World Health: the magazine of the World Health Organization: June 1986 [full issue]: smoking, alcohol, drugs

smoking· alcohol· drugs Cover: "Escape into night- mare" : drawing by Peter Davies after Francis Bacon's "Lying figure with hypodermic syringe, 1963." IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor : Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English. French. 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 Organ ization. Signed articles do not necessarily reflect WHO's views. World Health, WHO. Av. Appia, 1211 Geneva 27, Sw itzerland. Contents Putting a higher value on health by Norman Sartorius . . . . . . . . 2 The big killer by David A. Player . . . . . . . . . . . 4 Smoking in the Third World by Uma Ram Nath . . . . . . . . . . . . . . . . 6 Banishing tobacco by William U. Chandler. . . .. . . . . . .. . . . . 8 Demon drink . . . . . . . . . . . . . . . . . . . 12 One for the road? by Alex lrving . . . . . . . . . . . . . . . . • . . . 14 Smoking, alcohol and drugs. . . • 16-17 Drugs are big business by Anthony W. Clare . . . . . . . . . . . . . . 18 Escape into nightmare by lnayat Khan. . . . . . . . . . . . . . . . . . . 22 "Glue-sniffing" . . . . . . . . . . . . . . . . . 23 Chewing khat by Peter Kalix .... . . . . .... . .. .... . Designer drugs by Roger Highfield. . . . . . . . . . . . . . . . 26 International control of drugs by B. Juppin de Fondaumiere . . . . . . . 28 • Departments. Lifestyles and health : Giving up the weed by John Wickett. . . . . . . . . . . . . . . . . . 11 Meeting the threat of drug abuse by Marcus Grant . . . . . . . . . . . . . . . . . 20 Books and publications : Like a thief in the family. . . . . . . . . . . . 15 News Page . . . . . . . . . .. .. a .. . . • . Puning a higher value on health by Norman Sartorius U he abuse of psychoactive sub-stances-including alcohol, to-bacco and narcotic and psycho- tropic drugs-causes enormous dam- age to the health and productivity of nations. It undermines the quality of life of individuals and their families , and threatens the welfare of com- munities. The health consequences of abuse are also grave , and range from violence and deliquency to liver cir- rhosis, brain damage and lung cancer. Treatment of dependence on psychoactive substances is still imper- fect, can take a long time and may be expensive . Its effects are all too often of short duration. Yet treatment re- mains a necessary part of society's response to the damage done. Some- times it will have to be repeated; sometimes it will be discouraged by failure. Nevertheless, it must be pro- vided to those affected, often to save their lives. Fortunately, research during the last 100 years has produced sufficient knowledge about the prevention of abuse of these substances. If it were not for three giant obstacles, preven- tion programmes could be crowned with success. To remember the obsta- cles may help in our search for ways to succeed in spite of them. The first and most important of these is the low value which the popu- lations of the world assign to health. Humans organise their lives in the framework of values which they attach to themselves , to ideas and concepts, to people and to things that surround W OR LD HEALTH, June 1986 Good health implies a harmonious balance at the physical, mental and social level. Photo W HO/E. Mandelmann them. On the scale of all these values, health ranks low. In the presence of disease and pain, people take steps to rid themselves of these; but such steps are motivated by the value attached to life and to the absence of pain, not specifically to health. Pleasure has a much higher value; so have patriot- ism, productivity, popularity, esteem of others, physical appearance and attractiveness. Health implies an exist- ence in which a harmonious balance has been found between the total environment and oneself, and in which physical, mental and social functioning complement each other in maintaining this balance. The value of health, de- fined in this sense, fares badly in comparison with other values which make up the framework for human action. The second giant obstacle to the prevention of substance abuse, is the pharmacological nature of the sub- stances themselves. They produce pleasurable effects, change one's per- ception of the world, of oneself and of one's immediate problems. The addic- tive nature of the substances also makes it necessary to use them in ever WORLD HEALTH, June 1986 increasing quantities, which eventually result in serious damage to the func- tioning of the human body. The be- havioural patterns and cycles in which dependence occurs and is reinforced, as well as its complex socio-economic parameters, have often been described in detail and are reflected in a number of articles in this issue. They interact with the pharmacological properties of a drug in complex but by now well- known ways. The third giant hindrance that stands in the way of success is the nature of the environment in which most people of the world live today. Sharing a cigarette or a drink after a strenuous day may often offer more in human values than anything else avail- able. It may be particularly important in situations where no other pretext for sharing time and feelings is avail- able, because of the poverty of the environment, restrictions of a societal nature or personal reasons. Drug death toll in UK In the United Kingdom alone in 1984, at least 2,000 people died each week from the misuse of drugs. Cigarettes killed 1 ,900 people every week, 60 died from medicines (analgesics or similar compounds accounting for five deaths), and 40 from alcohol, according to two phar- macologists at St. George's Hospital Medical School 1n London . The latter two obstacles do not lend themselves easily to attack. It is un- likely that we shall ever be able to do much about the nature of addictive substances. There will always be drugs of one type or another which, if taken by humans , will cause dependence. History abounds in examples of peo- ple's inventiveness in creating new drugs of abuse. The most recent exam- ple-the appearance of designer drugs -is just one more to be added to the list. There will be others. It is also unlikely that , in the foreseeable fu- ture, we can hope to enrich the human environment-social, physical or bio- logical-sufficiently to prevent situ- Tai chi in China; martial art in slow motion. Photo WHO/D. Henrioud ations in which taking a drug will seem highly desirable. But we are left with one major field of action. We can help people to understand what health is all about and thus contribute towards raising the value that people attach to it. This will require joint action by workers in many social sectors-education, social welfare , medicine , industry , the opin- ion-formers and many others. They can take action now to raise the value of health by example , by legislation, by education and by other means. Finding and promoting worthwhile social alternatives to addictive be- haviour means more than listing possi- ble hobbies. It also means more than merely imposing controls , whether by tightening of borders around drug- producing countries or by increasing prices of alcohol and tobacco. It means leaving choices open to people , once everything possible has been done to ensure that they understand what health is and why it may be important to value it. If people esteem their own health and the health of others suffi- ciently highly, it becomes less likely that they will indulge in practices that harm it or that they will allow others to do so. Most importantly , the motivat- ing force for action against abuse of psychoactive substances will then cease to be external power, pressure or persuasion; instead, the framework for people's decisions about the way in which they spend-or ruin-their lives will include health as a determinant with a high value attached to it. If this happens, we will efficiently and permanently wipe out not only the problems of drug abuse, but a whole series of other problems and evils as well. • 3 The big killer lt is encouraging that adults in England and Wales are giving up smok- ing; it is appalling that ever more children are becoming hooked, writes the Director-General of the U K Health Education Council Two hundred and thirty black balloons floating into a grey London sky made a sombre sight, and appropriately so, since they symbol- ised the numbers of people who die each day in England and Wales as a result of smoking. The balloons were launched to mark publication by the United Kingdom's Health Education Council of The Big Kill, the most extensive statistical analysis ever undertaken of death and disease related to smoking in the two countries . They also marked a further step in an aggressive campaign against the smoking habit and, by extension, the tobacco industry . Smoking, of course, is an inter- national problem, and the tobacco in- dustry has worldwide interests. So it is essential for those of us concerned with health education and promotion to cooperate as closely as possible , and to learn from one another's experi- ences. Techniques which work in one country may well work in another, and the free exchange of ideas can help to save millions of lives, a vital contribu- tion towards our common goal of health for all by the year 2000. The battle is, of course, a hard one. In the United Kingdom alone , tobacco taxes contribute £4,550 million to the national economy and, while govern- ments may claim to have the health of their nations at heart , the economic arguments play a major part. When an industry provides huge sums of money and scarce jobs, few politicians are going to be brave enough to confront the issue effectively . So we must campaign. We must campaign hard and effectively. And 4 by David A. Player publication of The Big Kill has been an important contribution to the cam- paign in the UK where, unlike some countries, the smoking trend among adults is already downwards. Today 36 per cent of men smoke and 32 per cent of women, although men have been giving up the habit faster than women. Smokers are a minority in every social group, even though most smokers are The UK as a giant ash-tray; anti-smoking campaign by the Health Education Council. now to be found in the lower socio- economic classes. Among children, however, the trends are more worrying. The results of a survey published in 1984 showed that 22 per cent of children in secon- dary schools were smokers , many smoking more than 20 cigarettes a day. There was a sharp rise in the numbers of girls taking up the habit- from 15 per cent in 1982 to 24 per cent. It is encouraging that adults are giving up smoking. It is appalling that more and more children are becoming hooked . The tobacco industry argues that its promotional efforts are directed to- wards adult smokers, and aimed at persuading them to remain loyal to a particular brand or to switch to another brand of cigarette. It claims that it does not seek to recruit young smokers to its lethal product. This claim is nonsense. In the UK, tobacco promotion is limited by voluntary agreements with the government. Companies are free to advertise and promote their products, within certain restrictions, many of them specifically barring promotion to young people. Advertisements for cigarettes have been banned on television since 1965. Why , then , are young smokers on the increase? The answer is that the tobacco in- dustry has cynically ignored the agreements which it has made. In one month , advertisements in women's magazines were estimated to have reached over half of young women aged between 15 and 17. The industry has launched package holidays under cigarette brand names and sponsored racing cars and sporting events, all with an appeal to the young. In 1984, more than 330 hours of sport on television featured events sponsored by tobacco companies, with the events bearing cigarette brand names; adver- tisements for cigarettes were promi- nently featured , in breach of the agreed code. Sport is immensely attractive to young people , and research shows that W oRLD HEALTH, June 1986 children are most aware of cigarette brands which are associated with sport. Although there has been no direct advertising of cigarettes on UK television for 20 years, 76 per cent of children in a 1983 survey claimed to have seen such advertisements. How, then, to combat this menace? The approach, we believe , should be twofold-using techniques both of health education and health promo- tion. Education is necessary to draw continuous attention to the health hazards of smoking, to persuade smokers to give up, and to reinforce those who have given up. Education in schools is particularly necessary, and must take place at an appropriate age which, experience suggests, is 12 years. Introduce the topic later than that, and children may already have become hooked . But although education over the years has contributed to the decline in smoking in the UK, vigorous activity must take place in the political and economic sphere. There is a well- proven correlation between rises in the price of cigarettes and a decline in the numbers of smokers. So , while education can create a climate of opin- ion in which political action is possible, politicians must be reminded that ac- tion is necessary, the tobacco industry must be monitored and its activities, when in breach of laws or voluntary agreements, exposed. Airline bans cigarettes The Soviet airline Aeroflot is reported to have banned all smoking on domestic flights within the Soviet Union . The ban on smoking has also been strictly enforced for the airline's pilots. since research found that one cigarette smoked before a flight limited the angle of vision and compromised colour perception by as much as 20 per cent . The Big Kill was a major exercise on the political front. There were 15 volumes of analysis, one for every health region in England and Wales , setting out the numbers of deaths, numbers of smokers treated in hospi- tal for smoking-related diseases, and the cost to the health service. W ORLD HEALTH , June 1986 Riding for a fall ; many youngsters get the cigarette habit at the age of 12. Photo CIRIC © On a regional and national basis those figures were shocking enough -and we estimated that, if current trends continued , 1.5 million smokers will have died by the year 2000. But we decided to extend the analysis into much smaller units, and produced figures for every parliamentary con- stituency and for local government districts. Copies of the data were sent to members of parliament and civic leaders. The black balloons formed part of a publicity campaign surround- ing the publication which created enormous interest in the mass media , bringing massive publicity and rein- forcing the need for politicians and community leaders to take action. Where data are available for deaths or hospital treatment from ischaemic heart disease, lung cancer, and bron- chitis and emphysema-the three most common diseases related to smoking -a similar exercise could have an equal impact in any country. By mar- shalling statistics, encouraging re- search in areas where it is not taking place and ensuring that legislators and the general public are aware of the situation, the puny resources available to health promoters can challenge the billions of pounds spent by the tobacco industry. Public pressure can yield results , and an industry which purports to be socially responsible can be easily em- barrassed when its activities are ex- posed. The UK has learned from the Australian experience, where a group of concerned doctors and health cam- paigners calling themselves BUGA UP pioneered guerrilla tactics to de- face cigarette advertisements on bill- boards, and to disrupt tobacco promo- tions at sporting events and in public places. There are now two similar groups in the UK and, while I obviously cannot condone illegal activities, I certainly applaud the spirit which drives people to take direct action in the face of official inability to act decisively against a murderous addiction. Our policy is straightforward. We wish to see a ban on all cigarette advertising, except where cigarettes are sold. We wish to see all televised sports sponsorship by tobacco com- panies phased out over three years. We wish to see voluntary codes being strictly adhered to. And we wish to see rigorous enforcement of the law which forbids the sale of cigarettes to chil- dren under 16, a law which is being widely flouted . Each country will, of course, have a programme and tactics relevant to its own conditions, but I believe that the UK experience has elements which can be applied elsewhere. Particularly worrying is the advertising of ciga- rettes in Third World countries, using techniques which have long been for- bidden in the UK. Smoking is associ- ated with glamour and worldly suc- cess, which must rank as the most cynical marketing ploy of all time. Those of us concerned with health must use every tactic possible to pro- voke governments into action, because it is only at the political level that this lethal trade can be curbed. • 5 Smoking in lhe Third World by Uma Ram Nath The cycle of tobacco use, disease, debate and public action that is already fam- iliar in developed countries of the world is only just starting up in the Third World. In- deed , the developing countries today are poised dangerously between the first and second phases . Growing numbers of people are smoking and there is a discernible increase in smok- ing-related diseases. But we cannot wait for public debate to initiate action; governments must recognise the danger now and act to prevent the spread of the cigarette. There are, of course, many ways of using tobacco apart from the cigarette . Charutos are favoured by South Americans ; the goza or hookah is popular in the Middle East and is also common in South-West Asia; some people chew tobacco or, in India and Pakistan, the betel leaf, or paan . Re- search into the health implications of these habits has not yet delved as deep as the investigation of the cigarette in relation to lung cancer. In any case, skilful and aggressive marketing is now promoting the cigarette in the developing world. The traditional uses of tobacco are being replaced by the cigarette which is less 6 cumbersome than the hookah, for ex- ample . Cigarettes can generally be bought one at a time and not neces- sarily in a packet of ten or twenty and , of course, to the common man they are being promoted as a symbol of sophistication. The booming production of ciga- rettes (measured in billions) in some developing countries indicates the growth of the problem: 1979 1983 - - Kenya . . 4.6 5.3 Algeria 14.0 17.5 Egypt .. 29 .2 44.0 China .. 651.0 962.6 Indonesia . 69 .8 92.1 Cuba .... 28.0 30.0 In the industrialised nations there are fewer smokers than there used to be . But disturbing statistics from Afri- ca cited by Nigerian expert Dr Femi- Pearse show that 31 per cent of uni- versity students in Uganda smoke ; 51 per cent of people between 30 and 54 in one village of Ghana smoke; and 41 per cent of men aged over 20 in Lagos have the habit. Dr Femi-Pearse also points to the substantial numbers of children in secondary or middle schools who smoke: in Lagos- 17 per cent of boys , 2 per cent of girls; in Accra-boys 10 per cent, girls 8 per ~ 0 I s 0 0 .J;: Q_ cent ; in Lusaka- boys 40 per cent , girls 4 per cent. Twenty years from now these young people will begin to fall victim to tobacco-caused sickness. It is time now to prevent that happening. A report presented to WHO's Execu- tive Board last November condemned cigarette smoking as the major avoid- able cause of ill health and early death in the countries where the habit is widespread . It said that 90 per cent of all lung cancer , 75 per cent of chronic bronchitis and emphysema, and a quar- ter of ischaemic heart disease cases in men aged under 65 could be attributed to smoking. While in the developed countries the number of smokers is declining , and the habit is fast becom- ing socially less acceptable, in de- veloping countries it is on the increase "fuelled mainly by intensive and ruth- less promotional campaigns on the part of the transnational tobacco com- panies" . Those companies' activities are not subject to the legislative or advertising controls that generally ex- ist in the developed world , the WHO report said, and it warned that smok- ing diseases will appear in develop- ing countries before communicable diseases and malnutrition have been controlled. This is the urgent need today. While indigenous uses of tobacco may cloud W oRLD HEALTH, June 1986 the assessment of tobacco-related diseases , we can already see clear indi- cations of cigarette-related illness in developing countries. WHO believes tqat an epidemic of lung cancer can be expected as a result of the rapidly increasing cigarette consumption in many developing countries . For in- stance, in India, total cigarette con- sumption rose 400 per cent between 1970 and 1980, in Papua New Guinea it trebled between 1960 and 1980, and in Brazil about 135,000 million cigarettes were smoked in 1981 while cigarette-related diseases far out- stripped the infectious diseases as the leading cause of death . While cigarette manufacturers are endeavouring to sell the low tar cigarette in an attempt to make their product appear "safe" to " Western " consumers , their products bearing in- ternational brand names, but sold in the developing world, have much higher yields of tar and nicotine. A comparison of cigarettes in the Philip- pines and in the United States showed that the former had 50 per cent higher tar content than the latter and some- times twice as much nicotine as the American version. Another assess- ment of cigarettes from Australia and Singapore showed similar results. Cigarettes sold in China, India and Pakistan have a high tar and nic- otine content. Cigars and pipes are dangerous too As few as four cigars or four pipefuls of tobacco give the smoker as much toxic sub- stance as ten cigarettes . Doc- tors at Minnesota University's School of Public Health, in the USA. advised that even people who have never smoked ciga- rettes, only a pipe or cigars, should avoid those too. What can be done to limit the rise of smoking-related diseases in the Third World? One starting point could be to restrict the sphere of influence of the tobacco industry, for whom advertis- ing and promotion of cigarettes are the most powerful weapons. As long as W ORLD HEALTH, June 1986 the cigarette is associated with glamour, it will draw more and more people to it. Some developing coun- tries have been able to legislate on advertising of cigarettes. Malaysia , for instance , has banned all television and radio publicity for cigarettes, although it is still legal for newspapers to carry advertisements. There are a number of special fac- tors to consider in preparing a smok- ing-control package for developing countries. In a population with a low level of literacy, what sort of health warning should be given? What would be the use of such a warning if the indigenous products , such as tobacco for chewing or the bidi (a small hand- rolled cigarette) , carried no caveat? Restrictions on the promotion of cigarettes may be effective but what about the quality of the cigarettes sold? Third World governments need to fix upper limits to harmful sub- stances in cigarettes. The Fifth World Conference on Smoking and Health recommended in 1983 that "the pro- duction and export of cigarettes with a tar yield of more than 20 milligrams should cease worldwide," and that all cigarettes and tobacco products should carry a health warning and precise labelling of tar , nicotine and carbon monoxide content. A potter works with both hands and still draws on his hookah. Photo W HO/Zafar Tobacco is a lucrative export crop for some developing countries and some international agencies give de- velopment aid for the crop. Govern- ments earn money from tobacco tax- ation. Fewer cigarettes sold will mean less revenue. In India, changes to the excise tax structure resulted in the flooding of the market by new and competing brands. As the more expensive ciga- rettes fell within a higher tax bracket, their sales dropped. Challengers to the main producers are now offering cheaper cigarettes and in a plethora of brands. And the Indian smoker has taken these up . In the long run the consequences of sickness and disease , of work days lost and the drain on resources , will be far greater than the short-term gains of tobacco-generated income. Develop- ing countries still have a chance to prevent the growth of smoking. They can ensure that promoting non-smok- ing forms an integral part of an overall primary health care strategy. They can draw up widespread and well-formu- lated education programmes to sup- port the health message. And they can bring in legislation to curb the promo- tion of tobacco. Non-governmental and voluntary organizations will be valuable allies in this battle. In par- ticular the consumer movements that are emerging in developing countries can form the core of an anti-smok- ing network in support of popular initiatives for change. • 7 8 Banishing tobacco Smoking could be regarded ;as the world's most important preventable health problem. How can we dissuade youngsters from becoming addicted before they realise-all too late-that their new habit kills one out of every four smokers? by William U. Chandler .!: 0. B <Jj ~ u :i 0 :r: ~ 0 0 .!: CL Nothing apparently can stop the world's craving for tobacco. Despite the devas- tating evidence of its dangers to health, global consumption has increased by nearly 75 per cent over the past two decades. The world- wide cost in preventable deaths now approaches 2.5 million a year. At the present rate, consumption could rise by a further 50 per cent by the year 2000. While cigarette smoking remains at alarmingly high levels in the indus- trialised countries, it is in the countries of Eastern Europe and in China than its growth has been explosive. China is the world's largest producer of tobac- co and uses all it grows to meet domestic demand. Alone it accounts for half the global increase in the last ten years. Anti-smoking campaigns have made little impact on the young in many countries. More young people than adults now smoke in Eastern Europe, in Egypt and in Canada. In France, for instance, 43 per cent start the smoking habit before the age of 12. In Ethiopia, 32 per cent of boys and-so far-only three per cent of girls are smokers . But it is among young women in the West that the habit is spreading fast- est. Teenage girls in the United States and in many European countries now smoke more than boys of the same age group. Moreover, women of all ages in many countries are smoking in record numbers, including pregnant women. It is estimated that smoking by preg- nant women in the United States causes 50,000 miscarriages a year and is a frequent cause of premature deliv- ery. Infants born to mothers who smoke are frequently underweight , more prone to respiratory diseases and often slower than average in their physical and intellectual development. Another sign of the times: lung cancer was rare among American women be- fore they took up smoking . In 1981, This article is extracted from Banishing Tobacco , Worldwatch Paper No. 68, by William U. Chandler, published by the Worldwatch Institute, Washington D.C., US. A . W oRLD HEALTH, June 1986 for the first time, it was as prevalent as breast cancer among women aged over 55. That smoking causes more death and suffering among adults than any other toxic material in the environ- ment has long been known. But now the smoker is not only a danger to himself but increasingly a hazard for the non-smoker. For the evidence is growing that involuntary exposure to cigarette smoke causes more lung cancer deaths than any other pollutant. Studies carried out in Japan, Greece, the Federal Republic of Ger- many and the United States show that non-smoking wives who lived with heavy smokers are three times more likely to die of lung cancer than the wives of non-smoking husbands. In fact, passive smoking-the involuntary inhaling of others' cigarette smoke-is believed to cause more cancer deaths than all regulated industrial air pol- lutants combined. In the United States, the cost in lives may be as high as 5,000 a year. Protecting the non- smoking public from the potentially deadly effects of drifting cigarette smoke has become a high-priority worldwide health problem, which calls for a much more stringent tobacco control policy by governments and public health authorities. Smoker imperils plane A passenger aboard a light air- craft flying over Atlantic City, USA became so angry when told not to smoke that he attacked the pilot. The plane twice came close to crashing before another passenger res- cued the pilot and KO'd the would-be smoker. Though the health consequences of tobacco are now well known, mea- sures to deal with them are so far woefully inadequate. Practical action rarely goes further than warnings by governments that tobacco is un- healthy, the banning of advertising and the restriction of smoking on pub- lic transport and in theatres. No na- tional tobacco control effort has been launched with the vigour of, say, anti- W oRLD HEALTH, June 1986 drug campaigns or even of campaigns against toxic chemicals, although both hard drugs and chemicals claim far fewer victims than tobacco. Stronger measures in a dozen coun- tries have been largely counter-pro- ductive. Tobacco advertising is forbid- den in Poland, for example, and smok- ing is restricted in public places; yet Poland in 1982 had the ninth highest per capita cigarette consumption in the world. Similar anti-smoking mea- sures have been taken in China , the German Democratic Republic and the Soviet Union, but smoking in all those countries remains at very high levels. Better results have been achieved in Finland, Norway and Sweden, where advertising is banned and cigarette packages carry strong warning labels . Nevertheless, only in the United King- dom is consumption lower than it was 20 years ago when the first campaigns were launched. The irony of the situation is that tobacco is a dangerous drug which clearly should be banned. The tragedy is that governments promote and sub- sidise the tobacco industry, and the industry itself is powerful enough to nip in the bud any move to restrict the sales of tobacco products. Govern- ments move swiftly to remove unsafe medicines from the market. They con- duct paramilitary operations to des- troy fields of marijuana or opium. But The diseased lung of a deceased smoker impresses schoolchildren in Singapore. Photo WHO/Singapore Ministry of Health they take no such action with tobacco , a far deadlier .crop. For no avoidable condition claims more adult lives than tobacco addic- tion. While little remains to be known about its effects on health, scientific understanding of the addictive power of tobacco has progressed slowly. It seems certain that nicotine is the ad- dictive agent in tobacco. But in addi- tion to nicotine , cigarette smoke con- tains 4,000 other chemical com- pounds, hundreds of health-damaging agents and simple carbon monoxide . These agents and chemicals not only attack the lungs but reach the blood- stream, where they circulate, causing or accelerating clogging of the arteries, cancer of the internal organs and heart attacks . Fifteen to 30 per cent of all heart attacks in the United States and perhaps a third in the United Kingdom are caused by smoking, which is also the leading cause of death from car- diovascular diseases for persons of middle age and below in virtually all developed countries. Smoking also causes two other lung diseases, bron- chitis and emphysema (together known as Chronic Obstructive Lung Disease) , which kill 52,000 people a year in the United States alone. 9 No avoidable condition claims more adult lives than tobacco addiction. Photo W HO/Zafar · Studies have shown that only 15 per cent of teenagers who experimented with tobacco were later able to quit. Other studies found that 75 per cent who do quit smoking start again within six months. In those who do quit, the tobacco "craving" often lasts for sev- eral years. Health advocates generally dismiss stronger measures for dealing with smoking. The Royal College of Physi- cians in London, the first governmen- tal body in the world to launch a campaign to save the health of smok- ers, concedes that banning tobacco is impractical. They compared such a move to alcohol prohibition and feared it would lead to criminality. The ultimate solution is an outright ban on tobacco sales, but the opposi- tion to such a revolutionary move could hardly be more formidable. The fact is that governments all over the world work hand-in-glove with the 10 tobacco industry to protect and pro- mote its interests. In many countries, the government actually owns the to- bacco industry. In China, for instance, while one part of the government is telling the people that smoking is dangerous to health, the tobacco in- dustry is being expanded rapidly for economic reasons. But these same contradictions also apply in western nations. In the United States , to- bacco farmers benefit from a price- support system administered by the government. West European govern- ments subsidise tobacco growers to the tune of some US $660 million a year. This official tolerance and even endorsement of smoking seriously undermines the efforts of anti-smok- ing movements and casts doubt on the sincerity of government-backed information campaigns about the dangerous effects of smoking on health. Small wonder therefore if a child about to start smoking fails to take them seriously. Since an outright ban on tobacco sales is an impossible dream, the em- phasis has swung to the protection of passive smokers. Hence the emer- gence of a new movement in the United States and elsewhere to banish smoking in public places and to make the habit socially unacceptable. The campaign focuses on the work- place, public gathering places and public transport. It has enlisted unsus- pected allies, among them companies who realise that most of their employ- ees do not smoke and dislike breathing the smoke of others. In fact , US indus- try as a whole is responding rapidly to the non-smoker movement. Many companies now ban smoking on the job and some even refuse to hire smokers. The new movement could be the single greatest success in the campaigns to eliminate smoking. To date, the overall situation of anti-smoking efforts can be summed up as a relative failure in the industrial countries and a disaster in developing ones. At the current rate, the toll in lives can. only rise to even more devas- tating levels unless more stringent measures are taken on a global scale. These could include raising the tax on tobacco products , thus encouraging light smokers to quit and the young with low incomes not to start. Coun- tries with low smoking rates and no indigenous tobacco industry could stop importing tobacco products and thus impose a de facto ban. Above all, stronger action should be taken to protect the health of the innocent. Experience in such countries as the United States and Poland shows that tobacco can be banished from public buildings, from the workplace, from restaurants and public meeting places. In short, banishing cigarette smoking in the presence of non-smok- ers should be considered in all coun- tries as a minimum level of protection for the non-smoker. These measures will not be easy, nor will they solve the tobacco problem. They will not protect children in the home from the smoke of their parents or the unborn fetus from the results of its mother's tobacco habit. Nor will they persuade smokers themselves to quit, or guarantee that innocent young people do not become addicted before they realise, too late, that their new habit eventually kills one out of every four smokers. • WORLD HEALTH, June 1986 Lifestyles and Health Giving up the weed (J gave up smoking. Twice. The sec-ond time was somewhat less miserable than the first. Both my parents smoke, so I never really stood a chance. I tried my first cigarette at about the age of five, and it was inevitable that I should become a smoker. No one talked about it being bad for your health in those days, and it was such a terribly grown-up thing to do. In High School, I remember envying my friend David because he could smoke at least 20 a day, inhaling deeply and blowing magnificent smoke rings, while I would simply become ill. Every- body smoked . lt was not until my fourth year at university that I came across someone who actually decided to stop. Although he was my best friend, I still felt his behaviour was suspiciously anti-social. During my early 20s, I settled into a regular habit of about 20 a day. it was quite a treat to come to Switzerland in 1969, where 20 cigarettes cost 65 cen- times or $0.15 whereas in Canada they had been $0.35 and people were begin- ning to make noises about them being bad for your health . My boss at WHO smoked, as did my colleagues. By the time I was in my early 30s I was smoking over three packs a day of those strong cigarettes that cowboys like. Up until then smok- ing did not seem to be a danger or even an inconvenience to my health , although there were times when my tongue felt like a slab of smoked meat and my throat felt parched and scratchy. By this time, though, I was convinced that smoking was bad for you and that the number I was smoking per day was positively suicidal. Besides, other peo- ple were giving it up. lt would be difficult, and I had no confidence in acupuncture, hypnosis or nicotine chewing gum. Brute-force willpower, I felt, was the only way. After all I was giving up on the theory that I might live longer, not because I didn't like smok- ing . To mentally prepare myself, I set a target six months away as the day I would stop : my 35th birthday. This also W oRLD HEALTH, June 1986 by John Wickett fell on a Monday. I announced to one and all that I was going to stop, thus risking to look like a fool if I didn 't keep my word. Well. the last Sunday arrived and I smoked three packs of cigarettes and two cigars. Talk about drug withdrawal symp- toms! My nose dripped for a month, I had a sore throat for a month, my eye prescription changed, my intestines went beserk with burping and flatu- lence. I even had dizzy spells, no doubt getting "high" by breathing an unac- customedly large intake of oxygen in- "Two years later I was up to 30 cigarettes a day ... " Photo L. Sirman © stead of the normal smog. I put on weight; when you don't smoke you try to satisfy the gnawing feeling in your stomach with food or numb it with drink. After two weeks I permitted myself a cigar in the evening. The rationale here is that you don't inhale the cigar smoke, thus you don't risk lung cancer. And of course, you get your "hit" of nicotine as it passes through the mucosa of your mouth into your blood stream. lt proved virtually impossible to go without that one cigar a day. I didn't mind not smoking in the office during the day, though, which surprised me. This situation lasted three years. Then "stress" entered my life. I began to scrounge the occasional cigarette from one of my friends when out for an evening . I did not like the way my mouth would taste the next day, but .. .. My downfall was the arrival of a new colleague with whom I was to share an office. A smoker. In three months I was smoking again. Two years later I was up to 30 cigarettes a day although my colleague had moved to a separate office. By this time I was 1 00 per cent converted to the idea that smoking is totally stupid. I had even developed a cozy chronic little smoker's cough and my lungs felt heavy. But there was that little demon gnawing on my stomach which would only leave me alone if I would smoke. So I stopped . Since I had already stopped before, I knew what the with- drawal symptoms would be like . The day came when it felt as bad to smoke as I knew it would to stop, and my cigarettes ran out on a Sunday evening. Since Monday, 2 December 1985, I have smoked neither cigarette nor cigar. it hasn't been as bad as I feared . The only real physical discomfort was the gnawing in the stomach, and I did put on some weight. I have been pleas- antly surprised at how infrequently I have a desire for a cigarette. But I don't think it ever entirely goes away. None of my friends who have quit have en- tirely lost the urge. it really helps if you know what to expect. You may not believe this, but one of the most comforting documents I have ever read was the report of WHO's Director-General to this year's Execu- tive Board on the wHo Programme on Tobacco or Health . it accused tobacco of being more insidiously addictive than heroin, and described all those symp- toms I was experiencing upon stopping smoking . I recommend it. There is no magic potion to make you give up; it takes willpower and the foreknowledge of what you will experience when you do. You've got to make up your mind. And, by the way, I do feel better! • 11 The cup that cheers can be the cup that kills. Not only alcohol addiction itself but many disabling, and some fatal, physical and psychological conditions can be attri- buted to excessive drinking. In addition, alcohol-related traffic acci- dents account for a significant proportion of deaths in many countries , especially among young people. Accidents at work or in the home are more frequently related to over-drinking than is widely recognised. Excessive drinking disrupts family life and can often result in violence and neglect. Despite these known health hazards, the production of alcoholic drinks is increasing all over the world , and the consumption of alcohol per person is soaring on a global scale. Particularly in some of the developing countries, the rapid growth in consumption is likely, after some lapse of time, to be reflected in a higher incidence of alcohol-related prob- lems. These in turn will represent a very substantial drain on scarce economic and social resources. As the January-February issue of World Health reported, Or Samuel W. Hynd , chairman of Swaziland's National Council on Smoking, Alcohol and Drug Dependence , believes that "alcohol is destroying millions more than the famine in the Sahel, and in some countries the numbers of known alcoholics equals the population of the largest cities." And Professor Robert E. Kendell , of the University of Edinburgh, UK, said of the steadily increasing production of and trade in alcoholic drinks: "These are activities with inevitable public health implications that will have to be faced both by governments and by the world's alcohol industries." • W ORLD HEALTH, June 1986 W ORLD HEALTH , June 1986 Facing page : Blending whiskies in a Scottish distillery. But the dosser sleeping off his hangover will never figure in the glamorous liquor advertisements. Photos L. Sirman ©and W HO/H. Christoph This page: The contrasting view in Africa. In moderation, alcohol helps to make a party go; for the lone drinker, it can be a false friend, an untrustworthy crutch. Photos WHO/P. Almasy Inset left: This postage stamp from the Soviet Union warns: " Sobriety -the normal way of life. " Above : Norway's Minister of Health and Social Affairs, Leif Arne Hel~e, invites his countrymen to drink water. Photo Norwegian Directorate for the Prevention of Alcohol and Drug Problems © 13 One tor the road? It is just 100 years since the German inventor Gottlieb Daimler produced the first commercial automobile. Since then motor vehicles have grown from being the playthings of the rich few to constituting a trans- port system that plays an essential part in the lives of most people on this planet. The benefits in terms of con- venience and personal mobility have been immense. But there is a price to pay in terms of the lives lost and suffering caused through accidents. And one factor that has consistently been identified as increasing the likeli- hood of being involved in a road accident is the use of alcohol by road users , whether drivers or pedestrians. Recognition of the problem is not new. In fact it preceded the motor vehicle itself, in the form of laws introduced in the nineteenth century to deal with drunken drivers of horse- drawn and steam-powered vehicles and with drunken behaviour on the highways in general. The first few decades of this century saw increasing numbers of road acci- dents and a growing realisation that alcohol could be playing a significant part in causing theni. Governments reacted to the problem by enacting laws and imposing quite harsh pen- alties, including fines, licence with- drawal and imprisonment. The diffi- culty was how to judge the point at which a drinking driver became an unacceptable risk on the road. During the 1920s and 1930s it was determined that the amount of alcohol present in body-fluids could most con- veniently be measured by taking and analysing small amounts of blood, urine or even breath, which could readily be obtained from drivers. Courts which accepted body alcohol levels as evidence soon began to relate 14 by Alex lrving alcohol levels to the likelihood of the driver having been responsible for an accident or committing a serious traffic offence. Alcohol levels were usually defined for convenience as the amount present in the blood, which could be directly related to the amounts in the other fluids. The im- portant levels for driving ranged from about one half part to two parts of alcohol in one thousand parts of blood , which may be written as 0.5 per mill and 2.0 per mill. At levels of alcohol in the blood amounting to greater than one part in one thousand parts (1.0 per mill) a driver would be very likely to be convicted. Drunken drivers risk other lives besides their own. Photo W HO/P. Almasy Findings from the many studies made in recent decades seem to be universally applicable; the relative risks to drivers who drink are the same whether in Bangladesh, Belgium, Botswana or Brazil. The absolute numbers of accidents involving drink- ing in any one country will depend on other factors , including driver training, experience and attitudes, and the gen- eral road traffic situation. N everthe- less there was now an accepted yard- stick by which the accident risk due to alcohol could be judged. For legal purposes , two approaches emerged; in one the use of alcohol by drivers was effectively forbidden, and in the other a maximum allowable level of 0.8 per mill became the most popular choice. The 0.8 per mill level received support from international organizations, such as WHO, and from various country groupings. Today, enforcement procedures are relying more upon accurate breath- test machines, simple enough to be used by trained policemen but which provide legally acceptable evidence, rather than blood testing which in- volves medical attendants and costly analysis. The use of alcohol by road users is the largest single identifiable con- tributory factor to road accidents, and in theory should be relatively easy to prevent. In practice , the problem is surprisingly robust and resistant to treatment , especially in the developed countries , where both drinking and driving a car are integral social fea- tures of long standing. The developing countries may be in a much better position, and most of them have either imposed a com- plete ban on alcohol when driving , or have set maximum alcohol levels for drivers at about 0.8 per mill or lower. The experiences of the developed countries are being studied with some advantage and important lessons have been learned to benefit the Third World. During the early period of motor transport growth, the emphasis was on detection and punishment of offenders. With hindsight , it might have been more appropriate to con- centrate on public health education and reinforcing of social pressures against drinking and driving. • Further reading: The influence of alcohol and drugs on driving (1981), EURO Reports and Studies No . 38; Alcohol Policies , by M arcus Grant (1985), wHo Regional Publication, Euro- pean Series No. 18. W ORLD HEALTH, June 1986 • Books· and Publications Like a thief in the family "Palm wine 'tap- pers devote a great deal of time to that activity. Af- ter the wine has fermented , it is usually drunk in the company of friends . So all the effort provides no additional income for the family. Furthermore, a palm tree used as a source of wine ceases to bear fruit." This explanation accompanies an illustration showing a man in Africa perched up a palm tree and extract- ing its sap. it is one of the drawings in "Alcoholism", a health education handbook written by Nzungu Ma- vinga, B. Pierre and J. Courtejoie, and published by the Office of Health Promotion Study and Re- search in Zaire . The drawings themselves make up a small educational "film", the three-stage history of a happy family whose palm tree was a steady source of income. They sold the whole coconuts, the nut kernels or the oil extracted from the nuts in the local market. But one day "alcohol- ism found its way into the family, like a thief." A "friend" taught the father how to make palm wine, the traditional fermented drink. The wine robbed him of the desire to work, and induced him to buy other forms of alcohol, to neglect his household and to beat his wife . it was not long before the children went hungry, suffered from malnu- trition and could no longer attend school. Finally, the father was in- volved in a traffic accident which put him in hospital . The third stage shows the family restored to its happy and harmoni- W ORLD HEALTH, June 1986 ous state, having learnt to say No to alcohol. The father provides the family with good food such as fish, eggs, meat and vegetables . He pre- fers cycling to drinking beer, and the children, who are cheerful and well fed, work well at school. This little " film", which is offered to the health worker as an edu- alcoolisme alcoholism alcoolismo AFFICHE MURALE n~ 1 ALCOOLISME 1 cational tool, is one section of a comprehensive review, written in simple, readily understandable language, about alcohol and its consequences . The writers remind us that there are many traditional forms of alcohol in Africa, besides those that are imported mainly from Europe. Home-made or prepared in the vil- lages, they include those produced by fermentation - palm wine and beer made from sorgho (amarwa, intulire, indera). millet (dolo, tose). bananas (urwagwa, inkangaza), maize, and honey (mead, "ubuki "); or by distillation-liquor made from the palm, maize, bananas or pine- apples, and arki distilled from maniac. Alcohol consumption is a real threat in African society, which has so many other obstacles impeding its development. The handbook tells us that "what really has an effect is not prohibiting but informing." it does this very thoroughly, debunk- ing the myths that alcohol is good for you, giving a detailed account of the medical and social disorders that arise from alcohol abuse and analys- ing the various approaches to the control and prevention of alcohol- ism. it suggests how to run health education sessions and gives exam- ples of useful educational materials . Above all, the authors situate the control of alcoholism in the setting of integrated development, and show how this scourge affects all major social and economic fields. "Controlling alcoholism is one of the key factors in the social and economic development of a coun- try, and an important public health factor," they point out. The handbook- which is pub- lished in both French and En- glish-ends on an optimistic note; a young woman says with a smile: "I 'm doing well in my studies because I don't drink alcohol . " For further information, write to : Bureau d'Etudes et de Recherches pour la Promotion de la Sante, B.P. 1977, Kangu-Mayumbe, Re- public of Zaire. C. V. 15 Uhroughout history, human societies have recognised certain substances of natural origin which either offer temporarily heightened perceptions or suggest an escape route from the unpleasant features of life, whether real or imaginary. Fermented liquor from fruit or vegetables, or plant products such as opium, coca leaves, cannabis, khat and tobacco have been accepted in varying degrees as social lubricants or as private escape mechanisms. The drinking of wine and other fermented liquors were chronicled in the earliest literature known to us. But in comparatively recent times, voices have been raised against many such substances. For instance King James I of England, around the year 1600, inveighed against tobacco. lt was, he wrote, "a great contempt of God's good gifts that the sweetness of man's breath .. . shall be wilfully corrupted by this stinking smoke. " For good measure, he added that the habit was "a branch of the sin of drunkenness, which is the root of all sins ." But for every such grumbler, there were scores of poets, philosophers and physicians willing to speak out in praise of drinking, smoking or chewing one or another drug. What has come more slowly to the attention of the world is the realisation that these substances produce addiction, and lend themselves to abuse. Meagre compensation In the case of cigarettes, their mass production coin- cided with the First World War, when they were handed out virtually free as meagre compensation to soldiers enduring desperate conditions in the trenches. lt has taken many decades for medical science to confirm the causal relationship between smoking and such illnesses as lung cancer, ischaemic heart disease and bronchitis. Undoubtedly it could be said of alcohol, as it is already said of tobacco, that if these substances were invented and put on the market today, both would promptly be condemned and outlawed by all countries' food and drug authorities. This has already been the fate of heroin and its derivatives, the hallucinogenic drugs, and the many phar- maceutical products which were created to ease pain or treat disease but unfortunately turned out to lead to dependence and abuse. The positive response to all these substances is to find and promote worthwhile social alternatives to addictive behaviour. While more pressure can be brought to bear on governments to tighten the borders around drug-produc- ing countries or to increase prices of alcohol and tobacco, people must be left with an open choice. If individuals esteem their own health and that of others sufficiently highly, they are less likely to indulge in harmful practices. In the words of this year's World Health Day slogan : Healthy living-everyone a winner. • The cigarette that makes young boys feel like grown-up men; the alcoholic lift that gives a temporary rosy glow to life ; the narcotic " fix" that seems to offer an escape route from daily squalor. WHO Photos by H. Christoph, P Almasy and T. Urban W ORLD HEALTH, June 1986 ' Social alternatives to these scourges of civilisation are not far to seek- whether in competitive sports like running or in risk- taking adventures of all kinds. WHO Photos by E. Mandelmann and Zafar Drugs are Dig business Any nation will drink more alcohol, smoke more c1garettes or abuse more opiates if the relevant drug is made more available. The key to reducing drug-and alcohol-related problems lies In control- ing production, marketing, retailing and distribution by Anthony W. Clare lB onfronted by the deluge of statistics relating to the inter-national epidemic of cigarette smoking, the inexorable rise in alcohol production and consumption, the pro- liferation of opiate dependence and the remorseless growth of the psycho- tropic drug market, it is hard to resist adopting one of two attitudes. The first , a resolutely pessimistic approach, is to conclude that societies in every quarter of the globe are hell-bent on drugging themselves into a terminal state of euphoria and malaise. The second, ruggedly optimistic, is to draw comfort from the fact that there has never been a society on this earth which has not experimented with , habitually relied upon and oc- casionally abused some mind-altering substance. Which of these two positions the average individual adopts depends as much on his or her temperament as on the state of our contemporary and historical knowledge. Professionals working in the health field-doctors, nurses , primary health care workers, lay healers-all occupy an uneasy position within the drugs debate. They feel, and indeed are , morally obliged to document and pub- licise the extent to which we all ingest , smoke, drink and inject nicotine, al- cohol and drugs; yet in carrying out 18 such a valuable task they find them- selves slipping into or being pushed to adopt the role of moralisers, priests and social engineers. For while such drugs have profound biological conse- quences, the factors that primarily in- fluence their use are psychological , Drugs destroy families An English couple, both aged 37, have been jailed for ten and seven years respectively for the manslaughter of their 15- month-old daughter by giving her an overdose of a heroin substitute . Both had been medically prescribed the drug Methadone in an attempt to wean them off taking heroin . They told a London court that they gave the drug to the baby "to quieten her down ." social and cultural. Our understanding of a person's propensity to alter his or her mind with various chemical sub- stances will not be advanced by way of a narrow medical perspective. The medical profession ought not to de- duce that, because a certain drug be- haviour in a certain individual can legitimately be construed as an illness , the general use of such a drug in some way reflects a pathological society. The fact is that drugs-all kinds of drugs-constitute very big business throughout the world. In Zimbabwe , tobacco production is the nation's largest industry. In Malawi, 100,000 families rely on cash from tobacco , while in the Indian state of Andhra Pradesh, tobacco provides a living for 75 ,000 farmers and about two million other workers are engaged in curing, packing and processing. The soaring consumption of alcoholic drinks in Third World countries has just begun to worry health care workers at a time when it is taken by some economists as a sign of improving living standards and growing industrialisation. Spec- tacular growth rates in beer produc- tion have been achieved in countries as varied as Japan and Bulgaria, the Netherlands and Yugoslavia. In the past 20 years, Nigeria, Mexico and Brazil have become major beer pro- ducers by world standards and have joined such traditional producers as the Federal Republic of Germany and the United Kingdom at the top of the league. The situation is little different when it comes to illicit drugs. Ever since a fully fledged opium market was opened up in South-East Asia in the nineteenth century by the United Kingdom and other European impe- rial powers , there has been a massive W oRLD HEALTH , June 1986 Drugs are big business Left: Opium-smoking in South-East Asia. Commercial motives among the European imperial powers in the nineteenth cen- tury encouraged the opium trade. Photo CIRIC © Right: Why the insatiable need for drugs such as alcohol? Does it reflect the growing self-asser- tion of youth-since drug use and abuse is primarily an activ- ity of the young? Photo CIRIC ©and WHO/P. Hendricks international trade in the cultivation and distribution of opiates and related substances. Opium in the East , like rum and guns elsewhere, was offered by European traders in return for spices, silk and tea from China and the East. Now developed and developing countries alike are struggling to con- tain what has been termed "the global heroin economy," which includes street dealing in Manhattan, the prob- lems of opium farmers in India , Paki- stan, Sri Lanka and Thailand , and smuggling networks which criss-cross the world's airways and oceans. Her- oin use is spreading in poppy-growing countries themselves. While alcohol and nicotine tend to be regarded as licit drugs and the opiates in general are under elaborate international controls, other mind- a,ltering substances, such as cannabis and industrially produced psycho- tropic drugs, occupy a sort of no-man's land. One popular Jamaican rhyme reverses the usual image of alcohol as the superior, status-related drug and ganja (marijuana) as the inferior, down-market product: You drink white, rum you tumble down; You smoke kali weed, you succeed. The dramatic expansion of psycho- tropic drug prescribing in Scandinavia, the UK and North America in the WoRLD HEALTH, June 1986 1960s and 1970s was largely sanc- tioned by the medical profession. Only recently has it begun to provoke alarm, and there is evidence that a similar epidemic of drug use is spread- ing to the Third World . So why is there this seemingly insa- tiable need for drugs? Is it a reflection of the growing self-assertion of youth throughout the world, given that drug use and abuse, particularly of the illicit kind, is primarily an activity of the young? Does it reflect a world-wide loss of confidence, an international epidemic of anxiety and demoralisa- tion that is being "treated" by a wholesale recourse to intoxication? Is it a quirk of statistics? After all, it is often pointed out that no reliable statistics have ever been kept of the amounts consumed in Africa, Asia and Latin America of traditional fruit- or cereal-based alcoholic drinks. There is hardly an expert in this area who does not believe that many fac- tors play their part in drug use. But most would agree that the strongest single cause of the high levels of consumption is the rate of production and the energy and enthusiasm with which the product is marketed. Any nation will drink more alcohol, smoke more cigarettes or abuse more opiates if the relevant drug is made more available. Not surprisingly, doctors and nurses, primary health care workers and interested members of the public are beginning to realise that the key to reducing drug- and alcohol-related problems lies in controlling produc- tion, marketing, retailing and distribu- tion. And this realisation, in turn, sets the stage for a difficult confrontation between those anxious to reduce the negative impact of drugs on society and those for whom the production and distribution of such drugs repre- sents a livelihood. To paraphrase Sir William Osier, the desire to take drugs is one feature which distinguishes man, the animal, from his fellow creatures. It is, as that wise Canadian physician observed , one of the most serious difficulties with which we have to contend. He foresaw in the success of the pharma- cists in producing remarkable re- medies the danger that we would be- come used to assuming that for every ill there is a pill . That danger, if international statistics do indeed mean what they appear to mean, is already upon us. A Pandora's box has been opened, and a host of evils have been poured on the world. But let us not forget that, in the ancient Greek legend of Pandora, it was said that hope alone remained at the bottom of her box as a comfort to mankind . • 19 Lifestyles and Health Meeting the threat ol drug abuse U n March of this year. representa-tives from 30 countries met at Lan-caster House. London, for a confer- ence of Ministers of Health on narcotic and psychotropic drug misuse. This conference provided a unique oppor- tunity for the collective views of these governments to be brought to the at- tention of the world community . Their joint statement will be put before the 1987 UN Conference on Drug Abuse. The misuse of narcotic and psycho- tropic drugs leads to many other kinds of problem as well, but the focus of the London conference was specifically on health problems and on the action that health ministries can take to counter this threat. by Marcus Grant Action to reduce health problems arising from narcotic and psychotropic drug misuse still has to face powerful political and economic interests that are opposed to effective programmes. This is true at both national and international levels . Within and between countries. there are forces at work that seek to undermine efforts to develop a com- prehensive response to the health prob- lems related to drug misuse. The chal- lenge to the health sector is to dispel uncertainty about preventive and cura- tive action and to mobilise the will of ordinary people to join in the efforts to control drug-related problems. Unfortunately, both nationally and in- ternationally, the information available on the nature and extent of drug abuse problems is far from adequate . Al- though the general upward trend is clear, estimates of production and con- sumption are uncertain and information on the prevalence of particular prob- lems, including dependence, is very hard to obtain . There are many reasons for this. some of which relate to the illegal nature of the substances . A preventive strategy begins from an awareness of the multiplicity of factors Stomach pump treatment for a patient suffering from a drug overdose. Powerful forces are at work, seeking to undermine efforts to counteract drug misuse. Photo W HO!T. Urban involved in narcotic and psychotropic drug misuse. Efforts in recent years to reduce the supply of drugs through control mechanisms have not been suf- ficient to deal with the rising demand . As the emphasis shifts towards giving higher priority to st rategies aimed at reducing demand. the health sector must expect to play a more and more central role in developing national and international responses. Reducing demand will call for much more than health education, although the importance of educational strat- egies shou ld not be forgotten. Much health education has in the past been directed exclusively at young people. Although they remain an important group, others. such as parents and community leaders. must not be left out of the programme. it will also be important to change the practice of health professionals. and this will include training medical prac- titioners in better prescribing practices and appropriate legal measures. The development of activities at the com- munity level . mobilising the will of the people to take action to counter the threat of drug abuse. will greatly streng- then a national programme of preven- tion. Community development is based on knowledge of the community and its problems; individuals need to be iden- tified within the community who will work closely with the health sector. A programme of education and preven- tion should therefore involve the active participation of community leaders in its design, delivery and evaluation . On one level, a national policy on narcotic and psychotropic drugs cannot be separated from the overall national policy on health. but equally a national drugs policy will involve the essential collaboration of many other sectors of government. For each country, the process of defining a national drugs policy will require a balance between concerns for mental hea lth. for wider health issues. and for overall national development. A national policy, once formulated. must be kept under review. Within the framework of the policy, a national plan of action can be developed that leads to specific programme steps in preven- tion. treatmer-~t. research and training. But this occurs within a changing politi- ca l and economic climate. As circum- W ORLD HEALTH, June 1986 stances change, so must some aspects of the national programme. What re- mains constant is the commitment to long-term action and the recognition that the solution to drug misuse prob- lems lies in prolonged effort rather than in unplanned or uncoordinated initia- tives. however sensational some of those may be. Planning national pro- grammes means planning for action by many people working in harmony. Opportunities for international collab- oration are most likely to develop out of national policies on narcotic and psychotropic drug misuse. Thus. tech- nical cooperation between developing countries can, for example, include al- ready existing programmes to control drug misuse problems in each of the countries involved . Equally, linkages be- tween developing and developed coun- tries are likely to grow in strength as the advantages of effective cooperation become apparent. Producing countries and consuming countries may view drug misuse problems from somewhat different perspectives. but they are likely to be united in their con- cern to minimise their adverse health consequences. Despite social, cultural, economic and political differences. countries can learn from each other's failures as well as from each other's successes. All too often, experiments are repeated that are known by others to have been unproductive. A fuller and more open exchange of all types of experience at community and national level can lead to a better international response. Not only W HO but also other United Nations agencies certainly need to in- crease their current level of activities. Just as a com mitment to action is essential to make national programmes effective. so too is that commitment important for international efforts. The international agenc'ies have the techni- cal capacity and the will to take action . By eo-sponsoring the conference in London and by taking responsibility for its scientific preparation. WHO has demonstrated its w illingness to inten- sify its own efforts. In fol lowing up the recommendations of the conference, WHO and the participating countries will be working together to meet the major threat to the world's health that is being created by the misuse of narcotic and psychotropic drugs. • Vienna Conference 1987 Drug abuse presents as des- tructive a threat to present and future generations as the plagues which swept many parts of the world in earlier centuries. Unless controlled. its effects could be even more insidious and devastat- ing. In order to coordinate a con- certed and determined struggle on the part of the entire world com- munity, an International Confer- . ence on Drug Abuse and Illicit Trafficking will be held at ministe- rial level in June next year. at the International Centre in Vienna . A resolution of the UN General Assembly last December strongly urged all states to summon the utmost political will to combat drug abuse and illicit trafficking by generating increased political. cul- tural and social awareness. it also called upon the UN, the specialised agencies and other organizations of the UN system and non-govern- mental organizations to give the highest attention and priority pos- sible to international means to combat illicit production of. traf- ficking in, and demand for drugs. The resolution emphasises the need for all states to ratify the existing drug control treaties and to make serious efforts to comply with the provisions of these instru- ments . In convening the 1987 Vienna Conference. it urged the adoption of a comprehensive multi-disciplinary outline of future activities. which will focus on concrete and substantial issues di- rectly relevant to the problems. The Conference will undertake an in-depth review of existing mech- anisms. and will suggest govern- mental. inter-governmental and non-governmental objectives for combating all forms of drug abuse. drawing up strategic legislation and improving UN coordination. At this Conference. a thorough review will be given to subjects ranging from supply of substances of abuse to a reduction in demand. WHO has a special interest in these subjects and in particular in reduc- ing demand . The ministries of health have specific responsi- bilities in the area of epidemi- ological investigation. treatment and prevention of drug abuse. • 21 Escape into nightmare by lnayat Khan Throughout history , humans have known drugs of natural ori- gin which may help them to escape from the unpleasant fea- tures of life , whether real or imaginary , by using fermented liquor or plant products such as opium , coca leaves , cannabis and more recently khat: The realisation that these substances have the capacity to produce depen- dence and abuse came only slowly. Mor- phine was first recognised as a cure for opium addiction, and then found to produce addiction itself. Heroin, another synthetic substance ( diacetyl morphine) , was invented as a harmless cure for coughs but its dependence- producing properties were soon disco- vered and its use was outlawed. Cannabis in its various forms was used in different cultures, despite its harmful effects. Studies are continuing on plant material and the substances isolated therefrom to determine the therapeutic principles and explain the harmful effects. Chewing coca leaves was once the mainstay against hard work in the mountainous region of the Andes ; today cocaine is considered one of the most powerful dependence-producing substances obtained from natural resources. In fact , it was the large-scale use of some of these natural products which drew attention to the need for control of such dependence-producing substances and at the same time to the desirability of reducing the demand for them. There is still great concern in the minds of the public and national authorities about the abuse of narcotic drugs and psy- chotropic substances derived from plant material. Additional problems have arisen from the use of modern synthetic drugs cre- ated in large numbers by scientists in medicine and industry. Chemicals of great therapeutic benefit are now avail- able as narcotic drugs with an opiate- like action , and also in the wider area of psychotropic activity-stimulants of the 22 central nervous system, sedatives, hyp- notics and tranquillizers. These syn- thetic drugs do indeed produce relief, but they also produce dependence , and create nightmarish public health and social problems when they are diverted into illicit traffic. Efforts to provide an international legal framework for the control of psychoactive drugs , begun by the Inter- national Opium Commission in Shang- hai in 1909, have resulted in a number of international treaties. The formula- tion of the 1961 Single Convention on Narcotic Drugs, with its 1972 amending Protocol and the 1971 Convention on This painting by a heroin addict reflects the nightmare world of drug dependence. Photo WHO/K. Brodie Psychotropic Substances, are the major milestones in the development of coor- dinated international control of depen- dence-producing drugs . WHO gives high priority to the res- ponsibility assigned to it by the inter- national drug control treaties-responsi- bility which includes assessing each sub- stance for its medical qualities. Particu- larly over the past ten years, WHO has devoted greater resources and efforts to reviewing the benefit and risk ratio of narcotic drugs and psychoactive sub- stances. These reviews concentrated on three types of drug: amphetamine-like substances; opioid agonists and an- tagonists; and benzodiazepines. Amphetamines are synthetic powders formed into a variety of tablets and capsules for medical use , sometimes in combination with other drugs . In the 1950s and 1960s they were widely pre- scribed for depression and to suppress the appetite. Today they are little used , but are occasionally recommended for hyper-activity in children. Many of these substances produced dependence and have been widely abused, so they have been placed under very strict control in most countries. Some of the examples are fenetylline and cathinone. The latter is an active principle of the Catha edulis plant (khat). Opioid agonist and antagonist drugs are very useful in pain relief but can produce a state of dependence and thus are liable to abuse. On WHO's recom- mendation, pentazocine is the only drug of this type so far to have been placed under international control, while the others are being monitored by WHO. Benzodiazepines are used to control anxiety and tension, to sedate and to help induce sleep and muscle relaxation. They are the most commonly prescribed group of drugs in nearly every society and, being safer, they have replaced barbiturates for most medical purposes. These tranquillizers are taken by mouth and are not injected to any extent by drug abusers. The proportion of women using tranquillisers is double that of men. Many users may be dependent to some extent. Tranquillizers depress mental activ- ity and alertness, but don't generally make people as drowsy or as clumsy as barbiturates do . Nevertheless, they do impair driving and other skills. Like alcohol , they can sometimes release aggression by lowering inhibitions. On their own , tranquillizers rarely produce the euphoria associated with barbiturates or alcohol, a fact which probably accounts for their lack of popularity as recreational drugs. But psychological dependence on ben- zodiazepines is quite common amongst long-terms users and can be very dif- ficult to cope with. People sometimes feel confused, irritable and anxious after they stop taking the drug. In early 1984, the UN Commission on Narcotic Drugs, which had initially requested WHO's recommendations, placed 33 commercially available benzodiazepines on schedule IV of the 1971 Convention, thus cautioning pa- tients and those who prescribe these drugs and the concerned industry. These drugs already required a physician's pre- scription in developed countries, so this action alerted developing countries to use these useful drugs with caution. • W ORLD HEALTH, June 1986 ''Glue-sniffing'' U nhalants or solvents are chemicals which are volatile at room tempera-ture and produce effects similar to alcohol or anaesthetics when their vapours are inhaled . Some common members of this class of inhalants are toluene, gasolene, kerosene, carbon- tetrachloride , amyl nitrate and certain drugs used to induce anaesthesia such as halothane and nitrous oxide. Recent experience shows that in some countries the abuse of these agents is on the increase. The usual pattern is for children to start experi- menting with inhalants at around twelve years of age, but few people are still using them after the age of twenty- two. Those who do continue using these substances develop a psycho- pathological state and associated social problems. Most young inhalers turn to alcohol and cannabis as they grow older. Inhal- ants produce various effects ranging from an intoxication similar to alcohol to that induced by· hallucinogens; this effect develops rapidly and subsides within minutes. Inhalants are present in common objects found at home , such as glue, paints, nail varnish remover , dry cleaning fluids and de-greasing compounds . Others occur as propellent gases in aerosols and fire extinguishers, or as fuels (petrol or cigarette-lighter gas). Sometimes sniffers heighten the effects by increasing the concentration of the vapour and excluding air, for instance , by sniffing with a plastic bag placed over their head-a dangerous enough procedure even without the chemical substance. Inhaled solvent vapours are ab- sorbed through the lungs and rapidly reach the brain. Part of the effect is due to the reduced oxygen intake. Such body functions as breathing and heart rate are depressed, and repeated or deep inhalation can result in an "over- dose" causing disorientation , loss of control and unconsciousness. In normal circumstances, sniffers quickly recover. The experience is very like being drunk-youngsters get merry and fool about together. Experienced sniffers may go on to seek dream-like experi- ences ; but generally these are not true hallucinations, since youngsters don't confuse them with reality. The effects of solvent vapours come on quickly and disappear within a few minutes to half an hour if the sniffing is stopped. Afterwards the youngster may Punks sniffing glue in the squalor of a West European slum. Photo L. Sirman © experience a mild hangover (headache , poor concentration) for about a day. Accidental death or injury can hap- pen because the sniffers become "drunk", especially if they are sniffing in an unsafe environment- on a bal- cony or beside a river. Sniffing to the point of falling unconscious entails the risk of death through choking on vomit. If the method used to inhale the solvent obstructs breathing (large plas- tic bags placed over the head or sniffing in confined spaces) and the sniff er becomes unconscious, death from suf- focation may occur. Some products (notably aerosol gases and cleaning fluids) sensitise the heart and can cause heart failure, especially if sniffers exert themselves at the same time. Gases squirted directly into the mouth can also cause death from suffocation. Deaths are in fact rare and most can be avoided, even if sniffing itself can't be prevented. Sniffing glue from small bags held to the mouth and nose has directly caused very few deaths . Rela- tively more have been associated with, say, aerosol or butane gas inhalation , or with bags placed over the head , even though these are almost certainly less common practices. Very long-term heavy solvent mis- use-over ten years-might result in moderate but lasting impairment of brain function, affecting especially the control of movement. Chronic misuse of aerosols and cleaning fluids has caused lasting kidney and liver damage , whilst repeatedly sniffing leaded petrol may result in lead poisoning. Despite these possibilities, it seems that lasting damage attributable to solvent misuse is extremely rare. Whilst someone is sniffing repeat- edly, the " hangover" effects of pallor , fatigue, forgetfulness and loss of con- centration tend to become a recurring daily pattern. The youngster's perform- ance and functioning are affected and there can be weight loss, depression and tremor. But these will clear up once sniffing is discontinued. Tolerance develops , but physical de- pendence is not a significant problem. Psychological dependence develops in a minority of susceptible youngsters with underlying family or personality problems, and these will probably become "lone sniffers," as opposed to the more common pattern of sniffing in groups. I.K. Chewing khat More than seven centuries ago, a medical book written in Arabic recorded the effects of chewing khat. Today several million people in East Africa and the Arabian peninsula are habitual chewers-and some of them become addicted U he chewing of leaves of the khat shrub (Catha edulis) is common in certain countries of East Afri- ca and the Arabian peninsula, and some khat users are subject to psychic dependence on the drug. The effects of khat are reminiscent of that induced by amphetamine. Recently, the al- kaloid cathinone has been isolated from khat leaves and this substance produces effects in animals that are analogous to those of ampheta- mine and that correlate well with the effects observed in humans after chewing khat. The use of khat as a stimulant is thought to antedate that of coffee , and the first written account of the effects of khat appeared more than seven centuries ago in an Arabic medical book. Today, several million people are habitual khat chewers. Formerly , the use of the material was confined to the regions where the plant was grown, because only the fresh leaves give the desired stimulating effect. But in recent years the habit has expanded Khat is sold openly on the streets in many countries of the Middle East. Photo W HO 24 by Peter Kalix considerably because khat can be transported much more rapidly to dis- tant places. The cultivation and use of khat have profound socio-economic consequences for the countries con- cerned and make a considerable im- pact on the life of the individual. Khat chewers are mostly male and the harm to their families is due to negligence, dissipation of family income , and inap- propriate behaviour. Many of them spend money on khat while neglecting their vital needs, which indicates psychic dependence on the drug. The main effects of chewing khat are a moderate degree of euphoria and W ORLD HEALTH , June 1986 excitation often accompanied by loquacity . High doses may induce hyperactivity and, sometimes, manic behaviour. Although there have been several reports of cases of psychosis due to khat chewing, this is rather exceptional, probably because of the physical limits to the dose that can be absorbed. Khat is an effective anorec- tic , that is , it diminishes the appetite, and this largely explains the malnutri- tion often seen in habitual khat users. It also causes hyperthermia and an increase in respiration. The effects of khat are, of course, difficult to quantify since the leaves are a non-standardised material, the potency of which depends on freshness and origin, and there are certainly differences between chewers in the efficiency of the mastication process. The international organizations were confronted with the problems associated with khat as early as 1935 , when the League of Nations Advisory Committee on the Traffic of Danger- ous Drugs discussed two technical re- ports on the subject. Through the UN Commission on Narcotic Drugs , inter- national attention was once again di- rected to the nature and extent of khat use , and in 1971 the Commission W oRLD HEALTH, June 1986 recommended that the UN Narcotics Laboratory should reinvestigate the chemical composition of khat. These studies led to the isolation from khat leaves of an alkaloid that is chemically similar to amphetamine and for which the name cathinone was suggested. It was also observed that, to a certain extent, the cathinone content corre- lated with the market price of khat. Active principle Once this substance was recognised as the major active principle of the leaves, it was synthesised and made available to pharmacologists through WHO, which also appointed an advis- ory group to carry out an initial survey of the pharmacological properties of the new alkaloid . These studies re- veald that the pharmacological profile of cathinone closely resembles that of amphetamine. In experiments with such animals as rats and monkeys , which were trained to administer the drug to themselves, the pattern observed was described as "spree-type": the animals took the drug frequently day and night, stop- ping only upon becoming exhausted , and beginning again after recovery . Leaves of the Catha edulis plant. Left : People meet at khat parties to gossip and discuss business affairs. Unfortunately khat chewing can lead to addiction. Photos CIRIC © This pattern corresponds to that seen in amphetamine-dependent humans. Thus, in terms of pharmacology, the chewing of a portion of khat is tan- tamount to ingesting amphetamine-a fact discovered mainly through the impetus given by WHO to the identifi- cation and pharmacological investiga- tion of the new compound. This find- ing shows that there is a certain degree of danger associated with khat use. Although immediate and severe medi- cal problems are infrequent (because the cathinone is diluted in the other material of the leaves), the use of khat often leads to health problems, and this, taken together with the serious socio-economic consequences of the habit , makes its limitation desirable. Effective reduction of the use of khat would relieve several million people of a costly, counter-productive and potentially addictive habit. It would even free scarce arable land and irrigation water that are, at present, used for cultivating khat. Several countries concerned by the khat prob- lem are now taking steps to restrict its use , and in order to catalyse these efforts, WHO has sponsored field studies on medical and epidemiologi- cal aspects of khat chewing. • 25 Designer drugs Manufactured by expert chemists, a new wave of potent heroin analogues-far more deadly than heroin itself-is sweeping the USA. And the fear is that they might spread to other countries A new variety of street drugs is emerg- ing that presents a novel challenge to scientists and legis- lators. So-called de- signer drugs are made by performing small alterations in the molecular structure of a controlled substance. The result can be a drug that is thousands of times more potent than the original, yet can be technically legal to make and use . This is because most countries outlaw drugs of abuse by list- ing specific controlled substances in their legislati<?n, and the new substance "is not on the list. " Designer drugs have been made be- fore, notably XTC, a hallucinogenic, and various analogues of amphetamines. Today there is a new wave of potent heroin analogues, mostly being manu- factured by qualified chemists rather than amateurs in the United States, which are far more deadly. And the fear is that they may spread to other countries. Projected legislation in the US is aimed at eliminating the manufacture and distribution of substances which are chemically related to a controlled drug. In this way the US hopes to outlaw designer drugs that may not yet have been made , an approach which is being closely observed by other countries that are worried by the potential threat the new heroin analogues pose. A measure of the skill of the manu- facturers is that, when emergency legis- lation was introduced in the US that could outlaw a designer drug in six weeks , even within that time the under- ground chemists came up with new-and legal-variations. 26 by Roger Highfield Designer drugs may only have a few extra atoms , but they and, as important , their impurities , may offer enormously different potency and duration of action from the original. Fentanyl, for example is a powerful but short-acting narcotic which is a widely used anaesthetic. The derivative 3 methyl fentanyl is different Dr Gary Henderson, pharmacologist at the University of California, was the first to coin the term "designer drugs . " Photo WHO/University of California to the tune of a handful of atoms. It produces a "high" similar to heroin, yet is 1,000 times more potent. A couple of milligrammes are lethal. When and if fentanyl analogues be- come a problem in a country's popula- tion of heroin addicts, forensic scientists would find it extremely difficult to iden- tify the drug if presented with an over- dose victim or an addict. Tests must be designed capable of detecting around one thousandth of a millionth of a gramme of the material in body fluids. The best US assay, based on anti- bodies, can only detect certain fentanyl derivatives. Detecting fentanyls is one thing; but identifying the precise derivative re- quires an expensive piece of equipment called a mass spectrometer, which iden- tifies molecules by, in effect, weighing them. Even so, fentanyl derivatives tend to fall apart in the spectrometer and it takes a computer to work out the struc- ture of the orginal compound. Fentanyl derivatives are associated with over 100 overdose deaths in the US, and many other fentanyl-related deaths probably go undetected . How- ever, at the moment an inexpensive assay seems to be a distant prospect. The rewards reaped by the under- ground chemists can be staggering. Frank Sapienza, a US Drug Enforce- ment Administration expert, estimates that for an outlay of around $2,000 on equipment and chemicals, it is possible to produce a billion dollars ' worth of 3 methyl fentanyl. The chemist does not have to bother with poppy fields or running the gauntlet at the customs house. Just one gramme of 3 methyl fentanyl is enough to produce one mil- lion doses, so a single session in his laboratory will set him up for life. Heroin users in California pay up to 40 dollars for each dose of fentanyl derivative. Underground chemists use the same approach as many drug companies to discover new pharmaceuticals , by syn- thesising a number of molecules similar W oRLD HEALTH , June 1986 to a substance that is known to have pharmacological activity. But drug com- panies aim to make a product with enhanced activity and few side-effects , or that is not in breach of another company's patents. By contrast, the underground chemists are trying to make a legal version of an illegal sub- stance, with little concern for drug trials, quality control , or side-effects. With the " first generation " of de- signer drugs, notably the amphetamine analogues, there were no tragedies. Since then , several designer drug disas- ters have occurred in California , includ- ing the fentanyl overdose deaths already mentioned. Another disaster, associated with a different class of designer drug , could ironically benefit sufferers of Parkinson's disease. The drug was MPPP , a narcotic about three times as potent as morphine and some 25 times as potent as meperidine (from which it is derived). However , a simple error during its synthesis caused a different substance to emerge, known as MPTP. A mixture of MPPP and MPTP-marketed as "synthetic heroin" -led to the first disaster in 1982. Several people who used it began to " freeze"- they could neither move nor talk. Researchers , notably Dr William Langston at the Santa Clara Medical Center, California, found the symptoms were strikingly similar to those of Par- kinson's disease, caused by the death of neurones in an area of the brain called the substantia nigra. His latest work now suggests MPTP may mimic the disease more closely than was suspected. The disaster has provided the first animal model of Parkinson's disease and has given a fillip to research into the condi- tion. lri squirrel monkeys it was found that MPTP produced similar brain dam- age to that found in man. Such animal models may help researchers under- stand the way that MPTP causes damage, providing new insights into Parkinsonism. MPTP itself may be harmless, but it appears that it is converted into a toxic derivative, MPP +, by enzymes in the brain. MPP + is toxic to substantia nigra neurones , the same set that degenerate in Parkinsonism. The conversion of MPTP to MPP + can be blocked by certain substances, and these offer a new therapeutic avenue to be explored. Some 400 people who used the syn- thetic heroin will test such theories. They have, in effect, enlisted in a grim W ORLD HEALTH, June 1986 The new substances are sweeping the United States; other countries are worried by the potential threat they represent. Photo W HO!T. Urban epidemiological study since they may develop Parkinsonism at an unusually early age. Dr Donald Calne, a neurol- ogist at the University of British Colum- bia, recently enlisted the technique of positron emission tomography (Pet), to study six of these people , who had no outward signs of Parkinsonism. Pet showed they had indeed suffered neurological damage. The technique, which builds up a cross sectional picture of the concentrations of radioactively labelled compounds (which emit posi- trons) in the brain , found a decrease in the levels of dopamine, a neurotransmit- ter, in one area of the brain. The de- crease was similar to that found in cases of Parkinsonism. A breakthrough in this field would go a short way towards offsetting the harm that designer drugs have already caused and will cause in the future. The health authorities in a number of countries and WHO itself are watch- ing the situation and will take appropri- ate action to curb this serious public health threat. • 27 by B. Juppin de Fondaumiere The world-wide con- trol of narcotic drugs and psychotropic substances has been developed gradually over the last 70 years by a number of inter- national treaties which finally resulted in the adoption of the Single Convention on Narcotic Drugs in 1961. This was amended by the 1972 Protocol and in the Convention on Psychotropic Substances of 1971 . These treatiys were all adopted after long consideration , inter-governmental consultation and painstaking drafting . Each successive treaty brought forward complementary regulations and ad- vances in international law. From the beginning, however, the basic aim of the international drug control treaties has been to limit the use of drugs to medical and scientific needs only. The 1961 Convention provides for 28 Cocaine use increasing worldwide The availability of and trafficking in cocaine of South American origin has increased sharply in recent years. reflecting the determined efforts of traffickers to expand the illicit market in Western Europe. The Interna- tional Narcotics Control Board in Vienna said that more than one tonne of cocaine was seized in 1984, and almost half a tonne in the first half of 1985. The coun- tries reporting the largest total seizures were Spain, Federal Republic of Germany, the Uni- ted Kingdom. France. Switzer- land and the Netherlands. two distinct "international drug control organs" within the framework of the United Nations : the Commission on Narcotic Drugs of the Economic and Social Council and the International Narcotics Control Board . The different but complementary nature of these two organs may be summarised as follows: - The Commission on Narcotic Drugs is one of the six functional commissions of the Economic and Social Council. It is composed of governmental represen- tatives (at present 40 Members). Its terms of reference include advising the Council on all matters pertaining to drug control and preparing such draft international Conventions as may be necessary. - The International Narcotics Control Board (INCB) is an independent, semi- judicial organ composed of 13 Members (three members with medical , phar- W ORLD HEALTH , June 1986 macological or pharmaceutical experi- ence from a list nominated by WHO, and ten members elected by the Economic and Social Council not as representatives of their governments but in their personal capacity). The Board's functions are to "endeavour to limit the cultivation, production, manufacture and use of drugs to an adequate amount required for medical and scientific pur- poses, to ensure their availability for such purposes and to prevent illicit culti- vation, production and manufacture of, and illicit trafficking in and use of drugs". The Board is independent of governments in carrying out its func- tions in an impartial manner. Alongside the international drug con- trol organs, a voluntary trust fund was created in 1971: the United Nations Fund for Drug Abuse Control ( UNFDAC). It is responsible for financing an effective and coordinated approach to the problem of drug abuse, as part of the UN response to urgent requests from governments for assistance in support of their own drug control efforts. A fundamental fact which guides all activities and operations of the inter- national drug control system should be stressed from the outset: namely that the direct implementation of the system is primarily the responsibility of national authorities. It is they, and they alone, who have the power and the ultimate responsibility for controlling the move- ment of these substances within their respective jurisdictions. Two categories of drugs are control- led by the international drug treaties, namely narcotic drugs and psychotropic substances. At present, control is exer- cised over 105 narcotic drugs and some 80 psychotropic substances. The narco- tic drugs include opium and its deriva- tives, morphines, codeine and heroin , other synthetic narcotics such as methadone and pethidine, and cannabis and cocaine. These drugs are controlled under the provisions of the 1961 Single Convention and of the 1972 Protocol. The psychotropic substances com- prise, broadly, the hallucinogens, the stimulants and the depressants, and they are controlled by the 1971 Convention on Psychotropic Substances. To date, 117 countries are parties to the Single Convention in its original or amended form, while 80 states have adhered to the 1971 Convention. The Commission on Narcotic Drugs has the power to determine whether a new drug should be subject to control, and to transfer a drug from one control regime to another. In so doing, the W ORLD HEALTH , June 1986 Commission must take into account the findings and recommendations of WHO. Governments are required to main- tain a special administration- be it a central authority or a coordinating agen- cy-to implement the provisions of the Conventions. And to ensure that the drugs are used for legitimate purposes, the Conventions require that the culti- vation, manufacture, trade and distribu- tion of drugs be under licence or other similar control measures. Governments have to set up a system of inspection of manufacturers, exporters, importers and wholesale and retail distributors of drugs, and must provide for as frequent inspections of premises, stocks and records as are considered necessary. Under the import and export auth- orisation system (which applies to all narcotic drugs, but only to the most West European customs men seized this smuggled heroin recently-enough for 250,000 "fixes." Facing page: Spurious charm of the para- phernalia for shooting cocaine. Photos L. Sirman © dangerous psychotropic substances), no government may issue an export authorisation before a corresponding import certificate, issued by the com- petent authority of the importing coun- try, has been produced. The reporting requirements oblige governments to supply the INCB with detailed statistical information on the consecutive stages of the movements of the drugs in question, such as cultivation or manufacture, imports and exports and stocks (again these requirements apply to all narcotic drugs, but only to the most dangerous psychotropic sub- stances). The INCB examines these statistics to make sure that no weak- nesses exist in the international control system and that no drugs are diverted from licit trade to illicit channels. The Conventions require govern- ments to make arrangements at the national level for the coordination of preventive and repressive action against illicit traffic, and at the international level for mutual cooperation and for close cooperation with such bodies as Interpol or the Customs Cooperation Council. And the governments are called upon to prosecute and punish major illicit traffickers and arrange for extradition in cases . of drug trafficking offences. The overall task of the INCB is to promote compliance by governments with the various drug control treaties in the interest of the international com- munity as a whole. It has to administer the legal movement of narcotic drugs and psychotropic substances with the precise aim of limiting their production, manufacture, trade and use exclusively to medical and scientific needs. In coop- eration with governments, it ensures that legitimate demand for narcotic drugs is satisfied through the mainten- ance of a proper balance between supply and demand. And it tries to prevent the illegal or illicit cultivation, production, manufacture, traffic and use of drugs . In examining and analysing the infor- mation which it receives from some 190 countries and territories, the INCB is in a position to learn whether the treaties are being applied throughout the world as effectively as possible. It maintains a continuing dialogue with governments, and renders direct assistance by train- ing national drug control administrators at the INCB's headquarters in Vienna, or by on-the-spot training of national officials in countries which face specific problems. If necessary, the INCB may make use of various means of persuasion or pressure. It may request an explanation from the government concerned if it is suspected that the treaty provisions are not being observed, or if there is a serious risk that a country may become an important centre of illicit drug activity . The existing treaties require WHO to recommend narcotic drugs and psycho- tropic substances for international con- trol. WHO is also responsible for conven- ing an expert committee on drug depen- dence which recommends controls if necessary . . The Organization colla- borates with non-governmental orga- nizations (especially the International Federation of Pharmaceutical Manu- facturers Associations), governments and other UN agencies in carrying out these functions. • 29 The Graffiti On the Boards Down Under First in Sydney, then Mel- bourne, then Perth , and now in other Australian cities. graffit- ists are making their mark on billboards, and in the process on the public consciousness as well. They do so often with humour, at times bluntly, but tinged always with a certain Down Under robustness. Advertisers claim they are de- facing the billboards. The graffit- ists, armed with spray cans of paint usually in black, chrome and red, contend they are "re- facing" them. Items : • An advertisement for Ben- son & Hedges cigarettes that said "Excellence in extra mild" became, after one graffitist's touch, "Excellence in extra mil- dew. Rots your lungs and kills you." • An ad of a cowboy on a horse silhouetted against the sunset that said "New. Mild. And Marlboro" became "New. Vile. And a bore." • An ad that said "Anyhow, have a ... Winfield" became "Anyhow, have a coronary." • An ad of a prominent citi- zen endorsing Wills 30 Super Milds that said" Here's an offer worth shouting about," became "Here's a drug pusher shouting out" Photo: WHO/B. U.GA UP BUG activists at work "refacing" Marlboro country. • Dunhill became "Lung Ill" cigarettes. and Rothmans, "Rot Mans." The graffitists are plain but aroused citizens, who are part of a movement that not only signs itself as B.U.GA U.P., but describes its work that way as 30 Parliamentarians for Development Some 60 parliamentarians from 19 European countries have pledged themselves to seek increased f inancial sup- port for U.N. programmes and to work for a better pub- lic understanding of interna- tional development They became essentially "Parliamentarians for Devel- opment" at a two-day forum on child survival, women and population held at the Hague, hosted by the Netherlands parliament and opened in the presence of Her Majesty Queen Beatrix. Their support gave a much-needed boost to the U.N. system, now troubled by cutbacks in con- Photo . Organon Juten © Outside Netherlands Parlia- ment: Directors of UN FP A, UNICEF, WHO. tributions and under criticism as never before. To set the example, Mrs Edgje Schoo, Deputy Director of International Cooperation, announced the equivalent of a US $3 million contribution in Dutch currency for the provision of essential drugs to Third World nations. Parliamentarians heard keynote addresses by Rafael Salas, Executive Director of the U.N. Fund for Population Activities (uNFPA), an agency that has lost US $10 million in US contributions this year, James Grant, Executive Director of UNI CE F, and Halfdan Mahler. Director-General of WHO (left to right in photo) • •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• • ••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••••• • •••••••••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• well. The provocative acronym stands for "Billboard-Utilising Graffitists Against Unhealthy Promotion." They protest cigarette adver- tising, particularly on govern- ment property at railroad sta- tions and on buses. They ex- press outrage at images, aimed at impressionable adolescents, which equate smoking with ath- letic prowess, the good outdoor life or womens's lib. And they ridicule what they consider "unhealthy promotions" - or, at least. present their side of ad- vertisements. BUG activists say its move- ment piques the interest of youth. By speaking of the possi- bility of arrest. fines and even gaol for the cause, they find it easier to go on and discuss the health and social consequences of smoking. "Kids don't seem much interested in listening to a white-coated doctor lecture them on the evils of smoking," activists report Dr Arthur Chesterfield-Evans, a Sydney physician, joined the movement because he, like many others, was "frustrated by the government's refusal to curb advertisers." Being a phantom painter has led to his arrest and to a fine of Australian $20. But. by and large, arrests have been infrequent. and con- victions even less so. Even when magistrates enforce the law they have proved sym- pathetic to graffitists Still. a Fighting Fund has been set up to help pay fines. The movement began in 1979 with a membership of just three whose concern was the in- crease in billboards. Now, a lot of spray paint and thousands of billboards later. their number is up to hundreds from all walks of life, and B.U.GA U.P. is in New Zealand as well. A similar group, MOP UP (Movement Opposed to the Promotion of Unhealthy Promotions), has been estab- lished in Australia, and COUGH UP (Citizens' Organizations Us- ing Graffiti to Halt Unhealthy Promotions) in the United King- dom - all dedicated to the cause of "responsibility in advertis- ing. " • (For details. write· B.U.GA U.P. , P.O. box 78, Wentworth Bldg, University of Sydney, NSW 2006, Austral ia) Daughters Are Disadvantaged Right from Birth lt is evident in a Hindu's wish - " May you be blessed with eight sons" -bestowed upon newly-weds, and in an Arab epithet-" the father of daugh- ters" - spoken in derision. Such attitudes unfortunately are prevalent in virtually all societies 1n the developing world. More than poverty or under-development. they are to be blamed for the low esteem of daughters. and as a conse- quence for the poor health and illiteracy of women. Even though data on the sub- ject are considered "scanty", a review this year of research al- ready done is evidence enough that daughters are disadvan- taged from the moment of birth. Entitled "Health Implications of Sex Discrimination in Child- hood," the review was carried out by Sundari Ravindran, a con- sultant tO WHO and UNICEF. The son preference "deter- mines the quality of parental care, and the extent of invest- ment in the child's develop- ment." the review states. "In extreme cases, son preference may lead to abandonment of female infants, or even to infan- ticide, but it is most common in the sheer neglect of girls." Bangladesh, Jordan, Nepal, Pakistan the Republic of Korea, and Syria are the countries with the strongest preference for boys, according to the World Fertility Survey published by the International Statistical Institute in the Netherlands. Of 40 de- veloping countries surveyed, only two- Jamaica and Ven- ezuela-show a clear prefer- ence for daughters. Sons are preferred for reasons that are part cultural. part religious, and part econ- omic . In some societies, for instance, sons are expected to bear the prime responsibility for the support of parents. The WoRLD HEALTH, June 1986 preference is most pronounced w here the majority of people live- in rural areas. The discrimination against girls is evident in stud ies that show they are not fed as wel l as boys, that they are less cared for during illness, and that less money is spent on them, par- ti cu larly fo r education. " This kind of neg lect of female chi ldren," according to the review, "is not necessarily wilful. .. (but) more a conditioned response to a situation of scar- city " The results are excess female mortality in childhood and, in extreme cases, lower female life expectancy in many count ries. "Every sixth death of a female infant in India, Bangla- desh, and Pakistan is due to neg lect and discrim ination," the review states. Among recommendations made for change: • That hea lth and social worke rs, as well as parents, be made awa re of the risk to the health of girls in societies where discrimination is rooted in tra- dition, • That child mortality rates and life expectancy tables be calculated by sex as well as by age, to bring out the conse- quences of different treatment of sons and daughters, Photo: WHO Girls: Not as well fed as boys; less cared for when ill. • That practices such as dowry and "bride price," which are demeaning, be abolished, and • That countries provide ad- equate pensions for the elderly, to dispel the notion that a son is prized for his support of parents . • WORLD HEALTH, June 1986 Newsbriefs • The Mores of More. In societies consumed with the many "mores " of materialism-" more wealth, more food, more drink, more cars, more tobacco, more sex"- " it is not surprising if the 'more ' includes more narcotic and psychotropic drugs," Or Halfdan Mahler, WHO's Director- General told health ministers from 30 countries meeting recently in London. " If our social values makes drug-taking an acceptable norm among peer groups of youngsters, then it is these values that need to be 'reconsidered, " he suggested as a step to counter the virtually unchecked problem of drug abuse. "So perhaps it is not the youngsters we have to change, perhaps it is some of our social values, " he added. Figures presented to participants shows there are an estimated 750,000 persons world-wide addicted to heroin, 7. 7 million to opium, 4.8 million to cocaine, and 29 million to cannabis. • Adding Life to Years. Moderate exercise in adult life- regular walking, for instance-has been shown to reduce death rates from a quarter to a third in some 7 7, 000 graduates of Harvard University, who were followed from the early 7 960s through the late 7 970s. "There are a lot of sceptics who say people are active because they are healthy, " the New York Times quotes Or Ralph S. Paffenbarger Jr. , the study's director, as saying. However the findings, reported recently in the New Journal of M edicine, indicate the contrary- that " you're healthy because you are active. " • Another Campaign Trail. Former US President Jimmy Carter has pledged to "make up for past mis- takes" in his support for the tobacco industry by now campaigning against smoking. In a letter to the editor of the Journal of the American Medical As- sociation, he writes: "As the scientific evidence has become stronger, I have become increasingly active in attempt- ing to spare people from the tobacco addiction. "Should I have done more in the past? We all should have : educators, physicians, and patients. Let us make up for past mistakes by closing ranks to make our future efforts efficient, effective, and life saving. " Photo: USIA © Former US President, Jimmy Carter. • The Mailman's Message. During Malta 's recently held Health Educa- tion Week, postmen delivered not only mail but health messages too. That week all letters were postmarked Gawdi Sahhtex, or " Enjoy Your Health " - a simple, positive message aimed primarily at schoolchildren. A range of activities such as health walks, fitness and poster displays- on such topics as nutrition, sex education and exercise-stressed the theme of personal responsibility for health. " The idea of healthy living caught on like wild fire, " said Or Oureshi Y. Hayat, head of the Maltese health education unit, in reference to this year 's World Health Day theme : " Healthy Living: Everyone a Winner ". • WHO Award in Health Education. Nominations are being sought from health education institutions, both governmental and private, for this US $5,000 prize and plaque. The award recognises innovative approaches to health education and has been made possible by a grant from the L.l. S.Z. Foundation, a private US. philanthropic organization. Nominations must reach WHO's Division of Public Information and Education for Health by 37 August. In the next issue This year has been designated the International Year of Peace, and the July issue of World Health will address itse lf to fundamental aspects of health and peace. Other articles w ill discuss prepared- ness in case of disasters, the work of rural doctors in China, inequities in the world 's great cities, and the trai ning of medical technicians. Authors of the Month Dr Norman SARTORIUS is Director of WHO's Division of Mental Health in Geneva. Dr David A. PLAYER is Director General of the Health Education Council in London. Mrs Uma RAM NATH is a freelance journalist writing from New Delhi on Third World development themes. Mr William U. CHANDLER is a Senior Researcher with the Worldwatch ln- stitute ·in Washington D.C. Mr Alex IRVING is a researcher with the Transport and Road Research Laboratory in Crowthorne , Berk- shire , UK, specialising in problems of drugs and alcohol on road safety. Professor Anthony W. CLARE is with the Department of Psychological Medicine , St. Bartholomew's Hospi- tal Medical College , London. Dr Inayat KHAN is Senior Medical Officer for the Division of Mental Health, WHO, Geneva. Dr Peter KALIX is a teaching and research fellow at the Department of Pharmacology, University of Geneva Medical Centre. Mr Roger HIGHFJELD is a freela nce journalist based in London. Mr B. Juppin de FONDAUMIERE is Deputy Secretary of the United Na- tions International Narcotics Control Board in Vienna. Mr John WICKETT is a Consultant with WHO's Smallpox Eradication programme in Geneva. Mr Marcus GRANT is a Senior Scien- tist with WHO's Division of Mental Health. WORLD HEALTH For readers everywhere 1986 Subscription Rates US$ Sw. fr. One year Two years Three years 12.50 25.- 22.50 45.- 30.- 60.- ORDER FORM Please enter my subscription to " World Health " as follows : One year D Two years D Three years D I enclose cheque/international postal order in the amount of : ____ _ Name : __ ~--~---~~- Street: __________ _ City: _ ___:_:c.__ __ __::_ _ _ Country:--------- World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed t hrough the network of international bookstores and sub- scription agencies. For payment in national cur- rencies, please contact your usual bookseller. 31