YEAR IN REVIEW 1997: HEALTH-AND-DISEASE

MENTAL HEALTH In 1996, for the first time, a multinational study was able to demonstrate clear similarities and differences in the rates of specific mental illnesses in several countries throughout the world. Unlike previous investigations, in which different methods were employed in different countries, the new survey was based on a uniform methodology. Its purpose was to assess the pattern and extent of two conditions, major depression and bipolar disorder, in Canada, France, the former West Germany, Italy, South Korea, Lebanon, New Zealand, Puerto Rico, Taiwan, and the U.S. One principal finding was that major depression varied considerably in incidence. The lifetime rate ranged from 1.5 cases per 100 adults in Taiwan to 19 cases per 100 adults in Lebanon. Similarly, the annual rate ranged from 0.8 cases per 100 adults in Taiwan to 5.8 cases per 100 adults in New Zealand. There was, however, much less variation in the pattern of major depression. In all countries in the study, this condition had a similar age of onset (usually the mid- to late 20s) and affected more women than men. Persons who were separated or divorced had significantly higher rates of major depression than married persons in most of the countries. The majority of those affected reported both insomnia and loss of energy. In the case of bipolar disorder, the data showed more uniformity in both the incidence and the pattern of the disorder. The lifetime rates ranged only from 0.3 per 100 adults in Taiwan to 1.5 per 100 adults in New Zealand. The sex ratios were nearly equal, and the age at onset was earlier than for major depression. The investigators believed that cultural differences or varying risk factors may at least partially explain the differing rates of major depression. Nevertheless, some of the findings remained puzzling. For example, Paris, a city with a temperate climate and a stable economy and political structure, had a rate of major depression almost as high as that of Beirut, Leb., which was ravaged by war for some 15 years. Psychiatrists in London reported that black Caribbean and African patients suffering from certain psychotic illnesses differed from whites in the likelihood of involuntary hospitalization. The subjects were individuals from two areas in the south of the city; they had conditions such as schizophrenia and psychotic affective disorder. The higher rate of compulsory detention for blacks was independent of psychiatric diagnosis and was irrespective of other factors such as employment and marital status. The reasons for the disparity were unclear. The authors of the report speculated, however, that black people may perceive mental health services as "untherapeutic." They thus delay seeking help and thereby increase the chances that they will be hospitalized involuntarily. A major problem in treating psychotic patients was that up to 80% of them failed to take their medication as directed. Given the efficacy of modern antipsychotic drugs and the potentially serious consequences of relapse, ensuring compliance became a major goal of mental health researchers. One group in London showed that an approach known as "compliance therapy" could significantly improve patients' reliability in taking their drugs. It also produced long-lasting results. The therapy aimed to help people to change their behaviour by means of interviews intended to provide motivation but to avoid the confrontation and stalemate that often impair the relationship between patient and psychiatrist. In the London experiment, those receiving the new therapy were five times more likely to attain an acceptable level of compliance than patients simply given their medication and instructed to take it regularly but provided with no further encouragement or support. Researchers in Valencia, Spain, reported progress in helping patients with severe depression resistant to all drugs normally used to treat this condition. The new technique involved placing an electrical coil on the patient's scalp and creating a rapidly changing magnetic field, which reached the brain structures beneath, specifically a region known to be linked with depression. When 17 patients with intractable depression were treated in this way, 11 experienced a pronounced improvement that lasted for about two weeks. With further refinement of the therapy, more permanent results should be possible. An English trial of estrogen therapy for severe postnatal depression reported encouraging results. The subjects were 61 women who within three months of childbirth had developed major depression, which had then persisted for up to 18 months. During their three months of treatment with estrogen delivered by means of a skin patch, the women receiving treatment found that their depression waned rapidly. Although those receiving a placebo also felt slightly better, improvement in the estrogen-treated women was much more dramatic. (BERNARD DIXON) This article updates mental disorder. SPECIAL REPORT For Nursing,New Responsibilities, New Respect BY MARGRETTA MADDEN STYLES In remote villages around the world--whether in southern Africa, Latin America, or southwestern Asia--the community's mobilizer for health, sanitation, and housing services may well be a nurse. In the rural or inner-city U.S., a clinic serving the entire community may well be run solely by nurses. The head of a national family-planning program may be a nurse. The chief executive officer of a hospital or health care system may be a nurse with additional training in economics or business administration. The attorney representing a client in high-stakes health care litigation may be a nurse with training in the law. In fact, all of the above-mentioned positions are presently or have been held by nurses. Adapting to current social, economic, and health-care trends, nurses today are attaining higher levels of education than in the past and are applying their newly acquired knowledge, skill, and confidence to expanded roles and in novel settings. Worldwide, the nursing profession is responding to myriad health care needs and challenges. These include the escalation of health care costs, the fragmentation of care resulting from growing specialization, the rampant spread of AIDS, malaria, cholera, and tuberculosis, and other infectious diseases, and the worldwide increase in the number of elderly persons, with its corresponding increase in aging-associated health problems. Nurses have been called upon to meet these diverse challenges for a number of reasons. First and foremost, in most countries nurses constitute the largest group of health care providers. Because nursing is defined variably around the globe, it is difficult to arrive at exact figures, but, as just one example of their significant numbers, there are more than 2.2 million registered nurses in the United States alone. Nurses are geographically more evenly distributed than other health care providers, and more of them serve in rural, remote, and poor areas. Changes at the grassroots of nursing have been stimulated and assisted by both governmental and nongovernmental organizations (NGOs) on all levels. The governmental system includes, in ascending order, local, state, and federal departments or ministries of health and, internationally, the World Health Organization (WHO), with its six geographic regions. The International Labour Organisation (ILO), a UN agency, specifically addresses economic and general welfare issues for workers in all occupations, including nursing. Principal among the NGOs advocating for nursing are the 114 national nurses associations constituting the International Council of Nurses (ICN). Conveniently, the ICN, WHO, and the ILO are all headquartered in Geneva, where their close proximity permits intensive communication and cooperation. Nursing education has had to change dramatically to prepare nurses for their expanded roles. Traditional hospital-based nursing schools do not provide community nursing experience, nor can they offer the liberal arts curriculum of the university. Moreover, traditional nursing schools have isolated students from the mainstream of higher education. To remedy this situation, nursing education is now occurring increasingly in academic rather than clinical settings. In fact, in some countries the training of nurses has moved exclusively into the universities. Despite the extension and reform of nursing education, the costs of educating a nurse remain only a fraction of those required for educating a physician. As nurses have become better educated and their roles have been enlarged, the legal scope of their practice has been extended accordingly. In recent years, largely through the combined efforts of the ICN and WHO, there has been an accelerated movement to expand the practice boundaries of the profession. In some countries nurses are now authorized to make diagnoses, to prescribe medication, and even to admit patients to hospitals under their care. The government or private, so-called third-party, health insurers pay for some or all of health care in most countries. When nurses provide "expanded" services, the health care system must provide for their reimbursement, just as it does for physician-rendered services. In nations with centralized, single-payer health care systems, such adjustments have been easily accommodated. In the United States, ongoing negotiations with the federal government, state agencies, and private insurance companies have inched forward to gain authorization for reimbursement of advanced nursing services. Incentives have been a major enabling factor in the advanced-practice movement. Nurses are encouraged to seek additional education and to assume roles of greater scope and responsibility when patients recognize their expertise and seek out their care and when they are appropriately compensated by employers. The profession long suffered from the "a-nurse-is-a-nurse" complex, and little motivation was provided for nurses to better themselves. Although inequities in salaries and practice privileges persist, progress has been made in establishing career ladders and salary structures that appropriately distinguish those individuals who have attained higher qualifications and assumed greater responsibilities. Historically a female profession, nursing has long been a natural standard-bearer for the economic and social rights of women. Battles continue to be waged on many fronts and at many levels, with nurses and nursing organizations often leading the fray. As just one example, many nurses were at the negotiating tables of the UN Fourth World Conference on Women in September 1995 in Beijing, where they spoke persuasively for the educational, economic, and health rights of women around the world. The emerging new roles and responsibilities of nurses have already had a dramatic impact on health care. Studies show that the expanded services provided by well-qualified nurses are different in nature from those provided by physicians. For example, nurses spend more time with patients; the treatments they provide are often more conservative and less intrusive. Most telling, so-called outcomes--cure and survival rates, cost savings--are as good or better. As sweeping changes occur in health care technology and in the structure and priorities of health care delivery systems, nurses will continue to be at the patient's side, assuring quality care, providing expertise, and offering comfort. Margretta Madden Styles is president of the International Council of Nurses and the American Nurses Credentialing Center. VETERINARY MEDICINE Ramifications of the fatal cattle disease bovine spongiform encephalopathy (BSE), also known as "mad cow" disease, dominated the veterinary news in much of the Western world in 1996. The disease, found mainly in the U.K., was attributed to the practice of feeding dairy cows manufactured feeds containing protein material from sheep infected with scrapie, a similar disease. It takes some years for signs of BSE to appear in infected animals, the main manifestation being erratic behaviour and increasing difficulty in moving. First identified in England in 1986, BSE had been the subject of an ongoing eradication process based on the slaughter of affected animals. This process had been proceeding more or less according to plan; the numbers of new cases of BSE had declined sharply from a peak in 1993, and it was predicted that the disease would be eliminated from herds in the U.K. soon after the year 2000. In 1996, however, scientists announced a possible link between consumption of beef from BSE-infected cows and several cases of a new form of Creutzfeldt-Jakob disease, a fatal neurodegenerative disorder. Further, contrary to earlier predictions, preliminary results of long-term studies in the U.K. suggested that BSE might be transmissible from cow to calf. As a result, the European Commission prohibited the U.K. from exporting beef and beef products and cattle, and beef sales dropped sharply throughout Europe. The new findings prompted demands from the Commission for more urgent measures to eradicate the disease before the export ban could be lifted. These included the establishment of rigid precautions in slaughterhouses, as well as the destruction of hundreds of thousands of cattle born before 1993. The proposals for mass slaughter, which meant that many healthy cattle would have to be killed, caused an outcry from veterinarians, farmers, and animal welfare activists in the U.K. Many argued that the program already in place would have eradicated the disease just as quickly as the new plan. A report from the World Health Organization (WHO) on the progress of the European campaign to control--and, it was hoped, eradicate--rabies by laying vaccine-impregnated baits for foxes, the main carrier of the disease, found that rabies prevalence had been reduced to 20% of its former level. The success rates in the 14 participating countries differed considerably, however, and the cost--$83 million in total to date--was causing support to wane in some areas. The authors of the WHO report called for a review of the campaign to identify problems responsible for the variable success rate and to draw up guidelines for the future. The physical attributes of different breeds of dog are well-defined, but the temperamental characteristics, although of equal importance to a potential owner, are much less so. J.W.S. Bradshaw and colleagues at the University of Southampton, Eng., surveyed veterinarians and animal-care professionals to establish an objective assessment of behavioral traits such as excitability, watchdog behaviour, and aggression toward other dogs in 50 popular breeds. They also asked whether males or females were more likely to exhibit a particular behaviour. The results broadly confirmed existing anecdotal opinion. They showed that females were, in general, easier to train, more demanding of affection, and more mature than males. The most aggressive breeds were rottweilers, German shepherds, Doberman pinschers, and bull terriers; the least aggressive included the spaniels, setters, and sheepdogs. (EDWARD BODEN) See also Life Sciences: Molecular Biology. This article updates diagnosis; disease; infection; medicine. The Environment INTERNATIONAL ACTIVITIES International Cooperation. Controversy arose in 1996 over the wording of one chapter in Climate Change 1995, the latest report of the Intergovernmental Panel on Climate Change (IPCC). The Global Climate Coalition (GCC), an umbrella group of some 60 industrial concerns, claimed the part of the main text dealing with human influences on climate had been substantially rewritten after it had passed peer review and been approved. The IPCC mounted a robust defense of the published version, but the argument continued most of the year. On September 19 Canadian Foreign Affairs Minister Lloyd Axworthy presided at the signing ceremony in Ottawa of an agreement to create a joint Arctic Council, with the aim of protecting the environment while encouraging long-term development in the region. The eight signatory nations were Canada, Denmark (on behalf of Greenland), Finland, Iceland, Norway, Russia, Sweden, and the U.S. United States. On the evening of January 19, the North Cape, a 104-m (340-ft) barge, ran aground near Block Island, Rhode Island, a wildlife refuge, ruptured 9 of its 14 compartments, and eventually spilled more than 828,000 gal of heating oil from its cargo of 4 million gal (1 gal = 3.79 litres). The accident occurred after the tugboat towing the barge caught fire in a storm. About 600,000 gal of the oil were believed to have evaporated or dissipated in the water, but the remainder caused a 19-km (12-mi) slick, most of which was driven out to sea by the wind. Eklof Marine, which owned both the tugboat and the barge, accepted responsibility and hired workers and vessels to help with the cleanup and to pump the remaining oil into another barge. On January 21-22, 1.8 million gal of oil were removed, which left 1.4 million gal on board in undamaged compartments. Some of this was pumped out later. In December 1995 it was reported that Rep. Jim Saxton had drafted a bill to create a National Institute for the Environment, to be funded by combining environmental research programs from several federal agencies so that it would require no new financing. The idea was pursued by the Committee on Environment and Natural Resources (CENR) of the National Science and Technology Council. In May 1996 the CENR was said to be exploring ways of merging all federal environmental programs into a single network responsible for ecological research and monitoring and reportedly had identified about 30 suitable programs. The House of Representatives passed a bill in October approving a $21.5 billion budget for research by the major civil agencies in 1996. This was $3 billion less than the 1995 budget and $3.6 billion less than the budget requested by Pres. Bill Clinton. A large proportion of the 22% cut in the research and development budget of the Environmental Protection Agency (EPA) would be taken from research into global warming. The National Oceanic and Atmospheric Administration budget would be cut by 19%. In August U.S. District Judge Joseph Anderson rejected a request from South Carolina for an emergency injunction to prevent the shipment of spent fuel rods containing highly enriched uranium from Europe and South America to storage pools at the Department of Energy's Savannah River site. On September 23 the first cargo of 280 rods from Germany, Switzerland, Sweden, Colombia, and Chile arrived under Coast Guard escort at the Naval Weapons Station in North Charleston, S.C. The program to recover spent fuel aimed to prevent the proliferation of nuclear weapons and involved 41 countries. Agriculture and Food Supplies INTERNATIONAL ISSUES Food-Aid Needs. The FAO and other international aid organizations have stressed that two kinds of food-related assistance are usually needed. There is the short-run need for donors to provide food to meet emergencies caused by natural and man-made disasters. There also is the longer-run need to assist countries in improving their agricultural sectors. In the mid-1990s some LDCs--for example, Sierra Leone and Rwanda--emerged from prolonged civil strife and were facing the possibility of peace and increased stability. These countries would be especially suitable targets for longer-term assistance. A healthy agricultural sector would not only provide more food but also improve the incomes and access to food of the large proportion of the population that lived in rural areas. In 1996-97 the short-term food prospects improved in many low-income food-deficit countries (LIFDCs). Although food-aid needs declined worldwide, shortages persisted in many countries owing to crop failures, natural disasters, and continuing civil strife. According to the results of an annual analysis by the Economic Research Service of the U.S. Department of Agriculture (USDA), LDCs would need about 9 million to 11 million tons of food aid in the form of cereals during the 1996-97 crop year. Food-aid needs were concentrated in sub-Saharan Africa, Bangladesh, Afghanistan, and North Korea. The 1996-97 estimate was down from the previous year's estimated needs as a result of improved harvests and increased commercial imports at lower prices in countries receiving aid. Donor nations, however, were expected to supply only 7.5 million tons of cereal aid. ( See TABLE II.) The USDA estimate of food-aid needs was obtained by examination of the requirements of 65 LDCs. "Aid needs" for each country were defined as the difference between a target level of food consumption and what could be grown and commercially imported. The target was the average level of food consumption per capita over the previous five years. The 9 million to 11 million tons needed to meet this target in 1996-97 would still fall far short of supplying minimum nutritional standards. The FAO estimated that 40% of the population of Africa had been undernourished in recent years. In addition, civil strife in various parts of Africa had caused greatly diminished local food production and created several million refugees who needed emergency food aid. A year after the UN forces left Somalia, clan-based fighting continued, and the food emergency worsened in 1996. Cereal harvests also were much below normal. The fighting also disrupted emergency food aid to Somalia by international organizations. Poor cereal harvests and fighting created a food emergency in the capital, Mogadishu. The Sudan suffered from severe floods, pest infestation, and civil war that reduced cereal production and disrupted emergency food assistance. Continuing strife in Liberia also led to a sharp decline in food production in 1996 and disrupted food assistance. Much of the Liberian population took refuge in neighbouring states. By the end of the year, however, there was evidence that a peace agreement might enable relief supplies to move and allow farmers to return to their fields and tend the crops. In the Great Lakes region of Africa (Burundi, Rwanda, Tanzania, and Zaire), masses of refugees moved between countries to escape civil strife. Local food production was devastated. The food situation in these countries in 1996 was precarious, and emergency food was urgently needed. Thousands of refugees returned to their farms and homes in Rwanda in 1996 as some stability returned to the country. As a result, there was some recovery of food production. Owing to strong economic growth and above-average cereal harvests, food-aid needs were down in most of the LDCs in Latin America and Asia in 1996. In Afghanistan and Iraq, however, production was down, and food-aid needs increased. Food shortages also persisted in North Korea and Laos owing to extensive flooding. The countries of the former Soviet Union generally experienced increased cereal production and some expansion of commercial trade, which thus reduced their need for food aid. In Tajikistan and Turkmenistan, however, food shortages persisted. Food-Aid Supplies. Wealthy countries provided food aid to other countries in two ways: as a direct aid shipment and as a concessional sale at a reduced price or with a low-interest loan. Because of the world cereal shortage in 1995-96, cereal prices were at record highs. As a result, aid shipments were down, and concessional sales were nearly eliminated. The FAO estimated that LIFDCs increased their expenditures on cereal imports by 35% from the previous year, even though they imported less. Total cereal-aid shipments (mostly wheat) in 1995-96 were estimated by the FAO to have been 7.2 million tons, with 5.7 million tons having gone to LIFDCs and the remaining 1.5 million tons to other countries. The record-low aid to LIFDCs was down nearly 30% from the previous year and down nearly 40% from the average of the previous four years. Much of the decline in shipments was to sub-Saharan Africa, but aid shipments to Latin-American and Caribbean countries also declined sharply. Considerably more food aid was sent to North Korea. Food-aid shipments to countries in Eastern Europe and the former Soviet Union (non-LIFDCs) were down 30% from 1994-95. Among donor nations most of the decline was due to reduced shipments by the U.S. and the EU, which combined still accounted for 75% of the cereal food aid. Japan increased its aid shipments. In 1994-95, 30% of food-aid shipments went through multilateral channels such as the World Food Programme. In November 1996 the FAO estimated 1996-97 food-aid shipments at 7.5 million tons, an increase of 4% over the previous year. Most of the increase was expected to come from the EU and go to the LIFDCs in Africa and Asia. LAW As the sovereignty of nation-states was increasingly diluted by their inability to act on international issues without taking into account the views and possible reactions of the world and regional communities, international law continued to reflect this change. The emphasis on the judicialization of interstate relations and the structural politicization of those relations within regional and global organizations was a clear feature of international law in 1996 as it slowly took on a strong resemblance to constitutional law.