A Life for Ten Cents

by S. M. KEENY

1

IN ASIA at least one child in five dies before it is a year old. Until fairly recently it was generally assumed that this had to be. But in the last decade discoveries have been made in medicine that provide wholly new methods of attack on diseases that could not be brought under control before simply because it cost too much. With DDT we can wipe out malaria; with antibiotics we can cure yaws and trachoma; we can vaccinate successfully against t.b. But in Asia, with one third of the world’s population (there are 250 million children, excluding those in China), the job must be done on a gigantic scale.

Most readers have probably never seen a case of yaws, nor had I until five years ago. Then I found myself unexpectedly packed off to Bangkok to take charge of the Asia Office of UNICEF (the I nited Nations Children’s Fund), and I soon saw yaws aplenty.

Yaws is a disease of the tropics which is highly contagious. It is spread by direct contact from the open sore of a victim. In the villages, where nearly everyone goes barefoot and barelegged along paths bordered by briars and sharp-edged weeds, scratches are plentiful. In Indonesia more than half of the open sores start below the knees and often on the soles of the feet.

In Djakarta, the capital, Dr. Leimena, the Minister of Health, confirmed that there were millions of cases. There were few in the cities, but in the villages probably one person in ten had the disease. This meant at least 6 million cases, in every stage from the first raspberry-shaped ulcers and open sores as big as the palm of your hand to advanced cases where the bedridden patient was a mass of scars, with locked joints and wasted muscles.

The government was in a losing fight against the disease; 1500 rural “polyclinics,” each manned by a single male nurse, had been set up, where the patients were being treated with arsenicals. The disease could be cured if the patient came back perhaps ten times. Unfortunately, this seldom happened. After three or four treatments the sores healed, the patient thought he was cured, and that was the end of the matter— until the sores broke out again. Even if the case was cured, the patient could catch the disease again from others in the same village who had it.

The only way to get rid of yaws, said Dr. Leimena, was to go to the villages and treat all the cases. Otherwise the disease would keep spreading, for every child who had it would give it to others. But the outlook was not bright. There was a terrible shortage of doctors. As for the male trained nurses or mantris, the backbone of the rural health services, they were even scarcer, for the training courses during the war had largely collapsed. Even if the men were available, there was no money with which to expand health services. If anything more was to be done, it would have to be done with the existing trained staff, and with not many more rupiahs than were already being spent. The people were fatalistic: they believed that most of them would get yaws sooner or later. If sooner, then it was the will of Allah. Dr. Leimena had heard that the new drug, penicillin, might shorten the treatment. If this were true, and if they could get the penicillin, and if the nurses could be transported to the villages, something might be accomplished. The best man to consult was Dr. Kodijat, who was trying out some new methods in Central Java.

Dr. Kodijat is a cautious man. He told me that he thought penicillin would do the job; but, to make sure, he was treating a number of cases in a little hospital he had set up at Headquarters, where he could see day by day what happened. He showed me one case, a boy of two, who was covered with sores from head to foot. “If he’s cured, I’ll send you a photograph.”

Within a month there arrived two pictures of the little boy — one of him as he came to the hospital covered with ulcers, the other taken two weeks later. All the sores were gone. The skin was smooth and healthy; only the light spots of the new skin showed.

But it’s a long road in Indonesia from curing one case to curing a million a year under village conditions. Teams of field workers had to be trained and equipment and supplies found. We started with a dozen secondhand jeeps bought from the UN Trustees Commission — some of them are running yet. At the beginning UNICEF had to help out not only with laboratory equipment, sterilizers, syringes, and needles, but with office equipment from typewriters to carbon paper. We did not even have a service station to care for the jeeps. We really started from scratch.

In 1950, only 34,000 cases were treated; in 1951, 228,000; in 1952, 292,000; in 1953, 596,000. By 1953 we had reached the maximum number of cases that could be handled annually because there were no more male nurses to be recruited. It takes several years to train a nurse, and the Indonesian staff in East Java had been experimenting with an even simpler system than the mobile teams of half a dozen nurses. They now proposed that the case finding be done by young men with the equivalent of an American high school education. They had found that youngsters of this type could be trained in three months to identify cases of yaws and to assemble them on a given day to be treated by the nurse from the nearest clinic. The youngsters require more supervision, of course, and to provide this we promoted the best of the original mobile teams.

In 1954 we examined more than 10 million people and we treated more than a million. This job was done with only ten full-time Indonesian doctors and the part-time help of three UN staff— a serologist, a statistician, and an expert to appraise the work. As the number of treatments went up, cost went down. In the last four years the cost per case has dropped from about five dollars to eighty cents. And remember that every case treated means that about ten persons have been examined to find that case.

Of every dollar spent on this yaws program, the local government pays about two thirds. The entire cost to the UN for treating the million cases in 1954 was about $250,000. If you divide that among the 10 million persons examined (all of whom know and talk about the program), it comes to a little more than two cents each. What price international good will!

Of course they talk about it. Imagine what would happen in an American village of one thousand if a hundred persons, some limping, some unable to work, some bedridden, and all in pain, had their disease cured or arrested within a single month.

To the Director of Public Health all this means much more than the conquest of a single disease and the suffering that has been ended. It means that, when the next health campaign is to be started, the villages cured of yaws will be willing allies. Yaws campaigns are in many respects the ideal beginning of a better rural health service: the percentage of cures is very high — more than 90; the cure takes place within weeks and can be seen by everybody.

Up to now this sounds like the perfect success story in public health. But to get rid of yaws we must cure not only a lot of infectious cases, but all of them; and we must be sure that new cases do not break out and start the same cycle over again. Other mass campaigns, especially in Haiti, have shown that the later outbreaks can be practically wiped out if the whole population is given a small prophylactic dose. This must be done and it will be done — if there are penicillin and someone to inject it. With penicillin costing a dime per treatment and a population willing to walk miles for it, the job will be finished.

2

ANOTHER health campaign, still largely in the planning stage, is that against trachoma. Here again, the weapons of attack — aureomycin and terramycin — have become available, in the right forms and at the right prices, only within the last two years. The problem is primarily one of organization; for the cases must not only be found and progress checked monthly by a doctor’s diagnosis, but the ointment must be placed in the child’s eyes at least twice a day for at least two months. This means in practice that only children in school can be treated, and that the teacher or an older pupil must do the job. Even then good results are reasonably assured only if the children are in school morning and afternoon; and in the overcrowded East many of the schools have two or even three sessions daily.

In this campaign Formosa is showing the way with 1.3 million children being tested in an eighteenmonth period that will end in the spring of 1956. One third have already been tested — about half of whom have trachoma and another fourth conjunctivitis.

On a plan worked out with the assistance of an expert World Health Organization consultant and under the supervision of local eye specialists, doctors and nurses from each of the 365 health centers serving the island have been given short courses in identifying the disease. Each of them may have from 3000 to 5000 children to examine. On a carefully planned schedule, each doctor and his nurse work full time at the job for perhaps a month at the rate of 30 to 60 children an hour. All school superintendents are being taught their role, and they in turn bring together the teachers, who learn from a nurse how to apply the ointment.

Last November I dropped in to see how the system actually worked. Expecting to find a harassed teacher and squalling children, I was astonished at what I saw. The teacher gave the signal for the drill to his 50 children. At once all the children put on their armbands, each with a number. Half a dozen put on another kind of band — the Red Cross Committee. One child produced the list of children to be treated. Another manned the washbasin, for hands must be clean. Another issued the numbered tubes of ointment — to avoid cross infection — and saw to it that each child got his own. Then the queue formed, and the teacher drew down the lower lid of each eye and applied the ointment. Still another youngster handed out two small squares of tissue paper for each child to lay on his eyelids while he gently rubbed them to spread the ointment. Then the tubes were collected, and the children returned to their seats. Time elapsed: five minutes.

When the present campaign has been completed, each incoming class will be examined and treated in the same way, so that the chances of clearing up the disease in the schools are fairly good. But, to assure control, every case in every home must eventually be treated, especially in preschool children. A large order.

Even if the Formosa program is successful, it will not bring all of the answers for the other countries of Asia. Preliminary tests in Indonesia show almost as high a percentage of cases as in Formosa, although the local estimates were previously only about 20 per cent on Java and probably less on the other islands. Even on this basis, there are at least 10 million cases in this one country. School attendance in Indonesia is much lower than in Formosa, but there are 6 million children in schools in Java alone.

In planning anti-trachoma campaigns for Asia, we must start with the fact that nobody knows even roughly how many cases there are of this disease — probably the largest single cause of blindness in Asia. But the prospect is that the fight will be far bigger than that against yaws. The cost, too, is relatively high: about a dollar a case, of which thirty cents goes for the antibiotic. But prices are coming down and we are learning as we go. In five years the job should be well under way and expanding as the campaigns against yaws and malaria pass their peak.

3

THE campaigns against malaria are less spectacular than those against yaws but even more important. The number of people exposed in malarious areas in Asia is not less than 300 million, or about three times as many as are threatened by yaws, and they are to be found in practically every country instead of mostly in Indonesia and Thailand.

Malaria is the number one killer of children, especially infants. Farmers fear it because it devastates the workers at planting time and because it keeps out of cultivation otherwise excellent farm land; for when a large area of rich land is badly infected, farmers can cultivate only along the edges because they must get out of the danger zone before the sun goes down. Public health officers dread it because it makes such demands on their staff, hospital beds, and money.

When I was Mission Chief of UNRRA in Italy after the war, the Italian government got rid of malaria in Sardinia with the best technical aid from the Rockefeller Foundation — but at a cost of about ten dollars per person for the population of about one million. At this rate the protection of the 300 million in Asia would cost $3 billion.

But in the second half of the forties a wholly new method of using DDT was worked out that cut the costs by perhaps 90 per cent. When I arrived in Asia, early in 1950, I found that WHO was already testing with DDT in India, Pakistan, Burma, and Thailand. India and Pakistan had perhaps three fourths of all the malaria in Asia. All sorts of local adaptations had to be met, but in general the method worked, and at an estimated cost of only fifteen or twenty cents per person per year if the attack could be extended to cover millions of persons instead of the thousands in the tests.

UNICEF’s funds were limited, but we offered to match the government ton for ton in the increasing purchases of DDT needed. This meant that the government still had to pay about three fourths of the bill, for the cost of spraying almost equaled that of the DDT itself. But our offer was enough to start small mass campaigns, especially since it cut in half the need of foreign exchange for the campaign.

Then came the development of economic aid from the United States, with its emphasis on increasing production of food, the basic need of Asia. But to raise more food there must be less malaria, so that the U.S. recommended fighting malaria wherever the tests promised success.

The job was too big for UNICEF alone, so we offered to transfer to U.S. jurisdiction any of our programs they would accept, and to maintain the supply line until the other agency could deliver its DDT. We continued to help Pakistan in part because the U.S. funds for public health were not enough to meet all the urgent needs. At Burma’s urgent request, UNICEF took over support of the Burma campaign after the U.S. withdrawal from that country. These steps kept the work already done from being lost, and protected the people in the areas treated from the epidemics that sometimes follow when a campaign is stopped too soon and the people are left vulnerable after having lost the partial immunity developed after years of exposure to the disease.

In a word, the concern of all the agencies in the field is not who does the job but that it gets done. And it is getting done. Five years ago, only 15 or 20 million people were being protected. By the end of 1955, about 150 million will have had at least their first year’s protection.

As insurance against an indefinitely long drain upon its limited funds, UNICEF is helping several countries to make their own DDT. Two small plants already completed in India and Pakistan will produce enough DDT to protect 40 million persons a year or to do the necessary follow-up covering many more.

4

SECOND only to malaria as a killer in Asia is tuberculosis. It differs from the other diseases we have been discussing in that it is worst in the cities. In some of them, such as Bangkok, mass X-ray examinations of thousands of people from typical groups suggest that one person in twenty that one passes on the street has active tuberculosis. UNICEF and WHO have helped install about a dozen diagnostic and ambulatory treatment clinics, which receive from 4000 to 20,000 visits each month. This is a godsend for those sufferers who can attend these clinics, but it touches only the fringe of the problem. Moreover, most governments have not had the means to add many new clinics to meet the demand, and those started soon find so many cases that the few hospital beds become crowded — and there is no money for more.

UNICEF has therefore decided for a time to concentrate on vaccination by the BCG (Bacillus Calmette Guerin) method, which has helped reduce t.b. in Western Europe, particularly in Scandinavia, where levels in some countries are below that in the United States. This method offers no help for those children who have already been infected or who have developed a “natural” immunity against it through contact with active cases. But for the rest, usually about half, it offers a protection that among American Indians has been shown, over a period of ten years or more, to run about 75 to 80 per cent. Even if the figure for Asia turns out to be considerably lower, the job will still be well worth doing: it is the only preventive measure that Asia can afford.

In 1954 the total number of children tested had reached 73.6 million, with 32.5 million done within the year. This year’s target of 37.5 million is about three fourths as many children as there are in the United States. Even on this scale we are testing the children only half again as fast as they are being born; for the yearly crop of babies runs to about 25 million.

The cost? In India, where more than half the vaccinations in Asia are being done, the total per case tested last year was 2.9 cents, of which UNICEF paid .9 cent.

All these figures, running into the millions, may suggest vast outlays of money for many years. In fact, UNICEF in Asia spends only about $5 million a year, and only about a third of that on mass health programs. Moreover, of the $5 million spent annually by UNICEF, about one fourth is contributed by the countries in Asia themselves. Thailand alone contributes half a million dollars every year — more than twice as much as it receives. This is in addition to all local costs, which amount to almost double the aid received from abroad.

And what do the contributing countries, of which the U.S. is of course first, get for what they give? First of all, the knowledge that the risk of these contagious or infectious diseases spreading to other countries — West as well as East — is declining rapidly. Second, that the ground is being cleared not only for better health programs reaching into the hundreds of thousands of villages of Asia, but also for a gradual escape from the vicious circle of poverty and sickness. Finally, a growing measure of good will that is often grossly underestimated because it does not often appear in a formal letter of thanks. But the thanks are there, as anyone who has visited a village after it has been cleared of yaws or malaria will testify. It may be a plate of rice or of bananas or mangoes — or the cool water from a green coconut just brought down from the tree by a village boy.

Of all the forms of economic aid, few are in the form that can be seen and understood by the average villager. But cure a hundred cases of yaws in one village and it’s the talk of every household. I recall a comment from one of my friends, a leader of a yaws team in Central Java. “ You should have been along yesterday. We finished work in the district of X, and the villagers gave us a grand party. There was a plate for UNICEF.”