David J Sweanor, Faculty of Law and Centre for Health Law, Policy and Ethics, University of Ottawa, Canada in conversation with ETHealthworld elucidates how harm reduction is an umbrella term for interventions designed to lessen problematic consequences of behaviours. Even though harm reduction was originally and most frequently associated with substance use, it is increasingly being applied to a variety of other behavioural disorders.
Why is harm reduction an important aspect of public health?
The dramatic increase in global health over the past century and a half is one of the stellar accomplishments of humanity. We have emerged from a world where even the wealthiest nations had very high rates of child mortality to one where even some of the poorest now have sufficient centenarians to warrant research. Life expectancy in poor countries is now higher than it was in the wealthiest nations of the 1800s.
What has caused such a transformation?
The answer is exactly the approach that can perpetuate such progress. It is a matter of using science, reason and humanism. Where we find harms, we work pragmatically to reduce them. We seek to understand the life experience of those at risk, empower them to make better health decisions, and engage with them.
Why is harm reduction often controversial, with some people simply opposing it?
It is extraordinary that such pragmatic and successful risk reduction interventions on so many goods, services and activities have such a long history of opposition. But many people see products, activities, and even life situations in moralistic terms. They are seeking to battle a perceived evil rather than promote health. Others take positions on public health issues based on some overriding political or ideological agenda. Throughout my decades of work on public policy issues, I have constantly dealt with supposed advocates on issues who do not appear to care about the issue other than as a vehicle to pursue some other agenda. We should not be surprised when self-described health activists, environmental campaigners or other issue-oriented people do ineffective or counterproductive things when their overall interest is aligned with something else. Additionally, their claims of pursuing laudable goals often reduce the scrutiny of their ideas and activities.
Why is there a need for robust public health to address tobacco in India?
When we look at preventable harms it would be hard to not place tobacco/nicotine near the top of any list of priorities. Cigarette smoking is the world’s leading cause of preventable death, with the harm almost entirely due to the inhalation of smoke rather than the use of nicotine. There are also consumer acceptable alternatives without the smoke. Additionally, cigarettes are bought very frequently; typically daily. So, a transition to less hazardous products can be extraordinarily rapid, unlike measures to reduce risks from automobiles, building standards, road design and other things where replacements take many years. There are also many toxic smokeless tobacco products in India. Yet other consumer acceptable products can dramatically reduce those risks. Often, as with replacements for cigarettes, at no additional cost. The application of established public health principles in addressing tobacco caused disease in India could yield dramatic results, and shape policy globally. We can change public health history, with gains akin to those achieved through the elimination of smallpox.
What is the socio-economic impact of prohibition and bans?
Bans do not eliminate products consumers want or need. They merely lead to alternative, illicit, sources. We then lose the ability to regulate the products. Bans are not a form of regulation but an abdication of the responsibility of governments to effectively regulate. In the case of tobacco or nicotine, a ban on the least hazardous products simply moves demand to the more toxic products that remain available.
What has been the impact of India’s moralistic regulatory regime?
Bans on products like vaping reward those providing lethal alternatives such as cigarettes. It also implicitly tells the public that the lethal products must be safer as they remain available. This deprives consumers of the information necessary to make informed personal health decisions and the ability to effectively act when they are informed.
What are your expectations from WHO to take progressive steps around harm reduction this year?
During my long career, the WHO has transitioned from having very little interest in tobacco issues, to pushing the global agenda to reduce smoking, to taking an absolutist abstinence-only agenda that is protecting deadly cigarettes and other toxic products rather than public health. This has gone so far as to deny authorisation of a COVID-19 vaccine developed in Canada simply because a tobacco company has a small minority interest in the biopharma company that developed it. Such a move will, just as happens when WHO pushes for bans on low-risk alternatives to cigarettes, actually add to the toll of death and disease. It is worth pausing to think of how we got to the point that the WHO does things that foreseeably add to death and disease rather than pragmatically working to reduce health burdens. They need to be pressed to re-examine their priorities if we are to achieve global health goals.
What role can harm reduction play in addressing India’s tobacco goals?
India could dramatically reduce the staggering toll of morbidity and mortality caused by toxic nicotine delivery products simply by following established public health principles. Given the variety of toxic tobacco products in India and the ease of substituting safer alternatives, there is a huge public health opportunity. It is also an incentive for the the country’s esteemed scientists, engineers, and entrepreneurs to seize the opportunity to do well by doing good.