Concepts Of Medicine Adherence And Its Economic Burden Nursing Essay

Concepts Of Medicine Adherence And Its Economic Burden Nursing Essay Even though 45% of all medications prescribed in the UK are for older people, it is postulated that up to 50% of older people are non-compliant with their medication (SCIE, 2005). The prescription of various medicines is central to medical care and the overall drug costs account to about 10 percent of NHS expenditures. Surveys carried out in literature enlighten us with the fact that approximately 30% to 50% of patients do not use of take their medications as recommended by their prescriber. (1). Statistics show that in 2007- 2008, the NHS in England spent  £8.1 billion on drugs if as many as 50% of the patients dont take their medications as recommended, this could mean that  £4 billion worth of medicines were incorrectly used (2) . Furthermore the additional cost of unused or unwanted medicines within NHS totals up to  £100 million each year. On top of that the estimated drug cost of unused or unwanted medicines in the NHS is around  £100 million annually (3). A Cochrane review Interventions for enhancing medication adherence concluded that improving medicines taking may have a far greater impact on clinical outcomes than an improvement in treatments (4). Therefore if the prescription is inappropriate in the first place it not only translates as a loss to patient but also involves the healthcare system and the society. The costs included here are both personal and economic. Concepts of Adherence and terminology There are three major terms which are commonly used in the literature to describe medication-taking behaviours i.e Compliance, Adherence and Concordance (5). According to Pound (6) initially, the term compliance was used to illustrate the medication taking behaviour, which was then replaced by the term concordance. The term compliance came into disfavour because it suggested that a person is passively following a doctors orders, rather than actively collaborating in the treatment process (3) Whereas concordance refers to the anticipated outcome of the consultation between doctors and patients about medicine taking It is viewed as successful prescribing and medication taking based on the partnership with the patient (6). However the most current, fashionable and accepted terminology is adherence, which is defined by McElnay (7) , as the extent to which a persons behaviour (in) in terms of taking medicines, following diets or executing lifestyle changes, coincides with advice given by health care professionals Adherence shifts the balance between professional and patient about the prescribers recommendations. Pound (6) states that the above mentioned three terminologies tend to be used interchangeably but are incorrectly applied. Adherence can be viewed as the central aim, concordance is the process used to apply the central aim compliance is the outcome of the process. The benefits of medication might be restricted thereby causing a further deterioration in health as a consequence of non-adherence. . On top of this the economic costs do not only translate to wasted medicines only but also include the knock on costs which arise from increased demands for healthcare if (on the whole) health deteriorates. It is hence due to this reason that non-adherence is a major issue and should not only be seen as the patients dilemma. A fundamental drawback is represented in the provision of the healthcare, which is often due to a failure in completely agreeing with the prescription in the first place or to recognise the appropriate support that the patients might require later on during the treatment. Hence addressing non-adherence is by no means about getting patients to take additional medicines. Therefore tackling the issue of non-adherence involves the initial understanding of patients opinion on the medicine and then the various reasons to as why they are/m ight be reluctant or unable to use them. Causes of non-adherence There are many causes of non-adherence however they fall into two main overlapping categories i.e intentional and unintentional. Both types relate to the lack of an established pattern of medication taking which led to the incidental omission of medicines and may be experienced concurrently (8). Purposeful or intentional non-adherence occurs when a patient makes a specific decision not to take the prescribed medication. The anticipation of drug-related side effects and general dislike of taking medicines are common causes of intentional non-adherence (9). While accidental or unintentional non-adherence occurs as a result of forgetting or misunderstanding instructions about the drug schedule .Unintentional non-adherence is proposed to be range from a random departure to medication omissions from a prescribed treatment regimen (10). Hence the main features of unintentional non-adherence focuses on altering medication contingent on self assessment or perceptions of mental health, stress or anxiety, forgetting to take medicines or simply altering the doses of medicines to fit in with daily chores. A research carried out by Svensson (10) Kippen (11) showed that older people adherent with their medication often link the administration of medication to specific lifestyle events, location, time, and patterns of daily activities. Below table 1.3.1 shows the common perceptions and characteristics of adherent and non adherent medication taking behaviors. Table 1: Shows common perceptions and characteristics of adherent and non adherent medication taking behaviours. Perceptions related to medication taking behavior Intentional Non-adherence Unintentional Non-adherence Feeling unnatural taking medicines Fears of prescribing errors/addiction Life style change/ Disruption to daily routine Adverse effects of medicines Lack of faith in the prescriber Drug related memory loss/ Forgetfulness Long term risks of medicines Failure to accept diagnosis Altering dosing regimen Past experience of medicines Dislike of taking medicines Being asymptomatic Lack of comprehension of the need to take medicines. Testing medicines against symptoms Period of illness Vulnerable group of people Of all the age groups, medication taking behaviour in older people is of the highest concern. This is due to multiple reasons as described by Huges (12). Firstly, older people are highly likely to suffer from multiple diseases. Secondly, older people frequently administer three or more medicines concurrently to manage these conditions and third as a result of poly pharmacy, they are increasingly likely to mismanage their medicines (13). Furthermore, research shows the following as different lay beliefs by older people on medicine taking The need to reduce the symptoms of hypertension, to feel physically better (14). Fear of complications and desire to control blood pressure (10). Positive confidence in the prescriber (15). Apart from the elderly, another age group, where non- adherence is becoming a significant problem is in the pediatric population. In one of the studies carried out by Bush (16) it has been shown that one-third of the children in grades 3 to 7 reported they had used one or more prescription or non prescription medications in a 48 hour period. Adherence plans for children often require innovative approaches to encourage active participation in caring for their own health and how to use their medications appropriately. Consequences of medication non-adherence No matter how much critical the conditions are a patient might stick to his medication regimen, thus reflecting a loss of the health care system with increased use of medical resources, such as GP visits, unnecessary additional treatments, emergency department visits and hospital admissions. One of the recent research shows that about 3-4% of UK hospital admissions are as a result of avoidable medicine related illness (17) between 11 and 30 % of these admissions result from patients who dont use their medicines as recommended by their prescriber (3). In a similar manner, in 2006-2007, figures show that that the NHS expenditures on hospital admissions (excluding critical care costs) was approximately about  £ 16.4 billion (18). And the estimated costs of admissions, within the same year i.e. 2006 2007, resulting from patients not taking their medicines as recommended was found to be between  £36 and  £196 million respectively (18). Hence a reduction in these admissions and associated costs would be expected as the overall medicines adherence increases. Factors affecting medication adherence In accordance to WHO some of the main common factors reported to have a significant effect on adherence include: poverty, low level of education, illiteracy, poor socioeconomic status, unemployment, unstable living conditions, lack of effective social support networks, long distance from treatment centre, high cost of medication, changing environmental situations, high cost of transport, family related issues and culture lay beliefs about illness and treatment. In accordance to WHO the common belief of patients being the sole responsible for taking their treatment is misleading and most often reflects a misunderstanding of how other factors affect peoples behaviour and the capacity to adhere to their treatment. Adherence, in short, is a multidimensional phenomenon which is determined by the interplay of five different sets of factors, each of which are termed as dimension by WHO (5) . Each of these dimensions are listed as under and shall be discussed in detail Social/ economic factors Provider-patient/ health care system factors Condition related factors Therapy-related factors Patient related factors Social and economic dimension It includes limited access to health care facilities, medication costs, low health literacy, limited English language proficiency, unstable living conditions (homelessness), lack of family/social support network, and cultural beliefs about illness and treatment. Among these factors few shall be discussed in detail as under English language proficiency Both low health literacy and limited English language proficiency are barriers to adherence that deserve special consideration. Health literacy can be defined as the ability to read, understand and act on health information so that appropriate health decisions can be made. The risk of unsafe use of prescription medicine, is high among people with low health literacy and limited proficiency in English language due to the complex nature of the printed information that is available and because these people often do not receive adequate verbal communication or sufficient time from health care providers. Older adults with low health literacy may have trouble reading health information materials, understanding basic medical instructions, following prevention recommendations and adhering to medication regimens. Social factors Medication adherence is positively associated with social support and the availability of help from family and friends. Better outcome to treatment is observed in people who have social support from their friends/family (who assist them with their medication regimens) Cultural beliefs and attitudes Adherence to therapy, may overall be affected as a consequence of different attitudes which the patient may have towards health and medicine. Addressing these issues by the health care professionals is of prime importance so that the patients can get the most out of their medicines without compromising their health In case of adults, different components of health and healing cannot be explained by no one list. Therefore each individual must be considered on individual basis. Two major key components are requisite i.e asking non-judgmental questions listening, when it comes down to understanding the process of gaining an insight into patients beliefs (regarding health and healing) Patients belonging from various ethnic minorities bring along their practices in the health care system. This sometimes puts the health care professionals at test, who have been professionally trained in the light of western philosophy and medicine. Although groups of people may have beliefs or practices in common, yet that doesnt mean that they all can be classified under the same category. Within groups , the major differentiating factors include health status, educational level, sexual orientation etc (5). Respect Taking care of elder patients who belong from such backgrounds where they receive a great amount of respect (e.g. British Asian community ) should involve the element of respect combined with kindness. If they are approached with an attitude that consists even a tiny fraction of scolding or telling off, they might show resentment towards the adherence of medicine even though it may put their lives at risk. Therefore to put such patients at relieve it is of prime importance to show respect towards them . Traditional therapies and cause of illness Literature shows that two components such as religion and spirituality can play a vital role in the overall understanding of illness in its broadest sense among older people (19). The will of God for an improper behaviour, exposure to cold wind, natural causes etc are all different factors which older patients believe are major culprits for causing illness (20). This consequently leads them in such a situation where they end up giving God a chance to heal them or alternatively they seek help from a folk healer, try home remedies or pray for the treatment of their illness. An excellent example of this can be viewed within the Chinese culture where health may be seen as finding norm between ying yang, which is much more like hot and cold (21). Now patients who follow Chinese health belief may try such approaches which targets at restoring the balance between ying and yang (using different varieties of food and herbs). Likewise, some Asian ethnic groups rely solely on traditional remed ies for the treatment of long term conditions (21). At this stage it is also important to mention that the patient may not be cooperative if he believes that the health care provider may disapprove information surrounding the use of non-traditional remedies. This may ultimately lead to different interactions with the prescribed medications. Medication For some patients the preference lies in the dosage form or the size or colour of the medication. For example some cultures in Latin America view injections as more potent in comparison to oral medications. Likewise it is believed that Western medications are too strong by Chinese older patients hence therefore they might choose to not take the full dose of medicine (22). Health care system dimensions It includes different factors such as provider-patient relationship, provider communication skills, patient information materials written at too high literacy level, restricted formularies (changing medications covered on formularies), poor access or missed appointments, long waiting time and lack of continuity of care (23). The quality of the HCP-patient relationship is one of the most important health care system-related factors impacting adherence. Adherence to medicines can be increased as a result of good relationship between the patient and the HCP (which features the element of reinforcement and encouragement from the HCP), however there are many factors which have negative effect (24). These include lack of training and knowledge for health care providers on managing chronic diseases, lack of incentives and feedback on performance, poor medication distribution systems, short consultations, overworked health care providers, weak capacity of the system to educate patients and provide follow up, lack of knowledge on adherence and of effective interventions for improving it. Condition related dimensions It includes Psychotic disorders, severity of symptoms, chronic conditions, depression, lack of symptoms, mental retardation (25). Among these factors few shall be discussed in detail as under Chronic conditions and lack of symptoms Information within literature supports the fact that adherence to such treatment options (often declines as the time progresses) where medications have to be taken on an unlimited basis for the management of a chronic ailment. Example of two perfect clinical conditions which would fit into this profile include high BP and osteoporosis (26) , in which the symptoms are totally invisible to the patient. Furthermore, in the absence of symptoms these ailments lack the cues which would motivate the patient to adhere towards his treatment regimen. Depression A study carried out by Krueger (28) showed significantly lower rates of medication adherence among people with chronic illnesses and who are depressed. It is therefore crucial for the HCPs to be aware of the devastating impact, depression has on adherence consequently on regular basis should assess older patients who are sad all the time or who report symptoms of sleeping disturbances to eliminate the possibility of clinical depression. The slow onset of the pharmacological actions posed by different classes of antidepressants is classified as one of the major factor that contributes towards decreased adherence among elder patients. Adding on to that if the patient begins to experience the side effects (before even the symptoms are relieved), might consequence discontinuation of the therapy at a very early stage. In a similar fashion, a research conducted by Kemyttenaere (29) shows that once the patients (suffering from depression) start feeling bette,r they might stop the antidepre ssant therapy midway. Psychotic disorders A patients experience with unpleasant side effects is mainly one of the key causes which drives them from continuing their antipsychotic therapy. Literature shows that interventions which focus mainly on the persons attitude and beliefs about medications 9rather than on the knowledge) helps improve adherence. The addition of two key ingredients i.e Behavioral techniques motivational interviewing within compliance therapies, have proven to be very effective in improving medicines adherence among patients who suffer from psychotic disorders (31). Therapy related factors/dimensions It can be sub-divided into other different factors such as duration of therapy, lack of immediate benefit of therapy, frequent changes in medication regimen, actual or perceived unpleasant side effects, medications with social stigma attached to use, treatment requires mastery of certain techniques, complexity of medication regimen and treatment interferes with lifestyle or requires significant behavioural changes. Research by Tabor (32) Krueger (27) showed that decreased adherence is associated with medications with a social stigma attached to its use and with medications which require following complex regimen ( e.g. duration of therapy, number of daily doses required, or therapies that interfere with a persons lifestyle. Adherence can also be affected by other factors e.g. if administration of a medication requires the mastery of specific techniques like injections (32). In a similar fashion, when medications such as antidepressants are slow to produce effects, the patients/older person may believe that the medication is not working and might stop taking it. Likewise the side effects of a medication too can lower adherence if the patients start believing that they cannot manage or control them (25). Patient related factors/dimensions They can be sub-divided into two major factors i.e psychological/behavioral factors and physical factors. Psychological factors include fear of dependence or possible adverse effects, knowledge about disease, motivation, perceived risk to disease benefit of treatment, understanding reason of medication need, confidence in ability to follow treatment, feeling stigmatized by the disease, frustration with health care providers , psychosocial stress, expectations towards treatment and substance (alcohol) abuse. Physical factors include issues like swallowing problems, hearing, visual cognitive impairments and impaired dexterity or mobility. Few of these physical and psychological factors can be discussed in detail as under: Psychological factors that influence adherence The WHO proposes a foundation model for medication adherence which is based on three major factors i.e. motivation, information and behavioural change. Behavioural change has been found to be influenced effectively by making interventions based on this model (33). In accordance to WHO, adherence and non-adherence are different behaviours. In order to change behaviour, information is a prerequisite, but in itself it is insufficient to achieve this change. Hence at this stage behavioural and motivational skills are critical determinants. Motivation and information work largely through the behavioural skills to produce an impact on the behaviour. However, when the behavioural skills are uncomplicated or are familiar, the two aspects i.e motivation and information can produce a direct effect on the behaviour (33). Physical Factors that influence adherence The risk for non-adherence among older patients is increased due to physical and cognitive limitations. Visual Impairment Decreased ability to perform activities of daily living and an increased risk for depression is associated with vision impairment (34), (35). Furthermore there are many other medication safety issues associated with vision loss. A persons ability to read patient information leaflets, prescription labels, determine the colour and markings distinguishing a medication is affected by low vision and blindness. Therefore consequently people who cannot read prescription labels or distinguish among different medications have to rely on their memory or depend on someone else for help and hence may not be able to take their medications correctly. Hearing Impairment Hearing loss is directly related with age. The natural aging process not only affects the ability to detect sounds at lower levels but also the capability to understand speech at a normal conversation level (36). This condition does gets worse with age and is progressive. It is therefore important to not assume when a deaf person nods his head in acknowledgement that he/she has understood, as he/she might be relying on a family member or a companion to explain later (36). Impaired Mobility Older patients with poor mobility may have difficulty in self administration of medicines or in obtaining medicines from the pharmacy (37). Cognitive Impairment Poor medication adherence is associated with Impaired cognition (25). Elderly patients with memory problems and cognitive impairment may have difficulty in understanding when to take, how to take or how much to take their medications. Others factors also include as swallowing difficulties and impaired dexterity. PREDICTORS OF medication non-adherence Predictors of medication non-adherence can be a useful tool in the improvement of medicine adherence among older adults. Few of the non-adherence warning signs (38) include failure to fill in a new prescription, failure to fill in prescription for choric medication or failure to obtain refills as often as expected for medications taken on chronic basis. Below are some of the more common predictors of medicines non-adherence (38): Forgetfulness Lower cognitive function or cognitive impairment. Lack of insight into illness Lack of belief in benefit of treatment. Belief that medications are not important or are harmful. Complexity of medication regimen Tied of taking medications. Inconvenience of medication regimen. Side effects or fear of medication side effects. Missed Appointments. Substance Abuse Limited English language proficiency. Role of NICE (National Institute of Clinical Excellence): The issue of non-adherence to medicine is a very important issue in its own essence. After assessing and understanding the impact of non adherence on the NHS the NICE (National Institute of Clinical Excellence ) came into action and published a guidance in January 2009 (Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence) to tackle and address this core issue (of non adherence). Before moving further it would be essential here to describe the role of NICE in terms of its function. NICE was established as a special health authority on 1st April, 1999 is an independent organisation that provides national guidance on promotion of good health and prevention and treatment of ill health in England and Wales (39). The institutes main purpose is to offer NHS health care professional advice on how to provide patients with the maximum attainable standards of care and to decrease the variation in the quality of care . Furthermore, NICE is not part of the European Medicines Evaluation Agency (which assess the efficacy and safety of drugs), only licensed drugs on the basis of their added value relative to existing practice in the NHS are assessed by NICE (40). It has four programmes that produce guidance which are mentioned as under (39): Public health guidance Clinical Guidelines Interventional procedures Health technology appraisals ( for surgical interventions, pharmaceuticals, medical devices, etc) Most programmes take into account both the elements of cost-effectiveness (how well an intervention works relative to its cost) and effectiveness (how well an intervention works) NICE has an annual budget of 33 million pounds annually with over 250 full-time staff members working at offices based in London Manchester. The processes NICE uses in the development of its guidance are highly consultative, evidence based and transparent. It also involves all relevant stakeholders, including policy makers, health professional managers, specialist, academics, representatives of health care industries, general public and patients (39). The guidance that NICE produced to address the issue of medicine adherence was CG76 Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence. This guideline was produced taking into account the patients views as to what they perceive as barriers to effective medicines adherence and thus encourages healthcare professionals to have a discussion with patients about their prescribed treatment especially for long term conditions. In addition to this the guidelines also open a pathway for dialogue and negotiation between the patient and the health care professional regarding their medication. A quick summary of the guidelines is as mentioned below Summary of the NICE guidelines Bullet-points below quote from summarise recommendations from the CG76 guidelines (41). The key recommendations from NICE guidelines are as under Table 1: Shows the key recommendations from NICE CG76 guidelines. Involving Patients: Improve communication with patients Increase patient involvement in the decision making process about their medicines. Understand the patients perspective on their condition and possible treatments. Provide information about their condition and possible treatments. Supporting Adherence: Assess adherence levels Identify adherence issues Address adherence issues Review medication and its effective use Improve communication between health care professionals in the care pathway. From www.nice.org.uk/pdf/CG76fullguidelines.pdp Significance of the Study Community Pharmacists are the health care professionals which are most readily accessible to the general public and therefore continue to be the first line of Healthcare. They are experts on medicines and represent an important link in the chain of the health care professional team. Thus the main objective of this research project will be to provide a new insight as to what the community pharmacists reflect/perceive about these NICE CG76 guidelines. Hence their views and opinions will be assessed and analysed with regards to these NICE recommendations (as this would help in the implementation process). Any differences in the views of the pharmacists or any disagreement on the effectiveness of the NICE guidelines would mean that further investigation could be required to improve or update these recommendations. Hypothesis: H0 = There will be no statistically significant relationship between the years of experience of the pharmacists and the awareness of NICE CG76 guidelines. H1 = There will be a statistically significant relationship between the years of experience of the pharmacists and the awareness of NICE CG76 guidelines. H0 = Majority of the community pharmacists will not agree (on to a large extent) that CG76 recommendations have been effective in the improvement of medicines adherence among their patients. H1 = Majority of the community pharmacists will agree (on to a large extent) that CG76 recommendations have been effective in the improvement of medicines adherence among their patients.

Ecology: Petroleum and Caspian Sea

People from ancient times has an impact on the environment. As a result, this versatile centuries of human activity has left a deep mark on modern soil and vegetation, air and drinking (water) environment and wildlife. Man depletes non-renewable natural resources and threatens the production of those items that could be renewed. It changes the nature of the environment, upon which his physical and mental existence as biological and social phenomenon. Environmental pollution is becoming more acute, alarming. Barbarous, destructive attitude of the central departments of natural resources of Kazakhstan led 70-90. To the environmental crisis in the country, take in some regions of the catastrophic nature. One of the toughest environmental problems is the radioactive contamination of the territory of Kazakhstan. Nuclear tests conducted since 1949 at the Semipalatinsk test site resulted in contamination of vast territories in central and eastern Kazakhstan. The country has had five landfills, where nuclear tests were conducted in the vicinity of its borders is a Chinese Lop Nor test site. Radiation background in Kazakhstan increased as a result of the formation of ozone holes in spacecraft launch from the Baikonur. Huge challenge for Kazakhstan of the radioactive waste. Thus, UMP Factory has amassed about 100,000 tons of waste contaminated with uranium, thorium, and waste storage facility located in the city of Ust-Kamenogorsk. In Kazakhstan there are only 3 repository for nuclear waste and they are all located in the aquifer. That seriousness of the problem of radioactive contamination has led to one of the first laws of sovereign Kazakhstan was the decree of 30. 08. 1991, the banning of tests at the Semipalatinsk test site. One of the most serious environmental problems of Kazakhstan became the depletion of water resources. Increased consumption of fresh water, primarily for irrigated agriculture led to salinization and depletion of natural water sources. Particularly disastrous was the shallowing of the Aral Sea due to irrational use of water Amu Darya and Syr Darya. The sea level dropped by 13 meters, who uncovered the seabed turned into a salt desert. The annual dust storms spread the salt on the vast territory of Eurasia. The decrease mirrors the sea has led to a change in wind direction and climatic characteristics of the region. A similar situation exists in Lake Balkhash, the level of which is 10-15 years fell by 2. -3 meters. At the same time, the rise of the Caspian Sea, caused by ill-conceived decision stripping the Gulf of Kara-Bogazgol. Already flooded huge areas of coastal grazing areas and promising oil-bearing areas. Zyryanovsk lead and Leninogorsk polymetallic complexes have led to contamination of the Irtysh. Alarming environmental situation prevailing in the valley of the rivers Ili and the Urals. In the critical condition of the land resources of Kazakhstan, depleted fertile arable land, pasture becomes desert. Remains a serious problem of air pollution, especially in large industrial centers. National priority in the â€Å"Strategy 2030† RK include: environmental safety, rational use of natural resources, environmental well-being of citizens and some of the problems of social ecology. Reaction to the first environmental crises and catastrophes was expressed in the â€Å"Environment Act† of 1997. The problem of ecology and conservation – is rational and planned use of natural resources, protect the environment from pollution is a planned system of state control, international and public events aimed at the rational use, protection and restoration of natural resources, the satisfaction of material and cultural needs of future generations. National environmental issues Zones of ecological disaster in the Republic of Kazakhstan to continue to be the Aral Sea and Semipalatinsk regions, where there have been destroying the natural ecological systems, degradation of flora and fauna, due to unfavorable environmental conditions caused substantial harm to public health. Currently, the regions adjacent to the former Semipalatinsk test site (85 settlements with a population of almost 72 thousand people), there is a high level of cancer incidence and mortality, cardiovascular diseases, congenital malformations among newborns and the effects of premature aging. In the Aral Sea ecological disaster zone (178 settlements with a population of 186 thousand people) has a high level of gastrointestinal diseases and anemia, especially among women and children, infant mortality and birth defects. Depletion and pollution of water resources, and TZ problems associated with intensive development of resources of the Caspian Sea. Kazakhstan belongs to the category of countries with a large deficit of water resources. Currently, water bodies are polluted heavily in mining, metallurgical and chemical industries, utilities and cities represent a real environmental threat. Of the rivers of southern Kazakhstan the most polluted Badam and Talas. In Badam discharged wastewater Shymkent Oil-GIRO industrial complex in Talas – waste water of sugar and alcohol plants. Near Taraz sewage plant primary processing of wool, leather and shoe factory and other enterprises polluted Talas – Assinskoe field of groundwater, which is the only source of water supply the city of Taraz. Continuing pollution channel Talas-Asse and surrounding areas from sewage Taraz phosphorus plant. Wastewater Karaganda synthetic rubber plant, mercury-containing contaminated river Nura and Nurinskoe reservoir. Mercury-contaminated stream, and the Nura River, used for water supply and livestock watering. Water pollution has reached such proportions that in the basins of several rivers breached natural biological and hydro chemical regimes. Severe pollution are Syr Darya, Lake Balkhash, etc. The main pollutants of water sources are ferrous and nonferrous metallurgy, petroleum and chemical industries, waste water which significantly increases the water content of harmful substances. Transboundary environmental problems pose a real external threat to the ecological security of the country, a decision which is provided with modern actions of neighboring states in the framework of international treaties. In early 2003, Kazakhstan joined the Bazilskoy Convention on the Control of Transboundary Movements of Hazardous Wastes and their disposal, which allowed to establish new customs regulations on the declaration of hazardous wastes and prevent their subsequent flow into the territory of the Republic of Kazakhstan under the guise of recycled materials and products.

The Lamp At Noon By Sinclair Ross - 1326 Words

The human race likes to believe that it is the most intelligent and powerful life form on planet Earth. While mankind has proven to be capable of many remarkable feats, there is one force that proves that man is relatively fragile. This force; though not living, is capable of rendering even man utterly weak and powerless. This force is nature. Throughout Sinclair Ross’ short story The Lamp at Noon, the historical context of the Great Depression helps to reinforce the story’s theme that nature is more powerful than man. This is evident through the fact that in the story and in real life; nature caused the Great Depression, nature can cause man to do unusual things and the fact that nature continually outsmarts man. These examples have been exemplified throughout the text and history to help prove that nature is indeed more powerful than man. Firstly, nature was a principal cause of the Great Depression. The story takes place in the Prairies of Canada in the 1930s, a time of economic crisis for the majority of the area’s inhabitants. This includes Paul and Ellen, the story’s main characters. There was a great drought caused by nature which put a halt on agricultural production and thus caused the depression. Ellen explains this to Paul when she says: â€Å"Listen Paul,-I’m thinking of all of us-you, too. Look at the sky. What’s happening. Are you blind? Thistles and tumbleweeds-it’s a desert. You won’t have a straw this fall. You won’t be able to feed a cow or a chicken. PleaseShow MoreRelatedThe Lamp At Noon By Sinclair Ross1383 Words   |  6 Pagesa story. This is made evident by Sinclair Ross’ ability to effectively utilize the literary devices at his disposal to develop a powerful, efficient short story in â€Å"The Lamp at Noon†. In the story, imagery, dialogue, and the omniscient point of view from which the story is perceived are formidable examples of how literary devices provide a significant role in shaping the plot, conflict and themes for the reader to experience. Sinclair Ross’ â€Å"The Lamp at Noon† effectively showcases the powerRead MoreThe Lamp At Noon By Sinclair Ross1643 Words   |  7 Pageswho had fellowship from peers. Ellen from the short story The Lamp at Noon is a perfect example of the effect referenced in this study; the weather acts symbolically to show her isolation from the rest of the world, the consequence being the loss of her own child’s life. In this short story, the author Sinclair Ross uses parallelism between physical and emotional isolation to show the ultimate impacts of isolation on the human spirit. Ross shows that continuous isolation can lead to a mental breakdownRead MoreSymbolism : The Raven, By Edgar Allen Poe2339 Words   |  10 Pageswhich symbolizes loss and death. But very few authors use symbolism as effectively as Sinclair Ross did, in his famous short story â€Å"The Lamp at Noon.† Ross symbolizes objects, and personifies them in a way that they feel like actual char acters to the reader. She explores symbolism through three key tokens that carry a great importance throughout the story, the atmosphere in which Ellen and Paul live, the lamp, and the wind. These three essential symbols are used to reflect the struggles of coupleRead MoreThe Lamp at Noon722 Words   |  3 PagesMiscommunication in The Lamp at Noon In literature, authors often present characters who come from different backgrounds and fail to communicate. In the short story The Lamp at Noon by Sinclair Ross, a series of events trigger post Paul and Ellen’s argument which leads to a family disaster. Paul and Ellen’s different way of life before their coupling gives them different points of views. This leads to their dispute and resulting in the terrible decision to be made which results in the deathRead MoreThe Lamp At Noon Short Story896 Words   |  4 Pages In his story â€Å"The Lamp at Noon†, Sinclair Ross writes about the great depression and how it effects a couple and their baby as they live through it. The purpose of the story is to display the importance of decisions and how choosing the right one can effect us heavily. Ross does a great job to convey his message by showing us the severe consequences of some decisions. Everyday each of us are faced with decisions that in time produce an outcome that will affect our futures. Paul is one ofRead MoreLogical Reasoning189930 Words   |  760 Pagesargument or an explanation is present. However, if an argument is present, 30 60 If Betsy Ross says, The new flag I designed has red and white stripes with thirteen stars, is she explaining the flag? No, she is just describing it. She is not explaining where the flag came from or what motivated her to make it. She isn’t talking about causes. Nor is she arguing about the flag. However, if Betsy Ross says something a little more elaborate, such as The new flag I designed has red and white

The Diversity Of Washington County - 938 Words

The diversity seen in Washington County was in fact unique and although there is no short answer to why so many different European ethnic groups settled in the area, there are many plausible explanations as to the origins of their settlements. It is important to highlight the role of European immigrants as a whole in the United States before focusing in on Washington County. During the first fifty years following the American Revolution, very few European’s immigrated to the United States. Following those years, Europeans begin to immigrant in large groups for various geopolitical and economic reasons. Typical plains settlers were farmers in search of prime farm land that they could be the soul owners of. In most cases, European immigrants wanted to own land, and were unable to do so in their previous countries. Washington County was similar to the overlaying theme of immigration to the Great Plains. Washington County’s location in respects to Kansas City was a major driver for its diverse population. Many immigrants were able to travel via train to Kansas City, or if they took wagon, their goal was to reach Kansas City. With Washington County being relatively close to Kansas City, immigrants would flock to the area. With the Oregon trial running through the area, many European immigrants stayed in the region during the latter half of the nineteenth century. Furthermore, in the early nineteenth century, the area was seamed with roads converging towards Santa Fe, yet noShow MoreRelatedThe Columbia Basin Pygmy Rabbit1520 Words   |  7 Pagessouthern Idaho, central and northern parts of Nevada, central and eastern parts of Oregon, northwest Utah, and southeastern Washington. 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