The introduction this week of a proposal for an antitobacco convention at the World Health Organization's 10th "Tobacco or Health" conference is the latest indication that the public-health profession is more concerned with changing lifestyles than doing what it was originally established to do--cure disease. This conference in Beijing coincides with a Malaria Foundation meeting in Hyderabad, India, which is discussing ways to stop the millions being killed by malaria in the Third World every year. However, tropical diseases apparently aren't as interesting as vices in Western countries where the agenda for international health organizations is made. So funds that should be spent on malaria eradication are likely instead to be spent in Africa and Asia on antitobacco campaigns of dubious significance.
This misjudgment will have serious consequences. One-hundred years ago, the British scientist Ronald Ross discovered the role of the mosquito in the life cycle of the malaria parasite. According to the Malaria Foundation, malaria is expected to kill three million people, and infect as many as 500 million, world-wide in 1997. The number of cases has continued to proliferate since the abandonment of DDT insecticide spraying in the 1970s due to environmental problems experienced in the West. This was an early example of Western priorities being imposed on Third World people who may have made a different trade-off between wild and human life had the choice been solely theirs.
Such misplaced priorities continue to mar Western aid efforts today. The WHO has spent years in the doldrums suffering from its own form of illness. According to the British Medical Journal it has been "sapped by a system that generates corruption, authoritarianism and inefficiency." Its tobacco-control program is part of the WHO's attempt to show accountability to donors.
Impaired by the apparent success of the U.N. Environment Program's climate change treaty, the WHO program on Substance Abuse is angling for its own intergovernmental convention. The WHO puts the current annual World death rate from smoking at three million (split 2 to 1 between industrialized and developing countries), making tobacco a killer on par with malaria. Of course. most of the malaria deaths are in Third World countries. The number of tobacco- related deaths is projected to rise on the current trend to 10 million by 2025 (three million in developed and seven million in developing countries).
It is because of these alarming projections that the WHO is garnering support from the West for programs to "stop smoking before it starts." However, unlike the proposed program on malaria, the WHO's case for a tobacco convention is weak. The model used as the basis for the convention was devised by the WHO's Alan Lopez and Richard Peto of the (U.K. Imperial Cancer Research Fund. It is an indirect estimation method, which has been praised by antismoking advocates as ingenious. It is quick, dirty and cheap because it avoids the necessity of collecting real data--particularly troublesome in less developed countries where recording of vital demographic statistics (births, deaths, migration) is incomplete, unreliable or nonexistent.
The model simply takes the estimated risk of disease from smoking and multiplies it by the number of smokers to determine the statistical death rate from smoking. Complaints about sampling, modeling and data quality are unresolved, but this model remains the base for the WHO's war on tobacco. Political pressure from Western donor nations, especially the U.S., has ensured this is the case. In Britain, the Peto/Lopez model has produced smoking death rates by political constituency, which concentrates the mind of any politician. For example, Sports Minister Tony Banks can expect 425 deaths per year"due" to smoking in his east London seat of Newham.
Given the impact of these "death statistics," the urge for WHO officials to create a tobacco convention will be strong. But if the number of tobacco deaths is overestimated, a misallocation of resources might result. While warning would-be smokers of the dangers of tobacco is sensible, encouraging developing countries into antitobacco action, including demanding smoking bans, will divert resources from more urgent basic public-health needs such as ensuring a clean water supply.
The Beijing meeting will be well-attended by Western public-health officials. Satisfied with the moral position of their stand on tobacco, and replete with the money donated by countries such as the U.S., they are likely to gloss over the scientific and statistical problems of the model they will use as the basis of their convention.
Meanwhile. the WHO global strategy to combat malaria will languish for want of donor interest. Antimalaria campaigners are becoming so desperate that they are trying to promote the idea that so-called man-made climate change will bring malaria to the Western world. They think, it seems, that it will take a few hundred cases in Florida or Spain before the West will act on it.
It should be of concern to all of us that a change in policy emphasis from disease prevention to lifestyle control is occurring with almost no debate. The WHO is simply following the lead set by groups like the International Planned Parenthood Federation, who push birth control on the Third World because of Western preoccupation of an impending population explosion and food shortages. After all, smoking is not a disease but a personal choice. If the tobacco control convention comes into force, how long before one on alcohol, sexual practice or vehicle speeds is proposed, all of which indirectly kill millions of people every year?
The puritanical and paternalistic streak in the public-health profession is strong. As the prescient H.L. Mencken once warned, "the urge to save humanity is almost always a false front for the urge to rule." But the WHO was not set up to save us from ourselves but from diseases like malaria--it should confine itself to just that.
Ms. Mooney is a medical demographer and editor of a forthcoming book on public health.
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