We have a unique opportunity to begin the 21st Century with important
health issues high on the international agenda. The United Nations
Security Council has discussed the issue of HIV/AIDS, recognizing the
security threat to many countries. More importantly, the World
Health Organization has begun the negotiation to establish an International
Framework Convention on Tobacco Control, the first ever treaty on another
ongoing threat that has killed more people than any atomic bomb.
Last century, we set similar challenging goals in health and have achieved
some modest victories—Smallpox was eradicated from the world, polio
was eliminated from the Americas, and we are on our way to eliminating
measles from the Western Hemisphere. Vaccines now protect about
8 out of 10 of the world's children against six killer diseases.
While it is hard to predict which infectious diseases we will have
to conquer next, international travel and the transport of goods will
spread disease. However, the goods of greatest alarm are not infectious,
radioactive or technologic. The greatest threat both at home and
abroad is tobacco. As the world’s hyperpower, the Unites States
has a moral obligation to lead against death. Unlike the cold war battling
an ideological enemy, the new enemy abroad is a common icon—the Marlboro
Man—and the millions who follow his lead.
Even though the number of smokers in the United States has dropped
from 40 percent of all adults in 1964 to 23 percent in 1997, the number
of smokers in developing countries has been growing at an annual rate
of 3.4 percent. This translates into over 4 million people each
year dying from tobacco-related illnesses, including 1 million in China
and as many as 700,000 in India. At the current growth rate, more than
10 million people will smoke themselves to death each year by 2030,
70 percent of them in the Third World. This translates into
early death, increased health care costs and billions of wasted dollars.
This of course has great consequence on a planet where millions of children
go to sleep hungry each night.
Today the Highly Indebted Poor Countries face extreme poverty and financial
insolvency that will lead to despair and economic isolation.
Nonetheless, on a daily basis, people in these countries shorten their
life by smoking, yet we think little about them unless war or exotic
disease breaks out.
So, to protect the world from preventable death, a tobacco control
treaty process was unanimously endorsed by the World Health Organization
in May 1999. However, it can create false hope for the public
health community.
Embarking on a strategy to combat such an enemy is daunting.
It is a first step in raising the visibility of tobacco as a moral and
global responsibility. Although it most likely will meet
its demise in the U.S. Senate, the treaty suggests a global call to
action.
The challenge to extend health by limiting tobacco use will require
perseverance. While politicians argue about the language and governance
of a treaty convention, we must also continue to reduce teen access
to smoking, reduce the promotion and advertising of cigarettes, and
establish research funds to reduce the harm caused by tobacco.
Just as the U.S. has led the way in reducing childhood disease and shared
our medical know how, our leadership in tobacco control can be
an exemplar for the world.
The moral obligation to be successful can be achieved with a variety
of policy mechanisms. Economic disincentives to smoke such as
increased taxes on cigarettes are the strongest predictors of human
behavior. At the same time, we can use our communication
prowess to change social norms, deglamorize tobacco, limit availability,
and provide assistance for tobacco farmers to grow food instead.
Such activities will need to be carried out with the best minds in universities,
in business and the public sector. Perhaps we can even advance
a voluntary corporate leadership. Consider the possibility for
McDonalds to become smoke free throughout the world. If
we truly hope to see a smoke free generation in the 21st century, we
must consider the usage of Aristotle’s “all the available means of persuasion.”
Developing any treaty or international agreement provides a unique
challenge. Should we aim for the best, most comprehensive treaty
or one with minimal standards?
Any health issue requires a different level of sophistication as it
should be focused on the “ideal” —ideal to the community, ideal given
economic conditions, ideal based on the individual decision maker.
Ideal health is not measured by the amount of money spent or the proliferation
of modern day technologies—the number of MRIs, the human genome, or
the availability of a super medical facility. An ideal health
system does not rely on chemotherapy to treat all diseases and surgery
for tobacco related cancers, bur deters it from occurring with prevention.
While we wait for the global treaty on tobacco control, millions of
people will die, and millions more will begin to smoke. If the
U.S. professes to be the world’s moral compass, the U.S. can lead the
way with our wisdom to prevent disease, build a world with healthy economic
and environmental development, and offer scientific progress to support
quality of life and health.
Our new challenge in the 21st Century is not the microbe. Instead
humankind has advanced with the creation and marketing of an unparalleled
cause of death—the cigarette. Nonetheless, we can rise to
the challenge and use our power to communicate to begin to advance a
health age—an age which values life over death with decisions
that add rather than subtract years to life.
