Drug Abuse In the Global Village
Drug Abuse Among African Youth

Introduction
            Concern over drug abuse among the youth of Africa is a recent phenomenon. A radical change appears to have taken place about 30 years ago when substance abuse crept into the mainstream society. There has been a dramatic acceleration of this trend during the past 20 years. Concern regarding abuse of hard drugs such as heroin and cocaine is even more recent, starting about 15 years ago in some countries and escalating to involve more countries during the past 5 years.
            There is also consensus of opinion that these changes in drug abuse have been preceded and accompanied by a gradual and inexorable erosion of traditional social fabric and values. The African family, recognized in its extended form, occupied a primate and central position in this social system82. This system is disintegrating35. Social disintegration is also accelerating under the adverse influences of growing "poverty, civil war, tribal conflicts, droughts and other natural catastrophes (which leads) to famine and massive displacement of populations, creating a situation in which drug abuse worsens rapidly" 32.
            There is, therefore, not only a need to address the immediate factors contributing towards drug abuse, but also to look into factors that have contributed towards the disintegration of our families. The challenge is not only to turn the tide against drug abuse but also, to the extent possible, to repair the erosion of our family structures and social-economic systems47. This is an aspiration that is enshrined in the treaty establishing the African Economic Community 58.
            This paper deals with the extent of drug abuse among the youth in Africa, influencing factors, and the associated social and cultural disintegration, pointing out the dangers posed by drug abuse. It also examines regional and national responses to the threat of drug abuse, and suggest possible course of action in the light of experience in Africa and elsewhere in the world. Information and recommendations of this paper, among other sources, are based on a study tour of UNDCP Vienna, Addis Ababa Ethiopia, Cairo Egypt, Lagos Nigeria and Nairobi Kenya involving consultation meetings with governmental and non-governmental officials. More information was obtained from published papers and reports on problems of drug abuse among youth in Africa. The number of countries surveyed was limited by time and financial resources. The selection was based on existing information regarding drug abuse and availability of comparable data on drug use and abuse.

1. Historical Development

Cannabis, the main drug of abuse in Africa, was virtually unknown in Nigeria before the second world war (Asuni 1990; NDLEA 1994). There was no name for it in the vernaculars and it does not feature in a botanical survey of plants of West Africa carried out during the 1930s (Asuni 1992). This is supported by the absence of any traditional reference to ceremonial use (Ebie and Pela 1981b). Another support is the rarity of abuse of the drug among psychiatric patients of the times (Lambo 1965). The prevalence of smoking cannabis appears to have gained more foothold through soldiers returning home after the second world war from the Far East, Middle East and North Africa (Asuni 1992, Gureje and Olley 1993). During the 1970s there was increased abuse of cannabis, under the influence of soldiers who abused the drug to suppress timidity (Gureje and Olley 1993). Between the fourties and sixties, abuse of cannabis remained among the marginalized individuals and did not gain currency till the sixties and seventies (Asuni 1964; 1994). At present, however, it is becoming incorporated into the local youth culture. Diviners are already recommending it as a sexual charm and soil fertilizer (Befidi‑Mengue et al 1994; WHO 1993). Within the city of Lagos, for example, cannabis already features as a major drug of abuse among secondary school students. It is also the main drug abused among psychiatrict patients (Anumonye 1980).

While cannabis appears to have been introduced earlier in East and Southern Africa by oriental traders (Asuni 1990), for many years it remained among few marginalised individuals. The name used for cannabis in East Africa is 'bhang' a term from the Indian sub‑continent. Variations such as 'banga', 'mbanje', 'bangi', appear to be corruptions of the term 'bhang'. Soldiers returning from the two world wars may have spread the plant and smoking habit. There are some indications that Rastafarians from Jamaica who migrated to Shashemene in southern Ethiopia imported the plant and habit. Shashemene is well known for cannabis abuse in Ethiopia (ECA.PHSD 1994). The habit spread to other parts of the country involving youth, at about the same time that this was happening in the rest of Africa (Asuni 1964, 1992), coinciding with a period of expansion in industrial activities and urbanization.

Khat is a drug that is indigenous to East Africa. It grows naturally on the sides of mountains in Ethiopia, Kenya and to a lesser extent Tanzania. In the past, use of this substance was occasional and largely restricted to the areas where it grows naturally. The recent past has seen the expansion of cultivation and export of this drug to various countries. It is a major export earner for Ethiopia and Kenya (ECA.PHSD 1994, Omolo 1985). Cultivation, trade and use of khat was prohibited in Kenya until 1977 when a presidential decree repealed the prohibition. Since then abuse of khat has accelerated, especially in the urban areas of northeastern province.

Drug abuse in North Africa has a much longer history. The abuse of cannabis in Egypt goes back to the 12th century (Kott 1994). "Legend has it that Napoleon's armies found it so easy to defeat the Mamluks at the end of the 18th century because, according to one of his officers, 'the mass of the male population is in a perpetual state of stupor!' (Mabrouk 1991). Napoleon banned the sale and consumption of the drug. This order only lasted the duration of his military expedition in Egypt. The Ottoman Empire reimposed the ban during the 19th century without much success. The British in 1882 tried to control availability by license and tarriff without success. Licesing was rescinded in 1891. In 1918 cannabis was included together with opium in the prohibition of addictive substances. Abuse of these substances, however, continued to increase during the first world war and beyond. This led to the establishment of the Central Narcotics Intelligence Bureau, a forerunner of Anti Narcotic General Administration (ANGA) in 1929. This agency together with a series of legislative actions that followed was more successful in controlling cocaine abuse but less so the abuse of hashish and opium (Mabrouk 1991).

Apart from alcohol and tobacco, cannabis remain the main drug of abuse in Egypt, as it is elsewhere in Africa. The abuse of psychotropic substances emerged in the 1970s and has remained a major concern. The abuse of cocaine and heroin first emerged as a problem in the period following the first world war. It disappeared during the 1930s, a period of economic crisis, only to re‑emerge during the 1980s (Soueif et al 1986). In this period heroin was first seized in Egypt in 1982. Its abuse, which emerged seriously during the early 1980s, is on the ascendancy. By 1988 there were 490 heroin addicts who were treated at Abbasia Mental Hospital alone. Cocaine re-emerged in 1983 (UNDCP 1992).

Hashish abuse is also increasing among those seeking treatment. It was 2% 20‑15 years ago, 7% 15‑10 years ago, 8% 10‑5 years ago and 10% during past 5 years. With psychotropic drugs the rates were 5%, 10%, 20% and 22% for the 4 successive 5 year periods. For amphetamine by injection the percentages were 5%, 3%, 8%, and 12%. Heroin use at the El‑Ataba outpatient clinic reached its peak in 1987 when heroin users accounted for 68% of all patients coming to the drug dependence clinic (Soueif et al 1990).

The experience of Egypt notwithstanding, the history of drug abuse in Africa is very short barring cannabis abuse in northern and southern Africa and khat in north‑east Africa. It is, however, escalating and involving a wider range of people including the youth (Asuni 1986). Abuse of cocaine and heroin are the most recent alarming developments. Experience with these drugs is limited to a few countries and no more than three or four years. Abuse of these substances has been a direct effect of the use of African ports as transitting routes and Africans as couriers. This could turn into an explosion if reports that drug syndicates are working on cultivation of opium poppy in Africa turns out to be true (Geopolitical Drug Dispatch 1991).

Evolution of drug abuse in much of Africa in the two decades between 1950s and 1970s is perhaps best illustrated by the Nigerian scene. Between 1954 and 1959 (Lambo 1965) working at Aro Abeokuta identified only 0.45% addicts out of 4000 psychiatric patients. Cannabis and pethidine accounted for most of these. All patients presenting with pethidine addiction were health personnel. Cannabis and amphetamine abuse, as sources of clinical concern, were first noticed by Asuni (1965) during the early sixties. This coincided with a period of civil tensions when irresponsible political operatives gave thugs cannabis to smoke before sending them to carry out disruptive actions against their rivals (Asuni 1965). It is undoubted also that considerable change had already taken place in the process of urbanization, industrialization and associated tension on the integrity of families and local communities. By the mid‑seventies, abuse of hypnosedatives were also emerging (Ebie and Pela 1981a,1981b). In 1981, Ebie and Pela (1981(a) observed that heroin, cocaine, morphine and LSD did not feature at all among drugs of abuse in the youth population. In their own study of secondary school students in Benin City, only 2.2% of males admitted using cannabis, 6% of males admitted using stimulants and 2% males and 2% females admitted using hypnosedatives. No females used cannabis or stimulants. They also noted a trend towards an ealier age of experimenting with drugs. They attributed this to cultural changes brought about by the effects of civil war, rapid urbanization, industrialization and increased exposure to the outside world (Ebie and Pela 1981b). Abuse of amphetamines and hypnosedatives or tranquillosedatives defined the youth drug scene of the times (Sogunro et al 1980).

Abuse of heroin and cocaine was ushered in by illicit traffick in narcotics that started flourishing in the 1980s. Even then the commercial capital of Lagos took the brunt. In a study of secondary school students in Ogun, Adelekan (1988; 1989) found out that salicylate analgesics, mild stimulants, alcohol and diazepam were the main substances that were abused. Barbiturates, cannabis, solvents and cocaine were least abused. Narcotic analgesics and hallucinogens did not feature at all. Among undergraduates of University of Ilorin, Kware State, 42% were current users of alcohol, 35% stimulants, 18% hypnosedatives, 10% tobacco, 1.3% cannabis, 0.6% heroin or morphine, 0.6% cocaine, 0.3% hallucinogen and 1% organic solvents (Adelekan et al 1992). It is only fairly recently that abuse of heroin and cocaine is spreading to include the youth in the rest of the country.

There are many psychoactive substances indigenous to Africa with presumed addictive properties, that are known in the community, but are not widely abused such as "mudzepete" in Zimbabwe (Acuda et al 1991), "iboga" in Cameroon (Befidi‑Mengue 1994), "koubediara" in Senegal (ECA 1994), "kungu" and "msasawe" in Tanzania. The case of kolanuts in Nigeria also apply.

2. EXTENT OF DRUG ABUSE IN AFRICA

North Africa
            Cannabis is reported to be the most prevalent drug of abuse in Morocco followed by hypnosedatives. Abuse of volatile substances is also reported, though less frequently. Abuse of opiates, cocaine and amphetamines are reported to be rare84. To a varying degree, cannabis abuse is the main drug of abuse in the sub-region. Cannabis abuse and khat chewing are prevalent in Sudan. Other drugs reported to be abused are heroin, cocaine and barbiturates. A plant 'Argemone Mexicana' of the papaveraceae family grows in different areas of the country and is reported to be abused in the countryside84.
            A study involving a sample of 14656 Egyptian secondary school students revealed that 5.94% abuse drugs. Cannabis accounts for 85.75% of these, followed by opium 10%, cannabis combined with opium 1.61%, and cannabis combined with other substances 1.26%66. Regarding tobacco, 32.13% smoke less than 5 sticks of cigarettes daily, 37% 5 to 14 sticks of cigarettes daily, and 27.5% who can be considered heavy smokers, smoke 25 to more than 30 sticks of cigarettes daily66. This high prevalence of smoking is cause for concern since smokers appear to be more involved with the drug abuse culture70. Rate of regular use of alcohol is low in comparison. Among university students, only 14% take alcohol on regular basis69.
            It is estimated that currently, "more than 1 million Egyptians, most of them youth and young adults, abuse cannabis and 100,000 abuse opium. Heroin abuse has also been on the ascendancy. The number of heroin abusers is now 70% of addicts treated in the state hospital 'El Mamora' in Alexandria in 1989. Addiction is therefore threatening the most important developmental asset for Egypt ‑ human resources"39. Out of a sample of 5108 workers, 12.8% use either cannabis alone (90% of them) or cannabis and opium. The estimated number of addicted workers is between 60,000 and 100,000. This does not include occasional abusers and experimenters. Among workers 52.4% smoke on average 20 cigarettes per day, 20% use alcohol and 12.8% abuse cannabis and opium, and 1.8% abuse psychotropic drugs. Urine analysis of a random sample of drivers indicate that 23.5% had abused drugs (cannabis 8.5%, opium 6.9%, psychotropic drugs 6.2%, amphetamine 1.9%). More than 90% of all these workers started abusing drugs before reaching the age of twenty, majority of them starting between age 12 and 17 39. Urine analysis of 144 nurses sampled out of 2585 persons in 27 health facilities revealed barbiturate in 4.2%, benzodiazepine in 2.8%, opium 1.4%, hashish 1.4%, amphetamine 1.4%, propoxyphene 0.7% and multidrugs 0.7% (12.6% all told)81. 

West and Central Africa
            Cannabis is the main drug of abuse in Cameroon. It grows in most areas of the country. Since 1986 heroin and cocaine have been introduced into the country with increasing abuse of these drugs. An indigenous herb 'iboga' is also gaining popularity15. Cannabis, volatile substances and psychotropic medicines are abused throughout Burkina Faso, Chad, Cote D'Ivoire, Gabon, Ghana, Mali, and Senegal. Adolescents and young adults forms the bulk of the abusing population84. Heroin and cocaine abuse is also reported in most of these countries. A datura metel 'katiddatabe' is wild plant with hallucinogenic effects similar to LSD that is also reported to be abused in Senegal84.
            In a recent study of secondary school students in Northern Nigeria, prevalence rates of substance abuse (current use) ranged between 1.1 ‑ 3.5% with a male to female ratio of substance abuse of 3:1. 3% smoked cigarettes, 3.5% abused benzodiazepines, 1.5% solvents. Abuse of cocaine was 1.1% and heroin 1.3%. More than 25% of students indicated that it was very easy to obtain any of the above drugs. The situation is likely to become much worse since crack cocaine is now available in Lagos56. There are reports that even LSD is entering the market55. In a school survey of four regions, LSD features in each of them. Lagos had the highest rate of users (3.6%), followed by Benin (1.4%), Enugu (O.8%) and Ibadan (0.3%). Lagos also had highest rates of cannabis use (37.8%), Ibadan (20.3%), Enugu (11.9%) and Benin (7.3%). Lagos also had the highest rates for opiates (54.4%) and solvent (35.7%) use. Use of hypnosedatives was high in all the four regions: Lagos (61.1%), Benin (74.1%), Ibadan (71.4%) and Enugu (51.2%)31.
            Heroin can now be obtained in Lagos for a few hundred Naira. In the past it was abused mostly by the educated and affluent youth. There are now indications that its abuse is spreading to marginalized young unemployed males. A study carried out in fourteen mental hospitals, indicated that heroin abusers account for 13.8% of the total drug related admissions for 1992. Heroin is mostly smoked in combination with cannabis, sniffing and inhaling (chasing the dragon). Only a small proportion of the heroin abusing population is reported to inject the drug. Cocaine may be more abused than heroin. Mental hospital admissions for 1992 reveal that 18.3% of drug related admissions were due to cocaine addiction. Cocaine, like heroin is sniffed, and smoked with cannabis78. Details of rates of experimentation and drug abuse among the youth are provided in detail in table 2.

East and Southern Africa
            Cannabis, methaqualone and khat are substances of abuse that are entrenched in the region. Increase in abuse of these substances among the youth have recently raised much concern in all countries where information is available17;19;46;40;79;60;24;44;33;34;36;49;50;28;1. In Namibia 3.4% smoke cannabis on week-end or daily basis, and 0.5% methaqualone84.
Taking South Africa as an illustrative case, a study of Cape Peninsula high‑school indicate that among illicit drugs of abuse, cannabis is the most common with 2.4% current abuse, 1.6% smoking cannabis and methaqualone in a mixture called 'white powder' and 2.6% sniffing solvents24. A survey of students in Botswana during 1993 revealed that 1.7% of the youth were current abusers of cannabis, 1.6% of inhalants, 1.5% opiates, 0.7% cocaine and 0.5% hypnosedatives29. A similar survey in Uganda in 1992 0.3% of the youth were current abusers of cannabis, 5.5% inhalants, 2.0% opiates, 1.2% cocaine and 2.5% hypnosedatives50. In Lesotho 1989 study the figures for cannabis and inhalants are 7% and 4% respectively (table 3). In two studies of secondary school students carried out in large municipality and a small district headquarter in Tanzania revealed virtual absence of abuse of cannabis, opiates and cocaine in the district town and 2%, 0.5% and 0.7% respective abuse by the youth in the provincial municipality49;33. Notable differences in the sub‑region include smoking of mixture of cannabis and methaqualone in South Africa, established abuse and addiction to opium and heroin in Mauritius and abuse of khat in East Africa61. Rates of experimentation and abuse of various substances in these countries is provided in detail in table 3.

3. INFLUENCING FACTORS

Drug users were consistently more exposed to the various elements of what may be labelled "drug culture", (they had heard about and saw more of drugs, they had more friends and more relatives who themselves have been taking drugs ‑ in short, they were in a social environment that was more permissive to drug abuse and less stigmatizing of drug abusers65;66;69). Peer pressure, parental guidance, availability and perceived harmfulness may be part of the elements of this culture3. Parental drug use behaviour also influence children's behaviour. A study in Lagos and Kano clearly demonstrated this51. Parents who abuse drugs may also suffer from other social difficulties. Individuals from a background of family breakdown are often over represented among addicted patients63.
            The world view of this drug culture may include expectations and misconceptions of effects of drug use, which influence experimentation and continued abuse. There appears to be a  "meaningful association between drug use and beliefs about effects of such use"69. Smokers generally tended to belong to this culture. They were more preoccupied with drug taking, experimented more with drugs of abuse and more of them became drug abusers70. Elements of urbanization process appear to foster this culture. Substance abuse is, with some variation, generally more common in urban areas than in rural areas66;21. Urban life, together with rapid socio‑technical change, is associated with weakening of community integrity and family system37. Hugo30 and Caldwell18 have observed that the "most important social export from Europe to developing countries is the institution of nuclear family (with its) preoccupation with youth culture and abandonment of old people". Setting the stage for further disintegration towards marital separation, divorce and single parenthood59;74. Civil conflicts, economic depression, and migrant labour away from families in many countries have added to the stress that has found expression in substance abuse.
            Smoking and experimenting with cannabis and opiates increased the risk of falling into a pattern of regular abuse of these substances. One quarter of those who experimented on cannabis and opiates proceeded to become regular abusers of those substances67;69. Smoking was a good marker of experimenters who were likely to proceed to become regular drug abusers70. Bachelorhood was another risk faster for experimenters becoming established as drug abusers67. Experimenters who stopped taking drugs realized that the drugs could be harmful to their health (30.9%), would lead to financial embarrassment (14.9%), or would lead to social or legal difficulties (2.6%)67. Religious beliefs against drug taking were also associated with abstinence54. Women experimented less with drug taking and were less involved in drug abuse. This may partly be because close relatives are more important to women than other people as a source of information about drugs68.
            An important contributing factor to recent increase in drug abuse is the growing gap between the promises and allure of urban life of many African metropolis and the stark reality of poverty. Drug culture offers counterfeit satisfaction and, for some, dangerous means to a livelihood. Very depressed economic circumstances in Tanzania during the early eighties led many young people to stow away onto ships calling at Dar es Salaam harbour. They took the risk of being cast away on high seas to be preyed on by sharks. Some of these desperate youth were recruited as drug couriers during the latter half of the eighties, resulting in Dar es Salaam being used as a transitting station. This has predictably resulted in some of the heroin spilling over into the streets of Dar es Salaam. In a pattern similar to Lagos, pushers are targeting youth from affluent families. They are at first provided with free samples till when they are hooked, then they are forced to find money to pay for the habit.

4. FUTURE TRENDS

            Prospects appear gloomy. Economic forecasts for Africa indicate the best scenario of overall real growth of GDP averaging 2% over the next 5 years76, being outstripped by population growth and urbanization, factors that may contribute to further displacement of people and breakdown of community and family structures. This, together with unemployment that is expected to double during the next six years, should exert considerable negative pressure associated with rapid increase in illicit trafficking and abuse of drugs, attended by painful costs to individuals and society. Such a situation will further limit the capacity of African communities to address the problems of poverty and drug abuse effectively. Mauritius presents an illustrative example of how quickly drug abuse can get out of hand. During the early eighties there was very little abuse of heroin in the country. Between 1985 and 1986 the country experienced a sharp increase of registered heroin addicts from 200 to upwards of 500 due the operation of adverse social factors and availability of heroin caused by involvement of the country as a transitting route85.  Africa may, in the next ten to twenty years, witness a situation far worse than the experience of Pakistan or Colombia. Ten years ago Pakistan had 30,000 heroin addicts. Today there are 1.5 million addicts. In Colombia 130 individuals are recruited into drug abuse daily, 70% of them aged 12 to 22 (Merrem 1994). The only recourse for mitigation, it appears, is immediate and comprehensive attention to the problem of drug abuse and factors that fuel it.

5. CONSEQUENCES: HIGH COST PAID BY SOCIETY

            Substance abusers are generally in poor health31. Health consequences of drug abuse are many and varied, involving most areas of physical and psychological functioning. A major and growing consideration is the contribution of drug abuse to the spread of HIV disease. Intoxication with drugs leads to risky sexual behaviour that could be a major contributing factor to the rapid spread of this dreaded condition80. There is also evidence that many substances of abuse such as cannabis depress immunity, leading to easy spread of infections including HIV disease. There is evidence that even smoking one stick of cannabis can lead to demonstrable lowering of immunity for HIV disease25. Intramuscular or intravenous injections of drugs of abuse are a direct route of inoculating HIV into the blood stream. With the emergence of hard drugs on the African scene, this method of drug abuse is likely to increase, contributing enormously to the march of HIV spread in Africa. There already are reports of intravenous drug abuse in various parts of the continent. Drug abuse also influence the spread of many sexually transmitted diseases which are in their own rights co-factors in transmission of HIV disease. Other infections addicts are prone to include viral hepatitis, chest, heart, kidney infections and abscesses. Other physical effects include hormonal derangements leading to menstrual irregularity, infertility, deleterious effects on foetal growth and behavioural and developmental difficulties for the growing child. Effects on the brain leads to emotional instability, poor impulse control and poor intellectual functioning. Cannabis for example, affects spacial and temporal orientation, and impairs fine memory functions.  Drug abuse saps both physical and intellectual vitality, leading to reduced productivity in work and academic pursuits. It affects the senses in such a way that social and emotional cues are blunted, leading to stunting of social and emotional development, adversely affecting maturation of personality. Drug abuse is a major cause of fatalities from accidents, suicide, accidental poisoning and infections. It is also a major cause of poor performance at work and play as well as a major contributor of mental disorders.
            The most telling adverse effects of drug abuse are in family and social life39. Economic cost of drug abuse to the nation are enormous. Taking Egypt as an illustrative case, cost of substance dependence to Egypt in terms of cost of drugs, efforts to combat them, cost of treatment, loss of productivity and the social and health complications of dependence amount to 6.6 billion US dollars annually81. Social and political cost in the life of a nation can be even more staggering55. A proud nation could be reduced into a den of criminal drug syndicates  who control all national agencies and institutions, turning the whole puppet government machinery to their criminal devices. Drug abuse is therefore not only a drag on personality growth of the individual but a major impediment in the social and economic development of communities and nations.

6. EXISTING DEMAND REDUCTION EFFORTS

            UNDCP has played a major role in promoting and financing demand reduction programs in Africa, including sub-regional co-ordination of efforts. It has also encouraged an inter-disciplinary approach and linkages and harmonization of projects initiated by various organizations and agencies such as WHO, ILO, UNESCO, ICAA and other governmental and non-governmental organizations. In addition to collaborating with governments on demand reduction projects, the organization is also developing the capacity of NGOs to become more effectively involved in demand reduction activities. Towards this end, regional and sub-regional expert fora for demand reduction are being conducted. The fora involves other international agencies such as WHO, UNESCO, ILO, ICAA and others. The first such forum was held in Nairobi, November 1993, and the second in Yaounde, February 1995. There is also growing collaboration with international agencies, UNDCP is employing rapid assessment surveys as part of its effort to keep abreast with the quickly changing scene of drug abuse. UNDCP and WHO are jointly executing a pilot study on rapid drug abuse assessment in Cameroon, to be replicated in other Central African countries. In Mauritius, UNDCP, ILO and WHO undertook a joint assessment and needs-identification mission in 1993. In Zimbabwe, ILO is ensuring linkage between its own project in vocational training and a project it is executing for UNDCP in social re-integration75. WHO, ILO, UNESCO and ICAA are other organizations that have been very active in this area. WHO is involved in promoting rational use of psychoactive medicines, developing evaluation and research instruments, educational and clinical intervention modules, as well as training and provision of training materials on management and prevention of drug abuse. ILO is active in work place initiative program involving early intervention and community based counselling and prevention of substance abuse. UNESCO has developed guidelines for formal and informal school educational programs on demand reduction. ICAA has been very active in carrying out multi-disciplinary in-service training seminars both national and sub-regional in various parts of Africa.

(a) Educational Programs in School System
            Initiatives to introduce drug free lifestyle component into health promotion within the school system has been recent. This reflects the short history of concern over drug abuse among the youth in Africa. Many of the programs, therefore, are in their formative stage. Most initiatives have drawn from the experience of organizations like UNESCO, UNDCP, WHO and other international organizations or agencies.
            Tanzania, as an illustrative case, has a family life education program that was already being piloted in several regions of the country since 1987. This program is integrated into existing curriculum in such a way that the subject of family life is incorporated within the subjects that are already being taught such as biology, home economics et cetera without creating a new subject. Preventive aspects of substance abuse has a strong component in this program. Since 1989 the government of Finland through UNDCP provided assistance for drug abuse control in Tanzania. The preventive education against drug abuse component of this project linked with the ministry of education to strengthen the drug education aspects of family life education. The training has targeted teachers in schools where the program is in place, teachers of all teacher training colleges, and tutors and instructors of various training institutions such as social worker training colleges, schools of journalism, nurses training colleges and the like. The program is part of a wider program aimed at cultural orientation of the national community in general, and youth in particular towards a drug free lifestyle. Other activities have included involvement and education of mass media personnel, community mobilization through discussions with community leaders and involvement of parents and youth leaders. An example of this is that drug abuse has featured every year for the past 5 years during racing of the national torch throughout the country. Educational materials including a handbook on preventive education against drug abuse were produced and distributed to relevant target groups. This program is linked to other related initiatives such as UNDCP supported assistance in supply reduction, the ILO work place initiative, WHO improvement of standards of care project, IOGT community based care program and other NGOs.
            NDLEA in Nigeria has a similar program to the Tanzanian one which is going to be piloted soon. CRISA (Centre for Research and Information on Substance Abuse)55 is an NGO that conducts seminars and symposia for professionals on research and prevention of substance abuse. Egypt has a Comprehensive National Strategy for the Prevention and Treatment of Drug Addiction since 1986 45. This program target the youth and employ the educational channels in schools through lectures, cultural activities and youth participation. In Kenya, ICPA/IFLD Kenya National Committee for the Prevention of Alcoholism and Drug Dependence has a program of lectures in the school in all the classes of primary and secondary school7.

(b) Educational Programs in Informal Settings and Public Education.
            Most of the education in the informal settings is conducted by non‑governmental organizations. Nigeria, as an illustrative case, has many non‑governmental organizations which are involved in educating young people and mobilizing the masses. Example of these organizations are: service clubs, Lioness and Lions clubs, Rotary, Inner Wheel, International Federation for Women Lawyers, National Council of Women Societies, CRISA and ICAA. All African countries studied have non‑governmental organizations in various stages of development. Governmental agencies involved in education are health education agencies of ministries of health. These agencies can be promoted to do much more since they have access to national information systems. Public awareness campaigns exist in all countries, and employ the radio, newsmedia, rallies and public address, cultural media and visual aids. These are sometimes the main route of transmission of information in places where participation in formal education is very low.

(c) Treatment and Rehabilitation
            A large proportion of individuals who need counselling and support to overcome drug abuse continue to receive this within the setting of primary health care and community based services. Drug abuse being a recent problem in much of Africa, many health personnel attending these clients do not have skills and experience to provide the necessary attention. The few patients who require admission with specialized care are often admitted and treated together with mental patients. It is difficult under these circumstances to provide specialized treatment regimes tailored to the needs of addicted individuals. Rehabilitation services for after-care and social re-integration including trained personnel are generally lacking or are at initial stages.

7. IDENTIFIED NEEDS AND PROPOSAL FOR ACTION

A. General Approach
            Effective response to increasing drug abuse in Africa will in part depend on how well existing assets are employed. Foremost among these are surviving cultural assets. Asuni9 has observed that the negative attitude towards drug abuse in African communities can be fostered without prejudice to public education and assistance to addicts. Importance of family and community acceptance can also be effectively employed in promoting culture of healthy drug free lifestyles. The family, may, likewise meet most of the functions met by public social welfare systems in the West. There is need to mobilize elders in the community to resume their traditional role of counselling and guiding the youth communally and within families. It is important to redirect and awaken the traditional cultural value and expectations placed on children and young people, as well as the emotional investment accorded children by their families. These relationships may require new definitions but they are within reach. The African child is still very much loved and cherished57;82. Families and communities, however, need to define the necessary social and emotional nurturance for the growing child through adolescence and young adulthood. Some of these elements are now missing. Examples are increasing prevalence of single parenthood, migrant work away from families and the phenomenon of street children.
            Treatment modalities will also need special modification to be culturally relevant. Cultural and social climate in Africa differs in some respects from other regions in ways that should suggest some differences in approach to management of drug abuse. To a large extent social orientation is still directed to the family and community instead of the individual. In relationships the emphasis is still on interdependence instead of independence and autonomy52. Asuni10 has again suggested the family in its extended form could be much more involved in persuading and committing relatives to treatment and rehabilitation. He is of the opinion that in this regard the rights of the individual should be contingent on the rights and wishes of the family10.
            There is a need to examine carefully  African experience in management of substance abuse to see if there are more cost effective ways that can be adopted and promoted. One possibility is the agricultural based rehabilitation villages. For those patients who require a residential therapeutic community, agricultural based rehabilitation villages such as the El Ayat Rehabilitation Centre at Giza south of Cairo affiliated to Gamal Abou El Azayem Hospital. In this setting gardening and animal husbandry are built into the therapeutic milieu and offers direct orientation to the greater community life through farm produce that can compete with that produced by any other farmer. It is a setting for building up self‑esteem which is often battered by drug abuse. Similar agricultural rehabilitation villages have been established in Tanzania since the sixties38. Development of these villages took inspiration from the Aro Village at Abeokuta. Experience in this area could be harmonized for the purpose of improving their effectiveness. Another area that need to be studied is the contribution that traditional doctors can make towards prevention and management of substance abuse. There are more of them than western trained health personnel and they are very close to the community.
            While planning for treatment settings and modalities it is important to consider methods that have clearly demonstrated merits. Eliany23 has recently reviewed evaluated prevention and management programs in various parts of the world. Programs that offers the most promise are those that address the problem at all loci along a continuum of drug abuse risk. This also means that there should be health promotion programs that includes those at low risk, medium risk, high risk and drug dependent individuals.

B. Special Consideration for Vulnerable Groups
            Children in situations of conflicts, refugee status, school drop-outs and homelessness are especially vulnerable to the risk of drug abuse. Probably the worst circumstance associated with drug abuse is the emergence street children. They abuse volatile substances and other drugs to assuage hunger and fill a social and emotional void in their lives. They are easily recruited into taking and peddling other drugs of abuse. A study in Mwanza, Tanzania83 indicated that 52% of the street children were current abusers of cannabis, 22% abusing the drug on daily basis, and 17% were current abusers of volatile substances, 5% abusing the substances several times daily. The number of street children in Zambia is estimated at 35,00083 and in Lagos city 5,00051. The situation is similar in many of the large metropolis of Africa. Many of these children became street children because of the breakdown of family system that partly resulted from substance abuse. They are often also themselves victims of drug abuse. Many of these children have identifiable parents. A crucial challenge will be how to assist these parents to take up their responsibilities and to prevent others from similarly abdicating parental roles. There is need to involve various organizations and agencies necessary to alleviate the conditions of these children as well as mobilizing non-governmental organizations in this regard. An important part of this work is building alliances between local government agencies, business, NGOs, teachers, parents and children at local community level16.

B. Specific Proposals for Action
(a) In addition to rapid assessment surveys, there is a need to carry out in-depth studies that address the root causes of drug abuse. These should aim at clear identification of factors leading to community and family disintegration, and seeking ways of reversing the trend. This should include issues of culture of democratic governance, peace, and development of policies and programs that will promote community responsibility, family cohesion and parental responsibility on child upbringing.
(b) Development and promotion of comprehensive demand reduction programs, that balance supply efforts, covering health promotion, health enhancement, risk avoidance, risk reduction, early intervention and health recovery. Such programs need to exist at regional, national and community levels. They need to involve elders, parents and youth both as targets and participants in health promotion and health recovery. Such programs should take full cognizance of African and local cultures, as well as recognizing the primate position of the family in society. Research and evaluation should support these activities. These programs should be integrated within existing institutions and structure to the extent possible, and within the framework of the CMO (comprehensive outline of future activities in drug abuse control of the UN).
(c) Seek and promote special African assets such as the central role of the family, traditional doctors and ample agricultural land to the prevention of drug abuse.
(d) As mentioned above there is a need of programs that target special groups at risk such as street children, refugees, children in situations of conflict and students
(e) At the regional level there is a need for:
            (i) a focal point for co‑ordination and a forum for exchange        of information and skills
            (ii) development of standardized modules and instruments for     preventive and management programs as well as research and   evaluation activities
            (iii) promotion of research and evaluations that will                                 support preventive programs at all levels of risk.
            (iv) liaison between international agencies and   
            governments to improve collaboration in this enterprise.
            (v) development and establishment of information, training                      and research centers within African universities to develop         necessary expertise that is culturally relevant and                              sensitive to African cultures.
            (vi) international and national agencies such as UNDCP, WHO,            ILO, UNESCO, UNECA, UNAFRI, UNICEF, ICAA, UNDP, UNHCR, IFLD,             religious organizations and other NGOs can assume increased   role of promoting and implementing prevention programs in        harmony with the overall objectives and strategy encompassing   human development globally and regionally. To this end, there    is need for increased inter-agency collaboration leading to             joint programs that incorporate demand reduction components
            (vii) regional cooperation within existing regional                                    groupings such as ECOWAS, COMESA, ECCAS and Union of Arab             Maghreb
(f) At the national level there is need for a focal point of coordination between governmental, non-governmental and international agencies concerned with social services and development assistance. There is a need to involve all these organizations to address the issue of drug abuse prevention. Efforts at the national level should be backed by:
            (i) national master plan or action program that balances supply and demand reduction and integrates education on drug abuse within all channels of flow of information and             attitudes within society and communities, including         integration of drug abuse prevention within all relevant    educational curricula.
            (ii) a monitoring system on supply and demand for the purpose of closely following trends at local, national and regional             levels
            (iii) community participation in planning and implementation        of demand reduction activities. NGOs should be provided with more support to meet grassroots needs of individuals and        communities
            (iv) relevant training programs including teachers, mass media personnel and helping professionals
            (v) provision of relevant and culturally sensitive training materials and teaching manuals
            (vi) support to primary health care system to carry out               support and counselling services for drug abusing clients
            (vii) production of adequate educational materials that    can be freely shared between countries and various agencies
            (viii) employment of local cultural channels as medium of            information and education
            (ix) periodic evaluation of preventive activities to guide   future designs and activities
            (x) prevention of drug abuse should form part of national           philosophy and vision of the future of the nation. This     should be reflected in development planning

References and Notes
ANNEX 1: References

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Drug Abuse in the Global Village
Drug Abuse among African Youth

ANNEX II: Tables

Table 1 AGE OF ONSET:

Egypt (all drugs)

(Kott 1994, Soueif 1990)#

Kenya

(Mathai 1990)+

Tanzania (all drugs)

(Kaali 1992)#

Tanzania

(Mrango 1991)#

Uganda

(Nabunya 1992)#

Table 2 DRUG USE AMONG YOUTH IN NIGERIA

(Adelekan 1989)#, (N=990, M534 F377), Abeokuta Ogun    

(Adelekan 1992)+, N=649, Ilorin Kware

(Adelekan 1988)#, N=990, Abeokuta Ogun

(Nevadomsky 1981)#, N=1,500