If the man is Rodrigo Duterte, president of the Philippines, and you are the head of the World Health Organisation’s anti-tobacco division, you will send your personal congratulations. Never mind that Duterte’s indiscriminate shoot-to-kill policy for drug users has brought him to the attention of the International Criminal Court. Duterte has recently introduced a smoking ban and that, it seems, is enough for him to be embraced by the public health community.
A total lack of perspective? Perhaps, but an inability to look beyond petty lifestyle regulation has become the WHO’s calling card. Take North Korea, for example. Amnesty International says that this totalitarian hellhole is ‘in a category of its own when it comes to human rights violations’, but when WHO director-general Margaret Chan visited the country in 2010, she commented favourably on its low rate of obesity.
When the Ebola epidemic began in October 2014, Chan issued a statement saying that she was ‘fully occupied with coordinating the international response to what is unquestionably the most severe acute public health emergency in modern times.’ This was not entirely true. In reality, she was at a WHO conference in Moscow denigrating e-cigarettes and praising Vladimir Putin for his commitment to public health. Malaysian Airlines Flight 17 had been shot down above Ukraine only two weeks earlier.
Rodrigo Duterte, Kim Jong-un and Vladimir Putin. Is there any politician too brutal for the WHO so long as they take a firm line on fizzy drinks and smoking in bars? As international organisations go, this lot make FIFA look like the Girl Guides.
The WHO has been strongly criticised for its feeble response to the Ebola outbreak. There is little doubt that it was ill-prepared for the epidemic, which killed over 11,000 people, but then dealing with contagious diseases in poor countries no longer seems to be the WHO’s priority. Today, its main focus is tackling ‘non-communicable diseases’ and the lifestyle choices associated with them. To that end, the agency has produced reports in the last few weeks calling on governments to introduce taxes on sugar, bans on online food advertising and bans on e-cigarettes. It has previously invested its resources in campaigning against the depiction of smoking in films and for a ban on smoking outdoors; it was by complying with the latter demand that Rodrigo Duterte gained the agency’s respect.
WHO documents about nanny state issues are often published anonymously but when the authors can be identified they are almost invariably from the rich West and the quality of evidence they contain is rarely worthy of an august UN institution. Last month’s report on food taxation, for example, failed to provide any credible evidence that tax has been successfully used to improve health anywhere in the world and its claim at the weekend that vaping does not help smokers quit laughs in the face of the evidence.
Evidence aside, it is questionable whether the WHO should be using its limited resources to pester westerners about their lifestyle choices. When pressed, the agency justifies its approach by pointing out that more people die of non-communicable diseases than die of infectious diseases. This is true, and it is a jolly good thing. It is a mathematical certainty that non-communicable diseases will rise as contagious diseases decline, but contagious diseases tend to kill the young while non-communicable diseases tend to kill the old. It takes a moral imbecile to view the death of an elderly person from cancer no differently to the death of a child from malaria.
Public health used to mean medicine, vaccinations, quarantine and environmental protection — all actions that had to be taken collectively. Increasingly, it has come to mean regulation of personal behaviour, something that individuals are capable of handling themselves. The WHO has embraced the new definition of ‘public health’ wholeheartedly, but fate keeps conspiring to remind it that the original mission remains unfulfilled. Margaret Chan’s attack on e-cigarettes in Moscow in front of an audience of true believers (the media were banned) while Ebola ravaged Africa was a stark illustration of the difference between the health concerns of the rich world and those of the poor.
The organisers of that conference must have cursed their bad timing and hoped for better luck when they organised a follow-up conference for 2016. That conference got underway this week with e-cigarettes top of the agenda. The WHO’s preference is for governments to ban them outright but if prohibition is not feasible it at least wants a ban on vaping indoors to protect bystanders from the mythical threat of secondhand vaping. It is grimly ironic that the conference is being held in Delhi where a thick haze of smog has suffocated the city for several days. Levels of particulate matter are currently 90 times higher than the recognised safe level.
While the delegates inside chatter about plain packaging, film censorship and e-cigarettes, the city outside will serve as a potent reminder that there is still real public health work to be done.