The Center for Public Integrity

Heidi Vittetoe knows a thing or two about raising healthy animals. In 31 years, she’s sent more than 6 million pigs to slaughter from her Washington County, Iowa, farm.

To ward off possible illnesses, Vittetoe routinely injects weaning piglets with virginiamycin, a prescription-grade antibiotic. For nearly the rest of their lives, she adds 10 grams of other antibiotics to every ton of the herd’s food and water supply to prevent diseases and promote growth – something that should make her “golden in the eyes of the consumer,” she said in an interview.

“The animals we raise are the animals we eat,” Vittetoe said. “We have nothing to gain by having unsafe food but everything to gain by having food that consumers will accept, and antibiotics are a tool in achieving that.”

But preventive health measures don’t guarantee safe food, according to environmental health scientist Ellen Silbergeld, who told News21 that thousands of ranchers like Vittetoe have “squandered the use of antibiotics” by feeding and injecting healthy cows, pigs, chickens and turkeys with the same drugs used to cure human infections.

The result is bacteria that can no longer be killed by antibiotics and are still present in animals when they go to slaughter, said Silbergeld, a professor at the Johns Hopkins Bloomberg School of Public Health. The bacteria end up in consumer meat products sold at grocery stores across the country.

The journal Clinical Infectious Diseases reported this year that nearly half of all beef, pork, chicken and turkey purchased from 26 retail stores in Chicago, Washington, D.C., Fort Lauderdale, Fla., Los Angeles and Flagstaff, Ariz., contained drug-resistant bacteria. While thorough cooking may kill even resistant pathogens, Silbergeld said the risk of infection from cross-contamination is too high when handling raw meat and poultry.

“Antibiotic resistance is an immediate health risk,” she said. “This is the thing that will kill you.”

On Monday, December 27, 2010, Noor Atika Hasanah, a petite 28-year-old secretary in Jakarta, updated her Twitter feed. From her bed at the Jakarta Respiratory Centre clinic, she wrote: “To smoking parents, please do smoke as far as possible from your children … so that they won’t get lung cancer.”

Atika’s own lung problem had her down again, recalled her brother Faisal Rizal. Her parents had checked her into a clinic. Later, Atika wrote that she was still waiting for a transfer to a bigger hospital.

On Thursday at 5:35am, the move happened and Atika notified her Facebook friends: “Noor just checked in @PROF. DR. SULIANTI SAROSO hospital.” A friend wrote back, “Please don’t stay too long …. Get well soon sis!”

Noor Atika Hasanah passed away later that day.

Five months after Noor Atika Hasanah’s death, Rizal said Atika Hasanah’s passing was “because of God’s will. The cigarette smoke is only the pelengkap penderita.” He used a Bahasa Indonesia grammatical term which means “direct object.”

Atika’s chronicling of her illness offered friends and family an unusual glimpse at the consequences of runaway tobacco consumption in Indonesia, yet her death to tobacco-related disease is not unusual in one of the world’s last holdouts against signing the World Health Organization's treaty to limit the tobacco industry’s influence by restricting tobacco advertising and raising excise taxes.

With a population of around 240 million and weak government regulations, Indonesia is one of Big Tobacco’s smoking giants. As of 2009, 28 percent of Indonesian adults were smokers and more than half of men smoke, according to the World Lung Foundation.

Around 200,000 people die each year in Indonesia because of smoking-related sickness. At least 25,000 of the dead are like Atika — young, female and passive smokers, according to the WHO.

Close to the Ganges River, which flows through India’s holy city of Varanasi in the northern state of Uttar Pradesh, Janaki Devi is a textbook example of poor, working women who turn the wheels of one of India's most important industries.

Every morning she bathes in the river Hindus consider their holiest landmark. This is as restful as it gets for Devi; it’s just before she starts a grueling, eight-hour routine of filling reddish brown tendu leaves with 2 grams of tobacco flakes, then tying them with thread. Completing a bidi every 25 seconds, each day she must roll at least 1,000. For this, she earns $1 a day.

"I work without a break. I need the money to sustain my family,” says Devi, eyes focused on a large cane tray on her lap where she works. She earns $25 a month. That wage is low, even in India, where more than half of the population lives on an average of less than $2 a day.

Devi is among the roughly six million women who roll bidis in India; their arduous profession is the second-largest labor-intensive occupation in the world’s second-largest tobacco market – a country where a quarter of the population is said to be addicted to various forms of tobacco. Women constitute almost 75 percent of the total bidi workforce, which yields between 750 billion to 1.2 trillion sticks every year.

The bidi, which resembles a small marijuana cigarette, poses a big health risk for smokers and rollers. It contains more nicotine and tar than conventional cigarettes.

But the industry rides on a wave of significant political clout fueled by revenue of up to $20 billion annually, according to conservative estimates. In fact, in the global struggle to check tobacco consumption – the world’s leading preventable cause of death – India has been a losing proposition for public health advocates because of the bidi industry’s political influence and marketing muscle.

Low-income children relying on Medicaid or other government-funded health care have much more trouble finding a new doctor than children with private insurance, according to a Government Accountability Office report.

That difficulty is amplified when it comes to specialty care, particularly mental health, dermatology and neurology.

More than three-quarters of 932 doctors surveyed by the GAO reported having difficulty referring children with public insurance for specialty care, citing an overall shortage of specialists, and, in some cases, different waiting lists for children receiving Medicaid or Children’s Health Insurance Program (CHIP) benefits than children with private insurance.

In 2010, more than 40 million children in the country received health care through one of the two government programs. That care cost $79 billion in federal and state funds in 2009, the most recent year for which information is available.

The report estimated that 22 percent of all doctors don’t participate in Medicaid or CHIP.

Among participating doctors surveyed, only half accepted all children in Medicaid or CHIP as new patients, while 80 percent of those doctors accepted all children with private insurance. Nearly 10 percent of those doctors didn’t accept any new child patients on Medicaid or CHIP, citing low reimbursement rates and billing hassles as the two biggest reasons for not participating.

Doctors in rural areas were more likely to accept new patients with Medicaid and CHIP than doctors in urban areas, according to the survey, but rural primary care doctors experienced more difficulty referring their Medicaid and CHIP patients to specialists than their urban counterparts.

Once enrolled, children with Medicaid and CHIP were treated roughly the same by doctor’s offices as children with private insurance, with comparable wait times.

In post-Soviet Russia, the right connections can mean success in business. And in the country’s lucrative retail tobacco trade, Igor Kesaev has set a new standard for success.

Kesaev runs the multifaceted Mercury Group, with interests in everything from weapons manufacturing to real estate. Now he’s also Russia’s cigarette king, with an unprecedented 70-percent share of the distribution business, selling the popular brands of some of the world’s largest tobacco companies, Philip Morris International, Imperial Tobacco and Japan Tobacco International.

Last fall Russian Prime Minister Vladimir Putin outlined a new policy for reducing smoking: tobacco advertising will be totally prohibited in 2012; there will be no smoking inside some public buildings and on public transportation; and by 2015, excise taxes can go up 10 times the current levels. This, the government has said, helps Russia comply with the World Health Organization’s international treaty on tobacco control. But ties Kesaev has forged with key government agencies, through strategic charitable contributions, have Russian anti-tobacco activists and government transparency advocates skeptical that they can win meaningful smoking reforms and curb government spending on tobacco-related death and disease.

Dmitry Yanin, head of the Confederation of Consumer Associations, which promotes tobacco-control policy, said the relationships between cigarette distributors like Kesaev and Russia’s security services weaken tobacco reform efforts in Russia.

The country today “is profitable for tobacco business — distributors, producers — but not for reducing the number of smokers,” Yanin said.