Doi:10.1016/s0300-483x(03)00339-

Toxicology 192 (2003) 249–261 Reducing acute poisoning in developing countries—options for restricting the availability of pesticides Flemming Konradsen , Wim van der Hoek , Donald C. Cole , Gerard Hutchinson , Hubert Daisley , Surjit Singh , Michael Eddleston a Department of International Health, Institute of Public Health, University of Copenhagen, Panum, Blegdamsvej 3, 2200 Copenhagen, Denmark b International Water Management Institute, Colombo, Sri Lanka c Department of Public Health Sciences, University of Toronto, Toronto, Canada d Faculty of Medical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago e Department of Internal Medicine Nehru Hospital Postgraduate Institute of Medical Education and Research, Chandigarh, India f Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK g Department of Clinical Medicine, University of Colombo, Colombo, Sri Lanka Received 1 July 2003; received in revised form 1 July 2003; accepted 31 July 2003 Hundreds of thousands of people are dying around the world each year from the effects of the use, or misuse, of pesticides.
This paper reviews the different options to reduce availability of the most hazardous chemicals, focusing on issues in developingcountries. Emphasis is placed on the fatal poisoning cases and hence the focus on self-harm cases. Overall, it is argued herethat restricting access to the most hazardous pesticides would be of paramount importance to reduce the number of severe acutepoisoning cases and case-fatalities and would provide greater opportunities for preventive programmes to act effectively. Theaim should be to achieve an almost immediate phasing out of the WHO Classes I and II pesticides through national policies andenforcement. These short-term aims will have to be supported by medium- and long-term objectives focusing on the substitutionof pesticides with safe and cost-effective alternatives, possibly guided by the establishment of a Minimum Pesticide List, andthe development of future agricultural practices where pesticide usage is reduced to an absolute minimum. Underlying factorsthat make individuals at risk for self-harm include domestic problems, alcohol or drug addiction, emotional distress, depression,physical illness, social isolation or financial hardship. These should be addressed through preventive health programmes andcommunity development efforts.
2003 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute poisoning; Pesticides; Self-harm; Developing countries; IPM 1. Acute pesticide poisoning: extent of
the problem

∗ Corresponding author. Tel.: +45-35-32-7776.
The first global estimates of the extent of pesticide E-mail address: f.konradsen@pubhealth.ku.dk (F. Konradsen).
poisoning were published in 1990 by the World Health 0300-483X/$ – see front matter 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/S0300-483X(03)00339-1 F. Konradsen et al. / Toxicology 192 (2003) 249–261 Organisation Based on extrapolations off at once' when there is no water available and even from limited data, it was estimated that 3 million cases more to ‘see a doctor immediately' when the nearest of pesticide poisonings occurred world-wide annually is many miles away ( with 220,000 deaths, the majority intentional.
The irrelevance of workers' health to some agricul- tural employers in the developing world—where sick employees can be summarily dismissed and new work-ers taken on—will continue to impede better pesti- The WHO estimates, based on 2001 data, that cide handling. The pesticide practice of farmers can be 849,000 people die globally from self-harm each year frankly dangerous—observed practices include spray- (How many of these cases are a result ing without any safety equipment for far longer than of poisoning with pesticides is not known. However, recommended periods and even tasting pesticides to poisoning is the commonest form of fatal self-harm check for the correct mix (Different in rural Asia, accounting for over 60% of all deaths pesticides are frequently mixed together by farmers to make ‘more effective' pesticides, ensuring that sub- and is of far greater im- sequent medical management of poisoned patients is portance than hanging, and other physical forms of self-harm. Furthermore, a review of poisoning stud- A response has come from the International Labour ies reveals that pesticides are the commonest means Organisation (ILO) which, through its programme on of self-poisoning in many rural areas and associated occupational safety and health in agriculture, has fo- with a high mortality rate (A recent cused on the 50% of the world's labour force em- national survey in Bangladesh showed that 14% of all ployed in agriculture. The ILO supports the establish- deaths (3971 of 28,998) of women between 10 and 50 ment and implementation of national strategies for the years of age were due to self-poisoning, the majority improvement of occupational safety and health of ru- with pesticides The problem is ral workers Yet the widespread practice particularly severe in Sri Lanka ( of child labour continues to put children, particularly where pesticide poisoning was adolescents, at serious risk of occupational poisoning.
the commonest cause of hospital death in six rural A lack of facilities for safe storage and disposal districts during 1995 ( ensures frequent accidental poisonings, particularly In many countries, the widespread availability among small children ).
of acutely toxic pesticides used in agriculture has Similar to self-poisoning, a major factor in paediatric made selection of pesticides as the agents of choice poisoning is access to the poison. Children in indus- for self-harm well known to both health care work- trialised countries ingest common and relatively safe ers and public health authorities ( medications, such as analgesics ( In contrast, the wide availability of toxic pesticides inthe developing world produces a far higher accidental 1.2. Occupational and accidental poisoning death rate in children ( The significant problems of human illness and death that follow occupational and accidental exposure to 2. An approach to reducing pesticide poisoning in
pesticides have been well documented the developing world
Occupational illness is common be-cause it is impractical and expensive to use safety ve proposed a policy equipment in the humid tropics and strategic approach to deal with issues of occu- pational pesticide poisoning in developing countries.
instructions on containers are often written in unfamil- The strategy builds upon the classic industrial hygiene iar languages, many farmers are illiterate, and the in- ‘hierarchy of controls' ( structions themselves impossible to follow. After com- going from highest priority, most effective to lower ing into contact with pesticides it is difficult to ‘wash priority, least effective.
F. Konradsen et al. / Toxicology 192 (2003) 249–261 2.1. Most effective portance in reducing both the number and case-fatalityproportion of acute poisoning cases, and to provide 1. Eliminate more highly toxic compounds; greater opportunities for preventive programmes to act 2. Substitute with less toxic, equally effective alter- effectively. We acknowledge that comprehensive ac- tive clinical surveillance versus passive hospital-based 3. Reduce use through improved equipment; surveillance, would identify more non-fatal acute poi- 4. Isolate people from the hazard; sonings occurring in the occupational and accidental 5. Label products and train applicators in safe han- groups However, in this paper em- phasis is placed on the fatal poisoning cases and hence 6. Promote use of personal protection equipment; the focus on self-harm cases.
7. Institute administrative controls.
The different options available to reduce availabil- ity of the most hazardous chemicals are reviewed in 2.2. Least effective this paper, focusing on issues in developing countries.
The paper builds on an earlier paper published by The first set (1–3) includes engineering controls.
discusses four different av- They include complete elimination of the small num- enues with potential for reducing use and availability ber of highly to extremely toxic pesticides and their of pesticides important for acute poisonings: systematic substitution with less toxic products based • Voluntary guidelines, Safe Use Initiatives, and in- on an ongoing review of evidence, often after the in- ternational policy instruments; troduction of alternative pest control approaches. They • Changes in farming practice: integrated pest man- also include modifications to equipment, such as low agement (IPM) and plant biotechnology; flow spray nozzles or formulations, to reduce use or • Direct restrictions of pesticide use; exposure directly.
• A Minimum Pesticide List.
The second set (4–6) involves reducing population exposure. In rural settings of the developing world iso-lation might involve locked storage cabinets for pes- 3. Voluntary guidelines, Safe Use Initiatives, and
ticides. Activities focusing especially on the occupa- international policy instruments
tional poisonings include labelling and training of-ten implemented in conjunction with the promotion 3.1. The International Code of Conduct on the of personal protective equipment ( Distribution and Use of Pesticides Similarly, the provision of appropriate exposure mon-itoring and systems to evaluate the effects of training In the early 1980s, a debate about the effects of programmes would form part of this.
uncontrolled pesticide use on health in the develop- The final step is setting up administrative controls.
ing world grew around the world. International or- These controls do not reduce population exposure but ganisations, national governments, and industry all re- introduce a system in which applicators take turns ap- sponded to these concerns with a series of non-binding plying pesticides. This may therefore reduce individ- ual exposures in occupational settings.
The major response was the production of the In- The hierarchical approach proposed by ternational Code of Conduct on the Distribution and also have beneficial effects on Use of Pesticides in 1985 by the Food and Agricul- the number of acute intentional pesticide poisoning ture Organisation (FAO) of the United Nations. In cases. However, it will need to be adapted to address November 2002, FAO adopted a revised Code of Con- the issues of case management in hospital settings, duct incorporating concerns and experiences gener- programmes aimed at counselling for mental health ated since the drafting of the previous version. The problems, and improving underlying social issues at Code attempts to rationalise the use of pesticides and community level ( reduce the health and environmental risks associated Overall, we argue here that restricting access to the with pesticides ( most hazardous pesticides will be of paramount im- Its stated aim is to establish: F. Konradsen et al. / Toxicology 192 (2003) 249–261 . . voluntary standards of conduct for all public countries still do not have this necessary oversight ca- and private entities engaged in or associated with the distribution and use of pesticides, particularly In the second global survey finalised in October where there is inadequate or no national legislation 1994 to assess the state of implementation of the Code to regulate pesticides. (Article 1.1) of Conduct, it was concluded that although progress In particular, it wished to ensure that the benefits had been made towards compliance with various pro- derived from the use of pesticides be achieved without visions of the Code, especially in the Asia and Pa- significant adverse effects on people or environment cific region there is a continuing need by governments (Article 1.3).
for assistance. More than half the national agencies The new version of the Code of Conduct adapts a responding to the questionnaire indicated a need for ‘life-cycle' concept to address all stages from devel- technical assistance and increased government support opment of products to the final disposal of containers to strengthen their national capacities and infrastruc- and products. Manufacturers are requested to supply tures necessary to operate effectively their pesticide only pesticides of adequate quality, packaged and la- control schemes ( belled as appropriate for each specific market, and to The crucial role of national government capacity in retain an interest in the product as far as the ultimate enforcing the Code was explicitly acknowledged by consumer, keeping track of uses and the occurrence of the then Director of the FAO, in his introduction to problems requiring changes in labelling, directions for the Code in 1985 ( use, packaging, formulation or product availability. In In the absence of effective pesticide registration pro- particular, the Code stated that cesses and of a governmental infrastructure for con- pesticides whose handling and application require trolling the availability of pesticides, some coun- the use of personal protective equipment that is tries importing pesticides must heavily rely on the uncomfortable, expensive or not readily avail- pesticide industry to promote the safe and proper able should be avoided, especially in the case of distribution and use of pesticides. In these circum- small-scale users in tropical climates. (Article 3.5) stances, foreign manufacturers, exporters and im-porters, . . , must accept a share of the responsibil- The Code further stipulates that highly toxic and ity for safety and efficiency in distribution and use.
hazardous products (such as WHO Classes Ia and Ib)may be prohibited for importation, sale and purchase Unfortunately, in spite of increasing support to if other control measures or good marketing practices improve the capacity of national agencies since are insufficient to ensure that the product can be han- mid-1980s, policing of the Code is still so severely dled with acceptable risk to the user (Article 7.5).
hampered by the lack of resources and political will Many countries do not live up to these standards and that there is as yet no effective mechanism to en- if the Code were to be followed this would prohibit force it or publicise violations. Further, the Code of the use of Class I pesticides in many developing coun- Conduct does not give direct attention to the issue tries. This relates especially to occupational exposure of self-harm with pesticides and therefore fails to since the required safety equipment is expensive and provide policy guidelines or assign responsibilities cumbersome in the tropics, and almost never worn.
on this complex issue. Also, the fact that the revised National governments were called upon in the Code Code does not directly call for an elimination of the most hazardous pesticides and that adherence to thegreat majority of the articles in the Code is voluntary have the overall responsibility to regulate the avail- will likely reduce its overall effect on the number of ability, distribution and use of pesticides in their deaths from acute poisoning.
countries and should ensure the allocation of ade-quate resources for the mandate. (Article 3.1) 3.2. Efforts by producers of pesticides In spite of international efforts to support develop- ing countries in achieving the capacity to implement A number of producers of pesticides have been in- and supervise the Code of Conduct, many developing volved in attempts to limit unsafe pesticide use. The F. Konradsen et al. / Toxicology 192 (2003) 249–261 limit export of toxic pesticides by requiring ex- now renamed CropLife International established by porting countries to receive prior approval from the pesticide industry aimed to: the recipient country. The latter aims to phaseout production and use, or otherwise eliminate, communicate and promote Industry positions on 12 persistent organic pollutants, 9 of which are key issues . . (and) . . co-ordinate actions to face emerging challenges. (, 2003) Both conventions have the potential for reducing However, it also aimed to: availability of a number of highly toxic compoundsif the conventions are followed up, resources com- provide, through the GCPF Safe Use Initia- mitted and agreements adhered to. Importantly, the tive, training and guidance to achieve significant PIC Convention transfers the Article 9 of the Code progress in the safe, effective and environmentally of Conduct for the Distribution and Use of Pesti- responsible handling and use of crop protection cides from a voluntary procedure into a legally binding products. , 2003) mechanism. This includes the exchange of informa- This initiative set up pilot projects in Kenya, tion from one national regulatory authority to another Guatemala and Thailand. Audit of the Thai project if actions have been taken to ban or severely restrict found an increased awareness of safety issues by lo- a pesticide in order to protect human health (Article cal farmers, but little improvement in their actual use of pesticides The industry has described Other international policy instruments provide its Guatemalan project as a resounding success since more general policy guidelines focused on the envi- the number of pesticide poisoning cases nationally ronmental, biodiversity and long-term implications were noted to fall at the same time as its Safe Use linked to occupational exposure and food residues, including the Convention Concerning Safety in the more recent analysis has noted the poor quality of Use of Chemicals at Work, the Convention on Bio- the data linking the fall in poisonings to the Safe Use logical Diversity and the Agenda 21 of the United Project and raised doubts of a causal link ( Nations Conference on Environment and Develop- A 7-year study by Novartis, now ment (Chapter 19). The policy instruments may Sygenta and formerly Ceiby-Geigy and one of the not directly or in the short term reduce acute poi- largest pesticide producers in the world, found that soning cases but will overall encourage the devel- ‘safe use of pesticides' interventions in Latin Amer- opment of agricultural production approaches and ica, Africa and Asia were expensive and largely pest control initiatives based on reduced pesticide ineffective, particularly with smallholders ( However, it is possible that some of the con- The industry has for years worked with both FAO ventions and international agreements on pesticides and national governments to remove and destroy may imply trade-offs between environmental con- stockpiles of pesticides left in the tropics reducing the cerns and human health risk. In the process of overall availability of large quantities of hazardous phasing out some of the most environmentally chemicals (However, the effect of these unfriendly products they may be replaced with activities on the availability at household level needs chemicals with a high human toxicity, e.g. persis- tent organochlorine compounds with carbamatesin malaria control programmes. Similarly, the op- 3.3. International conventions posite may occur as chemicals assessed to be rel-ative safe for occupational use may have nega- Recent conferences have produced conventions tive effects on the environment and biodiversity, on Prior Informed Consent (PIC) ( e.g. substitution of pyrethroids for organophos- and Persistent Organic Pollutants (POP) phates. Clear policy statements are needed to in- The former serves as an early warning sys- dicate approaches that simultaneously meet both tem to notify developing countries of hazards and F. Konradsen et al. / Toxicology 192 (2003) 249–261 4. Changes in farming practice: IPM and plant
industry's view of IPM differs from that of many workers in the field in that it perceives a clear needfor pesticides in most situations 4.1. Alternative pest control methods Furthermore, its practice of paying pesticide sales-people on a commission basis, with increased sales In an attempt to slow the development of pest resis- being rewarded with increased earnings, is unlikely tance, improve the financial basis for agricultural pro- in practice to encourage a limited use of pesticides.
duction, and improve the health of the farming popu- If IPM is ever to be more widely used, incentives lation, systems of IPM have been introduced around for pesticide use will have to be removed. National the world. IPM is an ecological approach to plant pro- governments and donor agencies will also need to re- tection, which encourages the use of fewer pesticide consider their policies. Two World Bank studies have applications. The most toxic pesticides and those with shown that many developing countries and donor greatest local resistance are identified; their use is then agencies limit IPM by providing financial incentives restricted and a regimen of decreased applications im- for the use of pesticides via subsidising their im- plemented based on field monitoring and physical and port, domestic manufacture and marketing biological control methods, in order to protect natural These subsidised prices distort enemies of the pests. It is now widely recognised that the cost of various pest control methods and make IPM contributes significantly to the productivity and the use of agrochemical economically preferable to profitability of agricultural systems in an environmen- non-chemical methods. A review of all World Bank tally sound and equitable manner ( projects performed by the Pesticide Action Network For example, the Agenda 21 action plan, formulated North America for the period 1997 and 2000 found by the United Nations ‘Earth Summit', convened in that few had made any mention of IPM ( Rio de Janeiro in 1992, identified IPM as a key ele- ment in sustainable agricultural development.
The FAO, United Nations Environment Program In Sri Lanka, IPM trained farmers used less pes- (UNEP) and The World Bank have helped establish ticides and had less signs of poisoning than farmers IPM initiatives, such as the not trained in IPM (This was also documented in a study in Nicaragua which showed The Facility is developing the Integrated Pest and that after 2 years, the IPM trained farmers used fewer Plant Management-2015 project which aims to pro- pesticides, spent less money on pest control, made mote IPM on a global scale by 2015 alongside a higher net returns, and suffered less exposure to gradual phasing out of Class I and then Class II pes- cholinesterase-inhibiting pesticides than farmers who ticides. This initiative is currently in its design stages did not receive IPM training ( ut could provide a significant organisational support to IPM implementation on a large scale. This is im- The effects of IPM training on the incidence of portant because the pace of implementation of IPM self-harm still needs to be documented but there is is still slow and in many countries the agricultural good reason to believe that with the implementation of extension service is far from being able to reach all a successful IPM programme, including the phasing out of the most hazardous pesticides, proper storage,and overall reduced use and availability the number 4.2. Biotechnical advances of intentional, as well as unintentional cases will bereduced. The new Code of Conduct calls upon gov- In addition or in combination with the promotion ernments to give more emphasis to IPM and to make of IPM, technological advances in the field of plant a concerted effort to develop and use it more than pre- biotechnology is seen by some as carrying a great potential for reducing pesticide applications with- The pesticide industry states that it now fully sup- out reducing yields ports a policy of restricted pesticide use within an The first transgenetic IPM programme (However, the insect-resistant crop was grown in the USA during F. Konradsen et al. / Toxicology 192 (2003) 249–261 1994. Since then, there has been a rapid expansion in out Argentina in 1994. The last death from parathion the farming with transgenic plants and various vari- in Rosario was reported in 1995. There was subse- eties are now grown in over 12 countries around the quently a marked fall in the number of all deaths due world. Deployment of insect-resistant crops has been to poisoning: from 16 in the first half of the decade to associated with a 1 million kg reduction of pesticides 4 in the second ( applied for pest control in USA in 1999 compared Parathion was also banned in Jordan during 1981 after studies showed that it was responsible for >90% Transgenic plants expressing insecticidal proteins of deaths from pesticides in the country. The total from the bacterium, Bacillus thuringiensis (Bt), have number of poisoning deaths undergoing autopsy in been engineered into major crops that were grown on Amman fell from 58 in 1978 and 49 in 1980 to 28 in 11.4 million ha world-wide in 2000. Based on the data 1982 and 10 in 1984.
collected to date, the introduction of this new crop Paraquat was introduced to Samoa in 1974. Soon af- has resulted in a reduction in the use of insecticides ter, public health officials noticed a growing epidemic (However, the future promotion of self-poisoning (The total suicide of genetically modified plants is debated internation- rate increased from 10/100,000 in 1974 to 28/100,000 ally and fears have been expressed over the long-term in 1978 and 50/100,000 in 1982. Because of this epi- environmental and public health consequences. In par- demic, a community-based campaign was set up to re- ticular, issues related to intellectual property rights duce its use for self-harm. At the same time, however, and the need to buy new seeds every year have been imports fell temporarily due to financial problems. The raised by farmers in developing countries suicide rate fell rapidly, mirroring the fall in imports, to 15/100,000 within 2 years. Interestingly, the suiciderate between 1984 and 1988, although much reducedat 15–20/100,000, was still more than 80% due to 5. Direct restrictions of pesticide use
paraquat and has continued to rise since. Suicide withthis pesticide had become the method of choice. The 5.1. Pesticide restriction programmes pesticide was never banned and remained the causeof around 80% of all self-harm deaths ( WHO policies aim to reduce death rates by restrict- Banning paraquat is still the subject of active debate ing the availability of poisons commonly used for self-harm Physicians have Since the late 1980s, the Sri Lankan government taken a similar line, calling for the banning of partic- has taken an active role in determining which pesti- ular pesticides that generate local clinical problems, cides can be used in the country. By the mid-1990s, e.g. paraquat in Trinidad and aluminium phosphide all Class I pesticides were banned in Sri Lanka. As a result, the number of deaths due to metamidaphos and A number of examples world-wide have other Class I OPs fell dramatically as documented for shown that restricting the availability of highly toxic one district hospital Unfortu- or locally popular pesticides can indeed be effective nately, another highly toxic (although Class II) com- in reducing total death rates from self-harm.
pound, the organochlorine endosulfan, then replaced Piola and colleagues recently showed that a na- the Class I OPs in agricultural practice. The number tional ban on the organophosphate parathion reduced of self-poisoning deaths rose as endosulfan became the number of deaths reported to their poison centre more popular. Endosulfan was therefore banned in in Rosario, Argentina 1998 and deaths fell from 50 to 3 in the same dis- Between 1977–1985 and 1990–1994, 21 trict hospital over the next 3 years ( lethal pesticide poisoning cases were reported to the No single compound has since taken its place, centre, including 15 adult cases of self-poisoning and but there is currently an increase in importance of 4 accidental cases in children, 17 of which were due to WHO Class II OPs, such as dimethoate and fenthion.
parathion. Due to the high number of deaths occurring Sri Lanka is attempting to shift to less toxic pesti- nationally with this pesticide, it was banned through- cides in the hope that this will reduce the number of F. Konradsen et al. / Toxicology 192 (2003) 249–261 deaths from deliberate self-poisoning. Thus far, these self-harm. A similar reduction in self-harm deaths has attempts have been complicated by the replacement occurred in the UK, Japan, Australia and India fol- pesticides also being sufficiently toxic to cause deaths lowing the replacement of barbiturates with benzodi- from self-poisoning. Compared to the early 1990s, azepines as the most common sedative prescription there has been little overall effect—just switching from one form to another. Future attempts to ban pes- ticides must carefully predict the likely consequences tions on availability are currently being adopted by of switching to another pesticide in agricultural and the Ministers of Health of eight Central American and self-harming practice ( Caribbean countries. These countries have agreed to Generally, occupational exposure to pesticides will ban the 12 most problematic pesticides in their re- lead to milder signs and symptoms than poisoning due gion together with a list of 115 pesticides that are re- to self-harm ingestion. However, a restriction of avail- stricted in at least one of these countries ability of pesticides might have prevented the epidemic The organisers of this approach—the of occupational poisoning cases seen in north-western PlagSalud initiative—hope to reduce pesticide poison- Nicaragua during 1987 that followed the adoption of ing in Central America by 50% by restricting the most the Class I pesticides carbofuran and methamidophos toxic pesticides (No results are yet available.
An increased use of pesticides in the Philippines during the 1970s coincided with a 27% increase inmortality from non-traumatic causes among econom- 6. A Minimum Pesticide List
ically active men. The incidence in men between theage of 15 and 34 of stroke—a condition rare in this ve called for the establish- age group but which could be confused with some ment of an Essential or Minimum Pesticide List build- types of acute pesticide poisoning—also rose during ing upon the experiences achieved with the WHO's this period but then fell by more than 60% in the 2 model Essential Drugs List (EDL). The WHO's model years following a ban on endrin EDL was initiated in 1977 to support the rational use A recent Chinese study concluded that a major com- of pharmaceuticals The Model List to- ponent of preventive efforts to reduce acute poisoning day contains some 300 pharmaceuticals that should in rural areas will be restricting the ready availability satisfy the health needs of the majority of the people of pesticides. The authors pointed out that the ready for the majority of the time.
availability of potent pesticides in homes of most res- In countries that have successfully used the Model idents makes this the preferred method of self-harm List to develop their own essential drugs programme, (This study also supports the it has led to better supply of important drugs, more ra- idea that not all people who die following acts of tional prescribing and lower costs, and easier quality self-harm actually wish to die In assurance, procurement, storage, distribution and dis- a district in Sri Lanka, peaks of fatal self-harm poi- soning coincided with ploughing seasons. This was and drug information have become more focused; pre- not because people were more determined in their scribers have gained experience with fewer drugs and self-harm attempts in this season but because it was are able to recognise adverse reactions more quickly the time when farmers use paraquat and accurately. Essential drugs are usually cheap and Furthermore, the often impul- procurement of fewer items in larger quantities has sive behaviour linked with the ingestion of pesticides resulted in economies of scale.
and the influence of alcohol during events makes it im- The current situation with pesticides has some sim- portant to restrict pesticide availability at homes ilarities with that of pharmaceuticals in the 1970s.
Hundreds of active ingredients and thousands of for- Overall, these studies suggest that limiting the avail- mulations are available and promoted by both man- ability of toxic pesticides will reduce the number of ufacturers and distributors as being essential for crop deaths from poisoning and the number of deaths from production. ‘Rational use' with so many pesticides F. Konradsen et al. / Toxicology 192 (2003) 249–261 and competing claims is difficult. Perhaps lessons other pesticides would not be registered, removing a learned from the EDL could be applied to pesticides.
large number of obsolete and highly dangerous pesti- While the EDL has not achieved ideal implementa- cides from circulation.
tion, it has contributed to improved health care andproved to be a useful public health tool. Might an anal-ogous model Pesticide List be equally useful? Since many argue that no pesticide is everywhere ‘essential'and that further development of IPM will remove the Clearly, the four avenues of intervention outlined need for most synthetic pesticides, the list would be a in this paper could each play a role in bringing down model Minimum, rather than Essential, Pesticide List.
the problems associated with acute pesticide poison- The first task in producing such a Model List will ing in developing countries. However, in spite of the be to identify the minimal use of pesticides within an successes of certain programmes in specific situations, IPM system. All the available active pesticide ingredi- the overall picture still looks bleak with hundreds of ents would then be tabulated, based on priorities deter- thousands of people dying around the world each year mined by comparative efficacy across pests and eco- from the effects of the use, or misuse, of pesticides.
logical conditions, safety, convenience and cost. Di- The problem is urgent and at a level where interven- rect cost and animal toxicity data are readily available tions with an immediate effect will have to be given the but other data are less well developed and data less highest priority. This therefore supports programmes apparent. This is particularly true for the indirect costs and policies that call for a complete and immediate of pesticides on human health and the environment.
ban on the most hazardous pesticides. The evidence The toxicity of solvents, not just the active ingredient, is strong, indicating an immediate and significant im- will need to be considered as well as the environmen- pact following the elimination of the most hazardous tal consequences of the use of pesticides considered chemicals available at the household level. The aim safe for humans—e.g. although pyrethroids are rela- should be to achieve an almost immediate phasing out tively safe for humans, they are highly toxic to fish of the WHO Classes I and II pesticides through na- and crustaceans ( tional policies and enforcement. However, a national A template containing examples plus expert opinion policy to ban specific pesticides requires international and evidence would then be applied at the country level support in terms of exchange of information and en- to create an area specific Minimum Pesticide List with forcement of policies and may involve bilateral as well a sense of local ownership. Implementation at the local as multilateral organisations.
level would be tailored to local needs and problems These short-term aims will have to be supported (e.g. a major self-poisoning problem with a particular by medium- and long-term objectives focusing on the pesticide). Analogous to second-line antibiotics in the substitution of pesticides with safe and cost-effective EDL, reserve pesticides could be listed to deal with alternatives, possibly guided by the establishment of local problems of resistance.
a Minimum Pesticide List, and the development of The Model List would not be prescriptive but ad- future agricultural practices where the pesticide usage visory, giving under-resourced governments basic in- is reduced to an absolute minimum.
formation that should allow them to determine which The proposed Minimum Pesticide List would be a pesticides are currently useful for their agricultural major public health initiative requiring a global ap- needs. Unbiased assessment and comparison of pesti- proach and co-ordination to be most effective. This cides, using an explicit and transparent evidence-based would reduce duplication, encourage evaluation and approach, would provide an enormously useful tool maximise the use of previous evaluations of pesticides for both governments and small-scale farmers.
performed in the industrialised world. The WHO and While enforcement of legislation would still often FAO should develop a model Minimum Pesticides be difficult, a significantly reduced number of pesti- List in collaboration with other interested parties. The cides should simplify this process. A Model List would establishment of a model Minimum Pesticides List allow legislators to decide which few pesticides should would need inputs from a number of international be used in their region and then actively register them; actors involved in risk assessment, monitoring of F. Konradsen et al. / Toxicology 192 (2003) 249–261 effectiveness and establishing guidelines, such as the ing country context results in immense human suffer- International Program on Chemical Safety (IPCS) and ing. Overall, the revision of the Code of Conduct is the International Commission on Occupational Health a step in the right direction but significant additional and Pesticides (ICOH). However, critics of these in- resources are needed to support government agencies ternational actors have shown that additional scientific in its implementation. Likewise, increased resources scrutiny and increased independent input is needed, es- will have to be allocated to improve the surveillance pecially from the non-governmental organisations, to and analysis of data on pesticide poisonings, including balance the representation from the chemical industry registration at both community level and at health fa- in these programmes (Implementa- cilities. Without an improved health information sys- tion of a List would also result in the identification of tem it will be difficult to formulate specific guide- hazardous pesticides that should be banned or severely lines and policies and the under-reporting of cases will restricted through the POP and PIC conventions.
continue to be a significant problem ( The success achieved with IPM by community groups, non-governmental organisations and govern- The four general areas of interventions outlined in ment departments needs to be further promoted with this paper focus on the reduction of availability and the aim of reducing the availability of pesticides in use of pesticides and it is argued that this will have a the homes of farming communities. This will clearly positive effect on accidents, self-harm cases and would require that economic incentive systems currently in result in less occupational and environmental expo- place be changed to reduce the gains linked with the sure. However, for self-inflicted cases the situation is promotion and use of pesticides. The strongest incen- of course more complicated. Underlying factors that tive for a shift towards IPM approaches or other ap- make individuals at risk for self-harm include domes- proaches requiring limited or no inputs of pesticides tic problems, alcohol or drug addiction, emotional dis- may come from the consumers in developed as well as tress, depression, physical illness, social isolation or developing countries. This could come about if con- financial hardship ( sumers, through awareness campaigns, put pressure on the producers and national export organisations to 2002). These various underlying courses should be produce agricultural produce with limited use of pes- addressed through preventive health programmes and ticides. In addition, strong farmer unions, especially community development efforts but many of these in- in the plantation sector, may be in a position to place terventions would only show an impact in the long pressure on the management to give priority to health of the workers and the communities. Increased public Also, medical management needs to be improved awareness about the health problems associated with (but this is difficult with the few re- the use of pesticides may also place pressure on the sources available—case-fatality rates for pesticide poi- industry to change marketing practices, distribute in soning in parts of rural Sri Lanka exceed 50% during less concentrated doses and to place the highest em- some months (case-fatality phasis on the development of products that are less rates with aluminium phosphide or paraquat reach hazardous to human health. At a more specific level 70% in South Asia ( the industry may experiment more widely with the There are too many pa- formulations allowing for the inclusion of emetics to tients, too few doctors, too few drugs and ventilators, the pesticides. Although there is currently no evidence and too little good evidence about how to treat patients for benefit from this approach.
with overwhelming poisoning following ingestion The international efforts that are based on a volun- of these highly toxic compounds tary approach, such as the Code of Conduct, may gain The upgrading of the health wide support but at the same time it seems clear that care services to improve case management and the the industry is unable to self-regulate in the absence preventive and social and mental health care pro- of effective government law enforcement. While some grammes to reduce the number of self-harm cases of these pesticides may be safely used for restricted needs to be implemented in support of the overall pro- tasks in the West, their uncontrolled use in a develop- grammes aimed at reducing availability of pesticides.
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Preventing Drug Overdoses in Oklahoma Drug overdose deaths in Oklahoma have risen sharply during the past decade, according to Oklahoma City Addiction Medicine physicians Hal Vorse, MD, and Billy Stout, MD. Between 2002 and 2010, the Oklahoma Bureau of Narcotics and Dangerous Drugs Control (OBN) reports the number of overdose deaths in the state rose from 470 to 814 per year. Preliminary data indicates there were at least 795 drug overdose deaths in Oklahoma in 2011. Seventy-seven percent of the deaths were due to the use of prescription drugs in combination with other prescription drugs or alcohol.