International Relations and Global Health

1. Write in brief about the effect of globalization on infectious diseases.

As transborder mobility of humans, animals, food, and feed products increases, so does the
threat of the spread of dangerous pathogens and infectious disease. While new global markets
have created unprecedented economic opportunities and growth, the benefits have not been
equally distributed, and the risks--especially the health risks--of our increasingly interconnected
and fast-paced world continue to grow.
Although the burden is greatest for the developing world, infectious diseases are a growing
threat to all nations. However, the same globalizing forces that creates such rampant
opportunity for pathogens also can provide mechanisms for innovative, global efforts to control
infectious diseases. A new network of international public health partners is emerging.
Multinational partnerships are contributing to the increased availability of drugs and vaccines,
the development of healthcare infrastructures in developing countries, and better public health
education programs worldwide. The global proliferation of technology and information has the
potential to improve the identification, surveillance, containment, and treatment of disease in
both developed and developing countries. Growing international cooperation may lead to more
robust and transparent reporting regarding disease outbreaks and control efforts. Distance
learning, training, and research exchange programs are creating improved access for scientific
and medical professionals.
Globalization is by no means a new phenomenon; transcontinental trade and the movement of
people date back at least 2,000 years, to the era of the ancient Silk Road trade route. The global
spread of infectious disease has followed a parallel course. Indeed, the emergence and spread
of infectious disease are, in a sense, the epitome of globalization. By Roman times, world trade
routes had effectively joined Europe, Asia, and North America into one giant breeding ground
for microbes. Millions of Roman citizens were killed between 165 and 180 AD when smallpox
finally reached Rome during the Plague of Antoninus. Three centuries later, the bubonic plague
hit Europe for the first time (542–543 AD) as the Plague of Justinian. It returned in full force as

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the Black Death in the fourteenth century, when a new route for overland trade with China
provided rapid transit for flea-infested furs from plague-ridden Central Asia.

Even before the development of world trade routes, however, human pathogens had
experienced two major bonanzas. First, when people lived as hunter-gatherers, they were
constantly on the move, making it difficult for microbes to keep up with their human hosts.
Once people started living as farmers, they began residing in larger numbers in the same
place—and were in daily contact with their accumulating feces—for extended periods of time.
Second, the advent of cities brought even larger numbers of people together under even worse
sanitary conditions. In the Middle Ages, when people threw human waste out their windows in
England, they were said to be “blessing the passerby.”

Now, two millennia later, human pathogens are experiencing yet another bonanza from a new
era of globalization characterized by faster travel over greater distances and worldwide trade.
Although some experts mark the fall of the Berlin Wall as the beginning of this new era, others
argue that it is not so new. Even a hundred years ago, at the turn of the nineteenth century, the
tremendous impact of increased trade and travel on infectious disease was evident in the
emergence of plague epidemics in numerous port cities around the world. As Echenberg (2002)
notes, plague epidemics in colonial African cities were closely tied to the increased
communication, travel, and trade that accompanied the advent of the steamship. The economic
and social impacts of these epidemics were profound. In Johannesburg, in what is now South
Africa, the occurrence of plague led to the relocation of black residents in an effort to remove
what the white colonists believed was the source of the disease. At about the same time, the
influenza pandemic killed many millions of people worldwide.

Thus the current era of globalization is more properly viewed as an intensification of trends that
have occurred throughout history. Never before have so many people moved so quickly
throughout the world, whether by choice or force. Never before has the population density
been higher, with more people living in urban areas. Never before have food, animals,
commodities, and capital been transported so freely and quickly across political boundaries.

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And never before have pathogen had such ample opportunity to hitch global rides on airplanes,
people, and products. The future of globalization is still in the making. Despite the successful
attempts of the developed world during the course of the last century to control many
infectious diseases and even to eradicate some deadly afflictions, 13 million people worldwide
still die from such diseases every year

2. Explain the different types of Complementary and Alternative Medicine

(CAM) practiced in India.

Complementary and alternative medicine (CAM) refers to the array of therapies that extend
beyond conventional Western medical treatments. The term complementary describes

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treatments used in conjunction with standard care, and the term alternative relates to less
conventional methods of treatment. In recent years, the term “integrative health” has been
used to describe the incorporation of evidence-based CAM therapies into conventional
treatments for the purpose of enhancing overall health.
People seeking treatment for a range of mental health concerns may find some complementary
or alternative treatment approaches to be helpful when these treatments are undertaken with
the knowledge and support of a mental or medical health professional.
The branch of medical care referred to as complementary and alternative medicine has been in
practice in some parts of the world, such as China and India and among the numerous tribes of
the indigenous American peoples, for hundreds of years. These traditional techniques may not
necessarily be considered "complementary" or "alternative." Before the 19th century,
medicine was considered a supplemental field, and many techniques now viewed as
complementary or alternative were mainstream at that time. Formal hospitals were rare, and
most doctors practiced medicine part-time while satisfying other roles like judge, magistrate,
farmer, or shop owner. At the start of the 19th century, conventional medicine began to take
form, and over the course of the next several decades, the medical field grew rapidly.
According to the definition used by the Cochrane Collaboration, ‘complementary and
alternative medicine’ is a broad domain of healing resources that encompasses all health
systems, modalities, practices and their accompanying theories and beliefs, other than those
intrinsic to the politically dominant health system of a particular society or culture in a given
historical period. CAM includes all such practices and ideas defined by their users as preventing
or treating illness or promoting health and well-being. Boundaries within CAM and between the
CAM domain and that of the dominant system are not always sharp or fixed According to
Eskinazi16, alternative medicine can be defined as a broad set of health-care practices (i.e.
already available to the public) that are not readily integrated into the dominant health care
model, because they pose challenges to diverse societal beliefs and practices (cultural,
scientific, medical and educational). This definition brings into focus factors that may play a
major role in the prior acceptance or rejection of various alternative health-care practices by
any society. Unlike criteria of current definitions, those of the proposed definition would not be

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expected to change significantly without significant societal change. Alternative medicine
comprises a large and heterogeneous group of treatments, many of which are procedures that
are not readily testable under double-blinded conditions. Furthermore, alternative medicine
therapies may also possess a theoretical basis, may stem from a cultural tradition that is
seemingly antithetical to a quantitative, biomedical framework, or may possess little
foundational research on which to base a controlled evaluation16. It is also argued that the
different sets of axioms in diverse systems require new modes of evidence than the currently
dominant chemical paradigm. In the 1970s and 1980s the therapeutics that were mainly
provided as an alternative to conventional health care were collectively known as ‘alternative
medicine’. The name ‘complementary medicine’ developed as the two systems began to be
used alongside (to complement) each other. Over the years, ‘complementary’ has changed
from describing this relationship between unconventional health-care disciplines and
conventional care to defining the group of disciplines itself. Some authorities use the term
‘unconventional medicine’, synonymously. Other terms that are also used for CAM are
unproven, unorthodox, fraudulent, dubious, integrative, questionable, quackery17, irregular,
unscientific and naturopathic, propaganda-based medicine19 and opinion-based medicine15.
Such a diversity of labels bespeaks of judgmental attitudes, conditioned by cultural beliefs.
According to Fontanarosa and Lundberg there is no alternative medicine. There is only
scientifically-proven, evidence-based medicine supported by solid data or unproven medicine,
for which scientific evidence is lacking. Whether a therapeutic practice is ‘Eastern’ or ‘Western’,
is conventional or mainstream, or involves mind–body techniques or molecular genetics is
largely irrelevant, except for historical purposes and cultural interests.

 Ayurvedic Medicine
Practiced in India for more than 5,000 years, ayurvedic tradition holds that illness is a state of
imbalance among the body's systems that can be detected through such diagnostic procedures
as reading the pulse and observing the tongue. Nutrition counseling, massage, natural
medications, meditation, and other modalities are used to address a broad spectrum of
ailments.

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 Naturopathic Medicine
Naturopathic physicians work to restore and support the body's own healing abilities using a
variety of modalities including nutrition, herbal medicine, homeopathic medicine, and orient
medicine. A primary health-care system which emphasizes the curative power of nature,
treating both acute and chronic illnesses in all age groups.

 Homoeopathy
A medical system that uses infinitesimal doses of natural substances - called remedies - to
stimulate a person's immune and defense system. A remedy is individually chosen for a sick
person based on its capacity to cause, if given in overdose, physical and psychological
symptoms similar to those a patient is experiencing. Common conditions hoeopathy addresses
are infant and childhood diseases, infections, fatigue, allergies, and chronic illnesses such as
arthritis.

 Unani
Involves the use of plants and herbs, these remedies are known to provide cures for diseases
such as sinusitus , leucoderma, rheumatism, jaundice and elephantiasis.

3. What do you mean by Global health? Write in brief of Emerging and

Remerging diseases.

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Koplan et al. define global health as: ‘an area for study, research, and practice that places a
priority on improving health and achieving health equity for all people worldwide’. This is a
useful definition with a broad focus on health improvement and health equity. However, it is
wordy and uninspiring.
Kickbush defines global health as: ‘those health issues that transcend national boundaries and
governments and call for actions on the global forces that determine the health of people’ (7).
This definition also has a broad focus but has no clear goal, is passive in its call for action, and
omits the need for collaboration and research. Elsewhere, the European Foundation Centre
calls for a European approach which makes global health a policy priority across all sectors
based on a global public goods foundation.

Emerging and remerging diseases

Infectious diseases are dominant public health problem even in the 21st Century. WHO
estimates 25% of the total 57 million annual deaths that occur worldwide are caused by
microbes and this proportion is significantly higher in the developing world. There has been a
remarkable progress in the prevention, control and even eradication (Smallpox) of infectious
diseases with improved hygiene & development of antimicrobials and vaccines. But tragically,
with optimism came a false sense of security, which has helped many diseases to spread with
alarming rapidly. Emerging & Re-emerging zoonotic diseases, food borne and waterborne
diseases & diseases caused by multi resistant organism constitute the major threats in India.

“Emerging infectious diseases are those due to newly identified and previously unknown
infections which cause public health problems either locally or internationally”. In the past 20
years, at least 30 new diseases have emerged to threaten the health of hundreds of millions of
people.

The factors responsible for emergence and re-emergence of infectious diseases are :
 Unplanned and under-planned urbanization
 overcrowding and rapid population growth
 Poor sanitation

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  Inadequate public health infrastructure;
 Resistance to antibiotics
 Increased exposure of humans to disease vectors and reservoirs of infection in nature
 Rapid and intense international travel
 Practice of modern medicine and relaxation in immunization practices
 Deforestation
 Failure to control carriers or breakdown in water and sanitation systems
 Changes in genetic make up of the pathogen
 High risk human behaviour
 Channelling of funds to other problems

Fifty years ago many people believed the age-old battle of humans against infectious disease
was virtually over, with humankind the winners. The events of the past two decades have
shown the foolhardiness of that position. At least a dozen "new" diseases have been identified
(such as AIDS, Legionnaire disease, and hantavirus pulmonary syndrome), and traditional
diseases that appeared to be "on their way out" (such as malaria and tuberculosis) are
resurging. Globally, infectious diseases remain the leading cause of death, and they are the
third leading cause of death in the United States. Clearly, the battle has not been won.
Emerging infectious diseases are diseases that have not occurred in humans before (this type
of emergence is difficult to establish and is probably rare); have occurred previously but
affected only small numbers of people in isolated places (AIDS and Ebola hemorrhagic fever are
examples); or have occurred throughout human history but have only recently been recognized
as distinct diseases due to an infectious agent (Lyme disease and gastric ulcers are examples).

Re-emerging infectious diseases are diseases that once were major health problems globally or
in a particular country, and then declined dramatically, but are again becoming health problems
for a significant proportion of the population (malaria and tuberculosis are examples). Many
specialists in infectious diseases include re-emerging diseases as a subcategory of emerging
diseases.

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4. Write short notes.
a. Recent epidemics which have occurred throughout the world.
 Ebola virus disease
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The Ebola virus causes an acute, serious illness which is often fatal if untreated. Ebola virus
disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks, one in what is now, Nzara,
South Sudan, and the other in Yambuku, Democratic Republic of Congo. The latter occurred
in a village near the Ebola River, from which the disease takes its name.
The 2014–2016 outbreak in West Africa was the largest and most complex Ebola outbreak
since the virus was first discovered in 1976. There were more cases and deaths in this
outbreak than all others combined. It also spread between countries, starting in Guinea then
moving across land borders to Sierra Leone and Liberia.
The virus family Filoviridae includes three genera: Cuevavirus, Marburgvirus, and Ebolavirus.
Within the genus Ebolavirus, five species have been identified: Zaire, Bundibugyo, Sudan,
Reston and Taï Forest. The first three, Bundibugyo ebolavirus, Zaire ebolavirus, and Sudan
ebolavirus have been associated with large outbreaks in Africa. The virus causing the 2014–
2016 West African outbreak belongs to the Zaire ebolavirus species.

 Avian influenza A(H7N9) virus

Avian influenza A(H7N9) is a subtype of influenza viruses that have been detected in birds in
the past. This particular A(H7N9) virus had not previously been seen in either animals or
people until it was found in March 2013 in China. However, since then, infections in both
humans and birds have been observed. The disease is of concern because most patients have
become severely ill. Most of the cases of human infection with this avian H7N9 virus have
reported recent exposure to live poultry or potentially contaminated environments,
especially markets where live birds have been sold. This virus does not appear to transmit
easily from person to person, and sustained human-to-human transmission has not been
reported.

 Middle East respiratory syndrome coronavirus (MERS-CoV)

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Middle East respiratory syndrome (MERS) is a viral respiratory disease caused by a novel
coronavirus (Middle East respiratory syndrome coronavirus, or MERS‐CoV) that was first
identified in Saudi Arabia in 2012. Coronaviruses are a large family of viruses that can cause
diseases ranging from the common cold to Severe Acute Respiratory Syndrome (SARS).
Typical MERS symptoms include fever, cough and shortness of breath. Pneumonia is
common, but not always present. Gastrointestinal symptoms, including diarrhoea, have also
been reported. Some laboratory-confirmed cases of MERS-CoV infection are reported as
asymptomatic, meaning that they do not have any clinical symptoms, yet they are positive for
MERS following a laboratory test. Most of these asymptomatic cases have been detected
following aggressive contact tracing of a laboratory-confirmed case. Approximately 35% of
reported patients with MERS have died. Although the majority of human cases of MERS have
been attributed to human-to-human infections in health care settings, current scientific
evidence suggests that dromedary camels are a major reservoir host for MERS-CoV and an
animal source of MERS infection in humans. However, the exact role of dromedaries in
transmission of the virus and the exact route(s) of transmission are unknown.
The virus does not seem to pass easily from person to person unless there is close contact,
such as occurs when providing unprotected care to a patient. Health care associated
outbreaks have occurred in several countries, with the largest outbreaks seen in Saudi Arabia,
United Arab Emirates, and the Republic of Korea.

 Pandemic (H1N1) 2009

This is an influenza virus that had never been identified as a cause of infections in people
before the current H1N1 pandemic. Genetic analyses of this virus have shown that it
originated from animal influenza viruses and is unrelated to the human seasonal H1N1
viruses that have been in general circulation among people since 1977.
Antigenic analysis has shown that antibodies to the seasonal H1N1 virus do not protect
against the pandemic H1N1 virus. However, other studies have shown that a significant
percentage of people age 65 and older do have some immunity against the pandemic virus.
This suggests that some people in the older age group may have some cross protection from
exposure to viruses that have circulated in the more distant past.

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After early outbreaks in North America in April 2009 the new influenza virus spread rapidly
around the world. By the time WHO declared a pandemic in June 2009, a total of 74 countries
and territories had reported laboratory confirmed infections. To date, most countries in the
world have confirmed infections from the new virus.
Unlike typical seasonal flu patterns, the new virus caused high levels of summer infections in
the northern hemisphere, and then even higher levels of activity during cooler months in this
part of the world. The new virus has also led to patterns of death and illness not normally
seen in influenza infections. Most of the deaths caused by the pandemic influenza have
occurred among younger people, including those who were otherwise healthy. Pregnant
women, younger children and people of any age with certain chronic lung or other medical
conditions appear to be at higher risk of more complicated or severe illness. Many of the
severe cases have been due to viral pneumonia, which is harder to treat than bacterial
pneumonias usually associated with seasonal influenza. Many of these patients have required
intensive care.

 Influenza at the Human-Animal Interface (HAI)

Animal influenza viruses are distinct from human seasonal influenza viruses and do not easily
transmit between humans. However, zoonotic influenza viruses - animal influenza viruses
that may occasionally infect humans through direct or indirect contact - can cause disease in
humans ranging from a mild illness to death. Birds are the natural hosts for avian influenza
viruses. After an outbreak of A(H5N1) virus in 1997 in poultry in Hong Kong SAR, China, since
2003, this avian and other influenza viruses have spread from Asia to Europe and Africa. In
2013, human infections with the influenza A(H7N9) virus were reported in China.
Most swine influenza viruses do not cause disease in humans, but some countries have
reported cases of human infection from certain swine influenza viruses. Close proximity to
infected pigs or visiting locations where pigs are exhibited has been reported for most human
cases, but some limited human-to-human transmission has occurred. Just like birds and pigs,
other animals such as horses and dogs, can be infected with their own influenza viruses
(canine influenza viruses, equine influenza viruses, etc.).

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b. Essential drugs
World Health Organization (WHO) introduced the concept of essential drugs in 1977.
Essential drugs are those that satisfy the priority health care needs of the population. They

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are selected with due regard to public health relevance, evidence on efficacy and safety, and
comparative cost-effectiveness. Essential drugs are intended to be available within the
context of functioning health systems at all times in adequate amounts, in the appropriate
dosage forms, with assured quality and adequate information, and at a price the individual
and the community can afford. The implementation of the concept of essential drugs is
intended to be flexible and adaptable to many different situations; exactly which medicines
are regarded as essential remains a national responsibility. Experience has shown that careful
selection of a limited range of essential medicines results in a higher quality of care, better
management of medicines (including improved quality of prescribed medicines), and a more
cost-effective use of available health resources. The WHO has developed the first essential
drugs list in 1977 and since then the list has been revised every 2 years. The current one is
the 15th model list released in 2007. The essential drugs list contains limited cost-effective
and safe medicines, while the open pharmaceutical market is flooded with large number of
medicines many of which are of doubtful value. The model list of WHO serves as a guide for
the development of national and institutional essential drugs list. The concept of essential
drugs has been worldwide accepted as a powerful tool to promote health equity and its
impact is remarkable as the essential drugs are proved to be one of the most cost-effective
elements in health care.
This concept of essential drugs is relatively new to India and Tamil Nadu is the first state to
develop the essential drugs list as early as in 1994. Then government of Delhi too had
developed its own list. The government of India and many other individual states have their
own essential medicines lists, and the current national list was compiled during 2003.
Unfortunately, the list is not regularly up dated except for Tamil Nadu. As the list needs to be
developed locally and should be based on evidence not merely on individual's experience, it
is necessary first to develop clinical guidelines, called standard treatment guidelines (STG).
Then based on STG the list is compiled. Delhi took the lead in developing a comprehensive
Drug Policy in 1994 and was the only Indian state to have such a comprehensive policy. The
policy's main objective is to improve the availability and accessibility of quality essential drugs
for all those in need. Now many state governments too have developed STG for use within

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the state government health facilities. The Armed Forces Medical College (AFMC) has
developed STGs for quite large number of common conditions and the treatment cost is also
calculated.
Public health being a state subject, primary responsibility of free distribution of essential
drugs at public health facilities is that of State/Union Territory (UT) Governments. However,
under National Health Mission (NHM), financial and technical support is being extended to
States/UTs for free distribution of essential drugs to all those who access public health
facilities based on the proposals submitted by the States/UTs. The states are incentivized to
roll out free/subsidized provision of drugs. Roughly around Rs. 3000 -3300 Crores per annum
are being spent by the Central Government (during 2013-15) for encouraging the supply of
essential medicines by the States and UTs as per a press release dated 11 August 2015. In
addition, in 2008, Government launched the Jan Aushadi Scheme to make available generic
drugs at affordable prices to citizens and to encourage the prescription of generic medicines
rather than the branded ones. Union Government has also released operational guidelines/
standard operating procedures for facilitating states in the free provision of drugs,
diagnostics services and mobile medical units.

c. Reasons and effects of irrational use of drugs

There are many factors that contribute to the irrational prescribing or use of medicines.
These factors can be traced to various stages of the medicine use cycle, and can be broadly

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categorized into those emanating from patients, prescribers, workplace (health system),
supply system (including industry influences), regulation, drug information or misinformation,
or a combination of these factors. Uninformed patients who may have the perception that
there exists a pill for every ailment can exert undue pressure on health providers to prescribe
medicines, even when this is not needed. The influence of patients in the prescription of
certain drugs such as antibiotics has been widely documented . Macfarlane et al. for instance,
investigated the impact of patients’ pressure on antibiotic prescribing in the management of
acute lower respiratory tract illness at 76 primary care facilities in the UK. Their results
indicated that, of the patients evaluated, 74% were prescribed antibiotics, and that non-
clinical factors influenced prescribing 44% of those receiving antibiotics, of which patient
pressure was the reason in more than half. Additionally, doctors often find it difficult to
refuse prescribing for children, the elderly, persons well known to them, as well as individuals
they like. Regarding prescriber-related factors, irrational prescribing can arise as a result of
several internal or external factors. For instance, the prescriber may lack adequate training,
or there may be inadequate continuing education, resulting in the reliance on out-dated
prescribing practices which may have been learnt while under training. The lack of
opportunities for on-job continuing education is a challenge faced by many health
professionals in resource-poor countries. Moreover, workplace issues, such as lack of
laboratory facilities typical of many resource-poor settings may promote inappropriate
prescribing. For instance, a prescriber may want to conduct laboratory investigation to
confirm the presence of infection, but may have to resort to empirical treatment if laboratory
facilities are unavailable. Even where laboratory facilities are available, prescribers may be
reluctant to use them due to other factors, such as time constraints. In a study in Ghana by
Polage et al., for instance, over 90% of physicians indicated that time constraints meant that
they rarely ordered tests. Other issues, such as under-staffing, medicine shortages, and a lack
of an inventory of a list of medicines from which choices need to be made are some of the
factors known to promote irrational prescribing in many developing countries. There are also
practices by pharmaceutical companies that are seen to enhance irrational prescribing. For
instance, pharmaceutical sales representative visits to doctors have been found to not only

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increase the prescription of the promoted drug, but also to lead to a decrease in the market
share of competitor products. There is evidence to support that pharmaceutical sales
representatives often exaggerate the efficacy of their products while questioning the
integrity of competitor brands, and may even encourage off-label use. Over-reliance on such
sources of information could lead to irrational prescribing. A systematic review by Spurling et
al. regarding the information from pharmaceutical companies and the quality, quantity, and
cost of physicians’ prescribing identified that physician exposure to information from drug
companies sometimes resulted in lower prescribing quality.
The impact of irrational medicines use can vary widely. Firstly, when medicines are used
inappropriately, the risks of adverse drug reactions (ADRs) is increased, especially in geriatric
patients or in co-morbid individuals who may have compromised physiologic functions. For
instance, in a retrospective cohort study among older people in Australia, the presence of
comorbidity was a strong predictor of repeat admissions for ADRs, especially in those with
comorbidities which are being managed in the community. The cost implications of ADRs can
also be enormous. In Germany, for instance, ADRs are estimated to cost more than €430
million annually, whereas in the UK, the cost of emergency admissions subsequent to an ADR
has been estimated at £2 billion per year . According to the Nobel Laureate Joshua Lederberg,
“the future of humanity and microbes will evolve as episodes...of our wits versus their
genes”. Lederberg points out that bad human practice, such as the inappropriate use of
antibiotics is one the key factors underlying the global insurgence of antimicrobial resistance.
For instance, studies have shown that subtherapeutic antibiotic concentration contributes to
the development of antibiotic resistance by promoting genetic alterations, including changes
in gene expression and mutagenesis. The occurrence of antimicrobial resistance is seen not
only as a threat to the progress made in health, but one which can potentially draw humanity
back to periods like the pre-antibiotic era, where many individuals suffered and died from
untreatable bacterial infections. Irrational prescribing can also expose patients to the
possibility of developing drug dependence to certain medicines, such as pain killers and
tranquillizers. Inappropriate prescribing practices such as the overuse of injections can
expose patients to the contraction of certain injection-related conditions, such as abscesses,

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hepatitis B, and HIV/AIDS. Indiscriminate prescribing of injections can also increase workload,
as health professionals need to administer doses. When medicines are prescribed
indiscriminately, it may also exert a psychological effect on patients who may come to the
conclusion that there exists “a pill for every ill”, thereby causing a cycle of excessive demand
for medicines. In addition, the inappropriate use of medicines can lead to wastage of scarce
health resources, which can further reduce the availability of other vital medicines or
increase treatment cost. The WHO estimates that the appropriate use of medicines can result
in about 50%–70% cost-efficiency in medicines expenditure.
According to the WHO, irrational prescribing is a “disease” which is difficult to treat—
prevention is however possible. There exist various strategies to change patients’ and
prescribers’ behaviour towards the promotion of rational prescribing. These strategies can be
grouped broadly as targeted or system oriented approaches. Targeted approaches comprise
educational and managerial interventions, while system-oriented strategies include
regulatory and economic interventions. Educational interventions are often aimed at
persuading or informing, and this usually involves the use of printed materials, seminars, or
face-to-face contacts. However, according to Wettermark et al., educational interventions
may influence prescriber knowledge and awareness, but their effectiveness in changing
behaviour remains modest unless used in combination with other strategies. Managerial
strategies, on the other hand, are mainly aimed at guiding practice. Such managerial
interventions that may be employed include monitoring, supervision and feedback, the use of
a restrictive medicines list, drug utilization reviews, or the use of structured prescription
forms. An example in this case is the wise list in Sweden, which is an essential medicines list
(EML) with high adherence to just 200 medicines to improve physician familiarity with quality
medicines and reduce costs, which is supplemented with regular physician monitoring against
expert guidance. Economic strategies, on the other hand, are aimed at promoting positive
financial incentives while at the same time eliminating perverse incentives for prescribers.
Economic interventions that may be employed include the implementation of significant
changes in service providers’ reimbursement schemes or disallowing prescribers to sell
medicines themselves, which can remove the financial motivation for over-prescribing.

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Regulatory interventions utilize laws and regulations to influence prescribers’ practices
through restrictions and requirements. An example of such an approach includes allocating
each medicine a minimum level of prescriber or health facility; e.g., no injectable antibiotics
at primary health care centres, mandatory generic substitution at pharmacies, or requiring
prior authorization before the prescription of some medicines, as is the case for the
pharmaceutical benefits scheme in Australia. In order for an intervention to be very effective,
it must focus specifically on an identified prescribing behavior and be targeted at the facilities
or prescribers in greatest need of improvement. In many instances, multiple interventions
may have to be deployed to drive the necessary changes. Of note, again, is the fact that
efforts to promote rational medicine/prescribing should be multifaceted in nature, and must
also target aspects of patient and community behavior.

5. Fill in the blanks:

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a. Disease burden is expressed in terms of Disability Adjusted Life Years (DALY).
b. Among the Millennium Development Goals goal 4: Reduce child mortality, goal 5:
Improve maternal health, and goal 6: Combat HIV/AIDS, malaria and other diseases are
health related.
c. Mutation means change in the genetic structure of microorganism.
d. Vaccines have enabled the global eradication of small pox and regional elimination of
polio and measles.
e. World-health day is celebrated on 7th April of every year.

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