. Specialist physicians are relying more and more on specialty sales reps for product information, because they are more knowledgeable than primary care reps. 

The United States has 81,000 pharmaceutical representatives or 1 for every 7.9 physicians. The number and persistence of pharmaceutical representatives has placed a burden on the time of physicians. "As the number of reps went up, the amount of time an average rep spent with doctors went down—so far down, that tactical scaling has spawned a strategic crisis. Physicians no longer spend much time with sales reps, nor do they see this as a serious problem." 

Marketers must decide on the appropriate size of a sales force needed to sell a particular portfolio of drugs to the target market. Factors influencing this decision are the optimal reach (how many physicians to see) and frequency (how often to see them) for each individual physician, how many patients suffer from that disease state, how many sales representatives to devote to office and group practice and how many to devote to hospital accounts if needed. To aid this decision, customers are broken down into different classes according to their prescription behavior, patient population, and of course, their business potential. 

Marketers attempt to identify the set of physicians most likely to prescribe a given drug. Historically, this was done by measuring the number of total prescriptions (TRx) and new prescriptions (NRx) per week that each physician writes. This information is collected by commercial vendors. The physicians are then "deciled" into ten groups based on their writing patterns. Higher deciles are more aggressively targeted. Some pharmaceutical companies use additional information such as:

• Profitability of a prescription (script),
• Accessibility of the physician,
• Tendency of the physician to use the pharmaceutical company's drugs,
• Effect of managed care formularies on the ability of the physician to prescribe a drug,
• The adoption sequence of the physician (that is, how readily the physician adopts new drugs in place of older treatments), and
• The tendency of the physician to use a wide palette of drugs
• Influence that physicians have on their colleagues.

Physicians are perhaps the most important component in sales. They write the prescriptions that determine which drugs will be used by people. Influencing the physician is the key to pharmaceutical sales. Historically, this was done by a large pharmaceutical sales force. A medium-sized pharmaceutical company might have a sales force of 1000 representatives. The largest companies have tens of thousands of representatives around the world. Sales representatives called upon physicians regularly, providing clinical information, approved journal articles, and free drug samples. This is still the approach today; however, economic pressures on the industry are causing pharmaceutical companies to rethink the traditional sales process to physicians. The industry has seen a large scale adoption of Pharma CRM systems that works on laptops and more recently tablets. The new age pharmaceutical representative is armed with key data at his fingertips and tools to maximize the time spent with physicians.

Peer influence

Key opinion leaders

Key opinion leaders (KOL), or "thought leaders", are respected individuals, such as prominent medical school faculty, who influence physicians through their professional status. Pharmaceutical companies generally engage key opinion leaders early in the drug development process to provide advocacy and key marketing feedback. Some pharmaceutical companies identify key opinion leaders through direct inquiry of physicians (primary research). Recently, pharmaceutical companies have begun to use social network analysis to uncover thought leaders; because it does not introduce respondent bias, which is commonly found in primary research; it can identify and map out the entire scientific community for a disease state; and it has greater compliance with state and federal regulations; because physician prescribing patterns are not used to create the social network.

Alternatives to segmenting physicians purely on the basis of prescribing do exist, and marketers can call upon strategic partners who specialize in delineating which characteristics of true opinion leadership, a physician does or does not possess. Such analyses can help guide marketers in how to optimize KOL engagements as bona fide advisors to a brand, and can help shape clinical development and clinical data publication plans for instance, ultimately advancing patient care.

Colleagues

Physicians acquire information through informal contacts with their colleagues, including social events, professional affiliations, common hospital affiliations, and common medical school affiliations. Some pharmaceutical companies identify influential colleagues through commercially available prescription writing and patient level data. Doctor dinner meetings are an effective way for physicians to acquire educational information from respected peers. These meetings are sponsored by some pharmaceutical companies.

Journal articles and technical documentation

Recent legal cases and US congressional hearings have provided access to pharmaceutical industry documents revealing new marketing strategies for drugs. Activities once considered independent of promotional intent, including continuing medical education and medical research, are used, including paying to publish articles about promoted drugs for the medical literature, and alleged suppression of unfavorable study results.

Private and public insurers

Public and private insurers affect the writing of prescriptions by physicians through formularies that restrict the number and types of drugs that the insurer will cover. Not only can the insurer affect drug sales by including or excluding a particular drug from a formulary, they can affect sales by tiering, or placing bureaucratic hurdles to prescribing certain drugs. In January 2006, the United States instituted a new public prescription drug plan through its Medicare program. Known as Medicare Part D, this program engages private insurers to negotiate with pharmaceutical companies for the placement of drugs on tiered formularies.

To consumers

Only two countries as of 2008 allow direct to consumer advertising (DTCA): the United States and New Zealand. Since the late 1970s, DTCA of prescription drugs has become important in the United States. It takes two main forms: the promotion or creation of a disease out of a non-pathologic physical condition or the promotion of a medication. The rhetorical objective of direct-to-consumer advertising is to directly influence the patient-physician dialogue. Many patients will inquire about, or even demand a medication they have seen advertised on television. In the United States, recent years have seen an increase in mass media advertisements for pharmaceuticals. Expenditures on direct-to-users advertising have more than quintupled in the seven years between 1997 and 2005 since the FDA changed the guidelines, from $1.1 billion in 1997 to more than $4.2 billion in 2005, a 19.6% annual increase, according to the United States Government Accountability Office, 2006).

The mass marketing to users of pharmaceuticals is banned in over 30 industrialized nations, but not in the US and New Zealand, which is considering a ban. Some feel it is better to leave the decision wholly in the hands of medical professionals; others feel that users education and participation in health is useful, but users need independent, comparative information about drugs (not promotional information). For these reasons, most countries impose limits on pharmaceutical mass marketing that are not placed on the marketing of other products. In some areas it is required that ads for drugs include a list of possible side effects, so that users are informed of both facets of a medicine. Canada's limitations on pharmaceutical advertising ensure that commercials that mention the name of a product cannot in any way describe what it does. Commercials that mention a medical problem cannot also mention the name of the product for sale; at most, they can direct the viewer to a website or telephone number operated by the pharmaceutical company. 

Reynold Spector has provided examples of how positive and negative hype can affect perceptions of pharmaceuticals using examples of certain cancer drugs, such as Avastin and Opdivo, in the former case and statins in the latter.

Drug coupons

In the United States, pharmaceutical companies often provide drug coupons to consumers to help offset the copayments charged by health insurers for prescription medication. These coupons are generally used to promote medications that compete with non-preferred products and cheaper, generic alternatives by reducing or eliminating the extra out-of-pocket costs that an insurers typically charge a patient for a non-preferred drug product.

Economics

Pharmaceutical company spending on marketing exceeds that spent on research. In 2004 in Canada $1.7 billion a year was spent marketing drugs to physicians and in the United States $21 billion were spent in 2002. In 2005 money spent on pharmaceutical marketing in the United States was estimated at $29.9 billion with one estimate as high as $57 billion. When the US number are broken down 56% was free samples, 25% was detailing of physicians, 12.5% was direct to users advertising, 4% on hospital detailing, and 2% on journal ads. In the United States approximately $20 billion could be saved if generics were used instead of equivalent brand name products.

Although pharmaceutical companies have made large investments in marketing their products, overall promotional spending has been decreasing over the last few years, and declined by 10 percent from 2009 to 2010. Pharmaceutical companies are cutting back mostly in detailing and sampling, while spending in mailings and print advertising grew since last year.

Regulation and fraud

European Union

In the European Union, marketing of pharmaceuticals is regulated by EU (formerly EEC) Directive 92/28/EEC. Among other things, it requires member states to prohibit off-label marketing, and direct-to-consumer marketing of prescription-only medications.

United States

In the United States, marketing and distribution of pharmaceuticals is regulated by the Federal Food, Drug, and Cosmetic Act and the Prescription Drug Marketing Act, respectively. Food and Drug Administration (FDA) regulations require all prescription drug promotion to be truthful and not misleading, based on "substantial evidence or substantial clinical experience", to provide a "fair balance" between the risks and benefits of the promoted drug, and to maintain consistency with labeling approved by the FDA. The FDA Office of Prescription Drug Promotion enforces these requirements. 

In the 1990s, antipsychotics were "still seen as treatments for the most serious mental illnesses, like hallucinatory schizophrenia, and recast them for much broader uses". Drugs such as Abilify and Geodon were given to a broad range of patients, from preschoolers to octogenarians. In 2010, more than a half-million youths took antipsychotic drugs, and one-quarter of nursing-home residents have used them. Yet the government warns that the drugs may be fatal to some older patients and have unknown effects on children.

Every major company selling the drugs—Bristol-Myers Squibb, Eli Lilly, Pfizer, AstraZeneca, and Johnson & Johnson—has either settled recent government cases, under the False Claims Act, for hundreds of millions of dollars or is currently under investigation for possible health care fraud. Following charges of illegal marketing, two of the settlements in 2009 set records for the largest criminal fines ever imposed on corporations. One involved Eli Lilly’s antipsychotic Zyprexa, and the other involved Bextra. In the Bextra case, the government also charged Pfizer with illegally marketing another antipsychotic, Geodon; Pfizer settled that part of the claim for $301 million, without admitting any wrongdoing.

The following is a list of the four largest settlements reached with pharmaceutical companies from 1991 to 2012, rank ordered by the size of the total settlement. Legal claims against the pharmaceutical industry have varied widely over the past two decades, including Medicare and Medicaid fraud, off-label promotion, and inadequate manufacturing practices.

Company	Settlement	Violation(s)	Year	Product(s)	Laws allegedly violated (if applicable)
GlaxoSmithKline	$3 billion	Off-label promotion/failure to disclose safety data	2012	Avandia/Wellbutrin/Paxil	False Claims Act/FDCA
Pfizer	$2.3 billion	Off-label promotion/kickbacks	2009	Bextra/Geodon/Zyvox/Lyrica	False Claims Act/FDCA
Abbott Laboratories	$1.5 billion	Off-label promotion	2012	Depakote	False Claims Act/FDCA
Eli Lilly	$1.4 billion	Off-label promotion	2009	Zyprexa	False Claims Act/FDCA

Evolution of marketing

The emergence of new media and technologies in recent years is quickly changing the pharmaceutical marketing landscape in the United States. Both physicians and users are increasing their reliance on the Internet as a source of health and medical information, prompting pharmaceutical marketers to look at digital channels for opportunities to reach their target audiences.

In 2008, 84% of U.S. physicians used the Internet and other technologies to access pharmaceutical, biotech or medical device information—a 20% increase from 2004. At the same time, sales reps are finding it more difficult to get time with doctors for in-person details. Pharmaceutical companies are exploring online marketing as an alternative way to reach physicians. Emerging e-promotional activities include live video detailing, online events, electronic sampling, and physician customer service portals such as PV Updates, MDLinx, Aptus Health (former Physicians Interactive), and Epocrates. 

Direct-to-users marketers are also recognizing the need to shift to digital channels as audiences become more fragmented and the number of access points for news, entertainment and information multiplies. Standard television, radio and print direct-to-users (DTC) advertisements are less relevant than in the past, and companies are beginning to focus more on digital marketing efforts like product websites, online display advertising, search engine marketing, social media campaigns, place-based media and mobile advertising to reach the over 145 million U.S. adults online for health information. 

In 2010, the FDA's Division of Drug Marketing, Advertising and Communications issued a warning letter concerning two unbranded consumer targeted Web sites sponsored by Novartis Pharmaceuticals Corporation as the websites promoted a drug for an unapproved use, the websites failed to disclose the risks associated with the use of the drug and made unsubstantiated dosing claims.

Scattered disc

From Wikipedia, the free encyclopedia

Eris, the largest known scattered-disc object (center), and its moon Dysnomia (left of object)

The scattered disc (or scattered disk) is a distant circumstellar disc in the Solar System that is sparsely populated by icy small solar system bodies, which are a subset of the broader family of trans-Neptunian objects. The scattered-disc objects (SDOs) have orbital eccentricities ranging as high as 0.8, inclinations as high as 40°, and perihelia greater than 30 astronomical units (4.5×10⁹ km; 2.8×10⁹ mi). These extreme orbits are thought to be the result of gravitational "scattering" by the gas giants, and the objects continue to be subject to perturbation by the planet Neptune. 

Although the closest scattered-disc objects approach the Sun at about 30–35 AU, their orbits can extend well beyond 100 AU. This makes scattered objects among the coldest and most distant objects in the Solar System. The innermost portion of the scattered disc overlaps with a torus-shaped region of orbiting objects traditionally called the Kuiper belt, but its outer limits reach much farther away from the Sun and farther above and below the ecliptic than the Kuiper belt proper.

Because of its unstable nature, astronomers now consider the scattered disc to be the place of origin for most periodic comets in the Solar System, with the centaurs, a population of icy bodies between Jupiter and Neptune, being the intermediate stage in an object's migration from the disc to the inner Solar System. Eventually, perturbations from the giant planets send such objects towards the Sun, transforming them into periodic comets. Many objects of the proposed Oort cloud are also thought to have originated in the scattered disc. Detached objects are not sharply distinct from scattered disc objects, and some such as Sedna have sometimes been considered to be included in this group.

Discovery

Traditionally, devices like a blink comparator were used in astronomy to detect objects in the Solar System, because these objects would move between two exposures—this involved time-consuming steps like exposing and developing photographic plates or films, and people then using a blink comparator to manually detect prospective objects. During the 1980s, the use of CCD-based cameras in telescopes made it possible to directly produce electronic images that could then be readily digitized and transferred to digital images. Because the CCD captured more light than film (about 90% versus 10% of incoming light) and the blinking could now be done at an adjustable computer screen, the surveys allowed for higher throughput. A flood of new discoveries was the result: over a thousand trans-Neptunian objects were detected between 1992 and 2006.

The first scattered-disc object (SDO) to be recognised as such was 1996 TL₆₆, originally identified in 1996 by astronomers based at Mauna Kea in Hawaii. Three more were identified by the same survey in 1999: 1999 CV₁₁₈, 1999 CY₁₁₈, and 1999 CF₁₁₉. The first object presently classified as an SDO to be discovered was 1995 TL₈, found in 1995 by Spacewatch.

As of 2011, over 200 SDOs have been identified, including 2007 UK₁₂₆ (discovered by Schwamb, Brown, and Rabinowitz), 2002 TC₃₀₂ (NEAT), Eris (Brown, Trujillo, and Rabinowitz), Sedna (Brown, Trujillo, and Rabinowitz) and 2004 VN112 (Deep Ecliptic Survey). Although the numbers of objects in the Kuiper belt and the scattered disc are hypothesized to be roughly equal, observational bias due to their greater distance means that far fewer SDOs have been observed to date.

Subdivisions of trans-Neptunian space

The eccentricity and inclination of the scattered-disc population compared to the classical and 5:2 resonant Kuiper-belt objects

Known trans-Neptunian objects are often divided into two subpopulations: the Kuiper belt and the scattered disc. A third reservoir of trans-Neptunian objects, the Oort cloud, has been hypothesized, although no confirmed direct observations of the Oort cloud have been made. Some researchers further suggest a transitional space between the scattered disc and the inner Oort cloud, populated with "detached objects".

Scattered disc versus Kuiper belt

The Kuiper belt is a relatively thick torus (or "doughnut") of space, extending from about 30 to 50 AU comprising two main populations of Kuiper belt objects (KBOs): the classical Kuiper-belt objects (or "cubewanos"), which lie in orbits untouched by Neptune, and the resonant Kuiper-belt objects; those which Neptune has locked into a precise orbital ratio such as 2:3 (the object goes around twice for every three Neptune orbits) and 1:2 (the object goes around once for every two Neptune orbits). These ratios, called orbital resonances, allow KBOs to persist in regions which Neptune's gravitational influence would otherwise have cleared out over the age of the Solar System, since the objects are never close enough to Neptune to be scattered by its gravity. Those in 2:3 resonances are known as "plutinos", because Pluto is the largest member of their group, whereas those in 1:2 resonances are known as "twotinos". 

In contrast to the Kuiper belt, the scattered-disc population can be disturbed by Neptune. Scattered-disc objects come within gravitational range of Neptune at their closest approaches (~30 AU) but their farthest distances reach many times that. Ongoing research suggests that the centaurs, a class of icy planetoids that orbit between Jupiter and Neptune, may simply be SDOs thrown into the inner reaches of the Solar System by Neptune, making them "cis-Neptunian" rather than trans-Neptunian scattered objects. Some objects, like (29981) 1999 TD₁₀, blur the distinction and the Minor Planet Center (MPC), which officially catalogues all trans-Neptunian objects, now lists centaurs and SDOs together.

The MPC, however, makes a clear distinction between the Kuiper belt and the scattered disc, separating those objects in stable orbits (the Kuiper belt) from those in scattered orbits (the scattered disc and the centaurs). However, the difference between the Kuiper belt and the scattered disc is not clear-cut, and many astronomers see the scattered disc not as a separate population but as an outward region of the Kuiper belt. Another term used is "scattered Kuiper-belt object" (or SKBO) for bodies of the scattered disc.

Morbidelli and Brown propose that the difference between objects in the Kuiper belt and scattered-disc objects is that the latter bodies "are transported in semi-major axis by close and distant encounters with Neptune," but the former experienced no such close encounters. This delineation is inadequate (as they note) over the age of the Solar System, since bodies "trapped in resonances" could "pass from a scattering phase to a non-scattering phase (and vice versa) numerous times." That is, trans-Neptunian objects could travel back and forth between the Kuiper belt and the scattered disc over time. Therefore, they chose instead to define the regions, rather than the objects, defining the scattered disc as "the region of orbital space that can be visited by bodies that have encountered Neptune" within the radius of a Hill sphere, and the Kuiper belt as its "complement ... in the a > 30 AU region"; the region of the Solar System populated by objects with semi-major axes greater than 30 AU.

Detached objects

The Minor Planet Center classifies the trans-Neptunian object 90377 Sedna as a scattered-disc object. Its discoverer Michael E. Brown has suggested instead that it should be considered an inner Oort-cloud object rather than a member of the scattered disc, because, with a perihelion distance of 76 AU, it is too remote to be affected by the gravitational attraction of the outer planets. Under this definition, an object with a perihelion greater than 40 AU could be classified as outside the scattered disc. 

Sedna is not the only such object: (148209) 2000 CR105 (discovered before Sedna) and 2004 VN112 have a perihelion too far away from Neptune to be influenced by it. This led to a discussion among astronomers about a new minor planet set, called the extended scattered disc (E-SDO).  2000 CR105 may also be an inner Oort-cloud object or (more likely) a transitional object between the scattered disc and the inner Oort cloud. More recently, these objects have been referred to as "detached", or distant detached objects (DDO).

There are no clear boundaries between the scattered and detached regions. Gomes et al. define SDOs as having "highly eccentric orbits, perihelia beyond Neptune, and semi-major axes beyond the 1:2 resonance." By this definition, all distant detached objects are SDOs. Since detached objects' orbits cannot be produced by Neptune scattering, alternative scattering mechanisms have been put forward, including a passing star or a distant, planet-sized object.

A scheme introduced by a 2005 report from the Deep Ecliptic Survey by J. L. Elliott et al. distinguishes between two categories: scattered-near (i.e. typical SDOs) and scattered-extended (i.e. detached objects). Scattered-near objects are those whose orbits are non-resonant, non-planetary-orbit-crossing and have a Tisserand parameter (relative to Neptune) less than 3. Scattered-extended objects have a Tisserand parameter (relative to Neptune) greater than 3 and have a time-averaged eccentricity greater than 0.2.

An alternative classification, introduced by B. J. Gladman, B. G. Marsden and C. Van Laerhoven in 2007, uses 10-million-year orbit integration instead of the Tisserand parameter. An object qualifies as an SDO if its orbit is not resonant, has a semi-major axis no greater than 2000 AU, and, during the integration, its semi-major axis shows an excursion of 1.5 AU or more. Gladman et al. suggest the term scattering disk object to emphasize this present mobility. If the object is not an SDO as per the above definition, but the eccentricity of its orbit is greater than 0.240, it is classified as a detached TNO. (Objects with smaller eccentricity are considered classical.) In this scheme, the disc extends from the orbit of Neptune to 2000 AU, the region referred to as the inner Oort cloud.

Orbits

Distribution of trans-Neptunian objects, with semi-major axis on the horizontal, and inclination on the vertical axis. Scattered disc objects are shown in grey, objects that are in resonance with Neptune in red. Classical Kuiper belt objects (cubewanos) and sednoids are blue and yellow, respectively.

The scattered disc is a very dynamic environment. Because they are still capable of being perturbed by Neptune, SDOs' orbits are always in danger of disruption; either of being sent outward to the Oort cloud or inward into the centaur population and ultimately the Jupiter family of comets. For this reason Gladman et al. prefer to refer to the region as the scattering disc, rather than scattered. Unlike Kuiper-belt objects (KBOs), the orbits of scattered-disc objects can be inclined as much as 40° from the ecliptic.

SDOs are typically characterized by orbits with medium and high eccentricities with a semi-major axis greater than 50 AU, but their perihelia bring them within influence of Neptune. Having a perihelion of roughly 30 AU is one of the defining characteristics of scattered objects, as it allows Neptune to exert its gravitational influence.

The classical objects (cubewanos) are very different from the scattered objects: more than 30% of all cubewanos are on low-inclination, near-circular orbits whose eccentricities peak at 0.25. Classical objects possess eccentricities ranging from 0.2 to 0.8. Though the inclinations of scattered objects are similar to the more extreme KBOs, very few scattered objects have orbits as close to the ecliptic as much of the KBO population.

Although motions in the scattered disc are random, they do tend to follow similar directions, which means that SDOs can become trapped in temporary resonances with Neptune. Examples of possible resonant orbits within the scattered disc include 1:3, 2:7, 3:11, 5:22 and 4:79.

Formation

Simulation showing Outer Planets and Kuiper Belt: a) Before Jupiter/Saturn 2:1 resonance b) Scattering of Kuiper-belt objects into the Solar System after the orbital shift of Neptune c) After ejection of Kuiper-belt bodies by Jupiter

The scattered disc is still poorly understood: no model of the formation of the Kuiper belt and the scattered disc has yet been proposed that explains all their observed properties.

According to contemporary models, the scattered disc formed when Kuiper belt objects (KBOs) were "scattered" into eccentric and inclined orbits by gravitational interaction with Neptune and the other outer planets. The amount of time for this process to occur remains uncertain. One hypothesis estimates a period equal to the entire age of the Solar System; a second posits that the scattering took place relatively quickly, during Neptune's early migration epoch.

Models for a continuous formation throughout the age of the Solar System illustrate that at weak resonances within the Kuiper belt (such as 5:7 or 8:1), or at the boundaries of stronger resonances, objects can develop weak orbital instabilities over millions of years. The 4:7 resonance in particular has large instability. KBOs can also be shifted into unstable orbits by close passage of massive objects, or through collisions. Over time, the scattered disc would gradually form from these isolated events.

Computer simulations have also suggested a more rapid and earlier formation for the scattered disc. Modern theories indicate that neither Uranus nor Neptune could have formed in situ beyond Saturn, as too little primordial matter existed at that range to produce objects of such high mass. Instead, these planets, and Saturn, may have formed closer to Jupiter, but were flung outwards during the early evolution of the Solar System, perhaps through exchanges of angular momentum with scattered objects. Once the orbits of Jupiter and Saturn shifted to a 2:1 resonance (two Jupiter orbits for each orbit of Saturn), their combined gravitational pull disrupted the orbits of Uranus and Neptune, sending Neptune into the temporary "chaos" of the proto-Kuiper belt. As Neptune traveled outward, it scattered many trans-Neptunian objects into higher and more eccentric orbits. This model states that 90% or more of the objects in the scattered disc may have been "promoted into these eccentric orbits by Neptune's resonances during the migration epoch...[therefore] the scattered disc might not be so scattered."

Composition

The infrared spectra of both Eris and Pluto, highlighting their common methane absorption lines

Scattered objects, like other trans-Neptunian objects, have low densities and are composed largely of frozen volatiles such as water and methane. Spectral analysis of selected Kuiper belt and scattered objects has revealed signatures of similar compounds. Both Pluto and Eris, for instance, show signatures for methane.

Astronomers originally supposed that the entire trans-Neptunian population would show a similar red surface colour, as they were thought to have originated in the same region and subjected to the same physical processes. Specifically, SDOs were expected to have large amounts of surface methane, chemically altered into complex organic molecules by energy from the Sun. This would absorb blue light, creating a reddish hue. Most classical objects display this colour, but scattered objects do not; instead, they present a white or greyish appearance.

One explanation is the exposure of whiter subsurface layers by impacts; another is that the scattered objects' greater distance from the Sun creates a composition gradient, analogous to the composition gradient of the terrestrial and gas giant planets. Michael E. Brown, discoverer of the scattered object Eris, suggests that its paler colour could be because, at its current distance from the Sun, its atmosphere of methane is frozen over its entire surface, creating an inches-thick layer of bright white ice. Pluto, conversely, being closer to the Sun, would be warm enough that methane would freeze only onto cooler, high-albedo regions, leaving low-albedo tholin-covered regions bare of ice.

Comets

Tempel 1, a Jupiter-family comet

The Kuiper belt was initially thought to be the source of the Solar System's ecliptic comets. However, studies of the region since 1992 have shown that the orbits within the Kuiper belt are relatively stable, and that ecliptic comets originate from the scattered disc, where orbits are generally less stable.

Comets can loosely be divided into two categories: short-period and long-period—the latter being thought to originate in the Oort cloud. The two major categories of short-period comets are Jupiter-family comets (JFCs) and Halley-type comets. Halley-type comets, which are named after their prototype, Halley's Comet, are thought to have originated in the Oort cloud but to have been drawn into the inner Solar System by the gravity of the giant planets, whereas the JFCs are thought to have originated in the scattered disc. The centaurs are thought to be a dynamically intermediate stage between the scattered disc and the Jupiter family.

There are many differences between SDOs and JFCs, even though many of the Jupiter-family comets may have originated in the scattered disc. Although the centaurs share a reddish or neutral coloration with many SDOs, their nuclei are bluer, indicating a fundamental chemical or physical difference. One hypothesis is that comet nuclei are resurfaced as they approach the Sun by subsurface materials which subsequently bury the older material.

The False Promise of ‘Medicare for All’

Cost is only part of the problem. Single-payer systems create long waits and delays on new drugs.

By Scott W. Atlas

Nov. 12, 2018 6:48 p.m. ET 

Original link:   https://www.wsj.com/articles/the-false-promise-of-medicare-for-all-1542066511

 

Illustration: Chad Crowe

Health care was a priority for midterm voters, and for good reason. In nearly five years since ObamaCare’s major provisions came into effect, insurance premiums have doubled for individuals and risen 140% for families, even while deductibles have increased substantially. Hospitals and doctors continue to flee ObamaCare’s coverage network, to the point that almost 75% of plans are now highly restrictive. ObamaCare also encouraged a record pace of consolidation among hospitals and physician practices. All these developments will raise health-care prices, as fewer hospitals compete for payers.

The Democrats’ solution would make the problem far worse. Single-payer health care is an alluringly simple concept: a government guarantee for all medical care. Advocates insist that such care is “free.” The constitution of Britain’s National Health Service states: “You have the right to receive NHS services free of charge”—ignoring that the U.K. funds the program by taxing citizens some $160 billion a year, even with its severe limits on access to specialists, drugs and technology.

For California alone, single-payer health care would cost about $400 billion a year—more than twice the state’s annual budget. Nationwide “Medicare for all” would cost more than $32 trillion over its first decade. Doubling federal income and corporate taxes wouldn’t be enough to pay for it. No doubt, that cost would be used to justify further restrictions on health-care access.

But the problems with single-payer go well beyond cost. In the past half-century, nationalized programs have consistently failed to provide timely, high-quality medical care compared with the U.S. system. That failure has countless consequences for citizens: pain, suffering and death, permanent disability, and forgone wages.

Single-payer programs usually impose long waiting lists and delays unheard of in the U.S. Last year, a record 4.2 million patients were on England’s NHS waiting lists; 362,600 patients waited longer than four months for hospital treatment as of that March, and 95,252 waited longer than six months. By this July, 4,300 people had been on the wait list more than a year—all after receiving their diagnosis and referral—according to NHS England’s “Referral to Treatment” waiting-times data.

In Canada last year, the median wait time between seeing a general practitioner and following up with a specialist was 10.2 weeks, while the wait between seeing a doctor and beginning treatment was about five months. According to a Fraser Institute study, the average Canadian waits three months to see an ophthalmologist, four months for an orthopedist and five months for a neurosurgeon.

In single-payer systems, even patients referred for “urgent treatment” often wait months. More than 19% of patients in Britain’s NHS wait two months or longer to begin their first urgent cancer treatment, while 17% wait more than four months for brain surgery. In Canada the median wait for neurosurgery after seeing a doctor is about eight months. Canadians with heart disease wait three months for their first treatment. And if you need life-changing orthopedic surgery in Canada, like a hip or knee replacement, you’ll likely have to wait a startling 10 months.

America’s system is much quicker. Aside from transplants, one paper by the Organization for Economic Cooperation and Development states, “waiting lists are not a feature in the United States.”

A study in Health Affairs found that “in contrast to England, most United States patients face little or no wait for elective cardiac care.” The Agency for Healthcare Research and Quality has said that low-risk U.S. heart patients “sometimes have to wait all day or even be rescheduled for another day” for catheterization—that is, a wait for even one day is considered unusual.

Calls for reform were widespread in American media in 2009, though waits for appointments at that time averaged 21 days for five common specialties. With the exception of orthopedist appointments for knee pain, those waits were for healthy checkups, the lowest medical priority. In the U.S. even waits for checkups are usually far shorter than waits for seriously ill patients in countries with single payer.

Single-payer systems also impose long delays before debuting the newest drugs for cancer and other serious diseases. A 2011 Health Affairs study showed that the Food and Drug Administration approved 32 new cancer drugs in the decade after 2000, while the European Medicines Agency approved 26. All 23 drugs approved by both Europe and the U.S. were available to American patients first. Two-thirds of the 45 “novel” drugs in 2015 were approved in the U.S. before any other country.

These waits and restrictions have severe consequences for patients. Single-payer systems have proved inferior to the U.S. in outcomes for almost all serious diseases, including cancer, diabetes, high blood pressure, stroke and heart disease.

Meanwhile, the nations most experienced with single-payer systems are moving toward private provision. Sweden has increased its spending on private care for the elderly by 50% in the past decade, abolished its government’s monopoly over pharmacies, and made other reforms. Last year alone, the British government spent more than $1 billion on care from private and other non-NHS providers, according to the Financial Times. Patients using single-payer care in Denmark can now choose a private hospital or a hospital outside the country if their wait time exceeds one month.

A single-payer “guarantee” is no promise of access to quality medical care. If brought to the U.S., the only reliable promises of single-payer would be worse health care for Americans and higher taxes. America’s poor and middle class would suffer the most from a turn to single-payer, because only they would be unable to circumvent the system.
 
Dr. Atlas is a senior fellow at Stanford’s Hoover Institution and author of “Restoring Quality Health Care: A Six Point Plan for Comprehensive Reform at Lower Cost.”

Appeared in the November 13, 2018, print edition.