Former WHO director Professor Tikki Pang says the organisation has developed a dangerous blind spot on tobacco harm reduction.
In this interview, he explains why evidence is being ignored and what it would take to force reform.
Peter Beckett: Tikki Pang, thank you very much for joining us on Clearing the Air. If you could briefly introduce yourself and explain who you are, we’ll go from there.
Tikki Pang: Yes. My name is Tikki Pang. At the moment, I’m a visiting professor at a leading academic institution in Asia. Before this, I was Director of Research Policy and Cooperation at the World Health Organisation in Geneva, Switzerland, until I retired in 2012.
Peter Beckett: So you spent 13 years at the WHO. When did you first get the impression, or start to believe, that there was a systemic problem in its preferred tobacco control policies?
Tikki Pang: Well, as a bit of background, I got interested in tobacco harm reduction some time after I left the organization in 2012. It was likely just before COVID that someone brought to my attention why the WHO is taking such a tough, inflexible position against tobacco harm reduction while ignoring the evidence. I came at it not because of a particular interest in smoking, but because I’m a scientist by training. I’ve always believed that if there is good scientific evidence with an important impact on health, governments should be implementing it for the sake of the people. When I saw the WHO taking almost an opposite stance and ignoring the scientific evidence, I decided to speak up on this anomaly. It is definitely a big blind spot in terms of what the organization is supposed to do to improve global health, especially in lower-middle-income countries.
Peter Beckett: So you mentioned that it’s an anomaly and that you were looking into its causes. What do you think has caused this?
Tikki Pang: I think there are a couple of main reasons. The first, which many forget, is that the WHO actually gave birth to the FCTC. It’s the WHO’s baby. Like any mother, they will defend that position at all costs; they are quite possessive and dislike attempts to weaken the framework, including acknowledging the potential of harm reduction. Second, during the development of the FCTC, big multinational tobacco actively tried to sabotage the process through unethical practices. This legacy of bad behavior translates to today: anything coming from tobacco is a “no.” Tobacco companies aren’t invited to deliberations, nor are NGOs deemed sympathetic to or funded by them. Third is pressure from member states. Where I come from, Indonesia, we haven’t ratified the FCTC, and the domestic tobacco industry is a powerful political and economic force. The WHO is careful not to upset the Indonesian government by promoting anything that could reduce tobacco profits. Ten percent of Indonesia’s government revenue comes from tobacco tax, so any move to reduce smoking prevalence is something they cannot tolerate, and they support WHO attempts to stop harm reduction.
Peter Beckett: So in the case of Indonesia, you’re saying they are actively trying to sabotage it to sustain revenue from the tobacco-growing industry itself?
Tikki Pang: Yes, those three factors. Two former Indonesian ministers of health—one of whom was my colleague at the WHO—explained that in cabinet meetings, if they pushed to reduce smoking prevalence, the Minister of Finance would cite the 10% revenue loss, the Minister of Agriculture would worry about a million tobacco farmers, and the Minister of Industry would point to the million people manufacturing clove cigarettes. While the government isn’t always actively undermining it, these strong economic and political interests keep smoking going. Additionally, because the tobacco control lobby is powerful, the THR movement faces strong opposition, though I must credit the government for a fairly laissez-faire approach to vapes. They are easily available, unlike in other countries in the region where they are outright prohibited.
Peter Beckett: It sounds like you’re saying Bloomberg and the tobacco industry are almost on the same side when it comes to reducing the availability of reduced-risk products, albeit for different reasons.
Tikki Pang: Yes. But having said that, as mentioned in the presentation earlier today, the Bloomberg influence goes beyond just the WHO. It is influencing and funding NGOs which are strongly anti-THR, as well as many media organizations. It is a very massive and well-funded set of activities on the part of Bloomberg. People who want to fund the promotion of tobacco harm reduction are completely outgunned in terms of firepower. These guys are investing billions, and it’s a very uneven dogfight at the moment.
Peter Beckett: This brings me back to the WHO. With the US having pulled out and the organization facing serious financial issues, some wonder if this creates an opportunity for harm reduction. I worry it actually allows Bloomberg to strengthen his hold and make things worse.
Tikki Pang: I have a slightly more optimistic view. There is an opportunity because the WHO will elect a new Director-General next year. We don’t know who it will be, but there is hope that whoever takes over from Dr. Tedros will be more open, especially given the funding gap and the 30% reduction in headquarters staff. While it could provide an opportunity for Bloomberg, some names floating for the nomination come from countries sympathetic to tobacco harm reduction. If such a person is elected, the mindset might be more inclusive and evidence-based, rather than the current ideological and emotional stance.
Peter Beckett: Does just changing the person at the top really work? It seems there is an issue of institutional capture. Is the WHO able to self-correct, and if not, can governments trust it in other areas?
Tikki Pang: My answer might not be fully objective since I worked there for 13 years, but I still passionately believe in its value. They have dropped the ball in this case, but in areas like pandemic preparedness, no other organization can get countries to come together collectively. I agree that changing the leadership isn’t the only issue, but having leaders open to dialogue is a step forward. Ultimately, only the member states can change the WHO. If a coalition of 20 to 30 countries—like the UK, New Zealand, Japan, and others in Africa and South America—demanded action at the World Health Assembly, things would change. I’ve met heads of missions who tried to get THR on the agenda at COP11 but were too fragmented.
Peter Beckett: If they got nowhere before, why would they succeed now?
Tikki Pang: Because they were fragmented. If a country like the UK provided strong leadership and formed a coalition to demand change at the World Health Assembly, it would happen. It is a political organization; the Director-General listens to the member states. Regarding trust, some say “burn the house down,” like this guy in Brussels. But my question is: if you burn it down, what will you put in its place?
Peter Beckett: That was me and the “house” I was referring to was the FCTC Secretariat, not the whole WHO.
Tikki Pang: I see.
Peter Beckett: I was misquoted on the internet about that.
Tikki Pang: Oh, I see.
Peter Beckett: The internet is fun like that. But I worry that if the WHO’s public statements on alcohol or harm reduction are seen as nonsense or purely focused on commercial determinants of health, people won’t listen when it’s critical—like during a pandemic when they tell us to stay indoors. If 99% of what we hear is negative or contested, we won’t trust the 1% that is absolutely vital.
Tikki Pang: Well, I’m glad you mentioned it because I’ve heard criticisms of the organization many times, not just from you, but in many other fora, not just around tobacco harm reduction. And my response has always been, I think there’s a lot of misperception out there about what WHO can and cannot do. You in your own words, just now you said if WHO cannot respond by tomorrow, I’m not going to have any faith.
Peter Beckett: Specifically regarding instructions to stay at home.
Tikki Pang: Right.
Peter Beckett: The issue is that if I disagree with all their public lifestyle advice, my impression of them is tarnished when they speak on infectious disease control, which is their most important role.
Tikki Pang: Okay.
Peter Beckett: The question is, given that all of my interactions that everything that I hear from them publicly, I disagree with them. And not only I disagree with them on areas that are contested, like harm reduction, like lifestyle choices. The one thing that they do that is more important than anything else is around infectious disease control.
Tikki Pang: Right, right.
Peter Beckett: But if all I hear about most of the time is lifestyle determinants. What’s my impression going to be when they start talking to me about infectious disease?
Tikki Pang: But lifestyle determinants, Peter, are not the only critical issues during a response to a pandemic. What about the role of the WHO in the mobilization of critical personal protective equipment, such as masks and oxygen, during crises? Having said that, I think the other misperception—which was clear during the Ebola outbreak in West Africa—is that the WHO is not an emergency response organization. It cannot send 100 doctors, nurses, and hospital field equipment around the world in 48 hours. During Ebola, the best responders were the militaries of the US, France, Germany, and China. The most important role of the WHO is setting norms, standards, and best practices like the International Health Regulations, the Framework Convention on Tobacco Control, or codes to prevent the poaching of health workers. It’s about setting norms and standards, not emergency response to a pandemic. As the second Secretary-General of the UN, Dag Hammarskjöld, said, the United Nations does not exist to take us to heaven, but to prevent us from going to hell. I agree. There are huge criticisms of the WHO and the UN in general, suggesting it is just a big talk shop and ineffective.
Tikki Pang: Look at the Middle East; what has the Security Council done there? They haven’t even made a statement. Look what happened in Rwanda in 1994. You send in a peacekeeping force, but they’re not allowed to attack unless first attacked. Whatever criticism is leveled at it, the organization provides a platform, especially for poor countries. It is still a true democracy when it comes to voting on recommendations. The United States has one vote, and the Maldives has one vote. It’s the only platform for poor countries to have a say, which is a powerful reason for its raison d’être. Of course, the main weakness is that it is hugely political; the Director-General reacts when a Minister of Health calls. But its strength is its political legitimacy. It’s owned by 194 member countries. It doesn’t have legal powers to impose sanctions like the WTO, but it has moral authority.
Peter Beckett: If it misuses its moral authority so flagrantly as it is doing in this case, then it undermines everything else it does.
Tikki Pang: In this case.
Peter Beckett: Yes, it undermines everything else.
Tikki Pang: Yes.
Peter Beckett: Let’s look at that statement. You can get things wrong once by accident and correct course, or you can do it in a systemic and sustained manner. We are looking at the latter here, and that is dangerous. It bleeds into scientific discourse. People in public health are scared to speak out because they fear losing their funding or their jobs. It is culturally pervasive. How can we reach the silent majority in public health who recognize that we shouldn’t make people inhale burning poison if they don’t have to?
Tikki Pang: I agree. When Trump pulled out, he cited an incompetent response to the pandemic, inefficiencies, and corruption. I agree that the WHO needs reform. Every crisis is an opportunity for reform. The key reform should be in governance. The WHO was formed in 1948 when the only stakeholders were sovereign states. Since then, global health has become more complex with industry, philanthropists, and civil society.
The answer is no; member states cling to their power as an issue of sovereignty. Richard Horton of The Lancet was a prime force behind trying to change this. He brought together industry, philanthropists like Gates, and NGOs, but they couldn’t agree on an approach. The WHO governance is monolithic. Compare that to the Global Fund against HIV, TB, and malaria, which is much more open to industry and civil society.
Peter Beckett: It can do it through the PCC.
Tikki Pang: Exactly. This is the big challenge with governance. I’m not sure if sovereign states will be willing to give up that power to deal with the pharmaceutical industry. Yet, global health would not be where it is without them; they account for 45% of global R&D. Look at the vaccines during COVID. The political hold is worrying, and it doesn’t help that the Director-General is elected by member states, which creates opportunities for political favors. I got my position at the WHO by applying for an openly advertised post without political support, but I know many other positions are filled through ministers calling the Director-General. This leads to appointments that are sometimes inappropriate in terms of technical ability. Nepotism is still going on in many UN organizations.
Peter Beckett: Low-middle income.
Tikki Pang: So there are these perverse incentives. It ends up being a question of burning the house down.
Peter Beckett: You’re talking about a more inclusive reform to the structure, but hasn’t the FCTC already brought in its favored participants, many of whom are financed by Bloomberg Philanthropies? They won’t let anyone else in. Reforming the WHO’s governance to look like the FCTC doesn’t seem like a good idea to me.
Tikki Pang: I agree that’s not a good idea. Regarding the Conference of the Parties, organizations sympathetic to the WHO are invited, but only member states have the power to vote. If reform allows organizations like yours to be in official relations with the WHO, that would be a step forward. When I was in charge of NGO applications, any affiliation with the tobacco or arms industries was an automatic no. We’ll see what kind of major reform happens; it may be driven by economic necessity. I bet that in a year or two, the US will rejoin.
Peter Beckett: I agree. I suspect the US will eventually reconsider its position.
