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Eating the Elephant in the Room

Wednesday 26 March, 2014
by Ebil Matsutaro

Ebil Matsutaro participated in the McCabe Centre for Law and Cancer's Intensive Legal Training Programme in February - March 2014. Ebil is a lawyer from Palau working on cancer and NCD prevention and treatment issues.

As a participant in the McCabe Centre Intensive Legal Training Programme during February and March, I learned about important and pressing issues related to tobacco control, alcohol control, obesity, treatment and support for cancer, access to medicines, global action on NCDs, and international trade and investment. While taking it all in, I began to feel both overwhelmed and inspired. I felt overwhelmed because of the sheer amount of information presented, as well as the colossal impact I could see these issues have on Palauans, Pacific Islanders, and human beings all over the planet. I also felt inspired to take on the "elephant," as one of my colleagues put it, "one bite at a time."

Following my training, my goal is to share information about the topics covered during the training, along with recommendations for steps to be taken by the government, NGOs, and others supporting cancer prevention and treatment. I will start with the bigger picture of the reality facing the planet as a whole, and see what areas in the current Palauan law could be used to address that reality. In other words, I decided to map out exactly what sort of "elephant" of issues and laws currently sit in the room with Palau.

Some barriers that Palau faces when addressing issues relating to NCD control include: lack of political will, enforcement, limited expertise, and failure to coordinate all branches of government. Currently the political focus in Palau is on reforming its tax system. Fortunately just last year, legislation was passed to increase the tobacco tax, although it has been noted that after an increase in the tobacco excise tax in January 2015, there are no further increases on the political horizon, and no accounting for inflation.

Competing with the public health issues that Palau faces are also urgent issues related to climate change and the management of its natural resources. For instance, recently the President of Palau announced that it will be closing its exclusive economic zone to all commercial fishing. Palau's leadership is also currently lobbying to have oceans put on the global agenda for post-2015 sustainable development goals. Thus at this time, the challenge is to lobby for equal efforts to be made in relation to public health issues such as cancer prevention and treatment.

Enforcement of tobacco legislation and other public health laws is also an issue, mainly because it requires coordination between at least three different ministries: the Ministry of Health, Ministry of Finance, and Ministry of Justice. Coordinating among government ministries has proven to be a challenge due to the difficulty in getting ministries to focus on issues that are mainly seen as belonging only under the Ministry of Health. As the FCTC underlines, a national coordinating mechanism is needed in order to effectively address tobacco control. Getting that to actually happen on the ground, when each Ministry is overwhelmed with the tasks they are already given, has not been easy.

Like many Pacific Island countries, lack of expertise is also an issue when it comes to dealing with NCDs and cancer prevention and treatment. For instance, Palau's March 2012 needs assessment report for the implementation of the WHO FCTC noted that there was a misconception that the burden of packaging and labelling compliance should be borne by the Ministry of Health. The complete opposite is true - the tobacco industry should bear the cost of packaging and labelling compliance, rather than the FCTC's Parties.

There are many ways to tackle the barriers to progress discussed above. One way to start addressing the issues is perhaps to get all the NGOs and other concerned members of the public in one room to talk about a strategy that involves both document-related solutions (i.e. formulation of policy, regulations, or legislation), and people-related solutions (i.e. raising public awareness and educating the public), as a way to influence the political will and begin to make meaningful change in Palau.

In addition, Palau will be hosting the Pacific Islands Forum in late July of this year. There is huge potential between now and then to lobby the leadership to get NCDs and cancer prevention and treatment on the regional agenda, and for the Pacific Island countries to bring their voice strongly to the international agenda as well. It is recommended that supporters of cancer prevention and treatment also formulate a plan of action to capitalize on the Forum as a platform to tackle those issues.

Comprehensive stakeholder analysis is also needed, in order to begin to think about who should be briefed on these public health issues, and how stakeholders' needs and interests overlap and support one another.

Being a Palauan and a Pacific Islander, despite any despair I might feel about tackling such an "elephant", I also hold the hope that Palau and the Pacific region may rise to the occasion and become a microcosm of meaningful change.

The McCabe Centre training has given me a new respect for the sophistication of the issues related to cancer prevention and treatment, as well as for the people working behind the scenes to bring about much-needed change. It was wonderful to meet and share stories with colleagues from all over the world who are facing many of the same challenges as Palau. There are so many nuances and differences in each country's approach, and yet we all share the same goal - to eat that elephant in the room, one bite at a time.


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