ANTI-SMOKING LAWS

FEAR CAMPAIGN FORECAST IN WAR AGAINST SMOKES © Duncan Graham 2007

Indonesian lawmakers and health professionals face a rough, tough fight to tighten the country’s tobacco control laws according to an Australian activist.

Professor Mike Daube, a 33-year international veteran of the battle against smoking, predicted a heavy campaign by the tobacco industry to protect its business.

“They’ll be claiming a loss of freedom of speech and that sporting events and music shows will vanish without their sponsorship,” he told The Jakarta Post.

“Our experience shows that’s just not true. They’ll use all the second-hand arguments that have failed elsewhere in the world. That shows a real contempt for countries like Indonesia.”

Daube, professor of health policy at Western Australia’s Curtin University, was commenting on moves by 220 Indonesian legislators who are trying to butt out tobacco advertising and sponsorship.

The politicians have already been confronted by tobacco industry claims that millions will be thrown out of work if the laws are introduced.

The proposed changes, which include higher taxes and a ban on advertising, are based on the World Health Organization (WHO) Framework Convention on Tobacco Control.

Indonesia is the only country in Southeast Asia that has neither signed nor ratified the convention. So far 168 nations have signed and 141 ratified.

Indonesia has a huge tobacco industry employing thousands. How many? Supporters claim five million, but independent researchers have not dissected that figure.

House of Representatives member Hakim Sarimuda Pohan, who chairs the committee drafting the tobacco control bill, has been quoted as saying new laws are needed to stop children smoking.

He claimed that in the past five years there’s been a 900 per cent increase in children under ten smoking.

Indonesia has some of the slackest controls on smoking in the region. Cigarettes are cheap, taxes are low, adverts can be seen almost everywhere, and restrictions on smoking in public are widely ignored. Compulsory health warnings are miniscule.

Thailand insists cigarette packs carry gruesome pictures of the damage smoking can do to the body. Cigarettes can’t be displayed in shops and must be kept under the counter.

Although sales to minors in Indonesia are illegal the law isn’t policed. The sight of schoolboys brazenly smoking in the street is common. There’s even an open trade in tax-free fags, hand-made and sold in roadside eateries in East Java. These sell for around Rp 3,000 (US 30 cents) a packet, less than half the price of legal brands. The tobacco is apparently smuggled out of nearby factories.

According to 2003 research funded by the WHO and the American Cancer Society almost 70 per cent of Indonesian men smoke. The most effective ads link cigarettes with rugged masculinity and being “a real man.”

The good news is that only three per cent of women light up, largely because the culture links smoking to prostitution.

In 1969 the average cigarette consumption in Indonesia was 469 sticks a year. That’s now almost tripled. The death rate from smoking-related diseases is close to 50 per cent, with cancer and heart attacks as the main killers.

Daube was the first director of Action on Smoking and Health (ASH) in the UK in the early 1970s. He moved to Western Australia in 1984 to work for the government and got involved in tobacco control. Later he became CEO of the Cancer Council.

Along with other health professionals he advocated the establishment of a foundation financed by cigarette taxes. This would replace tobacco company sponsorship of sport, the arts, community events, and fund health research. (See sidebar).

Daube said that during his career he’d been served with three writs by tobacco company lobbyists. He alleged that a health minister who later went on the board of a cigarette company blocked his promotion in Britain.

He said tactics used in the past by the tobacco lobby included recruiting financial journalists to run stories claiming controls would trigger business collapses, and “flat earth doctors” denying medical evidence of the health dangers.

He said the argument that tobacco farmers would go bankrupt were false. In Australia growers had shifted to other crops.

Daube claimed the tobacco lobby was now less effective because top professional people were no longer prepared to work for a discredited industry. However the people who were now fighting against controls were probably “tougher and nastier.”

“Tobacco companies are immoral and evil,” he said. “Smoking kills about half the known users. It’s responsible for about ten per cent of global deaths.

“The industry will claim it has a right to advertise because there’s no scientific proof that advertising encourages people to start smoking, and that the product is legal.

“Newspapers and magazines will protest that they’ll lose revenue. Sports administrators will say games will suffer. We’ve heard all these claims before and seen them refuted.

“Politicians, doctors and other health workers really have to get their act together and fight this menace. There needs to be a coalition of health organizations and professionals, and sports stars.

“In Australia the involvement of doctors in anti-smoking campaigns has been critical.

“Sadly I’m told that up to 30 per cent of Indonesian doctors smoke. There’s no better ad for cigarettes than a doctor who smokes.”

SMOKES PAY FOR SPORTS

A scheme devised by Australian doctors 20 years ago to combat tobacco sponsorship of sport and culture has proved so successful it’s now being applied in Malaysia, Thailand and some European countries.

In Western Australia it’s know as Healthway, an independent organization funded by tobacco taxes. Last year it collected AUD $17 million (Rp 122 billion). This was used to sponsor sports and cultural events, conduct research and promote healthy lifestyles.

Executive director Neil Guard said that when Healthway started in 1990 about 25 per cent of adults in WA were regular smokers. That figure had now dropped to 15.5 per cent.

“Healthway has played a significant role in helping achieve this outstanding result in tobacco control,” he said.

“The key areas are advocacy, the creation of smoke-free environments, public awareness and education programs, support for smokers wanting to quit and prevention of people taking up smoking.

“Also important is research into new ways of tobacco control, and legislation to restrict smoking in public places and the sale of tobacco products.”

This year the WA government banned smoking indoors in hotels, restaurants and nightclubs, despite being confronted by claims that patrons would stay at home and businesses would collapse.

The hospitality industry is now opening outdoor eating and drinking areas to cater for smokers. Another factor in promoting change has been successful legal action by sick employees against companies that allow smoking in the workplace.

Guard said the creation of smoke-free areas at sporting and music events was a critical factor in lowering tobacco use.

Getting public support for anti-smoking laws was important. When tobacco advertising bans and other controls were proposed, surveys showed the public was prepared to tolerate higher “virtuous taxes” if these were used to help sport and culture.

Australia, Malaysia, Thailand and Singapore impose tobacco taxes starting at 70 per cent. The Indonesian rate is 31.5 per cent. Although prices will increase next March by up to Rp 7 a stick, smokes in Indonesia are around one fifth of the cost of those sold in nearby countries.

Guard said organizations that wanted Healthway sponsorship had to make the event smoke free and had to advertise a healthy lifestyle.

Before the law was changed cigarette companies claimed they were spending big amounts on helping sport, music and culture. However research revealed the donations were small.

Healthway had to pay only AUD $2.5 million (Rp 18 billion) to buy out cigarette sponsors of sporting and cultural events when the forecast was for almost four times that sum.

“Sport and the arts are doing much better with Healthway sponsorship than they ever did with cigarette companies,” he said. “They get more money with fewer restrictions.”

(Sidebar 2)

CREATING A CLEAN IMAGE

Not surprisingly tobacco companies don’t like being portrayed as purveyors of poisons and killers of citizens. So they try to boost their image by seeming to be socially responsible. A popular campaign is to clean up the environment – a cause that seldom attracts sponsors.

Ironically the tobacco industry is responsible for creating garbage like cigarette butts and packaging.

In Indonesia Sampoerna, now owned by the US giant Philip Morris, has sponsored signs urging people not to litter. In Australia British American Tobacco is behind the seemingly benign Butt Littering Trust.

This educates smokers in thoughtfully disposing of their fags and includes giving people little canisters they can use as personal ashtrays. It ignores the fact that people who don’t smoke don’t produce butts.

Activists say Australians flick away 18 billion non-biodegradable cigarette butts every year. Not all are dead. Careless smokers start more than 4,500 bush and home fires.

The trust claims it is independent, but critics say it’s wholly funded by BAT that has a representative on the board.

Another ploy is to fund educational institutions and scholarships. These are illegal in many countries when the company uses its own name or the name of a product.

So the Sampoerna Foundation, which gives the company the profile of a good corporate citizen, could not function under that title elsewhere because it would be seen as advertising.

(First published in The Jakarta Post 3 January 2007)

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HEALTH CARE FOR INDONESIANS

EXECUTIVE HEALTH CHOICES: HERE OR THERE?
Duncan Graham © 2006

It’s every hard-pressed manager’s nightmare: A gripping, vice-like chest pain. Maybe just indigestion after a rich meal. Maybe not.

Heart attacks are an occupational hazard for people in business and other high stress jobs. Victims are usually middle-age workaholics who smoke, eat the wrong food and don’t exercise. Most are men

They rush to a doctor and the prognosis is bad. Surgery is required. But where to go? Who wields the steadiest scalpel?

When former president Megawati Soekarnoputri had medical check-ups in Singapore she sent a clear message to all Indonesians about the quality of the nation’s health system.

Her husband Taufik Kiemas endorsed his wife’s views by choosing the nearby Western Australian capital Perth for his heart surgery.

It seems that if you’re an Indonesian with a serious health problem and plenty of money you head straight for the nearest airport rather than the closest hospital.

Back in the 90s before the economic crisis, many sick Indonesians chose Australia for treatment. Agents helped patients find the right doctors and hospitals, sort out visas and accommodation for the family, and somewhere to convalesce.

When the rupiah exchange rate multiplied exponentially those agents found business too tough and quit the market. Now the currency seems to have stabilized, and a new Australian company has entered the field.

Validus International is a health services management business linking the sick to the services they need. The company is contracted to Perth’s Mount Hospital to provide an international patient liaison officer and is affiliated to other hospitals and services, including a fertility clinic.

Validus is seeking patients from Mauritius, Malaysia, China and Indonesia – but according to managing director Mark Riseley the Indonesian market is the company’s priority.

It has opened an office in Jakarta managed by a doctor and will be running seminars for surgeons and general practitioners in the capital and other big cities in the coming months.

“The cost of surgery and other medical treatments in Perth is about the same as Singapore,” said Riseley in his Perth office. “The airfare is a little more expensive but that’s a small amount in the overall cost.

“Australia is ranked second by the World Health Organization for healthy life expectancy which reflects the quality of healthcare available. (Japan is number one.) The facilities in Perth are world class.”

Perth is close - just over three hours flight from Denpasar. The lifestyle is relaxed, the climate benign and the claims by Validus about fees and services may well be correct. But Indonesians (and many expats) prefer instead to head for Singapore where medical care is well promoted.

The tiny city state is closer to Jakarta and has some other significant advantages. It has a no-fuss, no-fee entry system. Most foreigners can just fly or ferry into the island and get stamped in on arrival for a short-term visit.

To visit Australia requires a visa in advance and forms with more than 40 questions. Malaysians and Singaporeans can apply for Australian visas through the Internet, but not Indonesians.

Medical visas are free. Tourist visas cost AUD $70 (Rp 500,000) which is non refundable if a mistake is made on the seven page application form. Although Embassy officials claim around 97 per cent of visa applicants are successful, the perception is that entry into Australia is difficult, and therefore unwelcoming.

Riseley said an Australian health visa can be arranged within three to five days – or 24 hours in an emergency. But however efficient the bureaucracy it can’t compete with Singapore’s simplicity.

“I’ve been talking to the Immigration Department and the current system of sending medical data for visa assessment by locked bag twice a week to Australia will soon be replaced by direct digital transmission,” said Riseley. “That should speed procedures.” A new visa application center has also been opened in Jakarta.

Riseley trained as a physiotherapist in Australia and Canada, then worked in the Middle East where he saw the need for international health care and patient management services.

The chair of Validus is health administrator Glyn Palmer, president of the West Australian Health Care Association. He was previously CEO of St John of God Health Care in Perth.

“In the past there were good contacts between the Catholic hospitals in Indonesia and Australia,” he said. “Australia is the equal of any country in the world in providing the best medical care.

“We also have a large knowledge base in medical care and this has to be shared.”

Palmer said he would organize seminars in Indonesia where doctors could get free information from visiting Australian surgeons and physicians on the latest procedures and medications.

He would also be talking to Indonesian doctors’ associations and working to build relationships with hospitals. He agreed that the pivotal point in getting business was the patient’s doctor who would usually offer advice on the best place for treatment. For Validus to succeed it’s critical that medicos are aware of facilities in Australia.

Doctors who refer patients to hospitals overseas can collect commissions of between four and ten per cent of the hospital bill.

The other gateway is medical insurers who have links with hospitals and laboratories where they direct their members.

Riseley said Singapore currently takes 370,000 overseas medical patients a year – Malaysia 270,000. Validus has set itself modest numbers for starters – just 450 by the end of next year.

“We understand that building relationships in Indonesia is extremely important,” said Palmer. “We must respect cultural differences.

“We’ll be going to Indonesia regularly, communicating and listening. We’re selling a good Australian product and we’d like more Australian government help.

“The visa process is frustrating – it takes too long. Singapore does a wonderful job, and we have a lot to catch up on.

“Australia is a favored education center for about 20,000 Indonesians a year so we can build on those contacts and family ties. Word of mouth is also important. The response so far has been enthusiastic.”

(First published in The Jakarta Post 18 December 2006)

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