Anthropogenic climate change and health in the Global South.

This paper explores evidence relevant to the hypothesis that human-generated climate change (global warming) is already, and will increasingly, add to the existing burden of disadvantage experienced by populations in low-income countries, the 'Global South'. Well recognised health manifestations of global warming include from heatwaves and other extreme weather events, changes to infectious disease patterns, and undernutrition, arising from higher food prices, reduced food availability and reduced nutrient concentrations of many foods. These effects have been called 'primary' and 'secondary'. Although these manifestations will have effects globally, their biggest impact on health is and will be upon poor and vulnerable populations in low-income settings. Also well recognised, manual labourers are increasingly vulnerable from excessive heat and humidity. There is less recognition that climate change interacts with social and political determinants of health, contributing to 'tertiary' health consequences including conflict, forced migration and famine. In turn, these effects may deepen poverty traps in the Global South. Human-generated climate change is principally caused by the policies and lifestyles of populations in high-income countries (the Global North). The recent recognition by the British government that climate change is an emergency is encouraging, and may help motivate the widespread global behavioural changes that are needed to reduce the many risks from global warming, including to the people of the South.

New visions for addressing sustainability.

Attaining sustainability will require concerted interactive efforts among disciplines, many of which have not yet recognized, and internalized, the relevance of environmental issues to their main intellectual discourse. The inability of key scientific disciplines to engage interactively is an obstacle to the actual attainment of sustainability. For example, in the list of Millennium Development Goals from the United Nations World Summit on Sustainable Development, Johannesburg, 2002, the seventh of the eight goals, to "ensure environmental sustainability," is presented separately from the parallel goals of reducing fertility and poverty, improving gains in equity, improving material conditions, and enhancing population health. A more integrated and consilient approach to sustainability is urgently needed.

The consumption bomb.

The explosion of the population bomb has long been predicted to cause massive famine in overpopulated countries. Rising consumption, even in a time of decreasing population growth rates, now threatens adverse global health effects more severe than localised famines. The world faces potential ecological entrapment. This has two dimensions: planetary eco-impoverisation and planetary eco-pathology. Eco-impoverisation, the depletion of natural capital, arises as the limit of the global human carrying capacity approaches. Eco-pathology, the disruption of ecological support systems, arises because of the way the biosphere has been modified by human activity and is caused particularly by unsustainable consumption for human purposes. Despite encroaching ecological entrapment, the dominant economic paradigm claims record levels of growth; a paradox that needs recognition. Reasons for denial of the gravity of ecological entrapment are discussed. Ways are suggested to defuse the consumption bomb and avert ecological entrapment.

Evaluation of ondansetron prescribing in US academic medical centers.

BACKGROUND: The study objectives were to characterize the use of the antiemetic ondansetron, a serotonin subtype 3 receptor antagonist, in US academic medical centers, and to assess ondansetron prescribing with consensus-derived prescribing guidelines used as evaluation criteria. METHODS: A multicenter, prospective, observational study was conducted in the inpatient and outpatient care areas of 23 US academic medical centers. A total of 670 patients received ondansetron (508 inpatients and 162 outpatients). The use of ondansetron was compared with consensus-derived prescribing guidelines on the basis of indication for use and dose administered. RESULTS: Only 253 (37.8%) of the 670 patients satisfied for prescribing guidelines for both indication for use and dose administered. The remainder of the patients did not satisfy the guidelines, in whole or in part. If all ondansetron use had met the prescribing guidelines in the patients studied, a reduction in ondansetron use of 31% (16 185/52 260 mg) would have been realized. At an estimated cost of $5 per milligram, this reduction represents a potential cost savings of nearly $81,000, or $121 per patient studied. CONCLUSION: Since its introduction in 1991, ondansetron has become a commonly used antiemetic in US academic medical centers. Although ondansetron is safe and effective in improving patients' tolerance of emetogenic therapies, including cancer chemotherapy, its high cost has added a significant burden to the pharmaceutical budgets of many institutions. The study data suggest that compliance with ondansetron prescribing guidelines, with elimination of indiscriminant use, could result in significant cost savings.

Evaluation of physician decision making with the use of prior probabilities and a decision-analysis model.

OBJECTIVES: To determine whether treatment decisions could be influenced by supplying probabilities and whether these decisions would be consistent with a decision-analysis model. DESIGN: Survey with case scenarios and a computerized decision-analysis model. SETTING: Family practice residency program. PARTICIPANTS: Forty family practice residents and faculty in the experimental group and six controls. INTERVENTIONS: Twelve cases scenarios of patients with hypertension and coexisting diseases were developed. Family practice physicians were asked to rank their drugs of choice for each case. In the second phase, six case scenarios included probabilities for efficacy and adverse reactions of step 1 antihypertensives. These drug selections were compared with a computerized decision-analysis model. MAIN OUTCOME MEASURES: Frequencies of matches between the drug selections of physicians and the computer model. RESULTS: The frequency of matches before probabilities were provided to physicians was low (45.6%) and there was a significant increase when probabilities were supplied (71.3%). Regardless of experience level, physicians increased their consistency with the computer model after probabilities were supplied. CONCLUSIONS: This study demonstrated that physician decision making for antihypertensive therapy can be influenced by patient-specific probability estimates. Probability data can help less experienced residents make decisions that are comparable to those of attending physicians. This study was conducted in one residency program and the generalizability to the practicing physician is unknown. These findings would suggest that educational efforts in residency programs, health maintenance organizations, or group practices may benefit from patient-specific probabilities that assist with decisions for drug therapy interventions.

Decision analysis as a quality-assurance screening tool.

BACKGROUND: The purpose of this pilot study was to examine whether the technique of decision analysis, including sensitivity analysis, could be used in a clinical quality-assurance program. METHODS: This research was performed in a family practice residency clinical practice. A computerized decision analysis model was developed for selection of initial drug therapy for hypertension. The medical records of 52 resident-managed patients with hypertension were then reviewed. The residents' drug prescribing was evaluated by faculty reviewers and also by the decision analysis model, including a sensitivity analysis. RESULTS: Faculty reviewers rated the residents' drug choices as "most appropriate" or "acceptable" in 59.6% of cases. There was good agreement between faculty reviewers and the computerized decision analysis model. For example, in those cases in which the resident chose the computer model's first-choice drug, faculty deemed the management as "most appropriate" or "acceptable" 93.3% of the time. When residents selected the computer model's third or fourth choice, faculty judged the residents' therapy as "inappropriate" or "an alternate drug would have been more desirable" in 61.9% of cases. CONCLUSION: The results suggest that computerized decision analysis techniques may be a useful adjunct to other clinical quality-assurance procedures in residency training programs.

A model of lifetime osteoporosis impact.

The study goal was to use population-based data to model aspects of lifetime osteoporosis impact not previously studied, specifically: (1) to estimate person-years of fracture-related functional impairment against the trajectory of functional status in the general population; (2) jointly to consider hip, vertebral, and Colles' fractures in estimating the percent of women who will ever fracture; and (3) to estimate the lifetime number of fractures expected in a cohort of 10,000 50-year-old white postmenopausal women. The model estimates that 54% of 50-year-old women will sustain osteoporosis-related fractures during their remaining lifetimes. Beyond the functional impairment expected in similarly aged, unfractured women, osteoporosis-related fractures are estimated to cause 6.7% of women to become dependent in basic activities of daily living; 7.8% are expected to require nursing home care for an average of 7.6 years.