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 Spanis h. 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 W HO 's views. World Health, WHO. Av. Appia, 1211 Geneva 27, Sw itzerland. Puning a higher Contents Putting a higher value on health by Norman Sartorius ...... 2 value on health The big killer by David A. Player ...... 4 Smoking in the Third World by Uma Ram Nath ...... 6 by Norman Sartorius Banishing tobacco by William U. Chandler...... 8 Demon drink ...... 12 One for the road? he abuse of psychoactive sub­ sometimes it will be discouraged by by Alex lrving ...... • . . . 14 stances-including alcohol, to­ failure. Nevertheless, it must be pro­ Smoking, alcohol and drugs. . . • 16-17 Ubacco and narcotic and psycho­ vided to those affected, often to save Drugs are big business tropic drugs-causes enormous dam­ their lives. by Anthony W. Clare ...... 18 age to the health and productivity of Fortunately, research during the last Escape into nightmare nations. It undermines the quality of 100 years has produced sufficient by lnayat Khan...... 22 life of individuals and their families , knowledge about the prevention of "Glue-sniffing" ...... 23 and threatens the welfare of com­ abuse of these substances. If it were Chewing khat munities. The health consequences of not for three giant obstacles, preven­ by Peter Kalix ...... abuse are also grave, and range from tion programmes could be crowned Designer drugs violence and deliquency to liver cir­ with success. To remember the obsta­ by Roger Highfield...... 26 rhosis, brain damage and lung cancer. cles may help in our search for ways to International control of drugs Treatment of dependence on succeed in spite of them. by B. Juppin de Fondaumiere ...... 28 psychoactive substances is still imper­ The first and most important of • Departments. fect, can take a long time and may be these is the low value which the popu­ Lifestyles and health : Giving up the weed expensive. Its effects are all too often lations of the world assign to health. by John Wickett...... 11 of short duration. Yet treatment re­ Humans organise their lives in the Meeting the threat of drug abuse mains a necessary part of society's framework of values which they attach by Marcus Grant ...... 20 response to the damage done. Some­ to themselves, to ideas and concepts, Books and publications : times it will have to be repeated; to people and to things that surround Like a thief in the family...... 15

News Page ...... a .. . . • . W OR LD 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. Tai chi in China; martial art in slow motion. The third giant hindrance that Photo WHO/D. Henrioud stands in the way of success is the nature of the environment in which most people of the world live today. ations in which taking a drug will seem Sharing a cigarette or a drink after a highly desirable. strenuous day may often offer more in But we are left with one major field human values than anything else avail­ of action. We can help people to able. It may be particularly important understand what health is all about in situations where no other pretext and thus contribute towards raising for sharing time and feelings is avail­ the value that people attach to it. This able, because of the poverty of the will require joint action by workers in environment, restrictions of a societal many social sectors-education, social nature or personal reasons. welfare, medicine, industry, the opin­ Good health implies a harmonious balance ion-formers and many others. They at the physical, mental and social level. can take action now to raise the value Photo W HO/E. Mandelmann of health by example, by legislation, Drug death toll in UK by education and by other means. In the United Kingdom alone in Finding and promoting worthwhile them. On the scale of all these values, 1984, at least 2,000 people died social alternatives to addictive be­ health ranks low. In the presence of each week from the misuse of haviour means more than listing possi­ disease and pain, people take steps to drugs. Cigarettes killed 1 ,900 ble hobbies. It also means more than rid themselves of these; but such steps people every week, 60 died merely imposing controls, whether by are motivated by the value attached to from medicines (analgesics or tightening of borders around drug­ life and to the absence of pain, not similar compounds accounting producing countries or by increasing specifically to health. Pleasure has a for five deaths), and 40 from prices of alcohol and tobacco. It means much higher value; so have patriot­ alcohol, according to two phar­ leaving choices open to people, once macologists at St. George's ism, productivity, popularity, esteem everything possible has been done to Hospital Medical School 1n of others, physical appearance and London . ensure that they understand what attractiveness. Health implies an exist­ health is and why it may be important ence in which a harmonious balance to value it. If people esteem their own has been found between the total health and the health of others suffi­ environment and oneself, and in which The latter two obstacles do not lend ciently highly, it becomes less likely physical, mental and social functioning themselves easily to attack. It is un­ that they will indulge in practices that complement each other in maintaining likely that we shall ever be able to do harm it or that they will allow others to this balance. The value of health, de­ much about the nature of addictive do so. Most importantly, the motivat­ fined in this sense, fares badly in substances. There will always be drugs ing force for action against abuse of comparison with other values which of one type or another which, if taken psychoactive substances will then make up the framework for human by humans, will cause dependence. cease to be external power, pressure action. History abounds in examples of peo­ or persuasion; instead, the framework The second giant obstacle to the ple's inventiveness in creating new for people's decisions about the way in prevention of substance abuse, is the drugs of abuse. The most recent exam­ which they spend-or ruin-their lives pharmacological nature of the sub­ ple-the appearance of designer drugs will include health as a determinant stances themselves. They produce -is just one more to be added to the with a high value attached to it. pleasurable effects, change one's per­ list. There will be others. It is also If this happens, we will efficiently ception of the world, of oneself and of unlikely that, in the foreseeable fu­ and permanently wipe out not only one's immediate problems. The addic­ ture, we can hope to enrich the human the problems of drug abuse, but a tive nature of the substances also environment-social, physical or bio­ whole series of other problems and makes it necessary to use them in ever logical-sufficiently to prevent situ- evils as well. •

WORLD HEALTH, June 1986 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

by David A. Player

Two hundred and publication of The Big Kill has been an day. There was a sharp rise in the thirty black balloons important contribution to the cam­ numbers of girls taking up the habit­ floating into a grey paign in the UK where, unlike some from 15 per cent in 1982 to 24 per London sky made a countries, the smoking trend among cent. It is encouraging that adults are sombre sight, and adults is already downwards. Today 36 giving up smoking. It is appalling that appropriately so, per cent of men smoke and 32 per cent more and more children are becoming since they symbol­ of women, although men have been hooked. ised the numbers of giving up the habit faster than women. The tobacco industry argues that its people who die each day in England Smokers are a minority in every social promotional efforts are directed to­ and Wales as a result of smoking. group, even though most smokers are wards adult smokers, and aimed at The balloons were launched to mark persuading them to remain loyal to publication by the United Kingdom's a particular brand or to switch to Health Education Council of The Big another brand of cigarette. It claims Kill, the most extensive statistical that it does not seek to recruit young analysis ever undertaken of death and smokers to its lethal product. This disease related to smoking in the two claim is nonsense. In the UK, tobacco countries. They also marked a further promotion is limited by voluntary step in an aggressive campaign against agreements with the government. the smoking habit and, by extension, Companies are free to advertise and the tobacco industry. promote their products, within certain Smoking, of course, is an inter­ restrictions, many of them specifically national problem, and the tobacco in­ barring promotion to young people. dustry has worldwide interests. So it is Advertisements for cigarettes have essential for those of us concerned been banned on television since 1965. with health education and promotion Why, then, are young smokers on the to cooperate as closely as possible, and increase? to learn from one another's experi­ The answer is that the tobacco in­ ences. Techniques which work in one dustry has cynically ignored the country may well work in another, and agreements which it has made. In one the free exchange of ideas can help to month, advertisements in women's save millions of lives, a vital contribu­ magazines were estimated to have tion towards our common goal of reached over half of young women health for all by the year 2000. aged between 15 and 17. The industry The battle is, of course, a hard one. has launched package holidays under In the United Kingdom alone, tobacco cigarette brand names and sponsored The UK as a giant ash-tray; anti-smoking taxes contribute £4 ,550 million to the campaign by the Health Education Council. racing cars and sporting events, all national economy and, while govern­ with an appeal to the young. In 1984, ments may claim to have the health of more than 330 hours of sport on their nations at heart, the economic now to be found in the lower socio­ television featured events sponsored arguments play a major part. When an economic classes. by tobacco companies, with the events industry provides huge sums of money Among children, however, the bearing cigarette brand names; adver­ and scarce jobs, few politicians are trends are more worrying. The results tisements for cigarettes were promi­ going to be brave enough to confront of a survey published in 1984 showed nently featured, in breach of the the issue effectively. that 22 per cent of children in secon­ agreed code. So we must campaign. We must dary schools were smokers, many Sport is immensely attractive to campaign hard and effectively. And smoking more than 20 cigarettes a young people, and research shows that

4 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 Riding for a fall ; many youngsters get the Australian experience, where a group have become hooked. cigarette habit at the age of 12. of concerned doctors and health cam­ But although education over the paigners calling themselves BUGA Photo CIRIC © years has contributed to the decline in UP pioneered guerrilla tactics to de­ smoking in the UK, vigorous activity face cigarette advertisements on bill­ must take place in the political and boards, and to disrupt tobacco promo­ economic sphere. There is a well­ On a regional and national basis tions at sporting events and in public proven correlation between rises in those figures were shocking enough places. the price of cigarettes and a decline in -and we estimated that, if current There are now two similar groups in the numbers of smokers. So, while trends continued, 1.5 million smokers the UK and, while I obviously cannot education can create a climate of opin­ will have died by the year 2000. But condone illegal activities, I certainly ion in which political action is possible, we decided to extend the analysis into applaud the spirit which drives people politicians must be reminded that ac­ much smaller units, and produced to take direct action in the face of tion is necessary, the tobacco industry figures for every parliamentary con­ official inability to act decisively must be monitored and its activities, stituency and for local government against a murderous addiction. when in breach of laws or voluntary districts. Copies of the data were sent Our policy is straightforward. We agreements, exposed. to members of parliament and civic wish to see a ban on all cigarette leaders. The black balloons formed advertising, except where cigarettes part of a publicity campaign surround­ are sold. We wish to see all televised ing the publication which created sports sponsorship by tobacco com­ Airline bans cigarettes enormous interest in the mass media, panies phased out over three years. bringing massive publicity and rein­ We wish to see voluntary codes being The Soviet airline Aeroflot is forcing the need for politicians and strictly adhered to. And we wish to see reported to have banned all community leaders to take action. rigorous enforcement of the law which smoking on domestic flights Where data are available for deaths forbids the sale of cigarettes to chil­ within the Soviet Union . The or hospital treatment from ischaemic dren under 16 , a law which is being ban on smoking has also been strictly enforced for the airline's heart disease, lung cancer, and bron­ widely flouted. pilots. since research found that chitis and emphysema-the three most Each country will, of course, have a one cigarette smoked before common diseases related to smoking programme and tactics relevant to its a flight limited the angle of -a similar exercise could have an own conditions, but I believe that the vision and compromised colour equal impact in any country. By mar­ UK experience has elements which perception by as much as shalling statistics, encouraging re­ can be applied elsewhere. Particularly 20 per cent. search in areas where it is not taking worrying is the advertising of ciga­ place and ensuring that legislators and rettes in Third World countries, using the general public are aware of the techniques which have long been for­ situation, the puny resources available bidden in the UK. Smoking is associ­ The Big Kill was a major exercise to health promoters can challenge the ated with glamour and worldly suc­ on the political front. There were billions of pounds spent by the tobacco cess, which must rank as the most 15 volumes of analysis, one for every industry. cynical marketing ploy of all time. health region in England and Wales, Public pressure can yield results, Those of us concerned with health setting out the numbers of deaths, and an industry which purports to be must use every tactic possible to pro­ numbers of smokers treated in hospi­ socially responsible can be easily em­ voke governments into action, because tal for smoking-related diseases, and barrassed when its activities are ex­ it is only at the political level that this the cost to the health service. posed. The UK has learned from the lethal trade can be curbed. •

W ORLD HEALTH , June 1986 5 ~ 0 Smoking in sI 0 0 .J;: lhe Third World Q_ by Uma Ram Nath

The cycle of tobacco cumbersome than the hookah, for ex­ cent ; in Lusaka- boys 40 per cent, use, disease, debate ample. Cigarettes can generally be girls 4 per cent. Twenty years from and public action bought one at a time and not neces­ now these young people will begin to that is already fam­ sarily in a packet of ten or twenty and, fall victim to tobacco-caused sickness. iliar in developed of course, to the common man they It is time now to prevent that countries of the are being promoted as a symbol of happening. world is only just sophistication. A report presented to WHO's Execu­ starting up in the Third World. In­ The booming production of ciga­ tive Board last November condemned deed, the developing countries today rettes (measured in billions) in some cigarette smoking as the major avoid­ are poised dangerously between the developing countries indicates the able cause of ill health and early death first and second phases. Growing growth of the problem: in the countries where the habit is numbers of people are smoking and widespread. It said that 90 per cent of 1979 1983 there is a discernible increase in smok­ - - all lung cancer, 75 per cent of chronic ing-related diseases. But we cannot Kenya . . 4.6 5.3 bronchitis and emphysema, and a quar­ wait for public debate to initiate Algeria 14.0 17.5 ter of ischaemic heart disease cases in action; governments must recognise Egypt .. 29 .2 44.0 men aged under 65 could be attributed the danger now and act to prevent China .. 651.0 962.6 to smoking. While in the developed the spread of the cigarette. Indonesia . 69 .8 92.1 countries the number of smokers is There are, of course, many ways of Cuba .... 28.0 30.0 declining, and the habit is fast becom­ using tobacco apart from the cigarette. ing socially less acceptable, in de­ Charutos are favoured by South In the industrialised nations there veloping countries it is on the increase Americans ; the goza or hookah is are fewer smokers than there used to "fuelled mainly by intensive and ruth­ popular in the Middle East and is also be. But disturbing statistics from Afri­ less promotional campaigns on the common in South-West Asia; some ca cited by Nigerian expert Dr Femi­ part of the transnational tobacco com­ people chew tobacco or, in India and Pearse show that 31 per cent of uni­ panies". Those companies' activities Pakistan, the betel leaf, or paan. Re­ versity students in Uganda smoke ; are not subject to the legislative or search into the health implications of 51 per cent of people between 30 and advertising controls that generally ex­ these habits has not yet delved as deep 54 in one village of Ghana smoke; and ist in the developed world, the WHO as the investigation of the cigarette in 41 per cent of men aged over 20 in report said, and it warned that smok­ relation to lung cancer. Lagos have the habit. Dr Femi-Pearse ing diseases will appear in develop­ In any case, skilful and aggressive also points to the substantial numbers ing countries before communicable marketing is now promoting the of children in secondary or middle diseases and malnutrition have been cigarette in the developing world. The schools who smoke: in Lagos- 17 per controlled. traditional uses of tobacco are being cent of boys, 2 per cent of girls; in This is the urgent need today. While replaced by the cigarette which is less Accra-boys 10 per cent, girls 8 per indigenous uses of tobacco may cloud

6 W oRLD HEALTH, June 1986 the assessment of tobacco-related the cigarette is associated with Tobacco is a lucrative export crop diseases, we can already see clear indi­ glamour, it will draw more and more for some developing countries and cations of cigarette-related illness in people to it. Some developing coun­ some international agencies give de­ developing countries. WHO believes tries have been able to legislate on velopment aid for the crop. Govern­ tqat an epidemic of lung cancer can advertising of cigarettes. Malaysia, for ments earn money from tobacco tax­ be expected as a result of the rapidly instance, has banned all television and ation. Fewer cigarettes sold will mean increasing cigarette consumption in radio publicity for cigarettes, although less revenue. many developing countries. For in­ it is still legal for newspapers to carry In India, changes to the excise tax stance, in India, total cigarette con­ advertisements. structure resulted in the flooding of sumption rose 400 per cent between There are a number of special fac­ the market by new and competing 1970 and 1980, in Papua New Guinea tors to consider in preparing a smok­ brands. As the more expensive ciga­ it trebled between 1960 and 1980, and ing-control package for developing rettes fell within a higher tax bracket, in Brazil about 135,000 million countries. In a population with a low their sales dropped. Challengers to the cigarettes were smoked in 1981 while level of literacy, what sort of health main producers are now offering cigarette-related diseases far out­ warning should be given? What would cheaper cigarettes and in a plethora of stripped the infectious diseases as the be the use of such a warning if the brands. And the Indian smoker has leading cause of death. indigenous products, such as tobacco taken these up. While cigarette manufacturers are for chewing or the bidi (a small hand­ In the long run the consequences of endeavouring to sell the low tar rolled cigarette), carried no caveat? sickness and disease, of work days lost cigarette in an attempt to make their Restrictions on the promotion of and the drain on resources, will be far product appear "safe" to " Western" cigarettes may be effective but what greater than the short-term gains of consumers, their products bearing in­ about the quality of the cigarettes tobacco-generated income. Develop­ ternational brand names, but sold in sold? Third World governments need ing countries still have a chance to the developing world, have much to fix upper limits to harmful sub­ prevent the growth of smoking. They higher yields of tar and nicotine. A stances in cigarettes. The Fifth World can ensure that promoting non-smok­ comparison of cigarettes in the Philip­ Conference on Smoking and Health ing forms an integral part of an overall pines and in the United States showed recommended in 1983 that "the pro­ primary health care strategy. They can that the former had 50 per cent higher duction and export of cigarettes with a draw up widespread and well-formu­ tar content than the latter and some­ tar yield of more than 20 milligrams lated education programmes to sup­ times twice as much nicotine as the should cease worldwide," and that all port the health message. And they can American version. Another assess­ cigarettes and tobacco products should bring in legislation to curb the promo­ ment of cigarettes from Australia and carry a health warning and precise tion of tobacco. Non-governmental Singapore showed similar results. labelling of tar, nicotine and carbon and voluntary organizations will be Cigarettes sold in China, India and monoxide content. valuable allies in this battle. In par­ Pakistan have a high tar and nic­ ticular the consumer movements that otine content. are emerging in developing countries A potter works with both hands and still can form the core of an anti-smok­ draws on his hookah. ing network in support of popular Photo W HO/Zafar initiatives for change. • 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 7 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

.!: 0. habit before the age of 12. In B

by William U. Chandler 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 .

8 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 drug campaigns or even of campaigns lutants combined. In the United The diseased lung of a deceased smoker against toxic chemicals, although both impresses schoolchildren in Singapore. States, the cost in lives may be as high hard drugs and chemicals claim far Photo WHO/Singapore Ministry of Health as 5,000 a year. Protecting the non­ fewer victims than tobacco. smoking public from the potentially Stronger measures in a dozen coun­ they take no such action with tobacco, deadly effects of drifting cigarette tries have been largely counter-pro­ a far deadlier .crop. smoke has become a high-priority ductive. Tobacco advertising is forbid­ For no avoidable condition claims worldwide health problem, which calls den in Poland, for example, and smok­ more adult lives than tobacco addic­ for a much more stringent tobacco ing is restricted in public places; yet tion. While little remains to be known control policy by governments and Poland in 1982 had the ninth highest about its effects on health, scientific public health authorities. per capita cigarette consumption in understanding of the addictive power the world. Similar anti-smoking mea­ of tobacco has progressed slowly. It sures have been taken in China, the seems certain that nicotine is the ad­ Smoker imperils plane German Democratic Republic and the dictive agent in tobacco. But in addi­ Soviet Union, but smoking in all those tion to nicotine, cigarette smoke con­ A passenger aboard a light air­ craft flying over Atlantic City, countries remains at very high levels. tains 4,000 other chemical com­ USA became so angry when Better results have been achieved in pounds, hundreds of health-damaging told not to smoke that he Finland, Norway and Sweden, where agents and simple carbon monoxide. attacked the pilot. The plane advertising is banned and cigarette These agents and chemicals not only twice came close to crashing packages carry strong warning labels. attack the lungs but reach the blood­ before another passenger res­ Nevertheless, only in the United King­ stream, where they circulate, causing cued the pilot and KO'd the dom is consumption lower than it was or accelerating clogging of the arteries, would-be smoker. 20 years ago when the first campaigns cancer of the internal organs and heart were launched. attacks. Fifteen to 30 per cent of all The irony of the situation is that heart attacks in the United States and Though the health consequences of tobacco is a dangerous drug which perhaps a third in the United Kingdom tobacco are now well known, mea­ clearly should be banned. The tragedy are caused by smoking, which is also sures to deal with them are so far is that governments promote and sub­ the leading cause of death from car­ woefully inadequate. Practical action sidise the tobacco industry, and the diovascular diseases for persons of rarely goes further than warnings industry itself is powerful enough to middle age and below in virtually all by governments that tobacco is un­ nip in the bud any move to restrict the developed countries. Smoking also healthy, the banning of advertising sales of tobacco products. Govern­ causes two other lung diseases, bron­ and the restriction of smoking on pub­ ments move swiftly to remove unsafe chitis and emphysema (together lic transport and in theatres. No na­ medicines from the market. They con­ known as Chronic Obstructive Lung tional tobacco control effort has been duct paramilitary operations to des­ Disease) , which kill 52,000 people a launched with the vigour of, say, anti- troy fields of marijuana or opium. But year in the United States alone.

W oRLD HEALTH, June 1986 9 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 No avoidable condition claims more adult tobacco industry to protect and pro­ lives than tobacco addiction. mote its interests. In many countries, tries with low smoking rates and no indigenous tobacco industry could Photo W HO/Zafar · the government actually owns the to­ bacco industry. In China, for instance, stop importing tobacco products and while one part of the government is thus impose a de facto ban. Studies have shown that only 15 per telling the people that smoking is Above all, stronger action should be cent of teenagers who experimented dangerous to health, the tobacco in­ taken to protect the health of the with tobacco were later able to quit. dustry is being expanded rapidly for innocent. Experience in such countries Other studies found that 75 per cent economic reasons. But these same as the United States and Poland shows who do quit smoking start again within contradictions also apply in western that tobacco can be banished from six months. In those who do quit, the nations. In the United States, to­ public buildings, from the workplace, tobacco "craving" often lasts for sev­ bacco farmers benefit from a price­ from restaurants and public meeting eral years. support system administered by the places. In short, banishing cigarette Health advocates generally dismiss government. West European govern­ smoking in the presence of non-smok­ stronger measures for dealing with ments subsidise tobacco growers to ers should be considered in all coun­ smoking. The Royal College of Physi­ the tune of some US $660 million tries as a minimum level of protection cians in London, the first governmen­ a year. for the non-smoker. tal body in the world to launch a This official tolerance and even These measures will not be easy, nor campaign to save the health of smok­ endorsement of smoking seriously will they solve the tobacco problem. ers, concedes that banning tobacco is undermines the efforts of anti-smok­ They will not protect children in the impractical. They compared such a ing movements and casts doubt on home from the smoke of their parents move to alcohol prohibition and the sincerity of government-backed or the unborn fetus from the results of feared it would lead to criminality. information campaigns about the its mother's tobacco habit. Nor will The ultimate solution is an outright dangerous effects of smoking on they persuade smokers themselves to ban on tobacco sales, but the opposi­ health. Small wonder therefore if a quit, or guarantee that innocent young tion to such a revolutionary move child about to start smoking fails to people do not become addicted before could hardly be more formidable. take them seriously. they realise, too late, that their new The fact is that governments all over Since an outright ban on tobacco habit eventually kills one out of every the world work hand-in-glove with the sales is an impossible dream, the em- four smokers. •

10 WORLD HEALTH, June 1986 Lifestyles and Health

Giving up the weed by John Wickett

gave up smoking. Twice. The sec­ fell on a Monday. I announced to one This situation lasted three years. ond time was somewhat less and all that I was going to stop, thus Then "stress" entered my life. I began (J miserable than the first. risking to look like a fool if I didn't keep to scrounge the occasional cigarette Both my parents smoke, so I never my word. Well. the last Sunday arrived from one of my friends when out for an really stood a chance. I tried my first and I smoked three packs of cigarettes evening . I did not like the way my cigarette at about the age of five, and it and two cig ars. mouth would taste the next day, but .. .. was inevitable that I should become a Talk about drug withdrawal symp­ My downfall was the arrival of a new smoker. No one talked about it being toms! My nose dripped for a month, I colleague with whom I was to share an bad for your health in those days, and it had a sore throat for a month, my eye office. A smoker. In three months I was was such a terribly grown-up thing to prescription changed, my intestines smoking again. Two years later I was up do. In High School, I remember envying went beserk with burping and flatu­ to 30 cigarettes a day although my my friend David because he could lence. I even had dizzy spells, no doubt colleague had moved to a separate smoke at least 20 a day, inhaling deeply getting "high" by breathing an unac­ office. and blowing magnificent smoke rings, customedly large intake of oxygen in- By this time I was 100 per cent while I would simply become ill. Every­ converted to the idea that smoking is body smoked. totally stupid. I had even developed a lt was not until my fourth year at cozy chronic little smoker's cough and university that I came across someone my lungs felt heavy. But there was that who actually decided to stop. Although little demon gnawing on my stomach he was my best friend, I still felt his which would only leave me alone if I behaviour was suspiciously anti-social. would smoke. During my early 20s, I settled into a So I stopped. Since I had already regular habit of about 20 a day. it was stopped before, I knew what the with­ quite a treat to come to Switzerland in drawal symptoms would be like. The 1969, where 20 cigarettes cost 65 cen­ day came when it felt as bad to smoke times or $0.15 whereas in Canada they as I knew it would to stop, and my had been $0.35 and people were begin­ cigarettes ran out on a Sunday evening. ning to make noises about them being Since Monday, 2 December 1985, I bad for your health. have smoked neither cigarette nor My boss at WHO smoked, as did my cigar. it hasn't been as bad as I feared . colleagues. By the time I was in my The only real physical discomfort was early 30s I was smoking over three the gnawing in the stomach, and I did packs a day of those strong cigarettes put on some weight. I have been pleas­ that cowboys like. Up until then smok­ "Two years later I was up to 30 cigarettes antly surprised at how infrequently I ing did not seem to be a danger or a day ... " have a desire for a cigarette. But I don't even an inconvenience to my health, Photo L. Sirman © think it ever entirely goes away. None although there were times when my of my friends who have quit have en­ tongue felt like a slab of smoked meat tirely lost the urge. and my throat felt parched and stead of the normal smog. I put on it really helps if you know what to scratchy. weight; when you don't smoke you try expect. You may not believe this, but By this time, though, I was convinced to satisfy the gnawing feeling in your one of the most comforting documents that smoking was bad for you and that stomach with food or numb it with I have ever read was the report of WHO's the number I was smoking per day was drink. Director-General to this year's Execu­ positively suicidal. Besides, other peo­ After two weeks I permitted myself a tive Board on the wHo Programme on ple were giving it up. lt would be cigar in the evening. The rationale here Tobacco or Health. it accused tobacco difficult, and I had no confidence in is that you don't inhale the cigar smoke, of being more insidiously addictive than acupuncture, hypnosis or nicotine thus you don't risk lung cancer. And of heroin, and described all those symp­ chewing gum. Brute-force willpower, I course, you get your "hit" of nicotine toms I was experiencing upon stopping felt, was the only way. After all I was as it passes through the mucosa of your smoking. I recommend it. There is no giving up on the theory that I might live mouth into your blood stream. lt proved magic potion to make you give up; it longer, not because I didn't like smok­ virtually impossible to go without that takes willpower and the foreknowledge ing . To mentally prepare myself, I set a one cigar a day. I didn't mind not of what you will experience when you target six months away as the day I smoking in the office during the day, do. You've got to make up your mind. would stop : my 35th birthday. This also though, which surprised me. And, by the way, I do feel better! •

W oRLD HEALTH , June 1986 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 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 He l~e, invites his countrymen to drink water. Photo Norwegian Directorate for the Prevention of Alcohol and Drug Problems ©

W ORLD HEALTH , June 1986 13 One tor the road? by Alex lrving

It is just 100 years alcohol levels to the likelihood of the drivers was effectively forbidden, and since the German driver having been responsible for in the other a maximum allowable inventor Gottlieb an accident or committing a serious level of 0.8 per mill became the most Daimler produced traffic offence. Alcohol levels were popular choice. The 0.8 per mill level the first commercial usually defined for convenience as the received support from international automobile. Since amount present in the blood, which organizations, such as WHO, and from then motor vehicles could be directly related to the various country groupings. have grown from being the playthings amounts in the other fluids. The im­ Today, enforcement procedures are of the rich few to constituting a trans­ portant levels for driving ranged from relying more upon accurate breath­ port system that plays an essential part about one half part to two parts of test machines, simple enough to be in the lives of most people on this alcohol in one thousand parts of used by trained policemen but which planet. The benefits in terms of con­ blood, which may be written as 0.5 per provide legally acceptable evidence, venience and personal mobility have mill and 2.0 per mill. At levels of rather than blood testing which in­ been immense. But there is a price to alcohol in the blood amounting to volves medical attendants and costly pay in terms of the lives lost and greater than one part in one thousand analysis. suffering caused through accidents. parts (1.0 per mill) a driver would be The use of alcohol by road users is And one factor that has consistently very likely to be convicted. the largest single identifiable con­ been identified as increasing the likeli­ tributory factor to road accidents, and hood of being involved in a road in theory should be relatively easy to accident is the use of alcohol by road prevent. In practice, the problem is users, whether drivers or pedestrians. surprisingly robust and resistant to Recognition of the problem is not treatment, especially in the developed new. In fact it preceded the motor countries, where both drinking and vehicle itself, in the form of laws driving a car are integral social fea­ introduced in the nineteenth century tures of long standing. to deal with drunken drivers of horse­ The developing countries may be in drawn and steam-powered vehicles a much better position, and most and with drunken behaviour on the of them have either imposed a com­ highways in general. plete ban on alcohol when driving, The first few decades of this century or have set maximum alcohol levels saw increasing numbers of road acci­ Drunken drivers risk other lives besides their for drivers at about 0.8 per mill or own. dents and a growing realisation that lower. alcohol could be playing a significant Photo W HO/P. Almasy The experiences of the developed part in causing theni. Governments countries are being studied with some reacted to the problem by enacting Findings from the many studies advantage and important lessons have laws and imposing quite harsh pen­ made in recent decades seem to be been learned to benefit the Third alties, including fines, licence with­ universally applicable; the relative World. During the early period of drawal and imprisonment. The diffi­ risks to drivers who drink are the same motor transport growth, the emphasis culty was how to judge the point at whether in Bangladesh, Belgium, was on detection and punishment of which a drinking driver became an Botswana or Brazil. The absolute offenders. With hindsight, it might unacceptable risk on the road. numbers of accidents involving drink­ have been more appropriate to con­ During the 1920s and 1930s it was ing in any one country will depend on centrate on public health education determined that the amount of alcohol other factors , including driver training, and reinforcing of social pressures present in body-fluids could most con­ experience and attitudes, and the gen­ against drinking and driving. • veniently be measured by taking and eral road traffic situation. N everthe­ analysing small amounts of blood, less there was now an accepted yard­ urine or even breath, which could stick by which the accident risk due to Further reading: The influence of alcohol and drugs on driving (1981), EURO Reports and readily be obtained from drivers. alcohol could be judged. Studies No. 38; Alcohol Policies, by M arcus Courts which accepted body alcohol For legal purposes, two approaches Grant (1985), wHo Regional Publication, Euro­ levels as evidence soon began to relate emerged; in one the use of alcohol by pean Series No. 18.

14 W ORLD HEALTH, June 1986 • Books· and Publications

Like a thief in the family

"Palm wine 'tap­ ous state, having learnt to say No to beer made from sorgho (amarwa, pers devote a alcohol. The father provides the intulire, indera). millet (dolo, tose). great deal of time family with good food such as fish, bananas (urwagwa, inkangaza), to that activity. Af­ eggs, meat and vegetables. He pre­ maize, and honey (mead, "ubuki "); ter the wine has fers cycling to drinking beer, and the or by distillation-liquor made from fermented, it is children, who are cheerful and well the palm, maize, bananas or pine­ usually drunk in fed, work well at school. apples, and arki distilled from the company of friends . So all the This little " film", which is offered maniac. effort provides no additional income to the health worker as an edu- Alcohol consumption is a real for the family. Furthermore, a palm threat in African society, which has tree used as a source of wine so many other obstacles impeding ceases to bear fruit." its development. The handbook tells This explanation accompanies an us that "what really has an effect illustration showing a man in Africa is not prohibiting but informing." it perched up a palm tree and extract­ does this very thoroughly, debunk­ ing its sap. it is one of the drawings ing the myths that alcohol is good in "Alcoholism", a health education for you, giving a detailed account of handbook written by Nzungu Ma­ the medical and social disorders that vinga, B. Pierre and J. Courtejoie, arise from alcohol abuse and analys­ and published by the Office of ing the various approaches to the Health Promotion Study and Re­ control and prevention of alcohol­ search in Zaire . ism. it suggests how to run health The drawings themselves make education sessions and gives exam­ up a small educational "film", the ples of useful educational materials. three-stage history of a happy family Above all, the authors situate the whose palm tree was a steady control of alcoholism in the setting source of income. They sold the of integrated development, and whole coconuts, the nut kernels or show how this scourge affects all the oil extracted from the nuts in the major social and economic fields. local market. But one day "alcohol­ alcoolisme "Controlling alcoholism is one of ism found its way into the family, alcoholism alcoolismo the key factors in the social and

like a thief." A "friend" taught the AFFICHE MURALE n ~ 1 ALCOOLISME 1 economic development of a coun­ father how to make palm wine, the try, and an important public health traditional fermented drink. The factor," they point out. wine robbed him of the desire to cational tool, is one section of a The handbook- which is pub­ work, and induced him to buy other comprehensive review, written in lished in both French and En­ forms of alcohol, to neglect his simple, readily understandable glish-ends on an optimistic note; a household and to beat his wife. it language, about alcohol and its young woman says with a smile: was not long before the children consequences. "I'm doing well in my studies went hungry, suffered from malnu­ The writers remind us that there because I don't drink alcohol . " trition and could no longer attend are many traditional forms of alcohol For further information, write to : school. Finally, the father was in­ in Africa, besides those that are Bureau d'Etudes et de Recherches volved in a traffic accident which put imported mainly from Europe. pour la Promotion de la Sante, him in hospital . Home-made or prepared in the vil­ B.P. 1977, Kangu-Mayumbe, Re­ The third stage shows the family lages, they include those produced public of Zaire. restored to its happy and harmoni- by fermentation - palm wine and C. V.

W OR LD HEALTH, June 1986 15 hroughout history, human societies have recognised certain substances of natural origin which either Uoffer 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

onfronted by the deluge of such a valuable task they find them­ The fact is that drugs-all kinds of statistics relating to the inter­ selves slipping into or being pushed to drugs-constitute very big business lB national epidemic of cigarette adopt the role of moralisers, priests throughout the world. In Zimbabwe, smoking, the inexorable rise in alcohol and social engineers. For while such tobacco production is the nation's production and consumption, the pro­ drugs have profound biological conse­ largest industry. In Malawi, 100,000 liferation of opiate dependence and quences, the factors that primarily in­ families rely on cash from tobacco, the remorseless growth of the psycho­ fluence their use are psychological, while in the Indian state of Andhra tropic drug market, it is hard to resist Pradesh, tobacco provides a living for adopting one of two attitudes. The 75 ,000 farmers and about two million first , a resolutely pessimistic approach, Drugs destroy families other workers are engaged in curing, is to conclude that societies in every packing and processing. The soaring An English couple, both aged quarter of the globe are hell-bent on 37, have been jailed for ten and consumption of alcoholic drinks in drugging themselves into a terminal seven years respectively for Third World countries has just begun state of euphoria and malaise. The the manslaughter of their 15- to worry health care workers at a time second, ruggedly optimistic, is to draw month-old daughter by giving when it is taken by some economists as comfort from the fact that there her an overdose of a heroin a sign of improving living standards has never been a society on this substitute. Both had been and growing industrialisation. Spec­ earth which has not experimented medically prescribed the drug tacular growth rates in beer produc­ Methadone in an attempt to with, habitually relied upon and oc­ wean them off taking heroin. tion have been achieved in countries casionally abused some mind-altering They told a London court that as varied as Japan and Bulgaria, the substance. they gave the drug to the baby Netherlands and Yugoslavia. In the Which of these two positions the "to quieten her down." past 20 years, Nigeria, Mexico and average individual adopts depends as Brazil have become major beer pro­ much on his or her temperament as on ducers by world standards and have the state of our contemporary and social and cultural. Our understanding joined such traditional producers as historical knowledge. of a person's propensity to alter his or the Federal Republic of Germany and Professionals working in the health her mind with various chemical sub­ the United Kingdom at the top of field-doctors, nurses, primary health stances will not be advanced by way of the league. care workers, lay healers-all occupy a narrow medical perspective. The The situation is little different when an uneasy position within the drugs medical profession ought not to de­ it comes to illicit drugs. Ever since a debate. They feel, and indeed are, duce that, because a certain drug be­ fully fledged opium market was morally obliged to document and pub­ haviour in a certain individual can opened up in South-East Asia in the licise the extent to which we all ingest, legitimately be construed as an illness, nineteenth century by the United smoke, drink and inject nicotine, al­ the general use of such a drug in some Kingdom and other European impe­ cohol and drugs; yet in carrying out way reflects a pathological society. rial powers, there has been a massive

18 W oR LD 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 1960s and 1970s was largely sanc­ Not surprisingly, doctors and and distribution of opiates and related tioned by the medical profession. Only nurses, primary health care workers substances. Opium in the East, like recently has it begun to provoke and interested members of the public rum and guns elsewhere, was offered alarm, and there is evidence that a are beginning to realise that the key by European traders in return for similar epidemic of drug use is spread­ to reducing drug- and alcohol-related spices, silk and tea from China and the ing to the Third World. problems lies in controlling produc­ East. Now developed and developing So why is there this seemingly insa­ tion, marketing, retailing and distribu­ countries alike are struggling to con­ tiable need for drugs? Is it a reflection tion. And this realisation, in turn, sets tain what has been termed "the global of the growing self-assertion of youth the stage for a difficult confrontation heroin economy," which includes throughout the world, given that drug between those anxious to reduce the street dealing in Manhattan, the prob­ use and abuse, particularly of the illicit negative impact of drugs on society lems of opium farmers in India, Paki­ kind, is primarily an activity of the and those for whom the production stan, Sri Lanka and Thailand, and young? Does it reflect a world-wide and distribution of such drugs repre­ smuggling networks which criss-cross loss of confidence, an international sents a livelihood. the world's airways and oceans. Her­ epidemic of anxiety and demoralisa­ To paraphrase Sir William Osier, oin use is spreading in poppy-growing tion that is being "treated" by a the desire to take drugs is one feature countries themselves. wholesale recourse to intoxication? Is which distinguishes man, the animal, While alcohol and nicotine tend to it a quirk of statistics? After all, it is from his fellow creatures. It is, as that be regarded as licit drugs and the often pointed out that no reliable wise Canadian physician observed, opiates in general are under elaborate statistics have ever been kept of the one of the most serious difficulties international controls, other mind­ amounts consumed in Africa, Asia and with which we have to contend. He a,ltering substances, such as cannabis Latin America of traditional fruit- or foresaw in the success of the pharma­ and industrially produced psycho­ cereal-based alcoholic drinks. cists in producing remarkable re­ tropic drugs, occupy a sort of no-man's There is hardly an expert in this area medies the danger that we would be­ land. One popular Jamaican rhyme who does not believe that many fac­ come used to assuming that for every reverses the usual image of alcohol as tors play their part in drug use. But ill there is a pill. That danger, if the superior, status-related drug and most would agree that the strongest international statistics do indeed mean ganja (marijuana) as the inferior, single cause of the high levels of what they appear to mean, is already down-market product: consumption is the rate of production upon us. A Pandora's box has been You drink white, rum you tumble and the energy and enthusiasm with opened, and a host of evils have been down; which the product is marketed. Any poured on the world. But let us not You smoke kali weed, you succeed. nation will drink more alcohol, forget that, in the ancient Greek The dramatic expansion of psycho­ smoke more cigarettes or abuse more legend of Pandora, it was said that tropic drug prescribing in Scandinavia, opiates if the relevant drug is made hope alone remained at the bottom of the UK and North America in the more available. her box as a comfort to mankind. •

WoRLD HEALTH, June 1986 19 Lifestyles and Health

Meeting the threat ol drug abuse

by Marcus Grant

n March of this year. representa­ Action to reduce health problems on the nature and extent of drug abuse tives from 30 countries met at Lan­ arising from narcotic and psychotropic problems is far from adequate. Al­ Ucaster House. London, for a confer­ drug misuse still has to face powerful though the general upward trend is ence of Ministers of Health on narcotic political and economic interests that are clear, estimates of production and con­ and psychotropic drug misuse. This opposed to effective programmes. This sumption are uncertain and information conference provided a unique oppor­ is true at both national and international on the prevalence of particular prob­ tunity for the collective views of these levels. Within and between countries. lems, including dependence, is very governments to be brought to the at­ there are forces at work that seek to hard to obtain . There are many reasons tention of the world community. Their undermine efforts to develop a com­ for this. some of which relate to the joint statement will be put before the prehensive response to the health prob­ illegal nature of the substances. 1987 UN Conference on Drug Abuse. lems related to drug misuse. The chal­ A preventive strategy begins from an The misuse of narcotic and psycho­ lenge to the health sector is to dispel awareness of the multiplicity of factors tropic drugs leads to many other kinds uncertainty about preventive and cura­ of problem as well, but the focus of the tive action and to mobilise the will of Stomach pump treatment for a patient London conference was specifically on ordinary people to join in the efforts to suffering from a drug overdose. Powerful health problems and on the action that control drug-related problems. forces are at work, seeking to undermine health ministries can take to counter Unfortunately, both nationally and in ­ efforts to counteract drug misuse. this threat. ternationally, the information available Photo W HO!T. Urban involved in narcotic and psychotropic stances change, so must some aspects drug misuse. Efforts in recent years to of the national programme. What re­ Vienna reduce the supply of drugs through mains constant is the commitment to Conference 1987 control mechanisms have not been suf­ long-term action and the recognition Drug abuse presents as des­ ficient to deal with the rising demand. that the solution to drug misuse prob­ tructive a threat to present and As the emphasis shifts towards giving lems lies in prolonged effort rather than future generations as the plagues higher priority to strategi es aimed at in unplanned or uncoordinated initia­ which swept many parts of the reducing demand. the health sector tives. however sensational some of world in earlier centuries. Unless must expect to play a more and more those may be. Planning national pro­ controlled. its effects could be central role in developing national and grammes means planning for action by even more insidious and devastat­ international responses. many people working in harmony. ing. In order to coordinate a con­ certed and determined struggle on Reducing demand will call for much Opportunities for international collab­ the part of the entire world com­ more than health education, although oration are most likely to develop out munity, an International Confer- . the importance of educational strat­ of national policies on narcotic and ence on Drug Abuse and Illicit egies shou ld not be forgotten. Much psychotropic drug misuse. Thus. tech­ Trafficking will be held at ministe­ health education has in the past been nical cooperation between developing rial level in June next year. at the directed exclusively at young people. countries can, for example, include al­ International Centre in Vienna. Although they remain an important ready existing programmes to control A resolution of the UN General group, others. such as parents and drug misuse problems in each of the Assembly last December strongly community leaders. must not be left co untries involved. Equally, linkages be­ urged all states to summon the out of the programme. tween developing and developed coun­ utmost political will to combat it will also be important to change the tries are likely to grow in strength as the drug abuse and illicit trafficking by generating increased political. cul­ practice of health professionals. and advantages of effective cooperation tural and social awareness. it also this will include training medical prac­ become apparent. Producing countries called upon the UN, the specialised titioners in better prescribing practices and consuming countries may view agencies and other organizations and appropriate legal measures. The drug misuse problems from somewhat of the UN system and non-govern­ development of activities at the com­ different perspectives. but they are mental organizations to give the munity level. mobilising the will of the likely to be united in their con­ highest attention and priority pos­ people to take action to counter the cern to minimise their adverse health sible to international means to threat of drug abuse. will greatly streng­ consequences. combat illicit production of. traf­ then a national programme of preven­ Despite social, cultural, economic ficking in, and demand for drugs. tion. Community development is based and political differences. countries can The resolution emphasises the on knowledge of the community and its learn from each other's failures as well need for all states to ratify the existing drug control treaties and problems; individuals need to be iden­ as from each other's successes. All too to make serious efforts to comply tified within the community who will often, experiments are repeated that with the provisions of these instru­ work closely with the health sector. A are known by others to have been ments. In convening the 1987 programme of education and preven­ unproductive. A fuller and more open Vienna Conference. it urged the tion should therefore involve the active exchange of all types of experience at adoption of a comprehensive participation of community leaders in its community and national level can lead multi-disciplinary outline of future design, delivery and evaluation . to a better international response. activities. which will focus on On one level, a national policy on Not only W HO but also other United concrete and substantial issues di­ narcotic and psychotropic drugs cannot Nations agencies certainly need to in­ rectly relevant to the problems. be separated from the overall national crease their current level of activities. The Conference will undertake an in-depth review of existing mech­ policy on health. but equally a national Just as a commitment to action is anisms. and will suggest govern­ drugs policy will involve the essential essential to make national programmes mental. inter-governmental and collaboration of many other sectors effective. so too is that commitment non-governmental objectives for of government. For each country, the important for international efforts. The combating all forms of drug abuse. process of defining a national drugs international agenc'ies have the techni­ drawing up strategic legislation policy will require a balance between cal capacity and the will to take action. and improving UN coordination. concerns for mental hea lth. for wider By eo-sponsoring the conference in At this Conference. a thorough health issues. and for overall national London and by taking responsibility for review will be given to subjects development. its scientific preparation. WHO has ranging from supply of substances A national policy, once formulated. demonstrated its w illingness to inten­ of abuse to a reductio n in demand. must be kept under review. Within the sify its own efforts. In fol lowing up the WHO has a special interest in these subjects and in particular in reduc­ framework of the policy, a national plan recommendations of the conference, ing demand. The ministries of of action can be developed that leads to WHO and the participating countries will health have specific responsi­ specific programme steps in preven­ be working together to meet the major bilities in the area of epidemi­ tion. treatmer-~t. research and training. threat to the world's health that is being ological investigation. treatment But this occurs within a changing politi­ created by the misuse of narcotic and and prevention of drug abuse. • ca l and economic climate. As circum- psychotropic drugs. •

W ORLD HEALTH , June 1986 21 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 Escape into nightmare the appetite. Today they are little used, but are occasionally recommended for hyper-activity in children. Many of these substances produced dependence and by lnayat Khan 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 Throughout history , central nervous system, sedatives, hyp­ is an active principle of the Catha edulis humans have known notics and tranquillizers. These syn­ plant (khat). drugs of natural ori­ thetic drugs do indeed produce relief, gin which may help but they also produce dependence, and Opioid agonist and antagonist drugs them to escape from create nightmarish public health and are very useful in pain relief but can the unpleasant fea­ social problems when they are diverted produce a state of dependence and thus tures of life , whether into illicit traffic. are liable to abuse. On WHO's recom­ real or imaginary, by Efforts to provide an international mendation, pentazocine is the only drug using fermented liquor or plant products legal framework for the control of of this type so far to have been placed such as opium, coca leaves, cannabis and psychoactive drugs, begun by the Inter­ under international control, while the more recently khat: national Opium Commission in Shang­ others are being monitored by WHO. The realisation that these substances hai in 1909, have resulted in a number Benzodiazepines are used to control have the capacity to produce depen­ of international treaties. The formula­ anxiety and tension, to sedate and to dence and abuse came only slowly. Mor­ tion of the 1961 Single Convention on help induce sleep and muscle relaxation. phine was first recognised as a cure Narcotic Drugs, with its 1972 amending They are the most commonly prescribed for opium addiction, and then found Protocol and the 1971 Convention on group of drugs in nearly every society to produce addiction itself. Heroin, and, being safer, they have replaced another synthetic substance ( diacetyl barbiturates for most medical purposes. morphine), was invented as a harmless These tranquillizers are taken by mouth cure for coughs but its dependence­ and are not injected to any extent by producing properties were soon disco­ drug abusers. The proportion of women vered and its use was outlawed. using tranquillisers is double that of Cannabis in its various forms was used men. Many users may be dependent to in different cultures, despite its harmful some extent. effects. Studies are continuing on plant Tranquillizers depress mental activ­ material and the substances isolated ity and alertness, but don't generally therefrom to determine the therapeutic make people as drowsy or as clumsy as principles and explain the harmful barbiturates do. Nevertheless, they do effects. Chewing coca leaves was once impair driving and other skills. Like the mainstay against hard work in the alcohol, they can sometimes release mountainous region of the Andes ; This painting by a heroin addict reflects the aggression by lowering inhibitions. today cocaine is considered one of the nightmare world of drug dependence. On their own, tranquillizers rarely most powerful dependence-producing Photo WHO/K. Brodie produce the euphoria associated with substances obtained from natural barbiturates or alcohol, a fact which resources. probably accounts for their lack of In fact , it was the large-scale use of Psychotropic Substances, are the major popularity as recreational drugs. But some of these natural products which milestones in the development of coor­ psychological dependence on ben­ drew attention to the need for control of dinated international control of depen­ zodiazepines is quite common amongst such dependence-producing substances dence-producing drugs. long-terms users and can be very dif­ and at the same time to the desirability WHO gives high priority to the res­ ficult to cope with. People sometimes of reducing the demand for them. There ponsibility assigned to it by the inter­ feel confused, irritable and anxious after is still great concern in the minds of national drug control treaties-responsi­ they stop taking the drug. the public and national authorities about bility which includes assessing each sub­ In early 1984, the UN Commission on the abuse of narcotic drugs and psy­ stance for its medical qualities. Particu­ Narcotic Drugs, which had initially chotropic substances derived from larly over the past ten years, WHO has requested WHO's recommendations, plant material. devoted greater resources and efforts to placed 33 commercially available Additional problems have arisen from reviewing the benefit and risk ratio of benzodiazepines on schedule IV of the the use of modern synthetic drugs cre­ narcotic drugs and psychoactive sub­ 1971 Convention, thus cautioning pa­ ated in large numbers by scientists in stances. These reviews concentrated on tients and those who prescribe these medicine and industry. Chemicals of three types of drug: amphetamine-like drugs and the concerned industry. These great therapeutic benefit are now avail­ substances; opioid agonists and an­ drugs already required a physician's pre­ able as narcotic drugs with an opiate­ tagonists; and benzodiazepines. scription in developed countries, so this like action, and also in the wider area of Amphetamines are synthetic powders action alerted developing countries to psychotropic activity-stimulants of the formed into a variety of tablets and use these useful drugs with caution. •

22 W ORLD HEALTH, June 1986 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 sniffer 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, common objects found at home, such say, aerosol or butane gas inhalation, or as glue, paints, nail varnish remover, with bags placed over the head, even dry cleaning fluids and de-greasing though these are almost certainly less ''Glue-sniffing'' compounds. Others occur as propellent common practices. gases in aerosols and fire extinguishers, Very long-term heavy solvent mis­ or as fuels (petrol or cigarette-lighter use-over ten years-might result in nhalants or solvents are chemicals gas). Sometimes sniffers heighten the moderate but lasting impairment of which are volatile at room tempera­ effects by increasing the concentration brain function, affecting especially the Uture and produce effects similar of the vapour and excluding air, for control of movement. Chronic misuse to alcohol or anaesthetics when their instance, by sniffing with a plastic bag of aerosols and cleaning fluids has vapours are inhaled. Some common placed over their head-a dangerous caused lasting kidney and liver damage, members of this class of inhalants are enough procedure even without the whilst repeatedly sniffing leaded petrol toluene, gasolene, kerosene, carbon­ chemical substance. may result in lead poisoning. Despite tetrachloride, amyl nitrate and certain Inhaled solvent vapours are ab­ these possibilities, it seems that lasting drugs used to induce anaesthesia such sorbed through the lungs and rapidly damage attributable to solvent misuse as halothane and nitrous oxide. reach the brain. Part of the effect is due is extremely rare. Recent experience shows that in to the reduced oxygen intake. Such Whilst someone is sniffing repeat­ some countries the abuse of these body functions as breathing and heart edly, the " hangover" effects of pallor, agents is on the increase. The usual rate are depressed, and repeated or fatigue, forgetfulness and loss of con­ pattern is for children to start experi­ deep inhalation can result in an "over­ centration tend to become a recurring menting with inhalants at around dose" causing disorientation, loss of daily pattern. The youngster's perform­ twelve years of age, but few people are control and unconsciousness. In normal ance and functioning are affected and still using them after the age of twenty­ circumstances, sniffers quickly recover. there can be weight loss, depression two. Those who do continue using The experience is very like being and tremor. But these will clear up these substances develop a psycho­ drunk-youngsters get merry and fool once sniffing is discontinued. pathological state and associated social about together. Experienced sniffers Tolerance develops, but physical de­ problems. may go on to seek dream-like experi­ pendence is not a significant problem. Most young inhalers turn to alcohol ences ; but generally these are not true Psychological dependence develops in and cannabis as they grow older. Inhal­ hallucinations, since youngsters don't a minority of susceptible youngsters ants produce various effects ranging confuse them with reality. with underlying family or personality from an intoxication similar to alcohol The effects of solvent vapours come problems, and these will probably to that induced by· hallucinogens; this on quickly and disappear within a few become "lone sniffers," as opposed effect develops rapidly and subsides minutes to half an hour if the sniffing is to the more common pattern of sniffing within minutes. Inhalants are present in stopped. Afterwards the youngster may 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

by Peter Kalix

he chewing of leaves of the khat considerably because khat can be to their families is due to negligence, shrub (Catha edulis) is common transported much more rapidly to dis­ dissipation of family income, and inap­ Uin certain countries of East Afri­ tant places. The cultivation and use of propriate behaviour. Many of them ca and the Arabian peninsula, and khat have profound socio-economic spend money on khat while neglecting some khat users are subject to psychic consequences for the countries con­ their vital needs, which indicates dependence on the drug. The effects cerned and make a considerable im­ psychic dependence on the drug. of khat are reminiscent of that induced pact on the life of the individual. Khat The main effects of chewing khat by amphetamine. Recently, the al­ chewers are mostly male and the harm are a moderate degree of euphoria and 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 W ORLD HEALTH , June 1986 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 ©

excitation often accompanied by recommended that the UN Narcotics This pattern corresponds to that seen loquacity. High doses may induce Laboratory should reinvestigate the in amphetamine-dependent humans. hyperactivity and, sometimes, manic chemical composition of khat. These Thus, in terms of pharmacology, the behaviour. Although there have been studies led to the isolation from khat chewing of a portion of khat is tan­ several reports of cases of psychosis leaves of an alkaloid that is chemically tamount to ingesting amphetamine-a due to khat chewing, this is rather similar to amphetamine and for which fact discovered mainly through the exceptional, probably because of the the name cathinone was suggested. It impetus given by WHO to the identifi­ physical limits to the dose that can be was also observed that, to a certain cation and pharmacological investiga­ absorbed. Khat is an effective anorec­ extent, the cathinone content corre­ tion of the new compound. This find­ tic, that is , it diminishes the appetite, lated with the market price of khat. ing shows that there is a certain degree and this largely explains the malnutri­ of danger associated with khat use. tion often seen in habitual khat users. Active principle Although immediate and severe medi­ It also causes hyperthermia and an cal problems are infrequent (because increase in respiration. Once this substance was recognised the cathinone is diluted in the other The effects of khat are, of course, as the major active principle of the material of the leaves), the use of khat difficult to quantify since the leaves leaves, it was synthesised and made often leads to health problems, and are a non-standardised material, the available to pharmacologists through this, taken together with the serious potency of which depends on freshness WHO, which also appointed an advis­ socio-economic consequences of the and origin, and there are certainly ory group to carry out an initial survey habit, makes its limitation desirable. differences between chewers in the of the pharmacological properties of Effective reduction of the use of efficiency of the mastication process. the new alkaloid. These studies re­ khat would relieve several million The international organizations veald that the pharmacological profile people of a costly, counter-productive were confronted with the problems of cathinone closely resembles that of and potentially addictive habit. It associated with khat as early as 1935 , amphetamine. would even free scarce arable land and when the League of Nations Advisory In experiments with such animals as irrigation water that are, at present, Committee on the Traffic of Danger­ rats and monkeys, which were trained used for cultivating khat. Several ous Drugs discussed two technical re­ to administer the drug to themselves, countries concerned by the khat prob­ ports on the subject. Through the UN the pattern observed was described as lem are now taking steps to restrict its Commission on Narcotic Drugs, inter­ "spree-type": the animals took the use , and in order to catalyse these national attention was once again di­ drug frequently day and night, stop­ efforts, WHO has sponsored field rected to the nature and extent of khat ping only upon becoming exhausted, studies on medical and epidemiologi­ use, and in 1971 the Commission and beginning again after recovery. cal aspects of khat chewing. •

W oRLD HEALTH , June 1986 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

by Roger Highfield

A new variety of Designer drugs may only have a few tify the drug if presented with an over­ street drugs is emerg­ extra atoms, but they and, as important, dose victim or an addict. Tests must be ing that presents a their impurities, may offer enormously designed capable of detecting around novel challenge to different potency and duration of action one thousandth of a millionth of a scientists and legis­ from the original. Fentanyl, for example gramme of the material in body fluids. lators. So-called de­ is a powerful but short-acting narcotic The best US assay, based on anti­ signer drugs are which is a widely used anaesthetic. The bodies, can only detect certain fentanyl made by performing small alterations in derivative 3 methyl fentanyl is different derivatives. the molecular structure of a controlled Detecting fentanyls is one thing; but substance. The result can be a drug that identifying the precise derivative re­ is thousands of times more potent than quires an expensive piece of equipment the original, yet can be technically legal called a mass spectrometer, which iden­ to make and use. This is because most tifies molecules by, in effect, weighing countries outlaw drugs of abuse by list­ them. Even so, fentanyl derivatives tend ing specific controlled substances in to fall apart in the spectrometer and it their legislati

26 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 The new substances are sweeping the United of the concentrations of radioactively stand the way that MPTP causes labelled compounds (which emit posi­ damage, providing new insights into States; other countries are worried by the potential threat they represent. trons) in the brain, found a decrease in Parkinsonism. Photo W HO!T. Urban the levels of dopamine, a neurotransmit­ MPTP itself may be harmless, but it ter, in one area of the brain. The de­ appears that it is converted into a toxic epidemiological study since they may crease was similar to that found in cases derivative, MPP +, by enzymes in the develop Parkinsonism at an unusually of Parkinsonism. A breakthrough in this brain. MPP + is toxic to substantia nigra early age. Dr Donald Calne, a neurol­ field would go a short way towards neurones, the same set that degenerate ogist at the University of British Colum­ offsetting the harm that designer drugs in Parkinsonism. The conversion of bia, recently enlisted the technique of have already caused and will cause in MPTP to MPP + can be blocked by positron emission tomography (Pet), to the future. certain substances, and these offer a new study six of these people, who had no The health authorities in a number therapeutic avenue to be explored. outward signs of Parkinsonism. of countries and WHO itself are watch­ Some 400 people who used the syn­ Pet showed they had indeed suffered ing the situation and will take appropri­ thetic heroin will test such theories. neurological damage. The technique, ate action to curb this serious public They have, in effect, enlisted in a grim which builds up a cross sectional picture health threat. •

W ORLD HEA LT H, June 1986 27 by B. Juppin de Fondaumiere

The world-wide con­ two distinct "international drug control trol of narcotic drugs organs" within the framework of the and psychotropic Cocaine use increasing United Nations : the Commission on substances has been worldwide Narcotic Drugs of the Economic and developed gradually Social Council and the International over the last 70 years The availability of and trafficking Narcotics Control Board. The different by a number of inter­ in cocaine of South American but complementary nature of these two national treaties origin has increased sharply organs may be summarised as follows: which finally resulted in the adoption of in recent years. reflecting the the Single Convention on Narcotic determined efforts of traffickers - The Commission on Narcotic Drugs is Drugs in 1961. This was amended by the to expand the illicit market in one of the six functional commissions 1972 Protocol and in the Convention on Western Europe. The Interna­ of the Economic and Social Council. It Psychotropic Substances of 1971 . tional Narcotics Control Board in is composed of governmental represen­ These treatiys were all adopted after Vienna said that more than one tatives (at present 40 Members). Its long consideration, inter-governmental tonne of cocaine was seized in terms of reference include advising the consultation and painstaking drafting. 1984, and almost half a tonne in Council on all matters pertaining to Each successive treaty brought forward the first half of 1985. The coun­ drug control and preparing such draft complementary regulations and ad­ tries reporting the largest total international Conventions as may be vances in international law. From the seizures were Spain, Federal necessary. beginning, however, the basic aim of the Republic of Germany, the Uni­ international drug control treaties has ted Kingdom. France. Switzer­ - The International Narcotics Control been to limit the use of drugs to medical land and the Netherlands. Board (INCB) is an independent, semi­ and scientific needs only. judicial organ composed of 13 Members The 1961 Convention provides for (three members with medical, phar-

28 W ORLD HEALTH , June 1986 macological or pharmaceutical experi­ Commission must take into account the ments to make arrangements at the ence from a list nominated by WHO, findings and recommendations of WHO. national level for the coordination of and ten members elected by the Governments are required to main­ preventive and repressive action against Economic and Social Council not as tain a special administration- be it a illicit traffic, and at the international representatives of their governments but central authority or a coordinating agen­ level for mutual cooperation and for in their personal capacity). The Board's cy-to implement the provisions of the close cooperation with such bodies as functions are to "endeavour to limit the Conventions. And to ensure that the Interpol or the Customs Cooperation cultivation, production, manufacture drugs are used for legitimate purposes, Council. And the governments are and use of drugs to an adequate amount the Conventions require that the culti­ called upon to prosecute and punish required for medical and scientific pur­ vation, manufacture, trade and distribu­ major illicit traffickers and arrange poses, to ensure their availability for tion of drugs be under licence or other for extradition in cases. of drug such purposes and to prevent illicit culti­ similar control measures. Governments trafficking offences. vation, production and manufacture of, have to set up a system of inspection of The overall task of the INCB is to and illicit trafficking in and use of manufacturers, exporters, importers and promote compliance by governments drugs". The Board is independent of wholesale and retail distributors of with the various drug control treaties in governments in carrying out its func­ drugs, and must provide for as frequent the interest of the international com­ tions in an impartial manner. inspections of premises, stocks and munity as a whole. It has to administer Alongside the international drug con­ records as are considered necessary. the legal movement of narcotic drugs trol organs, a voluntary trust fund was Under the import and export auth­ and psychotropic substances with the created in 1971: the United Nations orisation system (which applies to all precise aim of limiting their production, Fund for Drug Abuse Control narcotic drugs, but only to the most manufacture, trade and use exclusively ( UNFDAC). It is responsible for financing to medical and scientific needs. In coop­ an effective and coordinated approach eration with governments, it ensures to the problem of drug abuse, as part of that legitimate demand for narcotic the UN response to urgent requests from drugs is satisfied through the mainten­ governments for assistance in support of ance of a proper balance between their own drug control efforts. supply and demand. And it tries to A fundamental fact which guides all prevent the illegal or illicit cultivation, activities and operations of the inter­ production, manufacture, traffic and use national drug control system should be of drugs. stressed from the outset: namely that In examining and analysing the infor­ the direct implementation of the system mation which it receives from some 190 is primarily the responsibility of national countries and territories, the INCB is in authorities. It is they, and they alone, a position to learn whether the treaties who have the power and the ultimate are being applied throughout the world responsibility for controlling the move­ as effectively as possible. It maintains a ment of these substances within their West European customs men seized this continuing dialogue with governments, respective jurisdictions. smuggled heroin recently-enough for and renders direct assistance by train­ 250,000 "fixes." Two categories of drugs are control­ ing national drug control administrators at the INCB's headquarters in Vienna, led by the international drug treaties, Facing page: Spurious charm of the para­ namely narcotic drugs and psychotropic phernalia for shooting cocaine. or by on-the-spot training of national officials in countries which face substances. At present, control is exer­ Photos L. Sirman © cised over 105 narcotic drugs and some specific problems. 80 psychotropic substances. The narco­ If necessary, the INCB may make use tic drugs include opium and its deriva­ dangerous psychotropic substances), of various means of persuasion or tives, morphines, codeine and heroin, no government may issue an export pressure. It may request an explanation other synthetic narcotics such as authorisation before a corresponding from the government concerned if it methadone and pethidine, and cannabis import certificate, issued by the com­ is suspected that the treaty provisions and cocaine. These drugs are controlled petent authority of the importing coun­ are not being observed, or if there under the provisions of the 1961 Single try, has been produced. is a serious risk that a country may Convention and of the 1972 Protocol. The reporting requirements oblige become an important centre of illicit The psychotropic substances com­ governments to supply the INCB with drug activity . prise, broadly, the hallucinogens, the detailed statistical information on the The existing treaties require WHO to stimulants and the depressants, and they consecutive stages of the movements of recommend narcotic drugs and psycho­ are controlled by the 1971 Convention the drugs in question, such as cultivation tropic substances for international con­ on Psychotropic Substances. To date, or manufacture, imports and exports trol. WHO is also responsible for conven­ 117 countries are parties to the Single and stocks (again these requirements ing an expert committee on drug depen­ Convention in its original or amended apply to all narcotic drugs, but only to dence which recommends controls if form, while 80 states have adhered to the most dangerous psychotropic sub­ necessary . . The Organization colla­ the 1971 Convention. stances). The INCB examines these borates with non-governmental orga­ The Commission on Narcotic Drugs statistics to make sure that no weak­ nizations (especially the International has the power to determine whether a nesses exist in the international control Federation of Pharmaceutical Manu­ new drug should be subject to control, system and that no drugs are diverted facturers Associations), governments and to transfer a drug from one control from licit trade to illicit channels. and other UN agencies in carrying out regime to another. In so doing, the The Conventions require govern- these functions. •

W ORLD HEALTH , June 1986 29 lished in Australia, and COUGH The Graffiti Parliamentarians for Development UP (Citizens' Organizations Us­ On the Boards ing Graffiti to Halt Unhealthy Some 60 parliamentarians Promotions) in the United King­ Down Under from 19 European countries dom - all dedicated to the cause have pledged themselves to of "responsibility in advertis­ First in Sydney, then Mel­ seek increased financial sup­ ing. " • bourne, then Perth, and now in port for U.N. programmes (For detai ls. write· B.U.GA U.P. , P.O . box other Australian cities. graffit­ and to work for a better pub­ 78, Wentwo rth Bldg, University of Sydney, NSW 2006, Aust ral ia) ists are making their mark on lic understanding of interna­ billboards, and in the process on tional development the public consciousness as They became essentially well. They do so often with "Parliamentarians for Devel­ Daughters Are humour, at times bluntly, but opment" at a two-day forum tinged always with a certain on child survival, women and Disadvantaged Down Under robustness. population held at the Hague, Right from Birth Advertisers claim they are de­ hosted by the Netherlands facing the billboards. The graffit­ parliament and opened in the lt is evident in a Hindu's wish ists, armed with spray cans of presence of Her Majesty Photo . Organon Juten © - " May you be blessed with paint usually in black, chrome Queen Beatrix. Their support Outside Netherlands Parlia­ eight sons" -bestowed upon and red, contend they are "re­ gave a much-needed boost newly-weds, and in an Arab facing" them. Items : ment: Directors of UNFP A, to the U.N. system, now UNICEF, WHO. epithet-" the father of daugh­ • An advertisement for Ben­ troubled by cutbacks in con­ ters" - spoken in derision. son & Hedges cigarettes that tributions and under criticism as never before. Such attitudes unfortunately said "Excellence in extra mild" To set the example, Mrs Edgje Schoo, Deputy Director of are prevalent in virtually all became, after one graffitist's International Cooperation, announced the equivalent of a societies 1n the developing touch, "Excellence in extra mil­ US $3 million contribution in Dutch currency for the provision world. More than poverty or dew. Rots your lungs and kills of essential drugs to Third World nations. under-development. they are to you." Parliamentarians heard keynote addresses by Rafael be blamed for the low esteem • An ad of a cowboy on a Salas, Executive Director of the U.N. Fund for Population of daughters. and as a conse­ horse silhouetted against the Activities (uNF PA), an agency that has lost US $10 million quence for the poor health and sunset that said "New. Mild. in US contributions this year, James Grant, Executive Director illiteracy of women. And Marlboro" became "New. of UNI CE F, and Halfdan Mahler. Director-General of WH O (left to Even though data on the sub­ Vile. And a bore." right in photo) • ject are considered "scanty", a • An ad that said "Anyhow, review this year of research al­ have a ... Winfield" became ready done is evidence enough "Anyhow, have a coronary." that daughters are disadvan­ • An ad of a prominent citi­ ••••••••••••• ••••••• ••• ••• ••• ••••••••••••• •••••••••••••••••••••••••••••••••• ••••• •••••••••••• taged from the moment of birth. zen endorsing Wills 30 Super •••••••••• ••• •••••••••• ••• ••• ••• •••••••••• •••••••••••••••••••••••••••••••••••••••••••••••• Entitled "Health Implications Milds that said" Here's an offer ••• ••• ••••••• ••• ••• ••• ••••••••••••• •••••••••••••••••••••••••••••••••• ••• ••• ••• • •••••• ••• ••• •••••••••• ••• ••• ••• ••••••••• •••••••••••••••••••••••••••••• •••••••••••••••• of Sex Discrimination in Child­ worth shouting about," became ••• ••• ••••••• ••••••••••• ••••••• ••• •••••••••••••••••••••••••••••••••••••••• hood," the review was carried "Here's a drug pusher shouting ••• ••• ••••••• •••••••••• •••••• ••• •••••••••••••••••• out by Sundari Ravindran, a con­ out" sultant tO WHO and UNICEF. well. The provocative acronym Dr Arthur Chesterfield-Evans, The son preference "deter­ stands for "Billboard-Utilising a Sydney physician, joined the mines the quality of parental Graffitists Against Unhealthy movement because he, like care, and the extent of invest­ Promotion." many others, was "frustrated ment in the child's develop­ They protest cigarette adver­ by the government's refusal to ment." the review states. "In tising, particularly on govern­ curb advertisers." Being a extreme cases, son preference ment property at railroad sta­ phantom painter has led to his may lead to abandonment of tions and on buses. They ex­ arrest and to a fine of Australian female infants, or even to infan­ press outrage at images, aimed $20. ticide, but it is most common in at impressionable adolescents, But. by and large, arrests the sheer neglect of girls." which equate smoking with ath­ have been infrequent. and con­ Bangladesh, Jordan, Nepal, letic prowess, the good outdoor victions even less so. Even Pakistan the Republic of Korea, life or womens's lib. And they when magistrates enforce the and Syria are the countries with ridicule what they consider law they have proved sym­ the strongest preference for "unhealthy promotions" - or, at pathetic to graffitists Still. a boys, according to the World least. present their side of ad­ Fighting Fund has been set up Fertility Survey published by the vertisements. to help pay fines. International Statistical Institute Photo: WHO/B. U. GA UP BUG activists say its move­ The movement began in 1979 in the Netherlands. Of 40 de­ BUG activists at work "refacing" ment piques the interest of with a membership of just three veloping countries surveyed, Marlboro country. youth. By speaking of the possi­ whose concern was the in­ only two- Jamaica and Ven­ bility of arrest. fines and even crease in billboards. Now, a lot ezuela-show a clear prefer­ • Dunhill became "Lung Ill" gaol for the cause, they find it of spray paint and thousands of ence for daughters. cigarettes. and Rothmans, "Rot easier to go on and discuss the billboards later. their number is Sons are preferred for Mans." health and social consequences up to hundreds from all walks of reasons that are part cultural. The graffitists are plain but of smoking. "Kids don't seem life, and B.U.GA U.P. is in New part religious, and part econ­ aroused citizens, who are part much interested in listening to a Zealand as well. A similar group, omic. In some societies, for of a movement that not only white-coated doctor lecture MOP UP (Movement Opposed instance, sons are expected to signs itself as B.U.GA U.P., but them on the evils of smoking," to the Promotion of Unhealthy bear the prime responsibility describes its work that way as activists report Promotions), has been estab- for the support of parents. The

30 WoRLD HEALTH, June 1986 preference is most pronounced w here the majority of people Newsbriefs Authors of the Month live-in rural areas. Dr Norman SARTORIUS is Director of Th e discrimination aga in st WHO's Division of Mental Health in girls is evid ent in studies that • The Mores of More. In societies consumed with the many "mores " of Geneva. show they are not fed as well as materialism-" more wealth, more food, more drink, more cars, more Dr David A. PLAYER is Director boys, that they are less cared tobacco, more sex"- " it is not surprising if the 'more ' includes more General of the Health Education for during illness, and that less narcotic and psychotropic drugs," Or Halfdan M ah ler, WHO's Director­ Council in London. General told health ministers from 30 countries meeting recently in Mrs Uma RAM NATH is a freelance money is spent on them, par­ London. journalist writing from New Delhi on ticu larly for ed uca ti on. " If our social values makes drug-taking an acceptable norm among Third World development themes. " Thi s kind of neg lect of peer groups of youngsters, then it is these values that need to be Mr William U. CHANDLER is a Senior female chi ldren," according to 'reconsidered, " he suggested as a step to counter the virtually unchecked Researcher with the Worldwatch ln­ the review, "is not necessaril y problem of drug abuse. stitute·in Washington D.C. wilful. .. (b ut) more a conditioned "So perhaps it is not the youngsters we have to change, perhaps it is Mr Alex IRVING is a researcher with response to a situation of scar­ some of our social values, " he added. the Transport and Road Research Figures presented to participants shows there are an estimated Laboratory in Crowthorne, Berk­ city " The res ults are excess shire, UK, specialising in problems of female mortality in childhood 750,000 persons world-wide addicted to heroin, 7. 7 million to opium, drugs and alcohol on road safety. 4.8 million to cocaine, and 29 million to cannabis. and, in extreme cases, lower Professor Anthony W. CLARE is with female life expectancy in many • Adding Life to Years. Moderate exercise in adult life- regular walking, the Department of Psychological Medicine, St. Bartholomew's Hospi­ countri es. for instance-has been shown to reduce death rates from a quarter to a tal Medical College, London. third in some 77, 000 graduates of Harvard University, who were followed "Every sixth death of a Dr Inayat KHAN is Senior Medical female infant in India, Ba ngla­ from the early 7960s through the late 7970s. Officer for the Division of Mental desh, and Pakistan is due to "There are a lot of sceptics who say people are active because they are Health, WHO, Geneva. neg lect and discrim inati on," the healthy, " the New York Times quotes Or Ralph S. Paffenbarger Jr. , the Dr Peter KALIX is a teaching and study's director, as saying. However the findings, reported recently in the review states. research fellow at the Department of New Journal of M edicine, indicate the contrary- that " you're healthy Pharmacology, University of Geneva Among recommendations because you are active. " Medical Centre. made for change: Mr Roger HIGHFJELD is a freela nce • That hea lth and social • Another Campaign Trail. Former journalist based in London. workers, as well as parents, be US President Jimmy Carter has Mr B. Juppin de FONDAUMIERE is made awa re of the risk to the pledged to "make up for past mis­ Deputy Secretary of the United Na­ health of girls in societies where takes" in his support for the tobacco tions International Narcotics Control industry by now campaigning against discrimination is rooted in tra­ Board in Vienna. smoking. Mr John WICKETT is a Consultant dition, In a letter to the editor of the with WHO's Smallpox Eradication • Th at child mortality rates Journ al of the American Medical As­ programme in Geneva. and life expectancy tables be sociation, he writes: "As the scientific Mr Marcus GRANT is a Senior Scien­ calculated by sex as well as by evidence has become stronger, I have tist with WHO's Division of Mental age, to bring out the conse­ become increasingly active in attempt­ Health. quences of different treatment ing to spare people from the tobacco of so ns and daughters, addiction. "Should I have done more in the past? We all should have : educators, physicians, and patients. Let us make Photo: USIA © up for past mistakes by closing ranks WORLD Former US President, Jimmy to make our future efforts efficient, Carter. effective, and life saving. " HEALTH • The Mailman's Message. During Malta 's recently held Health Educa­ For readers everywhere tion Week, postmen delivered not only mail but health messages too. That week all letters were postmarked Gawdi Sahhtex, or " Enjoy Your 1986 Subscription Rates Health " - a simple, positive message aimed primarily at schoolchildren. US$ Sw. fr. A range of activities such as health walks, fitness and poster One year 12 .50 25.- displays- on such topics as nutrition, sex education and exercise-stressed Two years 22.50 45.- the th eme of personal responsibility for health. " Th e idea of healthy living Three years 30.- 60.- 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 : ORDER FORM " Healthy Living: Everyone a Winner ". Please enter my subscription to " World Health " as follows : • WHO Award in Health Education. Nominations are being sought from health education institutions, both governmental and private, for this US One year D $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. Two years D Foundation, a private US. philanthropic organization. Three years D Photo: WHO Nominations must reach WHO's Division of Public Information and Girls: Not as well fed as boys; Educa tion for Health by 37 August. I enclose cheque/international postal order in the amount of : _____ less cared for when ill. Name : __~--~---~~- • That pra ctices such as Street: ______dowry and "bride price," which In the next issue City: _ ___:_:c.______::_ __ _ are demeaning, be abolished, Thi s year has been designated the International Yea r of Peace, and Country :------­ and the July issue of World Health will address itse lf to fundamental World Health, WHO , Avenue Appia, • That countries provide ad­ aspects of health and peace. Other articles w ill discuss prepared­ 1211 Geneva 27 , Switzerland equate pensions for the elderly, ness in case of disasters, the work of rural doctors in China, World Hea lth is also distributed t hrough the to dispel the notion that a inequities in the world 's great cities, and the trai ning of medical network of international bookstores and sub­ son is prized for his support technicians. scription agencies. For payment in national cur­ of parents. • rencies, please contact your usual bookseller.

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