Public Health and Medical Sciences in the Pacific: A Forty Year Review 9780824892685

Table of contents :
PUBLISHER'S PREFACE
STANDING COMMITTEE MEMBERS
EDITOR'S PREFACE
CONTRIBUTORS
CONTENTS
Introduction: Aspects of Health in the Pacific
Australia
Canada
Chile
China: Taiwan
Indonesia
Japan
Malaya
Philippines
Thailand
United States—California
United States—Hawaii
Index

Citation preview

T E N T H PACIFIC SCIENCE CONGRESS SERIES

T E N T H PACIFIC SCIENCE CONGRESS

SERIES

Tenth Pacific Science Congress, Honolulu, 1961

AGRICULTURE Soil Conservation in the Pacific—A Symposium and Panel Discussion J . H. Christ, chairman ANTHROPOLOGY Ryukyuan Culture and Society—A Survey Allan H. Smith, editor BOTANY Ancient Pacific F l o r a s — T h e Pollen Story Lucy M. Cranwell, editor ENTOMOLOGY Pacific E n t o m o l o g y — R e p o r t of the Standing Committee Chairman J. J. H. Szent-Ivany GEOLOGY G e o l o g y and Solid Earth Geophysics o f the Pacific B a s i n — Report of the Standing Committee Gordon A. Macdonald, chairman MARINE BIOLOGY Physical Aspects o f Light in the S e a — A Symposium John E. Tyler, editor MEDICINE Public Health and Medical Sciences in the Pacific — A Forty-year Review J. Ralph Audy, editor

PUBLIC HEALTH AND MEDICAL SCIENCES

T E N T H PACIFIC SCIENCE CONGRESS o f t h e Pacific S c i e n c e

Association

HOST INSTITUTIONS N a t i o n a l A c a d e m y o f Sciences B e r n i c e Pauahi B i s h o p M u s e u m University o f H a w a i i

Honolulu, Hawaii, U.S.A. August 21 to September 6, 1961

U N I V E R S I T Y OF H A W A I I ,

PUBLIC H E A L T H A N D M E D I C A L SCIENCES IN THE PACIFIC A Forty-Year Review

1920-1960 J.

RALPH

AUDY

Editor

U N I V E R S I T Y OF H A W A I I Honolulu, H a w a i i , 1964

PRESS

C o p y r i g h t 1 9 6 4 U n i v e r s i t y of H a w a i i Press Library of Congress Catalog Card N u m b e r : 6 3 - 1 9 5 2 7

PUBLISHER'S

PREFACE

T h e papers published in this volume were presented at the T e n t h Pacific Science Congress of the Pacific Science Association held August 21 to September 6, 1961, on the campus of the University

of Hawaii, Honolulu, Hawaii, U.S.A., scene of the first meeting.

The

Congress

was sponsored jointly by the National Academy of Sciences, Bernice Pauahi Bishop Museum, and the University of Hawaii. T h e publisher is indebted to the chairman

for having assembled these papers from

the

far corners of the Pacific. In editing the material, American usage has been followed in the main, though the desire to put this material in print as soon as possible after it was assembled has been responsible for some degree of stylistic inconsistency. Funds toward the issuance of Tenth

Pacific Science Congress papers published by

the

University of Hawaii Press have been furnished by the Legislature of the State of Hawaii and the National Institutes of Health.

T h e preparation of this work was partly supported by the

University of California International Center for Medical Research and Training ( S a n Francisco School of M e d i c i n e ) with Research Grant No. A I - 0 4 1 8 9 from the National Institutes of Health, U.S. Public Health Service. It is believed that a useful purpose is served by bringing together in one volume distinguished papers on a common subject as it applies to conditions that prevail in the various countries of this increasingly important segment of the world scene.

vii

STANDING COMMITTEE

MEMBERS

K . F. M E Y E R , C h a i r m a n ; J . R A L P H AUDY, D e p u t y

VICTOR

Chairman

Australia

W.

Belgium

L. V A N D E N

Canada

B. D . B. LAYTON

Chile

HERNAN

China:

CHUN-HUI

Hong

Taiwan

ROBERT

Kong

MACFARLANE BERGHE

ROMERO YEN

KIRK

India

C. G . PANDIT

Indonesia

R.

Japan

MASAMI

Malaya

MOHAMMED D I N

MOCHTAR KITAOKA

N e w Zealand

D. D.

Panama

PEDRO GALINDO

MCCARTHY

Philippines

T . P. PESIGAN

Tahiti

E. MASSAL

Thailand

CHALOEM

United

W . E. K E R S H A W

Kingdom

PURANANANDA

U . S. A.

RICHARD K . C. L E E

U . S. S. R .

F. ZHDANOV

viii

EDITOR'S

PREFACE

T h i s v o l u m e a t t e m p t s to g i v e a brief r e v i e w of t h e c u r r e n t s t a t e of p u b l i c health a n d m e d i c a l sciences in c o u n t r i e s of the Pacific r e g i o n , t o g e t h e r w i t h the p r e c e d i n g d e v e l o p m e n t s over a p p r o x imately the last half-century.

It is in the f o r m of r e g i o n a l r e v i e w s w r i t t e n by m e m b e r s of

the

i n t e r n a t i o n a l S t a n d i n g C o m m i t t e e f o r P u b l i c H e a l t h a n d M e d i c a l S c i e n c e s of the Pacific S c i e n c e A s s o c i a t i o n , a n d by t w o invited c o n t r i b u t o r s r e p r e s e n t i n g C a n a d a a n d C a l i f o r n i a . T h e authors are to b e c o n g r a t u l a t e d for p r e s e n t i n g a solid r e c o r d of p r o b l e m s r e c o g n i z e d a n d c o m b a t t e d .

Some

have b e e n s o l v e d , b u t c o m p l e x p r o b l e m s r e m a i n w h i c h a r e i n c r e a s i n g faster than w e c a n d e v i s e m e a s u r e s to c o m b a t t h e m . W e n e e d not l o o k f a r to find the m a i n c a u s e of our p r e d i c a m e n t :

it

is the p o p u l a t i o n a v a l a n c h e and the s o c i o c u l t u r a l c h a n g e s w h i c h a c c o m p a n y it. In the years a h e a d we shall surely r e c o g n i z e that the s o c i o c u l t u r a l a s p e c t s of c o m m u n i t y health h a v e b e e n disastrously neglected. T h e c o n t r i b u t i o n s to this v o l u m e w e r e o r i g i n a l l y p l a n n e d so as to b e r e g i o n a l l y c o m p l e t e , to d e v e l o p i n t e r r e g i o n a l a n d i n t e r n a t i o n a l a s p e c t s of health p l a n n i n g , a n d to b e as c o n s i s t e n t

as

p o s s i b l e in the f o r m a t a n d r a n g e of m a t e r i a l s o t h a t t h r e a d s of c o n t i n u i t y could b e p i c k e d u p by the s t u d e n t w h e n p a s s i n g f r o m o n e r e g i o n to a n o t h e r . V i g o r o u s a t t e m p t s w e r e m a d e by us all to a c h i e v e these a i m s , b u t this p r o v e d i m p r a c t i c a b l e in the t i m e available.

It w o u l d h a v e r e q u i r e d

that each c o n t r i b u t o r study several t i m e s over all c o n t r i b u t i o n s a n d r e w r i t e his m a t e r i a l accordingly, and that m o r e c o n t r i b u t o r s b e a d d e d t o c o m p l e t e the r e g i o n a l picture.

T h e reader

will

t h e r e f o r e h a v e to m a k e allowances. T h e g r e a t e s t d e f e c t h e will find is that s o m e m a j o r r e g i o n s are not r e p r e s e n t e d .

It w a s not

p o s s i b l e for v a r i o u s r e a s o n s t o o b t a i n s o m e r e v i e w s in t i m e for delivery at the C o n g r e s s , and f u n d s m a d e a v a i l a b l e f o r p u b l i c a t i o n s w e r e firmly r e s t r i c t e d t o C o n g r e s s p a p e r s .

W e g r e a t l y regret the

lack of r e v i e w s f r o m Latin A m e r i c a n m e m b e r c o u n t r i e s ( w i t h the e x c e p t i o n of C h i l e ) , m a i n l a n d C h i n a , K o r e a , N e w G u i n e a , a r c h i p e l a g o e s of the S o u t h Pacific, N e w Z e a l a n d , the far eastern p a r t s of the U . S . S . R . , a n d certain p a r t s ( A l a s k a a n d O r e g o n )

of the U . S . A .

It is t o b e h o p e d that the E l e v e n t h Pacific S c i e n c e C o n g r e s s , to b e held in T o k y o in A u g u s t S e p t e m b e r , 1 9 6 6 , will p r o v i d e o p p o r t u n i t i e s for b u i l d i n g on the b a s i s of this v o l u m e .

J . R A L P H AUDY

Editor

IX

CONTRIBUTORS

J . R A L P H AUDY

T h e George W i l l i a m s Hooper Foundation, San Center, San Francisco, California, U . S . A .

MARGUERITE S. AUGUSTINE

H e a l t h Education Consultant, D e p a r t m e n t of P u b l i c H e a l t h , Berkeley, C a l i f o r n i a , U . S . A .

MOHAMMED D I N

Director of Medical Services, Federation of Malaya, Kuala Malaya

Francisco

Medical

Lumpur,

MASAMI KITAOKA

National Institute of Health, T o k y o , J a p a n

B . D . B. LAYTON

Principal Medical Officer, International Health Section, D e p a r t m e n t of National Health and W e l f a r e , Ottawa, Canada

RICHARD K . C. LEE

Director of Public H e a l t h and Medical Hawaii, Honolulu, Hawaii, U.S.A.

W . V. MACFARLANE

D e p a r t m e n t of Physiology, berra A C T , Australia

Australian

Activities,

National

University

University,

TRINIDAD P. PESIGAN

D e p a r t m e n t of H e a l t h of the Philippines, Manila, Philippines

CHALEOM PURANANANDA

Q u e e n Saovabha M e m o r i a l Institute, B a n g k o k ,

HERNAN ROMERO

Catedra de H i g i e n e y M e d i c i n a Preventiva, University of Chile, Santiago, Chile

HERMAN SOESILO

F o r m e r a s s i s t a n t to R . M o c h t a r ( d e c e a s e d ) , D e p a r t m e n t Health and Preventive Medicine, D j a k a r t a , Indonesia

CHUN-HUI

Commissioner China

YEN

X

of

Health,

Taiwan

Province,

of

Can-

Thailand Esaiela

Taipei,

de

Medicina. of

Public

Republic

of

CONTENTS PAGE

Introduction J. R A L P H A U D Y

3

AUSTRALIA W . V. M A C F A R L A N E

13

CANADA B. D . B. L A Y T O N

23

HERNAN

29

CHILE

CHINA:

ROMERO

TAIWAN

C. H . Y E N

45

INDONESIA HERMAN

SOESILO

53

KITAOKA

59

JAPAN MASAMI

MALAYA MOHAMMED

DIN

83

PHILIPPINES T R I N I D A D P. P E S I G A N

87

THAILAND CHALOEM

PURANANANDA

101

UNITED STATES—CALIFORNIA M A R G U E R I T E S. A U G U S T I N E

107

UNITED STATES—HAWAII RICHARD K . C. LEE

Index

117

129

PUBLIC HEALTH A N D MEDICAL SCIENCES

Introduction Aspects of Health in the Pacific1 J. R A L P H AUDY

DR. KARL F. MEYER, t h e d i s t i n g u i s h e d

a review of the sort we originally had in mind would not be possible because there are some wide gaps, and the material would, even so, justify a volume to itself. Therefore, although my thoughts have been set in motion while studying the 40-year reviews and have then been adjusted by discussions of the interim report in Honolulu by members of the Standing Committee, I must make it clear that I shall here be expressing a number of my own opinions— matters which seem vital to me but which will be seen in different perspective and with differing values by others. Much is to be gained by picking out certain trends and fundamental problems common to all the countries concerned, and by discussing these to help guide us in coping with future difficulties which are rapidly increasing in magnitude. I shall attempt to do this, limiting myself to a few points which deserve much deep thought and firm action. This is the place to say a few words about the human side of the history of medicine emerging clearly from between the lines of these 40-year reviews. Let us pay tribute to the individuals and small groups of men who have contributed so magnificently to the health professions, for these people serve not only their own countries but mankind in general. They range from isolated medical men to the dedicated nurses, dressers, and clerks who make public health measures and administration possible, as also do the dedicated teachers who are intellectual catalysts for the lucky people who are capable of being inspired. Institutions resist change, and many of the advances in

chair-

man of the Standing Committee on Public Health and Medical Sciences, has accorded me the privilege of preparing the present report to the Tenth Pacific Science Congress. In 1957 at the Ninth Congress in Bangkok, Dr. Meyer presented a very thorough review which ranged widely in time and subject matter (Meyer, 1962). In order to allow a new appraisal, members of our Standing Committee were invited to prepare reviews of the present situation and of progress over about the last 40 years. The majority of the expected regional reviews, obviously produced at the expense of much labor, were gratefully received by the chairmen and were presented at the Congress. These reviews form the substance of the present volume. It was subsequently decided that the present general report on aspects of health in the Pacific should accompany the regional reviews instead of being published in the Proceedings, A study of these documents has left me in a quandary. For me simply to produce a watered-down summary would be an impertinence to those who have so diligently prepared thought-provoking accounts with masses of useful information. For me to attempt to complete ' This, with m i n o r modifications, is the original R e p o r t of the S t a n d i n g C o m m i t t e e on P u b l i c H e a l t h and Medical Sciences, transferred to the present v o l u m e f r o m the Proceedings of the Tenth Pacific Science Congress. R e f e r e n c e should be m a d e to reports f r o m the preceding S t a n d i n g C o m m i t t e e in Proc. Ninth Pacific Sci. Congress, Vol. 17, p p . 1 - 3 6 (see references at end of the present r e p o r t ) .

3

4 theory and practice of medicine have been accomplished by men and women of courage often working under the most adverse circumstances —economically, socially, and politically. Let us hope that there will in time be even more people like these who do not bow to expediency or put their own gain first. There is an obvious corollary to the resistance offered to change by institutions and schools of thought: that those who feel strongly should not mince words and should indeed not hesitate to overstate if this will serve a useful purpose. In this report I shall try not to overstate, but it would be folly to avoid controversial subjects. NATIONAL

AND I N T E R N A T I O N A L

ASPECTS

OF H E A L T H

T o start on a cheerful note, I would refer first to international aspects of health, and then to the peculiarly significant place medicine occupies in society. W e have at this congress workers from all parts of the vast and variegated Pacific region, coming together to exchange scientific information and to work out even closer mutually helpful collaborations. Our 40year reviews are full of examples of the debt owed by solid advances of public health to the pooling at an international level of governmental and nongovernmental resources, and to the activities of international bodies such as the special institutions ( W H O , FAO, U N I C E F ; of the United Nations. I need not remind you that the United Nations came into being as a supranational instrument designed to halt the self-destructive course nations were taking before, during, and after World W a r II. Medicine at large and medical authorities in countries all round the world deserve special congratulation on a very wide use of this instrument for peace. Cooperation at levels above purely national interests is the only rational answer to controlling, containing, or eradicating infectious diseases anywhere. Apart from the very obvious gains from international cooperation, each country has devised its own ways of dealing with particular problems, and other countries may gain by studying these. One example, chosen because it can be described in very few words, is the

need to attend to isolated groups, which Australia has solved by its now well-established flying-doctor and special radio service. The solution of similar problems in other countries might possibly be made easier by studying the experience thus gained over some 30 years of operation. Congresses such as this offer opportunities for such exchange of information. Next, I should like to stress the plain fact that medical men have a unique type of training, which happens to be exceptionally useful in the world at present. Let me make my meaning ciear: I do not wish to imply what I do not believe, that medical men are in any way superior to others of similar ability. It is simply that they are given an experience and training which happens to fit them for a number of nonmedical activities, and that their potential usefulness to their nations is not fully recognized, either by others or by themselves. More—and more varied—use should be made of them. I make this plea because, first, medical education nowadays involves a scientific training which fits a proportion of doctors to tackle a great variety of problems in sound scientific fashion. Second, medicine has developed more infinitely detailed understanding of that animal, man, than obtains anywhere for any other living thing. Third, medicine is the discipline which can best determine how to increase man's mental and physical efficiency, and this is absolutely fundamental to economic efficiency. This point is so important that I drag myself away from it reluctantly. I go on to refer to three aspects of men and their movements which emerge from the various 40-year reviews. These concern mass movements, changes in quality of populations in situ, and mass multiplication. Mass

Movements

During the last 40 years large numbers of people have been uprooted and displaced, or have been attracted to places of promise, to take up temporary or permanent settlement in new conditions. Volumes could be written on the medical lessons to be learned from these, but very few have been. During the development of remote areas of the USSR, where large groups attempted to

5 settle, either they have suffered from some existing infection hitherto quietly circulating among animals or by their activities they have created some new health hazard. In other words, they have either picked up local unsuspected zoonoses or suffered a "man-made malady." Examples of the former are outbreaks of tick-borne encephalitis or of cutaneous leishmaniasis; of the latter outbreaks of malaria and or Japanese B encephalitis which followed manipulation of water supplies and the breeding of vector mosquitoes. During the same period, irrigation of the San Joaquin Valley in California was followed by mosquito multiplication and outbreaks of a similar encephalitis. These events led to an expansion of fieid and laboratory research and greatly advanced the development of an ecological outlook in medicine.

In this connection, we may note the interesting work done and being done by anthropologists concerned with the resettlement, in very different conditions, of people whose villages and fields were due to be sunk under water when dams were completed. T w o excellent examples come from Africa. T h e building of the K a r i b a dam on the Zambesi was preceded by a fascinating anthropological survey, and a team is now studying the people in their new conditions; a similar prior study is being made in W a d i Haifa in preparation for the flooding which will follow completion of the Aswan dam in Egypt. Nearer to us, we have anthropological studies designed to aid resettlement of islanders from Bikini and Eniwetok. Sources for many studies are described by Felix M. Keesing (1959).

Refugees and pilgrims offer special medical problems, some of which have greatly increased during this century. T h e s e problems include the introduction of disease-carriers who may start epidemics; raising of economic difficulties in housing and feeding refugees, often leading to the growth of squalid squatter-areas; and sociocultural difficulties affecting the host people whose lives may be seriously disturbed by conditions thus changed, also affecting the refugees, who may now live in very different and trying conditions without their former occupations.

" U r b a n sprawl," arising by the migration of rural refugees to towns, is a very serious and continuing predicament. It is accelerating in many countries on both sides of the Pacific, but usually presents its most urgent problems where there is insufficient industrialization and generality of education and technical skill to allow absorption of the newcomers. In California it is giving concern, but of a different sort from that which engages the authorities in many other places: for example, the population of Jakarta has increased, largely by accretion, from some three-quarters of a million to over three million in the last ten years. Growth by accretion differs in important ways from growth by local multiplication, but the effects of the two are discussed together below, as the "population avalanche (see p. 7 ) .

T h e 40-year review from Taiwan twice notes the influx of people with infectious disease: In 1955 refugees from the Tachin Islands included some 1,200 who had filariasis; six years later over 4 , 0 0 0 "returnees" from the Sino-Burmese border included 3 2 0 with malaria parasites in their blood. T h e South Korean report refers to the mass influx of refugees from overseas and from North Korea after 1945. T h i s required strong public health measures to protect the people, but mental health and maternal and child health were practically beyond management. Much can be learned from the handling of very large numbers of refugees in H o n g Kong. In Malaya there has been a very different activity: the resettlement into new and protected villages of many squatters and scattered villagers in an effort to combat the terrorists who formerly operated from the shelter of forests.

Four elements enter into the health hazards of urban sprawl: first, the grave economic difficulties of providing food, water, housing, and sometimes even space, useful occupation for the newcomers, and especially education and occupation for the youngsters; second, the growth of population groups living in the midst of dirt, hunger, and dejection, and therefore rife with disease which may spread beyond them; third, the overloading and disorganization (the two are different) of public health machinery; fourth, the socio-cultural disturbances of both the incoming and native group. Ill health is an inevitable accompaniment of such disturbances,

6 and I shall have more to say about this very important but much neglected matter. W i t h o u t doubt, the health of people who are driven or attracted to settle in new conditions is a very important subject for research. Many excellent opportunities for such research have been lost, usually because of lack of trained personnel and funds, but also because often the research opportunity is not seen or is not given the importance it deserves. I would make a strong plea that such research should be greatly encouraged, not only because it will aid those confronted with any form of refugee problem, but also because we have here vital human material which can teach us things we should know about human welfare in general. Circumstances are arranging experimental material for us on a large scale which no investigator can ever rival. It would be a sorry thing not to learn from this.

Changes in Quality of Populations

in Situ

Military screening of recruits always uncovers distressing facts. Admittedly setting strict and limited standards, screening shows that a substantial proportion of the population is unfit to serve because of deficiencies in physical health, mental health, intelligence, or literacy. T h e number of men and women so rejected during recruitment in W o r l d W a r II was so great as to lead to outcries in the newspapers wherever the figures were made public. I draw attention to this because I wish later to stress the importance of our paying much more attention to the seemingly healthy. A survey is only a cross-section showing incompletely what the situation is at a given time. W e know that this cross-section changes with time, but in spite of the great advances in mastering infectious and many other diseases, there is little to make us believe that the health of people at large is improving at the rate we should expect. I suspect that progress is being slowed because we have been concentrating much more on the seeds of disease than on the soil. T h e soil is now beginning to show its deficiencies. Let us therefore pay much more attention to that. T h a t history tends to repeat itself is a sad truth if we agree that we should steadily progress and thus improve on history. Furthermore, it is those who ignore history who must b e pre-

pared to repeat it, as George Santayana tells us. Therefore, each of us should take our lessons from those around us, lest we suffer through repeating the same mistakes from which they have suffered. Since everything is now done on a larger scale than ever before, thanks to technology, it follows that mistakes when repeated will be that much more calamitous. N o people can afford this. Health and disease cannot be s e p a r a t e d f r o m e c o n o m i c s and w a y - o f - l i f e . Therefore, in seeking guidance to better health by observing other populations, we should look much more widely than towards mere health measures. W e may then see that various processes have been at work in some countries, from whose humanly unavoidable misfortunes we can learn sharp lessons and then try to make sure that we do not reach the stage where distant misfortune becomes unavoidable. T h e excellent report from Chile notes the prosperity of that country before W o r l d W a r I, thanks to its virtual monopoly of nitrates and its wealth of copper. This balance was drastically upset by synthetic nitrate manufactured elsewhere and the opening up of copper mines in South Africa. Combined with natural calamities such as earthquakes and man-made misfortunes such as those obstructing land reform, this upset has brought the country to a very low level. Economic planning in relation to all internal resources and to other countries, and internal planning for maximal adaptability, artnecessary for preservation of balance. In many places, some forms of social security in the milieu of a particular culture may lead to unwanted effects: in Chile, for example, many in authority deplore the growing legions of indigent pensioners who could be leading more useful lives, and apparently this is due to a nonsensical element in the insurance system. It is ridiculous to suppose that all such matters do not concern health and are therefore outside the province of medicine at large. In the vitally important field of human genetics, lessons seem to come very slowly. Much is known in this field, and for those who wish to be introduced to it I recommend the succinct survey of medical genetics by Childs and Sidbury ( 1 9 5 7 ) . T w o features of genetics and human evolution seem to be widely overlooked.

7 The first is genetic selection by social forces rather than the "biological" forces familiar in the animal world. Society may, for example, accord greater social survival value to aggressiveness or to conformity. This has genetic repercussions of a sort very different from those of allowing people with deleterious genes to live and procreate. The second feature is even more subtle: evolution acts on a host-parasite assemblage or biocenose, on a social organism such as an interacting human community, or on an ecosystem, each in its entirety, as so many wholes, quite apart from natural selection acting on the individual members. T o illustrate what I mean by this last statement, I can do no better than refer to a termite colony of ten thousand busy individuals, in which nearly all the astonishing and highly evolved differentiation and specialization of behavior is invested in termites which are sterile, passing on no germplasm, while all the reproductive activity is restricted to the solitary "unspecialized" fertilized queen. Evolution has operated on termite colonies as whole systems, analogous to individual organisms. The Population

Avalanche

I prefer "avalanche" as being more accurately descriptive than "explosion." It is appalling how this accelerating population pressure elicits so little sense of personal involvement in spite of so much public attention in lay and medical publications. It tends to be best understood and felt where it is least urgently operative. Let us not waste time soothing ourselves by calculating how many people the world could feed if all the land were used cleverly and fertilized uniformly with the potential world output of fertilizers. The fact is that the late results of this avalanche are already observable in foci here and there, where there is starvation and local breakdown of government systems. Unless active steps are taken these foci will of course spread until much larger numbers starve and are diseased, and until government systems deteriorate rapidly on larger scales under social and economic crises. It is obvious that medicine has helped greatly to accelerate this avalanche by preserving life. Many have even questioned whether medicine is justified in starting major health programs

or controlling vectors. The answer to this is straightforward. There must be no slowing up of health programs on the silly assumption that this leads to more trouble than it cures. Medicine and health must never be divorced from economics, and sick people are economically at a disadvantage. Health is one requisite for economic progress. 2 Nevertheless, it certainly behooves medical men to pay much more attention than they have to the consequences of their collective actions, and to plan with others for the future as they pay attention to the present. For example, it has happened in the past that a dedicated healer has started a little hospital in a primitive area and has fought to help the people there against great difficulties, only to finish up with a larger number of people sick from some different cause such as apathy or alcoholism. I am reminded of the work of Dr. Theodor Binder near Pucallpa in Peru. From the day he started his little medical center in the forests, and in time built up the Binder Schweitzer Amazonian Hospital there, he and his colleagues paid attention to the other needs of the primitive people: teaching them birth control, and growing of good foodstuffs, bringing in better blood for the livestock, and protecting them against unscrupulous land purchasers and merchants. As a result this little community is being guided towards health in its broadest sense. W e make a great mistake in supposing that in more complex communities the field of medicine must needs be restricted to curing the sick or spraying the countryside with insecticides. CONSEQUENCES OF OUR ACTIONS

The flights of higher mathematics and the ranging of physics from subatomic particles to - For example, in one part of Iran by the Caspian shore, malaria control was instituted in 1950. In three years spleen rates dropped from 5 0 - 8 0 per cent to about 4 per cent, parasite indices from over 2 0 per cent to 2 - 3 per cent. As a result of the improved health, the area of land surface under cultivation more than tripled, and the output of silk doubled. It is worth noting that information about the marked economic improvement was given with grea: reluctance because of fear of increasing taxes (personal communication, Prof. Mario G i a q u i n t o ) .

8 the galaxies are ineffably inspiring and take one far from earthly troubles and the inefficiencies and pettiness of man. It is therefore of special social significance that many nuclear physicists, abruptly brought into contact with the inhumanity of humans, are now questioning the use and misuse of science by man almost as much as they question atomic structure. Very many scientists have powerful consciences, but consciences must be stirred before they boil. It is a pity that sometimes only a calamity such as a nuclear weapon can do this stirring. In the case of medicine, we the stirring of the conscience, tainly it has not started boiling. is necessary; that is what leads

can certainly see but equally cerY e t that is what to reforms.

Medicine has suffered through having started as a healing art. That is, it was concerned with treating sick individuals, and it had little or no scientific backing. W e now have the scientific backing, indeed so much of it that some clinicians are better described as medical scientists, so much have they lost the art of dealing with the sick. Paying only lip service to the saying that an ounce of prevention is worth a pound of cure, the primary purpose of the doctor still seems to be to earn his livelihood by treating the sick. This attitude can be inferred by a study of any medical curriculum. This has tended, firstly, to encourage the physician or surgeon to focus his attentions on the cure of disease, leaving the public health people who have developed around him to deal with prevention. Secondly, it has permitted him to ignore some consequences of his preoccupation and of the public philosophy which in the end decides his indoctrination in his medical school. One hears jokes about cultures where the patient pays the doctor only when he is well. Lest you think this is in every way facetious, I draw your attention to the fact that in all industrialized countries everyone who pays taxes or buys things does pay, directly or indirectly, for some preservation of his health, whether he is well or ill. This money, however, disappears into the wombs of treasuries or insurance agencies so that few people realize what is happening. H u m a n failings make it impracticable to pay the doctor only when one is well, because people would abuse this system by being per-

petually ill. But it is a good idea to remind ourselves of rational possibilities. In these circumstances, I would say that the most significant development in the recent history of medicine is the following: (1) public health workers, in contact with a wide range of nonmedical scientists as well as economists and civic administrators, are developing an ecological outlook on health; (2) the animal ecologists themselves have made tremendous advances in understanding complex living systems; (3) the fields of anthropology and psychology— social psychology, individual and social psychiatry, comparative animal psychology—are becoming unified and no longer widely separated from other medical fields; (4) the ecological outlook developed by those who deal with groups is permeating into the intensely personal world of the clinician who deals with sick individuals (and this permeation can already be detected in the medical curricula); (5) disease is now seen to be as much related to the social environment acting through the neuroendocrine system as it is to pathogens gaining entrance from outside. It follows that what the cyberneticists call "circular causal processes" within our skins cannot be separated from circular causal processes around it. (One aspect of the currently enlightened view of health has recently been delightfully reviewed by Stewart Wolf, 1961, while another aspect was reviewed at the Ninth Congress by Audy, 1962.) T h e net result is that medicine is at last taking its proper and efficient place in creating a healthy society. I believe the greatest and most persistent effort should be made to hasten this development of a sound basis of medical ecology. At the Ninth Congress and Tenth Congress, we arranged for at least one symposium on socio-cultural aspects of health; this time we have attempted to stress the ecological aspects in several symposia and grouped papers. I should like to think that many participants have gained much from those sessions, but I do wonder how many of them were attracted to more scientific or technical titles. A major purpose of ecology is to understand living systems well enough to see the most likely consequences of any change, of any action on our part. Preventive medicine is so

9 obviously a vital part of h u m a n ecology that I

present

shall say n o m o r e on the subject.''

w h e n elements are absorbed

needs.

(This

tends to be

overlooked

f r o m other

cul-

tures: what is good for A m p u r may b e of little use to U m b a l a . )

EFFICIENCY OF OUR ACTIONS

I should l i k e to link up what I have just said with the general efficiency of our efforts to prom o t e health by q u o t i n g D r . A. Stampar.

Some

forty years ago D r . S t a m p a r had already inspired a n u m b e r of doctors in Y u g o s l a v i a with ideas as advanced and as perspicacious today as they were then. O f these ideas "which had animated the work for the i m p r o v e m e n t of p u b l i c health with their full s t r e n g t h , " the following seem to m e to be particularly relevant to present conditions: " . . . ( 1 ) T h e question of p u b l i c health and of the work done for its advancement is not a m o n o p o l y o f the doctors; but everyone, without distinction, should take part in it. It is only by means of this universal cooperation that public health can i m p r o v e . . . . ( 2 ) A doctor should be mainly a social worker; he cannot g o far with individual

therapy

vides

means

the

achievement.

alone—social that

can

lead

therapy him

pro-

to

real

[ W h e n 1 read this I recalled the

lessons of my teacher of m e d i c i n e J o h n

Ryle,

w h o constantly stressed the study of the pathology

of

society

in

relation

to that

of

man.]

. . . T h e chief place for a doctor's work is in the dwellings of the p e o p l e — t h e places where men live and w o r k — a n d not in laboratories or in a doctor's c o n s u l t i n g - r o o m . . . .

(3)

A

doctor

should be a teacher of the p e o p l e . . . . " M a n y will o b j e c t that this is not practicable in a modern industrialized society, but I am sure that Stampar's words are worthy of much sober thought. H e was, of course, t h i n k i n g first of the people's health and not o f the doctor as o n e w h o earns his livelihood in medicine. T h e doctor is always at some risk o f n e g l e c t i n g the former. T o Stampar s c o m m e n t s we m i g h t add:

(a)

Each culture at any given t i m e must have its system of p u b l i c health, and the o p t i m a l use of its doctors, suited exactly to d e v e l o p m e n t of its Postscript: I would highly recommend S. E. Wood and A. E. Heller's California Going, Going .. . (California Tomorrow, a nonprofit educational institution at 334 Forum Building, Sacramento 14, 1962; 63 pages). This succinct but wide-ranging ecological review would help all those who are concerned with land usage and increasing urbanization. :i

( b ) S i n c e conditions

change

greatly in each culture, and especially since these changes are now extremely rapid, therefore the c o m p l e t e system, and the precepts on which it is based, must be re-examined at sufficiently freq u e n t intervals to p e r m i t means to be adapted to needs,

( c ) T h e sick are t h e failures in our

public health effort. T h e v must be treated, but they are not the primary o b j e c t of enlightened m e d i c i n e : first attention should b e given to the seemingly healthy.

It is the seemingly healthy

w h o will on another day be the sick. H e a l t h of the public largely stands or falls according to the amount of intelligent and firm support given by the people to their and their p u b l i c health workers. be obtained

without education,

doctors

This

cannot

a point

well

recognized and much advertised by bodies such as the W o r l d Health Organization.

In addition

to education, it is necessary to reach the man and people in their houses and to get them to cooperate cheerfully.

T h i s is where well-devel-

oped rural health centers and also sociological studies are essential.

We

may learn a lesson

from Britain's need during W o r l d

W a r I for

cereals or substitutes to m a n u f a c t u r e acetone for explosives. O n e ton of horse chestnuts, available over

the

whole countryside but

economically

quite impracticable to harvest, is the equivalent of half a ton of grain for this purpose.

The

apparently futile task of g a t h e r i n g this scattered harvest was handed over to school children w h o made astonishing efforts. People with a will to help can b e spurred to collectively

enormous

efforts if o n e goes about it the right way.

Dr.

T . F. F o x ( I 9 6 0 ) has described his impression of a concerted p u b l i c attack by individual effort on t h e " F o u r Pests" (sparrows, rats, flies, mosq u i t o e s ) in C o m m u n i s t China. M a n y will question the ultimate nature and justifiability of the spur applied to t h e people, and others will p o i n t out rightly that these are palliative

measures

( t h e rats and others will c o m e b a c k ) and may even lead to an u n f o r t u n a t e chain of events ( t h e sparrows

kept

down

insects

d a m a g e crops the m o r e ) .

which

will

now

H o w e v e r , the essen-

tial p o i n t illustrated is unrelated to these or to

10 the efficacy of the efforts: it is simply that one must have some means of carrying policy in an understandable way right into every home, preferably by people who believe they are wisely counselled, to people who have faith that what they are doing is right but are free to ask the reasons why. Here we may remind ourselves that there is one worrying gap between wisdom and knowledge, and another, perhaps wider, between knowledge and mass action. The latter is tremendously subject to subtleties of suggestion and conditioning associated with one's way of life, influenced by education and sanctions of various sorts. As it happens, the study of these is within the province of medicine. SOME M A J O R PRESENT-DAY

DEVELOPMENTS

I should like to conclude this report by referring to eradication projects and to what we may call maladies of the social organism. These two are of tremendous significance to us, and both are linked up in various ways with the population avalanche which is now gaining momentum so frighteningly. Nutrition is a third subject of similar importance, but that is the province of our sister division. Extensive control schemes and eradication projects tend to get involved in political pressures. Their long-term consequences are very complex and of great magnitude. The possibilities of future breakdown in the presence of economic stress cannot be ignored. Their conception, planning, and follow-through require an ecological outlook and a bold spirit, both of which are available among the authorities concerned, but which can be overwhelmed when political pressures sweep aside pilot studies on which even the wisest man must base sound decisions. After quoting the old saying "the higher they go, the harder they fall," I prefer to do no more than draw attention to the excellent review on this subject by Dr. T. A. Cockburn ( 1 9 6 1 ) and various published accounts of the East African Groundnut Scheme, which had as much to commend it as an eradication scheme, but which collapsed for reasons concerned with plant, animal, and finally human ecology (Alan W o o d , 1950).

By "maladies of the social organism" I mean defective functioning of a human community regarded as an organism or as a whole (the correct term being a system). This covers far too much ground to be summarized here. W e should recognize that a malady of a community expresses itself by signs and symptoms which many regard as normal to the community, or by purely individual ailments. A wide range of troubles, from apathy to excessive national fervor, from juvenile delinquency to rising divorce rate, from alcoholism and overeating to foodfads. pogroms, and wars, are wholly or to a considerable degree traceable dircctly from collective maladies down to individuals who express the signs and symptoms (discussed, e.g., by Audy, 1961 ). Just how much maladies of the social organism are responsible for the many mental diseases is hard to say, but we can be certain that the influence on people is profound. Mental illness is poorly reported and documented everywhere in the world, if it is not overlooked altogether. This is especially so with the milder neuroses. Perhaps the authorities in this audience will excuse me if I divide neuroses into those which cause most suffering to the neurotic himself (thus reducing his efficiency and adding somewhat to the average misery of the c o m m u n i t y ) , and those in which the sufferer is stolidly asymptomatic but makes people around him unhappy, strained, and in their turn neurotic. Both types are much more common in all communities than is generally realized; the second is probably by far the more troublesome, and the total effect on the efficiency and happiness of people is enormous. CONCLUDING REMARKS

I have touched on many points. If I have given the impression of an idle bee sampling many flowers without draining one of nectar, then I would like to believe that this is due to lack of space which prevents me from including more connecting links. T h e links can be found by reflection and by hunting around the points which have been made. The Pacific region is a boiling pot, for such reasons as its heterogeneity in the presence of active communication between different cul-

11 tures, and the hastening of all human activities by science, technology, and human multiplication. Health is a vital element in this maelstrom and its understanding has progressed enormously; but this understanding has been through development of a necessarily conservative, and somewhat ponderous, body of thought with its machinery for action. A new level of understanding has now been reached, where the pathology of the individual takes its proper and lesser place below the pathology of the social organism. At this level of understanding, the Mau Mau uprising in Kenya is seen as a pathological process in a society akin to inflammation as a pathological process in a man; and smog is a metabolite and not something in one's "external environment." Countries which are now rapidly developing in the Pacific region have a new opportunity to reassess the roles of medicine, public health, doctor, nurse, and auxiliary. They are in a position to produce for their own particular needs the machinery and exactly the kinds of people they require for their optimum development, without simply following what is accepted elsewhere as the usual thing to do. This is an exciting possibility, presenting itself at a time when rapid changes coincide with a newly developing outlook on health. Research, research planning, and guidance appropriate to each region must depend on cooperation at an international level. The fact that such cooperation leads to friendly understanding between different peoples must strike a chord with all of us; for friendly understanding between doctor, nurse, and patient is what makes medicine an art rather than only a science. ACKNOWLEDGMENTS

W e are all beholden to the members of the original Standing Committee, as well as to the invited contributors, Dr. B. D. B. Layton and Mrs. Marguerite S. Augustine, for the pains they have taken to prepare the solid and valuable reviews which form the present volume. I wish to express my personal appreciation to the chairman, Dr. Karl F. Meyer, and to Dr. Frederick L. Dunn, Dr. Harry B. Friedgood, and Dr. W . Victor Macfarlane for criticism of this review.

REFERENCES *AUDY, J . R. (1962). Some general aspects of the public health problem in Malaya. Proc. 9th Pacific Sci. Congress, 1957, Bangkok, 17: 18-21.

(1961). Man-made maladies. Ch. 7, pp. 1 0 0 - 1 1 2 , in S. M. Färber and R. H. L. Wilson, editors, The Air We Breathe. Springfield, 111.: Charles C. Thomas. (1962). The social aspects of disease: man contrasted with other animals. Proc. 9th Pacific Sci. Congress, 1957, Bangkok, 17: 155-158. CHILDS, B . , a n d J . B . S I D B U R Y ( 1 9 5 7 ) .

A survey

of genetics as it applies to problems in medicine. Pediatrics 20, Suppl. to No. 1: 1 7 7 - 2 1 8 . COCKBLRN, T. A. (1961). Eradication of infectious disease. Science 133: 1 0 5 0 - 1 0 5 8 . F o x , T. F. ( I 9 6 0 ) . Visit to Red China. Amer. J. Pub. Hlth., Supplement, June, 50: 2 8 - 3 5 . *FRYBERG, A. (1962). Rural health problems in Queensland, Australia. Proc. 9th Pacific Sci. Congress, 1957, Bangkok, 17: 12-14. •HERCLS, C. (1962). Public health problems in New Zealand. Ibicl.: 16-17. KEESING, F. M. (1959). Field Guide to Oceania. Washington, D. C.: National Academy of Sciences Pubn. No. 701. *KOBAYASHI, R. (1962). Health administration in Japan. Proc. 9th Pacific Sci. Congress, 1957, Bangkok, 17: 3 1 - 3 6 . *LARA, H. (1962). Public health problems of the Philippines. Ibid.: 2 8 - 3 0 . *LEE, R. K. C. (1962). Public health problems in Hawaii. Ibid.: 15. *MACFARLANE, W . V. (1962). Public health problems in Australia. Ibid.: 1 0 - 1 1 . * Reports by Chairman and Members of the Standing Committee on Public Health and Medical Sciences for the Ninth Congress, Bangkok, 1 9 5 T .

12 * M E Y E R , K . F. ( 1 9 6 2 ) .

R e p o r t of the

Chair-

man of the Standing Committee on Public Health and Medical Sciences in the Pacific Area. Ibid.: 1 - 9 . STAMPAR, A. ( 1 9 3 8 ) . Public Health in Jugoslavia. University of London: School of Slavonic and East European Studies, p. 9-

W O O D , A . ( 1 9 5 0 ) . The

Groundnut

Affair.

Lon-

don: Bodley Head.

W O L F , S. ( 1 9 6 1 ) .

D i s e a s e as a way o f

life:

neural integration in systemic pathology. Perspectives Biol. Med. 4: 2 8 8 - 3 0 5 .

Australia W . V. MACFARLANE

AUSTRALIA lies between 11 - 4 4 ° S latitude. The climate ranges from tropical monsoon areas in the north to the central desert zones through strips with moderate rainfall along the coasts. A b o u t one-third of the three million square miles of land is usefully inhabited. Arid regions or desert comprise 65 per cent of the continent. Since the end of the 1 9 1 4 - 1 8 war the population has risen from five million to ten million people. T h e population has become increasingly urban in distribution with the growth of manufacturing. In many ways this period can be compared with the period from 1890 onwards in the United States, when frontiers were settled and manufacturing expanded rapidly. T h e present distribution of population is officially recorded as 54 per cent metropolitan, 25 per cent urban, and 21 per cent rural. In 1920 the rural population comprised 38 per cent of the total, or almost double that of 1960. For metropolitan and urban areas in temperate- latitudes ( 3 0 ~ - 4 4 ° S ) , public health problems are comparable with those in Britain, the United States, and Scandinavia. In I 9 6 0 the birth rate was 22.4 per 1000 population. T h e infant mortality rate to age one was 20.2 per 1000 live births, and the crude death rate was 8.9 per 1000. These rates are higher than those of Japan, but comparable with those of Europe. There are, however, two factors affecting the smaller towns and rural population which do not occur in Europe or most of America. These are isolation and the influence of the tropics. Another quantitatively small (0.7 per cent of the population) problem is presented by the aboriginals; the questions of social medicine associated with them are largely unresolved. It seems useful, therefore, to consider changes in 13

public health over the past 40 years in four categories: those associated with the metropoles, with rural isolation, with the tropics, and with the aboriginals. The over-all pattern of diseases has changed during the period 1921-61. Some previously unidentified infective agents have been recognized, and viruses have risen in importance as bacteria have come under control. Trauma and degeneration occupy an increasing part of the public health picture. METROPOLITAN PUBLIC

HEALTH

Since 1920 the large cities have draped successive fringes of suburbs around the downtown nuclei. The usual demographic pattern of an aging population has developed. T h e crude death rate has fallen 27 per cent during the past 40 years, while infant mortality has decreased by 300 per cent. The reduction of summer diarrhoea in infants is attributed to the disappearance of horses (and flies) from towns, to the better treatment of water and milk, to the training of mothers in infant hygiene, and to the general level of civic development. The life expectancy for females at birth has increased by 16 per cent, and that of males by 13 per cent. With the expectation of approximately ten more years of life, the pattern of death has changed. " R e a l " wages have increased, relative to the 1911 base of 1000, from 1100 in 1921 to nearly 1500 in I960. This probably correlates with a decline of bacterial disease. Food and water hygiene has virtually eliminated typhoid, brucellosis, and dysentery. Tuberculosis has shown a decline in death rate from 60 per 100,000 to

14 about 5 per 100,000 per year in 40 years. The morbidity rate for tuberculosis is about seven times greater than the death rate. Case finding is increasingly intense; since 1956 more than half the population has been obliged by law to have chest X rays. Morbidity from tuberculosis is twice as high in the children of Queensland and Victoria, who do not have compulsory chest X rays, as in the children of the other states since 1956. In contrast to tuberculosis, neoplasms as a cause of death have increased by 70 per cent in the 40-year period. The steady increase in over-all cancer mortality may be contrasted with the tenfold increase in male lung cancer deaths in the same period. The increase in "real" income above subsistence for all produced a rise in morbidity from what were once luxuries—tobacco, alcohol, and automobiles. Beer consumption has doubled in 40 years, for instance, though spirits have not changed in quantity taken. During this century pipe smoking has declined. Cigarette smoking, which in 1906 comprised 12 per cent of the tobacco smoked, by 1956 made up 70 per cent of the consumption. The greatest rate of change in the use of cigarettes has occurred in the last ten years. If there is a causal and linear relation between bronchogenic carcinoma and the smoking of cigarettes, it is likely that by 1970 the incidence of the carcinoma will be about twice that in I960. Deaths from heart disease increased steadily between 1920 and 1940, then the curve flattened out at about three times the 1920 level after the second world war. Deaths from diabetes in older people followed the same pattern. Deaths attributed to coronary disease increased tenfold in the last 40 years, males maintaining a rate twice that of females throughout the period. Accidents. In 1920, 19 percent of accidental deaths were caused by vehicles on the road. By I960, 42 per cent of accidents were caused by automobiles. During the last 40 years real wages have increased 1.5 times while the number of vehicles has increased 20 times, from 15 to nearly 300 per 1000 people. Injuries brought about by automobile accidents have not risen as fast as the number of cars per 1000 persons.

In 1921 the injury rate was 1,480 per million per year. During the depression and during the war, cars were used less because of fuel costs or shortages, so that accident rates fell. Since 1946, however, there has been an increase in injuries from 3,250 per million people per year to 5,400 per million per year. The injury rate has increased four times since 1920. There has, however, been a reduction to half in the injuries and deaths per car on the road. Presumably road engineering, traffic regulation, and automobile construction, as well as the education of drivers, have contributed to this. Road Safety Councils have, under government aegis, maintained pressure to reduce accidents. The increase in population, however, exposes a greater density of people to risk, and the total amount of death and injury has increased as well as the risk per head of population. Roads are still not adequate from the point of view of visibility and safety, and education of drivers is rather haphazard. Safety belts and padded interiors are rarities. For the over-all population, there is a fairly steady increase in road mortality. However, for the younger age groups, it is particularly important. Among the group between 15-24 years, death rates in road accidents have increased more than threefold in the last 40 years, compared with a doubling for the whole population. Drownings (which also involve younger people) have remained unchanged over that period. New Zealand has 20 per cent more cars per head of population than Australia, but the fatality rate per car in New Zealand is 55 per cent of that in Australia. Among the factors contributing to this difference are the enforced 50 mph speed limit, and the "every road user his own traffic officer" policies in N e w Zealand. Aging. One consequence of the aging population is the need for increased hospital care and housing for old-age groups. Both private and public approaches to welfare for the aged have been made in the last decade, although pensions with means tests have been given since 1909- Limited medical services and drugs are provided from taxation for old-age pensioners. Some subsidy is offered to groups or societies raising money for low-cost housing for aged

15 persons. T h e r e is n o general policy of encouraging e m p l o y m e n t of people over 65, nor is sufficient e n c o u r a g e m e n t given to their continued activity. Australia is at present behind England, N e w Zealand, Holland, and Scandinavia in attitudes and organization to assist the aging population. Sickness. Hospital benefits u n d e r t h e N a tional H e a l t h Act began in 1946, and by 1958 payments m a d e by the federal g o v e r n m e n t to patients had reached £ A 1 per year p e r person f r o m taxes. In this plan the patient assures a limited r e f u n d of hospital and surgical expenses with an approved society. T h e r e are about 120 societies registered. T h e federal g o v e r n m e n t adds a subsidy to p r e m i u m s paid. Some coverage of medical practitioner expenses on a similar basis began in 1953 ( m e d i c a l b e n e f i t s ) , b u t like the U n i t e d States Blue Cross, there are limits to the a m o u n t of insurance; only p a r t of a long or serious illness may be covered. A b o u t 65 per cent of the population is protected, at least in part. A b o u t t'A2 per year p e r person is contributed f r o m taxes for practitioner services and drugs. T h e rate of admission of the insane to mental hospitals has remained at 3-4 to 3.6 per 1000 over the past 4 0 years. Neuroses have, however, increased as in other metropolitan societies. T h e r e has been considerable structural i m p r o v e m e n t in most mental hospitals, partly because of increasing federal aid since 1951. All doors are not locked, patients have some privacy, and considerably more occupational therapy is used. Most mental hospitals have beauty shops, barbers, and restaurants t o help the patients to some degree of individual morale. T h e more enlightened institutions have g r o u p s of cottages; there is segregation of the new admissions f r o m chronic psychotics f o r a n u m b e r of m o n t h s in houses resembling normal dwellings. Experiments are b e i n g m a d e also w i t h the daily attendance for m e n t a l therapy rather than full admission, and with t h e use of diagnostic units separate f r o m institutions, w h e r e early psychotic and neurotic manifestations may b e treated. A b e g i n n i n g has been m a d e with g r o u p therapy. Leucotomy has been used very little, b u t extensive d r u g therapy for t h e psychoses has been undertaken.

PUBLIC H E A L T H I N RURAL AREAS

In 1921 a few railways and earth-track roads wove h u n d r e d s or thousands of miles between t h e coastal settled areas and into the interior. A p a r t f r o m state-supported hospitals in towns of 1,000 or more people, with some subsidized medical service, there was little medical aid to the outback settler. Infection meant h o m e n u r s i n g with little medicine or advice. Accidents m e a n t long traumatic journeys to medical centers, perhaps h u n d r e d s of miles away. D u r i n g monsoonal rain such journeys were impossible. Similarly, telephone communication was frequently b r o k e n by flood or fire, and sheep and cattle stations were like islands or ships in their isolation. Public health in the small towns was neglected. Typhoid, dysentery, diphtheria, tuberculosis, brucellosis, and scarlet fever were transferred by water, flies, or unpasteurized milk. Houses were poor and crowded. Sewers were virtually u n k n o w n , and there was very little prophylactic i m m u n i z a t i o n in 1920. T h e protein and vitamin content of diets was o f t e n low in the outback. T h e m a i n developments which have taken place largely since the late 1930's were the extension of c o m m u n i c a t i o n s and u r b a n standards of hygiene to the frontiers of t h e desert. T h e railroads were used to take maternal and child welfare service carriages t o sidings along the tracks. Advice and assistance were given d u r i n g pregnancy, as well as to the m o t h e r and child in the years u p to school age. I m m u n i z a tion was provided and nutrition improved. Similar rail services on a mobile basis were provided for dental treatment. School health inspection increased. F r o m the hospitals, using the subsidized medical services of the outback, i m m u n i z a t i o n against diphtheria, typhoid, and w h o o p i n g cough was introduced on a voluntary basis. T h e Flying D o c t o r Service extended it f u r t h e r , and helped to reduce the already declining incidence of these infections. Since 1956 i m m u n i z a t i o n against poliomyelitis by Salk vaccine m a d e in Australia has been used; most children have been inoculated, both in the large and small centers. T h e r e has been little poliomyelitis since this c a m p a i g n in 1956-58.

16 The Flying Doctor Service was initiated by the Presbyterian Church in Queensland during 1928. This was a revolution both in method and in attitude. An electronic engineer, Alfred Trager, devised a foot-pedalled generator to drive a radio transmitter which allowed isolated stations to make contact with bases. T w o results flowed from this. One was the quick communication of news of accidents or illness to the Flying Doctor Service, with requests for advice or for an ambulance plane. This allowed the development also of a radio consultation service by the medical officers. The second result was a social one, since the radio telephone offered communication in regions where telephones were unreliable or absent. Cross-talk among stations developed some sense of community on the great plains between station hands, aboriginals, managers, and owners. In particular the wives found new social interests. As the Flying Doctor Service developed in the 1940's the expenses became too great for it to support its own planes; these were chartered as needed from one of the airline companies. The government has been increasing its subsidy for the Flying Doctor Services of all states. Between 25 and 55 per cent of the cost of the Services, depending on state policy, is now borne by state and federal governments, while the remaining funds come from public subscriptions and donations from patients. There are seven Flying Doctor Services with 12 bases, together with three government establishments in Australia. The extent of the Service may be illustrated by that in Queensland, the state in which this method of medical care originated. During I960, 148,000 nautical miles were flown in Queensland on 333 flights at a cost of 7 / — ( $ 0 . 7 5 ) per mile. There were 3364 aboriginal and 8610 white patients seen. Consultations by radio numbered 3709, and 64,800 radiograms were sent over the system. The Service in the 1950 s became increasingly a flying general practice rather than a purely emergency service. Regular visits by medical practitioners to outposts and school sessions are the most rapidly growing aspects of the Service. The development of social services grew out of the radio communications. In 1950 School

of the Air sessions began at Alice Springs in the center of the continent. There are now school sessions from all the Flying Doctor radio centers. Children call back to base to answer questions or ask advice as the lessons proceed. Federal and state governments have built some aspects of the Flying Doctor Service into the health policy of the Northern Territory. The Queensland government also initiated a flying surgical service, so that isolated hospitals could have regular access to specialist skill and opinion. It appears that northern Canada, Russia, and parts of Africa have adopted similar services more recently. H E A L T H IN T H E TROPICS

Tropical diseases. More than one-third ( 39 per cent) of Australia lies within the tropics, and in the early days of settlement from 1830 onwards, fevers were commonly encountered in the coastal regions. Colonial fever, by 1870, was identified as typhoid. Gulf fever in the north was shown in 1891 to be a mixture of malaria and typhoid fevers. Coastal fever was not dissected until the 1930s into its components of leptospirosis, malaria, and scrub typhus. Mossman fever was leptospirosis, and Sarina fever was probably scrub typhus. In 1920 the only clear entities in these complexes were malaria and typhoid. The Institute of Tropical Medicine was founded by the federal government at Townsville (19 C S) in 1910; it was to identify and prevent the tropical diseases of the region. It was transferred to Sydney in 1928. By 1923 it was clear that some of the fevers of north Queensland were similar to those of Japan (such as the mite-borne river fever) and to those of Malaya. It was not until 1933, however, that urban and scrub typhus were identified and shown to be the same as the Malayan diseases. Endemic foci in wet tropical areas persist and cause about 50 cases of R. tsutsugamushi infection each year. In 1933 leptospirosis (L. australis, a and b ) was diagnosed, and in the last 27 years 11 more types have been found. Borellia has also been detected among the fevers of the north. Q (for query) fever was discovered in Queensland in 1935, and since then it has been found in vir-

17 tually every country of the world. T h e r e are a b o u t 500 cases each year, mainly in Queensland. It appears that the k a n g a r o o can harbor t h e rickettsia, which is transferred t o k a n g a r o o ticks, and t h e ticks transfer it again to the fleece of sheep. F r o m the wool it has infected man, and outbreaks a m o n g shearers have recently been reported. These diseases have been of long standing in the c o m m u n i t y , b u t have been identified as specific entities only in the last 20 or 30 years. In that sense they are new diseases. And their control is still inadequate or difficult. T h e endemic tropical diseases have moved further f r o m the equator than the tropics on occasion. T h e usual southern limits, however, have been indicated by Derrick to be: malaria, 19 S; scrub typhus, 21.5°S; tick typhus, 28°S; filaria, 30°S; h o o k w o r m , 32°S; dengue, 33.5°S; Murray Valley encephalitis, 37 °S. T h i s indicates some of the t e m p e r a t u r e dependence of the vectors. Rainfall determines the m a i n foci of leptospirosis ( a b o v e 9 0 inches per y e a r ) , trombiculid typhus ( a b o v e 60 i n c h e s ) , and h o o k w o r m ( a b o v e 45 i n c h e s ) . These environmental factors affecting vectors are only partly controlled or controllable. Of k n o w n entities of the last century, malaria has almost disappeared. T h e reasons for this are obscure, but vector control is not the m a i n one. It is in fact negligible. T h e last e n d e m i c outbreak was probably in 1942; virtually n o endemic malaria is now present in Australia, although there are still many dense populations of mosquito hosts. T y p h o i d has yielded, probably, to chlorination of water and to the extension of sewers rather than to inoculation. Filariasis (F. bancrojti) is also virtually extinct, although at the b e g i n n i n g of the century its incidence was sufficient for Bancroft to be able to describe the organism in Queensland. D e n g u e periodically recurs, since the host, Aedes aegypti, is reasonably c o m m o n and uncontrolled. H o o k w o r m , which was prevalent in the 1920's, when all children w e n t about barefooted, and w h e n little sewerage was established, has become rare except in aboriginals. Part of the reduction is attributable to the hookworm campaign sponsored by the Rockefeller Institute d u r i n g t h e 1 9 2 0 s . T h e r e are still many children and adults w h o g o bare-

footed for c o m f o r t in t h e towns and stations of the tropics. T h i s adds to morbidity and mortality f r o m tetanus, which is four times c o m m o n e r in the tropics than in the south. Tetanus is also c o m m o n e r in the legs of those infected in the north. Various venomous and noxious animals and plants infest the tropics, but some control has taken place as bush has been cleared. A l t h o u g h antivenins are available their life-saving virtues are still in some doubt. In 1958 an antivenin to the T a i p a n ( w i t h its lethal and rapidly acting n e u r o t o x i n ) was m a d e at the cost of some lives, but clinical tests are still inadequate. Scorpions, stonefish, and cone shells all provide toxins for the unwary. Lethal cubomedusans, sea snakes, and man-eating sharks discourage sea b a t h i n g in tropical seas; consequently, baths or enclosures have been developed on the coast near towns. T h e arthropod-borne viruses have received attention in the last decade. G r o u p s A, B, C, and D viruses have recently been shown to b e present in Australia, and new serotypes are being found each year. T h e Murray Valley encephalitis virus (recognized in 1951) is k n o w n to infest horses, pigs, birds, and man; it was identified in Culex annulirostrii by D o h e r t y in I 9 6 0 . T h e r e are intercontinental implications of disease spread by these viruses w h e r e birds act as hosts. Indonesia and N e w G u i n e a must b e regarded as possible sources of f u t u r e epidemics. Lead nephritis. Lead poisoning of children in Queensland was first reported in 1892. In 1904 Gibson suggested that t h e railings on verandahs in houses of the tropical region, particularly where there was a high rainfall, m i g h t provide the lead which children ingested as they played. Tropical houses with slatted railings to verandahs, which were painted with lead paints d u r i n g the 1870's and 1880's, led to both acute and chronic lead poisoning. T h e life of t h e paint is only t w o or three years in such climates, since it peels off in flakes under the influence of sun and rain. Children played on t h e verandahs t o escape both the sun and t h e rain. A persistently higher incidence of lead p o i s o n i n g and of chronic nephritis appeared in Queensland f r o m t h e b e g i n n i n g of

18 this century. Henderson has shown that those who were known to have had lead poisoning as children died before the age of 40 from chronic nephritis latent since childhood. H e found a moving peak of deaths from nephritis in any age group. By 1920 the chronic nephritic rates per 100,000 was 320 in Queensland, compared with 80 for the whole of Australia. By 1940 it was 400 per 100,000 as against 50 for the whole of Australia. Public awareness of the lead hazard increased, and by 1922, laws were passed restricting the use of lead paint on houses. It was not until after 1930, however, that any considerable enforcement of the laws took place. Lead paint is still used on a number of structures other than houses. Lead nephritis (confirmed by post-mortem analyses showing three to five times more lead in the bones of nephritics than in control groups) increased until the middle 1940 s, and then began to decrease. The tropical environment appears to be responsible for this nephritis. In other places where verandahs are uncommon, where brick houses are used, or where a climate does not cause the peeling of paint, there has been a considerably lower (one-fifth to one-tenth) incidence of the nephritic syndrome than in the tropics. Control by legislation appears to have been slowly effective. The economics of building construction, however, probably played a considerable part in control of the disease. It is no longer possible for many to afford the space occupied by verandahs, so that tropical houses built in the last 20 years have largely been conventional boxes without verandahs. This must have played as large a part as legislation in controlling plumbism. Skin cancer. Rodent ulcers and epitheliomas have been encountered since the founding of Australia by white people. Since excision of the lesion was easily undertaken and the death rate was about three to five per cent, few good statistics exist on the incidence of skin cancer lesions. In the last 40 years there has been an increase in the number of individuals who have come for treatment of skin cancers. It is, of course, difficult to obtain a true incidence rate. However, there is a differential incidence between the temperate and the tropical regions.

The differential between latitude 40° and latitude 20° is in the order of ten times. Queensland has a population of 1.5 million people, most of whom are north European whites, although there is a small proportion of Mediterraneans who are relatively resistant to skin cancer. By I960 the incidence rate for males at 27 C S was 4,850 per million per year, and for females 2,804. At Townsville ( 1 9 C S ) , the rate had risen to 11,000 for males, and 5,690 for females per million per year. Nearer the equator at Cairns ( 1 7 ° S ) , the rates were 6,240 for males and 3,112 for females, but this may be due to the higher rainfall and greater cloudiness of the Cairns location. There is some evidence of greater incidence among the rural communities in the highly insolated inland regions, where the rate may be twice as high as on the coastal zone. Queensland with its tropical white population has an incidence three to seven times greater than that reported for Texas. Little propaganda and no public health measures have gone to controlling this condition. Over the last 40 years there has been greater exposure of children to the sun from birth, a decreasing use of hats and clothes, and more time for vacation. The habit of working in shorts and the availability of transport to sunbathing at beaches have tended to increase the exposure of the population to the sun. Assuming an ultra-violet etiology for these skin cancers, it would be predicted on the basis of 20 years' exposure before cancer developed, that the 1970s should show a further increase, perhaps, doubling the present skin cancer rate. Before 1930 the areas of body publicly exposed to sun were small, vacations short and few, and the development of tropical sunning resorts had not taken place. The population and skin surface at risk has probably quadrupled in 40 years. The largest tropical town. Townsville, on latitude 19°S, has the largest white urban population living in the tropics. The people are almost exclusively white Europeans. It may be used as an example of the response of a white population to a tropical environment on the coast, where there is or has been only a mild incidence of tropical disease. Since 1920 malaria and hookworm have

19 largely disappeared. So also has filaria. Dengue, however, is endemic, and scrub typhus occurs in the neighborhood. Skin cancer reaches 11,000 per million per year for males, and 5,690 per million for females. This is by far the highest incidence of skin cancer reported from anywhere in the world. It means that out of the population of 45,000, eight or nine hundred each year may suffer from skin cancer. W i t h an expectancy of approximately 70 years of life, it seems that few males are likely to escape skin cancer if they live in this region. Aboriginals are virtually free of skin cancer, and Mediterraneans have a low incidence. T h e case rate for diphtheria was high in the 1920 s. The population doubled between 1920 and I960, but the number of cases decreased steadily. This appears to have been associated with immunization against diphtheria, which began in 1931. For typhoid the same picture of high incidence in the twenties appears, with reduction after chlorination of the water supply in 1931. In spite of that typhoid cases flared up during the war, and then went down again. Introduction of sewerage in the 1940 s may be responsible for some of the later decrease of typhoid. T h e town is still not fully sewered. The use of T A B immunization on a wide scale since 1953 probably has had little effect on the disease. One strange aspect of tropical epidemiology is the increase in diagnosed tuberculosis that has occurred since the 1930 s. The over-all Australian picture is one of decreasing incidence and decreasing death from tuberculosis. In Townsville, however, during the depression and during the war the disease increased. This may be attributed to the social and economic disorganization of such periods. During the 1950s, however, even greater numbers of tuberculous infections were found, and this is not easy to explain. There has, since 1953, been more case-finding with the aid of chest X rays (which are not compulsory in Queensland), but the increase in infection of children has been considerable. T h e social and economic factors responsible for this are still obscure. Table 1 gives a comparison of the incidence of tuberculin reactions in the different latitudes and

TABLE

1

PERCENTAGE T U B E R C U L I N SKIN T E S T REACTORS AGE G R O U P LATITUDE

5-15

( degrees)

%

18-24

Tasmania

44-40

2.2

11.6

Victoria and South Australia

39-34

3-8

13-16

N e w South W a l e s

34-28

10

24

Queensland

28-11

23

35-58

states of Australia. There appears to be a steady increment in reaction rate from low levels in the south to higher rates in the north. This is not accounted for entirely by the relative distribution of wealth or social amenities. Tasmania is not so well endowed as Victoria or N e w South Wales, and yet the incidence of tuberculosis is higher in the richer communities. Nonspecific mycobacteria may be responsible for the northern reaction rates. There may be some relation also to dairy production, which is high and not entirely controlled in Queensland, but this again seems an inadequate explanation. Townsville was one of the chief places to suffer lead poisoning and the subsequent chronic nephritis. However, the incidence is falling as old houses are replaced, and as lead paint ceases to be applied to the more modern structures. The over-all fertility, morbidity, and mortality of Townsville white inhabitants compares very favorably with towns in the temperate region. There are clearly, however, some special tropical features which have been dealt with partly by public health measures, and partly by the increase in modern engineering of domestic and public services. T h e white population thrives, and a reasonable standard of production and civilization has been achieved. A university college is now in action, and some industrial growth has begun. ABORIGINALS

There are about 39,000 pure aboriginals and 31.000 half-caste aboriginals in Australia. Of the full aboriginals, 24,000 live in or near

20 towns or white c o m m u n i t i e s , and o f them, one-

and m e d i c a l expenses, f o r the elaboration

third live in g o v e r n m e n t - s u p p o r t e d settlements.

e q u i p m e n t and investigation, special provision

of

T h e r e are about 1 5 , 0 0 0 r o a m i n g over one mil-

for children and old age, for accidents and in-

lion square miles of arid country, s o m e o f w h i c h

dustrial hazards, seems inevitable. N e u r o s e s and

is set aside as native reserves.

the disabilities o f leisure need new

T h e feral natives receive little medical care and are exposed to trauma, t h e hazards of childbirth, and malnutrition, as well as to infections. T h o s e in contact with E u r o p e a n s in the outback receive a good deal of attention f r o m the Flying D o c t o r

Service.

In

towns

and

settle-

and adaptations.

T h e increasing

techniques

incidence

of

cardiovascular and neoplastic disease will require education and hospital services o f a different order f r o m those needed in the past 4 0 years. O n t h e rural side, the helicopter or

hover-

craft may help reduce the hazards of

medical

ments they have shown the usual high mortality

emergencies during the wet season.

f r o m European e x a n t h e m a t a , viruses, and tuber-

p h o n e c o m m u n i c a t i o n is already good, and the

culosis, while the diseases o f poverty continue.

increasing

Dysentery, typhoid, tuberculosis, and h o o k w o r m

areas will b r i n g better c o m m u n i c a t i o n s .

wealth

and

production

Radio-teleof

remote

are more c o m m o n than in w h i t e c o m m u n i t i e s .

M e d i c a l research has developed in seven uni-

Leprosy occurs almost exclusively ( 9 3 p e r c e n t

versities, in institutes, and in g o v e r n m e n t lab-

of

oratories. R e c e n t l y , several cancer research units

381

cases in

1958)

a m o n g aboriginals

their e n c a m p m e n t s in the N o r t h e r n

in

Territory,

Queensland, and W e s t e r n Australia.

have b e e n f o r m e d with the support of p u b l i c donations.

W i t h organization and effort a good deal of

uted

to

Insurance c o m p a n i e s have cardiovascular

contrib-

investigations,

and

a

i m p r o v e m e n t can be obtained. In the N o r t h e r n Territory

it is estimated that 2 0 p e r c e n t

of

children died by the age of two; this rate has been reduced

in the past

five

years,

TABLE

through

child welfare services, to five per cent. T h e r e is still much to do, however, particularly

INSTITUTE

among Hall

the groups on the f r i n g e of w h i t e towns.

LOCATION Melbourne

Baker

Melbourne

main even in groups taking on European work voting

rights, although

these

are

still withheld in some states.

viruses, i m m u n i t y ,

cardiovascular, blood proteins, endocrine

n o m i c status, of education, and of resources reand ways. In 1 9 6 2 the federal g o v e r n m e n t gave

INTERESTS

gastric functions

But

the basic troubles o f lack o f political and eco-

MAIN

and a u t o i m m u n i t y ,

Increasing contact with whites and assimilation of aboriginals are i m p r o v i n g hygiene.

aboriginals

2

M E D I C A L R E S F A R C H I N S T I T U T E S IN A U S T R A L I A

Medical

Research

Adelaide

Veterinary Kanematsu

cardiovascular, infection

Sydney

lymph, lipoids, atheroma

Medical

THE FUTURE

Research

Brisbane

Q fever, tropical fevers, parasites, vectors,

For the Australian ways of life, t w o assumptions on the future may b e made.

T h e first is

that the population will retain its present type of structure for a generation.

(It

is possible

arbor viruses Anatomy Cancer

that other races could increase t h e population, alter its distribution, and c h a n g e the tivity of the c o n t i n e n t . )

produc-

T h e second is that an

increasingly A m e r i c a n - E u r o p e a n type of civilization

will

develop

with

more

intense

in-

dustrialization. O n these postulates, social medic i n e directed towards wide coverage o f hospital

Commonwealth

Canberra

nutrition

Melbourne

treatment, statistics

Sydney

biochemistry

Brisbane

skin cancer

Melbourne

sera, a n t i t o x i n s ,

Serum

antivenins,

Laboratories

blood groups, vaccines

21 Heart Foundation Fund was raised by public subscription.

ology of skin cancer in Queensland: the incidence. Brit. ]. Cancer, 15, 409.

The National Health and Medical Research C o u n c i l has distributed a total sum of £A 100,000 to £150,000 each year to some of these institutes and to universities. Rather less money has come from private sources, but United States funds are beginning to be available. Some research has begun (through the Road Safety Councils of the Department of Transport) on accidents and their prevention, on engineering of roads and cars, and on education of drivers. Most ideas on neoplasm, degenerative processes, and urban disease have been imported, like the medical insurance scheme. It seems inevitable that thinking in public health must increasingly be concerned with the interaction between the environment and the population, human ecology, and with the unfolding of degenerations or neoplasma from cryptic genetic patterns.

DERRICK, E. H. ( 1 9 5 7 ) . The challenge of N. Queensland Fevers. Aust. Ann. Med., 6, 173.

The other side of public health, where knowledge is translated into action, is still vague and spasmodic, but it will probably be one of the most important aspects for the future.

DERRICK, E. H., POPE, J . H., and SMITH, D .

The Commonwealth Year Book.

1920-1959.

CARMICHAEI., G. G.

The epidemi-

J.

W . ( 1 9 5 9 ) . Outbreaks of Q fever in Queensland associated with sheep. Med. J. Aust., 1, 585. HENDERSON, D. A. ( 1 9 5 4 ) . A follow-up of cases of plumbism in children. Aust. Ann. Med., 3, 219. HENDERSON, D. A. ( 1 9 5 5 ) . Chronic nephritis in Queensland. Aust. Ann. Med., 4, 163. LANCASTER, H. O. ( 1 9 5 5 ) . The mortality in Australia from cancers for the period 1 9 4 6 1950. Med. ]. Aust., 2, 235. LANCASTER, H. O. ( 1 9 5 8 ) . Diabetic mortality in Australia. Aust. Ann. Med., 7, 145. Report of the Director-General of (1958). Commonwealth Govt. Canberra.

BIBLIOGRAPHY

(1961).

DERRICK, E. H. ( 1 9 6 1 ) . T h e incidence and distribution of scrub typhus in North Queensland. Aust. Ann. Med., 10, 256.

Health. Printer.

SOUTHWOOD, A. R. ( 1 9 5 7 ) . Preventive medicine and the new epidemiology: heart disease as a problem in community health. Med. J. Aust., 1, 73.

Canada B. D . B. LAYTON

Canada, but agriculture and forestry continue nevertheless to hold an i m p o r t a n t place in the Canadian economy. Arable land is one of the great natural resources, and Canada is one of the chief food-exporting countries in the world. T h e population growth for Canada since 1921, together with percentage increases as compared to the previous decade, is indicated in the following tabulation:

CANADA, by area t h e third largest country in the world, occupies most of the n o r t h e r n part of the N o r t h American continent. Its geography is dominated by the m o u n t a i n ranges r u n n i n g north and south on the western side of the continent and by the Precambrian Shield o n the east. Between t h e m lies the vast n o r t h e r n extension of the N o r t h American plain. T h e r e are six main regions determined by geographical conditions: the Appalachian-Acadian region, the Canadian Shield, the lowlands of the St. Lawrence and the Great Lakes, the interior plains, the Rocky M o u n t a i n region, and the Arctic Archipelago. T h e climate in the east and center presents greater extremes than similar latitudes in Europe; cold continental conditions are pred o m i n a n t . T h e southwestern part of the prairies and the southern part of the Pacific Slope are milder. In the north the climate is subarctic. W h i l e arduous at times, these climatic variations in Canada protect the population f r o m various afflictions which thrive in subtropical and tropical e n v i r o n m e n t s where the limiting effect of marked seasonal fluctuations of temperature is lacking. Also the relatively low humidity throughout Canada similarly discourages the survival of exotic disease vectors as well as the parasites themselves. Politically Canada is a federation of ten provinces and two territories ( N o r t h w e s t and Y u k o n ) . Each of the ten provinces has a separate legislature and administration. T h e provinces are divided into countries, which may in themselves be municipalities or may contain them.

YEAR

POPULATION

PER C E N T INCREASE

1921 1931 1941 1951 1961

8,788,000 11,381,000 11,507,000 14,009,000 18,164,000

21.9 29.4 1.1 21.8 29.7

M a x i m u m population increases of approximately equal m a g n i t u d e occurred in the two decades of generally high levels of prosperity, 1 9 2 1 - 3 1 , and 1 9 5 1 - 6 1 ; the per cent increases d u r i n g the two "war-time" decades were also almost identical. O n the other hand, the period of the "great depression," 1931 —41, saw almost a negligible increase in population numbers and per cent. T h e total area of Canada, m o r e than 3.5 million square miles, equals that of Europe, yet all regions of dense population lie within 200 miles of the southern border. T w o out of three Canadians live in u r b a n areas. Before W o r l d W a r II about 60 per cent of the population lived in rural areas. Advances in medical science, the developm e n t of health services, and elevated nutritional and other standards over the past several decades have contributed to a pronounced im-

In contrast with the earlier decades, the m a n u f a c t u r i n g industries now p r e d o m i n a t e in 23

24 p r o v e m e n t in t h e health o f C a n a d i a n s . are leading

to a d e c l i n i n g

death

These

rate and

a

l o n g e r e x p e c t a t i o n o f life. T h u s in t h e p e r i o d

T h e o r g a n i z a t i o n of the D e p a r t m e n t of N a Health

tional

1 9 2 1 - 5 6 , l i f e e x p e c t a n c y at b i r t h r o s e f o r m a l e s ,

health

leaders

f r o m 6 0 years to o v e r 6 7 . 6 , a n d

greater

and

f r o m 6 2 . 1 years t o 7 2 . 9 .

for

females,

T h e average age

at

health

390

under

to 6 1

years.

The

number

of

41.1

live births

in-

creased f r o m a n a v e r a g e of 2 4 7 , 5 3 8 in 1 9 2 1 - 2 5 , t o a total of 4 7 0 , 1 1 8

in 1 9 5 8 , b u t the

birth

the

who

dominion

foresaw

more

government

d e a t h in this p e r i o d a d v a n c e d f o r m a l e s , f r o m to 5 8 years, a n d f o r f e m a l e s , f r o m

in

government

b r o u g h t t o f r u i t i o n the e f f o r t s o f t h o s e p u b l i c

in

public of

necessity

of

participation

of

health

responsibilities a number

the

effective which

work.

Public

formerly

government

were

departments

w e r e c e n t r a l i z e d u n d e r this d e p a r t m e n t . ever, in the D e p a r t m e n t a l stated

that

How-

A c t it is e x p r e s s l y

the d e p a r t m e n t

shall

not

exercise

rate, w h i l e f l u c t u a t i n g t h r o u g h this p e r i o d , in-

any j u r i s d i c t i o n or c o n t r o l o v e r any

creased only very s l i g h t l y f r o m 2 7 . 4 t o 2 7 . 6 p e r

or m u n i c i p a l

1 , 0 0 0 live births. D u r i n g t h e s a m e p e r i o d , the

a u t h o r i t y o p e r a t i n g u n d e r the l a w s of a n y p r o v -

provincial

b o a r d of h e a l t h o r o t h e r

i n f a n t m o r t a l i t y rate d r o p p e d

f r o m 9 8 to

30,

ince.

and

5.0

per

D e p a r t m e n t of P e n s i o n s a n d N a t i o n a l

maternal

mortality

from

t o 0.6

1 , 0 0 0 live births.

In

health

1 9 2 8 the n a m e w a s c h a n g e d

to the Health,

f o l l o w i n g the d i s c o n t i n u a n c e of t h e D e p a r t m e n t of S o l d i e r s ' C i v i l R e - e s t a b l i s h m e n t ; in 1 9 4 4 the D e p a r t m e n t of N a t i o n a l H e a l t h a n d

DEVELOPMENT AND ORGANIZATION OF HEALTH SERVICES Constitutional

responsibility

dominion government. for

health

C a n a d a rests p r i m a r i l y at p r o v i n c i a l a n d levels.

in

local

A t the n a t i o n a l level the D e p a r t m e n t of

N a t i o n a l H e a l t h a n d W e l f a r e is r e s p o n s i b l e f o r implementing with

and

f e d e r a l health p o l i c i e s ,

through

provincial,

voluntary

health o r g a n i z a t i o n s

country,

and

co-operating

working

municipal,

and

throughout

the

in

international

health. T h e act o r i g i n a l l y

e s t a b l i s h i n g the

m e n t of N a t i o n a l H e a l t h

in

Depart-

1 9 1 9 stated

that

the d u t i e s , p o w e r s , a n d f u n c t i o n s of the d e p a r t ment

"extend

to a n d

include

all m a t t e r s

re-

l a t i n g to t h e p r o m o t i o n or p r e s e r v a t i o n of t h e health, social security a n d social w e l f a r e of the p e o p l e of C a n a d a o v e r w h i c h t h e P a r l i a m e n t of C a n a d a has jurisdiction."

By the British N o r t h

A m e r i c a n Act of 1867, the federal g o v e r n m e n t became

responsible

for

maritime

quarantine,

m a r i n e h o s p i t a l s , a n d f o r t h e c e n s u s a n d collection of vital statistics.

Hospitals, asylums, and

c h a r i t a b l e i n s t i t u t i o n s c o n t i n u e d t o b e the res p o n s i b i l i t y o f t h e p r o v i n c e s . T h u s , by the t e r m s of this act a n d by t r a d i t i o n , d i r e c t r e s p o n s i b i l ity f o r health s e r v i c e s rests w i t h the p r o v i n c i a l a n d local g o v e r n m e n t s . tory assists

responsibilities, the

provinces

In a d d i t i o n to its statuthe in

v a r i o u s health p r o g r a m s .

federal the

Welfare,

as it n o w e x i s t s , w a s c r e a t e d as an entity in the

department

advancement

of

T h e Health Branch of the d e p a r t m e n t prises

three

principal

directorates:

comHealth

Services, Medical Services, and Food and Drugs. The

Health

number

of

Services sections

Directorate and

includes

specialized

which are concerned mainly with

cooperation

w i t h the p r o v i n c e s in their v a r i o u s w i t h the p r o v i s i o n of

financial

a

divisions fields,

and

assistance

and

expert advice. T h e D i r e c t o r a t e of M e d i c a l S e r v i c e s is m a d e up

of

Indian

Quarantine, Mariners

and

Northern

Immigration,

Services,

Civil

Health

Medical, Service

Civil Aviation Medical Services.

Services, and

Health,

Sick and

Indian Health

Services provide preventive measures and medical a n d h o s p i t a l care f o r C a n a d a ' s I n d i a n s a n d Eskimos.

In

1955

a

division

Health Services was added

of

Northern

to p r o v i d e

coverage for the rapidly d e v e l o p i n g Territories.

T h e r e are approximately

Indians and about

similar

Northern

1 0 , 0 0 0 E s k i m o s in

158,500 Canada,

a n d b e c a u s e o f the v a s t a r e a s over w h i c h

they

a r e s c a t t e r e d , t h e m a i n t e n a n c e o f health s e r v i c e s f o r t h e m is a difficult a n d costly o p e r a t i o n . d o this, t h e d i r e c t o r a t e a d m i n i s t e r s mental

hospitals, 4 3

17

To

depart-

n u r s i n g stations, and

75

health c e n t e r s a n d clinics, m a n y of w h i c h

are

in e x t r e m e l y r e m o t e a r e a s of t h e c o u n t r y . T h e Food and D r u g Directorate

administers

25 Canada's Food a n d D r u g s Act and the Proprietary or Patent Medicine Act. These acts are designed to control t h e safety, purity, and quality, as well as t h e labelling and advertising of all foods, drugs, cosmetics, and therapeutic devices m a n u f a c t u r e d or sold in Canada. T h e directorate m a i n t a i n s a staff at administrative headquarters and in five regional laboratories across Canada. T h e s e regional offices are concerned with the examination of i m p o r t shipments, domestic foods, and drugs, with the inspection of food and d r u g m a n u f a c t u r i n g plants, with the scrutiny of radio and television advertising material, and with t h e examination of labelling claims of food and d r u g products. Considerable research is d o n e in setting u p standards and m e t h o d s of analysis for new products. T h e creation of the D e p a r t m e n t of N a t i o n a l Health and W e l f a r e has fostered progressively an intimate relationship a m o n g the provinces and the d o m i n i o n g o v e r n m e n t in all health matters. A m o n g other measures, the national p r o g r a m of grants-in-aid, introduced in 1948, has f u r t h e r strengthened the relationships between the provinces and the D e p a r t m e n t of N a t i o n a l Health. Grants, initially a m o u n t i n g to more than 30 million dollars, and in 1961 totalling some 54.5 million dollars, have m a d e possible the extension of preventive services, the training of larger n u m b e r s of public health personnel, the expansion of health research, the provision of new hospital beds and ancillary facilities, the i m p r o v e m e n t of maternal and child health, rehabilitation, and mental health programs, and many other services. T h i s is one of the important sections of the H e a l t h Services Directorate. P r o m i n e n t in this p r o g r a m has been t h e provision of assistance for medical research. Comm e n c i n g in 1948 with a grant of $100,000 for public health research, a rapid and progressive increase in both s u p p o r t i n g f u n d s and individual studies has followed. T h e level of available assistance in 1961 a m o u n t e d to over $3-3 million, involving 303 individual research projects in widely diversified areas related t o p u b l i c health. A historic event in medical research in Canada was the f o r m a t i o n in I 9 6 0 of the

Medical Research Council of Canada. It replaced the pre-existing Medical Division of the N a t i o n a l Research Council. T h i s followed a comprehensive study of g o v e r n m e n t support of medical research and its coordination. It is anticipated that the new council will provide a substantial stimulus in the advancement of medical research on a country-wide basis. Its budget for research projects and fellowships in 1961 totaled $3.3 million. Probably the most noteworthy development in t h e health field in Canada in recent years was the i m p l e m e n t a t i o n of the Hospital Insurance and Diagnostic Services Act. C o m p r e h e n sive p r o g r a m s were initiated in five provinces in mid-1958, and the plan became nation-wide in its coverage at the end of I 9 6 0 , with all ten provinces and two territories included. It provided insured hospital and diagnostic services for virtually all Canadians. This is also one of the more i m p o r t a n t responsibilities of the Health Services Directorate of the N a t i o n a l Health D e p a r t m e n t . Although there is much in c o m m o n in the organization of public health in the provinces, there are many developments which express characteristic differences in outlook and historical background. T h e records of each province are not only of interest, b u t they afford to the student of public health an understanding and an appreciation of the great accomplishments that have been m a d e in a period of hardly more than half a century. At the provincial level the organization of the health services in one province may be taken as a typical example. T h i s provincial D e p a r t m e n t of Public Health is headed by the Minister of Health with the D e p u t y Minister as his Chief H e a l t h Officer. H e is advised by a Health Services P l a n n i n g Commission and five branches: t h e Regional H e a l t h Service Branch, the Medical and Hospital Service Branch, the Psychiatric Service Branch, the Research and Statistics Branch, and the A d m i n istrative Service Branch. T h e division of responsibility in Canada at different levels of g o v e r n m e n t and between p u b l i c and private agencies has demonstrated the need for an effective co-ordinating body for planning. This role is fulfilled by the D o m i n i o n

26 Council of Health, which includes in its membership the Deputy Minister of Health of each provincial health department, as well as five members-at-large representing, individually, medical teaching institutions, agriculture, labor, and women's interests (as reflected in the two predominating Canadian cultures, English and French). Its chairman is the Deputy Minister of National Health. The council meets twice a year and acts as an agency for promoting joint planning between the federal government and the provinces and between individual provinces. In doing so it acts in an advisory capacity to the Minister of National Health and Welfare. The development of health planning in Canada has been advanced in recent years by two federal-provincial projects, the National Health Survey of 1948 and the Canadian Sickness Survey of 1950-51. Under the health survey, with the assistance of a federal grant, each province carried out studies of its health services and of its needs for the future. Through the sickness survey, an attempt was made to estimate the incidence and prevalence of illness, accidents, and permanent disabilities of all kinds, the amount of medical, nursing, and other health care received, and the volume of family expenditure for the various types of health service. As previously noted, executive planning of health services in Canada is primarily a provincial responsibility. Additionally, the larger municipalities usually provide basic public health services and supply medical services to the indigent. A rapid development of similar services in rural areas has taken place through the organization of health units with full-time staffs. These serve defined rural areas or groups of municipalities. At the local level the basic public health services such as environmental sanitation, communicable disease control, maternal, infant, and school health services, public health nursing, health education, and vital statistics are provided mainly through local health units or departments. These are directed usually by fulltime medical officers of health, assisted by nursing, sanitary, and auxiliary staff. The first health unit in Canada was established in British Columbia in 1921. By 1957

there were 221 local health units or districts (including urban health departments) serving nearly 14 million people out of 15.5 million in all provinces except Newfoundland, Prince Edward Island, and the two territories, for which data were not available. There have been substantial advances in preventive work, notably in maternal and child health, nutrition, and the full range of communicable diseases. Increasing emphasis has been placed recently on problems of chronic illness and on the rehabilitation of disabled persons. A review of the development and extension of public health work in Canada would be incomplete without mentioning the immensely valuable contribution made in the earlier years by the Rockefeller Foundation. This foundation assisted in the training of public health personnel by providing training fellowships and by establishing the School of Hygiene in the University of Toronto in 1925. Important studies have been financed in Nova Scotia, Manitoba, British Columbia, and other provinces. Assistance was given to faculties of medicine in a number of Canadian universities. In the development of full-time health services, the assistance of the foundation in the province of Quebec and in other provinces made possible the early establishment of full-time county health units and the demonstration of their value. An important contribution, also, was the granting of fellowships for the training of medical officers of health by the Connaught Medical Research Laboratories of the University of Toronto. These fellowships were initiated in 1927 and continued until the National Health Grants program made provision for increasing numbers through its professional training grant and other health grants. Under these grants training is provided in both general public health and specialized areas such as mental health and child and maternal health. In the history of the development of public health in Canada the role of national voluntary health agencies plays a most important part. The early national agencies included the St. John Ambulance Association, the Canadian Red Cross Society, and the Canadian Tuberculosis Association. N e w agencies were established to meet needs arising out of World W a r I. These

27 agencies were concerned with the control of venereal diseases and the problems of mental health. Since World War II other new agencies have been organized as special needs have been recognized. These include the National Cancer Institute supplementing the work of the Canadian Cancer Society, the Canadian Arthritis and Rheumatism Society, the Canadian Mental Health Association, and the National Heart Foundation. DISEASES

has become apparent. Accidents, especially traffic accidents, constitute a constant and tragic problem, particularly as they affect children. Also, Canada now shares the world-wide concern for exposure to radiation from medical and industrial causes as well as from fallout. T w o rather unique disease problems are emerging in the public health field: hydatid disease and rabies. Both have been detected with increasing frequency in the sparsely populated northern areas. Recently, rabies in particular has been detected in wild animal life extending into the more southerly and populous parts of Canada. For some years studies on liydatiuosis have been carried on by means of field surveys and laboratory investigations in the northern areas. These have also involved the relationship between the infecting organism in the Northwest Territories and those in the Y u k o n and Alaska.

An epidemiological summary today reveals that in terms of mortality, about 80 per cent of deaths are caused by diseases of the heart and arteries ( m o r e than 50 per c e n t ) , cancer, accidents, diseases of early infancy, the respiratory diseases (tuberculosis, pneumonia, and influenza ; , and nephritis. Deaths from causes that mainly affect children and young adults have declined. Diphtheria, for example, has been almost wiped out, and tuberculosis has been greatly reduced. On the other hand the aging of the population has increased the proportion of deaths from certain causes that affect older people. Thus, diseases of the cardiovascularrenal systems and cancer now account for a substantially larger proportion of all deaths than formerly.

In recent years the source of infection of rabies has completely changed, with the dog having given way to wild animals, especially the fox. Rabid small animals, foxes, and skunks have been detected increasingly in southern regions, even on the outskirts and sometimes within highly populated centers. This situation has caused a major modification in the rabies control program in Canada.

These trends indicate the remarkable success that health authorities have had in controlling the infective and contagious diseases, which in the past have constituted such a great hazard in the early and young adult years of life. They have similarly served to emphasize the emergence of the chronic and degenerative conditions of later life as the targets towards which the public health programs of the future will be directed. In effect, Canada has shared the experience of most western nations in exchanging a high mortality in younger life for high morbidity in older age groups. Heart and hypertensive disease, arthritis, and rheumatism rank among the leading causes of disability. Parkinson's disease, epilepsy, and multiple sclerosis also account for large numbers of disabled persons. In Canada mental illness is a major problem. T h e death rate for lung cancer continues to increase and cause controversy, although recently a clearer indication of causation

In Canada enheartening progress against poliomyelitis has been made through the national immunization program with Salk vaccine. In J u n e I 9 6 0 it was estimated that the full course of Salk vaccine had been given to 75 per cent in the ages 0 - 4 , 90 per cent in the ages 5 - 1 9 , and 45 per cent among the remainder up to age 40. W i t h the development of the oral, live polio vaccines, new techniques and testing procedures required in the control of these products have been developed at the National Virus Laboratories in Canada. Initially, experimental lots of the vaccine were tested for neurovirulence in monkeys and for genetic characteristics in tissue culture. Field demonstration trials were carried on in five selected areas in Canada. T h e need for continued effort was emphasized during the "polio season" of 1959 when one of the most serious outbreaks of paralytic poliomyelitis occurred in Canada. W h i l e 70 per cent

28 of all Canadians under age 4 0 had been fully immunized with the Salk vaccine, a total of 1,870 cases was reported, mostly occurring among unvaccinated persons. On March 6, 1962, the Minister of National Health and Welfare formally announced the licensing of live, oral, poliovirus vaccine of the Sabin type. A long-term study of the dental effects of water fluoridation, initiated in Canada in 1946 by the Department of National Health and Welfare, has been continued. T w o published reports on the outcome of these studies indicate that there has been a significant and progressive reduction in dental caries among the study group of children since 1948; there is no doubt as to the efficacy of a mechanically fluoridated water supply (containing about 1 p p m ) in very markedly reducing the caries experience in children born subsequent to fluoridation. A relatively new and rapidly expanding area of health interest is radiation protection. In 1949 the National Health Department initiated a program under which advice was provided to the Atomic Energy Control Board in Canada on health matters relating to control of the uses of radio-isotopes. A film monitoring service was also set up to serve all those engaged in the use of isotopes and in the operation of X-ray equipment. Through the intervening years these services have progressively developed to the extent that during I960, 1,054 applications for licences to procure radio-isotopes were processed. A s a related function, regular inspections of facilities are carried out to check upon handling methods, monitoring procedures, waste disposal, and records. Some 210 such inspections were made during I960. In addition to these field inspections, a continuous check on operating conditions is maintained through the film monitoring service. This is also provided upon request to all persons working with X-ray sources; currently it is supplied on a fortnightly basis to

approximately 10,000 radiation workers in Canada. Radioactive fallout measurements began in 1955, with estimations being made of the Strontium-90 content of powdered milk samples collected monthly at six stations across the country. In 1957 a radiochemical laboratory in the department was opened, and a comprehensive program has followed. FUTURE

The momentum generated in the earlier decades of public health in Canada has not only been sustained, but also progressively accele r a t e d in many diversified areas. There are indications of even greater progress in the traditional areas of public health interest, communicable disease control, air and water pollution, and general preventive measures, as well as in hospital and personal health care, and in ancillary services. In Canada the health promise of the future for all its citizens is bright and encouraging. T h e achievement of the principles so admirably expressed in the preamble to the Constitution of the World Health Organization becomes increasingly a reality for Canadians. ACKNOWLEDGMENTS

Generous reference to and use of selected sections of the following publications is gratefully acknowledged: First Report of the World Health Situation, 1 9 5 4 - 5 6 , Official Records of the World Health Organization, N o . 94. T h e Federal and Provincial Health Services in Canada, First Edition, published by the Canadian Public Health Association, 1959. T h e Canadian Year Book, Bureau of Statistics.

I960,

Dominion

Chile HERNÁN

GEOGRAPHICALLY

AND

IN

SPIRIT,

Chile

ROMERO

worthy of the name. Those who were not reduced to slavery and who merged early with the dominant race were exterminated by warfare and the effects of alcohol. T h e Araucanians that remain are confined chiefly to reservations. They number only about 100,000 exclusive of a few mestizos whose Indian blood is clearly apparent.

has

always been an island. Of all the American countries it is the farthest from Europe, from which it used to be separated by more than a month's sea voyage. Snow made the Andes impassable for a considerable part of the year, and the Pacific Ocean was a sort of back door to the world. On their arrival (towards the middle of the sixteenth century) the Spaniards found about one million Aboriginals who had probably migrated from Asia. Unlike the settlers who colonized North America and many other territories, the Conqiustadores came as the soldiers they were, without their families. The native women were polyandrous and accepted these men to whom the glamour of victory clung and who could enforce their will.

Few can have felt much interest in moving to so remote and unattractive a part of the world; also the settlers discouraged immigration. At the time of the Independence ( 1 8 1 0 ) there were probably some 98 aliens in Chile. Subsequently, there were never many more than 100,000, and today the children of foreign-born parents represent barely 2 per 1,000 of the total number of births. In contrast Argentina received 3 million immigrants in 50 years.

RACIAL BACKGROUND

Our geography is very strange. W i t h an area of 750,000 square kilometres Chile ranks seventh in size among the South American countries; only Ecuador, Paraguay, and Uruguay are smaller. However, it is larger than any of the countries of Europe with the exception of Russia. From north to south it is 4,200 kilometres long. In other words it could stretch from Copenhagen to Timbuctoo or from Lake Baikal to the northern Philippines. The poet exaggerated when he said that its breadth was "from east to west a hundred miles at widest," but it really measures only 90 kilometres across at one point in the north and a mere 15 at another in the far south. About three-quarters of this area is taken up by deserts, mountain ranges, and to a small extent forests, so t h e present inhabited portion covers no more than 200,000 square kilometres.

The result of this union was a fairly homogeneous racial mixture. It combines the individualism of the Spaniard with the gregariousness of the Indian, and has proved itself highly adaptable. It would seem to be made up of 65 per cent of mestizos, 30 per cent of Caucasoids, and 5 per cent of Mongoloids, deriving from the mingled strain of the natives of Asian origin. These percentages are only approximate and are based on the estimates of ethnologists. Since the country was poor and lacking in tropical crops the number of negroes brought to Chile did not exceed about 6,000. Their contribution to the race has been calculated to represent less than one per cent. Unlike those of other Latin American countries and like those of the United States and Canada, our aboriginal groups developed no civilization

29

30 Chile's territory lies between the 17th and 56th parallels latitude South, so one-sixth of it falls within the tropics. However, its climate is definitely temperate, thanks to the prevailing winds and the Humboldt Current, which flows all the way up the coast. Punta Arenas, at its southernmost tip, is situated farther south than any other town in the world. Y e t it is no colder than London and less so than N e w York. From one end of Chile to the other, average temperatures range from 19-5 to 6.6 degrees centigrade. The country is much too narrow a strip to show the slightest sign of continentality. ECOLOGY A N D E A R T H Q U A K E S

Despite the mildness of its climate and the beauty of its landscapes Chile's lot is a tragic one. In May I 9 6 0 it was scourged by a series of earthquakes, which (in combination with other natural p h e n o m e n a ) caused the worst devastation recorded in the history of such events. Other similar disasters have occurred several times over in every century and threaten to dog us indefinitely. Geologists have told us that a large part of the territory is characterized by a combination of three physiographical units with various rock formations, whose dates of origin probably extend from the Pre-Cambrian to the Quaternary period. This means that they cover geological developments ranging from those of over 500 million years ago to those of the last million years, and it is recognized that many geological faults may possibly exist in the three units. The modified scale devised by Cancagni, Mercalli, and Siebergh which is in use the world over, comprises 12 degrees of intensity. Of these, 12 corresponds to a major catastrophe which would wipe out all the works of man. In the earthquakes of I 9 6 0 intensities of 9 and 10 at several points ( a t one place even of 11) were registered. Upheavals and subsidences of over a metre in height or depth were observed in the local topography. T h e sea, which rolled back about 500 metres along some beaches, surged up one of the valleys for a distance of two and a half kilometres. It left a fine layer of sand whose heavy content of chloride will render the soil useless for farming for several years to come. T h e most violent

of the tidal waves laid waste a fishing village and swept some of the houses three kilometres inland. One of several tsunamis (series of ocean waves propagated by submarine seismic movements ) also caused considerable damage in Hawaii and Japan. T h e disaster seriously affected the welfare and peaceful existence of 30 per cent of the population of Chile, and the monetary losses involved are equivalent to two or three years' national investment. ECONOMY

Chile generally cuts a poor figure in international comparisons. According to our own publications, its rates of infant mortality and accidental death have been the second highest in the world. This is also true of death by immersion and drowning. T h e rates of mortality from road accidents to pedestrians and death by violence have actually been the highest. These remarkable data can be attributed to the existence of reliable statistics coincident with the prevalence of unsatisfactory conditions in the fields of public health, economy, and even culture. A dozen censuses have been taken, of which the most recent have reached satisfactory technical standards. T h e records which embrace more than a century can now be said to offer almost complete coverage. Undeniably our economy is unstable and its development beset by difficulties. U p to the first World W a r it enjoyed periods of great prosperity. Its mainstay was then exports of copper and, above all, natural saltpetre of which it had a monopoly. Since the manufacture of synthetic nitrate has been developed and the copper market invaded by competition from mines which can be worked at lower cost the balance has been seriously upset. Today annual per capita income in Chile is $315 as against $1,200 in Canada, $1,800 in N e w Zealand and $2,400 in the United States. While income has risen 40 per cent in the last three decades, the still greater increase in the population has reduced the per capita income of the less privileged classes by 10 per cent. T h e higher income groups (six per cent of the population) reap the benefit of over onethird of Chile's total production. Barely one-

31 fourth falls to the share of the 840,000 working-class families which represent 59 per cent of the population. T h e average incomes of the aforesaid six per cent are 22 times as high as those of the workers. Only 36 out of every 100 Chileans are gainfully employed. This is because nearly 4 0 per cent are under 15, many women still devote themselves entirely to house keeping, and the number of pensioners is steadily increasing. The Chilean farmer feeds only two people besides himself, while his counterpart in the United States provides for nine at a much higher level of nutrition. In contrast also to our situation there is plenty of margin in the United States for export and surplus. W h e n we were few in number we were able to export agricultural commodities to Peru and even to Australia. This export trade reached a peak during the California gold rush. N o w the volume of per capita production is 20 per cent smaller than a quarter of a century ago. In the last 12 years meat and wheat have had to be purchased abroad to a value of about 1,000 million dollars—an astronomical sum for our national accounts. Grants of crown lands were made in colonial times, and the recipients (encomenderos I who seized the vast estates of the Jesuits on the latter's expulsion developed

into the proprietors of latifundia. Of the privately owned farm land in Chile 64 per cent belongs to 750 individuals. In 1952, 32 per cent of our workers were employed in the agricultural sector, as against 27 per cent in Argentina and 25 per cent in Australia; but also as against 85 per cent in Haiti. Despite the advances it has obviously made, industry contributes only one quarter of the national income and produces mainly consumer goods. Presumably it is waiting for the requisite stimulus to be provided by drastic land reform and by improvement of farming methods. Another adverse factor is the inadequate rate of investment—a mere nine per cent in the last decade, which is lower than in most countries. DEMOGRAPHY

Illiteracy in the over-15 age group is stationary at about 20 per cent. According to U N E S C O , attendance at primary and postprimary schools is higher in Chile than in the other Latin American countries, with the possible exception of Costa Rica. Barely 1.4 per cent g o to the university and 2.4 per cent receive higher technical education. The former percentage is exceeded only in Argentina, where no matriculation restrictions exist.

TABLE

1

C H I L E A N P O P U L A T I O N — C E N S U S FIGURES

1835-1960

YEAR

1835 1843 1854 1865 1875 1885 1895 1907 1920 1930 1940 1952 1960

POPULATION

1,010,336 1,083,801 1,439,120 1,819,223 2,075,971 2,507,005 2,695,625 3,231,022 3,730,235 4,287,445 5,023,539 6,277,000 7,339,546

PERCENT

PERCENT

PERCENT

OF A N N U A L INCREASE

OF U R B A N

PERCENT IN CAPITAL

OVER 5 0 YEARS

POPULATION

CITY

O F AGE

0.9 3.0 2.4 1.4 2.1 0.8 1.7 1.1 1.5 1.7 2.1 2.1

6 6 7 9

28 35 42 45 43 46 49 52 60

10 14 17 19 23

—

25

8.9 7.2 8.4 9.2 12.5 11.4 11.5 12.0 13.0

32 O w i n g to t h e virtual absence of i m m i g r a t i o n , the g r o w t h of the p o p u l a t i o n was until recent times purely vegetative and consequently slow. N o w its rate is so rapid as to b e outstanding even in Latin America, w h e r e the rate of increase is one of the highest in major regions of the world. A f t e r three centuries of colonial rule the n u m b e r of inhabitants probably were fewer than one million. T h i s bears unfavorable witness to the sanitary conditions and t h e policy which the Spaniards imposed. Between 1835 and 1875 the p o p u l a t i o n doubled, and the 1960 census shows about seven and a half million inhabitants ( 7 , 3 4 0 , 0 0 0 is the tentative figure of the N o v e m b e r 30, I960, census). Large n u m b e r s of the population live in the vicinity of the land which they farm ( e i t h e r on their o w n account, or m o r e often on behalf of their patron). T h u s there are about 30,000 agglomerations of fewer than 500 persons. At the other extreme, over 25 per cent of the inhabitants of Chile are crowded together in the capital, the g r o w t h of which is disproportionate to that of the country as a whole. Between 1938 and 1951 the rural population followed a declining trend, while the urban increased by 900,000, of w h o m 350,000 lived in Greater Santiago. This characteristic of macrocephalic countries is c o m m o n to all those of Latin America and constitutes a serious obstacle to progress. Except in Brazil and Colombia, the n u m b e r of people concentrated in the capital of every one of our sister Republics is larger than the aggregate population of all the other towns with 100,000 or more inhabitants. Greater Buenos Aires contains about 30 per cent of the population of Argentina, and M o n t e v i d e o somet h i n g like 44 per cent of that of Uruguay. W i t h the exclusion of Uruguay within Latin America Chile's degree of urban concentration ( 4 0 p e r c e n t ) is lower only than Argentina's ( 4 8 per c e n t ) , and is followed by those of Cuba ( 3 3 per c e n t ) and Venezuela ( 3 1 p e r c e n t ) . VITAL AND H E A L T H STATISTICS

In t h e h u n d r e d years between 1850 and 1950 the nuptiality rate stood at a b o u t 7.5 per 1000. M o r e recently there is a slight tendency to in-

crease. S o m e t h i n g like 30 p e r cent of Chilean w o m e n marry before t h e age of 20. However, their age at date of marriage is in general higher than in the other A m e r i c a n countries, although lower than in those of Europe. From 1850 to 1950, the birth rate crept almost imperceptibly d o w n w a r d and by t h e end of the century it had declined by 20 p e r cent. T h i s proportion bears a suspicious resemblance to the percentage decrease in illegitimate births. Over and above a birth rate of 37 or 38 per 1000, 4 0 per cent of the children born in 1950 represented t h e fourth ( o r even a later) m e m ber of the family. For a long t i m e the mortality rate hovered around 30 per 1000. It began to decline sharply around 1920 and has recently remained stationary between 12 and 13 p e r 1000. In the aggregate, maternal mortality a m o u n t s to scarcely one per cent. T h o u g h highly preventable, it constitutes the third most i m p o r t a n t cause of death in w o m e n of 1 5 - 4 4 years of age. It is responsible for one out of every ten deaths a m o n g w o m e n aged f r o m 20 to 39 years. W h i l e it has d r o p p e d to considerably less than half its f o r m e r level in the course of the last 4 0 years ( f r o m 70.4 per ten thousand in 1920 to 32 in I 9 6 0 ) the rate is still very high; for example, about ten times higher than that registered in the U n i t e d States. In relation to age distribution, the maternity risk is least between 20 and 24 years of age. N e x t are t h e 2 5 - 2 9 and under-30 age groups. Subsequently, the risk increases in direct ratio to age.

TABLR

2

MARRIAGES, NATALITY, AND MORTALITY CRUDE RATES,

1920-1959 RAT H O F

MAR-

NATAL-

MOR-

RIAGES

ITY

TALITY

6.6 7.7

42.7 41.9

30.5

12.2

1925-27

2S.5

1

1930-34

6.4

40.2

16 2

1935-39 1940-44

7.6

36.0

24.0 22.7

8.2

35.5

19.4

1945-4 ;

7.8

35.6

16.9

1 8.7

1950-54

8.1

34.6

12.8

21.8

1955-59

7.5

35.6

12.5

23.1

YFARS

1920-24

:

NATURAL INCREASE

4

13.3 16.1

MARRIAGES. NATALITY AND MORTALITY CHILE 1920-1959

¡30-

MARR1AGES

35-39

1920-24

40-44

1955-59 YEARS

FIGURE 1

TABLE

3

M A T E R N A L M O R T A L I T Y BY A G E O F

AGE O F TOTAL

MOTHER

MATERNAL

LIVE

RATE PER

DEATHS

BIRTHS

10,000

"64

209,920

36.4

-15

5

491

101.8

15-24

200

76,622

26.1

25-34

330

90,143

36.6

35-44

209

34,829

60.0

45-54

18

2,147

83.8

2

5,688

unknown

U p to than for the m o r e hospitals. reversed.

1947 the rates were lower for h o m e hospital deliveries, probably because serious cases were concentrated in Since then the p r o p o r t i o n has been Today maternal mortality is highest

in the provinces where the percentage of maternity cases attended at h o m e is greatest. In the m e a n t i m e the percentage of hospital cases has risen f r o m about 16 per 100 live births in 1935 to over 60 at present. Toxaemia gravidica, accidents of delivery ( i n c l u d i n g h e m o r r h a g e and acute a n e m i a ) and puerperal sepses are more or less equally responsible for maternal mortality. Infections of this kind had previously shown an increase correlative to the decrease in accidents. This was p e r h a p s because a certain n u m b e r of w o m e n survived the latter by virtue of m o r e effective treatment only to fall victims later to sepsis. Since 1937 when antibiotics were introduced, there has been a marked reduction of puerperal sepses. This has accounted mainly for the d o w n w a r d m o v e m e n t registered by the maternal mortality rate.

34

TABLE

4

M A T E R N A L M O R T A L I T Y BY C A U S E S RATES PER 1 0 , 0 0 0 LIVE BIRTHS,

YEARS

MATERNAL MORTALITY

1920-59

ACCIDENTS

TOXEMIA

INFECTIONS

19

ABORTION

1920-24

70

4S

3

1925-29

57

37

2

18

1930-34

68

31

6

27

4

1935-39

77

28

6

32

11

1940-44

66

23

6

24

13

1945-49

40

18

5

11

6

1950-54

34

16

5

7

6

1955-59

31

14

3

4

10

Studies carried out during the thirties showed that just under 18 per cent ( 1 7 . 6 ) of natural deaths was attributable to induced abortions. Nowadays the corresponding proportion is nearly 37 per cent. T h e small contribution of abortions to maternal mortality during the earlier period is in marked contrast to what has been observed in the more advanced countries. Today we are closer to them in this respect. Our infant mortality is often referred to in textbooks, not only because it is far too high, but also because enough data are available for it to be traced from a long time back. Because the population of Chile was small and infectious diseases preponderant, infant mortality fluctuated widely during the first quarter of the present century. Subsequently, the curve flattened out and turned downward. This declining trend became a good deal more marked from 1936 to 1 9 5 3 , after which it again began to rise. By 1925 the rate was about 2 5 0 per 1000, and in I 9 6 0 was still as high as 132.5. It reached bottom around 1 9 5 3 ( 9 9 5 per thousand) and then turned upward. ENDEMIC

value of which is often conditional upon the water supply. It is an open secret that the effluent of the Santiago sewage system is used for such purposes as pig breeding and even vegetable growing. According to recent studies only 55 per cent of the urban and six per cent of the rural population enjoyed a satisfactory supply of drinking water; 4 0 per cent of the former and virtually none among the latter were served by a proper sewage system. In such circumstances it is not surprising that the typhoid morbidity rate should have fluctuated between 6 0 and 82 per hundred thousand during the last ten years. Thanks to modern therapeutics the corresponding mortality has dropped from 8 0 in 1 9 1 9 to 2.6 at the present time. Enteroparasitic infestations on whose diffusion little information is to be had, constitute a TABLE

R A T E S P E R 1 0 0 0 LIVE B I R T H S , DEATHS

1920-59 DEATHS

INFANT

UNDER

1-11

MORTALITY

2 8 DAYS

MONTHS

DISEASES

T h e r e is a shortage of water in Chile as there is everywhere along the western slopes of the Andes. Places can be found where it rains only a few times in the whole course of a century. This fact must be borne in mind in evaluating irrigation systems which are appallingly defective; also, the distribution of rural property, the

5

INFANT MORTALITY

RATE

7r

RATE

Or

1920-24

243

119

49

124

5 1

1925-29

224

106

47

118

53

1930-34

210

92

44

118

56

1935-39

215

94

44

121

56

1940-44

174

66

38

108

62

1945-49

146

54

37

92

63

1950-54

118

44

37

74

63

1955-59

118

37

31

81

69

INFANT

MORTALITY

CHILE 1920-1959 300

£200

INFANT

MORTALITY

1-11 MONTHS

UNDER

35-39

28

DAYS

40-4 4 YEARS

FIGURE

problem similar to that formerly represented by tropical diseases. Neither the public health services nor society at large has weapons or resources to combat their onslaught. At the beginning of the century the highly fertile valleys enclosed by vast tracts of desert in the north of Chile were seriously infested with malaria. It was eradicated by means of a persevering and skillful campaign, and nowadays only needs watching. Early in the century, when ocean trade was an important activity, we had epidemic outbreaks of yellow fever and plague brought from the East. W e were menaced even by trachoma. Now they are mere memories. In a survey carried out in I 9 6 0 only five cases of trachoma were registered in Chile, and none of plague or yellow fever in the last 40 years. The Scots who came to work the first

2

coal mines left Ancylostoma cluodenale in the deep shafts of submarine workings. W e have never had the Necator americanus of our continent. As it was a strictly occupational diseaseit affected only manual workers and was not difficult to eradicate. In so mountainous a country where a main range skirts a major part of the coastline, it is not surprising that goitre should be found in landlocked valleys. W e have shown that it was more common in the capital which used water primarily from underground sources, and that its prevalence perceptively declined with the change in the relative importance of the sources of supply. In a survey carried out among about 63,000 primary school pupils an over-all average of perceptible goitre was found in 16.4 per cent, and the proportions by areas fluctuated

36 TABLE

6

LEADING CAUSES O F D E A T H , 1 9 2 0 AND 1 9 5 9

1920 RANK

1st 2nd 3rd 4th 5 th 6th 7th 8 th 9th 10th

G R O U P O F CAUSES

1959

TY OVER

RATE PER

TOTAL

100,000

DEATHS

POPULATION

Respiratory System 26.4 Early Infancy 13.8 Ill-Defined Conditions 11.0 Infective and Parasitic Dis. 10.6 Digestive Diseases 9.4 Tuberculosis 8.6 Cardiovascular System 6.7 N e r v o u s System 5.3 Accidents 3.5 Neoplasms 1.6 O t h e r Causes 3.1 TOTAL

100.0

760 .397 317 305 271 248 193 153 101 46 89

G R O U P O F CAUSES

Respiratory System Early Infancy Digestive Diseases Cardiovascular System Ill-Defined Conditions Neoplasms Accidents N e r v o u s System Tuberculosis Other Infective Diseases O t h e r Causes TOTAL

1880

LEADING CAUSES OF

% OVER TOTAL

RATE PER

DEATHS

POPULATION

100,000

23.3 12.1 11.2 10.0 9.8 8.2 6.5 6.1 4.4 3.4 5.0

291 151 140 125 122 103 81 76 55 43 63

100.0

1250

DEATH

CHILE 1920 and 1959

0

5

10

15

20 •I. O V E R

FIGURE 3

25 TOTAL

DEATHS

37 between 11 and 33.5 per cent. Generally speaking, this condition is much less frequent in coastal districts and in the larger towns, where the composition and sources of foodstuffs are more diversified. M A I N HEALTH PROBLEMS

Chile's health problems are neither endemic nor related to climate or geography. They are social and are caused by our economic and cultural underdevelopment. Probably the most important is alcoholism because of its influence on nutrition, production of goods and services, stability of the family, and other aspects of national life. In 1950 it was estimated that there were approximately three alcoholics per 100 adults. W e thus ranked third in the world after France and the United States, which at that time probably had 5.2 and 4 per cent respectively. Of 13,501 inpatients attended between 1938 and 1943 by a Santiago medical service, 20.3 per cent were habitual drunkards. In 1944 the equivalent of 22.4 per cent of active workers were taken into custody for drunkenness, and 42 per cent of the arrests effected in 1949 was due to this cause. Similarly, intoxication was responsible for 18 per cent of Monday absenteeism among farm workers; 9-5 per cent in industry; and seven per cent in business. Between 1928 and 1948 per capita consumption of alcoholic beverages averaged 64.7 liters which absorbed 21.6 per cent of the family food budget. In 1954 a random sample of 20,000 persons in the over-45 age group living in a workingclass district established that nine per cent could be classified as alcoholics and 29 per cent as intermittent drunkards. These percentages are in striking contrast with those registered among women, which were 0.6 and 0.5 respectively. They represent incontrovertible proof that the social factor is the basic etiological mechanism. The over-all ratio between the sexes is from 11 to 13 and more males to every female. In town and country alike men drink on holidays and after work because they are bored and wretchedly housed, and many events are celebrated with much drinking. The second problem is probably that of in-

fant mortality which is founded on malnutrition and summer infant diarrhea, and consequently on the widespread propagation of enteric infections and infestations. The caloric deficiency in the diet of the nation as a whole is still estimated to be 11 per cent ( 1 8 per cent for Mexico); of children entering special hospitals, 20 or 25 per cent suffer from considerable degrees of dystrophia, and pediatricians have described many cases of multi-deficiency syndromes and a few of kwashiorkor. INFECTIOUS DISEASES

Ten years ago tuberculosis was still in the epidemic stage in Chile. The corresponding mortality, somewhat higher than 220 per ten thousand in 1948, declined slightly in that same year. Shortly afterwards it began to plummet downward. Recently it has become stabilized at about 60. Venereal diseases were at one time a source of concern. W e treated one thousand syphilitic patients with preparations of pentavalent arsenic in the second shortest space of time after the United States. Between 1945 and 1953 the number of new cases dropped to approximately one-fourth, and at this stage the problem seemed to sink out of sight. W e do not know what is happening now but a recrudescence is suspected. W i t h the exception of those of an enteric nature infectious diseases have lost a good deal of their importance. After ranking first among TABLE MORTALITY

'

FROM T U B E R C U L O S I S , T Y P H O I D

FEVER,

AND O T H E R I N F E C T I V E D I S E A S E S — R A T E S P E R 100,000 POPULATION,

1920-59 OTHER

TUBER-

TYPHOID

CULOSIS

FEVER

1920-24

228 246

50.3 27.5

228

1925-29 1930-34

243 224

7.6

169 147

YEARS

1935-39 1940-44

INFECTIVE DISEASES*

179

234

9.8 9.6

1945-49 1950-54

221

9.0

63

109

4.0

39

1955-59

62

2.7

36

* Excluding influenza.

1 R

MORTALITY FROM DIFFERENT

CAUSES

CHILE 1920-1959

CANCER

\

OTHER INFECTIVE D I S E A S E S

\ \

CIRRHOSIS OF T H E L I V E R

\

\

\ TYPHOID FEVER

1920-24

25-29

40-44

FIGURE

the causes of mortality, they

now hold

tenth

45-49

50-54

1955-59

Í

Chile.

During

the

three

centuries

of

the

place and account for 3.4 per cent of the total,

Colonial epoch and the first 1 2 0 years of the

as against 55 per cent in Honduras.

I n d e p e n d e n c e the disease was always there in

Epidemics

of diphtheria still appear notwithstanding an ac-

the background.

tive

demics

inoculation

program.

The

specific

mor-

tality rate has been gradually rising in the last

broke

At intervals

out.

At

the

large-scale

same

date

epias

five years, and in I 9 6 0 was over five per hun-

a C h i l e a n friar of the order of San J u a n

dred

Dios.

thousand.

That

of

slightly lower and that of

whooping

cough

measles about

is 28.

in

E u r o p e a n u m b e r of p e o p l e were vaccinated by Shortly

afterwards

the K i n g

of

de

Spain

sent to the colonies a g r o u p o f adolescents in

In the Indian reservations and a few other areas

whose arms the vaccine was k e p t alive by the

typhus was e n d e m i c , and the former were o f t e n

doctors

the source of e p i d e m i c outbreaks.

countless efforts

In 1 9 3 3 an

accompanying

e p i d e m i c of tragic p r o p o r t i o n s started in San-

was made

tiago.

completely

D u e chiefly to the use of residual

in-

secticides, the disease is now virtually eradicated.

the

expedition.

vaccination

compulsory disappeared

in

against

1921.

about

30

After

smallpox

The

disease

years

despite the fact that it exists in the

ago,

adjacent

efficient

countries. D u r i n g this interval t h e r e have been

lieutenant to H e r n á n Cortés in the conquest of

a couple of outbreaks started by travellers f r o m

M e x i c o and to P e d r o de Valdivia in that of

the countries in question but were q u i c k l y stifled.

Smallpox

obviously

served

as

an

39 Since we are islanders it is s o m e t h i n g of a disgrace that we have not yet eliminated rabies and that it should be increasing. T h e disease is e n d e m i c with cyclic outbreaks r e c u r r i n g fairly regularly every five years. In 1951 and again in 1955 there were 11 cases of h u m a n rabies. In t h e f o r m e r year 574 cases of animal rabies were registered; only 67 in 1957 and 65 in 1958. Of the total n u m b e r of cases in both species 88 per cent occurred in Santiago, and all of t h e m in the center and south of Chile. T h e only g r o u n d for o p t i m i s m is the fact that the p r o p o r t i o n a l relation between animal and h u m a n cases has decreased. T h u s it was 379 11 in 1955 and 580 7 in I 9 6 0 . These figures seem to indicate a clearer public awareness of the problem. In t h e latter year 8,776 b i t i n g dogs were kept u n d e r observation at h o m e in Santiago. From a set of 6,000 records it was possible to establish, in 1953, that one out of every 80 biting animals had rabies, which shows that the element of risk is considerable. This is b o r n e out by the fact that about 87 per cent of saliva samples f r o m h y d r o p h o b i c dogs has been found to contain virus. T h i s p e r m a n e n t danger necessitates the m a i n t e n a n c e of a complex and costly machinery. In 1947 Semple vaccine was replaced by the irradiated kind. Complications deriving f r o m p r e v e n t i v e treatment d r o p p e d f r o m approximately 1 3,000 to 1 20,000. N o w that use is being m a d e of the brain of a ten-dayold rat also exposed to ultraviolet radiation, better results may b e expected f r o m preventive inoculation. C H R O N I C DISEASES

Between 1926 and 1956 the r h e u m a t i c fever mortality rate fell f r o m 22 to 14 per h u n d r e d thousand. Since this decrease became a p p a r e n t b e f o r e any influence had been exerted by efficacious curative and more particularly, preventive practices, it must be attributed to higher levels of living and especially to t h e mitigation of overcrowding. A n o t h e r d e t e r m i n a n t is more effective methods of treatment, which lengthen the lives of these patients and give t h e m time to die f r o m other causes. Despite changes in nomenclature it is highly significant that in t h e m e a n t i m e the p r o p o r t i o n of deaths f r o m other

r h e u m a t i c diseases has almost quadrupled. T h e increase in these diseases must certainly have been far greater since their fatality rate is low. A quarter of a century ago mortality f r o m rheumatic fever was 14 times greater than the sum of t h e rates for all other forms of rheumatism, whereas today it is not even twice as high. In our e n v i r o n m e n t there is n o way of measuring disablement. A m o n g f o r m e r employees d r a w i n g social security pensions a rate of 27 100,000 was found. However, the criteria for classifying invalidity f r o m this cause differ considerably, and the g r o u p of individuals in question is in n o way representative. In international comparisons of mortality f r o m rheumatic fever and cardiopathies we appear in an intermediate position. This proves nothing, since generally the countries that take first place are best endowed in respect to diagnosis and treatment. W e have been particularly cautious in our research on rheumatism, believing that in underdeveloped countries only the nonsubmerged part of the iceberg is visible to the eye; also because changes may be more accurately attributable to the i m p r o v e m e n t in methods of diagnosis and reporting and the modification of classification criteria. T h e behavior of cardiovascular diseases in Chile seems disconcerting at first sight, but it is explicable u p o n f u r t h e r reflection. T h e data indicate that their prevalence has not increased d u r i n g the past quarter of a century. O n the contrary it has shown a marked d o w n w a r d trend d u r i n g the last five years. They hold fourth place a m o n g the principal causes of death and account for ten per cent of the total n u m b e r of deaths. T h e numerous health examinations carried out by the social insurance institutions reveal an incidence of 5.5 a m o n g males and 5.2 a m o n g females per thousand persons of working age. These diseases d o not, therefore, constitute the t r e m e n d o u s p r o b l e m which they represent in t h e highly developed countries. T h i s is understandable since in the latter the increment in cardiovascular affections is due to the aging of t h e p o p u l a t i o n ; also because these diseases have c o m e to supersede others as causes of death. In our case many people still die of diseases that could be prevented or more efficaciously treated. D e s p i t e the substantial in-

40 crease in the expectation of life at birth ( f r o m 30 to 55 years between 1930 and 1 9 5 9 ) age distribution has remained fairly stationary. T h u s the over-30 age group, which constituted 33.5 per cent of the population in 1920, represented 35.5 p e r cent in 1959T h e recent decline in these rates is partly explained by the transfer of many death certificates signed by witnesses to the "ill-defined causes" group; also by the manifest reduction of mortality f r o m rheumatic fever. This fact is obviously satisfactory. Paradoxical as it may seem, so is the 500 per cent increment between 1940 and 1959 in congenital cardiopathic diseases, because it undoubtedly reflects improvements in diagnosis. Conversely, there is n o t h i n g g r a t i f y i n g about the 65 per cent increase in coronary arteriosclorosis and that of 38 per cent in cerebral haemorrhages d u r i n g the same period. Generally speaking, mortality f r o m cardiovascular diseases is so powerfully conditioned by age that they constitute the leading cause of death a m o n g persons aged 65 years and over; the second, in t h e 5 5 - 6 4 age g r o u p ; and the third, between the ages of 45 and 54 years. It drops to sixth place in the 15—44 age group. T h e sharp u p s w i n g w h e n cold weather begins testifies that the p h e n o m e n o n is primarily one of senility. T h i s distribution over the year is in contrast with that shown by mortality f r o m cancer. Strangely enough, the mortality registered a m o n g w o m e n was the higher until 1945. In that year the curves transected each other and today that corresponding to males is clearly p r e d o m i n a n t , probably o w i n g to the considerable increase in coronary diseases in males. T h e distribution by provinces is highly orthodox, since the figure is perceptibly higher in provinces with the most intensive u r b a n concentration and the largest n u m b e r of inhabitants in the over-15 age groups. In the fifth quintil, however, the p r o p o r t i o n s in question are 33 and 59 per cent respectively; the u r b a n concentration is 85 and the p o p u l a t i o n over 15 years of age is 68 in the provinces of the first quintil. In the f o r m e r provinces mortality f r o m cardiovascular diseases is half as high as f r o m infectious diseases, and in the latter twice as high.

A t t h e international level Chile holds an intermediate position, r a n k i n g thirty-ninth a m o n g 6 6 countries that publish data. T h e countries a p p e a r i n g in the u p p e r p a r t of the table are primarily Anglo-Saxon and European, and in the lower are f o u n d those of Latin America and Asia. T h e r e are inconsistencies deriving f r o m t h e classification criteria adopted. T h e n u m b e r of deaths actually registered in Chile seems to be in line with the facts, since it closely coincides with what m i g h t b e expected in theory f r o m application ro our o w n p o p u l a t i o n of the average rates for 12 developed countries. In t h e course of the last 4 0 years the rate of mortality f r o m m a l i g n a n t tumors has trebled. Its contribution to the total n u m b e r of deaths has increased approximately five times over. T h i s i n c r e m e n t is mainly attributable to the i m p r o v e m e n t in diagnosis. Moreover, studies of our o w n reveal that the incidence of mortality f r o m cancer in each age g r o u p is notably similar in Chile and in the U n i t e d States. Apparent differences in the figures are d u e to the aging of the population. O u r expectation of life at birth has increased by one year every twelve months, and has risen f r o m a little over 30 years (estimated on the basis of the 1930 census d a t a ) to about 55 years. At the same t i m e the aging of our p o p u l a t i o n is almost imperceptible, no d o u b t because t h e birth rate has remained at a very high and almost unvarying level. Oddly enough the rate of mortality f r o m cancer of the digestive organs is twice as high in Chile as in the U n i t e d States ( a f t e r adjustm e n t for age d i s t r i b u t i o n ) . Moreover, 6 0 per cent of all deaths f r o m cancer is i m p u t a b l e to this cause. It remains to b e ascertained w h e t h e r the p h e n o m e n o n should be ascribed to diet habits, i m m o d e r a t e c o n s u m p t i o n of alcohol, or the low level of living. Cirrhosis of the liver represents a d i s t u r b i n g p r o b l e m to which we are devoting diligent study. N o other morbid process registers a m o r e rapid rate of increase. T h e risk of death has q u i n t u p l e d ( r i s i n g f r o m 0.1 to 1.7 per c e n t ) since 1920. This seems to be a g e n u i n e increment, mainly because it is in line with hospitalization data which are reliable and supplied by entirely i n d e p e n d e n t sources. Particularly since 1940 t h e curve shows such sharp fluctuations as

41 TABLE

8

MORTALITY FROM CANCER, DISEASES OF CARDIOVASCULAR SYSTEM AND CIRRHOSIS OF THE L I V E R — RATES PER 1 0 0 , 0 0 0 POPULATION, 1 9 2 0 - 1 9 5 9

YEARS

CANCER

CARDIOVASCULAR SYSTEM

1920-24

39 43 63 66 69 77 85 103

178 164 171 188 190 186 160 132

1925-29 1930-34 1935-39 1940-44 1945-49 1950-54 1955-59

CIRRHOSIS OF THE LIVER 3.4 4.3 6.1 8.7 9.6 15.2 16.5 21.6

to suggest the intervention of an infectious factor with epidemic peaks. On the basis of national statistics the increase cannot be attributed to a deterioration of nutritional levels or to an augmented ingestion of alcohol. It may be that the data in question fail to reflect the consumption of a fairly limited social group. It is true that the expectation of life has risen considerably and that the mean age at date of death from cirrhosis is nearly 48 years. Therefore, some influence may have been exerted by the fact that a greater number of individuals reach an age at which they are liable to suffer from what is to some extent an involutional process. It is none the less disconcerting that while Chile acknowledges from 120 to 220 thousand alcoholics (proportion by sexes is between 11 and 13 men to every woman) the annual number of deaths from cirrhosis is only 1,800. These comprise no more than two males to every female. The inference would seem to be that alcoholism is more serious in women and more quickly leads to malnutrition and rejection by society. We are continuing to conduct research on our over-all problem of hepatic cirrhosis which may shed some light on the unknown quantities in its etiology. OTHER HEALTH

PROBLEMS

Inasmuch as the volume of preventable diseases is still substantial, violent deaths rank eighth among the principal causes of mortality. The rate of 86.7 per hundred thousand inhabitants registered in 1958 is the highest in the

world. This must be taken with a grain of salt, as for many countries data are nonexistent or defective. Generally speaking, deaths by violence are on the increase, particularly those due to accidents. The latter are responsible for one out of every seven deaths among males over one year of age and two out of every three in the 20-25 age group; also for one death out of four among females aged 15 to 19 years. In regard to road accidents, we rank fourth in the world and first in respect to fatal accidents to pedestrians. Household accidents account for one-fifth of the total. Our figures for deaths from drowning and immersion are exceeded only by Finland's. In 1956 (the last year for which relevant data have been published) accidents at work would seem to have determined the loss of some two million days of effective working time, and over seven million in terms of imputed working time. Mental health is terra ignota among us, since owing to the deficiencies of the pertinent services no really comprehensive studies have ever been carried out. This problem is presumably being aggravated by the effects of urbanization which alter values and customs, by the breaking-up of the family, and by other social and cultural changes. The only epidemiological research conducted on mental morbidity covered a sample of 2,146 persons in the city of Santiago. It revealed that something like 20 per cent of the group were permanently or temporarily affected in one way or another. This proportion included five per cent of alcoholism, two per cent of epilepsy and 1.4 per cent of psychosis. MEDICAL

ORGANIZATION

The Spanish Crown obtained Papal authorization to collect tithes on condition that a part of these was to be used for works of charity. Consequently, and also as a result of private philanthropy, several hospitals were set up in Chile at an early date. Their principal purpose was to look after the spiritual and physical welfare of the sick. After a long period of evolution they ultimately became institutions for medical care. In 1932 they were grouped together in an organization known as the Social Welfare Services (Servicios de Beneficencia y

42 Asistencia Social). It took a long time for us to accept the notion that government doctors can help to improve the health of both individuals and the community. To combat our periodic epidemics emergency measures were often adopted. These subsequently lapsed into oblivion. Only in the second quarter of the present century was a Department of Public Health created. Even then its influence was weakened by budgetary and staffing shortages. In 1924 a Worker's Social Security Act came into force, the first of its kind in Latin America. Later a series of social security and savings institutions were set up. The benefits of these have been extended and multiplied without any form of consistent control or any regard for the limitations of the economy. At the present time the social security system represents a barrier to progress and an enormous drain on the country's finances. By 1952 the Social Welfare Services had practically a monopoly of the hospitals, and their outpatient services had already developed to a considerable extent. During this year the medical profession sponsored a merger of services which they named National Health Services. The merger was a fusion of the Social Welfare Services, the Department of Public Health, the medical services attached to the workers' social insurance system (plus the payment of subsidies), and also other minor organizations. This new body is in charge of all preventive and health measures, and also provides medical care for the indigent and for workers and their families. Two complementary acts made it obligatory for all doctors to be members of the College of Medicine ( C o l e g i o Medico: a guild or even a form of syndicate) and established a national register of physicians and surgeons. Consequently, the overwhelming majority of our colleagues are nowadays public servants. Their remunerations are fixed in accordance with the number of hours worked, plus a premium based on years of service and another (and smaller) "post allowance'' for the responsibilities that each has to carry. Exclusive devotion (full time) to the public service, or in other words, the abandonment of private practice, is also recompensed. Hence the exercise of medicine

as a liberal profession has been reduced to a minimum. In appraising this system, it must be constantly borne in mind that those devised for developed countries have obviously failed in our own; also that the foregoing solution is essentially an intermediate formula (compromise ) between such schemes and those put into effect by the European nations in their colonies and by the countries professing Marxist socialism. Perhaps because the experiment was too bold, or because we are still in the phase of readjustment, the results achieved have fallen far short of expectations. There has been a patently regressive trend in sanitary measures. In the meantime the overall and infant mortality rates and the rates of death from tuberculosis and other causes have either ceased to decline or have actually increased. It may be assumed that an epidemiological equilibrium has been established at a lower level and that the measures hitherto adopted are no longer capable of producing results. However, it is difficult to avoid suspecting a cause-and-effect relationship between these developments and the reform introduced in the health organizations. HCONOMY O F T H E MEDICAL SECTOR

In 1958 medical expenditure represented 4.9 per cent of the national income. Two-thirds of it represented the expenditure of the public sector to which fourth priority is assigned (9.8 per cent of the total). It ranks level with education and lower than social security (22.3 per cent), transport and communications ( 13.5 per cent) and national defense (12 per cent). The public sector referred to is constituted almost in its entirety (95 per cent) by the National Health Service and the National Medical Service for Employees. The State contributes about half their income and the social security institutions little more than one-third. On the private sector, about 90 per cent of medical expenditure corresponded in the same year to the outlays of persons exercising independent professions such as doctors, dentists, nurses and midwives. These disbursements represented 1.7 per cent of total consumer expenditure in the case of manual workers, 3.2 per cent in that of

43 own-account workers and 4.2 per cent in that of employees. In real terms national medical expenditure increased by at least 90 per cent in the period 1 9 4 5 - 1 9 5 8 and individual outlays by 45 per cent. The rate of growth was perceptively less rapid during the last five years of this period. However, the satisfaction of requirements in this field cannot be considered to have improved correlatively, since to a large extent these increments have been absorbed by the progressively increasing proportion of urban population which resorts to medical services. Slight as it is, the aging of the population exerts pressure for the solution of new problems and the progress of science is in itself a factor tending to raise costs. In 1958 the per capita cost of medical services was estimated to have been 19-7 dollars, a higher sum than that registered in New Zealand ( 1 5 dollars for 1954 to 1 9 5 5 ) . However, N e w Zealand's general mortality rate of nine per 1000 and its infant mortality rate of 24.1 are considerably lower than ours, which are 12.5 and 120 per 1000, respectively. Since 1953 the economic situation of Chile has entered upon a critical phase. Real medical expenditure per capita which in the period 1945-1953 had increased at an average annual rate of ten per cent declined by 1.3 per cent yearly. Immediately afterwards national income began ro fall. By 1958 it represented 88 per cent of the level attained in 1953. It was at this point that the infant mortality curve reversed its direction and began to rise. It therefore seems likely that there is a relationship between this phenomenon and socio-economic conditions and that it is very little influenced by increases in medical expenditure. MEDICAL P E R S O N N E L

It may be honestly said that the medical education given by our three universities is first class and is making manifest progress. Before the reform we already had one doctor for every 2,000 inhabitants. Thanks to the influence of the state organizations their distribution throughout the country was better than in many other parts of the world. A fourth school of

medicine has recently been established. However, its annual output will not keep pace with the rapid growth of the population without jeopardizing the standards of quality attained. Furthermore, the inevitable centralization recently brought about by the fusion of services has considerably upset our favorable distribution. Chile's supply of doctors may be rated at nearly six per 10,000; but the corresponding figure for the capital is 13, and 0.5 for one of the provinces. Our social workers and nursing profession also enjoy well-deserved prestige, but the yield of the university schools of nursing has decreased. They too are confronted with the disquieting problem of population growth. T o palliate the effects of the deficit of nurses and social workers strenuous efforts are being made to train ancillary medical personnel, such as administrators, statistical clerks, dietitians, laboratory technicians, sanitary inspectors, and nursing auxiliaries. T h e establishment in 1943 of the School of Public Health of the University of Chile represented a great stride forward. T h e school is now of regional status and receives students from all over Latin America. F U T U R E PROSPECTS

At the present time the government's chief concern is for the development of the economy and for the rehabilitation of provinces devastated by the I 9 6 0 earthquakes. Consequently, too little attention is being devoted to the medical services. T h e resources allocated to them are insufficient. Presumably this situation is bound to alter, and then the state of public health in Chile may improve rapidly and substantially. A far-reaching program of sanitary installations would suffice to produce solid results. The obstacles that hinder the campaign against infant mortality and a number of preventable diseases are mainly of an economic nature. More complex are those problems which derive from the rapid rate of increase of the population and, above all, from the disproportionate growth of the city of Santiago. T o tackle both a State policy is essential.

China: Taiwan C. H . Y E N

TAIWAN IS AN ISLAND PROVINCE of the R e p u b lic of China located between 2 1 - 2 5 ° N latitude and 1 1 9 - 1 2 2 ° E longitude. It has an area of 3 6 , 0 0 0 square kilometers; two-thirds of this area is covered by mountain ranges ( e a s t and cent r a l ) . T h e plain on the western section is wide, fertile, and densely populated. T h e northern half of the island lies in the subtropical and the southern half in the tropical zone. T h e climate is w a r m and humid, and the rainfall is high. T h e vegetation is luxurious and varied. T h e r e are frequent earthquakes and typhoons.

agriculture, forestry, and fishery. T h e chief export items are rice, sugar, tea, and fruits. A n agrarian reform in 1 9 4 8 m a d e the farmer owner of the land he tilled, and restricted land holding to a m a x i m u m of t w o acres per person. A rise in the standard of living for the main bulk of the population resulted. In the last decades there has been an increase in such industries as textiles, fabrics, pharmaceutics, electrical appliances, cement, paper, aluminium, and glass. T a i w a n has g o n e through three periods of administration since 1661, 1 6 6 1 - 1 8 8 9 , Chinese government; 1889-1945, Japanese government; since 1945, Chinese government. U n d e r the Chinese N a t i o n a l G o v e r n m e n t , there is the provincial g o v e r n m e n t which is responsible for the administration of the entire province. T h e administration is divided into 16 counties, five cities, and one special district. T h e s e 22 units are further subdivided into 361 villages, townships, and city districts.

T h e population of T a i w a n in D e c e m b e r I 9 6 0 was 10.8 million which is about three times that in 1920. T h e density of p o p u l a t i o n is extremely high, 284.5 persons per square kilometer ( 1 9 5 9 ) . It is still g r o w i n g fast with a high birth rate of 38.8 per 1,000 p e o p l e ( 1 9 6 0 ) , and a low death rate of 6.8 per 1,000 p e o p l e ( I 9 6 0 ) . T h e p o p u l a t i o n in I 9 6 0 consisted mainly of Chinese ( 9 8 . 7 per c e n t ) and a small number of aborigines ( 1 . 3 per c e n t ) . Between 1 9 4 5 - 6 0 there was an influx of 1.5 million Chinese f r o m the mainland to T a i w a n .

GENERAL HEALTH AND INCIDENCE OF DISEASE

C o m m u n i c a t i o n within the province is well developed. In I 9 6 0 there was a network of 3,873 kilometers of railways and 16,201 kilometers of highways. T h e r e is also an intraisland airline and five lines of coastal ship service.

Prior to 1946 there was no independent, governmental, public health service existing in this province. T h e r e were 12 g o v e r n m e n t hospitals and a medical college. U n d e r the police department there was a section dealing with medical registrations, sanitation control, and prophylactic inoculations. T h e s e jobs were carried out by the local practitioner as requested by the police. In this manner the J a p a n e s e administration was able to collect s o m e vital statistics and to m o p u p certain c o m m u n i c a b l e diseases such as cholera, smallpox, and p l a g u e which recurred from time to time ( F i g . 1 ) .

T h e economy of the province is based on

H o w e v e r , the incidence of diseases such as

Literacy is very high, as over 95 per cent of the children of school a g e attend school. In I 9 6 0 there were 1712 primary schools with 1.9 million children, 361 high schools with 3 5 4 , 5 6 1 pupils, and 22 colleges and universities with 35,060 students.

45

46 No. of Cases

Year

1912

1920

1925

1930

1935

1940

1945

1950

1955

1960

FIG. 1. Incidence of smallpox, cholera, and plague.

malaria, diphtheria, rabies, tuberculosis, and trachoma remained high. During W o r l d W a r II most of the government hospitals were demolished by aerial bombings. Immediately following W o r l d W a r II there was a tremendous increase in the incidence of malaria. Between 1 9 4 5 - 4 7 , 14 cases of bubonic plague, 3 , 9 0 8 cases of cholera, and 6 , 7 5 4 cases of smallpox occurred. General health conditions were alarming at this period when there was the change of administration from Japanese to Chinese. T h e Chinese government immediately set up rehabilitation work; a bureau of health service was organized under the Department of Civil Affairs in 1 9 4 7 . T w o years later this bureau was elevated to the same administrative status as the Department of Civil Affairs. It is called the Provincial Health Administration (department ), and is directly under the office of the provincial governor. Following its establishment, active measures were taken to solve the general health problems. As a result of this, since 1947 no more cases of plague, and since 1 9 4 8 no cases of cholera have occurred. T h e smallpox outbreaks were suppressed to sporadic

cases occurring among the evacuees from the Chinese mainland, and the disease was totally eradicated since 1956. In the ensuing years the provincial hospitals were rehabilitated and rebuilt with modern designs and provided with new equipment. T h e most outstanding work has been the building of an island-wide network of 22 health centers and 372 stations scattered to all villages and townships. In 1945 there were 15 stations; by 1 9 5 9 there were 3 6 0 stations. It is through this system of decentralized health units that effective public health services did reach the mass of people. At present the major disease conditions are gastro-intestinal infections, pneumonia, senility, cardiovascular diseases, malignancy, pulmonary tuberculosis, trachoma, virus encephalitis, intestinal parasitic infections, and mental disorder ( T a b l e 1 ) . T a b l e 1 illustrates significant reductions in incidence of death due to diseases such as pulmonary tuberculosis, malaria, and pneumonia. Incidences of death due to senility, cardiovascular disease, and malignancy remain high, in fact higher than figures available 4 0 years ago.

47 TABLE

trict has o n e h e a l t h c e n t e r

1

CHIEF CAUSES OF DEATH

N U M B E R DEATHS PER

DISEASE

1 0 0 , 0 0 0 PEOPLE 1921

(total

22)

under

d i r e c t c o n t r o l o f its r e s p e c t i v e g o v e r n m e n t , a n d

1921-59

u n d e r s u p e r v i s i o n of the P r o v i n c i a l H e a l t h A d ministration. county

1959

A

health

center

health d e p a r t m e n t )

(equivalent

is r e s p o n s i b l e

to for

all t h e health w o r k in a c o u n t y or city. It p e r -

Pneumonia Senility

374

87

and

child

66

62

health service, p r e v e n t i o n a n d c o n t r o l of

com-

Pulmonary tuberculosis

158

40

V a s c u l a r l e s i o n s of b r a i n

30

50

municable

Malignant neoplasms O t h e r d i s e a s e s of h e a r t

16 24

39 28

Malaria

188

f o r m s such

functions as: diseases,

maternal

medical

care,

food

and

d r u g c o n t r o l , l a b o r a t o r y s e r v i c e s , a n d o t h e r activities.

There are nine municipal and county

hospitals,

—

seven

one

hospitals

municipal for

maternity

infectious

hospital,

diseases,

three

t u b e r c u l o s i s centers, 2 2 l a b o r a t o r i e s , a n d s e v e r a l ORGANIZATION OF PUBLIC HEALTH SERVICE The

National

Health

Administration,

f o u n d e d in N a n k i n g as a n i n d e p e n d e n t m i n i s t r y in 1 9 2 8 , w a s i n c o r p o r a t e d i n t o the M i n i s t r y of Interior

in

1947

when

the N a t i o n a l

m e n t of C h i n a m o v e d t o T a i p e i .

Govern-

Its f u n c t i o n s

a r e : p l a n n i n g a n d i m p l e m e n t a t i o n of a n a t i o n a l health p r o g r a m , c o o r d i n a t i o n

and

cooperation

w i t h i n t e r n a t i o n a l health a n d f o r e i g n aid a g e n cies,

supervision

of

the

National

Narcotics

s a n a t o r i a u n d e r t h e c o n t r o l of health

centers.

T h e n u m b e r of p e r s o n n e l is f r o m 3 0 t o 5 0 in e a c h health c e n t e r ; t h e h o s p i t a l s h a v e

varying

n u m b e r s of staff f r o m 7 0 - 2 0 0 , d e p e n d i n g t h e n u m b e r of b e d s a n d v o l u m e o f

on

outpatient

services. H e a l t h s t a t i o n s u n d e r d i r e c t i o n of t h e health centers were established o n e for each township, v i l l a g e or city-district. were

established

in

Special

health

saltworkers'

stations

villages,

and

Ta-chen evacuees' villages.

and

A health s t a t i o n usually s e r v e s a p o p u l a t i o n

s u p e r v i s i o n of p r o v i n c i a l health a d m i n i s t r a t i o n s .

b e t w e e n 2 0 , 0 0 0 to 3 0 , 0 0 0 , a n d its p e r s o n n e l is

Bureau

and

the M e d i c a l

T h e Provincial partment),

Supply

Bureau,

Health Administration

located

at

Wu-feng,

(de-

Taichung

C o u n t y , has the over-all r e s p o n s i b i l i t y

for the

p u b l i c health services in T a i w a n P r o v i n c e , including curative and preventive medical

serv-

ices, i n s e r v i c e t r a i n i n g o f health p e r s o n n e l , a n d port quarantine services.

It is a l s o r e s p o n s i b l e

for the p l a n n i n g a n d s u p e r v i s i o n of t h e activities of the city a n d c o u n t y h e a l t h c e n t e r s

(de-

p a r t m e n t s ) . A t p r e s e n t it directly s p o n s o r s the following Child

health

Health

search I n s t i t u t e mental

institutions:

Institute (1948),

Sanitation

( 1959),

Maternal

and

Malaria

Re-

I n s t i t u t e of

( 1955),

four

Environ-

Tuberculosis

Control Centers ( 1 9 5 2 ) , Public Health Teaching

and

Demonstration

Center

(I960),

Hygienic Laboratory, six M a r i t i m e Q u a r a n t i n e Stations

( 1 9 4 5 ) , t w o A i r p o r t Q u a r a n t i n e Sta-

c o m p o s e d o f o n e or t w o d o c t o r s , t w o to n u r s e s a n d m i d w i v e s , a n d o n e to f o u r workers

(including

nursing

spector, and clerk).

five

health

aids, sanitary

It p r o v i d e s

in-

medical

care

to p a t i e n t s at its c l i n i c in t h e m o r n i n g s , c h a r g i n g m i n i m a l f e e s or n o t h i n g f o r the i n d i g e n t ;

in

the a f t e r n o o n s it c a r r i e s o u t s u c h p u b l i c health w o r k a s : m a t e r n a l a n d child health, health e d u cation, school health services, sanitary

inspec-

tion, h o m e visiting, immunization, and

disease

control. H e a l t h s u b s t a t i o n s are l o c a t e d in 1 5 8 r e m o t e or m o u n t a i n o u s

villages, and

function

mainly

as field d i s p e n s a r i e s u n d e r d i r e c t c o n t r o l of their r e s p e c t i v e health

stations.

In e a c h s c h o o l t h e r e is a health r o o m

with

a n u r s e in c h a r g e . T h e n u r s e s e r v e s as the coo r d i n a t o r b e t w e e n t h e health s t a t i o n s a n d

the

tions ( 1 9 4 5 ) , m a t e r n i t y h o s p i t a l , c h i l d r e n ' s hos-

school;

pital, two mental hospitals, provincial

g e n c e , " a n d c o n c u r r e n t l y g i v e s l i m i t e d first aid.

leprosa-

she

is u s e f u l

as t h e m e d i c a l

"intelli-

r i u m , a n d 14 g e n e r a l h o s p i t a l s w i t h t h r e e b r a n c h

S o m e s c h o o l s h a v e f u l l - t i m e p h y s i c i a n s , b u t in

hospitals.

the majority

Each municipality, county, and special

dis-

of

s c h o o l s t h e health

r e s p o n s i b l e f o r t h e c l i n i c a l service.

station

is

In a d d i t i o n

48 there

is

a

committee

on

school

health

and

health education jointly sponsored by the Pro-

rabies

vincial D e p a r t m e n t of Education and the Provincial H e a l t h In

I960

Administration.

health

personnel

in T a i w a n

con-

sisted o f : medical doctors, 4 , 7 2 5 ; dentists, 8 1 6 ; dentistry

assistants,

pharmacy

219;

assistants,

nurses, 1 , 4 8 4 ;

pharmacists,

422;

964;

midwives,

nursing assistants,

2,024;

618;

sanita-

rians, 1 , 1 2 3 ; herbalists, 1 , 6 8 8 .

To

prevent

Smallpox,

dren between the ages of six to 2 4

DPT

months.

T h i s mass vaccination is g i v e n free of charge, and is done through the health stations.

One

booster dose is given to these children

when

they are three or four. D i p h t h e r i a m o n o t o x o i d is also extensively given to t w o to six-year-old children w h o have not received D P T

vaccine

previously. S i n c e 1 9 5 9 D P instead o f D P T , is Any reported diphtheria case is given

free serum treatment. per

T h e n u m b e r of

1 0 0 , 0 0 0 population

has

I960.

D e s p i t e existing regulations

past years, rabies r e m a i n e d uncontrolled.

serum

is

and

vaccine

institute.

These

three How-

compulsory,

are required to be

may be revaccinated

every

Malaria.

M a l a r i a used to be a m a j o r scourge

in T a i w a n .

D e s p i t e vigorous efforts made by

Deaths

until recently.

T h e prevalence

of

the

disease increased right after W o r l d W a r II due to poor living conditions during the W a r and to the return of the population, heavily infected with plasmodia, f r o m m o u n t a i n o u s hide-outs to urban areas after t h e W a r .

In

1952

it

was

estimated that there w e r e over 1.2 m i l l i o n cases when the p o p u l a t i o n was about 8 million.

To

cope with this situation the g o v e r n m e n t established an Institute o f Malaria Control in

1948.

T h e work of t h e institute is summarized in the following tabulation: Prepatory

due

Phase

1.

Organization of provincial teams for island-

2.

T r a i n i n g of all categories of malaria control

3.

Survey of patients and vectors, and the deter-

4.

T e s t i n g of efficacies of various m e t h o d s and

5.

C o m p a r a t i v e survey on field costs and

wide anti-malaria work. workers. m i n a t i o n of areas of endemicity. drugs in vector control and case-treatment.

to

TABLE

m a n - p o w e r requirements.

2

M E D I C A L F A C I L I T I E S IN 1 9 6 0 IN T A I W A N MEDICAL

I

DENTAL

CLINICS

!

CLINICS

HOSPITALS

BEDS

36

3,845

372

Private

142

2,845

3,564

751

Total

178

6,266

3,936

751

Governmental i all categoiies )

per

four years.

also

provided free o f c h a r g e f r o m the g o v e r n m e n t ' s serum

plague.

children

o f the population

Flurry-Keler avianized vaccine, and the result was total eradication of the disease in the folHyper-immune

and

3

I960.

vaccinated within six m o n t h s of age. T h e rest

How-

ever, since 1 9 5 7 , dogs were vaccinated with the

years.

cholera,

and all n e w b o r n

requir-

ing registration and vaccination of dogs, in the

lowing

of

deaths

due to diptheria

dropped f r o m 1.3 in 1 9 2 1 to 0 . 8 in Rabies.

a high

ever, smallpox vaccination is still

abated

diphtheria,

triple vaccine m a d e locally was given to chil-

given.

from

the earlier administration, the disease had not

DISEASE CONTROL Diphtheria.

dropped

diseases have b e e n c o m p l e t e l y eradicated.

T a b l e 2 shows the medical facilities available in I 9 6 0 .

have

1 0 0 , 0 0 0 population in 1 9 5 1 to 0 in

( Combined with other services )

field

49 Attack

Phase

1. Promotion of island-wide residual spraying. 2. Detection and treatment of cases. 3. Promotion of sanitation control. Surveillance

Phase

1. Detection and treatment of new and old cases. 2. Establishment of an elaborate surveillance program. 3. Use of D D T spraying limited to special areas. In 1952 house spraying with D D T covered a population of 156,000. Maximum coverage was achieved in 1956 with 6.7 million people. During this period some areas were given five successive annual sprayings. By 1959 coverage dropped to 300,000 people as the disease came under control. The manpower required for the spraying work has been tremendous, and at its maximum in 1946, 7,862 workers were employed. Between 1 9 5 2 - 5 6 the spray work cost 72 million Taiwan dollars (N.T. currency). The parasite rate dropped from 9 per cent ( 1952) to 0.01 per cent ( 1 9 5 6 ) , and clinical cases from 1.2 million (estimated in 1952) to 609 ( F Y 1959), and 122 ( F Y - 1 9 6 0 ) . Since September, I960, there were no new cases noted, but there were 52 indigenous cases discovered and promptly treated. Among these, many were cases imported from outside the province. The surveillance program is now being strictly enforced and it is hoped that in another three years the disease may be completely eradicated. However, importation of cases from other areas is always a threat to the success of the program. During the month of April in 1961, 4,266 returnees from the SinoBurmese border arrived in Taiwan; among these, 320 cases with blood positive for the plasmodia of malaria were detected and treated promptly. At present the government gives prizes to any doctor or health worker who helps the health service in discovering an authentic case of malaria. Tuberculosis. Although tuberculosis has been an important cause of death in Taiwan, very little was done until after 1945 when the Chi-

nese government regained control of the administration. Since 1943 an intensive and progressive control program was started. BCG immunization was given to newborn children and children below age 20. Between 1948-59, 7.8 million individuals ( 8 5 per cent of that agegroup) were tuberculin-tested; of these, 4.4 million were reactors, and 4.37 million of these reactors were given BCG immunization. An X-ray chest survey has been carried out with use of seven mobile X-ray units in addition to routine X-raying in hospital admissions and clinics. Between 1950-59, 1.9 million individuals were covered by this project. Of this number, 62,520 ( 3.3 per cent) were found to be suspected tuberculosis cases. These were properly investigated and treated. A mass sputum examination to detect the presence of tubercle bacilli was sponsored since 1956. 372 health stations, all other health centers, and private clinics were encouraged to collect and examine sputum from patients and suspects. Culture tubes are also passed out to these health units, and collected back to 22 health centers' laboratories for incubation and reading of results. From 1957-59 this work covered the examination of 114,168 direct smears, 54,655 sputum cultures, and 64,238 laryngeal swab cultures; from these, 10,119 open cases of tuberculosis were detected and were kept in a registry for follow-up treatments. Since 1947 the government has been giving free treatment with INH and other drugs to all open cases of tuberculosis. Home visitors from the 372 health stations follow up the treatment at homes. Chemo-prophylaxis is a part of the control program. The administering of drugs to tuberculin reactors under age six with no other sign of the disease was started only this year. Except for special reasons such as an emergency or chest surgery, tuberculosis patients are treated at home. Health education regarding measures against cross infection at homes were given to each patient. After the introduction of the program and in recent years, there was a definite drop in the number of deaths due to all forms of tuberculosis. In 1947 the death rate per 100,000 population was 285; by 1959 it had dropped to 47.

50 B u t the p r o b l e m still exists. A c c o r d i n g t o a n island-wide

sample

s t a t i o n s a n d all g o v e r n m e n t a l a n d p r i v a t e clinics

1 9 5 7 , o f t h e 3 2 , 2 3 7 i n d i v i d u a l s e x a m i n e d , 3-9

collect a n d s e n d b l o o d s p e c i m e n s t o t h e s e lab-

per

o r a t o r i e s , a n d o b t a i n f r e e p e n i c i l l i n in return.

are X - r a y

survey

tuberculosis

made

tories s c a t t e r e d o v e r t h e i s l a n d ; the 3 7 2 health

in

cent

random

suspects

0.7 p e r c e n t a r e s p u t u m p o s i t i v e s .

A

r a n d o m survey is b e i n g p r o j e c t e d in

and

second

1962-63.

T h e i n c i d e n c e of t r a c h o m a r a n g -

Trachoma.

i n g f r o m 3 0 p e r c e n t t o 9 0 p e r c e n t in d i f f e r e n t localities

is c o n s i d e r e d

high.

Since

1954

While

the

incidence

specimens

collected

one per school treated.

cent

aureomycin

3-9 p e r c e n t in

the

children

were

annually

All

examined

and

In c e r t a i n v i l l a g e s w h e r e i n c i d e n c e of

the d i s e a s e w a s k n o w n t o b e h i g h , b l a n k e t treatm e n t f o r all i n h a b i t a n t s w a s a l s o c a r r i e d

out.

B e t w e e n 1 9 5 4 - 6 1 , over 6.9 million eye examin a t i o n s w e r e m a d e o n s c h o o l c h i l d r e n a n d of these, 3.4 m i l l i o n p o s i t i v e f i n d i n g s w e r e n o t e d . All these cases w e r e t r e a t e d w i t h the a n t i b i o t i c ointments. dences

The

among

reduction the p r i m a r y

of

trachoma

inci-

school e n t r a n t s

is

s t r i k i n g . T h e i n c i d e n c e o f t r a c h o m a in p e r cent e x a m i n e d w a s as f o l l o w s : 43;

1 9 5 4 - 5 5 , 54;

1956,

1 9 5 7 , 4 0 ; 1 9 5 8 , 19. P r i o r to 1 9 4 5 ,

Filariasis.

filariasis

had

been

(Pescadores

isles J , w h i c h is a b o u t 5 0 m i l e s w e s t of T a i w a n A m a s s b l o o d survey

in P e n g - h u

v e a l e d e i g h t p e r c e n t i n c i d e n c e in 1 9 5 7 . lowing

an

active

control

program

a

reFol-

similar

survey r e p e a t e d in I 9 6 0 s h o w e d a r e d u c t i o n to t h r e e p e r cent.

In T a i w a n p r o p e r the c a s e s a r e

m a i n l y l i m i t e d to the e v a c u e e s f r o m the coastal isles of the C h i n e s e m a i n l a n d .

In 1 9 5 5

when

1 8 , 0 0 0 r e f u g e e s c a m e t o T a i w a n f r o m the T a c h e n isles t h e r e w a s a ten p e r c e n t among

them.

These

were

infection

promptly

treated.

A c t i v e p r o g r a m s f o r the d e t e c t i o n of n e w cases a n d f o l l o w - u p t r e a t m e n t of all k n o w n c a s e s a r e b e i n g p r o m o t e d t o p r e v e n t the d i s e a s e f r o m bec o m i n g e n d e m i c in T a i w a n p r o p e r . c i p a l vector c u l e x is q u i t e p r e v a l e n t \ztnereal

disease

control.

T h e prinhere.

Organized

to c o n t r o l v e n e r e a l d i s e a s e ( V D )

only a f t e r 1 9 5 3 , w h e n a p r o v i n c i a l V D was established.

center

T h r o u g h this c e n t e r the g o v -

ernment provides free diagnosis and f o r all cases.

efforts

were started

treatment

T h e r e are 22 serological

labora-

from women

I960.

T a i w a n has five m e d i c a l s c h o o l s o f f e r i n g diff e r e n t d e g r e e s a c c o r d i n g to the l e n g t h of course.

the

A f u l l c o u r s e l e a d i n g to a b a c h e l o r of

m e d i c i n e takes s e v e n years, i n c l u d i n g o n e year f o r i n t e r n s h i p . A s p e c i a l f o u r - y e a r c o u r s e is off e r e d f o r s t u d e n t s w h o w i l l p r a c t i c e only in t h e a b o r i g i n a l area. A n o t h e r f o u r - y e a r c o u r s e is f o r t h o s e w h o will b e m e d i c a l l y q u a l i f i e d a f t e r c o m p l e t i n g the n a t i o n a l A

school

of

examination.

pharmacy

gives

a

p h a r m a c y a f t e r five years of study.

degree

in

T h e dental

s c h o o l s g i v e d e g r e e s a f t e r f o u r to six years of study. Admission

to all these s c h o o l s

is by

petitive examinations after graduation

p r a c t i c a l l y l i m i t e d to t h e P e n g - h u proper.

pregnant

MEDICAL EDUCATION

of

or terramycin.

sero-positives

w a s 9-9 p e r c e n t in 1 9 5 4 , it d r o p p e d d o w n to

g o v e r n m e n t has i m p l e m e n t e d a m a s s treatment c a m p a i g n w i t h the u s e o f local a p p l i c a t i o n

of

among

com-

from a

s e n i o r h i g h school. N u r s i n g s c h o o l s of v a r i o u s k i n d s o f f e r m a n y courses.

A f o u r - y e a r c o u r s e in n u r s i n g leads to

a bachelor degree. in

technical

T h e r e is a three-year c o u r s e

nursing.

A

three-year

vocational

n u r s i n g c o u r s e is g i v e n to j u n i o r h i g h graduates. given

Other

by

private

missionary

school graduates.

hospitals

school

courses

to j u n i o r

are high

T h e s e g r a d u a t e s h a v e to b e

qualified

by

national

examination.

Midwifery

nursing

the g o v e r n m e n t is t a u g h t

as

an

after

passing

additional

a

year

c o u r s e a f t e r a three-year n u r s i n g c o u r s e or as a three-year c o u r s e by itself. Various inservice training courses are given to

health

workers

employed

by

government

health institutes, c e n t e r s , a n d h o s p i t a l s , in a d d i tion to t h o s e g i v e n by t h e I n s t i t u t e of Health

in

the

National

Taiwan

Public

University

Medical College. MATERNAL AND CHILD HEALTH G r e a t i m p o r t a n c e h a s b e e n a t t a c h e d by g o v e r n m e n t t o the p r o m o t i o n of M C H

the

service

51 in the 3 7 2 h e a l t h s t a t i o n s .

In

1952

it

estab-

R e c e n t l y , there h a v e b e e n n a t i o n a l a n d p r o -

l i s h e d a P r o v i n c i a l M C H C e n t e r , w h i c h in 1 9 5 9

vincial

b e c a m e the P r o v i n c i a l I n s t i t u t e of M C H .

there

i n s t i t u t e has m a n y a c t i v i t i e s .

This

It c o n d u c t s

ma-

ternal a n d child health s e r v i c e in a d e m o n s t r a tion area w i t h

12,000 population.

It p r o v i d e s

i n s e r v i c e t r a i n i n g of p h y s i c i a n s , h e a l t h officers, nurses, a n d m i d w i v e s

in g r o u p s of

10-20

re-

c r u i t e d f r o m the 3 7 2 s t a t i o n s . It s u p e r v i s e s t h e local health stations.

It d o e s r e s e a r c h a n d sur-

veys o n local M C H p r o b l e m s , i n c l u d i n g tion.

It

offers

midwives.

refresher

courses

for

nutriprivate

It g i v e s d e m o n s t r a t i o n s of p r e - p r e g -

nancy c l i n i c s i n c l u d i n g r e g u l a t i o n of c o n c e p t i o n .

Water

works

in T a i w a n

in p a s t

years.

In

projects.

16,921

government.

houses

1955-60

built

by

the

F a c t o r s such as l i g h t i n g , ventila-

tion, drainage, and carefully

Between

such

toilet q u a r t e r s

considered.

These

have

been

are

ordi-

houses

narily sold to p e o p l e at t h e cost p r i c e o f a b o u t NT§26,000

to N T S 6 8 , 0 0 0

size a n d t y p e of the house. 2,852

depending on

the

A m o n g these were

units for farmers and

fishermen,

4,350

u n i t s f o r i n d u s t r i a l w o r k e r s , 2 , 2 8 9 u n i t s f o r city dwellers.

T h e y are p a y a b l e in ten-year

install-

ments. INTERNATIONAL AID AND COLLABORATION

SANITATION

proved

housing were

were I960

rapidly supply

imareas

Since

1948

the p u b l i c health s e r v i c e s

have

collaborated with and received assistance f r o m

r e a c h e d to 2 2 9 p l a c e s a n d c o v e r e d a p o p u l a t i o n

m a n y a g e n c i e s s u c h as the A m e r i c a n B o a r d f o r

of

M e d i c a l A i d s to C h i n a

3.2

million

( 2 9 . 6 3 per

p o p u l a t i o n in T a i w a n ) .

cent

of

the

total

T o t a l a m o u n t of w a t e r

s u p p l i e d is a b o u t 2 1 5 liters o f w a t e r p e r c a p i t a per day. C h l o r i n a t i o n of w a t e r w a s

introduced

in t h e l a r g e r w a t e r w o r k s , a n d b l e a c h i n g p o w d e r has b e e n used in the s m a l l e r w a t e r w o r k s .

Four

w a t e r e x a m i n a t i o n c e n t e r s in the p r o v i n c e c h e c k w a t e r s a m p l e s regularly.

S i n c e a l m o s t all C h i -

nese are t e a - d r i n k e r s , the w a t e r they d r i n k usually b o i l e d .

is

In o r d e r t o p r o v i d e s a f e w a t e r

in rural areas, 4 , 5 5 1 h a n d p u m p i n g w e l l s

with

complete covers were constructed. Village

( s i t e of the n e w p r o v i n c i a l g o v e r n m e n t ) , t h e r e no

underground

water

carriage

sewerage

s y s t e m in the cities. In T a i p e i s u c h a p l a n w a s d r a w n u p as a result of a three-year s t u d y ; h o w ever, this

it w o u l d could

be

take many constructed.

more

years

Meanwhile

d i t c h e s a r e the e x i s t i n g d r a i n i n g s y s t e m . require

constant repair

and

extension.

before open They Night

soil a n d g a r b a g e are s e p a r a t e l y collected

from

i n d i v i d u a l h o u s e h o l d s by m a n u a l w o r k .

They

a r e c a r r i e d a n d t r a n s p o r t e d by t r u c k t o d e s i g nated p l a c e s f o r d i s p o s a l .

Recently, composting

plants were established which combined

these

two

good

wastes

and

turn

out

fertilizer

of

q u a l i t y a n d s a f e for use. S e p t i c t a n k s h a v e b e e n used w i d e l y in m o s t of t h e m o d e r n h o u s e s , a n d e s p e c i a l l y in g o v e r n m e n t b u i l d i n g s s i n c e

1945.

(CMB)

( A B M C ) , China Med-

of the R o c k e f e l l e r F o u n d a -

tion, N A M R U N o . 2 ( U S A ) , J C R R agency),

ICA

(USA),

UNICEF,

M u c h technical assistance and

(bilateral

and

WHO.

financial

support

w e r e r e c e i v e d f r o m I C A e s p e c i a l l y in r e g a r d to the tuberculosis and hospital ships.

malaria control

program,

rehabilitation, sanitation, and

U N I C E F and W H O

fellow-

were most helpful

in g i v i n g t e c h n i c a l a n d m a t e r i a l a i d s especially in p r o g r a m s of v e n e r e a l d i s e a s e , t r a c h o m a , m a ternal

W i t h the e x c e p t i o n of C h u n g H s i n is

ical B o a r d

and

child

health,

nursing

education,

d i p h t h e r i a c o n t r o l , and f e l l o w s h i p s . T h e

JCRR

g a v e m u c h a s s i s t a n c e e s p e c i a l l y in r u r a l health p r o j e c t s a n d in the f i n a n c i n g of local e x p e n s e s for m a n y of t h e s e p r o j e c t s . N A M R U N o . 2 coll a b o r a t e d w i t h health services in and

in

research

in

many

field

subjects

trachoma and certain virus diseases.

surveys such

as

Rockefeller

Foundation g a v e fellowships and helped initiate the m a l a r i a c o n t r o l p r o g r a m , C M B g a v e f e l l o w s h i p s a n d a s s i s t a n c e in the t e a c h i n g a n d t r a i n i n g fields.

In all i n s t a n c e s of a n a i d e d p r o j e c t , the

w o r k a n d p r o v i s i o n of the e s s e n t i a l b u d g e t s a r e the

responsibility

of

the

government.

The

health s e r v i c e s h a v e a c c e p t e d I C A a n d

WHO

fellows who were

as

sent

from

as m a n y

15

c o u n t r i e s in the p a s t years f o r field o b s e r v a t i o n of the c u r r e n t health activities.

52 SUMMARY

wide n e t w o r k o f health centers and health sta-

T h e general health situation of T a i w a n during the past 4 0

years was presented.

Up

to

1 9 4 5 T a i w a n had b e e n under J a p a n e s e administration, and since then it has been under t h e R e p u b l i c o f C h i n a . T h e m a i n scourges of epidemic

such as smallpox, cholera, and

were e x t e r m i n a t e d after 1 9 4 5 . eradicated was rabies.

plague

A n o t h e r disease

Malaria is near eradica-

tion; diphtheria, trachoma, and tuberculosis are markedly reduced venereal disease,

in incidences. filariasis,

Problems

of

m e n t a l disorder, and

tions was established in stages after 1 9 4 7 .

These

health centers and stations m a d e it possible t o implement

public

health

activities

from

the

lowest level of g o v e r n m e n t services and reaching the mass of the populace.

Many

medical

and para-medical educational institutions established and expanded after W a r II. was a general from 24.3 fant

reduction

( 1921)

mortality

in crude death

to 6 . 9

from

were There rate

( I 9 6 0 ) , and of in-

155.4

(1931)

to

33.3

( 1 9 4 9 ) ; the birth rate r e m a i n s about t h e same,

other diseases still exist. R e h a b i l i t a t i o n of hos-

42.7

pitals were d o n e in t h e past decade. A n island-

( 1 9 5 1 ) , and 3 8 . 9

( 1 9 2 1 ) , 46.1

( 1 9 3 1 ) , 41.5 (I960).

(1941),

49

Indonesia H E R M A N SOESILO

T H E PURPOSE OF THIS REPORT is to p r o v i d e highlights of a 40-year development in medical science in the R e p u b l i c of Indonesia. T h e source of this article is the late Professor Mochtar's w o r k i n g p a p e r for the T e n t h Pacific Science Conference. T h i s summary report should be regarded as an abstract of Professor Mochtar's original p a p e r to which the reader should refer for m o r e d e t a i l . * It is presented by his assistant, who truly hopes that through this media Professor Mochtar's last scientific contribution will be preserved.

the lower income bracket and the rural population. They are therefore effective and sufficient for the nation as a whole. THE COUNTRY, CLIMATE, AND PEOPLE

T h e R e p u b l i c of Indonesia consists of approximately 4 0 0 0 inhabited islands of which Java, Sumatra, K a l i m a n t a n ( B o r n e o ) , Sulawesi ( C e l e b e s ) , Bali, L o m b o k , the M o l u k a s , and W e s t Irian are the largest. T h e area of all these islands together is about 7 5 0 , 0 0 0 square miles. T h e longest distance between the borders is 3,300 kilometers. A c c o r d i n g to the latest census the population is about 100 million. T h e islands are mostly mountainous and volcanic with low-lying plains in the coastal regions. T h e climate is tropical except in the higher altitudes, with a dry season f r o m May to September and a rainy season from N o v e m b e r to April. A b u n d a n t rainfall ranges f r o m 7 0 - 2 0 0 inches, and at higher altitudes it may be as much as 2 5 0 inches per year. Because the R e p u b l i c of Indonesia consists of islands it is never completely dry. T h e mean temperature in coastal regions is 8 0 . 6 ; F. For administrative purposes the country is divided into 2 0 provinces. Each province is divided into regencies and each regency into subdistricts and villages. In the health organization there are two types of local areas, the regency and the municipality. R u r a l health activities are directed to the former.

T h e report covers a period f r o m 1 9 1 9 to 1959, which can be divided roughly into the following periods: the Dutch colonial period which lasted till 1942, the J a p a n e s e Occupation from 1942 till 1945, the national revolution from 1945 till 1950 and the period after negotiations with the D u t c h which lasted f r o m 1950 until the present. D u r i n g the period between 1942 and 1950 all existing health services deteriorated because activity was concentrated on war matters. H o w ever, in these difficult years the late Professor Mochtar was successful in his attempt to restore rural health facilities in Central Java. T h e period after 1 9 5 0 will be emphasized to show the outside world that the young R e p u b l i c accomplished a r e m a r k a b l e job in a relatively short period in spite of very limited available facilities. A n effective public health service had to be organized immediately from the remnants left over after the war. In general, after the Independence, all health measures were really adapted to the needs of

M o s t of the p e o p l e are of the Islamic religion, with a few million Christians, B u d d h i s t s and Hindus. T h e official l a n g u a g e of the country is the B a h a s a Indonesia ( t h e Indonesian language).

Efforts a r e b e i n g m a d e to p u b l i s h D r . M o c h t a r ' s p a p e r in f u l l .

53

54 HEALTH

CONDITIONS

Health services in Indonesia were completely disorganized during the Japanese occupation and the national revolution. Communicable disease control was disrupted. After the transfer of sovereignty in December 1949 efforts were made to restore the health services. The main killer is malaria, followed by tuberculosis. Dysentery and typhoid fever are endemic. Yaws, leprosy and trachoma are also very prevalent in Indonesia. There is no yellow fever. Vital statistics for the country as a whole are estimated as follows: Crude death rate, 10 to 15 per 1000. Infant mortality rate, 70 to 250 per 1000 live births. Maternal death rate, 7 to 16 per 1000 births. Efforts to upgrade health conditions face many difficulties. The shortage of trained personnel in all areas of health is a real problem. In addition socio-economic problems are created by lack of knowledge of simple health measures among many people, crowded living conditions and poor housing in many areas. The many small islands also make it difficult to provide medical care within reach of all. Public health in Indonesia is the responsibility of the Ministry of Health, the supervising and coordinating body which determines the policy of medical and health services. The provincial government with a supplementary grant from the central Government is the executive authority for carrying out the program and financing it. Immediately after the war the emphasis in health services was for medical care with particular attention to major diseases. Gradually other areas of health services have been added to the program, especially from the preventive standpoint. Today the Ministry of Health embraces divisions of hospitals and curative medicine, education of health personnel, maternal and child health, environmental sanitation, dental health, rural health and health education, institutes for the major diseases and nutrition and laboratory services. Health activities today are developing towards an integrated public health program. The long-range plan will establish

the same pattern of services at the provincial level as in the Ministry of Health. The regency and municipality can be regarded as the local health unit. The Period

Before

1950

This era will deal specifically with the Dutch contribution to development in the medical field, since no worthwhile activities took place from 1942 until 1950. It must be recognized that medicine as a science was introduced by the Dutch. The following events can be noted as scientific achievements during this period: In 1808 Daendels started the Military Medical Service and was appointed head of the colonial administration in the Netherland s East Indies. In 1851 the first training course for midwives was organized, and in 1853 the first medical school was founded in Djakarta (Batavia). A Civil Medical Service which had its main interest in hygiene work was introduced in 1911. This agency was the first proof of the colonial government's desire to improve the health of the Indonesian people. Regulation in epidemics was enforced in an effort to combat communicable diseases. The lack of doctors was recognized so in 1913 a second medical school was established in Surabaya. The first dental school was set up in 1928 in the same city. Health Education. The Dutch were aware that health education is an important tool in hygiene work. However, full credit should be given to the American doctor J. L. Hydrick who was a representative of the Rockefeller Foundation in Indonesia. He spent 15 years on health education in this country. He started with a survey on hookworm disease in 1924, and when he left in 1939 he had already established principles of health education which suited the Indonesian people. Dr. Hydrick was also the founder of the first school for elementary health educators. When he returned to his native country he left a core of 2 5 0 elementary health workers, able persons who still form the nucleus of the present group. He also established a demonstration health unit which is still utilized as a study area for students and public health doctors.

55 Nutrition. It should be admitted that the Dutch achieved striking results in their research work on nutrition, which had its proper impact in the improvement of the nutritional state of the Indonesian people. The names of Gryns, Van Veen and Eijkman should be honourably mentioned in this instance. In 1934 a special institute for research on nutritional problems was established. Research included such matters as vitamin intake, water analysis, goiter and food poisoning. Malaria. Malaria is the main killer of the Indonesian people. This was recognized by the Dutch as a great economic loss. For this reason efforts were made to control the disease. Among the names historically connected to the malaria control in this country are Swellengrebel, Schiiffner, D e Vogel, Brug, Mangkuwinoto, Walch, and Soesilo. In 1924 a Central Malaria Bureau was founded. This agency operated closely with another section of the Ministry of Health; namely the section of Sanitation since control measures emphasized sanitation. However, this method turned out to be too expensive for a country like Indonesia because it is feasible and of practical value only in densely populated areas. In the villages where the houses are scattered this system is too costly. It should be mentioned that about 80 per cent of the Indonesian people live in villages. Therefore this method will not directly benefit the common man. The sanitation method was therefore abandoned after 1950. Yaws. Since this crippling disease was regarded as a nuisance which could harm the economy of the country a campaign was started to combat it. From the beginning of the battle against this menace Dr. R. Kodiat, a native of this country, played, and continues to play a leading role. Recently he was awarded the star of merit by the Indonesian Government for his contribution to this campaign. Before the Independence salvarsan was the drug of choice. The yaws campaign in Indonesia is a good example of prevention through curative measures, since the operation emphasizes detection of the source of infection and then cures it radically. T h e people were impressed by the immediate effect of salvarsan

shots and became more receptive to the health and medical program. Communicable Diseases and Control of Epidemics Plagtie. Plague was imported to Java in 1910. According to Peverelli there were approximately 125,000 deaths caused by plague, 1 9 1 1 - 1 9 2 7 . At the end of 1934 Otten introduced the plague vaccine. Meanwhile houses were checked for rats, the design of ratproof buildings was advocated and supervision was carried out. However, this method always lagged behind the epidemic and therefore was considered too slow. Cholera. Cholera entered the Indonesian territory in 1909, apparently imported by Mecca pilgrims. According to Previrelli there were 64,000 deaths reported in 1910. Preventive measures were taken such as enforcing quarantine regulations and mass vaccination programs. Smallpox. It is noteworthy that in 1917 the separated system of vaccination for smallpox was first introduced in East Java by Terburgh. According to this system infants were vaccinated separately from adults. The Period After

1950

Multilateral and bilateral agreements made after 1950 had accelerated the restoration and improvement of the health services and health activities, which were disorganized by the war and by the conflict with the Dutch. From that period on a steady stream of health personnel went abroad to deepen their knowledge and to study modern methods to improve the health of the nation. Education of paramedical personnel was intensified and new medical schools were established. In particular should be mentioned the affiliation between the University of Indonesia and the University of California which led to the introduction of a new curriculum in medical training. This brought about a shortening of the course from eight to six years and a change from a liberal study to a guided study. The results were remarkable. Without harming the quality of training the yearly output has increased from ten to 120 graduates. However, this system is very expen-

56 sive and requires a large number of instructors, which is feasible only in large and well-established medical schools like the one in Djakarta.

of public health. Efforts are being made to provide a course for health education in the near future.

With foreign aid, control programs of communicable diseases were expanded and intensified.

T o achieve its goal the subdivision cooperates closely with the Ministry of Education, the Department of Social Welfare, the Department of Agriculture, the Indonesian Red Cross, and women's organizations.

Development

of a Rural Health

Program

The division of rural health and health education embraces the development of a rural health program and the health education of the people. The aim of the government is to integrate the health services. The first effort toward this goal was the establishment of a pilot project in Bandung which is accordingly called the "Bandung plan." The pattern used was abandoned later since the plan depended too much on the erection of costly buildings. Attractive health center buildings are indeed desirable but not essential. The emphasis is now put on team approach. T o test this new concept another pilot project was introduced near Djakarta. The three targets of the rural health program are integrated health services, team approach, and maximum participation of the people. This rural health program is in fact a part of a larger project called the National Program of Community Development which was launched in 1956. In this program a large number of governmental and private agencies are involved. On health matters a number of agencies are now operating together; the agency for mass education, the division of home economics, the department of public housing, the department of public works, and several others. The Subdivision

of Health

Education

The responsibility of this subdivision is to coordinate, to stimulate, and to assist health education efforts throughout the country. It is recognized that health education is an essential part of every health activity. The Ministry of Education agreed that health education should be included as a course in the training of school teachers. Health education is taught in every school for health workers. There is great demand for health workers in this field. T o become a specialist in health education one must go abroad to take advanced courses at a school

The institute

of

Nutrition

The main target of the Institute is to improve the nutritional state of the population. Education of the public concerning nutrition is emphasized by professional workers to increase public understanding. Special courses were introduced to help meet the great demand for professional workers. Nutrition surveys were carried out among particular groups. Special efforts were made to detect inexpensive sources of protein, in particular the research on soyamilk which led to the establishment of a soyamilk plant in Central Java. Malaria. The sanitation method to combat malaria was abandoned. The use of insecticide is considered the most suitable method to protect the rural population within the shortest possible time. In 1950 the Malaria Institute carried out a pilot project to determine cost. In 1954 a five year plan was introduced with the aid of the W H O and the ICA. Its aim was to protect 30 million people by a spraying campaign of five years duration. Encouraged by the success of the campaign the government launched a malaria eradication program in June, 1959. T o accomplish this at least 75 million people must be protected. This population lives in about 18 million houses in which D D T spraying must be done twice a year or spraying with dieldrin every eight months. For this purpose the country is divided into 58 zones. Yaws. With the aid of the W H O and the U N I C E F the yaws campaign has been expanded and intensified. Its object is to detect sources of infection and then to eliminate them radically. Only the working methods are changed and adapted to modern concepts. T h e drug of choice is now penicillin.

57 In 1950 the campaign started with a new project called TCP or Treponema Control Project. In 1952 this method was modified to the TCPS or TCP simplified. TCP was regarded impractical for a mass campaign for it requires too many skilled personnel who are not yet available. The use of the TCP is now limited to campaigns connected with research. The TCPS is more suitable and practical for Indonesia as it makes use of local people to carry out the campaign. A person selected from the village people receives training in detecting and recognizing cases of yaws and gets further information and instruction in the proceedings of the campaign.

Tuberculosis. Tuberculosis is the second killer after malaria. During the Dutch period the control of tuberculosis was carried out mainly by private agencies. Since the Independence the government has played a leading role in combating this disease. W i t h the aid of UNICEF, a BCG campaign was started in Bandung in 1950 and has developed into a nation-wide attack against tuberculosis. The dilution of P P D is done at the Pasteur Institute in Bandung. Because of the extreme shortage of accommodation in tuberculosis sanatoriums in the country, a project is still going on to ascertain how effective would be the domiciliary treatment by Isoniazid.

Japan MASAMI

WITHOUT

CONSIDERATION

of

the

KITAOKA

T h e Oya Siwo Cold Current runs from the north to the south, and the K u r o Siwo W a r m Current from the south to the north along the east coast of the Japanese Islands. T h e Japan Sea Current runs from the south to the north in summer and from the north to the south in winter, along the west coast of the islands. T h e r e are several chains of mountains on the islands.

eco-system

in nature we can say very little about the health of the public in one country, because of the many factors which have marked effects on the public health through direct influences and interactions. A m o n g these factors are included geography, climate, natural resources, terrain, vegetation, wild and domestic animals and birds, and arthropods. Also of great significance are the influences exerted through densities of populations, economy, agriculture, education, industry, and communication.

During the period 1 9 2 1 - 1 9 4 5 , the Public Health authorities tried at all times to improve the sanitary environment, nutrition of the people, and procedures and practices for the control of infectious and other diseases. These efforts were made in the territories in the temperate zone and also in the subfrigid zone (Sakhalin and the Kuril Islands) and the subtropical area of Taiwan. Similar efforts were extended to the continental areas of Manchuria and Korea. Thus, during this period, the general public health was improved, even though slowly, and there resulted a decrease in morbidity from infectious disease, increases in height and weight of school children, and extension of the span of life. Public health activities were limited during the war and were even more curtailed immediately afterwards. However, since 1 9 5 0 public health improved more than in the pre-war period. M a j o r advances have included a general improvement in the administration of public health and welfare and particular advances in medical- and health-associated socio-economic developments relating to population control, medical and health education, environmental hygiene activities, and improved social security systems.

Since the end of W o r l d W a r II ( 1 9 4 5 ) , the territories, such as the south half of Sakhalin Island, the K u r i l e Islands, Korea, and Formosa ( T a i w a n ) , have been separated from Japan. At present Japan is a constitutional monarchy, a member of the U n i t e d Nations as well as of the W o r l d Health Organization. T h e Japanese Islands lie in a chain consisting of the four large islands, Hokkaido, Honshu, Shikoku, and Kyushu, and numerous smaller adjacent islands. T h e total area is 3 7 0 , 0 0 0 sq. km., and the island group extends between latitudes 4 6 " N and 2 8 ' N along the western Pacific Ocean off the east coast of Asia. J a p a n is relatively poor in natural resources and is now rapidly becoming an industrial country. R i c e is harvested all over Japan through intensive tillage associated with pelagic fishing. T h e natural vegetation and soils are found to differ somewhat from island to island among the larger four. T h e rainy season is usually in J u n e and the warmest month is August. T h e coldest months are January and February. T h e northeast trade winds from the south to the north are in July and the same winds from Siberia to the south are in January.

59

60 TABLE

POPULATION

The census taken on October 1, I960 indicates that the population in Japan totalled 93,419,000. That is an increase of 4,134,000 since 1955, representing a ratio of 1.7 times the population in 1920. Compared with populations in each country of the world as stated in the United Nations Monthly Bulletin of Statistics, March, 1961, Japan had the fifth largest population in the world in I960. This corresponds to 3.0 per cent of the assumed total population of the world. Considering the territory of Japan to be roughly 0.3 per cent of all territories on the earth, Japan has the highest population density (252 per sq. km.) in the world. Vital Statistics of

Population

Tables 1 and 2 indicate the vital statistics of population by five-year periods since 1920. From the tables it can be seen that the population increased roughly one million every year during the period 1925-1935, but after this the increase of population became slow due to the mobilization of many young people and the drain of the war. Since the end of the war the population has increased at a rate roughly twice that of the increase in the prewar period. To solve the overpopulation in Japan, family planning has become one of the most urgent social TABLE

1

V I T A L STATISTICS O F P O P U L A T I O N IN E A C H 5 Y E A R S D U R I N G T H E PERIOD

YEAR

1920 1925 1930 1935 1940 1945 1950 1955 1960 * t J §

1920-1960*

TOTAL

INCREASE

POPU-

IN P O P U -

OF

LATION

LATIONt

INCREASE

3,778 4,693 4,789 3,878 542$ 11,202 6,076 4,134

6.8 7.9 7.5 5.6 0.7 15.6 7.3 4.6

55,391 + 59,179 63,872 68,662 72,540 71,998 83,200 89,276 93,419

PER C E N T

POPULATION DENSITY PER

KM2

145

According ro the Kosei Hakusho, 1 9 6 1 . Compared with population 5 years before. 1 , 0 0 0 population. Decrease in population.

169 187 5 252

2

V I T A L STATISTICS O F LABOR

GROUP O F AGES

TOTAL YEAR

1920 1930 1940 1950 1960 1970+

POPULATION*

POPULATION

0-14t

15-64

55.4 63.9 72.5 83.2 93.3 102.2

20.2 23.3 26.1 29.4 28.0 23.2

32.3 37.5 43.0 49.7 59.9 71.9

OLDER THAN 6 4

2.9 3.0 3.4 4.1 5.4

7.1

* According to census reports issued from the Statistics Bureau, Prime Minister's Office, I 9 6 0 , and the assumed future population issued from the Population Institute, Ministry of Welfare, I 9 6 0 , and Kosei Hakusho, 1 9 6 1 . t Years of age per one million. X Assumed population.

affairs to be discussed in situ by the group mainly composed of housewives all over Japan. The health nurse in each health center, the midwife, and the gynecologist served as consultants on family planning to the housewives in each area. Since 1950 the increase of population has become gradually slower, with an increase of only 4.6 per cent during the period 1955-1960. At this rate the population of Japan may be expected to be 102.2 millions in 1970. Vital Statistics of the Labor

Population

The population changes in the past 40 years have markedly influenced each age group, especially among the laboring population. Before 1920 Japan was known to have a high fecundity rate and a high infant mortality rate. Since then the mortality rate of infants has become gradually lower. However, the composition of each age group from the newborn to those older than 80 still showed a stable pyramid like a figure of Mt. Fuji for the years 1925 and 1940 as shown in Fig. 1. Since the end of the war the age distribution has changed considerably. It is seen in the figure that the group below 10 years of age represents a much smaller proportion of the population than previously, and that in I960 the 0—4-year group represented considerably fewer persons than any other age group below 35 years, thus giving a somewhat unstable appearance to the population pyramid. As for the labor population, the 15-64-year age group increased in numbers from 32.3 millions

Age

To L™J 75- C ^ J 79

i m JLJJ^^g nr

Male

I I I960 l i i l H I I I I I 1940 1925

Female

4035-

rrrrrr

LLÜJ.L

11 il 11 I M 111111111111111 H 1111111:1111111111111 m 1111111 r

NI 111111:11111111 ITT

mu 11 in-

I mm*

million

500

400

300

111 ! 111 inn 200

100

FIG. 1. P o p u l a t i o n p y r a m i d in the 3 years Kosei no Shihyo, 1957 and 1961.

0

0

100

200

300

400

1925, 1940, and 1960; 1,000 population.

to 59-9 millions and also the numbers of those older than 64 years increased from 2.9 millions to 5.4 millions. Children 0 - 1 4 years of age had previously increased in number from 20.2 millions to 29.4 millions but decreased to 28.0 millions during the period 1920-1960. A similar age distribution pattern is expected and perhaps may be even more pronounced in 1970. Thus it will be necessary to direct even more attention to the older age groups, particularly in relation to their socio-economic affairs. Marriage and

TTI I I I I I I I I II I I II II I

I IT: 11111111

Divorce

In Japan the marriage rate is about 0.9 per cent of the total population annually, similar to that of West Germany. The average marriage ages of males and females were roughly 27.2 and 24.4 in I 9 6 0 and have not changed markedly since 1935. The divorce rate has declined gradually since 1920, with the exception of the high rate of 0.1 per cent of the population in 1947, which was presumably due

500

million

A c c o r d i n g to t h e

to social confusion following the war. In I 9 6 0 the divorce rate of 0.07 per cent was the lowest in the experience of this country and approximated the figure for Australia. Births Paiallel with the modernization of social life reflected by the development of a capitalistic economy, both birth and mortality rates have steadily decreased since 1920. Table 3 shows a sharp decline in birth rates between 1920 and I960, the fall being from 36.2 per cent to 17.2 per cent, with a notable exception to the trend TABLE 3 BIRTH RATES IN EACH 10 YEARS DURING THE PERIOD 1 9 2 0 - 1 9 6 0 * 1920

1930

1940

1947

1950

1960

36.2t

32.4

29.4

34.4

28.1

17.2

* According to the Kosei no Shihyo, 1961. t Per cent.

62 age

and organization and development of administrative, professional, and technical procedures for disease prevention and control and the advancement of health.

70

60

Deaths 50

40

/ male

30

- - • • female

20

FIG. 2 . A v e r a g e span o f l i f e ( " b y the census in each year, r e s p e c t i v e l y ) . A c c o r d i n g to t h e calculation o f assumed p o p u l a t i o n in t h e K o s e i no S h i h y o , 1 9 6 1 .

in 1947, a year of a temporary baby boom. At present there seems to be no marked difference in birth rates between urban and rural areas, although prior to 1955 the rates were consistently higher in the latter. Apparently the birth rate in Japan is approaching the rates in Denmark and England. Average Span of Life The span of life was surprisingly as short as 4 2 - 4 3 in 1920-1925, 4 7 - 5 0 in 1935-1936, and, exceptionally, as short as 23.9 for males and 37.5 for females in 1945 just at the end of the war. Since then the span of life has increased considerably with a ten-year increase occurring during the four-year period, 19471951, as indicated in Figure 2. Although there was some retardation due to the prevalence of influenza in 1956 and 1957, the general lifespan has continued to increase. In I960 it was 65.4 for males and 70.3 for females. These figures compare favorably with those for European countries and are considerably greater than those for Asian areas. The reasons for this increase in longevity are many and of course include such factors as improved socio-economic affairs, general environmental advancements,

Diseases causing death. In I960 the causes of death were in order as follows: vascular lesions affecting central nervous system ( B 2 2 ) , malignant neoplasms ( B 1 8 ) , heart diseases ( B 2 5 - B 2 7 ) , senility ( B 4 5 a ) , pneumonia and bronchitis (B31, B32, B43a), accidents (BE47, B E 4 8 ) , tuberculosis ( B l , Bs), suicide ( B E 4 9 ) , gastritis, duodenitis, enteritis, colitis (B36, B 4 3 b ) , and newborn diseases (B44). The order of the five main causes of death was not always fixed. The order changed from time to time, probably being affected by the introduction of effective drugs and other agents for the treatment and prevention of the various disorders. For example, in 1920, B31, B32, and B43a led and were followed by B36 and B43b, B l and B2, B22, and B45a; while in 1940, B l and B2 were first and B31, B32 and B43a, B22, B36 and B46b, and B45 followed. Following the introduction of effective anti-tuberculosis drugs, B l and B2 declined as principal causes of death and in fact have not been among the five main causes since 1957. Since 1953 the principal causes of death have been so-called adult diseases such as vascular lesions affecting the central nervous system ( B 2 2 ) , malignant neoplasms ( B 1 8 ) , and senility ( B 4 5 a ) . It is important to note that accidents (BE47, B E 4 8 ) occupied the sixth position among causes of death since I960. The mortality rate for the whole population has decreased year after year from 2.54 per cent in 1920 to 0.76 per cent in I960 as shown in Table 4. The infant mortality rate per 100 births also showed similar declines during this TABLE

4

MORTALITY R A T E OF W H O L E POPULATION IN EACH DECADE, 1 9 2 0 - 1 9 6 0 1920

1930

1940

1950

1960

2.54*

1.82

1.65

1.09

0.76

* Per cent.

63 TABLE

5

I N F A N T M O R T A L I T Y R A T E PER 1 0 0 BIRTHS IN EACH DECADE, 1 9 2 0 - 1 9 6 0 1920

1930

1940

1950

1960

16.57*

12.41

9.00

6.01

3.07

* Per cent.

period, falling from 16.57 per cent in 1920 to 3 07 per cent in I960 (Table 5). The mortality rate in Japan appears to be no higher than rates in the United States and many countries in Europe. However, it may exceed the latter somewhat if corrections are made for the population age distributions in these various countries. This applies to the infant mortality as well. In this connection, as Dr. Payne of Yale University pointed out, poliomyelitis has assumed more of an epidemic nature in Japan since the infant mortality rate fell to less than 5.0 per cent. Table 6 indicates that the causes of death in each decade, 1920-1960, are classified into five groups such as A -group caused by bacterial infections (B1-B17; B23; B30-B32; B36; B43a, pneumonia of the newborn; B43b, diarrhoea of the newborn); B-group being so-called adult diseases (B18; B19; B22; B25-29; B45a, senility without mention of psychosis); C-group caused by complications of pregnancy and birth, TABLE

6

CLASSIFICATION O F CAUSES O F D E A T H IN E A C H DECADE, YEARS

1920

Total

254l.lt

A groupî B

1330.9

C

"

D

"

E

"

427.0 151.7 66.5 565.0

1920-1960*

1930

1940

1950

1960

1816.7

1649.6 710.2

1087.6 387.0

756.1

441.7 107.0

356.1 79.2

412.5 28.0

792.9 417.8 125.3

congenital anomaly (B40; B41; B42; B43C, other infections of the newborn; B44); Dgroup (BE47-BE50), and ¿¡-group caused by other factors than A, B, C, and D, according to the International Lists of Diseases and Causes of Death ( W H O , 1955). From Table 7 it can be seen that the deaths caused by A -group have decreased markedly during the period 1920 to I960, from 52.4 per cent to 16.1 per cent of total deaths; while the B-group, so-called adult diseases, increased from 16.8 per cent to 54.6 per cent of total deaths. In Japan deaths occur more frequently in the winter season, especially in January, and less frequently in the summer season, especially in August. For example, deaths from cardiovascular diseases were about doubled; and those from pneumonia and bronchitis were about three times more in the winter than in the summer. Deaths caused by auto accidents occurred most frequently in December, with the lowest frequency in February, and deaths by drowning occurred chiefly in July and August. Suicides were recognized more frequently in April. Age at Death. In I960, 30,014 still-births were reported, of which 43.3 per cent resulted from fetal diseases and 47.9 per cent from diseases of pregnancy. Deaths of newborns were due largely to congenital abnormalities. Accidents were the most frequent causes of death in children 1-14 years of age, and pneumonia and bronchitis the second cause in those 1 - 9 years old. Fatalities from malignant neoplasms occurred in children 10-14 years of age, and accidents and suicides were observed as signifi-

121.6

63.1

53.6

61.4

64.6

417.5

337.1

203.9

129.3

* According to dynamic population issued from Statistics Division, Ministry of Welfare, 1961. t Per 100,000. I A group: B 1 - B 1 7 , B23, B30, B31, B32, B43a (pneumonia of the n e w b o r n ) , B36, B 4 3 b (diarrhoea of the n e w b o r n ) . B " : B18, B19, B22, B 2 5 - 2 7 , B28. B29, B45a (senility without mention of psychosis). C " : B40, B41, B42, B43c (infections of the newborn other than B43a and B 4 3 b ) . D " : BE47, BE48, BE49, BE50. E " Causes of death other than A, B, C, and D groups.

TABLE

7

C H A N G E O F R A T I O A M O N G CAUSES O F D E A T H D U R I N G T H E PERIOD YEARS Total

1920-1960

1920

1930

1940

1950

1960*

100.0* 52.4

100.0

100.0

100.0

100.00

43.6

35.6 32.7

B

"

16.8

23.0

43.1 26.8

C

"

6.0

D E

" "

2.6

6.9 3.5

6.5 3.2

7.3 5.6

22.2

23.0

20.4

18.7

A groupf

* Per cent, t Cf. Table 6.

16.1 54.6 3.7 8.5 17.1

64 cant causes of death in the 15-19-year-old group. Tuberculosis was the principal cause of death in the 30-39-year decade, while malignant neoplasms were most significant in those 4 0 - 5 4 years old. In the 55-79-year age groups cerebral vascular accidents were the principal causes of death. PUBLIC H E A L T H

Physical

Standards

T h e physical standards of people are influenced by heredity, environment, habits and m o d e of living, especially as regards foods consumed. There had been a steady increase in the physical measurements of Japanese youth f r o m the end of the 19th century until 1939. A f t e r the beginning of the war, however, there was some reduction in the rate of physical development, and in 1950 figures indicated this develo p m e n t to be somewhat less than in the pre-war period. For example, in 1947 youths aged 15 and 16 were one year behind their counterparts in the pre-war period in height development (Figs. 3 and 4 ) . Physical development has improved each year since 1950, no doubt following improvement in food supplies and general socio-economic betterment. In 1955 the growth averages reached the same level as those experienced in the pre-war period. T h e

10

14

19

22 2«

FIG. 4. Height of body, females 6 - 2 4 years of age, from all Japan in each decade (except for 1939), 1920-1960.

improvement in physical development appeared to be more marked for female than for male children. In I 9 6 0 the height, weight, and chest girth achieved by children and youths 6 - 2 4 all over Japan exceeded those previously experienced in this country (Tables 8, 9 ) . It is of interest that the menarche began at an average age of 13 years a m o n g girls in I960, this being approximately two years earlier than the occurrence in 1950. T h e Committee on Nutrition has developed the assumption that physical development of Japanese people will continue to increase through current nutritional practices. The group feels that by 1970 the physical development of Japanese people will approximate that of the nisei or 3rd generation of Japanese living in the United States. Nutrition

22

24

age

FIG. 3. Height of body, of males 6 - 2 4 years of age, from Japan in each decade (except for 1 9 3 9 ) , 1920-1960.

T h e problem of malnutrition was recognized in Japan prior to 1920 when it was appreciated beriberi was caused by eating polished rice. In 1920 the National Institute of Nutrition was established for the education and guidance of the people in nutritional matters and investigation of related problems. W h i l e there was n o reliable information with respect to nutrition of the people in the pre-war period, certain calculations can be made f r o m known food practices and data concerning food production and

TABLE

8

H E I G H T O F BODY, M A L E S AND FEMALES, AGED 6 TO 2 4 , IN E A C H ( E X C E P T FOR 1 9 3 9 )

1920

AGE (YEAR)

M

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

107.0 111.8 116.4 121.0 125.1 129.4 134.8 140.9 148.2 153.9 158.2 160.0 160.9 161.8 161.8 162.1 162.4 163.3

DECADE

1920-1960*

1930

1950

1939

1960

F

M

F

M

F

M

F

M

F

105.8 110.3 114.8 119.4 124.2 129.4 135.4 141.5 146.1 148.2 149.1 149.4 150.0 149.7 150.3 150.0 150.3 150.6

108.1 113.2 118.0 122.6 127.0 131.4 137.1 143.3 150.7 156.2 159.5 161.0 161.8 162.3 162.5 163.0 162.9 163.1 164.0

106.9 111.9 116.7 121.3 126.0 131.3 138.4 143.5 147.7 149.6 150.6 150.7 151.2 151.0 150.9 151.1 151.1 150.1 149.2

109.1 113.9 119.3 125.0 128.2 132.9 137.8 144.0 152.1 158.1 160.9 162.5 163.8 164.3 164.5 164.7 164.8 164.7 164.5

108.1 112.9 117.7 123.0 127.7 132.7 138.8 144.0 148.7 150.7 152.1 152.5 153.0 154.1 152.7 152.5 151.8 152.6 152.5

108.6 113.6 118.4 122.9 127.1 131.1 136.0 141.2 147.3 154.8 159.3 161.8 162.6 163.3 163.7 163.7 164.0 164.0 163.9

107.8 112.8 107.6 122.1 126.6 131.7 137.3 142.5 146.6 150.2 151.8 152.7 152.7 153.4 153.7 1533 153.4 153.0 152.5

111.7 117.0 121.9 126.8 131.6 136.2 141.9 148.1 155.1 161.2 163.6 165.0 166.3 166.4 166.4 166.5 166.5 166.3 166.1

110.6 115.9 121.1 126.3 132.0 138.1 144.0 148.1 150.7 152.7 153.3 153.7 154.7 154.8 154.7 154.7 154.6 154.4 154.2

CM

t

* Personal c o m m u n : c a r i o n : Statistics Division, Education Ministry, 1 9 6 1 . t S. Y o s h i d a : Physical T r a i n i n g and H y g i e n i c Statistics, 1 9 2 4 .

TABLE

9

BODY W E I G H T IN KILOGRAMS, M A L E S AND FEMALES, AGED 6 T O 2 4 , IN E A C H D E C A D E ( E X C E P T FOR 1 9 3 9 )

6 7 8 V 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1930

1920

AGE (YEAR)

1920-1960*

1939

1950

1960

M

F

M

F

M

F

M

F

M

F

17.6 19.3 21.2 23.3 25.2 27.5 30.4 34.4 40.0 45.3 49.1 51.8 53.5 54.4 54.5 54.6 54.5 54.3

17.0 18.6 20.2 22.3 24.5 27.3 31.2 35.7 40.1 43.4 45.6 47.2 48.6 49.4 49.1 48.8 48.8 48.6

17.9 198 21.8 23.8 25.9 28.4 31.8 36.2 42.0 47.1 50.6 53.0 54.3 54.8 54.8 54.7 54.8 54.9 54.7

17.3 19.0 20.9 23.0 25.4 28.5 33.2 37.7 42.1 45.0 46.7 48.1 49.3 49.0 48.9 48.6 48.3 48.7 48.0

18.5 20.3 22.5 24.6 26.9 29.3 32.5 36.9 43.6 48.6 51.8 51.3 55.2 55.6 55.7 57.3 55.7 55.7 55.8

17.7 19.4 21.7 23.7 26.5 29.5 33.7 38.2 43.3 45.0 47.5 48.8 50.0 49.7 49.6 49.3 49.1 49.6 48.3

18.5 20.4 22.4 24.4 26.4 28.7 31.5 35.1 39.7 45.7 49.9 52.6 53.9 54.6 55.0 55.3 55.0 55.0 55.7

17.9 19.8 21.8 23.8 26.0 28.8 32.6 36.9 41.2 45.2 47.7 49.1 49.8 50.5 50.7 50.6 50.6 50.2 50.3

19.1 21.0 23.2 25.5 28.0 30.7 34.6 39.3 45.3 51.0 54.1 56.1 56.8 57.0 57.0 57.2 57.1 57.1 57.0

18.5 20.5 22.7 25.2 28.2 32.3 36.9 41.5 45.3 48.1 49.6 50.4 50.0 50.3 50.1 49.8 49.6 49.1 48.9

t

* Personal c o m m u n i c a t i o n : Statistics Division, Education M i n i s t r y , 1 9 6 1 . t S. Y o s h i d a : Physical T r a i n i n g and H y g i e n i c Statistics, 1 9 2 4 .

66 family expenditures. It is seen in Table 10 that the total caloric intake is considered to have been about the same in the pre-war period as that after the war. However, it is noted that protein intake, particularly protein from animal sources, was increased considerably since the end of the war period. These changes seem to have continued since 11.5 per cent more milk and eggs were consumed in I960 than in 1959. Thus there has been a definite qualitative improvement in nutrition in the post-war period. It is pointed out, however, that vitamin Bi intake dropped two-thirds in I960 and that 60-70 per cent of the total caloric intake for people in Japan still comes from carbohydrates. Accordingly the standards of nutrition developed by the Committee on Nutrition in 1949 and 1952 should be revised, particularly in view of the increasing development of physical standards experienced over the past few years. Communicable

International List of Numbered Causes of Death, and also the list of Statistical Classification of Causes of Death, of which some are a little modified by the Japanese Committee. Their morbidity and mortality rates are indicated per 100,000 population. INTRODUCED FROM

ABROAD

Cholera ( B 5 ) . Cholera has never been found to be endemic in Japan but always to be transported from endemic areas in the southwest Pacific Region. This was so when cases were reported in Japan during the period 1920-1929 and in 1946, that is, after World Wars I and II respectively. No more cases have occurred since 1947 (Fig. 5 ) . Vaccination is, however, conducted for selected groups, and passengers are inspected at both seaports and airports by the International Quarantine Regulation whenever any risk of introduction of the disease into Japan might exist.

Diseases

Communicable diseases in Japan may be considered in two groups, one made up of those transported by ship and possibly by air from endemic areas overseas, and the other including those occurring endemically in Japan. The classification of diseases used here is that of the

Plague ( B l l ) . In 1922, plague was imported once from the continent (China) when 118 cases were reported, including 67 fatal cases (Fig. 6 ) . There have been no more cases since 1923.

TABLE

10

C A L O R I C I N T A K E P E R P E R S O N P E R D A Y IN E A C H D E C A D E ( E X C E P T FOR 1 9 3 4 - 3 8 ) , YEARS

1920

1934-38

1930

1930-1960

1950

1960

Caloric intake Cal p r

J.

Animal [Vegetative

s

Fat

2101

I" T o t a l

t

Inorganic

Vitamins -

(g)

fCa

(mg)

^P [Fe

(«) (mg)

A

(I.U.)

Bi

(mg)

B2

(mg)

[C

(mg)

2095

t

2098

54.9

68

6.8

7.2

45.6

47.7

unknown

(g)

Carbohydrate

substances

*

52.4

î

2096

t

69.7

17

24.7

51.0

45.0

18

24.7

418

398.8

16.6

0.27

(g)

389

1.82

1.33

46

13

2459

3023

1.52 0.72 107

* According to the food policy in the pre- and postwar issued from the Public W e l f a r e , bilization Board, the Government. t A n n u a l Report of Statistics, the Ministry o f Agriculture and Forestry. Î Nutrition of People, Nutrition Division, the Ministry o f W e l f a r e .

the Economic

(1180)

1.05 0.72 75 Sta-

67

FIG. 6. Annual morbidity and death rates f r o m plague ( B l l ) ; 1 9 2 0 - 1 9 6 0 . H e i g h t of column: morbidity rate. Portion in black: death rate.

ENDEMIC IN J A P A N

FIG. 5. Annual morbidity and death rates from cholera ( B 5 ) , 1 9 2 0 - 1 9 6 0 . Height of column: morbidity rate. Portion in black: death rate.

Smallpox ( B 1 3 ) . During the period 19201951 smallpox broke out in Japan almost every year. The mortality rates were very low: less than 0.1 during the period 1929 to 1944 (Fig. 7 ) . It might have been due to the countrywide vaccination by regulation. A big epidemic occurred in 1946 with 17,954 cases (3,029 fatal), presumably due to the low immune state of the community. Following this, smallpox vaccination was conducted in 7 0 - 8 0 per cent of all infants under one year old in Japan. There have been no more confirmed cases since 1952. Louse-borne epidemic typhus ( B 1 5 a ) . A few cases of epidemic typhus were reported in 1920 and 171 cases in 1921. During World W a r II and for five years after the end of the war the disease broke out in Japan every year, originating on the continent. The biggest epidemic totalled 32,366 cases, including 3,351 fatal cases in 1946. Compared with the high mortality rates during the period from 1943 to 1947, they became almost zero in 1948-1950, because of the effective antibiotics such as chloramphenicol and aureomycin and the effective typhus vaccine used for treatment and prophylaxis respectively (Fig. 8 ) . There have been neither cases nor evidence of endemicity of the disease in Japan since 1951.

Dysentery ( B 6 ) . Dysentery is still the most common infectious disease in Japan with approximately 80,000 cases being reported every year; though the number of reported cases once dropped to 14,665 in 1948 (Fig. 9 ) . The disease in Japan is mostly bacillary. Approximately 200 per year were reported as amebic dysentery ( B 6 c ) . T h e types of Shigella bacillus prevalent during the period 1920-1939 were mostly of A group with mortality rates varying from 12 to 35. T h e dysentery bacilli recently prevalent have belonged mostly to B and D groups with decreasing mortality rates of less than five since 1955. In other words, the mortality rate increased in number during the

FIG. 7. Annual morbidity and death rates from smallpox ( B 1 3 ) , 1 9 2 0 - 1 9 6 0 . Height of column: morbidity rate. Portion in black: death rate.

68

1920 '25

'30

'35

'40

'45

'50

'55

- — -

morbidity role d e a t h rote

FIG. 8. A n n u a l morbidity and death rates f r o m louse-borne epidemic typhus ( B 1 5 a ) , 1 9 2 0 - 1 9 6 0 . H e i g h t of c o l u m n : morbidity rate. Portion in black: death rate.

1920

'25

'30

'35

'40

'45

'50

55 \ 60

FIG. 10. A n n u a l morbidity and death rates from typhoid fever ( B 4 ) , 1 9 2 0 - 1 9 6 0 .

morbidity rare death rate

- death role

1920

'25

30

35

40

'45

'50

55

FIG. 9. A n n u a l morbidity and death dysentery ( B 6 ) , 1 9 2 0 - 1 S 6 0 .

'60 rates f r o m

1920 '25

'30

'35

'40

'45

50

55

60

FIG. 11. A n n u a l morbidity and death rates from paratyphoid fever ( B 1 7 a ) , 1 9 2 0 - 1 9 6 0 .

69 period 1920-1939 and then decreased until 1944; however, it increased again to 27.8 in 1945. Due largely to education and improved environmental conditions, there has been a steady decline since that time except for an increase in 1950 and 1951. A mortality rate of 2.2 was experienced in I960 due primarily to improved treatment with more effective antibiotics and other drugs. Drug resistance has been noted, however, and presents a problem requiring urgent elucidation. In recent years dysentery has occurred quite uniformly throughout the year; the summer peaks of incidence experienced before 1950 being no longer observed. The highest morbidity rates have been experienced among children 2 - 3 years old. The morbidity and mortality rates have been almost parallel. The maximum occurrence was reached in 1952 when there were 111,709 cases, of which 13,585 were fatal. More recently the case fatality rates have decreased, but the morbidity rates have continued to be high. Spread is believed to be principally through person-to-person contact. N o vaccine is yet available for practical use. Typhoid (B4) and paratyphoid (B17a). In 1920, 53,756 cases of typhoid fever (12,073 fatal) were reported. This was a morbidity rate of 97 per 100,000 which declined slowly to reach 49.6 in 1942. There was an increase to 80.5 in 1945 with a rapid decline thereafter (Fig. 10). In I960 there were reported a total of 1,572 cases, 29 of which were fatal. This vastly improved situation was partly due to the improved environment, education, and mass vaccination, and partly due to the advanced method of treatment with antibiotics and other drugs. Similar trends have been observed in the case of paratyphoid fever (B17a), with an exception in 1953 (Fig. 11). In I960 there were 319 cases of this illness with 6 fatalities. Scarlet jever (B7a). In 1920 the case incidence of scarlet fever was 1,368 with a low mortality rate. However, both morbidity and mortality rates increased in number later and reached the maximum of 28.1 (19,907 cases) and 0.7 (475 fatal cases) respectively in 1939. Since then, both rates decreased rapidly and reached the minimum of 3.0 and 0.1 respec-

tively in 1946. Since the end of the war, mortality rates became almost zero while the morbidity rates began to increase and reached the maximum of 22.5 in 1954. In I960, 8,786 cases were reported, including only 22 fatal cases due to advances in treatment (Fig. 12). No vaccine is yet used for the prevention of the disease. Diphtheria (B8). Since 1920 the cases of diphtheria increased gradually in number and reached the maximum of 94,274 cases including 6,192 fatal cases in 1944. And then the case incidence decreased rapidly reaching the lowest figure in 1952, 8,381 cases, including 639 fatal cases. A small peak of case incidence was observed in 1956 (Fig. 13) which was assumed to be due to the incomplete administration of diphtheria toxoid for children. In I960, 14,921 cases were still reported, including 497 fatal cases. Nevertheless, the preventive measures and adequate treatment with immune serum should be further undertaken to minimize both morbidity and mortality rates. Tetanus (B17c). During the pre-war period there were no accurate reports of tetanus. In

FIG. 12. Annual morbidity and death rates from scarlet fever ( B 7 a ) , 1920-1960.

70 1949, 2,168 cases were reported including 1,958 fatal cases. The morbidity and mortality rates decreased from 2.7 to 0.9 and 2.4 to 0.7 respectively during the period, 1949-1960. The persons to be exposed to the risk of infection with tetanus should be injected with tetanus toxoid for prophylaxis of the disease. Tetanus neonatorum is not a big problem for the newborn in Japan. Whooping cough ( B 9 ) . The number of whooping cough cases was not known accurately before 1947. In 1949, 126,110 cases were reported, including 9,105 fatal cases. However, with the increasing number of vaccinees the morbidity and mortality rates declined thereafter, there being 29,948 cases ( 4 7 8 fatal) in 1958, and 3,890 cases ( 6 5 fatal) in I960. The vaccine should be further used for the prophylaxis of the disease. Syphilis ( B 3 ) , gonorrhea ( 030), ( 0 3 6 ) , and lymphogranuloma

chancroid venereum

( 0 3 7 ) . The venereal diseases (syphilis, gonorrhea, chancroid, and venereal lymphogranuloma) were controlled by the Venereal Disease Control Law for the public health since 1900. The Law was amended several times since 1927. Another law was issued from the government in 1945. Thus, any case should now be reported by the physician to the Health Center. The morbidity and mortality rates of diseases per year were reported in the Kosei no Hakusho issued from the semiofficial association. However, the numbers reported may not be accurate. In 1948, the morbidity rates of syphilis, gonorrhea, chancroid and venereal lyphogranuloma were 270.8, 274.7, 45.9 and 0.9 respectively. Those figures have become lower, for example, 58.9, 184.8, 17.4 and 0.2 in 1952 and 10.8, 9-4, 0.2 and 0.0 in I960. There has been no more authorized prostitution in Japan since 1958. Such low figures, needless to say, are due to treatment and prophylaxis with the effective antibiotics. Examination for venereal diseases has been routinely conducted since 1948, especially in pregnant women and couples prior to marriage. Meningococcal injections (B10). Both morbidity and mortality rates for meningococcal infections decreased in number during the period 1920-19.32, except for a peak in 1924; then they increased with fluctuations and reached the maximum morbidity rate 6.1 and mortality rate 1.5 in 1945. They decreased gradually to 526 cases (112 fatal) in I 9 6 0 (Fig. 1 4 ) . They should be minimized by improved environment and adequate treatment with appropriate antibiotics and other drugs in the early stage of the disease.

1920 ' '25

'30 '35

'40

'45

'50

'55

'60

FIG. 13. Annual morbidity and death rates from diphtheria ( B 8 ) , 1 9 2 0 - 1 9 6 0 .

Leptospirosis ( 0 7 2 ) . In 1920, several thousand cases of Weil's disease were reported with hig'i case fatality rate among farmers, coal miners and people related with food. Since 1940 reported cases have decreased markedly. This has followed vaccination of individuals exposed to special risk through direct or indirect contact with rats, the reservoir of leptospira; and also following reduction of transmission hazards through environmental management in the reclamation of swamp lands. Beside: Leptospira icterohaemorrhagiae, L. canicola, L. heb-

71 ity and mortality rates in man for the general population, the preventive effect can be seen in Tokyo, Nagoya, and Okayama where the vaccination campaign was most active and systematic. In I960 there were 1,607 cases (morbidity rate 1.7) including 614 fatal cases (mortality rate 0.7). Mosquito control should be extended to get rid of the vector of the disease or reduce it to negligible levels.

FIG. 14. A n n u a l m o r b i d i t y and death rates f r o m meningococcal infections ( B I O ) , 1 9 2 0 - 1 9 6 0 .

dnmadis, L. automnalis, L. australis A, and L. bataviae are known to be endemic in certain areas, where epidemics break out after inundation of the river by typhoons. Japanese B encephalitis ( B 1 7 f ) . Japanese encephalitis was made a notifiable disease in 1946. Accordingly, only reports on Japanese encephalitis from some selected areas before then are available for epidemiologic review. Nevertheless, both morbidity and mortality rates of the disease during the period 1924 to 1942 except 1943 through 1945, and those 1946 through I960 are shown in Fig. 15. From the figure it seems likely that the occurrence of a countrywide epidemic is seen roughly every 10 years, such as the 6,125, 5,374, and 7,148 cases reported in 1924, 1935, and 1948 respectively with approximately 10-40 per cent of case fatality rates. However, the rise and fall of the morbidity rates can be seen generally in alternating years since 1948. The use of killed vaccine which is prepared from partially purified mouse brain infected with Japanese encephalitis virus has been authorized for public health since 1954. The vaccine has been proven to be effective, to some extent, in the prevention of the disease in horses. Though no markedly preventive influence of the vaccine has yet been surely recognized on both morbid-

( B 1 2 ) . Poliomyelitis Acute poliomyelitis has been a notifiable disease since 1948. According to references, two peaks of the mortality rate can be seen in 1923 and in 1938 (Fig. 16). Since the end of the war poliomyelitis has been seen in epidemic form in certain areas. The number of reported cases was 4,233 (570 fatal) in 1951. The morbidity rate began to decrease during the period 1952 to 1955 but increased to 6.0 in I960. The disease was most prevalent in the summer season and children under three years of age were the most susceptible. The vaccination campaign was organized to conduct vaccination of children against poliomyelitis with the Salk vaccine on the one hand and the investigation of Sabin vaccine on the other hand.

- -

m o r b i d i t y rate

—

death rote

FIG. 1 5 . A n n u a l m o r b i d i t y and death rates f r o m J a p a n e s e encephalitis ( B 1 7 f ) , 1 9 2 4 - 1 9 6 0 .

72 Influenza ( B 3 0 ) . Japan has suffered, to various degrees, in epidemics of influenza in the past. Due to the difficulty of obtaining accurate figures on patients all over Japan, none can be given except those obtained in specially selected areas. In 1950 and 1953, 39,324 and 89,942 cases were reported respectively all over Japan. In 1957 983,105 cases (morbidity rate 1,079.3) caused by A2 virus were reported, including 7,735 fatal cases (mortality rate 8 . 5 ) . In I 9 6 0 , 142,892 cases (morbidity rate 153.0) were reported, including 4,005 deaths (mortality rate 4 . 3 ) all over Japan. T h e fatal cases were mostly in old people. An influenza vaccination campaign was organized to protect school children and people in charge of important occupations, such as medical doctors, nurses, policemen, telephone operators, motormen and conductors of transportation, etc. Measles ( B 1 4 ) . In general the morbidity rate of measles has fluctuated, for example about 2 0 0 and 7 0 in alternating years until 1952. Since 1953, the morbidity rates dropped as low as 8 0 and 30. In I 9 6 0 , 48,395 cases were reported, including 1,346 fatal cases. T h e live vaccine is still under investigation by Dr. Okubo (Osaka University) and Dr. Matumoto (Tokyo University). Rabies ( B 1 7 h ) . Both rabid dog and human cases of rabies had disappeared from Japan be-

morbidity rate . death rate

FIG. 16. Annual morbidity and death rates from acute poliomyelitis ( B 1 2 ) , 1 9 2 3 - 1 9 6 0 .

fore the war. However, they reappeared in 1947 and increased in number to reach maxima of 74 human cases in 1949 and 2 5 6 rabid dogs in 1950. An antirabies campaign was then organized. Vaccination and restraining of dogs and hunting of homeless dogs were required by regulation. Since 1957 neither human cases nor rabid dogs have been reported in Japan. Trachoma ( 0 9 5 ) , tsutsugamushi disease ( 1 0 5 ) , Q-fever (108), and psittacosis ( 0 9 6 a ) . In 1948, 151,209 trachoma cases were reported. However, the number of cases has decreased gradually, probably due to improved environment and treatment with antibiotics since 1952. In I 9 6 0 , 45,173 cases were reported. Tsutsugamushi disease had originally been recognized as endemic in certain limited areas along the rivers in the northern part of Japan. Since the end of the war other types of the disease have been discovered. Thus, there are at least three different types in the epidemiologic pattern of the disease in Japan. Case incidence has decreased year after year. In I 9 6 0 , 6 3 cases were reported. There are no more fatal cases since effective antibiotics became available. N o isolation of Rickettsia burnetii has been obtained in Japan. However, in a country-wide survey for Q-fever, a few sera showed positive complement fixation. Since the end of the war, psittacosis was recognized in people who had close contact with birds. They were confirmed mostly by complement fixation tests and a few by isolation of the causative agent. The disease is still of minor importance to public health. Tuberculosis ( B l , B 2 ) . Tuberculosis has previously been the most important disease affecting the public health because of the very high mortality rates found in most groups, particularly the laboring population, during the period 1920—40 (Fig. 1 7 ) . Mortality rates remained high even after this, the principal decline beginning in 1950. B C G vaccination programs had already been begun by 1938. Following the end of the war the country-wide vaccination program was required by law and carried out on the basis of mass tuberculin testing. Patients who are discovered by X-ray

73 Mortality Rate 1000

500

100-

50

10

1920

'30

'40

'50

'60

FIG. 17. Mortality rate of tuberculosis in each age g r o u p under 40 during the period 1 9 2 0 - 1 9 6 0

year» (Bl,

B2).

examination to have tuberculosis are hospitalized by regulation and treated with antibiotics and supportive measures, including proper nutrition. Under this program, the mortality rate has decreased rapidly over the last 10 years, although it is still somewhat higher than that seen in parts of Europe and in the United

States. It should be noted that the mortality rates are considerably lower for children than for the older age groups and especially for the labor population (Figs. 18, 19). In I960, 489,715 cases of tuberculosis were reported (a morbidity rate of 524.2), including 31,959 fatal cases (mortality rate 34.2). Further effort to-

74 Vascular lesions affecting central nervous system ( B 2 2 ) . During the period 1920-1939 the mortality rate increased a little. It decreased to 117.9 in 1948, this probably due to the influence of food control by law during the war. It increased to 170.7 in I960 (Fig. 2 0 ) , thus occupying the top rank of the mortality rates.

Mortality

Diseases of the heart ( B 2 5 - B 2 7 ) . The mortality rates from heart diseases were almost the same, ranging between 60 and 70 during the 40-year period except for a high peak in 1957, coinciding with the epidemic of Asian influenza, and a tendency to increase can be seen in the past few years.

4

14

24

34

44

Si

44

74

FIG. 18. Mortality rate of tuberculosis in each age g r o u p in 1920, 1930, 1947, 1955, and 1960 ( B l , B2).

Senility without mention of psychosis ( B 4 5 a ) . In 1920, 73,468 fatal cases (mortality rate 131.3) of senility without mention of psychosis were reported. The mortality rate showed little fluctuation, ranging from 111.3 in 1926 to 138.6 in 1938; however, it began to decrease in number after 1947, with 100.3 in 1947, 70.2 in 1950, 55.5 in 1958, and 58.0 in I960. Thus, the rank of cause of death fell from the 3rd place during the period 1 9 5 3 1957 to the 4th in I960. Other

ward the reduction of both morbidity mortality from this disease is indicated.

and

Leprosy (B17.5). Leprosy cases are required by law to be isolated in special areas. The incidence of this disease has decreased gradually over the years. In I960 there were 257 cases reported, including seven which were fatal. So-called Adult

Diseases

Gastritis, duodenitis, enteritis, colitis, and diarrhoea of the newborn (B36, B 4 3 b ) .

500.0

Diseases

Malignant neoplasms ( B 1 8 ) . T h e mortality rate of malignant neoplasms was almost the same every year during the period 1920-1943. In view of the recent extension of the span of life, it was expected that both mortality and morbidity rates would increase. In contrast to the decrease in the mortality rate of tuberculosis, there has been a gradual increase in number of deaths during the past 10 years (Fig. 19). In I960, 93,773 fatal cases were reported, that is, a 100.1 mortality rate occupying the second rank in causes of death.

500 B1 B2

BIB. M o l i g n o n t -

-

-

- BIB?:

neoplasms

Tuberculosis

1.0

1920

25

'30

35

;

'40

;

'45

:

50

1

55

:

60

FIG. 19. A n n u a l death rates per 100,000 f r o m m a l i g n a n t neoplasms and tuberculosis, 1 9 2 0 - 1 9 6 0 .

75 Accidents

B 2 2 : V a s c u l a r lesions affecting central nervous system £25

: D i s e a s e s o f heart

B 4 3 b : Gastritis, d u o d e n i t i s , enteritis, colitis a n d d i a r r h o e a of the n e w b o r n

Fl3. 2 0 . Annual death rates from vascular lesions, heart diseases, and gastritis, etc., 1 9 2 0 - 1 9 6 0 . Upper solid line, B 2 2 ; lower solid line, B 2 5 ; broken line, B43b.

Diseases in this group were caused by various agents. Some of them might have been of secondary bacterial infection. Mortality rates of these diseases decreased gradually during the period 1920-1943 and have declined markedly since 1947, probably due to advances in treatment. In I960, 19,791 cases were reported (Fig. 2 0 ) .

Poisoning

Accidents (BE47, B E 4 8 ) ; suicide and selfinflicted injury (BE49)- In contrast to the recent marked decrease in the mortality rate of communicable diseases, the mortality rate of accidents by transportation is increasing; for example, 3,046 fatal cases in 1950 and 13,429 fatal cases in I960. Thus, the accident mortality rate became 6th in causes of death. The curve of accidents indicates a sharp peak in 1923, caused by accidents due to a big earthquake in Tokyo in the same year (Fig. 2 2 ) . Other fluctuations of the curve may be explained by relation with each war. From Figure 22, it is easily understood that the suicide mortality rate declined in the preand postwar periods. However, it increased and reached the maximum of 25.7 in 1958. It decreased to 21.6 in I960 and occupied the 8th rank of causes of death. Food poisoning ( 0 4 9 ) . In I960 food poisoning was reported 1,870 times, with 37,250 cases including 210 fatal ones. The causative agents might be microorganisms such as staphylococcus, Salmonella and other enteropathogenic bacteria, and toxins such as that of botulism. Such poisoning was mostly observed in the season from July to October.

Pneumonia and bronchitis (B31-B32. B43a). During the period 1920-1943, the mortality rates of pneumonia and bronchitis gradually declined with a little rise and fall. Since 1947, they decreased markedly and 46,045 fatal cases (the lowest mortality rate 49.3) were reported in I960 (Fig. 2 1 ) . Such decrease of the rate might be due to the effective antibiotics and drugs recently discovered. Nevertheless, the rate of these diseases was at the top of the mortality rate series of other diseases before 1925, but fell to the 5th rank in the series in 1960. Nephritis and nephrosis ( B 3 8 ) . The curve of annual mortality rates of nephritis and nephrosis was almost the same as those of B31, B32, and B43a during the past 40 years, though the former had lower rates than the latter. In I960, 15,429 fatal cases were reported (Fig. 21).

and Food

B 3 1 , B32, B 4 3 o ; P n e u m o n i a , bronchitis, a n d p n e u m o n i a of the n e w b o r n B38: Nephritis a n d n e p h r o s i s

10.0

0.1

1920

'25

'30

'35

FIG. 2 1 . Annual death rates from pneumonia, nephritis, and nephrosis, 1 9 2 0 - 1 9 6 0 . Broken line, B 3 1 , B 3 2 , B 4 3 a ; solid line, B 3 8 .

76 Parasitic

Diseases—Helminthiases

Ascariasis, ancylostomisasis, and enterobiasis are country-wide in Japan. Schistosomiasis japonica, Clonorchiasis, paragonimiasis, and filariasis are endemic in certain limited areas. The control measures undertaken against those diseases and their effect in the past 40 years are briefly summarized as follows. Ascariasis (130.0). The incidence of ascaris egg carriers was estimated by stool examinations to be as high as approximately 50 per cent of the whole population of Japan in 1930. This decreased to approximately 35 per cent in 1940. Since the end of the war the proportion of carriers reached the maximum level of approximately 55-60 per cent during the period 19461950. In 1952 the combined drugs santonin and kainic acid, which are not too expensive for mass administration, had been found effective for the eradication of ascariasis. Mass extermination of ascariasis has been conducted periodically by local groups all over Japan. Such widespread activity resulted in the gradual decrease to a carrier rate as low as approximately 18 per cent on an average all over Japan with a 5 - 6 per cent rate among urban inhabitants in Tokyo and Osaka in 1957. It should be pointed out that such a good result has been obtained in the past through the work of the Japanese Association of Parasitic Control, which was organized in 1955 and was composed of nonofficial groups in charge of education, mass examination of stools, administration of the drug, and consultation on control measures. Ancylostomiasis ( 1 2 9 ) . The positive rate of ancylostomiasis, as estimated by the singlesmear technique, was approximately 13 per cent on an average all over Japan in 1930. Later there was a gradual decline to 10 per cent in 1940 and 5 - 6 per cent in 1945. After the end of the war the method for stool examination was revised from a single-smear technique to the flotation concentration technique to find eggs more reliably in stools. As a result, the positive rate was as high as 20-30 per cent in rural areas on an average all over Japan. Such high figures served as a promoter for groups, official and nonofficial, to organize a parasitic

disease control association to eradicate the disease. At last l-bromo-2-naphtol was synthesized, which has been proven to be effective for eradication of ancylostomiasis. Accordingly the drug has been used officially and privately for mass extermination for several years. In 1959 the positive rate of ancylostomiasis fell to approximately 3 per cent, determined by examination of the single-smear technique in 1959, which was about half of that in 1945. Enterobiasis ( 1 3 0 1 ) . Enterobiasis is known to be widespread in countries in Europe and in the U.S.A. and Japan. However, the systematic control campaign has not been as extensively organized as for ascariasis and ancylostomiasis. Schistosomiasis ( 1 2 3 ) . Schistosomiasis japonica exists as an endemic disease in five limited areas in Japan. Since 1920 attempts have been made to eradicate Oncomelania nosophora, a vector of the disease, by using first CaO, and then calcium cyanamide as a molluscacide. The geographical distribution and the population of the snail became narrower in area and smaller in number for a time. However, the endemic area and the populations of the snail later became as they were before, following incomplete application of the molluscacide due to both shortages of manpower

500.0

BE47, BE48: Accidents BE49: Suicides a n d self-inflicted injury

100.0

10.0

n.j

1

1920

1

'25

1

'30

1

'35

1

'40

1

'45

1

'50

1

'55

'60

FIG. 2 2 . Annual death rates of accidents and suicides, 1 9 2 0 - 1 9 6 0 . B r o k e n line, B E 4 7 and B E 4 8 ; solid line, B E 4 9 .

77 and molluscacide during the war and for a few years after the end of the war. Since 1951 Na-PCP has been found to be a more effective killing molluscacide than calcium cyanamide and has been used since 1953. In addition, it has been found that the use of concrete irrigation ditches has had some effect on eradicating the snail in endemic areas. This practice has been followed since 1954. At present approximately 30 per cent of all irrigation ditches in endemic areas in japan are of concrete. Now the reported cases of schistosomiasis per year and the population of snails are very small percentages of those existing at the end of the war. In addition, the infectivity rate of snails has decreased markedly and is now only about Vl per cent, which is a reduction of 2 0 - 3 0 per cent below the rate found at the end of the war. Clonorchiasis ( 1 2 4 . 0 ) . The occurrence of clonorchiasis has decreased markedly since the end of the war, as has the infectivity rate of fresh-water fish. These reductions might be due to further education of the people concerning the disease. In addition and probably also effective has been the reduction in the population density of the host Parafossarul//s (Bithynia). Direct killing of the snail has been effected by improved cultivation methods and drainage and by the use of agricultural pesticides such as parathion. Paragonimiasis (124.1). A country-wide survey of the endemic areas of paragonimiasis has been carried on since 1957. Thus, the geographical distribution has been defined. At the present time ( I 9 6 0 ) the disease is controlled only through education of the people. Further investigation looking forward to more positive control measures is indicated. Filariasis ( 1 2 7 ) . An anti-filariasis campaign has been in effect in Japan for the past several years. Blood-parasite surveys to determine the extent of infection are being carried out in known or suspected endemic areas all over the country. Based on the findings of these surveys, mass treatments of infected individuals are accomplished. In addition, vector control programs are carried out. It is hoped through the

continuation of these programs that the incidence of filariasis in Japan may be markedly reduced in the future. Parasitic diseases—malaria. Forty years ago there were many endemic areas of malaria throughout Japan, from Hokkaido in the north to Kagoshima Prefecture in the south. Now the disease is almost entirely absent with only sporadic cases being reported. Its control may be attributed largely to draining and land reclamation in the endemic areas during the period 1 9 2 0 - 1 9 4 0 . At and immediately following the end of the war, however, the disease was brought back into Japan, principally by people returning from endemic areas in the southwest Pacific and the continent. Thus during the postwar period there were more than 1,000 cases per year for a brief time. However, this situation has changed markedly since 1952, and in I 9 6 0 less than ten cases of malaria were reported. At this time malaria can be considered almost eradicated from Japan. Reasons for its disappearance are not entirely clear. It is possible, however, that the country-wide programs and projects for mosquito and fly control by both official and nonofificial groups which have been carried on over the last ten years have been very effective in this great reduction in the occurrence of malaria. Mental

Health

It is of course important for people to enjoy life completely through good health, both physical and mental. It is estimated that there are approximately 130,000 cases of mental disorders in Japan, these including psychotic, psychoneurotic, and personality disorders. Some of these, of course, require removal from the community and hospitalization, some respond to treatment, and a good many require assistance for rehabilitation. The National Institute for Mental Hygiene is active and functioning to accomplish these purposes. Maternal

and Child

Health

After the end of the war the Juvenile Welfare Law was passed for the purpose of improving maternal and child health. Following

78 this, the mortality rates for newborns and infants decreased markedly. During the period 1 9 4 7 - 1 9 6 0 the mortality rate for newborn decreased from 31.0 to 17.0 and for infants from 76.7 to 30.7. However, there was not a parallel decrease in mortality among expectant and nursing mothers during that period. In Japan the three main causes of death of pregnant and nursing mothers are eclampsia, hemorrhage, and extra-uterine pregnancy, these accounting for about three-fourths of the total mortality in this group. In this country, however, puerperal fever does not occur as frequently as in many other countries. A study group in Japan has announced that perhaps 60 per cent of the mortality rate of pregnant and nursing mothers could be prevented by adequate treatment. Health Centers are organized to care for pregnant women and the newborn, particularly those born prematurely. This service now extends even into the towns and villages far removed from larger centers. Sanitation Water supply. In 1921 water was distributed only to approximately seven per cent of the Japanese population. This distribution was increased and reached 15 per cent in 1930 and 25 per cent in 1940. Because of conditions during the war period, the same situation prevailed in 1950. In I960, however, it was found that the distribution had doubled and that water was distributed to approximately 50 per cent of the population, with considerable variation from area to area, while as few as 11 per cent had directly distributed water in some situations. The principal reasons behind the difficulties in development of adequate water distribution are shortage of materials and problems involved in establishing adequate reservoirs of water. Current plans of the Ministry of Welfare contemplate provision of water distribution to 83.4 per cent of the Japanese population within the next ten years. Total consumption of water in Japan is considered to be approximately 4 0 0 liters per person per day, as of March, I 9 6 0 . Sewage. The progress of sewage drainage and disposal has been very slow. The Sewage

Law was established in 1920, but not amended until 1954. The reason for retardation of sewage drainage and disposal might be due to ( 1 ) enormous budget for their construction and ( 2 ) little attention of the people to sewage in the past. By I 9 6 0 sewage disposal systems had been constructed at 27 cities for approximately 4,700,000 people, corresponding to about 6 per cent of the whole population. It must be presumed that this retardation of sewerage construction has badly held up progress of control of oral infectious diseases such as dysentery. The Ministry of Welfare has a tenyear plan to construct sewage disposal systems for 29,000,000 (about 50 per cent of population of cities) by 1970. Night-soil disposal was already functioning for approximately 2,500,000 of the population in 97 cities and under construction for 2,200,000 in 62 more cities in I960. As for garbage and rubbish, 690 garbage-burning places were set up in 1958, and 121 more were to be set up in 1959. Thus 811 garbage burning places were functioning in I960. Slaughter houses. The slaughter house is important for meat hygiene. In I960, 875 slaughter houeses were scattered all over Japan. Public

Nuisances

Recent developments in transportation, industry, and nuclear energy, including atomic bomb resting, have resulted in increased atmospheric and water contamination with chemicals and radio-active and other substances. In addition, the problem of increased environmental noise both by day and by night has grown. These require study in order to learn to what extent they may be influencing the individual and the public. It is thought, for example, that atmospheric pollution through exhaust gases from motor vehicles may be one of the causes of lung cancer and that there is a possibility that radio-active substances may exert adverse genetic effects with the production of malformed or otherwise defective children. It is considered urgent that knowledge is gained through the study of these matters and that necessary steps be taken toward the elimination of harmful substances and noises. It is true

79 that now certain regulations are being applied. However, it is believed that much more effective measures are required for the protection of the public health. ADMINISTRATION FOR PUBLIC HEALTH Organization for Public Health Under Ministry of Welfare In order to keep people under good health conditions, the Ministry of Welfare has four bureaus, Public Health, Environment Sanitation, Medical Affairs, and Pharmaceutical and Supply. These operate in the interests of ( i ) general public health, ( ii ) school hygiene, and (Hi) labor hygiene, through ( a ) preventive medicine by mass vaccination and mass examination; ( b ) water supply, sewage disposal, and environment control; ( c ) nutrition, mental hygiene, and physical exercises; ( d ) treatment of disease; and ( e ) production and supply of medicaments and biological products. Besides these, compilation of vital statistics, testing of samples, education in hygiene, health nursing and other group activities are important factors for public health. T h e budget for public health and medical affairs was 27.8 per cent of the total budget of the Ministry of Welfare in 1 9 5 0 and 35.6 per cent in I 9 6 0 . Japan is composed of 45 prefectures. Each prefectural government has a sanitary bureau in charge of administration of public health and a prefectural hygienic laboratory serving for public health. Health

Centers

There are 7 9 3 Health Centers in Japan. They are divided into five types, urban, rural, urbanrural, land, and minor, according to the population density and industries where a health center is. It can be said each health center serves roughly 100,000 people. Persons working in health centers total 21,575 in all Japan, and include 1,793 medical doctors, 116 dentists, 5.534 health nurses, 8 1 7 nutritionists, sanitary engineers, 1,700 inspectors for food, 1,189 inspectors for environment and sanitation, 8 6 2 inspectors for slaughter houses and rabid dogs, 1.408 X-ray technicians, 1,097 laboratory men and 583 persons in charge of education for

public health. T h e budget for the health centers totalled 2,236 million yen in I 9 6 0 . T h e health center actually functions for consultation for the health of people, periodical mass physical examination, mass treatment, and mass vaccination, family visiting for consultation on health and for case-finding. In addition there are inspections of food, drinking water, milk, hotels, restaurants, public baths, theaters, slaughter houses, biological products, and medicaments; also education and guidance of group activities, especially in nutrition and mother and child health; also, biological and chemical examinations of test samples. School

Hygiene

In Japan there is a school hygiene regulation which applies to all persons attending or instructing in schools and universities. A principal function of the service provided is the conduct of periodic physical examinations to determine the status of health of the students, instructors, and school office workers. T h e service is provided in 4 5 , 7 2 4 schools throughout the country. Taking part in this service are 6 8 , 9 2 0 medical doctors, 4 7 , 8 9 2 dentists, 8,461 pharmacists, 10,085 health instructors, and 1,076 assistant health instructors. Labor

Hygiene

According to the concepts of ILO and W H O in 1950, persons who are employed in any occupation should be protected under the Labor Standard Inspection Office by the Labor Standards Law. Their health should be checked by the health administrator for the purpose of prevention and control of accidents and diseases, as well as for assessing risks and actual incidences. For example, out of 6 2 , 5 5 9 patients who complained of dust diseases, 8,653 ( 1.3.8 per c e n t ) were confirmed in Japan, I 9 6 0 . Hospitals, Medical Doctors, Pharmacists, and Nurses

Dentists,

T h e number of hospitals, public and national, was 7 6 with 7,253 beds in 1920. In 1940, general hospitals had increased in number to 141 with 12,471 beds, and insane hospitals in-

80 e l u d i n g p r i v a t e hospitals w e r e 163 w i t h 9 1 , 0 4 6 beds. In I 9 6 0 , hospitals totalled 6,094, includi n g 4,921 g e n e r a l hospitals, 5 0 6 insane hospitals, 14 leper houses, a n d 5 8 i n f e c t i o u s disease hospitals. T h u s , o n e h o s p i t a l is said to serve 15,000 p e o p l e . In 1920 in J a p a n t h e r e w e r e 4 5 , 4 8 8 m e d i c a l doctors e n g a g e d in practice. T h e r e w e r e 5 3 , 9 6 4 in 1940, 6 9 , 6 4 9 in 1950, and 9 6 , 0 3 8 in I 9 6 0 . T h u s in t h e years 1920, 1940, 1950, and I 9 6 0 t h e r e was respectively o n e p h y s i c i a n f o r every 1,230, every 1,354, every 1,088, a n d every 9 7 2 people. A t this t i m e t h e r e w e r e 9 , 6 4 9 w o m e n physicians in practice. In a d d i t i o n , t h e r e w e r e 4 , 7 6 9 m e d i c a l doctors e n g a g e d in i n v e s t i g a t i o n and a d m i n i s t r a t i o n . In I 9 6 0 , 1,766 medical s t u d e n t s g r a d u a t e d f r o m 4 6 m e d i c a l schools and passed a n a t i o n a l e x a m i n a t i o n for license to practice. In that year also t h e r e w e r e 31,797 d e n t i s t s in p r a c t i c e and 2 7 , 0 2 0 d e n t a l clinics. T h u s there was o n e d e n t a l clinic for each 3,000 persons. 5 8 , 0 0 0 p e r s o n s w o r k e d in these dental clinics, of w h o m t h e dentists c o m prised 55 p e r cent, d e n t a l nurses 16.4 p e r cent, and dental t e c h n i c i a n s 11.6 p e r cent. In that year t h e r e w e r e 2 1 , 1 1 9 d r u g stores in J a p a n and 6 0 , 2 5 7 p h a r m a c i s t s , of w h o m 32,923 w e r e e n g a g e d in hospital work and 1 1,232 w e r e w o r k i n g in p h a r m a c e u t i c a l m a n u f a c t u r e and allied activities. A d d i t i o n a l health p e r s o n n e l in J a p a n in I 9 6 0 included 13,010 health nurses, 52,337 m i d w i v e s , and 185,592 nurses, i n c l u d i n g assistants. T h u s for each 1 0 0 , 0 0 0 of p o p u l a t i o n there were 13 9 health nurses, 56 m i d w i v e s , and 198.7 nurses, i n c l u d i n g assistant nurses. AI ed

icaments—Budget

In I 9 6 0 m e d i c a m e n t s i n c l u d i n g vitamins, antibiotics, etc., of 176,012 m i l l i o n yen in cost w e r e m a d e in J a p a n , of w h i c h materials 6,457 m i l l i o n yen in cost w e r e e x p o r t e d and similar materials of 6,265 m i l l i o n yen in cost w e r e i m p o r t e d f r o m overseas. INTERNATIONAL

COLLABORATION

A s o n e of m e m b e r c o u n t r i e s of W H O , J a p a n has W H O R e g i o n a l C e n t e r s as well as W H O R e f e r e n c e L a b o r a t o r i e s for several diseases. T h e s e f u n c t i o n u n d e r t h e auspices of head-

q u a r t e r s of W H O in G e n e v a . T h e i r p u r p o s e is t o p r o m o t e t h e i m p r o v e m e n t of p u b l i c health in this c o u n t r y t h r o u g h c o o p e r a t i o n with w o r k e r s in f o r e i g n countries. J a p a n has also c o n d u c t e d q u a r a n t i n e a c c o r d i n g to t h e Intern a t i o n a l Q u a r a n t i n e R e g u l a t i o n s to p r e v e n t t h e spread of i n f e c t i o u s diseases. SUMMARY AND T H E FUTURE

It has been seen that, t h o u g h p r o g r e s s in p u b l i c health was i n t e r r u p t e d by t h e o u t b r e a k of t h e war, J a p a n has m a d e t h e s a m e great advances as e x p e r i e n c e d in other countries, h a v i n g t a k e n a d v a n t a g e of the discoveries of n e w a n d m o r e effective p r o p h y l a c t i c and therap e u t i c m e a s u r e s over t h e past forty years. It should b e noted, h o w e v e r , that t h e p o p u l a t i o n density of J a p a n is t h e greatest in t h e world and this o n relatively p o o r n a t u r a l resource land. It is also significant t h a t t h e p o p u l a t i o n p y r a m i d has so c h a n g e d as t o be a p p a r e n t l y unstable, d u e t o t h e e x t e n s i o n of t h e span of life and t h e decrease in t h e n u m b e r of b i r t h s b r o u g h t a b o u t by f a m i l y p l a n n i n g . In J a p a n t h e average s p a n of l i f e for a m a l e is 65.4 years and for f e m a l e s 70.3 years. T h e s e figures indicate a n a p p r o x i m a t e 25-year e x t e n s i o n of t h e span of life since 1920, that is, d u r i n g t h e last forty years. A m a r k e d increase in t h e p o p u l a t i o n of each age g r o u p can b e assumed for t h e n e x t decade. T h u s , n e w o u t l o o k s and a d m i n i s t r a t i v e practices in p u b l i c health will b e r e q u i r e d for t h e f u t u r e . M o s t i n f e c t i o u s diseases, particularly t h o s e of bacterial o r i g i n , have b e e n b r o u g h t u n d e r control. For e x a m p l e , tuberculosis, w h i c h was o n c e a m o s t i m p o r t a n t disease f r o m a p u b l i c health p o i n t of view, has b e c o m e t h e s e v e n t h in causes of d e a t h . H o w e v e r , it still r e m a i n s an i m p o r t a n t disease since it is still t h e first cause of d e a t h in t h e w o r k i n g g r o u p s of t h e p o p u l a t i o n . Physical d e v e l o p m e n t s of J a p a n e s e y o u t h s h a v e n o w reached a level n e v e r b e f o r e experienced. E v e n so, J a p a n e s e n u t r i tionists e x p e c t even f u r t h e r physical d e v e l o p m e n t by 1970, p e r h a p s like that of t h e nisei or t h i r d - g e n e r a t i o n of J a p a n e s e in t h e U n i t e d States. T h e so-called a d u l t diseases increased in n u m b e r d u r i n g t h e 40-year p e r i o d and n o w occupy t h e first t h r e e r a n k s of causes of d e a t h

81 in Japan. Further investigation of these conditions is indicated, with particular attention to food and living and working habits and environments. Water supply and sewage disposal require particular attention and the expansion of facilities for these purposes is urgently needed. In addition, the interests of public health demand increased attention and emphasis on problems of the nonbiological contamination of air and water arising from the rapidly developing industries and the increasing concentrations of radio-active substances.

BIBLIOGRAPHY Annual Report, Health Statistics of 1935, 1940, 1945, 1950, and 1959-

Japan,

Annual Report of Public Health Bureau, 1920, 1925, and 1930. Kosei Hakusho, 1956 and 1961. Kosei no Shihyo, 1958, 1959, and 1961. Ten-Year Progress of Health Center, I960. Twenty-Year History of the Ministry of Welfare, I960. Vital Statistics, Japan, 1959 and I960.

Malaya MOHAMMED

DIN

T H E REVIEW o f p u b l i c health work in Malaya,

and high mortality.

f r o m the early part o f the century to t h e p r e s e n t ,

malaria ensued. T h e g r e a t w o r k o f the p i o n e e r -

is

i n g health officers early in the c e n t u r y p r o d u c e d

closely

related

to

economic

and

political

A prolonged

fight

against

e v e n t s and c h a n g e s in this area w h i c h are now

r e m a r k a b l e and effective results, s t a n d i n g m o n u -

history.

m e n t s which are still in use today.

II

In

the

period

before

the stares of M a l a c c a

part

of

the Straits

facilities of

and

M a l a y States. federated and

formed

Here

hospital ahead

states, c o m p r i s i n g

States

and

the

this

action

is due

taken

and occasional.

to the v i g i l a n c e

by the health

and

personnel

Credit prompt of

that

In at least t w o states o f the U n -

and s m a l l p o x w e r e recorded, they w e r e always

services

conditions

were

in

hospital

comparatively

more

advanced. T h i s was due m a i n l y to s o m e m e a s u r e of

for

period. A l t h o u g h localized o u t b r e a k s of cholera

States

the

O u t b r e a k s o f serious i n f e c t i o u s diseases were, by and large, m i n i m a l

Unfederated

Malay

health

War

services w e r e well

nine

Malay

Penang

Settlement.

health

the r e m a i n i n g

Federated

and

World

autonomy

administration.

provided

in

These

states

their

government

were

thus

c o m p a r a t i v e l y b e t t e r situation at the of W o r l d W a r

in

a

outbreak

t h e result o f i m p o r t e d cases f r o m countries.

neighboring

T h e r e w e r e efforts also directed

to-

wards t h e t r e a t m e n t of diseases like yaws w h i c h were then heavily p r e v a l e n t With success

II.

in r i v e r i n e

t h e use o f n e o a r s e n o b i l l o n was

attained.

areas.

a degree

Hospital

service

of was

l i m i t e d largely to b i g t o w n s c a t e r i n g to governon

m e n t officials, the p o o r , and referred cases f r o m

the progress of health is the r e m a r k a b l e g r o w t h

estate hospitals. S o m e sort o f static and travel-

and

tin.

l i n g dispensary s e r v i c e was available also f r o m

China

and

these- hospitals.

A major in

the

Large

factor w i t h

two

large

numbers

a definite b e a r i n g

industries,

of

rubber

laborers

from

Sanitary

measures and

whole-

India m i g r a t e d i n t o the c o u n t r y at the turn o f

s o m e water supplies in b i g t o w n s w e r e steadily

the century.

being

With

t h e rapid

development

these industries, a c c e n t was placed on

of

improved.

proper

W o r l d W a r II b r o u g h t in its w a k e c o m p l e t e

and a d e q u a t e health m e a s u r e s for the

laborers

cessation of any progress in t h e health p a t t e r n

and o t h e r s involved, such as m i n i m a l

housing

o f t h e country.

standards

require-

hospital

ments.

A

problem

and

other

striking of

feature,

nutrition

groups, particularly to

the

search

relevant

of

was t h e r e f o r e Malaria

also

from

focussed

was

affected

on

the

a

reported,

services There

were

period

maintained

was m a r k e d

inade-

Fortunately, but

a

n o serious e p i d e m i c

breakdown

in

was

antimalarial

m e a s u r e s in m a n y localities caused an increase

with

in the m a l a r i a l i n c i d e n c e ; also scarcity o f p r o p e r

great

m e n a c e , and t h e o p e n i n g u p o f n e w land

D u r i n g the occupation

health

skeletal staff.

period.

Re-

combatting

to be

and

quacy o f drugs towards the latter p a r t o f this

owing

rice.

in c o n n e c t i o n

proved

with

certain

China,

overmilled

this p r o b l e m , particularly beriberi.

however,

which

those

consumption

health

food

for

produced

various

types

m a n i f e s t a t i o n s in t h e p o p u l a t i o n .

r u b b e r p l a n t i n g was f r a u g h t w i t h g r a v e hazards

at a standstill.

83

of

nutritional

R e s e a r c h was

84 For many years after the war a program of rehabilitation was set in motion to raise the services to their prewar level. However, a period of "Emergency" was declared in 1949 and further rapid progress towards the objective was retarded. Indeed, with the formation of numerous settlements as part of the government plan for the Emergency, new solutions had to be devised to meet the new designs. Into the settlements, which were of various sizes, squatters from the rural areas were grouped. In the planning of these settlements health advice was requested and accepted, which was most satisfying. All these newly formed settlements ultimately had adequate water supplies and environmental sanitary services in addition to regular static and travelling dispensary services. For protection against malaria the important project of residual spraying with D D T of all houses twice a year was adopted. This campaign has continued. After 1955 Malaya worked towards independence, which it obtained in 1958. At that point the Ministry of Health assumed responsibility for the health of the nation. The Medical Headquarters, which was then functioning purely in an advisory capacity, suddenly had all the states under its wing, and it was not surprising to find varying degrees of services and developments, although conforming to a general pattern. T h e situation in each state then reflected the state government's past medical and health policies. It was at this stage that the medical and health staff, with great dedication to duty, responded to the changes. With vigor they put themselves to the task of improving the health of the nation as dictated by the policies of government. With renewed political awareness, studies revealed the unhappy position of the rural population brought about by neglect in the past. The economic picture of the rural population was poor in comparison with the urban areas; likewise health facilities accorded to them were meager. Such evidence as the high infantile mortality rate in the rural population (twice that of the urban a r e a ) , prompted early implementation of concrete improvements aimed towards rural inhabitants. T h e first Five-Year Development Plan was

conceived to provide basic facilities and services for the country's expanding productive economy. In 1955 a rural health program was devised by the Medical Headquarters aimed at raising the rural health standards. Initially, it was aimed at correcting their infant deaths. T h e plan provides at the periphery, midwifery service for a population of approximately 2,000. These front line personnel are expected to take care of expectant and nursing mothers and to help educate the family unit in simple matters related to health. Five of these midwives are reinforced by other staff from a subcenter where ancillary medical and sanitary personnel trained for specific functions are located, to serve an area of approximately 10,000 of the population. In turn, five of the subcenters come under the direction of a main center where the supervisory personnel; the medical, health, and dental officials reside. Visits are made regularly by them within the district unit. A unit area of approximately 50,000 people will thereby receive both curative and preventive health services. Approximately half the population of the country resides in rural areas; the aim of this plan is to provide health services as early as possible. From a slow start, the implementation of the plan has now entered the second fiveyear phase, and large numbers of midwives clinics, subcenters, and main centers are already on the ground serving the rural population. T h e Rural Health Development Program thus assumed proportions of considerable size. In addition, there is need for improvement and expansion in other medical, health, dental, and pharmaceutical fields. It was clear, therefore, that adequately trained staff was essential; subsequently, a training program, unprecedented in the history of the country, was launched. Training schools of every type and category were opened or expanded, and with the cooperation of friendly countries, Malayan students were sent overseas for various forms of basic training. Through government scholarships and bursaries, large numbers were also sent abroad for specialist qualifications and to get experience. A medical school is scheduled for 1963 at the University of Malaya in Kuala Lumpur. H a n d s o m e assistance was received from W H O

85 and U N I C E F for both our health and training programs. T h e general and district hospitals throughout the country suffered through the war years and immediately after. Hence large sums of money have been provided under the Development Program for the improvement of wards and buildings, for new wards and clinics, and to provide sufficient and adequate equipment and instruments at all levels. District hospitals, in particular, in view of the proximity to rural areas, were accorded priority. T h e planning of new hospitals was not lost sight of, and it is anticipated that by the end of 1965, Kuala Lumpur, the federal capital, will have a new 1,000-bed hospital on the present general hospital site. The hospitals at Klang and Seremban will be replaced by new buildings incorporating modern facilities, and at least two rural towns will have small hospitals for the first time. There are still a number of tropical diseases prevailing in the rural areas of the country, which present to the Health Ministry problems necessitating solutions in the interest of public health. Particularly pressing they are, too, when the emphasis in this era is to uplift the status of the rural population. These diseases have alwavs been blamed for the ill health among this group of the population. Subsequently, various public health projects were undertaken to control them in the last decade. Mulliría. Although widely controlled in towns, malaria has been a source of anxiety in rural areas. An eradication program using new insecticides and measures found helpful in many parts of the world, would appear to be the solution for Malaya. However, certain factors peculiar to Malaya make it impractical. Malaria is not seasonal in this region on account of the constant rain falling throughout the year. Furthermore, there are several identified species of malaria mosquitos whose biology and natural behavior differ in many ways. A rimple attack with D D T does not provide the answer; for this reason a pilot project was launched for the purpose of finding suitable and practicable means of eradicating malaria in Malaya. For this project an area in Selangor was selected; an area covering 501 sq. mi. with a population of 110,000.

T h e final assessment of this project is expected in 1 9 6 3 - 6 4 . Tuberculosis. For many years malaria had been the major known killer, but in recent years it has been superseded by tuberculosis. Convinced that this disease is preventable, a national program was undertaken in 1961 to control tuberculosis as a major public health problem. As there is no difference in the incidence of this disease between urban and rural areas, the rural people will also benefit from this project. T h e first phase in this campaign was a training program started in Kuala Lumpur with the assistance of the Australian government, W H O , and U N I C E F . Filaria. Research on filaria control was sufficiently advanced in the 1950s for such programs to be expanded into all known areas where filariasis is known to exist. This project is being vigorously pursued but staff problems had to be overcome. Yaws. A campaign against yaws was started early in 1954 in the eastern states of Kelantan and Trengganu where it has now ceased to be a major public health problem. T h e campaign has been extended to three other states where pockets of resistance still exist. Leprosy. T h e problem of leprosy is apparently not so great. Nevertheless active measures have not ceased; these are directed towards the education of the public, improvements in leprosaria and the greater choice of suitable and practical methods in the rehabilitation of patients. Specific outpatient clinics have been organized and attached to general hospitals in two big centers for the early diagnosis and treatment of cases. T h e Institute for Medical Research has slowly but surely built up its reputation after the war in cooperation with research workers from abroad. Local personnel are slowly gaining experience and initiative while working with their brother scientists at the Institute. It should be mentioned that parallel improvements and expansion were also noticeable in the fields of our dental and pharmaceutical services. Their contribution towards improving health standards was by no means small.

86 Looking to the future, there is every reason to believe that better results and achievements will be forthcoming. Complete understanding as to the nature, the responsibilities of the var-

ious services involved, and the role each and every inhabitant must play in the national programs will dominate the trend towards major health success in Malaya in the years to come.

Philippines TRINIDAD P. PESIGAN

T H E PHILIPPINES is an archipelago above the equator in the western Pacific area It is located between latitude 21 degrees 25 m i n u t e s N o r t h , and 4 degrees 23 minutes N o r t h , and between longitude 116 degrees East and 127 degrees East. It has a land area of 2 9 7 , 4 1 0 square kilometers ( 1 1 4 , 8 0 0 square m i l e s ) . A total of 7 , 1 0 0 islands and islets m a k e u p this archipelago. M o r e than half of these islands are unnamed. T h e Philippines has a coastline of 10,850 miles which is twice that of the United States of America.

B e i n g near the equator and surrounded by water in many sectors, the Philippines is generally w a r m and humid. T h e temperature varies from 7 0 . 7 ° F to 8 1 . 1 ° F with an average of 8 0 . 3 C F . T h e humidity is f r o m 77 per cent to 88 per cent with an average of 8 0 per cent. In general, there are two seasons in the Philippines, the dry and wet seasons. Based on this four types of climate are described. T h e first has two distinct seasons, the dry season f r o m N o v e m b e r to April "and the wet season which prevails d u r i n g the rest of the year. T h i s type of climate is generally f o u n d in the western part of the Philippines. T h e second type of climate has a pronounced rainfall from N o vember to J a n u a r y and n o dry season. T h i s is generally f o u n d in the eastern portion of the Philippines f r o m southeastern Luzon to Mindanao. T h e third type includes n o defined seasons so it is relatively dry f r o m N o v e m b e r to April and relatively wet the rest of the year. T h i s is true in the central part of northern Luzon and there is spotty distribution in the Visayas and M i n d a n a o . T h e fourth type has rainfall distributed throughout the year and generally is found in M i n d a n a o , northeastern Luzon and patches in the Visayas.

T h e Philippines presents every type of topographical feature f r o m low marshes to high mountains. Generally, the Philippines has a rugged terrain with the highest m o u n t a i n found in the island of M i n d a n a o ( M o u n t A p o , 9,690 f e e t ) , and the second highest ( M o u n t Pulog, 9,593 f e e t ) in Luzon. T h e Philippines is divided into three m a i n groups; namely Luzon, Visayas, and M i n d a n a o extending from N o r t h to South, with Luzon and M i n d a n a o as the biggest and second biggest islands, respectively ( s e e m a p ) . T h e Visayas g r o u p is m a d e up of six intermediate-sized islands spread out between Luzon and Mindanao. There are extensive valleys mostly in the central portion, and s o m e coastal plains which are drained by b i g rivers and their tributaries like the Cagayan Valley in northern Luzon. T h e island of M i n d a n a o also has b i g valleys; the A g u s a n and C o t a b a t o valleys which are drained by rivers bearing the s a m e names.

POPULATION DISTRIBUTION

T h e census of 1918 showed that the Philippines had a p o p u l a t i o n of

10,314,310

which

increased to 19,234,182 in 1948 and further to

T h e Visayan g r o u p of islands is r u g g e d with coastal plains. A few are of rolling topography with high plateaus. T h e r e are n o b i g rivers in this area.

2 7 , 4 5 5 , 7 9 9 in I 9 6 0 . I960

by

the

27,783,347.

87

Estimated population for

Disease

Intelligence

Center

is

Since the majority of the p e o p l e

88 d e p e n d s o n f a r m i n g as a s o u r c e of l i v e l i h o o d a b o u t 8 0 p e r cent live in the rural areas. D u r i n g and i m m e d i a t e l y a f t e r the war there w a s a g r e a t tendency f o r p e o p l e to flock to u r b a n areas for security reasons. T h i s tendency is still m a n i f e s t today. E v e n the m e d i c a l g r o u p s like p h y s i c i a n s and nurses are concentrated in cities and b i g towns. For the p a s t 4 0 years there has b e e n no significant c h a n g e in p o p u l a t i o n c o m p o s i t i o n and distribution. PUBLIC HEALTH

In 1954 the R u r a l H e a l t h Act k n o w n as R e p u b l i c A c t N o . 1082 was passed by C o n gress, s t r e n g t h e n i n g health and dental services in the rural areas. T h i s w a s a m e n d e d in 1 9 5 7 by R u r a l A c t N o . 1891 which p r o v i d e d for f u r t h e r b r e a k d o w n of the t w o categories of the R u r a l H e a l t h U n i t s ( S e n i o r and J u n i o r ) i n t o e i g h t different c a t e g o r i e s b a s e d on p o p u l a t i o n . It was e n v i s i o n e d that a R u r a l H e a l t h U n i t w o u l d b e established in every town in the P h i l i p p i n e s . A t the close of fiscal year 1 9 5 3 there were 5 8 units c o m p a r e d to 1,280 u n i t s in I 9 6 0 . T h i s is short of 85 units for a t t a i n i n g the g o a l of 1,365 which w o u l d cover practically all the m u n i c i p a l i t i e s of the P h i l i p p i n e s . T h e c o m p o s i t i o n of the R u r a l H e a l t h falls under e i g h t c a t e g o r i e s as f o l l o w s

Unit (based

o n the p o p u l a t i o n served as p r o v i d e d in R e p u b lic A c t N o . 1 8 9 1 w h i c h a m e n d e d R e p u b l i c A c t 1082):

POPULATION

1

2 , 0 0 0 a n d less

2

2,000-5,000

3

5,000-10.000

4

10,000-20,000

5

20,000-30,000

6

30,000-40,000

;

40,000-50,000

cS

5 0 , 0 0 0 and over

ADMINISTRATION

T h e c o n c e p t of m o d e r n p u b l i c health s e r v i c e was born t o w a r d s the end of the last century at the b e g i n n i n g of the A m e r i c a n o c c u p a t i o n . In 1 8 9 8 the B o a r d of H e a l t h was established with a m u n i c i p a l laboratory f o r M a n i l a . F r o m this b e g i n n i n g the o r g a n i z a t i o n e x p a n d e d g r a d ually and later involved the w h o l e country. D i f f e r e n t d e p a r t m e n t s and laboratories were established such as a bacteriology d e p a r t m e n t , b i o l o g i c a l and c h e m i c a l laboratories, a p r o d u c tion laboratory for v a c c i n e and sera, a p l a g u e hospital, and a registration center for vital statistics. In 1 9 0 5 the B o a r d of H e a l t h ( l a t e r the B u r e a u of H e a l t h ) i m p r o v e d p u b l i c health service in the island. In 1941 the D e p a r t m e n t of H e a l t h and P u b l i c W e l f a r e was established a d d i n g w i d e c o v e r a g e of p u b l i c health service.

No.

CATEGORY

PERSONNEL Midwife Sanitary Inspector Public Health Nurse Midwife Sanitary Inspector Municipal Health Officer Public Health Nurse Midwife Sanitary Inspector Municipal Health Officer Public Health Nurse Midwives Sanitary Inspector Municipal Health Officer Public Health Nurses Midwives Sanitary Inspector Municipal Health Officers Public Health Nurses Midwives Sanitary Inspectors Municipal Health Officers Public Health Nurses Midwives Sanitary Inspectors 2 Municipal Health Officers 4 Public Health Nurses 4 Midwives 3 Sanitary Inspectors

HOSPITALS

B e f o r e 1 9 2 0 there w e r e only 13 h o s p i t a l s in the P h i l i p p i n e s . In 1 9 2 3 A c t N o . 3 1 1 4 w a s p a s s e d to aid the p r o v i n c e s in the construction, o p e r a t i o n and m a i n t e n a n c e of p r o v i n c i a l hospitals. T h i s was i n s t r u m e n t a l in the g r o w t h of hospitals, both p u b l i c and private. In 1 9 4 7 u n d e r E x e c u t i v e O r d e r N o . 94, the B u r e a u of H o s p i t a l s w a s created w h i c h has greatly enhanced the "health and h o s p i t a l c o n s c i o u s n e s s " of the p e o p l e . F r o m 1 9 2 3 to I 9 6 0 every p r o v i n c e w a s prov i d e d w i t h at least a g o v e r n m e n t p r o v i n c i a l hospital. T o w a r d s the e n d of I 9 6 0 there w e r e 3 5 6 hospitals, 2 0 8 of w h i c h were p r i v a t e hos-

89 pitals and the rest all government hospitals. Five of the latter are specialized government and training hospitals: Maternity and Children's Hospital, National Children's Hospital, National Mental Hospital, National Orthopedic Hospital and San Lazaro Hospital with an overall bed capacity of 7,050. The 356 hospitals have a bed capacity of 24,854 of which 15,545 are beds in government hospitals. Out of 24,854 hospital beds there are 2,453 for obstetrical cases; 2,023 of which are charity beds. DIAGNOSTIC

LABORATORIES

The growth of diagnostic laboratories in the Philippines runs parallel with the growth of medical science. In 1920 there were but a few selected diagnostic laboratories which were connected mainly with the few existing hospitals. W i t h the growth of medical science in the Philippines diagnostic laboratories sprouted in some urban centers of population, as in Manila, Cebu and Iloilo. Most of these centers were privately operated and performed such functions as routine laboratory examinations of bodily secretions, examination for venereal diseases and histopathological examination. The increase in the number of both private and government-owned hospitals to 356 in I 9 6 0 also increased the number of laboratories. The Institute of Hygiene established in 1927 formerly maintained a diagnostic laboratory principally for research; most of the referrals coming from the Philippine General Hospital. It also maintained a laboratory for the sanitary control of water supply, milk and milk products, and food and drugs. However, most of these activities were transferred in 1947 to the Bureau of Research and Laboratories. Other activities for sanitary control of sewage and waste disposal, vector control, air pollution and industrial hazard are now handled by different agencies of the government; the sanitary control of sewage and waste by the Division of Environmental Sanitation of the Bureau of Health Services, air pollution and industrial hazards by the Division of Industrial Hygiene, Bureau of Health Services, and vector control by the Bureau of Disease Control.

At present the existing government laboratories include 81 small laboratories of the Rural Health Units ( R H U ) ; 109 provincial and city laboratories usually connected with hospitals, including six training or specialized hospitals. This also includes the highly developed Manila City Health Department laboratory and six water analysis laboratories; five regional laboratories; six specialized laboratory services under the Division of Tuberculosis, Leprosy, Social Hygiene, Schistosomiasis, Malaria and Filaria; and one Central Laboratory, the Bureau of Research and Laboratories. Among other big laboratories which cooperate with the Department of Health are the National Bureau of Investigation Laboratory doing toxicological examination, the Institute of Hygiene Laboratory on virus studies, and the food and nutrition research center of the National Science Development Board. RESEARCH IN P U B L I C

HEALTH

After World War II the Philippines received both technical and financial assistance from the United States Public Health Service ( U S P H S ) , Internation Cooperation Administration, World Health Organization, United Nations Internation Children's Emergency Fund, and other allied agencies. With this help various research and control programs were worked out, including those for malaria, schistosomiasis, tuberculosis, yaws, and leprosy. This was in marked contrast to conditions before the last war when most research was confined to clinical aspects, notably drug evaluation. Notable among research projects in public health after 1948 were the following: Disease Control Schemes. Control programs were established against such prevalent diseases as tuberculosis, malaria, yaws, leprosy, and schistosomiasis. These were spurred by the results of basic research in the various aspects of the disease, especially in epidemiology, therapy, prevention, and control. Nutritional Research. Because of the growing importance of nutrition the Institute of Nutrition was established in 1948 (in accordance with Administrative Order No. 8 1 ) to conduct research and investigation on food and nutri-

90 tion. Examples of important research undertaken are as follows:

content such as minerals, vitamins, and protein quality.

Bataan enriched-rice project. Beri-beri b e i n g one of the first ten causes of death and rice being t h e staple food of the Filipinos, this research was undertaken in Bataan in 1947. As a result of the e x p e r i m e n t the incidence of beriberi eventually d r o p p e d in Bataan f r o m 14.30 per cent in 1 9 4 7 - 4 8 to 1.54 per cent in 1 9 4 9 50, while in the control area the incidence increased. Mortality due to beri-beri also d r o p p e d by 72 p e r cent.

Clinical and biochemical survey. Clinical surveys were m a d e a m o n g school children and the general p o p u l a t i o n to d e t e r m i n e deficiency diseases a m o n g them. Suggestive signs of vitamin A, B^, niacin, vitamin C and iodine deficiency were revealed.

Another a f t e r m a t h of the Bataan e x p e r i m e n t was the passage of R u r a l Act 832 which regulates the sale, exchange and delivery of rice. Enforcement of this law has recently gained acceptance as a cheap and efficient public health approach to our beri-beri and other nutritional problems. In 1956 41 provinces and 15 cities were already i m p l e m e n t i n g the law. In 1957 different committees were created to boost the P h i l i p p i n e Rice Enrichment Program. D u e to poor cooperation f r o m the rice millers e n f o r c e m e n t of the law is still far f r o m being satisfactory. T o bolster its effective enforcement several steps were taken. T h e Presidential Rice Enrichment C o m m i t t e e was organized and geared to improve the law itself. T h e Rice Enrichment Coordinating Committee, composed of Premixed Rice Manufacturers and Institute of N u t r i t i o n representatives, was to help coordinate activities of rice enrichment. T h e D e p a r t m e n t of Health Rice Enrichment C o m m i t t e e was to coordinate the work of the different paticipating agencies.

Research

Nutritional survey. This was undertaken a m o n g different g r o u p s such as p r e g n a n t women, low income group, rural and urban groups, coastal and interior groups, penitentiary group, military group, and preschool children. T h e findings in almost all the groups examined showed that the people had a fairly poor diet lacking in variety and quality, especially in protective nutrients. Research on nutritional value of Philippine foods. T o acquaint the general public with the food values of different native foods, different items of P h i l i p p i n e foods were assayed for

T o d e t e r m i n e the nutritive requirements of adult Filipinos a biochemical survey was done to assay and evaluate blood and urine content. in Neiv

Fields

A f t e r the war virology became a Virology. specialized field in the Philippines. W i t h freq u e n t visits of world-known virologists exposure of our local counterparts stirred new interest in this field. Frequent outbreaks of such epidemics as influenza, P h i l i p p i n e H-fever, and gastro-enteritis have afforded rich opportunities for workers in viruses. A virus diagnostic center will soon be established to provide better laboratory facilities and encourage research in this new field. So far only g o v e r n m e n t agencies have started to undertake virus research in the Philippines; namely the Institute of Hygiene, the Bureau of Research and Laboratories and the Public Health Laboratory of the Manila Health D e p a r t m e n t . Most of their research is focused on arbor and enteric viruses. Antibiotics research. Most of the work done in this field was on screening of soils, f u n g i and higher plants for antibiotic substance or antibiotic-producing microorganisms. T h i s work was only recently started by t h e Institute of Science and Technology and the Bureau of Research and Laboratories. T h e results of the screening have so far been satisfactory. Nuclear medicine. T h i s is an entirely new field in the Philippines. Recently a survey using radioactive substances was d o n e on t h e genetic factor of goiter a m o n g Filipinos. It was shown that there is strong indication that goiter is hereditary. O t h e r research in nuclear medicine ( d o n e by t h e Institute of H y g i e n e and the P h i l i p p i n e A t o m i c Energy C o m m i s s i o n ) concerns health hazards of atomic fallout in t h e Philippines.

91 T o bolster research in the Philippines the National Science Development Board was created in 1958 by Republic Act No. 2067. The constant support of international agencies and the Philippine government is a healthy sign of progress in the field of research in public health. MEDICAL, NURSING, AND MIDWIFERY PERSONNEL

In 1920 there were two medical schools, one government supported and established in 1907 and one privately supported and established in 1871. There was also one school of nursing established in 1910 in the Philippine General Hospital. In I960 the number of these schools had increased to seven medical schools, six of which are private, and 31 schools of nursing. There were 25 midwifery schools which opened after the war. In 1927 the School of Hygiene and Public Health was established in the University of the Philippines with enrollment limited to ten. This school of public health, now known as Institute of Hygiene, has operated continuously and in I960 had an enrollment of 51. In 1940 the Post-Graduate School of Medicine in the University of the Philippines was established in accordance with Commonwealth Act No. 401 approved that year. This was primarily designed to enable private practitioners to keep up with current advances in medical science. These post-graduate courses come in three types of training; namely refresher course, post-graduate assembly and special residency in the different clinical departments. Actually, however, these courses have not been given with regularity. Since the turn of the 20th century the urge for specialization in the different fields of medicine had been felt in line with the trend in Europe and America. More and more Filipino doctors took post-graduate studies abroad. Except in surgery and E E N T there are no specialty boards that pass judgment upon candidates for specialists in the different fields of clinical medicine in the Philippines. After World W a r II the doctors who felt they were competent to specialize started to group themselves into specialty socieites. These

societies have increased in number year after year. There are 18; namely the Ophthalmological and Otolaryngological Society, Obstetrical and Gynecological Society, Society of Psychiatry and Neurology, Radiological Society, Aero Medical Society, Society of Venereologists, Society of Pathologists, Heart Association, Leprosy Society, Society of Anaesthesiologists, Orthopaedic Association, Dermatological Society, College of Physicians, Association of Occupational Medicine, Diabetic Association, Society of Gastro-Enterology, Association of Military Surgeons, and College of Surgeons. In I960 at least a thousand graduated from the seven medical schools and more than a thousand each from the different schools of nursing and midwifery. These graduates have bolstered public service in the Philippines, especially with enforcement of the Rural Health Law known as Republic Act No. 1082. M A T E R N A I . AND CHILD H E A L T H

The health of babies has always been the concern of all peoples but proper guidance to promote this actively was not felt in the Philippines until the early American regime. In 1911 the Liga Nacional Filipina was organized to combat the high infant mortality rate of 30 per cent (300 per thousand). A year later Congress enacted a law to investigate the causes of high infant mortality which was found to be due mainly to infantile beri-beri. In 1913 the first puericulture center in the Philippines was organized in the city of Manila. To combat infantile beri-beri "tiki-tiki" extract was distributed to mothers with newly born babies. Bill No. 2633 in 1917 placed the organization of puericulture centers on a nation-wide scale so that 21 such centers were established at various strategic points of the island. Funds for this purpose were generously allotted by governmental and private concerns and in 1954 there were 531 such puericulture centers. The boost to maternal and child health service was actually felt upon the passage and implementation of Rural Health Law 1082. D u e to the subsequent increase of nurses and midwives professional services could be given to

92 mothers and children. Before this period maternity and charity clinics had f u n c t i o n e d with very limited facilities. T h e y actually lacked transportation and their supply of medicine was inadequate. Aside f r o m the Puericulture Centers and Rural Health U n i t s other agencies c o n t r i b u t i n g to Maternal and Child H e a l t h Service are t h e different governmental and private hospitals. These may be general hospitals and specialized hospitals for maternity and pediatrics cases, of which there are in I 9 6 0 a total of 2,453 maternity beds and 3,200 beds for children. Because of the continued interest of both governmental and private institutions the infant mortality rate has greatly declined f r o m 161.2 per 1,000 live births in 1920 to 72.44 in 1959. Likewise, the maternal mortality rate has dropped f r o m 7.76 in 1930 to 2.67 in 1959. ENVIRONMENTAL

SANITATION

Environmental sanitation is one of the basic activities of the Health D e p a r t m e n t today. D u r i n g the Spanish r e g i m e sanitation work was confined to the provision of potable water supply and e n f o r c e m e n t of a few public health laws on housing and factory sanitation. T h i s field expanded under the American regime. Since 1909 the Division of Sanitation in the Bureau of Health has focused its activities on various aspects such as construction of waterworks systems and artesian well drilling, campaign for pit privy construction, septic tanks, and even sewerage systems. A f t e r W o r l d W a r II ( 1 9 4 7 - 1 9 5 0 ) a p r o g r a m of water chlorination, establishment of stations for water analysis, public toilet construction, and e n v i r o n m e n t a l control of malaria were undertaken by the United States Public H e a l t h Service. In 1951 there was a boost in the environmental sanitation p r o g r a m under the MSA P H I L C U S A sponsorship for t h e p u r p o s e of i m p r o v i n g sanitary conditions t h r o u g h o u t the Philippines. Foremost in these activities was the construction of c o m m u n i t y water supply. At present the Division of E n v i r o n m e n t a l Sanitation of the Bureau of H e a l t h has a prog r a m which involves the General Sanitation

Project and the Food and D r u g Inspection Project. O t h e r agencies outside of the Department of Health that help the p r o g r a m are: ( 1 ) N a t i o n a l W a t e r w o r k s and Sewerage Authority ( N A W A S A ) which is charged with provision of a public water supply and sewerage; ( 2 ) Bureau of Agricultural Extension undertakes p r o m o t i o n of the individual water supply and excreta disposal in relation to home demonstration; ( 3 ) Presidential Assistant on C o m m u n i t y D e v e l o p m e n t coordinates and provides budgetary allocation for c o m m u n i t y develo p m e n t projects; ( 4 ) N a t i o n a l P l a n n i n g Commission for t o w n p l a n n i n g and zoning, and ( 5 ) P h i l i p p i n e H o m e s i t e and H o u s i n g Corporation for low-cost housing projects. Based on the latest survey of the different types of water supply undertaken by the N a tional W a t e r w o r k s and Sewerage Authority, it was reported that in the whole country there are 7 7 6 piped waterworks systems serving 6,100,000 people; 15,986 artesian wells serving 3,997,000 people and 1,607 developed springs serving 1,012,000 people. This means that a total of 11,109,000 or only 4 0 per cent of the people are served by the National W a t e r w o r k s and Sewerage Authority. Sanitary privies are available to less than 50 per cent of the population. T h e r e are five sewage disposal systems o p e r a t i n g and none of these undergoes sufficient treatment. T h e r e still exist the big problems of ( 1 ) pollution of bodies of water by i m p r o p e r sewage treatment and industrial wastes, ( 2 ) sanitary refuse, storage, collection, and disposal inviting another p r o b l e m of ( 3 ) insect and rodents prevalence, and ( 4 ) food sanitation. At present the Division of Environmental Sanitation as the steering agency has initiated pilot demonstration projects, stream pollution survey and abatement, short courses for food handlers, and in-service training of sanitary inspectors. INDUSTRIAL HYGIENE

Industrial Hygiene is a relatively new field of medicine in the Philippines. As early as 1924 there were rules and regulations p r o m u l gated by the Bureau of Health for the sanitary control of t h e factories of tobacco products. All laborers were required to submit to a physical

93 examination by the physicians and all those suffering from communicable diseases were not allowed to work. From 1925 competent men trained abroad in industrial medicine took active part in shaping the progress of industrial medicine. In 1932 the Free Emergency Medical Treatment Act was passed (Act No. 3961) and employment of a company physician was made compulsory. Before this period there were only a few companies that provided medical service in industry. This law was enforced by The Section of Industrial Hygiene of the Bureau of Health until 1944. The responsibility for its enforcement was transferred to the Department of Labor in 1946. In 1940 an industrial hygiene laboratory was established in the Bureau of Health, thus instituting application of the scientific approach to the diagnosis of occupational diseases and control and prevention of occupational hazards. An Industrial Hygiene survey covering 1,973 establishments, both industrial and commercial, was started in 1948 in Manila. In this survey it was found that only 190 establishments employed physicians. A nation-wide survey of both industrial and agricultural establishments showed that 160 city and 380 provincial establishments gave some form of medical service. The Bureau of Industrial Safety under the Department of Labor was created in 1949. The series of seminars and scientific meetings and the continued turnover of published articles both in local and foreign journals are silent witnesses to the earnest endeavor of the industrial hygienist to attain more progress in this new field of medicine in the Philippines. Among the leading occupational diseases encountered in the Philippines are poisoning by lead, gasoline, carbon monoxide and dioxides and agricultural insecticides, dermatitis and oxygen deficiency. Among those less frequently encountered are sulfur dioxide, silicosis, Caisson's disease, trichlorethane poisoning, benzol poisoning, and Bagassosis. DISEASE CONTROL

Tuberculosis. Until recently tuberculosis has been the leading cause of death in the Philip-

pines. The initial activity in the control of this "white plague" was launched in 1910, with the founding of the Philippine Anti-Tuberculosis Society, a private organization. The government took active part in tuberculosis control with the creation of the Tuberculosis Commission in 1930. Much of its activity was focused on health education and to a small extent on clinical services. After World W a r II tuberculosis control was greatly intensified. BCG immunization was accepted and in 1952 a mass BCG immunization program was launched, assisted by W H O and UNICEF. In the same year, with the assistance of Foreign Operation Administration and Philippine Council for United States Aid, chest clinics were established in the provinces. At present there is a total of 50 chest clinics to serve a population of 500,000 per clinic or 1:10,000. T o narrow down this ratio it was contemplated that 100 clinics should be established so each unit would serve 250,000 population. As it is today there are fewer than 3,000 hospital beds for tuberculosis patients at a ratio of one bed for 100 moderate and advanced cases. It is estimated that 4 - 5 per cent of the population in the Philippines is suffering from tuberculosis, one-fourth of one million individuals affected being in the moderate or advanced stage. The mortality rate has gone down considerably since World W a r II at an annual average of 4.1 per cent decline. At present this disease has ceased to be the leading cause of death. The results of integration of tuberculosis control (in a pilot area) have so far been very encouraging. In the pilot project in Ilocos Norte, better case finding and case supervision have reduced mortality from tuberculosis by 64 per cent in four years. Venereal disease. Venereal disease goes hand in hand with civilization. Its control has been hampered mainly because it has to deal with a human activity over which health authorities have no full control and in which antibiotics can be had without a prescription. The V D problem attracted attention even before the last war. It assumed great importance immediately after the liberation of the Philippines when a large number of cases was observed,

94 especially among the urban population in Manila. These cases were syphilis, gonorrhea and chanchroid. In 1945 the United States Armed Forces undertook an intensive control program among the inhabitants and the servicemen. Prophylactic stations were established. This activity was taken over by the Section and later the Division of Social Hygiene under the Department of Health created by Commonwealth Act No. 685; also by a similar division in the City Health Department of Manila. Compulsory examination was given at regular intervals and treatment of the population at large was also undertaken. From 1946 to 1949 V D control work was assisted by the USPHS which branched out with examination of population groups liable to get the infection and establishment of premarital and prenatal clinics. The data available on V D showed a decline of gonorrhea from 15 per cent in 1946 to 7 per cent in 1959 and on syphilis from 3 per cent to 0.7 per cent. It is felt, however, that 50 per cent of the cases have been missed in spite of intense effort toward case finding. In 1950 13 V D and skin clinics were established in the different parts of the country. A t the end of I 9 6 0 this number was increased to 18. In 1951, with W H O and UNICEF assistance, the Maternal and Child Syphilis program was started with the aim of minimizing if not eradicating prenatal or congenital syphilis. This work was done in cooperation with different maternity and health centers in the island. The incidence was placed at 0.77 per cent. As of I 9 6 0 there were 117,000 prenatal cases attended and treated. The drop in the incidence of venereal disease among pregnant mothers followed the general trend of gonorrhea and syphilis decline. At present early cases of syphilis are rarely seen. It is now felt that syphilis is more or less under control. However, gonorrhea is still a big problem since more than 1,000 new patients are reported annually. Yaws. Yaws or framboesia is a chronic disease with deforming and crippling complications. It has been found to be prevalent among inhabitants of islands, towns and barrios where

malnutrition and poor personal hygiene exist. This was recognized early as a public health problem in the Philippines. Although the disease has been a problem in rural and even urban areas, especially after World War II, there was apparently no organized governmental agency that ventured to work out a yaws control program. It was not until 1951 that the Treponematoses ( Y a w s ) Control Program was started with World Health Organization and United Nations International Children's Emergency Fund assistance. A pilot demonstration area in Samar and Leyte was established in 1951 with six specialized teams to make a survey and give treatment. The drug of choice was penicillin in oil with two per cent aluminum monostearate or PAM in short. A total of 1.3 million persons were examined and 55,000 cases treated from 1951 to 1953. Almost simultaneously with the establishment of the pilot demonstration area, six other specialized teams did similar surveys and treatment in six provinces of Mindanao; also in one island province of Catanduanes in Luzon where prevalence of the disease was found to be high. It was planned that all other provinces in the Philippines would be surveyed by the Rural Health Units in an integrated yaws control program in 1952. The actual integration, however, started in 1954. The procedure of yaws survey and treatment of both cases and contacts was essentially the same as that done by specialized units of the yaws control from 1951 to I960, when a total of 332,250 cases was treated and 140,505 contacts injected. Because of concentrated efforts by the different agencies mentioned above the yaws prevalence has decreased from 9-6 per cent in 1951 to 0.4 per cent in I960, showing that the yaws control program has been successful and that eradication of this disease might be possible in the Philippines. Leprosy. The Philippines has its share of the biblical disease which has been one of the major health problems since time immemorial. One of the oldest hospitals in the country, the San Lazaro Hospital, was established in 1578 principally as a sanctuary and for treatment of these "outcasts of society." With the establishment of the Culion Leper

95 Colony in 1907 the concept of systematic leprosy control started with compulsory segregation of all "open" cases. T h e San Lazaro Hospital then served for hospitalizing cases for research purposes. From 1907 to 1930 these two institutions were the centers of leprosy control activities in the Philippines. T h e experimental local Leprosarium called Cebu Skin Dispensary was also started as a pilot project in Cebu City sometime in 1927. In 1930 eight regional sanitaria were established which adopted a decentralization of the segregration scheme. A year later the Cebu Traveling Skin Clinic was established for a rapid method of leprosy survey. T h e Cebu Pilot Project, which operated until 1937, proved that the establishment of regional stationary sanitaria could encourage voluntary presentation and treatment of early cases. It also established that the traveling clinics were good for case finding. T o bring to the attention of the health authorities the need for a national leprosy control program, a stationary clinic similar to that in Cebu was established in Manila in 1938. This proved successfully the value of outpatient treatment of leprosy. In 1949 skin and tumor clinics were established in the San Lazaro Hospital and treatment with the sulfone drugs was tried in lieu of chaulmoogra oil, especially for outpatients. By 1950 a Division of Leprosy was created which was instrumental in enacting a law permitting domiciliary treatment of leprosy cases. In 1954 a program for Traveling Skin Clinics was started with U N I C E F and W H O assistance. Its main objectives were case finding and treatment. These investigations soon revealed that Hansen cases were found in all the provinces in the Philippines but principally in Cebu. Rizal, Iloilo, and the Bicol and Ilocos regions. By comparing the figures gathered from 1902 to 1929 and 1 9 3 0 - 1 9 5 5 a reduction of 54 per cent was also noted in the number of new cases. W i t h the recent reorganization of the Philippines Health Department, the Leprosy Control Program was launched all over the Philippines under the direct responsibility of the Division of Sanitaria. Facilities include a bed capacity of 7,620, four stationary skin clinics and ten

traveling skin clinics. Each of the ten mobile skin clinics could serve an average of 1.5 million population. T h e stationary and traveling clinics were able to discover as of 1959 a total of 3,048 new cases, 1,345 or 44 per cent of which were treated in the stationary clinics. Integration of leprosy control into the activities of the Rural Health Units is now on the way. It is felt that the success of the Leprosy Control Program in the Philippines will depend upon a full integration.

Malaria. Malaria used to be widespread in the rural areas of the Philippines with two million cases annually of which ten thousand died before World W a r II. D u r i n g the Japanese occupation, however, it was estimated that there were about four million cases and 20 thousand deaths annually. Malaria control, which consisted mostly of larvicidal, "naturalistic" and hydrotechnical methods of control, was started in the Bureau of Health as early as 1926 by the Division of Malaria Control. In 1953 a joint pilot project with M S A and W H O was established in Mindoro to determine the effect of D D T spraying in malaria control in the Philippines. T h e result was encouraging and soon a country-wide survey and residual spray program was launched. The activities were, therefore, confined to a yearly residual insecticides spray, maintenance of continuous surveillance activities, and research activities. Under this program there was annual spraying of 1,260,000 houses and treatment of 955,108 patients. This resulted in a marked reduction of spleenic index from 31 per cent in 1953 to 1.17 per cent in 1958 and a parasite index from 15 per cent to 0.04 per cent in nine index areas. In 1956 a bold decision was made to shift from malaria control to malaria eradication. Essentially, this was the same as the control scheme except that spraying of the 1,260,000 houses had to be done for four consecutive years instead of three; also 600,000 houses should be sprayed for the fifth consecutive year to counteract any possible or unanticipated outbreaks of malaria. Under this eradication program spraying was continued using D D T in 1956 and shifting to D N ( D i e l d r i n ) in 1957. Mass treatment of malarial cases was also intensified.

96 From 1957 to I 9 6 0 there has been a 97 per cent reduction in malarial incidence. On this basis it may be safe to conclude that malaria has been controlled in the Philippines. Filaria. Filariasis, a disfiguring insect-borne disease, was known to exist for quite a time in the Philippines. A preliminary survey conducted 1 9 5 5 - 1 9 5 7 showed that 18 out of 53 provinces were endemic for filariasis with a prevalence rate of from less than 1 per cent to 34 per cent or an average of 8.8 per cent. N o formal control program has yet been launched by the government except for the establishment of a Filaria Control Pilot Project in September 1959 in Sorsogon. Three teams were organized: a mobile survey team assigned to determine the magnitude of the filariasis problems in the Philippines and two stationary teams: one in Sorsogon and another in Palawan to gather baseline data on the epidemiology of the disease and partly to undertake research studies on the parasite, the disease, the mosquito vector and the control. Schistosomiasis. Schistosomiasis, a debilitating chronic disease, is considered one of the major public health problems affecting the country today. It is estimated that no less than 300,000 Filipinos are suffering from this dreadful disease. Schistosomiasis has existed in the Philippines since 1906. N o systematic survey has been done, except in 1940, when the Bureau of Health sent three field units for case finding and treatment and a little snail control. Before this period, other investigation consisted mainly of studies on the geographical distribution of the disease and habits of the snail intermediate host. Towards the end of World W a r II the schistosomiasis problem was brought to the limelight when around 2,000 cases occurred among the landing United States forces in Leyte and the Royal Australian Air Force. In 1948 a Schistosomiasis Research Program (later the Division of Schistosomiasis) was launched for the study, prevention, and control of this disease. Extensive surveys were undertaken by six field units. Important endemic areas were mapped out from 1 9 4 8 - 1 9 5 2 in at least 77 towns of 14 provinces of the Philippines. Be-

cause of the meager knowledge then available on the control of schistosomiasis both locally and abroad, a Schistosomiasis Control Pilot Project was established in 1953 with the assistance of FOA, PHILCUSA, W H O , and UNTA. The objective of the Pilot Project was to determine the most effective and economical means of controlling schistosomiasis in the pilot area. If successful a national control program for the whole Philippines would be undertaken. From 195.3 to 1959, the Project satisfactorily and progressively worked out a program of investigation in line with this objective. T h e activities consisted mainly of experiments on control methods and of collecting baseline data; fundamental research on the snail intermediate host, the parasite, the disease, and the human and animal reservoir host. The methods of control that yielded encouraging results were later duplicated in larger and greater numbers of snail habitats in the pilot area. As a result of these control measures the infection rate among the human, animal, and snail population was significantly reduced when evaluation was made in 1959. It was found also that a 95 per cent reduction of the snail population had been attained in those areas. Starting in 1959 and preparatory to the National Control Scheme, the integration of the schistosomiasis control into the activities of the Rural Health Units was tried in three other municipalities. Whatever results from this trial will greatly influence the National Schistosomiasis Control Program. E P I D E M I O L O G I C A L AND

STATISTICAL

EVALUATION

A more logical means of evaluating progress in public health apart from the growth and development of the various health and medical services would be to determine the degree of their effectiveness in terms of the epidemiological and statistical data collected during the period under review. Thus it is expected that a comparison of the figures obtained for 1920 and for I 9 6 0 would indicate changes in status of the nation's health. For this purpose the following indices may be used: changes in ( 1) the total health picture in terms of birth and death rates, ( 2 ) the

97 disease pattern, ( 3 ) life expectancy, and ( 4 ) per capita expense for health. 1) The total health picture. Based on figures released by the Disease Intelligence Center, Department of Health, the estimated population in 1920 was 10,740,759; in I960 it was 27,783,347. This means an average yearly geometric increase of about 2.4 per cent. This is indeed a marked increase inasmuch as the birth rate has remained almost constant (with some slight yearly fluctuations), from 33 to 29.2 per thousand. This increase may be readily explained by the excess of births over deaths. The marked reduction in death rate is not only remarkable in the crude death rate (which showed a decrease by more than half from 19 per thousand in 1920 to 7.7 per thousand in I 9 6 0 ) , but is much more evident among the more sensitive segment of the population, a reduction in the infant mortality rate to over one-half from 161.2 per thousand live births in 1920 to 73.1 in I960. Similarly, a marked reduction is notable in the maternal mortality from 7.8 per thousand in 1920 to 2.4 in I960. (Please see accompanying chart, Figs. 2 and 3.) 2 ) The disease pattern. The prevailing diseases in a community or in the whole country are usually recorded in terms of morbidity and mortality. Unfortunately, however, data on morbidity are rather inadequate and unreliable so mortality statistics are more frequently used to denote changes in disease pattern. For this reason reference will now be made to the leading causes of deaths by comparing the figures

obtainable for 1920 and those for I960 as shown in the table below. In 1920 the ten leading causes of death in the Philippines were communicable in nature. Malaria and tuberculosis were leading; followed by beriberi, dysentery, smallpox, typhoid, influenza, whooping cough, cholera, and measles in that order. Malaria and tuberculosis alone accounted for the death of at least five per cent or 50 out of every thousand alive in that year. Such pestilential diseases as smallpox and cholera were prevalent. Smallpox was the fifth while cholera was the ninth leading cause of death. Through the years, however, these diseases were effectively put under control. The last recorded death from smallpox was in 1949, and from cholera in 1937. In I960, however, while communicable diseases continued to be the major cause of death (six out of the ten leading causes were communicable in nature, with pneumonia and tuberculosis leading the list), another group of diseases not evident forty years ago came into the picture. These are the chronic degenerative diseases illustrated by the cardio-vascular conditions, cancer and accidents, which were the sixth, seventh and eighth leading causes of deaths. In addition it is significant to note that those leading communicable diseases have shown a tendency through the years to decline persistently although gradually; whereas the chronic degenerative diseases, on the other hand, have tended to increase. This is evidently the beginning of a shift in the disease pattern from one of communicable to another of chronic degenerative in nature.

MORTALITY LEADING CAUSES: NUMBER AND RATE ( P E R 1 0 0 , 0 0 0 POPULATION)

DISEASEJ Malaria Tuberculosis Beriberi Dysentery Smallpox Typhoid Influenza W h o o p i n g ccugh Cholera Measles

1920 NO.

RATE

29,653 26,474

276.08 246.48 121.36 85.62

13,036 9,196 6,632 2,848 1,630 1,289 1,194 848

61.75 26.52 15.18 12.00 11.12 7.90

DISEASES Pneumonia Tuberculosis Gastroenteritis Bronchitis Beriberi Cardio-vascular dis. Cancer Accidents Tetanus Influenza

1 9 2 0 AND I 9 6 0 1960

NO.

RATE

27,902 25,592

100.4 92.1

16,819 15,892 15,112 13,400 4,982 4,056 2,598 1,960

60.5 57.2 54.4 48.2 17.9 14.6 9.4 7.1

98 3) Life expectancy. The average life expectancy of a given population also reflects the effectiveness of health services being instituted and of the state of the nation's health. In this connection it may be noted that the life span of the average Filipino has doubled in the thirty-year period from 1918 to 1948. In 1918 the average Filipino was expected to live only 25.62 years from the time of birth, whereas in 1948 the same average Filipino was expected to live 51.17 years. In I960 life expectancy has further increased to 56.3 years. (See table below.)

Health and Public Welfare in 1941, our health budget was increased to P5,246,724 which was supposed to serve a total of 16,780,695 or a per capita of P0.31. Further increase was noted in 1946-47 (just after liberation) with an annual appropriation of PI3,237,464 for a population of 18,472,755 or a per capita of P0.72. Since then the increase has been rapid and persistent. In 1955 it increased to P22,938,318 for a population of 21,518,463 or a per capita expense of PI.06, and increased further in I960 to P54,987,950 s e r v i n g a p o p u l a t i o n of 27,455,799 or a per capita of P2.00. (See table below.)

PHILIPPINES—AVERAGE LIFE EXPECTANCY ACKNOWLEDGMENT CENSUS YEAR

MALE

FEMALE

1902 1918 1939 1948 1960

11.54 25.17 44.80 48.81 53.69

13.92 26.07 47.22 53.36 58.70

*

BOTH SEXES

12.73 25.62 46.01 51.17 56.29*

Estimate.

4) Per capita expense for health. Another indication of the growing health consciousness of our government and people that reflects progress is the gradual increase in the per capita expenditure for health. In 1920 the annual appropriation for the Philippine Health Service was only P3,035,694 for an estimated population of 10,740,759 or a per capita of P0.28 spent for health. Just before the war, with the organization of the Department of

The author wishes to express his deep appreciation and thanks to the Honorable Elpidio I. Valencia, Secretary of Health, Republic of the Philippines, for having granted him the permission to accept his appointment as member of the standing committee on public health and medical sciences, Tenth Pacific Science Congress. He is also grateful to the bureau directors, heads or chiefs of offices, divisions or sections and to the other officials both in and outside the Department of Health including heads of hospitals and institutions, public or private, for furnishing valuable materials needed in preparing this report. Without their wholehearted cooperation and support it would have been impossible to make an extensive coverage of the many topics reviewed. It must also be on record that it was through the pains-

P H I L I P P I N E P E R CAPITA EXPENDITURE FOR H E A L T H FOR THE PERIOD B E T W E E N 1 9 2 0 AND YEAR

1920 1941-42 1946-47

1955

1960

DOCUMENT

ANNUAL APPROPRIATION

1960

POPULATION

PER CAPITA EXPENDITURE

P.H.S. Act 2 8 7 5

P

3,035,694

10,740,759

P0.28

Pres. Budget for Dept. of Health and Public Welfare Pres. Budget for Dept. of Health and Public Welfare for F Y 1 9 4 6 - 4 7 Appropriation for the Dept. of Health R.A. 1150 for F Y 1955 Appropriation for the Dept. of Health for F Y I 9 6 0

P

5,246,724

16,780,695

P0.31

P13.237.464

18,472,755

P0.72

P22.938.318

21,518,463

PI.06

P54.987.950

27,455,799

P2.00

99 t a k i n g a n d d i l i g e n t e f f o r t s of D r . T . C. B a n z o n and his a s s i s t a n t s that brief s u m m a r i e s of

the

materials and information received were compiled. T h e writer is particularly i n d e b t e d t o D r . J . J.

Dizon,

Chief

of

Center, D e p a r t m e n t

the of

Disease

Intelligence

Health, and

his

staff,

for the statistical d a t a in the last p a r t of

this

r e p o r t w h i c h s e r v e d as a b a s i s f o r the e p i d e m i o l o g i c a l a n d statistical e v a l u a t i o n of the p r o g ress in p u b l i c health a c h i e v e d d u r i n g the p a s t forty years.

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C l i m a t o l o g i c a l Section, W e a t h e r B u r e a u . DIZON, G.

Journal

Phil. P u b l i c H e a l t h Y e a r b o o k ; J u l y , 1 9 5 3 . Progress

C e n s u s of the P h i l i p p i n e s , P o p u l a t i o n

Philippine

Na-

in

The

Problem

of

Venereal

D i s e a s e s in the P h i l i p p i n e s a n d the P r o g r e s s in V . D .

Control

Over

V.D. Control Seminar,

the L a s t Japan.

10

Years,

Thailand CHALOEM

PURANANANDA

THAILAND, an underdeveloped country, occupies most of the Malay Peninsula extending from Latitude 6° to 20° north. T h e whole area is approximately 200,000 sq. miles (about the size of Texas). The population is distributed all over the country but is most dense in the central region of low-lying rice fields. The other three regions comprise the northern hills, the eastern plateau, and the mountainous sandy south. The people are engaged in agricultural professions (mainly rice, teak, and r u b b e r ) , mining, and fishing. The climate is tropical, with three seasons: summer, rainy season, and winter. Since World W a r I the population of Thailand has increased from 8 million to 26 million. The capital city of Bangkok has two million, most of whom are engaged in government services, business, and light industries. In the metropolitan area public health work was started as early as 1918 as a department in the Ministry of Interior. There was assistance from foreign organizations as early as 1924, when the hookworm campaign was started with the aid of the Rockefeller Foundation, and in 1930 the survey of mosquitoes with the aid of the League of Nations. In 1942 the Ministry of Public Health was created, but little work was accomplished due to World W a r II. As soon as the war was over, great improvements were achieved with the aid of W H O , UNICEF, and ICA (International Cooperation Administration ). The improvements covered all metropolitan, urban, and rural areas. The Ministry of Public Health also instituted special campaigns against the most important diseases in the country. By the end of I960 many diseases were under control. Infectious

diseases are fewer, due to better sanitation, health education, and vaccinations. Most contagious diseases of bacterial origin have diminished and more virus infectious diseases have become known. Malnutrition is not a problem in the metropolitan area because food is plentiful, yet it remains a problem in the areas where the people feed themselves primitively. Organic diseases remain at the same level. Early cancer cases are diagnosed and more cases come for treatment. Road accidents increased for a few years and have been diminishing in the last three years. MEDICAL E D U C A T I O N A N D P E R S O N N E L

The School of Medicine, founded in 1889, was reorganized to international standards in 1923 with assistance from the Rockefeller Foundation. In 1928 the first graduating class with a medical degree numbered 18. A second school was opened in 1947. Over 200 doctors are now graduating from the two schools. A third school was established in northern Thailand in I960. By 1964 approximately 300 doctors will be graduating annually. There are 3401 first-class doctors and 626 second-class doctors in the country (population in midyear 1961 was 26,196,000). The first school for training nurses was founded in 1896. In 1961 there were nine nursing schools and three midwifery schools in the country. There are 9548 registered nurses and 2490 second-class midwives. Other faculties relating to medicine and public health are: Faculty of Pharmacy, established in 1913 and reorganized in 1940; Faculty of Dentistry, established in 1940; Faculty of

101

102 Public Health, established in 1948; Faculty of Medical Technology, established in 1957; Faculty of Tropical Medicine, established in 1960. LABORATORY DIAGNOSIS A N D CONTROL

OF

DISEASES

Facilities for clinical diagnosis can be obtained in most large hospitals. There are four main diagnostic laboratories: the Government Central Diagnostic Laboratory and three laboratories attached to the medical schools. Diseases under Control Plague. Plague has disappeared from Thailand. The last epidemic was in 1939. No cases have been reported since 1953. Malaria. A campaign against malaria was started in 1949 with the aid of W H O and UNICEF; later carried on by ICA using spraying and population surveillance. The mortality rate was reduced from 210 per 100,000 to 35 per 100,000 (Table 1). Tuberculosis. A campaign against tuberculosis was started in 1951 concentrating on tuberculin testing and BCG vaccination. About four million people have received the BCG vaccine. Other control measures include mobile mass radiography, dispensary services, and hos-

pital care with chest surgery. Domiciliary chemotherapy is gaining great importance in the treatment of tuberculosis. The campaign assisted by W H O and UNICEF was extended in 1961 (Table 2 ) . Yaws. A campaign was started in 1950; by 1959 the examination had covered more than 18 million persons and more than three million persons had been successfully treated. This campaign is assisted by W H O and UNICEF (Table 3). Trachoma. This disease is endemic in Thailand. The control program started in 1953 by the United States Operations Mission (USOM) was later abandoned. W H O and UNICEF will start a new campaign. Regular control of this disease has to be carried out among the school children. Leprosy. This is an old disease in the country and the first leprosarium was started in 1923. Now there are 14 colonies. The 200,000 leprosy cases are distributed mostly in the northeast (six colonies) and north (five colonies). There are two colonies in the central part of Thailand and one in the south. The campaign against this disease was taken up in 1953 with assistance from W H O and UNICEF. Over 1,400 cases have been labelled as cured and all of them were sent to a settlement where four

TABLE

1

MALARIA MORTALITY RATES

YEAR

DEATHS (thousands)

1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960

38 36 34 29 21 16 15 13 11 9 8 0

MORTALITY

100?000 210 195 183 153 111 84 73 57 46 39 35 0

SPRAYING (millions)

0.1 0.6 1.6 3.0 4.3 5.6 7.4 7.6 7.8 7.0 6.1

POPULATION PROTECTED SURVEILLANCE (millions)

— — —

0.1 0.4 1.6 3.0 4.4 4.5 7.6 4.8

TOTAL ( millions )

0.1 0.6 1.6 3.1 4.7 7.3 10.4 12.0 12.4 14.6 10.9

Source: Thai government, for 1950, assisted by W H O and UNICEF; for 1951, by W H O , U N I C E F , and ICA; thereafter by ICA.

103 TABLE 2 TUBERCULOSIS MORTALITY RATE NUMBER YEAR

1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957

All Over the Country 9,411 9,725 9,314 10,678 12,447 12,033 10,771 9,395 10,241 10,484 10,255 11,243

MORTALITY RATE PER 1 0 0 , 0 0 0 Bangkok 1,655 1,938 1,527 1,633 1,758 1,882 1,654 1,139 1,179 1,065 1,077 1,094

acres of land are allotted to each family. This settlement can take 500 families. Cholera. This disease is not endemic in the country as presumed by some foreign reports. When an epidemic starts its origin can be traced to other endemic areas. The latest epidemic was in 1958 and it has been under control since 1959Smallpox. This disease needs strict control. Yet an epidemic can flare up due to negligence of medical officers who issue medical certificates for travelling, without themselves vaccinating the persons. Had vaccination been carried out properly this disease could have disappeared a long time ago. The Ministry of Public Health is launching an eradication program this year aiming to vaccinate 80 per cent of the whole population in three years. Diphtheria. The use of toxoid since 1939 has reduced the incidence of this disease remarkably, and as it can be cured by antibiotics it seems to be well under control. N o adult cases have been reported. Whooping cough. Since this disease is considered to be important among children, a scheme to fight it is carried on by the Mother and Child Welfare Division with the help of W H O and UNICEF.

All Over the Country 53.1 55.6 52.4 59.1 67.8 64.5 56.8 48.8 52.4 52.8 46.1 50.4

Bangkok 191.4 217.3 167.4 175.1 184.4 193.3 166.4 112.3 113.9 100.9 81.1

Typhoid, dysentery and other intestinal infections. These diseases are well under control due to health education and better sanitation. Intestinal parasites account for a high percentage of morbidity in the northeastern part of the country. The rural health, sanitation, and health education programs have been concentrating in the fight against this problem since 1955. Round worms, especially hookworms, are the main causes. Snakebite. This problem is now under control. The majority of the population works in the fields, plantations, forests, and mines where five deadly poisonous snakes abound. A great number of casualties from snakebite occurred yearly. Since 1952 a small campaign against snakes was waged by buying live snakes. This reduced the number of snakes at large. Through the Colombo Plan the boosting of the production of antivenine sera was possible in 1956 by a donation of 101 serum-producing horses from Australia. This provided antivenine sera sufficient for distribution to all parts of the country. Rabies. This is an endemic disease mainly affecting dogs and is transmitted to man through dog bite. The production of rabies vaccine started in 1913. The law on dog control was promulgated in 1955 but it was not until 1959

104 TABLE

3

Y A W S C O N T R O L : ACHIEVEMENTS AND EXPENDITURE OF T C P , THAILAND PERSONNEL

YEAR

Total

Field Teams

1950 1951 1952 1953 1954 1955 1956 1957 1958 1959

46 136 252 294 302 291 271 269 271 263

3 5 18 22 31 33 31 31 31 31

EXPENDITURE IN TICALS

CASES F O U N D AND TREATED W I T H PAM

(millions)

YAWS

(in thousands) Total (Including Contacts)

0.3 0.5 1.1 2.0 3.0 3.0 2.2 2.0 1.8 2.2

18 83 113 140 347 250 147 97 85 37

18 85 124 177 412 489 557 821 539 139

3 10 10 8 9 7 8 8 7 6

13 18 9 4 3 2 4 4 4 3

166 112 81 46 23 14 14 9 13 42

18.1

1,317

3,363

76

4

23

PEOPLE EXAMINED

that the impounding of stray dogs became intensified; this has noticeably reduced the number of dog bite cases. Hyperimmune serum is also produced and used in severe exposure. Cerebrospinal meningitis. This is not an epidemic disease in this country; only sporadic cases are reported. METROPOLITAN AND URBAN PUBLIC HEALTH

Thailand is divided into 71 provinces. Apart from Bangkok, the metropolitan public health work is concentrated in the city health centers, and later general hospitals are developed. Between 1942 and 1957 the number of health centers and hospitals increased from a few centers to nearly 2,000. Hospital services in 15 provinces have extended to all 71 provinces. Some provinces have more than one general hospital. Bangkok itself has 31 general hospitals; altogether there are about 5,000 beds. The sanitation of Bangkok and other cities has been improved during the last 15 years, most remarkably during the last three years when water supply and other commodities have developed high standards. Health education has improved and campaigns against infectious diseases are in full swing. The annual mortality rate is 8.9 per 1,000. The average income per capita is rather low in comparison with that of the western countries, but personal needs are less by proportion. Luxuries such as tobacco

Total in Millions

Cost per Capita Examination

Treatment

and alcohol in the form of beer and rice gin (28° alcohol) are consumed by the middle class, but their use does not seem to be responsible for any outstanding diseases, such as lung cancer or liver diseases. The Thai people look younger than their age up to a certain time and then get old quickly. Their life expectancy is 57 years. The medical science branch of geriatrics was not given attention until the last five years. The old-age home is located in the suburb of Bangkok for the benefit of both the poor and those who can pay. As far as mental diseases are concerned there are over 4,000 beds available in Bangkok and as many up-country. Schools for the blind, deaf, dumb, and crippled are situated in Bangkok. PUBLIC HEALTH IN RURAL AREAS

In the early 1920s most communications were by waterways. There are four railway lines from Bangkok: one to the south, one to the east, one to the north, and one to the northeast. Public health work in olden days was difficult to develop in the rural areas; it remained only in the capital city of each province. Infectious diseases such as intestinal infections are propagated by water and flies. Tuberculosis and malaria are prevalent. Since the Thai people are not milk drinkers, milk-borne diseases are unknown. The infant mortality rate had been very high, and in many cases mothers also died.

105 After W o r l d W a r II great improvements were achieved by health centers and hospitals, by specific campaigns a g a i n s t i n f e c t i o u s diseases, and the creation of a Health Training and Demonstration Center with the aid of the International Cooperation Administration. This training center was started in Cholburi in 1951. Public health doctors, public health nurse supervisors, public health nurses, sanitarians, and junior health workers are trained and sent all over the country. The center has trained more than 3,000 personnel. The scheme of public health in rural areas is now definitely mapped out. The goal is 5,000 health centers all over the country in the form of first-class and second-class health centers and midwifery centers. There are already 153 firstclass health centers with 20 beds for in-patients and with staff including a doctor, nurses, and sanitarians. They are mainly situated in the districts and are essentially district health centers. The 675 second-class health centers with no doctors are run by nurses and sanitarians. Most of the 1,650 midwifery centers are located in villages all over the country, and there are altogether 4,600 villages. T h e whole scheme is to be accomplished by a community development program sponsored by the Ministry of Interior, the Ministry of Public Health, the Ministry of Agriculture and ICA. The training is done at the Health Training and Demonstration Center in Cholburi.

cardiovascular diseases will probably increase. The means of communication are improving; this will facilitate the work in curative and preventive medicine. T w o institutions produce biological products for the use of the whole country. The Medical Research Council was established in 1947 under the Ministry of Public Health and has discovered many diseases: scrub typhus, leptospirosis, and certain blood diseases. In 1958 the National Research Council was created and there is a Medical Science Section attached to the Council. Research projects have been carried out in three universities and four other institutes. The Ministry of Public Health is now concentrating on three new projects: sanitation, school health, and nutrition. ACKNOWLEDGMENT

The author wishes to thank Dr. Kandhorn Suvarnakieh, Director General of the Public Health Department, Ministry of Public Health; Dr. Beon Suvarnaaara, Deputy Director of Public Health Department; Dr. Piem Musikhadhuman and Dr. Caaaras Pnelphasukh of the Public Health Department, who have supplied information and necessary corrections for this paper. The author also wishes to thank Dr. Sriprapai P. Aksara, Deputy Director of Queen Saovabha Memorial Institute, and his secretarial staff.

THE F U T U R E

At this rate of development of public health, an optimistic conclusion can be drawn for the future of the country's health, though the population has increased threefold during the last 40 years. In 1935, the law of monogamy was promulgated. Educated people prefer to have few children; rural families have many children. Progress of the work on Mother and Child W e l fare has reduced the mortality rate in children. T a k i n g this into consideration, there will be a regular increase of population by about three per cent per annum. Once all community control programs in the rural areas are functioning, most of the infectious diseases will disappear. Accidents, industrial hazards, neuroses, and

BIBLIOGRAPHY Ambassador Alexis Johnson Reviews "Thai Progress During the Last 3 Years," April 1961. Annual Report 1959, Treponematosis Control Program. Commemorative Publication of 15 Years of W o r k of the Ministry of Public Health, 1957. Health Program, Department of Health, Ministry of Public Health, 1 9 5 9 - 1 9 6 0 . Public Health in Thailand, Ministry of Public Health, I960.

106 Quarterly Bulletin of the Health Organization, League of Nations, Vol. 1, 1932.

Report from Campaign against Leprosy, 1952— I960.

Report from Anti-malaria Campaign, Ministry of Public Health, I960.

Report on Prevention of Tuberculosis Campaign, 1953-1959-

United States—California MARGUERITE S. A U G U S T I N E

CALIFORNIA has an area of

158,693

square

miles. The range in width is from 150 to 375 miles; the length of shoreline on the Pacific Ocean is over 1,000 miles. The state extends from the Mexican border in the south to Oregon in the north. The greatest length is 780 miles. PHYSICAL

CHARACTERISTICS

Contrasting extremes of topography, climate, soils, minerals, plants, and animal life are found in California. About one-fourth of the terrain is level agricultural land between sea level and 500 feet (Central Valley and Imperial Valley). The rest is hills and rugged mountains, from 500 to 14,000 feet elevation (Sierra Nevada Mountains and Coast Range). Parts of southeastern California are desert. Unequal distribution of water is a problem. Rainfall varies from 40 inches a year in the northwest to two inches in the desert in the southeast. Consequently, great dams, water projects, and vast irrigation systems have been developed. California has about six distinct climatic zones, ranging from frostless thermal belts where subtropical fruits and flowers grow, to the arctic zones of the snow-capped mountain peaks. In general, along the coast and interior valleys there is a two-season climate; rainfall is concentrated in the winter and spring months, while the summer and fall months are dry. Except in the high altitudes there is no snow, and the temperature seldom goes below 32 °F. In the agricultural areas the rainfall is from 5 30 inches a year, and irrigation is necessary.

POPULATION

The population has grown from 3.4 million in 1920 to 15.8 million in I960, a 361 per cent increase. Most of the population is concentrated in two metropolitan areas: Los Angeles (the world's largest city in area), I960 population 2.4 million with 6.8 million in the metropolitan area; and San Francisco (major U.S. Pacific seaport), I960 population 730,490 with 2.8 million in the metropolitan area. San Diego County (outlet for Imperial Valley) is the next largest urban area with a population of one million. The state has 58 counties varying in population from a few hundred to more than five million people. Californians cluster along the coast and in the three major urban areas. Every decade since 1900, California has grown three times as fast as the rest of the United States. Migration has played the major role; natural increase has been less important. Only in the last decade has the birthrate in California been as high as that of the nation. The most important change in the geographic distribution of population in California during the last few decades has been taking place within the metropolitan areas. A decreasing proportion of people live in the central city, and an increasing proportion live in the suburbs. The automobile and California highways have been the main factors in this change. People can work in the city and live in the suburbs. In addition, people have moved to the suburbs from rural areas and small towns in order to work in the city. New health facilities are required in the suburbs. The facilities already developed in the central cities need to adjust to the loss and change in population.

107

108 In the past, California had a larger proportion of male residents, of young adults, and of persons 65 and over than had the nation as a whole. However, in recent years the state has become more like the rest of the United States in age and sex distribution. The bulk of migration into the state is of young people coming to work in industries. From 1 9 2 0 - 5 0 , people age 65 and over increased more rapidly than any other age group; for 1 9 5 0 - 7 0 , the greatest increase is expected to be in the under-25 age group. Although the actual number of persons over 65 will be much greater than now, the proportion is expected to be smaller. From 1 9 2 0 - 5 0 , life expectancy of women at age 45 increased from 28 to 32 years, while men of the same age added only one year to their average life expectancy. California men who reach 65 now, cannot expect to live any longer than men of the same age in 1920. In 1920 life expectancy from birth in California was 54.5 years for males and 58.4 years for females. In 1950 it was 65.8 for males and 72.7 for females. The majority of California's population was born elsewhere. Since 1920 there has been a fairly large migration from Mexico. Prior to 1940 most of California's nonwhite population was composed of Asiatics. Since 1940 the proportion of Negroes has risen substantially. California's nonwhite population tends to be younger than the rest of the population. P U B L I C H E A L T H ADMINISTRATION

The first full-time county health department in California was set up in Los Angeles County in 1915. One of the strongest contributions of the State Board of Health during the 1920s was the promotion of full-time county health departments; it was greatly aided by financial and administrative aid from the International Board of the Rockefeller Foundation. By 1930 tremendous development had taken place in local and state public health service and administration. In the last three decades there were two strong waves of public health progress. One came after the Social Security Act of 1935 made federal funds available for supplementing state and local public health funds; the other

came after World W a r II ended, when the California legislature passed enlightened public health legislation. In 1939 the legislature adopted the Health and Safety Code, codifying all the scattered health laws; the codification was completed in 1943 with a series of 13 public health bills. T h e code was amended to give the state director of public health more authority, and to make the State Board of Public Health an advisory body. The director was given a fouryear term after the appointment by the Governor; he was not to be removed during his term except on written charges of incompetence or neglect of duty. Qualifications for director were a year's post-graduate training in public health, and a minimum of five years practical experience as administrative officer of a wellorganized health department. T h e California Public Health Assistance Act of 1947 gave great impetus to the extension and improvement of local health services. The Act provided funds for extension of public health services with the State Department of Public Health administering the distribution of the funds to local governing bodies. This subsidy continues to augment local funds, and enables the department to require local health departments to meet certain standards in order to obtain allocations. The Public Health Assistance Act also established a California Conference of Local Health Officers consisting of all legally appointed health officers in the state. The State Board of Public Health and the State Department of Public Health must consult with the Conference in establishing the standards for services and personnel of local health departments receiving subsidy under the Act. An additional section, added to the Public Health Assistance Act by the 1953 legislature, makes it possible for a county with a small population to contract with the State Department of Public Health to organize and operate a local public health service; the county board of supervisors must request the contract, and has to appropriate at least 5 5 per capita per year for this purpose. At present 11 counties have contracted for services under this plan. Less than one per cent of the state's population

109 is now without full-time public health services. In 1937 a law was enacted which required the State Department of Public Health to license laboratory technicians and clinical and public health laboratories. That same year a Biologies Act gave the department regulation of the production and distribution of biologic products not licensed by the federal government. The Tuberculosis Subsidy Law of 1915 still functions, but the subsidy to tuberculosis hospitals has been increased. This subsidy made possible the handling of nonresident indigent tuberculous cases, as well as the general control of the disease. In 1927 as a result of the crippling polio epidemic of that year, the legislature passed the Crippled Children Act. This Act provided that a physically handicapped child could be given the treatment he needed at county expense (with some state subsidy) if his parents could not pay for it or could pay only part of it. By further legislation in 1945 and 1950, the definition of a crippled child was broadened to include one with heart disease, appropriations were increased, and court procedure was eliminated for bringing a child under care. The first child health conferences in the state were held in 1939. Since then these have been a major activity of local health departments; at present approximately 40 per cent of California's infants are under their supervision. In 1920 the infant mortality rate in California was 75.0 per 1,000 live births; by 1959 it was reduced to 23.6. Recently, the State Department of Public Health formed separate units for programs in alcoholic rehabilitation ( 1 9 5 9 ) , air sanitation ( 1 9 5 5 ) , radiological health ( 1 9 5 9 ) , and prevention of blindness ( 1 9 5 9 ) . These were all backed by legislative action. P U B L I C H E A L T H RESEARCH

Cancer. The State Department of Public Health set up a Tumor Record Registry in 1947 for voluntary reporting of all cancer cases by selected hospitals. This is a continuous epidemiological research project. The department made a study in 1953 of cancer, cigarette smoking, and certain occupations. This study confirmed that cigarette smoking is a factor in

lung cancer, and suggested that certain occupations may be a factor also. California Health Survey. In 1954-55 the State Department of Public Health made the first statewide survey of illness and disability in the United States. Prevention of Blindness. In 1954 the department began a three-year study of the prevalence and epidemiology of blindness and of the conditions leading to blindness. Two preventable conditions were discovered to cause a large share of blindness, glaucoma and amblyopia. Nutrition. The State Department of Public Health cooperated in a study ( 1 9 5 0 - 5 5 ) of the nutritional status of 600 persons over age 50. Insecticides. The State Department of Public Health carries on continuous research on the effectiveness of various insecticides. Air Pollution Research. The State Department of Public Health devised equipment and methods for measuring air pollutants, and for separating organic from inorganic pollutants. Home Accident Research. The department carried on a home safety project ( 1 9 5 3 - 5 6 ) under a grant from the W . K. Kellogg Foundation, showing that 40 per cent of all accidental deaths in California occur outside the realm of traffic, industry, and air-rail transportation. Viruses. Research is being done by the State Department of Public Health on adenoviruses and ECHO viruses. The State Department of Public Health laboratory developed a complement fixation test for diagnosis of polio, which is used throughout the United States, and a simplified test for rabies using fluorescent dye. Alcoholism. The State Department of Public Health is developing a method for determination of zinc in urine as a means of detecting hidden cirrhosis in a population, and providing a clue to the relationship between alcoholism and cirrhosis. It is making a three-year study of drinking practices (the first of its kind in the United States). Evaluation studies are being made of the use of various drugs for treatment of alcoholism.

110 Phenylketonuria. Public

Health

T h e State Department

with

the

College

of

of

Medical

this research, is available from the State Department of Public Health

film

library.

The

Evangelists has been studying phenylketonuria

Viral and Rickettsial Disease Laboratory of the

since

State Department of Public Health is working

1957.

A reliable diaper test has

been

developed for early detection of this disease, which is present in about one in 2 5 , 0 0 0 babies, and

which

causes

mental

retardation

if

diagnosed within six weeks after birth.

not The

on a skin test for W e s t e r n encephalitis. In 1 9 3 9 the St. Louis virus strain was recognized as causing human

encephalitis.

The

largest encephalitis outbreak in California was

damage can be prevented by a special synthetic

in 1 9 5 2 , with 375 cases of W e s t e r n and 4 5 of

diet low in phenylalanine. One per cent of Cali-

St. Louis encephalitis.

Most of the cases were

fornia's

in the Central Valley.

Mosquitoes, which are

institutionalized

mental

patients

are

phenylketonurics. Future research will tell how

the immediate source of human infection, breed

long infants must remain on this special diet

in these vast, irrigated areas.

to avoid brain damage.

Relapsing

MEDICAL, HOSPITAL, AND NURSING

FACILITIES

In 1947 the legislature passed the California Hospital Survey and Construction Act and the Hospital Licensing Act. Through this program the federal and state governments assisted in the expansion, development, and construction of hospitals, health centers, and related facilities. Priorities have guaranteed improved distribution and accessibility of these facilities. Almost half of the present approximately 1 3 5 , 0 0 0 beds in general hospitals, tuberculosis hospitals, psychiatric hospitals, and long-term care facilities were built in the last decade. Planning for the last several years has been based on recognition of the general hospital as the key institution in the hospital system. One objective is to develop diagnostic and treatment centers for ambulatory patients in all existing and proposed hospitals in the state. D u r i n g 1 9 5 9 the department studied needs for future coordination and expansion of hospital and health services in metropolitan areas.

fever

(tick-borne).

This

occurs

mainly in the mountain areas above 5 , 0 0 0 feet. First proved cases were reported in California in 1921.

Since then 3 6 9 cases have been re-

ported. N o known deaths have occurred since the disease became reportable in 1931. Coccidioidomycosis. K n o w also as Valley fever and coccidioidal granuloma, this occurs mainly in the arid parts of the state during wind and dust storms of summer. More than half the cases are in the San Joaquin Valley. T h e serious form of the disease, granuloma, occurs at the rate of about 25 cases per year. T h e primary infection may be asymptomatic, and it is quite general in the population of endemic areas. T h e etiologic agent is the fungus Coccidioides immitis. Q fever. T h i s is found mainly in two endemic areas of northern California and southern California where livestock raising or dairying are the

main

Coxiella

industries.

burnetii.

The

etiologic

agent

is

T h e mode of transmission is

milk from infected animals, dust-laden air of barns or pens, and direct contact with meat of

REGIONALLY

LOCALIZED

DISEASES

Arthropod-borne encephalitis. This occurs mainly in the Central Valley. In 1 9 3 8 the W e s t e r n virus strain was recognized as causing illness among humans. Twenty to 30 per cent of the cases occur in infants, and the sequelae are very severe. In 1 9 5 3 the State Department of Public Health began a study of the aftereffects; it was continued by Stanford University School of Medicine. A documentary film, "Sequelae of W e s t e r n Encephalitis," based on

infected animals. recorded,

Over 1 , 2 0 0 cases have been

mainly

in

Central

Valley

and

in

southern California, since it was first recognized in 1947. Rocky

Mountain

spotted

fever.

This

known to occur in northeastern California. etiologic agent is Rickettsia

rickettsii.

is The

Infected

ticks are the source and reservoir of infection. T h e r e were 2 1 6 cases reported since 1903, with more

than three-fourths of the cases in

counties in northeastern California.

two

Ill Murine typhus. This is endemic in five southern counties along the coast of California. T h e etiologic agent is Rickettsia prowazeki. The source of infection is fleas infected f r o m rats. Rats are the reservoir. T h e first cases were recognized in California in 1919. Since 1920 there have been 550 cases with 25 deaths, all within those five counties. G E N E R A L L Y D I S T R I B U T E D DISEASES

Of Special

Importance

Today

Forty years ago chronic diseases accounted for only about a third of all deaths in California. T h e m a j o r communicable diseases combined also accounted for about the same n u m b e r of deaths. N o w chronic diseases account for almost three-fourths of all deaths, and c o m m u n i cable diseases for less than one-twentieth. T h e rise in the p r o p o r t i o n of deaths f r o m chronic disease reflects both the steady aging of the population, and the measure of control over the c o m m u n i c a b l e diseases in the last four decades. Certain diseases, such as lung cancer and coronary heart disease, are increasing apart f r o m the change in age of the population; stomach cancer and rheumatic heart disease appear to be declining. Deaths are an inadequate measure of the a m o u n t of chronic disease. T h e California Health Survey ( 1954-55 ) showed that d u r i n g the survey year, 156 persons out of every 1,000 had at least one day of disability f r o m a chronic condition. Of all the days of disability d u r i n g that year, 70 per cent was f r o m chronic conditions. Heart disease. At present this is the leading cause of death in California f r o m age 35 on. Cancer. This is the second leading cause of death f r o m age 25 through 64. In 1928 for the first t i m e in California history, deaths f r o m cancer exceeded deaths f r o m tuberculosis. In 1940 t h e n u m b e r of deaths f r o m lung tuberculosis was five times those f r o m lung cancer. N o w there are about two deaths in California f r o m lung cancer for every death f r o m lung tuberculosis. T h e increase in lung cancer may be d u e to air pollution as well as to cigarette s m o k i n g and occupational exposure.

Accidents. These r a n k next to heart disease and cancer as a cause of death ( a b o u t six per cent of all d e a t h s ) . M o r e children ages 1 - 1 4 die f r o m accidents than f r o m all the c o m m u n i cable diseases combined. Most of these are h o m e accidents. So m a n y deaths of young children are f r o m accidental poisoning that poison i n f o r m a t i o n centers have been set up, one in southern and one in northern California. These centers give i n f o r m a t i o n to physicians by telep h o n e about specific poisons and their treatment. Dental decay. This is now the most prevalent disease of childhood, although certainly not the most serious. Fluoridation of water supplies decreases dental caries by approximately 65 per cent. Since 1951, w h e n the first water supply was adjusted for fluoride content in California, 27 communities have approved fluoridation. Approximately 1.2 million Californians are now receiving water s u p p l e m e n t e d with fluoride. Respiratory diseases. Excluding cancer, tuberculosis, asthma, and hay fever, these diseases disable more Californians than any other illnesses. T h e California Health Survey showed that each Californian is kept in bed, or kept f r o m his usual activities, three days a year f r o m acute, and a day and a half from chronic, respiratory conditions. T h e most serious chronic respiratory disease, aside f r o m the exclusions noted above, is chronic sinusitis. T h e most prevalent chronic respiratory condition is the combination of asthma and hay fever. T h e commonest acute respiratory condition is, of course, the c o m m o n cold; this is still a medical puzzle. T h e most serious acute respiratory conditions are p n e u m o n i a and influenza. Staphylococcal infections. These merit special attention at present. Indiscriminate use of antibiotics, and the resultant relaxation of aseptic hospital techniques enabled an antibiotic-resistant strain of Staphlococcus aureus to develop; this strain is causing serious trouble all over the U n i t e d States. Attack rates are often high and epidemics occur. N e w b o r n infants, the elderly, and the debilitated are especially susceptible. Mental illness. T h i s is o n e of the most chall e n g i n g unsolved public health problems. In

112 I 9 6 0 there were more than 5 1 , 0 0 0 mentally ill patients in California state hospitals and clinics. Suicide and alcoholism are both related to mental and emotional illness. Suicides are now the ninth cause of death in California. The alcoholism problem is greater in California than in any other state. Cirrhosis of the liver, often associated with alcoholism, is the eighth cause of death in the state. In the last 4 0 years advances have been made in the prevention of mental illness by control of the physical conditions which lead to damage of the brain and central nervous system. Fewer patients have been admitted to mental hospitals for disorders such as advanced syphilis (treatment with penicillin was started in 1 9 4 3 ) ; encephalitis from lead and other heavy metal poisonings; and mental cases following accidents. These are examples of mental illness with a biological basis. Recent research shows that schizophrenia, our commonest mental illness, may also have a biological basis. The 1957 legislature passed the Short-Doyle Act which subsidizes community mental health programs. Under the Act, the program administrator may be a health officer, a community hospital superintendent, or a psychiatrist-director. At present nine out of the 17 community programs are administered by local health officers. These community programs are helping to conserve the mental health of the people of California. Also under the Act, the California Conference of Local Mental Health Directors was set up to advise the State Department of Mental Hygiene. Substantially

Controlled

Diseases

Tuberculosis. Although the tuberculosis problem has greatly changed since 1920, tuberculosis still kills more Californians than the rest of the infectious diseases combined, except pneumonia. There were 8 1 4 deaths from tuberculosis in 1959, and 5,320 new cases were reported. Currently, more than 15,000 cases are under medical supervision. In 1 9 5 9 tuberculosis was the eleventh cause of death in California when the death rate dropped to a low of 5.3 per 1 0 0 , 0 0 0 people. In 1 9 2 0 when the "great white plague" killed 1 5 6 people out of every 100,000,

tuberculosis was the first cause of death. At the 1 9 2 0 rate almost 24,000 Californians would have died in 1959. Intensive case-finding and advances in treatment, mainly chemotherapy, have helped to bring about this great change; however, all the factors that have brought about the striking decline are not known. The shortened hospital stay, and the lengthened period of chemotherapy under supervision of private physicians in health departments have placed heavy burdens on local health departments. In 1927 California pioneered in the use of an X-ray motor clinic for tuberculosis case-finding. In 1 9 4 9 case-finding was intensified by the introduction of mass chest X-ray surveys of metropolitan areas. These surveys became accepted procedure; they were continued until recently when the low case rate no longer justified mass surveys. Specialized selective surveys using tuberculin tests are now a more useful method in California. Tuberculosis is no longer primarily a disease of adolescents and young adults. A larger proportion of the cases found each year are among elderly people. There has been also a shift toward increasing numbers of cases in males. In both deaths and case reports, the males outnumber the females almost three to one. Influenza. The most serious epidemic of influenza in California was the highly fatal 1 9 1 8 - 1 9 pandemic. The last important wave of influenza in California was in 1920 when 6 6 , 1 8 3 cases were reported with 2 , 7 1 5 deaths. No other serious outbreaks occurred until the 1 9 5 7 - 5 8 pandemic of the Asian strain; this outbreak was widespread but clinically mild. The first isolation of the Asian strain in the civilian population of the United States was made in the Viral and Ricksettsial Disease Laboratory of the California State Department of Public Health. Influenza is a changed, much milder disease since 1920. Medical science, however, can take little of the credit even though vaccines have been developed; most of the factors still are unknown. The 1 9 5 9 fatality rate in California for influenza and pneumonia combined was 27.8 per

113 100,000 population, or slightly more than three per cent of the total deaths (the sixth cause of death in the state). Pneumonia. The discovery of antibiotics changed pneumococcal pneumonia from a disease with a fatality rate as high as forty per cent of hospitalized patients, to one with a small fraction of that figure. With the virtual "conquering" of this type of pneumonia, other bacterial pneumonias and virus pneumonia have assumed greater importance. Virus pneumonia is either more prevalent today or is recognized oftener; the incidence is still low, and the fatality rate is 0.1 per cent. The virus or viruses causing it have not been isolated. Syphilis and Gonorrhea. The seriousness of syphilis also changed with the introduction of penicillin treatment in 1943. In the ten years following, there was a 70 per cent decrease in cases reported; deaths from syphilis declined 60 per cent; admissions to mental hospitals of cases resulting from central nervous system syphilis decreased 50 per cent. In 1939 laws were passed in California making compulsory premarital physical examinations and blood tests for syphilis, as well as prenatal blood tests for syphilis. Congenital syphilis has almost disappeared as a result. Although antibiotic treatment of gonorrhea is equally efficacious, control has not been so successful. Teen-age gonorrhea is a special problem at present. Smallpox. In the 28th Biennial Report ( 1 9 2 2 - 2 4 ) of the State Department of Public Health, the secretary reported that "never in the history of California has smallpox been so prevalent as it has been during the past two years." A virulent strain was brought in from Mexico around 1920. From 1920 through 1924, 23,671 cases were reported with 105 deaths. Control was tightened by compulsory vaccination legislation in 1921. The situation has improved steadily since vaccination in infancy has become a generally accepted procedure. There have been no civilian cases of smallpox reported in California since 1947. Smallpox has almost vanished from the state.

Typhoid. Nineteen-twenty-nine was the first year in the history of California when fewer than a hundred deaths from typhoid were recorded. From 1 9 0 0 - 2 9 typhoid caused the death of 229 people a year. In 1920 the death rate from typhoid was 4.8 per 100,000, and California public health officials were very proud of this reduction. In 1924, however, one of the most serious outbreaks in the state occurred. Chlorination of water supplies was introduced in California in 1913; modern water filtration plants further protected the people. Since 1924 not one epidemic of typhoid has been traced to large community water works. The disease is now rare enough that many physicians have never seen a case. An outbreak in 1954, with eight cases and one death, was traced to a typhoid carrier. All known carriers in California are registered and kept under health department surveillance. Malaria. Endemic malaria almost disappeared from California and the rest of the United States during the last 40 years. In the first decade, 1921-30, 1,277 cases were reported in California, bur the decline has been rapid since then. Modern control method, suppressive chemotherapy, and abatement of anopheline mosquitoes are responsible. Mosquito abatement districts were first formed in 1915 in California. The International Health Board of the Rockefeller Foundation lent staff for malaria surveys and for estimates of cost of drainage and control. The first outbreak of indigenous malaria in the United States since 1945 was in California in 1952. Thirty-five related cases occurred. The source was a veteran of the Korean War who had a relapse upon return to the United States. From 1950 through 1959, 1,983 cases have been diagno:ed in California; 1,495 cases were military personnel returned from foreign duty, and of the rest, only 80 were contracted in California (35 of these in the 1952 outbreak in Nevada County). Poliomyelitis. Poliomyelitis should have become one of the "conquered" diseases since 1955, when the Salk vaccine became available for general use; however, because of public

114 apathy toward the vaccination, the paralytic form of the disease is still a real threat. Possibly the newly introduced live-virus oral vaccine will be more readily accepted. Poliomyelitis was never a widespread disease in California; however, the state experienced two quite distinct periods of rising incidence, set off by several years of low frequency. The first period began in 1921, and reached a high incidence of 56 per 100,000 population in 1934. The second period began in 1936, and again reached a maximum frequency of 56 per 100,000 in 1948. Since 1948 the sharp fall in case ratio was not repeated, and successive years of relatively high incidence were noted until the introduction of the Salk vaccine. Since then the over-all attack rate has dropped to 2.7 per 100,000 in 1959, with the rate of 45 per 100,000 for unvaccinated children under age five. In July of I 9 6 0 it was estimated that only 40 per cent of California's population have the recommended protection against paralytic polio. Eleven per cent have been partially immunized with one or two of the recommended series of three injections, but 49 per cent have had no vaccine at all. Plague. Plague is another disease brought under control in this period; rare cases now occur sporadically. The first pneumonic plague epidemic occurred in Oakland in 1919- The original case was bubonic, terminating as pneumonic; there were 1 3 fatal pneumonic cases out of 14 cases among contacts. In 1924 pneumonic plague occurred in Los Angeles; there were 30 deaths out of 32 cases. At the same time, there were six cases of bubonic plague with four deaths in Los Angeles County. Sylvatic plague foci are widespread throughout the state; laboratory proof of infection in rodents was established in 36 counties by 1959. The past occurrence of pneumonic plague emphasizes the potential risk involved in endemic sylvatic plague; however, only nine cases with five deaths have occurred in the 20 years since 1940. All were bubonic, and one was a laboratory infection.

Diphtheria. The intensive immunization programs against diphtheria have resulted in virtual conquest of that disease. In the five years from 1 9 2 0 - 2 4 there were 44,000 cases; while in the five years from 1 9 5 5 - 5 9 there were 92. Although cases occur most frequently in children under age ten ( 4 0 per cent), there has been an interesting shift in the age distribution of cases recently. In 1949 half the cases reported were in people over 20. In metropolitan areas these are mainly among single men in the "skid-row" sections; in the rural areas these are mainly among the migratory workers. Pertussis. In the five years 1 9 3 0 - 3 4 , before active immunization was an accepted procedure, there were 61,000 reported cases of pertussis in California with 984 deaths; in the five years from 1 9 5 5 - 5 9 there were 16,126 cases with only 44 deaths. Over half of these deaths from 1 9 5 5 - 5 9 were infants under the age of six months; this points out the necessity for early immunization. Rare diseases. Hookworm ( ancylostomiasis), pellagra, and yellow fever disappeared from California during the period 1 9 2 0 - 6 0 . In 1920 and 1921 there were reported six cases of hookworm, three cases of pellagra with two deaths, and one case of yellow fever which ended in death. Leprosy. From 1920-50, 544 cases of leprosy were reported in California. From 1 9 5 0 - 6 0 , 128 cases were reported: 82 lepromatous, 41 tuberculoid, and the rest indeterminate. As a port of entry, California is open to infections from Hawaii, Japan, other Pacific islands, and China. Some of the cases have originated in those areas, but more have come from Mexico. Careful epidemiologic investigations have shown that out of the 651 cases reported from 1 9 1 3 - 5 4 , there have been only 16 cases contracted in California. ZOONOSES

Some of California's most serious diseases are among the zoonoses. Arthropod-borne encephalitis, rabies, and psittacosis, all viral in origin, are the most important at the present

115 time. Other zoonoses, not viral in origin, and of varying importance now are plague, relapsing fever, Rocky Mountain spotted fever, murine typhus, Q fever, brucellosis, and trichinosis. Tularemia and anthrax are now of minor importance. Rabies. Probably the most feared of the viral zoonoses is rabies. California now has the largest and most extensive reservoir of animal rabies in many years. Human cases are kept to a minimum by preventive treatment of persons bitten by rabid animals. Animal cases have occurred in practically all parts of the state, and the reported incidence varies from year to year. In the 10 years 1 9 2 0 - 2 9 , 41 human lives were lost from rabies; 4,000 animal cases were reported, mostly in dogs. In 1 9 3 0 - 5 9 , there have been 32 human cases; 16,399 cases were reported in domestic animals (over 90 per cent in dogs), and 9 0 9 cases were reported in wildlife. A human case in 1958 resulted from the bite of a laboratory insectivorous bat. There have been only two human cases since 1950, but the number of animal cases increased greatly. There was a decided rise in the number of wild animals involved. Regulations adopted by the State Board of Public Health in 1955 now make it possible for a local health officer or the State Department of Public Health to declare a "rabies epidemic area," extend the minimum period of quarantine of such areas to 365 days after the last recognized case of rabies, provide that vaccinated dogs may be released from quarantine requirements at the discretion of the local quarantine authority. These regulations provided, for the first time in California, a legal basis for the recognition of canine anti-rabies vaccination. Psittacosis. Psittacosis (a viral infection with the source and reservoir of infection in infected birds, especially pet birds) became a major public health problem in California in 1931, when the infection was proved endemic in the shell parakeet aviaries throughout the state. Outbreaks in other parts of the United States were traced to California. By 1943 the infection was brought under control. The epidemi-

ologic concept of the disease changed when other birds were found to be sources of human cases; however, 80 per cent of the 322 human cases reported since 1931 were traced to psittacine birds. Constructive legislation passed in 1955, made control of the disease possible in the pet bird industry. Brucellosis. The etiologic agent is Brucella melitensis, abortus, and suis. The sources are tissues of infected animals; the reservoirs are cattle, swine, sheep, goats, and horses. Brucellosis is a diminishing public health problem in California since the more complete pasteurization of market milk and since the elimination of the disease in domestic animals through the determined efforts of agricultural interests. Because of the difficulties of diagnosis, brucellosis cases are believed to be much more numerous than reports would indicate. In the 30 years since 19.30, a total of 4,787 cases have been reported with 74 deaths. In 1958 there were 35 cases reported with one death, and in 1959, 11 cases with no deaths. Trichinosis. The etiologic agent is Trichinella spiralis. The source of infection is meat of infected animals, chiefly pork, occasionally wild game. Swine, many wild animals, and rats are reservoirs of infection. The practice of feeding garbage to hogs has kept the disease prevalent in hogs. Since thorough cooking of meat kills the trichina, there should be no cases of trichinosis; however, in the five years 1 9 3 0 - 3 4 , there were 390 cases with 14 deaths. In the most recent five-year period, 1 9 5 5 - 5 9 , there were 38 cases and three deaths. Six recent cases came from eating home-frozen bear meat. Tularemia. The etiologic agent is Pasteurella tularensis ( named for Tulare County, California, where it was discovered in ground squirrels in 1 9 1 1 ) . Reservoirs of infection are wild animals, especially rabbits, some domestic animals, the bull snake, and wood ticks. The source of infection is the blood and tissue of infected animal hosts or an infective arthropod. The first case in California was recognized in 1927. Since then a total of 417 cases have been reported, 12 of them fatal. Twenty-four cases were reported in the last five years in contrast

116 to 125 cases in the same period, 1935-39. A study of the cases contracted in California, 1927-51, showed 81 per cent were contracted from wild rabbits.

present real dangers. Ionizing radiation is the newest addition to industrial hazards; physical hazards of extreme temperature, pressure, and vibration have increased also.

Anthrax. The etiologic agent is Bacillus anthracis. Reservoirs of infection are cattle, sheep, goats, horses, pigs, and other animals. The skin is infected by contaminated hair, wool, hides, bristles, or by direct contact with infected tissues. Since 1920 there have been 124 cases reported in California with 18 deaths. Only 26 cases have been reported in the last 20 years. In 1956, there were only two cases; in 1957 there was one case. N o cases have been reported since.

The largest number of reports of occupational disease comes from the manufacturing industry, although persons at greatest risk are the agricultural workers. The second greatest risk is in construction; the third greatest is in government employ. Manufacturing is the fourth in risk to workers.

O C C U P A T I O N A L DISEASES

California has had a compulsory workmen's compensation law since 1914; under it physicians are required to report occupational injury and disease to the State Department of Industrial Relations. Since the formation, in 1937, of an administrative unit within the State Department of Public Health concerned with occupational health, these physicians' reports of occupational disease have been analyzed by the department. In 1937 there were only 2.5 million employed persons in the state; of these only a small proportion were employed in occupations hazardous to their health. Now there are over six million in the civilian labor force and a large part of them are in potentially dangerous occupations. In common use now are dangerous chemicals, plastics, toxic solvents, and fuels which were almost unknown ten years ago. The many new insecticides and pesticides

T h e 1958 summary of reports of occupational disease in California shows that: diseases of the skin were 70 per cent; diseases of the respiratory system were six per cent; systemic effects of poisons were four per cent; infective and parasitic disease were four per cent. These were followed by arthritis and rheumatism, neuritis and other diseases of the peripheral nerves and central nervous system, effect of heat and insolation, diseases of the ear and diseases of the eye. In the 1958 summary, the first ten agencies of occupational disease were listed as follows with their approximate percentages: Poison oak and other inedible plant and animal products — Acids, alkalis, and other chemicals . Vibration, sudden impact, repeated motion, and other environmental conditions Infectious agents Food products Agricultural chemicals Chemicals used as solvents Dusts Gases Radiant heat, primarily exposure to sun — Other

25 20 10 7 5 4 4 3 2 2 IS

United States—Hawaii RICHARD K . C . L E E

THE HAWAIIAN ISLANDS rise above an elongated submarine platform that extends for almost 2,000 miles southeast to northwest between the parallels of 18° 40' to 2 8 ° 40' north and the meridians of 154° 30' to 178° 40' west. The total land area of the archipelago is 6,435 square miles; seven islands are inhabited (5,786 square miles). Hawaii is known for its strategic military position, and as a center for shipping and airlines. In I960 the estimated population of Hawaii was 632,772, or more than double the population of 1920. According to the I960 U.S. Census, the racial origin by per cent is listed as: Japanese Caucasian Part Haw'n Filipino Chinese

— 32.2 32.1 14.2 10.9 6.0

Hawaiian Korean Negro Other

1.6 1.1 0.6 1.3

These figures include approximately 52,000 military personnel stationed in Hawaii. Seventy-seven and four-tenths per cent of the population reside on Oahu, the third largest island. The state capitol, Honolulu is on Oahu; it has an exceptionally good natural harbor. The islands are volcanic; there are two active volcanoes on Hawaii, the largest island. The topography of all the inhabited islands is characterized by lofty mountain ranges, lush green valleys, and sandy or rocky coastlines. Some of the mountain slopes are cut by deep gorges or gulches. Although snow occasionally covers the two highest mountains on the island of Hawaii, Mauna Kea and Mauna Loa, the average temperature near sea level on all islands is 7 5 ° . Few regions in the world equal Hawaii in the great contrasts in annual rainfall between the

windward and leeward slopes of a mountain range. For example, the windward side of Haleakala, an extinct volcano on Maui, receives 200-300 inches of rain annually; the rainfall declines toward the summit and down the leeward slopes. At sea level the rainfall is under 20 inches a year. Agricultural production is primarily in sugar cane and pineapple. In addition, Hawaii's economy is dependent upon tourism and civilian employment in military establishments. In the past few years there has been an increase in the growth of service industries. Personal income has risen steadily since World War II. Public education is available to all through high school, and is required to age sixteen. Over half the high school graduates now go on for university or other advanced training. The University of Hawaii, a land-grant college, is a state-supported institution with a total enrollment of approximately 8,000. A high standard of living and high literacy rate have strongly influenced the health progress in Hawaii. In 1942, under military auspices, the entire population of Hawaii was immunized against typhoid, para A, and para B. T A B vaccination has been continued, since then, under a law which went into effect in Hawaii in 1945. This law makes it compulsory for all people residing in the state to be immunized against smallpox, diphtheria, and the typhoid fevers. Today practically all children over age three, many between ages one and three, are immunized against these diseases. Children are given also a combination of diptheria and tetanus toxoids with pertussis vaccine ( D P T ) as well as polio vaccine.

117

118 Death rates from communicable disease per 100,000 were: 1929, 418.5; 1939, 227.0; 1949, 62.7; 1959, 25.9. The principal causes of death from communicable disease and the only ones to appear on the ten leading causes of death in I960 were influenza and pneumonia (except pneumonia of newborn). Many communicable diseases have been completely eradicated from Hawaii. Table 1 shows a comparison between the number of cases in 1919 and I960. The tuberculosis death rate per 100,000 population was 179-4 in 1919 and 2.2 in I960. Diseases of the heart have been the leading cause of death in Hawaii continuously since 1935, with cancer and other malignant neoplasms second continuously since 1939- Since known preventive measures in these two leading causes of death are limited, effort has been placed in early detection, control, rehabilitation, and research. Mental illness, mental retardation, and dental caries are other public health problems. Community service together with treatment programs where indicated are organized to meet these problems. The importance of maintaining a sanitary environment has received constant attention. Recognition of the special problems that exist in the state was shown by the addition of personnel to augment the staffs of the Environmental Health Division's Branches of Sanitation, Health Engineering, Food and Drug, and Vector Control. From time to time, the federal government provided technical assistance and financial support for specific problems in the areas of water pollution, air pollution, radiation TABLE

1

CASES OF C O M M U N I C A B L E DISEASES IN HAWAII DISEASE

Smallpox Typhoid Diphtheria Tetanus Hansen's disease

1919 0 135 with 42 deaths 133 14 110

1960 0 0 0 4 20

surveillance, occupational health, housing, dengue control, and plague control. Water-borne disease is practically non-existent in Hawaii today. For over a decade there have been no recorded water-borne outbreaks due to typhoid, other salmonellae, or to bacteria of the shigella group. Honolulu is blessed with a soft artesian water supply which meets the Department of Health and U.S. Public Health Service drinking water standards without artificial purification. All milk for public consumption on the islands of Oahu and Kauai, and 99 per cent of the milk on the neighbor islands is pasteurized; consequently, the hazard of milk-borne diarrheal diseases is practically nil. PUBLIC HEALTH ADMINISTRATION

The Board of Health was established in 1850; by 1920 the basic services dealt chiefly with environmental sanitation, vital statistics, and communicable disease control. Some work was undertaken in nursing, infant care, tuberculosis, and venereal disease control. There was and still is today, a single, centralized public health department at the state level. Services are provided to all areas on all islands through state tax funds. As new health problems arose, federal legislation and appropriation of special federal funds to states helped strengthen local programs. These federal acts included the SheppardTowner Act of 1925, which provided funds for maternal and infant hygiene; and the Social Security Act of 1935, which provided matching funds for maternal and child health beginning April, 1936, and for crippled children's services beginning November, 1936. On May 24, 1938, the Venereal Disease Control Act was enacted. During the 1940s state appropriations were augmented by special grants through the public health services for general and mental health, and for tuberculosis, cancer, and heart disease control. The Hill-Burton Hospital Construction Act made matching funds available for the construction and equipping of non-profit hospitals and for medical facilities. In 1959 Hawaii became the 50th state; the government was reorganized the next year. Ef-

119 fective July 1, 1961, branches are under divisions. T h e divisions listed in the organizational chart of the Department of Health are Dental Health, Communicable Disease, Environmental Health, Medical Health Services, Special Health Services, Mental Health, and Mental Reardation. A state law provides for the appointment of a public health physician as the director of health of the State Health Department. This law stipulates that the director of health shall be a person who, during the ten years next preceding his appointment, has had at least six years of practical experience in public health work. This experience includes supervision or administration of such work in communities of not less than 100,000 population, or the United States Public Health Service as a commissioned medical officer. T h e Board of Health is advisory in nature. HOSPITALS

In 1920 there were two general hospitals in Honolulu providing 383 beds, and 30 other general hospitals throughout the rural areas providing 1,003 beds. Of the 30 general hospitals, 23 were operated by plantations. Hospitals for special use included four for tuberculosis, two for mental illness and the mentally retarded, two for Hansen's disease, one for children, and one for maternity and gynecological cases. There were 42 civilian hospitals with a total bed capacity of 3,688. In I 9 6 0 there were four general hospitals in Honolulu with 849 beds, and 20 other general hospitals in rural areas with a total of 984 beds. Hospitals for special use included: five for tuberculosis, one for the mentally ill, one for the mentally retarded, two for Hansen's disease, three for chronic disease, one for children, one for maternity and gynecology, and one orthopedic for children. There were 39 civilian hospitals with a total bed capacity of 4,997. W i t h the change in economic conditions and improved road networks, a number of small private and plantation hospitals closed. Other plantation hospitals were reorganized as community or county hospitals. T h e Hill-Burton Act provided federal assist-

ance for hospital construction or expansion. Many community or government hospitals used these funds to improve or build new hospitals according to established standards. PHYSICIANS

Hawaii's physicians are licensed upon graduation from a medical school or a college approved by the Council on Medical Education and Hospitals of the American Medical Association; they must have lived in Hawaii for one year and have passed an examination or have been certified by the National Board of Medical Examiners. Unlicensed physicians may serve only under the direction of a licensed physician. In 1920 there were 141 physicians; by I 9 6 0 there were nearly 850 physicians licensed in Hawaii. These represent every specialty of medicine. Honolulu's general and special hospitals provide intern and residency training for physicians. A state medical association affiliated with the American Medical Association and four local medical societies have active committees serving the community. They sponsor symposia and conferences to keep physicians abreast of recent developments. Private and government medical care is available to everyone in all areas of the state. NURSING

In 1920 there were only 96 registered nurses certified in Hawaii. T h e first school of nursing had been established only four years earlier, in 1916, at T h e Queen's Hospital. T o meet the need for nurses, additional schools of nursing were established at St. Francis Hospital in 1929, at Kuakini Hospital in 1931, and at the University of Hawaii in 1952. Graduates are admitted to examination by the Board of Nursing. Since 1947 this board has been empowered to inspect and approve schools of nursing. By I 9 6 0 there were 2,318 professional nurses licensed in Hawaii. Licensing of practical nurses was first established July 1, 1946. Three hundred licenses were issued the first year. A school of practical

120 nursing was established by the Department of Public Instruction in 1947 to meet the increasing need for additional nurses. Practical nurses are now employed in homes, in private physicians' offices, in industries, and in hospitals. By I960 the number of practical nurses licensed in Hawaii had reached 1,698; the demand exceeded this number. Public health nursing in 1920 was provided jointly by Palama Settlement, a non-official health and welfare agency, and by the Health Department. The Health Department had nine public health nurses in 1920. By legislative action the Health Department absorbed the Palarr.a nursing staff in 1941. As programs were added and the work increased, additional public health nurses were employed; by I 9 6 0 they numbered 79Public health nursing is an integral part of the course of study in the College of N u r s i n g at the University of Hawaii. MEDICAL RESEARCH AND DIAGNOSTIC C E N T E R S

The Queen's Hospital in Honolulu, established in 1859, was a center for medical care as well as the first diagnostic center in Hawaii. It still has the larg;st inpatient diagnostic center. Some medical research was done there throughout the years. There are now 24 general hospitals and nine specialized hospitals which act as diagnostic centers. Many of these hospitals also carry on some medical research. Group practice began in Honolulu in 1921 with the formation of the Straub Clinic. Since that time many other private medical groups have been established. These are medical diagnostic centers which usually have their own laboratories for X-ray and for general bacteriological, chemical, and serological examinations. One has a full-time pathologist. Special laboratory services were instituted from time to time as specific problems developed. In 1907 the Territory of Hawaii supplied funds for the setting up of plague laboratories in the Honolulu and H i l o areas, by the U.S. Public Health Service and by the Marine Hospital Service. At present, the State Department of Health maintains laboratories for the diagnosis of plague in Honolulu, in H i l o and Hono-

kaa on Hawaii, and in Kahului on Maui. This disease is endemic among the rodents on Hawaii and Maui. In 1914 a laboratory to study the problems of Hansen's disease was established at the Kalihi Receiving Station by the U.S. Public Health Service; this laboratory was operated under the auspices of the Public Health Service until 1942. In 1924 maternal health conferences were started by the Board of Health at Palama Settlement in Honolulu. These served as diagnostic centers, and were manned by "resident interns" from T h e Queen's and St. Francis hospitals. T h e Board of Health established a large number of these conferences throughout the territory. They have been reduced gradually so that the Health Department only operates three maternal health conferences. Hawaii offers some special opportunities for research. During the past decade there was a marked increase in medical and public health research by scientific personnel associated with the University of Hawaii, by governmental agencies, and by voluntary agencies. Medical, dental, and veterinarian practitioners also placed considerable emphasis on research during this period. TUBERCULOSIS

The territorial legislature first appropriated funds specifically for a Tuberculosis Bureau in 1909; at that time the reporting of tuberculosis and the maintenance of a Tuberculosis Case Register were made compulsory. Case reporting was required already by a public health regulation of 1900. Tuberculosis control activities, however, started before that date. D u r i n g the plague epidemic and fire of 1 8 9 9 - 1 9 0 0 , a large number of active cases of tuberculosis were discovered, and tuberculosis was recognized officially as a serious problem. In 1901 the first of the four tuberculosis hospitals was founded in Honolulu; shortly thereafter, the voluntary tuberculosis associations were founded. Each of the major islands built its own tuberculosis hospital; the latest was built on K a u a i in 1917. By 1950 there were over 1,200 modern beds available for the treatment of tuberculosis in a population of about 500,000 people.

121 Until 1929 casefinding was entirely on an individual basis; individuals with symptoms and contacts of known cases were examined. T h e chest clinics of the Health Department were established in 1922 to assist in the examination and to provide follow-up services to known cases. In 1930 mass casefinding by the survey method was initiated. School children were given the tuberculin test; positive reactors were further screened by X-ray and fluoroscopic methods. In 1942 the first mobile and stationary X-ray survey units using miniature films were put in active service. Today these surveys or casefinding units find about 40 per cent of the new cases reported each year. It is expected that they will continue, along with an increasing use of the tuberculin test in younger individuals, to be among the most important tools in tuberculosis control. Although the tuberculosis death rate in Hawaii, from 1920 to 1946 declined from 200 to 55 per 100,000 people, only six of the 48 states had a higher death rate in 1946. However, the 1960 death rate of 2.2 per 100,000 in Hawaii was one of the lowest in the nation. In 1946, 280 people died of tuberculosis. In I 9 6 0 only 13 tuberculosis deaths occurred although the population had increased by about 100,000. Forty years ago 14 per cent of all deaths were due to tuberculosis; today less than one-half of one per cent of deaths are from tuberculosis. Here, as elsewhere, the average age of persons dying of tuberculosis has increased. Twenty years ago 25 per cent of deaths occurred under age 20, with the peak at age 30. In the past five years only one tuberculosis death occurred under age 25 (that of a child under five in 1 9 5 6 ) . N o w , the greatest number of death from tuberculosis occurs in persons over 50. Although the tuberculosis problem has always differed in the various racial groups, (Hawaiians and Filipinos have the highest death r a t e ) , the rate of decline in the death rate has been the same for the various races. In recent years the people of Hawaii have been cooperating with and participating in tuberculosis control activities. Participation in the X-ray surveys reaches 80 per cent of the adult population in some areas, and in urban Oahu

up to 40 per cent. Through the years, there has been an increasing patient acceptance of the need for hospitalization. Between 75 and 80 per cent of active cases accept sanatorium care when it is recommended. This acceptance has improved markedly with sustained efforts to eliminate old ideas of stigma, and with the practical assistance of legislation passed in 1949 (it prohibited a "means test" for treatment of tuberculosis and provided mandatory free care for all in tuberculosis hospitals). Rarely does a death from tuberculosis occur now in an individual who has not been reported to the Health Department months or years before death; 40 years ago almost one-half of tuberculosis cases were unknown to the Health Department until only a few days before death or after death. Much of this public acceptance of the tuberculosis control activities is due to the health education efforts of the Health Department and of the Tuberculosis Association. The evidence indicates a decreasing opportunity for new infection. The problem now is one of attempting to pinpoint the casefinding efforts on the groups in which tuberculosis is most likely to be found. T h e largest and most important of these groups are those who have already been infected. These infected persons are most likely to be found in the older age group in the most recent immigrants from countries of known high tuberculosis incidence, and in those with a positive tuberculin test. Research in tuberculosis is in both the laboratory and public health fields. Laboratory research is being done on the classification of atypical acid fast organisms. A five-year tuberculin testing study in a high incidence area of Honolulu was completed in 1959- This showed that tuberculin testing was feasible as a casefinding method. Another public health study is to determine the need and feasibility for perpetual follow-up of so-called inactive cases of tuberculosis. H A N S E N ' S DISEASE

Hansen's disease (leprosy) was one of the chief problems of the Health Department in 1920; the expenses for care and treatment of leprosy patients took 38 per cent of the total

122 health budget as compared to 13 per cent today. Although the prevalence, as well as the incidence of leprosy was already on the decline from a peak in the 1890s, there were 662 patients hospitalized and 114 new cases admitted during 1920. T h e decline has continued so that today we have 278 patients hospitalized with an average of ten patients admitted annually. Most important in the Hansen's disease program was the introduction of sulfone chemotherapy in 1946. Within four years the mortality rate for hospitalized patients had dropped from ten to two and one-half per cent annually; within ten years, 237 patients had been released. T h e number returning to their homes upon completion of treatment now regularly exceeds the number of new admissions. Only 50 per cent of new cases now require hospital isolation; the others remain at their usual occupations and report to outpatient clinics for monthly examinations and for drugs. The public accepted the assurance of health authorities that inactive cases are non-infectious; discharged patients have been re-employed and accepted in their former communities. In 1949 rehabilitation of patients was made easier by the policy of hospitalization near Honolulu. The chief problem remaining in Hansen's disease lies with the group of recovered patients who developed serious disability and disfiguration prior to the advent of sulfone drug therapy. They have spent so many years at K a l a u p a p a Settlement, an isolated peninsula on the island of Molokai, that they consider that institution as their home. T h e public continues to provide liberally for the maintenance of K a l a u p a p a Settlement as a refuge for these patients. Plastic surgery has improved the appearance of a few, and physical therapy and prostheses have reduced some disability. While there has been marked reduction in the incidence of leprosy among Hawaii's nativeborn population, the incidence a m o n g immigrant peoples have become more noticeable. At present the number of new cases found among immigrant groups is 25 per cent of the total. Over half of the cases among immigrants develop within ten years, and two-thirds within 15 years of arrival in Hawaii. In one immigrant

group, which arrived in Hawaii 14 years ago, 23 cases have been diagnosed; 57 per cent of the cases developed within five years, and 91 per cent developed within ten years. Apparently, leprosy cannot be eradicated from Hawaii so long as it is prevalent in other parts of the Pacific. V E N E R E A L DISEASE

In 1918 the Department of Health adopted a regulation making venereal disease a reportable disease. During its session in 1921, the territorial legislature appropriated §15,000 for the biennium 1921-23 for the operation of a venereal disease clinic in Honolulu. With the cooperation and assistance of Palama Settlement, the venereal disease clinic was formally opened on August 1, 1921. This appropriation was discontinued in 1929 since this clinic benefited only Oahu residents. However, the government of the city and county of Honolulu recognized the importance of continuing this clinic and appropriated 37,200 annually for it from 1929 to 1945. With the passage of the Social Security Act, Title 6, federal funds were made available to Hawaii on July 1, 1936. In February 1937 regulations governing the reporting of venereal diseases were adopted by the Board of Health and became law. A public health nurse was employed to work under the supervision of the director of the Bureau of Communicable Diseases. A full-time venereal disease control officer was appointed in J u n e 1942 by the Health Department. T h e prenatal law requiring a serological test on all expectant mothers was passed in 1943. In September 1944 all houses of prostitution on Oahu, Hawaii, and K a u a i were closed by the police department. Prostitution was repressed on Lanai and Maui by the local police departments since there were no organized houses. In 1945 a premarital law was enacted; it required all marriage applicants to have medical examinations and blood tests for syphilis as part of their health certificate. T h e culture method for identifying the gonococcus was established in all Board of Health laboratories in 1941. In 1940, 31 cul-

123 tures were done; in 1941 the number had increased to 826. In 1944 penicillin was available through the Department of Health for the treatment of civilian gonorrhea cases in hospitals. This provided an excellent control measure in that each diagnosed case had to be reported according to regulation; the Health Department had the opportunity of interviewing patients while providing penicillin. In 1945, with increased production of penicillin, the drug was made available without any control by the Health Department. Penicillin was used then on all gonorrhea cases and most of the primary and secondary syphilis cases. For the treatment of central nervous system syphilis cases at the State Mental Hospital, as well as by a few private physicians on neighbor islands, therapeutic strain of quartan malaria was introduced through the U.S. Public Health Service in 1945. Mass serologic survey methods were used in the casefinding program. The Health Department cooperated with the selective service headquarters in taking blood specimens for syphilis tests on all selectees examined for induction. A state-wide master index of all reported syphilis cases was maintained by the bureau; this index helped physicians to secure the previous diagnostic status of patients under their care. Public health nursing services were provided to venereal disease clinics. A public health nurse, with the specific function of following all private cases, was made available to the physicians by the bureau in 1943. This service was continued for approximately ten years until the volume of such patients was reduced greatly. The bureau provides a continuous professional and lay educational program in venereal disease control through lectures, films, printed materials, radio and group discussion. The contacts of all diagnosed syphilis and gonorrhea cases are investigated immediately. This is the most effective method for finding new cases as well as for controlling the spread of these diseases. T h e staff of physicians, public health nurses, and investigator of the venereal

disease bureau working with the private physicians, military, and police departments have been effective in maintaining the low venereal disease rate in Hawaii. OCCUPATIONAL

DISEASES

On the sugar and pineapple plantations occupational diseases have been kept to a minimum through the combined efforts of physicians and plantation managers. One area that received special attention was the prevention of blindness due to industrial accidents. The use of protective devices, such as goggles of unbreakable glass, has reduced the incidence of blindness in industry. Skin diseases due to irritation from insecticides and herbicides have been problems at times. The incidence of these diseases was reduced by eliminating the irritation or by using, when possible, protective clothing. In some industries where detergents and disinfectants are used, there has been a marked increase in the cases of skin irritation in recent years. A few communicable diseases have at times been occupational in origin. An example is leptospirosis, which 20 years ago was found usually among plantation workers. Recently there has been a reduction in the number of cases in plantation workers; now housewives have the disease as frequently as field workers. T h e first workmen's compensation laws in Hawaii became effective July 1, 1915. These have been revised by almost every session of the biennial legislature since they were first enacted; today Hawaii has the most liberal workmen's compensation benefits in the United States. The Bureau of Industrial Hygiene in the State Health Department was established in 1941. Since then attention has been given to the elimination of health hazards at work sites; this includes programs which require safe fumigation practices, control of atmospheric pollution, healthful air-conditioning, radiation monitoring, and accident prevention. Special attention has been given to the prevention of deafness through the protection of workers against undue noise at work sites.

124 ZOONOSES A N D VECTOR-BORNE DISEASES

The human incidence of zoonotic and vectorborne diseases has decreased in Hawaii at the same rate as on the mainland. This decrease was due to communicable disease control programs conducted by state and local health departments. The true incidence of this group of diseases is most difficult to determine because of diagnostic and reporting deficiencies. Continued surveillance is necessary for effective control procedures, and in order to recognize the emergence of new or previously unrecognized pathogens which are transmitted from animals and insects to man. Salmonellosis, murine typhus, plague, trichinosis, and brucellosis, in that order of predominance, have accounted for the majority of officially reported human cases of zoonotic disease in Hawaii during the past 40 years. During the past decade these same diseases, with the exception of plague, have accounted for the majority of reported diseases which are transmitted from animals to man. However, their overall incidence has been greatly reduced. The relative importance of animals as disseminators of salmonellosis in Hawaii is difficult to evaluate because of insufficient data; however, available evidence indicates that they play a key role. Various salmonella serotypes have been repeatedly isolated from rodents, swine, and dogs, and, on occasion, from parrots, chickens, parakeets, cats, and cattle. Eleven per cent of fecal samples taken from 294 apparently healthy dogs held at the rabies quarantine station yielded salmonella types that have been associated with human outbreaks. Corresponding serotypes have been isolated from live hogs and from pork products. A new serotype to Hawaii, which was incriminated in human disease in California, was isolated from recently imported dairy cattle. Concentrated efforts at rodent and flea control, as well as improvements in housing, and in the area of environmental sanitation have been important factors in the marked reduction of plague and typhus morbidity during the past 40 years. For example, only one case of murine typhus was reported in I 9 6 0 compared with 163 in 1944. The last case of plague was rec-

ognized in 1949, while in 1922, 12 cases were reported. Reservoirs of plague continue to persist in certain areas of Hawaii. Pasteurella pestis has been isolated 1,225 times from individual rodents, rodent tissue pools, or flea pools during the period 1910-58. Isolation of the plague organism has occurred every year in the Hamakua district with the exception of 1951, 1952, 1958, 1959, and I960. An important research program on the ecology of plague was initiated in this district in order to determine the factors responsible for the persistence of this disease in this region. There is serological evidence that more than 12 per cent of rats in certain areas have had experience with typhus organisms; this again emphasizes the importance of continued surveillance and control programs. Brucellosis is known to be endemic in Hawaii's swine and cattle populations. Although the annually reported number of human cases is small, the persistence of this disease in our domestic animals creates a public health problem. An official bovine brucellosis control program supported by the Health Department was instituted by the Board of Agriculture and Forestry in 1957. Since then, approximately 99,000 cattle have been serologically tested with over 2,000 reactors recognized. To date, no certified modified areas have been established, but several herds have been certified as "clean." Fortunately swine brucellosis control programs, although purely voluntary, are becoming increasingly popular with swine raisers. There have been 235 human cases of Ieptospirosis reported since 1921, 80 per cent of them occurring on the island of Hawaii. Fifty cases were reported in 1937, the first year official reporting of leptospirosis was required. One hundred and twenty-six cases were recorded between 1941 and 1946, a period when this disease was extensively studied on the island of Hawaii. Prior to 1947 the majority of cases were seen in field workers on sugar-cane plantations and were attributed to contact with rodent excreta. Leptospira icterobemorrbagiae was considered to be the offending serotype. Twenty-three cases were reported in the past

125 decade s h o w i n g n o definite occupational pattern; there was n o i n f o r m a t i o n available concerning etiologic serotypes. T h e c h a n g e in occupational p a t t e r n may be explained by increased mechanization in the cane fields; this fact can also be considered in the reduction of reported cases. O t h e r cont r i b u t i n g factors are rodent control, poor reporting, and lack of diagnostic facilities. Recently better laboratory facilities have become available; they are being used to study the epidemiology of leptospirosis in Hawaii, and to learn about the prevalence of this disease in m a n and animals. Efforts are being directed also toward the discovery of the p r e d o m i n a t e serotypes. Preliminary results of a rodent and mongoose survey indicate a high carrier rate in these animals. T h e r e has been little reduction in the incidence of trichinosis since the first case was reported in 1937. Small outbreaks usually inv o k i n g six to ten people continue to occur; the last one was reported in 1959. T h e majority of cases occurred in Filipinos, a g r o u p k n o w n to like their pork raw. T h e pork causing these outbreaks was f r o m wild pigs. N o records are available concerning the incidence of bovine tuberculosis in Hawaii residents; however, the reduction of extra pulm o n a r y tuberculosis in h u m a n s has roughly paralleled the reduction of tuberculosis in cattle. In 1910 a bovine tuberculosis eradication prog r a m was inaugurated. Skin testing of cattle revealed that 32 p e r cent of the animals tested were infected, yet until 1933 most of the milk consumed was unpasteurized. It is p r o b a b l e that many people suffered f r o m tuberculosis infections of bovine origin. Currently less than o n e per cent of cattle tested in H a w a i i react to the skin test. O n e difficulty in p r e v e n t i n g the eradication of b o v i n e tuberculosis is the nonspecificity of t h e skin test. H e a l t h and agriculture agencies in H a w a i i are endeavoring to perfect a better diagnostic test. H u m a n cases of encephalitis caused by a r t h r o p o d - b o r n e viruses have not been recognized in Hawaii. Approximately 50 cases of acute or infectious encephalitis have been reported since 1930. U n t i l 1959, however, virus

diagnostic facilities were not available locally, and most of these cases received inadequate study. Reservoirs of arthropod-borne encephalitis viruses are k n o w n to occur in areas immediately to the east and west of the H a w a i i a n Islands. Potential hosts and vectors are readily available to p r o p a g a t e these diseases if t h e viruses are introduced through imported g a m e birds, migratory birds, or insects carried aboard ships or aircraft. Serological surveys are being m a d e in H a waii to determine if h u m a n s or wild birds have had experience with these virus agents. Mosquitoes are being collected and tested for virus also. T h e U.S. Public H e a l t h Service, N a t i o n a l Institute of Allergy and Infectious Diseases, has awarded the State H e a l t h D e p a r t m e n t a grant of $9,142 in support of these investigations. Only eight h u m a n cases of psittacosis have been reported; the last was in 1937. A l t h o u g h tropical climate would account for a low case rate, it is d o u b t f u l that n o cases occurred d u r i n g the past 20 years. T h e more likely explanation is the lack of diagnosis and reporting. Pet parakeets have been popular in H a w a i i and are shipped in f r o m infected areas of the mainland. A survey of birds in 1957 provided serological evidence of infection in wild pigeons and domestic chickens. A recent baseline serological study of virus diseases in h u m a n s revealed that three and one-third per cent of 261 sera tested with psittacosis antigen contained c o m p l e m e n t fixing antibodies titering 1:8 or higher. Further investigation of this situation is being planned. Ornithosis was diagnosed in I 9 6 0 for t h e first time f r o m imported g a m e birds. These birds, imported f r o m India, were being held in quarantine in H a w a i i prior to distribution here and on the mainland. Since 1957 three dairy herds on the island of O a h u have experienced severe outbreaks of mastitis caused by Nocardia asteroides. Preliminary studies at the University of California have indicated that these organisms may survive pasteurization. Since Nocardia asteroides is k n o w n to be p a t h o g e n i c for m a n , it is imp o r t a n t to prevent the milk of infected animals f r o m reaching t h e consumer.

126 Visceral larva migrans is not a reportable disease in Hawaii. In recent years, however, one pathologist at a large Honolulu hospital has diagnosed five human cases. This disease warrants consideration as a potentially serious public health problem since it is difficult to diagnose. In addition, Hawaii's climate is quite conducive to the propagation of dog and cat ascarids. Fortunately Hawaii is one of the few rabiesfree areas in the Pacific. Increasing importation of dogs and cats as well as the large resident population of mongooses in Hawaii make rabies a constant public health threat. It is hoped that animal quarantine regulations will continue to be effective in preventing the introduction of this disease. VIROLOGY I N

HAWAII

Smallpox has the oldest recorded history of any virus disease here. T h e first epidemic was recognized in 1852, and several apparently occurred up until 1912. In many of the intervening years up to 1930 small numbers of cases were observed on vessels arriving in Hawaiian ports. Influenza has been recorded every year in Hawaii since 1900. The number of cases reached epidemic proportions frequently; the most recent one was in 1957-58 with 24,216 cases. Influenza B was identified as the cause of the 1945 epidemic. Influenza A was identified in 1946. The 1953 epidemic was shown to be due to Influenza A. A strains were again isolated in 1956. First diagnoses of Influenza A-Asian type locally were made in 1957. These were in two civilians returning from a conference in the Philippine Islands. Influenza A-Asian has been diagnosed continually from that time until the present. Influenza B was also shown to be present in 1959. Poliomyelitis became reportable in 1911Statistics indicate that it was here even before then. The first epidemic was in 1939-41. Several epidemics have occurred since that time; the most recent was in 1958 when there were 78 paralytic cases. The first laboratory diagnosis of poliomyelitis was made by the Queen's Hospital Virus Laboratory in March 1958. The

Salk vaccine became available locally in 1956. It has been used rather extensively since that time. Trachoma cases numbered 930 in the 192627 period. This has gradually declined; sporadic cases occurred until 1949. None has been reported since that time. Hepatitis was made reportable in 1945. Until that time none was observed in the permanent population, although some cases were seen on ships in our ports. T h e number of cases from 1952-60 was between 50 and 90 annually. W i t h the exception of dengue, there has been no evidence of arthropod-borne virus diseases in Hawaii. This disease was endemic until 1923. In 1944 it was reintroduced in the South Pacific; a total of 1,648 cases occurred until it was suppressed by a concentrated mosquito control program in 1945. N o n e has occurred since that time. Laboratory virological diagnostic services were first started in Hawaii by the Army in May 1951. This was primarily for the benefit of the military workers. However, diagnostic services were offered to the Health Department and civilian hospitals. The Queen's Hospital in Honolulu started a virus laboratory in 1956. The polio virus responsible for the 1958 epidemic was isolated and identified as type I by this laboratory. Most of the enteroviruses can be handled by this laboratory with its mouse colony facilities and monkey kidney cultures. The U.S. Navy started a tissue culture virus laboratory in October 1957. Their services were offered to both military and civilian population. The work of this laboratory has been limited to diagnosis of those enteroviruses which can be cultivated by tissue culture. A small research project has been carried on with the use of oral live virus polio vaccine. The State Health Department organized a virus laboratory early in 1959; the principal objective was to offer complete virus diagnostic services for the civilian population. This laboratory is equipped for working with tissue culture, embryonated eggs, and mice; it offers isolation services for all of the enteroviruses, influenza, the arthropod-borne viruses, psitta-

127 cosis, adenoviruses, smallpox vaccinia, herpes simplex. Serological diagnoses are offered for all of the above-mentioned diseases, as well as mumps, Q fever, and typhus. A serological survey is being made to determine the antibody prevalence of the various virus strains. T H E F U T U R E IN P U B L I C H E A L T H

The future of public health in Hawaii holds forth exciting challenges. In the near future, Hansen's disease, tuberculosis, and poliomyelitis will have been eradicated. Mental health services will be well developed on all islands; routinely, private care will be a part of the general hospital system. Custodial care will be limited to those patients who show no response after long periods of treatment. Cure for most cancers will have been found; this health problem will no longer be the second leading cause of death. Alcoholism, suicide, accidental injuries, and

deaths will be leading problems of the state. Care of the aged and the chronically ill will have been greatly improved, and homemaker services and care for the homebound will be provided. Comprehensive health and medical services will be greatly improved and extended. School health and dental health services will have been improved. Occupational health and medical services will be expanded as the state becomes more industrialized. A medical school at the University of Hawaii will be established during the growth of the East-West Cultural Center. T h e school will serve state, national, and international needs. Health research programs will be carried out at the university, hospitals, health department, and other health agencies. Environmental health will continue to be an important part of the Health Department program for the prevention of air pollution and radiation contamination, and improvement in disposal of solid waste and sewage.

Index cancer, 14, 20, 27, 4 0 , 4 6 , 4 7 , 6 3 , 6 4 , 9 7 , 109; Fig., Japan, 74, Table, Chile, 41 skin, 18, 19 lung, 14, 2 7 , 78 cardiovascular diseases, 14, 2 0 , 27, 39, 4 0 , 4 6 , 4 7 , 6 2 ,

aboriginals Australia, 19 Taiwan, 4 5 absenteeism, 37 accidents, 14, 2 7 , 4 1 , 6 2 , 6 3 , 6 4 , 75, 79, 9 7 , 101, 109, 111, 123, 127; Fig., Japan, 7 6 adenoviruses, 127 adult diseases, Japan, 74 Aedes aegypti, 17 agriculture Chile, 31 Japan, 59 Malaya, 83 Philippines, 88 Taiwan, 4 5 U.S.-Hawaii, 177, 123 air pollution, 109, 118, 123, 127 alcoholism, 14, 3 7 , 4 0 , 4 1 , 109, 112, 127 American Board for Medical Aids to China ( A B M C ) , 51 Ancylostoma. see hookworm anthrax, 115, 1 1 6 anthropology, 5, 8 antibiotics, 50, 6 7 , 6 9 , 70, 72, 73, 8 0 , 90, 9 3 , 111, 113 antivenine production, 103 arboviruses, 17, 126, see dengue, encephalitis arthritis, 2 7 , 1 16 ascariasis, 76, 126 asthma, 111 Audy, J. Ralph, 3 Augustine, Marguerite S., 107 Australia, 1 3 - 2 1 , 6 1 automobiles, see accidents avalanche, population, 5, 7, 32 Bali, 53 Bandung plan, 56 Bataan enriched-rice project, 9 0 beriberi, 8 3 , 9 0 , 9 1 , 97 birth control Japan, 6 0 Taiwan, 51 births Canada, 24 Chile, 4 0 ; Fig. 3 3 , Table, 32 Japan, 6 0 , 6 2 , 8 0 ; Table, 6 1 Taiwan, 4 5 , 52 blindness, 109, 123 Borneo ( K a l i m a n t a n ) , 53 bronchitis, 6 2 , 6 3 , 75 brucellosis, 13, 15, 115, 124 Brug, 55

6 3 , 7 4 , 97; Fig., Japan, 75, Table, Chile, 41 Celebes (Sulawesi), 53 cerebrospinal meningitis, 104 chancroid, 9 4 changes in quality of populations, 6 child health, see maternal and child health Chile, 6, 2 9 - 4 3 China, 9, 4 5 - 5 2 , 6 6 , 83 China Medical Board, 51 chlorination, 51, 9 2 , 113 cholera, 4 5 , 4 8 , 52, 55, 6 6 , 8 3 , 9 7 , 103; Figs., Japan, 6 7 , Taiwan, 4 6 chronic degenerative diseases, 9 " , 111 Chung Hsin Village, 51 cirrhosis liver, 4 0 , 109, 112; Table, Chile, 41 climate Australia, 13 Canada, 23 Chile, 30, 37 Indonesia, 53 Japan, 59 Malaya, 85 Philippines, 87 Taiwan, 45 United States-California, 107 Clonorchiasis,

7

6,

7

1

coccidioidomycosis, 110 Colombo Plan, 103 Committee Members, Standing, ix, 11 communicable diseases, see infectious diseases communications and transport, 16, 4 2 , 4 5 , 6 6 , 75 consequences of our actions. 7 contamination and pollution, air and water, 78, 79, 81, see also air pollution control, 10, 4 5 , 4 7 , 4 8 , 4 9 , 50, 51, 55, 56, 57, 59, 6 2 , 71, 76, 77, 79, 8 0 , 8 5 , 8 9 , 9 3 - 9 6 , 101, 102, 112, 113, 115, 118, 121, 124 Cortés, Hernán, 38 Coxiella burnetii. 110 Culex amiuhrostris, l7 Daendels, 54 deafness, 123 deaths Canada, 27 Chile, 38, 4 0 , 4 3 ; Figs., 33, 35, 36, 3 8 , Tables, 32, 3 3 , 34, 36, 3 7 , 4 1 Indonesia, 54, 55 Japan, 6 1 , 6 4 , 6 6 , 6 7 , 6 8 , 6 9 , 70, 7 1 , 72, 73, 74, 7 5 , 78; Figs., 6 7 , 6 8 , 6 9 , 70, 71, 7 2 , 73, 74, 7 5 , Tables, 6 2 , 63 Malaya, 83

California, 1 0 7 - 1 1 6 caloric intake, T a b l e , Japan, 6 6 Canada, 2 3 - 2 8

129

130 Philippines, 93; Tables, 97 Taiwan, Tables, 47 Thailand, 105; Tables, 102, 103 U . S . - H a w a i i , 118, 121 dengue, 17, 118, 126 D e n m a r k , 62 dental caries, 28, 111, 118 dentistry, 15, 54, 80, 85, 88, 119 D e Vogel, 55 diarrhea, infantile, 13, 37, 63, 74, 75 diet, 37, 40 D i n , M o h a m m e d , 83 diphtheria, 15, 19, 27, 38, 46, 48, 51, 52, 69, 103, 114, 117; Fig., J a p a n , 70 disease pattern, 97 diseases of poverty, 20 distribution limits of diseases Australia, 17 Japan, 77 divorce, 61 Djakarta, 54, 56 doctor's role, 9 drownings, 14, 41, 63 drugs control, 25, 47 D u t c h , 54, 55, 57 dysentery, 13, 15, 20, 54, 67, 69, 78, 97, 103; Fig., Japan, 68 dystrophia, 37 earthquakes, 30, 43, 45, 75 E a s t - W e s t Cultural Center, 12"7 echinococcosis, 27 ecology, 8 economics Australia, 20 Chile, 30, 42, 43 Indonesia, 55 Japan, 59, 61 Malaya, 84 Taiwan, 45, 4 9 U . S . - H a w a i i , 117 economics and health, 6, 7, 55, 64, 66, 79, 80 education, health, 42, 45, 47, 48, 49, 54, 55, 56, 59, 64, 66, 69, 76, 77, 79, 84, 85, 88, 104, 105, 121, 123 education, medical, 43, 50, 51, 52, 55, 84, 91, 1 0 1 102, 119, 127 Eijkman, 55 emergency' period, Malaya, 84 encephalitis, arthropod-borne, 17, 46, 71, 110, 114, 125 encephalitis, lead, 112 encephalitis, viral, 17, 46, 110, 114, 125; Fig., J a p a n , 71 England, 62 enteric infections, 37, 46, 62, 74, 75, 90 enterobiasis, 76 enteroviruses, 126 e n v i r o n m e n t , 64, 69, 70, 72, 118, 119, 127 epidemics, 67, 68, 71, 72, 74 epidemiological picture, Philippines, 9 6 - 9 8 epilepsy, 2 7 , 4 1

eradication of disease, 10, 18, 19, 27, 35, 46, 48, 52, 56, 76, 77, 85, 95, 103 expenditure for health, Table, Philippines, 98 expense, health, per capita U.S.-California, 108 Philippines, 98 families, 41, 60, 66, 84 fertilizers, 51 filariasis, 17, 50, 52, 76, 77, 85, 89, 9 6 Five-Year D e v e l o p m e n t Plan, Malaya, 84 fluoridation of water, 28 Flying Doctor Service, 4, 15, 16 food poisoning, 55, 75 foreign aid, 47, 51, 56 Formosa ( T a i w a n ) , 59 Four Pests, 9 framboesia, see yaws France, 37 f u m i g a t i o n , safety, 123 f u t u r e prospects and forecasts, 20, 27, 28, 43, 80, 81,

86 gastroenteritis of newborn, see maternal and child health gastro-intestinal infections, 37, 46, 62, 74, 75, 90 genetics, 6, 64, 78 geography Canada, 23 Chile, 29, 37 Indonesia, 53 J a p a n , 59 Philippines, 87 T a i w a n , 45 Thailand, 101 U.S.-California, 107 U . S . - H a w a i i , 117 geography, medical, 1", 18, 110 geriatrics, 14, 39, 4 0 , 43, 46, 47, 61, 62, 63, 72, 74, 104, 121, 127 goiter, 35, 55, 90 gonorrhea, 94, 113, 123 government Indonesia, 53, 54, 55, 56 J a p a n , 59, 60, 70 Malaya, 83, 84 Philippines, 89, 92 T a i w a n , 45, 46, 4 7 , 51 U.S.-California, 1 0 8 - 1 0 9 , 112 U . S . - H a w a i i , 1 1 8 - 1 1 9 , 120 Gryns, 55 Hansen's' disease, see leprosy Hawaii, 117-127 hay fever, 111 healing art, 8 health insurance, 15, 20, 25, 39 health, socio-cultural aspects, 8 heart, see cardiovascular heights, Fig., J a p a n , 6 4 , Table, Japan, 65 helminthiases, 76, see ascariasis, enterobiasis, w o r m , hydatid

hook-

131 hemorrhages, cerebral, 40, 47 hepatic cirrhosis, 40, 41, see cirrhosis liver hepatitis, 126 heredity, 6, 64, 78 herpes simplex, 127 H o k k a i d o , 59 h o m e accident research, 109 h o m e nursing, 15 H o n d u r a s , 38 H o n s h u , 59 h o o k w o r m , 17, 20, 35, 54, 101, 103, 114 housing, 51, 55, 92, 118 hydatid disease, 27 1CA, 51, 56, 105 illegitimate births, 32 i m m u n i z a t i o n , 15, 27, 38, 39, 40, 45, 47, 48, 49, 55, 66, 67, 69, 70, 71, 72, 76, 79, 93 India, 83 Indian reservations, Chile, 38 Indonesia, 17, 5 3 - 5 8 industrial hygiene Philippines, 9 2 - 9 3 U . S . - C a l i f o r n i a , 116 U . S . - H a w a i i , 123 see industrial hygiene infant mortality Canada, 24 Chile, 37, 42, 43, 52; Fig., 35, Tables, 34 Indonesia, 54 J a p a n , 62, 78; Tables, 63 Malaya, 84 Philippines, 91, 92 U.S.-California, 109 infectious diseases, 97, 111, 1 17, 118, 1 19, 122, 124; Tables, Chile, 37, U.S.-Hawaii, 118 influenza, 27, 62, 72, 74, 90, 97, 111, 112, 117, 126 insecticides, 49, 56, 77, 85, 95, 109, 116, 123 Institute for Medical Research, Kuala L u m p u r , 85 institutions, medical and research Australia, 7, 16, 20 Chile, 42, 4 3 Indonesia, 55, 56 J a p a n , 64, 66, 79, 80 Malaya, 84, 85 Philippines, 88, 89, 94, 95 T a i w a n , 45, 47, 48, 50, 54 Thailand, 105 U . S . - C a l i f o r n i a , 110 U . S . - H a w a i i , 118, 119 see laboratories, diagnostic insurance, health, 15, 20, 25, 39; see health insurance International Lists of Diseases and Causes of Death, 63, 6 6 intestinal parasites, 17, 20, 35, 40, 54, 76, 101, 103, 104, 114, 126 Japan, 5 9 - 8 1 Java, 53, 55, 56 Kalaupapa Settlement ( l e p r o s y ) , 122 Kelantan, 85

Kitaoka, Masami, 59 Kodiat, R., 55 Korea, 5, 59 Kuala L u m p u r , 84, 85 Kurile Islands, 59 kwashiorkor, 37, see nutrition Kyushu, 59 laboratories, diagnostic Philippines, 89, 93 Thailand, 102 U . S . - H a w a i i , 120, 126 labor population, J a p a n , 73, 79; Table, 60 Layton, D . B., 23 lead nephritis, 17, see also nephritis -osis Lee, Richard K. C., 117 legislation, public health, 9, 18, 66, 77, 80 leprosy, 20, 54, 74, 85, 89, 9 4 - 9 5 , 102, 114, 119, 120, 121, 127 leptospirosis, 16, 70, 105, 123, 124, 125 life expectancy Australia, 13 Canada, 24 Chile, 40, 41 J a p a n , 59, 62, 74, 80; Fig., 62 Philippines, Table, 98 T h a i l a n d , 104 U.S.-California, 108 life-span, see life expectancy Lombok, 53 Macfarlane, W . V., 13 Malacca, 83 maladies of the social organism, 10 malaria, 16, 17, 35, 46, 47, 48, 51, 52, 55, 56, 57, 76, 83, 84, 85, 89, 92, 9 5 - 9 6 , 97, 102, 104, 113, 123; Table, T h a i l a n d , 102 Malaya, 5, 8 3 - 8 6 Manchuria, 59 M a n g k u w i n o t o , 55 m a n - m a d e maladies, 5 m a n p o w e r , 49, 76 marriages Chile, 32, 33; Fig., 33, Table, 32 J a p a n , 61 mass movements, 4 mastitis, 125 maternal and child health Chile, 32; Tables, 33, 34 Indonesia, 54 J a p a n , 62, 63, 77, 78, 79; Fig., 75 Malaya, 84 Philippines, 91, 92 T a i w a n , 47, 50, 51 Thailand, 105 U . S . - C a l i f o r n i a , 109 U . S . - H a w a i i , 117, 118, 119, 120, 121, 122 maternal mortality, see maternal and child health Mau Mau uprising, 11 measles, 38, 72, 9 7 medical facilities, see medical organization medical geography, 17, 18, 1 1 0 - 1 1 1

132 medical organization Chile, 41, 42, 43 Japan, 80 Malaya, 83, 84, 85 Philippines, 88, 91 Taiwan, 47; Table, 48 U.S.-Hawaii, 119 m e d i c a l r e s e a r c h , 2 5 , 5 5 , 57, 8 9 , 9 0 , 9 6 , 1 2 0 , 125 medical training, international collaboration, 55 N ' e m b e r s of t h e S t a n d i n g C o m m i t t e e , ix, 11,

n u r s i n g , 4 3 , 4 7 , 50, 5 1 , 7 9 , 8 0 , 9 1 , 1 0 1 , 1 1 0 , 1 1 9 120, 123 nutrition, 37, 41, 51, 55, 56, 59, 64, 66, 73, 79, 81, 83, 89, 90, 94, 101, 109

see

Committee Members, Standing m e n i n g o c o c c a l i n f e c t i o n s , 70; Fig., J a p a n , 71 m e n t a l h e a l t h , 15. 2 7 , 4 1 , 4 6 , 52, 7 6 , 1 0 4 , 1 1 0 , 1 1 1 , 1 1 2 , 1 1 3 , 118, 1 1 9 , 1 2 3 , 1 2 7 m e n t a l retardation, 110, 118, 119 mestizos, 29 metropolitan public health A u s t r a l i a , 13 U . S . - C a l i f o r n i a , 110 Mexico, 38 m i d w i f e r y , 5 0 , 51, 54, 8 4 , 9 1 , 1 0 1 , 105 m i g r a t i o n , r u r a l - u r b a n , 5, 32, 8 8 , 107 m i l k , 1 0 4 , 1 1 5 , 1 1 8 , 125 M o c h t a r , R „ 53 Molukas, 53 m o r t a l i t y , see d e a t h s m o s q u i t o a b a t e m e n t districts, 1 1 3 m u l t i p l e sclerosis, 27 m u m p s , 127 m u r i n e t y p h u s , 111, 1 1 5 , 124 Nagoya, 7 1 N A M R U N o . 2 ( U S A ) , 51 Nanking, 47 n a t i o n a l a n d i n t e r n a t i o n a l aspects of h e a l t h , 4 , 4 7 , 51, 5 5 , 5 7 , 6 2 , 6 6 , 8 0 , 8 4 , 8 5 , 8 6 , 8 9 , 9 6 , 113, 1 1 7 , 1 18, 122 n a t i o n a l h e a l t h services A u s t r a l i a , 15 C a n a d a , 24, 2 6 Chile, 39, 41, 42 I n d o n e s i a , 54, 5 5 , 56, 57 J a p a n , 6 4 , 7(), 7 2 , 78, 7 9 , 8 0 Malaya, 83, 84, 85 T a i w a n , 4 7 , 4 8 , 4 9 , 52 national income, 42, 43 N a t i o n a l P r o g r a m of C o m m u n i t y D e v e l o p m e n t , I n d o nesia, 5 6 N a t i o n a l Science D e v e l o p m e n t B o a r d , P h i l i p p i n e s , 8 9 , 91 Nccalor. see h o o k w o r m n e p h r i t i s , -csis, 17; Fig., J a p a n , 7 5 N e t h e r l a n d s ' East I n d i e s , 54 n e w b o r n , diseases o f , 6 2 , 6 3 , see m a t e r n a l a n d c h i l d health N e w G u i n e a , 17 N e w Zealand, 43 N i n t h Pacific Science C o n g r e s s , 3 nisei, 8 0 Nocardia mastion, 125 noise, 7 8

o c c u p a t i o n a l diseases, 17, 3 5 , 9 3 , 1 1 6 , 1 1 8 , 123, industrial hygiene O k a y a m a , 71 Oncomelania nosophora, 76 o r n i t h o s i s , 7 2 , 1 1 4 , 1 15, 1 2 5 , 1 2 6 - 1 2 7 Osaka, 76 O t t e n , 55

see

P a l a m a S e t t l e m e n t , 122 Parafossarulus (Bithynia). 76 p a r a g o n i m i a s i s , 7 6 , 77 P a r k i n s o n ' s disease, 27 Pasteurella, 115, 1 2 4 , see p l a g u e , t u l a r e m i a Pasteur Institute, B a n d u n g , 57 pellagra, 114 Penang, 83 penicillin, 56, 94, 113, 123 p e r t u s s i s , 15, 38, 7 0 , 9 7 , 1 0 3 , 1 14, 117 Peru, 7 Pescadores, 50 P e s i g a n , T r i n i d a d P., 8 7 pesticides, 4 9 , 56, 7 7 , 8 5 , 9 5 , 1 0 9 , 116, 123 pharmacy, 50, 79, 80, 85 p h e n y l k e t o n u r i a , 110 philanthropy, 41 Philippine H-fever, 90 Philippines, 8 7 - 9 9 physical d e v e l o p m e n t , 64, 65, 66, 80 p i l g r i m s a n d r e f u g e e s , 5, 4 6 , 5 0 , 55 p l a g u e , 3 5 , 4 5 , 4 8 , 5 2 , 5 5 , 6 6 , 102, 1 14, 1 1 5 , 1 18, 120, 1 2 4 ; Figs., J a p a n , 6 7 , T a i w a n , 4 6 p n e u m o n i a , 2 7 , 4 6 , 4 7 , 6 2 , 6 3 , 111, 112, 1 1 3 , 1 1 7 ; Fig., J a p a n , 75 poisoning, 111, 112, 1 ) 6 p o l i o m y e l i t i s , 1 5 , 2 7 , 6 3 , 7 1 , 1 0 9 , 11.3-1 14, 1 17, 1 2 6 , 127; Fig., J a p a n , 72 p o l l u t i o n , a i r a n d w a t e r , 7 8 , 7 9 , 81 population A u s t r a l i a , 13 Canada, 23 C h i l e , 2 9 , 3 7 , 4 0 , 4 1 , 4 3 ; T a b l e , 31 I n d o n e s i a , 5.3, 5 6 J a p a n , 59, 61, 62, 63, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81; Table, 6 0 Malaya, 84, 85 Philippines, 8 7 - 8 8 T a i w a n , 4 5 , 4 7 , 4 8 , 51 T h a i l a n d , 101 U.S.-California, 107-108 U . S . - H a w a i i , 117 p o p u l a t i o n a v a l a n c h e , 5, 7, 3 2 , 6 0 ; Fig., J a p a n , 6 1 p o p u l a t i o n i n c r e a s e , 2 3 , 4 3 , 6 0 , 8 0 , 9 7 , 101, 1 0 7 , 1 1 7 ; Fig., J a p a n , 6 1 p o p u l a t i o n p y r a m i d , J a p a n , See p o p u l a t i o n population avalanche p o p u l a t i o n s , c h a n g e s in q u a l i t y , 6 P r e v i r e l l i , 55

increase,

133 progress, scientific, 43, 54, 8 0 prostitution, 70 psittacosis, 72, 114, 115, 125, 1 2 6 - 1 2 7 public health Chile, 4 2 , 4 3 general, 9 Indonesia, 54, 55, 56, 57 J a p a n , 59, 60, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81 Malaya, 83, 84, 85 Philippines, 88, 92, 9 6 - 9 8 T a i w a n , 45, 46, 47, 4 8 , 49, 50, 51, 52 U.S.-California, 1 0 8 - 1 0 9 U . S . - H a w a i i , 1 1 8 - 1 1 9 , 123, 125 public health administration Australia, 13 Canada, 25 Chile, 42 Indonesia, 54, 55, 56 J a p a n , 59, 60, 79, 80 Malaya, 84, 85 Philippines, 88 T a i w a n , 45, 46, 47, 48, 49, 50, 51, 52 Thailand, 104-105 U.S.-California, 1 0 8 - 1 0 9 U.S.-Hawaii, 118-119 public health research Philippines, 89 U . S . - H a w a i i , 120 public health workers, 8, 79, 80, 105, 120 public nuisances, 78 puerperal sepsis, 33 P u r a n a n a n a n d a , Chaloem, 101 Q fever, 16, 17, 72, 110, 115, 127 q u a r a n t i n e , 66, 80, 115 rabies, 27, 39. 46, 48, 52, 72, 1 0 3 - 1 0 4 , 1 1 4 - 1 1 5 , 124, 126 radiation protection, 28, 109, 1 16, 1 18, 123, 1 2 7 radioactive fallout, 28, 90 Red Cross Canada, 26 Indonesia, 56 refugees and pilgrims, 5, 4 6 , 50, 55 regionally localized diseases, California, 1 1 0 - 1 1 1 rehabilitation, 43, 52, 77, 84, 85 relapsing fever ( t i c k - b o r n e ) , 110, 115 resettlement, 5 rheumatic diseases, 27, 39, 40, 116 rice e n r i c h m e n t Philippines, 90 Rickettsia, see rickettsioses rickettsioses, 16, 1 7 , 6 7 , 68, 72, 105, 110, 111, 115, 124, 127, see Q fever Rockefeller Foundation, 26, 51, 54, 101, 113 Rocky M o u n t a i n spotted fever, 110, 115 rodent ulcers, 18 role, doctor's, 9 R o m e r o , H e r n á n , 29 rural areas, public health Australia, 15

Indonesia, 54, 55, 56 Malaya, 84, 85 Philippines, 88, 89, 91 Thailand, 104-105 Rural H e a l t h D e v e l o p m e n t P r o g r a m , Malaya, 84, 85 Rural H e a l t h Units, Philippines, 89, 92, 94, 95, 96; Table, 88 rural-urban migration, 5, 32 Sakhalin Island, 59 salmonellosis, 68, 69, 75, 118, 124 sanitation, 42, 43, 45, 47, 49, 51, 54, 55, 56, 59, 78, 79, 83, 84, 92, 104, 118 Santiago, 37, 39, 41, 4 3 scarlet fever, 15; Fig., J a p a n , 6 9 schistosomiasis, 76, 77, 89, 9 6 schizophrenia, 112 schooling Chile, 31 J a p a n , 79 T a i w a n , 45, 47, 48, 50 Schüffner, 55 scrub typhus, 16, 17, 72, 105 Selangor, 85 settlement, 6, 84 sewage, 34, 51, 78, 81, 92, 127 Shigella, 67, 118 Shikoku, 59 slaughter houses, 78, 79 smallpox, 38, 45, 48, 52, 55, 83, 97, 103, 11.3, 1 17, 126, 127; Figs., J a p a n , 67, T a i w a n , 4 6 smoking, 14 snakebite, 103 socialism, Marxist, 42 social organism, maladies, 10 social security, 6, 39, 42, 59, 108, 118, 122 Social Security Act ( 1 9 3 5 ) , 108, 122 social workers, 4 3 socio-cultural aspects of health, 8, 4 1 Soesilo, H e r m a n , 53, 55 Stampar, D r . A., 9 standard of living T a i w a n , 45 U . S . - H a w a i i , 117 staphylococcal infections, 111 Straits Settlement, 83 suicide, 62. 63, 75, 112, 127; Fig., J a p a n , 76 Sumatra, 53 surveys, 50, 51, 56, 77, 90, 94, 109, 111, 112, 113, 120, 125, 127 Swellengrebel, 55 syphilis, 37, 70, 93, 1 12, 1 13, 1 2 2 - 1 2 3 , see venereal diseases systems, 10 T a c h e n Isles, 50 Taipei, 4 7 , 51 T a i w a n , 5, 4 5 - 5 2 , 59 T e r b u r g h , 55 tetanus, 69, 70, 117 Thailand, 1 0 1 - 1 0 6

134 Tokyo, 7 1 , 7 5 , 7 6 Townsville, 16, 18 trachoma, 3 5 , 4 6 , 5 0 , 5 1 , 52, 5 4 , 7 2 , 1 0 2 , 1 2 6 transport and communications, 16, 4 2 , 4 5 , 6 6 , 75 Trengganu, 8 5 T r e p o n e m a Control Project ( T C P ) , Indonesia, 57 treponematoses, see syphilis, yaws trichinosis, 1 1 5 , 124, 1 2 5 tropical adaptation, 18 tsunamis, 3 0 tuberculosis, 13, 14, 15, 19, 2 0 , 2 6 , 2 7 , 4 2 , 4 6 , 4 7 , 4 9 , 50, 51, 5 2 , 5 4 , 5 7 , 6 2 , 6 4 , 7 2 , 8 0 , 8 5 , 8 9 , 9 3 , 9 7 , 102, 109, 1 1 1 , 112, 117, 1 1 8 , 119, 120, 125, 127; Figs., J a p a n , 7 3 , 7 4 , Tables, Chile, 3 7 , T h a i l a n d , 103 tularemia, 1 1 5 typhoid, 13, 15, 16, 17, 2 0 , 3 4 , 54, 6 9 , 9 7 , 103, 1 13, 117, 118; Fig., Japan, 6 8 , Table, Chile, 37 typhoons, 4 5 , 7 1 typhus fevers flea-borne, endemic murine, 111, 115, 124 louse-borne, epidemic, 6 7 ; Fig., Japan, 6 8 scrub, mite-borne, tsutsugamushi, 16, 17, 7 2 , 105 tick-borne, Rocky Mountain spotted fever, 17 see Q fever underdevelopment, 3 7 , 3 9 U n i o n of Soviet Socialist Republics ( U S S R ) , development, 4 United Nations, 4, 59, 6 0 U N I C E F , 5 1 , 5 6 , 57, 8 5 , 9 3 , 9 4 , 101, 102 United States, 3 7 , 4 0 , 6 3 , 6 4 , 6 6 , 7 3 , 7 6 , 8 0 , 1 0 7 116,117-127 University of California, 55, 125 University of Indonesia, 55 University of Malaya, 8 4 urbanization, 5, 3 2 , 4 1

vaccination polio, 113, 114, 1 2 6 vaccinia, 127 Valdivia, Pedro de, 38 Van Veen, 55 Vector-borne diseases, Hawaii, 1 2 3 - 1 2 6 Venereal Disease Control Law, Japan, 7 0 venereal diseases, 3 7 , 5 0 , 5 1 , 52, 7 0 , 9 3 - 9 4 , 113, 118, 122 venomous animals and plants, 17 veterinary health and hygiene, 7 8 , 125 virology, 9 0 , 109, 1 1 0 , 112, 1 2 6 visceral larva migrans, 1 2 6 vital statistics, Japan, see Figures, Tables vitamins, 5 5 , 6 6 , 8 0 voluntary health agencies, 2 6 , 5 6

112-

W a l c h , 55 water supplies, 3 4 , 51, 5 5 , 7 8 , 8 1 , 8 3 , 8 4 , 9 2 , 1 0 7 , 113, 1 1 8 weights, J a p a n , Table, 6 5 W e s t Irian, 53 whooping cough, 15, 3 8 , 7 0 , 9 7 , 103, 114, 117 W o r k m e n ' s Compensation, 116, 123 W o r l d Health Organization ( W H O ) , 5 1 , 56, 59, 6 3 , 8 0 , 8 4 , 8 5 , 9 3 , 9 4 , 9 5 , 9 6 , 101, 102 W o r l d W a r I, 6 6 W o r l d W a r II, 4 6 , 4 8 , 59, 6 0 , 6 1 , 6 6 , 6 7 , 77, 83 X-ray mobile units, 112, 121 yaws, 5 4 , 55, 56, 57, 8 3 , 8 5 . 8 9 , 9 4 , Thailand, 104 yellow fever, 3 5 , 5 4 , 1 14 Y e n , C. H., 4 5 Yugoslavia, 9

102;

Table,

zoonoses, 5, 16, 2 7 , 1 14, 124, see specific zoonoses