Peru

1194

Marketing strategies involve tailoring a combination of the product, its price, its availability, and its image to girls and women. In the USA, Europe, and Australia the predominant approaches have involved a campaign known in the tobacco trade press as the "three Ls"-longer length, lower tar, and lower priced cigarettes.14 Individual brands such as ’Virginia Slims’ (USA), ’Kim’ (Europe), and ’Alpine’ (Australia) are marketed exclusively as "women’s cigarettes". Women’s magazines and televised sports events sponsored by tobacco companies have been used as vehicles to promote the idea that women who smoke cigarettes are slim, glamorous, emancipated, classy, and sporty.15,16 Increasingly urbanised, expanding populations with few controls on cigarette promotion offer receptive audiences for the tobacco companies. The imagery is often overtly directed at associating cigarettes with affluence, status, and sexual prowess. In countries such as Hong Kong, where only 3% of women smoke, "women’s brands" (eg, Virginia Slims) have been launched. In Brazil more money is spent on cigarette advertising than on any other product, and brands such as ’Charm’ are directed at women. WHY DO WOMEN SMOKE?

As the proportion of women who smoke approaches that of men, it is widely assumed in affluent countries that women smoke as a consequence of increased emancipation. But among established women smokers there is little evidence for the "emancipated smoker" outside the advertising imagery. UK research into why women smoke suggests that women’s motives for smoking differ strikingly from men’s and indicates that continuing inequalities in women’s lives--especially low income and responsibilities for family care--are important motivating factors. Three interrelated factors distinguish women’s motivation to smoke from men’s.18 First, women are more

likely than men to use cigarettes as an emotional safety valve-a response to perceived stresses. Second, women see themselves as more dependent on cigarettes than men; this is unlikely to be explained by a differential dependence on nicotine but rather as a social or "learned" dependence. Third, women--especially girls-are more likely than men to smoke cigarettes in an attempt to control their weight.19 Although recent evidence suggests that the assumed inverse association between smoking and body weight is weak among young women, 20 women fear weight gain as one of the main negative consequences of stopping smoking. It has been argued that this is because women in western societies learn to value their looks more than their health, which makes the promotion of cigarettes as a passport to slimness a potent force in encouraging women to smoke.

Round the World From

our

Correspondents

Peru POLITICS AND THE HEALTH CHALLENGE

said Dr Alfredo Calderon, to the detriment of the patients. Health services in this country are in a bad way, and I don’t know what can be done to save the situation." Dr Calderon is a leading gastroenterologist in the Peruvian capital, Lima. Like most South American doctors, he is a worried man. Public health here deteriorates almost daily as the country struggles under a massive foreign debt and a sharply rising cost of living. In March the cost of living increased by 42%, taking the inflation rate in the first quarter of the year to 198%. Basic medical care is out of the reach of the average wage-earning Peruvian, let alone the millions of poor peasants who live in the Lima shanty

"Everything

in Peru is

politics",

"Politics, politics, politics! Of course it is

towns.

The Government under President Alan Garcia

struggles

manfully and sometimes successfully to combat the spread of diseases; medical opinion is now that the health authorities are losing the battle. Health minister Luis Pinillos said this week that

poliomyelitis would be eradicated from the country by next year, countering criticisms that the campaign of mass vaccination was grinding to a halt through lack of money. Plans to vaccinate more than a million children under a programme called VAN 89 are due to start soon, but medical opinion is divided over how successful it will be. A more serious concern is the rapid reappearance of tuberculosis (TB) along Peru’s desert coastline, which includes Lima. In the coastal population in general up to 450 people out of every 100 000 examined have TB, compared with up to 70 in other parts of Peru. Dr Calderon is among many who think that unless there is immediate Government action the disease will be out of control. "We are seeing very serious forms of TB that we haven’t seen in Lima for years-of the spine, kidneys, and joints", he said. "There

B. JACOBSON AND OTHERS: REFERENCES Layde PM, Beral V Further analyses of mortality m oral contraceptive users. Lancet 1981; i: 541-46. 2. Austin DF. Smoking and cervical cancer. JAMA 1983; 250: 516-17 3. Royal College of Physicians. Fractured neck of femur: prevention and management. London: Royal College of Physicians, 1989. 4. Masironi R, Rothwell K. Tendences et effets du tabagisme dans le monde. WHO Stat Q 1988; 41: 228-41 5. Commission of the European Communities. Europe Against Cancer survey: Europeans and the prevention of cancer Brussels: EC, 1987. 6. World Health Organisation. Smoking control strategies in developing countries. WHO Tech Rep Ser no 695. Geneva WHO, 1983. 7. Jacobson B. Third world women-the invisible tobacco users. Hlth Policy Planning 1.

1986; 1: 357-59.

Chapman S. Cigarette advertising and smoking: a review of the evidence. London: British Medical Association, 1985. 9. Aitken PP, Leathar DS, Scott AL, Squair SI. Cigarette brand preferences of teenagers 8.

CONCLUSIONS

There is an urgent need to respond to the growing international threat that tobacco imposes on women’s health. Few countries have developed programmes which focus on the special health concerns of women, and many governments have yet to demonstrate their commitment to WHO’s goal of a tobacco-free society. Department of Community Medicine, City and Hackney Health Authority, London

BOBBIE

Department of Community Medicine, University of Edinburgh

AMANDA AMOS

Tata Institute of Fundamental

Bombay, India

JACOBSON

Research,

MIRA AGHI

and adults Hlth Promotion 1988; 2: 219-26. 10. Cole J. Women-a separate market. Tobacco 1988 March: 7-9. 11. Sobczynski A. Marketers clamor to offer lady a cigarette Advertising Age 1983; Jan 31: 14-16. 12. Targeting the female smoker. Tobacco Reporter 1983, April 44-45. 13. Rogers D. Tobacco Reporter 1982; February: 8. 14. Reisman E. Look to the ladies. Tobacco 1983; March: 17-19 15. Jacobson B Beating the ladykillers—women and smoking. London Gollancz. 1988. 16. Jacobson B, Amos A. When smoke gets in your eyes London. British Medical Association, 1985. 17. Graham H. Women’s smoking and family health Soc Sci Med 1987; 25: 47-56. 18. March A, Matheson J. Smoking attitudes and behaviour: an enquiry carried out on behalf of the DHSS, OPCS. London: HM Stationery Office, 1983. 19. US Department of Health and Human Sciences. The health consequences of smoking. Nicotine addiction. A report of the Surgeon General. Rockville Centers for Disease Control, Office on Smoking and Health, 1987. 20. Mart B, Tuomilehto J, Korhonen HJ, et al Smoking and leanness: evidence for change in Finland. Br Med J 1989; 298: 1287-90.

1195 much poverty, overcrowding, and ignorance that it is difficult end." This week Dr Mario Romo Mayur, director-general of the National Programme for the Control of Tuberculosis, warned the Government that much more help was needed. He suggested that a TB postage stamp should be printed to support the fight against the disease. A percentage of the money from the sale of the stamp could be used to pay for vaccinations and preventive care. The difference in prevalence of TB between the coastal and other parts of Peru is likely to widen as more and more peasants leave their Andean homes to seek work in Lima. Pueblos jovenes, meaning literally young towns but which in reality are more like slums, are growing uncontrollably around Lima. Dr Romo warned that unless coordination between health and Government agencies improved the spread of the disease could not be controlled. Another concern is the sharply rising cost of medical care, which takes even simple general-practitioner health checks out of the range of most Peruvians. And morale among doctors is low, because they are very poorly paid by comparison with their colleagues in other South American countries. After 40 years of practice in Lima Dr Calderon has a state pension of 400 000 intis GC170) a month. Peru is in the grip of political struggle. Maoist guerillas, the Sendero Luminoso (the Shining Path), are making a violent and often successful attempt to destabilise the country. Although their base is in the Andean province of Ayacucho, the guerillas have sometimes managed to create the impression that Lima is a city under siege, blackouts and bombings are frequent, and public health is one of the victims of the increasingly costly battle to keep the terrorists at bay. And there is another form of politics that is affecting medicine in Peru. According to Dr Calderon, Government appointments to the health authority are based more on the amount of party support the candidates have given than on their ability. "The whole medical profession is politics", said Dr Calderon. "At one hospital you have 50% communist doctors and 50% Apra-ists (the ruling party). They don’t agree and the patient suffers." Unfortunately, another South American feature also affects Peru. As Dr Calderon pointed out, the hospitals for the police and armed forces are in good condition and have the best facilities, whereas most civilian hospitals have difficulty supplying swabs and cotton buds. is

so

to see an

"

Lima, Peru

MICHAEL GILSON

USSR MOSCOW SPRING: IS PSYCHIATRY THAWING?

THE delegation of American psychiatrists and others who visited Soviet psychiatric establishments in February have yet to report. Meanwhile another window on Soviet psychiatry was opened last month in Moscow when the International Academy of Law and Mental Health joined with the Serbsky Institute (whose senior psychiatrists have come under strong criticism) in organising a symposium on Law and Mental Health. How is psychiatry faring under the 1988 statute that provides for certain protections in cases of involuntary admission to hospital, and states that psychiatrists "must act independently and be guided solely by medical criteria and the law"? Day 1.-S. V. Borodin, a jurist from the Soviet Institute of State and Law, asks for the new legislation to be assessed positively, any protection being better than none. In his view, all forms of internment should be decided by a court, and a patient should retain certain rights when in hospital. He also refers to "use of treatment for the convenience of the State and not the patient" and "medicine used to keep the patient quiet". The patient should have direct access to a court where he can challenge his treatment as well as compulsory admission. Borodin finishes with a reference to the Vienna Accords: "Let us extend our protections; important items are still missing from the law". These pronouncements anger some of the Soviet participants. Asked whether the new law meets the

requirements of the UN Covenant on Civil and Political Rights, Borodin replies, "If I thought everything was all right I would not have read my paper". Another wave of excitement comes with a contribution from V. Lanovoi, president of the Independent Psychiatric Association, who has gained admission unofficially and has been allowed to address us briefly. Speaking of grave difficulties in the recent past which continue, he refers to the authoritarian and paternalistic ethic of Soviet psychiatry. His association, he declares, aims to improve the level of professional competence, deal with the problems of "hyperdiagnosis", and protect doctors who suffer from "pressure". He ends, "Abuse of psychiatry hits the abused patient but also backfires on the whole of psychiatry, which is discredited". Lanovoi is subjected to heated and hostile questioning. Challenged to give names of current victims of abuse he starts to read a list, but after three or four names he breaks off saying "there is really no point; everyone knows it is happening". As the day wears on, relations between most foreign participants and the Soviet psychiatrists remain mutually suspicious. At a reception in the evening G. V. Morozov, director of the Serbsky, makes his first appearance. M. Vartanyan is also present. Day 2.-From the chair, Morozov states that, in the past, procedures for compulsory admission were unsatisfactory; the treatment regimens, furthermore, were not individualised. He recognises the need to pay more attention to "the preserved features of the personality" and to be less free with the use of drugs. A Bulgarian asks him about the "special hospitals" transferred to the Ministry of Health and inquires what he meant by the words strict regime. Morozov replies that he was speaking of the necessary security measures; "strict" was a slip of the tongue. Later, L. Kaplan (USA) speaks on deinstitutionalisation in the USA, the homeless mentally ill, and the danger of linking the psychiatric role to the police role; in the discussion session, a Leningrad psychiatrist asks "Is it true that in the US a policeman can hospitalise a patient?". At the close of the day comes a mini-bombshell: the evening visit to the Bolshoi has been cancelled. Is this a sign of

disapproval? Last day.-In a paper with the promising title Perestroika in Moscow Psychiatry, V. A. Tikhonenko (USSR) says that the time has not come to evaluate the effects of the new law. Total admissions have fallen from 80 000 to 70 000 a year; but "Aggressive patients have tried to pressure psychiatrists", particularly in 1988 after accusations in the Press against psychiatrists. He believes that too many outside legal controls would undermine the individual moral responsibility of psychiatrists. Then comes H. H. Horskotte (West Berlin), stressing the UN guarantees of human rights and the Vienna Accords and discussing how the rights of the mentally abnormal offender can be preserved. He mentions political abuse but does not refer to specific countries. The paper is well received. Not so the contribution from T. W. Harding (Switzerland), who draws a distinction between individual cases of disrepect for human rights and systematic abuses. As an example of the latter, he refers to a mental hospital scandal in England, 1921, in which both the profession and the Ministry of Health refused to acknowledge the wrongdoing and suppressed the facts, as well as the more recent abuses of psychiatry in Japan. And, for the first time at the symposium, reference is made to political abuse by Soviet psychiatry. There is no applause. Jonna Smit (Netherlands) dissects the new Soviet law and finds it vague and giving too much power to the psychiatrists. D. Weisstub (Canada) speaks of the need to avoid extreme legalistic positions and puts forwards a relativist view: "adapt models to cultural and social realities of a given country". Winding up the proceedings, Morozov comes close to admitting that abuses did happen in the past: "There were diagnostic errors, malpractice, bad treatment, improper conditions ..." He expresses satisfaction with the meeting: "We will borrow positive experience taking into account our cultural conditions". Extraordinary and sustained changes are under way in Soviet society. Psychiatry has been slow to join in the process of questioning past practices. Morozov did admit to major defects and to human-rights failings, but not to politically motivated abuse. Two East European psychiatrists remarked, as we said goodbye, "Give it time; in six months or a year Soviet psychiatry will change like

everything else".