It is a sad situation when we fear writing an academic medical article that supports the health of poor Ethiopians

IMG_0360 (478x640)        BAT poster 3 Shola

Bole tobacco seller
Young man selling tobacco on Addis Ababa street


Over three years ago, not too long after I arrived in Ethiopia as a volunteer professor of Medical Biochemistry, I witnessed the gradual appearance of hundreds of posters advertising Rothmans cigarettes, a brand of British American Tobacco (BAT), appearing all over Addis Ababa, Ethiopia’s capital city. After numerous enquiries, I discovered that these were not fake posters, but that BAT executives knowingly had them posted on the facades of stores all over Addis Ababa, including many impoverished areas.

I knew these posters were illegal in Ethiopia and was dismayed that a tobacco company from my own country, Britain, could advertise illegally such health-destroying products in Ethiopia, which has enough health problems to be concerned with and does not need an escalating epidemic of tobacco addiction and its consequent health-associated problems. At the time, Ethiopia had one of the lowest smoking prevalences globally.

I took many photos of these posters and submitted them, with a letter, to the editor of the world-renowned medical journal, the Lancet. Prior to submitting them, I had made numerous investigations as to their authenticity. That included contacting my Member of Parliament in the UK, who then contacted BAT for me. You see, prior to this, BAT would not answer my multiple online emails.

I have reproduced the text of the Lancet article at the end of this post, but the here is the link to the site:

Eventually, a BAT executive sent a letter to my MP, responding to my enquiries, and it then became quite clear that BAT knew that those posters were illegal in Ethiopia, and that they (BAT) had been given permission by the “appropriate” Ethiopian authorities, which must mean the Ethiopian government. There is only one tobacco company, National Tobacco Enterprise, in Ethiopia, and it is a government tobacco monopoly.

Nevertheless, it is illegal to advertise cigarettes in Ethiopia by posters or any other means.

I had been told by close friends, even colleagues at the medical school where I worked, to be “very careful” what I say, or I might end up being thrown out of the country or even put in jail. Whether these fears were well founded or not, many people advised me not to submit the posters and my concerns to the Lancet. I therefore submitted them to the Lancet’s editor and asked for my name to be anonymous. After I submitted them, and again after the article was published in the Lancet, I had weeks of sleepless nights, and days of constant fear, that I might get into trouble, and this for following my medical principles and ethics and showing concern for the health of poor Ethiopians?!

Eventually, I plucked up the courage and contacted the Ethiopian Ministry of Health, after more posters appeared. An MoH official responded with his telephone number and asked me to call him. He was very congenial and concerned about the posters, but had only recently heard about them (through the Lancet article?), but he hadn’t seen any of the posters, which surprised me, because there were hundreds around town. I sent him photos of the posters and advised him where he could see plenty of them.

Nothing happened for several weeks, but then I noticed 31 new posters appeared in a poor area of Addis, close to where I work. I called the official at the MoH again, and told him I was very concerned about the new posters. He said: “We will get them pulled down,” and several weeks later those 31 posters were gone from sight. Within another month or so, allof the hundreds of posters across Addis were pulled down. I managed to buy a poster from a small store, and still have it for posterity!

You can read about my experience with those BAT Rothman’s posters on this link:

Unfortunately, despite that victory against BAT in Ethiopia, in mid-2016, Japan Tobacco International, another of the “Big” tobacco companies eyeing developing countries for young cigarette addicts and the associated profits to be made from them, made a deal with the Ethiopian government to buy 40% of the shares of the Ethiopian tobacco monopoly (National Tobacco Enterprise) for a staggering and sickening US $510 million. This deal contravenes Article 5.3 of the WHO FCTC tobacco treaty, which is a legally binding document, which the Ethiopian government has signed and ratified, and which states that “…in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.”

This deal between the Ethiopian government and Japan Tobacco International promises to be devastating for the health of Ethiopians, and you can read a more detailed analysis about this dreadful deal in a future post which I plan to write soon.

This time, though, I have even more fear than I had 3 years ago, because Ethiopia is in a state-of-emergency and many people are telling me that speaking or writing anything perceived to be against the government may lead to serious consequences.

But this is not primarily about politics: it is quintessentially a humanitarian protest against a deal that will harm the health and well-being of people, especially poor Ethiopians who already have enough medical problems, not to forget that 15 million or more Ethiopians were at risk of famine this year due to a devastating drought there.

An escalation of smoking prevalence in Ethiopia will cause millions of Ethiopians to suffer from tobacco-related diseases such as heart disease, emphysema and many cancers: a third of so-called non-communicable diseases (NCDs) are due to smoking. It will lead to a huge increase in passive smoking, mostly in women and children who are exposed to the smoke of others, bringing with it more cases of childhood pneumonias, asthma and other diseases associated with passive smoking. And it may very well compromise the so-far successful efforts in Ethiopia that are presently helping to combat tuberculosis and HIV/AIDS, both of which are exacerbated by smoking. Some studies suggest that as many as one in every five tuberculosis deaths is due to smoking.

And if we ignore the wheelings and dealings (and lack-of-feelings) of tobacco company and government officials who collaborate with them for profits-over-people, we are breaking our own ethical principles. We must, as human beings, stand by our convictions, both religious and ethical. If we are medically trained, we are obliged by the Hippocratic and other medical oaths to speak out loudly and clearly for the health of people and against those- however powerful they are- who threaten the public health of society and the health of individuals. So let the consequences be what they will.

Below I’ve reproduce the text of the Lancet article from 2013 regarding the BAT posters in Addis Ababa. Photos of the BAT Rothmans cigarette posters that were published in the article are omitted.

Offline: A plague rises in Ethiopia

Lancet, Vol 382 November 2, 2013

“It’s time to revivify the campaign against tobacco in Africa. Last week a letter and photographs arrived from a physician in Ethiopia (who prefers to remain nameless). He writes: “I work in Ethiopia and am bringing to your attention posters that have appeared in Addis Ababa over the past several months that advertise Rothmans cigarettes. These posters would be illegal in the UK. They target poor people, in line with the targeting of many developing countries by tobacco companies. The posters and words on the cigarette packs are in English, not in Amharic (the official language of Ethiopia). So health warnings are in a language that is not understandable by many poor Ethiopians. The health warning is printed in a very small area of the pack, on the side, and in barely visible gold lettering. I ask you to ponder the health consequences and costs to human lives and health care in developing countries if the prevalence of smoking increases from less than 10%, as it is now, to 25–30% or more as a result of British American Tobacco (BAT) marketing and advertising in poor countries. Last week, a 3-year-old girl came up to me clutching a pack of Rothmans to her chest: her poor mother was trying to sell them to me.” According to Ethiopian news sources, the tobacco market in Ethiopia will grow substantially over coming years. Ethiopia’s National Tobacco Enterprise (NTE) has a monopoly on manufacturing and importing all tobacco products into the country. 78% of NTE is owned by the Ethiopian government. Which means the government is colluding in an epidemic of death among its own people, a truly extraordinary situation. NTE predicts, even boasts, accelerated sales of cigarettes over the next 5 years. Perversely, the company has said “our main focus is on social responsibility, rather than profit”. In January this year, Ethiopia’s Foreign Affairs (and former Health) Minister, Tedros Adhanom Ghebreyesus, visited the UK. One of his meetings was a roundtable discussion with over 30 UK companies—one of which was BAT. Come on Tedros, my friend, end this charade.”



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