A blank slate
With no meaningful history of traditional tobacco control, Malawi may be more open than other countries to the concept of harm reduction.
By George Gay
Malawi has a tobacco control commission but makes no interventions to control tobacco product consumption. There is, however, no anomaly here, as professor Gerry Stimson, a director of Knowledge Action Change (KAC), an organization that promotes health through harm reduction strategies, pointed out during an interview in London in April. This state of affairs merely reflects a tension within the tobacco fabric of Malawi. The Tobacco Control Commission is charged only with overseeing the leaf tobacco production industry—an industry so important to the economic welfare of the country that there is a reluctance on the part of the government to engage also in consumption-control activities.
Freshly returned from a visit to Malawi, Stimson related how tobacco packs in the country carried no health warnings, how the country imposed no age restrictions on tobacco product purchases and how taxation was not used as a vehicle for reducing consumption. Malawi was not party to the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) and employed none of the WHO’s MPOWER measures intended to assist in country-level implementation of interventions to reduce demand for tobacco.
Such reluctance to rigorously confront one of the greatest health issues of our time will be seen by some as concerning, but Stimson clearly senses an opportunity. When he looks at Malawi, he sees a country that, without a history of narrowly focused tobacco-consumption interventions, is perhaps open to ideas about tobacco harm reduction (THR).
KAC’s directors, Stimson and Paddy Costall, have been active in harm reduction for more than 40 years and, more recently, specifically in THR. They have helped stage the annual Global Forum on Nicotine (GNF) in Warsaw, Poland, since 2014. More recently, using funding from the Foundation for a Smoke-Free World (FSFW), KAC has introduced THR scholarships and launched the Global State of Tobacco Harm Reduction 2018 report.
That report, which was written by Harry Shapiro and launched last year in London, is currently the subject of an international roadshow, also funded by the FSFW, that has so far seen it taken to Australia, Kenya and Malawi, not all of which are necessarily the first countries that would come to mind when planning such a trip. In fact, Stimson admitted that, not long ago, he considered Africa to be off the map in respect of THR. But now, he said, there was a lot of interest and a lot of activity, and some “rising stars” among the people there. Malawi, for instance, was included on the roadshow schedule partly because two of KAC’s THR scholars based there, Chimwemwe Ngoma, who runs the campaigning organization, THR Malawi, and social scientist, Wilfred Jekete, had said they wanted to organize a THR meeting for government officials and others.
Open to ideas
That meeting, described by Stimson as “very interesting,” attracted more than 100 people representing health education and AIDS organizations, universities, nongovernmental organizations (NGOs), farming interests and tobacco community development bodies, as well as and the government departments of agriculture, health and trade, a lineup that seems to support Stimson’s contention that the country could be open to fresh ideas concerning the control of tobacco consumption.
But first there would need to be a shift in thinking away from the idea that acting against tobacco consumption locally could hurt the “health of the tobacco economy,” a shift that has been made successfully in other tobacco exporting countries, even in countries where, unlike Malawi, consumption is mainly of locally manufactured products.
Certainly, the argument that Stimson and his team presented was that the government could concern itself with the health of smokers without what it did affecting the health of the tobacco economy, because consumption of domestic tobacco was minimal. And the prospects in Malawi were good, Stimson said, because the government could develop an approach to tobacco consumption from what was almost a blank slate. It could look at consumption control from a THR approach in which it was concerned about health but was not working only with the rather heavy-handed tobacco control components of MPOWER. This just couldn’t be done in other countries, added Stimson, who made the point that the guest of honor at the meeting was the head of the country’s health service.
To a certain extent, getting across the idea of harm reduction means pushing at an open door because Malawi has a history of dealing with the effects of AIDS. In fact, the joint host of the meeting was JournAIDS, an organization that was originally set up by journalists around the fight against AIDS but that now deals with any number of health and social welfare issues. So it is possible that relaying messages about safer alternatives to smoking or quitting smoking could piggyback on health outreach structures that are already well-developed in Malawi in respect of AIDS, tuberculosis and malaria. Interestingly, there is in place a campaign aimed at raising awareness about the toxicants in smoke—but in this case the focus is on smoke from the open fires used during cooking.
However, there is one major problem with trying to introduce the idea of THR. Despite the wealth of the tobacco industry and the fact that Malawi has long been a major “stakeholder” in that industry, the country is economically constrained and many of its people are financially poor, so they could not afford to replace combustible cigarettes with, say, vapor products or Swedish-style snus. This means that THR would have to be based on alternative, acceptable, noncombustible products that could be produced in the country.
Campaigning for alternatives
Meanwhile, the roadshow in Kenya was scheduled to coincide with the launch by Joseph Magero of a pan-African THR network called the Campaign for Safer Alternatives (CASA), which has members also in other African countries, including the Democratic Republic of Congo, Malawi, Nigeria and Uganda. It included people working in slums, on AIDS and on drugs harm reduction, as well as those supportive of THR. It included, too, representatives of religious organizations, which are important operators in Kenya in the field of youth outreach.
Stimson described the situation in Kenya as fundamentally different to that in Malawi because in Kenya there was a strong alignment of anti-tobacco organizations that were part of the Framework Convention Alliance, which were strong supporters of the FCTC and for whom THR was seen as a threat. “It is a different, difficult situation,” he added, “but an interesting one because there are NGOs that have been working on harm reduction issues and that do get tobacco harm reduction as an idea. And this pan-African organization looks like it might have some traction.”
So, all in all, the Africa leg of the roadshow was a success? Well, said Stimson, the main aims of the roadshow had been to raise awareness about THR as a way to help people shift away from tobacco smoking and to strengthen the capacity of local people to promote THR. As an outsider, KAC could not do that, but it could help, nudge, support and enthuse local people, and it could provide them with the international contacts to enable them to put harm reduction and THR higher up the agenda. KAC was involved in a process of creating a conducive environment for harm reduction. It was a long process, and it was necessary to take every opportunity that presented itself. “I’m particularly enthused by the energy among the THR advocates in Malawi, and I’m particularly enthused by this new organization CASA,” he said. “You never expect things to change massively overnight, but everything seems to be pushing along the road towards harm reduction.”
Money well spent
As can be seen, Stimson is serious about the THR course he has set out on, but, having worked in harm reduction for so long, he is nothing if not a realist, and his answers are regularly punctuated with laughter as he recounts some of the obstacles that litter his path. One such is the reaction to KAC using FSFW money, which originally came from Philip Morris International (PMI) but over which PMI has no control and which cannot be returned to PMI. KAC had taken a risk accepting that money and had received a lot of flak for doing so, Stimson admitted, before going on to say, “… but … I would like to see it spent for the reason the money is there—to help shift people from smoking …. We think the money from the foundation can be well-spent.”
KAC had two Foundation-supported projects, Stimson said. One concerned the Global State of Tobacco Harm Reduction report for which KAC had made a grant application that was accepted and in respect of which there had been “absolutely no interference whatsoever from signing the contract to publishing the report. I have never experienced a donor who has been so hands-off,” he added.
And it was a similar story with its scholarships, which are funded by the Foundation but whose role is totally hands-off. “In my view,” said Stimson, “the ethical issue is no longer that PMI funded the foundation, but, given that the foundation has the money, it would be unethical not to spend it on the purposes for which it is intended.”
The Global State of Tobacco Harm Reduction 2018 report, now available in Mandarin as well as English, has been well-received, attracting a significant number of downloads for both it and the executive summary, which has been translated into a dozen languages. And, with what is now the assurance of a five-year FSFW funding agreement, the report is an ongoing project. Already since its launch, it has seen the addition of country profiles and a new tool that allows country comparisons to be made. And the latest project is adding an index that will measure how favorable governments are toward THR.
KAC has obtained a five-year funding agreement also for its scholarship program, which is run by Kevin Malloy and about which Stimson is “very excited.” The scholarships are designed to introduce and support people new to the field—to help build a new generation of people interested in research and communicating THR.
The program is nearing the end of its first year, during which it supported 15 scholars who initially were provided with a training program built around the 2018 GFN conference and who each received $7,500 to work, with the aid of a mentor, on an agreed project.
This year, the program, which attracted 50 applications, is being expanded and will see 20 scholars, 10 of them from Africa, each receive $10,000, and six who graduated with the first cohort receive $25,000 under an enhanced scholarship scheme. One of the enhanced scholars will be Malawi-based Jekete, who will be in charge of a program aimed at introducing stop-smoking and THR messages into other health organizations.
The fact that half of this year’s scholars will be from Africa was described by Stimson as “extraordinary.” Two years ago, he said, outside of South Africa, very little was happening in Africa in respect of THR.