YEAR IN REVIEW 1996: HEALTH-AND-DISEASE

MENTAL HEALTH Depression, suicide, suicidal behaviours, and other psychosocial disorders were all increasing rapidly among young people throughout Europe and North America, according to a major international survey conducted in 1995. The study group, chaired by Sir Michael Rutter of the Institute of Psychiatry at the University of London, could find no clear explanation for this growing problem, which was accompanied by similar trends in alcohol and drug dependence. Virtually the only area of mental health that did not show unambiguously worsening figures among teenagers was that of eating disorders. The survey also indicated that the incidence of suicide, substance abuse, and crime was particularly high among males, whereas depression, eating disorders, and suicidal behaviours were especially prevalent among females; however, the male and female rates for depression, substance abuse, suicidal behaviours, and crime were beginning to converge. From a global perspective, the outlook appeared no more optimistic. In a report issued in May at United Nations headquarters in New York City, a team of health authorities from 30 countries warned that increasing rates of mental illness in less developed countries threatened the social stability of the Third World. The group cited not only neuropsychiatric disorders such as epilepsy and schizophrenia but also behavioral problems such as substance abuse and violence. It noted that war and political upheaval were responsible for an increased risk of depression, anxiety disorders, and other forms of mental distress among the world's more than 40 million refugees and displaced persons. Concern about rising suicide rates among men under 35 in Europe prompted researchers in Helsinki, Finland, to assess the incidence of mental disorders in such individuals. The results showed that significantly more of these men had suffered from a psychotic illness, compared with those aged 35-59 who had committed suicide. The latter had higher rates of alcohol dependence and depression. The prevalence of psychotic disorders in the under-35 age group was much higher (25%) than in previous studies in similar groups in Canada (9%) and in Sweden and the U.S. (17%). However, the prevalence of personality disorders (43%) was about the same as in earlier surveys conducted elsewhere. Researchers in Edinburgh reported a disturbing trend in the rate of suicide during the first 28 days after discharge from psychiatric hospitals in Scotland during the years 1968-92. They found that although the incidence of suicide had declined by 40% among discharged male patients, the rate among female patients had almost trebled. The investigators pointed out that this development had occurred during a period when mental health services had changed from largely institutional to predominantly community-based programs, the number of psychiatric beds for adults having declined by 60%. A strong association between suicide and parasuicide (an act of self-injury not motivated by a genuine desire to die) emerged from work carried out in Bristol, England. Despite the difference in motivation between the two types of acts, socioeconomic deprivation emerged as a common element. A report by the Royal College of Psychiatrists and Royal College of Physicians of London focused on the importance of paying attention to the psychological needs and difficulties of medical patients. People with appreciable physical illness have at least twice the rate of psychiatric disorder of the population at large, yet many hospitals fail to provide appropriate services to assist with these problems, which include depression, mood disorders, and cognitive impairment. In addition to citing direct benefits to the patient, the report included evidence from the U.S. of economic benefits--for example, orthopedic patients in the U.S. who received psychiatric counseling had shorter hospital stays than those not offered such assistance. The report advocated integrated physical and psychiatric care for all patients with significant physical illness. Research published during the year contributed to the understanding of auditory verbal hallucinations ("hearing voices") in patients with schizophrenia. The investigators, psychiatrists and neurologists in New York City and London, used brain scanning to study patients with schizophrenia who complained of hearing voices. They also studied schizophrenics who did not hear voices, as well as a group of normal, healthy individuals (controls). The scans were designed to reveal alterations in blood flow as various parts of the brain became active. The procedure showed that there were no differences in blood flow between the hallucinators and the controls when they were asked to "think in sentences." There were differences, however, when the subjects were asked to imagine sentences being spoken in another person's voice--a task that required them to both generate and monitor so-called inner speech. In the latter case one brain region in the hallucinators functioned normally, but abnormally low responses occurred in two other regions, which were activated in both the controls and the nonhallucinating schizophrenics. This finding strongly suggested that a predisposition to "hearing voices" is associated with a failure to activate areas of the brain that play a role in monitoring inner speech. Those who are affected may misperceive such verbal thoughts as coming from external sources, or they may simply be unaware of having them. (BERNARD DIXON) This updates the article mental disorder. New, Resurgent, and Surprising Viruses The smallest of the microbes, the viruses, provoked the greatest concern in 1995. Australian scientists reported in April that they had identified the cause of a puzzling 1994 outbreak that killed several horses and their trainer. The culprit was a new virus, a member of the family that includes the measles virus and the organism responsible for canine distemper. An epidemic of Ebola virus in Africa prompted increased awareness of the potential dangers of so-called hot viruses, which cause deadly and virtually untreatable diseases in humans and other animals. Between January and April, 189 people in southwestern Zaire developed an acute illness marked by fever, vomiting, and bloody diarrhea. About a third of them died. Epidemiologists from the World Health Organization (WHO) soon incriminated the Ebola virus and initiated measures to prevent further spread of the infection. By August, when WHO announced that the epidemic was over, 315 people had become ill, and 77% of them were dead. In 1989 a fatal disease among laboratory monkeys imported into the U.S. from the Philippines had been linked to an Ebola-type virus. In their search for the origin of the Zaire outbreak, the WHO investigators captured over 3,000 birds, rodents, and other animals, plus several thousand insects, but failed to pinpoint the source of the virus. Firm evidence of a link between primates and Ebola virus infection in humans did come to light, however. In May French scientists reported that they had isolated a new strain of the virus from a researcher who became infected in Cte d'Ivoire while performing an autopsy on a chimpanzee. The troop in the wild to which the animal belonged had recently been decimated by a hemorrhagic disease similar to that caused in humans by the Ebola virus. That even relatively familiar viruses are capable of surprises was underlined by a report from Sweden of the mysterious spread of hepatitis C virus among 37 patients in a hospital ward. Although this virus is usually transmitted by intravenous drug abuse or through contaminated blood or donor organs, the Swedish scientists were convinced that it had not been spread via the usual routes or as a result of any lapse in hygiene. They concluded that the virus had been transmitted by some other, as-yet-unrecognized route--possibly through the air. Another surprise in 1995 was the publication of research from London and Glasgow, Scotland, indicating that childhood diabetes is related to infection with Coxsackie B viruses (relatives of the poliovirus). Although diabetes involves a genetic predisposition, environmental factors are also thought to play a role. The researchers found the genetic material of Coxsackie viruses in blood samples from 9 of 14 children at the onset of diabetes but in only 2 of 45 healthy children. This finding did not prove causation but was highly suggestive. (BERNARD DIXON) VETERINARY MEDICINE Japan was host to the 1995 World Veterinary Congress in September. The event, which was opened in Yokohama by Emperor Akihito, attracted representatives from 82 countries. The emperor noted that veterinary scientists, with their deep understanding of and rich experience with animals, had provided "many suggestions regarding the optimal relationship between human beings and animals." Speakers included Jean Blancou of the International Office of Epizootics, who reviewed the often devastating consequences of past disease outbreaks associated with the movement of animals between countries. As international trade in animals and animal products was likely to increase as a result of the newly established World Trade Organization, Blancou observed, a strengthening of veterinary surveillance arrangements and increased research on animal vaccines were called for. At the World Small Animal Veterinary Association Congress, which was held concurrently, the association's president, Peter Bedford of London, announced that the group's Eastern Europe continuing education program, which aimed to update veterinarians in former Eastern bloc countries, would be extended to help less developed nations elsewhere. Bovine viral diarrhea is a disorder that affects cattle worldwide and has serious adverse effects on health and productivity. The virus is passed from dam to fetus in the womb, and the calf is born with the infection. Calves often show no signs of disease until they acquire a form of the virus that rapidly causes mucosal disease and death. In the absence of any effective treatment, vaccination of female cattle before they are bred has been recognized as the route to control. Live vaccines have been developed and used in some countries, including the U.S., but have not eradicated the problem. In 1995 a new inactivated vaccine was shown to protect heifers exposed to the virus, and calves subsequently born to them, unlike control animals, were free from infection. The production of identical calves potentially would be valuable to the livestock industry by increasing the number of offspring from high-quality parents and to scientific research by providing genetically identical animals for comparative studies. Embryo-transfer and cell-division techniques have been used to this end, but the maximum number of calves produced by these methods was three. In 1995, however, W.H. Johnson and colleagues at the University of Guelph, Ont., succeeded in producing four identical calves from a single embryo. The embryo was divided at the four-cell stage and transferred to two recipients, which resulted in the births of two sets of identical twins--four genetically identical animals. (EDWARD BODEN) See also Life Sciences: Molecular Biology. The Environment INTERNATIONAL ENVIRONMENTAL ACTIVITIES International Cooperation. The threat of global warming continued to dominate environmental concerns in 1995, and for the first time, climatologists were confident they had detected conclusive evidence of it. Some progress was made by European countries toward curbing traffic pollution. What was said to be the third largest oil spill ever recorded, in the Russian Arctic, caused less damage than had been feared. Most of the oil was contained, and an effective cleanup operation was launched. In June Greenpeace protesters drew worldwide attention to an obsolete oil-storage platform, Brent Spar, which was to have been sunk in the Atlantic Ocean, and succeeded in persuading the owner, the Royal Dutch/Shell Group, to opt instead for disposal on land. Many scientists, however, believed deep-sea disposal would have been preferable from an environmental standpoint, and Greenpeace eventually discovered an error in the sampling on which it based its objections. The controversy over what constitutes "safe" disposal lasted throughout the year. (See Sidebar.) At a meeting on toxic-waste exports held in Dakar, Senegal, in March, Denmark offered to serve as host for further discussions on the substances covered by the Basel Convention on international trade in hazardous wastes. This deflected attempts to prevent an extension of the ban--agreed upon in 1994 on exports of waste from countries in the Organisation for Economic Co-operation and Development to non-OECD countries--to the export of substances intended for recycling. The U.S. government was delaying ratification of the convention until it was amended to permit such shipments, provided the countries involved agreed and the waste was handled by internationally agreed upon and environmentally sound methods. The U.S. Chamber of Commerce also opposed the ban, which it said would affect the $2.2 billion a year the U.S. earned from trade in recyclable materials. In September, however, the 89 signatory countries to the convention agreed to the extension, forbidding the 25 OECD members to ship wastes to non-OECD members for recycling after 1997. At a meeting of members of the OECD held in Paris in June, Canada and Australia blocked an agreement, proposed by the U.S. and the European Commission, to reduce the amount of lead in the environment by phasing out lead in such products as gasoline, solder used in food and beverage cans, and paint used on toys and to reduce exposure to lead from paint, ceramics, and crystalware. Australia and Canada favoured a "voluntary action plan" in which the lead-producing industry would finance a database on lead and its health risks and advise governments on ways to reduce exposure. European and U.S. officials said this was inadequate unless incorporated in an agreement committing member states to recognizing the need to reduce exposure. United States. In proposals for the fiscal 1996 budget presented to Congress by the White House on February 6, the Environmental Protection Agency (EPA) requested $7.4 billion, $138 million more than its 1995 budget. The Office of Research and Development asked for an $84 million increase, to $630 million, some of which would come from reclassifying research funds from elsewhere in the EPA. The EPA, which celebrated its 25th anniversary during the year, sought approval for an additional $42 million to be spent on external research grants and $5 million for more graduate student fellowships. On April 18 Vice Pres. Al Gore introduced the National Environmental Technology Strategy, a document describing environmental progress made in the U.S. since the first Earth Day, in 1970, and setting goals for the 50th, in 2020. On April 22 (Earth Day 1995), 30 environmental groups launched a major campaign opposing congressional plans to weaken environmental regulation. LAW There were two dominant themes in international law in 1995: adjudication and the United Nations. In the background was the steady development of regional economic organizations, as well as treaties containing laws governing the conduct of private parties. In spite of the occasional eruption of violence between nations and the insistent refusal of the U.S. to subordinate itself to international structures or to external adjudication, a powerful impression was emerging that the old sovereign separateness of the members of the family of nations, on which classic international law had been based, was being diluted as part of the process of constructing a genuine world order. In addition, international law was altering its character to become more of a mix of public and private law, matching the change in international conflict from military to political-economic.