Ritalin - Better Living Through Chemistry?
In 1961, the Food and Drug Administration (FDA) approved a medication named Ritalin for use by children with behavior problems. In 1975, roughly 150,000 American children were taking Ritalin.1 By 1988, that number had increased over 500 percent, to just about 1 million children.2 This year about 6 million American children--roughly one child out of every eight--will take Ritalin.3
No other medication in American history has had this kind of success in achieving and maintaining such a grip on its market: not Valium, not Prozac, not Viagra. The United States, with less than 5 percent of the world's population, now accounts for 85 percent of the world's consumption of Ritalin.4 But what is Ritalin? How did it get to be so popular? Why isn't it being prescribed as extensively in other countries as it is here?
WHAT IS RITALIN?
In terms of pharmacological effect, Ritalin--also known by its chemical name, methylphenidate--is a powerful stimulant in the same class as amphetamine ("speed") and cocaine. The Drug Enforcement Administration (DEA) has always assigned Ritalin to "Schedule II," the same schedule as amphetamine. In other words, the DEA considers Ritalin to have about the same potential for abuse as amphetamine has. Laboratory animals given the choice to self-administer cocaine or Ritalin make no distinction between the two.5 Gene Haislip, retired assistant administrator of the DEA, remarked that "we have become the only country in the world where children are prescribed such a vast quantity of stimulants that share virtually the same properties as cocaine."6 Critic John Lang wrote in 1997 that "Americans would be horrified to learn that two million children across the nation are being given cocaine by their parents and doctors to make them behave better in school, [but that's] so close to the truth that it takes a chemist to tell the difference. The effect is virtually the same. These kids are wired."7 Of course, if Lang were to write his article today, he'd have to say "six million children" instead of "two million children."
If it's true that Ritalin is similar to cocaine and amphetamines in its effect, then why isn't Ritalin addictive? Why aren't people stealing Ritalin and selling it in back alleys, the way cocaine is sold?
Actually, people are stealing Ritalin, and it is being sold in back alleys and other venues of the illicit drug marketplace. On May 16, 2000, the House Education and Workforce Committee held hearings on the illegal use of Ritalin. They heard testimony that one in five college students in the United States today uses Ritalin for "recreational" purposes.8 "Ritalin may be the greatest drug problem we have in this country," said committee chairman William Goodling (R-Pennsylvania). Ironically, the very same week that Congress was holding hearings on Ritalin, a circle of fifteen eighth-grade boys at a Chicago middle school was discovered to be trading Ritalin. All the boys were suspended, and criminal charges were filed against the five ringleaders.9 One month earlier, a seemingly healthy 14-year-old boy died from heart problems apparently triggered by taking Ritalin.10 In Muskego, Wisconsin, an elementary-school teacher was charged with stealing Ritalin from pupils' prescription bottles.11 James Smith, a 35-year-old teacher at Grassland Middle School in Nashville, Tennessee, was fined and sent to jail for stealing students' Ritalin tablets.12
But the truth is that there is not a huge illicit market for Ritalin. Why not? The answer is in the way the drug reaches your bloodstream. For a drug to be highly addictive, it's got to hit your system all at once, in a "rush." Ritalin, when taken by mouth, is absorbed fairly slowly. You won't get a rush. If the pills are ground up and snorted up the nose, however, then the user can achieve a high--similar to what's experienced by snorting cocaine. Some older students are now doing precisely that with their Ritalin tablets, according to Dr. Roger Weiss, clinical director of the drug abuse treatment program at McLean Hospital near Boston: they are grinding Ritalin tablets into a fine powder and snorting the powder up the nose.13
WHY IS RITALIN SO POPULAR?
Ritalin has been on the market for almost forty years. Nothing has changed in terms of its classification as a prescription drug under U.S. law; nothing has changed in the manner of its production or delivery. So why has its use increased roughly 500 percent over the past ten years and 4,000 percent over the past twenty-five years? To understand the answer to that question, you have to know something about attention deficit hyperactivity disorder, or ADHD.
As long as there have been children, there have been children who misbehave: those who don't listen, who can't sit still, who don't follow instructions no matter how many times you tell them. George Still, a British physician, appears to have been the first to suggest-- in 1902--that such children weren't just "ornery" or "stubborn": Dr. Still thought that they might have a neurological disorder, a form of brain damage. In the years since, Dr. Still's idea has gone through dozens of transformations, reflected in the myriad names that have been assigned to these children: minimal brain dysfunction, minimal brain damage, hyperkinesis, hyperactivity of childhood, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and, most recently, attention deficit hyperactivity disorder without hyperactivity. Psychiatry professor Gerald Coles has disparagingly remarked that "the whole notion has gone through so many metamorphoses as to suggest a catastrophe in terms of conceptual integrity."14
The typical ADD/ADHD child is bored, easily distracted, and not performing up to his ability in school. Medeva Pharmaceuticals has run a successful advertising campaign directed at physicians, marketing its brand of methylphenidate. The campaign features photographs suggesting that methylphenidate can transform an ADHD child into a pleasant, high- performing whiz kid. In many cases, methylphenidate can achieve precisely that transformation. But that doesn't explain why Ritalin use has exploded in the past twenty years. Is ADD/ADHD becoming more common? Or has it always been with us--in which case, why are doctors suddenly so much more willing to prescribe Ritalin?
Many scholars have considered these questions. Three major categories of answers have been suggested, and they are not exclusive: all three answers may be correct. I refer to them as television, testing, and Prozac.
The generation of students who began elementary school in the mid-1980s was the first one to be raised primarily indoors. As late as 1975, most American children spent most of their free time outdoors. Those of us who grew up before 1975 remember when there were only three channels on television (NBC, CBS, and ABC); there were no videocassette recorders, no home computers--and, for most of us, no air-conditioning. So there was no particular reason to spend free time indoors. We were outdoors whenever we could be--playing, arguing, sweating, listening to the Beatles or the Jackson 5 on transistor radios, wasting time. TV was a part of our daytime lives, but it was a small part. What kid wanted to stay inside and watch Love Is a Many-Splendored Thing, Days of Our Lives, or General Hospital on a black-and-white TV on a hot summer day?
All that changed in the late 1970s and early '80s, with the introduction of cable TV, the videocassette recorder, and the home computer (and the more widespread use of air-conditioning). Suddenly the options for having fun indoors multiplied.
The experience of watching television is very different from that of sitting on the front stoop watching cars drive by. Television is more exciting. Something different happens on-screen every few seconds. Matthew Dumont, writing in 1976, appears to have been the first doctor to draw an explicit link between watching television and ADD. "I suggest," wrote Dr. Dumont, "that the hyperactive child is attempting to recapture the dynamic quality of the television screen by rapidly changing his perceptual orientation. I also wonder if it is possible that amphetamines [and Ritalin] control his behavior by producing a subjective experience comparable to the fleeting worlds of television."15
The change in the way children spent their free time occurred with staggering speed. By 1985, researchers determined that the average child was spending 2_ hours per day watching TV versus just eight minutes reading. (That figure doesn't include reading required for homework, only reading the child chose to do for fun).16 It was at precisely this time that the really extraordinary rise in Ritalin usage began. The Annenberg Center at the University of Pennsylvania has just published a study showing that the average American child aged 8 to 16 now spends over six hours every day staring at some sort of video screen (television, computer, Game Boy, and so forth). This study also found that 70 percent of parents thought that Who Wants to be a Millionaire? was educational television.17
STANDARDIZED TESTING: 'A NATION AT RISK'
In 1983, the U.S. Department of Education released a report entitled A Nation at Risk: The Imperative for Education Reform. The report, which was personally supervised by Education Secretary Terrence Bell, sounded an alarm:
"We report to the American people that while we can take justifiable pride in what our schools and colleges have historically accomplished and contributed to the United States and the well-being of its people, the educational foundations of our society are presently being eroded by a rising tide of mediocrity that threatens our very future as a Nation and a people.18 "
This report was released at a time when American society was troubled on many fronts: economic recession, huge and growing government budget deficits, and profound social discord about whether America was moving in the right direction. Japan was held up as a model of social harmony and efficiency. The Japanese economy was (at that time) growing steadily, while the U.S. economy seemed to be stagnating.
A Nation at Risk specifically pointed to the Japanese to illustrate the dangers facing America:
"The risk is not only that the Japanese make automobiles more efficiently than Americans and have government subsidies for development and export. ... In order to keep and improve on the slim competitive edge we still retain in world markets, we must dedicate ourselves to the reform of our educational system for the benefit of all."
A principal aim of reform, according to the report, should be to prepare students to "consistently attain higher than average scores in college entrance examinations. ... Standardized tests of achievement should be administered at major transition points from one level of schooling to another. ... The purposes of these tests would be to (a) certify the students' credentials; (b) identify the need for remedial intervention, and (c) identify the opportunity for advanced or accelerated work.19"
The report's impact was enormous. According to the New York Times, it had "brought the issue of education to the forefront of political debate with an urgency not felt since the Soviet satellite [Sputnik] shook American confidence in its public schools in 1957."20 The report marked the beginning of an era in federal education policy, an era still with us today. In 1989 President Bush affirmed his commitment to the recommendations of the 1983 report; he called for nationwide standardized testing to allow ranking every school district in the country on the same scale. President Bush's program was continued without modification by his successor, President Clinton. In his 1997 State of the Union address, Clinton called for a "national crusade for education standards," emphasizing that what was needed "to help schools meet the standards and measure their progress" was a set of "national tests of student achievement in reading and math."21 IBM Chairman Louis Gerstner ominously warned his audience at the 1996 Education Summit that "here we are in 1996, being passed away by other countries ... and what was once a problem is now a crisis that threatens the entire country."22
"Never before has American government been so critical of public schools," according to educational researchers David Berliner and Bruce Biddle, "and never before have so many false claims been made about education in the name of 'evidence.'"23 A fundamental assumption of the Nation at Risk report was that the inferior quality of American education was responsible for America's poor economic performance compared to Japan. This assumption, however, no longer makes sense.
America in the year 2000 no longer has a record of poor economic performance in comparison with Japan. America has now enjoyed eight years of steady economic growth with low inflation, while the Japanese economy continues to struggle with its longest recession since 1945. The U.S. budget now enjoys large surpluses, which appear to be growing year to year, while the Japanese budget is showing larger and larger deficits. All these changes in the international scene began taking place before the recommendations in Nation at Risk had been widely implemented. (Many observers argue that the national standards recommended by the report still have not been truly implemented, for better or worse, because American teachers, for the most part, just ignore the standards.24)
When the American economy began to revive in the early 1990s, Stanford professor of education Larry Cuban wondered why politicians hadn't shifted gears and started praising our schools. The answer, according to Cuban, is that the whole thing was "a scam from the very beginning. ... Even though Presidents Bush and Clinton knew that stimulating economic growth depended far more on fiscal and monetary policies than turning around schools--they pressed for national goals and standards. ...The lack of praise for the performance of public schools as the economy has brightened exposes the deceitful political logic of a decade of school reform.25"
What does all this have to do with Ritalin? Bear with me, we're getting there. Despite the unsoundness of the conceptual underpinnings of A Nation at Risk, the 1983 report led to a substantial rewriting of federal and state laws regarding education. Many states now employ "high stakes" testing, which, by definition, means that state funding is allocated preferentially to school districts showing the greatest improvement in test scores. Principals are hired or fired depending on their school's test score results. Superintendents are promised large bonuses if their school districts' test scores rise; if the scores fall, a superintendent will likely be sacked. School test scores now affect many aspects of a community's self-image, including property values. If your family has to choose between moving to town A or town B, and A's schools get higher test scores than B's, aren't you more likely to move to town A? Other things being equal, the town with higher scores will have higher property values.
Principals and teachers aren't stupid. Faced with pressure to raise test scores, they change the curriculum to increase the likelihood of students scoring high. Because standardized tests measure reading, writing, and math skills, more time will be devoted to reading, writing, and math. Because the tests do not measure skills in music, art, gym, or playground social skills such as learning to play fair in a game of kickball, less time will be devoted to music, art, gym, and recess. In some schools, recess is being eliminated altogether. After all, if your mandate is to raise test scores, what's the point of recess? Some superintendents are so intent on doing away with recess that they are building new elementary schools without a playground. "Many parents still don't quite get it," says Dr. Benjamin Canada, the Atlanta school superintendent. "They'll ask, 'so when are we getting a new playground?' And I'll say, 'There's not going to be a new playground."26
The elementary school curriculum has been speeded up. If you want your second-graders to excel on their standardized tests, then first grade is too late to start them reading. Start them in kindergarten. The result is that kindergarten, in the sense that it existed in the 1960s, no longer exists in most American school systems. The first-grade curriculum has been pushed down into kindergarten, which Time magazine wryly suggested should be renamed "kinder grind." "Forget blocks, dress-up, and show-and-tell," said Time. "Five-year-olds are now being pushed to read."27
The problem is that 5-, 6-, and 7-year-old children--especially boys-- are not well suited to a school day that consists entirely of reading, writing, and arithmetic. Without the diversion of art, music, gym, and recess, these children find it hard to pay attention. Because boys' brains are physiologically one to two years less mature than girls' brains at this age, many boys are incapable of mastering a kindergarten curriculum that emphasizes reading, writing, and math.28 Without the experience of excelling at artistic and athletic subjects, that boy may label himself as a failure. He may conclude that he just isn't smart, and school isn't for him. He will lose interest.
I've seen this happen many times. Sometime around the end of first grade or the beginning of the second, the boy's parents are summoned to the school for a "team meeting." This formidable encounter typically consists of the parents at one end of the table, with the boy's guidance counselor, plus one or two of the boy's teachers, plus the principal, and sometimes the school psychologist sitting at the other end. "Johnny [or Brett or David or Justin] isn't reading at grade level," the counselor tells the parents. "He doesn't pay attention," the teacher adds. "He may have ADD," the psychologist warns. "We think you should speak with your child's doctor about getting your son on Ritalin." (The congressional hearings on Ritalin, mentioned above, heard extensive testimony describing how some schools pressure parents to put their children on Ritalin. Parents in some school districts were warned that their children might be expelled if they did not comply.29)
At that point I get to meet the little "psychopath." The parents bring their son to see me. I'm supposed to decide whether this six-year-old boy needs to be on Ritalin. (Psychologist William Pollack reports that almost 90 percent of children taking Ritalin are boys.30) As the boy's doctor, I have two choices. I can accept the recommendation of the counselor, teacher, principal, and psychologist; write a prescription for Ritalin; and move on to my next patient. Total time elapsed: five minutes. Or I can question the recommendation of the school professionals, do my own assessment of the child, interview the parents at length, and question the need for Ritalin. Total time elapsed: sixty minutes, maybe longer. Meanwhile, I have other patients in the waiting room, eyeing the clock, asking the receptionist why Dr. Sax is running so far behind. What choice would you make in my position?
Actually, I usually question the diagnosis and perform my own assessment. My staff has learned to allow sixty minutes for an appointment any time parents say that they've been advised to consider Ritalin for their child. But in this era of managed care, many other doctors don't have the liberty to allow sixty minutes for a "well-child visit." Also, most other doctors don't have a Ph.D. in psychology and therefore may feel less comfortable performing their own psychological assessment of a child.
THE AGE OF PROZAC
When I began medical school in 1982, psychiatric medication was usually prescribed by psychiatrists. Psychiatric medications on the market at that time had (or at least were thought to have) dangerous side effects. The most commonly prescribed psychiatric medications in the early 1980s were either known to be addictive (for example, Valium and Xanax) or were appropriate only for very serious psychiatric disorders such as schizophrenia or suicidal depression. In my residency, beginning in 1986, we were taught to refer most patients in need of psychiatric medications to psychiatrists.
The introduction of Prozac in 1987 profoundly changed the way American physicians prescribe psychiatric medications. For most patients, Prozac is completely safe. Very few people experience truly dangerous side effects with Prozac--a situation not true of Prozac's predecessors such as Nardil and Endep. And managed care began making it harder for family physicians to refer patients to psychiatrists. Again, if you have a choice between writing a prescription for Prozac (elapsed time, one minute) versus calling an HMO for authorization for a psychiatric referral (elapsed time, ten minutes or more, with no guarantee that the authorization will be granted), which would you do?
By 1990, the majority of prescriptions for Prozac were being written by doctors who were not psychiatrists. The medical profession discovered that no special magic was required to write a prescription for Prozac. For the most part, patients did fine. In fact, writing a prescription for Prozac in most cases requires less vigilance and less follow-up than writing prescriptions treating high blood pressure or diabetes.
So why not write a prescription for Ritalin? doctors began asking themselves. Almost all the increased prescribing of Ritalin can be attributed to nonpsychiatrist physicians. But Steven Baldwin, professor of psychology at the University of Teesside, believes that most pediatricians and family physicians are not qualified to distinguish a truly abnormal child from a child who is just exhibiting developmentally normal behavior. "This is a difficult, tricky area," says Baldwin. "Behavior reflects the feelings and thoughts of a child. If a child is running around making a lot of noise, not really settling to anything, you could say the child is being naughty, nasty, or wicked, or you could say the child is anxious, worried and angry because something is on his mind."31 At the congressional hearings on Ritalin mentioned above, Dr. Lawrence Diller suggested that today doctors wouldn't hesitate to put Tom Sawyer or Pippi Longstocking on Ritalin.32
THE INTERNATIONAL PERSPECTIVE
Now we have at least a sense of why Ritalin usage increased 4,000 percent in twenty-five years. But what about the other questions? Is Ritalin dangerous? Is it really necessary? How do other nations cope?
Despite the popularity of Ritalin, no comprehensive long-term studies of its safety have been performed. No one can say, for instance, whether taking Ritalin from the age of five to the age of fifteen without interruption has any effect on brain development. It may, or it may not. The medical risks of long-term use simply are not known.
I have seen some psychological risks. Teenagers have asked me for a Ritalin refill--long after we have agreed that they no longer need it-- because they are nervous about taking SATs without it, or they feel they need it to write ar term paper. There is no pretense of mental illness here. These kids want a performance enhancer, pure and simple. In a sense, they have become psychologically dependent on the drug. They no longer have confidence in their abilities without Ritalin.
How do other countries cope? Why haven't they experienced a huge surge in Ritalin use? First of all, one nation outside the United States, Great Britain, has experienced a huge surge in its use. In 1994, fewer than five thousand British children were taking Ritalin. The most recent figures for the year 2000 show that over 130,000 British children are now taking it.33 Many of the factors we've considered for the United States appear also to underlie Great Britain's 25-fold increase in just six years. A 1999 study by the London School of Economics found that British kids now spend substantially more time indoors than their German, French, and Spanish peers do. The study found that British children routinely spend more than thirty hours per week in their bedrooms watching television, playing video games, or surfing the Internet.34 The performance of British schools is increasingly assessed via standardized testing; just in the past five years, British politicians have become enamored of American-style standardized tests such as the SAT.35 And British physicians, bound by national health insurance, continue to experience strong pressures to prescribe psychiatric medication on their own rather than refer patients to psychiatrists.
Almost all other countries experience much lower rates of Ritalin usage. As I noted at the outset, America alone accounts for roughly 90 percent of the world's consumption of Ritalin. The three factors discussed above--television, testing, and Prozac--are much less prominent in most other developed countries. French, German, Spanish, Swiss, Japanese, and Australian children watch substantially less television than American children do. None of these countries experienced the collective hysteria precipitated by the publication of A Nation at Risk. All these countries still have kindergarten that is recognizable as kindergarten. In fact, in Germany there is a rapidly growing movement to have kindergartners spend all their time outdoors, essentially going on field trips into the woods every day. This new idea, known as Waldkindergarten ("forest kindergarten"), is the fastest growing educational movement in Germany today. Ten years ago there was not a single Waldkindergarten in Germany, today there are over a hundred.36 Incidentally, the Germans call standardized tests amerikanische Prufung--American tests.
Despite their stubborn refusal to medicate their children with Ritalin, these other countries do not lag behind the United States in academic performance. On the contrary: according to the most recent studies, France, Germany, and Japan continue to maintain their traditional lead over the United States in tests of math and reading ability.37Nevertheless, for Americans, it seems likely that Ritalin is here to stay, barring some new evidence of long-term hazard. But American practitioners and parents alike must realize that Ritalin is a treatment, not a cure. It's analogous to using Tylenol to bring down a fever: The medication works, the symptom is alleviated, but the underlying problem has not been fixed.
It's hard to resist the conclusion that American culture, particularly as seen in school systems, has played a role in increasing Ritalin usage over the past twenty years. Twenty years ago, it was OK to wait until first grade to teach Johnny how to read. Now he has to learn to read in kindergarten. We are in a hurry, and we have no time to "waste"--or so we believe.n
1.Richard DeGrandpre, Ritalin Nation (New York: W. W. Norton, 1999), 16.
2.DeGrandpre, Ritalin Nation, 18.
3.Keith Hoeller, "Ritalin Shouldn't Be Forced on Our Kids," Seattle Times, 8 Mar. 2000, B5.
4.Associated Press, "Behavior Pill Gets Dose of Scrutiny," Chicago Tribune, 17 May 2000, 12.
5.Christopher Johanson and Charles Schuster, "A Choice Procedure for Drug Reinforcers: Cocaine and Methylphenidate in the Rhesus Monkey," Journal of Pharmacology and Experimental Therapeutics 193 (1975):676-- 88.
6.John Lang, "Ritalin: Helpful or Harmful?" Denver Rocky Mountain News, 9 June 1997, 3A.
7.Lang, "Ritalin: Helpful or Harmful," 3A.
8.Associated Press, "House Panel Hears Tales of Ritalin Excesses in Schools," Chicago Tribune, 17 May 2000, 12.
9.Rummana Hussain, "Boy Given Probation in Ritalin Theft," Chicago Tribune, 27 May 2000, 5.
10."Doc Links Ritalin to Boy's Death," New York Daily News, 17 Apr. 2000, 54.
11.DeGrandpre, Ritalin Nation, 187.
12.DeGrandpre, Ritalin Nation,183.
13.Doug Hanchett, "Ritalin Speeds Way to Campuses; College Kids Using Drug to Study, Party," Boston Herald, 21 May 2000, 8.
14.Cited in DeGrandpre, Ritalin Nation, 131.
15.Matthew Dumont, letter to the editor, American Journal of Psychiatry, April 1976, 457.
16.Cees Koolstra and Tom van der Voort, "Longitudinal Effects of Television on Children's Leisure-time Reading," Human Communication Research 23 (1996):4--35.
17.Marisa Guthrie, "Plugged In," Boston Herald, 16 July 2000, 4.
18.National Commission on Excellence in Education, A Nation at Risk: The National Imperative for Education Reform (Washington, D.C.: U.S. Government Printing Office, 1983), 5.
19.A Nation at Risk, appendix A, 29.
20.Cited in Peter Sacks, Standardized Minds: The High Price of America's Testing Culture and What We Can Do to Change It (Cambridge, Mass.: Perseus, 1999), 77.
21.Sacks, Standardized Minds, 80.
22.Sacks, Standardized Minds, 81.
23.Sacks, Standardized Minds, 81.
24.Susan Ohanian, One Size Fits Few: The Folly of Educational Standards (Portsmouth, N.H.: Heinemann, 1999).
25.Sacks, Standardized Minds, 87.
26.Cited in Christina Hoff Sommers, The War Against Boys: How Misguided Feminism Is Harming Our Young Men (New York: Simon & Schuster, 2000), 95.
27.Amy Dickinson, "Kinder Grind," Time, 8 Nov. 1999, 61.
28.Leonard Sax, "Reclaiming Kindergarten: making today's kindergarten less harmful to boys," Psychology of Men and Masculinity, American Psychological Association (forthcoming).
29.Jonathan Riskind, "Schools Push Ritalin, Panel Told," Columbus (Ohio) Dispatch, 17 May 2000, 1A.
30.William Pollack, Real Boys: Rescuing Our Sons From the Myths of Boyhood (New York: Henry Holt, 1998), 257.
31.Sally Beck, "Are Too Many Children Needlessly Drugged?" Times (London), 20 June 2000, 14.
32."House Panel Hears Tales," 12.
33.Beck, "Too Many Children?", 14.
34.Peter Foster, "Anxious Adults Turning Children Into TV Addicts," Daily Telegraph (London), 19 Mar. 1999, 1.
35.Sonja Lewis, "Suddenly Britain's Politicians Are in Love With America's SAT," Guardian (London), 6 June 2000, 12.
36.Roland Gorges, "Der Waldkindergarten," Unsere Jugend, Spring 2000, 275--81.
37.Jodie Morse, "Summertime and School Isn't Easy," Time, 31 July 2000, 20. French students scored 23 points above the international average; Japanese students, 94 points above. German students on average were 5 points below the international average; American students, 39 points below.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||author analyses use of Ritalin in U.S. and places it in social context|
|Publication:||World and I|
|Article Type:||Statistical Data Included|
|Date:||Nov 1, 2000|
|Previous Article:||The multilaterals.|
|Next Article:||The Division of the World.|