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Tobacco control vs social justice
Publication Date : 19-09-2012
In Indonesia, many people have no access to potable water, adequate sanitation, food supplies or healthcare services. In fact, according to the Health Ministry, only 41.6 per cent of urban dwellers and 48.8 per cent of rural dwellers currently have safe drinking water, despite government intervention measures.
About 13 per cent of the population lives below the poverty line and 49 per cent lives on a daily income of less than US$2. The main cause of mortality in this country is communicable diseases with, for example, approximately 250 people dying each day of tuberculosis.
While smoking prevalence rates among males increased from 46.4 per cent in 1980 to 54.5 per cent in 2001, the Indonesian government has stubbornly refused to ratify the Framework Convention on Tobacco Control (FCTC), due primarily to a lack of local evidence on the harmful effects of smoking.
Unlike countries that have enforced the FCTC, Indonesia is faced with wide socioeconomic gaps that remain a huge challenge among its more than 237 million people. These disparities exist not only between the rich and the poor, but also between urban and rural areas and between regions.
While large corporations display increased profits, due in no small measure to globalisation, which saw Indonesia's gross domestic product (GDP) per capita propelled to a high of $2,914 in 2010, many remain unaware that Indonesia's wealthiest citizens represent less than one hundredth of 1 per cent of the population and yet they share between them a total wealth equal to 25 per cent of the country's GDP (Winters, 2011).
In the early 1990s, Indonesia's middle class was estimated to account for only 7 – 10 per cent of the population. Despite some increases, this figure probably remains low, mainly on account of the Asian financial crisis in 1997 and the current global recession.
The social inequality in the country is also reflected in its demographic indicators. In particular, Indonesia is struggling to bring down its maternal mortality rate, currently the highest among Asian countries, with 228 deaths per 100,000 live births.
Indonesia has the lowest doctor ratio compared to its neighbours, i.e. an average of 13 doctors per 100,000 of the population, with some provinces having as few as six doctors per 100,000 of the population in 2008. Health workers are not evenly distributed across the archipelago, as most prefer to work in urban areas.
Therefore, the provision of medical services alone in an effort to reduce health inequalities has been inadequate. Indeed, researchers are increasingly reaching the conclusion that, in relation to certain health problems in developing countries, traditional and unqualified practitioners should be recognised as an important resource and perhaps even as "the main providers of care".
While this means that there is a need to be more aware of the realities of health care-seeking behavior in Indonesia, it implies that one needs to be more sensitive to the fate of the less privileged.
Unfortunately, such sensitivity seems to be lacking. Although there is growing perception of social injustice among Indonesia's population, there is, paradoxically, also some weariness of it. This was neatly reflected by two recent events.
First, Indonesia's impoverished are due to benefit soon from nationwide health insurance under the 2004 Law on a National Social Security System (SJSN), but the implementation of the Social Security Providers (BPJS) Law, which is the SJSN's prerequisite, is still being debated, causing concern that the law may not be operational by 2014. Meanwhile, the fate of the poor hangs in the balance.
Second, there have been renewed efforts to push for the ratification of the FCTC-based Tobacco Control Bill. However, the initiative met with strong resistance, particularly from tobacco farmers.
Indonesia's long-standing tobacco dilemma was thus reignited, placing farmers’ welfare and fiscal benefits on one side and health concerns on the other. While the proposed bill may bear some health benefits, many choose to ignore that the impoverished are not among those who will gain the most from such a bill, despite the fact that they are the most affected by smoking-related health risks.
Viewers had a field day when a debate about the draft law was aired on national television. The debate revealed awkward arguments put forth by the anti-smoking camp, while exposing the rather primitive demeanour of the pro-smoking camp. Most agree there was no winner at the debate's conclusion.
The tobacco companies' role in the farmers' protests was obvious, but more interesting was the anti-smoking campaigners' claim that the Tobacco Control Bill would not affect the tobacco farmers’ income, based on the argument that prohibiting tobacco imports would safeguard their livelihoods.
While the import-ban initiative entails a distinct set of lobbying efforts with many uncertainties and no guarantee of success, the claim runs counter to the World Health Organisation's recognition of the FCTC’s negative consequences on tobacco farmers.
Few seem to realise that the familiarisation of any proposed bill needs to take into account the socioeconomic context in which it is being debated. It seems odd that the anti-smoking campaigners appear to think that such a process occurs in a vacuum.
Arguably, they have failed to grasp the extent of the wide social inequality in this country, considering that Indonesia's socioeconomic gaps remain largely underestimated in statistical surveys, as exemplified by the National Socio-Economic Surveys, which only cover 35 percent of household expenditures, leaving out non-food expenditures common in wealthier urban households (von Luebke, 2011).
At the end of the day, how urgent is the need to pass the Tobacco Control Bill? Many would argue that it is imperative and the bill must be endorsed before the implementation of the SJSN Law. But many more would say there are more crucial things to do, such as ensuring that the poor get safe drinking water as well as adequate sanitation and food supplies, while access to health care services is anticipated.
Perhaps it is high time to stop prioritising the interests of the small, more privileged elite at the expense of the large majority of underprivileged people. Perhaps also, anti-smoking campaigners should start recognising that health initiatives need to begin with real efforts to reduce social inequalities, by paying more attention to local contexts.
The writer is programme director at the Kapeta Foundation and a PhD candidate in sociology at the University of South Africa.