The Expert Committee, which had begun its work seven-teen years earlier, [is] today concerned not only with measures to prevent the abuse of drugs, but also with other problems connected with drug dependence and abuse, more particularly the sociological implications of drug dependence.
H. Halbach, to the Commission (1966)

NOTE: The figure 0.0 indicates that the subject is mentioned but takes up less than half a page. In 1950 no index was provided, and "drug dependence" was not part of a larger section. The structure of the report was in many ways different from that of other years. "Drug dependence" is used here as a heading although the actual terms used in the reports were: "addiction producing drugs" (1950), "drugs liable to produce addiction" (1955), "addiction producing drugs" (1960), and "drug dependence and drug abuse" (1965). Although the Division of "Pharmacology and Toxicology" was not established until 1966, this rubric is used for the entire period under review. The original headings covered by the rubric were: "international conventions, agreements and regulations of health" (1950), "drugs and other therapeutic substances" (1955), "biology and pharmacology" (1960 and 1965). For 1955 and 1960 the chapter "Co-operation with Other Organizations" has been included in the figure for "General review" for the sake of comparability. The headings for "Mental health" were: "mental well-being" (1950), "mental health and public health service" (1955). Although the space for "alcoholism" was limited in 1955, the paragraph was much more substantial than in later years. In the 1970s, "alcohol" and "drug dependence" were generally mixed; thus the index entries would often refer to the same page. It was difficult to compile comparable figures for the pre-WHO years (i.e. during the time of the League of Nations Health Committee) as the reports were then of activities between sessions and not by year. In 1972 the mental health section came under the Division of Non-communi-cable Diseases, which was originally the Division of Health Protection and Promotion.

We will begin with a consideration of the place of alcohol and other psychoactive drugs in WHO's pro-gram. The low priority given to matters of alcoholism and drug dependence compared to other concerns, is illustrate-d by table 5.1, the compilation of which was based on the annual reports of the WHO director-general to the World Health Assembly and the UN . The table shows that while the space given to "Pharmacology and Toxicology" (which embraces "Drug Efficacy and Safety," "Pharmaceuticals," "Drug Monitoring," and the like) in the reports has increased over the last twenty years, signifying its growing importance, that occupied by "Drug Dependence" has remained largely constant. It is significant that in 1%5 the amount of space allotted to "Pharmacology and Toxicology" was double that in 1960, while that given to "Drug Dependence" was halved. This coincides with the increased involvement of WHO in the promotion of drug safety in the face of drug-screening shortcomings which the thalidomide tragedy revealed. During the fifteenth World Health Assembly in 1962 a resolution was approved which requested that a study be made of the feasibility of WHO developing a program for the formulation of standards for drug evaluation, the exchange of information on drug safety and efficacy, for rapid reporting of adverse reactions to drugs. (For the thalidomide story see Sjiistram and Nilsson, 1972).

Alcohol is briefly touched upon in these reports. In the last two years there has been greater overlap between the contents of "Alcohol" and "Drug Dependence," and therefore the apparent increase shown in the table is somewhat exaggerated.

Evidence for the relative lack of importance attached to this field can also be found by looking at the projects which have been undertaken by VVHO and at the extent to which the Assembly and the executive board have adopted resolutions and made decisions in connection with drug dependence. As far as programs are concerned, the records reveal a modest range. In 1955 it was decided to embark upon a survey of alcohol problems in Europe, but by 1957 this was no longer listed as a project. Two "Drug Dependence" projects were mentioned for 1970 and 1971—one was, in fact, the convening of a working group; the other proposed the evaluation of the treatment of drug addicts in Hong Kong. In 1971 "alcohol" and "drug dependence" were jointly cited in reference to consultations on "National Responses to Problems of Alcohol and Drug Dependence" and an interregional training course--a seminar traveling to three European coutitries.
As for decisions reported in the WHO Handbook of Resolu-tions and Decisions of the World Health Assembly and the Executive Board covering the period 1948-70: alcoholism was featured four times but only during the period from 1948 to 1952, whereas twenty-three decisions were registered in relation to "Drug Dependence," divided into three categories—expert committees' decisions made between 1948 and 1953 ; control measures for psychotropic substances, 1965-70; and interna-tional conventions, 1948-66 (WHO Handbook of Resolutions and Decisions, 1971).

Historical descriptions of WHO's activities point in the same direction. In a paper on the mental health program of WHO from 1949 to 1972 (MH/72.4) little more than half a page out of a total of twenty is given to "dependence on alcohol and other drugs." And whereas alcohol and other psychoactive drugs were not given differential emphasis in a history of the first ten years of WHO, more attention was paid to the other drugs in the sequel—"The Second Ten Years." But even here attention to psychoactive drug-use problems was overshadowed by that paid to evaluation for safety and efficiency. (The First Ten Years of WHO [1958]; The Second Ten Years of WHO [1968)

These documents do not reflect the entire work program of the departments under review. In addition to the activities men-tioned, the Mental Health Unit is, according to the annual report for 1971, working on a glossary of psychiatric illnesses, featuring, among other items, alcoholism and drug dependence. The corresponding text on the Drug Dependence Unit does not say much about concrete activities and is more a description of an approach to the program. There are statements of principles on the multiple causation of drug dependence, on control measures based upon the limitation of availability and the limitation of demand through education and treatment, and on the importance of increasing knowledge of the causes and consequences of drug dependence. The Vienna Protocol is also mentioned.

The work of WHO is characterized by the use of a variety of competences; expert committees and scientific and study groups are regularly convened, and consultants are called upon, to deliberate on a particular topic. The most prestigious of these are the expert committees, which are composed of individuals appointed by the director-general of WHO. At least in the area which concerns us, WHO has usually followed the advice of the head of the Drug Dependence Unit in selecting these individuals. These experts are not representatives of their governments but serve in their personal capacity. Expert-committee members are selected from WHO's expert advisory panels, which are subject-oriented lists of individual experts who contribute information by correspondence or reports on matters falling within their particu-lar fields. Appointment to a panel is usually for a period of five years, and here WHO seeks the approval of the respective governments. In early 1969, 29 persons were listed on the Drug Expert Panel and 129 on the Mental Health Panel (EB 43/WP 2). Nearly half of the former were drawn from the U.S. and the U.K. (12), whereas world-wide representation is better reflected on the Mental Health Panel. Selection of expert-committee members is not confined to the corresponding expert panels but may be made from other panels. Expert committees usually comprise no more than ten members. They are convened to consider specific topics, and their reports serve as guides for governments and for action in WHO. As alcohol expert committees will be dealt with later (chapter 12), we will confine our remarks here to the Drug Dependence Expert Committee.

The Drug Dependence Expert Committee shoulders the main burden of WHO's obligations under the international drug treaties. In the League days, the Health Committee assisted in determining what substances were to be placed under the control schedules, but since WHO's inception this function has been performed by the Drug Dependence Expert Committee. Although we refer to this body as though it were a standing committee, its composition, in fact, varies from year to year and it is not to be compared with the permanent organs of the UN. The committee is in a unique position on account of its role under WHO's treaty obligations. In January 1952 the WHO executive board decided that all the reports of the expert committees (which are published) should bear the disclaimer "This report .. does not necessarily represent the decisions or the stated policy of the World Health Organization" (EB 9/R 74). Thereafter, this disclaimer can be found on the covers of front pages of the reports of all the éxpert committees except those of the Drug Dependence Committee. However, in the latter's report published in 1973 this disclaimer appears for the first time. The explanation for this may lie in a divergence of views between the director-general of WHO and the experts with regard to the Vienna Convention. The changing character of the committee may be another reason for the change.

The committee has met almost every year; during the period from 1949 to 1972 it met nineteen times. The committee convenes for a week at WHO headquarters in Geneva, and during that time a report is prepared for publication. As this requires much advance preparation, the organizers of the meeting in the secre-tariat usually undertake negotiations for the appointment of a chairman and a rapporteur ahead of tiine, so that the officers can be elected at the committee's first meeting.

So as to provide some clues to the work of the committees, an effort was made to classify all the recommendations which they have made since 1949 (see table 5.2). Before making any infer-ences from the figures, a word of caution is in order. It is not always clear from the reports what constitutes a recommendation by the committee, and recommendations are not always immedi-ately distinguishable from expressions of opinions and advice. At the same time, we have noticed that the term "recommendation" has been used with care and with the connotation that it is to be transmitted to the UN secretary-general, that is, the Division of Narcotic Drugs in practice. Our tabulation is therefore based on statements which bear these two attributes and which may be regarded strictly as recommendations; those which give rise to uncertainty are omitted. The results which we obtain do not therefore correspond to an earlier claim regarding how frequently the expert committee has recommended controls; for instance, it was said that the committee had recommended subjecting amphetamines to control in four reports (Cameron, 1971). Although views have been expressed by the committee on these occasions, they did not amount to general policy; moreover, no clear opinion was transmitted to the UN as a recommendation by the committee. This reinforces our belief that the impact of the committee on the development of controls is slighter than is generally supposed. Another shortcoming of the table is that it does not reflect changes in orientation; the first time Dale Cameron served as secretary to the expert committee, the ordering of the contents of its report was altered and the passages dealing with drug control notifications came at the end of the report instead of at the beginning. This may reflect a shift away from WHO's earlier orientation, which was towards "the drug or agent of addiction" rather than towards the individual or his environment (see Cameron, 1971: 145). Finally, one should not be misled by the figures in the table representing the number of control recommendations into thinking that the committee was procontrol. The committee has discussed some drugs (such as barbiturates) without making accompanying recommendations for control. Thus the areas untouched by recommendations must be borne in mind when noting those marked by them.

There have been 117 recommendations. Most of these were for the inclusion of a specific drug in one control schedule or another by application of the relevant provisions of the existing conven-tions. In addition, similar recommendations have been made without treaty paragraphs being invoked. Some recommenda-tions were for the acceptance of goverment notifications for the exclusion of a drug from international control; others advocated changing the status, or degree of control, of a drug. The number of other recommendations is relatively small, and the majority of them was made in the first two years. Government notificatibns provide the bulk of the committee's drug classification work. Following a decrease in the number of notifications, a significant decrease in the total number of recommendations occurred in 1%3. However, it should be noted that at the beginning many recommendations were made which were not instigated by notifications.

The largest number of notifications (about 40 percent), stems from the U.S.; France and the U.K. are next, and the three countries together account for about two-thirds of all notifica-tions. That the total number has diminished is due to at least tvvo developments. First, in recent years there has been less readiness to propose for international control, new drugs that are not yet, or not likely to be, marketed. Secondly, pharmaceutical research aimed at developing substitutes for morphine without addiction liability has become far less intense, discouraged by the failure of earlier efforts. This leads inevitably to a reduction in the number of recommendations, since the Committee has been engaged mostly in evaluating drugs of the morphine type.

Although these circumstances explain the decrease in recom-mendations in recent years, the impression gained from a com-parison of the reports is that, on balance, the committee's recommendations for placing new drugs under international control have tended to be sparing and to lag behind actual events. Barbiturates and amphetamines, for example, were discussed for years before a clear position endorsing international control emerged in the committee. There has been little interest in relating scientific knowledge to social purpose, and little discus-sion (at least insofar as can be judged from the reports) of the principles of drug control. Even given the fact that, during the first two years, heroin and its therapeutic use engaged much of the committee's attention, and statements relating to definitions and research were, contrary to later practice, framed as recommen-dations, the committee seems to have been more prone to controls in earlier years than later.

That slight attention has been paid to issues involving princi-ples may have to do with the fact that the expertise of the committee has lain predominantly in the field of pharmacology. The fact that WHO governmental representatives and professional secretariat members are preponderantly medical doctors may also have a bearing on the selection of members and, indirectly, on the nature of the decisions reached. One notes that of the represen-tatives in two VVHO meetings in 1%7 (the executive board and the World Health Assembly) over 70 percent and 65 percent, respec-tively, were physicians (Cox and Jacobson, 1973: 196).