A local and regional Alcohol and Drugs Monitor in the Netherlands: a tale of three cities.

Local and regional policymakers, care providers and prevention workers involved in addiction and addiction care need timely and reliable information. As few data on substance use are available at a local or regional level, an integrated local or regional monitoring system for alcohol and drugs (MAD) was developed. The MAD consists of four modules: a local social and information map, analyses of registration data of (addiction) care organisations, a local/regional survey among the general population and a community-based drug monitoring system aimed at collecting data on hard drug users. Both quantitative and qualitative research methods are used. This paper presents an overview of the MAD results with respect to alcohol and illicit drug use. Both quantitative and qualitative results show a substantial variation between regions, even in a country as small as the Netherlands. The study shows that a monitoring system can be an important source of information for local addiction policy, care and prevention.

Monitoring synthetic drug markets, trends, and public health.

The Drugs Information and Monitoring System (DIMS) in The Netherlands is a toxicoepidemiologic monitor of drug markets that was established in 1992. Its main focuses are to identify the compounds of synthetic drugs, describe prevalence and trends, and identify health risks. Here we discuss the insights gained in the Ecstasy market, based on the weekly testing of more than 100 drug samples, and key information of synthetic drug users delivering drug samples and personnel participating in the DIMS network. Pills used as Ecstasy may contain a wide variety of compounds. The percentage of samples containing MDMA increased slowly reaching almost 75% in 1996, but decreasing sharply in 1997. Amphetamines ("speed" and "ice") and experimental varieties were found in at least one third of the pills. Origins and effects of this development are discussed, as well as the risk assessment. In 1998 the percentage of MDMA pills increased more than ever before, indicating among other things that consumers prefer the conventional product. However, the use of "speed" and other drugs may also be stimulated by the decrease in 1997 of the percentage of MDMA pills. With more new types of drugs likely in the next century, a monitor such as DIMS provides important surveillance and data for public health and preventive aims.

Research methods for illegal drug use in hidden populations: summary report of a European invited expert meeting.

An Invited European Expert Group Meeting was held in Rotterdam that focused on research methods for hidden populations using illicit drugs. Experts from most European Community member states participated and contributed state-of-the-art presentations on various research methodologies. Attention was paid to the more quantitatively oriented research methods, such as surveys using questionnaires, interviews, and routine statistics from treatment and criminal justice as well as to more ethnographically oriented research methodologies. Recommendations were formulated for the near future: research methodology needs to meet all the classical methodological criteria, such as clear definitions, tests on reliability and validity, and clear sampling procedures. Interfacing methods is the key phrase. More quantitatively oriented methods, such as interviewing a random sample from a household survey, seem unsuitable for research on illicit drugs, except perhaps for the use of cannabis. A multifactorial problem, such as illicit drug use and related problems, should be approached in a multidisciplinary way; that is, the integration of different research methodologies. Comparability between individual research projects in different countries requires not only technical adjustments of the data, but also a "framework for communication." Data always need to be interpreted in terms of cultural context. A similar framework should enhance studies with respect to comparison of drug policies and their consequences in different cities or countries.

Chimpanzees in AIDS research: a biomedical and bioethical perspective.

The present article represents a consensus view of the appropriate utilization of chimpanzees in AIDS research arrived at as a result of a meeting of a group of scientists involved in AIDS research with chimpanzees and bioethicists. The paper considers which types of studies are scientifically justifiable in this species, the conditions under which such studies should be carried out, and the conditions which should be encouraged for post-experimental retirement of these animals.

Chimpanzees in AIDS research: a biomedical and bioethical perspective.

The present article represents a consensus view of the appropriate utilization of chimpanzees in AIDS research arrived at as a result of a meeting of a group of scientists involved in AIDS research with chimpanzees and bioethicists. The paper considers which types of studies are scientifically justifiable in this species, the conditions under which such studies should be carried out, and the conditions which should be encouraged for post-experimental retirement of these animals.

The contribution of unemployment to socioeconomic health differences.

Unemployment and socioeconomic status (SES) are both related to mortality and health inequality or differences. The main purpose of this study is to assess the contribution of these factors to health status. Data have been analysed from over 500 employed and 500 unemployed men, 30-50 years old, in two highly industrialized areas of the Netherlands. Three scales of self-reported health were used: somatic complaints, depressive complaints and chronic diseases. Experimentally, four SES measures were tested separately: education, occupation and household income as single measures, and a composite score constructed from the weighted sum of these measures. Results show a clear independent influence of SES as well as unemployment on health differences, when indicated by occupation or education. Household income appears to influence the results, the implications of which are discussed. Including the longitudinal follow-up there are three measurements over time. These data were used to test a homogenizing hypothesis, questioning processes that might indicate the existence of one unemployed (under) class. This hypothesis was rejected. Finally the data indicated a small contribution of health selection processes on the labour market.

Health effects of unemployment--I. Long-term unemployed men in a rural and an urban setting.

Between 1983 and 1987 in an urban and a rural Dutch area employed and long-term unemployed men, between 30 and 50 years old, have been interviewed. The main topics of the study were the independent health effects of unemployment, the factors related to these health effects and socio-cultural differences. Long-term unemployment is considered to be a social phenomenon that restructures individual's social positions into multiple deprived positions. The characteristics of this restructuring are a relative lack of socio-structural resources, low social participation and emotional problems. Independent effects on the health status (perceived somatic and depressive complaints and self reported chronic disease) have been found to exist among both the rural and the urban unemployed. There is no clear effect of unemployment on health care use, but regional differences in health care use among rural and urban unemployed have been found. Between the urban and rural unemployed there are more similarities than differences in the factors and models explaining ill-health. The most important factors are: loneliness, disadvantageous consequences of unemployment, money worries and ill-health prior to job loss (health selection at the labour market). One important difference is that among the urban unemployed the perceived size of the network is an explanatory factor, but among the rural unemployed perceived stigmatization is more important. In general, ill-health can be better explained for the rural unemployed than for the urban unemployed.

Health effects of unemployment--II. Men and women.

A comparison is made of the life situation and health effects of short term and long term unemployment in 30-50 year old urban men and women. The people under study were employed in an administrative branch of the labour market. Women's situation with reference to the labour market is more complicated than men's situation. In addition to the official, registered unemployment, only among women a substantial hidden unemployment exists. Health is measured by self reported diagnosed chronic diseases, depressive and somatic complaints; health care use i.e. physician consultations, the use of prescribed medicines and being under treatment of a medical specialist. Independent from ordinary confounders like education, age, having a partner etc. in the case of registered official unemployment an adverse health effect of unemployment equally exists for both men and women. The impact of such unemployment shows far more similarities than differences between men and women. Risk factors and paths leading from unemployment to ill-health are also the same among registered unemployed women and men. Contrary to common assumptions, the results indicate that the hidden unemployed form an empirically different category among the unemployed according to health status and to risk factors. The social context of the women's life situation is discussed to explore explanations for these results.

Health and social inequities in The Netherlands.

Although there is some knowledge of inequity in mortality due to socioeconomic differences in the late nineteenth and early twentieth century, we know very little about present mortality differentiated by socioeconomic status. However, at present there are signs that interest in this theme may be increasing, particularly among government authorities. An overview will be presented of the few, rather scattered, existing data on regional and socioeconomic differences, mortality and other indicators of ill-health. This includes results of a secondary analysis of mortality differences among middle-aged Dutch men in a rural town. In this analysis the central question was whether mortality differences related to socioeconomic status could be explained by different risk factors. Socioeconomic status and risk factors turned out to be independent predictors of mortality. Finally, a short description will be given of the awakening interest for such data among health policymakers.

Inter-mediating risk factors in the relation between socioeconomic status and 25-year mortality (the Zutphen Study).

In the Zutphen Study data were collected on occupation, smoking habits, blood pressure, serum cholesterol, height and weight of 856 men who were 40-59 years old in 1960. Between 1960 and 1985 detailed information was collected on mortality. The effect of socioeconomic status as indicated by occupation on 25-year mortality was studied in relation to cigarette smoking, systolic blood pressure, serum cholesterol and Body Mass Index. It was found that socioeconomic status was an important determinant of mortality only in the men who were 40-49 years old in 1960. The risk of all-cause mortality among small business owners and manual workers was more than twice as high as that of men in the highest social class. After adjustment for the influence of cigarette smoking and systolic blood pressure these relationships remained. It can be concluded that socioeconomic status was an independent risk factor for long-term all-cause mortality, in men aged 40-49.

Medical sociology and epidemiology: convergences, divergences and legitimate boundaries.

For the purpose of exploring the existence of problem areas that may give rise to the question whether there is a tendency to (illegitimately) trespass across boundaries between medical sociology and epidemiology, important convergences and divergences between both disciplines are described. To assemble arguments for the legitimacy of fields of study we trace comparatively the history of both disciplines, definitions of their fields under study and aims of study, as well as characteristic concepts and constructs. Current research themes are taken from international journals; divergent interests are briefly described and potential 'trespassing' of boundaries is discussed, referring to themes showing convergences of interest.

Selecting a health indicator for comparative health surveys among different social categories using employment as example.

In the last decade a number of subjective health indicators have been developed and validated. In view of the investment involved in developing a new one, a researcher designing a health survey will preferably choose one of the existing indicators. To facilitate such a choice, a set of criteria is developed. Six existing indicators are valued according to the stipulated criteria. Unemployment is taken as the example because there is a demand for comparative health surveys between unemployed and employed in order to validate findings in the unemployment literature. The comparison of the health of unemployed and employed is used as an example on the basis of which more general statements can be made about the comparison of the health of people in other polar social roles like divorced versus married, immigrants versus residents, that involve a transition from one social role to another.

Unemployment and health in macro-social analysis.

The hypothesis that unemployment is related to bad health arises from a general acceptance of the relationship between living standards and longevity. To confirm the hypothesis three analytical statements have to be true: (a) an increase of prosperity leads to a decrease of mortality; (b) a decrease of prosperity leads to an increase of mortality; (c) people with the relatively lowest prosperity, in this case the unemployed, have the relatively highest mortality and so are the least healthy. For this purpose important types of macro-social research are described and the results are interpreted, briefly evaluated and discussed. Research comparing differences in life-expectancy in rich and poor countries, shows rough differences; Research applying a new method, diffusionalist comparison, shows that increased prosperity does not infinitely lead to improvement of life expectancy; Research on economic fluctuations and mortality is the only type of research attempting to describe a process, not a state of affairs; Research on socio-economic categories within countries (classes, neighborhoods) shows differences in mortality and morbidity, but not why these differences exist; Research on the relationship between a population's body height (as a health indicator) and poverty/unemployment gives rise to more differentiated conclusions, but neither provides final answers; Some small retrospective researches with divergent methodologies and using small hospital samples give different results.