Protecting the mind [full issue]

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Adeoye Lambo Deputy Director-General of the World Health Organization or the third time in the space of nine years, an entire issue of World Health is being devoted to mental health. From the vantage point of 1985, this fact is significant for two reasons. Firstly, it comes as a necessary and timely reminder of the importance which the World Health Organization attaches to the psycho- social and behavioural dimension of health. Not only is " mental and social well-being " an inseparable part of the cornerstone definition of health written into the original WHO Con- stitution ; the collective effort of our Member States to make the strategy for Health for All a blueprint for social and economic action has highlighted the very practical sense in which the protection and promotion of mental health is not just a by-product of general health develop- ment but also its strong and positive reinforcer. The battle for healthy minds and healthy behaviour has to be fought at the front line of our struggle for Health for All : in the commun- ity, in the family, in the school and in the factory—that is to say, at the level of primary health care. Victories won at that front line will strengthen our conviction that psychosocial distress, alcohol and drug abuse, and health- damaging behaviour don't need to be the price paid for socio-economic development. Success in this field will also help to relegate to the past the tainted image of mental health as an euphemism for lifelong impairment, social stigma and custodial dependency. This explains the emphasis on prevention in many of the articles included in the present issue. The second reason for returning now to the theme of mental health is that the countdown for Health for All by the year 2000 has started in earnest, and we can be more optimistic than ever that the coming decade will be one of truly revolutionary advances in our understanding of the mechanisms of the mind and human behaviour, and of our capacity to intervene effectively to prevent and treat illness. Exciting discoveries about the ways in which neurotransmitters and neuromodulators— the chemical messengers of the brain—regulate mental and bodily functions, and about the human brain's astounding capacity for informa- tion processing, together with other achieve- ments of the basic neurosciences, represent just one end of the spectrum. To these developments will be added new knowledge about the role played by social support networks, social learning and the trans- mission of cultural values in shaping and unfolding the creative potential and resilience of the personality throughout the life cycle. How to translate such new knowledge into practical guidelines for the designing of health services and the training of future health work- ers will be one of the challenges of the coming decade. Sharing in this knowledge should lead to a realisation of how much can be done at present and in the immediate future to improve the quality of life of populations. The only proviso is that there must be the political will to apply the products of knowledge to the benefit of every inhabitant of our global village Earth. ■ 2 WORLD HEALTH, Aug./Sept. 1985 The battle for healthy minds must be fought at the front line of our struggle for Health for All: in the community, the family, the school, the factory. Photos WHO/B. Zeppilli, WHO/P. Harrison, WHO/ Ministry of Public Health, China, and WHO/Interna- tional Labour Office Cover : Prevention of mental ill-health starts at home, in the family. Drawing by Malky McCormick IX ISSN 0043-8502 World Health is the official magazine of the World Health illustrated 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, German, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. Articles and photographs not copyrighted may be repro- duced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Mental health for all by T. Adeoye Lambo 2 The role of prevention in mental health by Norman Sartorius ....... 4 Preventing alcohol problems by RamOn Florenzano 6 Preventing drug problems by Taha Baasher 8 Life's crises by C. David Jenkins 10 Suicide by Rene F. W. Diekstra 13 Raising awareness about mental health 16-17 Mental disability by Jaswant Singh Neki 18 Insult to the brain by Ade Longe 20 Role of the social services by Nils Johan Lavik 22 Department: HFA 2000 Prevention through the health system by Atanas Maleev 24 NGOs: participants in prevention by Stanislas Flache 26 Department: Education and Mental Health The role of schools by Michael Rutter 28 News Page 30-31 WORLD HEALTH, Aug./Sept. 1985 3 Protecting the mind The role of prevention in mental health by Norman Sartorius N t is becoming increasingly clear that many mental and neurological disorders can be effectively pre- vented. There are exciting oppor- tunities to prevent psychosocial prob- lems such as self-injury caused by excessive risk taking behaviour, al- cohol and drug abuse and attempted suicide. In addition, the occurrence, course and outcome of many of the so- called physical diseases could be sig- nificantly influenced by changes in behaviour of people. This issue of World Health is sub- titled Protecting the Mind. In a series of articles, it highlights the possibilities for preventing mental and neurologi- cal disorders and for reducing the behavioural risks and psychosocial problems that lie behind physical dis- eases. This is an effort which must be an essential part of primary health care, and should be included in na- tional policies and strategies to achieve Health for All. By concentrating upon prevention a deliberate choice has been made not to discuss two other important aspects of mental health programmes. The first is the task of helping those al- ready affected by mental and neuro- logical disorders. This includes those whose health is impaired because of these disorders and those who are suffering because of their dependence on drugs, alcohol, tobacco or because of their health-damaging lifestyles. The second task is that of promoting mental health, making people more aware of the value and importance that attach to it. Both promotion of mental health and the efforts to help those with disorders and impairments are of es- sential importance. They should be pursued parallel to and in harmony with the efforts to prevent disorders. In this issue of World Health, the focus Dr Norman Sartorius is the Director of the Division of Mental Health at WHO headquarters in Geneva. Concurrently he is Pro- fessor of Transcultural Psychiatry at the School of Medicine of the University of Zagreb, Yugoslavia. is on prevention for two specific reasons : firstly, in order to underline that the prevention of mental and neurological disorders and psychoso- cial problems is possible and deserves special emphasis. In recognition of this fact the Executive Board of the World Health Organization decided that it will discuss (in its January 1986 ses- sion) ways in which measures which have been shown to be useful can be applied now. But no health action can be fully successful without a wide involvement of many social sectors— education, social and welfare, labour and others—and of the general public. The current publication of this magazine is one of the efforts being undertaken in this respect. The second reason is of a practical nature : an adequate description of the needs and possibilities for intervention which would lead to the promotion of mental health and to an improved management of mental and neurologi- cal disorders would take much space —more than an issue of World Health devoted to prevention can offer. In a population of 100,000 people in a developing country (and the fi- gures are similar to developed coun- tries), there are at least 6,000 to 8,000 people who have mental or neurologi- cal disorders or who depend on al- cohol or drugs. Many others suffer from somatic problems and diseases significantly affected by psychosocial factors or even determined by people's behaviour. The pursuit of Health for All cannot be imagined without giving appropriate and urgent attention to these issues and without applying the measures which can prevent the oc- currence of mental, neurological and psychosocial problems and of their multiple negative consequences for health and quality of life of the indi- viduals affected, their families and communities, the world over. ■ 4 WORLD HEALTH, Aug./Sept. 1985 Above and below : In different parts of the world today, young people grapple with different levels of technology. But in the complex industrialised world or in the slower-paced rural areas, there are exciting opportunities to prevent psycho-social problems and to influ- ence the course of many physical dis- eases through changes in behaviour. Left : Togetherness begins with the bond between mother and child. The family, the extended family, the village, the community—all these levels play their part in preventing mental disor- ders in the individual. Photos WHO/J. Bland and (below) WHO/E. Mandel- mann Although many people are sceptical about the chances of modifying such an entrenched habit, a number of countries have been taking serious steps to do something to curb alcohol problems. The action has switched from focusing upon chronic alcoholism of the skid-row kind, to early detec- tion of problem drinking, and from treatment and rehabilitation to secon- dary and primary prevention. The concept of " problem " or "immoder- ate " drinking has replaced in many programmes the old concept of " al- coholism" that followed a classical medical model. One advantage of the new approach is that it does not lead to arguments with patients. Many per- sons who would adamantly refuse to accept being diagnosed as alcoholics, will much more readily concede that they have problems with the way they drink. Dr Ram6n Florenzano is Profes- sor of Psychiatry and Director, Office of Medical Studies, Division of Medical Sciences, Faculty of Medicine, University of Chile. Prevention in its comprehensive sense does also encompass rehabilita- tive activities. Tertiary prevention of alcoholism is effectively performed by self-help groups such as Alcoholics Anonymous in some countries or by other community-based organizations. In Chile, the Recovered Alcoholics Clubs have pioneered the self-care movement which appeared as a grass- roots self-help movement in the 1950s and early 1960s and is now regarded as quite trendy. This kind of communi- ty rehabilitation programme is now being applied to other chronic health conditions such as diabetes and hyper- tension with the result that there is much greater compliance with pre- scribed therapeutic regimes. Secondary prevention in this area means detecting the heavy drinker early in his or her drinking career. Primary care providers and the health personnel of general hospitals are in a good position to undertake this early detection. Our studies in general med- Prevention means detecting the heavy drinker early in his or her drinking career. Photo WHO Preventing Alcohol Problems by Raman Florenzano Alcohol problems are so common in many countries that they seem to form part of the national landscape. In Chile, the use of "chica " was brought into the country by the Incas and that of wine by the Spanish conquistadores. After independence, vineyards were formed with breeds of grapes brought from France, and a large and prosperous wine industry thrived. Today Chileans boast of their wines, but have to pay a heavy toll for the consequences ; they have one of the largest per capita alcohol consumptions in the world. Medical, family and social consequences of excessive drinking are of such magnitude that a recent study by the Chilean National Statistical Insti- tute showed that the economic cost of alcohol use (including lost productivity and treatment expenses) was actually larger than the nation's yearly revenues from copper exports. Chile's situation is similar in many other countries of the world, even in those that produce liquor or beer instead of wine WORLD HEALTH, Aug./Sept. 1985 ical wards in Santiago de Chile have shown that between one-third and one-half of the men in hospital are problem drinkers. House officers, however, diagnose only one out of five of such cases. We have been attempt- ing to improve this situation through an active training programme for med- ical interns and residents, aimed at increasing their awareness of early signs of alcohol over-consumption. A recent WHO survey of 275 primary physicians throughout the world con- firmed both their involvement in handling alcohol-related problems and their need for further training. Primary prevention seems to be the most promising approach to decreas- ing alcohol problems substantially. Such programmes have been criticised as naive or over-ambitious, but they seem to be well accepted by those communities where they have been implemented. The rationale for their focus on youth is that this is the age where normal or social drinking can trans- mute itself into troublesome or heavy drinking. The programmes are in- creasingly popular and their focus ranges from a narrow one on alcohol education, through intermediate pro- grammes which foster adolescent mental health, to much wider ones that focus upon adolescent health promotion. Adolescence and youth seem to be logical stages in the life cycle to centre on, given that many youngsters do experiment with alcohol as an attempt to work through the normal dilemmas of that period (such as reasserting their personal identity in defiance of parents, or as a password to relate better with their peers, or as a way to unfreeze in front of the op- posite sex). But this seemingly fitting manoeuvre turns out to be inappropri- ate in the many cases where young- sters start to drink to excess. They end up being cared for by their parents and being isolated from their peers of both sexes. Several such preventive pro- grammes have been developed in Chile, most of them focusing upon the school system. The Ministries of Edu- cation and Health share a country- wide programme aimed at primary school children. In Metropolitan San- tiago, we have developed Personal Growth Workshops which involve teachers, parents and students ; after The concept of "problem" drinking has replaced the old notion of "alcoholism" that followed the classical medical model. Photo WHO/P. Almasy an initial training, these become lead- ers of peer groups and thus widen the scope of the programme. The young people and adults involved have been exceedingly enthusiastic about the re- sults of the workshops, which have been replicated in other municipalities of greater Santiago. The middle- and long-term impact of such efforts has to be systematically evaluated later, however, to ascertain their real effectiveness. In town, the efficacy of educational preventive efforts needs to be com- pared with that of controlling alcohol availability through government inter- vention. This assessment of coercive methods versus educational strategies has to be done scientifically. But those of us who are involved in educational approaches are convinced that they are a very good way to boost commun- ity awareness of alcohol-related issues, and to commit groups of parents and other community leaders to a more active response to such problems. We have seen many citizens who were previously reluctant to become involved becoming really keen after participating in a school training workshop. A \Arm) collaborative pro- ject on community response to alcohol problems has developed technol- ogies for systematically promoting such responses. Even if the final outcome of primary preventive efforts to decrease immod- erate drinking cannot yet be assessed, we can attest to the usefulness of the process of developing such pro- grammes. This usefulness is reflected in the training of primary health care providers, educators and other com- munity leaders, and in the overall change of community attitudes toward heavy drinking in the programme areas. We think that this change alone proves that the effort is worthwhile until more systematic research can document the lasting impact in terms of decreasing alcohol consumption among young people. ■ WORLD HEALTH, Aug./Sept. 1985 7 Preventing drug problems Dr Taha Baasher was formerly Regional Adviser in Mental Health at WHO's Regional Office for the Eastern Mediterranean in Alexan- dria, where he is now working as a consultant in mental health. There is a general rise in the fre- quency and severity of drug abuse in most countries as well as changes in ways of use. Current trends show that more people are using multiple drugs or combining drugs and alcohol. Al- though different drugs are predomi- nant in particular cultures there is a general trend towards a wider diffu- sion of patterns of drug and alcohol use across national boundaries. Cocaine misuse needs special atten- tion. It is the most dependence-pro- ducing drug available and currently its misuse is reaching an epidemic level in some regions of the world, and is rapidly spreading in other parts. Tra- ditional coca-chewing among rural In- dians in the Andes has given way to coca paste-smoking in cities of the American continent. Opium-eating among rural South-Asian populations and in certain Middle East countries has developed into the much more dangerous use of heroin in the form of smoking or by injection. The leaves of the khat plant, which grows in the highlands of Ethiopia, Kenya and Yemen, were originally used as a stimulating beverage. How- Above left: The mosque can play an effective preventive role against both alcohol abuse and drug abuse. Photo L. Sirman In our time, drug problems have become more varied, becoming both more intricately complex and more global in character. Natural drugs such as cannabis, cocaine, khat (qat) and opium, which had previously been used only within certain cultural set- tings and confined to traditional ways of life, have been increasingly ex- ploited and now reach epidemic levels. Furthermore, manufactured drugs such as amphetamine, barbiturates, and a wide range of sedatives and tranquillisers have become more read- ily available on both the licit and illicit markets. Added to these are the growing habits among children and adolescents of sniffing volatile solvents and inhaling paints and glues. by Taha Baasher Throughout the history of mankind, there is hardly any country or culture which has not encountered problems with the use and abuse of drugs. Since the earliest recorded times, drugs have been employed for different reasons—mainly religious, recreational and medicinal. For example, alcohol and opium were both well known in ancient Egyptian culture, and cannabis was commonly used in Hindu ceremonial rites as well as in Indian and Chinese medicine. Drug-related problems, therefore, are not new. Often they affect a nation as a whole. Good models of preventing drug problems can also be traced in history. Fourteen centuries ago, alcoholism was one of the challenging problems among the pagan Arabian tribes and was successfully cealt with by systematic Islamic teaching, persuasion, religious conviction, collective action and good leadership 8 WORLD HEALTH, Aug./Sept. 1985 ever, khat is now almost universally used in some societies and brings with it a host of socio-economic, political and health problems. For instance, in Djibouti (population of 350,000) nine tons of khat are imported daily by air from a neighbouring country and are efficiently and widely distributed to 90 per cent of the adult male and 10 per cent of the adult female populations who indulge in its use, spending on it between 25 and 75 per cent of the family income. The drug scene is infested with a wide range of socio-economic prob- lems including criminality and viol- ence, as well as posing serious health hazards. Concern is growing in an ever increasing number of countries. Es- sentially, in order to develop effective preventive measures, it is important to identify the underlying motivation for using a drug. Next, practical efforts should be made to overcome this motivation. The reasons for using drugs are generally multiple and di- verse. Even within the same country, preventive programmes may have to vary in accordance with the nature of local problems and perceived needs. So the policies, goals, priorities and lines of action for prevention have to be in harmony with local conditions and relevant to the social setting. In north-east Afghanistan and in some areas of Pakistan, India, Burma and Thailand where rural health ser- vices are deficient, opium is used as a household remedy and for overcoming pains and discomforts caused by cold weather and the hardships of life. Due emphasis has, therefore, to be given to these priority needs in policy planning and in developing relevant interven tion programmes. What should be prevented and who should do the preventing ? In practice efforts are generally directed toward either controlling the supply of drugs or curbing the demand. At the global level, there are the international drug control treaties to control drugs like cannabis, cocaine, opium, amphe- tamines, barbiturates and mescalin. The parties to these treaties are re- quired to control illicit traffic in these substances and also to monitor their licit use for medical purposes. At national level, besides the en- forcement actions which may be undertaken by the police and customs, there are such familiar measures for controlling the supply as raising the price of tobacco and alcohol, or re- Drug abuse is increasing in frequency and severity in most countries, and there is a wider diffusion of patterns of drug and alcohol use across national boundaries. Photo L. Sirman @ stricting the availability of prescribed drugs. Public information, health edu- cation and the education of doctors in appropriate prescribing habits repre- sent some of the newer approaches aimed at reducing drug demand. Therapy for drug dependents is now being conceived as a means of preven- tion—since treatment not only stops any further deterioration of the drug user but may also reduce the number of persons who would be intro- duced to drug abuse by those already practising it. On the whole, the best preventive measures are those which are de- veloped by the people within the con- text of their culture and their social life. A religious group may be cultural- ly protected against the abuse of al- cohol and tobacco. Experience shows that the mosque and the religious communities in a number of Islamic countries can play an effective preven- tive role not only against alcohol abuse but also against that of drugs. Again, the parent movement in the United States is another example of organized members of the community being able to influence the formulation of nation- al policy, help in public information and encourage family participation in country-wide preventive activities against the use of drugs. Many countries have been striving long and hard to combat drug prob- lems. Concerted efforts have now to be made with a view to avoiding the mistakes of the past and learning from successful experiences. Blunders often arise from the fact that preventive measures may be unduly focused on the control of drugs or on the person using the drugs to the neglect of the political undercurrents, the economic determinants, the social context and the general prevailing circumstances. Thus certain countries in South-East Asia promulgated laws of prohibition and enforced measures to control the use of opium, without first preparing the community systematically for such action and without giving due con- sideration to existing socio-economic conditions. This action contributed to the fact that heroin soon replaced opium and the problems became much more serious. By contrast, the successful combat- ing of opium use in post-revolutionary China can be attributed to a number of factors, including changes in concept, attitudes, values and motivation, as well as the development of new social structures and the influence of an active political organization. Countries can also learn from suc- cessful national anti-smoking cam- paigns which have had an effective impact in the sense of changing, or at least influencing, personal and cultural attitudes. In conclusion, it must be reiterated that drug problems are among the most damaging menaces of modern life. Their effective prevention calls for the development of all-out efforts, involving clear long-term policies in close harmony with all the social sec- tors concerned and with active com- munity participation. Collaboration at bilateral, regional and international level has to be further expanded, par- ticularly with regard to drugs that have still not been brought under control. ■ WORLD HEALTH, Aug./Sept. 1985 9 Life's crises by C. David Jenkins "Whoever wishes to investigate medicine properly should proceed thus : In the first place to consider the seasons of the year... , the waters ..., the ground ..., and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess and given to indolence, or are fond of exercise and labour." These were the teachings in an- cient Greece of Hippocrates, the Father of Medicine. Now, 2400 years later, we can see even more clearly the many ways in which health is shaped by the way people live, how they think and feel, the crises they encounter and how they respond to them. In industrial- ised nations, about 50 per cent of the mortality from the leading causes of death can be traced to lifestyle, beha- vioural factors and stress. In developing nations, a different set of social and behavioural factors make major contributions to who gets sick and who stays healthy In thinking about how to promote health and prevent illness for our families, friends and ourselves, we must consider two major components, each of which has several aspects. First, our environment. Not only are its physical and biological aspects cru- cial to our health, but so are the social environment (the people around us) and the cultural-ideological environ- ment (the way our community is or- ganized, the kinds of occupations, availability of medicines and health workers, technology, and the world of knowledge, customs, ways of dealing with people, ways of eating, drinking, exercising and responding to symp- toms). The second major component to " manage " in promoting health in- cludes our "personal selves". We are not just biological bodies, but also have psychological resources and pro- cesses and behavioural patterns which we have learned. Now the remarkable thing is that the several aspects of our environ- ments and the blend of personal characteristics all interact in a remark- able symphony we call our daily life. There are things in each of these aspects that can go wrong and thus raise the risk of ill-health. Even more importantly, there are a host of posi- tive ways we can protect or strengthen each of the many parts of ourself and our environment. These positive ways increase our capacity to adapt to our world and its stresses, thereby promot- ing our health. So it follows that things we do to improve our physical health—like proper eating, avoiding tobacco and alcohol, getting enough rest and exer- cise—also help us to cope mentally and emotionally. Similarly, a positive problem-solving approach and effec- tive ways of dealing with emotional crises improve our ability to maintain physical and mental health. Recent research has identified the mechanisms by which stress changes cardiovascular function, anxiety in- creases the endorphines, and depres- sion suppresses the immune system. More than a random number of illnesses occur within six months of a major life crisis, such as the loss of a loved one. Photo L. Sirman @ WORLD HEALTH, Aug./Sept. 1985 Stress—like beauty—is in the eye of the behol- der. What matters is the way people perceive and react to even disastrous experiences around them. Original drawing by Peter Davies. Left: Particularly in Asia, people who regu- larly practise meditation or relaxation techni- ques achieve increased feelings of calmness and well-being. Photo WHO/C. Stauffer All this is in addition to the classic psychosomatic knowledge about such "stress disorders" as peptic ulcer, high blood pressure, migraine headaches and asthma. If you think back to recent illnesses your family and friends have had, you will probably recall that more than a random number of these occurred within about six months or so of a major life crisis, like the loss of a loved one, loss of a job, moving to a differ- ent community, or a serious problem in the family. Sometimes it is not a single major event that we recall, but rather an extended period of worry or loss of sleep about difficulties that frustrate or discourage us. Although many studies have shown that these stresses raise the chances of illness or accident, the majority of people going through even disastrous experiences remain well. What actual- ly happens in the way of crisis is less predictive of future health changes than the way people perceive and react to the conditions around them. To some degree, stress—like beauty— "is in the eye of the beholder. " Psychotherapy, counselling, and even the support and encouragement of Dr C. David Jenkins is Director of the WHO Collaborating Centre in Psychosocial Factors and Health, at the Department of Preventive Medicine and Community Health, the University of Texas Medical Branch, Galveston, USA. friends can help us to re-perceive, re- label and re-experience past and pre- sent crises in a less troubling, more adaptive manner and thereby protect both our physical and psychological health against the danger of stress. There are several promising ap- proaches to help reduce the chances that stress will lead to either psychological or physical disorders— and to get well faster if we do become ill. First, we should try to reduce the frequency and intensity of " overload " or upsetting demands, whether these be physical, biological, psychological, interpersonal or sociocultural in na- ture. Often these situational improve- ments can be accomplished by the managers of factories or agricultural workplaces, by local governments, or by neighbourhood cooperatives, families, or individuals. Many kinds of stress factor cannot be removed or escaped from. We can still do something about them, for example : —Helping ourselves to adapt better to the situation ; thus, learning how to deal with the new setting is especially important to new immi- grants ;—Changing the way we look at and evaluate situations : to give a medical example, it has been shown that providing helpful information and WORLD HEALTH, Aug./Sept. 1985 1 1 Life's crises emotional support prior to complex surgery not only reduces the number of complications but also shortens the length of hospital stay ;—Practising dealing with stressful situations in a protected setting ; introducing small amounts of the stress factor, as is done while training people in dangerous occupations, " immunises " them to the full stress, because it gives them a chance to plan and practise coping responses and to learn how to deal with fears of the situation. The presence of friendly people to listen to problems, make suggestions, lend emotional support, and even give a little practical help has a large influ- People with "social support"—who partici- pate in religious or social groups within their community—stay healthier and live longer than those who are socially isolated. Photo WHO/C. Stauffer ence on helping people to remain strong enough to resist illnesses. Two large community studies have shown that people with such "social support" —either informally or through partici- pation in religious or social groups— stay healthier and live longer than people who are socially isolated. Aids to relaxation Another approach to stress reduc- tion has been known and practised, particularly in Asia, for centuries. People who regularly practise medita- tion or relaxation techniques produce measurable bodily changes, including slower heart rate, decline in blood pressure and slower metabolism, as well as increased feelings of calmness and well-being. Physical exercise, like a vigorous walk or sport activity, is also a healthy way to relieve tension. By way of summary then, all of our environment—particularly its human aspects—and all of our personal characteristics and processes—espe- cially behaviours and emotions—in- teract to maintain good health. We have suggested four approaches to help you in promoting your total heal- th : —Build up your general " phy- sical" health through proper nutrition, exercise and rest, and by avoiding sickness-producing habits ;—Avoid or change any damaging aspects of your life situation ;—Change the way you perceive and interpret your situation, and your approach to problem-solv- ing ;—Change your body's and mind's reactions to stressful situations ; sub- stitute relaxation responses for dis- tressed responses, and substitute plan- ning and activity for fear, anger, or hopelessness. May your health grow ! ■ 12 WORLD HEALTH, Aug./Sept. 1985 Suicide by Rene F. W. Diekstra Raoul had just turned 18 when one day his mother found him, almost unconscious, in his bedroom after he had swallowed a large number of sleeping tablets that belonged to his father. Raoul was admitted to the emergency ward of a hospital nearby, where his stomach was pumped and he was kept under surveillance for almost two days. On returning home, Raoul and his parents avoided any discussion of the matter. Apparently both parties felt embarrassed and ashamed. Just one week later, Raoul's body was found beside a tall apartment building ; he had jumped off it at five o'clock in the morning while his parents were still asleep. In a suicide note, Raoul said he had been feeling hopeless and depressed over not being able to live up to what he perceived as his parents' expectations of him. He understood the silent reproaches of his parents with regard to his previous suicide attempt. His letter ended : " I do not want to be a burden and a disappointment to you any longer, being unable to finish school and find a decent job. I'm sure you will see thatthis is the best for all of us." Raoul is just one of hundreds of thousands of people in both developed and developing countries who each year die through their own hand. All over the world, like all others forms of violent death, suicide is more common among boys and men than among girls and women. Generally the rate of suicide increases with age, which among other things has given rise to the prevailing stereotype that suicide is typically of the elderly, isolated and depressed individual. However, it is clearly inappropriate to regard people who take their own lives as a homogeneous population on the basis of that one act. In recent years in most countries for which data are available, suicide rates have risen substantially, especially among teenagers and young adults. A health worker in the Caribbean comforts a depressed patient. Photo WHO/M. Beaubrun Suicide now ranks as the third or even the second cause of death among 15- to 29-year-olds in many countries. Scientists have put forward a number of explanations for this development, such as increasing economic instability leading to impoverishment, unem- ployment and crime, disintegration of traditional family ties and increasing divorce rates, and the dissolution of religious affiliations and the social re- lationships that tend to go with them. Although there is substantial evidence that these factors separately and com- bined correlate with recent changes in suicide rates, the exact nature of the relationship is still unknown. Since suicidal behaviour is both a socially as well as individually deter- mined phenomenon, a substantial re- duction of the annual incidence of WORLD HEALTH, Aug./Sept. 1985 13 PTITT^I IITTYVVTVIrltr, 1211.t14.: ilIVILIkw 1E5 $1111111d11111111111111NIUM111 111111111111111111111116 ,* -. -1011011111 11111111111111NN - 1111111111111411 11111111111111111 t 1111111111111111 11111111111111111 11111111111 BM I 111 111 Suicide A considerable potential exists for prevention of suicidal behaviour. Many countries have counselling services, often run as charities, to whom would-be suicides can telephone for words of comfort and understanding. s I '3111111111111111111111 / 1 I 411FA LF-RTI ..1.14FITITA1111 1 Mill111111111111111111111111111 1 11111111M11111P1101111111111111111111 I V 1 LW' . w 1 ME I Ilia AIM 1111111 11 - 111 11111111 6.11.0 wit Ii 11111 .11 If Alist 1 /Woof ilkottirtiattadt 1111111111til 1111E111i 1 1112 Left: This Swiss poster gives a telephone number for the Helping Hand service-"someone to talk to. - And the Swiss post office cooperates by making it a free phonecall. Right: In the industrialised world, but also in Latin America, suicide rates have risen substantially, especially among teenagers and young adults. For this Hungarian youth, help came too late; at the left, a policeman looks up at the roof from which the boy jumped. Photos WHOiLa Main tendue and WHO/T. Urban LA MAIN TENDUE suicide and suicide attempts requires the involvement not only of health professionals and the lay public but also of politicians and other policy makers. As far as the health professional is concerned, prevention of suicidal be- haviour lies first and foremost in iden- tifying individuals at risk. This is far from a straightforward task, but many studies show that a considerable po- tential exists for prevention of suicidal behaviour. More than half of the sui- cides and suicide attempters have pre- viously been in contact with medical and other professional helpers. But although they have indicated emotion- al and/or social difficulties in these contacts, they are usually not iden- tified as suicidal risks and are there- fore not appropriately treated. The reasons for this failure are still unclear. Some persons may be unable or reluc- tant to identify and discuss their suici- dal feelings. Or the health professional or lay helper may be unaware of suicidal signs and symptoms or unwil- ling to explore them and take appro- priate action. Professor Rene F. W. Diekstra is Chairman of the Department of Clinical Psychology at the State University of Leiden, Netherlands. Many people still wrongly believe that only mentally ill persons can at- tempt or commit suicide. If a person hears voices directing him or her to commit suicide, the risk of suicide is obviously increased. However, a con- siderable percentage of suicidal per- sons cannot be diagnosed as mentally ill, although they are clearly emotion- ally disturbed. An adequate assess- ment of suicidal risk is only possible if the helper is able to communicate openly and frankly with the individual at risk about his or her thoughts and feelings. The existence of suicidal ideas or a specific suicide plan can only be revealed if the helper asks directly : " Are you so upset that you are think- ing of suicide ? " or " Are you think- ing about hurting yourself ? " or " Do you have a plan worked out for killing yourself ? " Since a majority of suicidal persons suffer from depression, assessment of suicidal risk among depressed indi- viduals is always important. Symptoms of persons suffering from a depressive disturbance may be sleeplessness, ear- ly wakening, slowed down functioning, weight loss, loss of appetite, inability to work normally, lack of interest in sex, crying, restlessness and feelings of hopelessness. Depressed adolescents are often overactive, may fail in WORLD HEALTH, Aug./Sept. 1985 14 school, or may withdraw from the normal social context. Once it has been established that a person is at risk, it is of vital import- ance that the helper takes immediate action. Several techniques are possi- ble : relieving isolation ; removing lethal means ; encouraging alternative ways of expressing anger or other negative feelings ; avoiding a final decision of suicide during the crisis ; re-establishing social ties ; relieving extreme anxiety and loss of sleep (for instance, through sleep medica- tion for just a few days). This kind of crisis intervention is usually only a first step, and should be followed up by a more long-term ap- proach directed towards several goals. First of all, one should try to correct the psychological and social disturb- ances in the person's life. Equally important is to improve the person's self-image and develop approaches to WORLD HEALTH, Aug./Sept. 1985 Reasons people give for taking an overdose of sleeping tablets : To make others feel sorry, to give them a sense of guilt, shock them or pay them back. To make it clear to others how desperate you are. To influence somebody else or make them change their mind. To escape from an unbearable state of mind. To seek help (including profes- sional help, for instance). To find out whether somebody else really loves you or not. To escape temporarily from an unbearable situation. To show how much you love somebody else. To make things easy for others. To die. problems other than self-destructive behaviour. The suicidal person should be helped to find satisfactory social re- sources and to discover a satisfying life- plan ; these obviously depend upon social as well as psychological factors. Clearly then, prevention of suicide depends in the long run on the aware- ness of an emphasis upon psychologi- cal factors of mental health and well- being in a community. Exactly that point was made by Erich Fromm in his book The Sane Society (1952) when he wrote that the level of the suicide rate in a community is unequivocally an indication of its general level of mental health. In the light of recent trends in suicide rates in many countries, our present world is still not a very sane place to live in. But the potential for improvement and thereby for the pre- vention of unnecessary deaths through suicide clearly exists. ■ 15 Raising a he promotion of mental health and the preven- tion of mental disorders both require that people should be aware of what mental health means. Many of the basic con- cepts involved are quite simple, but are not necessarily seen by people as relating directly to their own lives. In order to try to bridge this gap, WHO asked Scottish artist Malky McCormick to create a character who could feature in a series of strip cartoons which would illustrate mental health themes. The result is Lani, the little child who appears here and on the front cover of this edition of World Health. Often Lani finds himself the victim of a world he does not understand. But always the means are available to alert him to the dangers and to he p him face up to the difficulties. These are messages of hope, which show what can be achieved by combining a little technology and a little love. We hope to find out how people in many countries like Lani. This is the first time he has appeared in print. Please write in to World Health and tell Js what you think of him. Does Lani have the potential to help JS raise awareness about mental health ? ■ Top left: Grandmother and child in Central America : old age and youth often complement each other. Left: Life seems both puzzling and alarming for this child of migrants leaving Spain for the New World. Bottom left: Three boys strike playful poses in an Indian city. Having fun is all part of the process of growing up. Photos WHO/PAHO/J. Vizcarra, WHO/P. Almasy and WHO/C. Stauffer Nareness about mental health LANI and vision g °' A ktrOze, At. • L' AI • c' ~ ti • ,©.1 VI 414 1 ORIP" _ .. ilitrO . A r re 1 , .ipi t• • WORLD HEALTH, Aug.!Sept. 1985 17 Professor Jaswant Singh Neki, former Director of the Postgradu- ate Institute of Medical Education and Research in Chandigarh, India, is now a WHO consultant for the National Mental Health Pro- gramme in Tanzania. Mrs. B., the 25-year-old wife of a diplomat, had a severe phobia of pol- lution. She had to spend almost three hours every morning in the protracted ritual of her ablutions. Her family pleaded with her to interrupt this ritu- al but in vain. She realised her folly, put felt helpless before it and was herself very miserable. To worsen her predicament she gave birth to a baby whose toilet needs multiplied her ritu- al to several times a day. By now she was spending most of the day in her bathroom. The whole family was in misery. Fear of pollution (misophobia) is only one of many kinds of phobias. The incidence of phobic disorders suf- ficiently severe to cause definite dis- ability is between one and two per thousand in the developed world, where they account for between two and three per cent of psychiatric pa- tients. A high proportion of these are agoraphobics—those who have fear of open spaces. They cannot leave their homes unaccompanied and are there- fore severly incapacitated individuals. There are many other varieties of phobia. As an airliner took off from Athens airport not long ago, a middle- aged man sprang to his feet and shouted, "My heart ! my heart !" he clasped his chest with his hands and his brow was studded with sweat. Being the only doctor on board, I was called in to assist. I listened to his heart and took his blood pressure ; both looked normal. I asked him, "Do you fear closed spaces ?" "Yes", he replied "I didn't want to fly, but had to." A great many people are afraid of lizards, mice, spiders, cockroaches or Unfortunately disability resulting from men- tal disorder generates greater repulsion in the public than physical disability. Photo WHO/L. Solmssen WORLD HEALTH, Aug./Sept. 1985 Mental disability by Jaswant Singh Neki Disability is a complex concept. It ranges from physical, through psychological, to social disable- ment. Its manifestations differ widely in visibility and hence in the concern they evoke. Such physi- cal disabilities as blindness and deafness, being most visible, have easily attracted the active inter- est not only of health professionals and charitable organizations, but also of many governments. Disability resulting from mental disorder, on the other hand, has attracted insufficient attention from the public even while it generates greater anxiety, disgust and repulsion than physical disa- bility. Yet it can often be equally devastating, and afflicts not only the disabled but also many of those around them, especially members of their family 18 what have you. Yet their disability is often known to themselves alone or to those immediately around them. These are by no means the only disabled group of psychiatric patients. Dr K. L., a 45-year-old physicist, was stricken with depression. He stayed in bed, uncommunicative. He had even to be cajoled to eat, which he barely did, and in four weeks lost four kilo- grams of weight. Previously, he had loved his laboratory and his family —but now would not even look at them. His mind was full of gloomy thoughts and he spent much of the time planning how to end his own life. He had twice attempted suicide, but each time prompt medical help saved him. His illness had incapacited him more than any paralysis would. Again, depressive illness is quite a common condition. Its life-expectancy rates obtained from population studies vary from 9 to 18 per 1,000 for males and 22 to 28 per 1,000 for females. The most dreaded of all psychiatric illnesses is schizophrenia, which is as- sociated with a variety of handicaps and disabilities. First, there is the " premorbid handicap "—the hand- icap due to factors that precede the illness. These include poor social class, lack of education, poverty of skills, and social isolation. Next, there is the primary handicap due to the illness itself, with such " negative " symptoms as impoverishment of feeling, social withdrawal, poverty of speech, slow- ness of movement, lack of motivation and initiative. The schizophrenic is thus walking a tight-rope, in danger on the one hand of an under-stimulating environment aggravating his or her " negative " symptoms, and over- stimulation on the other hand aggra- vating the overt psychotic symptoms such as delusions or hallucinations. Certain secondary handicaps, not aris- ing from the illness directly, may result from prolonged institutionalisation. These include apathy, loss of interest, loss of initiative, lack of individuality, lack of assertiveness, and deteriora- tion of personal habits. These handicaps not only aggravate disability but also make rehabilitation an arduous task. Where psychiatric help is not readily available, families really do not know how to contend with schizophrenic kinsfolk. Loss of social Mental retardation may call for special schools and special guidance services. Photo WHO/T. Takahara skills render them particularly unfit to fulfil their expected roles — whether as wage-earner, housekeeper, spouse or parent. They present a wide spectrum of incapacitation and disability. Cultural variations especially seem to characterise the disability of this disorder. There is perceptibly less dis- ability from schizophrenia in the de- veloping than in the developed world. This difference is further widened by the higher and more complicated ex- pectations of patients in the developed world. The disability from which epileptics suffer may appear only intermittently but social handicap is present all the time. They may not drive, nor swim, and must not expose themselves to dangerous situations, for instance by working with heavy machinery. The prevalence of epilepsy is much higher among psychiatric patients (3 to 10 per cent) than that found in the gener- al population (0.6 per cent). Mental retardation is another condi- tion beset with severe disability. Though detected in childhood, this condition may continue well into adulthood due to improved chances of survival of the patients. There may be need for the provision of special schools, special residential placements and special guidance services. Then there is the disability pro- duced by treatment itself. Most drugs used in treating mental disorders have side-effects — luckily reversible in a majority of cases. But sometimes a severely disabling and irreversible dis- orde• may remain behind. Electrocon- vulsive therapy can produce memory disturbances, especially disabling in those who have to do intellectual work. Luckily, they tend to recede with time, but may take several months to disappear completely. Clearly psychiatric disability has a very wide spectrum. Though the phys- ically disabled have already become a powerful pressure group in contem- porary society, the same cannot be said of the psychiatrically disabled. They offer a major challenge to soci- ety in their search for equal rights. ■ WORLD HEALTH, Aug./Sept. 1985 19 Insult to the brain by Ade Longe A 46-year-old manager of a successful accounts firm in Nigeria was rushed from his office to hospital. He had slumped over his table with sudden paralysis of his right limbs and gone mute while discussing business matters with customers. At the hospital, doctors were alarmed at the height of his blood pressure, while his wife moaned about his reluctance to take his blood pressure pills despite repeated admonitions from his private physician. Twelve months later, still unable to communicate adequately in speech or writing, and severely handicapped by the weakness of his right limbs, he was forced to retire. "A brilliant and promising career so abruptly ended, what a shame r sympathised colleagues, friends and customers alike. It was as though he was dead because his brain had suffered such damage that he could not continue in gainful employment nor look after his affairs. Was his stroke an unfortunate occurrence or an avoidable insult to the brain ? Stroke, epilepsy, cerebral palsy and other mental or physical handicaps re- sulting from trauma to, or intoxications of, the brain are some of the manifesta- tions of acquired, and often preventable, brain damage. In developed countries, steps have been taken to combat known causes of brain damage. Specific mea- sures include enforcement of regulations to prevent traffic and industrial acci- dents, while improved health care has drastically reduced the incidence of in- juries to the child's brain during delivery and childhood infections. Brain injuries associated with sports, though relatively uncommon, have recently received the spotlight of public attention, and greater concern is being expressed about the safety of boxing and heading the ball in a soccer game. Dr Ade Longe is lecturer in Medicine-Neurology at the Univer- sity of Benin, Benin City, Nigeria. In developing countries, the situation is reversed. As industrialisation takes its first tentative steps, a disproportionate number of persons suffer brain injuries per kilometre of paved roads or vehicles per capita. As bacterial infections and parasitic infestations of the brain are beginning to decline among adults, ad- missions to hospitals for strokes now account for nearly half of all patients with nervous system disorders. The tragic story about the Nigerian manager is an all too common event. It was also predictable. A person whose blood pressure is elevated has a seven times higher risk of suffering a stroke compared to one with normal blood pressure. High blood pressure is the most serious risk factor for stroke. Heart disease is the second. A decline in the incidence of strokes, which began over the last two decades in the United States, coincided with a vig- orous campaign for effective treatment of high blood pressure in the medical community. Preventive treatment for several factors which place people at high risk of stroke is available for those who have access to health facilities. This knowledge should be more widely dis- seminated and utilised. It is the ignorant millions in the rural areas of developing countries, and elsewhere, who have Brain injuries received during boxing matches are causing greater public concern than ever before. Photo L. Sirman 20 WORLD HEALTH, Aug./Sept. 1985 WU never had their blood pressures taken and are unaware of the risks they run, who deserve sympathy. Urgent action is called for to strengthen medical services at primary care level. The story of epilepsy, a condition which may stem from severe brain dam- age or be the only manifestation of a scar so small as to be invisible to the naked eyed, is illustrated by Chuma, a young accounts clerk, in Nigeria. His first convulsion occurred at age 17 years, after his final examinations in the secondary school. The commotion in his school and the despondent reaction of his parents after his second fit put paid to his plans for a university education. His fits were controlled by medication. However, he took the absence of fits as proof that his illness was cured, much against the advice of his doctor. He began to use his drugs irregularly. Then he had a fit at work. Colleagues with whom he shared office space thereafter refused to work in the same room with him. The social stigma associated with epilepsy was so strong that they could not be persuaded to change their at- titude. Chuma managed to remain in his job only at the cost of being transferred to a distant city after strong representa- tions by his doctor. Since epileptic fits are easily control- led with drugs in many patients, Chuma was largely responsible for his immedi- ate crisis. He had better than average intelligence, secondary education, ac- cess to medical treatment, a good job and was planning to get married. He had perhaps more advantages than many patients with his condition could expect. If he persisted in neglecting advice on Head injury on a building site. Our precious but delicate brains deserve all the respect and protection they can get. Photo WHO/International Labour Office his treatment, not only would frequent fits cost him his present social advan- tages but he could also suffer further brain damage. Parasitic infestations, tuberculosis of the brain, childhood in- fections such as measles and whooping cough, birth trauma and brain injury from traffic accidents, all these contri- bute their quota to the three-to-tenfold higher prevalence of epilepsy in de- veloping countries compared with the developed ones. Many of these factors can be controlled. Industrialisation brings with it em- ployment opportunities but also serious social consequences, unless steps are taken to control the latter. Industrial chemicals and wastes, insecticides, leaded gasoline fumes and materials used in batteries and paint businesses all pose occupational hazards to factory workers and residents around industrial complexes. Where these materials are properly handled and precautionary me- asures against pollution stringently en- forced, there is little danger to health. Such safety precautions are not suffi- ciently enforced in many parts of the world, and people are exposed to grave risks of brain damage from environmen- tal toxins. The lessons of such toxic brain disorders which have occured in the past, sometimes with almost epidemic proportions, should remind in- dividuals and communities of the poten- tial dangers of neglecting measures to prevent brain injuries from environmen- tal pollution. Along the evolutionary process, the brain has attained its highest level of specialisation in humans. The large vol- ume of the human brain in relation to total body size and the highly complex structural and functional organization of its numerous cells endow us with im- mense powers of intellect and communi- cation, as well as giving us tremendous dexterity in our limb movements. The brain must remain intact for us to have optimum use of these powers. Unfortunately, the capacity of our brain to recover lost function or adapt its residual function to cope with lost capabilities is rather limited compared with less specialised organs of our body. As if to underscore this point, nature located the brain in a protective bony cage to ward off physical injury. If only man would learn to avoid directing ex- cessive physical forces to the skull— as usually happens in traffic accidents, falls from heights, missile head injuries and violent assaults—our precious but deli- cate brains would get the respect and protection they deserve. In general, the prevention of brain injury should be seen as a responsibility of the individual, the community, and the state. The individual's behaviour is crucial to guard against traffic accidents, reck- lessness at work and play, excessive use or abuse of alcohol, inadequate nutri- tion and neglect of medical conditions which are risk factors for brain damage. We need to foster community action directed at participation in the develop- ment of health services, ensuring safe play and work environments and prom- oting accident consciousness. This type of action will stimulate governments to emphasize those measures that prevent brain injuries. Improved maternal care and immunization against childhood in- fections will reduce the incidence of brain damage at birth and in childhood. Detection and treatment of medical conditions which threaten the integrity of the brain, and enforcement of traffic and anti-pollution legislation, have been shown to be effective in preventing brain damage. As our cities become larger and in- dustries grow, the problem of brain damage becomes increasingly promi- nent. The developed countries have al- ready learnt from painful experience, and are striving harder to prevent it. Urgent action is required now in the developing countries, where an ever- increasing number of people suffer from this condition. ■ WORLD HEALTH, Aug./Sept. 1985 21 Role of the social services by Nils Johan Lavik Both professional health workers and lay people are well aware of the strong relationship between mental health and social life. A depressed person may not be able to continue in his job, anxiety may produce difficulties in dealing with many of the everyday demands, a confused elderly man cannot live alone, and the psychotic breakdown of a mother will heavily disturb the whole family. Many societies have built up social services to reduce the consequences of mental dis- orders. Not only do mental disorders have social consequences, but social dis- turbance frequently has mental consequences. An unemployed person is at risk of depression and stress, a crisis may produce anxiety, isolation of the elderly may result in confusion and paranoid symptoms, and disturbed family relations may affect the mental functioning of its members. How can social services contribute to the reduction of social dysfunctioning and thereby promote mental health ? The development of the indus- trialised societies has broken down or reduced the influence of the tradition- al social network. Because of this, and for other historical reasons, a new system of assistance has emerged based on professional competence. The development and organization of the social services vary greatly from one country to another, depending on their economic growth, political sys- tem and cultural conditions. Not only material needs but also social issues and interpersonal relations are within their scope. In practice, their opera- 22 WORLD HEALTH, Aug./Sept. 1985 Role of the Social Services tions will comprise a whole range of strategies. The social services may develop programmes at the family level aimed at preventing the development of maladaptive behaviour patterns in small children. In one area of Oslo, parents were invited to attend group sessions to discuss sleeping and nutri- tional problems among their children. At first the parents were reluctant. One mother said: "If I attend such a group, I feel like a bad mother because I have problems with my child." When the text in the announcement was changed to " discussing sleeping and feeding habits", the number of partici- pants increased considerably. Once a trustful atmosphere had been established, the parents were able to talk freely and give each other support within a whole range of family matters. The sessions were led by a professional social worker. The con- clusion reached was that such a group contributes by giving the parents more confidence and competence in coping with everyday interactions in the family. At certain stages of the life cycle, and during upheavals and crises in the external life situation, human beings are exposed to more stress than at other times, so enabling us to define certain risk groups. Such risk groups include children of recently divorced parents, elderly people living alone, the unemployed, migrants and refu- gees. For all these groups, the social services have an important part to play by helping to supplement material needs and by pointing the way to new activities, or by training people to fulfil new social roles. Dr Nils Johan Lavik is with the Psychiatric Institute in Oslo, Norway. The number of elderly people is growing in many parts of the world. In many places, the social services have made a substantial contribution by setting up programmes to combat so- cial isolation and mental breakdown, which are obvious threats at this stage of life. Tor and Mary Hansen are an Regular visits by social service staff to pa- tients' homes help to stimulate to the full their mental, physical and social resources. Facing page: Social services contribute to promoting mental health among the elderly by helping to combat social isolation. Photos WHO/P. Almasy and L. Sirman elderly couple living in a small town in the south of Norway. He, aged 74, has a heart disease. His wife, 73, is seri- ously disabled by arthritis and cannot fulfil her tasks as a housewife. They live alone in a small house, and their grown-up children have moved to other parts of the country. They are bOth mentally unimpaired but suffer from time to time from depression and anxiety when thinking about their fu- ture. They both want to continue to stay in their home. The local social services offer pro- grammes which will enable them to remain in their home for several years. These consist of : A home service by a person who comes to the house three times a week, helping with domestic clean- ing, ironing and so forth ; The offer of cheap transport for shopping and visits to social and cultural events in the nearest town ; Cooperation with the health ser- vices to facilitate visits for medical check-ups and physical therapy pro- grammes. Such support given by the social services can be cheap and effective when it is flexibly adapted to the specific needs of individuals and their families. In the turbulent world of migrants and refugees, there is a vast amount of physical discomfort, hunger, disrup- tion, disturbance of social relation- ships and psychological losses and frustrations. In many of the host coun- tries, the social services have taken action in an effort to improve matters, and have thereby helped to prevent mental breakdowns among these populations groups. Such activities in- clude : A specific counselling service focus- ing on the painful experiences of migrants, their unsolved problems and the new challenges confronting them in the new country ; Arrangement of language courses to improve their ability to communi- cate with the local people ; Counselling and support as regards housing and employment. Eventually the refugees themselves and their organizations have taken over responsibility for such services. What has been described so far refers largely to the primary and sec- ondary preventive roles of the social services. Social services also function in cooperation with the health service at the level of tertiary prevention. In the context of mental health, this means reducing dysfunction, social withdrawal and deterioration, which tend to develop especially among pa- tients with chronic psychoses. There may be regular visits to the patient's home, the provision of sheltered work and accommodation, or the arranging of sports activities and entertainments. The aim is to stimulate and utilise to the maximum the full mental, physical and social resources of the patient. Given plenty of initiative and a flexible organization, the social ser- vices can contribute at many levels and through a whole range of strategies towards the overall objective of main- taining good mental health. ■ WORLD HEALTH, Aug./Sept. 1985 23 if Health for all by the year 2000 Prevention through the health system by Atanas Maleev At present, health systems rarely contribute their full potential to the prevention of mental ill-health. There are two main reasons for this. Firstly, the prevailing concept of health relates to physical wellbeing ; mental health rates too low in the scale of priorities to justify large investments in preventive action. Secondly, there is a relative scarcity of mental health technologies in the field of primary prevention which are cost-effective and acceptable, and can be readily introduced by the health systems. Prevention as a humane alternative to custodial care of the mentally ill was advocated long ago by leading representatives of European psychiatry, but it was first formulated as part of mental health care ideology by Soviet psychiatrists in the 1920s. This prevention-based approach was put into practice through a wide network of psychiatric dispensaries, the first of which came into being in Moscow in 1924. Bulgaria adopted the preventive approach in the field of mental health through a system of psychiatric dispensaries in 1952 Even today, secondary and tertiary prevention constitutes the principle activity of these dispensaries. The basic technologies in this respect are : early detection of relapses ; active reintegration into society after dis- charge; and work rehabilitation. Hos- pital treatment is reduced to a brief episode which prepares the patient for living within the family and the community. Strong public involvement is essen- tial : present-day psychiatry has found the right formula for channeling com- munity participation in the care of psychiatric patients through a con- stantly evolving series of out-patient psychiatric services and a variety of home and family services. Psychiatric care has convincingly demonstrated the potential of this approach for pre- venting any serious social conse- quences from major mental illness. Even this is only a fraction of what the preventive approach can contri- bute towards mental health. There is Professor Atanas Maleev is Pre- sident of the Bulgarian Medical Academy in Sofia. a crying need for practical measures to protect the mental health of the population in general and that of per- sons at risk in particular. In 1976, the Bulgarian government endorsed a programme for the Protection and Enhancement of Mental Health, which clearly reflects the concern of the State and its institution for the mental wellbeing of all citizens. The national health system, more than any other institution, is committed to this programme. In recent decades, we have be- come very much aware of the risk factors associated with lifestyles. 24 WORLD HEALTH, Aug./Sept. 1985 Much knowledge has been accumu- lated about the behavioural determi- nants of many conditions of major social significance, such as cardiovas- cular disorders, problems related to alcohol and drugs, accidents of vari- ous kinds, and mental disorders in the broadest sense. Many of these condi- tions tend to be chronic, demand continuous care, defy attempts at de- finitive cure, and have multiple psychological and social conse- quences for the patient and his or her family. Living with a crippling condi- tion and nevertheless finding meaning in life has become a very real chal- lenge for a great many people. When we talk of the mental health of the general population and the preventive functions of the health systems, we leave the setting of the specialised network of psychiatric services and enter a different setting —one where community-based care is provided for those affected by these conditions, and where solutions are sought for a variety of psychoso- cial problems that people face. A correct understanding of the network of biological, psychological and social factors involved in the natural history of these disorders is the basis from which the health systems should start. This is vital if they are to com- bine biological and psychological tech- nologies in their approach ; if they are to set up structures that could make use of these technologies ; if they are to provide the training needed to pro- duce professionals capable of apply- ing them. A good point of departure for disen- tangling this complicated issue is an awareness that the mental wellbeing of the patient is an asset of tremen- dous importance to limit the negative effects of any illness. Any investment aimed at securing the mental well- being of the sick must thus be " cost- effective", apart from being a humane act, even if the benefits are too intan- gible to be expressed in terms of statistics. If health systems could be- come more receptive to this kind of reasoning, the integration of mental health components into primary health care would be greatly facilitated. And we would be a step nearer towards fulfilling the recommendations of the 1978 Alma-Ata Conference. Living with a crippling condition and finding meaning in life is a very real problem for a great many people. Photo WHO/L. Solmssen An alternative point of departure could be to regard the sick person as someone whose mental health is at risk. In some groups of people the risk is particularly high—for example, the disabled, cancer patients, the so- called "over-utilisers" of health ser- vices, or the accident-prone. Some formula could be devised for the ap- proach—specific to each group within a certain culture—which health sys- tems should adopt to prevent mental ill-health among those at risk. Such a formula could come about through a broader exchange of ideas and experi- ence between the psychiatric world and the national health systems. The plan of work of the WHO Collaborating Centre for Research and Training in Mental Health, set up last November at the Medical Academy in Sofia, reflects the desire to carry over some of the most positive achievements of psychiatry, including interventions in the psychosocial field, into the prac- tice of the polyclinics. This is one example of a particularly welcome development which WHO is trying to stimulate. Health systems have accumulated a huge potential of knowledge and experience in areas of universal sig- nificance. This knowledge may not be disseminated to the public because of the inadequacies of health education programmes, or because of disparag- ing attitudes on the part of profession- als. In the field of mental health in particular, health education is for the time being the main channel for prim- ary prevention. What we need here is a formula which will render intelligible to the general public all that is known about the role of emotional stimuli within the human environment in the origin of ill-health. The degree to which the health competence of the public is carefully fostered should be considered as an important indi- cator of the degree to which a health system is really community-oriented. The attainment of WHO's goal of Health for all demands such health compe- tence. ■ WORLD HEALTH, Aug./Sept. 1985 25 NGOs The NGOs interested in health-re- lated fields represent a sizeable group. Over 130 of them have been admitted into "official relations" with WHO, having fulfilled specific and strict ad- mission criteria determined by the World Health Assembly in 1948. But relatively few international NGOs have their activities centered specifically on mental health problems. Indeed the growth of voluntary mental health as- sociations is, with very few exceptions, comparatively recent. One thinks of them mainly as a legacy of World War II, after which there was a drive to humanise many institutions, including schools and prisons, and to rationalise mental health care. Throughout the world, leaders and policy makers have only recently become aware of the spe- cial needs of the mentally ill ; even more recently has the full potential for action in the promotion and protection of men- tal health become widely know and supported. Participants in prevention by Stanislas Flache Despite their extreme diversity of size, scope, orientation and financial means, non-governmental organizations seem to share one basic feature which underlies their primary purpose of voluntary action : and that is the age-old purpose of helping, which today takes the shape of efforts to achieve a better quality of life. While their desire to help and to participate in the affairs of nations and of the world expresses itself in different ways, most NGOs share some common traits : a certain independence of government influence, a potential for dynamism and flexibility, a capacity to act quickly, due usually to simple structures and lack of bureaucracy, a will to experiment and to pioneer, easy access to the community and good awareness of people's real needs. The greatest common strength which the voluntary movement seems to share lies in the NGOs' human resources—a reservoir of people highly motivated, with initiative, vision and great devotion to their mission Dr Stanislas Flache was formerly an Assistant Director-General with WHO in Geneva and is now rep- resentative to the UN and WHO of the World Federation for Mental Health. Let us look at some individual NGOs in official relations with WHO which are engaged specifically in the prevention of mental health problems. It is difficult to consider this preventive aspect of their activities in isolation from the con- tinuum of mental health care, which includes promotion, detection, curative services and rehabilitation. The International Council on Alcohol and Addictions, founded in 1907, fo- cuses its objectives on reducing and preventing the harmful effects of the use of alcohol and addictive substances. It has regional offices in Latin America and Africa and a membership composed of national societies, research institutes, universities, government departments and individuals in 72 countries. It or- ganizes triennial international congres- ses as well as regional conferences and Rural improvement club in the Philippines —a reservoir of devoted and well-motivated voluntary workers. Photo WHO WORLD HEALTH, Aug./Sept. 1985 Participants in prevention training courses for selected professions in India, Malaysia, Nigeria and Zambia. The council addresses prevention in the 1980s as the major issue in all its programmes, trying to enlist the support of all organized groups, including churches, to create community involve- ment and using education as the major strategy. The International Association for Child and Adolescent Psychiatry and Allied Professions promotes the study, treatment, care and prevention of men- tal and emotional disorders and de- ficiencies of children, adolescents and their families. It mainly operates by means of international study groups held in conjunction with quadrennial international congresses (up to 1982 there have been ten, and the next will be next year in Paris). The Association will take an active part in designing and carrying out wHo projects, for example by promoting the healthy psychosocial development of the child with emphasis on activities which can be undertaken by the family and at primary health care level, or on the mental health implica- tions of child custody and divorce. The International Association for Sui- cide Prevention (tAsP) attempts to find a common platform for interchange of acquired experience, literature and in- formation about suicide, and dissemi- nates the fundamentals of suicide pre- vention in both professional and public circles. It also encourages the network of crisis telephone services. The International League against Epilepsy, founded in 1909, advances and disseminates knowledge concerning epilepsy. Its plan of action has long- range goals for the prevention of epilepsy. The International Society for the Study of Behavioural Development pro- motes the advancement and application of knowledge of humans' behavioural developmental processes at all stages of the life span. It cooperates with wHo in drawing up innovative research projects for effective action in preventive work in mental health. The activities of the International Un- ion for Child Welfare, founded in 1920, go beyond mental health programmes, but include the prevention of mental retardation through early stimulation programmes and projects to be carried out by wHo on the psychosocial devel- opment of the child. The Joint Commission on Inter- national Aspects of Mental Retardation is an organization providing for joint action by two NGOs in this field. The International Association for the Scien- tific Study of Mental Deficiency pro- motes scientific multi-disciplinary study, whereas the International League of Societies for Persons with Mental Hand- icap brings together national associa- tions, concentrating more on creating international pressure and support for improved services for the mentally handicapped and their families. The Joint Commission played an active part in assisting wHo to prepare a booklet, Mental Retardation : meeting the chal- lenge (wHo Offset Publication No. 86). The World Psychiatric Association coordinates the activities of its 69 na- tional member societies, and advances studies in causes, pathology and treat- ment of mental illness. Preventive ap- Social clubs for the elderly and disabled—just one of the ways in which non-governmental organizations contribute to better mental health. Photo WHO/L. Solmssen proaches to mental health problems are incorporated in its global programmes. The World Federation for Mental Health defines its objectives in terms of promoting the highest possible stan- dards of mental health and preventing mental illness. It helps and encourages its member associations - about 100 in 59 countries - in improving mental health services in their own countries. Most of the national organizations concerned with mental health are affili- ates of the international NGOs, and pre- sent a similar diversity. But they are much nearer to the grass-roots mental health problems and better suited to dealing with concrete daily difficulties. Most of them have some degree of professional support in a broad range of mental health activities, but an increas- ing proportion introduce new forms of lay involvement, including that of former patients and their relatives. The growth of self-help and mutual aid groups is very striking. One such group insisted : " We must try to stay a rela- tives' organization, and not fall into the hand of ' experts '. We have special knowledge and experience which we must share with the government. " A survey supported by the World Federation for Mental Health and the European Regional Office of wHo looked at the activities of 29 voluntary mental health associations around the world. They included professional men- tal health education and training, suicide prevention centres, promotion of mental health in schools, video playlets cover- ing 16 subjects of stress, teaching materials in mental health and social clubs for elderly people. The Canadian Mental Health Associ- ation has developed an expertise which is of significant value to developing countries. It has been supporting the national mental health associations in Zambia and Zimbabwe since 1983 and is assisting, in cooperation with wHo, in developing a regional network in Africa for the exchange of mental health infor- mation. There is general agreement that the NGOs, international, national and local, engaged in promotional and preventive mental health programmes play a vital role in the developmental effort exer- cised in this domain by governments and by intergovernmental agencies such as WHO. There is an even greater inherent potential in the impact which they could have on progress in mental health devel- opment. What is needed is still more effective coordination of action between them and the concerned national gov- ernment. wHo has an essential role to play in this process. Mental health programmes the world over, but especially in developing coun- tries, would have everything to gain if collaborative WHO-NGO groups on men- tal health, under wHo leadership, would engage - at both global and regional levels - in joint planning, programming and even joint fund-raising, preferably within the framework of primary health care. ■ WORLD HEALTH, Aug./Sept. 1985 27 Education and Mental Health The role of schools by Michael Rutter During recent years there has been increasing recognition of the influence of schools on children's psychosocial development, and of the potential of the educational system as a means of fostering mental health. At first sight it may not be obvious why schools should have an important place in preventive programmes after all, schools do not cause mental disorder, so why should improved schooling aid in the prevention of psychiatric problems ? Yet schools are important in prevention, because a vulnerability to mental disturbances is much affected by people's life circumstances. For children, schooling occupies a high proportion of their waking hours during much of their growing years. Moreover, school experiences constitute a major social influence on behaviour. It is not just a matter of learning to read, write and do sums schools constitute social groups of children working and playing together, supervised by adults who serve as models for their behaviour. Whether or not schools aim to do more than teach, they will have social effects. The challenge is to ensure that the effects are positive, rather than negative Research findings have shown that schools vary considerably in the ex- tent to which they succeed in that goal. Some schools catering for so- cially disadvantaged children have poor academic results, high rates of absenteeism and extensive disruptive behaviour. Other schools serving similar populations have good exam results, good attendance and general- ly well-behaved pupils working well in a harmonious atmosphere (although, of course, even the best schools have some pupils with problems). It seems that the better functioning schools share several characteristics. To begin with, there is an appropriate degree of academic emphasis with sensibly high expectations of work and behaviour, combined with an ef- fective style of classroom manage- ment. A degree of discipline is neces- sary but this seems to be best achieved by an approach in which praise and encouragement outweigh punishments, in which teachers set a Professor Michael Rutter is with the Department of Child and Ado- lescent Psychiatry at the Institute of Psychiatry in London, UK. good example, and where there is a pleasant school environment in which staff respond to children's personal needs. However, the ways in which chil- dren are treated as individuals are also influential. It is helpful for there to be a widespread range of opportunities for pupils to take responsibility and par- ticipate in the running of the school. Similarly, there are gains from having occasions on which staff and pupils are engaged together in shared ac- tivities (in or out of school) so that they get to know each other better and, it is to be hoped, learn to appreci- ate each other's positive qualities. People sometimes debate whether schools should concentrate on high levels of achievement or on making schools happy places. This is a false dichotomy. Children tend to work bet- ter and learn more when they are enjoying their school experiences ; conversely, they are more likely to feel pleased and satisfied if they can be helped to accomplish well. Nevertheless, there is one important 28 WORLD HEALTH, Aug./Sept. 1985 aspect to this issue ; namely the rec- ognition that children vary in their academic potential. It is important that children be valued and rewarded for those things they do well rather than being penalised because some other children reach even higher levels. These considerations stem from re- search that has been concerned with the overall level of functioning of groups of children. We need also to ask how good schooling affects the individual child. In what way might it serve a protective function? Studies of children at psychiatric risk empha- sise that two types of experience are particularly important in counteracting the ill-effects of stress and adversity. These are : close, harmonious warm personal relationships ; and the experi- ence of success leading to a sense of self-esteem and self-efficacy. Schools are potentially influential with regard to relationships in the oppor- tunities they provide for friendships between children, but also for the rather different kind of relationships that children can develop with adults (other than parents) whom they like and respect. Children need to be liked and respected by others if they are to like and respect themselves. That these experiences really mat- ter in practice was shown by our own studies of girls reared in severely disadvantageous circumstances, in which family discord was followed by an institutional upbringing. As a group, not unexpectedly, these girls showed more psychiatric problems than nor- mal on reaching early adult life. How- ever, what was striking was that the outcome was significantly better in those girls who had success and good experiences at school. It seemed that their own recognition that they could cope successfully in one arena of life led them to cope better with the stresses and challenges that they faced later in other arenas. How people cope with, or respond to, life stresses is in part a matter of self-confidence and of social support, but in part it is also a function of having learnt social-problem-solving skills. It seems that this learning is best done in real-life situations, and that schools have an important role in helping children learn such skills. Schools and parents Research has shown that schooling is most effective when it has the support of parents and makes good use of parents' skills. Most parents want their children to do well at school, but many feel alienated by the professional competence of teachers and discouraged by their own educa- tional limitations. This need not hap- pen if schools take the time and trouble to involve parents in ways that enhance, rather than detract, from parental responsibilities. This has been most strikingly shown in work with nursery schools but it is equally evident with older age groups. Thus, one study showed the marked ben- efits of getting parents (even those who were semi-literate) to listen to their children reading. Later, too, the role of the family will have an impor- tant bearing on children's commit- ment to learning, and on educational advancement when compulsory edu- cation comes to an end. Finally, there is a very substantial association between child psychiatric disorders and learning difficulties. For that reason, steps that are effective in aiding the learning of children with special educational difficulties are likely to have psychiatric benefits. But this must be done in a way that increases the children's sense of self- Schools—where children spend most of their waking hours during much of their growing years—have a major influence on social behaviour. Photo WHO/C. Stauffer esteem and enables them to cope successfully in ordinary society. This is probably best accomplished by im- proving the standard of schools gen- erally rather than by creating separate institutions for children with special needs. Schools cannot be expected to compensate for the ills in the rest of society. Nevertheless they can be a force for the good, with benefits that are especially marked for the disad- vantaged. The overall psychological impact of the school is relatively mod- est compared with that of the family. But in terms of prevention, schools have a major advantage in that they can affect many children, while at the same time society has the power to ensure that the schools do indeed provide good environments in which to live and to learn. That is no small advantage, but its potential for pre- venting mental ill-health has not yet been fully realised. ■ WORLD HEALTH, Aug./Sept. 1985 29 0410 0• 0• 11100 S O O••• OO 0 0• 000 000000 •.• 41 0 0• 0• 00 0 0 0000 M •• . *oli o •s 0 100 0• 00• 0• 000 110• 000 ••• 000 ••• ••0 OO O•• 0•• ••• ••• 0000•• •• 0 00• .• 0 0 • •• OO• •• • ••• • • • 04, 41 ••• ••• ••• 0041 0.0 0• •• • ••• 41• 0 • ••• ••• 0• 0• Limiting 'Sensible' Drinking To So Many 'Standard' Drinks WINNERS FOR HEALTH CHAMPIONS DE LA SANTE 'Sport For All' Joins Up With 'Health for All' Both the International Olym- pics Committee and WHO have their headquarters in Switzer- land, and on the shores of Lake Leman—in Lausanne and Gene- va respectively. Both organiza- tions have member states : loc with 90 plus 160 national com- mittees, and WHO with 166. But more significantly, both are pledged to virtually identical goals—the former to "the devel- opment of those physical and moral qualities which are the basis of sport", and the latter to health as a "state of complete physical, mental and social well- being." Says lac President Juan An- tonio Samaranch : "You call it ' Health for All' ; we call it 'Sport for All '." Addressing WHO's 38th World Health Assembly in May, he pointed out that "these twin concepts are so noticeably simi- lar that it was obvious that we should work together... in a programme of action ...called 'Winners for Health.'" And he added : "We should have been Photo WHO/?. Farkas IOC's Samaranch, WHO's Mahler signing aide-memoire working together for a long time." He named physical exercise ("performance, endurance, self- control "), nutrition ("a balanced and sufficient diet"), and per- sonal responsibility ("good habits of personal hygiene and personal self-care") as among the major messages that the two organizations should promote. "That is why I ask you", he told delegates, "to join together with ioc and wHo ...Come to- gether with the youth of the world, in the race for life, for fitness, for health..." An aide-memoire signed ear- lier by lac and by WHO's Director- General, Dr Halfdan Mahler, says, in part, that "physical and mental health for all is a goal whose attainment can be ad- vanced through acts of interna- tional solidarity." ■ How much is enough ? What's a "sensible" limit to drinking ? How much is too much ? More often than not, the typical response to such questions is still a hesitant, "well, that depends" —on the weight and height of the drinker, for instance. Or, as drink affects different people in differ- ent ways, on individual person- ality. Or on what is drunk. But irrespective of the reply, it is usually couched in generalities. Now however, there are indica- tions of more directness : In France, a health education message, carried on television for over a year, says unequivocally : "Un verre ca va...trois verres, bonjour les degats." (An approxi- mate English rendering : "One glass, okay...three glasses, the devil to pay.") In England, the Health Edu- cation Council, London goes further. In a recent brochure, enti- Photo WHO/UK Health Education Council What is the limit? tied "That's the Limit : A Guide to Sensible Drinking ", it not only sets out limits but defines "sens- ible" drinking. According to the council : A half pint of beer or lager, a single measure of spirits (whisky, gin, rum, vodka, for instance), a glass of sherry, a measure of vermouth or aperitif—as these drinks are served in pubs—each "contain roughly the same amount of pure alcohol." Thus, they can be considered as simply "one standard drink." On that basis—that a half pint of beer, a glass of wine and a mea- sure of whisky all have the same alcohol content—these are the limits defined as safe and sens- ible : For men, four to six standard drinks, two or three times a week. Or, at most, from 18 to 20 standard drinks weekly. For women, two or three standard drinks, two or three times a week. Or, at most, from 9 to 13 standard drinks weekly. The limits differ between the sexes because of the different water content in the body. In men, it is between 55 to 65 per cent of body weight, while in women it is less—between 45 and 55 per cent. Thus, alcohol is more diluted in men than in women. Although anything over those limits constitutes a risk of alcohol- related illness, there are times when even a few drinks can be too much—before driving, or be- fore operating machinery at work, for instance. It is estimated that the liver burns up one standard drink—a half pint of beer, a glass of wine, a measure of whisky—in an hour. A heavy drinking session at midday, therefore, is likely to leave the drinker unfit for the drive home at five-thirty. Among words of advice to help stay within limits : pace yourself and, if caught up with a free- spending crowd of hard drinkers, say you'd rather pay for your own. In another appeal, the council makes the point that "alcohol is loaded with calories that go straight to the bloodstream". A pint of beer, for instance, con- tains 180 fattening calories— hence the mocking term "beer belly". Among the dangers cited of drinking beyond limits are the following : hepatitis (inflammation of the liver) and cirrhosis (scarring of the liver), stomach disorders, cancer (mouth, throat, gullet), brain damage, and "sexual dif- ficulties". Despite a common be- lief, alcohol is not a stimulant, but a depressant. To help drinkers—both the so- cial and habitual type—to deter- mine just how much they drink in a week, the brochure invites readers to fill in their own drinking chart. (For more information, write to : Health Education Council, 78 New Oxford Street, London, WC1 A 1 AH.) ■ 'In Some Stricken Areas Even Vultures Have Left'— FAO Seven million tons of food are needed this year—more than double last year's needs—for 21 countries in Africa suffering the "recurring torture of hunger" brought on by a three-year drought. According to Edouard Saouma, Director-General of the U.N. Food and Agriculture Organization : "Africa's history has not recorded a catastrophe of this magnitude. In some drought-stricken areas, even the vultures have left." In addition, "one in every five people in these countries is threatened by hunger", and "political tension and war... have made one of every 200 Africans a refugee." Thus far, "the response has been generous", he adds in an article written in April for the editorial pages of the Internation- al Herald Tribune. "Pledges equal almost three-fourths of the total need." But an up-date on the crises, presented a month later in Nairobi, showed that some 40 per cent of the grain promised by donors had not been received by then. As a consequence, the six most affected countries—Chad, Ethiopia, Mali, Mozambique, Niger and Sudan—face a major disaster. "These six countries consti- 30 WORLD HEALTH, Aug./Sept. 1985 If you would like to obtain the catalogue of WHO publications, or re- ceive sample copies of other WHO periodicals which you want to evaluate before placing a subscription, please contact : World Health Organization, Distribu- tion and Sales, 1211 Geneva 27, Switzer- land. tute the hard core of the problem in terms of sheer size of areas and human numbers affected, the degree of malnutrition, and threat to life", the report says. In Chad and Ethiopia alone, an estimated 1.5 million and 9 mil- lion people respectively are on the brink of starvation. Yet in both countries even the food aid delivered has not all been distri- buted throughout rural areas for lack of trucks. In addition, relief is hampered by other problems. In the case of landlocked Chad, it is the limited port capacity in Cameroon and Nigeria through which food must be trans-shipped ; and in the case of Ethiopia, civil unrest in the north hinders delivery to areas hardest hit by drought. The roots of African famine, however, lie less in the drought and more in the land, which is at one and the same time difficult to cultivate and under-cultivated. According to FAO, only a fourth is suitable cropland, and of that area just a fourth is cultivated. Even of the arable land, only two per cent is irrigated. In short, "African agriculture has been on a low collision course with catas- trophe", as FAO's director-general put it. Africa's needs therefore, are more than food. It needs research to produce drought-resistant, high-yield food crops. It needs new farming practices to protect the fragile soil. And Mr Saouma adds : "Along with the bags of wheat, we must unload fertilizer, pesticides, and seeds. Unless, we do, emergency aid will only perpetuate dependency." ■ Photo WHO/UNEP/Stewart Drought, political tension, war, hunger, refugees Newsbriefs By Act of Congress. Through Joint Resolution 50, the U.S. Congress designated the first week of April as "World Health Week", and 7 April—which marks the coming into force of WHO's Constitution in 1948—as "World Health Day". Through a proclamation, President Ronald Reagan called upon citizens to practise "the lifestyles that promote good health "—that is to exercise regularly, to maintain proper diets, not to smoke, and not to misuse alcohol and drugs. It was an endorsement of WHO's World Health Day theme this year of "Healthy of Youth: Our Best Resource." River Blindness, Now 10 Years On : The blackfly which transmits onchocerciasis—or river blindness—is considered "under control" in 90 per cent of the 764,000 square kilometers in these seven countries of the Volta River Basin : Benin, Burkina Faso, Ghana, Ivory Coast, Mali, Niger and Togo. This area is about the size of France and the United Kingdom put together. As a consequence, riverine lands have been declared safe for re-settlement and agricultural production. The 10th anniver- sary of the Onchocerciarsis Control Pro- gramme will be featured in the October issue of World Health. The success has been made possible by contributions from 19 countries and institutions totalling US $160 million, and weekly larviciding of breeding sites of the blackfly along some 18,000 km of rivers. As a result some three million children born over the last decade will never become blind, WHO says. Now plans are under way to add 556,000 sq. km to the area of operations beginning from 1986. A total of $135 million is projected for the next six years for the programme in Guinea, Guinea-Bissau, Senegal and Sierra Leone. Separating Politics from Health. Dr Suwardjono Surjaningrat of Indonesia, presiding over the 38th World Health Assembly in May, pleaded with delegates "to avoid bringing here political issues which are better dealt with at other fora of the United Nations." This plea followed a statement by Dr Halfdan Mahler, WHO's Director-General, who said : "There is a tremendous difference between national policy decisions that affect health and interna- tional political differences." Another delegate, U. S. Surgeon General Everett Koop, put it another way: "We all know what we should be doing. We should be talking about communicable diseases, immunizations, maternal and child health, the WHO budget." Tip of the Iceberg. According to WHO estimates, there are 48 million people around the world who abuse and misuse drugs. Of that total, 30 million smoke cannabis, 1,7 million depend on opium, and 700,000 on heroin. In addition, several million are hooked on cocaine, described as the "most dependence-producing drug available". Bad as this sounds, such figures only represent the "tip of the iceberg", according to WHO officials, as there is no information from many countries. Errata : In our June issue, the article on an International Insulin Pump Study included the Federal Republic of Germany among the seven countries cooperating with WHO. This should have read the German Democratic Republic. And on page 22, we said that the Basic Radiological System "cannot make x-ray plates". This should have read "cannot do fluoroscopy." Dr G. GOrnez Crespo points out that the photograph on page 6 was not taken by him but by the General Electric Company. WORLD HEALTH For readers everywhere 1985 Subscription Rates One year Two years Three years US$ 12.50 22.50 30.— Sw. fr. 25.— 45.— 60. ORDER FORM Please enter my subscription to "World Health" as follows : 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 cur- rencies, please contact your usual bookseller. WORLD HEALTH, Aug./Sept. 1985 31 in te d in S w itz e rla n d — R o to -S ad ag G e ne ve National health syfterns recognise the "cost-effectiveness" of irvest-nents atmea at the mer:al well- being of the elderly, the sick or the disabled. See page 24. PFotp L. Sirman 0