salutogenesi versus paradigma prometeico della scienza medica
TRANSCRIPT
Salutogenesi versus paradigma prometeico della scienza medica
Pier Paolo Dal Monte, MD Bologna, Italy
Board member Associazione Italiana di Bioetica Chirurgica
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domenica 30 novembre 2014
Dipinte in queste riveSon dell'umana genteLe magnifiche sorti e progressive G.Leopardi, La ginestra
domenica 30 novembre 2014
Fonte: Jim Oeppen and James W. Vaupel Science 10 May 2002
Fonte: Angus Maddison, The World Economy: Historical Statistics (Paris: OECD, 2003); 2002–2003 data: World Bank.
very concepts of macroeconomics and (cyclical)
stabilization policy are essentially twentieth-
century creations—this topic has been dealt with
extensively in earlier World Economic Outlooks.
This chapter incorporates some of the many
insights contained in two supporting studies
commissioned for the World Economic Outlook.1
“Globalization and Growth in the Twentieth
Century” (IMF Working Paper 00/44), by
Professor Nicholas Crafts of the London School
of Economics, discusses real developments dur-
ing the twentieth century and was particularly
important for the discussion of growth and di-
vergence. “The International Monetary System
in the (Very) Long Run” (IMF Working Paper
00/43), by Professors Barry Eichengreen and
Nathan Sussman of the University of California
Berkeley and Hebrew University Jerusalem, re-
spectively, provides an overview of the interna-
tional monetary system over the last thousand
years, and was particularly important for the
discussion of the changing nature of interna-
tional monetary relations in the twentieth
century.
Global Economic Growth and IncomeDistribution
The two most striking characteristics of
twentieth-century economic growth are its stag-
gering size and acceleration when compared
with developments in previous centuries, and its
uneven distribution among different countries
and regions of the world.
Growth of Output and Population
Using conventional GDP estimates over a long
historical period, the total amount of goods and
services produced in the twentieth century is es-
timated to have exceeded the cumulative total
output over the preceding recorded human his-
CHAPTER V THE WORLD ECONOMY IN THE TWENTIETH CENTURY
150
Real GDP and Population(1900 = 100)
Growth in 50-Year Intervals(period total, in percent)
Real GDP
Population
GDP Population
2000
1600
1200
800
700
600
500
400
300
200
100
0
400
01750
1700–50 1750–1800 1800–50 1850–1900 1900–50 1950–2000
1800 1850 1900 1950 2000
Figure 5.1. World GDP and Population Since 1750
During the twentieth century both output and population growth increased. However, as a result of accelerating technical progress, output growth increasingly exceeded population growth.
Source: Bradford J. DeLong, “Estimating World GDP, One Million B.C.–Present.” Available via the internet at: http://econ161.berkeley.edu.
1In addition to being issued as IMF Working Papers,
both studies are being published in World Economic
Outlook: Supporting Studies 2000 (Washington: IMF,
forthcoming).
Anatomia di un secolo
Speranza di vita alla nascita (paesi OCSE)
domenica 30 novembre 2014
1. HEALTH STATUS
HEALTH AT A GLANCE 2011: OECD INDICATORS © OECD 2011 25
1.1. Life expectancy at birth
1.1.1 Life expectancy at birth, 2009 (or nearest year), and years gained since 1960
Source: OECD Health Data 2011; World Bank and national sources for non-OECD countries.1 2 http://dx.doi.org/10.1787/888932523253
405060708090 0 5 10 15 20 25 30
83.082.381.881.881.681.681.581.481.081.080.880.780.780.680.480.480.380.380.380.080.080.079.579.579.079.078.478.2
77.375.875.375.075.0
74.073.873.3
72.671.2
68.764.1
51.7
15.210.9
12.012.0
10.79.9
8.68.3
10.77.2
9.79.4
11.37.1
11.79.6
11.210.4
27.910.2
11.010.0
15.611.2
6.610.5
21.48.3
6.78.0
17.86.5
4.46.0
25.526.7
18.130.0
0.021.7
2.6
Life expectancy at birth, 2009 Years gained, 1960-2009
Years Years
JapanSwitzerland
ItalySpain
AustraliaIsrael
IcelandSwedenFranceNorway
New ZealandCanada
Luxembourg
OECDDenmark
NetherlandsAustria
United KingdomGermanyGreeceKorea
ChinaBrazil
SloveniaChile
United StatesCzech Republic
PolandMexicoEstonia
Slovak RepublicHungaryTurkey
BelgiumFinlandIreland
Portugal
IndonesiaRussian Federation
IndiaSouth Africa
1.1.2 Life expectancy at birth and GDP per capita, 2009 (or nearest year)
Source: OECD Health Data 2011; World Bank and national sources fornon-OECD countries.
1 2 http://dx.doi.org/10.1787/888932523272
0 10 000 20 000 30 000 40 000 50 000 60 000 70 000
84
80
76
72
68
64
JPNCHEITAESP
AUSISR
ISLSWE
NOR
FRANZL
LUXCAN
NLD
AUTGBR
DEU
GRCKOR
IRL
BEL
FIN
PRT
DNKSVN USACHLCZE
POL
MEX SVKEST
HUNTURCHN BRA
IDN
RUS
IND
R! = 0.54
GDP per capita (USD PPP)
Life expectancy in years
1.1.3 Life expectancy at birth and health spending per capita, 2009 (or nearest year)
Source: OECD Health Data 2011; World Bank and national sources fornon-OECD countries.
1 2 http://dx.doi.org/10.1787/888932523291
0 2 000 4 000 6 000 8 000
84
80
76
72
68
64
R! = 0.69
AUS
AUT
BEL
BRA
CAN
CHLCZE
DNK
EST
FINFRA
DEUGRC
HUN
ISL
IND
IDN
CHN
IRL
ISR ITA
JPN
KOR
LUX
MEX
NLDNZL NOR
POL
PRT
RUS
SVK
SVN
ESP SWE CHE
TUR
GBRUSA
Health spending per capita (USD PPP)
Life expectancy in years
Source: OECD Health Data 2011; World Bank and national sources for non-OECD countries
Anatomia di un secolo
domenica 30 novembre 2014
20
18
16
14
12
10
8
6
4
2
0
17.4
12.0
11.8
11.6
11.5
11.4
11.4
11.0
10.9
10.3
10.1
10.0
9.8
9.7
9.6
9.6
9.6
9.5
9.5
9.5
9.3
9.2
9.1
9.0
8.7
8.5
8.5
8.4
8.2
7.9
7.8
7.4
7.4
7.0
6.9
6.4
6.1
5.4
4.6
4.2
2.4
Public Private
% of GDP
United
States
Netherl
ands
1
Franc
e
German
y
Denmark
Canad
a
Switzerl
and
Austria
Belgium
2
New Ze
aland
Portug
al
Sweden
United
Kingdo
mIce
land
Greece
Norway
OECDIre
land
Italy
Spain
Sloven
ia
Finlan
d
Slovak
Repub
licBraz
il
Austra
liaJa
pan
South
Africa
Chile
Czech R
epub
licIsr
ael
Luxe
mbourg
3
Hunga
ry
Poland
Eston
iaKore
a
Mexico
Turke
y
Russia
n Fed
eratio
nChin
aInd
ia
Indon
esia
Total health expenditure as a share of GDP, 2009
OECD Health Data 2011; WHO Global Health Expenditure Database
Il costo della salute
domenica 30 novembre 2014
7. HEALTH EXPENDITURE AND FINANCING
HEALTH AT A GLANCE 2011: OECD INDICATORS © OECD 2011 151
7.2. Health expenditure in relation to GDP
7.2.1 Total health expenditure as a share of GDP, 2009 (or nearest year)
1. In the Netherlands, it is not possible to clearly distinguish the public and private share related to investments.2. Total expenditure excluding investments.3. Health expenditure is for the insured population rather than the resident population.
Source: OECD Health Data 2011; WHO Global Health Expenditure Database.1 2 http://dx.doi.org/10.1787/888932526103
20
18
16
14
12
10
8
6
4
2
0
17.4
12.0
11.8
11.6
11.5
11.4
11.4
11.0
10.9
10.3
10.1
10.0
9.8
9.7
9.6
9.6
9.6
9.5
9.5
9.5
9.3
9.2
9.1
9.0
8.7
8.5
8.5
8.4
8.2
7.9
7.8
7.4
7.4
7.0
6.9
6.4
6.1
5.4
4.6
4.2
2.4
Public Private
% of GDP
United
States
Netherl
ands
1
Franc
e
German
y
Denmark
Canad
a
Switzerl
and
Austria
Belgium
2
New Ze
aland
Portug
al
Sweden
United
Kingdo
mIce
land
Greece
Norway
OECDIre
land
Italy
Spain
Sloven
ia
Finlan
d
Slovak
Repub
licBraz
il
Austra
liaJa
pan
South
Africa
Chile
Czech R
epub
licIsr
ael
Luxe
mbourg
3
Hunga
ry
Poland
Eston
iaKore
a
Mexico
Turke
y
Russia
n Fed
eratio
nChin
aInd
ia
Indon
esia
7.2.2 Total health expenditure as a share of GDP, selected OECD countries, 2000-09
Source: OECD Health Data 2011.1 2 http://dx.doi.org/10.1787/888932526122
18
16
14
12
10
8
6
4
2
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
United StatesSwitzerlandCanada
OECDUnited KingdomKorea
% of GDP
7.2.3 Annual average growth in real per capita expenditure on health and GDP, 2000-09 (or nearest year)
Source: OECD Health Data 2011.1 2 http://dx.doi.org/10.1787/888932526141
-1 0 1 3 5
11
9
7
5
3
1
0
-1
SVK
KOR
ESTPOLGRC
TURIRLCZE
CHLNZL
GBR
NLDBEL
FINESPSVNCAN
SWEDNK
USAMEX AUS
HUNJPN
NOR
AUTFRA
DEU CHE ISLITAISRPRT
LUX
Annual average growth rate in real GDP per capita (%)
Annual average growth rate in real health expenditure per capita (%)
OECD
1. HEALTH STATUS
HEALTH AT A GLANCE 2011: OECD INDICATORS © OECD 2011 25
1.1. Life expectancy at birth
1.1.1 Life expectancy at birth, 2009 (or nearest year), and years gained since 1960
Source: OECD Health Data 2011; World Bank and national sources for non-OECD countries.1 2 http://dx.doi.org/10.1787/888932523253
405060708090 0 5 10 15 20 25 30
83.082.381.881.881.681.681.581.481.081.080.880.780.780.680.480.480.380.380.380.080.080.079.579.579.079.078.478.2
77.375.875.375.075.0
74.073.873.3
72.671.2
68.764.1
51.7
15.210.9
12.012.0
10.79.9
8.68.3
10.77.2
9.79.4
11.37.1
11.79.6
11.210.4
27.910.2
11.010.0
15.611.2
6.610.5
21.48.3
6.78.0
17.86.5
4.46.0
25.526.7
18.130.0
0.021.7
2.6
Life expectancy at birth, 2009 Years gained, 1960-2009
Years Years
JapanSwitzerland
ItalySpain
AustraliaIsrael
IcelandSwedenFranceNorway
New ZealandCanada
Luxembourg
OECDDenmark
NetherlandsAustria
United KingdomGermanyGreeceKorea
ChinaBrazil
SloveniaChile
United StatesCzech Republic
PolandMexicoEstonia
Slovak RepublicHungaryTurkey
BelgiumFinlandIreland
Portugal
IndonesiaRussian Federation
IndiaSouth Africa
1.1.2 Life expectancy at birth and GDP per capita, 2009 (or nearest year)
Source: OECD Health Data 2011; World Bank and national sources fornon-OECD countries.
1 2 http://dx.doi.org/10.1787/888932523272
0 10 000 20 000 30 000 40 000 50 000 60 000 70 000
84
80
76
72
68
64
JPNCHEITAESP
AUSISR
ISLSWE
NOR
FRANZL
LUXCAN
NLD
AUTGBR
DEU
GRCKOR
IRL
BEL
FIN
PRT
DNKSVN USACHLCZE
POL
MEX SVKEST
HUNTURCHN BRA
IDN
RUS
IND
R! = 0.54
GDP per capita (USD PPP)
Life expectancy in years
1.1.3 Life expectancy at birth and health spending per capita, 2009 (or nearest year)
Source: OECD Health Data 2011; World Bank and national sources fornon-OECD countries.
1 2 http://dx.doi.org/10.1787/888932523291
0 2 000 4 000 6 000 8 000
84
80
76
72
68
64
R! = 0.69
AUS
AUT
BEL
BRA
CAN
CHLCZE
DNK
EST
FINFRA
DEUGRC
HUN
ISL
IND
IDN
CHN
IRL
ISR ITA
JPN
KOR
LUX
MEX
NLDNZL NOR
POL
PRT
RUS
SVK
SVN
ESP SWE CHE
TUR
GBRUSA
Health spending per capita (USD PPP)
Life expectancy in years
Il costo della salute
OECD Health Data 2011; WHO Global Health Expenditure Database
Aspettativa di vita alla nascita e spese sanitarie 2009
Crescita annua delle spese sanitarie pro capite
domenica 30 novembre 2014
Illimitato progresso tecnologico (senza riguardo per i costi a lungo termine)
L’ innovazione tecnologica definisce gli obiettivi della sanità
(modifica continuamente i mezzi e i fini)
Il complesso medico-industriale guida il progresso e gli obiettivi della medicina
L’identità culturale della medicina moderna
Il modello contemporaneo è basato sul progresso infinito
Daniel Calllahan, Sustainable Medicine: Two Models of Health Care! ! Giannino Bassetti Foundation - 2005
domenica 30 novembre 2014
Visione lineare(Modello prometeico)
L’identità culturale, che è una specificità spazio-temporale,
diminuisce la possibilità di trovare modelli o soluzioni alternative
Il “cultural lock in”
domenica 30 novembre 2014
Il modello contemporaneo di medicina “scientifica”
Progresso tecnico e creazione di un massiccio complesso medico-industriale
Caratteristiche:
•Terapia invece che cura (cure rather than care)•Interventi tecnologici invece che promozione ! della !salute/prevenzione•Maggiore attenzione alle patologie acute che a quelle croniche•Paradigma quantitativo: durata piuttosto che qualità della vita
Daniel Calllahan, Sustainable Medicine: Two Models of Health Care! ! Giannino Bassetti Foundation - 2005
domenica 30 novembre 2014
Attualmente non esiste, in nessun paese, un Sistema Sanitario sostenibile
Aumento dellʼetà media e dei bisogni di curaAumento continuo del costo della tecnologia (con benefici marginali)
RisultatoRischio del crollo dellʼidea di Sistemi Sanitari “universali”
Se le cure non sono sostenibili non possono essere equamente distribuite
Discriminazione di censo
L’aporia del modello contemporaneo
domenica 30 novembre 2014
Tutto questo è fantastico, ma che cosa succederà se non potremo più permettercelo?
domenica 30 novembre 2014
USA, Ottobre 2013
domenica 30 novembre 2014
Sostenibilità: Legge dei ritorni marginali decrescenti
In economia, I ritorni marginali di un fattore di produzione in genere diminuiscono con l’aumento di input del fattore
medesimo!
David Ricardo. On the Principles of Political Economy and Taxation (1817)
Decrescita del ritorno per aumento della complessità !! J. Tainter, The collapse of complex society 1988
Col 20% degli investimenti può essere ottenuto l’80% di successo; ma è necessario l’80% degli
investimenti per arrivare al 100%
domenica 30 novembre 2014
Produttività del sistema sanitario U.S.A. 1930-1982.
Indice di Produttività = Aspettativa di vita/ spese per la sanitàTainter, The collapse of complex society ,1988
Sostenibilità: Legge dei ritorni marginali decrescenti
domenica 30 novembre 2014
Crisi economica
Il nostro modello è sostenibile?
Scarsità materie prime
Sovrappopolazione
Cambiamento climatico
Guerre per le risorse
Disoccupazione
Migrazioni
Distruzione della biosferaPicco del petrolio
OTC 2009 Topical LuncheonHouston, Texas
Le esigenze dell’economia e quelle ecologiche sono radicalmente irreconciliabili Probabilmente sarebbe necessaria una depressione economica mondiale di entità
catastrofica per salvare la specie umana dal rischio di estinzione Philip Goodchild, Capitalism and religion, 2002
domenica 30 novembre 2014
Il caso della Russia dopo il crollo dell’Unione sovietica
Vladimir M. Shkolnikov, France Mesle:The Russian Epidemiological Crisis as Mirrored by Mortality TrendsIn: DaVanzo, Julie and Gwen Farnsworth. Russia's Demographic ''Crisis''. Santa Monica, CA: RAND Corporation, 1996.
domenica 30 novembre 2014
Anatomia di un secolo
domenica 30 novembre 2014
Anatomia di un secolo
domenica 30 novembre 2014
Condizioni di vita
IgieneAlimentazione
Tecnologia Medica
AntibioticiChirurgia asettica
Tecniche anestesiologiche
Aumento dell’aspettativa di vita XX secolo
domenica 30 novembre 2014
Poichè la malattia è universale, ogni società umana ha sviluppato un paradigma, una filosofia, una serie di
categorie per cercare di comprenderla.
Nelle moderne società industrializzate, esso si può definire cosiddetto “paradigma patogenetico”
Esso è alla base del complesso delle istituzioni sanitarie che abbiamo creato
Salutogenesi
Aaron Antonovsky, SALUTOGENESIS: STUDYING HEALTH VS. STUDYING DISEASE, 1990
www.salutogenesis.net A. Antonovsky . conference in Berlim 1
this is a www.salutogenesis.net initiative
post your message at
SALUTOGENESIS
EASESTUDYING DIS. STUDYING HEALTH VS Aaron Antonovsky
,Lecture at the Congress for Clinical Psychology and Psychotherapy 1990 February 19, Berlin
Abstract
The paper's point of departure is the proposal that the pathogenic paradigm which at present dominates disease research and clinical practice in the industrialized world is of decreasing power as we try to understand and deal with the health and illness of human beings. The limitations of the paradigm are not resolved by preventive medicine or the biopsychosocial model. Five important contrasts are presented to show that the difference between the pathogenic and the salutogenic model, which posits that the great mystery is the origin of
health, are fundamental.
The search for the answer to the question "What explains movement toward the health end of the health/ illness continuum?" led to formulation of the sense of coherence concept and its three components, comprehensibility, manageability and meaningfulness. The overarching hypothesis, then, became: the stronger the SOC, the greater the likelihood of moving toward
the health end of the continuum.
The major determinants of the SOC are located in macrosocial and historical factors. Finally, it is noted that there are many roads to a strong SOC and health, and that health is not the only
value in human life.
domenica 30 novembre 2014
1. Come è classificato lo stato di salute delle persone?Classificazione dicotomica (salute/malattia) piuttosto che secondo un
continuum
2. Che cosa bisogna comprendere e trattare?Diagnosi specifica vs. valutazione dello stato di salute globale
3. Quali sono i fattori eziologici importanti?Fattori di rischio particolari vs. “storia” globale del paziente
4. Come sono concettualizzati i fattori di stress?Fattori inusuali e patogenetici vs fattori di ubiquitari e non direttamente
causali
5. Come trattare la sofferenza? Guerra coi “proiettili magici” contro la malattia vs rafforzamento delle
risorse personali
Salutogenesi
domenica 30 novembre 2014
Salute
Promotori di Malattia(esogeni e endogeni)
Inibitori di malattia(esogeni e endogeni
L’organismo umano è un sistema adattativo complesso (Prigogine: struttura dissipativa) ed è, quindi, soggetto all’entropia
Il vero mistero non è comprendere perchè le persone si ammalano e muoiono. Il vero mistero è capire perchè alcune persone hanno una salute migliore di altre
domenica 30 novembre 2014
Carta di Ottawa (1986): requisiti fondamentali per la salute
Pace Adeguate risorse economiche
Alimentazione Abitazione
Ambiente di lavoroSviluppo personale
Comunità Ecosistema stabile
Uso sostenibile delle risorse.
Salute
"Uno stato di completo benessere fisico, mentale e sociale e non la semplice assenza dello stato di malattia o di infermità." (WHO, 1948)
Inestricabili legami esistenti tra le condizioni socioeconomiche, l'ambiente fisico, lo stile di vita delle persone e la salute
domenica 30 novembre 2014
Occupational class differences in life expectancy, England and Wales, 1997–1999
Life expectancy is shorter and most diseases are more common further down the social ladder in each society. Health policy must tackle the social and economic determinants of health.
What is known
Poor social and economic circumstances affect health throughout life. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Nor are the effects confined to the poor: the social gradient in health runs right across society, so that even among middle-class office workers, lower ranking staff suffer much more disease and earlier death than higher ranking staff (Fig. 1).
Both material and psychosocial causes contribute to these differences and their effects extend to most diseases and causes of death.
Disadvantage has many forms and may be absolute or relative. It can include having few family assets, having a poorer education during adolescence, having insecure employment, becoming stuck in a hazardous or dead-end job, living in poor housing, trying to bring up a family in difficult circumstances and living on an inadequate retirement pension.
These disadvantages tend to concentrate among the same people, and their effects on health accumulate during life. The longer people live in stressful economic and social circumstances, the greater the physiological wear and tear they suffer, and the less likely they are to enjoy a healthy old age.
Policy implications
If policy fails to address these facts, it not only ignores the most powerful determinants of health standards in modern societies, it also ignores one of the most important social justice issues facing modern societies.
• Life contains a series of critical transitions: emotional and material changes in early childhood, the move from primary to secondary education, starting work, leaving home and starting a family, changing jobs and facing possible redundancy, and eventually retirement. Each of these changes can affect health by pushing people onto a more or less advantaged path. Because people who have been disadvantaged in the past are at the greatest risk in each subsequent transition, welfare policies need to provide not only safety nets but also springboards to offset earlier disadvantage.
10
Professional
Skilled non-manual
Managerial and technical
64LIFE EXPECTANCY (YEARS)
Skilled manual
Partly skilled manual
Unskilled manual
Men Women
66 68 70 72 74 76 78 80 82 84
OCC
UPA
TIO
NA
L CL
ASS
1 . T H E S O C I A L G R A D I E N T
Fig. 1. Occupational class differences in life expectancy, England and Wales, 1997–1999
Donkin A, Goldblatt P, Lynch K. Inequalities in life expectancy by social class 1972–1999. Health
Statistics Quarterly, 2002
18
Stress in the workplace increases the risk of disease. People who have more control over their work have better health.
What is known
In general, having a job is better for health than having no job. But the social organization of work, management styles and social relationships in the workplace all matter for health. Evidence shows that stress at work plays an important role in contributing to the large social status differences in health, sickness absence and premature death. Several European workplace studies show that health suffers when people have little opportunity to use their skills and low decision-making authority.
Having little control over one’s work is particularly strongly related to an increased risk of low back pain, sickness absence and cardiovascular disease (Fig. 4). These risks have been found to be independent of the psychological characteristics of the people studied. In short, they seem to be related to the work environment.
Studies have also examined the role of work demands. Some show an interaction between demands and control. Jobs with both high demand and low control carry special risk. Some evidence indicates that social support in the workplace may be protective.
Further, receiving inadequate rewards for the effort put into work has been found to be associated with increased cardiovascular risk. Rewards can take the form of money, status and self-esteem. Current changes in the labour market may change the opportunity structure, and make it harder for people to get appropriate rewards.
These results show that the psychosocial environment at work is an important determinant of health and contributor to the social gradient in ill health.
Policy implications
• There is no trade-off between health and productivity at work. A virtuous circle can be established: improved conditions of work will lead to a healthier work force, which will lead to improved productivity, and hence to the opportunity to create a still healthier, more productive workplace.
• Appropriate involvement in decision-making is likely to benefit employees at all levels of an organization. Mechanisms should therefore be developed to allow people to influence the design and improvement of their work
Fig. 4. Self-reported level of job control and incidence of coronary heart disease in men and women
5 . W O R K
Adjusted for age, sex, length of follow-up, effort/reward imbalance, employment grade, coronary risk factors and negative psychological disposition
RISK
OF
CORO
NA
RY H
EART
DIS
EASE
(WIT
H H
IGH
JOB
CON
TRO
L SE
T AT
1.0
)
2.5
2.0
1.5
1.0
JOB CONTROL
High Intermediate Low
Self-reported level of job control and incidence of coronary heart disease
( opportunity to use skills and decision-making authority)
Bosma H et al. Two alternative job stress models and risk of coronary heart disease. American Journal of Public Health, 1998
Salute
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KEY SOURCES
27
Fig. 8. Mortality from coronary heart disease in relation to fruit and vegetable supply in selected European countries
Diet, nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert Consultation. Geneva, World Health Organization, 2003 (WHO Technical Report Series, No. 916) (http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf, accessed 14 August 2003)
First Action Plan for Food and Nutrition Policy [web pages]. Copenhagen, WHO Regional Office for Europe, 2000 (http://www.euro.who.int/nutrition/ActionPlan/20020729_1, accessed 14 August 2003).
Roos G et al. Disparities in vegetable and fruit consumption: European cases from the north to the south. Public Health Nutrition, 2001, 4:35–43
Systematic reviews in nutrition. Transforming the evidence on nutrition and health into knowledge [web site]. London, University College London, 2003 (http://www.nutritionreviews.org/, accessed 14 August 2003).
World Cancer Research Fund. Food, nutrition and the prevention of cancer: a global perspective. Washington, DC, American Institute for Cancer Research, 1997 (http://www.aicr.org/exreport.html, accessed 14 August 2003).
Source of Fig. 8: FAOSTAT (Food balance sheets) [database online]. Rome, Food and Agriculture Organization of the United Nations, 25 September 2003.
WHO mortality database [database online]. Geneva, World Health Organization, 25 September 2003.
Health for all database [database online]. Copenhagen, WHO Regional Office for Europe, 25 September 2003.
Policy implications
Local, national and international government agencies, nongovernmental organizations and the food industry should ensure:
• the integration of public health perspectives into the food system to provide affordable and nutritious fresh food for all, especially the most vulnerable;
• democratic, transparent decision-making and accountability in all food regulation matters, with participation by all stakeholders, including consumers;
• support for sustainable agriculture and food production methods that conserve natural resources and the environment;
• a stronger food culture for health, especially through school education, to foster people’s
900
800
700
600
500
400
300
200
100
0 100 150 200 250 300 350 400 450
Greece
AG
E-ST
AN
DA
RDIZ
ED D
EATH
RA
TES
PER
100
000
MEN
AG
ED 3
5–74
SUPPLY OF FRUIT AND VEGETABLES (KG/PERSON/YEAR)
Ukraine
Russian Federation
Lithuania
Poland
Germany
FranceSpain
Belarus
knowledge of food and nutrition, cooking skills, growing food and the social value of preparing food and eating together;
• the availability of useful information about food, diet and health, especially aimed at children;
• the use of scientifically based nutrient reference values and food-based dietary guidelines to facilitate the development and implementation of policies on food and nutrition.
United Kingdom
Italy
Mortality from coronary heart disease in relation to fruit and vegetable supply in selected European countries
FAOSTAT (Food balance sheets) [database online]. Rome, Food and Agriculture Organization of the United Nations, 25 September 2003.
KEY SOURCES
21
Beale N, Nethercott S. Job-loss and family morbidity: a study of a factory closure. Journal of the Royal College of General Practitioners, 1985, 35:510–514.
Bethune A. Unemployment and mortality. In: Drever F, Whitehead M, eds. Health inequalities. London, H.M. Stationery Office, 1997.
Burchell, B. The effects of labour market position, job insecurity, and unemployment on psychological health. In: Gallie D, Marsh C, Vogler C, eds. Social change and the experience of unemployment. Oxford, Oxford University Press, 1994:188–212.
Ferrie J et al., eds. Labour market changes and job insecurity: a challenge for social welfare and health promotion. Copenhagen, WHO Regional Office for Europe, 1999 (WHO Regional Publications, European Series, No. 81) (http://www.euro.who.int/document/e66205.pdf, accessed 15 August 2003).
Iversen L et al. Unemployment and mortality in Denmark. British Medical Journal, 1987, 295:879–884.
Source of Fig. 5: Ferrie JE et al. Employment status and health after privatisation in white collar civil servants: prospective cohort study. British Medical Journal, 2001, 322:647–651.
Fig. 5. Effect of job insecurity and unemployment on health
Policy implications
Policy should have three goals: to prevent unemployment and job insecurity; to reduce the hardship suffered by the unemployed; and to restore people to secure jobs.
• Government management of the economy to reduce the highs and lows of the business cycle can make an important contribution to job security and the reduction of unemployment.
• Limitations on working hours may also be beneficial when pursued alongside job security and satisfaction.
Unemployed
RISK
OF
ILL
HEA
LTH
(WIT
H S
ECU
RELY
EM
PLO
YED
SET
AT
100)
Long-standing illness
Poor mental health
EMPLOYMENT STATUS
Securely employed
Insecurely employed
300
250
200
150
100
50
0
• To equip people for the work available, high standards of education and good retraining schemes are important.
• For those out of work, unemployment benefits set at a higher proportion of wages are likely to have a protective effect.
• Credit unions may be beneficial by reducing debts and increasing social networks.
Effect of job insecurity and unemployment on health
Ferrie JE et al. Employment status and health after privatisation in white collar civil servants: prospective cohort
study. British Medical Journal, 2001KEY SOURCES
25
Fig. 7. Socioeconomic deprivation and risk of dependence on alcohol, nicotine and drugs, Great Britain, 1993
Bobak M et al. Poverty and smoking. In: Jha P, Chaloupka F, eds. Tobacco control in developing countries. Oxford, Oxford University Press, 2000:41–61.
Makela P, Valkonen T, Martelin T. Contribution of deaths related to alcohol use of socioeconomic variation in mortality: register based follow-up study. British Medical Journal 1997, 315:211–216
Marsh A, McKay S. Poor smokers. London, Policy Studies Institute, 1994.
especially in the case of tobacco, has hampered efforts by governments to use price mechanisms to limit consumption.
Policy implications
• Work to deal with problems of both legal and illicit drug use needs not only to support and treat people who have developed addictive patterns of use, but also to address the patterns of social deprivation in which the problems are rooted.
• Policies need to regulate availability through pricing and licensing, and to inform people about less harmful forms of use, to use health education to reduce recruitment of young people and to provide effective treatment services for addicts.
• None of these will succeed if the social factors that breed drug use are left unchanged. Trying to shift the whole responsibility on to the user is clearly an inadequate response. This blames the victim, rather than addressing the complexities of the social circumstances that generate drug use. Effective drug policy must therefore be supported by the broad framework of social and economic policy.
Meltzer H. Economic activity and social functioning of residents with psychiatric disorders. London, H.M. Stationery Office, 1996 (OPCS Surveys of Psychiatric Morbidity in Great Britain, Report 6).
Ryan, M. Alcoholism and rising mortality in the Russian Federation. British Medical Journal, 1995, 310:646–648.
Source of Fig. 7: Wardle J et al., eds. Smoking, drinking, physical activity and screening uptake and health inequalities. In: Gordon D et al, eds. Inequalities in health. Bristol, The Policy Press, 1999:213–239.
DEPRIVATION SCORE
RISK
OF
DEP
END
ENCE
(WIT
H M
OST
AFF
LUEN
T SE
T A
T 1)
Most affluent
Most deprived
10
9
8
7
6
5
4
3
2
1
00 1 2 3 4
Alcohol
Nicotine
Drugs
Socioeconomic deprivation and risk of dependence on alcohol, nicotine and drugs, Great Britain, 1993
Wardle J et al., eds. Smoking, drinking, physical activity and screening uptake and health inequalities. In: Gordon D et al,
eds. Inequalities in health. Bristol, 1999
Salute
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Metabolismo sociale
Processo economico (nel mondo reale)Processo termodinamico
Flusso di materia ed energia a bassa entropia
Flusso di materia ed energia ad alta entropia (inquinamento, rifiuti)
domenica 30 novembre 2014
Che cos’è la ricchezza?
La ricchezza (wealth) non è altro che materia ed energia in forme utilizzabili dagli uomini e dal metabolismo sociale
domenica 30 novembre 2014
Conflitto inevitabile tra concezione economica che richiede crescita esponenziale e mondo fisico
La crescita del consumo di materia/energia ha limiti finiti mentre la crescita monetaria (che è un’astrazione )
non ne ha alcuno
Economia astratta e “mondo fisico”
domenica 30 novembre 2014
La ricchezza reale (i beni) obbedisce alle leggi della termodinamica
Il denaro è un’unita di misura simbolica che può essere creata dal nulla e distrutta a piacimento
Non si può contrapporre un’assurda convenzione come l’incremento spontaneo del debito (interesse composto) alla legge naturale dello spontaneo decremento della ricchezza
(entropia) Frederick Soddy
Ricchezza reale e virtuale
domenica 30 novembre 2014
AlimentazioneValore d’uso
Proprietà nutrizionali
Proprietà organolettiche
Impatto ambientale
domenica 30 novembre 2014
• Privilegiare il Trasporto di persone e merci per nave e ferrovia (in ordine decrescente: acqua, ferro, asfalto)• Modificare la catena distributiva alimentare e prediligere il
cibo prodotto nelle vicinanze (filiera corta)• Favorire l’agricoltura biologica poichè necessita di minori
apporti di combustibili fossili• Limitare la produzione globalizzata che richiede il trasporto
delle merci per migliaia di chilometri
Matthew P. Simmons, Banchiere e consigliere strategico per l’energia di G.W.Bush
Suggerimenti per la sostenibilità
domenica 30 novembre 2014
L’energia fossile necessaria per una dieta mista è circa il doppio di quella necessaria per una dieta
vegetariana
!
Dieta vegetariana e dieta mista
domenica 30 novembre 2014
!
!
…..E così anche il tempo
domenica 30 novembre 2014
Più della metà dei cereali prodotti negli USA (40% nel mondo) usata per alimentazione animale (323 MT)
Pimentel and Pimentel,Food, Energy, and Society, CRC Press 2008)
Consumo cereali pro capite USA (1997): 1015 Kg116 consumo diretto, 615 alimentazione animale, 100
produzone birra, più altri usi (dolcificanti, melasse, ecc)
Consumo cereali pro capite nel mondo (1997): 345 kg160 consumo diretto, 185 altri usi
M. Giampietro,Multi-scale integrated analysis of agro-ecosystems, CRC Press 2004
L’impatto delle proteine animali
domenica 30 novembre 2014
!
Il “costo” delle proteine animali
domenica 30 novembre 2014
!
Consumo idrico nella produzione di alimenti (traspirazione)
domenica 30 novembre 2014
Undertaking primary prevention at the source to reduce health risks resulting from these global influences is a formidable challenge.
It requires conceptual insights beyond the conventional understanding of causation and prevention, as well as political will, trust, and
resources.
For populations to live sustainably and with good long-term health, the health sector must work with other sectors in reshaping how
human societies plan, build, move, produce, consume, share, and generate energy.
Globalization, Climate Change, and Human HealthAnthony J. McMichael, M.B., B.S., Ph.D. N Engl J Med 2013
Un concetto più ampio di “prevenzione”
domenica 30 novembre 2014
Il paradigma patogenetico è sempre meno efficace nel cercare di comprendere e trattare la malattia cronica. Le limitazioni di questo paradigma non sono risolte
neppure dalla medicina preventiva o dal modello psicosociale
Aaron Antonovsky, SALUTOGENESIS STUDYING HEALTH VS. STUDYING DISEASE, 1990
domenica 30 novembre 2014
Antonovsky “Sense of coherence”
Sense of coherence: Percezione di pienezza di significato della propria vita
Il SOC è possibile soltanto in una società che favorisca l’autonomia, la creatività, l’equanimità, il calore nelle relazioni
umane, la dignità e il rispetto delle persone
Aaron Antonovsky, SALUTOGENESIS STUDYING HEALTH VS. STUDYING DISEASE, 1990
Maggiore è il “sense of coherence” di una persona, più essa sarà in grado di far fronte agli invitabili fattori patogenetii
dellaesistenza
domenica 30 novembre 2014
Grazie per l’attenzione
domenica 30 novembre 2014