The Hazy Daze of Sarawak

I am under a haze this week, something more than the Lazy, Hazy, Crazy Days of Summer in the song of the same name. It is the annual Hazy Daze of South East Asia. The Air Pollution Index has reached hazardous levels not only in Sarawak but also in mainland Malaysia. There is talk of issuing masks to everyone in the University campus in Samarahan, just an hour from downtown Kuching. Concern about navigational safety is rife with visibility reported at 1 mile. Office workers in Kuala Lumpur report that it looks like a wall of solid grey cement outside the windows. Essential supplies in some remote areas are seriously depleted because aircraft have been unable to fly due to poor visibility.

Smoke haze has been a problem in Malaysia for more than ten years. The first thing to acknowledge is that health issues are almost always political. Take breast feeding. Most women in Malaysia breast feed for somewhere between a week and a month, only 29% continue for the recommended 6 months. The Malaysian Ministry of Health is right now considering action against 8 of the 12 powerful multinational companies selling infant formula who have transgressed ethical marketing guidelines at least three times. I don’t know about you, but I thought this had been sorted out years ago. Kudos to Malaysia for keeping tabs on the infant formula multinationals.

So if breast feeding, the original motherhood issue, is political, just imagine the action around air quality. For years, Malaysia has been experiencing smoke haze for several months between May and October. The haze is worse in Sarawak and the southern part of peninsular Malaysia. Malaysians seem to believe the haze arrives on southwesterly winds from Indonesian Borneo and Sumatra. Both legal and illegal logging has increased due to population pressures in Indonesia with much of the land clearing being done for agriculture using ‘slash and burn’ techniques. Satellite photography verifies there are more than 600 forest fires on the Indonesia side of Borneo this week compared to 40 on the Malaysian side, so there is some truth to the allegation.

But air pollution or haze, is also a result of increased burning of fossil fuels in vehicles, industries and power stations as well as emissions from millions of inefficient cookers burning wood and other biofuels. Malaysia has been one of the most rapidly industrialized and motorized countries on the planet. So it is pretty clear, that there are plenty of home grown contributions to air pollution. In fact, neither country is off the hook.

And just in case you were starting to think this has nothing to do with you and your world, UN scientists have documented that haze affects rainfall and farming putting hundreds of thousands of people in the region in jeopardy. And for those of you further afield, a pollution parcel such as the South East Asia haze which stretches three kilometers high, can travel half way around the globe in a week. It has become, in the words of the same UN scientists, a regional and global menace.

The government’s response at the top of the haze crisis in 1997 was to make the Air Pollution Index an official state secret. For the next eight years there was a ban on publishing the air pollution numbers. Politicians were worried the numbers would give a grim and distorted picture thus negatively affecting the tourism industry, the second largest foreign exchange earner in Malaysia.

The haze did not go away and the complaints did not go away, just the numbers. Last year, August 10, 2005, the government lifted the ban. This year we have the haze, the complaints and the numbers. I, for one, am glad that we now have the numbers. I believe we never really address difficult health problems until we have the numbers. Now I believe we have a fighting chance. I also think we need more numbers. We need to know about the relative contributions of vehicles, industry, logging and agricultural burning. We need to know how much of an improvement we can get from the various mitigations available to us.

The situation parallels the history of air pollution. For the longest time we knew that air pollutants, such as sulfur dioxide and particulate matter, caused ill health but what we lacked were the numbers. How many people get sick and how sick? It wasn’t known if there was a safe level or threshold for pollutants, or how much of which components caused the damage. It is only in the last twenty years that a body of well-documented studies have been able to substantiate scientifically, with numbers, the damage to health.

One of the most quoted reports about air pollution is that of the dense London Smog of 1952. The dramatic increase in airborne particulates that occurred during the Great Smog was tracked and it was noted that one day later there was an overall increase in daily deaths which didn’t return to pre-smog levels until the smog cleared. Somewhat later analysis showed that the 4000 'extra' deaths during the smog were chiefly cardiovascular and respiratory deaths and they were highest in the elderly.

The association was however somewhat less than complete evidence for a causal relationship. Polluters were still able to say that the London Smog is a worst case scenario and we are causing much less impact on air quality and may not even be causing ill health. Outside of the Clean Air Act which made a dramatic difference to Londoners, very little happened for more than 35 years.

There were a number of problems associated with making the causal link between air pollution and ill health. One problem was in determining which of the many pollutants are responsible for ill effects and at which level or concentration. Air pollution was and is a “soup” of many different pollutants. Another was the ethical concern about doing human studies which may expose people to potential dangers. What we were left with was observation of current situations, many of which were small company towns without the needed numbers of exposed people.

In the late 1980s, C. Arden Pope, a PhD in Agricultural Economics at Brigham Young University, who up until that time had only done agricultural studies, noticed that when a mill was on strike there were 2/3 less children with respiratory conditions in a Utah town. I am not sure how, but he teamed up with DW Dockery, an environmental epidemiologist at Harvard. I imagine him thinking, “Professor from Harvard, an environmental epidemiologist, just the ticket.” On the other hand, maybe it all started because they were old friends having a poolside drink in small town Utah, sputtering in the blue air and exclaimed, "Got to be possible to show this is bad for our health”. Or maybe, having all his data in hand, Pope went to Dockery for help in documenting a possible association lurking somewhere in the numbers. However it came about, it was an inspired partnerships, for there were many detractors ready to pounce on the first and subsequent studies.

More papers followed. The science improved. Better testing was devised. We learned that PM10 – particles the size of 10 microns, the ones everyone had been measuring, weren’t the problem. It was the smaller particles of 2.5 microns that did the respiratory damage. So we switched from monitoring PM10 to monitoring PM2.5. Guidelines were altered. Once we had the numbers, despite their limitations, we started to move ahead much more quickly with control and prevention activities.

I am hoping that now we have the numbers to talk about, to improve and to augment, that we can begin to move ahead with control and prevention of air pollution in South East Asia. If I had my druthers I would set up a number of medical research grants specifically to address air pollution, respiratory and cardiovascular health in Malaysia. This effort is going to need the mobilization of the whole population, individually and collectively. The more numbers there are to convince them, the easier it will be.

I also can’t help but notice that these breakthroughs in medical science, such as Pope made in air quality, seem to be done by people working outside their usual professional boundaries. In this case, even outside of medicine. Medical science is so much based on methodical, incremental improvements that that is all many medical researchers do. Careers are built on it. Physicians as a result, think along traditional lines and often seem hampered in taking the creative leaps needed when a brick wall looms. This feels like a topic for a further blog.