Working with substances hazardous to healt Introduction

This leaflet describes how to control hazardous substances at work so that they do not cause ill health. It will help you understand what you need to do to comply  with the Control of Substances Hazardous to Health (COSHH) Regulations 2002 (as amended) which apply to the way you work with these substances. If you run a small business or are self-employed, you need this information to  make sure you are protecting your employees. If you run a medium-sized or large  business, where decisions about controlling hazardous substances are more complex, you will also need professional advice. The leaflet will also be useful for trade union and employee health and safety representatives.

Why do I need to read this leaflet?

Every year, thousands of workers are made ill by hazardous substances, contracting lung disease such as asthma, cancer and skin disease such as dermatitis. These diseases cost many millions of pounds each year to:

■ industry, to replace the trained worker;

■ society, in disability allowances and medicines; and

■ individuals, who may lose their jobs.

You, as the employer, are responsible for taking effective measures to control  exposure and protect health. These measures can also improve production or cut  waste.

Looking after your business Your aim in running your business is to make a profit. You know what you do, and  how you are doing it. You know what ‘processes’ and ‘tasks’ are involved. You  know the short cuts. Ensuring your workers remain healthy may also lead to healthy profits.

Which substances are harmful?

■ Dusty or fume-laden air can cause lung diseases, eg in welders, quarry workers or woodworkers.

■ Metalworking fluids can grow bacteria and fungi which cause dermatitis and asthma.

■ Flowers, bulbs, fruit and vegetables can cause dermatitis.

■ Wet working, eg catering and cleaning, can cause dermatitis.

■ Benzene in crude oil can cause leukaemia.

Many other products or substances used at work can be harmful, such as paint, ink, glue, lubricant, detergent and beauty products.Ill health caused by these substances used at work is preventable. Many substances can harm health but, used properly, they almost never do. Find out the dangers in your business – ask your supplier, your trade association, and check for your trade on HSE’s website: www.hse.gov.uk. Substances can also have dangerous properties. They may be flammable, for example solvent-based products may give off flammable vapour. Clouds of dust from everyday materials, such as wood dust or flour, can explode if ignited. This leaflet does not deal with flammability or explosion hazards (see ‘Find out more’).

Look at each substance Which substances are involved? In what way are they harmful? You can find out by:

■ checking information that came with the product, eg a safety data sheet;

■ asking the supplier, sales representative and your trade association;

■ looking in the trade press for health and safety information;

■ checking on the Internet, eg HSE’s website pages for your trade. Think about the task If the substance is harmful, how might workers be exposed?

■ Breathing in gases, fumes, mist or dust?

■ Contact with the skin?

■ Swallowing?

■ Contact with the eyes?

■ Skin puncture?

Bear these in mind when you look at the tasks.

Exposure by breathing in

Once breathed in, some substances can attack the nose, throat or lungs while others get into the body through the lungs and harm other parts of the body, eg the liver.

Exposure by skin contact Some substances damage skin, while others pass through it and damage other parts of the body. Skin gets contaminated:

■ by direct contact with the substance, eg if you touch it or dip your hands in it;

■ by splashing;

■ by substances landing on the skin, eg airborne dust;

■ by contact with contaminated surfaces – this includes contact with  contamination inside protective gloves. 

Exposure by swallowing People transfer chemicals from their hands to their mouths by eating, smoking etc without it washing first. Texas Essential Knowledge and Skills for Health Education  Subchapter A. Elementary

In health education, students acquire the health information and skills necessary to become  healthy adults and learn about behaviors in which they should and should not participate. To  achieve that goal, students will understand the following: students should first seek guidance  in the area of health from their parents; personal behaviors can increase or reduce health  risks throughout the lifespan; health is influenced by a variety of factors; students can recognize and utilize health information and products; and personal/interpersonal skills are needed to promote individual, family, and community health. Kindergarten students are taught basic factors that contribute to health literacy. Students learn about their bodies and the behaviors necessary to protect them and keep them healthy. Students also understand how to seek help from parents and other trusted adults.

Healthcare industry

This section provides background information on the size, geographic distribution, employment, and economic condition of the healthcare industry.  Facilities described within the document are also described in terms of their North American Industry Classification System (NAICS) codes.  The NAICS, which was developed jointly by the United States, Canada, and Mexico to provide new comparability in statistics about business activity across North America, has replaced the U.S. Standard Industrial Classification (SIC) system, under which Health Services is designated 80. Facilities in the healthcare industry are identified under NAICS code 62.

Note that, while there are benefits to the NAICS codes for organizing categories of business, there are disadvantages in the case of the healthcare sector. For the most part, healthcare organizations, whether large or small, in-patient or outpatient, have some level of complexity to their operations and functions.  Even small multi-service hospitals have complex service offerings, and generate a large variety of waste.  Therefore, the NAICS code information presented below is supplemented with a more robust picture of the rapidly changing healthcare universe.

Introduction, Background, and Scope of the Notebook

The healthcare and social assistance industry (NAICS code 62) comprises many subsectors including ambulatory healthcare services, hospitals, nursing and residential care facilities, and social assistance. This Notebook focuses primarily on the activities performed at hospitals. However, many of these activities can be performed by others in the healthcare  industry, and as such, this notebook applies to those providers as well. 

The specific subsectors covered in this industry document are: CNAICS 621. Ambulatory Healthcare Services. The following types of facilities are covered under this NAICS code: 

• 1.     Physicians’ offices,
• 2.     Dentists’ offices,
• 3.     Other health practitioners’ offices,
• 4.     Outpatient care centers,
• 5.     Medical and diagnostic laboratories,
• 6.     Home healthcare services, and
• 7.     Other ambulatory healthcare services.

These entities may be free standing and perhaps privately owned or may  be part of a hospital or health system.  Currently, most hospitals (NAICS  622) also offer ambulatory healthcare services.  For some facilities, these services represent as much as 60-70 percent of hospital business.  Much of this change has been driven by adjustments in healthcare finance and reimbursement, advances in technology, and new and effective pharmaceuticals, that eliminate the need for inpatient and invasive care services. Also of note is the growing emergence of complementary healthcare services that are also ambulatory in nature.  These include chiropractic care, massage, acupuncture, and acupressure. C NAICS 622. Hospitals. The following types of facilities are covered under this NAICS code:

1.     General medical and surgical hospitals,

2.     Psychiatric and substance abuse hospitals, and

3.     Specialty (except psychiatric and substance abuse) hospitals.

This category potentially includes many types of hospitals such as academic medical center/university-based/teaching hospitals, community hospitals, speciality hospitals (i.e., orthopedic or pediatric), and tertiary care facilities that are qualified to handle major trauma cases (i.e., burns and catastrophic accidents). There are also distinctions between public and private hospitals, hospitals that are part of a healthcare system (i.e., organizations such as Kaiser Permanente),  Veterans Administration hospitals, and other types of facilities. Hospitals and healthcare systems are continually changing their service offerings, and responding to various internal and external forces including reimbursement issues, advances in technology, and shifts in the populations they serve. CNAICS 623. Nursing and Residential Care Facilities. The following types of facilities are covered under this NAICS code:

1.     Nursing care and assisted living facilities,

2.     Residential mental retardation/health and substance abuse facilities,

3.     Community care facilities for the elderly, and

4.     Other residential care facilities.

Nursing care and residential care facilities offer nonacute care to individuals, either those suffering from a chronic condition (e.g., dementia, developmental delay, multiple sclerosis, Parkinson’s disease, autism), aging, or mental health problems.

As population demographics in the United States shift and demand for care services and facilities increases, more and more facilities offering some component of the above services will arise.

The veterinary services industry (NAICS 541940) also performs many activities similar to the healthcare industry.  Veterinary facilities may find some of the information in this

Notebook relevant and useful. C NAICS 541940. Veterinary Services. This industry includes establishments of licensed veterinary practitioners primarily in the practice of veterinary medicine, dentistry, or surgery for animals, and establishments providing testing services for licensed veterinary practitioners.

Health Inequalities: What Do We Know About the Health Status of Canadians?

Section 3 examines significant inequalities in the health status of Canadians. Whether it is measured using self-reports of overall health status, infant mortality rates, chronic conditions, activity limitations/disability status or the Health Utility Index, health status is worse for those with lower incomes. Cut another way, the health status of groups that are particularly vulnerable to poverty (e.g. lone mothers, Aboriginal persons, Atlantic Canadians) is consistently worse than that of the general population. Evidence shows that countries with less inequality and/or less poverty than Canada have better health outcomes and fewer health inequalities.

Examples presented in this section illustrate clearly that patterns of inequality in health status correlate very closely with patterns of inequality in SES. That is, groups with the lowest SES are also the groups most likely to have poor health status. While this evidence is certainly very suggestive, such informal evidence does not prove that there is causal link between poverty and health.

Does Poverty Cause Poor Health?

Sections 4, 5, and 6 of the report examine more formal, generally multivariate analyses that attempt to establish that poverty causes poor health. Studies of this type can be divided into those with a micro or individual orientation (i.e. personal direct experience of poverty is associated with personal health status) and those with a macro or populationorientation (i.e. living in a society with a more unequal distribution of income is associated with worse population health outcomes).

The key finding from the individual/micro-level research is that there is a very clear and very robust relationship between individual income and individual health. That is, poverty leads to lower health status. Additional findings include: 

•  While increases in income are associated with increases in health status across the  full income spectrum, the gains are largest for those at the bottom of the incomedistribution scale.

•  Longer-term measures of income have larger health associations. 

•  Long-duration poverty has larger associations with health than occasional episodes  of poverty. 

•  While both income level and changes in income level are important, the former is  more important. 

•  Negative ìshocksî to income have bigger consequences than positive shocks. 

•  For children, spells with low SES in the early years are most important in terms of impact on health. At the population/macro-level, a flurry of research has tested the hypothesis that societies with more inequality have worse health outcomes. Explanations for this phenomenon vary: 

•  The absolute income hypothesis suggests that health status increases with the level of personal income but at a decreasing rate, so that countries with more equally distributed incomes will be observed to have higher average levels of health.

•  The relative position (or psycho-social) hypothesis emphasizes individual position within a social hierarchy, independent of standard of living, as the key to understanding the link between socio-economic inequality and health. 

•  The neo-materialist hypothesis argues that high levels of income inequality are simply one manifestation of underlying historical, cultural, political and economic processes that simultaneously generate inequalities, for example, in social infrastructure (e.g. medical, transportation, educational, housing, parks and recreational systems). From this perspective, inequalities in health derive from inequalities in all of the above aspects of the material environment.

The Right to Health

As human beings, our health and the health of those we care about is a  matter of daily concern. Regardless of our age, gender, socio-economic  or ethnic background, we consider our health to be our most basic and  essential asset. Ill health, on the other hand, can keep us from going to  school or to work, from attending to our family responsibilities or from  participating fully in the activities of our community. By the same token,  we are willing to make many sacrifices if only that would guarantee us  and our families a longer and healthier life. In short, when we talk about  well-being, health is often what we have in mind. 

The right to health is a fundamental part of our human rights and of our  understanding of a life in dignity. The right to the enjoyment of the highest  attainable standard of physical and mental health, to give it its full name,  is not new. Internationally, it was first articulated in the 1946 Constitution of the World Health Organization (WHO), whose preamble defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The preamble further states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The 1948 Universal Declaration of Human Rights also mentioned health as part of the right to an adequate standard of living (art. 25). The right to health was again recognized as a human right in the 1966 International Covenant on Economic, Social and Cultural Rights. Since then, other international human rights treaties have recognized or referred to the right to health or to elements of it, such as the right to medical care. The right to health is relevant to all States: every State has ratified at least one international human rights treaty recognizing the right to health. Moreover, States have committed themselves to protecting this right through international declarations, domestic legislation and policies, and at international conferences. In recent years, increasing attention has been paid to the right to the highest attainable standard of health, for instance by human rights treatymonitoring bodies, by WHO and by the Commission on Human Rights (now replaced by the Human Rights Council), which in 2002 created the mandate of Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health. These initiatives have helped clarify the nature of the right to health and how it can be achieved.

This fact sheet aims to shed light on the right to health in international human rights law as it currently stands, amidst the plethora of initiatives and proposals as to what the right to health may or should be. Consequently, it does not purport to provide an exhaustive list of relevant issues or to identify specific standards in relation to them.The fact sheet starts by explaining what the right to health is and illustrating its implications for specific individuals and groups, and then elaborates upon States' obligations with respect to the right. It ends with an overview of national, regional and international accountability and monitoring mechanisms.

Health and life skills kindergarten to grade

Health and life skills involves learning about the habits, behaviours, interactions and decisions related to healthy daily living and planning for the future. It is personal in nature and involves abilities based on a body of knowledge and practice that builds on personal values and beliefs within the context of family, school and community. Some examples of these learnings include the ability of students to:

•  make effective personal decisions for current and future issues and challenges

•  plan and set goals

•  employ critical reflection

•  cope with change and transition

•  manage stress

•  analyze and manage career and health-related information

•  recognize and expand personal skills

•  recognize, explore and expand career opportunities and options

•  explore service learning/volunteerism

•  commit to lifelong learning.

The home, school and community play important roles in contributing to the healthy personal development of students, by providing an opportunity for them to consider information and acquire, practise and demonstrate strategies for dealing with the challenges of life and living. The aim of the Health and Life Skills Kindergarten to Grade 9 Program of Studies is to enable students to make well-informed, healthy choices and to develop behaviours that contribute to the well-being of self and others. To achieve this aim, students require an understanding of self as the basis for healthy interactions with others and for career development and lifelong learning. Students also require a safe and caring school and community environment in which to explore ideas and issues surrounding personal choice, to seek accurate information, and to practise healthy behaviours.

Comprehensive School Health This health and life skills program of studies provides a basis for instruction in schools. To achieve overall health goals for students, curriculum connections between services and resources within the school and wider community are needed. A comprehensive school health approach is desirable.

A comprehensive school health model incorporates:

•  health and physical education instruction that promotes improved commitment to healthy choices and behaviours health and community services that focus on  health promotion and provision of appropriate services to students who need assistance and  intervention

•  environments that promote and support behaviours that enhance the health of students, families and school staff. The health of students is viewed as an integral  component of a larger system of health within the  home, school and community environment. It involves the establishment of collaborative partnerships among students, parents, educators,  health care professionals and other community  supports to address social and environmental factors that influence and determine optimal health.

Responsible, Healthy Choices To make responsible and healthy choices, students need to know how to seek out relevant and accurate information. They learn health-related information from many sources, including home, school, peers, the community and the media. The health and life skills program assists students in identifying reliable sources of information and in becoming discerning consumers of health-related information. Students research, evaluate and synthesize information in an effort to understand health issues and to apply the learning to current and future personal situations. Choices, as evidenced by related behaviour, are based on attitudes, beliefs and values.  The family is the primary educator in the development of student attitudes and values.  The school and community play a supportive and crucial role in building on these attitudes and values.

In the health and life skills program, students develop decision-making skills that build resiliency and self-efficacy, help expand strategies for coping, and support informed personal health practices.  Students develop personal responsibility for health, learn to prevent or reduce risk, and have opportunities to demonstrate caring for self and others. Students focus on personal and collective safety, as well as injury prevention.  Outcomes related to safety and injury prevention promote strategies to assess risk, to reduce potential  harm, and to identify support systems for self and others. 

Students learn about products, substances and behaviours that may be injurious to their health.  They also learn strategies to use in unsafe situations. Students are encouraged to promote and maintain health as a valued and valuable resource, and to examine health issues and factors that promote or limit good health.  They gain an understanding that, in addition to the effect of their individual behaviours on their health status, there are social and environmental factors that are beyond their immediate control, which also have a significant impact on their health.

In an environment of acceptance, understanding, respect and caring, students in the health and life skills program can learn to acknowledge and express personal feelings and emotions, as well as to appreciate the strengths and talents of self and others. There are opportunities for students to accept and appreciate diversity and the uniqueness of self and others in our global society.  This program emphasizes healthy interactions and values, such as integrity, honesty and trust that underlie safe and caring relationships. Friendship skills are developed and then extended to incorporate skills for working in groups. Such skills include conflict management, consensus building, negotiation and mediation. Students examine the various sources of stress in relationships, which include behaviour-related factors and those due to natural life cycle changes and transitions.  They learn strategies to deal with unhealthy relationships, as well as traumatic events. Throughout the program, students build and expand upon safe and supportive networks for self and others that link the home, school and community.

Students also develop the skills of goal setting, prioritizing and balancing various roles and life/work priorities.  As students develop decisionmaking skills, they begin to realize that the locus  of control, or their ability to influence or control many outcomes and results, is within their own power.

Through the health and life skills program,  students acquire a strong foundation of knowledge, skills and attitudes basic to employability.  Successful careers are founded on a basis of self-knowledge, self-esteem, healthy interactions, lifelong learning and skill development.  A fundamental aspect of career education is to move students from being dependent learners to being independent and interdependent, contributing citizens.  Students gain confidence and a sense of commitment to family, school and community through opportunities for participation in cross-age interactions, volunteerism and meaningful involvement in a variety of activities. Beginning in the early school years, students develop personal and group skills.  These are reinforced as the program expands to include practical skills directly related to further education, job seeking and career path exploration.  Skills related to the management of personal resources, such as time, energy, creativity, money and personal property, are essential elements that build personal capacity and lead toward future career productivity. Students build upon the knowledge, skills and attitudes required to recognize opportunities, critically evaluate options and expand career strategies to meet current and future challenges.

Creating A Healthy Environment: The Impact of the Built Environment on Public Health

Here at the start of the 21st century our understanding of which factors promote health and which damage health has grown considerably. The diseases of the 21st century will be “chronic” diseases, those that steal vitality and productivity, and consume time and money. These diseases-heart disease, diabetes, obesity, asthma, and depression- are diseases that can be moderated by how we design and build our human environment. It is now accepted that, in addition to direct hazards from infectious diseases and environmental toxins, human behaviors play a critical role in determining human health. As we begin to include consideration of these factors into our health-related decision-making, we must additionally guard against using too narrow a definition of the environment. Every person has a stake in environmental public health, and as environments deteriorate, so does the physical and mental health of the people who live in them. There is a connection, for example, between the fact that the urban sprawl we live with daily makes no room for sidewalks or bike paths and the fact that we are an overweight, heart disease-ridden society.

Obesity can increase the risk of (adult-onset) type 2 diabetes by as much as 34 fold, and diabetes is a major risk factor for amputations, blindness, kidney failure, and heart disease. The most effective weight loss strategies are those that include an increase in overall physical activity. In a recent type 2 diabetes trial, weight loss and physical activity were more effective in controlling the disease than medication. In addition, for treatment of relatively mild cases of anxiety and depression, physical activity is as effective as the most commonly prescribed medications. It is dishonest to tell our citizens to walk, jog, or bicycle when there is no safe or welcoming place to pursue these “life-saving” activities.

Respiratory disease, especially asthma, is increasing yearly in the U.S. population. Bad air makes lung diseases, especially asthma, worse. The more hours in automobiles, driving over impervious highways that generate massive tree-removal, clearly degrade air quality. When the Atlanta Olympic Games in 1996 brought about a reduction in auto use by 22.5%, asthma admissions to ERs and hospitals also decreased by 41.6%. Less driving, better public transport, well designed landscape and residential density will improve air quality more than will additional roadways.

In order to address these critical health problems we must seize opportunities to form coalitions between doctors, nurses, and public health professionals and others such as architects, builders, planners and transportation officials, so that we are all “at the table” when environmental decisions are made. Such decisions include whether to install sidewalks in the next subdivision. It means thinking about what constitutes safe and affordable housing, safe neighborhoods, providing green space for people to enjoy where they live and work, and rethinking how we travel from one place to another.

Land-use decisions are just as much public health decisions as are decisions about food preparation. What, for example, are the implications for children with asthma of building yet another expressway? We must also question whether a fatality involving a pedestrian isn’t actually the result of poor urban planning, thoughtless land use, or inferior urban design rather than “simply” a motor vehicle crash. We must be alert to the health benefits, including less stress, lower blood pressure, and overall improved physical and mental health, that can result when people live and work in accessible, safe, well-designed, thoughtful structures and landscapes. We must measure the impact of environmental decisions on real people, and we must begin, in earnest, to frame those decisions in light of the well being of children, not only in this country but across the globe.

The health of Europeans

More than three-quarters (76%) of Europeans consider that they are in good health. Approximately one in five citizens believes  that  he  or  she  is  in  very  good  health (21%) or has a more neutral position (19%) as regards his or her health.  Only 5% of respondents described their health as bad (5%) or very bad (1%).

In the European Union, respondents in a majority of the new Member States tend to be more pessimistic about their health in general. The percentages vary considerably from one Member State to another: a small majority of Latvians and Lithuanians (52%) consider that their health is good or very good while the corresponding percentage is close to or higher than 85% in Denmark (84%) and Ireland (87%).There are similar differences if only the results of the “very good” replies are taken into consideration: the Irish (43%) and Danish (44%) are again among those who consider that their health in general is  very good. This time, however, they are  joined by citizens in Greece (46%) and Cyprus (40%). Citizens of the Baltic countries (from 5 to 11% of respondents from those countries consider themselves to be in very good health) while Hungarian citizens are more “negative” (11%) about their health in general. Among the candidate and accession countries, Turkey is the only one where the levels are very close to the EU average. On the other hand, those of the other countries are below the EU average.

An analysis of the replies by socio-demographic variables reveals that men are more optimistic about their health. Fairly logically, age is a discriminating variable; while 89% of young people (aged between 15 and 24) consider that their health is good, only 59% of people aged 55 and over make the same positive diagnosis of their health. The heaviest respondents and those who consider that they are overweight are more  likely  to  view  their  health  negatively.  This  suggests  that  such  people  are aware of the negative health effects of a high body weight.

Health and food

In recent decades, important socio-economic changes in most developed countries have undeniably affected the eating habits and level of physical activity of citizens. This trend is clearly illustrated by the current increase in illnesses directly or indirectly related to the increase in overweight and obesity.

It has been established that that a poor diet and insufficient physical activity are among the main risk factors for various diseases. Physical activity can also help to combat stress.The European Commission and in particular its Directorate General health and Consumer Protection wants to improve public health in the European Union, prevent disease and human ailments and eliminate human health risk factors. The aim of this survey, commissioned by the Directorate General Health and Consumer Protection is to study several areas having an impact on the health of European citizens. More precisely, the intention is to use the results of this study to establish the physical characteristics of European  Union citizens and assess the opinion of citizens on subjects such as health, diet and physical activity in the form of sport.

It is not the first survey carried out on these subjects. Two previous surveys concerning, on the one hand, physical activity and, on the other hand, health and diet, were carried out at the end of 2002 and the beginning of 2003. In relation to those previous studies, the current questionnaire has been revised, but several questions can still be used for comparative purposes in 15 of the 25 European

Union Member States. 

The main themes addressed in this survey are:

- The health and physical characteristics of Europeans,

- Eating habits in the European Union,

- Diet and problems related to being overweight,

- The respondent’s physical activity.

This survey was carried out in November and December 2005. It was commissioned by the Directorate General Health and Consumer Protection and carried out by TNS Opinion & Social, a consortium formed by TNS and EOS Gallup Europe. The methodology used is that of the standard Eurobarometer surveys of the Directorate General Press and Communication (“Opinion  Polls, Press Reviews, Europe Direct” unit). A technical note concerning the interviews carried out by the institutes of the TNS Opinion & Social network is annexed to this report. That note specifies the interview method, as well as the intervals of confidence.

About of the Health

Improvement in the health and nutritional status of the population has been one of the major thrust areas for the social development programmes of the country. This was to be achieved through improving the access to and utilization of Health, Family Welfare and Nutrition services with special focus on under  served and under  pr ivi leged segments of the population. Over the last five decades, India has built up a vast health infrastructure and manpower at primary, secondary and tertiary care in government, voluntary and private sectors. These institutions are manned by professionals and paraprofessionals trained in the medical colleges in modern medicine and ISM&H and paraprofessional training institutions. The population has become aware of the benefits of health related technologies for prevention, early diagnosis and effective treatment for a wide variety of illnesses and accessed available services. Technological advances and improvement in access to health care technologies, which were relatively inexpensive and easy to implement, had resulted in substantial improvement in health indices of the population and a steep decline in mortality. The extent of access to and utilization of health care varied substantially between states, districts and different segments of society; this to a large extent, is responsible for substantial differences between states in health indices of the population.

During the 1990s, the mortality rates reached a plateau and the country entered an era  of dual  disease burden. Communicable diseases have become more difficult to combat because of development of insecticide resistant strains of vectors, antibiotics resistant strains of bacteria and emergence of HIV infection for which there is no therapy. Longevity and changing life style have resulted in the increasing prevalence of non-communicable diseases. Under nutrition, micro nutrient deficiencies and associated health problems coexist with obesity and non-communicable diseases. The existing health system suffers from inequitable distribution of institutions and manpower. Even though the country produces every year  over  17,000 doctors  in modern system of medicine and similar number of ISM&H practitioners and paraprofessionals, there are huge gaps  incritical manpower in institutions pro viding primary health care , especially in the remote rural and tribal areas where health care needs are the greatest. Some of the factors responsible for the poor functional status of the system are:

·         mismatch between personnel and infrastructure;

·         lack of Continuing Medical Education (CME) programmes for orientation and  skillupgradation of the personnel;

·         lack of appropriate functional referral system;

·         absence of well established linkages between different components of the system.

Human healt

This chapter describes the observed and projected health impacts of climate change, current and future populations at risk, and the strategies, policies and measures that have been and can be taken to reduce impacts. The chapter reviews the knowledge that has emerged since the Third Assessment Report (TAR) (McMichael et al., 2001). Published research continues to focus on effects in high-income countries, and there remain important gaps in information for the more vulnerable populations in lowand middle-income countries.

State of health in the world Health includes physical, social and psychological wellbeing. Population health is a primary goal of sustainable development. Human beings are exposed to climate change through changing weather patterns (for example more intense and frequent extreme events) and indirectly though changes in water, air, food quality and quantity, ecosystems, agriculture, livelihoods and infrastructure. These direct and indirect exposures can cause death, disability and suffering. Illhealth increases vulnerability and reduces the capacity of individuals and groups to adapt to climate change. Populations with high rates of disease and debility cope less successfully with stresses of all kinds, including those related to climate change.

In many respects, population health has improved remarkably over the last 50 years. For instance, average life expectancy at birth has increased worldwide since the 1950s. However, improvement is not apparent everywhere, and substantial inequalities in health persist within and between countries (Casas-Zamora and Ibrahim, 2004; McMichael et al., 2004; Marmot, 2005; People’s Health Movement et al., 2005). In parts of Africa, life expectancy has fallen in the last 20 years, largely as a consequence of HIV/AIDS; in some countries more than 20% of the adult population is infected (UNDP, 2005). Globally, child mortality decreased from 147 to 80 deaths per 1,000 live births from 1970 to 2002 (WHO, 2002b). Reductions were largest in countries in the World Health Organization (WHO) regions of the Eastern Mediterranean, South-East Asia and Latin America. In sixteen countries (fourteen of which are in Africa), current levels of under-five mortality are higher than those observed in 1990 (Anand and Barnighausen, 2004). The Millennium Development Goal (MDG) of reducing under-five mortality rates by two-thirds by 2015 is unlikely to be reached in these countries. stroke and cancer, account for nearly half of the global burden of disease (at all ages) and the burden is growing fastest in lowand middle-income countries (Mascie-Taylor and Karim, 2003).

Communicable diseases are still a serious threat to public health in many parts of the world (WHO, 2003a) despite immunization programmes and many other measures that have improved the control of once-common human infections. Almost 2 million deaths a year, mostly in young children, are caused by diarrhoeal diseases and other conditions that are attributable to unsafe water and lack of basic sanitation (Ezzati et al., 2003). Malaria, another common disease whose geographical range may be affected by climate change, causes around 1 million child deaths annually (WHO, 2003b). Worldwide, 840 million people were undernourished in 1998-2000 (FAO, 2002). Progress in overcoming hunger is very uneven. Based on current trends, only Latin America and the Caribbean will achieve the MDG target of halving the proportion of people who are hungry by 2015 (FAO, 2005; UN, 2006a)