Raising awareness on tobacco harm reduction (THR) within the World Health Organization (WHO), the Conference of Parties (COP/FCTC) and the United Nations (UN)

I. RATIONALE & CONTEXT

Member states of the WHO, especially in the developing world, still look closely towards the WHO for guidance on developing their own health policies. Therefore, raising awareness and stimulating action within the WHO/UN Nations system on tobacco harm reduction (THR) is important for four main reasons:

To commit Member States of the WHO to a plan of action for implementing THR strategies and interventions, in conjunction with traditional tobacco control measures, with the ultimate objective of reducing mortality and morbidity caused by tobacco use and smoking;

To raise the visibility of THR as an important strategy towards smoking cessation internationally to

(1) stimulate more research & development efforts on various aspects of THR, including new, safer, more effective technologies; (2) catalyse global action and initiatives to mobilize the resources needed to support programs and research on THR;

To promote inter-sectoral awareness and visibility of THR among UN agencies and other organizations beyond those dealing directly with health issues, e.g. UNEP (UN Environment

Programme), UNFCC (UN Framework Convention on Climate Change), UNICEF (UN Children’s Fund),

FAO (Food & Agriculture Organization) etc.

To highlight Indonesia’s rising international clout, influence and leadership in the health arena, especially on health issues important for Asia – which is needed as a counter-balance to traditional western influences.

II. GOVERNMENT PERSPECTIVES

Plan of action and necessary steps to stimulate action within the WHO/FCTC/UN

There are two main objectives of a plan of action for THR in the context of WHO/UN:

To pass a resolution at the World Health Assembly (WHA) of the WHO, endorsed by all 194 of its Member states, for WHO to discuss and endorse the potential benefits of THR, therefore committing member states to implement an action agenda pertaining to various aspects of THR.

To promote a more open, transparent and inclusive discussion1 of THR at the Conference of Parties (COP) of the Framework Convention on Tobacco Control (FCTC)2 for further action and implementation, in accordance with Article 1.d FCTC:

More specifically: to grant “observer status” to key stakeholders with harm reduction focus, to include media in proceedings, to permit member states to include stakeholders in delegations, to have transparent processes for selection of the experts who produce reports, to allow public sharing of draft reports and proposed guidelines, to have open consultation processes, with adequate stakeholder participation

While the Convention Secretariat is hosted by the WHO & works with relevant WHO departments and other international organizations and accredited NGOs, the COP and WHO are autonomous organizations with their own governing bodies. The work of the COP Secretariat is governed by Article 24 and other relevant articles of the Convention, as well as by the Rules and Procedure and decisions of the COP. The Convention Secretariat has its own workplan and budget, and reports to the Conference of the Parties on its implementation.

1 “ ‘tobacco control’ means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke” (Article 1.d, p. 4)

Suggested set of necessary steps

The preparation of a comprehensive and independent scientific review to assess and summarize the current state of evidence on various aspects of THR including efficacy, safety, regulation, impact on youth, etc.

The review then informs, and forms the core, of an official and formal request from enlightened, sympathetic and progressive member states (e.g. UK, New Zealand, Japan, Germany) to the Director-General of the WHO to have THR included as an item for discussion and deliberation for the WHA;

A similar request can be made to the Secretariat of the COP/FCTC to include such an agenda item at the next meeting/regular session of the COP.

On receipt of such a request, the WHO Secretariat and the Convention Secretariat of the FCTC will request one of its technical units to prepare a document which will then be included as an agenda item under ‘Technical and Health Matters’ (WHO) and ‘Treaty Instruments and Technical Matters”

(COP/FCTC) . Such a document will normally contain (1) relevant technical background information and (2) a resolution requesting the WHO/COP Secretariat, its member States and the international scientific community to implement and pursue a set of actions to alleviate the global tobacco problem. Such a resolution normally contains multiple components known as ‘operative paragraphs’;

In the case of the WHO, the agenda item is first discussed by the WHO Executive Board (EB) which normally meets in January-February of each year (and holds a planning meeting a few weeks prior)3. Following discussion and endorsement by the Executive Board the item is then tabled for discussion at the WHA normally held in May of the same year. This intermediate step before the gathering of all member/states/parties does not seem to exist for the COP process.

(Note: In relation to WHO, it is important that support from other Member States is obtained prior to the discussion at the Executive Board to ensure its approval by the Board)

The agenda for the WHA is endorsed by the EB at its January meeting.

During the WHA held in May of the same year, and during the regular session of the COP/FCTC, the item is discussed by all Member States and, if agreed, is endorsed by the WHA/COP thus committing all Member States to implement the resolution;

In subsequent WHA’s and COPs the Secretariat is normally asked to prepare periodic ‘progress reports’ on the implementation of various resolutions as a means of monitoring and evaluating progress11.

Current members of the WHO Executive Board (34): Benin, Burkina Faso, Eswatini, Gabon, Kenya, Tanzania, Zambia (AFRO); Argentina, Brazil, Chile, Grenada, Guyana, USA (PAHO); Bangladesh, Indonesia4 (until 2021), Sri Lanka (SEARO); Austria, Finland, Georgia, Germany, Israel, Italy, Romania,

While it is desirable to have an agenda item first discussed/approved by the EB, member states can also directly request an agenda item to be included at the WHA without going through the EB first.

Contact needs to be made with individuals within the Indonesian MOH in charge of international affairs/relations-this is the part of the ministry responsible for liaison with WHO and FCTC/COP.

2 Tajikistan (EURO); Djibouti, Iraq, Sudan, Tunisia, UAE (EMRO); Australia, China, Japan, Singapore, Tonga (WPRO)5. As of January 2020, there are 181 parties which have ratified the FCTC.

While it is an advantage for a Member State proposing an agenda item to be a member of the Executive Board of the WHO, any Member State can propose an agenda item. In view of the fact that Indonesia’s membership of the EB expires in 2021, this becomes an important consideration as, realistically, the item will not be ready until the January, 2021 meeting of the EB at the earliest (the EB agenda is normally finalized by Oct-Nov of the preceding year).

Mid- and longer-term strategy: to build support among sympathetic and progressive member states who have a more enlightened attitude towards THR (e.g. UK, New Zealand, Japan, Germany) to raise the matter at the WHA and the COP/FCTC meetings Especially influential would be member states who are major contributors to the budget of WHO/COP (e.g. USA, Germany, Japan, UK, etc.)

Although voting occasionally takes place, the overwhelming preference is for unanimity in WHA/COP decisions. This makes it incumbent upon the proposing Member State(s) to do a lot of preparatory work before and during the WHA/COP to garner support among other member States and to deal with any possible objections.

It would also be advisable to include monitoring and evaluation processes as part of the resolution and make this part of the action plan, and not just rely on monitoring by the WHO Secretariat.

III. NON-GOVERNMENTAL PERSPECTIVES

While it is obviously important to utilize the formal, government-led, ‘top-down’ approaches to changing the WHO/FCTC position on THR, it is perhaps equally important not to neglect non-governmental, ‘bottoms-up’ influences on the reform process. The following stakeholders should be considered as complementing government-led efforts:

Harm reduction groups/NGOs/initiative/foundations/professional societies, including community and faith-based organizations;

Academic groups and scientific bodies supportive of THR;

The media: both traditional media and social media;

Vapers: especially those who have quit smoking;

Industry: technology leaders in production of safer and more effective THR products must come forward and speak up.

In terms of what specific actions can be taken, the following can be considered:

Reach out to governments (including ministries of trade, commerce, finance, agriculture etc.) for open dialogue and public consultation to explain importance of including harm reduction in WHO/FCTC –and need to remove unjustifiable barriers to NGO and media participation in FCTC.

Organize petition(s)/open letters to advocate publicly and to WHO/FCTC for more open, transparent, accountable processes at WHO/FCTC-and the need for harm reduction to be discussed.

For current members and their terms: https://apps.who.int/gb/gov/en/composition-of-the-board_en.html

3 Find ‘THR Champions’ and ‘Goodwill Ambassadors’ who can influence public perception and opinions

Coordinating the activities of various groups into a ‘Global Coalition for THR’

IV. STRATEGIC CONSIDERATIONS IN DEVELOPING A PLAN OF ACTION

From a strategic perspective, it is important that the plan of action is developed strategically in the context of existing and relevant WHO/UN documents and initiatives including in particular:

The Framework Convention on Tobacco Control (FCTC)-see above;

Report of the WHO Study Group on Tobacco Product Regulation (2019)

WHO DG list of key health challenges for the next decade which includes “Protecting people from dangerous products” (Jan 13, 2020);

The UN’s Sustainable Development Goals (SDGs). Target 3.A of the SDGs aims to “Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate” focused on tobacco control;

The UN General Assembly Outcome Document on Noncommunicable Diseases (NCDs) (2014) which included four strategic time-bound national commitments for transformation which included FCTC implementation;

Beyond the WHO, it may also be possible to raise awareness about THR at the United Nations General Assembly (GA) in New York. With regards to health issues, this has happened on three occasions in the past in relation to HIV/AIDS (UN Security Council resolution, 2000), non-communicable diseases (UN GA resolution, 2010) and universal health coverage (UN GA, Sept,

2013). However, given the mostly political and security focus of the UN GA and Security Council, it is unlikely that a specific disease topic or risk factor (e.g. smoking, THR) will warrant discussion at this level.

V. A CASE STUDY OF APPROACHING WHO

The International Society for Neglected Tropical Diseases (ISNTD) is currently organizing a movement to persuade WHO to designate a ‘World Dengue Day’. The strategies and approaches they have adopted to achieve this goal (See Annex 1) may hold some lessons for THR initiatives in the future. Please note how countries are involved in getting WHO’s attention, the use of petitions/open letters, the links to regional organizations (e.g. ASEAN) and advocacy activities.

Tikki Pangestu

January 2020

4 Annex 1

PERSUADING WHO TO ENDORSE ‘WORLD DENGUE DAY’-

A LETTER FROM KAMRAN RAFIQ, CO-FOUNDER OF THE ISNTD

Dear Colleagues,

I hope all is well with you and that 2020 has started well. We just wanted to share some good news/ updates with you – as you know we’ve been trying to get country requests to be put in by the Ministries of Health directly to the Executive Board of WHO which is meeting on the 4th Feb, 2020 for their annual planning meeting – the hope is to use the country requests to ask them to allow member states a resolution to vote on a World Dengue Day ( the consensus position we’ve been working on is to turn the existing 15th June Asian Dengue Day into a World Dengue Day) this would take place at the World Health Assembly in May 2020.

After lengthy discussion with the ASEAN Secretariat – Dr Ferdinal Fernando, Head Health Division ASEAN , has confirmed that the MOH Indonesia will fully support our proposal for a World Dengue Day and have sent forward their country request to the Exec Board WHO ahead of the EB WHO Planning meeting which starts from 4th Feb.

2.Saudi MOH have also backed the World Dengue Day and have instructed their permanent mission in Geneva to ask the WHO Exec Board to put this on the agenda for a vote – we have email confirmation of this.- a huge thank you to DAG (Dengue Advisory Group) member Dr Ashwaq Al Nawazi for pushing this within the Saudi MOH. This is especially good news since Saudi Arabia have officially taken on leadership of the G20 nations and so hopefully their request will carry weight at the WHO Exec Board meeting.

Pakistan have said they are backing it and its now in process, I believe that they will be sending in their country request shortly ( we haven’t had email confirmation of this but I have seen the request that was sent to the Country WHO officer) – a huge thank you to DAG member Dr Somia Iqtidar without whose effort none of this would have been possible – I had the pleasure of meeting with the Punjab Government Dengue effort in Lahore last month and you may have seen an interview that we published with them which covered their amazing control efforts and also their ground breaking use of apps.

I had the pleasure of being invited by the Government of the Punjab to Lahore for their recent ICD 2020 where I had the chance to present our case for a World Dengue Day – participants included the Sec. for Health Dr Zafar Mirza, Minister for Health Punjab DR Yasmina Raashida and also the Chief Minister of the Punjab Major Bazdur – the WDD case was extremely well received.

Prof Lulu Bravo has been added to the DAG – she is Professor Emeritus at the College of Medicine, University of the Philippines Manila. She is the former Vice Chancellor for Research and Executive Director of the National Institutes of Health – I’ve just been informed this morning that Prof Bravo has met with the Secretary of Health Dr Francisco Duque and that the Philippines MOH have agreed to support the WDD and will be preparing and sending in a country request to the WHO Exec Board meeting. A huge thank you to Lulu and also to Dr. Anna Lisa Ong Lim – Section of Infectious &

5 Tropical Disease, University of the Philippines and Philippine General Hospital whom we’ve also added to the DAG.

Maldives MOH have said that they will be supporting this and its in process – we have been speaking directly to the MOH Maldives we haven’t had confirmation its under review.

Uganda MOH have said that they will be supporting this and its in process – again no confirmation and its under review

A warm welcome also to Pr. Tikki Pang – Lee Kuan Yew School of Public Policy, National University of Singapore who has also very kindly agreed to be part of the DAG.

8. .A warm welcome also to Pr. Simon Hay – Institute for Health Metrics and Evaluation, University of Washington who has also joined the DAG

9.Just returned from the Fondation Merieux in Annecy , France – 3 day workshop on Dengue Pre-vaccination screening strategies – presented the case for WDD.

I’ll be in Malaysia at the ICID 20th to 23rd Feb will have a booth and a film team the aim is to not only increase petition signings but also to produce a short film montage looking at the emotional response of doctors treating dengue and then to use this in our advocacy

Our public petition which has been live effectively since 1st Nov ( we used the 2 weeks from Oct

15t to Nov 1st to develop and test our digital strategy) for 11 weeks is currently on 14 951 from across the world and we are aiming at around 10000 by end of Jan – any tweets or shares from you within your organizations and networks would be greatly appreciated – please feel free to check the live progress of this petition – the link is https://www.change.org/p/world-health-organization-make-world-dengue-day-a-reality Please bear in mind that when the Chagas Day was awarded by the WHO last year they had just over 10 000 signatures – our aim was to at the very least match this and we are fully confident that we can go significantly over this with your help. To that end would it please be possible to disseminate the link throughout your organisations, universities and networks to further

We have started preliminary planning around a launch for the WDD on the 15th June in Singapore ( we will be at the Asia Dengue Summit which will be 12th to the 14th June) and an early idea is to organise a ministers roundtable and also to have you the DAG members present – more details to come and in fact this is something that we would greatly value your input on and so perhaps this would be a good point to raise and cover at our next DAG telecon call?

Thanks for taking time to read this and for your amazing and invaluable help to date. Take care hope to catch up with you in person soon – fingers toes etc crossed that the WHO will take positive action on the country requests and these joined with our petition and year long advocacy ( interviews, articles and emotive patient stories) will have an impact.

Kamran Rafiq

Co-Founder & Communications Director

The International Society for Neglected Tropical Diseases, London, UK.