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

Osamu Kuniiab; Shuzo Kanagawaa; Iwao Yajimac; Yoshiharu Hisamatsud; Sombo Yamamurae; Takashi Amagaif; Ir Sachrul Ismaila 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 Online publication date: 05 April 2010 To cite this Article Kunii, Osamu , Kanagawa, Shuzo , Yajima, Iwao , Hisamatsu, Yoshiharu , Yamamura, Sombo , Amagai,

Takashi and Ismail, Ir Sachrul(2002) 'The 1997 Haze Disaster in Indonesia: Its Air Quality and Health Effects', Archives of Environmental Health: An International Journal, 57: 1, 16 22 To link to this Article: DOI: 10.1080/00039890209602912 URL: http://dx.doi.org/10.1080/00039890209602912

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The 1997 Haze Disaster in Indonesia: Its Air Quality and Health Effects
OSAMU KUNll SHUZO KANAGAWA Department of International Community Health Graduate School of Medicine The University of Tokyo Tokyo, Japan and International Medical Center of Japan Tokyo, Japan IWAO YAJIMA Environmental Management Center Bapedal, Indonesia YOSHl HARU HISAMATSU Department of Community Environment Sciences National Institute of Public Health Tokyo, Japan SOMBO YAMAMURA Department of Protection of the Human Environment World Health Organization Geneva, Switzerland TAKASHI AMAGAI Institute for Environmental Sciences University of Shizuoka Shizuoka, Japan IR T SACHRUL ISMAIL . Department of International Community Health Graduate School of Medicine The University of Tokyo Tokyo, Japan and Environmental Management Center Bapedal, Indonesia

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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 dioxide, 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 individuals. 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 Pollution 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 respiratory symptoms, and elderly individuals suffered a serious deterioration of overall health. In multivariate analysis, the authors determined that gender, history of asthma, and frequency 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 significant source of trace gases and aerosol particulates. It ultimately affects atmospheric chemistry and cloud properties, and the global radiation budget is also profoundly affected by this pra~tice.-~ Consequently, cli16

mate dictates4t5that the bulk of the worlds 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 natural fires triggered by atmospheric lightning6 Among nations that have dense, tropical forests,
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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 conditions 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., airbus 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 1,446,120 cases of acute respiratory infection reported. In South Sumatra, the number of acute respiratory infection 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 community-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 communitys 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. During 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 protective, we measured particulates inside and outside 3 types of buildings in Jambi. The size distribution of particulates 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 conjunctivitis 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 Students 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 worsened following exposure to haze. In this model, we used a 4-point scale to present the severity of respiratory problem(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 problems, 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

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Air pollution. The concentration of particulates 0.3 5.0 pm in size gradually increased as one moved closer 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 it was approximately 8 times higher than the maximum level of PMlo in the 1987 forest fire disaster in California, which consumed more than 2.4 million ha.9 CO also exhibited a high concentration at the very 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

of 3 buildings in Jambi. The indoor/outdoor particle concentrations were 428,978 particles/m3 and 435,719 particles/m3, respectively, of a farmers 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 conditioned). However, outdoor concentrations of the coarse particles (i.e., 5.0 pm) were considerably higher than indoor concentrations. The indoor and outdoor concentrations were 209 and 226, respectively, for the farmers 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 particulates, the concentration of S042-(i.e., 37.98 pg/m3)was 5-1 0 times higher than concentrations in Tokyo, whereas CI- (4.98 pg/m3)and NO3-(5.3 pg/m3)concentrations

n
25
20

300 200

+ 03-50Urn

i
t--*
Jambi

15
_______

10 5

p=Eq

100

0
Jambi Grisik Prabumulih Tanjungkarang Palambang Martapura Jakarta

Fig. 2. Carbon monoxide (CO) and carbon dioxide (COz) concentrations 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
0.01 0.02 0.03 20 1,635

C
0.01 0.004 0.06 20 1,864

PSI
18

SO2 (ppm) NO2 (ppm) 0, (ppm) CO (ppm) PMlo (pg/m3)

0.01 0.01 0.03 20 1,684

54 247 1,584

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.

Notes: SO2 = sulfur dioxide, NO2 = nitrogen dioxide, 0 = , oxides, CO = carbon monoxide, and PMlo = particulate matter 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 indicates moderate air quality, 101-200 represents unhealthful air, 201-300 indicates very unhealthy air, and a value > 300 indicates hazardous air.

18

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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 symptoms, 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 life. Among those with respiratory problems, 31.1 YOexhibited fever, 46.6% were short of breath when they walked, 34.1 Yo experienced chest discomfort, 18.5% experienced depression, and 28.8% experienced appetite loss. In Table 4 are shown preexisting illnesses and severity of health problems. The chi-square test revealed that those with a past history of asthma and heart problems presented the most severe health problems. The group of individuals 60+ yr of age had a higher proportion of persons who perceived that their health condition was
Table 2.-Concentrations (vg/m3) of Polycyclic Aromatic Hydrocarbons (PAHs) in Particulates
Molecular weight

much worse; among females, there was a slightly higher proportion who perceived that their health condition worsened (Table 5). Physical examination revealed the presence of conjunctivitis 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 pattern (FEVl.o [FEVl,dFVCl < 80%); and both patterns were found in 68.2%, 38.6%, and 22.7%, respectively, 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 production 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 breathlessness when they worked hard had a signifi-

* *

Table 3.4ncidence and Severity of Reported Symptoms that Developed after Exposure to Haze
Severity of symptom Moderate Severe
n

Mild Symptom Respiratory problems* Eye irritation Headache Fatigue Short of breath when walking Short of breath with hard work Chest discomfort Fever Appetite loss Sleeplessness Nausea Palpitations Abdominal pain Depression Dizziness Diarrhea At least 1 symptom cited abovet
n

Yo
91.3 78.9 61.5 61.5

Yo
8.9 3.4 4.2 2.4 3.2 6.3 3.7 2.5 2.8 5.8 16 . 0.0

492 425 331 280

231 276 199 206

47.0 217 64.9 135 60.0 119 73.6 67

4. 41 31.7 35.8 24.0

44 1 4 1 4 7
8

239 44.4 155 64.7 77 32.1

PAHs Fluoranthene Pyrene Triphenylene Benz(a)anthracene Chrysene Perylene Benzo(e)pyrene Benzo(b)fluoranthene Benzo(k)fluoranthene Benzo(a)pyrene Indeno(l,2,3-c,dpyrene Benzo(g,h,r)perylene Dibenz(a,c)anthracene Dibenz(a,h)anthracene Benzo(b)chrysene Coronene Dibenzo(a,e)pyrene Characteristic Particle (pg/m3) Air volume (m) Collected amount of particles (gm) Sampling time (hr)

Jambi

Jakarta

16.7 21.1 20.2 16.8 41.7 2.60 14.7 1. 51 6.45 15.3 11.1 12.8 0.428 0.823 1.66 0.914 3 15 .
Jambi

0.255 0.396 0 41 .1 0.438 09 0 .1 0.219 1.22 1.62 0.793 1.05 2.24 1.78 01 . 58 01 . 20 01 . 64 0 12 . 1 -

202.3 202.3 228.3 228.3 228.3 252.3 252.3 252.3 252.3 252.3 276.3 276.3 278.4 278.4 278.4 300.4 302.24
Jakarta

192 35.7 1 9 56.8 7 36.9 12 0 1 175 11 6 151 129 126 121 32.5 29.8 18.0 23.9 23.3 22.5 19 0 107 108 84 11 0 62.5 66.7 71.3 65.0 80.3 88 72.4 59 4 9 39 38 23 33 33.8 30.8 25.9 29.2 1. 81 27.6 6 4 4 7 2 0

121 22.4 89 73.6 28 23.1 4 3.3 95 17.7 55 57.6 32 33.7 8 8.7 22 4 1 . 0 0 0 17 77.3 5 22.7 . 16 3.0 11 68.8 4 25.0 1 6.2

532 98.7 200 37.6 262 49.2 70 13.1

1,707 565

167 1,995 0.3338 23.8

0.9646 5.2

Included cough, sneezing, runny nose, sputum production, and sore throat. tlndividuals who developed 1 or more symptoms or had a symptom that worsened. If an individual had at least 1 severe symptom, it was classified as severe. lf an individual had at least 1 moderate symptom, but had an absence of a severe symptom, it was classified as moderate. If only mild symptoms were present, they were classified as mild.

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cantly ( p = .042) lower FEVl.o (62.9 f 36.7%) than individuals with mild breathlessness (91.8 A 19.6%); individuals 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 significantly ( 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 respiratory 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. O f 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). Those who were 60+ yr of age worried less about their

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 concentration produced an extremely high incidence of respiratory problems; approximately 30% of the individuals 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 predisaster time, the generalizability of our findings and a cause-effect relationship between haze and health impact are questionable.
Table C.-Multiple Linear Regression Analysis of Severity of Respiratory Symptoms
Variable Gender History of asthma Frequency of using mask (Constant) Multiple R B* 0.312 -0.219 0.754 -0.049 1.602

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Table 4.-Preexisting Illnesses and Severity of Health Problems in 532 Subjects

Severity of illness Mild Moderate - Severe Illness Asthma
(-)

Rt
-0.143 0.258 -0.095

P .001 ,000 .023

n*

YO

YO

YO

pt

493 197 40.0 243 49.3 39 3 7.7 19 48.7

53 10.8

< .001
(+)

17 43.6 63 12.2

Heart (-) problem

(+)

518 199 38.4 256 49.4 14 1 7.1 6 42.9

< .001
7 50.0

*Respondents who developed at least 1 symptom or who had a symptom that worsened. tChi-square test.

Notes: Dependent variable is the severity of respiratory problem (0 = none, 1 = mild, 2 = moderate, and 3 = severe). Independent variables and values of the study included are as follows: gender-1 = male, 0 =female; history of allergy, asthma, bronchitis, and heart disease-1 = yes, 0 = no; and frequency of using mask when remaining outside-1 = never, 2 = sometimes, 3 = often, and 4 = always. *Unstandardized regression coefficients. tstandardized regression coefficients.

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

Health condition Extremely worse Age and gender Total no. of subjects ( N = 539) Age (yr) 0-19 (n = 343) 20-59(n=149) 60+ (n = 47) Gender Male (n = 296) Female (n = 243) *Chi-square test.
n

Worse
n
YO

Unchanged
n

YO
8.2 4.4 12.8 21.3 9.5 6.6

Yo

Better %

P*

44

348 216 105 27 176 172

64.6 63.0 70.5 57.4 59.5 70.8

87 53 24 10 57 30

16.1 15.5 16.1 21.3 19.3 12.3

60 59 1 0 35 25

11.1 17.2 0.7 0.0 11.8 10.3

15 19 10 28 16

< .001

< .05

20

Archives of Environmental Health

Table 7.-Perceptions

and Activities of Subjects ( N = 539) in Response to Haze, by Age

Age group (yr) 20-59
YO

Total Perception/activity Worry about future Yes No Want to evacuate Yes

n

0-1 9

60+
n

YO
82.2 17.8 43.2 56.8 62.5 13.4 12.6 11.5

YO
87.2 12.8 57.7 42.3 54.4 24.2 6.7 14.8

YO
48.9 51.1 8.5 91.5 44.7 38.3 8.5 8.5

443 96 233 306 337 72 68 62

290 53 216 127 235 18 54 36

84.5 15.5 63.0 37.0 68.5 5.2 15.7 10.5

130 19 86 63 81 36 10 22

23 24 4 43 21 18 4 4

< .001

< ,001
< .001

No
Use mask outside Never Sometimes Often Always

Epidemiological studies of health effects caused by from biomass burning is quite different from that of fosvegetation fires or biomass burning are limited. An sil-fuel combustion. One reason is that the chemistry of increase in emergency room visits of asthmatic patients respirable particles might be different between 2 types was shown in the reports of an urban warehouse firelo of haze. Another reason is that the complexity and variand the 1987 bush fireg in California. But, in studies of ability of the mixture of air pollution-the interaction the 1991 urban wildfire in California and the 1994 and intercorrelation for which might be important in Sydney bush fires,12 little or no increase in asthma producing adverse health effects-must vary. The techemergency room visits was evident. Several studies nical feasibility and scientific validity of isolating the have addressed occupational exposure of forest and effect of single pollutants in such complex mixtures and wildland fire fighters, and they have reported relatively analyzing the interaction and intercorrelation of pollumild and reversible respiratory health effects.13-15Such tants require further research and careful consideration. public health impacts of smoke might be determined by In our study, the result of multivariate analysis might exposure patterns (i.e., exposure time and concentrasupport a hypothesis that the frequent use of masks contions of air pollutants), demographic characteristics, tributes to a reduction in severity of respiratory proband susceptibility of the affected population group, lems during haze episodes. In Indonesia, we observed diagnostic fashions, emergency room practices, etc. that many affected people wore simple surgical masks Compared with fire events in previous studies, the 1997 or simply covered their mouth with a handkerchief or haze disaster in Indonesia affected more individuals at thin cloths. However, surgical and other simple masks higher concentrations of particulates for a longer perimay not be useful in preventing inhalation of fine partiod, thus producing a greater public health impact. cles because they cannot filter particles of less than 10 In typical urban air pollution from fossil fuel compm-the main pollutant of the haze. Therefore, these bustion, PMto,or much-finer PM2.5, is reportedly assodevices may give a false sense of security to the users. ciated significantly with several indicators of acute Respirators are special masks designed for the protechealth effects (e.g., mortality,16,17 hospital admistion of workers exposed to occupational health hazs 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 ~ ~ , ~ ~ ) . 0.2 pm or more than 0.4 pm and 80% to 99% of than In addition, several studies indicated that PMlo or PM2.5 particles between 0.2 pm and 0.4 pm. They are, howwas associated significantly with overall and diseaseever, uncomfortable, and they increase the effort of specific mortality. 2,1 Several reviews of these breathing, thus making them less than suitable for indistudies suggest that a 1O-pg/m3 change in PMlo is assoviduals with severe cardiopulmonary symptoms. Moreciated with a 1.0-1.6%, 3.4%, and 1.4% change in over, the efficiency of filtration can last only for 8 hr; ~ v e r a l l , respiratory, and cardiovascular mortality,26 ~~,~~ therefore, it may not be feasible to sell or distribute respectively. If we apply the formula of urban air polluenough respirators to protect all those affected for sevtion presented by the World Health Organization,28 eral months, especially in developing countries, even excess deaths resulting from the increase in PMlo are though these respirators cost only 2 or 3 U.S. dollars. estimated at about 15,000 in the haze-affected area of Staying indoors i s generally recommended in haze Indonesia. Nevertheless, only 527 deaths were reported episodes. This action reduces exposure to particulate from affected province^.^ This reported number might air pol lution,26and evidence shows that indoor particbe underestimated as a result of possible misclassificaulate concentrations are one-half the outside particulate tion and miscoding of haze-related cases, incomplete concentration^.^^,^^ However, in our study we could not documentation, and reporting. Nevertheless, the vast find any such difference in the indoor and outdoor condisparity implies that the health effect of PMlo arising centrations of fine particulates. Perhaps the size of par3t25-27

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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 ones 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 diseases and incidence of lung cancer, as well as the longterm change of overall and disease-specific mortality.

* * * * * * * * * *
We wish to thank Yutaka lnaba and Momoko Chiba for their technical 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 Center, the Embassy of Japan, and the Japan International Cooperation 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 manuscript. lwao Yajima, Yoshiharu Kisamatsu, and Takashi Amagai contributed 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, Bunkyoku, Tokyo, 113-0033, Japan.

* * * * * * * * *
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