Geneva antimicrobial zone of inhibition evaluation discount augmentin 1000 mg with mastercard, World Health Organization bacteria of the stomach purchase augmentin 625 mg without prescription, 2007 (Evidence for Action Technical Paper) virus ny 1000 mg augmentin visa. Risk factors for adverse perinatal outcomes in imprisoned pregnant women: a systematic review antibiotic weight gain discount 1000mg augmentin visa. United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (the Bangkok Rules). Prevention of acute drug-related mortality in prison populations during the immediate post-release period. The older prisoner and complex chronic medical care Brie Williams, Cyrus Ahalt, Robert Greifinger Key points · Prisonersareoftenconsideredgeriatricattheageof 50 or 55 years. Older prisoners should be assessed for their ability to perform physical prison tasks such as standing to be counted, getting in and out of a top bunk or responding to alarms, and adaptations made as needed. The growing number of older prisoners with complex medical co-morbidity has become a global challenge. Over the past decade, while overall prison populations have grown in nations as varied as Turkey (90% increase), Argentina (55%), Kenya (40%), Spain (30%), the United Kingdom (15%), the United States (13%) and China (10%) (1), in many places there has been a concurrent disproportionate growth in the number of older prisoners. In the United States, where the total prison population grew 100% between 1990 and 2009, the number of prisoners aged 55 years or older increased by more than 300% in the same period (2). In Japan, the number of older adults in prison has doubled in the last decade despite just a 30% increase in the number of older Japanese overall. Many other nations are also experiencing an increasing number of older prisoners, reflecting trends in ageing and in criminal justice policy. At the same time, more and more adults are growing old in prisons as countries embrace tougher criminal justice policies, including the increased use of life sentences, stronger drug and immigration laws and mandatory minimum sentencing practices. Regardless of nation-specific criminal justice policies that contribute to these shifting demographics, the growing population of older prisoners is expected to increase as the world population ages, unless there are significant policy changes. Many prisons now provide primary care to a growing number of medically vulnerable older prisoners. Accordingly, prison health care systems must evaluate and optimize their ability to deliver complex chronic medical and social care for older prisoners if prison administrations are to provide for the basic rights of all prisoners. This imperative is also critical from a fiscal perspective as the ageing population in detention is a principal driver of the rising cost of incarceration, primarily due to greater health care costs (3). To provide cost-effective and adequate health care to the growing number of older prisoners, prison administrations must first acknowledge the unique challenges associated with the ageing prisoner population. Ageing in general brings with it new physical, psychological and social challenges. For older prisoners, this introduces additional challenges to safety, functional ability and 165 Introduction General population ageing is a worldwide trend in nearly all regions outside sub-Saharan Africa, with prisons no Prisons and health health (4). Additionally, for older adults the health risks following release from prison may be magnified by challenges such as receiving only limited social support, being frail in unsafe neighbourhoods and having complex medication needs (5). Thus, for a growing number of older adults in countries around the world, prisons occupy an important place on the health care continuum. This chapter applies the fundamental tenets of geriatric medicine to correctional health care to illustrate how to optimize care for older prisoners. Other studies similarly reveal higher rates of chronic illness in older versus younger prisoners for conditions including hypertension, arthritis, heart disease, chronic obstructive pulmonary disease and cancer (11). The multimorbidity care model uses care coordination, patient education and shared decision-making between the health care clinician and the patient to weigh the risks and benefits of each medical decision on the individual patient. In acknowledgement of the complex needs of older adults, geriatric medicine is often practised in teams that include, for example, physician and nurse clinicians, social workers and pharmacists. Many older adults entering prison will not have had extensive contact with the health care system prior to their incarceration, and a complete medical assessment on arrival is often an important first step in diagnosing chronic disease, cognitive impairment and disability. The results of a comprehensive assessment can also help with decisions related to housing, security risk and programming eligibility. The goal of geriatric medicine (and gerontology, its counterpart in nursing and the social sciences) is to increase the health, independence and quality of life of older adults by providing high-quality, patient-centred, interdisciplinary care (6). In the prison setting, geriatric care models may often be appropriate for prisoners who are younger than the 65-year cut-off typically used to define the elderly in the non-incarcerated population. This is because many medically and socially vulnerable adults (such as homeless or impoverished people, refugees and prisoners) experience accelerated ageing, that is, they develop chronic illness and disability approximately 1015 years earlier than the rest of the population (7). Older prisoners often fall into several categories of the medically vulnerable, owing to a history of poverty, poor access to health care, substance use or other factors. As a result, many criminal justice systems consider prisoners to be older, or geriatric, by the age of 50 or 55 years (5,7,8). Prison health care administrations should take accelerated ageing into account when determining the eligibility criteria for age-related screening tools and medical care protocols. Polypharmacy A key barrier to the optimal management of chronic disease for older patients is polypharmacy. Defined as the inappropriate use of multiple medications, polypharmacy is a particular risk for older adults because of age-related changes in the metabolism, clearance and delivery of many medications. This heightened risk is also increased when multiple medications are used at one time and with specific high-risk medications. Several lists of inappropriate and potentially inappropriate medications in the elderly exist and should be made easily available to prison health care clinicians. Medications with anticholinergic properties, for example, should be avoided in older adults as these drugs can result in sideeffects that include falls, delirium (acute confusion) and urinary retention (12). Anticholinergic properties are found in many classes of medication including antihistamines, some benzodiazepines and some antibiotics (13). In addition to being aware of important medications to avoid in the elderly, it is also critical that prison health care clinicians use caution when adding new medications to the regimens of older adults. Older prisoners should have their entire medication list reviewed regularly to assess the need for continuation of each medication while considering the possibility of drugdrug interactions with other concurrent medications. In keeping with the geriatric care model, a team approach may help to ensure proper management of medications in older prisoners. Geriatric medicine and the multimorbidity model of care the first step towards optimizing the care of older prisoners is to adapt care models already developed and tested in the fields of geriatrics and gerontology to older prisoner health care. Rather than focus on a single disease, the multimorbidity care model prioritizes the chronic medical conditions that most affect health status and quality of life for each individual (9). As with all older adults, the prevalence of multiple chronic medical conditions in prisoners increases with age. One study from the United States found that 85% of prisoners aged 50 years or older in the Texas prison system (which holds more than 150 000 prisoners of all ages) have one or more chronic medical conditions and 61% have two or more conditions. In contrast, just 37% of prisoners in Texas aged 3049 years and 16% of those aged under 30 years reported two or more chronic medical conditions 166 the older prisoner and complex chronic medical care Geriatric syndromes Geriatric syndromes are conditions that have multifactoral etiologies, significant morbidity and adverse effects on quality of life and are more common in older adults (14). The common geriatric syndromes considered here include falls, dementia, incontinence, sensory impairment and symptom burden. Health care providers who specialize in older adults focus as much time on assessing and addressing geriatric syndromes as on the diagnosis and management of chronic medical illnesses. In prison, geriatric syndromes are similarly important, affecting many older prisoners and increasing their risk for adverse health events. Falls Studies have found that approximately 30% of people aged over 65 years fall each year, a rate that increases with advancing age (12). Of those who fall, approximately 2030% suffer injuries with significant consequences for their independence and functioning, and even their risk of death (15). Older prisoners are at heightened risk of falls if they are housed in institutions with poor lighting, uneven flooring or poorly marked stairs or if they are required to perform activities beyond their functional ability, such as standing for long periods or climbing onto a top bunk. Other factors contributing to the increased risk of falls in prison could include allocation to accommodation that necessitates the use of many stairs, crowded areas where others are moving quickly and may jostle the older prisoner, or the use of ankle and/or wrist shackles which can affect normal gait by decreasing arm swing and can restrict the ability to compensate for imbalance with a wide-spaced gait. In addition, vitamin D deficiency can lead to abnormal gait, muscle weakness and osteoporosis, increasing the risk of injury from falls. One study of older women prisoners in the United States found that 51% experienced a fall over a one-year period in custody (16). Effective interventions to reduce falls in the community include exercise programmes to promote balance and muscle-strengthening, environmental modifications such as grab bars and reviews of medication to avoid polypharmacy. Dementia Dementia is defined as a decline in two or more areas of cognitive functioning severe enough to cause functional decline. The prevalence of dementia doubles every five years from the ages of 60 years to 80 years, when it affects one third to one half of the population (12). The dementia risk is worse for people that are also at risk of incarceration, including those with a history of posttraumatic stress disorder, low educational attainment, traumatic brain injury or substance abuse. Some of these factors are also associated with the earlier onset of dementia, such that prisoners could be at risk for cognitive decline at young ages. Cognitive impairment can be harder to detect in prison, given that many of the daily tasks necessary for independence in the community are frequently not required of prisoners, such as doing their laundry, cooking and balancing their finances.
See Weight entries Bolivian hemorrhagic fever antibiotics for uti and pneumonia generic augmentin 375mg visa, 598 Bone density virus scan free order augmentin 375 mg otc, 967 Bone disease anaerobic infections antibiotics for urine/kidney infection order augmentin 625mg with mastercard, 533 drug-induced treatment for dogs eating rat poison order augmentin 1000mg online, 1140t neck pain in, 198 osteomalacia, 967 osteoporosis, 965 P. See Heart disease Cardiac glycoside poisoning, 141t Cardiac tamponade, 60t, 689 Cardiac toxicity, 733 Cardiobacterium hominis infection. See also Varicella-zoster virus infection Chikungunya virus infection, 596 Child-Pugh classification, of cirrhosis, 869t Chinese herbal nephropathy, 812 Chlamydial infection, 469, 561 cervicitis, 465, 471 epididymitis, 463, 471 pelvic inflammatory disease, 465, 471 proctitis, 468, 471 salpingitis, 471 urethritis, 463464, 471 Chlamydia pneumoniae infection, 563 atherosclerosis and, 563 Chlamydia psittaci infection, 562 Chlamydia trachomatis infection, 469, 561 Chloral hydrate poisoning, 144t Chlorambucil, 341t Chloramphenicol for Bartonella infections, 526t for meningococcal infections, 506t for plague, 164t, 526 for relapsing fever, 553 for Rocky Mountain spotted fever, 555 for scrub typhus, 557 for tick-borne spotted fevers, 555 for tularemia, 165t, 524 Chlordiazepoxide dosage and action of, 1089t poisoning, 143t Chloroquine for inflammatory bowel disease, 840 for malaria, 638t preventive treatment, 640t poisoning, 153t for porphyria cutanea tarda, 977 Chlorpheniramine for allergic rhinitis, 880 for urticaria/angioedema, 879 Chlorpromazine for delirium, 50t dosage and adverse effects of, 138t, 139t, 1091t for migraine, 186t for serotonin syndrome, 152t Chlorthalidone for edema, 243t for hypertension, 695t Cholangiography, 270 Cholangiopancreatography, 846t, 848 Cholangitis, 847 E. See also specific types diagnosis of, 995, 996t, 997t, 999t differentiation of major types, 997t sleep disorders in, 227 Dementia with Lewy bodies, 995998, 997t, 1001 Dengue fever, 595, 1116 Dengue hemorrhagic fever/dengue toxic shock syndrome, 110, 599 Cyclophosphamide (Cont. See Polycythemia Erythroderma, 108t, 110 Erythroid:granulocytic ratio, bone marrow, 323 Erythroleukemia, 345t Erythromycin for acne, 318 for bacillary angiomatosis, 479t 1197 for Bartonella infections, 526t for campylobacteriosis, 458 for cellulitis, 479t for chancroid, 476 for C. See Chancroid Haemophilus influenzae infection, 508 epiglottitis, 509 Hib, 508 meningitis, 508509 nontypable strains, 508509 pneumonia, 509 Haemophilus influenzae type b vaccine, 438t, 509, 1108t1109t Haemophilus species infection. See also specific types causes of, 183t drug-induced, 1138t symptoms suggesting serious underlying disorder, 184t Head and neck cancer, 367 infections in cancer patients, 433t local disease, 368 locally advanced disease, 368 Glucocorticoid therapy (Cont. See also Cardiovascular disease cardiac mass, 670, 672t computed tomography in, 672t, 673 congenital. See Ventilatory support Mechlorethamine, 341t Meclizine for nausea and vomiting, 48, 245 for vertigo, 214t Mediastinal mass, 781 Mediastinitis, 781 Mediastinoscopy, 752 Medical emergencies. See Leprosy Mycobacterium marinum infection, 549 Mycobacterium tuberculosis infection. See also specific types drug-induced, 1074, 1075t, 1140t inflammatory, 1072, 1073t weakness in, 219t, 220t Myophosphorylase deficiency, 1073 Myositis, 481. See also specific types drug-induced, 1138t ischemic, 821, 823f Nephrosclerosis, arteriolar, 824 Nephrostomy tube, 830 Nephrotic syndrome, 279, 803 ascites in, 273t causes of, 804, 804t drug-induced, 1138t evaluation of, 806t Nerve agents, 169, 170t clinical features of exposure, 169 treatment of, 169171, 170t Nerve gas, 142t Nervous system tumor, 1031 metastasis to nervous system, 10331034, 1034t Nesiritide, for heart failure, 734, 734t Neuralgia, 34. See Hookworm infection Neck infections, 307 Neck pain, 196 Neck weakness, 1024 Necrotizing fasciitis, 108t, 110, 477, 478 mixed anaerobic-aerobic infection, 533 streptococcal, 497498, 498t treatment of, 479t480t, 480 Necrotizing myelopathy, acute, 408 Nedocromil sodium, for asthma, 755 Nefazodone, 1087t Negri bodies, 592 Neisseria gonorrhoeae infection. See specific types paraneoplastic, 408t, 409t Neuroprotection, for stroke, 84 Neurosyphilis, 473, 474t, 475 Neutron particles, 171 Neutropenia, 331 in cancer patient, 115 drug-induced, 329, 344 febrile, 331 approach to , 435436, 435f P. See Typhus, scrub Oritavancin, for staphylococcal infections, 494t Orlistat, for obesity, 940 Oroya fever, 526t, 527 Orphenadrine poisoning, 138t, 144t, 153t Orthostatic hypotension, 209t, 210, 1015 evaluation of, 1016 neurogenic, 1015 in pheochromocytoma, 693 treatment of, 1019, 1019t Osborn (J) waves, 127 Oseltamivir, for influenza, 579, 579t preventive treatment, 580581 Osmolar gap, 18 Osmoregulation, 3t Osmotic demyelination syndrome, 67 Osteoarthritis, 900 low back pain in, 192 Osteomalacia, 967 drug-induced, 1140t Osteomyelitis, 483 acute hematogenous, 483484 chronic, 483, 486 contiguous-focus, 483, 486 diagnosis of, 483484, 484t E. See Fluke infection, lung flukes Parainfluenza virus infection, 583 Paralysis, 218 periodic, 1074 site of responsible lesion, 219, 219t Paralytic shellfish poisoning, 124 Paraneoplastic syndromes emergent, 113 endocrine, 405 neurologic, 407, 408t Paranoid personality disorder, 1084 Paraparesis, 220t, 221f Parasitic infection blood, 322, 421 diagnosis of, 413, 420t eosinophilia in, 330 intestinal, 421 tissue, 421 Parasympathetic system, 1014f, 1015t Parathyroidectomy, 963 Paravertebral abscess, brucellosis vs. See Enterobiasis Pioglitazone, for diabetes mellitus, 945t Piperacillin for osteomyelitis, 485t for otitis externa, 305 Piperacillin-tazobactam for anaerobic infections, 534t indications for, 425t for osteomyelitis, 485t for P. See Kidney cancer Renal disease approach to , 785 azotemia, 274 chronic classification of, 275t treatment of, 795796 clinical and laboratory database for, 786t dialysis in, 796 drug-induced, 341t, 1138t end-stage, 794 renal transplant in, 798 fatigue in, 289t glomerular, 785, 801 hypertension in, 693, 698, 786t, 788, 795796 infections in immunocompromised patients, 434, 436t metabolic acidosis in, 17t, 18 monoclonal immunoglobulins and, 812, 812t nephrolithiasis, 786t, 788, 826 nephrotic syndrome, 786t, 787 reference values for renal function tests, 1165t renal tubular disease, 786t, 787788, 808 renovascular disease, 820 urinary abnormalities in, 276 urinary tract infection. See also Lung disease bronchoalveolar lavage in, 752 bronchoscopy in, 751752 chest x-ray in, 751 computed tomography in, 751 diagnosis of, 751 drug-induced, 1136t emergencies, 111 extraparenchymal, 748, 748t infections in immunocompromised patients, 434, 436t meningococcal, 504 M. See Typhus, endemic murine Rifabutin, for tuberculosis, 541542 Rifampin adverse reactions to , 428 for anthrax, 164t for arthritis, infectious, 482 for Bartonella infections, 526t for brucellosis, 523 for diphtheria, 502 for human granulocytotropic anaplasmosis, 558 indications for, 427t for infective endocarditis, 445t for Legionella infections, 522 for leprosy, 546547 for meningococcal disease prevention, 506t, 1045 for nontuberculous mycobacterial infections, 548 for osteomyelitis, 485t for primary biliary cirrhosis, 871 for Q fever, 559 resistance to , 427t for staphylococcal infections, 496 for tuberculosis, 541, 543t, 545t546t Rifapentine, for tuberculosis, 542 Rifaximin for C. See also Nematode infection intestinal, 420t Rubella, 585 congenital rubella syndrome, 585586 Rubella vaccine, 585 Rumination, 244 Russian spring-summer encephalitis, 596t597t S Saccharomyces boulardii therapy, 462 Sacroiliitis, 898t St. See Systemic sclerosis Scombroid poisoning, 124 Scopolamine for nausea and vomiting, 48, 245 poisoning, 138t for vertigo, 214t Scorpionfish envenomation, 123 Scorpion sting, 126 Scotoma, 215, 216f, 295 Screening recommendations, 1103 Sea anemone injury, 122 Seborrheic keratosis, 311f Secobarbital, 143t Sedative-hypnotics, poisoning, 131t, 143t Seizure, 988. See Melanoma prevention of, 364, 367, 1104t screening for, 1123t squamous cell carcinoma, 366 Skin disease acne, 317 arrangement and shape of lesions, 309, 310f312f in cancer patients, 432 diagnosis of, 311313 distribution of lesions, 309 drug-induced, 319, 342t, 1133t1134t eczematous, 315 history in, 310 lesion characteristics, 309, 310f312f in malnutrition, 41 papulosquamous, 314 primary lesions, 309, 313t in returned traveler, 1118 secondary lesions, 309, 313t sepsis-associated, 106 vascular disorders, 318 Skin infection, 316, 477 anaerobic, 533 clostridial, 531 P. See Filariasis X Xanthelasma, 970 Xanthoma, 970, 973974 Xerostomia, 890891 D-Xylose absorption test, 256 D-Xylose urinary excretion test, 852 Y Yaws, 551 Yellow fever, 110, 599 Yellow fever vaccine, 1116t Yellow jacket sting, 126 Yersinia pestis infection. Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 Email: kathmandu@jaypeebrothers. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. The publisher is not associated with any product or vendor mentioned in this book. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The actions done with passion cause misery, while he whose deeds are dark is cursed with ignorance. Based on feedback from users of previous edition who found this condensed material very useful and attractive, the past practice of this combination of new edition of companion-book with revised edition of the mainbook started 15 years back has been continued this time too. Thus, the revised editions of both the books have been prepared and released simultaneously. The material contained in the book may be considered adequate for students of some courses such as those pursuing paramedical courses. Each major heading in the small book has cross-references of page numbers of the 7th edition of my textbook so that an avid and inquisitive reader interested in simultaneous consultation of the topic or for clarification of a doubt, may refer to it conveniently. While much more knowledge has been condensed in the baby-book from the added material in the main textbook, effort has been made to keep its volume reasonable. It is hoped that the book with enhanced and updated contents continues to be user-friendly in learning the essential aspects of pathology, while at the same time, retaining the ease with which it can be conveniently carried by the users in the pocket of their white coats. Preparation of this little book necessitated selection from enhanced information contained in the revised edition of my textbook and therefore, required application of my discretion. In this regards, generous suggestions and comments from colleagues and users of earlier edition have been quite helpful and are gratefully acknowledged. I thank profusely the entire staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their ever-smiling support and cooperation in completion of the book in a relatively short time, just after we had completed the mammoth task of revision work of 7th edition of the main textbook. Finally, although sincere effort has been made to be as accurate as possible, element of human error is still likely; I shall humbly request the users to continue giving their valuable suggestions directed at further improvements of its contents. The Skin 9 r9 i - n U V d the i 110 137 148 G R Contents 156 185 197 230 249 281 314 328 340 381 425 466 482 507 519 536 569 590 601 25. Pathology is, thus, scientific study of changes in the structure and function of the body in disease. For the student of any system of medicine, the discipline of pathology forms a vital bridge between initial learning phase of preclinical sciences and the final phase of clinical subjects. Health may be defined as a condition when the individual is in complete accord with the surroundings, while disease is loss of ease (or comfort) to the body. Lesions are the characteristic changes in tissues and cells produced by disease in an individual or experimental animal. These can be recognised with the naked eye (gross or macroscopic changes) or are studied by microscopic examination of tissues. Causal factors responsible for the lesions are included in etiology of disease. Functional implications of the lesion felt by the patient are symptoms and those discovered by the clinician are the physical signs. Clinical significance of the morphologic and functional changes together with results of other investigations which help to arrive at an answer to what is wrong (diagnosis), what is going to happen (prognosis), what can be done about it (treatment), and finally what should be done to avoid complications and spread (prevention). Pathology has evolved over the years as a distinct discipline from anatomy, medicine and surgery, in that sequence. The link between medicine and religion became so firmly established throughout the world that different societies had their gods and goddesses of healing; for example: 2 mythological Greeks had Aesculapius and Apollo as the principal gods of healing, Dhanvantri as the deity of medicine in India. The insignia of healing, the Caduceus, having snake and staff, is believed to represent the god Hermes or Mercury, which according to Greek mythology has power of healing since snake has regenerative powers expressed by its periodic sloughing of its skin. This theory suggested that the illness resulted from imbalance between four humors (or body fluids): blood, lymph, black bile (believed at that time to be from the spleen), and biliary secretion from the liver. His pupils, Gabriel Fallopius (15231562) who described human oviducts (Fallopian tubes) and Fabricius who discovered lymphoid tissue around the intestine of birds (bursa of Fabricius) further popularised the practice of human anatomic dissection for which special postmortem amphitheatres came in to existence in various parts of ancient Europe. Antony van Leeuwenhoek (16321723), a cloth merchant by profession in Holland, during his spare time invented the first ever microscope by grinding the lenses himself. Marcello Malpighi (16241694) used microscope extensively and observed the presence of capillaries and described the malpighian layer of the skin, and lymphoid tissue in the spleen (malpighian corpuscles).
Sociocultural change typically occurs slowly augmentin 1000mg low cost, on a time scale of decades (although abrupt changes can sometimes occur 2012 antimicrobial susceptibility testing standards 1000mg augmentin mastercard, as in the case of wars or political regime changes) antibiotic induced c diff order augmentin 1000 mg with amex, while economic changes tend to occur more rapidly treating uti quickly safe 1000mg augmentin. As a result of this spatial and temporal dependence of drivers, the forces that appear to be most significant at a particular location and time may not be the most significant over larger (or smaller) regions or time scales. N Indirect Drivers In the aggregate and at a global scale, there are five indirect drivers of changes in ecosystems and their services: population change, change in economic activity, sociopolitical factors, cultural factors, and technological change. Collectively these factors influence the level of production and consumption of ecosystem services and the sustainability of production. Both economic growth and population growth lead to increased consumption of ecosystem services, although the harmful environmental impacts of any particular level of consumption depend on the efficiency of the technologies used in the production of the service. These factors interact in complex ways in different locations to change pressures on ecosystems and uses of ecosystem services. Driving forces are almost always multiple and interactive, so that a one-to-one linkage between particular driving forces and particular changes in ecosystems rarely exists. Even so, changes in any one of these indirect drivers generally result in changes in ecosystems. The causal linkage is almost always highly mediated by other factors, thereby complicating statements of causality or attempts to establish the proportionality of various contributors to changes. There are five major indirect drivers: Demographic Drivers: Global population doubled in the past 40 years and increased by 2 billion people in the last 25 years, reaching 6 billion in 2000 (S7. Developing countries have accounted for most recent population growth in the past quartercentury, but there is now an unprecedented diversity of demographic patterns across regions and countries. Some high-income countries such as the United States are still experiencing high rates of population growth, while some developing countries such as China, Thailand, and North and South Korea have very low rates. In the United States, high population growth is due primarily to high levels of immigration. About half the people in the world now live in urban areas (although urban areas cover less than 3% of the terrestrial surface), up from less than 15% at the start of the twentieth century (C27. Some developing-country regions, such as parts of Asia, are still largely rural, while Latin America, at 75% urban, is indistinguishable from high-income countries in this regard (S7. Economic Drivers: Global economic activity increased nearly sevenfold between 1950 and 2000 (S7. In the case of food, for example, as income grows the share of additional income spent on food declines, the importance of starchy staples (such as rice, wheat, and potatoes) declines, diets include more fat, meat and fish, and fruits and vegetables, and the proportionate consumption of industrial goods and services rises (S7. In the late twentieth century, income was distributed unevenly, both within countries and around the world. Fertilizer taxes or taxes on excess nutrients, for example, provide an incentive to increase the efficiency of the use of fertilizer applied to crops and thereby reduce negative externalities. Currently, many subsidies substantially increase rates of resource consumption and increase negative externalities. Annual subsidies to conventional energy, which encourage greater use of fossil fuels and consequently emissions of greenhouse gases, are estimated to have been $250300 billion in the mid-1990s (S7. At the same time, many developing countries also have significant agricultural production subsidies. Sociopolitical Drivers: Sociopolitical drivers encompass the forces influencing decision-making and include the quantity of public participation in decision-making, the groups participating in public decision-making, the mechanisms of dispute resolution, the role of the state relative to the private sector, and levels of education and knowledge (S7. These factors in turn influence the institutional arrangements for ecosystem management, as well as property rights over ecosystem services. There is a declining trend in centralized authoritarian governments and a rise in elected democracies. The trend toward democratic institutions has helped give power to local communities, especially women and resource-poor households (S7. The importance of the state relative to the private sector-as a supplier of goods and services, as a source of employment, and as a source of innovation-is declining. Cultural and Religious Drivers: To understand culture as a driver of ecosystem change, it is most useful to think of it as the values, beliefs, and norms that a group of people share. Broad comparisons of whole cultures have not proved useful because they ignore vast variations in values, beliefs, and norms within cultures. Nevertheless, cultural differences clearly have important impacts on direct drivers. Cultural factors, for example, can influence consumption behavior (what and how much people consume) and values related to environmental stewardship, and they may be particularly important drivers of environmental change. It is calculated without making deductions for depreciation of fabricated assets or for depletion and degradation of natural resources. The twentieth century saw tremendous advances in understanding how the world works physically, chemically, biologically, and socially and in the applications of that knowledge to human endeavors. The impact of science and technology on ecosystem services is most evident in the case of food production. Much of the increase in agricultural output over the past 40 years has come from an increase in yields per hectare rather than an expansion of area under cultivation. For instance, wheat yields rose 208%, rice yields rose 109%, and maize yields rose 157% in the past 40 years in developing countries (S7. At the same time, technological advances can also lead to the degradation of ecosystem services. Advances in fishing technologies, for example, have contributed significantly to the depletion of marine fish stocks. This change reflects structural changes in economies, but it also results from new technologies and new management practices and policies that have increased the efficiency with which ecosystem services are used and provided 66 Ecosystems and Human Well-being: S y n the s i s substitutes for some services. Even with this progress, though, the absolute level of consumption of ecosystem services continues to grow, which is consistent with the pattern for the consumption of energy and materials such as metals: in the 200 years for which reliable data are available, growth of consumption of energy and materials has outpaced increases in materials and energy efficiency, leading to absolute increases of materials and energy use (S7. Global trade magnifies the effect of governance, regulations, and management practices on ecosystems and their services, enhancing good practices but worsening the damage caused by poor practices (R8, S7). Increased trade can accelerate degradation of ecosystem services in exporting countries if their policy, regulatory, and management systems are inadequate. At the same time, international trade enables comparative advantages to be exploited and accelerates the diffusion of more-efficient technologies and practices. For example, the increased demand for forest products in many countries stimulated by growth in forest products trade can lead to more rapid degradation of forests in countries with poor systems of regulation and management, but can also stimulate a "virtuous cycle" if the regulatory framework is sufficiently robust to prevent resource degradation while trade, and profits, increase. While historically most trade related to ecosystems has involved provisioning services such as food, timber, fiber, genetic resources, and biochemicals, one regulating service-climate regulation, or more specifically carbon sequestration-is now also traded internationally. Urban demographic and economic growth has been increasing pressures on ecosystems globally, but affluent rural and suburban living often places even more pressure on ecosystems (C27. Dense urban settlement is considered to be less environmentally burdensome than urban and suburban sprawl. And the movement of people into urban areas has significantly lessened pressure on some ecosystems and, for example, has led to the reforestation of some parts of industrial countries that had been deforested in previous centuries. At the same time, urban centers facilitate human access to and management of ecosystem services through, for example, economies of scale related to the construction of piped water systems in areas of high population density. Direct Drivers Most of the direct drivers of change in ecosystems and biodiversity currently remain constant or are growing in intensity in most ecosystems. Only biomes relatively unsuited to crop plants, such as deserts, boreal forests, and tundra, have remained largely untransformed by human action. Both land cover changes and the management practices and technologies used on lands may cause major changes in ecosystem services. New technologies have resulted in significant increases in the supply of some ecosystem services, such as through increases in agricultural yield. In the case of cereals, for example, from the mid-1980s to the late 1990s the global area under cereals fell by around 0. For marine ecosystems and their services, the most important direct driver of change in the past 50 years, in the aggregate, has been fishing (C18). At the beginning of the twenty-first century, the biological capability of commercially exploited fish stocks was probably at a historical low. As noted in Key Question 1, fishing pressure is so strong in some marine systems that the biomass of some targeted species, especially larger fishes, and those caught incidentally has been reduced to one tenth of levels prior to the onset of industrial fishing (C18. Fishing has had a particularly significant impact in coastal areas but is now also affecting the open oceans. For freshwater ecosystems and their services, depending on the region, the most important direct drivers of change in the past 50 years include modification of water regimes, invasive species, and pollution, particularly high levels of nutrient loading. It is speculated that 50% of inland water ecosystems (excluding large lakes and closed seas) were converted during the twentieth century (C20.
