Leaders take easy way out on health issues

Lisa Williams-Lahari
The woman is thin-framed, a young mother who has not seen her family all day—it’s late and she is hungry.

A nil-by-mouth sign sits with her files which have been on the bed with her since she arrived this morning. It is evening, and she is still waiting to see a doctor. She will spend the night and most of the next day in a public hallway with more than 20 other urgent cases, connected to a drip and coughing her way through conversation.

She has been smoking for more than 20 years now, not including the few times when she tried to quit since lung cancer claimed her mother two years ago.

Now, with the pain and the coughing ripping through her lungs, she is desperate for a cigarette but knows the hospital is a smoke-free zone. Even her foray into the toilets to look for a private window is in vain—the windows don’t open.

I try to make sense of her pain, picking on the invisible doctors who have caused this long wait by people too ill to complain, suffering for hours on end in this one place which at this point, is their lifeline.

“Well,” her tone is bleak with truth as she nods towards the door, “there are a lot of sick people out there.”

Yes, there are a lot of sick people in this part of the world, many of them ticking time bombs of preventable ill-health who reached this point through a lifetime of cumulative choices.

For those Pacific Islanders who have smoked their way to illness, often on a ride of a pack a day, hospital resources, trained doctors, specialist care, even basic bedding and space are already stretched with those who got there first through overeating, binge-drinking and too little exercise.

It’s estimated that three out of every four deaths in the Pacific can be linked to non-communicable, lifestyle diseases.

Unlike death by accident or injury, dying from a lifestyle disease is ironically the most likely way Pacific Islanders will leave this world—and the most preventable.

Pacific scenario

The Pacific scenario above is becoming an all too common one for islands governments whose health budgets could do with financial injections and more skilled nationals willing to return home from expensive overseas training—and remain there.

Also worrying is the impact on women, making up around half of those affected by lifestyle ills, but still carrying the caregiver and domestic-nurse work when other family members fall sick. Take them out of the equation due to their own ill-health and the impact is a double hit to islands homes.

Nutrition and stop-smoking educators face the same advocacy problems confounding their counterparts working to stop sexually transmitted infections such as HIV/AIDS—how to make people take the information gained from awareness campaigns, apply them to their own behaviour and turn the risk around?

The stop-smoking lobby has two items in its basket of solutions which other lifestyle diseases don’t have. One is an international anti-smoking treaty, known in development jargon as the Framework Convention on Tobacco Control, or FCTC. The other is a senator from Palau by the name of Caleb Otto.

The FCTC is a leading global document which lists a range of prohibitive measures from pricing to packaging.
Otto is a physician-turned-politician who has made it his personal crusade to ensure Pacific nations act on the treaty and achieve the goal of a smoke-free Oceania.

Already signed by all 16 Pacific member states of the World Health Organisation, including Australia and New Zealand, the treaty starts making life uncomfortable for the Pacific tobacco industry beginning October 2008, when Fiji meets its five-year deadline for a comprehensive ban on tobacco advertising, promotion and sponsorship.

Australia, the Cook Islands, Marshall Islands, Nauru, New Zealand, Palau and the Solomon Islands face the same in 2009. By the end of 2010, Vanuatu, Tuvalu, Tonga, Samoa, Niue, Federated States of Micronesia and Kiribati are also committed to the same.

Saying no to industry dollars is only one part of the equation. Increasing tobacco taxes and removing duty free status, clearer product labelling and legislation restricting product sales are all part of supporting the to-do list under the international tobacco treaty.

For Otto, a lot of progress has been made in terms of commitments. But political leaders are “taking the easy way out on health issues” by spending on highly visible curative care rather than less popular prevention areas.

A former pack-a-day smoker who kicked the habit after 15 years, he attributes his advocacy to losing several of his cousins to cancer from smoking; including one raised as his brother.

He says watching that cousin-brother end his days struggling to feed through a straw because he no longer had a jaw fuelled his personal conviction.

By the time he came across an article featuring a leading US tobacco company CEO and his now infamous response: “We don’t smoke that shit. We just reserve the right to sell it to the young, the poor, the blacks and the stupid,” Otto had met his tipping point.

“I knew I had to be personally involved in a big way because Palauans fall into all of these categories they target for profit,” says Otto.

Tobacco consumption, he argues, represents a new and more dangerous colonialism than the histories of foreign administration which islands nations have emerged from.

The mind-enslavement represented by tobacco addiction is one encouraged on a global scale; he points out, not just by a well-oiled industry, but by pharmaceutical companies pushing their drugs through government links to medical outlets in the islands.

In so doing, they create another layer of addiction to curative, rather than preventative health.  

Sanctioned murder

He terms the selling of cigarettes as “sanctioned murder”; blaming an industry ready to bribe, and leaders willing to blind themselves to “the devastation that tobacco use does to individual lives, families and budgets” for the current scenario.

Nearly 5 million people die from tobacco-related illness every year, and that could double to 10 million annually by 2030 with most of those fatalities happening in the developing countries. Pacific populations already feature a large smoking brigade. WHO surveys show just over 48 in every 100 Nauruans smoke an average of a pack a day. Isolation and access to key ports is not an issue. The atoll-nation of Tokelau features 46 in every 100 who smoke on a daily basis, more than Fiji’s 43 in every 100 with a habit, and far more than the Cook Islands, Samoa and American Samoa, all around the high 20’s and 30’s per 100 people.

Otto’s penchant for joining the dots between the seemingly opposite themes of a cigarette break and social justice keeps him in demand at international forums on tobacco control—from a key meeting in Thailand where he was part of the Pacific team last July, to being one of five key speakers at the Oceania Tobacco Control conference hosted by New Zealand. But his toughest moments remain on his own senate floor back in Palau, where tobacco control legislation—as is the situation in the Solomon Islands, Papua New Guinea, and Nauru—is painfully choking its way into existence.

“During the House of Delegates debate on our proposed (tobacco) legislation, only four delegates spoke—all against the bill,” he recalls. “They all had one argument—that it would hurt businesses and that there was a lack of data to support damage at the local level. The speakers were either users of tobacco, had tobacco selling business or had relatives that had tobacco selling business.”

That scenario of the personal informing the political agenda is a familiar one in Pacific parliaments, whatever the debate. But Otto says in the case of tobacco control, an influential industry is there to shape the debate in the most comfortable direction.

In the case of British American Tobacco, which has Pacific outposts in Fiji, Papua New Guinea and the Solomon Island, the language of persuasion is rich with soothing reassurances that it supports the key tenets of the FCTC, but it edges away from outright support for implementation and begs to disagree on some key arguments from the WHO lobby, such as economic impacts of smoking versus. banning consumption.

Taxes are a key area where the tobacco industry feels unfairly dealt with, arguing that higher prices will fuel black market illicit trade rather than impact in real terms on how many and how much people smoke.
British American takes its disclosure policy on donations into the political realm, noting on its website that “political donations are generally not encouraged,” are stringently managed, and only paid out to political parties “to influence the debate on issues affecting the company”.

In 2006, three of the only four nations worldwide where political payments were made came from the Pacific. Australia and Canada are on the list. Political donations were made in Fiji to the tune of almost F$50,000 and in the Solomon Islands, where more than S$105,000 was used to influence debate. Who received the money, and whether it had the desired influence, isn’t clear. But Otto says tobacco industry money in the islands does more than just promotion through posters, billboards, sweepstakes and other forms of advertisement.

“Leaders are made to put barriers on strong legislation through industry bribes and the protection of businesses of family members or friends,” says Otto.

Advocates in places like Fiji and Tonga, where legislation on smoking already comes close to supporting the framework convention, don’t have the uphill climb which Otto is experiencing. In Niue, where Premier Young Vivian has said he would pay smokers to quit if it meant decreasing the island nation’s million-dollar annual health bill, draft legislation banning smoking in public areas and all government departments is planned.

The Solomon Islands was to have passed legislation earlier this year, but the minister in charge of the bill deferred the bill, ostensibly to build more public awareness, until late 2007.

Vanuatu, Tuvalu and Kiribati also targeted this year for legislating to control tobacco use, albeit at different levels and stages

And despite his cynicism over corrupt colleagues, Otto believes it is still Pacific leadership that will push action towards the vision of a smoke-free Pacific.

He’s not far off the mark. A new post-Pacific Forum Leaders statement on Health delivered in Tonga called for “immediate action to halt and reverse NCDs...through multi-sectoral engagement”. In a summit busy with setting up a long to-do list for regional organisations such as the Pacific Community, Forum Fisheries and the new Western Pacific Tuna Commission to work on, the leaders couldn’t get down to pointing specific fingers at the treaty and the tobacco industry.

But if the advocates make the right connections, Otto may be joined by some new heroes: in their joint statement, our Pacific prime ministers did find the time to throw in the need for a Super 14 Pacific Rugby team.