Chapter five
r Jo Asvall, Director of the European Region of the World Health
Organisation, is concerned at the growing division of the continent
in terms of the quality of health. The split is mirrored by the
rapacious inroads made by western tobacco companies, the health
toll of which looms large on the horizon of the 21st century.
"There is a tremendous difference between the eastern and western parts of Europe in relation to tobacco," says Asvall. "This has several dimensions. First, there is the difference in the amount of smoking, which is increasing in eastern Europe, and which is stable or even decreasing in many of the western countries.
"Second, there is a difference in health status in the sense that the health impact of smoking is rising faster in the eastern countries. For instance, if you look at cardiovascular diseases you find that they are still on the rise in the east. This has to do with lifestyle issues where smoking is an integral element. It has been demonstrated that when you examine life expectancy for men around the age of 35, in terms of their chances of reaching the age of 70, some 10 percent of this group in western Europe will die of smoking-related diseases, whereas in the east twice that percentage will die early."
The opening up of the markets paved the way for the tobacco invasion, one effect of which has been an increase in smoking among women and young people--sections of the population that in the past were more on the periphery of tobacco use.
But the new upturn in tobacco use will take time to make its mark, though, Asvall points out, the health impact meshes with an overall deterioration in people's health.
"I think that with regard to smoking rates, changes in health in eastern Europe are occurring now and since recent years. Some of these changes are very abrupt. We have seen a sharp rise in infant mortality and a decline in life expectancy. I don't think these problems are in themselves smoking-related; they are to do partly with the general social and economic conditions. But the medium-term changes we are seeing in cardiovascular diseases and lung cancer are related quite clearly to smoking, as well as to things such as nutrition. It will take some 15-20 years before we see the full impact of smoking on lung cancer."
"All of us should be frustrated at the situation and also with ourselves. Those who can change the problem are those who know about it, and they are the public health physicians, and internationally it is the WHO. We are the ones who are responsible for overall health and who are trying to stimulate countries to promote it. We did much good work with the WHO Madrid Conference in 1988 and there has been a lot of follow-up work in countries. But all this has been much slower than anticipated, and we in the Regional Office have been less involved in the early 1990s than we were at the end of the 1980s.
"The reason is very simple--because of the collapse of the Soviet Union, eastern Europe and the war in former Yugoslavia. WHO-Europe went suddenly from 31 countries to 49, of which about 10-15 are in reality developing countries with enormous problems. We also suffered a 15 percent budget cut. We had to completely reorganise our work and we simply did not have the capacity.
"That situation has now stabilised. We are back to a more balanced situation in developmental terms, and it is now time for us to return to the tobacco issue because it is clear we are not making the headway we should. In 1984 the Regional Committee of WHO-Europe of the then 31 member countries set an 80 percent non-smoking target for the year 2000. Not a single country is going to reach that."
"I think that we have come to a kind of milestone in our work," says Asvall. "It is time to reflect on where we are now and compare it to how far we thought we would have come. The 1988 Madrid Conference came out with six basic ethical principles and action strategies that are still the bases of our work. What we can add to them concerns mainly tactics. If you look at Europe in general there is clearly a situation where there is not the progress we anticipated. One reason is because of what happened in the east, and a problem is that for those countries tobacco prevention is given relatively low priority compared with the other problems that have to be dealt with.
"Another reason is that in western Europe we have been too slow in all countries. How can it be that in Norway, for instance, we have such a high ratio of smoking among young men and women despite the enthusiastic efforts of the health sector? In part, lack of progress is due to the fact that we have not managed to get key decisions taken. There are some measures, such as smoke-free environments, where legislation is being used. But it has been too slow, and the reason is that the public health lobby has not been active enough and there has been a lot of resistance by politicians.