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The 1997 Haze Disaster in Indonesia: Its Air Quality and

Health Effects
a b a c d
Osamu Kunii , Shuzo Kanagawa , Iwao Yajima , Yoshiharu Hisamatsu , Sombo
e f a
Yamamura , Takashi Amagai & Ir T. Sachrul Ismail
a
Department of International Community Health , Graduate School of Medicine, The
University of Tokyo , Tokyo, Japan
b
International Medical Center of Japan , Tokyo, Japan
c
Environmental Management Center , Bapedal, Indonesia
d
Department of Community Environment Sciences , National Institute of Public Health ,
Tokyo, Japan
e
Department of Protection, of the Human Environment , World Health Organization ,
Geneva, Switzerland
f
Institute for Environmental Sciences University of Shizuoka , Shizuoka, Japan
Published online: 05 Apr 2010.

To cite this article: Osamu Kunii , Shuzo Kanagawa , Iwao Yajima , Yoshiharu Hisamatsu , Sombo Yamamura , Takashi Amagai
& Ir T. Sachrul Ismail (2002) The 1997 Haze Disaster in Indonesia: Its Air Quality and Health Effects, Archives of Environmental
Health: An International Journal, 57:1, 16-22, DOI: 10.1080/00039890209602912

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 The 1997 Haze Disaster in Indonesia:
Its Air Quality and Health Effects

OSAMU KUNll SOMBO YAMAMURA

SHUZO KANAGAWA Department of Protection
Department of International Community Health of the Human Environment
Graduate School of Medicine World Health Organization
Downloaded by [New York University] at 12:08 11 October 2014

The University of Tokyo Geneva, Switzerland

Tokyo, Japan TAKASHI AMAGAI
and Institute for Environmental Sciences
International Medical Center of Japan University of Shizuoka
Tokyo, Japan Shizuoka, Japan
IWAO YAJIMA IR T. SACHRUL ISMAIL
Environmental Management Center Department of International Community Health
Bapedal, Indonesia Graduate School of Medicine
YOSHl HARU HISAMATSU The University of Tokyo
Department of Community Environment Sciences Tokyo, Japan
National Institute of Public Health and
Tokyo, Japan Environmental Management Center
Bapedal, Indonesia

ABSTRACT. In this study, the authors assessed air quality and health effects of the 1997 haze
disaster in Indonesia. The authors measured carbon monoxide, carbon dioxide, sulfur diox-
ide, nitrogen dioxide, ozone, particulate matter with diameters less than or equal to 10 pm,
inorganic ions, and polycyclic aromatic hydrocarbons. The authors also interviewed 543
people and conducted lung-function tests and determined spirometric values for these indi-
viduals. Concentrations of carbon monoxide and particulate matter with diameters less than
or equal to 10 pm reached “very unhealthy” and “hazardous” levels, as defined by the Pol-
lution Standards Index. Concentrations of the polycyclic aromatic hydrocarbons were 6-1 4
times higher than levels in the unaffected area. More than 90% of the respondents had res-
piratory symptoms, and elderly individuals suffered a serious deterioration of overall health.
In multivariate analysis, the authors determined that gender, history of asthma, and fre-
quency of wearing a mask were associated with severity of respiratory problems. The results
of our study demonstrate the need for special care of the elderly and for care of those with
a history of asthma. In addition, the use of a proper mask may afford protection.
<Key words: forest fires, haze, health effects, Indonesia, particulates, respiratory symptoms>

BIOMASS BURNING (i.e., burning of living and/or
dead vegetation for land-clearing and its land-use
change or as fuel for cooking and heating) is a signifi-
cant source of trace gases and aerosol particulates. It
ultimately affects atmospheric chemistry and cloud
properties, and the global radiation budget is also pro-
foundly affected by this pra~tice.’-~Consequently, cli-
mate dictates4t5that the bulk of the world’s biomass
burning occurs in the tropical forests of Southeast Asia
and South America and in the savannas of Africa;
approximately 90% of the burning results from human
actions, and only about 10% occurs as a result of “nat-
ural” fires triggered by atmospheric lightning6
Among nations that have dense, tropical forests,

16 Archives of Environmental Health

 Indonesia has historically been affected repeatedly by
forest fires (e.g., in 1982, a 3.5-million hectare [ha] area
was burned; in 1987, a 50,000-ha area was burned; in
1991, a 120,000-ha area was burned; and, in 1994, a
160,000-ha area was burned’). In 1997, the dry condi-
tions that prevailed in Southeast Asia that resulted from
the El Niiio Southern Oscillation climate phenomenon (El
Niiio), together with land-clearing practices, caused the
second largest forest fire disaster in this century in
Indonesia. Subsequent to June 1997, more than 1,500
fires consumed more than 300,000 ha (i.e., mainly in the
Kalimantan and Sumatra islands) and had generated
intense smoke, which affected neighboring countries
(e.g., Singapore, Malaysia, Thailand) and the Indonesian
Islands for several months. The haze smoke paralyzed
transportation and triggered secondary disasters (i.e., air-
bus and tanker crashes).
Between September 1997 and November 1997 in
Indonesia, there were 527 haze-related deaths, 298,125
cases of asthma, 58,095 cases of bronchitis, and
Downloaded by [New York University] at 12:08 11 October 2014
1,446,120 cases of acute respiratory infection reported.
In South Sumatra, the number of acute respiratory infec-
tion cases increased 3.8 times during the aforementioned
time period, compared with the prior year.’ However,
there were no data or information about the health effects
of this haze episode on the general public. Even for the
other vegetation fire episodes-such as the 1987 forest
fires in California and the 1994 Sydney bush fires-there
were hospital-basedstudies, but there was a lack of com-
munity-based studies. In the current study, we (1)
assessed air quality, (2) investigated overall health effects
and factors that influenced the severity of respiratory
problems, and (3) determined the affected community’s
perceptions and practices in response to the haze in
Indonesia.
Methods
All of the following surveys were conducted between
September 29, 1997, and October 7, 1997. This period
of time was in the middle of the forest fire disaster that
occurred from June 1997 through December 1997. Dur-
ing this period, the haze smoke had constantly covered
many parts of Indonesia.
1. Air quality. The size distribution of particulates and
the concentration of carbon monoxide (CO) and carbon
dioxide (C02)were measured at 8 sites between Jakarta
(in Java),which was affected only minimally by the haze,
and Jambi (in Sumatra), which was severely affected by
the haze. To determine if remaining indoors could be pro-
tective, we measured particulates inside and outside 3
types of buildings in Jambi. The size distribution of par-
ticulates was determined with a light-scattering particle
analyzer (RION KM-07). Carbon monoxide and C 0 2
were measured with the detector and tubes.
We measured sulfur dioxide (SO2),nitrogen dioxide
(NOz),ozone (03), particulate matter less than 10 microns
in diameter (PMlo), CO, and C 0 2at 3 sites of Jambi. Sulfur
dioxide, NO2, and O3 were measured by the
Parazosanilin, Saltzmann, and kalium iodine methods,
respectively. PMlo was collected and measured with a
January/February 2002 [Vol. 57 (No.l)]
low-volume air sampler. Airborne particulate samples
were collected with a high-volume air sampler, and
inorganic ions (e.g., chloride [CII, nitrate [NO3],sulfate
[S042-],and ammonium [NH4+]) were analyzed with ion
chromatography. From other samples, which were also
collected with a high-air volume sampler, we analyzed
polycyclic aromatic hydrocarbons (PAHs [also known as
carcinogens]) with the high performance-liquid
chromatography spectrofluorometric/computer system.
2. Health effects, perception, and preventive
behavior. A face-to-face structured interview was
administered in Indonesian language to 543 persons who
were selected by convenience sampling at 6 sites in
Jambi City (i.e., 105 in an elementary school, 102 in a
secondary high school, 110 in a high school, 53 in a
nursing home, 94 in a local government office, and 79 in
a small village). The interview, which required 10-15
min, included the following: 41 questions about past
histories of asthma, bronchitis, and heart diseases; 21
questions about types of health problems (i.e., whether
health problems developed or worsened following
exposure to haze and determination of the severity of
each health problem [classified as “mild”-to the extent
that daily life was undisturbed; “moderate”-to the
extent that daily life was disturbed, but medical help was
not required; and “severe”-to the extent that daily was
disturbed and medical help was required]). We also
asked whether the interviewees wanted to evacuate to
safer places, whether they were worried about their
future prospects as a result of the haze, and, while
remaining outside, how often they put on a mask for
protection.
We examined every 4th respondent who developed or
exhibited exacerbated respiratory problems (a total of
138 individuals), to establish whether they had conjunc-
tivitis and abnormal respiratory sound, as determined by
inspection and by auscultation, respectively. We also
tested lung functions of these individuals with spirometry.
Statistical analysis. Data were stored and analyzed
with the SPSS statistical package version 7.5 developed
by SPSS lnc.8 We used the chi-square test to assess the
significance of the differences in the severity of
respiratory problems between those who had and those
who did not have preexisting histories of asthma or heart
problems. We also used it to examine the significance of
differences in the change of general health conditions
between age groups and between males and females, as
well as the difference between age groups with respect
to perception and protective practices taken in response
to the presence of haze. We used Student‘s t test to
examine the differences in lung function (i.e., forced
vital capacity [FVCI and forced expiratory volume in 1
sec [FEVI.ol) between 2 age groups and between males
and females.
We performed multivariate analysis with the stepwise
linear-regressionmodel to determine if factors associated
with severity of respiratory problems developed or wors-
ened following exposure to haze. In this model, we used
a 4-point scale to present the severity of respiratory prob-
lem(s) (0 = none, 1 = mild, 2 = moderate, 3 = severe) as
dependent variables, and we used 7 items (i.e., gender,
17
 age, history of allergy, asthma, bronchitis, heart prob-
lems, and frequency of using a mask) as independent
variables. All tests were two-tailed, and a p value of I
.05 was indicative of a statistically significant difference.
Results
Air pollution. The concentration of particulates 0.3
5.0 pm in size gradually increased as one moved closer
- tioned). However, outdoor concentrations of the coarse
to the heavily affected area, whereas the concentration
of particulates > 5.0 pm in size increased very little (Fig.
1). The concentrations of CO and C 0 2 also increased in
the affected sites, although the concentrations
increased only slightly in Jakarta; perhaps this increase
reflected typical urban air pollution (Fig. 2).
A major air pollutant of the haze in Indonesia was
particulates that far exceeded the “hazardous” level and
the maximum value of 500 in the Pollutant Standards
Index (PSI) (Table 1). The concentration of 1,864 pg/m3
was more than 10 times higher than that in Jakarta, and
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of 3 buildings in Jambi. The indoor/outdoor particle
concentrations were 428,978 particles/m3 and 435,719
particles/m3, respectively, of a farmer’s house (not air
conditioned); 432,283 and 436,234, respectively, of a
hotel (air conditioned); and 438,172 and 454,215,
respectively, of a local government office (air condi-
particles (i.e., 5.0 pm) were considerably higher than
indoor concentrations. The indoor and outdoor con-
centrations were 209 and 226, respectively, for the
farmer’s house; 21 8 and 401, respectively, for the hotel;
and 155 and 275, respectively, for the local government
office (air conditioned).
With respect to inorganic ions in suspended particu-
lates, the concentration of S042-(i.e., 37.98 pg/m3)was
5-1 0 times higher than concentrations in Tokyo, where-
as CI- (4.98 pg/m3)and NO3-(5.3 pg/m3)concentrations

it was approximately 8 times higher than the maximum n

level of PMlo in the 1987 forest fire disaster in Califor- 25
nia, which consumed more than 2.4 million ha.9 CO
also exhibited a high concentration at the “very
20
unhealthful” level of the PSI, but SO2, NO2, and O3
were at a “good” or “moderate” level.
There was little difference in particle concentrations
-
in the 0.3-5.0-pm size range in the indoor/outdoor air

+ 03-50Urn p=Eq
200
300 ‘i _______
15

10

100
t--*- 5

0
Jambi Grisik Prabumulih Tanjungkarang
Jambi Palambang Martapura Jakarta

Fig. 2. Carbon monoxide (CO) and carbon dioxide (COz) con-

centrations measured in 8 sites of Indonesia on October 1,
1997.

Table 1.-Air Pollutants Measured in 3 Sites in Jambi,

Indonesia (October 34,1997)

Site
Pollutant A 6 C PSI

SO2 (ppm) 0.01 0.01 0.01 18

NO2 (ppm) 0.01 0.02 0.004 -
0, (ppm) 0.03 0.03 0.06 54
CO (ppm) 20 20 20 247
PMlo (pg/m3) 1,684 1,635 1,864 1,584

Notes: SO2 = sulfur dioxide, NO2 = nitrogen dioxide, 0, =

Fig. 1. Particle concentrationsof sizes 0.3-5.0 pm and 5.0 p+
measured in 8 sites of Indonesiaon October 1,1997. Note: The
values of 0.3 and 5.0 pm are cut-off sizes of the light scattering
particle analyzer.
oxides, CO = carbon monoxide, and PMlo = particulate mat-
ter with a diameter of < 10 p. PSI = Pollutant Standards Index,
developed by United States Environmental Protection Agency.
The PSI determines the daily index number for each of the 5
pollutants herein, and the highest of the 5 figures is reported.
A PSI value < 50 indicates “good” air quality, 51-100 indi-
cates ”moderate” air quality, 101-200 represents “unhealth-
ful” air, 201-300 indicates “very unhealthy” air, and a value >
300 indicates hazardous air.

18 Archives of Environmental Health

 were almost identical, and NH4+concentrations (0.69
1g/m3)were slightly less than concentrations of CI- and
NO3-.The concentrations of the 5-7-ring PAHs in the
affected area were 6-14 times those in the unaffected
area (i.e., an almost proportional value to the particle
concentration), and the 4-ring PAHs in Jambi were
40-60 times higher than in Jakarta (Table 2).
Health effects. Of the 543 interviews conducted, we
collected 539 usable answers. The mean age of the 539
respondents was 24.9 yr (standard deviation [SDI = f
18.9 yr); 296 (54.9%) of the respondents were male.
Some of the respondents had a preexisting history of
allergy (20.8), asthma (7.4), bronchitis (8.21, and heart
problems (2.8%). Almost all of the respondents (98.7%)
developed or suffered from an exacerbation of symp-
toms, and 91.3% had respiratory symptoms (Table 3).
Most of the health problems were mild, but 13.1YO
perceived their health problems as severe (i.e., to the
extent that they required medical help), and 49.2%
reported that the health problems disturbed their daily
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”much worse”; among females, there was a slightly
higher proportion who perceived that their health con-
dition worsened (Table 5).
Physical examination revealed the presence of con-
junctivitis in 33.3% of respondents, wheezing in 8.7%
of respondents, and other abnormal respiratory sounds
in 2.9% of respondents. In lung function tests, a
restrictive respiratory functional pattern (YOFVC [FVC
measured/FVC predicted] < 80%); an obstructive pat-
tern (FEVl.o [FEVl,dFVCl < 80%); and both patterns
were found in 68.2%, 38.6%, and 22.7%, respective-
ly, of respondents. Whereas there was no significant
difference in percentage FVC between age groups and
between male and female groups, elderly individuals
(i.e., > 60 yr of age) had a significantly ( p < .001)
lower FEVl.o (65.7 f 27.5%) than younger individuals
(91.1 * 18.5%). Individuals with severe mucus pro-
duction had a significantly ( p = .011) lower FEVl.o
(59.1 * 30.2%) than individuals with mild sputum
production (85.0 f 20.3%). Individuals with severe

life. Among those with respiratory problems, 31.1 YOex- breathlessness when they worked hard had a signifi-
hibited fever, 46.6% were short of breath when they
walked, 34.1 Yo experienced chest discomfort, 18.5%
experienced depression, and 28.8% experienced Table 3.4ncidence and Severity of Reported Symptoms
appetite loss. that Developed after Exposure to Haze
In Table 4 are shown preexisting illnesses and sever-
ity of health problems. The chi-square test revealed that Severity of symptom
those with a past history of asthma and heart problems Mild Moderate Severe
presented the most severe health problems. The group Symptom n Yo n % n % n Yo
of individuals 60+ yr of age had a higher proportion of
persons who perceived that their health condition was Respiratory
problems* 492 91.3 231 47.0 217 44.1 44 8.9
Eye irritation 425 78.9 276 64.9 135 31.7 14 3.4
Table 2.-Concentrations (vg/m3) of Polycyclic Aromatic Headache 331 61.5 199 60.0 119 35.8 14 4.2
Hydrocarbons (PAHs) in Particulates Fatigue 280 61.5 206 73.6 67 24.0 7 2.4
Short of breath
when
Molecular walking 239 44.4 155 64.7 77 32.1 8 3.2
PAHs Jambi Jakarta weight Short of breath
with hard
work 192 35.7 109 56.8 71 36.9 12 6.3
Fluoranthene 16.7 0.255 202.3 Chest
Pyrene 21.1 0.396 202.3 discomfort 175 32.5 10962.5 59 33.8 6 3.7
Triphenylene 20.2 0.411 228.3 Fever 161 29.8 10766.7 49 30.8 4 2.5
Benz(a)anthracene 16.8 0.438 228.3 Appetite loss 151 18.0 10871.3 39 25.9 4 2.8
Chrysene 41.7 0.910 228.3 Sleeplessness 129 23.9 8465.0 38 29.2 7 5.8
Perylene 2.60 0.219 252.3 Nausea 126 23.3 10180.3 23 18.1 2 1.6
Benzo(e)pyrene 14.7 1.22 252.3 Palpitations 121 22.5 88 72.4 33 27.6 0 0.0
Benzo(b)fluoranthene 15.1 1.62 252.3 Abdominal
Benzo(k)fluoranthene 6.45 0.793 252.3 pain 121 22.4 89 73.6 28 23.1 4 3.3
Benzo(a)pyrene 15.3 1.05 252.3 Depression 95 17.7 55 57.6 32 33.7 8 8.7
Indeno(l,2,3-c,dpyrene 11.1 2.24 276.3 Dizziness 22 4.1 0 0.0 17 77.3 5 22.7
Benzo(g,h,r)perylene 12.8 1.78 276.3 Diarrhea 16 3.0 11 68.8 4 25.0 1 6.2
Dibenz(a,c)anthracene 0.428 0.158 278.4 At least 1
Dibenz(a,h)anthracene 0.823 0.120 278.4 symptom
Benzo(b)chrysene 1.66 0.164 278.4 cited
Coronene 0.914 0.121 300.4 abovet 532 98.7 200 37.6 262 49.2 70 13.1
Dibenzo(a,e)pyrene 3.15 - 302.24
‘Included cough, sneezing, runny nose, sputum production,
Characteristic Jambi Jakarta
and sore throat.
tlndividuals who developed 1 or more symptoms or had a
Particle (pg/m3) 1,707 167 symptom that worsened. If an individual had at least 1 “se-
Air volume (m’) 565 1,995 vere” symptom, it was classified as ”severe.” lf an individual
Collected amount of had at least 1 “moderate” symptom, but had an absence of a
particles (gm) 0.9646 0.3338 severe symptom, it was classified as “moderate.” If only mild
Sampling time (hr) 5.2 23.8 symptoms were present, they were classified as ”mild.”

january/February 2002 [Vol. 57 (No. l)] 19

 cantly ( p = .042) lower FEVl.o (62.9 f 36.7%) than indi-
viduals with mild breathlessness (91.8 A 19.6%); individ-
uals with severe breathlessness had a significantly (p =
.047) lower FVC (58.7 *
11.9%) than those with mild
breathlessness (76.4 *
13.0%). Subjects who had a
wheezing respiratory sound by auscultation had a signif-
icantly ( p < .001) lower FEVl.o (49.3 f 18.5%) than those
who did not have wheezing sounds (86.2 2 22.7%).
Factors associated with the severity of respiratory
symptoms. Factors associated with severity of res-
piratory symptoms, developed or exacerbated by haze,
as determined with multiple linear-regression analysis,
are shown in Table 6. Gender (female), history of
asthma, and less frequent use of a mask were associated
significantly with development or exacerbation of
severe respiratory symptoms.
Perception and protective practice toward haze. Of
the respondents, 82.2% and 43.2%, respectively,
worried about their future prospects as a result of the
haze or wanted to evacuate to safer places (Table 7).
Downloaded by [New York University] at 12:08 11 October 2014
future, and they worried less about evacuation than the
other age groups. In this older age group, 62.5% had
never put on a mask when they were outdoors, and the
young generation (i.e., 0-19 yr) used masks less
frequently than the other age group.
Discussion
In our study, particulate matter-especially inhalable
or respirable particulate matter-was a major source of
air pollution, and its concentration reached levels that
were very hazardous to humans. In addition, this con-
centration produced an extremely high incidence of
respiratory problems; approximately 30% of the indi-
viduals had an infection and a high prevalence of
aggravated lung function. However, given that we used
a convenience sampling method in our study and we
made no comparison between unaffected area or pre-
disaster time, the generalizability of our findings and a
cause-effect relationship between haze and health

Those who were 60+ yr of age worried less about their impact are questionable.

Table 4.-Preexisting Illnesses and Severity of Health Table C.-Multiple Linear Regression Analysis of Severity of
Problems in 532 Subjects Respiratory Symptoms

Severity of illness Variable B* Rt P

-
Mild -
Moderate -
Severe Gender 0.312 -0.143 .001
Illness n* n YO n YO n YO pt History of asthma -0.219 0.258 ,000
Frequency of using mask 0.754 -0.095 .023
(Constant) -0.049
Asthma (-) 493 197 40.0 243 49.3 53 10.8 Multiple R 1.602
< .001
(+) 39 3 7.7 19 48.7 17 43.6
Notes: Dependent variable is the severity of respiratory prob-
lem (0 = none, 1 = mild, 2 = moderate, and 3 = severe). Inde-
Heart (-) 518 199 38.4 256 49.4 63 12.2
pendent variables and values of the study included are as fol-
problem < .001 lows: gender-1 = male, 0 =female; history of allergy, asthma,
(+) 14 1 7.1 6 42.9 7 50.0 bronchitis, and heart disease-1 = yes, 0 = no; and frequency
of using mask when remaining outside-1 = never, 2 = some-
*Respondents who developed at least 1 symptom or who had times, 3 = often, and 4 = always.
a symptom that worsened. *Unstandardized regression coefficients.
tChi-square test. tstandardized regression coefficients.

Table 5.4hanges in General Health Condition of Respondents, by Age and Gender

Health condition
Extremely
worse Worse Unchanged Better
Age and gender n YO n YO n Yo n % P*

Total no. of subjects

( N = 539) 44 8.2 348 64.6 87 16.1 60 11.1
Age (yr)
0-19 (n = 343) 15 4.4 216 63.0 53 15.5 59 17.2 < .001
20-59(n=149) 19 12.8 105 70.5 24 16.1 1 0.7
60+ (n = 47) 10 21.3 27 57.4 10 21.3 0 0.0
Gender
Male (n = 296) 28 9.5 176 59.5 57 19.3 35 11.8 < .05
Female (n = 243) 16 6.6 172 70.8 30 12.3 25 10.3

*Chi-square test.

20 Archives of Environmental Health

 Table 7.-Perceptions and Activities of Subjects ( N = 539) in Response to Haze, by Age

Age group (yr)

Total 0-1 9 20-59 60+
Perception/activity n YO n YO n YO n YO P

Worry about future

Yes 443 82.2 290 84.5 130 87.2 23 48.9 < .001
No 96 17.8 53 15.5 19 12.8 24 51.1
Want to evacuate
Yes 233 43.2 216 63.0 86 57.7 4 8.5 < ,001
No 306 56.8 127 37.0 63 42.3 43 91.5
Use mask outside
Never 337 62.5 235 68.5 81 54.4 21 44.7 < .001
Sometimes 72 13.4 18 5.2 36 24.2 18 38.3
Often 68 12.6 54 15.7 10 6.7 4 8.5
Always 62 11.5 36 10.5 22 14.8 4 8.5

Epidemiological studies of health effects caused by from biomass burning is quite different from that of fos-
Downloaded by [New York University] at 12:08 11 October 2014

vegetation fires or biomass burning are limited. An
increase in emergency room visits of asthmatic patients
was shown in the reports of an urban warehouse firelo
and the 1987 bush fireg in California. But, in studies of
the 1991 urban wildfire in California” and the 1994
Sydney bush fires,12 little or no increase in asthma
emergency room visits was evident. Several studies
have addressed occupational exposure of forest and
wildland fire fighters, and they have reported relatively
mild and reversible respiratory health effects.13-15Such
public health impacts of smoke might be determined by
exposure patterns (i.e., exposure time and concentra-
tions of air pollutants), demographic characteristics,
and susceptibility of the affected population group,
diagnostic fashions, emergency room practices, etc.
Compared with fire events in previous studies, the 1997
haze disaster in Indonesia affected more individuals at
higher concentrations of particulates for a longer peri-
od, thus producing a greater public health impact.
In typical urban air pollution from fossil fuel com-
bustion, PMto,or much-finer PM2.5, is reportedly asso-
ciated significantly with several indicators of acute
health effects (e.g., mortality,16,17 hospital admis-
s i o n ~ , ~emergency
,’~ visit^,'^,^^ physical/functional limi- ards. Such masks filter almost 100% of particles of less
tation,2’ symptom manifestations,22lung f ~ n c t i o n ~ ~ , ~ ~than
In addition, several studies indicated that PMlo or PM2.5
was associated significantly with overall and disease-
specific mortality.’ 2,1 3t25-27 Several reviews of these
studies suggest that a 1O-pg/m3 change in PMlo is asso-
ciated with a 1.0-1.6%, 3.4%, and 1.4% change in
~ v e r a l l , respiratory,
~ ~ , ~ ~ and cardiovascular mortality,26
respectively. If we apply the formula of urban air pollu-
tion presented by the World Health Organization,28
excess deaths resulting from the increase in PMlo are
estimated at about 15,000 in the haze-affected area of
Indonesia. Nevertheless, only 527 deaths were reported
from affected province^.^ This reported number might
be underestimated as a result of possible misclassifica-
tion and miscoding of haze-related cases, incomplete
documentation, and reporting. Nevertheless, the vast
disparity implies that the health effect of PMlo arising
sil-fuel combustion. One reason is that the chemistry of
respirable particles might be different between 2 types
of haze. Another reason is that the complexity and vari-
ability of the mixture of air pollution-the interaction
and intercorrelation for which might be important in
producing adverse health effects-must vary. The tech-
nical feasibility and scientific validity of isolating the
effect of single pollutants in such complex mixtures and
analyzing the interaction and intercorrelation of pollu-
tants require further research and careful consideration.
In our study, the result of multivariate analysis might
support a hypothesis that the frequent use of masks con-
tributes to a reduction in severity of respiratory prob-
lems during haze episodes. In Indonesia, we observed
that many affected people wore simple surgical masks
or simply covered their mouth with a handkerchief or
thin cloths. However, surgical and other simple masks
may not be useful in preventing inhalation of fine parti-
cles because they cannot filter particles of less than 10
pm-the main pollutant of the haze. Therefore, these
devices may give a false sense of security to the users.
Respirators are special masks designed for the protec-
tion of workers exposed to occupational health haz-
) . 0.2 pm or more than 0.4 pm and 80% to 99% of
particles between 0.2 pm and 0.4 pm. They are, how-
ever, uncomfortable, and they increase the effort of
breathing, thus making them less than suitable for indi-
viduals with severe cardiopulmonary symptoms. More-
over, the efficiency of filtration can last only for 8 hr;
therefore, it may not be feasible to sell or distribute
enough respirators to protect all those affected for sev-
eral months, especially in developing countries, even
though these respirators cost only 2 or 3 U.S. dollars.
Staying indoors i s generally recommended in haze
episodes. This action reduces exposure to particulate
air pol lution,26and evidence shows that indoor partic-
ulate concentrations are one-half the outside particulate
concentration^.^^,^^ However, in our study we could not
find any such difference in the indoor and outdoor con-
centrations of fine particulates. Perhaps the size of par-

January/February 2002 [Vol. 57 (No. 1)] 21

 ticulates was so small as to travel and intrude into any
space; the concentration of pollutants was extremely
high, and the indoor environments of buildings in
Indonesia were rarely exempt from these pollutants.
However, staying indoors might play a meaningful role
in avoiding physical activities, thus preventing an
excess load on one’s cardiorespiratory system and an
excess inhalation of pollutants.
There is little evidence about long-term health effects
of biomass-generated air pollution. Investigators need
to evaluate the development of chronic respiratory dis-
eases and incidence of lung cancer, as well as the long-
term change of overall and disease-specific mortality.
* * * * * * * * * *
We wish to thank Yutaka lnaba and Momoko Chiba for their tech-
nical assistance, and Hirofumi Nitta, Hidekazu Matsueda, Kazuo
Nomiyama, and Susumu Wakai for their analysis and interpretation of
the results. We also appreciate the cooperation of the central and
local governments of Indonesia, the Environmental Management
Downloaded by [New York University] at 12:08 11 October 2014
Center, the Embassy of Japan, and the Japan International Coopera-
tion Agency Office in Indonesia.
Osamu Kunii was the principal investigator, contributor to, and
implementor of the study design. Dr. Kunii helped with data analyses
and wrote the draft manuscript. Shuzo Kanagawa also contributed to
the study design, its implementation, and the writing of the manu-
script. lwao Yajima, Yoshiharu Kisamatsu, and Takashi Amagai con-
tributed to the study design, its implementation, and air pollution
analysis. Sombo Yamamura and Ir. T. Sachrul Ismail contributed to the
study design, supervised its implementation, and the analyses of the
data. All investigators contributed to the interpretation and the editing
of the final version of the manuscript.
Submitted for publication April 17, 2000; revised; accepted for
publication December 8, 2000.
Requests for reprints should be sent to Osamu Kunii, M.D., M.P.H.,
Ph.D.; Department of International Community Health, Graduate
School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-
ku, Tokyo, 113-0033, Japan.
* * * * * * * * *
References
1. Crutzen PI, Andreae MO. Biomass burning in the tropics: impact
on atmospheric chemistry and biological cycles. Science 1990;
250:1669-78.
2. Levine IS, Cofer WR, Cahoon Dr, et al. Biomass burning: a driver
for global change. Environ Sci Techno1 1995; 29:120A-25A.
3. Kaufman YJ, Fraser RS. Confirmation of smoke particles’ effects
on clouds and climate. Science 1997; 277:1636-39.
4. Penner JE, Dickenson RE, O’Neill CA. Effects of aerosol from bio-
mass burning on the global radiation budget. Science 1992;
256:1432-34.
5. Hobbs PV, Reid IS, Kotchenruther RA, et al. Direct radiative forc-
ing by smoke from biomass burning. Science 1997; 275:
1776-78.
6. Andreae MO. Biomass burning: its history, use, and distribution
and its impact on environmental quality and global climate. In:
Levine JS (Ed). Global Biomass Burning: Atmospheric, Climatic,
and Biospheric Implications. Cambridge, MA: MIT Press, 1991;
pp 3-21.
22
7. Ministry of Health Indonesia. Haze disaster and health impact in
Indonesia. Proceedings of the Bioregional Workshop on the
Health Impacts of Haze-Related Air Pollution (June 1-4, 1998).
Kuala Lumpur, Malaysia: 1998.
8. SPSS, Inc. SPSS 7.5 for Windows: User’s Guide. Chicago, IL:
SPSS, Inc., 1997.
9. Duclos P, Sanderson LM, Lipserr M. The 1987 forest fire disaster
in California: assessment of emergency room visits. Arch Environ
Health 1990; 45:53-58.
10. Lipsett M, Waller K, Shusterman D, et al. The respiratory health
impact of a large urban fire. Am J Public Health 1994; 84:
434-38.
11. Schusterman D, Kaplan JZ, Canabarro C. Immediate health
effects of an urban wildfire. West J Med 1993; 158:133-38.
12. Smith MA, jalaludin B, Byles JE, et al. Asthma presentations to
emergency departments in western Sydney during the January
1994 bushfire. Int J Epidemiol 1996; 25:1227-36.
13. Rothman N, Ford DP, Baser ME, et al. Pulmonary function and
respiratory symptoms in wildland fire fighters. J Occup Med
1991; 333163-67.
14. Betchley C, Koenig JQ, van Belle G, et al. Pulmonary function
and respiratory symptoms in forest fire fighters. Am J Ind Med
1997; 31 :503-09.
15. Liu D, Tager IB, Balmes JR, et al. The effect of smoke inhalation
on lung function and airways responsiveness in wildland fire
fighters. Am Rev Respir Dis 1992; 146:1469-73.
16. Wordley J, Walters S, Ayres JG. Short-term variations in hospital
admissions and mortality and particulate air pollution. Occup
Environ Med 1997; 54:108-16.
17. Thurston GD. A critical review of PMlo mortality time-series stud-
ies. J Expos Anal Environ Epidemiol 1996; 6:3-21.
18. Pope CA 111. Respiratory hospital admissions associated with
PMlo pollution in Utah, Salt Lake, and Cache valleys. Arch Env-
iron Health 1991; 46:90-97.
19. Goldsmith JR, Griffith HL, Detels R, et al. Emergency room
admissions, meteorologic variables, and air pollutants: a path
analysis. Am J Epidemiol 1983; 118:759-79.
20. Samet JM, Bishop Y, Speizer FE, et al. The relationship between
air pollution and emergency room visits in an industrial commu-
nity. J Air Pollut Control Assoc 1981; 31 :236-40.
21. Ostro BD. Air pollution and morbidity revisited: a specification
test. J Environ Econ Management 1987; 14:87-98.
22. Ostro BD, Lipsett MI, Wiener MB, et al. Asthmatic responses to
airborne acid aerosols. Am J Public Health 1991; 81 :694-702.
23. Ackermann-Liebrich U, Leuenberger P, Schwartz J, et al. Lung
function and long-term exposure to air pollutants in Switzerland.
Study on air pollution and lung diseases in adults (SAPALDIA)
team. Am J Respir Crit Care Med 1997; 155:122-29.
24. Scarlett IF, Abbott KJ, Peacock JL, et al. Acute effects of summer
air pollution on respiratory function in primary school children
in southern England. Thorax 1996; 51 :1109-14.
25. Saldiva PH, Pope CA 111, Schwartz J,et al. Air pollution and mor-
tality in elderly people: a time-series study in Sao Paulo, Brazil.
Arch Environ Health 1995; 50:159-63.
26. Dockery DW, Pope AC 111, Xu X, et al. An association between
air pollution and mortality in six U.S. cities. New Engl J Med
1993; 329:1753-59.
27. Pope CA 111, Schwartz 1, Ransom MR. Daily mortality and PMlo
pollution in Utah Valley. Arch Environ Health 1992; 47:211-17.
28. World Health Organization (WHO). Health and environment
analysis for decisionmaking: a methodology for estimating air
pollution health effects. Geneva, Switzerland: WHO, 1995.
29. Li CS, Relationship of indoor/outdoor inhalable and respirable
particles in domestic environments. Sci Total Environ 1994;
151~205-11.
30. Lewis CW. Sources of air pollutants indoors: VOC and fine par-
ticulate species. J Expos Anal Epidemiol 1991; 1:31-44.
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