Is multilateral approach the best the world can get?
‘Global governance has failed, Multilateralism is in crisis’, PM Modi’s remarks as he opened a Foreign Ministers’ meeting of the G20 where Russia’s war in Ukraine had taken center stage. Various multilateral bodies haven’t been effective in defusing the situation and little has been achieved by global governance. The Kashmir deadlock between India and Pakistan was finally broken by the former when it quelled article 370/35A in J&K – culminating in investment and development.
In the 80’s, characterization of the HIV virus by WHO as a ‘rich man’s disease’ led to time being lost on public health interventions and the approval of vital drugs that could have saved lives. The transition from WHO’s Global Programme on AIDS to United Nations Program on HIV/AIDS (UNAIDS) was needed to make effective strides towards finding a cure. An unlikely alliance of activists, lawyers, and generic drug companies made HIV treatment affordable where WHO’s negotiations failed. UNAIDS’ broader mandate helped bridge this gap between Geneva and the globe and is a significant driver of the AIDS response’s remarkable progress.
More recently WHO delayed alerting member countries, leading to COVID-19’s rapid spread. India stood distinguished by taking an independent customized approach to fight the virus at the scale we did.
Tobacco induced diseases are another public health crisis that stands compromised – WHO indicates tobacco smokers will increase to 1.2 billion in 2025. With 8 million deaths every year and an additional 1.2 million caused by second-hand smoke, the smoking of tobacco is more dangerous than World War I. India alone has 100 million people who smoke cigarettes (28million) or bidis (72million). Reduction of tobacco smokers worldwide proceeds at a much slower rate than possible. Owing to the number of users, tax revenue and livelihood of farmers, tobacco cannot be removed from India, leaving safer alternatives as the only ray of hope for saving lives.
WHO’s tobacco policies don’t include any safer alternatives to tobacco. They have completely overlooked reduced risk solutions and even actively opposed them, leading to the loss of many lives and a threat to many more. WHO’s tobacco control policy unfortunately doesn’t work for low-income countries. Ex–WHO officials – Prof. Robert Beaglehole and Prof. Ruth Bonita have said in a Lancet report that only 30% of countries are on track to achieve WHO’s target of 30% relative reduction by 2030 in adult tobacco usage.
FDA approves certain category of safer alternatives based on scientific data, WHO has a conflicting stance, suggesting they expose legal age smokers to harmful substances.
Also pertinent is that primary health risks associated with smoking arise from the combustion of tobacco and toxic additives in tobacco. Most toxic substances are released on combustion. Burning/smoking a cigarette generates temperatures exceeding 850 degrees Celsius. These temperatures generate a complex mixture of over 6000 harmful chemicals and carcinogenic particles that are inhaled, causing disease. Some novel safer alternatives available globally require no heating at all while others can control temperature very precisely, operating at 350 degrees Celsius, avoiding combustion and its by-products, hence reducing risk tremendously. Alternatives to oral tobacco include snus (a highly purified and refined preparation of oral tobacco) and nicotine pouches (with zero tobacco) which can dramatically reduce the disease burden in oral tobacco users – most significant when India has over 200 million oral tobacco users
Countries like UK, Sweden & Japan have adopted a tailored policy using safer alternatives to reduce the economic burden of tobacco. It is important for countries to adopt a customized approach as national policy can’t be a ‘one size fits all’, especially for low- and middle-income countries.
UK’s health department concluded that safer alternatives are 95% less harmful than combustible tobacco, helping 2.5 million smokers switch & eventually quit tobacco. Sweden will soon be the first country to become smoke-free. The number of smokers has fallen from 15% to 5.6% in just 15 years with the help of a mix of safer alternatives, ironically achieved by ignoring WHO’s guidance. Further, they witnessed a 41% lower incidence of cancer, lowest across EU. Japan has witnessed a 5.2% fall in smoking rate between 2016 and 2019, coinciding with the roll out of safer alternative, pointed out an American Cancer Institute study.
It becomes an urgent requirement for decision makers to draft a tobacco control policy customized for the need of the end user, ensuring their wellbeing. Technology that can eliminate toxic tobacco products has put us on the precipice of a public health revolution of historic significance. We can do what has worked so well for so long on so many other public health issues. It merely requires us to embrace science, reason, and humanism. Simply put, when opportunity knocks, answer the door.
(This article is authored by David T Sweanor, Faculty of Law, University of Ottawa and Kiran Melkote, Orthopaedic Surgeon; Director, AHRER)
