By Z. Sigmor. Globe Institute of Technology.

Today there is a tendency to believe that people become ill because they want to (as for example in the view that cancer results from ‘stress’ or depression) or because they deserve to (because they smoke or drink too much) purchase sildigra 25 mg amex erectile dysfunction treatment san francisco. While people who succumb to viruses or bacteria are generally regarded as unfortunate and worthy of sympathy buy generic sildigra 25mg on line erectile dysfunction therapy treatment, those who get cancer or heart disease are, at least to a degree, held up to blame for their unhealthy lifestyle. Infection with HIV, though a virus, is ideally suited to the prevailing discourse of individual moral culpability because of its major modes of transmission in Britain—through sex, particularly gay sex, and drug abuse. If disease is the wages of sin in modern Britain, medicine has become a quasi-religious crusade against the old sins of the flesh. The trend for religion to give way to science and for the scientist to take over the role of the priest has been a feature of modern society since the Enlightenment. The success of scientific medicine in the twentieth century has particularly enhanced the social prestige of the 6 INTRODUCTION medical profession. Yet it seems that the final triumph of doctors as guardians of public morality comes at a time when they are generally incapable of explaining or curing the major contemporary causes of death and disease. Successive governments have taken up the issue of health as a convenient vehicle for promoting the gospel of individual responsibility in a period of increasing fragmentation and insecurity. From the late 1970s onwards, advocates of the new public health have promoted the World Health Organisation’s definition of health as ‘a state of complete physical, mental and social wellbeing’ to legitimise the expansion of state medical intervention into wider areas of the life of society (MacKenzie 1946). Though given some impetus by the Health of the Nation initiative of the early 1990s, there was always some Conservative reticence about the level of state intervention it demanded. It was not until after the Labour victory in 1997 that the agenda of the new public health could be implemented without restraint. By the time of the 1998 public health Green Paper, the conception of health put forward by the government seemed to have little to do with disease at all. At the outset it defined good health as ‘the foundation of a good life’ (DoH February 1998:7). This recalls the classical motto, popularised in the Victorian era— ‘a healthy mind in a healthy body’—and establishes a link between physical condition and moral character. It implies that self- discipline and abstinence, the ‘mortification of the flesh’, can improve the quality of life, in a sense by purifying the soul. Even more insidiously and offensively, it also implies that physical impairment or disease either express or entail moral turpitude, a ‘bad’ life. However, by contrast with the Victorian notion of a link between individual fitness and national efficiency, New Labour’s interest in health is not inspired by any wider social vision. On the contrary, it reflects the outlook of a society which has abandoned any grand project, in which the horizons of the individual have been reduced to their own body: No matter what goes wrong in life—money, work or relationship problems—good health helps sustain us. How often have we all heard somebody say that although things may not be going well—at least they have their health. In a society of low expectations, the goal of human existence is redefined as the quest to prolong its duration. Once health is linked with virtue, then the regulation of lifestyle in the name of health becomes a mechanism for deterring vice and for disciplining society as a whole. The new government health policies no longer focus on health in the familiar sense of treating illness and disease, but rather encourage a redefinition of health in terms of the ways in which we live our lives. Under cover of the dubious notion that an extended life (at whatever cost to ourselves and to society) is good for us, the government is providing, and even imposing, its version of the good life. This good life is not simply a longer life, but a longer life lived healthily, which is to say, virtuously. This process is nonetheless insidious for being both well- intentioned and well-supported by many doctors, medical bodies and voluntary organisations. While answering the deep need of some for a framework through which to pull society together in troubled times, for those who are unable or unwilling to respond to the demands of the new public health, it may well be experienced as paternalistic if not overtly oppressive. One of the few writers to comment on the moralising of disease from a liberal humanist viewpoint is the American critic Susan Sontag. In Illness as Metaphor, published in 1978 following her personal experience of cancer, she discussed the way in which the myth of individual responsibility has shifted in modern times from tuberculosis to cancer. In her 1989 sequel, Aids and its Metaphors, she noted that the main theme in the response to Aids in the USA is the backlash against the ‘permissiveness’ of the sixties: ‘fear of sexuality is the new, disease-sponsored register of the universe of fear in which everyone now lives’ (Sontag 1989:159). She regretted the impact of the Aids panic in America in both reinforcing moralistic attitudes towards sex and the wider culture of individualism. Sontag also reflected on the reasons why the Aids panic had such a resonance in modern America. She noted the popularity of apocalyptic scenarios such as nuclear holocaust and ecological catastrophe, reflecting a sense of cultural distress and of society reaching a terminus: ‘There is a broad tendency in our culture, an end-of-an-era feeling, that Aids is reinforcing; an exhaustion for many of purely secular ideals’ (Sontag 1989:164). While people with Aids adopted programmes of self-management and 8 INTRODUCTION selfdiscipline, diet and exercise, Sontag recognised that the wider Aids panic connected with a public mood of restraint, ‘a positive desire for stricter limits on the conduct of personal life’, encouraging attitudes such as ‘Watch your appetites. The prevailing climate of impending doom provided ideal conditions for health scares and for the promotion of virtuous life-styles. In response to criticisms of the ‘victim-blaming’ character of much health promotion propaganda, its leading advocates have attempted to soften its individualistic emphasis.

Many spinal cord injuries happen to late adolescents or young adults at the stage when they are beginning to form relationships 57 ABC of Spinal Cord Injury and establish independence from parents sildigra 50mg sale erectile dysfunction drugs from india, and they may be very concerned about their ability to do so generic 50 mg sildigra fast delivery erectile dysfunction help. It takes time and the realisation that people do think that they are still worthwhile before necessary self-esteem can return. These adjustments are likely to take place after discharge from hospital because then the issues become clearer. Many people find that the initial period after discharge can be very stressful. Work is of varying importance to patients, but most will see it as giving a sense of purpose to their life and crucial to their self-esteem, and will want to return to their former occupation if at all possible. Early contact with the patient’s employer to discuss the feasibility of eventual return to his or her previous job is important. If the degree of a patient’s disability precludes this, some employers are sympathetic and flexible and will offer a job that will be possible from a wheelchair. However, many patients initially find life outside hospital difficult enough, having to cope with their disability and adjust to living again in the community, without having the added responsibility of a job. In these circumstances a period of adjustment at home is advisable before they return to work, as it may be two or three years or longer before a patient is psychologically rehabilitated. If patients are keen to return to their previous job, school, Figure 11. Recommendations are then made to the placement, assessment, and counselling team (PACT) or local education authority, if alterations to the buildings or the installation of Box 11. If patients are considering returning to work, time spent in a rehabilitation workshop can be helpful. In this environment they should be able to test their aptitude for activities such as carpentry, engineering, electronics and computer work, build Box 11. Benefits to assist with disability: Good community support, including practical help with the • Disability Living Allowance (DS 704) tasks of caring, and also the imaginative provision of resources • Attendance Allowance (if over 65 years of age) (DS 702) • Disabled Person’s Tax Credit (information available from the to enable the person and carers to participate in normal Inland Revenue) community activities, are likely to help the process. Tired • Industrial Disablement Benefit (DB1) people who have limited social satisfactions will find it more • NHS Charges and Optical Voucher Values (HC12) difficult to make the necessary adjustments. Studies indicate that people with spinal cord Income maintenance benefits: • Statutory Sick Pay (for 28 weeks) (information available from the injuries are not as psychologically distressed or depressed by Inland Revenue) if in employment and not self employed their injury as able-bodied people, including experienced staff, or imagine. Many people with spinal cord injury do lead active • Incapacity Benefit (IB1 IB203) up to 28 weeks if self-employed fulfilling lives, though this may take time to achieve. If 16–20, or under 25 and in full time education, contributions discounted Finance If not enough contributions Adequate finance is a major factor in determining successful • Income Support (IS20) means tested (SD2) • Severe Disablement Allowance (if eligible) (SD3) if claimed rehabilitation, but many severely disabled people are living in before April 2001. Not only do patients and their families have to cope with all Income Support will “top up” any of the above if income is below the the stresses of injury; they may have to live on a severely reduced assessed needs level. It is also • War Disablement Pension (WPA—leaflet—1) more expensive to live as a disabled person. Disability Living • Housing Benefit and Council Tax Benefit (administered by Allowance, or Attendance Allowance for over 65 year olds, district councils) (RR2) provides some help with the more obvious costs, but no provision • Invalid Care Allowance (SD4) (paid to some carers) exists for tasks such as decorating, repairs, and gardening, which • Working Families Tax Credit (information available from the the disabled person may no longer be able to perform. Inland Revenue) Even if the person receives financial compensation this may (DSS leaflet numbers are given in parentheses) take several years to be granted, and though interim payments 58 Social needs of patient and family can be made, in some circumstances they are not always Table 11. Because of the interruption in, or possible loss of, earning Where patients go % capacity many people will be dependent for long periods on Able to return to own home with adaptations 55 welfare benefits administered by the Department of Social Had to move to live with relatives 11 Security. These are complex, and various studies have shown Required rehousing provided by District Council that many disabled people are receiving less than their or Housing Association 29 entitlement, sometimes by quite substantial amounts. It is Required rehousing, patient or family bought property 5 therefore important for those working with disabled people to be aware that they may be underclaiming benefits and to advise them accordingly. Housing presents a continuing problem because, • Accessible light switches, sockets, door locks though patients may return to an adapted house or be • Accessible kitchen and facilities rehoused from hospital, they may well want to change house in • Patio area in the garden the future, especially as spinal cord injuries typically occur in • Thermostatically controlled heating system young people who would normally move house several times. A • Through-floor lift or stair lift disabled person may have difficulty in finding a suitable house, • Internal ramps and there can be time restrictions on further provision of grants for adaptations. There are also mandatory and discretionary limitations on grants which may be made available to assist in the adaptation of a property. Many people find the discrepancy between local authorities in their interpretation of the legislation around this frustrating. Consequently, any move can be difficult to achieve and has to be planned well Employment—what patients do % ahead. The services of community occupational therapists, In work or job left open 30 housing departments, and social workers may be required. In education or training 10 A considerable number of statutory services are concerned No employment on discharge, but previously employed 38 with providing services for disabled people. Voluntary No employment on discharge—not employed when admitted 22 organisations also provide important resources. They can act as pressure and self-help groups, and organisations of disabled people have the knowledge and understanding born of personal experience. Tel: 0800 882200 in what they can provide in different geographical areas, is a • Citizens Advice Bureau major undertaking. Too often disabled people fail to receive a • DIAL (Disabled Information Advice Line) (Name of town)—A service that would be of benefit or they may feel overwhelmed voluntary organisation operating in some areas and not in control of their own lives, with consequent damage • Disability Rights Handbook (Price £11. Disabled people and their families annually by the Disability Alliance Educational & Research should have access to full information about the services Association, Universal House, 88–94 Wentworth Street, London available and be enabled to make their own decisions about E1 7SA.

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Rabbit blood is preferred if the target bacterium is from reaction of the blood to the growth conditions used (37° C in the group known as group A Streptococcus cheap 50mg sildigra visa erectile dysfunction causes nhs. Gamma hemolysis is a char- preferred if the target bacterium is Haemophilus para- acteristic of Enterococcus faecalis buy 100mg sildigra mastercard erectile dysfunction and premature ejaculation underlying causes and available treatments. Certain species of bacte- It is typically not used for this purpose, however, due to the ria, such as group B Strep (n example is Streptococcus agalac- expense of the medium. Other, less expensive agars will do the tiae) are weakly beta-hemolytic. What blood agar is uniquely suited for is the deter- in close proximity with a strain of Staphylococcus the beta- mination of hemolysis. This forms the basis of a test blood cells by a bacterial protein known as hemolysin, which called the CAMP test (after the initials of its inventors). The determination of hemolysis and of the hemolytic Many types of bacterial posses hemolytic proteins. These pro- reactions is useful in distinguishing different types of bacteria. For example, a beta hemolytic reaction is brane or disrupting the structure of the membrane in some indicative of a Streptococcus. The exact molecular details of hemolysin action is organisms with bacitracin is often the next step. Streptococcus pyogenes strains are almost unifor- remove a molecule called fibrin, which participates in the clot- mally sensitive to bacitracin. The absence of fibrin ensures that clotting of the Streptococcus are not bacitracin sensitive. See also Laboratory techniques in microbiology; Staphylo- There are three types of hemolysis, designated alpha, cocci and staphylococcal infections; Streptococci and strepto- beta and gamma. Alpha hemolysis is a greenish discoloration coccal infections that surrounds a bacterial colony growing on the agar. This type of hemolysis represents a partial decomposition of the hemoglobin of the red blood cells. Alpha hemolysis is charac- teristic of Streptococcus pneumonia and so can be used as a Blood borne infectionsBLOOD BORNE INFECTIONS diagnostic feature in the identification of the bacterial strain. Beta hemolysis represents a complete breakdown of the Blood borne infections are those in which the infectious agent hemoglobin of the red blood cells in the vicinity of a bacterial is transmitted from one person to another in contaminated colony. Infections of the blood can occur as a result of the hemolysis is characteristic of Streptococcus pyogenes and spread of an ongoing infection, such as with bacteria includ- some strains ofStaphylococcus aureus. Gamma hemolysis is a lack of hemolysis in the area ever, the latter re considered to be separate from true blood- around a bacterial colony. Bacterial blood borne infection can occur, typically in Exposure to the blood from an infected person or the sharing of the transfusion of blood. Such infections arise from the con- needles among intravenous drug users can transmit these tamination of the site of transfusion. In Canada, the contamination of rate of such infections is scarce, the risk of transmission of donated blood and blood products with the hepatitis viruses bacterial infections via transfusions is thought to be at least and HIV in the 1980s sickened thousands of people. For example, figures from the system for blood donation and the monitoring guidelines the United States Food and Drug Administration indicate that for the blood and blood products was completely overhauled. Since then, example, it has been estimated that the chances of acquiring a definitive tests for the hepatitis C virus at the nucleic acid level urinary tract infection (which can subsequently spread to the have been developed and put into routine use. These so-called hem- tions, the typical agents of concern in blood borne infections are protozoa and viruses. The protozoan Trypanosoma brucei orrhagic fevers may have become more prominent because of is transmitted to humans by the bite of the tsetse fly. The sub- human encroachment onto formerly wild regions, particularly sequent infection of the blood and organs of the body produces in Africa. Open wounds present an opportunity With respect to viral blood borne diseases, hepatitis A, for blood to splatter on a cut or scratch of a doctor or nurse. For example, in the United States, some 20% of adult Oscillatoria, Spirulina, Microcystis, and Anabaena hemophiliacs are infected with HIV, about 56% are infected Cyanobacteria were monumentally important in shap- with the hepatitis B virus, and almost 90% are infected with ing life on this planet. HIV is the most common cause of death human and other life was generated by cyanobacterial activity among hemophiliacs. Many oil deposits that were laid down in Other viruses pose a potential for blood borne transmis- the Proterozoic Era were due the activity of cyanobacteria. Human herpesvirus 6 and 7, Epstein-Barr virus and Another huge contribution of cyanobacteria is their role in the cytomegalovirus require close contact between mucous mem- genesis of plants. The plant organelle known as a chloroplast, branes for person-to-person transfer. Abrasions in the genital which the plant uses to manufacture food, is a remnant of a area may allow for the transfer of the viruses in the blood. The microbes also contain the same chlorophyll resulted in an increase in the incidence of certain blood borne a compound used by plants.

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Certainly generic 100mg sildigra with mastercard impotence in men symptoms and average age, some “malingerers” use wheelchairs when they can really walk order sildigra 25 mg without a prescription erectile dysfunction treated by. Unscrupulous wheelchair vendors sometimes prey on people who cannot effectively use their items or ser- vices but can’t say no. Nonetheless, the overwhelming majority of people see walking as more convenient than wheeled mobility. This practical real- ity, compounded by strong internal and societal pressures, suggests that relatively few people seek mobility aids unless they actually need them. The system is carefully structured to prevent abuses that people with mo- bility difficulties probably rarely commit, but it carries the unfortunate consequence of impeding or denying valid needs. Policies to ensure strict separa- tions can save money, an important goal. Take someone like Jimmy Howard, in his late forties with a high school education. He was fired from his job because arthritis and foot problems prevented him from lifting heavy boxes, but he could do non- manual work, especially with a power wheelchair to get around quickly and efficiently (arthritis in his hands and elbows makes manual wheelchairs in- feasible). Jimmy has qualified for SSDI, but Social Security does not pay for assistive technologies, like a power wheelchair that could return him to “substantial gainful activity. Two years after receiving his first cash benefits, Jimmy will receive Medicare. He could then apply for a power wheelchair through Medicare but would almost certainly be denied: he does not need it at home, where he still navigates with his cane. So Jimmy draws dollars from Social Security and Medicare and neither contributes taxes nor builds his retirement pension. He is happy, home with his wife who also doesn’t work: “Arthritis has put a hindrance on my life, but it hasn’t stopped my life. I figure, as long as God can bless me to get up and see another day, hey, I’m ready to go. Jimmy presumably could live decades longer and, if employed, could perhaps improve both his financial standing and sense of contributing. He had worked ever since his hands were big enough to hold a snow shovel. Although Social Security pays disability income, it does not cover assistive technol- 266 inal Thoughts ogy to permit work. Finally, Medicare pays for power wheel- chairs only if people must use them within their homes—not outside, where they might return to work and leave SSDI. Somebody like Jimmy Howard would not need highly sophisticated equipment. Jimmy Howard would need to adapt his house, at a minimum installing a ramp or constructing a spot in his garage to recharge the batteries. Both her legs were amputated because of severe peripheral vascular disease, and she is too weak to propel herself in a manual wheelchair. With- out question, her private health insurer paid for a power wheelchair, and she happily acquired her new wheels. Her elderly husband cannot put the wheelchair into their car, so she can’t take it anywhere. Insurance refused to pay the $1,900 for an automatic car lift, which she and her husband can’t afford. Abbott’s family have pitched in and are buying the car lift on installment. Even though these costs add up, they nevertheless fall far short of Jimmy Howard’s income support or payment for people to run the errands Mrs. Numerous contradictory policies include the following: • reimbursement only for restorative physical therapy, not ther- apy to maintain function or prevent its decline • limited coverage of mobility aids by private, employment- based health insurance (for which employers choose insurance benefits packages that should—in theory—restore mobility so that able employees could return to work and maximum pro- ductivity) • payment for mobility aids but not for the training to show people how to use them daily in their homes and communities Final Thoughts / 267 • no allowance for trial runs with mobility aids to see if they are helpful (people generally abandon incompatible devices, rarely recycling them to someone who could really benefit) • payment for only one assistive technology in a lifetime or over long periods, so people must get equipment anticipating future needs rather than devices appropriate to their current func- tioning • no allowance for what are seen as expensive “extras,” like spe- cial wheelchair cushions to prevent decubitus ulcers, but reim- bursement for surgical treatment when ulcers occur • withdrawal of coverage for home-health services when people get wheelchairs and leave home independently, without con- siderable and taxing effort Policy analysts speak of “the woodwork effect”—once new benefits be- come available, untold numbers emerge from the woodwork, seeking the service. Predicting demand for services when policies change is therefore difficult. If, for example, insurers suddenly relax their policies and pur- chase power wheelchairs, how many requests would arise? Among people reporting major mobility difficulties, al- most 80 percent (an estimated 4. Who knows how many of them would benefit from manual or power wheelchairs? If 10 percent, this translates into roughly 458,500 people; if 5 percent, approximately 229,200 people. With wheel- chairs costing from about $1,500 to over $35,000 for the most technologi- cally sophisticated models, potential costs are substantial, especially for the one-time expense of meeting unfilled needs. Among people with major mobility problems, 11 percent say they need railings at home but do not have them, while just over 13 percent need bathroom modifications, 5 percent need kitchen modifications or automatic or easy-to-open doors, and around 4 percent need stair lifts or elevators, 268 inal Thoughts alerting devices, or accessible parking. Abbott’s doctor didn’t know who to ask for advice, so they turned to me. I e-mailed Julie Internet addresses of prominent wheelchair manufacturers so she could study their offerings.

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