The incidence of environment related illnesses in North Bengkulu, Indonesia.

Introduction

The western environmental health professional working in rural areas of Southeast Asia is likely to be amazed and overwhelmed by the range and nature of conditions that fall within the scope of his or her responsibility. For this reason, as more sanitarians and environmental health specialists become active in research and employment in this part of the world, they must be aware of the problems likely to be faced in order to develop effective and efficient solutions. This study provides a "snapshot" view of the state of environmental health in the North Bengkulu region of Bengkulu Province, Indonesia, and may serve to outline the conditions that exist in rural Indonesia as well as in other Southeast Asian nations.

The province of Bengkulu is located in the southwestern part of the island of Sumatra, bounded on the west by the Indian Ocean. It is divided into three large administrative areas. The most northern of these is North Bengkulu with an area of 9,585 square kilometers and a population of 335,321. Of these, 11,442 are under one year of age and 48,580 are between one and four years old. The area is served by one general hospital, 33 puskesmas (health centers), 148 puskesmas pembantu (auxiliary health centers), 29 puskesmas keliling (mobile health centers), and 605 posyandu (health posts). This compares favorably with healthcare available in other parts of Indonesia, but because the population of North Bengkulu is primarily rural and scattered, there is a need for more comprehensive facilities (1). The healthcare establishment in North Bengkulu is staffed by 37 doctors, 9 dentists, and 337 other medical practitioners, including registered nurses (1).

Data

The data discussed here were collected in connection with the 1991 annual Health Profile for North Bengkulu which is designed to survey the instances of serious illness in the region as well as the facilities available for treatment and prevention. Figures were tabulated based on records made by healthcare personnel for patients seeking treatment at the hospital, health centers, and health posts throughout the region. For each set of data presented below, "percentage of total cases" refers to the portion of all cases treated for any reason at all healthcare facilities.

While the data collected concerned serious illnesses of all types, the present study is limited to those conditions arising from or involving an environmental component. Table 1 shows the incidence of several illnesses related to environmental conditions that occurred in North Bengkulu in 1991 across all age groups as well as the percentage of new patients treated for that illness. It should be noted that "tertian malaria" refers to falciparum malaria while "clinical malaria" refers to other types of malaria, notably vivax. The distinction is made because of the considerably more serious clinical picture presented by falciparum malaria and its higher case fatality rate which may reach 10% (2).

Overall, 38.54% of patients treated at healthcare facilities in North Bengkulu during 1991 were suffering from some illness involving an environmental component. Malaria, which is considered locally to be of most concern to medical and public health workers, accounted for 24.1% of all patients treated. However, most of the cases were of the less severe form of malaria. Another 12.6% of patients were treated for some diarrheal disease, of which about one-fifth were identified as having bacillary dysentary.

Table 2 shows the incidence of these illnesses for children under the age of one year and also includes neonatal tetanus which is specific to this age group.

Over 44% of patients under the age of one year seeking treatment at healthcare facilities in North Bengkulu in 1991 were suffering from an illness with an environmental component. Diarrhea, including bacillary dysentary, accounted for 32.6% of those treated. Some form of malaria, with falciparum significantly less frequent than vivax, accounted for 10.2% of the total cases treated for this age group.

Table 3 shows the incidence of environment related illnesses occurring among children aged one to four years in North Bengkulu during 1991.

Review of the data indicates that the incidence of the various environment related illnesses of interest here varies with the age group under consideration. For all ages, the incidence of malaria is greatest. Diarrheal illnesses are second when all age groups are considered. Not surprisingly, for children, the incidence of diarrhea is greater than that of malaria, although malaria is clearly a serious problem among children aged under one year and those aged one to four years. This fits with the well-known pattern in developing nations where diarrhea poses a serious threat to infants and young children (3).

Table 1. Incidence of Environment Related Illnesses in North Bengkulu in 1991
for All Age Groups and Percentage of Total Cases Treated.

                                  Cases       Incidence/      % Total
                                 Treated     100,000 Pop.      Cases

Clinical Malaria                  9,571        2,793.63        23.5
Diarrhea (Agent Unknown)          4,198        1,225.33        10.3
Bacillary Dysentary                 941          274.66         2.3
Ascariasis                          427          124.63         1.04
Typhoid                             313           91.35         0.8
Tertian Malaria                     248           72.38         0.6

Total                            15,698           --           38.54
Table 2. Incidence of Environment Related Illnesses in North Bengkulu in 1991
for Children Under the Age of One Year and Percentage of Total Cases Treated
for this Age Group.

                                  Cases       Incidence/      % Cases
                                 Treated     100,000 Pop.     Treated

Diarrhea (Agent Unknown)            938        8,197.87        30.8
Clinical Malaria                    409        3,574.55        10.0
Bacillary Dysentary                  73          638.00         1.8
Ascariasis                           35          305.89         0.9
Typhoid                              12          104.88         0.3
Tertian Malaria                      11           96.14         0.2
Neonatual Tetanus                     3           26.22         0.07

Total                             1,481           --           44.07
Table 3. Incidence of Environment Related Illnesses in North Bengkulu in 1991
for Children Under the Age of One to Four Years and Percentage of Total Cases
Treated for this Age Group.

                                  Cases       Incidence/      % Cases
                                 Treated     100,000 Pop.     Treated

Diarrhea (Agent Unknown)          1,587        3,266.78        18.5
Clinical Malaria                  1,332        2,741.87        15.5
Bacillary Dysentary                 266          547.55         3.1
Ascariasis                          150          308.76         1.7
Typhoid                              49          100.86         0.6
Tertian Malaria                      36           74.10         0.4

Total                             3,420           --           39.8

The high incidence of diarrheal illnesses would seem to indicate serious problems with water supply in North Bengkulu. While the region certainly has no shortage of water, it does lack centralized systems for providing drinking water, disposing of wastes and waste water, and providing sewage treatment for most of its population. This is a general condition in rural as well as urban areas in Indonesia (and in many other developing countries) (4).

In North Bengkulu, approximately 4.7% of the population has access to water piped from a central distribution point. Another 3.5% use water from a standpipe connected to an unregulated source. Hand-dug shallow wells provide water for 24.5% of the population. Rain water is the source of household water for 2.9%, while 3% depend on springs. Most of the population, 61.3%, rely on water from other sources including streams, rivers, and ponds (5).

With the exception of those enjoying piped water and those who collect rain water, most of the population of North Bengkulu take their household water from sources which provide considerable opportunity for infection with the diarrheal illnesses common in the region. Shallow wells and open water may be particularly susceptible to contamination with disease-causing organisms through runoff from areas where livestock are kept or which are used as privies. Approximately 23.6% of the population use outdoor privies located wherever is convenient regardless of the proximity to the source of drinking water. When indoor plumbing is in use, septic tanks are usually located wherever space permits and are rarely installed by trained personnel. They may serve as another source of contamination of drinking water.

The population of North Bengkulu is generally knowledgeable about the need for boiling drinking water before use, although it is likely that many do not understand the actual method by which this makes the water safe to drink. Boiling is done more by habit and custom than through knowledge. Nonetheless, lack of adequate boiling, failure to use boiled water for preparation and washing of food to be consumed raw, as well as accidental ingestion of contaminated water may contribute to the high incidence of diarrheal illnesses in the region.

The high incidence of malaria noted in North Bengkulu indicates a problem with vector control and availability of breeding sites. There is generally no shortage of water suitable for harboring mosquito larvae. The larvae are frequently found in flooded rice fields (where local residents sometimes introduce larvae-eating fish), semi-permanent puddles, tree stumps, and parts of human dwelling places where water can collect. Stored drinking water rarely serves as a breeding site for mosquitoes in North Bengkulu, as it may in many parts of the world where water is scarce (3), because water is plentiful making storage for long periods within the house unnecessary.

Because the Anopheles species of mosquito, which act as a vector for malaria bites in the evening, the type of dwellings in use in North Bengkulu may have some bearing on the spread of the illness. Only 50.5% of the population occupy dwellings termed "permanent" under the classification system of the Indonesian census, while 29.5% live in structures classified as "semi-permanent," and a full 20% occupy dwellings that are "non-permanent" (5). The designation "permanent" refers to a house that is built entirely of brick or concrete. A "semi-permanent" dwelling is partially brick or concrete (foundation, structural supports) with most of the structure of wood or other materials. A "non-permanent" structure is built entirely of wood or materials other than brick or concrete. Many houses are built wholly or in part of woven bamboo, and only houses constructed of brick or concrete might possibly have internal walls finished in plaster. For this reason, dwellings classified as "semi-permanent" or "non-permanent" often have many chinks and gaps, that would not be present in a more sturdily built dwelling where mosquitoes can enter. The use of mosquito nets while sleeping might have an effect on the opportunity for mosquitoes to bite, but how widespread the use of netting is in North Bengkulu is unknown.

The incidence of typhoid in the North Bengkulu region, while not great in comparison to other illnesses present in the area, is nonetheless of concern due to the case fatality rate which may reach 10%, and the rate of relapse which is 5 to 10% and may be higher (2). Because typhoid is transmitted through food or water contaminated by Salmonella typhi (2), the presence of this illness in North Bengkulu may signal a general lack of hygiene surrounding the preparation of food and the separation of privies from sources of drinking water.

Ascariasis has also been found to be a problem in North Bengkulu. Not surprisingly, the incidence of this parasitic infection is highest among the one to four year old group. Children this age are mobile and, in the hot damp climate, are often barefoot and scantily dressed. Their games and activities probably provide ample opportunity for infection with Ascaris lumbricoides through ingestion of egg-infested soil on their hands or which may be carded inside and ingested with food.

Conclusion

Data from the annual Health Profile show that a range of illnesses with an environmental component are present in the North Bengkulu region of Indonesia. The situation here may serve as a good indication to environmental health professionals of what conditions they may face while working or conducting research in rural areas of the developing nations of Southeast Asia and may be helpful in developing effective methods for the improvement of environmental health in these areas.

References

1. Profil Kesehatan Kabupaten Bengkulu Utara (1992), Dinas Kesehatan Kabupaten Dati II Bengkulu Utara, Bengkulu, Indonesia.

2. Benenson, A.S. (1985), editor, Control of Communicable Diseases in Man, American Public Health Assoc., Washington, DC.

3. Morley, D., J. Rohde, and G. Williams (1989), Practicing Health for All, Oxford University Press, Oxford, England.

4. Hardoy, J.E. and D.E. Satterwaite (1987), "Third World Cities and the Environment of Poverty," World Health Forum, 8:86-93.

5. Statistik Kesehatan Lingkungan (1992), Pusat Kesehatan Lingkungan, Bengkulu, Indonesia. Source not cited in text: Sensus Indonesia (1992), Kantor Statistik Kabupaten Dati II Bengkulu Utara, Bengkulu, Indonesia.