Laos Health Survey: Mekong Valley, 1968-1969 0824803787

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Health Survey: Mekong Valley 1968-1969 :

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. - o . ¢ ¢ u - r - 1 - - -

.

.=\ SURVEY CON DUCTED AS A ]0INT PRO] ECT OF

The Royal Lao Government Vientiane, Laos

The University of Hawaii School of Public Health Honolulu, Hawaii The Thomas A. Dooley Foundation, Inc. San Francisco, California

Sun7e§7:

Mekong 1968-1969

GAIL F. BREAKEY EMMANUEL VOULGAROPOULOS

'I HP L \ I \ FRSI my PRESS OF l I . \ W A I l H() \ OLULU

1.

Copyright 9 1976 by The University Press of Hawaii All Rights Reserved. Nu part of this work may be reproduced or transmitted in any form or by any means, electronic or mechainical, including photocopying and recording, or by any informaLion storage or retrieval system, without permission in writing

from the publisher. Manufactured in the United States of America

Library* of Congress Cataloging in Publication Data Breakcy,

Gail F

aw:

i--'

Laos health s u r e , Mekong Valley, 1968-1969.

Bibliography: p1. Public health-Laos. 2. Health sutvcysLaos. 3. Public health-Mekong Valley. 4. Health sL1rveys-Mekong Valley. I. \f"0ulgaropoLllos, Emmanuel, joint author. II. Laos (Kingdom).

Ill. llawaii. University, Honolulu. School of Public Health. IV. Thomas A, Dooley Foundation. V. Title. [DNLEVL 1. Health surveys-Laos. W.\900

]L2 BSL] RA54].L28B73 6i4.4'2594 76-14 ISBN U-8248-0378-7

Contents Fore w'Ulld

vi i

Acknowledgments

ix

Introduction

1

Background on Laos

5

Description of the Survey Villages

15

Environmental Sanitation and Related Disease Patterns

27

Cultural Attitudes Related to Health Fertility and Mortality Data Maternal and Child Health Nutrition and Nutritionally Related Conditions Mosquito-Bornc Diseases

38 47

51 54 69

Diseases Transmitted via the Respiratory Route

76

Diseases Transmitted by intermediate Snail I-lost

85

Diseases Transmitted by Direct Contact

9]

Miscellaneous Conditions Summary and Record mendations Appendix A

97

Appendix B Bibliography

102 Ill

119 127

Foreword AS in so many developing nations, reliable health statistics For the Kingdom of Laos are scarce or nonexistent. During the period when it was a part of French Indochina, the authorities seemed to have little interest in public health practices and reporting except as may have related to areas of French domicile. Since independence, continuing warfare, political division, and guerrilla activity have prohibited the development of any national health system or an administrative infrastructure

capable of accumulating and reporting health data. In recent years, the Laotian Ministry of Health has benefited from enlightened and intelligent leadership. its effectiveness, however, has been diluted by problems of politics, inadequate budget, scarce trained manpower, poor communications, and large refugee population groups. Foreign assistance has provided considerable input to aid the government meet the health needs of the accessible urban and rural areas, primarily in Vientiane Prov~

ince and adjacent to the Mekong Rivet. effective utilization of this assistance has been hindered by inadequate information on the health status of the population. The Laos health survey was generated to provide baseline data, thereby assisting the Ministry of health in its efforts to improve

the health of the people along the Mekong River. The Laos health survey in the Mekong Valley as herein reported represents the second cooperative effort between the

viii

LAOS I~lRAI.TH SURVEY

Dooley Foundation and the School of Public Health of the University of I fawaii. The first was a health survey of the Kingdom of Nepal (1965-1966) by Dr. Robert M. Worth and Dr. I . K. Shah and reported in a University Press of Hawaii publication in 1969 . The Laos survey as designed and supervised by Dr. Emmanuel Voulgaropoulos and Ms. Gail F. Breakey was a very difficult and frustrating undertaking, but represents the dedicated and talented efforts of a great many outstanding individuals. It is hoped that, though limited in scope, it will reinforce the data presently available and make a significant contribution to our current knowledge of health conditions in Laos and its future health planning. Verne Chaney, M.D., M.P.H. President, Thomas A. Dooley Foundation, Inc.

Acknowledgments THE labors of many people contributed to the success of the Mekong Valley health survey of 1968-1969 in Laos. Because of the scope of the survey, not every personal assistance can be separately mentioned; however, the efforts of all these people will never be forgotten by those who participated in the survey . Dr. Robert M. Worth, epidemiologist at the School of Public Health, University of 1-Iawaii, generously shared his knowledge and experience gained from the Nepal health survey. He helped in adapting laboratory techniques and survey forms employed in Nepal for use in the Laos survey. Dr. Verne Chaney, president of the Thomas A. Dooley Foundation, was responsible for hiring personnel, selection and provision of equipment, and general financial support of the project. Miss Zola Watson, overseas program director of the Dooley Foundation, was in charge of personnel and of shipping supplies to Laos. Mr. Craig Meyers, administrator of Dooley Foundation programs in Laos, gave support to the project in Laos. Dr. Mary Davia, who had three years previous medical experience in Laos, served as the field physician during the entire survey. Miss Dodie Stokes was in charge of laboratory work for the first ten villages; her previous experience with the Nepal health survey proved an invaluable asset. Loren Senseman, a medical technician with a master's in public health, assisted with

X

LAOS IIIC.~\LTH SUI-WF.\'

laboratory work in addition to working with the advance party. George Little replaced Miss Stokes and Mr. Senseman after the tenth village and completed survey laboratory work. Anne Gilmartin performed many tasks as survey nurse, as did Rose Qrrozak, also a nurse, who assisted with physical examinations

and X-rays. Mr. Truong Van Birth ably assisted in making arrangements with village leaders, in obtaining local transportation, and in serving as medic-interpreter. Mr. Kham Tui, Miss Manichan Plcngrasy, and Miss Aron yen Villareuya also served as

interpreters and were most helpful in assisting the medical team. Five airline stewardesses on temporary assignment to the Dooley Foundation in Laos (Kay Miller, Doris Dieter, Lauralee Gillespic, Lauren Brown and Donna Davis) were of great help to the team by assisting the professignal staff. There are many persons outside the team who contributed much and without whose help the survey could not possibly have been completed. These incl de a number of United States Agency for International Development QU 'XID officials: Charles A. Mann, director; liarIJ. Young, area coordinator (AC) for Vientiane Province; Sanford J, Stone (AC) Savannakhet; Earl Diffendorfer (AC) Pakse; Bob Worley, Bob Dakin, Anthony Cauterucehi, Virati Dharmasakti, Barnett Chessin, _lack Davis, Galen Beery, and numerous people in various service departments of USAID in Laos. Dr. Charles Weldon and Dr. Karen ()I fess of USAID Public Health Department provided much information concerning health and disease in Laos, as did the World Health Organization advisory team of Laos. The lnterna~ tonal Voluntary Service staff and field members were most help-

ful. The American Military Attaché staff and (Jeneral Kouprasith Abhay provided information on the security situation and also provided air transportation where necessary. Dr. Khamphai .-\bhay, secretary of state for Fublic Health, gave his unfailing support and encouragement. The School of Public Health of the University of Hawaii, with a grant (No. GM 15421) from the National Institutes of Health, supplied the computer time. Mrs. Carol Burial, data

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xi

programmer at the School of Public Health, did the programming for data processing. involved in the data analysis were a number of consultants including Dr. Norman Sloan, leprosy specialist; Dr. Jerry ]ohnson, sanitarian; Dr. Pisit (lhularerk, visiting professor in tropical medicine; and Dr. Theodore Bell, epidemiologist-all associated with the School of Public Health. Dr. ]can larkin directed the analysis of nutrition data and Dr. Udomporn Chularerk, student at the School of PLlblic I lealth, assisted in the data processing. Dr.

Robert Marks, formerly chief of the Tuberculosis Division of the Hawaii State Department of Health, read all the chest X-rays and assisted in data interpretation. Special thanks go to Steve Kaplan and Thelma Furukawa. Mr. Kaplan developed the initial sampling plan, and assisted in statistical a r l y and final editing. Mrs. Furukawa oversaw the typing of many drafts and communication with numerous people concerning the manuscri.p.t. W also wish to thank many members of the faculty at the U university of Hawaii who have given valuable help in editing the manuscript. To these people particularly, and many others, including the Laotians, who were so very cooperative, go much gratitude and many thanks. . ..

. .. ..

(Jail Blakey

l~`. Voulgaropoulos

Introduction THE Mekong Valley Health Survey was undertaken as a joint project of the Royal Government of Laos, the Thomas A. Dooley Foundation and the International Health Program, School of Public Health, University of Hawaii. The purpose of the survey was to establish baseline data on some of the health problems found among the people of the Mekong Valley in Laos. It is hoped that the data obtained in fifteen villages representative of this area will augment existing health information and be helpful in developing guidelines to solve these problems . The decision to conduct a survey grew out of the long-term commitment of the Dooley Foundation in Laos and the interest of the School of 'Public Health in health problems of developing Asian countrify The foundation, as well as several other agencies, has been involved for over a decade in assisting the Royal Government of Laos to provide basic curative health services for its people. However, it is increasingly apparent that a comprehensive public health approach is needed to combat effectively the

multiple problems of a large number of the Lao. Anion the health problems that have not yet been substantially red recd are malaria, high infant mortality, schistosomiasis, endemic typhoid , intestinal parasitosis, cholera, dysentery, and tuberculosis. Hospital and dispensary records have provided a fair amount of information on Lao who have sought medical care, however, few reports are available on the health of the general population. lt

'up 1.

I..-XOS HE;\L'llf I SURVEY

appeared that studies of Health conditions and disease prevalence

in the villages would be valuable in gaining an overview of health problems in Laos. ()it of the discussions of Dr. Verne Chaney, Dr. Khamphai Abhay, Dr. Emmanuel Voul aropoulos, and Dr. Robert W'orth, it was fell. that it would be worthwhile to do a health survey of certain areas in Laos. The completed report would achieve an immediate goal of providing baseline data for measuring the effectiveness of the Dooley Foundation programs in Laos. It would also he useful as a basis for instruction in the actual needs of the Lao in public health courses in the medical and nursing schools in Laos. Data from the report could be further utilized in long-range planning for future health programs, which could be implemented as political and economic conditions permit.

The protocol for the survey was designed in January and February of 1968. For several reasons the geographic region of study was to be restricted to the Mekong River Valley, thus

excluding the mountainous areas of Laos. This region appeared to be the least threatened by the military upheaval in and around Laos, and the river offered a good mode of transportation. Approximately 75% of the Lao live on or near the river, SO that the sample would be drawn from the bulk of the population. (This is a

rough estimate and includes the whole valley region where the population density is approximately 180/sq. mi., as compared to inland densities of I 6/sq. mi.) Initially this decision meant that ethnic groups who populate the hills and mountains would not he represented. Subsequently in the field, however, we found we could include four villages representative of these hill tribes,

which are now living in refugee 'villages in the Mekong Valley. The scope of' the study included observation of sanitary conditions, a household interview to obtain census data, information on nutrition, reproduction and weaning practices, and a physical examination including laboratory work on each person in the sample. The original plan was to follow a two-stage random sampling system for choosing the villages and the population within each

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20 LAUS Hl~IAI,TH SURVEY

size of which was about 5 by 12 feet. Down the lane, there were several large houses of five rooms, constructed of a beautiful red wood with ornate carving on the veranda and window frames. A typical Lao house is built on wood stilts or cement pilings, depending upon size, some 6 feet from the ground. The floor and walls are made of bamboo matting or wood. The roof is peaked and covered with rice stalk thatching, or sometimes tile or sheet metal. (irutters are set under the eaves with a trough Teading to a

large drum. A ladder leans against the front veranda, providing the main entrance into the house. Several windows along the side of the house and one at each end provide light and air. The house proper consists of one to four rooms, two rooms were most often seen. The veranda and inner room are social centers, at night the

inner room may be the sleeping quarters for the entire family. Furnishings are simple. The average house has straw sleeping mats, blankets, a few pillows, a few low woven stools, and cooking utensils. More elaborate homes have wooden chairs and tables, wooden bed frames, perhaps mattresses and mosquito nets.

The area under the house is used for storage of equipment, including a loom, a plough and harrow, other farming tools, often a foot-mill for pounding rice, and a variety of sizes and shapes of baskets used for various Functions. Animals arc stabled under the house at night. This is also an activity area where the whole family

may congregate during the day, pantieularly in-hot weather when the rooms above are uncomfortable. The mother may be weaving while chatting with friends; older girls are apt to b`e poundingrice, while younger children play and a small baby is asleep in a net hammock.

Most Lao own livestock which, however, are not always utilized as a family food source. Buffalo and cows are used in plowing; chickens arc often raised to produce eggs or for sale in the market. Only a few households in a village have cows, and fresh milk is never consumed. Many farmers have given up raising ducks, which tend to die of d tick cholera. A few goats were noted

in one village.

DV;SCRIP"1"\0N OF VILL.»A\G}i3

2I

URBAN v11..L.-\G1s SFTTING The three urban sections which were surveyed included Ban Phone Kheng (09; population 1,9()U) in Vientiane; Ban Chamkeo (I 1; population 1,022) in Savannakhet; and Ban Sankalok (14; population 480) in Liang Prabang. Phone Khcng is located on the side of Vientiane away from the river and extends for 6 kilometers outside the city. Bordered on one side by a military camp, it straddles a main road lcadingout of town, along which there is a small produce market and approximately eight stores. (The presence of the military camp does not affect the sampling system, as most military families live inside

the encampment.) There are rice fields belonging to the village. Although some are farmers, many of the village men work as clerks and government officials. There are a large 'Wat and two schools. A city water-s apply tank, from which water is piped throughout the settlement, terminates in public taps. There are no boats, but many bicycles and motorbikes, a few automobiles, and frequent taxi service. lt is also only one-half kilometer from Operation Brotherhood Hospital, which many people utilize. (Operation Brotherhood is a Philippine medical organization which has six to eight hospitals in Laos. The organization operates under the contract to the USA! I).) Houses in this urban area are much closer together than in the rural villages. Many houses arc all wood; 67 are of cement construction in French-colonial style. Traveling from rural to urban areas, we observed an increase in number, size, and sophistication of wooden houses. Unlike homes in rural areas, which are unfurnished, homes in urban sections have wooden tables, chairs, and beds, and a few have plasticcovered living-room sets, children's toys, tricycles, and carts are often seen in the yards. Ban Chamkco is located on the river parallel to the main street of Savannakhet, near a an lac factory and one-half kilometer from the central market and USAID offices. (Lau Ian is a local rice liquor; literally translated as "Lao alcohol.") Again, there are many bicycles and motorbikes. The Thai samlor, a tricycle-like

22

L\()S H1~jAL'III-I SURVEY

vehicle, is utilized in place of the taxi inside the city. Chamkeo has approximately 20 pirogues and small motorbikes. Many people are employed in town as clerks and government officials. Ban Sankalok is similar to Ban Chamkeo. It is also on the river, but while politically a section of Luann Prabaiig, it is located on the outskirts, slightly separated from the main section of town. The 'war is a well-known and important one, and some prestigious families have come from this village. There are three stores and a school. Transportation facilities include 11 pirogues, many bicycles, motorbikes, taxis, and two trucks. There are differences between the urban and rural villages. Living quarters are generally more elaborate in the city. '\ better water supply and a larger variety of meat and other produce are available in the urban market. Medical facilities are more accessible. However, there is also greater crowding in the city. ()Tl-Il*:R

ETHNIC VILLaGer~:S

The four non-Lao ethnic groups surveyed include the Thai Dam (Black Thai), Thai Luc, Mco, and Yao. All are either mountain or mountain-valley people who have migrated into northern Laos from Yunnan Province within the last two centuries. All four groups originally settled in the regions of Muong Sing and Nam 'I`ha and migrated to the Ban Houei Sai area within the past few years as the Pathet Lao took over their villages and surrounding

territory. The Thai Dam and Thai Lue are mountain plains people and are ethnically and linguistically Thai. The Meo and Yao are hill-trihc peoples who have intermarried with the Chinese

for centuries; thus Chinese influence is reflected in language and culture. Only the Thai Lue are Buddhist. The rest are animistic, and the Moo practice a modified ancestral cult in addition to animism. The sociopolitical systems of the Thai groups are semifeudal and built upon two distinct social classes, so that a nohfe class maintains soeiopolitieal power over a commoner class. The Men and Yao sociopolitical structure is built upon a clan system which, in the ease of the Meo, extended originally to a Meo

DES(jRIP'llI()N OF VIl,I..-1GHS

23

nation, while the Yao system docs not extend beyond the village level. The sociopolitical systems of all these groups have been modified from the original, because of their situation as refugees. .-\ more detailed description .of each of the four groups is in Appendix A, and each village will be briefly described below. (Material in this section is based on LoBar, Hickey, a.nd Musgrave 1964; and Young 1961.) The Thai Lue village of Ban Maysingkam (05; pop. 728) is the cleanest and most charming we surveyed. The inhabitants migrated from Muong Sing, approximately four years before the survey. Located three hours up river of Ban llouei Sai, the village is arranged in blocks, with a main thoroughfare leading to the large war and with many cross streets and lanes. A stream meanders through the center and paddies and large gardens are located behind the village. Ban Maysingkam appears to be of average wealth compared with other survey villages and has an equal number of wood and bamboo houses. The houses are similar to Lao houses; one notable difference is that the cooking area of the Thai Luc house is in the main room instead of in a separate kitchen. In addition to the usual animals, Thai Luc have ponies which arc stabled under the house. Each house is surrounded by a usually well-swept yard and a bamboo fence. There are several stores, a rice mill, a lumber mill with five elephants owned by a family from Thailand, a seamstress, and three silversmiths. The c a o Muong for the district lives at Banon and maintains an office. There arc 46 bonzes and novices in the war. Every morning a few women travel 1 kilometer to market in the next village where a / medic works in a clinic. Villagers often use it instead of traveling

to the hospital in Ban Houei Sai. There is considerable travel to nearby bozms,to Ban Houei Sai, and to other areas many kilometers away to visit friends and relatives. From this, it may be assumed that social and perhaps political relationships with other Thai Luc villages have not completely broken down. The c/Jao Muong mentioned a general increase in illness, particularly malaria, during the rainy season, but could not remember any real epidemics there.

24

LAOS HFi,=\L'llH suwlw

The Thai Dam village of Tong Om (07, pop. 165) suffers the poorest living conditions of all villages surveyed. lt is located 20 kilometers inland from Ban Houei Sai. Tong Om is a temporary refuge within a complex of Thai Dam villages which have been in this location for about a year awaiting transfer to a permanent settlement 3 kilometers away. The inhabitants originally lived in Nam Tha. The complex is located inland, about a 25-minute walk from the river. There are no stores, no markets, only a. few paddies and gardens, and very little livestock. The food supply is thus meager, based mainly upon the small amounts of rice grown, supplemented by US.'\Il) rice, and forgings from the forest and streams. There are no transportation facilities except for a tractor, which belongs to the village priest. Boats come near the vicinity very infrequently; the nearest regular boat service is 12 kilometers away. lt is difficult for these villagers to get to the nearest medical facility at the Ban Houei Sai Hospital. Although it is a bleak place, the inhabitants remain surprisingly cheerful and energetic. This seems principally d u e to the presence of the Catholic priest, who is most solicitous of their welfare. llc runs the school, ho] Cis L

religious services every evening, and maintains a clinic to the best of his ability. In addition to apboban, there is a Chao muong whose

office is nearby in the complex. A military establishment is about 1 kilometer away, supported by an airfield serviced by the US \ID. A well was built in the neighboring Tong Chi Tai with the help of the USAID. .\s the population of Tong ()m is only 165 persons, we included a statistically random sample from this village. Tong Chi Tai is also a Thai Dam refuge of 16 households, and is only a few minutes walk from Tong Om..

The people of the Men village of Ban Nam Nagao ((iS; pop. 250) ca me from the region of Nam Tha about four years ago. Nam Nagao is located about 10 kilometers north of Ban Houci Sai and 3 kilometers inland from the Mekong in a hilly section of the valley. The Meo in Laos traditionally live in the mountains at approximately 5,000 feet altitude. This village is haphazard in appearance; no grass grows as a result of the foraging of animals, and the entire terrain is either dust or mud, depending upon the season .

l)iis(lRl p'Ill(_)n (JF VILLAGES

25

All survey houses but one arc made of bamboo matting. This indicates that the village is quite poor since the Meo usual]y build their houses of wood. Nearly all houses are noted to have moderate to severe deterioration. Unlike the Lao, the Men build their

houses on the ground. The front sections of a Meo house serve as the working and social area. 'l`w o hearths are constructed, one for cooking and the other for social gatherings. A spirit shrine is set up in a special area in the main room. VlTlork implements and personal possessions are strewn along the walls; corn and pieces of meat are

hung from the roof over the hearth to cure. Sleeping quarters are partitioned off at the rear of the house if the house is large enough . The roofs are of thatch or wood. Sheds are built around the house for use as granaries and stables. As an extended family gets larger,

the son's families build their own houses near the parent's house. livery family has at least one pony, the chief mode of travel. There are small pirogues, but no bicycles or other vehicles in this village . The Catholic priest holds sick call. The trip to the Ban Houei Sai hospital involves walking 3 miles to the river and catching a public river boat. In social characteristics, the Meo differ considerably from the Lao. In general, they arc characterized by an aggressive, independent spirit. They are avid hunters, and have developed their own style of crossbows and rifles. They cultivate dry, hill rice and gardens, and one of their major cash crops is opium. They are renowned as shrewd traders. Two major social problems are noted in this village. First, the

resident Catholic priest feels that inbreeding has resulted in some "mental deterioration." Second, the priest pointed out 22 families in the village that have at least one opium smoker. The priest estimates that the average smoker spends 4 bahtfday and that the

heavy smoker spends 8 baht/day for opium. (One Thai baht equals about five U.S. cents.) At that rate, the yearly sum would range from $72 to $144, which is equal to or more than the average yearly income. This disastrous expenditure results in poor nutrition for the family. Pigs and chickens are sold to buy opium, and the children eat only rice and a few greens. The addict's health is

26 LAOS H1~1.1xL'rII SURVEY

drastically affected. Wf c found one old man, little more than a living skeleton, huddled by the household fire. An addict for over thirty years, he died ten days after the survey team left the village. '1`he Yao village of Ban Houei Au (06, pop. 1,060), located an hour up river from Ban Maysingkam, is one of the most interesting that we surveyed. its people appear to be living in the normal Yao tradition and to be little affected by their refugee status. The village encircles the top of a hill, and, with a section extending down along the river, forms the shape of a Q. Most of the people came from the Muong Sing and Nam Tha regions from six to twenty-four months before the survey. The people, particularly the t s e n g and some of the older men, are Mongoloid in appearance. The village is fairly wealthy in appearance, as many animals roam about. The Yao houses, similar in style to those of the Meo, are large, and several of them are like one-story apartment buildings,

usually housing an extended family. The tassel's house, for example, is long, the size of three houses together, and made of a red wood with heavy doors, wooden floors, a few windows, and a

tiled roof. There are three main rooms, and a hallway in back leading to many sleeping cubicles. Seventeen people live in the house; each main family group occupying one of the large rooms. Furnishings include wood-frame beds, tables, chairs, a stove, many agricultural tools, saddles, cooking utensils, and baskets. Other houses resemble this arrangement on smaller scales, some houses are made of bamboo. There are several stores in the village, located next to a Thai Lue village, it also has access to the stores there. f\ large lumber

mill is located in the Thai Luc section, but apparently the owners hire only Thai Lue. The Yao keep ponies for transportation and do not have pirogues. However, they frequently use the large public motor-powered river boats.

Environmental Sanitation and Related Disease Patterns S.'\Nl'll.-\RY c c routinely observed \ conditions were for evcrv survcv y household in each village during a househol cl interview (see Appendix B). Most of these observations are presented in Table 2. During the last part of the survey, a sanitarian who had spent several years in Thailand was with the team and contributed his observations. The World llealth (.)rganization

sanitarian in Vientiane was consulted for his impressions of sani-

tation in Laos. It is the opinion of these experts that sanitary conditions in Laos were similar to those noted in a United States

Operations .\'lission (USUN-'1) report on Northeast Thailand (Reynolds 1966).

W.-WER SOLJRCI-:S .-'-\ND sTop =\c,1~; People obtain water from six sources: the Mekong River, tributary streams, rain catchments, shallow seasonal wells, shaft wells, and centralized tower systems that draw from a well.. The only sources that do .not appear grossly contaminated arc the newer,

covered, cement ring wells with pumps, ant1 the water-tower system. Although these arc cleaner than other sources, they cannot he considered completely safe, as they arc untreated. The Mekong, streams and shallow and uncovered wells are subject to gross colltamination by surface runoff and groundwater containing human and animal feces. Wells from which water is obtained by a bucket are subject to contamination from the bucket's being set down on contaminated ground .

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34

'L-ws HEALTH

SURVEY

gram, it seems probable that most of the positive reactions detected were due to recent infection rather than to previous inoculation. In considering the water supplies and general sanitation of the villages where high titers were found, it was noted that the four southern villages have no privies and use mainly river water for all purposes (sec Table 2). Opportunity for fecal contamination of drinking water was considerable. \Vell water was available to the population in the Vientiane area, but only45% of the people claimed to use it. Sanitary conditions within the homes of the more crowded urban area may have also contributed to the higher proportion of people with positive reactions. . .. .

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urban and military areas. This was one of the villages having the lowest rate of positive serological reactions for syphilis. Also, no trachoma was noted here. The most w idespread sign of nutritonal deficiency was angular stomatitis, which was found in every village. A few persons with Faso-Iabial-seborrhea were also found. Dvspigmented or lusterless hair was found in all villages. \ \early 8. 5 % of the population, including one-third of the popula-

tion of Village 08, demonstrated these hair changes, and 10% of children under six, including half of this age group in Village 08 , had these symptoms. Scarlet tongue, atrophic papillae, and tongue fissures were found in many villages. Some 10 to 20% of the hill-tribe population had scarlet tongue. A total of 100 enlarged thyroids were found in the survey sample. The highest prevalence was found in the refugee villages; 18% of the population of the Yao village (06) had goiters . FOOD A:\'D DIETARY FINDINGS Household interviews were done by three trained Lao interpreters in order to obtain a 24-hour family' dietary recall. Amounts were described in terms of usual household utensils; such as half a coconut shell, various sizes of bowls, and in kilograms. The wife

was usually the informant. In evaluating these data, it was necessary to discard some household data where Elm()llI'lts were not recorded (see Tables 12, 13). The actual 24-hour intake per household was calculated both in terms of nutrients and in amounts of food groups consumed. (Average minimum per capita food intake by area and average minimum per capita dietary

intake by village are shown in Tables 14 and 15.) Although a 24-hour recall is a crude technique, the large sample size and the wide seasonal variation increases its credibility. However, we recognized the possibility of recall error and underreporting and consider these group values as minimal estimates. The dietary calculations do not show distribution of food intake within the family. The calculations conceal the fact that mothers and children likely receive the lowest intakes. In some households a preferential pattern of eating is followed in which

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