Thursday, October 31, 2019

Crime and Punishment Assignment Example | Topics and Well Written Essays - 2000 words

Crime and Punishment - Assignment Example As a result, countries like America reflect increasing number of prisoners as recorded over the years. However psychologists are still continuing their researches on the causes of crimes and trying to decipher why individuals are entering the criminal justice system (Benson 2003). The basic roles of a prison system include: social isolation and confinement, repentance, punishment and deterrence, protection and reformation. A prison system leads to an isolation of the prisoner from the society such that the man’s violations of the legal system do not affect the lives of the common people. It is expected that he would repent on his wrong deeds if kept isolated. Also, with some pain and suffering, it would create some fears among the criminals. It is also the role of the prison system to protect the society from criminals which can be achieved through captivating the criminals. Reformation is the role that is focused on changing the attitude and mental condition of the individual s such that they do not repeat crimes (Bura 2012). Rehabilitation proves to be an essential role of the prison system since it is the prime motive of the justice system to rehabilitate the individuals who have committed crime. If rehabilitation is not focused, then bad people would only turn into worse. Instead, rehabilitation functions to restore the lives of the criminals by changing their mental condition, health conditions and their attitudes trying to prevent them from committing crimes again. Only then these individuals would be able to live normal lives once they are back into the society (Tanner 2012). Effectiveness of Prisons for Rehabilitation: The Present Day Situation: With the rates of punishment being increased and less focus being given on the resettlement needs of the criminals, the rehabilitation of the offenders in the prison system has become less likely to achieve in the present times. It is observed that most of the prisoners who are released are re-offending an d are taken back to prisons. This reflects the fact that the present day prison system is not proving to be effective in rehabilitating the prisoners and instead turning the mental state into worse through punishment measures (Cavadino 2006). Conclusion: Thus from the above study, it can be realized that although it is the role of the prison to make the criminals realize of their wrongdoings and rehabilitate them such that they can lead normal lives without affecting the society, yet in the present times the prison systems have proved not to be effective enough for rehabilitation of individuals, with their focus being more eon punishing the criminals and not correcting them as is needed. Task 2: Prison Does Not Work: Introduction: Prison punishments have been expected to prevent crimes and correct the mental attitudes of the criminals. Yet in the present times it is observed that prison overcrowding has become one of the major causes of concerns, particularly in countries like the A merica. Similar situation is observed in other countries as well presenting a doubt on whether the modern day prison system works or not (Big Question: Does the modern prison system work? 2013). Prison: The Dominant Form of Punishment: The use of prisons for punishing criminals had been into existence since over 200 years ago. Before

Tuesday, October 29, 2019

Discussion Essay Example | Topics and Well Written Essays - 250 words - 141

Discussion - Essay Example It comprises of both the internal and external attributes of the business. Selecting output as an indicator demonstrates to the customers that the firm values environmental, economic and social development. It also illustrates that Coca-Cola considers product safety and the changing customer demands. Hence, reporting on the firms output and giving the consumers a chance to contribute towards the same improves Coca Colas public image (Pride, Hughes & Kapoor, 2014). Customers behavior is an indicator of satisfaction or the reverse. Incorporating it gives Coca Cola an opportunity to gauge the products progress. A dissatisfied consumer base is an indication that the firm should invest in product innovation. It also enables efficient marketing and formulation of pricing mechanisms. Therefore, observing customer behaviors through comments, photos guides policy formulation and organizational culture. A customers attitude can result in either high profits or loss to the business. A bad attitude lowers the profit margin while a positive attitude enhances sales. Therefore, taking into consideration the customers attitudes gives Coca-Cola a competitive edge. It also facilitates product awareness across the globe (Pride, Hughes & Kapoor,

Sunday, October 27, 2019

Research into Rational Drug Prescribing in Yemen

Research into Rational Drug Prescribing in Yemen CHAPTER 1 1.0 Introduction In Yemen as well as in many other developing countries the quality of health services which constitute social indicators of justice and equity is far from being satisfactory. Inappropriate, ineffective, and inefficient use of drugs commonly occurs at different health facilities (Abdo-Rabbo, 1993; Abdo-Rabbo, 1997). Irrational prescribing is a habit, which is difficult to cure. This may lead to ineffective treatment, health risks, patient non-compliance, drug wastage, wasteful of resources and needless expenditure. According to the Yemeni constitution, â€Å"patients have the right to health care and treatment† i.e. appropriate care, consent to treatment and acceptable safety. Therefore, health workers should concentrate on making patients better and patients should concentrate on geting better. Health care in general and particularly the drug situation in any country is influenced by the availability, affordability, and accessibility of drugs as well as the prescribing practices. There are many individuals or factors influence the irrational prescribing such as patients, prescribers, workplace environment, the supply system, including industry influences, governments regulations, drug information and misinformation (Geest S. V. et al, 1991; Hogerzeil H. V., 1995).Improving rational use of drugs (RUD) is a very complex task worldwide because changing behavior is very difficult. The 1985 Nairobi conference on the rational use of drugs marked the start of a global effort to promote rational prescribing (WHO,1987). In 1989, an overview of the subject concluded that very few interventions to promote rational drug use had been properly tested in developing countries (Laing et al., 2001). The selection of drugs to satisfy the health needs of the population is an important component of a national drug policy. The selected drugs are called essential drugs which are the most needed for the health care of the majority of the population in a given locality, and in a proper dosage forms. The national list of essential drugs (NEDL) is based on prevailing health conditions, drug efficacy, safety, and quality, cost- effectiveness and allocated financial resources. WHOs mission in essential drugs and medicines policy is to help save lives and improve health by closing the huge gap between the potential that essential drugs have to offer and the reality that for millions of people particularly the poor and disadvantaged medicines are unavailable, unaffordable, unsafe or improperly used. The organization works to fulfill its mission in essential drugs and medicines policy by providing global guidance on essential drugs and medicines, and working with countries to implement national drug policies to ensure equity of access to essential drugs, drug quality and safety, and rational use of drugs. Development and implementation of national drug policies are carried out within the overall national health policy context, with care taken to ensure that their goals are consistent with broader health objectives. All these activities ultimately contribute to all four WHO strategic directions to: reduce the excess mortality of poor and marginalized populations reduce the leading risk factors to human health develop sustainable health systems,and develop an enabling policy and institutional environment for securing health gains. The greatest impact of WHO medicines activities is, and will continue to be, on reducing excess mortality and morbidity from diseases of poverty, and on developing sustainable health systems. The people of our world do not need to bear the present burden of illness. Most of the severe illness that affects the health and well-being of the poorer people of our world could be prevented. But first, those at risk need to be able to access health care — including essential medicines, vaccines and technologies. Millions cannot — they cannot get the help they need, when they need it. As a result they suffer unnecessarily, become poorer and may die young. A countrys health service cannot respond to peoples needs unless it enables people to access essential drugs of assured quality. Indeed, this access represents a very important measure of the quality of the health service. It is one of the key indicators of equity and social justice. (Dr Gro Harlem Brundtland, Director-General, World Health Organization Opening remarks, Parliamentary Commission on Investigation of Medicines, Brasilia, 4 April 2000). 1.1 Background 1.1.1 Brief history of antibiotics According to the original definition by Waksman, antibiotics substances which are produced by microorganisms and which exhibit either an inhibitory or destructive effect on other microorganisms. In a wider, though not universally accepted definition; antibiotics are substances of biological origin, which without possessing enzyme character, in low concentrations inhibit cell growth processes (Reiner, 1982). Up to now, more than 4,000 antibiotics have been isolated from microbial sources and reported in the literature, and more than 30000 semi-synthetic antibiotics have been prepared. Of these, only about 100 are used clinically as the therapeutic utility not only depends on a high antibiotic activity but also on other important properties such as good tolerance, favorable pharmacokinetics etc. These antibiotics are today among the most efficient weapons in the armoury of the physician in his fight against infectious diseases. They are therefore used a large extent and constitute the largest class of medicaments with respect to turnover value. Today, antibiotics are also used in veterinary medicine and as additives to animal feed. In the past they were used addition, as plant protection agents and as food preservatives. In this review we have confined ourselves to a brief description clinicallyuseful antibiotics. These belong to various classes of chemical compounds, differ in origin, mechanism of action and spectrum activity, and are thus important and representative examples of known antibiotics. 1.1.2 Problem Statement This study examines drug use in Yemen and factors leading to inappropriate use of medicines particularly antibiotics and the prescribing pattern. It defines rational drug use and describes policy developments, which aim to encourage appropriate use. In Yemen, as well as in many developing countries, the quality of health services is far from being achieved. Therefore, doctors should concentrate on making patients better and patients should concentrate on getting better. The rational use of drugs requires that patients received medications in appropriate to their clinical needs, in doses that meets their own requirements for an adequate period of time and at the lowest cost to them and their community (Bapna et al, 1994). This means deciding on the correct treatment for an individual patient based on good scientific reasons. It involves making an accurate diagnosis, selecting the most appropriate drug from these available, prescribing this drug in adequate doses for a sufficient length of time according to standard treatment. Furthermore, it involves monitoring the effect of the drug both on the patient and on the illness. There is plentiful evidence of the inappropriate use of drugs, not through self-medication or unauthorized prescribing, but inadequate medical prescribing and dispensing. Normally, patients in Yemen enter health facilities with a set of symmetrical complaints, and with expectations about the care they typically receive; they typically leave with a package of drugs or with a prescription to obtain them in a private market. In previous study in Yemen (misuse of antibiotics in Yemen, a pilot study in Aden) (Abdo-Rabbo, 1997) showed that imported quantity and total consumption of antibiotics is increasing. There is a lack of information about the problems created from antibiotics among the community and about the proper efficacy, safety, and rational use of antibiotics among health authority and workers. No supervision or strict rules are applied in the use of antibiotics. They are easily obtained without prescription and available in some shops. The percentage of prescriptions containing antibiotics was more than a quarter of the total prescriptions contained antibiotics, also antibiotics constituted about 25% of all prescribed drugs. 1.1.2.1 Inappropriate Drug Use Increasing use of medicines may lead to an increase in the problems associated with medication use. The use of medicines, as well as improving health, can lead to undesirable medical, social, economic and environmental consequences. Aspects of drug use, which lead to such undesirable consequences, have been called inappropriate drug use (DHHCS, 1992; WHO, 1988). Inappropriate drug use may include under-use, over-use, over-supply, non-compliance, adverse drug reactions and accidental and therapeutic poisoning (DHHCS, 1992). It also includes medicating where there is no need for drug use, the use of newer, more expensive drugs when lower cost, equally effective drugs are available (WHO, 1988) and drug use for problems which are essentially social or personal (Frauenfelder and Bungey, 1985). 1.1.2.2 Quality Use of Medicines In an attempt to encourage the appropriate use of medicinal drugs and to reduce the level of inappropriate use in Yemen, a policy was developed on the quality use of medicines. The stated aim of the policy is: to optimise medicinal drug use (both prescription and OTC) to improve healthoutcomes for all Yemenis. The policy endorses the definition of quality drug use as stated by the World Health Organisation, Drugs are often required for prevention, control and treatment of illness†. When a drug is required, the rational use of drugs demands that the appropriate drug be prescribed, that it be available at the right time at a price people can afford, that it be dispensed correctly, and that it be taken in the right dose at the right intervals and for the right length of time. The appropriate drug must be effective, and of acceptable quality and safety. The formulation and implementation by governments of a national drug policy are fundamental to ensure rational drug use (WHO, 1987 ; DHHCS, 1992). The rational use of drugs can be impeded by the inappropriate selection of management options, the inappropriate selection of a drug when a drug is required, the inappropriate dosage and duration of drug therapy and the inadequate review of drug therapy once it has been initiated. 1.1.2.3 The Requirement of Drug Information for Quality Use of Medicines A medicine has been described as an active substance plus information. (WHO, 1994). Education, together with, objective and appropriate drug information have been two of the factors consistently identified as necessary for rational drug use (Naismith, 1988; Soumerai, 1988; Carson et al, 1991; Dowden, 1991; Henry and Bochner, 1991; Tomson and Diwan, 1991). The WHO guidelines for developing national drug policies also identify the importance of information provision for facilitating drug use: Information on and promotion of drugs may greatly influence their supply and use. Monitoring and control of both activities are essential parts of any national drug policy (WHO, 1988). Objective and appropriate drug information is a necessary factor for quality drug use. It is the basis for appropriate prescribing decisions by medical practitioners. Medical practitioners require objective product, specific drug information and comparative prescribing information. Objective drug information is avai lable to medical practitioners through continuing education programs co-ordinated by professional bodies, medical and scientific journal articles, drug information services and drug formularies and guidelines. 1.1.2.4 Problem with antibiotic use The concerns regarding inappropriate antibiotic use can be divided into four areas: efficacy, toxicity, cost, and resistance. Inappropriate use of antibiotic can be due to: Antibiotic use where no infection is present, e.g. continuation of peri-operative prophylaxis for more than 24 hours after clean surgery. Infection, which is not amenable to antibiotic therapy, e.g. antibiotics prescribed for viral upper respiratory infection. The wrong drug for the causative organism, e.g. the use of broad anti-Gram negative agents for community acquired pneumonia. The wrong dose or duration of therapy. Such inappropriate use has a measurable effect on therapeutic efficacy. For example, one study showed that mortality in gram-negative septicemia is doubled when inappropriate empiric agents were used (Kreger et al., 1980). Since most initial antibiotic therapy is empiric, any attempt at improving use must tackle prescribing habits, with particular emphasis on guidelines for therapy based on clinical criteria. Inappropriate antibiotic use exposes patients to the risk of drug toxicity, while giving little or no therapeutic advantage, antibiotics are often considered relatively safe drugs and yet direct and indirect side effects of their use are frequent and may be life-threatening, allergic reactions, particularly to beta-lactam agents are well recognized and have been described in reaction to antibiotic residues in food (Barragry, 1994). Life threatening side effects may be occur from the use of antibiotics for apparently simple infections, it is estimated, for example, that eight people per year in UK die from side effects of co-trimoxazole usage in the community (Robert and Edmond, 1998). Indirect side effects are often overlooked: especially as may occur sometime after the antibiotic has been given. These include drug interactions (such as interference of antibiotic with anti-coagulant therapy and erythromycin with antihistamine) (BNF, 1998), side effects associated with the administration of antibiotics (such as intravenous cannula infection) and super-infection (such as candidiasis and pseudomembranous colitis). Each of these may have a greater morbidity, and indeed mortality, than the initial infection for which the antibiotic was prescribed (Kunin et al., 1993). The medical benefit of antibiotics does not come cheap. In the hospital setting, up to fifty percent of population receive one antibiotic during their hospital stay, with surgical prophylaxis accounting for thirty percent of this (Robert and Edmond, 1998). The first penicillin resistant isolate of Staphylococcus aureus was described only two years after the introduction of penicillin. Within a decade, 90% of isolates were penicillin resistant. This pattern of antibiotic discovery and introduction, followedby exuberant use and rapid emergence of resistance has subsequently been repeated witheach new class of antibiotics introduced. Bacteria can so rapidly develop resistance due to two major evolutionary advantages. Firstly, bacteria have been in existence for some 3.8 billion years and resistance mechanisms have evolved over this time as a protective mechanism against naturally occurring compounds produced by other microorganisms. In addition, they have an extremely rapid generation time and can freely exchange genetic material encoding resistance, not only between other species but also between genera. The vast quantities of antibiotics used in both human and veterinary medicine, as a result present in the environment, have lead to eme rgence of infection due to virtually untreatable bacteria. Multiply drug resistant tuberculosis is already widespread in parts of Southern Europe and has recently caused outbreaks in hospitals in London (Hiramatsu et al., 1997). Anti-infective are vital drugs, but they are over prescribed and overused in treatment of minor disorder such as simple diarrhea, coughs, and colds. When antibiotics are too often used in sub-optimal dosages, bacteria become resistant to them. The result is treatment failure where patient continue to suffer from serious infections despite taking the medication (Mohamed, 1999). Drugs prescribed are in no way beneficial to the patient s management if there are some negative interactions among the various agent prescribed, over prescribed, under prescribed or prescribed in the wrong dosage schedule. How does one ensure that good drug are not badly used, misused, or even abused? How can drugs be used rationally as intended? What is rational use of drugs? What does rational mean? 1.1.3 Rational Use of Drug Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community (Bapna et al., 1994). These requirements will be fulfilled if the process of prescribing is appropriately followed. This will include steps in defining patients problems (or diagnosis); in defining effective and safe treatments (drugs and non-drugs); in selecting appropriate drugs, dosage, and duration; in writing a prescription; in giving patients adequate information; and in planning to evaluate treatment responses. The definition implies that rational use of drugs; especially rational prescribing should meet certain criteria as follows (Ross et al., 1992): Appropriate indication. The decision to prescribe drug(s) is entirely based on medical rationale and that drug therapy is an effective and safe treatment. Appropriate drug.The selection of drugs is based on efficacy, safety, suitability, and considerations. Appropriate patient. No contraindications exist and the likelihood of adverse reactions is minimal, and the drug is acceptable to the patient. Appropriate information. Patients should be provided with relevant, accurate, important, and clear information regarding his or her condition and the medication(s) that are prescribed. Appropriate monitoring. The anticipated and unexpected effects of medications should be: appropriately monitored (Vance and Millington, 1986). Unfortunately, in the real world, prescribing patterns do not always conform to these criteria and can be classified as inappropriate or irrational prescribing. Irrational prescribing may be regarded as pathological prescribing, where the above- mentioned criteria are not fulfilled. Common patterns of irrational prescribing, may, therefore be manifested in the following forms: The use of drugs when no drug therapy is indicated, e.g., antibiotics for viral upper respiratory infections, The use of the wrong drug for a specific condition requiring drug therapy, e.g., tetracycline in childhood diarrhea requiring ORS, The use of drugs with doubtful/unproven efficacy, e.g., the use of antimotility agents in acute diarrhea, The use of drugs of uncertain safety status, e.g., use of dipyrone, Failure to provide available, safe, and effective drugs, e.g., failure to vaccinate against measles or tetanus, failure to prescribe ORS for acute diarrhea, The use of correct drugs with incorrect administration, dosages, and duration, e.g., the use of IV metronidazole when suppositories or oral formulations would be appropriate. The use of unnecessarily expensive drugs, e.g., the use of a third generation, broad spectrum antimicrobial when a first-line, narrow spectrum, agent is indicated. Some examples of commonly encountered inappropriate prescribing practices in many health care settings include: (Avorn et al., 1982). Overuse of antibiotics and antidiarrheals for non-specific childhood diarrhea, Multiple drug prescriptions, prescribe unnecessary drugs to counteract or augment, Drugs already prescribed, and Excessive use of antibiotics in treating minor respiratory tract infection. The drug use system is complex and varies from country to country. Drugs may be imported or manufactured locally. The drugs may be used in hospitals or health centers, by private practitioners and often in a pharmacy or drug shop where OTC preparations are sold. In some countries, all drugs are available over the counter. Another problem among the public includes a very wide range of people with differing knowledge, beliefs and attitudes about medicines. 1.1.3.1 Factors Underlying Irrational Use of Drugs There are many different factors that affect the irrational use of drugs. In addition, different cultures view drugs in different ways, and this can affect the way drugs are used. The major forces can be categorized as those deriving from patients, prescribers, the workplace, the supply system including industry influences, regulation, druginformation and misinformation, and combinations of these factors (Table 1.1) (Ross et al., 1992). Table 1.1: Factors affecting irrational use of drug Impact of Inappropriate Use of Drugs The impact of this irrational use of drugs can be seen in many ways: (Avorn et al., 1982). Reduction in the quality of drug therapy leading to increased morbidity and mortality, Waste of resources leading to reduced availability of other vital drugs and increased costs, Increased risk of unwanted effects such as adverse drug reactions and the emergence of drug resistance, e.g., malaria or multiple drugs resistant tuberculosis, Psychosocial impacts, such as when patients come to believe that there is a pill for every ill. This may cause an apparent increased demand for drugs. 1.1.3.2 The Rational Prescription (i.e. the right to prescribe) The rights to prescription writing must be ensuring the patients five rights: the right drug, the right dose, by the right route, to the right patient, at the right time. Illegible handwriting and misinterpretation of prescriptions and medication orders are widely recognized causes of prescription error. The medicines should be prescribed only when they are necessary, should be written legibly in ink or, other wise, should be led, and should be signed in ink by the prescriber, The patients full name and address, diagnosis should be written clearly, the name of drugs and formulations should be written clearly and not abbreviated, using approved titles only. Dose and dose frequency should be stated; in the cases of formulations to be taken as required, a minimum dose should be specified (British National Formulary, 1998). 1.2 Overview on Essential Drug Concept (EDC) Essential drugs relate to an international concept proposed by the World Health Organization (WHO) in 1977. WHO in that year published the first model list of essential drug and WHO has put in enormous resources into the campaign to promote the concept of essential drugs (EDL). Essential drugs were defined as a limited number of drugs that should be available at any time to the majority of population in appropriate dosage forms and at affordable prices. In other words, it meets the criteria generally abbreviated as SANE [that mean safety , availability, need efficacy] (John, 1997). The essential drug concept is important in ensuring that the vast majority of the population is accessible to drugs of high quality, safety and efficacy relevant to their health care needs, and at reasonable cost (New Straits Times, 1997a). In support of this concept, the WHOissued a model drug list that provided examples of essential drugs. The list is drawn up by a group of experts based on clinical scientific merits, and provides an economical basis of drug use. This list is regularly, revised and, since 1997, eight editions have been published. This ensures that the need for essential drugs is always kept up-to-date with additions and deletions. Despite such rigorous revision, the number of drugs in the list remains at about 300, although the initial list comprised less. Most of the drugs are no longer protected by patents and can therefore be produced in quantity at a lower cost without comprising standards (WHO, 1995). This is indeed important for countries like Yemen not only because health care are rapidly escalating, but also because the country is still very dependent on imports of strategic commodities like drugs. The EDC will enable Yemen to focus on becoming self-reliant where generic equivalents of essenti al drugs can be manufactured and popularized to meet the health needs of the majority of the people. The limited number of drugs regarded as essential on the list offers a useful guide for practitioners as well as consumers. It underscores the general principle thata majority of diseases can be treated by similar drugs regardless of national boundaries and geographical locations (New Straits Times, 2000) Moreover, certain self-limiting diseases may not need drug treatment as such. For example, in the case of diarrhea, certain so-called potent anti-diarrhoeal drugs (including antibiotics) are not generally recommended. The more preferred treatment is oral rehydration salt that could easily be obtained or prepared at a fraction of the cost while giving the most optimum outcome. The goal of the Yemen Drug Policy was to: Prepare a list of essential drugs to meet the health of needs of the people. Assure that the essential drugs made available to the public are of good quality Improve prescribing and dispensing practices Promote rational use of drug by the public Lower cost of the drugs to the government and public Reduce foreign exchange expenditure 1.3 Yemen Essential Drug List and Drug Policy in Yemen The Concept of Essential Drugs (EDC) developed by World Health Organization (WHO) in 1977 has provided a rational basis, not only for drug procurement at national level but also for establishing drug requirements at various levels within the health care system. The WHOs Action Program on Essential Drugs (DAP) aimed to improve health care. It was established in order to provide operational support in the development of National Drug Policies (NDP), to improve the availability of essential drugs to the whole population and to work towards the rational use of drugs and consequently the patient care. The program seeks to ensure that all people, whenever they may be, are able to obtain the drugs they need at the lowest possible price; that these drugs are safe and effective; and that they are prescribed and used rationally. The first WHO Model List of Essential Drugs was published in 1977 (WHO, 1977). Since that time essential drugs become an important part of health policies in developing countries; but the Essential Drugs Program has been criticized because it emphasis in improving supply of drugs rather than their rational prescribing. The recent revised WHO Model List of Essential Drugs was published the 13th edition in April 2003 (WHO, 2003). Yemen was one of the first countries in the region adapted the EDC in 1984 and implemented this concept in the public sector (Hogerzeil et al., 1989). The first Yemen (National) Essential Drugs List (YEDL) was officially issued in 1987 based on the WHO List of Essential Drugs and other resources. The second edition of the Yemen Drugs list and the Yemen Standard Treatment Guidelines were published in 1996 (MoPHP/NEDL, (1996); MoPHP/NSTG, (1996).Recently the latest edition was published in 2001 with the Standard Treatment Guidelines (STG) in the same booklet (Mo PHP/YSTG and YEDL, 2001). The new edition of the Treatment Guidelines and the Essential Drugs List has been created through a long process of consultation of medical and pharmaceutical professionals in Yemen and abroad. Review workshops were held in Sanaa and Aden and more than 200 representatives of the health workers from different governorates including the major medical specialists participated. Essential drugs are selected to fulfil the real needs of the majority of the population in diagnostic, prophylactic, therapeutic and rehabilitative services using criteria of risk-benefit ratio, cost-effectiveness, quality, practical administration as well as patient compliance and acceptance (Budon-Jakobowiez, 1994). The YEDL was initially used for the rural health units and health centers as well as some public hospitals, but not applied for all levels of health care and the private sector. However, despite the recognition of the essential drug concept by the government of Yemen represented by the Ministry of Public Health and Population (MoPHP), drugs remain in short supply to many of the population and irrationally used. Procurement cost is sometimes needlessly high. Knowledge of appropriate drug use and the adverse health consequences remain unacceptably low. In addition, diminished funding in the public sector resulted in shortage of pharmaceuticals. The 20th century has witnessed an explosion of pharmaceutical discovery, which has widened the therapeutic potential of medical practice. The vast increase in the number of pharmaceutical products marketed in the last decades has not made drug available to all people and neither has resulted in the expected health improvement. While some of the newly invented drugs are significant advance in therapy, the majorities of drugs marketed as â€Å"new† are minor variations of existing drug preparations and do not always represent a significant treatment improvement. In addition, the vast number brand names products for the same drug increases the total number of products of this particular drug resulting in an unjustified large range of drug preparations marketed throughout the world. The regular supply of drugs to treat the most common diseases was a major problem for governments in low-income countries. The WHO recommends that activities to strengthen the pharmaceutical sector be organized under the umbrella of the national drug policy (WHO, 1988). In 1995, over 50 of these countries has formulated National Drug Policies (NDP). The NDP is a guide for action, containing the goals set by the government for the pharmaceutical sector and the main strategies and approaches for attaining them. It provides a framework to co-ordinate activities of patients involved in pharmaceutical sector, the public sector, the private sector, non-governmental organizations (NGOs), donors and other interested parties. A NDP will therefore, indicate the various courses of action to be in relation to medicines within a country. The Yemen National Drug Policy was developed since 1993 with the objectives of ensuring availability of essential drugs through equitable distribution, ensuring drugs efficacy and safety, as well as promoting the rational use of drugs. Unfortunately, it has n Research into Rational Drug Prescribing in Yemen Research into Rational Drug Prescribing in Yemen CHAPTER 1 1.0 Introduction In Yemen as well as in many other developing countries the quality of health services which constitute social indicators of justice and equity is far from being satisfactory. Inappropriate, ineffective, and inefficient use of drugs commonly occurs at different health facilities (Abdo-Rabbo, 1993; Abdo-Rabbo, 1997). Irrational prescribing is a habit, which is difficult to cure. This may lead to ineffective treatment, health risks, patient non-compliance, drug wastage, wasteful of resources and needless expenditure. According to the Yemeni constitution, â€Å"patients have the right to health care and treatment† i.e. appropriate care, consent to treatment and acceptable safety. Therefore, health workers should concentrate on making patients better and patients should concentrate on geting better. Health care in general and particularly the drug situation in any country is influenced by the availability, affordability, and accessibility of drugs as well as the prescribing practices. There are many individuals or factors influence the irrational prescribing such as patients, prescribers, workplace environment, the supply system, including industry influences, governments regulations, drug information and misinformation (Geest S. V. et al, 1991; Hogerzeil H. V., 1995).Improving rational use of drugs (RUD) is a very complex task worldwide because changing behavior is very difficult. The 1985 Nairobi conference on the rational use of drugs marked the start of a global effort to promote rational prescribing (WHO,1987). In 1989, an overview of the subject concluded that very few interventions to promote rational drug use had been properly tested in developing countries (Laing et al., 2001). The selection of drugs to satisfy the health needs of the population is an important component of a national drug policy. The selected drugs are called essential drugs which are the most needed for the health care of the majority of the population in a given locality, and in a proper dosage forms. The national list of essential drugs (NEDL) is based on prevailing health conditions, drug efficacy, safety, and quality, cost- effectiveness and allocated financial resources. WHOs mission in essential drugs and medicines policy is to help save lives and improve health by closing the huge gap between the potential that essential drugs have to offer and the reality that for millions of people particularly the poor and disadvantaged medicines are unavailable, unaffordable, unsafe or improperly used. The organization works to fulfill its mission in essential drugs and medicines policy by providing global guidance on essential drugs and medicines, and working with countries to implement national drug policies to ensure equity of access to essential drugs, drug quality and safety, and rational use of drugs. Development and implementation of national drug policies are carried out within the overall national health policy context, with care taken to ensure that their goals are consistent with broader health objectives. All these activities ultimately contribute to all four WHO strategic directions to: reduce the excess mortality of poor and marginalized populations reduce the leading risk factors to human health develop sustainable health systems,and develop an enabling policy and institutional environment for securing health gains. The greatest impact of WHO medicines activities is, and will continue to be, on reducing excess mortality and morbidity from diseases of poverty, and on developing sustainable health systems. The people of our world do not need to bear the present burden of illness. Most of the severe illness that affects the health and well-being of the poorer people of our world could be prevented. But first, those at risk need to be able to access health care — including essential medicines, vaccines and technologies. Millions cannot — they cannot get the help they need, when they need it. As a result they suffer unnecessarily, become poorer and may die young. A countrys health service cannot respond to peoples needs unless it enables people to access essential drugs of assured quality. Indeed, this access represents a very important measure of the quality of the health service. It is one of the key indicators of equity and social justice. (Dr Gro Harlem Brundtland, Director-General, World Health Organization Opening remarks, Parliamentary Commission on Investigation of Medicines, Brasilia, 4 April 2000). 1.1 Background 1.1.1 Brief history of antibiotics According to the original definition by Waksman, antibiotics substances which are produced by microorganisms and which exhibit either an inhibitory or destructive effect on other microorganisms. In a wider, though not universally accepted definition; antibiotics are substances of biological origin, which without possessing enzyme character, in low concentrations inhibit cell growth processes (Reiner, 1982). Up to now, more than 4,000 antibiotics have been isolated from microbial sources and reported in the literature, and more than 30000 semi-synthetic antibiotics have been prepared. Of these, only about 100 are used clinically as the therapeutic utility not only depends on a high antibiotic activity but also on other important properties such as good tolerance, favorable pharmacokinetics etc. These antibiotics are today among the most efficient weapons in the armoury of the physician in his fight against infectious diseases. They are therefore used a large extent and constitute the largest class of medicaments with respect to turnover value. Today, antibiotics are also used in veterinary medicine and as additives to animal feed. In the past they were used addition, as plant protection agents and as food preservatives. In this review we have confined ourselves to a brief description clinicallyuseful antibiotics. These belong to various classes of chemical compounds, differ in origin, mechanism of action and spectrum activity, and are thus important and representative examples of known antibiotics. 1.1.2 Problem Statement This study examines drug use in Yemen and factors leading to inappropriate use of medicines particularly antibiotics and the prescribing pattern. It defines rational drug use and describes policy developments, which aim to encourage appropriate use. In Yemen, as well as in many developing countries, the quality of health services is far from being achieved. Therefore, doctors should concentrate on making patients better and patients should concentrate on getting better. The rational use of drugs requires that patients received medications in appropriate to their clinical needs, in doses that meets their own requirements for an adequate period of time and at the lowest cost to them and their community (Bapna et al, 1994). This means deciding on the correct treatment for an individual patient based on good scientific reasons. It involves making an accurate diagnosis, selecting the most appropriate drug from these available, prescribing this drug in adequate doses for a sufficient length of time according to standard treatment. Furthermore, it involves monitoring the effect of the drug both on the patient and on the illness. There is plentiful evidence of the inappropriate use of drugs, not through self-medication or unauthorized prescribing, but inadequate medical prescribing and dispensing. Normally, patients in Yemen enter health facilities with a set of symmetrical complaints, and with expectations about the care they typically receive; they typically leave with a package of drugs or with a prescription to obtain them in a private market. In previous study in Yemen (misuse of antibiotics in Yemen, a pilot study in Aden) (Abdo-Rabbo, 1997) showed that imported quantity and total consumption of antibiotics is increasing. There is a lack of information about the problems created from antibiotics among the community and about the proper efficacy, safety, and rational use of antibiotics among health authority and workers. No supervision or strict rules are applied in the use of antibiotics. They are easily obtained without prescription and available in some shops. The percentage of prescriptions containing antibiotics was more than a quarter of the total prescriptions contained antibiotics, also antibiotics constituted about 25% of all prescribed drugs. 1.1.2.1 Inappropriate Drug Use Increasing use of medicines may lead to an increase in the problems associated with medication use. The use of medicines, as well as improving health, can lead to undesirable medical, social, economic and environmental consequences. Aspects of drug use, which lead to such undesirable consequences, have been called inappropriate drug use (DHHCS, 1992; WHO, 1988). Inappropriate drug use may include under-use, over-use, over-supply, non-compliance, adverse drug reactions and accidental and therapeutic poisoning (DHHCS, 1992). It also includes medicating where there is no need for drug use, the use of newer, more expensive drugs when lower cost, equally effective drugs are available (WHO, 1988) and drug use for problems which are essentially social or personal (Frauenfelder and Bungey, 1985). 1.1.2.2 Quality Use of Medicines In an attempt to encourage the appropriate use of medicinal drugs and to reduce the level of inappropriate use in Yemen, a policy was developed on the quality use of medicines. The stated aim of the policy is: to optimise medicinal drug use (both prescription and OTC) to improve healthoutcomes for all Yemenis. The policy endorses the definition of quality drug use as stated by the World Health Organisation, Drugs are often required for prevention, control and treatment of illness†. When a drug is required, the rational use of drugs demands that the appropriate drug be prescribed, that it be available at the right time at a price people can afford, that it be dispensed correctly, and that it be taken in the right dose at the right intervals and for the right length of time. The appropriate drug must be effective, and of acceptable quality and safety. The formulation and implementation by governments of a national drug policy are fundamental to ensure rational drug use (WHO, 1987 ; DHHCS, 1992). The rational use of drugs can be impeded by the inappropriate selection of management options, the inappropriate selection of a drug when a drug is required, the inappropriate dosage and duration of drug therapy and the inadequate review of drug therapy once it has been initiated. 1.1.2.3 The Requirement of Drug Information for Quality Use of Medicines A medicine has been described as an active substance plus information. (WHO, 1994). Education, together with, objective and appropriate drug information have been two of the factors consistently identified as necessary for rational drug use (Naismith, 1988; Soumerai, 1988; Carson et al, 1991; Dowden, 1991; Henry and Bochner, 1991; Tomson and Diwan, 1991). The WHO guidelines for developing national drug policies also identify the importance of information provision for facilitating drug use: Information on and promotion of drugs may greatly influence their supply and use. Monitoring and control of both activities are essential parts of any national drug policy (WHO, 1988). Objective and appropriate drug information is a necessary factor for quality drug use. It is the basis for appropriate prescribing decisions by medical practitioners. Medical practitioners require objective product, specific drug information and comparative prescribing information. Objective drug information is avai lable to medical practitioners through continuing education programs co-ordinated by professional bodies, medical and scientific journal articles, drug information services and drug formularies and guidelines. 1.1.2.4 Problem with antibiotic use The concerns regarding inappropriate antibiotic use can be divided into four areas: efficacy, toxicity, cost, and resistance. Inappropriate use of antibiotic can be due to: Antibiotic use where no infection is present, e.g. continuation of peri-operative prophylaxis for more than 24 hours after clean surgery. Infection, which is not amenable to antibiotic therapy, e.g. antibiotics prescribed for viral upper respiratory infection. The wrong drug for the causative organism, e.g. the use of broad anti-Gram negative agents for community acquired pneumonia. The wrong dose or duration of therapy. Such inappropriate use has a measurable effect on therapeutic efficacy. For example, one study showed that mortality in gram-negative septicemia is doubled when inappropriate empiric agents were used (Kreger et al., 1980). Since most initial antibiotic therapy is empiric, any attempt at improving use must tackle prescribing habits, with particular emphasis on guidelines for therapy based on clinical criteria. Inappropriate antibiotic use exposes patients to the risk of drug toxicity, while giving little or no therapeutic advantage, antibiotics are often considered relatively safe drugs and yet direct and indirect side effects of their use are frequent and may be life-threatening, allergic reactions, particularly to beta-lactam agents are well recognized and have been described in reaction to antibiotic residues in food (Barragry, 1994). Life threatening side effects may be occur from the use of antibiotics for apparently simple infections, it is estimated, for example, that eight people per year in UK die from side effects of co-trimoxazole usage in the community (Robert and Edmond, 1998). Indirect side effects are often overlooked: especially as may occur sometime after the antibiotic has been given. These include drug interactions (such as interference of antibiotic with anti-coagulant therapy and erythromycin with antihistamine) (BNF, 1998), side effects associated with the administration of antibiotics (such as intravenous cannula infection) and super-infection (such as candidiasis and pseudomembranous colitis). Each of these may have a greater morbidity, and indeed mortality, than the initial infection for which the antibiotic was prescribed (Kunin et al., 1993). The medical benefit of antibiotics does not come cheap. In the hospital setting, up to fifty percent of population receive one antibiotic during their hospital stay, with surgical prophylaxis accounting for thirty percent of this (Robert and Edmond, 1998). The first penicillin resistant isolate of Staphylococcus aureus was described only two years after the introduction of penicillin. Within a decade, 90% of isolates were penicillin resistant. This pattern of antibiotic discovery and introduction, followedby exuberant use and rapid emergence of resistance has subsequently been repeated witheach new class of antibiotics introduced. Bacteria can so rapidly develop resistance due to two major evolutionary advantages. Firstly, bacteria have been in existence for some 3.8 billion years and resistance mechanisms have evolved over this time as a protective mechanism against naturally occurring compounds produced by other microorganisms. In addition, they have an extremely rapid generation time and can freely exchange genetic material encoding resistance, not only between other species but also between genera. The vast quantities of antibiotics used in both human and veterinary medicine, as a result present in the environment, have lead to eme rgence of infection due to virtually untreatable bacteria. Multiply drug resistant tuberculosis is already widespread in parts of Southern Europe and has recently caused outbreaks in hospitals in London (Hiramatsu et al., 1997). Anti-infective are vital drugs, but they are over prescribed and overused in treatment of minor disorder such as simple diarrhea, coughs, and colds. When antibiotics are too often used in sub-optimal dosages, bacteria become resistant to them. The result is treatment failure where patient continue to suffer from serious infections despite taking the medication (Mohamed, 1999). Drugs prescribed are in no way beneficial to the patient s management if there are some negative interactions among the various agent prescribed, over prescribed, under prescribed or prescribed in the wrong dosage schedule. How does one ensure that good drug are not badly used, misused, or even abused? How can drugs be used rationally as intended? What is rational use of drugs? What does rational mean? 1.1.3 Rational Use of Drug Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community (Bapna et al., 1994). These requirements will be fulfilled if the process of prescribing is appropriately followed. This will include steps in defining patients problems (or diagnosis); in defining effective and safe treatments (drugs and non-drugs); in selecting appropriate drugs, dosage, and duration; in writing a prescription; in giving patients adequate information; and in planning to evaluate treatment responses. The definition implies that rational use of drugs; especially rational prescribing should meet certain criteria as follows (Ross et al., 1992): Appropriate indication. The decision to prescribe drug(s) is entirely based on medical rationale and that drug therapy is an effective and safe treatment. Appropriate drug.The selection of drugs is based on efficacy, safety, suitability, and considerations. Appropriate patient. No contraindications exist and the likelihood of adverse reactions is minimal, and the drug is acceptable to the patient. Appropriate information. Patients should be provided with relevant, accurate, important, and clear information regarding his or her condition and the medication(s) that are prescribed. Appropriate monitoring. The anticipated and unexpected effects of medications should be: appropriately monitored (Vance and Millington, 1986). Unfortunately, in the real world, prescribing patterns do not always conform to these criteria and can be classified as inappropriate or irrational prescribing. Irrational prescribing may be regarded as pathological prescribing, where the above- mentioned criteria are not fulfilled. Common patterns of irrational prescribing, may, therefore be manifested in the following forms: The use of drugs when no drug therapy is indicated, e.g., antibiotics for viral upper respiratory infections, The use of the wrong drug for a specific condition requiring drug therapy, e.g., tetracycline in childhood diarrhea requiring ORS, The use of drugs with doubtful/unproven efficacy, e.g., the use of antimotility agents in acute diarrhea, The use of drugs of uncertain safety status, e.g., use of dipyrone, Failure to provide available, safe, and effective drugs, e.g., failure to vaccinate against measles or tetanus, failure to prescribe ORS for acute diarrhea, The use of correct drugs with incorrect administration, dosages, and duration, e.g., the use of IV metronidazole when suppositories or oral formulations would be appropriate. The use of unnecessarily expensive drugs, e.g., the use of a third generation, broad spectrum antimicrobial when a first-line, narrow spectrum, agent is indicated. Some examples of commonly encountered inappropriate prescribing practices in many health care settings include: (Avorn et al., 1982). Overuse of antibiotics and antidiarrheals for non-specific childhood diarrhea, Multiple drug prescriptions, prescribe unnecessary drugs to counteract or augment, Drugs already prescribed, and Excessive use of antibiotics in treating minor respiratory tract infection. The drug use system is complex and varies from country to country. Drugs may be imported or manufactured locally. The drugs may be used in hospitals or health centers, by private practitioners and often in a pharmacy or drug shop where OTC preparations are sold. In some countries, all drugs are available over the counter. Another problem among the public includes a very wide range of people with differing knowledge, beliefs and attitudes about medicines. 1.1.3.1 Factors Underlying Irrational Use of Drugs There are many different factors that affect the irrational use of drugs. In addition, different cultures view drugs in different ways, and this can affect the way drugs are used. The major forces can be categorized as those deriving from patients, prescribers, the workplace, the supply system including industry influences, regulation, druginformation and misinformation, and combinations of these factors (Table 1.1) (Ross et al., 1992). Table 1.1: Factors affecting irrational use of drug Impact of Inappropriate Use of Drugs The impact of this irrational use of drugs can be seen in many ways: (Avorn et al., 1982). Reduction in the quality of drug therapy leading to increased morbidity and mortality, Waste of resources leading to reduced availability of other vital drugs and increased costs, Increased risk of unwanted effects such as adverse drug reactions and the emergence of drug resistance, e.g., malaria or multiple drugs resistant tuberculosis, Psychosocial impacts, such as when patients come to believe that there is a pill for every ill. This may cause an apparent increased demand for drugs. 1.1.3.2 The Rational Prescription (i.e. the right to prescribe) The rights to prescription writing must be ensuring the patients five rights: the right drug, the right dose, by the right route, to the right patient, at the right time. Illegible handwriting and misinterpretation of prescriptions and medication orders are widely recognized causes of prescription error. The medicines should be prescribed only when they are necessary, should be written legibly in ink or, other wise, should be led, and should be signed in ink by the prescriber, The patients full name and address, diagnosis should be written clearly, the name of drugs and formulations should be written clearly and not abbreviated, using approved titles only. Dose and dose frequency should be stated; in the cases of formulations to be taken as required, a minimum dose should be specified (British National Formulary, 1998). 1.2 Overview on Essential Drug Concept (EDC) Essential drugs relate to an international concept proposed by the World Health Organization (WHO) in 1977. WHO in that year published the first model list of essential drug and WHO has put in enormous resources into the campaign to promote the concept of essential drugs (EDL). Essential drugs were defined as a limited number of drugs that should be available at any time to the majority of population in appropriate dosage forms and at affordable prices. In other words, it meets the criteria generally abbreviated as SANE [that mean safety , availability, need efficacy] (John, 1997). The essential drug concept is important in ensuring that the vast majority of the population is accessible to drugs of high quality, safety and efficacy relevant to their health care needs, and at reasonable cost (New Straits Times, 1997a). In support of this concept, the WHOissued a model drug list that provided examples of essential drugs. The list is drawn up by a group of experts based on clinical scientific merits, and provides an economical basis of drug use. This list is regularly, revised and, since 1997, eight editions have been published. This ensures that the need for essential drugs is always kept up-to-date with additions and deletions. Despite such rigorous revision, the number of drugs in the list remains at about 300, although the initial list comprised less. Most of the drugs are no longer protected by patents and can therefore be produced in quantity at a lower cost without comprising standards (WHO, 1995). This is indeed important for countries like Yemen not only because health care are rapidly escalating, but also because the country is still very dependent on imports of strategic commodities like drugs. The EDC will enable Yemen to focus on becoming self-reliant where generic equivalents of essenti al drugs can be manufactured and popularized to meet the health needs of the majority of the people. The limited number of drugs regarded as essential on the list offers a useful guide for practitioners as well as consumers. It underscores the general principle thata majority of diseases can be treated by similar drugs regardless of national boundaries and geographical locations (New Straits Times, 2000) Moreover, certain self-limiting diseases may not need drug treatment as such. For example, in the case of diarrhea, certain so-called potent anti-diarrhoeal drugs (including antibiotics) are not generally recommended. The more preferred treatment is oral rehydration salt that could easily be obtained or prepared at a fraction of the cost while giving the most optimum outcome. The goal of the Yemen Drug Policy was to: Prepare a list of essential drugs to meet the health of needs of the people. Assure that the essential drugs made available to the public are of good quality Improve prescribing and dispensing practices Promote rational use of drug by the public Lower cost of the drugs to the government and public Reduce foreign exchange expenditure 1.3 Yemen Essential Drug List and Drug Policy in Yemen The Concept of Essential Drugs (EDC) developed by World Health Organization (WHO) in 1977 has provided a rational basis, not only for drug procurement at national level but also for establishing drug requirements at various levels within the health care system. The WHOs Action Program on Essential Drugs (DAP) aimed to improve health care. It was established in order to provide operational support in the development of National Drug Policies (NDP), to improve the availability of essential drugs to the whole population and to work towards the rational use of drugs and consequently the patient care. The program seeks to ensure that all people, whenever they may be, are able to obtain the drugs they need at the lowest possible price; that these drugs are safe and effective; and that they are prescribed and used rationally. The first WHO Model List of Essential Drugs was published in 1977 (WHO, 1977). Since that time essential drugs become an important part of health policies in developing countries; but the Essential Drugs Program has been criticized because it emphasis in improving supply of drugs rather than their rational prescribing. The recent revised WHO Model List of Essential Drugs was published the 13th edition in April 2003 (WHO, 2003). Yemen was one of the first countries in the region adapted the EDC in 1984 and implemented this concept in the public sector (Hogerzeil et al., 1989). The first Yemen (National) Essential Drugs List (YEDL) was officially issued in 1987 based on the WHO List of Essential Drugs and other resources. The second edition of the Yemen Drugs list and the Yemen Standard Treatment Guidelines were published in 1996 (MoPHP/NEDL, (1996); MoPHP/NSTG, (1996).Recently the latest edition was published in 2001 with the Standard Treatment Guidelines (STG) in the same booklet (Mo PHP/YSTG and YEDL, 2001). The new edition of the Treatment Guidelines and the Essential Drugs List has been created through a long process of consultation of medical and pharmaceutical professionals in Yemen and abroad. Review workshops were held in Sanaa and Aden and more than 200 representatives of the health workers from different governorates including the major medical specialists participated. Essential drugs are selected to fulfil the real needs of the majority of the population in diagnostic, prophylactic, therapeutic and rehabilitative services using criteria of risk-benefit ratio, cost-effectiveness, quality, practical administration as well as patient compliance and acceptance (Budon-Jakobowiez, 1994). The YEDL was initially used for the rural health units and health centers as well as some public hospitals, but not applied for all levels of health care and the private sector. However, despite the recognition of the essential drug concept by the government of Yemen represented by the Ministry of Public Health and Population (MoPHP), drugs remain in short supply to many of the population and irrationally used. Procurement cost is sometimes needlessly high. Knowledge of appropriate drug use and the adverse health consequences remain unacceptably low. In addition, diminished funding in the public sector resulted in shortage of pharmaceuticals. The 20th century has witnessed an explosion of pharmaceutical discovery, which has widened the therapeutic potential of medical practice. The vast increase in the number of pharmaceutical products marketed in the last decades has not made drug available to all people and neither has resulted in the expected health improvement. While some of the newly invented drugs are significant advance in therapy, the majorities of drugs marketed as â€Å"new† are minor variations of existing drug preparations and do not always represent a significant treatment improvement. In addition, the vast number brand names products for the same drug increases the total number of products of this particular drug resulting in an unjustified large range of drug preparations marketed throughout the world. The regular supply of drugs to treat the most common diseases was a major problem for governments in low-income countries. The WHO recommends that activities to strengthen the pharmaceutical sector be organized under the umbrella of the national drug policy (WHO, 1988). In 1995, over 50 of these countries has formulated National Drug Policies (NDP). The NDP is a guide for action, containing the goals set by the government for the pharmaceutical sector and the main strategies and approaches for attaining them. It provides a framework to co-ordinate activities of patients involved in pharmaceutical sector, the public sector, the private sector, non-governmental organizations (NGOs), donors and other interested parties. A NDP will therefore, indicate the various courses of action to be in relation to medicines within a country. The Yemen National Drug Policy was developed since 1993 with the objectives of ensuring availability of essential drugs through equitable distribution, ensuring drugs efficacy and safety, as well as promoting the rational use of drugs. Unfortunately, it has n

Friday, October 25, 2019

Systems Paper :: essays papers

Systems Paper Part I 1.Animal food cycles 2.Energy flow 3.In identifying parts of the system for the Tsembaga in New Guinea. I will start with the solar energy and rainfall that are the major contributors to life and the growth of plant and human life. The sun produces energy for plants to photosynthesize and the 150 inches of water per year that the Tsembaga receive facilitates this process. The Tsembaga grow a variety of crops including: taro, sweet potatoes, yams, manioc, greens, sugar cane, and some tree crops. Human labor to sustain the growth of these crops includes cutting, fencing, planting, maintaining, harvesting, and walking back and forth. The men usually perform these labors. Another strategic part of the soil maintenance includes the fallowing and rooting of the ground by pigs. The pigs are usually taken care of by the women of the group. After the crop has grown it is harvested by the men and stored for later consumption by the human population as well as the pig population. In times of Physiological stress which includes m isfortune and emergency the pigs are killed by the men and then the flesh is distributed to the group that the stress is greatest. The storage of the crops also leads to not only the consumption of the crop but the crops can also be used in trade outside of their territories for such objects as stone axes. 4.Applying the above in to the Culture Core Model I started with the base of the pyramid, economics. The reason for the growth of the crops has an economic reason, using the crop as an item to exchange goods with for things like stone axes. Also the more of the crop you have the more pigs you can sustain, which inevitably means the more protein you can get from eating the pigs. The Tsembaga also have territories that they live, grow and raise pigs on. That is there largest economic commodity. Social aspects of the model include the division of labor, which could also be a political matter, but the society is egalitarian so that everyone is equal and there are no chiefs. The men work the crops and fight while the women cook, clean, watch the children and over see the pigs. Politically they patrilineal clans, which are organized into smaller groups. Men are the only ones that are allowed to fight. When a pig is killed it is pre decide who will get it depending on need, men during time of war, and in times of illness or injury it is the victim that gets the meat.

Thursday, October 24, 2019

Walmart Security Issues

Review our  cookies information  for more details Special report:  Managing information A different game Information is transforming traditional businesses Feb 25th 2010 | from the print edition * * IN 1879 James Ritty, a saloon-keeper in Dayton, Ohio, received a patent for a wooden contraption that he dubbed the â€Å"incorruptible cashier†. With a set of buttons and a loud bell, the device, sold by National Cash Register (NCR), was little more than a simple adding machine. Yet as an early form of managing information flows in American business the cash register had a huge impact.It not only reduced pilferage by alerting the shopkeeper when the till was opened; by recording every transaction, it also provided an instant overview of what was happening in the business. Sales data remain one of a company's most important assets. In 2004 Wal-Mart peered into its mammoth databases and noticed that before a hurricane struck, there was a run on flashlights and batteries, as mi ght be expected; but also on Pop-Tarts, a sugary American breakfast snack. On reflection it is clear that the snack would be a handy thing to eat in a blackout, but the retailer would not have thought to stock up on it before a storm.The company whose system crunched Wal-Mart's numbers was none other than NCR and its data-warehousing unit, Teradata, now an independent firm. A few years ago such technologies, called â€Å"business intelligence†, were available only to the world's biggest companies. But as the price of computing and storage has fallen and the software systems have got better and cheaper, the technology has moved into the mainstream. Companies are collecting more data than ever before. In the past they were kept in different systems that were unable to talk to each other, such as finance, human resources or customer management.Now the systems are being linked, and companies are using data-mining techniques to get a complete picture of their operations—â⠂¬Å"a single version of the truth†, as the industry likes to call it. That allows firms to operate more efficiently, pick out trends and improve their forecasting. In this special report * Data, data everywhere * All too much *  »A different game * Clicking for gold * The open society * Show me * Needle in a haystack * New rules for big data * Handling the cornucopia Sources & acknowledgementsReprints Related topics * China * Nestle * IBM * Royal Shakespeare Company * WalmartConsider Cablecom, a Swiss telecoms operator. It has reduced customer defections from one-fifth of subscribers a year to under 5% by crunching its numbers. Its software spotted that although customer defections peaked in the 13th month, the decision to leave was made much earlier, around the ninth month (as indicated by things like the number of calls to customer support services). So Cablecom offered certain customers special deals seven months into their subscription and reaped the rewards. Agony and t orture Such data-mining has a dubious reputation. â€Å"Torture the data long enough and they will confess to anything,† statisticians quip.But it has become far more effective as more companies have started to use the technology. Best Buy, a retailer, found that 7% of its customers accounted for 43% of its sales, so it reorganised its stores to concentrate on those customers' needs. Airline yield management improved because analytical techniques uncovered the best predictor that a passenger would actually catch a flight he had booked: that he had ordered a vegetarian meal. The IT industry is piling into business intelligence, seeing it as a natural successor of services such as accountancy and computing in the first and second half of the 20th century respectively.Accenture, PricewaterhouseCoopers, IBM and SAP are investing heavily in their consulting practices. Technology vendors such as Oracle, Informatica, TIBCO, SAS and EMC have benefited. IBM believes business intellige nce will be a pillar of its growth as sensors are used to manage things from a city's traffic flow to a patient's blood flow. It has invested $12 billion in the past four years and is opening six analytics centres with 4,000 employees worldwide. Analytics—performing statistical operations for forecasting or uncovering correlations such as between Pop-Tarts and hurricanes—can have a big pay-off.In Britain the Royal Shakespeare Company (RSC) sifted through seven years of sales data for a marketing campaign that increased regular visitors by 70%. By examining more than 2m transaction records, the RSC discovered a lot more about its best customers: not just income, but things like occupation and family status, which allowed it to target its marketing more precisely. That was of crucial importance, says the RSC's Mary Butlin, because it substantially boosted membership as well as fund-raising revenue. Yet making the most of data is not easy. The first step is to improve the accuracy of the information.Nestle, for example, sells more than 100,000 products in 200 countries, using 550,000 suppliers, but it was not using its huge buying power effectively because its databases were a mess. On examination, it found that of its 9m records of vendors, customers and materials around half were obsolete or duplicated, and of the remainder about one-third were inaccurate or incomplete. The name of a vendor might be abbreviated in one record but spelled out in another, leading to double-counting. Plainer vanilla Over the past ten years Nestle has been overhauling its IT system, using SAP software, and improving the quality of its data.This enabled the firm to become more efficient, says Chris Johnson, who led the initiative. For just one ingredient, vanilla, its American operation was able to reduce the number of specifications and use fewer suppliers, saving $30m a year. Overall, such operational improvements save more than $1 billion annually. Nestle is not alon e in having problems with its database. Most CIOs admit that their data are of poor quality. In a study by IBM half the managers quizzed did not trust the information on which they had to base decisions. Many say that the technology meant to make sense of it often just produces more data.Instead of finding a needle in the haystack, they are making more hay. Still, as analytical techniques become more widespread, business decisions will increasingly be made, or at least corroborated, on the basis of computer algorithms rather than individual hunches. This creates a need for managers who are comfortable with data, but statistics courses in business schools are not popular. Many new business insights come from â€Å"dead data†: stored information about past transactions that are examined to reveal hidden correlations. But now companies are increasingly moving to analysing real-time information flows.Wal-Mart is a good example. The retailer operates 8,400 stores worldwide, has mo re than 2m employees and handles over 200m customer transactions each week. Its revenue last year, around $400 billion, is more than the GDP of many entire countries. The sheer scale of the data is a challenge, admits Rollin Ford, the CIO at Wal-Mart's headquarters in Bentonville, Arkansas. â€Å"We keep a healthy paranoia. † Not a sparrow falls Wal-Mart's inventory-management system, called Retail Link, enables suppliers to see the exact number of their products on every shelf of every store at that precise moment.The system shows the rate of sales by the hour, by the day, over the past year and more. Begun in the 1990s, Retail Link gives suppliers a complete overview of when and how their products are selling, and with what other products in the shopping cart. This lets suppliers manage their stocks better. The technology enabled Wal-Mart to change the business model of retailing. In some cases it leaves stock management in the hands of its suppliers and does not take owner ship of the products until the moment they are sold. This allows it to shed inventory risk and reduce its costs.In essence, the shelves in its shops are a highly efficiently managed depot. Another company that capitalises on real-time information flows is Li & Fung, one of the world's biggest supply-chain operators. Founded in Guangzhou in southern China a century ago, it does not own any factories or equipment but orchestrates a network of 12,000 suppliers in 40 countries, sourcing goods for brands ranging from Kate Spade to Walt Disney. Its turnover in 2008 was $14 billion. Li ; Fung used to deal with its clients mostly by phone and fax, with e-mail counting as high technology.But thanks to a new web-services platform, its processes have speeded up. Orders flow through a web portal and bids can be solicited from pre-qualified suppliers. Agents now audit factories in real time with hand-held computers. Clients are able to monitor the details of every stage of an order, from the ini tial production run to shipping. One of the most important technologies has turned out to be videoconferencing. It allows buyers and manufacturers to examine the colour of a material or the stitching on a garment. â€Å"Before, we weren't able to send a 500MB image—we'd post a DVD.Now we can stream it to show vendors in our offices. With real-time images we can make changes quicker,† says Manuel Fernandez, Li ; Fung's chief technology officer. Data flowing through its network soared from 100 gigabytes a day only 18 months ago to 1 terabyte. The information system also allows Li & Fung to look across its operations to identify trends. In southern China, for instance, a shortage of workers and new legislation raised labour costs, so production moved north. â€Å"We saw that before it actually happened,† says Mr Fernandez.The company also got advance warning of the economic crisis, and later the recovery, from retailers' orders before these trends became apparent. Investment analysts use country information provided by Li ; Fung to gain insights into macroeconomic patterns. Now that they are able to process information flows in real time, organisations are collecting more data than ever. One use for such information is to forecast when machines will break down. This hardly ever happens out of the blue: there are usually warning signs such as noise, vibration or heat. Capturing such data enables firms to act before a breakdown.Similarly, the use of â€Å"predictive analytics† on the basis of large data sets may transform health care. Dr Carolyn McGregor of the University of Ontario, working with IBM, conducts research to spot potentially fatal infections in premature babies. The system monitors subtle changes in seven streams of real-time data, such as respiration, heart rate and blood pressure. The electrocardiogram alone generates 1,000 readings per second. This kind of information is turned out by all medical equipment, but it used t o be recorded on paper and examined perhaps once an hour.By feeding the data into a computer, Dr McGregor has been able to detect the onset of an infection before obvious symptoms emerge. â€Å"You can't see it with the naked eye, but a computer can,† she says. Open sesame Two technology trends are helping to fuel these new uses of data: cloud computing and open-source software. Cloud computing—in which the internet is used as a platform to collect, store and process data—allows businesses to lease computing power as and when they need it, rather than having to buy expensive equipment.Amazon, Google and Microsoft are the most prominent firms to make their massive computing infrastructure available to clients. As more corporate functions, such as human resources or sales, are managed over a network, companies can see patterns across the whole of the business and share their information more easily. A free programming language called R lets companies examine and p resent big data sets, and free software called Hadoop now allows ordinary PCs to analyse huge quantities of data that previously required a supercomputer. It does this by parcelling out the tasks to numerous computers at once. This saves time and money.For example, the  New York Times  a few years ago used cloud computing and Hadoop to convert over 400,000 scanned images from its archives, from 1851 to 1922. By harnessing the power of hundreds of computers, it was able to do the job in 36 hours. Visa, a credit-card company, in a recent trial with Hadoop crunched two years of test records, or 73 billion transactions, amounting to 36 terabytes of data. The processing time fell from one month with traditional methods to a mere 13 minutes. It is a striking successor of Ritty's incorruptible cashier for a data-driven age. from the print edition | Special report Recommend 140 * * * Submit to reddit * inShare2 * View all comments (4) Related items TOPIC:  China  Ã‚ » * Recommended economics writing: Link exchange * Trade: Mexico rising * The Economist: Digital highlights, November 24th 2012 TOPIC:  Nestle  Ã‚ » * Consumer goods in Africa: A continent goes shopping * Schumpeter: Pretty profitable parrots * Nestle buys Pfizer Nutrition: Feeding little emperors TOPIC:  IBM  Ã‚ » * Schumpeter: Taking the long view * IBM's mainframes: Old dog, new tricks * Phase-change memory: Altered states TOPIC:  Royal Shakespeare Company  Ã‚ » * William Shakespeare: A digital reinvention Culture: Going for gold * Green architecture: The retrofit revolution More related topics: * Walmart Want more? 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By continuing to browse the site you are agreeing to our use of cookies.Review our  cookies information  for more details Special report:  Managing information A different game Information is transforming traditional businesses Feb 25th 2010 | from the print edition * * IN 1879 James Ritty, a saloon-keeper in Dayton, Ohio, received a patent for a wooden contraption that he dubbed the â€Å"incorruptible cashier†. With a set of buttons and a loud bell, the device, sold by National Cash Register (NCR), was little more than a simple adding machine. Yet as an early form of managing information flows in American business the cash register had a huge impact.It not only reduced pilferage by alerting the shopkeeper when the till was opened; by recording every transaction, it also provided an instant overview of what was happening in the business. Sales data remain one of a company's most important assets. In 2004 Wal-Mart peered into its mammoth databases and noticed that before a hurricane struck, there was a run on flashlights and batteries, as might be expected; but also on Pop-Tarts, a sugary American breakfast snack. On reflection it is clear that the snack would be a handy thing to eat in a blackout, but the retailer would not have thought to stock up on it before a storm.The company whose system crunched Wal-Mart's numbers was none other than NCR and its data-warehousing unit, Teradata, now an independent firm. A few years ago such technologies, called â€Å"business intelligence†, were available only to the world's biggest companies. But as the price of computing and storage has fallen and the software systems have got better and cheaper, the technology has moved into the mainstream. Companies are collecting more data than ever before. In the past they were kept in different systems that were unable to talk to each other, such as finance, human resources or customer management.Now the systems are being linked, and companies are using data-mining techniques to get a complete picture of their operations—â€Å"a single version of the truth†, as the industry likes to call it. That allows firms to operate more efficiently, pick out trends and improve their forecast ing. In this special report * Data, data everywhere * All too much *  »A different game * Clicking for gold * The open society * Show me * Needle in a haystack * New rules for big data * Handling the cornucopia Sources & acknowledgementsReprints Related topics * China * Nestle * IBM * Royal Shakespeare Company * WalmartConsider Cablecom, a Swiss telecoms operator. It has reduced customer defections from one-fifth of subscribers a year to under 5% by crunching its numbers. Its software spotted that although customer defections peaked in the 13th month, the decision to leave was made much earlier, around the ninth month (as indicated by things like the number of calls to customer support services). So Cablecom offered certain customers special deals seven months into their subscription and reaped the rewards. Agony and torture Such data-mining has a dubious reputation. â€Å"Torture the data long enough and they will confess to anything,† statisticians quip.But it has become far more effective as more companies have started to use the technology. Best Buy, a retailer, found that 7% of its customers accounted for 43% of its sales, so it reorganised its stores to concentrate on those customers' needs. Airline yield management improved because analytical techniques uncovered the best predictor that a passenger would actually catch a flight he had booked: that he had ordered a vegetarian meal. The IT industry is piling into business intelligence, seeing it as a natural successor of services such as accountancy and computing in the first and second half of the 20th century respectively.Accenture, PricewaterhouseCoopers, IBM and SAP are investing heavily in their consulting practices. Technology vendors such as Oracle, Informatica, TIBCO, SAS and EMC have benefited. IBM believes business intelligence will be a pillar of its growth as sensors are used to manage things from a city's traffic flow to a patient's blood flow. It has invested $12 billion in the past four years and is opening six analytics centres with 4,000 employees worldwide. Analytics—performing statistical operations for forecasting or uncovering correlations such as between Pop-Tarts and hurricanes—can have a big pay-off.In Britain the Royal Shakespeare Company (RSC) sifted through seven years of sales data for a marketing campaign that increased regular visitors by 70%. By examining more than 2m transaction records, the RSC discovered a lot more about its best customers: not just income, but things like occupation and family status, which allowed it to target its marketing more precisely. That was of crucial importance, says the RSC's Mary Butlin, because it substantially boosted membership as well as fund-raising revenue. Yet making the most of data is not easy. The first step is to improve the accuracy of the information.Nestle, for example, sells more than 100,000 products in 200 countries, using 550,000 suppliers, but it was not using its huge buying po wer effectively because its databases were a mess. On examination, it found that of its 9m records of vendors, customers and materials around half were obsolete or duplicated, and of the remainder about one-third were inaccurate or incomplete. The name of a vendor might be abbreviated in one record but spelled out in another, leading to double-counting. Plainer vanilla Over the past ten years Nestle has been overhauling its IT system, using SAP software, and improving the quality of its data.This enabled the firm to become more efficient, says Chris Johnson, who led the initiative. For just one ingredient, vanilla, its American operation was able to reduce the number of specifications and use fewer suppliers, saving $30m a year. Overall, such operational improvements save more than $1 billion annually. Nestle is not alone in having problems with its database. Most CIOs admit that their data are of poor quality. In a study by IBM half the managers quizzed did not trust the informatio n on which they had to base decisions. Many say that the technology meant to make sense of it often just produces more data.Instead of finding a needle in the haystack, they are making more hay. Still, as analytical techniques become more widespread, business decisions will increasingly be made, or at least corroborated, on the basis of computer algorithms rather than individual hunches. This creates a need for managers who are comfortable with data, but statistics courses in business schools are not popular. Many new business insights come from â€Å"dead data†: stored information about past transactions that are examined to reveal hidden correlations. But now companies are increasingly moving to analysing real-time information flows.Wal-Mart is a good example. The retailer operates 8,400 stores worldwide, has more than 2m employees and handles over 200m customer transactions each week. Its revenue last year, around $400 billion, is more than the GDP of many entire countries . The sheer scale of the data is a challenge, admits Rollin Ford, the CIO at Wal-Mart's headquarters in Bentonville, Arkansas. â€Å"We keep a healthy paranoia. † Not a sparrow falls Wal-Mart's inventory-management system, called Retail Link, enables suppliers to see the exact number of their products on every shelf of every store at that precise moment.The system shows the rate of sales by the hour, by the day, over the past year and more. Begun in the 1990s, Retail Link gives suppliers a complete overview of when and how their products are selling, and with what other products in the shopping cart. This lets suppliers manage their stocks better. The technology enabled Wal-Mart to change the business model of retailing. In some cases it leaves stock management in the hands of its suppliers and does not take ownership of the products until the moment they are sold. This allows it to shed inventory risk and reduce its costs.In essence, the shelves in its shops are a highly eff iciently managed depot. Another company that capitalises on real-time information flows is Li & Fung, one of the world's biggest supply-chain operators. Founded in Guangzhou in southern China a century ago, it does not own any factories or equipment but orchestrates a network of 12,000 suppliers in 40 countries, sourcing goods for brands ranging from Kate Spade to Walt Disney. Its turnover in 2008 was $14 billion. Li ; Fung used to deal with its clients mostly by phone and fax, with e-mail counting as high technology.But thanks to a new web-services platform, its processes have speeded up. Orders flow through a web portal and bids can be solicited from pre-qualified suppliers. Agents now audit factories in real time with hand-held computers. Clients are able to monitor the details of every stage of an order, from the initial production run to shipping. One of the most important technologies has turned out to be videoconferencing. It allows buyers and manufacturers to examine the col our of a material or the stitching on a garment. â€Å"Before, we weren't able to send a 500MB image—we'd post a DVD.Now we can stream it to show vendors in our offices. With real-time images we can make changes quicker,† says Manuel Fernandez, Li ; Fung's chief technology officer. Data flowing through its network soared from 100 gigabytes a day only 18 months ago to 1 terabyte. The information system also allows Li & Fung to look across its operations to identify trends. In southern China, for instance, a shortage of workers and new legislation raised labour costs, so production moved north. â€Å"We saw that before it actually happened,† says Mr Fernandez.The company also got advance warning of the economic crisis, and later the recovery, from retailers' orders before these trends became apparent. Investment analysts use country information provided by Li ; Fung to gain insights into macroeconomic patterns. Now that they are able to process information flows i n real time, organisations are collecting more data than ever. One use for such information is to forecast when machines will break down. This hardly ever happens out of the blue: there are usually warning signs such as noise, vibration or heat. Capturing such data enables firms to act before a breakdown.Similarly, the use of â€Å"predictive analytics† on the basis of large data sets may transform health care. Dr Carolyn McGregor of the University of Ontario, working with IBM, conducts research to spot potentially fatal infections in premature babies. The system monitors subtle changes in seven streams of real-time data, such as respiration, heart rate and blood pressure. The electrocardiogram alone generates 1,000 readings per second. This kind of information is turned out by all medical equipment, but it used to be recorded on paper and examined perhaps once an hour.By feeding the data into a computer, Dr McGregor has been able to detect the onset of an infection before ob vious symptoms emerge. â€Å"You can't see it with the naked eye, but a computer can,† she says. Open sesame Two technology trends are helping to fuel these new uses of data: cloud computing and open-source software. Cloud computing—in which the internet is used as a platform to collect, store and process data—allows businesses to lease computing power as and when they need it, rather than having to buy expensive equipment.Amazon, Google and Microsoft are the most prominent firms to make their massive computing infrastructure available to clients. As more corporate functions, such as human resources or sales, are managed over a network, companies can see patterns across the whole of the business and share their information more easily. A free programming language called R lets companies examine and present big data sets, and free software called Hadoop now allows ordinary PCs to analyse huge quantities of data that previously required a supercomputer. It does th is by parcelling out the tasks to numerous computers at once.This saves time and money. For example, the  New York Times  a few years ago used cloud computing and Hadoop to convert over 400,000 scanned images from its archives, from 1851 to 1922. By harnessing the power of hundreds of computers, it was able to do the job in 36 hours. Visa, a credit-card company, in a recent trial with Hadoop crunched two years of test records, or 73 billion transactions, amounting to 36 terabytes of data. The processing time fell from one month with traditional methods to a mere 13 minutes. It is a striking successor of Ritty's incorruptible cashier for a data-driven age. rom the print edition | Special report * Recommend 140 * * * Submit to reddit * inShare2 * View all comments (4) Related items TOPIC:  China  Ã‚ » * Recommended economics writing: Link exchange * Trade: Mexico rising * The Economist: Digital highlights, November 24th 2012 TOPIC:  Nestle  Ã‚ » * Consumer goods in Africa: A continent goes shopping * Schumpeter: Pretty profitable parrots * Nestle buys Pfizer Nutrition: Feeding little emperors TOPIC:  IBM  Ã‚ » * Schumpeter: Taking the long view * IBM's mainframes: Old dog, new tricks * Phase-change memory: Altered states TOPIC:  Royal Shakespeare Company  Ã‚ » William Shakespeare: A digital reinvention * Culture: Going for gold * Green architecture: The retrofit revolution More related topics: * Walmart Want more? Subscribe to  The Economist  and get the week's most relevant news and analysis. * Print edition X Feb 27th 2010 Feb 20th 2010 Feb 13th 2010 Feb 6th 2010 * Next in The world this week X Politics this week * Next in The world this week X Business this week * Next in The world this week X KAL's cartoon * Next in Leaders X Technology The data deluge Businesses, governments and society are only starting to tap its vast potential * Next in LeadersX Argentina and the Falklands The beef in Buenos Aires The Kirchners could have more oil if they stopped bullying Argentine business * Next in Leaders X Japan's frustrating politics Nagasaki fallout Japan’s prime minister, Yukio Hatoyama, should jettison his Svengali, Ichiro Ozawa * Next in Leaders X India Ending the red terror It is time India got serious about the Maoist insurgency in its eastern states * Next in Leaders X Genetically modified food Attack of the really quite likeable tomatoes The success of genetically modified crops provides opportunities to win over their critics Next in Letters X Letters On Spain, al-Qaeda, Yemen, torture, Britain, juries, stereotypes, Benjamin Disraeli * Next in Briefing X Argentina under the Kirchners Socialism for foes, capitalism for friends While some private businesses in Argentina have faced harassment or even nationalisation, others†¦ * Next in Briefing X The first family's businesses Welcome to the Hotel Kirchner Such a lovely little earner * Next in United States X Health reform Seizing the reins, at long las t After leaving Congress in charge for too long, Barack Obama unveils his own plan * Next in United StatesX Mitt Romney and the Republicans Fired up, ready to go Mitt Romney takes centre-stage * Next in United States X The administration's economists Grading the dismal scientists How good is the Council of Economic Advisers? * Next in United States X The economy Back to the crash The American economy has just had its worst decade since the 1930s * Next in United States X Arkansas politics Democrats beware A spirited scramble for suddenly open Democratic seats * Next in United States X Schools and testing The finger of suspicion Is too much weight given to testing? * Next in United States XCalifornia's prison-guards' union Fading are the peacemakers One of California’s most powerful political forces may have peaked * Next in United States X America's children Protecting the weakest The recession may hurt America’s vulnerable children * Next in United States X Lexington Is Barack Obama tough enough? Conservatives call him too weak to be a warrior. Tell that to the Taliban * Next in The Americas X Corruption in Brazil The money trail Many corruption scandals stem from the high cost of politics, and unrealistically tight†¦ * Next in The Americas X Presidential ambitions in PeruPolitical satire Jaime Bayly’s breath of fresh air * Next in The Americas X Latin American summitry In ever-closer union, divided we stand * Next in The Americas X Canada's Mohawks Get out of our canoe When a Canadian is not a Canadian * Next in Asia X Tackling Japan's bureaucracy Floundering in the foggy fortress The DPJ is finding that it needs to befriend its bureaucrats, as well as bash them * Next in Asia X India's Naxalite insurgency Not a dinner party India’s Maoist guerrillas carry out two slaughters, then offer a truce * Next in Asia X Western aims in AfghanistanPlayed for fools Hamid Karzai’s shenanigans make the going even harder for NATO * Next in Asia X Migrant workers in Thailand Inhospitality Life gets harder for Thailand’s guest-workers * Next in Asia X China's National People's Congress Democracy in action Making sure that China’s supreme legislative body is toothless * Next in Asia X Animal welfare in China Off the menu The right to eat cats and dogs is under threat * Next in Asia X Banyan The mother of all dictatorships To understand North Korea, look not to Confucius or the Soviet Union, but to fascist 1930s Japan * Next in Asia X