TOBACCO : THE TWENTIETH-CENTURY EPIDEMIC
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- Title
- TOBACCO : THE TWENTIETH-CENTURY EPIDEMIC
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swasth hind
Chaitra-Jyaistha
Saka 1918
April - May 1996
Vol. XL, No.4-5
In this issue
Tobacco - the 20th Century Epidemic
37
World No - Tobacco Day - 31 May 1996
- Backgrounder
40
Dr. Anil Kumar & M.L. Mehta
OBJECTIVES
World No-Tobacco Day —31 May 1996
Swasth Hind (Healthy India) is a monthly
journal published by .the Central Health
Education Bureau, Directorate General of
Health Services, Ministry of Health and
Family Welfare, Government of India, New
Delhi. Some of its important objectives and
aims arc to:
REPORT and interpret the policies,plans,
programmes and achievements of the Union
Ministry of Health and Family Welfare.
-Message
44
Dr. Hiroshi Nakajima
Tobacco-free Sport. Arts & Health Promotion
45
Tobacco in Africa
46
Derek Yach
Health Hazards of Tobacco — Some Facts
53
Primary Prevention of Coronary Disease
54
Dr C. Shyam
World Health Day—7 April 1996
— Backgrounder
ACT as a medium of exchange of informa
tion on health activties of the Central and
State Health Organisations.
63
Dr. (Mrs.) K. Kehar, Dr. Anil Kumar & M. S. Dhillon
Role of Education With Regard to Environmental
Hygiene and Promotional Activities
FOCUS attention on the major public health
problems in India and to report on the lat
est trends in public health.
68
Dr. C.R Mishra
World Health Day 1996— Message
72
Dr. Hiroshi Nakajima
KEEP in touch with health and welfare
workers and agencies in India and abroad.
REPORT on important seminars, conferences, discus
sions, etc. on health topics.
Editorial and Business Offices
Central Health Education Bureau
(Directorate General of Health Services)
Kotla Marg, New Delhi -110002
Articles on health topics are invited for publication in this Journal.
State Health Directorates are requested to send in reports of their
activities for publication.
The contents of this Journal are freely reproducible Due
acknowledgement is requested.
The opinions expressed by contributors arc not necessarily those of
the Government of India.
SWASTH HIND reserves the right to edit the articles sent for
publacations.
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WORLDWIDE TRENDS IN TOBACCO CONSUMPTION AND MORTALITY
TOBACCO: THE TWENTIETH-CENTURY EPIDEMIC
Every ten seconds, somewhere in the world, tobacco kills another victim. If current
smoking trends continue, this toll will increase up to one tobacco- caused death
every three seconds over the next thirty or forty years
Recent data have confirmed that
the risks of smoking are
substantially higher than previously
thought. With prolonged smoking,
smokers have a death rate about
three times higher than
nonsmokers at all ages from young
adulthood. Tobacco products are
known or probable causes of over
two dozen diseases or group of
diseases. If, as is likely, much of the
excess mortality from these
diseases is directly attributable to
tobacco use, then this implies that
the lifetime risk of a smoker being
killed by the use of tobacco products
is at least 50%. Therefore, a lifelong
smoker is as likely to die as a direct
result of tobacco use as from all
other potential causes of death
combined 1
Other problems ensue because
the negative health consequences
of tobacco are not as immediate as
with other hazardous substances.
The health risks of tobacco are
vastly underestimated by the public,
and even by many of those who
are responsible for protecting and
promoting public health. Yet the
risks of smoking are very high when
compared to other risks faced in
everyday life(see table 1).
Widespread underestimation of
risks associated with tobacco use,
is a major reason why tobacco
products are still widely available,
and why lenient tobacco policies
have been allowed to occur. But
nothing can alter the fact that
ZXpoil - May 1996
1—4 DGHS/ND/96
tobacco use is one of the major
public health chalenges facing the
world as it enters the twenty-first
century.
Tobacco products have no safe
level of consumption, and are the
only legal consumer products that
kill when used exactly as the
manufacturer intends. Researches
have rated nicotine as even more
addictive than heroin, cocaine,
marijuana or alcohoal. The Tenth
Revision of the International
Classification of diseases reserves
classifaction for * tobacco
dependence syndrome ”. Yet
tobacco products continue to be
aggressively marketed by tobacco
companies. The result of global
tobacco consumptionhas doubled
since medical science conclusively
proved, 30 years ago, that these
products are unrivalled killers. And
consumption is still increasing in
many areas of the world.
An analysis of trends in cigarette
consumption for WHO regions
indicates that the two regions which
the highest average per capita (adult)
consumption in 1990-1992 were
Europe (2290 cigarettes per adult
per year ) and the Westren Pacific
(2000). The lowest consumption
was observed in African region
(540). For the developed countries
as a whole, per captia adult
consumption is currently about
2400 cigarretes, which is still
significantly greater than the average
consumption in the developing
TABLE 1. ESTIMATED ANNUAL RISK OF DEATH
SELECTED CAUSES, USA, 1989
Selected cause
Annual deaths
per million exposed persons
Smoking
7000
Alcohol
541
Traffic accidents
187
Drowning
22
Passive smoking
19
All other air pollutants
6
Lightning
0.5
Source : United States Surgeon-ueneiai,
37
RELATIVE CHANGE IN
figUre 1
CIGARETTE CONSUMPTION
Ratio of cigarette consumption
per adult in developed to that in developing countries
world (1370 cigarettes).
The gap is rapidly narrowing,
however.
In
1970-1972,
consumption per adult in the
developed countries was 3.25 times
higher than in the devolping world
(see figure 1). By 1980-82, this
ratio had narrowed to 2.38, and by
1990-1992, to 1.75. During the last
decade, per capita consumption has
declined by an average of 1.4% per
year in developed countries, but has
risen by 1.7% annualy in devolping
countries. If these trends continue,
consumption of cigarettes per adult
in the devolping world will exceed
levels in the developed world
sometime between the years 2005
and 2010, ie. within two decades.
other hand, the increasing
consumption in the Westeran Pacific
(2.2%) and South East Asia (1.8%) is
primarily due to trends in China and
India respectively. From 1983, per
capita (adult) consumption in China
rose by 3.9% per year to reach 1990
cigarettes in 1990-1992. In India,
where about 90% of cigarettes are
consumed in the form of bidis
(traditional hand-rolled cigarettes),
adult consumption has been risen
by about 2% per year from the last
decade and exceeds 1200 cigarettes
(including bidis).
WHO estimates that there are
about 1100 million regular
smokers in the world today. About
300 million (200 million males and
100 million females) are in the
developed countries, and nearly
three times as many (800 million :
700 million males and 100 million
females), in devolping countries. In
developing countries, 41% of men
are regular smokers, as are 21%
of women (see figure 2). Half the
men living in developed countries
are smokers, compared with about
8% of women.
The health consequences of the
smoking epidemic in developed
countries have been quantified by
WHO, in close collobration with
the Imperial Cancer Research
Fund’s Cancer Studies at the
University of Oxford, UK. A major
report giving detailed estimates of
There have been very noticeable
differences in trends among WHO
regions. Over the last decade, the
fastest decline in per capita
consumption occurred in the
Americas. Nor was this entierly due
to declines in consumption in
Canada and United States of
Amrica; excluding those two
countries, per capita consumption
in the region still declined by an
annual average of 1.7%.On the
Hind
the number of the numbers and
rates of smoking attributed deaths
for over 50 countries, or group of
countries has been published.
Between 1950 and 2000, it is
estimated that smoking will have
caused about 62 million deaths in
the developed countries (12.5% of
all deaths: 20% of male deaths and
4% of female deaths). More than
half of these deaths (38 million) will
have occurred at ages 35-69 years.
Currently , smoking is the cause
of more than one in three (36%)
male deaths in middle age, and
about one in eight (13%) of female
deaths. Each smoker who dies in
the age-group loses, on average,
22 years of life compared with
average life expectancy. During
the 1990s, the report estimates
that almost 2 million people a year
will die from smoking in developed
countries ( 1.44 million men and
0.48 million women).
As regards cigarettes the health
consequences of tobacco use are
much more difficult to estimate in
developing countries owing to lack
of data. Currently, it is estimated
that tobacco causes about 1 million
deaths a year in developing
countries, but there is substantial
uncertainty about this figure. If
current trends continue, and if the
risk of death from tobacco use are
similar in developing countries to
those that have been observed in
the industralized world, then the
annual toll of mortality from
tobacco will rise dramatically to
around 7 million deaths per year
in the 2020s or early 2030s (see
table 2). The chief uncertanity is
not wheather, but rather when,
these deaths will occur if currently
trends in tobacco use persist.
TABLE 2. ESTIMATED NUMBERS OF DEATHS
CAUSED EVERY YEAR BY TOBACCO
Developed countries
Developing countries
Total
Decade
Deades
1990s
2020s/early 2030s
2 million
1 million
3 million
3 million
7 million
10 million
Let’s Say No To Smoking
• Tobacco kills nearly 30 lakh people every year globally. One out of everry five victims is from India.
Smoking leads to various fatal diseases .These are-cancer of lungs, mouth, voice box, food pipe, urinary bladder,
cervix(among women), pancreas etc.
o 50 per cent increase in tobacco consumption increases chances of cancer by 25 per cent. Besides, diseases
like bronchitis, paralysis, hypertension, gangrene of limbs, heart diseases, peptic ulcer, diminished vision and
every sterility may result from tobacco use.
o Tobacco contains about 4,000 chemical substances. Importing among them are nicotine and tar, which are
largely responsible for their harmful effects.
a The burning of tobacco releases carbon monoxide, which is poisonous and reduces oxygen carrying capacity
of blood. As a result body gets less oxygen. Smoking therefore, is a slow action poison.
• Use of tobacco adversely affects like wrinkled skin, fragile hair, red eyes, foul smell and discoloured teeth.
There are even indications of low fertility, early menopause etc.
• Tobacco does not harm smokers alone; even non-smokers (passive smokers) are equally harmed when they
are in the vicinity of smokers.
Cost of tobacco use can only be partially measured. A large portion like human suffring, loss of resources,
environmental degradation are not easily measurable.
• It is now time to generate a movement to disseminate the information that the ’gains’ of tobacco at the
begining have to be paid very heavily tn future.
April - May 1996
39
BACKGROUNDER TO WORLD NO TOBACCO DAY 31st MAY 1996
“SPORT AND THE ARTS WITHOUT
TOBACCO:PLAY IT TOBACCO FREE!”
Dr. Anil Kumar
M.L. Mehta
THE OBJECTIVE
Alarmed by the scientifically proven risks to health
that smoking causes, the member-countries of
W.H.O.including India,have committed themselves
to fighting this menace. Moreover,the smokers
alone are not at risk. Even the passive smokers are
also at risk.
World No tobacco day is observed on 31st May
each year.lt is intended to encourage
governments,groups and individuals to become
aware of the problem and to take appropriate
action to combat this harmful behaviour.
To help them in this task, W.H.O.since 1989,
suggests a well-defined theme for thought and action
each year.
This year, World No-Tobacco Day is dedicated
to the theme: “Sport and the arts without tobacco:
play it tobacco free!” The theme is significant
because it provides a unique opportunity to mobilise
athletes, artists and the media, as well as the public
in general, to promote a society and a life-style
where tobacco use is no longer an accepted norm.
World’s giant tobacco industries are now
targeting developing countries of Asia, Africa and
South America.India,being the 2nd most populous
country in the world, is the prime target.The modus
operand! of these companies is to sponsor
important sport and the arts events and to associate
tobacco use with the sport and the arts. Millions of
people, young and old, are glued to their T. V. sets
to watch sport events like world cricket and football
cups. They watch with rapt attention the teams of
different countries vying with each other for the
coveted prize.On viewing the sport stars and artists
as role models, the younger population particularly,
accept tobacco-use unwittingly when they see these
events on T.V. or otherwise.
40
This is an era of electronic media. Television has
almost reached every nook and corner of the
world.Important and larger sport and the art events
are being organised world over with live coverage
on television. Sponsoring is a modern way of
marketing which catches its target group in their
leisure time when the audience is more receptive
and susceptible to messages.These events however,
require sponsorships to meet the higher cost
involved in organising them.Tobacco industry which
is one of the highest profit earning industry
competes with other Industries.Tobacco industry has
chosen the method of sponsoring these events to
promote their product and reach the target groups.
This is because advertisements of their product are
banned in most of the countries. Under these
circumstances it is essential to motivate politicians
and decisions-makers to generate necessary political
will against tobacco sponsorship. It is also necessary
to educate the community to seek their participation
and to put adequate pressure on politicians and
decision-makers.
SOME FACTS
TOBACCO KILLS
Tobacco kills one person every ten seconds in
the world and every forty seconds in India. One
out of two smoker dies of smoking-related diseases.
The latest epidemiological studies indicate that death
rates for smokers are two to three times higher
than for non-smokers at all ages.
By the end of the century, cigarette smoking will
have killed about 62 million people in developed
countries: 52 million men, 10 million women.
In India tobacco kills 10 lakh (1 million) people
Shasth
Hind
TOBACCO USE IS A KNOWN OR
PROBABLE CAUSE OF DEATH FROM :
Cancers of the:
Respiratory diseases:
Lip, oral cavity and pharynx
Tuberculosis
Oesophagus
Pancreas
Larynx
Pneumomia and influenza
Bronchitis and emphysema
Asthama
Lung, trachea and branchus
Chronic airway obstruction
Urinary bladder
Kidney and other urinary organs
Paediatric diseases:
Cardiovascular diseases:
Low birth weight
Rheumatic heart disease
Respiratory distress syndrome
Hypertension
Ischaemic heart disease
Pulmonary heart disease
Other heart diseases
Newborn respiratory conditions
Sudden infant death syndrome
Lung cancer and possibly
other diseases caused by
passive smoking
Cerebrovascular diseases
Atherosclerosis
Aortic oneurysm
Fires caused by smoking
materials
Other arterial diseases
In addition, betel-quid chewing, and consumption
of Khaini, Mawa, Mishri, Godakha and Pan
Masala cause the largest number of mouth cancers.
Millions of smokers suffer from crippled lungs and
over-strained hearts.
*
*
ILL-EFFECTS ON CHILDREN
*
*
*
*
Excessive and frequent coughs, colds,
pneumonia, asthma, headache, tonsillitis, ear
aches, stomach aches, bad breath and bad
teeth.
Higher rates of absence from school and
reduction of fitness levels, reaction time,
vigilance and concentration.
More prone to disease/death from lung
cancer, heart disease, bronchitis and mouth
cancer later on in life.
Delayed physical and mental growth
ILL-EFFECTS ON WOMEN
Apart from the usual effects, women who smoke
may have the following:
* Wrinkled skin, fragile hair, red eyes, bad smell,
ZXP>OIl_
1QQ&
discoloured teeth and hoarse voice.
Low fertility, higher still-births, more abortions,
early menopause and low calcium in bonesfractures.
Smoking during pregnancy may cause death
of fetus in utro or result in the birth of babbies
with resultant effects.
ILL-EFFECTS ON PASSIVE SMOKERS
(ENFORCED SMOKING)
*
People inhale other persons’ smoke either
from the burning end of cigarette, bidis or from
exhaled smoke of smoker. Children get smoke
from parents, and wife from husband or vice
cersa. They are called passive smokers.
Passive smoking leads to the almost same type
of diseases as in active smokers.
NICOTINE-THE CULPRIT
Tobacco contains 4000 chemical substances.
Important among them are Nicotine, Carbon
monoxide and Tar. These are responsible for
various diseases.
41
TOBACCO SPONSORSHIP - HOW MUCH
DO WE LOSE?
Today, direct advertisement of tobacco is banned
both in print and electronic media in most of the
countries the world over. The tobacco industry
therefore has found out this alternative i.e.
sponsorship of sport and the arts events. World Cup
1996 for Cricket which was jointly hosted by India,
Pakistan and Sri Lanka and was telecast live world
over was sponsored by a Tobacco giant. Although
there was no advertisement of the tobacco product
as such; but the name of the company which is
almost synonymous to its product, was written in
bold letters on the ground. It was shown on T.V.
hundreds of times everyday. People, specially
younger ones, who saw their favourite cricket star
hammering the ball for fours and sixes and making
a century associated this performance with the
tobacco company. They, therefore unconsciously
were attraced towards the tobacco product. More
likely, it was a beginning to start using tobacco in
various forms. Similarly, various arts events are also
being sponsored by tobacco companies.
Sport and the arts promote health and healthy
habits. But, events sponsored by tobacco companies
are likely to result in increased tobacco use with
resultant tobacco-related diseases. Similarly, the
national government or its subsidiary while
organising the events for earning some money
through sponsorship by a tobacco company are in
fact losing manifold. For, they have to spend more
on establishment and maintenance of health care
facilities for tobacco-related disease. They are also
losers due to loss of manhours because of tobacco
and resultant inefficiency and related diseases
indirectly. This is besides the unmeasurable loss
suffered by the victim and his family.
SPECIAL PROBLEM RELATED TO BIDI
WORKERS IN INDIA
In India, there is an astonishing variety of forms
of tobacco use. It includes manufactured cigarettes,
hand-rolled cigarettes, bidis, chutta, reverse chutta,
smoking hookah, Panmasala Khd.ini* tobacco
toothpaste, etc. Of these, bidi smoking is very.
widespread widely and its consumption is more than.
900 billion bidies per year. These bidis are hand
rolled in small factories and ccottage industries. This
provides employment to a number of a bidi workers.
Therefore, bidi escapes taxation; the result: it is
42
cheap. There are enough public health resons to
impose tax on bidi. However there are a number of
people and institutiosn with an interest in the
continuous supply of cheap bidis. The taxation on
bidi, therefore, is not likely to be imposed in the
near future.
STRATEGIES TO
SPONSORSHIP
STOP
TOBACCO
These facts prove that organising sport and the
arts events through tobacco sponsorship is much
more costlier than organising them through Govt.
fund. The need is to educate people about it, the
real solution of the problem however lies in
understanding this equation.
It has been observed that 10% increase in tax on
tobacco products reduce consumption by 7%. There
is therefore an urgent need to increase tax on
tobacco, the revenue earned through this tax can be
used to fight tobacco menace. This tax can be termed
as tobacco control tax for the defined purpose.
This money can be used to increase awareness
among politicians, decisionmakers and the
community besides sponsoring sport and the arts
events. The pro-health and anti-tobacco messages
can be given before, during and after the event on
the electronic media and otherwise.
Revenue earned through tobacco control tax can
also be used to provide alternative employment for
bidi workers and their welfare. This in turn will
generate community support and political will against
tobacco use. If tobacco companies are still able to
sell more products they generate more revenues
through tobacco control tax and make anti-tobacco
efforts stronger. They will thus free the human
beings frpm the menace of tobacco use.
TALKING POINTS
Efforts should be made to emphasise the
following points for convincing politicians, decision
makers, health workers and the community.
(1) Tobacco use by the community is very costly. It
consists of direct, indirect and unmeasurable cost
and much more than one can think of.
(2) Sponsorship of sport and the arts events is a
form of indirect advertisement and the name of
the tobacco companies becomes synonymous
with thier product.
(3) Huge sums of money are being spent on these
Swasti-i Mind
related messages which generate revenue and
sponsorships not because of their interest in
prove less costly to sponsor.
sport and the arts but basically to promote the
5. Organisers of sports and/or cultural events and
use of their product.
the officers of sports and cultural associations
(4) When the tax on tobacco product increase its
should make this commitment. "I undertake not
use decreases.
to promote the use of tobacco and its derivatives
(5) The revenue being earned on tobacco products
in connections with sport and/or cultural
should only be used for sponsoring sports and
activities.”
arts events and events wherein anti-tobacco and
7. Young people may be invited to exercise their
prohealth messages can be given.
creative talents on tobacco-free themes in many
(6) There is a need to generate a movement against
fields of artistic endeavour like essays, drawings
tobacco use and tobacco sponsorship.
and photographs, comics, cartoons, etc. Prizes
may be awarded for the best presentations.
(7) Promote good health and a tobacco-free life-style
in conjunction with cultural and art events. It will 8. To persuade the sports persons, cinema artists
contribute not only to improving people’s health
and other eminent personalities not to promote
but also to giving full expression to the creativity
tobacco products.
and vitality of different groups and cultures.
9. I.E.C. programmes should be organised to
SUGGESTED ACTION
counter the advertisement of tobacco at all levels.
10.
What can each one of us do to give up smoking?
1. Community organisations should put pressure
*
If
we are smokers, let us promise ourselves
on the politicians and decision-makers to
that we will not smoke at least on this Day. We
increase tax on tobacco product.
might find it difficult but it can be done.
2. Revenue earned through tax should only be used
* If we are non-smokers let us encourage one
to :
smoker each to stop smoking for one day on
a) organise sport and the arts events
31st may. the smoker might be a family member,
b) give anti-tobacco and pro-health messages
friend, colleague or a neighbour.
c) give alternate employment to bidi workers
* If we are teenagers, let us take a pledge that
d) promote alternate farming for tobacco
we will never smoke a cigarette, not even for
producer.
the fun of it. One drug could lead to another and
3. As sport or the arts promote health, these events
eventually to addiction.
be organised by community participation and
* Let us resolve to say 'No' while we still can
they should give pro-health messages through
despite the invisible persuasion of sponsors of
these events.
sport and arts events by the tobacco industry.
4. folk arts events should be used to spread health
SMOKING SHOULD BE BANNED IN PUBLIC PLACES AND OFFICES
APRIL Mz\Y
1QQ&
43
Message
WORLD NO - TOBACCO DAY 31 MAY 1996
SPORT AND THE ARTS WITHOUT TOBACCO: PLAY IT TOBACCO FREE I
Dr. Hiroshi Nakajima
DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION
T he
lives
and
accomplishment of sports
heroes, leading actors,
musicians and other artists are
highly visible and attract
widespread interest all around
the world. Young people in
particular look to sports stars
and art performers as a role
models. It is fitting therefore
that the World NO-Tobacco
day 1996 should be dedicated
to the theme Sport and the
arts without tobacco. Athletes
and artists can lead the way in
promoting healthy life styles
where tobacco use is no longer
the social norm.
Every year, World No
Tobacco Day is a special
occasion for the World Health
Organization and the people
from all its Member States to
call attention to the harm that
results from tobacco use. It is
also a day when governments,
communities groups and
individuals together explore the
ways through which they can
stem the tobacco epidemic,
and especially prevent young
people
from
becoming
addicted to this harmful
substance. We applaud those
individuals who have already
given up tobacco use, and
encourage those who still use
tobacco to make a special
effort to finally break free from
this dependence.
World No-Tobacco Day
1996 is cosponsored by the
United Nations Educational,
Scientific
and
Cultural
Organization (UNESCO) and
the International Olympic
Committee (IOC). These
organizations have welcomed
the initiative of combining the
sport and the arts to promote,
jointly with WHO, the
prevention of tobacco use.
They too have fully realized the
importance of athletes and
artists as role models who can
convince the public in general
and young people in particular
that a healthy lifestyle should
be "smoke-free".
Communities and societies
express themselves through
their arts and culture.
Promoting good health and a
tobacco-free lifestyle in
conjunction with cultural and
artistic events will contribute
not only to improving people’s
health but also to giving full
expression to the creativity and
vitality of different groups and
cultures.
We also want to promote
"sport for all" as the fight for
all human beings to participate
in sport and physical activities
for recreation and to improve
their health and well being.
Regular physical activity is vital
for good health : it provides
protection from a wide variety
of physical and mental
ailments. Physical fitness and
good health, however, can be
ruined by tobacco use. It is
estimated that about half of the
adolescents who start smoking
cigarettes and continue
throughout their lives will
eventually die from tobaccorelated diseases. Not only
smoking but all forms of
tobacco consumption are
extremely hazardous.
Unfortunately, the tobacco
industry has geared its efforts
towards developing positive
images for its products
through extensive sponsorship
of sports and cultural
personalities, organizations
and events. In many countries,
sport and the arts rely heavily
on the sponsorship from
commercial enterprises, and
tobacco companies are among
the main sponsors. In many
cases, sport and cultural
events, which should celebrate
good health, physical prowess,
intellectual freedom and
cultural independence are
cynically
used
as
an
opportunity to promote
addictive and hazardous
products among the young
(Continued on page 45.)
44
SkM/xsTi-i Hind
TOBACCO-FREE SPORT, ARTS
AND HEALTH PROMOTION
SPORT AND ARTS OFFER EXCELLENT OPPORTUNITIES FOR HEALTH PROMOTION, ESPECIALLY
IN THE AREA OF TABACCO CONTROL. DEVELOPING PARTNERSHIPS WITH SPORT AND ARTS
GROUPS WITH HEALTH IN MIND IS IN CONTRAST TO THE TABACOO INDUSTRY POLICY OF
USING SPORT AND ARTS TO SELL CIGARETTES.
gport and arts offer the
tobacco industry lucrative
opportunities because of the
size of the audience exposed
to the tobacco messages immediate audiences of
spectators, and much larger
and more significant audiences
through electronic and print
media.
young
people
are
encouraged to associate
smoking with high profile
sports, arts and cultural
achievers. The tobacco
industry has exploited to
maximum this use of sport
and arts achievers and role
models to sell cigarettes.
Promoting cigarettes: Marketing
not only highlights the name
of a company’s product ,
but also promotes the
product in subtle ways
associating
cigarette
smoking with strength,
sexual prowess, glamour,
beauty,
wealth
and
elegance.
Promoting cigarettes : Patronage
Innovative methods are used
to promote the marketing
message.
Tobacco
companies use marching
girls, signs around the
perimeters
of
sports
grounds, signs in the foyer
of arts and cultural events,
signs on cars for motor
sport, international telecasts
of high profile speeches that
mention
tobacco
sponsorship and ceremonies
to present trophies branded
with the tobacco company’s
name and logo. The range
of marketing methods used
.Cigarette companies also
see sponsorship as an op
portunity to enlist support.
They do this by encouraging
sport and arts organization
and personalities to support
their cause and by making
good use of preferential
seating at sport and arts
events to influence senior
decision makers to support
legislation and financial
policy at a state and national
level.
In contrast, tobacco-free
sports and cultural events are
ideal venues to promote good
health and healthy lifestyle.
Alliances must be forged be
tween the public, the health
sector and all those who are
active and interested in sports
and the arts to sponsor sports
and cultural organizations so
that these no longer need to
depend on tobacco sponsor
ship.
Health organizations can spon
sor sporting and cultural activi
ties, and in so doing create ma
jor opportunities to convey
their health promotion mes
sages in novel and effective
ways. Such sponsorship, how
ever, requires resources. Some
governments have generated
new revenue for this purpose
by increasing taxes on tobacco
products, a measure which has
also helped to decrease tobacco
consumption.
This has been done in many
places around the world.
The sponsorship of sports
and the arts by tobacco com
panies is now widely recog
nized as ethically unaccept
able. More land more people
and communities are giving
precedence to health and be
ing able to live in a tobaccofree environment. With all the
people and sectors con
cerned, WHO will work to pro
mote tobacco-free events
which celebrate good health
together with excellence in
sports and the arts - a winning
combination for all 1
In
particular,
sports
sponsorship links smoking
strongly to an active, sporting
lifestyle, thereby undermining
warnings of the health
consequences of smoking.
Tobacco Industry use
of sponsorship
of sport and arts.
Promoting cigarettes:
Using role models
A positive association is
created between sport and
arts, and cigarette smoking.
Consumers,
especially
(continued from page
April - May 1996
2—4 DGHS/ND/96
TOBACCO IN AFRICA
Derek Yach
Tobacco has been a common commodity in Africa for over three centuries. By 1993, some
500000 tonnes of tobacco were being grown in 33 African countries, with only two countries ex
porting more than they import. Attempts to measure the current and potential impact of the to
bacco business on health, society and the environment are still in their early stages, but the
need for preventing action is already inescapably clear.Comprehensive control strategies are
urgently required to prevent a major epidemic of tobacco- related disease in Africa.
Tobacco was introduced to
Africa in the seventeenth
century by the Ottoman
conquests in the north and
the slave trade. Cultivation
spread rapidly throughout the
continent. All commercial
plants are variants of the
same species, Nicotia na
tabacum.
On his first
expedition to trace the course
of the Niger in 1875, Mungo
Park, a Scottish explores,
found tobacco in demand
wherever he went, more for
smoking than for snuff. A
typical entry in his journal
reads. “The natives of all
descriptions take snuff and
smoke tobacco. Their pipes
are made of wood, with an
earthen bowl of curious
workmanship. Tobacco often
served as a gift”.
The growth of the industry
Nicotiana tabacum was
first produced in Zimbabwe by
Father
Boos
at
the
Chisawasha Mission outside
Harare in 1893. The tobacco
industry grew rapidly in
Zuimbabwe . In 1900 a small
Department of Agriculture
was established, and its
46
officials took immediate steps
to encourage the production
of tobacco in the new colony.
As "Rhodesia" moved into
the twentieth century, Earl
Grey, a director of the British
South Africa Company,
charged with administration in
the colony, saw the potential
of tobacco production and
sent one of his officials, a Mr.
Odium, to the USA for a year
to learn about it. On his
return to the colony, Odhum
pioneered Rhodesia’s first
curing barn and the production
of “some nice yellow leaf of
decent texture”.
The first major tobacco
manufacturing group can be
traced back to 1880 when
United Tobacco was set up in
South Africa. The most im
portant tobacco company in
South Africa now is the
Rembrandt group, which be
gan in 1948. By the 1990s
Rembrandt had established
one of the major multination
als. Richemont, based in
Switzerland. Its luxury goods
and media divisions comple
ment the marketing and pro
motional activities of the ma
jor
tobacco
division,
Rothmans International.
They are poised for even fur
ther growth through the 1990s
worldwide.
The world’s major tobacco
trading companies are British
American Tobacco (BAT), R.J.
Reynolds, Philip Morris,
Imperial Group, Rembrandt/
Richemont, and France’s
SEITA (Service d’exploitation
industrielle des tabacs et
allumettes), and they are all
Represented
in
Africa.
Together these companies
control 89-95% of the world’s
leaf tobacco. They control all
the essential aspects of the
business:
-
the supply of fertilizer,
pesticides and machinery;
-
the cultivation of crops;
-
the processing, production,
marketing and selling of
the final product;
- tobacco prices.
By exercising this control
and offering inducements to
farmers, they have made
tobacco the most widely grown
non-food crop in many
Hind
African countries. (1)
In 1978, Muller warned
that cigarettes were being
pushed by high-pressure
marketing to the most remote
corners of the world, and that
tobacco-related disease would
constitute one of tomorrow’s
major epidemics (2). His
prediction is being fulfilled in
Africa.
Agriculture and trade
The
United
States
Department of Agriculture
estimated that about 500000
tons of tobacco were grown in
33 African countries in 1993.
Of this, 90% was grown (in
order of magnitude)
in
Zimbabwe, Malawi, South
Africa,
Kenya,
United
Republic of Tanzania and
Nigeria, with the first two
countries accounting for 74%
of the total for the continent.
The All Africa Tobacco
Control Conference in Harare
(1993) was regarded as a
historic meeting between
tobacco growers and public
health professionals (3). A
small
success
of
the
conference was to elicit a
statement from Mr. Henry
Ntaba,
head
of
the
International
Tobacco
Growers’ Association, in
which he conceded that he
was 'a farmer first, a tobacco
farmer second". This opened
the door to a major discussion
on diversification. Ronald
Watts,
an
agricultural
consultant from Zambia with
40 years ’ experience in
Africa, listed 53 alternative
crops and ways of using the
land . These included maize,
export horticulture, fruit, nuts
and fibre crops. He showed
that the average return per
April - May 1996
dollar invested could be higher
for several of the crops.
However, the alternatives are
limited for small-scale farmers
without irrigation, such as
most of the Malawi tobacco
growers. No single crop
should be considered as a
replacement. Successful case
studies of diversification are
now appearing from the
Congo, South Africa and
Zimbabwe. These case studies
and the whole effort to
diversify need more support
from
the
international
community, particularly if
Malawi and Zimbabwe are to
reduce
their
national
dependence on one crop.
At the Harare Conference
the Zimbabwean Health
Minister, Dr. Timothy Stamps,
observed that there was a need
to separate the production and
the consumption of a
commodity when framing
national policy on tobacco
control. He also stated that
he would not compromise his
position as Minister of Health
by failing to tackle tobacco
control as a major public
health problem. He suggested
that farmers in Zimbabwe
would be able to ensure their
long term livelihood far better
if they were to accelerate
diversification. Of the 44
countries which trade in
Africa, only 50% export
tobacco. Malawi (with over
75% of its export earnings
coming from tobacco) and
Zimbabwe (with over 25%) are
atypical of the continent,
accounting for 94% of its
entire export earnings from
tobacco. Kenya and the
United Republic of Tanzania
contribute almost all the rest,
and the other trading nations
import more than they export.
In 1992 Angola, Ethiopia,
Nigeria, Senegal and South
Africa reported negative
annual tobacco trade balances
of more than US$ 100 million.
This loss deprives countries of
precious foreign exchange (3).
Environment
A
series
of
papers
commissioned by the Panos
Institute, an international
environmental group based in
London, have documented the
environmental and social
consequences of tobacco
growing in Kenya, the United
Republic of Tanzania and
Uganda (4).
This work
provides detailed accounts of
the extent and consequences
of deforestation in relation to
tobacco growing and curing.
They show that the amount of
surviving trees in reforestation
projects had been vastly
overestimated, particularly in
Kenya, the United Republic of
Tanzania and Uganda. For
example, over the past 50
years Tanzania’s area of
natural forest has been halved.
Extensive use of wood fuel for
curing tobacco leaves (500000
to 750000 m3 of solid wood
in 1993) has contributed to
this decline. Reforestation
has fallen far behind these
depletions.
There is also growing con
cern about the health of work
ers in the tobacco industry.
Methyl bromide and ethylene
dibromide both extremely dan
gerous chemicals, are used ex
tensively for fumigating seed
beds and other land. The use
of ethylene dibromide for to
bacco growing is illegal in the
USA. According to a recent
report”Much of the equipment
used for spraying chemicals is
47
of poor quality. Workers of
ten don’t wear protective
clothing and are usually un
aware of the potential health
risk of their work” (4). Moves
are being made to improve
safety, but it is clear that to
bacco is more dependent on
hazardous chemicals than
many other crops.
Tobacco advertise
ments range from scenes
of football players and
leaping tribesmen to up
wardly mobile young
couples with sports, cars
and high fashion cloth
ingA reduction of the area of
land used for tobacco crops
would reduce this dependence
and the dangers that
agricultural workers are
exposed to.
Wealth,
control
consumption
and
The relation between gross
national product, disposable
income
and
cigarette
consumption has been well
documented globally. At the
lowest economic levels,
money is simply not available
to buy cigarettes. Increases
in income of 10% in lowincome countries have been
estimated by the World Bank
to result in a 7% increase in
consumption, while increases
of 10% in even lower-income
countries are associated with
an increase in consumption of
13%(3).
The Food and Agriculture
Organization of the United
Nations projects that the level
of tobacco consumption in
Africa will grow to one of the
highest in the world unless
new national policies are
introduced to change the
trend. Between 1985 and
1990 the estimated annual
increase in consumption for
the developing world was
3.4%, and for Africa 2.4%.
However, for the period 19952000 the estimated figure is
2.7% for the developing world
and 3.2% for Africa, with a
slight reduction for the
developed world.
This growth in tobacco
consumptio.n is related to both
demographic
and
socioeconomic change. As
more children survive and
reach young adulthood,
tobacco
consumption
increases. In Africa, infant
mortality rates are continuing
to decline. In addition, a
combination of urbanization,
westernization land increased
disposable income has led to
an increase in smoking. These
changes are well advanced in
many African countries.
Other factors associated with
increased smoking relate to
the promotional and marketing
strategies of the tobacco
industry, particularly in most
African countries where the
absence of legislative controls
and high levels of illiteracy
make people more vulnerable
to sales efforts..
Sub-Saharan countries can
be broadly categorized into
four groups as shown in the
Table.
In the richer countries the
rate of increase in tobacco use
is likely to continue to be
rapid. In the case of South
Africa and Mauritius, control
measures including legislation,
excise
tax
and
the
development of tobacco
control organizations are
advanced. In Botswana there
is a complete ban on tobacco
advertising, a ban on smoking
in many public places, and a
tobacco control office in the
Ministry of Health.
In
Mauritius and South Africa
there are bans on sales of
cigarettes
to
children,
increasing bans on smoking in
public places, and the start of
media campaigns against
tobacco.
In
the
middle-income
Relation between tobacco consumption and socioeconomic indicators in sub-Saharan Africa
Poorer tobacco
exporting countries
poorer
countries
Richer
countries
Middle-income
countries
Gross National product
in 1992 (US$)
2000+
c. 800
<600
Examples
Botswana
Mauritius
South Africa
Cameroon
Senegal
Malawi
Mozambique
Zimbabwe
Zimbia
<60
60-750
Infant mortality rate,
48
1990-95 (per 100 000 live births)
Adult literacy rate (%)
>60
60-60
c.50
60-140
37-75
80-140
33-73
Cigarettes consumed per
adult per year
1000-2000
c. 800
180-600
<350
EBpvjxxsti-j Mind
countries there have been
marked increases in cigarette
consumption, especially in the
West African francophone
countries since the early
1980s. Legislation which
exists is not implemented.
There are signs of the
development of strong
tobacco control movements,
particularly in the case of
Senegal,
where
the
Movement anti-tabac has
focused on building a base for
future tobacco control by
targeting school-children.
In the poorer countries
which export tobacco, the
strength of the tobacco
growing fraternity and their
influence on government have
combined
to
prevent
legislation
from
being
introduced. However, there is
evidence of growing non
governmental tobacco control
activity, for example by the
Kenyan Medical Association.
In the other poorer
countries, tobacco marketing
is less extensive, and the
preventive potential is thus
greater. It is significant that
despite their relatively low
levels of wealth, health
ministries in several of these
countries have already
introduced legislation, for
instance in Mozambique and
Zambia, which bans certain
forms of advertising. In
Ghana the media emphasize
the dangers of tobacco, and in
Zambia the Anti-smoking
Society, often in combination
with the Zambian Medical
Association, has been active
in building up campaigns
aimed at tobacco control.
In general, the aggressive
ness of tobacco advertising
April - May 1996
and promotional activities in
African countries seems to be
increasing. In Ghana, there
are lavish cigarette displays
near tourist sites; free ciga
rettes are openly handed out
in markets by the Embassy
cigarette company; Embassy
sponsors the Miss Ghana pag
eant; the support of tobacco
companies for reforestation
by farmers is publicized as an
example of corporate respon
sibility by the industry; and
tobacco advertisements are
placed on road signs . Such
efforts are seen in several Af
rican countries. Tobacco ad
vertisements elsewhere range
from scenes of football play
ers and leaping tribesmen to
upwardly mobile young
couples with sports cars and
high fashion clothing. In
Kenya, tobacconists’ shops
are painted in the BAT
colours and free mobile cin
emas bring cigarette adver
tisements and free cigarettes
to villagers.
Health Impact of tobacco
There are four national
cancer registries in Africa
(Algeria, the Gambia, Mali and
South Africa), and national
mortality data are available
only for Mauritius, Sao Tome
and Principe, Seychelles and
South Africa. Estimates of
total mortality from cancer for
western and eastern Africa are
much lower than those for
western Europe. The only
countries in sub-Saharan
Africa where there is solid
evidence of rising mortality
caused by tobacco are South
Africa and Zimbabwe. For
sub-Saharan Africa as a
whole, lung cancer constitutes
5.8% of all cancers. This is
in sharp contrast to the over
20% found in countries where
the smoking habit has been
practised for several decades.
In southern Africa the
proportion of lung cancer
attributable to smoking is 86%
for men and 39% for women.
International experience
shows that this figure could
exceed 90% once tobacco use
becomes more established.
Because the current lung
cancer rate is based on past
consumption, often with a
time lag of decades, the recent
increase in consumption will
cause an inevitable increase in
illness in the future.
In Zimbabwe, lung cancer is
now the third cause of
neoplasm deaths among
African men, and rates among
African men equal those
among Europeans. In the
same country, the lung cancer
rate in African women is one
third that of European
women, reflecting the fact
that smoking rates were low
two decades ago.
Trends in South Africa
indicate that among Whites,
tobacco use has declined during
the last 15 years, while it is
rising among Blacks and
continues, though to a lesser
extent, to be high and rising
among Coloureds. For the
country as a whole, lung
cancer already accounts for
24% of all deaths from cancer
in men, and 10.6% of all such
deaths in women. Cape Town
researchers recently showed
that lung cancer rates had
increased by more than 100%
among Coloureds of both
sexes and among White
women over the last two
decades . These trends were
mirrored by trends in chronic
obstructive lung disease mortality.
49
Poor data precluded similar
analysis for Blacks. However, since
smoking rates among Black African
men exceeded 50% in the late
1980s, an epidemic of lung cancer
can certainly be expected early in
the next century. Smoking rates
among Black African women arc
still low but starting to increase in
metropolitan areas (6).
The International Agency
for Research on Cancer, using
data from three locally based
African cancer registries, has
shown that a more than
tenfold difference exists for
the occurrence of lung cancer.
The highest incidence in males
is found in Setif Wiloya at
11.7 per 100000, compared
to 2.6 in Bamako and 1.0 in
the Gambia. Among women,
lung cancer rates arc still very
low, from 0 in the Gambia to
2.6 in Bamako.
In 1982 a WHO meeting
on tobacco control was held
in Mbabane, Swaziland, and
concluded that in most of
Africa, health departments
were still struggling to
eliminate diseases of poverty
such as toberculosis, measles,
malaria, trypanosomiasis and
cholera. With the rise of
tobacco consumption, health
departments would be forced
to siphon scarce financial and
human resources into dealing
with smoking-related diseases
requiring the expensive
diagnostic and therapeutic
resources of large hospitals.
This is in sharp contrast to
nutritional and infectious
diseases which require a
relatively low-cost preventive
community approach. Thus,
acting vigorously now,
particularly to prevent African
women from starting to
smoke, would yield long-term
50
savings for the health system
in the next century.
WHO’s
Regional
committee for Africa, which
met in Gabion in September
1995, stressed the need for
concerted action to prevent
increases in tobacco use in
Africa. Countries called for a
ban on tobacco advertising, a
regional effort to harmonize
and increase tobacco excise
duty,
and
improved
educational programmes for
children. Malawi’s Minister of
Health
appealed
for
international support for his
country’s efforts to reduce its
dependence on tobacco
revenue.
Tobacco control
The World Bank has be
come so concerned about the
health and economic impact of
tobacco that it has adopted a
policy which requires health
sector work to include anti-tobacco activities, and prohib
its the Bank from lending for
producing, processing, im
porting or marketing tobacco,
whether for domestic con
sumption or for export. Be
tween 1974 and 1988 the
World Bank provided loans to
Benin, Malawi, Swaziland and
the United Republic of Tanza
nia for agricultural projects
supporting tobacco produc
tion, so this new policy repre
sents a significant change.
Legislation
Roemer’s recent review of
legislative action to control
tobacco use shows that
progress has been slow in
introducing this approach in
Africa (7). Only a few
countries have introduced
bans on sales to children
(Mauritius in 1990, Botswana
and South Africa in 1993); and
only slightly more have
introduced partial advertising
bans. Senegal (1981) and the
Gambia (1985) were among
the earliest to do so, but the
Senegalese legislation was
later partly rescinded. Health
warnings are required on
advertisements in Ghana,
Kenya, Nigeria and South
Africa. However, in Ghana
and Kenya the warnings are
so small that they are barely
visible. The new warnings
required as of May 1995 in
South Africa are among the
strongest in the world and are
backed by a strong media
campaign. Countries like
Botswana and Mozambique
have bans on broadcast
advertising, but they are
within the radio reception
area of South Africa, which
makes the bans ineffective. In
Mauritius the ban on smoking
in public places includes
health, education and sports
facilities.
Roemer recommends that
a comprehensive approach to
legislation
should
be
developed to
forestall
epidemics of tobacco related
disease. She warns against
entering into voluntary
agreements with the tobacco
industry, and the South
African experience with such
agreements supports this
viewpoint.
She
also
recommends that regional
meetings should be held
regularly for the exchange of
scientific and technical
information so that both
national
and
regional
approaches to tobacco
control can be developed.
□hasth Hind
International agencies such
as WHO, the World Bank, the
United Nations (through its
new Project on Tobacco or
Health), and UNICEF could
play a very significant role in
controlling tobacco use in Af
rica, where such agencies are
held in high esteem. Conti
nental bodies such as the Or
ganization for African Unity,
health-related organizations
such as the Pan-African Asso
ciation of Cardiologists, the
International Lung Associa
tion and the International
Union against Cancer (Africa
sections) have unique and
complementary roles to play
in helping countries plan and
carry out tobacco control
strategies.
)
Excise tax
Excise tax affects the
affordability of cigarettes,
especially for children and
poor people, and is thus an
important device for tobacco
control. However, in Africa
there are concerns about
smuggling and shifting to
high-tax homemade products
which limit the scope for
control by increasing taxes
and require systematic study.
Information is also needed on
the level of excise tax (in
relation to inflation) on
tobacco products in each
country, as well as the
existence
of
regional
preferential trade areas and
their implications for the
harmonization of excise tax.
Information on the elasticity
of demand in relation to price
will be needed for a range of
countries at varying levels of
development. This involves
gathering data on price
changes in relation to
consumption over time.
April - May 1996
Here and in the area of
legislation, shortage of human
resources
is
a
major
impediment to progress.
There is a dearth of health
economists in Africa. For
richer countries the use of
excise tax to fund health
promotion and reduce the
dependence of sporting and
cultural activities on tobacco
should
be
considered.
Initiatives of this kind are
under way in South Africa.
Control Commission for
Africa was set up in order to
speed up the process of
designing and implementing
the necessary measures. Its
specific objectives are as
follows :
The role of women In tobacco control
- to identify data needs and
research priorities in
relation to all aspects of
tobacco control (including
biomedical, agricultural,
economic, environmental,
legislative and political
issues) and assist in the
funding and implementation
of such research;
The role of women in
tobacco control has become
more clearly defined in recent
years. It is now recognized
that preventing women from
starting to smoke can improve
the health of their unborn
children and children in the
household, and curb long-term
use of tobacco products.
Proposed strategies for
preventing smoking among
women include making more
use of women to lobby for
legislation and enforce it
through social pressure;
promoting positive role
models, such as successful
women who do not smoke, to
spread the message that it is
smart not to smoke; and
ensuring that health education
programmes continuously
reinforce
anti-smoking
attitudes and behaviour. Such
strategies should include
assertiveness training to
strengthen self-confidence, so
that women can change their
position
from
relative
powerlessness and take the
lead in protecting their own
health and that of their
families.
Tobacco Control Commission for Africa
In
1994 the Tobacco
- to facilitate the training of
tobacco control advocates in
Africa and thereby build
sustainable human and
institutional capacity for
long-term tobacco control;
- with other agencies.already
active in tobacco control in
Africa such as WHO,
nongovernmental
and
government organizations,
' to provide advice to
governments continental,
regional and international
organizations about policy
development in relation to
tobacco control;
- to disseminate relevant
information regularly to
tobacco control groups and
individuals in Africa or
working with Africans ;
- to develop long-term
sustainable sources of
funding through country
based tobacco excise taxes
and other methods.
Political leadership
In recent years, ministers
of health from several African
countries have voiced their
51
support for tobacco control as
a crucial component of
primary health care, and in
1994
Nelson
Mandela
announced his opposition to
tobacco companies using his
name to promote their
campaigns. His statement was
in response to a proposed
“Benson and Hedges Nelson
Mandela cricket tournament”.
President Mandela said “I
personally discourage people
from smoking and I therefore
dissociate myself from any
campaign using my name to
promote this habit”. He said
he would contact concerned
parties both in South Africa
and abroad to ensure that any
misrepresentation of this
position is rectified”. He was
successful in this, and Benson
and Hedges will no longer be
sponsoring cricket as of 1996.
In recognition of his
contribution to tobacco
control, President Mandela
was awarded a WHO medal on
World No Tobacco Day, 1995.
Such political leadership in
Africa bodes well for the future
of tobacco control.
References
1. Yach D. The impact of smoking in
developing countries with special
reference to Africa International
Journal of health services, 1986, 16
:279-292.
2. Muller N. Tobacco in the Third
World: tomorrow's epidemic,
London. War on Want, 1978.
3.
Conference on Tobacco Or Health,
Harare 1993, Parow, Cape Town,
Medical Research Council, 1993.
4. Tobacco costs the health.
Panoscope, 1994, 41; 14-21
5.
Chapman S. Wai-Leng W.
Tobacco control in the Third World. A
resources atlas Kuala Lumpur,
International Organization of
Consumers Unions, 1990.
6. Yach D, McIntyre D, Saloojee Y.
Smoking in South Africa. The health
and economic impact. Tobacco control
1992,1:272-280.
7. Roemer R. Legislative action to
control the world tobacco epidemics,
2nd ed. Geneva, World Health
Organization, 1993.
Courtesy: World Health
Forum Volume 17 1996.
Proceedings of the All Africa
JOINT DECLARATION
OF THE INTERNATIONAL OLYMPIC COMMITTEE (IOC)
THE UNITED NATIONS EDUCATIONAL, SCIENTIFIC AND CULTURAL ORGANIZATION (UNESCO)
AND THE WORLD HEALTH ORGANIZATION (WHO)
Good health cannot be taken for granted; its protection and improvement depend on
the active involvement of individuals and communities in many different activities. The
promotion of a tobacco-free environment is one such activity and encouragement of
cultural, sporting and artistic events is another. They go together naturally to add
vitality and happiness to our lives.
Each in our own areas of competence, IOC, UNESCO and WHO are working for
human well-being and friendship through sports, culture and health. World NO-TO
BACCO DAY 1996 gives us a special opportunity to join forces and remind the world
that physical and mental well-being is of the utmost importance to all of us. These two
aspects of health ore inseparable and should always be promoted together. To make
sports and the arts even more rewarding, we invite everyone to " Play it tobaccofree!"
7
52
□nasth Hind
HEALTH HAZARDS OF TOBACCO
- Some Facts
Qmokers and non-smokers
alike often do not fully
appreciate the health risks of
tobacco use, particularly
cigarette smoking. The latest
epidemiological
studies
indicate that death rates for
smokers are two to three times
higher than for non-smokers
at all ages. This means that
half of all smokers will
eventually die as a result of
their smoking. If current
smoking trends persist, about
500 million people currently
alive, nearly 9% of the world’s
population will eventually die
as a result of tobacco.
People who die from
tobacco use do not die only in
old age. About half of all
smokers who are killed by
tobacco die in middle age. On
average, these smokers who
die in middle age lose about
20-25 years of life expectancy.
Smoking Trends
-^Cigarettes consumption in
developing countries has
been rising among men
over the last three or four
decades.
In
some
developing countries, the
health effects of this
increase in tobacco use are
already evident. For
example,
in
China,
smoking is estimated to be
the cause of at least half a
million deaths a year,
mostly men (per capita
cigarette consumption in
China has increased almost
four-fold since the early
1970s).
April - May 1996
3—4 DGHS/ND/96
-> Most smokers live in
developing countries. Of
the 1.1 billion smokers in
the world in the early
1990s, 800 million (7075%) live in the developing
world.
In developing countries
50% of men smoke (plus
about 8% of women ). The
proportions for men and
women in the developed
countries are 41% and 21%
respectively.
-> In developed countries the
proportion of female
deaths in middle age due to
smoking has increased six
fold since 1955, rising from
2% to 13% by 1995.
-> Per capita consumption is
falling in the developed
countries at about 1.5% per
year,
but
rising
in
developing countries at
about 1.7% per year. As a
result, it is projected that
per capita (adult) cigarette
consumption
in
the
developing world will
exceed consumption in
developed countries within
the next decade.
Passive Smoking
Passive smoking is a cause
of additional episodes and
increased severity of
symptoms in asthmatic
children.
Asthmatic
children are up to 2.5 times
more likely to have their
condition worsened by
passive smoking. In the
United States alone it is
estimated that 200000 to
one million asthma:':.
children
have
their
condition worsened by
passive smoking.
-> Exposure to environmental
tobacco smoke (ETS or
“passive smoking”) is a risk
factor for new cases of
asthma in children who
have no previously dis
played symptoms.
The risk of lower respira
tory tract diseases (such as
croup, bronchitis and
pneumonia) is estimated to
be about 50-60% higher in
children exposed to ETS
during the first 1-2 years of
life, compared with unex
posed children. About 1015% of lower respiratory
tract disease in young chil
dren under 18 months of
age is attributable to pas
sive smoking.
•^In children, exposure to
environmental tobacco
smoke is causally associ
ated with increased preva
lence of fluid in the middle
year, sysmptoms of upper
respiratory tract irritation,
and a small but significant
reduction in lung function.
Environmental tobacco
smoke is a cuase of lung
cancer in lifelong nonsmokers exposed to ETS.
Epidemiological studies
carried out in several
countries suggest that the
lung cancer risk is about 2030% higher than for never
smokers not exposed to ETS.
□
PRIMARY PREVENTION OF
CORONARY ARTERY DISEASE
Dr.C.Shyam
Epidemiological studies have finally established that cigarette smoking
independentally predisposes to myocardial . Infarction (MI) and sudden car
diac death in populations with mean plasma cholesterol level in excess of
180 mg%. A large body of data suggests that this causal relationships be
tween smoking and Coronary Artery Disease (CAD) is strong, gradual, con
sistent, temporarily connected, prospectively demonstrable, independent of
other risk factors, and additive to the other risk factors.
*Phe proven “ Prevention is
better than cure” has been
recognised in case of
communicable diseases long
ago. And the concept has
become broad based and
extended
to
noncommunicable diseases too,
including chronic diseases
such as coronary Artery
Disease (CAD) Hypertension,
Cancer, etc.
It is customary to define
prevention in terms of three
levels :
-
Primary Prevention
-
Secondary Prevention:
Early Diagnosis and
Treatment
-
Tertiary
Prevention:
rehabilitation
Primary Prevention can be
defined as Action taken prior
to the onset of the disease,
which removes the possibility
that a disease will ever occur.
The concept of primary
prevention is now being
applied to the prevention of
chronic disease such as CAD,
Hypertension, Cancer, etc.
based on elimination or
modification of “Risk Factors”
54
of the disease.
This is basically based on
the study of natural history of
CAD. The study of natural
history of CAD with its many
critical points clearly indicates
that Primary Prevention is the
mainstay of community
prevention of CAD.
Atherosclerotic coronary
artery disease is the most
common of the killer diseases
the world over. The human and
economic costs of CAD are
enormous. The symptomatic
phase of the disease-develops
quite late in the history of
atherosclerotic CAD.
Aherosclerosis has a pediatric
beginning and takes several
decades to develop and to
prevent into clinical phase.
Hence attempts to control the
ravages of CAD after clinical
presentation would be a
delayed action.
Hence Primary Prevcention
is the vital strategy.
Some authorities differen
tiate betwen primordial pre
vention and primary preven
tion and others treat them as
the same. Primordial preven
tion involves preventing the
emergence and spread of CAD
risk factors and lifestyles that
have not yet appeared or be
come endemic. The term has
been basically introduced to
cover the concept of lifestyle
modifications.
In
1981 the expert
Committee of WHO on
prevention of CAD identified
a number of lifestyle and
environmental factors as the
underlying causes of CAD and
described a comprehensive
strategy for the prevention of
this disease.
1.
Population strategy :
Prevention in the whole
population
Primordial prevention in
the
whole population
2.
High risk strategy
3.
Secondary prevention
Population strategy :
The WHO recommends a
population of community
approach for altering the
lifestyle and environmental
characteristics and their social
and economic determinats that
BkMxxBTW
Hind
collectively cause coronary
disease.
Various heart
societies/associations make
the
following
recommendations as corner
stones of good health in a
community.
1. Elimination of smoking.
2. Control of Hypertension by
diet / medication
3.Reduction
of
serum
cholesterol content
4. Maintenance of ideal body
weight
5. Regular moderate physical
exercise
6.Control of diabetes mellitus
The strategy aims at a
community adoption of
healthy
lifestyle
and
progressive reduction of the
prevalence of coronary risk
factors.
Risk factors for CAD
Non-modifiable Modifiable
Age : Cigratte smoking
Sex: High blood pressure
Family histgory : Elevated
serum cholesterol
Genetic factors : Diabetes
Personality: Type A
behaviour : Obesity
Sadentary habits Stress Oral
contraceptive drugs
High risk strategy :
Interventions in high risk
individuals :
WHO recommends the
identification and assessment
of an individual’s coronary
risk from the data vcailable at
a routine medical checkup
including age, sex, weight,
April - May 1996
family history of CAD, oral
contraceptive use, smoking,
hyperglycemia,
habitual
physical inactivity and
electrocardiographic
abnormalities.
These
individuals need intensive and
individualised preventive
programme. The coronary
risk
handbook
based
onFramingham study data aids
in
multi-variate
risk
assessment predicting a rough
estimate of the probability of
cardiovascular
events.
Estimation of lipid profile and
exercise test in individuals at
high risk can further help in
the risk stratification.
that raised serum cholesterol
predominantly Low Density
Lipprotein (LDL) cholesterol,
a strong independent and
consistent causal factor for
atherosclerosis and ischaemic
heart disease.
Secondary prevention :
Among high risk groups
with low HDL levels the largest
consists of men with high
triglyceride concentration like
triglyceride more than 150
mg% and HDL less than 40
mg%.
Secondary prevention must
be seen as a continuation of
primary prevention. It forms
an important part of an overall
strategy.
The aim of secondary
prevention is to prevent a
recurence and progression of
CAD. This is like a type of
“high risk strategy”.
Each strategy-population/
high risk/secondary prevention/has its advantages and
disadvantages but population
strategy has the greatest po
tential.
Risk factor modifica
tion; Risk factor interven
tion trials - Hyperlipedemi :
Framingham heart study
data established that a one per
cent increase in total
cholesterol produced 2 per
cent increase in CAD
incidence. Apart from this
there is considerable evidence
from diverse sources experimental, pathological,
epidemiological and genetic
The protective role of High
Density Lipoprotein (HDL)
cholesterol (especially HDL 2)
levels is well documented.
The protective role of High
“Density Lipoprotein (HDL)
cholesterol (especially HDL 2)
levels is well documented and
high
HDL/LDL
ratio
correlates with low prevalence
of CAD.
Combining HDL with other
cholesterol fractions greatly
enhances the prediction of
CAD.
At low cholesterol concen
tration a very high risk group
also has a very low <40mg%
of HDL.
Similarly at high cholesterol
levels one can see a low risk
group who has very high HDL
concentration.
Diet:
Serum
lipids
are
determined by a host of
factors - diet, genetic,
metabolic abnormalities,
systemic diseases
with
abnormal lipid metabolisms
and others. But diet has
emerged as a powerful
modifiable determinant of
serum lipids. The relationship
55
of dietary
content
of
cholesterol and saturated
versus poly or monosaturated
fatty acids with changes in
serum cholesterol is so
consistent that qualitative
equation have been developed
to predict the changes in the
serum cholesterol due to
changes in dietary cholesterol.
A diet with high levels of
cholesterol ( >300 mg/day)
and high proportion of
saturated with low proportion
of poly/mono unsaturated
fatty acids results in high
serum cholesterol and high
prevalence of CAD.
There are three important
studies to assess the role of
dietary interventions to reduce
cholesterol level in the blood
and the prevalence of CAD.
1. Los Angeles Veterans Ad
ministration Study: Random
ized double blind study.
2. Finnish study - cross over
trial.
3. Oslo primary prevention
trial.
Even MRFIT data subset
analysis
normotensive
hypercholesteremic male
smokers showed special
interventions caused reduction
in CAD mortality.
A healthy diet should
contain 300 mg cholesterol,
10% or less of calories by
saturated fats and 10-12% of
calories by poly unsaturated
fats. A potential though
infrequent hazard of long term
use of poly unsaturated fats if
the
occurrence
of
cholelithiasis.
Drug therapy :
Several drugs can lower
serum cholesterol. A strong
5G
body of data now suggests that
some drugs reduce the
occurrence of CAD in
hyperlipedimic subjects.
1. Clofibrate therapy
Advent of newer and more
powerful cholesterol lowering
drugs like lovastatin may alter
the situation even more
favourably.
2. Cholestyramine
Smoking:
3. Gemfibrozil
4.Lovastatin
Newer agents:
1. Calcium channel blockers
2. Anti-oxidants.
Clofibrate trial by WHO
showed reduction of incidence
of non-fatal Myocardial
Infaction (MI), no decrease in
coronary mortality and
increase in overall mortality
over 5 years.
The increase in overall
mortality was attributed to
pancreatitis
and
other
abnormalities caused by
clofibrate.
Lipid research clinics
coronary primary prevention
trial (LRC-CPPT): This trial
compares the effect of
cholestyramine with diet with
placebo and diet therapy which
has shown reduction in
coronary mortality and nonfatal Mis and signficant
reduction in all other
cardiovascular end points.
Helsinki Heart Study: This
compared the effect of 600 mg
of gemfibrozil twice a day
versus
placebo
in
asymptomatic middle aged
men with hyperlipedimis for 5
years. Exercise, cessation of
smoking and low cholesterol
diet were advised to all.
Gemfibrozil caused a
decrease
in
LDL
and
triglycerides and increase in
HDL cholesterol and 34%
decrease in the incidence of
CAD.
Epidemiological studies
have firmly established that
cigarette
smoking
independently predisposes to
MI and sudden cardiac death
in populations with mean
plazmo cholesterol level in
excess of 180 mg%.
A large body of data sug
gests that the causal relation
ship between smoking and
CAD is strong, gradual, con
sistent, temporally connected
prospectively demonstgrable,
independent of other risk fac
tors, and additive to the other
risk factors.
Smoking adds to coronary
mortality by a number of
ways. It is suggested that the
increased risk of CAD due to
smoking is largely reversible
on cessation of smoking over
a varying period of 2 to 10
years.
After smoking is.discontinued the coronary risk de
creases within an year. Heavy
smokers have even more dra
matic reduction in risk than
light smokers.
The number of years a
person has been smoking is
the best measure of coronary
disease risk irrespective of the
number of years since giving
up of smoking.
British Regional Heart
Study shows that the benefit
of smoking cessation is more
gradually acquired and less
complete.
This evidence would
support the emphasis on
Snabtw Hind
primordial prevention i.e.,
prevention of the smoking
behaviour itself.
Cessation of smoking
lowers plazma fibrinogen
levels and increases HDL/LDL
ratio.
Overall evidence that
cessation of smoking reduces
morbidity and mortality due to
cardivascular diseases is
overwhelming.
At the
community level all effforts
should be made for public
health education to lessen
smoking in adults and reduce
adoption of smoking by
tenagers and women.
Hypertension :
There is a proportionate
increase in the prevalence in
cardiovascular diseases with
rising levels of blood pressure.
The lack of change in blood
pressure with age in some
rural and nomadic tribes
shows that the so called
“normal” increase in blood
pressure with age in urbanized
people
is
biologically
abnormal and associated
increased risk is potentially
preventable. This is the
conceptual
basis
for
primordial prevention in this
setting.
And also it has been
estimated in population studies
that even a small reduction in
the average blood pressure by
a mere 2 or 3 mm Hg would
produce a large reduction in
cardiovascular complications.
In a paper published in
American Journal of Medicine
1991 February, the effects of
anti-hypertensive drugs on
mortality from stroke/CADF
and non-vascular causes have
April - May 1996
been studied in 14 trials in
more than 37,000 patients.
In the treated patients blood
pressure was 5-6 mm Hg
lower than that placebo
treated patients.
The
mortality from stroke was
reduced by 42% but CAD
mortality reduced by only
14%.
A major reason for this
lack of effect on CAD
mortality is apparently the
adverse effect of the primary
drugs used in these trials
(diuretics and beta blockers)
on glucose intolerance lipid
levels and insulin resistance.
The
ACE
inhibitors
favourably influence many
CAD risk factors and their use
can be expected to reduce
CAD mortaility in patients
treated for hypertension.
The benefits of ACE
inhibitors include not only
reduction in blood pressure
but also improved insulin
responsiveness, prevention of
potential loss and diminished
myocardial oxygen demand.
Overall data strongly
supports early detection and
control of hypertension in the
community. An initial trial of
non-pharmacological
methods should always be
made.
Concomitant
reduction of other risk factors
like smoking, cholesterol and
obesity is vital.
At the population level
adoption of a healthy lifestyle
to prevent the development
of
hypertension
in
normotensives and a shift of
overall hypertensive profiles
of the community may be the
most rewarding strategy in
terms of the magnitude of
benefit in primary prevention
of CAD.
Diabetes mellitus and
impaired glucose tolerance:
Diabetes mellitus occurs in
2-6% of population and
impaired glucose tolerance is
up to 20% depending on the
criteria used. Risk of CAD is
signficantly increased in
diabetics than non-diabetics.
The increase is particularly
striking in women.
The
relative risk due to diabetes at
any level of smoking,
hypercholesteremia
or
hypertension is three to four
fold. The mortality from
myocardial infarction is higher
among diabetics.
Glucose intolerance doubles
the occurrence of Ithe CAD in
men and triples or quadruples
in women, particularly women
below 50 years of age.
Atherosclerosis occurs
early in diabetics and is
diffused and extensive in both
the sexes.
Obesity worsens both
occurrence of diabetes as well
as its complications.
Diabetes may produce
atherosclerosis and CAD by a
number
of
ways
Dislipedemia, hypertension,
obesity, altered platelet
functions, microvascular
disease, etc.
Control of hyperglycemia
alone does not eliminate
coronary risk though it does
decrease the risk of CAD.
Control of diabetes and
impaired glucose tolerance by
diet and weight reduction and
if required insulin and possibly
newer oral hypoglycemic
agents with antiplatelet activity
like gliclazide may be useful.
57
Obesity :Obesity is a weak
independent risk factor
especially in women and the
elderly but its effect through
other risk factors is far more
powerful.
The predominant rationale
of control of obesity is to
control
hypertension,
impaired glucose tolerance,
diabetes, hyperinsulinemia,
hyperlipedemia with elevated
LDL and low HDL levels and
hyperurecomia.
Central obesity appears to
be an independent risk factor.
Weight reduction by diet
low in saturated fats,
cholesterol and in total
calories is recommended
though no confirmatory
evidence from intervention
studies is available. Because
weight reduction has many
systemic
benefits
and
moderate diet therapy has no
apparent adverse effects it
should be tried.
Physical activity: A per
suasive body of data from vari
ous epidemidiogical studies
show an inverse relationship
betwseen physical actiity and
prevalence of CAD and a
causal relationship is often in
ferred.
As per the paper published
in Clinical Sports Medicine
1991 January entitled,The
role of exercise in the primary
and secondary prevention of
CAD, ' there is now
substantial evidence linking
exercise training to a reduced
risk for CAD and for mortality
after myocardial infarctions.
The actual mechanism by
which physical activity aids in
reducing
the
risk for
developing CAD or death
from CAD has still to be
elucidated. Several possible
58
mechanisms have been
postulated including decreased
myocardial oxygen demand,
increased myocardial oxygen
supply, reduced propensity
towards
ventricular
arrhythmias reduced platelet
aggregation,
increased
fibrinolytic activity and
modification of multiple CAD
risk factors. Irrespective of
the precise mechanism it now
appears that lower levels of
physical activity are needed to
reduce the risk for CAD than
are needed to optimise
cardiorespiratory fitness. In
this regard it is recommennded
that the type, frequency,
intensity and duration of
exercise training be modulated
to achieve a weekly energy
expenditure of between 14
and 20 kcal/kg of body
weight. Although aerobic
activities
should
be
emphasized,
muscle
strengthening and flexibility
exercises should also be
incorporated into the training
programmes in order to
promote muscular and skeletal
health
Personality and behavioural
factors : Certain personality
and behavioural patterns
described as type A or
coronary prone behaviour are
associated with the occurrence
of severity and progression of
CAD.
The western collaborative
study group characterized this
group by excessive time
urgency,
hostility,
aggressiveness, ambition,
competitiveness, impatience,
feeling of excessive external
pressure and frustration and
found that type A behaviour
was associated with double the
risk of CAD independent of
other risk factors.
Though an association
between personality trait and
prevalence of CAD has been
noted by others also, the
causal link has not been
established and it is premature
to recommend aggressive
changes in personality/
behaviour
and
stress.
Hoewever, proven relaxation
techniques like yoga and
biofeedback and recreational
activitiees involving modest
exercises may have other
benefits in addition to reducing
stress and are desirable.
Other risk factors:
Oral contraceptive drugs:
Oral contraceptive drugs
increase body weight, blood
pressure
(BP),
serum
triglycyceride levels impair
gulucose tolerance and reduce
serum HDL. levels In addition
they
increase
blood
coagulability,
platelet
adhesiveness,
reduce
fibrinolytic activity and may
adversely effect vascular
^endothelium. Women using
these drugs have an increased
mortality from MI, stroke and
other thromboembolic events.
The drugs are relatively safe
in young (<35 years) non
smoking women who do not
have hypertension or other
risk factors. An increase in the
prevalence of CAD is de
scribed after natural or surgi
cal menopause. Estrogen re
placement does not help.
Oral contraception should
be discouraged in diabetics,
smokers, hypertensives and
older women (>35 years).
Primary prevention unrelated
to conventional risk factors:
1. Aspirin: Aspirin as an anti
platelet agent has been found
Snasth Hind
to be useful in the secondary
prevention of various subsets
of vascular diseases like acute
MI, unstable angina, chronic
ischaemic heart disease, after
coronary surgery, etc.
Two primary prevention
trials have evaluated the role
of laspirin in middle aged
physicians in the prevention
of CAD.
In physicians health study
in USA, 325 mg of aspirin A/
D in healthy male physicians
(without contra indications to
aspirin) caused 50% reduction
in the incidence of MI with a
slow incidence of adverse GI
events.
In British physicians trial
using aspirin 500 mg daily vs
placebo significant benefit was
not demonstrated, probably
due to smaller sample size and
lower drug compliance.
Overall effect was consid
ered beneficial but more data
are required before aspirin
therapy is recommended to
the whole middle aged popu
lation. There is no data on
benefit to women.
Fish oils: Epidemiological
studies show an inverse
relation between age adjusted
mortality from CAD and
ingestion of these oils
especially those rich in
omega3 poly unsaturated fatty
acids.,
Cardio-vascular diseases in
the elderly:
A symposium was held in
February 1988 in California
on CVD in the elderly which
addressed the following
questions.
1. Are data derived from
younger subjects appli
cable to elderly.
April - May 1996
2. Is control of risk factors
such
as
hyperlipoproteinemia,
hypertension and diabetes
important in preventing
cardiovascular diseases in
the elderly.
3. How do these recommen
dations of national choles
terol
education
programme panel on de
tection, evaluation and
treatment of high blood
cholesterol in adults apply
to the elderly.
4. Is
reversal
of
atherosclerosis feasible in
the elderly or is the
process irreversible.
5. What directions should
future research take in this
area.
The value of preventive
treatment for CAD in the
elderly still needs to be
determined. Few studies have
discussed this issue. But extra
polation of data on younger
patient suggests that even
modest benefits may, translate
into real gains in the elderly
who form a group at high risk
for CAD mortality.
In
future
preventive
treatment for CAD may
revolve around elevation of
HDL level posibly through
treatment with gemfibrozil or
other HDL increasing agents.
Resolved and unresolved
issues in the prevention of
CAD:
Advances in cardiovascular
research during the past two
decades have resulted in an
improved understanding of the
chain of events that lead to
end-stage CAD.
These
developments have been
paralleled by the rapeutic
advances and now make it
possible to interven virtually at
every
stage
in
the
development of advanced
cardiac
disease
from
asymptomatic persons at risk
of developing coronary
atherosclerosis to patients
with endstage heart failure. By
interupting this chain of
events, perhaps at multiple
sites it may be possible to
prevent
or
slow
the
development of symptomatic
heart disease and hopefully
prolong life.
The epidemiologic evidence
linking HDL level with CAD is
persuaive. But between
population comparisons of
HDL and CAD do not match
within population relations.
Animal research on the
relation between HDL,
atherogenesis and CAD has
been relatively scanty.
Problems with measurement
of HDL have inhibited
widespread recommendation
for its use in preventive
programmes.
Hence a
consensus regarding the
prevention of CAD by
increasing HDL level could not
be achieved.
Inter-nation variation and
inter-country differences:
International information on
risk factor trends for any age
group is limited.
On a purely cross sectional
basis,
average
serum
cholesterol levels were related
to ischaemic heart disease
mortality across 19 countries
in men aged between 40-69
years in 1980.
About 45% of the wide
international variations in the
mortality was explained by
inter-country differences in
cholesterol levels.
59
lipoprotein profiles of ciga
rette somokers from ran
domly selected families:
Enhancement
of
hyperlipidemia and depres
sion of high density
llpoprottein. Am.J. Cardiol
52:675, 1983.
HDL : cholesterol was
found to have the usual
protective relation.
Approximately 32% inter
national variations in IHD
mortality was explained by
variation in HDL cholesterol
concentration.
6.
The British Cardiac Society
Working Group on Coronary
Prevention: Conclusions
and recommendations. Br.
Heart J. 57:188, 1987.
7.
Clin - Cardiol 1991 Aug: 14(B
Supply):
1468:-71
Caradioprotective Potential
of angiotensin - Converting
enzyme inhibitors
However, the differences
could not be explained
completely.
Apart
from
these,
methodological limitations and
difficulties to correlate
observational data and
experimental data do exist.
We have to answer
ourselves if we can make
generalised a statement and
recommendations based on
International studies or should
we repeat the whole process
again to evolve conclusions to
be suitable to the Indian
context ?
References:
1.
2.
American Journal of Cardiol
ogy : 1990 Sep4, 66(6): 3A6A
High Density Lipoprotein
Cholesterol and Coronary
artery disease: survey of
evidence
3.
4.
5.
60
Brischetto C.S., Connor W.E.,
Conner L : Plasma lipid and
Hjermann I., Holme I., Velve
Byre K., et. al. : Effect of
diet
and
smoking
intervention
on
the
incidence of coronary heart
disease. Report from the
Oslo Study Group of a
randomised in healthy men.
Lancet 2:1303, 1981.
9.
Cook D.G., Shaper A.G.,
Poecock S.J., Kussick S.J.:
Giving up smoking and the
risk of heart attack. A
report from the British
Regional Heart Study.
Lancet 1986: 11:1376-80
17.
The health consequences of
smoking for women: A
report of the Surgeon
General. S Dept, of Health
and Human Services, Public
Health Service Office on
Smoking and Health, 1980.
10.
Community Prevention and
control of cardiovascular
diseases: WHO technical
report series 732, 1986.
18.
11.
Coronary Risk Handbook :
Estimating Risk of Coronary
Heart Disease in Daily
Practice. American Heart
Association, Dallas, 1986.
Inter Society Commission
for
Heart
Disease
Resources:
Optimal
resources for primary
prevention
of
atherosclerotic diseases.
Circulation 70: 153A. 1984.
19.
Kannel W.B., D’Agostino
R.B.,, Beranger A.J.
Fibrlogen cigarette smoking
and risk of cardiovascular
diseasae: Insights from the
Framingham Study. Am.
Heart J.113:1006,1987.
20.
Kaplan N.M., Diabetes and
glucose intolerance : In
prevention of coronary
heart disease. Kaplan N.M.,
Stamler J.
(eds) W.B.
Saundeers Company London
1983, p.113.
21.
Lipid Research Clinics
Program:
The
lipid
Research Clinics Coronary
Primary Prevention Trial
Results. Reduction In
incidence of coronary heart
disease II. The relationship
of reduction In incidence of
coronary heart disease to
12.
13.
Am-Heart-J 1991 Apr. 121(4)
(Pt.l): 1244-63
Resolved and unresolved
issues in Prevention and
Treatment of Coronary
artery disease; a workshop
consensus staement
16.
Clin - Sports - Med 1991 Jan:
10(1) : 87-103The role of
exercise in the Primary and
Secondary Prevention of
Coronary artery disease.
American Journal of
Cardiology : May 2, 1989
Vol. 63 No. 16
A symposium : Cardio-Vascular
Disease in the elderly
15. Harker L.A.: Clinical trials
evaluating
platelet
modifying drugs in patients
with
atherosclerotic
cardiovascular disease and
thrombossis. Circulation
73:206, 1986.
8.
Am-J-Med 1991 Feb 21,
90(2A): 195-305
Cardiovascular risk reduction:
The
role
of
antihypertensive treatment.
American
adults.
A
Stgatement for physicians
by an Ad hoc comlttee
appointed by the Steering
Commltee. American Heart
Association.
Circulation
75:1339A.1987.
14.
Dayton S., Pearce M.L.,
Hashimoto S., et. al. : A
controlled clinical trial of
diet high in unsaturated fat
in preventing complications
of
atherosclerosis.
Circularation 40 (suppl.II): 1,
1969.
Gotto A.M.,Witties E.H..,
Diet, serum' choiessterol,
Lipoproteins and coronary
heart disease in Prevention
of Coronary Heart Disease
Kaplan N.M., Stamler J. (eds.)
W.B. Saunders Company
1983, London, p.33
Grundy S.M., Greenland P.,
Herd
A.,
et.al.
Cardiovascular and risk
factor evaluation of healthy
Bpmzxstj-i Hind
cholesterol lowering. JAMA
251:351, 365, 1984.
Manninen V., Elo.O., Frick
M.H.,
et.al.:
Llplda Itgerations
and
decline in the incidence of
coronary heart disease In
the Helsinki Heart Study,
JAMA 260:641, 1988.
22.
Multiple
Risk
Factor
Intervention Trial Research
Group: Multiple Risk Factor
Intervention Trial: Risk
factor
changes
and
mortality Results JAMA
248:1465, 1982.
23.
24.
Paffenbarger R.S. Jr. Hyde
R.,T., Wing A.L. et. al.:
Physical activity, all cause
mortality and longevity of
college alumni. N. Engl. J.
Med. 314:605. 1986.
25.
Pallowen V., Pechacek :
Smoking and ischemic heart
disease
Facts
and
Controversies. Ann. Clin.
Res.20:121, 1988.
26.
Primary Prevention of
coronary Heart Disease.
Euro Reports and Studies 98,
1985.
27.
Prevention of coronary
heart
disease.
WHO
technical report series 678,
1982.
28.
Peto R., Grey R.» Collins R.,
et. al.: Randomised trial of
prophylactic dally aspirin In
British male doctors. Br.
Med. J. 296, 1988.
29. Rose G., Hamilton P.J.S.,
Colwell L., et. al.: A
randomised controlled trial
of anti-smoking advice: 10
years results. J. Epidemiol
Comm. Health 36:102; 1982.
30.
31.
32.
Report of the Committee of
Principal Investigators:
WHO cooperative Trial on
Primary
Prevention
of
Ishaemic Heart Disease with
clofibrate to lower serum
cholesterol: Mortality follow
up. Lancet 2:379. 1980.
Riopal D.Aa., Boerth R.C.,
Coates T.J., et.al.: Coronary
risk factor modification in
children:
Smoking:
A
statement for physicians by
the
Committee
on
Atherosclerosis
and
Hypertension in Childhood
of
the
Council
on
Cardiovasacular Disease in
the Young. American Heart
Association.
Circulation
74:1192A, 1986.
Rosenman R.H., Brand R.J.,
Jenkins C.D. et. al.
Coronary heart disease In
the Western Collaborative
Group Study. Final follow up
experience of 8 and half
years. JAMA 233:872. 1975.
33.
Ruderman N.B., Haudenschild
C.:
Diabetes
as
an
atherogenic factor Prog.
Cardiovasc
Dis.26:373,
1984.
34.
The Steering Committee of
the Physicians ‘Health Study
Research Group Preliminary
report : Findings from the
aspirin component of the
ongoing [Physicians’ Health
Study.
N.Engl.
Med.
318:L262., 1988.
35.
Schweiz-Med-Wochenschr.
1991 Dec. 28: 121 (51-52):
1922-31. Drug Therapy
Prevention of Coronary
schrosis.
36. Shaper A.G., Ischemic Heart
Dissease: Risk factors and
Prevention: In Diseases of
Heart, Jullian D.G., Camm
J.,
A.
Fox K.M., Hall R.J.C.,
Poolewilson.
P.A.(eds.)
aillieere Tindal London
1989,P.1001.37.
Study
Group,
European
Atheroscleroesis Societey.
Strategies for the prevention
of coronary heart disease: A
Policy Statement. Eur. Heart
J.8:77, 1987.
ACHIEVING SPORT AND ARTS WITHOUT TOBACCO IN INDIA
Tobacco company sponsorship of sport and
arts is wide spread in many countries. India,
the world’s second most populous country,
is far from immune to this phenomenon.
Sports sponsored by tobacco companies in
India cover an astonishing range including
field hockey, football, cricket, billiards, golf,
wrestling, archery and even kite flying.
It has been suggested that a special tax on
tobacco products (cigarettes, bidis and
others) could be used to finance tobacco
control activities, and replace tobacco
company sponsorship with health
promotion sponsorship. Such an approach
ZXpril - May 1996
would build on the succesful model of health
promotion sponsorship pioneered by the state
of Victoria in Australia and funded by new
revenue raised from special tobacco surtaxes.
The application of this model in India would
require adoption. A wide variety smoking and
smokeless tobacco products are consumed in
India. Except for manufactured cigarettes, which
represent only a small fraction of the total
tobacco market, taxes on tobacco products in
India could be difficult to impose and collect.
Therefore, tobacco sponsorship replacement
in India should be considered in conjunction
with strategies to improve tobacco imposition
and collection.
61
The World's first Smoke-free World
of the stands, the track and field area, the
Championship
Athletics,
changing-rooms, the press centre or in the
Gothenburg 1 995, was launched by
public premises in the stadium. Tobacco
Sweden's Institute of Public Health and the
sales were banned inside the arena as well
Swedish
in
Medical
Association.
It
immediately received the
backing of the Swedish
Athletics Federation,
whereupon
the
International Athletics
Federation declared the
1995 Athletics World
SMOKE-FREE OLYMPIC GAMES as
any
advertising
marketing of tobacoo.
1 988 Calgary
1 988 Seoul
1 992 Barcelona
1 992 Albertville
1 994 Lillehammer
1996 Atlanta
pharmacies
with
and
Nearby
expanded
hours of operation had available
a supply of nicotine substitudes,
such as chewing gum and
patches. An information tent,
manned almost round the clock
provided information on a
Championships a smoke-free event.
number of non-smoking themes. A survey
Separate specially designated areas were
carried out consequent to the Games found
available for those who wished to smoke.
that the majority of smokers supported the
However, smoking was not allowed in any
smoke-free event.
TOBACCO CONTROL AND CHILDREN
Tobacco control efforts are often underminded by the promotion of cigarettes on the most
powerful medium to which children are exposed ; television broadcasts of tobacco sponosred
sports. In some countries coveragbe of such events are regulated by a voluntary agreement
between the tobacco industry and national authorities. One aim of the agreement is to protect
children from the exposure to tobacco promotion by confining television coverage to events
wirch on adult audience.
Yet, studies have shown many children aged between 9 and 15 claim to see cigarette advertising
on TV . What they are seeing are sporting events sponsored by tobacco companies: tennis,
rugby, motor racing, cricket, snooker, sailing competition,etc.
In surveys of children’s attitude to smoking, the sponsorship of sports and other events by
cigarette companies is cited as evidence that the government is not seriously concerned about
the problem of smoking. "If they really want to make us realise smoking is dangerous, why
do they allow all this sponsorship", is a typical comment.
Children sec things straight. We should be straight with them.
Sir Donald Maitland, Chairman
Health Education Authority, UK.
62
□nabtw Hind
BACKGROUNDER
WORLD HEALTH DAY-7 APRIL 1996
THEME : HEALTHY CITIES FOR BETTER LIFE
Dr. (Mrs.) K. Kehar
Dr. Anil Kumar
M.S. Dhillon
gvery Year on 7 April, the
World Health Organization
celebrates World Health Day
to commemorate the coming
into force of the Constitution
of the Organization on April
7,1948. This year, the theme
for World Health Day is
“Healthy Cities for Better Life”
WHO has chosen this
theme because of the dramatic
growth of cities since the
beginning of this century.
Back in 1900, one person in
ten lived in a city. By 1948 the
proportion was three in ten.
And by the year 2000 over half
the world’s population will be
urbanites. A second reason
for this theme is the impact
urban growth is having on the
health of city dwellers. In
developing countries, for
example, more than 600
million urban dwellers are
living in conditions that
threaten their health, even
their lives.
Within 15 years, 20-30
cities will have over 20 million
people slightly more than the
population of Australia today.
As cities grow, so does their
adverse impact on health.
Cholera, mednutrition, mental
illness, accidents and chronic
respiratory infections thrive in
an unhealthy urban setting.
Keeping the alarming
world situation in view the
WHO launched a Healthy
Cities Programme. The basic
April - May 1QQ6
aim behind the programme is to
bring together the local
governments and community
associations to improve urban
health and solve various related
problems. The programme is
found to be extremely successful.
The theme has been chosen to
draw attention of the world
community towards the problem
and discuss and find out solutions
to implement at various levels.
WORLD SCENARIO
Urbanisation has been
rightly described as one of the
most charateristic features of the
20th century. The unimaginable
fast pace of unplanned and
uncontrolled urbanisation has
already become a matter of
global concern. A direct
consequence of population
explosion, it is already being
referred to as “Urban Crisis” and
“Urban Explosion”. Like
“Population Explosion”, the
“Urban Explosion” is therefore
a self-inflicted malady which the
mankind has brought upon itself.
Consequently,
numerous
problems are becoming more
and more difficult to tackle with
the existing resources. An
unpredictable influx of migrant
population from rural to urban
areas in search of means of
livelihood is also responsible for
the crisis. The urban authorities
and local bodies are finding it
extremely difficult to solve this
problem due to several
constraints. As a result slums
and shanty towns have been
cropping up
at
an
unbelievable unprecedented
rate. Besides this, the migrant
population have also been
using roadside pavements and
footpaths for their temporary
shelter. The fast pace of
urbanisation in its wake has
given rise to problems of
housing, transport, health and
medical care, water supply
and sanitation, education and
other public services,
environmental pollution and
also paycho-social problems
leading to deteriorating law
and order situations.
DEVELOPING COUNTRIES
Cities in the developing
world are the worst affected.
According to WHO it has
already become a major
challenge for “Health for All”
by 2000 AD since according
to current projections, by the
turn of the century there will
be 60 mega cities in the world
of over 5 million population
each, of which no fewer than
45 will be in the developing
world, compared with just one
in
1950. Population
projections (based on
population size in 1985) for
the year 2000 in respect of
world’s 49 largest cities
indicate that 24 of them will
cross 10 million mark. This
includes 3 Indian cities also,
63
namely Calcutta (15.94 million),
Greater Bombay (15.43 million)
and Delhi (12.77 million). At the
beginning of the 19th century,
only 3 per cent of the world
population lived in towns. By
the beginning of the next century,
more than half will be living in
cities . More than 1000 million
men , women and children are
living in shanty’towns where
living conditions and hygiene are
appalling. Urban poverty is
consistently on the increase and
likely to outstrip rural poverty in
the 10 years time. The mean
salary has already gone down by
at least 25 per cent in many
developing countries. Although
the demand for health care has
never been so high in the past
and is' consistently on the
increase, it is not commensurate
with the funds available. More
than 50 per cent population of
the Third World cities is living in
conditions of obvious poverty.
Millions of children among these
population who are growing up
today under such horrible
conditions, are not going to
realize their full mental and
physical potential. Among these
children, diarrhoeal diseases
account for 25 per cent deaths
in the least developed countries.
Respiratory infections and
malnutritions, the 2 major causes
of morbidity and mortality in
young children have become
part and parcel of life in urban
fringe areas. With increasing
urban poverty, the situation is not
likely to improve - on the
contrary may worsen.
The population of people in
the older age group is also
registering an increase. There
are 300 million people aged 65
and above in the world today. In
thee next 10 years time, their
64
number if likely to surpass 400
million mark. It has been
projected that by 2025 AD, 70
per cent of these will be living in
the developing countries, a
majority of them in the urban
areas, where they will be facing
deplorable living conditions,
struggling for survival, looking for
employment in the absence of
any guarantee of their social
security and family support.
In 1990 at least 600 million
people living in cities in
developing countries were being
threatened by lack of food,clean
water and shelter and situation
is not improving since then..
DISHEARTENING URBAN
SCENARIO -INDIA
As regards India, slum areas
and shanty towns are cropping
up at unprecedented rate with no
prospects of control or proper
planning in future. Half of the
population of Bombay continues
to live in slums. During 1985,
nearly 78 per cent of the families
were found to be living in single
room tenements and sharing a
lavatory. Bombay still has the
dubious distinction of housing
more than 40,000 people in
Asia’s largest slum - Dharavi.
However, the problem is not
peculiar to Bombay alone. It has
already afflicted all major/mega
cities and even towns of our
country. Madras was supposed
to be having 21.08 lakh slum
dwellers . Ahmedabad 11.33
lakh , Hyderabad 11.12 lakh,
Bangalore 10.37 lakh, Kanpur
8 lakh, Pune 5.15 lakh and even
a relatively small city of
Bhubaneswar about 30000 slum
dwellers during 1990 according
to one official estimate.
It is a known fact that
population in cities in India
especially in metropolitan cities
is growing rapidly so as to make
it difficult for the local municipal
authorities to cope up with the
problems of public health.
Failure of sewage system,
collection of water in diffirent
localities, noise, water and air
pollution, overcrowding are the
problems one can easily observe.
But rest of the problems are
much more beyond one’s
observation. Problem of rapid
urbanization is affecting
everyone’s life and therefore it
requires
everybody’s
involvement to solve the
problem.
Children
in
Indian
Metropolitan cities are more
prone to respiratory diseases due
to increase in air pollution as a
result of increase in the number
of vehicles. In the city of Delhi
alone more than 2.5 million
vehicles emit poisonous smoke
leading to an increase in the
prevalence of respiratory
diseases. The incidence of such
disease is 12 times more than
the national average. Pollution
also leads to nervous weakness,
and irritation of the eye, allergy,
etc.
There is urgent need to
improve the health of urban
population through concerned
participatory and multi-sectoral
approaches. There is also a
need to share the experiences at
regional and national levels of all
concerned so as to maximally
utilize indigenous technology,
channels of communication
keeping social and cultural
factors in mind.
In India, most of our
population is living in rural areas,
there is a need to improve not
only the cities but also the towns
and villages, and so the concepts
EBi/xizxsth Hind
of healthy cities has to be
suitably modified to include
healthy towns and healthy
villages. This would help reduce
the migration of our people from
rural areas to urban areas.
In order to achieve the aim of
healthy cities, it is essential to
ensure that the smaller individual
units are healthy also, for
example Schools, Market places,
industrial units, etc.
TEN SIGNS OF
A HEALTHY CITY
A Healthy City
1.
2.
is clean and safe
provides safe and durable sup
plies of food,water and
energy, and efficient waste
disposal
3.
through a diversified, robust,
innovative economy, meets
the basic needs of all citizens
for. food, water, shelter,
income, safety and work.
4.
has a strong mutually
supportive community, in
which different organizations
work in partnership to
improve health
5.
enables its citizens to work
together to shape the policies
that effect their lives generally
and their health and well
being in particular
6.
provides entertainment and
leisure activities that facilitate
interaction
and
communication among
individual groups
7.
values the past and respects
the diverse cultural heritage
and specificities of its citizens,
regardless of race or religion
8. regards health as an integral
component of public policy
making and gives its citizens
April — May 1QQ6
the right to adopt behaviour
consistent with a healthier
life
9.
is constantly making efforts
to improve the accessibility
and quality of health services
10. is one in which people live
long in good health and
suffer less from disease.
“A healthy city is one that
improves its enviornments
and expands its resources
so that people can support
each other in achieving their
highest potential ...... A
healthy city is conscious of
health as an urban issue
and is striving to improve
it. Any city can be a healthy
city if it is committed to
health ”
Healthy city is not just the
outcome of a process but is a
process itself. To make a city
healthy it is required to improve
environmental, social and
economic determinants of health
or in other words improving the
conditions at home, at school,
or at work place, etc.
PROBLEMS OF CITIES
A. Lack of food, clean water
and shelter
Cost of living in cities is
generally high and food, etc. are
beyond the reach of the people
belonging to the lower socio
economic segments of the
population. In terms lof quality
of food, it does not sometimes
fulfil the criteria set up under local
Acts. Safe potable water may not
be available to the slum
community and if available
becomes contaminated during
supply, transportation, storage
or use. As the prices of houses
are sky high in the cities a large
number of people are forced to
live in jhuggies and 'jhoparies'
not even fulfilling the basic
requirements of healthy living.
B.
Overcrowding
The fast and unregulated
urbanisation is leading to the
growth of large slums and
squatter settlements in bigger
cities. This phenomenon has
created social tensions and inter
regional imbalances and is
leading to environmental
degradation and deprivation of a
large section of population from
basic services.
Large families may be found
living in a small enclosure with
no privacy. In such an
environment, it is no wonder that
husband-wife relationship
become unstable and other
forms of vices like gambling,
drinking, stealing, drug-abuse,
etc., thrive.
C.
Inadequate Waste disposal
It is very difficult for local
municipal authority to keep pace
in providing basic amenities like
sewage systems with growing
population leading to collection
of waste water and human
excreta in low lying areas of
unplanned urban settlements
threatening human life and
health. The absence or
inadequacy of drainage is directly
linked to the resurgence of
malaria, filaria, and diarrhoeal
diseases.
□ . Hazaarduous
conditions
working
Rapid urban development is
often preceded by haphazard
industrial development leading to
hazarduous working conditions
at workplace threatening not
only the life of workers but also
65
indirectly affecting the health of
their family members. It also
leads to labour unrest, lock outs,
affecting economy and leading
to inhealthy living condition.
E. Pollution
Air and noise pollution are
parts of modern urban life.
During recent past the number
of vehicles in Indian cities has
increased rapidly. Pollution level
of noise and dangerous
ingredients in air has crossed all
the set acceptable standards.
Air pollution has assumed an
alarming increase in several cities
around the country. Mere
breathing of air in Bombay now
equals to smoking of 10
cigarettes per day. Every day in
Bombay, over 1200 metric
tonnes of pollutants are released
by vehicles which is 60 per cent
of the total load of pollutants.
Delhi done has a record number
of 25 lakh vehicles emitting
pollutants in the air, besides
industrial pollution. The annual
cost of treatment of pollution
related ailments in Bombay has
been worked out at Rs.400
crores. The growing number of
automobiles, in all urban areas
has now become a matter of
major concern.
Besides
automobiles, industrial and
domestic sources are also
responsible for increasing air
pollution in urban areas where
respiratory infections and
chronic lung irritation are
predisposing more people to
lung cancer.
These factors are also
responsible for increasing noise
pollution in urban areas.
Although WHO has fixed 45 dB
as the “safe noise level”, cities
like Bombay, Calcutta and Delhi
66
register over 90 dB. Bombay in
fact holds the dubious distinction
of being the third noisiest city in
the world. The noise levels have
also been found doubling every
6 years or so therefore by 2000
AD (target year for Health for
All), it is possible that no one
above the age of 10 will have
normal hearing capacity.
Rapid urbanization, increase in
population, deforestation and
depletion of greenery is causing
increase in level of carbondioxide
and is added to Green-house
effect and global warming. It has
been found that the dust content
of the air drops by 40 per cent
in green spaces which also
absorb and dissipate sound
energy and thus a good means
of protection against air and
noise pollution.
Increased solid and liquid
wastes and particularly the
discharge of domestic sewage
and industrial wastes has resulted
in Ithe contamination of river
and surface water as well as
ground water in most of the
cities. The. water supply and
sanitation services in slum and
squatted settlements are
practically non-existent. People
therefore are forced to use
unsafe sources of water. They
use open land and water bodies
for defaecation, thereby polluting
surface and ground water.
F. Accidents/Street violence/
Suicides
With the increase in
industrialisation and urbanisation
of the country, the vehicular
traffic has registered nearly
seventy fold increase since
independence. There is road
accident every two minutes and
a fatality every nine minutes in
India. Hi-designed, ill-maintained
and narrow roads, negligent or
drunken driving are the chief
factors for accidents. Maximum
brunt of injuries are borne by
pedestrians and two wheeler
users including cyclists.
Thousands of workers die every
year due to occupational
accidents in the industrial
establishments.
Increasing social tensions in
the metropolitan cities physical
violence is becoming more
prevalent as a way to deal with
certain problems at various
levels. The in stinctual tendency
of humans to agress under
frustration, neglect, deprivation,
disputes is more evident.
Violence has become a standard
topic in films, TV,newpapers and
magazines to which youth are
getting exposed more and more.
Stress, depression, mental
disorders are on the increase in
cities due to socio -cultural factors
and family disputes because of
maladjustments., such factors
are responsible for the increasing
incidents of suicides.
STRATEGIES TO CONVERT
EXISTING CITIES INTO
HEALTHY CITIES
A. Setting up Task Force
Any effort to make city healthy
should involve both municipal
agency to local government
administration and population
groups. The member of task
force from government should
be one who can take decision
and member from community
should be the local leader who
have a say in the community and
whose decisions are acceptable
to a large segment of the
community. Basic function of
Task Force should be as follows:
Skasth
Hind
1.
analyze
3.
Contact key individuals
based on priorities,
4.
Help in implementation of
municipal- health plans,
5.
Gain support from different
sources.
Gather *and
information,
2. Set up priorities,
B.
Formation of local
committees to implement
decisions taken by Task Force
Local committees may be
formed at the level of schools,
offices, industrial units, etc. so as
to make a healthy school,
healthy office and healthy
industrial units. Ultimately, the
objective is to make the city
healthy. Local community
workers, union leaders etc.
should invariably be involved in
forming commitees.
C. Action at Community Level
To implement a programme
at the grossroot level community
members should be consulted.
Local voluntary organisations
play a vital role in taking the
community in confidence.
Appreciation of city’s unique
cultural privilege and sense of
place in community can be a
powerful driving force to
motivate the people to improve
the living conditions.
SUGGESTED ACTION
1. Encouraging local cottage
industries, agriculture based
industries.Shifting
heavy
industries to suburban areas so
to reduce the movement of
poppulation towards cities.
2. Shifting hazardous industries
from residential areas to
outskirts of the city to reduce its
effect on human population.
APRIL — N4ZXY 1996
3. Planning the city roads,
industrial areas, offices and
residential areas in such a way
so as to reduce the traffic
movement.
4. Development of green belts
and construction of parks, tree
plantation to reduce air pollution.
5. Encouraging people to use
public transport, and pooling of
vehicles to reduce traffic.
6. Constructing buildings in such
a way so as to reduce traffic,
noise at work and in residential
colonies.
7. Encouraging the use of
biogradable material for
packaging and for other daily
use.
8. Establishing library and
recreation centres in residential
areas.
SUGGESTED
EDUCATIONAL ACTIVITIES
Media plays an important role
in the dissemination of
information and creating
awareness, if planned properly.
The general educational activities
related to different situations are
listed below. Appropriate items
may be selected by the
concerned agencies individually
or collectively to suit their
resources.
1. Special broadcasts/telecasts
on the theme could be arranged
in the form of talk, discussion,
plays, spot announcements,
slats, quiz programme, etc. on
Radio and Doordarshan.
2. Short film sequences on
different aspects of the theme
can be incorporated to illustrate
news programmes, talks,
discussions,etc.
on
9. Starting movement to
Doordarshan.
develop
good
human
3. Feature articles written in
relationships among the
simple and non-technical
members
of
different
language and messages from
communities.
public leaders can be issued to
10. Action plan by the
newspapers and magazines to
government to reduce and
suit different target groups. This
improve living conditions in
may be followed by issuing of
slums.
periodic handouts to the Press.
11. Educating community
Special supplements in local
regarding healthy habits and
language of regional newspapers
may also be brought out. Liaison
healthy lifestyles utilising all the
with the Press should be
existing channels.
12. Encouraging people to form maintained throughout the year.
4. Educational and publicity
groups to supervise public health
material such as posters, leaflets,
works and to help reduce source
pamphlets, folders,etc. written in
of infection and its transmission.
simple non-technical language
13. Encouraging government can be distributed at the PHCs,
agencies to implement health
MCH centres,public places and
related legislation strictly.
other educational industrial and
14. Organising seminars,
professional institutions.
conferences,etc. in different
SHEBs/Voluntary organisations
cities/towns to share their
can produce such materials. Held
Publicity Units, Public Relation
experiences.
Departments, Health Centres
Contd on page 71
67
ROLE OF EDUCATION WITH REGARD TO
ENVIRONMENTAL HYGIENE AND
PROMOTIONAL ACTIVITIES
Dr. C.P.Mishra
After describing population dynamics and its implications and existing scenario of
environmental hygiene, in this article, the author emphasises on strategic changes for
the improvement of environmental hygiene. Referfence has been made about innovative
approaches that may be of immense help in planning and execution of health education
programmes. It is their effective implementation that will decide the future of our
efforts to safeguard environment and promote human health.
The world population is going
through its third, and greatest,
substained surge and is projected
by UN demographers to reach
9 billion by 2030 and 11-12
billion later in the next century.
Approximately 90% of this
growth will occur in the poor
third world, where pressures on
dwindling supplies of arable and
pasture lands are extending
erosion, desertification and other
forms of land degradation. The
unprecedented combination of a
huge and rapidly expanding
population, resource intensive
industrial practices and land
exhausting agriculture is causing
the systemic overloading of the
‘carrying capacity’ of Earth’s
natural systems.
Considering the facts that
world is witnessing a phenom
enal growth of urban popula
tions (i.e. more than half of the
population in cities) particularly
in developing countries and rapid
and unplanned urbanization is re
sponsible for severed risks of city
life, concern for better urban life
will be of very high priority on
68
the social agenda of the 21st
Century. City dwellers of devel
oping countries are threatened
by lack of food,clean water and
shelter. The other serious prob
lems are related to availability of
safe housing, solid waste disposal
and health care services. Prob
lem of social outcasts, drug ad
dicts and street gangs have
broadened the scope of environ
mental hygiene or sanitation by
adding social environment to it
and giving a concept of
environmental health.
The urban population of India
is increasing at a faster rate than
rural
population.
The
proportion of urban to total
population has increased from
11% in 1901 to 26% in 1991. It
is estimated to be around 30%
by 2001 and 40% in the next
two decades. Due to migration,
which accounts for 40% of the
urban population growth, and
fast urbanization, in metropolitan
and large cities about 40-50% of
the urban dwellers are estimated
to be living in slum areas where
the health status of the people
is as bad as, if not worse than,
in rural areas. Although we have
recommendations for creating
infrastructure for health care in
rural areas in the form of Bhore
Committee Report, nothing was
specified for urban areas till
recently. Some guidelines for
health care in slum areas are
provided in the Government of
India’s documents like Minimum
Needs Programme (1976) and in
the working Group on Family
Planning and Primary Health
Care services in urban areas
(Krishnan Committee Report,
1983).
Recently a number of schemes
(viz. ODA assisted projects,
World Bank assisted India
Population
Projects,
Environmental Improvement of
Urban Slums and Urban Basic
Services for the poor) have been
initiated in the country for slum
improvement. Organic linkages
are being developed between
health sector and Urban Basic
Services for comprehensive
development of health and
welfare services.
SkNZ\STH
Hind
THE EXISTING SCENARIO
Good sanitation and proper
nutrition prevent many common
illnesses. Poor sanitation helps
spread infectious diseases
particularly in congested areas.
The high incidence of mortality
and morbidity rate among infants
and children is attributed largely
to unsafe water supply, poor
hygienic practices and insanitary
environment. Many people
think that sanitation means only
a sanitary latrine. This is not
corect. No doubt, exposed
human excreta is one of the
major sources of disease.
However, even when latrines are
used, this does not always
eliminate the diseases of bad
sanitation. Good sanitation
depends mainly on practices
and attitudes of the people. It
relates to a package of healthrelated measures. In fact,
environmental hygiene covers all
aspects of environmental and
household cleanliness as well as
personal cleanliness or hygiene.
It may be well understood by
H.W. and 4 Fs.
Environmental hygiene refers to
H : Housing
W : Water supply
F : Faeces disposal (provision
of Latrines)
F : Flies control (Solid Waste
Management)
F : Food hygiene
F : Finger related practices.
Housing : Housing has ben
primarily self-help activity for the
majority of households.
Backlong of housing exists both
in urban and rural areas. Though
achievements of Indira Awas
ZXpoil - May 1QQ&
Yojna in rural areas and several
housing schemes, in urban areas
(viz. Social housing schemes for
different income groups, Nehru
Rozgar Yojna and Footpath
Dwellers Night Shelter Scheme)
have been significant, sheer
number of additional housing
with increasing population
presents a formidable task.
the quality of drinking water at
consumption points, and (d)
Quality of water samples from
standposts (Public taps and
Handpumps) was satisfactory.
Well water and samples from
water storage vessels were
heavily polluted. Pollution of
water mainly occurred due to
unsatisfactory water use
practices.
In rural areas, traditional types
In fact, such situations exist in
of houses with poor ventilation
many urban areas of the country.
and illumination continue to be
constructed. Programmes such
Provision of latrines : In
as Gobar Gas Yojna and
rural India 89.2% households are
Smokeless Chullahs have been
without latrine. Even where
on low profile. Villages still have
latrines have been constructed
major reliance on traditional
either majority of them are not
cooking fuel which produces
in usable condition or they are
considerable smoke leading to
not being used. This has
respiratory diseases
in
happened in those areas also
housekeepers.
where community members
have shared the cost of
Water supply : Though
construction of latrines. This
Handpumps are contributing
dearly demonstrates that in rural
significantly in the provision of
areas latrines have not become
safe water supply in rural areas,
the felt need of the community.
still wells continue to be the
It is understandable that the rural
predominant source of water
developmental activities, being
supply. Chlorination of wells
pursued through Community
have been on low profile. A
Development Block, are
recent study in Varanasi District
technocentric and target
has revealed that enough
oriented. Unless multisectoral
importance has not been
linkages
(viz. Rural Development,
accorded to safe water supply by
Health and Education.) are
the PHCs/CHCs studies.
established, utilization of such
Interesting findings, as given
services seems to be a remote
below, have been observed in a
possibility. Situation is not better
study conducted in Urban
in urban areas. In 1985, only
Mirzapur of Uttar Pradesh.
28% of urban population had
(a) Private source of water supply access to proper sanitation. Our
were 71%, 41% and 14% in
experience under Ganga Action
developed, slum and village type
Plan in Urban Mirzapur has
shown that many families are
areas of urban Mirzapur,
respectively, (b) Scarcity of
not using latrines just because of
drinking water has been
the absence of superstructure.
perceived as topmost problem
Indiscriminate throwing of
babies’ stool persists in the area.
by 77% of the respondents; (c)
Scarcity of water during summer
Solid Waste Disposal :
months had direct implication on
Construction of compost and
69
* GIVE A MAN A FISH AND YOU FEED HIM FOR A DAY.
TOMORROW ... HE MAY BE A BEGGAR.
* TEACH A MAN TO FISH AND YOU FEED HIM FOR LIFE.
TOMORROW ... IF WELL TAUGHT ... HE WILL
BE TEACHING OTHERS.
MORLEY &LOVEL, 1986.
soakage pits has been on low
profile in rural area. People have
not perceived their importance.
Schools have failed to set good
examples. In the absence of
proper drainage facilities,
masquito borne diseases are
rampant in rural and urban
areas. Heaps of garbage and
choked open drains are
common sites in urban slums. In
busy urban pockets, renovation
work is responsible for huge
collections.
Unplanned expansion of cities
are posing a serious challenge.
Collection of water around water
sources and submerging of
standposts during rainy season
has been responsible for
outbreak of water borne
diseases. Accumulation of
garbage in rural and urban areas
is responsible for high fly density
and this has caused outbreaks of
gastrointestinal disorders, more
so in those pockets were open
field daefication has been in
vogue along with bad food
hygiene. Unsatisfactory refuse
storage and collection at family
level and indiscriminate throwing
of refuse, even in those areas
where community pits exist,
pose serious challenge to
behavioural scientists. Once
community understands the
implications of accumulation of
refuse and water collection, they
may emerge as ‘PRESSURE
70
GROUPS’ to force town
Committee/Nagarpalikas/
Corporations to take corrective
measures.
Food hygiene : The condition
of edible items sold in many
shops and schools are far from
satisfactory. It is common to find
hawkers, selling good items in
urban slums, being surrounded
by children and women.
Unsatisfactory bottle hygiene for
infant feeding is contributing
significantly to infant mortality.
Personal hygiene : Personal
cleanliness helps to prevent
contracting diseases. It is not
rare to find bad personal
hygiene in rural and some urban
schools,
children
attendingAnganwadi Centres
and Creches. Practice of using
mud for washing hands after
defecation still continues in the
villages. During winter months,
daily bathing is rarely done by
children in rural areas. Bad eye
and oral hygiene are common
finding in many school surveys.
It is not uncommon to find
children playing in dirt and muddy
water.
Emerging problems :
Environmental
problems
associated with home based
industries and their ill-effects (Viz.
refractive errors, musculoskeletal
disorders and reduction in PEFR
in carpet weavers of Urban
Mirzapur), issues related to urban
ecology (e.g. traffic accidents, air
pollution, river pollution, sound
pollution, alcoholism, drug
addiction, enhanced risk of STDs
and AIDS), obscene posters,
advertisements and magazines
polluting social environment, and
nutritional problems in urban
areas are serious emerging
challenges for health planners
and Environmental scientists.
STRATEGIC CHANGES
It is obvious that only supply
oriented and technocentric
approaches are not going to
make perceptible difference in
the environmental hygiene of the
people and promotion of their
health. Human and behaviour
aspects concerning water and
sanitation facilities and
promotive activities have to be
taken into account. We should
not take it for granted that
’people know it’,. In fact, Health
education, an enabling process,
should be integral part of any
service activity.
Multisectoral involvement, mul
timedia mix and community
based communication tech
niques with community being it
self the ultimate communicator
are major concerns in health
education today. Mass commu
nication media and print media
have full potential of demand
Shasth
Mind
generation but they need careful
planning. Outstanding leaders in
many countries have successfully
built social reformation and free
dom movements utilising the pre
vailing cultural and religious
knowledge, attitude and practices
and mechanisms of communica
tion and working together. These
cultural and religious traits and
power of the people, if mobilized,
may prove very costeffective In
formation, Education and Com
munication (IEC) strategy.
(e)
Involvement of Mother’s
clubs (Nepal) NGO’s and
Youth groups;
(f)
Participatory communication
process through religious
leaders (Bangladesh and
Bhutan). Frontline Personal,
Traditional Healers and
Village Social Functionaries
(Varanasi), and trained
Community Volunteers,
leaders (Urban Mirzapur and
Varanasi);
INNOVATION APPROACHES
Experiences of following
innovative approaches may be of
immense help in planning an
effective IEC programme:
(a) Media Seminars on Health
(Sri Lanka)
(b)
Establishment of infrastructure
for effective production and
dissemination of health
education materials;
(c)
Mobile health education teams
for areas with difficult terrain;
(d)
Strengthening
of
communication
and
conselling skills of health
Contdfrom page 67
can produce such materials. Held
Public Units, Public Relation
Departments, Health Centres
can be entrusted the responsibility
of distribution of such eduactional
material.
5. Small exhibitions and displays
on different aspects of the theme
can be organised at schools, fairs,
shopping centres, public places.
6. Film shows and slide-shows
are very useful in educating the
masses. Cartoon films may
specially be shown to students for
educational purpose, if available
April
Programmes of Indonesia);
workers;
M/xy 1996
(g)
Use of entertainment to
incorporate
health
communication (Varanasi);
(h)
Use of social marketing
principles to enhance health
education inputs in CBD
project (Varanasi);
fi) Campaign approach in
health programmes with
intra and intersectoral
collaboration
and
involvement of the private
sector
(Karnataka
experience);
(j)
(k)
Promotion of sanitation
through
Anganwadi
Workers in India; and
(1)
WHO’s Healthy
Programme.
City
THE FUTURE
The success of health education
measures in improving
environmental hygiene and
promotion of health will depend
on how well IEC strategies are
defined, plans are made and
executed and extent of
community participation in the
planning, execution, utilisation
and evaluation of IEC
programmes.
‘IF YOU ARE PLANNING
FOR A YEAR......SOW RICE
‘IF YOU ARE PLANNING
FOR A DECADE...... PLANT
TREES
‘IF YOU ARE PLANNING
FOR
A
LIFE
TIME....EDUCATE THE
PEOPLE
Education through Schools
(viz. The Little Doctor
on subject.
7. Advertisements relating to
the theme sponsored by wellknown industrial establishments
and philanthropists, can be
issued to newspapers,
magazines, etc.
8. Folk media coulud be
advantageously employed for
the purpose of educating the
masses Prabhat pheries,
Puppetry, folk dances are some
of the popular folk media.
9. Cultural programmes by
involving song & drama parties,
magicians and folk singers,etc.
sponsored by the Song & Drama
Division of the Ministry of
Information and Broadcasting
may be organised to disseminate
the messages on the theme.
10. Competitions on activities
relating to the theme such as
Essay Writing, Painting/Drawing
competitions, etc. may be
organised at various levels of
observance. Regioinal officers of
the Dte. of Field Publicity, Youth
organizations, Lions Club,
Rotary
Club,
various
development agencies, voluntary
organisations may be involved to
organise such competitions.
71
MESSAGE FROM DR HIROSHI NAKAJIMA,
DIRECTOR-GENERAL OF WHO
WORLD HEALTH DAY 1996
HEALTHY CITIES FOR BETTER LIFE
On this World Health Day
therefore, let us resolve to
make our cities healthy so as
to ensure a healthy life for all
their inhabitants.
The proportion of people
in the world living in cities is
escalating. Many of the
world’s cities are expanding
far beyond their mid-20thcentury frontiers. The result?
Hundreds of millions of
people - the world’s urbanites
as they are called - are now
living in conditions that are
detrimental to their health
and even endangering their
lives. “Healthy Cities”, the
theme chosen by WHO for
World Health Day 1996, ad
dresses this crisis.
In 1990, already the
health of at least 600 million
people living in cities in de
veloping countries was being
threatened by lack of food,
clean water and shelter. Over
crowding, inadequate waste
disposal, hazardous working
conditions, polluted air and
street violence were contrib
uting to what have now be
come the routine, but no less
intolerable, risks of city life.
Since 1990, on the whole,
the situation has not been
getting any better. By the end
of century, more than half of
the developing world’s popu
lation will be living in urban
areas and thus exposed to
major health hazards.
72
Against this alarming
backdrop was born WHO’s
Healthy Cities Programme.
The main aim of the
programme is to call the lo
cal governments and commu
nity associations to form coa
litions for improving urban
health
and
solving
enviornmental problems.
To date, the Healthy Cit
ies Programme has been ex
tremely successful. It has
been adopted as a model for
promoting urban health - par
ticularly of low income popu
lation groups - in over 1000
cities around the world. Many
cities councils are using the
“Healthy Cities” slogan to
publicize health and environ
mental issue. And in some
places, the concept has been
broadened to include other
sectors of society, such as
“Healthy Islands”, “healthy
Villages” and even “Healthy
Schools”.
Cities committed to im
proving the health of their
populations through con
certed, participatory and
“multisectoral” approaches
are linking their efforts and
sharing their experiences
through national and regional
networks that exploit the
many existing channels of
communication that serve for
exchange of goods, services,
technology and information.
Most encouraging, a glo-
bal network now seems to be
emerging. International ef
forts to improve urban living
conditions are being under
taken by WHO together with
other United Nations agen
cies, in particular the UN Cen
tre of Human Settlements
(UNCHS), the UNDP, the 1LO
and the World Bank. In June
1996, representatives from
these agencies will gather in
Istanbul for “Habitat II”, the
second Conference on Hu
man Settlements, at which
WHO’s Healthy Cities
Programme will be of pivotal
interest.
The health of urban popu
lations deserve our urgent at
tention. If we continue to let
our cities grow without proper
planning, local government
authorities will be over
whelmed and unable to pro
vide even the most basic con
ditions for health such as
housing, employment, and
safe environment. At a time
of explosive urban growth,
the health of city populations
is a challenge for all con
cerned with human develop
ment - from municipal and
national authorities to inter
national health and develop
ment organizations.
Through the Healthy Cities Programme, WHO has
taken up the challenge.
SkN/^xsTH Wind-
MESSAGE FROM DR UTON M. RAFEI
REGIONAL DIRECTOR
WHO SOUTH-EAST ASIA REGION
WORLD HEALTH DAY 1996
also have resources to im
Over the years, the world
shelter close to half of their
has seen a phenomenal
populations in substandard
growth of urban populations,
housing with little or no ac
particularly in developing
cess to the basic necessities
countries. It is, therefore, un
of water, sanitation, and
derstandable that concern for
health care.
better urban life will be of
Over the next decade the
very high priority in the so
world is.expected to have 20-
cial agenda of the 21st cen
30 cities with a population of
tury. Under present trends,
over 20 million each, more
by the year 2000, we can
than the present combined
expect half the world’s popu
population of Bhutan, Nepal
lation to be living in urban
and Maldives. Our Region,
settlements.
with five of the 32 most
While cities have been re
populous countries in the
ferred to as engines of devel
world, already accounts for
opment that fuel economic
nearly a fourth of world popu
progress, they are also in
lation. In less than a decade,
creasingly being seen as the
six people out of ten will be
prime machines that pollute
city dwellers in our Region.
the
The problems of cities -
enviornment, creating condi
heavy traffic, noise and air
tions for ill-health that jeop
pollution, inadequate housing
ardize the very hope of bet
and basic civic amenitics-are
ter living for which the city
only too well known to city
dweller aspires. The densely
dwellers. Cities, however,
and
degrade
populated cities of our Region
Published by Central Health Education Bureau, Kotala Road, New Delhi - 110002
prove the living conditions of
their citizens. What is needed
is a partnership between the
civic authorities, the private
sector and the people. A
partnership to tackle existing
urban problems and to pre
vent others from becoming
threats to the health of citi
zens.
WHO has chosen the
theme “Healthy Cities For
Better Life” for this years
World Health Day. The Or
ganization
has
already
launched a global healthy cit
ies initiative to help make cit
ies healthier. I am confident
that by raising the necessary
awareness and taking urgent
action we will be able to
achieve our goal of making
the cities of today and those
of tomorrow healthier and
happier places to live in.
SWASTH HIND
1988 Calgary
1988 Seoul
’ 1992 Barcelona
1992 Albertville
1994 Lillehammer
1996 Atlanta
_____ No. D-(C) 359
Regd. No. 4504/37"*
Position: 3179 (3 views)