The shape of the world a generation from now will be influenced far more by how we communicate the values of our society to others than by military or diplomatic superiority. William Fulbright, 1964

Friday, June 01, 2007


TOUGH GUYS DIE HARD © Duncan Graham 2007

The United Nations has designated Thursday 31 May as World No Tobacco Day. A worthy idea – but one that's unlikely to have much impact in Indonesia, ranked five in the world for tobacco consumption.

For the figures are rising. According to the World Health Organization (WHO) more than 62 per cent of adult males in Indonesia smoke – up almost ten per cent in six years.

If current trends continue WHO reckons that by 2020 tobacco-related illnesses will be the world's largest single health problem, killing 8.4 million people a year. Half these deaths will be in Asia.

The figures are so big and consistent, the science so conclusive that no one seriously doubts that smoking cripples and kills. So why do people continue? Duncan Graham tried to find out:


Solikia needed no prompting to tell his story – and pass on a warning.

The 70-year old rice farmer from Blitar in East Java had been admitted to Malang's biggest public hospital just five days earlier suffering from acute shortness of breath and chest pains.

The diagnosis wasn't good. He has emphysema and bronchitis. His lungs are irreparably damaged. His body is thin and frail as though he's come from an industrial slum, not a lifetime of open-air work in the country.

He was being treated with antibiotics and when his condition stabilizes he'll be sent home. His body has been so severely weakened he'll probably soon succumb to pneumonia and die.

Solikia said he smoked one and a half packets of cigarettes every day for more than 50 years. Doctors have told him that this is the reason he is now so sick.

"If we got all the packets I've used it would more than fill this room, it would overflow into the corridor," he said in short breaths at the Dr Saiful Anwar Hospital's lung diseases ward.

"My message to all young men and boys, to everyone, is never to smoke. If you feel the need, just suck a sweet or chew something. I started because all my friends, everyone smoked. It was just what we did. But I didn't know anything. Now I regret that I ever started."

Sitting on his bed he tapped his skeletal ribs with his left hand. The other he held up, palm first, as in a pledge: "I swear before God that I will never smoke again."

Discounting accidents and maternity cases, the four top reasons for seeking help at the hospital are upper respiratory infections, tuberculosis, asthma and lung diseases, according to pulmonary diseases specialist Dr Nunuk Sri Muktiati

"Apart from TB the others are all linked to smoking," she said.

"Ninety per cent of the patients I see are smokers. I want to be angry – but to whom do I direct that anger? Smoking is linked to masculinity in Indonesian culture.

"It's difficult to get the message across that smoking kills. I don't know how we can break the connection between smoking and being a strong man."

But she does know how to reach women. Most of her patients are men and they often bring their families to consultations and treatment. This gives Dr Nunuk the chance to empower wives and mothers to protect their children.

"The message I try to get through to the family is that the female head of the household must control what happens in her home," she said. "She should throw away ashtrays and tell guests who want to smoke that it's not allowed."

(A national survey conducted three years ago showed that most Indonesian men light up at home, exposing their families to carcinogenic fumes. The research estimated that 97 million people are unwilling passive smokers – and almost half are children.)

The X rays Dr Nunuk studies during her rounds are graphic enough, made doubly so when the surrounds are clinical. The lungs of a smoker with emphysema exposing collapsed tissue; the dreaded black spots. You don't need to be a radiologist to understand the pictures are death sentences with no appeals.

But there are other more soothing images, much easier to access. The billboards just 200 metres outside the sterile white-tiled walls show fit and happy young men climbing mountains, racing four-wheel drives into stunning scenery and generally having a jolly carefree time.

They're not shown smoking – that's illegal in Indonesia. Advertising mustn't carry pictures of cigarettes and must include a prolix health warning. But the link is clear: The good-life fantasies may be out of reach, but buying and burning thin rolls of tobacco leaf is a fine substitute for the unattainable.

Dr Nunuk also hands out brochures produced by the Association of Indonesian Lung Specialists. She's a past chair of the local branch.

Although providing useful information these are wordy and poorly illustrated leaflets that will never win design awards when ranked against the tobacco industry's smart and seductive ads.

Surprisingly Dr Nunuk isn't just battling timid housewives reluctant to stamp their authority across their domain. The hospital bosses seem equally unwilling. Although corridors and wards have No Smoking signs, the rules are not enforced – except in the areas directly under the control of Dr Nunuk and her like-minded colleagues.

"I want the campaign to create smoke free areas expanded," she said. "Everyone seems to think this is too difficult because of the culture.

"The labels on cigarette packets should be bigger and the message more stark. I understand that the government wants to get tax from tobacco and that many people make their living from the industry.

"My message to the government is that production should be curbed. The authorities should think about the benefits to the health of the community.

"Maybe we should be promoting the idea that men who stop smoking are strong – not the other way around."

Sidebar 1


About ten per cent of total government revenue comes from tobacco tax. According to WHO figures, tax as a proportion of the total cigarette price averages 31 per cent in Indonesia – one of the lowest tax rates in the region.

Jobs in tobacco manufacturing make up one per cent of the total industrial sector employment. That's about one million people. Most are women.

This figure doesn't take into account farmers, field processors, transporters, sales staff, advertisers, retailers and others who directly and indirectly make a living from the tobacco industry.

The tobacco market is controlled by a few multinational corporations from the US, Japan and Britain. The value of tobacco leaf imports into Indonesia exceeds the value of exports by US $ 44 million.

(sidebar 2)


Despite the overwhelming evidence that lung cancer is the world's leading cause of preventable death – and that tobacco use is linked to 90 per cent of cases - there are even some doctors who don't get the message, effectively undermining Quit campaigns.

When your health care provider reeks of tobacco smoke his warnings of the hazards are worthless.

Dr Andreas Infianto recalled his time as a medical student in Bandung.

"About 30 per cent of my colleagues were smokers," he said. "It was part of the lifestyle. If we didn't smoke we weren't really considered to be men. Our culture and environment encourage smoking.

"Studying was hard. Smoking seemed to be the only thing that would ease the tensions and get rid of the problems. Then I got asthma and realized I had to give it up.

"But I know many doctors who can't kick the habit."

(Sidebar 3)


Most Westerners who love this country can clearly recall their first moments on Indonesian soil. The sultry heat; the cacophony and the seemingly aimless crowds; the density of the roadside shadows and flickering lights offering hints of mystery.

Add to these images the smells – of burning cooking oil and kretek cigarettes. It's the distinctive and unique odor of the archipelago.

Airports are normally smoke-free. But in Indonesia the tobacco companies have thoughtfully installed glass-walled smoking rooms where nicotine addicts can huddle together in a strange ritual of slow asphyxiation.

The culture shock continues with the posters, banners and billboards. It's like going back in time, to an era when tobacco advertising was legal, a period recalled only by the elderly.

The streetscapes of Singapore, Malaysia, Thailand and other countries aren't polluted by such signage. Cigarettes cost up to ten times more than brands in Indonesia and in many cases aren't on open sale.

Supply to minors is illegal and the law is strictly enforced. Offending shopkeepers are heavily fined. Health warnings are stark and confrontational.

In France you buy a product that screams Fumer Tue (smoking kills) across one third of the pack. Singapore packets carry photos of sick people in hospital. In Thailand they show diseased gums and other gross medical conditions.

In Indonesia some brands carry sports' images. One has the slogan: The Real Man. The picture shows a Caucasian.

(Sidebar 4)


Could the addition of one word on cigarette packs help deter smokers? Muslim psychiatrist Dr Andri Sudjatmoko thinks so.

The word would be haram – meaning forbidden to Muslims, who usually check that anything they consume is halal – allowed. Even plastic bottles of standard drinking water carry the label halal.

"Islam prohibits the use of intoxicants and drugs," Dr Andri said. "No one is allowed to smoke at Mecca during the haj (pilgrimage).

"Nicotine is a highly addictive drug that affects the brain. People start with cigarettes; some then go on to use alcohol and illegal drugs.

"Smoking creates mood disorders. It depresses taste and affects concentration. Many know the risks but ignore them. I'd like to see a real anti-smoking campaign, something like the one now being employed against drug use.

"Fortunately few women smoke. (WHO figures show 1.3 per cent in Indonesia. In some Western countries women have overtaken men as smokers.)

"That's because of the stigma; a woman who smokes is considered to be a prostitute.

"In this country there's a strong link between smoking and masculinity. Fathers who smoke pass the habit onto their sons when they are teenagers. This connection has to be broken – that's the responsibility of the family.

"Education is the key. Research shows that most smokers have low education levels. The better educated the person, the less likely they are to smoke.

"This is a serious problem in Indonesia. It's complex and multi-functional and has to be tackled on many fronts – including compensation for farmers who want to stop growing tobacco."


(First published in The Jakarta Post 30 May 07)

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