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His condition is interpreted according to a set of abstract rules in a language he cannot understand cheap 20mg apcalis sx overnight delivery. Language is taken over by the doctors: the sick person is deprived of meaningful words for his anguish discount apcalis sx 20 mg on line, which is thus further increased by linguistic mystification order apcalis sx 20mg without prescription. As in antiquity the patient stutters, flounders, and speaks about what "grips him" or what he "has caught. Finally, increasing dependence of socially acceptable speech on the special language of an elite profession makes disease into an instrument of class domination. In fact, the overwhelming majority of diagnostic and therapeutic interventions that demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members. For example, the price of what is significantly health-furthering in Canadian medicine is so low that these same resources could be made available to the entire population of India for the amount of money now squandered there on modern medicine. The skills needed for the application of the most generally used diagnostic and therapeutic aids are so elementary that the careful following of instructions by people who are personally concerned would probably guarantee more effective and responsible use than medical practice ever could. When the evidence about the simplicity of effective modern medicine is discussed, medicalized people usually object by saying that sick people are anxious and emotionally incompetent for rational self-medication, and that even doctors call in a colleague to treat their own sick child; and furthermore, that malevolent amateurs could quickly organize into monopoly custodians of scarce and precious medical knowledge. These objections are all valid if raised within a society in which consumer expectations shape attitudes to service, in which medical resources are carefully packaged for hospital use, and in which the mythology of medical efficiency prevails. They would hardly be valid in a world that aimed at the effective pursuit of personal goals that an austere use of technology had put within the range of almost everyone. Insofar as this image depends on the new techniques and their corresponding ethos, it is supranational in character. But these very techniques are not culturally neutral; they assumed concrete shape within Western cultures and express a Western ethos. The image of a "natural death," a death which comes under medical care and finds us in good health and old age, is a quite recent ideal. Each stage has found its iconographic expression: (1) the fifteenth-century "dance of the dead"; (2) the Renaissance dance at the bidding of the skeleton man, the so-called "Dance of Death"; (3) the bedroom scene of the aging lecher under the Ancien Rgime; (4) the nineteenth-century doctor in his struggle against the roaming phantoms of consumption and pestilence; (5) the mid-twentieth-century doctor who steps between the patient and his death; and (6) death under intensive hospital care. At each stage of its evolution the image of natural death has elicited a new set of responses that increasingly acquired a medical character. The history of natural death is the history of the medicalization of the struggle against death. Nevertheless, the frequency of ecclesiastical prohibitions testifies that they were of little avail, and for a thousand years Christian churches and cemeteries remained dance floors. Dancing with the dead on their tombs was an occasion for affirming the joy of being alive and a source of many erotic songs and poems. In the shape of his body Everyman carries his own death with him and dances with it through his life. From dancing with dead ancestors over their graves, people turned to representing a world in which everyone dances through life embracing his own mortality. Death was represented, not as an anthropomorphic figure, but as a macabre self-consciousness, a constant awareness of the gaping grave. With Chaucer and Villon, death becomes as intimate and sensual as pleasure and pain. Primitive societies conceived of death as the result of an intervention by an alien actor. No figure of "a" death appears at the deathbed, just an angel and a devil struggling over the soul escaping from the mouth of the dying. Only during the fifteenth century were the conditions ripe for a change in this image,12 and for the appearance of what would later be called a "natural death. Death can now become an inevitable, intrinsic part of human life, rather than the decision of a foreign agent. Death becomes autonomous and for three centuries coexists as a separate agent with the immortal soul, with divine providence, and with angels and demons. The Danse Macabre In the morality plays,13 death appears in a new costume and role. Death has become an independent figure who calls each man, woman, and child, first as a messenger from God but soon insisting on his own sovereign rights. By 1538 Hans Holbein the Younger15 had published the first picture-book of death, which was to become a best-seller: woodcuts on the Danse Macabre. The representation of each man as entwined with his own mortality has now changed to show his frenzied exhaustion in the grip of death painted as a force of nature. The intimate mirror-image of the "self" which had been colored by the "new devotion" of the German mystics has been replaced by a death painted as the egalitarian executioner of a law that whirls everyone along and then mows them down. Now death becomes the point at which linear clock-time ends and eternity meets man. The world has ceased to be a sacrament of this presence; with Luther it became the place of corruption that God saves. With the predominance of serial time, concern for its exact measurement, and the recognition of the simultaneity of events, a new framework for the recognition of personal identity is manufactured. Death ceases to be the end of a whole and becomes an interruption in the sequence. The new machine, which can make time of equal length, day and night, also puts all people under the same law. By the time of the Reformation, postmortem survival has ceased to be a transfigured continuation of life here below, and has become either a frightful punishment in the form of hell or a totally unmerited gift from God in heaven. Thus during the sixteenth century, death ceases to be conceived of primarily as a transition into the next world, and the accent is placed on the end of this life. The finality, imminence, and intimacy of personal death were not only part of the new sense of time but also of the emergence of a new sense of individuality. Of course, once death had become such a natural force, people wanted to master it by learning the art or the skill of dying. Ars Moriendi, one of the first printed do-it-yourself manuals on the market, remained a best-seller in various versions for the next two hundred years. The most widely circulated version was published by Caxton at the Westminster press in 1491: over one hundred incunabula editions were made before 1500 from woodblocks and from movable type, under the title Art and Craft to knowe ye well to dye. This was not a book of remote preparation for death through a virtuous life, nor a reminder to the reader of an inevitable steady decline of physical forces and the constant danger of death. The book is not written for monks and ascetics but for "carnall and secular" men for whom the ministrations of the clergy were not available. Fantastic horror stories about dead bodies and artistic representations of purgatory both multiplied. The Spaniards brought the skeleton man to America, where he fused with the Aztec idol of death. Their mestizo offspring,24 on its rebound to Europe, influenced the face of death throughout the Hapsburg Empire from Holland to the Tyrol. Simultaneously, medical folk-practices multiplied, all designed to help people meet their death with dignity as individuals.

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Studies in Europe and the United States have shown that migraine affects 6 8% of men and 15 18% of women (5 purchase apcalis sx 20 mg on line, 6) buy apcalis sx 20 mg cheap. A similar pattern probably exists in Central America: in Puerto Rico generic apcalis sx 20mg overnight delivery, for example, 6% of men and 17% of women were found to have migraine (7). A recent survey in Turkey suggested even greater prevalence in that country: 9% in men and 29% in women (9). Similarly, in India, although major studies are still to be conducted, anecdotal evidence suggests migraine is very common. High temperatures and high light levels for more than eight months of the year, heavy noise pollution and the Indian habits of omitting breakfast, fasting frequently and eating rich, spicy and fermented food are thought to be common triggers (10). Migraine appears less prevalent, but still common, elsewhere in Asia (around 8%) and in Africa (3 7% in community-based studies) (3). The higher rates in women everywhere (2 3 times those in men) are hormonally driven. It may be stress related or associated with musculo- skeletal problems in the neck. As experienced by very large numbers of people, episodic tension-type headache occurs, like migraine, in attack-like episodes. Chronic tension-type headache, one of the chronic daily headache syndromes, is less common than episodic tension-type headache but is present most of the time: it can be unremitting over long periods. Headache in either case is usually mild or moderate and generalized, though it can be one- sided. It is described as pressure or tightness, like a band around the head, sometimes spreading into or from the neck. Tension-type headache pursues a highly variable course, often beginning during the teenage years and reaching peak levels around the age of 30 40 years. Episodic tension-type headache is the most common headache disorder, reported by over 70% of some populations (12), though its prevalence appears to vary greatly worldwide (3). Lack of reporting and under- diagnosis were thought to be factors here, and it may be that cultural attitudes to reporting a relatively minor complaint explain at least part of the variation elsewhere. Cluster headache Cluster headache is one of a group of primary headache disorders (trigeminal autonomic cepha- lalgias) of uncertain mechanism that are characterized by frequently recurring, short-lasting but extremely severe headache (1). Episodic cluster headache occurs in bouts (clusters), typically of 6 12 weeks duration once a year or two years and at the same time of year. Strictly one-sided intense pain develops around the eye once or more daily, mostly at night. Unable to stay in bed, the affected person agitatedly paces the room, even going outdoors, until the pain diminishes after 30 60 minutes. The eye is red and watery, the nose runs or is blocked on the affected side and the eyelid may droop. In the less common chronic cluster headache there are no remissions between clusters. Though relatively uncommon, probably affecting no more than 3 per 1000 adults, cluster head- ache is clearly highly recognizable. It is unusual among primary headache disorders in affecting six men to each woman. Most people developing cluster headache are 20 30 years of age or older; once present, the condition may persist intermittently for 40 years or more. Medication-overuse headache Chronic excessive use of medication to treat headache is the cause of medication-overuse head- ache (15), another of the chronic daily headache syndromes. Medication-overuse headache is oppressive, persistent and often at its worst on awakening in the morning. A typical history begins with episodic headache migraine or tension-type headache. In the end-stage, which not all patients reach, headache persists all day, uctuating with medication use repeated every few hours. A common and 74 Neurological disorders: public health challenges probably key factor at some stage in the development of medication-overuse headache is a switch to pre-emptive use of medication, in anticipation of the headache. All medications for the acute or symptomatic treatment of headache, in overuse, are associ- ated with this problem, but what constitutes overuse is not clear in individual cases. Suggested limits are the regular intake of simple analgesics on 15 or more days per month or of codeine- or barbiturate-containing combination analgesics, ergotamine or triptans on more than 10 days a month (1). Frequency of use is important: even when the total quantities are similar, low daily doses carry greater risk than larger weekly doses. In terms of prevalence, medication-overuse headache far outweighs all other secondary headaches (16). It affects more than 1% of some populations (17 ), women more than men, and children also. In others for whom there are no published data, in Saudi Arabia for example, clini- cal experience suggests this disorder is not uncommon, with a tendency to be more evident in afuent communities. Serious secondary headaches Some headaches signal serious underlying disorders that may demand immediate intervention (see Box 3. Although they are relatively uncommon, such headaches worry nonspecialists because they are in the differential diagnosis of primary headache disorders. The reality is that intracranial lesions give rise to histories and physical signs that should bring them to mind. Over-diagnosed headaches Headache should not be attributed to sinus disease in the absence of other symptoms indicative of it. Many patients with headache visit an optician, but errors of refraction are overestimated as a cause of headache. In developed countries, tension- type headache alone affects two thirds of adult males and over 80% of females (12). Extrapolation from gures for migraine prevalence and attack incidence suggests that 3 000 migraine attacks occur every day for each million of the general population (6). Less well recognized is the toll of chronic daily headache: up to one adult in 20 has headache on more days than not (17, 18). In other cases headache mours, brain scanning is not justied as a routine investi- or eye pain may be episodic and mild. Idiopathic intracranial hypertension is a rare cause of Meningitis, and its associated headache, occur in an obvi- headache not readily diagnosed on the history alone. The signs of fever and neck stiffness, later illoedema indicates the diagnosis in adults, but is not seen accompanied by nausea and disturbed consciousness, re- invariably in children with the condition. These Unless there is a clear history of similar uncomplicated epi- infections need to be recognized wherever they are likely sodes, these characteristics demand urgent investigation. New headache in any patient over 50 years of age should Other disorders seen more in the tropics that may pres- raise the suspicion of giant cell (temporal) arteritis. These are often diagnosed only on imaging or Jaw claudication is highly suggestive. No signicant mortality is associated with headache disorders, which is one reason why they are so poorly acknowledged. Nevertheless, among the recognizable burdens imposed on people affected by headache disorders are pain and personal suffering, which may be substantial, im- paired quality of life and nancial cost.

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This would give drug pro- antee for whistle-blowers to clarify guidance to bility order apcalis sx 20mg fast delivery, aligning with demand and the availability of curement agencies and generic medicine man- employees in all countries 20 mg apcalis sx. In tandem purchase 20mg apcalis sx free shipping, the chance of misconduct being reported and Pfzer can publish the status of its patents, to tackled. A low proportion of Pfzer s R&D projects Maternal and neonatal target high-priority product gaps with low com- Pfzer s portfolio targets all disease categories and The company has medicines and vaccines in mercial incentive. The company pany performs poorly overall, across all themes Pfzer commits to developing medicines and has a mix of strengths and weaknesses: it is test- of analysis. It was found to have breached vaccines for multiple relevant diseases, and rec- ing a way of optimising access to its established anti-corruption laws in a country in scope ognises the need for collaborative R&D to sup- products portfolio, but the transparency of its (China). It is unclear, few companies with no access-related fnancial Ethical marketing practices lag behind industry however, whether the company s commitments incentives for employees. The company does not objectives and a business rationale: the company any information about its marketing activities in commit to ensuring access-oriented terms considers its access programmes to be impor- countries in scope. Plus, its provisions of ano- (such as supply commitments or afordable pric- tant for building long-term value for investors by nymity for whistle-blowers do not clearly pro- ing strategies) are systematically included in its strengthening reputation and creating opportu- vide guidance to global employees. The Performance management system, but no discloses its policy positions on access to med- company upholds high standards of clinical trial access-related incentives. However, Requests are frst reviewed by an internal com- company does not have dedicated fnancial it does not provide information on the politi- mittee, and any denied or partially approved incentive structures in place to reward employ- cal contributions it makes in countries in scope. Although Pfzer does have a stakeholder Furthermore, Pfzer does not provide informa- bial resistance. Pfzer signed the Declaration engagement strategy, it publishes only general tion about a confict of interest policy for inter- by the Pharmaceutical, Biotechnology information about its related activities. Multiple breaches of criminal, civil law and thereby committing to investing in R&D that codes of conduct. In 2015, Pfzer entered an agreement via evaluated its assets and capabilities for address- improper promotion of a medicine in China. Pfzer has a volunteering programme in which but provides no information about whether employees are able to engage with and sup- these processes have been applied. It is also used by Pfzer to gain insight into local stake- Rises three places in R&D. The project aims to improve the quality of ing, this lack of transparency contributes to its emergency obstetric and neonatal care ser- Pfzer rises one place, remains in middle group. Since 2015, demonstrate that it implements its pricing strat- that sets out its approach to fling for or enforc- Pfzer has partnered with PharmAccess, CarePay egies. It has now also provided details of a global ing patents in low- and middle-income countries. Pfzer (as ViiV Healthcare) showed positive results: M-Tiba has now been ing to more products since 2014. Together, these but limits its support of compulsory licens- dinate technical support, grant funding and cap- strategies reach only some (22%) of the corre- ing to extraordinary circumstances or extreme ital investment for local entrepreneurs creat- sponding priority countries. Pfzer monitors prices via an internal elec- capacity, weaker in pharmacovigilance. The strengthening supply chains, and innovative ini- atively large in scale and scope in Index coun- degree and frequency of monitoring difer per tiatives related to health fnancing. It is engaged in two structured donation country depending on local laws and policies. Pfzer does not lance, and it does not consistently target local provide evidence of having disease-specifc tar- needs. It does not publish its criteria for decid- Strengthening supply chains with a focus on During the period of analysis, Pfzer donated 128 ing where to register products, or whether and identifying falsifed medicines. Pfzer is actively million treatments of azithromycin (Zithromax ) where products are registered. In November 2015, it donated the 500 newest products in a few priority countries (dis- ships and information sharing. For example, to millionth dose in its structured donation ease-specifc sub-sets of countries with a par- help address falsifed medicines moving from programme. Pakistan to the Philippines, the company jointly Most of these products were frst launched 10 to trained authorities from the two countries. Pfzer does not provide evi- Weak performance in strengthening pharma- grammes to Pfzer. Pfzer has donation agree- dence that it adapts its brochures or packaging covigilance systems. For its structured donation pro- ronmental, cultural or demographic needs of but does not demonstrate routine safety label grammes for trachoma, countries are required people living in countries in scope. It has not yet established system, as evidenced by cases of misconduct settled since a structured product donation programme. Takeda has strong R&D commitments related to access capacity building, particularly for R&D and pharmacovigilance. Takeda has a new burdens in low- and middle-income countries can also implement intra-country equitable pric- commitment to considering the use of volun- and plans to ensure afordable pricing. Takeda can strengthen the link Join eforts to combat antimicrobial resist- It can actively seek potential partners (including between access and its corporate strategies to ance. The company can company moves ahead with an increased focus take action to increase access to these med- Implement access plans as company expands on access. As Takeda expands its pipeline and the Takeda can join global eforts to address anti- geographic scope of its pharmaceutical busi- Expand use of equitable pricing strategies. The company s Ethical Drug Division market the company s of-patent medicines and 200,000 accounts for its largest share of sales, derived focus on the generic medicine market. Takeda 0 from its small presence in the consumer health- has sales in 29 countries within the scope of the 2011* 2012* 2013* 2014 2015 care market. Takeda is con- Maternal and neonatal Multiple categories company is developing medicines and vac- ducting multiple projects targeting high-priority cines for seven communicable diseases, three product gaps with low commercial incentive. Its projects are mainly in early stages of development, targeting 17 dis- people living in low- and middle-income countries. It has also disclosed infor- Comprehensive policy to ensure clinical trials Rises three positions due to new access strat- mation about its confict of interest policy, but are conducted ethically. Its poli- in its business strategy and its new system for Auditing system in place. Takeda has a risk- cies are strong: they include, alongside stand- tracking access-related performance. Takeda s access strategy has been where it operates, audits are undertaken annu- updated, drawing on the Access to Medicine ally or every two years, depending on risk fac- High transparency around clinical trial data. Wherever issues are identifed, an audit the company upholds high standards of transpar- within the strategy include vaccines, less devel- following year is mandatory. This dashboard standards of behaviour, such as due diligence intellectual property for leishmaniasis and reports on the overall implementation and pro- and monitoring. The company also shares intellectual allows divisions to track the progress of key ini- non-compliance. The com- Rises four places due to performance in equi- pany maintains that it acted appropriately.

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Prisons might be used to keep criminals until their hearing order apcalis sx 20mg line, their execution buy apcalis sx 20mg on-line, or their judicial mutilation apcalis sx 20 mg generic. Andreas Perneder, Van Straff und Pern alter undjeder Malefitz handlungm ain kurtzer Bericht, ed. Popular but reliable; a composite picture of the day-by-day life of the physician at the time of Moliere. More than 500 reproductions of artistic representations of sick people since the Renaissance; allows a study of perception. For a medical study of ergotism in the past based on its representation in paintings, see Veil Harold Bauer, Das Antonius Feuer in Kunst und Medizin (Heidelberg: Springer, 1973); bibliog. Painting and plastic arts provide an invaluable complement to the history of patient-doctor relations: Eugen Hollander, Die Medizin in der klassischen Malerei, 4th ed. Laue, Mass und Mitte: Eine problemgeschichtliche Untersuchung zur fruehen griechischen Philosophic und Ethik (Mnster: Osnabrueck, 1960). Measure in antiquity was related to virtue and proportion, not to operational verification. The English version is Indo-European Language and Society (Miami: University of Miami Press, 1973). Hoffman, "Die Geschichte vom verlorenen Spiegelbild," in Die Abenteuer einer Sylvesnacht, 1815). Hauff, "Des steinerne Hertz," in Das Wirtshaus im Spessat (1828), the hero exchanges his heart for one of stone to save himself from bankruptcy. Emanuel Berghoff, Entwicklungsgeschichte des Krankheitsbegriffes: In seinen Haupzgen dargestellt, 2nd ed. On the history of "normality" in psychiatry see Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Pantheon, 1965). Werner Leibrand, Heilkunde: Eine Problemsgeschichte der Medizin (Freiburg: Alber, 1953). Fritz Hartmann, Der rztliche Auftrag: Die Entwicklung der Idee des abendlndischen Arzttums aus ihren weltanschaulich-anthropologischen Voraussetzungen bis zum Beginn der Neuzeit (Gttingen: Musterschmidt, 1956). Hans Freyer, "Der Arzt und die Gesellschaft," in Der Arzt und der Stoat (Leipzig: Thieme 1929). Richard Toellner will publish a parallel volume, Erfahrung und Denken in der Medizin. For a dozen sociological perspectives on the contemporary hospital, consult Eliot Freidson, ed. Ironically, it was only the other inmates who suspected that the pseudopatients were normal. The hospital personnel were not able to acknowledge normal behavior within the hospital milieu. Szasz, Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement (New York: Harper & Row, 1970). Ronald Leifer, In the Name of Mental Health: Social Functions of Psychiatry (New York: Aronson, 1969). Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (1961; paperback ed. He promises to raise the epistomological question about sickness in general in a book soon to be published by Harper & Row. At the time of dismissal less than one-third have understood what disease they have been treated for, and less than one-fourth, what therapy they have been subjected to. Negrete, "Doctor- Patient Communication," Scientific American 227 (August 1972): 66-9. Georges Contenau, La Mdicine en Assyrie et en Babylonie (Paris: Librairie Maloine, 1938). In contrast, for a history of medical language see Johannes Steudel, Die Sprache des Arztes: Ethjmologie und Geschichte medizinischer Termini (seen only in extracts). The "season" at the great spas played a political function analogous to summit meetings today. See Walter Ruegg, "Der Kranke in der Sicht der brgerlichen Gesellschaft an der Schwelle des 19. Jahrhunderts," and Johannes Steudel, "Therapeutische und soziologische Funktion der Mineralbder im 19. Edwards (New York: Macmillan, 1967), 2:307-9, gives a short and lucid introduction to the knowledge of death and of the fear of death. Jos Echeverria, Rflexions mtaphysiques sur la mart et le problme du sujet (Paris: J. Christian von Ferber, "Soziologische Aspekte des Todes: Ein Versuch ber einige Beziehungen der Soziologie zur philosophischen Anthropologie," Zeitschrift fr evangelische Ethnik 7 (1963): 338-60. The author believes that death repressed, rendered private and a matter for professionals only, reinforces the exploitative class structure of society. Garrison, "The Grfeek Cult of the Dead and the Chthonian Deities in Ancient Medicine," Annals of Medical History 1 (1917): 35-53. Jocelyn Mary Catherine Toynbee, Death and Burial in the Roman World (London: Thames & Hudson, 1971). Sauer, Untersuchungen zur Darstellung des Todes in der griechisch-rmischen Geschichtsschreibung (Frankfurt, 1930). Kroll, "Tod und Teufel in der Antike," Verhandlungm der Versammlung deutscher Philologen 56 (1926). A synopsis in English: Philippe Aries, Western Attitudes Towards Death: From the Middle Ages to the Present, trans. I am interested in the image of this natural death, and its evolution during the four centuries in which it was common in Western civilizations. I owe the idea of approaching my subject in this way to Werner Fuchs, Todesbilder in der modernen Gesellschaft (Frankfurt: Suhrkamp, 1969). Backman, Religious Dances in the Christian Church and in Popular Medicine (Stockholm, 1948); trans. Religiongeschichtlich," in Die Religion in Geschichte und Gegenwart (Tbingen: 1962), 6:612-14: For the history of dances in or around Christian churches, see L. Baloch, "Tnze in Kirche und Kirchhfen," Niederdeutsche Zeitschrifi fr Volkskunde, 1928. Spanke, "Tanzmusik in der Kirche des Mittelalters," Neuphilosophische Mitteilungen 31 (1930). Germanic precedents to Christian cemetery dances: Richard Wolfram, Schwerttanz und Mnnerbund (Kassel: Barenreiter, 1937); only partly in print. Ladner, The Idea of Reform: Its Impact on Christian Thought and Action in the Age of the Fathers (Cambridge: Harvard Univ. For Pelagius death was not a punishment for sin, and Adam would have died even had he not sinned.