A MEDICO - GEOGRAPHICAL OVERVIEW OF SOUTHEAST ASIA RURAL RESIDENCE IN ms LANSING wczmm URBAN DECENTRALIZAT‘ION Thesis for the Degree of M. A. MICHIGAN STATE UNIVERSITY MELINDA MEADE 1970 IIIIIIIIIIIIIIIIIIIIIIIIIIII L, ’ LIBRARY L” ”AiChasgafl State University 5— amimc av ‘5' HMS & SUNS' WEEAWQWYJEQ A Medico - GeOgraphical Overview of Southeast Asia by ‘0’ Melinda‘tfieade Submitted to Dr. John H. Hunter in partial fulfillment of the requirements for a master's degree. J anuary, 1970 /" r’ i '/ ' ‘ .r' , . \ (- 3 xii L) 2 I, (I k (I 7- /(. I. CONTENTS Focus A. Perspective B. Structure ofWHedical GeOgraphy The Pattern of Southeast Asia Infectious Disease m Diseases A. Yaws B. Leprosy C. Smallpox D. Tetanus E. Tuberculosis Zggtgr2§gggg_Diseases A. Malaria B. Filariasis C. Plague and Typhus D. Arbovirus l. encephalitis 2. dengue-hemorrhagic E. Ra.bies Consumed Disease§ A. Cholera 5. Typhoid . Dysentery D. Liver Fluke: Opisthorchiasis 3. Cultural Barriers "J 'x) 11 11 1M 15 16 17 39 no no #1 u. 'VY J." IT ‘0 I'utnu 3531 A. Deficiem $0 :amc IV. Nutritional Disease #4 A. Deficiency “5 1. National Survey 45 2. Beriberi 55 3. XeroPhthalmia 56 u. Coronary condition 57 5. Allowances 58 B. Maternal and Infant Health 60 C. Involvement of Other Diseases 70 l. Intestinal Parasites: 7O Hookworm;Roundworm;whipworm 2. Influence of other diseases 76 V. Diseases of Other Causation 78 A. Cancer 73 B. Pollution 80 VI. Conclusion: Implications for the Future 81 VII. Research Directions and Applications 91 VIII. Bibliography of References 95 Focus The purpose of this paper is to review the factors and their in- terrelationships concerning the ecology of disease in Southeast Asia. The approach used is not comprehensive. but rather Openly selective of disease, nation, and literature. It is an attempt to render evident certain patterns of relationship between the physical, pathological, and cultural phenomena which are taken individually for study by other sciences of specialty. As such. this approach implies much about an orientation to and conception of'the nature of geOgraphy in general and of medical geography in particular which should first be made explicit. The revolutions in theory and stochastic technique which have occurred in geOgraphy recently have served to redirect attention to the search for universal relationships and generalities on a basis of more rigorous thinking and technique than predecessor schools enjoyed. It is through its concern with integration - whe- ther of many factors in one place or of one factor in many places - that geOgraphy has made its greatest contributions. The comments of a Schaefer and a Bunge were needed to point out to a geography 'generally immersed in large-scale studies of a particular nature that uniqueness is itself a matter of scale and generalization, so that one may see unique qualities in two falling stones and common - -alities in two continental regions. Geography has always been inter- ested in the integration of variables through the spatial correlation (if their patterns. When it has truly risen to attempt the challenge of integration. - as in the age of discoveries. or the confrontation with new landforms wan]. selection grout input on go wading sciences. such as climtolo. $0100 and also 0mm. and oduc concom with Yuri 0M! nde it an 1”Wins. In 0th. °f cmpiler. of 1 fl“ Pralinance o n11. flexing it or 300109 or so they 3°93! scarce “helping: the meant-1°“ haw -2- with new landforms in the American West. or the need to relate natural selection and human societies after Darwin - it has had great impact on general, popular knowledge as well as on the sur- rounding sciences. During such periods it has generated sciences such as climatology, oceanography, geodecy. meteorology, or geomor- phology and also contributed greatly to anthropolOgy, history, ec- onomics. and education. These were periods when the geographical concern with variation in the distribution of all manner 'of phen- omena made it an originator of knowledge and research direction and impetus. In other periods geOgraphy has played the role of supporter, of compiler, of "handmaiden" to history or other studies. Despite the prominence of locational theory, this is its present role; even while flexing its new techniques, it continues to draw from economics or geology or sociOIOgy more than it contributes to them, so that they seem scarcely aware of its existence. The situation,, however. is belying: the stochastic techniques and general theoretical re- orientation have attracted concern to consideration of systems analy- sis and ecology which provide powerful new integrating methodolOgies, at the very time when their parent sciences. using the techniques but lacking the geographical perspective, are facing crises of over- specialiaation and non-communication. It is as though application of analytical. scientific procedures to the ways of human society had so sub-divided the cloth that none can any longer even glimpse the overall fabric; and so there is a flurry of activity in interdis- ciplinary research and interdepartmental studies in an attempt to gain some means of communication and coordination in the face of a vital.need to return the pieces, better understood, to their orig- .inal.unity. In its concern for spatial variation across all areas of the earth, gec plethora of more is its dawning p. for relevancy vi of developing g9 Women: for th W "as the ho 0! our civilizat condjLtion of soc study anything 1 condemgd for m: mergency Proce: “Madge b9 1m Problems Creatg,‘ is its tmditim Medical €903: §SOgraphy as (391 of the earth. geography has the skills and orientation that the plethora of more defined and specialised sciences are seeking: such is its dawning potential. The exigencies of the social imperative for relevancy will continue to impact on the form and structure of developing geography. Whereas the study of earth‘s physical phenomena for their own sake had to give way to the study of the earth "as the home of man.” the day is approaching when the crisis of our civilization will demand every study to be relevant to the condition of society and approbrium may indeed fall on those who study anything for its own sake. While such a develOpment can be condemned for many sound reasons. it can also be taken as a simple emergency procedure produced under critical stress that all of man's knowledge be intensively and immediately applied to solving the problems created by man. Again, geography's strength and attraction is its tradition of application. Medical geography is not at all peripheral to the field of geography as described above: it is of geography's body. Despite its concern for interlocking cycles of develOpment and multivariate causality, the powerful techniques of probabilistic stochastic models and systems analysis have only started to diffuse into its practice, and so its Operative techniques remain largely descriptive or car- tographic. Even at that level it has an important role to play in the integration of data. In the words of Douglas Lee, writing in the First Report of the Commission on Medical GeOgraphy for the IInternational GeOgraphical Union in 1952 (p.11): One of the greatest weaknesses of our rapidly expanding scientific knowledge is the inadequacy of integrative con- We r 3.131. f IW'C ‘C' N. "Y’J cept....The wholt lectutl parts. i: when between p their content... long and thoroug felt essecietior ductions. and 3: Ship. One train: sciences may 10. infiltration of mm. that th abuse has occu: 39° gnPhY has 1 aWool-ates and a “N Prevalent 1r Elevations. Olin: in Men; times teur diverted a] till recent Yea Prudent, On an e attention 0“ ti hash“ Wpuh‘ to Nah“ the in different F the Place, inc -h- cept....The whole is greater than the sum of its intel- lectual parts, if only because consideration of inter- action between parts must be added to consideration of their content....The mind. steeped in the evidence by long and thorough examination of its details, makes felt associations rather than logically defensible de- ductions, and sets up tentative expression of relation- ship. One trained in the rigorous logic of the basic sciences may look askance at this process. fearing the infiltration of mysticism. It can not be denied. of course, that there are opportunities for abuse or that abuse has occurred: but that is true of any tool. GeOgraphy has been involved with medicine since the days of Hippocrates and Galen and their observations that certain diseases were prevalent in certain locations under influences of various elevations. climates. and races. The potential of such an approach in modern times was never realized because the discoveries of Pas- teur diverted all attention to the micro-organisms. and it remained till recent years to realize that the pathOgens themselves are de- pendent on an environments Medicine had concentrated its specialized attention on the nature of the parasitic organisms. and it took the massive papulation movements and Western involvement in other areas to realize that the same pathologic agent produced different results in different places. Measles was a harmless children's disease in one place, and a killer ‘in another: the same amount of vitamin A produced normalcy in one place. xerOphthalmia in another. and kerato- malacia in a third; the same techniques of residual spraying wiped malaria out in one place and had no effect in another: the incidence of yaws varied mysteriously between villages less than a mile apart: with no apparent change in contact, disease endemic in an area became rampantly epidemic. Medicine has been forced to widen its perspective to include the effect of cultural practices and environments differing in climate, tapography, accessibility. and the blood composition of . its peoplOS- Such the increa8°d ““9 iacy and Vitality probleusw-E' the Parts 'Of the wt: to the “WWW health hazards W centers; and “*9 populations for < the most cmcial tonon-Hestem . new kinds of 500 its obvious c he problems 01‘ ical techno.’Log;.r Mection and d s‘GOgraphy in th the Wally its peOples. Such an Opening toward the comparative approach invites the increased attention of geography. The whole is given new immed- iacy and vitality by the on-going nature and development of medical problems.e.g. the rapid urbanization of peasant societies in many parts tof the world. the extension of Western medicine from the cities to the up-country fastnesses of tradition: the new deve10pment of health hazards by man's techn010gy. especially in industrialyurban centers; and the implications of today's jet contact and mobile pOpulations for disease potential. Problems of communications are the most crucial of all, as the greatest contrast of Western medicine to nonAWestenn is one of prevention to cure. prevention requiring new kinds of social organization, control, and public c00peration. The obvious challenge to geOgraphy is to apply its techniques to the problems of pollution, of migration, of diffusion of the new med- ical technology, and to understanding of the existing patterns of infection and deficiency. Participation will inevitably involve geography in those questions which it has tried to ignore concerning the dynamically mutual relationship between mankind and its environ- ment. the extent to which man is in fact determined.circumscribed. and influenced by that environment and by his own historically cum- ulative effect on that environment. The issue of the influence of health on the course of civilizations has been Opened to speculation and legitimate study by the discoveries of the permanent damage to physical and mental growth caused by protein deficiency and the un- doubted role of nutrition and disease in general in influencing the M... ./ ..._ .a ., .-...v..,...,we a. .. . . 8.9:: m .. .1 aza .u. x. . . ..., ,. ._ 5.4:... . i 000 000 on; miaom . w» l on». .. o I II. . 5- / cog. <_m< pmqupaom . teas“ . z‘za—v 2.3. .I .\:.\\. . faimoj a» «zmam \ .\ .' “L20: .. . N ‘0. .‘i a A (32.! a. - m .m , m a s u n “K . WHY/nan} ‘ .o \X ‘ / \ \ O a, _ . rfi \ \ Inouoddy o THE PATTERN OF SOUTHEAST ASIA Southeast Asia in this paper consists of Burma, Thailand, Malaysia, Cambodia, Laos, North and South Vietnam, Indonesia, and the Philip- pines. Most of the literature considered concerns Thailand, Malaysia and Indonesia, and to some extent Vietnam. This area was not even recognized as a region until after World War 11, and perhaps its out- standing regional characteristic remains its variety. Of the four above, Thailand, Malaysia and Indonesia were once subject to Indic influences; Vietnam to Chinese. Thailand is Theravada Buddhist, Malaysia is Moslem, Indonesia is Moslem with enclaves of Hinduism, Vietnam is Confucianist or Mahayana Buddhist. Thailand remained independent during the colonial era, Malaysia was subject to the British, Indonesia to the Dutch, Vietnam to the French. Across all these countries in varying degrees is added the vast numbers of alien Chinese immigrants superimposed by the needs of colonial econ- omies. Major language families include Tibeto-Burman, Thai, Malayo- Polynesian, and other Sino varieties. The countries differ consid- erably in the degree of central control, partly according to their minority problems: Burma wars with her Chins, Kachins, Karens and Shans, Indonesia is practically and empire onto itself, Malaysia suffers from the Malay-Chinese schism, and Thailand today with the Philippines enjoys relative homogeneity. Productivity, standard of living and pressure on the land also vary considerably. Densities vary from 140 inhabitants per cultivated acre in Laos to 585 in Java or 370 in the Philippines. The Gross National Product per capita 0f the Philippines and Thailand, at $lh0 and $110 respectively, are among the highest in Asia, but their annual increase in pOpulation is over jfi per annum. -10- Patterns nevertheless manage to reach across all of these divisions. The valleys and plains of Southeast ASia are filled with paddy and worked with water buffalo. In most of the countries the cycle of life turns on the wet-and-dry monsoon climate, with its dependent practi- ces of fish harvest, seasonal feasting, barriers to communication, and storage problems. Houses are on stilts and utilize the adaptable bamboo. With the possible exception of Vietnam and the Philippines, the influence of Indie culture is reflected in art, amsic, dancing , language and phllOSOphy. In its capacity as a land bridge for migrat- ing peoples, the very location has tended to impose a similitude of history. Despite the variety, certain problems and cultural practices are common to the area and, as described hereafter, have a definite impact on the ecology of health and disease. 5.3.3.02 I cohmomdwamwlwo B x2e: I 8:35.38 13325090244: *0 mommd EOE ...... www2_IU 2 OOJOZIPM «3.63. 83.218: Boa .uow.faom .o .e_._.( uu¢30m 3.309 ooo.ooo.on _ wqdum . _ ‘ k - men . con 53 3. . l 0 .wwwwww; o 0853 p n O 80.83 03 3. mm>o. 0N70N m :6 ‘32.. $23.54;; 3 - o I $230F m..:2 wmdaom mud 9.24.2922. 20:443aom “.0 >h_mzwo b 0:30.56 is 0.060.; 03 can 0 III. INFECTIOUS DISEASES The trOpics have long been considered unhealthy, and it is primar- ily the infectious diseases that peOple were considering. Besides being subject to most of the diseases of temperate regions, such as smallpox and tuberculosis, many diseases seem to especially thrive or exist only in the hot, humid climate which characterizes most of Southeast Asia. One of the most important factors affecting the in- cidence of disease is the year-round prepagation of vectors and agents which are often adapted to a dry period and never know freezing. It is also commonly recognized that the high density of pOpulation in good agricultural land is a factor. Less often recognized is the role that cultural practices and attitudes play in the disease ecol- ogy. gigggt_Diseases include those which man contracts through direct contact with the agent, whatever be its means of entrance into the body. This section is highly selective of diseases, omitting for lack of literature, importance or interest such diseases as scarlet fever, influenza, measles, whooping cough, and mycosal diseases, an mong many others. Although most diseases in this group are transmit- ed from human host to human host, many other infections may be inclndp ed here. Helminthic infections such as hookworm, for instance, would be classified here but are considered later under the heading of nu- trition. A. Spirochetes: Yaws and Syphilis Yaws is endemic in every country of Southeast Asia. Data gathered on the prevalence of yaws for UNESCO after World War 11 indicated L‘KH‘ £1311 -219395'5‘!‘ that 15,1 of th 111de over Yaw: flourish: rainfall of 0 fails to esta “‘0 We: 1 mains wstif; have greatly hue, involv W99. and vs dePings 1: lhrough its unable to f P0273}. Th °ld 31%. son, Mb! 81°“ “leer; u“ “11 (. scratching °f the di 3| Dietary -12- that 15% of the Indonesian p0pulation was infected; and in parts of Thailand over #0% had had the disease(Jungalwalla,WHO Symposium,1952). Yaws flourishes around the mean isotherm of 80degrees Fahrenheit and rainfall of over fifty inches. When exported beyond the trepics, it fails to establish itselfCHill,WHO Symposium,p.l7). Altitude within the tropics is therefore significant. The pattern of the disease re- mains mystifying, as frequently two villages less than a mile apart have greatly different incidence. The key variable seems to be mois- ture, involving both the humidity and the effect of drainage, soil type, and vegetation upon the soil.moisture. Hill discounts the sore- droppings idea and considers the geologic formation to be important through its influence on drainage; SaetOpe and Wasito, however, were unable to find any relation to geologic formation (WHO Symposium,l952. p.273). The greatest infectiousness is in the six-to-twelve year old group, and infection increases consistantly during the rainy sea- son. Chambers thinks the source of infection, apart from plantar le- sion ulceration, is the re-exacerbation due to the saggy condition of the soil (quoted in WHO Symposium, 1952,p.150). Brush and frequent scratching or injury are also believed to be important in contraction of the disease. Dietary connections are not apparent, since the admittedly higher rate among undernourished people also reflects the general condition of living. Sanitary conditions are usually low, but that, too, is not the only factor of causation because yaws is a rural disease, rarely found in urban areas regardless of sanitary conditions. Cultural practices influential in the disease probably include the wearing of footwear and more clothing in urban areas. Control has history has be tion cure with b? intonation communicable c Eradication p' "51011 will al "111 fit the dugmds, t] of apprmm. cillin. In noted that t by an intiide highly ends: and ”*0 Pm: 1“ 315113110. ($31180 of c of “nit-am The Greg -13- Control has long been a problem. The greatest breakthrough in yaws history has been the fulfillment of Ehrlich's dream of a single-injec- tion cure with the deveIOpment of penicillin and the massive attack by international cOOperation to apply a new concept: a control of a communicable disease by mass treatment (WHO Symposium,l952.p.l.). Eradication pregrams sponsored largely by UNICEF have attempted designs which will allow of later fusion into local health services and also will fit the local budget. The plan included surveys of prevalence, diagnosis, treatment, resurveys, training and demonstration, and a cost of approximately $2.35 per person treated, half of which was for peni- cillin. In 1961 during a survey of child health in Thailand, Stahlie noted that the effectiveness of the antiqyaws campaign was illustrated by an incidence of only two cases out of l3lh children in a previously highly endemic area. The encouraging results in Thailand, Malaysia and the Philippines Open up the prospect of totally eradicating yaws in Southeast Asia. Much of the effectiveness of the program lies in its simplicity: no return visits or self-dosage of medicine and no change of custom is required of patients - not even a basic knowledge of sanitation or disease communication. The cross-immunity of syphillis and long-term yaws is noteworthy. Lower temperatures alter the characteristics of the disease until it resembles syphillis. In the Philippines, Hill traced yaws up the mountains and found that ulceration gradually withdrew from exposed areas and sought warmth and moisture in the mucocutaneous junctions of the mouth, anus, and genitalia (WHO Symposium, 1952.p.20). Given the similarity of the microbes, their response to penicillin, their clinical manifestation, their cross-immunity, and the alteration of ysws with temperature decrease, there is a fair case for speculation concerning a common origin, separate development and reintroduction .I M‘fl arfiu“ of syphilis : a serious pr 10,? of pregn reported to 129,000 occu 8,000 in m 0f the papu] Porting. tho 01' VldBSprm The imam e. stigma to t' control of Mains an B. Leprosy Lepmsy the first d ities, Ever. Centers “l l as“ by 15 the only cc m5 @389: I -11.}... of syphilis into the tropics. Be that as it may, syphilis is certainly a serious problem now. Few studies are available, but Robinson found 10% of pregnant women in Rangoon positive for syphilis (1936). Cases reported to the World Health Organization include in 1961 or 1962 129,000 occurrences in Burma,21,000 in Cambodia, almost 9,000 in Laos, 8,000 in Thailand, and over 2,000 in Vietnam. Wilcocks estimated 15% of the papulation of Java to be infected (l944,c). Given under-re- porting, there is general evidence of widespread incidence, but also of widespread treatment for the nervous system is rarely involved. The known efficacy of penicillin treatment and the lack of any social stigma to the disease in Southeast Asia probably explains the effective control of the disease's development despite high infectivity: it remains an important cause of infant death. B. Leprosy Leprosy occurs in all countries of Southeast Asia and was one of the first diseases to draw the attention of European medical author- ities. Even in uncolonized Thailand missionary groups had built five centers with beds for a thousand and had identified 20,000 to 50,000 cases by 1937. Although lepers still.number in the tens of thousands, the only country where they are a serious problem is Burma. There the cases are not only numerous, but seem to be in a more acute form, possibly due to less resistance (Wilcocks,l9##,a). The highest rate is in the Arakan Hills and the Shan States, where over 5% of the popu- lation may be infected, while probably slightly under lfl of the total papulation is infected. A W.H.0. project raised the numbers .of re- ported,registered leprous cases from 4600 in 1952 to 77,815 in 1961 and lhh,670 in 1964, about 20% of the cases being lepromatous: com- plete coverage of the endemic area is expected to register about 250,000 -15- patients (Chronicles,vol.21,l967). The differential infectivity of lepromatous and tuberculoid cases there produces a respective morbid- ity rate of 7.8% and 0.7; (w.H.o. Technical Report #71). While cultural factors are undoubtedly important to the prepagation of leprosy, the yet mysterious nature of the disease defies their def- inition. It is the consensus of Opinion that the disease requires long and continuous contact to be infective, and that the children are not congenitally infected but may have lower resistance. There is a lep- rosarium at Chiengmai, Thailand, on the eastern margin of the mountains which form Burma's most endemic area. Lepers there are cared for in the advanced facilities of the Presbyterian.Mission while across the road from them are housing and schools for the children and non-leprous spous- es. Sundays are Open visiting days for all, thus avoiding both prolonged contact and the aversion of patients to residence for fear of estrang- ing their children. In personal communications, doctors have reported leprosy in northern Thailand to be under control, although the lepro- sariums remain filled to capacity, and the doctors have been turning most ~of their attention to advanced treatment and physical as well as socio-economic rehabilitation. Treatment of ambulatory patients through oral drugs and mobile teams has also proved effective. C. Smallpox In 1966, over 75% of the 65,000 cases of smallpox remaining in.the world were reported from Southeast Asia. Although there are more cases known today, it is hard to evaluate the trend because to a large measure the increase in cases reflects improvements in the reporting and surb veillance system. The chief endemic areas remaining are Afghanistan, India, Indonesia, and Nepal. Although Indonesia is the only country of direct concern here, it should be noted that the effort in India has been truly massive, involving over 500 million vaccinations from 1960 to 1966. In Thailand the fliseass has been eradicated, in former Indochina it remains a promisir dared by 1 nesia rou‘ route res peak of i krava rtk the war 1 lowered - epidemic reached People 1 is now 1 1966. It 1 11331101 Men -16- it remains very low, and in Burma it has been much reduced. That is a promising develOpment, for former attempts at eradication were hin- dered by reinfection along the India-Assam-Burma-ThailandéMalaya-Indo- nesia route. In Kedah, northwest Malaya, reinfection in 1946 from that route resulted in almost 300 deaths and 600 notified cases, the double peak of infection age indicating a neglect of infant vaccination (Dha- krava rthy, 1958). According to Gispen, compulsory vaccination before the war had effectively prevented epidemics, but during the war the lowered protection and surveillance led to reinfection (1949). The epidemic of Kedah reached Sumatra through Singapore in 1947 and reached Batavia in 1949. Emergency innoculations of over a million peOple failed to control the epidemic. As mentioned above, Indonesia is now considered endemic for smallpox, with 10,113 notified cases in 1966. It is generally agreed that eradication is feasible. Along with financial and administrative problems go problems of maintenance and surveilance in areas of loose governmental control. There is also the difficult problem of obtaining vaccine of adequate potency, especially since the intense sunlight and heat and humidity cause the potency to be lost very quickly, so that extensive field programs are occasion- ally rendered useless because of impotent vaccine. D. Tetanus Although tetanus is fairly common among the predominantly farming papulation subject to frequent injuries, it is included here because of the importance of the infant form. Although cause of death is nowhere certified directly by doctors and general categories are inappropriate, age-of-death data can be used to approximate tetanus -17- causality of death, especially if followed by description of the death depicting clear clinical cases. In Thailand, a study by Stahlie found a peak on the eighth day following an earlier decline and accounted for solely by rural areas (1960). Using descriptions of death also, he ascribed the peak to tetanus and concluded that 38% of neonatal deaths definitely and 13% very possibly were due to tetanus. In her studies in Bang Chan, Thailand Hauck found 35% of deaths under eleven months to be due to tetanus (Hauck,l952,a). De Reus in Indonesia in the period 1956-1961 found 102 cases of neonatorum tetanus admitted to three estate hospitals, with 155 cases of all other types of tetanus. In both Thailand and Indonesia, and presumably in the rest of Southeast Asia, the high incidence of neonatoral tetanus is ascribed to the un- sanitary practice of midwives who universally cut the umbilical cord with a piece of sharpened bamboo, using for the counterpressure a clod of earth. De Reus sees the only h0pe for Indonesian conditions in prior immunization of the mother. UNESCO, however, is sponsoring widespread courses to train indigenous and practicing midwives in sanitary procedure. 3. Tuberculosis Tuberculosis is by far the most serious disease discussed in this section. In Malaya, it causes more deaths than any other single disease, the death rate being estimated at 115/1oo,ooo. Sodhy estimated that 6-7% of deaths are due to tuberculosis (Sodhy,1954). In Burma, tuber- culosis is more serious than leprosy, incidence being especially high in Rangoon. In Thailand before the Japanese invasion, it probably accounted for over 10,000 deaths a year and at that time already accounted for 10,5% of hospital deaths there (Wilcocks,1944,d). Remembering that infection is not synonymous with disease, sensitivity tests showed -18.. 70% of adults on Java positive for tuberculosis. After the war, when tuberculosis was an incidental finding in patients dying of oedema, dysentery and malaria, tuberculosis was found in 89% of post mortem examinations (Straub, 1949). In a study of Chinese school children in Djakarta after the war, 57% of the 4-9 year olds, 79% of the 10-14 year olds, and 92% of those over 14 reacted positively to the Mantoux test and X-ray examinations, reaffirming De Haas' 1933 statement that almost all Chinese in Djakarta have a tuberculosis infection before they reach adult age (Gan,1953). Although information on morbidity is scarce, the disease obviously reaches immense prOportions. It is striking that in Thailand, Malaysia and Indonesia the Chinese are constantly described as having by far the highest incidence. Tuberculosis thrives, of course, in an urban environment of frequent contact, and the Chinese are the most urbanized peeple; nevertheless, even within urban pOpulations they seem more commonly stricken. In discussing the incidence among the three major races of'Malaysia, Malp ard describes the Malays as having low resistance, due primarily to inferior diet, but also having low infectivity due to a more rural and isolated existence - a condition frequently disastrous for those who move to the city(1950). The Indians. working primarily on roads and rubber estates, he describes as being better off in dietary protec- tion but worse in infective contacts. The Chinese in turn are described as being relatively resistant but living under conditions of high incidence. He and Sodhy ascribe the condition to the Chinese shep- houses (I954). These structures, which typify the Chinese sections of all Asian cities, are usually two stories with a narrow street frontage on the Open shOp but extending back from the street scores of yards in a linear progression of use. .‘e‘; ‘ ”LI...“- . ‘ ‘ gr)una . IN“ {MI 0 0 0 0 O C: Meghaui- so, 5 f‘P‘C— 1" i “ ‘ udder fl 1' Hm I I 1‘ '- 3 Vin} I I - "A :06 Ht 081N303! a -19.. Author's Sketch of Chinese COffeeshOp, Satuk, Thailand ground floor I Hc.‘ SI." , Poop/15M l ‘ Lfifl F E LSwme .‘_ 0 o 0 O SfOL-k‘ .l d C) tuau \I L D . ' h- : 1. E refuge-mm “d" wer can 79.. . " lm¢gM'/‘- s op upper floor lc/ I l Scale ." 1 U . (a, Jew '_t 1 I Wanow win/0|) IL l 5+0?!- T 1‘ ITL£1 I'wu”_ The upper residential floor must follow the same pattern, each bedroom accommodating either an honored couple or a whole family. There is little penetration of sunlight or circulation of air in the long interior rooms, but there is high room density and conditions of severe overcrowding in the major cities. The housing situation throughout the area is critical, and the situation can only be exac- erbated as new groups of peeple continue to pour into the cities. Tuberculosis in much of Southeast Asia is of an especially acute nature that has raised considerable controversy. Gussenhoven, Ob- serving that the conditions in 1949 were ten times more serious than in Western countries, was one of many who ascribed the virulence to recent introduction and lack of immunity. He found that Open tubercu- losis developed in an average space of little over a year. Statis- tically significant variables included responsibility of employment, income as calculated per member of family, education, number of chil- dren, age, place of residence, and subjective feeling of illness (1952). EWISQE Van Joost introduced, a. reports in In to murals and As early as t] 3011' or "anc: and Van Prug were free of ‘ in Asiatics. or death in D; Sitsen and H91 °f °ld 01' new °f Indonesia . been noted for It Seems 11 ag° by the Hi“ accounting for pl" tod‘3'. ‘: van Joost denies vehemently that the disease has been recently introduced, and traces it back through early medical and military reports in Indonesia, generally discounted or even denied in EurOpe, to murals and sculptures of Hindu influence as far back as 750 A.D.(l961). As early as the turn of the century, the controversy over the "virgin soil” or "ancient origin“ themes, he claims, sprang up between Homer and Van Praag, who discussed whether the Chinese and Indonesian races were free of tuberculosis and whether it had a more rapid, lethal course in Asiatics. In 1912, when tuberculosis was the fourth commonest cause of death in Djakarta, the controversy was confirmed and continued by Sitsen and Heineman. Without data on infant mortality rates, the issue of old or new is difficult to resolve. Differences among the races Of Indonesia - especially the high infectivity of the AmbOinesee has been noted for a century. It seems likely that the disease was, indeed, introduced centuries ago by the Hindus and had a differential spread among the islands, accounting for the differences in resistance among the Indonesian peo- ples today. Not only has the urbanization and collective plantation living increased contact, but the severe overpOpulation has seriously lowered resistance. Oppers in a study on Timor found 10% of the pOpu- lation to suffer manifest lung tuberculosis and 61% primaryzphthisis (1952). He computed the infection rate for the general pOpulation at a neardy'mathematical 2% per year and 200% in infected families. In comparison, the morbidity rate indicates that the rule is to contract the disease at a single exposure. He explains the discongruency between the possibility of infection and actual morbidity by the poor protein consumption. -2}. Treatment thus far has been rather unsuccessful for a complex of reasons. Amouroux excused the poor results of his hospital in Vietnam, which cured h% of its tuberculosis patients, because the patients re- fused to undergo and persevere with treatment (1952). It was not an empty excuse. Victims know of few peeple who have been cured, and the treatment has been prolonged, difficult, and in isolation from their families. In countries where the folk culture has not yet ac- cepted the concept of contagion, where families are close and important both socially and economically, it is not surprising that few victims want to desert their families and die alone in an unsuccessful sani- tarium. Remembering that, given the poor nutritional state in Indonesia and elsewhere, a single exposure probably means contraction of the di- sease, it would seem important to expand hospital beds for tuberculosis and push for isolation of contagious people. Malard, while suggesting isolation camps for 'good chronics," also stresses that governments must provide for care of dependents of the patients, or they will not be c00perative (1950). Ultimately, successful attack on the disease depends on uplifting housing conditions, sanitation and nutrition. For the present, governments are relying on massive BCG vaccination campaigns to provide increased resistance, if not immunity, and attempt to break the accelerating spiral of infectivity. Burma and Thailand have pushed hardest in that line with a million and a half vaccinations each between 1960-1964; although Malaysia at that time, with 155,000 vaccinations was not yet committed to the efficacy of the campaign, BCG vaccination has since become routine with smallpox at all maternal and child health clinics. lggtggrggggg_Diseases include those which are arthr0pod-borne, or communicated to man by insect vectors through organic (rather than mechanical) means. PathOgens so transmitted include amoeba, bacteria, helminths, and virus. The intermediary host which brings the disease to man is usually an insect, but if the role of vector control in disease prevention is considered, the transmission by mammals of rabies to man must also be here classified. A. Malaria Malaria must head any list of vector-borne diseases. Although it kills only 1% directly, it is a chronic, invalid-producing di- sease which saps vitality and lowers the resistance of its victims to other diseases. Besides the costs of treatment, the incapacita- tion of productive workers brings additional costs in loss of wages and crops. ”It is a scourge of humanity, stunting physical and mental develOpment, restricting social growth, and blighting agricultural develoPment," (Pampana and Russell, 1955). At the end of World War 11, it was the most common disease in the world. The drive against malaria must rank as one of the greatest ac- complishments of the World Health Organization. Historical.methods of malaria control include drainage, drugs, larvicides, and adulti- cides. The development of residual spraying techniques with DDT was an historic breakthrough in cheap adulticide control. The cost of control was for the first time feasible, running 20-50¢ per capi- ta per'year - less than the cost of quinine and other treatment (Wilhar,l951). Demonstration began in 1949, in hyperendemic areas of Thailand and soon Burma, Indonesia, and the Middle East. The results in Ceylon are well known, and those in Thailand were almost -23- as impressive. In Chiengmai, Thailand the infant parasite rate drap- ped from 29.07» to 2.5% with one spraying, to 0.11% with two, and to 0.0% with three sprayings and the nearly total elimination of the vector species (Pampana, 1955). In South Asia as a whole, of the 703,247,000 inhabitants (1966), 38,495,000 were never malarioussdra- matically, of the 66h,752,000 originally malarious, 257,168,000 have had malaria eradicated, 237,151,000 are under consolidation prOgrams, 128,992,000 are under attack pragrams, 3,3h6,000 are under programs in preparation, and only 38,205,000 have had no pregress or program against malaria (WHO Chronicle,l967,vol.21,no.9). Although highly successful in some areas, such as Thailand, the program has had little success in Indonesia and other places. There are a few cultural pat- terns that may interfere, such as the practice of leaving the sprayed village for temporary field shelters near harvest time; more important cultural interference would be found in problems of control, super- vision and maintenance after the danger ceases to be apparent. For the most part, however, the relative success or failure of the pragram depends on the ecology of the local vector. The vector, of course, is AnOpheles, but there are as known species of AnOpheles in Malaya, and 98 species in Indonesia alone, each one having its own breeding and feeding habits. Anopheles ngporiensis, A. candidiensig, A. maculatus, and A. sinensis breed in still water in the sun and are responsible for transmitting low-grade malaria in the flat, rice-growing deltas of former Indochina, Thailand, and Bur- ma. Some natural control is exerted by the heavy silt loads of the rivers and the tidal flushings which are both inimical to breeding. In the clear running streams of’the foothills breeds A, minimus gigip mug, and especially in Indonesia and the Philippines, A, minimus flay virostus, both extremely anthrOpophilic and responsible for the most serious malaria. In Thailand, the mountain streams of the north and south suit In the Phi has been h and the 51 From the S chiefly re A third hr home of A, -2u- south suit A, minimus and promote the high endemicity of those areas. In the Philippines, malaria is mainly a disease of the foothills and has been held partly responsible for the isolation of the hill areas and the slow cultural and economic prOgress there (Deutschman, 1945). From the Shan States of Burma to the hills of Annam, A, minimus is chiefly responsible for the yet-wild state of the extensive foothills. A third breeding area is the brackish coastal swamps which are the home of A, sundaicus, which is fortunately strongly attracted to ani- mals. The affect of this distribution upon malaria can be seen in Viet- nam, where the Red River delta and Saigon usually have benign tertiary. malaria; the highlands of Cochin China and the hills of Annam and Ton- king have subtertian malaria; and backwater fever is especially common in the mountains of Annam and Tonking (Wilcocks,l9h4,b). An additional variant is climate, with continual transmission - and eventual.immun- ity - in some areas, and seasonal transmission with repeated loss of immunity and seizure in others. These differences make it difficult, among other things, for labor to move from one ecological zone to ano - ther. Perhaps a more long-run difficulty is that caused the malarial eradication campaigns. A, flaviristus is in the Philippines and Indo- nesia, and it does not roost on walls after gorgin and so does not contact the spray; A, sundaicus, common to the coasts oflMaltysia and Indonesia and the Philippines, has changed its habits of roosting as an immune response (Pampana, 1958). Their occurrence in Indochina and the Philippines largely accounts for the relative failure of the malaria program there. The additional problem now is the increasing occurrence of the gene for DDT immunity. This is widespread now, not only in areas like the environs of Djakarta, which have been early -25- and frequently sprayed, but in areas like Bangkok where South East Asia Treaty Organization tests show immune strains even thoughthe area has never been subject to a DDT spraying pregram (Neely,l959). Since agent, vector and host must all be present for the disease to occur, if only the vector can be depressed long enough to break the cycle of transmission it is of less importance whether or not the vector eventually returns. The greatly varied ecology of vector in Southeast Asia, however, renders simultaneous eradication in the whole region impossible and endangers past accomplishments with constant reservoirs for re-infection. The danger of re-infection is acute because, the disease having shortly been suppressed, the entire pOp- ulation has lost its immunity and is at risk, dependent upon continued spraying. DDT by itself raises problems: the very residual prOperties which make it ideal for adulticide also endanger the health of the human pepulation. The danger is hypothesized after personal observa- tion of a town in Thailand after a team had Sprayed everything with DDT, including food and beds as well as walls and furniture, leaving a white coating on everything contacted by human skin. The entire population of the town had a headache for three days, and individuals persisted nearly a month. It is a moot question how much DDT is in the tissues of sprayed pOpulations. The impact has been dramatic and, in some areas, almost totally successful. Given stubborn areas, DDT immunity, and population over-exposure, new techniques must now be developed. Although incomparable to the low-cost mass-attack of re- sidual spraying, mass prOphylactic drugs might be a logical succession in attack methods. In time, the agent will probably adjust to such drugs. The success, failure and future of the malarial control pro- jects serve to emphasize the dynamic relationship between man and his environment and to stress the limitations of technolOgy. -26- B. Filariasis Filariasis occurs throughout Southeast Asia. In Ddakarta, where the vector is Qulgx,guingufosciatus, incidence is 23%; in Sumatra blood samples were 39.3% positive for Hugheria gglgzi, in some vil- lages over 20% of adults having visible elephantiasis (Rees,l959). ElsGWhere the disease seems to be less serious. In Thailand, endemic filariasis is restricted to the flat, low-lying rural areas of the eastern coastal belt, where, however, the incidence of microfilariae was 29% (Iyengar, 1963). The causative agent in Thailand is Suchegia gglgzi, transmitted by nine species of mosquito (four'Mansoni and five AnOpheles). HOpe for control of this disease also rests currently on residual spraying programs. C. Plague and Typhus Bubonic plague remains endemic in Southeast Asia, but it is no longer serious in dimensions. It was imported into Rangoon in 1905 and diffused along transportation lines, probably carried in merchandise to become established at Meiktila, Pyanburi, and the North Shan states: Burma then served as a focus of infection for other countries for years (Wilcocks,l944,a). After'World War 11, there were over a thou- sand cases a year, but the incidence has been brought down to 68 in 1962. 3“ in 1963, and 11 in 196“ with a seasonal high from November to April. Thailand was infected in 1904 and has been cleared and reinfected several times since, although the disease has never been strongly established there. There have been epidemics, as in Korat in 1917- 1918 when 10% of the pepulation died, but except for a saall,contin- uing focus in Korat the country has been free of the disease since World War II. Centers of endemicity in former French Indochina are principally the Chinese cities and centers: Cholon in Cochin China, Phan-Thiet in Annam, Lang Bian on the plateau of South Vietnam, Phnom -27- Penh in Cambodia and also occurrences in Haiphong, Boc Ning, and Hongay (Wilcocks,1944,b:Pollitzer, 1954). As late as 1964 South Vietnam still reported 290 deaths, and in 1967 5574 cases. The most serious situation is in Indonesia. East Java was infected in 1911 and the disease spread westwards. During the 1920's over ten thousand deaths were reported yearly, with a peak of 23 thousand in 1931. After Otten's vaccine was introduced by the Dutch, there was a gradual decline (Pollitzer, 1954). While West Java is now free, Central Java remains a relatively high endemic focus. The ecology of plague is that of rats and fleas. Rats are so numerous in the rice lands, where they steal a significant portion of the harvests, that it is remarkable plague has not been more dan- gerous. Thailand, for instance , has never had a high incidence and Wilcocks ascribes this to the fact that the Thai rat, Rattug,norwegigus, has less contact with man that R. w m (Wilcocks', 1944,d)._ In Java the thatched native houses were infested with rats; the Dutch had some success with a major drive at house improvement - sealing bamboo and replacing thatched roofs - but also increased malaria by leaving depressions ideal for mosquito breeding (Wilcocks,l944,c). The disease seems in general to be well under control today and on the decrease, but still remaining in endemic foci with a potential for epidemic flareuup if control should break down. Typhus is considered in this section because it too is associated generally with fleas and lice. Actually, the louse-borne variety is not too serious, occurring mainly in crowded urban slums in very lim- ited numbers. A second type, borne by mites and called "scrub typhus,“ occurs in brush and grassland and has been mainly a problem for tr00p movements, although it remains a potential hazard to agricultural -28.. expansion. Recent studies of the habitat of the mite have differenti- ated a grassland-scrub preference, but at least one mite, Lgptotrom- bigum.diliensis, also exists in the forest where its presence supports speculation about a "jungle tsutsugamushi" (scrub fever) disease (Hu- bert, 1963; Gentry, 1963). Other disease might be considered here, such as leptospirosis which has been found to be surprisingly widespread, judging by antibodies, but to produce little clinically serious disease. Of more importance are the arthrOpod-borne viruses. D. Arbovirus The term "arthropod-borne" was introduced in 1942 to describe ence- phalitus which multiplied in the vector, undergoing an integral part of its life cycle development in the gut walls and salivary glands of the vector. The first arboviruses recOgnized were Yellow Fever and Sandfly fever, and then the general group of encephalitus, grad-~ ually denoted by place names. On an antigenetic basis the were divided into Group A and Group B viruses. Most are known to be mainp tained principally in a cycle with a vertebrate host other than man (W,H.O.,1967). Yellow Fever, for instance, persists all year round in monkey reservoirs in jungle areas, which seems to render total eradication impossible. This disease, remarkably, has never been reported from Southeast Asia, although the vector and monkey reser- voir and susceptible human pOpulation are all present. For the arbo- virus to survive in colder climates, a wintering mechanism is needed: these include mass migration of birds - as with Russian Spring-Summer Encephalitus and bird migration to Burma - or tick transmission, since they have been shown to transmit infection transovarially (W.H.0.,l967). Of 280 arbovirus known to produce human disease, as of I96? 131.have been recovers in this part itus (JE), I-IL' encephalitus This section Encegalitus When Hale Observed th: was an lining T5611 Pond am ing agent in eQ‘fi-nes, deg human reside; high Proport 100; accordi m1“ Wage during the J 1h“? among night °°cur Since the pod‘b0me v1 not brought been recovered from mosquitoes. Group B is the more important group in this part of the world, including the viruses of Japanese encephal- itus (JE), Murray Valley encephalitus (MVE), Russian Spring-Summer encephalitus (RSSE), Saint Louis encephalitus (SLE) and dengue fever. This section shall first consider encephalitus and then dengue fever. Encephalitus When Hale first reported Japanese B encephalitus in Malaya, he observed that there were no epidemics and concluded that his case was an unimportant accident of an animal-vector cycle (Hale, 1952). Then Pond and others observed and reported that JE was a common infect- ing agent in Malaya, with not only the majority of pigs, bovines, equines, dogs and goats having antibodies, but also 74% of lifelong human residents (Pond, 1954). In a later study Hale reported that a high pr0portion of Asian residents have antibodies - from 62.5% to 100% according to age groups - and that the sharp increase after age twelve suggests the possibility of an epidemic twelve years previously during the Japanese occupation; he concluded that the virus circulated freely among animals, and that increased incidence of human infection might occur again if mosquito control broke down (Hale, 1955). Since then, several surveys have been done of antibodies for armre- podéborne virus. Due to the mild nature of many infections, most are not brought to a doctor, and even fewer are reported, so that antibody presence remains the best measure of extent. Over 80% were positive for JE in Malaya, Thailand, and North Vietnam: RSSE virus was positive. in 10-15% in.Malaya. There are also reports of neutralizing agents against Ntaya (8%),Zika and Ilheus in the south but not north, and Uganda 8, Bunjamwera, Semliki Forest, West Nile, SLE, and others (Pond, 1963). The high incidence of plurally protective serum evinces obvious -30- endemicity. According to Pond, JE and RSSE occur in Southeast Asia, but Zika, Ilheus, Semliki Forest, Uganda S, and SLE do not and their antibodies are best explained by unknown antigenic interrelations, especially since they are frequently associated with JE. This supposition brings out the greatest difficulty in working with the arboviruses - the interrelationship and host-immunity which makes them difficult to identify and follow. anguggflemorrhagic Egggg ArthrOpod-borne virus hemorrhagic fever seems to be expanding every- where in several readily distinguishable entities. This section is concerned with the mosquito-borne hemorrhagic fevers of Southeast Asia, but at first they were confused with the other distant entities. West- ern medical literature first became acquainted with Hemorrhagic Fever during the war in Korea, when the United Nations tr00ps contracted a fever called by the Russians Hemorrhagic nephrosos-nephritis, and by the Japanese Epidemic Hemorrhagic Fever - the name which has come to predominate. The etiological agent has still.never been identified, with the Russians blaming a flea vector and the Japanese a mite and the Americans unable to find any agent or to establish the disease in an animal host (Gajdusek, 1962:Lim, 1954). The Russians advanced quick- ly and were instrumental in recOgnition of three broad groups of hemorrhagic fevers in the Soviet Union: Epidemic Hemorrhagic Fever with renal syndrome in Korea, Manchuria, the Amur Basin, Scandinavia, and.Hungary; Southern Soviet Hemorrhagic Fever. including Crimean hemorrhagic fever, Uzbekistan hemorrhagic fever, Kirghiz hemorrhagic fever, and Bulgarian hemorrhagic fever: and Russian.8pring-Summer Encephalitus Hemorrhagic Fever, including Omsk hemorrhagic fever, -31- Bukovinian and Kyasumur Forest hemorrhagic fever in India. Outside of Russia, cases have since been reported from Finland, Hungary, Eastern Eur0pe, Central Asia, and Argentina. When an epidemic fever involving gastro-intestinal and sub-cutan- eous hemorrhaging broke out in.Manila in 1954, the Korean connection was first suspected; but the disease has since been identified as a separate entity with no renal involvement, frequently a state of shock before death, and transmission by mosquito. In 1958 an epidemic occur- red in Bangkok, where it was first restricted to the urban areas of the Central Plains and later, in 196#, spread to towns in north and north- east Thailand; in 1958 there was an outbreak in Hanoi; in 1960 in Singapore; in 1962 in Penang; June 1963 in Saigon; December 1963 in Calcutta; Cambodia and Rangoon in 1963 had dengue epidemics. It has not yet (1968) been reported in Indonesia or East Pakistan. The vector everywhere is Agggglaegypti. An early name for.Hemorrhagic Fever in Thailand was simply "mystery disease" and so in many ways it still remains. The disease is asso- ciated with multiple strains of dengue virus. Dengue fever, or "break- bone Fever" is transmitted by Agggg.aeggpti around the world, but the incidence has long been notably high in Southeast Asia (where there is no Yellow Fever). It is a non-fatal disease; the disputes over whether or not infection gave long-standing immunity were apparently solved by distinguishment of two strains of dengue virus, dengue l and dengue 2. Patients sick in hospitals with hemorrhagic fever’have yielded strains of the following(W.H.0.,1966): Philippines: since 1954, peaks every four years, isolation of dengue 2,3,and 4. -32- Thailand: sporadic occurences from 1954 on, then epidemic out- breaks in 1958, peaks every two years, isolation of dengue 1,2,3,4,?5,?6, and chikungunya. Vietnam: Western Vietnam and then Saigon, 1963, isolation of dengue 2. Laos: reported 1962, etiological agent not known. India: two peaks in 1963-1964, the first hemorrhagic and associated with dengue 2 and the second classical dengue, associated with chikun- gunya. Cambodia: widespread infection of dengue in 1963, but no hemorrhagic phenomena yet reported: isolations of dengue l, 4, and chikungunya. Burma: dengue-like disease in Rangoon in 1963: no isolation done. The most intensive study of hemorrhagic fever has been done in Thailand by Harmon and Halstead, using the facilities of the Southeast Asia Treaty Organization (SEATO). Two forms have been recognized: that caused by chikungunya, a virus of Group A which was heretofore known only in Africa and has yet not been connected with a fatal case: and that caused by dengue virus, which often produces shock and death. Mortality is about 10% of those hospitalized, but many minor cases are not hospitalized. It is a children's disease: of 10,367 cases with 694 deaths in Bangkok, 1958-1963, all but 25 were under 1». Ac- cording to the W.H.0. study noted above, a check of 3% of the Bangkok population disclosed 4000 children with hemorrhagic fever in 1962. Including illnesses caused by dengue and chikungunya, epidemic prepor- tions were enormous: from checks of clinics and private physicians, the total illness in 1962 estimated at 150,000 to 200,000 children un- der fifteen in a total age pepulation of 870,000! The disease occurs in seasonal peaks associated with the rainy season and mosquito ecolp ogy. It further has biannual surges, as shown by those hospitalized in Bangkok, where bed facilities for reception can be assumed to have -33- remained constant: 1958 - 2418 caSes: 1959-124; 1960 -1742: 1961.-481: 1962 -4185: 1963 -l657: 1964 -6358. There is no apparent difference in incidence among ethnic groups, such as Thai and Chinese in Bangkok, but not one Caucasian is known to have contracted the disease. While all the cases around them are hemorrhagic fever, Caucasians get dengue. Clinical descriptions of the disease are serology analyses are provided by Nelson (1960), Hammon and Sather (1964),Dasanayaveja (1961), Chastel (1963 ) , and Voulgarepoulos (1965 ) . The critical question raised by all of the above background infor- mation is whether or not hemorrhagic fever is caused by a pathological mutation of the dengue virus, and thus poses the potential danger of spreading around the world in the trOpical dengue belt, transmitted by the ubiquitous Agdgg aegypti. Following the directions of Scott Halstead, three general propositions should be considered (1965): l) Dengue mutation: this seems the most logical explanation to account for the sudden appearance, spread, and association with dengue viruses and vector. Searches of hospital records for the period before World war II have disclosed no unrecognized cases. Est it would be expected that any chance mutation would take place only in a single dengue virus type in one given short span of time - and it is confusing that hemor- rhagic fever is associated with different types of dengue in different places. Also, a new mutant virus should probably affect adult Asians, too,un1ess they are accredited with immunity due to previous dengue: such immunity, in any case, does not apply to resident Caucasians who continue to report hundreds of cases of dengue fever but no hemorrhagic. 2) Hypersensitive-immune reaction is suggested by the endemic nature of dengue virus and the presence in victims of multiple strains of virus. Chikungunya was present in Thailand, but not, however, in the -31.. Philippines and Malaysia, and in Ubon, Thailand only a single type of dengue was found. Indeed, it was first thought that children repeated- ly exposed but not yet with adult immunity to dengue viruses contracted hemorrhagic. A study reported by Halstead of the 1964 outbreak in Ubon (pOpulation 27,000), 300 miles northeast of Bangkok, confirmed an ab- sence of dengue disease in recent years and yet an age structure of hemorrhagic incidence identical to Bangkok’s (1965). In addition, serology showed no JE antibodies and suggested primary Group B infec- tion. 3) Host-specific factors are suggested by the failure of Caucasians to contract the disease. Immunological reaction would be possible, but visiting foreigners and young indigenous children are in approxi- mately the same immunological state as regards dengue. Nutritional status or genetic control might conceivably play a role, but there seems to be equal incidence among all sectors of a varied indigenous population. The possibility was entertained that there might be a host-specific characteristic of the Caucasians which rendered them immune to the dengue mutant- namely, vaccination for Yellow Fever (also Group B) before they were allowed into the Yellow Diner-free zone. A review of the literature disclosed a study of dengue epidemics in Panama where antibody interaction with.the nearauniversal vaccination for Yellow Fever was specifically considered and none was found (Rosen, 1958). This summer Thailand has had its severest epidemic yet. figg,maga- zine reports a crippling outbreak in Hanoi, killing over 1000 under fifteen years old (October 10,1969). Any efforts at prevention or control must concentrate on the vector. Aedes aegzpti is generally 53 llllllllll"! )7 ‘_ —-_ —-——-——- - - ....... [‘4' ll”HUM“? I. 1 W" \” lllll \ w miiilii. ”II” DENGUE VECTORS and HEMORRHAGIC FEVER \\ e. “l"“l . O a .60") I \‘ a a > .- ~... 0 '- - ”on o c 3 .2 ““2 a ., O >~ “- 3.2. g 3 Duo 3 a” 3' I. *5“ - 7.22 =33 02° ° .::3 39% :0“ W ”-00- '53 o. 0 b o 5:) .2 ‘U U GE‘- in; w). 0 00 3;: 3 < < )5: (0."; .0 ”3:3 ': 033° .— K) K o I .2 llIIIfll E g. . O «n equal also poopsUuon l< IO0,000, 000 annulus!“ silence: AREAL SCALE considered to have been introduced into Southeast Asia before 1900 from Africa, and has since become very widespread in coastal and urban areas and upcountry following lines of communication. It is the most urbanized of mosquitoes, extremely anthrOpophilic, and preferring to breed in any water in or about human habitation. It feeds during daylight hours so that netting is of no use for prevention. In the absence of Yellow Fever, Aggg§,aegypti was not heretofore considered a dangerous mosquito and cities like Bangkok were never sprayed. Many items of cultural practices facilitate its breeding. Peeple catch rainwater or otherwise store water in large Shanghai jars called gag, A comfortable town house may have up to a dozen of these standing around. The bilge water in numerous canal boats, especially of the migrant canal pepulation, is another favored site: but even a coconut husk, a rut in the dirt road, or the crown of a banana tree will do. Since peOple seldom approach doctors for children's sicknesses, the insidious onset - which resembles influenza - also causes a delay in medical attention which raises the mortality rate. Since the presently most logical assumption is that the virus is indeed a mutant of dengue, and since the vector Agdgspaegypti is widespread, and the host is universal, quarantine procedures and mosquito control are needed to prevent possible pandemics. Es Rabies Rabies is a serious health problem throughout Buddhist Southeast Asia, but is especially so in Thailand. According to W.H.0. statis- tics, in 1961 Burma had 63 cases, Cambodia 3, and Thailand 208: in 1962 the figures were Cambodia 2, Vietnam 2, and Thailand 244. The condition is usually attributed to Buddhist aversion to the killing -36- of dogs. Packs of ownerless, mangy dOgs roam the streets begging, stealing and scavenging food, and often living in the protection of the temple compound. Even owned dogs are kept primarily to bark at thieves and are fed "to teach them their owner" but are otherwise left untrained and unconfined. At least during the last five years the government has sponsored periodical dog-destruction by poisoned meat in rural towns, but the measures are not nearly adequate and with every hot season dogs continue to go mad. From personal obser- vation, vaccination of pets over large areas remains impossible be- cause of the difficulties of transportation and lack of refrigeration. The pOpulation remains Opposed to the deliberate destruction of animal life, and while the periodic government measures arouse no active cp- position, there is also little appreciation or cooperation. Jackals, wolves, foxes, and vampire bats do not occur so the dag is the only important vector. C,W'. Wells sounds rather frustrated when he writes that,"There is a high incidence of rabies in Thailand and no attempt to control it. The northern states of'Malaya are Open to introduction of the disease and are the principle foci in Malaya." (W.H.0.Bulletin,l954) While the northern states are usually endemic, in 1952 there was an outbreak of 198 cases of canine rabies, occurring even in Kuala Lumpur eighty miles south of the nearest infected locality} The outbreak was suppressed by stringent legislation on vaccination of all.dogs and followbup of the vaccination team by another which shot a11.untagged dogs. In 1952, 73,100 dogs were vaccinated and 44,500 destroyed. While no more cases or rabies in dogs have occurred since June, 1953, programs of compulsory vaccination,quarantine of incoming dogs,and constant "dOg destruction weeks” have continued. Such a program is sorely needed inThailand, although the difficulties of obtaining, maintaining and distributing the vaccine are considerable. III. CONSUMED DISEASES Diseases in this section are transmitted in the third major method: the pathogenic organisms are consumed in food or drink. The interac- tion of cultural and physical environments has a strong influence on this category. For instance, despite the high incidence of pulmonary tuberculosis described already, other forms are rare: bovine tuberculo~ sis is inconsequential as a source of human infection because milk is not consumed. Yet the watery world of wet rice cultivation brings flooding of contamination and pollution of drinking supplies, provides a wide range of still and moving water of varying organic content, and, flowing from village to village, affects everything the people eat, drink, or wear. The climate over mainland Southeast Asia is predom- inantly of the wet-dry monsoon type, and that alone has great signifi - canoe for the practices of water storage and sanitation. The favor- able conditions for year-round prOpagation of the insect life also effects the incidence of mechanical transmission of disease by arthro- pods such as the fly. Studies of water supplies are not Optimistic. During the rainy season rain water is consumed and disease incidence is low. During the dry season, however, peOple rely on well water or even canals and the buffalo ponds. A study of wells in northern Thailand found 50% of the wells poorly constructed and situated with no regard to geological situation or irrigation channel depressions and not at all imperviously constructed (Schulz, 1957). Sources of pollution cited -38- included : (1) seepage from pit-latrines: (2) surface washings of human and animal faeces in flood time: (3) method of extraction of water with a common dipper. Every well was found grossly contaminated with coliform bacteria. Such is the background for the transmission of consumed diseases. This section will briefly consider cholera, typhoid, dysentery and liver fluke. A. Cholera Cholera continues to be highly endemic in the delta of the Ganges, and there is also a minor endemic area in the delta of the Irrawaddy in Burma. These areas are characterized by being near sea level, densely pOpulated, with a surface water system. Yet, in similar areas such as the deltas of the Menam Chao Phraya in Thailand or the Mekhong in Vietnam, cholera has never become established and occurs only in virulent epidemic outbreaks of explosive‘nature. In Indonesia, the last major epidemic occurred in 1918; Java has been free of cholera for a quarter of a century. In Burma the incidence is highest in Lower Burma and endemic to the Myangmya district of the Irrawaddy delta. In addition, frequent reinfection occurs from Calcutta (Pollitzer, 1959). The seasonal peak of cholera is during the dry season which occurs in Lower Burma during April—May and Upper Burma during August-September. Diffusion from endemic Lower Burma in the dry seasonal peak unfortunately reaches Upper Burma in time for the dry seasonal peak there. Although it is one of the most-studied diseases, cholera remains mysterious, es- pecially in its epidemic outbreaks. For unknown reasons, the disease in Thailand is characterized by three-five year outbreaks alternating with interbepidemic periods. The canal water pollution is the greatest source of danger and the highest incidence is among the riparian pepulation. Some success has been achieved by government use of galvanized tanks with alum and chlorine for water storage: Wilcocks thought the pregram might usefully be expanded (1944,d). Today it is common practice for at least public schools to be provided with such galvanized tanks to store rain water. Spreading outward from Burma through Thailand, cholera breaks out a year later in Cambodia and Cochin China and lasts a year longer than in Thailand, but otherwise follows the same epidemic pattern (Pollitzer, 1959). In Malaya, the dispersed character of kampong settlement helps buffer the disease, although concentrated settlements are increasing and the protected wells and sanitary dis- posal systems which have been provided are not used (Choong, 1959). The extensive rubber plantations of Malaya, moreover, do not offer the same conditions for cholera as the great river deltas. vaccination offers only short-term control because its immunity lasts only a year. It is best used to control epidemics, although widely given to school children also. The general trend for cholera is down, but there remains wide year to year fluctuations, as'W.H.0. figures for the following years indicate. . REPORTED CASES OF CHOLERA year Burma Cambodia Indonesia Malaysia Philip, Thailand Vietnam 1963 3019. 79 529 153 * 220a * 1964 1016 150 326 513 ‘ 959 20202 1967 9 4 707 - 2130 148 7921 1968 - 8 135 15 2976 #08 246 - no cases reported * no reportings made B. Typhoid Typhoid occurs frequently throughout Southeast Asia and is spread by numerous flies and poor sanitary habits in general. In particular, health legislation is poor and even more poorly enforced, so that there is no practical control of food handlers or food inspection. Epidemics -40- are brought under control with emergency vaccination programs. The considerable fluctuation in reported cases may again be compared: REPORTED CASES OF TYPHOID ygar Burma Cambodia Indonesia Laos Malaysia Thailand Vietnam 1963 452 347 60a: 345 980 2u12 3166 1964 + 319 3904 355 204 2424 + 1967 + 120 + 90 1027 15 + 1968 + 178 + 136 1015 36 + + reported as present C. Dysentery Dysentery is so common as to be accepted and expected and very seldom reported. Besides the afore-mentioned flies, lack of effec- tive food legislation, and poor sanitary conditions, it is Spread by practices in many countries of using human faeces as fertilizer for garden produce. There are two forms, a bacillary dysentery which is more frequent and less dangerous: and an amoebic form which is less frequent but usually chronic or permanent in infection and difficult to heal. In Indonesia before the war, Wilcocks estimated dysentery to account for 4.5% of hospital deaths (1944.0). It is extremely common among infants and the major cause of death, as shall be men- tioned later under nutrition and maternal and infant health. Although data on reported or hospitalized cases are not very meaningful, they do help give an appreciation of the dimensions and patterns(W.H.O.). REPORTED CASES OF DYSENTERI year Burma Cambodia Indonesia Laos Malgygig_2h§ilggg__yig§ggm_ 1961 de589 c.4645 Ce29729 Ce18u69 Ce156u 0e22072 Ce10757 1962 d.258 2713 8723 15841 1528 26721 61799 d. Bunma- died Ce cases D. Liver Fluke: Opisthorchiasis The studies reviewed were conducted in Thailand, but liver fluke is -41... also common in Vietnam and Laos. The regional distribution of liver fluke in Thailand is clear: incidence in the South was 0,0%, in the Central Plains 0.3%. in the North 10.3%. and in the Northeast 29.8%. It varied within the Northeast from over 30% in the north to 3.9% in the south along the Cambodian border (Harinsuta, 1960). The pattern is simply explained by the Lao custom of eating §2i_§l§g, a raw fish dish sold in every market, whereas the Cambodians do not eat raw fish and the Central Thai cook the fish that is consumed raw in the North- east. Certain species of fish were found by Harinsuta in the Northeast to be heavily infected with cysts, but only the snail Bithynia had cer- cariae. Relations with respect to both molluscan and fish hosts are little known. There is an apparent relationship to cirrhosis and pri- mary carcinoma of the liver which is common in the Northeast (Sadun, 1955). Out of a pepulation in 1955 of 18 million, Sadun estimated at least 1% million peeple to be infested with liver fluke. He also found the animal reservoir in cats and dogs to be greater, particularly in areas where there was no human infection. Three measures might be useful in control: extermination of the snail Bithynia; greater use of latrines; and prohibition of the consumption of raw fish. The dif- ficulties of diagnosis, lack of a cheap and effective anthelminthic, and the existence of animal host reservoirs preclude many of the usual methods of parasite control. Sadun thinks the best hepe lies in a com- bined effort of public health laws against the selling of raw fish in markets or restaurants and an educational drive. E. Cultural Barriers In Jacques May's conception, one of the major Operations of culture is to erect a barrier between society and disease. To a large extent, -42- the establishment of these barriers constitutes the basis of the "Health control" that is revolutionizing health conditions around the world. Barriers include, most importantly, systems and practices of surveilance and inspection of food and water supplies; acceptance and practice of vaccination; and habits of sanitation including use of latrines, washing of hands, and the scrubbing with disinfectant of infected areas or objects. These lie at the base of the greatest innovation Western medicine can offer: the idea of prexgntize medicine. By no means all of Asian remedies or medical practices are "quack"; but they all attempt to deal with a fgit'accompli, usually somewhat fatalistically and ex- plicitly without belief in man's ability to control his environment. The concept of contagion is slow to be fully understood, but its real- ization catalyzes the erection of cultural barriers. Several indigenous customs also function effectively as barriers, such as the drinking of tea in some areas while those in others consume river water directly. Each of the three types of transmission discussed has its own most apprOpriately effective means of attack and control. For diseases trans- mitted directly, the greatest help is to be had from vaccination, as for smallpox, and from increasing isolation of contagious peeple, as in tuberculosis hospitals, and from general public awareness of con- tagion. For those transmitted by vectors, the greatest help in the present day yet lies in vector control by insecticide spraying, although other methods such as sterilization or natural parasites may become viable for vector control in the future. As mentioned before, these methods will hepefully be superseded by others, of which the most hepeful is mass prephylactic treatment of the human host to remove it from the cycle. The presence of natural, wild reservoirs for many .43.. diseases complicates man's attempts to tamper with the transmission cycle. For individual diseases, such as malaria, mass treatment with prephylactic drugs may become viable; but considering the wide range of arthrOpod-borne diseases, continued attempts to eradicate implicated Species of mosquito and ticks and lice seems the only practical way. The third form of transmission, consumption, lends itself most easily to cultural control. The efficacy of public water works and sewage systems is undoubted, but the will and means to make the investment is what is lacking. In rural areas, a major and continuing effort at adult education is needed to get across the concepts 'of contagion and.life-cycles of helminths - in short, to encourage and insure the use of latrines as well as their construction. Wells must be dug deeper, covered and pumped. Facilities to store rain water for the dry season need goveernment subsidy, at least for public insti- tutions. With public health legislation controling the conditions of food handling, with water works and urban sewage systems, the consumed disease of cholera or typhoid will one day be well controlle d. -414... IV. NUTRITIONAL DISEASES The paradox has often been noted that Southeast Asia is a food surplus area, and yet malnutrition is widespread and serious. Nor is it confined to critical areas such as Java where environmental limitations and historical processes have combined to produce one of the most desperate situations on earth. Malnutrition exists among food-exporting peoples and upper - class peeple with money. No other division of medical geography shows so clearly the role of cultural factors in disease ecology. The great variety of the region of Southeast Asia has been mentioned. One of its common regional characteristics is that milk is not consumed; a second is that rice is regarded as the ”true" food, the real strength and support of life. The influence of these cultural attitudes on the common- ality of the nutritional problems in the region will become ob- vious, but one must not lose sight of the cultural factors of var- iation, either. Theravada Buddhists of Burma, Cambodia, Thailand and Laos; Chinese; Chinese-influenced Vietnamese; Moslem Malays and Indonesians; Moslem and Hindu Indians; and Christian Filippinoes display a wide range of food customs and related health effects. The whole nutritional situtation is, in turn, bound up with the in- cidence of other diseases, including intestinal parasites, in great complexity of cause and effect. Nutrition-related problems most clearly manifest the multi-variate nature of disease causation. This section will first survey the protein, calorie and vitamin deficiencies of the region; it will then focus on the health conditions of mother and infant, including, where pertinent, non-nutritional diseases; it will next turn to a consideration of the influences of other diseases such as helminthic infections and malaria on nutri- tional problems and, lastly, some of the influences of nutritional problems on other diseases. .45- A. Deficiencies Given the different nutritional demands of various body types and ways of life, it is rather arbitrary to establish a daily-allowance minimum limit below which peeple are unequivocally malnutritioned. Because of the chronic, gradual, and non-infectious nature of defi- ciency diseases, they are seldom regarded as diseases until their extreme develOpment, and so data on morbidity are almost impossible to obtain. To quote Bailey (l961,p.289), "In regions where famine or hunger oedema is widespread, e.g. India, China, Indonesia.... no comprehensive reports on the number of hospitalized cases or the incidence, aetiology and epidemiology of adult nutritional oedema in the community, either in normal times or in times of famine, are available." Reliance for any sort of evaluation of the situation must be laid on spotty case studies. Indonesia In Indonesia there can be no doubt of malnutrition, and this paper can only consider a small part of it. The data are drawn from a fourupart report of a study of endemic hunger oedema carried out in Central Java between 1957 and 1959 by K.V. Bailey (1961). The area is agriculturally and economically poor, with cassava the sole relatively productive plant. The soil is highly calciferous, rocky, often the entire tOpsoil having been lost by erosion. The terrain is mountainous in the north and hilly in the south, with the elevated plain of Wonosan in the center. The pepulation density in this agri- cultural area in 1959 was 964 peeple per square mile. Even greater hardships than the annual hunger season, although one not considered in detail here, is the water shortages as streams go underground and wells dry up, leaving only a few polluted lakes miles distant. In 1958 the average daily intake was 1350 calories and 15.6 grams of protein per head, amounting to 19% of the protein requirements - with children getting even less. The protein is further of poor quality, with the limiting amino acids being those containing sulphur. Jagjakarta, the most densely pOpulated area of Java, was known in pre- war days as a ”minus area" with epidemics of oedema following succes- sive cr0p failures. The dislocations and exploitation of the Japa- nese occupation and the war caused an exacerbation of the situation. Bailey distinguishes several categories of hunger oedema: 1. Sporadic: diet is low in protein, but calorie deficiency is the proximate cause a. in cities b. in rural rice-maize areas. 2. Endemic: in cassava areas. The rate of occurrence of oedema shows a downward trend from the maize harvest until the cassava harvest, when it swings upward again. The maize is harvest in FebruaryaMarch, and the rice in April- May, and the cassava in July-August. Therefore the acute food short- age extends from October to January, or, in the case of’those too poor to raise any rice, until July. In Gunung Kidul, a district in the endemic hunger oedema and cassava areas, adult male intakes have been estimated at less than 1000 calories and 5 grams of protein daily! Bailey describes three typical diets. All three diets here provide 1590 calories, wvith protein contents of 18.3.12.0, and 9.2 grams respectively. There was no animal protein consumed in 1958. A. Adult man, Central Java, Whole Year 64% calories from cassava 22% protein from cassava 62% protein from rice and maize Suggested supplement:soybean tempeh,sweet potatoes, leaves and coconuts. ____J 417- B. Common Farm Family, Usual Diet no maize 11$ rice admixture after harvest 85% calories from cassava 48% protein from cassava 10% calories from rice 29% protein from rice C. Typical Man of Gunung Kidul for most of the year 95% calories from cassava 70% protein from cassava 30% protein from beans and vegetables The proximal cause of hunger oedema in Indonesia, it is repeatedly emphasized, is calorie deficiency, with the severe protein deficiency only a prediSposing factor. Prolonged sub-optimal intakes are the rule, but acute starvation ten years ago was still rare. Malaysia Regarding kwashiorkor, the Institute for’Medical Research at Kuala Lumpur reported in 1949 that, "There is good evidence that this con- dition is not uncommon in Malaya and it appears to be found relatively more frequent among Malays than in other races... it appears probable that the Malay beliefs about child feeding may sometimes be the cause. The widespread view that rice is good for infants and fish bad for young children result in diets which are poor in protein and high in carbohydrates, for fish is practically the only form of animal protein consumed." C.D. Williams at that time noted that"cases of malnutrition were on the whole very much more common in Malaya than in Wtst Africa,“ (quoted in Dean, 1961). There was fear that kwashiorkor might be widespread but not recognized: mothers occasionally, for instance, brOught children suffering from kwashiorkor to eye clinics with complaints of night blindness (Dean, 1961). A survey of the states of Pahang, Treng- ganu, Kelantan, Kedah, Perak, Selangor and Negri Sembilan disclosed .48- kwashiorkor in 4% of Kelantan, Kedah, and Negri Sembilan samples and 22% in Perak (Dean,l959). In Uganda, 3.5% have kwashiorkor and it is considered an important public health problem (Dean, 1961). In Perak, over 20% had full kwashiorkor and 10% more had oedema only. Thomson, who observed the disease over a period of four years in the Perak districts of Ipoh, Batu, Gazah and Parit, concluded that kwashiorkor gave rise to chronic ill health rather than outright, acute illness (1954). She claimed that the indigenous peeple are only beginning to realize that a child's health can be improved. She describes the disease in Malaya as follows: onset comes with anorexia for rice and apparent craving for the articles deprived; growth is retarded in all three races, but most severely for the Malays, whose bigger children often cannot walk; dyspigmentation occurs in many cases of the skin and occasionally of the hair; dermatoses are common but not as severe as elsewhere; oedema is frequent but not usually severe condition and an enlarged liver is always present. While percentages for clinic attendance were 12% Malay,68% Chinese and 20% Indian, cases of kwashiorkor were 84% Malay, 14% Chinese, and 2% Indian. Thomsen feels that this reflects dietary difference, with the Indians offering some cow‘s milk and the Chinese using vegetables, fruit and eggs when available, whereas the Malays have a prejudice against foods other than polished rice. Welf contends that.Ma1ays in his study were relatively wealthy, and that there was no good reason for them to be deficient in diet (1965). The monotony of the diet, he thought, intensified the imbalance. Eating customs might also be involved, as he asserts there is no set time for meals, and so the peeple eat when hungry and the children often snug :- feed away from home on left-over rice. The diet is almost totally defi- cient in meat, but it should be remembered that the most prevalent and available source of meat, pigs, is forbidden to Moslem.Malays. Cultural patterns are definitely indicated as controlling factors. Studies of the Perak peeple describe them as proud, friendly, and traditional (Dean,l959,l96l). They adhere strictly to Malay customs, especially returning home for childbirth, conforming to pantang - or six weeks of confinement post-partum on restricted diet - and forbid fish to children until they are two. River fish are not pepular, but an important factor in malnutrition in Perak is the poorly-orga- nized supplies of fish from the sea, due largely to the absence of Chinese traders along the Perak River. As Dean comments, "If the economic and cultural isolation of the Malays of the Perak River is responsible in part for the malnutrition of their children, it will be interesting to watch the effects of the breakdown of that isolation by the new road” (1959). Thailand Knowledge of nutrition in Thailand comes largely from.an intensive, long-term, many-faceted study by Cornell University researchers in the village of Bang Chan, in the Central Plains. The study included 166 persons in 31 village households and 233 primary school children. Com - plete physical examinations were reportedly given over'the period 1952-1954; houses were visited during food preparations, methods were observed and food was carefully weighed. Fully 46% of school childre n and 47% of family sample were free of any signs of nutritive deficien- cies. The remainder had one to seven signs each, with older peeple thawing more. The only deficiency disease observed was beriberi, but 5'" -50- deficiency of vitamin A and riboflavin was indicated. Hemoglobin values of 11.5 gm. or less per 100 ml. were observed in 9% of school children and in 6% of the males and 25% of the females over fifteen.. The most usual signs were as follows: xerosis, 15%; phrynoderm,5%; liver enlargement,9% - uncertain whether caused by protein deficiency or parasitism; 14 children had leg ulcers, and some had no knee jerk; other signs included changes in tongue, lips, skin and hair; no malnutrition of the sort that causes apathy was found (Hauck,l954,a). Starvation is unknown, but neither are many peeple overweight. Rice is consumed at a rate of 285 kg. per capita per'year, or 780 grams per person per day. These days very few peeple mill the rice them- selves, and the resultant polishings are mills are not used for human food. Rice supplied the calories, phosphorus, and thiamine. Flesh foods are enjoyed, but they are inhibited by the Buddhist re- ligion and few peeple will raise animals purposely for slaughter and their own consumption (Swine, for instance, are raised mostly by the Chinese, or perhaps by the Lao farmers for eventual export to Hong Kong; when the market is poor, few pigs are raised for home consumption, although their role is that of a scavenger and they are not compfititive with man for food). Dead buffalo are eaten, as are such wild creatures as turtles. frogs, rats and bats. Chickens are raised by 90% of fam- ilies, and 37% had ducks; while chicken eggs are usually sold, many duck eggs are eaten at home, an average of 1/3 egg per day. Fishing in the rivers and ponds and paddy fields is well deve10ped, with specific techniques used according to the species and time of maturing. Most houses have a fish pond, which is harvested two or three times a year. Under Food and Agriculture Organization encouragement, Tilapia -51- cultivation was tried, but given up when the market collapsed - without economic incentive, none cultivated the fish for improvement of home dicta Mushroom cultivation had the same history and fate. While spices and chile are commonly grown, the vegetables and fruit encouraged by the government are little grown. In part, this is due to the shortage of garden land, since the earth mounded for the house site is limited and the rice paddy land is flooded and valuable. Commonly purchased foods (from vendors in boats on the canals) included onions, garlic, liver, coconut, and palm sugar,.fish soy and shrimp paste; the more affluent also purchased vegetables, such as cucumbers, egg plant, white raddish, and bamboo shoots. Without buying, it was considered that peeple had enough to eat but lacked variety and so an average of 0.44 baht per day (2¢) was spent (Haucks, l954,b). The above report em- phasizes the self-sufficient nature of Thai farming, even in an area of commercial rice agriculture. Tilapia, mushrooms, eggs - all gave ernment-encouraged food - is raised for sale. This practice raises the question of whether the sale of home foods increases the village supply enough to offset the loss to home consumption. The research team constituted two groups for study, judging from symptoms that Group A had poorer nutrition and Group B better nutri- tion. In Group B, the average protein, calories, iron, niacin, and ascorbic acid exceeded allowances, while in Group A only niacin and ascorbic acid exceeded allowances. Riboflavin was feund to be 33% of allowance, calcium 20%. and fats and sugar intake very low. In addition, there is considerable food interest in the ggggg, or fes- tivals, because of the prominent place of food, with its cultural significance and relatively high cost. Merit is made by feeding the -52- monks at these religious festivals, and it is desired to feed the greatest number of monks as lavishly as possible. Those participat- ing share the considerable food remaining. The foods are rich in meat, vegetables, and prominent purchased foods. As there are many of these festivals and celebrations during the dry season, a considerable im- pact on nutrition should occur then. The matter is complicated by several factors. First, the consumption of "empty" calories - sugar and alcohol - also greatly increases, while normal.meals at home are neglected. Secondly, those left behind, such as children, are adverse- ly effected in food intake. Also, the most needing of extra meat - the poor - seldom attend because they have no way to reciprocate. A famous poem written by King Ram KhamHaeng at the dawn of the Thai alphabet proclaims: "In the fields there is rice; in the water there is fish. The faces of the people are smiling as they attend their markets." Many observers have considered the situation in Thailand as the best in Asia, but, as will be considered later under beriberi, maternal-infant health, and other diseases, anemia, helminthic infec- tions and other njtritional problems are still serious. The Cornell Research Project desired that Kesetsaart (agricultural) University identify and provide or promote green and yellow vegetables which would help meet the critical shortages of vitamin A and riboflavin, and also be high in calcium, low in oxalic acid, and mature when the canals are low (Haucks,195h,b). Hauck stresses that, while the diet in the Central Plains is not very deficient in protein, it is not distributed pr0portionately to needs, resulting in the usual failure of infants to gain weight. It needs also to be mentioned that available studies deal with the Central Plains, which is the most prosperous part of Thailand. In the arid Northeastern Korat Plateau, for instance, poverty is greater, fruit scarce, vegetables cultivated in the dry season only by great exertions in carrying water from wells, and even the rice cr0p often fails and produces deficiency and induces migration, lower living standards, and increased malnutrition. 2212a Over 9300 examinations were conducted among servicemer,, but no evidence of protein malnutrition was found (Interdepartmental Defense Survey,c). Signs noted included the following: loss of ankle jerk (vitamin B deficiency) 1.5%; angular lesions of the mouth (riboflavin deficiency) 4.8%; goitre in 2.0%; thickening of the bulbar conjunctivi- tus in 52.1%. Over 62% of the energy was derived from rice, 11.2% from groundnut oil, 6.8% from pulses, 6.0% from meat. Most nutrients were found to be adequate, with riboflavin the most critical. The source of animal protein was fish, of which some seventy grams a day were consumed. The Burmese averaged 2150 calories. A less optimistic earlier study was more concerned with the varied civilian pOpulation. Wilcocks noted that malnutrition oedema, with protein deficiency, hookworm and malaria, was common near Rangoon (19h#, a). Goitre was endemic in the hilly areas - Meiktila, Minbu, Shan and Kachin, in the Upper Chindwin and Salween. Malnourished children, he thought, reached 6-2Mfi, especially with vitamin A and B deficiencies. The Hindu influence was noted - ghee was a common food - but only the Hindus themselves drank milk. Postumus found that 19% of women had never eaten any meat or animal food, such as chicken or eggs (1958). A major source of protein was n a i, the fermented fish sauce which supplied most of the calcium. He provides the following chart: -54. poor class middle class nutrient unit quantity _% negg_ Quantity fi need calories cal. 1853 71+. 0 1964 78 06 protein animal gm. 1h.7 39.2 20.8 55.h protein vegetable gm. 29s} 9803 3002 100.0 fat nge 29e9 - 3600 '- calcium mg. 131 10.0 15“ 11.9 iron mg. 608 75e5 8 89 .0 thiamin mg. 0.46 30.7 0.#8 32.0 ribOflaVin mg. 0027 1102 0030 1205 Ilia-Gin mg. 8014' 6702 901 7209 Indochina Concerning nutrition in the former Indochina, Wilcocks wrote, "nutrition is poor. Half the year there is just adequate quantity and poor quality, and the other half near starvation," (19h4,b). While the wealthier may have an adequate diet, consuming vegetables, fish, pigs and dOgs, he believes that the vast prOportion of people eat only rice and salt. A survey of the military and dependent papulation found angular lesions in 2.3% and excretion of vitamin B, riboflavin in the urine to show inadequate intakes (Interdepartmental Defense Survey,b). Studies in the maternity hospital in Saigon found 75% or the women lacking in riboflavin and calcium. The military diet, provided 3123 calories with 100 grams of protein, of which 12.8 were of gamma origin, also relied heavily on up to sixty grams of fish sauce daily. Nguyen-Thi-Lau reports that Nuocnam, the national condiment fish sauce made from whole fish, is used by the wealthy,midd1e and poor classes in daily amounts of 15,30, and 60 m1., respectively (1959). Along with the salted fish and more expensive fresh fish, it constitutes a valuable source of protein and also provides most of the calcium, phosphorus and potassium. Beriberi Beriberi has been singled out for special consideration because of its special status as a regional problem. Modern technology has brought the steam mill to the villages and each year fewer peOple hand-mill their own rice. Not only is the milled rice white, clean, and high in status, but it also relieves housewives of a time-consuming chore. Handmilling remains only in some rural parts of Burma, Cambodia, and Laos. When the rice mill removes the husk, it also removes the vitamin B. Where rice is the only food, even that meager supply loses its vitamin value. The Dutch, who did much of the early work on beriberi, controlled rice milling in Indonesia and there used to be little beri- beri (Wilcocks, 19h4,c). Cooking procedures also complicate the sit- uation, as the general procedure is to cook the rice in excess water, which is then discarded. In Thailand, the papulace is being urged to cook rice so as to absorb all the water and attempts are being made to encourage the use of the polishings in other foods (Haucks,195#,b). One of the most serious manifestations of the disease concerns ma- temal and infant health. In l9h4, Wilcocks reported hand-milling to be universal. In 1958, Postumus claims that only highly milled rice is eaten, except for very remote areas. Rural distribution is local and supplies peOple with 750 ug. thiamin daily, while allowances are 930 (80%): in Rangoon, peeple obtain 570 and require and estimated 960 (60%) - and these figures are before cooking in excess water. Beriberi has become a regular feature, especially around Rangoon which doubled to one milp lion peOple since the war. Infant mortality was 26.l$ for the poor and 12% for the middle class, with a peak (50%) of'deaths occurring between two and five months - ascribed to thiamin deficiency -in Burma. -56- Infantile beriberi has three stages: acute cardiac from two to four months; sphonic from five to seven months; and pseudcmsningeal from eight to ten months (Jelliffe, 1955). In the Philippines, it is re- sponsible for 28% of the deaths under one year, and in Bien Hos Jelliffe estimates Zflfi. The maternal.diet is responsible, as its pathogenesis is poor storage in foetal life and low thismin intake in breast milk. As professional rice milling seems to be an irreversible trend, solutions must be directed at control or provision of other sources of vitamin. The most likely solutions include enrichment of rice, or at least intermixing with enriched rice - the prOblsm.here is mostly distribution and initial.investment; lowbmilling requirements by law - and the problem here is a high dependence on supervisionary and inspectional procedures thatmthe govelrnment organisation, dis- cipline, and standards of remuneration would not likely be able to support; and substitution of vegetables and other sources of vitamin B, which may be feasible over generations but provides no immediate ”ll-Cf e gemphtha'tha Oomen, reporting for the first'W.H.0. worlddwide survey, approached the incidence of xerophthalmia through the census figures on beginning of blindness: first weeks - cpthalmia neonatorum; third and fourth year - xerophthalmia; adolescence -trachoma; old age - cataract and glaucoma (1964). He complains that the disease is often passed over by doctors and parents, with the resultant 30% mortality in the severe cases which are finally hospitalised. Diarrhoea is a supporter or predisposing factor and keratomalacia with perforation and death may follow. In the Philippines, xerophthalmia is the third major cause of blindness, especially in the squatter areas of Manila. In Sabah and Sarawak, data gathered by Wallace, 1956-1960, indicates 21% of all blindness was due to xerOphthalmia (Oomen, 1964). In Malay- sia conditions have improved since the war, but lesser numbers and more chronic degrees suggest the latent danger, with breakouts threatening in times of stress such as that caused by measles or dysentery. In Vietnam, xerosis is the principle cause of blindness in children. Seasonal variations are proof that xerOphthalmia follows in the wake of infectious disease (Jelliffe,l953; Oomen,l964). Writing earlier for the United Nations, Oomen stressed the im- portance of.the indicative value of xerOphthalmia in the diagnosis of malnutrition (Oomen, 1953). Requirements for vitamin A are closely linked, Oomen says, to growth demand, with the result that children on higher levels of protein often have eye lesions where marasmic children do not. "Lack of knowledge of child care in general and feeding in particular and not lack of food per se lies behind the problem ” (Oomen, 196k). Such social factors as maldistribution of food within a family seems to be an important cause. Yet even knowledge of proper foods is of no value if it cannot be applied - Oomen points out that encc>uraging milk in Indonesia, for instance, is absurd: local substitutes and sources must be found. Coronary Condition Not always, one must note, are Western dietary conditions the most desirable. With its three races - Chinese, Malay, and Indian- living under the same conditions of the physical environment, Malay- sia~ and Singapore have been the site of many studies of the effects of differential cultural habits on health. Danaraj (1959) and Muit (1960) studied differential coronary disease, and found the incidence -53- among Muslim Indians to be twice that among the Malay or Chinese. Muit puts the age of maximum incidence at Sl~60 for the Chinese, alaso for the Malays. and 36-45 for the Indians, ascribing the difference to their diets. In Thailand, Hirst found involvement of the coronary arteries in Bangkok only half that in Los Angeles from the fifth decade on and also found coronary occlusion and myocardial infarction eight times more common in Los Angeles (1962). He as- cribed the protection from arteriosclerosis to low - although highly saturated - fat consumption and the rarity of obesity in Bangkok. AIIOwances Although the World Health and Food and Agriculture Organizations have established standards for minimal needs, little is actually known of physiological differences among the races of man, of the varying demands on his system levied by different climatic stresses, or by the varying demands of different ways and paces of life. Rel- ative to the Harris and Benedict Basal Metabolism standard, for instance, the Burmese are a negative deviation of 1.16 and the Chins and Kachins of Burma a positive deviation of 6.9, the higher metabo- lism possibly reflecting their Chinese origin (Chitre, 1959). The adaptation of the human organism to adverse nutritional conditions are also little understood. Adjustments are made to conserve water or salt, calories, heat, and protein. Even in the most endemic areas of kwashiorkor in Indonesia, school children have been pronounced bas- ically healthy, evincing considerable metabolic adjustment. Bailey goes so far as to suggest the possibility that the peOple have devel» oped the ability to digest some cellulose (1961) I Stahlie has questioned the validity of W.H.O. minimal requirements(l960), and continuing nutritional and physiological research will certainly modify -59- Even recOgnizing such limitations upon the measuring of standards, however, certain regional patterns in protein-calorie malnutrition remain clear. The peOple of Southeast Asia are overwhelmingly depen- dent on fish for their protein: eggs and chicken play a minor role, pork is important for the Chinese, and buffalo, beef, dog and birds are rarely and milk almost never consumed. Fish ponds are ubiquitous, but are dependent usually upon the natural water cycle of the flooding rivers, and the overpOpulation is causing the rapid over-fishing of the rivers. Considerable thought is rightly being put into construc- tion of the Mekhong Project which, with its dams, Will greatly alter the ecolOgy of the river systems and fish life. In Cambodia, for instance, the annual reversal of flow of the Tonle Sap quadruples the size of the lake, flooding the forest and providing fish habitats so favorable that the fish pOpulation reaches densities greater than the best-known fishing banks; when the waters recede, the Cambodians trap the fish and harvest practically the year's supply of protein. Attempts to control the drainage of the Tonle Sap, retaining the water for agricultural use in the dry season, is certainly desirable but will inevitably interfere with the fish cycle. Yet another serious threat to fish productivity is the increasing spraying of insecticides to provide a higher rice yield at the price of killing the fish in the paddy. Throughout the area, rice is thought of as the only ’true food's and hnguistically it alone is referred to as food, everything else being referred to as ”with-rice" (522.5222!)° Rice makes you strong, with-rice makes you weak and is eaten only for flavoring and variety. The considerable food value of rice is diminished seriously with vitamin deplenishment due to the power milling. More seriously than that, cultural attitude is adverse to the consumption of vegetables and -60- consequently a critical shortage of vitamin A results. The literature is replete with cries of exasperation that the peeple do not eat the vegetables growing around them. Governments are making strong educa- tional drives to encourage the eating of more "with-rice", and there may be some success if living standards are raised. Haucks reported that many peOple ascribed the custom of eating little with-rice to fru- gality (l954,b). In many.agriculturally poor lands the resources avail- able are pitifully small, but even these are further subject to maldis- tribution: usually the male gets first food, than the children -within the limits of food policy for children - and lastly the mother. The youngest children and pregnant women receive less than their propor- tional share of the small supply of protein, often leading to maternal and infant health problems. B. MATERNAL AND INFANT HEALTH It is rather arbitrary to separate maternal and infant health from nutrition, since they depend so much upon it, but the special practi- ces, beliefs and needs involved require separate consideration. Cul— tural factors, such as attitudes toward childbirth and beliefs about what is "good for" children play an even more important role than is the case for nutrition alone. Lourdenadin, describing the generally poor health and anemia in particular as the nightmare of practicing obstetricians, recognized the social, economic, educational and reli- gious factors which included thesezall races commonly believe that good and plentiful food leads to a big baby and difficult labor, and so pregnant women should curtail their diets as much as possible; none look upon pregnancy as requiring any special care or food; empha- -6l- sis is placed upon the taste of food rather than its nutritional value, and good food is often secondary to other demands on the budget; the family is often large and puts great demands on the mother (196h). Other common ideas include the beliefs that rice is good for infants, that fish is bad because it causes worm, and that vegetables should be avoided because they cause green diarrhea. Many of the beliefs center around a conception of humoral pathology rather similar to that of Galen but, Foll thinks, pro-existing in India (1959)..The universal- ity with which foods are viewed as "hot" or "cold” and in ”balance with wind" and are evaluated, used and consumed on that basis, may show the extent of Indie influences, crossing, as it does, all barriers of religion, language and race. ans-a In Burma, women rarely eat flesh (as traditionally they were not supposed to eat flesh in Thailand),and they even eat less rice in order to produce a smaller baby and avoid a difficult labor. Postumus enumerates: vegetables are avoided since they cause wind and diarrhea in the baby; fruits are considered "cold,” causing coughs and dyspepsia; eggs putrify the intestine; milk and sugar increase the secretion of mucus; - and the result is a diet during pregnancy of highly milled rice (1958). One of the first consequences of such diets is anemia. In a Malay- sian study of 1000 mothers in an ante-natal clinic, Lourdenadin feund the hemoglobin level among Indians to be 65.6, among Chinese 65.7, among Malaysian 66.4, and among EurOpeans 78.7 (l96h). Since the more mally accepted minimum figure is 76, here yielding 76.9% below, the the figure used was 65.0 which yielded 2.2% below (Again the problem of minimum standards). In this series, 35% of the patients had hemo- globin less than five gram percent. The commonest form.of anemia, micromcystic in 76.3% of cases, was produced by a combination of defec- -52- tive nutrition, and iron deficiency. Lourenadin states that, al- though the caloric intake may be high and even sufficient iron be present, the low calcium and high phosphate in the rice creates a shortage of iron because of the formation of insoluble iron phos- phates. The anemia did not cause any noticeable rise in the incidence of abortion, but only 16.1% went the full nine months and there was no known cause for the high rate of premature labor except the pres- ence of anemia. In accordance with folk belief, it should be noted here that anemic patients were observed to have a quick, easy and spontaneous labor, with a very low incidence of forcepts delivery and little postpartum hemorrhage; however, the mothers were prone to shock with even slight loss of blood and there was a high incidence 16.5% of puerperal pyrexia. The weights of the foetuses were low, only 58% above 5.5 pounds and fully 17.1% below h.5 pounds, with a resultant perinatal mortality of 15.5% and increasing stillbirths. Maternal deaths were 12.1%(196u). Ihailand Stahlie, working in Thailand, found the same prejudice about food and a high anemia of 15.5% in Bangkok maternal hospitals and higher in the Northeastél960). Beriberi he ranks as a problem of first rank, with over 10 out of 100 nationally and over 20 in 100 in the Northeast suffering from it. It is implicated in honorrhaging. Stab- lie's purpose in reporting the study was to show that patterns of pregnancy and childbirth were too different from Western patterns to blindly cepy services. He notes that there are few abnormal presentations or toxaemia, a low incidence of obstetric pathology and consequently low stillbirth rate (8.5 per 1000). The danger -63- period is post-partum because of hemorrhage, occurring in over 2; in Bangkok and rising in areas of high beriberi to 23%. Stahlie notes that the maternal mortality rate has decreased from 7.8 in 1938 to 5.5 in 1955, and blamed the still-high rate on three factors: (1)in- accessibility or unavailability of well-staffed hospitals; (2) 85% of births are still not assisted by modern, skilled attendents; (3) influ- ence of endemic malaria. He believes the present development of provincial roads and hospitals and malarial eradication campaigns will have a great impact. Rough figures are available from the World Health Organization statistics, which in 1969 reports the following maternal death rate per 100,000 live births, 1964-1966: Singapore: “3.3 Philippines: 218.8 The Thai rate, Stahlie reported, for 1932 was 780 per 100,000 and still 550 in 1955. are further broken down for Thailand. Largely due to his work, the W.H.O. figures The high death rate among older women, most of whom already have dependent children, is clearly part of the tragedy of lack of birth control measures and concerned government programs or policies. year all under 20 20-24 g5-29 430-34 35-39 40-44 45-49 1951-53 532.3 506.5 519.6 515.1 632.9 7H6.8 1025.5 1118.4 1961-63 377.1 #65.7 265.1 267.7 371.8 494.2 74#.6 1003.3 1964-66 309.1' 319.0 230.5 212.5 280.5 389.7 575.5 739.9 Jelliffe reports that the nutritional situation is strikingly better than in neighboring countries (1953). There is prolonged breast feeding, from two to three years, which Stahlie holds responsible for the biolog- ically Optima1.child spacing of almost three years (1960). Stahlie also reports that in his study, 9.1% of babies had a birthweight less than 2500 grams, but suggests 2250 grams as a more realistic premature stand- -6#- ard weight limit for Asian babies (1961). The influences of urban- ization is shown in the 7.h¢ not breast-fed in Bangkok when compared with the 1.8% in rural areas. In rural areas, Stahlie reports 90% breast-fed at twelve months, 75% at fifteen, and occasionally up to three and a half'years. Over 40% of infants receive rice and the mashed banana El!21.2§fl.!2. in the first month. He notes that ten out of a hundred lactating Thai women had beriberi and ascribed the com- paratively low incidence of the disease in children to the banana, which has #0 ug. of thiamin per 100 grams. In later infancy adult food is consumed - rice, some fish, and eggs. Jeliffe regards avita- minosis A as common, but kwashiorkor as occurring uncommonly and usually secondarily to gastroenteritus (1953). During post-partum, rice, fish, and bananas are considered safe foods. As Hanks makes clear, many of the same traditional ideas occur, but are not today followed as strictly as in Malaysia or Burma (Haucks, l95h,b). Tra- ditionally women did not eat flesh, but today do when available. Rice is the only real food, and infants are early fed pro-chewed rice and banana and are weaned to rice broth. Fish are still suspected of causing worms, but some infants have fish and eggs by six months and most by one year. Most two year olds, however, do not yet eat veget- ables. Women practice a period of 122.£229 or sitting at the fire, after childbirth and have a restricted diet, but in practice the period has been reduced from a month to a week and there is a tendency in Bangkok to make the observance almost symbolic. Malaysia In Malaya, Llewellyn Jones found the highest preportion of deaths among Malays, who preferred to deliver at home, and among women having -65- their sixth or subsequent child (1957). It was slightly less for the primigravidae. Of hospital deaths, he considered 38% to be due to lack of cooperation on the part of the pateint, 23% to lack of prOper obstetrical care outside, and 13% to inadequate care inside the hospital. The leading causes of death were toxaemia, hemorrhage, and anemia. It is one of the critical conditions of national life in Malaysia that one cannot Speak of Malaysian in most instances, but must refer to Chinese, Malays, Moslem and Hindu Indians, and aborigines. The following description is drawn from Jelliffe (1953). Indians practice conscientious and prolonged breast feeding, later supplemented with canned or powdered milk if possible. The Tamils and Sikhs thus belong to a milk culture that is foreign to Southeast Asia. The diet is often poor, and in Ipoh, where they are a minority, Indian children are often emaciated. The Sikhs especially give diluted boiled cows milk and eggs to small children, which seems to prevent typical kwashiorkor. The Chinese have a serious problem of artificial feeding among all classes. This is partly due, Jelliffe says, to a tradition of despis- ing the female figure, binding the breasts and encouraging atrOphy; partly it is also due to beriberi and inadequate lactation; and partly it is due to the common absence of the mother at work. A11.Malay Chinese feed kégji, a rice broth, to the infant even from the age of one week while the mother is away at work. Children are weaned early only the family fare of polished rice and dried fish, with vegetable soup when possible. The Chinese encourage children to eat fish and meat, but these are limited because so expensive for the urban Chinese. Children early develop sore mouths, skin changes, oedema, enlarged livers, and diarrhea. -66- All non-milk caltares Seem to suffer a set-back at the time of weaning, but the Malays impose several additional burdens. Mothers practice pantang or confinement in a heated room for #4 days while they eat only fish and rice. Children are forbidden fish and eggs for fear of worms. They are erratically fed by breast for two years, sometimes today supplemented with diluted condensed milk, and weaned to a rice broth. The first week of life they are fed rice and bananas. The Malays are rural, peasant, and traditional and their children evince the most severe malnutrition. ”Toddlers lead unhealthy lives sitting in dark houses with little attention," Jelliffe says. He quotes Thomson,"It is not uncommon for a Malay to bring a totally blind child, who has presumably been sitting in the house in this way for two years, with the complaint of no appetite" (quoted in Jelliffe, l953,p. 52). There is successful lactation in 55% of Chinese, "over half" of Indians and 63% of Malays, reaching 93% in rural areas. There is a fall in breast-feeding for all ethnic groups in Singapore: of those not breast-feeding, 73% "just flatly refuse." awe In working on nutrition in Burma, F011 found 28% of babies under the 5.5 pound index of prematurity (cf. Stahlie in Thailand) (1958). The total infant mortality he estimated at 183.u/1ooo live births, the main causes of infant mortality being inadequate breast feeding and fly-borne intestinal infection. Causes of death under five years were commonly dysenteries and enteric fevers, or respiratory infections and tuberculosis; deficiency disease F011 felt were relatively unim- portant. There is prolonged breast-feeding, often three years if there is not pregnancy. The first semi~solid food consists of a rice broth -67- given from three months to a year. Jelliffe feels that the predom- inant deficiencies of anemia and marasmus are due to ignorance rather than absolute lack(l953). Indonesia Bailey, working in the cassava areas of Indonesia, found the gen- eral condition of lactating women to be superficially good despite the added need for calories and protein (1961). He was primarily concerned with develOping a rapid method of assessing the danger of endemic oedema, and few researchers had concerned themselves with lactating women, who might be a sensitive parameter. He found a sur- prisingly high incidence of oedema - 90% - in one month of lactation, h7¢ after nine months, 30% after eighteen months, lflfi after twenty- four months. Oedema not only declined with lactation, it declined af- ter six months while lactation continued. Bailey concluded that the stress the traditional view laid on the demands of lactation overlooked the earlier demands of pregnancy, and after considering nitrogen re- tention processes he concluded that the high incidence of oedema in the early lactation period was due to tissue depletion resulting from the inadequacy of maternal diets under the increased requirements of pregnancy. Infants are breast-fed from one to two years or until pregnancy. Semi-solid food, consisting of rice and mashed banana, is given early.. There are food prejudices against fish or meat for children, thought to cause worms, and those local food preparations of nutritional value such as the nasitin composed of rice, green vegetables and soyabean, are neglected (Jelliffe, 1955). Nutritional disease in infancy is rampant, with avitaminosis A and anemia the most frequent and kwashior- kor common. -68- Indochina As Jelliffe describes the situation in Indochina, breast-feeding is prolonged lB-Zh months, but the quantity is early inadequate61955). In the first months the diet is made calorically adequate by provid- ing chewed rice and rice water. Later children may be given dried fish and small quantities of fruits. Babies are large, fat, flabby, often with kwashiorkor syndrome - "like sugar babies in the West Indies." Philippines In the Philippines, semi-solid food of rice pap and banana is also given followed later by fish and adult food. Breast-feeding in the villages is still common, but the bottle is becoming more prevalent. Dietary supplement, such as tikitiki containing synthetic vitamin B, is bought and used. The major problem is the lack of high-quality protein in the transitional diet, and beriberi. Anemia and marasmus are frequent, avitaminosis A and kwashiorkor are common. The general deficiency in protein is felt especially keenly by infants who are traditionally denied many of the few sources. The greatest cultural barrier to nutrition is the almost religious faith in the efficacy of rise coupled with prejudices against fish and eggs, so that the infant is weaned to a diet of polished rice pap. An in- troduced cultural pattern which presents danger for the future is the increasing substitution of over-diluted, sugar-sweetened condensed milk for breast feeding, often supplying the milk in unsanitary bot- tles to increase gastro-enteritus also. In infant nutrition especially the problem is not so much the lack of food as the disuse of it. Education as to the use of acceptable supplements, such as soya-bean -69- preparations, may improve the situation. Efficaoious practices, of course, must take into consideration the local beliefs: one of the most successful practices in Malaysia seems to be one of assuring mothers that their fears of fish apply only to uncooked fish, but that preperly cooked fish are in fact beneficial for their children: the Malay belief is thus recOgnized, and not attacked but circumvented. Other hopes for the future include provision of more antenatal clinics and trained midwives. The introduction of effective clinics in Kuala Lumpur, for instance, reduced the maternal mortality from 7.0 to 3.7 perlOOO between 1953 and 1956 (Llewellyn-Jones, 1957). The pOpulation must also be educated to use the clinics. The Malays, for example, have the highest preportion of deaths because they prefer to deliver at home and come to the clinic only when seriously sick: they are 50% of the pOpu- lation, but comprise only 11% of clinic patients. The clinics when established and used could do useful work in educating mothers on infant nutrition and even balanced adult diets. The child Health Services of Kuala Lumpur, for example, carries out antednatal sessions for women of every race free, with complete examination and hospital delivery of first and seventh babies, and visiting at home for ten days after all births: smallpox and BCG vaccination are givensfree milk is given as needed, along with feeding instruction: family plan- ning is explained and made available (Wylde, 1961). The infant mortal- ity rate for those using the clinics has dropped from #4 in 1959 to 26 in I961, while it is still over 70 for the nation as a whole. It seems a worthy model project. -70- C. INVOLVEMENT WITH OTHER.DISEASES It seems logical that any parasitic disease agent feeding upon the human host should have an influence on the host's nutrition. The rela- tionship is complex, involving as it does decreased intake, increased loss, and increased needs. One parasite affecting nutrition is the malarial protozoa. In endemic areas a child between six months and three years suffers continuously while acquiring the immunity of adult life: malarial parasites are a direct drain on the host's protein. Another common burden is the intestinal parasite. Intestinal parasitism is acquired directly, but its most damaging impact is its effect on nutrition. The roundworm and hookworm are of primary concern, but trichuris the whipworm is also involved. A third burden commonly con- sists of the bacterial infections which have already been described. It should be noted in passing that gastro-enteritus occurs more virulent- ly in a malnourished child and, in turn, often precipitates kwashiorkor (Jelliffe, 1955). As mentioned, the intestinal parasites hookworm, roundworm, and whip- worm are really directly-acquired diseases with an uncomplicated trans- mission cycle best typified by hookworm, usually Necator americanug. Briefly, when the eggs hatch in the soil, the larva need a certain amount of warmth, moisture, and protection from the sun for them to flourish, and their viability time is so determined. Soil type, pres- ence of shade, season, precipitation, thus are all important. The larva penetrates human skin through the follicles, enters the blood-~ stream and procedes up to the lungs, journeys up the trachea and is swallowed into the intestines where enzymes stimulate the deve10pment and behavior of the adult hookworm. Shoes are of undoubted aid in pre- -71.. venting the penetration, and often the differential incidence rates of urban and rural areas are ascribed to shoe-wearing alone. In the intestines, the adult worms feed on blood and cause hemorrhaging by their fastening. They cOpulate and produce eggs which are then ex- creted by the host. The habits of promiscuous defecation are thus of great importance in disseminating the eggs through the soil. There is some evidence from age and sex and place specific incidences that hookworm is contracted in the fields, while roundworm may be Spread around the house compound by small children. For control of both latrine construction is being energetically pushed in health projects, community development and education. Swellengrebel revived a controversy in Indonesia between Kiewet de Jonge(l90u) and Schuffner over whether all carriers of hookworm should be considered diseased or not (1957). He points out an ex- periment by Foster and Cort in 1932 which induced high levels of resistance to hookworm infection in dogs and then made their diets inadequate, causing the dogs to become ill, re-infected, and their worms to be more productive of ova: those returned to an adequate diet expelled the worms, and those not returned died. He holds that Schuff- ner worked with a pepulation of indentured laborers whose diet was deficient, causing them to be extremely sensitive to hookworm so that every carrier was, indeed, a potential patient: by eliminating beri- beri, Schuffner caused the deathrate to drOp from 50 to 0, although infestation persisted. Tasker, however, working in Kuala Lumpur con- cluded that the papulation had anemia partially because of hookworm infection, but that there was no indication that malnutrition had an effect on hookworm infection rates (1958). -72- In Burma hookworm is widespread but varies greatly in intensity. In general, the delta and coast are moderately severely infected, the central zone lightly, and the Shang states very severely. As-~ caris is common(Wilcocks,l9h4,a). In the former Indochina, Wilcocks estimated that hookworm infesta- tion rates were 50.68% in Tonking, 15-25% in Cochin China and South Annam where the dry season is short, and 29% in Laos and 17% in Cam- bodia (l944,b). Ascaris was not common or serious, he thought. Bauge found 86.9% to be infested intestinally, with the most common being trichocephale (61%),Ascaris lumbricoides, and a lesser rate for anky- lostrom (hookworm 27%) and Entamoeba dysenteria (195“). Although Asian civilians were more infested than the EurOpean civilians (90.9% to 75.8%), the Europeans until the age of 15 were more infested (0.5 years, EurOpean 57.0, Asian h3.#: 5-15 years Eur0pean 100, Asian 93%) raising the possibility of greater Asian immunity. Indonesia before the war commonly had a low intensity of worm loads, and acute anemia resulted only when malaria was also present, although 80-90% of the papulation was infected with hookworm (Wilp cocks,l9uh,c). Lie found in autOpsies in Djakarta,l952-l955, that 99% of the Indonesians and 87% of the Chinese were infected with intestinal worms, including Necator americanus, tricylostoma, tri- churis, Ascaris lumbricoides, Oxyuris, Strongyloides, and trichostrongy- lus (1959). Hookworms were the most frequent, with an incidence of 85.5% and an average worm load of 60.8, although 11% were over 200 and a maximum of 877 was reached. The peak age was 16-25. Trichuris was 84.9% incidence with an average worm load of 12.7: Ascaris had an incidence of 60.8% and an average worm load of 5.3. The wormloads were lower than can be explained by the high incidence and only a small prOportion resulted in clinical anemia - but hookworm is so widespread that the numbers were absolutely large. Kho and Markin reported than only heavy infection of over eleven eggs/ml. is always accompanied by clinical signs; moderate infections were sometimes and light infections seldom so manifested (I962). They found light infections with severe anemia and so suspected additional causes. According to Lie, the residence of Djakarta are divided into brick houses on paved roads with adequate facilities and bamboo houses along back lanes without facilities (1959). Defecating, bathing, and laundering is in the same water in the latter housing, and the p90p1e also go barefoot and eat with unwashed hands. The conditions for larva and eggs are ideal - a temperature average over 27 degrees centigrade, a high relative humidity of 80%, and a high annual rainfall of 80 inches. During 1925-28 Russell conducted what has become a classical study of helminthic infection in the Straits Settlements of Malaya (193“). Those studied included Malay, Chinese (Hakka, Cantonese, Khehs,Tiewa chius) and Indians (Tamils, Telegus, Malayalis, Punjabis, Bengalis) and also Siamese, Japanese, Arabs, and Sinhalese. Using flotation techniques, hookworm infection with Necator americanus and Ancylostoma duodenale was found to be 69.8“. The soil in shady places was hospit- able to larvae throughout the year, the Malays, Indians and Chinese rarely wore shoes, and sanitary latrines outside the cities of George- town and Malacca were uncommon. The Chinese, urbanized, had a lower infection rate. Among all groups the rate was higher in the oldest age groups, the curves rising with age- probably denoting lack of immunity. Ascaris lumbricoides had a total incidence of 62.7, similar to hookworm, but the curve falls with age after twelve although such -74. factors as dust and water Operated equally. The curve for whipworm incidence resembles roundworm, except that the rates were higher among Chinese than for Indians while the reverse is true for hookworm and roundworm. The incidence, then, of hookworm infection among all races tended to increase with age while roundworm and whipworm de- creased. The incidence in all age groups for all three parasites was highest among Malays. In another study by Robertson, a surprisingly low hookworm incidence of 12% as compared with a rounddworm incidence of 53% was found, when the more careful salt flotation method of analysis was used, to be underrating incidence (1929). The incidence was quite high - over 60”- but the degree of intensity was low, with severe infections of clinical ankylostomiasis limited to about 2%. There have been several studies of hookworm, ascaris and trichuris in Thailand. There is great regional variation in environment and hence in incidence of various intestinal parasites. Hookworm was found generally more prevalent among rural than urban pepula tion, but not so for ascaris or trichuris. In the Southern Peninsula there is year-round rain and heat tagether with the shady conditions of rubber farms and tin mines, and Sadun found the incidence of hookworm, ascaris and trichuris to be h3%, 70% and 63% of the peeple, respective- ly, but with a surprisingly low level of intensityCl956). In the Central Plains region, hookworm is uncommon where the land is under water for large parts of the year. In another study by Sadun, the incidence and intensity were found to be highest among children and females and so the infections were believed to be spread around the houses by young childrenCl955). The infection of ascaris was acquired more quickly and lasted a shorter time than with trichuris. Intensive campaigns for control of hookworm, ascaris and trichuris are needed in the South through latrine construction, mass treatment and inten- sive educational propaganda. In pilot programs, it was emphasised that it was only the use and not the presence of latrines that counted, and considerable reduction of infection was possible with treatment when villagers were encouraged to build their own latrines (Sadun, 195h). INCIDENCE OF INTESTINAL PARASITES IN THAILAND area tot. examined ascaris hookworm trichuris strongyl, i neg. North 105 3.8 0.9 - 3.8 89.5 NortheaSt #11 1.2 301 - - 9209 E. Central 24 8.3 12.5 20.8 12.5 41.7 We Central 11“ 2702 6e9 " "' 7206 Ne Peru-1181.118 117 51e3 Be“ 1101 - 3707 S. Peninsula 19 84.2 - 63.2 - 15.8 Bangkok 260 12.7 - - - 87.3 (Stahlie,l961,p.87). As may be gathered from the controversy described above between Kiewet de Jonge and Schuffner, peOple with light worm loads often manifest no sickness at all, although today's studies detect lower serum protein. Usually only severe loads produce the clinical Hook- worm Disease, anemia, as through consumption and hemorrhaging the body protein is drained by the worms and the blood depleted of iron- bearing red blood cells. As described by Strausky, the first stage of "compensated anemia" is characterized by increased erythrOpoietic activity of'the bone marrow with sufficient protein and iron intake to retain the hemoglobin level despite blood loss. The second stage, which can develOp rapidly if the diet is deficient, is characterized by anemia, microcytosis, and hypochromia. The third stage of full anemia develOps after years of poor intake and continual infestation into breakdown of the bone marrow and panmye10phthisis (1950). The following graphs, taken from Tasker, illustrate the association between hookworm infection and anemia (1958). The-strong correlation -76- and the definite differentiation of types of anemia supports the contention that anemia is the result rather than the cause of in- creased infection. While hookworms are more prone to blood-letting, ascaris may interfere with nutrition through blockage by its mass presence of prOper absorption or through its anti-enzyme secretions.. Worm infestation, however, remains only one factor in the etiology of anemia. Most pe0ple infected by intestinal parasites are not diseased and there is no doubt that other factors, such as age, social condition, sex, and especially nutrition are major factors in the etiOIOgy of the disease. Parasitic infections such as heck- worm, ascaris or malaria have an influence on nutritional status, especially through their added demands on an already marginal situation; they are frequently the precipitating factor in deficiency disease. There is considerably more contention over the role of nutrition in susceptibility to infection. This is part of the general problem- atic consideration of the influence of nutrition on diseases. Any determination of the importance of nutritional predisposition to disease awaits develOpment of further techniques of control,analy- sis and measurement. Authors frequently speak of the role of nutrition, as when Malard notes the low resistance of Malays to tuberculosis and asserts the importance of nutrition, noting that the Chinese and Indians have better food than the Malays. Indeed, there is an unmistakable correlation between poor nutrition and the incidence and intensity of most diseases - tuberculosis, yaws, and hookworm being only the most frequently cited examples. The greater virulence of gastro-en- teritus in malnourished children has already been alluded to. It cannot usually be stated, however, whether the greater incidence among the poorly nourished is primarily due to nutrition or not: the poorly 1"‘5 Li nourished are usually the poor, who also have poor sanitary conditions, crowded conditions of living, greater exposure to infection, less treat- ment of infection, greater weakening by previous diseases, and many other characteristics which may be related to susceptibility or re- sistances to disease. Correlation is not causation. -78- 7. DISEASES OF OTHER CAUSATION There remains a myriad of diseases which seem to defy consistent classification. What can cancer, paranoia, allergies, congenital afflictions, and diseases resulting from pollution be said to have in common? Perhaps more than most diseases they exemplify the dif- ferential impact of the environment upon the uniqueness of organism. The genetic heritage and chemical composition with which each individ- ual faces the mental tensions and the noxious gasses of his urban environment or changing society is etched in relief by the differential response of the cancers, asthmas, and nervous breakdowns. On another scale, cultural practices may tend to expose or protect the pepulation at risk to various diseases. Cancer is widely known to vary greatly in the site of its most frequent occurrence from country to country. The patterns of incidence may reflect aSpects of the physical environment - such as skin cancer and ultraviolet radiation or stomach cancer and trace elements in ‘water. More likely, it reflects the influence of cultural practices such as chewing betel, smoking cigarettes, overcooking food, early marriage or artificial feeding of babies. Chinese and EurOpeans, for instance, have a similar incidence of peptic ulcer, whereas it is almost unknown among Javanese (Konwenaar, 1951). Much of the Javanese cancer, in contrast, is carcinormata of a cirrhotic liver - probably due, Konwenaar thinks, to malnutrition. Yet he finds the overall incidence of malignant tumors the same as for EurOpeans, providing the age structure of the pepulation is taken into consideration. Betel chewing is an example of a cultural practice involved with cancer. Cancer of the mouth is high among Indonesians, Malays, and Indians. In a study near Kuala Lumpur, 50% of the women were found to chew betel . in“. egg-j! before they were twenty(l968)., Reasons included the belief that they would relieve toothache, relieve nausea due to pregnancy, relieve depression, or simply please their friends. The quid chewed is a combination of betel leaves, areca-nut, lime, and sometimes tobacco. This study found a high likelihood that betelpchewing causes lesions of the mouth, but no evidence for cancer. In earlier studies,Sanghvi found chewing associated with oral cavity cancer, but Balendra felt it was not directly carcinogetic but produced dental attrition, knife- edged teeth, and traumatic ulcer (1955). Otherwise, betel chewing seems to reduce the incidence of dental caries but increase peri- dental disease. Malaysia is an especially interesting place to study cancer because of the presence of so many races and cultural groups living under identical conditions of the physical environment, and having widely differing incidences of cancer. The table below was deve10ped from the report of’Marsden, working with llAO cases at Kuala Lumpur (1953). respiratogy skin stomach mouth penis breast uterus Chinese 27% (14) 143304) 57604) 3%(M) mm 18W) 31am 7 11 9 27%(M) 11 7 Indian 32 35%(F) Iifllfiy ? 32 7 3 2 Nome e e 1088 London 14 0. ’4 10 9 .7 1 30 16 The role of physical environment, cultural practice, and infective agent is still far from understood in relation to such patterns. The role of cultural practices in producing environment conditons detrimental to health is more obvious. "Occupational hazards" such its black lung have long been recOgnized. RecOgnition of the hazards accruing to an occupant of a technological society is merely beginning. my ‘ J!!! -80- In the most developed and critical situations, such as that existing in the United States, the dangers of the internal combustion engine, insecticides, and accumulating wastes are only beginning to be realised by the public and those publicly responsible. The problem of pollution in Southeast Asia already has reached serious preportions, but goes practically unconsidered. Chemical» pollutants include the widespread use of DDT as a residual spray against mosquitoes; spraying techniques are often careless, and millions of peeple sit and walk in constant tactual contact with the poison. Indirect infection is also serious, as the ever-greater'yields lead to application of insecticides to rice cultivation - with ill affect,on the fish which grow with the rice and constitute the major protein supply. The major cities, such as Bangkok, are already choked with an exhaust pollution far more noticeable than New York's. Many of the factors which cause this condition could bezfor instance, public and private vehicles in a state of poor mechanical repair and burning cheap grades of the always-expensive petroleum are conspicuously guilty. The chemical and gaseous pollution of the environment is ouooso . _ 1.3933 23.33:: . schooner . .— . 2.44aao sane _ sea-snug. zu>hznou OU>U>SSO 80.5.00“ (UIC afloamuxu 6‘98 80:. l ><’x..8 U814 (:05 '.'.' >¢¢ozaou >h8=Ou u- - _ 3: unseen .e neeeu m>m3m .juzxm: I cuIOOJO . .24e menwnmnNmfi _nN 0N hm mu mmon N MN NN _N ON m. m. w. m. m. h. m. N_=o_mw~u e.g.-De... us an: esteem \I! '11-'11"! I’ll]. 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J . _ _ol...os.‘ _ 22.5., 205... mu "coco; u>g..o >3... 5.3.333 T4 Eon 322.0. a u . / _ -14- DESCRIPTION OF ANALYSES AND RESULTS Questionnaire Responses The responses to the questionnaire are tabulated in Table 2 by the percentage of responses in each zone falling into the various categories of response. While the results are generally instructive and rewarding of careful study, several items are especially noteworthy. An average of over two-fifths of households surveyed lived in farm houses, the pro- portion rising to over half in Zone C; yet, an average of little over a tenth, reaching a fifth in Zone C, were farmers. Interviews indicated that when farmland is consolidated, the surplus farmhouse is frequently sold as a private residence. Since the farmhouse usually is on a lot of from two to ten acres, along with a barn and chicken house or other build- ings, this portion of the non-farming rural population is completely camouflaged to the eye of a passing motorist. A clear majority of the heads of household grew up "rural farm." Over a third have lived in their present rural residence for at least twenty years. What is sur- prising, however, is that more than a quarter have lived there less than five years, and over sixteen percent claimed that their last previous residence was in a city of over ten thousand people. In accordance with established ideas concerning the stagnation of rural population, a full quarter of heads of household were over sixty; what is more remarkable, forty percent were under forty. Another surprising finding was that forty-five percent of rural households have no children dependent, while an additional forty-seven percent have two children or less. Lastly, it is important to note that almost a third of the heads of house were factory workers and another third, responding in the "other, please .\l}]." \il‘l. .Ill‘ll' I.‘ 11". TABLE 2. — RESPONSE TO QUESTIONNAIRE Question Percentage of Zone Responses Number Category Zone A Zone B Zone 0 Survey Mean House type Farm 14.2 34.5 52.7 37.0 Old 59.5 19.1 17.8 27.0 New 26.1 34.5 18.9 27.0 Trailer 0.0 11.9 10.4 8.5 No answer 0.0 3.0 ‘.0 0.0 1. length of residence Under 1 year 9.5 9.8 10.8 10.1 1-5 years 21.4 5.8 21.6 16.7 6-10 years 16.6 17.6 13.5 15.5 11-20 years 19.0 21.5 18.9 19.7 over 20 years 33.3 45.0 35.1 37.7 no answer 0.2 0.3 0.1 0.2 2. Place of previous residence same community 56.0 56.9 62.1 68.7 elsewhere in Michigan 41.4 40.5 28.3 36.0 out-of-state 2.4 2.5 9.4 5.1 no answer 0.2 7.1 0.2 ”.2 3. Size of previous residence city over 10,000 24.3 12.8 16.2 16.“ suburban development 19.5 0.0 1.3 4.6 in town 9.7 11.5 20.2 14.5 outside town, nonfarm 21.9 21.7 13.5 18.6 rural farm 21.9 51.2 45.9 43.0 mobile home 2.4 2.5 2.7 2.5 no answer 0.3 0.3 0.2 0.3 4. Place of growing up city over 10,020 17.9 11.3 8.2 11.5 suburban development 7.6 1.2 1.3 2.6 small town 23.0 16.4 23.2 20.4 outside town,nonfarm 12.8 11.3 10.9 11.5 rural farm 38.4 59.4 56.1 53.9 no answer 0.3 0.4 0.3 0.3 5. Plans to move no plans 75.4 93.6 86.6 86.3 yes, to city over 10,100 3.3 0.0 1.3 1.? yes, to suburbs 0.0 2.1 1.3 1.2 yes, to town 12.8 0.0 9.3 7.4 yes, to nonfarm outside town 5.1 4.7 1.3 3.1 yes, to rural farm 3.3 0.0 0.0 1.1 TARIE 2, continued. “ -16- RESPONSE TO QUESTT (INN/11131? Question Percentage of Zone Resgonses Number Category Zone A Zone B wn'Zone C Survey Mean 6. Age of head of house uncer 21 0.0 2.5 0.0 1.0 21-30 11.9 25.6 15.7 18.8 31-40 14.2 29.4 18.4 21.9 41-50 19.0 15.3 15.7 16.5 51-60 23.8 6.4 22.3 16.3 over 60 30.9 20.5 27.6 25.5 no answer 0.2 0.5 0.3 0.3 7. Children still dependent 0 46.6 39.3 48.6 44.8 1 28.8 22.7 20.2 23.2 2 8.8 33.3 24.3 23.7 3 6.6 4.5 5.4 5.4 4 or more 8.8 T.0 1.3 2.7 no answer 0.4 0.2 0.2 0.3 8. Occupation ' retired 23.2 17.7 13.5 17.3 factory 18.6 25.3 44.6 31.1 farming 0.0 13.9 21.6 13.8 self-employed 9.3 6.3 1.4 5.1 government employee 9.3 5.1 0.0 4.1 other 39.5 31.6 18.9 28.6 no answer 0.1 0.1 0.1 0.1 9. Length of time 8n job not employed 36.1 32.4 37.8 35.2 under 1 year 8. 5.1 10.8 8.3 1-5 years 11.1 24.6 17.5 19.2 6-10 years 11. 20.7 5.4 12.8 11-23 years 11.1 11.6 14.8 12.8 over 20 years 22.2 5.1 13.5 11.7 no answer 0.1 0.5 0.2 0.3 10. Time journeying to workC no journey 36.8 29.0 36.9 34.7 under 20 minutes 16.9 12.7 8.? 12.4 20-50 minutes 20.0 18.1 32.8 24.3 50-89 minutes 21.0 29.1 8.2 18.1 over 80 minutes 6.1 10.9 13.6 10.3 no answer 0.0 0.3 0.3 0.2 11. Acres under 2 43.9 42.1 25.0 35.9 2-10 29.? 17.1 18.3 23.1 11-60 7.3 10.5 16.6 12.1 61-200 14.6 18.4 25.0 21.1 over 200 4.8 11.8 15.2 11.6 no answer 0.2 0.1 0.2 0.2 .C in "-1-:ng a..- j I _.'-\ 'n 11M? Aw ... el,... .. 5"}? -17.. TATHE 2, continued. - RESPONSE TO "l'ESTTOl‘N/J‘W Question Percentage of Zone Responses Number Category Zone A Zone 8 Zone 0 Survey Mean 12. Own or rent own 87.5 95.7 88.8 91.2 rent 12.5 4.2 11 1 8.7 no answer 0.0 0.1 0.1 0.1 13. Pleasure: have the following vegetable garden 53.6 69.2 54.7 60.4 chickens 7.3 0.0 4.1 3.1 horse 2.4 3.8 1.3 2.6 none 36.5 26.9 39.7 33.8 no answer 0.2 0.1 0.2 3.2 14. Ever supported self by farming yes 24.3 45.4 48.6 42.1 no 75.6 54.5 51.3 57.8 no answer 0.1 0.1 0.1 0.1 15. Percentage of income from farming 0 78.0 70.1 54.7 65.9 1-20 17.0 15.5 16.4 16.2 21-40 0.0 1.2 6.8 3.1 41-60 2.4 2.5 1.3 2.0 61-83 0.0 3.0 1.3 0.5 81-100 0.0 2.5 2.7 2.0 no answer 2.6 8.2 16.8 9.2 16. Net family income under $5030 23.0 13.1 33.3 20.8 35000-7500 22.5 38.1 24.2 10.4 37503-10,030 32.5 25.0 24.2 26.3 over 10,000 25.0 23.6 21.2 23.0 no answer 0.0 3.2 0.1 0.1 17. Reason for changing rural residence better for children 17.5 26.9 16.4 20.9 lower taxes, cheaper land 2.5 1.2 2.7 2.0 less congestion,more room 57.5 33.3 35.6 39.? away from riots and crime 3.0 0.0 2.7 1.0 lower rent 5.0 1.2 1.2 2.0 near employment 7.5 5.1 4.1 5.2 homestead farming and other 10.0 32.0 36.9 29.3 no answer 0.0 0.3 0.4 0 7 a truck drivers,construction laborers, etc. retired,unemployed,farmers d=w8 in minutes travelled absolutely, later categori7ed s 4* _‘.'I‘-‘_~*<-‘-x-.n—;_.g._-- -18- specify" category, were teachers, construction laborers, or people who held other jobs in urban areas. After study of the questionnaire responses with their variations by zones and categories, five null hypotheses are advanced. (1) The responses concerning commuting journey will not be significant- ly different by background of the population, as measured by re- sponses concerning place of growing up. (2) The preference scores derived from the questions on the value of rural living will not be significantly different by background of the population, as measured by responses concerning the place of growing up. (3) There will be no difference among the three survey zones with regard to preference scores. (4) There will be no difference among the three survey zones with regard to occupational structure. (5) The length of commuting journey of the non-farming population will not correlate significantly with scores on the ten rural preference questions. It is expected that all five of these null hypotheses will be re- jCCtede Statistical Analysis Since a significant Chi-square indicates the presence of a rela- tionship, but not the strength, Pearson's coefficient of contingency, c, was calculated in addition to Chi-square.3 When the responses on 3 Chi-square is a measure of the significance of differences between observed frequencies in nominal categories and the frequences that would be expected from normal percentages of total distribution. If the differ- -19- journey time are classified as short (twenty minutes or less) or long (over twenty minutes) and place of growing up is classified as farm or non-farm, the Chi-square for the two-by-two table is significant at the .001 level. The null hypothesis of no difference in journey by place of growing up is rejected. (C is a moderate 0.31). When the total scores on the preference questions are classified as low (under 26), medium, or high (over 32) and a Chi-square analysis is done with the five categories of place of growing up, the three-by- five table produces a Chi-square which is significant at the .001 level. The null hypothesis of no difference is rejected. (C is a strong 0.55). If the three categories of scores are compared on the basis of farm- nonfarm origin, the Chi-square falls barely short of being significant at the .05 level. Hypotheses three and four concern differences among the survey zones. When the total preference scores are again classified as low, medium, or high and a Chi-square for the three- by-three matrix is calculated, it (is not significant at the .05 level. The third null hypothesis is accepted. When the occupational classifications of retired, factory, farmer, and "other" are compared by survey zone in a three-by-four table, Chi-square is significant at the .05 level. The fourth null hypothesis is rejected. (C is 0.27). The survey zones, established by distance from.Lansing, are differentiated by occupation, but there is no significant difference among them concerning the value the population ascribes to ences are significant, the strength of the relationship can be measured by the coefficient of contingency, which is calculated by dividing the Chi-square by the sum of itself and the total population and then taking the square root. Since the upper limits of the contingency coefficient depend on the number of categories, it can not be interpreted as a tetra- choric coefficient of the same magnitude. The coefficients are comparable only when the tables are of the same size. In a two-by-two matrix, the upper Inuit is 0.706; there is no negative value. Ili'li‘l- ll -20.. rural living. The following percentages are also illustrative of dif- ferences among the zones. TABLE 3. - JOURNEY TO WORK BY ZONE Percent of Heads of Household Zone Journey to work Journey to work over 20 Minutes A 67.4 46.5 B 67.1 53.9 C 63.0 54.8 Mean 65.6 53.1 Continuing the analysis of differences among zones, the Kruskal- wallis H statistic is calculated for zone and for house types against rank of distance traveled to work, scores for each of the preference questions, and total preference scores.“ Zone is significant at the .05 level with "Suburban better off" (question 22) and with "Repulsion of the city" (question 27). Housetype is significant at the .05 level with "Jour- ney time" (question 11), "Good for children" (question 25), "Isolation" (question 26), and with the total preference score. The fifth null hypothesis is that length of journey to work will not be correlated with rural preference scores. The zone, or distance from Lansing, can not be used here because the Lansing labor shed over- laps with that of major cities such as Flint and envelops that of smaller cities such as Albion (see Map 2). Especially in Zone C, a head of house- hold may be relatively far from Lansing, for instance, but near to another urban center where he works. 4 The non-parametric statistical program.of the Computer Institute for Social Science Research,‘Michigan State University, program version 40.09 is used. The Kruskall-Whllis H, calculated by the routine 0P,KNA, is used because the assumption of homoscedasticity and normality for analy- sis of variance could not be met, while the Kruskal-wallis H test is ap- J11}?! -21- An initial analysis is made of the median values of the preference scores for each of the times of journey (18) given.5 The Chi-square for the large matrix is small and no significant difference is found in rural preference scores by length of journey to work. To correlate the jour- ney time and preference scores, Kendall's tau is calculated with grouped data because of the large number of ties among the ranks of both prefer- ence scores and journey time. Tau varies from plus to minus one and gives equal weight to all pairs of scores, being less affected by ex- tremes than other rank coefficients. A four-by-four matrix of high, medium high, medium low, and low ranks for scores and journey time is composed, and tau is found to be -.078. There is no significant cor- relation between journey time and scores. A simple regression of jour- ney time against preference scores also yields an r of -.065, confirming the rank correlation. The fifth null hypothesis of no correlation be- tween journey time and preference scores is accepted. Significant differences thus exist for place of growing up - jour- ney time, place of growing up'- rural preference score, and zone of res- idenceI- occupation. There is no significant difference among rural preference scores by either zone of residence or thme spent traveling to work. The above analyses begin to focus a picture of a rural population which is undergoing considerable change in composition and economic orientation. Within the last few years large numbers of working-age people have moved into rural areas, building new homes, trailer camps, appropriate for ordinal and nominal scale data. It involves a couparison of the sums of the rankings for each of the categories of the nominal scale variable. 5 In the above program version 40.09, routine 0P,HED is used to produce a Chi-square relating the median values of one variable for each of the categories of another variable. -22.. small subdivisions, or, frequently, occupying old farm houses whose former lands have been consolidated with other farms. Economically important farms are large, usually five hundred acres or more. The majority of the rural population, however, owns less than twenty acres and frequently less than two. If they farm at all, it is small-scale and for pleasure. The journey to work of those interviewed is shown on‘Hap 2. Those peo- ple who grew up on farms have longer journeys and higher rural preference scores. Paradoxically, journey time is not correlated‘with preference scores. Furthermore, despite the significant difference in occupational structure among the three zones, preference scores are not significantly different. Rural preference scores seem to be related only to the back- ground of the head of house, not to his proximity to Lansing or time spent journeying to work. People moving into new houses in rural areas tend to journey farther to work than commuters from.farm houses, who often work in nearer towns. The more recent residents tend to be more vehe- ment about their rural preference and, while admitting to some inconven- ience from isolation, tend to be convinced that country living is better for the children than the over-crowded city. Factor Analysis So far the questionnaire response matrix has been analyzed with respect to specific categories. The nature of the population surveyed, however, is reflected in the internal structure of the matrix, in the overall correlation and covariance of all responses for all categories. Factor analysis is a technique of multivariate analysis which deals with such internal matricular structure. Although developed by the psychologists Spearmen, Thomson, Thurstone and Burt, the "Rpmode"common ll‘ljllll 1i} I ‘I‘lil'l‘l' tea-.4 \\ . . . -. - , ll eagles—ea .ev. 9 .aseaemc. 3:. 3. O .aeeeee :— eaa— ans.— ..cELEa. z¢_h<._ 9ch a— r._m>mbm wm >QZMDOa Mao? // I \ \ \ l l t \ -24- factor analysis used here is widely used in geography for purposes of description and summation because of its ability to collapse numerable variables into "factors" of their major components. For such uses, no assumptions of normality are needed and nominal, ordinal and interval data may all be used; however, use of the results of factor analysis with other tests for statistical inference may thereby be limited. The ‘major assumption is one of linearity. The factors generated are vectors in space, and by rotation are so positioned as to be as near as possible to a maximum number of variables. The variables most highly correlated are thus most important for that vector, and are said to be "loaded" highly on the factor. When, as in the present case, the rotation used is orthogonal, or at right angles, the factors generated are by mathe- 'matical definition uncorrelated. The scores of individual observations on each factor may be computed, and since they have been normalized and are uncorrelated may serve as data input for further analyses requiring such assumptions.6 Prom.the statistical analysis of the questionnaire responses already completed, three major components of rural population are postulated: (1) An old residential component (2) A new, young, working component with social motives for residence (3) A new, young, working component with economic motives for residence. Unlike the nonparametric programs previously used, factor analysis has no provision for missing data.7 Incomplete questions and full-time fanmers with no journey (to whom.many questions are no applicable) must therefore be dropped and the analysis based on one hundred and nine ob- For calculation of factor scores and factors, see Harman, 1960. 7 Michigan State University's Computer Institute for Social Science Research's library programLFactor AA is used in this factor analysis. -25.. servations. It should be noted that full-time farmers and the retired are not represented in the following factors; essentially, the factors reflect the rural, economically active but non-farming population. It is also necessary to recode the numerous categories as simple binomial presence or absence, and these new categories are defined in Appendix B. Responses to the ten value questions are still recorded as scores weighted from zero to four. Journey time to work and total preference scores are expressed in rank order.8 The rotated factor loadings for the eight factors are shown in Table 4. The eight factors explain a total of fifty-six percent of the variance with rather moderate communalities (percent of the variance of the variables involved in the pattern of factors). The highest proportion of variance is explained by factor two, la- belled "stability." It is loaded highly on length of residence, age, work permanence, ownership of land, and negatively on intention to move. It is interpreted as representing the established and stable families which have long resided in their present location. The head of house tends to be older than the head of house represented on other factors. He has worked at his present job for years and owns his own land. In contrast, factor eight represents an unstabilized component of the popu- lation. It explains only 5.3 percent of the variance and is highly loaded on intention to move, willingness to move for more income, belief that suburban schools are better than theirs, and loaded negatively on the reason for living in the country. These people are dissatisfied, are consideringymoving, and would do so for more income. In general, they 8 The categories of journey time and rank order of journey time were omitted from.the following factor analysis for purposes of later regression against the scores. Their inclusion here would be collinear. They were, however, included in an earlier analysis which reported essentially the same components, loading the journey time inversely to children on factor 4. -26.. did not come for reasons of social utility, but for economic attractions such as cheaper rent or proximity to work. They are not stably settled and will follow economic utility in the future. Factor seven is labeled "Dissatisfaction" and explains 8.3 percent of the variance. It is loaded highly on the inconvenience of shopping, isolation, disconvenience for housewives, willingness to move for income, and strongly negative for rank preference scores. The component of pop- ulation which it describes is dissatisfied with rural living and, while presently of low income, hopes to move in the near future. Factor three, "New Rural," explains 7.3 percent of the variance and isolates that component of rural population which has recently come. It is loaded highly on housetype, and strongly negative for number of acres, past support by farming, present income from farming, and length of residence. The peeple live in new houses on one-and-two acre lots, get little income from farming, and seldom have a background of farming. They tend to be young and have a good income. Factors four and five, "Ho Urban Advantage" explaining 7.2 percent of the variance and "Children's Benefit" explaining 7.3 percent, respec— tively, describe those who place a high social value on rural living. Factor four represents those with many children who see no benefits in city or suburban life. Since those strongly agreeing with the statements, "The city has more life," and "The suburbs are better off" were given low rural preference scores, a high positive loading actually represents sen- timents opposite to the statement. Factor five is especially strong on benefits of the countryside for raising children and on the repulsion of the city. They are differentiated mainly by previous residence, with those represented by factor four moving in from a local area and those represented by factor five moving in from outside the community and having newer jobs. -27.. The last two factors, one and six, explain 6.4 and 5.5 percent of the variance, respectively. "Old Rural" and "Old Rural Background" have the same direction of loading for "like rural living," "children," and "rank preference scores." Information gained during surveying aids in inter- preting these loadings. Not only did peOple living on farmateads and in old houses tend to have more children (when they were not retired) and to prefer country living; they also were less evangelistic and idealistic about the benefits of country living and more ready with recognition of its shortcomings than were the newer residents. Thus, scores on liking for rural living and neighborliness may have resulted in the negative loadings because of more critical appraisal than.was often given, although the total preference scores remain positive. The differential between these two factors lies with income and occupation. It is suggested that factor 1 represents fanning and low income people and factor 6 represents those who, while growing up on rural farms (size previous residence, place grow up) have factory occupations and higher income. Perhaps the factors reflect the major differential of ten years age between those who took on part-time factory jobs and those who did not. The hypothesized dimensions are present, but divided and over-shadowed by the unanticipated dimensions of stability and dissatisfaction. The old residential component is probably involved in the factor labeled "Sta- bility," and also in "Old Rural"; but it fails to emerge as a single fac- tor. The naw, young working component is reflected in "New Rural" and probably in "Children's Benefit." The new, economically-oriented popu- lation dimension is involved in "Instability" and possibly in "Dissat- isfaction." Despite doubts over the statistical validity of mixing binomial‘categories and weighted responses, meaningful and descriptive components have been defined. Qq.n cmfiu mmofi Mawvmofi Leuomm u Ce. 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