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Aids vs Cancer. You choose.

I almost got hit by a car this afternoon. I was debating with Jennifer Holt, our Deputy Director, about our former colleague Rod Nixon’s “Condom & Smokes” idea.  In a nutshell, Rod is planning to launch a project that distributes condoms by packaging them with cigarettes. The cigarettes act as a delivery mechanism, making sure the condom gets to where it’s needed, namely a truck stop bar on the road to Mombasa at 2am on a Saturday.

It’s a fascinating idea because, to use Rod’s words, this will:

(a) overcome distribution challenges, thereby contributing to both HIV/AIDS prevention and family planning objectives in weak states; (b) reduce stigma associated with purchasing condoms in the village and settlement, since the purchase of the condom will be masked in the purchase of the companion product; and (c) contribute to the normalisation of condoms in the community.

Back to the debate. The problem is obvious. Cigarettes are also a pretty good delivery mechanism for something else: lung disease and cancer. We were discussing the ethical issues involved in this project and whether a good outcome could justify a concurrent bad outcome (ie. prevent aids but get cancer).  We’re both pragmatic enough to believe that every choice comes with some negative aspects and that if the good outcome was large and overwhelming likely, then it would justify the risk of a smaller negative outcome that is far less frequent.

"More doctors recommend Zen Condom Smokes than any other brand"

But aids vs cancer? That’s a stark choice.

Can the social benefit of condom distribution be gauged accurately enough that you could say “If we distribute 200,000 condoms in the Nyanza province of Kenya, it will prevent x cases of HIV.”? I may get Kavya-the-intern on that one. (By the way, she’s been promoted. So were accepting new intern applications.)  Assuming you could measure the benefit of the condoms accurately, how would you measure the increased likelihood of cancer? That data is readily available, but I suspect it can’t easily be applied to the Africa context. Because, sadly, African life expectancy is the worst in the world. In some places, like Zambia, it can be as low as 42 years. Africans simply aren’t living long enough to get cancer.

That dark patch on the map? That's not good news.

I was taking the position that if you could help lower the death rate from AIDS but there was a direct correlation with the increase in cancer it would still be worth it. In other words, if you could prevent 23 cases of aids, but those 23 people then went on to get cancer and die, it would still be worth it because they would presumably die later in life and therefore there was a net benefit. Sounds harsh, but ask yourself, if you could choose between dying in 5 years from AIDS or in 20 years from lung cancer, which would you pick?

But here is the problem, the thought that stopped me in my tracks as I was crossing 42nd Street: what if 23 different people got cancer? In other words, you prevent some people from getting aids, but in the process other people who weren’t going to get cancer did. Then what?

42nd St. from the PDT office. Not the best place for a debate.

I don’t know the answer. But I do know I narrowly avoided getting hit by a car as I stood dumbly thinking about it.  What do you think?

NB: Rod’s concept is much more nuanced than my overview suggests and proposes to distribute condoms in the packaging of a series of different types of consumer products. We just focused on the most interesting one, smokes.

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  1. Lydia says:

    I think the question is how many people who don’t smoke would buy the cigarettes to get the condom? And that is not an easy answer, maybe some field study could be done beforehand but really, can it truly be measured until there’s ‘real’ data to work with? and by then, might it be too late?

    Of course the idea could also be to make sure the condom is inside the package somehow (without a doubt far more problematic to accomplish than ‘attaching’ it to the outside) but in a way it wouldn’t incite people to buy it just for the condom… well, in theory. Who knows, once it gets out that the smokes are smokes+condom how many more would buy it? And thus back to square one.

    Personally I think as ideas go, it’s a great one for it makes sure that people will be able to access it in an easy way… it would definitely be better to educate everyone about safe sex and using condoms but since this is planet is not Utopia, we definitely have to agree on the fact that this idea has certain merit.

    Although, if you think about it, maybe the study that should be done is in regards to: packets of cigarettes = # intercourse during the packet’s “life” ?

  2. It’s nothing new, it’s an old ethics conundrum. There is even a name for it: the trolley problem. Google it and be amazed how much literature comes up.

  3. Rod Nixon says:


    I am sorry you were almost hit by a car while debating this idea, but of course relieved you avoided injury. I admit this is one health risk I had never considered.

    Also, thanks for the interesting points you raise.

    The short version of my response remains as articulated in the earlier ‘Zen’ paragraphs. Namely:

    “The use of tobacco products, despite their known health risks, is proposed because of the level of consumption of cigarettes and the serious nature of the epidemic. From a harm-minimisation perspective, smoking is bad, but smoking and practising unsafe sex is worse.”

    If this concept ends up being trialled with cigarettes only, and if sales of cigarettes end up increasing specifically because of the fact that condoms are included in the packaging, then this should be seen as a positive sign. Because then it will be clear to manufacturers and distributors of other (potentially more benign) products that they too can increase sales and profits by including condoms in their packaging.

  4. Adrian says:

    The most significant difference between AIDS and cancer is that the former is very contagious whereas the latter is not. This means that 23 people with cancer will ‘just’ make 23 people dying from it while 23 people with AIDS will most probably make a lot more in the long run.

    Taking into account that treatment costs for cancer and AIDS are both very expensive (and unaffordable for most of the poor) and that cancer, usually, takes longer to appear and to kill (long suffering however must be put in the equation), it seems that cancer, in terms of social cost, is less harmful than AIDS just because of this contagious factor.

    However, I don’t think that providing condoms along with cigarettes (or any other product) will necessarily make people smoke more cigarettes or have safer sex, or at least, to a significant extent. We don’t live in Utopia indeed, but in the same way as we cannot trigger economic growth by simply throwing banking notes from an airplane (or should we try?), it happens that education and capacity-building, among others, are fundamental in achieving development outcomes.

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