WORLD HEALTH ORGANIZATION

Rapional Offlco Buroau rlgional for tho Eastrnrn Mmdltorranoan pour la Mlditorranlo oriontah

WHO Inter-Regional \\'orkskiop on Prevention and Treatment of Drug Dependence

Alexandria, 16 - 21 October 1978

Drug I)epe~ldencc~In Couritrles

of Eastern h!editcrra~~eanRegion

Dr Taha A. Baasher Regional Adviser on Mental Health WHO Eastern Mediterranean Hogional Office, Alcxandrla TABLE OF CONTENTS

I 111 STORI CAL PERSPECTIVE

1. Origin and early use of drugs 2. Early abuse and prohibition 3. New synthetic substances

I I NATURE AND EXTENT OF DRUG ABUSE

1. Extent of opium us< and abuse 2. Cannabis me and abusc3 3. Studies on khat 4. Abuse of synthetic drugs

I I I FACTORS INFLUENCING DRUG ABUSE

1. Genelal features 2. Number of factors

XV PR, CRAMME DEVEWPME'NT IN DRL'G DEPENDENCE

1. Objectives and strategy in programme development 2. Constraints of programme development 3. General guidelines for programme development (a) Limitation of availability of dependencc- producing drugs (b) hleasures directed at the individual and the group (c) Measures directed towcirds the environment

VI REFERENCES The drugs which are commonly abused in countries of the Eastern Mediterranean Region (EMR) can be generally grouped into five major categories namely, opium and its derivatives, cannabis, khat, alcoholic beverages and a variety of synthetic substances.

In general tho abuse of these drugs is more than a pharmacological reaction. For it transcends the drug user and is intricataxenmeshed An the historical back- ground of the communities under study, the socio-cultural matrix and the prevailing ecological environment. Hence, in discussing the complex problems of drug dependence, due consideration will be given to these inter-r-lated and varied factors.

In this pape? an attempt will be made to briefly describe the historical perspect- ive of drug dependence in countries of EMR, outline the nature and extent of the exist- ing problems, define the objectives, and suggest general guidelines for future planning and programming in tllir complex field. I . HI SMRI CAL PERSPECTI VE 1. Origin and Early Use of Drugs The countries of EMR are among the most ancient in the world and drugs, as shown by recorded history were variouely used at different times and places.

The two varieties of opium poppy, Papaver somniferwn and Papaer rhoeas for instance, seem to have Men known in ancient Egypt and can be clearly recognized from ancient paintings an@ writings. It is believed that the opium poppy was introduced (1) during the Eighteenth Dynasty into Egypt from Mesopotamia.

Importantly, whatever the origin of opium and its mode of spread into the ancient countries of EMR, it seems to have been essentially used for the relief of pain and induction of sleep. Apparently there $s no evidence to indicate that it was abused in these ancient civilizations. It is to be remembered, however, that the healing arts at that time were part of the priest-physician cult and knowledge regarding thera- peutic medications of opium poppy were later transmitted through Greece-Roman times to early Islamic physicians.

In contrast to recorded history on op$um poppy, there is no evidence to indicate the use of cannabis in ancient Egypt. However, its therapeutic use as an anaesthetic was first reported inan early Chinese treaticre on remedies and gradually spread to India, the Tigris and Euphrates Regions, Iran and ~rabia!') Slgnificsntly, cannabis was known to the arabs as Indian herb. Similar to opium and cannabis, since early times, khat (catha edulis) has been known in some countries of E?dR, notably Djibouti, Somalia and Yemen. The first available references date back the cultivation of khat in Ethiopia to the fourteenth century and from there it was reported that in the fifteenth century the plant found its way into the northern part of Yemen. (3

2, Early Abuse and Prohibition Over the years the use of these natural drugs was no longer restricted to thera- peutic practices and were non-medically abused. The earliest reference to the abuse of opium in countries of EMR was made by Al-Biruni of Khawarizm (973 - 1051 A.D. ). He described how people living in hot countries got into the habit of using opium to relieve themselves of the physical distress and secure longez period of sleep. (4) Significantly, he observed that though, at the start, the doses used were small, they were sometimes increased to lethal levels,

In principle, Islamic teachings advocate that the use of any substance which leads to clouding of the mind and causes confusion of thinking should be strictly prohibited. However, as the use of opium and cannabis, unlike alcohol, was not explicitly dealt with in early Islamic doctrines, this might have led to their traditional acceptance.

Along with economic, social and cultural decadence which crept from the tenth century onwards into many countries of -, an escalated abuse of opium and cannabis as pleasure-producing substances seemed to have taken place. Interesting accounts in this respect were given by the renowned traveller, Ibn ~uba~er'~)of the (6) 12th century and later on by distinguished historians such as A1 Maqriai.

Realizing the harmful effects on society from the wide use of cannabis, early attempts of prohibition in some countries were made by various rulers including Napolean after his conquest to Egypt in 1800.(7)

Alcoholism which seems to have been strikingly prevalent in pre-Islamic era in the Arabian Peninsula, has been exceptionally the focus of attention since the early inception of Islam in the seventh century. Prohibition was gradually introduced and the new religious system had brought about far reaching socral and behavioural changes which made hluslim believers readily respond to Islamic teachings. The Holy Koran contains several verses which are concluded as follows "Satan's plan is to excite enmity and hatred among you with intoxicants and gambling, and to hinder you from the remembrance of God and from prayer. Will you not then abstain'" (Sura five,verse 91 A1 Maalda). 3. The New Synthetic Substances In contradistinction to opium, cannabis, khat and alcohol, which havc beer. tr-41- tionally abused in countries of EMR, there are the new synthetic substanCes, whjch have been posing increasing problems since the turn of this century. With the growing industrial productivity of modern narcotic drugs, closer relationship between countries and faster communication, more and more of these substances have bocope readily available for public use. It has to be remembered that the hazardous nature of these new narcotics may take some years before they are recognized. Heroin (diacetylmorphine) which was originally therapeutically used as a non-aqd$ctive substitute for morphine, provides in this respect an illustrative examplo, When it was first used towards the end of last century, it was hailed as an effectlvo cure against morphine addiction. It was only by the beginning of this century th8t ita addictive charcteristics were recognized. However, this same drug was soon intro- duced into some countries of EMR and serious problems ensued. Tho aacot.Int given by El ~adka'~)on the "forty years of campaign against narcotic drugs in the United Arab Republic" presents a vivid and informative example. It clearly deWnltrate8 the changing pattern of drug dependence in countries of EMR. For until the Mginn$ng of the First World War, the new narcotic substances often referred to 8s "white drugs" namely cocaine, heroin and morphine were generally unknown. Thi o I& t~ati~q, however, was no longer obtained and the abuse of the new synthetic sub$tance$ raon became one of the major health problems.

11. NATURE AND EXTENT OF DRUG ABUSE

Accurate statistical dataon the nature ard extentof drug abuse in coyntries of Em are generallylacldng.Only rough estimates are available in some countries and hence the need has been felt for organized research and better collection of qnformltion. Recently, increasing national and international efforts, including that of WHO, WVe been directed towards this end and some of the relevant findings will be briefly presented here.

1. Extent of Opium Use and Abuse As previously stated since the dawn of recorded history opium use as a tWr8peutic substance has been known in some countries of EMR. Todate there are four Countrie~ in this Region namely: Afghanistan, Egypt, Iran and Pakistan, where qpiun .bum &# considered as a major problem in the field of drug dependence. In Afghanistan, since 1973, various attempt8 by United Nations agencies have Wen made to measure this problem.(9'10'11) Despite the paucity of information, preliminary estimates showed that the incidence of opium dpendence in the northern areas of the country varies from five per cent (Faizabad) to sixty per cent (Zabak). In hdakhshen Province (population of 500,000), where preliminary study was made, it was roughly estimated that one out of five of the general population was suffering from opium dependence!12) Other field surveys are now underway to provlde .ore information $or dealing more effectively with this problem, The importance of fiead surveys nwQ no emphasis here. It may be of interest, however, to point out that only few patiantq with opium dependence report for treatment and that records from the health services reflect rather poorly the magnitude of the problem. For example, while it was eltima- ted that there were 100,000 persons in Badakhshan Province, who were regulerly abusing opium, during the ten-year period from 1965 to 1974 Only twnety-fo~r opiua) odJi~t$wore admitted into Sanayee Hospital of Kabul University, the only institution with In-prtisnt (13) psychiatric facilities in the country.

Studies were also conducted in other countrios. In 1974 an attempt wit8 m@de to assess the number of persons in Egypt who were dependent on opium and the following two approaches were applied (14) : (a) official figures of the annual amounts of opium seized by the Narcotic Control of the Egyptian police were used as a basis for estimating the number of regular uwyr. (b) twelve experienced psychiatrists were asked to provide estimate on the siae of the problem.

Based o? the figures of supplies of opium and on an average consumptibn rate of 1.5 to 2 grams per day per individual, it was estimated that there were approximately 25 to 30 thousand persons suffering from opium dependence in Egypt.

Similarly the consensus of medical opinion estimatnd the chronic abuse of op$m in Egypt in the range of 25 to 33 thousand persons, mostly older IIIaleb who were in the lower socio-economic stratum of the society.

The majority of opium-dependent persons seemed to be concentrated in urban centres, mostly Cairo, where again the consensus of opinion among the clini~ian8interviewed put the number at approximately 15 000. Though these findings gave a rather rough mpfsw- ing index, they were still very useful for overall planning and development oS appr0.r priate treatment facilities. In some countries of EMR such as Iran, opium abuse ahow8 a unique hietorio8L and social background and is so deeply ingrained in the culture that it is not easy to draw a distinct line between occasional use and sustained dependence. Thir is elearly one of the problems in case-finding and in the proper assessment of the exOent of opium-dependence.

Because of lack of systematic field studies, early estimates of opium abuoe in Iran, wore rather impressionistic and generally unavailable. In 1955, hawever, it was estimated that there were a million and half persons using opiw out of a population of 20 million, Later on, in 1972 Azaraksh (15) put the figures of opium u8ers between 200 OW and 300 000 out of a population of 30 million. Obviously there is a Signi- ficant difference between the estimate in 1955 (7.5 per oent) and that of 1972 (one per cent). It has to be recalled that in 1955 the use of opium was prohibited in Iran, and that this measure was superseded in 1969 by a new policy which restricted the use of opium. Furthermore, as the methodology were different it wlll not be possible to draw any reliable conclusions from the two estimates.

As a rough index of opium dependence in Iran, use has been made of the registra- tion records, which are routinely kept. In 1974, for instance, official reoords based on ration cards showed tuat the number of registered opium-dependent persons was 153 613. This figure only shows tho number of persons who voluntarily reportod for taking rations of opium on medioal certification, or because of age - 60 years and over, as stipulated in the law of prohibition. Again in 1976, Mohrrreri stated thqt there were over 170 000 officially registered opium addicts and that "this figure.. .. is believed to represent only between one-third to one-half of the real number of the (16) add1c t population".

Similar to other countries until very recently there were no available valid data on the extent of opium abuse in Pakistan, In 1974, however, it was reported by a UN hlission that in certain villages within the opium producing areas in Pakidtan more tun 20 per cent of the male population were dependent on opium. More recently, MaGlothlan et a1(17) gave a higher prevalence rate in certain opium cultivated area.. In luri. village (Swat District), for example, opium dependence was estimated as high as 60 per cent among adult persons, including 4 to 5 per cent of adult female population. Furthermore, on systematic interviewing the daily opium users purch8sing through the vends in Rawalpindi, it was estimated that "the percentage of the overall popul8ti~n addicted to opium is about 0.5". In a previous survey, however, the percentago of male opium dependent persona in the city of Lahore was estiaated to be 3.7 (Hussin 1972).(18) Due to differences in methodological appr~aches,OOIparison Wtween Rawal#nd and Lahare estimates does not seem appropriate and obviously no geni$rallzat$on on national prevalence of opium abuse in Pakistan can be made from availabln informotion. However, these preliminary findings provide useful indic~tionfgr future drug dependence progranme 11d call for extending the current studies to other parts of the country.

In sharp contrast to country-wide opium use as previously described in ~fghanistan, Egypt, Iran and Pakistan, there are countries where limited pockets etand out cloqrly in the epidemiological scene of drug dependence and thesodo-cultural study of drug dependent persons in Port Sudan area, is worthy of llmntioning in tws regpeat,(19)

2. Cannabis Use and Abuse Reference has already been made to the use and abuse of cannabis (Mshirh, bhang, bango, charas etc. in historical perspective. In rccent years special stud4es on its behavioural (20) and psycho-social aspects were carried out. Though Gobar based on his ".:perience in Afghanistan, stated that "the populat$on of hashish abusers cannot be estimated as they are scattered diffusely throughout the country" in 1974 he reported that 75 cases of "hashish intoxication" which constituted 13 per Cent 0%all psychiatric patients were admitted into Senayee Hospital during the period, 1960 - 1969. It is clear that this is a high rate of admission and the severity af toxic confus~- ional states which may lead to hospitalization is well supported by general observa- tion in this country, as well as in others. Among other features it 48 calimed t4at the potency of the Afghan hashish, due to its relatively higher THC-4-9 oontento,was six to eight times stronger than marijuana. There are no available valid information which permi ts adequate comparison between the active contents of cannabis in countries of EMR and other regions and organized research studies are indicated to fill up this important information gap.

A promising study is the extensive survey, which covered nine towns in the Sudan Td 2200 persons were interviewed to find out the extent of cannabis use and abuse. Analysis of the results showed that approximatoly 3Q per cent of the male population interviewed used cannabis and that more than ha1 f of them were still ~~tin~ingto (23) smoke this substance for a period which varled from one month to four yeaps, As the selection of the sample was not adequately described, it is difficult to say how far it was representative. Consequently, no generalization on national prevalence can be made from this study. Nonetheless, it clearly indicated the seriousness of cannabis abuse which calls for more effective measures in order to deal more properly with this problem.

3. Studies on Khat The UN Commission on Narcotic Drugs (1956) and the Pentianent Anti-Narcotic Bureau, League of Arab States,(24) nre among the first organizations to show intereat in systematic studies on kaat. The document on "The Question of ~hat','(~~)submitted to IHD Regional Committee (EMR) gave an all-round statement from tho international and national viewpoint. Information regarding the medical aspects of the khat plant (catha edulis Forskal) were fairly well documented in previous publications. (26,371

Preliminary studies on socio-cultural aspects and on the extent of khat-chewing in Yemen were initiated by EMRO in 1973!28) More elaborate data were collected by an inter-disciplinary team and the preliminary findings demonstrated that the prevalence of khat-chewing among adult males may reach 80 per cent in major cities and 90 per cent in the villages where *hat was Concern by certain national authorities has been increasingly shown for more elaborate studies and for practical approaches in the prevention and management of the multi-sided problems of khat-chewing. Co- ordination of national activities with international input is a well-worthy effort in this respect.

4. Abuse of Synthetic Drugs The abuse of synthetic drugs, has been observed, to a varying extent, in some countries of EMR. A variety of substances ranging from narcotic to stimulant drugs have been reported from several countries.

It has often been observed that whenever the supply of traditional natural drugs is put under control resort to synthetic substances may take place. The abuse of heroin, in the form of sniffing or inhaling, was believed to have increased in Iran, followfigtb suppression of opium production in 1955. In 1973 for example, it was estimated that there were approximately 20 to 30 000 heroin users among the general population. Though this figure is relatively small when compared to opium users, those admitted into Vanak Hospital* with heroin dependence formed 55 per cent of the total admissions. As a new subculture, heroin abuse,dif ferent from opium dependence, is commonly popular among the youth of higher income group living in major urban centres.

In recent years, the abuse of methaqualone in the form of mandrax, has created, ( 30) similar to other regions, alarming concern due to its serious complications e.g. escalation to alcoholism, cardiovascular complications, epileptic seizures etc.

In some countries which are undergoing rapid socio-economic changes and where extensive long distance moior-ways have been constructed, such as Saudi Arabia, abuse of amphetamine by truck-drivers has often been reported. Other forms of abuse of stimulant drugs have been popular with the student population.

111. FACTDRS INFLUENCING DRUG ABUSE

1. General Features On reviewing the nature of drug abuse in countries of EMR there are general features which can be clearly delineated as follows:

(a) the long past of the tendancy for drug abuse in several countries. (b) that no country has been immune to the abuse of drugs. (c) the variety of drugs abused in different countries. (d) the change in drug abuse and in the pattern of dependence with change in time, circumstances and place. (e) the importance of the availability of drugs liable to cause dependence and their social and cultural acceptance.

Traditionally, drug abuse has been popular with the male population and the vulnerability of youth stands out strikingly in all countries. Even in chronic opium users, which is commoner in older people, the first experience with the drug in the majority of cases may be traced to a generally younger age group.

* Vanak Hospital was then the only institution in Teheran providing special important facilities for drug dependent persons. 2. A Number of Factors Apart from social conformity and the influence of tradition, a number of factors can be elicited in the use and abuse of drugs. In certain traditional societios, the abuse of drugs has been wrapped in mythical beliefs, bizarre sexual notions and pleasure-inducing tendencies. As a psycho-social behaviour, several parameters mainly identification, motivation, stimulus and reward effects etc., coauuonly seen among the peer-groups, are considered important determinant factors in drug abuse. Again, various assumptions have also been advanced, ranging from metabolic(31) to (32) psycho-dynamlc disorders , to explain the phenomena of drug dependence, However, it IS most likely that all depends on an interplay of factors, particularly the personality structure, the psycho-pharmacological effects of the drug and the psycho- social environment.

On the other hand there are the obvious and straight forward causes of drug dependence which are secondary t, mundwlying 1llnesSCr behg Socially induced.

In a country like Afghanistan opium dependence has been attributed to lack of health services and to its traditional use as a medication against diarrhoea1 diseases, chronic respiratory conditions etc., and for relief of pain in cases of injury, arthritls, febrile episodes, toothache, pruri tis and physical distress during the cold weather . I v . PROGRAMME DEVEMPMENT IN DRUG DEPENDENCE I t can be concluded from available information that concentrated efforts have to be made, at national, regional and international levels for dealing more effectxvely with the current overriding issues of drug dependence. Because of increasing aware- ness and growing nature and complexity of drug abuse, several countries in EMR have expressed keen interest to develop preventive and therapeutic measures in this field.

The policy basis and the role played by WHO in the field of drug dependence have been covered by the same author in another paper.

It seems appropriate, however, to review the general objectives and strategy, define the difficulties besetting programme development to reach these objectives and discuss relevant guidelines for future programming. 1. Objectives and Strategy in Programme Development The general objectives in programme development in countries of EMR should aim at preventing the occurrance of drug dependence, reducing its disabilitie~~whenthey exist, and resolving the problems, with which it is commonly associated.

To achieve these objectives the strategy to be followed should be based on an integrative approach to ensure active collaboration and close coordination between the various authorities concerned and facilitate maxim effectiveness in the mobiliza- tion of available resources in respective countries for efficient control of drugabrse ani proper management of drug dependent persons.

2. Constraints of Programme Development There are several difficulties in the field of drug dependence that impede develop- ment of satisfactory programes to meet the needs of countries. In brief these difficulties are:

(a) lack of accurate statistical data, wh~chare so important for proper planning and deci sion-making . (b) deficiencies of facilities and lack of good models which can be appropriately developed in preventive, therapeutic and rehabilitative programmes. (c) shortage of qualified manpower and lack of formal training programmes in all the countries of EMR. In practice, several professionals have been sent to drug dependent centres in technically advanced countries for general orientation and for getting acquainted with current knowledge and skill in this field. The fact that there are no teaching material and no formal academic experience relevant to local conditions and in harmony with the psycho-social background of the trainee, constitute a serious obstacle, in manpower development, particularly with regard to auxilliary and para-professional workers. (d) in view of the deficiencies of central organizational and administrative machinery, drug dependence programmes in many countries are disjointed and f ragrnented. (e) legal regulations and drug laws are often out-moded and out of date with respect to the rapidly changing national and international situations. (f) some of the countries are still not parties to the International Conventions on Narcotic Drugs. This will obviously hamper mutual activities between the national and international community.

3. Gencral Gui-ines for Programme Development In principle, the general guidelines formulated by the WHO Expert Committee (IW~)!~~)form a useful frame work for the development of effective drug dependence programmes. The measures to be used should bc! primarily directed to deal with three inter-related and basic issues which are: - limitation of the availability of dependence-producing drugs. - management of individual and group users of drugs. - coping with the environment.

(a) Limitation of Availability of Dependence-Producing Drugs The limitation of the availability of drugs is a crucial issue in the prevention of drug dependence. In some countries, such as Syria and Tunisia, where appropriate measures have besn undertaken for the control of narcotic drugs, it has been noted that the incidence of opium and cannabis abuse, for instance, has become generally low.

Again the classical example of the spread of heroin into Egypt indicated the importance of early recognition of dependence-producing drugs and the need for coopera- tion at the national and international levels to facilitate the exchange of information and ensure world-wide control of illicit trafficking.

At the national level, much efforts are needed for proper monitoring and rational use of narcotic and psychotropic substances. Control of illicit cultivation, pro- duction and use of such drugs as opium and cannabis, which are traditionally grown in countries of EMR, have to be considered within the context of socio-economic needs and mutual participation of the communities at risk. Crop substitutions, which have been recently introduced in some countries, show promising results. Still one has to go a long way on this difficult road before successful results can be proclaimed.

(b) Measures Directed at the Individual and the Group (1) General Ideally, programme development in drug dependence should aim at a total approach for prevention, treatment and rehabilitation of individuals and groups, who are either potentially at high risk, or actually suffering from drug abuse. This by necessity should involve a range of social institutions and community agencies. Due regards has to be given to the role of: the family, education, health and social services; religious institution, mass media, political groups, peer-groups etc. The importance of close cooperation between these various agencies need no further emphasis here. The programme, however, should be relevant to the local needs and geared towards the realities of the local conditions.

( ii ) Treatment and Rehabilitation Programme In practically all countries of Em, difficulties have been encountred in the establishment of treatment facilities and the development of appropriate therapeutic * modalities. While the first project in Shirae for out-patient treatment of opium (34) addicts shows encouraging result, the detoxification programme based on moth8donec withdrawal cover, which has been implemented in various parts of Iran, had many drawn backs and failed to makeany break-through. (35,361

However, attempts at establishing comunity-based centres, such as the Ataba Clinic, Cairo, hold many possibilities for integrative programmes and for the wider utilization of community resources. The site of tho clinic in areas known to be exposed to drug dependence problems and the application of a multi-team approaeh have proved more appropriate to the psycho-social complexity and broad nature of the drug abuse problems. It is envisaged that prospective controlled study of the spociiia services provided in this Clinic and the follow-up of results may yield useful inform- tion which should be helpful in promoting the efficiency of the treatment and rehatpi- 11 tation programme.

(c) Measures Directed towards the Environment The close interaction between individuals or groups and their surroundings in cases of drug dependence calls for special attention to be given to socio-oconomic background, cultural norms, physical conditions etc. The approach to the khat problem, for example, due to unique socio-economic and cultural problems, should be relevant to the prevailing conditions of the target communities. One of the recent measures, for instance, undertaken in Somalia for reducing the use of khat is it8 prohbition during office work. Such a measure seems appropriate to a Special social sector of the community and deals with only one feature of the problem. This action is one of the very early steps. It certainly expresses the official concern of Somalia regarding this problem. In People's Democratic Republ~cof Yemen, more broador measures, which restricted the use of khat to week-ends and holidays, :ere recently enforced, It is difficult to say at this stage what will be the offects of such measures on the use of khat in Somalia and Yemen, however, it is clear that more elaborate action has to be taken in order to get to the roots of the habit and doel with probloms of khat abuse as part of an overall socio-economic plan.

An important issue which also needs proper reviewing is the legislation of drug dependenco, Detailed information on legislation in E ypt, Iran and Pakistan cao be (37) t 388 (30) obtained from publications by Dixon, Mclaughlin ct a1 and Khan and Wadud. In many countries of EMR, the laws which are regulating and controlling the uso of narcotic drugs and which have far-reaching effects in the social and cultural environment, are inappropriate and generally defective.

More efforts are roquirod to update the existing regulations and render them more relevant to the current needs. In ths paper an attempt has been ~bdeto describe the historical perspeotive of drug abuse in countries of EMR with duo reference to its deep psycho-social roots and changing patterns in relation to time and place.

Rough estimates regarding the size of the problem are given and guiding prinoiples with relevant examples to meet the growing needs of countries are provided.

Programe development in all the countries are beset with organieational diffl- culties, inadequacy of coordination, shortage of trainod personnel, defcctlv~ regulations, inappropriate therapeutic and rehabilitative models etc. Conaerted efforts are, therefore, generally needed to effectively deal with conturieo-old problems of drug abuse in this Rogion. REFERENCES

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A1 Biruni, Abu Rayhani, M. Kitab el Sayadanah, edited and translated by Hakim Mohamed Said. Hamdrad National Fou.~dation, Pakistan, 1973.

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35. Baasher, T.A. Report on Mental Hoalth Activities in Iran. EM/MENT/Sl. WHO Alexandria, 1973.

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37. Dixon, W.H., Narcotic Legaslation and Islam in Egypt. Bull. on Narcotics. XXIV, 4, 11 - 18, 1972. 38. McLanghlin, G.T., and T.M. Quinn. Drug Control in Iran. A Legal and Historical Analysis. Iowa Law Review. Vol. 55, No. 3, 469 -524, 1974.

39. Khan, I. and K. Abdol Wadud. Drug Abuse in Pakistan. Bull. on Narcotics, Vol. XXIX, No. 4, 21 - 40, 1977. Colitributiorl by Unesco to the Wor!csiloi 011 Prevdfitlo:~LLI~~ Ti e~t~l~l?), t 011 Drug Dcpe~ld*~,ct>(~le~di,(lrl~, 16 - 21 0ct;ber i'j'jh,

Idducatlon collcerlllll& tlli\ pro-bJcrns2>soclattd wlth --the -- use --- of druts

1. Introduc t Ion

The role of educaclon 111 pleverlLlo~~strategies has been 1ncreaslngJy emphasized and dema~ldshave been made from various sectors (law enforcen~eilt, etc.) on .Unesco to develop ~tsprogrdtnmc In this field. "Drug educdtlon" has beer1 consldered at first as "a luxury", to quote a statement made several years ago in an international United Natlorls meeting, in the same mariner more or less as education itself was at one tl~ne consldered aa a privilege a~ldoften a luxury. However, again like educatlon In general, "drug educatlon" was soon to become a need and a right.

After havlng been consldered a superfluous item, it was expected to work wonders and requested to produce "qulck and spectacular result". Thls was forgettug that education deals wlth the mlnds and feellngs of human belngs that hardly ever change overnight. More over, in a field as complex as that of drug use, ~t myst be remembered that there 1s always "a bolutlon quick, slmple and wrongf1.

Drug educatlor~lids i~ornetlnr~sbee11 accused of contrlbutlng to the extension of the use 01 datlgcrous sub-it,-t,~ces. Thls statement was based mairlly on a number of exl~erlmc?l~ts~fl,~de d~ the begin~llngof the implementatlo11 of educational progrz1,ilnes 111 th13 fleld. Jus L as drugs themselves, drug educatlo~land drug ~nforrnatloI arcb not good 01. bad per se but their value depends on how they are used, that IS, what methods they utilize, what audlen- ces they are meant for and in what contexts they are situated.

Concerning drug demand and i~reverltlveeducatlon one ~houldconslder on the one hand the facts, whlch can be measured by epidemiology (extension of the phenomenon, number of occasional, regular, dependent users, etc.), on the other hand, the way ln which the sltuatlon 1s perceived. From the point of view of educatlon thls perception of the phenomenon is the most impo~~tant aspect. Indeed, the authorities, the teachers or the pdrents will, noL LiIcc the sdme educatlorlal steps del,e~~dlng011 wilr~therthey belleve thlt tl~cPI-ob4t.m 1s not serlous or they tl11111i there is -~ILepldcmlc, deuendlilg on whether tlicy cor~slderdrugs as either good or bad or i hey think ihat a11 drugs h,lve potential for both good or bad effect.

2. Unesco pollcy a~idactivltles

It should be clarified that fro~ntht. po,nt of vlew of Uriesco t,ht~ term "drugsf1 covers all types of substances whc-cher legal or illegal anti lncludes therefore the use of alcohol , tobacco, ovt r- the-counter drugb, pl~~s- cription drugs, as well as ca11nabls, her 0111, etc. But the problems sssocldted with the use of drugs are collsldered less ,is deperitilng on substailces than as

f "Drugs Demystlfied, Iqtroduct ~orl,p dge 12 psychosocial problems closely linked with the cultural and economlc environ- ment of the various countries. Also, contrary to what h,~s$been a prevail lng attltude In recent years, the Organization has refused to equate drdR problems with problems of youth.

In its activities Urlesco has trled to brill!.;

The Organlzatlon has endeavoured to defirle situations relating to drug use, to foster the exchange of experiences of educatlonal materlal and teach- lng staff and to support educatlonal approaches adapted to the various situations.

Far from trylng to gather on a world level educators from the greatest possible number of aountries the Orgdnlzation has limlted partlclpatlon 111 ~tsmeetings to groups corresponding to certaln categories of Member States. Priorlty has been glven first to ~ndustriali,e~i-ountrles, then to more limited groups of these countrles, and to studles bearlng on specific age groups (meetlng on Youth and the use of drugs, study on the youth press, study on therehabilitatlon of young ex-drug users, etc.) All these actlvlties have formed a basis for the pamphlet : "Drugs Demystlfled" which, in splte of ~ts general value 1s flrst of all based on the situation 111 hlghly ~ndustriall~ed countrles. The Organlzatlon has then tried to glve assistance also to countrle in Latin America and the Carlbbean, to help them deflne the problems reldtcd wlth the use of drugs such as they appear 111 the reglon, taking xuto uccout~t very substantial differences from one cou~ltryto allother (national studies, overall study by a consultant, recloncil tqeetirig in Llma, 1976, etc.)

Thls has been followed by the launching of all experimental project 111 secondary sahools of one Member State In the reglon (~rgentlna),and by the convening in the Caribbearl of two Workshops for the preparation of education materlal for teachers, parents, and youth groups. One of those meetings was intended for Engllsh speaklng Caribbean countrles (Kingston, Jamaica) the other for Spanish speaklng Carlbbean and Cc~~tralAmerxcan countries and Hexlco (Santo Domingo, Dominican Republic).

In Africa a slmilar approach has been adopted on a more modest scale. The first step concerned three Engllsh spedklng and three French speaking countries where national studles were u~idertaken,consultants provided and an expert meeting organl~ed(~om;, 1976). This was followed by the gPailtilig of fellowships to educators from other Frer~chdnd Engllsh speaking countries which wxll lead to the organlzatiori of educatlonal materlal workshops 111 1979.

In Asia a meeting (Penang, Maldysia, 1977) Intended for ten countrles was again preceded by study tours awa~dedto educators and by studies on the attitudes of youth towards drugs and drug education.

In the Arab States a survey has bee11 Inu~~chedor1 the basis of questloll- nairea and the vlsit of a consulta~~tto five of the countrles concerned.

3. Exlstlng programmes of educatior~concerning the poblerns associated -wlth the use of drugs.

The varioua studles and meetlng:~ ul~dertakenby Unesco have showrl that educational activitres are still comp,ircitlvely limlted as far as problems of drug use are concerned. However, some #embpr States have taken serlous measurea to institutionalize ~t.The first level of lnterventlon has often La..- &L.- -..L--l At the school I eve1 I L is of ttxrs conbidered useful to Include Information and guid,lr~ce111 the currlcul,~for the varlouo levtls an? types of teaching, in which case the teachers are in charge of tl~is'act~on'.Thus : "At the elementary level the puplls can be taught about tobc~cco,

"At the lntermedlate and hlgher levels, educatlon should be directed towards matters that come hithin the fields of ~nterest,both of sociology and the n'atural ociences. At the 11lgher level, opportunities wlll be found to dlscuss behaviour and the results of scientific surveys on thls subject and the role of publlclty in shrlpirlg attitudes. It 1s ~mportantth,iL tilt? school should cooperate closely wlth parents and wlth representatives of the different health inatltutlons and agencies so as to reinforce the elerneLlts learned In school ." "All teacher-tra~nxngcolleges now have a compulsory eight-hour course for all teachers, irrespective of the subject they will be teaching." (1) In this case what is consldered is health education, education and training to develop certaill patterns of behavlour and guidance in relation to trndltion- a1 customs, It is consldered that the school has responsibilities concernxng educatlon as well as leisure time.

In a number of countries the exist.1~1~~nfrast~~ucture of youth organl*a- tions for example, or trade unions 1s used for the spreading of ~nforrnatlor~ and for the establishment of commun~cationwith varlous sectors in the ge~icral public. In some cases ~t IS consldered that youth groups for example must take responsibility for this actlon, with a government subver~tion,because adults lack credibility wlth young people,

Other experimerits show the irnporta~~ceof an overall actlon. In some countries "national organizations are working hard to stir up communities and get everyone to participate In dealing with the problems of drug addiction. To this end these organizations have initiated lnformatlon programmes for the general public, programmes in the industrial sector, programmes almed at parents, teachers, and specialists in educatlon and the treatment of drug addicts, programmes aimed at motorists, and programmes dlrected at other particular groups," (2)

In the countries where the problem has only been perceived at a recent date, it seems that the flrst steps in prevention actlvitles have always been Inspired by the same reaction , it 1s considered that a serious dall~er exists and the risks involved in the use of lldrugsll have been given wide publiolty, moet of the tlme witilout distinguiehir~gbetween the various produots and the various types of use.

This type of educatlon or rather blased inforrnatlon usually generates more harm than good and 1s then followed by an attempt at more efflcler~t methoda. Obviously ~t would be better r~atLo start by stlrrlng up curiosity, rejection or diebelief of the informdtion, all of which contribute to niaking further activities more d~fflcult. It would be advisable therefore to encourage the states that Lave 11ot yet undertake11 thls type of programmes to flrst request asslstarlce in order to study the preset ,i SI tultiort, to tr,tln qualified staff arid to prepare adequate met!lods ai~dteacllll~g mdterlal or ,idapt to the local soclo-cultural colldltlorls whlcti may be nvil~dblc.Iri other countrie It 1s equally lmpol tailt to advlse the xuthorltlos not to uildertlite farge nntlonal programmes at the outset but to st,+rt by experlmer~tlrlf:<:nd evaluatlrig the methods whlch appear to be best silltcd Lo thtlr cou~itry.

4, Some requlremerits for actlvltles of e~iucatlollconcerlil~lg the problemb associated with the use of drugs.

As already stated prevention must flrst alm dt creatlng an awaretlesb of the problem among the authorltles, among people 111 charge of educatlor~2nd soclal services as well as among those who are responslble for actlvltles concerning either youth or out of school educatlon for ddults.

T~

If cooperation mechanisms are essential ~t also seems necessary that the bodiee set up for that purpose only serve as coordlliators. For example, slnce the responsibility for lmplementat~ondoes not belong to the coordina- ting agenciee or committees but to mlnistrles of educatlon, teachers them- selves, parents or leaders of youth organlzatlons lt 1s Important for them to contribute to the settlng up of the programmes and activities for whlch they wlll be executors.

11. Education in treatment and rehabllltatlon of drug users

Drug users have very frequerltly 011 ly be~lefitedfrom an incomplete education and have often dropped out of school, whether the use has occurred as a result of abandonment of educallol~~illnstltutions or has preceded ~t, It is therefore essential that an edu~~~t~o~~~lactlon be undertaken 111 co~inect- ion wlth medical or social treatment.

Education should therefore aim oti tl~eone hand at changlng the attitudes of the drug users, at glving them gei~eralknowledge background and the prerequieltes for further schooli~lgof vocat~onaltralnlng. It should am also at strengthening the personality of the individuals and equip them to function as useful and responslble members of soclety. On the other hand, educational programmes should be directed to the drug users family, to the community and to employers in order to make them aware of thelr responslblllty with regard to former drug users and to encourage them to provide emotional and psychological support as well as opportunities for skills tralning scd job placement.

The problem of education in soclal relntegratlon programmes has been mentioned with more and more emphasis In recent meetlngs organized by Unesco and will be given increased ~mportance11 the programmes of the Orginl..,itlon in the next biennium, provided those are approved by the General Conference which will meet in October and November 1978. In both prevefrtioll ,~ndreh~blilt ~tlu~, G~UL ,tluti ~~rugrnrntae~U:leoro hopes for a contlliued and i1icre2~edc,oc?pcr.,tlo,l with LIIG other. Age ~cltis of the Urllted Natlo~~sfamlly alld wltll IIOI t:ovcr.iiine LL,~org41il dtlo~is. Paper prepared for WIT0 WnrRshop on Prevention and Treatmcnt of Drug Dependence Teheran, 15-20 October 1978

The Role of the International Labour Organloation in the Fleld of Drug Abuse Control

The ILO In co-operation wlth other agencles and organlsatlons, 1s responsible r that sector of drug abuse control programmes concerned wlth reduction of nand- In particular, the ILO1s fleld of responslbil~tycovers: - advising on the development and organlsatlon of vocatlonal rehabllltatlon faclllt~esand programmes In co-ordlnatlon wlth medlcal treatment and with- drawal centres for drug adlcts; - advlslng on the vocatlonal guidance, assessment, vocatlonal preparation, placement and resettlement of those discharged from medlcal treatment and WI.thdrawal centres; - advlslng on the need for estab.llshing workshops, co-operatives, rural actlv~tles , self-employment schemes, etc. , for f omer addicts; - advislng on the developent of follow-up programmes for former addlcts to help ensure the success of those placed in employment; - tralnlng the necessary voca tl onal rehab111 tati on, placement and follow-up staff; - advlslng on the developnent and co-ordination of public lnformatlon programmes and community involvement almed at facllltating the relntegratlon of former addlcts lnto the community; - research Into problems affecting the vocatlonal rehabllitatlon, relntegratlon and follow-up of addicts.

Backgromd to the ILO Programme The ILO has from its outset been concerned w~ththe improvement of social xditions and the protection of workers. Its activltles have included attentlon the employment needs of the handicapped.

with the adoption in 1955 of ILO RecommendatLon No. 99 concerning the zatlonal rehabilitatlon of the disabled, comprehensive International guldellnes r action were establxshed whrch st111 remaln relevant In today's world. Vocational rehabllitation may be described as that part of the continuous and -0rdinated process of rehabilitatlon whlch lnvolves the provlslon of vocatlonal cvices, e.g. vocational evaluation, job counselling and guidance, prevocatlonal 3paratlon and vocational training, selective placement and follow-up. These iividuallsed servlces are des~gnedto facilitate the securlng and retalnlng of itable work.

Experience has now shown that the methods and techniques of vocatlonal ~abllitatlonare particularly relevant In those joint community efforts aimed the reintegration of drug-dependent persons. Undoubtedly, the absence of such :ational servAces or then inadequate provlslon and organlsataon can represent -lous limitations to the success of treatment and rehabllitation programmes. In addition to aosistlng in the development of such services the ILO can also ~y an important role in the creation of job opportunltles for the drlla annnnAA-I to cnsure that employment can be secured. Thls includes the creatlon of workuhops, co-operatives, small-scale zndustry and in settlng up rural and handicraft actlvltles.

At the offlcial request of the governments 1 volv~d,IIJO can make avazlable the servlces of reglonal advlsers for short-term consu2 tatlons on vocational rehablllta- tlon questions. Moreover, the ILO Information and Documentary Servlce has developed s section on the vocatlonal rehabllltatlon of drug-dependent persons.

I. I110 Tripa~tlsmand Drug Dependence As the ILOts structure 1s based on the tripartlte system (collaboratlon between lovernment, employers' and unlon representatives) ~tsact~on In the fleld of :ehabllitatlon of drug dependents attempts, wherever possible, to encourage the )artlcipatlon of these important sectors. At the 58th Session (1973) of the International Labour Conference, Geneva, a esolutlon concerning alcoholism and drug dependency was submitted by the Workers' elegatlons of Canada and the United Klngdom. The Resolution lnvzted ILO member tates and workerst and employers* organlsatlons "to do thelr utmost in thelr own ountriesn, lnter alla "to promote effective tripartlte or, appropriate trade unlon anagement consultations at all stages of the elaboratron and implementation of rogrammes of treatment and rehabilitatlontl, and 'It0 promote posltlve attrtudes such ) the recognltlon of alcoholism and drug dependence as illness for whlch there is elp and treatment, and to provlde the best possible treatment and rehabllitation acxlltles in all camm~nities.~ Presently, however, a11 too few unlons* and employers1 organlsations are pre- ared to offer jobs to rehabilitated addicts. Much progress remains to be made In his area. It is certain that pdejudlce In hlrlng former drug-dependent persons as contributed to the failure of many a rehabllltation effort and to the former ependents "going back to the habit1' out of sheer drscouragement. If he belreves here IS little hope la obtaining work after vocational rehabilitation, it would e difficult to either attract him to such a programme or to expect his whole- earted participation ~f admitted to it. Too low a priorrty, in relatlon to other actlon in the field of drug abuse ontrol, has been given to the psycho-social needs of the drug dependent. Yet it s encouragrng that attention is increasingly being focussed m thls dlrectlon. ~t much more needs to be known about how to improve our effectiveness in offering slp to members of this group. Additional experience and knowledge should be ought primarily through programmes of actlon and not through too heavy a reliance 1 research findings and aurvey results.

) mestlons for Future Actlon (a) Drug users should not automatically be labelled as drug dependent. With lis in mind, the criteria for rehabllitation intervention should be based on the 3gree to which an individual is capable of relatrvely stable and responsible (as atemlned either by himself ar his community) functioning with respect to hls bmmunrty. (b) In the formulation of criteria for the evaluation of rehabilltation out- mes, one should take lnto account improved psycho-soclal and economlc functioning. (c) The full co-ordination and contlnulty of all treatment, rehabilrtation and her services necessary to the drug dependent should be assured both on local and tional levels. Thls could best be assured locally by professionals actively volved in treatment and/or rehabilitation programmes; and on national levels by co-ordlnatlng committee with all relevant representation of ministries and private ctors (Fnclud~ngcommunity groups [church, parents, etc.] , unlons and employers ganlsations) . (d) As a general rule, rehabili$ation programmes should be non-institutional in ture and not require large financial investments. Wherever feasible, there ould be a variety of progrmnes which will correspond to important differences in characteristics of the drug-dependent population (such as the need for highly uctured as opposed to loosely organised activities; residential rogrammes as osed to the availability of short-term aeslstance as needed, etc. y. Rehab111 ta- in programmes should be commun~ty-based and should avold a ton h~~~ ---" along with professionals In the rehabllltation process, wherever possible, as they have been found to play a very constructive role. (e) The full range of vocatlonal servlces (vocatlonal evaluation and guidance, job preparation, vocational tralnlng, select~veplacergent and follow-up) should be made ava~lable,all or In part according to needs, as one of the phases of the treatolcnt/rehabllltation contlnuwn. (~elevantdocumentation and lnformatlon as well as technical assistance servlces are available through the ILo.)

(f) Industries and unlons should be encouraged to consider alternatikes to the outrlght ter~nlnatlonof employees who have been ldentifled as drug dependent. Programmes of employee drug education, counselling and therapeutic asslotance should be developed wlth a vlew to cut down employee turnover, improve employee job funct~onlngand reduce losses In property damage, accidents dnd absenteeism. (g) lndustrles and unlons should be encouraged to offer job try-outs to rehabilitated job applicants. A person should be judged by hls present performance and not by hls past or by labels that society may have placed upon hlm. (h) Professional tralnlng schools (e.g. medicine, nursrng, social work, pharmacy, pollce, church, etc.) should be encouraged to lnclude some orlentation, her ever relevant, on the range of programmes and services as well as signlflcant problems In vocations1 rehabllltatlon of drug-dependent persons. ILO1sWork In the Field of Drug Abuge Control Over the Past Year (1977-1978)

The main thrust of the ILO1s technical input in the past year has been directed towards the soclal and vocational rehabilltation component of projects Ln Pakistan and Burma supported by the UN Fund for Drug Abuse Control. An ILO vocational rehabilltation expert jolned the Pakistan project in 1977. A voca- tional rehabilitatlon workshop was opened recently in Hyderabad and plannlng of a second workshop In Karachi 1s well advanced. Both workshops are closely associated with newly established treatment centres in ,those two cities. Moreover, vocational rehabilitation activities are being developed within the context of the rural sector ~f the project in the Buner area. In Burma, ILO assistance is taking the form of short-term consultancies under- taken by ILO headquarters staff. As a result of the flrst consultancy, a detailed pork plan for the Soclal Welfare Sector was drawn up wkch allows for a start to be nade on the identification and registration of addl cts and the establishing of four vocational tralning centres. ILO has also assisted in drawlng up comprehensive sts of equipment for these centres. A further short-term consultancy visit is b.nvisaged in the near future to help local specialists plan for the expansion of che pilot faclli tles. The past year also saw the actlve involvement of ILO reglonal experts in the Lrug abuse control programme. Ip Bolivia, Malaysia and Thailand, for example, LO regional experts In the fields of vocational rehabilitatlon, co-operatives and mall-scale industry have advised governments and lndlvldual rehabilitation facill- ies on the development of trainlng and work programmes for drug-dependent persons. The ILO is also active in supporting the efforts of other agencies and organlsa- Ions in the field of reduction of demand, including contributions to the study on h1s subject undertaken by the UN Divislon of Narcotic Drugs and to WHO meetings on pidemiology of Drug Dependence. In collaborationwithWH0 the ILO also recently lroduced a questionnaire for trial field testlng in several on-going projects. The im and purpose of the questionnaire is to obtain baslc information to pemlt an valuation to be made of the effectiveness of soclal and vocational rehabllltation. The need for more attention and hlgher priority to be given to the questlon of teductlon of demand for drugs was emphaslsed at the February 1978 Sesslon of the nited Nations Commission of Narcotlc Drugs. With tbs lmportant consideration in it seems likely that the call for ILO speclalist expertise in the vocational habilitation and soclal reintegration of drug addicts - an Important element of concerned wlth reduction of demand - will increase in the year ahead. Annex I1

An ILO Questionnaire/Inqu~ryForm Relating to the Entry of Drug-Dependent Persons to Rehdbilbtation Yrogramrnes and Subsequent Pollow-u~ h his form is currently belng fleld-tested)

Soc~~l/Vocationalltiformat~on Sl~ect (for drur: dcpcndcnt r~crsons) ~ehab~l~tationPro~mn~me Entry Form] Date-- of Report : : [optional] Sex . male female age : date of birth : Fermanent address : Local current address : Ethnic group . Marital Siatxs : single (never married) married othcr (specify) non-licensed marriage separated - divorced widowed Living willl-whom : spouse(s) or fam~ly friend member s of same alone Instltutlon (hospital, other jail, school, rehab. etc.) peferred to rehabilitation service by seu- family other (specify) hospital Pollce /court Fume of incmrore_ : salary, wages spouse, family other (spectfy) public asststance, charity friends eto. yurnber of dependents : (how many people depend for support) Have you any family, relatives or friends willing and able to help in some way in your rehabilitation ? (who) Education: llliterate literate a number of completed years of education Job Tralnlnx baa any been received (~na centre, school or froin someone) If yes, specify which typc(s) How long did training last Diploma, certlf~cate,licei~se etc. received !@*' [List jobs below in chronological order, startmg with most recent] 1) last job : duties how long worked : rcason for leaving 2) job duties : how long worked : reason for leav~ny Elow many jobs were held in tho last 18 months Longest time that any job lasted during last 18 months Llst the d~fferenttypcs of occupntions held during last 18 months ;c_nt- -- !r;gcll-s~_atus

3s- --of II~erapy,services or Ilclp prcviou:,ly rgcetvcd . nled~caltreat~llent legal ass~stance (how many times) housing asslsta~ice indivldual/group otkcr (s) counselling -- job guldance job training

e ) TERMINATION OF R ElIA 13ILITA TION PROGRA hlhtl?

son(9- - ior-- leavjng--- -programmg :

Left to obtaln work I left for further education or tratnlng absconded started taking drugs other (specify) -_-rices and help --_____ received- vrhlle--- in programme------_ :

collnsell~ng job guidance job trainlng- job placement legal assistance housing help Soceial Vocal tonal 130hnbtl11;1t1onProjir:~mme for llru:: ~c~~cnclcntl'crsons (date ) FOT4LOW-IIP 1WRM 3nc, six, twelve, eighteen l~lonlhsafter leaving programme (plcasc circle apprupr late IUDbcr of months) ] finj~qy&g-j eft~~og~rnme,-fo_uie~udd~ct~ cauuatbe located : moved (no new address) other (spectfy) 'ne~mlent- ----status gainfully clnployed house responsibilit ics student or trainee unen~ployed(seelrung other work) [please givc detalls on itclns checked]

ork : [List jobs below in cllronologlcal order, startlng wlth most recent] --- * 1) last job, duties how long worked - reason for leavtng 2) job duties : how long worked : reason for leaving : w many jobs were held since leaving rehab. progranlme or slnce last follow-up

ingest time that any job lasted during thls period 3t the different types of occupations held during: this period

---rrent ~oblemswhich appear to require speclal help *------heal&------f mane ial em ployme 11t fan1 Ily personal drug taking other (specify) (please give details on items checked]

.e important changes occurred in hisher life ? ------working legal status 1 (specify) living arrangement marital status (specify) (specify) schooling other (specify)

I or will an attempt be made to help former addlct to get thc assistance be appears ------4 ------. ------:eaglre (specify actton recommended and/or to be taken

Qr - -relevant ------comments------or -suggestions ------