Sub-Saharan Africa
New customs, new practices
Dr Kemal Cherabi
Public health physician at the Institute for African Medicine and Epidemiology,
Bichat Hospital, Paris mspimea@hotmail.com

In the part of the world which has been the most severely hit by the AIDS epidemic, access to an expanding range of drugs is becoming increasingly easy. Drug-taking practices have changed, and so have the modes of consumption: the injection mode is developing, for example, both in urban zones and in some rural areas.

Multi-drug abuse is a frequent occurrence, since it is possible in some places to procure all kinds of legal and illicit products.

Sub-Saharan Africa, where 25 million persons have been infected by the HIV virus and AIDS, accounts for 90% of all the cases of AIDS recorded in the world (34.4 million cases in all). At roughly the same time as the AIDS epidemic was starting up in the 1980s, Africa was also beginning to discover the problems associated with drugs, although there was no direct link yet between the two. The background was similar, however, in both cases: in many countries, the socio-economic situation was changing, often for the worse.

The consistently high unemployment rates which resulted from the poorly assimilated free market economy principles introduced on the African continent gave rise to a feeling of social exclusion among the members of these very young populations, where at least 55% of the inhabitants are under 25 years of age. Alcohol is still one of the most frequently consumed drugs in this part of the world. But cannabis is now being grown intensively in many of the African countries, and this continent has become one of the centres of the international drug trade as far as cocaine and heroin are concerned: these illicit dealings have left their mark on the local patterns of drug addiction (1). The figures published in 1996 and 1997 by the U NDCP regional office for Western and Central Africa suggest that the Western African sub-region still serves as a major point of transit between the drug-producing and drug-consuming countries. And those involved in the public health and legal aspects of drug abuse generally i recognise that the drug dealers are tending nowadays tend to adapt the drug supply to the context, however poor the countries may be in which the demand for drugs has arisen.

This process has been considerably amplified by the climate of regional conflict and political disorder which has given rise to a general feeling of instability in some countries, such as Sierra Leone and Liberia. These conflicts have increased drug abuse, especially the consumption of amphetamines* by soldiers, including child soldiers.
In addition, the migratory movements which have occurred -either for economic reasons or because refugees and populations have been forced to flee- have increased the levels of poverty and unemployment.

THE ILLICIT USE OF MEDICINAL PRODUCTS

In this unstable context, the drug supply turns out to include a surprisingly wide range of consumable goods in the urban areas. Multidrug abuse is a frequent occurrence, since it is possible in some places to procure all kinds of legal and illicit products, whether one is looking for cannabis, cocaine, heroin, amphetamines*, benzodiazepines, alcohol or glue to be sniffed -or pharmaceutical substances to be used for illicit, non-therapeutic purposes. There is considerable demand for the latter drugs among the drug addicts, who are becoming increasingly dependent on substances of this kind.
Medicinal products can now be obtained from many sources, which, according to the local specialists, distribute goods which have been either illicitly imported or pilfered from public or humanitarian stocks, such as those intended for use in the framework of emergency aid to refugees from countries in a state of war.
The abuse of psychoactive substances of this kind for non-therapeutic purposes is developing fast, especially among the destitute members of the rural population, who have to put up with quite intolerable working conditions (2). Owing to the sensitive public health stakes involved, is difficult to fight this illicit drug market, which can have such dramatic effects in terms of drug dependence, drug resistance and therapeutic failure.

IMAGES CONDUCIVE TO SOCIAL EXCLUSION

From the psycho-social point of view, both society as a whole and family circles tend to picture drug abusers as people who behave asocially or even irresponsibly, so that they actually end up by adopting the attitudes for which they have been stigmatized by society, from which they cannot escape. After being rejected, they therefore tend to behave as they were expected to, and this leads to a tendency to self-exclusion or even selfdestruction. Taking illicit substances can thus revive psychological traumas and aggravate the process of social exclusion.
Many drug addicts thus end up in a vicious circle: the more they are pushed to the fringes of society, the more likely they are to use combinations of substances which are often of very poor quality, and hence all the more dangerous. Their state of health eventually degenerates and they become more susceptible to various infections, especially since these populations are completely cut off from all medical and social structures. Paradoxically, one might even say that the higher the risks they take, the less contact drug users will have with members of the medical and social professions.
Surveys carried out in Nigeria and Cote d'Ivoire have shown that the only structures catering for drug addicts in these countries are usually psychiatric hospital wards, which are extremely short of staff and equipment. Religious and charity institutions sometimes help to provide the treatment and social assistance required. However, the methods used in hospitals and the options with which drug addicts are presented are usually rather antiquated (3). Under these circumstances, drug addiction is bound to become an ineluctable, uncontrollable process. Under the present market conditions, multi-addiction tends to develop: the users are driven by their insoluble personal and social problems to try various combinations of the many products available because of the lack of any strict control over their distribution. In this framework, the abuse of drugs and medicinal products alleviates many sufferings: the physical sufferings which accompany disease when there is no alleviating treatment available, those resulting from difficult living or working conditions, and the psychological sufferings caused by social exclusion and lack of confidence in the future. This is all the more true since the population involved in drug abuse seems to consist mainly of social drop-outs, who are often young males, and tend to have no future prospects or achievements to look forward to.
In addition to the ready-made products, there are also the home-made ones: these are often powerful hallucinogens capable of causing vertigo, inebriety and delirium which trigger in those who take them asocial behaviour and critical states which are extremely difficult to understand from the medical point of view. These drug abusers also tend to take particularly frequent sexual risks (see p.64).
One of the main concerns of those faced with the increasing use of drugs in most of the countries in sub-Saharan Africa has been that of the changing modes of drug administration. The INCB has reported that the most clear-cut tendency has been the recent rise in injecting heroin abuse in urban settings where the consumption of heroin and cocaine was already on the increase (4). Although injection still accounts for a fairly small proportion of all the modes of drug abuse, the fact that it is on the increase is an ominous sign in a region where the rate of prevalence* of the HIV virus and AIDS is one of the highest in the world.

1 LABROUSSE, Alain, in Journal du Sida n°86/87, juinjuillet 1996, p. 57.

2 WERNER, JF, Marge, Sexe et Drogue à Dakar, Karthala, Orstom, Paris, 1993.

3 cf. UNDCP report AD/RAF/97/C86.

4 International Narcotics Control Board: the 2000 Report. Available at the following website: www.incb.org

THE IDENTITY OF MIGRANTS AND THEIR VULNERABILITY

In studies on migrants and AIDS, little attention seems to have been paid so far to the problem of drug addiction (1). Some authors have put forward the idea, however, that there may exist a drug addiction problem which is specific to migrants, especially in the case of young people who have lost their cultural roots and whose sense of identity "is strongly marked by the parents' cultural background, shows distinctly oral tendencies, and is characterised by a particularly strong relationship and identification with the mother and the lack or complete absence of a father-figure"(2).

However, drug addiction, like many other problems, is a component of some people's lives which is bound up in a complex way with their sense of identity and their inner and social being. Drug addiction among African and North African migrants has sometimes been attributed to the fact that these people have been cut off from their origins, their values and their culture, and have therefore lost their bearings or their sense of belonging to a family. Some young drug addicts have been sent back to their parents or their families for this reason, in the hope that they will recover a real sense of their own identity. This rather unusual, enforced type of migration provides yet another opportunity for stressing the links which exist between drug abuse, the HIV risk and the vulnerability of migrants. New modes of consumption and new habits are therefore being introduced on the African continent at the same time as human migrants travel from one place to another.

1 Cherabi (K.), Fanget (D.), VIH/SIDA en milieux migrants, 1997.

2 R. Bertellier 1993

Source: PEDDRO december 2001