3 skincare rules you need to live by

Remember to apply sunscreen throughout the day. Handout TNS

 

As a dermatologist, treating my patients’ skin, hair and nail issues is my top priority, but educating them comes in a close second. I keep a running list of questions I receive and advice I give that fall outside of the “basics,” so I’ll be sharing these in the coming weeks.

Here, then, are three rules you need to live by to protect your skin:

Rule No. 1: Don’t use old doxycycline or tetracycline. We know you are not supposed to use expired medications; however, we often keep them in our cabinets anyway. Drug manufacturers are required by law to place expiration dates on prescription products, and this date represents the final day the manufacturer guarantees the full potency and safety of a medication. 

There are two main issues with expired drugs. First, the expired drugs might not work and second, expired drugs can be dangerous. Doxycycline and tetracycline (brand names include Oracea, Soladyne and Minocin) are often prescribed by dermatologists to treat acne or rosacea. Expired doxycycline and tetracycline fall into the dangerous category because they can cause kidney disease such as Fanconi’s syndrome. For this reason, be sure to toss old doxycycline or tetracycline antibiotics after their expiration date.

Rule No. 2: Use an SPF of at least 15 every day. Many people know to wear SPF when doing prolonged outdoors sports such as golf and tennis. However, small increments of unprotected daily sun exposure add up and cause skin aging, unwanted pigmentation and skin cancer. One study in the February 2004 Dermatology Therapy journal, “An analysis of cumulative lifetime solar ultraviolet radiation exposure and the benefits of daily sun protection,” showed that wearing a SPF of 4 to 10 every day can reduce the accumulated lifetime UV exposure by 50 percent or more. In other words, when you are in your 70s, you will have roughly half the sun damage compared to those who do not wear and SPF of at least 4 every day.

Most people only apply 25 percent of sunscreen necessary to achieve the SPF on the label. (Half a teaspoon is the correct amount.) For this reason, we recommend a SPF of 15 every day to make up for the fact that most people do not apply enough and do not reapply throughout the day. And it goes without saying, prolonged sun exposure (more than 15 minutes of direct sun) requires a waterproof sunscreen of SPF 60 or higher—and don’t forget to reapply every hour.

Rule No. 3: Avoid combination sunscreen/bug repellent products. Several studies have looked at the efficacy of SPF and insect repellent when used together. It has been found that sunscreen loses efficacy when used with the insect repellent N, N-Diethyl-meta-toluamide (DEET). An August 2000 JAAD study, “The effect of sunscreen on the efficacy of insect repellent: A clinical trial,” it was shown that sunscreen does not affect the efficacy of insect repellent. However, when these products are combined, you need to reapply sunscreen more often (but you should not have to increase the amount of insect repellent that you use).

Do you have a skincare question that you’d like me to answer? Post it on our Facebook page and we just might include it in an upcoming story about other skincare rules you should be following!

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By Dr. Leslie Baumann
drb@drbaumann.com

Dr. Leslie Baumann is a board-certified dermatologist, New York Times best-selling author and CEO of Baumann Cosmetic & Research Institute in Miami.

Read more here: http://www.miamiherald.com/living/health-fitness/skin-deep/article91829762.html#storylink=cpy

Your anti-aging arsenal: Retinol and retinoid skincare products

The Food and Drug Administration approved the over-the-counter sale of Differin, which had only been available by prescription. It is a retinol product that helps with anti-aging.

Read more here: http://www.miamiherald.com/living/health-fitness/skin-deep/article96087222.html#storylink=cpy

Dermatologists often say that sunscreen is the number-one anti-aging product because it prevents the damage that eventually appears as visible signs of aging. But when it comes to anti-aging products that improve existing signs of aging, my product pick is retinol (and retinoids). Best, you can find effective products at all different price points at the drugstore, department store and your dermatologist’s office.

Understanding the difference between retinol and retinoids can be confusing, so here are the basics. Retinol (which is available over-the-counter) is part of the retinoid family of compounds. The retinoid family also includes prescription-based tretinoin, tazarotene and adapalene under a variety of brand names (such as Retin-A, Tazorac and Differin). These medications bind to retinoic acid receptors within the skin, where they turn on good genes (like the ones that promote collagen production) and turn off bad genes (such as the one that prompts the production of an enzyme that breaks down collagen).

It’s never too early to start using a retinol or retinoid product. Many teens use prescription-based retinol to improve acne, and this may help keep their skin looking younger and healthier longer. Even if you’re not acne-prone, the 20s are a great time to start using these products. Collagen production starts to slow in this decade, so it’s important to keep your skin’s production going strong.

You’re also likely to still be experiencing breakouts at least occasionally, and retinol helps promote the skin’s natural exfoliation process so dead skin cells don’t stick around and clog pores — a main trigger for acne. In the 30s and beyond, retinoids’ collagen-stimulating effect helps smooth fine lines and wrinkles, and its exfoliating effect helps maintain the skin’s radiance.

Although retinoids are widely prescribed for anti-aging purposes, they were originally studied for their effect on acne. Dr. Albert Kligman performed the Retin-A research trials for acne in the 1970s along with another dermatologist named Jim Leyden. They noticed that as their research subjects aged, they had less wrinkles. They were able to prove to the FDA that retinoids improve wrinkles, and that’s extremely difficult to do from a scientific standpoint. This eventually led to the approval of Renova, the first prescription topical for wrinkles caused by photoaging.

Anyone using a prescription-based retinoid for anti-aging knows that these products can cause some sticker shock at the pharmacy—but there was an exciting retinol development over the summer. The Food and Drug Administration approved the over-the-counter sale of Differin, which had only been available by prescription. This is great news because now everyone can reap the anti-aging (and anti-acne) benefits of this topical skincare product without a trip to the doctor’s office.

Just remember to start slowly, and only apply every third night at first. Then, increase to every other night, then every night once you know your skin can tolerate it. Dryness and flaking are common side effects when starting to use a retinoid, but if you stick with it, you’ll see the skin improvement is well worth it.
_____

By Dr. Leslie Baumann
drb@drbaumann.com

 

Dr. Leslie Baumann is a board-certified dermatologist and CEO of Baumann Cosmetic & Research Institute in Miami.

Read more here: http://www.miamiherald.com/living/health-fitness/skin-deep/article96087222.html#storylink=cpy

World Humanitarian Day 19 August

Secretary-General Ban Ki-moon (shown on screens at left and right) addresses the closing ceremony of the World Humanitarian Summit, which took place in Istanbul, Turkey, on 23-24 May 2016.
UN Photo/Eskinder Debebe

"World Humanitarian Day is an annual reminder of the need to act to alleviate the suffering. It is also an occasion to honour the humanitarian workers and volunteers toiling on the frontlines of crises. I pay tribute to these dedicated women and men who brave danger to help others at far greater risk." — UN Secretary-General, Ban Ki-moon

 

2016 Theme: One Humanity

 

Every day, humanitarian aid workers stand on the front lines of war and disaster, braving tremendous dangers and difficulties to deliver assistance to those who need it most. World Humanitarian Day (WHD), which takes place every year on 19 August, recognizes the aid workers who risk their lives in humanitarian service, and mobilizes people to advocate for humanitarian action. The day was designated by the General Assembly seven years ago to coincide with the anniversary of the 2003 bombing of the United Nations headquarters in Baghdad, Iraq. 

This World Humanitarian Day, the UN and its partners are calling for global solidarity with the more than 130 million people around the world who need humanitarian assistance to survive. Under the theme of ‘One Humanity’, World Humanitarian Day will highlight how the world came together in Istanbul for the World Humanitarian Summit earlier this year, and made commitments to support people affected by crisis and ensure that aid workers can safely and more effectively deliver to those in need. 

Events will be held around the world on 19 August to honor the work of humanitarian workers and to celebrate the theme of ‘One Humanity’. In New York, a wreath-laying ceremony will take place at the United Nations headquarters, and a high-level event will be held in the General Assembly Hall. In addition a digital campaign will be launched on the day to raise awareness of the impossible choices that people caught in crisis face. World Humanitarian Day will also feature photo exhibitions and film screenings documenting the lives of those affected by conflict and disaster.

Sex ban man John O'Neill 'violent to all partners'

John O'Neill is attempting to have his Sexual Risk Order lifted

A man who must notify police 24 hours before he has sex told a nurse he had been violent to every girl he had slept with, a court has heard. 

John O'Neill, 45, from York, is attempting to have his Sexual Risk Order (SRO) lifted. He was cleared of rape last year.

York Magistrates' Court is to decide whether the interim order should be extended.

North Yorkshire Police has said it was satisfied the order was proportionate.

The SRO requires Mr O'Neill to disclose any planned sexual activity to the police or face up to five years in prison.

Oliver Thorne, for the police, read extracts from a report written by a community psychiatric nurse who spoke to Mr O'Neill in 2014.

Her notes said he had been sexually violent to past girlfriends and he was "not sure" if they had consented.

He told her he needed women "to be scared" during sex or "I don't respond", the court heard.

'Needs to be stopped'

The nurse noted he had suicidal thoughts and had been "preoccupied with killing himself and others" - an idea he found "soothing".

She also wrote Mr O'Neill thought "it would be safer for everyone if he was dead".

Magistrates were also told about a conversation between the father-of-two and his GP in which he discussed "biting and choking" sexual partners.

Dr Miriam Hodgson wrote her patient had "homicidal and suicidal thoughts" and had said his sex life had become violent.

Her notes added: "Thinks he may have raped someone, it went further than she expected" and "Patient thinks he is dangerous and needs to be stopped."

Mr O'Neill also told her he thought about killing a partner "a lot" and had "choked her unconscious several times," the court heard.

Earlier, Mr O'Neill had told the BBC's Victoria Derbyshire programme that he was homeless and sleeping rough in a wood near York.

The hearing continues.

Source: BBC

Poor Sanitation Persisted at U.N. Missions Long After Haiti Cholera Crisis

A man bathing in the Meye River in Meye, Haiti, in 2012. Studies have traced the 2010 cholera outbreak there to infected United Nations peacekeepers whose fecal waste had leaked into the river.  

Credit Damon Winter/The New York Times

Years after medical studies linked the 2010 cholera outbreak in Haiti to infected United Nations peacekeepers, the organization’s auditors found that poor sanitation practices remained unaddressed not only in its Haitian mission but also in at least six others in Africa and the Middle East, a review of their findings shows.

The findings, in audits conducted by the United Nations Office of Internal Oversight Services in 2014 and 2015, appear to reflect the organization’s intent to avoid another public health crisis like cholera.

But the findings also provide some insight into how peacekeepers and their supervisors may have been either unaware of or lax about the need to enforce rigorous protocols for wastewater, sewage and hazardous waste disposal at United Nations missions — despite the known risks and the lessons learned from Haiti, where at least 10,000 people have died from cholera and hundreds of thousands have been sickened.

The United Nations acknowledged for the first time this week that it bore some responsibility for the Haiti disaster, after having repeatedly presented a public face of ignoring the incriminating evidence and invoking its diplomatic immunity from legal action. The acknowledgment came after the organization’s special adviser on the cholera epidemic, in a confidential report seen by The New York Times, called such a position morally indefensible.

The audits may illustrate a more systemic weakness of United Nations peacekeepers, the blue-helmeted soldiers who are supposed to protect the vulnerable and uphold high moral standards in the 16 missions they operate. They are not supposed to be public health risks.

The peacekeeping missions that were audited — in Haiti, the Darfur region of Sudan, the Democratic Republic of Congo, Ivory Coast, Lebanon, Liberia and South Sudan — all practiced varying degrees of “unsatisfactory” waste management.

“The results are egregious and show that this is a massive problem across U.N. missions around the world,” said Beatrice Lindstrom, a lawyer with the Institute for Justice and Democracy in Haiti, a Boston-based advocacy group that has been pressuring the United Nations for accountability in the cholera crisis.

The audits, Ms. Lindstrom said, showed a pattern of unsanitary practices “that continued to be a problem, not only in Haiti.”

In Liberia, for example, auditors of peacekeeping facilities found untreated sewage in rainwater drains, inadequate plumbing, cracked septic tanks and inadequately contained “gray water,” or waste from sinks, bathtubs and washing machines. In Lebanon, they found failures to maintain septic tanks and remove sludge, and the unacceptable mixing of hazardous and organic wastes.

In the Democratic Republic of Congo, they found insufficient septic tanks and “soak pits,” which are porous chambers that allow wastewater to slowly leach into the ground. In Darfur, they found partly treated wastewater had been discharged into open fields and farms. In one location, the Darfur audit said, “kitchen organic waste was dumped into open pits exposing them to rodents and bugs and the growth of microbial pathogens.”

Perhaps most troubling were the findings in Haiti, which showed that more than three years after the cholera outbreak, peacekeepers were pouring inadequately treated sewage into public canals, ignoring laboratory warnings about fecal contamination, failing to inspect water treatment plants and septic tanks, and leaving some camps laden with garbage and overflowing toilets.

Several studies have traced the cholera outbreak to a contingent of Nepalese peacekeepers in the Haitian mission whose fecal waste had leaked into a river adjacent to their base. The bacterial strain of cholera in Haiti, where the disease had not been seen for a century, was similar to the strain in Nepal, where a cholera outbreak was underway.

The audits have not been publicized by the United Nations, although they are accessible on the Office of Internal Oversight Services’ website by searching for “waste” on the Internal Audit Reports page. The audit of the Haiti mission, however, was not accessible for months after it had been completed, for reasons that remain unclear.

Ms. Lindstrom and other lawyers for Haitian victims of the cholera epidemic, who have been trying to sue the United Nations for compensation, first learned of the Haiti mission audit this month when Fox News reported it was on the oversight office’s website. But it took a broader search of the website to find the audits of the other United Nations missions.

It is unclear from the audits, which are generally available online 30 days after they are completed, whether the sanitation problems they enumerate have been addressed.

In an emailed response on Thursday to requests for comment, the office of the United Nations Departments of Peacekeeping Operations and Field Support, which is responsible for the missions, said that all 13 of the auditors’ “critical recommendations” had been met, as had 14 of their 19 “important recommendations.” It did not specify which problems remained.

The office also said that all of the waste management audits in the missions had been undertaken after the Haiti cholera crisis began.

Similar audits are planned this year and next for the missions in the Central African Republic, Mali and Somalia.

Waste management specialists who reviewed the audits said they found them troubling but were not necessarily surprised. They acknowledged the challenges of minimizing public health risks from poor sanitary practices in some of the world’s most unstable places.

Daniele Lantagne, a professor of civil and environmental engineering at Tufts University who specializes in water treatment, said the audits showed that in some places like Haiti, peacekeeping missions installed on-site sanitation facilities but failed to maintain them, contributing to “breaks in the system that could lead to transmission of disease.”

Ms. Lantagne, who was a member of a panel of experts commissioned by the United Nations to study the cholera outbreak, also tempered her criticism.

“On-site sanitation is hard. It requires a good system and ongoing maintenance,” she said. “What you see in these reports is that in some places they try to do something better, and in some places it’s not a simple problem to solve.”

Source: The New York Times, By RICK GLADSTONE

Obamacare Hits a Bump

Supporters of the Affordable Care Act gathered outside the Supreme Court in 2015. Credit Doug Mills/The New York Times

More than two and a half years have gone by since the Affordable Care Act, a.k.a. Obamacare, went fully into effect. Most of the news about health reform since then has been good, defying the dire predictions of right-wing doomsayers. But this week has brought some genuine bad news: The giant insurer Aetna announced that it would be pulling out of many of the “exchanges,” the special insurance markets the law established.

This doesn’t mean that the reform is about to collapse. But some real problems are cropping up. They’re problems that would be relatively easy to fix in a normal political system, one in which parties can compromise to make government work. But they won’t get resolved if we elect a clueless president (although he’d turn to terrific people, the best people, for advice, believe me. Not.). And they’ll be difficult to resolve even with a knowledgeable, competent president if she faces scorched-earth opposition from a hostile Congress.

 

Which country in the world has the highest life expectancy?

Source: World Health Organization (WHO)

List by the World Health Organization (2015)

Life expectancy is a statistical measure of the average time an organism is expected to live, based on the year of their birth, their current age and other demographic factors including sex. 

2015 data published in May 2016.
HALE: Health-adjusted life expectancy

Country	Both sexes rank	Both sexes life expectancy	Female rank	Female life expectancy	Male rank	Male life expectancy	Both sexes rank (HALE)	Both sexes life expectancy (HALE)
Japan	1	83.7	1	86.8	6	80.5	1	74.9
Switzerland	2	83.4	6	85.3	1	81.3	4	73.1
Singapore	3	83.1	2	86.1	10	80.0	2	73.9
Australia	4	82.8	7	84.8	3	80.9	15	71.9
Spain	4	82.8	3	85.5	9	80.1	9	72.4
Iceland	6	82.7	10	84.1	2	81.2	7	72.7
Italy	6	82.7	7	84.8	6	80.5	5	72.8
Israel	8	82.5	9	84.3	5	80.6	5	72.8
Sweden	9	82.4	12	84.0	4	80.7	12	72.0
France	9	82.4	5	85.4	16	79.4	8	72.6
Republic of Korea	11	82.3	3	85.5	20	78.8	3	73.2
Canada	12	82.2	10	84.1	8	80.2	10	72.3
Luxembourg	13	82.0	12	84.0	13	79.8	17	71.8
Netherlands	14	81.9	20	83.6	10	80.0	11	72.2
Norway	15	81.8	17	83.7	13	79.8	12	72.0
Malta	16	81.7	17	83.7	15	79.7	18	71.7
New Zealand	17	81.6	26	83.3	10	80.0	19	71.6
Austria	18	81.5	14	83.9	19	79.0	12	72.0
Ireland	19	81.4	23	83.4	16	79.4	20	71.5
United Kingdom	20	81.2	27	83.0	16	79.4	21	71.4
Belgium	21	81.1	22	83.5	22	78.6	26	71.1
Finland	21	81.1	16	83.8	24	78.3	28	71.0
Portugal	21	81.1	14	83.9	27	78.2	21	71.4
Germany	24	81.0	23	83.4	21	78.7	23	71.3
Greece	24	81.0	20	83.6	24	78.3	15	71.9
Slovenia	26	80.8	17	83.7	28	77.9	26	71.1
Denmark	27	80.6	29	82.5	22	78.6	25	71.2
Cyprus	28	80.5	28	82.7	24	78.3	23	71.3
Chile	28	80.5	23	83.4	29	77.4	29	70.4
Costa Rica	30	79.6	30	82.2	31	77.1	31	69.7
United States of America	31	79.3	33	81.6	32	76.9	36	69.1
Cuba	32	79.1	34	81.4	32	76.9	35	69.2
Czech Republic	33	78.8	32	81.7	38	75.9	33	69.4
Maldives	34	78.5	41	80.2	32	76.9	32	69.6
Qatar	35	78.2	43	80.0	29	77.4	47	67.7
Croatia	36	78.0	36	81.2	42	74.7	33	69.4
Albania	37	77.8	38	80.7	39	75.1	38	68.8
Panama	37	77.8	37	81.1	42	74.7	42	68.1
Brunei Darussalam	39	77.7	47	79.2	36	76.3	29	70.4
Estonia	40	77.6	31	82.0	65	72.7	37	68.9
Poland	41	77.5	35	81.3	52	73.6	39	68.7
Bosnia and Herzegovina	42	77.4	45	79.7	40	75.0	40	68.6
United Arab Emirates	43	77.1	57	78.6	35	76.4	44	67.9
Uruguay	44	77.0	40	80.4	56	73.3	44	67.9
Bahrain	45	76.9	71	77.9	37	76.2	55	67.0
Mexico	46	76.7	46	79.5	48	73.9	52	67.4
Slovakia	46	76.7	41	80.2	62	72.9	42	68.1
Oman	48	76.6	47	79.2	40	75.0	63	66.7
Antigua and Barbuda	49	76.4	57	78.6	46	74.1	50	67.5
Argentina	50	76.3	44	79.9	65	72.7	49	67.6
Jamaica	51	76.2	57	78.6	48	73.9	58	66.9
Ecuador	51	76.2	53	79.0	53	73.5	55	67.0
China	53	76.1	80	77.6	44	74.6	41	68.5
Montenegro	53	76.1	65	78.1	46	74.1	44	67.9
Bahamas	53	76.1	50	79.1	62	72.9	65	66.6
Viet Nam	56	76.0	38	80.7	81	71.3	65	66.6
Hungary	57	75.9	50	79.1	71	72.3	52	67.4
Turkey	58	75.8	54	78.9	68	72.6	73	66.2
Macedonia	59	75.7	76	77.8	53	73.5	50	67.5
Algeria	60	75.6	81	77.5	50	73.8	75	66.0
Serbia	60	75.6	61	78.4	62	72.9	47	67.7
Iran	62	75.5	86	76.6	45	74.5	65	66.6
Peru	62	75.5	66	78.0	59	73.1	80	65.6
Barbados	62	75.5	71	77.9	59	73.1	65	66.6
Tunisia	65	75.3	76	77.8	61	73.0	63	66.7
Saint Lucia	66	75.2	71	77.9	68	72.6	74	66.1
Malaysia	67	75.0	83	77.3	65	72.7	70	66.5
Romania	67	75.0	55	78.8	78	71.4	59	66.8
Brazil	67	75.0	56	78.7	78	71.4	81	65.5
Lebanon	70	74.9	87	76.5	53	73.5	79	65.7
Thailand	70	74.9	66	78.0	74	71.9	59	66.8
Sri Lanka	70	74.9	63	78.3	75	71.6	55	67.0
Armenia	73	74.8	79	77.7	75	71.6	59	66.8
Nicaragua	73	74.8	71	77.9	77	71.5	103	63.7
Colombia	73	74.8	61	78.4	84	71.2	85	65.1
Kuwait	76	74.7	93	76.0	51	73.7	78	65.8
Honduras	77	74.6	85	77.0	71	72.3	90	64.9
Mauritius	77	74.6	76	77.8	78	71.4	59	66.8
Latvia	77	74.6	47	79.2	95	69.6	54	67.1
Saudi Arabia	80	74.5	93	76.0	58	73.2	96	64.5
Bulgaria	80	74.5	66	78.0	86	71.1	72	66.4
Georgia	82	74.4	63	78.3	91	70.3	70	66.5
Morocco	83	74.3	99	75.4	56	73.3	90	64.9
Jordan	84	74.1	96	75.9	70	72.5	88	65.0
Venezuela	84	74.1	60	78.5	94	70.0	83	65.2
Paraguay	86	74.0	93	76.0	73	72.2	83	65.2
Samoa	86	74.0	81	77.5	87	70.9	65	66.6
Dominican Republic	88	73.9	84	77.1	87	70.9	85	65.1
Grenada	89	73.6	91	76.1	84	71.2	88	65.0
Lithuania	89	73.6	50	79.1	104	68.1	75	66.0
Tonga	91	73.5	88	76.4	89	70.6	75	66.0
El Salvador	91	73.5	71	77.9	99	68.8	98	64.1
Cabo Verde	93	73.3	103	75.0	81	71.3	97	64.4
Saint Vincent and the Grenadines	94	73.2	100	75.2	81	71.3	94	64.6
Seychelles	94	73.2	66	78.0	98	69.1	81	65.5
Libya	96	72.7	98	75.6	92	70.1	101	63.8
Azerbaijan	96	72.7	97	75.8	95	69.6	93	64.7
Belarus	98	72.3	66	78.0	119	66.5	85	65.1
Republic of Moldova	99	72.1	90	76.2	106	67.9	92	64.8
Vanuatu	100	72.0	107	74.0	92	70.1	94	64.6
Guatemala	101	71.9	100	75.2	102	68.5	116	62.1
Bangladesh	102	71.8	113	73.1	89	70.6	111	62.3
Suriname	103	71.6	105	74.7	101	68.6	107	63.1
Ukraine	104	71.3	91	76.1	120	66.3	98	64.1
Trinidad and Tobago	105	71.2	104	74.8	106	67.9	104	63.3
Kyrgyzstan	106	71.1	102	75.1	111	67.2	101	63.8
Egypt	107	70.9	111	73.2	99	68.8	113	62.2
Bolivia	108	70.7	110	73.3	103	68.2	113	62.2
Democratic People's Republic of Korea	109	70.6	107	74.0	113	67.0	100	64.0
Russian Federation	110	70.5	89	76.3	127	64.7	104	63.3
Kazakhstan	111	70.2	105	74.7	123	65.7	104	63.3
Belize	112	70.1	113	73.1	110	67.5	111	62.3
Fiji	113	69.9	113	73.1	113	67.0	108	62.9
Bhutan	114	69.8	126	70.1	97	69.5	120	61.2
Tajikistan	115	69.7	109	73.6	116	66.6	116	62.1
Micronesia	116	69.4	124	70.6	104	68.1	109	62.5
Uzbekistan	116	69.4	116	72.7	122	66.1	110	62.4
Solomon Islands	118	69.2	121	70.8	106	67.9	116	62.1
Nepal	118	69.2	121	70.8	109	67.7	121	61.1
Indonesia	120	69.1	119	71.2	112	67.1	113	62.2
Iraq	121	68.9	118	71.8	121	66.2	124	60.0
Mongolia	122	68.8	111	73.2	127	64.7	119	62.0
Cambodia	123	68.7	123	70.7	116	66.6	130	58.9
Philippines	124	68.5	117	72.0	126	65.3	121	61.1
India	125	68.3	128	69.9	115	66.9	126	59.5
Timor-Leste	125	68.3	126	70.1	116	66.6	123	60.7
Sao Tome and Principe	127	67.5	130	69.4	124	65.6	128	59.1
Senegal	128	66.7	132	68.6	130	64.6	132	58.3
Myanmar	129	66.6	133	68.5	130	64.6	127	59.2
Pakistan	130	66.4	137	67.5	125	65.5	134	57.8
Kiribati	131	66.3	131	68.8	136	63.7	128	59.1
Turkmenistan	131	66.3	125	70.5	143	62.2	125	59.8
Guyana	133	66.2	133	68.5	134	63.9	130	58.9
Rwanda	134	66.1	120	71.1	150	60.9	140	56.6
Gabon	135	66.0	138	67.2	127	64.7	137	57.2
Namibia	136	65.8	135	68.3	139	63.1	136	57.5
Yemen	137	65.7	138	67.2	132	64.3	135	57.7
Lao People's Democratic Republic	137	65.7	138	67.2	133	64.1	133	57.9
Botswana	137	65.7	136	68.1	137	63.3	138	56.9
Madagascar	140	65.5	141	67.0	134	63.9	138	56.9
Ethiopia	141	64.8	143	66.8	140	62.8	143	56.1
Congo	142	64.7	144	66.3	138	63.2	140	56.6
Eritrea	142	64.7	141	67.0	141	62.4	145	55.9
Syrian Arab Republic	144	64.5	128	69.9	154	59.9	143	56.1
Sudan	145	64.1	146	65.9	141	62.4	145	55.9
Comoros	146	63.5	151	65.2	144	61.9	145	55.9
Djibouti	146	63.5	150	65.3	145	61.8	148	55.8
Haiti	146	63.5	148	65.5	147	61.5	150	55.4
Kenya	149	63.4	147	65.8	148	61.1	149	55.6
Mauritania	150	63.1	153	64.6	146	61.6	152	55.1
Papua New Guinea	151	62.9	149	65.4	152	60.6	142	56.4
South Africa	151	62.9	145	66.2	158	59.3	153	54.5
Ghana	153	62.4	155	63.9	149	61.0	151	55.3
Uganda	154	62.3	154	64.3	153	60.3	156	54.0
Niger	155	61.8	158	62.8	150	60.9	154	54.2
United Republic of Tanzania	155	61.8	156	63.8	154	59.9	155	54.1
Zambia	155	61.8	152	64.7	161	59.0	158	53.6
Liberia	158	61.4	157	62.9	156	59.8	160	52.7
Gambia	159	61.1	159	62.5	156	59.8	157	53.8
Zimbabwe	160	60.7	160	62.3	161	59.0	163	52.3
Afghanistan	161	60.5	161	61.9	158	59.3	164	52.2
Benin	162	60.0	164	61.1	163	58.8	162	52.5
Burkina Faso	163	59.9	167	60.5	160	59.1	161	52.6
Togo	163	59.9	164	61.1	164	58.6	159	52.8
Democratic Republic of the Congo	165	59.8	163	61.5	165	58.3	166	51.7
Burundi	166	59.6	162	61.6	168	57.7	164	52.2
Guinea	167	59.0	171	59.8	166	58.2	166	51.7
Guinea-Bissau	168	58.9	167	60.5	169	57.2	168	51.5
Swaziland	168	58.9	164	61.1	171	56.6	172	50.9
Malawi	170	58.3	170	59.9	170	56.7	169	51.2
Mali	171	58.2	175	58.3	166	58.2	171	51.1
Equatorial Guinea	171	58.2	169	60.0	171	56.6	169	51.2
Mozambique	173	57.6	172	59.4	175	55.7	175	49.6
South Sudan	174	57.3	173	58.6	173	56.1	174	49.9
Cameroon	174	57.3	173	58.6	174	55.9	173	50.3
Somalia	176	55.0	176	56.6	176	53.5	176	47.8
Nigeria	177	54.5	177	55.6	177	53.4	177	47.7
Lesotho	178	53.7	178	55.4	179	51.7	179	46.6
Cote d'Ivoire	179	53.3	180	54.4	178	52.3	178	47.0
Chad	180	53.1	179	54.5	179	51.7	180	46.1
Central African Republic	181	52.5	181	54.1	181	50.9	181	45.9
Angola	182	52.4	182	54.0	181	50.9	182	45.8
Sierra Leone	183	50.1	183	50.8	183	49.3	183	44.4