Japan - a healthy society?

Japan has long fascinated health promoters given its health statistics, principally life expectancy. Japan consistently tops the league table, with life expectancy at birth standing at 82.73 (for both sexes combined), ahead of the next three countries, Switzerland, Hong Kong and Australia. The UK comes 23^rd, with a life expectancy of 79.53 years.  An article in The Lancet in 2011 suggested some causes of the rapid increase in life expectancy in Japan. See: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61055-6/fulltext

Among the reasons put forward are good educational opportunities and good health care, with equal access to them, and a variety of public health measures that tackled the particular problems facing Japan, such as strokes.

Having just spent a month in Japan, I’ve thought about these statistics and also developed some of my own ideas about them, and about the health of Japanese society. Of course, it’s never possible to understand another culture fully or even partially, and a month is no time at all, but certain things were striking. Although I could begin to see why Japan’s people might live long lives, the experience also made me query the difference between health and wellbeing and caused me to delve into some issues and statistics that might indicate the state of wellbeing of Japanese society.

There are noticeably fewer overweight and obese people in Japan, and the diet struck me as far healthier than that in Europe of North America. The statistics bear this out – in the USA 30% of people are classed as obese, compared with 3.5% in Japan. Portion size is a factor and Japanese people consume 25% fewer calories than Americans. I seemed to eat a lot and enjoyed many wonderful Japanese meals – but in fact I lost weight during my month there. Returning to Europe, the diet struck me immediately as being much more calorific and somehow unhealthier. If Japanese employees’ waistlines go over a certain specified amount, they have to receive counseling by the health insurance system.

The statistics also tell us that Japanese people live illness- and disease-free for more years – it’s not only quantity of years but there is quality in those extra years too, and Japan is well known for having a higher ratio of centenarians than anywhere else in the world. There are now 54,397 Japanese centenarians, compared with only 153 in 1963. However, there is an emerging concern that younger Japanese people are not having children, and the population has been declining for the last ten years. Fewer babies were born in 2012 than in any other year on record. Media commentators talk about a ‘flight from intimacy’ and it does appear that Japan is going through a major social transition. A study carried out by the Japan Family Planning Association in 2103 showed that 45% of women aged 16-24 were “not interested in or despised sexual contact”. Another survey two years earlier showed that 61% of unmarried men and 49% of unmarried women aged 18-34 were not in a romantic relationship, a rise of 10% from five years earlier.

Speculating on the reasons behind these figures is tempting. One possible explanation is that in a society where traditional gender roles are strong, and where, as a Japanese saying goes, ‘marriage is a woman’s grave’, younger women are choosing to prioritize their careers. Indeed, I both met and heard of women who would have been expected to give up their careers upon marriage, even women who were in highflying academic jobs. The Gender Equality Index just published, puts Japan as 101^st out of 137 countries, indicating that it is not within the top 100 countries as far as equality between men and women is concerned. Although prime minster Abe has revived plans to improve workplace conditions for working mothers and women in general, these lag far behind what is expected in other developed countries. 70% of Japanese women leave their jobs on the birth of their first child.

Another explanation put forward for younger Japanese to eschew intimacy lies in the preoccupation with digital technology, which provides surrogate relationships and enables people to live in a virtual world. In a society that values ‘deep reserve’ there is already a strong cultural tendency towards isolation and introversion. Linked with the high costs of living, the expectations facing married men and women and the fact that Japanese society seems well geared up to solo living all drive the trend to staying single. In contrast to the expectations of women’s participation in the workforce, those on men are huge. The stereotype of salary men working all hours is not far from the truth. The commuter trains in Tokyo are still crammed at 9 o’clock in the evening and it’s not unusual for men to socialize with their colleagues after work too. Japanese people are known to apologise to their co-workers for taking their holidays, and taking leave can be interpreted as a sign of lack of commitment. A survey by the Health, Labour and Welfare Ministry in November 2013 showed that full time Japanese employees only take 47.1% of their paid leave. Although entitled to an average of 18.3 days, they took only 8.6 days; men took 44.2% and women 53.4% of the holidays they were entitled to. These figures were confirmed through my anecdotal discussion with Japanese colleagues, and rendered redundant a typical topic of conversation among co-workers – that is, where are you going for your holidays?

My limited exposure to health promotion in Japan indicated that a medical model predominates; one example is the lecture I gave to 65 young women training to become school health specialists, where there was incomprehension, not only due to the language, but because of the concepts, where a health inequalities discourse, a social model of health and the idea of wellbeing seemed completely foreign. The idea of focusing on minorities, a common preoccupation within health promotion, seems an embarrassment within a society that emphasizes the importance of homogeneity. One proverb perhaps illustrates something happening culturally - “if you see a nail sticking up, hammer it down”, which relates to the idea of not sticking out, but conforming. What is it like to be ‘different’ in Japanese society or to question it? The Ainu people of Hokkaido are a minority that are rendered invisible and have had to fight, and are still fighting, for their rights. The Ainu have been systematically discriminated against and successive governments have been reluctant to recognize their status for fear of preferring rights over and above those given to anyone else. See: http://scholarspace.manoa.hawaii.edu/bitstream/handle/10125/21976/v1i1_02okada.pdf

The Burakumin are a group that are still seen as the ‘untouchables’ within mainstream Japanese society yet are genetically, linguistically and culturally the same as other Japanese people. Prejudice and discrimination against buraka, as a hidden lower caste, continues: http://www.hurights.or.jp/archives/focus/section2/2008/06/present-day-buraku-discrimination.html

Japanese society seems ‘tolerant’ of sexual minorities yet the government has been criticized for spending very little on meeting the needs of gay people for information. HIV infection rates for gay men in Japan are higher than anywhere else in the developed world.

Another proverb relates to “The fire across the river”, meaning that the problem is over there, not here. There has been a great deal of speculation over why, in 2011 following the tsunami, the Fukushima nuclear plant was allowed to get to a state where there was the most serious incident since the Chernobyl disaster, given the huge stress on health and safety in Japan. It appeared that no-one was prepared to speak out to criticize what was happening, plus it was seen as a problem that was ‘over there’. This makes the secrecy bill currently going through the Japanese Parliament at the moment all the more worrying. The government is being criticized for not saying how they government will guarantee the public’s right to know what is going on, how the freedom of the press will be protected, and how the government will decide what is a state secret. Professor Noriko Hama, writing in The Japan Times notes that what’s happening is worthy of ‘Yes Minister’ where a government ‘keeps secret what secrets it deems especially secret’: http://www.japantimes.co.jp/news/2013/11/30/business/the-secret-of-keeping-official-secrets-secret/#.UsElgyjKkRk

Certainly Abe’s premiership seems deeply worrying to anyone with leftish politics, and the stress on nuclear energy and rearmament are major discussion points in a country with its particular history. It was moving to see survivors of the Hiroshima nuclear bomb turning up each day to sit in the peace park to talk to the many school groups and other tourists about the reality of what happened. The clock in the peace museum records how many days it has been since the last nuclear test – when I was there is was 49 days ago. See: http://www.pcf.city.hiroshima.jp/top_e.html

In the years since 2001 when the peace clock was put in place, it has been re-set 14 times after nuclear testing, serving as a powerful indicator that nuclear testing and nuclear bombs are very much in evidence globally despite the experiences of Hiroshima and Nagasaki.  It was a deeply moving and very strange experience to be standing in the place where the bomb detonated, an event so much a part of our collective history.

Japan is often described as a country of deep contradictions and as being inexplicable to a foreigner. For me, one major contradiction was between the intense beauty of gardens and temples and the stunning attention to the creation of simple pleasing vistas, and the enormous ugliness of urban landscapes and urban sprawl that characterizes so much of the scarce land that has been built on to house the population of 126 million. The visibility of electricity cables in an earthquake prone country, rendering burying cables unfeasible, doesn’t help the visual clutter. It’s not a country to visit for wilderness experiences, even in Hokkaido, where I went to watch the red-crowned cranes in their wintering grounds. But there is a huge amount to visit Japan for; under the reserve, Japanese people are massively helpful and kind. The courtesy and consideration for others are remarkable; the younger people I met everywhere were great fun and once in a situation where they can let off steam, such as in a bowling alley, they certainly know how to have a good time. 

A glimpse at Japanese society perhaps highlights the difference between health and wellbeing. Health statistics might show a picture of ‘progress’ yet there are ways in which Japanese society could be seen as deeply ‘unhealthy’. From a professional interest point of view, I’m left with a series of questions about health and wellbeing. What explains the very low rates of crime and the high rates of personal security? What lies behind Japan’s supposedly high suicide rates? These rates have been questioned, with a suspicion that some suicides are actually murders: http://www.japantimes.co.jp/news/2013/02/03/national/japans-suicide-statistics-dont-tell-the-real-story/#.UsEqMijKkRk

However, Japan is described as a ‘suicide tolerant’ society and doesn’t have the religious taboos against it that can predominate elsewhere. Suicide rates are three times those in the UK, and 30,000 Japanese people have taken their own lives every year for the past 14 years. See: http://thediplomat.com/2013/01/searching-for-answers-japans-suicide-epidemic/

The Tokyo underground runs efficiently and smoothly yet I wonder about the stress caused by using it every day; as a feminist, the geisha culture caused us endless hours of discussion – women, it’s claimed, can earn huge amounts, empowering them to set up their own businesses after they leave that profession, yet to me it was all about a male gaze and an idealized form of femininity, and seemed to sum up something about gender roles more generally; the lack of green spaces within the big cities feels like an alienation from nature; how can we explain the obsession (of some) with slot games like pachinko and the with the lottery?; I’m not sure what to make of the preoccupation with ‘Japanese-ness’ and traditional culture, and the aversion to immigration.  All personal views and thoughts – if you have any other views, please post them to me!

Ghana, 'galamsey' and sustainable wellbeing

People outside of Ghana might not have heard of the term ‘galamsey’. It’s derived from the phrase ‘gather them and sell’ which was used during colonial times to refer to miners illegally gathering minerals such as gold and selling them. Stamping out galamsey is now a major rallying cry and something that all Ghanaians are aware of. There are adverts on the main television news, Joy News, with an appeal to the citizenship values of the Ghanaian people. The practice is regard as leading to environmental destruction, water pollution, deforestation and is moreover seen as anti-social, selfish and running counter to African community values. I learnt more about galamsey during the last few weeks as nearly all of our 19 Ghanaians enrolled on our new Masters’ course which we have just started to deliver in Ho, Volta Region, mentioned it in their formative essays. It’s clearly at the forefront of their minds!

It’s also on the government’s mind, as this official government site shows: http://www.ghana.gov.gh/index.php/2012-02-08-08-32-47/features/1234-galamsey-operations-and-sustainable-development-in-ghana

One colleague has joined the course from Sierra Leone, but otherwise all our new students are from Ghana. We are delivering the course at the new public University of Health and Allied Sciences, which is currently being built under the able leadership of the Vice-Chancellor, Professor Fred Binka. Students will gain a Leeds Met Masters degree, along the lines of the course delivery we currently offer in Zambia and The Gambia.

Health promotion is relatively strong in Ghana, though there has been a slow approach to implementing the government’s health promotion policy, which has been in draft form since 2005. Recently, there was a high level meeting to consider how to progress health promotion and adopt more joined up thinking and a more upstream approach cross the entire policy spectrum. Our role in educating more health promoters will contribute to this scaling-up, and we already propose that we will have a further intake in October 2014. The Commonwealth Scholarships Commission has willingly sponsored 15 students in the first intake.

Galamsey is not the only major health hazard facing sustainable development in Ghana. It is however, often the act of desperate people – most people do not ‘choose’ to behave in lawless ways unless they are constrained in the ‘choices’ available to them. Ghana has recently made much of the fact that it has been proclaimed as a middle-income country. The economy is doing well, the government is stable – President Mahama has recently laid down strict guidance on ethical behavior for all those in public office. So although there is still plenty of poverty and the ‘core poor’ make up a good proportion of the population, there area signs that overall Ghana is ‘doing well’. The emergence of a larger middle class, those who are in salaried jobs, and moreover, have not joined the exodus of well-educated Ghanaians that characterized the brain drain of recent decades, has changed the face of Ghana. There are now classes who, freed from the precariousness of everyday life, are able to envision a future, to plan, to save, and to enjoy aspects of life enjoyed by the leisured classes in other countries. There are new shopping malls, and the first mall has opened in Ho. Ghana is going through both an epidemiological transition as well as a demographic one, as these more affluent families plan for fewer children.

Much has also been made of the emergence of non-communicable disease in sub-Saharan Africa. It’s debatable how long these health problems have been around, as they are not particularly well documented, but certainly in West Africa, heart disease, hypertension, cancer and diabetes are prominent in the media. In one newspaper, Hajia Mary Salifu Boforo, MP for Savelugu and Chair of the Women’s Caucus, is reported discussing Breast Cancer Awareness Month in October, and she described the discrimination faced by women diagnosed with breast cancer, and that it’s still seen as a source of shame. She said that over 20% of women face divorce shortly after diagnosis. There are many issues to overcome before a full screening programme can be established, and we all know that breast cancer caught early stands a much better outcome.

Sodzi Sodzi-Tettey had a full-page article in the Daily Graphic on November 9^th calling for more integrated health programmes to tackle diabetes, obesity, hypertension and cancers. In a well written and thought provoking article, he refers to a recent paper in the BMJ by Patricio Marquez and Jill Farrington on how communicable and non-communicable diseases can be tackled alongside each other in those countries where both need tackling. It’s interesting to me that an article in one of the world’s top medical journals has been picked up and translated into a useful piece of health education in a daily newspaper in Ghana.  For the article in the BMJ, see: http://www.bmj.com/content/345/bmj.e5812

These kinds of disease often run alongside the trappings of a westernized lifestyle, and not all of its characteristics are to be welcomed. There can be a reduction in overall life satisfaction and happiness – does being able to shop in a new mall really bring greater well-being? Maybe it does, but countries like Ghana are clearly on the cusp of needing to think about what kind of priorities it wants, how to retain its strong Ghanaian, African identity in a globalizing world, and what well-being means in the twenty first century. As Kwame Nkrumah said so many years ago, “We shall measure our progress by the improvement in the health of our people. The welfare of our people is our chief pride, and it is by this that we ask to be judged.”

Sustainability is an obvious concept to arise in a global South context, and together with the paradigm drift that we’re witnessing, into ‘well-being’ alongside ‘health’, the obvious question to raise is: how can Ghana continue on a path of sustainable well-being for all of its citizens?

Dying for work?

The English have an expression when they are desperate for something, which is “I’m dying for…” as in “I’m dying for a cup of tea”. Health educators have used the double entendre and coined slogans such as “I’m dying for a cigarette”.  With so many people out of work, especially young people, they might be forgiven for saying that they are “dying for a job”. Discussing the determinants of health, as we have been these last few weeks, there’s been general agreement that productive employment is possibly the single most important determinant, as it brings income, purpose, esteem, structure, identity – in short, a package of economic and psycho-social benefits that mean it’s no surprise that the suicide rate for the long term unemployed is many times that of the employed in the global North.   

Two utterly shocking news events of the last couple of weeks have shown that ‘dying for a job’ all too often becomes a reality – firstly the scandal of the situation facing Nepali workers building the football stadia in Qatar, and secondly the plight of migrants escaping from lack of opportunities in Africa, through Libya, and drowning in the Mediterranean.

If the International Labour Organization’s definition of modern-day slavery is used, the Nepalese workers can be described as such. They are reported to have said things like, “ We were compelled to come just to make a living; we’d like to leave, but the company won’t let us”. The Guardian newspaper has stated that almost one worker died every day during this summer (44 workers between 4 June and 8 August), usually from heart attacks or accidents at work. These are largely fit young men but they were reportedly denied water, food, pay, and lived in appallingly squalid conditions. The Nepalese government put the figure of dead at 70 this year and warned that 4,000 deaths could occur before the kick off in 2022. More than a million workers are building the nine new stadia plus the entire infrastructure required to hold the football World Cup. The International Trade Union Confederation has also waded in to defend migrant workers from the Indian subcontinent, warning that 600 deaths could occur annually.

It remains to be seen what will occur as a result of the exposure of the scandal, including the criticism of FiFa, who arguably, in this world where football is so powerful, have the strongest voice. That workers are ‘dying’ to get into the job opportunities perceived as existing in Europe was even more starkly shown by the sinking of a ship carrying migrants earlier this month. That it’s unknown exactly how many people the boat was carrying (500?) is telling in itself, as is the fact that those still unaccounted for originated from one of Africa’s poorest countries, Eritrea. With bad weather and the winter coming on, the boat was joined by about another 350 people who decided to risk the crossing. More women than men are among those who did not survive, with many simply crammed into the boat’s hold, now 47 metres down on the seabed. Cecile Kyenge, Italy’s first and only black minister, commented that it was absurd that survivors of shipwrecks are immediately put under criminal investigation, given that underground immigration is a crime. Kyenge, originally of Congolese nationality, has herself been subjected to all sorts of racist abuse. Take a look at the Open Democracy website for a truly shocking account of what the Minister of Integration has had to endure: http://www.opendemocracy.net/can-europe-make-it/susi-meret-elisabetta-della-corte-maria-sangiuliano/racist-attacks-against-cécile

The writer evokes Franz Fanon’s Black Skin, White Masks to demonstrate the white-gaze that is turned on those without white skins. If a government Minister can face this kind of abuse, there’s little sympathy in many quarters for those drowning in the seas off Italy.

These two incidents, shocking as they are, make the news for a short time. What’s happening in the background however is an ongoing scandal. There have been two more sinkings (and many more fatalities) since the major one hit the headlines last week near Lampedusa, one off Malta and one off the Egyptian shore. There’s been an estimated 19,000 migrant deaths from drowning since 1988 and tens of thousands attempt the crossing each year. The prime minister of Malta, Joseph Muscat, has said that Malta, which picks up many of the struggling migrants, feels abandoned by the EU, which, he says, has talked but taken no action.

Once migrants do make it to a country where there is work they are likely to be in unskilled manual work. Over 900,000 of Qatar’s 1.2 million migrant workers are in the ‘unskilled manual’ category and nearly a quarter of them are from India, with another quarter from Pakistan. These are all countries where work is hard to find, countries which have traditionally exported their labour. What’s unusual about Qatar is that migrant workers make up 70% of its total population, and a staggering 94% of its total workforce. Where labour is plentiful and replaceable, it has not been in the interest of the employing classes to look after that labour particularly well. Industries such as mining, construction, forestry and heavy engineering account for a disproportionate number of deaths. Yesterday marked the centenary (1913) of the biggest mining disasters ever in the UK , where 440 workers were killed in Senghenydd, Wales, after an explosion.  However, behind these major incidents is a steady drip drip of deaths at the workplace that are often unreported. The USA, possibly the country that can most afford a good safety record, still sees deaths in mining of about 35 per year (2012 figures); about 12,000 miners are killed globally each year, much of that figure being made up by China, which although it only accounts for 40% of global coal production, accounts for 80% of global mining deaths. Mining unions in middle-income countries such as South Africa and Chile have urged governments to do more, as the technology is there, but the political will is lacking. Meanwhile, in an interesting and brave move, Ghana has recently expelled illegal Chinese miners.

So work for many is highly injurious to health, as is the search for it, which takes many literally into dangerous waters. We’ve said that work that is decent work, properly paid and safe, can be the biggest factor affecting a person’ health. Where that work is not safe, not decent, or is exploitative, then clearly it has a commensurate effect on health and contravenes basic human rights.

Thinking and teaching about inequalities

We have just welcomed our new cohort of students to our MSc Public Health – Health Promotion. It’s always an exciting time of year, not only seeing how many students we have, but welcoming new faces, new backgrounds and beginning to form a new group of interested minds with interesting experience to bring.

It’s important that we outline, at the beginning, our philosophy of what we think health promotion is all about. Of course it’s a bit too late for students to change their minds at this stage and decide it’s not for them! But we presume too that they have read our websites and have some idea of what we’re about. It’s important for us that students know that they will not emerge as experts on epidemiology, or having detailed knowledge of particular diseases, or knowing about health care systems. What they will come out with is an in-depth understanding of the social determinants of health, of how to tackle health inequalities, and an understanding of the politics of health. In short, they will be clear that there is a great deal of health injustice in the world. A global dimension inevitably emerges from the composition of the class – this year we have students from the UK, Pakistan, Kenya, Uganda, Ghana, Cameron, Nigeria, Sudan. There will be those who know first hand the effects of conflict, and the destruction of primary health care as a result; about the progress towards the Millennium Development Goals; about rural-urban inequalities. Those who have practiced principally in the UK will be able to share their experiences of the changing fortunes and structures of public health in England.

One of the first things we do is to discuss inequalities in health, with a session on the facts – the empirical data on inequalities, together with their possible causes, and then next week, a session on the ethical dimensions of inequalities – the normative aspects, which asks how the world could and should be different. Students from overseas might be surprised to find glaring inequalities in the UK, such as a ten-year difference in life expectancy between certain groups depending on social class and neighbourhood. There are also groups about which detailed data is missing (an interesting fact in its own right), such as travellers and gypsies, who are reputed to have a life expectancy for men of only about 48 years.  And of course some of the ‘developed’ countries have huge levels of inequality - the USA for example, ranks as the fourth least equal society in the world in terms of wealth. (Russia, Ukraine, and Lebanon are above it).

The Millennium Development Goals aimed to decrease inequalities in poorer countries. Failure to meet all the MDGs has led to some analysis of those policies put in place to achieve them and also to what is becoming known as the Post-2015 framework. The Post-2015 Framework emphasizes the importance of decreasing inequality, which is known to have an independent effect on a range of other social variables (see Wilkinson and Pickett 2009 The Spirit Level). More unequal societies appear to experience more health problems, social unrest and economics ills, irrespective of their level of development. Apart from the moral imperatives to tackle inequity, the strategy of improving life chances and wellbeing through addressing inequality is an important plank of policy alongside the other main approaches to development, viz. addressing the situation of only the poorest, and of using a whole population approach.

One of the influential thinkers about development and inequality whose work we admire, is that of the Indian economist and Nobel Laureate Amartya Sen. His book published in 1981, Poverty and Famines: An Essay on Entitlement and Deprivation showed that hunger was not simply because there isn’t enough food. Rather, hunger is caused by inequities in the mechanisms that distribute food. Later, in an article titled ‘Equality of What?’ he developed the ‘capability approach’ which emphasizes the importance of understanding how people in different groups are able to mobilize resources to improve their lives, and of how governments and other policy players can mobilize resources on their behalf. Sen has always declined to specify exactly which capabilities are important, preferring instead to leave this to the exact context of the country in question, in contrast to Nussbaum’s “ten central capabilities”. (These are easily found on Google – see especially her book “Women and Human Development”).  Sen’s stance mirrors the fact that we do not have adequate knowledge of which policies and actions enable people to develop capabilities to control their environments, just as we do not have robust enough evidence of which policies and actions decrease inequalities.

This is the first year that we have our own textbook available, which of course, we have recommended students to buy, as we structured it to follow the modules that make up our Masters’ course. See Dixey, R. (2012) Health Promotion: Global Principles and Practice http://bookshop.cabi.org/default.aspx?site=191&page=2633&pid=2454

Any comments on the book or feedback will be gratefully received – you can email me on r.dixey@leedsmet.ac.uk

Here’s a short quiz that we will be using as a little group exercise. Answers below!

The Quiz: Inequalities - 12 entirely arbitrary questions on inequality compiled by Rachael Dixey, September 2013

1.How many people live below the poverty line globally? 

2. Which African country is at the bottom of the Human Development Index?

3.What’s the average life expectancy in Chelsea and Kensington (England)?

4.What’s the average life expectancy in Glasgow city (Scotland)?

5.Which group in the UK is widely agreed as being the most ‘at risk’ of health problems and dying younger than any other group?

6.In the USA black people make up 12% of the population. What proportion of new HIV cases are black people?

7.How many people globally live in slums?

8.What proportion (percentage) of total wealth do the poorest 50% of the American population have?

9.Out of 141 countries, the U.S. has the 4th-highest degree of wealth inequality in the world. Which three countries have more wealth inequality?

10.Malnutrition (measured by stunting) affects what proportion of children in developing countries?

11.How much does Wayne Rooney make per day?

12.What’s the average wage in the UK?

Answers:

1.How many people live below the poverty line globally?  1300 million

2. Which African country is at the bottom of the Human Development Index? Niger

3.What’s the average life expectancy in Chelsea and Kensington? 82.4 years

4.What’s the average life expectancy in Glasgow city? 72.9 years

5.Which group in the UK is widely agreed as being the most ‘at risk’ of health problems and dying younger than any other group? Gypsies and travellers

6.In the USA black people make up 12% of the population. What proportion of new HIV cases are black people? 50%

7.How many people globally live in slums? 800 million

8.What proportion (percentage) of total wealth do the poorest 50% of the American population have? 2.5%

9.Out of 141 countries, the U.S. has the 4th-highest degree of wealth inequality in the world. Which three countries have more wealth inequality? Russia, Ukraine, and Lebanon.

10.Malnutrition (measured by stunting) affects what proportion of children in developing countries? 32.5%

11.How much does Wayne Rooney make per day? £28,571

12.What’s the average wage in the UK? £26,000