Medical and social problems of drug addiction in West Africa

Sections

1. Incidence
Community mental health research project, Dept. of Psychiatry, University of Ibadan
2. Factors contributing to the spread of drug addiction in developing countries
3. Personality characteristics and social life of chronic hemp-smokers in West Africa
4. Psychiatric problems
5. Total management of chronic abusers of cannabis in West Africa
6. Conclusion
Acknowledgement

Details

Author: T.A. LAMBO
Pages: 3 to 13
Creation Date: 1965/01/01

Medical and social problems of drug addiction in West Africa *

With special emphasis on psychiatric aspects

O.B.E., M.D., F.R.C.P. (Ed.), D.P.M. T.A. LAMBO Professor of Psychiatry, University of Ibadan, Nigeria

1. Incidence

The problem of drug addiction in West Africa is a fairly recent phenomenon. It was relatively unknown in most areas, although sporadic in some African countries before the second world war; but it is now widespread throughout the continent and has important medico-legal implications. Recently, many West Africans have been prosecuted in the United Kingdom for trafficking in cannabis. The incidence of drug addiction, just as alcoholism, crime, prostitution, delinquency, and other behaviour deviations in developing countries of Africa cannot be safely ignored as measurable indices of the health of the population, especially in relation to socio-economic change. In most of the people seen the most constant finding was the varying degrees of impairment of mature, responsible adjustment to family, social, and vocational problems.

The most commonly abused drug is Indian hemp ( Cannabis sativa), which is illegally cultivated in many parts of West Africa and distributed widely. The resin-like substance (cannabinol), which is found only in female plants, produces the narcotic effects. It is on this drug that most of our present findings are based. It is used as a narcotic and the most popular mode of use is by smoking its dried leaves, which are rolled into cigarettes. Cannabis is used by individuals varying from schoolboys to migrant workers, and also by groups varying from organized political thugs to recently evolved secret societies with criminal aims, such as Odozi Obodo and the Leopard-men Society of Nigeria.

Throughout West, East, and Central Africa today, at a time when the pace of development is so rapid, heterogeneous medico-social problems are becoming apparent. After a seven-year study of the relative frequency of this condition of abuse of drugs, especially marihuana, it is now known that indiscriminate use of cannabis is more frequently seen in " marginal " Africans. Between 1959-1960 it accounted for 15 % (32) of the total admission to Aro hospital (201) and 20 % (33) of the total out-patient population (165) of the Psychiatric Clinic of the University College Hospital, Ibadan.

Map showing area under intensive epidemiological research

Full size image: 19 kB, Map showing area under intensive epidemiological research

It is important to state the present position of other addiction-forming drugs in so far as West Africa is concerned. Drugs such as opium and its derivatives, and synthetic substances such as pethidine, have always been used as therapeutic agents, but within recent years four senior nurses (male and female), two pharmacists and a doctor have had psychiatric treatment for intractable pethidine addiction in Nigeria. The same experience has been reported by psychiatrists working in other parts of Africa. For example, Crawford (1963), working in Kenya, writes: "At the present moment in Kenya I have a few educated Africans who are pethidine addicts." The incidence of morphine and pethidine addiction is rising among professional Africans, especially in the medical and allied professions. Amphetamine psychosis has been reported in African college students (Lambo, 1961). The incidence is steadily rising, and many of these students are also addicted to barbiturates. Abuse of alcohol is fairly common in the cities, usually in the depressed communities of the low socio-economic groups. In equatorial Africa this is a major social disease and one which influences productivity. For example, it has been reported that absenteeism is highest on Mondays and the days following pay-days - alcohol and its effects are causal factors.

Apart from these cases, true addiction does not occur in the indigenous population of Africa. In 1957, I wrote: "... drug addiction strictly speaking is uncommon among primitive Africans, and where it is found (in the primitive setting) it is usually associated with ritualistic orgies." It is therefore necessary at the outset to mention here that in practice it is hard to determine whether the abuse of drugs that we now encounter in the West African meets all the accepted criteria of addiction. As far as my experience goes, our evidence is less conclusive about whether the habitual abusers of cannabis in West Africa are in the strictest sense addicts. Certainly in the majority of the patient and non-patient population of chronic abusers under our observation the continued presence of the drug is not necessarily required for their normal functioning - that is, there is no physical or physiological dependence. We have also failed to observe the compulsive use of increasing doses in many of the victims. In addition, the classical abstinence syndrome has not yet been encountered by us consequent upon the withdrawal of the drug, except in ten people who were ex-soldiers and who acquired this habit in India during the war. Therefore, it would seem necessary here to mention that the degree of addiction does not fall within the accepted criteria of defining addiction in the strictest sense.

In Nigeria, for our epidemiological work, we have set up an operational criterion of measuring addiction based upon the degree of impairment of social and occupational adjustment or functioning of an individual. This has turned out in practice to be a fairly reliable index. However, at the expense of watering down the meaning of addiction, our operational criterion does offer us one meaningful approach to the study of such problems.

There is considerable variation in the reports received from different West African countries and even from different districts in the same country. Thus in Nigeria abuse of drugs, especially hemp, is rare in the north and not very frequent in the north-east, but very noticeable in the western region. It is decreasing in the region around Ilorin and in the western loop of the Niger. On the other hand, there is a definite increase in the number of abusers in the south-western corner. The causes of the recent increase are complex; two factors which have received special study are: (i) the effects of migration (both internal and international) on the incidence; and (ii) the socio-economic circumstances leading to increased exposure. These two and other factors will be fully discussed later.

TABLE 1

Social class categories

Social class

Definition

I
Professional and political leaders - e.g., doctors, lawyers, clergy, nurses, ministers, etc.
II
Intermediate, including managers, proprietors, and highly qualified technical workers, such as fitters, electricians, building contractors, etc.
III
Skilled manual and clerical workers, such as motor mechanics.
IV
Partly skilled, such as tailors, carpenters, masons, laundrymen.
V
Unskilled, such as labourers, especially migrant workers, including motor drivers, porters, atten-dants, house servants.
VI
Others, such as college and university students, sailors, drug peddlers.

Before going any further, let us examine our sources of information on this subject. There are three major sources, and these are: (i) surveys, conducted within the community (Lambo, 1960; [ 1] Leighton, Lambo et al., 1963) (see map of area under intensive epidemiological study); (ii) hospital statistics, and (iii) data of migration, especially into the city. [ 2]

During the period 1957-1960, sample surveys were made on two new industrial centres and stratified samples (within each stratum selection was by random sampling) of African workers were interviewed and full data were collected on the social, occupational, residential and educational background of the respondents. Efforts were made to evaluate the degree of social change involved in their new occupation and the respondent's perception of the change. Through individual case history over a period of fourteen months; new hypotheses were advanced on the subject. In 1961, Lambo and Leighton joined forces to carry out an epidemiological survey (morbidity survey) in terms of sociological variables in a small but effective sample of the Nigerian population (non-patient population of the Egba sub-tribe). The relevant part of the findings from the report (Leighton, Lambo et al., 1963) will also be employed here to buttress the findings of this special study on drug addiction in Africa.

FIGURE II

Full size image: 165 kB, FIGURE II

Community mental health research project, Dept. of Psychiatry, University of Ibadan

Up-to-date information has been obtained from psychiatric hospitals from West and East African countries, but in this study I will only employ the Nigerian hospital statistics to interpret our findings. It should also be pointed out here that this index of measurement is not entirely reliable because of socio-cultural bias and other mitigating factors which under hospitalization rates unreliable indices of incidence and prevalence of diseases, especially in Africa. This is particularly true when dealing with psychiatric disorders.

Data on social and psychological consequences of migration into the city as part of our study have been systematically collected over a number of years, since we discovered that this factor appears to have a marked influence on the incidence of psycho-social disorders in Africa, especially crime, delinquency, prostitution, drug abuse and alcoholism. During our survey of two industrial centres, detailed information was obtained on the social habits, place/type of residence, and details of past and present illnesses of the respondents who were found to be using cannabis indiscriminately and frequently.

An interim-measure correlation was established with those variables which prima facie appeared to be most significant as a result of our previous observations. These were: (1) age; (2) marital status; (3) social and occupational class; (4) ethnic group; (5) distance from worker's home to place of work; (6) sex and religion. Young migrant workers are more prone to abuse of cannabis than their non-migrant elders. This is paralleled in other West African countries. Another double conclusion to be drawn from the study of marital status variable is that married workers are more stable than bachelors, and monogamous more than polygamous married men. There is no relationship between ethnic or tribal group and incidence of drug abuse.

This and other attempts at assessing the epidemiology of many disorders form the main part of our intensive population research (see figures I and II). Health problems of Africa in transition cannot be assessed with confidence and overcome unless reliable epidemiological data are available - epidemiological inquiry which takes account of all the socio-9economic and ecological factors affecting the health of a population group. Our primary aim has always been to discover or define the interrelation between socio-economic factors and morbidity rate, especially social morbidity. Migration is only one of many variables considered and its study and possible effects on social behaviour and disease incidence have provided valuable additional information. While all the data collected are suggestive and no doubt valuable, they cannot be said to demonstrate convincingly the complex relationship of all the factors involved in the problems of drug addiction in West Africa.

These studies as well as other ecological studies (Lambo 1960, 1962) have demonstrated beyond any doubt that abuse of drugs, unlawful possession, sale, or its purchase, etc. are spread through the principal channel of direct social contact of addicts with vulnerable individuals or potential addicts. Our previous study has shown that when adaptation to new and stressful life situations becomes difficult for the " marginal " African, anxiety with psychosomatic manifestations with or without criminal behaviour is apt to occur. Abuse of drugs can be viewed as one of the many neurotic attempts made at restitution by certain individuals. Many young adolescent non-addict users of cannabis look upon the use of this drug as a means of (and in most cases it has altered their method of) coping with their environment. It is therefore important to examine constitutional factors, social conditions and group relations for possible explanation why these people react abnormally while the vast majority react differently to the same or similar social conditions (differential susceptibility).

It has been said that the rate of addiction everywhere is highly related to the availability of narcotic drugs. Our study has shown that there are more complex variables other than availability that affect the rate of addiction. Individual and sociological factors are a few of the variables which enter into the complex causality of drug addiction in Africa. If the problem is viewed in this light it is to be seen that it is dynamically related to a variety of other phenomena in the same social field (community). Several implications are to be seen as a result of this viewpoint.

One is that the falsity of viewing drug addiction as itself a cause of various types of mental disorder is immediately apparent. Drug addiction and other socio-pathological phenomena, including crime, may vary concomitantly, but this variation itself may indeed be reflecting a change in a third phenomenon as, for example, the disintegration of the traditionally supported kinship groups giving rise to social isolation and economic deprivation of certain individuals. It would certainly deepen our understanding of drug addiction in West Africa today if we view it and many of its concomitant social manifestations, not as causes and effects, but rather as concomitant neurotic adjustment of individuals within changing or transitional social, cultural and economic systems. It is virtually impossible in practice to separate out in terms of causes and effects the relationships of abuse of cannabis or drug addiction to crime of various types, to poverty, the decline of traditional social mores leading to sexual promiscuity and prostitution, divorce and one thousand and one other changes going on in many parts of Africa today.

The incidence is very low among the West African women. In the cities where women are gradually taking to tobacco and alcohol, and prostitution is rampant, abuse of drugs, especially marihuana, is not rare, as the present-day social and economic conditions hamper them more and more in the exercise of their traditional maternal functions and force them into activities which are essentially anti-social. Only 4 out of 33 patients treated at the University Psychiatric Clinic for psychiatric disorders associated with prolonged use of Cannabis sativa were women. Three of them knew each other well, having been imprisoned together for short sentences for prostitution. The fourth was a young girl of 19 years who had recently been brought into the city by an older distant relative who was a prostitute.

These are some of the considerations which may explain the incidence and prevalence of drug addiction in many of the developing countries in Africa.

2. Factors contributing to the spread of drug addiction in developing countries

In our consideration of the factors contributing to the spread of drug addiction in West Africa, that of population movement, especially of internal and inter-territorial migration, comes first. The spread of drug addiction is facilitated in populous regions frequented by tourists and by seasonal workers, and districts where the inhabitants have easy access to large centres of population for business or pleasure and are, therefore, within reach of temptations which lay them open to the risk of illicit drug use and drug peddling. Sporadic or mass shifts of population to urban areas, especially to new industrial centres with no infrastructure (or with infrastructure such as a housing programme but imperfectly adjusted to the economic possibilities and to the needs of the inhabitants) constitute a major source of spread.

The advent of seasonal workers and workers taking part in big constructional undertakings - for example, Tema harbour in Ghana, Kariba hydroelectric scheme on the Zambesi, the making of railways, motor roads, etc. - has contributed significantly to the spread of abuse of hemp in Africa. Prison camps have also done their share. Crawford (1963), in his personal communication, writes: " Not so long ago I had a patient who was admitted from Nairobi Prison, apparently mentally sick, but, however, after about ten days he said he was better and wanted to go back to prison; he stated he was able to get bhangi [cannabis] in prison but not in Mathari hospital! " Many of these artificially constituted communities are culturally heterogeneous, and this tends to impede social integration, produces a lack of sense of identity and psychological support, leading to the formation of socially marginal groups.

The second factor is the socio-economic vis-a-vis population shifts. New industrial centres where work is believed to be plentiful and wages high constitute an actual or potential reservoir because " there is normally in these places a floating population of unskilled workers without regular employment but who are, nevertheless, unwilling to leave these centres to take up gainful employment which is available in the rural areas." Effective control must include efficient epidemiological contact studies of these areas. The rural areas, on the contrary, are but little affected, even though most of the plantation of Cannabis indica takes place there. These rural areas consist of small villages and hamlets in which simple and healthy customs still prevail, which present no features of interest for the tourists and the seasonal workers, and where the inhabitants move very little since nothing attracts them in the town.

TABLE 2

Social class distribution (per cent) of Indian hemp (marihuana) addicts treated in Nigeria (1955-1960)

 

Occupational class

 

Area of origin

I

II

III

IV

V

VI

All classes

Abeokuta & environs
1
-
2 2 51 44 100 (201)
Ibadan
2 2 3 1 60 32 100 (952)
Enugu
-
5 1 6 40 48 100 (480)
Lagos
5 20 2 13 20 40 100 (960)
Elsewhere
-
-
5 10 70 15 100 (80)

In their present stage of economic development and under the pressure of over-population in some areas, many African countries cannot meet the growing needs of their people. For example, farming, especially in the traditional way, does, of course, bring in an income, but not enough for the farmers to meet their growing needs (improved status, children's education, taxes, aid to the family, clothes, repayment of loans, provision of bride price and so on). Consequently, many young people become migrants to obtain more money to meet these needs and, in many cases, the wives stay behind to look after the house, the crops, the livestock and the children. While the young ones are on the move to sell their labour and become pedlars, the older ones stay behind and explore other means of acquiring cash: many grow a cash crop, the cheapest with the greatest remuneration being cannabis. The seasonal agricultural worker [ 3] who is constantly on the move is therefore a ready agent for the transmission of the knowledge of the cultivation of marihuana.

Economically, the African labour market remains fluid and largely unstable, as evidenced by some figures of labour turnover. For example, in the Ivory Coast, of the 30-35,000 migrant workers, 50% change their employment every two months. Lack of well-defined social policy and welfare amenities in many developing countries of Africa is definitely conducive to the development of psycho-social disorders the nature and incidence of which vary from country to country in Africa.

In a densely populated small country as the Republic of Upper Volta, a country which is poor, dry, frequently hit by famine and with a totally inadequate economic base, not less than 150,000 seasonal workers leave annually. Interterritorial migration in Africa provides an economic safety valve for the densely populated and economically depressed countries, but the repercussions in terms of social morbidity and other health problems are great. [ 4] The significance of population movement in Africa, which may increase further as a result of current political changes, is great for the epidemiology of many "old" and "new" diseases.

" The circulation of workers between their tribal areas and commercial and industrial enterprises is a familiar phenomenon all over the world where Western civilization has come into contact with tribal peoples " (Mitchell, J. C., 1961). Houghton (1958) has quoted an estimate of 5 million migrant labourers in Africa. In 15 villages near Abeokuta covered during our epidemiological survey (Leighton, Lambo et al. 1963) over 60 % of the 'adult able-bodied men between 25-45 years were absent (temporary or fairly permanent) from tribal homes at any given moment and practically all have commuted between their villages and big towns at some time or another.

If we examine tables 1 and 2 showing the social class categories and distribution (per cent) of Indian hemp patients treated in Nigeria (1955-1960), we notice that the social class VI is mainly composed of school and college students. Teen-age abuse of drugs, especially of Indian hemp, has become prevalent in many African communities, and our studies show that more than half of the patients reaching us are under 25 years of age with a history of at least three to five years' duration. Unemployed African school-leavers of today are most vulnerable, and they in turn function as " vectors" for this social malady. Psychological dependence on drugs is more marked in this younger age group. Abuse of drugs in African adolescents is not uncommonly found in combinations - amphetamines, barbiturates, and cannabis. School and college boys boarded or living with distant relatives have higher incidence than their counterparts living at home.

There is a sharp rise in the rate of population growth in many African nations. Most African countries today have been found to have an annual population increase from 2-3% and concomitant with this increase is the comparative youth of these populations. It is now estimated that 35-40% of the populations of the new African nations are under the age of 15. This changing age structure coupled with economic pressure may have some important implications for the epidemiology of many diseases (for example, schizophrenia) in developing countries of Africa. Gallaway (1963), writing on the problem of " Unemployment among african school-leavers ", observed: " Of course, there is nothing necessarily ill-advised about having such increases in population and sending such a large number of children to schools. The question is whether individual countries have the capacity to propel the higher rate of economic progress necessary to match the expectations people have for improvements in their living standards." He further noted: " For the individual... the young African hoping to place himself in the modern world ... a long period of unemployment may undermine his self-confidence and turn his optimism to disillusionment." We have discovered that the main centres of attraction for these youths are the principal administrative and industrial cities. In the main, these youths in search of employment tend to follow those relatives and other village people who have gone before them, thus establishing " lines of migration ".

In our 1957 study (" Survey of displaced and detribalised people in Yoruba country ", Lambo, 1960), we found that the rate of social morbidity, as measured by crime, incidence of venereal disease, hemp abuse, absenteeism, malignant anxiety, dismissal rate, was highest among the group of individuals who were perpetually out of work. Therefore, unemployment as a potent economic factor may help to spread the use of cannabis within the community, since the man living in idleness is likely to be a prey to the temptations of drug peddling.

It is evident that the main forms of social change, including migration - spontaneous and controlled, modern and indigenous types of commuting - have some bearing on the coping and other adjustment processes of individuals passing from indigenous to industrial economy, from one social class to another (social mobility) or from rural to urbanized community. We now have at least some reasonably unanimous evidence incriminating social change, and scientists working in other countries (Ödegaard, 1932, 1945, 1961; and Jaco, 1957) have produced overwhelming evidence to show that migration to a metropolitan area or main city of a country may have a more adverse effect on mental health than from migration elsewhere.

All these details seem necessary not only to emphasize that the psychodynamics of drug addiction in the African seem better explained in terms of the multiple factor theory than in terms of a general theory of individual proneness, but also to demonstrate that although most advanced countries went through similar socio-economic evolution with its attendant hazards for health, yet there is no reason for the developing countries to chart the same or similar paths. Unfortunately, many developing countries think that the transfer, pure and simple, of methods employed in highly developed countries (such as model prisons, remand homes and so forth) would provide all the answers. It would appear that the need in most of these countries is still more a matter of providing a carefully designed social infrastructure for the marginal groups in urban societies.

3. Personality characteristics and social life of chronic hemp-smokers in West Africa

Like many other forms of psychosocial disorder such as alcoholism, crime, and gangsterism, there is a tendency for chronic hemp-smokers to discover one another, thus establishing contacts leading to the formation of an abnormal group with distinctive sub-cultural mores. The present author has in disguise attended two hemp-smoking sessions by Ibadan adolescent schoolboys.

In our clinical studies of the types of breakdown associated with chronic abuse of cannabis, special attention has been given to social data on the early lives of these patients. Concrete evidence of inconsistent and unstable affective reactions to many reality problems was obtained in well over 60% (260) of the total of 434 patients with severe behaviour disorder.

The psychological data for the entire group varied, but there was demonstrable evidence of emotional instability with the tendency towards neuroticism and immaturity coupled with other signs of maladaptation as observed in general behaviour. Chronic abuse of cannabis, especially when associated with alcoholism, has been found to be closely associated with a general failure of personality integration, developing under the impact of social and emotional difficulties encountered by personalities culturally and psychologically ill-equipped to meet them. The basic psychopathology is one of chronic inadequacy, anxiety and frustration in many cases. It would, however, be misleading if I did not point out that psychiatric and psychological examinations of some chronic cannabis smokers (non-patient population) failed to show conclusive evidence of early or current demonstrable deep personality defect or disorder.

There is an urgent need to study the differential psychological reactions to various drugs in different cultures (Lambo, 1957). In order to understand the effects on behaviour and experience of drugs commonly used in our practice, we have had to resort occasionally to psycho-analytical treatment of our data. Unfortunately, the formal Freudian theories rely primarily on psychological data based upon individuals in an entirely different society. The application of these theories and concepts, in spite of their heuristic importance, to the African society by ad hoc investigators has some- times been without the support of critical appraisal of the original research, and often by inference from an investigation designed for an entirely different purpose.

We have found the broad psychodynamic approach of greater application in understanding the development of drug addiction in the African. Therapeutic application of drugs, especially ataraxics and hallucinogenics, has thrown some light on the complex aspect of this problem. Abreactive drugs have also been made use of in our practice in the indigenous population of Nigeria, thus providing us with rich avenues of exploration. Lambo (1963) closely observed seven patients who were using cannabis to obtain relief from severe non-rational anxiety. Cannabis was used over periods varying from 9 to 16 weeks. These patients smoked the dried leaves at irregular intervals totalling an average period of 20 to 25 minutes a day. From six weeks upwards anxiety was markedly reduced with an appreciable degree of relief of symptoms. Five gave reports of improved psychological and psychomotor functioning which gradually gave way to insensitivity, egocentricity and major defects in social behaviour. The problem of physiological dependence did not arise in all when the drug was stopped. The patients were successfully treated with massive doses of chlorpromazine.

Prince (1960), working at Aro, used lysergic acid experimentally on some members of the staff (doctors and nurses) and detailed his findings in an unpublished report. All these studies (Prince, 1960; Lambo, 1963; Lambo & Edozien, 1961) have shown a variety of disparate observations. After observing African patients from heterogeneous, social and cultural backgrounds, and in the light of many variables, a more fundamental objection can be raised to the theory that there is a personality pattern prone to the abuse of drugs per se.

The conceptual and methodological problems in investigating the effects of drugs on behaviour are great, and are in need of urgent consideration. There is no uniform application of foolproof methods and techniques to this field of study.

4. Psychiatric problems

(See table 3)

Although cannabis taken over a long period does not necessarily produce permanent disturbance of personality, nevertheless in some people it does give rise to various types of impairments of mental health which could be classified clinically. Apart from the clinical manifestations which will be described below, hemp smoking over a long period affects social and occupational capabilities of individuals and, in addition, endangers society and the family. In three skilled labourers under observation recently, efficiency was markedly impaired, though two showed greater (quantitative) output initially.

TABLE 3

Number of men treated (in- and out-patient) showing diagnosis and age (1959-1960) (Nigeria)

Diagnosis

All ages

Less than 30 years

30-49 years

50-69 years

Symptomatic disorders
543 427 94 22
Confusional states
156 95 11 50
Schizophreniform disorders
670 486 173 11
Manic disorders
94 61 30 3
Depression
72 10 15 47
Psychoneurosis
363 59 173 131
Disorders of behaviour and character
785 337 434 14
All diagnoses
2,673      

Much caution has been exercised in making our diagnosis of the types of breakdown associated with chronic use of cannabis. Where in doubt, we have classified this under symptomatic disorders.

  1. Disorders of behaviour and character (785) form the largest group encountered in our series of 2,673 patients between 1955 and 1960 for all ages. These disorders ranged from criminal acts to many forms of deviant behaviour. In many individuals there has been evidence of disturbance in their ability to learn by experience, emotional difficulties and well-marked alteration in their method of coping with their social environment. In the schoolboys, there were gross emotional and other behaviour difficulties - taciturn manners, aggressive and impulsive behaviour, truancy, obtaining money by false pretences, sexual promiscuity, assault, and many anti-social acts. Many came from good homes. [ 5] This is a very significant factor, which tends to support Ansubel's contention that the illegal status of drug addiction increases its attractiveness for aggressively-minded adolescents temporarily alienated from the norms of the adult world. The chief feature of this disorder is the gradual alteration of personality with complete lack of appreciation of the consequences of their acts. The prognosis is usually poor.

In spite of our reservation, reservation brought about by the complex interrelatedness of many variables, in attempting to break down and over-simplify drug addiction into cause and effect, our tentative findings in West Africa on the incidence of crime among chronic abusers of Cannabis indica will, however, be summarized below using prison, police, and hospital statistics and records.

During the year 1962, about 471 persons were prosecuted in Nigeria, and of these, 400 people were either fined heavily or sentenced to various terms of imprisonment. In 1963 the figure almost doubled itself. In the rest of West African countries between 1962 and 1963, crimes and offences in which cannabis was a factor were fourth on the list.

The relationship of cannabis to crime and anti-social behaviour is complex and elusive. Not only do people commit crime under the influence of cannabis but, indeed, a large number of non-habitual offenders are led to the use of cannabis, because without it they cannot effectively operate. Its use, under these circumstances, produces a relief from fear and anxiety, and replaces passivity with aggressivity.

The following crimes were compiled from the lists of three West African countries (one French-speaking and two English-speaking) over a two-year period, and the number of offenders who came into this group was recorded. Approximately 25 % (2,057) of the total had previous convictions.

  1. Murder 73, of whom 37 (50.6%) were long-standing users of cannabis with pronounced psychological dependence;

  2. Assault and battery 263, of whom 82 (31.1%) had a definite history of cannabis;

  3. Sex offences against women 472, of whom 123 (26%) with a definite history;

  4. False pretences - very common in young adolescents manifesting overt hostility and resentment. Cannabis had been used in combination with amphetamines over varying periods of months to years; 863, of whom 404 (46.8%);

  5. Burglary 2,880, of whom 1,764 (61.2%) with a history of cannabis. 70% (2,016) had previous convictions.

  6. Culpable driving 3,665, of whom 1,963 (53.6 %) with a definite history of cannabis smoking and illegal trafficking.

It has been reported that the number of underworld marihuana traffickers increases at a rate of 100% yearly (Cano, 1961). There is definite evidence that this incidence is steadily rising in many West African countries with increasing use of cannabis to produce temporary euphoria, blunting of critical judgement, disinhibition and increased confidence. In many West African countries, reports have been received of highly-organized political thugs who are prepared to undertake any form of villainy. Usually, these hired individuals, who are constantly "fed" on Cannabis indica and alcohol liberally, "protect" their political overlords who hire them. We also suspect that the use of cannabis enhances suggestibility in certain individuals, and this may be a factor in the commission of crime by these chronic abusers.

  1. Schizophreniform disorders. - This clinical category is the next group of disorder occurring very frequently, more especially among the age group of "less than 30 years ", which is about the common mean age for the outset of schizophrenia. This group is a fairly heterogeneous clinical group resembling schizophrenia in its clinical manifestations with usually good prognosis. They tend to clear up fairly rapidly with intensive drug treatment. Paranoid and depressive colouring are frequent with disorders of perception.

  2. Symptomatic disorders. - These range from mono-symptomatic disorders of restlessness, nocturnal agitation and sleeplessness to periodic thought confusion; predominantly found in the age group of "less than 30 years" with good prognosis. Phobic symptoms are fairly frequent, and in about 25% (136) of the group treated, these were the only symptoms.

  3. Psychoneurosis. - This group is usually made up of anxiety-hysteria. In our experience, these patients are more in need of psychotherapeutic handling. The prognosis is fair. Relapse rate is high, even when the patient has abstained from use of cannabis.

5. Total management of chronic abusers of cannabis in West Africa

Persistent abuse of cannabis, not unlike alcoholism, if not a disease of the personality, may produce a disorder requiring special treatment and rehabilitation programme. What is happening in many advanced countries of the world has clearly shown that there is very little to be gained "when society adopts a punitive approach towards victims of a behaviour disorder and treats them as criminals". Ansubel (1960) has stated rather bluntly: "Technically speaking, of course, drug addiction per se is not a crime. But since all drug addicts are guilty of unlawful possession, sale, or purchase of drugs, or of illegal diversion of legitimate stocks for personal use, drug addiction, for all practical purposes, is a criminal offence." In most West African countries, possession of cannabis is a criminal offence.

Total management of this problem in Africa may be envisaged under the following headings:

  1. Tracking the "disease";

  2. Institutional treatment;

  3. Intensive health and civic education;

  4. The legal measures.

  1. Tracking the "Disease"

Wherever there is an efficient medical service dealing with patients in relatively small centres or communities, the treatment centres act as agents of propaganda as well as curative and preventive establishments, but it is just these centres that are lacking in West and East African countries today. The only way of supplying this lack is to make use of the general practitioners and the health workers who must assume responsibility for diagnosis and referral; indeed, in West and East African countries, without the collaboration of these people, the campaign against abuse of drugs cannot be carried on effectively.

But this collaboration necessitates on the part of the practitioners and health workers some knowledge of specific social disease which they will be asked to recognize, and of the treatment which the general practitioners will be asked to apply. Otherwise, correct "identification of a case" is impossible, rapid treatment or referral will not be carried out, the risk of spread or "contagion" will be great, and may threaten both the family and the community.

Above all, if one desires to carry out a really effective preventive campaign, the health workers, the general practitioners, the law officers, the factory medical personnel, especially in big cities, must be given a new orientation, and must know how to recognize this and other related disorders, the types of vulnerable persons (not only the inadequate immature individuals seeking for hedonistic satisfaction, but the culturally vulnerable and economically deprived), the tendency of the disorder to spread once established, and how these dangers of spread affect society, the family and the immediate neighbours of the patient. Definite social policy must be established in which public health and social medicine will play an indispensable role. Here, if anywhere, lies a problem for preventive medicine.

  1. Institutional Treatment

In Africa today, especially south of the Sahara and north of the Kalahari, many hospitals, especially psychiatric, are not designed for the effective treatment of drug addicts; essential features such as adequate psychotherapy, vocational guidance and training, effective follow-up services within the community are lacking. Our experience in Nigeria has shown that continuous supervision is necessary to ensure that the patient adheres to the treatment prescribed but, unlike pethidine addiction, many cannabis addicts can safely be treated on an ambulatory basis.

Rehabilitation is an essential part of the treatment programme. It is essential that this should start as soon as the patient enters the hospital and not to leave this part of the management until the patient is about to leave the hospital. In West Africa rehabilitation is not simple, since the patient is usually a man in transition, and his problems - personal, economic, social or a combination of these - are invariably of the same nature. In West Africa today there are many non-addict users of cannabis who have "problems" with no clear guide as to how to solve them.

  1. Intensive Health and Civic Education

The education of the public in these matters plays a vital role in the entire management of these conditions. We now know that in many cases the origin of abuse of drugs and drug addiction can be traced to social contacts in urban areas. The main agents influencing the spread of drug abuse in metropolitan areas are the domestic servant, the unemployed, the migrant worker, the soldier, the sailor, the long-distance lorry driver, the factory worker, and the student. In most African countries propaganda does not reach the ordinary haunts of many of these groups, especially the illiterate inhabitants. Propaganda obviously is not limited to the classes of population already mentioned, since politicians have been seen by the author to be victims, but should be made available to all, and should take advantage of any chances that are offered: public welfare centres, workshops, factories, sports clubs, etc.

It is important that propaganda should be adapted to the way of life of the people. The community leaders, the chief, the priest, the schoolmaster play a very important role here because of the authority which belongs to their status. It is said that the whole basis of health education is now being discussed in authoritative quarters. It is to be hoped that this aspect will not be overlooked.

  1. The Legal Measures

The present author has made a special study of the situations in many African countries. There are no legal measures against drug addiction in any of the West and East African countries. This problem is not only recent, but is still tucked away from the full view of many leaders, administrators and medical men. Although virulent and destructive to society, not unlike venereal disease, drug addiction must receive special attention to enable proper legal and administrative provisions to be made which would not only encourage voluntary treatment but enforce certain individual victims to obtain medical help. Legal and administrative programmes should also give major consideration to effective control and prevention.

The above observations have unequivocally demonstrated the necessity for co-operation between all the medical and health services on the one hand, and the law enforcement officers on the other. Control or eradication demands not only knowledge of the cause and measures of prevention among all workers concerned (medical, health, social scientists and law officers), but also the full participation and voluntary co-operation of the community. National development planning should ideally be considered in relation to the neighbouring region of the continent.

6. Conclusion

This is an attempt at stock-taking of our work rather than the result of intensive research. Most of our psychosociological information is derived from empirical observations of the African in transition employing all available data - clinical, police, prison, demographic and sociological to formulate further hypotheses. In addition, attempts are being made to re-examine older concepts and theories of addiction in the light of new or more refined empirical evidence.

Lambo (1963), writing on the mental health problems in less-developed areas of Africa, emphasized the resultant effects of changing socio-economic structure in Africa. He writes: "In terms of mental health, one of our main research activities has been to study in detail the reactions of individuals in changing situations - whether they are African students in London, unstable migrant workers in Lagos, ageing old ladies living for the first time in an African city, or illiterate but intelligent young traders trying to enter into the cosmopolitan economy in Accra - irrespective of whether these changes were spontaneous within the group or due to outside influences." The incidence of some psychiatric disorders in sub-Saharan Africa would seem to correlate with social change, especially of a rapid and exacting nature and out of proportion to adaptational capacities of individuals. These rapid and stressful changes would seem to engender, in addition, those deviations of human behaviour which are usually merely considered from ethical or legal standpoints, such as delinquency, alcoholism, prostitution, drug addiction, vagrancy, etc.; they also include many social phenomena which are very often dealt with on the basis of purely economic principles or on very general lines, phenomena such as the various manifestations of social unrest, of embitterment between classes, of strikes, and of disturbances inside the individual workshop and factory.

Our observations have pointed to the fact that the causation of the abuse of cannabis and drug peddling in West Africa, like many related socio-pathological phenomena such as crime, alcoholism, delinquency, prostitution, gangsterism, etc., is multifactorial. The changing socio-economic and demographic patterns, the psychological and cultural receptivity of the individual, accessibility of certain drugs, overt group identification and other psycho-sociological factors are important for our consideration. In our study of individual patients, we have learnt that in the formulation of each case one must take into account the possibility of a disorder at each of many levels. Drug addiction, like crime, is the product of many variables. In some cases the disorder of constitution plays an important aetiological role; in some cases there are definite emotional or temperamental idiosyncrasies; in some patients special experiences have sensitized the patients in certain directions.

The new medico-social problems of Africa are not unrelated to the major social change involving town and rural planning, industrial development, including problems of labour and employment, migratory pattern and movements, health, education, cultural activities, leisure, etc., on which concrete and realistic policies have yet to be made. This connexion between these changes and the appearance of new disorders or the aggravation of the existing ones is far from being fortuitous.

Further work of a more scientific kind designed to gain new knowledge is required and it is hoped that a multidimensional approach, which will permit the participation of many interested disciplines, will be made in this field.

Acknowledgement

I acknowledge with thanks the most valuable information and statistics given by the Office of the Inspector-General of Police, Lagos, Nigeria, and the cooperation of the Deputy Commissionner of Police, Western Nigeria, and their counterparts in many East and West African countries. I thank all my medical colleagues from various African countries who have been in communication with me on this subject. I also thank the S.T.R.C. Secretariat (Publication Office), London, for their co-operation. Finally, I should like to express my appreciation to the final-year medical students who took a very active part in many of the surveys about two to three years ago.

r000

Based on the Scientific Report given as Expert-Consultant to the United Nations, United Nations Seminar on Narcotics Problems in Developing Countries in Africa, Addis Ababa, 11 to 22 November 1963.

r001

It has not been possible to include the results of the breakdown of the questionnaire in this paper.

r002

Includes S.T.R.C. research data on migration in West Africa, 1961.

3

The Navetanes of Senegal come from Guinea and the Sudan every year to find work growing and harvesting ground-nuts. The Mossis of the Ivory Coast and Ghana belong to the Upper Volta, and mainly come to Ghana to work in the cocoa plantations. In Madagascar, the Antadroys seem to be particularly prone to migrate, and swarm throughout the island (sugar plantations of Nossi-Be and the Petsiboka, part of Diego-Suarez, etc.). For further details; see R. Blanc: Handbook of Demographic Research in Under-developed Countries, S.T.R.C. publ. No. 36.

4

Endemic diseases, under- and mal-nutrition, venereal diseases. Endemic diseases, especially malaria and the enteric-parasitic group, are not uncommonly aggravated by chronic use of Cannabis indica. Acute brain syndromes are much more common in the migrants than would seem to occur in the normal population.

5

Value judgement based on material standards.I

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