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Free energy change of a biological reactions is reported as the standard free energy change 0’ (ΔG ) 0’- ΔG is the value of ΔG for a reaction at standard conditions for biological reactions (pH 7 carafate 1000mg on-line gastritis diet what can i eat, o 1M order carafate cheap gastritis define, 25 C cheap carafate line gastritis what to avoid, 1 atmosphere pressure) Free energy change is used to predict the direction and equilibrium of chemical reactions If ΔG is negative – net loss of energy (exergonic) - reaction goes spontaneously If ΔG is positive - net gain of energy (endergonic) reaction does not go spontaneously If ΔG is zero- reactants are in equilibrium C - Oxidation-Reduction Reactions The utilization of chemical energy in living system involves oxidation – reduction reactions. For example, the energy of chemical bonds of carbohydrates, lipids and proteins is released and captured in utilization form by processes involving oxidation- reductions. Determined by measuring the electromotive force generated by a sample half-cell with respect to standard reference half- cell Anegative E’o = lower affinity for electrons A positive E’o = higher affinity for electrons - H + 2e H2 E’o = - 0. In biological systems the primary electron donors are fuel molecules such as carbohydrates, fats and proteins. The free-energy change of an oxidation – reduction reaction can be calculated from the difference in reduction potentials of the reactants using the formula: O ΔG ’= - nFΔE’o Where n= 2 (No of electrons transferred) F= 23. This occurs by the help of energy conserving system in the inner mitochondrial membrane of eukaryotes or plasma membrane of prokaryotes. The fuel molecules are metabolized to a common intermediate called aceyl CoA which is further degraded by a common pathway called Kreb’s cycle. This metabolic pathway in addition to providing energy provides building blocks required for growth, reproduction, repair and maintenance of cellular viability. Structurally it is bounded by two separate membranes (outer mitochondrial membrane and inner mitochondrial membrane) Out membrane - smooth and unfolded - Freely permeable to most ions and polar molecules (Contain porous channels) Inner membrane - folded into cristae-increased surface area - Highly impermeable to most ions and polar molecules Contain transporters which access polar and ionic molecules in and out Cristae are characteristic of muscle and other metabolically active cell types - Protein-rich membrane (about 75%) Inter membrane space – space between outer and inner membranes Matrix-the internal compartment containing soluble enzymes and mitochondrial genetic material Fig 3. Inside matrix pyruvate is oxidized into acetylCoA by pyruvate dehydrogenase complex which is complex of E1, E2 and E3 enzymes. Reactions take place in cytosol of prokaryotes and mitochondria matrix of eukaryotes 63 Fig 3. Considerable free energy is lost as heat due to hydrolysis of thisester bond (drive the reaction forward). Isomerization of citrate to isocitrate by aconitase Aconitase contains iron - sulfer (Fe:S) cluster that assists the enzymatic activity fluoroacetate (potent rodenticide) inhibits aconitase with the ultimate effect of blocking Kreb’s cycle and oxidative phosphorylation. Oxidative decarboxylation of α- ketoglutarate by α - ketoglutarate dehydrogenase complex α-ketoglutarate is structurally and functionally similar to pyruvate dehydrogenase complex of three enzymes (A’ B’ C’) 66 A’ (α - ketoglutarate dehydrogenase), B’ (transuccinylase), C’ (dihydrolipoyl dehydrogenase). This enzyme has the same coenzyme requirement to that of pyruvate dehydrogenase complex. Transfer and accept two electrons at a time Cytochromes – heme conjugated proteins 2+ 3+ Heme = Fe /F + porphyrin Include classes of cytochromes designated a, b, and c. Iron at the center of cytochromes accept and donates single electron 2+ 3+ - Cytochrone Fe Cytochrome – Fe + e (reduced) (Oxidized) Cytochrome with relatively less positive reduction potential (i. CoQ and cytochrome C are mobile electron carriers which act as a link between the complexes. The free energy released is captured at three sites to pump protons against concentration gradient from matrix to inter membrane space generating proton gradient across inner mitochondrial membrane. As a result of this pH gradient is also formed, more positive (acidic) on the outer side more negative (basic) on the inner side of mitochondria. Now the kinetic energy of electrons is transformed into the proton – motive force. They also dissolve the vitamins, which are fat-soluble and assist their digestion. Complex lipids:- Esters of fatty acids and alcohols together with some other head groups. Glycolipids:- Lipids containing fatty acid, sphingosine and carbohydrate residues. Others:- Include sulfolipids, amino lipids and lipoproteins, which are modified forms of lipids. The simplest naturally occurring lipids are triacylglycerols formed by esterification of fatty acids with glycerol. Mostly the double bond occurs at the 9 carbon as we count from the carboxyl group end. In a different way the position of the double bond(s) can be indicated as shown in the second expression without the delta. Poly unsaturated fatty acids are released from membranes, diverted for the synthesis of prostaglandins, leukotriens and thromboxanes. They act as fat mobilizing agents in liver and protect liver from accumulating fats (fatty liver). Triacylglycerols or also called as triacylglycerides, exist as simple or mixed types depending on the type of fatty acids that form esters with the glycerol. Both saturated and/or unsaturated fatty acids can form the ester linkage with the backbone alcohol. Structure of phosphatidate Phosphatidate is the parent compound for the formation of the different glycerophospholipids. If choline is attached it is called phosphatidyl choline (lecithin), if ethanolamine is attached it is called phosphatidyl ethanolamine. The second largest membrane lipids are sphingolipids, which contain two non-polar and one polar head groups. One unit shall definitely be N-acetyl neuraminic acid (sialic acid) 6% of grey brain matter is ganglioside. Cerebrosides:- These are glycolipids which have no phosphate group but neutral head group and contain one or two sugar groups usually glucose or Galactose Functions of phospholipids 1. Phospholipids are components of membrane; impart fluidity and pliability to the membrane. Dipalmitoyl choline (lecithin) acts as surfactant and lowers the surface tension in alveoli of lungs. Lecithin along with sphingomyelin maintains the shape of alveoli and prevents their collapse due to high surface tension of the surrounding medium. Some premature infants can’t secrete lecithin; therefore suffer from respiratory distress syndrome. Steroids are complex fat-soluble molecules, which are present in the plasma lipoproteins and outer cell membrane. Cholesterol is one of the important non fatty acid lipid that is grouped with steroids. Cholesterol is important in many ways: • For the synthesis of bile salts that are important in lipid digestion and absorption. Digestion and Absorption of Lipids Diet contains triglycerides, cholesterol and its ester, phospholipids, fattyacids etc. Thus 3 fatty acids and one glycerol molecule is produced from the digestion of dietary triglyceride. Phospholipase B acts on Lysophospholipid, produces glycerophosphoryl choline and free fatty acid. Cholesterol esterase hydrolyses cholesterol ester to free cholesterol and one fatty acid. Cholesterol, long chain fatty acids are esterified and absorbed in form of micelles. Impaired secretion of lipases from the pancreas and bile salts from liver results in failure in fat absorption and causes steatorrea (excessive passage fatty stool).

However cheap carafate generic gastritis quick cure, now that chronic non-infectious diseases prevail carafate 1000 mg on line juice diet gastritis, its efficacy has not only become ques- tionable order carafate with paypal alcoholic gastritis definition, but also the issue has been raised of its economic justification. The extension of biomedical approach and attri- bution of equal importance to psychosocial factors have become an imperative in the improvement of treatment efficacy and disease control, together with humanisation of relations between health staff and patients. A new biopsychosocial model has been suggested, that takes into account all relevant determinants of health and disease and that supports the integration of biological, psychological and social factors in the assessment, prevention and treatment of diseases. It does not diminish the significance of biological factors, but extends a rather narrow approach. The biopsychosocial model served as incentive for many studies o how psychological and social factors influence the development, course and out- come of a disease, giving rise to the development of interdisciplinary field – particularly the fields of health psychology and psychoneuroimmunology. Their contribution to better understanding of the impact of psychosocial factors on health stimulates greater interest of medical theory and practice in more holistic approach to a patient. However, the changes of the old, organ oriented approach are still too slow and too narrow. Key words: biopsychosocial model, health psychology, behavioural medicine Introduction The assumption that disease is not exclusively the Such an organ-oriented medical practice stimulates disorder occurring at the cellular, tissue, and organ lev- the development of medical techniques and procedures els, but rather the state of the organism as a whole with that extend the knowledge about cell, tissue and organ equally important effects of biological, psychological and functioning, and by which the mechanisms of develop- social factors, is practically as old as the written history ment and treatment of certain somatic diseases can be re- of mankind. However, by not taking into account wider psycho- still today, after ample scientific evidence about close in- social aspects of diseases, such organ oriented approach terrelation between biological, social and psychological has little to offer in guiding the kind of preventive efforts factors in health issues and development of disease, in that are needed to reduce the incidence of chronic diseases medical theory and practice there still dominate biomedi- by changing health beliefs, attitudes and behaviour. Internal causes of disease oped as direct consequence of dissatisfaction with official fall into three large categories – vascular, immunologic medicine2. The role of a physi- ther development of technology, scientific research and cian was to help in the establishment of healing condi- new medical knowledge are viewed upon as the future tion, serving as a mediator between the patient and the universal remedy that will soon solve health problems of nature4. The subordination of medicine to nature was a humans and eradicate all severe diseases. It is ment of natural sciences, specifically chemistry, molecu- implied in the emphasis which Hippocrates places on the lar biology, pharmacology, physics, electronics – undoubt- control of the patient s regimen, especially the elements edly substantiate these hopes. The discovery of »intelli- of his diet, the exercise and the general circumstances of gent drugs«, major improvement in the efficiency and ac- his life. Medicines or drugs perform an auxiliary func- curacy of diagnostic procedures, marked enhancement of tion. The physician must surgical techniques, successful revealing of tumour de- combat the disease along with the patient and must velopment mechanism, all to the revolutionary decipher- therefore know the patient as an individual, and all the ing of human genome, significantly contribute to the relevant circumstances of his life as well as particular cir- strengthening of the position of those who are in favour cumstances of the disease. The practice of medicine thus of organic and technology oriented visions of medical appears to require more than scientific knowledge of practice development. It requires the knowledge and skills not be denied, the dominance of such an approach could to persuade the patient to cooperate. The man, not the lead not only to further dehumanisation of relations be- disease, is to be treated, and to treat him well, physician tween medical staff and their patients, but socially even must examine the man as a whole, not merely the organ more dangerous situation occurring as a result of such an or body part in which the disorder seems to be located. Indeed, these early assumptions The causes can be traced far back in ancient history of multiple actions of various factors on health are the and are mostly related to fundamental philosophical con- beginning of present-day holistic approach to health, the cern about the relation between soul and body, i. This everlasting philo- over the responsibility for one’s own health by employing sophical and religious dilemma was in different historical the forms of behaviour that preserve health and treat periods addressed in different ways and from different disease. The holism of that time, when the personality of a pa- The History of Biomedical Approach tient was more important than the disease, gradually dis- appeared in later years. The earliest systematically written evidence on the Galen, a much more influential physician of ancient knowledge about the relation between soul and body, be- time, directed the early holistic concept elaborated by tween physiological, or organic, and psychological, can be Hippocrates toward searching »local pathology«, i. Treatment of the disorders part as if it could be when in disharmony – the harmony being influenced by isolated from the living unity of the whole man is, to external, natural factors, hence its lack results in di- Galen, one of the deplorable consequences in medical sease3. In these early writings the signs of multifactorial practice of atomism or mechanism in medical theory[4]. Although even at that time man body was forbidden, Galen came to a conclusion the dualistic approach prevailed in the understanding of that practically all diseases were caused by pathological soul and body, still the human behaviour was considered lesions in organs and that different lesions caused differ- an important factor in health and in treatment of disease. He was of opinion that there was not any The balance of body humours, considered the most im- disease that could develop without evident disorders in portant health factors, could be achieved by proper be- certain parts of the body. Treatment started to be based exclusively on one-dimen- sional model of disease, i. In medieval period in Europe the development of The consequences of such a narrow approach may be medicine underwent significant regression and so did seen in exclusive focusing of medical procedures on chan- other ideas and knowledge about body-mind relations. It ging the disease condition by surgical, radiological, phar- was not before the 13th century that new ideas about macological and similar methods, which is almost a me- body-mind relations appear. Saint Thomas Aquinas, a fa- chanical approach to disease where human body is viewed mous philosopher of the Dominican order, rejected in his as a complex organic mechanism that the physicians will writings the idea of soul and body as separate entities. The assumption The new position within the Church itself, actualised by here is that there is strict division between the non-ma- the only recognised philosopher and scientist at that terial spirit, i. Every the perennial problem of body-mind relations, the inter- change in bodily function thus occurs separately from ests that by the beginning the Renaissance led to wide the changes in mental functions, and vice versa. Yet ginning of the 15 century was for a long time strongly the efficacy of biomedical model became highly question- influenced by French philosopher Rene Descartes and able when massive new non-infectious chronic diseases his categorical opinion about body and mind being com- occurred, in the development of which there participated pletely separated. Although Descartes was of opinion numerous risk factors, among which a great number of that mind and body could communicate through certain 4 psychological and social factors. The new diseases could not nisms of digestive and other body systems, the discovery be efficiently controlled by extensive vaccination of the of a microscope; for all of these medicine turned toward population nor merely organ-oriented therapeutic meth- looking for physiological causes and means of treatment ods. The model became too narrow and the need to over- of most common bodily illnesses. Diagnostic efficacy and come it was substantiated by ever increasing scientific treatment of diseases are significantly improved, espe- evidence about psychological and social effects on health cially when microorganisms as causative agents of many and disease. The introduction of hy- In his paper »The need for a new medical model«, gienic measures, e. Prevention of diseases by vaccination fur- new bio biopsychosocial model by which he supports the ther increases the efficacy of treatment and strengthens integration of biological, psychological and social factors the biomedical concept of disease. However, despite the evident efficacy, more and more According to Engel the biomedical model is a reduc- criticism is addressed to the biomedical concept, the most tionistic one since it is based on the philosophical princi- common one being that it reduces the disease to the low- ple that complex problems are derived from simple pri- est level, i. Furthermore, it is a sin- also, that it is dualistic in terms of separating the mental gle-factorial model describing diseases only as a disorder from somatic processes. Engel further states that the in biological functioning of the body; it is based on dual biomedical model has almost become a medical dogma re- concept of body and mind; it considers body and mind to quiring that all diseases, including the mental ones, be be two separate entities in spite of ample scientific evi- conceptualised on primarily physical, chemical and other dence of complex interactions between body and mind; it biological mechanisms. He also claims that the border- over-emphasises disease, ignoring health and important line between disease and health has never been clear and 305 M. Relations between biological, psychological and social aspects in biosociopsychological model of health and disease (according to Serafino3). Engel provides concrete reasons for which he is of The Role of Biopsychosocial Model opinion that new approach is needed in modern medi- cine, like for instance, that patients with the same diag- The role of biopsychosocial model is particularly im- nosis and laboratory tests can present with completely portant in the studies of how psychological stress affects different course of disease for different psychosocial cha- the development of somatic diseases, since they have racteristics; that for proper diagnosis it is necessary to identified numerous facts about the interactions between extensively interview the patient during which impor- the nervous, endocrine, immune and other organic sys- tant, not only biomedical, information can be obtained tems in stressful situations. Many mechanisms of direct for correct diagnosis and treatment method; that psy- influence of stress on single organ and system functions chosocial factors often determine whether the patients have been established together with the indirect ones, considers her/himself sick or in need for medical assis- like for instance increase in stress induced risk beha- tance; that psychosocial factors are interrelated with the viour6. Wide evidence of the accuracy of Melzack and biological ones to the extent that they may influence the Wall’s holistic pain theory, i. Such an in- physicians and not psychologists or sociologists, the bio- teraction takes place within one unique system specific psychosocial model has contributed more to structural for each individual, a system within which all three ma- changes in psychology and sociology. In medicine the jor subsystems communicate by exchanging information, model provided the greatest contribution in the develop- energy and other substances. The centre of interest in ment of preventive programs in public health and the biopsychosocial model is not the disease but a sick indi- smallest in clinical medical practice. In the diagnosis and treatment, beside medical ence is significant in education of medical professionals procedures, the model employs all other methods related in terms of introducing many behavioural sciences topics to psychological and social aspect, i.

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Poor health purchase 1000 mg carafate mastercard atrophic gastritis symptoms uk, both individual and public carafate 1000mg with visa helicobacter pylori gastritis diet, along with lack of education and lack of an enabling political structure 1000 mg carafate gastritis smoking, are major impediments to a country’s development and are the roots of poverty. Poor health impoverishes nations and poverty causes poor health, in part related to inadequate access to quality healthcare. Healthcare costs for respiratory diseases are an increasing burden on the economies of all countries. If one considers the lost productivity of family members and others caring for these individuals, the cost to society is far greater. Furthermore, studies show that underdiagnosis ranges 72–93%, which is higher than that reported for hypertension, hypercholesterolemia and similar disorders. Smoke exposure in childhood may predispose to the development of chronic lung disease in adult life [18]. This measure will also greatly reduce the morbidity and mortality of other lung diseases. Identifcation and reduction of exposure to risk factors are essential to prevent and treat the disease, and avoiding other precipitating factors and air pollution is important. Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators can help patients with frequent exacerbations and severe airfow obstruction. Patients with low levels of oxygen in their blood may require supplemental oxygen. Maintaining physical ftness is key because difculty breathing may lead to a lack of activity and subsequent deconditioning. Vaccination against seasonal infuenza may reduce the risk of severe exacerbations triggered by infuenza. Asthma Scope of the disease Asthma aficts about 235 million people worldwide [1] and it has been increasing during the past three decades in both developed and developing countries. Although it strikes all ages, races and ethnicities, wide variation exists in diferent countries and in diferent groups within the same country. It is the most common chronic disease in children and is more severe in children in non-afuent countries. In these settings, underdiagnosis and under-treatment are common, and efective medicines may not be available or afordable. It is one of the most frequent reasons for preventable hospital admissions among children [20, 21]. In some studies, asthma accounts for over 30% of all paediatric hospitalisations and nearly 12% of readmissions within 180 days of discharge [21]. Genetic predisposition, exposure to environmental allergens, air pollution, dietary factors and abnormal immunological responses all promote the development of asthma. The timing and level of exposure to allergens and irritants may be crucial factors leading to the development of disease. Early viral infections and passive tobacco smoke exposure have been associated with the development of asthma in young children. Airborne allergens and irritants associated with asthma occur in the workplace and can lead to chronic and debilitating disease if the exposure persists. Prevention The cause of most asthma is unknown and thus its prevention is problematic. People who smoke and have asthma have a much more rapid decline in lung function than those who do not smoke. Avoiding smoking during pregnancy and avoidance of passive smoke exposure afer birth can reduce asthma severity in children. Occupational asthma has taught us that early removal of allergens or irritants may ablate or reduce the disease. Treatment Asthma is a generally a lifelong disease that is not curable, but efective treatment can alleviate the symptoms. They also reduce the need for reliever inhalers (rapid-acting bronchodilators) and the frequency of severe episodes (“exacerbations”) requiring urgent medical care, emergency room visits and hospitalisations. Unfortunately, many people sufering from asthma do not have access to efective asthma medicines. Universal access to efective, proven therapies for controlling asthma and treating exacerbations is an essential requirement to combat this disease. Lack of availability of medicines is not the only reason that people with asthma do not receive efective care. Widespread misconceptions about the nature of the disease and its treatment ofen prevent people from using the most appropriate treatments. Educational campaigns to encourage the use of inhaled corticosteroids and avoidance of exposures that trigger asthma attacks are an important part of efective asthma control programmes. Control or elimination Research is critical to better understand the origins of asthma, the causes of exacerbations and the reasons for its rising worldwide prevalence. Making inhaled corticosteroids, bronchodilators and spacer devices widely available at an afordable price, and educating people with asthma about the disease and its management are key steps to improve outcomes for people with asthma. Policy-makers should develop and apply efective means of quality assurance within health services for respiratory diseases at all levels. Strategies to reduce indoor air pollution, smoke exposure and respiratory infections will enhance asthma control. Acute respiratory infections Scope of the disease Respiratory infections account for more than 4 million deaths annually and are the leading cause of death in developing countries [24]. Since these deaths are preventable with adequate medical care, a much higher proportion of them occur in low-income countries. In children under 5 years of age, pneumonia accounts for 18% of all deaths, or more than 1. In Africa, pneumonia is one of the most frequent reasons for adults being admitted to hospital; one in ten of these patients die from their disease. Viral respiratory infections can occur in epidemics and can spread rapidly within communities across the globe. Every year, infuenza causes respiratory tract infections in 5–15% of the population and severe illness in 3–5 million people [10]. Its lethality mobilised international eforts that rapidly identifed the cause and the method of spread. Stringent infection control measures reduced its spread and were so efective that no further cases were identifed [26]. This is in stark contrast to the 1918 infuenza pandemic that claimed the lives of between 30 and 150 million persons. Primary prevention strategies for respiratory infections are based on immunisation programmes that have been developed for both viruses and bacteria. Vaccines are efective against these agents, as well as measles and pertussis (whooping cough). Treatment Most bacterial respiratory infections are treatable with antibiotics and most viral infections areions are self-limited. The failure to prevent these deaths largelyhs largelyy results from lack of access to healthcare or the inability of the healthcare system to care for thesefor thesseee individuals. The most efective way to manage these diseases is through standard case management. Case management is defned as “a collaborative process of assessment, planning, facilitation, carecare coordination, evaluation, and advocacy for options and services to meet an individual’s andand family’s comprehensive health needs through communication and available resources to promoteo promomoootetetee quality cost-efective outcomes” [27].

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Kemp and Joanne Neale order carafate 1000 mg without prescription gastritis green tea, “Employability and problem drug 55 Impacts of Drug Use on Users and Their Families in Afghanistan buy genuine carafate on-line gastritis green tea. In particular order carafate with paypal gastritis pain remedy, the stigmatizing attitudes towards people who use drugs 8 that may extend to staff in health-care services can get in the way of their ability to deliver effective treatment to drug users. Third, addi- the perceived threat of needle-related injuries and of trans- tional barriers may arise from social circumstances, such mission of blood-borne viruses. Fourth, many people with drug use disorders may for hepatitis C, and 65 per cent reported that such dis- be acutely aware that limited skills, poor or no qualifica- crimination was a result of being a drug user, with females tions, gaps in their work history, particularly related to more likely than males to experience discrimination imprisonment, and a criminal record can make looking because of their status with regard to hepatitis C. Furtado, “Stigmati- zation of alcohol and other drug users by primary care providers in Southeast Brazil”, Social Science and Medicine, vol. Spencer and others, Getting Problem Drug Users (Back) into drug use: the realities of stigmatization and discrimination”, Health Employment (London, United Kingdom Drug Policy Commission, Education Journal, vol. The lead to high levels of incarceration (for a more detailed implementation of evidence-based programmes remains discussion, see the subsection entitled “Criminal at very low levels of coverage in many parts of the world67 justice”). In Myanmar, for example, alternative develop- ment projects in Wa Special Region 2 resulted in several benefits on the health front: vaccinations reduced infant Drug demand reduction efforts and the entire continuum mortality and eliminated leprosy among children; and of care for people who use drugs, when successful, reduce electricity and potable water were brought to some town- drug use and therefore its impact on public health. Drug use prevention programmes have also been in Dir District, Khyber Pakhtunkhwa (formerly North- shown to lead to a decrease in a range of other risky West Frontier Province), resulted in the provision of drink- behaviours, such as aggressiveness and truancy. Alternative devel- but it takes a well-developed framework to implement opment programmes often create and strengthen social them effectively. Even at the level of monitoring the extent organizations and generally enhance the level of organiza- of drug use, developed countries are typically better placed tion of rural communities, enabling progress on various than developing countries to assess the extent of the prob- fronts, especially when such programmes encourage the lem. For example, heroin use in Europe has undergone a direct participation of beneficiaries in the design, planning significant decline in recent years, and this improvement and implementation of projects. The results are also enhanced when the linked to the objective of drug control, which is to ensure interventions employ and expand the use of evidence- access to controlled drugs for medical and research pur- based tools systematically. In the pream- of care interventions can be even more effective when it ble to the Single Convention on Narcotic Drugs of 1961 incorporates evidence-based measures aimed at minimizing as amended by the 1972 Protocol, the parties to the Con- the adverse public health and social consequences of drug vention recognized that the medical use of narcotic drugs abuse, including appropriate medication-assisted therapy continues to be indispensable for the relief of pain and programmes, injecting equipment programmes as well as suffering and that adequate provision must be made to ensure the availability of narcotic drugs for such purposes. Wilson and others, “The cost-effectiveness of harm reduc- 65 “International standards for the treatment of drug use disorders: tion”, International Journal of Drug Policy, vol. Economic aspects can also have an in the management of pain and other medical uses, in impact on the evolution of illicit drug markets, as varia- some countries the strategies in place to prevent the abuse, tions in income levels and purchasing power may influence misuse and diversion of controlled substances may some- drug consumption patterns. Human has an impact on illicit drug markets, the drug problem Rights Watch reviewed the national drug control strategies can also have economic ramifications. The economic cost of 29 countries and found that 25 of them failed to iden- of drug use that is incurred, for example, when drug-using tify the issue of ensuring availability of controlled sub- segments of the workforce do not receive adequate treat- stances for medical and scientific use as an objective or to ment, can impact on productivity. These aspects are discussed below, in the sections on economic development and environmental sustainability. Impact of economic development on the drug problem Furthermore, when the response to illicit drug use neglects the health aspects of drug use and treats the problem exclu- One way to look at how economic development affects sively as a criminal offence, excessively focusing on pun- the drug problem is to compare the latter across different ishment, consequences can ensue for the well-being of countries on the basis of their economic development. These aspects are discussed below, in the sub- multitude of factors that can play a role in shaping the section on criminal justice. Proximity to a drug-pro- Finally, when the response to the drug problem fails to ducing area or to a major drug trafficking route, for exam- take into account the particular needs of women, it may ple, explains more than economic development the higher contribute to undermining the objectives of gender parity than global rates of opiate use in the Near and Middle East and of the empowerment of women and girls. This applies and South-West Asia or the higher rates of cocaine use not only to direct interventions against the drug problem (including “crack” cocaine) in South America and West but also to the monitoring of drug use, as women are likely Africa. Nevertheless, a global macrolevel analysis can still to be under-represented in research identifying prevalence, provide insights into how economic development may needs, risks and outcomes of drug use, leading to a gap in have a bearing on the drug problem, although the rela- tionship between development and the drug problem needs to be viewed in dynamic terms. Drugs: A Review of Their Risks, Experiences and Needs (Sydney, 70 Human Rights Watch, “National drug control strategies and access National Drug and Alcohol Research Centre, University of New to controlled medicines” (2015). As figures 8 and 9 show, cocaine is the the prevalence of past-year use of cocaine in South America drug most clearly associated with high income. The asso- is not very different from the figure for North America, ciation between the problem of drug use and development the majority of cocaine users in the United States use can also be noted in terms of disability-adjusted life years cocaine in salt form, whereas in South America the use of (see figure 3, page 65). Moreover, some of the “products” con- Development and the evolution of drug use sumed in base form in South America are siphoned off and consumer markets from intermediate stages of the cocaine-processing chain, Drugs that command a relatively high price, and ulti- when they may still contain high levels of impurities and mately greater profits for traffickers, may find an easier are thus usually considered to have less potential to fetch foothold in countries with relatively higher levels of per high prices. Although historically there have been dif- smoking) in the United States is believed to be obtained ferent dynamics (including licit use) that have triggered from a reverse step that reverts to base form (in this case, the onset of the use of certain drugs, it is likely that income “crack”) from salt form. Another possible illustration of levels play an important role in enabling drug use to take this pattern is the case of the domestic heroin market in hold and consolidate. Reports by the Government of India indicate that ties show the magnitude of the amounts spent on drugs: heroin in the domestic retail market is considered to be of in 2010, people in the United States who used a drug at “low value” and that this reflects a distinct market from least four times a month spent an average of $10,600 a the heroin transiting India from Afghanistan and headed year on cocaine, $17,500 on heroin and $7,860 on meth- for other destinations. This is particularly the case for cocaine and socioeconomic well-being, such as income levels and heroin, which originate in confined and well-defined areas employment status, are only visible at the subnational or of production, creating a scenario in which consumers community level. In contrast, cannabis and, to a certain extent, some the section entitled “Social development”). The study ten- some of them becoming cocaine or heroin transit areas), tatively suggests that, given typical transaction sizes in whereas the same cannot be said of the prevalence rates of practice, the minimum cost for achieving intoxication was cannabis use, which have tended to be even higher than frequently lower. The use of unprocessed drugs such as cate that the median costs of “crack” and cocaine transac- opium and coca leaf remains largely confined to the places tions are comparable ($27 for cocaine salt versus $25 for in which they are cultivated, where they have been used “crack” cocaine). Because of their different modes of for centuries, while their derivatives have not always found administration, the typical experience associated with a large market in the countries of origin. Heroin use, for “crack” use is shorter but reportedly more intense than example, is quite low in Latin American countries, that of cocaine salt, so it can be argued that users of cocaine although opium is cultivated in the subregion and is also salt would need to spend more to achieve the same level processed into heroin. The differences may also extend to the poten- tial for users to develop tolerance and dependence. Just as different drug categories display different patterns, different drug subcategories may also explain some of the complexities of illicit drug markets. Kilmer and others, What America’s Users Spend on Illegal Drugs: 75 Kilmer and others, What America’s Users Spend on Illegal Drugs: 2000-2010 (Santa Monica, California, Rand Corporation, 2014). Generally, even though wealthy societies appear to be more This pattern is also consistent with data on drug use in vulnerable to drug consumption, within those societies, Colombia, which show very distinct patterns for past-year economic and social disadvantage is a significant risk factor drug use and for drug use disorders in different socioeco- for drug consumption to translate into drug dependence nomic classes. Poverty is associated with drug use example, there is a progressive increase in rates of occa- disorders, not because of any link with discretionary sional (past-year) use with higher levels of socioeconomic income but because poor people are more vulnerable and status (see figure 10), but overall drug use disorders are more likely to live on the margins of society. Higher socioeconomic groups may play a separate role in facilitating the onset of recreational use as a first step in the subsequent formation and consolidation of illicit drug As mentioned earlier, poverty is a significant risk factor markets. The mechanisms that drive this interaction merit for drug use; conversely, drug use itself frequently places further study, but they may be attributable to a higher a significant strain on the finances of people with drug propensity to experiment, higher income levels, higher dependence and on their families’ finances. The extent of association with an urban location of residence and dif- the financial strain brought about by drug use may be related not only to the price of a drug but also to the ferent patterns of entertainment among people in the potential of the person using the drug to develop a toler- higher socioeconomic brackets. A study on cannabis use ance to that particular drug, and hence to its pharmaco- demonstrated this phenomenon by drawing on evidence logical properties. In the case of heroin, for example, it is from France, Germany and the United States. The study believed that experienced users may seek much higher showed how, at the outset, it was mostly well-educated doses than first-time users. People with fewer economic men in the countries examined who started to experiment resources who use drugs may also be exposed to higher with cannabis use. Gradually, this shifted to men with low levels of harm as they resort to cheaper variants of drugs. Women followed at lower rates and Lower prices may be associated with lower purity levels, the change was not as marked; moreover, the people who which imply higher health risks because of the presence transitioned to daily cannabis use were predominantly 76 of adulterants, by-products and other substances.