Give ‘second, reduce harm’ a chance in post-pandemic era

The smoking epidemic remains a major and intractable global problem.

THE ancient Greek physician Hippocrates, in his book Of the Epidemics, famously says “primum non nocere”, or “first, do no harm”. This call has become one of the key mantras of modern medicine.

However, views have been expressed that this idea is impractical and not even possible. So perhaps, in the context of contemporary public health, what may be a more pragmatic complementary idea to Hippocrates’ original call is a “second, reduce harm” idea. This has led to the development of the concept of “harm reduction”; I will use some examples to illustrate the argument for this idea.

First, the obvious and current example comes from the ongoing Covid-19 pandemic, which has seen more than 300 million cases and more than five million deaths globally. Unprecedented and rapid innovations in vaccines, medicines and diagnostics, developed in record time, are clear examples of interventions that have had a huge impact in reducing the serious harm caused by Covid-19 infection.

Covid-19 vaccines, together with anti-viral medicines, prevent and ameliorate severe cases of the disease, hospitalisations and death among those affected, especially the elderly and those with underlying conditions.

In one study, vaccination markedly reduced adverse outcomes, with non-ICU hospitalisations, ICU hospitalisations, and deaths decreasing by 63%, 66% and 69%, respectively.

At a higher level, widespread vaccine coverage and uptake protect not only the individual from harm but entire societies and populations. In addition, the harm reduction value of vaccines clearly extends beyond Covid-19 and applies to all vaccine-preventable diseases.

Second, it is a well-known fact that globally, nearly three million people die every year due to violence, road traffic accidents and injuries. With regard to reducing harm from road traffic accidents, the use of seat belts and motorcycle helmets, which is mandatory by law in many countries, has had a very significant impact on the prevalence, severity and mortality from road traffic accidents involving both cars and motorcycles, especially in developing countries.

Some estimates indicate that among drivers and front-seat passengers, seat belts reduce the risk of death by 45% and cut the risk of serious injury by 50%. Similarly, a study analysing helmet usage and road traffic death rates among motorcyclists showed that for each 10% increase in helmet usage, one life per one million inhabitants can be saved per year.

Third, many interventions have been successfully used in dealing with the harms associated with various forms of substance abuse. Alcohol abuse and alcoholism, for example, have been successfully addressed through counselling, behavioural therapy and motivational interviewing at the individual and family levels. In addition, some medications have also been approved by the United States Food and Drug Administration as interventions for the treatment of alcohol dependence.

Drug and narcotics addiction, which are serious health and social problems in rich and poor countries alike, are another example where harm reduction interventions have been successfully used to alleviate the problem. Safe needle exchange programmes in many countries have dramatically reduced the risk of transmission among addicts of life-threatening infections such as HIV/AIDS and hepatitis C (HCV).

A systematic review of 15 studies analysing needle-syringe programmes found them associated with decreases in the prevalence of HIV and HCV and decreases in the incidence of HIV. In one study, decreases were shown in HIV prevalence from 50% to 17% and in person-years at risk for HIV, from 3.55 to 0.77 per 100 person-years.

The drug methadone is most commonly used to treat addiction to heroin or other opioids, and to reduce the risk of a fatal overdose from street drugs. Numerous studies have shown that harm-reduction-based methadone treatment, in which the use of illicit drugs is tolerated, is strongly related to decreased mortality from natural causes and from overdoses.

Finally, we can ask whether there are innovations that can help reduce the harms associated with tobacco use. The smoking epidemic remains a major and intractable global problem, with the number of smokers worldwide increasing to 1.1 billion in 2019 and tobacco smoking causing 7.7 million deaths – including one in five deaths in males worldwide.

Indonesia currently has about 60 million smokers with nearly 300,000 deaths annually due to smoking- related diseases, with two in three males being smokers.

So what innovations are available to reduce the global epidemic of smoking and its harms on human health, which include cancer, heart disease, stroke, pulmonary diseases and diabetes? In addition to standard counselling and nicotine replacement therapies (NRTs), new innovations in the form of alternative tobacco products (ATPs) such as electronic cigarettes, heat-not-burn devices and snus (a smokeless form of tobacco) have been shown to be significantly less harmful than combustible cigarettes and more effective in helping those who want to quit smoking compared with NRTs.

While policies are well in place in many countries, for example, on the need to be vaccinated, the use of seat belts and facilitating the safe use of needles and syringes among addicts, such policies are lacking in most countries with regard to ATPs for tobacco harm reduction, despite the scientific evidence suggesting their safety and potential value in helping smokers who want to quit smoking.

Harm reduction is a simple fact of everyday life that is seen in almost all problems facing societies globally, and in many ways, all interventions in contemporary life and medicine are a form of harm reduction.

Infectious diseases, road traffic injuries, substance abuse and tobacco use continue to be important challenges facing all countries, rich and poor alike. As countries struggle with limited resources and fragile health systems in the aftermath of the Covid-19 pandemic, harm reduction strategies can play an even more critical and important role in ensuring that health and health equity continues to be achieved for all of humanity. – The Jakarta Post/Asia News Network

Tikki Pangestu is a former director of research policy and cooperation at the World Health Organisation.