Alcohol and drugs [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION AUGUST 1981 O0 Alcohol and drugs 11•~01111 ■•• ■••• wil•" 41, ■• Apo NOP so. .1110 dip oir di. nip 41110 MOW 40, NOP 411.' 40' MP .40P irate_ Z . . stroll -Ow de, .11.1e 4410— .an• •••• *IMF ••■■•• .1.1i •■•■•■•■■4"%:"..48":".."M' .11.• 'OW 41110. AO* AM. .01. ■■•• I.. AM* +M. 101. AMP .1.0. .111. 4.:"."410:asoi.:419. 4110. lip vie. .01. 41111. 4114. 4111111. Z .1•• ob. 41IP •OIN. gr. = .4111. .411. .41a. <VP .11. 4111. ANS Anw ,figp .. .. IOW Aso 4111. Ible• 41/p. .100 411. 0141. AIM ligp .1. 'OP ...... AMP ..... . ... .... .. 410 OOP 0141P Eat Since time immemorial, mankind has taken pleasure in consuming substances which affect the mental state. Fer- mented grapes, the juice of berries, fungi containing hal- lucinogens, the leaves of certain plants different cultures have discovered and exploited these vegetable sources of euphoria either for religious or ritual purposes as an agree- able «extra» to the life-style, or as a routine part of the diet L n some communities, the use of these substances carried their own particular taboos. Perhaps only a priestly hierarchy had access to them, or different strata of society might have their own preferred drug. But the excessive use, that is, the abuse of these substances, must have been commonly recognised, even if in some communities the victims of drug depen- dence were tolerated or even venerated as "holy fools". Today we can agree that many — though not all — of these substances, when used appropriately, need not be harmful in themselves. Thus, deriva- tives of the opium poppy such as codeine or morphine are valued items in the pharmacopeia, and indeed both of these figure on WHO's model list of Essential Drugs. But what happens when moderate use, or medically-controlled use, spills over into excessive use and addiction? Alcohol, in the form of fermented or distilled liquor from a huge range of plants, is the most obvious example of a mood-changing drug whose abuse is universally recognised as a threat to public health. A high proportion of hospital beds are occupied, year after year, by the physically and mentally damaged victims of alcohol depen- dence. To these sufferers must be added uncountable thousands more who are maimed in various kinds of accidents, particularly those directly caused by drinking and driving. (In few countries do the traffic statistics truly reflect the real scale of this problem.) Opium has been in regular use in parts of Asia for millennia as an escape- hatch into an unreal world of dreams. Trendy rebels against conformity ad- opted it in the Western world some 200 All-too-familiar stereotypes of opium- smoking, alcohol-drinking. The modern reality of alcohol and drugs is probably more secretive, and more insidious. ( Photos L. Sirman ©) years ago. Today its more sinister derivative, heroin, has become the scourge of unhappy youngsters all over the world, starting them on the slippery slope of addiction, crime and sordid death. "Magic mushrooms", with which some Mexican communities have long been familiar, have set experimenters on the trail of halluci- nogenic substances such as mescaline and lysergic acid diethylamide (LSD). Coca, khat, cannabis (under various names including hemp, hashish, ganja, bhang and marihuana), and tobacco these plants commonly used for their stimulant or tranquillising action may seem to have less serious conse- quences in the short term, but the long- term effects on health are giving medical science ever-growing concern. All these various substances have their own "social behaviour"; this global problem therefore consists of many sub-problems which are country-, region- and culture-specific. In the particular case of alcohol, tobacco and heroin, the purely public health aspects have tended to be swamped by the huge commercial interests that are involved — openly and competitively in the first two cases, clandestinely and in defiance of anti- smuggling laws in the case of heroin. Today there is clear evidence that the level of consumption of alcohol in a society is directly related to the harmful effects on that society and on the individual. The seriousness of the problem related to consumption of all types of stimulants differs widely in different contexts; and to add to the complexity, patterns of consumption may sometimes be transferred from one culture to another. This issue of World Health sheds light on some aspects of the global situation, and outlines the various programmes through which WHO hopes to help its Member States to stem the spread of alcohol- and drug-related problems. Alcohol and drugs yield only a distorted vision of the world. 0) 0 Cover design by Peter Davies AO IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, Portuguese, Russian and Spanish, and four times a year in Arabic and Persian. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WH 0, Av. Appia, 1211 Geneva 27, Switzerland . Contents Alcohol and drugs 3 The cost of a drink by John Madeley 5 Alcohol and women by Eva Zabolai-Csekme 9 The African experience by Muyunda Mwanalushi 13 Alcohol and youth by Olivier Jeanneret 16 Drug dependence and WHO by Awni Arif 20 International drug control treaties by Inayat Khan 22 Drugs in the Islamic world by Taha A. Baasher 24 Drug abuse in the Americas by Marilynn E. Katatsky 27 News Page 30 JHB

The cost of a drink It is a drug which gives pleasure and relaxation to millions. Yet the problems posed by alcohol block social and economic development, and even threaten to overwhelm the health services by John Madeley L t causes between a third and a half of all road deaths in industrial countries and a growing number in the Third World. It is a drug that can disrupt family life, and cost people their jobs, financial security and social standing in the community. It causes up to three out of ten of all accidents at work, results in loss of production and in some countries is a chief cause of crime. Its use can lead to liver cirrhosis. It puts a heavy strain on health services around the world—in Australia nearly half the patients admitted to psychiatric establish- ments are there because of its effects. And yet at the same time this is a drug which gives pleasure and relaxation to millions. It is enjoyed in many different situations and plays a key role in celebrations, festivals and happy occa- sions. It is a drug known throughout the world as alcohol. Consumption of alcohol has shot up in the last three decades, more than doubling in many countries. But as consumption has increased, so too have alcohol related problems, which are now more serious and widespread than is generally recognised. "Evidence suggests", says Dr T.A. Lambo, Deputy Director-General of wito, "that alcohol related problems may even constitute an important obstacle for socio- economic development, and will threaten to overwhelm the health services unless appropriate measures are taken". A resolution passed by the World Health Assembly in 1979 recognised that Consumption of alcohol has more than doubled in many countries in recent years. And alcohol related problems have soared too. (Photos J.-M. Proust (D) problems relating to alcohol rank among the world's major public health problems. It urged member states to take all appropriate measures to reduce the consumption of alcohol in their country. Between one per cent and ten per cent of the populations of most countries are affected by "the alcohol dependence syndrome" they are either dependent on alcohol or cannot sufficiently control their intake of the drug. They are disabled by drinking. An international review of the preven- tion of alcohol related problems was published last year on behalf of WHO by the Addiction Research Foundation, Toronto, Canada (from whom copies may be ordered). Compiled by Mrs Joy Moser, of WHO's Division of Mental Health, with the help of contributors from more than 80 countries, the review looks at measures and policies for preventing these problems. Evidence from the vast majority of these countries shows there is every reason why governments are becoming increasingly concerned about these problems. And yet governments often find themselves in a dilemma. For alcohol is a drug that, in most cases, plays an important role in national economies. In developing countries, the establish- ment of a brewing industry is often one of the first steps to industrialisation. In the majority of countries, both developing and industrialised, taxes on the production and sale of alcohol make up a significant part of government revenue. Alcohol industries provide employment; in France ten per cent of the workforce earn their living in the production or sale of alcoholic beverages. Large powerful companies are involved in its production and distribu- tion; high profits are involved. But although alcohol brings economic be- nefits, it also imposes economic costs. Doctors, hospitals and health services have to devote time and resources to dealing with alcohol related problems which might otherwise be spent on alleviating other health and welfare hazards. Millions of working days are lost each year through alcohol related pro- blems. The United States government calculates that the cost of alcohol through lost production in the factories is over $20,000 million a year. The cost of heavy drinking can be especially high when the drinker has an occupation which affects the lives of others. Errors of judgement induced by drinking among, for example, highly placed civil servants, engineers, mass transport drivers, physicians and surgeons can be catastrophic. Supply and demand There are two chief ways of preventing alcohol related problems; the first is to limit the supply of alcohol, the second is to reduce demand for alcohol. A number of countries seem to have an unwritten policy of making alcoholic beverages available to meet the "legiti- mate" demands of populations, while introducing restrictions aimed at limiting any possible harmful effects. A WHO Expert Committee, which in 1979 exam- ined problems related to alcohol consumption, said that evidence to date strongly suggests that "controls are the most effective tools governments have to affect the level of alcohol consumption in the population and to reduce many of the 5 problems associated with such consump- tion". There are three main types of controls that governments can use. First of all they can control production. Between 1960 and 1972, recorded production of alcohol increased by 19 per cent for wine, by 68 per cent for beer and by 61 per cent for distilled spirits in 177 countries. Prohibition is the most direct way in which countries can control production. Several studies have found that in the early years of its introduction, prohibition leads to a decline in alcohol related problems. This occurred in the United States in the 1920s and 1930s. Today prohibition is in force in Libya, Saudi Arabia, the Yemen Arab Republic, Kuwait, and parts of India. But is prohibition the answer? Evidence suggests that attempts at complete prohibition break down after a period. Illegal production of alcohol and lawlessness associated with prohibition, together with the impact of the depression and changing values, caused the United States govern- ment to abandon the experiment in 1933. A less extreme measure than prohibition is for a government to limit the number of licences that it issues for the commercial production of alcoholic beverages. Secondly the government can control distribution and trade—although interna- tional measures would be needed to control trade effectively. Distribution can be controlled by, amongst other measures, restricting the times at which public houses and off-licences can sell liquor. However, this may not always lead to less heavy drinking. Although in some countries it appears that shorter opening hours do encourage people to drink less, certain authorities have suggested that more widespread availability of alcohol pro- motes moderate and responsible drinking. But evidence does indicate that more women under 30 are becoming heavy drinkers because alcohol is available at all times of the day in supermarkets. The third way for a government to control availability is for them to tax alcohol more heavily, thus increasing the price at which it is sold, and at the same time to restrict sales promotion. Higher taxes should compensate in part, if not in full, for falling alcohol sales should overall control be successful. But many govern- ments are reluctant to increase alcohol taxes for fear it will make them politically unpopular. Higher taxes need therefore to be combined with educational measures to show the dangers of excessive alcohol consumption. In many cases it seems that the advertising of alcoholic beverages has been responsible for an increase in consump- tion, and that vulnerable groups, particularly young people, have been the direct targets of advertising. But promo- tion of advertising is restricted in a growing number of countries and there is some evidence of success. Advertising of alcoholic beverages is completely prohi- bited in Poland. In Canada, Costa Rica, Mexico, Sweden, the United Kingdom and Zambia there are special regulations banning or restricting alcohol advertising on radio and television. Dutch breweries have announced voluntary restriction of advertising campaigns. France, the country with the largest per capita alcohol consumption in the world, bans alcohol promotion on television, in sports facilities and in places where young people gather. There is evidence from France of a slight decline in alcohol consumption. Efforts to reduce demand for alcohol centre on education, information and motivation. The international review points out that nearly all national programmes have an information and educational component. However, in some countries, despite mass media efforts of public education, the demand for alcohol has continued to grow. Left: ...This is a drug which gives pleasure and relaxation to millions. It plays a key role in celebrations, festivals and happy occasions... Right: ...Although alcohol brings econom- ic benefits to a country, it also imposes economic costs. Millions of working days are lost each year through alcohol related problems. And the cost of heavy drinking can be especially high when the drinker has an occupation which affects the lives of others... ( Photos L. Sirman ©) The mass media have been used to present information about the dangers of alcohol, especially for people who are driving, but results have not always been encouraging. "There is little evidence" states the review "that simple educational programmes disseminating factual in- formation about the dangers of a particular substance are sufficient to prevent its use". But some public education programmes seem to have been more successful. In France, for example, where two national bodies have cooperated to reduce demand for alcohol, a programme has been carried out which made specific proposals about alcohol consumption. Adults were recom- mended not to exceed an alcohol consumption level of 0.3g ethanol per 1000g body weight per main meal, which corresponds to about a quarter litre of table wine. Opinion polls in France now suggest that a higher percentage of the population recognise that alcoholism is a real danger to the country. Other countries are attempting to develop educational programmes aimed at specific target groups of people. Educa- tional techniques have been adopted in Britain and Canada, for example, which involve schoolchildren in finding out about health problems, including those related to alcohol consumption, and making decisions about how to act themselves. Such programmes aim at 6 preventing the development of irrespons- ible behaviour in relation to health. A key target group is, of course, the group of people who are either dependent on alcohol or in danger of becoming dependent. The review suggests that general medical practitioners, nurses, midwives and primary health workers, people in the community whose views are highly respected, have a key role to play in helping to motivate people to do some- thing about their drinking problem. Much can be done too in the workplace. Over 2,000 US companies have set up counsell- ing services to help employees who are heavy drinkers. Australia has a national industrial committee to advise on alcohol and drug programmes in industry. A silent "health worker" is the label on the bottle to warn drinkers of alcohol's dangers. Health warnings on cigarette packets are now becoming commonplace throughout the world, but similar warn- ings on alcohol bottles are seen in only a few countries. In India, for instance, the alcohol drinker is warned by a label on his bottle, "consumption of liquor is injurious to health". The effectiveness of such a warning would be difficult to evaluate. Another target group is vehicle drivers who drink before driving. There is little general agreement among countries about the safe permitted limit of alcohol in the bloodstream, and levels range from zero to 1.5g ethanol per 1,000g blood. Czechoslovakia, East Germany, Hun- gary, Poland, Rumania and the USSR, for example, prohibit alcohol consumption completely before and during driving. Several other countries Finland, Greece, Iceland, Netherlands, Norway, Sweden and Yugoslavia — impose an upper legal limit of 0.5g ethanol per 1,000g blood. One of the most concentrated attempts to control drinking by drivers was made in 1967 by the United Kingdom government which introduced a road safety act that for the first time in Britain permitted random breath testing followed by convictions. The act was brought in during an intensive three months public information cam- paign, and strong enforcement measures were taken. There was an immediate fall of 15 per cent in fatal casualties in the first year. However, despite a continued high level of enforcement, the number of casualties started to rise after a few years and in 1976 the situation was more serious than in 1967 a development which points to the need for continued preventive effort. Preventive action The international review suggests that national and worldwide programmes concerning alcohol related problems need to be developed in a coordinated way. For the problems cannot be solved in isolation. Health, welfare, moral, educational and economic aspects all need to be taken into account, and a programme on alcohol problems needs to be situated in the general framework of a policy to promote health, welfare and development. The 1979 Expert Committee pointed out that alcoholism, "while prevalent and a matter for serious concern, constitutes only a small part of the gamut of alcohol related problems". Aware of the "limited efficacy and high cost of the existing treatment or management of most of these problems, and their high prevalence in many parts of the world", the Committee recommended that "prevention should be given clear priority". One of the impediments to initiating preventive action programmes can often be the lack of a suitable organization, such as a national coordinating committee, to take responsibility for promoting action. Such committees can be valuable, for example, in researching and collating information, and coordinating the dif- ferent aspects of the programme. Despite the seriousness of alcohol related problems, there has never been any worldwide policy concerning prevention. But Joy Moser suggests that the economic aspects of the problems, including the implications of international trade in beverage alcohol and the economic consequences of alternative preventive measures, need to be approached at the international level. ■ 7 ~~'";, Alcohol and women Women react to their own alcoholism differently from men. They tend to have extreme guilt feelings and to blame themselves for their drinking habit. Their loss of self-respect may lead them to self-destructiveness by Eva Zabolai-Csekme L n some industrialised countries the number of women alcoholics is estimated to equal that of men. This fact surprises many, for alcoholism is generally regarded as a male disease. In the United States alone, the number of alcoholic women is rated at about five million. However it is not only the extent of the problem which commands urgent attention but also the fact that women alcoholics are not "just like" alcoholic men. Their drinking habits are different; society has a different reaction toward them and their rehabilitation process requires different measures. Female alcoholism is one of the most carefully hidden problems because of the social stigma attached to it. Heavily- drinking women are looked down upon more than their male counterparts. They are regarded as irresponsible, loose persons, who ruin themselves and their families. As a result women do not want to be identified as alcoholic, and even their relatives help them to conceal the fact in order to save the family's reputation. Families are often afraid to admit even to themselves that the problem exists — no one likes to believe that the hand that rocks the cradle might be a shaky one. The result of this conscious or subcon- scious refusal to acknowledge female alcoholism is that women are not encouraged to seek treatment. Often even physicians and psychiatrists fail to recog- A special social stigma attaches to women who over-drink. No-one likes to believe that the hand that rocks the cradle might be a shaky one. (Photo J.-M. Proust C)) nise alcoholism in women. Misjudging the symptoms, they prescribe tranquillizers, which in turn cause an even more dangerous double addiction. The causes of alcoholism in women are manifold, but there are certain indications which necessitate a new look at the problem. In the United States, the average alcoholic woman is middle class, is in her forties, is married and has two to three children. An estimated 15 per cent of housewives are dependent on alcohol or drugs by their eighth wedding anniversary. Certainly, drinking almost always starts in social situations, but the tranquillizing and uninhibiting effects of alcohol are soon discovered. It is then used to serve multiple purposes, among them oblivion, outlet for anger, anxiety, pressure or boredom. There is evidence that alcoholism in women is often related to specific life situations such as a divorce, the death of a loved one or bad marital relationships. Often it conceals the unmet and unsatisfied emotional needs of love, security, signifi- cance and a sense of belonging. The loneliness of the suburban housewife is also recognised as an inciting factor for the use of alcohol. On the other hand the career woman, who must function in a business world which is highly competitive and which considers her inferior despite her professional achievements, may com- pensate for feelings of unfair competition with alcohol and/or drugs. Therefore when assessing the situation one must not just ask what is wrong with the woman but, above all, what is it in her environment that makes her want to escape from the scene. A serious look at the condition of women in all countries is a necessary precondition for an adequate understand- ing of the problems. Some studies suggest that as many as two-thirds of alcoholic women are or were married to problem drinkers and that over 25 per cent had alcoholic fathers. Rising figures for teenage alcoholism beg the question: what influence does an alcoholic mother have on her children, especially since most women drink at home while men tend to drink in company and often in public places? Not only do women have to hide their drinking habits, but for most of them the home is the place of "employment". They drink at home because they work at home and spend their day there. These so-called 9 a.m. to 3 p.m. drinkers may to a certain extent conceal their problem from their husbands but it is less easy to do so from their children. Alcoholism in mothers has not only a negative impact on growing children, who 9 are in the process of developing physically, emotionally and intellectually. Heavily- drinking women have a much higher chance of giving birth to children with certain abnormalities, such as congenital anomalies, growth retardation or func- tional abnormalities detectable through neurological examination. The so-called fetal alcohol syndrome can also lead to premature births or even stillbirths. Another indication that women's re- productive functions are affected by heavy alcohol consumption is the recognition that alcoholic women tend to have more gynaecological disorders and higher rates of sterility than non-alcoholic women. Women especially during their pre- menstrual phase -- are physiologically more sensitive to alcohol than men. Unfortunately it is during this period that women drink most in order to alleviate depression. It takes less alcohol over a shorter period of time to damage them. They develop liver disease faster and get it more seriously than men do. A survey in a London hospital in 1977 showed that more women with alcohol problems suffered from serious liver disease than men with alcohol problems, although their alcohol intake was less; they also responded to treatment less favourably and died younger than their male counterparts. In spite of these serious consequences, alcoholism in women is on the rise. Admission to hospital for treatment of alcoholism in England and Wales during 1970-1978 increased by 77 per cent for men and 137 per cent for women. During the same period, deaths from cirrhosis of the liver rose by 27 per cent for men and by 64 per cent for women. The psychological and social conse- quences of alcoholism for women are extremely severe. First of all, they react to their own alcoholism differently from men. This difference is mainly related to the incongruity of their socialisation processes. Women tend to have extreme guilt feelings and blame themselves for their drinking habit. They internalise society's contempt and often detest themselves. This loss of self-respect in turn leads to a loss of identity and to a self- destructiveness which further aggravates the problem. In addition, they face the strong criticism of society. People disapprove of alcoholic women more than they do of alcoholic men. Heavily-drinking women are blamed for neglecting home and children much more than their menfolk. Certainly if it is the woman who becomes alcoholic, the family has a much higher chance of falling apart. While nine out of ten women stay with an alcoholic husband, nine out of ten men leave an alcoholic wife. The consequences are not only devastating for the family, but also for the rehabilita- tion process of the woman. She finds herself deserted, without the emotional support of the family and often without sufficient financial resources. In many cases she also lacks adequate education or vocational training and finds it extremely difficult to enter or re-enter the job market. Not only does she have to deal with her drinking problem alone, but she has to reconstruct her life if she wants to escape destitution or suicide. In view of this complex situation there is a need for a holistic rehabilitation process which takes the different aspects of Below: Alcoholism in women often conceals the unsatisfied emotional needs of love, security and a sense of belonging. Facing page: Rising figures for teenage alcoholism beg the question: what influence does an alcoholic mother have on her children? ( Photos J.-M. Proust © and L. Sirman ©; facing page, L. Sirman C)) the woman's needs into consideration. Unfortunately treatment of alcoholic women often reflects the unwarranted assumption that the needs of women in treatment exactly mirror those of men. Yet alcoholic women are not "just like" other women and not "just like" alcoholic men. The first and foremost task of the rehabilitation process should be to bring about a better informed general public with changed attitudes toward the alcohol- ic women. Without such efforts many women will never seek treatment, out of shame and fear for their own and their family's reputation. Society must learn to regard alcoholism as a social and physical disease which needs treatment and which can be successfully treated. This message has to be communicated in such a way as to reach the alcoholic woman who now is socially isolated and uncommunicative, and who uses defence mechanisms such as denial, rationalisation or self-deception to ward off even more psychological suffering. Another imperative is the training of social workers, prison officers, psychia- trists and all types of health workers to detect alcoholism in women. Early inter- vention resulting from early detection might save many lives. Treatment for women will also have to include provision for supportive services, such as child care facilities. Otherwise they will only seek treatment when the family has already fallen apart, and their rehabilitation process will be a much more complicated one. Nobody should imagine that rehabilita- tion can happen overnight. Successful recovery takes a minimum of two to three years and involves the whole person: the physical being, the psychological- emotional being and the spiritual being. As a result a multidisciplinary approach is necessary. Rehabilitation processes for women have to take into consideration their low self-esteem and high degree of depression and anxiety. Re-building of self- confidence must be part of the treatment. The alcoholic woman should be helped to identify her strengths and positive aspects, and to look at herself as a valuable, capable human being who has the power to reconstruct her life. Too often she blames herself for the problem and tends to turn her aggressivity against herself. This fact stands in contrast to behavioural patterns of alcoholic men, whose aggres- sivity usually turns against others — a striking difference which calls for urgent examination of those factors which form the personalities of women and men. Successful recovery is also highly dependent upon the emotional support of the woman in treatment. Unfortunately husbands are frequently unwilling to accept treatment along with their wives, even if they are still around. In most cases, the woman is already deserted by husband, family and friends and lacks their emotional aid. As a result new sources of support have to be created. A group of former alcoholics or a women's support group can provide this much-needed sustenance. Since women are often forced to start an entirely new existence during and after the rehabilitation process, vocational training leading to employment should be available to them as part of the treatment. Widespread alcoholism in women is a relatively new phenomenon, and the response given to it is so far insufficient. Research related to alcoholism still focusses mainly on men. In the USA, for example, the National Institute of Alcohol Abuse and Alcoholism awarded 384 grants between 1971 and 1976 for research projects; of these, 16 had something to do with women — and just five dealt specifically with women's problems. ■

The African experience by Muyunda Mwanalushi Those societies which encourage unlimited, unrestricted drinking, and which fail to provide alternatives for the functions fulfilled by alcohol, and which further fail to develop adequate means to deal humanely with individual problem drinkers, and, finally, which fail to develop programmes which would minimise the socially disruptive aspects of alcohol use, deserve the alcohol problems they get. N.A. Scott L I ollowing a Workshop on Alcohol and Drug Dependence Problems held in Nairobi in September 1974, the Association of Psychiatrists in Africa noted that: "Problems related to consumption of alcohol and dependence- producing drugs are widely prevalent in African countries: they appear to be increasing and in some areas they are changing in nature... In most African countries, alcoholism and other effects of excessive alcohol consumption appear to create at present far more serious and extensive problems than the use of dependence-producing drugs." The Asso- ciation went on to recommend, among other things, the collection and collation of data on the nature, extent and cost of alcohol and drug problems and the resources for dealing with them. To date, very little systematic work of this nature has been undertaken on the continent of Africa. However, two major initiatives directed at these problems have been gathering momentum over the past five years: an active research programme on drug use among school-going youth in sub-Saharan Africa has been underway since 1976 under the auspices of UNESCO; and concurrently WHO has been support- ing research on alcohol in Zambia research which, it is expected, will be Clients drinking home-made beer at an open-air tavern in Southern Africa. In many African countries today, greater consump- tion is giving rise to growing alcohol-related problems. ( Photo International Federation of Blue Cross Societies C)) undertaken in other African countries using the model developed in Zambia. The government of Zambia has long been concerned about the bad conse- quences of alcohol abuse resulting from a rapid increase in consumption since independence. Leading public figures have from time to time expressed concern about the problem of alcohol drinking and dependence while feature articles on alcohol abuse appear periodically in the press. But the government has not been able to plan effective programmes for the prevention, control and treatment of alcohol-related problems because ade- quate information was lacking on which to base such planning. The project on Community Response to Alcohol Related Problems in Zambia, on which I have been working with Dr Alan Haworth, was initiated primarily to address this issue. More specifically, the project was aimed at establishing what were the drinking practices in Zambia; the nature and extent of problems arising from the use and abuse of alcohol; how these problems are handled by formal and informal agencies; evaluating these "com- munity responses" and—where they are found to be less effective suggesting ways by which they could be made more effective. The first description of drinking prac- tices in Zambia comes from a visitor to what is now the Eastern Province. Monteiro-Gamitto, who visited the area in 1831, said that the Chewa were "distin- guished by moderation, sobriety, industry and activity" whereas the Bisa, from further west, had beer throughout the year and were described as "very intemperate". In 1851 David Livingstone, on arrival at Sesheke in Western Province, described drinking practices among the Lozi, .and observed that "Sekeletu, now in power, received us in what is considered royal style, setting before us a great number of pots of boyaloa, the beer of the country. These were brought by women, and each bearer takes a good draught of the beer when she sets it down, by way of 'tasting' to show that there is no poison." More recent observers have noted that all important ceremonies, such as marriage, took place in the months immediately after the harvest when people had plenty of food and beer. Beer was made from various ingredients, including millet, maize, sorg- hum, manioc, and sugarcane. It is evident that beer drinking was quite common and widely practised in tradi- tional Zambian society. These early descriptions of drinking practices are almost unanimous in stressing the integra- tive functions rather than the disruptive effects of alcohol. In the first place, beer was (and still is) considered as a food it is a source of vitamin B (for this reason, beer was included as part of the rations issued to mine workers on the Rand, South Africa). Secondly, and more importantly, alcohol was interwoven into the social and cultural fa,bric of African societies: beer was used for ceremonial purposes (birth, marriage, initiation, death), as an offering to ancestral and other spirits, and to express and reinforce social organization (hospitality, reward for communal labour, tribute to chiefs, facilitation of the work of courts or councils). Thus, one traveller 13 remarked of the Bemba that "abundance of beer is the glory of a commoner's hospitality, or a chief's court. Without it tribal councils cannot be held, and marriage or initiation ceremonies do not take place." Despite the widespread use of alcohol in various spheres of social and cultural life of traditional Zambian society, drunken- ness was infrequent and alcohol problems were unknown. This was no doubt due to a combination of many factors; the alcohol content of traditional beer was very low (approximately three per cent), the availability of beer was restricted to the harvest period and immediately after, and since drinking was a social event, individuals rarely drank alone, so that the amount drunk per person was limited by rules of social etiquette. With the advent of colonialism, the alcohol scene changed considerably. First- ly, the availability of alcohol was no longer confined to periods of the year when grain Home-brewed beer may be made from various ingredients, including millet, maize, sorghum, manioc and sugarcane. ( Photo International Federation of Blue Cross Societies 0) was in abundance, nor was brewing now a family affair confined to the domestic setting. Secondly, due to ready availability and increased outlets for alcoholic be- verages, alcohol became a major commercial enterprise, particularly in the urban areas. However, the African's access to alcohol, particularly potent brands such as lager and spirits—was limited by numerous discriminatory regulations. On the attainment of Independence (24 October 1964) all restrictive and discrimi- natory measures concerning availability of and access to refined alcoholic beverages were removed. This factor, combined with the economic viability of the country which gave it, until a few years ago, one of the healthiest economies in Africa, has affected the consumption of alcohol. There has been a tendency towards greater consumption by an increasing number of people, including the youth. A study of about 1,000 persons attending health centres in various parts of the country in 1969 found that only one-third of the men and two-thirds of the women were abstainers. Murphy and Gieske (1972) conducted a survey of drinking in ten secondary schools involving 1,125 pupils aged from 15 to 19 years; 64 per cent of the boys and 26 per cent of the girls stated that they were drinkers. In a study done at the University of Zambia in 1971 involving 1,200 students (mean age 22.1 years), it was found that 26 per cent were abstainers, 36 per cent occasional drinkers, and 38 per cent regular drinkers. Consumption of commercial beverages showed a tendency to rise between 1961 and 1976, when per capita consumption increased from 41.5 to 150 litres per annum respectively, with a peak of 202 litres in 1974. Changing drinking habits also gave rise to a number of alcohol related problems, including alcoholism, road traffic accidents, and social and economic difficulties. From the returns made to the Ministry of Health from all hospitals in the country, patients are classified according to diag- nosis on discharge or death. In the years 1973, 1974 and 1975, 515, 408 and 487 persons respectively were diagnosed as suffering from alcoholism an average rate of 18.5 per 100,000 population. With regard to road traffic accidents, a pathologist examining blood alcohol levels of deceased accident victims reported that 55 per cent had levels of 150 milligrams per 100 millilitres, or more. As for social and economic problems, one survey done in 1968 revealed that, in 3,167 court hearings, alcohol was a contributory factor in almost 24 per cent of the cases. These problems have long been recog- nised and some voluntary organizations, such as the Alcoholics Anonymous and the National Council on Alcoholism and Addiction, took measures to counter the problems. Simultaneously, the govern- ment acknowledged the serious reper- cussions of these problems on the well- being of the nation. However, there is as yet no official or broadly accepted policy for the prevention and management of alcoholism or other alcohol related disabilities. Thus, although the health infrastructure has undergone remarkable 14 development since independence, there are no services developed specifically for persons with alcohol related problems within the health services or elsewhere. The present response to alcohol related problems in Zambia is therefore clearly inadequate. For this reason the Alcohol Project was undertaken with the objective of formulat- ing a plan for a more comprehensive response to alcohol related problems, varying from prevention through streng- thening informal responses to improving provision of services. The plan takes note of the fact that alcohol abuse is an ecological problem involving the "host", the "agent", and the "environment". The "host" is the individual who takes alcohol but also his knowledge about alcohol, his drinking behaviour, and the attitudes which influence his drinking patterns; the "agent" is alcohol itself its content, distribution, and availability; and, finally, the "environment" refers to the social and cultural context within which drinking occurs. Alcohol problems arise from an interaction of these factors and a preventive programme demands what may be termed the "total approach", that is, a simultaneous attack on all aspects of the problem, coordinated according to a carefully conceived operational strategy. My recommendations for an enhanced "community response" would be based on planning activities undertaken at the community and national levels. Specific- ally, I would propose that the following might be considered: The government's reliance on the alcohol industry for revenue should be reconsidered, since this indirectly en- courages production (and therefore the expansion of the alcohol industry). Control on availability should be exercised by reducing production, curbing the hours of drinking, reducing the number of outlets through restrictions in the issue of liquor licences, and raising the age of eligibility to 21 years. Alternatives to drinking should be promoted by providing more recreational and educational activities, such as cultural dances, football, reading, home economics and so forth. In this connection, commun- ity centres in the various communities should be revamped and other social or church organizations should be en- couraged to actively provide alternatives to drinking. A road accident in the Ivory Coast attributed to "the demon drink -. Can a community-based response to the problem of alcohol bring about an improvement? (Photo International Federation of Blue Cross Societies C)) Alternative, more moderate and responsible styles of drinking should be encouraged through the inculcation of values supportive of "healthy" attitudes to drinking. — Alcohol education should be related to the experiences of the people, and undue weight should not be placed on the pathological aspects of drinking since this is likely to produce a "boomerang" effect. Education should be seen as a community responsibility, and all com- munity agencies political, church and school groups, clinics, community centres and so on should be called upon to contribute to this instructional effort. In addition, it has been suggested that a legally constituted Commission on Alco- holism and Alcohol Abuse should be established to continue carrying out research on alcohol and alcohol problems. This would work with the government (which should diversify its health services to include those specifically intended for persons with alcohol problems) and with various non-governmental agencies con- cerned with alcohol-related problems at national and local levels. These various suggestions are situated in the framework of prevention, and such a preventive programme should be located in the broader context of national development. This proposed response, together with the actual findings of the Alcohol Project, will be the subject of a national conference to be held later this year. It is expected that several other African countries, which have expressed interest in undertaking similar research, will be represented at the conference. ■ 15 t WS L hen the parents drink, it's the children who pay." This anti-drinking slogan was launched in France soon after World War II, and it accurately sums up how the offspring suffer if one, or worse still both, of their parents drink too much. It was also one way of appealing to adult consciences in a society otherwise highly tolerant of those who drink alcohol. Certainly the children of alcoholic parents (of alcohol dependents or of those with alcohol related problems, according to the current terminology of wHo) run a number of risks. They risk being beaten, neglected or malnourished; but beyond that, they may suffer long-term harm from the memory of terrible or even tragic "scenes"; they may be discriminated against by people outside the family; and the development of their personal, family, professional and civic attitudes may be inhibited. Today several remarkable psycho-social studies are being made into the future development of children of alcoholic parents who are adopted by non-drinking foster-parents, in an attempt to compare the respective influence of the different sets of parents; this seems largely to depend on the child's age at the time of separation. A belief lingers on among the general public for which recent research can find no confirmation—the idea that alcohol- ism can be inherited. It just is not true. There is no transmission, through the chromosomes, of any kind of predis- position from generation to generation. However, following a number of papers published in French which attracted insufficient attention in Europe, some American writers have in turn drawn attention to the risks which the embryo and/or the fetus runs when the mother abuses alcohol. "Fetal alcohol syndrome" is usually characterised by retarded growth before and after birth, too small a head (microcephaly) and other possible physical and mental impairments. In terms of preventive medicine, it is obvious that mothers should drink only very moderate amounts throughout pregnancy — and that those who cannot drink moderate amounts should abstain altogether. But the risks for adolescents are in my view much greater. Why should this be so? The syndrome mentioned above affects only a very tiny minority of children, whereas the encounter between the adolescent and alcohol is a worldwide phenomenon and one that is almost inevitable. Even those countries and regions which up to now have been spared this problem for religious reasons (the Islamic world), or for economic or geographic reasons, no longer seem likely to avoid exposing people to alcohol. It may occur late in life, but seems to be happening at an ever earlier age. This encounter may be only a light- hearted episode; but it can also have serious consequences. The daily papers regularly report tragic traffic accidents involving some adolescent road-user under the influence of alcohol and resulting in a fatality. As one commentator observed, "driving a car while in a drunken state is particularly dangerous for an adolescent who knows neither how to drive, nor how to drink". Eventually he may be taught how to drive (in the USA it takes several Alcohol and youth Driving while drun< is highly ris<y for ado- lescents who know neither how to drive nor how to drink. Eventually they may learn to drive but who will teach them how to drink? by Olivier Jeanneret 16 The "morning after" brings a hangover— and remorse. Whether youngsters abuse alcohol, drink in moderation or don't drink at all depends on a multitude of factors, some of which still defy analysis. (Photo L. Simian ©) years), but does anyone teach him how to drink? Before we could undertake to make such training both feasible and effective, we obviously need to know more about adolescents. For instance, their normal habits, the changes in those habits at different ages and with the passage of time, what motivates the adoption of new habits, the models which key persons represent (parents, other family members, friends, popular "idols" and so on), and the dominant attitudes of society and its degrees of tolerance for behaviour seen as outside the norm, particularly on the part of the young. To illustrate what I mean by motives, the adjoining table has been extracted from the first cross-sectional epidemiolog- ical study ever made in Switzerland, carried out recently under the aegis of the Swiss Institute against Alcoholism. So- ciologist Richard Mueller sent out questionnaires to a representative sample of the country's three linguistic regions where German, French and Italian are spoken. The sample covered 196 classes of three successive school years and totalled 3541 adolescents of both sexes aged between 12 and 16; 3257 gave an answer about their motives. This table lends support to the fairly classic hypothesis that the terms in which people answer such a questionnaire — even though it may be anonymous and confidential respond, as Mr Mueller states, "less to profoundly felt motives than to socially acquired attitudes and meanings". What we have to recognise in each case, whether it concerns parent, teacher, educator, or adolescent, is that behind the observed reality are hidden a multitude of factors which rigorous analysis must take into account if we are to avoid an over- simplified vision of that reality, of its causes and consequently of the counter- measures to be taken, whether of an educational or a repressive nature. One hears people say all too often: "What's the good of all these surveys in the end? If the youngsters of today drink more, drink more often and drink at an earlier age, it's all the fault of... so all we have to do is..." The fact is that these multiple factors also have a bearing on other behaviour patterns characteristic of adolescents, such as experimenting with, using regularly and even abusing other drugs beside alcohol; the same is true of all other kinds of experimentation affecting their bodies, their emotions and their intelligence, at the various stages of maturity of these three "instruments". The whole range of "tunes" played on these instruments are today recognised by an increasing number of specialists in the problems of adolescence as useful, and even indispensable, to the processes of growing up which eventually bring every adolescent as close as possible to the status of adulthood, as it is defined in most societies. But what used to be a short initiation phase in pre-industrial societies has now been replaced by a long period of 17 What motivates young people to drink alcohol? Percentage of all Yes replies Motives (Swiss children aged 12 to 16) German- French- Italian- speaking speaking speaking Self-gratification 56.9 52.0 65.8 "because I like it" 36.9 746 34.7 268 48.6 226 "because it feels good to be a little tipsy" 8.2 166 12.7 98 12.0 56 "because I am bored" 11.8 239 4.6 36 5.2 24 Symbolic participation/ pressure from young people of the same age 31.1 35.2 18.8 "because my friends drink too" 10.9 220 15.5 120 8.2 38 "so my friends won't think me a wet blanket" 6.5 131 7.0 54 3.1 14 "because most adults drink too" 9.2 185 6.5 50 4.3 20 "so as to mix more easily with other people" 4.5 90 6.2 48 3.2 15 Psycho-dynamic relief 12.0 12.8 15.4 "to give me courage and self- confidence" 3.8 76 4.5 35 5.8 27 "to calm myself down" 5.7 116 6.1 47 7.7 36 "so I can talk more easily to people" 2.5 50 2.2 17 1.9 9 Total 100 2019 100 773 100 465 (The figures in italics refer to the actual number of responses) uncertain groping and experimentation which is both fascinating and dangerous: in other words, adolescence. Fully aware of all the complexities of this field of studies, a British writer, Marcus Grant, tried to identify six different strategies for an educational approach to young people and alcohol. These are: Promoting moderate drinking. A system of self-control should enable most adolescents to become adults on familiar terms with alcohol-but without alcohol problems. Reducing the reasons for resorting to alcohol and cutting down the occasions of drinking. Obviously this calls for a sound knowledge of those reasons and those occasions. Starting with situations under adult control, especially within the family, it should be possible to make young people self-reliant on their own decisions and capable of resisting the promptings of comrades of their own age. If this succeeds in developing a capacity for self-control, it may also form an element in broader programmes covering other fields of risk, such as sexual behaviour. Suggesting or even recommending alternatives. As Mr Grant says: "This is a more ambitious attempt to modify the existing models of cultural values, in which alcoholic drinks rate very high." This is where religious and moral considerations - whether traditional or new (to the Western world) have a role to play, but so too have such active leisure pursuits as sport and the return to a more natural way of life, including diet. - Limiting the harmful effects of over- drinking. The risks entailed in driving any vehicle, from a bicycle to a sports car, while under the influence of alcohol, have already been mentioned. But there are also well-known harmful effects on mental performance (in school examinations) or physical trials (in sporting events)-and perhaps less well-known effects on sexual activity. Encouraging youngsters to accept help in good time, and even to seek such help. "In good time" means at the moment when problems of all kinds arise as a result of excessive, repeated or prolonged drinking, followed by alcohol dependence itself. Trying to change the ways of speaking and behaving within the family, at school, at work and even in society itself. By spotlighting mature personalities who are capable of living without dependence on any drug, this strategy tries to promote new models precisely contrary to those offered by commercial propagan- da in favour of alcohol (and tobacco), but using similar methods. Clearly, after considering the "why" we have to decide on the "how", and must move on from theory to practice or better still to practices in the plural! But this involves taking very careful account of the cultural, economic, social and even legislative context, so that the practical steps that are available are practically infinite in their variety. Our choice falls on a project developed recently in the suburbs of a city of the United States. Its authors, H.T. Blane and M.A. Greenwald, describe the city as stable, integrated, offering a broad range of social and economic opportunities, and with a proportion of four whites for every one black. The aim of Project MAP (Minimising Alcohol Problems) is to promote respons- ible drinking and to reduce the risk of alcohol abuse, with all its consequences. It has four component parts. Component I: Education about alcohol, addressed to older schoolchildren, consists in turn of a formal course lasting two school terms, with discussions centred on feelings and attitudes in this age group towards different people's drinking habits; working groups where the children look in depth at subjects of their own choice (alcohol and pregnancy, alcohol and accidents and so on); and for the more motivated individuals among them, addi- tional training aimed at making them the "pupil-teachers" for subsequent sections of the Project. Component II: The preventive pro- gramme, aimed at high-risk schoolchild- ren, uses three distinct but interlinked 18 The encounter between the adolescent and alcohol is a worldwide phenomenon and one that is almost inevitable. Furthermore it seems to be happening at an ever earlier age. ( Photo WHO/E. Mandelmann) methods. The "capacity for living" groups are formed by the youngest children and meet, on a voluntary basis, twice a week during one term. While helping them to develop self-awareness, self-confidence and the ability to communicate and establish authentic interpersonal relation- ships (sometimes with the help of the pupil-teachers), the object is to correct any "dysfunctional social behaviour", which is considered a leading factor in this specific risk. "The Drop-in", a meeting-place situated on the school premises, affords an opportunity to give individual help and support, either casually or systematically. Finally, the teaching support groups, which are flexible, transitory and on a small scale, are arranged at the request of the pupils themselves. Component III: This takes the form of a general programme of health education, lasting one whole school year, in which all pupils participate. The section devoted to alcohol and drugs lasts nine weeks. Component IV: Under the heading "community development", this com- prises two distinct elements. Community integration refers as much to the school institution itself as to the local community where the youngsters live. "Emulation of young people of the same age" is a programme in which young adults aged from 18 to 25, who are active in the community and who have passed muster in every sense (but particularly with scholas- tic success), are presented as ideals. In this rather cursory description of Project MAP, it will be seen that the strategies suggested by Mr Grant are all taken into account. So although it might not work in every setting, it seems at least a good working model. Now we have to wait for the results to be evaluated this will take several years. It is to be hoped that the local community as well as the school system will be sufficiently sti- mulated to keep this programme going after the project itself comes to an end. There is plenty to be said about research in this field. But since space is short, let me just underline that there seems to be a gap in the literature of social medicine on one subject, and that is the study of adolescents and adolescent groups with a normal social upbringing who, spontaneously and completely, simply quit drinking alcohol and smoking either tobacco or cannabis. Might there not be in this kind of "natural immunity" some phenomenon which deserves much closer study? If such studies already exist, they surely deserve to be better known. ■ 19 don't waste it by taking drugs MOW IA -.4111M Mr ar Life is for living. A poster from the li'estern Pacific Region drives home the message that drugs debase life. (Photo WHO) Drug Dependence and WHO by Awni Arif it he problem of drug dependence reminds me of an acute observation made by the Danish poet Piet Hein. He said that a problem that is worthy of attack always proves its worth by hitting back. Judged by this criterion, drug dependence is particularly worthy of attack. What are the main areas of wHo's activity in the field of drug dependence? They are, first of all, collaboration with Member States in country programmes which in- clude prevention, treatment and rehabilita- tion, epidemiological surveys, evaluation and training; then, the development of strategies and technology for reducing the effective demand for drugs; the dissemina- tion and exchange of information; the development of manpower; the fulfilment of obligations under the international drug control treaties; and, finally, collaboration in matters concerning the non-medical use of drugs with other organizations of the UN system and with governmental and non- governmental bodies. During the past few years, collaborative drug dependence programmes at country level have started in the following coun- tries: Afghanistan, Bolivia, Burma, Colom- bia, Ecuador, Egypt, Iran, Malaysia, Pakistan, Peru and Thailand. In planning and implementing these programmes, WHO staff collaborate with the national authori- ties and with the International Labour Organisation, the UN Division of Narcotic Drugs, the UN Fund for Drug Abuse Control and the UN Educational, Scientific and Cultural Organization UNESCO. The objectives of these programmes are to develop, at national and local levels, flexible and dynamic management systems that will contribute to prevention and reducing the non-medical use of drugs. Programmes may include training key personnel through fellowships, pilot and operational research, epidemiological sur- veys in rural and urban target communities, and the systematic evaluation of treatment programmes. As well as developing more realistic and effective treatment methods, these pro- grammes are expected to contribute to knowledge of the etiology and nature of drug dependence problems. The global nature of drug dependence problems, the negative impact of drug abuse on social, health and economic development (particularly in developing countries), and the rapid changes in the types of drugs used and the patterns of drug use all contribute to the need for great flexibility in planning and developing coun- try programmes. Three essential considera- tions in this connexion are the transfer of experience, integration with existing activi- ties, and the training of suitable personnel. In view of the considerable gap in resources, knowledge and experience in matters connected with drug dependence between developed and developing coun- tries, a well-organized international system for the transfer of experience and exchange of information can obviously be of benefit. One basic principle in developing a pro- gramme must therefore be to select from the experiences of other countries, and to adapt them to the needs, resources and social, health and cultural systems of the recipient country. The drug dependence programme must, wherever possible, be integrated with exist- ing health, welfare and economic develop- ment services. The magnitude and nature of the health and social damage from drug abuse has to be assessed in the context of each country's overall health, social and economic problems. As for suitable personnel, while there is a need for some specialists in clinical re- search, epidemiology and programme planning, it is unrealistic to employ a wide range of specialists for most programmes in developing countries. In many cases medic- al assistants, primary health care workers, community nurses, and other health auxi- liaries could be trained to carry out tasks in the field of drug dependence under the supervision of physicians and others with advanced training. People outside the health field, such as welfare workers, teachers, the police and recovered patients, can also make contributions to both prevention and treatment programmes. Drug dependence programmes have a number of points of contact with other wHo programmes for underserved populations. The following are three areas in which collaboration can be particularly effective. Primary health care. Many of the rural areas where opium is produced have little or no health service. Frequently opium is the only medicine available and is widely used for the relief of pain and disease symptoms. In such areas, eliminating opium produc- tion without providing treatment for common illnesses is unacceptable. The whole purpose of WHO's primary health care programme is precisely to develop basic health services in areas where none now exist. Primary health care is based on a combination of scientific health technology and acceptable traditional healing prac- tices, and it should be possible to introduce modern chemotherapy and other techni- ques to replace the current reliance on opium. Moreover, the primary health care worker could be trained in the field of prevention and to provide treatment and after-care for opium-dependent persons. Country health programming. One of WHO's priorities is to assist countries in developing primary health care as an essential in overall country health program- ming. If national health authorities decide that drug dependence is a serious social and health problem, then a part of the overall health programme should be a national drug dependence programme based on the best available data and on a realistic assessment of available resources. Health education. Behaviour and at- titudes conditioned by culture, by the social, economic and family environment, and by learning play a direct role in the development and spread of drug use and drug dependence. Education about the use and misuse of drugs forms part of WHO's health education programme, which is based on the principle that success in preventing and controlling any disease depends inter alia on an informed and motivated public. Health education can thus contribute an essential element in any comprehensive plan to decrease the current 20 Many of the rural areas where opium is produced lack health services; opium may be the only common medicine available. Primary health care should make modern chemo-therapy techniques available to replace the current reliance on opium. (Photo L. Sirman ©) non-medical use of psychoactive drugs and to prevent further increases. Global strategy In order to complement and provide technical support for the wHo collaborative programmes at country level, the Organiza- tion has embarked on a programme, in collaboration with other international ag- encies, based on a global strategy of drug abuse prevention and control. This pro- gramme comprises four interrelated activi- ties: development of technology, develop- ment of manpower and infrastructure, dissemination and exchange of informa- tion, and promotion of intercountry cooperation. The technology needed for an effective reduction in the demand for drugs has been developed in accordance with the WHO principle that in order to be appropriate —technology must be scientifically sound, within a country's means, acceptable to the community, and suitable for widespread application by non-specialised personnel. One example of the type of preventive programme that is envisaged is furnished by the joint wno/uN project in Pakistan. Following a survey of the extent of opium sedation of infants and the dangers of infant deaths from overdose, an education- al campaign will be launched and alter- natives provided to the use of opium for infants. In the field of manpower development, the training activities of the joint wHo/ United Nations country programmes have so far been restricted in general to visits by trainees from developing countries to set- tings where expertise and facilities are available. The settings have often failed to provide the kind of comprehensive ex- perience needed to train teachers who have to go back and train core personnel in their own countries. Furthermore, the ex- perience gained is not always transferable. Interregional training courses have therefore been developed in settings that can provide a training combining formal course material with field visits to a variety of clinical and research programmes. The first such interregional training course was held in Hong Kong late in 1979 and was attended by 26 participants from eight countries. The model developed by the joint WHO/ UN drug abuse programme in Thailand for training primary health care workers in opium-using villages is an example that might be followed in other settings. As regards the dissemination and ex- change of information, WHO publications which report collaborative studies, regional meetings, and reviews of technical subjects provide part of the basis for regional and interregional meetings of technical person- nel and for training courses. They are also distributed to ministries of health, to the drug abuse planning agencies of govern- ments and to interested institutes and organizations. The fourth activity is the promotion of intercountry cooperation. The resources and expertise available in any one country are rarely sufficient to meet all of its needs for planning, training and technical work. In addition, there are some countries that share common drug abuse problems and, because of geographical or cultural reas- ons, provide a natural grouping for cooperative action. Examples of such nat- ural groupings are the opium producing and consuming countries of the Middle East and Asia, the khat producing and using countries of the Arabian Peninsula and East Africa, and the coca producing and using countries in the Andean moun- tain range. OBJECTIVES AND PRIORITIES The objectives of WHO's drug depen- dence programme, which forms part of its overall mental health pro- gramme, are to: Cooperate with countries in im- proving the capability of health and social service delivery systems to de- velop effective, low-cost methods for the treatment and rehabilitation of drug dependents. Develop strategies for treatment and prevention through primary health care within the framework of country health programmes. Coordinate international research in drug dependence. Strengthen the planning of prevention and control programmes by the international collection and exchange of data in the epidemiology of drug dependence. Ensure that adequate and relevant training programmes are provided to meet manpower needs, especially in developing countries. Fulfil responsibilities under in- ternational conventions on drugs. Establish an effective coordinating mechanism by which knowledge and experience available in nongovern- mental organizations and centres may be transmitted and adapted to coun- tries and regions with scarce technical and human resources. The initial mechanism for encouraging cooperation within and between countries is the convening of meetings of key planners and technical personnel to review current approaches to demand reduction. Such meetings build on the experience gained during two vviio interregional workshops on prevention and treatment of drug depen- dence, the first of which was held in 21 Alexandria, Egypt, in October 1978 and the second in Bangkok, Thailand, in Novem- ber 1979. Valuable results have been obtained from a meeting on epidemiologic- al and intervention programmes in rural opium-using communities held in Chieng- mai, Thailand, and a regional meeting to review coca and cocaine abuse held in Peru. WHO's obligations under two interna- tional drug control treaties, the Single Convention on Narcotic Drugs of 1961 and the Convention on Psychotropic Sub- stances of 1971, are described in the next article. The testing and evaluation of drugs in general and of psychotropic substances in particular is complex technical work and requires considerable expertise. Neverthe- less, the 1971 Convention provides a mechanism for the international commun- ity to decide as early as possible whether a substance creates a drug abuse problem so that remedial steps can be taken. As synthetic pharmaceutical products are in- creasingly available in all parts of the world, this drug control mechanism offers equal benefit to the developing and developed countries. RECENT WHO PUBLICATIONS ON DRUG DEPENDENCE Published in 1980-1981. WHO Public Health Paper No. 73 — ""Drug Problems in the sociocultural context: a basis for policies and programme planning". WHO Offset Publication No. 50 — "A methodology for student drug-use surveys". WHO Offset Publication No. 52 — ""Review of general population sur- veys of drug abuse". WHO Offset Publication No. 55 — ""Drug-abuse reporting systems". WHO Offset Publication No. 56 — ""Core data for epidemiological stu- dies of non-medical drug use". Report of Scientific Working Group under the International Programme on the Diagnosis and Classification of Mental Disorders, entitled "Nomen- clature and classification of drug and alcohol related problems: A WHO Memorandum" published in the Bull- etin of the World Health Organiza- tion,Vol. 59, No. 2,1981, pp. 225-242. To be published as WHO Offset Publications "A methodology for evaluation of drug dependence treatment" "Drug users among non-student youth". Five institutions have already been desig- nated as WHO Collaborating Centres for Research and Training in Drug Depen- dence. They are in Toronto (Canada), Mexico City, Rockville (Maryland, USA), Bangkok, and Penang (Malaysia). One of the closely coordinated activities of these centres is to assist WHO in reviewing and evaluating various policies and pro- grammes aimed at reducing the demand for and supply of drugs, including alcohol. ■ he earliest attempts to control the production and trade of dangerous drugs, for example, opium and cannabis and other natural plant products, were brought about because of the obvious damage to individuals and society caused by the use of these products. In 1909, for instance, the Shanghai Opium Commission was convened, in which 13 countries participated, to discuss the international ramifications of the Chinese opium problem. Since that time, interna- tional treaties have been negotiated and modified as situations changed, in an effort to control the flow of narcotic drugs. More recently, because of the explosion in the manufacture of synthetic products, a systematic scientific examination of nar- cotic and psychotropic substances has been undertaken in order to determine the benefit/risk ratio and the need for controls of specific substances. Two significant international agree- ments are the Single Convention on Narcotic Drugs of 1961 as amended by the Protocol 1972, and the Convention on Psychotropic Substances of 1971. The Single Convention is an effort to control natural drugs such as opium, cannabis and coca leaves which are often produced in developing countries, but it also includes controls on a number of synthetic drugs such as those of the morphine type. The 1971 Convention relates primarily to the control of psychotropic drugs which are manufactured by the pharmaceutical industries of the developed countries. Both treaties have four schedules categorising drugs into four groups. This classification is based on the balance between the potential harm that can be caused by a substance as against its therapeutic usefulness known as the benefit/risk ratio. Each succeeding Schedule in the 1971 Convention lists drugs with increasingly greater therapeutic value and decreasing dependence liability and abuse potential. In the case of the 1961 Single Convention on Narcotic Drugs, Schedule I contains 40 substances including peth- idine, morphine and other commonly used analgesic drugs. Schedule II lists 10 substances, including codeine and dextro- propoxyphene, which are thought to have a less severe dependence-producing effect as compared to those in Schedule I. Schedule III lists most of the drugs in Schedule II which, when compounded with one or more ingredients and containing not more than a specific quantity, are not likely to produce a risk to public health. These preparations are exempted from certain control measures. Schedule IV contains only six substances already listed in Schedule I, heroin being an example, which are considered most harmful and are most rigidly controlled to the extent that even their use in research and therapy requires a special mandate from national health authorities. The 1971 Convention on Psychotropic Substances today controls 46 substances under its four schedules. There are 19 substances listed under Schedule I: hallucinogenic substances of no proven therapeutic value, such as LSD (lysergic acid diethylamide) and three analogues of "angel dust" (PcP-phencyclidine). These drugs fall under the most rigid controls, and their use even in research must be under the strict surveillance of concerned governmental departments. The eight substances listed under Schedule II include amphetamine and methamphetamine; these substances are rigidly controlled and require prescription by a qualified physician. The five listed in International drug control treaties The role of WHO by Inayat Khan 22 Right: Efforts to control the trade in dangerous narcotic drugs mean that international travellers risk being subjected to random body searches. Below: Young heroin addicts in South- East Asia undergoing a voluntary cure by taking an emetic and drinking water until they vomit. Heroin is among the most harmful and most rigidly controlled of the drugs listed in international drug control treaties. (Photos L. Simian 0) Schedule III are mostly barbiturates; secobarbital is an example. There are 14 substances listed under Schedule IV, varying from anxiolytics like meprobamate to anoretics like amfepra- mone. Because of their relatively higher degree of therapeutic usefulness and low degree of abuse potential, these drugs are less rigidly controlled. For example, phenobarbital, which is a very useful drug in the treatment of epilepsy, is often prescribed and administered by nurses, with the specific authorisation of the government concerned. WHO's Role WHO has been given responsibility for evaluating available data and making recommendations for the control of narcotic and psychotropic substances. The 1971 Convention requires that WHO "communicate to the UN Commission on Narcotic Drugs an assessment of the substance, including the extent or likeli- hood of abuse, the degree of seriousness of the public health and social problem and the degree of usefulness of the substance in medical therapy, together with recom- mendations on control measures, if any, that would be appropriate in the light of its assessment". During the last three years, WHO has made recommendations to the UN for controls to be applied to 22 substances under the 1971 Convention, as well as five substances under the 1961 Convention. The final decision on these recommenda- tions is taken by the 30-member UN Commission on Narcotic Drugs, a func- tional body of ECOSOC—the UN Economic and Social Council. The recommendations of wHo to this body are determinative as far as medical and scientific evidence is concerned. The International Narcotics Control Board, located in Vienna, has been given responsibility for monitoring the produc- tion, distribution and use of the substances controlled under the two Conventions. Each year the INCB publishes this information in a report which is available to all interested persons. Data for this report is collected from the countries who have ratified the treaties and also, on a voluntary basis, from non-signatory nations. The UN Division of Narcotic Drugs, also located in Vienna, has important functions assigned to it under the treaties. It acts as a secretariat to the UN Commission on Narcotic Drugs. The UN Fund for Drug Abuse Control was created about ten years ago to facilitate the functioning of the various drug abuse control organs through financing certain projects. Drugs controlled under the Single Convention require INCB to grant a quota for use of an individual drug; however, this is not the case for drugs controlled under the Psychotropic Convention. In most instances, unless specifically exempted by a national health authority, these controll- ed drugs must be prescribed by a qualified physician, and dispensing pharmacies are required to keep a detailed record of their sales. In the large majority of countries, the sale and use of pharmaceutical products are entirely controlled at the national level. Of course, this depends on the availability of raw material. The international phar- maceutical industry has developed systems of recording production, sale, price and other details. This information is kept for restricted sale to interested persons on a commercial basis. The manufacturers keep strict records of the movement of their products on the national and international market. In addition, they attempt to keep up with sales and developments of the products of competitors. But they are not obliged to share this information with others. On the other hand, when a narcotic or psychotropic substance is brought under international control, the producer loses his monopoly on the production, promotion and sale of the product for as long as the drug remains under interna- tional control. ■ 23 Early Islamic physicians became ac- quainted with the therapeutic uses of cannabis through contacts with Greek culture and medical literature. ( Photo WHO) Facing page: A busy market scene in a city of the Eastern Mediterranean. Islamic law has clearly stipulated that whatever constitutes a dependence- producing drug should not be used by a true Muslim. ( Photo WHO/P. Almasy) Drugs in the Islamic World Broadly speaking, wherever and whenever at certain times in history social decadence prevailed and Islamic precepts were not closely observed, certain Muslim communities fell an easy prey to drug abuse with all its harmful consequences by Taha A. Baasher tehe drugs which have been commonly abused in countries of the Islamic World can be grouped into five major catego- ries, namely: alcoholic beverages, opium and its derivatives, cannabis, khat and certain manufactured psychoactive chemicals. However, with the exception of alcohol, there is no reference to any of these drugs in the early Islamic era. There is no direct mention of them, either in the Holy Scripture or in the Prophet Mohammed's all-embracing Hadith/Sunna (sayings and practices). At later periods in history, the lack of specific references to these drugs created, amongst the laity in some Islamic countries, something of a dilemma with regard to the use of dependence-producing drugs. To this day, one may come across a patient with bhango-dependence (cannabis) in the Sudan or opium-dependence in Egypt with the firm conviction that it is not wrong to indulge in the use of these drugs "because they have not been prohibited by God and anyway they are not mentioned in the Koran". Based on the experience with khamr, however, Islamic law has clearly stipulated that whatever constitutes a dependence-producing drug and should, therefore, be regarded as harmful, should not be used by a true Muslim. Islamic jurists and scholars This article makes use of material from a fuller paper on the same subject which will be published in the September 1981 issue of The British Journal of Addiction. The permission of the Editor of that journal is acknowledged. have primarily formulated the defini- tion of a narcotic substance on the original Islamic concept of khamr, which has been clearly described as "any substance which causes clouding of the mind and interferes with rational thinking". (It is interesting to note, in this connection, that the word khamr is derived from the word "khemar" meaning "veil"; hence it implies here anything which veils the mind.) While the strong movement against alcohol generally continued in the Islamic World, the history of the use of dependence-producing drugs in the various Islamic countries has been somewhat varied and complex. Availa- bility of the drug concerned, the socio- cultural environment, economic con- ditions, political powers and a host of other factors have in one way or another influenced the spread or the control of dependence-producing drugs. Several questions can be raised regarding the factors contributing to the spread of the non-medical use of drugs, and the potential measures for control. How has Islamic doctrine been involved in such circumstances, and how have Islamic institutions been used in the prevention and treatment of drug abuse? It is clear from available data that the nature and extent of drug-related problems vary from one Islamic country to another. This seems attributable to a number of factors. Studies conducted in Egypt in the early 1960s indicated, for example, that the main reasons for the use of cannabis in Egypt were: identification with the peer-group, recreational purposes, curiosity, assertion of manliness, amelioration of psychological tension, and elevation of mood. In other Islamic countries, studies of opium use in Iran and Pakistan have shown that the drug culture has been accepted with general social approval, 24 ALCOHOL In historical perspective, the brewing of alcohol from dates, grapes, honey and sorghum was generally popular among pre-Islamic communities living in the Arabian peninsula. However, at the very beginning of the Islamic era, the drinking of wine was clearly identified as a disruptive social evil and was effectively dealt with. After fourteen centuries, the successful Islamic model of alcohol abstention and prohibition still stands out as exceptional, indeed, almost unique, in human history. OPIUM Since pre-Islamic times, the two varieties of the opium poppy were known in ancient Mesopota- mia and Egypt and can be seen in early Egyptian writings and paintings. Whatever the origin of opium and its mode of spread into ancient Islamic countries, all available evidence indicates that it was initially used for the relief of pain and to induce sleep. The medical use of the opium poppy seems to have continued throughout Graeco- Roman times and was propagated to early Islamic physicians either through the original Greek writings or through Syriac versions. CANNABIS There is no evidence to indicate the use of cannabis in ancient Islamic countries. However, its therapeutic use as an anaesthetic was first reported in an early Chinese treatise on remedies; the information gradually trickled to India, the Tigris and Euphrates region, Iran and Arabia. It is instructive to note that cannabis was popularly known among Arab scholars as "Indian hemp". Again, early Islamic physicians became acquainted with the therapeutic uses of cannabis through contacts with Greek culture and medical literature. Over the years, the use of cannabis shifted from the sphere of therapeutic remedies to that of social recreation and pleasure-producing effects. KHAT Khat (catha adulis) is a tree that grows at high altitude in East Africa and both Yemens. The leaves and young shoots of this plant have been traditionally used in a variety of ways and for different reasons. Of particular interest is its stimulant effect, which seems to have led to its wide use in several countries. An 18th century traveller observed that he "never saw the Arabians use opium like the Turks and Persians. Instead, they chewed kaud (khat)." Realising the impor- tance of conducting research studies on the spot, staff members of the United Nations narcotic laboratories visited Yemen in 1974 and obtained fresh khat leaves, which were immediately treated with various solvents for systematic investigation and analysis. The discovery of new substances such as cathinone bears out previous doubts about whether the presence of an alkaloid called cathine in khat was sufficient on its own to explain its stimulant effects. SYNTHETIC DRUGS Since the turn of this century, the drug scene has witnessed the colossal increase of manufactured chemicals and the build-up of new narcotics. With increased productivity and closer relationships between industrialized and Islamic countries, more and more of the synthetic narcotics are becoming available for public use. 25 Alcohol and driving don't mix. Where Islamic precepts were not closely observed, some communities fell an easy prey to drug abuse. (Photo WHO/A. Khan) even when drugs are administered to infants. Here it seems that there is a complete ignorance of Islamic precepts regarding the "sinful" and harmful social consequences of narcotic sub- stances. This does not mean to say that some of the Islamic jurists or leaders were oblivious to this fact; on the contrary they were adequately know- ledgeable and keen to see the Muslim communities desisting from the use of psychoactive drugs, as has been observed by the author in Iran in 1975 and Pakistan in 1978. Broadly speak- ing, wherever and whenever at certain times in history social decadence prevailed and Islamic precepts were not closely observed, certain Muslim communities fell an easy prey to drug abuse with all its harmful consequences. The Islamic rule, as clearly revealed in the Koran, is to desist from khamr; present day experience generally shows that countries which strictly observe this commandment have been par- ticularly immune to the consumption of alcohol and related problems. This is especially significant, since alcohol is the only psychoactive substance with immense social and public health problems still not subject to any legal international restrictions or controll- ing measures. Along with the basic principles embodied in Islamic doctrine for social justice and the attainment of a high quality of life, the daily or seasonal religious practices seem to be most helpful for personality adjustment and mental well-being. The fasting month of Ramadan and the pilgrimage of Mecca, in particular, provide optimal opportunities for breaking away from habit-forming and dependence- producing drugs. The mosque as a social and religious institution, as experience has proved in Egypt, can play a most effective and useful role in the prevention and treatment of drug dependence. This is particularly so at a time when, nationally and internationally, there is the great movement to attain Health for all by the year 2000, and also when increasing emphasis is being given to community participation. In Islamic countries, the potentialities of religious communities and religious institutions have not yet been adequately utilised, but so far the results which have been obtained from the collaboration of religious leaders in drug prevention and treatment augur well for future planning and programming in this field. The importance of enhancing the role of religious institutions seems all the more logical when it is realised that methods of prevention such as legal prohibition of opium, cannabis, khat and synthetic psychoactive substances, which has been introduced in the majority of the Islamic countries at various times, have proved in many circumstances alien, ineffective and inappropriate. One of the glaring examples of this was the opium rationing and maintenance pro- gramme in Iran which itself became a source of illicit use. An interesting recent development in Pakistan is the introduction of what is called the Prohibition (Enforcement of Hadd) Order, 1979. This aims "to modify the existing law relating to prohibition of intoxicants so as to bring it into conformity with the injunctions of Islam as set out in the Holy Koran and Sunna." Prior to February 1979, the laws regulating narcotic drugs in Pakistan were principally: the Opium Act, 1878; the Dangerous Drugs Acts, 1930; and the West Pakistan Prohibition of Opium Smoking Act, 1958. With the rising Islamic movement in Pakistan, it was not surprising to see the enforcement of Hadd and growing official efforts to bring about major changes in order to control the unrestricted sale of opium and abolish the licensed vends (shops). In essence the law seeks, in the Islamic spirit, to prohibit possession, manufacture, transport, import, ex- port, sale and consumption of intoxicants. The degree of success of the Prohibition Order, 1979, depends on a number of factors, particularly the willingness, conviction and effec- tive support of the people. This by necessity takes time. Another promis- ing development is the country-wide drug treatment programme with strong official commitment and in- ternational support. It is still early to assess the evolving activities. Nonethe- less, it is obvious that serious attempts are being made towards a visible breakthrough in the deeply-rooted and challenging problems related to drugs. Since 1979, major developments in the drug scene have also taken place in the newly-established Islamic Republic of Iran. The Narcotic Control Ad- ministration of the Ministry of Health and Welfare has undertaken "a series of effective measures to eliminate drug addiction and traffic of narcotics." However, there is as yet no available information regarding the nature of The opium poppy is still legally grown in some parts of the Eastern Mediterranean. Legal prohibition of narcotic drugs has frequently proved ineffective and inappro- priate. ( Photo L. Sirman C)) these measures nor their impact on drug-dependent persons. Although both Iran and Pakistan are endeavouring, in principle, to comply with the Islamic doctrine, they will not find a better model than the one which was first implemented at the dawn of Islam at Medina, the holy Islamic city in Saudi Arabia and site of the Prophet Mohammed's tomb. It was there that due consideration was given to the prevailing ecological factors and a step-by-step system of gradual desensitisation, reciprocal inhibition, persuasion and effec- tive community involvement was first applied. ■ 26 Drug abuse in the Americas The sheer numbers of people involved particularly young people give cause for concern. There is no vaccine we can give our children to protect them, and there are no easy answers. Effective prevention requires action by the entire community, including the youngsters by Marilynn E. Katatsky nce thought to be confined to the more developed countries, drug abuse is now a recognised public health and social problem in many parts of the developing world. While there are few hard data available to measure the exact extent and magnitude of the problem, it is clear that many of the countries of the Americas, particularly those where marijuana and coca are indigenous, have experienced increasingly serious drug-related problems. Although public attention tends to focus on the abuse of illegal substances particularly marijuana and derivatives of coca research indicates that alcohol continues to have the most widespread negative social and public health conse- quences. In a 1975 survey of drinking practices in five major Latin American cities, the author found that rates of heavy drinking among adult males aged 15-64 ranged as high as 30-35 per cent in some cities. Fully half of those persons identified as heavy drinkers reported having ex- perienced some type of social, economic or health problem related to their drinking. While research focused on rural popula- tions in Latin America tends to be rather more anecdotal in nature, there are indications that alcohol, again, has a very serious negative impact on health and social development. The myth that alcohol problems are somehow only the domain of the very poorest and least educated of society is quite prevalent among development ex- perts and public health authorities alike. But the data collected on urban popula- tions in Latin America indicate otherwise. Among men, alcohol problems are about equally distributed among different social classes. Among women, however, alcohol problems tend to be positively related to social class. The more educated, middle and upper class women are more likely to drink and to drink more heavily than lower class women. Because alcohol is an accepted element of social life in the countries in the Region of the Americas, and because the impact of alcohol problems is not likely to be appreciated fully, other drugs, particularly marijuana, are perceived as much more pernicious. The paucity of reliable information on drug abuse patterns for the majority of countries makes it difficult to assess and monitor the situation. Isolated cross- sectional studies, performed largely on student populations, do not provide a full description of the drug problem. Taken together, the data are not comparable, and in some ways, present a very biased picture. There are several factors which would lead us to suspect that drug problems may be far more widespread and damaging than would, otherwise, be evident from the existing data. First, the effective control and regulation of psychoactive substances in some countries is almost non-existent and, where it does exist, numerous loop- holes can be found. Implementation of effective control is limited by a lack of trained manpower and other resources. For example, in Bolivia, the drug control system includes provisions for three or four persons to monitor phar- macies throughout the country. With literally hundreds of establishments to cover and limited travel resources, three or four persons are inadequate to monitor even the capital city. In Brazil, where psychoactive drugs are strictly controlled in their pure form, manufacturers have begun marketing these controlled sub- stances in combination with other substances. These combination drugs are not subject to such strict controls and many may be purchased over the counter. In Peru, a cough medicine containing codeine was widely and freely available over the counter. Despite the fact that the public health authorities detected high levels of abuse among youngsters, several months passed before appropriate action to control sales was taken. If we look at the various types of drug abusers in Latin America, we see roughly the same types identified as have been observed in more developed countries. Although the adolescent who is a multiple drug abuser is perhaps the most widely recognised in several countries, including 27 MOTOCICLETA S TERNOS PUNO 506 s. *51 —..INP*1"-"*• LA FENIX PERU. 'OMPANIA DE SEGO! Drug abuse in the Americas Left: Noisy traffic and strident street-signs bludgeon the ear and eye in a Latin American town. Urban stress is at least a contributing factor to the steady increase in alcoholism and drug dependence those easy escape-routes for the unwary and the uninformed. Right: Relaxing after a day of heavy labour in a South American banana plantation. Among young, male groups like these, the use of alcohol is an accepted element of social life. From this point on, it is only a short step to alcohol abuse, and experimentation with other drugs. ( Photos WHO/P. Almasy) Argentina, Brazil, Colombia, Ecuador, Mexico and Peru, recent studies carried out in Peru and Bolivia found the highest levels of non-medical use of tranquillizers amphetamines, and barbiturates among young to middle-age, middle class women. This pattern tends to mirror the observa- tions made in the more developed countries, where high rates of non-medical drug use among women aged 25-45 have been reported. An unpublished study of prescribing patterns in Bolivia, again, indicates that tranquillizers are prescribed more frequently and in greater quantities than might be medically indicated, especi- ally for women. Informal studies of overdoses in Peru and Mexico, again, confirm that young to middle-age women are most often involved. As in the more developed countries, advertising and marketing campaigns of the major drug companies have tended to reinforce the idea that women somehow "need" these drugs. One problem which is being studied by the Institute of Psychiatry in Mexico is the abuse of volatile substances by children and adolescents. Glue, gasoline, and paint thinner are widely available substances which youngsters inhale. As in the more developed countries, the most affected group are generally lower class boys aged 8-15, living in the poorest sections of large cities, particularly in makeshift squatter settlements. While there are no estimates of the numbers of children involved, reports from Peru, Panama, Bolivia, and Colombia all indicate that this phenomenon is highly prevalent among certain groups of poor children. In Mexico City, it has been found that 13 out of every 1,000 children aged 14-17 have used solvents, and 3 out of every 1,000 aged 14-24 used them on a regular daily basis. Inhalation of volatile substances is a problem of great concern to public health authorities, because of the adverse medical effects on such young children and adolescents. While the possibility of acute cardiac arrest, asphyxiation, accidents, and organ failure are reasons enough to cause alarm, recent findings also suggest that chronic users may suffer neuropsychological impairments. The real impact of solvent abuse is unknown. The social and public health costs have yet to be defined with any precision. Suffice it to say, however, that thousands of young people in the developing countries are affected. Since the psychological, neurological, and phys- ical effects may not be reversible, the use of these substances can have a significant impact not only on the individuals involved but also on the social and economic development of their com- munities for many years to come. The abuse of volatile substances has received little attention compared with other types of drug abuse. It affects the poor and the uneducated. Middle and upper class children usually are less affected, having access to other, more socially accepted drugs. The adverse effects, again, are not very evident, at least not in the short run. And finally, controlling the sale of an ever-increasing array of organic and other solvents is difficult. Some steps have been taken in the United States, for example, to alter the odour of some products, thereby reducing the desirability of inhaling them. Similar efforts, as well as some controls on sales, have been undertaken in other countries. However, more hope for prevention seems to lie in other areas, particularly commun- ity development and education. Second in use only to alcohol, marijuana is the most widely abused drug in Latin America. Although comparable statistics on patterns of use in the Region are not available, in one Bolivian city, the rate in school populations has been estimated at about 5 per cent. In Colombia rates range from 5-17 per cent. When compared with rates of 30-35 per cent of the student 28 populations in Canada and the USA for the use of marijuana, the figures seem rather low. Although several population studies have been done to estimate the extent of use, little is known about the extent or nature of the adverse public health effects of marijuana in Latin America. Aside from some isolated studies of heavy users, in which clinical effects are examined, there has been little or no attention given to monitoring or estimating the overall public health impact of this drug. A relatively new drug of abuse in Bolivia and Peru is coca paste, an intermediate product in the manufacture of cocaine from coca leaves. It is a semi-solid preparation containing cocaine sulphate, other coca alkaloids, and several chemicals including benzoic and sulphuric acid. The paste is usually mixed with tobacco or marijuana and then smoked. First noted in the mid-1970s in Peru, coca paste smoking seems to have spread quickly in popularity among young, predominantly middle class males. The drug is widely available in some parts of Bolivia and Peru, at relatively low prices (about US $1 per cigarette). Some authorities feel that the production and sale of coca paste by drug traffickers represent a spill-over from their more lucrative trade in cocaine. Having created a new market in these countries, traffickers have reduced their risk, and at the same time enjoy reduced costs and increased profits. In Peru, coca paste is the main drug of abuse reported by patients admitted to psychiatric hospitals. In Santa Cruz, Bolivia, officials have concluded that coca paste smoking has become the norm among 12 to 20-year-olds. The physical and psychological effects of this habit are now being researched. Preliminary evidence indicates it is a powerful drug which can cause physical and psychological dependence. Acute psychotic episodes, the most frequently reported adverse effect, are a common cause of admissions to hospital emergency rooms. The long-term effects on the individual are still largely unknown. In summary, most experts would agree that the drug abuse problem in Latin America warrants further study, careful monitoring, and immediate efforts in prevention. The sheer numbers of people involved, particularly young people, give cause for concern. These youngsters are the strength and the hope for the future of their countries. There is much work to be done in Latin America toward achieving economic growth and building a strong institutional base. If young people could be brought into this process of contribut- ing to their communities early, perhaps the trend to increasing drug abuse could be reversed. Prevention efforts so far have had only limited success partly because we have thought narrowly about the nature of social problems. The fact is that drug abuse is a complex social problem, requiring multi-sectorial solutions. There is no vaccine we can give our children to protect them. There are no easy answers and no miracles can be expected. Reducing the availability of psychoactive substances by tighter controls on legal and illegal supplies is one important, but difficult, preventive measure to implement. But we cannot hope to find a total solution, solely through control. Nor will a solution be found in isolating drug abusers from society locked away in rehabilitation centres so as not to "contaminate" others. Effective prevention will require the input of the entire community, including young people themselves. In some coun- tries this approach is beginning to take shape and is showing considerable pro- mise. However, it will take time, and, more important still, it will take the commitment of people who recognise the significant contribution they can make by sharing in community participation. ■ 29 The elderly: Eventually including all of us. (Photo WHO/E. Mandelmann) "Add Life to Years," WHO Theme for '82, Urges Attitude Changes towards Aging 0410 WOO 000 000 000 OOOOO• 000 *90 1190941.0 090 00* 000 009 090 00000• ... 000::: Moo. S..... 00• 0.• 000 000 000 008 000 0041 000 00* 00411 0,0 5" 00• 00* 000 000 000 OOOOOO 000 04141000 000 *00 000 0041 WOO ••• •••••• 00111 000 000 900 00• 000 0410 000 000 *Oil SOO By the end of the century, the number of persons over age 60 throughout the world is expected to rise to 580 million, up from 307 million during the seventies. Faced with a projected in- crease of such dimensions, Dr. Halfdan Mahler, WHO Director- General, is urging "an overall change in attitude towards aging." Through a theme each year— and as part of World Health Day, 7 April —WHO selects a topic important to public health on which to focus public attention. The theme for 1982 will be "Add Life to Years" to raise consciousness to the needs of the aging. It is linked to the U.N.'s World Assembly on Aging set from 26 July to 6 August in Vienna. "The increasing number of aging persons is an entirely new phenomenon for humanity, and a topic of growing concern for all countries," Dr. Mahler says in advising health administrations of the theme. There is the need to turn away from stereotypes that depict those growing old as persons with "physical and psychological impairments and a loss of ability to function," and to end the "segregation" of the elderly, and their treatment as "second-class citizens." Those in the early sixties — referred to as the "young old" — "who are relatively healthy and disengaged from the formal work force, represent human resources on a huge scale: no society can afford to leave this resource untapped..." In the developing world, where "countries have already begun to shake off the legacy of short life expectancy," the proportional growth of those over 60 is expected to be the greatest. The message to them is to preserve their tradition — to "keep the elderly within the family unit, according them respect and esteem..." In all countries, there is the need to provide aging popula- tions with "social security, minimal incomes, housing, meals, homemaker services, and transportation within the com- munity." WHO's goal for the year 2000 is "Health for All." According to the Director-General, "The health of the elderly must not be neglected, but integrated into... primary health care..." After all, he notes, the elderly is "a group which eventually includes all of us." Seldom has an issue before the World Health Assembly attracted such worldwide attention as the international code on marketing of breastmilk substitutes. When it was adopted—over- whelmingly—last May, some 10 years of discussion and debate and four drafts, each the product of consultation among all in- terested parties, including indu- stry, had gone into its making. Earlier, it was the subject of much controversy on the one hand between consumer groups, health workers and many scient- ists, and on the other, infant formula manufacturers. A par- ticular point of contention was Article 5 on advertising and promotion. (For excerpts of key provisions, see box, p. 31.) Naturally enough, there were comments from editorialists. A sampling of those received as the News Page went to print shows more came down on the side of reasonable regulations in the marketplace and the need to place the health of infants ahead of business-as-usual. Excerpts: – Asiaweek: "Plainly there is nothing wrong with established breastmilk substitutes... B ut there is a lot wrong with the manner in which the leading companies exploit social pressures, ig- norance or poverty in selling their products..." Egyptian Mail: ""We can neith- er expect the problem to be resolved for us abroad... Failure to institute legislation controlling the sale of milk preparations... would put the authorities embar- rassingly on the side of the industry against the needs of the public." Indian Express: "The endorse- ment of a code... is a significant step towards reducing the high rate of infant mortality and morbidity prevailing in Third World countries." Jeune Afrique: Said publicity for breastmilk substitutes is difficult to accept in Africa considering the formula's high cost and the "grave dangers" associated with use. London Times: ""It is important that this basic form of consumer protection should be provided to people of the developing world —that it should be maintained by keeping a constant watch on how it is observed." – New York Times: "...the proposed code is not irrespons- ibly drawn. It suggests that advertising for infant formulas not be directed to the public and that it be limited when directed at health professionals. The code would not in fact be much more restrictive than the voluntary Publicity: Not directed at mothers. (Photo WHO/A.S. Kochar) codes adopted by some formula manufacturers, and it would surely be modified to fit local circumstances and customs." Time Magazine: "...powdered formula is not strictly a Third World concern: increased use of baby formula among poor fami- lies accounts for infant illness in the U.S." Washington Post: "The code infringes on commercial free speech and restrains trade, it is asserted. It does — but such infringement in one degree or another, for the sake of the public interest, is an accepted practice all over the world..." The code's adoption closes out but a first chapter in fostering better infant and young child health. As delegates left Geneva and headed home, they face a host of tasks to give effect to the code's provisions, foremost am- ong which are two: the framing of legislation, regulations or other measures aimed at protect- ing and promoting breastfeeding, and the monitoring mainly through consumer and commun- ity groups—of compliance with the code. In two years' time there will be a status report made to the 36th World Health Assembly, and, if needed, a revision of the code's provisions in the light of ex- perience gained. Code's Adoption Closes Chapter in Bettering of Infant, Child Health 30 Briefs African Mental Health Growing African concerns over mental health problems, once wrongly thought of as afflicting the developed countries only, are reflected in four bilateral programmes recently announced. They are between Belgium and Rwanda; Denmark and Tanzania; Norway and Botswana; and Sweden and Zambia, the last two countries working together in a programme against alcoholism. Another indication is the establishment of a 7-member African Mental Health Action Group comprising the four African countries plus Kenya, Lesotho, and Swaziland. And as a sign of world-wide concern, the World Health Assembly, at its recently-concluded 34th meeting, selected "Alcohol Consumption and Alcohol-Related Problems" as the theme for its technical discussions next May. Budget The World Health Assembly has adopted $468,900,000 as WHO's budget for the biennium 1982-83. The sum represents a total increase of 9.7 per cent over the current two years, but only 2.2 per cent represents real growth, with 7.5 per cent provided to cover cost increases. "Personal Environment" Between 80 and 90 per cent of all forms of cancer are rooted in 'Personal environment" in an individual's preference for alcohol, cigarettes, diet, exposure to sun, and, in the case of women, even motherhood. In developed countries particularly, motherhood is often purposely put off in favour of careers until a woman is "up against the biological clock", that is, until she is almost too old to have a baby. "We know that having a baby before age 19 makes a woman the least susceptible to breast cancer", explains Dr. John Higginson, director of WHO's International Agency for Research on Cancer. Smoking Mothers Pregnant women who smoke are more likely to miscarry than those who don't. Their babies are more likely to be of low birth weight. And generally the infant mortality rate is higher in cases of mothers who smoke. Thus, says Dr. Roberto Masironi, of WHO's smoking and health programme: "The risk to children's health from smoking begins even before they are born." "Worm Bank" The parasite Onchocerca volvulus, taken from the skin of those afflicted with onchocerciasis, a tropical disease, is being frozen and air-shipped to "worm banks" at the London School of Hygiene and Tropical Medicine. Workers in Sudan are trained to collect and pack the parasite—with an inexpensive portable device of liquid nitrogen—for study in the United Kingdom. The project typifies the cooperation between research institutions in developed and developing countries. Their aim is the development of a vaccine against the disease that is commonly known as "river blindness". Onchocerciasis afflicts an estimated 15 to 20 million in parts of Africa and Latin America. Excerpts from Code Preamble: "...breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants..." "...when mothers do not breastfeed, or only do so partially, there is a legitimate market for infant formula..." "...products should not be marketed or distributed in ways that may interfere with the protection and promotion of breastfeeding..." Article 5: "There should be no advertising, or other form of promotion to the general public of products..." "Manufacturers and distributors should not provide... to pregnant women, mothers, or members of their families, samples..." Article 9: "Labels should be designed... so as not to discourage breastfeeding..." Report on Strategy To Go to UN Assembly The report on the "Global Strategy for Health for All by the Year 2000" will be presented to the UN General Assembly this November by Dr. Halfdan Mah- ler, WHO's Director-General. Adopted in May by the World Health Assembly, the report sets out measures needed nationally, regionally and internationally to provide health services for the world's population, particularly those in rural areas where the need along with the neglect — is greatest. Among its key parts: An assessment of world health and related socio-economic pro- blems and trends; A call for countries to set targets "for the completion of certain activities and the attain- ment of certain objectives"; A list of indicators to monitor and evaluate progress. Many in "influential circles" still regard the concepts behind "Health for All" with scepticism, the Director-General has said. But "these ideas will soon become increasingly adopted and applied. Indeed, future generations, on reading the Strategy as an historical docu- ment, will wonder what novelty it contained since its contents will have become accepted practice." A draft plan of action, the next step in giving effect to the strategy, has been drawn up by WHO's Executive Board. It will go for regional reviews at the end of this year, back to the board in January next year, and to the 35th World Health Assembly for adoption in May 1982. (For a copy of the report, write World Health Organization, Av- enue Appia, CH-1211 Geneve 27) In the next issue Cancer is one of the most feared diseases of the modern world, and one which takes its toll in developing as well as developed countries. The September-October issue of World Health looks at some of the different forms that cancer takes, and assesses the pro- gress that is being made in the global efforts to stage a counter-attack. Authors of the Month John MADELEY is a freelance journalist specialising in development and health. Ms Eva ZABOLAI-CSEKME, formerly Direc- tor of the Women's Office of the Lutheran World Federation, is now a consultant in development education with WHO in Geneva. Professor Muyunda MWANALUSHI, for- mer Dean of Humanities. University of Zambia, Lusaka, was the co-principal investigator, with Dr Alan Haworth, on Phase I of the WHO Community Response to Alcohol Problems Project in Zambia. Professor Olivier JEANNERET is Director of the Institute of Social and Preventive Medicine at the University of Geneva, Switzerland. Dr Awni ARIF is the Senior Medical Officer in charge of the drug dependence programme in WHO's Division of Mental Health. Dr Inayat KHAN is a Senior Medical Officer with the Division of Mental Health at wiso headquarters, Geneva. Dr Taha A. BAASHER is the Regional Adviser on Mental Health for wHo's Eastern Mediterranean Region. Dr Marilynn E. KATATsicv . is Regional Adviser on Alcohol and Drug Abuse at WHO's Regional Office for the Americas, in Washington D.C. Professor Robert WEALE, a contributor to our July issue, is Director of the Departement of Visual Science at the London Institute of Ophthalmology (and not, as erroneously stated in that issue, at the London School of Economics). WORLD HEALTH 1981 Subscription Rates US$ Sw. fr. One year 15.— 25.— Two years 27.— 45.— Three years 36 60.— ORDER FORM Please enter my subscription to World Health as follov■is: One year ❑ Two years ❑ Three years ❑ I enclose cheque / international postal order in the amount of. Name Street • City • Country • World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national currencies, please contact your usual bookseller. Kbat—the plant which these youths are chewing while smoking cigarettes 'n an Afri.-:ar capital city —is a stimulant that has long been known in the Islamic world (see page 24) (Photo L Sirman ©) 1:5 Pr in te d in S