Global Epidemiology A GEOGRAPHY OF DISEASE AND SANITATION run) x ; Jen ) fancro-ecvr(! ¢ suDAN SOUTHWEST BECHUANALAND, AFRICA! AFRICA 1000 Scale of Miles Global Epidemiology A Geography of Disease and Sanitation BY JAMES STEVENS SIMMONS, B.S., M.D., Pu.D., Dr.P.H., Sc.D. (Hon. Brigadier General, United States Army, Retired; Dean and Professor of Public Health, Harvard University School of Public Health TOM F. WHAYNE, A.B. M.D, M.P.H, Dr.P.H. Colonel, M.C., United States Army; Chief, Preventive Medicine Division, Office of the Surgeon General, United States Army GAYLORD W. ANDERSON, A.B, M.D., Dr.P.H. Mayo Professor and Director, School of Public Health, University of Minnesota HAROLD MACLACHLAN HORACK, BS. M.D. Member of Staff, Department of Medicine and Section of Cardiology, Ochsner Clinic, New Orleans; Instructor in Medicine, Tulane University School of Medicine ASSOCIATE AUTHOR RUTH ALIDA THOMAS, A.B., M.A., M.P.H. Research Associate, School of Public Health, University of Minnesota; Instructor, Department of Tropical Public Health, Harvard University School of Public Health AND COLLABORATORS VOLUME TWO Africa and the Adjacent Islands Philadelphia London Montreal J. B. LIPPINCOTT COMPANY CorYRIGHT, 1951 By J. B. Lerincort CoMPANY THIS BOOK IS FULLY PROTECTED BY COPYRIGHT AND, WITH THE EXCEPTION OF BRIEF EXTRACTS FOR REVIEW, NO PART OF IT MAY BE REPRODUCED IN ANY FORM WITHOUT THE WRITTEN PERMIS- SION OF THE PUBLISHERS PUBLIC BBALTHE LIB. REPLACING 7 M7285 73¢ PRINTED IN THE UNITED STATES OF AMERICA DEDICATED TO SIR PATRICK MANSON Physician, teacher and investigator, whose life and work have been an inspiration to all medical men in the tropics; called the Father of Tropical Medicine, his funda- mental research on poms dis- eases, including filariasis and malaria, introduced the concept of insect transmission, and laid the foundations for the development of modern methods of control which will assure to future Africans a greater measure of health and prosperity. M808258 abies weed Se a Sd cna Preface to Volume Two This volume is designed to provide a con- cise summary, by political units, of current health conditions on the continent of Africa. It is the second in a series bearing the title, Global Epidemiology, which deals with the distribution of disease and the status of public health, in all parts of the world. The publication of this series was originally undertaken during World War II by the Preventive Medicine Service of the Office of The Surgeon General of the United States Army, at the instigation of the Committee on Information of the Division of Medical Sciences of the National Research Council. The purpose of the authors was to make available, in a condensed form, some of the information collected by the Medical In- telligence Division, which was organized within the Preventive Medicine Service in 1941. This Division was charged with the responsibility for collecting and assembling data relating to the medical, health and sani- tary conditions in all the regions stretching from the arctic to the equator, to which American troops might be sent, either in a belligerent or a friendly capacity. As the war rapidly assumed a global nature, the areas surveyed increased in number to em- brace extensive portions of both hemi- spheres. Although the primary function of the surveys prepared by this Division was to furnish the information necessary to fa- cilitate planning for the health protection of troops, matters of civil importance were included, since it is impossible to divorce military from civilian health in any area. When the Global Epidemiology series was first undertaken, it was intended to utilize these surveys as a basis for successive vol- umes dealing with the countries of Africa, Europe, the Middle East and Latin Amer- ica. Seven years have intervened between the publication of the first volume on India, the Far East and the Pacific Area, and the present book. This delay was caused, in part, by the demobilization of the personnel vii of the Medical Intelligence Division and, in part, by the difficulties encountered in collecting material which was widely scat- tered and frequently sketchy and incom- plete. After the war, the completion of the remaining volumes of this series, as a peace- time project, was made possible through grants from the United States Public Health Service to the School of Public Health of the University of Minnesota. In this volume on Africa we have fol- lowed the general outline of the preceding book, with a few modifications. For each country the sections dealing with local health administration, medical facilities, en- vironmental sanitation and disease prob- lems have been retained, but they have been augmented by a discussion of the racial, social and economic factors which influence the health status of the people. The concept of the Global Epidemiology series, which arose out of the desire to make available to students of world health some of the vast amount of information accumulated by the Medical Intelligence Division, has broad- ened, even as public health has become in- creasingly international in scope. Political and economic interest has been directed within recent years to areas little known before World War II, and it is hoped that the dissemination of the data presented in this series will be of assistance, not only to professional workers in the fields of medi- cine and public health, but also to the agencies working toward world understand- ing and international co-operation. In assembling the material for the present volume on Africa, we have had the support of many health officials and representatives of research and educational institutions, without whose help our work would have been impossible. It is recognized that the book is incomplete, but the omissions are due largely to the inaccessibility of precise information or, as in the case of the section on fauna and flora, to the necessity for selec- viii Preface to Volume Two tion in the interest of brevity. As in the preparation of the original surveys, we have had access to official publications of colonial and local governments, to the reports of re- search institutions, to scientific papers in American and foreign journals, to books dealing with the different areas, and to cor- respondence and conferences with authori- ties in this country and abroad. Much of the recent data was collected by Miss Thomas in the course of a survey trip in the winter of 1950, during which she visited the various colonial headquarters in Europe and certain countries in Africa, including Egypt, the Anglo-Egyptian Sudan, Kenya, Uganda, Northern Rhodesia, the Belgian Congo, Nigeria, the Gold Coast and French West Africa. Detailed acknowledgment of the in- valuable assistance obtained in all the places visited would require more space than can be allotted in this volume, but we wish to express our thanks to the many medical and health workers who unselfishly contributed of their time and knowledge toward the compilation of the information here pre- sented. We wish also to acknowledge our indebt- edness to the many administrative and re- search authorities who responded so will- ingly to our requests for reports, maps and other material, and especially, by reason of the variety of their contributions, to Médecin Général Inspecteur Vaucel and his associates in the Direction du Service de Santé Colonial, Ministére de la France d’Outre-Mer, Paris; Dr. Joa Fraga de Aze- vedo, of the Instituto de Medicina Tropical, Lisbon; Dr. Ricardo Teresa Robles, of the Direccion General de Marruecos y Colonias, Madrid; Dr. R. M. Morris and others in the Department of Public Health, Southern Rhodesia; Dr. E. P. Pratt in the Ministry of Health, Anglo-Egyptian Sudan; Dr. J. C. R. Buchanan and others connected with the Colonial Office, and representa- tives of the Foreign Office, Administration of African Territories, London; and the personnel of the Office of International Health Relations, United States Public Health Service. We wish to thank the following for re- viewing certain chapters in the book: Dr. Jerome Rodhain and his colleagues at the Institut de Médecine Tropicale Prince Léo- pold, on the Belgian Congo; Dr. D. Bagster Wilson, on the colonies of British East Africa; Dr. Eric S. Horgan, on the Anglo- Egyptian Sudan; Dr. Joseph N. Togba, on Liberia; Dr. J. H. S. Gear, on much of the section on South Africa; and Dr. G. W. Gale, Dr. W. H. leRiche and Dr. E. Gaynor Lewis, on the Union of South Africa; Dr. Philip B. Stones and Dr. Leonard Bruce- Chwatt, on Nigeria; Dr. John Karefa- Smart, on Sierra Leone; Mr. Charles W. Lynn, on the Gold Coast and Nigeria; and Dr. Frederick J. Brady, on Nigeria, Sierra Leone and the Gold Coast. We gratefully acknowledge the encour- agement and the practical assistance of Dr. Arthur R. Turner, currently Chief of the Medical Intelligence Branch, Preventive Medicine Division, Office of The Surgeon General, U. S. Army; and the generous co- operation and helpful criticisms of Dr. Donald L. Augustine, Professor of Tropical Public Health, Harvard School of Public Health. We also thank Dr. Fred L. Soper, Dr. Willard H. Wright, Dr. Louis L. Wil- liams, Dr. Karl F. Meyer, Dr. Arne Bark- huus and Dr. J. C. Bequaert for their ready response to our numerous queries, and Brigadier General Stanhope Bayne-Jones, U. S. Army (Retired), for a summary of the military contributions to the control of disease in Africa during World War II. Finally we wish to express our gratitude to Miss Nancy Allen and Dr. Edwin Raisz for the construction of the sectional and in- dividual sketch maps; to Miss Roberta Hill for her work in the preparation of the manuscript; and to Mrs. Geraldine Scott and Mrs. Blanche Quinlisk for their many and varied services. James S. SIMMONS Tom F. WHAYNE GavLorD W. ANDERSON Harorp M. Horack Ruta A. THOMAS Preface to Volume One and the Pacific Area India, the Far East Be it in war or in peace, public health is vital to a nation’s strength. As rapid com- munication shortens effective distances, the problems of international health and the spread of diseases become accentuated. To meet these problems, the widest dissemina- tion of information regarding each other’s health problems is essential. It is hoped that publication of the material herewith pre- sented may aid in this process. The book represents an excursion into the unexplored field of geo-medicine, bring- ing together in one place certain data on medical, health and sanitary conditions of various geographic areas of the world. The material is based on surveys made for the Medical Department of the United States Army. Materials of purely military inter- est and information not suitable for pub- lication at this time have been deleted. This first volume includes medical information about India, the Far East and the Pacific area. In subsequent volumes similar data about Africa, Europe, the Near East and the Western Hemisphere will be made avail- able. The surveys here assembled represent the work of a large number of individuals asso- ciated at some time with the Medical In- telligence Division of the Office of The Sur- geon General of the United States Army. The present Division of Medical Intelligence had its beginning during May, 1940, when the senior author made arrangements for a reserve officer, Lt. Colonel (now Colonel) Ira V. Hiscock, Sn.C., Professor of Public Health at the Yale University School of Medicine, to come on temporary active duty in the Office of The Surgeon General and draw up a plan for health protection of troops who might be assigned for duty out- side of the country as part of a program of hemispheric defense. The work was con- tinued by Lt. Col. (now Colonel) William A. Hardenbergh, Sn.C., editor of Public Works, and Lt. Col. Albert W. Sweet, Sn.C., of the New Jersey State Health Depart- ment. These three prepared surveys of a number of countries of the Western Hemi- sphere. In June, 1941, this organization with a complement of two officers became a divi- sion under the direction of Capt. (now Lt. Col.) Tom F. Wahyne who continued in charge until April, 1943, when he departed for overseas duty. Since that time, under the direction of Lt. Col. Gaylord W. Ander- son, the activities of the division have con- tinued to expand, and its personnel now includes eleven officers, five civilians of pro- fessional grade, and clerical staff of fifteen. The individuals who have actually prepared material for inclusion in surveys used in these volumes are as follows :* Captain Paul X. Blattler Major Richard S. Buker Captain Orlando Canizares Miss Rose A. Centanni Dr. Carl Dauer Dr. Clara Day Captain James R. Eckman Major Ross Gauld Captain George Gordon Major David M. Greeley Captain Carlo Henze Major Harold M. Horack Major William A. Howard Captain Saul Jarcho Lieutenant Morris Leikind Miss Jane Lyman Captain John K. Meneely, Jr. Mrs. Frances Sullivan Miller * To them, as well as to subsequent and present members of the staff of Medical Intelligence, the authors express their indebtedness. ix “a X Preface to Volume One Captain George O. Pierce Captain George Rosen Lt. Col. Robert B. Rutherford Major Paul R. Slater Dr. Isadore Snapper Miss Ruth A. Thomas Dr. Arthur R. Turner Dr. C. W. Wells In their work, they have enjoyed the utmost co-operation of a large number of agencies and persons having special knowledge re- garding the various areas under study. They have scoured the libraries, obtained assist- ance from numerous other governmental agencies and had access to a large amount of previously unpublished material. To all these collaborators, many of whom must remain anonymous, who have furnished in- formation or assisted in the collection of this material we are deeply indebted. Every reasonable attempt has been made to use the latest available information on all the countries studied. The reader will realize, however, that in many countries conditions as to governmental organization, general sanitation and medical facilities have been altered by enemy occupation or as a result of military operations. Exact in- formation on such changes is often not avail- able. Even friendly occupation may have changed many conditions, yet details of change cannot be revealed for obvious rea- sons. Except as otherwise noted, conditions in countries subjected to enemy occupation have been described as they were known to exist at the outset of hostilities. Other con- ditions such as fauna and flora are not sub- ject to such immediate change, so it can be assumed for lack of more specific knowledge that conditions existing prior to occupation still prevail. The arrangement and grouping of dis- eases has, of necessity, been arbitrary. In the original surveys, grouping was dictated by military considerations; to follow such arrangement in a volume intended for other purposes would result in undesirable group- ings. For example, typhoid fever which can be readily prevented by immunization and is therefore a minor military problem, would be separated from the dysenteries which constitute a major military problem. It has seemed preferable to arrange the material so far as possible according to principal mode of spread, though realizing that cer- tain diseases have multiple avenues of trans- mission and that considerable uncertainty and even controversy persists as to the mode of spread of others, e.g., poliomyelitis and infectious hepatitis. In the editing of this material for pub- lication, invaluable assistance has been gen- erously given by Dr. W. C. Davison, Dr. Morris Fishbein, Dr. Richard M. Hewitt and Dr. Robert N. Nye, representing the Division of Medical Sciences of the Na- tional Research Council. The arduous edi- torial details were handled by Captain James R. Eckman. A special debt of grati- tude is due to Mr. Elon Clark, of Duke University School of Medicine, who pre- pared the large maps of world-wide disease distribution. The smaller maps of individ- ual countries were prepared by the staff of Colonel James E. Ash, M.C., Curator of the Army Medical Museum. To the late Mr. Archie Woods, of the John and Mary R. Markle Foundation, a special debt of grati- tude is owed for the initial suggestion that these surveys be prepared for publication and for material assistance in the prepara- tion of the volume. The Mayo Clinic and the office of the American Medical Associa- tion have likewise assisted in the final prep- aration of the manuscript. The authors are indebted to all of these for their assistance but can attribute to them none of the short- comings of the volume. Finally, special mention should be made of our colleagues, both professional and clerical in the Pre- ventive Medicine Service who have ren- dered invaluable service throughout this undertaking. James S. SIMMONS Tom F. WHAYNE GavLOrRD W. ANDERSON Harorp M. Horack Introduction In Africa, as elsewhere, the problems of health are part of an intricate pattern formed by the intermingling of numerous forces. It is impossible to dissociate health from the many other factors which deter- mine the life fabric of the people. Any study of the disease picture of Africa offers much to excite the imagination, both of the scien- tist and the humanitarian, but a real under- standing of the health problems of the con- tinent must depend upon a knowledge of the progress in social development of the diverse regions. The ancient history of most African races is obscure, except in the Nile Valley where a highly organized culture flourished under the Egyptian dynasties for over 3,000 years before the Christian era. Under the influence of differences in climate and topography, and against a background of successive wars of conquest, intertribal strife and devastating slave raids, a medley of civilizations has evolved. Although Arab- Berber peoples predominate in the Medi- terranean area, “Sudanese Negroes” along the Guinea Coast and Bantu in the southern half of the continent, the relative isolation of different regions and the absence of co- hesive elements have produced a diversity of types, languages and customs. Superim- posed upon this African mosaic are outposts of European colonization which reach their greatest concentration along the shores of the Mediterranean, and in the Union of South Africa, the Rhodesias and Kenya. This interracial complex is further confused by the settlement of considerable numbers of Asiatics along the east coast from the Cape to Kenya. The health problems encountered among these heterogeneous population groups are contingent not only upon the climatic and etiologic factors which influence the spread of specific infections but also upon the social, educational and economic progress of the people themselves. The increasing in- dustrialization and development of com- munication facilities within the last half century have wrought changes in the life and the ambitions of the people, the full significance of which is still uncertain. Fore- most among the problems of the different territories, regardless of their political affil- iations, are those of public health—as re- lated not only to medical care but also to basic sanitation, nutrition, improved stand- ards of living and education. In many re- spects, environmental factors appear to have a more direct bearing upon the health of the inhabitants than in more highly de- veloped countries. The inadequacy of water supplies over considerable areas ; soil erosion and the loss of soil fertility under primi- tive methods of cultivation; and the con- gestion in limited areas, such as the Nile Valley, the Lake Victoria region, Ruanda- Urundi and sections of the Guinea coast, as opposed to the relative sparsity of popula- tion over most of the continent, are prob- lems which cannot be separated from those of health and social or economic welfare. Recognition of the influence of the poor nutrition, the ignorance and the poverty of the native populations upon the morbidity and mortality rates in different areas em- phasizes the need for close co-operation between the various governmental and pri- vate agencies interested in their develop- ment. Moreover, the thoughtful observer must be impressed not only by the inter- relationship of vital issues in these under- developed regions but also by the inter- dependence of one territory upon the other. The expansion of communications has en- larged the boundaries for the control of epidemic diseases. The health and standards of living of the inhabitants of West Africa, for example, are no longer of purely local concern but affect directly or indirectly the xii Introduction lives and the economic well-being of other peoples, not alone in adjacent portions of the continent but throughout the world. Although the insect-borne and so-called tropical infections are popularly regarded as typical of Africa, any review of the causes of human suffering and death must include also most of the diseases usually associated with temperate climates. Moreover, the spread of such diseases as tuberculosis, meningococcus meningitis and pneumonia is frequently more rapid under African con- ditions, and the outcome more serious where poor nutrition and chronic parasitism are common to large sections of the people. Perhaps a characteristic feature of the gen- eral disease picture on the continent is the prominent role attributed to animal infec- tions. Sylvatic plague and “jungle” yellow fever are prevalent in many areas. Trypano- somiasis is a scourge of man and animals throughout the entire central zone inhabited by the tsetse fly vectors. The results of the human disease are obvious, but the impact of widespread animal infection upon man, although indirect, may be equally impor- tant. The limitations which this disease im- poses upon the raising of livestock exert a profound influence upon the agricultural economy and nutrition of the people. The problem, which is regarded by many as a major obstacle in the development of the affected areas, has many ramifications, how- ever, and is intimately linked with those of resettlement, overstocking, soil erosion and the control of epizootic diseases, such as pleuropneumonia, East Coast fever and rinderpest. The interdependence of sociologic and health problems is magnified in many parts of Africa by conditions peculiar to special population groups. The large volume of migratory labor and the continuous drift of workers between the industrial areas and their home villages, frequently over con- siderable distances, the constant movement of nomadic tribes over large expanses of semidesert country and the transcontinental pilgrimages of West African Moslems, en route to Mecca, are potent factors in the spread of infectious disease. In the absence of valid statistics, current knowledge of the health status of the different indigenous peoples is fragmentary, except in a few limited areas where facilities for reporting are reasonably complete. Even in the larger cities with organized health services, esti- mations of morbidity and mortality rates are admittedly inaccurate, while in most territories, no more than a fraction of the rural population can be reached by the pres- ent inadequate medical facilities and per- sonnel. A critical review of the current trends in Africa seems to suggest an acceleration of the social, economic and political changes which have been in progress over the last few decades. The cultural and natural re- sources are impressive, and the potentiali- ties for the future are challenging. The op- portunities in the field of public health are equally great. It is now possible to envision more effective control over the spread of major epidemic diseases, as malaria, African sleeping sickness, typhus fever, relapsing fever and smallpox, a reduction in the mor- tality in infancy and early childhood, and a gradual introduction of higher standards of nutrition. Although the hurdles to be sur- mounted differ throughout the continent, common factors of almost universal sig- nificance are found in the increasing popula- tion pressures on arable lands, and the ten- sions arising from the impact of this mech- anized century upon basically feudal and tribal societies. The local programs for the improvement of health and social condi- tions vary with the political complex of the territory, as well as with its size, population density and economic resources, but all recognize the growing need for co-operative effort. Beacon lights which reflect the aware- ness of the different governments regarding the vital role of public health in their over- all development programs include the pro- motion of medical research, the extension of preventive services and the increase in fa- cilities for the training of native personnel to participate in medical and health activi- ties at all levels of endeavor. Within recent years regional conferences, attended by representatives of all the interested terri- tories, have been convened for the inter- change of information and the study of various problems. Those touching upon pub- lic health include conferences on medical problems, on trypanosomiasis and tsetse fly control and on food and nutrition. At the African Regional Scientific Conference, held in Johannesburg in 1949, a Scientific Coun- cil for Africa South of the Sahara was pro- posed, and the details of its organization have since been discussed in meetings in Paris and London. The resurgence of interest in medical and health projects since World War II is evi- denced in the British colonies by the alloca- tion of enlarged grants, under the Colonial Development and Welfare Acts, to individ- ual colonies and regional organizations, as the East Africa High Commission, for the conduct of research and field investigations ; the formation of specialist committees which function in conjunction with the Colonial Office for the direction and co- ordination of research in the colonies, and the creation of a Colonial Research Service. In the French territories comparable pro- grams of expansion have been undertaken under the aegis of the Instituts Pasteur and the Office de la Recherche Scientifique d’Outre-Mer. In addition to the activities of the established laboratories in the Union of South Africa, Egypt, the Anglo-Egyptian Sudan, the Belgian Congo and the British and the French dependancies, special studies are being sponsored by various European institutions with colonial affiliations, such as the London School of Hygiene and Tropi- cal Medicine, the Liverpool School of Trop- ical Medicine, the Instituto de Medicina Tropical, in Lisbon, and the Institut de Médecine Tropicale Prince Léopold, in Ant- werp. New projects, which will provide cen- ters for international research and should promote interest in the health problems of these tropical areas, include the creation in 1947 of the Institut pour la Recherche Scientifique en Afrique Centrale, in the Belgian Congo, and the Liberian Institute of Introduction xiii Tropical Medicine, in Liberia. The incor- poration of a medical school conforming to European standards in the University Col- lege of Nigeria, established at Ibadan in 1948, marks a new era in the development of medical education for Africans. The mag- nitude of the task of providing adequate health and medical facilities in large, under- developed territories with widely scattered populations necessitates the active partici- pation of local personnel, but the growth of an adequate body of native workers equipped for leadership will necessarily be contingent upon the pace of general educa- tion under the different governments. It is impossible to conclude a summary of the forces at work for the promotion of health in Africa without mentioning the outstanding work of philanthropic organi- zations, as the International Health Divi- sion of the Rockefeller Foundation, the British Empire Leprosy Relief Association, and others; the pioneering efforts of various religious mission groups, and the farsighted programs of numerous public-spirited in- dustries. Since its inception, the World Health Organization has assumed a promi- nent role in the study of major health prob- lems in Africa, particularly those of tuber- culosis, schistosomiasis and malaria, and its activities will be facilitated by the recent establishment of a Regional Office for Africa, at Geneva. Important contributions to our knowledge of the epidemiology and the control of certain diseases in Africa were also made during World War II. The military situation afforded a unique oppor- tunity for the field testing of various new preparations and methods for the control of epidemic typhus, bubonic plague and other serious diseases. These achievements, which represented the joint contributions of the Armed Forces of the United States and her Allies, and of associated governmental and unofficial agencies, assisted enormously in the protection of the health of the military personnel in the area and provide technics whereby the devastating epidemics of these diseases may now be prevented. No one can predict what the future will xiv Introduction bring to Africa, but the potentialities for the development of better living conditions among all racial groups appear to be greater than at any time in the past. The scientific knowledge accumulated within the lifetime of the present generation on the etiology, the epidemiology, the treatment and the control of many infections, and the develop- ment of modern methods for improving the standards of health of large aggregations of people afford effective tools by means of which the inhabitants of Africa may free themselves from their ancient bondage of disease and suffering. Not only is this in- formation at hand, but the various peoples and their respective governments are be- ginning to show an increased interest in its application. If the data collected in this volume serves to help in the constructive task of promoting better health conditions on the great African continent, it will have fulfilled its purpose. GENERAL BIBLIOGRAPHY 1. Boyd, Mark F.: Malariology, Philadelphia, Saunders, 1949. 2. DeMeillon, Botha: Anophelini of the Ethi- opian geographical region, Publ. South African Inst. Med. Res. (Johannesburg) X: No. XLIL (Sept.) 1947. 3. Faust, E. C.: Disease in the tropical war zones, III. The diseases of the Mediter- ranean Basin and of tropical Africa, Gastroenterology 2:13-31 (Jan.) 1944. 4. Findlay, G. M.: The present position of yel- low fever in Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 35:51-72 (Sept.) 1941. 5. Fitzgerald, Walter: Africa. A Social, Eco- nomic and Political Geography of Its Major Regions, ed. 4, New York, Dutton, 1942. 6. Garnham, P. C. C.: Distribution of wild- rodent plague, Bull. World Health Organ. 2: (No. 2) 271-278, 1949. 7. Gear, H. S., and Gear, James: Medical and health problems of Africa and their study, South African M. J. 24:60-65 (Jan.) 1950. 8. Githens, Thomas S.: Drug Plants of Africa. African Handbooks, No. 8, Philadelphia, Univ. Penn. Press, 1948. , and Woods, Carroll E., Jr.: The Food Resources of Africa. African Handbooks, No. 3, Philadelphia, Univ. Penn. Press, 1943. 10. League of Nations. Health Organization: Annual Epidemiological Reports. 11. ——: Weekly Epidemiological Records. 12. Lord Hailey: An African Survey. A Study of Problems Arising in Africa South of the Sahara, London, Oxford, 1938. 13. Maisel, Albert Q.: Africa. Facts and Fore- casts, New York, Duell, Sloan & Pearce, Inc., 1943. 14. May, Jacques M.: Map of the world distri- bution of poliomyelitis, Geog. Rev. 40: (Oct.) 1950. 15. McDougall, John B.: Tuberculosis. A Global Study in Social Pathology, Baltimore, Wil- liams & Wilkins, 1949. 16. Muhlens, P.: Krankheitsgeschehen und Ges- undheitswesen, Berlin, de Gruyter, 1943. 17. Platt, B. S.: Colonial nutrition and its prob- lems, Trans. Roy. Soc. Trop. Med. & Hyg. 40:379-99 (Mar.) 1947. 18. Proceedings of the Fourth International Con- gresses on Tropical Medicine and Malaria. Washington, May 10-18, 1948, Washing- ton, Department of State, 1948. 19. Sawyer, W. A.: The Present Geographic Dis- tribution of Yellow Fever and Its Sig- nificance. Harvey Lectures, Series 30, Baltimore, Williams & Wilkins, 1936. 20. Smithburn, K. C., and Jacobs, H. R.: Neu- tralization tests against neurotrophic viruses with sera collected in Central Africa, J. Immunol. 44:9-23 (May) 1942. 21. Symposium on the Rickettsial Diseases of Man, organized by the Section on Medical Sciences of the A.A.A.S., Boston, Decem- ber 26-28, 1946. Washington, American Association for the Advancement of Sci- ence, 1948. Edited by F. R. Moulton. 22. Trowell, H. C.: Malignant Malnutrition (Kwashiorkor), Trans. Roy. Soc. Trop. Med. & Hyg. 42:417-32 (Jan.) 1949. 23. United Nations. Non-Self-Governing Terri- tories: Summaries and analyses of infor- mation transmitted to the Secretary-Gen- eral during 1947, Lake Success, New York, 1948. : Summaries and analyses of informa- tion transmitted to the Secretary-General during 1948, Lake Success, New York, 1949. 25. United Nations Relief and Rehabilitation Administration: Health Division. Epi- demiological Information Bulletins, Vol. I and II, 1945 and 1946, Washington, D. C. 26. United States. Federal Security Agency: Public Health Service. Public Health Re- ports. 24. 27: 28. 29. 30. 31. Wieschoff, H. A.: Colonial Policies in Africa. African Handbooks, No. 5, Philadelphia, Univ. Penn. Press, 1944. Wilcocks, Charles, Corson, J. F., and Shep- pard, R. L.: A Survey of Recent Work on Trypanosomiasis and Tsetse Flies, 1932- 1944. Review Monograph No. 1, London, Bureau of Hygiene and Tropical Diseases, 1946. Wilson, D. Bagster, Garnham, P. C. C., and Swellengrebal, N. H.: A review of hyper- endemic malaria, Trop. Dis. Bull. 47: 677-98 (Aug.) 1950. World wide distribution and prevalence of leprosy. Internat. J. Leprosy 12: Supp. (Dec.) 1944. World Health Organization: Chronicle of 32. 33. 34. 33. 36. Introduction XV the World Health Organization, 1947-1950, Geneva. Weekly Epidemiological 1947-1950, Geneva. Epidemiological and Vital Statistics Reports, Volume I, IT and III, 1947-1950. Worthington, E. B.: Science in Africa, Lon- don, Oxford, 1938. Wright, Willard H.: Studies on schisto- somiasis. The geographical distribution and molluscan intermediate hosts of the schis- tosomes maturing in man, Bull. Nat. Inst. Health, USPHS 189:1-48 (Jan.) 1947. Zeiss, H.: Seuchen-Atlas. Herausgegeben im Auftrag des Chefs Wehrmachtsanitats- wesens, Berlin, 1942-1944. Records, F ‘ 8 > - i E i i : § - 1 + | i . g ~ i » Contents SECTION ONE THE NILE VALLEY 1. Ecyrr 2. ANGLO-EGYPTIAN SUDAN Geography and Climate... 5... ol. A an ee Population and Socio-Economic Conditions ................................ Population i... i i ci ei a ee ma SR Vital Statistics Social Beonomy =... LL... eR a he Food and Nutrition Housing... i a an a en Environment and Sanitation Water Supplies Waste Disposal Fauna and Flora Food Sanitation: 0... a a a Se Health Services and Medical Facilities Health Organizations Medical Institutions Personnel Diseases iu. ul. a a a sD Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts Diseases Spread Chiefly Through the Respiratory Tract Diseases Spread or Contracted Chiefly Through Contact Diseases Spread by Arthropods Nutritional Diseases STIRIMATYEL. Slo hd er Bibliography Geooraphy and Climate... 0 Ll ced h i E Population and Socio-Economic Conditions Population tiene of Sl mi i Ra a eS Vital Statistics Social Beonomy..i. oc. 0 i lh a ae Food and Nutrition Housing ohn srs ll aie aan a Environment and Sanitation Water Supplies Waste Disposal Fauna and Flora Food Sanitation w Ww ONT NON nth Pp 11 11 11 12 14 14 14 17 xviii Contents 2. AncrLo-EcypTiaN SupaN— (Continued) Health Services and MedicaliPacllitiest. ho coo fo, Sel innit on casio 34 Health Oroanizationsie.. 0: on fai a BS sl anh 34 Medical Institutions: 0 ob aah tis Sa 34 Personnel li or ni a nL a a a se da Sa 35 Diseases cou ol) le fe a i 35 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 36 Diseases Spread Chiefly Through the Respiratory Tract ............ .... 38 Diseases Spread or Contracted Chiefly Through Contact ................ 39 Diseases Spread by Arthropods 0 i din ih iid 40 Nutritional Diseases) =... . 000 6 Caaab dtd Sia andi 43 MiscellancousiCondlions .. .. 0... vse. lin Jain, 5h thn ai, 44 SUMMARY. sv io FF i in J a a Sh Le 44 Biblleetaphiy’ o.oo a a ed ae a Sl 44 SECTION TWO THE ETHIOPIAN HIGHLANDS BA RUEREA i a ee BS RAE TRE NE 49 Geography andsClimate.. o.com ae LIS Di, LR i EL 49 Population and Socio-Economic Conditions .... 4. 0uliliL cali ae... 50 Population ......0..... . 0 i. oo LL BREE AL 50 VitallStatisties 2.00... dd i eh a RE RR SS Se 51 Social BeonOmy . ic. ii i RRA LTR 31 Food andNmirition: «0 1 afi des vidi Li tad hh wariian sian Se tal in Dh 52 Housing... obo alt dd din dl as Ra SRR el 52 Environmentiand Santtabion’ i. cid. nine hides Lo ins ian vane, asa, 52 Water Supplies... .. J shunned dui van, Adnnsi bil oa, 52 Waste Disposal... ..0 0. atl Salaiatn Se 53 Fauna ondiBlova .. ........... Jo ni iiil Sana i ih sine ae 53 Food Sanitation i... .. 0 hhh oon i Le a a, 54 Health Services and Medical Facilities .... .... ons died seh se stints 54 Health: Organizations: ... 0. ivi doi cai so niliihiat cS th ie 54 Medical Institutions... coo... oi a a a 33 Bersonmel 7. ih la a A re a a A 55 Diseases, i. ae hE a ER a 35 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 55 Diseases Spread Chiefly Through the Respiratory Tract ................ 56 Diseases Spread or Contracted Chiefly Through Contact ........ ...... .. 57 Diseases Spread by Avthwopods. .-....... ane ich Jo on en 57 Nutritional Diseases. 10 tuo ooo J Sl i Re il, Th a, 59 SUMMATY 5 a eR a a Rs SR Rus al 59 Bibliography... at as a a shai nk Sasa 59 A BPHIOPIA ha Ee en Se SR a 62 Geography and Climate Contents xix Population and Socio-Economic Conditions ................ 006.0 iain 63 Population 0h a A Ee a el, 63 VitaliStatisties i 0 0 en ar i Er LL HL 64 Social Beonomyins lao ho Lin i a a a 64 Food and INUIEIHION 0. 1 fi its soci Bd a at tans Soin ho 64 House re SS a 65 Environment and Sanlfation: i a a a a 65 Water Supplies iil. oh on a Se LL et, 65 A aste DISPOSAL. i a fea a a at 66 Fauna and Flora a ti il i a Ba ns is Sts ad es lal Ba le as 66 Food Sanitation... i... aos ns i ni ais hr te 67 Health Services and Medical Facilities... . .... 0... coe dd hide ctish ds eosin 67 Health Organieations ... ........0. 0000. Shiite t vies es doi ct 67 Medical Institutionen a i Brtab thin dia it yy REE RE 67 Personmel oe a AN St El 68 DISEASES 0 hi Ati Re i LE 68 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 68 Diseases Spread Chiefly Through the Respiratory Tract ................ 69 Diseases Spread or Contracted Chiefly Through Contact ................ 70 Diseases Spread hy. Avthropods:........ J fc Gaiidlo daiiniis dani ain 71 Nutritional IDSA, us. tui a. . kin whut Sable badd 6 Live TET Le SG 72 Miscellimeous Contilions =... . Lc... eis vias Siidnid ei dain ey Sh a ol 72 Summary... RR Se 72 Bibegraphy | |... cou re i Sh hh a STE 73 8, BRITISH SOMALILAND... ot i ed hi a vis se alenid sii 73 Geography and Climate... ... o.... adi l ih d oS ned 75 Population and Socio-Economic Conditions ............................... 75 Population oh SE CE 75 Vital Statistics i a a 76 SocialiBeonomy —. in aE ee 76 Food and Nutrition 0. v.00. an i A a a 77 Housing 0. voi ia ee 77 Environment and Sanitation 0... i 0. i ve ea eine ie a ET 77 Water Suppliessl. on al doi Aa a 77 Waste DISPOSAL 0, ve ii ns dd Bok i 77 Bauna and Plora oo. i i ne eae a 78 Food Sanitation. vi. Lis in ids ate Sanaa CL 79 Health Services and Medical Pacllities ....c. ssi cumin sini hanib 79 Health Oroamizations .. 0... is Bei can bette Di 79 Medical Institutions... . 0. Lh ian al ain ahs, St 80 Personnel 0 a Ee 80 HET CR BRR Re SRS NE AC SB ER en 80 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 80 Diseases Spread Chiefly Through the Respiratory Tract ............ . .. 81 Diseases Spread or Contracted Chiefly Through Contact ........... . . . . 81 Diseases Spread by Arrapods ...........oci. ibis evans di sitar 82 Nutritional Diseases... oe oo rans Sse 83 Summnary LL La ate ana SE ER 83 Bibliography |. a ee 84 XX Contents 6. TRENCH SOMALILAND... 0... a or a dr BEA eg 85 Geographyand Climate... 0... 00. a a i ah 85 Population and Socio-Economic Conditions ............................... 85 Poprlafion «0 oo id id ae asa 85 Vaal SS atistiCs: os hh ne ee pe wilt rs a tena 86 Soclll Beonomye i. 00.0 i lh a a sa 86 Rood andINutrltion. 0 rei a aE 86 Housing: i. a LS Ra 87 Environment and Sanliation ...).. coon oc. i a dd 87 Water Supplies... se Sa ae 87 Waste Disposal ea. 4. 0 a) a a i a IES 87 Baunaand Blota 4. 000 hii Baas imine oh. Sas Binney 87 BoodiSanitation ......... 0 ..aiidis J AL ae En Ah 87 Health Services and Medical Facilities ..........u... 00 dosh oiutensivns usinh 87 Health Oroonisations 0... a al sri ha 87 Medical Institutions... .... co. i on i hats ve ea 88 Personnele Laide, chins 0 aah a I a eS a 88 Biseasesh. tui. in dd ip ES Sr SL LL er 88 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 88 Diseases Spread Chiefly Through the Respiratory Tract ................ 89 Diseases Spread or Contracted Chiefly Through Contact ................ 89 Diseases Spreadiby Avthrapods o.oo rl 89 Nutritional Diseases uf... . in. Sain aa hh a 90 SUNY i ee a a he 90 Beara iy a we 91 IRESOMATIA L.-T ol a iE LL i 92 Geography and Climate... 0 on a a cess ei 92 Population and Socio-Economic Conditions ......... ...... 50 cc cevs enna. 93 Population... 0... doi he a To Ma 93 NL Stalstles a er a eh 93 Social FCOhOMY 0. rid es a i te 93 Foodland NUnIfion ©. | a or de se he 94 Housing’. SE es RL 94 Environment and Sanfiation:. ...... ce tinny 94 Mater sSupplies .. .. La a 94 Waste ISp0sal bc a heh ih sig ted 95 Fauna and Bora i... in i ie ey wiv a ne 95 Rood Samitation s.r an ead Ad ae ae, 96 Health Services'and Medical Facilities ...... 0... ..... 0 insane. 96 Health Ouoantastlons i. [i i a 96 Medical Institutions ©... 0. id. id vn Chl be 97 Personnel ik i ei en 97 Bigeases od a i a a 97 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 97 Diseases Spread Chiefly Through the Respiratory Tract ................ 98 Diseases Spread or Contracted Chiefly Through Contact .............. .. 99 Diseases:Spreadiby. Arthropods... 0... Loo 929 Nutvitional Diseases... ...... ... 0.00 a Lr i 101 Miscellanegus Conditions .............. 0 tv a as 101 SUMMALY dion sl a a Ta LL SRE Re 101 Bibliography ..... hihi See a nest La RE 101 Contents xxi SECTION THREE EAST AFRICA Br RENTAL A a a a aR a a SL 107 Geography anduClimnte ©, . i. ii a Se Sa a ae 107 Population and Socio-Economic Conditions ............................... 107 Population: o.oo hl a SU Ee 107 Vital Statice... 00 a I a 108 Social BCOmOMY: io... i iva sein id a SG a Shale Sa EC Se 109 Bood and Nateition ©... Lc cui. ss na a 109 Housing... ie a Ee a Sa a Le 110 Environment and Sanitation . .... 50... coe em i a a 110 Water Supplies 5... ie ah a a SE 110 Waste Disposal i. cf. oi ca si a an ie is ba ea 111 Fama and Blown, oi... 00.0 i dn san dap aati 111 Hood i Saniaton:. Sli chin ous ile br iim ie se sds late Sri s 115 Health Services and Medical Facilities .................................... 116 Health Oreanizatlonss J. i, dd nb hr Lh a ae es 116 Medical Tnstituflons 0. hh dn ai dihies tba 117 Rersommel i... ri ES Ee eR 117 DD SESE i ii dhe veins hie laine es Sie Iai Se Coa Rah 118 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 118 Diseases Spread Chiefly Through the Respiratory Tract ................ 119 Diseases Spread or Contracted Chiefly Through Contact ................ 121 Diseases: Spread vy Arthropods... ..... .. 0. dein vi Sins esis leints 122 Nutritional IDISEISES: ©... ru rials dal a Meta iy ws sae ele chat os SA) 126 SHMMALY: =. a a a 126 Bibliography: |... i ei i se IL ie at i ee a 126 O UGANDA. ne LE 130 Geography and CHmate oo. iii oi vie sini 505 bie ae a ait pe le ET 130 Population and Socio-Economic Conditions ............................... 130 Bopulation i... 0. oe a RS 130 VitalaStatisticn oily. ahi avn nes nil faa betsy ts ir Tin dBm tain hd 131 SOCIAL IRCOROMY bois tes i ant i A ti Ph a, el, 132 Food and NUriton 0. i aie Sai wile Satelit 132 Wousing: alec oo nl re a LG 133 Environmentand Sanitation i... oi... ot. Ld le iG a se 133 WateraSupplies oi, a i EE a 133 WastetBisposal ac 0c i a aE aA 133 BaunzsandiiBloras. 0 0h i nn RE aa 134 Food Samtalion i... ca a a te sR hr A, 137 Health Servicesrand Medical Facilities ............coo0ivn iin iinniinnansus 137 Health®Oreanizationsd. .... 0 0 ne nh ad as, 137 Medicalenstitutions =... ....c.. 0 Nh abel Sail A 137 Personnel: oo ir. oa DS a os er yd Se he 139 Diseases. =. 0 ui a Sh RB 139 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 139 Diseases Spread Chiefly Through the Respiratory Tract ................ 141 Diseases Spread or Contracted Chiefly Through Contact ................ 141 xxii Contents 9. UcanNpa— (Continued) Diseases— (Continued) Diseases Spread by Arthropods: .. chu ni snl vai si aon ail, 143 Nutritional Diseases i co 0 0 LL a 146 MiscellaneoustCondifions:. . .. duis Joi San aN ue 146 SUMMOEy: Ce a a A Lea 146 Biblloaraphy tio its ch eB SR 147 BOP ARGANYIRA Lf. a Lh at oy hn CN SE BIE ING Eh dy 149 Geography and Climates. oo. ou) 0 a a Sh se tLe LE 149 Population and Socio-Economic Conditions ............................... 149 Population: J naa ivi lun a en A 149 Natal Statistics. eo 150 Social Beonomiye. i. 1.00. od A La a na 151 Foodand Nutrition i... 0... 0. or Ls da he ae, 151 OuSing rn 152 Envitonmemt and Sanitation... 00. 0 ak 152 Water Supplies 000. 0 a EE a 152 Waste Bisposall. a 153 Faunaiand Blovat too. voit Le a a ah te 153 Food Sanitation i. i ie Linnie ioe ae hate aE 156 Health Services and Medical Facilities .. ......... co 0 i, 156 Health Oreanizationses. .. 0 cl cal. a ah a a Se, 156 Medical Institutions «0 a id a a a 15% Pefsannel a Ca ea a 158 DISEASES vr i ehh Ld Sea Us Be i nS 158 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 159 Diseases Spread Chiefly Through the Respiratory Tract ................ 160 Diseases Spread or Contracted Chiefly Through Contact ...... ........ .. 161 Diseases Spreadiby Arthropods... . 0... 0 oi an aaa 162 Nutritional Diseases: iv... i Jo ait vedi id a dn a 165 Miscellaneous Conditions... i Li rou cd a a 166 SmmaEyEG RS Nr Das de a re 166 Bibliography... no lel a a a a i Ee 166 HIANVASALAND eo hh sail ayy Laila Bia nin. dha fst 169 Geography and Climate... 0. oc pa. ina A cai a LR Ss, a 169 Population and Socio-Economic Conditions ............................... 169 Population or fier coon onl ano en URE Lt a 169 Nital Statistics: viv conoid vo nl. tu DRE I eh ie 170 SecisbiBEeonomy .. (0.0... sn Ee i PER 170 Food andNUinition Sunni. oda pd a 171 Mousing rn a ee a SOUR SE Cah 171 Environment and Sanitation... .... oi. 00a an ER av a ay 172 WateraSupplies ic. a0. 0 Liane Dion ami Laas 172 Waste Disposal con ord oo Linn nl Rn i a EL ee 172 Faunaand Blora, . 0.0.0. 0 2b 00 FO np I J 172 Food Sanitation «o.oo ilo a a a rs 173 Health Services and Medical Facilities -'/. ....... [LL 0 00 uv DL 173 Health Oroanieations'c. J. 0h dn as RT a, 173 Medicallnstitutions.... .... ven oh. vis nds bn in Late 0 ei 174 Bersonhelidr Baie afte d Jo ake Led RO a UE eR 174 Diseases t. . . F200 UNE An AREAL Ra a 174 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 175 Contents xxiii Diseases Spread Chiefly Through the Respiratory Tract ................ 176 Diseases Spread or Contracted Chiefly Through Contact ................ 176 Diseases Spread hy Avtlwopods |. Ul i00a d al anise 177 Nutritional Diseases 105. &, dob B.D BAL REL ed ate di Jog is 178 Sammaryie oe GE Le ON are eS 178 Bibliography ©. 20 SL LEN BRA RE 178 12, INORTHERN RHODESIA 4... i sii as J ERG 180 Geography andiClimate. iui 0 cio bivdidad si sa 180 Population and Socio-Economic Conditions '............... 0 180 Bopulation 180 Vital Statistics oor. 0 0. a aida i ae RL Ca Or a 181 SecialiFeonomyt. 05 i ol I Rs Sr A 181 Food and Nutrition J... . 0c ad ot iad od rai a a 182 Housing: oon bid oih aa, Se RG Re 182 Environment and Sanitation»... 4.0. Le LE 183 Water Supplies oho ah an eR 183 Waste Disposal ot: ond a ar he 183 Faunaiand Bota... ©... ii i 183 Food Samitation sa: oh aie a sale a 185 Health Services and Medical Facilities... ....... 0.00 cob ciao 186 Health Organizations... 0.0. tar Sh Dae Je a, 186 Medical Institudons'. ..... oun a nse Er 186 Personnel a a 187 Diseases ....ilo oi am na, Alaa uh Le 187 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 187 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 189 Diseases Spread or Contracted Chiefly Through Contact ......... ..... .. 189 Diseases Spreadiby Avthropeds®, =... 00 Lf Sn i il Ca LL 190 Nutritional ADiseasestt a a 191 Miscellaneous Conditions... 0... 6. cL a ee 192 SHmmMARY er he 192 Biblograpliy |... i hs a a 192 13, SOUTHERN RHODESIA. &.... i... dav vn bb ha Gy Se hs Be, 194 Geography and Climate... 0.0. i ad a Sie tei a 194 Population and ‘Socio-Economic Condilions ................L 0. 000i, 194 Populallon bili i hl ean 194 Vital Statisficg tei i. le i a a a Re 195 TE BEET A ET SI a i Re BEL TC 195 Faeod and Nutrition... oi, 2h iu os i he oe 196 Housing i. 0. ond gly or sb A Ne rh a, 196 Eavironment and Sanitation. |... 0 da Sa 196 Water Supplies se. th. Go RE hu i i 196 Waste Disposal: 0 dl eda eS RE 197 Fanmpiand: Rlova 0. 0 vn wb dda JES ah ee te 197 Food Sanitation... i aii sive si va a IBIS A S50 i Sn 199 Health Services and Medical Facilities... .. ui voi. bn Sislis bt: 199 Health 'Oroamizations 0... 0. odie a dad pantie ay 199 Medical Institutions ......... .... 0.0. a dan da duly nels fib 200 Petsonnel si nn tn a sa he SR 201 Diseases ....u. 0b al a Re le 201 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 201 XXiv Contents 13. SouTHERN RHODESIA— (Continued) Diseases— (Continued) Diseases Spread Chiefly Through the Respiratory Tract ................ 202 Diseases Spread or Contracted Chiefly Through Contact ................ 203 Diseases Spread by Arthropods L. ..... 0... cf ids ais. 204 Nutritional Diseases, .... ... fl LG a caahalin f 205 Miscellanegus Conditions: ... .. . io... oval anbh ll didn aa 206 SUBMBACY: 1. a et iE ee LS a 206 Biboguaphy io on ee al nL 206 14 MOZAMBIOUE: =... cfs ists ain a aR yma a eb LA i 208 Geography and CHIME... it to lh aun ia th hh os 208 Population and Socio-Economic Conditions ............................... 209 Population. caso) or 0 Sata a Ee A 209 Vitale Statistics 0 oi, a NR a 210 Social Beenomy ....... 5... 0 i ada i a, Cl 210 Food and Nutrition. i... . 0... i oo a Sissi 211 Housing es ee a 211 Envitonmentiand Sanfation :....... 0c... li dianih bh dans vide alo hhh le 212 Water Supplies | 0. oo a a Se a a t 212 Waste Disposal... 0. ud cis EN ak ee A ed 212 Baunasand Blom... Lou oi ah hii ty wd 0 212 Food Samitation i un. c.f esd iia ob al Eh te nas 214 Health Services and Medical Facilities... ................ 00... 0 LL 0 0 218 Heth:Oroanlzations:. .... 0... 0 or i ih a een 215 Medicalinstitutlons .. 0... cu ni a Sn a, 216 Rersonuel |. © rls ae a Te eh SA WL 216 DS eaSEs i ie en en Lh 217 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 217 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 218 Diseases Spread or Contracted Chiefly Through Contact ...... .. ...... .. 218 Diseases Spread by Avthropods i... ................. 0. 0 en J 219 Nutritional Diseases i. x, 0. in en i naa pe aa 220 Summmdry: ol ene SL a a SE SEE RR Ee 220 Biblloordphy x. vi a ar a 221 SECTION FOUR THE ISLANDS OF THE INDIAN OCEAN 13." ZANZIBAR PROTECTORATE: =... ee vats oi ie sda dies tien aii SALE 225 Geozraphyiand Climates... o.. .. ..oe vn in BEDS Es ES 225% Population and Socio-Economic Conditions ............................... 2258 Popwiation Lc. cid va he a 225 Vital Statislics 0 [i ih ie a ee EAE ee 226 Social ECONOMY. cvs fis ists Us aaa EE 226 Food andiNuteitioni..... .. 0. 0. ui ei a a 226 Housing... LLonais fn ia ann a MEE ta 227 Contents XXV Favivonment andiSaniation 0.0 bain DUT n a GS 227 Water Supplies. >... ovo. J Ee OE aR 2217 Waste Disposal i... 0 J a a an 227 Famaiand Mora... .. odes le tos als Sha, 227 Food Sanitation... ..... 5h 5 0 A i Soy Ls a 228 Health Services and Medical Facilities ....... co. 0 2 hl ls Ls, won 228 Health Organizations... ... 0 0 os nia), Dh is Ba 228 Medical Institutions ©... 0 0 Los un aint dW a a 229 Personnels... iil... 00. oan iis RE ER SE 229 Senses oe a ee ad NT Eh a Aes he i EL] 229 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 230 Diseases Spread Chiefly Through the Respiratory Tract ................ 230 Diseases Spread or Contracted Chiefly Through Contact ................ 231 Diseases Spread by Arthropods ........... 00 iii sam sia ins 231 Nutritional Diseases .... 0... 0 i i a Sr aL 232 SUMIMINY: a ne Ee 232 Bibllography ..... 0 ce re i ee Cd he J RE 233 16. MADAGASCAR AND THE COMORES ARCHIPELAGO ...........utniuuunnennnennnnnns 234 Geography and Climate’... .o.. hb. oi eh aad dns 234 Population and Socio-Economic Conditions ............................... 235 Population ui, inh Tl Le a a le RS LEE 235 Vital Statistics) 0. a ce ee ae EE 236 Socigl Beonomy. ...c.... dove. ean Be dh 236 Foodand Nutrition s. . .... 0... Loh od is ama tl 237 Housing... oui ead od i Es a ai oo as 2317 Bavironment and Sanitation .........0. 00. ils a a 237 Water Supplies... ...... cL 0. de EE a 237 Waste Disposal o.oo. lia ds A her 237 Fauna andiBlorn o.oo. sii anid bbs nies So a Se 238 Food Sanitation cs... o... bd i hh Saha Sh iB pi a BD te 239 Health Services and Medical Facilities .......... 0000. i vraad divas 239 Health Organizations... .... 00. a aad in es Li es 239 Medical Institutions... 0. oii bed de vata it nadia, 240 Personmel 0... a SAR Th naa aR 241 DUSeASEE | ei i ei a te iss whee eee i a at SETS SARS 241 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 241 Diseases Spread Chiefly Through the Respiratory Tract ................ 243 Diseases Spread or Contracted Chiefly Through Contact ................ 244 Diseases Spread hy Avtheapeds ©... o.oo ol a va 245 NutritionalilDiseases ..... Li... oh alias es ita il ttn 248 SUMMAry: 0. a a LL Rn SS Ei 248 Biblezraphy i a a a Ra dn 248 Bl MAURIEIUG ih J ss 0 ote sn nit ain ain ie loos ails Ae LO 250 Geographyviand' Climafer. ... i... ..... vd SA a a 250 Population and Socio-Economic Conditions ............................... 250 Population ©... zich a a i J Foto pe 250 Vila) Statistiesia- 0. oo Lae de ra as RT 251 SocialiBeOnOMY. ... o.oo i hb a a 251 Foodamd Nutrition... ....0 0... ein asain as ue 252 Housing: coi. hdd i svi als, ir, ash Ta ae ie 252 XXVi Contents 17. Mauritius— (Continued) Environment and Sanftation ci. oop. aL LL sn i i Ee 232 Waters Supplies vi... 0 a ae sh a 252 WastelDisposal cr i oh el ie 252 BaunaandiBlora och. 2000. i Sli hai sakes 232 [Food Sanitation: 0... cous hh ind pol bas sha ida ed 253 Health Services'and Medical Facilities... ...... cdi inh sc ardnabio con 253 Health. Ovoanjzations’ . ...... 0... .. Lamia ie hndmid ne he 253 Medical Institutions =... 0. Ja. ci i co hana 254 Personnel. weir a a a EL Se Se SE 254 DISEASES a: hte het aE lh hE GT SEL ih bike Ah be all ena Se i CR 254 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 254 Diseases Spread Chiefly Through the Respiratory Tract ................ 255 Diseases Spread or Contracted Chiefly Through Contact ................ 256 DiseasesiSpread hy Avthropods i... 0) 0. dics dirdiov, Sue 256 Nutritional DISEASE 1. i, di a Sl lh de banat 257 SUMMARY. a 0 rr ay AE a ee ee LS AE at 257 Bibliography. oot a I a 257 IR REUNION i. a hy a a a a se 259 Geography andeClimate s, . .1 Jo. hale oh eH i ea 259 [Population ‘and Socio-Economic Conditions ............. 0... 00 il... 259 Bopulation RR 259 Vital Statistical ai air a a a a 260 Soclal Economy. . i... da Se BE A 260 Food and Nutritlon 1. 4. cl an. a 260 Environment and Sanitation oo... ohio. cu A SE 260 HealthiServicesiand Medical Facilities ............. uo iuh si 260 Health Oroanizations 0. LL ca chs SINT Rs LO ST BE 26Q Medical Institutions... 0. co 0h ab NL ada dee a 261 Pevsonmelni iid, oo pan Si a an dA iE RE aL 261 Diseases i a aD AE rg 261 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 261 Diseases Spread Chiefly Through the Respiratory Tract ................ 262 Diseases Spread or Contracted Chiefly Through Contact ................ 262 Diseases Spread by Arthropods =... . . ...... 0 GE Jo piu ls 262 Nutiitional Diseases Ll... i ital fi os San adda Sn Go, 263 SUMMARY EE me BR ed) 263 Bibliography: io. wiiiian aisha Sain on die Jal nau Reh 263 SECTION FIVE SOUTH AFRICA 19. UNION. OF SOUTIL AFBICA .. 00. is den this ve fa dn ints said nlets Sewn ais TE, 267 Geography and Climate... ons i A aie de AR ON Je 267 Population and Socio-Economic Conditions ........ 0 00 nb i Ladi. 268 Population 0 5... a A en SE ES Re al 268 Nital Statistics onion anid i AER J ee 269 Social BeOnOMIV: «iv. 0 ri ls, Gh a ne, HR A 270 Contents xxvii Food andiNuteition@ [5 oi 0) Jini aan cnaanasmi tb sat an, 270 Housing... 05 bn Lea, ns nL ane in Beinn Jn said 271 Environmentand Sanitation... ..... 0... LoL cocanii aig chil da Bubs il 272 Water Supplies: .i.o.o ch. ci. lh saa 272 Waste Disposal ....0 Lh... a J Eek ae 272 Famaand Blora 0... 0... 0 0 oh eal, Salad 273 Food Sattation i... 0. aaah Lah astra andl 276 Health Services and Medical Facilities ............ 0 i i mad. foo, 276 Health Oveanizations: .............o. 000 an ieA Shad p Bib 276 Medical Institutions .......... lssek il dian nnn ciliate, 278 Peisonnel: .-.. 0. ...... 00000 veniam Ya Sl 279 DISCARES: Uv. x vy itd inte iin Sa ie we RSL LES EAE LL CE 280 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 280 Diseases Spread Chiefly Through the Respiratory Tract ................ 282 Diseases Spread or Contracted Chiefly Through Contact ................ 283 Diseases Spread by Arthropods i... vib oS iiauls losis alerass + in leds tele +p nin ol 285 Nutritional AISCASES ci. Lh vi teh bin vi itinisaTon nin saison pois andl ie sa li 287 Miscellaneous Conditions ... .. . . ivibie sc mathe + ls intgiiets sso iis 288 Summary Von a sa So A RR a beh SRR 288 Biblloowaphy Lo. an hs a aa a a 289 20: SOUTH WEST AFRICA... i dasha hl Re 292 Geogtaphyeand iClimate t.. .. vo a a a 292 Population and Socio-Economic Conditions ............................... 292 Population i... aa 292 Vital Statistics ol... a iE 293 Social Economy 0h. on i a a an 293 Foodland Nutrition. Lo... 0... 0 a dn i ee 294 Housing. 0.0 a aa hy, 294 Eanvitonment and Sanitation’... .......... 0 ah a 295 Water Supplies i. L. e 295 Waste Disposal... ii hin. a ES EE 295 Fauna andePloea. 8 inal on aa i a 295 Food Santaflonl. ii. us A ie 296 Health Services and Medical Facilities . .....................5...coonun.s, 296 Health Organizations... Lo... 00s ARN UE Ee a, 296 Medical Institutions... . 0 i... oc. 00 el. ls 296 Revsommel i. i. a. ET HACER 297 DISEASES i. hh i hi ies ies ate id a ate ds i A A 297 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 297 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 298 Diseases Spread or Contracted Chiefly Through Contact ............. . .. 298 Diseases Spread hy Avthropods .:. . 0... bb ir S80 de aa 299 Nutritional ‘Diseases: on ... un ii. Wn BNE ai BL Sn, 299 Summary aL Ln sa a Ln LE Tn 299 Biblegraphy’ i LS a le A 300 21. THE Hic CoMMISSION TERRITORIES OF SOUTH AFRICA ....................... 301 BASUTGUAND Yi: hs nh i ath a Sn Se a 301 Geography land Climate. ........L..... 0. ce a ines Ly 301 Population and Socio-Economic Conditions ........................ ... ... 301 Population... 0... 0h a Ged na 301 Social Beonamy &.. Luvs clu i ee Ee elias 302 xxviii Contents 21. Tue HicH CoMMISSION TERRITORIES OF SOUTH AFRICA— (Continued) Population and Socio-Economic Conditions— (Continued) Foodand Nutrition... ...... 0. 2. 5. LG asia i, 302 Housings... 0. hh A tl a 303 Environmentiand Sanltation ......... 000 Sioa. clad in 303 Water Supplies... oS DA SL 303 Waste BIsposal 0... on. fo i Ea a Ms 303 Pawmaand Bora... ooh i ah an iL ti adn, 303 Food Sanitation... 0. 0.0. ci is al ae Se 303 Health Services and Medical Facilities ............ 0000 0 000i 303 Health Organizations... ...... 0... 0 sa El a, 303 Medical Institutions... 0.0. hi. co LT a A 304 Personmelnt rd soni LC OBR SR ae 304 Biseqses, cory loti, nat MEE iS I SE LE 304 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 304 Diseases Spread Chiefly Through the Respiratory Tract ................ 305 Diseases Spread or Contracted Chiefly Through Contact ................ 305 Diseases Spread by Artlwopeds ......... 0 L008 0 RE a 306 Nutritional Diseases ................. .. 0 cal sn ba ae 306 SummanvE, oo ea ba en SS a a pi SE a 306 BECHUANALANDIPROTECTORATE ... os sdb ay J wo ae we aliE t 307 SeographyiandClimate 0... Joh a, ee Le 307 Population and Socio-Economic Conditions ............................... 307 Bopulation: 1 si a ee a a SE 307 SoclallBeOROMY i... a Ss a an a a LB 308 Food and NUtrition ..... in i oi a rs hh Tha 308 Housing. a i a ee ies RA TO 309 Eavitonment and Sanitation ......... 0... 000. 0h a EG a ve frat site le 309 Water Supplies... LL a ad i 309 Waste BiSposalll cc... . co a san a LR eR 309 FamaandBlora Lv 0n. 0 oS ad a ae be A Se 309 Food Sanitation... 0. er Rh eS ei ee Ra 310 Health Services and Medical Facilities .........................c.ciua.n. 310 Health Organizations... ........ 0... 00h cl sidim nnn od pT as is 310 Medical Institutions... ...... 0. virus aie bate Sa 0 ats nis 310 Personmel ion lo hy 0 a a RR 310 IDISRases oo ase a Se 310 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 310 Diseases Spread Chiefly Through the Respiratory Tract ................ 311 Diseases Spread or Contracted Chiefly Through Contact .............. .. 311 Diseases Spreadiby Arthropods... . i iv. iid aaa sees 312 Nutritional Diseases... ..... ....... 0. c.. evimnduidan mnie sais, 313 SWIMMABY ole oe i Sa ee Sh THe 313 SWAZIANDE, a Le Le Lr LE Re SL 313 Geography andi Climates... col. 0 a ah aa 313 Population and Socio-Economic Conditions ............................... 313 Bopulatlon |. .0 0... ho Las ais Lins sania ky 313 Social Economy .......... 0 Lon dosneenai olde Sas nd te iu, 314 Food and Nutrition .............. cell Bnei laa 314 Housing: onl nh a i i Cs en ES RS RE EN 315 Contents XxXix Environment sndiSonitation . i. 0.0 Ls 00 a Ea a ds LL RL. 315 Water Suppliess ov. arn oe Sha i Jn La 315 Waste Disposal... rr a eR 315 FaunmanandBlora. a aa 315 Health Services and Medical Facilities... ...... 0 0 dhe nic didnt, 315 Health Organizations... nna sh wide aie i: he, 315 Medical Instifutions =... uo. esos eR Bhs 1s ins tn ao AR, 315 Personnel... ee in aT a er 316 DISEASES ©... is chai init Bs maiko nn ett ite ie 4 srg abl fa Gone 316 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 316 Diseases Spread Chiefly Through the Respiratory Tract ................ 316 Diseases Spread or Contracted Chiefly Through Contact ................ 316 Diseases Spread by Arthropods’... . .... 0 cosa 317 Nutritional IIISeases: «iil vans sh tin sabe das nla ets a NEE 317 SHIMIMALY: Am i La Sl as bs a ins PO al GE 317 BIBLIOGRAPHY... ii iis ih sn sa lei ae 317 Basutoland iit Gn oi cr ub a i 318 Bechuanaland Protectorate ........... 0d ead see no 318 Swaziland Lh el a ae RE 318 SECTION SIX EQUATORIAL AFRICA ANGOLA... iE se i eB CS 323 Geography and CHMAtE ....... 00 Sh viii Saleen eiviain diets sobs nn eines a elagotine 323 Population and Socio-Economic Conditions ............................... 324 Population: oe ia te te rae ttn 324 Vital Statistics oo... Ls 325 SOC BCONOMYe i a i i dod is wate ea abit 325 Foodiand Nutvllon . ... .. cn ad hs bee del 326 HOUSING Te ee a ie a 5 he a i AL GN 326 Enviionment and Sanliatlon . ............ cou eds sahiodis visain ua sa biaisiattin tats 326 Walter Supplies... 326 Waste Disposal = 0... ou 326 Famaand Rlara 0... 0. a a 327 Food Sanitation. Ji. iu... 0. re A Ee a 328 Health Services and Medical Facilities .......... 0... 00 00 hE, 329 Health-@reamteations ................. 0h 2 of SEL aie de 329 Medical ‘Tnstitutions®.. ci... ....L. 0. Ed is a 329 Pessonnel .. nn ah ES a ee 330 Diseasestt on. i. nl Sa sen bse MER BT SR an 330 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 330 Diseases Spread Chiefly Through the Respiratory Tract ................ 331 Diseases Spread or Contracted Chiefly Through Contact ................ 331 Diseases Spread‘by Avthropods:. Ll cou) Lo A 332 Nutritional Diseases: . .. ......... 00 2 de Gl Es ashi aR el 333 Miscellaneous Conditions’... ............ 00 Jb Forlani nn 334 BAA i ash a Sd EG ER 334 Bibliography XXX Contents 23- BELGIANICONGS 1... isa sa ls Sanne nan wren sind 336 Geography and Climate... 0 0. 0. ae ane tire i 336 Population and Socio-Economic Conditions ............................... 337 Population 1... 0. rl RR a 33% Vital Statistics. oni 0. a a eR 338 SOCUREONOmY 5 in. oR re A 339 Food and Nutrition. 2 ©. inset Lr en aa i hn sal 340 Bonsing: 2c one hate an 340 Environment and Saniiation .. .. co. haat dh Le en a a 341 Wateri Supplies 0, A Re An 341 Waste Disposal. Li nll. nS A 341 Famaian@elioras. of oe A i a a 341 Food Sanitation oi. .. ... coe Se hy a 344 Health Servvicesiand Medical Facilities ................ ... oad ha, 344 Health Ouoanizafions c,h. ce ei Eas a oiaga als 344 Medical Institutions ................0..... nl Se el 345 Personnels. 2) bo dv in 346 Biseases i... i te tsi Se a RE 347 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 347 Diseases Spread Chiefly Through the Respiratory Tract ................ 349 Diseases Spread or Contracted Chiefly Through Contact ............ .. .. 350 Diseases Spread by Avthwopods=, ....0. 0 Lo a ra a 352 Nutritional Diseases... eS a en 356 Miscellaneous Conditions. . £405 Abii Fests ceed ii, 356 en ED TO REE a SE BC a eR Es a EVR BEE 0) CNR 356 BROS TS Sa, 357 2d RUANDAUBUNDT oh a. hd SL Ra Sn A 360 Geography and Climatelia 1... 0 ie or ra nn a 360 Population and Socio-Economic Conditions ............................... 360 Bopiiation aL oot ia ll a a he 360 VitaleStatisties i. fr a, a 361 Social eOROMIY: a, a Le 361 Food and NUEBHION oi sn el ih Caters tsa als ats gna hatu 362 Mousing 0. he ae Le 362 Environment and Sanflation ..... er i le erie 362 WatersSupplles Lo 0... nas a a a 362 Waste Disposal oi i. ne a 362 Fama andi BIora ©. 0s i i a res a i bs 362 Food Sanitation... ln 0 at a eile in asin di Ser 363 Health Services and Medical Facilities... ........ 50 i bnambadd dn idan 363 Health Groonizations is iv iv. a J waists L500 0, 363 Medical Instititionsic.. 4 vile ciao de se a 363 Bersonnels Lon ea a al ol Se 364 DISEaSeTm if od dia Ta bli uhir et SFL EE lati idokasae th nie ieashabs SLA ee NO hs i ET 364 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 364 Diseases Spread Chiefly Through the Respiratory Tract ........ .. _ .. . . . 365 Diseases Spread or Contracted Chiefly Through Contact ...... ...... | 365 Diseases Spread hy Arthropods. . ....... . cu 56dl ie tis siadd iin. 365 Nutritional IDISEases ui hr Biel 5 ved bei Ei EL 366 SUMMALY = he, J ee ee Sl a nett 366 Bibliography... 0, dl a a as sil Co petri BLE) 367 Contents XXXi 25. FrENCH EQUATORIAL AFRICA... .. J... vin. ansiiosni nal lim an nah alanis 8 368 Geography and Climates.) . 0. 0. a a et 368 Population and Socio-Economic Conditions... ..... J. dr cS Ces, 369 BopUlIOn a ne La 369 Vital Stalin: (AS a aE ads aS a eh 370 Social Beonomy ........ 0h a a 370 Food and Nutrition. ...... 0.00 lL da Sah de Dh ie is 370 Housing... 0. io fa a i EE wohl Eavivonment andiSamitation:......... 0.0 in ads Si a ee 371 Water Supplies. i, oa ee 371 Waste Disposal 0. na 371 Famaam@ Blova oo... i A Kaa 371 Food Sanitation... 0... ci oh i hs as a ae ala 373 Health Services and Medical Tacilitles .. ...... co ni fo 0 373 Health: Orvoanlzations, 0... Lub vo di gs PE 373 Medical Institutions... 0. 0 oy, i hats Ri 374 Personnel ...... a a 374 DISEASES. i vs ee a 374 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 375 Diseases Spread Chiefly Through the Respiratory Tract ................ 376 Diseases Spread or Contracted Chiefly Through Contact ........ ... ... .. 376 Diseases Spread by Arthropods... .: 0.6... i ii ah vals as 377 Nutritional Diseases |... 0 0 0 a ah deals ad Gd 380 Sammany: a 380 Bibflegraphy ©... ee aE 380 26. SpaNiSH GUINEA (Rio Muni and Fernando Péo) .............................. 382 Geography ‘and CHUMale 5.0. oni a JE ea Se 382 Population and Socio-Economic Condiions ...........000 ..csceesivamisisnaeio 382 Population. co... 0 ar A Eh 382 Vital Staffetios | ou sd na TL a RS 383 Social Beonomyy. i... 0 i es ne an re a 383 Foodiand Nutrition .. .o ci. 000. ca ha bn hh a rn 384 Housing... 0 oo i 384 Envivonment and Sanitation. ....... on hi a i 384 Health Services and Medical Facilities. . ....... .. ond, bi a ad 384 Health Oroanizations dro - oon ot A a Lr ee Sie 384 Medical Institutions... . 0. oan Lad NG BIL a 384 Personnel i. Ls Fd ri sa 385 DISRASES © a a a a Ee el SB 385 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 385 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 385 Diseases Spread or Contracted Chiefly Through Contact ................ 385 Diseases Spread by Arthropods... ........o. ond Johns leaning 386 Summary CL RL SL St ei Le ae RE 386 Bibliography. cv. iu ni EG en a BEE EE 387 2 CAMEROONS |, i a a as iis vie ie a ak So EE EE LL 388 CAMEROONS APRENCH) oh tn sib dai DRS) atin Too is Bi 388 Geographyiand Climate 0... ind dala i SERRE 388 Population and Socio-Economic Conditions ..... oc 0. die wii ik 388 Population ..c..n. oi Dn ot ee 388 Vital Statistics iii in ob en he ea A i ed 389 xxxii Contents 27. CaMmERroONS (FrENCH)— (Continued) Population and Socio-Economic Conditions— (Continued) Social ECONOMY. 5. i a i hh th nets 389 Food and INIRIIEION oe i Sis Shin wells ea aieks 390 Housing lar Na nd A 390 Envitonmentand Saniation ........ 0... 000 vin Gl ee a eat rte le 391 Water Supplies i. Ea hi 391 Waste Disposal... .... 0. a iis Si a aa as ele 391 Ramanand Blora ls 0. oo on a i sin ish eee 391 Boodi Sanitation i x i. coi nas aa Sr 391 Health Services and Medical Facilities... ...... hui in sss vain tonsa 391 Health QroaniZatlons 0. i aE i wd fw i ee ns 391 Medical Institutions 0... sa cai da en tes lene 392 Personnel i a YE Sn Eh ite SARL 392 Cases A SE ar BE a va a 392 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 393 Diseases Spread Chiefly Through the Respiratory Tract ................ 393 Diseases Spread or Contracted Chiefly Through Contact .............. .. 394 Diseases Spread by Arthropods ©. 0... oc a a 394 INI HORA DISEASES. rr. i ret ire SE ais a a we ty leas ae ait od 395 IRA a a ee ales iain io a Sala 395 CAMBROONS UBEITISHY i an de ls iy i i 396 Geporaphyiand Climate 0.0... 0 00 i, i Sah Le 396 Population and Socio-Economic Conditions ............................... 396 Environment and iSamibation rc... ........0. L000 coi a de 397 Health Organizations and Medical Facilities ...............0.. vu vuinansn unas 397 SCaSes te a A A a aa ei 397 BIBHOGRAPHIY: 0 oe a a ak 398 Cameroons (BrenchYy 0. aE a AL, 398 Comeroons (Bris 1 5.0. vr el ah oh saa he aes es SE 398 28. SA0 TOME AND PRINCIPE ............. ates an eR i ein Cl 400 SECTION SEVEN WEST AFRICA 20. INTCERIA: ih sah fl iba a3 2 ith otal wa his 0 esis A in on ba te ta 0 a Mee 403 Geography and Climatels. ...........c 0 danior sada gh ll nn LLL ae 403 Population and Socio-Economic Conditions ............................... 404 Bopalation co. i or ri a ed Sn en RE Se 404 Vital Statistics... 0... 00 nL ea, 405 SOClal ECONOMY. i te RR TE Le E , 405 Foodand Nulrilion i... Liss abc Bad aa Ea 406 Housing: is he es AE Sl a 406 Environment and Samation i. ai ch SiR ee wii a 8 STG tli i a 407 Water Supplies... Ln ri a se nS 407 Waste Disposal 7... nn da se Ee 407 Contents xxxiii Famavandi Flora... el ae a Rt, 408 Food Sanitation io i oa vs ohh is a idan a thls sat asa oh 410 Health Services and Medical Facilities... ... ois. Boas nisin sant a 411 Health Oreamizalions i us cid vias sditanies she tore dines sia drenies ss 411 Medical Institutions... 0. 0. 0, ohn ie Fas Astin 411 Personnel Co ln Amati ira the el ET 413 Diseases ts. ti. 0 aE Sh Se 413 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 413 Diseases Spread Chiefly Through the Respiratory Tract ................ 414 Diseases Spread or Contracted Chiefly Through Contact .............. .. 415 Diseases Spread thy Arnthropods =~... ...... LL. Ld an 417 Nutritional Diseases... ............00 0 vias ibn 420 Miscellaneous Conditions. ..... 0.5. LL ois so ais Anak aa, 420 Summary. won a a I En 420 Bibllogiaphy .. elvis on Sh le i Le 421 BOIGOIDECOAST oi Ea Cs he es a 423 Geography and CHIMAte 7. 0. cL ch evict nas tiansis ala 423 Population and Socio-Economic Conditions ..............0. co 00. 0.00. 423 Population’... oe i i a aes a 423 Vital Statistics. on oo 000. ea RE rn 424 BOC RCOnOMY fi i i a a SA 424 Food amd Nuteltion ........ 0... 0 00 Lit nia 425 Housing: 0 i eS Ra Rr 426 Envivenment and Sanitation .<.. .ccivn ia AE A ey 426 Water Supplies... oo A a A 426 Waster Disposal: on 0 sa la ana ela ne A 426 Fauna and Blora ........... ....... 0 hh a 426 Food Sanitation. . ic. Ee 428 Health Services and Medical Facilities”... .... 0.6. 0k dove i vai li 428 Health Organizations... oo. i. tide. el 428 Medical Institutions... .....0.¢. onon tan 429 Personnel... 0 in SL A Te 430 Bisengasie vn, ae LL a ei ee i Ee EE 430 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 430 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 431 Diseases Spread or Contracted Chiefly Through Contact .............. .. 432 Diseases Spread by Arthtopods .......... 0... an hea 432 Nutritional DISeases -.... ho. ca it 0 se SiS 433 Miscellaneous Conditions ........... 0. 0. hie, Lai aa 434 Summary te, an SER ae 434 BIDROSEAPIY co a es he BE A 434 Sl OROT AND: a em a a eC 436 BOGOTARD: (ERENCE)... 0. Lt doen Sard is i RY aE 436 Geographyiand Climate ©. .vt ibis. Li ida fa a a 436 Population and Socio-Economic Conditions ............................. .. 436 Euvivenment and Sanitation iu... 0, nL ee re 437 Health Services and Medieal Facilities... .......... 0. 0 0 bh ian 437 Biseases i ih eh ht A EE 438 TLOCOLAND (BRITISH) 0 oo sn LL Ls Lhe Re a eE 438 Geography and Climate... 0.0... ae a a 438 XXXIV Contents 31. TocoranD (Britisu)—(Continued) Population and Socio-Economic Conditions +... olin bu bn ol ote 438 Environment and-Sanitationii. i hs dn obi rr 439 Health Services and Medical Facilities... conn EL oi ai ol ad dee 439 Biseases vi 0 0 nl ad ie BA SR a Ss . 440 BIBTIOGRAPIINV oh en A a IR i Ea 440 Togoland(Brenchy i... ca. usa LL hl Be, sae Le 440 Togoland (British. oo. fc ie asain, BE a a 440 3 ABERIA dB i SAH i ar ER 441 Geosmaphy and Climate i... 0, oo as de sab 441 Population and Socio-Economic Conditions... uc... cut aod dil LL 442 Population =... 0 sr, Li i le ae ali vate EE 442 Vital Statistics to 00 i a ee A LE 443 Social ReonomY ... i. LSE a sean AT REL 443 Bood and INULHGON 0 a a 444 Mousing 0. 0... 00 Rd re ei te 444 Environment and Sanitation... ii. idols aa ea 444 Water Suppliest:(~..... . % 0 s aa e 444 Waste Disposal. no ha i aE 444 Bama znd Blora co al , L 445 Food Sanitation tc... ch hh i a REL a 447 Health Services and Medicalt Facilities 5... oy be ch ia i 447 Health. Organizations. o. o.. hsh dete Strada cl 447 Medical InSt_UtIONS: nr Ti soit 4 an enia ie, fh I 447 Personnel. rc LR Ee 449 Disease i Le SE de Lt 449 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 449 Diseases Spread Chiefly Through the Respiratory Tract ................ 450 Diseases Spread or Contracted Chiefly Through Contact ................ 450 Diseases Spread hy Arthropods... (i... oli oh dha stinians « vabiu, 451 Nutritional BDiseases ti... co... el oh 452 SUMIMALY i A 452 Bibliooraphy. oi. fa has GR 453 SIERRA LEONE i. i A a SS Ae a 455 Geoorphy and Climate 5... oh oor i 455 Population and Socio-Economic Conditions ............................... 455 Bopulation er. oor A 455 Vital Statistics. 0... 8 0 a se a anil SE 456 Social Beonomiy:. 5.00. ce hi. Lo sna ae al 456 Food and NUtrtlont ou. i ve ri i RS 457 Bousing oo. ra A RE 457 Envitonment and Sanitation... .. LL cl Ga Gn a ra, 457 Water Supplies... 0 es ee i ei 457 Waste DISPOSAL iL co Le oe Ba Sa 458 Faunoand Boras. 5... i i OR Li hia te nia hill 458 Food Sanitafion i... .... 00. cs be vrata oe 459 Health Services and Medical Facilities... i on. Ln in aha a ine 459 Health Oraamizations v.00... 00h le sh ei 459 Medical Institutions... wa. oc vie ie La SR 460 Personnel Contents XXXV Diseases tii. hr re a Sia ERR 461 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 461 Diseases Spread Chiefly Through the Respiratory Tract ................ 461 Diseases Spread or Contracted Chiefly Through Contact ................ 462 Diseases Spread hy Arthropods... ...... oil an nl aL 463 Nutritional-Diseases .. .v. . a, Siig Jos oo ea diim il gg taa 464 Miscellaneons Conditions"... co... ni diibnie sda ade BL ei 464 Summary.) a rae SL 464 Bibliography so... SE Lh 464 3, PORTUGUESE GUINEA ah da idan sna sala sah lb Jb ERE 466 Geagraphy and Climate J... eh. i a a 466 Population and’ Socio-Economic Conditions ...........0.. Lo. AL a0 oo 466 Population: .... 0 io iii. 0 or ee a 466 Vital Statistics... nS i i EE i AEE 467 SegialBeonomy. ii... nin a Ae a Ra 467 Foodamd Nutrition... 0h 0. 0 oo sis 467 Housing ou. oii fas. on ola Bi nn aah on to i 467 Environment and Sanftation iii. oo... Ld uh a ES 467 Water Supplies... 0... 00 ra a ea a 467 Waste Disposal 0 ha lL a a 468 Fauna and Flora Health Organfzafionsi 0... 0.0 i dr 468 Medical Institutions... coo. J hoa it a le a 469 Bersonuel © oh. Licl 0 Sw Sb CT RE eC 469 Diseases © ou. RI eh ai Go 469 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 470 Diseases Spread Chiefly Through the Respiratory Tract ............. ... 470 Diseases Spread or Contracted Chiefly Through Contact ........... ... .. 470 Diseases Spread yy Arthropods... ... 0 de 471 Nutritional: Diseases... rh 0, od sre ee 472 Summarys. La Le eR 472 Bibliosraphyici. oot a a sa iE TE 472 BSE TRE GAMBIA Lh sd a ea ise el EE 474 Geagraphyiand Climate. 00 col ei Es TS 474 Population and Socio-Economic Conditions .......................... . . 474 Population... 2.00 0s ims Ee A eR RE 474 Vitali Statistics 1. oo vs. LL ds aL Ee Sean a ey 475 Social Beonomiy: i i ion aes isa ER 475 Foodand Nuteitlon 0... vo. ono, aes wins Snide ie ol 475 Housing: iu Shon ah be ie Le SHER a fe 476 Environment and: Santation .............. J RN a a 476 Waten Supplies... 0 cai dey nL SRE SE 476 WastelDisposal io... iia EN aN 476 Fauna and Flovas. o.oo, 0 0 0 iain san di a Clie og 476 Rood Samitation oi. illinois a eS 477 Health Services:and Medical Facilities ..«........ lo onl ona 477 Health! Ovganizationsi i... 0... LoL nna niad die fn sew 4717 MedicaltUnstitutions o.oo. irs ae 477 Personnel 478 XXXVi Contents 35. THE GamBiA— (Continued) Diseases. it inl BE ETL ER i 478 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 478 Diseases Spread Chiefly Through the Respiratory Tract ................ 478 Diseases Spread or Contracted Chiefly Through Contact ................ 479 Diseases Spread by Arthropods: =... ... 0.0. co di huh Londen, 479 Nutritional Diseases, 1. 0 LoL saad), eleiE Eo Sn 480 SUMMARY. 8. hy a al a lr eM 480 Bibliography ©. a Se Ee a Br a 480 36, BRENCEHIWERST AFRICA (0 nr i i id at seed men hs a sia ay ate oh Sela 482 Geozraphyiand Climate =... co... i Ca a TE RR 482 Population and: Socio-Economic ConGitions .... ... . iv. vols vu seaside 483 Papulation. a a an dee ne ete te ats RTE) 483 Vital Statisticss. 0. in ov av 485 Social BONY. Lo... hn i i eis a a 485 FoodiandNUteition i... 1 voi. «oa a a a ee aE 486 Housing: -& 0. hon he a diab a Se at 487 Environment and: Sanitation... ... c.f ae. shins a ah 487 Water Supplies... nee Ese Sn 487 WeastelDisposal bi... . 0. 0, SRG ae Un ei 488 Farina ands Bora 1... of es ida i sl es Ti ha 488 Food Sanltalion... ..t..... bs ies pia ad aa Am ah EE a 492 Health Services and Medical Facilities. ........ 0... 0 hana LG whi ahs, 492 Health Orzanizations vo. 0. 0... od. ia ol ad Le as 492 Medical Institutions... oh as dis dv insists haha, DEL 493 Personnel: of. oe. a eG ne a eae 494 Diseases svn a dE a i et Rn Ne ST 495 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 495 Diseases Spread Chiefly Through the Respiratory Tract ................ 497 Diseases Spread or Contracted Chiefly Through Contact .............. .. 498 Diseases Spread by Arthropods... 0. 0h sw aad ns ie 500 Nuttitional Diseases’, .. 0 oor. ws ee i, Ls Se a 504 Miscellanedus Conditions ... Jf... .. oo ie a a a 1 504 SUMMAIY il. anil, on re PR Eh RR a 504 Bibleseaphy's i... dt i a Eh A RE RE, 505 B70 CAPE VERT TOUANDS il. ihn dha tS ns BG Sa TL 508 Geography and Climate: 0h bo SRG Re 508 Population and Socio-Economic Conditions... xc. cuca iii aii 508 Bopulation 0b br se ae 508 Vital Statlstlesi, . i... lad Jo a a ne Se 509 Social BEONOMY. ..it'. . vl aah ent a i en SR Da Sai Se 509 Feod and Nutrition... Loi cui Lule. ho cde adnan len vung 509 Housing... coy. a en ad as Le LE 510 Envivonment and Sanitation... ui. wads ao ash Sih an eR 510 WateraSuppliess 2... oi LBL Bl eA iE 510 Waste Disposal. 0... oho ea AR Se 510 Famaand Blom ©... a as ain ha aly 510 Food Sapitation'. i. ih a i a a 511 Health Services and Medical Facllities. . i... i. is veoh pining, . Sh Health Oroanieations:. 0... cual c-Si Calan Sane 0 Ea EE 511 Medical institutions. oo 0. «ooo Jul, asa aR 511 Personnel. i Smee hb Le aR a Be 511 Contents XXXVii Diseases’... cout ir vn fo se SAR AR Lae ah el at S11 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 512 Diseases Spread Chiefly Through the Respiratory Tract ................ 312 Diseases Spread or Contracted Chiefly Through Contact ............. ... 512 Diseases Spread by Arthropods: cs obi int ois iy aiesleies sees ee eiatoie } 513 Nutritional Diseases «0. 00 ane oh sis we aS 513 SHMMATY 0... ar Sd Le 513 Bibliography... cio. dna sae EE LR 514 SECTION EIGHT NORTHERN AFRICA BS CANARY ISTANDS a a ae el Ee 517 Geooraphy and Climate 5. . o.oo di hs riers re eel i 517 Population: and Socio-Economic Conditions .............. 00. hs 0 8 517 Population 0... 5 re ae eR Re hg S17 Nital Statistics 0. 0. 2 nia as de 518 Social Beonomy .. Li. 0. 0d i a ll Se 518 Foodiand NUtrIHOn:. Loo hi nie eo oe i 518 Wousing 1... 0 Re eS se 518 Environment and Sanitation... ....0. 0 a a ee 518 Water Supplies ii lon NS a 518 Waste Disposal... vais le Te Ss LS 519 FPawmaand Flora oh... ivi vs ao aie. hal ge ass 519 FoodiSanltation Ll. rl vd a A ea 520 Health Services and Medical Facilities... ... ... 0.0 nh nahi ca aed 520 Health Oroantzations: . .-.. 00. 0 0, aa ee ed 520 Medical InSUHIONS: oi. ie ie i CAE 520 Petsonnel i Le a ee 521 Diseases. nl a he eT LE Le 521 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 521 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 522 Diseases Spread or Contracted Chiefly Through Contact ............. ... 522 Diseases Spread hy Avthroapods =... Ln ini. th chien alin td 523 SHMMALY: S.C a 523 Bibllagraphy: ...... nS an a ne 524 30 SPANISHSAHARA AND LENT i. a. i se 525 Geography and Climate i. 0. 0.0 eR El 525 Population and Socio-Economic Conditions ................0 00h 526 Population: ©... .. on A LR 526 Social Beonomy ti. i. ub nl LEE i SE a ES 526 Food and Nutrition. «=. 5... oo. SL Rn a 526 Housing: .... co... a. a SG a UL eld] 527 Environment and Sanitation’ J... 0... 5 iis cn cin ede ER a Be 527 Health Services and Medical Facilities. ........... couiii is caidas odd visits 1 527 Health ‘Organizations: 0... 0 or 0, oo an sl nigel mle 327 Medical Unstitwdions: 0.0 00 Col i a rE ie 527 Personnel 050.0 ahlar Lisi arb sn aiide tel on iS Te Eek Se ot 528 XXXVili Contents 39. SPANISH SAHARA AND IFNI— (Continued) Diseases. wie vn) A A iE a SE Bt 528 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 528 Diseases Spread Chiefly Through the Respiratory Tract ................ 528 Diseases Spread or Contracted Chiefly Through Contact ................ 528 Diseases Spread by Avtlwopods:'........... 00 i. oon aad al, 529 STMT RL: Jo, a hh LE a 529 Bibliography 0. bel oe Le Re 529 AO MMGROCEE Ihr fr CE SE 530 Geographyand Climate... 0 00 ee ae a 530 Population and Socio-Economic Conditions ....... .............. ... .... ... 531 Bopulation 0... 0 Sn rae 531 Vital Statistics 0 0 vd a ls Ss 531 SecisliBeonomy: =... 0.0) ee lls Le LR 532 Food and Nutultion:. &... 0. i. 0 se a si et 532 ousting re es Sint 533 Eavitonmentand Samifation .. ............ 0. in sea a 533 BV ater Supplieshis tT he ith Sia es Stas ie 533 Waste dDIsposal 0 ne a ae a i 534 Fama andi Blova ro... as i a a a a Se 534 Food Sanitation... i... coh, Sa SR 536 Health Services and Medical Facilities... ......... 0.0 cia iw iid cdi 536 Health Organizations... 0. at Sh a, 536 Medical Institutions... ich iui. S ah ea 537 Personnel re Bn ak nL 538 Diseases ts, nt, au hn Ee a SL te le 538 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 538 Diseases Spread Chiefly Through the Respiratory Tract ................ 540 Diseases Spread or Contracted Chiefly Through Contact ................ 541 Diseases Spread by Avthropods 0... i i Al 542 Nuttitional Diseases... LU. a0 aa hn as 544 Miscellaneous Conditions i... .. 0. oo. Lu. LL an sd i a, 544 SUMMALY: oo Sl Tr Tae Sr Fa 545 Bibliosraphy a, cL san 545 Al SPANISH IMOROCEO. ui... en eR 548 Georvaphy and CHmate oo... aa nda 548 Population and Socio-Economic Conditions ............................... 548 Fopulatiomes sr. So, nan ea pn rR SL 548 Vital Stabistles io i a ah 549 Social BeOHOMY. cl i i isin se tad a eh ht he a 549 Food and Nuteltion. ........ Lo sn ov as on Li 550 Housing 00 0. a a a a ae 3 aE 550 Envitonmentiand Sanitation ........... 0. coo ila Ra RL 550 Bealth.Services and Medical Facilities . .............. 0.0. iil bolllg fd. 550 Health Organizations. .................. dae ol 550 Medical institutions: vo al. oa a 531 Bersonmell i. fh a i a ee te De 552 Diseases ining Siri Ls LS es SE ns Na 552 Diseases Spread Chiefly Through the Intestinal or Urinary Tracts ...... . 552 Diseases Spread Chiefly Through the Respiratory Tract .......... ... . .. 552 Diseases Spread or Contracted Chiefly Through Contact ............ .. . . 553 Contents XXXIX Diseases Spread by Arthropods... o.oo. Clini ain auido ion Je 553 Nutritional Diseases... oo. lin ind ve ian land Ba a ie 554 SUMMIT a ed 554 Bibliography, Loot Shin nih Laan LL Se et el 555 A DANGIER a a ne aT 556 A ALCERTIA i et A eh Ae ah 558 Georvaphyiand Climate ...0. 00 i Ea di ny 558 Population and Socio-Economic Conditions. .............. ... ... 00.00 559 Population. -... oo. civ a SR SS 559 NilalbStatistiey ccc Lor te, as A 560 Social Beonomy 0. 0. cn Ln a re EY 560 Foodiand Nutrition ..i.n nh a SS 561 Housing: a a eh a 561 Envitonment and Sanitation... .. 0. LA a 562 savateriSupplles La 562 Waste Disposal tc ul oh se se ET 562 Fanmnand Flora Li). 00 0h. in sides os eg 563 Food Sanitation. i... aad eh 565 Health Services'and Medical Facilities ©... oi unui it a i hd 565 Health Oreamizations |... 0. se a ae ee 565 Medical Institutions... 0000 an Se ed 565 Bersonmel .. i eT 566 ESEASESI el ee ie es Be ales all ie 567 : Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 567 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 568 Diseases Spread or Contracted Chiefly Through Contact ........ ...... .. 569 Diseases Spread by Arthropods... 0 00 fo re 571 Nutvitional Diseases... .... 4. 0... a sD AR a Si 57a Miscellaneous Conditions 1.x... 1. vi hes aN ha) 574 SAY i a i 574 Bibllography |. ox a dd LG Re 575 SASIRUNISIAL ol. a Se es Se LE 578 Geography and Climate ts ih i ae far a 578 Population and Socio-Economic Conditions ............................... 579 Population... i id va AN a i 579 Vital Statistics =. 0 he a cha ee ra a 580 Social Economy so bi. dv. hyve ha Sa Gh Re 580 Food and Non... . «0 ulin ohh dibs on wisn Waele enh li 581 Mousing ho a Ge LE a NS ae 581 Environmentiand Samitation'’. «un ai aa Ee 581 Mater Supplies: a a ah i rs aa dah Sh tr i 581 Waste Disposal v.00. 00 on. oul oon oli ade nn Sn, a Te 582 Fama and Blaras. 0.0... dias sc Ra 582 Food Sanitation... 0. 0s 0. La tna al LL . 584 Health Services and Medical Facilities ........... nn ih ai 584 Health Organizations»... 0 is aa sa i he . 584 Medical Institutions oo... ou. bi. 0. ih ee SER ea oh 534 Personnels =, oll ats ou iy alas a hel Si Eh ent 585 Diseases t.ho RS ca Le 585 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 585 Diseases Spread Chiefly Through the Respiratory Tract ............. .. 587 Diseases Spread or Contracted Chiefly Through Contact ............ .. . 588 x| Contents 44. TunisiA— (Continued) Diseases Spread hy Arthropods... .. 5. nv hie hs Ld ia, 588 Nutritional DISEases: oo. rn hs a a lin haan ai a0 591 Miscellaneous Conditions. i7 o d S e eats ae 591 SWIIMARY a She ST 591 BibMOataphy «eR he ita 592 AS. LIBYA Ee LN EO RR 595 Geostaphye and CHMAte i i ri eS ioe aa 595 Population and Socio-Economic Conditions ................ 0000 iia db. 596 Bopulation or. EE a Se a sea 596 Nital Statistics nS 596 Social ReonOmMIV EC... i i ht Ea a 596 Foodiand Nutnifion oc ON tr bi i aR 597 Housing to rl a en 597 Environmentiand Sanitation =. 0. Lc a CL 597 Water Supplies... o.oo a, edit 597 WastelDisposal vi oo an 598 PaounaandiBlenais 1. 0 a i ah a a 598 Food Sanitation... ci 0 a he he 599 Health Services and Medical Baclllies 7... vii dvs cniioinin sn ois ten at 599 Health. Oreanizations ........ 0.0 00 adi is nh srl 599 Medical institutions ©... rb i a Es a, 600 Personnel RE RS 600 AS EaSeSs Na ee 601 Diseases Spread or Contracted Chiefly Through Intestinal or Urinary Tracts 601 Diseases Spread Chiefly Through the Respiratory Tract .............. .. 602 Diseases Spread or Contracted Chiefly Through Contact ........ ...... .. 602 Diseases Spreadby Artlwapods . .............. 0... 0 ov av 603 Nutritional Piseases SE a 604 Miscellaneous Conditions: vi. . cv bh dS RE aa 604 SUNY 604 Bibliocraphy i ar aE aa a Sr ih LR a 604 APPENDIX Maps SHOWING DISTRIBUTION OF THE PRINCIPAL TROPICAL DISEASES ...... .......... 607 HEAL HINTS FOR THE I ROBIES of Tis ivis nin s sins wn mie aetaian or wlata le 617 HRS dUGHION 1. dh i ih ai en Eh ve SED A an ea be Se te A 617 CHAE a a A 617 Vater a a a a 618 BOO i it eh ae eT A eg al este ei AN ST 619 Insects and Insect Vectors of Disease... didi di sii nny, 620 Damunizaton oo. a i a i A a Se a Ee 622 Miscellanegus Tnts co il vii Se ai sa i Shed 625 CC ONGIIS ON A Ea Le a 627 BIbHooraphy co. ht a Se ER a i eR, 627 * * * * SECTION ONE The Nile Valley Ia Bevery. ai LC od rl ERD 2. ANCIORGYPTIAN SUDAN... i... a a ea, E00 Alexandria Port Sudan ter ETN ; GE/ZT\RAVY Ko SJ ANGLO-EGY PT HA ) i / . El Fasher i KORDOFAN P 6pY {. YDAR FUR / The Nile Valley Egypt GEOGRAPHY AND CLIMATE Egypt, located in the northeast corner of the continent, is one of the few independent countries in Africa. Essentially a vast barren desert, pierced by the fertile valley of the Nile, it covers approximately 586,000 square miles, stretching from the Mediterranean to the Anglo-Egyptian Sudan and from the Libyan frontier to the Red Sea. The narrow strip of land on either side of the Nile and the funnel-shaped Delta at its mouth, some- what less than four per cent of the total land area, constitute the major part of in- habited Egypt. The country is commonly divided into Lower and Upper Egypt, a designation deriving from the ancient days of two rival kingdoms, or, more properly, into the Delta and the Nile Valley by a hypothetical line drawn just south of Cairo. Another method of division, which is sometimes used, is that of Lower, Middle and Upper Egypt, with Middle Egypt as the district between Cairo and Asyut. As the Nile enters Upper Egypt it flows through a narrow valley which for some dis- tance barely exceeds two miles in width. From Aswan, the southern boundary of the Nile Valley proper, the flood plain is en- closed by steep cliffs characteristic of the rift-valley type. Here, the cultivated land is less than ten miles in width, with the greater part on the west bank. In Lower Egypt the valley fans out into a low-lying, featureless deltaic plain, one hundred miles in depth, which extends along the Mediter- ranean from Alexandria to Port Said. This triangular alluvial plain, containing the richest and most highly cultivated land of Egypt, is irrigated by the Damietta and the Rosetta arms of the river and by an exten- sive network of canals. Toward the Medi- terranean it degenerates into low sand hills intersected by a series of coastal lakes backed by salt marshes. The Faiyum oasis, southwest of Cairo, is fertilized by an old canalized branch of the river and contains the 30-mile lake, Birket-et-Kurun, a rem- nant of the ancient Lake Moeris. The Nile Valley and the Delta owe their fertility to the annual rise and fall of the river, which from August through October or November overflows its banks and, as it recedes, leaves a deposit of rich alluvial mud from the Ethiopian highlands. The waters are at their lowest point in June but grad- ually attain flood level as the Blue Nile flow increases ; they reach their height about the middle of September. By means of canals, basins, dams and barrages, the Nile flood is utilized for irrigation to an ever- increasing extent, with the resultant recla- mation of additional land for agriculture. On either side of the Nile Valley and extending to the borders of Egypt are vast stretches of desert broken in the west by occasional oases. The region known as the Arabian Desert occupies the area between the Nile and the Red Sea. It varies from 90 to 350 miles in width and ends in a chain of high rugged mountains running parallel with the Gulf of Suez and the Red Sea. The western desert, which north of Aswan is called the Desert of Libya, has no natural barrier for hundreds of miles and is essen- tially part of the vast Sahara. The deserts of Egypt contain some stretches of the tra- 4 Egypt ditional sand dunes, but for the most part they are made up of gravelly limestone plateaus broken by outcroppings of granite. South of Cairo they rise to an elevation of 1,000 to 1,500 feet above sea level in a series of terraces intersected by narrow ravines and dotted with isolated hills cut by channels, or wadis. In the western desert there are five large oases, fertile, cliff- bordered valleys eroded over a thousand feet below the general level of the plateaus. Individually isolated, each supports a popu- lation which varies from about 8,000 to 22,000. Kharga, sometimes called the Great Oasis, is the largest and most southerly, but Dakhla, to the northwest, is the most populous. ; The triangular Sinai peninsula east of the Suez Canal is wilderness rather than desert. The high, arid, limestone-capped plateau of El Tih occupies the major part of the penin- sula, which terminates in bare and steep mountains at the apex. The most distinctive feature of the cli- mate of Egypt is the relative dryness of the atmosphere. The humidity is less than 60 per cent, even during the winter when it reaches its peak. The temperature is high during six months of the year but, though hot in the daytime, it drops at sunset and in the desert may be close to freezing. The heat of the day is further relieved by the persistent northerly winds which blow from the Mediterranean throughout the year. The mean temperature at Alexandria may fluc- tuate between 57° F. in January and 81° F. in July, with a mean maximum in the neigh- borhood of 99° F. At Cairo, where the proximity of the desert begins to be felt, it ranges from about 53° F. in January to 84° F. in July, with a mean maximum of 110° F. Further south at Aswan, the mini- mum and maximum temperatures average 42° F. in January and 118° F. in July. The annual rainfall varies from 20 inches in certain mountainous areas in southern Sinai to a minimum approaching zero in the desert. Along the Mediterranean coast where rain is frequent during the winter months, the precipitation averages from 5 to 10 inches a year, but at Cairo, which is depend- ent upon occasional rains in December and January, it approximates 2 inches. In the open desert the rain is local, irregular and scanty, although severe storms are encoun- tered from time to time. Snow falls in the mountains of Sinai and in the Red Sea Hills. The early spring months are character- ized by the burning, sand-laden khamsin winds which blow from the southern Sahara. They have a devastating effect upon life in general, but fortunately they rarely last more than three or four days at a time. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopPULATION According to the census of 1947, the popu- lation of Egypt was estimated at 19,170,000, but recent reports indicate that it is now in the neighborhood of 20 million. This rapid expansion, an increase of almost 100 per cent since the first census in 1897, repre- sents a problem which constitutes a threat to the well-being of the country. The popu- lation is remarkably homogeneous, outside of Cairo and similar large cities. Special groups include the Bedouins, nomadic Arabs of the desert, and the Nuba Nubians, a people of Arab-Negro descent who inhabit the Nile Valley between Aswan and Don- gola, in the Sudan. The unassimilated for- eign communities, comprising various na- tionalities from Europe and the Near East, total between 175,000 and 200,000. The majority of the Egyptians are Mos- lems. As of 1947, the Christians totaled about 8.2 per cent; the Jews, less than 0.5 per cent of the population. The majority of Christians are Copts, adherents of the old Coptic church of Egypt. Arabic is the uni- versal language, although English is spoken by some professional and other groups in the larger cities and towns. Less than 15,000 square miles of the total Egypt 5 land area of Egypt is inhabited, while the remainder is largely desert wasteland. The population density averages over 1,300 per square mile; it may reach from 20,000 to 40,000 per square mile in the larger cities. Small towns and villages are numerous; roughly, three quarters of the people live in the compact rural areas or in towns of less than 10,000 population. In 1947 Cairo, the capital and largest city, had an esti- mated population of 2,100,000. Alexandria, on the Mediterranean at the western end of the Delta, had a population of 925,000; and Port Said at the northern entrance of the Suez Canal, 178,000. Asyut, the commercial center of Upper Egypt had a population of 90,400. Administratively, Egypt is divided into six governorates: Cairo, Alexandria, Damietta, Suez, Canal (Port Said and Ismailia) and the Frontier Districts, and fourteen provinces (six in Lower Egypt and eight in Upper Egypt). The Egyptian government has under- taken an extensive reform program since the Anglo-Egyptian treaty and the acquisi- tion of independence in 1936. Major handi- caps, particularly in the field of public health, have been the ignorance and the re- sistance to change on the part of a large section of the population. In 1936? it was estimated that about 81 per cent of the men and 96 per cent of the women were illiterate. There are two distinct systems of educa- tion: general elementary education and modern Europeanized education under gov- ernment, mission or private auspices. The elementary schools, as distinct from the regulation primary schools, were developed in 1919 to provide a rudimentary education for the great mass of the people. It is planned to extend the system throughout the country as rapidly as qualified teachers become available. A third form of education is based upon the Moslem University of Al Azhar and its subsidiary Mosque schools. Al Azhar, which was started A.D. 970, is one of the principal theological centers of the Moslem world. VITAL STATISTICS The reporting of vital statistics is incom- plete, especially in the areas outside of the jurisdiction of public health officers. The birth rates are high, as evidenced by the rapidly increasing density of population, but they are accompanied by comparably high death rates and infant mortality rates. The birth rates approximate 40 to 44 and the death rates 26 to 28 per 1,000 popula- tion. In 1944 the average life span was esti- mated at 31 years for men and 36 years for women. According to the official reports, the in- fant mortality rates range from 160 to 170 per 1,000 live births for the country as a whole, but average from 200 to 250 for the urban districts. The actual infant mortality rates are possibly almost twice the recorded rates, however, and may reach 300 to 400 per 1,000 live births in the rural areas. The infant mortality rate for Cairo was 248 in 1942, and for Alexandria, 204. This exces- sively high mortality is attributed to the prevalence of diarrhea and enteritis, which accounts for over half of all infant deaths. An analysis of deaths by specific age groups shows that from 35 to 40 per cent of all Egyptian children die before the age of five. Although children under five years of age comprise only about 14 per cent of the population, the deaths in this age group rep- resent 65 per cent of the total mortality.!? SociaL Economy Egypt is a land of paradoxes—of wealth, education and modern ideas and of poverty, ignorance and primitive living. As in ancient times it is predominantly agricultural, al- though modern irrigation and the introduc- tion of cotton have effected many changes in its total economy. About 75 to 80 per cent of the population is engaged in agriculture, but over two thirds of the land is divided into large estates, and in the remaining areas the individual holdings are small. The peasants, or fellaheen, live at bare subsist- ence levels and are separated by a wide gulf 6 Egypt from the proportionately small upper and middle classes. The government is faced with the prob- lem of providing for a rapidly growing population in an already overcrowded coun- try. Fortunately, the soil of the Nile Valley and the Delta is extremely fertile and allows for from 50 to 100 per cent more crops than similar areas elsewhere. The Nile control project involving the construction of dams at Lake Victoria and Lake Albert and the canalization of the Sudd marshes, which was recently sponsored by the British and the Egyptian governments, will ultimately increase the productive land area by seven million acres. At present, almost one third of the land under cultivation is planted in cotton, which represents about 75 to 80 per cent of the total exports. Industrial development has been slow, but the number of plants for processing cotton, sugar cane, phosphates and other raw materials is increasing rapidly. The pro- jected hydroelectric plant at the Aswan Dam will facilitate further expansion. Egypt is in a favorable position for traffic with other countries through her ports on the Mediterranean and the Suez Canal and is also an important junction for airlines between Europe, Africa and the Far East. Internal communication is largely by steamer service on the Nile or by means of a government-owned railroad which con- nects the larger cities of the Delta and parallels the river from Aswan to Cairo. Caravan routes link the oases with the Nile ports, while Kharga is reached by rail. Foop AND NUTRITION The system of cultivation and the crops vary in different parts of the country. In the Delta and in the Nile Valley north of Asyut, a system of perennial or controlled irriga- tion permits multiple crops and the use of the land throughout the year. Cotton, sugar cane and rice are grown chiefly in the sum- mer; wheat, barley, maize and vegetables, in the winter. In most of Upper Egypt where the only planting follows the annual flood, maize and millet are the major crops. Bread is the basic food of all classes of the population and probably constitutes 80 per cent of the national diet. Maize, millet and barley are the principal cereals, with millet predominating in Upper Egypt. Rice is also an important food in the Delta re- gion and in the oases. Vegetables are utilized in all parts of the country, especially be- tween October and July when they are most plentiful. A wide variety is grown, but beans, cucumbers, onions and lentils are the most popular. The cultivation of lentils is confined largely to Upper Egypt, where they are used more widely than in the Delta region. They are also prized by the Bedouin tribes of the desert. In the oases of the western desert the cultivation of land is lim- ited by the lack of rainfall and the scarcity of water. Date palms constitute the princi- pal crop except in Kharga and Dakhla, where rice, barley and wheat are grown. The native fruits include apricots, figs, melons, grapes, oranges and tangarines. The average Egyptian is able to afford little meat except on special occasions. The flesh of goats, cattle and camels is utilized, but religious restrictions forbid the use of pork. Chickens are raised in small numbers in both rural and urban areas, while along the northern coast, near the Suez Canal and in the lake villages, fish is an important source of protein. Milk from the gamoose, or buffalo cow, which has a fat content almost twice that of cow’s milk, is used in many areas; also the milk from goats, sheep and, among the desert tribes, camels. It is rarely consumed unless boiled or fer- mented. Ghee (clarified butter) and skim- milk cheese are important milk products. Malnutrition and dietary deficiencies are common, and reports indicate that in some districts from 65 to 80 per cent of the people are seriously undernourished.?* The average peasant probably subsists on a diet which is not only several hundred calories below the normal requirements but markedly deficient Egypt 7 in protein and vitamins. The supply of food is frequently inadequate, notably in the single crop food areas, in localities where sugar cane is cultivated, in some of the oases in the western desert, and in the towns along the Red Sea shore. Nutrition research and surveys are car- ried on under the direction of a Permanent Nutrition Committee composed of repre- sentatives of the various governmental departments concerned with the problem. The Committee was organized within the Ministry of Public Health in 1939 to pro- mote higher levels of nutrition throughout the country. Housine In Cairo, Alexandria and other large cities all gradations are found between the mod- ern and palatial houses of the wealthy and the mud hovels of the poor. The standards of living of the laborers in the towns and of the rural peasants, or fellaheen—groups making up over four fifths of the popula- tion—are uniformly low. The Egyptian peasants live in villages, or in esbahs, groups of houses on large estates, under the same primitive conditions that have prevailed for centuries. The villages are compact and raised a few feet above the surrounding fields. The streets are narrow, tortuous and dirty. Even in rural Egypt the peasants live in close proximity to each other, and isolated dwellings are relatively rare. The average homes are constructed of mud bricks with flat roofs and two, three or occasionally more rooms. In districts adjacent to the desert, particularly in Upper Egypt, stone is sometimes employed as a building material. Overcrowding is common, while the family and its livestock frequently occupy the same limited quar- ters. The rooms are dark, with small win- dows which are rarely protected by glass. In most instances the entrance is through the courtyard or stable in which manure is piled for future use as fertilizer or fuel. Most families have little furniture and live in close contact with the earthen floors, which may become heavily contaminated. ENVIRONMENT AND SANITATION WATER SUPPLIES Due to the low level of sanitation through- out the country, both the surface and ground supplies are liable to pollution. In the cities and the towns on the Nile, the water supplies are most frequently taken from the river or from near-by canals. A few places have deep wells which may be main or supplementary sources of supply. In Cairo and the principal cities the water supplies are treated by filtration and chlo- rination. The Cairo system, which utilizes water from the Nile, and that of Heliopolis, which obtains water from thirty deep wells, are interconnected. Water is distributed to individual houses in half of the city and to public outlets in the remainder. In the rural villages the inhabitants use water from the canals or from community wells. In 1945 the Ministry of Public Health undertook a program to assure water sup- plies to the rural areas. Up to 1950 about 22 per cent of the rural population had been provided with sanitary water supplies. Almost 10 per cent of the 4,000 villages had supplies which were controlled by the gov- ernment. In many instances, general baths and laundries have been constructed in con- nection with the new village supplies. Wells are practical in most of the Delta region and in Upper Egypt, but in the northern Delta and in Faiyum Province the subsur- face water is usually too brackish for pota- bility. In such areas the government is constructing filtration plants for the treat- ment of canal or river water prior to its distribution to the villages. The oases are practically rainless, and the people are dependent not only for their drinking water but for irrigation supplies upon the numerous springs and wells. A few deep wells have been drilled into the under- lying Nubian sandstone at public expense. 8 Egypt Three deep wells have been drilled in Kharga and five in Dakhla to deliver water for irrigation. WasTE DisrosaL Except in certain sections of the larger cities and towns, the standards of sanitation are low, and defecation in the streets or in a convenient canal or water hole is common practice. Community latrines are estab- lished in connection with the mosques, but according to custom they are used only by the men. The institution and the improve- ment of public latrines is one of the objec- tives of the government’s rural health pro- gram. Individual installations are rare in the rural areas, and surveys have shown that probably less than 5 per cent of the houses are equipped with sanitary facilities of any kind. The gradual introduction of the borehole type of latrine is proposed for the villages in the southern part of the Delta and in Upper Egypt. A number of the larger cities have sewer- age systems which serve part of the popula- tion, the sewage being discharged subse- quently into some adjacent body of water or upon the land for irrigation. Many of the existing systems, however, are inade- quate for handling all of the wastes from the districts served. The Cairo plant em- ploys a combination of screening, sedimen- tation and trickling filter treatment. The effluent is used for irrigation and the dried sludge for fertilizer. About 30 to 50 per cent of the city is connected with the sewerage system; the remainder has occasional indi- vidual cesspools. In Alexandria about 90 per cent of the city is supplied with sewers. Fauna AND FLora Arthropods. Mosquitoes. Eleven or more species of anopheline mosquitoes are re- ported. Anopheles sergenti and A. pharoen- sis are probably the only important vectors of malaria, although the infection rates of several other species have not yet been adequately determined. A. pharoensis is the principal vector of malaria in the Delta and in Upper Egypt and is also encountered in the Suez Canal Zone and in the oases. It breeds in the stagnant, vegetated pools of flooded grass- lands, in the rice fields and the marshes and occasionally in shallow wells and water tanks. A. sergenti transmits malaria in the oases (Faiyum, Bahariya, Kharga and Dakhla), in Sinai and the Suez Canal Zone, but not in the Nile valley. Wherever pres- ent, it is apparently the most efficient vec- tor. In 1939 this species was reported for the first time near the border of the Delta at Inshas. It breeds in rice fields, burrow pits, irrigation ditches and in the oases in the seepages from springs. A. multicolor is widely distributed, breed- ing in small pools, drains, shallow wells and in saline desert waters. It has been consid- ered a vector on epidemiologic evidence, but its role in the transmission of malaria has not been established. A. d’thali may be a potential vector in some areas. A. coustani tenebrosus, A. algeriensis and A. superpictus are also present. A. gambiae, the most dangerous vector of malaria in tropical Africa, was introduced into Egypt from the Sudan in 1942. It ad- vanced northward along the Nile Valley, reaching communities in the neighborhood of Asyut in the summer and the early fall of 1942 and again in 1943. Its progress was watched with apprehension, as it was feared that it might invade the Delta during the autumn floods when conditions are excellent for breeding. A service was organized by the Egyptian government in 1943 for the eradi- cation of A. gambiae from Egypt, and in 1944 the International Health Division of the Rockefeller Foundation joined in the development of a comprehensive control program. The success of the campaign is demonstrated by the fact that A. gambiae has not been reported from Egypt since February, 1945. In 1946-48 a malaria-control program was undertaken in the Kharga and the Dakhla oases by the government authori- ties, with the co-operation of the Rocke- Egypt 9 feller Foundation. Treatment of the breed- ing places with DDT solution was effective in eradicating 4. sergenti, the most impor- tant vector, but was less successful in the case of A. pharoensis and A. multicolor. Anopheline control measures are carried on routinely around Cairo and other large cities. Antilarval sprays with oil or DDT are employed in the treatment of breeding sites in most areas. Residual house spray- ing with DDT has also been introduced in the villages of Faiyum Province. Several species of Aedes mosquitoes are reported, including Aedes aegypti, A. de- tritus, A. caspius, A. algeriensis and A. cla- viger. A. aegypti is common and probably the only species of medical importance. It transmits dengue fever, which is endemic and at times epidemic, but yellow fever is not present. Approximately 14 species of Culex mos- quitoes have been recorded, but only C. pipiens and C. quinquefasciatus (=C. fa- tigans), vectors of Wuchereria bancrofti, are of known importance from the stand- point of health. In Rosetta, a local focus of filariasis, C. pipiens breeds in the numerous brackish wells which are used for house- hold purposes. C. modestus, C. tritaenior- hynchus, C. molestus and C. sinaiticus are frequent pests. Other species of Culex mos- quitoes reported from Egypt are zoophilic. Fries. Flies are prevalent throughout the year, but especially during the summer months. At least 11 species of the genus Musca have been noted. M. vicina, and to a lesser extent, M. domestica and M. sor- bens, are abundant in both urban and rural areas. Other indigenous flies of the family Muscidae include Muscina stabulans, M. pabulorum, Philaematomyia crassirostris and Stomoxys calcitrans. All have been sus- pected of being mechanical vectors of intes- tinal and eye diseases. Numerous species of Tabanus, Chrysops and Hippobosca are reported. Wohlfahrtia magnifica is a common cause of human myiasis. Several species of Sar- cophaga, including S. haemorrhoidalis and S. exuberans, have also been implicated in occasional human cases. Other species capable of infecting human tissues in- clude Chrysomyia megacephala, Calliphora erythrocephala and several species of Lu- cilia. Hypoderma bovis and Rhinoestrus purpureus are also found. The sandfly, Phlebotomus papatasii, transmits sandfly fever and is a potential vector of cutaneous leishmaniasis in north- ern Egypt. The black fly, Simulium grisei- collis, occurs, although probably not in great numbers. Biting midges of the genera Leptoconops and Culicoides are numerous. Lice. All species of human lice are abun- dant. Lack of personal hygiene and the serious overcrowding habitual among the poorer classes provide favorable conditions for their spread. The body louse, Pediculus humanus corporis, is an important vector of typhus and of relapsing fever, both of which have been epidemic in Egypt within recent years. FrEas. The rat flea, Xenopsylla cheopis, is the principal vector of plague and prob- ably of murine typhus. X. astia is also present but is probably of minor impor- tance. Nosopsyllus fasciatus, which rarely attacks man but must be considered as a possible vector of plague, is also reported. Pulex irritans is relatively rare. The stick- tight flea, Echidnophaga gallinacea, causes an itching dermatitis. Bepsucs. The bedbugs, Cimex hemipterus and Cimex lectularis, are widespread, but their role in the transmission of disease is unknown. Ticks anp Mires. The tampan tick, Ornithodorus moubata, is probably respon- sible for the transmission of relapsing fever in the western oases. O. savignyi is present in the drier parts of the country, but its role as a vector is uncertain. Numerous species of ixodid ticks, including R#iipi- cephalus sanguineus, are found. The common itch mite, Sarcoptes scabiei, is usually abundant. The tropical rat mite, Liponyssus bacoti, and the grain itch mite, Pediculoides wventricosus, are responsible 10 Egypt for cases of dermatitis. The latter attacks persons who handle grain or sleep on straw mattresses and may cause a severe derma- titis, with fever. Allodermanyssus san- guineus normally parasitizes rats but may attack man. ScorriONS AND SPIDERS. Scorpions are prevalent, and each year numerous cases of scorpion sting are reported in the late summer and the early fall. In one repre- sentative year (1939) at least 462 persons were treated for scorpion sting in the Cairo area; 19 cases were fatal. The most com- mon and most dangerous scorpion is Buthus quinquestriatus, which is widely distributed in the southern provinces. B. acutecari- natus, B. occitanus and B. leptochelys are also present. Prionurus citrinus and Scorpio maurus are common, particularly in the north. Numerous species of spiders occur, but none is regarded as dangerous. OrHER ArTHROPODS. Several species of centipedes are recorded ; the bites of Scolo- pendra candidus, and probably of S. mor- sitans, are painful but not dangerous. The harvesting ant, Messor barbarus, is note- worthy because of the painfulness of its bite. Reptiles. Six or more highly venomous snakes inhabit this region. The Egyptian cobra, Naja haje, is widely distributed, while the spitting or black-necked cobra, Naja nigricollis, is found in southern Egypt. The small sand vipers, Aspis cerastes (= Cerastes cornutus) and A. vipera (C. vipera), and the carpet viper, Echis cari- natus, are native to the desert. The puff adder, Bitis arietans, is encountered fre- quently, both in grassy and rocky areas. Rodents. Rattus rattus alexandrinus and R. rattus frugivorus are the most numerous of the indigenous species of rats, but R. rat- tus rattus, R. norvegicus and possibly R. rattus rufescens are found in the various port towns. These rodents serve as the hosts of fleas which may be the vectors of plague, murine typhus and other diseases. The role of wild rodents in the transmission of plague in Egypt has not been determined. Two species, Arvicanthis niloticus and Acomys cahirinus, may be potential reservoirs of infection. Mollusks.* Numerous species of fresh water snails have been identified, of which two are known to be of medical importance. Bulinus truncatus is the intermediate host of Schistosoma haematobium throughout the Nile Valley and in the oases. Planorbis (Biomphalaria) alexandrina is the interme- diate host of S. mansoni which is endemic in the Delta region. The distribution of snails and parasites is directly related to the type of irrigation prevailing in the dif- ferent parts of the country. Bulinus snails are common in most of Middle Egypt and the Delta, where they exist in the slow- moving water of the irrigation ditches. They are rare in Upper Egypt between Dairut and Aswan, where the so-called basin irri- gation prevails and the land is watered only during the Nile floods. Planorbis snails are confined to certain areas of the Delta where the dead-ends of small tertiary canals and the village ponds provide the necessary con- ditions of sluggish or stagnant water. They cannot survive in the portions of the central Delta where the canals are flooded and dried * For the sake of uniformity in reporting the work of different authors, we have adopted the nomencla- ture for the intermediate snail hosts of schistosomiasis suggested by Dr. J. C. Bequaert, Harvard University, as follows— Schistosoma haematobium Physopsis africana Physopsis africana globosa (= Physa globosa) Bulinus truncatus (= B. contortus, = B. dybowski) Bulinus tropicus Bulinus (Pyrgophysa) forskalii Schistosoma mansoni Planorbis (Biomphalaria) alexandrina (= Planorbis boissyi) Planorbis (Biomphalaria) alexandrina pfeifferi (= Planorbis pfeifferi, = P. ruppellii, — P. adowensis) Planorbis (Biomphalaria) alexandrina tanganyicensis Planorbis (Biomphalaria) alexandrina choanomphala Planorbis (Biomphalaria) alexandrina stanleyi Egypt 11 in rotation, or in Upper Egypt where basin irrigation is employed. Pirella conica is prevalent in the brackish streams and lakes of the coastal region and is an intermediate host of Heterophyes heterophyes. Since 1940 an active campaign for the eradication of the snail hosts has been undertaken by the Bilharzia Snail Destruc- tion Section of the Ministry of Public Health. The methods employed include the clearance of weeds from the canals and the streams at regular intervals and treatment with copper sulphate. Plants. Six or more species of Euphorbia, the milky sap of which causes dermatitis on contact with the skin, are found in Egypt. The sap of E. thymifolia in particular causes severe blistering. Rumex acetosella, which produces a dermatitis in certain indi- viduals, also occurs. The berries of the black nightshade, Solanum nigrum, are highly poisonous. Numerous grasses (GRAMINEAE), which are theoretically capable of producing allergic manifestations in susceptible per- sons, are recorded from various sections of the country, but the majority are of minor importance. Foop SANITATION The inspection of shops, restaurants, bazaars and other premises where food sup- plies are manufactured or sold is carried on by the municipal health authorities in Cairo and Alexandria and by government officers in other cities and towns. Vendors of food are licensed yearly, and tests to determine the presence of disease or the carrier state are performed. The enforcement of health regulations varies in different communities, but, in general the standards of sanitation outside of the more prosperous sections of the cities are relatively low. Foods retailed in the shops are exposed to dust and flies. Moreover, fruits and vegetables are fre- quently grown in fields on which raw sewage has been used as a fertilizer, or they are washed in the polluted canals en route to the market. Dairy herds are not inspected, and the sanitary quality of milk is not controlled. Chemical tests to detect adulteration are performed at regular intervals. Few sup- plies are pasteurized, but since the people habitually boil milk before use, compulsory pasteurization is not regarded as necessary by the health authorities. The supervision of meats before and after slaughtering is the responsibility of the Veterinary Department of the Ministry of Agriculture. Approved meats are stamped by the government in- spectors. Few facilities for refrigeration are available. HEALTH SERVICES AND MEDICAL FACILITIES HearTH ORGANIZATIONS The Anglo-Egyptian Treaty of Alliance of 1936 marked Egypt’s debut as a modern state. In that year, the supervision of public health, formerly a function of the Ministry of the Interior, was transferred to a newly created Ministry of Public Health under the direction of a Minister, who is appointed by the King and assisted by two Under Secretaries of State and two Assistant Under Secretaries. The Ministry is divided into numerous departments, all of which have their head- quarters in Cairo. According to the reor- ganization effective in 1950, the divisions concerned with certain phases of preventive medicine operate under the jurisdiction of one of the Under Secretaries of State. They include departments of Preventive Medi- cine, Endemic Diseases, Rural Health and Quarantine, the National Research Insti- tute and an International Health Section, established in 1949 to effect liaison with the World Health Organization. Each depart- ment incorporates several sections. The Preventive Medicine Department admin- isters an Epidemic Disease Control Section, which is responsible for the organization of facilities for the reporting and the control of epidemic diseases; a Food Control Sec- 12 Egypt tion which exercises supervision over the chemical and sanitary quality of foodstuffs; the Abbasia Fever Hospital and an Institute for the training of sanitary inspectors. The Endemic Diseases Department contains four sections, for Ancylostoma and Bilharzia, Malaria, Leprosy and Insect Control. They conduct investigations in their respective fields and maintain facilities for the treat- ment of cases. The Rural Health Depart- ment includes a Health Centers Section for the promotion of village health units, a Bilharzia Snail Control Section and Rural Sanitation and Engineering Sections. The departments dealing with the medi- cal care of the population are directed by an Assistant Under Secretary of State. They include a Therapeutic Department, with sections responsible for the establish- ment and the maintenance of the general hospitals and the ophthalmic hospitals, a Universities Hospitals Department, respon- sible for the management of the five Univer- sity hospitals, and a Medical Commission Department. Social Hygiene, Mental Diseases and General Inspectorate Departments, and a Health Projects Section are grouped under the supervision of a second Under Secre- tary; the Laboratories Department, a Fac- tories and Food Establishment Licensing Department, and Medical Permits and Frontiers Medical sections, under an Assist- ant Under Secretary. The Social Hygiene Department comprises Chest Diseases, Ve- nereal Diseases and Maternity and Child Welfare Sections, each of which operates preventive and curative medical programs. It also contains a section for the promotion of health education. The Laboratories De- partment is responsible for the direction of the governmental bacteriologic and chemi- cal laboratories, the Serum and Vaccine Institute and the Anti-Rabic Institute. The establishment of Health Bureaus, under full-time medical officers, to func- tion as local administrative units in areas containing approximately 30,000 persons throughout the country is proposed by the Ministry. By 1944 health bureaus had been established in 237 localities, which served approximately one third of the population (4,431,000 in urban communities and 1,313,000 in rural districts). The municipalities of Alexandria and Cairo have independent health departments. However, the Ministry may function in both cities in the event of an epidemic, while in the case of Cairo it retains the management of the hospitals. The health services of Port Said and other municipalities are operated under the direction of the Ministry. Supplementary medical and public health services are conducted by other ministries. In 1950 the government established a Min- istry of Municipal and Village Affairs which includes among its functions the promotion and the control of water supplies and sani- tation in both urban and rural areas. The Ministry of Waqfs, which handles large endowments for philanthropic and religious work, directs certain hospitals and dispen- saries through its medical department. The Ministry of Social Affairs operates social centers which incorporate nursing and medi- cal services. The Statistical and Census Department of the Ministry of Finance pub- lishes weekly, quarterly, annual and trien- nial reports of vital statistics based on data collected by the Ministry of Public Health. The Department of Labor of the Ministry of Commerce and Industry is responsible for the health and welfare of the workers. Several benevolent organizations, includ- ing the Red Crescent Society, conduct hos- pitals and clinics in different parts of the country. MEepicAL INSTITUTIONS Hospitals and Dispensaries. Approxi- mately 95 per cent of the hospitals in Egypt are maintained by the government. The re- mainder are located in the large cities and operated by religious societies or private groups, the latter usually for the benefit of the foreign communities. Almost all of the government hospitals are under the direc- tion of the Ministry of Public Health, but Egypt 13 the Ministry of Waqfs and other ministries have jurisdiction over a few small institu- tions. The Ministry of Public Health operates four general hospitals and two children’s hospitals connected with the University medical schools in Cairo and Alexandria. These include the Kasr el Ainy Hospital with a capacity of 1,200 beds, the Fouad I Hospital with 1,500 beds, the Demerdash Hospital with 500 beds, and the Munira Children’s Hospital with 200 beds, in Cairo; and the Farouk I Hospital with 600 beds, and a children’s unit with 50 beds, in Alexandria. The Ministry maintains general hospitals which range in size from 100 to 250 beds in the capitals of each of the provinces and in the governorates. It also provides hos- pitals with a capacity of 20 to 30 beds or more in each county, or markaz. The separate sections of the Ministry operate hospitals for the treatment of the specific diseases for which they were organ- ized. The Ophthalmic Hospitals Section maintains 45 hospitals and permanent and traveling clinics for the care of trachoma and other eye diseases. The Leprosy Control Section administers two leper colonies, with facilities for 600 to 700 patients, and leprosy clinics in various parts of the country. The Chest Diseases Section operates tuberculo- sis sanatoria at Cairo, Alexandria, Asyut, Mahalla and Mansoura, with a total capac- ity of 1,300 beds for men and 500 for women; also 13 provincial tuberculosis hospitals ranging in size from 25 to 100 beds, four tuberculosis preventoria, three hospitals for the care of patients with bone and joint infections, two village settlements and about 23 dispensaries. A large 1,000-bed sanatorium was under construction at Kas- sasin in 1949. Centers for the treatment of malaria, ancyclostomiasis, bilharzia and ve- nereal diseases and for maternal and child welfare function under the auspices of their respective sections. Mental hospitals are located at Abbasia and Khanka. Manv of the rural health centers have facilities for the care of emergency cases. Over 200 centers have been established, but, due to a shortage of trained personnel, only 120 were functioning in 1950. Laboratories. The Laboratory Depart- ment of the Ministry operates a central laboratory in Cairo and provincial labora- tories in Alexandria, Port Said, Luxor, Asyut, Tantah and Mansoura. The central laboratory performs bacteriologic, serologic and chemical examinations for Cairo and the neighboring provinces, and pathologic and toxologic tests, and food and drug anal- yses for the whole country. It also carries on a limited amount of research. The pro- vincial laboratories are equipped for the conduct of routine bacteriologic, serologic and chemical examinations. The Serum and Lymph Institute prepares various vaccines and serums for use throughout the country. The Anti-Rabic Institute provides antirabic vaccine and treatments, Clinical laboratories function in connection with all the larger hospitals. The National Research Institute in Cairo conducts investigations on all types of para- sitic diseases, while the Memorial Oph- thalmic Laboratory at Giza specializes in research on eye infections. In addition, the Veterinary Pathological Laboratory and the Serum Institute of the Ministry of Agriculture manufacture certain biologic products. Schools. There are three medical schools in Egypt. Two are affiliated with the Fouad I University in Cairo—the Kasr el Ainy Faculty of Medicine and the more recent Abbasia Faculty of Medicine. They are independent schools, but their students qualify for the same examinations. The University awards the degrees of Bachelor of Medicine and Surgery and Doctor of Medicine and also special degrees for post- graduate study in Forensic Medicine, Radi- ology and Ophthalmology. Degrees in Pub- lic Health and in Tropical Medicine and Hygiene are offered by the Institute for Tropical Diseases in association with the Kasr el Ainy Faculty of Medicine. 14 Egypt A third medical school is established at Farouk I University in Alexandria. Schools of Dentistry, Pharmacy and Veterinary Medicine are included within Fouad I Uni- versity. Nurses training schools are connected with the Kasr el Ainy and the Demerdash hospitals in Cairo. A school is also being organized at the Farouk I Hospital in Alex- andria. Short courses are offered by several sections of the Ministry of Public Health for the training of assistant nursing per- sonnel. PERSONNEL Physicians. In 1950 there were about 4,370 registered physicians in Egypt. Prob- ably 80 per cent of the doctors practice in the larger towns and cities, and 20 per cent in the villages where over three quarters of the people live. The ratio of physicians to population is about 1 to 1,100 in the large cities, and 1 to 13,000 in the rural areas. The government is training doctors as rapidly as possible, with an ultimate objec- tive of one physician to each 1,000 of popu- lation—a goal for which at least 17,000 additional doctors will be required. Dentists. In the same year 640 dentists were reported to be practicing in the coun- try. Nurses. The nurses employed in govern- ment hospitals and child welfare centers in 1949 totaled 1,409, including 525 nurses, 250 nurse-midwives, 359 assistant nurses and 275 assistant midwives. Others. Reports for 1950 indicate that 562 veterinarians, 1,274 pharmacists and over 300 assistant pharmacists were regis- tered in the country. DISEASES The crowded and insanitary conditions under which a large proportion of the people live, their indifference to hygienic measures and their general poor health as the result of parasitic infection and undernutrition all contribute to the spread of communicable disease and to relatively high mortality rates. Evaluations of the incidence of spe- cific infections are subject to error, since reporting is incomplete, both in the cities and in the rural areas. Probably less than one half of the cases of illness are reported. Moreover, mortality statistics are frequently inaccurate, since at least two thirds of the deaths are certified by nonmedical persons. The major health problems of Egypt are the control of schistosomiasis, ancylosto- miasis, trachoma, malaria and tuberculosis. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UriNARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fever is endemic in all parts of the country. For the nine years, 1940-48, the recorded annual incidence averaged 29.2 per 100,000 population, and the fatality rates 16.8 per cent. Although grouped with the paratyphoid fevers in the official reports, typhoid probably accounts for 75 to 90 per cent of the cases. Bacteriologic and sero- logic tests on the inhabitants of a rural village near Cairo in 1949 suggest the pres- ence of a high degree of unrecognized infec- tion. On the basis of these findings it was estimated that the typhoid infection rate in this village, and probably in comparable areas, approached 1,400 per 100,000 popula- tion. Paratyphoid A predominates among the paratyphoid fevers, but infections caused by the B and C groups of organisms are also encountered. The incidence of typhoid fever increases during the summer months, usually reaching a peak in Upper Egypt during August and September. In Lower Egypt two peaks may be expected, one in March and the second in July or August. There is some indication that the inci- dence of typhoid fever has increased in the larger cities within recent years, particularly in Cairo. This is ascribed to the large migra- tions of laborers to the cities, the generally poor sanitary conditions, and a probable increase in the number of carriers. Dysenteries. Both amebic and bacillary Egypt 15 dysentery are widespread. The total annual incidence, including both types of disease, averaged 11.2 per 100,000 population in 1940-48, but the recorded cases probably represented only a fraction of the actual in- fections. The fatality rates ranged from 15 to 32 per cent. Bacillary and amebic infec- tions are identified with about equal fre- quency in the government laboratories in Cairo. Flexner strains of Shigella are iso- lated in a large proportion of the cases, with Schmitz and Sonne next in order. Shigella dysenteriae is encountered irregularly. Diarrhea and Enteritis. Reports from health bureau districts indicate that roughly one third of all deaths and over one half of the infant deaths are due to diarrhea and enteritis. Enteritis is the leading cause of death in children under five years of age. The fact that approximately 60 to 65 per cent of the total deaths from all causes, which are reported each year, occur among children under five years of age reflects the seriousness of the problem. Cholera. Prior to 1947, cholera had not been present in Egypt since 1902, when a major outbreak was responsible for ap- proximately 35,000 deaths. Subsequently, quarantine measures were tightened at all ports, and the inspection of pilgrims return- ing from Mecca was instituted at El Tor in Sinai. In the latter part of September, 1947, cholera broke out in a small village in Shargiya Province in the northeastern part of the country and spread rapidly through the overcrowded and fly-infested rural dis- tricts. The provinces east of the Damietta arm of the Nile were most seriously affected, but cases were reported from most parts of the country. The exact scope of the epidemic is not known. After its termination in De- cember it was estimated that at least 25,000 cases had occurred with an average fatality rate of from 45 to 60 per cent. The Cairo- Port Said-Suez triangle was promptly iso- lated by the health authorities, and travel in this area was prohibited, except for per- sons possessing certificates of immunization against cholera. An intensive immunization campaign was undertaken, and approxi- mately one third of the six million inhabit- ants of the infected districts were inoculated with cholera vaccine. A fly-eradication pro- gram was also carried on in Cairo, the houses being sprayed with DDT, both from the air and from the ground. International co-operation was offered to the Ministry of Public Health in fighting the spread of the disease. Cholera vaccine and other assist- ance were supplied by various governments and by the International Health Division of the Rockefeller Foundation. Helminthiases. Scuistosom1asis. Schis- tosomiasis is a major problem in Egypt, affecting the health and the social outlook of a large percentage of the people. In 1949 the Ministry of Public Health estimated that 14 million persons, or about two thirds of the total population, were infected. The incidence probably approximates 60 per cent in the country as a whole and 75 per cent in the rural areas. The disease is most widespread in the Delta where the system of controlled irrigation affords conditions favorable to the development of the inter- mediate snail hosts. Schistosoma haemato- bium infections are encountered throughout the greater part of the Nile Valley, but S. mansoni infections are more limited in distribution. In areas where S. mansoni is prevalent, both species are frequently found in the same individual. Schistosomiasis may be responsible for 5 to 10 per cent of the total deaths, depending upon whether one or two species are present. Many observers have estimated that the infection rates are several times higher among men than among women. The opportunities for infection are greater among the men, since they go about barelegged in the irrigation waters and com- monly urinate or defecate near canals in order that they may readily perform the ablution required by religious rites. The relative distribution of the two species is shown by studies published in 1936.58 These indicated that at least 60 per cent of the population throughout the Delta H- Schistosoma haematobium M-Schistosoma mansoni Schistosomiasis in Egypt and in the districts of Upper Egypt where perennial irrigation is employed were in- fected with S. haematobium. Comparable infection rates with S. mansoni prevailed in the northern and the eastern parts of the Delta, but in the south central part the inci- dence declined to 6 per cent. In the regions south of Asyut, under flood irrigation, the infection rates with S. kZaematobium did not average over 5 per cent, while S. mansoni was totally absent south of Cairo. S. kaema- tobium is prevalent in the oases of Dakhla, Bahariya and Kharga. The fresh water snail, Bulinus truncatus, is the important intermediate host of S. haematobium, and Planorbis (Biompha- laria) alexandrina of S. mansoni. The Ministry of Public Health carries on an active program for the control of schisto- somiasis. Treatment units are operated by its Endemic Diseases Section, while the Bilharzia Snail Destruction Section carries on a campaign for the eradication of the snail hosts. Ancyrostomiasis. Hookwork infection, caused by Ancylostoma duodenale, is one of the oldest and most widely distributed dis- eases in Egypt. It is believed that it dates back to ancient times and is probably iden- tical with a disease mentioned in the Ebers Papyrus. Necator americanus is not known to be endemic in any part of the country. The prevalence of ancylostomiasis varies in different localities but averages about 50 per cent throughout the greater part of the country. In some communities such as Maasara, near Helwan, it reaches 90 per cent, while in many places in the northern part of the Delta and in Faiyum Province it is less than 20 per cent. The infection rates are approximately the same in both sexes in early childhood, but after the age of 10 the males are usually more frequently and heavily infected. The disease exists as a relatively low-grade infection in most areas, but severe cases are encountered occa- sionally. Ancylostomiasis is not present in the Dakhla and the Kharga oases. Oruer Hrerminta INrFecTiONs. The roundworm, Ascaris lumbricoides, is wide- spread. In the Delta region approximately 40 to 50 per cent of the population is in- fected, and in some villages the rate may be almost 100 per cent. In general, the dis- tricts in the south-central portion of the Delta are most seriously affected. In Upper Egypt the average infection rate is less than 20 per cent. Even in areas where ascariasis is prevalent, however, the intensity of infec- tion tends to be low. The incidence among women and children is normally higher than among men. Infections with Enterobius vermicularis, Trichuris trichiura and to a lesser extent Strongyloides stercoralis are common. Tri- chostrongylus colubriformis, a parasite of sheep and goats, may occasionally infect man. Infection with the beef tapeworm, T'aenia saginata, and more rarely with the pork tapeworm, 7. solium, is sporadic. Hymeno- lepis nana and to a lesser extent, H. dimi- nuta, are common. The fluke, Heterophyes heterophyes, is present in the Delta, espe- cially around lakes of the northern littoral. Infection in man results from eating raw mullet and certain other fish which are the secondary intermediate hosts. Other Infections. Undulant fever is re- ported sporadically. Brucellosis is prevalent Egypt 17 among the gamoose cattle and goats, but little information is available regarding the incidence of human infections with Brucella abortus and B. melitensis. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. The incidence of tubercu- losis is believed to be high, although the total rate of infection is not known. During the period 1940-49, an average of 3,500 deaths from pulmonary tuberculosis was re- ported annually. However, reliable esti- mates place the probable deaths at 20,000 to 30,000 a year, or from six to ten times the recorded rates. Pulmonary infections predominate, but other forms, including tuberculosis of the bones, are frequent. An analysis of over 52,800 tuberculin tests, performed between 1937 and 1947 by the medical officers of the Ministry of Pub- lic Health”? showed 73.4 per cent positive reactors among individuals under five years of age; 63.0 per cent at 5 to 10 years, 73.5 per cent at 10 to 15 years and 86.4 per cent among adults. In Cairo, Alexandria and other cities, the rate of positive reactions among adults approaches 95 to 98 per cent. Facilities for diagnosis and treatment are inadequate at present. The Ministry of Public Health operates from 20 to 25 spe- cial dispensaries in various parts of the country and tuberculosis sanatoria and hos- pitals with a combined capacity of over 5,400 beds. The standards of institutional care are high, but the available beds are probably less than one half the number required. The Ministry proposes to expand its dispensary system as rapidly as possible, with the ultimate goal of a dispensary for every 300,000 population. A program of im- munization with BCG vaccine was initiated in November, 1949, with the co-operation of the Scandinavian Red Cross, UNICEF and WHO teams. Bovine tuberculosis is highly endemic among the local gamoose cattle, but the extent of human infection of bovine origin has not been determined. Its spread prob- ably is restricted by the almost universal habit of boiling milk before use. Smallpox. Vaccination has been compul- sory in Egypt for many years, but the degree of enforcement varies, especially in the rural areas. The disease appeared to have been suppressed almost completely until 1943 when the worst outbreak in 58 years was reported. A total of 4,138 cases was recorded in 1943, and 11,194 in 1944. The majority were from Gharbiya Province and from Cario. The mortality rates aver- aged between 9 and 10 per cent. An intensi- fication of the vaccination program was followed by a gradual decline in the extent of infection. Only 16 cases were reported in 1948. Measles. The death rates from measles are unduly high, particularly among chil- dren under five years of age. The annual incidence in 1940-48 averaged 45.2 per 100,000 population ; the case fatality rates, 28.5 per cent. Moreover, the recorded sta- tistics do not present a complete picture of the seriousness of the problem. In an effort to reduce the number of deaths from measles, health visitors are dispatched to the villages when outbreaks are reported to instruct the mothers in the fundamentals of child care. Diphtheria. The incidence of diphtheria averaged 16.8 cases per 100,000 annually in 1940-48. The fatality rates ranged from 32 to 48 per cent, indicating inadequacy of case reporting and treatment. In some dis- tricts mass immunizations against diph- theria are carried on among children be- tween one and ten years of age, but only a small percentage are reached in this way. Cases of wound infection with Coryne- bacterium diphtheriae are not uncommon. Meningitis. Although supposedly rare in Egypt prior to 1917, localized outbreaks of meningococcus meningitis have been experi- enced almost annually since that date. In 1932 a large outbreak occurred in which 4,508 cases were reported. In 1940-49 the recorded cases ranged from 65 to 212 a 18 Egypt year ; the fatality rates, from 28 per cent in 1948 to 75 per cent in 1945. Pneumonia. Recent reports indicate that both virus and pneumococcus pneumonia are prevalent, while disproportionately large numbers of deaths are recorded. In 1941-49 the annual case rates per 100,000 population averaged 29.7 ; the fatality rates, 70.8 per cent. A study made in Cairo in 1933-35 showed that pneumonia and bron- chitis rank second only to enteritis as causes of death among children one to three years of age, and are the primary causes in chil- dren from three to five. Other Infections. Mumps, whooping cough, chickenpox and poliomyelitis are endemic. Recognized cases of poliomyelitis occur primarily among children under five years of age, with the greatest frequency between March and May, and in October. Scarlet fever is sporadic. Diseases SPREAD OR CONTRACTED CuierLy TaroucH CONTACT Venereal Diseases. Syphilis, gonorrhea, chancroid, lymphogranuloma venereum and granuloma inguinale are all reported from Egypt. Little is known regarding their actual prevalence, but available records in- dicate that at least 12 per cent of the people are infected. Many authorities believe that the estimated rate should be considerably higher, particularly in the cities and among certain groups of migratory workers. Spe- cial venereal disease clinics are operated by the Ministry of Public Health in the larger cities and towns. In 1942 about 30,700 per- sons were treated for syphilis, 15,100 for gonorrhea and 119,800 for other venereal diseases. The Egyptian government at- tempts to control prostitution by licensing brothels and prostitutes, but the medical supervision of prostitutes is impossible, since any woman may avoid examination by claiming to be married, and the law exempts married women. Prostitutes found to be infected are hospitalized and treated. Diseases of the Eyes. Trachoma is widespread in both urban and rural areas. In many villages, the entire population is affected. Trachoma was diagnosed in 98.5 per cent of over 13,170 children examined in clinics conducted in 40 government pri- mary schools in Cairo, Alexandria and other parts of the country in 1942. Almost one third of the cases were in the serious stages of the disease.!” Acute purulent conjunctivitis is preva- lent. Gonococcal infections predominate and may be epidemic during the fly season from April to October when it is not uncommon to see the eyelashes of the children rimmed with flies. A large proportion of the younger children is infected repeatedly, with re- sultant damage to the cornea. The Ministry of Public Health operates hospitals and permanent and traveling oph- thalmic clinics for the treatment of various conditions of the eyes. The extent of the problem may be measured by the fact that roughly 2 per cent of the population suffers from blindness, most of which may be at- tributed to trachoma or acute conjunc- tivitis. Diseases of the Skin. Chronic ulcers, many of which become phagedenic in char- acter, are frequent. Such lesions, known locally as “desert sores,” may develop at any time of the year but are most likely to appear between May and September. Since flies are abundant at this season, observers feel that they may play an important role in the transmission of the infecting organ- isms. Corynebacterium diphtheriae is fre- quently identified from desert sores. Scabies is indigenous in all sections of the country. Myiasis is encountered occa- sionally. Fungus infections are numerous. Cases of mycetoma, or Madura foot, are also observed. Leprosy. The incidence of leprosy is uncertain, but in 1943 the Ministry of Pub- lic Health estimated that there were ap- proximately 30,000 lepers in the country, or 1.2 per 1,000 population. The distribution varies with the standard of living in differ- ent areas. Within recent years, the number of reported cases has decreased from 545 in Egypt 19 1940 to an average of 145 in the years 1946-48. However, discrepancies in report- ing are indicated by the fact that 995 cases of leprosy were diagnosed in the leprosy clinics in 1940; 728, in 1941; and 825, in 1942. Tt is claimed that leprosy does not occur in some of the oases, namely Kharga and Dakhla. The Ministry operates two leper colonies, each of which has from 300 to 500 patients. It also maintains treatment facilities in various parts of the country. In 1942 there were 8 leper clinics and 36 branch units. Other Infections. Canine rabies is enzootic, and numerous human cases are reported every year. Facilities for antirabic treatment are provided in Cairo and Asyut. Tetanus and leptospirosis are common. Human anthrax infections occur sporadi- cally. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is mildly endemic throughout the Nile Valley and may reach serious proportions in parts of Faiyum Province, the Suez region and the western oases. Except under unusual epidemic con- ditions the reported incidence ranges from 6,000 to 22,000 cases a year. The infection rates differ from village to village, but aver- age from 1 to 5 per cent in Upper Egypt and from 3 to 10 per cent in the Delta where the areas of greatest prevalence are found in the vicinity of the rice fields and the lakes. The incidence in the larger cities compares favorably with that in the rural areas. In 1943 only 200 to 300 cases were reported from Cairo and 775 from Alex- andria. Both malignant and benign tertian ma- laria are common in the Nile Valley, but the proportionate distribution varies with the season and the locality. In the Delta region, the percentage of infections due to Plasmodium vivax remains high from Feb- ruary to June and declines to a low point in November and December. With P. falcip- arum the reverse is true. The infection rate increases steadily from the beginning of the year and reaches a peak in November or December. Although the reported cases give little indication of the actual incidence, they may reflect the species distribution. Among the 11,397 cases recorded from Lower Egypt and the Canal and Suez gov- ernorates in 1942, 65 per cent were caused by P. vivax and 33.5 per cent by P. falci- parum. Corresponding estimates among the 1,397 cases reported from Upper Egypt and the oases indicate 50.4 per cent P. vivax infections and 49 per cent P. falciparum. P. malariae infections were reported in small numbers, primarily from the oases. In Faiyum Province the incidence of P. ma- lariae infection is relatively high, especially in the late summer and the early fall. In October and November P. falciparum ma- laria predominates. Quartan malaria is also present in the western oases. Up to 1939 it was not encountered in the Delta region, but within recent years occasional cases have been recorded. One case of infection with P. ovale was reported from Zagazig in 1936. In 1943-45 a severe outbreak occurred in Upper Egypt due to the introduction of Anopheles gambiae from the Anglo-Egyptian Sudan. Official reports, which represent but a small percentage of the total cases, record a sharp increase from 16,530 cases in 1943 to 256,078 in 1944. The epidemic was most severe in the provinces of Kena and Aswan, where poverty and malnutrition contributed to a high mortality. Official estimates have indicated that although only 3,000 deaths were reported from these provinces between January, 1942, and June, 1944, at least 200,000 probably occurred. On this basis it may be assumed that there were between one and two million cases of malaria in the two provinces during the same period. The institution of vigorous control measures by the Egyptian health authorities, in co- operation with the International Health Division of the Rockefeller Foundation, was responsible for the eradication of A. gambiae in 1945 and the control of epi- demic malaria in Upper Egypt. 20 Egypt Blackwater fever is apparently rare in spite of the relative prevalence of falcip- arum infections. Rickettsial Infections. Both epidemic louse-borne and murine typhus fevers are endemic, but their relative incidence and distribution are uncertain, since the differ- entiation between the types of infection is rarely made in official reports. The principal focus exists in the Delta region, but out- breaks are reported with considerable fre- quency from Upper Egypt. As in other countries where typhus is endemic, it tends to increase during years of social and eco- nomic stress. Widespread epidemics, each with an estimated total of over 110,000 cases, occurred in 1915-20 and in 1940-45. The recent period of accelerated incidence reached its peak in 1943 when 40,188 cases and 8,252 deaths were recorded. Outbreaks were reported as far south as Asyut, with the maximum number of cases during the months of April and May. The migrations of labor appear to be an important factor in determining the preva- lence of typhus in Lower Egypt. The inci- dence is especially high in the provinces of Beheira and Gharbiya, which are divided into large estates worked by transient la- borers who live under primitive conditions with little or no medical care. Some Egyp- tian observers claim that these migratory workers are largely responsible for the out- breaks that occur periodically throughout the country. At least 30 per cent of the typhus cases recorded from the Delta be- tween 1921 and 1939 were reported from the provinces of Minufiya and Daqahliya, which supply most of the labor for the estates in Beheira and Gharbiya. In con- trast, the provinces of Qalubiya and Shar- giya, which ordinarily supply little labor to other areas, reported only 6 per cent of the cases during this period. The unusual prevalence of typhus in Kena and Girga provinces in 1939 was attributed to the em- ployment of large numbers of workers from infected provinces of Lower Egypt on the Mohammed Ali Barrage.'® The migration of thousands of workers to Cairo, Alexandria and the ports on the Suez Canal during World War II was accompanied by an in- crease in cases in these cities from 16 per 100,000 in 1941, to 125 in 1942. Since the introduction of DDT powder for the control of louse infestation the inci- dence of epidemic typhus has been rela- tively low. Only 173 cases were recorded in 1947, and 325 in 1948. Murine typhus is probably common in the Suez Canal Zone, and outbreaks have been recorded from Port Said, Geneifa, Qasassin and Beni Youssef. Infection with murine typhus has been demonstrated in both Rattus norvegicus and R. rattus rattus in these areas. R. rattus alexandrinus, the usual house rat throughout most of Egypt, is a potential reservoir, but no data are available concerning its role in the spread of the infection. Only rare cases of tick-borne typhus have been observed in Egypt. Plague. Plague has occurred almost every year since its introduction in Alexandria in 1899. Today potential foci exist in Upper Egypt as well as in the port cities, where outbreaks of the disease appear sporadically as the result of its spread by way of ship- ping from the East. The incidence of plague declined gradually from an annual average of over 1,000 cases in 1906-10 to 15 cases in 1941-42. Beginning in 1943, however, outbreaks were again recorded from the Suez Canal region, and it was not until 1947 that the infection rates returned to the low level of 1942. Plague was epidemic in 1943-44 in the town of Suez where the peacetime population had been increased at least 50 per cent by the influx of laborers and other war workers. The shortage of housing was acute, the sanitary conditions unusually poor, and the rats abundant. Tt is estimated that between November, 1943, and June, 1944, there were at least 1,100 cases. Approximately four fifths were of the bubonic type with a case fatality of about 60 per cent. In the remaining pneumonic and septicemic cases, the fatality rate was Egypt 21 nearer 100 per cent. Small outbreaks were also reported from Suez, Port Said and Ismailiya in 1944-46. The major endemic focus in Upper Egypt is in Asyut Province, where the first cases were recorded in 1902 and a major outbreak in 1907. The infection remained active in this area until recently but has almost com- pletely subsided within the last few years. The importance of this focus may be in- ferred from the fact that between 1907 and 1930 approximately 17 per cent of the total of 15,970 cases reported from Egypt were attributed to Asyut Province. In 1931-35 the percentage of cases originating in this province rose to 41; in 1936-37, to 85; and in 1938-40, to 90 per cent. Outbreaks total- ing from 100 to 200 cases were reported from several localities in 1939 and again in 1940, but in 1941 only four sporadic cases were recorded from the entire province. Certain features characterize the epidemiol- ogy of plague in Upper Egypt. The dove- cotes on the roofs of many houses and the stone-embankments of the canals provide excellent harborage for rats. The concentra- tion of the initial cases in an outbreak in areas adjacent to the canals is attributed to the fact that the rats flee from the fields and the embankments in August and September to escape the floods and take refuge in the outlying houses. During the autumn they also find shelter in piles of cotton and maize stalks left drying in the fields. In the winter when these stalks are strewn on the roofs of the houses the rats frequently go with them. The incidence of plague in Upper Egypt is normally highest in February and March, while the peak associated with the outbreaks in Lower Egypt is likely to come in July. The roof rat, Rattus rattus alexandrinus, is the most frequent reservoir of infection in the provinces, while R. rattus rattus and R. norvegicus are implicated in the spread of the disease in the port cities. Campaigns for the extermination of rats are conducted continuously in Alexandria, Port Said and Suez, and in Asyut Province. In addition, rat extermination teams are sent into the provinces whenever a case of plague is re- ported. Immunization with antiplague vac- cine is carried on in the affected districts. Relapsing Fever. Although both louse- borne and tick-borne relapsing fever are reported, only the former disease is regarded as of major significance. Outbreaks occur at regular intervals, usually when disturbed social conditions favor the propagation of lice. The epidemic of relapsing fever which swept across North Africa in 1942-46 spread to Egypt from Tripolitania. In 1944 ten relatively mild cases were reported from Asyut and Beni-Suef provinces. From there the disease spread rapidly throughout Upper Egypt and subsequently penetrated to Cairo, Alexandria and the canal ports. From a total of 18,277 cases in 1945, the incidence increased progressively up to April, 1946, and then began to decline. About 35,430 cases were recorded in April, and 29,897 in May, while the total for 1946 exceeded 100,000. The following year 229 cases were reported, but in 1948, only 6. Tick-borne relapsing fever is common on the western oases. The tick, Ornithodorus moubata, is the probable vector, although O. savignyi may also be implicated. Filariasis. Wuchereria bancrofti infec- tions are endemic in the neighborhood of Cairo, in Rosetta and possibly in other parts of the country. In the endemic areas near Cairo, which cover about 200 square miles west of the city, the infection rates average about 25 per cent. Cases of elephantiasis are rare, but at least one quarter of the infected males may have hydrocele. In Rosetta an infection rate of 10 per cent was demonstrated in a group of 1,000 indi- viduals examined in 1936; 18 had elephan- tiasis of the extremities. The areas of trans- mission are associated with the prevalence of brackish wells used for household pur- poses, which provide favorable conditions for the breeding of the vector, Culex pipiens. In the villages outside of Rosetta, where such wells are few in number, filariasis is not observed. Both C. pipiens and C. quin- 22 Egypt quefasciatus (= C. fatigans) are widely dis- tributed, and it is possible that filariasis occurs in other areas as yet not adequately investigated. A few cases of onchocerciasis have been reported from the Sinai Peninsula and from pumping stations in the desert. The infec- tion may be transmitted by Simulium griseicollis. Such reports need confirmation inasmuch as many observers regard the Anglo-Egyptian Sudan as the northern limit of this infection. Leishmaniasis. Cases of cutaneous leish- maniasis are reported occasionally. An en- demic focus was discovered near Zagazig in 1933, in which 17 per cent of the in- habitants examined were found to have active infections, while 27 per cent had scars of old lesions. Sporadic cases have been described from other localities, primarily Cairo, Alexandria, Rosetta, Suez and Port Said in the north, and Beni Mohamed in Asyut Province. The sandfly, Phlebotomus papatasii, is the probable vector, although other species may be present. Rare cases of kala-azar have been recorded from Cairo and Alexandria. Other Infections. Sandfly fever is en- demic in northern Egypt and in the Suez Canal Zone where it is transmitted by Phlebotomus papatasii. Cases begin to ap- pear in March, reach their greatest numbers by August and disappear in December. Dengue fever is also endemic and some- times epidemic. The latest severe outbreak occurred in Cairo in 1937 and lasted from September to December. The full extent of the epidemic is uncertain, but on the basis of the absenteeism in the schools and in certain government offices it was estimated that there were at least 400,000 cases. The infection was encountered concurrently in other parts of the country. Yellow fever never has been reported from Egypt, but since Aedes aegypti is pres- ent in large numbers, there is constant dan- ger of its introduction. The nearest endemic area is in the southern Anglo-Egyptian Sudan, where a serious outbreak was re- corded from the Nuba Mountains in 1940. Dracontiasis, caused by the guinea worm, Dracunculus medinensis, is reported spo- radically from the Nile valley. NuTtriTIONAL DISEASES Malnutrition and hypovitaminosis are common among the poorer Egyptians. No records of the incidence of deficiency dis- eases were kept prior to 1940, and such as are now available are inadequate. Rickets is observed frequently, especially in Upper Egypt, where less milk is used than in the Delta region. In the three years 1940-42, an average of 834 cases and 158 deaths was recorded annually. Pellagra is widespread. The incidence varies with the food habits of the people in different localities but is generally lower in Upper Egypt than in the Delta. It has been estimated that from 1 to 7 per cent of the people in individual villages in the Delta region have pellagra. The reported incidence usually ranges from 700 to 2,000 cases a year. Vitamin A deficiencies are prevalent. In 1940-42 from 735 to 1,042 cases of osteo- malacia were reported annually. Night blindness is common in the Delta and in parts of Upper Egypt. Scurvy occurs pri- marily in the oases, but within recent years subclinical vitamin C deficiencies have been observed with increasing frequency among the poorer inhabitants in the cities. Beriberi is relatively rare, but occasional cases are recorded. Goiter is endemic in the oasis of Dakhla and possibly in other areas. A survey of the village of Kalamoun in 1932 showed that all of the 100 men examined had enlarged thyroids, while three out of 35 children were cretins. The women were not available for examination. The incidence of goiter was found to be considerably lower in other vil- lages on the oasis. MisceLLaANEOUS CONDITIONS Infectious hepatitis is endemic, and local- ized outbreaks are common. Egypt 23 SUMMARY The Ministry of Public Health is respon- sible for the protection of the health of the people in Egypt. The functions of the Min- istry, which is located in Cairo, are divided into 12 major departments and numerous subordinate sections. About 95 per cent of all hospital beds are maintained by the Egyptian government. The Ministry op- erates four hospitals with about 3,400 beds in Cairo, two hospitals with 650 beds in Alexandria, hospitals with a capacity of 100 to 250 beds in the capitals of each province, and hospital units of 20 to 30 beds in the smaller administrative centers. In addition, hospitals and clinics are established for the treatment of ophthalmic diseases, venereal diseases, leprosy and tuberculosis. Modern water supply systems are found in the larger cities, but rural supplies which are obtained from wells or from the Nile and its subsidiary canals are frequently con- taminated. Sewerage systems which service part of the population are found only in a few of the large communities. The stand- ards of sanitation vary but are generally low in the rural villages throughout Egypt. Schistosomiasis, hookworm infection, tra- choma and acute purulent conjunctivitis, venereal diseases, skin infections and under- nutrition are major problems. Malaria is endemic in most parts of the country, with the highest incidence in the oases and in the rice-growing and the lake regions of the Delta. Tuberculosis, leprosy, dysentery and typhoid are prevalent. Extensive epidemics of cholera, louse-borne relapsing fever and louse-borne typhus fever have occurred within recent years. Plague and smallpox are frequent. The mortality from pneu- monia and the common respiratory diseases is unusually high. 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A. and Whitman, Loring: Yel- low fever immunity survey of North, East and South Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 29:397-412 (Jan.) 1936. Scott, J. Allen: Incidence and distribution of the human schistosomes in Egypt, Am. J. Hyg. 25:566-614 (May) 1937. : Observations on infection with the common roundworm, Ascaris lumbrio- coides, in Egypt, Am. J. Hyg. 30:83-116 (Nov.) 1939. ——: Observations on mortality and mor- bidity from schistosomiasis in Egypt, J. Trop. Med. & Hyg. 40:125-132 (June) 1937. ——: Observations on the transmission of hookworm infection in Egypt, Am. J. Hyg. 26:506-526 (Nov.) 1937. : Prevalence and distribution of hook- worm infection in Egypt, Am. J. Hyg. 26:455-505 (Nov.) 1937. ——, and Barlowe, Claude H.: Limitations to the control of helminth parasites in Egypt in means of treatment and sanita- tion, Am. J. Hyg. 27:619-648 (May) 1938. 64. 65. 66. 07. 68. 69. 71, 72. 73. Egypt 25 Shousha, A. T.: Cholera epidemic in Egypt (1947). A preliminary report, Bull. World Health Org. 1: (No. 2) 353-381, 1948. ——: Species eradication. The eradication of Anopheles gambiae from upper Egypt, 1942-1945, Bull. World Health Org. 1: (No. 2) 309-352, 1948. Shousha Pasha, A. T.: Schistosomiasis (Bil- harziasis). A World Scourge. Cairo, Govt. Press, 1947. The study of the main health problems of Egypt by the Ministry of Public Health: J. Egyptian M. A. 24:419-444 (Sept., Oct., Nov.) 1941. The Times Book of Egypt. (Reprinted from the Egypt Number published 26 January, 1937). London, The Times Publishing Co., Ltd., 1937. Van Rooyen, C. E., and Morgan, A. D.: Poliomyelitis. Experimental work in Egypt, Edinburgh M. J. 50:705-720 (Dec.) 1943. . Wakil, A. W.: A study of child mortality in Cairo, J. Egyptian M. A. 23:338-353 (June) 1940. ——, and Hilmy, F.: Dengue epidemic of 1937 in Cairo, J. Egyptian M. A. 21:716- 737 (Nov.) 1938. Wilson, W. H.: Food problem in Egypt, J. Egyptian M. A. 22:283-318 (June) 1939. Zimmerli, E.: Tuberculosis in Egypt, J. Egyptian M. A. 21:190-217 (Apr.); 241-260 (May) 1938. . ——: Tuberculosis in Egypt, Brit. J. Tuberc. 30:62-71 (Apr.) 1936. COG GGG GY GEOGRAPHY AND CLIMATE As its name implies, the Anglo-Egyptian Sudan is a condominium under the joint sovereignty of Great Britain and Egypt. According to the terms of the agreement made between these powers in 1899, the Sudan is a British dependency subject to Egypt’s juridicial co-partnership. The Governor-General is appointed by Khedi- vial decree upon the recommendation of the British government. The nine provincial governors and the directors of the major technical departments are at present Brit- ish, but the Sudanese are participating in the central and the local government to an increasing extent. A vast area of 967,000 square miles, the Sudan is bounded on the north by Egypt, on the east by the Red Sea, Eritrea and Ethi- opia, on the south by Kenya, Uganda and the Belgian Congo, and on the west by French Equatorial Africa. The northern and the western frontiers meet in the Libyan Desert. The Nile dominates the country, traversing a circuitous route of 2,000 miles from Nimule to Wadi Halfa. Geographically, the Sudan may be di- vided roughly into three more or less dis- tinct zones. Except for the lands adjacent to the Nile, the region north of Khartoum is virtually a continuation of the great African-Arabian desert. The eastern Nubian desert is separated from the Red Sea by a range of mountains which run parallel with the coast and rise to heights of 4,000 to 7,000 feet. The central zone, which includes Darfur, Kordofan, Blue Nile and Khartoum provinces, the northern corner of Upper GGG IG SCEEGGLY, a a aa PFPA SST 2 Anglo-Egyptian Sudan 26 Nile Province and the southern half of Kassala Province, contains extensive areas which are well watered and fertile. From the Nile basin westward the country is char- acterized by steppelike plains broken by hills sometimes rising 2,000 feet in height and, on the western border, by mountains with an average altitude of 6,000 feet. The southern portion of the Sudan is largely tropical savannah and forest, with great swamps in the Sudd region between the Bahr el Ghazal and the Bahr el Jebel. Scarcely more than one fifth of the Sudan is potentially arable land. With the excep- tion of the Gash delta in the east and por- tions of the Darfur highlands in the west, most of the cultivable land is associated with the Nile and its tributaries. In the region between the Blue Nile and Atbara rivers and in the fork between the White Nile and the Blue Nile (the Gezira), the soil is exceptionally fertile and productive under irrigation. The Anglo-Egyptian Sudan lies partially within the tropics. The temperatures are uniformly high, although regional varia- tions occur. Throughout the northern and the central provinces the relative humidity is low, and marked daily fluctuations in temperature are common. The mean tem- perature at Wadi Halfa is approximately 76° F.; the mean minimum, 28° F.; and the mean maximum, 126° F. Corresponding temperatures at Khartoum average 84° F., 41° F. and 117° F., and at Wau, 81° F,, 50° F. and 115° F., respectively. Rainfall is the predominant climatic factor. In the northern regions desert conditions prevail, but toward the south the rainfall becomes Anglo-Egyptian Sudan 27 progressively heavier. In the central portion of the country south of Khartoum, it aver- ages from 10 to 30 inches a year with marked yearly variations. The rainy season extends from mid-June to September; the dry season, dominated by the desiccating northeast trade winds, extends from No- vember to March. Dust storms are frequent during May and June. In the heavy rain area to the south the annual precipitation averages from 30 to 50 inches, while the rainy season extends from April to Sep- tember. In this Sudd region the climate is more equable than in the north, but it is humid and tropical. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruLraTioNn According to the estimates for 1948 the population of the Anglo-Egyptian Sudan was slightly over 8 million. Exclusive of migratory West African communities, the foreigners totaled approximately 40,370, with less than 7,000 Europeans and from 12,000 to 14,000 Egyptians. Ethnically and politically, the country may be divided into two parts, the northern and the southern. North of a hypothetical line through 12° N. latitude, the inhabitants are predominantly Arab and Moslem. They are not racially homogeneous, however, but represent various admixtures of Caucasian and Negro blood. Two large Hamitic groups have become arabicized, the Beja tribes of the Red Sea hinterland and the Nubians along the banks of the Nile between the first and the fourth cataracts. In the south- ern Sudan the people are Negroid and have more in common with the inhabitants of Uganda and the Congo than with their northern countrymen. They comprise a medley of primitive tribes, the most promi- nent of which are the Shilluks, the Dinkas, the Bongos, the Azande and the Nuba, a race of aborigines distinct from the so-called Nubians. These pagan Negroid tribes have no cultural or linguistic unity. Less than 10 per cent of the population is urban. The larger cities are almost entirely in the central and the northern portions of the country. The population density of Khartoum Province, including the cities of Khartoum and Omdurman, is roughly 66.5 per square mile. In 1949 the population of Khartoum, the administrative capital, was 74,978. That of Omdurman, the principal native city, was 126,670, and of Khartoum North, 37,303. The fertile Blue Nile Prov- ince has a population density of approxi- mately 31.5 per square mile, but in the rest of the provinces it is less than 12 per square mile. Vast areas are sparsely inhabited by nomadic tribes, while thickly settled com- munities are clustered along the banks of the Nile tributaries. Probably the most densely populated rural districts are found in the regions inhabited by the Dinkas and the Shilluks. In the northern Sudan, the populations of the larger towns have become more or less Europeanized and have little in common culturally with the rest of the country. Under the influence of Western culture and education, a small native intelligentsia has developed, but in most areas the majority of the inhabitants are illiterate. As yet, only a minor percentage has received even a rudi- mentary type of education. Different edu- cational systems prevail in the north and in the south. In the Moslem areas, village schools are maintained by the local author- ities, and elementary, intermediate, second- ary and technical schools by the govern- ment. There are no mission schools except in Khartoum and Omdurman. Gordon Me- morial College, in Khartoum, has branches in arts, science, engineering and agriculture. It was reorganized in 1945 and now ranks as a University College, affiliated with the University of London. In the southern provinces, including Equatoria, Bahr el Ghazal, most of Upper Nile and the Nuba Mountains section of Kordofan, education is primarily a mission activity, with gov- ernment supervision and subsidies to ap- proved schools. Large numbers of bush 28 Anglo-Egyptian Sudan schools of varying quality, and a few ele- mentary, intermediate and trade schools are conducted by both Protestant and Catholic missions. Arabic is the medium of instruc- tion in the north, and the tribal languages in the south. However, in order to equalize the opportunities for advanced education, English has been introduced at the inter- mediate school level. VITAL STATISTICS With the exception of a few of the larger towns, no vital statistics are available in the Sudan. Moreover, in the absence of an accurate census, such statistics must be re- garded as of doubtful value even in the case of Khartoum and Omdurman. The registration of births is probably more com- plete than that of deaths, although there may be a tendency to evade the notification of female births, especially stillbirths. In 1949 the birth rate in Khartoum was 22.5 per 1,000 population; in Omdurman, 23.0; and in Khartoum North, 27.0. The death rates were 10.4, 9.3 and 8.2 per 1,000 popu- lation, respectively. Approximately 12.2 per cent of the registered deaths were among infants under one year, and 30.0 per cent among children under five years of age. The infant mortality rates for these cities in 1945 averaged 78.5 per 1,000 live births, rates which compare favorably with those of the neighboring countries. Sociar Economy The Anglo-Egyptian Sudan is still in a stage of transition, having evolved within the last half century from a primitive state of continuous internal warfare. The major part of the territory is pastoral, devoted to the raising of large herds of cattle, sheep, goats and camels; meat and hides are im- portant exports. The nonnomadic riverain peoples are primarily peasant farmers. In many areas the government is attempting to introduce improved methods of cultiva- tion and co-operative production measures, both with respect to food and commercial crops. By means of large-scale irrigation projects, the triangular area between the Blue Nile and the White Nile, commonly known as the Gezira plain, and the Gash River valley have been converted into fertile cotton lands. The Gezira scheme represents a partnership between the State and the cultivators from which the Sudan govern- ment derives a considerable part of the revenues allocated to its various social serv- ices. Every year there is a slow, irregular but persistent immigration of laborers from western Africa through this region, which reaches its peak during the cotton harvest in November and December. A few settle, but the majority eventually drift further east and make the pilgrimage to Mecca be- fore returning along the same route to their home communities. This constant influx of migratory workers introduces problems of social and health significance. The only ex- port crops besides cotton are millet, sesame and peanuts. Gum arabic is also exported, and the government has undertaken to pro- tect the industry and preserve the acacia forests in Darfur, Kordofan and Kassala provinces. The mineral resources are lim- ited, although small amounts of gold are mined. The construction of a hydroelectric and irrigation project with dams on the Victoria Nile and the Albert Nile in Uganda and at Lake Tana, the source of the Blue Nile, in Ethiopia, as well as a system of canals through the Sudd region of Anglo-Egyptian Sudan, is proposed as a joint venture of the British, Uganda, Egyptian, Sudan and Ethiopian governments. The Owen Dam in Uganda, the first step of the project, was started in September, 1949. It is anticipated that this program, when completed, will in- crease the cultivable area of the Sudan by 1.5 to 2.5 million acres. The development of transport has been slow, and large sections of the country are still relatively isolated. The chief means of communication north of Khartoum is by rail, the 946-mile stretch of the Nile to the Anglo-Egyptian Sudan 29 Egyptian border being dangerous to naviga- tion because of innumerable rapids and six cataracts. South of Khartoum, steamer serv- ice on the White Nile, the Blue Nile, the Bahr el Ghazal and the Sobat rivers is the principal means of transport. Roads or cara- van routes connect the interior settlements with the river towns. Railways, owned and operated by the government, link the larger centers with Egypt and provide access to the Red Sea, with terminals at Port Sudan and Suakin. Khartoum is an important sta- tion on the transcontinental air routes and, in addition, the focal point of radiating local services which are operated by the Sudan Railways. Foop AND NUTRITION The majority of Sudanese live close to subsistence levels, the agriculturalists on the few crops which they are able to produce and the pastoralists on grain and animal products. The staple food is grain, about 60 per cent of the crop being large millet, or dura, and 25 per cent spiked millet, or dukhn. Small amounts of wheat and maize are also grown. Legumes and peanuts are important articles of diet, but leafy vege- tables are rare except along the banks of the Niles. Dates are produced on holdings along the Nile north of Khartoum and to a lesser extent in Darfur and Kordofan prov- inces. The meat-eating habits of the pastoral tribes vary ; many consume meat regularly, others only occasionally and chiefly on cere- monial occasions. On the other hand, most Negroid tribes regard their animals as wealth and seldom dispose of them for slaughter. Among some tribes milk and cheese constitute major articles of diet at certain seasons, while many use consider- able amounts of semn, a form of boiled butter. Along the Niles and the Red Sea coast, fish represents an important food; large quantities are salted for local use and for export to Egypt. The dietary of the vari- ous tribes differs in quantity and diversity, but in general the standards of nutrition are low as judged by accepted minimum re- quirements. Housine In the northern and the central provinces the sedentary tribes in the rural settlements and in the villages along the rivers live in permanent houses with mud walls and thatched roofs. Inland and among the Ne- groid tribes of the south, the huts usually are constructed of grass or grainstalks. In the areas with a regular flood season, they may be built on rough wood piles. Fre- quently, such homes are poorly constructed and offer inadequate protection against the weather. The nomadic tribes regularly live in tents under equally poor sanitary con- ditions. In the towns and the cities the more prosperous sections are well planned. The individual compounds, or diems, are built of brick or mud and consist of a flat-roofed dwelling, usually of two or three rooms, a stable and other structures which line the walls of the courtyard. Modern homes and compounds of improved design are being constructed in Khartoum and Omdurman as part of large-scale municipal housing proj- ects. In the poorer districts overcrowding and a lack of sanitary facilities are common. ENVIRONMENT AND SANITATION WATER SUPPLIES The Nile and its tributaries provide the principal source of water for domestic sup- plies and for irrigation purposes. The water supplies of Khartoum, Omdurman, Wadi Halfa, Malakal and other towns on the Nile are taken from the river. The supplies of Khartoum and Omdurman are treated by filtration and chlorination before distribu- tion to communal fountains and in certain limited areas to individual buildings. Ven- dors with carts also peddle water in gallon cans. Bacteriologic and chemical controls are enforced by the government health au- thorities. 30 Anglo-Egyptian Sudan The provision of adequate water supplies is frequently difficult in localities at a dis- tance from the rivers. During prolonged dry seasons, the shortage of water may be acute in many areas. The supply for Port Sudan is piped from wells at Khor Arbaat, 18 miles away, and stored in underground tanks. Deep wells or boreholes have been developed at many points in Kordofan, Darfur and Kassala provinces. In the last province the construction of reservoirs for the collection of rain water has also been undertaken. Rural supplies are derived from wells, rivers and shallow depressions, or /Xafirs. Because of the generally poor sanitary con- ditions, such supplies are apt to be con- taminated. The #Aafirs, in particular, are frequently polluted by man and animals. Moreover, the Sudanese customarily carry water for considerable distances in skins, crocks and other containers which may be sources of secondary contamination. A pro- gram of village sanitation, which incorpo- rates filtration treatment of the water sup- plies, has been initiated in the Gezira by the Sudan health authorities. Major irrigation projects have been undertaken on the White Nile, the Blue Nile and the Gash rivers. The Sennar dam on the Blue Nile controls the irrigation water supply for the Gezira plain. The con- struction of the Jebel Auliya dam on the White Nile below Khartoum was started by Egypt in 1933 as part of a large-scale scheme for harnessing the flood waters of the Nile. The reservoir has affected the agricultural communities upstream, neces- sitating the development of a resettlement and irrigation program for that area by the Sudan government. WasTE DIsPosAL Except for private installations in the Palace and the Grand Hotel in Khartoum, no water-borne systems of sewage disposal exist in the Sudan. In Khartoum, Omdur- man, Kosti, Malakal and other large towns, the double-bucket system of disposal is em- ployed. Collections are made at night, the material being trenched in designated areas on the outskirts. In the rural communities around the larger towns, pit latrines and privies are sometimes used. In most villages, however, no methods of sanitary disposal are available, and in the irrigated areas the canals are frequently polluted with human excreta. Pit latrines are being introduced at cost by the Sudan health authorities in a pilot village sanitation project in the Gezira region and in a resettlement program among the Azande. Fauna anDp Frora Arthropods. Mosquitoes. Numerous species of anopheline mosquitoes are en- countered, the most important of which are Anopheles gambiae and A. funestus. A. gambiae, the principal vector of malaria, is found throughout the country. It breeds in small exposed collections of water and particularly in the residual pools left as the river waters recede. A. fumestus is also a significant vector in the southern Sudan. A. pharoensis is prevalent as far north as Khartoum but probably does not play a major role in the transmission of malaria. A. d’thali may be regarded as a potential vector in some regions. A. rhodesiensis, A. nili and A. pretoriensis have been found naturally infected but are of doubtful im- portance as vectors of malaria. A. rufipes, which is frequently caught in human habi- tations during the winter in Kordofan Province, may be responsible for the spread of the infection in that area. At least 26 species of Aedes mosquitoes are reported. Aedes aegypti, the species commonly associated with the transmission of urban yellow fever, is widespread but, with the exception of areas on the Red Sea coast, is not prevalent north of Khartoum. Considerable attention has been given to the distribution of various species of Aedes since the outbreak of yellow fever in the Nuba Mountains in 1940. A. vittatus and Anglo-Egyptian Sudan 3) A. taylori were shown to be the principal vectors in that region, but A. furcifer, A. luteocephalus and A. metallicus may have been implicated to some extent.?® A. aegypti was of minor importance in most localities. A. simpsoni lilii, a potential vector, is also present in the southern Sudan. Aedes mos- quitoes generally begin to appear when the rains commence and in the Nuba Mountains area are most prevalent from August to October. Twenty-eight or more species of Culex have been identified, but only Culex quin- quefasciatus (=C. fatigans) is of possible medical importance. It is a known vector of Wuchereria bancrofti; but in the recog- nized foci in the Sudan Anopheles gambiae is regarded as the primary transmitter. Taeniorhynchus (Mansonia) africanus and T. (M.) uniformis are found as far north as Kosti and Sennar. Eretmopodites chryso- gaster, though present, is rare. Anopheline control measures are carried on in the municipalities and the larger town- ships. They include draining and filling, the routine clearing of depressions and pools, the breeding of top minnows and the use of oil or DDT as larvicides. No control is at- tempted in the rural areas except in certain limited regions. In many districts under irrigation the dead ends of the canals, or dawarans, are treated routinely with oil. Since 1949, residual house spraying with DDT has been undertaken on a small scale in four sections of the Gezira and in the villages along the White Nile affected by the Jebel Auliya dam. In some areas the marshes and the #Xafirs are stocked with larval-feeding fish of the genus, Gambusia. Special anti-Aedes measures are enforced in communities along the major travel routes, and A. aegypti is now more or less under control in the urban areas. Inspection and disinfection of aircraft are carried out at Khartoum, Malakal, Juba, Geneina, El Fasher and Port Sudan. Fries. Five species of tsetse flies have been recorded. Glossina palpalis is found along the rivers and the streams in the southwest, in the regions adjacent to French Equatorial Africa and the Belgian Congo. It is the vector of Trypanosoma gambiense, which has been endemic in this area since its introduction about 1911. As the result of a systematic control program, the incidence of G. palpalis and of sleeping sickness has now been reduced to low levels. G. mor- sitans, and G. fuscipleuris are also present and responsible for the transmission of animal trypanosomiasis, which is a consider- able problem in the areas affected. G. pal- lidipes has been reported recently from the Boma plateau. G. tachinoides was collected at Kigille near the Ethiopian border in 1948. Control measures carried on against G. palpalis include the development of bar- rier clearings along infested streams for the protection of villages, road crossings and watering places, as well as the hand catching of flies according to the “block” system. Numerous species of Stomoxys, Haema- topota, Musca and Tabanus are present. They are not only annoying pests but may be important agents in the mechanical transmission of intestinal, skin and eye infections. Chrysops distinctipennis and C. longicornis occur in the southwest, where they are considered as vectors of Loa loa. Various myiasis-producing flies are encoun- tered, the most important as regards man being Wohlfahrtia nuba and Cordylobia anthropophaga. The blowflies, Chrysomyia bezziana and C. putoria, are prevalent. Various species of Sarcophaga are reported, the larvae of which occasionally infest man. Oestrus ovis, Rhinoestrus purpureus and species of Gasterophilus may be responsible for accidental cases of human myiasis. Auchmeromyia luteola is abundant in the south. Its blood-sucking larvae, known as “Congo floor maggots,” produce lesions which may readily become infected. At least 14 species of Simulium have been identified. Simulium damnosum is the vec- tor of Omnchocerca volvulus, which is en- 82 Anglo-Egyptian Sudan demic in Bahr el Ghazal and Equatoria provinces. The fly also breeds in limited areas along the Blue Nile and on the main Nile as far north as the second cataract, near Wadi Halfa. S. griseicollis is a trou- blesome pest in the Dongala region. Over 40 species of sandflies of the genus Phlebotomus have been recorded. Kala-azar and cutaneous leishmaniasis are reported from widely distributed foci. The vectors have not been established, but P. orientalis may transmit kala-azar in the districts near the Ethiopian border. P. papatasii is wide- spread, while P. clydei has been found as far north as Atbara and also south of the Bahr el Ghazal swamps. The biting midges, Culicoides grahami and possibly C. austeni, are vectors of the filarial worm, Acantho- cheilonema perstans, in the southwest. Non- biting midges swarm in clouds at certain seasons and may be a serious plague near Khartoum and Wadi Halfa. Lice. The body louse, Pediculus humanus corporis, is prevalent, particularly in the northern Sudan. It is a vector of louse-borne relapsing fever, which occurs in sporadic outbreaks. P. humanus capitis, and to a lesser extent Phthirus pubis, are also found throughout this region. Freas. Both Xenopsylla cheopis and X. brasiliensis infest the rats in the Sudan. X. cheopis is the most numerous and at times is the only rat flea encountered in the vicinity of Khartoum. The cat flea, Cteno- cephalides felis, attacks both cats and dogs. Synosternus pallidus is found in some lo- calities. The human flea, Pulex irritans, is rarely encountered in this region. The sand flea, Tunga penetrans, is widely distributed. It is responsible for frequent disabling sores, particularly on the toes. BepBucs. Two species of bedbugs are indigenous. Cimex lectularis predominates the northern portion of the Sudan west of the Red Sea hills, and C. kemipterus on the coastal plain. Both species are plentiful in the southern provinces. In these areas, C. hemipterus is observed most frequently in the native villages, while C. lectularis is confined to the larger towns. Ticks anp Mrtes. Ticks are widespread. The tampan tick, Ornithodorus moubata, is rare but has been reported from localities along the Uganda border. O. erraticus sonrai is found occasionally in the south, while O. savignyi is widely distributed in the northern provinces. Numerous species of ticks infest the wild and domestic animals and may be re- sponsible for the transmission of protozoal and other diseases. Among the ticks spe- cifically recorded are: Rhipicephalus san- guineus, R. simus, R. evertsi and R. falca- tus; species of Amblyomma, including A. variegatum ; Boophilus decoloratus, Hya- lomma aegyptium; and species of Apo- nomma and Dermacentor. The dog tick, Haemaphysalis leachi, is prevalent. Argas brumpti and A. persicus are also known to be present. Mites are abundant. Infestation with the itch mite, Scarcoptes scabiei, is more or less general in some areas. Scorpions. Several species of venomous scorpions are found, including Pandinus imperator, P. exitialis, P. pallidus, Buthus occitanus, B. quinquestriatus, B. amoreuxi, B. mimax and B. acutecarinatus. The stings of some of these species may be fatal to young children. OtHER AwrTHROPODS. Mylabris nubica, Epicauta sapphirina, species of Paederus, and other types of blister beetles are en- countered frequently. Centipedes of the genus Scolopendra sometimes cause inflam- matory lesions on the skin. Reptiles. Venomous snakes are nu- merous. Three cobras are found, Naja nigri- collis, N. melanoleuca, and particularly in the dry regions of the north, N. kaje. The common mamba, Dendroaspis angusticeps, has also been reported. The puff adder, Bitis arietans, the gaboon viper, B. ga- bonica, and the rhinoceros-horned viper, B. nasicornis, are widely distributed in the southern Sudan. The saw-scaled viper. Anglo-Egyptian Sudan 33 Echis carinatus, and the burrowing viper, Atractaspis microlipidota, are most fre- quently implicated in the deaths due to snake bites in the north. The night vipers, Causus rhombeatus and C. resimus, are present. The sand viper, Aspis cerastes (=Cerastes cornutus), inhabits the sandy regions. The rear-fanged boomslang, Dis- pholidus typus, has been recorded from cer- tain areas. The pythons, Python regius and P. sebae, and the constrictor, Eryx thebaicus, are sometimes encountered ; although not veno- mous, they are dangerous to small animals. Rodents. Rats are abundant throughout the Sudan. Rattus rattus rattus and R. rat- tus alexandrinus are widespread. R. rattus frugivorus is prevalent in the Port Sudan area. R. norvegicus is also present in the port towns. Rat control measures are vigor- ously applied in the vicinity of Port Sudan and Suakin, where rat proofing and steel ship guards are compulsory. Mollusks.* Several species of mollusks are present in the fresh-water pools and streams of the Nile basin and in the irriga- tion canals. Bulinus truncatus is the prob- able intermediate host of Schistosoma haematobium. Physopsis africana globosa is also present and is suspected of being an intermediate host, although infection has not yet been proved. Planorbis (Biompha- laria) alexandrina and P. (B.) alexandrina pfeifferi are the intermediate hosts of S. mansoni. Bulinus (Pyrgophysa) forskalii is reported from various regions. Plants. Calotropis procera is used in the preparation of native beer, and occasional cases of poisoning have been reported, pre- sumably due to excessive quantities of the toxic ingredient. Datura poisoning is em- ployed frequently in the northern Sudan to drug individuals preliminary to robbery or other criminal practices. Serious cases of poisoning may also result from the addition of Datura to beer to enhance its intoxicating properties. Both Datura metel and D. stra- * See footnote, p. 10. monium are found, but the former is the more widespread. Hyoscyamus muticus is also used as a narcotic. The cultivation of Cannabis sativa, or hashish, is forbidden by law, but occasional cases of addiction are observed. Adenium hongkel, Euphorbia calycina and E. venentifica are employed as arrow poisons by the different tribes of the southern Sudan. The last may be used also for homicidal purposes. Erythrophleum guineense is used by some primitive tribes in “trials by ordeal” to establish the guilt or the innocence of suspected persons. The bark or the fruit of numerous other plants is commonly added to water to poison or stupify the fish so that they may be caught readily. Sometimes poisoning is recorded as the result of the excessive or incorrect use of certain plants as foods. Capsicums and the vetch, Lathyrus sativa, may produce serious systemic reactions. The bitter cassava, Manihot utilissima, has cyanogenic prop- erties when improperly prepared. The wild yam, Dioscorea dumetorum, is used exten- sively in times of famine and may be re- sponsible for poisoning if the washing and detoxification are inadequate. Inflammatory skin conditions are some- times produced in susceptible individuals from contact with certain plants, as Ruta tuberculata. The Sudd grasses, Vossia cuspi- data and Echinochloa pyramidale, are known to cause mechanical irritation of the skin. Other grasses are potential allergens, but their differentiation is incomplete. Foop SANITATION Supervision over the sale and the pro- duction of milk, meats and other foodstuffs is attempted only in the larger towns. In the municipalities the inspection and the control of milk supplies is undertaken by the local health authorities under the direc- tion of government health inspectors. Much of the milk is produced under insanitary conditions. Facilities for pasteurization are almost completely lacking. The supervision 34 Anglo-Egyptian Sudan of slaughter-houses and of meat supplies is the responsibility of the veterinary author- ities. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The health and medical facilities are ad- ministered by the Sudan Medical Service which, since the reorganization of the gov- ernment in 1948, has been integrated in a Ministry of Health. The headquarters are located at Khartoum. In addition to the Director of Medical Services, there are assistant directors in charge of hospitals, public health and research. The hospital division is responsible for the operation of the central hospitals in Khartoum and Omdurman and of the hospitals and the dispensaries in the provinces. The public health branch directs the public health and sanitary services. It is organized on a pro- vincial basis, with a Medical Officer of Health in charge of the program in each of the provinces. Khartoum has a munic- ipal health department which functions under the jurisdiction of the Ministry of Health. In the other areas local authority resides in municipal or rural district coun- cils under the supervision of the provincial public health officials. The research division incorporates the Stack Medical Research Laboratories and the Wellcome Chemical Laboratories in Khartoum and an entomo- logic unit at Wad Medani. A quarantine organization within the public health division is administered by a deputy assistant director. In addition to the usual port quarantine services, it operates stations at Wadi Halfa for the examination of immigrant labor from Egypt and at Suakin for the medical supervision of the pilgrimage traffic from the Sudan. In 1950 a post was also established at Geneina for the control of laborers and pilgrims enter- ing the territory from the west. A Medical Mission accompanies each pilgrimage to Mecca and maintains a field hospital at Jeddah and two dispensaries for the treat- ment of both Sudanese and non-Sudanese pilgrims. The institution of school health services, of antenatal and maternity services in the northern provinces, and of infant and child welfare clinics in Khartoum and Port Sudan are important features of the government’s health service program. The Ministry also maintains facilities for the training of medi- cal personnel and a museum for the dis- semination of public health information at Khartoum. Four religious mission societies carry on medical and educational work among the non-Moslem communities : the Church Mis- sionary Society, the Sudan United Mission, the American Mission and the Sudan In- terior Mission. MEepicAL INSTITUTIONS Hospitals and Dispensaries. In 1950 the Ministry of Health maintained 40 hos- pitals in various parts of the country, which provided a total of 5,927 beds. The central hospitals at Khartoum and Omdurman have a combined capacity of almost 800 beds and are well-equipped teaching institutions. To- gether with the Kitchener Memorial Medi- cal School, the Stack Medical Research Laboratories and the Graphic Museum, they constitute a closely integrated medical unit. From 2 to 7 hospitals, ranging in size from 50 to 350 beds, are established in each of the provinces, with the exception of Upper Nile, which has only one 254-bed hospital at Malakal. In that province, how- ever, a hospital boat patrols the White Nile, from which traveling clinics visit the rural villages and refer surgical cases to the ship for treatment. The majority of government hospitals have facilities for the conduct of routine laboratory examinations, while the largest institutions in each province possess roentgenologic apparatus. As of 1947, the government medical services operated 347 rural dispensaries, some of which are grad- ually being converted into fully staffed health centers. Anglo-Egyptian Sudan 35 The Church Missionary Society main- tained a 70-bed hospital in Omdurman and three small hospitals in the southern Sudan. It also conducted 5 infant welfare centers and 7 dispensaries. Five dispensaries were operated by other mission organizations. The capacity of the hospitals and the dispensaries in the Sudan in 1947 was ap- proximately 7,387 beds or slightly less than one bed per 1,000 population. Laboratories. The Stack Medical Re- search Laboratories and the Wellcome Chemical Laboratories in Khartoum and the medical entomologic service at Wad Medani are laboratory units of the Ministry of Health. The Stack Medical Research Laboratories are equipped for the conduct of research, the performance of routine pathologic, serologic and bacteriologic ex- aminations, and the manufacture of small- pox and other vaccines. The director also maintains a degree of supervision over the hospital laboratories in the provinces. The Wellcome Chemical Laboratories carry out chemical analyses of food, water, milk and drugs, as well as mineral and industrial compounds. Schools. The Kitchener Memorial School of Medicine at Khartoum provides a com- prehensive medical education along British lines and is said to rank favorably with simi- lar schools in the Middle East. Complete medical training includes a premedical course at Gordon Memorial College and two postgraduate years as house surgeon in one of the larger hospitals. Graduates of the school are eligible for a number of higher examinations of the Royal Colleges of Physicians and Surgeons of England and for certain higher diplomas of the Univer- sity of London. The School of Hygiene, subsidiary to the Kitchener Memorial School of Medicine, operates a 3-year course for the training of public health (sanitary) officers and shorter courses throughout the year for sanitary overseers. Schools for medical assistants are conducted in the hospitals at Omdurman in the north, and at Juba in the southern Sudan. A school for the training of midwives is located at Omdurman. Male nurses are trained in the Khartoum and the Omdur- man hospitals, and in several other institu- tions throughout the country. The only school for women nurses, however, is con- nected with the hospital in Omdurman. Provision is also made by the Ministry for the training of dispensers, assistant radiog- raphers, medical assistants and laboratory assistants. A veterinary school is connected with Gordon Memorial College. PrrsoNAL Physicians. According to estimates made in 1946, there were about 134 physicians in the Sudan, including the doctors connected with the government services and with mis- sion hospitals. A small number, probably not over 20, are engaged in private practice serving the Greek, the Egyptian and the Syrian communities. In 1950, 33 British and 83 Sudanese physicians were connected with the Ministry of Health. Dentists. As of 1946, there were reported to be only 11 dentists in the country. One dentist was employed in the medical services. Nurses. The roster of the Ministry for 1950 listed 30 British and 24 Sudanese nurses. Others. In the same year 429 midwives were registered in the Sudan, 9 of whom were on the government staff. The British personnel of the Ministry included an ento- mologist, 2 chemists and 3 doctors with training as bacteriologists or pathologists. There were numerous Sudanese medical as- sistants and other personnel. DISEASES The geographic and climatic conditions and the ethnic composition, customs and manner of living of the people differ mark- edly in the northern and southern Sudan. Correspondingly, the distribution of the various endemic and epidemic diseases is influenced by factors which vary in the diverse sections of the country. Hospital 36 Anglo-Egyptian Sudan and dispensary statistics give an incomplete picture of disease incidence, especially in the southern provinces where a large per- centage of the people lives beyond reach of the established medical facilities. Moreover, in the north fatalism frequently prevents individuals from seeking medical assistance in case of illness. Supplementary informa- tion is available for a few diseases, as schis- tosomiasis, yellow fever and leprosy, which have been the subject of special surveys. DiseASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or UriNARY TRACTS Dysenteries. Dysentery is prevalent in the Sudan where the insanitary habits of the people and the abundance of flies breeding in unprotected latrines and disposal sites are important factors facilitating its spread. From 2,000 to 4,000 cases of dysentery are treated in the government hospitals each year. About 10 to 15 per cent of the cases are reported as bacillary infections, a pro- portion which probably is not valid, due to the lack of facilities for bacteriologic diag- nosis in the smaller hospitals. Amebiasis is a presumptive diagnosis in many areas, and there appears to be a general tendency to classify all dysenteries as “amebic” without sufficient justification. Amebic dysentery is most frequent in the Port Sudan area, where in 1946 it accounted for 54 per cent of the total dysenteries reported. Amebiasis was re- sponsible for over 15 per cent of the hospital admissions in that province (Kassala). The incidence of bacillary dysentery cannot be estimated, since the recorded cases are not indicative of the extent of infection. Among 172 dysentery strains isolated at the Stack Medical Research Laboratories in 1946, 39 were identified as Shigella dysenteriae and 110 as S. paradysenteriae (Flexner). Schmitz, Sonne and Boyd strains are also encountered with some regularity. Typhoid and Paratyphoid Fevers. Ty- phoid occurs sporadically and in small lo- calized outbreaks in all parts of the country. Cases are most frequently reported from the urban centers and from localities along the main traffic routes. Omdurman is an established endemic focus. In the decade, 1937 to 1946, from 115 to 340 cases were treated in government hospitals each year. Typhoid infections predominate, but para- typhoid A is not uncommon in the northern Sudan. Paratyphoid B is also observed occa- sionally. Cholera. Cholera has not been reported from the Sudan since 1898, when the disease attacked the British troops during their march up the Nile from the Mediterranean. Persons embarking for Mecca are inoculated with cholera vaccine, and all returning pil- grims are examined at Suakin. During the cholera epidemic in Egypt in 1947 traffic from that country was subjected to strin- gent quarantine regulations. Helminthiases. ANcyLosToMIASIS. In the north, hookworm infection, known locally as “Egyptian chlorosis,” is said to be re- stricted to a few small foci in Northern Province. It is a serious problem in the south, however, especially in Bahr el Ghazal and Equatoria provinces. Juba, Kajo-Kaji, Rumbeck and Wau are the districts most affected. In 1944-46, an average of 6,490 cases was reported annually from the Sudan; 6,180 from these two provinces (then combined under Equatoria Province). As a precaution against the further spread of hookworm in the northern Sudan, labor- ers from Egypt are detained in quarantine at Wadi Halfa until examinations for ova are carried out. Infection is due to Ancylo- stoma duodenale. Scuistosom1asis. Schistosomiasis is en- demic along the Nile River in Northern Province, in Dueim and Kosti districts on the White Nile, in the Gezira region, in the Gedaref district of Kassala Province and in small areas in Darfur Province. It also occurs in the Juba district of Equatoria Province but is negligible in other portions of the southern Sudan. In the Northern Province, schistosomia- sis is due chiefly to Schistosoma haema- tobium. The infection rates, as ascertained Anglo-Egyptian Sudan 37 from the routine examinations of school- boys and of patients in the government hos- pitals and dispensaries during the 5-year period, 1943-47, averaged 18.4 per cent in Wadi Halfa district and 5.4 per cent in Dongola and Merowe districts. The highest incidence is noted from March to May when the Nile is low and pools favoring the propa- gation of snails are plentiful. Since there is little permanent irrigation in this area, con- trol measures center around the annual ex- amination and treatment of the population. Minor foci of S. mansoni exist along the upper reaches of the river and in the irri- gated area of Zeidab. : Both types of schistosomiasis are found in the White Nile reservoir and Gezira areas. The infection rates in the Dueim and Kosti districts in the former region aver- aged 8.7 per cent with S. Zaematobium and 1.1 per cent with S. mansoni among the indi- viduals examined in 1947. In the permanently irrigated areas of the Gezira, the spread of the infection is a mat- ter of considerable concern to the public health officials. Extensive surveys within re- cent years indicate a patchy distribution of both species. In 1945-47 the infection rates with S. haematobium ranged from 3 to 5.5 per cent among the children in different localities and from 1.2 to 2.0 per cent among the adults; with S. mansoni they ranged from 1.8 to 6.3 per cent among the children and from 1.4 to 3.0 per cent among the adults.** S. haematobium infections in the Sudan are relatively mild as compared with the disease in Egypt, but schistosomiasis due to S. mansoni ranks as one of the most serious diseases in the country. The Gezira district is continually exposed to infection by migratory cotton pickers from west Africa. Preventive measures em- ployed by the government for the eradica- tion of the various foci and for the protection of the Gezira include the exami- nation of the indigenous population and the treatment of cases, the cleaning of the canals and treatment with copper sulfate during the nonirrigation period from April H- Schistosoma haematobium M- Schistosoma mansoni Schistosomiasis in the Anglo-Egyptian Sudan to July, the safeguarding and the improve- ment of water supplies, the installation of village latrines and the removal of villages from infected sites. Migratory laborers from Egypt are detained for examination at Wadi Halfa, others at Dueim and Kosti. Bulinus truncatus is the principal interme- diate host of S. haematobium. Planorbis (Biomphalaria) alexandrina and P. (B.) alexandrina pfeifferi are intermediate hosts of S. mansoni. Oruer HELMINTH INFECTIONS. Ascaria- sis, trichuriasis and strongyloidiasis are rarely reported in the northern provinces, but they are prevalent throughout the south, especially among children. Echinococcosis is common in parts of Equatoria Province. Taenia saginata, the beef tapeworm, is found in the cattle-raising areas of the northern Sudan, but the pork tapeworm, T. solium, is not reported from this region. Hymenolepis nana infections are frequent. Other Infections. Brucellosis, caused by Brucella melitensis, is thought to be com- mon in the districts along the Ethiopian border. Sporadic cases are reported from other parts of the country, but they do not average over 20 to 70 a year. B. abortus infection is enzootic among the cattle in the 38 Anglo-Egyptian Sudan northern Sudan; human cases undoubtedly occur, but the incidence is not known. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread, predominantly in the northern prov- inces, but also in the remote villages of the south where the infection is said to be increasing slowly. Surveys among the Dinka tribes in Bahr el Ghazal Province, reported in 1935, suggest that the disease has been introduced into this region relatively re- cently. About one third of 5,100 individuals tested gave positive reactions with tuber- culin. In one survey in the Eastern District, the positive reactors among 3,662 persons tested totaled 7.5 per cent in children under 5 years of age, 19.6 per cent at 5 to 10 years, 36.1 per cent at 10 to 25 years and 50.7 per cent among adults over 25 years of age. In the six years, 1942-47, an average of 678 cases of pulmonary and 495 of nonpul- monary tuberculosis was admitted annually to government hospitals in the northern Sudan; 112 cases of pulmonary and 73 of nonpulmonary in the southern Sudan. Fa- cilities for diagnosis and treatment are inadequate, and recognized infections prob- ably represent but a small proportion of the total incidence. Bovine tuberculosis is rarely found in the Zebu cattle in the north but is present among the breeds raised in the southern provinces. Meningitis. Outbreaks of meningococcus meningitis occur at irregular intervals, usu- ally with the greatest frequency in the southern half of the country. Following a major epidemic in which over 13,000 cases were recorded in 1936, the incidence de- clined precipitously to a low level. It began to rise again in 1939, reaching peaks in 1940 and 1945 of 4,032 and 6,166 cases, respectively. Subsequently, it dropped to an annual average of 587 cases in 1946-47. The outbreaks are consistently seasonal; they start during the dry season and die out with the onset of the rains. They vary in severity, but the successful adoption of field treat- ment with sulfonamide drugs has resulted in a reduction of the fatality rates from 80 to 10 per cent. However, in many areas the fatality rates remain high, due largely to the tardiness of the people in seeking treatment. The quarantine of infected vil- lages and the evacuation of the inhabitants to individual, temporary shelters are among the control measures employed during se- vere outbreaks. Attempts to immunize the population with an antimeningococcus vac- cine have been abandoned by the health authorities. Smallpox. The Sudan is exposed continu- ally to the introduction of smallpox from Egypt by way of the traffic on the Nile, from West Africa through the agency of bands of pilgrims crossing the country to and from Mecca, and within recent years from Ethiopia and Eritrea. Sporadic out- breaks are reported from time to time, but epidemic spread has been prevented by means of extensive vaccination campaigns. It is estimated that 60 per cent, and in some areas 80 per cent, of the population have been effectively immunized. However, a considerable proportion of susceptible indi- viduals remains, particularly among the women and among the tribes in the remote districts of Darfur and Equatoria provinces. The disease is predominantly of the mild type (alastrim), but sporadic cases of malig- nant smallpox are recorded. From 1941 through 1944 the reported incidence did not exceed 250 cases a year. Not a single case was reported in 1945 or 1946, but in 1947 scattered epidemics developed along the major lines of communication in Kordofan, Blue Nile and Kassala provinces. Over 970 cases were reported, and the actual inci- dence was undoubtedly higher. Most of the cases were among the immigrant laborers settled in the area. Other Infections. Pneumonia is a major disease, ranking as the chief cause of death among hospital and dispensary patients. Outbreaks of influenza are reported occa- sionally. Anglo-Egyptian Sudan 39 Diphtheria occurs in sporadic outbreaks, usually in the towns or in areas in close communication with other countries. Since 1937, from 200 to 400 cases have been re- ported each year, primarily from the north- ern and the eastern provinces. Scarlet fever is rarely observed, but septic throat lesions are not uncommon. Measles is endemic, fre- quently giving rise to severe epidemics with a high mortality among the children. Chickenpox, mumps, poliomyelitis and whooping cough are also endemic. Diseases SPREAD OR CONTRACTED CuierLy TarouGH CONTACT Venereal Diseases. Venereal diseases are widely distributed throughout the Sudan. Syphilis is prevalent, particularly among the tribes of Darfur and Kordofan provinces. It has been estimated that, in a few districts, the infection rates are as high as 40 per cent. Gonorrhea predominates in the urban areas. Among the Sudanese, syphilis usually appears in a mild form, and it is claimed that the disease does not mate- rially influence the abortion rate. Gonorrhea is generally regarded as a more serious problem. Over 125,000 persons are treated for venereal infections in government hos- pitals and dispensaries each year. Chancroid is frequent; lymphogranuloma venereum and granuloma inguinale are also reported but are relatively rare. Prostitution is not regulated but in some towns is restricted to districts designated for that purpose. Leprosy. The prevalence of leprosy varies in different parts of the country. The dis- ease is comparatively rare in the northern Sudan, where it is found among the settled populations rather than among the nomadic tribes. However, it is widespread among the Negroid peoples of the south, especially in the districts along the southwestern border. The infection rates in this region probably range from 1 to 3 per cent. In a total of 8,602 known cases in 1947, over 80 per cent were located in Equatoria Province (now Bahr el Ghazal and Equatoria provinces), 14 per cent in Kordofan Province, and 3 per wm ola Wadi Haifa Leprosy in the Anglo-Egyptian Sudan cent in Blue Nile Province, while the re- mainder were scattered throughout the ter- ritory. In the northern Sudan, the lepers are allowed to remain at home under the super- vision of the public health authorities. In the south, the Ministry of Health has adopted the policy of segregation in leprosy settlements. Li Rangu, in the Azande coun- try, is the largest settlement in the Sudan. Smaller village settlements are established in other areas, and within recent years the facilities in Moru, Bari and Fung districts have been extended. In general, most leper settlements are built and maintained by the government but staffed by the mission or- ganizations. Of the 8,602 cases recorded in 1947, 1,321 were segregated in settlements. The British Empire Leprosy Relief Asso- ciation assists in the conduct of surveys and the supervision of new settlements. Yaws. Formerly, yaws was widely dis- tributed throughout the southern Sudan. However, as the result of an effective con- trol program it is now largely restricted to the more remote districts of Bahr el Ghazal and Equatoria provinces. Occasional cases are also reported from a few inaccessible foci in Darfur, Upper Nile, Blue Nile and Kordofan provinces. In 1947 a total of 40 Anglo-Egyptian Sudan 26,792 cases was treated in the government hospitals and dispensaries; 25,684 were na- tives of Equatoria Province (as then consti- tuted). Diseases of the Eyes. Trachoma, known locally as “Egyptian ophthalmia,” is wide- spread in the northern provinces. It is com- mon among the school children, the highest incidence and severest cases being found in the Koranic schools. In 1944 the prevalence of active trachoma in the Xhartoum schools was estimated at 40 per cent in the Koranic schools; 33 per cent in the elementary schools; 19 per cent in the inter- mediate schools; 9 per cent in the secondary schools; and 3 per cent in the higher schools.*” Some indication of the geographic distribution of the disease is afforded by the government hospital and dispensary statis- tics. Among over 183,380 cases treated in 1947, approximately 93 per cent were attrib- uted to Khartoum, Blue Nile, Northern and Kassala provinces. Trachoma accounted for almost one third of the total eye diseases treated. The Ministry of Health main- tains special facilities for the treatment of trachoma and its complications in districts where the infection predominates. It also operates an eye-hospital with 110 beds in Khartoum. Onchocerciasis, which is included under the term, “Sudan blindness,” is considered under the arthropod-borne infections. Diseases of the Skin. As in other tropi- cal countries, so-called tropical ulcers are of frequent occurrence, especially in Bahr el Ghazal and Equatoria provinces where such ulcers constitute one of the major causes of disability. Increased facilities for early treatment have reduced the incidence to some extent, Myiasis due to the infesta- tion of abrasions and other lesions of the skin with the maggots of various flies, par- ticularly Wohlfahrtia nuba and Cordylobia anthropophaga, is not unusual. Mycotic in- fections are prevalent. Madura foot is re- ported occasionally, the highest percentage of cases being from the Gezira district of Blue Nile province. The itch mite, Sarcoptes scabiei, is indigenous throughout the Sudan. Other Infections. Human rabies occurs sporadically, with from 3 to 18 deaths re- corded each year. Antirabic treatment is given in the government hospitals. Usually from 300 to 600 cases of dog bite are treated annually. Occasional cases of tetanus and anthrax are reported. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is one of the most im- portant diseases in the Sudan. The incidence varies markedly from year to year and in different parts of the country, being influ- enced by rainfall conditions, the rise and the fall of the Nile and its tributaries, and the extent of irrigation. North of the eight- eenth parallel the incidence of malaria is determined primarily by the Nile flood, and sporadic outbreaks coincide with the fall of the river from April to June. To the south and including the Khartoum area, two peaks are noted: in March and April, conform- ing to changes in the river levels, and from August to October, toward the end of the rainy season. In the central provinces, ma- laria follows the rainfall pattern, with out- breaks of greater or lesser intensity during and after the rainy season, usually from July to November. In the southern Sudan, malaria is present throughout the year, the incidence being greatest in the low marshy areas, and least on the Yei plateau and the Imatong Mountains in the extreme south. With the exception of small foci around Tokar and Suakin, the Red Sea littoral is not malarious. In general, Plasmodium falciparum pre- dominates and may account for 50 to 95 per cent of the total infections. P. vivax is encountered most frequently in the northern and the central provinces, while P. malariae occurs in localized foci, the most important of which are in the Berber and the Fung districts, in the region between the Zeraf and the Sobat rivers, and in the Mongalla area of Equatoria Province. Between 200,000 and 350,000 cases of malaria are reported annually, totals which probably Anglo-Egyptian Sudan 41 represent a small part of the true incidence. Extensive malaria control programs are carried on by the Ministry of Health in the urban centers and in the populous irrigated areas of the northern Sudan. In the highly endemic irrigated regions, as the Gezira, anopheline control may be supple- mented by specific-drug treatment and pro- phylaxis. Anopheles gambiae is the principal vector, but A. funestus is a significant vec- tor in many areas. Blackwater fever is not uncommon. From 5 to 30 cases are reported annually. It is usually recorded among the Europeans and the northern Sudanese, but may be observed among the peoples of the south. Relapsing Fever. Extensive epidemics of louse-borne relapsing fever have resulted within recent years. The disease apparently is not indigenous to the Sudan but was introduced from Egypt in 1908-24; from French West Africa in 1926; and from Ethiopia and Eritrea in 1936.2 In the period from 1937 to 1943 the reported inci- dence increased gradually from 374 to 10,505 cases a year, then rose precipitously to 22,672 cases in 1944, and 17,392 cases in 1945. Subsequently, the epidemics were brought under control through the wide- spread use of DDT powder as a deverminiz- ing agent. Cases are reported primarily from the irrigated area of the Gezira, and from Darfur, Kordofan and Kassala provinces along the major travel routes across the central Sudan. Outbreaks regularly occur between the latter part of the rainy season, in August or September, and the end of the cotton harvest in December. The highest incidence is encountered among the migra- tory laborers who maintain a lower standard of living than the Sudanese. In 1945 an extensive outbreak was reported for the first time among the primitive Shilluk peoples. Tick-borne relapsing fever has been re- corded occasionally from localities near the Uganda border. The vector, Ornithodorus moubata, is rare, even in the border dis- tricts. Yellow Fever. Only one case of yellow fever has been reported since the severe epidemic in the southern part of the Nuba Mountains (Kordofan) in 1940 in which over 15,000 cases were recognized, and in- fections totaling at least twice that number probably occurred.'* In this outbreak, re- ported to be the most extensive ever re- corded in Africa, the fatality rate was almost 10 per cent. By means of strenuous meas- ures, including quarantine, the immuniza- tion of potentially exposed persons and Aedes control, it was possible to localize and to stamp out the disease in this area. Since 1940 anti-Aedes measures have been extended throughout the Sudan, and ex- haustive yellow fever control studies have been undertaken by the government health authorities in collaboration with the Yellow Fever Institute at Entebbe in Uganda. On the basis of protection test surveys, the Sudan south of the line through El Fasher, El Obeid, Kosti, Sennar and east- ward to the Ethiopian border must be re- garded as an endemic area. Evidence de- rived from surveys in different regions since 1933 indicates an absence of immunity among the people in the northern section of the Nuba Mountains and at El Obeid. In certain villages to the south, however, a high percentage of immune sera has been found among the inhabitants. In the Fung area between the White Nile and the Blue Nile, high immune rates were discovered among adults in many localities, but there was no evidence of immunity in children un- der 16 years of age. In the vicinity of Mala- kal and in the Wau, the Juba and the south- eastern sections of Equatoria Province, pro- tection test surveys have demonstrated the presence of immunity not only in adults but also in children under 15 years of age. The discovery of a fatal case of yellow fever at Torit in 1942 suggests the possibility of a focus in the Imatong Mountains, compa- rable with that found in the Semliki forest in Uganda.?* Aedes aegypti is abundant during the rainy season. In the Nuba Mountains out- 42 Anglo-Egyptian Sudan Lo Wad! Halfa jomiesidy 6 El fasher N 2 Leishmaniasis in the Anglo-Egyptian Sudan break, however, A. vittatus and A. taylori were regarded as the principal vectors. Leishmaniasis. Kala-azar, caused by Leishmania donovani, is endemic in certain areas along the Eritrean and the Ethiopian borders and occasionally is reported from other widely distributed localities through- out the Sudan. The principal focus is found in Kassala and Fung districts, along the course of the Blue Nile and its tributaries and the upper sections of the Atbara River. In the vicinity of Melut, it may extend as far as the White Nile, since an outbreak was reported among the Dinka tribe in 1936-39. Minor foci exist in Kapoeta district, in the corner between Ethiopia, Kenya and Uganda, and in Darfur Province. Sporadic cases of dermal leishmaniasis are reported annually from the same endemic areas. The recorded incidence of all forms of leishmaniasis averages from 200 to 500 cases a year. Infections are seasonal, with the majority of cases occurring between July and October. Numerous species of Phlebotomus flies are present, including P. papatasii and P. orientalis, a potential vector of kala-azar in the districts on the Ethiopian border. Trypanosomiasis. Sleeping sickness, caused by Trypanosoma gambiense, is en- demic in the southwestern Sudan. From 1911, when the first epidemic was recorded, localized outbreaks have occurred at irregu- lar intervals. As the result of a systematic program, incorporating antitsetse-fly meas- ures, the resettlement of villages and the treatment of cases, the infection has been re- stricted to limited areas along the southern borders of Bahr el Ghazal and Equatoria provinces. Since 1942 the reported incidence has averaged from 30 to 95 cases a year. In certain regions where the people live in ac- cessible villages, periodic inspections are conducted by the chiefs with the assistance of the Ministry of Health laboratory staff. A pass system for residents of “infected areas” traveling between the Sudan and French Equatorial Africa and the Congo has been employed with considerable success. Filariasis. Infections with Wuchereria bancrofti are reported from isolated foci in the Nuba Mountains and in the southern provinces, west of longitude 30° E. and be- tween latitudes 4° and 6° N. Anopheles gambiae is said to be the most important vector. Elephantiasis and hydrocele are relatively rare. Filariasis due to Acantho- cheilonema perstans is widely distributed LI Wad: Halfa SE i | —-- 7 ( Human Trypanosomiasis in the Anglo-Egyptian Sudan in Equatoria and Bahr el Ghazal provinces, where species of Culicoides are responsible for its transmission. Loa loa is prevalent in the southwestern border districts. In some regions from 15 to 20 per cent of the popu- lation is affected.’* Chrysops distinctipennis is the usual vector, but other species of Chrysops may be implicated. Onchocerciasis is endemic in the Bahr el Ghazal region. Simulium damnosum is con- sidered the principal and probably the only vector. Field surveys in six different locali- ties in the southern Sudan, reported in 1947.21 showed a high incidence of micro- filariae in the skin among the persons exam- ined. In one focus, no onchocercal nodules were observed, but in the others they were demonstrated in from 3 to 46 per cent of the cases. Onchocerca volvulus infections are responsible for a high rate of endemic blindness in localized areas. In one place covered by the above surveys the incidence of blindness was 10 per cent, while in three it averaged between 4 and 5 per cent. Among 1,400 persons examined in two areas on the Sué River, nodules were found in 3.1 per cent and blindness in 0.48 per cent, while skin infection was evident in up to 77 per cent 52 Onchocerciasis in the Anglo-Egyptian Sudan Anglo-Egyptian Sudan 43 Rickettsial Infections. Louse-borne typhus fever is not considered endemic in the Sudan, although it exists in Egypt and Ethiopia. No authentic cases were recorded until 1943. During the epidemic of typhus in Egypt in 1943-44, 22 cases were reported from the Sudan: 17 from Wadi Halfa, 4 from Merowe and one from Khartoum. Rigorous control measures, including the supervision of traffic through Wadi Halfa, the detention and the delousing of all immi- grants and the systematic delousing of the town population at 20-day intervals were effective in controlling the spread of the infection. At that time DDT was not avail- able, but it is now used routinely by the quarantine service at Wadi Halfa. A few sporadic cases of apparent tick-borne typhus have been observed, namely, from the Gezira and Juba regions. The presence of murine typhus has been suspected, but not con- firmed, in localities on the Ethiopian border. Other Infections. Plague appears to be absent from this area, in spite of the fact that active foci have appeared within recent years in Egypt and Kenya. Precautionary measures against its introduction are en- forced at the Red Sea ports. Rat control is carried out, and travelers from endemic areas are detained in quarantine for suit- able periods. Sandfly fever and dengue fever are en- demic, and the vectors are widely distrib- uted. Cases of Rift Valley fever are ob- served occasionally in man. Infections with West Nile and other viruses have been recorded from the southern Sudan. Infection with the guinea worm, Dracun- culus medinensis, is endemic in Blue Nile, Bahr el Ghazal and Equatoria provinces, the Nuba Mountain region of Kordofan Province, the Gedaret area of Kassala Prov- ince and the Bor district of Upper Nile Province. From 2,500 to 3,000 cases are reported annually. NUTRITIONAL DISEASES Many of the tribes live at low subsistence levels, particularly at certain seasons of the 44 Anglo-Egyptian Sudan year. The most obvious deficiencies are in protein, in members of the vitamin B com- plex and in vitamin C. Scurvy is relatively common in areas where fruits and vege- tables are in short supply. Pellagra and pellagroid lesions are encountered among some of the grain-eating tribes in the north- ern Sudan. Diseases of the eye are prevalent, and it is possible that many are the result of a vitamin A deficiency. MisceLLANEOUS CONDITIONS Infectious hepatitis is endemic. The pres- ence of the infection was first recognized in 1944 when scattered outbreaks were re- ported from Equatoria and Kordofan prov- inces. A condition designated as “acute” rheumatism is frequent, and from 5,000 to 7,500 cases are treated in the hospitals and the dispensaries each year. SUMMARY The Anglo-Egyptian Sudan may be di- vided into two distinct regions, the northern and the southern, which differ in climatic conditions, in the ethnic and cultural back- ground of their populations and in the fac- tors influencing the health of the people. Essentially an agricultural and pastoral country, the urban population represents a very small percentage of the whole. The public health and medical services are ad- ministered by the Ministry of Health from the headquarters organization established in Khartoum. In 1950 the Ministry operated 40 hospitals with a combined capacity of 5,927 beds, and about 368 dispensaries in the rural areas. The provision of adequate water supplies represents a basic problem in areas at any distance from the Nile. The supplies of the larger towns are treated ade- quately, but most sources are apt to be contaminated. The methods of sewage dis- posal are primitive. The disease problems of the southern Sudan not only contrast sharply with those encountered in the north, but they are fre- quently more serious, due to the inaccessi- bility of many areas and the customary indifference of the inhabitants. Malaria, schistosomiasis and venereal diseases are major disease problems. Intestinal infec- tions, tuberculosis and pneumonia are prev- alent. Trachoma is widespread in the north. Louse-borne relapsing fever is occasionally epidemic, especially in the northern and the central provinces. Leprosy, yaws, ancylo- stomiasis and trypanosomiasis are of pri- mary importance in the southern Sudan. Yellow fever is endemic, but only rare cases have been reported since the epidemic in the Nuba Mountains in 1940. Localized out- breaks of smallpox and meningococcus meningitis are frequent. Leishmaniasis and filariasis have a limited distribution. Typhus fever is almost unknown except for a few cases of louse-borne infection on the Egyp- tian border in 1943-44 and isolated cases of apparent tick-borne infection. Plague has not been recorded from this area. BIBLIOGRAPHY 1. Archibald, Robert G., and Mansour, Has- seeb: Some observations on the epidemi- ology of kala-azar in the Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 30:395-406 (Jan.) 1937. 2. Atkey, O. F. H.: La bilharziose au Soudan anglo-egyptian, Bull. Office internat. d’hyg. pub. 22:662-666 (July-Aug.) 1940. : Distribution of leprosy in the Sudan, Internat. J. Leprosy 2:193-200 (April- July) 1934. 4. Bloss, J. F. E.: The Control of leprosy among the Azande, Anglo-Egyptian Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 39:423- 436 (Apr.) 1946. 5. ——: The Meridi outbreak of sleeping sick- ness, Tr. Roy. Soc. Trop. Med. & Hyg. 39:59-76 (Sept.) 1945. Bryant, J.: Endemic retino-choroiditis in the Anglo-Egyptian Sudan and its pos- sible relationship to Onchocerca volvu- lus, Tr. Roy. Soc. Trop. Med. & Hyg. 28: 523-532 (Mar.) 1935. 7. Buchanan, R. M.: A comparative study of o Anglo-Egyptian Sudan 45 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22 schistosomiasis in the Berber region of the Anglo-Egyptian Sudan, J. Helminthol. 15:183-202 (Dec.) 1937. Burrows, Sydney M.: A Tuberculosis Survey of the Dinkas in the Eastern District, Bahr-el-Ghazal Province—Southern Sudan. Studies of Tuberculosis Among African Natives. Tubercle Supplement, January, 16-30, 1935. . Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947. London, H. M. Stationery Office, 1948. Corkhill, N. L.: Malnutrition and snake poisoning in the Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 42:613-616 (May) 1949. ——: The poisonous wild cluster yam, Dioscorea dumentorum Pax, as a famine food in the Anglo-Egyptian Sudan, Ann. Trop. Med. 42:278-287 (Dec.) 1948. Pellagra in Sudanese millet-eaters, Lancet 1387-1390 (June 30) 1934. Davey, T. H.: Trypanosomiasis in British West Africa. London, H. M. Stationery Office, 1948. . Findlay, G. M., Kirk, R., and Lewis, D. J.: Yellow fever and the Anglo-Egyptian Sudan: The differential diagnosis of yellow fever, Ann. Trop. Med. 35:149-164 (Dec.) 1941. ——, Kirk, R., and MacCallum, F. O.: Yellow fever and the Anglo-Egyptian Sudan: Distribution of immune bodies to yellow fever, Ann. Trop. Med. 35:121- 139 (Dec.) 1941. Hamilton, J. A. de C.: The Anglo-Egyptian Sudan from Within. London, Faber and Faber, Ltd., 1935. Hewer, T. F.; Some observations on yaws and syphilis in the southern Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 27:593-608 (May) 1934. Hunt, A. R., and Bloss, J. F. E.: Tsetse fly control and sleeping sickness in the Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 39:43-58 (Sept.) 1945. Kirk, R.: An epidemic of yellow fever in the Nuba Mountains, Anglo-Egyptian Sudan, Ann. Trop. Med. 35:67-108 (Oct.) 1941. : The epidemiology of relapsing fever in the Anglo-Egyptian Sudan, Ann. Trop. Med. 33:125-140 (July) 1939. ——: Observations on onchocerciasis in the Bahr-el-Ghazal Province of the Sudan, Ann. Trop. Med. 41:357-364 (Dec.) 1947. : Some vegetable poisons of the Sudan, Sudan Notes and Records. 27:127-152, 1946. 23. 24. 23. 26. 27. 23. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. ——: Studies in leishmaniasis in the Anglo- Egyptian Sudan. V. Cutaneous and muco- cutaneous leishmaniasis, Tr. Roy. Soc. Trop. Med. & Hyg. 35:257-270 (Mar.) 1942. ——: Studies in leishmaniasis in the Anglo- Egyptian Sudan. I. Epidemiology and general considerations, Tr. Roy. Soc. Trop. Med. & Hyg. 32:533-544 (Jan.) 1939. ——, and Drew, C. B.: Preliminary notes on dermal leishmaniasis in the Anglo- Egyptian Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 32:265-270 (Aug.) 1938. Lewis, D. J.: The extermination of Anopheles gambiae in the Wadi Halfa area, Tr. Roy. Soc. Trop. Med. & Hyg. 42:393-402 (Jan.) 1949. : General observations on mosquitoes in relation to yellow fever in the Anglo- Egyptian Sudan, Bull. Entom. Res. 37: 543-566 (Mar.) 1947. Glossina tachinoides in northeast Africa, Bull. Entom. Res. 39:529-530 (Mar.) 1949. Mosquitoes in relation to yellow fever in the Nuba Mountains, Anglo- Egyptian Sudan, Ann. Trop. Med. 37: 65-76 (April) 1943. ——: The mosquitoes of the Jebel Auliya Reservoir on the White Nile, Bull. Entom. Res. 39:133-157 (May) 1948. : Observations on the distribution and taxonomy of Culicidae (Diptera) in the Sudan. Tr. Roy. Entom. Soc. 95:1-24 (June) 1945. Mabhaffy, A. F., Hughes, T. P., and Kirk, R.: The isolation of yellow fever virus in the Anglo-Egyptian Sudan, Ann. Trop. Med. 35:141-148 (Dec. 31) 1941. Mabhaffy, A. F., Smithburn, K. C., and Kirk, R.: The isolation of yellow fever virus in the Anglo-Egyptian Sudan, Ann. Trop. Med. 35:141-148 (Dec.) 1941. Mabhaffy, A. F., Smithburn, K. C., and Hughes, T. P.: The distribution of im- munity to yellow fever in central and east Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. Maurice, Major G. K.: The history of sleeping sickness in the Sudan, J. Roy. Army M. Corps. 55:161-174 (Sept.); 241- 259 (Oct.) 1930. Muir, E.: Leprosy in East Africa, Internat. J. Leprosy 7:383-394 (July-Sept.) 1939. ——: Leprosy in the Southern Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 31:107-110 (June) 1937. Pratt, E. P., Drysdale, A. D., and Kirk, R.: Typhus fevers in the Anglo-Egyptian 46 Anglo-Egyptian Sudan 39. 40. 41. 42. 43. 44. 45. Sudan, J. Trop. Med. & Hyg. 52:157-160 (Aug.) 1949. Stephenson, R. W.: Bilharziasis in the Gezira irrigated area of the Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 40:479-494 (Mar.) 1947. ——: An epidemic of kala-azar in the Upper Nile Province of the Anglo-Egyptian Sudan, Ann. Trop. Med. 34:175-179 (Sept.) 1940. Sudan Government: Report on the Ad- ministration of the Sudan in 1947. Fur- nished by the Governor-General to his Britannic Majesty's Government in the United Kingdom and to the Royal Egyp- tian Government. Khartoum, McCorquo- dale and Co., Ltd., 1949. ——: Report of the Sudan Medical Service for the Year 1939. Khartoum, McCorquo- dale and Co., Ltd. ——: Report of the Sudan Medical Service for the Year 1940. Khartoum, McCorquo- dale and Co., Ltd. ——: Report of the Sudan Medical Service for the Year 1941. Khartoum, McCorquo- dale and Co., Ltd. ——: Report of the Sudan Medical Service 46. 47. 48. 49, 50. 3%. 52. 53. 54. for the Year 1942. Khartoum, McCorquo- dale and Co., Ltd. : Report of the Sudan Medical Service for the Year 1943. Khartoum, McCorquo- dale and Co., Ltd. ——: Report of the Sudan Medical Service for the Year 1944. Khartoum, McCorquo- dale and Co., Ltd. : Report of the Sudan Medical Service for the Year 1945. Khartoum, McCorquo- dale and Co., Ltd. : Report of the Sudan Medical Service for the Year 1946. Khartoum, McCorquo- dale and Co., Ltd. : Report of the Sudan Medical Service for the Year 1947. Khartoum, McCorquo- dale and Co., Ltd. ——: The Sudan. A Record of Progress, 1898-1947. Woodman, Hugh M.: Filaria in the Anglo- Egyptian Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 42:543-558 (May) 1949. ——: Filariasis in the southern Sudan, East African M. J. 25:95-104 (Feb.) 1948. ——, and Bokhari, Ahmed: Studies on Loa loa and the first report of Wuchereria ban- crofti in the Sudan, Tr. Roy. Soc. Trop. Med. & Hyg. 35:77-92 (Sept.) 1941. a a a a aes GG >< PG GOGO SECTION TWO The Ethiopian Highlands 5: Brrrswa 0, 10, Baird a nt, on dah ni a nena SR Se eid 0 ET aomIoOPIA. 0, aE, Ta te BE TE Se Ra OT 3 BorrSHaSOMATILAND: Jc LLL aE Bas RE A TS GO. "EerNcH SOMATILAND: lL hth eenfhs nal ee TE SASS 7. SoMALIA . 92 odafui FR. SOMALILAND ¢&/7 Tra TESH: ; X ~~ Ns The Ethiopian Highlands Eritrea GEOGRAPHY AND CLIMATE Eritrea, an Italian colony for almost half a century, is located on the southern shores of the Red Sea and is bounded inland by the Anglo-Egyptian Sudan, Ethiopia and French Somaliland. From 1936 to 1941 it formed an integral part of Italian East Africa, and its territory was enlarged to in- clude the Ethiopian province of Tigrai. The original frontiers were restored in 1941, and since that date the country has been admin- istered by British authorities, pending a decision as to its ultimate destiny. Eritrea may be divided geographically into two distinct portions, the fan-shaped colony proper and the narrow corridor of mountainous Danakil country which skirts the Red Sea from the Buri peninsula to the Somaliland border. It has an approximate area of 48,000 square miles, including the coastal islands and the Dahlak archipelago, which protects the harbor of Massawa. A narrow coastal plain varying from 10 to 40 miles in width extends along the entire 670 miles of Red Sea coast, except in a narrow sector south of Massawa where the moun- tains come close to the sea. The south-cen- tral portion of the territory forms an inner triangle which is contiguous with the Tigrai highlands and part of the great Ethiopian plateau. Rising from the coastal plain in steep escarpments, the plateau has an aver- age altitude of 6,500 to 7,000 feet and is characterized by deep rifts and fertile, well- watered valleys and plains. North of Keren, it gives way to irregular hill country which is bisected by the Anseba and the Barca river valleys. Toward the north and the 49 west the plateau sinks in sloping terraces and undulating plains which stretch toward the Sudan. They comprise at least one third of the country and provide indifferent pas- turage with stretches of arable land along the water courses. The eastern slopes and the sector between the Bahr Setit and the Gash rivers are well wooded, but the Danakil country is largely mountainous waste. Innumerable streams traverse the mountains and the plateaus, which are dry nine tenths of the year but become cascad- ing torrents during the rainy season. The Bahr Setit, on the southwestern border, is a tributary of the Atbara, which feeds into the Nile. The climate varies greatly in different sections of the country, depending upon the topography and the distance from the sea. However, it conforms roughly to three gen- eral types characteristic of the maritime zone, the plateau and the plains extending toward the Sudan. The coast is hot and humid. The mean temperature at Massawa approximates 86° F., but readings of 120° F. are not infrequent during the summer. The average maximum temperature is 104° F., and the average minimum, 77° F. Unlike the plateau where the most abundant rains occur during the summer, the rainfall on the coast is confined to a limited period during the winter months. The annual rain- fall at Massawa rarely exceeds 8 to 10 inches and frequently is appreciably less. The slopes of the eastern escarpment form a transitional zone in which summer rains and heavy winter fogs combine to yield an aggregate rainfall of 30 to 40 inches a year. The south central plateau region enjoys a 50 Eritrea healthy and moderate climate, with little seasonal change in temperature. The yearly mean temperatures for both the plateau and the hill country are about 67° F. to 70.5° F. in May and 63.5° F. in December. At Asmara, the average maximum tempera- ture is 77° F., and the average minimum, 46° F. The main rains, which total 16 to 24 inches a year, occur between June and September, while lesser rains, approximat- ing 2 to 5 inches, may be experienced in February and March. In general, the rain- fall decreases toward the north and the west. On the western plains the total pre- cipitation averages only 12 to 14 inches, while the spring rains are usually negligible. The mean yearly temperature is in the neighborhood of 80.5° F. to 89.5° F. in May and 70° F. in January. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTion In 1946 the population of Eritrea was estimated at 1,019,000, including about 22,000 Italians and 16,000 of other na- tionalities. In spite of persistent efforts to promote colonization, the proportion of Italian settlers remained relatively small until 1934-35 when Eritrea became the base for the conquest of Ethiopia. Within a brief period the non-native population increased tremendously. At the time of the British occupation in 1941, the Italian population totaled 55,000, but since then has been re- duced by repatriation. Limited numbers of Arabs, Indians, Jews and Greeks are found in Asmara, Massawa and the larger towns, where they generally live in compact com- munities. The majority of Eritreans are of Hamito- Semitic origin and may be divided into two groups: the Coptic Tigrinya-speaking peo- ple of the south-central plateau, racially and culturally related to the Ethiopians, and the Tigre-speaking inhabitants of the north- ern hill country and the plains. The Bani Amir tribes in the west and the northwest constitute the largest division of the latter group. All are Moslems, while many adhere to a strict caste system which involves un- solved master-and-serf problems. In addi- tion, several unrelated peoples are settled in limited areas. The Rashaida, a nomadic tribe and the only pure Arabic community outside of the urban areas, are located on the Sahil coast near Das Kasar. Numerous Negroid tribes of Nilotic origin have become established in the settled areas of south- western Eritrea. Representative among them are the pagan Kunama and the Baria, who have accepted Islam. The natives of the Danakil coast, only part of which is in- cluded within the political boundaries of Eritrea, are closely related to the Somalis, but employ their own Afar language. Swedish and Catholic missions have been active in the country for many years and claim approximately 50,000 converts, as against almost 500,000 each of Copts and Moslems and an indefinite number of pagans. In addition to the various native languages, Arabic is used extensively in the settlements along the coast and elsewhere by the traders and the tribal chiefs. The highland plateau is the most densely settled and homogeneous section of the country. It comprises less than one quarter of the total land area but contains over one half of the population. In other areas the villages are scattered, and a large propor- tion of the inhabitants leads a seminomadic pastoral life. Asmara, in the center of the highlands, is the capital and the largest city. In 1949 it had a population of 126,000, in- cluding approximately 40,000 Europeans. Massawa, the leading port, had a popula- tion of 26,000. The education of the Eritreans has been retarded to a serious extent, and as of 1949 probably less than 30 per cent were literate. Recently, the British administrations have attempted to promote education through village schools with instruction in Tigrinya Eritrea 51 or Arabic, according to the racial complex of the area. Intermediate classes have also been started in Asmara and Keren. A few schools are operated by private or mission groups, while education at undergraduate levels is provided for Italians and other na- tionalities in church and subsidized com- munity schools. VITAL STATISTICS No valid statistics are available for Eritrea. The reporting of births and deaths is required for European residents and for Eritreans residing in the municipalities. Reporting is incomplete; moreover, the population is not stable. Figures for the European populations are reasonably accu- rate, but in view of the fact that the ma- jority are Italians who took up residence in 1934-36 and have stayed under abnormal conditions, they are of little significance in evaluating present health conditions. SociaL Economy The economic status of the average Eritrean is low. Except for a relatively small contingent in the larger cities, the population is predominantly rural. Agricul- ture is practiced in all parts of the country except along the coast and in the more arid stretches of the north and the northwest. Conforming to the mountainous nature of the terrain, the holdings are small, and the methods of cultivation are primitive. Irri- gation is not employed except in the valleys of the Gash and the Barca rivers. In the highlands most of the cultivated land is held by the villages as communal property, and permanent tenure through family ownership occurs only in rare instances. Frequently, this system of communal holdings has miti- gated against the introduction of improve- ments and the best utilization of the land. The easily irrigated areas of the Agordat- Tessenei plain are extensively cultivated and generally more productive than the highlands. Most of the larger farms are Italian-owned concessions. Grains, vege- table fibers, coffee, tobacco, cotton and fruits are the chief agricultural products. The rocky slopes of the highlands and the plains of the north and the west are inhabited by pastoral tribes, representing about one third of the total population. While some, located along the water courses, are seminomadic and cultivate small patches during the rainy or flood seasons, the majority engage only in the raising of sheep, goats, cattle and camels. Livestock and hides are exported. The mineral wealth of Eritrea was par- tially exploited by monopolistic companies subsidized by the former Italian govern- ment. It contributes little to the total econ- omy, however, since the majority of ore deposits are inaccessible and of poor grade. Salt is the only important product. Exten- sive salt pans exist in the interior of the Danakil country and on the Buri penin- sula, while factories for the manufacture of salt from sea water are established at Massawa and Assab. Industry, which under the Fascist government was developed pri- marily for the purpose of aiding the war with Ethiopia, is in an unsettled transitional state, but some raw materials are processed for local consumption and for export. An excellent system of motor highways connects Eritrea with Ethiopia and the Sudan. Arterial routes through Gondar and Dessie link Asmara and Addis Ababa. Main highways also run from Agordat to Kassala, and from Keren and Assab into Ethiopia, while secondary roads or camel and mule paths connect the smaller towns. A govern- ment-owned railway links Asmara, Keren and Agordat with the port of Massawa. Since 1941 a spur of the Sudan Railway has been constructed from Malawiya, southwest of Kassala, to Tessenei. Thus the short dis- tance from Tessenei to Agordat is the only gap in the rail route between Khartoum and Massawa, between the Nile and the Red Sea. In addition, a cableway, the longest in the world, connects Massawa and Asmara. Massawa has an excellent harbor and is an 52 Eritrea old, established port of call for steamer traffic. Airfields are available at Asmara and at Assab on the Danakil coast. Foop AND NUTRITION Eritrea does not produce enough food to meet the needs of the population, but large amounts of grain are imported from the neighboring countries of Ethiopia and the Anglo-Egyptian Sudan. Food shortages are frequent, and malnutrition and vitamin de- ficiencies are widespread. The major food crop is grain; millets, both dura (Andro- pogon sorghum) and taff (Eragrostis abys- sinica), maize and small amounts of barley and wheat are cultivated. The breads and the porridges which make up a large part of the diet of most Eritreans are usually supplemented by peas, beans and various other vegetables. Red peppers, used as an ingredient of sauces, are a major source of vitamin C. Adequate green vegetables and fruits are rarely available to the poorer classes. Sheep, goats and cattle are raised, but meat constitutes a small part of the average diet. Fish are obtainable on the coast. Milk is consumed, but the indigenous cattle are poor milkers, and the supplies of milk and dairy products are uncertain. Butter is prized more as a cosmetic than as a food. Nutritional deficiencies are particularly prevalent among the nomadic tribes which subsist almost wholly on grain and milk products. Housine Modern stone, concrete and brick dwell- ings are found in the cities with large Euro- pean communities. Serious housing prob- lems, necessitating the erection of numerous temporary structures, accompanied the rapid growth of the urban populations under the stimulus of preparation for war with Ethiopia in 1934-36. The situation has been relieved within recent years by the re- patriation of almost two thirds of the Italian residents and by the construction of new buildings, but overcrowding prevails in many areas. Two types of dwellings are common in the rural villages ; the ordinary African hut of stone or mud with a thatched roof, and a two-room triangular structure of stone, with a dirt roof supported by rows of pillars. The majority serve both as home and stable. The nomadic herdsmen live in primitive huts made by covering a wooden frame with mats or blankets. Whether in settled or nomadic communities, the average Eritrean lives under crowded and insanitary condi- tions which are conducive to the spread of disease. ENVIRONMENT AND SANITATION WATER SUPPLIES Streams, catchment areas and shallow wells constitute the principal sources of water supply in Eritrea. The majority show some degree of pollution. Asmara has a municipal supply which is adequate under favorable conditions. Ap- proximately two thirds is derived from arti- ficial lakes, and the remainder from wells or underground galleries at Sembel, Godaif and Mai Coiet. The main supply is treated by filtration and chlorination and is pumped to a reservoir at Valle Gnecchi. The Sembel and the Godaif sources are filtered and chlorinated at the Godaif pumping station, but that from the Mai Coiet galleries is treated by chlorination only. The municipal water supply is distributed to twelve com- munity outlets, and from there to service cisterns or tanks in the better class of houses. Water is also distributed by water carts from a borehole source outside of the main system. A subsidiary supply from the Acria Lakes may be used for the fountains in the native village during the rainy season. The water for Massawa is piped from a dual source at Dongali, 11 to 12 miles west of the city: a perforated pipe sunk 15 feet below the surface in the bed of the Eritrea 53 Khor Agala at Old Dongali and three interconnected wells in the riverbed at New Dongali, one mile upstream. The two sup- plies are joined just outside of the city and flow by gravity to the town wells. Small underground service tanks are installed in many of the buildings in the European quarter. A supplementary supply for ice manufacture and for drinking purposes is obtained by the distillation of sea water. Water for use on the land is piped from a well at Moncullo, but this source is too highly mineralized for human consumption. WASTE DisposaAL The methods of sewage disposal are gen- erally primitive. In many towns, the better- class dwellings have septic tanks or cess- pools; latrines are found in other areas. Limited sewerage systems exist in Massawa and Asmara. In Massawa the system serves most of the European section and has an outlet on the beach where the sewage is washed out to sea. The buildings in part of the city of Asmara are connected with a sewer main from which the sewage is discharged over the mountainside about five miles from the city. Many of the houses and buildings in the remainder of the city have individual cesspools. However, in both urban and rural areas the natives commonly defecate on the ground in a convenient sandy spot. Fauna anp FrorA Arthropods. Mosquitoes. At least 14 different species of Anopheles are found in Eritrea. The most important local vector of malaria is 4. gambiae, which breeds in sunlit collections of clear or muddy water, such as the borrow pits, puddles, animal footprints and other accumulations of water found abundantly during and after the rainy season. A. cinereus, A. funestus, A. coustani and A. rhodesiensis are present in limited numbers and may have some significance as potential vectors. Nine or more species of Aedes are re- ported. A. aegypti, A. aegypti queenslan- densis, A. vittatus, A. luteocephalus, and A. simpsoni lilii occur and may be potential vectors of yellow fever. A. aegypti is also an important vector of dengue fever. A. aegypti breeds prolifically in the earthen- ware jars and tins which are used by the natives for the collection of rain water. Recently it has been collected at an altitude of 2,400 meters.%? Numerous species of Culex mosquitoes, as well as T'heobaldia longiareolata, Urano- taenia mashonaenis and Taeniorhynchus (Mansonia) uniformis have been identified. Mosquito-control measures, such as drainage and the antilarval treatment of standing water, are carried on in Asmara, Massawa, Decamere and parts of the Ac- chele Guzai plain. Recently Aedes control has been intensified in Massawa and As- mara. House-to-house inspections were or- ganized in Massawa and in the surrounding villages in 1942, and in 1948 the average monthly index was 0.007. Fries. Flies are abundant, and a variety of species are reported. Species which may be implicated in the mechanical transmis- sion of micro-organisms causing cutaneous or intestinal infections include Musca domestica, Stomoxys calcitrans, Calliphora vomitoria, Lucilia caesar, L. macellaria, and Dermatobia nuxialis. Cordylobia anthropo- phaga is sometimes responsible for cases of human myiasis. Other myiasis-producing species are Sarcophaga carnaria, Gastero- philus equi and Hypoderma bovis. Phle- botomus papatasii and P. africanus are known to be present. Lice. The body louse, Pediculus humanus corporis, and the head louse, P. humanus capitis, are common, especially in the high- land areas. Freas. The human flea, Pulex irritans, the dog flea, Ctenocephalides canis, and the rat fleas, Xenopsylla cheopis and Nosopsyl- lus fasciatus, are specifically reported from Eritrea. Others may be present. The chigoe flea, Tunga penetrans, is widespread. Ticks aNp Mites. Ornithodorus moubata and O. savignyi are indigenous on the west- 54 Eritrea ern plains, where they are potential vectors of tick-borne relapsing fever. Rhipicephalus sanguineus, R. appendiculatus, R. simus, R. pulchellus, Amblyomma variegatum Boophilus decoloratus and Argas persicus are widely distributed. The former species are the probable vectors of tick-borne typhus fever. The itch mite, Sarcoptes scabiei, is found in all parts of the country. Scorpions. Venomous scorpions of the genera Buthus, Parabuthus and Pandinus are common. The most prevalent species are possibly Pandinus magrettii and Parabuthus liosoma abyssinicus. Reptiles. Vipers of the species FEchis carinatus, Bitis arietans, Atractaspis irregu- laris and A. magrettii are numerous. The spitting cobra, Naja nigricollis, and the Egyptian cobra, Naja haje, are also present. The mamba, Dendroaspis antinorii, is occa- sionally reported but is relatively unimpor- tant in this area. Rodents. Rattus rattus rattus and pos- sibly other subspecies of R. rattus are widely distributed. The brown rat, R. nor- vegicus, has not been found in surveys in Massawa, and no evidence is available of its presence elsewhere. Numerous varieties of wild rodents occur. Mollusks.* Planorbis (Biomphalaria) alexandrina pfeifferi is found in fresh-water pools in the highlands. It is the probable intermediate host of Schistosoma mansoni which is endemic in a few limited foci. Foop SANITATION Sanitary regulations governing the sale and the production of foodstuffs are en- forced only in the township areas. The sani- tary supervision of food and water supplies, and the inspection of markets and food establishments is undertaken by the health authorities. Controls are imposed on the collection and the distribution of milk, and on the manufacture of dairy products such as butter and cheese. Pasteurization plants * See footnote, p. 10. exist in Asmara and Keren. In 1943 it was estimated that two thirds of the milk offered for sale was pasteurized. Cold storage facili- ties are available in Asmara and Gura. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS Since 1941 the public health services in Eritrea have been operated by the Medical Department, a division of the British Mili- tary Administration up to 1949 and sub- sequently of the British Administration. Before 1941, Eritrea was under the juris- diction of the Italian Ministry for East Africa, and health matters in the colony were the responsibility of the local Inspec- torate of Health. The Military Administra- tion retained Italian public health legisla- tion and utilized the established health organization as extensively as possible. The work of the Medical Department in most areas is carried on by Italian and Eritrean personnel under the supervision of a skele- ton staff of British medical officers. The headquarters, still designated as the Inspec- torate of Health, is located at Asmara. Medical officers are in charge of the medical and health activities in each of the six prov- inces and constituent districts of the coun- try. Municipal health organizations exist in the cities of Asmara, Massawa, Adi Ugri and Decamere, which in Asmara and Massawa are supervised directly by the regional officers. A child welfare program was initiated by the Medical Department in 1942, but the following year the work was taken over by the newly organized Eritrean Children’s Welfare Society. However, the Department furnishes medical supplies and the services of Italian doctors. In 1949 child welfare and antenatal clinics were in operation in Asmara, Massawa, Assab, Adi Ugri, Adi Caieh, Keren and Decamere. A branch of the Italian Red Cross Society carries on work among the European communities. Eritrea 55 MebpicAL INSTITUTIONS Hospitals and Dispensaries. In 1949 the Chief Administrator of the British Ad- ministration reported that there were 8 hos- pitals, providing 417 beds for Europeans and 1,447 beds for Eritreans, and 105 dis- pensaries in operation throughout the coun- try. The hospital in Asmara has 750 beds and is divided into European and native sections. The civilian hospital at Massawa has about 32 beds for Europeans and 200 for Eritreans. Laboratories. A central public health laboratory which serves the entire country is located at Asmara. It has facilities for the conduct of routine bacteriologic, serologic, pathologic and biochemical examinations and for research. A Sero-Vaccine Institute is established at Asmara. It prepares all the vaccines and serums used by the veterinary and medical authorities in Eritrea and, in addition, exports smallpox vaccine. Clinical laboratories are connected with the larger hospitals. Schools. A small medical school for Italians has functioned in Asmara since 1941. It offers a 5-year course and has from 17 to 24 students. The examinations for diplomas in medicine and surgery are given in Rome. Courses are conducted at the Asmara hospital for the training of male and female nurses and of midwives, both European and native. PERSONNEL Physicians. In 1949 six British and 50 Italian doctors were employed in the gov- ernmental medical and health services. Nurses. Many of the Italian nurses in the Eritrean hospitals are affiliated with religious orders. In 1949 three British nurs- ing sisters were connected with the training school of the Asmara hospital. Small num- bers of locally trained nurses, both Italian and Eritrean, are also available. Others. The Medical Department em- ployed one British and six Sudanese public health inspectors in 1949. Medical assist- ants in various categories are included among the subordinate Italian and Eritrean personnel. DISEASES Available statistics give a wholly inade- quate picture of disease incidence in Eritrea. The hospital and dispensary reports are rea- sonably reliable, but comparisons of morbid- ity statistics compiled under different re- gimes are subject to obvious errors. The extent of specific infections among the rural and nomadic tribes is a matter of conjecture in most instances. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fevers are endemic. Cases occur sporadically and in small localized out- breaks, particularly in the urban areas. From 10 to 300 cases are treated in the hospitals and dispensaries each year. In the event of an outbreak free immunization with typhoid-paratyphoid vaccine is pro- vided by the health authorities. The accept- ance of this procedure by the Eritreans is demonstrated by the fact that over 10,150 persons were immunized in connection with a small outbreak in Hamasien Province in 1948. Paratyphoid A infections are seen occa- sionally, but the relative incidence of the different types of paratyphoid fevers is not known. Dysenteries. Both amebic and bacillary dysentery are common. Bacillary dysentery appears to be most frequent in the winter months. The majority of infections are due to organisms of the Flexner type, but Shiga strains are also encountered. The infection rates for amebiasis are estimated at 8 to 30 per cent in different parts of the country. The disease is prevalent in the neighborhood of Asmara and Agordat but relatively rare in the western lowlands. From 1947 to 1949, 56 Eritrea from 8 to 147 cases of bacillary dysentery and from 423 to 1,355 of amebic dysentery were reported annually. However, the ob- served cases are not a true index of infec- tion, as a large percentage never come to the attention of the medical officers. Diarrhea and enteritis are taken as a matter of course by the native populations. The insanitary habits of the people and the prevalence of flies contribute to the spread of intestinal infections. Helminthiases. ANcyrLosToMmIasis. Hook- worm infection has become established within recent years in the rural highland districts. Apparently it is widely distrib- uted, and infection rates of 10 to 20 per cent are recorded from many villages. The ma- jority of cases are caused by Necator americanus. Ancylostoma duodenale is rare but was encountered in one village in 1944.28 Scuistosom1asts. Schistosomiasis, caused by Schistosoma mansoni, is endemic, par- ticularly in the region between Asmara, Saganeiti and Adi Ugri. The existence of other foci in the highland districts is sus- pected, but the eastern and the western lowlands are apparently free from infection. The disease was first described in 1934,%® when infection was traced to Dadda Falls north of Asmara. Planorbis (Biomphalaria) alexandrina pfeifferi has been found natu- rally infected in pools in edemic areas. OtHER HELMINTH INFECTIONS. Ascariasis and other round worm infections are preva- lent. Taeniasis, caused by T'aenia saginata, is widespread. The incidence among the native cattle is high, and human infections are frequent. Echinococcosis is sporadic. Brucellosis. Undulant fever is common. Brucella melitensis is endemic among the goats, the cattle and other livestock. Human infections are frequent and occasionally severe. The fatality rates average between 9 and 10 per cent but may be influenced by the presence of intercurrent infections. The known cases are usually urban and result from the consumption of milk or cheese. B. abortus is not reported. Cholera. Cholera has not been reported since 1891, when it occurred in the Setit River region. However, there is always dan- ger of its introduction by way of pilgrims entering from Mecca. All Eritrean pilgrims are immunized with cholera vaccine before leaving the country. Diseases SprEap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Reports indicate that tu- berculosis was relatively rare in Eritrea prior to 1910, and that the incidence has increased steadily since the return of the native troops from Libya during the 1920’s. The present infection rates are not known. The number of cases treated in the hos- pitals and the dispensaries rose from 218 in 1947 to 904 in 1949, but some of this increase must be attributed to a greater willingness on the part of the Eritreans to seek treatment. Although pulmonary cases predominate, a high percentage of nonpul- monary infections is observed among the indigenous populations. The disease usually follows a rapid course. On the basis of tuberculin survey in Asmara, reported in 194926 it was estimated that approximately 40 per cent of local Eritreans gave a posi- tive reaction to tuberculin. The highest per- centages of positive reactions were obtained in the urban centers ; they are reputed to be higher in Massawa than in Asmara. The amount of infection of bovine origin is probably slight. The native cattle, par- ticularly the highland breeds, are relatively resistant to infection. Meningitis. Localized outbreaks of meningococcus meningitis occur sporadi- cally. Scattered epidemic foci flare up at irregular intervals, with an average inci- dence of 5 to 150 cases a year. Cases are most frequently reported between February and April. Smallpox. Immunity against smallpox is maintained at a fairly high level among the Eritrean population by the use of wide- spread vaccination, but occasional cases are reported. In 1948 the infection was intro- duced from Ethiopia. A total of 8 cases was Eritrea 57 recorded, while others probably existed. The Ethiopian border along the Setit River was closed to traffic, with the exception of Om Hagger, and travel in the western provinces was prohibited without valid evidence of vaccination. An extensive vaccination cam- paign was also carried on throughout the affected area. Diphtheria. Diphtheria occurs sporadi- cally, most frequently among the European children. Although clinical diphtheria is relatively uncommon among the Eritreans, Schick tests on representative groups of children from six months to ten years of age, in 19347 revealed a high degree of specific immunity. Approximately 13 per cent of 2,437 children tested in Asmara gave a positive reaction, and from 2.7 to 7.6 per cent of 871 children in different racial groups in Massawa. Other Infections. Influenza and pneu- monia are prevalent. Whooping cough and measles are frequently epidemic, while pol- iomyelitis and scarlet fever are reported sporadically. Cases of bronchopulmonary spirochetosis are encountered occasionally. Diseases SPREAD OR CONTRACTED CuierLy TaroucH CONTACT Venereal Diseases. Syphilis, gonorrhea, lymphogranuloma venereum and soft chancre are prevalent, and a large percent- age of the indigenous population is reported to be infected. Syphilis is the most frequent disease of this group among the Eritreans, while gonorrhea ranks first among the Italians. Although the hospital and dispen- sary statistics are not indicative of actual incidence, they may suggest the probable proportionate distribution of these diseases. In the three years, 1947-49, an average of 7,920 persons was treated annually for syphilis, 3,530 for gonorrhea, 1,566 for soft chancre and 189 for lymphogranuloma venereum. Diseases of the Eyes. Trachoma is wide- spread among the Eritreans, particularly on the high tableland and on the descending slopes near Asmara. The largest focus is in the Mareb River basin. The percentage of infection in Hamasien Province has dimin- ished within recent years, but there are still many villages in the vicinity of Asmara in which practically all of the inhabitants are affected. Probably 40 to 70 per cent of the total eye infections treated in the hospitals and clinics may be attributed to trachoma. From 4,000 to 6,500 cases are recorded each year. Many are mild, but blindness is not uncommon. Outbreaks of infectious conjunctivitis are frequent. The crowded and insanitary con- ditions under which the people live, together with the climatic factors, favor the spread of eye diseases. Leprosy. Leprosy is endemic, but the extent of infection is not known. In the course of an incomplete survey among the non-nomadic tribes in 1931,%° only 559 cases were discovered, but the actual incidence was probably several times that number. Within recent years, from 4 to 32 new cases have been reported annually. Diseases of the Skin. Mycotic infec- tions, including tineas and other dermato- mycoses are prevalent. Tropical ulcers are one of the principal causes of disability among the indigenous workers. Myiasis, produced by the larvae of Cordylobia an- thropophagia and other flies, is encountered occasionally. Scabies is widely distributed. Other Infections. Yaws is relatively rare. A few cases have been reported, but all are thought to have been exogenous in origin. Rabies is enzootic among the local dogs, and sporadic outbreaks occur. The region around Asmara is the major focus, and a sharp outbreak was reported from this prov- ince in 1948-49. From 900 to 2,000 persons are treated annually with antirabies vaccine prepared at the Sero-Vaccine Institute in Asmara. Nevertheless, a few cases of hydro- phobia are recorded each year. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is prevalent, particu- larly in the foothill areas and on the coastal 58 Eritrea and western plains. The season and the incidence vary locally, being governed by the rainfall which comes during the winter months on the coastal plains and during the summer on the plateau and in the west- ern lowlands. The zone of major intensity extends from sea level to about 3,000 feet and is followed by a gradual reduction in incidence up to 6,000 feet, after which infec- tion is rare. Certain towns, such as Asmara, Senafi, Adi Cariet and, since the introduction of effective antianopheline measures, Mas- sawa, are reported to be malaria-free. Agordat, on the other hand, is highly ma- larious, and the splenic index is about 80 per cent. In other areas, such as Biscia, Barentu, Ugara, Sciagelett, Scharg-el-Gash and Tessenei, the splenic index approxi- mates 50 per cent, while in Ghinda and Gura it averages from 10 to 16 per cent. Decamere and Keren are usually only mildly malarious. Infections with Plasmodium falciparum predominate and in some regions are re- sponsible for 100 per cent of the malaria. P. vivax infections are also prevalent and may occur with equal frequency in some localities. Plasmodium malariae is rare. Anopheles gambiae is the principal vector, although other species may be important in certain areas. During the Italian administra- tion the malaria-control program was lim- ited, to a large extent, to the prophylactic use of quinine, but within recent years con- siderable anopheline-control work has been undertaken. Rickettsial Infections. Louse-borne ty- phus fever is endemic in the highland districts, and localized outbreaks occur almost annually in the urban centers. The greatest prevalence is really observed dur- ing the cold, rainy months of the year. In 1945-47 extensive epidemics were reported which centered around Hamasien and Serae provinces. The peak was reached in 1946, when over 2,400 cases were recorded. A sharp drop to 205 cases was registered in 1948 and to 109 in 1949. Control measures included the quarantine of infected villages and widespread disinsectization, using DDT powders. Murine typhus is common in the high- land areas, particularly in the vicinity of Asmara. The extent of infection is un- certain. Tick-borne typhus fever is reported from widely scattered foci, predominantly in the lowland areas. The ticks, Rhipicephalus sanguineus and R. appendiculatus, are re- garded as the most probable vectors. Relapsing Fever. Louse-borne relapsing fever is endemic in the districts near the Ethiopian border. It appears in sporadic outbreaks during the winter months, with an average incidence of 100 to 200 cases a year. A recrudescence of infection coincided with the recent typhus epidemics in north- ern Africa. A total of 370 cases was reported in 1947. Tick-borne relapsing fever is re- corded from the lowland districts of the western plain. Leishmaniasis. Kala-azar and cutaneous leishmaniasis are encountered occasionally, but both are relatively rare. Five cases of visceral infection were reported from the lowland districts in 1947, and three in 1949. In view of the proximity of Kassala dis- trict in the Sudan where a focus has been known to exist for many years, it is pos- sible that kala-azar is more widespread in Eritrea than official reports indicate. Yellow Fever. Clinical yellow fever has not been reported from Eritrea, but the presence of the infection within recent years has been established by mouse protection test surveys in different parts of the coun- try. Immunity to the yellow fever virus was found in children in three localities near the coast in a survey reported in 1946.3¢ In 1942 mass immunization against yellow fever was inaugurated in Massawa. The entire country, with the exception of the port of Massawa and a ten-kilometer zone around the city of Asmara, is included in the zone designated as endemic for yellow fever quarantine purposes by the World Health Organization. In these cities, exemp- Eritrea 59 tion is contingent upon the maintenance of a satisfactory Aedes index. Other Infections. Sporadic cases of dengue fever occur, usually from April to June, and again from October to December. Plague, filariasis and sandfly fever have not been reported. However, the vectors are present, and each must be regarded as a potential menace. NutriTioNAL DISEASES Malnutrition is widespread, particularly among the nomadic tribes. Avitaminosis is common, but clinically evident deficiency disease is rare. The nutritional elements most frequently lacking are proteins and vitamins A and C. Beriberi is reported occa- sionally. SUMMARY Prior to its conquest by British forces in 1941, Eritrea was an Italian colony and an integral part of Italian East Africa. Since that date the country has been administered by British authorities, pending the decision of the United Nations regarding its future government. The health and medical serv- ices are supervised by the Medical Depart- ment of the British Administration from the headquarters at Asmara. In 1949 it operated 8 hospitals with 417 beds for Europeans and 1,447 for Eritreans, and 105 dispensaries scattered throughout the country. Streams, shallow wells and catchment areas constitute the major sources of water in the territory. Massawa and Asmara have municipal water supplies. The methods of sewage disposal in the small towns and villages are universally primitive, but sewer- age systems serve limited areas in Asmara and Massawa. The level of sanitation is gen- erally low, and insect vectors of disease are abundant. Malnutrition and avitaminosis are common. Typhoid fever, dysentery, helminthiasis, trachoma, tuberculosis and the various ve- nereal diseases are widespread. Malaria is prevalent in the foothill areas of the plateau and on the coastal and western plains. Smallpox occurs sporadically, although a high degree of immunity is maintained by means of an active vaccination program. Outbreaks of louse-borne typhus fever and of louse-borne relapsing fever are reported almost annually. Dengue fever, murine typhus, tick-borne relapsing fever, leish- maniasis and lepropsy are endemic. Foci of Schistosoma mansoni infections are found in the highlands. Brucellosis is common. Plague, filariasis, yellow fever and sandfly fever are not reported from Eritrea, but their usual vectors are abundant. BIBLIOGRAPHY 1. Agostini, M.: La lebbra in Eritrea (con- dizioni presenti: relievi nosografici, epi- demiologici e profilattici), Gior. med. mil. 85:169-182 (Feb.) 1937. 2. Andruzzi, A.: Problemi igienici dell’Impero coloniale (Profilassi della lebbra), Arch. ital. sci. med. colon. 19:19-30 (Jan.) 1938. 3. Archetti, I.: Considerazioni sull’amebiasi nelle terre dell’ Impero, Riv. di biol. colon. 1:281-291 (Aug.) 1938. 4. 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Soc. ital. di med. e ig. trop. (Eritrea) 4: No. 2, 369-375, 1944. ——: Studio sulla bilharziosi intestinale da Schistosoma mansoni in Eritrea, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 8: No. 1-2, 5-17, 1948. Studio sulla tubercolosi dei nativi eritrei, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 9: No. 1, 17-55, 1949. 27. 28: 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. : Studio sulle malattie del gruppo del dermotifo in Eritrea, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 8: No. 3-4, 110-145, 1948. : Ulteriori indigeni sull’anchilostomiasi in Eritrea, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 9: No. 2, 130-134, 1949. ——: Researches on nutrition and malnutri- tion in Eritrea. Note 1. Nitrogen balance in Eritrean natives living on millets diet (Andropogon sorghum and Eragrostis abyssinica), Boll. Soc. ital. di med. e ig. trop. (Eritrea) 7: No. 3-4, 171-191, 1947. : Studio sul kala-azar in Eritrea, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 2: 5-13, No. 3, 1943. Franchini, G.: Le febbri ricorrenti nelle nostre colonie africane, Arch. ital. sci. med. colon. 18:293-308, 1937. Ganora, Romualdo: La distribuzione della malaria in Eritrea, Arch ital. sci. med. colon. 13:26-31, 1932. La Face, L.: Fauna anofelinica delle colonie italiane, Riv. di parassit., suppl. mono. to vol. 1, 1937. Lega, G., Raffaele, G., and Canalis, A.: Missione dell’Istituto di Malariologia nell’Africa orientale italiana, Riv. di malarial. 16:325-387 (July) 1937. Longrigg, Stephen H.: A Short History of Eritrea. Oxford, Clarendon Press, 1945. Mahaffy, A. F., Smithburn, K. C., and Hughes, T. P.: The distribution of im- munity to yellow fever in central and east Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. Mara, Luigi: Considerazioni sul rinveni- mento dell’Aedes aegypti L. (Dip Aedi- nae) ad altitudini d’eccezione e brevi note sulla fauna culicidica del M. Bizen (Eri- trea, A. O.), Boll. Soc. ital. di med. e ig. trop. (Eritrea) 5: No. 5-6, 189-197, 1945. Pistoni, F.: L’ emogramma della malaria nella colonia Eritrea, Arch ital. sci. med. colon. 18:84-99 (Feb.) 1937. : Fauna murina in Eritrea e nello Scioa. Ricerche parassitologiche, Arch. ital. sci. med. colon. 19:388-394 (July) 1938. : Note epidemiologiche e batteriologiche sulla meningite cerebro spinale in Eritrea, Arch. ital. sci. med. colon. 18:461-471 (Feb.) 1937. Rennell, Lord: British Military Administra- tion of Occupied Territories in Africa during the Years 1941-1947. London, H.M. Stationery Office, 1948. Sforza, M.: Dermotifo in Eritrea (identi- ficazione dei virus storico, murino e da Eritrea 61 43. 44. 45. 46. zecche). Boll. Soc. ital. di med. e ig. trop. (Eritrea) 7: No. 5-6, 430-63. Sofia, F.: Ricerche sperimentali sul virus esantematico in Asmara. Nota 1. Virus murino, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 3: No. Unico, 242-275, 1944. Spadaro, O.: Considerazioni sulla profilassi antivaiolosa nel Bassopiano orientale, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 2:83-88, No. 2, 1943. ——: Osservazioni sulla dengue, Bull. Soc. ital. di med. e ig. trop. (Eritrea) 1:65-68, 1942. ——: Studio sulle brucellosi umane in Eritrea, Boll. Soc. ital. di med. e ig. trop. 47. 48. 49. 50. (Eritrea) 7: No. 1-2, 32-63, 1947. Speziale, V., and Berger, R.: Leishmaniosi viscerale in adulto proveniente dall’Eritrea, Ann. di med. nav. e colon. 45:332-338 (July-Aug.) 1939. Stella, E.: Gli ixodidi dell’Africa orientale italiana, Riv. di biol. colon. 12:135-153, 1938-39. Zavattari, E.: I problemi sanitari dell'Im- pero: schistosomiasi e malacofauna nell’- Africa orientale italiana, Ann. d'ig. 48:573- 582 (Sept.-Oct.) 1938. Zanettin, G.: Il tracoma nella popolazione indigena dell’Eritrea, Arch. ital. sci. med. colon. 18:618-631 (Dec.) 1937. Ethiopia GEOGRAPHY AND CLIMATE Ethiopia is one of the few independent countries on the continent of Africa. For a brief period following its conquest by Italy in 1936, it formed the nucleus of the Fascist empire of Italian East Africa. The kingdom was liberated by British forces in 1941, when his Imperial Majesty, Haile Selassie, again resumed the throne. Ethiopia is a landlocked territory of 350,000 to 400,000 square miles, the shortest approach to the sea being along the Danakil coast of Eritrea. Topographically, it is a subtabular plateau, bisected north and south by a sector of the Great Rift Valley of East Africa. From Lake Rudolf to Danakil the Rift Valley has an average width of 30 miles. Toward the south, it is sometimes obscured by spurs of the escarpment, but north of the Guga Mountains it fans out in a broad triangle. The south-central portion is characterized by a chain of lakes, while the Danakil plains in the northern angle are largely desert waste. The northwestern, or Ethiopian, plateau occupies nearly one half of the territory. It slopes from east to west toward the valley of the Upper Nile, and is dissected by broad steep valleys into table-topped hills and iso- lated irregular mountain masses. The north- ern portion has an average altitude of 7,000 to 9,000 feet. In the south the general ele- vation is lower, except where mountain ranges rise above the plateau with peaks reaching up to 15,000 feet. The eastern escarpment has a mean height of 7,000 to 8,000 feet in the north, where it dominates the Danakil plains like a high precipitous 62 wall but becomes lower and less abrupt toward the south. The valley of the Awash River forms a broad breech in the center which constitutes a natural gateway to the plateau. The western escarpment is broken by river valleys, while the border districts form the eastern edge of the Sudan plains. Lake Tana in the northwest is the source of the Blue Nile, which emerges as the Abbai River and cuts a deep winding gorge through the plateau. All of the rivers, large and small, become raging torrents during the rains. The vegetation varies with the elevation, from tropical forest in the river valleys below 4,000 feet to rolling prairie land in the upland areas above 8,000 feet. The Somali plateau on the opposite side of the Rift Valley stretches eastward with a gradual slope toward the Indian Ocean. A large portion lies in Somaliland outside of the boundaries of Ethiopia. Except for the arid stretches near the Somalia frontier, it has many of the general characteristics of the Ethiopian plateau. The escarpment, which has an elevation of 6,000 feet on the Kenya border, reaches 10,000 feet in the center where the crest rises in mountainous peaks above the Somali plain. It then de- creases in height toward British Somali- land, with the outer face rising abruptly from 3,000 to 5,000 feet above the adjoining country. The permanent streams in the in- terior unite to form the Juba and the Scebeli rivers. The vegetation of the Somali pla- teau is similar to that of its northern coun- terpart, but it is slightly more luxuriant in the upland areas of the northwest and more arid toward the east. Ethiopia lies wholly within the tropics, Ethiopia 63 but under the influence of the elevation and the topography a wide variety of climatic conditions is encountered. In general, the year is divided into rainy and dry seasons. The period of maximum rainfall, which accounts for 80 per cent of the annual pre- cipitation, occurs from June through Sep- tember, at the time of the southwest mon- soon, and is characterized by tempestuous rains and frequent thunderstorms. In many areas erratic and variable rainfall is ex- perienced from February to May, but in the southwestern portion of the country the demarcation between the heavy and the little rains may be slight. On the eastern slopes, which intercept the winds of the northeast monsoon, heavy fogs and occa- sional rains may occur from October to March. On the Ethiopian plateau the an- nual rainfall decreases from south to north, being about 71 inches at Gore in the south- west, 61 inches at Jimma, 50 inches at Addis Ababa, and 33 inches at Adowa. On the western slopes and on the Sudan plains it averages between 34 and 50 inches. On the Somali plateau the precipitation is more or less evenly distributed between March and September. The annual rainfall approxi- mates 36 inches at Harar but diminishes progressively in amount toward the sub- desert regions of Somalia. In the Rift Valley the rainfall is appreciably less than on the plateaus, while on the Danakil plains it be- comes almost negligible, rarely exceeding 4 inches a year. Although high temperatures are encoun- tered in the river valleys below 4,000 feet and on the plains, the climate of the plateau country is temperate and relatively equable in nature. The monthly range does not ex- ceed 7° F., but during the winter months the daily range may be 20° F. or more. On the slopes of the escarpment the monthly and daily fluctuations are somewhat greater. The mean temperatures range from 68° F. to 82.4° F. at elevations below 6,000 feet, and from 60.8° F. to 68° F. at elevations between 6,000 and 8,000 feet. The highest temperatures are usually experienced from March to May, and the lowest from Novem- ber to January. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopULATION Since there has been no reliable and com- plete census, the population of Ethiopia is not known. It is variously estimated at be- tween 10 and 15 million. The indigenous peoples may be divided into four main groups, among which the Amharas and the Gallas are the most prominent. The Am- haras, the so-called true Ethiopians, number slightly less than one third of the total population and inhabit the former king- doms of Tigre, Amhara and Gojjam, and part of Shoa Province. In spite of minor differences, the Amhara tribes are all Se- mitic in origin, employ the state language, Amharic, and conform to the Christian faith of the Coptic Church. The Gallas, the most numerous group, are located chiefly in the southern and the western parts of the country and account for almost one half of the total population. They are eastern Hamites, and may be divided into various branches, all of which speak some form of Galla. About one half are Moslems and the remainder pagans. Two small un- related minorities, the Guragies and the Falashas, also dwell in the highlands. The latter practice the Jewish religion, but con- stitute a non-Semitic race of controversial origin. They are settled primarily in the re- gion northeast of Lake Tana; in other parts of the country they live in more or less segregated communities. A third section of Ethiopian peoples is formed by the nomadic Moslem tribes of the east and the southeast—approximately 200,000 Danakils and one million Somalis. The remaining group comprises a medley of Negro and Negroid tribes in the west and the southwest which speak a variety of lan- guages, predominantly of Bantu origin. Besides Amharic and Galla, Arabic is employed extensively in the urban com- 64 Ethiopia munities, while Tigrinya is spoken in the province of Tigre. In religion the inhab- itants probably are divided about equally into Copts, Moslems and pagans. The non-native population is composed of several thousand Europeans and Asiatics who are settled chiefly in the principal towns. The largest communities are the Italians, the Armenians and the Greeks. The Ethiopians are essentially a rural people with an aversion to community life. Probably not over 200,000 live under urban or semirural conditions. The most densely settled areas are found in the country around Gondar, on the central plateau from Magdala to Addis Ababa and in the lake region. Extensive areas on the periphery are only sparsely populated. There are few towns with permanent populations in ex- cess of 10,000, although several are trading centers with large periodic markets. The population of Addis Ababa, the capital, is estimated at between 150,000 and 500,000. Harar, the center of the coffee country, and Diredawa, on the Somali plateau, have populations of 20,000 to 50,000. The educational facilities are poorly de- veloped, and the majority of Ethiopians are illiterate. However, a modernization and an expansion of the school system were under- taken in 1941, after the reorganization of the Ethiopian government. VITAL STATISTICS No vital statistics are available for Ethiopia. Registration of births and deaths is not required, and in the absence of a census there are no basic population figures. Most reports indicate that the infant mor- tality is high in all sections of the popula- tion. The life span of the average Ethiopian probably does not exceed 45 to 50 years. Sociar. Economy Agriculture is the bulwark of the Ethio- pian economy, but, except in the coffee- producing areas, the average individual cultivates little beyond his immediate needs, Communal land tenure by villages or tribes is common, although the principle of individual ownership is gradually being recognized in a modified form. Mixed farm- ing is practiced in the arable regions of the plateaus and in the lake section of the Rift Valley. In the southern and the southeast- ern parts of the country, which are devoted to grazing, large herds of goats, cattle and sheep are raised. Hides and skins and coffee are the principal exports. Industrial development is slight, but small industries, devoted to the processing of raw materials, were organized in Addis Ababa, Diredawa and Harar during the Italian regime. The territory is reputed to be rich in minerals, but few have been ex- ploited. Due to the inaccessibility of the plateaus, Ethiopia has remained more or less isolated until recently. After the conquest of the country, the Italians constructed a network of radial highways to link Ethiopia with the other territories of their East Afri- can empire. Motor roads connect Addis Ababa with population centers in all the neighboring countries, and Diredawa and Harar with Berbera and Mogadiscio. A single-track railroad from Addis Ababa to Djibouti, completed in 1917, provides Ethi- opia’s principal outlet to the sea. Since 1946, a government-owned air line has operated between the larger cities, with con- nections to Europe and the Near East. Foop AND NUTRITION Mixed farming or stock-raising are prac- ticed over the greater part of Ethiopia. The proportion of useless arid country is rela- tively small, while extensive areas of rich agricultural land exist, particularly in the temperate zones above 4,500 feet. In most regions two, and in many three, crops a year are not uncommon, but primitive methods of cultivation restrict their yield. The most important food crops are millets (both teff and dura), maize, barley, red peppers, sesame and musa (a bananalike plant). The mainstay of the average Ethiopian diet is injera, a native bread. Teff is the Ethiopia 65 most extensively used cereal, but dura and maize are also of major importance. Barley is grown over wide areas, although in rela- tively small amounts. Wheat, oats and rye are raised sometimes. Most of the common legumes, native potatoes and a few green vegetables, particularly the local cabbage, are widely cultivated but consumed irregu- larly by the poorer peasants. Red peppers are a significant source of vitamin C. Numerous indigenous fruits are known but are rarely eaten. In the lowland areas musa is raised for its food value and for its fiber; also, limited amounts of bananas. The most universal oleaginous plants are sesame and peanuts. Milk and butter are popular foods, but the native cattle are poor producers, and both foods are scarce in most parts of the country. The former is a staple article of diet among the nomadic tribes, particularly the Danakils. Large numbers of cattle, sheep and goats are raised, but meat is a luxury in the ordinary family and is usually pre- pared with vegetables and spiced or curry sauces. Raw meat, almost invariably beef or goat’s meat, is consumed on ceremonial oc- casions. Chickens are eaten in many com- munities. Fish are often utilized in the lake and the river regions. The average Ethiopian diet is deficient in fats, animal proteins and vitamins. It is moderately well balanced, but inadequate and of low caloric value. The nutritional status of the people is low in all parts of the country, due in part to poverty, and in part to religious observances among both the Copts and the Moslems which include long periods of fasting. Housine The Amharas and the Gallas live in small, scattered villages or family communes. The typical dwellings are circular huts, con- structed of maize stalks and grass in the warmer areas and of wattle and daub or, more rarely, of stone in the cooler climates. In most localities they have wide, overhang- ing roofs of thatch to carry off the rains. These huts, or tukuls, may contain one room or two, with an inner circular living compartment. They usually house both the family and the livestock, but in the larger family groups separate tukuls may serve as kitchens or as stables for the domestic ani- mals. The nomadic tribes live in tents under equally primitive conditions. In the winter months, when the temperatures drop appre- ciably at night, neither tents nor huts provide adequate protection against the weather. The more prosperous Ethiopians live in one- or two-storied houses of unhewn stone and plaster, with roofs of corrugated iron or thatch. As elsewhere, the urban dwellings vary in size and construction according to the prosperity of the owners, but over- crowding and insanitary conditions prevail in all the poorer districts. ENVIRONMENT AND SANITATION WATER SUPPLIES Water is available from lakes, streams and springs, and from deep or shallow wells. Abundant potable supplies may be obtained on the Ethiopian plateau, in the Rift Valley and on the crest of the Somali plateau. In the lower regions of the eastern and the western escarpments, in the Danakil plains and in the Ogaden country toward Somali- land, water supplies are frequently scanty and seasonal. The wells are apt to be pol- luted; moreover, the water is drawn by hand and often carried for long distances in skins or tins. In a few of the larger cities and towns, public supplies are piped to limited areas. The municipal supply of Addis Ababa serves about one half of the population. The prin- cipal source is from springs on the head- waters of several mountain streams near the city. It is treated by filtration and chlo- rination. The supply is inadequate during the dry season and is being augmented gradually by the construction of artesian wells which will contribute a considerable portion of the supply. It is piped to a limited number of dwellings and to public 66 Ethiopia fountains. The distribution system is not adequately supervised, however, and pollu- tion is frequent. From 400 to 500 individual wells are found in the city. Limited town supplies are also available in Diredawa, Dessie, Jimma and Harar. Springs and infiltration galleries are the usual sources. Waste DisposaL Except for a small and incomplete sew- erage system in part of Addis Ababa, which becomes useless in the heavy rains, there is no organized method of sewage disposal. Septic tanks are in general use in the better residential sections of the larger towns. Latrines are found in some other areas, but pollution of the soil is a common practice. Fauna AND Frora Arthropods. Mosquitoes. At least 22 species of anopheline mosquitoes have been reported from Ethiopia. Their distribution is restricted by the varying conditions of elevation and rainfall, but in general anoph- elines are found abundantly in all areas below 4,000 feet, in the deep river valleys and in the foothills of the escarpments bor- dering the Rift Valley. Anopheles gambiae occurs in the lowland areas throughout the country and is the principal vector of malaria. It breeds in exposed residual pools in the river beds, in the clear, shallow moun- tain streams between spates, along the flooded margins of the lakes, and in the desert areas in small collections of water re- maining after the rains. A. funestus is a secondary vector of malaria in the river valleys of the northwestern plateau region. A. pharoensis and A. d’thali are found in the Rift Valley, where both are suspected of transmitting the infection in localized areas. Seven species of Aedes occur, including Aedes aegypti, A. simpsoni lilii, A. africanus and A. vittatus, all potential vectors of yellow fever. Eleven species of Culex mosquitoes are reported, but none is of medical importance, although Culex quinquefasciatus (= C. fat- igans) may be a potential vector of Wuch- ereria bancrofti. Three species of Taeni- orhynchus and one of Theobaldia are also present. Fries. Flies are abundant, but few in- dividual species have been recorded. Many probably play a significant role in the trans- mission of intestinal and skin infections. Tsetse flies are present in the southwest along the Sudan border. Glossina morsitans is found in the Omo and Dadessa river re- gions, and G. palpalis in the Galla-Sidamo area. G. longipennis and G. pallidipes are also found in scattered foci. Simulium damnosum exists in several localities in western Ethiopia, particularly in the vicinity of Bonga, Gore, Lekemti and Gardulla, where it is a vector of Onchocerca volvulus. Phlebotomus papatasii, implicated in the transmission of sandfly fever and pos- sibly of cutaneous leishmaniasis, is widely distributed. Both diseases are reported from various sections in the western part of the country and from the Diredawa area. P. congolensis and P. argentipes, potential vectors of kala-azar, are also present. P. congolensis has been identified at camps along the Omo River and on the route from Nairobi to Addis Ababa. Lice. The human lice, Pediculus humanus capitis and P. humanus corporis, are preva- lent on the plateaus, but less frequent in the Danakil lowlands. Freas. Infestation with the human flea, Pulex irritans, is common. Xenopsylla cheopis, a potential vector of murine typhus and of plague, is prevalent. Other species of rat fleas, as well as the dog and cat fleas, Ctenocephalides canis and C. felis, are un- doubtedly present. The chigoe flea, Tunga penetrans, is widely distributed in all portions of the country except in the Danakil region. BepBucs. The bloodsucking bedbug, Cimex hemipterus, is universally encoun- tered. Ticks AND Mites. Ornithodorus moubata and O. savignyi are reported from numerous localities on the plateaus. The former is a Ethiopia 67 vector of relapsing fever, which is endemic in sections of eastern Ethiopia. Rhipiceph- alus sanguineus is widespread and may be implicated in the transmission of tick-borne typhus fever. R. pulchellus is also regarded as a possible vector. R. appendiculatus is abundant in the southwest. At least 6 other species of Rhipicephalus, 6 of Amblyomma and 2 of Hyalomma have been identified ; also Haemaphysalis leach. Infestation with the itch mite, Sarcoptes scabiei, is general in many areas. Reptiles. Snakes are found primarily in the lowlands. Available reports indicate that several species of poisonous snakes are present. The mamba, Dendroaspis antinorii, has been recorded but is apparently rare. The puff adder, Bitis arietans, and the spit- ting cobra, Naja mnigricollis, are probably indigenous; also species of Echis and Atractaspis. Rodents. Rats which harbor fleas capa- ble of transmitting plague are abundant in most parts of the country. Rattus rattus rattus and R. rattus alexandrinus are com- mon along the traffic routes but have not penetrated far into the interior. Large numbers of wild rodents, including Arvi- canthus testicularis, Laphouromys flavo- puncta zephiri and Mastomys coucha lateralis, are found in the rural areas. Mollusks.* The fresh water snail, Planorbis (Biomphalaria) alexandrina, is found in the lakes around Harar and in other localities in southeastern Ethiopia. It is a potential intermediate host of Schistosoma mansoni in the Harar area. Unidentified species are also described from Tigre Province. Foop SANITATION Regulations for the sanitary control of milk, meats and other food supplies exist, but the degree of enforcement is variable. The supervision of markets, dairies and slaughtering establishments is carried on in Addis Ababa, within the limits of available trained personnel. The inspection of meats * See footnote, p. 10. is the responsibility of the veterinary serv- ices of the Ministry of Agriculture. There are few facilities for the pasteurization of milk, and none outside of Addis Ababa. HEALTH SERVICES AND MEDICAL FACILITIES HeaLTH ORGANIZATIONS The present public health organization in Ethiopia has evolved since the liberation of the country in 1941. The Public Health De- partment functions under the Ministry of Health, which was established in 1947 under the direction of a Vice-Minister of Health. The central organization, with head- quarters in Addis Ababa, is administered by a nonmedical Director-General of Public Health. He is assisted by an Inspector-Gen- eral of Public Health, who is a foreign medical advisor to the Ministry, and by a Director of Hygiene. The Ministry is re- sponsible for the promotion of public health, the control of epidemic and other diseases, and the maintenance and the supervision of medical facilities. Operational units in- clude central statistical and pharmaceutical divisions. A Central Administrative Board of Health advises the Minister on matters of policy, legislation and finance. The public health program in each of the 12 provinces is in charge of a medical of- ficer, who is also director of the hospital in the administrative headquarters. Municipal health services are developed only in Addis Ababa. The local department, which was organized in 1948, is charged with the en- forcement of sanitary measures and the operation of clinics. The Ethiopian Red Cross Society was re-established in 1947. It co-operates with the Public Health Department in the pro- vision of courses in home nursing and bed- side care for voluntary health workers. MEebpicAL INSTITUTIONS Hospitals and Dispensaries. At the time of the liberation of Ethiopia in 1941, the medical facilities in the country were 68 Ethiopia completely disrupted. Personnel and equip- ment have been assembled gradually, with assistance from various voluntary and gov- ernmental groups, and from the United Na- tions Relief and Rehabilitation Administra- tion. In 1947 about 38 civilian hospitals were functioning, the majority of which were operated by the Ethiopian government under the supervision of the Public Health Department, or by mission and other or- ganizations having contracts with the gov- ernment. Aside from the hospitals in Addis Ababa, one or more institutions, ranging in size from 10 to 20 beds, are located in each of the provinces. Eight hospitals are estab- lished in Addis Ababa, the largest of which are the Menelik II, with 600 beds, and the Haile Selassie, with 200 beds. The govern- ment also maintains a 100-bed tubercu- losis hospital in Harar, a 100-bed mental hospital in Addis Ababa and a leprosarium, near Addis Ababa, with provision for 700 lepers. The total hospital capacity in 1947 was approximately 3,300 beds, or about 0.2- 0.3 beds per 1,000 population.?> In addition, over 120 clinics and dispensaries were conducted by the Addis Ababa health authorities, by the government or by various missions. Laboratories. The Imperial Ethiopian Medical Research Institute, in Addis Ababa, is the central laboratory of the gov- ernment health services. It carries out diagnostic, bacteriologic, serologic, para- sitologic and chemical examinations for the entire country; it also conducts field re- search in epidemic areas and prepares antirabies, smallpox, cholera and other vaccines. Clinical laboratories are attached to the larger hospitals. Schools. In 1946 a program for the training of medical personnel was developed with the co-operation of UNRRA and, later, of the World Health Organization. The training of dressers and nursing aides is conducted in three hospitals in Addis Ababa and in four in the provinces. Courses for the training of sanitary inspectors are given in Addis Ababa. Courses for the preparation of medical auxiliaries, pharmacy assistants and other medical personnel are offered in Addis Ababa and Harar. Schools for the training of medical as- sistants and nurses were organized at the Haile Selassie Hospital in Addis Ababa in 1948. PERSONNEL Physicians. Up to 1948, there were no Ethiopian physicians practicing in the country, but doctors of various nationali- ties were employed in government and mis- sion services, or engaged in private work. From 74 to 110 physicians were registered in Ethiopia in 1947, about two thirds of whom were located in Addis Ababa. Others. Estimates of the number of foreign registered nurses in 1947 range from 67 to 93. One bacteriologist, one chemist and one veterinary surgeon were connected with the Medical Research Institute. The number of qualified Ethiopian per- sonnel is relatively small, and the majority have been trained since 1946. DISEASES The data regarding the incidence of dis- ease in Ethiopia are meager and contra- dictory. The difficulties of reporting usually associated with underdeveloped areas are enhanced by the acute shortage of public health facilities and personnel. Research studies made during the Italian regime, and more recent surveys carried out by the United States Technical Project, the World Health Organization and other groups, pro- vide valuable sources of information, but many are limited in scope and do not re- flect the health conditions in the country as a whole. Summaries of the prevalence of specific diseases are necessarily incomplete and must be interpreted on an area basis. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL OR URINARY TRACTS Typhoid and Paratyphoid Fevers. Evi- dence regarding the prevalence of enteric Ethiopia 69 fevers is conflicting. The records of the hos- pitals in Addis Ababa and Harar, where facilities for bacteriologic diagnosis are available, indicate that typhoid fever is not common. However, Salmonella infections are apparently frequent. Dysenteries. Both amebic and bacillary dysentery are widely distributed. Acute amebiasis is common, particularly in the towns of the plateau region. Various ob- servers have reported Endamoeba histolytica in from 7 to 60 per cent of the stools ex- amined in different parts of the country. Bacillary dysentery is prevalent and prob- ably more widespread than the amebic dis- ease. Shigella dysenteriae infections occur but the relative incidence is not known. Diarrhea and Enteritis. Gastro-intesti- nal disturbances are general and reflect the low level of sanitation prevailing through- out the country. Severe diarrhea and enter- itis are prevalent among infants and young children and undoubtedly contribute to the reputedly high infant mortality. Helminthiases. ANcyLosToM1asis. Hook- worm infection is endemic in scattered foci on the southwestern plains. Ancylostoma duodenale is the only species specifically re- ported. ScuistosoM1asts. Schistosomiasis is rare and localized in distribution. Occasional cases are seen in the Menelik II hospital in Addis Ababa. Infections with Schistosoma mansoni and S. haematobium have been de- scribed from foci in Tigre province, and with S. mansoni from Harar. Oruer HELMINTH INFECTIONS. Ascariasis is widely distributed. Infection rates of 17 to 55 per cent are not unusual in many parts of the country. Strongyloides stercoralis in- fections are prevalent in the highlands, less frequent on the plains. Cases of trichuriasis, and, in some areas, of enterobiasis are numerous. Taeniasis, caused by Taenia saginata, ranks high among the helminth diseases re- ported from Ethiopia. The infection is enzootic among the native cattle, but recent observations indicate that human infection is not as universal as is popularly supposed. Beef is sometimes consumed raw, partic- ularly on ceremonial occasions, but meat in any form is not an important part of the average Ethiopian diet. Infections with T. solium are not recorded. Hymenolepis nana is observed occasionally. Cholera. Cholera has not been reported from Ethiopia since 1892-93, but several epidemics probably occurred in the last century. The country is exposed continually to the importation of the disease through the participation of members of the Moslem communities in the pilgrimages to Mecca. Other Infections. Brucellosis is common among the Danakils in the northeast but apparently rare in other parts of the country. Diseases SpreAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is widespread and, from all reports, appears to be increas- ing rapidly. The opening of communica- tions in the more remote areas, together with war conditions which resulted in the displacement of large numbers of the popu- lation, have helped to facilitate the spread of the infection. It is somewhat more prev- alent in the larger towns than in the vil- lages but is present in both plateau and lowland regions. A tuberculin survey in 1940-43°7 revealed positive tuberculin reac- tions among the people in the rural areas, ranging from 25.8 per cent in Galla-Sidamo to 35.3 per cent in Shoa; in the urban areas from 35.5 per cent in Jimma, and 52.5 per cent in Addis Ababa to 71.8 per cent in Diredawa. Subsequent surveys among the pupils in four schools in Addis Ababa and Hadama-Nazareth and among the admis- sions to the medical department of the Haile Selassie Hospital in Addis Ababa indicate that from 50 to 60 per cent of individuals give a positive reaction by 10 to 16 years of age. Pulmonary infections pre- dominate and frequently follow a rapid course. With the exception of a hospital at Harar, 70 Ethiopia there are no special facilities for the isola- tion and the treatment of tuberculous pa- tients. Smallpox. Smallpox has been endemic in Ethiopia since ancient times, and small sporadic outbreaks are reported almost an- nually. Extensive vaccination campaigns were undertaken by the Italian health of- ficials in 1936-41 and have been carried out since that period by the Ethiopian authori- ties. Smallpox vaccine is produced at the Imperial Ethiopian Medical Research Insti- tute at Addis Ababa. Meningitis. Meningococcus meningitis breaks out in epidemic form from time to time. Endemic foci have been described re- cently in Upper Ogaden, in the vicinity of Harar and Jijiga, in Tigre Province and in the west and the southwest. Since outbreaks frequently occur in the interior far from the main traffic routes, a large proportion of the cases and the deaths is not reported. Other Infections. Pneumonia is espe- cially common at the higher altitudes. The fatality rates average between 30 and 40 per cent. Clinical diphtheria is relatively rare, but Schick test studies reported from Addis Ababa in 19398 suggest that a high degree of immunity may exist. Measles, whooping cough and chickenpox are endemic. Scarlet fever is seldom seen. Diseases SPREAD OR CONTRACTED CuIierLy TaroucH CONTACT Venereal Diseases. Venereal diseases constitute a major problem, their increase within the last two decades being aggra- vated by the unsettled conditions associated with the wars of conquest and liberation. The extent of infection is not known but is variously estimated at 30 to 50 per cent. Syphilis and gonorrhea predominate, but chancroid and lymphogranuloma inguinale are also common. Multiple infections are numerous. In 1946-47, syphilis constituted about 70 per cent of the cases of venereal disease under treatment in government in- stitutions; gonorrhea, slightly less than 12 per cent. Syphilis may reach epidemic pro- portions in urban centers, as Addis Ababa, Harar and Diredawa. Its distribution in the rural areas is suggested by sample surveys in three widely separated villages in 1944 and 194525 in which positive serologic reac- tions were found in 50 to 84 per cent of the individuals examined. Pronounced skin and mucous lesions are frequent clinical manifes- tations of the disease. No special facilities for diagnosis and treatment exist except in Addis Ababa, where two clinics are equipped for the treatment of venereal infections. Since 1947, the WHO Mission to Ethiopia has assisted the governmental health authorities in the organization of a program for the control of venereal diseases. Leprosy. Leprosy is endemic, especially in Harar Province. No comprehensive surveys have been undertaken, but conserva- tive estimates place the incidence at slightly over one per 1,000 population. All forms of the disease are encountered, although the nodular cases are more noticeable than the maculo-anesthetic. Approximately 700 lepers are accommodated in the Akaki leprosarium near Addis Ababa, which also includes a 40-bed hospital. Diseases of the Eyes. Trachoma is prev- alent in many parts of the country, both in the lowlands and on the plateau. It appears in a relatively mild form, and serious com- plications are unusual. Surveys among the school children in the towns have shown that a large percentage are infected. The condition is most frequent among the Somalis in the Harar and the Ogaden re- gions. Conjunctivitis of an infectious and non- infectious nature is general. Poor hygiene, excessive amounts of dust and the prev- alence of flies are contributory factors. Diseases of the Skin. Skin infections are a major cause of disability. Various fungus infections of the skin occur in all sections of the country. Tropical ulcers are prevalent, particularly in the lowland areas. Infestation with Sarcoptes scabiei is wide- spread. Tunga penetrans is indigenous in Ethiopia 71 most areas, except in the Danakil country. Yaws. Yaws is found in the western dis- tricts along the borders of the Sudan. The disease appears to be limited in distribu- tion, but the incidence may be higher than reports indicate, since some cases probably are diagnosed as syphilis. Other Infections. Large numbers of dogs, hyenas and jackals have been found infected with rabies, and human cases are reported regularly from Addis Ababa and the western provinces. Human infections are more frequent among the Copts than among the Moslems, who regard dogs as unclean and avoid contact with them. Occasional cases of tetanus are treated in the hospitals. Tetanus neonatorum is not specifically recorded, but infections are un- doubtedly frequent. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is widely distributed but varies in prevalence, depending upon local conditions of climate and rainfall. The records of incidence are incomplete, but, in general, malaria is common in all regions below 6,000 feet, particularly in the valleys of the larger rivers and in the foothills of the escarpment bordering the Danakil plain. It is endemic in the lowland areas below 3,000 feet; at the higher altitudes it occurs in seasonal epidemics, usually between April and June, and September and Novem- ber. The outbreaks tend to decrease in severity at elevations above 4,500 feet, while localities over 6,000 feet are relatively free from infection. Reports from specific areas contribute to this over-all pattern of incidence. In the Rift Valley, where the numerous small lakes and residual pools formed by the tor- rents from the mountains influence anophe- line breeding, malaria is hyperendemic in the proximity of permanent water; else- where it is epidemic and seasonal. However, near the southwestern border and in the Danakil Desert, the semiarid regions away from the rivers may be malaria-free. In the deep gorges of the Omo and the Abbai (Blue Nile) rivers and their tributaries, the dis- ease is endemic. On the Ethiopian and the Somali plateaus malaria occurs in seasonal outbreaks, but indigenous cases are not usually recorded from Addis Ababa and regions over 6,000 feet. Anopheles gambiae is the principal vector in all parts of the country. The relative prevalence of different spe- cies varies with the locality and the season. In southern and eastern Ethiopia at least two thirds of the infections are due to Plasmodium falciparum, but in the northern highland area P. vivax may be the pre- dominant form. P. malariac is relatively rare. Blackwater fever is sporadic. Rickettsial Infections. At least three different forms of typhus fever are common in Ethiopia. Classical louse-borne typhus is endemic in the highlands where it frequently reaches epidemic proportions. It is present throughout the year but most prevalent during the damp, rainy season and subse- quent dry months; usually from July to October or November. From 3,000 to 6,000 known cases are recorded each year. The fatality rates vary in different outbreaks from 5 to 35 per cent. Flea-borne typhus is also prominent, primarily in the cooler highland areas where infestation with fleas is general. Tick- typhus is reported from foci in the western lowlands. Rhipicephalus sanguineus is the most frequent vector, but R. pulchellus has been found infected in a few instances. Mass immunization programs have been carried on by the Italian and Ethiopian health authorities. Weigl’s vaccine which was employed by the Italians, has been re- placed by the Cox type vaccine since 1945. Within recent years DDT has been used extensively as a deverminizing agent. Relapsing Fever. Both louse-borne and tick-borne relapsing fevers are endemic. Foci of louse-borne infection are found in urban and rural areas in Tigre, Shoa and the western provinces. The disease appears in sporadic outbreaks with the highest in- 72 Ethiopia cidence between July and September. Epi- demics have been reported within recent years from the northern part of the country around Adowa, Axum, Macalle, Adigat and Debra Tabor, from Addis Ababa and from Lekemti. Tick-borne relapsing fever is endemic in the vicinity of Diredawa and in numerous localities on the Somali plateau. The vector, Ornithodorus moubata, has been re- ported from the region around Addis Ababa and Fiche, but available evidence seems to indicate that the infection is of minor im- portance on the Ethiopian plateau. Filariasis. Conditions clinically resem- bling filariasis are observed, but confirma- tion by the demonstration of Wuchereria bancrofti has not been reported. Onchocerciasis is found in the southwest- ern part of the country, conforming to the distribution of the vector, Simulium dam- nosum. Probable endemic foci are centered around Jimma, Bonga, Shabe, Gore, Le- kemti and Gardulla. Yellow Fever. Little is known concern- ing the presence of yellow fever in Ethiopia. A case was described recently from the Dagobur region (Ogaden), and immunity to the virus was found in a few individuals. In a mouse protection test survey covering 7 localities in the southwestern part of the country, reported in 1946,>® no conclusive evidence of immunity was found among the native inhabitants examined. The infection is endemic in adjacent sections of the Sudan and undoubtedly occurs across the border. Aedes aegypti is widespread, except at the higher altitudes. Leishmaniasis. Kala-azar is reported sporadically from southwestern Ethiopia along the Sudan border and in the region around Lake Rudolph. Cutaneous leish- maniasis, or oriental sore, is common in many areas. It has been described from Tigre Province, from Gore, Jimma and Lekemti in the west and from Diredawa and Harar in the east. Other Infections. Only a few doubtful cases of plague have been reported, but the necessary rodent hosts and flea vectors are found abundantly in all the centers of popu- lation. Dengue fever is endemic in the vicinity of Harar and Diredawa and in the eastern highlands. Outbreaks occur sporadically, the incidence being less among the Somalis than among the Ethiopians and the Euro- peans. Sandfly fever has been reported from Gore and Diredawa and undoubtedly is present in other areas where Phlebotomus flies are found. No cases of human trypano- somiasis have been recorded. NutritioNAL DISEASES The nutritional status of the average Ethiopian is low, but frank deficiency dis- eases are generally rare. The usual dietary is poor in proteins and in caloric value. Malnutrition and subclinical avitaminosis are widespread, but specific data as to prev- alence are not available. MisceLLaNEOUS CONDITIONS Infectious hepatitis is endemic in all parts of the country. SUMMARY Ethiopia suffered materially from the war of occupation in 1936, and the government has been reorganized since its liberation in 1941. The Public Health Department op- erates under a Ministry of Health which was established in 1947. The central organi- zation, with headquarters in Addis Ababa, administers the public health activities and supervises the medical facilities in the country. A municipal health organization functions in Addis Ababa. Much has been accomplished since 1944, but progress is handicapped by a lack of trained Ethio- pian personnel. In 1947 about 38 govern- ment and mission hospitals, with an ap- proximate capacity of 3,300 beds, were in operation in the population centers through- out the country. Water supplies are generally adequate on the plateaus and in the Rift Valley but Ethiopia 73 scarce on the Danakil plains and in the eastern part of the Somali plateau. The methods of sewage disposal are primitive. The standards of nutrition are low, but frank deficiency diseases are relatively rare. Malarial, venereal diseases, typhus fever, relapsing fever and intestinal infections are the major public health problems. Tuber- culosis, leprosy, trachoma and serious skin infections are widespread. Smallpox is a constant menace but has been partially controlled by extensive immunization. Schistosomiasis, leishmaniasis, yaws, bru- cellosis and onchocerciasis are limited in distribution. Dengue fever and rabies are endemic. The nontropical respiratory infec- tions, pneumonia, whooping cough, varicella and measles, occur with more or less fre- quency. Plague, cholera, human trypano- somiasis and yellow fever are not reported. BIBLIOGRAPHY — Angelini, G.: L’ittero nella febbre ricorrenti (dell’altipiano etiopico), Gior. ital. clin. trop., N.S. 2:4-11, 1938. 2. Barkhuus, Arne: Diseases and medical prob- lems of Ethiopia, Ciba Symposium 9:710- 723 (Oct.) 1947. 3. ——: Field Reports. Public Health, Ethiopia. Foreign Economic Administration, U.S. Technical Project in Ethiopia, 1944-45. 4. : Nutrition in Ethiopia. Foreign Eco- nomic Administration, U.S. Technical Project in Ethiopia, 1945. 5. ——: Preliminary Report on Results of Medical Survey of the Villages Ambo, Shabe and Gawani in Ethiopia. Foreign Economic Administration, U.S. Techni- cal Project in Ethiopia, 1945. 6. ——: Public health in Ethiopia, Ciba Sym- posium 9:698-709 (Oct.) 1947. 7. ——: Public Health Service in Ethiopia. Foreign Economic Administration, U.S. Technical Project in Ethiopia, 1945. 8. Borra, E.: Contributo allo studio dell’in- fezione difterice in Ethiopia, Rass. sanit. del’A.O.I. 1:49-53, 1939. 9. 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Cupi, Nino: Primi casi di pian riscontrati nel Governo dell’Amara, Boll Soc. ital. di med. e ig. trop (Eritrea) 2:45-50, No. 3, 1943. 17. ——: Studio sulla sifilide cutanea e mucosa degli indigeni in A.O.I., Boll. Soc. ital. di med. e ig. trop. (Eritrea) 2: No. 2, 89- 106, 1943. 18. Dagnino, Vincenzo: Contributo alla noso- grafia del Gimma-Abba-Gifar (Ethiopia), Arch. ital. sci. med. colon. 11: No. 10, 613-620, 1930. 19. D’Arcangelo, Domenico: Studio sulle moda- lita di esordio e do decorso della tuberco- losi polmonare negli indigeni dell’Etiopia (Nota tisiogenesi), Boll. Soc. ital. di med. e ig. trop. (Eritrea) 2: No. 6, 48-62, 1943. 20. ——: L’indici tubercolinico nelle popola- zioni native dell’Impero etiopia, Riv. di tisiologia 13: No. 10, 381-389, 1940. 21. d’Ignazio, Camillo: Sulle parassitosi intes- tinali di Etiopia, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 6: No. 5, 227-237, 1946. 22. ——, and Codeleoncini, E.: L’opera dei Medici italiani nella lotta contro il demo- tifio in Etiopia (1937-1947), Acta med. italica 3: 295-303 (Nov.) 1948. 23. de Meillon, B., and Lavoipierre, M.: New records and species of biting insects from the Ethiopian region, J. Ent. Soc. S. Africa 7: 38-67, 1944, 24. Elsdon-Dew, Ronald: A pathologist’s Abys- sinian notes, South Africa M. J. 16:416- 417 (Dec. 12) 1942. 25. Fadda, Siro: La lebbra nelle nostre colonie e nell’Etiopia, Gior. di med. mil. 84:206- 213 (March) 1936. 26. Familiari, P.: Considerazioni clinico-sociali 74 Ethiopia 27. 28. 29. 30. 31. 32. 33. 34, 33, 36. 37. 38. 39. 40. sulle diffusione del tracoma fra la popo- lazione indigena dell’Africa orientale itali- ana, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 3: No. 1, 464-496, 1944. Cenni geografici eclimatologici nel commisariato di Bisciuftu, Gior. ital. clin. trop., N.S. 2: 189-202, 1938. Gasperini, G. C.: Considerazioni sulla epi- demia di febbre ricorrente nei distretti di Asghede, Tsellion Biet e Dembé Acrai (Tigrai orientale) nell’ottobre-novembre 1940, Boll. Soc. ital. di med. e ig. trop. (Eritrea) 1: No. 3, 32-36, 1942. Ghidini, Gian Maria: Nuovi dati sulla dis- tribuzione delle glossine nelle terre dell’- Impero, Riv. di biol. colon. 3:329-333, 1939. Giaquinto, Mario Mira: Presenza del Simu- lium damnosum theobald in varie localita del territorio dei Galla e Sidamo e pos- sible esistenza di focolai di oncocercosi fra le popolazioni indigene di alcune re- gione dell’A.O.I., Arch. ital. sci. med. colon. 20: No. 12, 657-662, 1939. Giovannola, Arnaldo: Schistosomiasi intes- tinale da S. mansoni nell’Harar e sua trasmissione con il Planorbis boissyi, Riv. di parassit. 1: No. 2, 157-162, 1937. : Schistosomiasi intestinale da S. man- soni nell’Harar e sua trasmissione, Rendic. Ist. san. publ. (Roma) 1: 805-810, 1938. Girolami, Mario: La profillassi della schis- tosomiasi nell’Africa orientale, Arch. ital. sci. med. colon. 16: No. 12, 844-852, 1935. Guerra, P.: La diffusione del tracoma in Addis Ababa, Rass. sanit. dell'Impero 1: 20-25, 1937. Guthe, Thorstein: Venereal diseases in Ethiopea. Survey and recommendations, Bull. World Health Org. 2: 85-137 (Mar.) 1949. Jemmi, Carlo: Nosografia della zona uom- berta Tzora-Atzbi (Tigrai orientale), Gior. ital. clin. trop., N.S. 3:35-44, 1939. Lega, G., Raffaele, G., and Canalis, A.: Missione dell'Istituto di Malariologia nell’- Africa orientale italiana, Riv. di malarial. 16: No. 5, 325-387, 1937. Mahaffy, A. F., Smithburn, K. C, and Hughes, T. P.: The distribution of immun- ity to yellow fever in central and east Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. Manson-Bahr, Philip: Prevalent diseases of Italian East Africa, Lancet 1:609-612 (May 10) 1941. Mariani, G.: Particularités épidémiologiques du typhus exanthématiques sur le haut plateau ethiopien, Bull. Office internat. 41. 42. 43. 44. 45. 46. 47. 48. 49, 50. si 52. 53. 54. 33. 56. 57: 58. d’hyg. pub. 31: 1225-1232 (July) 1939. Le rickettsiosi umani dell’Africa italiana, Gior. ital. mal. esot. e trop. 11: No. 5, 77-84, 1938. : Appunti per la nosografia di Addis Ababa, Gior. ital. mal. esot. e trop. 11: No. 3, 37-51, 1938. ——: Appunti sulla nosografia di Addis Ababa, Rass. sanit. dell'Impero 1: No. 2, 1937. ——, and Chionetti, U.: La sifilide in Eti- opia, Gior. ital. clin. trop. 1:103-105, 1937. Melville, A. R., Wilson, D., Bagster, Glas- gow, J. P., and Hocking, K. S.: Malaria in Abyssinia, East African M. J. 22:285- 294 (Sept.) 1945. Naegeslabch, E.: Arztlische Erfahrungen im Hochland von Abessinien, Archiv. f. Schiffs und Trop.-Hyg. 8:100-112, 147-155, 1934. Patrassi, Gino: La lotta antitubercolare ni suoi nuovi aspetti coloniale, Lotta contro la tuberc. 8: No. 5, 417-424, 1937. Pistoni, Ferruccio: Fauna murina in Eritrea e nello Scioa. ricerche parassitioliche, Arch. ital. sci. med. colon. 19:388-394 (July) 1938. , and Mancini, A.: Inchiesta epidemio- logica della tubercolosi nell’indigeno dello Scioa attraverso la cutireazione v. Pirquet, Lotta contro la tuberc. 9:609-614, 1938. Rey, C. F.: The Real Abyssinia, Philadel- phia, Lippincott, 1935. Robinson, P.: Typhus fever in Addis Ababa, Ann. Trop. Med. & Hyg. 37:38-41 (April) 1943. ——: Relapsing fever in Addis Ababa, Brit. M. J. 216-217 (Aug. 22) 1942. Sandford, Christine: Ethiopia under Haile Selassie, London, J. M. Dent and Sons, Ltd., 1946. Scaffidi, Vittorio: Caratteri della febbre ricorrente dell’altopiano nord-etiopico, Arch. sci. med. 64: No. 4, 333-394, 1937. : Ricerche sperimatali preliminari sulla febbre ricorrente dell’altipiano etiopico, Nota iii, Arch ital. sci. med. colon. 18: 423-429 (Feb.) 1937. Steenkamp, William P.: Some medical im- pressions of Ethiopia, South African M. J. 15:475-480, 1941. Thomson, D. R.: The Tuberculosis Control Programme in Ethiopia. United Nations, World Health Organization. May 1, 1949. (W.H.O., Geneva.) World Health Organization: Mission to Ethiopia. Summary Progress Report, Janu- ary 31, 1946 to August 31, 1948. (W.H.O., Geneva.) British Somaliland GEOGRAPHY AND CLIMATE The segment of Somali Territory known as British Somaliland has been administered as a protectorate by Great Britain since 1884. It comprises a small part of the so- called Horn of Africa and has a total area of 68,000 square miles, with a coastline of 400 miles on the Gulf of Aden. The Protectorate may be divided roughly into two regions: the maritime zone and the central plateau, which stretches south- ward to form part of the great Haud plain of Ethiopia and Somalia. The coastal re- gion, a semidesert country interspersed with patches of alluvial land, reaches a depth of 60 miles at Zeila, but narrows to a fringe less than 3 miles in width from Bulhar to the Italian frontier. The mari- time hills, which rise in steep escarpments from the coastal plain, have an average alti- tude of 3,000 to 4,000 feet and are bisected by small inland plains with stretches suita- ble for grazing on their gentler slopes. The seaward scarp of the interior plateau rises above these coastal mountains and attains heights of 7,000 to 9,500 feet in the War- sangeli and Goli ranges. Toward the south the plateau drops in gently sloping terraces to the Haud plain and provides extensive areas of excellent grazing land. There are no permanent rivers, but the mountains are traversed by numerous water courses run- ning north and south which, though dry for the greater part of the year, become impass- able torrents after the rains. The climate of the maritime zone is gov- erned by the monsoons. Heavy showers and intermittent thunderstorms are experienced in November and December with the onset 75 of the northeast monsoon, while light rains may occur at the beginning and end of the southwest monsoon, which usually blows from May to September. The rainfall is variable in amount, but averages between 2 and 6 inches annually on the coast and be- tween 10 and 20 inches on the slopes of the mountains. At Zeila and Berbera over one half of the precipitation for the year has been known to fall in one day. The mean annual temperature approximates 83° F. to 85° F., with a mean minimum of 76° F. to 77° F., and a mean maximum of 90° F. to 92° F. During the hottest months, from May to September, temperatures may reach 110° F. on the coast and 118° F. in the in- terior. The temperatures on the interior plateau are normally 10° F. to 20° F. lower than those of the coastal region. The mean maximum temperature at Hargeisa is 84° F. to 86° F., and the mean minimum 56° F. to 58° F. Except for occasional thunderstorms between March and June, most of the rain- fall on the plateau is concentrated in the summer months. It averages between 10 and 20 inches a year in the north and some- what less in the south, while years of re- duced rainfall and droughts are frequent. The hot, dust-laden southwest winds, known as the kkarif, blow part of each day in July and August in the maritime zone and for a shorter period in the interior. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLAaTION Due to the nomadic character of the population, no more than an approximate enumeration has been attempted, but in 76 British Somaliland 1946, it was estimated at 720,000. The Somalis, a mixed people of Hamito-Semitic origin, are divided unevenly between the three Somali territories under British, French and Italian administration. Seven main tribes and numerous minor offshoots are settled in the British protectorate. Ac- cording to local legend, they represent two distinct races, the Asha tribes of Arab descent and the Hawiya tribes of Galla de- scent. In addition, there are certain scat- tered Sab or “outcast” tribes of Galla stock, namely, the Tomals, the Yebirs and the Midgans. The majority of Somali are Mohammedans of the Sunni sect, deeply religious and often fanatical in their ob- servances. The Sab tribes are also adherents of Islam. Somali is the universal language, but Arabic is used extensively in the larger towns. With the exception of a few established communities, British Somaliland is inhab- ited largely by nomadic tribes and has a population density which does not exceed 8 to 10 per square mile. There are few towns and villages. Most of the Somali live in small encampments, or rer, made up of one large family or a group of families trav- eling together for the sake of protection. They migrate over the country and even across the frontiers with their livestock, each tribe frequenting a designated area shared with one or more other tribes. In the coastal towns, the permanent population is relatively small but is augmented during the cooler months by a large influx of Somali traders. Berbera, the principal port and trading center, has a population of be- tween 5,000 and 10,000 throughout the greater part of the year, but it may reach 15,000 or 20,000 in the more favorable winter months. Hargeisa, the administrative headquarters, had an estimated population in 1949 of 32,000. Owing to the nomadic habits of the people little progress has been made in edu- cation outside of the settled areas. The gov- ernment operates elementary schools in the larger towns; a boarding school provides more advanced instruction at Sheikh. The level of literacy is low, and difficulty is encountered in recruiting Somalis with suf- ficient education for training to work in the medical and other services. VITAL STATISTICS The birth and death rates for British Somaliland are not known. An attempt was made by the government in 1937 to require the registration of births and deaths, but the statistics were so incomplete that it was abandoned the following year. The rigors of a nomadic existence in which only the fittest survive, the vicissitudes of the climate and the poverty and the undernutrition prevail- ing among large sections of the population are conducive to a high mortality, partic- ularly among infants and children. Informa- tion collected in the course of a medical survey in 1946* indicates a mortality rate of at least 73 per 1,000 births among infants under one year of age, and of 236 among children under five years. The stillbirth rates were estimated at 91 per 1,000, or more. Sociar Economy British Somaliland is essentially a pas- toral country, its principal wealth being in its livestock. Large numbers of hides and of sheep, goats, cattle and camels are exported, but, due to recurrent drought conditions, they are frequently of inferior quality. Other exports are gums, resins and ghee. The agricultural products are negligi- ble; only one three-hundredth of the land area is under cultivation. Food crops are raised chiefly in the districts west of Har- geisa. Little is known of the mineral wealth of the territory, but oil, coal and mica de- posits have been found in the coastal region. Since the British occupation there has been a steady growth of small local indus- tries, but, on the whole, the country has offered little opportunity for economic de- velopment. There are no railroads, but motor roads and caravan routes connect the British Somaliland 77 larger towns. Berbera is an important port for shipping traffic with Aden and the East African colonies, while air services are available from both Berbera and Hargeisa. Foop AnD NUTRITION The Somalis subsist largely upon milk and meat. The milk of the camel, which is widely used, has antiscorbutic properties. The flesh of sheep is usually preferred as meat. Maize, millet and beans are the major food crops, but small amounts of barley and wheat are also cultivated. Ghee is con- sumed in considerable quantities in the urban centers and in the coastal region, where rice and dates are also supplementary articles of diet. Since few fruits and vegeta- bles are grown locally, they do not consti- tute an important part of the average Somali diet. Malnutrition and avitaminosis are chronic among the Somali, while, during periods of drought when the livestock suffer from lack of forage, serious famine conditions may prevail. At such times the government often feeds thousands of families for long periods. Housine In the settled areas, the towns are made up of whitewashed stone and mud houses surrounded by a fringe of thatched Somali huts of poles and matting. The rapid in- crease in the size of the towns within recent years has led to serious overcrowding with a resultant deterioration in sanitary condi- tions. The nomadic tribes, on the other hand, live in temporary huts made of mats and grouped within enclosures for the pro- tection of their livestock. Living conditions are primitive in these traveling communi- ties which are continually exposed to the uncertainties of the weather and to potential shortages of food and water. In 1947 a Central Town Planning Board with statutory powers was established to regulate the expansion of the towns along lines compatable with the health and the welfare of the people. ENVIRONMENT AND SANITATION WATER SUPPLIES Water is scarce throughout a large part of the country. Many of the supplies for man and animals are derived from wells which vary from 5 to 250 feet in depth. In certain areas along the coast, subterranean streams flow just below the surface of the ground and are easily tapped by shallow wells. In other sections shafts and boreholes are driven in the narrow drainage channels, or tug beds. At points on the southeastern plateau the only permanent supplies are obtained from wells or cracks in the gypsum rock. Seasonal waterholes are the most fre- quent source of supply in the grazing areas. Hargeisa and Berbera are the only towns with any form of piped water supply, but in several others, water is pumped from wells to community storage tanks. In some the purveying of water by donkey-boys is a profitable industry. In Hargeisa the water supply is obtained from wells in the dry river bed and is piped to the European area and to the hospital. The principal source of supply for Berbera is from thermal springs at Dubar, 7 miles distant at the base of the maritime range. The water, which is saline and hard, is cooled and piped to Berbera where it is distributed through mains. In a few towns, particularly Borama, Erigavo and Hargeisa, the well supplies are aug- mented by the collection of rain water. There are no facilities for the treatment of town water supplies, and no system of bac- teriologic or chemical control. Due to in- sanitary methods of excreta disposal, all of the drinking waters in the Protectorate must be regarded with suspicion. Irrigation is not practiced except in the valleys of a few coastal streams where crude hand-operated pumps are employed. WasTE DisposaL In Berbera the sewage wastes of the hospital, most of the European residences and a few of the Asiatic are flushed into in- 78 British Somaliland dividual septic tanks. In other sections of the town the sewage is collected by the bucket system and conveyed out to sea by barges. The high level of subsurface water prevents the use of pit latrines in the native area. In the other townships, disposal is by means of the bucket system or pit latrines. However, the Somali customarily defecate in the open, often beyond demarcated boundaries. Fauna anp Frora Arthropods. Mosquitoes. At least 6 spe- cies of anopheline mosquitoes have been specifically reported from British Somali- land. Anopheles gambiae, which is probably the only important vector of malaria, breeds in various clear or muddy collections of water, wholly or partially exposed to sun- light. A. pretoriensis and A. rhodesiensis have been found naturally infected with malaria but, due to their limited distribu- tion, they are not regarded as important. A. d’thali is present in small numbers and is suspected of transmitting malaria on the basis of epidemiologic evidence. A. turkhudi and 4. macmahoni are also found, but 4. funestus has not been recorded from the Protectorate. Aedes aegypti is prevalent, particularly in the coastal towns. House surveys in 1943 revealed a larval index of 13.4 in Zeila, 11.5 in Berbera and 0.6 in Burao. This species is a local vector of dengue fever and a poten- tial vector of yellow fever. A. aegypti queenslandensis has been collected in Ber- bera, Burao, Laferug and Upper Sheikh. A. cumminsi, A. hirsutus, A. vittatus and A. arabiensis have also been identified. Eleven species of Culex have been re- ported, the most important of which are C. quinquefasciatus (= C. fatigans) and C. pipiens. Mosquito-control measures are carried on in the township areas. However, since domestic wells constitute an important source of anopheline breeding, the usual antilarval measures have a limited appli- cation. In 1946-47 experiments were under- taken using briquettes saturated with DDT in oil in the wells to control breeding. As of 1947, the Medical Department planned to introduce a program of residual spraying of the Somali huts, as soon as adequate per- sonnel and supplies of DDT became avail- able. Aedes control is carried on in Berbera, Zeila and other towns. Fries. Flies are numerous, but the rec- ords of specific species are incomplete. Species of TaBanmae which have been re- corded include representatives of the genera Chrysops, Pangonia, Tabanus and Haema- topota. The stable fly, Stomoxys calcitrans, is abundant and with other blood-sucking species may be responsible for the mechani- cal transmission of various infections. The tumbu fly, Cordylobia anthropophaga, an agent of human myiasis, and Auchmeromyia luteola, whose larvae are blood-sucking pests, are widespread in this general area. Phlebotomus flies, including P. papatasii, are presumably present since they are de- scribed from adjacent areas in Ethiopia, and occasional cases of sandfly fever and leish- maniasis are reported. Lice. Infestation with Pediculus humanus capitis and P. humanus corporis is common, particularly in the township areas. Freas. Little is known about the fleas indigenous to British Somaliland, but it may be assumed that a variety of species may be found. Xenopsylla cheopis has been collected at several points in the contiguous plateau area. It is a potential vector of plague and murine typhus, but neither dis- ease is known to be endemic in this region. The chigoe, or burrowing, flea T'unga pene- trans, is widely distributed. BebBucs. Cimex hemipterus and C. lectu- laris are abundant in the township areas. Ticks aAnp Mites. The camel tick, Ornithodorus savignyi, is common in open- air camp sites, while the tampan tick, O. moubata, infests permanent buildings, such as houses, coffee shops and mosques. Both are potential vectors of relapsing fever, which is endemic on the central plateau. Boophilus decoloratus, Hyalomma British Somaliland 79 aegyptium aegyptium, Rhipicephalus ap- pendiculatus and R. sanguineus are present. Argas persicus produces painful bites which may become secondarily infected. The itch mite, Sarcoptes scabiei, is prev- alent. Reptiles. The principal snake in the Protectorate is probably the carpet viper, Echis carinatus, which inhabits the sandy regions. Numerous other venomous snakes are reported from “Somaliland,” including the puff adder, Bitis arietans,; the black- necked spitting cobra, Naja nigricollis; the Egyptian cobra, Naja haje; and three spe- cies of Atractaspis—A. engdahlii, A. leuco- melas and A. microlepidota. Several species of CoLUBRIDAE are present but are not re- garded as especially dangerous, since their venom has a relatively low toxicity. Pela- mydrus platurus, the black-and-yellow sea snake, is said to range into the Gulf of Aden. Its venom is toxic, but it rarely at- tacks man except when forcibly restrained, as in fishermen’s nets. Rodents. Rats and other rodents are nu- merous. Rattus rattus rattus, R. rattus alexandrinus and R. norvegicus are widely distributed throughout this region, and it may be assumed that the first species, at least, is present in the Protectorate. Rat- control measures, adopted as a precaution against the introduction of plague, involve primarily the trapping of rats at the various seaports. There has been no evidence of plague among the rodent population. Mollusks.* Species of Planorbis snails have been reported from Sheikh and Gedeis. They are potential vectors of Schistosoma mansoni, but the presence of infection is uncertain. Plants. Among the poisonous plants re- ported from British Somaliland are Croton confertus, Bridelia somalensis, Acocanthera schimperi and Adenium somalense. The milky sap of Euphorbia nigrispina and E. noxia produces severe local reactions on contact with the skin. Numerous other * See footnote, p. 10. plants are found which have medicinal properties. The shrub, Catha edulis, is employed by the Somali as a substitute for Cannabis, or hashish. The use of this plant, known locally as Khat, is increasing rapidly and has become a matter of considerable medi- cal importance. When chewed or steeped as an infusion, the leaves yield a stimulant which dissipates fatigue and prevents sleepi- ness. The drug is used extensively during the period of Ramadan when the Moham- medans may eat and drink only after sunset. The excessive use of Khat is said to render the victim unfit for work. Its sale is re- stricted by ordinance to licensed dealers in Berbera, Borama, Hargeisa and Zeila. Foop SANITATION Little control is exercised over food sup- plies except in the larger towns. There is no system of meat inspection, except in Hargeisa where a native sanitary inspector remains in attendance during the process of slaughtering and condemns carcasses un- suitable for sale. Milk is sold in the local markets and is peddled from door to door by native vendors. There are no organized sanitary controls or facilities for pasteuriza- tion. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The Medical Department of the Protec- torate government is responsible for the protection of the health of the people and for the maintenance of hospitals and dis- pensaries. It is administered by a Director of Medical Services who is appointed by the Colonial Office in London. The present Department has evolved from the Civil Affairs Medical Department of the British Military Administration which assumed control of the government in 1941, follow- ing the 1940 campaign and the brief period of Ttalian occupation. The headquarters establishment is located at Hargeisa, while 80 British Somaliland medical officers direct the medical facilities and supervise the sanitary services in the five districts. The public health activities of the Department are restricted largely to the population centers, since personnel and equipment are not available to provide mobile units for the medical care of the people during the seasons when they are dispersed on the distant grazing grounds. A new maternity and child welfare clinic was opened in Hargeisa in 1946. Women’s and children’s clinics are conducted at Ber- bera, Burao, Borama and Erigavo under the voluntary supervision of the women of the European community. MEebpIcAL INSTITUTIONS Hospitals and Dispensaries. The Medi- cal Department operates central hospitals at Hargeisa and Berbera, and small regional hospitals at Borama, Burao, Erigavo, Sheikh and Las Anod, which provided a total of 625 beds in 1948. Special surgical and ma- ternity facilities are available at Hargeisa. An isolation camp for infectious diseases is maintained in connection with the hospital at Berbera. The leper camp, formerly lo- cated at Berbera, was moved to Borama in 1947. District dispensaries are established in the various population centers. Laboratories. A medical laboratory is at- tached to the hospital at Hargeisa which conducts diagnostic bacteriologic, serologic, chemical and pathologic examinations for the entire country. Smaller clinical labora- tories are located in the Berbera and other hospitals. Schools. A school is conducted by the Medical Department at Hargeisa for the training of Somali dressers and nurses. Instruction is also provided for sanitary assistants. PERSONNEL Physicians. There are no civilian doctors in British Somaliland, other than those of the Medical Department. In addition to the Director, from 8 to 11 European physicians and 3 Indian assistant medical officers were connected with the Department in 1948. Others. The European staff of the Medi- cal Department also included one pathol- ogist, five nursing sisters, one pharmacist and two health inspectors. The Somali staff consisted of 10 or more medical assistants, 106 dressers, 42 nurses and various other subordinate personnel. DISEASES Due to the nomadic nature of the popula- tion and the lack of continuity in medical services during the last decade, little infor- mation is available regarding the incidence of specific diseases in British Somaliland. The morbidity statistics compiled from hos- pital and dispensary reports are scarcely representative, since a large proportion of the patients is drawn from the towns where health conditions are not comparable with those in the rural areas. Malaria and medi- cal surveys authorized by the Medical De- partment in 1946 provide supplementary data, which, though incomplete, are useful in evaluating the distribution of infectious diseases. DisEASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. Dysentery is prevalent, par- ticularly among the children. On the basis of the meager evidence available, a large percentage of the cases appear to be bacil- lary in origin. In 1946-47 an average of 314 cases was reported annually, of which 247 were bacillary, 27 amebic, and the remainder unspecified. Outbreaks of diarrhea and enteritis are common and undoubtedly include many cases of unrecognized Shigella infections. In 1946 the medical survey unit estimated that 17 per cent of the deaths in childhood were caused by diarrhea and dysentery, while the experience of the child welfare clinic in Hargeisa suggests a higher mortality rate.* Typhoid and Paratyphoid Fevers. British Somaliland 81 Cases of typhoid fever are reported sporadi- cally, but, due to a lack of laboratory facilities, paratyphoid infections are rarely identified. Cholera. This disease has not been pres- ent since the nineteenth century when out- breaks were recorded from this region. However, there is always danger of its introduction by returned pilgrims from Mecca or through traffic with the Far East. Helminthiases. The incidence of infec- tion with different intestinal worms is not known. Ascariasis, enterobiasis and strongy- loidiasis are probably common, although relatively few cases are treated in the gov- ernment hospitals and outpatient dispensa- ries. Rare cases of schistosomiasis are re- ported without designation as to species. Infections with the beef tapeworm, Taenia saginata, are reported occasionally. A high rate of taeniasis was observed in the Ethiopian Refugee Camps at Borama in 1936-37, and at Manjasch in 1938. Other Infections. Cases of undulant fever are recorded from time to time. Large numbers of goats are raised in the Protec- torate, and the use of goat’s milk is rela- tively common. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread; from 500 to 600 cases are treated by the government services each year. About one half are pulmonary infections; bone and glandular lesions are also numer- ous. The Somalis possess a relatively low degree of resistance, and cases of pulmonary tuberculosis usually follow a rapid course. Smallpox. Epidemics of smallpox break out sporadically. Vaccination campaigns have been conducted at irregular intervals in the urban centers, but among the persons examined by the medical survey unit in 1946, only 40 per cent were found to be protected against smallpox, either by pre- vious infection or by vaccination. Vaccina- tion is compulsory for travelers entering the country. Prior to the disorganization occa- sioned by the recent war, vaccinators were stationed along the main traffic routes to vaccinate travelers and to isolate or exclude individuals suspected of having smallpox. Meningitis. Sporadic cases of meningo- coccus meningitis are reported almost an- nually, but no major outbreaks had been recorded within recent years until 1947-48, when the disease became epidemic in Burao and spread rapidly to Hargeisa and Ber- bera. The fatality rates among the treated cases were low. Other Infections. Pneumonia is preva- lent. From 450 to 600 cases are treated in the hospitals each year, about 50 to 70 per cent of which are listed as lobar pneumonias. Influenza and other respiratory infections are common. Chickenpox, measles, whooping cough and mumps are endemic. Scarlet fever, diph- theria and poliomyelitis are relatively rare. DiseEASES SPREAD OR CONTRACTED CHIEFLY THROUGH CONTACT Venereal Diseases. Syphilis and gonor- rhea are prominent among the diseases recorded, particularly in the towns of the coastal area. Soft chancre and other ve- nereal infections are also present. An aver- age of 4,565 cases was treated annually in the government hospitals in 1946 and 1947. Approximately 50 per cent were attributed to syphilis, from 29 to 39 per cent to gonor- rhea, from 3 to 3.5 per cent to soft chancre, and the remainder to other venereal in- fections. Separate venereal diseases clinics are conducted at Hargeisa, Berbera and Burao. Diseases of the Skin. Phagedenic ulcers are prevalent, both in the coastal regions and on the central plateau; they appear to be more frequent among men than among women. From 10,000 to 16,000 cases are treated each year. Ringworm and other mycotic infections are widely distributed. Madura foot occurs, and cases frequently require amputation 82 British Somaliland due to neglect and delay in seeking treat- ment. Actinomycosis is reported occasion- ally. Scabies is one of the principal skin dis- eases in all parts of the country. Human myiasis is sometimes encountered, espe- cially in the eastern districts. The burrow- ing flea, Tunga penetrans, is widespread and produces lesions which readily become sec- ondarily infected. Diseases of the Eyes. Trachoma is endemic, and from 20 to 100 cases are treated in the hospitals each year. The most prominent eye condition is conjunctivitis caused by the dust and the sandstorms of the kharif season. Thousands of cases of this noninfectious type of conjunctivitis are observed annually. Leprosy. The actual number of lepers in the Protectorate is not known, but in the opinion of the medical authorities the dis- ease is relatively rare. In 1939 the leprosy rate was estimated at 0.58 per 1,000 popu- lation.® The highest incidence is found in the vicinity of Hargeisa and along the Ethiopian frontier. Other Infections. Rabies is enzootic among the dogs, the jackals and the hyenas, and cases of human rabies are reported sporadically. Human anthrax infections are encoun- tered from time to time. DisEASES SPREAD BY ARTHROPODS Malaria. Malaria is a major cause of ill- ness in the Protectorate. The infection is = GULF OF ApEN Plu SEASON . ° OCCASIONAL * st." 7, (NEAR WATER) | Malaria in British Somaliland widespread but varies in distribution and in seasonal incidence in different parts of the country. The coastal plain is relatively free from malaria, except in scattered localities where special conditions favor anopheline breeding. The disease is also nor- mally absent or rare on the high central plateau, from Erigavo through Sheikh and Hargeisa, at elevations over 3,500 to 4,000 feet. Endemic malaria is encountered in numerous foci in the foothills of the north- ern escarpment, in the vicinity of perma- nent watercourses and around the many waterholes dug in seasonal streambeds. Ex- tensive outbreaks may occur after the rains when Anopheles gambiae breeds abundantly in the additional residual pools. The inci- dence of malaria among the pastoral tribes is governed by grazing conditions and the length of their sojourn in the endemic re- gions. In the south, in the grazing areas of the Haud plain, malaria appears in severe seasonal epidemics which vary in intensity with the rainfall. A high level of transmis- sion is reached about one month after the onset of the rains and persists for from two to three months, or longer in the vicinity of the larger rain pans. Infections with Plasmodium falciparum predominate. In 1946, 35 per cent of the 2,791 cases of malaria treated in the gov- ernment hospitals were diagnosed as sub- tertian and 32 per cent as tertian, while the remainder were unspecified. In 1947, 46 per cent of 2,551 cases were designated as subtertian and 2 per cent as tertian. In over 600 blood examinations made in the course of a provisional malaria survey in 1946,'8 P. falciparum was found in 68 cases, P. malariae in 8, and P. vivax in 2. Among 198 persons examined in the northern foot- hill country the parasite rates ranged from 22 per cent in children under 10 years of age to 9 per cent in adults over 20 years; the spleen rates ranged from 62 to 39 per cent, respectively. Comparable examina- tions among 618 Somalis on the southern plains revealed parasite rates of 10.2 per British Somaliland 83 cent in children under 10 years of age, and 6.3 per cent in persons over 20 years, while the corresponding spleen rates ranged from 29.6 to 22.4 per cent. Antimalarial drugs for treatment are dis- tributed free of charge at the hospitals and the dispensaries, and at the various police posts in the interior. Occasional cases of blackwater fever are reported. Relapsing Fever. Tick-borne relapsing fever is prevalent in certain endemic areas, particularly in the districts of Burao and, to a lesser extent, of Hargeisa and Borama. Cases occur sporadically and in minor out- breaks which are largely confined to the towns and the villages. From 400 to 800 cases are reported each year, which prob- ably represent less than half of the actual incidence. The tampan tick, Ornithodorus moubata, is common in the native buildings, as houses, coffee shops and mosques, and is probably the principal vector. Tickproofing of stone buildings, as the Masjid Jama Mosque in Burao, the disin- fection of walls and floors and such drastic measures as the burning of infected prem- ises have been effective in reducing the incidence of the disease. The residual spray- ing of coffee shops and other buildings with Gammexane was started on an experimental basis in Burao and Borama in 1946-47. Louse-borne relapsing fever is not re- ported from British Somaliland. Outbreaks are frequent, however, on the Ethiopian plateau, and the infection may have invaded the Protectorate in 1929, if not more re- cently. Rickettsial Infections. Neither epi- demic louse-borne typhus nor the flea-borne murine type has been reported. Louse-borne typhus is endemic in Ethiopia and the danger of its introduction cannot be ignored. Tick-borne typhus apparently occurs spo- radically ; a positive diagnosis was made in a European officer in 1936. Yellow Fever. Yellow fever has not been reported from this area, but the vec- tor, Aedes aegypti, is prevalent. British Somaliland is included in the zone desig- nated by the World Health Organization as endemic for yellow fever. Other Infections. Dengue fever is en- demic in the coastal areas where the vector, Aedes aegypti, is present. Pappataci, or sandfly, fever is rare but has been reported occasionally. Cases of cutaneous leish- maniasis and kala-azar are sometimes en- countered. Sporadic cases of guinea-worm infection, or dracontiasis, are recorded. There is no evidence that plague is endemic in this re- gion. NuTrITIONAL DISEASES Large numbers of the Somalis are con- tinually undernourished. Moreover, during years of drought conditions, famine condi- tions may prevail over extensive areas. Little information is available regarding the incidence of specific nutritional diseases. Beriberi is the most prevalent deficiency condition, but scurvy is also common. Rickets is reported occasionally. SUMMARY British Somaliland is an undeveloped pastoral country with a population which is largely nomadic. The health and medical care of the people is the responsibility of the Medical Department of the Protectorate government, which functions under the Colonial Office in London. The headquarters organization is established at Hargeisa. The Department maintains seven hospitals with a total of 625 beds and several rural dispensaries in various parts of the country. Water is usually obtained from shallow wells, many of which tap subterranean streams just below the surface of the ground, from deep bore wells, from springs in the maritime mountains and from water- holes and rainpans in the grazing areas. Small piped supplies are available in Har- geisa and Berbera. The methods of sewage disposal are primitive. The dietary stand- 84 British Somaliland ards of the people are low, and chronic malnutrition and deficiency diseases are common. Malaria, tuberculosis, tick-borne relaps- ing fever, venereal diseases and dysentery are major public health problems. Pneu- monia is prevalent. Skin and eye infections are common. Sand storms are responsible for a high incidence of conjunctivitis. Sporadic outbreaks of smallpox occur al- most annually. Dracontiasis, dengue fever, leishmaniasis, sandfly fever and human myiasis are encountered occasionally. Ra- bies, meningococcus meningitis, measles and whooping cough are endemic. Scarlet fever and diphtheria are rare. BIBLIOGRAPHY 1. Adamson, P. B.: Tropical ulcer in British Somaliland, J. Trop. Med. 52:68-76 (April) 1949. 2. Anderson, T. F.: Tick control by gam- mexane, East African M. J. 24:259-261 (July) 1947. 3. Boulenger, G. A.: A list of the snakes of northeast Africa from the Tropic to the Soudan and Somaliland, including Soco- tra, Proc. Zool. Soc., London, Part 4, 641-658, 1915. 4. British Somaliland. Medical Department: Annual Report, 1946. ; : Annual Report of the Medical Department for the year 1947. 6. Drake-Brockman, Ralph E.: British Somali- land, London, Hurst and Blackett, Ltd., 1942. 7. Glasgow, J. P., and MacInnes, D. G.: Anoph- eles of British Somaliland, East African M. J. 20:176-179 (June) 1943. 8. Great Britain. Colonial Office: Somaliland Colonial Report, London, H. M. Stationery Office, 1939. 9. Leprosy in British Somaliland: Leprosy Rev. 10: 89-100 1939. 10. Loveridge, A.: Check List of Reptilia Re- corded from British Territories in East Africa, J. E. Africa and Uganda Nat. Hist. Soc. Special Supp. No. 3 (May) 1924. 11. Lovett, W. C. D.: Control of mosquito breeding by the use of DDT solution ab- sorbed on briquettes, East African M. J. 24:196-198 (May) 1947. 12. Manson-Bahr, Philip: The prevalent diseases of Italian East Africa, Lancet I:609-612 (May 10) 1941. 13. Peltier, M.: Géographie médicale de la Cote des Somalis, Les grandes endémies tropi- cales 8:142-159 (March) 1936. 14. Somaliland Protectorate: Annual Medical and Sanitary Reports for the Years End- ing December 31, 1936-1939. 15. Thompson, A. Beeky: Water-supply of Brit- ish Somaliland, Geog. J. 51:154-160 (April) 1943. 16. United Nations: Non-Self-Governing Terri- tories. Summaries and Analyses of Infor- mation Transmitted to the Secretary- General during 1948, Lake Success, New York, 1949. 17. Van Someren, G. R. C.: Notes on the mos- quitoes of British Somaliland, Bull. Ent. Res. 34:323-328 (Dec.) 1943. 18. Wilson, D. Bagster: Malaria and relapsing fever in British Somaliland, Unpublished. 1946. 19. Yearbook and Guide to Southern Africa: 1950 Edition. London, Sampson, Low, Marston and Co., Ltd., 1950. French Somaliland GEOGRAPHY AND CLIMATE French Somaliland, the small section of Somali coast encircling the Gulf of Tad- joura, has a total land area of 9,000 square miles and a maximum depth of 130 miles. It is situated at the head of the Gulf of Aden and is surrounded by Eritrea, Ethiopia and British Somaliland. The interior is moun- tainous, while the coastal region, ranging in depth from less than 1 to 20 miles, is largely desert, broken by low isolated hills and occasional patches of arable land. The country south of the Gulf is a lofty undulat- ing plain, but to the north and the west it rises irregularly to the high mountains of the Ethiopian plateau. The lower portions of the interior hill country are almost de- void of vegetation, while the higher spurs contain stretches suitable for grazing. On the slopes of the Gouddah and the Mabla Mountains, north of the Gulf of Tadjoura, scattered forests and fair pasturage are found, but the rocky crags to the west and the northeast are without vegetation. Few rivers have water throughout their length, even in flood season. Several drain to in- terior lakes, but the Douila in the southeast is the only river which flows to the sea. The Ambouli, a subterranean stream of consider- able importance to Djibouti, fills for brief periods only after the rains. The climate of the coastal region is hot and humid. The annual mean temperature at Djibouti approximates 86° F., and the seasonal variations are relatively slight. The highest temperatures are experienced at the time of the southwest monsoon, which usu- ally extends from May to September. At 85 this season the temperature varies from 90° F. to 115° F., while the relative humid- ity averages between 50 and 60 per cent. Hot, sand-laden winds blow at frequent in- tervals in July and August. During the northeast monsoon, which lasts from No- vember to March but may be erratic until January, the prevailing temperature fluc- tuates around 77° to 80° F., and the relative humidity from 70 to 95 per cent. The an- nual rainfall at Djibouti averages between 4 and 5 inches, with the precipitation chiefly during the months of November and March or April. The rain is irregular in distribu- tion and sometimes falls in violent down- pours. Periodic droughts occur ; occasionally the rains may fail for successive years. No meteorologic data are available for the interior. In general the temperature is higher, and the rains are variable but most abundant in the summer months. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTion Due to the nomadic habits of the people, the population of French Somaliland is not accurately known, but, according to the census of 1946, it was estimated at approxi- mately 44,800. The size of the European and foreign communities fluctuated, but throughout the year they totaled from 1,400 to 2,000; over one half were French. In ad- dition to the indigenous tribes, the popula- tion included about 5,600 Arabs, 5,700 Somalis from the surrounding territories and small numbers of Sudanese, Malgaches and other groups. 86 French Somaliland The native inhabitants belong to two related but hostile peoples, both of eastern Hamitic origin. The Danakils, commonly designated as Afars, are settled in the northern and the western portions of the country. They comprise two separate groups, the peaceful Adoiemara tribes of the coastal region and the less numerous warlike Assaiamara tribes, located on the Ethiopian border. The Somalis who occupy the lands to the south belong to the Issa section of the Somalis; frequently they are referred to simply as Issas. The Danakil and the Issa tribes are Moslems. The Afar and the Somali dialects are distinct, but both are unwritten and are derived from the Galla of Ethiopia. Arabic is the usual medium of trade in the coastal towns, but many of the natives in Djibouti are familiar with French, the official language of the colony. The nonindigenous population is concen- trated to a large extent in Djibouti, the capital and the only town of importance. Its population is variously estimated, but in 1946 it approximated from 15,000 to 18,000. With the exception of small settlements on the coast and a few semipermanent com- munities in the mountains, the majority of the inhabitants have no fixed residence but migrate with their herds within designated tribal areas. The population outside of the settled minority is predominantly illiterate. The government maintains elementary and voca- tional schools for natives in a few centers and a separate school for Arabs in Djibouti. Catholic mission and small secular private schools are also established in the colony. VITAL STATISTICS Adequate vital statistics are not available for French Somaliland. Because of the nomadism of the people, the compilation of valid demographic data is impossible. The registration of births and deaths is required in Djibouti, but the transient nature of a large part of the population de- tracts from the value of such statistics. In 1948 the reported death rate was 17.7 per 1,000 population; the birth rate, 23.4. The infant mortality rate was unduly low—50.8 per 1,000 live births. SociaL Economy The barrenness and the aridity of the terrain and intertribal strife have adversely affected the cultural and economic develop- ment of the country. The majority of the inhabitants live a nomadic life under diffi- cult and primitive conditions. Large num- bers of camels and goats, along with smaller herds of cattle and sheep, are raised. With the exception of livestock and skins, the only export is salt. The working of extensive salt deposits at Lake Assal and in the vicin- ity of Djibouti constitutes the major local industry. Diibouti derives a certain prosperity from the fact that it is the terminus of the Franco-Ethiopian railroad which links it with Addis Ababa and represents Ethiopia’s major outlet to the sea. The town is favor- ably located at the head of the Gulf of Aden and is an important port of call for steamer traffic between Europe, Southern Africa and the Far East. Air services are also available to France and to other African territories. Land communications are meager; roads connect Djibouti with Zeila in British Somaliland and with Diredawa in Ethiopia. Elsewhere camel paths are the chief means of travel between the village communities. Foop AND NUTRITION The products of their flocks, supple- mented by millet, rice and dates, constitute the staple foods of the nomadic tribes. Milk is the principal and sometimes the only food. Meat is not generally eaten, except when animals are slaughtered as a matter of neces- sity or on feast days. The dietary of the settled populations is similar but more vari- able. Fish are used extensively along the coast. The aridity of the soil precludes agri- cultural development, although a few vege- French Somaliland 87 tables are raised by Arabs in the oases at Ambouli, near Djibouti, and at Tajura. Dates and the dum palm, which is valued for its sap, are grown around Djibouti. Undernutrition is general, and during periods of drought the shortage of food for both man and livestock becomes a matter of health and economic importance. Housine Living conditions in Djibouti differ in the European and the Arab quarters, as well as in the adjacent native villages, which are made up of primitive round mud huts. The town has developed irregularly, and the standards of sanitation are uniformly low. Recently a program calling for the erection of low-cost prefabricated housing has been undertaken by the government to relieve the serious overcrowding. The nomadic tribes live in temporary shelters, which are easily dismantled and transported. The usual dwelling of the Danakils is the portable oval tent made of boughs covered with skins or palm-leaf mats. The tents of the Issas are slightly more commodious, but neither type of shelter provides ample protection against the weather. ENVIRONMENT AND SANITATION WATER SUPPLIES Water is scarce throughout French So- maliland. There are few perennial streams, and the permanent lakes of the coastal region are strongly saline. In many areas, shallow wells that have been sunk in sub- terranean stream beds provide ample sup- plies of water, but in most localities such water is highly mineralized. Sink-holes con- stitute the major sources of supply along the travel routes of the interior. Djibouti obtains an adequate supply of water from the subterranean Ambouli River. The water is pumped to a collecting reservoir from wells 65 to 980 feet in depth, which tap the Ambouli about two miles from the city. It is piped to a limited num- ber of residences, chiefly in the European quarter, and to public fountains. The water is brackish and hard. The town supply is treated by chlorination but may be pol- luted after heavy rains. Drinking water which is ferried across the Gulf of Tad- joura from Obock and distilled and car- bonated waters of local manufacture are also sold. Waste DisposaL The methods of sewage disposal are primitive, even in Djibouti. There is no central collection system for the town, but many of the more modern houses have indi- vidual cesspools. Indiscriminate pollution of the soil is the general practice among the native tribes. Fauna anp Frora The arthropod vectors and the animal hosts which are responsible for the trans- mission of infectious diseases are essentially the same as those found in the adjacent territories of Eritrea and British Somali- land. Foop SANITATION Measures for the sanitary control of food supplies are enforced only in the town of Djibouti. The local Bureau d’Hygiéne is re- sponsible for the inspection of meats and other foods and for the control of retailing establishments. HEALTH SERVICES AND MEDICAL FACILITIES HeartH ORGANIZATIONS The medical and sanitary services are ad- ministered by the Direction du Service de Santé de la Cote Francaise des Somalis which functions under the Direction du Service de Santé Colonial of the Ministére de la France d’Outre-Mer in Paris. The headquarters of the Direction are located in Djibouti. Because of the nomadic nature of 88 French Somaliland the population, the activities of the depart- ment are largely confined to the capital and its environs, They include the maintenance of hospital and dispensary facilities, the control of communicable diseases, the su- pervision of environmental sanitation and the enforcement of port and air quarantine regulations. The director is a French colonial medical officer who is also chief of the hospital. Sanitary measures in the town of Djibouti are carried out by the local Bureau d’Hygiéne. Subsidiary welfare services are conducted with the co-operation of the Croix Rouge and the Goutte de Lait. MEebpicAL INSTITUTIONS In 1948 the Direction du Service de Santé operated a hospital and two dispen- saries (one for women and children and one for men) in Djibouti. The Hopital Colonial, which is the only general hospital in the country, has a capacity of 220 beds, and in- cludes special maternity, ophthalmologic and tuberculosis sections. The Direction also conducts rural dis- pensaries at Dikhil and Tadjoura, each with beds for emergency cases, and small infirmaries at Obock and Ali-Sabieh. The latter cares for both civilian and military patients. Small maternity wards are con- nected with the dispensary at Dikhil and with the Chapon-Baissac dispensary in Djibouti. The construction of a small tuber- culosis sanatorium in the mountains at Ali- Sabieh is planned for 1951. A diagnostic laboratory with facilities for the conduct of bacteriologic and serologic examinations is located in the hospital at Djibouti. PERSONNEL The European staff of the Direction du Service de Santé includes both military and civilian officers, some of whom are attached to the garrison infirmary. In 1948 it com- prised 5 physicians, 2 dentists, 2 pharma- cists, 1 veterinarian, 12 male nurses, 4 nursing sisters and 1 midwife. About 72 native nurses were employed in the hos- pital and the dispensaries. DISEASES The reports of disease incidence in French Somaliland are fragmentary, particularly among the nomadic tribes of the interior. No more than broad generalizations can be made in assessing the relative prevalence of specific infections. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or URINARY TRACTS Dysenteries. Both amebic and bacillary dysentery are common, but bacillary infec- tions apparently predominate. The majority are benign, although serious cases, caused by Shigella dysenteriae, are not infrequent. The incidence of amebiasis is relatively low in the indigenous population. Vegetative or cystic forms of Endamoeba histolytica were demonstrated in 30 out of 445 stool exami- nations made in the laboratory of the hospital in Djibouti in 1940; 14 were from Europeans, 8 from nonindigenous Africans, 3 from Asiatics and 5 from natives. Amebic abscess of the liver is seldom seen. Typhoid and Paratyphoid Fevers. Enteric fevers are endemic. Cases of typhoid fever and paratyphoid fever are reported sporadically, the known cases being asso- ciated primarily with the European popu- lations. Water-borne outbreaks are occa- sionally recorded. Helminthiases. ScHistosoMIasis. Schis- tosoma haematobium probably has not be- come established in the colony, but rare cases of suspected S. mansoni infection have been recorded. A few cases of schistosomi- asis, caused by S. haematobium and S. man- soni, are treated in the hospitals and the in- firmaries each year, but the majority are attributed to military personnel from Sene- gal or Madagascar. Ancyrostomiasis. Hookworm infection exists in the agricultural areas around Djibouti. Among the 445 stool specimens examined in the hospital laboratory in French Somaliland 89 1940 hookworm larvae were identified in 26, or 6 per cent. OtueErR HELMINTH INFECTIONS. Taeniasis caused by the beef tapeworm, T'aenia sagi- nata, is frequently observed, but the pork tapeworm, 7". solium, is rare. Infections with the dwarf tapeworm, Hymenolepis nana, are reported occasionally. Ascariasis and strongyloidiasis occur sporadically. Cholera. Cholera has not been present within recent years, but outbreaks were reported from the Somali coast during the past century. The possibility of the intro- duction of the disease by returning pilgrims from Mecca and other travelers is a threat to the town of Djibouti. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread. All forms are observed, but pulmo- nary infections predominate, particularly among the inhabitants of Djibouti and the small settlements along the coast. Bone and glandular lesions are seen frequently in the areas outside of Djibouti. The fatality rates are high; the infection almost invariably follows a rapid course, and the average native is reluctant to seek treatment until the disease is well advanced. Chronic under- nutrition and poor living conditions contrib- ute to the high morbidity and mortality rates. BCG vaccine was employed in the immu- nization of infants in Djibouti during the 1930’s, but the program was interrupted by the war in 1939. Smallpox. Mass vaccination has been carried on by the government health services since 1929, when an epidemic of hemorrhagic smallpox was responsible for 119 cases and 111 deaths. Subsequently, minor epidemics were recorded from Djibouti and Tadjoura in 1935, and from the Danakil country in 1940. Within recent years only sporadic cases have been reported. Other Infections. Pneumonia is preva- Ient. Measles, whooping cough and mumps are endemic, Outbreaks of meningococcus meningitis and poliomyelitis are reported at irregular intervals. Diphtheria is spo- radic, and scarlet fever is rare. Diseases SPREAD OR CONTRACTED CHierLY THROUGH CONTACT Venereal Diseases. The incidence of venereal infections is high and apparently is increasing. Hospital statistics provide an incomplete index of prevalence, since the natives rarely seek treatment, but they may give some indication of the proportionate frequency of the diseases of this group. In a total of 88 cases of venereal disease reported from Djibouti hospital in 1938, over 50 per cent were listed as syphilis and almost 25 per cent as gonorrhea. The remainder were about equally divided between soft chancre and lymphogranuloma venereum. Prosti- tutes are numerous; registered prostitutes are subjected to periodic examinations. Diseases of the Skin. Phagedenic ulcers are widespread and usually account for from 8 to 11 per cent of all the cases seen by the medical personnel. The infections are fre- quently serious and may involve bone le- sions. Mycotic infections are numerous. A highly contagious pemphigoid impetigo is not infrequent among Europeans. Diseases of the Eyes. Trachoma and other eye diseases are common. During the summer severe conjunctivitis may result from the trauma produced by the sand- laden monsoon winds. Other Infections. A few cases of leprosy have been recorded, but it is claimed that the majority were imported from the adja- cent territories. Tetanus infections are ob- served sometimes. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is irregular in distribu- tion. Two endemic foci are recognized: the Ambouli oasis located from 2 to 3 miles inland from Djibouti, and possibly the region around Dikhil, about 60 miles to the southwest. Until 1939 the town of Djibouti and the population centers on the 90 French Somaliland southern coast of the Gulf of Tadjoura were relatively free from the disease. Within recent years outbreaks of malaria have been reported from Djibouti, centering around the native villages. In 1944-46 the incidence ranged from 1,429 to 2,475 cases a year. The spread of infection from Ambouli was facilitated by the disturbances of the war period and the influx of Africans and Euro- peans into the area. Plasmodium falciparum is responsible for a large percentage of the malaria in this region. Among 391 cases diagnosed in the malaria laboratory at Djibouti in 1946, P. falciparum was dem- onstrated in 91 per cent, P. vivax in 9 per cent and P. malariae in 0.3 per cent. Anopheles gambiae is the most important vector. Antilarval measures are carried on by the health authorities in Djibouti in con- junction with the campaign against Aedes aegypti. Specific drug prophylaxis is also promoted among the affected populations. Filariasis. Cases of filariasis are observed occasionally, but usually among laborers from other parts of Africa. The infection probably is not indigenous to this area. Yellow Fever. Yellow fever has not been reported for over 50 years. In a protection test survey conducted by members of the staff of the Institut Pasteur de D’Afrique Occidentale Francaise of Dakar in Djibouti and Tadjoura in 1947 no evidence of im- munity to the yellow fever virus was found among the native residents. Aedes control measures are carried on in the vicinity of Djibouti, and the index of Aedes aegypti is maintained at less than 1 per cent. As a re- sult of the mosquito-control campaign the entire territory, including Djibouti, was ex- cluded from the yellow fever endemic area as defined by the World Health Organiza- tion in 1950. Other Infections. Dengue fever is en- demic, and outbreaks occur intermittently. Mild cases of the so-called “Obock” and “Massawa” fevers are regarded by many observers as forms of dengue fever. Tick-borne typhus fever and relapsing fever are not reported, but sporadic cases may occur since the potential vectors are present and foci of infection are found in the surrounding countries of Ethiopia, Eritrea and British Somaliland. The louse- borne infections have not been recorded. There are no records of the existence of plague in Djibouti, although it has been found within recent years in other Red Sea ports. Potential rodent hosts and flea vec- tors are abundant. NutriTiIoONAL DISEASES The existence of chronic malnutrition and avitaminosis among the inhabitants has been reported by many observers, but pre- cise information regarding the incidence of specific deficiency diseases is lacking. Scurvy is common, particularly among the nomadic tribes. Beriberi occurs sporadi- cally, while minor vitamin B deficiencies are general during the dry season when the supply of milk is limited. SUMMARY The medical and sanitary services of French Somaliland are administered by the Direction du Service de Santé de la Cote Francaise des Somalis, which operates under the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer in Paris. The activities of the department are concentrated around the town of Djibouti, and little or no provision is made for the medical care of the nomadic tribes. Water is scarce, except in Djibouti; fre- quently it is highly mineralized and pol- luted. Methods of sewage disposal are uni- versally primitive, and standards of com- munity sanitation are low. Intestinal diseases, tuberculosis, venereal diseases and skin infections of various kinds are prevalent. Malaria is endemic in limited foci, and within recent years outbreaks have been reported from Djibouti. Smallpox and meningitis occur in sporadic outbreaks. Severe conjunctivitis is common during the sand storms of the summer months. Dengue fever, trachoma, pneumonia, measles and whooping cough are endemic. Leprosy, French Somaliland 91 schistosomiasis and filariasis are reported relapsing fever probably occur. Plague, occasionally, but the majority of cases are yellow fever and cholera are not reported, not indigenous. Tick-borne typhus fever and but all are potential hazards. BIBLIOGRAPHY 1. Aubert de la Rue, E.: La Somalie frangaise, 8¢ édition, Paris, Librairie Gallimard, 1939. 2. Fighting France Yearbook: New York, France Forever, 1943. tion en Cote francaise des Somalis, Bull. Soc. path. exot. 38:344-356 (Nov.-Dec.), 1945. 8. Peltier, M.: Géographie médicale de la Cote 3. France: Ministere de la France d’Outre-Mer. des Somalis, Les grandes endémies tropi- Direction du Service de Santé Colonial. cales 8:142-159 (March) 1936. Rapport a la stuntion sanitaire dans les 9. Rapport sur le fonctionnement technique de eae d'outre-mer pendant I'Institut Pasteur de I’Afrique occidentale ann e . . . . . ry francaise: Dakar, Imprimerie africaine, 4. : Ministére de la France d’Outre-Mer. ae b Direction du Service de Santé Colonial. ] . rit Ay . Situation sanitaire de PEmpire francais. 10. République francaise: Ministére des colonies. Tableaux statisques 1941-1945, Marseilles, Agence générale des colonies, Service des Imprimerie Le Conte. renseignements, La Cote francaise des 5. ——: Secrétariat d’Etat aux Colonies. Direc- Somalis, Paris, 1930, Sh tion du Service de Santé. Le Gall, La situa- 11. Vogel, E. and Riou, M.: Les maladies épi- tion sanitaire de I’'Empire frangais pendant démiques, endémiques et sociales dans les P’année 1940, Paris, Charles Lavanzelle et colonies francaises pendant I'année 1937, Cie, 1943. Ann. méd. et pharm. colon. 37:257-551, 6. Grostilez et LeFevre: Les maladies transmis- 1939. sibles observées dans les colonies fran- 12. , and le Rouzic, J.: Les maladies trans- caises et territoires sous mandat pendant l'année 1938, Ann. méd. et pharm. colon. 38:183-359, 1940. 7. Leitner, A. J.: Etude sur la sous-alimenta- missibles observées dans les colonies fran- caises et territoires sous mandat pendant année 1936, Ann. méd. et pharm. colon. 36:352-520; 633-725, 1938. Somalia GEOGRAPHY AND CLIMATE Somalia, a long narrow strip of territory on the eastern border of the “Horn of Africa,” has a coastline of over 1,100 miles on the Indian Ocean and is bounded on its land side by Kenya, Ethiopia and British Somaliland. It varies from 90 to 250 miles in width and incorporates approximately 194,000 square miles. The southern portion became an Italian Crown Colony in 1910, but the northern part remained a protec- torate, ruled by the Sultans of Mijjerteins and Obbia until 1925-27. At that time the area of the colony was extended by the ces- sion of Kismayu (Chisimaio) and the land west of the Juba River to Italy by Great Britain. Under the Fascist regime, Somalia became part of the territorial unit desig- nated as Italian East Africa, but from 1941, following the occupation of the Italian colonies by the British forces, to 1950 it was governed by British Administrations. By resolution of the General Assembly of the United Nations in November, 1949, the country was restored to Italy, to be admin- istered under United Nations trusteeship, pending the decision of the Somalis them- selves regarding independence and self- government. The British authorities for- mally withdrew from Somalia in April, 1950. Topographically, the country is divided into a narrow coastal plain and a vast in- terior plateau which has an average altitude of 3,000 feet in Somalia, but it reaches greater heights as it extends westward into Ethiopia. The short strip of hilly country along the Gulf of Aden terminates in Cape Guardafui, while about 90 miles to the 92 south, the rocky peninsula of Ras Hafun marks the most easterly point on the Afri- can continent. The interior plateau is bi- sected by the Nogal, the Scebeli and the Juba rivers, which flow in a parallel south- east direction to the Indian Ocean. Both the Juba and the Scebeli are perennial ; but the Scebeli is deflected southward by a line of sand dunes about 12 miles from the ocean and, after flowing parallel with the coast for 170 miles, it disappears in the Bali Marshes north of the Juba estuary. The sandy hills and plains of the coastal area afford stretches of good grazing land and occasional belts of forest, but the most fertile soils are found in the narrow alluvial valleys of the Scebeli and the Juba rivers Except for limited stretches of alluvial land in the region between the rivers, the interior plateau is largely a barren, limestone waste about which little is known. The climate of Somalia is dominated byv the monsoons, the northeast monsoon blow- ing from November to March, and the southwest from May to September. During the northeast monsoon the highest tempera- tures are found on the south coast and in the interior, but at the time of the south- west monsoon the reverse is true. Few read- ings have been recorded, but the tempera- ture of southern Somalia is said to fluctuate between 58° F. to 60° F. and 100° F. to 104° F. The temperature of the interior is always higher and more variable than that of the coast. In the north the sand-laden kharif winds blow intermittently from July to September. The rainfall averages 10 inches annually on the coast and 20 to 30 inches in the interior, where the rains extend Somalia 93 over a longer period. Rain falls primarily in the transitional periods, with peaks in May and June and in October and November. The intervening months are relatively dry. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTion The population of Somalia was estimated at slightly over 1,750,000 in 1947. With the exception of a few Bantu tribes in the south and a sprinkling of Indians and Arabs in the urban communities, the inhabitants are chiefly Somalis, a mixed people of Hamito- Semitic origin. In addition, several thousand Italians are settled in the country, primarily in Mogadiscio and in the agricultural areas of the Juba and the Scebeli valleys. The total European population numbered about 12,800 in 1941 but decreased to 7,400 in 1947, largely as the result of the repatria- tion of Italian nationals. The Somalis may be divided into nu- merous groups and subgroups. Some are widely distributed throughout British and French Somaliland and Somalia, but others, as the Hawiya and the Rahanwin, are settled only in the latter territory. The Mijjerteins, natives of the old Sultanate of that name, are the most numerous tribe in the northern province. All of the native populations, including the Negroid peoples of the south, are Moslems. Somali is the universal language, but a profusion of dia- lectal variations is encountered among the different tribes. Swahili is employed by the Bantu of the south, while Arabic is exten- sively used in the towns and is the common language of trade. The agricultural areas of the Juba and the Scebeli plains and the commercial cen- ters along the coast are more or less densely settled. The rest of the territory, however, is sparsely populated by nomadic tribes and contains extensive areas of uninhabited wasteland. Mogadiscio, the capital and the only community of any considerable size, had a population in 1947 of 3,319 Europeans and 40,000 natives. Educational facilities for Italian children in Mogadiscio and the surrounding area are well developed, but little provision has been made for the edu- cation of the indigenous population. In 1938 a few schools were operated by Protestant and Catholic missions, largely in the towns of the southeastern coastal area. VITAL STATISTICS No reliable statistics are available for Somalia. While the reporting of births and deaths among the European residents is rea- sonably complete, the instability of the population within recent years detracts from the validity of the statistics. The compila- tion of demographic data among the no- madic tribes has never been attempted. The infant mortality among the Somalis is re- putedly high. It probably approximates 50 per cent during the first years of life in many areas. SociaL Economy The Somalis are essentially a nomadic, pastoral people and raise large numbers of camels, sheep, goats and other livestock. The settled Somalis are in the minority. They are found in the coastal towns, where they engage in trade, and in the agricultural areas of the south. The native artisans are to a large extent members of certain out- cast tribes, as the Midgans, the Yebir and the Tomals. The Bantu of southern Somalia are cultivators and are concentrated pri- marily on the fertile lands near the rivers. The Italian farming areas are restricted to the lower Juba and Scebeli valleys, where irrigation has been developed, especially in the vicinity of Genale and Villaggio. The Societa Agricola Italio-Somalia had 3,650 acres under cultivation at Villaggio Duca degli Abruzzi in 1942, almost 88 per cent of which was planted in sugar cane. A large percentage of the Italian-owned lands was worked by native tenantry. The mineral wealth of the territory is slight, but valuable salt deposits are located in the north. Other natural resources include 94 Somalia gum arabic, myrrh and frankincense, which are found abundantly in the interior. Hides and livestock are the major exports. The areas opened up for Italian occupa- tion are adequately supplied with good motor roads, but elsewhere the communica- tions are meager. Mogadiscio is connected with the southern provinces of Ethiopia by a system of roads which were constructed to facilitate the development of Eritrea, Ethiopia and Somalia as one administrative unit. It is also an important air and sea port for traffic with Europe and the East. The Juba is the only river which is navigable throughout the year. Foop AND NUTRITION The dietary of most Somalis is meager ; although it varies somewhat with the sea- son and the locality, undernutrition and vitamin deficiencies are almost universal. The nomadic tribes subsist largely on milk and on the flesh of camels, sheep or goats, supplemented by small amounts of millet and ghee. Beef is eaten infrequently. Dates are utilized when available, but green vege- tables and other fruits are almost com- pletely lacking. In the coastal areas, rice and tea constitute basic items of diet, to- gether with meat, milk and breads. Millet, the staple crop of the Somalis, is grown in all the agricultural regions. In the fertile Juba and Scebeli plains the crops are varied. In good years two plant- ings are possible: the main crops in April and May, and the second crops in October and November. Millet, maize, beans, pea- nuts, sesame and bananas are raised by the various native tribes, but rarely in amounts beyond their immediate needs. Before the war a large part of the Italian-owned land was devoted to maize, sugar cane, fruits and vegetables. However, within recent years the farms have suffered from lack of labor, and many crops have been abandoned. A large percentage of the fruits and the vege- tables is imported ; they are available only in the cities. Fish is an important source of protein in the coastal towns. Housine Marked contrasts exist between the living conditions of the different races. In Moga- discio the residences and the shops in the European section are well-built brick or stone structures. The native homes are pre- dominantly of two types: multiple houses of two or more stories and closely packed mud and wattle, thatched roof huts, both of which are apt to be overcrowded and insani- tary. The typical native dwelling in the agricultural areas is the primitive mud-and- wattle hut. The pastoral tribes move with their flocks and live in temporary tent com- munities. ENVIRONMENT AND SANITATION WATER SUPPLIES Villages adjacent to the Juba and the Scebeli rivers are assured of water through- out the year, although the river levels may be low in the dry season. In other parts of the country wells which tap the subterra- nean streams along the dried water courses, known as tugs, provide the main source of supply. Elsewhere water is obtained from springs or from natural or artificial collec- tions of rain water. Water sources are usually brackish on the maritime plain, while in the interior they have a high degree of hardness. The water supply of Mogadiscio is de- rived from numerous public and private wells; although potable, this water has a high saline and sodium sulfate content. Water is piped to tanks or cisterns in the European and more prosperous Arab houses. In the poorer sections it is frequently dis- pensed from water carts. The municipal supply is treated by chlorination. Bottled distilled water is also produced in munic- ipal plants. The water supply from the public wells and distilleries is controlled by the health authorities, and bacteriologic and chemical examinations are made at weekly intervals. Few protected water supplies are found Somalia 95 outside of Mogadiscio. Most surface and well waters are subject to contamination. Waste DisposaL Septic tanks and cesspools are the usual methods of sewage disposal in the sections of Mogadiscio which are provided with a piped water supply. Public and private latrines serve other parts of the town. Latrines are found in some rural areas, but in most native communities sewage disposal is a matter of soil pollution. Fauna anp Frora Arthropods. MosquitoEs. Several species of anopheline mosquitoes have been re- ported from Somalia, but Anopheles gambiae and A. funestus are the only important vec- tors of malaria. A. gambiae is the predomi- nant, if not the only, vector in the Juba and the Scebeli valleys. Abundant breeding places occur in the pools formed along the Juba as the river recedes during the dry season and in the areas affected by the over- flow of the Scebeli. Irrigation projects on both rivers also contribute to the breeding of anophelines. Other reported species in- clude A. pharoensis, which has been found naturally infected with malaria but is not regarded as a significant vector, and 4. cou- stani, A. rhodesiensis, A. claviger and A. squamosus. Aedes aegypti is prevalent in the coastal region. A. vittatus, A. albicosta, A. cum- minsi and other species are also present. Numerous kinds of culicines are found, among which Culex quinquefasciatus (= C. fatigans) and C. pipiens are the only species of potential medical importance. Mosquito-control measures are carried on in Mogadiscio and the larger population centers. In the Juba and the Scebeli plains antilarval programs involve the drainage of swampy areas, the cleaning of irrigation ditches, and the treatment of other bodies of standing water with oil, Paris green or DDT. During periods of heavy rainfall, effective control is practically impossible, due to the abundance of swampland. Larvae- eating fish are used extensively in areas where the domestic wells constitute major sources of anopheline breeding. In Moga- discio, Aedes control is facilitated by the enforcement of dry periods during which all the water containers must be emptied and dried in the sun. The larval index in the city is usually maintained at a low level except after rains that have been abnormally heavy. Fries. Numerous species of Chrysops, Tabanus and Haematopota are reported. Stomoxys calcitrans is common, and other related species may also occur. They are probably responsible for the mechanical transmission of intestinal infections. Tsetse flies are encountered in certain well-defined areas in southern Somalia, par- ticularly in the Juba region. Glossina pal- lidipes and G. austeni have been identified. Trypanosomiasis of animals is enzootic in some areas. Cordylobia anthropophaga, frequently implicated in cases of human myiasis, and Auchmeromyia luteola, a species with blood- sucking larvae, are present in Kenya and possibly in Somalia. Phlebotomus papatasii is specifically re- ported from Afmadu in the Scebeli region and from Bender Cassim in the Mijjertein territory. P. argentipes and P. congolensis, potential vectors of kala-azar, are also present. Lice. The reports regarding the preva- lence of human lice in Somalia are meager. Both Pediculus humanus corporis and P. humanus capitis are probably indigenous in the cooler districts. Freas. The common rat fleas, Xenopsylla cheopis and X. brasiliensis, are undoubtedly present, as in other parts of East Africa. Both are potential vectors of plague, al- though the disease has not been reported from this region within recent years. Ctenocephalides canis, C. felis and other species are probably numerous. The chigoe flea, Tunga penetrans, is found in the southern part of the country. BepBues. The bloodsucking bedbugs, 96 Somalia Cimex hemipterus and C. lectularis, are widely distributed. Ticks aNp Mites. Numerous species of ticks are reported from this area. Ornitho- dorus moubata and O. savignyi are abun- dant in the south, where O. moubata is found in the native houses, and O. savignyi in the open around the wells and the camp- ing sites. The former species is the vector of relapsing fever, which is endemic, par- ticularly in the vicinity of Villaggio. Rhipicephalus sanguineus, R. appendicu- latus, Amblyomma hebraeum and species of Boophilus are present and may be vectors of tick typhus in some localities. The itch mith, Sarcoptes scabiei, is wide- spread. Reptiles. A variety of poisonous snakes has been described from Somalia. Two cobras are reported, the spitting cobra, Naja nigricollis, and the Egyptian cobra, Naja haje. Elapechis boulengeri, a cobra- like aquatic species, also occurs. Dendro- aspis angusticeps, much dreaded because of its particularly poisonous venom, is found in the low-lying, dry bush country. D. anti- norii is described from adjacent Ethiopia and may be present in Somalia. The puff adder, Bitis arietans, inhabits rocky areas, especially near streams. The night vipers, Causus resimus and C. rhombeatus, and the carpet viper, Echis carinatus, are indigenous to many areas. Sand vipers of the genus Aspis (= Cerastes) are also reported, but the species are not specifically identified. Three species of burrowing snakes, Atract- aspis engdahlii, A. leucomelas and A. micro- lepidota, are recorded. Fourteen species of CorusripaE are found but are not usually regarded as dangerous. The black-and- yellow sea snake, Pelamydrus platurus, abounds in the Indian Ocean. Its venom is toxic but it does not usually bite unless forcibly restrained, as in fisherman’s nets. Rodents. The common domestic rat is Rattus rattus rattus. However, the roof rat, R. rattus alexandrinus, and the brown rat, R. norvegicus, are widely distributed throughout East Africa and may also be present. All three species are capable of serving as reservoirs of plague and may harbor the vector flea, Xenopsylla cheopis. Gerbils and other wild rodents are found in the semidesert areas. Mollusks. Fresh-water snails of the genera Planorbis, Ampularia, Bulinus and Physopsis are reported from numerous foci in southern Somalia. Species of Physopsis are probable intermediate hosts of Schis- tosoma haematobium, which is endemic in the irrigated farming areas. Foop SaNiTATION The inspection of markets, restaurants and other food establishments is carried on in Mogadiscio by municipal sanitary inspec- tors. Food handlers are licensed and are examined at regular intervals. Meat animals are slaughtered in the municipal abattoir under the supervision of the health authori- ties. The production of milk is not con- trolled, and raw milk is generally unsafe. Limited pasteurization facilities are avail- able, and the processing of butter and cheese is restricted to the use of pasteurized milk. The manufacture of ice is also super- vised by the sanitary inspectors. Samples of water, ice, milk and other foodstuffs are subjected to chemical and bacteriologic ex- aminations periodically. The sanitary conditions in the areas out- side of Mogadiscio vary. In some towns the food establishments and the slaughter houses are inspected by the medical per- sonnel. In general, however, the standards of sanitation are relatively low. HEALTH SERVICES AND MEDICAL FACILITIES HearLTH ORGANIZATIONS Since 1950, when Italy again assumed re- sponsibility for the government of Somalia, the health and medical services have been administered by the Ispettorato della Sanita Pubblica, a division of the newly created Ufficio di Sanita ed Istruzione Pubblica. The policies of the department are directed Somalia 97 by the Ispettorato Generale di Sanita, in Rome. The headquarters organization, which is located in Mogadiscio, has branches concerned with the maintenance of preven- tive services and of hospitals and dispensa- ries for the medical care of the population. The functions of the former branch include the control of infectious diseases, the super- vision of sanitation in urban and rural dis- tricts, the enforcement of quarantine regu- lations in Mogadiscio and other ports, the provision of laboratory facilities and the conduct of special programs for the control of tuberculosis, and malaria and yellow fever. Local health offices exist in Moga- discio and the larger towns which are re- sponsible for the environmental sanitation in their respective areas. MebpicaL INSTITUTIONS Hospitals and dispensaries. In 1951 the Ispettorato della Sanita Pubblica operated 3 hospitals with an aggregate capacity of 922 beds in Mogadiscio and 7 hospitals, pro- viding 267 beds, in the provinces. In addi- tion, it maintained 12 infirmaries with a total of 121 beds in the rural areas, 41 dis- pensaries and 6 clinics for women and chil- dren. The Ospedale Principale “De Martino” in Mogadiscio is the central hospital in the territory. With its annex, the Ospedale Rava, which specializes in the care of Italian children, it has a capacity of 672 beds. The third hospital in the city is for the treatment of infectious diseases and tuberculosis. Provincial hospitals, which range in size from 20 to 65 beds, are located at Chisimaio, Baidoa, Villaggio Duca degli Abruzzi, Belet Uen, Gallacaio, Bender Cassim and Alula. A leper settlement at Alessandra, an island in the Juba River, has facilities for the care of 150 lepers. Laboratories. The Ispettorato maintains a laboratory in Mogadiscio which has medi- cal and chemical sections. It performs the microscopic, bacteriologic, serologic and chemical examinations for the entire terri- tory. Clinical laboratory facilities are also available in the larger hospitals. The Istituto Siero Vaccinogeno of the veterinary depart- ment is situated at Merca. It prepares the smallpox and rabies vaccines used in Somalia and conducts research on the con- trol of various animal diseases. Schools. A school for the training of native nursing orderlies, nurses and dressers is operated in connection with the Ospedale Principale “De Martino” at Mogadiscio. Courses in midwifery are also given for Somali nurses. PERSONNEL Physicians. As of March, 1951, there were 37 physicians on the staff of the Ispet- torato della Sanita Pubblica. Nurses. In the same year the nursing personnel consisted of 16 Italian nurses, 26 native nurses and 28 nursing sisters belong- ing to religious orders. Others. The Italian staff of the Ispet- torato included 3 pharmaceutical chemists and 2 assistant pharmacists, 1 midwife and 26 sanitary inspectors. The roster of native personnel listed 6 midwives, about 250 hos- pital attendants, 5 sanitary inspectors and over 250 sanitary assistants. DISEASES The records of the incidence of com- municable diseases in Somalia are incom- plete. The morbidity statistics from the hospitals and the dispensaries provide a means of evaluating the presence of specific infections in the population centers but con- tribute little to our knowledge of health conditions among the nomadic tribes. Con- fusion in reporting and a dearth of basic research have been natural accompaniments of the successive changes in administration within the last 15 years. DiseASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. The dysenteries are wide- spread. Amebic dysentery predominates 98 Somalia among the known cases. Reports from all parts of the country for 1945-48 show an average annual incidence of 2,740 cases of amebic dysentery, as against 472 of bacil- lary. The differential diagnoses are probably unreliable except in the Mogadiscio hos- pitals, where the medical officers estimate that the proportion of proved cases aver- ages five amebic to one bacillary.® The incidence of mild bacillary infections is undoubtedly high, in view of the insani- tary conditions prevailing throughout the country. Low standards of personal cleanli- ness and the extensive pollution of water supplies are factors influencing the spread of intestinal infections. Typhoid and Paratyphoid Fevers. Both types of infection are endemic, al- though the number of cases reported an- nually is relatively small. Sporadic cases are treated in the hospitals, but few epi- demic outbreaks are recorded. Atypical in- fections, apparently related to the typhoid- paratyphoid group, are not uncommon in the Mogadiscio and the Bender Cassim (Mijjertein Province) hospitals. Helminthiases. ANcyrosTomiasis. Hook- worm infection is widely distributed in Benadir Province, particularly in the Vil- laggio and the Afgoi districts. Infection rates of 55 to 75 per cent are found in many localities in the lower Juba and Scebeli valleys. Both Ancylostoma duodenale and Necator americanus are present. Occasional cases are also reported from the upper Juba and the Mijjertein regions. ScuistosoMiasis, Schistosomiasis, caused by Schistosoma haematobium, is prevalent in the lower Juba valley and in the irri- gated areas of the Scebeli. Foci of high inci- dence exist in the vicinity of Brava and Merca. The reported cases number between 500 and 900 a year. Schistosomiasis also occurs around Wadi Sen Uen in the north- ern part of the country. Occasional cases of infection with S. mansoni have been re- corded, but none was acquired locally. OraER HELMINTH INFECTIONS. Ascariasis is the most prominent infection of this group; strongyloidiasis and enterobiasis occur less frequently. Tapeworm infections, caused by Taenia saginata, are common. T. solium is rarely encountered, as the population is predominantly Moslem, and the consumption of pork is forbidden. Cholera. Cholera has not been reported from Somalia territory within this century. During the epidemic in Egypt in 1947, cer- tification of anticholera immunization was required of all persons arriving at the port of Mogadiscio. Other Infections. Occasional cases of undulant fever, caused by Brucella meli- tensis, have been diagnosed in the hospitals in Mogadiscio. The extent of infection among the local animals is not known. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread but most prevalent in the urban areas and in Mijjertein Province in the ex- treme north. Among the 900 to 1,200 cases reported annually in 1945-48, over one half were from Mogadiscio. In general the dis- ease decreases in extent in direct proportion to the increase in nomadism among the tribes. Pulmonary infections predominate, except in the north where osseous, glandular and cutaneous forms occur with consider- able frequency. The low standards of nutri- tion contribute to high fatality rates. A tuberculin test survey among 173 Somalis in the® lower Scebeli region, reported in 1942.16 showed positive tuberculin reactions in about 23 per cent of the children and 34 per cent of the adults. A section of the in- fectious diseases hospital in Mogadiscio was opened in 1946 for the care of tuber- culous patients. Smallpox. Only sporadic cases of small- pox have been reported within recent years, most of which have been mild forms of the disease. Vaccination programs are carried on in the population centers by the health authorities. Other Infections. Pneumonia is preva- lent, particularly in the northern part of Somalia 99 the country. Whooping cough, chickenpox, influenza and mumps are frequently epi- demic. Measles is endemic, but the reported rates are not high. Meningococcus menin- gitis occurs sporadically and occasionally assumes epidemic proportions. Diphtheria and scarlet fever are rare. Diseases SPREAD OR CONTRACTED CuIierLy THROUGH CONTACT Venereal Diseases. Syphilis and gonor- rhea are prevalent among both the native and the European populations. Syphilis is widely distributed, not only in the towns and the villages but also in the pastoral dis- tricts where the nomadic habits of the peo- ple facilitate its spread. In most areas the percentage of stillbirths resulting from syphilitic infection is unusually high. Gonorrhea is also widespread, but soft chancre and lymphogranuloma venereum are encountered primarily in the coastal towns and the trading centers. The inci- dence of venereal infections is not known. Among the cases reported annually from the hospitals and the dispensaries in 1945-48, the number of cases of syphilis ranged from 12,000 to 21,400; of gonorrhea from 4,000 to 7,400 and of soft chancre from 1,300 to 1,800; while lymphogranuloma venereum was relatively rare. In 1945 the medical authorities estimated that prostitu- tion was practiced clandestinely by fully 30 per cent of the native women in Moga- discio. Leprosy. Leprosy is common in Benadir and Upper Juba provinces. Occasional cases are also encountered in the Mijjertein terri- tory in the north. The incidence is not known, but from 10 to 35 new cases are reported each year. The percentage of recog- nized infections is apparently decreasing. In 1939 about 175 lepers were segregated in the leper settlement on Alessandra Island, but in 1948 the resident population was only 112. Yaws. Yaws occurs among the inhabit- ants in the villages along the larger rivers and particularly in the lower Scebeli valley between Balad and Bulo Burti. The disease is rare in other parts of the country, but sporadic cases are reported. From 250 to 650 cases are treated in the hospitals and the dispensaries each year. Diseases of the Skin. Phagedenic ulcers are one of the most frequent causes of ill- ness in Somalia. From 38,000 to 65,000 known cases are recorded annually. The eti- ology of the condition is uncertain, but the ulcers are usually associated with under- nutrition, lack of cleanliness and trauma. The condition is widespread among the So- malis and is not uncommon among the Europeans. Mycotic infections are numerous. Infec- tions with Tinea cruris are prevalent, while actinomycosis and Madura foot are also observed. A condition of the lower lip has been reported in which the mucosa, irritated by the dust of the monsoon winds, becomes infected with pyogenic organisms. The ex- udate which forms dries in large crusts, and makes speaking or eating difficult. Infestation with the itch mite, Sarcoptes scabiei, is general, particularly in the up- country districts. The chigoe flea, Tunga penetrans, is indigenous in the southern provinces. Other Infections. Trachoma is present in the south, especially around Bardera, Lugh Ferrandi, Mogadiscio, Merca and Brava. From 25 to 250 cases are treated each year. Tetanus is sporadic. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is one of the most im- portant diseases in Somalia. It usually accounts for over one half of the cases of communicable disease reported from the provinces. The distribution and the sea- sonal incidence of malaria vary, depend- ing upon local conditions, which favor the breeding of the predominant vector, Anopheles gambiae. Except for a narrow strip of territory along the coast, which is relatively free from anopheline mosquitoes, malaria is widespread throughout the south- ern part of the country. It is highly endemic, 100 Somalia Malaria in Somalia with conditions approaching hyperendemic- ity, in the populous irrigated areas of the lower Juba and the Scebeli valleys. Trans- mission takes place throughout the year, with peaks of incidence from April to June and in October and November. In localities such as Villaggio Duca degli Abruzzi, Gen- ale, Lugh Ferrandi and Margherita, spleen rates ranging from 50 to 90 per cent and parasite rates around 40 per cent are com- monly encountered. In Upper Juba and Mudugh provinces malaria occurs in seasonal epidemics which are governed by the rainy season. The in- fection is rare in the northern part of the country except in two small foci—in the valley of the Daror River and around Eil on the Nogal. Plasmodium falciparum predominates and is responsible for from 75 to 90 per cent of the malaria treated in the hospitals and the dispensaries. P. vivax and P. malariae infections also occur but vary in prevalence in different localities. Mosquito-control measures are carried on in the population centers. Prophylactic treatment with antimalarial drugs is em- ployed extensively, chiefly in the European communities. Blackwater fever is occasionally seen. Relapsing Fever. Tick-borne relapsing fever is common in southern Somalia, where from 50 to 150 cases are reported each year from widely separated areas. The principal foci of infection are centered around Vil- laggio, in Benadir Province, and Dagabur in Ogaden Province (transferred to Ethiopia in 1948). The highest incidence is usually recorded between June and October. The native dwellings and rest houses are fre- quently infested with Ornithodorus mou- bata, the primary vector. Louse-borne relapsing fever is not known to be present, although epidemics are fre- quent on the Ethiopian plateau. Rickettsial Infections. Tick-borne ty- phus fever is endemic, and potential tick vectors are prevalent. Neither louse-borne typhus nor murine typhus has been re- corded. Plague. Epidemics of plague occurred prior to 1924, but since that date the dis- ease has not been included in Italian or British reports. There is some evidence that sporadic cases of bubonic plague appeared during 1935 in localities along the Scebeli and in the region between the river and the coast. Whether or not plague was recently established in Somalia, the disease must be regarded as a potential menace in view of its presence in Kenya and in the Arabian ports. Yellow Fever. Yellow fever has not been reported from this territory, and immunity surveys in Mogadiscio and other coast towns in 1942 indicate that probably the infection has not existed there within the lifetime of the present generation. Somalia is in- cluded in the endemic yellow fever area as defined by the World Health Organization. Aedes mosquitoes capable of transmitting the virus are abundant. Moreover, endemic foci were discovered in Kenya in 1943. Leishmaniasis. Cases of kala-azar are encountered occasionally. Proved infections Somalia 101 have been traced to localities in the Scebeli valley and near the Ethiopian frontier. Other Infections. Dengue fever is en- demic. Sandfly fever may occur. The vector, Phlebotomus papatasii, is present in Bendar Cassim where an epidemic of possible sand- fly fever was noted in 1936. Cases of dracontiasis, or guinea-worm in- fection, are sometimes admitted to the hos- pitals, but the majority of cases are not indigenous. Animal trypanosomiasis is enzootic in the extreme south, but human infections have not been reported. NurtritioNAL DISEASES Malnutrition and vitamin B and C de- ficiencies are widespread among the Somalis, particularly in the northern part of the country. Even in the fertile river valleys, fresh fruits and vegetables are scarce. The nomadic Somalis subsist to a large extent on the products of their herds and on grain. In the areas where camel’s milk is a staple article of diet, severe constipation is fre- quent. When the milk supply is curtailed, due to seasonal shortages or to outbreaks of disease among the herds, nutritional de- ficiencies may become serious. Scurvy and beriberi are common, while pellagra is re- ported occasionally. MiscerLaNEoUs CONDITIONS Infectious hepatitis is endemic in most parts of the country. SUMMARY The health and medical services in So- malia are administered by the Ispettorato della Sanita Pubblica, a division of the Ufficio di Sanita ed Istruzione Pubblica, with headquarters in Mogadiscio. The policies of the department are directed by the Ispettorato Generale di Sanita, in Rome. In 1951 the Ispettorato operated 3 hos- pitals with a capacity of 922 beds in Moga- discio, 7 hospitals with 267 beds in the popu- lation centers in the provinces and 12 in- firmaries with a total of 121 beds in the rural areas. It also conducted 41 dispensaries and 6 clinics for women and children. Water supplies are obtained from wells and springs or from the only two permanent rivers, the Juba and the Scebeli. Mogadiscio has a small piped supply which is chlori- nated, but most other supplies are untreated, and the majority are polluted to some ex- tent. The methods of sewage disposal are universally primitive. The dietary standards of the Somalis are low, and malnutrition and avitaminosis are commonly encoun- tered. Malaria, dysentery, tuberculosis and ve- nereal diseases are major public health problems. Relapsing fever, ancylostomiasis, schistosomiasis, trachoma, yaws and leprosy are prevalent, though restricted in distribu- tion. Pneumonia and upper respiratory in- fections are frequent. Various types of skin diseases are encountered. Vaccination pro- grams are carried on, but smallpox oc- curs sporadically. Outbreaks of meningococ- cus meningitis are reported occasionally. Whooping cough and measles are endemic, while the former is frequently epidemic. Dengue fever, sandfly fever and tick-borne typhus are endemic. Plague, louse-borne typhus, yellow fever and trypanosomiasis are not reported, but the insect vectors are present. BIBLIOGRAPHY 1. Albani, C. B.: La patologia e la terapia presso i Somali, Arch. ital. sci. med. colon. 19:439-448 (July) 1938. 2. 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La Face, L.: Fauna anofelinica dell Colonie italiane, Riv. di parassit. 1:1-120 (Jan.) 1937. Lega, G., Raffaele, G., and Canalis, A.: Missione dell'Instituto nell’Africa orien- tale italiana, Riv. di malarial. 16: (Sez. 1) 325-386, 1937. 4 , ——: Rapporto preliminare della missione dell’Instituto di Malariologia “Ettore Marchiafava” in A.O.I., Arch. ital. sci. med. colon. 18:309-315 (May) 1937. Lenti, P.: Il problema della tubercolosi negl’- indigeni africani; la tubercolosi dei neri, Arch. ital. sci. med. colon. 18:515-557 (Sept.), 579-605 (Oct.) 1937. Loveridge, A.: Check List of Reptilia Re- corded from British Territories in East Africa, J. E. Africa and Uganda Nat. Hist. Soc. Special Supp., No. 3 (May) 1924. Manson-Bahr, P.: The prevalent diseases of Italian East Africa, Lancet I:609-612 (May 10) 1941. Mariani, G., and Lopresti, A.: I parassiti intestinale della popolazione bianca in Somalia (dati statistici e considerazioni patogenetiche), Ann. dig, 46:480-496 (Nov.) 1936. Massa. F.: Contributo alla distribuzione geo- Somalia 103 40. 41. 42. 43. 44. 45. 46. grafica delle zecche “ornithodorus” nella Somalia italiana, Gior. di med. mil. 84: 453-459 (May) 1936. : Episodio epidemico di febbre ricor- rente nella Somalia italiana, Gior. de med. mil. 84:107-113 (Feb.) 1936. : Malaria somala, Gior. di med. mil. 84:643-651 (July) 1936. Mennonna, G.: Contributo alla conoscenza della malaria somala risultati degli accer- tamenti microscopici, Arch. ital. med. sci. colon. 17:678-683 (Nov.) 1936. Modugno, G.: La febbre ricorrente in Somalia, osservazioni cliniche ed epidemio- logiche, Gior. ital. di clin. trop., N. S. 1: (No. 2) 36-39 (Feb. 28) 1937. Moise, Regolo: Osservazioni sulle elimin- tiasi d’interesse epidemiologico ni Somalia (1932-37), Ann. med., nav. e colon. 44: 444-451 (Sept.-Oct.) 1938. Pepeu, F.: Studi sull’ofidismo nelle colonie italiane, Terapia 25:353-363 (Dec.) 1935. Polidori, I.: I micetomi in Somalia, Arch. 47. 48. 49. 50. 51; ital. sci. med. colon. 17:19-33 (Jan.) 1936. Rossi, G.: Cenni nosografici della Migiurtinia settentrionale (territorio della R. Resi- denza de Alula), Arch. ital. sci. med. colon. 19:449-461 (Aug.) 1938. Spoto, F.: Il trachoma ed altre malattie oftalmiche nella Somalia italiana, Rass. ital. d’ottal. 8:588-611 (Sept.-Oct.) 1939. Stefano, U.: Nosografia del Basso Uebi Scebeli (notizie raccolte in una spedizione del 1933), Arch. ital. sci. med. colon. 16: 819-829 (Nov.) 1935. Taddia, L.: Febbre esantematica da spiro- chete in Somalia, Arch. ital. sci. med. colon. 18:106-110 (Feb.) 1937. Talamonti, L.: Elmintologia e protozoologia intestinale negli indigeni del Basso Uebi Scebeli, Arch. ital. sci. med. colon. 14:111- 124, 1933. . Wilson, D. B., and Notley, F. B.: Malaria in southern Somalia (Italian Somaliland), East African M. J. 20:255-262 (Aug.) 1943. ETE SECTION THREE East Africa 10. 11. 12. 13. 14. KENYA UcaNpa TANGANYIKA NvAsALAND NORTHERN RHODESIA . SoUTHERN RHODESIA . MozAMBIQUE «107 . 130 . 149 . 169 . 180 . 194 . 208 ok Moshi Ap iV LW G > { TA A A Or ; NY. / 3 ~~ ~QElisabe N Zz Ft. Jameson’, / wr’ i Pretoria ~~, | o Preto 10 3 ol +2 Johannesburg, Mbdbo rr ~~ £ TIA SWAZH. OTT) - SANDY urengo Marques East Africa Kenya GEOGRAPHY AND CLIMATE The British territory of Kenya, which until 1920 was known as the East African Protectorate, comprises the Colony proper and the Protectorate, the 10-mile strip of coastal plain from the Tanganyika border to the mouth of the Tana River with the islands of Mombasa and the Lamu Archi- pelago, which are held on lease from the Sultan of Zanzibar. It is situated on the equator and extends from Tanganyika Ter- ritory in the south to Ethiopia in the north, and from Lake Victoria and Uganda in the west to Somalia and the Indian Ocean in the east. The territory, which covers an approxi- mate area of 225,000 square miles, is divided into topographically distinct regions. A fer- tile plain, varying in width from 2 to 10 miles, extends along the coast, while inland the country rises gradually to the highland plateau, which has a general altitude of 5,000 to 10,000 feet and contains some of the richest agricultural land in the world. The highlands are furrowed north and south by the eastern Rift Valley and include Mt. Kenya, the second highest mountain in Africa, from which the country derives its name. Toward the west the land slopes rap- idly to the shores of Lake Victoria. The northern three fifths of the Colony forms a vast plain, broken by mountain ranges in the west, which becomes arid wasteland toward the northern frontier. On the coast the temperature averages only 80° F., but the humidity, ranging from 74 per cent in December to 89 per cent in April, renders the climate damp and ener- vating. At Mombasa, the mean temperature during the hottest months, February to April, is from 82° to 86° F. and in the coolest months, June to August, from 72° to 76° F. In the highland plateau the tempera- ture is influenced by the altitude. In general, the atmosphere is bracing, the days are warm and the nights cool, with frost at the higher elevations. The mean temperature in Nairobi is about 67° F.; the mean maximum is 77° to 79° F., and the mean minimum, 56° to 57° F. The climate of the lake region is typically tropical, but because of the higher elevation the mean temperatures tend to range slightly lower than those of the coast. In general, the greater part of the territory north of the equator is hot and dry. Although the rainfall is extremely scanty in the area between Lake Rudolf and Somalia, the country as a whole expe- riences two rainy seasons: the “long rains” from March to June and the “short rains” from October to December. The annual rainfall along the coast averages between 40 and 50 inches, with about half recorded during April and May. The rainfall tends to decrease inland, with variations governed by the altitude, but averages 40 inches a year in the highlands and 100 inches on the densely wooded slopes of Mt. Kenya. In the region abutting Lake Victoria, it ap- proximates from 50 to 70 inches, with heavy precipitation during almost every month of the year. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTioN At the time of the census in 1948, the population of Kenya was given as 5,377,393. 107 108 Kenya It included 29,660 Europeans, 90,528 In- dians, 24,174 Arabs, 10,484 Goans and other non-native groups, and about 5.2 million na- tives. Almost three quarters of the popula- tion was concentrated in two of the six provinces, Central and Nyanza, which in- corporate the highland and lake regions. The white colonists are largely of British or South African descent, permanent settle- ment having started early in the current century. The Asiatics have a long history of contact with this region, especially along the coast where most of the Arab commu- nity is settled. Indian infiltration into the interior coincided with the British occupa- tion and was accelerated by the need for labor on the Uganda railway. This com- munity had increased from roughly 44 per cent of the non-native population in 1911 to almost 59 per cent in 1946. The indigenous populations comprise a congeries of tribes belonging to three ethnical groups, Bantu, Hamite and mixed Negroid-Hamite, but in- clude one pure Nilotic people, the Jaluo of Kavirondo, and large numbers of Swahili, located in the coastal areas. The best-known tribes are the Masai, a warlike pastoral peo- ple of the plains, the Kavirondo of the Lake region and the Kikuyu of the highlands. Bantu dialects predominate, but Swahili is used extensively as a means of communica- tion between the different races. The major- ity of natives are pagan, although the Chris- tian missions have made many converts in the interior, and the inhabitants in contact with the Arabs of the coast have assimilated Mohammedanism. A large part of the highland plateau, comprising roughly one fifth of the country is owned by the white settlers. The native “reserves,” in the contiguous portions of southern Kenya, embrace approximately 52,000 square miles. In 1948 almost 40 per cent of the indigenous population lived in Central Province, and 36 per cent in Nyanza Province, bordering on Lake Victoria. The population density in some agricultural dis- tricts is excessive. On the arable lands of the Kikuyu reserve, it is over 230 per square mile, while the Bunyaro and the Margoli districts of North Kavirondo support popu- lations of 750 to 1,200 per square mile. Nairobi, the capital of Kenya, is located in the center of the highlands. In 1948, after barely 50 years of settlement, it had a population of almost 120,000, including 10,830 whites, 37,935 Indians and 5,814 per- sons belonging to other racial groups. Mombasa, the second largest city and prin- cipal port, had a population close to 95,000. The white residents totaled only 2,027 in a non-native population of 41,893; while the Indians numbered 23,847, and the Arabs 13,485. The four other municipalities are Kitale, Eldoret and Nakuru, agricultural centers, and Kisumu, a rail and steamer terminus on Lake Victoria. Education presents a fourfold problem in Kenya, with separate school systems for Europeans, Indians, Arabs and natives. It is developed at elementary, primary and secondary school levels, and since 1942 it has been compulsory for all European chil- dren from 7 to 15 years of age, and for Indians living in Nairobi, Mombasa and Kisumu. Native education is conducted largely by the missions with financial assist- ance from the government. Since 1940, how- ever, elementary education in the native areas has been supported to an increasing extent by the Local Native Councils, either through grants to existing mission institu- tions or by the establishment of new village schools. A large section of the indigenous population is illiterate, while probably less than one half of the children of suitable age are enrolled in schools of any kind. It is the policy of the government to develop educa- tion along practical lines, in order to pro- mote the cultural and the economic develop- ment of the people. Increased opportunities for training to participate in the administra- tion of the country are being provided for qualified students. VITAL STATISTICS The registration of births and deaths is incomplete for both native and non-native Kenya 109 populations. In the absence of reliable population figures, no means are available for determining the health status of the indi- vidual tribes and the effect of the increasing urbanization upon the birth rates and death rates. In the case of the Asiatics, fre- quent migrations and the observance of racial practices and superstitions make the compilation of vital statistics difficult. Rea- sonably accurate statistics are available for the municipality of Nairobi. In 1948 the birth rate per 1,000 population was 24.6 among the Europeans, 53.9 among the Asi- atics and 23.6 among the natives. The death rates were 10, 8.2 and 12.2 respectively. The evaluation of statistics in the native population is always subject to error, since there is a continuous movement of people to and from the surrounding areas. The infant mortality rates in the 6-year period, 1943 through 1948, ranged from 33 to 75 per 1,000 live births among the Europeans; from 56 to 98 among the Asiatics ; and from 131 to 224 among the natives. The infant mortality rates in the reserves are generally high. Sociar Economy The economy of Kenya is primarily agri- cultural, although stock raising and forestry are important industries in certain regions. Extensive agricultural lands comprising most of the highland area are owned by Europeans, either individuals or companies. In 1946 pyrethrum, coffee, sisal and tea, which are largely grown on European estates, represented 75 per cent of the total agricultural exports. The social development of the tribes in Kenya has been slower than in Tanganyika and Uganda, but the production of the na- tive export crops, cotton, peanuts and oil seeds, has risen steadily. Soil conservation and the promotion of modern methods of cultivation among all races are prominent features of the development and reconstruc- tion program adopted in 1947. The natives constitute the major source of unskilled and semiskilled labor in the country. A large proportion are occasional workers who leave their villages for short periods, depending upon the labor demands of the port areas and of the coffee, sisal and pyrethrum estates. The majority of the Indians are traders or artisans, but a few are employed in the government service and in various professions. Small numbers have taken up land for cultivation in the lowlands. The mineral resources of the Colony are mostly of local importance, but some gold, soda ash and cyanite are exported. Within recent years there has been considerable de- velopment of secondary industries. Communication facilities in southern Kenya are comparatively well developed. The port of Mombasa is connected with Nairobi, Kisumu, and the agricultural dis- tricts, and with Uganda and Tanganyika by means of the Kenya and Uganda rail- way. A network of roads links the popula- tion centers, while motor roads connect Mombasa and Nairobi with Uganda, Tan- ganyika and the Sudan. Steamers ply from Kisumu to other Lake Victoria ports. Air transport and flying boat services, with con- nections to the principal towns, join Nai- robi to the United Kingdom, as well as to other countries in Africa. Foop AND NUTRITION There is considerable variation in the dietary customs of the different races and tribes of Kenya. Maize is the staple article of diet, but wheat, barley and oats are also grown by the European farmers, and millet and sorghum on the native holdings. Rice, peanuts, coconuts, legumes and indigenous fruits and leafy vegetables are cultivated by the various tribes. Cattle are raised in some areas, particularly in Central Kavi- rondo and in the northern uplands. The consumption and the availability of meat and dairy products differs among the tribes; milk is not used to any great extent, except by certain pastoral peoples such as the Masai. Fish is an important part of the diet of the inhabitants of the coastal and the lake regions. 110 Kenya It is probable that food always has been periodically scarce in Kenya, since the rec- ords point to two factors pre-eminent in curtailing the growth of the indigenous populations: tribal warfare and famine. Acute food shortages are experienced dur- ing periods of continued drought, as in 1943-44. Within recent years the Kenya gov- ernment has made a consistent effort to improve the native dietary. The highly publicized studies of the health and phy- sique of the Masai, a tribe subsisting largely on meat, blood and milk, and of the Kikuyu who live on maize, tubers and legumes, demonstrated that both diets were deficient in important nutritional elements. The government has also endeavored to pro- mote mixed farming and to educate the natives in sound methods of agriculture and dairying. Housine The traditional native dwelling in the re- serves is a circular, mud-and-wattle or brushwood hut, with a thatched roof. In many tribes four or five huts housing the members of the family and the livestock are clustered together. Pollution of the soil around such clearings by man and animals is common, especially where drainage is poor. The thatch roofs also provide ex- cellent harborage for rodents. However, improvements in village sanitation are grad- ually being introduced, and among the en- lightened natives there is an increasing demand for larger dwellings of improved construction. In the towns the problem of housing is often acute. Home building has not been able to keep pace with industrial development. In Nairobi and other munic- ipalities the natives live in designated areas or “locations.” Overcrowding is general, while insanitary temporary structures house large numbers of migratory workers. Vari- ous government departments, the railway administration, a few municipalities and some private companies have constructed modern sanitary dwellings of permanent materials for their workers, but in many cases the living conditions are as primitive as in the rural areas. In 1943 a Central Housing Board was appointed by the gov- ernment to study and stimulate improve- ments in native housing. Large sums were also granted from the Colonial Development and Welfare funds in 1944-45 in support of government and municipal programs in Nairobi, Mombasa and other urban areas. New projects are taking the form of public estates with individual brick or stone dwell- ings, accommodating from 2,000 to 3,000 or more families, and including clinic and rec- reational facilities. The Indian sections of the towns are fre- quently overcrowded, while the bazaars are dilapidated and a menace to the health of the community. The first development of workingmen’s homes and flats for Asiatics was completed in Nairobi in 1946. Closely allied with the question of hous- ing is that of settlement. Resettlement of the people within the native areas to facili- tate the promotion of modern methods of agriculture and animal husbandry, and also the absorption of surplus populations on new lands represent two aspects of a complicated problem which has a definite, though indirect, bearing on health. ENVIRONMENT AND SANITATION WATER SUPPLIES Water is a problem of primary concern in all parts of central Kenya. Only 11 per cent of the country experiences an an- nual rainfall exceeding 40 inches, while in approximately 40 per cent it is less than 20 inches. The village supplies are derived from streams, springs, boreholes and sur- face waterholes, sometimes at a consider- able distance. Deforestation, overstocking and primitive native methods of cultivation have had a serious effect on the physical condition of extensive areas. The retention of ground moisture, the yield of springs and the period of flow in the rivers have been reduced materially. Modern water supply systems exist in Kenya 111 Nairobi, Mombasa and some of the larger towns. The supply for Nairobi is derived from a reservoir at Gethinguri on the Ruiru River, 19 miles from the city. It is piped to a pumping station on the outskirts and treated by filtration and chlorination before distribution to individual outlets in the European and Asiatic quarters and to com- munal taps in the native locations. Bacterio- logic and chemical examinations are made almost daily. The present supply is inade- quate to meet the rapidly growing needs of the city, and in years of low rainfall acute shortages may occur. The storage capacity of the Gethinguri reservoir has been in- creased recently from 120 million gallons to 700 million gallons. The work on the dam was completed early in 1950. A second reservoir at Sasumua, on the Chania River, is in process of construction and probably will be ready by 1954-55. The new reser- voir will have a capacity of 1,600 million gallons. The water for Mombasa and the adjoin- ing port area is supplied from streams in the Shimba Hills near Kwale, about 20 miles southwest of the city. It flows by gravity to three reservoirs, arranged in series at Changamwe, where it is chlo- rinated. Mombasa, like Nairobi, experiences serious shortages of water during periods of drought, and the possibility of tapping sup- plementary streams in the Shimba Hills is being investigated. Additional well supplies are available on Mombasa Island which are used for irrigation purposes, and to some extent by the native and the Indian com- munities. The water supplies of most of the remaining towns are obtained from bore holes ; a few from rivers. The water derived from treated supplies may be considered safe under normal conditions. However, the springs and the wells in the native areas are apt to be contaminated because of the in- sanitary practices of the people and the primitive methods of sewage disposal. Waste DisposaL Although there has been a progressive improvement in sanitation, conditions throughout the country are far from satis- factory. Nairobi has a modern sewerage system, but at present it serves only the congested central area. The sewage is dis- charged into the Nairobi River following treatment. In the European residential sec- tions septic tanks are employed. In the built-up areas, they are connected with con- servancy tanks, which are emptied at regu- lar intervals. The bucket system is still in use in a large part of the city. The need for a central sewerage system in Mombasa is acute. Cesspools are used extensively in some areas, but they require constant attention and constitute a source of contamination to the underlying water- bearing strata. In the larger and more mod- ern buildings, the sewage is treated in septic tanks prior to its discharge into cesspools. However, the bucket system is employed by considerable sections of the general pop- ulation. The night soil is trucked to a con- fined area near the inlet to Kilindini Har- bor; when the tide flows out, the gates are opened, and the sewage is carried out to sea. This method of disposal is considered a serious menace because of flies. In the smaller townships both soakage pits and pail collection with subsequent trenching of night soil are employed. An effort is being made to introduce pit-latrines in the native reserves. In 1944 alone over 2,000 latrines were constructed, largely under the guidance of the Colonial health authorities. The contamination of surface and ground water supplies is to be expected with the insanitary methods of sewage dis- posal prevailing in most areas. Fauna anp Frora Arthropods. Mosqurtoes. Thirty-seven species of anopheline mosquitoes have been recorded from Kenya. The only species of known medical importance, however, are Anopheles gambiae and A. fumestus, both vectors of malaria. A. gambiae breeds in small pools and artificial collections of water exposed, at least partially, to sun- 1312 Kenya light. Within its temperature requirements, it flourishes even at the higher altitudes and is implicated in the transmission of malaria in Nairobi and the highlands at elevations up to 8,500 feet. It is often responsible for epidemic malaria in areas at altitudes of over 5,000 feet. A. fumestus breeds in the clear or stagnant waters along the edges of swamps, the weedy sides of streams, rivers and ditches and the protected margins of lakes and ponds. It is also found in the numerous wells, especially in the vicinity of Nairobi. 4. funestus is usually secondary to A. gambiae in importance but may be the primary vector of endemic malaria in some areas. In general, A. gambiae is the vector during the rainy season, but 4. fu- nestus, when present, carries on transmis- sion for a more prolonged period, extending into the dry season. Numerous species of Aedes mosquitoes have been reported. Aedes aegypti, the vec- tor of yellow fever and dengue fever, is one of the most prevalent mosquitoes in the territory. It is particularly abundant in the coastal area and in the vicinity of Kisumu, Kakamega and Nairobi. A. simpsoni, a known vector, and A. vittatus, a laboratory vector of yellow fever, are widely distrib- uted. A. aegypti is prevalent in the recently discovered Taveta and Langata forest foci near Nairobi. In the former area, A. simp- soni is also frequent. In the latter, A. de- boeri is the most numerous species in the forest canopy,'® #2 but its role in the trans- mission of the virus has not been estab- lished. A. taylori and A. furcifer, known vectors in the Sudan, are found in the vicinity of Nairobi and in the coastal region. A. metallicus, which has been shown to be capable of transmitting the virus in monkeys in the Sudan, occurs at Nairobi and Kisumu, as well as on the coast. 4. africanus, an important vector of sylvan yellow fever in Uganda, is present in the Kisumu and the coastal areas but is absent in the Nairobi region. Over 30 species of Culex mosquitoes have been recorded; Culex quinquefasciatus (=C. fatigans) is found throughout the country. It is a known carrier of Wuchereria bancrofti, and with Anopheles gambiae is responsible for the transmission of filariasis in Kenya. Eretmopodites chrysogaster, Taeniorhynchus (Mansonia) africanus and T. (M.) uniformis are present. The last species is particularly widespread. Programs for the control of Anopheles and Aedes mosquitoes are carried on in Nairobi, Mombasa and the larger town- ships. Anopheline control measures include permanent drainage projects and the routine treatment of surface waters with oil, DDT and other larvicides. The intensity of Aedes control varies in the different towns but has been reinforced since the discovery of a case of yellow fever at Kisumu in 1942. The Aedes index is maintained at a low level; in 1947 the mean index at Nairobi was 0.19, and at Mombasa, 0.3 to 0.4. Mos- quito control is undertaken by the munic- ipal authorities in Nairobi and Mombasa and by the Insect-borne Diseases Division of the governmental health services in other localities. Field experiments in anopheline control which have been carried on by this division in the last few years have included the impregnation of native huts with DDT preparations and the use of DDT smokes. Fries. Eight species of tsetse flies are recorded from areas which total over one seventh of the territory. Glossina palpalis is found in the Lake Victoria region, along the shores of the lake and the banks of the rivers which feed into it. It is the vector of Trypanosoma gambiense, the most frequent cause of human trypanosomiasis in Kenya. G. pallidipes is widely distributed ; in 1942 it was incriminated in a small outbreak of T. rhodesiense in Central Kavirondo, un- doubtedly an extension of the Busoga epi- demic in Uganda. G. swynnertoni has also been implicated in the transmission of T. rhodesiense. 1t was the probable vector in a small outbreak in the sparsely settled Masai district on the Tanganyika borders in 1947. This species is found primarily in the savannah country, east of the Mara Kenya 113 f ner HA : victofiga™ ar fi oNarohi 62 Pe “Wea kins 2 Lin ~ P. Glossina pallidipes P.Glossina palpalis L - Glossina longipennis A. Glossina austeni M. Glossina morsitans S.Clossina swynnertoni Distribution of Tsetse Flies in Kenya River in southwestern Kenya. Five other species are likewise involved in the trans- mission of animal trypanosomiasis: G. lon- gipennis in large sections of the savannah country; G. morsitans in the northeast cor- ner of the Colony; G. austeni in the coastal region; and G. brevipalpis and G. fusci- pleuris in small foci along the densely wooded banks of certain rivers. Control measures vary in different locali- ties, depending upon the habits of the tsetse flies indigenous to the region. Tsetse-fly control is important not only from a medi- cal standpoint but also for economic rea- sons. Trypanosomiasis of cattle is a major problem throughout East Africa, since it affects the nutrition and the prosperity of the people. Linear waterside clearings, bar- rier clearings, fly trapping and other meth- ods of control are carried on continuously by the Kenya medical and veterinary de- partments. The Tsetse and Trypanosomiasis Research and Reclamation Organization was established by the East Africa High Commission in 1948 for the purpose of co-ordinating the research and the reclama- tion programs of Uganda, Tanganyika and Kenya. The Organization maintains its headquarters in Nairobi. It functions in an advisory capacity and also operates centers for the conduct of field and laboratory in- vestigations. The Shinyanga Research Sta- tion in Tanganyika and the proposed Trypanosomiasis Research Institute at Sukulu, near Tororo in Uganda, come within the Organization’s program. At least 12 species of SiMULIIDAE, or buffalo gnats, have been identified. Simu- lium neavei, the principal vector of Oncho- cerca volvulus in Kenya, is found in nu- merous foci in the Lake Victoria region. S. damnosum occurs in small numbers in localized areas but probably plays a minor role in the transmission of onchocerciasis. S. dentulosum has been recorded from South Kavirondo and from the foot of Mt. Kenya. S. macmahoni and S. kenyae are common. Control programs are carried on in some foci. In 1946 S. neavei was eradicated from the Kodera area of South Kavirondo by treatment of the Sandra and the Kitare rivers with DDT emulsions. The following year the project was extended to include other foci in the Kakamega-Kaimosi region. The blowfly, Chrysomyia chloropyga, is prevalent in the humid sections of the coun- try, particularly during July and August, and is a frequent cause of human myiasis. C. bezziana and C. marginalis have also been reported as responsible for occasional cases of myiasis. Cordylobia anthropophaga, the African “tumbu fly,” is responsible for myiasis among Europeans and natives in Nairobi and the surrounding areas. Gaster- ophilus intestinalis is found in the Nairobi and the Naivasha regions, and its larvae sometimes cause creeping myiasis in man. Sarcophaga haemorrhoidalis and Oestrus ovis are also common. Auchmeromyia lu- teola is widely distributed. Its larvae, known locally as “Congo floor maggots,” may be annoying bloodsuckers. Twelve species of sandflies have been re- corded, including Phlebotomus clydei, P. congolensis, P. africanus, P. schwetzi and P. signatipennis. P. clydei is suspected of being the vector where kala-azar has oc- curred in Frontier Province. The biting midges, Culicoides austeni and C. trichopes, are known to be present. Eye gnats of the 114 Kenya genus Hippelatus are prevalent in some areas. Lice. Infestation with lice is common among the various tribes. All three species of human lice, Pediculus humanus corporis, P. humanus capitis and Phthirus pubis, are present. Lice were implicated in the serious outbreak of relapsing fever in the vicinity of Mombasa in 1945. Freas. Xenopsylla cheopis is the principal vector of plague, while X. brasiliensis is of major, though secondary, importance. X. cheopis is the dominant species in epi- demic outbreaks of plague in the urban areas. X. brasiliensis is usually associated with the rats nesting in the roofs of the native huts and is the chief vector in the rural areas. It may also be found in large numbers in the Indian bazaars and grain warehouses. X. humilis, X. nubicus, and X. robertsi are plentiful. The cat flea, Ctenocephalides felis, infests both cats and dogs. Ctenophthalmus cabirus, Dinopsyllus lypusus and other species are present. None, however, has yet been proven a vector of plague. The sand or chigoe flea, Tunga penetrans, is common in many areas. It is frequently responsible for foot-and-leg sores among the natives. Bepsucs. The bedbugs, Cimex hemipterus and C. lectularis, are prevalent. The latter is most plentiful in the rainy season. Ticks anp Mires. The tampan tick, Ornithodorus moubata, which transmits Borrelia duttoni, the causative agent of re- lapsing fever, is widely distributed. It has been reported from localities up to 9,000 feet, but it is found most frequently in the native huts and camping sites along the coast from Mombasa to Lindi, on Mt. Kenya and in the Kavirondo area of Nyanza Province. O. savignyi, which must be re- garded as a potential vector, is present in the drier portions of the country. RhAipi- cephalus sanguineus, R. simus, and Haema- physalis leachi are the principal vectors of tick-borne typhus fever. R. pulchellus, the pepper tick, is abundant in the hotter re- gions; R. appendiculatus, R. evertsi and R. capensis are also found. Amblyomma variegatum and other species are reported from many areas. The itch mite, Sarcoptes scabiei, is in- digenous. Oruer ArtHrOPODS. The vesicant bee- tle, Paederus crebripunctatus, colloquially known as the “Nairobi fly,” occurs irregu- larly throughout the territory. Its body juices are very irritating and may cause blistering, if the beetle is crushed on the skin, or conjunctivitis, if they reach the eye. Driver ants of the genus Dorylus are en- countered in some areas, where they are known as “safari ants.” Several species of hairy caterpillars are found, some of which cause a painful urticaria. Reduviid bugs are numerous. Scorpions of the families PANDI- NIDAE and ButHIpaAE are found in the dry country. Reptiles. Numerous venomous snakes occur, particularly on the coastal plain. The common mamba, Dendroaspis angusti- ceps, which because of its ferocity is con- sidered by many to be the most dangerous snake in Africa, is found in the south, along the coast and in the Sabaki River valley. The green mamba, Dendroaspis jamesonii, is present in the Kavirondo region. Ela- pechis guentheri, the African garter snake, is common in the Nairobi area. The Egyp- tian cobra, Naja haje, is found throughout Kenya, especially between the coast and Nairobi, while N. nigricollis is reported from Nairobi and from the Lake Rudolf region. N. melanoleuca is sometimes encountered. The puff adder, Bitis arietans, is widely distributed. B. nasicornis is found in the western part of the Colony; and B. worth- ingtoni, in the Lake Naivasha area. The night viper, Causus rhombeatus, exists around Nairobi and in the Kavirondo dis- tricts, while Causus resimus is present near the coast, and C. lichtensteinii, in the west. Echis carinatus inhabits the steppe country of Turkana and Northern Frontier districts. The burrowing vipers, Atractaspis irregu- laris and A. bibronii, are also reported. The Kenya 115 rear-fanged Dispholidus typus is found in the western districts. The rocky python, Python sebae, is common in some areas. Though nonpoisonous, it may attack the smaller domestic animals. Rodents. Rattus rattus alexandrinus is present in large numbers and constitutes the primary rodent host of human plague in both urban and rural foci. It is rapidly replacing the usual house rat, Mastomys coucha, in the native reserves. R. rattus frugivorus and other subspecies of R. rattus are present, identification of which is still uncertain. R. norvegicus is found in the port areas. A desert rat of the genus Tatera may be a reservoir of sylvatic plague, but its role has not been established. Arvicanthis abyssinicus and Otomys angoniens are present but have not been implicated in the transmission of plague as in other terri- tories. Mollusks.* The land snail, Planorbis (Biomphalaria) alexandrina pfeifferi, is the intermediate host of Schistosoma mansoni in the Nairobi River region and along the shores of Lake Victoria. Physopsis africana globosa and Bulinus (Pyrgophysa) forskalii are found in the Digo Reserve and in central and south Kavirondo, where infections with S. haematobium are common. B. tropicus is prevalent, but its association with schisto- somiasis in Kenya has not been established. Plants. Numerous plants are found in Kenya which are responsible for occasional deaths among the poultry and the livestock. The weeds and the herbs include Datura stramonium, Cestrum aurantiacum, the water-parsnip, Stephanorossia palustris, and possibly Senecio ruwenzoriensis. Prominent among the shrubs with toxic properties are Phytolacca dodecandra and Turraea ro- busta. The leaves of the trees Elacodendron keniense and Agauria salicifolia are poison- ous, as is the fruit of Melia azedarach. Acocanthera freisiorum, which is wide- spread, is the most frequent source of native arrow poisons. A. longiflora and species of Adenium and Strophanthus are also used. * See footnote, p. 10. Adenium volkensii has been suspected in several human cases of poisoning. The castor oil plant, Ricinus communis, is common. The fruit, which is highly toxic, may be consumed accidentally, while the seeds are sometimes found as contaminants in food- stuffs used for the livestock. Some grasses, as the Naivasha stargrass, Cynodom plecto- stachyum, produce hydrocyanic acid poison- ing when in a wilted condition. Pyrethrum dermatitis, caused by contact with the flowers of Chrysanthemum (Py- rethrum) cinerariae folium, occurs among certain individuals working with the flower- ing plants. Rashes are also produced among lumbermen by the African timber tree, “mvule” or Chlorophora excelsa. Dermatitis caused by contact with the flowering shrub, Montanoa bipinnatifida, has been described. Among the plants which have allergenic properties, the stargrass, Cynodon dactylon, and the golden wattle, Acacia podalyriifolia, are most frequently responsible for symp- toms of hay fever. Foop SANITATION Rules and regulations governing the pro- duction, the inspection and the marketing of milk and milk products, and the inspec- tion and the storage of meat are in force in the larger municipalities. Routine inspec- tions are made by municipal or government inspectors as frequently as is consistent with the limited staffs available. In Nairobi all dairies are licensed, but milk is usually distributed in bulk, and the opportunities for adulteration and contamination are numerous. Only a few of the larger Euro- pean dairies have facilities for pasteuriza- tion. A large part of the milk supply for Mombasa and the vicinity is derived from cows housed within the town. Strict supervi- sion is maintained over stall-fed cattle dairies. European and native dairy farms on the mainland provide supplementary sources of supply, but the conditions in the latter are usually insanitary. The slaughtering houses and meat sup- plies are inspected in Nairobi, Mombasa 116 Kenya and the larger townships. Supervision is at- tempted in the smaller communities, but uncontrolled sources are always available. The markets, bakeries, restaurants and other establishments where food is pro- duced or sold are subject to inspection by the municipal health inspectors. Sanitary conditions in the smaller communities and trading centers are frequently primitive. In the native areas, the responsibility for the introduction and the enforcement of sani- tary regulations resides in the Local Native Councils, but advice and assistance are given by the inspectorate staff of the Kenya Medical Department. HEALTH SERVICES AND MEDICAL FACILITIES HEALTH ORGANIZATIONS Responsibility for the promotion of public health in Kenya resides in the Colo- nial government, acting through its Medical Department and the representative local authorities. The Department functions under the general control of the Member for Health and Local Government in the Kenya government. It depends for advisory services, staff recruitment and grants for special projects upon the Colonial Office in London. The Medical Department is administered by a Director of Medical Services. It is or- ganized on a provincial and district basis with the headquarters establishment in Nairobi. The activities of the Department include the provision of hospital care for the native and other non-European groups, the control of communicable diseases, the operation of laboratory services, the train- ing of native medical asistants, and the supervision of sanitation in urban and rural areas. A laboratory and research branch, which incorporates an Insect-borne Diseases Division, forms part of the headquarters organization. In the urban areas the responsibility for the maintenance of public health has been delegated to the local township authorities. Nairobi has an organized health depart- ment, which functions under the Municipal Council, and for which the Medical Depart- ment assumes part of the operational costs. Municipal Boards are the responsible au- thorities in Mombasa, Nakuru, Eldoret, Ki- tale and Kisumu, but their health services are staffed by government personnel. These local authorities are charged with the sup- port of dispensaries, child welfare and an- tenatal clinics, maternity services and en- vironmental sanitation programs. In the smaller towns, in the farming districts which are sparsely settled by Europeans, and in the native areas, this responsibility is retained by the central government. In accord with the policy of the Kenya government to promote the local adminis- tration of native affairs as rapidly as possi- ble, certain powers of local government were conferred upon Local Native Councils in 1937. Since that date, the Councils have co- operated to an increasing extent with the government staff in the promotion of pre- ventive measures. Moreover, in some re- serves the dispensaries and maternity and child welfare services are now financed en- tirely through tribal funds. Further expansion of the medical services and training facilities, the establishment of health centers throughout the country, and extensive programs of malaria and tsetse-fly control are projected in the development and reconstruction program adopted in 1947. The East Africa High Commission, which was established in 1948, administers certain interterritorial programs. Among those which have a bearing on public health in Kenya, as well as in Uganda and Tan- ganyika, are the East African Bureau of Research in Medicine and Hygiene, and the Tsetse and Trypanosomiasis Research and Reclamation Organization. The headquar- ters of both departments are located in Nairobi. Numerous mission societies function in Kenya 117 native areas, many of which operate hos- pitals and training schools in co-operation with the government health services. MEebpICAL INSTITUTIONS Hospitals and Dispensaries. Most of the hospitals in Kenya are administered by the Medical Department. In the municipali- ties, hospitals are also conducted by the local authorities and by private groups ; and in the native areas, by mission organiza- tions. Hospitals were formerly maintained by the Medical Department for the care of white residents in Nairobi, Mombasa and Kisumu. In 1946, however, a European Hos- pital Authority was incorporated to foster the provision of facilities for the hospital care of white residents. It has gradually taken over the control of all European hos- pitals, government and private, in Nairobi and the larger townships. Plans for hospital insurance are included in the Authority’s program. The Medical Department operates all the general hospitals for natives, both in the townships and in the reserves. Special facili- ties for Asiatics are available in the native hospitals in Nairobi, Mombasa, Kisumu, Nakuru, Eldoret and Kitale. The hospital in Nairobi has a capacity of from 550 to 625 beds; in the remaining townships they range in size from 79 to 250 beds. In 1947 the Department also conducted 38 hospitals and 134 dispensaries, with an aggregate ca- pacity of 2,240 beds, in the native areas. Infectious disease hospitals are located in Nairobi and Mombasa, and a mental disease hospital at Mathari, near Nairobi. Almost all of the hospitals are equipped for minor operations, but the more serious surgical cases must be transferred to one of the larger institutions. The accommodations available in government hospitals in 1947 totaled 112 beds for whites, 184 beds for Asiatics and 4,167 beds for Africans. The hospital facilities are inadequate, particu- larly as regards the native population. The growing popularity of obstetric and child welfare services, in particular, imposes a strain on the present limited resources. Seven hospitals with a combined capacity of 587 beds are operated by mission organi- zations, with financial assistance from the Colonial government. Laboratories. The Medical Research Laboratory at Nairobi is the headquarters of the laboratory division of the Medical Department. It has diagnostic, biologic and research divisions and incorporates the laboratories of the Insect-borne Diseases Division. Branch laboratories at Mombasa and Kisumu carry on routine investigations and research relating to the control of in- sect-borne and other diseases. The Veteri- nary Research Laboratory is located at Kabete. Clinical laboratory facilities are available in all the larger hospitals. Schools. There is no medical school in Kenya, but students are sent at govern- ment expense to the Medical School at Makerere University College in Uganda. Qualified natives are trained at the Medical Training Depot at Nairobi as medical as- sistants, nurses, laboratory assistants, com- pounders and health inspectors. Training schools for hospital assistants and orderlies are conducted in several mission hospitals. At present there are no government schools for the training of midwives. They are trained at the Municipal African Ma- ternity hospitals in Nairobi and Mombasa and in mission institutions. PERSONNEL Physicians. In 1947 about 50 European, 31 Asiatic and 6 native doctors were em- ployed by the Medical Department. In ad- dition, physicians are connected with mu- nicipal, mission and railway hospitals and are engaged in private practice. According to the official Gazette for 1949, approxi- mately 52 physicians were registered in Kenya, outside of the Medical Department, but probably from 15 to 20 per cent were no longer practicing in the territory. 118 Kenya Nurses. In 1947 there were 68 European and 9 Asiatic nurses on the staffs of govern- ment institutions, besides a few attached to mission and private hospitals. Others. The European staff of the Medi- cal Department also included 3 pathologists, 1 biochemist, 1 parasitologist, 2 entomolo- gists, 2 entomologic field officers and 13 health inspectors. The native personnel comprised hospital assistants, compounders, laboratory assistants, sanitary assistants and health visitors. DISEASES Reporting is incomplete in all parts of Kenya, and statistics based on hospital and dispensary records may give erroneous im- pressions of disease incidence, since large sections of the population are not included. Among the native peoples, considerable numbers live beyond reach of medical facili- ties or adhere to their own primitive forms of tribal medicine. Except where sample surveys have been made, as in the case of tuberculosis and leprosy, or special investi- gations conducted for the control of specific diseases as trypanosomiasis, estimations as to the extent and the distribution of dif- ferent infections are necessarily subject to inaccuracies. Nevertheless, they are valua- ble in helping to determine the factors re- sponsible for the spread of the endemic and the epidemic diseases of the area. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or UriNARY TRACTS Dysenteries. Both bacillary and amebic dysentery are common. Approximately one half of the total cases reported are amebic infections, but it is probable that more re- liable reporting would reveal a proportion- ately higher incidence of bacillary infec- tions. In most cases amebiasis tends to be atypical or chronic. Acute infections are in- frequent, and abcesses of the liver are rela- tively rare. From 1943 through 1947, from 3,650 to 5,100 cases of amebic dysentery were reported annually. Amebiasis occurs chiefly in the townships. Sample surveys in- dicate that the morbidity rates are rela- tively low in the native reserves. In the same period the cases of bacillary dysentery reported ranged from 1,000 to 2,770 a year, and of unidentified dysentery from 2,900 to 3,450. Paradysenteries pre- dominate among strains recovered from stool cultures in the Nairobi area, but Shigella dysenteriae is isolated occasionally. Pure cultures of paracolon strains, in asso- ciation with cases of clinical dysentery, are common. Low standards of personal hygiene, the prevalence of flies and the frequent use of human excreta as fertilizer are factors re- sponsible for the prevalence of dysentery and diarrheal infections. Diarrhea and enteritis contribute to the high level of infant mortality among the native popula- tions. Typhoid and Paratyphoid Fevers. En- teric fevers are endemic. From 300 to 900 cases, with an average fatality rate of from 10 to 20 per cent, are treated annually in the government hospitals, but these un- doubtedly do not reflect the true incidence in the country as a whole. Of the 543 cases reported in 1947, 503 were diagnosed as typhoid fever, 14 as paratyphoid fever A, and 9 as paratyphoid B. Free immunization with typhoid-paratyphoid A and B vaccine is offered by the Medical Department. Cholera. Cholera has not been present in Kenya since 1900 when cases were reported from Mombasa. In view of the large volume of traffic with the Middle East and the Far East, the possibility of its introduction is a constant source of concern to the health authorities. Helminthiases. ANcyrosTomIasts. Hook- worm infection is widespread but reaches significant proportions chiefly in the south- ern coastal region. In some localities south of Mombasa the average incidence ap- proaches 95 per cent. The infections are generally severe in Digo district and in the Kilifi area but relatively mild elsewhere. Major foci also occur in South Kavirondo Kenya 119 and in Kiambu district of Central Province. Necator americanus is the principal species. Ancylostoma duodenale may be found con- currently in the coastal areas but is rare in other parts of the colony. In the routine ex- amination of almost 80,000 stool specimens in Nairobi between 1938 and 1944, hook- worm was found in 9.7 per cent of the sam- ples from Africans, 1.4 per cent from Asi- atics and 0.5 per cent from Europeans.®® ScHistosom1asis. Infections with Schis- tosoma mansoni are prevalent in numerous foci along the shores of Lake Victoria and in the Fort Hall area north of Nairobi. The intermediate snail hosts are Planorbis (Biomphalaria) alexandrina pfeifferi and in certain low-lying districts, possibly other species. The disease is particularly prevalent among children and workers in the rice fields. Schistosomiasis due to S. haematobium is endemic in the Digo district and in the Kavirondo region, where Phy- sopsis africana globosa and Bulinus (Pyr- gophysa) forskalii act as the intermediate hosts. Infection is usually heavy, and more frequent among boys than among girls. Otuer HELMINTH INFECTIONS. Ascariasis is common, especially in the Teita and the Kavirondo districts. Strongyloidiasis, trich- uriasis and, to a lesser degree, enterobiasis are frequent. Taenia saginata, the beef tapeworm, is widely distributed throughout the country. The reported cases of taeniasis in 1947 numbered 24,501, as against 15,862 of ascariasis and 2,240 of ancylostomiasis. The infection rates are particularly high in the cattle-raising areas. Cysticercosis is found in roughly 30 per cent of the cattle killed in the municipal abattoir at Nairobi. This high percentage of infection among slaughter animals constitutes a nutritional as well as an economic problem. The sale of infected meats is permitted after treat- ment by boiling. The pork tapeworm, 7. solium, is rarely reported. Echinococcus granulosus occurs in scattered foci in Masai district. Hymenolepis nana is encountered occasionally. Infections with Dipylidium caninum, the dog tapeworm, are sometimes observed in man. Brucellosis. Brucellosis is enzootic among the native cattle and goats, and human infections are sporadic. Cases are reported most frequently from the districts north and west of Mt. Kenya. Brucella melitensis is the predominating species, but B. abortus is also present. Among 85 posi- tive cultures isolated at the Medical Re- search Laboratory in 1949, only two were identified as B. abortus. Other Infections. Anthrax is common among the natives on the reserves. The disease is prevalent in the cattle, and fre- quently human infections are acquired not only by contact but through the con- sumption of infected meat. From 600 to 800 known cases are reported each year. The fatality rates average from 2 to 5 per cent. Diseases SpreaD CHIEFLY THROUGH THE RESPIRATORY TRACT Pneumonia. Pneumonia is a serious problem in Kenya. The prevalence and the severity of pneumococcal infections are probably higher in the central highlands than in other parts of the country. An aver- age of 9,000 to 12,500 cases is treated each year in the government hospitals. Lobar pneumonia usually represents about two thirds of the total. Poor nutrition and un- satisfactory standards of living, together with concurrent malaria and helminthiasis, contribute to a high mortality, particularly among the native peoples. With the intro- duction of modern chemotherapy, however, the fatality rates have decreased from 27.5 per cent in 1937 to 9 per cent in 1947. In the latter year the pneumonias were re- sponsible for 23.4 per cent of the total deaths recorded from the hospitals and the dispensaries operated by the Medical De- partment. Studies made from 1930 to 1935 in the Medical Research Laboratory at Nairobi on 766 cases of lobar pneumonia revealed that while the majority of severe and fatal 120 Kenya cases were caused by Type I organisms, many were due to Group IV strains. Of these, Type KWL (U. S. Type V) predomi- nated and was responsible for all of the cases of pneumococcus meningitis not at- tributed to Type I organisms. Type KW] (U. S. Type VII) was recovered in most of the remaining cases. Tuberculosis. Tuberculosis is prevalent among the non-European peoples of Kenya. It has been well established on the coast for many years and recently has spread progres- sively inland. The number of cases seeking treatment at government hospitals increased steadily from 657 in 1928 to 4,621 in 1947. This annual increase in cases probably indi- cates more than an expanding confidence in hospital treatment, since it exceeds simul- taneous increases in other diseases in the same institutions. The death rates are higher among the natives than among the Europeans, because of their poorer physical condition and lack of resistance to infec- tion, and a general tardiness in diagnosis. Many natives refuse to seek treatment be- cause of the current belief that the disease is incurable. A large proportion of the cases are in a hopelessly advanced condition when admitted to the hospitals, the autopsy find- ings revealing little evidence of fibrosis or chronicity. In a survey made in 1948-492° during which tuberculin tests were performed on over 42,000 individuals in different parts of the country, the percentage of positive re- actors was found to vary with the standards of living and the mobility of the different tribes. They ranged from 27 per cent among the Kikuyu living in the more remote high- land districts to 58 per cent in villages of the coastal region, and 67 per cent in Nai- robi. The positive reactors among children, from 7 to 12 years of age, in the same groups averaged 9, 38 and 38 per cent respec- tively. On the bases of these studies the probable incidence of tuberculosis was esti- mated at 9.7 per 100 population in Nyanza, 10.9 in Coast and 12.5 in Central provinces. Overcrowding and insanitary habits of living promote the spread of infection in both rural and urban areas. In the latter, also, the difficulties of adjustment to new forms of work and diet are contributory factors. Resources for early diagnosis and treatment are urgently needed, as well as extended facilities for the care of the ad- vanced cases. Bovine tuberculosis is found among the cattle in some parts of the highlands, but the relation of bovine to human infections has not been studied. About 4 per cent of the slaughter animals show evidence of infec- tion. Smallpox. Outbreaks of smallpox occur annually; the danger of its introduction into the coast ports by travelers from the East, or across the border by migrant labor- ers is always present. In 1943 an epidemic of mild smallpox broke out in the vicinity of Nairobi, spreading rapidly to other por- tions of the country. Over 3,500 cases were recorded in 1943, and 3,372 in 1944. More- over, as the mortality rate was negligible, many probably remained unrecognized. The epidemic declined toward the end of 1944, when only sporadic cases were reported. In 1945 an explosive outbreak of malignant smallpox occurred in Kisumu, which spread to the surrounding areas. The fatality rate was 31 per cent. Within recent years the cases have been generally mild, but small foci of high virulence are recorded almost annually. The reported incidence usually fluctuates between 400 and 900 cases. Wide- spread vaccination is carried on by the medical officers. Meningitis. Meningococcus meningitis is endemic. It exists irregularly in severe out- breaks which follow a cyclic pattern, par- ticularly in the highland area. In 1942-43 it spread to Kenya from Tanganyika Ter- ritory; in the four years from 1942 to 1945, an average of 600 cases a year was reported. Subsequently, the incidence declined to 512 cases in 1946, and 253 in 1947. The conges- tion in the native quarters, and the climatic conditions are factors influencing the sever- ity of the outbreaks characteristic of the highlands. The fatality rates range from 20 to 35 per cent. Other Infections. A few cases of diph- theria are reported each year. Measles, whooping cough and mumps are endemic and sometimes epidemic. Occasional iso- lated cases of scarlet fever are observed. In 1945 the first epidemic of scarlet fever was recorded in Nairobi, at which time 19 Euro- pean children were affected. Outbreaks of poliomyelitis, attacking all racial groups, are reported sporadically. DisEASES SPREAD OR CONTRACTED CHIEFLY THROUGH CONTACT Venereal Diseases. Statistics as to the true incidence of venereal diseases are not obtainable because of inadequate reporting and a widespread confusion among native tribal dressers as to the differential diagnosis between syphilis and yaws. Syphilis and gonorrhea are highly prevalent. Lympho- granuloma venereum and chancroid are present to some degree. Reports during the war indicated that venereal diseases were spreading steadily among both the Afri- can soldiers and the civilian populations The increased mobility of the native and the large volume of migratory workers dis- playing a tendency to congregate in the towns and other labor centers contribute to the spread of these infections. Syphilis is common on the reserves, particularly in the populous Kavirondo districts. Usually clin- ically mild, it is responsible for a high incidence of abortions and stillbirths. In general, the disease is less prevalent in dis- tricts where yaws is universal, and vice versa. Since gonococcal infection is not seriously regarded by the natives, the cases reporting for treatment in no way reflect the extent of infection. Between 16,000 and 20,000 cases of syphilis and about the same number of cases of gonorrhea are recorded each year. Special clinics for the treatment of vene- real diseases are operated by the Medical Department and the local authorities in Nairobi and Mombasa. Clinics for women Kenya i2i are also conducted at Nanyuki and Gilgil. Treatments are given in all the government hospitals. However, it is difficult to keep cases under observation and treatment, once the acute symptoms have been relieved. Yaws. Yaws is widespread among the pastoral and agricultural tribes but is on the decrease as the result of the inaugura- tion of intensive treatment and educational programs. Leprosy. Leprosy is encountered in all parts of Kenya; no tribe may be considered entirely free from infection. Although the actual incidence is not known, there appears to be some evidence that it is increasing. A series of sample surveys was made in 1948 by a leprologist appointed by the three East African territories in co-operation with the British Empire Leprosy Relief Associa- tion?” The incidence was found to be high- est in Nyanza Province, with the greatest concentration of cases in the Kavirondo re- gion near the lake. Among the persons ex- amined, roughly 31.7 per 1,000 were found to be infected. The incidence was moderate in the coastal area, averaging 7 per 1,000 population in the localities visited. In the intervening districts the distribution of cases varied, but the incidence was rela- tively low. In over 53,800 persons ex- amined, leprosy was diagnosed in 552, or 10.2 per 1,000. It was estimated that there are at least 35,000 and probably 50,000 lepers in the country. Factors which may contribute to the prevalence of the disease include the insanitary living conditions and generally poor state of health of the people, the high average humidity in the lake and the coastal regions, and the failure to segre- gate cases, especially children. Treatment is provided by the Medical Department in the infectious disease hospitals at Nairobi and Mombasa and in mission institutions at Tumutumu and Chogoria in central Kenya. Leper camps are maintained by the Depart- ment at Kakamega in Lake Province and at Msambweni in the coastal region, but no active treatment is given. Their capacity was 197 and 40, respectively, in 1948. 122 Kenya Diseases of the Skin. Human myiasis occurs sporadically. It is produced by the maggots of a variety of flies, particularly by species of Chrysomyia. The “tumbu fly,” Cordylobia anthropophaga, is responsible for occasional outbreaks of myiasis in Nairobi district which sometimes involve a high percentage of Europeans. Tropical ulcers are common. In 1947 over 58,200 cases were treated in the gov- ernment hospitals and dispensaries. Infec- tion with Sarcoptes scabiei is prevalent. Various mycoses, including “mossy foot” and ringworm, are frequent. The sand or chigoe flea, Tunga penetrans, is widespread. Diseases of the Eyes. Trachoma is en- demic among both Asiatics and natives in many areas. The condition is only mildly infectious, however, and blindness is rela- tively rare. Conjunctivitis, some of which may be trachomatous in origin, is wide- spread. Gonorrheal ophthalmia is prevalent in some tribes. Around Kakamega and Kodera fully half of the population is said to suffer from retinochoroiditis and affec- tions of the cornea due to onchocerciasis. In the vicinity of Nairobi a form of conjunc- tivitis, popularly called “Nairobi eye,” is caused by the irritating body juices of the crushed beetle, Paederus crebripunctatus. Other Infections. Tetanus is reported frequently. Occasional outbreaks of rabies occur among the dogs and the jackals, and human cases are observed sometimes. Hu- man anthrax infections are numerous and may be transmitted through contact or through the intestinal tract. In some tribes infection may result from the use of the fat of infected animals for oiling the skin. DiSEASES SPREAD BY ARTHROPODS Malaria. The incidence of malaria is va- riable. In many areas it occurs in waves which may reach epidemic proportions, usually following periods of increased rain- fall. The cases treated in government hos- pitals and dispensaries averaged over 110,- 000 a year in 1946 and 1947, in contrast with about 57,000 in the drought years of 1942 and 1943. The outbreaks affect par- ticularly the rural areas, since the incidence in the urban communities is checked to some extent by anopheline-control measures. Marked differences in the incidence and in the period of transmission of malaria are encountered in various sections of the Colony, depending upon the altitude and the rainfall seasons. The extensive regions of semiaridity, the mountains and the very high plateaus experience little or no malaria. Few areas below 5,000 to 6,000 feet of eleva- tion are free, while within recent years the disease has become established in western Kenya at increasingly higher altitudes. Since 1941 severe epidemics have been re- corded from various localities up to 8,000 feet. In the lake region, where the rainfall is heavy almost every month in the year, both Anopheles gambiae and A. funestus breed prolifically, and malaria is highly prevalent. In some areas 65 per cent of the population is infected, the children more heavily than the adults. The country around Kisumu is considered one of the most malarious parts of the country. In the hyperendemic coastal area, 4. gambiae is the most im- portant vector, although both species are abundant. The disease incidence follows the anopheline density curve with peaks be- tween May and August and again in De- cember or January. Studies of the tribes in 8 over 6 mos. S% 3-6 mos. 7 less than 3 mos. . Malaria in Kenya Kenya 123 the Digo district of this area have shown that while the infants are heavily para- sitized and subject to acute attacks of malaria, the adults normally show few symptoms and have relatively few parasites in their blood. Malaria is endemic in the Nairobi area and epidemic at frequent in- tervals. A. gambiae breeds abundantly, in spite of the 5,500 foot elevation, while A. funestus, though occasionally found, is of minor importance. The malarial season lasts from May through July. Although 4. funestus is usually associated with endemic and hyperendemic malaria, localized epi- demics in the Kenya highlands have been attributed to it.?3 The species incidence fluctuates with the season. Plasmodium falciparum accounts for from 85 to 90 per cent of the total in- fections recorded each year. P. malariae may predominate in the dry season and under certain conditions may be responsible for infection rates of from 50 to 75 per cent in young children. P. vivax is of lesser im- portance, although apparently increasing in prevalence, especially in the districts ad- jacent to Somalia. P. ovale is relatively rare. Routine malaria-control measures are un- dertaken in all the municipalities and larger townships. Experimental programs are also carried on by the Insect-borne Diseases Division. Within recent years these have included air-spraying of swamps near Kisumu with DDT emulsions and residual spraying of the native huts in rural sections of the highlands. Mass chemoprophylaxis has been introduced in localized controlled areas. Blackwater fever, as a complication of malarial infections, is relatively infrequent. An average of 25 to 40 cases is reported each year. Trypanosomiasis. Human trypanosomi- asis is endemic in two areas: along the northeastern shores of Lake Victoria and on the Tanganyika border in the Masai re- serve. The disease is caused primarily by Trypanosoma gambiense, which is trans- mitted by Glossina palpalis. Since an exten- sive epidemic in 1905, when the population was evacuated from the tsetse-infested areas on the shores of Lake Victoria, control measures have been carried on continuously. The disease was gradually brought under control until in 1936 only 9 new cases were reported. In 1937, however, 133 cases were discovered in South and Central Kavi- rondo. From that date until 1944, when a further outbreak occurred in Kavirondo, the annual incidence averaged between 35 and 100 cases. In the 1944 epidemic 1,168 cases were treated in two dispensaries es- tablished for that purpose. The following year the outbreak subsided in Central Kavi- rondo but persisted in the southern district. Over 750 cases were reported in 1945, but in subsequent years the totals decreased gradually, with less than 55 cases recorded in 1947. Small localized outbreaks were re- ported again in 1949. Except for occasional cases in Central Kavirondo, associated with the Uganda outbreak in 1942, T'. rhodesiense was not re- ported from Kenya until 1946-47, when scattered cases occurred in the sparsely set- tled Masai reserve on the Tanganyika border. The vector was probably G. swyn- nertoni, which is concentrated in that re- gion. No great extension of 7. rhodesiense is feared, unless the more widely distributed G. pallidipes should become infected.3° Plague. East Africa is an established plague center. In Kenya the disease is endemic in North and Central Kavirondo and in the Kikuyu reserve in the central highlands. The incidence has declined from over 1,100 cases in 1925 to an average of 33 cases in the three years 1946-48, but epi- demic outbreaks flare up from time to time. Outbreaks occur almost every year in Kisumu, the center of the grain and cotton seed trade, usually starting in the dilapi- dated and overcrowded Indian bazaars. Nairobi also has been an endemic focus for many years. As in Kisumu, epidemics usually break out in the Indian section, invading the African but rarely the more 124 Kenya sanitary European communities. In 1940-42 a serious outbreak of bubonic plague was recorded in Nairobi; from January, 1941, to April, 1942, there were 340 cases and 240 deaths in the city alone. Early in 1942 it subsided in the urban area but continued to spread in the surrounding country. Official reports for the entire territory list over 1,500 cases in 1941-42, with a drop to 17 in 1943. In 1941 the first outbreak of plague since 1928 occurred in Mombasa. The infections were all of the pneumonic type and were traceable to contact with a case from Nair- obi. Within recent years sporadic cases have been reported, primarily from Nakuru dis- trict in Rift Valley Province and from Nairobi, Kiambu and Nyeri districts in Central Province. However, the cities of Nairobi and Mombasa have remained free. Rat-control measures are carried on routinely in the urban areas and, in the event of an outbreak, in the affected vil- lages. Rattus rattus alexandrinus and other subspecies of R. rattus are the rodent hosts responsible for the spread of the infection. Xenopsylla cheopis and, secondarily, X. brasiliensis are the vectors. There is no con- crete evidence of sylvatic plague in Kenya, although the presence of a wild-rodent reservoir is suspected by many authorities. During an epidemic mass inoculations with antiplague vaccine are carried on among the populations in the areas concerned. Relapsing Fever. Two types of relapsing fever exist. African tick fever, caused by Borrelia duttoni and transmitted by the tick, Ornithodorus moubata, is endemic and increasing in prevalence in the tick-infested labor camps scattered throughout the coun- try. From 400 to 750 cases are reported each year among natives on the coast from Mombasa to Lindi, and in the interior along the major traffic routes through Nairobi and Meru. The principal endemic centers are found in the Kikuyu, Meru, Nyanza and Teita native reserves. Roughly, one third of the cases usually occur in Meru district, where an important focus is found in the Jombeni Mountains at an elevation of over 4,500 feet.™ With the exception of minor outbreaks among the Ethiopian refugees in Northern Frontier Province in 1937, louse-borne re- lapsing fever, caused by Borrelia recur- rentis, was not reported from East Africa until 1945. In February of that year, it was introduced from South Arabia by traders arriving at Mombasa. Rigid sanitary meas- ures prevented an epidemic in the city, but a high incidence was reported among the natives in the crowded villages within 25 miles of the periphery. The customs and the clothing of the people facilitated its spread, and from August, 1945, to the end of Janu- ary, 1946, almost 2,000 cases and 400 deaths were reported. Among other control meas- ures, mass DDT dusting was employed for the deverminization of the inhabitants, of all travelers into the area and of the huts in which new cases and contacts resided. This outbreak was probably associated with the 1942-46 epidemic in North Africa. No re- crudesence has occurred, but stringent con- trol over the dhow traffic is maintained. Small localized outbreaks of relapsing fever are reported occasionally from Moyale near the Ethiopian border. The vector is not certain, but lice are suspected, since O. moubata has not been found in that region. There is considerable experimental evidence that the East African strain of B. duttoni may be transmitted by lice.?! Rickettsial Infections. Tick-borne ty- phus is endemic in Kenya, particularly in the central highland and Rift Valley dis- tricts. The incidence is not known, but an average of from 25 to 80 cases is re- ported each year. The fatality rates range from 2 to 10 per cent. The disease is trans- mitted by Rhipicephalus sanguineus, R. simus, Haemaphysalis leachi and possibly other species. The pepper tick, R. pulchel- lus, is also regarded by some observers as a potential vector. Murine typhus is reported occasionally. A few cases have been de- scribed from Mombasa and Nairobi in Kenya 125 which Xenopsylla cheopis was the probable vector. Yellow Fever. Prior to 1942, yellow fever had not been reported from Kenya, although it was known to exist in the neighboring countries—the Anglo-Egyptian Sudan, Uganda and the Belgian Congo. The first case was discovered in Kitale in 1942, and the second in Kisumu in Novem- ber, 1943. In the latter case, the disease probably was acquired at a camp near Langata Forest in the vicinity of Nairobi. Subsequent protection tests revealed im- munity to the virus in one child and in two adults among the permanent residents in the forest.’ Further evidence of immunity among both the people and the monkeys of the forest suggests the presence of the in- fection in this area within recent years. Pro- tective antibodies have also been found in bush babies in the coastal area.*’ Aedes mosquitoes are prevalent, and A. aegypti, the principal vector, is universally distrib- uted in both urban and rural areas. Since 1947 an extensive organization has been built up for the control of yellow fever. Anti-Aedes measures are carried on in the larger towns and coast ports and along the central railway, the larval index being held at a low level at all essential points. Mass immunization to establish a buffer zone of noninfectibles has been undertaken in the coastal belt and will be extended to Nyanza Province should yellow fever ap- pear there. Kenya is included within the yellow fever endemic area as defined by the World Health Organization. Filariasis. Infections with Wuchereria bancrofti, and associated elephantiasis and hydrocele, are endemic in the coastal and the lake regions. Major foci of infection are found along the Tana and the Yala rivers, while in the vicinity of Lamu the infection rate is estimated at from 30 to 40 per cent. The disease is present around Mombasa, although the incidence is relatively low. Occasional cases are seen in Nairobi but may have been acquired elsewhere. The vector is uncertain, but Culex quinque- fasciatus (= C. fatigans) and Anopheles gambiae, both efficient vectors of Wucher- eria bancrofti, are widespread. Acanthocheilonema perstans infections occur in central and western Kenya but are not commonly reported. However, a study of 200 or more children in two villages in North Kavirondo in 1944 revealed that from 10 to 18 per cent were infected with a filarial parasite resembling that species. Infection with the filarial worm, On- chocerca volvulus, is endemic in Kavirondo, in the Kaimosi Forest and in the western half of the Kericho reserve. The lesions may range from cutaneous eruptions to subcu- taneous tumors, retinochoroiditis and in- volvement of the cornea. These conditions have been observed among Lumbwa and Kisii tribesmen for some time but have not been identified until recently. Europeans are affected similarly. The microfilariae are transmitted by the so-called buffalo gnats, Simulium neavei. As the result of an experi- mental program initiated in 1945 by the In- sect-borne Diseases Division, S. neavei has been eradicated from certain infested rivers in South Kavirondo by means of treatment with emulsions of DDT. The elimination of this vector from the entire Kakamega-Kai- masi area is projected. Leishmaniasis. Isolated foci of kala-azar exist in Northern Frontier Province, while sporadic cases have been reported from Machakos district in Central Province. Re- cent evidence indicates that a small endemic focus may exist at Sericho on the Uaso River. The vector has not been estab- lished, but several species of sandflies have been found, including Phlebotomus clydei, the species responsible for the transmission of leishmaniasis in the Sudan. Mucocutaneous leishmaniasis occurs in Northern Frontier Province. A few cases’ have also been described from the Kamba reserves near Kitui. Other Infections. Dengue fever is en- demic, especially in the coastal area where 126 Kenya Aedes aegypti is prevalent. However, cases are reported infrequently. Human cases of Rift Valley fever are encountered occasion- ally. The West Nile and related viruses may be active at times throughout this general region. Sandfly, or pappataci, fever has been de- scribed by individual observers, but it has not been reported officially, and it is not clear that the disease is indigenous to the country. The usual sandfly vectors are not known to be present in Kenya, although re- lated Phlebotomus flies are found. Infections with the guinea worm, Drac- unculus medinensis, occur in the northern districts. NuTrITIONAL DISEASES The dietary habits of the various peoples differ markedly, but undernourishment and hypovitaminosis are common among most of the tribes. The major deficiencies are due chiefly to poverty and ignorance, and during periods of drought to a shortage of food supply. The generally low standard of nutrition is one of the major factors deter- mining the lack of resistance to pneumonia, tuberculosis and other infections. Beriberi, rickets and scurvy are ap- parently rare. Pellagra is sporadic among the maize-eating tribes. A syndrome, vari- ously described as infantile edema or “kwashiorkor,” is common, especially in the vicinity of Mt. Kenya and in the coastal region south of Mombasa. From 200 to 300 cases are treated each year in govern- ment hospitals, and the incidence probably is much greater. The fatality rate averages 25 per cent. Kwashiorkor is not observed in adults to the same extent as in Uganda, but cases are recognized with increasing fre- quency. SUMMARY The health problems of Kenya Colony and Protectorate are complicated by the fact that the population is heterogeneous and made up of races and tribes with widely different customs and standards of living. The medical and public health program is administered by the Medical Department of the Colonial government, with headquarters in Nairobi. In the municipal areas certain responsibilities have been delegated to the local authorities. A considerable expansion of health and medical activities is antici- pated under the development and recon- struction program. Hospitals are maintained under government, mission and private auspices. Facilities are available for Euro- peans, Asiatics and natives but are inade- quate, particularly in the native rural areas. Water is a major problem in most localities, and all but the municipal supplies are fre- quently polluted. A modern sewerage system serves part of Nairobi; elsewhere the methods of waste disposal are generally primitive. Sanitary controls over foodstuffs exist in the urban areas, but the standards are low in the native areas. Poor housing and malnutrition contribute to the spread of disease among the natives. Malaria is widely distributed, but the intensity of infection varies in different sections of the country. Tuberculosis, lep- rosy, yaws, venereal diseases and intestinal infections are widespread. Pneumonia is prevalent and a major cause of death among the indigenous populations. Outbreaks of epidemic meningitis and smallpox occur frequently. Plague, sleeping sickness, relaps- ing fever, typhus, filariasis, leishmaniasis and schistosomiasis are endemic in certain areas. BIBLIOGRAPHY 1. Anderson, T. Farnsworth: Pellagra in adult natives in Kenya, East African M. J. 15: 385-390 (Feb.) 1939. 2. Bally, P. R. O.: The Useful Plants of the East African Countryside, Part I and II. East African Field, Farm and Garden. 3. Blacklock, D. B.: Methods of disposal of human excreta and refuse employed in the British colonies, Ann. Trop. Med. 38: 58-72 (Apr.) 1944. 4. Buckley, J. J. C.: Studies on human oncho- cerciasis and Simulium in Nyanza Prov- ince, Kenya. I. Distribution and incidence of O. volvulus, J. Helminthol. 23:1-24 (1-2) 1949. 5. Buxton, P. A.: Trypanosomiasis in Eastern 10. 11. 12. 13. 14. \ 16. 17. 18. 19. 15. Africa, 1947, London, H. M. Stationery Office, 1948. Coles, A. 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E.: Alleged poisoning with an extract of Adenium Volkensii Harms. East African M. J. 27:135-138 (Mar.) 1950. Findlay, G. J., Stefanopoulo, G. M., and MacCallum, F.: Présence d’anticorps con- tre la fievre de la Vallée du Rift dans le sang des africains, Bull. Soc. path. exot. 29:986-996 (Nov.) 1936. Findlay, G. M.: The spread of yellow fever, East African M. J. 18:2-7 (Apr.) 1941. Fitzgerald, Walter: Africa: A Social, Eco- nomic and Political Geography of Its Major Regions, edition 4, New York, Dutton, 1942. Fleming, A. McK.: Scarlet fever in Nairobi, East African M. J. 23:348-351 (Nov.) 1946. Garnham, P. C. C.: Acrodendrophilic mos- quitoes of the Langata Forest, Kenya, Bull. Ent. Res. 39:489-490 (Mar.) 1949. ——, Davies, C. W., Heisch, R. B., and Timms, G. L.: An epidemic of louse-borne relapsing fever in Kenya, Tr. Roy. Soc. Trop. Med. & Hyg. 41:141-170 (Sept.) 1947. , and MacMahon, J. P.: The eradica- tion of Simulium neavei Roubaud from an 21. 22. 23. 24. 2s. 26. 27 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. Kenya 127 onchocerciasis area in Kenya Colony, Bull. Ent. Res. 37:619-628 (Mar.) 1947. Great Britain: Colonial Office. Annual Re- port on the Colony and Protectorate of Kenya for the Year 1946, London, H. M. Stationery Office, 1948. ——: Colonial Office. Annual Report on the Social and Economic Progress of the Peo- ple of Kenya Colony and Protectorate, 1937, London, H. M. Stationery Office, 1938. ——: Colonial Office. Colonial Research, 1948-49, London, H. M. Stationery Office, 1949. ——: Economic Advisory Council. Sum- mary of Information Regarding Nutrition in the Colonial Empire. First Report, Part II, Committee on Nutrition in the Colo- nial Empire, London, H. M. Stationery Office, 1939. Haddow, A. J.: The mosquito fauna and climate of native huts at Kisumu, Kenya, Bull. Ent. Res. 33:91-142 (June) 1942. Harley-Mason, R. J.: Filarial blinding in Kenya, East African M. J. 15:363-368 (Feb.) 1939. Hawking, Frank: Distribution of filariasis in Tanganyika Territory, East Africa, Ann. Trop. Med. 34:107-119 (Sept.) 1940. ——: The distribution of filarioid infections in East Africa, J. Trop. Med. 45:159-165 (Dec.-Jan.) 1942-1943. Haynes, W. S.: Tuberculosis Among Africans of Kenya Colony. Unpublished. Heisch, R. B.: Rhodesian sleeping sickness in Kenya Colony, J. Trop. Med. 51:225- 228 (Nov.) 1948. ——: Studies in East African relapsing fever, East African M. J. 27:1-58 (Jan.) 1950. : Two years of medical work in the Northern Frontier Province, Kenya Colony, East African M. J. 24:3-15 (Jan.) 1947. ——, and Harper, J. O.: An epidemic of malaria in the Kenya Highlands trans- mitted by Anopheles funestus, J. Trop. Med. 52:187-190 (Sept.) 1949. Hobley, C. W.: Kenya, from Chartered Company to Crown Colony, London, Witherby, 1929. Hudson, J. R.: Notes on animal diseases. XXIV. Plant poisoning, East African Agri. J. 10:No. 2, 101-108 (Oct.) 1944. Huxley, Elspeth, and Perham, Marjory: Race and Politics in Kenya, London, Faber, 1942. Innes, J. R.: Leprosy in Kenya, East Afri- can M. J. 26:32-35 (Feb.) 1949. Kenya, Colony and Protectorate of: Annual Medical Report for the Years ending 31st 128 Kenya 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49, 50. 31. 52. 53. 54. $3. 56. 57. 58. 59. December, 1922-1937, Printer, 1923 on. : Medical Department. Annual Report, 1943, Nairobi, Govt. Printer, 1944. ——: Medical Department. Annual Report, 1944, Nairobi, Govt. Printer, 1945. ——: Medical Department. Annual Report, 1945, Nairobi, Govt. Printer, 1947. ——: Medical Department. Annual Report, 1946, Nairobi, Govt. Printer, 1948. ——: Medical Department. Annual Report, 1947, Nairobi, Govt. Printer, 1949. ——: Medical Department. Annual Report, 1948, Nairobi, Govt. Printer, 1949. ——: Second Progress Report of Tsetse Fly and Trypanosomiasis Survey and Control in Kenya, Nairobi, Govt. Printer, 1947. : Third Progress Report of the Tsetse Fly and Trypanosomiasis Survey and Con- trol in Kenya Colony, Nairobi, Govt. Printer, 1949. Kitchen, S. F.: Laboratory infections with the virus of Rift Valley fever, Am. J. Trop. Med. 14:547-564 (Nov.) 1934. Lewis, E. Aneurin: Tsetse flies and develop- ment in Kenya Colony, East African Agri. J. 7: Part I, 183-189 (Apr.) 1942. Mabhaffy, A. F.: The epidemiology of yel- low fever in Central Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 42:511-524 (Mar.) 1949. ——, Smithburn, K. C., and Hughes, T. P.: The distribution of immunity to yellow fever in Central and East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-83 (Aug.) 1946. McMahon, J. P.: Simuliidae of Kenya, East African M. J. 24:51-56 (Jan.) 1947. Nairobi Municipality, Kenya: Eighteenth Annual Report of the Medical Officer of Health, Nairobi, 1947. Nineteenth Annual Report of the Medical Officer of Health, Nairobi, 1948. Piers, F.: Mucocutaneous leishmaniasis in Kenya, Tr. Roy. Soc. Trop. Med. & Hyg. 40:713-718 (May) 1947. Plant dermatitis due to Montanoa bipinnatifida, East African M. J. 27:99- 101 (Feb.) 1950. Pitman, Capt. Charles R. S.: A Guide to the Snakes of Uganda. Kampala (Uganda), Uganda Soc., 1938. Plum, D.: The plague epidemic in Nairobi, with special reference to place incidence and treatment, East African M. J. 19:3-9 (Apr.) 1942. Prevalence of plague in recent years: Chron. W. H. O. 4:83-87 (Mar.) 1950. Roberts, J. I.: A comparison of haemato- Nairobi, Govt. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71, 72, 73. logical results in Europeans and Africans suffering from active malaria, J. Trop. Med. & Hyg. 51:228-234 (Nov.) 1948. ——: A protozoological and helminthologi- cal survey of three races in Nairobi, Kenya, J. Trop. Med. & Hyg. 52:49-59 (Mar.) 1949. Rat and flea conditions in a rural endemic plague area in Kenya, J. Hyg. 39:355-360 (July) 1939. : The relationship of field rodents to plague in Kenya, J. Hyg. 39:334-344 (June) 1939. ——: The transmission of plague in Kenya, J. Trop. Med. & Hyg. 53: Part II, 103- 109 (May) 1950. ——: Plague conditions in an urban area of Kenya (Nairobi Township), J. Hyg. 36: 467-484 (Nov.) 1936. Sawyer, W. A., and Whitman, Loring: The yellow fever immunity survey of North, East and South Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 29:397-412 (Jan.) 1936. Smithburn, Kenneth C., and Jacobs, Henry R.: Neutralization tests against neuro- tropic viruses with sera collected in Cen- tral Africa, J. Immunol. 44:9-23 (May) 1942. Swynnerton, C. F. N.: The tsetse flies of East Africa, Tr. Roy. Ent. Soc. 84:1-579 (Nov.) 1936. Symes, C. B.: Malaria in Nairobi, East African M. J. 17:291-307 (Nov.); 332- 355 (Dec.) 1940; 414-430 (Jan.); 445- 463 (Feb.) 1941. ——: Notes on Rats, Fleas and Plague in Kenya. II. Records of the Medical Re- search Laboratory, No. 3. Medical De- partment. Colony and Protectorate of Kenya. (Jan.) 1932, Nairobi, Govt. Printer, 1932. , and Hopkins, G. H. E.: Notes on Fleas of Rats and Other Hosts in Kenya. Records of the Medical Research Labora- tory, No. 1. Medical Department. Colony and Protectorate of Kenya. (Jan.) 1932, Nairobi, Govt. Printer, 1932. , and Roberts, J. I.: A list of the Muscidae and Oestridae causing myiasis in man and animals in Kenya. Recorded at the Medical Research Laboratory, Nairobi, East African M. J. 9:18-20 (Apr.) 1932. Tonking, H. D.: Pyrethrum dermatitis in Kenya, East African M. J. 13:7-13 (April) 1936. Trowell, H. C.: Public health in British Tropical Africa, Intern. Rev. Miss. 28: 407-414 (July) 1939. Kenya 129 74. 75. 76. 77 73. Walker, A. J.: Aspects and prospects of schistosomiasis control on the Kenya coast, East African M. J. 25:362-366 (Sept.) 1948. Walton, G. A.: Relapsing fever in the Meru district of Kenya, East African M. J. 27: 94-98 (Feb.) 1950. Wilcocks, C.: The problem of tuberculosis in East Africa, East African M. J. 9:88-98 (July) 1932. Wilson, Christopher J.: One African Colony. The Native Races of Kenya, London, Sign- post Press, 1945. Wilson, D. B.: Implications of malarial endemicity in East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 32:435-446 (Jan.) 1939. 79. ——: On the present and future malaria out- look in East Africa, East African M. J. 26:378-85 (Dec.) 1949. 80. Yearbook and Guide to Southern Africa: Edition 50, London, Sampson Low, Marston and Co., Ltd., 1950. 81. Young, W. A., Farr, A. G., and McKendrick, A. J.: A report of the occurrence of oncho- cerciasis in Mahenge, Tanganyika and in the southern area of Lake Victoria, East African M. J. 23:351-353 (Nov.) 1946. Uganda GEOGRAPHY AND CLIMATE The British Protectorate of Uganda, situated astride the equator on the east cen- tral African plateau, is surrounded by the Anglo-Egyptian Sudan on the north, Kenya Colony on the east, Lake Victoria, Tan- ganyika Territory and Ruanda-Urundi on the south and the Belgian Congo on the west. A compact territory of some 94,000 square miles, including roughly 14,000 square miles of open water, it embodies a diverse terrain; uplands of tropical savan- nah, snow-capped mountains, vast tracts of swampland, scattered areas of dense forest and regions of desolate aridity. The most notable feature of the topography is the rise of the Nile at Ripon Falls on the north- ern coast of Lake Victoria. About 70 miles north of Lake Victoria, the river flows through the extensive and irregular Kioga lake system, which occupies a large part of central Uganda and is virtually a huge, marshy backwater. Lakes Edward and George, the Semliki River, Lake Albert and the Albert Nile occupy the floor of a long rift valley on the western border. Although generally moderate, the climate varies with the elevation and the proximity to Lake Victoria. The annual means of the daily maximum temperatures are in the neighborhood of 80° to 85° F. and of the minimum, 60° to 65° F., the range increas- ing with the distance from the lake. Records covering from 30 to 40 years indi- cate that the mean maximum temperature at Kampala is about 86.6° F.; at Fort Portal, near the western frontier, 77.6° F.; and at Gulu, in the north, 85.1° F. Corre- sponding mean minimum temperatures are 62.5° F., 55.9° F. and 66.4° F., respectively. The greater part of the Protectorate has two rainfall seasons: the long rains from March to June and the short rains from September to November, with a relatively dry period between December and February. The rain- fall averages 50 inches a year but varies considerably in different sections of the country. In the Lake Victoria littoral a lake climate is superimposed upon the normal seasonal variations. Some rain falls during every month of the year, with annual aver- ages ranging from 50 to 90 inches in various localities. West of Lake Victoria, the rain- fall on the slopes of Mt. Ruwenzori and in the Ankole-Kigezi areas may approach 40 to 60 inches but is appreciably lower around lakes Albert and Edward. In Karamoja district in the northeast, a single rainy sea- son extends from April to August, with a total fall of less than 20 to 30 inches. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopruLATION Uganda is divided into four provinces: Eastern, which includes the southeastern districts of Busoga, Mbale and Teso ; North- ern, which was re-established in 1947 and covers the northern half of the country; Buganda, which incorporates the native kingdom of that name; and Western, which comprises Kigezi district on the southwest- ern frontier and the native kingdoms of Bunyoro, Toro and Ankole. In the census reports for 1948, the popu- lation is enumerated at almost 5 million, 130 Uganda 131 including 3,448 whites, 37,517 Asiatics and other non-native groups, and 4,885,760 na- tives. The majority of Asiatics are Indians, but small numbers of Goans and Arabs are settled in the larger towns. The indigenous population comprises a diversity of tribes. In 1931 it consisted of 2,322,627 Bantu, found chiefly in Buganda; 698,628 Nilotes, in the regions east of the Nile; 469,935 half-Hamites in the west and the south, and 25,272 Hamites in the extreme east, with small numbers of Pygmies, forest Negroes and Nubians that are found in scattered areas. Except for the populous Kigezi uplands in the southwest corner of the Protectorate, the population is largely concentrated around the shores of Lake Victoria. It has increased considerably since the 1931 census when the population density of Buganda averaged 50.5 per square mile but varied from 28.5 in Mubende to 93.3 around Kam- pala. In the eastern districts it ranged from 6.1 in Karamoja to around 146 in Bugwere and Budama. In Western and Northern provinces, as then constituted, the densities were 62.2 and 27.4, respectively. There are few large towns. Kampala, the only dis- tinctly urban community, has a population of 60,000 to 100,000, including the adjacent native area of the Kibuga, the seat of gov- ernment of the Buganda. Other important centers are Jinja, Mbale, Soroti and En- tebbe, the administrative capital of the Protectorate. Uganda enjoys a relatively high order of social development. Although the native languages are predominantly Bantu, the multiplicity of dialects has represented a serious handicap to progress. However, Luganda is now taught in the schools in many sections of the country, while Swahili is frequently employed as a medium of communication between the different races. A knowledge of English is relatively com- mon among the Buganda. Since the 1870’s the Protestant and the Catholic missions have played a leading role in the educa- tional and cultural advancement of the peo- ple. Also, a substantial number of natives are Mohammedans, descendants of the first religious converts from the prevailing pa- ganism. Elementary and secondary education is largely under mission control, with govern- ment supervision and subsidies for approved schools. In response to a widespread de- mand for education, the native local author- ities themselves are financing the establish- ment of elementary schools to an increasing extent. Schools for European, Indian and Goan children are operated by the Uganda government. Makerere College in Kampala, which serves the East African territories, has branches in arts, medicine, science, agri- culture, education and veterinary science. In 1950 it was accorded the status of a University College by the British Inter- University Council for Higher Education in the Colonies. VITAL STATISTICS Vital statistics are compiled by the Uganda Medical Department, with the co- operation of the tribal chiefs. The registra- tion of births and deaths is compulsory. In the period, 1940-47, the birth rates, based on estimated population totals, ranged from 25.6 to 30.3 per 1,000 population; the death rates from 18.1 to 22.5 per 1,000 population. The infant mortality decreased from 136.9 per 1,000 live births in 1942 to 99.0 in 1947. The maternal mortality also decreased from 7.98 per 1,000 births and stillbirths in 1940 to 5.3 in 1947. The infant mortality varies in different sections of the country. In 1947 it was 25 per 1,000 live births in Kigezi district, 79 in Mengo district and 214 in West Nile district. A marked reduction in infant mortality has paralleled the develop- ment of maternal and infant welfare work. A study of the statistics of Mengo Hospital, covering a period of 20 years up to 1920, re- vealed that the deaths under one year of age were then at least 330 per 1,000 among the Buganda. Ignorance, malnutrition, ve- nereal diseases and malaria are contributing factors. 132 Uganda Social Economy Uganda is an agricultural and pastoral country. Large-scale farming is rare, and, with the exception of sugar cane, both food and export crops are grown almost exclu- sively by small cultivators. The principal exports are cotton, coffee, hides and skins and a variety of minor products, among which tobacco, soya beans, sugar and pea- nuts are the most important. The majority of Europeans are govern- ment officials or missionaries, but a few are plantation-owners, mine-owners, traders or engineers. The Asiatics are predominantly traders, although a small number are en- gaged in government services or various professions. A considerable proportion are permanent settlers, many of whom were born in the Protectorate. Immigration is controlled, primarily for the protection of the indigenous populations, and restrictions are imposed on the sale and the lease of land. In addition to its agricultural wealth, the country contains valuable stands of timber, chiefly muvule (iroko) and mahogany, which the Uganda government is protecting from further exploitation. Its mineral re- sources have not been fully developed. Limited amounts of tin, copper and gold are mined, while a large deposit of rock phosphate has been discovered recently (1942-43) in Tororo district. The dam and the hydroelectric plant, which are under construction at Owen Falls, near Jinja, will permit the expansion of industry in that area. The project is sponsored by the Brit- ish and the Egyptian governments. Communications are well developed. Uganda has an excellent system of roads, reputed to be the best in East Africa. Steamer services are available on lakes Victoria, Kioga and Albert, and on the Vic- toria Nile and part of the Albert Nile. Direct rail connections between Kampala, Jinja and Soroti, and Mombasa provide an outlet to the Indian Ocean. Air services are also established between Uganda and the Sudan, Kenya and other African territories. Foop AND NUTRITION About 75 per cent of the cultivated land of Uganda is planted in food crops. Except in the arid regions of the northeast, the agricultural practices of the people conform to two broad types, contingent upon the conditions of soil and rainfall. In the settled districts bordering on Lake Victoria and in the highlands of the south and the south- west, the principal food crops are plantain, sweet potato and cassava. The soil is rich, and biannual plantings are possible in many regions. In the “short grass” areas which cover the rest of the country, the rainfall is less abundant, and millet is the most im- portant crop. Cassava raising and the accu- mulation of communal stores are encour- aged by the local authorities as a protection against the food shortages recurrent in these regions. Some wheat is grown in sections of Western Province, and rice in parts of Eastern Province. The agricultural depart- ment and the missions have been active in introducing improved methods of cultiva- tion. The chief cattle-raising regions are in Buganda Province and Ankole, Busoga, Lango, Karamoja and Teso districts. Both the short-horned Zebu and the long-horned Ankole cattle are raised, but the importa- tion of occidental strains has not been suc- cessful. Sheep and goats are produced for food, but pigs are rare. Trypanosomiasis is prevalent, and progressive encroachment of the tsetse fly on the livestock areas is a matter of concern to the local authorities. The food habits of the people vary in dif- ferent parts of the country. Their diets are largely vegetarian, consisting of plantain or millet, supplemented by sweet potatoes, cassava and various indigenous vegetables and fruits. Legumes, peanuts and oil seeds provide the major sources of proteins and fats. Milk is sometimes used in the cattle- raising areas, but the supply in other dis- Uganda 133 tricts is limited. Little meat is consumed, except by the pastoral tribes and the more prosperous groups of the population. Chronic malnutrition is common, while the widespread deficiency in animal proteins has a deleterious effect on the health and the resistance of the people. Within recent years, the consumption of meat and fish has increased materially as the result of the activities of the medical authorities, and the progressive breakdown of tribal traditions and taboos. Housine Throughout the settled agricultural areas, the typical holdings consist of circular or rectangular huts of wattle and daub, sur- rounded by a few acres planted partly in cash crops and partly in food crops. In some sections the thatched roofs, which afford ex- cellent harborage for rats and vermin, are gradually being replaced by corrugated iron. The sanitation of the villages and the small settlements is primitive. Reforms in housing and sanitation are being introduced, but progress is slow, since such measures fre- quently appear to conflict with individual interests or tribal customs. The majority of Europeans and many of the Asiatics live in comfortable homes of modern design. In the townships and the trading centers, however, the poorer classes tend to crowd together in quarters con- nected with shops or business buildings. The shortage of housing accommodations is a major problem in the larger townships. ENVIRONMENT AND SANITATION WATER SUPPLIES Despite a wealth of lakes and rivers, the need for water conservation is an important factor in many portions of Uganda. The water supplies for household purposes and for agriculture and stock are mainly con- tingent upon the seasonal rainfall. More- over, much of the rain is lost as the result of deforestation, overstocking and soil ero- sion. Shortages are essentially local, the rainfall in most areas being sufficient to meet the requirements of the people, pro- vided that facilities for storage exist or can be created. The water resources are be- coming increasingly inadequate, however, in the Masaka-Ankole grasslands, and in Karamoja district where, due to the gen- eral aridity, the lack of water is frequently acute. Drinking supplies are obtained from springs, shallow wells and streams and in some areas from rainwater tanks which collect the runoff from roofs. All of these sources are liable to contamination. In the drier localities, a large part of the popula- tion relies upon the use of surface water- holes. However, improvements are grad- ually being effected in the protection of surface supplies and in the development of conservation measures. Numerous dams have been constructed, primarily in the northern and the eastern provinces. In other areas springs have been impounded in covered reservoirs. Where adequate underground waters are available and the density of population justifies the expense, deep wells are being drilled. The town- ships of Entebbe, Kampala, Jinja, Masindi, Tororo and Mbale have water supplies which are treated by filtration and chlorina- tion. The water supply for Kampala is piped from Lake Victoria, while that for Jinja is derived from the Victoria Nile near its point of origin. All township supplies are tested chemically and bacteriologically at regular intervals. Although the water of Lake Victoria is fresh, that of lakes Ed- ward and Albert ranges from salty to slightly brackish and is unsuitable for do- mestic supplies. Waste DisposaL Sanitary conditions in the rural areas of Uganda are primitive. The bucket system is the general method of sewage disposal in the larger towns where the night soil is col- lected and buried in trenches. Septic tanks 134 Uganda are employed in the European and the Asiatic government quarters in Entebbe, Jinja, Mbale, Gulu, Masindi and Masaka, and are being introduced to an increasing extent wherever piped water supplies are available. Kampala is the only community with a sewerage system. It serves approxi- mately 85 per cent of the township and is connected with a modern sewerage treat- ment plant which was erected in 1940. The use of pit latrines is being promoted in the rural areas on the periphery of the towns and in the surrounding villages. Fauna aND Frora Arthropods. Mosquitoes. The most im- portant anopheline mosquitoes in Uganda are Anopheles gambiae and A. funestus, both dangerous vectors of malaria. 4. gambiae breeds throughout the Protectorate except in the desert and the mountainous areas. A. funestus breeds chiefly in shady clear waters, such as swamps, weedy margins of streams and protected shores of lakes and ponds. Potential vectors of lesser signifi- cance are A. christyi, which is reported to have been incriminated in the outbreak of malaria in Kigezi district in 1944; and A. hancocki and A. moucheti, which may be of importance when they occur in large numbers. A. nili has also been found natu- rally infected, and in limited areas where it accumulates in great numbers in native huts and camps, this species may be a poten- tial vector. A. gibbinsi, A. marshalli, A. pharoensis and A. pretoriensis have occa- sionally been found infected in nature but are probably of no concern in the transmis- sion of malaria. 4. gambiae and A. funestus are also possible vectors of Wuchereria bancrofti. Forty-two other species of Anopheles are recorded from Uganda, but as yet none has been implicated in the trans- mission of disease. Forty or more species of Aedes mos- quitoes are found in the Protectorate. Aedes aegypti is widespread. A. simpsoni was shown to be the vector in a human outbreak of yellow fever in Bwamba County of West- ern Province in 1941.17 It breeds in the axils of certain indigenous plants and is abundant in the cultivated clearings around the settlements on the fringe of the forest. A. africanus, a sylvan species found at a level of 50 to 60 feet in the forest canopy, is the principal vector among the forest monkeys; A. luteocephalus and other spe- cies may also be concerned in the transmis- sion of the virus. Over 55 species of Culex have been found, but only Culex pipiens and C. quinquefasci- atus (= C. fatigans), potential vectors of Wuchereria bancrofti, are considered of medical importance. Eretmopodites chrysogaster, Taeniorhyn- chus (Mansonia) africanus and T. (M.) uniformis are also present. Mosquito-control measures are carried on in the vicinity of the larger townships. They include antilarval treatment with oil or DDT, stocking of bodies of standing water with larvivorous fish, plantings with euca- lyptus trees, drainage and the filling of waterholes. Following unusually heavy rains, however, control is difficult and fre- quently unsuccessful. Field experiments in- volving the residual spraying of dwellings with DDT preparations have been under- taken recently in selected areas by a Colonial Insecticides Committee unit. Fries. At least 12 species of tsetse flies have been identified in Uganda, the most important being Glossina palpalis, the vec- tor of Trypanosoma gambiense; G. mor- sitans, the usual vector of T. rhodesiense, and G. pallidipes, a potential vector of T. rhodesiense when present. G. brevipalpis and G. fuscipleuris are implicated in the transmission of animal trypanosomiasis. G. palpalis is limited to the shady banks of lakes, rivers and streams. It is found in the vicinity of lakes Albert, Edward and Victoria, the Albert Nile and the western part of the Victoria Nile. G. morsitans and G. pallidipes commonly inhabit open savan- nah. Both species have spread within recent years. G. morsitans has invaded new areas in Acholi, Lango and Karamoja districts Uganda 135 and in Buganda Province. G. pallidipes has been reported from four counties in Buganda Province, and Busoga, Mbale and northern Ankole districts. Measures for tsetse-fly control are directed chiefly toward destruction of the breeding place and crea- tion of barrier clearings. Animal trypano- somiasis constitutes a problem of equal or greater importance than the human disease, since the decimation of cattle represents a considerable economic loss and seriously affects the food supply. A separate Depart- ment of Tsetse Control, combining the activities of the medical and the agricul- tural departments has been established re- cently by the Uganda government. The pro- gram of Uganda is correlated with that of Kenya and Tanganyika Territory by the Tsetse and Trypanosomiasis Research and Reclamation Organization which was cre- ated by the East Africa High Commission in 1948. Field investigations on the effi- ciency of different methods of application of DDT were initiated in the Lake Victoria region in 1948 by a research unit of the Colonial Insecticides Committee. The stable fly, Stomoxys calcitrans, is widespread and in some instances it has been thought to be responsible for the me- chanical transmission of animal trypano- somiasis. The house flies, Musca domestica and Musca sorbens, are abundant. Nu- merous species of tabanid flies are encoun- tered, including T'abanus fasciatus, T. afri- canus and T. secedens. It is suspected, but not proved, that the last species may be able to transmit Trypanosoma pecorum to cattle. Several species of flies are responsible for accidental myiasis in man. The best-known is probably the tumbu fly, Cordylobia anthropophaga, which is particularly com- mon in the drier parts of the country. The larvae of Chrysomyia bezziana and Lucilia cuprina have been identified in a few human cases of wound infestation. Other species of Chrysomyia and of Sarcophaga are recorded. Black flies or so-called buffalo gnats, members of the family SimuripAE, are abundant. The “Mbwa” fly, Simulium dam- nosum, breeds prolifically in the head waters of the Victoria Nile and in the streams along the foot hills of the Ruwenzori range and of Mt. Elgon. It is a vector of Oncho- cerca volvulus, the principal focus of which is found in an area covering over 1,000 square miles north of Jinja. Preliminary studies for the control of S. damnosum in this region are being undertaken by Co- lonial research personnel in order to fore- stall its spread following the construction of the dam at Owen Falls. S. neavei is present in localized areas, where it prob- ably also constitutes an important vector of onchocerciasis. Numerous other species of Simulium are recorded, but all are con- sidered as annoying pests of no medical significance. Culicoides austeni and C. grahami are known to be the vectors of Acanthocheilo- nema perstans, which is prevalent in some sections of Uganda. Several species of Phlebotomus are present, but their classi- fication is not complete. Lick. Infestation with lice prevails among the members of most tribes, particularly those who wear garments of skins. More- over, the influx of laborers in recent years has increased the degree of louse infesta- tion in many areas. Pediculus humanus capitis and P. humanus corporis are both present. Where tribal custom calls for the removal of pubic hair, Phthirus pubis is sometimes found on the eyebrows. Freas. Both Xenopsylla brasiliensis and X. cheopis are vectors of plague in Uganda. The latter species predominates in the cot- ton areas, which are important foci of the infection. The cat flea, Ctenocephalides felis strongylus, infests the dogs in this re- gion and may accidentally feed on human beings; it can transmit Pasteurella pestis under experimental conditions but is not regarded as a probable vector. X. bantorum and Dinopsyllus lypusus may transmit the infection among the field rodents. Ctenoph- thalmus cabirus is also encountered. The chigoe flea, Tunga penetrans, is com- 136 Uganda mon. It penetrates the skin of the feet and sometimes is associated with ulcerations severe enough to require amputation. Ticks AND MrTES. A wide variety of ticks is indigenous. Ornithodorus moubata, the local vector of African tick fever (relapsing fever), is widespread. It is especially preva- lent along the caravan routes, where it is found in the old native huts. Rhipicephalus appendiculatus, R. sanguineus and Ambly- omma variegatum, common to much of the country, may be responsible for the trans- mission of tick-borne rickettsial fevers which are reported sporadically. R. simus, R. capensis, R. evertsi, Amblyomma he- braeum, Haemaphysalis leachi, Margaropus annulatus and Boophilus decoloratus are also present. The red larvae of the mite, Trombicula irritans, are widely distributed. The itch mite, Sarcoptes scabiei, is likewise preva- lent. Scorpions. A venomous scorpion, prob- ably Pandinus imperator, is present in the dry regions. It may be responsible for occa- sional deaths among young children and old persons and is greatly feared by the people. OruEer ArTHROPODS. The centipede, Scolo- pendra morsitans, secretes a venom which is highly irritating and may cause tempo- rary paralysis. The vesicant beetle, Paederus crebripunctatus, is common throughout this region. Its juices cause blistering on the skin, or conjunctivitis when rubbed in the eye. Driver ants of the genus Dorylus, known locally as “safari ants,” may attack young children caught in their paths. Reptiles. The number of harmful snakes is said to be considerably higher in Uganda than in Kenya or Tanganyika. The most important venomous vipers are the puff adder, Bitis arietans, which is found in the grasslands and the rocky areas; the rhinoc- eros viper, Bitis nasicornis, which is con- fined to swampy regions, and the gaboon viper, Bitis gabonica, which inhabits heavy forest. Three night vipers, Causus lichten- steinii, C. resimus and C. rhombeatus, are reported, as well as species of Athkeris. The burrowing vipers, Atractaspis corpulenta and A. aterrima, are found in the semiarid regions. The green mamba, Dendroaspis jamesonii, is native to the rain forest, but the common mamba, D. angusticeps, has not been reported from Uganda, although it is present in contiguous parts of Kenya. The African garter snake, Elapechis guen- theri, is widely distributed. Three cobras are present : Naja melanoleuca, in the vicin- ity of Lake Victoria and Mount Elgon; N. nigricollis, in the savannah of the north- ern districts ; and NV. kaje, in low-lying areas and in Karamoja district. The boomslang, Dispholidus typus, is widespread. Twa pythons are reported: Python regius and P. sebae. They are not normally dangerous to man, but a few authenticated casualties have been attributed to the rock python, P. sebae. The Nile crocodile, Crocodilus niloticus, is responsible for the loss of numerous lives each year. Rodents. Four species of rodents are po- tential reservoirs of plague: the rats, Rattus rattus rattus, Mastomys coucha ugandae and Arvicanthus abyssinicus rubescens, and the gerbil, T'ateroma smithi. R. rattus rattus is the primary host of plague in the Protecto- rate. It is prevalent in the townships and is gradually replacing M. coucha ugandae in the rural areas. It infests both the thatched and the iron roofs of the native huts. Cya- nide dust has been used with considerable success in the control of rats in the town- ships. Mollusks.* Several types of fresh-water snails are of medical importance. Physopsis africana globosa and Bulinus tropicus are the intermediate hosts of Schistosoma haematobium. Planorbis (Biomphalaria) alexandrina pfeifferi and P. (B.) alexan- drina tanganyicensis are the probable inter- mediate hosts of S. mansoni. Bulinus (Pyrgophysa) forskalii is also present. Plants. Prominent among the plants used by the indigenous tribes as sources of arrow poisons are species of Acocanthera, Adenium * See footnote, p. 10, Uganda 137 and Strophanthus. Numerous trees and shrubs, the leaves or fruits of which are poisonous to livestock, are found through- out East Africa. Common species in Uganda include Phytolacca dodecandra, Turraea robusta and Agauria salicifolia pyrifolia. The herb, Senecio ruwenzoriensis, which grows freely at elevations above 4,000 feet, is also suspected of causing occasional deaths among the livestock. Foop SANITATION Although large numbers of cattle are raised in Uganda, milk is produced in lim- ited quantities. The milk supplies are gen- erally inadequate, particularly in the town- ships. All dairy farms which retail milk are licensed, and the chemical examination of samples is carried on routinely by the local health authorities. No bacteriologic tests are made, and no organized pasteurization exists, even in the principal towns. In the township areas, the inspection of meat supplies and slaughtering establish- ments is conducted by the local veterinary officers. The sanitary condition of bazaars, butcher shops, bakeries, restaurants and other premises where food is prepared or sold is inspected more or less regularly by the health authorities. A large percentage of the food offered for sale is displayed in markets or roadside stands, which are un- protected against flies or dust, and, as else- where, the enforcement of measures for the protection of foods in such establishments is difficult. HEALTH SERVICES AND MEDICAL FACILITIES HeAaLTH ORGANIZATIONS Responsibility for the maintenance of medical and public health services is con- centrated in the Uganda Medical Depart- ment. The department is administered by a Director of Medical Services, with head- quarters at Entebbe. It functions as a major division of the Protectorate government, which is advised on policies pertaining to public health by the medical staff of the Colonial Office in London. The activities of the Department are developed on a district basis. Medical officers in each district are responsible for the direction of all the medical and sanitary services within that area, while senior medical officers supervise and co-ordinate the work within each province. The functions of the Department include the provision of medical care, preventive and sanitary services, the maintenance of laboratory facilities and the training of native medical personnel. Within recent years, it has placed increasing emphasis on public health, with an expansion of its ma- ternity and infant welfare work, school medical services and rural sanitation pro- gram. Many of the dispensaries are essen- tially village institutions, since the initial costs, and sometimes the recurrent charges, are met to a large extent by the constituted native authorities. As such, they function as agencies through which improvements in village sanitation and public health can be initiated. Several Protestant and Catholic missions work in close co-operation with the Medical Department in the development of medical and welfare services and in the training of African personnel. The most active are the Church Missionary Society, the White Fathers Missions, aided by the White Sisters, and the Mill Hill Fathers with their associates, the Franciscan Sisters from St. Mary’s Abbey. An East Africa High Commission was organized in 1948 for the co-ordination of certain interterritorial services in Uganda, Kenya and Tanganyika Territory. Among the departments related to public health are the Tsetse and Trypanosomiasis Re- search and Reclamation Organization and the Bureau of Research in Medicine and Hygiene. The headquarters of both are established in Nairobi, Kenya. MepicAL INSTITUTIONS The Department maintains Hospitals and Dispensaries. Uganda Medical 138 Uganda hospitals at the administrative headquarters of each district and in several other towns, while subsidiary dispensaries and subdis- pensaries are scattered throughout the coun- try. In 1949 it operated 27 hospitals and 139 dispensaries with a total capacity of 3,531 beds for natives; 10 hospital units with 90 beds for Asiatics; and 4 hospitals, at Entebbe, Kampala, Jinja and Mbale, with 72 beds for Europeans. The hospitals vary in size, the largest being Mulago Hos- pital at Kampala, which is a modern, well- equipped institution and the nucleus of the medical training program of East Africa. This hospital had a capacity of over 600 beds in 1949, and plans for the construction of new buildings were under consideration. Isolation wards are located in the larger institutions. The Department also main- tained 38 rural maternity centers, with ap- proximately 450 beds, in addition to the maternity wards in the general hospitals. A hospital for the treatment of nervous and mental diseases is located at Kampala. Numerous hospitals and dispensaries are established under mission auspices. The Namirembe Hospital (sometimes called Mengo) at Kampala, conducted by the Church Missionary Society, is the leading mission hospital in eastern Africa. It is a well-equipped institution with approxi- mately 200 beds, including accommodations for Europeans and Asiatics. The same or- ganization operates hospitals for all races at Fort Portal and Kabale and for Asiatics and Africans at Ngora in Teso district. The Catholic missions maintain hospitals for Asiatics and Africans at Nsambya (Kam- pala), at Nkokonjeru in Mengo and at Fort Portal in Toro districts. In 1945 the govern- ment and the mission hospitals combined provided approximately one bed per 1,360 of the total population. Five institutions for the care and the treatment of lepers are operated by mission organizations, with financial assistance from the Medical Department. The Franciscan Sisters maintain leper settlements at Na- magera (Busoga) and at Nyenga (Mengo). The Church Missionary Society operates a settlement for children at Kumi and one for adults at Ongino in Teso district, and a colony on Bwama Island in Lake Bunyoni. They have combined accommodations for over 2,000 lepers. Laboratories. The Medical Laboratory in Kampala houses the laboratory division of the Uganda Medical Department. It has branches in bacteriology, serology, pathol- ogy, biochemistry and entomology. Excel- lent laboratories are also established in Mulago Hospital for routine diagnosis and for the investigation of various medical problems. The Veterinary Department has well- equipped research laboratories at Entebbe, where investigations are conducted on bovine tuberculosis, animal trypanosomiasis and other cattle diseases. This division maintains a separate sublaboratory for the preparation of antirinderpest serum. The Virus and Rickettsial Research Insti- tute, formerly the Yellow Fever Research Institute, at Entebbe, is one of the foremost laboratories in Africa. It was organized in 1936 for the conduct of research on yellow fever and was financed in part by the Inter- national Health Division of the Rockefeller Foundation until 1950. In addition to its research activities, the laboratory dispenses yellow fever vaccine for use in eastern and central Africa and offers diagnostic and con- sultation services to the neighboring coun- tries. Since the withdrawal of the Rocke- feller Foundation, the Institute has been operated by the Colonial Medical Re- search Service and the governments of Uganda, Kenya and Tanganyika Territory. Its facilities have been expanded to include research on virus, rickettsial and other dis- eases. Schools. The Medical School of Makerere College at Kampala offers medical training to students from all the British East Afri- can territories. The school is affiliated with Mulago Hospital, and the course of instruc- Uganda 139 tion covers seven years, diplomas being granted by the Joint East African Examin- ing Board. In Uganda and elsewhere stu- dents are qualified for posts as assistant medical officers in the Medical Department. As yet the number of graduates is small: in 1949, six students qualified, four of whom were natives of Uganda. The Medical Department maintains schools for the training of African medical personnel. A school for medical assistants is operated in connection with the hospital at Masaka, and for the nursing orderlies at Lira. A training center for assistant health inspectors and hygiene orderlies is located at Mbale. Nurse’s training schools are established at Mulago Hospital and at the Namiembe and Nsambya mission hospitals. No course for midwives is provided in the government institutions, but schools at the Namirembe and Nsambya mission hospitals are subsi- dized by the Medical Department. PERSONNEL Physicians. With the exception of a few practitioners in the larger towns, most of the physicians in Uganda are in government service or attached to one of the mission hospitals. In 1949 the medical roster of the Protectorate listed 145 registered practi- tioners (General Medical Council, Great Britain) and 86 practitioners fulfilling the local requirements for licensure. However, all were not in active practice in the territory. In the same year the staff of the Uganda Medical Department included 49 European medical officers, 11 Asiatic medi- cal officers and subassistant surgeons and 62 African assistant medical officers. A Joint East African Examining Board in Medicine was formed in 1936 to ensure the main- tenance of uniform medical standards throughout East Africa. Dentists. In 1949, 13 dentists were lo- cated in Uganda, 9 of whom were registered practitioners. Two dentists are employed in the dental clinics of the Medical Depart- ment at the European and the Mulago hos- pitals in Kampala. Nurses. Approximately 54 nurses with British General Nursing Council qualifica- tions and 55 meeting other standards were practicing in the Protectorate in 1949. British nursing sisters are also registered as midwives. European nurses are employed by the Medical Department and by the dif- ferent mission organizations. Over 500 locally trained native nurses serve in the hospitals and dispensaries or are engaged in other health activities. Others. The European personnel of the Medical Department, as of 1948, included 11 health inspectors, 5 pharmacists, 4 pa- thologists, 4 entomologists and at least one chemist. The native staff consisted of locally trained personnel in various categories. About 540 native midwives were registered in the Protectorate in 1949. DISEASES The evidence regarding the true incidence of different infections in Uganda is incom- plete. The official reports are usually com- piled from government hospital statistics and give only relative estimates of the prev- alence of specific diseases. The reports of the mission services are rarely included. Moreover, large numbers of the people, particularly in the less-developed areas, con- form to their traditional medical practices, and considerable proportions of the cases of illness are never seen by medical officers. Specific surveys and special research investi- gations provide supplementary evidence re- garding the distribution of certain infec- tions, such as trypanosomiasis, leprosy, yellow fever and other virus diseases. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UrINARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fever is endemic in all parts of the country. The number of observed cases has risen gradually since 1930, but the ap- 140 Uganda parent increase may be due to better diag- nosis and expanded laboratory facilities. Paratyphoid fever is reported occasionally ; among the verified cases, paratyphoid C oc- curs more often than either paratyphoids A or B. From 200 to 300 cases of typhoid fever and from 10 to 20 of paratyphoid fever are treated each year in the govern- ment hospitals; these totals represent but a small percentage of the actual infections. The incidence is highest in the more densely populated areas adjoining the larger town- ships, where contamination of the surface water supplies is frequent. Dysenteries. Both bacillary and amebic dysentery are widespread, from 2,000 to 5,000 cases being reported annually from the government hospitals. Amebic dysen- tery usually predominates, but the statistics may be misleading, since a large proportion of the cases are not classified as to type. Clinical amebiasis is usually mild through- out this region. Localized epidemics of bacil- lary dysentery are common. Infections are most prevalent in the northern part of Uganda where water is scarce and the available supplies may be grossly polluted. Outbreaks of Shiga type dysentery are rela- tively rare. However, an endemic focus ex- ists in Kigezi district in the southwest, and an extensive epidemic was recorded in 1944-45. Diarrhea and enteritis are prevalent, al- though apparently decreasing with the im- provements in sanitation. Approximately 40 to 50 per cent of the reported cases occur among children under two years of age. Cholera. The presence of cholera never has been recorded from this region. Helminthiases. Scuistosomiasis. Both urinary and intestinal forms of schistoso- miasis are reported from the Protectorate. Schistosoma mansoni infection occurs fo- cally in all parts of the country. It is most prevalent in West Nile district, where a survey in the vicinity of Arua, in 1945, re- vealed 12 per cent infection among 1,000 school children.’ The principal intermedi- ate hosts are Planorbis (Biomphalaria) alexandrina pfeifferi and P. (B.) alexan- drina tanganyicensis in West Nile and Lango districts and probably in other areas. S. haematobium was thought to be of lesser importance until 1949 when new foci were discovered in the Lake Kioga region. A study of Lango, Samia and Nyoro tribes- men reported in 19498 indicates a general prevalence of from 2 to 3 per cent. In some localities, infection rates up to 40 to 60 per cent have been found recently among the school children. Physopsis africana globosa and Bulinus tropicus are potential inter- mediate hosts of S. haematobium around Lake Kioga and in Gulu and Chua districts in the north. ANcyrostomiasis. Few districts can be considered free from hookworm infection. The relative incidence may be estimated from reports for 1947, which indicate that 5,609 persons were treated in the govern- ment hospitals and dispensaries for ancylos- tomiasis and 8,723 for other types of hel- minthiasis, exclusive of schistosomiasis. Necator americanus is apparently the pre- vailing species. Oruer HermiNTH INFECTIONS. All types of round worm infection are widely distrib- uted, but recent data regarding the inci- dence of specific species is lacking. Ascaria- sis is probably most prevalent in the western districts. Tapeworm infections are largely confined to Ankole and the areas inhabited by the cattle-raising Nilotic tribes. Treat- ment is rarely attempted on a broad scale, since the clinical manifestations in all types of helminthiasis are usually mild, and re- infection is more or less immediate. Brucellosis. Only occasional cases of brucellosis are reported, although the infec- tion is enzootic in the cattle of certain areas. Brucella abortus is probably the responsi- ble organism in the majority of cases. In the past, outbreaks due to Brucella meli- tensis, originating in the local milk goats, have been recorded from the vicinity of Lake Albert. Other Infections. Human cases of anthrax are reported from time to time, in Uganda 141 which infection follows the consumption of meat from infected animals. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is a serious disease among the native inhabitants, and one of the major causes of death. The actual incidence is not known, and as yet little has been done to control the spread of the infection. From 600 to 1,000 cases are reported annually, but since the facili- ties for diagnosis and treatment are inade- quate, such records serve as a poor index of the extent of the infection. Pulmonary infections predominate, but other forms of the disease also occur. The incidence of tuberculosis is reported to be particularly high among the mine workers and the itinerant laborers from Ruanda-Urundi. Bovine tuberculosis is enzootic among the Ankole breed of cattle, but relatively rare among the Zebu. Little raw milk is con- sumed, but tuberculosis of bovine origin sometimes occurs among individuals with a history of close contact with cattle. Pneumonia. From 3,000 to 10,000 cases of pneumonia are treated in the government hospitals each year. The incidence is par- ticularly high among immigrant laborers, where malnutrition and low standards of living may be considered as contributory factors. The fatality rate averages between 8 and 10 per cent. Pneumococcus menin- gitis is a frequent cause of death. In 1947 slightly over 9,400 cases were recorded, among which about 44 per cent were diag- nosed as lobar pneumonia and 33 per cent as bronchopneumonia, while the remainder were unclassified. Meningitis. Meningococcus meningitis occurs periodically in epidemic outbreaks, which frequently assume serious propor- tions. The disease was epidemic in 1945-47, especially in Eastern Province and in West Nile district on the northwestern border. A total of 6,348 cases was reported in 1946 at the height of the outbreak. Although the recorded incidence declined to 2,630 cases in 1947, the fatality rates rose abruptly from 11 to 19 per cent. The mortality is highest in the remote areas, due to the ob- vious delay in diagnosis and treatment. Smallpox. From 1918, when over 8,000 deaths occurred in the course of a severe epidemic of malignant smallpox, until 1943 only limited outbreaks were reported. In that year a mild form of the disease was introduced from Kenya, which spread rap- idly to all parts of the country. In 1944 the known incidence reached 4,737 cases, with the greatest number recorded from Busoga district. The epidemic continued into 1945 but declined gradually in extent, with a re- duction in the number of cases from 1,558 in 1945 to 389 in 1947. During this period three cases of variola major were diagnosed in Mbale in 1945, but the infection was promptly brought under control. Vaccina- tion against smallpox is carried on by the health authorities in all parts of the Pro- tectorate. Other Infections. Epidemics of measles, whooping cough and chickenpox are fre- quent. Scarlet fever and diphtheria are rare, although occasional cases are reported. Poliomyelitis is endemic, but the number of known cases is relatively low. The high- est incidence within recent years occurred in 1939 when 49 cases were recorded. Nor- mally from two to ten cases are admitted each year to the government hospitals. Diseases SPREAD oR CONTRACTED CuierLy THROUGH CONTACT Venereal Diseases. The incidence of syphilis varies geographically, being less common in areas where yaws is widespread. Syphilis is very prevalent among the Bantu peoples, less frequent among the Nilotic tribes of Northern Province. When an anti- venereal disease campaign was first insti- tuted among the Buganda in 1906, it was estimated that from 80 to 90 per cent of the population was infected in some areas. From 1934, when 74,361 cases were re- ported, the disease decreased steadily up to 1941, probably as the result of the active 142 Uganda control efforts of the government health au- thorities. However, there is considerable evidence that it has been increasing in recent years, not only among the Bantu but among the Nilotic tribes as well. The num- ber of cases treated in government institu- tions rose from 19,692 in 1942 to 45,464 in 1947. While this may be attributed in part to the fact that more cases are seeking medi- cal care in expanded medical facilities, it also undoubtedly reflects a marked increase in incidence. Gonorrhea is prevalent throughout Uganda, but particularly in Buganda Prov- ince. The number of reported cases has risen within recent years; 30,111 cases were treated in 1947, while the annual mean for 1934-1945 was about 11,130 cases. The treated cases give little indication of the extent of infection, which is probably wide- spread in large segments of the population. Special venereal disease clinics are op- erated in connection with Mulago Hospital in Kampala. Yaws. The incidence of yaws is decreas- ing slowly. In 1947 a total of 37,803 cases was reported, while the annual mean for 1934-43 was 47,761 cases. Large foci of in- fection exist in Lango and Teso districts and on the Sesse Islands. In Lango district, yaws is one of the most frequent diseases treated in the government dispensaries. A study of the dispensary attendance in 1928-36 revealed that 20.9 per cent of the patients were treated for yaws, and 1.1 per cent for syphilis at Lira in Lango district, in contrast with corresponding rates of 1.6 per cent and 17.5 per cent at Masaka.l® Leprosy. Leprosy is widely distributed, particularly in the western districts along the Congo border. It is also common in Lango district and in the southeastern part of Eastern Province. Estimates based on a survey made in 194727 by a leprologist, ap- pointed for the British East African terri- tories of Kenya, Uganda and Tanganyika Territory, indicate that there are probably 100,000 lepers in Uganda, an infection rate of at least 20 per 1,000 population. The Leprosy in Uganda. Areas of Greatest Prevalence greatest prevalence was found in the vicinity of Fort Portal, Masindi and Arua, where the infection rates approximated 116 to 118 per 1,000. The lowest rates were found in the Entebbe, Kampala and Masaka areas, where they did not exceed 6 per 1,000. Lepromatous cases averaged from 15 to 20 per cent of the total in the areas surveyed. The Protestant and the Catholic missions operate 5 leper settlements which are par- tially supported by grants from the Medi- cal Department and the British Empire Leprosy Relief Association. In 1947 a total of 2,780 lepers were under observation: 689 were under treatment in government hos- pitals and dispensaries, while 2,091 were in residence in mission-controlled settlements. Of the latter, 288 were located in Namagera 190 at Nyenga, 708 at Lake Bunyoni, 375 at Kumi and 530 at Ongino. Diseases of the Eyes. Trachoma is an important problem in the Protectorate, as may be deduced from the fact that from 2,000 to 8,000 cases have been reported an- nually in the last decade. These probably do not reflect the true incidence of the dis- ease. Observations made during the exami- nation of recruits for the British forces in 1943 indicated that at least 70 per cent of the natives in certain areas have some form of trachoma. In the same year a campaign of personal prophylaxis was initiated in Karamoja district. Purulent conjunctivitis and other infections of the eyes are common. Uganda 143 Diseases of the Skin. Tropical ulcers constitute one of the major causes of dis- ability; from 25,000 to 50,000 cases are treated annually in the government hos- pitals and dispensaries. It is thought by many that this condition is associated with malnutrition and avitaminosis. Mycotic infections are prevalent. Scabies is widely distributed, and over 30,000 per- sons are treated each year in the government dispensaries. Human cases of myiasis some- times occur. Several species of flies are implicated, but chiefly Cordylobia anthro- pophaga, which is abundant in the drier sec- tions of the country. Other Infections. Human rabies is re- ported occasionally. Canine rabies is en- zootic in West Nile district and sporadic in other parts of the country. It is also known to be present among various species of wild animals. From 50 to 100 cases of tetanus are re- corded annually. DisEASES SPREAD BY ARTHROPODS Malaria. Malaria is the foremost disease problem in Uganda. From 40,000 to 120,000 cases are recorded annually, while the dis- ease usually accounts for 25 to 50 per cent of the cases treated in the government hos- pitals, and for 15 to 30 per cent of the deaths. It is estimated that the spleen rates reach 75 per cent among children under two years of age and then drop gradually to 10 per cent in adults. The infection is wide- spread throughout the Protectorate but is most prevalent in the Lake Victoria littoral. In general, variations in incidence corre- spond to differences in altitude or in the concentration of swamps, rivers and lakes in the region. Infection takes place through- out the year in most parts of the country with the exception of the semiarid regions of the northeast and the southwestern high- lands. Plasmodium falciparum, the predominat- ing species, is usually responsible for 75 to 85 per cent of the cases. P. malariae occurs in widely distributed foci, almost exclusively in young children. P. vivax is relatively rare at all ages. The incidence of P. malariae and P. vivax fluctuates in different localities from year to year. Among the cases in which the species was determined in the decade, 1930-39, roughly 78 per cent were due to Plasmodium falciparum, 12 per cent to P. vivax and 10 per cent to P. malariae. The principal vector is Anopheles gambiae, although A. funestus is of major secondary importance. In 1944 an epidemic occurred in the Kigezi highlands, at elevations which previously had been considered free from infection. In this outbreak A. christyi*® 50 was reported as a vector for the first time, but proof of its role is lacking in view of the simultaneous presence of A. gambiae and A. funestus. The incidence of malaria in Kigezi district has increased within re- cent years as the result of the intensive cultivation of the swampy valley areas and the influx of susceptible workers. Anopheline control measures are carried on in the larger townships. Malaria has now been effectively controlled in Entebbe and Kampala. Blackwater fever is reported sporadically, but the average incidence has decreased within recent years. In 1947, 78 cases were reported, of which 76 were Asiatics, one European and one African. Trypanosomiasis. Sleeping sickness was epidemic in the Lake Victoria region in 1902-05, when over 200,000 cases were re- corded from the Busoga area.” The entire population was evacuated from the lake shore, and since that date large sums of money have been expended for the control of the disease. Trypanosomiasis still per- sists but is no longer a serious problem except in limited areas. Infection with Trypanosoma gambiense occurs in the west- ern part of the country, primarily in West Nile, Acholi, Bunyoro and Toro districts, where the vector, Glossina palpalis, breeds along the banks of the Albert and the Victoria Niles and their tributaries and to a lesser extent on the banks of the 144 Uganda streams in the foothills of the Ruwenzori range. The incidence decreased from 425 cases in 1940 to less than 100 in 1947, while the average fatality rate in this period was only 1.4 per cent. Trypanosomiasis, caused by 7. rhode- siense, recently appeared in epidemic form in the eastern Lake Victoria region. From late 1940 to 1943, 2,432 cases and 274 deaths were reported from Eastern Prov- ince, with the peak in 1942. By 1944 the disease had been brought under control to a large extent but continued in south Busoga district, in the Mbale region and on Buvuma Island, south of Jinja. From 1944 to 1947 the annual incidence decreased from 148 to 34 cases. The principal focus now exists in the region of Lumino, within a few miles of the Kenya border. Research undertaken by the Uganda Medical Depart- ment in Busoga district in 1943 revealed that Glossina pallidipes is responsible for the transmission of 7". rkodesiense in this area. Evidence pointed to the fact that the infection was introduced into Uganda from Tanganyika Territory by immigrant work- ers to the sugar estates near Jinja.** The trypanosomiasis-control program of the Medical Department is directed pri- marily toward the treatment of the human reservoir. It includes periodic surveys of the populations in endemic areas with the treatment of infected individuals and, when necessary, the evacuation and the resettle- Distribution of Human Trypanosomiasis in Uganda, 1940-1950 ment of the inhabitants from infected locali- ties. Antitsetse-fly measures are undertaken chiefly by the new Department of Tsetse Control. The establishment in the near future of a Trypanosomiasis Research Insti- tute near Tororo is planned by the East Africa Tsetse and Trypanosomiasis Re- search and Reclamation Organization. Relapsing Fever. Tick-borne relapsing fever is a disease of considerable impor- tance, particularly in the districts along the main routes of travel from the south. The principal foci are found in Ankole and Masaka districts and to a lesser extent in Kigezi and Toro districts. Within recent years the incidence apparently has in- creased, possibly because of the infestation of new areas by the vector, Ornithodorus moubata. It is thought that the tick may have been spread by the large number of laborers from Ruanda-Urundi and Tan- ganyika Territory who have traversed the country en route to employment centers in the north. The personal belongings of per- sons using the camp at Kakitumba, the chief point of entry into the Protectorate, are disinfested by the health authorities, but this route is readily evaded. The num- ber of cases treated annually in the govern- ment hospitals in the 5-year period from 1943 through 1947 ranged from a maximum of 1,370 cases in 1946 to a low level of 664 in 1947. Plague. Plague has long been endemic in the Lake Victoria ports and adjacent areas. In 1929 over 5,000 persons, including a few Asiatics and Europeans, are said to have died from plague in Uganda. Since 1935, when a little over 2,000 cases were re- ported, the disease as decreased steadily. In 1944, 7 cases were recorded, and in 1947 only one. Recently the cases have been limited to Buganda Province. Preventive measures center around the destruction of rats in the townships. Permanent control is difficult however, in view of the primitive living conditions of the people and the in- adequate storage facilities for cotton, grain and similar products. Rattus rattus rattus is Uganda 145 the principal reservoir, and Xenopsylla cheopis and X. brasiliensis are the vectors. Sylvatic plague has not been reported from the territory. Rickettsial Infections. Three forms of typhus fever probably exist in Uganda. In 1934 an outbreak of louse-borne typhus fever, involving more than 100 cases, was described from Kigezi, but there is no evi- dence that the infection, which was intro- duced from the Belgian Congo, spread be- yond this district. Infestation with lice is common among the inhabitants in this re- gion, who habitually wear sheepskin or goatskin garments with the hair turned in. Systematic delousing campaigns are carried on routinely by the Medical Department in the villages throughout Kigezi district, and since 1934 only rare cases of louse-borne typhus have been recorded. Murine typhus is endemic and probably widely distributed. The presence of the in- fection in the area northwest of Kampala has been confirmed by means of laboratory diagnosis. Rickettsial infections, apparently trans- mitted by ticks, are reported occasionally from Buganda Province, particularly in the vicinity of Entebbe and Kampala. They are suspected of being cases of tick-borne typhus. The vector is not known. Both Rhipicephalus appendiculatus and Ambly- omma variegatum are present in localities from which many of the cases are recorded. Filariasis. The incidence of filariasis is unknown, but the fact that several hundred cases of elephantiasis were formerly in- cluded in the annual reports of the Medi- cal Department suggests the presence of Wuchereria bancrofti. The infection appar- ently has a limited geographic distribution. A small focus is known to exist in Lango district, where in one survey, microfilariae were found in 5 per cent of the blood films made at midnight.?* Hydrocele is relatively common in the area. Culex quinquefasciatus (=C. fatigans), Anopheles gambiae and A. funestus, all potential vectors, are preva- lent. Observations of suspected filariasis have also been recorded from widely sepa- rated points in Teso, Ankole and West Nile districts. Acanthocheilonema perstans is widely distributed throughout southern and central Uganda. Infections with Onchocerca volvulus are common in certain parts of Busoga and Mengo districts, where the headwaters of the Nile and of its tributaries are broken by rapids. A survey of one village in Busoga district, in 1937, revealed that 14 per cent of the people had typical subcutaneous fibrous nodules. However, the severe eye infections observed in Kenya and the Sudan are rarely seen. The vector is Simulium damnosum, which is prevalent over an ex- tensive area north of Jinja. A secondary focus of onchocerciasis has been discovered recently in Kigezi district. The vector has not been established, but S. neavei is sus- pected. Yellow Fever. Except for one case in 1941, yellow fever has not been reported from Uganda, but field studies made by workers of the Yellow Fever Research In- stitute (now the Virus and Rickettsial Re- search Institute) at Entebbe indicate that the infection is endemic in many areas. The presence of yellow fever foci on the northern and the western borders of Uganda was first suspected in 1936. An intensive survey in 1937 revealed an important focus in Bwamba County on the Belgian Congo border, in the Semliki River valley west of the Ruwenzori Mountains and on the east- ern fringe of the Ituri Forest. Mouse pro- tection tests on blood sera from the native inhabitants have shown that the infection was present in Bwamba County in 1939-41 and that it involved from 25 to 80 per cent of the population in the settlements on the edge of the forest. During the investigation yellow fever virus was isolated from a human patient and from wild Aedes simp- soni. While clearly implicated in this human outbreak, 4. simpsoni must be regarded as a vector of secondary importance, since it is found only in the cultivated areas around 146 Uganda the dwellings. More recent evidence points to the fact that A. africanus is the principal vector in the transmission of yellow fever virus among the forest monkeys. A large percentage of the Bwamba monkeys has been shown to be immune. The red-tail monkey, Cercopithecus nicitans impange, a frequent crop raider, is suspected of being the chief reservoir in the spread of the virus to man. Since 1941 an immune zone has been created around this endemic area, and from 90 to 95 per cent of the population has been immunized against yellow fever. Quar- antine and anti-Aedes measures have been instituted. Outside of Bwamba County there is no evidence that the infection ever has been epidemic, but immunity tests on human sera from scattered localities in the central, the northern and the western parts of the coun- try indicate that limited outbreaks have occurred over a wide area.?® Other Infections. Dengue fever is re- ported infrequently. However, the common vector, Aedes aegypti, is widespread in the Protectorate. Rare cases of cutaneous leishmaniasis and kala-azar have been observed, but all were shown to be of exogenous origin. Species of Phlebotomus, potential vectors of leish- maniasis, are found particularly in the northeastern part of the country. Sandfly fever is not known to be present. Cases of Rift Valley fever are reported occasionally. Obscure fevers which may be attributed to the Bwamba fever or related viruses prob- ably occur from time to time. The West Nile virus may be widely distributed, but the extent of human infection is not known. Encephalitis lethargica is recorded occa- sionally. Dracontiasis, or guinea-worm infection, is frequent in the northern districts. NurriTioNAL DISEASES Only sporadic instances of specific nutri- tional diseases are reported from Uganda. Pellagra occurs occasionally, but cases of scurvy and beriberi are rare. Tribal customs vary, but the average native dietary is usu- ally deficient in proteins, fats, vitamins A and B, calcium and iron. The examination of over 1,000 individuals in Teso district at the end of the dry season in 1934-35 showed clinically recognizable vitamin A deficien- cies in 30 per cent of the children and in almost 9 per cent of the adults.®'. Malnutri- tion is widespread, particularly among the migratory laborers. Kwashiorkor, or malig- nant malnutrition, is common in the Kam- pala region. MisceELLANEOUS CONDITIONS Infectious hepatitis is not reported regu- larly. However, in 1943 an explosive out- break occurred among the native laborers on one of the sugar plantations, and a tenta- tive diagnosis of infectious hepatitis was made in the case of 14 patients sent to the Jinja hospital, all of whom died. It is claimed that 6 other cases were treated locally, but no further fatalities were re- corded. The excessively high fatality rate was considered worthy of a comment by the government medical authorities. Silicosis has been described recently among the miners employed in the mines of Ankole. Tuberculosis was found as a complication in a large percentage of the cases. SUMMARY Uganda is a British protectorate with a population of almost 5 million, of whom 3,448 are Europeans and 37,517 belong to other non-native groups. The population is largely rural and reaches its greatest density around the shores of Lake Victoria. The health and medical services are administered by the Uganda Medical Department, with headquarters in Entebbe. In 1949 the De- partment operated 27 hospitals and 139 dis- pensaries for natives, also 10 hospital units for Asiatics and 4 for Europeans. Other hos- pitals and dispensaries are maintained by various mission groups. Water supplies are obtained from streams, shallow and deep wells, springs and rainwater tanks. Modern, Uganda 147 treated supplies exist in only 5 townships. Methods of sewage disposal are primitive. The control of food sanitation is restricted to the urban communities. The most pressing disease problems of the Protectorate are malnutrition, trypano- somiasis, malaria, relapsing fever and intes- tinal infections, including ancylostomiasis. Tuberculosis, leprosy, yaws and venereal diseases are prevalent among the native peoples. Filariasis, typhus fever and plague are present in limited areas. Schistosomiasis is widely distributed. Smallpox outbreaks occasionally occur. Pneumonia, meningococ- cus meningitis, measles, whooping cough and respiratory infections are common. BIBLIOGRAPHY 1. Barrett, R. E.: Epidemiological observations on plague in the Lango district of Uganda, East African M. J. 10:160-180 (Sept.) 1933. : Notes on the epidemiology of sleep- ing sickness with special reference to con- ditions in the West Nile district of Uganda, East African M. J. 11:20-28 (Apr.) 1934. 3. Blacklock, D. B.: Methods of disposal of human excreta and refuse employed in the British colonies, Ann. Trop. Med. 38: 58-72 (Apr. 19) 1944, 4. ——: Water supplies in the British colonies, Ann. Trop. Med. 37:211-220 (Dec. 31) 1943. 5. Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. 6. Cook, A. R.: The medical history of Uganda, East African M. 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S.: The mosquitoes (sic) of the funestus series in East Africa, Bull. Ent. Res. 28:587-603 (Dec.) 1937. Leprosy in East Africa: Internat. J. Leprosy 7:383-394 (July-Sept.) 19309. Loewenthal, L. J. A.: The assessment of the nutritional state of natives of Uganda, East African M. J. 15:239-255 (Nov.) 1938. ——: An inquiry into vitamin A deficiency among the population of Teso, Uganda, with special reference to school children, Ann. Trop. Med. 29:349-360 (Oct.) 1935. : A note on tick typhus in the Eastern Province of Uganda, East African M. J. 13:141-145 (Aug.) 1936. MacKichan, I. W.: Rhodesian sleeping sick- ness in eastern Uganda, Tr. Roy. Soc. Trop. Med. & Hyg. 38:49-60 (Aug.) 1944. Mahaffy, A. F.: The epidemiology of yel- low fever in Central Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 42:511-524 (March) 1949. ——, Smithburn, K. C., and Hughes, T. P.: The distribution of immunity to yellow fever in Central and East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. , Smithburn, K. C., Jacobs, H. R., and Gillett, J. D.: Yellow fever in western Uganda, Tr. Roy. Soc. Trop. Med. & Hyg. 36:9-20 (June) 1942. Mitchell, J. P.: Medical education in Uganda, South African M. J. 19:242-245 (July) 1945. Pitman, Capt. Charles R. S.: A Guide to the Snakes of Uganda, Kampala (Uganda), Uganda Society, 1938. Smithburn, K. C.: Neurotropic Viruses of Central Africa. Proc. 4th International Congress on Tropical Medicine and Ma- laria, Washington, D. C., 1948. 1:576-583. , and Haddow, A. J.: Semliki Forest virus. I. Isolation and pathogenic proper- 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. ties, J. Immunol. 49:141-159 (Sept.) 1944. ——, Haddow, A. J., and Lumsden, W. H. R.: An outbreak of sylvan yellow fever in Uganda with Aedes (Stegomyia) africanus Theobald as the principal insect host of the virus, Ann. Trop. Med. 43: 74-89 (April) 1949. ——, Haddow, A. J., and Mabhaffy, A. F.: A neurotropic virus isolated from Aedes mosquitoes caught in Semliki Forest, Am. J. Trop. Med. 26:189-208 (March) 1946. , Mahaffy, A. F., and Haddow, A. J.: Semliki Forest virus. II. Immunological studies with specific antiviral sera and sera from humans and wild animals, J. Im- munol. 49:159-173 (Sept.) 1944. Steyn, J. J.: The effect of the anopheline fauna of cultivation of swamps in Kigezi district, Uganda, East African M. J. 23: 163-169 (June) 1946. Thomas, H. B., and Scott, Robert: Uganda, London, Oxford, 1935. Trowell, H. C.: Malignant malnutrition (Kwashiorkor), Tr. Roy. Soc. Trop. Med. & Hyg. 42:417-433 (Jan.) 1949. ——, and Muwazi, E. M. K.: A contribu- tion to the study of malnutrition in Cen- tral Africa. A syndrome of malignant mal- nutrition, Tr. Roy. Soc. Trop. Med. & Hyg. 39:229-243 (Dec.) 1945. Uganda Protectorate. Medical Department: Annual Reports for the Years Ended De- cember 31, 1930-1943, Entebbe, Govt. Printer, 1931 on. : Annual Report for the Year ended December 31, 1944, Entebbe, Govt. Printer, 1945. Annual Report for the Year ended December 31, 1945, Entebbe, Govt. Printer, 1947. ——. ——: Annual Report for the Year ended December 31, 1947, Entebbe, Govt. Printer, 1949. Worthington, E. B.: (Uganda Protectorate.) A Development Plan for Uganda, Entebbe, Govt. Press, 1946. Yearbook and Guide to Southern Africa: 1950 ed., London, Sampson Low, Marston and Co., Ltd., 1950. 10 Tanganyika GEOGRAPHY AND CLIMATE Tanganyika Territory, the major part of former German East Africa, has been ad- ministered by Great Britain since 1922, under a mandate from the League of Na- tions and subsequently as a United Nations Trust Territory. It has an approximate area of 360,000 square miles, including parts of Lake Victoria, Lake Tanganyika and Lake Nyasa. The Territory is bounded by Kenya on the northeast, Uganda and Ruanda- Urundi on the northwest, the Belgian Congo on the west, and Northern Rhodesia, Nyasa- land and Mozambique on the south. On the east it borders on the Indian Ocean, with a coast line over 500 miles in length, and embraces several small islands of which Mafia, near the mouth of the Rufiji River, is the largest. Tanganyika is a country of plains and plateaus. The central plateau, which com- prises the greater part of the Territory, rises from a narrow coastal plain, averaging from 10 to 20 miles in width, to a general eleva- tion of 4,000 feet. It is divided by the Great Rift Valley, containing Lake Nyasa, while the escarpment of the Albertine Rift marks its western boundary at the edge of Lake Tanganyika. Chains of highlands with ele- vations of 5,000 to 10,000 feet are found in the northeast and the south. Mt. Kiliman- jaro, the highest known peak in Africa, with an altitude of 19,321 feet, is located near the Kenya border. The climate varies markedly in different localities. In parts of the coastal belt and in the region around Lake Victoria, there are two well-defined rainy seasons: from March 149 to May, and from October to November. temperature, which averages betwee and 80° F., is moderated somewhat extend from Iringa to Lake Nyasa, enjoy a climate which is almost European. POPULATION AND SOCIO-ECONOMIC CONDITION PoruraTion In the census of 1948 the population of Tanganyika Territory was estimated at 150 Tanganyika 7,402,699, including 10,648 Europeans, 44248 Indians, 11,074 Arabs, and 4,190 Goans and other non-native communities. The indigenous population is predominantly Bantu, although representing a variety of tribes with widely different customs and social organizations. The remaining native peoples include Hamitic-Bantu; the Ha- mitic Masai, seminomadic tribes divided between Kenya and Tanganyika; Swahili of Arab-Bantu blood, located along the coast; and a few aboriginals, descendants of the early dwarflike inhabitants of Central Africa, concentrated in remote areas around Lake Eyasi and in northern Central Prov- ince. The majority of the tribes are pagan, but the natives of the coastal areas and of the older inland towns are largely Mos- lems. The Christian missions, which have been active in Tanganyika since the days of Livingstone in 1857, have also made large numbers of converts. In addition to the diverse tribal languages and dialects, Swa- hili is used extensively throughout the Territory. For administrative purposes, the country is divided into 8 provinces. The most popu- lous areas are the coastal plains, the Lake Victoria littoral, the Arusha-Moshi high- lands and sections of Southern Highlands and Central provinces. Crude density calcu- lations have little value, since most of the districts contain large stretches of unin- habited country. In two small districts, Rungwe and Kwimba, the population den- sity is over 100 per square mile; but in 12, containing extensive areas of tsetse-fly in- fested bush, it is less than 10. The Masai reserves support a nomadic cattle-raising population of less than 2 per square mile. The northern highlands, where a large per- centage of the European estates are located, have been closed to further white settle- ment. In Moshi district the average popula- tion density is 75 to 80 per square mile, while in the agricultural areas of Arusha it is over 500, although the cattle ranges bring the total for the district down to less than 10. There are no designated “native reserves” as in Kenya, but over one third of the indigenous population is concentrated in Mwanza and Bukoba districts, bordering Lake Victoria, and in Tabora district. The Indians and the Goans are largely urban; over 40 per cent of the former and 65 per cent of the latter reside in the coastal towns of Dar es Salaam and Tanga. Dar es Salaam, the capital and principal seaport, had a pop- ulation in 1947 of 60,000, and Tanga, the second largest port, of 32,000. At the time of the 1948 census there were 1,726 white residents in Dar es Salaam and 355 in Tanga. Education is developed on a racial basis. A large proportion of the natives and many of the older Asiatics are illiterate. Elemen- tary and secondary education is provided in government schools and in private or mis- sion institutions subsidized by the Tan- ganyika government. Elementary educa- tion, in the case of the natives, is largely in the hands of the missions. However, in many areas, and particularly in Lake Province, the Native Administrations have been active in providing educational facilities for their villages. Out of a total of over 1,200 primary schools in 1947, 48 were operated by the government and 219 by the local native authorities. Indian schools are con- ducted in most instances by Indian agencies, with assistance from the government. There are few postelementary schools for Euro- pean children in the Territory. VITAL STATISTICS The birth rate and the death rate for the Territory are not known. The registration of births is required only when one or both parents are white, but the registration of deaths is compulsory for all the non-native communities. The infant mortality is re- ported to be high. In the rural areas it probably exceeds 150 per 1,000 live births. Ignorance, tribal superstitions and unhy- gienic methods of care are contributory factors of major importance. The reduction of the infant mortality is recognized as one of the most urgent problems before the health authorities. Sociar Economy Agriculture is the primary source of wealth in Tanganyika. The European set- tlers are largely planters. They operate ex- tensive sisal, coffee, tea and cotton planta- tions, particularly in the northern high- land areas. The Indians control much of the commerce and most of the retail trade, as well as almost 30 to 40 per cent of the capital invested in agriculture. The coconut plantations on the coast and on the island of Mafia are chiefly in the hands of the Arabs. The majority of the natives are either peasant cultivators or pastoralists. In addition to subsistence crops, they raise at least three quarters of the coffee and most of the cotton-oil seeds and peanuts grown for export. The chief cattle areas are North- ern, Central, especially Singida district, and Lake provinces. Hides are an important source of income, although the distribution of livestock is limited by the prevalence of trypanosomiasis and other parasitic dis- eases. The Territory is rich in natural resources, but only a few minerals have been exploited. Important gold deposits are found to the south and the west of Lake Victoria. Major diamond-producing areas are located in Mwanza and Shinyanga districts. Limited amounts of tin, salt and mica are also mined, while deposits of coal are being in- vestigated in Southern Province. The sparsity of the population over two thirds of the Territory and the lack of ade- quate communications are among the major handicaps in the development of Tangan- yika. An extensive system of roads has been built, but many are impassable to motor traffic during the rainy season. Rail communications between the principal cen- ters are provided by two lines, the Tanga railway from Tanga to Arusha, with an ex- tension to Voi forming a link with the | Tanganyika | 151 Kenya and Uganda railway, and the Central railway from Dar es Salaam to Kigoma, with a branch from Tabora to Mwanza. A second branch line to serve the mining areas of Mpanda in Western Province was under construction in 1947. Communication with adjacent countries is also available by means of steamer traffic on lakes Victoria and Tanganyika, and by air services from Dar es Salaam, Lindi and Tabora. The expansion of communications and the development of modern methods of agriculture are important features Territory’s development program. the plan for the large-scale mechanized pro- duction of peanuts in Kenya, Northern Rhodesia and Tanganyika, which was in- augurated by the British government in 1947, approximately 50,000 acres had| been cleared around Kongwa, in central Tangan- yika, in June, 1949. Foop AND NUTRITION Food shortages resulting from drought conditions are recurrent, and even during years of optimum rainfall most of the peo- ple live at subsistence levels. Approximately two thirds of the population are concen- trated in one tenth of the total land area, and soil erosion and primitive methods of agriculture have combined to limit the crop yield to such an extent that it is inadequate to meet the needs of the people. The nutri- tional standards among the laborers in the mines and on the plantations vary, but they are generally low among the workers in the towns. Bulrush millet is the basic food in many areas, Maize is also grown in large quanti- ties, and rice is cultivated in the lake re- gions and in the river valleys. Wheat and barley are raised in the uplands by the European settlers. Sweet potatoes, cassava, legumes and peanuts are used to a varying degree by the native inhabitants, but green vegetables are relatively scarce. Bananas and plantain are staple foods in the districts near lakes Victoria and Tanganyika. 152 Tanganyika Other indigenous fruits are also available, but the citrous varieties are rare. Coconuts and oil palms are plentiful near the coast. Meat and milk are not widely used ex- cept by the pastoral tribes. Domestic ani- mals are scarce in vast areas which are infested with tsetse fly vectors of trypano- somiasis, while in most parts of the country the meat supply is limited by the reluctance of the people to slaughter their livestock, which they regard as a measure of wealth. Moreover, the consumption of both milk and eggs is taboo among some tribes. Fish is abundant on the coast and in the lake regions, and recently the government has sponsored the development of the dried fish industry near Lake Rukwa. Ghee, a form of clarified butter, is an important article of diet in the towns but is rarely utilized in the rural areas. The average native diet is deficient in vitamins, fats and proteins. The Tangan- yika government has attempted to remedy this defect by introducing new crops and better strains of livestock and by educating the people in improved methods of agricul- ture. However, the ignorance, the apathy and the migratory habits of many tribes impose serious obstacles to rapid improve- ment in the standards of nutrition. In some areas it has been necessary to require the villagers to plant sweet potatoes or cassava as a bulwark against famine. A nutrition of- ficer was appointed for the Territory in 1947. Housine Housing conditions throughout the coun- try are generally poor. Native dwellings are, traditionally, of wattle and daub with thatched roofs, but in some areas there is a growing demand for homes of more perma- nent materials and modern design. In urban areas the housing accommodations for Europeans, Asiatics and natives are gen- erally inadequate. Some of the most acute problems are encountered in Dar es Salaam. Built originally by the Sultan for his capital and rebuilt by the Germans in 1887, the town is spaciously planned with broad palm- lined avenues. However, sanitation is primi- tive, and overcrowding is general. The Asi- atic quarter in particular is squalid and ramshackle. In the native town large mud-walled huts with palm-thatched roofs accommodate several families and are vir- tually single-storied tenements. As a pre- liminary step in the government’s plans for improved native housing, blocks of experi- mental houses with coral masonry walls, concrete floors and makuti roofs have been built. An attempt has also been made to introduce houses of clay brick construction in certain sleeping-sickness areas, to obviate the necessity for excursions into the fly-in- fested bush for poles and other building materials. ENVIRONMENT AND SANITATION WATER SUPPLIES One of the most pressing needs in the Territory is the development of adequate sources of drinking water for men and cat- tle. Probably not over one tenth of the coun- try is well supplied with surface or shallow sources of water, and such lands are rapidly approaching a state of congestion. In a few areas deep wells have been bored to meet the most urgent demands, but many have yielded water with a high degree of salinity. Recent projects have included the construc- tion of earth dams and storage works. An investigation of the water resources of the country is being undertaken as part of the development program. Because of the low standards of sanita- tion, most of the water supplies are liable to contamination. Protected wells are rarely found, even in the larger villages. Piped water supplies are available to limited sec- tions of the larger towns, but only a few are treated by filtration or chlorination. The water supply for Dar es Salaam is derived from boreholes, springs and infiltration gal- leries ; it is chlorinated before distribution. A modern filtration plant is under construc- tion, and the development of additional Tanganyika 153 sources is planned. The water supply for Tanga is obtained from boreholes and is treated by chlorination. The remaining towns draw water from boreholes, springs, wells or surface sources. The water supply for Dar es Salaam is tested bacteriologically and chemically at regular intervals, but the examination of other supplies is infrequent. WasTE DisposaL The methods of sewage disposal are primi- tive. Pit latrines are employed in the towns and in many villages. There are no modern sewerage systems, but water-borne facili- ties, with disposal by means of individual septic tanks and absorption pits or drains, are available in the European sections and in other limited areas in the larger towns. In Dar es Salaam, the construction of three- storied buildings in the commercial district has introduced acute problems of sewage disposal, emphasizing the need for a sewer- age system to serve that section. Fauna AND FLora Arthropods. Mosquitoes. Twenty-five or more species of anopheline mosquitoes have been recorded from Tanganika Terri- tory. However, only two, A. gambiae and A. funestus, are of medical importance as vectors of malaria and possibly of filariasis. A form of A. gambiae, which breeds in the brackish coastal waters but differs from the A. gambiae melas of West Africa, is also a vector. It is less efficient than the fresh- water form in the transmission of malaria but more effective as a vector of filariasis. A. nili, A. christyi, A. pharoensis, A. pre- toriensis, A. brunnipes and A. rhodesiensis are also present but have not been found infected in Tanganyika. A. gambiae transmits malaria throughout the Territory except in the high moun- tainous regions. It is the most important vector on the coast and the only vector in the arid sections of the interior. It breeds in the numerous small collections of water and in slowly flowing streams, being more or less dependent on the rainy seasons. A. funestus, which breeds throughout the year in partially shaded, slowly flowing streams or along the protected margins of lakes and ponds, is common both along the coast and in the highlands, especially in areas under intensive cultivation and irri- gation. It probably does not breed to any extent at altitudes over 4,000 feet and dis- appears completely from arid regions such as Dodoma. From 20 to 30, or more, species of Aedes mosquitoes are present in Tanganyika. Aedes aegypti, the common vector of urban yellow fever in other countries, is wide- spread and is probably the most important. It breeds near houses in small domestic collections of water, in puddles and in brackish well water. A. simpsoni lilii, a potential vector of yellow fever, is a com- mon tree-hole breeder on the coast. Other Tanganyikan species include A. taylori, A. metallicus, A. luteocephalus, A. africanus and A. vittatus. Numerous species of culicine mosquitoes occur, but only two, at present, deserve con- sideration. Culex quinquefasciatus (= C. fatigans) and C. pipiens transmit filariasis due to Wuchereria bancrofti. Taeniorhyn- chus (Mansonia) africanus and T. (M.) uniformis are also common. Mosquito-control measures vary accord- ing to local conditions. Drainage, canaliza- tion, filling, and the treatment of standing waters with antilarval applications of Paris green, oil or DDT are carried on in the urban areas and on some estates. Fries. Flies are numerous and may consti- tute a serious menace to health. The most important are the tsetse flies, vectors of trypanosomiasis. Eight different species are found in the Territory: Glossina morsitans, G. swynnertoni, G. palpalis, G. pallidipes, G. longipennis, G. brevipalpis, G. austeni and G. fuscipleuris. Glossina morsitans, G. swynnertoni and possibly G. pallidipes are vectors of the highly fatal form of human trypanosomiasis caused by Trypanosoma rhodesiense. G. palpalis transmits the less virulent form 154 Tanganyika M.Glossina morsitans P- Glossina pallidipes P,-Glossina palpalis S-Glossina swynnertoni B- Glossina brevipalpis A-Glossina austeni Distribution of Tsetse Flies in Tanganyika caused by T. gambiense. G. morsitans and G. pallidipes are the most widely distrib- uted vectors of animal trypanosomiasis, which is not only a problem of economic im- portance but one which affects the nutrition of the people and the settlement of large sections of the country. Glossina morsitans, which inhabits mi- ombo woodland and stretches of savannah, is found in the eastern and the western parts of Tanganyika and has recently in- filtrated into the central region. Two wide belts in which this species abounds extend roughly northeast-southwest from Lake Vic- toria to the southern end of Lake Tangan- yika and from the Usambara and the Paré mountains to the borders of Mozambique. Recent migrations into Central Province from the east and the west have resulted in a secondary belt in that area, while lesser foci exist along its edges and in the eastern Rift Valley. G. swynnertoni has spread from the Lake Victoria region over the northern part of the Territory, across Masailand and into the Moshi area. It inhabits a drier, more open type of woodland than G. morsitans and shows a preference for groves in which acacia trees predominate. It also abounds in savannah-covered areas. G. palpalis, dependent for its existence on the presence of permanent surface water, has a limited range in Tanganyika. It is found chiefly along the shores of Lake Vic- toria and Lake Tanganyika and the banks of the rivers leading to them. Tsetse-fly control measures are carried on by the Tsetse Research Department of the Tanganyika government, in co-operation with the medical, agricultural and veteri- nary services. “Barrier,” “rod” and other types of clearings have been developed against the different species. Game destruc- tion has also been introduced on an experi- mental basis in the vicinity of Shinyanga. Field experiments on the application of DDT and other insecticide sprays were started in 1948 by units of the Colonial In- secticides Committee in conjunction with the Department. In 1948 co-ordination of the trypanosomiasis control programs of Tanganyika, Kenya and Uganda was ef- fected by the creation of the Tsetse and Trypanosomiasis Research and Reclama- tion Organization under the East Africa High Commission. This department, which has its headquarters in Nairobi, advises with the government services on the re- clamation of tsetse-infested lands and various phases of trypanosomiasis control. It sponsors research directed toward the control of tsetse flies and of animal and human trypanosomiasis at Shinyanga and Tinde. Other species of Muscipae are abundant and probably responsible for the spread of enteric diseases. Musca vicina is the most prevalent representative of this family, although M. nebula, M. domestica and M. sorbens are common. Stomoxys calcitrans, S. nigra and S. taeniata are also present. TaBaNiDAE are numerous. Although the bites of many are painful and troublesome, only the mango flies, Chrysops dimidiata and C. silacea, are of potential medical im- portance. These flies are known to carry Loa loa in the Belgian Congo and West Africa but have not been implicated in Tan- ganyika. Various species of Lucilia, Sar- Tanganyika 155 cophaga and Chrysomyia are found. Cases of human myiasis due to Chrysomyia albi- ceps and Rhinoestrus purpureus have been noted occasionally. The tumbu fly, Cordy- lobia anthropophaga, a common cause of human myiasis, is widespread. The blood- sucking larvae of Auchmeromyia luteola, known as “Congo floor maggots,” infest the earthen floors of the native huts in some areas. Six species of SiMULIIDAE are known to exist in Tanganyika, but many more are probably present. The only known species of importance are Simulium damnosum and S. neavei, vectors of the filarial worm, On- chocerca volvulus. S. hirsutum, S. vorax, S. medusaforme and S. lepidae are also re- ported. S. damnosum is described from localized areas in southwestern Tangan- yika, where it is found in greatest numbers during the dry seasons, when the water level of the rivers is low and well-aerated breed- ing places abound. Sandflies of the genus Phlebotomus have not been described from Tanganyika but may be present. As yet no proven cases of sandfly-borne disease have been reported from the Territory. The midges, Culicoides austeni and C. grahami, are widely dis- tributed throughout most areas in this gen- eral region. Lice. The human lice, Pediculus humanus capitis and P. humanus corporis, are prev- alent; Phthirus pubis is slightly less so. FrEas. Xenopsylla cheopis is the species most frequently associated with the rats in Dar es Salaam and other urban areas, as well as in the Lake Victoria districts. X. astia is also abundant in Dar es Salaam but absent or rare in the Lake region. X. brasili- ensis infests the rats nesting in the thatch of the roofs in the native villages and with X. cheopis constitutes an important vector of plague. Numerous other species of rodent fleas are encountered. Ctenocephalides felis attacks both cats and dogs. The human flea, Pulex irritans, is a frequent pest. The chigoe flea, Tunga penetrans, is prevalent in the agricultural areas. BepBucs. Both Cimex hemipterus and C. lectularis are indigenous to this region. Ticks anp MrtEs. Ornithodorus moubata is the vector of relapsing fever caused by Borrelia duttoni. It may be encountered in the native huts, particularly along the routes traveled by the migratory laborers. Several Ixodid ticks have been reported from the Territory, among which Rhi- picephalus sanguineus and Haemaphysalis leachi are of medical importance. They are the most probable vectors of tick-borne typhus, which occurs sporadically. R. ap- pendiculatus, R. simus, R. evertsi and R. capensis are widely distributed. The itch mite, Sarcoptes scabiei, is com- mon. OTHER ARTHROPODS. Several vesicant beetles are present, including Paederus crebripunctatus, sometimes called “Nairobi fly,” P. sabaeus, Mylabris praestans and M. haecolyssa. Reptiles. Over one hundred species of snakes are found in Tanganyika, of which at least 22 are known to be dangerous to man and animals. The pythons include Python sebae and the East African sand boa, Eryx thebaicus. They are not poisonous but may attack small animals. Certain tribes believe that it is bad luck: to kill pythons; consequently, they are plentiful in certain areas, usually in the vicinity of the larger rivers. Three cobras are found: Naja melanoleuca, often erroneously called the “black mamba,” N. kaje, variously re- ported from southern Tanganyika and the southeastern part of Lake Province, and the rare N. nigricollis. The mambas include Dendroaspis angusticeps, D. sjoestedt (Lonnberg’s mamba), D. jamesonii and the African garter snake, Elapechis guentheri. The puff adder, Bitis arietans, the best known and most widely distributed of the Tanganyikan vipers, is found in many habitats below 5,000 feet. Bitis gabonica, an ugly and highly poisonous snake, is re- corded from Kilwa and the Usambara Mountains. Three species of night vipers are reported : Causus rhombeatus, C. resinus 156 Tanganyika and occasionally C. defilipii. The tree vipers, Atheris squamiger, A. nitschei and A. cera- tophorus, are found at high altitudes on the outskirts of the rain forests. Species of bur- rowing vipers, including Atractaspis ir- regularis, A. katange and A. rostrata, are encountered more rarely. The boomslang, Dispholidus typus, is also present through- out much of this region. Two species of crocodiles, Crocodilus niloticus and C. capophratus, are known to infest the rivers and the lakes. In some areas several persons are killed each year. Rodents. Rats are extremely prevalent throughout Tanganyika. Several species of Rattus rattus are found and constitute the principal reservoir of human plague. Their classification as to subspecies is still incom- plete. Innumerable species of wild rats and mice occur, but none has been proven to be infected with either plague or murine typhus. Mollusks.* Twenty-six or more species of fresh-water snails have been identified in the Territory, but only two have been im- plicated in the transmission of disease. Physopsis africana globosa is the inter- mediate host of Schistosoma haematobium, which is widespread especially in Northern, Lake and Eastern provinces. Planorbis (Biomphalaria) alexandrina pfeifferi is the intermediate host of S. mansoni. It occurs primarily in the Lake Victoria region but also around Lake Nyasa and in Tanga Prov- ince. Bulinus (Pyrgophysa) forskalii and B. tropicus are found but have not been shown to be infected. Plants. Many native plants have toxic properties and are used by the tribal medi- cine men in the preparation of drugs and charms. Species of Strophanthus, Aco- canthera, Adenium, Vernonia and Scilla are employed by the different tribes as arrow poisons, while Tephrosia vogelii, Mundulea sericea and species of Euphorbia are used as fish poisons. Human deaths have been reported due to the accidental consumption of water treated with Euphorbia. Plants * See footnote, p. 10. sometimes responsible for homicidal or ac- cidental deaths include the sassybarks, Erythrophleum guineense and E. afri- canum, Phytolacca dodecandra, Dioscorea sansibarensis, Albizzia versicolor, Courbonia camporum and species of Cucumis and Datura. Sporadic cases of poisoning occur, due to the contamination of grain supplies with the seeds of Datura. Deaths among the livestock are some- times attributed to the consumption of the leaves or fruit of poisonous plants, par- ticularly Twurraea robusta, Dichapetalum stuhlmannii and the timber tree, Agauria salicifolia pyrifolia. Foop SANITATION In urban areas the premises on which food for human consumption is sold, in- cluding shops, restaurants, dairies, markets and slaughterhouses, are subject to inspec- tion by the local health authorities. The inspection of livestock before and after slaughter at the abattoirs is the function of the government’s Veterinary Department. Sanitary regulations cover the control of milk supplies in the principal townships. In most areas, however, milk is poor in quality and is produced under insanitary conditions. There is no pasteurization and, with the ex- ception of chemical analyses in Dar es Salaam, no laboratory examinations are un- dertaken. Sanitation varies in the smaller townships and in the rural areas. Supervi- sion is restricted by the lack of sufficient inspectorate personnel. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The medical and public health services are operated by the Medical Department, a major department of the Tanganyika gov- ernment. It is administered by a Director of Medical Services, with headquarters in Dar es Salaam. The policies of the Depart- ment are controlled indirectly by the medi- cal advisory staff of the Colonial Office in Tanganyika 157 London. Its activities are organized on a provincial basis, with a medical officer in charge of one or more of the eight prov- inces. Subordinate district officers are re- sponsible for the work of the Department in the separate districts. In urban communities, sanitation is the responsibility of the township health or- ganization, while in the rural areas certain functions pertaining to public health are undertaken by the constituted Native Au- thorities under the supervision of the dis- trict medical and administrative officers. In 1948 the Native Authorities supported 402 dispensaries in various parts of the country, which provide an effective, al- though elementary, means of reaching an increasingly large proportion of the popula- tion. The difficulties encountered in the pro- vision of medical and preventive services are tremendous. The size of the Territory and the paucity of communications render many areas almost inaccessible. An increase in both medical and public health services is contemplated as an integral part of the Territory’s development program. A series of interdepartmental rural health centers is planned, and pilot organizations have been started in Sukumaland and in Moshi and Rungwe districts. The East Africa High Commission, which was organized in 1948, administers certain interterritorial services. Those pertaining to public health include the East African Bureau for Research in Medicine and Hy- giene and the East Africa Tsetse and Try- panosomiasis Research and Reclamation Organization. The former sponsors filariasis research and medical survey units in Mwanza and a Malaria Unit in Tanga, all of which are supported in part by the Colonial Medical Research Committee. Various missionary groups carry on medi- cal, health and educational work through- out the Territory, generally with financial assistance from the government. At least 12 Protestant organizations are represented, including the Universities Mission and the Church Missionary Society. The activities of the Catholic missions are divided on a regional basis, the Black Fathers working in the northeast, the White Fathers in the West and the Benedictine Fathers of St. Ottilien in Bavaria, in the south. Much of the maternity and child health work in the Territory is carried on by the missions. MEepIcAL INSTITUTIONS Hospitals and Dispensaries. In 1947 the Medical Department of the Territory operated 71 hospitals and 53 rural dispensa- ries, which provided 131 beds for Europeans, 141 for Asiatics and 3,725 for natives. From 2 to 8 hospitals are located in each of the provinces. The largest, in Dar es Salaam and Tanga, have 241 and 275 beds, respec- tively. Accommodations for Asiatics are available in the principal centers. Hospital units for the care of white residents are established in Dar es Salaam, Tanga and ten other towns. In addition to its general hospitals, the Medical Department main- tains a maternity hospital at Dar es Salaam, infectious disease hospitals at Dar es Salaam and Tanga, a tuberculosis hospital at Kibon- goto and mental disease hospitals at Do- doma and Lutindi. It also operates mater- nity and child welfare clinics in Dar es Salaam, Tanga, Dodoma and Tabora. Some of the Native Authority dispensa- ries have a few beds for emergency cases. The 402 dispensaries supported by the Na- tive Authorities in 1948 provided a total of 232 beds. The missions maintain hospital facilities in different areas; in 1947 there were 63 mission hospitals, including 14 under the direction of European physicians, and 43 dispensaries, providing a total of 48 beds for Europeans, 120 for Asiatics and 2,945 for natives. They also conducted 10 ma- ternity and child welfare clinics. The gov- ernment co-operates fully in the mission activities and provides grants for various purposes. Several of the larger companies and estate owners also support hospitals and dispensaries for the care of their workers. 158 Tanganyika In 1947 there were 27 leper settlements, with subsidiary dispensaries, in Tangan- yika, 11 of which were operated by the Medical Department, 15 by the various missions and 1 by a Native Authority. Laboratories. All of the medical labora- tories in the Territory are conducted by the Medical Department. The Central Labora- tory, with pathologic, clinical and chemical divisions, is located at the Sewa Haji Hos- pital at Dar es Salaam. Branch laboratories function in the provincial hospitals in Moshi, Tanga, Tabora, Mwanza, Mbeya and Lindi. The government’s malaria research labo- ratory at Muheza, near Tanga, is now part of the Malaria Unit under the East African Bureau for Research in Medicine and Hy- giene. Laboratories are also operated in connection with filariasis and medical survey units at Mwanza. An interterritorial laboratory for research on human and ani- mal trypanosomiasis is established at Tinde ; also a station for the study of methods of tsetse-fly control at Shinyanga. Both were formerly operated by the Tanganyika gov- ernment but now come within the scope of the East Africa Tsetse and Trypanosomiasis Research and Reclamation Organization. Schools. There is no school for medical practitioners in the Territory, but qualified students are sent to the Medical School at Makerere College in Uganda. Comprehen- sive courses of instruction for medical assistants are provided by the Medical De- partment at Dar es Salaam and by the Universities Mission’s school in Minaki. Government schools at Mwanza and Tukuyu offer courses for medical auxiliaries training for work in the rural dispensaries. Most of the larger government and mission hospitals also train “dressers” and other subordinate medical personnel. Nurses training schools are conducted in the Dar es Salaam and Tanga hospitals and in three mission institutions. Intensive theo- retical instruction is provided at Dar es Salaam and Tanga in conjunction with prac- tical work in the provincial and district hos- pitals. Midwives are trained in the mater- nity hospital in Dar es Salaam and in the mission hospitals. Laboratory assistants are trained in the Central Laboratory in Dar es Salaam. Courses for African sanitary in- spectors are conducted at Dar es Salaam, and for malaria assistants at Muheza. PERSONNEL Physicians. At the end of 1947 there were 168 physicians in the Territory: 103 Europeans, 61 Asiatics and 4 Africans. Of these, 51 Europeans, 40 Asiatics and 4 Africans were employed in government service. Of the remainder, 12 were con- nected with mission institutions, 10 with various refugee camps, and 15 with indus- trial concerns, while 36 were engaged in private practice. Fifty were licensed to practice in the Territory but were unable to comply with British registration require- ments. In 1947-48 there were about 2.3 doc- tors per 100,000 population in the country. Dentists. The registered dentists totaled 7 in 1947; 3 were connected with the Medi- cal Department. Nurses. Over 200 European nurses were registered in 1947; 54 were in government service. All government nurses are also cer- tified midwives. DISEASES Information regarding the incidence of disease in Tanganyika is derived from hos- pital and dispensary statistics, from sample surveys and from the reports of investiga- tions in different areas. Such sources are in- complete but furnish a relative estimate of the distribution and the extent of various infectious diseases. The influence of the tribal “medicine men” is strong, even in areas where the established medical facili- ties are reasonably adequate. The insect- borne diseases common to tropical Africa are prevalent, as well as the usual respira- tory infections associated with more tem- perate regions. The low standard of nutri- tion is a major factor in determining the lack of resistance of the native peoples to Tanganyika 159 both endemic and epidemic infections, while insanitary living conditions and ignorance of basic hygiene contribute to their spread. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. Bacillary and amebic dys- entery are prevalent. The proportionate in- cidence of amebic and bacillary infections fluctuates, but it is probable that both are more extensive than official reports suggest. In the five years, 1943-47, from 450 to 1,100 cases of amebic dysentery were treated an- nually in government hospitals and dis- pensaries ; also from 500 to 1,650 cases of bacillary and from 2,500 to 3,700 cases of unclassified dysentery. High infection rates are frequently encountered among the con- tract laborers on the large estates. In 1943- 44 outbreaks of bacillary dysentery were particularly numerous, especially in the western part of Lake Province. In the latter year the incidence reached 6,377 cases, of which 1,651 were diagnosed as bacillary dysentery, and 1,024 as amebic. Typhoid and Paratyphoid Fevers. Lo- calized outbreaks of typhoid fever are fre- quent. From 100 to 400 cases of typhoid fever and from 20 to 45 of paratyphoid fever were treated annually in the government hospitals between 1938 and 1947. These cases undoubtedly represent but a small percentage of the total incidence. Moreover, adequate diagnostic facilities are not avail- able outside of the larger centers. Cholera. Cholera has not been reported from Tanganyika Territory within the present century, but may have occurred be- tween 1860 and 1890. Helminthiases. ANcyLosTom1asts. Hook- worm infection is widespread over most of the Territory and especially in the low-lying sections of the coast and of Lake Province. In the latter region it is most intense in the districts near the lake shore and in the min- ing areas. Necator americanus apparently predominates but both species are present. Although reports vary, it is probable that over 25 to 40 per cent of the population is infected. In 1943-47 the fatality rates aver- aged 6.4 per cent. Among 1,123 native re- cruits examined at Dar es Salaam in 1941, ancylostomiasis was detected in 59 per cent.?® The examination of the stools from a group of boys in the African central schools in Dar es Salaam and Mpwapwa in 1940 revealed hookworm eggs in 18 per cent and 6 per cent, respectively. A comparable survey among the school children in Tanga in 1944 showed that 25 per cent were in- fected. Hookworm infection is not confined to the native population. Scuistosomiasis. A high incidence of schistosomiasis exists in many sections of the country, and an average of 10,000 to 15,- 000 or more cases is treated each year in government institutions. The disease is es- pecially prevalent in Lake, Eastern and Western provinces, while the areas in the immediate vicinity of Mt. Kilimanjaro and Mt. Meru are reported to be the most highly endemic in the Territory. The re- gional infection rates among army recruits in 1942 were 85 per cent in Maswa, 38 per cent in Uzaromo, 15 per cent in Dodoma and 3 to 6 per cent in Njombe and Mbeya dis- tricts, and 27 per cent in Dar es Salaam. It is feared that the increasing amount of irri- gation in Lake Province will result in an extension of the disease. Schistosomiasis caused by Schistosoma haematobium is widely distributed, the probable molluskan host being the fresh- water snail, Physopsis africana globosa. A study, reported in 1949,* of the prevalence of infection in army recruits showed that it ranged from 5.3 per cent to 30.3 per cent in the representatives of nine different tribes. Infections with S. mansoni are encountered less frequently but predominate in the Mwanza district of Lake Province and in the Lake Rukwa area of Western Province. The intermediate host is Planorbis (Bi- omphalaria) alexandrina pfeifferi. Oruer Herminta INrecTiONS. The roundworm, Ascaris lumbricoides, is re- ported with the same relative frequency as 160 Tanganyika hookworm, between 20,000 and 30,000 cases a year, but even these figures probably are underestimated. Ascariasis is especially prevalent in the hill regions of Northern Province and in Iringa district. Oxyuriasis, strongyloidiasis and trichuriasis are moder- ately common. Multiple infections are fre- quent, particularly in the humid forested areas. Pigs are not numerous in the Territory, and infection with the pork tapeworm, Taenia solium, is rare. The incidence of T. saginata infection in cattle varies. It is low in Shinyanga district but almost 100 per cent in other parts of the country. Human infections with 7. saginata are reported, chiefly from Iringa district and from North- ern, Lake and Central provinces. Echino- coccus granulosus infections are seen occa- sionally. Other Infections. Brucellosis is en- countered sometimes, and both Brucella melitensis and B. abortus have been identi- fied. Human infections may result from contact or from the consumption of the milk or the milk products from infected animals. B. abortus is probably endemic in the cattle-raising districts, particularly Mpwapwa, Tanga, Tukuyu and Kilosa. Between 50 and 100 cases of human anthrax are reported almost every year from various sections of the country. As in other areas, infections among primitive tribes are most frequently attributed to the consump- tion of infected meat. Diseases SpreEAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis probably ranks third or fourth among the causes of native mortality. Population surveys sug- gest that a large proportion of the children and from 50 to 95 per cent of adults in dif- ferent areas are tuberculin-positive. It is apparent that the incidence of tuberculosis has been increasing within recent years. The insanitary habits and the poor nutri- tion of the people, the increasing urbaniza- tion with resultant overcrowding, and the influx of susceptible individuals from the “bush” to employment centers are among the factors contributing to its prevalence. On the basis of surveys in 1930-36 the in- cidence of the disease was estimated at about 11.5 per 1,000 population for the coun- try as a whole,* but higher rates are en- countered in the highland and the coastal districts. Both pulmonary and nonpulmo- nary infections are common. From 2,300 to 3,300 cases of pulmonary tuberculosis and 1,200 to 1,700 of nonpulmonary are treated in government institutions each year. The infection rates are especially high in the towns of Dar es Salaam, Tanga and Moshi. Reports from Dar es Salaam for 1944-47 in- dicate a rise both in the rate of infection in the Asiatic and the native populations and in the proportion of severe cases. Specific proposals for an extension of diagnostic and treatment services are in- cluded in the development plans of the Medical Department. The government maintains a tuberculosis hospital at Kibon- goto on the slopes of Mt. Kilimanjaro, with ten outlying dispensaries and a village where convalescents can live and work with their families under medical supervision. In 1947, 1,766 cases were under treatment in the Kibongoto Hospital and dispensaries. Bovine tuberculosis is relatively rare among the humped Zebu cattle indigenous to Tanganyika. The amount of human infec- tion of bovine origin is unknown but is probably negligible. Meningitis. Meningococcus meningitis is always a serious problem in Tanganyika. Epidemics occur in cycles of irregular dura- tion and intensity. The recent major out- break started in 1939. The peak was reached in 1942, when the incidence rose sharply to a level almost four times that of the pre- ceding year, possibly as the result of the concentrations of labor necessitated by the war. The most serious outbreaks occurred in Lake and Western provinces, although cases were reported from other parts of the country, particularly from Southern, East- ern and Central provinces. Cases normally Tanganyika 161 occur throughout the year but increase markedly in July or August, reach a peak between September and November and then fall off sharply. In 1942 the fatality rate was 14.7 per cent in a total of 11,687 cases; in 1943, 15.8 per cent in 8,800 cases. The re- ported incidence dropped to 1,789 cases in 1946 but was still greater than the annual average for the decade prior to 1939. Pneumonia. Pneumococcal infections are one of the principal causes of death among the native populations. The disease is present in all parts of the Territory but probably reaches most serious proportions in Tanga and Southern Highlands provinces. Over 3,000 cases are reported each year, probably a small part of the total incidence. Smallpox. Smallpox is endemic and at times epidemic. Free vaccination is avail- able at all medical centers, but widespread control is difficult because of the scattered population and the lack of adequate trans- portation facilities in many areas. Exten- sive vaccination campaigns are undertaken in the event of an outbreak, but losses in potency of the vaccine under severe climatic conditions detract from their efficiency. Only sporadic cases had been reported for several years up to 1944, when epidemic conditions became established. In 1943 a mild form of smallpox was introduced across the northern border and spread rapidly in the highly susceptible population. Cases oc- curred in all parts of the country, with an average fatality rate of less than 1 per cent. Toward the end of 1944 and in 1945 scat- tered foci of malignant smallpox appeared in widely separated portions of the country, primarily in Lake, Central, Northern and Western provinces. Both forms of the in- fection occurred simultaneously. Over 12,- 000 cases were reported in 1945 and again in 1946—more than 100 times the average number in nonepidemic years. The incidence declined to 2,960 cases in 1947, but the fatality rate remained high. It averaged 20.7 per cent in 1947, as compared with 0.7 to 1 per cent in 1943-44 and 15 per cent in 1945-46. Other Infections. Sporadic cases of diphtheria occur every year. Scarlet fever is rare. Mumps and measles are endemic and sometimes epidemic. Whooping cough exists in all portions of the Territory; it is frequently epidemic, attacking individuals of all ages. Poliomyelitis is occasionally re- ported. Diseases SPREAD OR CONTRACTED Cuierry TaroucH CONTACT Venereal Diseases. Venereal diseases are widespread, particularly in the larger towns. In the 7 years from 1940 to 1947 an average of about 38,000 cases of syphilis and 17,000 of gonorrhea was reported an- nually, but such morbidity figures are un- doubtedly low. The relative incidence of syphilis and gonorrhea varies in different localities, even in areas, as Lake Province, where the venereal disease rate is usually high. In 1947 it was estimated that 7.8 per cent of the total hospital and dispensary cases in Bukoba were syphilitic infections, and 8.5 per cent were gonococcal. Com- parable rates in Ikoma were 19.4 per cent for syphilis and 3.6 per cent for gonorrhea. In contrast, the rates in Ngara were 0.03 per cent and 0.04 per cent, respectively. In some regions considerable confusion is en- countered in determining the prevalence of syphilis due to the simultaneous presence of yaws. A special venereal disease clinic is con- ducted at Sewa Haji Hospital in Dar es Salaam. Elsewhere, cases of venereal disease diagnosed at the government and tribal dis- pensaries are sent to the nearest govern- ment hospital for treatment. Personal edu- cation and follow-up work is undertaken, wherever possible, by health visitors and nurses. As in other territories, the natives rarely continue treatment after the acute symptoms have subsided. Yaws. Yaws occurs throughout the Ter- ritory; over 90 per cent of the population are infected in some areas. The disease is most extensive along the shores of Lake Nyasa, on the coast in the neighborhood of 162 Tanganyika Dar es Salaam, and in sections of Lake and Western provinces. It is also encountered frequently in Dodoma district and near Kilimanjaro. The number of cases reported has decreased in the last ten years—from 132,469 cases in 1938 to 51,259 in 1946. In- tensive antiyaws campaigns have been suc- cessful in eliminating early yaws in many districts, but skin and tertiary lesions are still observed in the older people. Leprosy. Leprosy is endemic among the indigenous populations of Tanganyika. As the result of surveys conducted in 1947 and 1949 by an interterritorial leprologist ap- pointed by the governments of Kenya, Uganda and Tanganyika, in conjunction with the British Empire Leprosy Relief As- sociation, the incidence of leprosy in the Territory was estimated at 14.3 per 1,000 population. On this basis the number of lepers was calculated at about 80,000. The infection conforms in distribution to the population density. It is most prevalent in the coastal regions, along the lake shores and in the foothills of the mountains. The highest infection rates occur among the tribes living under crowded conditions in areas of high atmospheric humidity, as in Lake Province, Rungwe district in the vi- cinity of Lake Nyasa, the Matombo Hills and the low country around Lake Manyara. Roughly 20 per cent of the cases show lepro- matous lesions. Facilities for the isolation and the treat- ment of lepers are inadequate. In 1947 there were 27 leper settlements with 38 sub- sidiary dispensaries in the Territory; 11 settlements and 4 dispensaries were oper- ated by the Medical Department, 15 settle- ments and 34 dispensaries by the missions, and one settlement by a Native Authority. In that year, 3,796 lepers were segregated in settlements, while 4,030 others were under observation. The Makete settlement in Southern Highland Province accommodates from 800 to 1,000 patients. It is subsidized by the Medical Department and staffed by the British Empire Leprosy Relief Associa- tion. The Morogoro and Mahenge settle- ments, each with a capacity of about 600 lepers, are operated under mission auspices. Diseases of the Skin. In some sections of Tanganyika Territory, tropical ulcers assume primary importance, in that they seem to occur in epidemics and cause con- siderable disability among the laborers. They result from neglected cuts, insect bites and chigoe sores, while low tissue resistance due to dietary deficiencies and intercurrent helminthiasis is thought to be a predisposing factor. Scabies is common. Myiasis caused by a number of flies, and especially the tumbu fly, Cordylobia anthropophaga, is encountered frequently. The chigoe flea, Tunga penetrans, is prevalent. It burrows beneath the skin of the feet, causing lesions which, in the west especially, are apt to be- come infected. Phialophora verrucosa and related fungus infections, which are some- times referred to as “mossy foot,” are fre- quent. “Dhobie itch,” or ringworm, pityria- sis vesicolor and other dermatomycoses are widespread. Diseases of the Eyes. Trachoma is a common affliction among both natives and Asiatics. In a survey of the schools in Mbeya, Iringa and Tukuyu districts of Southern Highlands Province in 1945, 38 per cent of 600 children were found to have trachoma. The infections are usually mild. Various types of conjunctivitis, including gonorrheal ophthalmia, are prevalent. Other Infections. From 50 to 100 human cases of anthrax are recorded each year, which result both from contact with in- fected animals and from the consumption of infected meat. Occasional cases are ob- served among the hide-warehouse employees in Dar es Salaam. Rabies is present among the dogs of this region, and human cases are sometimes reported. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is almost universally prevalent in Tanganyika but varies some- what in incidence and seasonal distribution, conforming to the climatic conditions gov- erning the propagation of the vectors, Tanganyika 163 Anopheles gambiae and A. funestus. Infec- tions transmitted by A. gambiae are wide- spread but seasonal, occurring during and immediately after the rains. 4. funestus is slightly more restricted in distribution, but transmission takes place throughout the year. The incidence of malaria has increased within recent years. The rise in the number of cases treated in the government hospitals and dispensaries, from 73,080 in 1940 to 132,700 in 1947, probably reflects not only an extension of medical facilities but also a valid increase in the extent of infection. Malaria is hyperendemic in the coastal plain region. In 1933-34 a survey of typical rural villages in the neighborhood of Tanga showed that acute infections are found al- most exclusively in children under two years of age and that adolescents and adults usually develop a high degree of immunity. In the urban communities of Tanga and Dar es Salaam the age incidence characteris- tic of this hyperendemic area prevails, but the total number of infections is normally from 20 to 30 per cent lower as the result of antimalarial measures. In Dar es Salaam from 60 to 80 per cent of malarial infec- tions are acquired during the four months of high A. gambiae incidence, namely, from April through July. In the inland rural areas of Southern Highlands, Northern and Tanga provinces, the incidence varies from little or no malaria at altitudes over 4,000 feet, and in the sparsely settled arid regions, to the hy- perendemicity prevailing near the coast. In central and southern Tanganyika the disease tends to be seasonal, while epidemic malaria is encountered in the highlands around Kilimanjaro and in the south. In Lake Province, where the rainfall is heavy throughout the year and 4. gambiae and A. funestus are always present, it is highly endemic. Western Province is also mala- rious. A large percentage of the cases in all sec- tions of the country are caused by Plas- modium falciparum. P. malariae infections occur predominantly in children and are usually more numerous than those of P. vivax. P. ovale is occasionally encountered. Mixed infections are common. Extensive control measures have been in- stituted in many sections of the Territory but have been confined to areas where the results could be expected to justify the ex- pense involved. In the rural hyperendemic areas, where anopheline control is impos- sible, reliance has been placed upon the treatment of infected individuals. Blackwater fever, usually associated with P. falciparum infections, is sporadic. Trypanosomiasis. The presence of both forms of human trypanosomiasis consti- tutes a serious problem in Tanganyika. Though fairly well controlled in some areas, the disease has been increasing in recent years. The incidence of new cases rose from 439 in 1943 to over 800 in 1944 and 1946, with slight recessions in 1945 and 1947. Trypanosoma gambiense infections are now confined to limited areas along the shores of Lake Victoria and Lake Tan- ganyika, conforming to the distribution of G. palpalis. Although from 25 to 80 per cent of the population in localized areas were affected following its introduction from the Congo early in the century, this form of sleeping sickness has now been controlled to a large extent, and the incidence is probably relatively low. However, trypanosomiasis, caused by T. rhodesiense, is widespread, and may assume almost epidemic proportions. The principal focus is apparently in West- ern Province, from which it has spread into Lake and Northern provinces. Small foci of infection also exist in the Masasi, Tunduru and Liwale districts of Southern Province and in Mahenge district of Eastern Prov- ince. Since 1946 epidemic outbreaks have occurred in the Kondoa-Irangi area of Cen- tral Province, where overpopulation and soil erosion have forced the inhabitants to settle in the tsetse-infested bush. In 1943 the infection was reported in a European at South Kahama. Extensive control measures, including the treatment of cases and the suppression of 164 Tanganyika = Distribution of Human Trypanosomiasis in Tanganyika, 1947 the tsetse fly, are carried on continuously by the government authorities. The evacua- tion of the populations from heavily infested areas and their concentration in suitably protected settlements is sometimes under- taken. A constant watch is also maintained for the presence of cases outside of known sites of infection. Research on human and animal trypanosomiasis is carried on at Tinde and studies on methods of tsetse-fly control at Shinyanga under the direction of the Tsetse and Trypanosomiasis Research and Reclamation Organization. Relapsing Fever. Relapsing fever caused by Borrelia duttoni is widely distributed, particularly along the main travel routes through Bagamoyo, Morogoro, Songea, Lindi, Rungwe, Ufipa, Kigoma, Tabora and Mwanza districts. Transmitted by the tick, Ornithodorus moubata, it is commonly des- ignated as “African tick fever.” In areas where the ticks are established they infest the poorly built native huts, hiding in the cracks and the crevices by day and biting by night. During the war years the unprecedented movements of natives contributed to a spread of the tick. The incidence of relaps- ing fever throughout the Territory has in- creased steadily since 1940. In 1944, when a total of 4,634 cases was recorded, the most extensive outbreaks occurred in Lake Province, primarily in Mwanza, an old endemic focus, and in Musoma and Bil- haramulo districts. An increased number of cases which were said to be unusually virulent and resistant to treatment was also reported from Southern Province. The epi- demics continued into 1946 and 1947, with 5,770 and 5,299 cases, respectively. The average fatality rate was from 1 to 2.5 per cent. Filariasis. Filariasis, due to Wuchereria bancrofti, has a variable distribution in Tanganyika. In the coastal region the infec- tion rates average 25 per cent. In the west- ern third of the Territory they are also high. They approximate 25 per cent at Mwanza but diminish gradually, as the distance from Lake Victoria increases, to 19 per cent in Kahama, 9 per cent in Kigoma and 7 per cent in Tabora. In a small area at the north- ern tip of Lake Nyasa and in the vicinity of Mahenge and Liwale, W. bancrofti in- fections are also endemic. Hydrocele and elephantiasis are common. Infections due to Acanthocheilonema perstans are encountered in two areas: in the Lake Victoria region, where from 40 to 48 per cent of the population may be in- fected, and in the Liwale area and along the shores of the Mbemkuru River in Southern Province, where the infection rates average between 30 and 40 per cent. A few ap- parently indigenous cases occur around Mwanza and Dar es Salaam, but the re- maining portions of Tanganyika are rela- tively free. The vector is not mentioned in available reports, but the midges, Culicoides austeni or C. grahami, may be implicated. Onchocerciasis is encountered occasion- ally in a limited area around Tukuyu, Njombe and Mufinde in southwestern Tan- ganyika, and in 1942 it was discovered near Mahenge. The parasite, Onchocerca vol- vulus, is transmitted by Simulium dam- nosum and S. neavei. Plague. Plague is endemic in eastern Tanganyika 165 Africa, particularly in the Lake Victoria basin and along the wall of the Great Rift. Outbreaks occurred in Shinyanga district in 1931 and in Mwanza in 1937. With the exception of sporadic cases the disease was then quiescent until 1948, when it broke out in Singida district, following an epizootic among the rats of the region. In the human outbreak, a total of 312 cases was reported, with a fatality rate of 57 per cent. Only 17 cases were recorded in 1949. Although not proved, the infection appears to exist en- zootically in the wild rodents of north- central Tanganyika, from which it may spread to Rattus rattus under favorable cir- cumstances. The local vectors are Xenop- sylla cheopis, X. brasiliensis and possibly X. astia. Antirat campaigns are carried on in the endemic areas, and strict quarantine measures have been instituted in the ports. The seaports have been free from infection since 1918, and the Lake Victoria ports, since 1933. Yellow Fever. Clinical yellow fever never has been reported from Tanganyika, but the infection may have been present in localized areas at some period within the life of the present generation. Investiga- tions by workers from the Yellow Fever Research Institute at Entebbe in 1941 sug- gested that the infection is apparently ab- sent from the western part of the country. Mouse protection tests on the blood of 467 persons in 15 different localities yielded negative results, except for one case near the Ruanda border.?* However, sub- sequent tests on 284 samples of blood taken in 1946 and 1947 showed evidence of im- munity in six individuals.*? All were adults, 20 to 25 years of age, who supposedly had not been outside of their home districts. Three were from Lindi, two from Tanga and one from Moshi. The following year im- munity was demonstrated in five other per- sons in the vicinity of Tanga, four of whom were under 15 years of age. Regardless of the extent of the infection in this area, yellow fever constitutes a serious threat to the Ter- ritory, since it is endemic in western Uganda and in 1943 appeared in Kenya. The Terri- tory is especially vulnerable because of the presence of the mosquito vectors and the in- accessibility of vast areas in which recogni- tion of the disease might be delayed with serious consequences. The natural vector, Aedes aegypti, is widely distributed, while potential vectors, A. simpsoni lili, A. vitta- tus and A. africanus, are also found. Pro- tective measures have been instituted, in- cluding the inspection of planes and pas- sengers at the airports in Dar es Salaam, Dodoma, Moshi and Musoma and else- where; the inspection of ships and dhows and control of passenger traffic at sea and lake ports, with the exercise of par- ticular precautions at Kigoma and at Mwanza ; Aedes surveys in towns, communi- cation centers and representative rural areas; Aedes-control measures in Dar es Salaam, Tanga and other densely popula- tion areas of potentially high infestation; and the immunization of government per- sonnel and others, wherever feasible. In 1950 arrangements were being made by the World Health Organization to include Tan- ganyika Territory in the endemic yellow- fever area. Other Infections. Tick-borne typhus fever is sporadic. It is said to be endemic in Dodoma but is not reported officially from that area. No detailed studies of its epidemiology in Tanganyika have been made, but the ticks, Rhipicephalus san- guineus and Haemaphysalis leachi, are prob- able vectors. Dengue fever is present, although not often reported. The vector, Aedes aegypti, is found in large numbers in many parts of the country. Occasional cases of guinea-worm infec- tion, caused by Dracunculus medinensis, have been reported, but they probably were acquired outside of the country. NuTrITIONAL DISEASES The standard of nutrition among the natives is low. Vitamin A deficiencies in the form of night blindness and skin lesions are 166 Tanganyika prevalent. A seasonal deficiency in vitamin C is encountered constantly, particularly in the drier parts of the Territory where fruits and vegetables are scarce. Outbreaks of scurvy are frequent in the Lupa gold-min- ing area. Pellagra and beriberi occur spo- radically. Malignant malnutrition,or kwash- iorkor, is common, particularly in infants, and may be responsible for fatality rates as high as 50 per cent. It is also observed in adults subsisting on deficient diets or suffering from severe or chronic infections. MiscELLANEOUS CONDITIONS Silicosis has been reported recently among the underground gold-mine workers. Spo- radic cases of onyalai are recorded. SUMMARY The health and medical services are ad- ministered from Dar es Salaam by the Medical Department of the Tanganyika government, in co-operation with the local authorities and with various mission groups. Hospital accommodations for Europeans and Asiatics are available in all the principal centers. In 1947 approximately 71 hospital units of varying size were operated by the Medical Department, and 63 by various mission organizations. Sanitation is poor; the water supplies are protected only in the larger towns; and sewage disposal is uni- versally primitive. The water resources of over nine tenths of the Territory are inade- quate, resulting in a congestion of popula- tion in the remaining areas. Malnutrition and avitaminosis are common among the natives in all parts of the country, but par- ticularly in the township areas. Malaria is widespread, while trypano- somiasis is prevalent in many sections of the country. Tuberculosis and pneumonia are major causes of death among the native populations. Epidemics of meningococcus meningitis and smallpox are frequent. Fila- riasis, schistosomiasis and African tick fever are important problems in localized areas. Intestinal infections, yaws, leprosy, trachoma and various skin conditions are common. Syphilis is widespread in the towns and is spreading in the rural districts. Gonorrhea is prevalent in all parts of the country. Plague, tick-borne typhus, measles and whooping cough are endemic. Diph- theria, scarlet fever and poliomyelitis are sporadic. BIBLIOGRAPHY 1. Blacklock, D. B.: Methods of disposal of human excreta and refuse employed by the British colonies, Ann. Trop. Med. 38: 58-72 (Apr.) 1944. : Water supplies in the British colonies, Ann. Trop. Med. 37:211-220 (Dec.) 1943. 3. Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. 4. Dewhurst, Kenneth E.: The tribal distribu- tion of bilharzia in East Africa, East African M. J. 26:90-92 (Apr.) 1949. 5. East Africa High Commission: East African Economic and Statistical Bulletin, No. 5, September 1949. Kenya, East African Sta- tistical Dept., 1949. 6. Fairbairn, H.: Sleeping sickness in Tangan- yika Territory, 1922-1946, Trop. Dis. Bull. 45:1-17 (Jan.) 1948. 7. Gear, H. S.: African tsetse and trypano- somiasis problems. The Brazzaville Con- ference, 1948, South African M. J. 22: 342-344 (May) 1948. 8. Gillman, Clement: A population map of Tan- ganyika Territory, Geog. Review 26:353- 375 (July) 1936. 9. Great Britain. Colonial Office: Colonial Re- search, 1948-49, London, H. M. Stationery Office, 1949. 10. —— ——: Report by His Majesty's Gov- ernment in the United Kingdom of Great Britain and Northern Ireland to the Trus- teeship Council of the United Nations on the Administration of Tanganyika for Year, 1947, London, H. M. Stationery Office, 1948. 11. ——. Economic Advisory Council: Summary of Information Regarding Nutrition in the Colonial Empire. Committee on Nutrition in the Colonial Empire, First Report, Part II, London, H. M. Stationery Office, 1939. 12. Handbook on Tanganyika: London, Mac- millan, 1930. 13. Harkness, John: Deficiency diseases in the Bukoba district, Tanganyika Territory, Tr. Tanganyika 167 14. 13, 16. 17. 18. 19. 20. 21. 22. 23. 24. Zs8. 26. 27. 28. 29. 30. 31. 32. Roy. Soc. Trop. Med. & Hyg. 28:407-412 (Jan.) 1935. Hawking, Frank: Distribution of filariasis in Tanganyika Territory, East Africa, Ann. Trop. Med. 34:107-119 (Dec.) 1940. : The distribution of filarioid infections in East Africa, J. Trop. Med. 45:159-165 (Jan.) 1943. : Onchocerciasis in Tanganyika Terri- tory, Ann. Trop. Med. 34:211-215 (Dec.) 1940. Higgins, Major R. H. C.: Diseases of ani- mals in Tanganyika Territory communi- cable to man, East African M. J. 16:480 (March) 1940. Innes, James Ross: Leprosy in Tanganyika; a survey of the Lake Province, East Afri- can M. J. 26:199-201 (July) 1949. ——: Leprosy in Tanganyika. A survey in the Southern Highlands Province, East African M. J. 26:212-215 (Aug.) 1949. Leprosy in Tanganyika. Results of sample surveys in a wide range of places, East African M. J. 26:202-203 (July) 1949. Jarvis, J. F.: Tropical ulcer, East African M. J. 22:134-144 (May) 1945. Joelson, F. S.: The Tanganyika Territory, London, T. Fisher Unwin, Ltd., 1920. Leprosy in East Africa: Internat. J. Leprosy 7:583-594 (July-Sept.) 1939. Mahaffy, A. F., Smithburn, K. C., and Hughes, T. P.: The distribution of im- munity to yellow fever in Central and East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. Mozley, Alan: Report on the fresh-water mollusca of Tanganyika and their relation to human schistosomiasis, Tr. Roy. Soc. Edinburgh 59: Part III, 687-744, 1939. Raymond, W. D.: Native poisons and native medicines of Tanganyika, J. Trop. Med. 42:295-303 (Oct.) 1939. ——: Tanganyika arrow poisons: A medico- legal problem, East African M. J. 15:419- 431 (Mar.) 1939. Scott, R. R.: The medical training of Afri- cans in Tanganyika Territory, South Afri- can M. J. 16:83-86 (Feb.) 1942. ——: The yellow fever problem as it affects Tanganyika Territory, East African M. J. 9:283-293 (Jan.) 1933. Shelley, Horace M.: Tick typhus, East Afri- can M. J. 20:300-301 (Sept.) 1943. Swynnerton, C. F. N.: The tsetse flies of East Africa, Tr. Roy. Ent. Soc. Lond. 84:124-480 (Nov.) 1936. Tanganyika Territory: Annual Medical and 33. 34. 35. 36. 3%. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. Sanitary Report for the year ended De- cember 31, 1935, Dar es Salaam, Govt. Printer, 1937. ——: Annual Medical and Sanitary Report for the year ended December 31, 1936, Dar es Salaam, Govt. Printer, 1937. : Annual Medical and Sanitary Report for the year ended December 31, 1937, Dar es Salaam, Govt. Printer, 1938. ——: Annual Report of the Medical De- partment for the year ended December 31, 1938, Dar es Salaam, Govt. Printer, 1939. ——: Annual Report of the Medical De- partment for the year ended December 31, 1939, Dar es Salaam, Govt. Printer, 1940. ——: Annual Report of the Medical De- partment for the year ended December 31, 1940, Dar es Salaam, Govt. Printer, 1941. : Annual Report of the Medical De- partment for the year ended December 31, 1941, Dar es Salaam, Govt. Printer, 1942. ——: Annual Report of the Medical De- partment for the year ended December 31, 1942, Dar es Salaam, Govt. Printer, 1943. ——: Annual Report of the Medical De- partment for the year ended December 31, 1943, Dar es Salaam, Govt. Printer, 1944. ——: Annual Report of the Medical De- partment for the year ended December 31, 1944, Dar es Salaam, Govt. Printer, 1945. : Annual Report of the Medical De- partment for the year ended December 31, 1947, Dar es Salaam, Govt. Printer, 1949. ——: Annual Report of the Medical Depart- ment for the year ended December 31, 1948, Dar es Salaam, Govt. Printer, 1950. : Census of the Native Population, 1931, Dar es Salaam, Govt. Printer, 1932. Trowell, H. C.: Malnutrition in Africans as an indication of their dietary requirements, East African M. J. 23:34-43 (Feb.) 1946. White, Thomas H.: Cerebrospinal meningi- tis in Tanganyika: A survey of two hun- dred and eighty-eight cases among Afri- cans, East African M. J. 19:172-183 (Sept.) 1942. Wilcocks, Charles: Tuberculosis in natives of tropical and subtropical regions, Tr. Roy. Soc. Trop. Med. & Hyg. 32:669-697 (April) 1939. ——: Tuberculosis in the natives of Tan- 168 49. 50. 51. 52. Tanganyika ganyika Territory. Studies of tuberculosis among African natives, Tubercle, Supple- ment 16:31-47 (Jan.) 1935. ——: The tuberculosis of the natives of Tanganyika Territory, Brit. J. Tuberc. 31:223-231 (July) 1937. Wilson, D. B.: Human brucellosis in Tan- ganyika Territory, Tr. Roy. Soc. Trop. Med. & Hyg. 29:313-319 (Jan.) 1936. ——: Report of the Malaria Unit, Moshi, 1936, Dar es Salaam, Govt. Printer, 1938. : Rural Hyperendemic malaria in Tan- ganyika Territory, Tr. Roy. Soc. Trop. 33. 54. $5. Med. & Hyg. 29:583-617 (April) 1936. Yearbook and Guide to Southern Africa: 1950 Ed., London, Sampson Low, Marston and Co., Ltd., 1950. Young, W. A, Farr, A. G., and McKendrick, A. J.: Relapsing fever in the Lake Prov- ince of Tanganyika, with an account of a case in an eight-day-old infant, East Afri- can M. J. 23:345-347 (Nov.) 1946. ——: A report of the occurrence of oncho- cerciasis in Mahenge, Tanganyika and in the southern area of Lake Victoria, East African M. J. 23:351-353 (Nov.) 1946. 11 Nyasaland GEOGRAPHY AND CLIMATE Nyasaland, a British protectorate since 1889, is a long narrow strip of country com- prising approximately 37,500 square miles, which extends along the western and the southern borders of Lake Nyasa, the third largest lake in Africa, and projects south- ward some 200 miles into Mozambique terri- tory. The depression of Lake Nyasa merges with the valley of the Shire River to the south to form part of the Great Rift Valley. The region to the west of the lake is broken plateau country with an average altitude of from 3,500 to 5,000 feet, its most distinc- tive features being the mountains, which rise to 8,000 feet in the north, and the plains of the Angoni plateau, which slope from the escarpment bordering the southwestern shores of the lake toward the Zambezi. In the south, the Shire highlands rise 1,500 feet or more above the surrounding plain be- tween Lake Shirwa and the river and are surmounted by the Zomba uplands at a gen- eral elevation of 7,000 feet and by the Mlanje massif, with peaks rising to 9,800 feet. This region includes some of the most fertile and well-watered areas in the Pro- tectorate. The coastal strip, which varies from one to ten miles in width and is inter- rupted by long stretches of the escarpment, is usually fertile, but the plains comprising the floor of the rift are semiarid. The climate of Nyasaland is diversified but may be roughly divided into two types, that of the lowlands and that of the moun- tains and the plateaus. Along the lake shore the temperature ranges from 65° to 80° F. in May to August and from 80° to 98° F. in October to December. In the Shire Valley the temperature is generally higher and may reach 115° F. in October and November. In other parts of the country it varies with the altitude. At Zomba (3,020 feet) in the Shire highlands, the mean maximum temperature is around 78° F., and the mean minimum, 61° F. There are only two seasons, the rainy season from November to April, and the dry, from May to October. In the north- ern part of the country, the rainfall averages 55 inches along the lake shore and 79 to 87 inches in the mountains. On the central plateau it approximates 35 to 45 inches but is frequently variable, and water may be scarce during the dry season. The rainfall in the Shire highland area ranges from 50 to 60 inches at Zomba and from 90 to 110 inches in the Mlanje Mountains, while in the valley it averages less than 25 to 35 inches. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTion The population of Nyasaland, at the time of the latest census, in 1945, included 1,948 Europeans, 2,940 Asiatics and about 2,055,- 000 natives. However, estimates for 1948 show an increase in all sections of the popu- lation to roughly 3,000 Europeans, 4,000 Asiatics and 2,400,000 natives. The white residents are predominantly British. Among the Asiatic community, roughly two thirds are immigrants from India, while the re- mainder were born in the Protectorate. The majority are Moslems, but slightly less than one third are Hindus. The native population 169 170 Nyasaland represents a medley of Bantu tribes, de- veloped under the influence of successive tribal invasions and slave raids. The most important representatives of the original peoples are the various divisions of the Nyanja, located chiefly in the. southern half of the territory. The principal nonindigenous races are the Yaos, migrants from the north; the Ngoni, a branch of the Zulus; and the Nguru from Mozambique. A variety of tongues and dialects is employed, but Chin- yanja, which has been accepted as the official native language, is the most widely used. Yao is also employed in some areas, while Swahili is generally understood throughout the Protectorate. The prevailing religions are pagan, but some tribes have adopted Christianity; others, Mohamme- danism. For administrative purposes the Protec- torate is divided into three provinces: Northern, Central and Southern. The ma- jority of Europeans live in the Shire high- lands or in the plateau districts of Central Province. There are no tribal reserves, but approximately 87 per cent of the territory is set aside for native occupancy under terms of individual or tribal tenure. The density of the population varies, ranging in the south from about 297 per square mile in parts of the highlands to 16 in the arid regions in the Shire Valley ; and in the Lake Nyasa region, from 70 in the fertile Dowa district to 8 in the mountainous portions of Karonga. The principal towns are located in the Shire highlands. Zomba, the capital, had a population in 1948 of 7,165, including 325 Europeans and 240 Asiatics. That of Blantyre totaled 6,567, with 606 Europeans and 650 Asiatics. Education is controlled by the govern- ment through grants to approved schools, but with the exception of the Jeanes teacher- training center, it is conducted entirely un- der private, Native Administration or mission auspices. A number of mission or- ganizations carry on educational work among the natives, and village elementary schools are accessible to the majority of children. The native languages are employed as a medium of instruction at the lower levels. Estimates as to the rate of literacy in the vernacular range from 10 to 50 per cent. Facilities for secondary education are available to native children, but Europeans are sent to schools in Southern Rhodesia. VITAL STATISTICS No vital statistics are available for the country as a whole. In 1944 the European birth rate was 21.0 per 1,000, and the death rate 13.4. Comparable figures are not given for the Asiatic community, but in 1939 when the population numbered 1,656, 40 per cent of the present figure, the birth rate was esti- mated at 51.9 per 1,000 and the death rate at 10.2. The registration of births and deaths was made compulsory for natives in 1947 but is still in an experimental stage. Sound- ings from three widely separated localities in 19421? indicated birth rates of 47.8 per 1,000 population in the Fort Manning dis- trict near the Northern Rhodesia-Mozam- bique frontier; of 57.3 in the Tenganis area in the extreme south; and of 38.8 around Karonga, on the lake shore near the Tan- ganyika border. The death rates were 20.4, 34.0 and 30.1, respectively. No accurate information is available re- garding infant mortality, and incomplete surveys show variations from 75 to 250 per 1,000 live births. Social Economy The development of Nyasaland Protec- torate has been almost entirely agricultural. Cattle are raised on the Angoniland plateau, but in other areas the industry is restricted by the presence of the tsetse fly and try- panosomiasis. The major exports are tea, tobacco, cotton, tung oil and timber. Tea is grown on the large European estates in the Shire highlands. Tobacco is also cultivated by the Europeans but is predominantly a native industry, while cotton is raised al- most exclusively by native farmers. As a Nyasaland 171 result of the primitive methods employed on tribal lands, soil erosion and deforestation have become major problems, affecting the productivity of extensive areas. The Pro- tectorate government is attempting to pro- mote modern methods of cultivation and has undertaken projects for reforestation and the development of water supplies to permit the resettlement of overcrowded areas. Agri- cultural experimental stations are main- tained at Port Herald, Zomba and Lilongwe. Various mineral deposits have been dis- covered in the Protectorate, but the major- ity are relatively inaccessible. Only small amounts of gold, mica and corundum have been mined. Outside of agriculture and vari- ous small local industries, the opportunities for employment are meager, and large num- bers of native adults leave the country each year for work in Rhodesia, Tanganyika and the Transvaal. Even more than in the sur- rounding territories, the large volume of migratory labor seriously affects the health and the welfare of the population. Internal communications are well de- veloped. Main roads for motor traffic con- nect Zomba, Blantyre and Lilongwe with the population centers of the neighboring coun- tries, while branch roads link the smaller towns in the Protectorate. With the con- struction of the bridge across the Zambezi at Mutarara in 1935, direct rail connection through Port Herald and Blantyre was es- tablished between the coast at Beira and Lake Nyasa. Steamer traffic is maintained on the lake. Commercial air service is also available between Blantyre and Salisbury, Beira, Lusaka, Nairobi and the Union of South Africa. Foop AND NuTrIiTION Maize forms the basis of the average na- tive diet, except in the lowlands along the lake, where the soil is unsuitable for its cultivation. In such areas cassava is the staple food, and even in the grain-producing regions it is frequently a reserve crop. Rice is also grown in the lake areas. Millet is sometimes cultivated, but its use is largely restricted to the making of beer. The stand- ard of living is generally low, and the aver- age native subsists for the greater part of the year on a diet which, by European standards, is deficient in animal proteins and fat and in vitamins A and C. Fishing is important along the lake shores; and with the development of the local industry, smoked fish is being used to an increasing extent in the inland communities. Cattle, 95 per cent of which are concentrated in Northern Province, pigs and goats are raised in small numbers, but both fish and meat play a minor role in the native dietary. The consumption of milk varies from tribe to tribe. Goat’s milk is almost never used, while very little cow’s milk is available out- side of Northern Province and the European centers. Eggs are tabooed by most tribes. A wide variety of wild and cultivated vege- tables is employed, including the indigenous sweet potato, pumpkins, spinach, peas, beans and the European tomato. Numerous fruits are also available. Peanuts are grown for local consumption and constitute a major source of fat. Ghee is used extensively in the north. Although the nutrition of the native pop- ulations varies in different areas, the major deficiencies are generally seasonal or con- tingent upon the poverty and the ignorance of the people. Housing The traditional native dwelling is of wattle and daub with a thatched roof; it is round or oblong in shape, depending upon the customs of the different tribes. Under the stimulus of improved housing condi- tions in the townships and on the larger estates, features such as windows, outside kitchens and pit latrines are gradually being adopted in many areas. Sun-dried brick is being used as a building material to an in- creasing extent. The non-native residents usually live in 172 Nyasaland bungalows, constructed of brick, with gal- vanized iron, thatch or tile roofs. ENVIRONMENT AND SANITATION WATER SUPPLIES The water supplies in the Protectorate are obtained from Lake Nyasa, from inland streams and from wells, boreholes and waterholes. Piped supplies are found only in the towns of Zomba, Blantyre and Lilongwe. The water supply of Zomba is impounded from a stream halfway up Zomba Mountain and is distributed by gravity to the town. It is not treated, but its purity is checked at regular intervals by chemical and bacteriologic examinations. The water supply of Blantyre is taken from an impounded reservoir fed by the Mudi River. It is treated by filtration and chlo- rination. Frequently, the small rural sup- plies are heavily contaminated, particularly during the dry season when the water levels are low. Waste DisposaL Individual septic tanks and the double- bucket system are the usual methods of sewage disposal in the townships. In Zomba, Blantyre, Limbe and Lilongwe, septic tanks are connected with most of the European dwellings ; the remainder, and the Asiatic and the native areas are served by the bucket system. Communal pit latrines are used in the native section of Zomba and in many villages. Among the more enlightened tribes, family pit latrines are slowly being introduced with the encouragement of the health authorities. However, a large per- centage of the natives prefer the bush or, in the dry season, the protected pools and the empty water courses. Fauna anp Frora Arthropods. Mosquitos. Numerous spe- cies of anopheline mosquitoes are found, but only Anopheles gambiae and A. funestus are thought to be of medical concern. Both are major vectors of malaria, which is present in all regions below 5,000 feet. A. gambiae is the predominating species during and immediately following the rains, when it breeds prolifically in the various small natu- ral and artificial collections of water and later in the residual pools in the stream beds. It is rarely encountered in the dry season. A. funestus persists throughout the year and is of considerable importance as a vector. A. rhodesiensis is also abundant during the cooler months but is probably of little or no significance in the transmission of the infection. Over 16 species of Aedes are encountered, including at least 3 which are potential vec- tors of yellow fever: Aedes aegypti, A. simp- soni and A. vittatus. No large-scale control programs have been undertaken, but antimosquito meas- ures, adapted to the specific local conditions, are applied in all the township areas. These include drainage, the canalization of streams and ditches, the filling of burrow pits and the routine treatment of stagnant water with oil or DDT. Fries. A wide variety of flies is reported, the most important being the tsetse fly, Glossina morsitans, which is known to exist in extensive areas scattered throughout the territory. It is responsible for small sporadic outbreaks of human trypanosomiasis, caused by Trypanosoma rhodesiense. G. brevi- palpis is widely distributed in the northern districts, while G. pallidipes has been col- lected from the region south of Lake Nyasa. The presence of tsetse flies renders large sections of the country useless for the raising of livestock and seriously affects the nutritional and economic welfare of the people. Muscipak are prevalent, including Musca sorbens and several species of Stomoxys. They are probably of significance in the mechanical transmission of intestinal infec- tions. Numerous species of Tabanus and Haematopota are present. The larvae of Auchmeromyia luteola, known as “Congo floor maggots,” are frequent pests. Simulium damnosum is encountered in portions of the Shire highlands where it is a vector of the filarial worm, Onchocerca volvulus. Lice. Infestation with human lice, both Pediculus humanus capitis and P. humanus corporis, is common, particularly in the up- land areas. Freas. Numerous different species of fleas infest the domestic and wild rodents. The potential vectors of plague, which occa- sionally occurs in limited foci, are X. bra- siliensis, responsible for the transmission of the infection among the house rats, and X. piriei, responsible for its spread among the wild rodents. Bepsucs. The bedbugs, Cimex hemipterus and C. lectularis, are almost universal. Ticks anp Mites. Ornithodorus moubata is widespread and responsible for the spread of tick-borne relapsing fever in the terri- tory. The ticks hide in the wattle-and-daub walls of the native huts, making eradication difficult. The prevalence of O. moubata sometimes necessitates the evacuation of whole villages. Rhipicephalus sanguineus and Haemaphysalis leachi are common and probably are implicated in the transmission of occasional cases of tick-borne typhus. R. appendiculatus, Amblyomma hebraeum and Dermacentor reticulatus are numerous. The itch mite, Sarcoptes scabiei, is widely distributed. Reptiles. Most of the venomous snakes indigenous to East Africa are encountered in Nyasaland. The most important are the cobras, Naja haje and N. nigricollis, the mamba, Dendroaspis angusticeps, and the puff adder, Bitis arietans. Rodents. Rats and mice are plentiful. The usual domestic rat is Rattus rattus alexandrinus, which frequents the thatch roofs and the primitive grain stores in the native villages. Sylvatic plague is enzootic among the wild rodents in the sandy regions of the lake basin and in the Shire River valley where the gerbil, Tatera nyassae shirensis, is the major reservoir of infection. The multimammate rat, Mastomys coucha, is the principal link in the spread of the dis- ease from the wild to the domestic rodents. Nyasaland 173 Mollusks.* The fresh-water snail, Phys- opsis africana globosa, is abundant in the streams, pools and swamps throughout the territory. It is an intermediate host of Schistosoma haematobium, which is widely distributed, particularly in Southern Prov- ince and in the low-lying lake-shore regions. S. mansoni occurs to some extent in Lower Shire, Cholo, Mlanje, Zomba, South Nyasa, North Nyasa, Kota Kota and Lilongwe dis- tricts, where Planorbis (Biomphalaria) alexandrina pfeifferi is the probable inter- mediate host. Bulinus (Pyrgophysa) fors- kalii is also present but has not been found infected, although it must be regarded as a potential host. Foop SANITATION The supervision of markets and food establishments in the township areas is undertaken by the government health in- spectors on behalf of the local authorities. Meats and meat animals are regularly in- spected at the abattoirs in Blantyre, Limbe, Zomba and Lilongwe by qualified meat inspectors. In Zomba milk is sold from a - central supervised distributing point. In other towns it is delivered directly to the customers. The larger milk supplies are con- trolled by chemical and bacteriologic exami- nations, but there is no organized pasteuri- zation, HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The health and medical services of the Protectorate government are concentrated in its Medical Department, which is admin- istered by a Director of Medical Services with headquarters in Zomba. The Depart- ment functions directly under the Governor of the colony who may be advised on mat- ters pertaining to public health by the medi- cal officers of the Colonial Office in London. It is responsible for the maintenance of facilities for the medical care of the differ- * See footnote, p. 10. 174 Nyasaland ent racial groups, the supervision of rural and urban sanitation and for the promotion of preventive health measures. However, its activities are restricted by a shortage of supervisory personnel. In spite of the rela- tive compactness of the territory, a large proportion of the population in the outlying areas, particularly in the northern province, is without adequate medical or health services. A Nyasaland Native Welfare Committee was organized in 1935 to develop co- operation between the governmental depart- ments concerned with social and environ- mental problems influencing the health status of the people. The Committee is com- posed of representatives from the Admin- istration and the Medical, Agriculture, Forestry and Education departments. Various mission organizations carry on medical and health programs, many of which are subsidized by the government. Maternity centers, child welfare centers and village services form an integral part of the activities of four Protestant and Catholic mission groups. MepicAL INSTITUTIONS Hospitals and Dispensaries. In 1948, 19 hospitals for natives, with an aggregate capacity of 1,117 beds, were operated by the Medical Department. The hospital at Zomba, with 200 beds, is the center of its medical training program. The others range in size from 30 to 50 beds. Small govern- ment hospitals for white residents are lo- cated at Zomba, Blantyre and Lilongwe, while accommodations for the Asiatic popu- lation are available in separate wards in the Zomba, the Blantyre and the Lilongwe African hospitals and, as needed, in the majority of government institutions. The Department also had 95 rural dispensaries scattered throughout the territory, a few of which had been converted within recent years into health units. The mission organizations maintain a number of hospitals and dispensaries for natives, as well as leper colonies and ma- ternal and child welfare clinics. In addition there is a small mission hospital, with ac- commodations for Europeans and Asiatics, in Cholo district. Laboratories. A Central Pathological Laboratory, in charge of the Department pathologist, is located at Zomba. With the exception of the routine microscopic exami- nations performed in the local hospitals, this laboratory provides all of the diagnostic services for the territory. The Vaccine Lymph Laboratory, which was opened in Zomba in 1942, manufactures smallpox vaccine for use in the Protectorate. Schools. A school for the training of hospital assistants and medical aides is op- erated in connection with the hospital at Zomba. Nurses and midwives are trained in the Zomba and the Blantyre hospitals and in several mission institutions, but some difficulty is experienced in recruiting eligible girls and women. Courses for sanitary assist- ants are also offered at Zomba. PERSONNEL Physicians. Besides the Director, 20 Col- onial medical officers were connected with the Medical Department in 1948. The staff also included 11 Asiatic subassistant sur- geons. In the same year 7 physicians were affiliated with mission institutions. There are no European private practitioners in the territory. Dentists. One dental officer is engaged in government service. Others. The auxiliary European staff of the Medical Department, in 1948, included a pathologist, 18 nursing sisters, a pharma- cist and 4 health inspectors. The native staff consisted of 46 hospital assistants, 265 medical aides, 74 nurses and midwives and 72 sanitary assistants and vaccinators. Nurses are attached to all the mission hospitals and dispensaries. DISEASES The actual incidence of specific diseases is not known. Available evidence is based Nyasaland 175 upon the statistics of the government hos- pitals and dispensaries and gives little indication of the extent of infection in the outlying areas. Moreover, the inclina- tion of the native to return to his home village before death detracts from the sig- nificance of hospital mortality returns. The medical facilities are inadequate, and large sections of the people adhere to their tra- ditional forms of medical practice. Sam- ple surveys and special field investigations yield valuable supplementary data, how- ever, in the case of a few diseases of par- ticular prominence, such as schistosomiasis, malaria and hookworm infection. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UriNARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fevers are endemic. The cases ad- mitted to the government hospitals usually average from 20 to 50 a year and are pre- dominantly typhoid infections. Dysenteries. The incidence of dysentery is high, as the result of the insanitary con- ditions prevailing throughout the country. Both amebic and bacillary dysentery infec- tions are frequent. In 1948 a total of 245 cases of amebic, 131 of bacillary and 196 of unclassified dysentery was recorded. Diarrhea and enteritis are prevalent, and several thousand cases in all age groups are treated each year. Large percentages are undoubtedly cases of unrecognized bacillary dysentery. Helminthiases. ANcyLosTom1as1s. Hook- worm infection is widespread among the native populations, particularly in the low- lying regions bordering Lake Nyasa and the Shire River. Surveys undertaken by the Medical Department in 1935, covering areas with an altitude of 3,000 feet or less in 7 districts, revealed infection rates of 39 per cent in children from two to ten years of age and of 43 per cent in persons over ten years. In 5 other districts the rates in villages at an elevation of 3,200 feet to 5,200 feet were 11 per cent and 18 per cent, re- spectively. The infection rates are especially high, approximating 50 to 75 per cent, in the lake plain region around Fort Johnston in the south and Karonga in the north, and in the heavy rainfall areas of Mlanje dis- trict. Necator americanus is regarded as the predominating species, but Ancylostoma duodenale also occurs in most sections of the country. Scuistosomiasis. Schistosomiasis is a major cause of morbidity in Nyasaland. Infections with Schistosoma haematobium are widespread in the south and in the low- lying districts of the northern provinces. Infection with S. mansoni is also prevalent but more restricted in distribution. In the medical surveys mentioned above? infec- tion rates with S. haematobium in persons over two years of age were found to average from 25 to 45 per cent in areas at an altitude of 3,000 feet or less, and from 2 to 10 per cent in localities at 3,200 to 5,200 feet eleva- tion. S. mansoni infections were not encoun- tered at the higher altitudes, but they averaged from 4 to 10 per cent in 4 of the 7 districts, which included the locations at 3,000 feet and under. The examination of 9,861 urine and 13,090 stool specimens from persons in Kota Kota district on the western shore of Lake Nyasa, in 1935-44,% indicated infection rates of 53 per cent with S. Zaema- tobium and of 1 to 7 per cent with S. man- soni. The incidence of S. mansoni infections is unusually high in the northern lake shore region, from the Songwe River to Florence Bay. A survey in 19371 revealed from 76 to 80 per cent infection rates with S. mansoni in children 2 to 10 years of age, and from 62 to 82 per cent in the older age groups. Comparable rates with S. haematobium were 36 to 42 per cent and 22 to 38 per cent, respectively. OrHER HELMINTH INFECTIONS. Ascariasis is foremost among the remaining helminth diseases. It is widely distributed, the heavi- est infections being encountered in the southeastern districts. In the medical sur- veys of 1935, the infection rates ranged from 6 per cent in infants under two years of age 176 Nyasaland to 32 per cent in persons over ten years in the areas up to 3,000 feet elevation, and averaged 12 to 19 per cent in those over 3,000 feet. Infections with the beef tapeworm, Taenia saginata, and the pork tapeworm, T. solium, occur sporadically but are rela- tively rare. Other Infections. Undulant fever is re- ported occasionally. The cases are not nu- merous, however, since little cow’s milk is available outside of the European areas, and goat’s milk is rarely used. Diseases SPreAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is widespread and apparently increasing in prevalence. The true extent of infection is not known, since only the advanced cases are usually observed by the medical officers, but from 300 to 800 cases are admitted to the govern- ment hospitals and associated dispensaries each year. The native customs of sleeping in poorly ventilated and crowded huts and of employing communal eating utensils, together with low standards of personal hygiene, are conducive to the spread of the disease. Pulmonary infections predominate, but other forms may account for roughly one fourth of the known cases. Bovine tuberculosis is enzootic among the cattle, and in the cattle-raising districts the consumption of meat from animals dying of the disease is a potential source of in- fection. Smallpox. Sporadic outbreaks of small- pox occur almost annually. A vaccination program is carried on by the Medical De- partment, but its effectiveness is limited by the lack of co-operation among the inhabit- ants in many areas. An extensive epidemic of the virulent form of smallpox was re- ported in 1947-48 from the districts along the southern shores of Lake Nyasa and the region to the south. Over 4,800 cases were recorded in 1948 alone, with an average fatality rate of 12.5 per cent. An intensive vaccination campaign prevented the spread of the infection into the northern part of the country. Meningitis. Meningococcus meningitis is endemic, and sporadic outbreaks among the laborers on the large estates in Southern Province are frequent. The mortality rates in the villages are usually high, as the result of delayed treatment and reporting. Other Infections. Measles and whooping cough are both endemic and epidemic. Pneu- monia and influenza are common. Diph- theria is sporadic. Poliomyelitis and scarlet fever are reported occasionally. DiseAsES SPREAD OR CONTRACTED CurerrLy THROUGH CONTACT Venereal Diseases. Syphilis and gonor- rhea are prevalent among the native popula- tions, while other forms of venereal disease are also encountered. Over 7,000 cases of syphilis and 1,000 of gonorrhea are reported annually. The incidence of syphilis appears to exceed that of gonorrhea, but the indiffer- ence of the people to gonococcal infection and the tendency to consult the tribal medi- cine men lend doubt to the value of hospital statistics as a measure of the extent of in- fection. A campaign against venereal dis- eases was inaugurated in 1945 with the aid of grants from the British Colonial Develop- ment and Welfare funds. Special clinics are established at Zomba and Blantyre, and facilities for treatment are available at gov- ernment and mission hospitals and dispen- saries. Over 18,000 cases were treated in 1948, in contrast with 5,671 in 1945. How- ever, few patients continue treatment after the clinical signs of infection have dis- appeared. Leprosy. Leprosy is widely distributed, but the highest incidence is probably found in the populous lake shore areas south of Domira Bay. The extent of infection is un- certain but may average 20 per 1,000 popu- lation in many districts. In the course of a partial census undertaken by the native vil- lage authorities in 1943, 3,510 cases were discovered apart from those under treat- ment in leper settlements and hospitals: Nyasaland 177 1,379 in the north and 2,131 in the south. Settlements for the segregation of lepers are maintained by the missions with financial assistance from the government. In 1948 ap- proximately 975 cases were cared for in mission institutions, while 411 were treated in government hospitals and rural dispen- saries. Yaws. Yaws is endemic in the regions along the lake shore and in the Shire River valley. The highest incidence is found among the tribes in the districts in the extreme north and south of the Protectorate. Diseases of the Skin. Mycotic skin dis- eases are numerous. Tropical or phagedenic ulcers represent one of the most frequent conditions treated in the government hos- pitals and dispensaries. They are observed primarily in the rainy season when the flies are abundant. Scabies is more or less gen- eral in many areas. Other Infections. Rabies is sporadic among the dogs and other domestic animals, but known human infections are usually few in number. Trachoma is common, and from 40 to 50 cases are reported annually. Occasional cases of tetanus are recorded each year. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is prevalent everywhere up to 5,000 feet. Transmission takes place throughout the year in the lowland areas and reaches almost epidemic proportions during the rainy season. The increased inci- dence is associated both with the seasonal prevalence of Anopheles gambiae and with the accelerated activity of A. funestus. In a study conducted in 1934,2* during which random samples of blood were examined from native children under ten years of age in representative highland and lake villages, the parasite rates ranged from 43 to 60 per cent, depending upon the location and the season. Plasmodium falciparum was the causative agent in from 83 to 92 per cent of the cases and P. malariae in 8 to 15 per cent. P. vivax was not found but P. ovale was identified on three occasions. In a pre- vious survey carried out on 103 children near Fort Johnston in 1931, blood examinations performed at monthly intervals for a year revealed malarial parasites in 96 per cent. P. falciparum was identified in 97 per cent, P. malariae in 35 per cent, and P. vivax in 8 per cent; mixed infections were not un- common. Malarial infection is usually in- tense in children under two years of age, but subsequently subsides with the development of a relative tolerance in the older age groups. In over 28,000 cases reported in 1948, roughly 25 per cent were diagnosed as sub- tertian, 6 per cent as benign tertian and 2 per cent as quartan, while the remainder were unclassified. Blackwater fever occurs sporadically, generally among the Asiatics. Trypanosomiasis. Limited foci of trypa- nosomiasis are found in widely separated sections of the country, in which human infections with Trypanosoma rhodesiense are occasionally observed. New cases are most frequently reported from Kota Kota district, where the native villages have en- croached upon country infested with Glos- sina morsitans to an increasing extent. An aggregate of 5 to 30 new cases is recorded each year. Relapsing Fever. African tick fever, caused by Borrelia duttoni, is endemic in extensive areas, conforming to the distribu- tion of the vector, Ornithodorus moubata. On the average, from 400 to 700 cases are recorded annually. The majority come from Northern and Central provinces. Plague. Cases of human plague are some- times reported following epizootics of the disease among the wild rodents. Sylvatic plague is enzootic in limited areas, namely, in the districts along the southwestern bor- der. The investigation of a case of bubonic plague in Central Shire district in 1939 re- vealed evidence of three human infections subsequent to an outbreak among the rats in that area. No cases were recorded in 1940-50. Filariasis. Filarial infections, caused by 178 Nyasaland Wuchereria bancrofti, are encountered in patchy areas in the extreme northern and southern sections of the country. Oncho- cerciasis is present in the mountainous dis- tricts of the Shire highlands. Yellow Fever. Yellow fever has not been reported from Nyasaland, but surveys un- dertaken in co-operation with the Yellow Fever Institute at Entebbe show evidence of immunity among 5 to 16 per cent of the individuals examined in scattered localities. The entire territory is included within the endemic yellow fever area, as defined for Africa by the World Health Organization in 1950. Other Infections. Tick-borne typhus fever is sporadic, but louse-borne and murine typhus have not been reported. Infections with the guinea worm, Dracun- culus medinensis, are recorded occasionally. NurtriTioNAL DISEASES Various subclinical conditions, which may be attributed to defective nutrition and the shortage of one or more elements in the diet, are prevalent. Marginal deficiencies, partic- ularly in vitamins A and C, are widespread, although largely seasonal in distribution. However, severe nutritional diseases are un- common. Cases of scurvy and beriberi are seen occasionally in the government hos- pitals and dispensaries; pellagra occurs somewhat more frequently. Rickets is rela- tively rare. A serious condition of the gums and the jaw, resembling Vincent’s angina and locally known as “chiseye,” attacks 40 per cent of the children at some time be- tween 2 and 15 years of age. Faulty nutri- tion is regarded as a contributory cause by many medical authorities. SUMMARY Nyasaland is a small British protectorate which skirts the western edge of Lake Nyasa. Responsibility for the health and medical care of the populations resides in the Medical Department of the Protectorate government. It is administered by a Direc- tor of Medical Services, with headquarters in Zomba. The Department operates hos- pitals for white residents in Zomba, Blan- tyre and Lilongwe, and 19 hospitals and 95 rural dispensaries for the care of the native peoples. Hospitals and dispensaries, mater- nity and child welfare services and leper settlements are also maintained by mission organizations, many of which are subsidized by the government. Water supplies are ob- tained from Lake Nyasa, and from streams, wells, waterholes and boreholes. Piped sup- plies are available in Zomba, Blantyre and Lilongwe, but only that of Blantyre is treated. The methods of sewage disposal are primitive. Standards of nutrition vary, but, while marginal deficiencies are preva- lent, serious nutritional diseases are un- common. The diseases responsible for the highest morbidity are malaria, schistosomiasis, an- cylostomiasis, tropical ulcers, tuberculosis and venereal diseases. Tick-borne relapsing fever, leprosy, intestinal infections and yaws are prevalent. Trypanosomiasis is reported sporadically from several widely separated foci. Outbreaks of smallpox occur almost annually. Minor epidemics of meningococ- cus meningitis are also recorded, usually among the laborers on the large estates. Filariasis and onchocerciasis are endemic, while plague and tick-borne typhus fever are reported occasionally. BIBLIOGRAPHY 1. Blacklock, D. B.: Methods of disposal of human excreta and refuse employed in the British colonies, Ann. Trop. Med. 38: 66-72 (Apr. 19) 1944. : Water supplies in the British colonies, Ann. Trop. Med. 37:211-220 (Dec. 31) 1943. 3. Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. 4. Conferéncia Intercolonial sobre Tripanos- somiases: 26 a 31 agosto de 1946. Vol. I, Lourenco Marques, Imprensa Nacional de Mocambique, 1947. 5. Gelfand, M., and Ross, W. F.: The inci- dence of schistosomiasis in South Central 10. 11, 12. 13, 14. 15. Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 42:559-564 (May) 1949. Gopsill, W. L.: Onchocerciasis in Nyasaland, Tr. Roy. Soc. Trop. Med. & Hyg. 32:551- 552 (Jan.) 1939. Great Britain: Colonial Office, Annual Re- port on the Nyasaland Protectorate for the Year 1948, London, H. M. Stationery Office, 1949. . ——: Rhodesia-Nyasaland Royal Commis- sion Report, March 1939, London, H. M. Stationery Office, 1939. Kuczynski, R. R.: Demographic Survey of the British Colonial Empire, vol. 2, Lon- don, Geoffrey Cumberlege, Oxford Uni- versity Press, 1949. Lamborn, W. A., and Howat, C. H.: A pos- sible reservoir host of Trypanosoma rho- desiense, Brit. M. J. 1153-1155 (June 6) 1936. Leprosy in Nyasaland: Leprosy Rev. 11: 9-17 (Jan.) 1940. Murray, S. S.: A Handbook of Nyasaland, London, Crown Agents for the Colonies, 1932. Nyasaland Protectorate: Annual Medical and Sanitary Report for the year ending December 31, 1935, Zomba, Govt. Printer, 1936. ——: Annual Medical and Sanitary Report for the year ending December 31, 1936, Zomba, Govt. Printer, 1937. ——: Annual Medical and Sanitary Report 16. 17. 18. 19. 20. 2%. 22. 23, 24. 23. Nyasaland 179 for the year ending December 31, 1937, Zomba, Govt. Printer, 1938. : Annual Medical and Sanitary Report for the year ending December 31, 1939, Zomba, Govt. Printer, 1940. ——: Annual Medical and Sanitary Report for the year ending December 31, 1940, Zomba, Govt. Printer, 1941. : Annual Medical and Sanitary Report for the year ending December 31, 1941, Zomba, Govt. Printer, 1942. : Annual Medical and Sanitary Report for the year ending December 31, 1942, Zomba, Govt. Printer, 1943. ——: Annual Medical and Sanitary Report for the year ending December 31, 1943, Zomba, Govt. Printer, 1944. : Annual Medical and Sanitary Report for the year ending December 31, 1944, Zomba, Govt. Printer, 1945. : Medical Department, Report of the Medical Department for the Year 1948, Zomba, Govt. Printer, 1949. Ransford, O. N.: Schistosomiasis in the Kota Kota district of Nyasaland, Tr. Roy. Soc. Trop. Med. & Hyg. 41:617-628 (Mar.) 1948. Thomson, J. Gordon: Malaria in Nyasaland, Proc. Roy. Soc. Med. 28:391-404 (Feb.) 1935. Year Book and Guide of the Rhodesias and Nyasaland: 1938-9 Ed., Salisbury, Rho- desian Publications, Ltd., 1939. 12 Northern Rhodesia GEOGRAPHY AND CLIMATE Northern Rhodesia became a British Crown Colony in 1924 after 35 years under the administration of the British South Africa Company. It is bounded on the north by the Belgian Congo and Tanganyika Ter- ritory, on the east by Nyasaland, on the south by Mozambique, Southern Rhodesia and Bechuanaland, and on the west by Angola. The colony, which comprises a total area of 290,000 square miles, is divided by a salient of the Belgian Congo into two portions, formerly administered as North- eastern and Northwestern Rhodesia. A large part of the territory is high plateau covered with tropical or subtropical savannah. With the exception of the valleys of the Luangwa, Luapula, Kafue and lower Zambezi rivers, the entire region has an elevation of from 3,000 to 5,000 feet above sea level. The plateau terminates in the Muchinga Moun- tains, which extend from southwest to northeast across the eastern arm of the territory and contain peaks rising to 8,000 feet. Between this escarpment and the range of hills on the Nyasaland border, the Luangwa River cuts a minor “rift” valley, dividing the eastern district from the main body of the colony. Lake Bangweulu, the only large lake wholly within the territory, and its surrounding swamps cover an ap- proximate area of 3,800 square miles. In the northwestern portion of the colony the ele- vation decreases from that of the plateau in the north to the valley of the upper Zam- bezi and its tributaries in the west and the southwest. The lower Zambezi marks the boundary between Northern and Southern Rhodesia. Due to the moderating influence of the altitude, the climate of Northern Rhodesia is largely subtropical rather than tropical. The annual rainfall averages about 50 inches in the north and the east but decreases to less than 30 inches in the southwest. There are two seasons: the rainy season from November to April, and the dry from May to October. Approximately 70 to 90 per cent of the yearly precipitation occurs during the period from November to March, while in- termittent thunderstorms mark the months of transition. The heaviest rainfall is usu- ally experienced in January and February. During the winter months, which coincide with the dry season, the mean temperatures on the plateau vary from 55° to 75° F., with a mean maximum of about 86° F. and a mean minimum around 40° F. The daily temperature range may approximate 35° F. In the low-lying regions, the mean winter temperatures fall between 70° and 90° F., with a mean maximum of 103° F. and a mean minimum of 56° F. Somewhat higher temperatures are encountered during the wet season. However, the hottest months occur toward the end of the dry season in October and November, when mean maxi- mum temperatures of 95° and 99° F. and mean minimum of 60° to 70° F. are recorded on the plateau. Extreme heat is experienced only in the Zambezi and the Luangwa River valleys. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopruLATION In 1946 the population of Northern Rho- desia was estimated at over 1,683,800, in- 180 Northern Rhodesia 181 cluding 21,907 Europeans, 1,117 Asiatics, 804 colored (of mixed blood) and approxi- mately 1,660,000 natives. Provisional figures for 1948 place the white population at 28,000 and the indigenous at 1,690,000. The Europeans derive chiefly from Great Britain or the Union of South Africa. The majority are settled in a narrow strip of country on either side of the railroad between Living- stone and Ndola, while fully one half reside in the “Copperbelt” sector south of the Congo border. Small contingents have taken up land in the outlying settlements around Abercorn on the Tanganyika border and Fort Jameson in the southeast. European settlement has been influenced to a large extent by the development of copper-mining interests in the territory. The Asiatics are concentrated chiefly in the Fort Jameson area. The natives are Bantu, but represent over 60 tribes with 30 or more different languages or dialects. The prevailing re- ligions are pagan, although large numbers of converts are claimed by the Protestant and the Catholic missions in the territory. The density of population in the country as a whole averages 5 per square mile. Ex- tensive areas remain sparsely inhabited be- cause of lack of water or infestation with the tsetse fly, while others have been appro- priated for future European settlement. Out of 170 million acres earmarked for exclu- sive native occupancy, 71.5 million acres have been divided into numerous separate “native reserves.” These include the native kingdom of Barotseland in the southwestern part of the country, which is ruled by a paramount chief and protected by special treaties. The population density in the re- serves varies, but in the more thickly settled portions it frequently reaches 110 to 160 or more per square mile. The present re- served lands are insufficient to support the indigenous population under the existing conditions of soil deterioration. For administrative purposes the Colony is divided into six provinces. Lusaka, the capi- tal, had a population in 1949 of approxi- mately 3,000 Europeans and 30,000 natives. Other urban areas are Livingstone, Broken Hill, Ndola and the four Copperbelt town- ships in the north. Each has a population of 20,000 to 45,000, including from 2,400 to 4,000 white residents. Lusaka and Ndola are the only municipalities. The sparseness of the population has re- tarded the development of education, but schools providing instruction for Europeans at primary and junior secondary school levels have been established. Native educa- tion is largely controlled by mission organi- zations, with government grants for ap- proved schools, although a limited number of government and Native Authority schools also exist. The Munali Training Centre at Lusaka is the only complete secondary school for natives in the Colony. In spite of an accelerated interest in education within recent years, probably less than half of the children of school age receive any form of education. VITAL STATISTICS Reasonably accurate statistics are pub- lished for the European population, al- though in view of the small numbers con- cerned considerable fluctuations may occur from year to year. In 1947 and 1948 the birth rate and the death rate for Europeans averaged 29.4 and 5.9 per 1,000 population, respectively. The infant mortality rate was 44.6 per 1,000 live births in 1947, and 29.8 in 1948. No vital statistics are available for the Bantu tribes, but the general mortality is reported to be high. In many areas the in- fant mortality rates approximate 150 to 250 per 1,000 live births. Sociar Economy The economic life of Northern Rhodesia centers around the copper mines in the vi- cinity of Ndola, Nkana, Nchanga, Luanshya and Mufulira. The Colony possesses some of the richest copper deposits in the world, which are operated by large companies registered in Great Britain. Lead, zinc and vanadium are mined at Broken Hill. Small 182 Northern Rhodesia amounts of gold, silver, selenium and other minerals are also produced. European agriculture is confined to the region adjoining the railroad from Living- stone to Broken Hill, and to the settlements around Abercorn and Fort Jameson. Ap- proximately 2.5 million acres of land have been assigned to Europeans for farming purposes, but in 1940 less than 100,000 acres were under cultivation. The economic development of agriculture has been re- tarded by the dearth of transportation and marketing facilities. The cultivation of maize and wheat, cattle raising and dairy- ing are carried on in Central and Southern provinces. Tobacco is grown successfully in Eastern Province around Fort Jameson; coffee in the north near Abercorn. The or- ganization of co-operative societies and credit associations, for the benefit of both European and native producers, is fostered by the Rhodesian government. The Bantu are fundamentally agricul- turalists. The majority practice a combina- tion of subsistence farming and cattle rais- ing. Because of soil erosion, overstocking and lack of guidance in the development of more efficient methods, the agricultural economy of the numerous tribes is deterio- rating rapidly. The chief cash crops of the natives are maize and tobacco. The main cattle areas are Southern Province and Barotseland ; cattle raising is restricted in over half of the territory by the presence of the tsetse fly. Large numbers of natives, particularly from the poorer areas in North- ern and Eastern provinces and Barotseland work more or less intermittently in the mines, in the towns or on the European farms. The continuous absence from the native villages of possibly half of the adult male population is reflected in the disrup- tion of tribal economy and authority. Industrial development is negligible ex- cept for the manufacture of timbers, ferro- concrete and other products for local con- sumption. Plans now under consideration for the utilization of the hydroelectric resources of the Zambezi and the Kafue rivers will promote the industrial expan- sion of the Colony. Communication facili- ties are inadequate. The railroad, which traverses the country from Livingstone to Ndola, makes connections with Beira and Cape Town, but the distances are great, and the cost of transportation is correspondingly high. All-weather motor roads parallel the railroad and also link Lusaka with Aber- corn, Fort Jameson, and Salisbury in South- ern Rhodesia. Feeder roads are practically nonexistent outside of the railroad zone and Copperbelt. Until the recent construction of a road from Lusaka to Mongu, Barotse- land was completely dependent upon water transport up the Zambezi River. A limited amount of steamer traffic is available on Lake Tanganyika. Air services with ter- minals at Livingstone, Lusaka and Ndola connect Northern Rhodesia with the neigh- boring colonies and with England. Foop AND NUTRITION Malnutrition and avitaminosis, particu- larly deficiencies in protein and vitamins of the B complex, are common among the Bantu. The principal foods are maize, millet and cassava, supplemented by sweet pota- toes, peanuts, beans and various indigenous vegetables and fruits. Eggs and fish are consumed by some tribes, but milk is rarely used. Normally, little meat is eaten even among the pastoral tribes; cattle and goats are slaughtered primarily for ceremonial occasions. The large mining concerns and industrial and agricultural employers provide rations for their native labor, which in most in- stances exceed the minimum requirements. However, the nutritional standards are low among the independent workers in the urban areas. Housinc The Bantu on the reserves live under primitive conditions in round or rectangular thatch huts grouped together in kraals. Considerable variation is encountered in the tribal villages. Northern Rhodesia 183 In the industrial areas, the housing facili- ties for the native laborers differ markedly. The larger mining companies house their workers in well-constructed and ventilated buildings. Within recent years there has been an increasing tendency to introduce the separate hut system for married workers, thus permitting the maintenance of a nor- mal family life. On the European farms and in the urban communities the living conditions are generally inferior. Many urban compounds are poorly constructed, overcrowded and insanitary, while in some towns the shortage of housing has lead to the development of squatter’s camps on the periphery. In most areas the dwellings of the white residents conform to reasonably high stand- ards. The houses are usually modern in de- sign and are built of brick with corrugated iron, tile or thatch roofs. ENVIRONMENT AND SANITATION WATER SUPPLIES The abundance and the quality of water vary in the diverse sections of the country. Although there are no extensive dry areas in Northern Rhodesia, the rainfall is some- times irregular, particularly in Barotseland, and periods of drought are common. The chief sources of supply are streams, lakes, springs and shallow or deep wells. Artesian wells are found occasionally in the hilly districts. On the reserves, the shallow village wells which supply large numbers of people are usually unprotected against pollution. Moreover, water is commonly transported and stored by the Bantu in large drums or earthenware pots and is subject to second- ary contamination. Piped water supplies are found in the larger townships. In Lusaka the water for part of the town is obtained from deep boreholes. Some penetrate the underlying limestone strata, however, and the danger of contamination through fissures is fre- quently serious. The water is chlorinated before distribution to individual taps in the European quarter and to communal foun- tains in the native locations. Private wells serve the remaining inhabitants. The water supply for Livingstone is pumped from the Zambezi River and is treated by filtration and chlorination. The Copperbelt townships derive their water from river or under- ground sources, which are subjected subse- quently to chlorination, filtration or both. All urban supplies are controlled by labora- tory examinations, but the degree of super- vision varies. The supplies in the smaller communities and in the rural areas are gen- erally contaminated to some extent. WasTE DisposaL In Lusaka, Livingstone, Ndola and Broken Hill individual septic tanks are em- ployed in parts of the town, while bucket latrines provide the common method of sewage disposal in the remaining areas. Sewerage systems incorporating communal septic tanks and treatment works serve the four mine townships. In the rural areas the means of disposal are universally primitive. Fauna anp Frora Arthropods. Mosquitoes. Sixteen or more species of anopheline mosquitoes are encountered in this region, but only Anoph- eles gambiae and A. funestus are considered important as vectors of malaria. 4. gambiae breeds abundantly from December to April in small pools and various man-made col- lections of rain water which are exposed to the sun. During years when the rainfall conditions are favorable it is prevalent even in the higher altitudes and may be respon- sible for epidemic outbreaks of the disease. A. funestus is more independent of local rainfall conditions; within its temperature requirements it breeds throughout the year in swamps, streams and shaded pools. It invades the built-up areas to only a slight extent but is a significant vector of malaria among the rural populations. A. coustani is prevalent but has not been implicated in the transmission of malaria. At least 42 species of Aedes have been 184 Northern Rhodesia found. Aedes aegypti is widespread. Nu- merous species have been identified since 1943, when a focus of sylvan yellow fever was discovered in Barotseland. Besides A. aegypti, the potential vectors of yellow fever include A. africanus, A. simpsoni, A. luteocephalus, A. vittatus, A. metallicus and A. taylori. Culex quinquefasciatus (= C. fatigans) is prevalent and may be concerned in the transmission of Wuchereria bancrofti. Taeniorhynchus (Mansonia) uniformis and T. (M.) africanus are widely distributed. Eretmopodites chrysogaster, also a possible vector of yellow fever, is found in the Balo- vale area but not in the south. Mosquito-control measures are carried on in Ndola, Livingstone and the townships of the Copperbelt. Those employed in differ- ent localities include the drainage of ponds and swamps, the canalization of streams, the antilarval treatment of all collections of water with oil or DDT, and in localized areas the residual spraying of native huts with DDT or Gammexane. At Ndola the swampland bordering the Itawa River was flooded, and its banks were planted with eucalyptus trees. Fries. Tsetse flies infest at least five eighths of the territory and are important as vectors of human and animal trypanoso- miasis. The human disease is limited in dis- tribution, but animal trypanosomiasis by curtailing the production of cattle, creates a problem of importance to the health and the welfare of the people. Glossina morsitans, the principal vector, is widespread. The Luangwa River region and the area within the bend of the Kafue River are especially heavily infested. G. palpalis is common on the shores of lakes Tanganyika and Mweru and along the banks of the Luapula River. G. brevipalpis is found in scattered areas in the Luangwa River valley and near Lake Tanganyika. Recently, G. pallidipes has been reported from the Luangwa River re- gion. G. tachinoides and G. swynnertoni are also present. Antitsetse fly measures carried on by the government’s Game and Tsetse Department are directed primarily toward the protection of the farming areas. They vary in different localities but include road- side and discriminative clearings and the exclusion or destruction of game. Stomoxys calcitrans, Pangonius (Steno- phara) oldii, Musca domestica, Chrysops fuscipennis and at least five species of Tabanus are known to exist. Many are re- sponsible for the mechanical transmission of intestinal infections. Auchmeromyia lu- teola is found in some regions. Its blood- sucking larvae, known as “Congo floor maggots,” may attack persons sleeping under the trees or on the floors of the native huts. Simulium flies have not been reported. Phlebotomus schwetzi and P. congolensis have been identified. Lice. Infestation with Pediculus humanus corporis, P. humanus capitis and Phthirus pubis is common among the Bantu, but lice have not yet been incriminated as vectors of disease in the Colony. Freas. The rat flea, Xenopsylla brasili- ensis is the vector of human plague in this area. X. eridos infests the field rodents and is commonly associated with the spread of sylvatic plague. Other species taken from wild rodents in different localities include X. hipponax, X. syngenus, X. mulleri, Dinopsyllus lypusus and Echidnophaga gal- linacea. The principal focus of sylvatic plague lies in the region east of the upper Zambezi from Mongu, on the edge of the Barotse plain, to Balovale district beyond the Kabompo River. A second focus in the Luangwa River valley has been known since 1917. The presence of the infection in Sesheke district on the southern border is also suspected. The human flea, Pulex irritans, is present. The chigoe, Tunga penetrans, frequently causes sores on the feet, which may become secondarily infected. BepBucs. Cimex hemipterus is widely dis- tributed. C. lectularis may also occur. Ticks aNnp Mites. Ornithodorus moubata is common in many parts of the country, where it is a vector of relapsing fever caused by Borrelia duttoni. The thatched native huts are well adapted for harboring ticks. Numerous cattle ticks are found, among which Boophilus decoloratus, B. microplus and Rhipicephalus evertsi have been impli- cated in the transmission of protozoal in- fections in the cattle and horses. Ambly- omma variegatum is the vector of Rickettsia ruminantium among cattle, sheep and goats. Hyalomma aegyptium and the dog tick, Haemaphysalis leachi, are also present. Sarcoptes scabiei is widespread. OTHER ArTHROPODS. The button spider, Latrodectus indistinctus, and several species of scorpions are capable of causing toxic manifestations. Blister beetles of the family Paussidae, which excrete an irritating sub- stance on the skin, are found in the semi- tropical regions. The cockroaches, Peripla- neta americana and Blatella germanica, are prevalent. Reptiles. Numerous dangerous snakes are encountered in this region. The cobras, Naja melanoleuca and N. nigricollis, occur in limited numbers. The mamba, Dendro- aspis angusticeps, is found in subtropical districts in the vicinity of rivers and streams where the vegetation is dense. The African garter snake, Elapechis guentheri, is pres- ent. The vipers, Bitis arietans and B. ga- bonica, are reported occasionally. The night vipers, Causus defilipii, C. resimus and C. rhombeatus, are common in some areas. The “boomslang,” Dispholidus typus, a tree snake with a highly toxic venom, is widely distributed. The Ringhals cobra, Sepedon haemachates, occurs in the neighborhood of the Zambezi River. Rodents. Species of Rattus rattus are common in the townships. In Barotseland, the multimammate rat, Mastomys coucha, is the chief domestic rodent. The gerbils, Tatera liodon, T. lobengulae and T. brantsi, are probably the principal reser- voirs of sylvatic plague, while Mastomys serves as the intermediary in the spread of the infection to man. The most important Northern Rhodesia 185 accessory hosts among the wild rodents are the swamp rats, Pelomys fallax frater and Dasymys nudipes, and the vlei rat, Otomys irroratus. Mollusks.* Freshwater snails are widely distributed, many of which may be potential intermediate hosts of Schistosoma haema- tobium and S. mansoni. Physopsis africana globosa is probably the principal intermedi- ate host of S. haematobium. It has been found infected in localities in Balovale, Mazabuka and Livingstone districts and in the vicinity of Broken Hill and Fort Jame- son. Bulinus tropicus and Bulinus (Pyrgo- physa) forskalii are also present in many areas. Planorbid snails are numerous, but the intermediate hosts of S. mansoni have not been identified. Plants. Numerous poisonous fungi and plants are found. Contact with the wet wood or the sawdust of the African teak, Chlorophora excelsa, causes severe derma- titis. Poisonous plants which are sometimes used by the Bantu for homicidal or other purposes include Erythrophleum guineense, E. berlinia, Phyllanthus engleri and Cu- cumis naudinianus. Species of Strophanthus are prominent among the plants employed as arrow poisons. Foobp SANITATION In Livingstone, Lusaka, Broken Hill, Ndola and the Copperbelt townships, the sanitary inspection and control of foods are carried on by the local and government health authorities within the limitations of available personnel. The standards of food sanitation in the smaller communities and in the rural areas are generally low. Meats are inspected and stamped by qualified veterinary officers at the abattoirs. In most areas the supply of milk is limited. Fre- quently it is obtained from small Bantu producers or transported long distances without refrigeration. The large dairies which supply milk to Lusaka, Broken Hill, Ndola and some of the Copperbelt town- * See footnote, p. 10. 186 Northern Rhodesia ships have pasteurization facilities. Samples are submitted for bacteriologic examination at regular intervals to the laboratories op- erated by the government health authorities or the mining companies. However, because of the short supply, the existing sanitary regulations governing the production and the distribution of milk are rarely enforced. Dried milk is used extensively. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS The Health Department of Northern Rhodesia is responsible for the operation and the supervision of public health services in the Colony. It functions under the Mem- ber for Health and Local Government and is administered by a Director of Medical Services, with headquarters in Lusaka. The Rhodesian government is advised on mat- ters relating to the health of both white and Bantu populations by the medical staff of the Colonial Office in London. The Depart- ment is organized on a provincial basis, with medical and health officers directing its activities in the urban areas, rural dis- tricts and native reserves. In Ndola and the Copperbelt, where local authority is divided between contiguous mine and non- mine townships, the health services are su- pervised by medical officers of the Depart- ment. In view of the limited staff and the lack of communication facilities, public health programs, other than sanitation, have neces- sarily been incidental to medical care. Under the development plans of the Colony, how- ever, considerable expansion of health ac- tivities is contemplated. In 1946 a Silicosis Medical Bureau was organized within the Health Department for the study of condi- tions in the mine areas and the development of measures for the protection of European and native workers. Permanent headquar- ters with modern facilities for diagnosis and research were established in Kitwe in 1950. Co-operation between the health organi- zations of Northern Rhodesia, Southern Rhodesia and Nyasaland is effected through representative committees of the Central African Council. This body was created in 1944 to co-ordinate interterritorial policies. The copper-mining companies main- tain hospitals, dispensaries and general health services in the mine townships. Spe- cial maternity and child welfare clinics are supported jointly by the companies and the Rhodesian government. Various missions also operate hospitals and dispensaries and carry on health and educational programs, often with financial assistance from the government. MEepicAL INSTITUTIONS Hospitals and Dispensaries. In 1948 the Health Department operated 7 hospital units for the care of the white residents and 14 for the care of the indigenous popula- tions. The largest, in Livingstone, Lusaka, Broken Hill and Ndola, provided from 20 to 30 beds for white patients and from 100 to 125 for natives. The remaining hospitals vary in size and equipment. In general, the facilities are inadequate except at Lusaka, Livingstone and Ndola. The government also maintained 63 rural dispensaries in various parts of the country, many of which have a few beds for emergency cases. Ten other dispensaries were in the course of construction. In addition to the regular hospital dispensary services, 8 general clinics for natives are conducted in the urban centers, and special maternity and child welfare clinics for Europeans in Lu- saka, Livingstone, Broken Hill and Ndola. Modern, well-equipped hospitals, each with from 28 to 53 beds for Europeans and from 112 to 237 for natives, have been established by the mining companies at Luanshya, Nkana, Mufulira and Nchanga. These hospitals are operated primarily, but not exclusively, for the mine employees and their families. There is also a small hospital at the Zambezi Sawmills at Livingstone. Some of the missions maintain hospitals, as well as dispensaries, for the care of the Northern Rhodesia 187 indigenous population. The majority are subsidized by the government. In 1947 the government and other institutions offered 506 beds for white residents and 2,249 for natives. There are 11 leper settlements in the Colony, 10 of which are conducted under mission auspices. The Health Department operates a settlement at Kawambwa, which until 1947 was maintained by the London Missionary Society. These settlements have combined accommodations for almost 1,000 lepers. Laboratories. The Pathological Labora- tory in Lusaka is the central diagnostic, public health and research laboratory of the Health Department. It is equipped for the performance of parasitologic, bacteriologic, serologic, pathologic and chemical examina- tions. Clinical laboratories are maintained in the government hospitals at Lusaka, Livingstone and Ndola, and in the hospitals of the mining companies. A laboratory for veterinary research is located at Mazabuka. Schools. An African Medical Training School was established in Lusaka Hospital in 1936 and was expanded in 1943. Two types of instruction are given: a 3-year course for hospital assistants and a 4-year course designed to train medical assistants to direct the rural dispensaries. Native girls are also admitted to the School and to a few mission hospitals. PERSONNEL Physicians. Most of the doctors residing in Northern Rhodesia are employed by the Health Department. Its medical staff in 1948 totaled 51, including 6 physicians attached to the Silicosis Medical Bureau. Among the other physicians in the Colony in 1950, 5 were affiliated with the mining companies, 3 with the railroad and 4 with different mission organizations. Only 4 were engaged in private practice: 3 in Lusaka and one in Ndola. Dentists. Five dentists were registered in 1950; one was connected with the Health Department. Others. The 1948 roster of the Health Department also included 9 health inspec- tors, 10 pharmacists, 79 nurses, one nutri- tion officer, two pathologists and one ento- mologist. DISEASES Except in limited areas which have been covered by special surveys, the true inci- dence of specific diseases is not known. Available information is derived largely from hospital records and does not include the cases treated in the rural dispensaries. The disease statistics of the medical services operated by the mining companies and the missions are not incorporated in the annual reports of the Health Department. More- over, tribal medical men, erroneously called “witch doctors,” care for a large percentage of the native population. DiseAsES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. Both bacillary and amebic dysentery are prevalent. The majority of reported cases are unclassified, due to the absence of adequate laboratory services in many areas. Bacillary dysentery predomi- nates, and epidemics are frequent, particu- larly in the hot, dry months toward the end of the year when flies are abundant. Shigella dysenteriae, S. ambigua, S. sonnei and S. paradysenteriae are among the strains iso- lated. Amebic infections tend to be mild and chronic in both Europeans and natives. Carriers are common; in a survey of 509 employees in the Roan Antelope copper mines at Luanshya, 33.4 per cent were found to harbor cysts of Endamoeba histolytica.’ From 20 to 100 cases dysentery are recorded annually in the European population and from 150 to 500 in the Bantu. Typhoid and Paratyphoid Fevers. Typhoid fever occurs in all portions of the country, frequently in sporadic outbreaks which are believed to be water-borne but sometimes are fly-borne. Typhoid and para- typhoid fevers are grouped in the govern- 188 Northern Rhodesia ment reports, but it is probable that most of the cases may be classified as typhoid fever, since the milder infections are rarely hospitalized. Outbreaks of paratyphoid fever are common in the Livingstone area. Roughly from 30 to 150 cases of typhoid and paratyphoid fever are treated each year in the government hospitals. Helminthiases. ANcyLosToMIAsIS. Hook- worm infection, caused primarily by Neca- tor americanus, is widespread. In a survey of the northwestern half of Northern Prov- ince in 1945! infection was found to be universal, with rates fluctuating between 16 per cent and 78 per cent, depending upon differences in climate and in the agricultural habits of the people. The highest incidence was found in the low-lying regions around Lake Bangweulu and in the Luapula Valley. In general, heavy infections were encoun- tered among the inhabitants in the cassava- growing areas, where the gardens are located close to the villages. In the millet-growing regions the contamination of the fields, usu- ally at some distance from the villages, was slight, and the degree of infection was rela- tively low. The incidence in other parts of the country may be inferred from the hos- pital reports. In 1946 the presence of hook- worm infection was established in 44 per cent of the hospital admissions in Living- stone, in 41 per cent at Choma and in 27 per cent at Kasama.!® In the mines which recruit labor from all sections of the Colony, and to some extent from the Congo and neighboring territories, the rate of infection among new workers approximates 50 to 70 per cent. In the mine townships consider- able attention is given to the diagnosis and the treatment of cases and to the sanitation in the compounds and the mine shafts. ScuisTosoM1asis. Schistosomiasis, caused by Schistosoma haematobium, is endemic over a wide area. It occurs particularly in the vicinity of the upper Zambezi, Mar- amba, Saisi, Luapula and Bwengo rivers and in the Kafue and the Bangweulu swamp regions. S. mansoni has a limited and irregu- lar distribution. It is probably more preva- lent in Balovale district than elsewhere. In the helminthologic survey of the north- western part of the Colony in 1945! the in- fection rates in the localities visited aver- aged 14.7 per cent for S. haematobium and 6.99 per cent for S. mansoni. Both were found to have a spotty distribution, with rates ranging from zero up to 60 to 61 per cent. In the case of S. haematobium, the incidence was higher among children than among adults. In persons examined in the Fort Rosebery, Lower Luapula and Aber- corn highland regions, the rates were 45.9 per cent and 20.6 per cent, respectively. Comparable differences in incidence were not apparent with S. mansoni. Potential snail hosts of both species are numerous. Phy- sopsis africana globosa is probably the most important intermediate host of S. kaema- tobium. The intermediate hosts of S. man- soni have not been determined. Ortuer HELMINTH INFECTIONS. Strongy- loidiasis is prevalent, and in the region surveyed in 1945! it paralleled hookworm in distribution. The average incidence was 13.3 per cent, while rates in different locali- ties ranged from zero to 35 per cent. Strongyloides stercoralis predominated, but S. fiilleborni was isolated on a few occasions from human subjects. Ascaris lumbricoides, Taenia saginata, T. solium, Hymenolepis nana and Trichuris trichiura vary in fre- quency. The average infection rates in the 1945 survey, which may or may not reflect conditions throughout the Colony, were 3.7 per cent for Ascaris lumbricoides, 0.85 per cent for Enterobius vermicularis, 0.3 per cent for Trichuris trichiura, 0.08 per cent for Hymenolepis nana, 0.04 per cent for H. diminuta and 0.04 per cent for Taenia infections. Other Infections. Brucellosis is common among the cattle and goats, and sporadic cases of human infection are encountered. Anthrax is enzootic among the cattle, and infections sometimes occur among the na- tives as the result of eating meat from infected carcasses. Cholera has not been re- corded from Northern Rhodesia. Northern Rhodesia 189 Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is apparently increasing in the indigenous population, where unhygienic living conditions and mal- nutrition are predisposing factors. All forms of tuberculosis are found, but pulmonary infections always predominate. Among na- tives who have worked in the mines, either in Rhodesia or in the Union, tuberculosis is often associated with silicosis. In 1948, 203 cases of pulmonary tuberculosis and 112 of other forms of tuberculous infection were treated in the government hospitals. How- ever, such totals do not reflect the extent of infection. No special facilities for the treatment of tuberculosis exist in the Colony. The erection of a tuberculosis wing is proposed for the new hospital under con- struction at Kitwe in the Copperbelt in 1950-51. Smallpox. Smallpox is endemic, and widespread epidemics occasionally occur. Coincident with the outbreaks in Tangan- yika Territory and Nyasaland in 1945, smallpox spread to all portions of the Colony except Barotseland and limited areas in the extreme south. Almost half of the cases were reported from the Copperbelt region, but the incidence was also high in the rural districts and reserves of Northern and Southern provinces. In that year, 6,158 cases of mild smallpox, or alastrim, and 107 cases of typical smallpox were reported. The epidemics were brought under control by means of an intensive vaccination cam- paign during which approximately one fourth of the total population was immu- nized. In 1947-48, two outbreaks of variola major were reported. The first, at Luanshya in the Copperbelt, extended from late 1947 through January, 1948. A total of 71 cases, with 34 deaths, was recorded. From March to September (1948) epidemic conditions prevailed in a remote and inaccessible sec- tion of Gwembe district in the Zambezi River valley. This outbreak, in which there were at least 612 known cases, was prob- ably an extension of an earlier epidemic in Wankie district in Southern Rhodesia. The fatality rates approximated 30 per cent but probably were higher in many villages. Both epidemics were localized by means of mass vaccination. In Gwembe district, the vaccination program was impeded by the lack of transportation and the difficulties encountered in maintaining the potency of the vaccine under tropical conditions. Meningitis. Meningococcus meningitis is endemic, usually occurring in small localized epidemics. The cases hospitalized in gov- ernment institutions averaged from 6 to 39 a year in the decade 1939 to 1948. The fatality rates ranged from 25 to 65 per cent. The disease exists primarily among the na- tive populations; only rare cases are re- corded among the white residents. Other Infections. Acute respiratory in- fections are prevalent, with the highest incidence in the period just before the onset of the rainy season. In an investigation of the causes of pneumonia in the Roan Ante- lope Copper Mines in 19312° the cases were found to occur predominantly among work- ers from low-altitude regions. Widespread epidemics of whooping cough and measles are frequent, and the mortality is usually high among young children Measles is responsible for considerable blindness in the Bantu population. Scarlet fever is rare, but sporadic cases and occa- sional small outbreaks are reported among the white inhabitants. Poliomyelitis is en- demic. Localized outbreaks were recorded in the mining communities in 1943, 1946 and 1948. DiseasEs SPREAD OR CONTRACTED CuierLY TarOUGH CONTACT Venereal Diseases. Syphilis and gonor- rhea are widely distributed, particularly in the mining areas and in the urban commu- nities along the railway strip. Syphilis ap- parently predominates, being responsible for over one half of the known cases of venereal infection. However, the true incidence of both syphilis and gonorrhea is not known. 190 Northern Rhodesia Cases of chancroid and lymphogranuloma venereum are less numerous. Venereal dis- eases are treated in the government hos- pitals and dispensaries and in the urban clinics. Leprosy. No comprehensive survey of the incidence of leprosy has been made. In 1934 it was estimated that there were about 6,748 lepers in the Colony—a case rate of 5 per 1,000 population.!? Leprosy exists in all por- tions of the country but is probably most prevalent in Balovale district. In the decade 1939 to 1948, from 60 to 188 new cases were reported each year. In 1947 the Health De- partment assumed control of the Luapula Leprosy Settlement at Kawambwa, for- merly operated by the London Missionary Society. At that time 148 lepers were in residence. Ten other settlements are main- tained by the missions and subsidized by the Department. In 1948 a total of 975 lepers was under treatment in government or mis- sion institutions. Yaws. Yaws is endemic among the Bantu living in the more remote subtropical river valleys and especially in Western Province near the Congo border. Within recent years, the cases treated in the government hos- pitals have rarely exceeded 100 per year. The actual prevalence is not known. Diseases of the Skin. Myecotic skin dis- eases are widespread in the hot, low-lying areas. Tropical ulcers are also prevalent, particularly among the laborers in the copper mines. Human cases of myiasis are encountered occasionally, and scabies is ubiquitous. Other Infections. Outbreaks of rabies are sporadic among dogs, jackals and numerous smaller animals, particularly in the Zambezi River valley. Human cases are reported from time to time. Human anthrax infections are frequent. The majority follow the consumption of meat from infected ani- mals, but some may result from contact. Trachoma is not uncommon. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is endemic and fre- quently epidemic over the major portion of the territory. Except in the low-lying areas where anopheline breeding may persist throughout the year, transmission is limited to the period during and immediately after the rainy season, extending into May. Anopheles gambiae is the principal vector, but A. funestus is also important in many regions. Infections with Plasmodium fal- ciparum predominate, but P. vivax, and more rarely P. malariae, are also found. Malaria usually accounts for from 10 to 15 per cent of the total admissions to govern- ment hospitals. Extensive antimalarial control work has been carried on in Lusaka, Livingstone, Ndola and the Copperbelt townships, with a resulting decrease in the local incidence of infection. The risk of ‘malaria is now slight in the larger towns. Blackwater fever is reported sporadically, usually among the white population. Trypanosomiasis. Glossina morsitans is widely distributed, and human trypanosomi- asis, caused by Trypanosoma rhodesiense, constitutes an important problem in lo- calized areas. Endemic foci are found in the Zambezi River valley along the southeast- ern border of Central Province, in the Luangwa River valley, in the country around Fort Jameson and in a sector be- tween the Kafue and the Lunga rivers. In 1935 an outbreak was reported from the region within the bend of the Kafue River in the vicinity of Mumbwa, the highest in- cidence being in the villages adjacent to the game reserve. Certain villages were evacu- ated, while others were regrouped within clearings at least one mile in width. Within recent years another epidemic focus has been recognized in Feira district, near the junction of the Zambezi and the Luangwa rivers. The continuous migration of laborers from endemic foci through tsetse-infested territory facilitates the spread of the infec- tion. Glossina palpalis is present along the banks of lakes Tanganyika and Mweru and along the Luapula River. Occasional cases of infection with 7". gambiense are reported Northern Rhodesia 191 from a residual focus on Lake Tanganyika, near Abercorn. Within recent years, roughly 40 to 120 new cases of trypanosomiasis have been treated annually in all parts of the Colony. Control measures are carried on by the Health and the Game and Tsetse Control departments. Depending on circum- stances, they include the treatment of cases, the removal of villages from infected areas, antitsetse fly clearings and the regulation of game. A special campaign against trypa- nosomiasis was initiated in Feira district in 1947. Relapsing Fever. Tick-borne relapsing fever, caused by Borrelia duttoni, is en- demic. Established foci exist in the vicinity of Kasama, Fort Jameson and Shiwa Ngandu, but sporadic cases are reported from other areas. The vector, Ornithodorus moubata, is widespread. Within recent years the spread of the infection has been acceler- ated by the continuous movement of labor across the country. Up to 1940 the number of cases treated annually did not exceed 100; in 1947, it totaled 596; and in 1948, 857. Rickettsial Infections. Louse-borne ty- phus fever is not reported, but other rick- ettsial fevers are common. Tick-typhus is endemic and apparently increasing in in- cidence. The disease is relatively mild, how- ever, and the extent of infection is not known. Potential tick vectors are abundant, particularly toward the end of the rainy season. Murine typhus undoubtedly exists in certain areas. Outbreaks of murine typhus were recorded from Luanshya dis- trict in 1941, and the Roan Antelope (Lu- anshya) and the Mufulira Mine townships in 1945. Yellow Fever. Typical clinical yellow fever has not been reported from Northern Rhodesia, although one suspected case was admitted to the Balovale Hospitals in 1943, and protective antibodies were demon- strated in the serum. Subsequently, im- munity was demonstrated by means of mouse protection tests in 8.5 to 15 per cent of the population in various localities in Balovale district and along the bend of the Zambezi River. The presence of infection in this region within the lifetime of the resi- dents has thus been established, but infor- mation regarding adjacent areas is still in- complete. Barotse Province and Balovale district in Western Province are now in- cluded within the yellow fever endemic zone as defined by the World Health Organ- ization in 1950. Aedes aegypti is prevalent throughout the Colony. The species respon- sible for the transmission of the virus in Barotseland have not been determined, but several potential vectors have been identi- fied, including Aedes simpsoni, a vector of rural yellow fever in Uganda. Plague. Two known foci of plague exist: in the Luangwa Valley and on the plains of the upper Zambezi. The former has been quiescent within recent years, but repeated small localized outbreaks of human plague have been reported from the latter area since its discovery in 1937. The plague out- breaks almost invariably coincide with the rainy season, between October and Feb- ruary. Plague is enzootic among the wild rodents in Barotseland which was probably invaded from established foci in the Kala- hari desert region. Filariasis. Acanthocheilonema perstans is widely distributed. Occasional cases of infection with Wuchereria bancrofti are re- ported from Lusaka, Ndola, Kasama and other localities but some doubt exists as to their origin. The infection may be indige- nous in Feira district. Loa loa is encoun- tered sporadically in Southern Province, but the infection probably is not endemic. Rare cases of onchocerciasis occur along the Congo border. The usual vector, Simulium damnosum, is not specifically reported from the Colony. NUTRITIONAL DISEASES Malnutrition and avitaminosis are more or less general among the Bantu. Scurvy is prevalent in the northern and the eastern districts. Both beriberi and pellagra are re- ported sporadically. Rickets is frequent in 192 Northern Rhodesia the mining areas where the adoption of European habits of dress may be one of the predisposing factors. Kwashiorkor, or malig- nant malnutrition, is found among the chil- dren in certain urban communities and the fatality rate is normally high. Goiter is endemic in a broad belt along the Congo- Angola border in the northwest. In some vil- lages in Salwezi and Mwinilunga districts, the incidence approaches 100 per cent. Nutrition surveys in Serenje district were sponsored by the Colonial Medical Research Committee in 1947-48, with the co-operation of the Friends Ambulance Unit. Subsequent work is being carried on by a nutrition officer attached to the Health Department. MisceLLANEOUS CONDITIONS Silicosis is an industrial hazard among workers in the copper mines, the incidence being higher in Mufulira than in the other mines. A survey of miners with over five years’ experience in the Rhodesian copper mines was initiated in 1944, but conclu- sive statistics regarding its prevalence as compared with that in other areas are not yet available. Among 853 natives ex- amined in 1945 uncomplicated silicosis was found in 3.9 per cent, and silicosis with tuberculosis in 0.8 per cent. In a similar group of 135 Europeans, uncompli- cated silicosis was discovered in 6.6 per cent. Periodic examination and certification of all European workers are made by the Silicosis Medical Bureau. The turnover among the Africans is so great that radio- logic examinations at present are restricted to men completing five years of service and to recruits known to have worked in mines outside of Rhodesia. Lead poisoning sometimes occurs among the surface workers at the Broken Hill mine, where metallic lead is produced. SUMMARY Responsibility for the maintenance of health and medical facilities resides in the Health Department of Northern Rhodesia. It is administered by a Director of Medical Services with headquarters at Lusaka. In 1948 the population was estimated at slightly under 1.7 million, including 28,000 white residents. The economy of the Colony centers, to a large extent, around the copper mines located near the northern border. Out- side of the Copperbelt and the railroad zone, the majority of people live in sparsely set- tled rural areas or in widely scattered native reserves. The Health Department operates 7 hospital units for Europeans and 14 for natives, and 63 rural dispensaries in the re- serves. In addition, the four mining com- panies and various missions maintain hos- pitals and clinic facilities. Water supplies are derived chiefly from streams, springs and shallow or deep wells. Treatment is undertaken by the larger townships, but the supplies in the rural areas and on the re- serves are frequently contaminated. The methods of waste disposal are primitive, ex- cept in sections of Lusaka and certain mining townships where sewerage systems serve a part of the population. The stand- ards of nutrition and living conditions among the Bantu are generally low, partic- ularly in the urban areas. Malaria, trypanosomiasis, relapsing fever, schistosomiasis, leprosy, tuberculosis and venereal diseases constitute the principal disease problems. Typhoid fever, dysentery and other intestinal infections are preva- lent. Outbreaks of smallpox, meningococcus meningitis, whooping cough and measles are reported with more or less frequency. Plague, murine typhus and filariasis are en- demic in limited areas; tick typhus is widely distributed. BIBLIOGRAPHY 1. Buckley, J. J. C.: A helminthological survey in Northern Rhodesia, J. Helminthol. 21: 111-174 (No. 4) 1946. 2. Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. 3. Central African Council. Keyston, Dr. J. E.: A Report on the Regional Organization of Northern Rhodesia 193 10. 11. 12. 13. 14. 13. Research in the Rhodesias and Nyasaland, Salisbury (S. R.), Central African Coun- cil, 1948. Conferéncia Intercolonial sobre Tripanos- somiases: Lourenco Marques, 26 a 31 de agosto de 1946. Vol. I, Lourenco Marques, Imprensa Nacional de Mocambique, 1947. Dowds, J. H.: A preliminary report on a series of cases of murine-type typhus in Northern Rhodesia, South African M. J. 15:30-32 (Jan.) 1941. English, R. B.: Carriers of Entamoeba his- tolytica in Africans of Northern Rhodesia, South African M. J. 19:380 (Oct.) 1945. Gear, J. H. S.: Studies in poliomyelitis. V, South African M. J. 20:670-673 (Nov.) 1946. Gilkes, Humphrey: The investigation of an outbreak of sleeping sickness in Northern Rhodesia, Tr. Roy. Soc. Trop. Med. & Hyg. 30:213-222 (July) 1936. Great Britain: Colonial Office, Annual Re- port on Northern Rhodesia for the Year 1948, Lusaka, Govt. Printer, 1949. : Rhodesia-Nyasaland Royal Commis- sion Report, March, 1939, London, H. M. Stationery Office, 1939. Hinden, Rita: Plan for Africa, London, Allen & Unwin, 1941. Leprosy in Northern Rhodesia: Rev. 11:18-24 (Jan.) 1940. Mabhaffy, A. F., Smithburn, K. C., and Hughes, T. P.: The distribution of im- munity to yellow fever in Central and East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-83 (Aug.) 1946. Northern Rhodesia: Abbreviated (Wartime) Medical Report on Health and Sanitary Conditions for the Year 1943, Lusaka, Govt. Printer, 1944. : Abbreviated (Wartime) Medical Re- port on Health and Sanitary Conditions Leprosy 16. 1%. 18. 19. 20. 21. 22. 23. 24. 25. 26. for the Year 1945, Lusaka, Govt. Printer, 1946. : Health Department, Annual Report for the Year 1946, Lusaka, Govt. Printer, 1949. : Health Department, Annual Report for the Year 1947, Lusaka, Govt. Printer, 1949. : Health Department, Annual Report for the Year 1948, Lusaka, Govt. Printer, 1950. ——: The Silicosis Medical Bureau, Annual Report for the Year 1947, Lusaka, Govt. Printer, 1949. Ordman, David: Pneumonia in the native mine labourers of the Northern Rhodesia copperfields with an account of an experi- ment in pneumonia prophylaxis by means of a vaccine in the Roan Antelope Mine, Publ. South Afr. Inst. Med. Res. 37: Vol. 7, 97-124 (Apr.) 1935. Robinson, G. G.: A note on mosquitoes and yellow fever in Northern Rhodesia, East African M. J. 27:284-288 (July) 1950. Thomas, R. H.: A brief survey of the ma- laria problem in Livingstone and the Vic- toria Falls, Northern Rhodesia, and the measures taken to combat it, J. Roy. San. Inst. 61:82-93 (Jan.) 1941. United Nations: Non-Self-Governing Terri- tories, Summaries and Analyses of Infor- mation Transmitted to the Secretary-Gen- eral during 1948, Lake Success, New York, 1949. Year Book and Guide of the Rhodesias and Nyasaland: 1938-39 ed., Salisbury, Rho- desian Publications, Ltd., 1939. Yearbook and Guide to Southern Africa: 1950 ed., London, Sampson Low, Marston and Co., Ltd., 1950. Yellow Fever Research Institute: Annual Reports, 1947 and 1949, Entebbe, Uganda. COOGEE OCT OCEOOCSOOOOCOSSOOGCHOOL SECS OHCESOECEEEESECHSSHSEESS 13 Southern Rhodesia GEOGRAPHY AND CLIMATE Southern Rhodesia is a self-governing colony of the British Empire. Constitu- tionally, it occupies a position midway be- tween that of a Colony and a Dominion, and matters of policy between the Southern Rhodesian and the British governments are handled through the Commonwealth Rela- tions Office. The territory was developed and administered by the British South Africa Company until 1923, when the present form of government was adopted. It has an area of 150,333 square miles, ex- tending from the Zambezi River and North- ern Rhodesia in the north to the Limpopo River and the Union of South Africa in the south, and from Mozambique in the east to Bechuanaland in the southwest. Almost two thirds of the country is a high plateau, which has an elevation ranging from 3,000 to 5,000 feet and is characterized by undu- lating, grassy plains broken by series of well-wooded hills. Mountain ranges mark the eastern boundary, in which Inyangani, with an altitude of 8,250 feet, is the highest peak. Although Southern Rhodesia is wholly within the tropics, climatic conditions in the upland areas approximate those of the tem- perate zone. The temperature, which in- creases slightly toward the north and the west, is governed to a large extent by the altitude. On the high veld the mean annual temperatures range from 65° to 72° F. at 3,000 to 4,000 feet and from 63° to 68° F. at 4,000 to 5,000 feet. In the lowlands along the basins of the larger rivers the climate is subtropical. In areas between 2,000 and 3,000 feet, roughly 22 per cent of the total land area, the mean annual temperatures average 70° to 77° F. In the low veld below 1,000 feet, which occupies about 15 per cent of the territory, they approximate 74° to 830°: F. The rainfall is concentrated to a large extent in the summer months, from October to April. It is highest in the mountains along the eastern border and decreases toward the south and the west. Two well- defined periods are apparent. In the first half of the rainy season the rainfall is ir- regular, but in the months from January to March it becomes more monsoonal in type. It normally ranges from 20 to 36 inches a year over at least four fifths of the Colony, but is less in the Limpopo region. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopurLATION The population of Southern Rhodesia, as enumerated in the Census of 1946, includes 82,382 Europeans, 2,913 Asiatics, 4,567 colored (of mixed blood) and approxi- mately 1,674,000 natives. Estimates for 1948 bring the total white population to 103,000 and the indigenous to 1,866,000. The native population is composed of numerous tribes belonging ethnologically to two groups, the Matabeles and the Ma- shonas. Although all are southern Bantu in origin, they have fundamental differences in language, customs and religion. The Rhodesian government has set aside 29.5 million acres in numerous separate reserves for the occupation of the Bantu under their 194 Southern Rhodesia 195 traditional system of communal ownership. In addition, 7.5 million acres contiguous to the reserves are held subject to individual lease or purchase. Roughly 70 per cent of the natives live on these reserves where the population density varies from 2.5 to 60 per square mile. The white residents are settled primarily on the high central ridge, about equally divided between Mashonaland and Matabe- leland. Slightly over 40 per cent are concen- trated in the two largest cities, Salisbury and Bulawayo. They are predominantly British, with a large percentage of South Africans. Salisbury, the capital, had an estimated population of 81,729 in 1948, in- cluding 23,000 Europeans and 56,660 na- tives. Bulawayo, an industrial and agri- cultural center, had an estimated population of 55,847, with 20,000 whites and 33,847 natives. The educational standards in Southern Rhodesia are relatively high. Primary and secondary schools are maintained by the government for European and for Indian and colored children. However, native edu- cation is largely in the hands of the Protes- tant and the Catholic missions, though con- trolled by the government through grants to approved schools. In certain populous areas education is compulsory for the chil- dren of all races from 7 to 15 years of age. The government has made a consistent effort to raise the standard of living on the reserves: the maintenance of agricultural schools at Domboshawa and Mzingwane, and the employment of trained demonstra- tors to advise the people regarding home building, village planning, and improved methods of agriculture are prominent fea- tures of its educational program. VITAL STATISTICS In 1948 the birth rate of the European population was 27.7 per 1,000, and the crude death rate 8.0 per 1,000. The infant mortality rate was 32 per 1,000 live births, as compared with rates of 40 in 1943 and 45 in 1939. Up to 1948 no statistics were available for the indigenous populations. Sample surveys were undertaken by the Central African Statistical Office in 1947-48, and the representative indices probably will be included in subsequent governmental re- ports. In 1949 the birth rate was estimated at about 46, and the death rate 18 per 1,000 population. The infant mortality averaged at least 130 per 1,000 live births and prob- ably was higher in many areas. SociaL Economy The prosperity of Southern Rhodesia de- pends largely upon the fact that it contains an extensive gold-producing region and valuable deposits of asbestos, chrome, coal and other minerals. The mineralized areas are more scattered than in other parts of South Africa, and the government, which now owns all of the mineral rights, has en- couraged their development by small pro- ducers. Agriculture plays an important role in both European and native economy. Over one half of the best farming land on the high plateau is reserved for white occu- pancy, but only a small portion is actually under cultivation. Large holdings, many of which are owned by operating companies or absentee landlords, are devoted to the rais- ing of tobacco, maize or cattle, but within recent years there has been an increasing tendency toward subdivision and the pro- motion of mixed farming. In 1944 two mil- lion acres, or more than three quarters of the total land under cultivation, was worked by the Bantu, usually according to primi- tive methods. The tribes of Mashonaland are predominantly agriculturalists; those of Matabeleland, pastoralists. Industrial development has expanded twofold and threefold since 1938. The es- tablishment of new industries is encouraged by the Rhodesian government. Also, many of the basic resources of the country, as the iron and steel works at Que Que, the textile mills at Bulawayo and Gatooma and the proposed hydroelectric plant at Kariba 196 Southern Rhodesia Gorge on the Zambezi, have been developed as government enterprises. The Colony is reasonably well supplied with all-weather roads and rail connections. A State railway system links Bulawayo with the port of Beira in Mozambique, and through a junction with the South African Railways, with the ports of Cape Town, Durban and Port Elizabeth. It also includes services through Northern Rhodesia to the Belgian Congo. Air transport is maintained between Salisbury and Bulawayo and other countries in Africa, Great Britain and con- tinental Europe. Foop AND NUTRITION Although Southern Rhodesia is an agri- cultural country, regional food shortages are frequent, due to transportation difficul- ties, periodic droughts, overrapid immigra- tion and the increased demand for indus- trial labor. The food habits of the white and colored communities reflect the circumstances of the individual, and such deficiencies as occur result chiefly from poverty or igno- rance. The standards of nutrition are gen- erally low in the native populations, partic- ularly in the townships. Maize and millet are staple foods among most tribes. Upland rice is grown in some localities. Vegetables and fruits, both wild and cultivated, are em- ployed to a variable extent. Cattle, sheep and pigs are raised, but relatively little meat is consumed by the poorer families. Dairy products are used in negligible amounts, except in southwestern Matabeleland. Fish are relatively scarce. Poultry are kept in most villages, but eggs are often subject to local taboos. Peanuts and beans often con- stitute the major sources of protein and fat. Increased attention has been given re- cently to the nutritional needs of the dif- ferent races. In the course of medical in- spections in the government schools in 1948, the nutritional standards of over 11 per cent of the European children were found to be unsatisfactory. Similar examinations in 15 schools for Colored (mixed blood) and Asiatic children, and in 9 schools for natives revealed 27 per cent substandard nutrition in both groups.2? In 1947 a Nutrition Coun- cil, composed of members from the Health, Agriculture and Native Affairs departments, and representatives from the principal farmers’ and women’s organizations and the mining industry, was established to survey the situation. Housine Considerable variation exists in both European and native housing. At present a shortage of suitable dwellings is encountered among all sections of the population. The homes of the white settlers are usually well constructed, of brick with corrugated iron, tile or thatch roofs. The natives on the re- serves commonly live in kraals in crude huts with mud walls and peaked thatched roofs, but in a few areas, brick houses of permanent construction are gradually being adopted. The living conditions on the re- serves and in the “native purchase areas” are generally superior to those in the urban communities where residence is largely re- stricted to “locations” provided by the townships or municipalities. Many such settlements are old and insanitary, while even the more modern, such as Bulawayo and Salisbury, are overcrowded to a degree inconsistent with health and family welfare. Low-rental housing programs, subsidized by the government or the local authorities, have been undertaken at Victoria Falls and in the six municipalities—Bulawayo, Salis- bury, Umtali, Gwelo, Gatooma and Que Que. For the most part, the larger mining companies make ample provision for the housing and the nutrition of their workers. As there is no legal minimum standard for native housing, the compounds of the other laborers differ markedly. ENVIRONMENT AND SANITATION WATER SUPPLIES In the settled portions of Southern Rho- desia, the water supplies are generally ade- quate, though varying in amount. Water is derived chiefly from streams, springs and shallow wells and in the drier areas of the south and the west, from various collections of surface water. In the rural districts, borehole supplies are common. The six municipalities have piped water supplies which are collected in impounded reservoirs and treated by chlorination be- fore distribution. Bulawayo obtains its water from two reservoirs: one with a ca- pacity of 1,200 million gallons on the Khami River, 13 miles from the city, and another of more recent construction, fur- nishing 3,100 million gallons, on the Ncema River, 35 miles distant. The Salisbury water supply is at present derived from a 500-million-gallon reservoir at Prince Edward Dam on the Hunyani River, 10 miles from the city. The construc- tion of a new 5,500-million-gallon reservoir and dam at Hunyani Poort was scheduled to start in 1950. A subsidiary supply is now available from a 200-million-gallon reser- voir at Cleveland Dam. It is treated by fil- tration only. Several irrigation projects are in opera- tion. The oldest and smallest is the Mazoe River development, which furnishes water to the citrus estates near Salisbury. The government-owned irrigation project at Umshanbigi Dam, near Fort Victoria, sup- plies the wheat farmers in that area. Surveys have also been made for the construction of dams in the Sabi River valley and at Kariba Gorge on the Zambezi. The primary purpose of the latter project would be the provision of hydroelectric power, with irrigation of secondary importance. It would benefit Northern Rhodesia and Nyasaland, as well as Southern Rhodesia. WasTE DisposaAL Bulawayo and Salisbury have water- borne sewerage systems which serve the business and the residential districts and limited sections of the native locations. Other urban areas depend largely upon the use of septic tanks or bucket latrines. Septic Southern Rhodesia 197 tanks are frequently employed on the larger European farms. The methods of sewage disposal in the rural areas and in the labor camps are generally primitive. Contamina- tion of the soil is the usual practice on the reserves. In some areas, native hygiene demonstrators are now attempting to intro- duce sanitary methods of waste disposal. Fauna AnD Frora Arthropods. Mosquitoes. At least 16 species of anopheline mosquitoes have been reported from Southern Rhodesia, but Anopheles gambiae and, to a lesser extent, A. funestus are chiefly responsible for the transmission of malaria. 4. gambiae is sea- sonal in occurrence in all parts of the Colony, except in the high country of the central plateau and eastern mountains and in the low veld. It is abundant toward the end of and following the rains, usually from January to May. In the regions below 2,500 feet, as in the Zambezi and the Sabi river valleys, it is found throughout the year. A. gambiae breeds in small exposed collections of water which are readily warmed by the sun, such as irrigation canals, puddles and open muddy pools devoid of vegetation. A. funestus has become restricted in distribu- tion within recent years. It breeds chiefly along the shady margins of slowly moving streams. Aedes aegypti is prevalent throughout the territory. Numerous species of culicines are present but are considered of significance as pests rather than as vectors of disease. Mosquito-control measures are carried on in the vicinity of the larger towns and in a few European rural areas. They include drainage projects and antilarval treatment of surface waters with oil or DDT. Experi- ments have also been undertaken with the residual spraying of rural dwellings. A comprehensive program for the eradication of malaria by use of residual insecticides was initiated in the Upper Mazoe Valley in 1949, with financial assistance from the State Lottery funds. Fries. Tsetse flies formerly covered the 198 Southern Rhodesia greater part of the territory but now exist in scattered foci; a recession which is at- tributed in part to the decimation of the wild game reservoir by the rinderpest epi- zootic in 1896-97.° Glossina morsitans is found in a belt south of the Zambezi River from the Mozambique border west to Wankie. It is a vector of animal trypano- somiasis and of human infections with Trypanosoma rhodesiense, which occur spo- radically in the Zambezi Valley. The south- ern part of the Colony is free from tsetse flies, except in Melsetter district where G. morsitans has become established in the region between the Sabi and the Lundi rivers. A number of farms along the eastern border are also subject to invasion by G. brevipalpis and G. pallidipes from the adjoining districts of Mozambique. Other areas threatened from Mozambique are Mtoko district, where G. morsitans is ad- vancing up the Luenka River, and Umtali district, where it has been found recently in the railroad zone between Umtali and the border. It may also be present in parts of Inyanga district. Eradication measures instituted in the infected areas have con- sisted primarily in the controlled destruc- tion and fencing off of game. On the eastern border, which is sometimes infested with G. brevipalpis and G. pallidipes, total and partial bush clearings are employed. Numerous species of Tabanid flies are present, many of which are implicated in the mechanical transmission of intestinal infections. Musca vicina and M. domestica are universal, but the former species is most abundant. Stomoxys calcitrans is prevalent. Myiasis-producing flies of the genera Hy- poderma, Oestrus, Lucilia and Sarcophaga are widely distributed and with Cordylobia anthropophaga are occasionally responsible for cases of human myiasis. Auchmeromyia luteola is also found. Its bloodsucking larvae may infest the floors of the native huts. Lice. Pediculus humanus capitis and P. humanus corporis infest the inhabitants in many areas but are rarely if ever implicated in the transmission of human infections. Freas. Xenopsylla brasiliensis is the most prevalent rat flea. Numerous other species are recorded, but the wild rodent flea, X. eridos, is the only one of importance. It is a potential vector of sylvatic plague, which is enzootic in the adjoining regions of Bechuanaland and Barotseland, but has not yet spread to Southern Rhodesia. The chigoe flea, Tunga penctrans, is present. BepBucs. The bedbugs, Cimex lectularis and C. hemipterus, are found in all parts of the country. Ticks anxp Mires. The tampan tick, Ornithodorus moubata, is common through- out Southern Rhodesia and responsible in some districts for the transmission of re- lapsing fever. Amblyomma hebraeum, Rhipicephalus appendiculatus, Boophilus decoloratus and Haemaphysalis leachi are also present. They may be vectors of tick- typhus, which is reported sporadically during the summer months. The itch mite, Sarcoptes scabiei, is widely distributed. OTHER ArTHROPODS. The button spider, Latrodectus indistinctus, is reported from some localities. It is capable of producing a toxemia which is occasionally fatal. Blister beetles of the families MELOIDAE and Paussipae are indigenous in the sub- tropical regions. They secrete an irritating substance on the skin which causes painful blisters. Reptiles. A large number of poisonous snakes are found in Southern Rhodesia. The most important vipers are the puff adder, Bitis arietans, and the night vipers, Causus defilipii, C. resimus and C. rhombeatus. Burrowing vipers of the genus Atractaspis are encountered occasionally. The Cape cobra, Naja flava, is present in limited num- bers throughout the Colony. The mamba, Dendroaspis angusticeps, exists in areas covered with dense vegetation in the vicinity of the rivers and the streams in the sub- tropical parts of the country. The boom- slang, Dispholidus typus, a rear-fanged tree snake which possesses a highly toxic venom, is widely distributed. The spitting Ringhals cobra, Sepedon haemachates, inhabits cer- tain regions in the south. The python, Py- thon sebae, has also been recorded from this region. It is not venomous but may be dan- gerous to small animals. Rodents. Rodents are prevalent through- out the territory. Rattus rattus rattus and R. rattus alexandrinus may occur in the urban areas. Wild rodents, including the gerbil, Tatera, and the multimammate rat, Mastomys coucha, are numerous. These species are the most frequent reservoirs of sylvatic plague in the neighboring terri- tories of Barotseland and Bechuanaland. However, wide sections of the country are forested with Copaifera mopane, and are relatively rodent free. Mollusks.* Two species of freshwater snails are implicated in the transmission of schistosomiasis. Physopsis africana globosa, the intermediate host of Schistosoma haematobium, is widespread, but Planorbis (Biomphalaria) alexandrina pfeifferi, the intermediate host of S. mansoni, has a more restricted and patchy distribution. Both species thrive in slowly moving streams, either along the edges or in the shelter of various aquatic plants, and in the residual surface pools in the low-rainfall areas. Bulinus tropicus is present in some areas but has not been found infected. Lymnea natalensis is also widespread and, although of no known medical importance, is readily confused with the other species. Plants. Prominent among the indigenous poisonous plants are Cucumis ficifolius and Euphorbia abyssinea which are used some- times by the Bantu for homicidal purposes. Species of Acocanthera and Strophanthus are employed as arrow poisons, and Datura as a means of imposing tribal judgments. Eragrostis is not only poisonous but pro- duces severe contact dermatitis. Several plants, including species of Di- chapetalum, are occasionally responsible for the loss of livestock. The Indian hemp, Cannabis sativa, is well known throughout * See footnote, p. 10. Southern Rhodesia 199 this region on account of its narcotic properties. Foop SaNiTaTION The sanitary quality of meats, milk, butter and other foodstuffs is supervised by the government and the municipal health authorities. Meat animals are inspected routinely, before and after slaughter. In- spection of the larger dairies is undertaken by the dairy division of the government’s Department of Agriculture. Pasteurization is compulsory in the municipalities and some of the larger towns. Conditions vary in the rural communities but are generally poor in the native areas. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The Public Health Department of South- ern Rhodesia was given divisional status under the Minister of Health in the Rho- desian government in 1948. It is adminis- tered by a Secretary for Health, who is Medical Director of the department and Chief Health Officer. The headquarters or- ganization is established at Salisbury. The Department is divided into two main branches, Curative Services and Preventive Services, each under the authority of a Director. The functions of the Curative Services include the maintenance of hos- pitals, maternity homes and clinics for the care of all sections of the population; the conduct of laboratory and training facili- ties ; and liaison with the mining companies, the missions and the other agencies that are operating medical services. The Preventive Services branch is re- sponsible for the supervision of the munici- pal and other local health authorities; the sanitation of all areas outside of the munici- palities; the control of communicable dis- eases; the maintenance of medical, dental and nutritional services in the schools; the regulation of industrial health conditions; the training of native hygiene demon- 200 Southern Rhodesia strators; and the conduct of research on schistosomiasis and malaria. This division is developed on a regional basis, with Medical Officers of Health in charge of its activities in each region. In 1939, a special schistosomiasis research unit was estab- lished which receives annual grants from the State Lottery Trustees. The six municipalities, Salisbury, Bula- wayo, Umtali, Gwelo, Gatooma and Que Que, support health services with financial assistance from the central Public Health Department. In Salisbury and Bulawayo they are under the direction of full-time Medical Officers of Health. Liaison between the Public Health De- partment of Southern Rhodesia and the Colonial health organizations of Northern Rhodesia and Nyasaland is obtained through a Standing Medical Sub-Committee of the Central African Council, which was created in 1944 to promote co-operation between the three governments. Committees of the Council also deal with specific health problems. Several mission societies maintain hos- pitals and other medical services, which are subsidized by the Public Health Depart- ment. The larger mining companies and some industrial concerns support health and hospital facilities for the benefit of their workers. The St. John’s Ambulance Associa- tion, and the Southern Rhodesia Central Council of the British Red Cross undertake first aid and home-nursing training, and co- operate in the nonprofessional services in the hospitals. MepicAL INSTITUTIONS Hospitals and Dispensaries. The Public Health Department operates 15 hospitals, with European and native sections which provide 614 beds for Europeans and 1,258 beds for native and other non-European pa- tients. The largest hospitals are located in Salisbury and Bulawayo. In 1948 the hos- pital in Salisbury had 139 beds for Euro- peans and 232 beds for natives. The hos- pital in Bulawayo had 228 and 330 beds, respectively. In the same year, the Depart- ment maintained 79 rural dispensaries for natives and planned the establishment of 12 others. In addition to the general hos- pitals there were 12 maternity homes for Europeans, 10 of which were run by the Department and 2 under private auspices. New 80-bed maternity hospitals for natives were under construction in Bulawayo and Salisbury. Other government institutions include leper hospitals at Ngomahura and Mtemwa, a mental hospital at Ingutsheni, an orthopedic center in Salisbury and a tuberculosis sanatorium under construction at Mkumbi. Infectious disease hospitals are located in the municipalities of Salisbury and Bulawayo. A few private nursing homes are found in the larger cities. The mission organizations also maintain hospitals in various parts of the Colony, which are partially supported by government subsidies. Laboratories. Public Health Laborato- ries, with facilities for the performance of routine diagnostic examinations, are op- erated by the government. The principal laboratories are situated in Salisbury and Bulawayo, and subsidiary laboratories are established in the hospitals at Gwelo and Umtali. The Department also maintains an analytical laboratory in Salisbury. A re- search laboratory is conducted by the schistosomiasis unit of the Preventive Serv- ices. Clinical laboratory facilities are found in the larger hospitals. Schools. There are no medical schools in Southern Rhodesia. Prospective students in medicine and dentistry are usually sent to schools in the Union of South Africa or in Great Britain. Nurses training schools are operated in connection with the hospitals at Salisbury and Bulawayo. The Public Health Department provides training facilities for native personnel in several of its hospitals. Schools for male nursing orderlies are located at Salisbury and Bulawayo, for female nursing assistants Southern Rhodesia 201 at Bulawayo, and for maternity assistants in Umtali. The Department has recently established a school for native health demonstrators at Domboshawa. PERSONNEL Physicians. In 1948 a total of 346 doc- tors was listed on the register of the Medi- cal Council of Southern Rhodesia. Probably 207 were engaged in active practice. About 82 were employed by the Public Health Department, 12 by mining companies and 14 by various mission organizations. Dentists. In the same year 56 dentists were registered by the Council, about two thirds of whom were practicing. Five were connected with the Department. Nurses. The nursing personnel listed in the Council register for 1948 included 638 general nurses, 28 mental nurses and 12 special nurses. Over 300 were engaged as general nurses by the health services; and 20 as district nurses. Others. The roster of the Council also included 143 pharmacists, 10 opticians, 41 health inspectors, 36 meat and food inspec- tors, 2 health visitors and 298 midwives. A medical entomologist was connected with the research organization of the Depart- ment. About 115 native nursing orderlies and 20 native health demonstrators worked for the Department in addition to assistants in various categories. DISEASES The reporting of infectious disease is un- satisfactory for both the European and the native populations. The government re- ports are incomplete and do not include the records of the mission hospitals and dis- pensaries. Moreover, a large percentage of the population in the reserves lives beyond the reach of the present medical services. Estimates of incidence are invariably low and can be interpreted only in terms of rela- tive prevalence. More reliable information is available with respect to certain diseases which are the subject of special investiga- tions, as trypanosomiasis and schistosomi- asis. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. Amebic and bacillary dys- entery are common and frequently occur in small epidemics which may be traced either to contaminated food or water supplies. Flies are abundant in all parts of the Colony, while the standards of sanitation among the native populations are generally low. Bacillary infections probably predomi- nate. Amebic dysentery is widespread, par- ticularly in the northern and the western parts of the country. A differentiation be- tween amebic and bacillary infections is not made in the government hospital re- ports; the cases of “dysentery” under treat- ment totaled 813 in 1947 and 564 in 1948. Typhoid and Paratyphoid Fevers. Sporadic outbreaks of typhoid fever are frequent, the incidence of infection being high among all races. The disease is espe- cially prevalent in the rural areas where it is spread primarily by means of contami- nated water supplies. The reported incidence probably represents only a small percentage of the actual cases. In the four years, 1945- 48, the cases of typhoid fever ranged from 108 to 211 a year; of paratyphoid fever, from 5 to 30. The fatality rates averaged 8 to 10 per cent. Cholera. Cholera is not reported from Southern Rhodesia or from the neighboring territories. Helminthiases. ScuistosomIasis. Schis- tosomiasis is one of the most important dis- eases in Southern Rhodesia. Infections caused both by Schistosoma haematobium and S. mansoni are encountered over a wide area, particularly in the northern and the eastern districts. The two species exist con- currently in numerous limited foci, while S. haematobium constitutes a major prob- lem in all parts of the Colony. In a helminth- 202 Southern Rhodesia ologic survey made in 1930-33? the infection rates with S. kaematobium averaged 10 to 30 per cent among the inhabitants of the re- serves in various parts of the country. The rates with S. mansoni ranged from 1.8 to 9.2 per cent, except in Melsetter district where they reached 16.6 per cent and ex- ceeded those for S. haematobium. More recent surveys’ indicate a general infection rate of 2 to 2.5 per cent for both species in the European population, and of 10 per cent for S. mansoni and 27 per cent for S. haematobium in the native. The highest in- cidence is usually associated with areas under irrigation. In the Mazoe Valley north of Salisbury the infection rates with S. haematobium reach 25 to 41 per cent among native children from 1 to 5 years of age, and 56 to 79 per cent in children 6 to 10 years of age. The research unit of the Preventive Services has been active in developing a diagnostic skin test, using a cercarial anti- gen, and in perfecting rapid treatment tech- nics with sodium antimony tartrate. In 1947 it co-operated with the British Medical Research Council in the conduct of field trials for the mass treatment of patients with the thioxanthone preparation, Miracil D. Extensive work is also undertaken by the research staff in the control of the snail hosts by the use of molluscides. The inter- mediate molluscan host of S. haematobium is Physopsis africana globosa and that of S. mansoni, Planorbis ( Biomphalaria) alex- andrina pfeifferi. Ancyrostomiasis. The incidence of hook- worm infection is generally high. In the course of a survey which included repre- sentative native reserves and mixed urban communities in 1930-312 the infection rates were found to range between 0 and 23 per cent. Marked variations in prevalence were noted in adjacent villages or kraals. The highest rate of infection was found in Umtali and Melsetter districts in the eastern part of the Colony. Infections were also disclosed among the workers in two mines selected for study, a shallow coal mine and a deep gold mine. Subsequent evidence has shown that the incidence probably approxi- mates 50 per cent or more in some regions. Necator americanus is the predominating species, but Ancylostoma duodenale may be found in limited foci. Otuer HELMINTH INFECTIONS. Ascariasis is prevalent among the native populations and exists in scattered foci among the Eu- ropean. In the 1930-31 survey, infection rates of 0.7 to 12.1 per cent were found in different communities, the lower incidence being characteristic of the drier portions of the Colony.? Hymenolepis nana, Enterobius vermicularis, Trichuris trichiura, Strongy- loides stercoralis and, to some extent, S. fiilleborni, are widely distributed. Ternidens deminutus is present in the eastern and the southeastern districts. In 1931-32 it was found in 10 to 16 per cent of the people examined. Taenia saginata infections are frequent in the cattle-raising areas. Other Infections. Brucellosis is enzootic among the cattle. Occasional cases of un- dulant fever, caused by Brucella abortus, are reported among the white residents. The incidence in the native rural areas is not known, but human infections undoubtedly result from the ingestion of milk or from contact with the infected livestock. Sporadic cases of anthrax are encoun- tered among the Bantu, often as the re- sult of the consumption of the meat from infected animals. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is a major problem, particularly among the native pop- ulations. Within recent years the rate of in- fection has increased in both urban and rural areas. There is also considerable evi- dence that foci have been established in the more remote villages. In many districts the increase in pulmonary infections in women and of bone infections in children has been marked. Overcrowded and poorly ventilated home and working conditions, and low dietary standards favor the spread of the disease, which among the Bantu normally Southern Rhodesia 203 runs a rapid course. In 1948 a total of 450 cases was reported, 412 pulmonary and 38 nonpulmonary. In the absence of adequate diagnostic and treatment facilities, no means are available for assessing the extent of in- fection. However, it is probable that the known cases represent but a fraction of the total. Relatively high infection rates are observed among the gold-mine workers. The construction of a tuberculosis sana- torium for natives at Mkumbi in Chin- damora Reserve, near Salisbury, was near- ing completion in 1948. An intensive survey of pulmonary tuberculosis was being car- ried on in Matabeleland by the Public Health Department in 1949-50, before initiating an experimental immunization program, employing BCG vaccine. Smallpox. Smallpox is endemic and sometimes epidemic. Since 1940 a vaccina- tion program has been undertaken on a country-wide basis, and, in addition, mi- gratory laborers from other territories have been vaccinated at their point of entry into the Colony. No cases were reported from 1941 to 1945, when 33 cases of mild small- pox were discovered at Bulawayo among immigrant laborers from Northern Rho- desia. Subsequently, the disease was intro- duced into the sparsely settled Wankie dis- trict from Bechuanaland. Among 181 known cases in 1946, 148 were from this region. In spite of mass vaccinations in the affected areas, the epidemics spread, with 568 cases reported from Matabeleland and 117 from localized foci in northern Mashonaland in 1947. The fatality rate was 18 per cent in the former area, the highest recorded since 1922. The epidemic persisted in Matabele- land in 1948, where the incidence totaled 1,181 cases and the fatality rate, 35 per cent. The majority of the cases occurred in remote areas between Wankie and the Zambezi River. The same year, 642 cases of variola minor were reported from other localities, including Bulawayo where the first European cases since 1939 and the first European death since 1919, were recorded. Widespread vaccination was carried on among the native populations, but the mul- tiplicity of small scattered foci made control difficult. Diphtheria. Small localized outbreaks of diphtheria occur, most frequently in the rural areas. In the four years from 1945 to 1948, the incidence fluctuated between 25 and 66 cases among the Europeans, and be- tween 76 and 430 cases among the natives. The fatality rate averaged from 0 to 6.5 per cent for Europeans and from 10 to 29 per cent for natives. Widespread immunization against diphtheria is carried out by the gov- ernment health authorities in the epidemic areas. Also, free immunization and Schick tests are available to all children in the government clinics and dispensaries. Other Infections. Pneumonia is prev- alent and responsible for a high mortality among native laborers. Measles, mumps, chickenpox and whooping cough are en- demic among all races. Outbreaks of epi- demic cerebrospinal meningitis are not infrequent. Scarlet fever is common in the white, but relatively rare in the indigenous population. Poliomyelitis is reported spo- radically in all racial groups. The peak of incidence, within recent years, was observed in 1946 when 55 cases were recorded. DiseaSES SPREAD OR CONTRACTED CuierLy TaroucH CONTACT Venereal Diseases. Both syphilis and gonorrhea are prevalent, especially in the towns and the mining areas. The actual in- cidence is not known, but reports indicate an apparent increase in these diseases. It is estimated that in certain localities the infection rates among the Bantu may exceed 50 per cent. Syphilis, in particular, is wide- spread, being found in the most remote por- tions of the Colony. Chancroid and lympho- granuloma venereum are also present to a limited extent. Measures for the control of prostitution are not enforced, and both professional and clandestine prostitutes are numerous in the urban and the mining areas. Moreover, the large volume of migratory native labor and 204 Southern Rhodesia the fact that the registration laws govern- ing the travel and the residence of natives do not apply to women serve to complicate the problem. Special facilities for the treat- ment of venereal diseases are available in the government hospitals and in most na- tive clinics. Leprosy. Leprosy is endemic in all parts of the Colony, but particularly in the low- land areas. In 1939 the total incidence was estimated at between 6,000 and 7,000 cases, or 5.6 per 1,000 population.'> The govern- ment maintains two institutions for the treatment of lepers: the Ngomahura Lep- rosy Hospital with facilities for the care of all races and the Mtemwa Settlement for natives. In 1948 a total of 1,739 patients was treated, including 6 Europeans. Diseases of the Eyes. Trachoma is com- mon among the indigenous population. In 1945-48, an average of 57 cases was reported annually, which probably represents a small fraction of the total infections. An investi- gation of eye diseases and causes of blind- ness is scheduled for the near future by the health authorities. Diseases of the Skin. The incidence of tropical ulcers is high in all parts of the ter- ritory, but especially in the mining areas. Mycotic skin infections are frequent in the subtropical regions. Occasional cases of human myiasis are recorded. Infestation with the chigoe flea, Tunga penetrans, and with Sarcoptes scabiei is more general. Other Infections. Sporadic cases of tetanus and of tetanus neonatorum are re- ported. Canine rabies is enzootic, and human infections occur from time to time. Di1sEASES SPREAD BY ARTHROPODS Malaria. Malaria affects the greater part of the Colony, while extensive areas are subject to annual epidemics. A. gambiae is the principal vector, although A. funestus is also implicated in many localities. In the river valleys and areas below 2,500 feet, malaria is present at all times of the year. At the higher altitudes the incidence is gov- erned by the seasonal variations in temper- 0 yy. # Endemic 4 Annual epidemic Malaria in Southern Rhodesia ature and rainfall. Transmission takes place from December through May, but most abundantly during March and April. In the low-rainfall areas of the south, the failure of an outbreak in any one season is usually followed by a more explosive epi- demic the following year. Malaria is rare in Salisbury and similar communities at alti- tudes of 5,000 feet or more, but epidemics may occur when abnormal climatic condi- tions favor the breeding of 4. gambiae. The disease is especially prevalent in Sinoia, Que Que, Gatooma, Hartley, Umbuma, Bulawayo, and northern Marandellas dis- tricts. Within recent years the increased migration of native laborers from reserves in nonmalarial areas to agricultural devel- opments in the lowlands has been responsi- ble for large-scale epidemics. A total of 2,794 cases was treated in the government hospitals in 1948: 1,040 were Europeans; 1,754 were natives and colored. The hos- pital admissions, however, give little idea of the extent of infection. Plasmodium falciparum usually predomi- nates. Among the blood films examined at the Public Health Laboratory in Salisbury in 1948, Plasmodium falciparum was identi- fied in 289 cases, P. vivax in 1, and P. malariae in 5. Corresponding examinations at the Public Health Laboratory in Bula- wayo revealed 751 cases of P. falciparum in- fection, 29 of P. vivax and 1 of P. malariae. Infections with P. ovale are also seen occa- sionally. Southern Rhodesia 205 Malaria-control measures are undertaken in the municipal areas. An experimental rural program was initiated in the Mazoe Valley, one of the most malarious sections of the country, in 1949. It involves prophy- lactic drug therapy and the eradication of anopheline vectors by residual spraying of dwellings with DDT. Blackwater fever is sporadic in the Euro- pean population but rare in the native. Typhus Fever. Tick typhus, or South African tick-bite fever, is endemic in the eastern half of the Colony. The disease occurs at all seasons of the year, but par- ticularly toward the end of the rainy sea- son, when the tick vectors, Amblyomma hebraeum, Rhipicephalus appendiculatus and Boophilus decoloratus, are present in large numbers. The recorded incidence aver- ages from 1 to 10 cases a year, but the majority probably are never reported. Although louse infestation is common among the native populations, louse-borne typhus fever has not been observed. Murine typhus is not reported but is thought to exist in Southern Rhodesia, since the infec- tion has been recognized in adjacent areas in South Africa. Trypanosomiasis. Extensive areas in the northern part of the country are in- fested with tsetse flies. Human trypano- somiasis, due to Trypanosoma rhodesiense, is endemic in limited foci in this region, and cases are reported from time to time. Foci in the West Hartley and the Sebingwe dis- tricts, which were discovered in 1934, have been brought under control, but the disease continues to smolder in the Zambezi Valley. In 1946 a total of 13 cases with 3 deaths marked the highest incidence of the disease since its recognition in Southern Rhodesia in 1912. Only 5 were indigenous cases, oc- curring in natives from villages in the east- ern Zambezi Valley, while the remainder were migratory workers from Northern Rhodesia and Mozambique. In 1947 and 1948, 10 and 9 cases were reported, respec- tively. The infected areas are sparsely popu- lated, and the danger of a widespread epi- demic is slight. The source of infection of all new cases is thoroughly investigated to ensure the prompt detection of new foci. Glossina morsitans has invaded limited areas on the eastern border from Mozam- bique, and the appearance of human cases in that area is regarded as a possibility. Relapsing Fever. African tick fever, the tick-borne form of relapsing fever caused by Borrelia duttoni, is sporadic. It is trans- mitted by the tick, Ornithodorus moubata, which is widely distributed throughout Southern Africa. Yellow Fever. Yellow fever has not been reported from the Colony. However, evi- dence of previous infection among the in- habitants of scattered villages south of the Zambezi was obtained in the course of sur- veys made in 1946-48 by members of the Yellow Fever Research Institute of Entebbe, Uganda. Mouse protection tests performed on the blood sera of individuals from differ- ent localities revealed the presence of im- munity in 1.0 to 6.0 per cent. Aedes aegypti and other potential vectors are widely dis- tributed. Other Infections. Plague has not been reported within recent years. Sylvatic plague is endemic in Barotseland and northern Bechuanaland, but there has been no evidence of its spread to Southern Rhodesia. Filariasis is encountered occasionally among migratory workers from endemic areas. In the course of routine malaria and trypanosomiasis surveys in the Zambezi Valley in 1948, five cases of infection with Wuchereria bancrofti were found. These are probably the first confirmed cases in the indigenous population.?® Dengue fever is not reported. Various encephalidides are occasionally observed. NUTRITIONAL DISEASES Malnutrition is common in all sections of the population but particularly among the natives living in urban communities. Mar- ginal avitaminosis, due to deficiencies of the B complex and especially riboflavin, are 206 Southern Rhodesia widespread. Pellagra is reported occasion- ally but less frequently in Matabeleland than elsewhere. Hunger edema is encoun- tered, but frank beriberi is rare. Scurvy is prevalent, especially toward the end of the dry season and during periods of drought. Approximately 100 to 250 cases are ad- mitted to the government hospitals each year. The incidence is especially high among the mine and industrial laborers. Vitamin A deficiencies are unusual, but localized out- breaks of night blindness are recorded occa- sionally. Rickets is frequent. The syndrome of malignant malnutrition, or kwashiorkor, is seen sometimes in young children. En- demic goiter is observed in certain localized areas. MisceLLANEOUS CONDITIONS Silicosis may affect the workers in the gold mines and is often associated with pulmonary tuberculosis. Onyalai, a hemorrhagic disease of un- known etiology, is recorded occasionally among the native peoples in this general area. SUMMARY Southern Rhodesia is an agricultural country but derives a large portion of its wealth from rich deposits of gold and other minerals. The responsibility for the health of the people resides in the Public Health Department of Southern Rhodesia, which functions under the Minister of Health. Tt is administered by a Secretary of Health who is Medical Director and Chief Health Officer. The headquarters establishment which is divided into Preventive and Cura- tive Services is located in Salisbury. In 1948 the Department operated 15 hospitals with 614 beds for Europeans and 1,258 for na- tives, and 79 dispensaries in the native rural areas. Hospitals are also maintained by the larger mining companies and by numerous missions. The water supplies are generally adequate. Those of Salisbury and Bulawayo and the four other municipalities are treated before distribution, but frequently the sup- plies of the smaller communities are con- taminated. Water-borne sewerage systems serve small sections of Salisbury and Bula- wayo, but elsewhere methods of waste dis- posal are primitive. Malnutrition is wide- spread in all races and especially among the natives in the township areas. Scurvy and vitamin B deficiencies are prevalent, while other conditions are not infrequent. Malaria, schistosomiasis and venereal diseases are important problems in all parts of the Colony. Typhoid fever, dysentery, helminthiasis and other intestinal infections are widely distributed. Tuberculosis is prev- alent, especially in the native population. Occasional outbreaks of smallpox occur, but control is effected by large-scale vaccina- tion. Trypanosomiasis, tick-typhus, leprosy and the respiratory infections common to temperate regions are endemic. Tick-borne relapsing fever is sporadic. A few cases of filariasis have been reported recently. BIBLIOGRAPHY 1. Alves, W. D.: T. A. B. and brucella agglu- tinins in an uninoculated native popula- tion, South African, M. J. 10:7-8 (Jan. 11) 1936. 2. Alves, W., and Blair, D. M.: Schistosomiasis: A review of work in Southern Rhodesia in 1946, South African M. J. 21:332-357 (May 24) 1947. 3. Blackie, William K.: A helminthological survey of Southern Rhodesia, London School of Hygiene and Tropical Medicine, Memoir Series 5:1-91, 1932. 4, ——: Onyalai: A review, Tr. Roy. Soc. Trop. Med. & Hyg. 31:207-226 (July) 1937. 5. Blair, D. M.: Human trypanosomiasis in Southern Rhodesia, 1911-1938, Tr. Roy. Soc. Trop. Med. & Hyg. 32:729-742 (Apr.) 1939. 6. ——: Infections with Plasmodium ovale Stephens, in Southern Rhodesia, Tr. Roy. Soc. Trop. Med. & Hyg. 32:229-236 (Aug.) 1938. 7. ——: Schistosomiasis in Southern Rhodesia. Public health aspects, South African M. J. 22:462-467 (July 24) 1948. Southern Rhodesia 207 10. 11. 12. 13. 14. 153, Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. Central African Council. Keyston, J. E.: A Report on Regional Organization of Re- search in the Rhodesias and Nyasaland, Salisbury, Central African Council, 1948. Conferéncia intercolonial sobre tripanos- somiases: Lourenco Marques, 26 a 31 de agosto de 1946, Vol. I and II, Lourenco Marques, Imprensa Nacional de Mocam- bique, 1947. Great Britain: Rhodesia-Nyasaland Royal Commission Report, March, 1939, Lon- don, H. M. Stationery Office, 1939. Leprosy in Southern Rhodesia: Leprosy Rev. 11:29-37 (Jan.) 1940. Mozley, Alan: The Control of Bilharzia in Southern Rhodesia, Salisbury, Rhodesian Printing and Publishing Co., Ltd., 1944; Abst. Trop. Dis. Bull. 42:516 (June) 1945. Sandground, J. H.: Studies in the life history of Ternidens deminutus, a nematode para- site of man, with observations on its inci- dence in certain regions of southern Africa, Ann. Trop. Med. 25:147-180 (Aug.) 1931. Southern Rhodesia: Public Health Depart- ment, Report of the Public Health for the Year 1939, Salisbury, Rhodesian Printing and Publishing Co., Ltd., 1941. . ——: Public Health Department, Report of the Public Health for the Year 1940, Salis- bury, Rhodesian Printing and Publishing Co., Ltd., 1942. 18. 19. 20. 2% 22. 23: 24. . ——: Public Health Department, Report of the Public Health for the Year 1945, Salis- bury, for the Government Stationery Office, by the Rhodesian Printing and Pub- lishing Co., Ltd., 1946. : Public Health Department, Report of the Public Health for the Year 1946, Salisbury, for the Government Stationery Office, by the Rhodesian Printing and Pub- lishing Co., Ltd., 1947. ——: Public Health Department, Report of the Public Health for the Year 1947, Salisbury, for the Govt. Stationery Office, by the Rhodesian Printing and Publishing Co., Ltd., 1948. ——: Public Health Department, Report of the Public Health for the Year 1948, Salisbury, for the Govt. Stationery Office, by the Rhodesian Printing and Publishing Co., Ltd., 1949. ——: Report of the National Health Serv- ices Inquiry Commission, 1945, Salisbury, for the Govt. Stationery Office, by the Rhodesian Printing and Publishing Co., Ltd., 1946. Standing, T. G.: A Short History of Rhodesia and her Neighbors, London, Longmans, 1935. Yearbook and Guide of the Rhodesias and Nyasaland: 1938-39 ed., Salisbury, Rho- desian Publications, Ltd., 1939. Year Book and Guide to Southern Africa: 1950 ed., London, Sampson Low, Marston and Co., Ltd.. 1950. 14 Mozambique GEOGRAPHY AND CLIMATE Mozambique, a Portuguese colony on the southeast coast of Africa, is frequently designated as Portuguese East Africa. It is extremely irregular in shape and has an approximate area of 295,000 square miles, surrounded by Tanganyika Territory in the north, by Lake Nyasa, Nyasaland and the Rhodesias in the west, by the Union of South Africa in the southwest, and by the Mozambique Channel and the Indian Ocean in the east. For a period the administration of the Colony was divided, large sections being developed and controlled by chartered companies. Almost 65,000 square miles in the central portion were governed by the Mozambique Company from 1891 to 1942, and 73,000 square miles in the north by the Nyassa Company from 1894 to 1929. With the surrender of its sovereign rights by the Mozambique Company in 1942, the entire territory was united under Portuguese colo- nial administration. The Colony as a whole lies along the edge of the great central plateau of southern Africa. The coastal plain, which exceeds 1,400 miles in length, is low and narrow, broadening out in the valleys of the larger rivers and in the region north of Delagoa Bay. The coast is sandy, with stretches of swampland in the south, but toward the north it is characterized by rocky promon- tories and rugged cliffs. A wide sloping shelf with a general elevation of 800 to 2,000 feet lies between the coastal lowlands and the inland plateaus. Its undulating surface is broken by numerous detached groups of hills and mountains, the most prominent of which are the Namuli highlands, which reach an altitude of 8,000 feet between Quelimane and Mogambique districts. The eastern escarpment of the continental pla- teau is broken in the Zambezi basin, but includes mountain ranges with heights of 6,500 to 8,000 feet along the Rhodesian frontier and again in the northern part of the country. In the Lake Nyasa border the mountains rise precipitously from the east- ern shores of the lake. The grassy plains of the plateau, west of the escarpment, have an average altitude of 3,500 feet. The terri- tory is drained by numerous rivers, the most important being the Limpopo and the Zam- bezi, with their tributaries. The Zambezi flows for 550 miles through the central and widest part of the country and fans out into a broad delta about 80 miles from its mouth. Mozambique has two distinct seasons; a dry season, usually with correspondingly lower temperatures, from April to October, and a rainy season throughout the re- mainder of the year. In general, the lowest temperatures occur in June or July, and the highest from November to January. Cli- matic conditions vary in different parts of the country. In the northern coastal area the climate is dominated by the monsoon system of the Indian Ocean. The yearly temperatures average from 76° to 80° F., with variations of 9° to 11° F., while the humidity approximates 60 to 80 per cent. The annual rainfall ranges from 27 to 51 inches, with the maximum precipitation in the period from December to April. The southern coastal region of Lourenco Mar- ques and Inhambane districts enjoys slightly lower mean temperatures, 72° to 75° F.,, 208 Mozambique 209 with seasonal fluctuations of 13° to 15° F. The daily range also exceeds that of the north. The most extreme variations occur in the summer and may reach 30° to 50° F. The rainfall averages 24 to 47 inches but differs considerably from year to year. The heaviest precipitation is encountered in the Zambezi delta region where the annual rain- fall reaches 60 to 80 inches. In the inland areas the temperature and the rainfall are governed by the elevation and the physical features of the terrain. The mean tempera- tures range from 68° to 79° F., with sea- sonal fluctuations of 36° to 45° F., while the rainfall varies from 20 to 70 inches a year. The rainy season does not coincide completely with that of the coast, since the rains are sometimes delayed until January. The highest temperatures and frequently the widest fluctuations are found in the upper Zambezi River valley. The mean tempera- ture at Tete approaches 80° F., and the rainfall 20 inches. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopPULATION In 1946 the non-native population totaled a little over 60,000, while the native popu- lation was estimated at slightly in excess of 5 million. According to the census of 1945, the non-native contingent included 31,221 Europeans, 6,304 Goans (Portuguese In- dians), 3,396 Indians, 15,784 mulattoes, 1,565 Chinese and 1,845 “civilized” Africans —natives who by reason of education or property are exempt from the “pass” sys- tem. About 85 per cent were Portuguese nationals. The white settlers are primarily Portuguese or British, with small numbers of Germans, Italians and Greeks. Almost 50 per cent reside in the city of Lourenco Marques. The natives are predominantly Bantu. North of the Zambezi River the tribes are chiefly Makwas (Macaus), with Yaos in the northwestern corner. A medley of tribes inhabit the Zambezi valley, the most nu- merous of which are the Sengas. Small groups of Angoni, a people of Zulu origin found primarily in Rhodesia, are established in Tete district. South of the river the in- digenous natives belong to various divisions of Rongas, Tongas and Shopes, while infil- trated among and dominating them are Vatua tribes of Zulu stock. The principal native languages and dialects conform to three groups: Yao, Makwa and Ronga. The speech of the Sengas is widely understood in the Zambezi valley, while Swahili is em- ployed in many areas on the coast. The natives are essentially pagans, although many tribes have been influenced by the Europeans and the Arabs with whom they have come in contact. Some of the coastal tribes and many of the Yaos have adopted Mohammedanism. Large numbers through- out the country have been converted to Christianity by the Catholic and the Protes- tant missions working in the territory. The Colony is predominantly rural; only two per cent of the total population is con- centrated in urban communities. The popu- lation density averages about 14 per square mile, but wide variations occur, and many of the towns, particularly along the coast, are highly congested. In 1946 the popula- tion density in the city of Lourenco Marques exceeded 1,240 per square mile, and in Beira, 2,200. The natives are not segregated in the cities, but the majority congregate in the poorer sections or dwell in kraals on the pe- riphery. The largest cities are Lourenco Marques, the capital, and Beira, the eastern terminus of the transcontinental railway, and until 1942 the headquarters of the terri- tory administered by the Mozambique Com- pany. In 1946 Lourengo Marques had a population of 69,861, including 16,149 white residents and 8,642 non-natives be- longing to other racial groups. Beira had a population of 25,487 with 3,999 Europeans and 3,390 other non-natives. Mogambique had a population of 9,174. Education is provided under government, private and mission auspices and is compul- sory for non-native children up to 13 years 210 Mozambique of age. There is only one secondary school in the territory, which is located at Lourenco Marques. Primary schools for natives are maintained by the missions in different sec- tions of the country. The total facilities are inadequate, and only a small percentage of the natives receives more than the most rudimentary education. Portuguese is the medium of instruction in all schools ; teach- ing in the indigenous languages is prohibited except in religious classes. VITAL STATISTICS Vital statistics and other demographic data are compiled and published by the Statistical Office (Reparticio Técnica de Estatistica) of Mozambique, which main- tains branches in each of the four provinces. The registration of births and deaths has been compulsory since 1929. In 1946 the birth rate for the non-native population, based on the census figures for 1945, was roughly 35.7 per 1,000; the death rate, 11.7 per 1,000. The infant mortality rate was approximately 55.9 per 1,000 live births, and the stillbirth rate, 24.3. The statistics for the native tribes, which constitute 98.9 per cent of the total population, are meager and of little value. Sociar Economy Agriculture is the principal industry in Mozambique. The natives are mostly sub- sistence farmers, working small plots by primitive methods. By way of contrast, ex- tensive plantations are operated by Euro- peans, sometimes by individuals, but more frequently by corporations. However, the agricultural lands are only partially devel- oped, even in the fertile areas of the lower Zambezi Valley and Quelimane district. The major export crops are sugar cane, coconuts, sisal, oil seeds, maize and cotton. Sugar cane is grown on large estates in the lower Zam- bezi, Save, Buzi and Incomati river valleys. Extensive coconut and sisal plantations are found in the central and the northern coastal areas. Maize is grown in many sec- tions of the country by both Europeans and natives. Cotton is primarily a native crop, the most productive areas being Zambezia and Manica e Sofala provinces. Secondary exports include fruits, rubber, coffee and tea. Ranching is carried on in Lourenco Marques, Inhambane and Tete districts, but the prevalence of trypanosomiasis and other animal diseases retards its expansion. Man- grove bark and various hard woods are ex- ported in limited volume. Industrial development in the Colony is slight and is associated primarily with the processing of local agricultural products. Sugar, soaps and oils, tobacco products and cement are major manufactures. Various minerals are mined under government con- cessions. Gold deposits exist in many sec- tions from Delagoa Bay to the Zambezi, but the richest reefs are located northwest of Beira. Coal fields are worked in the neigh- borhood of Tete and north to the Nyasaland border. Copper, tin and iron are found in small amounts. The large-scale agricultural, mining and manufacturing industries are chiefly in the hands of Europeans, while the Indians con- duct most of the small retail trade. The native population is a major reservoir of labor, not only for Mozambique but also for the neighboring territories. Thousands of natives leave annually for work in the mines of the Transvaal and the Rhodesias. Re- cruiting is supervised by the government, which derives a considerable revenue from permits and other assessments on the con- tract laborers. The Mozambique Conven- tion between the governments of the Colony and the Union of South Africa restricts re- cruitment for the gold mines of the Trans- vaal to the southern districts and fixes the maximum at 80,000 a year. A comparable restrictive agreement is in force between Mozambique and Southern Rhodesia. The natives from the northern districts migrate to the mines in the Rhodesias or to the plantations in the Beira, Quelimane and Zambezi areas. This mobility and conse- Mozambique 211 quent detribalization of the natives has serious implications for health and social development. Another important source of revenue for the Colony is derived from transit fees im- posed on traffic from the interior to the ports of Lourenco Marques and Beira. Two government-owned railways link Lourenco Marques with the Transvaal: one by direct connection with the Union system at Ko- mati Poort, the other with a line to Goba and bus service to the Union railway ter- minal at Bremersdorf. Major inland con- nections are made by two railways from Beira. The Beira road, which is operated by a British company, forms a link with the Rhodesian railways in a transcontinen- tal system, while the Trans-Zambezia line joins with the Central African and the Nyasaland railways, after crossing the Zam- bezi at Mutarara by the longest railroad bridge in the world. Several short lines handle the internal traffic between impor- tant agricultural centers and the coastal ports. Motor roads unite the southern dis- tricts with adjacent areas in Natal and the Transvaal, and Tete district with Salisbury and Blantyre. However, most of the roads in the territory are not practical for motor traffic during the rainy season. Steamships ply between Mozambique and the Union of South Africa, Europe, India and the Amer- icas. The Zambezi River is navigable by shallow draught vessels for about 400 miles; the Limpopo and other rivers, for variable distances. Some traffic is carried on across Lake Nyasa. Government-controlled air services are maintained between the larger cities and to Johannesburg, Broken Hill, Salisbury and Lisbon. Foop AND NUTRITION For the white settlers the cultivation of food supplies is secondary in importance to the export crops. Numerous tropical and subtropical fruits are abundant, but green vegetables are scarce throughout the greater part of the year. Large amounts of rice, the staple food of the Arab and the Indian pop- ulations, and meat are imported, since local production is inadequate to meet the re- quirements. Market supplies of meat, milk, butter and eggs are available principally in the southern districts. The native dietary is predominantly vege- tarian. Among most tribes it centers around breads and porridges of maize, millet or cassava. Supplementary foods, as rice, pea- nuts, legumes, sweet potatoes, pumpkins and indigenous greens and fruits are used to a varying degree by the different tribes. Goats, pigs and poultry are raised in most villages, but little meat is consumed except by the more prosperous families. Milk is usually used in a fermented form. The standards of nutrition are low, and the aver- age native diet is deficient in animal pro- teins and vitamins. Moreover, local food shortages are common, and famine condi- tions resulting from droughts, floods or the destruction of crops by locusts and other agents are not infrequent. Housing Lourengo Marques and Beira are modern cities, while the former is a popular resort, as well as a thriving industrial center. The housing of the different races varies, but overcrowding and insanitary conditions are typical of the poor sections in the urban communities. The villages and the dwellings of the natives conform to various types, charac- teristic of the individual tribes, but in gen- eral the huts are larger and of better design and construction among the northern peo- ples, exposed for generations to Arab influ- ence. Round huts of thatch on wooden frames are prevalent among the southern tribes. The settlements are usually open, each dwelling being surrounded by a plot of ground, with separate kraals for the live- stock. In contrast, the round huts of the Makonde in the north are constructed of clay with straw roofs and are huddled close together. The Yaos and some of the Makwas 212 Mozambique build rectangular houses of thatch and plas- ter, which may be commodious with veran- das, doors and glass windows. The Yaos, in particular, live in large settlements. ENVIRONMENT AND SANITATION "WATER SUPPLIES Most sections of Mozambique are sup- plied with water from the numerous rivers and lakes. Over 50 rivers flow eastward to the Indian Ocean, but only the larger streams are perennial. The majority of towns and villages are located on or near the river courses. Shallow wells are a com- mon source of water supply, but in many areas cisterns have also been constructed for the collection of rain water. The supplies in the rural areas and in the native sections of the towns are usually primitive and sub- ject to contamination. The only modern municipal water supply in the Colony is that of Lourengo Marques. The system, which is operated by a private British company, serves 90 per cent of the population; the remainder are dependent upon surface wells and rain water collec- tions. The water is obtained from the Umbe- luzi River, 18 miles distant, and is treated by filtration and chlorination before dis- tribution. There is only one storage reser- voir in the city, and during the dry season the supply is inadequate. Limited piped water supplies are also available in Vila de Joao Belo, Inhambane and Quelimane. In Beira, which has no piped supply, rain water is collected in cisterns by individual householders, and during the dry season drinking water is brought in barges from the Pungwe River. Wells provide a supplemen- tary source of supply, but they are usually brackish, especially during the dry season. Several small irrigation projects have been constructed on the lower Zambezi to furnish water to the large sugar plantations along its banks. The river normally floods twice a year, in December or January, and again in February or March, the former rise being influenced by the local rains and the latter by the rainfall conditions near the headwaters of its many tributaries. Plans have been projected recently for the build- ing of irrigation dams on the Limpopo and the Umbeluzi rivers. Waste DisposaL A municipal sewerage system is in opera- tion in Lourengco Marques, but in other urban communities, sewage disposal is by means of the bucket system, and in some areas by the use of septic tanks or cesspools. In Lourenco Marques sewers serve the older section of the city, which is built on low land at a level with the dock area. The sewage is emptied into Espiritu Santo estu- ary near the Matola River. The ground water level in this part of the city is at or near the surface, and pools of water collect during the rainy season in spite of the con- struction of storm sewers and open ditches to prevent it. The sewerage system does not reach the upper portion of the town which contains the newer houses and hotels, and there individual septic tanks are commonly employed. Pit privies constitute the usual means of sewage disposal in the rural areas. Pollu- tion of the soil is common in the native villages. Fauna AND Frora Arthropods. Mosquitoes. The principal vectors of malaria are Anopheles gambiae and A. funestus, which are widely distrib- uted throughout the Colony. A. gambiae breeds prolifically in the small rainwater pools, at least partially exposed to the sun, which are abundant during and immediately after the rainy season. A. funestus, on the other hand, breeds in the rice fields and the swamps, and along the weedy sides of streams and ditches in which there is a sluggish but persistent flow of water. A. nili, A. pharoensis, A. pretoriensis and A. rhodesiensis are found in various parts of the country. Although potential vectors, they are of minor significance in the trans- mission of malaria. Nineteen or more other Mozambique 213 species of anopheline mosquitoes are re- ported from Mozambique, but all are pests and of no known medical concern. At least 23 species of Aedes mosquitoes have been recorded, among which Aedes aegypti is of major importance. It is par- ticularly abundant in Lourenco Marques and the coastal towns. This species trans- mits dengue fever in the Colony and is a potential vector of yellow fever, although the infection is not known to occur in this area. Numerous species of culicines are also re- ported, including Culex pipiens and C. quin- quefasciatus (= C. fatigans), which are possible vectors of filariasis in the coastal regions. Both Taeniorhynchus (Mansonia) africanus and T'. (M.) uniformis are present. Mosquito-control work is carried on in the vicinity of Lourengo Marques and Beira, but little is attempted in other parts of the country. The program includes the antilarval treatment of designated breeding places, the elimination of sources of stag- nant water, and in Lourengco Marques the spraying of huts and houses with DDT and other insecticides. Fries. Four species of tsetse flies are re- corded, Glossina morsitans, G. brevipalpis, G. pallidipes and G. austeni. Probably two thirds of the country is infested with tsetse flies; the provinces of Manica e Sofala, Zambezia and Niassa are the most seriously affected. The exact distribution of the vari- ous species is not known. G. morsitans is found in extensive areas between the Save River and the Tanganyika border, but its southern limits have not been definitely as- certained. G. brevipalpis and G. pallidipes are widely distributed throughout the north- ern part of the Colony, while the former species also exists in the region between the Save and Zambezi rivers and in the extreme south. G. austeni has a somewhat more lim- ited range but is present in numerous foci near the western border in the Buzi and the Pungwe river regions, in the Maputo River valley in the south and along the northern coast from Quelimane to Porto Amelia. An increased prevalence of tsetse flies with the invasion of new territory has been reported recently from the northwestern part of the country. All four species are vectors of animal trypanosomiasis, which represents a problem of considerable economic impor- tance and restricts the development of ex- tensive areas. G. morsitans is the vector of human trypanosomiasis, which is endemic in the northern and the western districts. A special sleeping sickness service, the Missdo de Combate as Tripanossomiases, carries on a tsetse fly and trypanosomiasis control program. The antitsetse fly measures employed in different localities include bush clearance, controlled game destruction and the use of DDT and Gammexane. Several species of Cordylobia, Lucilia and Sarcophaga are found, the most important being Cordylobia anthropophaga, which is responsible for occasional cases of human myiasis. Gasterophilus intestinalis and Hy- poderma lineata also occur. Auchmeromyia luteola is prevalent in many areas. Its larvae, known as “Congo floor maggots,” attack man, producing severe inflammation. Species of Chrysops, Tabanus, Haematopota and Stomoxys are abundant. They probably are responsible for the spread of enteric dis- eases and may be implicated in the mechani- cal transmission of animal trypanosomiasis. A variety of species of Musca is present. Simulium damnosum and other species of SiMULIIDAE are encountered over wide areas. Midges of the family CERATOPOGONIDAE exist in large numbers. Species of Culicoides are vectors of Acanthocheilonema perstans. Lice. All species of human lice are pres- ent, and infestation of the inhabitants is frequent in many parts of the country. Louse-borne typhus fever has not been re- ported from the Colony, although the vector, Pediculus humanus corporis is indigenous. Freas. Mozambique has been free from plague within recent years, but the potential vectors, Xenopsylla cheopis and X. brasili- ensis, are widespread. The cat and dog fleas, Ctenocephalides felis and C. canis, and the human flea, Pulex irritans, are common. 214 Mozambique The chigoe flea, Tunga penetrans, is abundant in the central and the northern sections of the country. BepBuces. Both Cimex lectularis and C. hemipterus are indigenous. Tricks AnD MrrEs. Ornithodorus moubata and O. erraticus are widely distributed. O. moubata is the vector of tick-borne re- lapsing fever, which is most prevalent in the districts north of the Zambezi River. Numerous other ticks are present, including Haemaphysalis leachi, 8 species of Rhipi- cephalus, and several species of Ambly- omma, Boophilus and Hyalomma. Tick-bite fever occurs sporadically in different parts of the country, and is probably transmitted by one or more of the species mentioned above. The itch mite, Sarcoptes scabiei, is widely distributed. OTtHER ArTHROPODS. A variety of scor- pions has been identified, many of which are more or less venomous. The poisonous spiders of the genus Latrodectus may also exist in some southern localities. Blister beetles of the family MerLoiaEe, and espe- cially Epicanta ruficollis, are reported from several areas. Reptiles. Numerous species of poisonous snakes are found in Mozambique. The dreaded mamba, Dendroaspis angusticeps, the cobras, Naja haje and N. nigricollis, and the Ringhals slang, Sepedon haemachates, are all present. The most important vipers are the puff adder, Bitis arietans, and the gaboon viper, B. gabonica. The night adders, Causus rhombeatus and C. resimus are com- mon. Vipera superciliaris is found in the coastal regions. The boomslang, Dispholidus typus, although a rear-fanged snake, is much feared because of its highly active venom. The sea snake, Pelamydrus platurus, in- habits the waters off the coast and is respon- sible for occasional fatalities among fisher- men. The rock python, Python sebae, is the only potentially dangerous, nonpoisonous snake reported. Rodents. Rattus rattus rattus and R. rat- tus alexandrinus are the usual domestic rats in most areas, while R. norvegicus is found in the port cities. Numerous species of wild rodents, some of which may be potential reservoirs of sylvatic plague, also abound. Although definite foci have not been estab- lished, sections of Mozambique must be regarded as within the endemic plague zone of southern Africa. Mollusks.* The principal intermediate snail hosts of Schistosoma haematobium are Physopsis africana globosa and possibly Bulinus (Pyrgophysa) forskalii. Both spe- cies are widely distributed, particularly in the vicinity of Lourenco Marques and in the Zambezi, the Crocodile and the Limpopo river basins. S. mansoni is encountered in limited areas in the south where Planorbis (Biomphalaria) alexandrina pfeifferi is the chief intermediate host. Plants. Detailed information regarding the poisonous plants of this area is lacking. Several species are employed by the various tribes as fish or arrow poisons or for homi- cidal and other purposes. Among the better- known species are Erythrophleum guineense and Datura fastuosa, preparations of which are used by the Tongas to determine guilt in tribal judgments. Nerium oleander, Adenium multiflorum, Acocanthera venenata and spe- cies of Strophanthus, including S. apocyna- ceae and S. kombe, are utilized frequently as arrow poisons. Abrus precatorius, Cy- perus longus, Melia azedarach, Paullinia pinnata, Strychnos spinosa, Sophora tomen- tosa and Urginea burkei are also present. Several species of Dichapetalum are repre- sented and are suspected of causing occa- sional deaths among the livestock. Indigenous plants which may produce a contact dermatitis include Rhus insignis, R. glaucescens and Cannibis sativa, or In- dian hemp, which is most widely used as a narcotic. Foobp SANITATION The sanitary control of markets, bakeries, restaurants and other establishments manu- facturing or selling foods for human con- * See footnote, p. 10. Mozambique 215 sumption is undertaken by the sanitary police of the various administrative dis- tricts. Municipal abattoirs are operated in the larger cities. The veterinary services of the government are responsible for the regu- lation of the dairy industry and the inspec- tion of meats. Sanitary supervision of milk supplies is maintained in Lourenco Marques and Beira. About 10 per cent of the milk sold in Lourenco Marques is pasteurized, but facilities for pasteurization are not available in other parts of the country. The dairy herds which supply milk to Lourenco Marques and Beira are tuberculin-tested regularly under the supervision of the vet- erinary officers. Large-scale refrigeration facilities are found in Leurengo Marques; smaller plants, in Beira. The sanitary conditions outside of the larger cities are generally primitive. The poverty, the ignorance and the superstitions characteristic of large sections of the popu- lation contribute to the low standards which prevail. HEALTH SERVICES AND MEDICAL FACILITIES HEALTH ORGANIZATIONS The Direcgio dos Servicos de Saude, with headquarters in Lourenco Marques, is re- sponsible for the provision of medical care and the maintenance of public health in the Colony. It functions directly under the Gov- ernor, who is accountable to the Ministerio das Colonias in Lisbon. The Servicos de Saude e Higiene in the Direcc¢io Geral de Administracio Politica e Civil in the Min- isterio advises on matters of health in the colonies. The Colonial department is charged with the conduct of medical services, laboratories and training facilities, the prevention of communicable diseases, the supervision of sanitation and port quarantine, the opera- tion of social assistance, child welfare and other special services for the native popula- tion, and the control of pharmaceuticals. It administers a malaria-control service in Lourenco Marques district, and also the medical section of the Missdo de Combate as Tripanossomiases. This section replaces the Missdo da Doenca do Sono which was organized within the department in 1939. Provincial offices of health (Circulos de Saude) are established in each of the four provinces: at Lourenco Marques in Sul de Save, at Beira in Manica e Sofala, at Queli- mane in Zambezia and at Mocambique in Niassa. The provincial officers administer the health and medical services within their respective areas through subordinate health bureaus (Delegacies de Saude). These bu- reaus, located in the various districts and the larger cities, are in charge of physicians who supervise the regional medical services and function as health officers. The trypanosomiasis-control program of the government is concentrated in the Mis- sio de Combate as Tripanossomiases, a semiautonomous agency which is divided into medical, veterinary, entomologic and laboratory sections. It is subordinate to a Council composed of representatives of the health, veterinary, agriculture and Native Affairs departments. The Instituto de Medicina Tropical in Lisbon consults with the Ministerio das Colonias on health problems in the colonies, operates a postgraduate school in tropical medicine for the colonial physicians and conducts investigations on the different en- demic or epidemic diseases. It plans to establish a permanent research center in Lourenco Marques in the near future. Numerous Catholic and Protestant mis- sions carry on medical and health work among the various tribes and, through their educational activities, help to promote bet- ter standards of living. Some of the larger plantations and industrial concerns provide hospital and dispensary services for the care of their workers. The Commissdo Central de Assisténcia Publica de Mocambique furnishes medical and other assistance to needy Portuguese, while the Sociedade Humanitaria Portu- guesa Cruz do Oriente maintains first-aid 216 Mozambique stations for the care of all races. The local branch of the Portuguese Red Cross also carries on welfare services. MEDICAL INSTITUTIONS Hospitals and Dispensaries. In 1946 the Direccdo dos Servicos de Saude operated a central hospital in Lourenco Marques and 8 provincial and district hospitals, with beds for Europeans and non-Europeans. It also maintained 50 regional hospitals and infirmaries, as well as 109 sanitary posts and numerous mobile medical units in the native areas. The Miguel Bombarda Hos- pital in Lourenco Marques is the leading hospital in the Colony. It is a modern, well- equipped institution with from 600 to 800 medical and surgical beds, and an affiliated maternity hospital. The hospital at Beira has from 150 to 250 beds, and that at Queli- mane, 200 beds. The district hospitals range in size from 20 to 50 beds. The regional hospitals and infirmaries are collections of native-style, brick huts built around a cen- tral building which houses the operating room, the laboratory and other technical units. In addition to the central maternity hospital in Lourenco Marques, maternity facilities are provided at Manhica, Magude and Chinde, and in 17 rural units and 34 in- firmaries. Child health dispensaries are lo- cated at Lourenco Marques, Quelimane and Mocambique. The health services maintain a small mental hospital for natives at Marracuene, near Lourengo Marques, and 8 leprosaria in different parts of the country. The Missdo de Combate as Tripanossomiases operates a hospital at Tete and mobile field services. Several mission organizations maintain well-equipped hospitals and dispensaries, while two provide institutions for the care of lepers. In 1946 approximately 60 field hospitals or ambulance units were conducted under mission auspices, 47 by Portuguese and 13 by other groups. A few small private nursing homes are found in Lourenco Mar- ques and Beira. Laboratories. The central laboratories of the Direccdo dos Servicos de Saude are at- tached to the hospital in Lourengo Marques. They are equipped for the performance of routine diagnostic tests and analyses, for research and for the preparation of vaccines and therapeutic sera. There are two divi- sions: bacteriology and histopathology, and chemistry and toxicology. A branch labora- tory which is located in Beira serves the northern provinces. Smaller diagnostic labo- ratories are connected with the provincial, the district and the larger regional hospitals. The antimalaria unit in Lourengo Marques and the sleeping sickness hospital and field services are also provided with laboratory facilities. : The government’s veterinary department maintains a laboratory in the capital, with sections in bacteriology and pathology. Its functions include the preparation of small- pox vaccine and of vaccines for the control of certain animal diseases. A central phar- maceutical laboratory is also operated in Lourenco Marques by the health services. Schools. The Escola Técnica dos Servigos de Saude in Lourenco Marques is the center for the training of medical assistants, nurses and midwives in the Colony. Additional facilities are available in the larger hospitals in other parts of the country. PERSONNEL Physicians. In 1949 the medical officers attached to the Direccdo dos Servicos de Saude totaled 126, 16 of whom were spe- cialists in government institutions. Physi- cians are also connected with mission hos- pitals and various industrial concerns or are engaged in private practice in the cities, particularly in Lourenco Marques. Dentists. Between 10 and 15 dentists are settled in the Colony, primarily in Lourenco Marques and Beira. Five dentists were em- ployed by the Direccdo dos Servigos de Saude in 1949. Others. Roughly, 195 male nurses, 40 nursing sisters and 21 nurse-midwives, and Mozambique 217 from 100 to 200 nursing aides were attached to the government health services in 1947. Nurses and nursing sisters are also affili- ated with the various mission organizations. Small numbers are connected with private concerns or practice independently. The 1949 roster of health service person- nel also included 18 pharmacists, 4 entomol- ogists and 4 veterinarians, and medical assistants in various categories. DISEASES Morbidity and mortality statistics are compiled from the records of the govern- ment hospitals and small health units throughout the country. The reports of dis- ease incidence in the rural and the native areas are necessarily incomplete. Moreover, large sections of the native and the Asiatic populations adhere to their traditional forms of medical practice and are never seen by the government physicians. Changes in territorial status must be considered in comparing the reports of different decades. The statistics of the present district of Beira are not included in the government reports until 1943, when the Mozambique Company was liquidated. DiseasESs SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fever is endemic. The recorded incidence is disproportionately low in view of the insanitary conditions prevailing throughout the country. From 30 to 100 cases are reported annually, usually from 50 to 75 per cent from the city of Lourenco Marques. Cases occur sporadically and in small localized outbreaks. A few cases of paratyphoid fever are recorded each year, but the actual extent of infection is not known. Dysenteries. Both amebic and bacillary dysentery are prevalent. Of the 2,696 cases of dysentery reported in 1943, 2,229 were listed as amebic and 12 as bacillary, while 455 were unclassified. Amebic infections were reported from all parts of the country with over 30 per cent from the city and the district of Lourenco Marques. The recorded cases of bacillary dysentery do not reflect the extent of infection. The disease is com- mon in Lourenco Marques during the summer months, from October to May. Contaminated foods, particularly raw fruits and vegetables, and unsafe water supplies are the major sources of infection. Between 150 and 200 cases of diarrhea and enteritis are reported each year. These probably represent only the most severe cases, and a large percentage may actually be undiagnosed cases of bacillary dysentery. Cholera. Cholera has not been reported from Mozambique since the middle of the last century. Helminthiases. ANcyLosToM1asis. Hook- worm infection represents a serious health problem, particularly in the lowland areas. Both Necator americanus and Ancylostoma duodenale are widely distributed. In a total of 1,323 cases reported in 1943, about one half were attributed to Niassa Province, and one quarter to Sul do Save. Scuistosomiasts. Infections with Schisto- soma haematobium and S. mansoni are en- demic, but the former species is more extensive. Between 8,000 and 12,000 cases are reported annually, from all sections of the country, the greatest number from Sul do Save and Niassa provinces, and the smallest from Manica e Sofala. The infec- tion rates vary, but average from 55 to 95 per cent in many localities. S. mansoni occurs sporadically; from 150 to 350 cases are reported each year, primarily in Lou- renco Marques and Quelimane districts. Both types of schistosomiasis are present in the valleys of the Limpopo River and its tributaries and in the lower Zambezi area. The low level of sanitation and the nomadism of the indigenous population facilitate their spread. OtaeErR HELMINTH INFECTIONS. Ascaria- sis, trichuriasis and enterobiasis are wide- 218 Mozambique spread. Infections with the beef tapeworm, Taenia saginata, are frequent in the cattle- raising areas, while 7". solium is encountered primarily in the south. Echinococcus infec- tion is observed sometimes. Other Infections. Brucellosis is known to be present, but no information is avail- able regarding its incidence. A few foci of anthrax have been established in the south- ern provinces, and human cases are reported sporadically. In the tribal areas they may result from the consumption of meat from infected animals. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is prevalent throughout the Colony. The actual inci- dence is uncertain, but at least 900 to 1,400 cases are reported annually. In 1944-46 an average of 215 cases a year was treated in the government hospitals, with a fatality rate of 50 to 80 per cent. Pulmonary infec- tions predominate, but other forms also occur. The low economic and nutritional status of the people and the repatriation of native workers who have acquired the infection in the Transvaal and the Rhodesias contribute to the spread of the disease. Facilities for the treatment of tuberculosis are inadequate. The patients admitted to the general hospitals are usually in the ad- vanced stages of the disease, and little pro- vision is made for the detection and the care of early cases. The erection of sana- toria in the Limpopo Mountains and on the high Tete plateau has been proposed. Dairy herds are tuberculin-tested in Lourengo Marques district, but statistics are not available to indicate the amount of tuberculous infection among the cattle. Smallpox. Vaccination against smallpox is compulsory, but enforcement is incom- plete, particularly in the native rural areas. Localized outbreaks are reported periodi- cally, with an average incidence of from 100 to 500 cases a year. The majority of infec- tions are mild, but sporadic cases of malig- nant smallpox appear almost annually. Only one case of variola major and 71 of variola minor were reported in 1943. In contrast, 638 cases were recorded in 1939, of which 97 were listed as variola major and 317 as variola minor, with the remainder undif- ferentiated. Meningitis. Meningococcus meningitis is endemic in all portions of the Colony. Within recent years localized epidemics have been experienced in Mozambique, as well as in the neighboring countries. Sta- tistics for 1943 list 166 cases and 69 deaths in the Colony and 27 cases and 4 deaths in the city of Lourengo Marques. The peak of incidence usually falls in August and September. Other Infections. Pneumonia, influenza and the common upper respiratory infec- tions are prominent among the causes of morbidity in all sections of the population. Measles and whooping cough are frequently epidemic. Diphtheria and poliomyelitis are sporadic, but scarlet fever is relatively rare. Diseases SPREAD OR CONTRACTED CuierLy TuroucH CONTACT Venereal Diseases. Venereal diseases are widespread, particularly among the native peoples. Almost 30,000 cases are reported annually, which probably represent a low estimate of the extent of infection. Syphilis predominates in most areas, accounting for approximately two thirds of the known cases. The incidence of congenital syphilis is unusually high. Little or no attempt is made by the health authorities to control either venereal diseases or prostitution. Leprosy. Leprosy is endemic among all the tribes and particularly those of Niassa Province. The actual prevalence is not known, but it probably approximates 5 to 10 times the number of known cases. In 1946, 4,051 lepers were segregated in the 8 leprosaria operated by the govern- ment in different parts of the Colony. The largest, at Alto Mol6cué in Zambezia Prov- ince, had a registration of 1,307. In addition, a considerable volume of work is carried on by Catholic and Protestant mission organi- Mozambique 219 zations. A leprosy survey was initiated in Sul do Save Province in 1941, but the an- tagonism of the people to segregation and fear of detection makes the determination of an accurate index difficult. Yaws. Yaws is prevalent, and almost 40,000 cases are recorded annually. The disease is reported from all of the districts. However, at least one half of the total cases are referred from the northern coastal areas of Mogcambique and Porto Amélia, while the lowest incidence is observed in the inland district of Tete. Other Infections. Diseases of the skin, such as tropical ulcers and various mycotic infections, are common. Scabies is more or less general among the native inhabitants. Cases of human myiasis are encountered occasionally, usually as the result of infes- tation with the larvae of Cordylobia anthro- pophaga. Tetanus is sporadic. Canine rabies is enzootic, and human infections sometimes occur. DiseAsES SPREAD BY ARTHROPODS Malaria. Malaria is the foremost disease in all parts of the country. Over 35,000 cases are reported annually, which represent a fraction of the total incidence. In spite of the magnitude of the problem, few compre- hensive studies have been made, and little precise information is available regarding the geographic and seasonal distribution of the disease. In general, the infection is hyperendemic in the lowlands of the coastal region and the valleys of the major rivers, and epidemic during and after the rainy sea- son throughout most of the remainder of the Colony. The malarial infection rate is low in the city of Lourenco Marques but relatively high in the contiguous resort areas along the shores of Delagoa Bay. A survey in the vicinity of Lourenco Marques reported in 1938%¢ showed infection rates of 60.8 per cent in children between two and five years of age, and 28.7 per cent in adults. Plasmodium falciparum infections predomi- nate at all ages, but the incidence of P. malariae and P. vivax varies in different localities and from year to year. In 1943 malarial parasites were found in 1,739 blood films in the laboratory at Lourenco Mar- ques. Approximately 88 per cent were identified as P. falciparum, 8 per cent as P. vivax, 4 per cent as P. malariae and 0.1 per cent as P. ovale. Malaria-control measures are undertaken by the Direccdo dos Servigos de Saude, in Lourengo Marques and Beira. Its anti- malaria unit, in Lourengo Marques, with branches at Xipamanine and in the port health office, carries on an active program, including malarial surveys, anopheline con- trol and the free distribution of antimalarial drugs. Blackwater fever is reported sporadically. Trypanosomiasis. Human trypanoso- miasis, caused by Trypanosoma rhodesiense, is endemic in scattered foci in Manica e Sofala and Niassa provinces, particularly in Tete, Nampula and Porto Amélia districts. The vector, Glossina morsitans, is widely distributed throughout the northern part of the country, but the extent of human infec- tion is restricted by the relative sparseness & Known foci of human trypanosomiasis 3 Distribution of " tse-tse flies Trypanosomiasis in Mozambique 220 Mozambique of the population. Within recent years the incidence has increased from less than 100 cases a year in the decade 1932 to 1941 to 200 to 305 in 1942-47. Since 1941, localized epidemics have been reported in the Macim- boa da Praia and the Porto Amélia areas in the northern coastal region, in the Zumba area on the Rhodesian border and along the shores of Lake Nyasa. The trypanosomiasis-control program is concentrated in the government’s Missdo de Combate as Tripanossomiases. Its medical division, which functions under the Direcg¢io dos Servicos de Saude, operates mobile treat- ment and survey teams in the endemic areas and maintains special hospital facilities at Tete. Relapsing Fever. African tick fever, or tick-borne relapsing fever caused by Bor- relia duttoni, is prevalent, particularly in the districts north of the Zambezi River. The infection is frequently contracted also in the open country around Lourengo Mar- ques. From 500 to 700 cases are reported each year. The fatality rates are usually low. The disease is transmitted by Ornitho- dorus moubata, which is found in most portions of the Colony. Louse-borne re- lapsing fever has not been recorded, al- though the potential vectors are present. Rickettsial Infections. South African tick-bite fever, or tick-borne typhus fever is endemic in the Colony. Information regard- ing the incidence and the distribution of the infection is meager, but cases are reported sporadically from Lourengo Marques and Beira. The potential vectors, Amblyomma hebraeum, Boophilus decoloratus, Rhipi- cephalus appendiculatus, R. sanguineus and Haemaphysalis leachi are all present. Louse-borne and flea-borne typhus fevers have not been reported. The latter infection, in particular, is endemic in adjacent areas, and the possibility of its existence here cannot be overlooked. Filariasis. Filariasis, caused by Wuche- reria bancrofti, is endemic in the coastal regions. The actual incidence is not known, but from 85 to 100 cases are usually re- ported annually. Elephantiasis and hydro- cele are frequently encountered. Culex pipiens, C. quinquefasciatus (=C. fati- gans), Anopheles gambiae and other mos- quitoes capable of transmitting the micro- filariae are present. Onchocerca volvulus infections are not specifically reported, although the potential vector, Simulium damnosum, is found. Other Infections. Human plague has not been reported within recent years. How- ever, foci of sylvatic plague occur in the Transvaal and in Northern Rhodesia, and its spread to the wild rodents in the border districts is a possibility. Yellow fever is not known to exist, but the usual urban vector, Aedes aegypti, is prevalent in the coastal regions, and the introduction of the infection is a constant threat to the country. Dengue fever is en- demic, but no major outbreaks have been recorded since 1924. NuTrITIONAL DISEASES Malnutrition and avitaminosis are com- mon. Little is known as to the actual inci- dence of nutritional disease. A few cases of scurvy, beriberi, pellagra and rickets are treated each year in the government hos- pitals. SUMMARY Mozambique is a Portuguese colony which has been developed to a large extent by agricultural and mining concessions to Europeans and by the growth of an impor- tant transit trade through the ports of Lourenco Marques and Beira. The econ- omy of the indigenous peoples is primarily agricultural. The responsibility for the pub- lic health and the medical welfare of all races resides in the Direcgdo dos Servigos de Saude of the Colonial government. Pro- vincial and district offices administer the health and medical services in their respec- tive areas. Medical facilities for Europeans and non-Europeans are provided in a cen- Mozambique 221 tral hospital at Lourenco Marques and in 8 provincial or district hospitals. In 1946 the Direc¢io also operated 50 regional hos- pitals and infirmaries, as well as 109 sani- tary posts and numerous mobile units in the native areas. Various Protestant and Catholic mission organizations maintain hospitals, field hospitals and ambulance units in different sections throughout the country. Surface streams and lakes, shallow wells and rain-water cisterns constitute the usual sources of water supply. Modern water supply and sewerage systems are found only in Lourenco Marques. Else- where, sanitary conditions are primitive. Insect pests and vectors of disease are abundant. Malaria, dysentery, hookworm and other intestinal helminth infections, yaws, vene- real diseases, tuberculosis and pneumonia are prevalent. Localized outbreaks of small- pox occur sporadically. Epidemics of men- ingococcus meningitis, measles and whoop- ing cough are common, but diphtheria and scarlet fever are relatively rare. Leprosy, schistosomiasis, trypanosomiasis, tick-borne relapsing fever, tick-borne typhus fever and filariasis are endemic. Plague, louse-borne and flea-borne typhus fever and yellow fever are not reported, although the vectors are present. BIBLIOGRAPHY 1. Conferéncia intercolonial sobre tripanosso- miases: Lourenco Marques, 26 a 31 de agosto de 1946, Vol. I, Lourengco Marques, Imprensa Nacional de Mogambique, 1947. 2. ——: Lourenco Marques, 26 a 31 de agosto de 1946, Vol. II, Lourenco Marques, Im- prensa Nacional de Mocambique, 1947. 3. De Meillon, Botha, and Pereira, Mario de Carvalho: Notes on some anopheles (Dipt. culicidae) from Portuguese East Africa, documentario trimestral, No. 23, 1940, Lourenco Marques, Imprensa Na- cional, 1940. 4. Ferreira, F. S. da Cruz: As tripanossomiases nos territorios africanos portugueses. Africa ocidental (Angola e Guiné). Africa oriental (Mocambique), Abst. Trop. Dis. Bull. 46:530-532 (June) 1948. 5. Hornby, H. E.: Report on the tsetse fly prob- lems of Maputo (Mozambique), Abst. Trop. Dis. Bull. 45:1068-1069 (Dec.) 1948. 6. Moreira, Edwardo: Portuguese East Africa, New York, World Dominion Press, 1936. 7. Mogambique, Colénia de: Boletim oficial da colonia de Mogambique (1 Série), numero 51, 22 dezembro, 1949, suplemento, Lou- renco Marques, Imprensa Nacional de Mocambique, 1949. 8. ——: Direccdo dos Servigos de Saude, rela- torio do director dos Servigos de Saude de Mogambique, Dr. Aires Pinto Ribeiro, 1943, Vol. I and II, Lourenco Marques, 1946. 9. ——: Direc¢do dos Servicos de Saude, rela- torios dos Servigos de Saude, ano de 1939, (12. Lourenco Marques, Imprensa Nacional de Mogambique, 1942. 10. ——: Missdo de combate as tripanossomia- ses, relatorio anual de 1947, Lourengo Marques, Imprensa Nacional de Mogam- bique, 1948. : Reparticio técnica de estatistica, Anu- ario Estatistico, 1940, Lourenco Marques, Imprensa Nacional de Mocambique, 1941. : Repartigdo técnica de estatistica, Anu- ario Estatistico, 1941, Lourenco Marques, Imprensa Nacional de Mogcambique, 1942, : Repartigio técnica de estatistica, Anu- ario Estatistico, 1942, Lourenco Marques, Imprensa Nacional de Mogambique, 1943. 14. ——: Reparticdo técnica de estatistica, Anu- ario Estatistico, 1944, Lourenco Marques, Imprensa Nacional de Mogambique, 1945. : Repartigio técnica de estatistica, Anu- ario Estatistico, 1945, Lourenco Marques, Imprensa Nacional de Mogambique, 1946. 16. ——: Reparticido técnica de estatistica, Anu- ario Estatistico, 1946, Lourenco Marques, Imprensa Nacional de Mogambique, 1948. 17. ——: Reparticio técnica de estatistica, Boletim trimestral de estatistica, 1946, Lourengo Marques, Imprensa Nacional de Mogambique, 1946. 18. ——: Reparticdo técnica de estatistica, Es- tatistica dos Servigcos de Saude, ano de 1938, Lourenco Marques, Imprensa Na- cional de Mogambique, 1941. : Reparticio técnica de estatistica, Es- tatistica dos Servigos de Saude, ano de 1939, Lourenco Marques, Imprensa Na- cional de Mogambique, 1942. 11. 13, 15. 19. 222 Mozambique 20. Pereira, Mario de C.: Culicideos da pro- vincia do Sul do Savé (Africa oriental portuguesa), An. Inst. Med. Trop. 3:341- 365 (Dec.) 1946. 21. ——: Culicini (Diptera, Nematocera) da colonia de Mogambique, An. Inst. Med. Trop. 3:365-373 (Dec.) 1946. 22. Portugal. Instituto Nacional de estatistica: Anuario estatistico do Império coldnial 1945, Lisboa, Sociedade tipografica, Lda., 1946. 23. —. : Anuario estatistico do Império colonial 1946, Lisboa, Tipografica portu- guesa, Lda., 1947. 24. Prates, M.: A bilharziose na Africa oriental portuguesa e a sua importancia na etiologia dos carcinomas primitivos do figado nos indigenas., An. Inst. Med. Trop. 5:149- 175 (Dec.) 1948. 25. Salavar Leite, A., Bastos da Luz, J. V., and de Meira, M. T. V.: Pe musgoso africano, An. Inst. Med. Trop. 5:7-31 (Dec.) 1948. 26. Soeiro, Alberto, and Rebelo, Antonio: Notes on the epidemiology and parasitology of malaria (according to an inquiry now pro- ceeding in Lourenco Marques), South African M. J. 12:841-847 (Nov. 26) 1938. 27. Yearbook and Guide to Southern Africa: 1950 Ed., London, Sampson Low, Marston & Co., Lid., 1950. SECTION FOUR The Islands of the Indian Ocean 15. 16. 17. 18. ZANZIBAR PROTECTORATE . MapAGASCAR AND THE COMORES ARCHIPELAGO MAURITIUS REUNION . 2228 . 234 «250 + 239 RCH. Zs ee Die go-Suarez 2Tamatave NU IS °Tananarive \ Mauritius) i Q : = La Réunion = < ase? Tuléa ~ < < W © Q 224 The Islands of the Indian Ocean 15 Zanzibar Protectorate GEOGRAPHY AND CLIMATE Zanzibar is a sultanate and British protec- torate, comprising the two islands of Zanzi- bar and Pemba and the small islands in the adjacent territorial waters. The majority of the inhabitants are subjects of the Sultan who, as President of the Executive Council, wields considerable power. However, the British Resident presides over the Legis- lative Council and is the virtual head of the Protectorate. Zanzibar, the largest coralline island on the coast of Africa, is separated from the mainland of Tanganyika Territory by a channel 22 miles in width at its narrowest point. It has an approximate area of 640 square miles. The island of Tumbatu rounds out the northwest corner, being cut off from the larger island by a channel one mile wide. The island of Pemba lies from 25 to 30 miles to the northeast and almost due east of the mainland port of Tanga. It is smaller than Zanzibar, with an area of about 380 square miles. Owing to their insular position and the fact that none of the prevailing winds blows from over the African continent, the islands enjoy an unusually equable temperature. The mean daily range is about 7° to 8° F. on Zanzibar and 10° to 11° F. on Pemba. The mean maximum temperatures average between 84° and 85° F. on Zanzibar and between 86° and 87° F. on Pemba; the mean minimum temperatures, between 76° and 77° F. on both islands. The hottest weather is experienced between November and the end of April. The rainfall approximates 56 inches an- 225 nually on Zanzibar but is consistently higher on Pemba, where the precipitation averages 75 inches. This difference is due to the fact that Pemba has a higher altitude and is in a position to intercept the moisture-laden winds of the southwest monsoon. The hu- midity is high, and the climate is ener- vating. Rain falls during every month of the year, but the rainy seasons are well defined. The heaviest rains occur in April and May, and the lighter, more variable rains in November and December. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLATION According to the census of 1948, the pop- ulation of Zanzibar Protectorate was esti- mated at 265,872, including about 300 Europeans, 15,800 Indians, 43,500 Arabs and 3,400 of other groups. Approximately three fifths of the inhabitants live on the island of Zanzibar; most of the remainder on Pemba. With the exception of various mainland immigrants, the natives may be divided into two groups: the Swahili, of mixed Arab and Negro blood, and the abo- rigines. The latter include the Wahadimu, who occupy the east coast of Zanzibar and such of the southern portion as is habitable; the Wapemba, the original incumbents of Pemba Island; and the Watumbatu, an ethnologically distinct tribe living on Tum- batu. A cosmopolitan society, the peoples of the islands live amicably without the frictions sometimes found in other hetero- geneous populations. Swahili is the pre- dominating language. The majority of the 226 Zanzibar Protectorate inhabitants adhere to the Islamic faith, al- though both Hinduism and Mohammedan- ism are represented among the Indian com- munities, and the Christian missions have made some converts among the natives. Except for the port of Zanzibar, situated on a small bay on the western portion of that island, there are no large towns. The center of government and trade for the Protectorate, the township of Zanzibar has a population of about 45,000, which consti- tutes roughly one sixth of the total for the islands. Zanzibar now reflects but a shadow of her former glory as the center of a great Moslem empire in East Africa. A large percentage of the rural population is illit- erate, except for the religious instruction given in the village Koranic schools. How- ever, increased facilities for education are planned, with the extension of a practical program into the rural areas. Schools are conducted under government, mission and private auspices. Government primary schools provide instruction for the Arabs and the Africans, and government-aided schools, located largely in the towns, for the Indians. There are three secondary schools, all interracial. VITAL STATISTICS The registration of births and deaths is compulsory for all races, but the statistics are incomplete for the rural areas. In 1948 the reported birth rate was 26.5 per 1,000 population, and the death rate 17.8. Re- turns for the individual islands for the period 1935-44 indicated an average annual birth rate on Zanzibar of 16.0 per 1,000 population, and on Pemba, of 15.6; death rates were 14.7 and 10.3, respectively. The infant mortality rate for the Protectorate from 1945 through 1948 ranged from 34 to 60 per 1,000 live births. The stillbirth rate for the same period varied from 4 to 9 per 1,000 births. A reduction in infant mortality within recent years is apparent, since in 1938 the mortality rate is said to have exceeded 200 per 1,000 live births. Social Economy A large percentage of the population is dependent upon the cultivation and the export of cloves and coconuts. The clove and the coconut plantations are ostensibly owned by the Arabs, ownership being in the trees rather than in the soil. Since the aboli- tion of slavery, many of the larger holdings have been broken up, and the improved cir- cumstances of the Swahili are reflected in their increasing tendency to acquire trees, both on Zanzibar and on Pemba. The native peoples engage in agricultural and pastoral pursuits and constitute the main source of labor for the towns and the plantations. The Indians, mostly traders, tend to segregate in communities within the towns and the villages and have exercised little political influence until recently. Steamer services connect the port of Zan- zibar with Europe, India and Africa. Air lines also link the island with Mombasa and Dar es Salaam. Foop AND NUTRITION There is considerable variation in the diets of the different races, but health sur- veys have shown that malnutrition and vitamin deficiencies are common, particu- larly among the poorer inhabitants of the towns. Moreover, school examinations have revealed gross undernutrition among the rural natives; slightly less among the rural Arabs. In 1948 the examinations in the schools on Pemba indicated that only 12 per cent of the children at Weti were prop- erly nourished, only 38 per cent at Chake Chake and 37 per cent at Mkoani. Com- parable results on Zanzibar showed 49 per cent of the boys undernourished and 58 per cent of the girls. Rice, cassava and coconuts form the basis of most native and working-class Indian and Arab dietaries. Important supplemen- tary foods are sweet potatoes, plantain, legumes and sometimes maize or millet. Many varieties of fruits are grown, but few are indigenous. The major deficiencies in the average island dietary are proteins, iron Zanzibar Protectorate 227 and vitamins of the B complex. Meat is rarely consumed, except on ceremonial occa- sions; fish and shellfish provide the most abundant source of proteins. Although chickens are raised in almost every village, they are rarely eaten. Eggs are consumed by the Arabs but seldom by the natives. Housine Overcrowding and insanitary conditions are common in the towns, particularly in Zanzibar, which houses approximately one third of the inhabitants of the island, as well as a large migrant population. Both islands are densely populated, with an aver- age of 250 persons per square mile. In Zan- zibar the Arabs and the Indians live in “Stone Town”; the Swahili in congested hutted quarters. In the towns and the rural villages the usual native dwellings are rec- tangular huts of wattle and daub with thatched roofs, which vary in size, depend- ing upon the affluence of the owner. A program for the improvement of hous- ing conditions in Zanzibar town and in three urban localities on Pemba has recently been undertaken by the Protectorate government. The construction of model housing in the native section of Zanzibar town was started in 1946. ENVIRONMENT AND SANITATION WATER SUPPLIES Adequate supplies of water are obtained from springs, cave wells and streams scat- tered throughout the islands. Zanzibar town has an excellent supply from a spring about one half mile inland which, according to some geologists, originates on the African continent about 30 miles distant. However, in the native quarter the water is distributed to the houses by means of water carriers— a method which is insanitary and a menace to the health of that community. The nu- merous cave wells which are found on both islands provide water for the native villages. The settlements of Weti and Chake Chake on Pemba derive their water supplies from springs in the neighborhood ; both are chlo- rinated. The water supplies of the larger towns are tested routinely for purity by the health authorities, but most rural supplies are apt to be contaminated. WasTE DisposaL In the towns, sewage disposal is by means of pit latrines, cesspits or septic tanks. In the congested sections of Zanzibar town the cesspits and the septic tanks are built inside of the houses. The septic effluents of a part of the town are discharged through sewers into the sea or into an adjacent creek. At Chake Chake (Pemba) some of the latrines are connected with a drainage system. In the townships the construction of pits is controlled by health regulations, but condi- tions in the rural areas are generally insani- tary. A program to provide pit latrines for each hut or family group has been initiated recently by the Protectorate government. Apathy and even hostility to this project have been encountered, since the average native prefers to defecate on the ground. Fauna AnD FLora Arthropods. Mosquitoks. Because of the damp climate and the prevalence of swampy areas, mosquitoes are abundant on the islands, especially on Pemba. They are most numerous from April through June. Eight or more species of anopheles occur on Zan- zibar and probably on Pemba as well, but only A. gambiae and A. funestus are of importance as vectors of malaria. Aedes aegypti is prevalent and represents a pos- sible yellow fever threat to the islands. Aedes pembaensis and A. argemteus have also been reported from Pemba. Culex quin- quefasciatus (= C. fatigans) is the most commonly encountered species, but other culicine mosquitoes, including species of Taeniorhynchus, are also present. Extensive Anopheles and Aedes control work is carried on each year in Zanzibar town and in a protective belt outside of the township. Regular inspections are made, and the breeding sites are treated with oil, 228 Zanzibar Protectorate DDT or other larvicides. Residual spraying with DDT is undertaken in a limited number of buildings. Control projects have also been instituted at Weti and at Chake Chake. In 1948 the Aedes index (per cent) was about 0.4 in Zanzibar and in the sur- rounding protective zone. Fries. Flies are numerous, especially after the rains. One species of T'abanus, pos- sibly T. africanus, is especially vexatious; it frequently bites in the popliteal space, producing intense inflammation and some- times transitory stiffness of the knee joint. Chrysops longicornis and Stomoxys calci- trans are common. Glossina austeni is the only species of tsetse fly recorded, and human trypanosomiasis is unknown on the islands. Species of Phlebotomus have been collected in the mangrove swamp areas of Zanzibar and Pemba. Lice. Infestation with lice is frequent. All three species of human lice, Pediculus humanus capitis, P. humanus corporis and Phthirus pubis, are present. Freas. Xenopsylla cheopis is the species most often associated with the rats of Zan- zibar, but X. brasiliensis is also encoun- tered. The cat and dog fleas, Ctenocepha- lides felis and C. canis, are abundant. The sand flea, Tunga penetrans, is plenti- ful on both islands. BepBucs. The bedbug, Cimex lectularis, is widespread throughout the Protectorate. Ticks. The dog ticks, Rhiipicephalus san- guineus and Haemaphysalis leachi, are widely distributed. The latter is the prob- able vector of tick-borne typhus fever, which is reported occasionally. The tampan tick, Ornithodorus moubata, may be pres- ent, but the evidence is conflicting. Several species of ticks infest the cattle of both Zanzibar and Pemba. OTHER ArTHROPODS. Ants and termites are common. The red tree ant bites human beings when they disturb the clove trees which it inhabits. The bite is momentarily painful but not poisonous. Centipedes and scorpions are numerous and may invade the most modern houses. The natives of both islands have an intense fear of centi- pedes, although there is little reason to be- lieve that they are dangerous. The bites of the scorpions may be extremely painful, but are not serious for adults. Reptiles. The spitting cobra, Naja nigri- collis, is reported, but is relatively rare. The cobras, Elapechis niger and E. boulengeri, are found on Zanzibar; also the burrowing viper, Atractaspis irregularis. The python, Python sebae, is present on both islands. Rodents. The black rat, Rattus rattus rattus, is the most frequent species on Pemba, and probably on Zanzibar. The sub- species, R. rattus frugivorus and R. rattus rufescens, have also been identified on Pemba. Rattus norvegicus is found in the warehouses and the clove sheds but rarely in private houses. Mollusks.* The freshwater snail, Phy- sopsis africana globosa, occurs in many lo- calities. It is an intermediate host of Schis- tosoma haematobium which is endemic. Foop SANITATION Markets, eating houses, bakeries and other food establishments in the town of Zanzibar are licensed and are inspected regularly by the local health authorities. Food vendors are also licensed and super- vised. However, the standards of food sani- tation are generally low, particularly in the smaller communities. The milk supply for Zanzibar is obtained from government-con- trolled dairies and small rural producers. It is tested bacteriologically and chemically at frequent intervals. Meats and meat ani- mals are inspected by the veterinary serv- ices in Zanzibar and by the Health Depart- ment agents on Pemba. HEALTH SERVICES AND MEDICAL FACILITIES HearLtH ORGANIZATIONS The protection of the health of the in- habitants of the Protectorate is the function * See footnote, p. 10. Zanzibar Protectorate 229 of its Health Department, which is adminis- tered by a Senior Medical Officer, with headquarters in Zanzibar town. The De- partment is a major division of the local government, which is directed on matters of health by the medical staff of the Colonial Office in London. It is responsible for the maintenance of medical care and sanitary services and, in addition, is undertaking an increasing amount of preventive work. It conducts active school health and maternity and child welfare programs, which have been effective in reducing the child mor- tality. The expansion of training facilities and the inauguration of tuberculosis and malaria surveys are prominent among its development plans. Both the Society of the Holy Ghost and the Universities Mission carry on medical as well as educational work in the Pro- tectorate. Effective work is also performed by the Zanzibar Maternity Association. MebpicAL INSTITUTIONS Hospitals and Dispensaries. The Health Department operates hospitals at Zanzibar, Weti, Chake Chake and Mkoani. The hos- pital in Zanzibar is divided into European and native sections which have an aggre- gate capacity of about 175 beds. The hos- pitals in Weti, Chake Chake and Mkoani provide 60, 53 and 15 beds, respectively. In 1946, 27 dispensaries were established at various points on the islands; they were connected with the main hospitals by ambu- lance service. Special institutions include a hospital for mental diseases, a tuberculosis hospital at Walezo and two leper settlements. The settlement at Makondeni is conducted by the government, and that at Walezo by the Catholic Mission. Women’s, and maternity and child welfare clinics have been organ- ized on the islands of Zanzibar and Pemba; also an eye clinic in Zanzibar town. Laboratories. The central laboratory of the Health Department is located in the Zanzibar hospital. It is equipped for the performance of bacteriologic, serologic, parasitologic, biochemical and other diag- nostic examinations. Small clinical laboratories are attached to the larger hospitals. Schools. There are no medical schools in Zanzibar, but qualified students are sent on government scholarships to the Medical School of Makerere College (Mulago) in Uganda. Courses for the training of nurses, medi- cal attendants and midwives are conducted in the Zanzibar hospital. Classes for sanitary inspectors are given by the staff of the Health Department. PERSONNEL Physicians. Eight doctors of the Colonial Medical Service were connected with the Health Department in 1948. The medical staff includes several Asiatic subassistant surgeons; also native medical assistants who are graduates of the medical school in Uganda. A few physicians are affiliated with mission institutions or engaged in private practice on the islands. Dentists. One or more dentists are at- tached to the staff of the Health Depart- ment and participate in its school health program. Nurses. Eleven European nursing sisters were listed on the roster of the Department in 1948. Others. In the same year the European staff included one pathologist, in charge of the laboratory, and one sanitary superin- tendent. Indian, Goan and native assistants are employed in various categories. DISEASES Hospital statistics and the reports of spe- cial investigations are the principal sources of information regarding the incidence of specific diseases on the islands of Zanzibar and Pemba. The data available are incom- plete but provide a means of evaluating the health conditions in the Protectorate. The disease problems are comparable, to a large extent, with those encountered in adjacent portions of the mainland. 230 Zanzibar Protectorate Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or URINARY TRACTS Typhoid and Paratyphoid Fevers. From 10 to 40 cases of typhoid fever are treated each year in the government hos- pitals. The reported cases are essentially urban in distribution. Paratyphoid fevers are occasionally included in the hospital re- turns, without differentiation as to type. . Dysenteries. Both amebic and bacillary dysentery are common. From 1946 through 1948 an average of 123 cases of amebic, 51 of bacillary and 121 of unclassified dysen- tery was reported annually. The cases treated in the government hospitals un- doubtedly represent but a small percentage of the total number of infections. In 1945 Shigella dysenteriae was isolated from 11 cases ; this is the first time this infection has been identified in Zanzibar. Diarrhea and enteritis are prevalent. In 1946-48 the reported annual incidence aver- aged 148 cases in children under two years of age and 793 in persons over two years. Unquestionably, many were unrecognized dysentery infections. Helminthiases. ANcyLosToM1asis. Hook- worm infection is a major problem. In 1945-48 from 5,000 to 7,200 cases were treated each year in the government hos- pitals. Reports indicate a high rate of in- fection in the rural areas, coupled with a high tolerance to the parasite. Rural school surveys in 1938 revealed 27 per cent infection among children in the south of Zanzibar and 65 per cent among children on Pemba.!® In recent years the government has conducted extensive campaigns for the control of ancylostomiasis with some suc- cess. The number of clinical cases reported in 1932 was almost twice that in 1945. Ancylostoma duodenale is the predominat- ing species. Scuistosomiasis. Schistosomiasis is wide- spread on Pemba; less so on Zanzibar. Be- tween 300 and 600 cases of schistosomiasis are diagnosed in the government hospitals and dispensaries each year; presumably, all infections with Schistosoma haematobium. Schistosomiasis due to S. mansoni rarely, if ever, occurs. A study of 127 apparently normal native children and adults in the vicinity of Weti on the island of Pemba in 1930 showed 36 per cent infection with S. haematobium. An infection rate of 18 per cent was found in the town natives ex- amined as against 45 per cent in the rural group.® The freshwater snail, Physopsis africana globosa, is the probable intermedi- ate host. OrHER HEeLMinTH INFECTIONS. Other types of intestinal worms are widely dis- tributed, but the treated cases do not exceed 50 to 75 a year. Ascariasis is prevalent, par- ticularly in the southeastern portion of Zanzibar island. Infections with Trichuris trichiura and with Strongyloides stercoralis are about equally common. Occasional cases of tapeworm infection, due to Taenia sagi- nata, are encountered. Other Infections. Brucellosis occurs sporadically. Cholera has been introduced in Zanzibar from time to time, but has not been reported since 1912. DistasEs SpreaD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. The prevalence of tuber- culosis cannot be estimated with any degree of accuracy, since a large proportion of the population is migratory and the majority of patients seek medical care only in the ad- vanced stages of the disease. From 200 to 350 cases of pulmonary tuberculosis and from 10 to 60 of nonpulmonary are treated annually in government hospitals. These probably represent a small fraction of the total cases. In a survey reported in 1933, the morbidity rate was estimated at 2.7 per 1,000 population in the rural areas of Zan- zibar and at 6.8 in the town.” The Indian population is said to be especially heavily infected. Malnutrition, overcrowding and poor sanitation, particularly in Zanzibar town, are predisposing factors. Patients are cared for in the general hospitals and in the tuberculosis hospital at Walezo. Zanzibar Protectorate 231 Pneumonia. Respiratory infections are numerous and often serious. An average of from 600 to 700 cases of lobar pneumonia and from 70 to 150 of bronchopneumonia are reported from the government hospitals each year. Pneumonia is one of the major causes of death in the Protectorate. Smallpox. The Health Department con- ducts an energetic vaccination campaign on both islands, and only occasional cases of smallpox are encountered. Other Infections. Epidemics of influenza are frequent. Measles and whooping cough are endemic. Sporadic cases of diphtheria and scarlet fever are recorded. Meningococ- cus meningitis is normally rare, but localized outbreaks have occurred at approximately 6-year intervals. Diseases SPREAD OR CONTRACTED CurierLy THROUGH CONTACT Venereal Diseases. Venereal diseases are prevalent. In 1946-48 an average of 579 cases of syphilis, 1,092 of gonorrhea and 67 of other venereal diseases was treated annually by the medical officers. A sero- logic survey, employing the Kahn test, among school children in Zanzibar, reported in 19451! revealed 11.5 per cent positive reactions, 12 per cent among Africans and 8 per cent among Asiatics. The significance of such serologic tests in childhood is un- certain, however, because of the high inci- dence of yaws and malaria. The adults in the vicinity of the schools covered in this survey gave 58.6 per cent positive serologic reactions. Yaws. Yaws is widespread but may be decreasing slightly in extent. Totals of 3,408 and 3,608 cases were registered in 1947 and 1948, respectively, as against 4,400 in 1932. The highest incidence is recorded as existing in the northern part of Zanzibar island. Leprosy. Leprosy is widely distributed, but the actual incidence has not been de- termined. From 20 to 75 cases are treated annually in the government hospitals. In December, 1948, 47 lepers were accommo- dated in the Catholic Mission Settlement at Walezo and 51 in the government colony at Makondeni. During the year 19 new cases were admitted. Segregation is not compul- sory. Diseases of the Eyes. From 30 to 120 cases of trachoma are reported each year. The disease is relatively rare among the natives but common among the Muscat and the Hadramant Arabs living in Zanzibar. Both infectious and noninfectious eye diseases are general. The Health Depart- ment maintains a special eye clinic in Zanzibar. Diseases of the Skin. Infestation with Sarcoptes scabiei and Tunga penetrans is widespread, and secondary infections are frequent. As elsewhere in East Africa, tropi- cal ulcers are numerous among the laborers. Scattered cases of myiasis are reported. Other Infections. Tetanus is sporadic. Rabies has not been reported within recent years. Wild dogs abound, especially on Pemba, and would constitute a potential menace if the disease were introduced. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is of major public health importance in the Zanzibar Protec- torate. Although the islands may properly be regarded as hyperendemic areas, limited outbreaks of malaria occur from time to time. It is possible that these may be at- tributed to some extent to the continuous influx of susceptible persons from India and the mainland. Normally, the disease is more prevalent on the island of Pemba than on Zanzibar. In the course of the examination of the rural school children on Pemba in 1938, spleen rates of 56 per cent and para- site rates of 51 per cent were revealed. Comparable rates in three rural schools in southern Zanzibar were 39 per cent and 12 per cent, respectively. Transmission takes place throughout the year in the well- watered, highly cultivated districts, but it is limited to the periods during and follow- ing the rains in the drier regions. The vec- tors are Anopheles gambiae and A. funestus. 232 Zanzibar Protectorate The incidence of malaria varies from year to year; from 5,700 to 12,000 cases are treated annually in the government hos- pitals. Plasmodium falciparum is the pre- dominant species. Among 3,000 blood films in which malarial parasites were identified in the central laboratory in 1947, P. falcip- arum was found in 1861, P. vivax in 700 and P. malariae in 100, with the remainder un- classified. Comparable findings in 2,269 blood films in 1948 were 1,502 P. falcip- arum, 525 P. vivax, 44 P. malariae and 198 unidentified. Blackwater fever occurs sporadically. Filariasis. Filariasis due to Wuchereria bancrofti is endemic. Microfilariae have been found in the blood of from 32 to 39 per cent of the individuals examined in different surveys on Zanzibar, and of from 23 to 40 per cent of the adults on Pemba.? Microfilaria of Acanthocheilonema perstans were not found. Elephantiasis and other clinical manifes- tations of infection are common. The sta- tistics of the government hospitals in 1945 indicate that elephantiasis was present in 1.4 per cent in-patients on Zanzibar and in 0.6 per cent on Pemba. Mosquito surveys have shown that Culex quinquefasciatus (=C. fatigans), Anopheles gambiae and A. funestus are important vectors. Relapsing Fever. Outbreaks of relapsing fever, presumably louse-borne infections, occur from time to time. In 1945 about 35 cases were discovered among the passengers and the crews of dhows arriving at Zan- zibar from southern Arabia. The immediate enforcement of quarantine regulations pre- vented the spread of the infection to the local population. The following year 233 cases were reported, but the source is not specified. Fourteen cases were listed in 1947, and the same number in 1948. The presence of tick-borne relapsing fever is not recorded. Yellow Fever. Yellow fever has not been present on the islands for several decades, but Aedes aegypti is prevalent, and its pos- sible introduction is feared by the health authorities. Aedes-control measures and pro- tective quarantine regulations are continu- ally in force. Large-scale immunization with yellow fever vaccine is also carried on. Plague. The islands have remained free of plague within recent years. However, Zanzibar town is very vulnerable: it is one of the largest ports on the eastern coast of Africa, and its harbor is usually thronged with ships and dhows from the East. Anti- rat campaigns are conducted continuously. Other Infections. Dengue fever is en- demic and at times epidemic. Tick-borne typhus fever is sporadic, but louse-borne infections are not reported. Human trypanosomiasis does not occur. NutriTioNAL DISEASES Malnutrition and avitaminosis are gen- eral, particularly among the poorer inhabit- ants. Little evidence is available regarding the incidence of specific deficiency diseases, but from 500 to 900 cases, classified as nutritional diseases, are treated annually by the hospital officers. The patients admitted to the hospitals frequently show evidence of vitamin B deficiency in the form of periph- eral neuritis. Frank beriberi is rare, but a few cases are recorded each year. From 1 to 20 cases of pellagra may also be observed. Vitamin A and C deficiencies are unusual. Mild rickets is common, and severe cases are sometimes reported among the Indian families living in the congested bazaar dis- tricts. Anemia is prevalent, and in some cases complicated by generalized edema. SUMMARY The island colony of Zanzibar is both a sultanate and a protectorate of Great Brit- ain. Health conditions in the islands of Zanzibar and Pemba are comparable in most respects with those prevailing in the adjacent coastal regions of Kenya and Tan- ganyika. Responsibility for the health and the medical care of the population resides in the Health Department of the Protec- torate government which functions under the Colonial Office in London. The Depart- Zanzibar Protectorate 233 ment is administered by a Chief Medical Officer with headquarters in Zanzibar town. Hospitals are maintained in Zanzibar, Weti, Chake Chake and Mkoani, with an aggre- gate capacity of approximately 300 beds. About 26 dispensaries are scattered over the islands, with auxiliary ambulance services. Water supplies are derived largely from springs, streams and cave wells. The meth- ods of sewage disposal are generally unsatis- factory. Overcrowding and lack of sanita- tion are typical of many areas, particularly in Zanzibar and other towns. Malnutrition is prevalent, and serious vitamin deficien- cies, especially of the B complex, are common. Malaria, hookworm infection, tuberculo- sis and venereal diseases are major public health problems. Intestinal infections are widespread. Leprosy, yaws, filariasis, uri- nary schistosomiasis, respiratory infections and diseases of the skin and the eyes are common. Mass vaccination against small- pox is carried on, and only occasional cases are observed. Outbreaks of louse-borne re- lapsing fever, influenza and meningococcus meningitis occur sporadically. Whooping cough, measles and dengue fever are en- demic. Yellow fever and plague are not known to be present, but the vectors are prevalent, and preventive measures are en- forced. BIBLIOGRAPHY 1. Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. 2. Great Britain, Colonial Office: Annual Re- port on Zanzibar for the Year 1946, Lon- don, H. M. Stationery Office, 1948. 3. Hawking, Frank: Distribution of filariasis in Tanganyika Territory, East Africa, Ann. Trop. Med. 34:107-119 (Dec.) 1940. 4. ——: The distribution of filarioid infections in East Africa, J. Trop. Med. 45:159-165 (Dec.-Jan.) 1942-43. 5. Ingrams, W. H.: Zanzibar, its History and its People, London, Witherby, 1931. 6. Mansfield-Aders, W.: Notes on malaria and filariasis in the Zanzibar Protectorate, Tr. Roy. Soc. Trop. Med. & Hyg. 21:207-214 (Nov.) 1927. 7. Mathews, R. J.: The state of tuberculosis in the Protectorate of Zanzibar. Studies of tuberculosis among African natives, Tuber- cle, Supplement 16:48-97 (Jan.) 1935. 8. McCarthy, D. D.: Medical notes from Weti, Pemba, Tr. Roy. Soc. Trop. Med. & Hyg. 23:401-412 (Jan.) 1930. 9. Mozley, Alan: The fresh-water mollusca of the Tanganyika Territory and Zanzibar Protectorate, with their relation to human schistosomiasis. Tr. Roy. Soc. Edinburgh 59: Part III, 687-744, 1939. 10. Pearce, F. B.: Zanzibar, the Island Metrop- olis of Eastern Africa, London, T. Fisher Unwin, Ltd., 1920. 11. Young, W. A.: Kahns at schoo. age in Africa, East African M. J. 22:74-79 (Mar.) 1945. 12. Zanzibar Protectorate: Medical and Sani- tary Reports from British Colonies, Pro- tectorates and Dependencies for the Year 1937, Abs. Trop. Dis. Rull. Supp. 36: 77-82 (Nov.) 1939. : Medical and Sanitary Reports from British Colonies, Protectorates and De- pendencies for the Year 1938, Abs. Trop. Dis. Bull. Supp. 37:44-47 (Dec.) 1940. : Annual Medical and Sanitary Report for the Year Ended December 31, 1943, Zanzibar, Govt. Printer, 1944. : Annual Medical and Sanitary Report for the Year Ended December 31, 1945, Zanzibar, Govt. Printer, 1946. 16. ——: Annual Medical and Sanitary Report for the Year Ended December 31, 1946, Zanzibar, Govt. Printer, 1947. : Annual Medical and Sanitary Report for the Year Ended December 31, 1947, Zanzibar, Govt. Printer, 1948. : Medical and Sanitary Report for the Year Ended December 31, 1948, Zanzibar, Govt. Printer, 1949. 19. ——: Statistics of Zanzibar Protectorate, 1893-1932, Zanzibar, Govt. Printer, 1933. 13. 14. 1s. 17. 16 Madagascar and the Comores Archipelago GEOGRAPHY AND CLIMATE Madagascar, a French colonial possession, is the fourth largest island in the world. It is situated at the entrance of the Indian Ocean, due east of Mozambique, and is separated from the mainland by a channel at least 240 miles in width at its narrowest point. The island is roughly 1,000 miles in length and from 250 to 360 miles in width. Together with its dependencies, the Co- mores archipelago in the northern part of the Mozambique Channel, the coastal islands of Nossi-Bé and Saint-Marie, and scattered small islands in the Indian Ocean, it has an approximate area of 241,000 square miles. The characteristic physiographic feature of Madagascar is the high central plateau which occupies over one third of the island, extending north and south for almost its entire length. It has a general altitude of 4,000 to 5,000 feet but incorporates peaks rising to 8,000 feet and deep valleys occu- pied by lakes and marshy plains. The high- est elevations are found in the north and in the east where the plateau drops abruptly in two hilly terraces to a narrow coastal plain. In contrast, the highlands are sepa- rated from the coast on the western side by broad, sandy lowlands which slope grad- ually toward the channel. The southern portion of the island is arid, semidesert country. Numerous sizable rivers with fer- tile valleys cross the western plains, but the streams on the eastern slopes are short and full of rapids. Lakes, lagoons and marshes fringe the coast in the eastern part of the island. The climate varies markedly in the dif- ferent regions. The effects of the northeast monsoon winds of the Indian Ocean are felt most noticeably on the east coast. Rain falls throughout the year, except for a short period in October and November. The an- nual precipitation exceeds 100 inches along the entire littoral and reaches 116 to 127 inches in the vicinity of Tamatave. The temperature averages from 75° to 77° F., while the humidity is generally high. Tor- nadoes are prevalent between January and March. In the central highlands, the rain- fall is concentrated in the summer months, from December to April. The annual pre- cipitation totals only 49 to 53 inches, but torrential thunderstorms and floods are fre- quent. The dry season, which extends throughout the remainder of the year, is characterized by fogs and cold mists. The mean temperature ranges from 54° to 56° F. in July and from 68° to 70° F. from De- cember to February. Two seasons are also encountered on the western plains. The temperature averages from 78° to 80° F., several degrees higher than in comparable sections of the east coast, but the fluctua- tions are greater. The annual rainfall varies from 58 inches at Majunga in the north- west, to semidesert conditions in the south. In the extreme north, at Diégo-Suarez, it approximates 38 to 40 inches, but along the southern coast it rarely exceeds 14 inches 234 Madagascar and the Comores Archipelago 235 and may be interspersed between long periods of drought. The Comores archipelago was formerly a province of Madagascar, but in 1946 it was granted administrative and financial autonomy under the authority of the Governor-General of Madagascar. It in- cludes four main islands and several islets, with an aggregate area of 790 square miles. The largest, Grande Comore, contains an active volcano over 7,800 feet in height. The other islands, in order of size, are Anjouan, Mayotte and Mohéli. Their climate is simi- lar to that of northwestern Madagascar but somewhat more favorable except during the tornado season. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopPULATION In the census of 1941 the population of Madagascar was enumerated at almost 4.2 million, including 136,000 inhabitants of the Comores archipelago. The non-native popu- lation consisted of 52,383 Europeans and different Asiatic peoples. In a subsequent count in 1947 the indigenous population of Madagascar was estimated at 4,094,000, and the non-native at 57,860. The latter group comprised 38,002 French, of whom over 13,400 originated in France, about 15,032 Asiatics and 3,927 of other nationalities. The population of the Comores was about 152,300. The native tribes, known collectively as the Malagasy, are of diverse origin. Al- though Madagascar is associated geographi- cally with the African mainland, the racial complex and the customs of the people are more closely related to those of the islands of the Indian and the Pacific Oceans. There are 20, or more, distinct and disunited tribes, the most prominent being the Merina, Betsimisaraka, Bétsiléo, Tsimihety and Sakalava. The majority represent mix- tures of aboriginal and Indo-Melanesian stock, but Malayan elements predominate among the Merina, and Bantu among the Sakalava and certain minor groups. The Merina, sometimes referred to as the Hova (a class within the Merina), are settled in the northern part of the central highlands and the Bétsiléo in the southern. The Tsimihety inhabit the mountainous country in the northeast, the Betsimisaraka the east coast from the Bay of Antongil to the region around Mananjary, and the Sakalava the western lowlands. The language of the islands is known as Malagasy, but the numerous tribal dialects, although related, are frequently distinct. Bantu tongues are spoken in the northwest coastal region, while the Comoros employ a mixture of Sakalava and Swahili. French, the official and trade language, is rarely used outside of the urban centers. The people are essen- tially pagans, but Protestant and Catholic missions have been active for over a cen- tury and have made large numbers of con- verts, particularly among the Merina and the Bétsiléo. Moslem influence antedated the Christian, and many of the inhabitants in the coastal towns and on the Comores are Moslems. Extensive portions of Madagascar are sparsely settled. The population density averages 20 per square mile, but varies from 50 to 100 in certain districts on the east coast and in the highlands to less than §S in the west coast region. Tananarive, the capi- tal, is the only large city. In 1947 it had a population of 165,477, including about 20,000 Europeans and other non-native groups. The ports of Tamatave, Majunga and Diégo-Suarez have populations of be- tween 20,000 and 30,000, while Fianarantsoa and Antsirabé in the highlands have popu- lations of 15,000 to 18,000. Two systems of education are supported by the Colonial government, the European and the native in which instruction is given in Malagasy and in French. Separate Indian schools are maintained in the towns on the west coast. Schools are also conducted by the Protestant and the Catholic missions in various parts of the island. Advanced edu- cation in medicine, law, administration and 236 Madagascar and the Comores Archipelago applied arts is available in Tananarive. However, even in the urban centers not over 50 per cent of the children are enrolled in schools at any level, while in the rural com- munities the proportion probably decreases to 10 per cent. The government schools in the Comores combine Koranic and standard forms of instruction. VITAL STATISTICS The native birth rate for Madagascar in 1947 was 20.9 per 1,000 population, and the death rate 16.9. The statistics are little more than approximations, since reporting is incomplete except in certain cities such as Tananarive. In general the birth rates and the death rates which reflect the degree of reporting are lowest in the east and the west coast districts. The birth rates were given as 32.2 per 1,000 population in the plateau districts, 12.9 on the east coast and 16.0 on the west. The death rates were 26.9, 10.4 and 15.5, respectively. The estimated mortality among infants from 0 to 1 year of age was 167 per 1,000 births in 1946, and 143 in 1947. In these two years the deaths among children under five years of age aver- aged from 27 to 29 per cent of the total deaths. Undernutrition, malaria, syphilis and neglect of basic principles of infant and maternal hygiene are primary factors responsible for the high infant mortality. Separate statistics for the European pop- ulation in 1947 indicate a birth rate of 22.4 and a death rate of 12.3 per 1,000. SociaL Economy Agriculture is the primary occupation of the people on all the islands. In Madagascar only a small proportion of the total land area is under cultivation, however, while the methods of production are usually primi- tive, except on farms owned by colonists or by co-operative groups. Export crops, culti- vated on individual holdings or on large estates, include coffee, vanilla, sugar cane, cloves and other spices, cocoa, coconuts and sisal. Coffee is the most valuable export, but the island ranks second or third among the world’s producers of vanilla and cloves Cattle are raised in some areas, principally on the western plains and in the semiarid south coast region. Hog raising, a promi- nent adjunct of the meat canning industry, is concentrated to a large extent on the central plateaus. Livestock and meat prod- ucts, as well as hides, are major exports. The government has endeavored to promote better crops and modern methods of culti- vation through the establishment of agri- cultural schools and experiment stations. It also encourages the formation of co-opera- tive and credit organizations as a means of bolstering the native economy. Extensive forest reserves contribute to the potential resources of the Colony. The principal minerals are graphite and mica, but commercial deposits of semiprecious stones, and of uranium and gold are also found. Industrial development is limited chiefly to the processing of local agricul- tural products, such as rice, tapioca, fiber goods and essential oils; the canning of meats and fruits and the tanning of leathers. Vanilla, coconuts and perfume plants are produced on all the islands of the Comores archipelago, but sugar cane and rum are of major importance on Mayotte, and timber on Grande Comore. The 10-year plan re- cently proposed for the rehabilitation of French overseas territories, as applied to Madagascar, includes the expansion of agri- culture through the promotion of mecha- nization and the development of irrigation, the exploitation of the coal deposits around Sakoa and the improvement of communica- tion facilities. Trunk roads radiate from Tananarive to Tamatave, Diégo-Suarez, Majunga and Fort Dauphin, while subsidiary roads connect the lesser population centers. However, large portions of the interior are inaccessible by modern means of conveyance, particularly during the rainy season. A railroad links the port of Tamatave with Tananarive and Antsirabé, while a subsidiary line runs from Moramanga to Ambatosoratra in the north. Another small line extends from Fianaran- Madagascar and the Comores Archipelago 237 tsoa to Manakara on the coast. Tamatave is the principal port for steamer traffic with Europe, Asia and Africa, but Majunga and Diégo-Suarez are important secondary ports. Steamers ply between the Comores islands and Madagascar at irregular intervals. Air transportation is available between the prin- cipal islands and from Madagascar to France, Africa and Réunion. Foop AND NUTRITION The food habits of the population are influenced by differences in race, as well as by caste distinctions among the Malagasy tribes. In spite of the fact that the island is virtually self-supporting and climatic and soil conditions permit the cultivation of a wide variety of foods, the nutritional stand- ards of the people are generally low. On the central plateaus rice is the staple article of diet, supplemented by maize, meat, fish, manioc, sweet potatoes, legumes and other vegetables and fruits. In many areas the extensive use of polished rice is responsible for a high incidence of beriberi. In districts where rice is not grown, manioc and maize constitute the basic foods of the people. Cattle, sheep, goats and fowl are raised in most parts of the Colony, but meat plays a minor role in the average dietary. Peanuts are popular in many areas. Coconuts are grown on the coast, but primarily for ex- port. The nutrition of the Comoros is com- parable with that of the Malagasy. The majority subsist on a vegetarian diet in which rice, imported from Madagascar, forms the basic food. HousinG The dwellings, characteristic of the dif- ferent tribes, vary in type and in building materials. In the rural areas the people live in small villages. While some tribes may follow their flocks for part of the year, few are nomadic. In the coastal regions the houses may be constructed of grasses, palm leaves, bamboo or wood, but in the high- lands they are usually made of mud or brick, with grass or tile roofs. The houses in the urban centers are generally more sub- stantially built of wood, brick or concrete, with galvanized iron roofs. In the larger cities and the towns, the Europeans and the Malagasy may live side by side or in sectors dominated by the different races or castes. Extensive overcrowding is encoun- tered in Tananarive and other towns, par- ticularly in the older native quarters. Since 1945 the Colonial government has sponsored programs for the construction of modern housing in the urban areas and in the co- operative farming communities. ENVIRONMENT AND SANITATION WATER SUPPLIES Water is obtained from streams, natural springs and wells. The supply is adequate, except in the semiarid districts in the south- ern part of the island, but in certain areas it may be seriously depleted during long periods of drought. Water supply systems are found in the larger cities and towns. In most instances, however, supervision is ir- regular, and the supplies are subject to contamination. Mantasoa Dam, near Tana- narive, provides water for the city and for irrigation and power purposes. The drink- ing water supply is treated by filtration and chlorination before distribution to public fountains and to individual buildings in the modern sections of the city. The purity of the supply is controlled by the municipal health authorities and by the Institut Pas- teur de Tananarive. In other towns, such as Fianarantsoa, Antsirabé and Diégo- Suarez, domestic supplies are derived chiefly from springs. Adequate sources of supply are available on all of the Comores islands except Grande Comore, where the inhabit- ants are sometimes forced to rely upon water collected in cisterns during the rainy season. Waste DisposaL The methods of sewage disposal are primitive. No sewerage systems exist, even in Tananarive, but in the cities and the 238 Madagascar and the Comores Archipelago towns, septic tanks, cesspits and bucket la- trines are employed. Night soil is collected in carts, and in most instances the sewage is dumped untreated into near-by rivers and harbors. In the rural areas and in the native villages indiscriminate pollution of the soil is general. Fauna anDp Frora Arthropods. Mosquitoes. Ten or more species of anopheline mosquitoes have been identified on Madagascar. Anopheles fu- nestus, A. funestus imerinensis, A. gambiae, A. coustani and A. squamosus are widely distributed, while A. pharoensis, A. maculi- palpis, A. splendidus, A. rufipes and A. demeilloni are found in localized areas. A. funestus and A. gambiae are the only significant vectors of malaria. 4. funestus, the dominant species, maintains a high rate of endemicity in all portions of the island. However, A. gambiae is responsible for sea- sonal epidemics and under abnormally fa- vorable climatic conditions may temporarily become the most abundant species. A. fu- nestus breeds throughout the year, with maximum intensity from November to May. Suitable breeding places are found, espe- cially on the plateaus, in the cultivated and fallow rice fields, irrigation canals, streams, swamps and other permanent bodies of water. The garden watering holes, which are characteristic of Madagascar, also provide excellent places for breeding. A. gambiae breeds in various exposed collections of clear or muddy water, including the brick holes, similar to the Indo-Chinese borrow pits, which are used extensively on the island. It appears toward the end of the rainy sea- son, primarily from February to May, but is almost wholly absent during the remain- ing months. Both A. funestus and A. gam- biae have been found naturally infected with the microfilaria of Wuchereria ban- crofti. Aedes mosquitoes are numerous. Aedes aegypti, A. albopictus, A. fryeri, A. fowleri, A. monetus and A. pembaensis are known to be present. A. aegypti is a vector of dengue fever and a potential vector of yellow fever, although that disease has not been reported from Madagascar. Many species of Culex occur, the most important being Culex quinquefasciatus (=C. fatigans), a vector of Wuchereria bancrofti. At least 13 other species have been identified, including C. pipiens, C. univittatus, C. tigripes, C. decens and C. invidiosus. Eretmopodites quinquevit- tatus, Taeniorhynchus (Mansonia) wuni- formis, T. grandidieri and two species of Uranotaenia are also reported. Mosquito-control measures are carried on around Tananarive, Fianarantsoa, Antsi- rabé, Tamatave, Majunga and other popu- lation centers by the Service Antipaludique of the Madagascar health organization. They incorporate drainage projects, sys- tematic cleaning and antilarval treatment of breeding sites with oil or Paris green, the residual spraying of houses with DDT, the spraying of marshes from the air with DDT or Paris green mixtures and the exten- sive use of larvivorous fish. Fries. Flies are abundant and may be of considerable medical and economic impor- tance, as well as annoying pests. The house- fly, Musca domestica, is prevalent and, with other species, is probably implicated in the spread of enteric infections. Several species of Stomoxys, Tabanus albitibialis, T. albi- pictus and Chrysops madagascariensis are known to be present. The Tabanid flies are suspected of being responsible for the me- chanical transmission of anthrax among the livestock. Several species of Simulium have been reported, but none is a known vector of dis- ease. Phlebotomus flies occur in several parts of the island, but only one species, P. squamipleuris, has been identified. It has been found in two sections of the town of Diégo-Suarez. Lice. The head and the body lice, Pedic- ulus humanus capitis and P. humanus cor- poris, are common. The crab louse, Phthirus pubis, is also found. Freas. Numerous studies of the indig- Madagascar and the Comores Archipelago 239 enous fleas and rodents have been made since 1921 when the presence of endemic foci of plague was recognized on the islands. Xenopsylla cheopis is the most important species and in routine surveys accounts for from 50 to 70 per cent of the fleas examined. In the plateau region it hides in the dust which accumulates in the cracks in the houses; it often attacks man. Syropsylla fonquernii is found frequently on rats cap- tured during the winter season. It is known to transmit plague among rodents, but its role as a vector of human plague has not been determined. The cat and dog fleas, Ctenocephalides felis and C. canis, are in- digenous. The human flea, Pulex irritans, is also reported. Numerous other species infest the small animals, but all are of doubtful importance as regards man. The chigoe flea, Tunga penetrans, is a widespread pest. BepBucs. Both Cimex lectularis and C. hemipterus are encountered, particularly in the native areas. Ticks. Numerous species of ticks have been identified. Ornithodorus moubata is the vector of tick-borne relapsing fever in a few scattered foci. O. megnini attacks the ears of cows, sheep and goats, and some- times of men who live in close contact with their animals. Rhipicephalus simus, R. san- guineus, Boophilus decoloratus, Ambly- omma variegatum and Margaropus annu- latus are widespread and responsible for the transmission of protozoal diseases among the livestock. Some may be implicated as occasional vectors of tick-bite fever in man. Several species of Haemaphysalis have been recorded. OtHER ArTHROPODS. The reduviid bug, Triatoma rubrofasciata, is present in the northern part of the island. The venomous spider, Latrodectus menavody, is common and is regarded as sacred by the native inhabitants. Several dangerous species of scorpions are found. Their bites are not fatal, but some may produce painful and disabling lesions. Reptiles. No poisonous snakes are re- ported from the island. However, two con- strictors have been identified : one, a species of the genus Constrictor: the other Boa (Sanzinia) madagascariensis. The latter fre- quently attains a length of 7 feet or more. The crocodile, Crocodilus madagascariensis, inhabits the inland waters, and human be- ings are frequently bitten. Rodents. Rattus rattus rattus and R. rat- tus alexandrinus, the principal reservoirs of plague in Madagascar, and R. rattus frugi- vorus are common. R. norvegicus is intro- duced occasionally in the port areas but is relatively rare. Sylvatic plague apparently does not occur, but potential wild rodent reservoirs are present. The giant rat, Dyno- psylla lypusus, and Brachytarsomys albi- cauda are among the most prominent. Mollusks.* Foci of urinary and rectal schistosomiasis are widely distributed, but the specific snail hosts have not been identi- fied positively. Planorbis (Biomphalaria) alexandrina pfeifferi madagascariensis is suspected of being the intermediate host of Schistosoma mansoni. Bulinus (Pyrgo- physa) forskalii is the probable intermedi- ate host of S. haematobium. Lymnea nata- lensis is important as the intermediate host of Fasciola hepatica, a liver fluke of sheep. Foop SANITATION Markets, restaurants and establishments where food is processed or sold are inspected by the local health services in the major cities. Samples of milk and other foods suspected of contamination are examined in the chemical laboratory of the Institut Pasteur in Tananarive. The inspection of meats is the responsibility of the govern- mental veterinary services and is carried on only in the larger towns. Municipal abat- toirs exist in Tananarive and other cities. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS The administration of the health and medical services in Madagascar and the de- * See footnote, p. 10. 240 Madagascar and the Comores Archipelago pendent islands is the responsibility of the Service de la Santé Publique, which has its headquarters in Tananarive. The organi- zation is a major division of the Colonial government, which is advised on matters of health by the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer in Paris. The activities of the Service include the control of epidemic and certain endemic diseases, the super- vision of sanitation, the maintenance of hospitals and facilities for the medical care of the native peoples (Assistance Médicale Indigéne) and the institution of measures for the protection of the health of children and other population groups. Subsidiary services for the control of plague, malaria, leprosy, tuberculosis and venereal diseases are incorporated in the department. The last four are centralized in the Institut d’Hygieéne Sociale in Tananarive, which operates the program throughout the Col- ony. Bureaux d’Hygiéne are charged with the direction of the local health and sani- tary services in the larger cities and towns. Since 1946 the Service de Santé des Comores has functioned under the jurisdiction of the administrator of that territory, but it re- mains dependent upon the Service de la Santé Publique de Madagascar for its tech- nical services. Branches of the Croix Rouge and Gouttes de Lait carry on child welfare work in co- operation with the Service de la Santé Publique. Several Catholic and Protestant mission organizations conduct hospitals and dispensaries on the island. MEDpICAL INSTITUTIONS Hospitals and Dispensaries. In 1947 the Service de la Santé Publique operated hospitals in Tananarive, Tamatave, Ma- junga, Diégo-Suarez and Fianarantsoa with facilities for the care of Malagasy and Europeans, as well as 51 smaller hospitals in the provinces and constituent districts. The Hopital Principal in Tananarive, a well-equipped institution with 1,000 beds for natives, is the center of the depart- ment’s medical care and teaching program. Separate hospitals for Europeans (civilian and military) and for children are located in Tananarive. The aggregate capacity of the central, the provincial and the district hospitals was approximately 4,800 beds. In addition to its general hospitals, the department maintained 229 dispensaries in various parts of the country, 46 infirmaries for maternity cases and 256 rural maternity clinics, 14 leprosaria and 12 leper villages, and a mental disease hospital. The Institut d’Hygiéne Sociale conducts treatment centers in Tananarive and other parts of the island under the direction of its malaria, leprosy, tuberculosis and vene- real disease services. In 1947 the medical facilities on the islands of the Comores archipelago included 7 hospitals, 2 maternity homes, 3 rural dis- pensaries, 3 leper hospitals and 1 leper vil- lage. The total number of beds available in government institutions on Madagascar was about 13,000, and on the Comores, 237. Hospitals, dispensaries and leprosaria are also maintained by the different mission organizations. Laboratories. The Institut Pasteur de Tananarive, the principal research and diag- nostic laboratory in Madagascar, was cre- ated in 1899. It has branches for research on various human, animal and plant diseases, for the preparation of vaccines and serums and for the performance of chemical, patho- logic and bacteriologic examinations, in co- operation with the Service de la Santé Publique. A laboratory for the preparation of small- pox and other vaccines for the Service is located at Diégo-Suarez. Laboratories are also connected with the tuberculosis and other divisions of the Institut d’Hygiéne Sociale in Tananarive. Clinical laboratory facilities are available in the larger hos- pitals. Schools. The Ecole de Médecine was es- tablished in conjunction with the Hopital Principal in Tananarive in 1896. It offers a 5-year course of training and graduates Madagascar and the Comores Archipelago 241 native physicians qualified for work in the Colonial health services. Two-year courses are also given for dental technicians. A school of pharmacy is operated in con- junction with the medical school. Schools for midwives and visiting nurses are conducted at the Hopital Principal in Tananarive. Training courses of a lower standard are also given in regional schools for midwives. Native male nurses are trained in the hospitals at Tananarive, Majunga, Diégo- Suarez, Fianarantsoa and Tamatave. Short courses for male and female nurses are pro- vided in all the larger government hospitals. A school for the instruction of assistants in the malaria-control services is established at Tananarive. PERSONNEL Physicians. The medical staff of the Service de la Santé Publique in 1947 in- cluded 61 European and 350 Malagasy doc- tors. Three European and 5 Malagasy doc- tors were stationed on the Comores. Others. Other Europeans in the Service consisted of 7 pharmacists, 27 male and female nurses and 17 sanitarians. The Malagasy staff included 354 midwives, 60 visiting nurses, 200 graduate male nurses and 680 male and female nurses with mini- mal qualifications, 40 hygiene (malaria con- trol) assistants and various other subordi- nate personnel. The native staff on the Comores com- prised 3 midwives, 27 nurses (male and female) and 1 visiting nurse. DISEASES The statistics of the government hospitals and dispensaries provide useful data for the evaluation of health conditions on the islands, but outside of the larger cities and towns the reporting is incomplete, and the diagnoses frequently are misleading. While the diseases encountered on the Comores archipelago and the other islands are essen- tially the same as those of the adjacent coastal regions of Madagascar, their inci- dence may be influenced by the habits and the customs of the people. Less is known regarding the extent of disease in the sparsely settled west coast districts of Mad- agascar and on the small islands than in the populous central plateau region. A large percentage of the Malagasy adhere to their traditional forms of medical practice, many of which conflict with the efforts of the health authorities to combat the spread of epidemic diseases. Valuable supplementary information in specific fields is derived from the research and field investigations of the Institut Pasteur de Tananarive, and more recently from the work of the special serv- ices of the Institut d’Hygiéne Sociale. DiseAsES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid and paratyphoid fevers are promi- nent among the diseases endemic on the islands. In 1941-46 the reported incidence ranged from 87 to 504 cases a year. The in- fections are predominantly urban and exist sporadically or in small localized outbreaks. The water supplies are frequently contami- nated, but no major water-borne outbreaks have been attributed to Tananarive within recent years. Typhoid fever predominates among the known cases, but paratyphoid fevers A, B and C are also recorded. Other Salmonella infections are also numerous. Dysenteries. Amebic dysentery is wide- spread, particularly in the central highlands, where a considerable portion of the popula- tion is concentrated. From 3,500 to 5,500 cases are reported each year, a rate of 90 to 110 per 100,000 population. Probably about 20 per cent of the infections occur in chil- dren under 5 years of age. Amebiasis is char- acteristically mild in the native inhabitants. Amebic abscess is relatively rare. The incidence of bacillary dysentery is uncertain, since the majority of patients do not come to the attention of the health authorities. Extensive outbreaks are infre- quent, but in 1941-46 the reported cases 242 Madagascar and the Comores Archipelago fluctuated between 85 and 772 a year. Paradysentery strains of the Flexner group are responsible for a large percentage of the cases. Shigella dysenteriae infections are common, and small localized epidemics are ‘sometimes recorded. Helminthiases. Scuistosomiasis. Nu- merous endemic foci of schistosomiasis are recognized, and from 500 to 1,400 cases of Schistosoma haematobium infection and from 250 to 500 of S. mansoni are reported each year. In general, the areas of en- demicity of the two species are distinct. S. haematobium is found in the central high- lands from Tananarive to Fianarantsoa and throughout the west coast region, particu- larly in the northwest from Diégo-Suarez to Analalava and in the vicinity of Majunga, Morondava and Tuléar. S. mansoni is widely distributed in scattered foci on the plateau and in the valleys leading to the east and the south. The areas of highest incidence are located in the southern highlands around Thosi, Betroka and Midongy and in Fara- fangana and Vatomandry districts. Small = ; Ma, NN 2 : Distribution of Schistosoma haematobium Infection in Madagascar = & NY = ; nar ive Distribution of Schistosoma mansoni Infection in Madagascar localized foci also exist near Analalava, Morondava and Tuléar on the west coast. The snail, Planorbis (Biomphalaria) alexandrina pfeifferi madagascariensis is suspected of being the intermediate host of S. mansoni, and Bulinus (Pyrgophysa) forskalii, of S. haematobium. Ancyrostomiasis. Hookworm infection is prevalent in the central and the eastern low- lands. The most extensive foci are found in the vicinity of the Antalaha and the Mana- jary rivers. Both Ancylostoma duodenale and Necator americanus are encountered. OrHER HELMINTH INFECTIONS. Intestinal parasites are widespread; from 30,000 to 70,000 cases, exclusive of schistosomiasis, are treated each year in the government hospitals and dispensaries. The incidence is highest in the east coast districts, especially south of Tamatave, and in certain highland areas. Ascariasis usually predominates, but in many localities Trichuris trichiura infec- tions are only slightly less numerous. Enter- obiasis and strongyloidiasis are common. Madagascar and the Comores Archipelago 243 Taeniasis is frequently encountered, but the relative incidence of human infections with the beef tapeworm, T'aenia saginata, and the pork tapeworm, 7. solium, is not known. Cystocerciasis in man is reported occasionally. Cases of hydatid disease, caused by Echinococcus granulosus, and infections with the dwarf tapeworm, Hymenolepis nana, are not unusual. Human infections with the tapeworm of birds, Raillietina madagascariensis, have been de- scribed. Incidental transmission to human beings of Fasciola hepatica, which is en- zootic among the sheep, and of Dicrocoelium dendriticum, which parasitizes both cattle and sheep, has been observed. Infections with Clonorchis sinenis are seen sometimes in the Asiatic population but are not of local origin. Other Infections. The presence of bru- cellosis is not recorded, but the disease un- doubtedly exists among the cattle and the goats, and human infections probably occur. Cholera has not been reported from the island within this century. Diseases SpreAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. The true incidence of tu- berculosis among the different tribes has not been determined, but the over-all rate, based upon reported cases, approximates 100 to 150 per 100,000 population. In 1941-46 an average of 3,676 pulmonary and 700 non- pulmonary infections was treated annually by the government health services. The cases of pulmonary tuberculosis remained relatively constant in number, but the non- pulmonary fluctuated from 360 to 1,263. The Service Central de la Tuberculose was organized as a unit of the Institut d’Hygiéne Sociale in Tananarive in 1933. It maintains a diagnostic and treatment clinic in Tananarive and a staff of visiting nurses for the surveillance of cases in their homes. Examinations for tuberculosis are also conducted in some of the schools. The facilities for diagnosis and treatment are inadequate in other parts of the island. Tuberculosis patients are cared for in the larger government hospitals, but consider- able resistance is encountered among the Malagasy toward hospitalization. The con- struction of a large sanatorium and preven- torium is contemplated by the health au- thorities. A program of immunization using BCG vaccine is carried on in certain areas on the central plateau. The vaccine is prepared at the Institut Pasteur de Tananarive. From 1927, when the production of BCG vaccine was started, to 1942 almost 109,000 infants and children were immunized. Due to a shortage of supplies the preparation of the vaccine was suspended from 1943 to 1947. Bovine tuberculosis is present among the native cattle, particularly in the west and the south. Generalized lesions are found at postmortem in about one per cent of the animals seen in the abattoirs in the cattle districts. Meningitis. Localized epidemics of cere- brospinal meningitis occur at irregular inter- vals, with 5 to 10 sporadic cases a year in the intervening periods. Within recent years, outbreaks have been recorded in 1916-17, 1933, 1940-41 and 1946. The epidemic of 1940-41 was the most extensive; 868 cases were reported in 1940, and 164 in 1941. It was largely concentrated in the highland region, but major foci developed around Tananarive and Tamatave, the points most affected by the increased concentration of population occasioned by the war activities. The fatality rate was 20 to 25 per cent. Neisseria meningitidis, Type A, was identi- fied as the causative organism in all of the cases referred to the Institut Pasteur de Tananarive for bacteriologic diagnosis. In 1946 the distribution of the infection was more diffuse. From a total of 240 known cases, the east and the west coasts each claimed 20 per cent. Smallpox. Smallpox has not been re- ported since 1918, when an outbreak oc- curred in the Comores islands. An extensive immunization program is carried out, in- cluding the compulsory vaccination of in- 244 fants 0 to 1 year of age. Between 300,000 and 500,000 persons are vaccinated each year. Mass vaccination campaigns were undertaken in Madagascar and the Comores in 1948, following the discovery of a case of smallpox on a boat sailing from Mombasa to Mauritius. Smallpox vaccine is prepared at the Institut Pasteur and at the vaccine laboratory in Diégo-Suarez. Other Infections. Both lobar and bronchopneumonia are prevalent, particu- larly in the highland districts. The highest incidence is noted in the cool, foggy months from May to October. Localized epidemics of pneumonia are frequent; usually the Merina (Hovas) and the Bétsiléo are most seriously affected. Outbreaks of influenza also occur. Poliomyelitis is endemic. Sporadic cases are observed each year, but the first epi- demic recorded from Madagascar was expe- rienced early in 1946. A total of 121 cases and 15 deaths was reported, but as only the most severe cases were recognized, the ex- tent of the infection could not be deter- mined. Starting from Tananarive, the dis- ease spread rapidly along the major lines of communication. The more humid regions were most seriously affected. Traffic was suspended between Madagascar and the Comores islands, which remained free from infection. Epidemics of measles, mumps and whoop- ing cough are frequent. Diphtheria is spo- radic. From 25 to 90 cases are reported each year, about 50 to 80 per cent being among the native inhabitants. Scarlet fever is re- ported occasionally among both Europeans and Malagasy. DiseEAsEs SPREAD OR CONTRACTED Cuierry THROUGH CONTACT Venereal Diseases. Venereal diseases are widespread among all racial groups. In 1941-46 an average of 222,000 cases of syph- ilis was treated annually in the government hospitals and dispensaries. In the latest year syphilis accounted for 8.8 per cent of the total recorded morbidity on the island. Madagascar and the Comores Archipelago Roughly 25 to 35 per cent of the cases are usually reported from the west coast dis- tricts, in spite of the proportionately low population density. Congenital syphilis is common. The cases of gonorrhea treated in the same period ranged from 43,000 to 59,800 a year. The difference between known cases and actual incidence is probably greater in the case of gonorrhea than of syphilis, because of the marked stigma at- tached to that infection. The majority of cases are never seen by the medical officers. About 4,500 to 5,500 cases of chancroid and 300 to 550 cases of lymphogranuloma vene- reum are also treated annually. A venereal disease control service is organized within the Institut d’Hygiéne Sociale, which op- erates a diagnostic and treatment center in Tananarive and numerous clinics in the principal towns on the island. Yaws. Yaws is endemic among the native tribes in most humid regions below 3,000 feet elevation. It is encountered with great- est frequency on the east coast between Vohemar and Vohipeno, on the west coast between Ambanja and Morondava, and on the islands of the Comores archipelago. Approximately 20,000 persons are treated by the government medical personnel each year. The extent of infection probably is considerably greater than available reports would indicate. Leprosy. Leprosy is widely distributed on Madagascar and the Comores. From 300 to 1,000 new cases are reported annually. The actual prevalence is not known, but in 1938 the number of lepers was estimated at 40,000, or about 10 to 12 per 1,000 popula- tion.2® Limited surveys are made each year by the Service de la Lépre of the Institut d’Hygiéne Sociale, and up to 1946 a total of 12,240 cases of leprosy had been investi- gated. In that year the Service operated 11 mobile teams and 8 diagnostic and treat- ment centers. Over 2,040 lepers were in resi- dence in 26 leprosaria and agricultural villages. Leper hospitals and a leper village are also located on the Comores. Skin Conditions. Tropical ulcers are a Madagascar and the Comores Archipelago 245 frequent cause of disability among both Malagasy and Europeans. The number of cases treated in government hospitals and dispensaries increased from an annual aver- age of 31,000 in 1940-42 to 86,000 in 1946. In the latter year, 55 per cent of the total cases were reported from the sparsely settled west coast region, 25 per cent from the east coast and 20 per cent from the central plateau. Myecotic infections are prevalent. Blasto- mycoses and Madura foot are encountered in many areas. A condition anatomically similar to noma is observed in the highland regions. It occurs predominantly among young children and is regarded as a primary infectious disease by local observers.? The fatality rate of this malady is usually about 80 per cent. Infestations with the itch mite, Sarcoptes scabiei, and the chigoe flea, Tunga pene- trans, are widespread. Rabies. Rabies is enzootic among the dogs on the island. Stray dogs are numerous, and human infections develop from time to time as the result of bites by dogs or other animals. From 80 to 200 persons are treated each year at the Institut Pasteur de Tanana- rive. Patients are transported to Tananarive from the outlying districts by airplane. Rabies vaccine, prepared by the Fermi technic, is furnished by the Institut Pasteur for use in the Colony. Other Infections. Trachoma is relatively rare. The known cases, which are found chiefly among the Asiatic population, usu- ally average from 1 to 10 a year. However, the incidence has increased within the last few years. In 1946 a total of 44 was recorded. Tetanus is endemic; from 110 to 130 cases are reported annually. Anthrax is enzootic among the livestock. Roughly, two million animals are inoculated each year with anti- anthrax vaccine produced at the Institut Pasteur. The extent of human infection is uncertain, but incidental cases undoubtedly occur. Weil’s disease, or leptospirosis, is common, especially in the port cities. Ap- proximately 350 to 400 cases are reported each year. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is one of the most im- portant diseases in Madagascar and repre- sents at least 30 per cent of the total morbidity registered in the government hos- pitals and dispensaries. Within the period 1940-46, the cases treated annually ranged from about 796,000 to 963,000. The infec- tion is present throughout the year in many lowland districts and occurs in seasonal epidemics in the highlands. The incidence reaches its maximum in the first four months of the year, with the greatest num- ber of cases toward the end of the rainy season. In 1946 the infection index per 1,000 population was 163.6 among the Europeans and 208.4 among the Malagasy. Correspond- ing rates, according to region, were 112.0 and 362.2 in the central plateaus; 458.8 and 150.5 in the west coast; and 48.0 and 121.7 in the east coast districts.® The spleen rates usually range from 2 to 6 per cent in the semiarid areas of the south to 40 to 60 per cent in the highlands; the parasite rates from 2 to 10 per cent to 23 to 35 per cent, respectively. In some hyperendemic sec- tions, as in the vicinity of Lake Alaotra and in Betafo district, spleen rates of 70 to 90 per cent and parasite rates of 35 to 40 per cent are general. Roughly 20 to 30 per cent of the infections occur in children under five years of age. Infections with Plasmodium falciparum predominate in all parts of the Colony. In general, P. falciparum is the prevailing in- fection during the epidemic season. P. vivax gains ascendancy in the latency period and is the most prevalent species on the plateaus in November and December. P. vivax infec- tions exist primarily among children under 15 years of age, while P. falciparum is found at all ages and is the principal cause of malaria in adults. P. malariae is encoun- tered infrequently, and almost exclusively in children. Mixed infections are relatively rare. P. falciparum was identified in about 246 Madagascar and the Comores Archipelago 83 per cent, P. vivax in 17 per cent, and P. malariae in 0.1 per cent of the blood films examined at the malaria dispensary in Tananarive during 1946. A characteristic of P. vivax in Madagascar is its tendency to produce many of the symptoms usually as- sociated with P. falciparum. Since 1947, an ambitious antimalaria program has been undertaken by the gov- ernment health authorities. It includes anopheline control measures and the pro- motion of prophylactic drug therapy among the children. Antimalarial drugs are distrib- uted for children O to 6 years of age through the dispensaries and the nurseries, and for older children through the schools. An investigation of malaria morbidity among the peoples of the Comores archi- pelago was undertaken by the Service Anti- paludique in 1941.’ The infection is preva- lent on all of the islands, with the highest rates on Mayotte and Mohéli, and the lowest on Anjouan. The endemic pattern corre- sponds to that of the west coast districts of Madagascar. On Mohéli, the splenic index was found to be 50 to 80 per cent, and the parasite index, 20 to 35 per cent. On Anjouan, which rises to 4,300 feet, the in- fection rates were low at the higher altitudes where P. vivax was the only species encoun- tered. The splenic indices averaged 20 to 25 per cent; the parasite indices, 12 to 20 per cent. On Grande Comore, the prevalence varies markedly from village to village. The cisterns used for the collection of drinking water supplies provide favorable sites for the breeding of the anopheline vectors. The splenic index was 65 per cent at Moroni and 7 per cent at Foubouni, but the para- site indices were 18 per cent and 26 per cent, respectively. Anopheles gambiae and A. funestus are the only vectors in the Madagascar region. Blackwater fever is common among both Europeans and Malagasy, particularly in the plateau districts. From 300 to 750 cases are reported annually. Plague. Plague has been present continu- Distribution of Plague in Madagascar ously in Madagascar since 1921, when an endemo-epidemic focus was established in the plateau region, centering around Tana- narive and the medical districts of Fiana- rantsoa, Emyrne, Ambositra and Vakinan- karatra. Previously sporadic outbreaks had occurred only in the port areas. No extensive epidemics have been re- corded within recent years, but the per- sistence of the infection, with recurrent localized outbreaks, confirms the disease as one of the major public health problems of this area. Since the introduction of a mass immunization program in 1935, the annual average incidence has declined from about 3,400 in 1931-36 to 231 in 1941-48. The human disease normally follows a seasonal pattern, with sporadic cases from May to September and a recrudescence in the en- demic foci at the beginning of the rainy season, when the rats seek shelter in the native dwellings in increasing numbers. The highest incidence is recorded between No- vember and February. In Madagascar the disease is character- Madagascar and the Comores Archipelago ized by the presence of a large proportion of pneumonic infections. In a total of 1,338 cases of plague reported in 1941-46, roughly 61 per cent were bubonic, 9 per cent sep- ticemic, and 30 per cent pneumonic in type. The fatality rates, including all types of in- fections, averaged 85 to 91 per cent. The dis- persal of the population in small scattered villages, and the tendency of the Malagasy to conceal evidence of infection in order to avoid segregation as contacts and to ensure the observance of their traditional funeral rites hamper the prompt discovery of cases and the enforcement of the usual preventive measures, The Service Central de la Peste of the Madagascar health organization conducts an active program for the control of plague on the islands. Measures carried on by its permanent mobile units include the isola- tion of the sick and the interment of the dead in special cemeteries, the quarantine of contacts, the disinfection of contaminated dwellings and clothing, the destruction of rodents and the immunization of the popu- lation in the affected areas. Recently, DDT powder has been used extensively in the disinsectization of market places and living quarters in the villages from which cases of plague have been reported and in the surrounding areas. The Institut Pasteur de Tananarive co- operates with the Service in the conduct of field and laboratory investigations. The live culture E.V. (Madagascar) vaccine of Girard and Robic, which is employed in the government’s immunization program, was developed in its laboratories. This vaccine and an antiplague therapeutic serum are prepared at the Institut Pasteur for use throughout the Colony. Sylvatic plague has not been observed in Madagascar, but the disease may be enzootic among the rats in the major foci. The ex- amination of captured rodents for evidence of infection constitutes an important part of the control program. Plague is not reported from the islands of the Comores group. 247 Filariasis. Filariasis, caused by Wu- chereria bancrofti, is common, particularly in the west coast districts. The highest in- cidence is recorded from the region around Morondava. From 300 to 700 cases are treated each year in the government hos- pitals and dispensaries, but the known cases do not provide an adequate index of the extent of infection. On the island of Mohéli in the Comores about 60 per cent of the inhabitants are reported to have elephanti- asis. Culex quinquefasciatus (=C. fati- gans), the most frequent vector, is wide- spread, as well as species of Anopheles and Aedes. Other forms of filariasis are not known to occur. Relapsing Fever. Sporadic cases of tick- borne relapsing fever, caused by Borrelia duttoni, are reported each year. Up to 1946 the annual incidence averaged 12 to 48 cases, the majority being from foci in the vicinity of Majunga, Tulear, Parafangana and Ambositra. In 1946 an increase to 126 cases was recorded, 103 of which were ascribed to the east coast region. The vector is probably Ornithodorus moubata. Rickettsial Infections. The official re- ports do not indicate the presence of either epidemic or endemic typhus fever on the islands. In 1942, however, a small outbreak of apparent murine typhus was recorded among army personnel at Diégo-Suarez. It is possible that flea-borne typhus exists in other areas, although the diagnosis has not been established. Tick-bite fever is en- countered occasionally, and potential vec- tors are abundant. Other Infections. Dengue fever is en- demic in the east coast and the plateau areas. A few cases are reported every year, and more extensive outbreaks at irregular intervals. The vector, Aedes aegypti, is widely distributed. Foci of sandfly fever are known to exist in the vicinity of Diégo-Suarez and on the island of Mayotte, and reports suggest that the infection is present from time to time in other parts of the Colony. Phlebotomus 248 flies are numerous in the Diégo-Suarez re- gion, but the vectors have not been identi- fied. Yellow fever, trypanosomiasis and leish- maniasis are not reported from Madagascar or its dependencies. NutriTioNAL DISEASES Beriberi is prevalent in many areas. It frequently exists in epidemic form, es- pecially in the region between Nossi-Bé and Majunga on the west coast, and around Tamatave. The disease is attributed to the widespread consumption of polished rice. Treatment and educational programs are carried on in the most seriously affected areas. Other deficiency diseases are seldom recorded, although the nutritional standards of the native peoples are low, and undernu- trition is common. SUMMARY Madagascar, the fourth largest island in the world, has a population of over 4 mil- lion, while that of the islands of the Comores archipelago totals about 152,300. Responsi- bility for the health and the medical care of the people resides in its Service de la Santé Publique, which is advised by the Direction du Service de Santé Colonial of the Ministére de la France d’Outre-Mer. The headquarters of the organization are lo- cated at Tananarive. A subsidiary unit, the Institut d’Hygiéne Sociale, directs its malaria, leprosy, tuberculosis and venereal disease control programs. In 1947 the de- partment operated hospitals in Tananarive, Tamatave, Majunga, Diégo-Suarez and Fianarantsoa with provision for the care of Madagascar and the Comores Archipelago Malagasy and Europeans, 51 smaller pro- vincial and district institutions and 46 ma- ternities, as well as rural dispensaries and maternity clinics scattered over the island. The Institut Pasteur de Tananarive co- operates with the Service de la Santé Publique in research and field investiga- tions of specific diseases. The Service de Santé des Comores administers the health facilities on the Archipelago, with the ex- ception of the technical services. In 1947 there were 7 small hospitals, 2 maternity homes and 3 rural dispensaries on the islands. Water supplies are derived from streams, springs, wells and rainwater cisterns. Mu- nicipal water-supply systems are available in the larger cities. The methods of sewage disposal are universally primitive. The standards of nutrition vary among the tribes. Undernutrition is general, but no frank deficiency diseases are reported, ex- cept beriberi, which is frequent in localities where polished rice is a staple food. Malaria, intestinal infections, tubercu- losis, skin diseases and veneral diseases are prevalent. Leprosy is widespread. Major foci of plague are found in the highland districts of Madagascar. Schistosomiasis, hookworm infection and tick-borne relaps- ing fever are common in localized areas. Epidemics of meningococcus meningitis, measles, whooping cough and pneumonia are frequent. Smallpox is controlled by mass vaccinations, and no cases have been re- ported since 1918. Filariasis, poliomyelitis, dengue fever, rabies and tetanus are en- demic. Trachoma, tick-bite fever, diphtheria and scarlet fever occur sporadically. BIBLIOGRAPHY 1. Archives de Institut Pasteur de Tananarive: Année 1948 (Extrait du rapport annuel), Tananarive, Imprimerie officielle, 1949. 2. Boulnois et Rabedaoro, Bouillat, Bajolet, Favarel et Ramiandrasoa: Le noma 2a Madagascar, Bull. Soc. path. exot. 41:569 (9-10) 1948. 3. Buck, G.: Existence d’Ornithodorus megnini Dugeés a Madagascar, Bull. Soc. path. exot. 41:567-568 (9-10) 1948. 4. Colas-Belcour, J., and Millot, J.: Contribu- tion a l'étude des ixodidés de Madagascar. Sur une variété nouvelle de Haemaphysalis hoodi. Parasitisme humaine par un Booph- ilus, Bull. Soc. path. exot. 41:384-388 (5-6) 1948. 10. 11. 12, 13. 14. 13. 16. 17. Madagascar and the Comores Archipelago Dandouau, A.: Géographie de Madagascar, Paris, Emile Larose, Libraire-Editeur, 1922. Encyclopédie par I'Image: Madagascar, Paris, Librairie Hachette, 1931. Favarel, R.: Le role du pou de I'homme dans le transmission de la peste & Madagascar, Bull. Soc. path. exot. 41:576-580 (9-10) 1948. France. Ministére de la France d’'Outre-Mer: Direction du Service de Santé Colonial, Rapport sur la situation sanitaire dans les territoires frangaises d’outre-mer pendant P’année 1946. ——. ——: Direction du Service de Santé Colonial, Situation sanitaire de I’Empire francais. Tableaux statistiques 1941-1945, Marseilles, Imprimerie Le Conte, 1946. ——: Secrétariat d’Etat aux Colonies: Di- rection du Service de Santé, Giordani, Meédecin colonel, Protection de la mater- nité et de l'enfance indigenes pendant Pannée 1940, Paris, Charles-Lavanzelle & Cie, 1943. . ——: Direction du Service de Santé, Le Gall, Médecin colonel, La situation sani- taire de Empire francais pendant l'année 1940, Paris, Charles-Lavanzelle & Cie, 1943. Girard, G.: Foyers persistants de peste murine a Tananarive, Bull. Soc. path. exot. 33:209-211 (Jan.) 1940. : Les ectoparasites de ’homme dans I’épidémiologie de la peste, Bull. Soc. path. exot. 36:4-41 (1-2) 1943. ——, and Robic, J.: L’état actuel de la peste a Madagascar et la prophylaxie vac- cinale par le virus-vaccin E. V., Bull. Soc. path. exot. 35:42-49 (1-2) 1942. Grosfilez et LeFévre: Les maladies trans- missible observées dans les colonies fran- caises et territoires sous mandat pendant Pannée 1938, Ann. méd. et pharm. col. 38:183-359 (April, May, June) 1940. Le Gall, R.: Les bilharzioses en Afrique occi- dentale francaise, au Togo et a Madagascar de 1939 a 1941, Bull. Office internat. d’hyg. pub. 36:116-126 (No. 3-4) 1944. ——: La meningite cérébro-spinale dans les colonies Frangaises au cours des derniéres anneés, Bull. Office internat. d’hyg. pub. 36:27-40 (Jan.-Feb.) 1944. 18. 19, 20. 21, 22. 23. 24. 28, 26. 27. 28. 29. 30. 249 ——: Le paludisme en Afrique occidentale francaise, au Togo et a Madagascar en 1941, Bull. Office internat. d’hyg. pub. 36: 203-224 (Nos. 5-6) 1944. ——: La peste a Madagascar, Bull. Office internat. d’hyg. pub. 35:318-348 (Nos. 7-8) 1943. ——: Vue d’ensemble sur les maladies pesti- lentielles, endémo-épidémiques, transmissi- bles et sociales a Madagascar entre 1936 et 1940, Bull. Office internat. d’hyg. pub. 35:417-450 (Nos. 9-10) 1943. Neel, R., Payet, M., and Counet, C.: La fievre récurrente a tigues de Madagascar. Historique. Etat actuel de la question, Bull. Soc. path. exot. 42:384-394 (7-8) 1949. ——, Dorel, R., and Journe, H.: Premiéres souches humaines et animale de salmo- nelles du groupe C isolées a Madagascar, Bull. Soc. path. exot. 41:121-124 (3-4) 1948. , Szturm, S., Piechaud, M. and D.: Etude de 84 souches de Shigella isolées a Mada- gascar d’adut 1948 a juillet 1949, Bull. Soc. path. exot. 42:533-538 (11-12) 1949. Poisson, H., and Randriambeloma: Note sur le cysticerose bovine a Madagascar, Ext. du Bull. Soc. path. exot. 21:272-274 (Jan. 19) 1928. Repartition des Schistosomiases dans les Pays africains de 1'Union francaise. Mol- lusques vecteurs: Unpublished (Courtesy of Dr. J. Gaud). Robic, J.: Prémunition antituberculeuse des nourrissons a Madagascar. Etat actuel de la vaccination par le vaccin B. C. G., Bull. Soc. path. exot. 30:327-331 (3) 1937. Sorel, F. P. J.: Essai de démographie des colonies frangaises, Bull. Office internat. d’hyg. pub. 30:1-154, Supplement 2, 1938. Prophylaxie de la lépre dans les colonies frangaises, Bull. Office internat. d’hyg. pub. 30:1-21, Supplement 6, 1938. Vogel, E., and Riou, M.: Les maladies épi- démiques, endémiques et sociales dans les colonies frangaises pendant l'année 1937, Ann. méd. et pharm. col. 37: Supp. 257- 551 (Apr.) 1939. Wilson, D. Bagster: Malaria in Madagascar, East African M. J. 24:171-176 (April) 1947. 17 Mauritius GEOGRAPHY AND CLIMATE Mauritius, one of the Mascarene Islands, in the Indian Ocean about 550 miles east of Madagascar, and several minor island dependencies comprise the British colony of that name. From 1715 until its occupation by the British in 1810, the island was owned by France and called the Ile de France. Mauritius is a small volcanic island of about 720 square miles, surrounded by a fringing reef and numerous small islets. The entire central portion is an irregular pla- teau with an average elevation of 1,000 to 1,800 feet, which rises abruptly from a narrow coastal plain on all sides, except in the north, where it slopes gently toward the ocean. The plateau is broken by chains of mountains with rocky peaks, the highest of which is 2,710 feet. There are numerous rivers, but the majority are short and inter- rupted by a series of waterfalls. The climate on the island varies with the altitude. It is essentially tropical in the low- lands of the north and the west, and sub- tropical in the central highlands, which are subjected to the moderating influence of the -outheast trade winds. There are two main seasons : summer from November to April, and winter during the remaining months. The mean temperature averages 74° to 77° F. at Port Louis and 67° to 75° F. in the highlands. The mean annual range is about 11° F., while the highest and the lowest extremes approximate 90° to 95° F. and 45° to 53° F., respectively. The mean daily range is around 12° to 14° F. at all seasons of the year. In spite of its equable temperatures the climate of the island is frequently trying, because of the high humidity. The mean relative humidity ranges from 70 per cent at sea level to 80 to 90 per cent in the highlands. The rainfall is distributed unevenly. In the coastal belt of the east and the south- east it averages 50 to 75 inches a year, while on the eastern slopes of the plateau it reaches 125 to 200 inches. The driest areas are found on the plains of the west and the northwest, where the annual precipitation rarely exceeds 30 to 40 inches. The rainfall is heaviest during the summer months, which are dominated by the tropical cy- clones of the Indian Ocean. They occur most frequently between January and March and may be responsible for consider- able destruction of life and property. Periods of drought are experienced at irregular intervals. The smaller islands of the Colony are widely scattered in the Indian Ocean. The most important is Rodriguez, an island of about 42 square miles, approximately 350 miles east of Mauritius. Diego Garcia, the next largest in size, is the principal island of the Chagos group, situated about midway between Mauritius and Ceylon. Agalega and Cargodos Carajos are minor dependencies. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopruraTiON In 1947 the population of Mauritius (ex- clusive of a little over 12,000 inhabitants on the lesser islands) was enumerated at about 438,700. For statistical purposes, the popu- lation is divided into three groups: the gen- 250 Mauritius 251 eral population, which includes Europeans and peoples of European, African and mixed origins ; the Indo-Mauritians; and the Chi- nese. In the 1947 estimates, the general population totaled 147,520; the Indian, 278,800; and the Chinese, 12,380. The white residents are primarily British or French, many of whom are descendants of the old French aristocracy who migrated to the island in the seventeenth century. A large percentage of the Indians descend from laborers imported between 1842 and 1910 for work on the sugar plantations. While English is the official language, French and a creole patois are used extensively in all parts of the island. The religious affiliations of the inhabitants correspond to their racial complex. The general population is almost exclusively Christian, while about 77 per cent of the Indians are Hindus, 22 per cent Moslems, and 1 per cent converts to Chris- tianity. The density of population averages about 589 per square mile, but it varies from a little over 100 in the western lowlands to more than 1,500 on the plateau. About 37 per cent of the inhabitants are concentrated in the township areas. In 1949 the popula- tion of Port Louis, the capital and principal trading center, was about 70,000. That of the second town, Curepipe, was around 29,000. Elementary and secondary school facili- ties are provided by the Colonial gov- ernment, by various missions, with and without financial assistance from the gov- ernment, and by private groups. English is the medium of instruction in schools above the primary level. In 1948 it was estimated that the literacy in the general population averaged 45 per cent, and in the Indian 21 per cent for the men and 6 per cent for the women. VITAL STATISTICS In the 8 years from 1940 to 1947, the birth rates ranged from 29.8 to 43.8 per 1,000 population, and the death rates from 20.1 to 36.1. The birth rates in the general popu- lation fluctuated between 31.3 and 36.9, and in the Indian population between 28.7 and 50.6. Correspondingly, the death rates ranged from 17.5 to 28.5 in the general population, and from 21.6 to 40.4 in the Indian. The infant mortality varies from 100 to 300 in different localities but usually aver- ages 150 per 1,000 live births for the island as a whole. In 1945 it reached 188.0, but in 1947 it declined to 113.9. The stillbirth rate was 5.5 per cent in the general population in 1946, and 9.7 per cent in the Indian; in 1947 it was 4.9 and 7.6 per cent, respec- tively. The maternal mortality approxi- mated 10 to 15 per 1,000 live births (in- cluding stillbirths). The high incidence of parasitic and intestinal infections contrib- utes to the elevated infant mortality rates. SociaL Economy The economy of Mauritius centers around the sugar industry, which represents over 95 per cent of the income of the Colony. In 1945 about 29 per cent of the total land area was planted in sugar cane. It is grown on large estates and individual farms; roughly one fourth of the acreage is worked by small planters who contribute 20 to 25 per cent of the total crop. Tea, tobacco, aloe fiber, or the so-called Mauritius hemp (Furcroea gigantea), and food crops are also cultivated. Milch cows and other live- stock are raised in many areas. Sugar, rum, alcohol, aloe fiber and copra are the only exports, but numerous small industries have been developed for the manufacture of local products for home consumption. The island is well supplied with roads, although the majority are not adapted to motor transport. Seven short railway lines, which are owned and operated by the gov- ernment, cross the island or otherwise link the agricultural areas with the port towns. The longest is 352% miles in length; the shortest, between 3 and 4 miles. Steamer traffic connects Mauritius with its island dependencies and with ports in Africa, Europe and the Far East. Air service is also 252 Mauritius available from Plaisance, near Mahébourg, to Réunion and to Johannesburg and Nai- robi, with connections to Europe. Foop AND NUTRITION The Colony is not self-supporting but im- ports about nine tenths of its food supply. In 1948 only 28,000 acres were planted in food crops, or less than one fifth of the acreage which was devoted to sugar cane. The prin- cipal crops raised for food are maize, pea- nuts, rice, and various roots and other vege- tables. The production of maize and certain root crops is encouraged by means of gov- ernment subsidies. Numerous varieties of tropical fruits are indigenous to the islands. Undernutrition and nutritional diseases are common. Their distribution is influenced by the relatively high cost of imported goods and by the low economic status of a con- siderable proportion of the population. A nutrition officer was appointed in 1946 to investigate means of raising the level of nutrition among the inhabitants. Housine The standards of housing are generally inferior. The thatched mud hut constitutes the typical dwelling of the average peasant, but within recent years the increasing prev- alence of insanitary shacks of temporary construction has become a serious problem. In contrast, the homes of the more affluent Mauritians, and particularly the suburban country houses, are large and spacious. ENVIRONMENT AND SANITATION WATER SUPPLIES The water supplies on Mauritius are de- rived from streams and wells. Most localities are provided with piped supplies from large or small impounded reservoirs. The water supply for Port Louis is obtained from a reservoir at Pailles en the Grand River North West and frcm the government's Mare aux Vacoas project. The latter reser- voir, which has a capacity of 597 million cubic feet, furnishes water for Curepipe and other towns in Plaines Wilhems district and for parts of Moka and Port Louis districts, as well as for irrigation and hydroelectric purposes. Both supplies are filtered and chlorinated. They are controlled bacterio- logically and chemically by the Colonial health services. The water supplies in the rural areas are frequently contaminated, particularly in the northern districts where the rainfall is de- ficient over a large part of the year. The irrigation requirements of the low- rainfall areas are met by two reservoirs, while a third was nearing completion in 1948. WasTE DisposaL The only sewerage system on the island serves the municipality of Port Louis. A large part of the town is connected with the sewer, which discharges into the sea. The sewage of Curepipe is collected by the bucket system and is treated in a central septic tank disposal plant at Phoenix. In other localities, individual septic tanks are connected with many of the larger dwell- ings, but pit and bucket latrines constitute the usual methods of disposal. Indiscrimi- nate pollution of the soil is general in the rural areas, even when other methods of disposal are available. Fauna AND FrLora Arthropods. Mosquitoes. Several species of anopheline mosquitoes have been identi- fied, but only Anopheles funestus and A. gambiae are important as vectors of mala- ria. A. funestus is plentiful throughout the year, while 4. gambiae breeds abundantly during the rainy season. Both species decline in frequency above 1,000 feet, although under favorable climatic conditions, A. gambiae may be found at elevations above 1,800 feet. A. coustani and A. maculipalpis are also present. 4. gambiae melas was identified for the first time at St. Martin in Savanne district in 1947.14 Species of Aedes and Culex are common. Culex quinquefasciatus (= C. fatigans), Mauritius 253 Anopheles gambiae and A. funestus are im- portant vectors of filariasis. Anopheline control measures are carried on in all parts of the island. Prior to 1946 they consisted primarily in the canalization and the clearing of streams, the drainage of marshes and the antilarval treatment of breeding sites. In that year the residual spraying of dwellings was initiated on an experimental basis in several localities in the Black River region. Subsequently, control operations were organized in the central and the northwestern districts of Plaines Wil- hems, Moka, Port Louis and Pample- mousses. In November, 1948, a comprehen- sive two-year program for the eradication of mosquitoes from the island was undertaken under the direction of the Colonial Insec- ticides Committee of the Colonial Office. The experiment combines spraying with DDT preparations or other insecticides and, where necessary, the usual antilarval meas- ures. Fries. Numerous species of flies are prev- alent, many of which may be responsible for the mechanical transmission of intestinal in- fections. Species of Musca, Stomoxys, Tabanus, Lucilia, Calliphora and Hippo- bosca have been identified. Stomoxys nigra is widespread and is regarded by many as an important vector of trypanosomiasis, which is enzootic among the livestock. Spe- cies of Glossina are absent from the island. Biting midges are widespread pests. OtuER ArTHROPODS. Fleas, lice, bedbugs and ticks are plentiful. The vesicant beetle, Catharis, is indigenous. Reptiles. No poisonous snakes have been reported from Mauritius. Rodents. Rattus rattus alexandrinus is widely distributed. R. norvegicus is preva- lent in the port towns. R. rattus rattus and R. rattus frugivorus are encountered fre- quently. Wild rodents are numerous, but none has been implicated in a reservoir of human infection. Mollusks.* Fresh-water snails are found in the numerous streams throughout the * See footnote, p. 10. island. Bulinus (Pyrgophysa) forskalii, which is probably the local intermediate host of Schistosoma haematobium, is abun- dant in the northwestern districts. Foop SANITATION The inspection of markets, abattoirs and food establishments is the responsibility of the local authorities in Port Louis, Cure- pipe, Beau Bassin-Rose Hill and Quatre Bornes, and in other localities, of the Colo- nial health organization. There are six public and four private abattoirs in the Colony ; the former are su- pervised by veterinary officers appointed by the local health services. Milk supplies are obtained from large numbers of individual producers. Chemical tests for adulteration are made at frequent intervals, but no bac- teriologic controls are enforced. There is no organized pasteurization. HEALTH SERVICES AND MEDICAL FACILITIES HeaLTH ORGANIZATIONS The Medical and Health Department ot the Colonial government is responsible for the supervision of public health and the operation of medical facilities on Mauritius and its dependent islands. The Department functions directly under the Governor of the Colony, who is advised in matters of health by the medical officers of the Colonial Office in London. The Department is organized on a dis- trict basis and is administered by a Director of Medical Services with headquarters at Port Louis. It has special branches for hookworm and malaria control, and port quarantine. The Maternity and Child Welfare So- ciety carries on work among the women and the children in co-operation with the De- partment. The activities of the Société Pas- teur de la Goutte de Lait were taken over by the municipality of Port Louis in 1947. The Catholic and the Protestant mission organizations contribute to the health of the 254 Mauritius inhabitants through their educational and welfare services. MebicAL INSTITUTIONS Hospitals and Dispensaries. In 1947 the Medical and Health Department operated general hospitals at Port Louis and Quatre Bornes with a capacity of 323 and 269 beds, respectively. It also conducted six district hospitals on the island of Mauritius, which ranged in size from 65 to 106 beds and sup- plied a total of 513 beds. Special facilities included a mental hospital with 594 beds and a leprosarium with 55 beds. The Department maintained 39 rural dis- pensaries in various parts of the island, and two mobile units to serve the remote areas. It also supported 10 maternity and child welfare centers, and antenatal clinics in the Port Louis and the Flacq hospitals. About 32 different estates conduct dis- pensaries, with an aggregate capacity of 712 beds for the benefit of their workers; in ad- dition, a small co-operative industrial hos- pital is established in the northern part of the island. The medical facilities on the island of Rodriguez include a government hospital at Port Mathurin and two rural dispensaries. Laboratories. The Medical and Health Department has a central laboratory, with bacteriologic, hematologic, and biochemical divisions at Réduit. Branch laboratories are located in the general hospitals in Port Louis and Quatre Bornes. Clinical laboratory facilities are available in the larger district hospitals. A laboratory for malaria and entomologic research is con- nected with the headquarters of the malaria control unit in Port Louis. Schools. Nurses training schools are con- ducted in the hospitals at Port Louis and Quatre Bornes. Scholarships are available to qualified graduates for further training in the United Kingdom to meet the require- ments for registration. Courses for the train- ing of midwives are given in the maternity and child welfare centers. Courses for sani- tary inspectors are provided in Port Louis and other towns. PERSONNEL Physicians. In 1948 the staff of the Medi- cal and Health Department included 24 physicians, 2 of whom were health officers. Doctors are employed on some of the sugar estates, and a few are in private prac- tice. Others. The roster of the Department in 1948 listed one dentist, two pathologists, two chemists, a radiologist, an entomologist, a sanitary officer and a nutrition officer. Three midwives were connected with the Department, and 28 with the Maternity and Child Welfare Society. Nurses are employed in the government and industrial hospitals and dispensaries. DISEASES Records of the incidence of specific dis- eases in Mauritius are derived from govern- ment hospital and dispensary statistics. They are incomplete but probably give a fair picture of health conditions on the island, since a relatively large proportion of the population is settled within reach of the medical facilities. The field investigations of the malaria-control organization provide supplementary information within the scope of its activities. The island dependencies of Rodriguez, the Chagos archipelago, Agalega and Cargados Carajos are not included in the discussion of the diseases characteristic of the Colony. DiseAsES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. En- teric fevers are endemic. From 300 to 700 cases are reported each year, usually with a peak of incidence in the months of March and November. The greatest number of cases occur in the low-rainfall districts in the north and the northwest, where the water supplies are inadequate and fre- Mauritius 255 quently polluted. An antityphoid immuniza- tion program is carried on in the areas of highest endemicity by the Colonial health authorities. Dysenteries. The low standards of sani- tation and the absence of sanitary water supplies in many rural areas contribute to the prevalence of dysentery and other in- testinal infections. In the three years 1945 to 1947, from 3,200 to 7,000 cases of dys- entery were recorded annually. In the hos- pital statistics no distinction is made as to type, but both amebic and bacillary infec- tions are undoubtedly widespread. End- amoeba histolytica is frequently identified in the fecal specimens sent to the central laboratory for diagnosis. The cases of diar- rhea and enteritis treated in the government hospitals and dispensaries average from one to two times the number diagnosed as dys- entery. Helminthiases. ANcyLosToMmiasts. Hook- worm infection is prevalent in the agri- cultural districts. The highest incidence is found in the lowland areas in the northern part of the island, where infection rates of 70 to 90 per cent were recorded in 1938. The active educational and treatment campaign carried on by the hookworm-control unit of the Colonial health services in the previous decade was curtailed in 1945, due to a shortage of personnel. Nevertheless, the re- ported cases declined gradually from 10,261 in 1945 to 8,063 in 1947. Scuistosomiasis. Infection with Schis- tosoma haematobium is endemic in lo- calized foci, particularly in the northwestern part of the island. An average of 454 cases of schistosomiasis was recorded annually in 1944-47. The fresh-water snail, Bulinus (Pyrgophysa) forskalii, is the probable in- termediate host. S. mansoni is not reported. OtHER HELMINTH INFECTIONS. Ascariasis is widely distributed, the cases treated an- nually by the medical personnel being almost as numerous as those of hookworm infection. Infections with Trichuris trichiura and Strongyloides are common, but Enter- obius vermicularis is infrequent. The beef tapeworm, Taenia saginata, occurs sporadi- cally among the cattle, but human infections are relatively rare. Echinococcosis and in- fections with the pork tapeworm, 7. solium, and with the dwarf tapeworm, Hymenolepis nana, are encountered occasionally. Cases of infection with the fluke, Fasciola hepatica, are seen sometimes, usually in the Asiatic population. Other Infections. Cholera has not oc- curred in Mauritius within the present century, but 6 epidemics were recorded between 1775 and 1862, when the disease was last reported from the island. Brucel- losis, caused by Brucella abortus, has re- cently been recognized among the dairy herds, and the existence of occasional human infections is probable. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread, but the extent of infection is not known. In 1945-47 an average of 1,260 cases was treated annually in government insti- tutions. The recorded death rate is roughly 45 to 65 per 100,000 population. Smallpox. Smallpox has not been re- ported on Mauritius since 1913. An exten- sive vaccination program is undertaken by the Colonial health authorities. Approxi- mately 60 to 65 per cent of children are vaccinated in infancy by government agents, while others are vaccinated by private prac- titioners. Poliomyelitis. Poliomyelitis is endemic, and severe epidemics were reported in 1945 and 1948. The disease broke out in Rose Hill in February, 1945, and spread rapidly throughout the island, where the housing conditions had deteriorated as the result of recent cyclones. Between February and May, 1,095 cases were recorded—over 70 per cent in the month of March. The out- break gradually subsided, but the total cases for the year reached 1,116. About 95 per 256 Mauritius cent were in children under 10 years of age, while almost two thirds were in children under 5 years. Sporadic cases only were diagnosed in 1946 and 1947, but a recrudes- cence occurred in 1948. From December through January, 1949, 362 cases were reported, predominantly among children under 4 years of age. The fatality rate was 3.6 per cent, in contrast with the rate of 7.3 per cent in 1945. The incidence decreased steadily in 1949, and only sporadic infec- tions were noted after the first quarter. At the time of the first epidemic, a temporary hospital was created at Floreal. Orthopedic services were organized with financial as- sistance from British Colonial Development and Welfare funds. District clinics were also established for the care and the rehabil- itation of convalescent cases. Other Infections. Outbreaks of influenza are frequent. Pneumonia is most prevalent in the northern and the western districts. Bronchitis, asthma and other respiratory conditions of uncertain etiology are com- mon. Diphtheria is sporadic. Measles and whooping cough are endemic. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH CONTACT Venereal Diseases. All forms of venereal disease are encountered. From 900 to 1,600 cases of syphilis, from 300 to 1,100 cases of gonorrhea and from 50 to 180 cases of soft chancre are treated each year in govern- ment institutions. However, the known cases are not a reliable index of the extent of infection. Leprosy. Leprosy is common in the lowland areas. The disease was supposedly introduced from Madagascar in 1770. No record of incidence is available, but 55 pa- tients were under treatment in the leper hospital in 1948. From 3 to 11 new cases are admitted each year. Other Infections. Mycotic infections and phagedenic ulcers are widespread. Scabies is general. Infections of the eyes are numerous among all sections of the population. Di1seEASES SPREAD BY ARTHROPODS Malaria. Malaria is one of the most im- portant public health problems in Mau- ritius, but the provisional results of the mosquito-control program suggest the pos- sibility of its disappearance, subject to suit- able quarantine regulations. The infection was introduced in 1865 and spread rapidly. Malaria is hyperendemic in the coastal belt and in the lowlands of the central and the northern districts of Plaines Wilhems, Moka, Port Louis and Pamplemousses. Elsewhere, it occurs in seasonal epidemics. Transmission takes place throughout the year at sea level, but the period of highest incidence coincides with the latter part of the rainy season and usually extends from January to June. The intensity of infection varies in different localities, and spleen rates ranging from 4 to 90 per cent are encoun- tered. In a survey in 19421? the spleen rates in children from 2 to 10 years of age aver- aged 46 per cent, and the parasite rates 36 per cent in localities below 600 feet. Except under epidemic conditions, the spleen rates decreased to 13 per cent at 600 to 1,200 feet, and to 8 per cent at 1,200 to 1,800 feet. The degree of immunity among the native popu- lations is relatively low. Plasmodium falciparum infections pre- dominate. Among the malarial parasites found in 183 blood specimens diagnosed in the central laboratory in 1947, 99 were iden- tified as P. falciparum, 79 as P. vivax and 5 as P. malariae. Occasional cases of P. ovale infection have been observed. As the result of antianopheline measures carried out in the vicinity of Port Louis and Mahébourg in the early 1940’s the spleen rate was reduced from 50 to 20 per cent. The mosquito-eradication experiment initiated in 1948 incorporates the application of re- sidual insecticides, augmented by antilarval measures and the treatment of the inhabit- ants with antimalarial drugs. Preliminary results obtained in 1949 after one applica- tion of insecticide sprays to buildings and other places harboring mosquitoes indicate Mauritius 257 a reduction in the parasite rates in 6 dif- ferent areas from between 2.5 and 14 per cent to between 0.2 and 8 per cent; in the spleen rates from between 6 and 53 per cent to between 0.8 and 28 per cent. Filariasis. Infection with Wuchereria bancrofti is endemic, with rates of 16 to 28 per cent in many villages in the coastal re- gion and the river valleys. Elephantiasis is common. The mosquito-eradication experi- ment now in progress, if successful, will also free the island from this disease. Other Infections. Plague has not been present within recent years. In the last major outbreak in 1899-1908, over 6,000 cases were recorded, and 4,400 deaths. Dengue fever is endemic. Typhus fever, re- lapsing fever and yellow fever are not reported. NUTRITIONAL DISEASES The standards of nutrition are low, and deficiency diseases are widespread. In 1945- 47 from 12 to 43 cases of beriberi, from 188 to 482 of pellagra, from 24 to 32 of rickets and from 26 to 33 of scurvy were treated annually in the government hos- pitals and dispensaries. In addition, from 800 to 1,800 cases of undifferentiated avi- taminoses were included among those ad- mitted for treatment. SUMMARY The British colony of Mauritius includes an island of 720 square miles and several minor dependencies located in the Indian Ocean. In 1947 the population of the island of Mauritius was 438,700, and of the lesser islands about 12,000. The economy of the Colony is founded upon the sugar industry. Responsibility for the administration of the public health and medical care services of the Colonial government resides in its Medi- cal and Health Department, with head- quarters at Port Louis. In 1947 it operated 2 general hospitals and 6 district hospitals, with an aggregate capacity of 1,100 beds, and 39 rural dispensaries on the island of Mauritius; 1 hospital and 2 dispensaries on the island of Rodriguez. Water supplies are obtained from streams and wells. The town- ships are provided with piped supplies, which are treated by filtration and chlorina- tion, but the water supplies in the rural areas are frequently contaminated. A sewer- age system serves part of the municipality of Port Louis, but the methods of disposal are primitive in other areas. The standards of nutrition are low, and deficiency diseases are common. Malaria, dysentery and other intestinal diseases, hookworm and other helminth in- fections, venereal diseases and skin infec- tions are widespread. Filariasis, caused by Wuchereria bancrofti, tuberculosis, severe bronchial infections and enteric fevers are prevalent. Schistosoma haematobium is present in numerous foci. Smallpox is con- trolled by vaccination and has not been reported since 1913. Extensive epidemics of poliomyelitis were recorded in 1945 and 1948. Outbreaks of cholera and plague have occurred in the past, but not within recent years. BIBLIOGRAPHY 1. Adams, A. R. D.: Studies on bilharzia in Mauritius. II. The recovery of adult Schis- tosoma haematobium after development in Bulinus (Pyrgophysa) forskali, Ann. Trop. Med. 29:255-60 (July) 1935. 2. Anderson, Daniel E.: The Epidemics of Mauritius with a Description and His- torical Account of the Island, London, Lewis, 1918. 3 Gebert, S.: Notes on filariasis and its trans- mission by Mauritian anophelines. Tr. Roy. Soc. Trop. Med. & Hyg. 30:477-480 (Jan.) 1937. 4. Great Britain. Colonial Office: Annual Re- port on Mauritius for the Year 1948, Lon- don, H. M. Stationery Office, 1949. : Colonial Research, 1948-1949, Lon- don, H. M. Stationery Office, 1949. 6. Jepson, W. F., Montia, A., and Courtois, C.: The malaria problem in Mauritius; the bionomics of Mauritian anophelines. Bull. Ent. Res. 38:177-208 (May) 1947. 3 258 Mauritius 7. Mauritius, Colony of: Annual Report of the Registrar General, 1947, Port Louis (Mauritius), Govt. Printer, 1948. : Annual Report on the Medical and Health Department, 1939, Port Louis (Mauritius), Govt. Printer, 1941. 9. ——: Annual Report on the Medical and Health Department, 1940, Port Louis (Mauritius), Govt. Printer, 1941. : Annual Report on the Medical and Health Department, 1941, Port Louis (Mauritius), Govt. Printer, 1942. 11. ——: Annual Report on the Medical and Health Department, 1944, Port Louis (Mauritius), Govt. Printer, 1946. 12. ——: Annual Report on the Medical and Health Department, 1945, Port Louis (Mauritius), Govt. Printer, 1946. 13. ——: Annual Report on the Medical and Health Department, 1946, Port Louis (Mauritius), Govt. Printer, 1947. : Annual Report on the Medical and Health Department, 1947, Port Louis (Mauritius), Govt. Printer, 1949. 10. 14. 15. 18. 19. 20. : Blue Book of Mauritius and its De- pendencies, 1945, Port Louis (Mauritius), J. Eliel Felix, Acting Govt. Printer, 1948. . Mauritius. Malaria Eradication Experiment: Unpublished Report, 1949-50. (Courtesy of Mr. C. B. Symes, Colonial Insecticides Committee.) McFarlan, A. M.: The epidemiology of the 1945 outbreak of poliomyelitis in Mauri- tius. (Summary), Proc. Roy. Soc. Med. 39:323-24, 1945-46. , Dick, G. W. A,, and Seddon, H. J.: The epidemiology of the 1945 poliomyelitis outbreak in Mauritius, Quart. J. Med. 15:183-208 (July) 1946. Sippe, G., and Twining, May: Survey and field treatment of malaria in Mauritius, London, Crown Agents for the Colonies, 1946, Abst., Trop. Dis. Bull. 45:134-135 (Feb.) 1948. Webb, J. L., and Webb, A. M. L.: A first record of Brucella abortus (Bang) in the cattle of Mauritius; and data on the possi- ble occurrence locally of undulant fever in man. J. Hyg. 46:419-421 (Dec.) 1948. 18 Réunion GEOGRAPHY AND CLIMATE The island of Réunion, formerly known as Bourbon, has been a French possession since 1643. In 1948 its status was changed from that of a colony to an overseas depart- ment of France. The island, which has an approximate area of 970 square miles, is located in the Indian Ocean about 420 miles east of Madagascar. It is volcanic in origin, with a high regular coastline, but a complex mountainous surface which presents a va- riety of features: narrow coastal lands, hill country, mountain masses and high pla- teaus. In the north the rugged massif of Piton des Neiges rises boldly from the coast to an elevation of 10,068 feet. The peak is flanked by three craters with grassy, culti- vated slopes which are surrounded by an almost perpendicular rocky wall. To the southeast a second mountain mass culmi- nates in two craters over 8,300 feet in height, one of which is still active but has not erupted since 1926. The encircling moun- tain wall is unique in its regularity. The massifs are joined by high tablelands which occupy the greater part of the island. They are fissured by deep canyons and narrow gorges through which numerous small streams cascade to the sea. Owing to the marked differences in topog- raphy, a wide variety of climatic conditions is encountered, ranging from tropical along the coast to alpine in the mountains during the winter, when the peaks are capped with snow. The year may be divided into two seasons: the hot and rainy, from November to April, and the cool and dry, from May to October. The mean temperatures on the 259 coast approximate 73° F. in the winter and 78° F. in the summer. The maximum is about 94° F., and the minimum about 59° F. The relative humidity averages 90 per cent. On the plateau and on the slopes of the mountains the climate is temperate, while the mean temperatures range from 62° to 66° F. Several popular resorts are located in this area, particularly near the mineral springs around Piton des Neiges. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopULATION In the census statistics of 1947 the popu- lation of Réunion was enumerated at 242,- 000—an increase of almost 50,000 since 1920. The inhabitants are not indigenous to the island but are composed of various pure and mixed elements of European, Malagasy and Asiatic origin. About 97 per cent are French, and the remainder predominantly Indian or Chinese. Prominent among the French are the creoles, descendants of the early settlers in the seventeenth and the eighteenth centuries. The language of the island is a creole patois which represents a mixture of French, Malagasy and Indian words, containing various local idioms. The population is largely concentrated in the coastal region, in the urban centers or in the villages along the road which encircles the island. Saint-Denis, the capital, had a population of about 36,000 in 1946. Several other towns with from 10,000 to 25,000 population are located along the coast. Numerous elementary schools are main- tained by the government and by private 260 Réunion groups, but until recently the standards of education have been relatively low. There are only two lycées, one for boys and one for girls. VITAL STATISTICS In 1947 the birth rate was calculated at 40.8 per 1,000 population, and the death rate at 21.4. The infant mortality rate was 145.5 per 1,000 live births. The infant deaths usually contribute about one third, and the deaths among children under 5 years of age about 40 to 50 per cent of the total mor- tality. Sociar Economy The economy of the island is essentially agricultural, but only 35 per cent of the land is inhabited and under cultivation. Of this acreage roughly 40 per cent is devoted to sugar-cane plantations, while almost 10 per cent is planted in manioc. Other com- mercial crops include vanilla beans, which are second only to sugar in value, perfume plants, cocoa and coffee. The inaccessibility of the pasturelands on the plateaus pro- hibits the extensive raising of livestock. The local industries are largely based upon the agricultural products of the country. Sugar, rum, tapioca, flour, vanilla and geranium essence are the chief exports. Steamer and air transport services link Réunion with centers in Africa, Europe and Asia, as well as with the islands of Mada- gascar and Mauritius. Pointe-des-Galets, an artificial harbor on the northwest coast, is the chief port. It is connected by an 80-mile coastal railway with Saint-Denis in the north, Saint-Benoit in the east and Saint- Pierre on the southwest. Foop AND NUTRITION A large proportion of the arable land is devoted to commercial crops, and the island is dependent upon imports for a considera- ble part of its food supply. Maize, potatoes, beans, rice and a wide variety of fruits are grown locally. There are few cattle or goats on the island, but pigs are raised in some localities on the plateau. Little or no milk is available, and meats are scarce. Fish are used extensively, but the average diet is deficient in animal proteins. The level of nutrition is governed to a large extent by the economic status and the customs of the family. Undernutrition and deficiency con- ditions are general. Beriberi is widespread. ENVIRONMENT AND SANITATION The water resources of Réunion are de- rived from the numerous rivers and streams which originate in the mountains and course through the deep canyons to the sea. The water supplies are adequate, except on the west coast where the rainfall is deficient and the streams are negligible in volume during the dry season. In many localities of this area the inhabitants are dependent upon the collection of rainwater in catch- ment basins. None of the towns has a treated water supply, and pollution is frequent in both urban and rural areas. The standards of sanitation are low, and the methods of sewage disposal are primi- tive. The arthropod vectors are numerous. Little detailed information is available, but the species are probably essentially the same as those found on the neighboring island of Mauritius. HEALTH SERVICES AND MEDICAL FACILITIES HeaLTH ORGANIZATIONS The Direction de la Santé, with head- quarters in Saint-Denis, is responsible for the health and the medical care of the popu- lations of Réunion. When the status of the island was changed from that of a colony to an overseas department in 1948, the local health services were transferred from the jurisdiction of the Direction du Service de Santé Colonial, of the Ministére de la France d’Outre-Mer in Paris, to the Ministere de la Santé Publique et de la Population. The Direction, which has curative and preven- Réunion 261 tive divisions, functions directly under the Prefecture of the Department. MebpIcAL INSTITUTIONS Hospitals and Dispensaries. The Direc- tion de la Santé operates 5 general hospitals, at Saint-Denis, Saint-Paul, Saint-Louis, Saint-Pierre and the port at Pointe-des- Galets. The largest, at Saint-Denis, has a capacity of approximately 150 beds. Mater- nity wards are available in all of the hos- pitals; in addition, a maternity hospital of 116 beds is located at Saint-Denis. A leper hospital with accommodations for 30 lepers is established near Saint-Denis. The Direc- tion maintains from 40 to 45 dispensaries in the smaller towns and rural areas, and child welfare clinics in Saint-Denis and Saint- Louis. Laboratories. The Institut d’Hygiene et de Microbiology, in Saint-Denis, is the cen- tral laboratory of the island health services. It conducts all the bacteriologic, serologic and hygienic examinations for the territory. Clinical laboratory facilities are avail- able in the larger hospitals. PERSONNEL Physicians. No recent information is available but 26 physicians were reported to be practicing in Réunion in 1939. In addi- tion, 14 government physicians were con- nected with the health services. Others. In the same year 5 dentists and 20 pharmacists were located on the island. Twenty-seven midwives were employed in the health services, while 11 were in private practice. Nurses are attached to all hos- pitals and dispensaries. DISEASES Records of the incidence of specific dis- eases in Réunion are based upon hospital and dispensary statistics. Reporting is in- complete and until recently was seriously affected by the changes in personnel and other dislocations which accompanied the war from 1939 to 1945. Diseases SPREAD oR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fever is endemic, and water-borne in- fections frequent. In the 7 years, 1940 to 1946, from 21 to 68 cases were reported an- nually. No sanitary water supplies are found on the island, and pollution is general. A relatively low infection rate exists among the native inhabitants which is attributed by the local health authorities to a probable autoimmunization of the population. The paratyphoid fevers are not differenti- ated in the hospital reports. Eberthella typhi predominates in the cases diagnosed in the bacteriologic laboratory in Saint- Denis, but paratyphoid organisms are iso- lated occasionally. Dysenteries. Both bacillary and amebic dysentery are widespread. The actual in- cidence is not known, since the diagnosis is rarely confirmed by laboratory examina- tions and a large percentage of the infec- tions are not reported. The returns for 1940- 45 would indicate less than 100 cases a year. In 1946, however, 1,531 cases of amebic dysentery and 1,649 of bacillary dysentery were recorded. Dysentery and enteritis are second only to malaria as causes of death in infancy and early childhood. Helminthiases. ANcyLosToMmIAsts. Hook- worm infection, caused by Ancylostoma duodenale, is common in the agricultural areas of the coastal region. OrHER HELMINTH INFECTIONS. Ascaris, Strongyloides and Trichuris infections are prevalent. Tapeworm infection is sporadic. The species is not designated in available reports but is presumably Taenia solium, since few cattle are kept on the island. Schistosomiasis is not known to be pres- ent: Other Infections. Cholera has not been reported within the last century, but was known to be epidemic in 1817-21. 262 Réunion Diseases SpreAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is apparently increasing among the inhabitants. A total of 730 cases was recorded in 1946; and 116 deaths. Moreover, health authorities believe that a survey might reveal a greater preva- lence. No special facilities for diagnosis or treatment exist on the island. Poverty, ignorance of the basic principles of per- sonal hygiene, undernutrition and poor living conditions favor the spread of the disease. Pulmonary infections predominate, but all forms of tuberculosis are encountered. Smallpox. Vaccination against smallpox is required, and no cases have been reported within recent years. Poliomyelitis. An epidemic of poliomye- litis occurred in 1949 in which a total of 148 cases was recorded. The majority of the cases were in children under 7 years of age. Forty of these children were flown to Paris in December for treatment. Previous rec- ords are fragmentary, but the infection is probably endemic on the island. Other Infections. Pneumonia is preva- lent. Epidemics of influenza have occurred from time to time. Localized outbreaks of meningococcus meningitis are sporadic. Measles and whooping cough are fre- quently epidemic. The incidence of diph- theria is normally low but an outbreak of 496 cases was recorded in 1946. Immuniza- tion of children against diphtheria was made compulsory in 1948. Scarlet fever is rare. DiseASES SPREAD OR CONTRACTED CuierLy TuroucH CONTACT Venereal Diseases. All forms of venereal disease are recorded. Syphilis predominates, but its prevalence cannot be determined since relatively few cases seek treatment in government institutions. In 1946, which may be regarded as a representative year, 1,580 cases of syphilis were recorded, while 1,427 children under five years of age were treated for congenital syphilis. In the same year 518 cases of gonorrhea, 58 cases of chancroid and 42 cases of lymphogranuloma venereum were reported. Leprosy. Leprosy is widespread, but all attempts to survey and treat the cases sys- tematically have met with failure, due to the tendency of the inhabitants to conceal cases of infection. In 1946, 32 new cases were diagnosed, which brought the total of known lepers to 832. Thirty patients were under treatment in the leprosarium near Saint-Denis. Diseases of the Skin. Mycotic infections and phagedenic ulcers are numerous. Scabies is widely distributed. Other Infections. Tetanus, and particu- larly tetanus neonatorum, are common. In 1948 tetanus ranked fourth among the causes of death attributed to infectious dis- eases. From 50 to 70 cases are treated in the hospitals and dispensaries each year. Since 1948, immunization against tetanus has been compulsory. Occasional cases of trachoma are ob- served. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is the major cause of illness and death in Réunion. The coastal belt is most seriously affected, but the in- fection has become established at progres- sively higher altitudes since its introduction in 1870. Transmission takes place through- out the year in the lowland areas where the vectors, Anopheles gambiae and A. funestus, breed abundantly in the numerous small streams and marshes. In the highlands, malaria is more seasonal in distribution, with the greatest incidence during and after the rains. From 15,000 to 20,000 cases are treated annually—roughly 15 to 35 per cent of the total morbidity reported from the government hospitals and dispensaries. About 20 per cent of the cases are in chil- dren less than five years of age. Plasmodium falciparum and P. vivax are the principal species but P. malariae is also encountered. Malarial-control measures include pro- phylactic treatment with antimalarial drugs and limited antilarval programs in the town- Réunion 263 ship areas. In 1949 an antimalaria cam- paign, based upon the use of DDT, was inaugurated by the health services. Filariasis. Filariasis, caused by Wuch- ereria bancrofti, is endemic, although no recent records of prevalence are available. Other Infections. Plague has not been reported since 1927. Typhus fever and re- lapsing fever are not recorded as present. Yellow fever is not known to occur, but immunization against the disease is car- ried on. NutriTioNAL DISEASES Various degrees of malnutrition are ob- served. Avitaminoses are common, but beri- beri constitutes the most serious nutritional disease on the island. In 1946 over 1,000 cases were treated in the government hos- pitals and dispensaries. The prevalence of deficiency conditions may be influenced by the high rate of chronic alcoholism in the population, as well by the poor standards of nutrition. SUMMARY Réunion, a small island of 970 square miles in the Indian Ocean, has been a French possession since 1643. In 1948 it was made an overseas department of France. The local Direction de la Santé, with head- quarters at Saint-Denis, is responsible for the health and the medical care of the popu- lations. It functions under the Ministére de la Santé Publique et de la Population in Paris. The Direction operates 5 general hos- pitals, a maternity hospital, a leper hospital, from 40 to 45 rural dispensaries and 2 child welfare centers on the island. The standards of sanitation are generally low. Water sup- plies are obtained from streams and in some areas from rainwater cisterns. The township supplies are not treated, and pollution is common in both urban and rural areas. The methods of sewage disposal are primitive. Undernutrition and avitaminoses are wide- spread. Beriberi is prevalent, while a high rate of chronic alcoholism contributes to other nutritional deficiencies. Malaria, dysentery, enteric fevers, hel- minthiasis, tuberculosis, skin infections and syphilis are the principal diseases on the island. Leprosy, tetanus, pneumonia, hook- worm infection, syphilis and other venereal diseases are common. Outbreaks of polio- myelitis, meningococcus meningitis, diph- theria and influenza occur sporadically. Measles and whooping cough are endemic and sometimes epidemic. Smallpox is con- trolled by compulsory vaccination, and no cases have been recorded within recent years. Filariasis is endemic. Yellow fever, plague, typhus fever, relapsing fever and cholera are not now reported. BIBLIOGRAPHY 1. France. Ministére de la France d’Outre-Mer: Direction du Service de Santé Colonial. Rapport sur la situation sanitaire dans les territoires francais d’outre-mer pendant Pannée 1946. 2. ——. ——: Direction du Service de Santé Colonial. Situation sanitaire de I’Empire francais. Tableaux statisques, 1941-1945, Marseilles, Imprimerie LeConte. 3. ——. Secrétariat d’Etat aux Colonies: Direc- tion du Service de Santé. Giordani, Meédecin colonel, Protection de la mater- nité et de lenfance indigénes, Paris, Charles-Lavanzelle & Cie, 1943. 4, ——. : Direction du Service de Santé. LeGall, Médecin colonel, La situation sani- taire de empire francais pendant I’année 1940, Paris, Charles-Lavanzelle & Cie, 1943. 5. Grosfilez and LeFévre: Les maladies trans- missible observées dans les colonies fran- caises et territoires sous mandat pendant Pannée 1938, Ann. méd. et pharm. colon. 38:183-359 (April, May, June) 1940. 6. Sorel, F. P. J.: Essai de démographie des colonies francaises, Bull. Office internat. d’hyg. pub. 30:1-154, Supplement 2, 1938. 7. ——: Prophylaxie de la lépre dans les colonies frangaises, Bull. Office internat. d’hyg. pub. 30:1-21, Supplement 6, 1938. 8. Vogel, E., and Riou, M.: Les maladies épidémiques, endémiques et sociales dans les colonies frangaises pendant I’année 1937, Ann. méd. et pharm. col. 37: Supp. 257-551 (April) 1939. SECTION FIVE South Africa 19. Tur UNION oF SOUTH AYRICA.. . |. . a iW eine ont Li nti 267 20. SOUTH IVESTAERRICN . 0 i. oo il wii LE cli iE 200 21. Tue Hica ComMIsSION TERRITORIES . . . . . . . . . . .301 Basutoland... Leste, L0G RG i SO Bechuanaland: Protectorate... + + + hd hui wit 0800 Swaziland. ©. Cueto he) ik aia tad ah SESS 001 ynog 44390213 104 uopuoT §sD3 = JT (roo OTe SS ve CW sanbibp oduaun: W ) = Duoeigoe anbjquiDz0N 19 Union of South Africa GEOGRAPHY AND CLIMATE The Union of South Africa, the southern- most country of the continent, is a Do- minion in the British Commonwealth of Nations. It came into being in 1910 with the union of its four component states, now provinces, the British colonies of the Cape of Good Hope and Natal and the former Boer republics of the Orange Free State and the Transvaal. The greater part of the territory, covering an area of approximately 472,500 square miles, is a vast interior pla- teau which slopes gradually to the west and is encircled on the east, the south and the southwest by a series of mountain ranges running more or less parallel with the coast. The plateau, or high veld, has an average altitude of 4,000 feet, rising to 6,000 feet in the northeast, and includes a large part of Cape Province, the Orange Free State and the Transvaal. Essentially an undulating plain broken by irregular, flat-topped hills, it is divided into wide stretches of grass- lands and savannah of various types. The coastal zone ranges in width from 30 to 150 miles ; in northern Natal it is characterized by fertile, subtropical lowlands. Two well- defined belts of semiarid tableland lie south of the escarpment. The most southerly, the Little Karroo, has an average altitude of 1,500 feet and is separated from the coast by the Cape ranges and from the second belt, the Great Karroo, on the north, by the Swartberg Mountains. The latter plateau has an elevation of 2,000 to 3,000 feet and terminates in the west in sandy plains which eventually merge into the Kalahari Desert. The only portions of the territory which lie below 1,500 feet consist of the narrow fringe along the coast and a section of the Limpopo River Valley. The highest elevations are at- tained along the edge of the eastern escarp- ment in the Drakensberg Mountains of the Transvaal and the Drakensberg, or Quatha- lamba, mountains of Natal. Peaks of 11,000 feet are found in Natal and Basutoland. The major river systems draining the in- terior plateau are the Limpopo, on the northern boundary, and the Orange, which rises in the mountains of Basutoland and flows across the territory to empty into the Atlantic Ocean. The slopes of the escarp- ment and the coastal ranges form the water- sheds of numerous small rivers which flow east to the Indian Ocean. The climate is characterized by the in- tensity of the sunlight, the dryness of the atmosphere, and the uniformity of the an- nual mean temperatures over a large part of the country. The mean temperature at Cape Agulhas, the most southerly point on the continent, at an elevation of 62 feet above sea level, is approximately 61.3° F., as com- pared with 60.4° F. at Johannesburg with an altitude of 5,925 feet. The mean tem- peratures on the east coast, which is warmed by the Mozambique Current, average from 10° to 12° F. higher than those in com- parable latitudes on the west coast, which feels the effects of the cold Benguela Cur- rent. However, the areas in which the an- nual mean temperatures exceed 70° F. are confined to the coastlands of northern Natal, the low veld of the eastern Transvaal, the valley of the Limpopo River and lowland areas along the western reaches of the Orange River. The seasonal differences be- 267 268 Union of South Africa tween the mean temperatures for the summer months, October through March, and the winter months, April through Sep- tember, increase with the altitude and the distance inland. The mean range approxi- mates 12° F. at Durban and 25.6° F. at Kimberley. Marked daily fluctuations in temperature are characteristic, averaging 15° F. along the coast and from 25° to 30° F. in the interior plateau region. Maxi- mum temperatures of 90° to 95° F. on the high veld and of 100° F. in the lowlands are not uncommon during the summer months. The rainfall, which averages 17.5 inches a year over the entire territory, decreases in amount from east to west and varies from 70 inches in limited areas in the southern and the eastern mountains to 5 inches along the west coast. Natal receives the heaviest annual rainfall—35 to 50 inches over two fifths of the province and 25 to 35 inches in the remainder. However, in the north- western third of Cape Province semidesert conditions prevail with a rainfall of from 5 to 15 inches per year. From 70 to 95 per cent of the annual precipitation occurs dur- ing the summer months over the greater part of the country, but in the Cape Penin- sula and the adjacent west coast a narrow belt of winter rainfall is encountered. In the south there is a transitional, nonseasonal zone. In many areas, heavy thunderstorms account for a large proportion of the rain- fall. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTion The census statistics for 1946 placed the population of the Union at 11,258,858, an increase of 17.4 per cent over that of the previous decade. This included 2,335,460 Europeans, 7,735,809 native Africans, 282,539 Asiatics, and 905,050 colored (per- sons of mixed blood). The provinces having the largest populations were Cape Province and the Transvaal, with 4,016,801 and 4,138,779, respectively. Natal had a total population of 2,182,733, and the Orange Free State, of 875,545. The European population is largely of English or Afrikaner descent, but includes from 6 to 7 per cent of Jews, most of whom are of eastern European origin. Over 95 per cent of the white residents are South Africans by birth, and a small percentage by naturalization. Approximately 45 per cent are located in the Transvaal, and 37 per cent in Cape Province, with the re- mainder about equally distributed in the other two provinces. Two languages are recognized officially, English and Afrikaans, a South African variant of Dutch. A con- siderable proportion of the white population is bilingual, but, according to the 1936 census returns, about 39 per cent employed English in their homes, and 56 per cent, Afrikaans. The predominance of Afrikaners in the farming communities is shown by the fact that 84 per cent in the rural areas spoke Afrikaans and 14 per cent English, in contrast with corresponding estimates of 41 per cent and 53 per cent in the urban populations. The Asiatics are largely descendants of laborers imported from India in the 1860s, and later, for work on the sugar plantations of Natal. Immigration was restricted in 1913, and it is estimated that 85 per cent of the present population was born in the territory. In 1946 approximately 77 per cent resided in Natal, 13 per cent in the Trans- vaal and 10 per cent in Cape Province. Slightly less than three fourths are Hindus, and about one fifth are Moslems. The colored section of the population comprises various groups of mixed blood. Since about 90 per cent live in Cape Province, they are frequently designated as “Cape Coloureds.” With the exception of small residual com- munities of Hottentots and Bushmen in the semidesert region north of the Orange River, the indigenous peoples are southern Bantu and belong to two main groups of tribes that speak several different languages and a variety of dialects. The Suto-Chwana Union of South Africa 269 tribes are located primarily in the high veld of the Free State and the Transvaal. The Zulu-Xosa tribes are found in Natal and Zululand and in the eastern part of Cape Province. An aggregate of almost 38.7 mil- lion acres has been set aside in the four provinces as “reserves,” for exclusive native occupancy. The largest is the Transkei in northeastern Cape Province, which has a population of 1,500,000 or more. In addi- tion, over 15 million acres are held in trust, subject to lease or purchase. The majority of Bantu live under rural conditions on the reserves, or in family groups, or “stads,” on the European farms, but a large percentage reside in native “locations,” or townships, adjacent to the European cities and towns. Roughly 39 per cent are settled in the Transvaal, 30 per cent in Cape Province, 22 per cent in Natal and 9 per cent in the Free State. In 1946 the average density of the Euro- pean population ranged from 3.1 per square mile in Cape Province to 9.4 in the Trans- vaal; of the non-European from 11.4 in Cape Province to 55.3 in Natal. Only 25 to 30 per cent of the inhabitants dwell in urban communities, which by definition comprise all areas administered by designated local authorities and may include townships es- sentially rural in character. Probably not over 65 per cent of the white population and from 20 to 25 per cent of the Bantu may be classified as “urban,” while the “rural” groups are distributed unevenly. There are fewer than 10 to 15 cities with a white population in excess of 20,000. Pretoria, the administrative capital, had a total population in 1946 of 236,637, includ- ing 124,542 Europeans. Corresponding fig- ures for Cape Town, the parliamentary capital and the principal seaport, were 454,052 and 214,000. The heaviest concen- tration was found in the southern Trans- vaal ; Johannesburg and the adjacent “reef” towns had a white population of almost 700,000 and a total population of over 1,600,000. The standards of education are compara- tively high but vary in the different prov- inces and with respect to the segregated racial groups. Education is compulsory for Europeans up to 15 or 16 years of age; and both primary and secondary education are free for Europeans in all the provinces. There are seven independent universities and two constituent colleges of the Univer- sity of South Africa. Educational facilities for the Bantu are largely provided by the missions with varying degrees of state aid. The majority do not proceed beyond the lowest grades, while a large percentage of the children on the reserves receive little or no education. The South African Native College at Fort Hare is the only college for non-Europeans, but qualified students are also admitted to the Universities of Cape Town and Witwatersrand (Johannesburg). VITAL STATISTICS The Office of Census and Statistics in the Department of the Interior functions as the central statistical agency for the Union. In 1945 the European birth rate was 25.5, and the crude death rate 9.3 per 1,000 popula- tion. The infant mortality rate of 40.3 and the maternal mortality rate of 2.1 per 1,000 live births represented the lowest then on record. The infant mortality rates for the non- Europeans are significantly higher. In 1944 they averaged 90.1 per 1,000 live births for the Asiatic community in the country as a whole, but 83.5 in Cape Province, 89.6 in Natal, and 101.1 in the Transvaal. Among the colored population, they approximated 162.7 for the Union, but were 128.5 in Natal, 162.8 in Cape Province, 165.7 in the Trans- vaal and 242.5 in the Free State. The re- cording of deaths is more reliable than that of births, however, and such figures may be unduly high. Vital statistics for the Bantu are lacking, except for scattered surveys among selected groups. The infant mortality rates are gen- erally high and range from 150 to 500 in different areas. Evidence derived from a nutrition survey in the Ciskei-Transkei re- 270 Union of South Africa gion in 1939 shows that, in general, from 15 to 25 per cent of the children die during the first year of life; from 25 to 38 per cent during the first two years and from 30 to 60 per cent before 18 years of age. Among the rural populations covered by the Polela Health Center unit in Natal, the birth rate was 43.6, and the crude death rate was 21 per 1,000 population in 1947. The infant mortality rate declined from 275 per 1,000 live births in 1942, shortly after the unit was started, to 155 in 1946.7 SociaL Economy The Union of South Africa is not only en- dowed with natural resources, but the com- bination of cheap electrical power, abun- dant unskilled labor and well-developed transportation facilities has helped to pro- mote a rapid industrial expansion. The country is the largest gold-producing area in the world. The extensive Witwatersrand reef in the Transvaal is worked by 46 op- erating companies, while other deposits are being developed in the northern part of the Orange Free State. Diamonds constitute the second most valuable source of mineral wealth. They are found in isolated “pipes” from northwest Cape Province to the Trans- vaal, and in alluvial deposits in certain por- tions of the Orange and the Vaal river valleys and along the coast of Namaqua- land. An appreciable amount of coal is mined in the eastern Transvaal and north- ern Natal, and asbestos, silver, platinum, corundum, tin and copper in various areas. Steel is produced near Pretoria and Johan- nesburg. Agriculture contributes a considerable share to the national economy. Wool, hides and skins, and a variety of cultivated prod- ucts, including deciduous and citrus fruits, and sugar are exported. Industrial and agri- cultural development is largely controlled by the European populations. The Asiatics are predominantly urban, but in Natal a large percentage work in the collieries and on the tea and sugar plantations. The Bantu constitute the principal source of unskilled labor. Under the present primitive system of agriculture, with extensive soil deteriora- tion and erosion, the reserved lands are in- adequate to support the growing population, and young adults have migrated to the cities in large numbers. The majority are em- ployed on a more or less temporary basis in the mines, in industry or in domestic service, but many have become detribalized and per- manently settled in urban locations or town- ships. The transportation facilities are well or- ganized. The railways, the harbors and motor-bus services are owned and operated by the government. A network of railways connects the populous industrial and agri- cultural centers, while roads link the larger settlements. However, intercommunications are poor in the thinly settled areas and in the native reserves. Air service is main- tained between the important cities within the Union and with other African terri- tories; also with the United Kingdom and continental Europe. Foop AND NUTRITION Standards of nutrition vary among the different racial and economic groups. In the urban areas they are largely contingent upon the availability and the cost of the so-called protective foods. Maize and wheat are the most widely cultivated food crops. Large herds of cattle and sheep are raised in the eastern half of the country, but the supply of milk is limited in many districts. Seasonal and regional shortages of fruits and vegetables are common. Nutritional de- ficiencies are encountered among all races, where poverty and ignorance are predispos- ing factors rather than differences in dietary habits. The results of social surveys in vari- ous cities™ indicate that at least 10 per cent of the European families, from 45 to 50 per cent of the Asiatic and from 50 to 60 per cent of the colored live at subsistence levels and are unable to purchase food to meet the minimum dietary requirements. The nutrition of the Bantu is governed, to a large extent, by occupational and en- Union of South Africa 271 vironmental considerations. On the reserves, maize is the staple article of diet. It is sup- plemented by millet, beans, pumpkins and other vegetables, and a variety of edible roots, weeds and indigenous fruits. Meat is eaten irregularly, since the natives regard their livestock as wealth rather than a source of food and rarely slaughter except on ceremonial occasions. Though more re- stricted as regards fruits and vegetables, the diets of the agricultural workers and the tenant farmers are, on the whole, com- parable with those of the tribes on the reserves. Among the Bantu living in the locations adjacent to the European towns and cities, poverty is a primary factor, and the level of nutrition is generally low. The average dietary is deficient in protein and vitamins, particularly vitamin A, ribo- flavin and niacin. In a survey of three urban and six rural areas in 1938-39%? obvious signs of undernutrition were apparent in from 43 to 90 per cent of over 7,000 school children examined. In contrast, the nutri- tional status of the workers in the gold fields is relatively high. The gold-mining companies are required to provide adequate and well-balanced rations for their workers, but the standards are not uniform in other industries. A National Nutrition Council advises the government on matters of nutrition, while the Division of Nutrition and Health Edu- cation, which was created within the De- partment of Health in 1947, fosters nu- trition education and undertakes surveys among the different population groups. The Department of Agriculture maintains re- search stations and field services to promote soil conservation and improved methods of farming. Housine The problem of housing parallels that of nutrition in importance. Regulatory powers with regard to town planning reside in the provincial authorities. However, the short- age of housing in the urban areas has impelled the central government to assume the responsibility for subsidizing local housing programs for the different racial groups. The National Housing and Plan- ning Commission, which was established in 1945 as a corporate body under the Minis- try of Health, has been given broad pre- rogatives for a limited period, including the authority to undertake the construction of dwellings for Europeans, with the necessary controls over labor and materials, and the approval of loans to individuals and to local authorities for the erection of low-income homes intended for lease or purchase. The better-class European dwellings conform to modern standards of construction, but areas of inferior housing are found in most cities. The municipalities are required to set aside land for native locations in which all urban Bantu are compelled to reside, with the exception of workers living on the prem- ises of their employers, and certain land owners. The standards of housing are gen- erally low, except in some of the newer loca- tions and townships. The influx of the Bantu into the industrial centers and the increase of the urban population by over 100 per cent in the decade, 1936-46, has been ac- companied by overcrowding and insanitary conditions. The resulting slum areas and the large number of squatters’ camps on the periphery of the native areas create condi- tions which have serious implications from the standpoint of health. The residential unit on the reserves is the “kraal,” a collection of huts housing the different branches of the family, with sepa- rate enclosures for the cattle and frequently for cooking and storage. The arrangement of the huts in the kraals and the method of construction vary among the tribes. The typical huts in Zululand are of the “bee- hive” type, made of wooden frames thatched with reeds or grass. In the Transkei they are circular with walls of wattle and daub or of sod. The roofs may be conical or flat- tened and domeshaped, and are made of thatch or woven reeds. They are usually sooty and verminous, but the floors are hardened and well brushed. Overcrowding 272 Union of South Africa exists, but its effects as regards disease transmission are counteracted to some ex- tent by the native custom of living in the open. The housing conditions of the agri- cultural laborers and tenant farmers are usually primitive and approximate those found on the reserves. The laborers in the gold mines are quar- tered in compounds maintained by the com- panies. ENVIRONMENT AND SANITATION WATER SUPPLIES The water supplies in different parts of the Union vary, not only as to source, but also in quantity and quality. In all of the larger cities modern facilities for the stor- age, the treatment and the distribution of the municipal water supplies are available. The main supplies are usually obtained from impounded reservoirs in near-by rivers, but occasionally springs or wells are employed as secondary sources. In most cases the sur- face waters are treated by sedimentation, filtration and sometimes coagulation, with chlorination before distribution. The water supply of the Witwatersrand gold-mining area, including the city of Johannesburg and nine neighboring municipalities, is con- trolled by the Rand Water Board. Most of the water is obtained from a reservoir created by a barrage across the Vaal River, 40 miles from the city. It is fed from the Vaalsbank Dam further up the river, which is the largest dam in southern Africa. The Vaal supply is supplemented by boreholes and wells in the Klip River valley. Pretoria also obtains part of its water from the Rand Water Board supplies. The Cape Town sup- ply is derived from the Kogel Berg and the Steenbras rivers and from springs on Table Mountain. A large conservation dam is being constructed on the Umgeni River to maintain the water supply of Durban. In the small towns and villages, in the rural areas and on the reserves, water sup- plies are obtained from streams, springs, irrigation dams and deep or shallow wells. The native locations adjacent to the Euro- pean cities usually have community outlets connected with the municipal water supply. In some cases, however, they may have in- dependent supplies from shallow wells. In general, the storage tanks and the wells of the small supplies are not protected against pollution. Water is scarce in large sections of the country, but irrigation has been introduced in many areas where soil and water condi- tions are suitable. In 1934-35 approximately 352,900 acres were under irrigation, 41 per cent of which were planted in cereal crops. The development of irrigation has been largely a co-operative enterprise undertaken through the medium of Irrigation Boards subsidized by the government. Within recent years the government has assumed the responsibility for financing large-scale projects; ten were under construction or completed in 1940. The largest, the Vaal River Development Scheme, will ultimately irrigate some 103,000 acres through 80 miles of main canal and 700 miles of distribution canals. The construction of borings and small dams in the cattle- and sheep-raising areas, and various soil conservation meas- ures are encouraged through loans and technical assistance. WasTE DISPOSAL Various methods of waste disposal are employed in the Union, which range from the modern sewerage systems in the larger towns to the complete lack of facilities encountered in the native rural areas. About 40 municipalities with considerable Euro- pean populations have partial or complete sewerage. In the towns along the coast the sewage wastes are discharged into the ocean after suitable treatment to reduce the impurities to within specified limits. In Johannesburg and the other inland towns the sewage is fully treated by different methods, including filtration and activated sludge digestion. Occasionally the effluent, after sedimentation, is spread over land Union of South Africa 273 under cultivation. In the smaller communi- ties, in the unsewered sections of the larger towns and in the native locations, the double bucket system of disposal is generally em- ployed, collections being made by the local authorities at regular intervals. In some districts septic tanks and cesspools are in common use, but in the rural areas pit latrines constitute the usual method of dis- posal. The sanitation on the reserves is primitive, and pollution of the soil is fre- quent. Fauna anp Frora Arthropods. Mosquitos. Altogether about 25 species of anopheline mosquitoes have been recorded from South Africa, but only Anopheles gambiae and A. funestus are considered important in the transmis- sion of malaria, which occurs in the north- western, northern and eastern Transvaal and in the northern half of the coastal zone of Natal. A. gambiae is widely distributed throughout this region. It breeds in pools denuded of vegetation and in various small exposed collections of water, primarily during and after the rains. At this season it spreads up the rivers and is responsible for periodic epidemics in the late summer and autumn. A. funestus is found only east of the Drakensberg, in the Transvaal and Natal, where it is an important vector of endemic malaria in the semitropical areas below 2,500 feet. It breeds throughout the year, except possibly for brief periods during the winter months. Occasionally 4. pretoriensis has been found to be infected but is thought to be of little importance in the transmission of malaria. Antianopheline measures are carried out in all the major endemic and epidemic areas, but they are controlled by different agencies and vary in scope and effectiveness. In sec- tions of the Transvaal and in the native re- serve areas of Natal, the Union Department of Health assumes responsibility for anoph- eline control. Elsewhere in Natal it is under- taken by statutory committees with the co- operation of the Department’s inspectorate staff. Other governmental departments also carry on limited malaria-control programs in the regions under their jurisdiction, with the advice of the Department. Various anti- larval measures are employed, including the drainage of swamps, the clearing of water courses and the spraying of breeding places with oil, Paris green or DDT. The residual spraying of dwellings with DDT and other insecticides is used extensively in many rural districts. In 1946 experimental areas in the Transvaal and Zululand were sprayed by means of an airplane with 10 per cent DDT and oil mixtures, but with inconclu- sive results. Twenty-seven, or more, species of Aedes mosquitoes have been found in the Union, but the distribution of the potential vectors of yellow fever is not accurately known. Both Aedes aegypti and A. simpsoni are en- countered in the coastal region of Natal and in other parts of the country where climatic conditions are favorable for breeding. A large variety of culicine mosquitoes is reported, among which Culex pipiens is the most numerous. Fries. Flies are abundant in all sections of the country. Species of Musca, Tabanus, Haematopota and Chrysops are prevalent and probably are implicated in the mechan- ical transmission of intestinal and other in- fections. Lucilia, Sarcophaga and numerous species of myiasis-producing flies are en- countered, the most important of which, as regards man, is the “tumbu fly,” Cordylobia anthropophaga. The tsetse flies, Glossina pallidipes and G. brevipalpis, are found in northern Natal and Zululand, where outbreaks of nagana occur among the cattle. G. morsitans, the vector of Trypanosoma rhodesiense in ad- jacent areas, has not been reported, but surveys undertaken by representatives of the Southern Rhodesian, the Mozambique and the Union governments in 1941 and 1945 established the presence of the fly along the southern banks of the Save River in Mozambique and about 75 to 100 miles from the northern boundary of Kruger Na- 274 Union of South Africa tional Park. The possibility of its encroach- ment into northeastern Transvaal from the Save River valley is recognized, and suitable precautions are being taken by the Union government. Between 15 and 20 species of SIMULIIDAE have been identified from localized areas in the Transvaal and Natal, including Simu- lium damnosum, the vector of onchocerci- asis in other parts of Africa. Lice. Infestation with Pediculus humanus corporis and P. humanus capitis is common among the Bantu, particularly on the re- serves, where inadequate washing facilities and insanitary living conditions favor the propagation of lice. P. humanus corporis is responsible for sporadic outbreaks of louse- borne typhus fever in the temperate regions of the Transkei and neighboring areas. Fras. The common rat fleas are Xenop- sylla cheopis and X. brasiliensis, but X. eridos, X. piriei, Chiastopsylla rossi, Dinop- syllus ellobius and various other species parasitize the wild rodents. Sylvatic plague is enzootic throughout the drier portions of the inland plateau, where it is transmitted by X. piriei in the Karroo, and by X. eridos in the north. Infections are not infrequently spread to man by plague-infected X. brasi- liensis. The transmission of murine typhus is also recorded from several widely sepa- rated areas, both urban and rural. The dog and cat fleas, Ctenocephalides canis and C. felis, are abundant. The chigoe flea, Tunga penetrans, is found in Natal, particularly in the northern coastal region. BepBucs. The bedbugs, Cimex hemipterus and C. lectularis, are prevalent, especially in the reserves and the native townships. Ticks anp Mites. The tampan tick, Ornithodorus moubata, is common, partic- ularly in Zululand, the Transvaal and northern Cape Province. It is the vector of African tick or relapsing fever, which is endemic in parts of Cape Province and the Transvaal and occurs in scattered outbreaks in other areas. The ticks are abundant in the native huts, and frequently are spread over new territory by migratory laborers. Some tribes are reported to carry ticks with them in the belief that it will protect them against attacks of fever when they return to their kraals.5? Rhipicephalus appendiculatus, R. san- guineus, R. evertsi, Amblyomma hebraeum, Boophilus decoloratus and Hyalomma aegyptium are widespread on the veld and are implicated in the transmission of tick- bite, or tick-borne typhus fever. In the suburban districts of the towns and the cities of the Cape and of the Witwatersrand the dog tick, Haemaphysalis leachi, has been found to harbor the causative rickettsiae. The itch mite, Sarcoptes scabiae, is prev- alent. Liponyssus bacoti, a normal parasite of rats, may occasionally attack human beings. Seipers. The venomous spiders, Lac- trodectus indistinctus, L. indistinctus kar- rooensis and L. geometricus, are widely distributed in South Africa. OTHER ArTHROPODS. Beetles of the fami- lies PaussipaE and MEeLoipae, which pro- duce painful skin blisters, are not uncom- mon in the semitropical regions of the northeast. Reptiles. Numerous poisonous snakes are present, some of which are widely dis- tributed, and others somewhat localized in habitat. Among the cobras, Naja flava is common in Cape Province, while N. nigri- collis, N. haje and N. anchietae are found in the northern districts of Natal and the Transvaal. The smaller spitting cobra, Ringhals or Sepedon haemachates, is wide- spread but most prevalent in the north. Aspidelaps lubricus occurs in the Cape area and Namaqualand, and A. scutatus in Natal. The mamba, Dendroaspis angusti- ceps, is encountered in the bush country of the northeastern Transvaal and the coastal region of Natal. One of the most dangerous snakes is the rear-fanged boomslang, Dispholidus typus, a tree snake which has a highly toxic venom. It is found through- out the country. A variety of vipers is Union of South Africa 275 present. Bitis arietans is widely distributed, while B. atropos and B. inornata are found in the south, and B. caudalis and B. cornuta in the southwest from the Cape to Nama- qualand. Causus rhombeatus occurs in southern Cape Province. Atractaspis bi- bronii is common in the southern and the western sections of the Cape and also in Natal. Rodents. Rattus rattus rattus, R. rattus alexandrinus and R. rattus frugivorus are prevalent, particularly in the native villages of the interior, where the walls of the kraals and the thatched roofs of the huts provide excellent nesting places. R. norvegicus is also common in the coastal towns. Sylvatic plague is enzootic among the veld rodents, primarily the gerbils, Tatera brantsi and T. schinzi, on the high veld and Desmodillus auricularis in the Karroo districts. The water rats, Otomys irroratus, and the striped mice, Rhabdomys pumilio, are also impli- cated. Epizootics occur every 5 to 6 years, which usually start from sylvatic foci in the northern Free State and eastern Cape Prov- ince. They frequently spread to the domestic R. rattus rattus and thence to man. The semidomestic multimammate rat, Mastomys coucha, is associated with both domestic and veld rodents and forms the connecting link in the transmission of the disease. Cam- paigns for the extermination of rodents are carried on in the urban areas by the munici- pal authorities and in the affected rural areas by the government health authorities. Mollusks.* The fresh-water snails, Pkys- opsis africana, P. globosa, Bulinus (Pyr- gophysa) forskalii and possibly B. tropicus are intermediate hosts of Schistosoma haematobium, which occurs in the northern Transvaal and the eastern coastal region. They are present in numerous sluggish streams and stagnant pools, protected by vegetation, in the coastal belt from Sundays River northeast to the Umtamvuma River, in all portions of Natal below 4,500 feet and in the Transvaal, north of the line through * See footnote, p. 10. Mafeking and Krugersdorf to the Swaziland border. Planorbis (Biomphalaria) alexan- drina pfeifferi is the intermediate host of S. mansoni in scattered foci in the Trans- vaal and Natal. Plants. Large numbers of poisonous plants are found in the Union, many of which are of value for their medicinal prop- erties. Numerous plants are poisonous to the livestock, and some, like Dichapetalum cymosum and Ornithoglossum glaucum, are responsible for heavy losses to the farmers. Cases of “bread poisoning” are occasionally reported from the wheat-producing districts. They are caused by flour contaminated with the plant or seeds of Senecio, usually S. latifolius or S. burchellii, as the result of careless harvesting and milling. Deaths have also been reported due to the inclusion of seeds of Ricinus communis, Datura stra- monium and D. tatula in maize, wheat or beans. Deaths may occur accidentally from overdosage of various native herbalists’ preparations, particularly of Bowiea volu- bilis or Cucumis myriocarpus. Cases of poi- ‘soning sometimes occur among the Indians of Natal, due to the consumption of Lathyrus, or “Indian pea,” as a food. Other poisonous plants which have been responsible for occasional deaths include species of Phytolacca and Croton, Solanum macrosolum, Adenium digitata and Jatropha curcas. Erythrophleum lasianthum and E. guineense are used by the Zulus for homi- cidal purposes. Species of Strophanthus, Euphorbia and Acocanthera were frequently used by the primitive tribes as arrow poi- sons. Several species, including Peucedanum tenuifolium and P. galbanum, produce serious contact dermatitis. Allergy-producing plants are common and may be divided into seasonal groups.*? The grasses, the GRAMINEAE, are responsible for most of the pollinosis occuring in the summer months. They are primarily im- portant in the grasslands of the interior plateau but also occur in the different types of savannah characteristic of the northern 276 Union of South Africa and eastern Transvaal, Natal and northern and eastern Cape Province. The flowering trees are represented by the cypress, Cu- pressus, five species of which are widely dis- tributed. The pollinating season varies in different areas but extends roughly from June to October. No other species are of major importance, but the plane tree, Platanus acerifolia, the privet, Ligustrum japonicum, and the pepper tree, Schinus molle, may be contributory allergens. Weeds are prevalent but are considered of minor importance as allergens, with the exception of the khaki weed, T'agestes minuta, and the cosmos, Cosmos bipinnata, both of which flower in the late summer. Serious cases of allergy are reported occasionally from con- tact with the seed or oil cake residue of the castor bean, Ricinus communis. Foop SANITATION The standards of food sanitation are rela- tively high in the larger towns, but effective control is difficult in the rural districts and in the native areas. Markets and food es- tablishments are supervised by the local health authorities, and sanitary conditions vary markedly in different localities. Regu- lations governing the examination of slaughter animals and the inspection and the condemnation of meats are enforced by the local authorities. All abattoirs and slaughter places are registered annually ; in the urban areas the abattoirs are operated by the municipalities with supervision by veterinarians or qualified inspectors. Ade- quate large-scale cold storage and refrigera- tion facilities are found in the principal cities. The larger towns exercise authority over licensed producers and distributors of milk. The inspection of dairies, and sometimes the testing of cattle, is carried out by health inspectors. Milk is graded and controlled by routine laboratory examinations. Pas- teurization is not compulsory, but facilities are available in many areas. In the small communities and the rural areas, however, little or no supervision is undertaken. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS In the Union of South Africa, the Depart- ment of Health, which was established in 1919, functions under the Ministry of Health in the Union government. The Sec- retary and Chief Health Officer, who is the administrative head of the Department, and the headquarters staff are stationed in Pretoria. Regional offices are located at Cape Town, Durban, East London, Bloem- fontein and Tzaneen. The Minister and the Department are advised in the planning and the direction of health services by a Na- tional Council of Health. The responsibili- ties of the Department are discharged through its various divisions and include advice and financial assistance to the pro- vincial and the local authorities, the control and the prevention of communicable dis- eases, the promotion of public health, the operation of extra-institutional medical services and special facilities for the treat- ment of leprosy, tuberculosis, venereal dis- eases and mental illness, the maintenance of public health laboratories and research on special health problems in co-operation with other agencies. A National Nutrition Coun- cil and a National Housing and Planning Commission are incorporated under the Ministry of Health and co-operate with corresponding divisions in the Department. The responsibility for the establishment and the maintenance of general hospitals resides in the provincial administrations rather than with the central government. Collaboration is effected through a Central Health Services and Hospitals Co-ordinating Council, which was created in 1946. The enforcement of public health meas- ures devolves upon the local authorities, which constitute any municipal, town, vil- lage, or other geographic unit governed by a magistrate. In 1946 they totaled 737. The local health services vary markedly in scope, from those provided by highly organized municipal departments with full-time health Union of South Africa 277 officers to the elementary health activities of the village councils. In the Transvaal a special Peri-urban Areas Health Board functions as a local authority in the popu- lous zones on the periphery of the “reef” townships. Similar functions are carried on in Natal by a local Health Commission. Infectious disease hospitals and general clinics are operated by the municipalities; antenatal, child welfare, venereal disease and tuberculosis clinics, as well as home nursing services, are maintained by the larger local authorities. Comprehensive district nursing services are supervised and subsidized by the Union Health Department and the provincial ad- ministrations. District surgeons provide medical care for indigent persons, and in the absence of a medical officer of health they officiate as health officers. The district surgeons represent the Department of Health but operate under the Magistrate, who is an officer of the Department of Justice. In 1942 a commission was appointed at the instigation of medical, public health, labor and business organizations to advise the government upon the establishment of a National Health Service. The Commis- sion reported in 1944 after a study of the medical and health needs of the different racial groups in relation to the services available. It urged the adoption of a broad National Health Service program and the incorporation of all the governmental health agencies under a central Ministry of Health. The government accepted the report, in principle, except for the recom- mendation providing for the integration of the general hospitals with the general health services. It has taken steps to aug- ment and co-ordinate existing services in line with the other recommendations. The report calls for the division of the country into 24 regions, each under the supervision of a health officer, and the establishment of 400 or more health centers to be adminis- tered by the Union Department of Health. Beginning in 1940, the Department ini- tiated the development of a Health Center program. By the end of 1949 about 30 cen- ters were in operation in various parts of the country where the existing medical services were inadequate. The Health Cen- ters provide integrated preventive and cura- tive services, with emphasis on the social, economic and psychological aspects of dis- ease and welfare. At the same time, the Department organized a training project for Health Center personnel, based upon several centers serving representative population groups: Polela, a rural unit in Natal which was started in 1940 and subsequently adapted to the present program, and peri- urban and urban centers near Durban. The training headquarters is now established at Clairwood, Durban. The health activities of other government departments are numerous and frequently overlap. The Native Affairs Department co- operates with the Health Department in various measures for the improvement of the health of the Bantu. The Railways and Harbors Administration contributes toward health service programs for its employees and carries on antimalarial work through- out its system. The Department of Mines controls the health conditions in the mines and the medical care of the native mine laborers, while the Department of Agricul- ture conducts programs which help to im- prove the standards of living in the rural areas. In addition, numerous private agencies are active in the field of public health. Various mission groups maintain hospitals and clinics in the native areas, many of which receive financial assistance from the government. The South African Red Cross Society, the St. John’s Ambulance Associa- tion, the ‘“Noodhulpliga,” the National Council for Child Welfare, the Anti-Tuber- culosis Associations and other voluntary or- ganizations, and different professional socie- ties also sponsor service or educational pro- grams. The Transvaal Chamber of Mines has been active in promoting medical and social services, while unemployment and 278 Union of South Africa sick benefits are furnished to Europeans through the Witwatersrand Gold Mines Em- ployees Provident Fund and the Mines Benefit Society. Medical Benefit societies also serve other industrial and private groups. The National War Memorial Foun- dation was organized in 1945 for the pur- pose of promoting preventive health serv- ices. MEebpICAL INSTITUTIONS Hospitals and Dispensaries. The hos- pital facilities of the Union are inadequate to meet the demands of the free hospitaliza- tion program. The shortage of beds is par- ticularly acute in the case of non-European communities. Many urban hospitals are overcrowded, while in the rural areas large sections of the population are far removed from medical services of any kind. There are approximately 150 to 160 general hos- pitals, ranging in size from 25 to over 2,000 beds, which are controlled directly, or through grants, by the provincial authori- ties. The methods of operation and the standards of equipment vary in the different provinces. In general, however, the larger hospitals are well equipped and have x-ray and laboratory facilities. The distribution of hospitals in 1940 was as follows: lation. The beds for non-Europeans aver- aged in the neighborhood of 17,900, or ap- proximately 2 per 1,000 population. The Department of Health operates 5 leper institutions, 5 tuberculosis sanatoria, a large hospital at Rietfontein, near Jo- hannesburg, and several smaller units for the treatment of venereal diseases and 3 hospitals for the care of mental patients. Plague, smallpox, and other communicable diseases are also hospitalized at Rietfontein. Laboratories. The South African Insti- tute for Medical Research, in Johannesburg, is the foremost laboratory in the Union of South Africa. It is supported by the govern- ment, the Witwatersrand Native Labour As- sociation and the Council for Scientific and Industrial Research. The Institute conducts extensive research on medical and public health problems in bacteriology, serology, pathology, entomology and nutrition, carries on the large-scale production of serums and vaccines, many of which are widely used throughout southern Africa, and maintains a routine diagnostic service at Johannesburg and in its branch laboratories at Port Eliza- beth and Bloemfontein. The Union Department of Health oper- ates Pathological Laboratories at Cape Town, Durban, and East London which DistriBuTION OF HoSpiTALS, 1940 CAPE ORANGE UNION OF PROVINCE NaAtaL TRANSVAAL FREE STATE SOUTH AFRICA General io... ...0. 0. 0, 70 36 40 10 156 Private nursing homes ........ 56 24 40 19 139 Maternity homes ............ 58 13 64 14 149 Infectious disease hospitals . ... 28 3 5 4 40 Mine and factory hospitals . . .. 3 12 49 3 69 Total... va 217 88 198 50 553 In addition, 65 hospitals with an ap- proximate capacity of 2,800 beds are main- tained by different mission societies in the native reserves. The majority receive some financial support from the provincial ad- ministrations. In 19447 the number of beds available to Europeans was estimated at about 12,000, or almost 5.5 per 1,000 popu- perform routine diagnostic and special laboratory examinations; a Vaccine Insti- tute at Rosebank, Cape Town, for the manu- facture of smallpox vaccine; and a Biolog- ical Laboratory, also at Cape Town, which controls the standards of therapeutic prod- ucts utilized in the country. A yellow fever vaccine laboratory is conducted at Rietfon- Union of South Africa 279 tein by the South African Institute of Medi- cal Research in behalf of the Health De- partment. Clinical laboratory facilities are available in all the larger hospitals. The Veterinary Research Institute at Onderstepoort, Transvaal, functions under the Division of Veterinary Services of the Department of Agriculture. It carries on research on the control of diseases in ani- mals and on problems connected with the production and the storage of meat and dairy products, and prepares vaccines and other substances for use in veterinary medi- cine. Schools. Medical schools are connected with the University of Cape Town, the Uni- versity of Witwatersrand and the University of Pretoria. The last institution, which was started in 1943, teaches in Afrikaans. Post- graduate diplomas in Public Health are awarded by the Universities of Cape Town and Witwatersrand. The University of Witwatersrand provides instruction for higher degrees in medicine, surgery, gyne- cology, obstetrics and tropical medicine. It also graduates students in dentistry and grants diplomas in Public Health Dentistry. Courses for veterinarians are given at the University of Pretoria in close co-operation with the research institute at Onderstepoort. In 1947 there were 121 recognized hos- pital schools of nursing. At present the South African Nursing Council is endeavor- ing to promote the establishment of nursing colleges and hopes to place all basic nursing education under the collegiate system. Six such nursing colleges have been established. Twenty-seven hospitals offer midwifery training. Diplomas of nursing are granted by the Universities of Cape Town and Wit- watersrand to graduate instructors of nurs- ing and midwifery. Courses to qualify grad- uate nurses as health visitors are given in eight approved technical colleges. PERSONNEL Physicians. A total of 4,802 doctors was registered with the South African Medical and Dental Council in 1947, but all were not engaged in active practice. A consider- able number are connected with govern- mental, industrial or mission institutions. The distribution of practicing physicians with relation to population is uneven. In 1939 the number of Europeans per doctor was estimated at 570 in Natal (proper), 870 in the Orange Free State, 1,100 in Cape Province (proper), and 1,200 in the Trans- vaal. Comparable figures for the non-Euro- pean population were 2,100 in Cape Prov- ince (proper), 2,800 in the Orange Free State, 6,000 in the Transvaal, 13,000 in Natal (proper), and roughly 17,300 in the Transkeian Territories and Zululand.®? The National Health Services Commission esti- mated that there were only 380 Europeans per doctor in Cape Town, but that in the rural areas of Cape Province the ratio was from 10 to 100 times greater. Over two thirds of the medical specialists in the Union are located in the two cities of Jo- hannesburg and Cape Town. Dentists. In 1947, 824 dentists were registered with the Council. A few dentists are employed by government, provincial and local authorities, but the majority are in private practice. Nurses. In 1948 the registry of the South African Nursing Council listed 11,573 nurses, some of whom were not practicing, and 7,242 midwives. The majority of mid- wives are also nurses. Most of the nurses, among them many Bantu, were trained in South African hospitals, but a small per- centage were graduated from British, Cana- dian and Australian institutions. Others. Approximately 180 to 200 veter- inarians are practicing in the Union. Most of these are employed in the Veterinary Services of the Department of Agriculture. A few are in private practice in the cities. A total of 1,844 chemists and druggists was registered with the South African Pharmacy Board in 1947. Other personnel on the roster of the Medi- cal Council included several hundred health and food inspectors. 280 Union of South Africa DISEASES The distribution and the relative inci- dence of the diseases common to both tem- perate and semitropical regions, which are encountered in the Union of South Africa, are influenced not only by differences in topography and climate but also by the diverse social conditions and standards of sanitation prevailing among European, Bantu and Asiatic populations. The evalu- ation of the health status of the country, as a whole, is further complicated by the fact that reporting is incomplete in the more re- mote districts and on the native reserves. In many areas, also, a large proportion of the native peoples conform to their own systems of medical practice and are de- pendent upon “witch doctors” and herbal- ists. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fever is one of the most important dis- eases in the Union. It occurs in sporadic outbreaks, most frequently in the rural dis- tricts or in the urban areas that are inade- quately provided with health services. Urban outbreaks are usually traceable to the contamination of milk or food supplies by carriers, while the rural epidemics are commonly associated with small water sup- plies which are exposed to pollution, partic- ularly during periods of drought. The an- nual reported incidence averages from 4,000 to 7,000 cases and reaches a peak between January and March. In the year 1946-47, 4,019 cases were recorded—1,968 urban and 2,051 rural. The infection rate approximated 26 per 100,000 in the European population, 32 in the native, 53 in the colored and 137 in the Asiatic. The death rate ranged from 1.3 per 100,000 population among the Euro- peans to 10.2 among the Asiatics. The para- typhoid fevers are endemic but are not dif- ferentiated in the official reports. The enforcement of more effective con- trols over water, food and milk supplies, and the reduction of the fly menace are urged by the Union Department of Health. In the event of an outbreak, immunization with typhoid-paratyphoid vaccine is under- taken in the affected areas. The vaccine is provided by the Department without cost to the local authorities. Dysenteries. Bacillary dysentery is prev- alent, especially during the summer months. The infections are usually mild but may be responsible for several hundred deaths each year. Among 65 paradysentery cultures isolated in Cape Town in 1947, 27 be- longed to the Sonne, Flexner V.W.Z. or Flexner 103 groups. One was Shigella para- dysenteriae Boyd, but the remainder were not identified. Amebic dysentery is endemic in all the provinces but is of minor concern outside of Natal, where because of its prevalence noti- fication was made compulsory for a time in 1945. In the 30 months from January, 1945, to July, 1947, about 13,700 cases were re- ported from Natal, almost two thirds of which were attributed to the city of Durban. The case rate approximated 226 per 100,000 population. The infection is most extensive among the Bantu, but a large proportion of the cases occur among the white residents. The mortality among the native peoples averages from 5 to 10 per cent, in contrast with the 0.05 to 5 per cent common among Europeans. In the course of investigations to determine the carrier rates in representa- tive racial groups in Durban and southern Natal in 1943-44 infection with End- amoeba histolytica was found in S per cent of the Europeans examined, in 3 per cent of the Indians and in 17 per cent of the na- tives. Direct contamination of foods by carriers is thought to constitute the most important means of spread in the urban communities, but flies and polluted water supplies are frequently implicated in the rural areas. Diarrhea and Enteritis. Gastro-enteritis is common, particularly in the urban loca- tions, where from 15 to 25 per cent of the population is affected each year. Infections Union of South Africa 281 are most prevalent in the summer months, when flies are abundant. Helminthiases. Scristosomiasis. Schis- tosomiasis, caused by Schistosoma haema- tobium, is widespread, not only in the east- ern portion of the country, where numerous small streams and pools are sources of in- fection, but also in limited areas in the neighborhood of the Orange and the Vaal rivers. The disease is prevalent in the northern Transvaal and in the east coast region as far south as Port Elizabeth and Humansdorp. S. mansoni is more restricted in distribution, but numerous foci occur in the eastern and central Transvaal and in Zululand. With the trend toward an in- creased mobility of the native population and with the damming of water courses for irrigation purposes it is feared that the in- fection will spread into new territory. The disease occurs largely among the Bantu and the Asiatics, but in some areas cases are frequent in the European population. The most important intermediate snail host of S. haematobium is Physopsis afri- cana, and of S. mansoni, Planorbis (Bi- omphalaria) alexandrina pfeifferi. A special Bilharzia Committee in the Transvaal carries on a treatment program among school children as well as educational projects for the control of schistosomiasis. ANcyrostomiasis. Both Ancylostoma du- odenale and Necator americanus are com- mon in the low-lying sections of Natal and the northern Transvaal but are rarely en- countered elsewhere in the Union. The highest incidence is found in the coastal areas in Natal and Zululand. Hookworm was prevalent among the miners in the Witwatersrand gold mines in 1925-35, but since then has been almost completely eradi- cated. Cases of dermatitis, caused by con- tact with the dog hookworm, Ancylostoma brasiliense, are often acquired on the beaches in Natal. OraErR HELMINTH INFECTIONS. Ascariasis is widespread and represents the predomi- nating helminth infection in many districts of Natal and the Transkei. Ova of Ascaris H - Schistosoma haematobium M- Schistosoma mansoni Schistosomiasis in the Union of South Africa lumbricoides were identified in from 39 to 50 per cent, and of Trichuris trichiura in from 31 to 47 per cent of the fecal specimens from both Bantu and Asiatics examined at the Springfield Health Center (Durban) in 1946-4735 Infections with Strongyloides stercoralis and Enterobius vermicularis are less frequent. Ternidens deminutus infec- tions are encountered occasionally among the natives in the Transkei and Natal. Taeniasis, caused by the tapeworms, Taenia solium and T. saginata, is common. Cysticercosis is prevalent in the local pigs and to a lesser extent in the cattle, partic- ularly in the animals raised in the native areas. Occasional cases of cysticercosis are seen in man. Infections with Echinococcus granulosus occur in the sheep-raising dis- tricts of Cape Province and the Orange Free State. It is feared that the incidence of hydatid disease in man may reach serious proportions in the Transkei and other areas, where the Bantu are engaging in sheep farm- ing in increasing numbers. Hymenolepis nana is sometimes observed, most frequently in the Transvaal. Rare cases of Fasciola hepatica infection in man are recorded. Trichinosis has never been reported from the Union. Brucellosis. Sporadic cases of undulant fever are reported each year, usually from the Transvaal, the Karroo districts of Cape Province and Natal. Infections with Bru- 282 Union of South Africa cella abortus are apparently more numerous, but the actual incidence is not known. Tests on 1,900 blood sera in 1936-38 showed posi- tive agglutination with B. abortus and B. melitensis in 2.5 per cent from the country as a whole, but in 3.4 per cent from the Transvaal, in 1.1 per cent from Cape Prov- ince and in 1.0 per cent from the Orange Free State.! Positive reactions were almost twice as numerous among Europeans as among Africans. Cholera. Cholera has not occurred since the 1890’s, and rigid quarantine measures are enforced at all the ports to forestall its introduction. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is a major disease problem. Some progress has been made in controlling the disease in the Euro- pean population, with a decline in the death rate from 58.3 per 100,000 in 1921, to 18.2 in 1946-47. The rates for the non-Europeans, however, are considerably higher and, on the basis of available evidence, appear to be rising. The true extent of infection among the native populations is not known, since reporting is incomplete, and even in the urban areas less than 50 per cent of the cases are diagnosed before death. In 1946- 47 the case rate for pulmonary tuberculosis was 50.7 per 100,000 population for the Europeans; 153.1 for the natives; 247.1 for the Asiatics; and 416.4 for the coloreds. Tuberculosis is most prevalent in the southern and the eastern coastal regions and in the mining areas of the central plateau. In general, the incidence on the reserves is relatively low, but increasing with the gradual deterioration in nutrition and the continued repatriation of cases from the in- dustrial areas. Tuberculin surveys in the Transkei Territories have shown that from 80 to 90 per cent of the individuals over 20 years of age in the southern districts and from 60 to 65 per cent in the northern give a positive reaction to tuberculin.’® In the urban locations, where poverty, overcrowd- ing and poor nutrition are predisposing factors, the case rate is mounting steadily. Combined mortality statistics for Cape Town, Durban and Port Elizabeth show that the death rates per 100,000 rose from 345 in 1938 to 779 in 1945 for the natives, and from 380 to 520 for the colored. Among the mine workers of all races, silicosis is frequently complicated by tuber- culosis. In the case of the Bantu, however, the incidence of tuberculosis, alone or in association with silicosis, is disproportion- ately high. In the native populations, par- ticularly in the urban and the mining areas, the disease frequently follows a rapid and fulminating course. Pulmonary infections predominate, but from 10 to 15 per cent of the cases are non- pulmonary in type. Only occasional cases of known bovine origin have been reported. Bovine tuberculosis occurs in the dairy herds of imported breeds but is rare among the native cattle. A broad program for the control of tuber- culosis has been undertaken by the Depart- ment of Health with the support of the provincial Anti-Tuberculosis Associations and other voluntary organizations. The medical facilities, both for diagnosis and for treatment, are inadequate ; in 1942 only 70 per cent of the beds required for the care of European cases and 13 per cent for the care of non-Europeans were available. How- ever, plans have been projected for the ex- pansion of the existing institutions and the development of increased diagnostic facili- ties in the larger towns within the near future. Smallpox. In spite of relatively wide- spread vaccination, smallpox smolders in the Union and breaks out sporadically in small scattered epidemics which total from 600 to 1,500 cases a year. It commonly occurs in a mild form, known locally as “kaffir-pox” or “amaas,” and, with the ex- ception of occasional cases in Europeans, is largely confined to the rural native popu- lations. Union of South Africa 283 From 1942 through 1946 an epidemic of a somewhat more virulent type of the dis- ease was reported from Natal where a large percentage of the Bantu had resisted vac- cination on religious grounds. An increased incidence was observed in all four provinces, due probably to the influx of unvaccinated workers into the industrial centers. During the peak year, 1944-45, 49 European and 3,268 non-European cases were recorded from the Union, with a case fatality of 9.2 per cent, as compared with the usual rate of less than 1 per cent. Mass vaccination cam- paigns were conducted in all the provinces; where necessary the compulsory provisions of the Public Health Act were enforced. Subsequently, in 1948, malignant smallpox was reported from the Witwatersrand area of the Transvaal. Diphtheria. Epidemic outbreaks of diph- theria are common, the incidence being highest among European children under 5 years of age. Clinical diphtheria is rare on the reserves, and cases among the native populations are limited primarily to the urban areas. However, occasional small outbreaks have been reported from the Transkei. The case rates per 100,000 popu- lation, which approximated 10.7 for the native population as against 46.5 for the European in 1946-47, are meaningless in view of the inadequacy of reporting. A high rate of infection among the Bantu is sug- gested by a Schick test survey made in 1942.41 In a total of 875 children from 6 to 8 years of age, only 11.8 per cent were found to be Schick positive in rural areas, and 17.2 per cent in urban, in contrast with com- parable rates of approximately 60 per cent customarily observed among European children. The disease is typically mild in all races, with an average fatality rate of from 5 to 6 per cent. Immunization is voluntary, but free toxoid is supplied to the local authorities by the Department of Health. Meningitis. Sporadic outbreaks of men- ingococcus meningitis occur most frequently on the Witwatersrand and in the populous areas in Cape Province and Natal. From 600 to 1,000 cases are normally recorded each year. The fatality rates average from 10 to 15 per cent. Poliomyelitis. Poliomyelitis is endemic in South Africa, the average incidence in the decade prior to 1944 being 35 to 90 cases per year. In 1944 an extensive epi- demic was experienced, the only severe out- break since that of 1917-18. The localities most seriously affected included Durban, Johannesburg, the Cradock area of Cape Province and, to a lesser extent, Cape Town. The epidemic was nation-wide; localized outbreaks of varying intensity, as well as scattered cases, were reported from the majority of districts throughout the coun- try. For the year 1944-45 a total of 1,380 cases and 104 deaths was recorded, with the peak of incidence in November and Decem- ber. The susceptibility of the European population was almost ten times that of the African. The reported case rate per 100,000 was 35.1 for the European population, 5.5 for the native, 11.7 for the colored and 17.8 for the Asiatic. Less than one half of the cases occurred in children under 5 years of age. The epidemic abated in the winter of 1945, but a recrudescence was again re- ported in 1948. Other Infections. Scarlet fever is com- mon, and epidemics are frequent among the European children. Although throat swabs in sample surveys indicate a high percentage of streptococcus infection in the native and the colored populations, only occasional cases are reported from the urban areas. The infections are usually mild, but variations in virulence are noted in different outbreaks. Measles and influenza are prevalent. The fatality rates are particularly high among the non-European populations, where in- adequate nutrition and poor standards of living are contributory factors. Diseases SPREAD OR CONTRACTED CuierLy THROUGH CONTACT Venereal Diseases. Syphilis, gonorrhea, chancroid and, to a lesser extent, lympho- granuloma venereum are prevalent. Occa- 284 Union of South Africa sional cases of granuloma inguinale are also seen. The incidence of venereal infections in the European population is highest in the port and inland industrial areas but prob- ably compares favorably with that of similar groups in other countries. Among the non-European races, syphilis is the predominating infection. The prevalence is not known, but sample surveys indicate that at least 25 to 30 per cent of the native population, both urban and rural, is in- fected. The incidence of early syphilis in Cape Town was estimated in 1940 at 0.9 per 1,000 population for Europeans and 4.58 for non-Europeans ; of congenital syphilis at 1.9 and 24.0, respectively.*® Gonorrhea is also widespread, although the cases under treat- ment in the hospitals and the clinics are approximately one tenth as numerous as those of syphilis. A large percentage of cases of both infections remain untreated, and the majority lapse treatment as soon as the obvious symptoms disappear. The system of migratory labor and the social conditions prevailing among the non- European populations in the urban areas are major factors in the spread of venereal diseases. Prostitution among the natives is common, particularly in the larger cities and the mining areas. The Department of Health provides hospital facilities for the treatment of venereal diseases. Approved programs, including hospitals, clinics and treatment centers, operated by the local authorities are wholly subsidized by the government. The mission hospitals and dis- pensaries also receive free drugs and certain allowances for maintenance. Leprosy. Leprosy occurs in all portions of the country. The Department of Health maintains 5 leper hospitals in which approx- imately 2,100 patients were under treat- ment in 1947. The majority were natives, but 3.5 per cent were Europeans, 0.4 per cent Asiatics and 4 per cent colored. In addition, 2,286 discharged cases were under surveillance in their homes. About 36 per cent were from the Transkei, and 31 per cent from the Transvaal. The disease is ap- parently decreasing in the Transkei where education regarding the nature and the treatment is more widespread than in other areas. Diseases of the Skin. Various mycotic skin diseases are encountered throughout the Union. Large outbreaks of sporotri- chosis, caused by the fungus Sporotrichium beurumanni, have occurred among the un- derground workers in the Witwatersrand gold mines. Scattered cases of infections with Torula histolytica have been reported from the Transvaal, Natal and the Port Elizabeth area of Cape Province. Sporadic cases of chromoblastomycosis, actinomy- cosis and histoplasmosis are encoun- tered. Tropical ulcers are frequent, particularly among the native laborers in the northern Transvaal. Cases of human myiasis occa- sionally occur, some of which are caused by the larvae of Cordylobia anthropophaga. Scabies is prevalent among the non-Euro- pean populations. Cases of “creeping erup- tion,” caused by the dog hookworm, An- cylostoma brasiliense, are often acquired on the beaches of Natal. Diseases of the Eyes. Trachoma is com- mon in some districts. From 50 to 150 cases are reported each year among all races, but particularly among the Bantu in the Trans- vaal. It is the most frequent cause of blind- ness in the native and the colored popula- tions. Rabies. Human rabies occurs sporadically over a wide area. The infection is enzootic among small veld carnivora throughout the entire Free State, in the southern and southeastern Transvaal and in northwest- ern Cape Province. The majority of cases in man are caused by the bite of the “rooi” or yellow meerkat, Cynictis penicillata. The mongoose and the genet cat are also occa- sionally responsible for human infections. Other Infections. Cases of human anthrax are encountered frequently in the cattle- and sheep-raising areas. Yaws is rare. It was formerly reported among the underground workers in certain mines in Union of South Africa 285 the Transvaal, but a confusion in diagnosis between yaws and syphilis has been sus- pected by many authorities. No evidence of the presence of leptospirosis (Weil’s dis- ease) has been found in South Africa.? DISEASES SPREAD BY ARTHROPODS Malaria. In the eastern Transvaal and Natal, the river valleys and the low-lying areas below 3,000 feet are highly malarious, but the intensity of infection is governed by local conditions of climate and rainfall. Anopheles gambiae is the principal vector throughout most of this region. However, in the foothills where small permanent streams are numerous, A. funestus is also an important vector. In such areas trans- mission takes place throughout the greater part of the year, and malaria is hyper- endemic. In the districts skirting the eastern slopes of the northeastern Drakensberg, the spleen rate approaches 83 per cent in chil- dren under 15 years of age and 50 per cent in adults; the parasite rates, 65 per cent and 37 per cent, respectively. Elsewhere, the disease occurs seasonally, during and after the rainy season, and varies in severity from year to year. It spreads from foci of permanent breeding in patchy local out- breaks and under favorable conditions of temperature and rainfall, in extensive epi- demics which may involve the greater part of the Transvaal and the entire coastal belt of Natal and Zululand. Sporadic outbreaks are also reported from the Orange River i ° Johannesburg i foo Malaria in the Union of South Africa Epidemic Typhus Fever in the Union of South Africa, 1936-1945 valley in the northern part of Cape Province. Infections are caused most frequently by Plasmodium falciparum, less commonly by P. vivax and rarely by P. malariae. P. ovale has been described, but the infection was thought to have been acquired outside of the Union. Malaria-control measures are carried on by the Department of Health in the Trans- vaal, by special committees in Natal and by other government departments on lands under their administration. Except during epidemic’ years, high malaria rates among the European population are recorded only from lowland areas where no organized con- trol work is undertaken. Rickettsial Infections. Three types of rickettsial infection are common in South Africa. Louse-borne typhus is widespread among the rural Bantu and occurs in epi- demic form in the native territories of the Transkei and Ciskei, in the high veld re- gion of the eastern Transvaal and the Free State, and in the border districts of Natal. The subtropical areas of the Transvaal and of Natal and Zululand are rarely affected. Outbreaks are largely confined to the re- serves and to the farming areas where the natives live under primitive conditions, and louse-infestation is common. From 1933 to 1945 the known incidence ranged from 600 to 7,000 cases a year, with major epidemics in 1934-35 and 1944. Ap- proximately 70 to 95 per cent of the cases 286 Union of South Africa were reported from the Transkei. The dis- ease is relatively infrequent among Euro- peans, although from 1 to 100 cases are recorded each year among persons in close contact with infected natives. Widespread control measures are under- taken in the affected areas by the local and government authorities, which include in- tensive disinfestation and immunization. A modified Cox-type vaccine and a vaccine prepared from gerbil cultures by the Zinsser- Castaneda technic have been employed in various epidemics, while more recently a “one-shot” alum-precipitated vaccine has been used with success in the rural areas. Control has been facilitated by the develop- ment of a field diagnostic test by workers of the South African Institute of Medical Re- search. The Department of Health has em- barked upon a campaign for the eradication of louse-borne typhus in the Transkeian Territories which incorporates the sys- tematic delousing of the indigenous popu- lations. Since 1944, DDT powder and sprays have been used extensively in typhus con- trol, and the incidence of the disease has declined appreciably. Human cases of flea-borne typhus are re- ported sporadically from widely separated areas in the Union. The disease is especially frequent in the seaport cities and adjacent areas. The causative organism, Rickettsia mooseri, has been isolated from rats in nu- merous different localities in Cape Province, Natal and the Transvaal. Tick-bite fever, the South African variety of tick typhus, occurs in all parts of the country, and especially in the northern and eastern Transvaal and in the coastal belt of Natal and Cape Province. The incidence in the native populations is not known, but frequently cases are reported among Euro- peans following excursions into tick-infested country. The infection is transmitted by a variety of ticks, including Amblyomma hebraeum, Rhipicephalus appendiculatus and the dog tick, Haemaphysalis leachi. The last species has been shown to be the vec- tor in sporadic human cases in suburban teed . > ‘Johannesburg® 1 Cope Towr=="— Tick-borne Relapsing Fever in the Union of South Africa localities in the Cape and Witwatersrand areas. “Q” fever has recently been described from the western Transvaal. Relapsing Fever. African tick fever, or tick-borne relapsing fever, is endemic in the northern and the eastern parts of the coun- try, conforming to the distribution of the tick vector, Ornithodorus moubata. Cases are frequently reported from the northern and sometimes the eastern and the western Transvaal, from the sandy coastal belt of northern Natal and from northwestern Cape Province, where the tick may infest the native huts and compounds. With the in- flux of laborers from other endemic areas the disease has spread, and within the last decade serious epidemics, involving from 400 to 1,800 cases, have occurred in the Transvaal and in two districts of north- western Cape Province. Imported cases are common among the native laborers in the gold mines. An extensive outbreak was re- ported in the base metal mines in Griqua- land West in 1947. Louse-borne relapsing fever is not known to occur in the Union. Plague. Sylvatic plague smolders con- tinuously among the gerbils and other veld rodents in the plateau country of the Orange Free State, the southern Transvaal and the northern and western parts of Cape Prov- ince ; frequently it encroaches on the adjoin- ing areas. Severe epizootics occur from time to time, in which the disease is occasionally transmitted to man, usually through the Union of South Africa 287 Human Plague in the Union of South Africa, 1920-1946 intermediary of the multimammate rat, Mastomys coucha, by the flea vector Xeno- psylla brasiliensis. Small localized epidemics of human plague are reported sporadically from the rural areas and the native reserves, in which both pneumonic and bubonic in- fections occur. Periods of high incidence were recorded in 1923-25 and 1934-36. The most active foci in recent years have been located in four districts in the Orange Free State and in two areas in eastern Cape Province, the Port Elizabeth region and the districts bordering on the Transkei. The majority of infections occur among the native populations, the average inci- dence being from 25 to 100 cases per year. In the event of an outbreak suppressive measures are enforced in the affected areas by the local and government authorities, in- cluding wholesale rodent extermination and the mass immunization of the population with live (avirulent) antiplague vaccine. Intensive rodent control programs are con- ducted by the government in all the port cities. Yellow Fever. Yellow fever is not known to exist within the borders of the Union, but endemic foci have recently been discovered in Barotseland in Northern Rhodesia and in the Lake Ngami region in northern Bechuanaland. With the probable extension of the endemic area, south along the Zam- bezi River to the Ngamiland and the Chobe areas of Bechuanaland, the possibility of the introduction of the disease constitutes a potential menace to the country. The exact distribution of the vectors has not been determined, but Aedes aegypti and A. simp- soni are prevalent in the coastal regions of Natal, in the northern Transvaal and in other areas. Precautionary measures in com- pliance with the International Sanitary Conventions are enforced at all airfields, and immunization against yellow fever is required of all persons traveling through endemic areas. Trypanosomiasis. Indigenous cases of human trypanosomiasis have not been re- ported, but nagana is common among the cattle in Zululand. The introduction of Trypanosoma rhodesiense by migratory la- borers from Bechuanaland and Rhodesia and the threat of the infiltration of Glossina morsitans into the northeastern Transvaal from Mozambique are matters of concern to the government authorities. Other Infections. Occasional epidemics of dengue fever occur along the Natal coast, where the vector, Aedes aegypti, is preva- lent. Encephalitis “Africana” is apparently widespread, although the recognized cases are not numerous. Transmission by an insect vector is suspected but not proved. Sporadic cases of tick paralysis, produced by ticks of the genus Ixodes, are reported. NuTtrITIONAL DISEASES Nutritional surveys sponsored by the Na- tional Nutrition Council have demonstrated malnutrition and marginal avitaminosis among the children of all races. Except during periods of severe drought, malnutri- tion is primarily the result of the shortage and high cost of foods in the protective foods group. The full extent and distribution of the deficiency conditions has not been deter- mined, but the manifestations are most acute among the native and the colored populations in the larger towns. In many cases the diagnosis of avitaminosis is ob- scured by more obvious disease conditions. Skin abnormalities and mouth lesions indic- 288 Union of South Africa ative of vitamin deficiencies are prevalent among native children in both rural and urban areas. Rickets is rarely seen on the reserves but is encountered to an increasing degree among the urbanized natives, most of whom live in extreme poverty. Scurvy, ariboflavinosis and pellagra are common. Beriberi occurs irregularly. Nutritional edema and other signs of the lack of animal protein are frequent among young infants in the native areas. Endemic dental fluorosis is prevalent among both Europeans and non-Europeans in many areas in the Orange Free State, the Transvaal and northwest Cape Province, where the fluorine content of the drinking water supplies ranges from 1.5 to 13 parts per million. Large numbers of adults are said to suffer from a form of chronic fluorine poisoning which simulates a rheumatoid condition. This disease has not been studied adequately, but 8 cases were described from Pretoria district in 1941.%* Goiter is endemic in localized areas in the Orange Free State and in northwest Cape Province. MisceLLANEOUS CONDITIONS Silicosis, alone and complicated by tuber- culosis, is common among both European and native miners. Preventive measures and compensation benefits are required under the Miners’ Phthisis Acts, and extensive re- search is continually directed toward the improvement of working conditions by the South African Institute of Medical Re- search and the Miners’ Phthisis Medical Bureau. SUMMARY A wide diversity of public health condi- tions is encountered in the Union of South Africa. Not only do the climatic factors influencing the spread of insect-borne dis- eases vary in different areas, but marked contrasts in education, standards of living and sanitary environment exist between the various racial and economic groups. Public health administration is complicated, with the responsibility for the health and the medical care of the people divided between the Department of Health and the provin- cial and local authorities. The Department of Health functions under the Ministry of Health, with its headquarters in Pretoria. A broad health service program is under consideration, and increased medical and public health facilities are in the process of development. General hospitals are operated by the provincial administrations and vari- ous industrial, mission and private organi- zations; hospitals for the care of specific diseases are operated by the Department of Health and the local authorities. In 1944 the hospital beds available were estimated at 5.5 per 1,000 for the European popula- tion, and 2 per 1,000 for the non-European. High standards of medical practice and re- search are maintained. Modern and efficient water supply and sewerage systems are found in all the larger cities, but sanitary conditions in the rural areas and in the native reserves are primi- tive. Marked differences also exist in the standards of food sanitation. Malnutrition and varying degrees of avitaminoses are frequent, particularly among the low-income groups in the urban areas. Typhoid fever and dysentery are wide- spread. Schistosomiasis and ancylostomiasis are common, but localized in distribution. Tuberculosis is the major disease problem among the native and the colored popula- tions. The major respiratory infections com- mon to temperate climates are endemic, and epidemics occur frequently. Syphilis and the other venereal diseases are prevalent, the infection rates being especially high among the non-Europeans in both rural and urban districts. Leprosy occurs in all of the prov- inces. Malaria is endemic in the north- eastern sections of the Transvaal and north- ern Natal and is often epidemic over exten- sive areas. Louse-borne typhus fever is widespread among the native peoples, while plague and African tick fever occur in sporadic outbreaks. Tick-bite fever (tick- Union of South Africa 289 borne typhus), trachoma, brucellosis, an- thrax and rabies are endemic. Epidemics of dengue fever are reported occasionally. 10. 11. 12. 13; 14. 1s. Yellow fever and trypanosomiasis do not occur at present, but both infections repre- sent potential threats to the Union. 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S.: Typhus 290 Union of South Africa 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. fever in the Transkei, South African M. J. 18:144-148 (Apr. 22) 1944. , and Murray, N. L.: Typhus fever in the Eastern Transvaal, with special refer- ence to an epidemic occurring in 1945, South African M. J. 21:214-218 (Apr. 12) 1947. ——, Wolstenholme, B., and Cort, A.: “Q” fever. Serological evidence of the occur- rence of a case in South Africa, South African M. J. 24:409-441 (June 3) 1950. Geerling, R.: Encephalitis Africana. A pre- liminary report, South African M. J. 24: 339-343 (May 6) 1950. Gitlin, G., Schaffer, S., and Gunn, C. S.: Intestinal helminth infection, South Afri- can M. J. 22:788-793 (Dec. 25) 1948. Gray, F. C.: Two cases of torula meningitis with special reference to laboratory find- ings, South African M. J. 14:65-70 (Feb. 24) 1940. Harris, L. C., and Saner, R. G.: Rats as vectors of disease: A survey of the rats of Johannesburg, South African J. M. Sc. 7:160-172, 1942. Ingram, Alexander, and DeMeillon, Botha: A mosquito survey of certain parts of South Africa, with special reference to the carriers of malaria and their control, Part 1, Publ. S. African Inst. Med. Res. 4: No. 22, 1-81 (Oct.) 1927. Kark, Sidney L., and le Riche, H.: A health study of South African Bantu school chil- dren, South African M. J. 18:100-103 (Mar. 25) 1944. League of Nations: Report of the Pan- African health conference at Johannes- burg, November, 1935, Quart. Bull. Health Organ., League of Nations 5:1-209 (March) 1936. Murray, J. F.: Diphtheria amongst the Bantu, J. Hyg. 43:159-169, 1943. National Health Services: South African M. J. 19:222-223 (July 14) 1945. Nelson, H.: Our high infant mortality rates, South African M. J. 21:695-702 (Sept. 27) 1947. Ockerse, T.: Endemic fluorosis in the Pre- toria district, South African M. J. 15: 261-266 (July 12) 1941. O'Malley, C. Kevin: Syphilis in South Africa, South African M. J. 14:459-462 (Dec. 14) 1940. Ordman, David: African relapsing fever in South Africa, South African M. J. 13:491- 498 (July) 1939. ——: Allergic sensitivity to the castor bean, (Ricinus communis), South African M. J. 24:141-145 (Mar. 4) 1950. 48. 49. 50. 51, 52. 53, 54. $3. 56. 37. 58. 59. 60. 61. 62. ——: Pneumococcus types in South Africa, Publ. S. Afr. Inst. Med. Res. 9: No. 63, 1-27, 1938. ——: Pollinosis in South Africa, South Afri- can M. J. 21:38-48 (Jan. 25) 1947. : The occurrence of relapsing fever and the distribution of Ornithodorus moubata in South Africa, South African M. J. 15:383-388 (Oct. 11) 1941. Porter, Annie: The larval tremadota found in certain South African mullusca, with special reference to schistosomiasis (bil-" harziasis), Publ. S. African Inst. Med. Res. 8: No. 62, 1-492, 1938. Ravenscroft, A. R.: The geographical dis- tribution of medical practitioners in the Union, South African M. J. 18:27-38 (Jan. 22) 1944. Report of Tuberculosis Research Committee: Tuberculosis in South African natives, Publ. S. African Inst. Med. Res. 5: No. 30, 11-429, 1932. Sandground, J. H.: Studies on the life his- tory of Ternidens deminutus, a nematode parasite of man, with observations on its incidence in certain regions of Southern Africa, Ann. Trop. Med. 25:147-180 (Aug.) 1931. Sawyer, W. A., and Whitman, L.: The yellow fever immunity survey of North, East and South Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 29:397-412 (Jan.) 1936. Smithers, Reay H. N.: The distribution of the “Knopiespinnekop” (Lactrodectus in- distinctus), South African M. J. 17:293 (Sept.) 1943. Snyman, P. S.: The study and control of the vectors of rabies in South Africa, Onderstepoort J. Vet. Sc. & Ani. Ind. 15:9 (July-Oct.) 1940. Steyn, Douw G.: Fluorine Poisoning in Man and Animals, Cape Town, Cape Times Ltd., 1938. : Food Poisoning Caused by Substances other than Bacteria and their Products, Cape Town, Cape Times Ltd., 1938. : Poisoning with the seeds of Argemone mexicana (Mexican poppy) in human be- ings. Indian epidemic dropsy in South Africa, South African M. J. 24:333-339 (May 6) 1950. Thornton, E. N.: Position in regard to plague in the Union of South Africa, Quart Bull. Health Organ., League of Na- tions 5:96-102 (Mar.) 1933. ——: Position in regard to plague in the Union of South Africa and the mandated territory of South West Africa, Quart. Union of South Africa 291 63. 64. 65. 66. 67. 68. 69. 70. 7. Bull. Health Organ., League of Nations 2:64-82 (Mar.) 1933. Turnbull, N. S.: Diphtheria in African na- tives in the Transkei, South African M. J. 23:551-556 (July 2) 1949. Union of South Africa: Annual Report of the Department of Public Health, Year ended June 30, 1940, Pretoria, Govt. Printer, 1941. ——: Annual Report of the Department of Public Health, Year ended June 30, 1941, Pretoria, Govt. Printer, 1941. ——: Annual Report of the Department of Public Health, Year ended June 30, 1942, Pretoria, Govt. Printer, 1942. ——: Annual Report of the Department of Public Health, Year ended June 30, 1943, Pretoria, Govt. Printer, 1943. ——: Annual Report of the Department of Public Health, Year ended June 30, 1944, Pretoria, Govt. Printer, 1945. : Annual Report of the Department of Public Health, Year ended June 30, 1945, Pretoria, Govt. Printer, 1946. ——: Annual Report of the Department of Public Health, Year ended June 30, 1946, Pretoria, Govt. Printer, 1947. ——: Annual Report of the Department of 72. 73. 74. %5. 76. 77. 78. Health, Year ended June 30, 1947, Pre- toria, Govt. Printer, 1949. Department of Health. Nutrition in South Africa, Second Report of the National Nutrition Council, Pretoria, Govt. Printer, 1947. : ——: Office of Census and Statistics. Official Year Book of the Union of South Africa, No. 22, 1941, Pretoria, Govt. Printer, 1941. ——: Report of the National Health Serv- ices Commission, 1942-44, Pretoria, Govt. Printer, 1944. Viljoen, Noel Francis: Cysticercosis in swine and bovines, with special reference to South African conditions, Onderstepoort J. Vet. Sc. & Ani. Ind. 9:337-570 (Oct.) 1937. Watt, J. M.: Plants and poisoning in man, with a short account of plant allergy, South African J. M. Sc. 33:702, 1937. ——, and Breyer-Brandwijk, Maria Gerdina: The Medicinal and Poisonous Plants of Southern Africa, Edinburgh, Livingstone, 1932. Year Book and Guide to Southern Africa: 1950 Ed., London, Sampson Low and Marston & Co., Ltd., 1950. 20 South West Africa GEOGRAPHY AND CLIMATE South West Africa, a former German colony, is administered by the Union of South Africa, under the terms of a mandate confirmed by the Council of the League of Nations in 1920. Exclusive of Walvis Bay, a section of 374 square miles, which is tech- nically, but not administratively, part of the province of the Cape of Good Hope, the territory comprises a total area of 317,725 square miles. It has a coast line of approxi- mately 1,000 miles on the Atlantic Ocean and is bounded inland by Angola, Bechu- analand Protectorate and the Union of South Africa. Since 1939, the remote eastern portion of the Caprivi Zipfel, the narrow 300-mile strip separating Angola and North- ern Rhodesia from Bechuanaland, has been administered by the Union. Topographically, South West Africa is essentially a vast plateau, with an average elevation of 3,600 feet, and a gradual in- crease in altitude from 2,500 feet in the south to around 4,800 feet in the north. It is separated from the coast by a stretch of almost rainless desert, the Namib, which varies in width from 50 to 90 miles. The plateau is broken by small ranges of moun- tains and isolated peaks, a few of which rise to 8,000 to 8,500 feet in height. The most prominent ranges are the Kaokoveld Mountains, which mark the edge of the escarpment in the north, and the Auas Mountains which dominate the central uplands. Semidesert conditions prevail throughout most of the southern part of the country, frequently called Great Nama- qualand. The northern section is well wooded and even semitropical in some areas, while the central plateau affords stretches of grassland providing excellent pasturage for livestock. With the exception of the boundary rivers, the Orange in the south, and the Kunene and the Okavango in the north, all of the rivers of the territory are seasonal and intermittent and flow only after heavy rains. The climate of the territory is influenced by the antarctic Benguela current which sweeps the entire coast. The annual rain- fall averages less than one inch in the Namib Desert, but heavy fogs are experi- enced almost daily near the ocean through- out most of the year. On the plateau the rainfall varies with the altitude, ranging from about 6 inches in the south to 22 inches in the north. Two distinct seasons prevail over the greater part of the country —a rainy summer from October to April and a dry winter from May to September. In southern Namaqualand the winter rains characteristic of the western Cape are en- countered. The annual mean temperatures vary from 60° F. at Swakopmund along the coast to 72° F. at Tsumeb in the north- eastern part of the interior. At Windhoek in the central highlands the annual mean temperature approximates 66° I.; the mean maximum, 78° F., and the mean minimum, 53° F. The absolute temperatures range from 95° F. in the summer to 30° F. in the winter. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoprurLATION The population of South West Africa in 1946 was approximately 374,500, including 292 38,020 Europeans as enumerated in the census of that year. For the purposes of administration, the country is divided into two sections, the Police Zone and the area outside, which consists of the northern terri- tories of Kaokoveld, Ovamboland and Oka- vango and the western Caprivi Zipfel. The Police Zone, so named because police pro- tection is afforded to the inhabitants, in- cludes over two thirds of the total land area and is open to white settlement. Within the Zone, 18 reserves have been set aside for occupation by various indigenous tribes. These reserves and the northern territories are exclusively native areas, in which white people are not admitted except by permit. In 1946 the non-European population within the Police Zone included about 44,600 colored (of mixed blood) and 94,600 natives, of whom 24,500 lived on the reserves. The population outside of this area was slightly in excess of 197,000. The white settlers are predominantly South Africans, with a residue of Germans, who have become South African nationals. English and Afrikaans are recognized as the official languages. A large percentage of the colored, most of whom are descendants of early immigrants from Cape Province, live in a reserve in the central highlands known as Rehoboth Baster (Bastard) Gebiet. The native peoples comprise several groups of Bantu origin, namely the Ovambos, the Okavango tribes and the Hereros, and be- tween 20,000 and 30,000 each of Bushmen, Hottentots and Berg Damaras (Klip Kaf- firs). The Ovambos, who represent numeri- cally about half of the entire native popu- lation, occupy Ovamboland and parts of the Kaokoveld and the Okavango areas. The Bantu races employ a wide variety of dia- lects, while the Berg Damaras use the Nama language of the Hottentots. The Ovambos, the Hottentots and the Hereros were formerly the dominant races in the territory, but the latter two peoples were scattered and almost exterminated during the German regime. However, the policy of the present government has been to South West Africa 293 strengthen tribal organization and to restore a degree of self-government through tribal councils of headmen. The territory as a whole is sparsely popu- lated, while the Namib and the Kalahari regions are uninhabited except for wander- ing bands of Bushmen. A large section of the European farming community is con- centrated in the central highland areas. Windhoek, the capital, had a population of 14,710 in 1946, including 6,863 white set- tlers. The towns next in size, Keetmanshoop and Swakopmund, had populations of ap- proximately 5,500, roughly 50 to 60 per cent of which were natives. Within the Police Zone, the natives outside of the reserves reside in the European rural areas or in urban “locations,” adjacent to and con- trolled by the municipalities. The Ovambos in the northern territories, unlike other tribes of South Africa, do not congregate in villages but in large family kraals, each of which is an independent economic unit. The promotion of education is handi- capped by the sparsity of population over extensive areas and by the diversity of lan- guages among both white and native com- munities. Education is compulsory for white children, for whom the government pro- vides schools in the centers of population. Native education is largely in the hands of the missions but is fostered and subsidized by the government. VITAL STATISTICS Vital statistics are available only for the European residents. The reporting of births and deaths is incomplete and therefore un- reliable among the non-European popula- tions, particularly in the areas outside of the Police Zone. In 1945 the European birth rate was 24.3 per 1,000 population, and the death rate 6.7. The infant mortality was 41.2 per 1,000 live births. Social Economy South West Africa is essentially a pas- toral country. Agricultural production is negligible, except in the northern areas 294 South West Africa where the supply rarely exceeds local re- quirements. Karakul sheep ranching has been successfully introduced in the southern and the central portions of the territory, and the export of pelts represents an important feature in the national economy. Cattle raising and dairy farming are carried on extensively in the northern part of the Police Zone. Livestock are exported in large numbers to the Union, cattle from the north, and sheep and goats from the south. Butter and wool are important supplemen- tary products. The diamond industry also contributes to the wealth of the territory. Alluvial dia- monds are found in the valley sands in a 300-mile stretch north of the Orange River. Tin, vanadium and gold are mined in lim- ited quantities in the northwest in the Tsumeb-Grootfontein area. Copper deposits exist, but production was interrupted dur- ing World War II. Enormous reserves of salt are found in the extensive pans, scat- tered throughout the northern part of the country. The natives on the reserves conform to their traditional system of communal land tenure. Except in Ovamboland, where millet is extensively cultivated, the majority en- gage in cattle or sheep raising, depending upon local conditions. However, the basis of native economy is slowly changing, con- sistent with the increasing demand for im- ported goods. Large numbers of workers are employed annually in the urban areas, in the mines and on the European ranches. Transportation is difficult in view of the distances to be covered, but a network of main and secondary roads links the centers of population. The railroad, which is op- erated by the South African Railways Ad- ministration, connects with the Union sys- tem at Nakob in the southeast corner of the territory and runs north through Keetman- shoop and Windhoek to Walvis Bay. Branch lines serve the port of Luderitz, the center of the diamond industry, and the mining areas in the northeast. Air service is main- tained from Windhoek to Cape Town and Johannesburg. Foop AND NUTRITION Because of the generally low rainfall pre- vailing throughout the country, the cultiva- tion of food crops is limited. Local food shortages are common, and during periods of drought it frequently becomes necessary for governmental agencies to supplement the supplies in the tribal areas. Many foods must be imported. In the north, where rain- fall conditions are moderately favorable, millet, maize, potatoes, pumpkins and leg- umes are cultivated. Wheat is grown in lim- ited amounts, under irrigation, in the Auob and the Nosob river valleys. Green vege- tables and fruits are always scarce. Meat is available in all portions of the country, but its consumption varies with the customs and the prosperity of the tribes. Milk and dairy products are used in the cattle-raising dis- tricts. Undernutrition and vitamin defi- ciencies, especially of the B complex, are prevalent. The South African government is pro- moting the introduction of modern methods of cultivation and the organization of gar- den projects, but the latter are dependent upon the availability of water supplies. It also conducts programs for the development of improved strains of cattle and sheep, and for the protection of the livestock from various diseases, primarily hoof and mouth disease, anthrax and blackquarter. Housine The standards and the types of dwellings vary among the different tribes. The huts are usually of wattle and daub with thatched roofs. The complicated and self-contained kraals of the Ovambos are a characteristic feature of the northern territories. Housing conditions in the larger urban centers are frequently poor, with overcrowding in both the European and the native communities. As in the Union, the natives live in “loca- tions” adjacent to the European townships. South West Africa 295 ENVIRONMENT AND SANITATION WATER SUPPLIES Water supplies in South West Africa are obtained almost exclusively from springs, wells and boreholes. There are no perennial rivers, with the exception of those marking the northern and the southern boundaries. However, numerous sandy river beds exist in which water flows intermittently for vari- able distances during the rainy season, and underground supplies are usually available a few feet below the surface. Water for live- stock and for irrigation purposes is fre- quently obtained by the construction of surface dams, or weirs, across the sandy stream beds. Constant and reliable artesian supplies are found in many areas, particu- larly in the vicinity of the Auob and the Nosob rivers. Boreholes constitute the source of most township water supplies. That of Wind- hoek is derived from the Avis Dam reser- voir and is augmented by borehole supplies. A part of Luderitz is dependent upon the use of distilled sea water. Waste DisposaL Outside of the municipality of Windhoek, in which a water-borne sewerage system services a large part of the town, the meth- ods of sewage disposal are primitive. Pit privies constitute a common method of dis- posal in the smaller townships and Euro- pean rural areas. Indiscriminate contamina- tion of the soil is general in the reserves. Fauna anp Frora Arthropods. Mosquitoes. Anopheles gambiae and A. funestus are probably the only significant vectors of malaria in South West Africa. Both species are found in the northern part of the territory where rain- fall conditions are favorable for breeding. A. gambiae may also become prevalent in the semiarid regions during years of in- creased rainfall. A. listeri is present in the north, but it is uncertain whether it plays any part in the spread of the infection. The information regarding the anopheline mos- quitoes of this area and the role of each species in the transmission of malaria is still incomplete. Aedes aegypti is common in many por- tions of the country, exclusive of the desert regions. Numerous species of Culex occur. Few mosquito-control measures are carried out, except by individuals in close proximity to their homes. Fries. Flies are abundant, but no bio- logic vectors of human disease have been reported. The territory has not been sur- veyed for tsetse flies, but a “fly belt” is known to exist in Angola near the border. Cordylobia anthropophaga is common in the north and with various other species may be responsible for occasional cases of human myiasis. Species of Cynomyia, Lu- cilia and Sarcophaga are numerous. The house flies, Musca domestica and M. vicina, probably are implicated in the spread of intestinal infections. Lice. Infestation with Pediculus humanus corporis is common among the natives on the reserves, and small outbreaks of louse- borne typhus fever are reported from time to time. Freas. Numerous species of fleas infest the gerbils and other wild rodents. Xeno- psylla eridos is probably the most important vector of sylvatic plague, while X. brasili- ensis transmits the infection among the domestic rats and occasionally to man. Plague is enzootic among the veld rodents in Ovamboland and may spread as far south as Windhoek. Ticks. The tampan tick, Ornithodorus moubata, is widespread in the semiarid country of the south, where it is a vector of relapsing fever. Amblyomma hebraeum, Rhipicephalus appendiculatus and Boophi- lus decoloratus also occur. OTHER ArtHROPODS. The button spider, Latrodectus indistinctus, is sometimes re- ported. Its bite is capable of producing a severe toxemia which may end fatally, Sev- 296 South West Africa eral species of scorpions, and blister beetles of the family Paussipak are also found. Reptiles. Various species of venomous snakes have been reported from the terri- tory. The most important probably are the viper, Causus defilipii, and the puff adder, Bitis arietans. B. atropos is found occa- sionally. The boomslang, Dispholidus ty pus, is common along the water courses. The cobra, Naja flava, and the mamba, Dendro- aspis angusticeps, occur in some areas. The spitting Ringhals slang, Sepedon haema- chates, is reported from the south. Rodents. Numerous species of wild ro- dents inhabit this area. The species chiefly concerned with the transmission of sylvatic plague in Ovamboland are the gerbils, of the genus T'atera, and the semidomestic rat Mastomys coucha. Plants. Numerous plants produce dis- eases among the livestock, which are often fatal. The Bushmen sometimes use Euphor- bia virosa and E. candelabrum as arrow poisons; and the Hottentots, species of Acocanthera. The Ovambos use Adenium boehmianum and species of Pachypodium as arrow poisons, and Adenium multiflorum as a fish poison. Foop SANITATION Meat inspection is carried on at the abat- toirs in Windhoek and Keetmanshoop but is not generally enforced in other com- munities. Municipally owned cold storage facilities are available in Windhoek. Little or no sanitary control is exercised over the production of milk and the preparation of foods for human consumption, even in the larger towns. HEALTH SERVICES AND MEDICAL FACILITIES HearLTH ORGANIZATIONS The responsibility for the public health in South West Africa resides in a Chief Medical Officer who acts as advisor to the Administrator (High Commissioner) of the Territory. He is appointed by the Public Service Commission of the Union of South Africa and, in effect, functions as a decen- tralized officer of the Union Department of Health. The Administration headquarters are lo- cated at Windhoek. The health program of the territory is concerned primarily with the maintenance of medical facilities. The dis- trict surgeoncy system operates as in the Union, with part-time district surgeons as- signed to all of the districts in the Police Zone. A full-time medical officer is in charge of the Ovamboland and the Kaokoveld areas. The district surgeons provide cura- tive services for indigent persons of all races, treat venereal diseases and, when necessary, carry out measures for the con- trol of epidemics. They also make periodic surveys in the outlying rural areas. Medical inspection services were introduced in the schools in 1944. A large proportion of the medical and health work in the reserves and in the northern territories is conducted by Protestant and Catholic mission groups, with financial assistance from the govern- ment. In the expansion of the health services, as planned by the Administration, emphasis is placed on the need for adequately trained personnel. The appointment of a special officer for venereal disease control, and the division of the country into five regions, each in charge of a full-time medical officer, are among the changes in organization which are contemplated. Municipal sanitation is the responsibility of the local authorities. Health inspectors were appointed in Windhoek and Keetman- shoop in 1946. MEepicAL INSTITUTIONS Hospitals and Dispensaries. Hospitals are operated by the local authorities, with financial assistance from the government, at Windhoek, Keetmanshoop, Mariental, Karasburg, Grootfontein, Luderitz and Walvis Bay. They provide an aggregate capacity of 120 to 150 beds for Europeans, and at Luderitz and Walvis Bay include South West Africa 297 facilities for the care of native and colored patients. Native hospitals, ranging in size from 12 to 120 beds, are maintained by the government in Windhoek, Keetmanshoop, Omaruru and Grootfontein. A dispensary has also been established in the native loca- tion at Windhoek. Various mission organizations operate five or six small hospitals in the Police Zone. The institutions at Windhoek and Otjiwa- rango are exclusively for Europeans. A lim- ited number of private nursing and ma- ternity homes are located in the larger centers. Facilities for the treatment of their workers are also provided by the mining companies in the Grootfontein and the Luderitz areas. The bed capacity in the hos- pitals in the Police Zone is roughly 3.5 per 1,000 of total population. All of the hospitals in the northern terri- tories are operated by the missions, with the aid of government subsidies. Four hospitals, varying in size from 10 to 80 beds, are located in this area, three in Ovamboland and one in Kaokoveld. Medical services and drugs are also furnished at most mission stations. Laboratories. Clinical laboratories are available in the larger hospitals. The nearest diagnostic and research laboratories are the Pathological Laboratory of the Union Health Department in Cape Town and the South African Institute for Medical Re- search in Johannesburg. PERSONNEL The medical personnel in the country is limited. The doctors are few in number, and the majority are employed by govern- mental or local authorities, or by the mis- sion societies. A small number is engaged in private practice in the larger towns. European nurses are connected with the various hospitals, while native assistants are trained in the larger institutions. DISEASES In view of the fragmentary reporting from the tribal areas, only rough estimates can be made regarding the incidence of spe- cific diseases among the native populations. Public health activities outside of the Police Zone are limited to the work of one Medical Officer and a few medical missionaries. Even in the urban communities, the majority of natives follow their traditional customs, and the presence of infection is rarely recorded except in the case of threatened epidemics. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UriNARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fever occurs in sporadic outbreaks, generally toward the end of the rainy sea- son, which may be extensive during years of heavy rainfall. The methods of sewage disposal are primitive, and water supplies are frequently polluted. The disease is prob- ably widespread, but outbreaks are most frequently reported from the urban areas. Severe epidemics have been experienced in Windhoek, Swakopmund, Keetmanshoop and other towns. Paratyphoid fevers are not reported but they are undoubtedly endemic in most areas. Dysenteries. Both amebic and bacillary dysentery are common. Amebic dysentery is particularly prevalent in Ovamboland and Kaokoveld, but sporadic cases are re- ported from all sections of the country. Due to the generally low level of sanitation, both food and water supplies are subject to con- tamination. Bacillary dysentery usually oc- curs in small outbreaks during the summer months. Diarrhea, much of which is prob- ably unrecognized bacillary dysentery, is frequently epidemic, particularly among young children. Helminthiases. Various helminth dis- eases are common. Ancylostomiasis is present in limited areas in the northern territories, where the soil conditions are favorable for the development of the larvae. Infections with the beef tapeworm, Taenia saginata, are prevalent in the cattle areas. Occasional cases of echinococcosis are en- countered in the sheep-raising districts. 298 South West Africa Brucellosis. Undulant fever, caused by Brucella melitensis, is widely distributed. The highest incidence is encountered in the goat- and sheep-raising areas of the south, but cases are reported with increasing fre- quency from the northern districts. The possibility that the karakul sheep may be an important reservoir of infection has been suggested. In the absence of adequate fa- cilities for differential diagnosis, the extent of B. abortus infection is uncertain. How- ever, contagious abortion is reputed to be relatively rare among the native cattle. Other Infections. Human cases of an- thrax are frequent in the native areas, par- ticularly in Ovamboland, due largely to the consumption of meat from infected animals. Contact infections are occasionally recorded among the Europeans. Diseases SPreEAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread, but no criteria are available for determining the relative incidence. The cases reported from the Police Zone, which average from 40 to 80 annually, represent chiefly the cases hospitalized in the urban areas. A large percentage of these occur in the native population among whom the conditions of life away from their natural environment, overcrowding and undernutri- tion are predisposing factors. In the tribal reserves the highest incidence probably is encountered among the Hottentots in the south. The disease is also relatively common in sections of Ovamboland, although the manner of living of the tribes restricts the spread of the infection to a certain extent. Cases are not usually seen in the govern- ment and mission hospitals before the ad- vanced stages, when they run a rapid and acute course. Infections of bovine origin are rare. Smallpox. Epidemics of smallpox occur almost annually in the northern territories, along the borders of Angola and Bechuana- land. An intensive mass vaccination pro- gram has been carried on among the tribes of Ovamboland within recent years. The vaccination of the European children of school and preschool age is undertaken peri- odically, especially when outbreaks of small- pox are reported from the adjoining areas of the Union. Other Infections. Outbreaks of menin- gococcus meningitis are sporadic, particu- larly among the workers in the diamond fields and in the mines of the Grootfontein area. Pneumonia is prevalent. Localized outbreaks of diphtheria are common. Whooping cough and measles are endemic and at times epidemic. Occasional cases of scarlet fever are recorded. Diseases SPREAD OR CONTRACTED CHIEFLY THroUGH CONTACT Venereal Diseases. Venereal diseases are prevalent among the native populations in all parts of the territory, both in the urban locations and on the reserves. Syphilis and gonorrhea are most frequently encountered, but chancroid, lymphogranuloma venereum and granuloma inguinale also occur. Syph- ilis is particularly common in Ovamboland. In 1946, 2,074 natives were treated for syph- ilis, and 1,431 for gonorrhea in the Police Zone; 1,542 for syphilis, and 145 for gonor- rhea in Ovamboland. Treatment statistics may be misleading, however, in view of the differences in the composition and the dis- tribution of the two populations and in the readiness with which the various tribes utilize the medical facilities available. Ob- servations among the Herero and the Hot- tentot tribes of the south, as well as among those in the northern territories, indicate that the majority of individuals seek syph- ilitic treatment only in the later stages of the disease. Free treatment for venereal dis- eases is given at all government and mission hospitals and by the district surgeons, usu- ally at special centers. Leprosy. Leprosy occurs in Ovamboland and in the Okavango and the Caprivi Zipfel areas. Indigenous cases are not encountered in the Police Zone. No surveys have been made, but the incidence probably is rela- South West Africa 299 tively low. The cases under observation average from 10 to 30 annually in Ovambo- land. The infection rates in the other areas are somewhat higher. Other Infections. Rabies is enzootic among the wild meerkats and genets, and sporadic canine outbreaks occur. Human in- fections are frequently reported, generally from Ovamboland or the Okavango region. Tetanus is endemic in all parts of the coun- try. Eye infections, including trachoma, are common. Tropical ulcers and various my- cotic skin infections are not unusual in the northern areas. Scabies is widespread, and cases of human myiasis are seen occa- sionally. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is widespread, except in the arid regions of the south. It occurs during and after the rainy season and varies in incidence in different parts of the coun- try, as well as from year to year, depending upon the rainfall. Serious outbreaks are experienced annually in the northern terri- tories, particularly in Ovamboland and along the banks of the Nosob and the Auob rivers. During years of unusually heavy rainfall, extensive epidemics may involve the low rainfall districts to the south, in which the incidence is normally light. Little or no malaria is encountered in Luderitz and in the coastal desert region. Infections are predominantly subtertian in type, rarely quartan. The vectors are Anopheles gambiae and to a lesser extent A. funestus. Rickettsial Infections. Louse-borne ty- phus fever was first recognized in South West Africa in 1934. Since that time, small outbreaks have occurred sporadically, namely, in the Keetmanshoop, the Warmbad and the Windhoek areas. In an epidemic in the native location near Windhoek, in 1936, 15 cases and 2 deaths were reported. The huts in which cases were found were burned to the ground, and the contacts were quarantined. Tick-borne and flea-borne typhus have not been reported. The former infection is probably present since foci are found in the Union and in Bechuanaland. Plague. Sylvatic plague is enzootic in extensive foci from Windhoek to the north- ern frontier, but human infections are largely confined to Ovamboland. Between 1932, when the presence of the disease was first established, and 1939 approximately 800 cases and 100 deaths were reported from this region. Control measures employed in the affected areas include the extermination of rodents and disinfestation of the kraals. No cases were recorded in 1946. Other Infections. Tick-borne relapsing fever is endemic in the native areas. Cases of guinea-worm infection are frequent in many areas. Yellow fever apparently does not occur. However, the arthropod vectors are widely distributed, and the introduction of clinical cases constitutes a potential menace. Trypanosomiasis is a minor threat, since tsetse flies are encountered only on the Angola border. NuTtriTIONAL DISEASES Undernutrition and vitamin deficiencies are common among the poorer natives in the urban areas, and prevalent throughout the country during years of low rainfall and subsequent crop shortages. Pellagra, scurvy and beriberi are reported occasionally. SUMMARY South West Africa is a sparsely populated country, largely devoted to the raising of livestock. It was mandated to the Union of South Africa by the League of Nations and is governed by an Administrator appointed by that government. For purposes of admin- istration it is divided into two areas: the Police Zone in which white settlement is permitted, and the northern territories which are exclusively native. A large pro- portion of the natives, both in and outside the Police Zone, live under primitive tribal conditions. Public health in South West Africa is the responsibility of a Chief Health Officer who is advisor to the Administra- tion. The hospital facilities in the Police 300 South West Africa Zone include 7 hospitals for Europeans which are operated by the local authorities, 4 government hospitals for natives and 6 mission hospitals. Four hospitals are main- tained in the northern territories by the various mission organizations. The country is largely dependent upon subsurface sources for water supplies, the majority of which are derived from wells sunk in sandy stream beds and from boreholes. Sanitation is prim- itive. Malnutrition and avitaminosis are common, particularly during years of low rainfall. Intestinal infections, tuberculosis and venereal diseases are widespread. Malaria is prevalent, with seasonal outbreaks in the north and severe epidemics during years of heavy rainfall in the south. Outbreaks of louse-borne typhus and plague have oc- curred sporadically within recent years. Leprosy and tick-borne relapsing fever are endemic in the tribal areas. Smallpox, measles, pneumonia and diphtheria are com- mon. Outbreaks of meningococcus menin- gitis are frequent, particularly among the mine laborers. BIBLIOGRAPHY 1. Barnetson, James: Undulant fever: Its inci- dence in South Africa, South African M. J. 13:230-233 (Apr. 8) 1939. 2. Flourie, L.: Report on plague in Ovambo- land. South West Africa, Union of South Africa. Annual Report of the Department of Public Health for the Year ended June 30, 1932, Pretoria, Govt. Printer, 1932. 3. Hinsbeeck, F. C. S.: The plague situation in Ovamboland, Quart. Bull. Health Or- gan., League of Nations 2:82-90 (Mar.) 1933. 4. Karsten, Fr.: Die Brucellose der Haustiere in Siidafrika, insbesondere in Siidwest- afrika, Deutsche tropenmed. Ztschr. 45:- 240-246 (Apr.) 1941. 5. Lippelt, H.: Malta-Fieber Diagnose, Klinik und Therapie (Beobachtungen in Deutsch Stidwestafrika, 1938-39), Deutsche trop- enmed. Ztschr. 45:235-240 (Apr.) 1941. 6. Muhlens, P.: Die Bedeutung des Fleckfiebers fiir Afrika, Deutsche tropenmed. Ztschr. 45:248-256 (Apr.) 1941. 7. Nauck, E. G.: Die Bedeutung des Gelbfiebers fir Afrika, Deutsche tropenmed. Ztschr. 45:272-277 (Apr.) 1941. 8. Ordman, David: Relapsing fever in South Africa, South African M. J. 13:491-498 (July 8) 1939. 9. Sonneschein, Curt: Gesundheitsdienst in Siid- westafrika in Nachkriegszeiten, Deutsche tropenmed. Ztschr. 45:225-240 (Apr.) 1941. Thornton, E. N.: Position in regard to plague in the Union of South Africa and the mandated territory of South West 10. Africa, Quart. Bull. Health Organ., League of Nations 2:64-82 (Mar.) 1933. 11. Union of South Africa: Annual Report of the Department of Public Health, Year ended June 30, 1932, Pretoria, Govt. Printer, 1933. 12. : Annual Report of the Department of Public Health, Year ended June 30, 1946, Pretoria, Govt. Printer, 1947. 13. : Report by the Government of the Union of South Africa on the Adminis- tration of South West Africa for the Year 1946, Pretoria, Govt. Printer, 1947. 14. ——: Report Presented by the Government of the Union of South Africa to the Coun- cil of the League of Nations, Concerning the Administration of South West Africa for the Year 1936, Pretoria, Govt. Printer, 1937. 15. ——: Report Presented by the Government of the Union of South Africa to the Coun- cil of the League of Nations, Concerning the Administration of South West Africa for the Year 1938, Pretoria, Govt. Printer, 1939. 16. ——: Union Office of Census and Statistics: Official Year Book of the Union and of Basutoland, Bechuanaland Protectorate and Swaziland, No. 22, Pretoria, Govt. Printer, 1941. 17. Werner, Heinrich: Das Sanititswesen von Deutsch-Siidwestafrika in der Vergangen- heit mit Ausblick auf die Zukunft, Deutsche tropenmed. Ztschr. 45:209-218 (Apr.) 1941. 18. Year Book and Guide to Southern Africa: 1950 ed., London, Sampson Low, Marston & Co., Ltd., 1950. 21 The High Commission Territories of South Africa The High Commission Territories include the British protectorates of Basutoland, Bechuanaland and Swaziland. Although closely associated with the Union of South Africa, both geographically and economi- cally, they are governed independently under the control of the High Commissioner for South Africa, who is stationed in Pre- toria. Each protectorate is administered by a Resident Commissioner, while close co- operation between the Territories and the Union is attained through a standing joint advisory conference. The protectorates have certain features in common. They are all essentially native territories in which the people govern them- selves through their own hereditary Para- mount Chiefs. However, the British admin- istrations are responsible for the health services, the promotion of education, the development of industry and agriculture and the maintenance of justice. Registra- tion of native births and deaths is not re- quired in any of the territories, and conse- quently data from which to compile vital statistics is lacking. Basutoland GEOGRAPHY AND CLIMATE Basutoland, a mountainous country of approximately 11,700 square miles, is com- pletely surrounded by the provinces of the Union of South Africa. Along the eastern frontier the precipitous escarpment of the Drakensberg range, which includes peaks 301 rising to 11,000 feet, separates it from Natal and the East Griqualand section of the Cape. In the north and the west the Caledon River marks its boundary with the Free State, and in the north its frontier with Cape Province consists, in part, of the Orange River. With the exception of the narrow western plain which is a continua- tion of the great central plateau (5,000 feet), the entire country is rugged and mountainous. The climate is temperate, the maximum temperature being about 93° F. and the minimum around 11° F. Both seasonal and daily extremes of temperature are experi- enced, with a daily range in some areas which approaches 30° F. In the eastern mountains snow may fall in any month of the year. The annual rainfall is variable, approximately 30 inches in the eastern part of the territory but slightly less in the west, where the grassy plains become parched in the winter. About 70 per cent of the rain occurs during the summer months from November to March, usually in the form of heavy thunderstorms. Years of decreased rainfall and periodic droughts are common. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLAaTION The Basuto nation was welded during the first half of the last century, by the para- mount chief, Mashesh, from the remnants of Bantu tribes broken up by the wars with 302 The High Commission Territories of South Africa the Zulus. Under British protection since 1868, Basutoland has remained a native state with a high degree of local autonomy. The preliminary figures of the 1946 census indicate a population of 556,380, including 1,678 Europeans, 545 coloreds (of mixed blood) and 340 Asiatics. The density of population for the country as a whole has been estimated at 50 per square mile. Because of the preponderance of mountainous country, however, a dispro- portionately large percentage of the inhabit- ants live in the fertile lowlands of the west. Within recent years, the pressure of popu- lation and the shortage of arable land have combined to force the establishment of per- manent villages in the mountains and the development of agriculture on the slopes formerly devoted to grazing. Maseru, the capital and largest settlement, has a popula- tion of less than 5,000. The white residents live to a large extent in the administrative centers of the seven districts, all but two of which are located in the western plains. Both Protestant and Catholic missions are active in the country and have attracted large numbers of converts from their tra- ditional paganism. With the exception of a few government schools, educational facili- ties are conducted by the missions, fre- quently with financial assistance from the government. The school enrollment is high but attendance is irregular. Moreover, the proportion of boys is low, since tribal cus- tom demands that they follow the flocks for a large part of each year. Sociar Economy The majority of Basutos are peasants. The land is communal property; sections are allotted to each family for farming, but after the harvest they usually revert to the tribe for common pasturage. In 1946 only 16 per cent of the total land area was under cultivation. In general, primitive methods of agriculture and lack of individual respon- sibility have resulted in a progressive de- terioration of soil fertility. Maize is the most important crop in all parts of the territory. Canadian varieties of wheat have been intro- duced recently in the upland areas and are in increasing demand for export to the Union where little hard wheat is grown. Large herds of cattle, goats and sheep are raised in all parts of the country. Wool is the major export, with livestock and hides and skins second in importance. In most areas the pastures have been seriously de- pleted by soil erosion, due primarily to overgrazing, deforestation and the effects of the heavy rains on the steep, denuded slopes. In 1935 a soil conservation program was initiated with the aid of grants from British Colonial Development and Welfare funds. There are no mines or industries in Basuto- land; consequently, there is little demand for local labor. Taxation and the growing popularity of imported goods have forced large numbers of workers to seek employ- ment outside of the territory, usually in the mines of the Union. While the majority remain away for only a few months at a time, the annual exodus of a large percent- age of the adult males, and to small extent, of the female population, gives rise to se- rious social and economic problems. As may be expected from the mountain- ous nature of the terrain, the communication facilities are poor. A main road links the administrative posts on the western plain with each other and with adjacent areas in the Union. Secondary roads, up to 40 miles in length, lead to the foothills, but the re- mainder of the country can be reached only by bridle paths. A short 16-mile line of railroad runs from Maseru to Marseilles where it forms a junction with the Union system. Foop AND NUTRITION Basutoland usually produces ample grain for home consumption, but during periods of drought serious food shortages occur. The staple foods are maize, wheat, kaffir corn (a form of millet) and peas and beans. In the smaller villages and to some degree in the towns, these are supplemented by a variety of wild greens and roots. In spite of The High Commission Territories of South Africa 303 the large herds of cattle in the territory, milk is relatively scarce. Moreover, accord- ing to tribal custom, the use of milk and eggs by the women is tabooed. Meat is con- sumed irregularly, since the people kill their cattle only on ceremonial occasions. Mar- ginal avitaminosis is common, particularly among the children in regions where little milk is available. The Agriculture Depart- ment endeavors to promote the consumption of fruits and vegetables and employs dem- onstrators at various centers to advise the people on the development and the culti- vation of terraced gardens. This campaign, which was started following the famine of 1934, has caused considerable improvement in the health of the people. However, the growing popularity of refined maize meal is said to have a disturbing effect upon the native nutrition. The amount of pellagra has increased, particularly in the plains where the purchase of refined meal is common practice. Housine The Basutos live under primitive condi- tions in round or square mud-brick huts with thatched roofs, which are grouped together in small irregular villages in close proximity to their cattle kraals. The homes of the chiefs, the subchiefs and the wealthy tribesmen are frequently constructed of dressed stone or brick. In the villages ad- joining the administrative centers, where the people are influenced to a certain extent by European customs, the standards of living are generally higher than in the out- lying regions. ENVIRONMENT AND SANITATION WATER SUPPLIES The water supplies of the townships and the villages are derived from springs, shal- low wells and rivers. Subsurface sources are readily available in the uplands even during periods of drought. In the administrative centers water is normally piped from im- pounded reservoirs or near-by streams. The supervision of the water supplies is the re- sponsibility of the government health au- thorities, and up to 1942 almost 850 village springs had been protected from pollution. Part of the supply for Maseru is treated by filtration and chlorination. WasTE Di1sposaAL Primitive methods of sewage disposal are in use in all portions of the territory. The bucket system is employed in Maseru and other administrative centers, but elsewhere surface pollution is almost universal. Fauna anp Frora In general, the vectors and the reservoirs of disease are the same as those encountered in the surrounding areas of the Union of South Africa, subject to modifications re- sulting from differences in climatic condi- tions. Anopheline mosquitoes do not nor- mally occur. Flies, lice, fleas and ticks are widespread. Most of the field rodents com- mon to South Africa are present, and syl- vatic plague is enzootic in many areas. Freshwater snails are abundant in the western part of the country, but none has been found infected with Schistosoma. Foop SaNiTATION The standards of food sanitation are gen- erally low. Few facilities for cleanliness exist, and flies are abundant. In the Euro- pean settlements, regulations governing the handling of milk and the slaughtering of animals are enforced, but in the native areas only primitive methods are employed. HEALTH SERVICES AND MEDICAL FACILITIES HEALTH ORGANIZATIONS The Basutoland Medical Department ad- ministers the government hospitals and is responsible for the public health and sani- tation of the country. Both the funds and the staff available are inadequate, consider- ing the difficulties to be surmounted in covering a territory, a large portion of 304 The High Commission Territories of South Africa which is relatively inaccessible. The Direc- tor and the headquarters staff are located at Maseru. Medical officers are in charge of the health and medical services in each of the seven districts. The organization also includes field typhus and antirodent units and a leprosy inspectorate service. Little preventive work is attempted, but ante- natal and child welfare clinics are conducted in conjunction with the maternity ward of the Maseru Hospital. The activities of the Catholic and the Protestant missions are largely educational. However, they exert a considerable indirect influence on the health standards of the population. MEDICAL INSTITUTIONS In 1948 the Medical Department op- erated 9 hospitals, with an aggregate ca- pacity of 342 beds, and 12 dispensaries. A few beds are reserved in the larger hos- pitals for the use of white patients. It also administers a leper settlement at Botsabelo, near Maseru. Three hospitals were maintained by mis- sion groups: the Roma Hospital in Maseru with 40 beds, the Scott Hospital in Morija with 30 beds, and the Paray Hospital at Ntaotes with 18 beds. All are subsidized by the government. The total beds in all hos- pitals averaged about one per 1,300 popu- lation. Training courses for nurses and midwives are conducted in the larger government hos- pitals. Grants are also provided by which qualified Basutos may be sent to the Union for training as doctors or nurses. PERSONNEL Including the staffs of both government and mission institutions, only 21 doctors were available in Basutoland in 1948 to pro- vide for the health and medical care of over 550,000 persons. A total of 14 physicians was employed by the government medical service, 2 of whom were specialists con- nected with the leper settlement. About 31 nurses were present in the territory. Eighteen European and 9 native trained nurses, were listed on the roster of the Basutoland Medical Department; also a European health inspector, a sanitary officer and various native medical assistants. DISEASES Information regarding the incidence of disease in Basutoland is incomplete, since a large proportion of the people live in out- lying villages beyond the reach of medical attention. Reports based on hospital and dispensary statistics do not provide a true index of the prevalence of specific infections. DiseASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UrIiNARY TRACTS Typhoid and Paratyphoid Fevers. Lo- calized ‘epidemics of typhoid fever are common. The majority are water-borne ; the insanitary habits of the people lead to fre- quent pollution of the village springs and accumulations of rainwater. The number of known cases usually fluctuates between 150 and 350 a year, but major outbreaks are frequently responsible for an increase in incidence. A total of 369 cases was reported in 1944 as the result of an outbreak in Maseru district, which was considered to be fly-borne in origin. A series of village epi- demics caused by contaminated water sup- plies were reported in 1946, chiefly in Maseru and Mafetong districts, in which 556 cases were recorded. Water-borne out- breaks usually occur at the end of the rainy season. Immunization with typhoid-para- typhoid vaccine is employed routinely as a control measure in the affected areas. Para- typhoid fevers A and B are endemic but morbidity statistics are not available. Dysenteries. Only 70 to 80 cases of dysentery are treated in the hospitals and the dispensaries each year, but the observed cases probably represent a small fraction of the total incidence. No differentiation is made between amebic and bacillary infec- tions in the government reports, but both forms are known to occur. The High Commission Territories of South Africa 305 Diarrhea and Enteritis. Intestinal infec- tions are prevalent. In 1946, 2,898 cases of diarrhea and enteritis were recorded in chil- dren under two years of age, and 2,433 cases in persons over two years of age. In addi- tion, 211 cases of epidemic diarrhea were reported. As in the case of typhoid fever and dysentery, the known cases are not in- dicative of the extent of infection. Helminthiases. Various intestinal para- sites are common. Ascariasis and taeniasis are widely distributed, but ancylostomiasis is not reported. Human cysticercosis and hydatid disease are sometimes encountered. Other Infections. Undulant fever is re- ported occasionally. Brucellosis is enzootic among the native cattle and goats, but the incidence of human infection is not known. Diseases SPreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread. No special facilities for diagnosis or hospitalization are available, and the extent of infection is not known. Since 1941, following a brief period of reduced incidence attributed to improvements in nutrition, there has been an apparent increase in the disease. A total of 337 cases was reported in 1941; 980, in 1944; and 1,108 in 1947. Pulmonary infections predominate and are responsible for from 50 to 75 per cent of the total cases. Smallpox. From 1907, when a general vaccination program was inaugurated by the government, until 1942 only occasional cases of smallpox were observed. In the latter year an outbreak involving 161 cases occurred in Leribe and Mokhotlong districts in the northern part of the territory. Al- though covering a wide area, the cases in each village were few in number and were confined to individuals who had evaded the vaccination campaign in 1938 and 1939. The epidemics continued through 1944, when 576 cases were recorded from the central and the southern districts. The fatality rate was less than one per cent. Immunization was undertaken by the Basutoland Medical De- partment, but, due to lack of co-operation from the tribal chiefs, the disease continued to smolder in the mountain villages. In 1946, 27 cases were reported, and in 1947 only one. Other Infections. Whooping cough, measles, mumps, pneumonia, and influenza are endemic and at times epidemic. Menin- gococcus meningitis, scarlet fever, poliomye- litis and diphtheria occur sporadically. In 1946 the incidence of diphtheria increased from a yearly average of between 10 and 20 cases to 67 cases, the largest number ever recorded in the territory. The majority of these were from Quthing district in the southwestern corner of the country. The disease was mild, with a fatality rate of about 5 per cent. DiseasEs SPREAD OR CONTRACTED CuierLy TuroucH CONTACT Venereal Diseases. All forms of vene- real disease are observed, their spread being facilitated to a large extent by the periodic migration of laborers to and from the terri- tory. Treatment statistics give an erro- neous impression of relative incidence, par- ticularly in the case of gonorrhea, which the Basutos regard as a matter of course. Free treatment is provided at all government and mission dispensaries, but, since the patients frequently come from considerable dis- tances, few are seen after the initial visits. In 1947 a total of 6,908 known cases of syphilis was reported, 20 per cent of which were congenital. The same year, 2,423 cases of gonorrhea and 100 cases of gonococcal ophthalmia were observed. Leprosy. Leprosy is endemic, and the Melikan River Valley, in the southeastern district of Qachas Mek, is the largest single focus in the territory. In 1943, 685 patients were in residence in the government’s leper settlement at Botsabelo, near Maseru. Dur- ing that year, there were 135 new admis- sions, 20 per cent of which were children under 16 years of age. A leprosy inspectorate service is organized in the Medical Depart- ment, and 8 native inspectors are employed 306 The High Commission Territories of South Africa to search out new cases and follow up on discharged patients and contacts. The inci- dence of leprosy in the territory was esti- mated at roughly 2 per 1,000 population in 1936.22 Other Infections. Anthrax occurs spo- radically. Human cases result both from contact with infected animals and from the consumption of infected meat. Trachoma has not been observed. Actinomycosis and various other fungus infections are common. Scabies is wide- spread. In the course of a leprosy survey of the eastern districts in 1936, scabies was found in from 5.8 to 13.2 per cent of the inhabitants in different areas.?? DiSEASES SPREAD BY ARTHROPODS Malaria. Because of the mountainous nature of the country and the usual absence of anopheline vectors, indigenous malaria rarely, if ever, occurs. Rickettsial Infections. Localized out- breaks of louse-borne typhus are reported almost annually. Louse infestation is com- mon, and since the typhus epidemic in 1933-34, which was responsible for thou- sands of cases,” permanent delousing sta- tions have been maintained in the admin- istration centers. Between 50 and 150 cases a year have been reported in the last decade, and prior to the use of DDT, con- trol in the more remote villages was com- plicated by the necessity of transporting the deverminizing apparatus over precipitous pack trails. In 1944 an epidemic in the mountainous Quthing district on the border of Cape Province accounted for most of the 177 cases of typhus reported during the year. The importation of delousing facilities was considered impractical, but the pop- ulation of the area was immunized with alum-precipitated typhus vaccine. Sporadic cases of tick-bite fever, or tick typhus, are encountered. Plague. Plague is enzootic among the field rodents, and sporadic outbreaks of human infection are reported. Small epi- demics occurred in 1934 and in 1936, but they were checked by a systematic extermi- nation of field and domestic rodents. In 1942, 10 cases with 4 deaths were reported from three neighboring villages in Maseru district; 9 were bubonic and 1 septicemic in type. Wholesale fumigation of the huts was undertaken, while 385 inhabitants of the affected villages received injections of a live avirulent antiplague vaccine. The use of strychnine-poisoned wheat by the natives in the lowlands to safeguard their crops from destruction has reduced the rodent population in the cultivated fields. Other Infections. In the absence of the insect vectors, trypanosomiasis, yellow fever, filariasis and dengue fever do not occur. Relapsing fever and the vector, Or- nithodorus moubata, have not as yet been reported. NuTrITIONAL DISEASES In general, the Basutos are a happy, healthy people, much sought after by the mining industry because of their physique and endurance. However, malnutrition and marginal vitamin deficiencies are common in many areas, particularly during poor crop years. Most diets are deficient in milk and meat, and nutritional edema, due to pro- tein deficiency, is sometimes seen among young children. Scurvy occurs primarily in the populous settlements in the lowland dis- tricts. A total of 315 cases was treated in 1946. Pellagra is prevalent, and is increas- ing as a result of the modern tendency to employ refined maize in the preparation of the staple dish, porridge. Over 2,500 cases of pellagra were recorded, in 1946—almost double the number in the preceding years. Only 1,468 cases were reported in 1947. A seasonal increase in pellagra is noted, with the maximum incidence in November and a marked reduction in cases from March to October. Rickets occurs sporadically. SUMMARY The health and medical facilities are ad- ministered by the Basutoland Medical De- partment. There are 8 government hospitals The High Commission Territories of South Africa 307 and 3 mission hospitals, providing approxi- mately 340 beds and auxiliary dispensary services. The medical staff and the facilities are inadequate to care for the population, a large percentage of which lives in remote mountain villages. Springs, wells and rivers are the primary sources of village water sup- plies which are frequently contaminated. The standards of sanitation are low, and the methods of waste disposal are uni- versally primitive. Nutritional deficiency diseases are common in some areas. Intestinal infections are widespread. Tuberculosis, leprosy and venereal diseases are prevalent. Annual localized epidemics of typhus are reported, while plague occurs in sporadic outbreaks. The common respira- tory infections are endemic. Immunization against smallpox is undertaken by the Basutoland Medical Department, but occa- sional outbreaks occur in the mountainous areas where vaccination is evaded. Malaria, filariasis, trypanosomiasis, yellow fever, dengue fever and relapsing fever are not re- corded. Bechuanaland Protectorate GEOGRAPHY AND CLIMATE The Bechuanaland Protectorate, the largest of the High Commission Territories, has a land area more than twenty times the size of Basutoland and over forty times that of Swaziland. It covers an approximate area of 275,000 square miles, surrounded by Southern Rhodesia, Southwest Africa and the Cape and Transvaal provinces of the Union of South Africa. The Territory is an extension of the great central plain of South Africa and has an average altitude of 3,000 to 4,000 feet. The most characteristic fea- ture of the country is the general absence of surface water throughout the greater part of the year. The narrow strip of land drained by the Marico and the Crocodile rivers on the southeastern border, and the Chobe River area and the Okovango delta in the north are reasonably well watered, but the remainder is dependent upon a capricious summer rainfall. The Kalahari Desert occu- pies the entire southwestern part of the country and includes over one half of the total land area. Designated as a desert be- cause of the dearth of available water, it is covered with dense bush and is studded with salt pans and the remains of old water- courses and lakes. The annual rainfall, which varies from 20 to 25 inches in the east to 10 inches in the west, fluctuates ap- preciably from year to year with recurrent periods of severe drought. Except in the winter months, from May to August, the climate is changeable, and the heat is fre- quently excessive. At Mafeking, the admin- istrative capital, which is located in Cape Province just south of the border, the mean maximum temperature is 80° F., and the mean minimum, 50.5° F.: the absolute maximum is 102° F., and the absolute mini- mum, 14.5° F. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLaTION According to the census of 1946, the popu- lation was estimated at 252,869, less than half that of Basutoland. In addition to the indigenous peoples, it included 2,325 Euro- peans, 1,708 coloreds and 98 Asiatics. The country is unevenly settled, with the popu- lation concentrated, to a large extent, be- tween the desert and the eastern border. Except for a contingent of traders, mission- aries and government officials, temporary residents in the native reserves, the white population lives apart in definitely demar- cated European areas. These comprise some 2,000 square miles of ranch land along the Transvaal border, the Tati mining conces- sion in the northeast and a small Afrikaan farming settlement at Khangi on the west- ern edge of the desert. The Bechuana belong to the Suto-Chuana group of Bantu and are divided into several large independent tribes, each of which lives on its own “reserve” or designated tribal area. One large reserve is located in the 308 The High Commission Territories of South Africa Lake Ngami region of the northwest, the others between the desert and the European settlements on the eastern border. The in- habitants live in large central towns or vil- lages rather than in the small communities usually characteristic of the southern Bantu. Each season the population moves in family groups to the cultivated fields and the graz- ing grounds which are situated on the periphery of the towns, often at a distance of 20 miles or more. Serowe, the headquarters of the Bamang- wato, the largest and wealthiest of the tribes, has a population of approximately 30,000, and Kanye, the center of the Bang- waketse, of 15,000. The townships outside of the reserves are all small. Lobatsi and Francistown are the only European towns within the territory. The population of Mafeking, the historic capital which is lo- cated on the southern border in the Union, totaled only 6,000 in 1946. Large portions of the Kalahari Desert are uninhabited ex- cept by nomadic bands of aboriginal Bush- men. Tribal customs which require the absence of the boys at the cattle posts and of the girls in the fields represent obstacles to the development of education among the Bech- uana. Probably less than one quarter are literate. The government maintains primary schools for the European children, who are subsequently sent to institutions in the Union or in Southern Rhodesia. Native edu- cational facilities, which are controlled by committees representing the government, the various Protestant and Catholic missions and the respective tribes, consist of ele- mentary village schools and a limited num- ber of central schools providing a more advanced curriculum. Sociar Economy The social and economic life of both the European and the native populations is largely dependent upon the vicissitudes of the cattle industry. Lacking industrial de- velopment and mineral wealth, outside of the limited gold and copper deposits in Tati district, the resources of the territory are almost entirely agricultural. However, the meager and uncertain rainfall prohibits the extensive cultivation of crops and jeopard- izes the successful raising of cattle and other livestock in many areas. Within recent years, dairy farming has become increas- ingly popular among the European farmers and to some extent among the native, with the result that a profitable industry is gradually being developed. Native society is semipastoral. On most reserves communal land tenure and com- munity grazing have militated against the introduction of modern methods of cultiva- tion and the improvement of the livestock. The native cattle and hides and skins are inferior and consequently of low economic value. About one third of the adult males leave the reserves each year in search of employment, most frequently in the Wit- watersrand gold mines and the diamond diggings at Lichtenberg. This expanding volume of migratory labor has facilitated the spread of disease and introduced prob- lems of major social significance. The territorial and economic separation of the European and the native communities is aggravated by the lack of adequate means of communication. The railway from the Union to Southern Rhodesia traverses the eastern parts of the territory. Outside of the roads in the railway zone, and between Ngamiland and the towns on the eastern border, the transportation facilities are meager. However, the proposed promotion of ranching and agriculture in the Okovango delta will entail the development of new methods of communication between the urban centers of the Union and the northern part of the Protectorate. Foop AND NUTRITION The majority of Bechuana live at sub- sistence levels. The well-watered Chobe and Ngamiland districts are normally self-sup- porting, but production in the more arid regions is limited. Maize, kaffir corn (mil- let), beans, pumpkins and melons are raised The High Commission Territories of South Africa 309 by the various tribes, but the average dietary is deficient in fruits and green vege- tables. With the growth of the population, the wild plants formerly used as supple- mentary foods have become increasingly scarce. The consumption of protein is low. Fish are plentiful only in permanent rivers, and the livestock, which are regarded as a form of currency, are rarely slaughtered for food. The milk supply is unreliable and, moreover, is not available to the young children, except during the periods when the families visit the cattle posts. Through- out a large part of the year, grains consti- tute the principal and sometimes the only foods. Undernutrition and nutritional dis- eases are common, while semifamine condi- tions may be experienced in many areas during long periods of drought. Housine The standards of living among the Bechuana are generally inferior to those of the tribes in the surrounding territories. The majority live in primitive mud huts with thatched roofs, but sometimes stone or brick dwellings are owned by the chiefs and the more prosperous families. During the sea- sonal excursions to the grazing grounds and the cultivated fields, crude, semipermanent huts of poles or reeds, plastered with mud, provide the usual means of shelter. In Lobatsi, Francistown and other European towns, the natives live in designated areas or locations. ENVIRONMENT AND SANITATION WATER SUPPLIES Water supplies are obtained from village wells, surface dams and tribal boreholes, but are limited in amount and unreliable through the greater part of the Protectorate. Water is frequently derived from shallow wells, sunk in the sandy beds of the water courses. In Ngamiland, underground streams approach the surface at intervals, but in the eastern districts, boreholes con- stitute the usual source of supply. Consider- able development of tribal supplies, by means of water-boring operations and the construction of surface dams to provide for the conservation of rain water, has been undertaken recently, with the aid of grants from British Colonial Development and Welfare funds. Outside of the population centers little organized effort is made to protect the local supplies, and the majority are subject to pollution. Waste DisposaL The methods of sewage disposal are primitive. Septic tanks and bucket latrines are in use in the European towns, but sani- tary services are generally nonexistent on the reserves. Fauna anp Frora Little is known regarding the vectors of disease in the Protectorate. Anopheles gambiae is widespread, while A. funestus is also responsible for the transmission of malaria in Ngamiland and the Chobe swamp area. Aedes aegypti and other potential vectors of yellow fever are present during the summer season. The vectors of the virus in the potentially endemic areas of Ngami- land are not known. Mosquito-control work is undertaken at Maun and other centers of population in the endemic regions; also by certain farmers in the vicinity of their dwellings. The tsetse fly, Glossina morsitans, and possibly G. tachinoides occur in Ngamiland. The most extensive areas of infestation are in the vicinity of the Chobe River and in the Okovango swamp region, while the southern limit of the fly belt is a few miles south of Maun. Control measures, consist- ing of bush clearance, game fencing and game destruction, are carried on by the Tsetse Fly Control staff of the government health services. Species of Chrysops, Simu- lium and Culicoides are probably present but have not been implicated in the trans- mission of disease. Fresh water snails are numerous ; the probable intermediate hosts of schistosomiasis are Physopsis africana 310 The High Commission Territories of South Africa and Bulinus tropicus. Plague is frequently enzootic in Kalahari and Ngamiland, where the gerbils, T'atera and Desmodillus, and the multimammate rat, Mastomys coucha, are the principal reservoirs. The latter is the intermediary in the spread of infection from wild to domestic rodents. X. eridos and X. hipponax are the vectors of rodent plague; X. brasiliensis, of the human disease. Foop SaNiTaTION Sanitation is primitive, and few controls are exercised over the meat and milk sup- plies outside of the European townships. Meat inspection is carried on routinely by the government’s health inspectors at Lobatsi, Francistown and Maun. The pro- duction of milk is supervised in the dairy areas. Elementary controls over village sani- tation and meat inspection have also been introduced in the tribal center at Kanye. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS The government Medical Department is responsible for the health and medical care of the population. It is administered by a Director of Medical Services, stationed in Mafeking. Medical officers are in charge of the hospitals and the dispensaries in the European and the native areas, but only two health inspectors are available to cope with the promotion of sanitary measures through- out the territory. The activities of the Medi- cal Department have been expanded re- cently under the stimulus of grants from the British Colonial Development and Wel- fare funds, but the work in the outlying areas is limited by the small size of the staff and the distances to be covered. Health centers have been established at Tsau, Gaberones, Maholapye and Kanye. Several mission organizations carry on medical work in the reserves, the mission hospitals and doctors in some areas being subsidized by the government. Maternity and child welfare services are carried on in their maternity centers at Maun, Serowe and Ramoutsa. MepicAL INSTITUTIONS There are 9 hospitals in the Protectorate, government hospitals at Maun, Lobatsi, Serowe and Francistown, and mission hos- pitals at Kanye, Mochudi, Molepolole, Maun and Sofala. Outpatient clinics are maintained in connection with each hos- pital, and in some cases subsidiary clinics are held at intervals in near-by villages. The total hospital beds approximated 345 in 1948, but a few are also available at the maternity and health centers. The adminis- tration staff is cared for in the Victoria Hos- pital at Mafeking, which is operated under the authority of Cape Province. Diagnostic laboratory services are obtained at Mafe- king. Nurses training courses are conducted in the larger government and mission hospitals, while instruction in midwifery is given at Serowe. PERSONNEL In 1948 about 14 doctors were practicing in the Protectorate. The staff of the Medical Department averaged from 8 to 10 over the greater part of the year. Other medical per- sonnel included 1 dentist, 15 nurses, 3 mid- wives, 6 veterinarians and native assistants in various categories. DISEASES In view of the shortage of medical per- sonnel, the ignorant and superstitious char- acter of the native population and the vast distances to be covered, information regard- ing the actual incidence of specific diseases in the Protectorate is necessarily incom- plete, except in the case of serious outbreaks of more than local significance. DiseASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UriNARY TRACTS Typhoid and Dysentery. Outbreaks of typhoid fever, amebic dysentery and bacil- The High Commission Territories of South Africa lary dysentery occur frequently as the result of contaminated food or water sup- plies. Dysentery and diarrhea are especially prevalent during the summer months. Helminthiases. SCHISTOSOMIASIS. Schis- tosoma haematobium infections are common in the eastern part of the country, partic- ularly in association with the Taung, the Metsemotlaba, the Marico and the Notwani rivers. The intermediate snail hosts, Phy- sopsis africana and Bulinus tropicus, are abundant. S. mansoni infections have not been reported. OrHerR HELMINTH INFECTIONS. Ascariasis is common in all parts of the country. Taenia saginata is present among the native cattle, especially in the northern districts, and human infections occur sporadically. Ancylostomiasis, caused by Necator ameri- canus, is encountered in a few localized areas, mostly in the northern part of the country. Other Infections. Occasional human cases of brucellosis are observed. The ex- tent of infection among the dairy cattle and the goats is not known. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is widely dis- tributed and constitutes one of the most menacing diseases in the territory. Avail- able evidence indicates that the disease is increasing with the gradual deterioration of the nutritional status of the people and the development of new foci around the re- patriated laborers. The Bechuana have little resistance to the infection, which character- istically follows a rapid course. The unhy- gienic living conditions in the large native villages and inadequate facilites for the iso- lation and treatment of cases are important factors in the spread of the disease. Since 1946 x-ray facilities have been available in the government hospitals, while shelters for the accommodation of tuberculous patients have been erected in connection with hos- pitals at Lobatsi, Molepolole and Serowe. From 600 to 1,000 cases are reported each 311 year. The majority are pulmonary, but non- pulmonary infections are frequently en- countered. Plans have been made for the inauguration of a tuberculosis survey. The incidence of bovine tuberculosis is not known. Smallpox. Smallpox occurs in scattered epidemics which are usually mild in char- acter but sometimes are associated with a high mortality. The indifference of the people to the frequent outbreaks of variola minor and failure to report the occurrence of cases facilitate the spread of virulent smallpox when it is introduced. Mass vacci- nation is attempted in the event of an out- break, but the difficulty in reaching the scattered groups on the reserves makes the enforcement of adequate measures difficult. In 1949 vaccination was made compulsory for all laborers recruited for work in the Union. Other Infections. Pneumonia and unde- fined bronchial infections are prevalent. Measles, whooping cough and meningococ- cus meningitis are endemic and sometimes epidemic. The incidence of diphtheria is normally low, but occasional outbreaks are recorded. In 1947-48 an epidemic occurred in which almost 250 cases were reported, chiefly from the Bokalaka-Francistown and Serowe areas. Immunization against diphtheria was undertaken on a large scale, especially among the school children. Small localized epidemics of poliomyelitis occur sporadically. Scarlet fever is rare. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH CONTACT Venereal Diseases. All forms of venereal diseases are encountered, with infection rates in the neighborhood of 40 to 50 per cent. Syphilis, the predominating disease in this group, is widespread and apparently increasing. Serologic tests on unselected hos- pital patients from 1936 to 1946 indicate a probable incidence of 30 to 35 per cent sero- positive syphilis.2¢ The high degree of promiscuity in the towns and the large 312 The High Commission Territories of South Africa volume of migratory labor are socio-eco- nomic factors predisposing to the spread of venereal infections. Treatment centers are maintained by the government, but the na- tives rarely remain in attendance after the most obvious lesions have disappeared. Leprosy. Leprosy is encountered in all portions of the country, but the incidence is not high. In 1934 it was estimated?’ that the total number of lepers did not exceed 40 to 50—a rate of less than one per 5,000 popu- lation. Other Infections. Yaws is endemic among some tribes. Trachoma is common, particularly in the northern districts. Tropi- cal ulcers, various mycotic skin infections, human myiasis and scabies also occur. Outbreaks of rabies are frequent among dogs, and sporadic human cases occur. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is encountered in all parts of the country. The disease is hyper- endemic in the swamp areas of Ngamiland and Chobe district where both Anopheles funestus and A. gambiae are vectors. Else- where, 4. gambiae is the only vector, and transmission is seasonal, during and after the rainy season. The incidence varies from year to year, but under proper conditions localized or widespread epidemics may be experienced. Infections with P. falciparum predominate, while P. vivax and P. malariae are relatively rare. Plague. Sylvatic plague is enzootic among the veld rodents, and human cases are occa- sionally reported, principally from the re- gion north of the Kalahari Desert. In Oc- tober-December, 1944, the largest outbreak of human plague ever recorded from South Africa occurred in Ngamiland, centering around three separate foci—Sehitwa on the northeastern edge of Lake Ngami, and two areas on the Botletle River. A total of 304 cases and 156 deaths was reported. The majority of infections were bubonic in type, although a number of pneumonic cases were also described. Epizootics among gerbils and multimammate rats of the region preceded the human outbreaks. The affected areas were promptly quarantined, and control measures were instituted, including treat- ment of the native huts with cyanogen gas, the extermination of the rodents, the establishment of disinfestation stations along travel routes through the areas, and the immunization of the population with live avirulent plague vaccine. The outbreaks were brought under control before the end of the year, but cases continued to occur sporadically until March, 1945. Further small outbreaks were observed in 1946, totaling 68 cases and 57 deaths. Since 1946, the huts in the endemic areas have been treated at regular intervals with DDT in talc, under the supervision of government health inspectors. Trypanosomiasis. Sporadic cases and, at irregular intervals, localized outbreaks of trypanosomiasis, caused by Trypanosoma rhodesiense, are reported from Ngamiland and Chobe district. A severe epidemic oc- curred in 1942-43 in the Boyanke-Tsau area, in which over 800 cases were transferred to the Maun hospital for treatment. The popu- lation was evacuated from the infected area. Subsequently, the incidence was apparently negligible until 1949, when a small outbreak of 35 cases was recorded from the same region. Yellow Fever. Clinical yellow fever has not been reported, but human immunity surveys in 1945 revealed the presence of ap- parent foci of infection in the Ngamiland and Chobe districts. Immunity to the yellow fever virus was found in up to 12 per cent of the adults tested among the populations in the Okovango swamp area.?> A further survey was undertaken in 1949 by members of the staff of the South African Institute for Medical Research. Northern Bechuanaland from the border south to 21° parallel of latitude, and be- tween 23° and 25° E. meridians of longi- tude, is included in the yellow fever endemic area, as defined by the World Health Or- ganization in 1950. Other infections. Louse-borne typhus The High Commission Territories ot South Africa 313 is not present, but tick-borne infections occur sporadically. Ornithodorus moubata is widespread in the eastern portion of the South African plateau, and occasional cases of tick-borne relapsing fever are encoun- tered in the Protectorate. Guinea-worm infection was recorded, for the first time, from Maun in 1948. NutriTiIoNAL DISEASES Malnutrition and avitaminosis are prev- alent, and within recent years have been en- countered with increasing frequency. The rejection by medical officers at Johannes- burg of men recruited for work in the gold mines averages 25 per cent among the Bechuana as against 2 to 5 per cent for men from other areas? Scurvy is widespread. Manifestations of ariboflavinosis and vita- min A deficiency are common. Beriberi and pellagra are reported sporadically. SUMMARY Bechuanaland Protectorate is an unde- veloped pastoral country in which the major part of the white population is settled along the Transvaal border, and the native popu- lation in reserves between the eastern and the northern frontiers and the Kalahari Desert. The medical and public health ac- tivities of the government are carried on by the Medical Department, augmented by the work of various mission organizations. There are 9 hospitals, 4 maintained by the government and 5 by the missions, which provided a total of 345 beds in 1948. In addition, there are 3 subsidized mission maternity centers and a few government health centers. The water supplies are in- adequate and dependent upon a precarious rainfall except in the vicinity of the per- manent rivers on the northern and the east- ern borders. Sanitation is primitive. The dietary of the tribes is restricted, and mal- nutrition and deficiency diseases are com- mon. Tuberculosis, malaria and venereal dis- eases are prevalent and widespread in distribution. Schistosomiasis, plague, tryp- anosomiasis and African tick fever occur in localized areas. Leprosy is endemic. In- testinal infections, the ordinary respiratory diseases, and various skin and eye conditions are common. Northwestern Bechuanaland is included within the endemic yellow fever zone. Swaziland GEOGRAPHY AND CLIMATE The Swaziland Protectorate, the smallest of the High Commission Territories, com- prisec some 6,700 square miles in the north- east corner of the Union, and is surrounded on the north, the west and the south by the Transvaal and on the east by Mozambique and Zululand. Geographically, the country is divided into three zones, sloping from the high veld with an altitude of 4,000 feet or more in the west, to the semitropical low- lands at 400 to 800 feet above sea level in the east. The western and the central por- tions are watered by innumerable small streams and by several rivers which flow east to the Indian ocean. The climatic conditions are similar to those in comparable areas in the Transvaal. The temperature varies with the altitude, the mean annual temperature being 60° to 61° F. at Mbabane, at 3,800 feet elevation, and approximately 9° F. higher in the low- lands. The mean maximum temperature at Mbabane is 69° to 73° F., and the mean minimum 49° to 52° F. The rainfall, which is largely concentrated in the summer months, averages 54 inches a year at Mbabane and 34.8 inches at Bremersdorf. In the low veld region in the east, the rain- fall is capricious; the annual precipitation rarely exceeds 25 inches, and serious droughts are frequent. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuraTion , At the time of the latest census, in 1946, the population was estimated at 186,880, 314 The High Commission Territories of South Africa including 2,871 Europeans, 2,782 foreign Bantu, 600 to 700 coloreds (of mixed-blood) and a few Asiatics. With the exception of a small number of Zulus in the southeastern part of the territory, the indigenous peoples are all Amaswazis. They are closely related to the Zulus and speak a similar Bantu language. As the result of wholesale concessions by the native chiefs in 1878-90, over one half of the land is held by Europeans, and large tracts in the hands of absentee landlords remain undeveloped. The tribal lands are divided into 35 separate reserves, which to- gether equal only 40 per cent of the total land area. In 1943, however, the government set aside 334,000 additional acres for native settlement. The majority of Swazis live in a traditionally primitive manner in small scattered villages in the reserves, but at least 15 to 18 per cent are squatters on Euro- pean lands. There are only five townships. Mbabane, the administrative headquarters, and Bremersdorf are the largest. Each has a white population of approximately 500. Mission groups, representing 23 religious organizations, carry on evangelical, educa- tional and welfare work in the territory. The government maintains schools for the Euro- peans, but the education of the natives and the coloreds is largely conducted by the mis- sions, usually with subsidies from the gov- ernment. In addition to the mission schools there are 5 government-controlled central schools, and 3 which are supported by the Swazi National Fund. Interest in education is developing slowly, but in general the school attendance is irregular, and the ma- jority of children do not proceed beyond the lowest grades. Sociar Economy Swaziland is an impoverished territory. The agricultural resources are not effec- tively exploited ; at least 50 per cent of the land is suitable for cultivation, but only about 10 per cent is utilized. Maize, citrus and deciduous fruits, cotton and tobacco are grown by the white settlers, but farming development has been retarded by lack of capital and transportation facilities. Cattle raising is a major source of wealth, both for the Europeans and the Swazis. The exports of importance are meat, cat- tle, hides and skins, and asbestos. Asbestos is produced on a large scale in the north- western part of the country. Considerable gold has been recovered from mines near the Transvaal border, but within recent years operations have been partially sus- pended. Some alluvial tin is panned by primitive methods near Mbabane, and un- developed coal and iron ore deposits exist in the lowlands. Large numbers of young adults leave each year for short-term labor contracts in the Union of South Africa, the majority of whom are recruited for work in the Witwatersrand mines. As in other native territories, major social and health prob- lems are associated with this large exodus of migratory labor. Communication facilities are poor. There are no railways, but roads suitable for motor traffic link the larger population centers. A bus service, operated by the Union Rail- ways Administration, connects the more im- portant towns with Natal and the Trans- vaal, while the Portuguese railway runs a biweekly service from its terminus at Goba to Stegi. Foop AND NUTRITION Maize is the major grain crop, although millet is grown by the Swazis, and wheat and other cereals by the European farmers with irrigation facilities. All types of fruits—citrus, deciduous and tropical—are cultivated and, with the exception of small amounts of citrus, are consumed locally. Cattle, sheep and goats are raised in large numbers. Within recent years a flourishing dairy industry has been developed among the European and the native producers in the southwest. The diet of the Swazis does not differ ma- terially from that of the Zulus and other closely related tribes in southeast Africa. However, the natives themselves raise only The High Commission Territories of South Africa 315 about one fifth of the food necessary to meet their normal requirements. An effort is being made to promote the use of modern methods of agriculture, but progress has been slow. The effects of the general poverty and the high cost of foods are manifest in a considerable degree of undernutrition. The major deficiencies are proteins, fats and vitamins of the B complex. Housine The conditions of living among the Swazis are primitive and similar to those found among the Zulus of northern Natal. In some areas in the south, however, an im- proved type of housing of burnt brick con- struction is gradually being adopted. ENVIRONMENT AND SANITATION WATER SUPPLIES The water supplies are derived from the numerous streams and from springs and wells. The supplies for the European sec- tions of Mbabane, Bremersdorf, Hlatikulu, Goedgegun and Stegi are chlorinated and in some cases filtered. The water is usually piped to a limited number of outlets. In Mbabane, distribution is by means of open earth furrows, and the main supply is sup- plemented by individual sources from spring and rainwater tanks. The construction of a modern treatment and distribution system is under consideration. Most of the water supplies on the reserves and in the rural areas are unprotected and subject to pollu- tion. WasTE DisposaL The methods of sewage disposal are prim- itive. Pit latrines and occasionally septic tanks are employed in the township areas. Latrines are also used in some of the larger Swazi villages, but in the rural reserves soil pollution is the usual practice. Fauna anp FrLora The insect vectors of disease encountered in Swaziland are essentially the same as those found under comparable climatic con- ditions in the eastern Transvaal and north- ern Natal. HEALTH SERVICES AND MEDICAL FACILITIES HearLTH ORGANIZATIONS The Medical Department is responsible for the public health and medical activities of the government. The Department oper- ates two hospitals and several dispensaries in the outlying areas and conducts a limited preventive program involving the control of certain diseases, widespread vaccination against smallpox, the inspection of the water supplies in the townships and a mini- mum amount of mosquito control. It is administered by a Director of Medical Serv- ices with headquarters at Mbabane. Several mission groups carry on active medical programs which supplement the ac- tivities of the Medical Department. Ma- ternity and child welfare work is a promi- nent feature of all the health centers, but there is only one established infant welfare center. MebpicAL INSTITUTIONS There are three hospitals in the territory : two operated by the Medical Department and one by the Nazarene Mission. The gov- ernment hospitals at Mbabane and Hlati- kulu have a total capacity of 12 beds for Europeans, 3 for coloreds (Hlatikulu) and 85 for natives. The mission hospital in Bremersdorf has 8 beds for Europeans, 2 for coloreds and 76 for natives. In general, the hospitals are overcrowded and poorly equipped. Several health centers and a few dispensaries, subsidiary to the government and mission hospitals, serve the population in the outlying areas. There are no central laboratory services, but clinical laboratory facilities are available in the hospitals. Nurses’ training courses are conducted at the mission hospital, but there are no organ- ized facilities for the training of other types of medical personnel. 316 The High Commission Territories of South Africa PERSONNEL In 1945 there were only 7 physicians in the country, 4 medical officers in the employ of the Medical Department, and 3 mission doctors, subsidized by the government. The medical personnel is inadequate to cope with the many medical and public health problems affecting both the European and the native populations. The doctors aver- aged one per 26,000 of population. The nursing personnel in the territory totaled 21 European and 49 native nurses in 1948. In addition, there were 4 veter- inarians. DISEASES As in the other territories, only a rough approximation of the incidence of disease can be obtained from the available reports. The reported cases based on the statistics of the government hospitals and dispen- saries undoubtedly represent but a small proportion of the total. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Dysentery. The level of sanitation in Swaziland is generally low. Typhoid fever, the dysenteries, diarrhea and enteritis are prevalent, and there is some in- dication that amebic dysentery, in partic- ular, is increasing. Helminthiases. Scuistosomiasis. No adequate survey has been made, but infec- tion with Schistosoma haematobium is known to be extensive, especially in the middle and lowland areas. A study of three schools in 1943 suggested that the infection rate among the students was at least 36 per cent.?® A large proportion of streams in the northern, the eastern and the southern por- tions of the territory are infested with the intermediate snail hosts, Physopsis africana and Bulinus tropicus. Oraer Herminta INFECTIONS. Hook- worm is not reported, but Ascaris lumbri- coides and other round worms are common. Taenia saginata infections are frequent in the cattle-raising areas. Other Infections. Undulant fever occurs sporadically. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread. On the average, from 300 to 500 cases are treated each year, and the tendency of the Swazis to take the disease as a matter of course suggests that a relatively small percentage of cases are reported. There are no facilities for the hospitalization of in- fectious cases. Smallpox. A high degree of immunity to smallpox exists among the population as the result of an extensive vaccination program over a period of years. However, vaccina- tion is opposed by certain religious groups, and cases occur sporadically. A total of 30 cases of mild smallpox was reported in the northern and the southern districts in 1943. Malignant smallpox appeared in the south- ern district in 1946, but the prompt enforce- ment of control measures prevented its spread. Other Infections. Pneumonia, influenza, measles and whooping cough are endemic. Occasional cases of diphtheria and menin- gococcus meningitis also occur. Diseases SPREAD OR CONTRACTED CuIerLy THrOUGH CONTACT Venereal Diseases. Syphilis is prevalent, even in the rural areas. In 1945 syphilis was responsible for almost one quarter of the total admissions in both clinics and hos- pitals. Gonorrhea is also common, but the relative incidence is not known. Leprosy. The incidence of leprosy is rela- tively low, probably not over one case in 1,000 of population. Until recently there has been no attempt to provide isolation and treatment facilities. The first leper set- tlement was established in 1943-44 with 64 residents—48 adults and 16 children; the second was under construction in 1946. The High Commission Territories of South Africa 317 Other Infections. Various diseases of the eyes are common, but trachoma, which is prevalent in other native territories, has not been reported. Ophthalmia neonatorum is a major cause of blindness. Occasional cases of tetanus and of human anthrax are re- ported. Scabies is widespread. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is highly endemic. Transmission takes place primarily during the period toward the end of the rainy sea- son, and during years of heavy rainfall epidemic conditions may be experienced since Anopheles gambiae is prevalent. The highest incidence is encountered in the low- lying regions in the eastern third of the territory, where 4. gambiae breeds prolifi- cally in the water-filled depressions on the cattle-grazing grounds. A parasite rate of 50 per cent was demonstrated among the children in 1945, but as this was a year of unusually low rainfall, the incidence is probably higher under normal conditions. The most severe outbreak on record, with over 50,000 cases, was reported from the middle and low veld region in 1946. Inten- sive anopheline control measures were en- forced, and antimalaria drugs were distrib- uted without cost. A. funestus is found in the western portions of the country but is of minor importance in the transmission of malaria. Plasmodium falciparum infections predominate. P. vivax is also common, but P. malariae is rare. One case of P. ovale was identified in 1942. Other Infections. Ornithodorus moubata is encountered over a wide area, but only occasional cases of tick-borne relapsing fever are reported. Sporadic cases of tick- bite fever, or tick typhus, occur. Louse- borne typhus is absent, since the climatic conditions do not favor the degree of in- festation with lice which is encountered in the other native territories. Animal tryp- anosomiasis is enzootic, but human cases are not reported. Plague and yellow fever are not present, but they represent potential threats to the country. NUTRITIONAL DISEASES Malnutrition is widespread, affecting par- ticularly the children in the younger age groups. Scurvy is prevalent. Rickets, beri- beri and pellagra are also observed. SUMMARY Swaziland is retarded in social and eco- nomic development. The public health and medical activities are carried on by the gov- ernment’s Medical Department, with the active co-operation of numerous mission groups. There are three hospitals in the territory with an aggregate capacity of 186 beds. The medical facilities and personnel are inadequate for the care of the scattered European and native populations. Sanita- tion, as regards water supplies, foods and waste disposal, is universally primitive. Malaria, schistosomiasis, venereal dis- eases, tuberculosis and nutritional diseases constitute the major disease problems. In- testinal infections are prevalent. Leprosy and relapsing fever are endemic. Plague, yellow fever and human trypanosomiasis have not been reported. BIBLIOGRAPHY 1. Barnetson, James: Undulant fever: Its inci- dence in South Africa, South African M. J. 13:230-233 (Apr. 8) 1939. 2. Buxton, P. A.: Trypanosomiasis in Eastern Africa, 1947, London, H. M. Stationery Office, 1948. 3. Great Britain. Economic Advisory Council, Committee on Nutrition in the Colonial Empire: Summary of Information Regard- ing Nutrition in the Colonial Empire, First Report, Part IT, London, H. M. Stationery Office, 1939. 4. Kuczynski, R. R.: A Demographic Survey of the British Colonial Empire, Vol. II. London, Geoffrey Cumberlege, Oxford, University Press, 1949. 5. Notes on the High Commission Territories of South Africa: Geog. J. 101:79-84 (Feb.) 1943. 6. Ordman, David: The occurrence of relapsing 318 The High Commission Territories of South Africa oh 10. 11. 12. 13. 14. 18, 16. 17. 18. 19. 20. 25n fever and the distribution of Ornithodorus moubata in South Africa, South African M. J. 15:383-388 (Oct. 11) 1941. Overseas Reference Book of the Union of South Africa, including South-West Africa, Basutoland, Bechuanaland Protectorate and Swaziland: London, Todd Publishing Co., Ltd., 1945. Perham, Margery F.: The Protectorates of South Africa, London, Oxford, 1935. Porter, Annie: The larval termatoda found in certain South African mollusca, with special reference to schistosomiasis (bil- harziasis), Publ. S. African Inst. Med. Res. 8: No. 62, 1-492 (Dec.) 1938. Sawyer, W. A. and Whitman, L.: The yellow fever immunity survey of North, East and South Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 29:397-412 (Jan.) 1936. Union of South Africa: Annual Report of the Department of Public Health, Year ended June 30, 1945, Pretoria, Govt. Printer, 1946. : Annual Report of the Department of Public Health, Year ended June 30, 1946, Pretoria, Govt. Printer, 1947. ——: Union Office of Census and Statistics: Official Year Book of the Union of South Africa and of Basutoland, Bechuanaland Protectorate and Swaziland, No. 22, Pre- toria, Govt. Printer, 1941. United Nations. Non-Self-Governing Terri- tories: Summaries and Analyses of Infor- mation Transmitted to the Secretary-Gen- eral during 1948, Lake Success, New York, 1949. Year Book and Guide to Southern Africa: 1950 ed., London, Sampson Low, Marston and Co., Ltd., 1950. BASUTOLAND Basutoland: Annual Medical and Sanitary Report for the Year ending December 31, 1941, Maseru, 1942. ——: Annual Medical and Sanitary Report for the Year ending December 31, 1942, Maseru, 1943. ——: Annual Medical and Sanitary Report for the Year ending December 31, 1944, Maseru, 1945. ——: Annual Medical and Sanitary Report for the Year ending December 31, 1946, Maseru, 1947. ——: Annual Medical and Public Health Report for the Year ending December 31, 1947, Maseru, 1948. ' Dutton, E. A. T.: The Basuto of Basutoland, London, Oxford, 1935. 22, 23, 24. 23. 26. 24. 28. 29. 30. 31. 32. 33. 34. 38. 36. 37. Germond, R. C.: A leprosy survey of the eastern border districts of Basutoland, Internat. J. Leprosy 6: No. 3, 303-314 (July-Sept.) 1938. Great Britain. Colonial Office: Colonial An- nual Reports, Basutoland, 1946, London, H. M. Stationery Office, 1947. Strachan, P. D.: Leprosy and leprosy treat- ment in Basutoland, Internat. J. Leprosy 2: No. 4, 431-439 (Oct.-Dec.) 1934. BECHUANALAND PROTECTORATE Bechuanaland Protectorate: Annual Medi- cal and Sanitary Report, 1945, Mafeking, 1946. ——: Annual Medical and Sanitary Report, 1946, Mafeking, 1947. ——: Annual Medical and Sanitary Report, 1948, Mafeking, 1949. ——: Annual Medical and Sanitary Report, 1948, Mafeking, 1950. Davis, D. H. S.: A plague survey of Ngami- land, Bechuanaland Protectorate, during the epidemic of 1944-45, South African M. J. 20:462-467 (Aug. 24) 1946; 511- 515 (Sept. 14) 1946. Dyke, H. W.: Leprosy in the Bechuanaland Protectorate, Internat. J. Leprosy 2: No. 4, 441-442 (Oct.-Dec.) 1934. Gear, J. H. S., and DeMeillon, B.: Labora- tory investigations of two cases of trypano- somiasis contracted in Ngamiland, Bechu- analand, South African M. J. 13:233-236 (Apr. 8) 1939. Hodgson, Margaret L., and Ballinger, W. G.: Britain in Southern Africa, No. 2, Bechuanaland Protectorate, Johannesburg, Lovedale Press, 1936. Schapera, I.: Migrant Labour and Tribal Life. A Study of Conditions in the Bechuanaland Protectorate, London, Geof- frey Cumberlege, Oxford University Press, 1947. SWAZILAND Great Britain. Commonwealth Relations Office: Annual Report on Swaziland for the Year 1946, London, H. M. Stationery Office, 1947. Jamison, R.: A note on leprosy in Swazi- land, Internat. J. Leprosy 2: No. 4, 443 (Oct.-Dec.) 1934. Marwick, Brian Allen: The Swazi: an Eth- nographic Account of the Natives of the Swaziland Protectorate, Cambridge, Cam- bridge Univ. Press, 1940. Swaziland: The Annual Medical and Sani- tary Report for the Years ended Decem- ber 31, 1931-40. The High Commission Territories of South Africa 319 38. ——: The Annual Medical and Sanitary Re- 40. ——: The Annual Medical and Sanitary Re- port for the Year ended December 31, port for the Year ended December 31, 1943. 1945. 39. ——: The Annual Medical and Sanitary Re- 41. ——: The Annual Medical and Sanitary Re- port for the Year ended December 31, port for the Year ended December 31, 1944, 1947. SECTION SIX Equatorial Africa 22. 23. 24, 25. 26. 27. 28. ANGorAa BeLcian ConNco RuaNDA-URUNDI FRENCH EQUATORIAL AFRICA SpaNisH GUINEA (Rio Muni and Fernando Péo) . CAMEROONS: French Cameroons British Cameroons . SAo ToME AND PRINCIPE , . 323 . 336 .:360 . 368 . 382 . 388 306 . 400 . 0 Zinder >..r Kano 3 3 3 PST NH ai ND, fr hy SOT SN BY ORITR : / 0s v. . oF : - 5 WS Brazzavilleg A 577008 a tc & Pointe Noire 2 =e" “¢_/CLéopolgville 7 cagiNDAE” LE GPOL o£ Cabindab Equatorial Africa 22 Angola GEOGRAPHY AND CLIMATE Angola, sometimes designated as Portu- guese West Africa, has been a Portuguese possession almost continuously since the explorations of the fifteenth century. It has an approximate area of 523,000 square miles, with a coast line of over 1,000 miles on the Atlantic Ocean. The Colony is surrounded inland by the Belgian Congo, Northern Rhodesia and South West Africa; the Cabinda enclave, a separate section of 3,000 square miles north of the Congo River, is surrounded by French Equatorial Africa and the Belgian Congo. The major portion of the territory is a high, broken tableland which constitutes part of the great central plateau of southern Africa. It rises from a narrow coastal plain in a steplike escarpment with intervening wooded uplands and slopes gradually east- ward toward the basins of the Congo and the Zambezi rivers. The coastal plain aver- ages from 30 to 50 miles in width but fans out to a depth of 150 miles along the south- ern bank of the Congo River. It is primarily low bush country, except in the valleys of the larger rivers, which becomes increasingly arid toward the south. Rugged mountain chains, running parallel with the coast, mark the western edge of the Huila and the Benguela highlands, the southern and the central portions of the inland plateau. Peaks rising to 7,500 feet or more dominate the rolling grassy plains of the plateaus, which have a general elevation of 4,000 to 6,000 feet. North of the wide, shallow valley of the Cuanza River, the Malange highlands rise in a series of terraces to an average altitude of 5,000 feet and sink eastward to the lowlands of the Cuando and the Kasai river basins. The uplands are drained by innumerable streams, the majority of which constitute the headwaters of tributaries to the Congo and the Zambezi systems. The principal rivers flowing toward the ocean are the Cuanza, between the northern and the central plateaus, and the Cunene, which forms part of the border with South West Africa. The construction of a joint reclama- tion project on the latter river is proposed by the Portuguese and the Union of South Africa governments. The climate of Angola is influenced by two factors: the altitude and the antarctic, or Benguela current, which flows parallel with the coast. In general, it ranges from temperate to subtropical in the southern coastal region and on the plateaus; from subtropical to tropical in the northern coast- lands and in the intermediate zones of the western escarpment and the interior. The year is divided into rainy and dry seasons. The rainy season extends from October to May, with periods of maximum precipita- tion in October and November and again in March and April. In the coastal belt, where the effects of the cold Benguela current are felt, the annual rainfall ranges from about 30 inches in the Congo region to a fraction of an inch south of Mossamedes. Heavy fogs are encountered along the southern coast and on the western slopes of the mountain ranges. In the highlands of the interior the rainfall decreases from north to south: from 60 inches to 40 inches on the plateaus, and to 20 inches on the plains of the escarpment. The dry season covers the period from May 323 324 Angola to October, the months from June to August being practically rainless in all sections of the country. The mean temperatures along the coast approximate 70° to 80° F. and in the highlands, 70° to 85° F. Both the sea- sonal and the daily fluctuations are slight in the coastal areas. In the highlands, how- ever, daily variations in temperature of from 25° to 50° F. are common during the dry season. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTION The census statistics for 1940 placed the population of Angola at approximately 3- 738,000, including 44,083 whites and 28,035 mulattoes. The population was further divided into “civilized” and “uncivilized.” The former group totaled 91,611 of all races, among whom 24,211 were native Africans. The population for 1946 was estimated at slightly over 3,868,800, with 51,400 whites and 31,600 mulattoes. The white population is predominantly Portuguese. Other groups, which totaled 1,468 in 1940, comprise small contingents of Italians, Poles, Germans and English-speak- ing peoples. Between 200 and 400 Afri- kaners, remnants of a colony founded in 1876, are settled in Huila district in the south. After a long period of dissension, the majority were moved by the government of the Union of South Africa in 1928 to the Gobabis and the Grootfontein areas of South West Africa. The immigration of Portuguese nationals has increased steadily since 1920, partially as a result of the efforts of the Portuguese government to promote colonization. The mulatto segment of the population is largely concentrated in the coastal region. With the exception of minor aboriginal admixtures in the south, the native peoples of Angola represent various branches of the Bantu family. They are divided into numerous tribes with wide differences in speech, customs and social development, but, in general, they conform to four groups: the Kongo of the northwest, the Lunda of the northeast, the Mbunda of the central coastal and highland regions, and the het- erogeneous tribes of the south. Kikongo and Umbundu are the languages most ex- tensively employed. Scattered primitive and warlike tribes are encountered in the Cuando and the Cuanza river areas. The inhabitants of the south include Ovambos, Hereros, small groups of Bushmen or Hot- tentot origin, and Barotsi, the predominant element in the southeast. The natives are pagans and fetish worshipers, but large numbers have been converted to Christi- anity by the various Catholic and Protestant missions. The Colony, as a whole, is sparsely settled, with a population density ranging from 2.5 to 15 per square mile. In accord with the Portuguese policy of assimilation, there are no designated native reserves similar to those found in some of the adjoining colo- nies. There are numerous small towns but few large cities. In 1946 Luanda, the admin- istrative capital and principal port, had a population of almost 67,000, including about 9,500 white residents. Lobito, the second port, and Benguela, both on the trans- continental railway, have populations of roughly 5,000 Europeans and 10,000 na- tives. The most important centers on the plateau are Nova Lisboa, Silva Porto and Sa de Bandeira. The educational system is designed to promote the integration of the various tribal and racial groups. Portuguese is the official medium of instruction, and teaching in the indigenous languages is prohibited, except in the most rudimentary mission schools and in elementary classes prepara- tory to the teaching of Portuguese. The degree of literacy among the native and the mixed groups is relatively low. Among the 91,611 “civilized” inhabitants enumerated in the census of 1940, 35,641 were classified as illiterate. Primary and secondary schools are maintained under government, mission and private auspices. The Centrale Lycée, in Luanda, offers some courses at the post- secondary level. VITAL STATISTICS Vital statistics are not available for the Colony as a whole. In 1940 the death rates, per 1,000 population, were estimated at 15.9 in Luanda, 18.5 in Nova Lisboa and 19.7 in Silva Porto. The infant mortality is high. At least 32 per cent of the deaths recorded in Luanda in 1940 occurred in infants under one year of age. Among many of the more primitive tribes the infant mortality is re- ported to be as high as 60 per cent.?! SociaL Economy Agriculture is the principal occupation of both the indigenous and the white popula- tions. The natives are primarily peasant farmers, who work the land on an individual or tribal basis. In the case of the white set- tlers, however, large plantations or ranching concessions are frequently operated by com- panies or by co-operative organizations. All exports are subject to high preferential tariffs, except in the Congo basin where in- ternational free trade agreements are in force. The major agricultural exports are maize, coffee, sugar, various oil seeds and cocoa. Maize, the staple native crop, is grown over a wide area, but chiefly in Luanda and Benguela provinces. Coffee is cultivated in the north, sugar cane in the central coastal region and in the Catumbela and the Cuanza river valleys, and cocoa in the Amboim and the Cabinda areas. Oil palms grow abundantly in many parts of the country. Castor-oil beans are cultivated on a large scale in Benguela Province, and coconut palms in the northern coastal re- gion. Sisal, wheat, peanuts and beeswax are being produced in increasing quantities. Conditions are favorable for ranching on the Huila and the Benguela plateaus, and large numbers of cattle and sheep are raised ; both hides and meat are potentially valuable export products. The Portuguese government is endeavoring to promote set- tlement of the highlands and the introduc- Angola 325 tion of modern methods of agriculture and stock raising. Rich deposits of diamonds and other minerals contribute materially to the wealth of the Colony. Extensive alluvial diamond fields, which are worked by large companies, are found along several rivers in the north- eastern corner of the country. Lesser fields occur in the Cuilo River basin and along the Cubango River in the south. Gold, copper, coal and mineral salt are mined in appreciable quantities, and petroleum has been located along the coast in the Luanda area. Industrial development is restricted by laws governing the processing of raw ma- terials. Manufactures of primary economic importance include preserved meat, fish and dairy products, sugar and various fish and vegetable oils. Extensive reserves of timber are available, but the lack of transportation facilities retards their exploitation. A large percentage of the white popula- tion, other than the Portuguese administra- tive officials, is affiliated with commercial, agricultural or mining concerns. The natives are the principal source of labor, which, be- cause of the low population density, is rela- tively scarce in many areas. The central government exercises controls over the sup- ply and the distribution of native labor. Angolans are also recruited through their chiefs for work on the sugar plantations of Sado Tomé and Principe islands. A system of good motor roads connects all the European, administrative and mili- tary settlements. Transportation between native communities outside of this network is largely by means of paths. Four railroads serve the fertile upland districts, with ter- minals in port towns. The Benguela railway from Lobito to the Congo border forms a link with the Rhodesian system, providing outlets on both the Indian and Atlantic oceans for the mineral areas of Katanga and the Rhodesias. Government-owned lines connect centers in the Malange highlands with Luanda, and on the Huila plateau with Mossamedes. A short secondary road from Porto Amboim serves the local coffee and 326 Angola oil districts. Steamer service is available to Europe and the Americas and between the coastal and the Congo ports. Air transporta- tion facilities are maintained between the larger cities and with the Belgian Congo and Portugal. Foop AND NuTrITION The climate of Angola is highly diversi- fied, and a wide variety of food crops, char- acteristic of temperate and tropical regions, is cultivated. Among the most important are wheat, maize, millet, legumes and other vegetables. Poverty and malnutrition are prevalent among the native populations, particularly in the urban areas. Local food shortages frequently occur as the result of unfavorable weather conditions or trans- portation difficulties. The basic foods of the natives are maize, bulrush millet and cassava. Important sec- ondary foods include peanuts, yams, pump- kins, legumes, bananas and various other tropical fruits. Rice is cultivated in the northern coastal region. Goats, sheep, pigs and chickens are found in most villages. Cattle are raised in areas free of the tsetse fly but are regarded primarily as a form of wealth rather than a source of food. Meats are consumed freely, although tribal taboos are common. Milk and eggs are rarely used. Insects, rodents and similar forms of animal life are regarded as delicacies by many tribes. Housing Marked contrasts are observed between the housing in the cities, as Luanda, and the rural areas, and between the dwellings of the white settlers and the traditional huts of the native inhabitants. Stone and con- crete are common building materials in the towns ; adobe bricks, in the European farm- ing communities. Roofing may be of corru- gated iron or tile, or in the rural areas, of thatch. The native huts vary in design among the different tribes but are usually built of mud plastered on a framework of poles, with thatched roofs. In general, the square dwell- ings of the Congo tribes are of better con- struction than the simple round huts found in other areas. The most primitive are the temporary structures of boughs and grass used by the nomadic pastoral peoples of the south. In some tribes the family units live in self-contained kraals, many of which have a characteristic complex arrangement. Over- crowding in the huts is common, and sani- tary conditions are generally poor. ENVIRONMENT AND SANITATION WATER SUPPLIES Angola is traversed by innumerable rivers and streams, and adequate supplies of water are available in most sections of the country from surface sources or from shallow wells. In the coastal region few of the rivers are perennial, but moderate supplies of water may be obtained during the dry months, from May to September, from shallow wells in the sandy stream channels. In the arid sections of the south, water is frequently scarce over wide areas during the dry sea- son. In the southwest it is collected during the rains and stored in metal tanks or con- crete basins. Local water supplies vary in quality and are always subject to contami- nation. Some of the larger cities have sani- tary municipal water supplies. That of Luanda is derived from artesian springs and is pumped to a reservoir about 18 miles from the city. The water is treated by filtration and chlorination before distribution. Ben- guela, Lobito and Catumbela are served by a joint plant at Catumbela. Mossimedes, Sa de Bandeira, Silva Porto and Nova Lisboa also have central water systems. WasTE DI1sPosAL Water-borne sewerage systems have been constructed in 7 of the larger cities: Mossa- medes, Benguela, Lobito, Luanda, Malange, Nova Lisboa and Silva Porto. In many sections of these cities, however, and in all of the smaller towns, pit latrines constitute the general means of sewage disposal. In Angola 327 the native villages disposal is usually on the open ground, although frequently at a dis- tance from human habitations. Fauna anDp Frora Arthropods. Mosquitoes. The principal vectors of malaria in Angola are Anopheles gambiae and A. funestus. Both species are found abundantly in the lowland areas, par- ticularly in the coastal region and the river valleys of the north. They decrease in prev- alence in the higher altitudes, although 4. gambiae may be encountered on the pla- teaus following periods of heavy rainfall. A. gambiae breeds during the rainy season in various small exposed pools and other collections of water, both natural and arti- ficial. A. fumnestus breeds in the numerous small streams where the vegetation affords suitable conditions of shade. 4. nili and A. pharoensis are also present in the Colony but are of negligible importance in the transmission of malaria. Aedes aegypti is widespread, and 4. afri- canus has been identified in many areas. Both species are potential vectors of yellow fever. However, the disease has not been reported from the Colony since 1900. Numerous species of Culex are found. The majority are merely troublesome pests, but Culex quinquefasciatus (= C. fatigans) is a potential vector of Wuchereria bancrofti in the northern and the central coastal regions. Taeniorkynchus (Mansonia) uni- formis and T. (M.) africanus have been recorded. Fries. Seven species of tsetse flies are reported from areas covering at least one third of the colony. Glossina palpalis (with its varieties wellmani and fuscipes) is found along rivers and streams below 3,500 feet from the Catumbela River to the Congo frontier. Its distribution in the south is not known accurately, but minor foci may exist along the Cunene, the Cubango, the Cuito and the Cuando rivers. G. morsitans occurs in apparently unrelated foci in central An- gola, north of the Benguela railway between the Zambezi River and the Rhodesian bor- der, and in the Cuando River region in the southeast. G. longipalpis, G. brevipalpis, G. fusca, G. pallicera and G. schwetzi have a more limited distribution. Both animal and human trypanosomiasis are important problems in the tsetse-fly-infested regions of the north and the southeast. By means of extensive bush clearance, G. palpalis has been eradicated from many areas in the central coastal region, but it persists in the Congo and the Cuanza river basins. Various species of Stomoxys, Musca, Ta- banus and Haematopota are abundant and may be responsible for the mechanical trans- mission of intestinal diseases. Numerous species of myiasis-producing flies are pres- ent. The tumbu fly, Cordylobia anthropo- phaga, is occasionally the cause of myiasis in man. Chrysops dimiditata and C. silacea are vectors of Loa loa in northern Angola. Auchmeromyia luteola is found throughout the Colony. Its larvae, known as “Congo floor maggots,” are troublesome pests. Simu- lium damnosum breeds in the small upland streams in certain areas, where it is a vector of Onchocerca volvulus. Sandflies of the genus Phlebotomus are found, but the spe- cific species have not been identified. The midges, Culicoides grahami and C. austeni, are reported as vectors of Acanthocheilo- nema perstans in many areas. Lice. Infestation with Pediculus humanus corporis and P. humanus capitis is common among the natives. P. humanus capitis, in particular, is prevalent among the women of the plateau tribes. The style of headdress is a means of differentiating between vari- ous groups; it is always elaborate. The hair is oiled and held in place with clay and is never combed unless a change of personal status necessitates a new coiffure. In spite of the prevalence of lice, epidemic typhus fever and louse-borne relapsing fever are rarely reported. Fras. Xenopsylla cheopis and X. bra- siliensis are found on the domestic rodents. The common dog flea, Ctenocephalides canis, is also present. Since 1931-32, when sylvatic plague was introduced from Ovam- 328 Angola boland in South West Africa, a focus of infection has existed in the southern part of the country. X. eridos is responsible for the spread of the disease among the wild rodents. X. brasiliensis has occasionally been implicated in its transmission to man. The human flea, Pulex irritans, has been identified in Benguela. The chigoe, Tunga penetrans, is indigenous along the coast and occasionally is encountered in the interior. It burrows beneath the skin, usually of the fingers or the toes, and produces sores which readily become infected. BepBuGcs. Cimex lectularis and C. hemip- terus, the ordinary bedbugs of Africa, are widespread. Ticks AND Mites. Ornithodorus moubata is widely distributed but rarely encountered in areas below 2,000 feet. It is a vector of relapsing fever, which is endemic in many portions of the Colony. Amblyomma varie- gatum, A. splendidum, Rhipicephalus san- guineus, R. appendiculatus, Haemaphysalis leachi and Boophilus decoloratus are among other species known to be present. The itch mite, Sarcoptes scabiei, is abun- dant. The rat mite, Liponyssus bacoti, sometimes attacks man. OrtHER ArTHROPODS. Various species of scorpions of the families BuTtHipAE and ScorriOoNIDAE are encountered in the Col- ony. The sting of large scorpions of the genus Pandinus may produce temporary or complete paralysis in adults and is occa- sionally responsible for the death of young children. Reptiles. Numerous species of venomous snakes are found. The mamba, Dendroas pis angusticeps, and the cobras, Naja nigricollis, N. anchietae and Elapechis guentheri, are reported from various localities. The most dangerous vipers are Bitis arietans and B. gabonica, but B. caudalis and B. perin- gueyi are also present. Causus resimus is the most common night viper. The boomslang, Dispholidus typus, is encountered fre- quently. Rodents. The domestic rats, Rattus rat- tus rattus and R. rattus alexandrinus, are widespread, while R. norvegicus is present in the port towns. However, active extermi- nation measures have reduced the rat popu- lations in the urban areas. Sylvatic plague is enzootic along the southern border, in the area encircled by the Cunene and the Cubango rivers. The rodents primarily af- fected are the gerbils, Tatera lobengulae schinzii and T. lobengulae Joannas. The multimammate rat, Mastomys coucha, is an intermediate reservoir in the trans- mission of plague from the wild to the domestic rodents. The infection was intro- duced from South West Africa in 1931-32, having spread from the Kalahari region in Bechuanaland. Posts are established on the frontier for the systematic collection and examination of rodents. Control measures are carried on in the vicinity of villages where human outbreaks have occurred, but the nature of the terrain and the sparseness of the population limit their effectiveness. Mollusks. Physopsis africana globosa and a species of Bulinus, the intermediate snail hosts of Schistosoma haematobium in Angola, are found in streams and pools in scattered foci throughout the country. Plants. Poisonous plants with which man may come in contact, accidentally or on purpose, include Erythrophleum guineense, Adenium boehmianum and species of Stro- phanthus. The juices of Focea multiflora, which is widely distributed, are used by the natives in the preparation of poisoned arrows. Euphorbia candelabrum and Cracca vogelii are employed to poison the water for fish and game. Dickapetalum veninatum frequently causes the death of animals eat- ing the young shoots hidden in the grass, and may be of considerable economic im- portance, Foop SaNIiTATION In the larger towns the supervision of markets, the inspection of meats and the control of food and water supplies are undertaken by the local branches of the Colonial health organization. Sanitary regu- lations are enforced by special sanitary Angola 329 police, but the degree of control varies in different localities. The standards of sani- tation in the native areas are uniformly low. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The Direcgdo dos Servigos de Saude e Higiene is responsible for the health of the population. It functions under the Servicos de Saude e Higiene, an advisory technical service in the Direccio Geral de Adminis- tracdo Politica e Civil of the Ministerio das Colonias in Lisbon. The Colonial or- ganization, with headquarters in Luanda, includes divisions in charge of the distribu- tion of pharmaceutical supplies, the super- vision of the medical facilities of the Colony, the administration of the hospitals in the city of Luanda, the training of medical as- sistants and the plague-control program. Health bureaus are established in each of the five provinces which have authority over the government hospitals and dispen- saries, the health centers and subsidiary units in the larger towns and the scattered sanitary posts in the rural areas. Relatively little preventive work is undertaken by the government, except in relation to the con- trol of certain specific communicable dis- eases. The Servicos da Assisténcia Médica ao Indigena e do Combate a Doenca do Sono, a semiautonomous division in the govern- ment health organization, conducts an ac- tive ‘sleeping sickness” control program and provides medical care for the natives in the northwestern part of the country. It operates in an area, including Luanda Province and the adjoining sections of Benguela and Malange provinces, which is divided into 14 medical districts, each in charge of a full-time medical officer. It maintains a headquarters in Luanda and permanent treatment stations and ambu- lance units in the districts. Various Protestant and Catholic mission societies carry on educational and medical work in different parts of the country and contribute materially to the promotion of better health and living conditions among the people. Medical facilities are also main- tained by certain industrial concerns for the benefit of their employees. The Com- panhia de Diamante de Angola supports measures for the control of the tsetse fly, Glossina palpalis, in the northeastern corner of Luanda Province. The Instituto de Medicina Tropical in Lisbon operates in conjunction with the Ministerio das Colonias. It maintains per- manent research organizations in certain colonies and plans to establish a unit for the study of yellow fever and other virus diseases in Angola. MEepIcAL INSTITUTIONS Hospitals and Dispensaries. The Lu- anda Hospital is the largest medical institu- tion in Angola, and is the nucleus of the government’s medical care program. It is a well-equipped teaching hospital with from 250 to 300 beds for white and native pa- tients. In 1950 there were 25 government hospitals in the provinces, which ranged in size from 20 to 150 beds; 7 in Luanda, 9 in Benguela, 3 in Huila, 2 in Malange and 3 in Bie provinces and 1 in Cabinda Dis- trict. The Colonial health services also operated a maternity hospital and a mental hospital in Luanda, and three child welfare centers. In addition, each of the 114 rural sanitary posts provides two or three beds for emergency cases. About 10 to 15 hospitals and numerous rural dispensaries have been established by Protestant and Catholic missions, which furnish medical assistance to the natives in various parts of the Colony. Several mining and one large agricultural concern maintain hospitals and clinics in their respective areas for the care of their workers. However, the total capacity of all state and private hos- pitals probably does not exceed 0.7 beds per 1,000 of population. A mission-operated leprosarium is lo- cated at Camundongo in Benguela Province. 330 Angola Laboratories. The laboratory of the Lu- anda Hospital is the central diagnostic and public health laboratory for the Colony. It is equipped for the performance of chemical, bacteriologic and pathologic examinations. Diagnostic laboratories are also attached to the larger provincial hospitals. Laboratory facilities are available at the divisional headquarters of the Servicos da Assisténcia Médica ao Indigena e do Combate a Doenca do Sono. The laboratory of the plague- control program is located at N’Giva. Serums and vaccines are prepared in two laboratories under the Servicos de Veteri- naria e Industria Animal de Angola. Schools. A school for the training of medical assistants, nurses, midwives, sani- tary agents and health visitors is conducted in Luanda under the direction of the head- quarters organization of the government health services. PERSONNEL Physicians. Most of the doctors in the Colony are connected with the Direccdo dos Servigos de Saude e Higiene. In 1950, the staff comprised 102 medical officers and 32 medical specialists, including 4 dentists, at- tached to the government hospitals and laboratories. From S to 12 doctors of differ- ent nationalities are connected with the mission hospitals, while others are employed by industrial concerns. A small number are engaged in private practice in the European centers. Others. A total of 18 pharmacists, about 165 male nurses and 74 nursing auxiliaries, 12 nurse-midwives, 2 visiting nurses, 47 sanitary agents and 1 entomologist were working with the health services in 1950. Nurses were also affiliated with nursing homes and with mission and industrial hos- pitals, while a few are engaged in private work. Twenty-eight veterinarians were in government service in 1946. DISEASES Morbidity and mortality statistics are compiled by the government health serv- ices. While the data pertaining to the white population may be regarded as rea- sonably complete, figures for the native tribes are probably inaccurate. Moreover, a large percentage of the deaths is ascribed to unknown causes. The persistence of prim- itive forms of medicine among the native peoples, combined with the fact that the established medical facilities reach only a small portion of the population, must be considered in evaluating the incidence of disease. Sanitary conditions are generally poor, and, except in the case of a few dis- eases such as smallpox, trypanosomiasis and plague, little preventive work has been at- tempted. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UrINARY TrACTS Typhoid and Paratyphoid Fevers. Enteric fevers are endemic. From 20 to 250 cases of typhoid and paratyphoid fever are reported annually, but the recorded low incidence probably reflects the lack of ade- quate facilities for diagnosis in the rural areas, as well as incomplete reporting. Dysenteries. Amebic dysentery is wide- spread. From 900 to 1,500 cases are reported annually, usually predominantly from the coastal districts. The proportionate inci- dence in the plateau districts varies from year to year. Relatively few cases of bacil- lary dysentery are reported—from 20 to 140 a year—but available statistics give no indi- cation of the extent of infection. In approxi- mately 3,300 cases of dysentery recorded in 1940, over one third were attributed to amebiasis, while almost two thirds remained unclassified. A large percentage of the latter group were probably undifferentiated bacil- lary infections. Over one half were from Luanda Province where outbreaks of intes- tinal infections are common, due to the greater concentration of population and the frequent contamination of the water sup- plies. Diarrhea and Enteritis. At least 6,000 to 7,000 cases of diarrhea and enteritis are listed each year, probably a fraction of the cases which actually occur. These intestinal infections represent one of the principal causes of death, both in infants and in the older age groups. Helminthiases. ANcyLosToM1asts. Hook- worm infection is present in most parts of the country, except in the arid sections of the south. The highest incidence is found in the low-lying districts of the northern coastal region and the Congo River basin. Necator americanus is the predominating species, but Ancylostoma duodenale is also encountered. From 2,800 to 5,000 cases are reported each year. Scuristosomiasis. Foci of infection with Schistosoma haematobium are widely dis- tributed, particularly in the coastal districts. The incidence is apparently increasing; an average of 1,660 cases was reported an- nually from 1936 to 1941, in contrast with 4,000 cases in 1947. Infection rates of 45 to 60 per cent have been found among chil- dren in some localities in Cuanza-Sul dis- trict. Rates of 60 per cent among children and 22 per cent among adults are also recorded in the Cuchi region of Bie Prov- ince.?? The intermediate snail hosts are abundant in the numerous small streams throughout the colony. S. mansoni is not reported. Oruer HELMINTH INFECTIONS. Infections with Ascaris lumbricoides and other intes- tinal worms are prevalent. Other Infections. Anthrax is enzootic among the cattle and the sheep. Occasional human cases occur as the result of contact, or the ingestion of meat from infected ani- mals. Undulant fever is sporadic. Cholera has not been reported from southwestern Africa. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Smallpox. Outbreaks of smallpox are ex- perienced periodically, in spite of extensive vaccination. From 1931, when 1,408 cases were recorded, until 1940, the annual inci- dence did not exceed 200 to 600 cases. In Angola 331 the latter year, almost 1,100 cases were re- ported, about 75 per cent of which were diagnosed as alastrim. The case rate re- mained high through 1943 but dropped to the level of the previous decade by 1947. The fatality rates fluctuate between 3 and 12 per cent. Tuberculosis. The incidence of tubercu- losis is not known, but the disease appears to be increasing; over 770 cases were re- ported in 1940, in contrast with 395 cases in 1938. Deaths from pulmonary infections are at least ten times as numerous as those from other forms of the disease. Among the native populations unhygienic and crowded living conditions, dietary deficiencies and the repatriation of infected laborers from the mining and the industrial areas to their home communities contribute to the spread of the infection. Other Infections. Pneumonia is a major problem. In 1946 it ranked second only to malaria among the deaths attributed to in- fectious diseases. Over one quarter of the reported deaths were among children under 5 years of age. Whooping cough, mumps, measles and meningococcus meningitis are endemic, and epidemics occur from time to time. Diphtheria and poliomyelitis are re- ported sporadically; scarlet fever, rarely. Diseases SPREAD OR CONTRACTED Cuierry THROUGH CONTACT Venereal Diseases. All forms of venereal disease are present; syphilis and gonorrhea are widespread. Statistics from government institutions give little indication of the true extent of these infections, but the propor- tionate incidence of syphilis appears to be increasing and gonorrhea to be decreasing. Approximately 3,500 cases of syphilis and 4,100 cases of gonorrhea were reported in 1938 ; 4,300 cases of syphilis and 2,100 cases of gonorrhea in 1947. Leprosy. Leprosy is endemic in many parts of the Colony. The infection rates vary in different localities but are highest in the lowlands of the Congo basin and on the central plateau. Although the actual prev- 332 Angola alence is uncertain, available data suggest that the disease is decreasing in importance. Leprosy was recorded from all of the prov- inces in 1938, where in a total of 458 known cases, 35 per cent were credited to Luanda Province and 50 per cent to Bie. In 1940, however, Malange and Huila provinces were apparently free from infection. Only 268 cases were reported, roughly 80 per cent being about equally distributed between Luanda and Bie provinces. Most of the re- mainder were from Benguela Province. In 1947 the number of known lepers had de- creased to slightly less than 100. A lepro- sarium is maintained under mission auspices at Camundongo, and also small temporary camps on the plateau. Yaws. Yaws is prevalent throughout northern Angola, between 8,000 and 10,000 cases being recorded each year. The inci- dence is particularly high among the tribes of the Congo district and the northern and the central coastal regions. At least 85 per cent of the 9,300 or more cases listed in 1940 were from Luanda Province. Diseases of the Skin. Mycotic infections are numerous and may be severe. Infections with Trichophyton ferrugineum and Sporo- trichum beurmanni are frequent. Tropical, or phagedenic, ulcers are responsible for considerable disability. Cases of “mossy foot” are encountered occasionally. Scabies is widely distributed, and cases of human myiasis, caused by the larvae of Cordylobia anthropophaga and other flies, are seen sometimes. Other Infections. Rabies is enzootic among the dogs and the jackals, and spo- radic cases of human infection are reported. Trachoma and infectious conjunctivitis are common. Tetanus occurs irregularly, usually in newborn infants. Human anthrax infec- tions are sometimes observed. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is of primary impor- tance in all sections of the Colony. It is hyperendemic on the coastal plain from the Congo to the Cuanza and in the river val- leys of the north, and epidemic in the pla- teau regions and in the semiarid country of the south. From 50,000 to 70,000 cases are recorded annually, from 50 to 65 per cent from Luanda Province. Transmission takes place during the greater part of the year in the tropical lowland areas. At the higher altitudes and in the more arid regions, out- breaks coincide with periods of heavy rain- fall. Plasmodium falciparum infections pre- dominate, while the proportionate incidence of P. vivax and P. malariae varies from year to year. P. ovale is encountered occasion- ally. Blackwater fever is sporadic; cases are usually observed among the white residents. Trypanosomiasis. Trypanosomiasis, caused by Trypanosoma gambiense, is en- demic throughout most of the region north of 12° S. latitude. From 1938 through 1945 the total prevalence averaged approximately 14,960 cases a year. From 2,000 to 2,600 new cases are reported annually, usually about 30 to 40 per cent from the coastal districts of Cabinda, Zaire, Luanda and Cuanza-Sul, from 35 to 40 per cent from the frontier districts of Congo and Lunda, and the remainder from Cuanza Norte dis- trict, with scattered cases in the lowland z pe ; Ei S87 2) . we a Ox 50> i | INFECTED Human Trypanosomiasis in Angola Angola 333 areas of Malange, Bie and Huambo dis- tricts. In 1945,'° the infection rates in the different medical districts ranged from 0.3 per 1,000 population in Golungo and Noqui to 10.5 in Bembe, 10.7 in S. Salvador, 15.7 in Quissama and 19.3 in Cambambe. A minor focus of infection also exists in the Cuando area in the southeast. No human cases of trypanosomiasis have been reported from other tsetse-infected regions. A vigorous campaign against sleeping sickness is carried on by the Servigos da Assisténcia Médica ao Indigena e do Com- bate a Doenga do Sono. The area covered by the Servicos, including all of Luanda Province and adjacent infected sections in Benguela and Malange provinces, is divided into 14 medical districts, each in charge of a full-time medical officer. The Servigos con- ducts diagnostic surveys and maintains per- manent centers for the treatment of sleeping sickness and other diseases, as well as travel- ing dispensary or ambulance services. The movement of people from endemic areas is controlled by means of a health permit system. Plague. Prior to 1929 outbreaks of plague were occasionally reported from the port towns. More recently, however, sylvatic plague has been found to be present in the southern section of the country. It was intro- duced in 1931-32 when the enzootic infection spread from the Kalahari region of Bechu- analand to South West Africa and thence across the border to Angola. In the period from 1931 to 1937 a total of 62 cases of human plague was recorded among the in- habitants in the southeastern corner of Huila Province. The peak occurred in 1934, when 34 cases were discovered in the neigh- borhood of Bocoio. No human cases have appeared since 1937, although the disease continues to smolder among the veld rodents. When the epizootic threatened in 1931-32, a plague-control unit was created within the governmental health organization, and pre- ventive measures were initiated in the zone encircled by the Cunene and the Cubango rivers. Medical posts were established near the frontier ; the inhabitants in the exposed areas were protected by antiplague vaccine. Relapsing Fever. Tick-borne relapsing fever is common, particularly in the fron- tier districts. Usually between 400 and 700 cases are treated in the government hos- pitals and dispensaries each year. Outbreaks appear primarily among the rural tribes, however, and the recorded cases probably constitute but a small fraction of the actual incidence. The vector, Ornithodorus mou- bata, is widely distributed throughout the Colony. Yellow Fever. Yellow fever has been epidemic from time to time in all of the port towns, but no cases have been reported since 1900. The vector, Aedes aegypti, is abundant, especially in the warm, humid areas. In the course of an immunity survey reported in 1934,° blood samples from 949 persons in 19 communities in the north- eastern and coastal regions were tested, but protective antibodies were found in only 11 individuals (4 children and 7 adults), most of whom lived near the Congo border. Filariasis. Infections with Wuchereria bancrofti, frequently associated with ele- phantiasis, are endemic in the coastal re- gion. Acanthocheilonema perstans is wide- spread. Loa loa and Onchocerca volvulus are reported from scattered foci in northern Angola. Other Infections. Louse-borne typhus fever rarely, if ever, occurs, although louse infestation is almost universal among the native populations. Murine typhus has not been identified, but tick-borne infec- tions have been reported. Cases of leish- maniasis were recorded in 1921-22 but have not been reported since that date. NuTrITIONAL DISEASES Deficiency diseases are frequent; the dietary of the different tribes is often inade- quate and poorly balanced. Beriberi is not unusual, especially among the poorer in- habitants in the coastal districts. Scurvy is reported sporadically. Goiter is endemic in 334 Angola certain upland regions in Malange, Benguela and Bie provinces. MiscerLLANEOUS CONDITIONS Onyalai, a hemorrhagic disease of un- known etiology which is described from central Africa, is prevalent on the Benguela plateau. SUMMARY Angola, a vast and sparsely settled coun- try, has been a Portuguese possession since the fifteenth century. Responsibility for the public health and medical care of the popu- lation resides in the Direcgdo dos Servicos de Saude e Higiene of the Angola govern- ment, which functions under the health or- ganization of the Ministerio das Colonias in Lisbon. Subordinate provincial bureaus con- trol the administration of the government hospitals, township health units and rural sanitary posts in their respective areas. A semiautonomous Servicos da Assisténcia Meédica ao Indigena e do Combate a Doenca do Sono provides medical care for the na- tives and conducts an active “sleeping sick- ness” control program in the northwestern part of the country. In 1950 there were 27 government hospitals, that at Luanda being the largest. In addition, from 10 to 15 hos- pitals and numerous rural dispensaries are operated by various mission groups, while a few industrial concerns provide medical facilities for their employees. Innumerable small streams traverse the country, and ample water supplies are avail- able from surface and shallow subsurface sources. The small local supplies are fre- quently unprotected and contaminated. Some of the larger cities have sanitary municipal water supplies. Seven of the cities have water-borne sewerage systems, but the methods of sewage disposal in the smaller communities and in the rural areas are primitive. Undernutrition is common; beri- beri and goiter are the chief known de- ficiency diseases. Intestinal infections and malaria are re- sponsible for the highest morbidity rates among both native and white populations. Ancylostomiasis, urinary schistosomiasis, venereal disease, tuberculosis, pneumonia, leprosy and relapsing fever are widespread. Trypanosomiasis and yaws are prevalent in the north; filariasis, in the coastal area. Sylvatic plague is enzootic in southeastern Angola, and outbreaks of human infection have been reported. Outbreaks of smallpox occur periodically in spite of extensive vac- cination. Meningococcus meningitis, measles and whooping cough are frequently epi- demic. Diphtheria, scarlet fever and typhus fever are rare. Yellow fever has not been reported since 1900. BIBLIOGRAPHY — Angola, Colénia de: Direcgdo dos Servicos de Satde e Higiene. Boletim sanitirio de Angola, referente ao bienio 1937-1938, Luanda, Imprensa nacional, 1940. 2. ——: Direccio dos Servigos de Satde e Higiene. Boletim sanitdrio, ano de 1940, Luanda, Imprensa nacional, 1941. 3. ——: Direcgdo dos Servigos de Saude e Higiene. Boletim sanitario, ano de 1941, Luanda, Imprensa nacional, 1943. : Direcgdo dos Servicos de Satde e Higiene. Boletim sanitdrio, ano de 1942, Luanda, Imprensa nacional, 1944. 5. ——: Direcgdo dos Servigos de Saude e Higiene. Resumo das doencas transmis- siveis e epidemicas, 1947, Luanda, Im- prensa nacional, 1947. 6. ——: Orcamento geral para o ano econémico de 1950, Luanda, Imprensa nacional de Angola, 1950. : Repartigio técnica de estatistica geral, Anuario estatistico de Angola, ano de 1939, Luanda, Imprensa nacional, 1941. 8. ——: Reparticao técnica de estatistica geral, Anuério estatistico de Angola, ano de 1948, Luanda, Imprensa nacional, 1950. 9. Beeuwkes, Henry, Mahaffy, A. F., Burke, A. W., and Paul, J. H.: Yellow fever pro- tection test surveys in the French Came- roons, French Equatorial Africa, the Bel- gian Congo and Angola, Tr. Roy. Soc. Trop. Med & Hyg. 28:233-258 (Nov.) 1934. 10. Conferéncia Intercolonial sobre Tripanosso- Angola 335 11. 12. 13. 14. 15. 16. miases, 26 a 31 de agosto de 1946. Vols. 1 and II, Lourengo Marques, Imprensa na- cional de Mogambique, 1947. Delachaux, Theodore, and Thiebaud, Charles E.: Pays et peuples d’Angola, Paris, Edi- tions Victor Attinger, 1934. Ferreira, F. S. da C.: As tripanossomiases nos territdrios africanos portugueses Africa ocidental (Angola e Guiné) Africa oriental (Mocambique) 1948, Abst. Trop. Dis. Bull. 46:530-531 (June) 1948. Hollenbeck, H. S.: Leprosy in Angola, Tr. Roy. Soc. Trop. Med. & Hyg. 28:655-656 (April) 1935. Portugal. Instituto Nacional de Estatistica: Anuario estatistico do império colonial, 1943, Lisbda, Sociedade Astoria, Lda., 1945. ——. ——: Anudrio estatistico do império colonial, 1944, Lisboa, Sociedade Astoria, Lda., 1945. ——. ——: Anudrio estatistico do império 17. 18. 19. 20. 2%. 2 colonial, 1945, Lisboa, Sociedade Tipo- grafica, Lda., 1946. ——. ——: Anuario estatistico do império colonial, 1946, Lisboa, Sociedade Tipo- grafica, Lda., 1947. Salazar Leite, A., Bastos da Luz, J. V., and de Meira, M. T. V.: Pé musgoso africano, An. Inst. med. trop. (Lisbda) 5:7-30 (Dec.) 1948. ——: Relatério da Missdo médica Instituto de Medicina Tropical a Angola em 1945, An. Inst. med. trop. (Lisboa) 4:465-500 (Dec.) 1947. Sarmento, Alexandre: Nota sobre um foco de bilharziose vesical em Angola, An. Inst. med. trop. (Lisbda) 1:375-380 (Dec.) 1944. Tucker, John T.: Angola. The Land of the Blacksmith Prince, London, World Do- minion Press, 1933. . Yearbook and Guide to Southern Africa: 1950 ed., London, Sampson Low, Marston and Co., Ltd., 1950. 23 Belgian Congo GEOGRAPHY AND CLIMATE The Belgian Congo came into being in 1908 with the annexation by Belgium of the Congo Free State. Located on the equator in the heart of the African continent, the Colony has a total area of over 910,000 square miles. It is almost completely sur- rounded by French Equatorial Africa, the Anglo-Egyptian Sudan, Uganda, Ruanda- Urundi, Tanganyika Territory, Northern Rhodesia and Angola, but has a coastline of 25 miles on the Atlantic Ocean. The country lies within the basin of the Congo River and, in many respects, the two are virtually synonymous. The entire cen- tral region is a depressed plateau which at its lowest point, in the vicinity of Lake Leopold II, is at least 1,100 feet above sea level. The mountains comprising its western rim extend along the west coast and are largely outside of the Colony, except in the strip of territory which projects toward the ocean. In the southwest the basin is limited by the northern escarpment of the Angolan plateau, and in the southeast by the rugged highlands of the Katanga region, which range in elevation from 4,000 to 6,000 feet and constitute a prolongation of the great South African plateau. The eastern border is marked by high mountain ranges, aver- aging from 6,000 to 8,000 feet in height. Beginning just south of Lake Tanganyika, they form the western edge of the Albertine (Eastern) Rift Valley, which incorporates lakes Tanganyika, Kivu, Edward and Al- bert; Lake Kivu is the only one wholly within Belgian territory. The region be- tween lakes Edward and Albert includes the Ruwenzori range, with volcanic peaks rising to over 16,000 feet. Northwest of Lake Albert the rim of the basin is defined by a stretch of plateau country with an average altitude of 3,000 to 4,000 feet, which forms a segment of the Congo-Nile divide. The greater part of the territory is characterized by dense tropical forest, interspersed by wooded savannah which merges into grassland and sometimes arid steppe in the upland areas. The equatorial forest is particularly dense in the Maniema region, west of Lake Tanganyika, and along the Aruwimi River in the northeast, where it is known as the “Ituri” or “Great Congo” forest. The entire area is drained by the Congo River and its tributaries. The river, which springs from various sources in the Lake Tanganyika area, flows for over 3,000 miles to the Atlantic Ocean and is the only river in the world to loop the Equator. It emerges from the Mitumba Mountains as the Lua- laba River and later, on its northward course, becomes known as the Upper Congo. From Stanley Falls, the main river flows northwest and then south and is navigable for about 980 miles to Stanley Pool at Leopoldville. Below Stanley Pool the river cuts a gorge through the western mountains and is interrupted by a succession of rapids and cataracts until it expands into a wide estuary about 85 miles from its mouth. The Congo receives many large tributaries, one of the most important being the Kasai River, which with its many branches drains the South African plateau. The central portion of the Belgian Congo lies within the equatorial rain belt. Rains 336 Belgian Congo 337 occur at all seasons of the year, with peaks of precipitation from March to May and from October to December. On the periph- ery one interval of minimal rainfall becomes longer and more pronounced, but no well- defined dry season is experienced except in the southern highland districts. Subject to local modifications, a period of relative dry- ness, extending from May or June to the end of September, is encountered in the regions of the lower Congo and on the Katanga plateau. The mean annual rainfall in the equatorial districts approximates from 60 to 75 inches, with lower averages in the surrounding areas; from 50 to 60 inches in the north, from 40 to 55 inches in the eastern mountains and the Katanga re- gion, and from 35 to 55 inches in the dis- tricts of the lower Congo. In general, the temperatures are uni- formly high throughout the Congo basin, with means of 75° to 80° F. in the coolest months (November and December at the equator, July and August elsewhere) and 78° to 82° F. in the hottest (February to April). The annual range seldom exceeds 2° to 4° F. at the Equator but approaches 6° to 8° F. in the north and 7° to 10° F. in the south. In the Katanga highlands lower temperatures are experienced; the yearly mean approximates 68° F., fluctuating from around 60° F. in May to July to 75° F. in October and November. The daily range is slight in the equatorial region but increases gradually toward the north and the south; depending upon the seasons, it may reach 20° to 40° F. in the Katanga. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTION As of January, 1949, the population of the Belgian Congo was estimated at slightly in excess of 10,950,000. The white population was enumerated at 51,639, including roughly 36,510 Belgians, 3,092 Portuguese, 2,396 British and from 1,400 to 1,800 each of French, Greeks and Italians. The approxi- mate concentration of Europeans and na- tives in the province of Katanga (Elisa- bethville) was 16,371 and 1,242,000, respectively; of Leopoldville, 14,165 and 2,355,000; of Oriental (Stanleyville), 8,012 and 2,303,000; of Kivu (Costermansville), 6,390 and 1,526,000; of Kasai (Lusambo), 3,721 and 1,879,000; and of Equator (Co- quilhatville), 2,980 and 1,599,000. The indigenous populations are predomi- nantly of Bantu origin, but pygmy, Sudanic and Nilotic elements are also encountered, as well as communities of Arabisés (of mixed Arab and Negro descent) in the province of Oriental. The Batwa, or Pyg- mies, are the representatives of the abo- riginal inhabitants of this area. They live in isolated groups in various parts of the coun- try, particularly in the equatorial forests of the Tturi, the Tshuapa and the Kivu regions and near Lake Tanganyika and the Luapala River. The Sudanic Negroes are found in the extreme north, the most important tribes being the Banda and the Bwaka, near the bend of the Ubangi River in the northwest, and the Azande, in the vicinity of the Uélé River in the northeast. Several tribes of Nilotic Negroes (semi-Hamites) are located in the area around Lake Albert and the Semliki River. The majority of Congolese belong to heterogeneous tribes of Bantu stock, in which varying degrees of admixture with Hamitic and other peoples are evident. They are divided into numerous large groups of allied tribes; they include, among others, the Bakongo and the Yombe of the coastal corridor, the Bangala, the Ababua and the Mongo of the forest and the Balunda, the Baluba and the Bushongo of the savannah areas. At least 200 Bantu dialects are spoken by the different peoples of the Colony, four of which are used over wide areas and receive official recognition from the government. Lingala is the lingua franco of the tribes in the Congo River area from Leopoldville to Stanleyville. Kikongo is employed in the Bas-Congo and Kwango districts, and Tshiluba in the provinces of Kasai and 338 Belgian Congo Katanga; while Kingwana, a modification of the Swahili of East Africa, is extensively used in the east and the southeast. The primitive tribes are all pagan. Roman Cath- olic and, to a lesser extent, Protestant mis- sions have been active in the Colony for many years, however, with the result that probably one quarter of the inhabitants have been converted to Christianity. The Arabisés and various tribes in the north are Moslems. The Belgian Congo is sparsely populated and has an average density of 11 to 12 per square mile. Even in the more thickly settled Mayumbe and Kivu areas, the density rarely exceeds 75 to 80 per square mile, while in certain semiarid regions in the southeast it drops to 5 or less. Consistent with the economic and industrial develop- ment of the Colony, there has been a rapid concentration of populations in the commer- cial and the mining centers. Leopoldville, the capital and principal city, had a popula- tion, in 1946, of roughly 6,000 whites and 110,000 Congolese. Elisabethville, the nu- cleus of the Katanga mining area, had a comparable white community and a native population composed of some 40,000 per- manent residents and a large contingent of transient workers. Other large cities are: Jadotville, a Katanga mining center; Stan- leyville, in the Kivu area; and Matadi, an important port on the Congo estuary. In all cities and towns the European and the Con- golese sections are sharply defined. The government attempts to regulate immigra- tion to the cities to conform to specific demands for labor. However, the increasing urbanization of the Congolese, has created major problems of social and public health significance. Educational facilities are available to Eu- ropeans in the larger cities. The government institutions are usually conducted by re- ligious orders, but within recent years sev- eral secular schools have been established. Native education is provided by “national” and “foreign” missions, the former classi- fication being acquired by a two thirds rep- resentation of Belgians in the administra- tion. Its expansion is fostered by the gov- ernment through subsidies to approved schools. Schools are also maintained by spe- cial agencies and by industrial enterprises. In general, education is directed toward the elevation of the masses and the acquisition of practical skills by individuals. Instruc- tion is in the vernacular of the region, except in the postprimary schools, where the use of French is compulsory. In spite of the continuous increase in educational facilities, the level of illiteracy is high. Even in areas to which education has pene- trated, a large percentage of the children are enrolled in small, nonsubsidized mission schools providing the most rudimentary instruction. Moreover, the attendance in many tribes is largely restricted to the boys. Some of the most urgent problems in the Colony center around the adaptation of the evolués (the more prosperous and edu- cated Congolese), and the promotion of higher standards of education for women. VITAL STATISTICS Vital statistics are available for the Euro- pean population, but demographic data per- taining to the Congolese are incomplete and unreliable, except in limited areas where work has been carried on by FOREAMI (Fonds Reine Elisabeth pour 1’Assistance Médicale aux Indigénes) or certain mission groups for a period of years. For purposes of census enumeration, registers are main- tained at the headquarters of each admin- istrative district, but the difficulties inherent in keeping such records cast doubt upon their accuracy in many regions. In 1946 the birth rate for the European population was 19.4 per 1,000, and the death rate, 6.8 per 1,000. The infant mortality was 31.4 per 1,000 live births, as against 81.2 for 1945 and 64.2 for 1944. Compilations of vital statistics among the Congolese in the province of Leopoldville in 1946 indicate a birth rate of 27.1 per 1,000 and a death rate Belgian Congo 339 of 17.5 per 1,000 in the native section of the city of Leopoldville; 37.6 and 25.5, re- spectively, in the Kwango sector in which FOREAMI was operating. The infant mor- tality, as determined by FOREAMI, was 104.4 per 1,000 live births in 1946; 136.6 in 1945 and 165.8 in 1942. Such statistics are not representative of the country as a whole because of the intensive medical program underway in the Kwango area. Birth, death and infant mortality rates vary markedly from tribe to tribe and from year to year. In 1936-38, the infant mortality rates in the Kwango sector ranged from 170 to 350 per 1,000 live births in different villages. The proportion of infant deaths to general mor- tality varies from 12 to 60 per cent in different parts of the country. Sociar Economy The agricultural and industrial develop- ment of the Belgian Congo has been under- taken largely by commercial concerns. Ex- tensive coffee, sugar, oil palm, cocoa and rubber plantations are operated in various parts of the country by Belgian and other companies. Small-scale farming by white colonists is restricted chiefly to the Katanga plateau and the upland areas around Lake Kivu. Under tribal conditions the natives engage in the shifting cultivation of food crops by primitive methods. Within recent years, however, the Belgian government has encouraged the participation of Congolese peasants in the production of export crops, especially cotton and coffee. Cotton is grown extensively in the valleys of the Uélé and the Ubangi rivers in the north, and of the Kwango, the Kasai and the Sankuru in the south. The Congolese also share in the oil- palm industry, contributing approximately one quarter of the total output. The Institut National pour I’Etude Agro- nomique du Congo Belge carries on plant and animal research, and education among both white and native farmers in improved methods of cultivation. It maintains 20 ex- perimental stations in areas exposed to different soil and climatic conditions, beside the headquarters service at Yangambi, near Stanleyville. The Centres Agricoles de 'Uni- versité de Louvain au Congo also conducts experimental centers and schools at Kisantu, Kamponde and Bunia for the purpose of promoting higher standards of agriculture among the Congolese. The Colony is rich in mineral resources, which have been developed by large com- panies controlled from Belgium. The Ka- tanga plateau is one of the most highly mineralized areas on the continent, second only to the “Rand” in the Union of South Africa. Copper is the major product, al- though important supplies of tin, cobalt, uranium ore and other minerals are also found. Gold is the second most valuable metal, the Kilo-Moto mines in the north- eastern part of the country being the largest producers. Extensive reserves of tin are worked in Maniema and Kivu districts. Diamond fields are located in the Bakwango area, and alluvial beds along the Kasai River in the vicinity of Tschikapa. The abundant forests contribute valuable sup- plies of mahogany and other hard woods for export. Small industries, such as the manufacture of tobacco, textile and dairy products, brewing and printing, have been developed in some of the principal centers. In order to assure an adequate and com- petent labor supply, the larger companies have introduced farsighted educational, wel- fare and housing projects for the benefit of their workers. In 1943 over 574,500 were engaged in paid labor, 58 per cent in indus- try, 34 per cent in agriculture and 8 per cent in commerce.’ The communication facilities are based upon the 7,000, or more, miles of navigable waterways along the Congo and its major tributaries. These are implemented at stra- tegic points by railways. The principal rail- roads are the Matadi-Leopoldville line, which bypasses the Congo gorge ; the Grand Lakes route from Stanleyville to Ponthier- ville, and from Kindu to Albertville, with 340 Belgian Congo steamer connections across Lake Tangan- yika; and the Bas Congo-Katanga railway which links the Katanga area with the Congo waterways at Port Francqui on the Kasai River, and ties in with the transcon- tinental system having port facilities at Beira, Lobito Bay and Cape Town. A net- work of highways suitable for motor traffic joins the larger towns and cities. Steamer connections with Europe and other African ports are provided through Matadi. Local and overseas air services link the major cities of the Colony with neighboring areas on the continent and with Belgium. Foop AND NUTRITION Because of differences in tribal customs, and in soil and climatic factors governing the cultivation of food crops, it is impos- sible to make broad generalizations regard- ing the nutritional standards of the native peoples. In general, root crops, bitter and sweet cassava, yams and sweet potatoes form the basis of the dietary of the forest tribes ; millet, maize and upland rice, of the inhabitants of the savannah and steppe country. Yams, sweet potatoes, legumes, cabbage, squash and peanuts are widely cultivated but vary in importance in differ- ent areas. Tropical fruits and palm oil are common accessories, particularly among the forest dwellers. Goats and chickens are found in most villages. Sheep are numerous in the savannah regions ; pigs, in the forest. Cattle, however, are raised only in limited areas in the lower Congo, the eastern high- land and the Kasai districts. Tribal practice regarding the consumption of meat and milk varies. Goat’s milk is used sometimes, but cow’s milk is most frequently converted into cheese and, in a few sections, into butter. Fish are abundant and constitute a major article of food among the river tribes. As elsewhere, the food habits of the urbanized Congolese are modified by the economic and educational status of the indi- vidual, as well as by the availability of sup- plies. Extensive investigations on the health and nutrition of the laborers in various mining camps have led to the enactment of laws imposing minimum standards for the diets of native workers. Several of the large industrial concerns also provide balanced rations for the families of their employees. Housine Marked contrasts exist between the well- constructed, modernized homes in Leopold- ville, Elisabethville and other cities and the primitive dwellings in the tribal areas, which house from 75 to 80 per cent of the population. The forest peoples typically settle in simple villages composed of single or double rows of huts, which are square or rectangular and constructed of poles and thatch with an overhang forming a veranda. The savannah tribes tend to live in villages of from 100 to 200 huts grouped around a central space, dignified by the chief’s dwell- ing and communal buildings. The huts vary in design and building materials, ranging from beehivelike grass structures to rec- tangular houses with ornamented clay walls and thatch roofs. Most of the huts are small, providing protection primarily at night and during the rains. The interiors are dark and poorly ventilated ; frequently the mud floors are polluted both by children and animals. The most primitive living conditions are found in the pygmy encampments in the equatorial forest. Concrete, stucco and brick are employed by the Europeans in the construction of homes and other buildings. In Leopoldville and the larger cities the native sections are made up of rows of individual dwellings which, depending upon the quarter, may range in type from woven palm, bamboo and thatch huts to small houses of cement or stucco. Projects to supply modern hous- ing for the evolués, clerks and skilled work- ers have been undertaken in many parts of the country. The big mining concerns pro- vide detached homes and organized com- munity services for their workers. The insti- Belgian Congo 341 tution of separate housing helps to minimize the health and social problems associated with labor camps in other colonies. ENVIRONMENT AND SANITATION WATER SUPPLIES Surface supplies are the principal sources of water. The village supplies are derived from rivers, streams, lakes or springs, which are prevalent throughout the country, but are usually subject to pollution. Wells are not common in the rural areas but may be used in the native sections of cities when piped supplies are not available. Supervised municipal water supplies exist in Leopoldville, Elisabethville, Jadotville, Stanleyville, Coquilhatville, Boma, Matadi and Costermansville. All, except that of Stanleyville, are derived from river sources. The water for Leopoldville is piped from the Lukonga River. It is filtered and ozonized before distribution. The supply of Elisa- bethville is obtained from the Lubumbashi River and is treated by filtration and chlo- rination. In Stanleyville the present supply is obtained from subterranean galleries, but a supplementary river source is under con- struction. Water is commonly distributed to individual houses in the European sections, and through communal taps at convenient locations in the native areas. Purification by ozonation, filtration, chlorination, or a com- bination of processes is used in the treat- ment of all municipal supplies. Bacteriologic and chemical examinations are performed at regular intervals in the provincial labora- tories. Waste DisposaL In most Congo communities septic tanks are employed for the digestion of sewage wastes from the dwellings of white residents. The effluent is discharged into the rainwater sewers in the cities and into cesspits in the rural areas. Septic tank installation is con- trolled by the municipal health authorities. Elisabethville, however, has a modern sew- age-treatment plant. Borehole latrines are used by the Congolese in the industrial cen- ters and in some tribal villages. Numerous individual installations are found in the modern cities, but in the rural areas com- munal latrines are usually constructed on the outskirts of the villages. Indiscriminate pollution of the soil is a common practice, particularly among the primitive tribes. Fauna anDp Frora Arthropods. Mosquitoes. Anopheline mosquitoes are abundant in all parts of the Colony, except the mountainous regions of the east and the southeast. At least 32 spe- cies have been identified, 4 of which, Anopheles gambiae, A. funestus, A. mou- cheti and A. nili, are of primary importance in the transmission of malaria. A. gambiae is a universal vector but varies in prevalence in different areas. A. fumestus is the pre- dominating species responsible for the trans- mission of the disease in certain sections of Leopoldville, Kasai, Katanga and Oriental provinces. A. gambiae is the primary vector in Leopoldville; A. funestus in Katanga. A. moucheti and A. nili are significant vec- tors in limited areas. A. pharoensis, A. hancocki and A. hargreavesi may be poten- tial vectors in some localities. A. gambiae breeds in small pools of stagnant water, both natural and artificial, which are at least partially exposed to the sunlight. The water-filled depressions created in the course of agricultural, mining and lumbering op- erations are prominent breeding places. A. funestus, A. moucheti and A. nili breed in the shaded grassy margins of slow-flowing streams. Twenty-nine or more species of Aedes have been collected in various parts of the country. Aedes aegypti, the principal vector of yellow fever, is widespread. Species of possible importance in the transmission of sylvan yellow fever are A. africanus, A. vit- tatus, A. luteocephalus and A. simpsoni. Numerous species of Culex are present, including Culex quinquefasciatus (= C. fa- 342 Belgian Congo tigans), an effective vector of filariasis. Various other genera, including species of Eretmopodites, Taeniorhynchus and Mega- rhinus, have been described. Mosquito control is difficult and economi- cally impractical, except in limited areas in the vicinity of the larger towns. Intensive anopheline control programs, incorporating the elimination of breeding sites by drain- age and filling, or the antilarval treatment of permanent bodies of water, are carried on in Boma, Matadi, Leopoldville, Coquilhat- ville, Elisabethville, Jadotville and other populous centers, particularly in areas ad- jacent to European communities. The effec- tiveness of palliative antilarval measures is reduced by the fact that the larvae of the stream-breeding anophelines thrive among the tall grasses, in sites where penetration with oil, Paris green or DDT is difficult. Since 1947, a program based upon residual spraying with DDT has been undertaken in Elisabethville and the surrounding villages. Residual spraying has also been attempted in Leopoldville, but with negligible success. In 1949 mass spraying with DDT, by means of an airplane, of Anopheles gambiae breed- ing areas along the river was initiated, and a more extensive experiment covering the environs of the city and certain endemic centers on the lower Congo was planned for 1950. Aedes-control measures are enforced in Leopoldville, in the ports of the lower Congo and in some of the cities of the interior. In 1948 the general Aedes index was 0.01 to 0.1 per cent in Leopoldville, Co- quilhatville, Jadotville, Matadi and Boma. Fries. Thirteen species of tsetse flies are known to exist in the Colony. Glossina pal- palis, G. morsitans, G. pallidipes, G. swyn- nertoni, G. brevipalpis and G. fusca are important as potential vectors of human or animal trypanosomiasis. G. palpalis is the predominating species in the transmission of the human disease. It is abundant along the banks of the streams in many regions throughout the country but is absent at the higher altitudes in the eastern mountains. Antitsetse measures, such as bush clearance and fly-trapping, are undertaken only in limited regions. Trypanosomiasis control has been carried on since 1918. The pro- gram is directed primarily toward the sterilization of the human reservoir. Numerous other MuscIDAE occur, among which species of Musca and Stomoxys are probably implicated in the mechanical transmission of intestinal diseases. Musca euthbertsoni is one of the most troublesome flies in Leopoldville. Species of Tabanus, Chrysops and Haematopota are abundant. Chrysops silacea and C. dimidiata are vec- tors of Loa loa in localized areas. Prominent among the flies responsible for cases of human myiasis are Cordylobia an- thropophaga, C. rodhaini and Chrysomyia putoria. The last species abounds in the vicinity of Leopoldville. Aucheromyia lu- teola is indigenous, and its larvae, known as “Congo floor maggots,” are common bloodsucking pests. SIMULIIDAE are present in enormous num- bers. Simulium damnosum is widely dis- tributed and is the principal vector of Onchocerca volvulus. Other species include S. dentulosum and S. neavei, the latter is a secondary vector of onchocerciasis in the Lusambo area. In 1948 a successful experi- ment for the control of S. damnosum by means of DDT solutions sprayed from an airplane was undertaken at Leopoldville.®® The fly which breeds in considerable num- bers in the rapids below Stanley Pool was eradicated completely from both banks of the river. The biting midges, Culicoides grahami and C. austeni, are reported from this region and may be vectors of Acantho- cheilonema perstans. Various species of Phlebotomus are encountered. Lice. Both Pediculus humanus corporis and P. humanus capitis are common. P. hu- manus corporis may be a vector of typhus fever in Maniema district on the eastern border. Phthirus pubis is also present. Freas. Xenopsylla brasiliensis and X. cheopis are found abundantly on the wild and domestic rodents and sometimes in the Belgian Congo 343 native huts. X. nubicus is reported from the Leopoldville area. Ctenocephalides canis and C. felis strongylus are prevalent. X. brasiliensis is a vector of sylvatic and human plague in two separate areas in the region of lakes Edward and Albert. X. cheopis is also implicated in the trans- mission of plague in the Lake Albert region and is a vector of murine typhus in nu- merous scattered foci. Species of Dinopsyl- lus, Ctenophthalmus and Ctenocephalus are recorded. The chigoe flea, Tunga penetrans, is widely distributed. BebBucs. Cimex hemipterus or C. lectula- ris are found in the native dwellings in most areas. Ticks AND Mites. Ornithodorus moubata is encountered in the eastern plateau regions and in sections of Leopoldville Province, where it is responsible for the transmission of relapsing fever. Numerous other species have been de- scribed, the most important potential vec- tors of disease among man and animals being Haemaphysalis leachi, Rhipicephalus appendiculatus, R. simus, R. sanguineus, Boophilus decoloratus and Amblyomma variegatum. The itch mite, Sarcoptes scabiei, is in- digenous in all parts of the Colony. ScorrioNs AND SpiDERS. Numerous spe- cies of venomous scorpions are reported. Among the Buruipae which have been identified are Buthus (Buthus) trilineatus, B. (Hottentota) hottentota, Babycurus cen- tririmorphus, B. jacksoni, Isometrus macu- latus, Lychas asper, L. burdoi, and species of Parabuthus and Uroplectes. The Scor- PIONIDAE include Pandinus viatoris, P. cari- manus and Opisthacanthus africanus. Less is known regarding the distribution and the venomous properties of the spiders. The larger species are greatly feared by the inhabitants. Perhaps the most dangerous are Scodra griseipes, Heteroscodra crassipes, Hysterocrates didymus, Phoneyusa biden- tata and possibly species of CTENIZIDAE, CTENIDAE and ARGIOPIDAE. OtuErR ArtHROPODS. Dorylus ants are destructive and sometimes dangerous pests in the forest regions. Large centipedes, which may be poison- ous, include Scolopendra morsitans, S. sub- spinipes subspinipes and Ethmostigmus tri- gonopodus. Irritation of the skin is caused occasionally by the juices of Diplopodis iuliformes and other vesicant beetles. Spe- cies of Paederus has been reported spe- cifically from the vicinity of Leopoldville. Reptiles. Various species of poisonous snakes are found in the Congo. The cobras are represented by Naja mnigricollis, N. melanoleuca and Elapechis guentheri. The mambas, Dendroaspis angusticeps and D. jamesonii, are fairly frequent. Vipers are widespread, the most prominent being Bitis arietans, B. nasicornis, B. gabonica, Causus rhombeatus, C. lichtensteinii, Atractaspis congica and A. irregularis. The less dan- gerous Atheris nitschei, A. squamiger and Psammophis sibilans are numerous. The nonpoisonous constrictor, Python sebae, also occurs. Rodents. Rattus rattus rattus, R. rattus alexandrinus, R. rattus frugivorus and R. rattus wroughtoni are common domestic rats in different areas. R. norvegicus may be found in the port towns but does not occur in Leopoldville and the inland cities. Syl- vatic plague is enzootic in two foci: west of Lake Albert and in the Ituri-Kivu region northwest of Lake Edward. The infection has been demonstrated in R. rattus alex- andrinus, R. rattus kijabius, Arvicanthus abyssinicus and Mastomys coucha ugandae. The last species serves as a link in the trans- mission of the disease between wild and domestic rodents. It is found frequently in native dwellings and constitutes one of the major reservoirs of infection. Several spe- cies of wild rodents are potential reservoirs, including the rats, Cricetomys gambianus, Otomys tropicalis elgonis, and Cryptomys lechei, and the gerbil, Tatera nigrita beni- ensis. Mollusks.* Several species of freshwater * See footnote, p. 10. 344 Belgian Congo snails are implicated in the transmission of schistosomiasis, which is prevalent in nu- merous foci throughout the Colony. Plano- ribis (Biomphalaria) alexandrina pfeifferi and P. (B.) alexandrina choanomphala, a lake species, are known to be intermediate hosts of S. mansoni. P. (B.) alexandrina tanganyicensis and P. (B.) alexandrina stanleyi are also found and may be potential hosts in localized areas. Physopsis africana globosa is the intermediate host of S. Ahae- matobium and S. haematobium interca- latum. Bulinus (Pyrgophysa) forskalii is ap- parently present in some foci. Plants. A wide variety of poisonous plants is found, many of which are used by the indigenous tribes for medicinal or other purposes. Prominent among the plants valued as sources of arrow poisons are several species of Strophanthus, including S. hispidus, S. kombe and S. gratus, Acocan- thera venenata, Periploca nigrescens and species of Tephrosia, Crotalaria, Strychnos and Dichapetalum. Species of the last genus are sometimes responsible for the death of grazing animals. Preparations from the bark of Erythrophleum guineense and Securidaca longipedunculata may be employed by some primitive tribes as a measure of guilt in “trials by ordeal.” From 50 to 60 species of wild and culti- vated yams of the genus Dioscorea are de- scribed from the Congo. Some are known to be poisonous but are consumed during periods of food shortage after detoxication. Cases of serious poisoning may result unless the toxic principal is adequately removed from the tissues. Species in this category in- clude D. sativa, D. bulbipera and D. lati- folia. D. hirsuta may be used medicinally. The native hemp, Agave exigida, grows wild in many areas. Smoking of the dried flowering tops produces a mild intoxication and is widely practiced by the natives. Foop SANITATION High standards of food sanitation are en- forced in the urban areas by the govern- ment and local health authorities. Super- vision is maintained over markets and food establishments. The purity of imported foods is also controlled. All meats and dairy products are subject to inspection by the veterinary departments, and a stamp of ap- proval is required on meats offered for sale. However, the use of condemned carcasses is sometimes permitted after sterilization by boiling. Commercial and frequently indi- vidual refrigeration facilities are available. In the rural native villages the level of sani- tation is usually low. HEALTH SERVICES AND MEDICAL FACILITIES HeartH ORGANIZATIONS Responsibility for public health in the Belgian Congo resides in the Direction Générale des Services Meédicaux, which functions under the direct authority of the Governor-General. The policies of the Colo- nial government are controlled by the Min- istere des Colonies in Brussels, which is ad- vised on matters affecting public health by an Inspecteur General de 1'Hygiene. The Direction Générale is administered by a Médecin-en-Chef with headquarters in Leo- poldville and includes four divisions: hygiene, medical assistance, laboratories and research, and medical education. Conduct of the preventive and curative programs in each of the six provinces is delegated to a provincial Direction de Serv- ice Médical, the technical services being co- ordinated through the central organization. The public health functions of the provincial departments are undertaken by Services de I’Hygiene, which are responsible for sanita- tion and communicable disease control in urban, port and rural areas, the protection of the health of native workers, and the con- duct of campaigns against arthropod vectors and animal hosts of human disease. The medical activities, concentrated in Services d’Assistance Médicale, consist in the main- tenance of facilities for the medical care of the white and the indigenous populations. Emphasis is placed upon the establishment of rural hospitals and dispensaries and the operation of itinerant medical services in the tribal areas. The laboratories and re- search branch of the Colonial health organi- zation directs the operation of the provincial laboratories and carries out investigations on various endemic and epidemic diseases. Municipal health authorities exist in Leo- poldville, Elisabethville and Jadotville. They are charged with the enforcement of local health measures, primarily with regard to sanitation. The work of the Direction Générale des Services Médicaux in the Belgian Congo is integrated closely with that of various un- official organizations, medical missions and industrial concerns. Responsibility for the health of the natives in certain stipulated areas is delegated to collaborating organiza- tions, as the Croix Rouge du Congo, the Fondation Médicale de ’'Université de Lou- vain au Congo and various medical missions which receive subsidies from the govern- ment. The Fonds Reine Elisabeth pour I’As- sistance Médicale aux Indigénes (FORE- AMI), an autonomous organization af- filiated with the Colonial health services, carries on a comprehensive health program in designated areas. It has large financial resources derived from a fund created by the Belgian government in 1930, with a sub- stantial contribution from Queen Elisabeth. The policy of FOREAMI is to undertake a complete health survey and sponsor the de- velopment of medical and welfare services on an intensive scale in a limited region— turning the work over to the regular gov- ernment officers as soon as it has become well established. The program was initiated in the Bas-Congo district of Leopoldville Province in 1930 and was transferred to the adjacent areas in the Kwango region in 1939. Numerous philanthropic organizations co- operate in the care of the native peoples. The Croix Rouge du Congo maintains cen- ters for the treatment of venereal disease in Matadi, Leopoldville and other cities, and operates a program for the control of Belgian Congo 345 leprosy in the Pawa-Nepoko (Ituri) region and supplementary general medical facili- ties throughout the area. The Fondation Médicale de 1’Université de Louvain au Congo carries on medical, educational and research work from two centers, Kisantu (Bas-Congo) and Katana (Kivu). The Centre Médical de I'Université de Bruxelles au Congo Belge has organized a tuberculosis detection program in Maniema district. The Comité National du Kivu supports mobile units for the treatment of yaws and provides general medical care for Europeans and na- tives in Kivu district. The Oeuvre Nationale de I’Enfance and the Oeuvre de la Maternité et de ’Enfance Indigénes operate welfare centers and maternity hospitals in many areas. Both are subsidized by the govern- ment. The Fondation “Pére Damien” was created in 1939 to carry on research in the control and the treatment of leprosy. A large volume of medical and health work is undertaken by various Catholic and Protestant mission groups, “national” and “foreign.” Medical, educational and welfare services are also operated by industrial con- cerns for the benefit of their employees. The conditions of the plantation and mining concessions require the provision of medical facilities, but in addition, several of the companies carry on extensive work among the families in the neighboring villages. The Institut de Médecine Tropicale Prince Léo- pold in Antwerp co-operates with the Colo- nial medical service in the training of European personnel and the conduct of laboratory and field research. MEDICAL INSTITUTIONS Hospitals and Dispensaries. In 1948 the provincial Directions de Service Médical operated 36 general and maternity hospitals with an aggregate of 499 beds for Euro- peans ; also 59 hospitals with 6,883 beds for natives. The largest institutions are located in Leopoldville and Elisabethville. The mis- sion and philanthropic organizations and the private agencies maintained 48 hospital and maternity units, providing 628 beds for 346 Belgian Congo Europeans and 135 units with 19,205 beds for natives. There were also 1,088 rural dispensaries, of which 531 were conducted by government services, 199 by subsidized philanthropies and 358 by private organizations. Numerous child welfare clinics, leprosaria and centers for the treatment of other specific endemic diseases are scattered throughout the Colony. Including hospitals, dispensaries and special institutions for the treatment of trypanosomiasis, leprosy and tubercu- losis, there were approximately 59,400 beds in government and private institutions in 1948—slightly over 5.4 per 1,000 population. The larger hospitals in the provincial capi- tals and major industrial centers are well equipped and have laboratory and x-ray facilities. Laboratories. Hygienic, bacteriologic, pathologic and serologic laboratories are operated by the government health services in Leopoldville, Coquilhatville, Stanleyville and Elisabethville. The largest laboratory, the Institut de Médecine Tropicale Prin- cesse Astrid, is located in Leopoldville. All are equipped for the performance of routine examinations, the preparation of biologic products and the investigation of special problems. In addition to the hygienic divi- sions in these large provincial laboratories, regional hygienic units are located at Banana, Boma, Matadi and Albertville. Special laboratories for the study of plague are established at Blukwa and Lubero. Clin- ical laboratories are also maintained in the larger hospitals—government, mission and private. The Croix Rouge du Congo con- ducts a laboratory for research on leprosy at Pawa. Several of the industrial concerns, as the Union Miniére au Katanga and the Compagnie Miniére des Grands Lacs, sup- port research as well as clinical laboratories. The Institut pour la Recherche Scienti- fique en Afrique Centrale, Congo Belge, was organized in 1947. It will provide centers for research in the physical, the social and the biologic sciences and other fields related to tropical medicine. Laboratories for the investigation of biologic problems have al- ready been established at Uvira on Lake Tanganyika and on Lake Tumbu, near Coquilhatville. Another, devoted to nutri- tion studies, is located at Astrida in Ruanda- Urundi. The Institut, which functions under the Ministére des Colonies, is affiliated with the Institut de Médecine Tropicale Prince Léopold in Antwerp. Laboratories are maintained by the veter- inary services at Kissegnie and at Elisabeth- ville. Veterinary and agricultural research laboratories are also operated by the Institut National pour I’Etude Agronomique du Congo Belge. Schools. The Belgian government has adopted the policy of educating Congolese assistants to participate in all phases of its health program. The Colonial health services operate a school for medical assistants and auxiliary doctors at Leopoldville, while the Fondation Médicale de I’Université de Louvain au Congo (FOMULAC) maintains a similar school at Kisantu. Government schools for the training of nurses are located in the capital cities of each province except Kasai, which sends its students to Leopold- ville. Nurses’ training schools are also con- ducted by mission or philanthropic organiza- tions at Kibunzi, Kisantu, Sonabata and Yakusu. Schools for midwives and nurse’s aides are established in connection with the provincial hospitals. Training courses for nurse’s aides are also offered in mission hos- pitals at Leopoldville and Lusambo, by pri- vate agencies at Lusambo and Costermans- ville and by FOMULAC at Katanga. Schools for sanitary assistants are located in Leopoldville and Elisabethville. PERSONNEL Physicians. In 1948 a total of 411 physi- cians was registered in the Belgian Congo, representing a ratio of roughly one to every 28,000 inhabitants. Of these, 211 were em- ployed in the various governmental health services, 12 in the headquarters staff, 12 in the laboratories, 10 as health officers, 2 in the schools and the remainder as medical officers. A total of 121 doctors was connected with private companies, 36 with mission so- cieties and 8 with philanthropic organiza- tions. Thirty-five were engaged in private practice. Dentists. In the same year, there were 18 dentists in the Colony: 2 in government service and 16 in private practice. Nurses. Belgian religious orders superin- tend and perform the nursing services in the government hospitals. In 1948 about 360 nursing sisters and 21 lay nurses (Euro- pean) were working in the country. About 435 locally trained native nurses were em- ployed in the various government and mis- sion services ; also 1,852 nurse’s aides. Others. The roster of European medical personnel for 1948 listed 31 pharmacists and about 360 sanitarians. In addition to nurs- ing personnel, the native staff of the Colo- nial health services and the mission organi- zations included 52 medical assistants, 62 sanitary agents and 142 midwives. DISEASES The Belgian approach to the major health problems of the Congo is characterized by intensive attacks upon specific diseases in circumscribed areas. Morbidity statistics are relatively complete for certain regions, such as those covered by FOREAMI, but are lacking or unreliable in others. More- over, the patients treated by the mission and the private organizations, which care for a large proportion of the native population, are not always included in the government reports. The influence of tribal medicine prevails over extensive areas. In view of the vastness of the territory and the wide varia- tions in the living conditions and the social development of the people in different parts of the country, generalization is hazardous. However, available data provide criteria for evaluating the presence and the potentiali- ties for spread of the principal endemic dis- eases. Belgian Congo 347 Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fever is endemic in all sections of the Colony, especially along the major trade routes. Epidemics occur sporadically, usually in the dry seasons when the water supplies are low and the possibilities of pol- lution are increased. Outbreaks are largely restricted to the populous communities, the highest incidence being recorded from Leo- poldville and Katanga provinces. Typhoid fever and the paratyphoid fevers are grouped in the government reports, but the former usually predominates. In the period 1941-48, from 14 to 61 cases were reported annually among Europeans; from 176 to 434 among natives, Paratyphoid B and C are encountered with almost equal fre- quency. However, paratyphoid A appears to be irregular in distribution and is rarely isolated at the laboratory in Leopoldville. Systematic immunization with TABC or TBC vaccines against typhoid and paraty- phoid fever is enforced among government personnel and workers in the larger indus- tries. Immunization is also employed in the event of a major outbreak. Dysenteries. Bacillary and amebic dys- entery are prevalent. Outbreaks of bacillary dysentery are common among both white and native populations. Leopoldville Prov- ince and the densely populated sections of Oriental and Kivu provinces are affected most seriously. Epidemics of Shigella dys- enteriae and of S. paradysenteriae fre- quently occur, often threatening large com- munities. Several thousand cases are usually recorded in the major outbreaks, and the actual incidence is always considerably higher. The fatality rates range from 10 to 30 per cent. Extensive foci developed in the Lake Kivu area in 1944-45 and in the Mahagi and the Djuga territories of Ori- ental Province in 1946. Shigella dysenteriae is encountered chiefly in the eastern prov- 348 Belgian Congo inces; only one case was observed in Leo- poldville in the period from 1936 to 1949. Immunization with antidysentery vaccine was carried on in the epidemic areas in 1944-46. Amebic dysentery is endemic in many sections of the country. The prevalence of flies, ignorance of basic principles of hygiene and lack of sanitary facilities promote the spread of the infection. In the decade, 1939- 48, an average of 408 cases was reported an- nually among Europeans. Among natives the recorded incidence increased from an average of 6,560 in the 5-year period 1939-43 to 12,182 in 1944-48. The fatality rates range from 1.3 to 3.5 per cent. The incidence is particularly high in Leopoldville, Equator and Oriental provinces. Amebic abscess of the liver is relatively rare. Helminthiases. ANcyLosToMIasIS. Hook- worm infection is widespread, especially in the southwestern part of the country. From 90,000 to 100,000 cases are reported an- nually. The disease is typically mild, and the recorded cases probably represent a small proportion of the total incidence. Roughly, from 25 to 30 per cent are attrib- uted to the Kwango sector in which FORE- AMI operates. Both Ancylostoma duodenale and Necator americanus are encountered, although Necator usually predominates. Occasional cases occur among Europeans; from 100 to 130 are reported each year. ScuisTosoM1as1s. Schistosomiasis is an important problem in most parts of the country. Schistosoma mansoni, in partic- ular, is widely distributed, with prominent foci in the eastern and the southern prov- inces. In 1948, 8,537 cases of S. mansoni in- fection were treated by the government and FOREAMI medical services, as against 789 of S. haematobium. In 1947 the cases num- bered 7,539 and 1,174, respectively. S. mansoni is prevalent in the northeast- ern part of Oriental Province—in the basin of the Ituri River, in the Bay of Bobandama on Lake Edward and in the Kasenye region near Lake Albert. The examination of the inhabitants of five villages in the neighbor- hood of Kasenye in 1939 showed average in- fection rates of 45 per cent in the men, 39 per cent in the women and 14 per cent in the children. In comparable exami- nations in the Kilo-Moto mining region the rates were 40, 6 and 20 per cent, respec- tively.*” A survey of Djuga district in 1948 also indicated 38 per cent infection in the fishing villages on the shores of Lake Al- bert.® Extensive foci of S. mansoni are found in Katanga Province, particularly in the southern and the western districts, where the incidence ranges from 5 to 80 per cent. The Lubumbashi River at Elisabethville is heavily infected. Smaller foci exist in Kasai Province, primarily along the Lubilash River and in the Lake Foa region. Investiga- tion of the disease in the Lubilash River area in 1945 revealed a high incidence of infection among the cotton cultivators, ap- proaching 50 per cent in some localities.*? Minor limited foci are also reported around Kimpese in the southwestern part of Leo- poldville Province and around Bosobolo in the northwest corner of Equator Province. The known centers of urinary schistoso- miasis are largely restricted to the areas along the major routes toward the interior. The most important are found in the Bas- Congo district of Leopoldville Province and in the eastern part of Katanga Province, in the vicinity of Elisabethville and around lakes Mweru and Tanganyika. Studies re- ported in 1934 showed 9 per cent infection with S. haematobium in 1,343 persons ex- amined in Chibambo on the banks of the Luapula River. The incidence increased from S per cent at 0 to 5 years of age to 31 per cent at 10 to 15 years and decreased gradually to zero at 40 to 45 years.'® Small isolated foci of S. haematobium also exist in the upper Ituri region in the northeastern corner of the Colony. A mild form of intestinal schistosomiasis, caused by a variant of S. haematobium, designated as S. haematobium intercalatum, is reported to be common in the fishing vil- Belgian Congo 349 lages for about 100 miles along the Congo River from Stanley Falls to the mouth of Lomani River, and in localized areas in the lower reaches of the Lindi River. Infection is acquired by bathing and washing in the streams which are habitually used as public latrines. Infection rates approximate 50 to 80 per cent in children and young adults and 0 to 4 per cent in persons over 30 years of age. Physopsis africana globosa is the prin- cipal intermediate host of S. haematobium and S. haematobium intercalatum. Planorbis (Biomphalaria) alexandrina pfeifferi and P. (B.) alexandrina choanomphala are the only species known to be involved in the transmission of S. mansoni. The presence of foci of schistosomiasis in the eastern districts is regarded with ap- prehension by the government authorities, in view of the increasing industrial develop- ment of the Colony. An autonomous com- mission was created within the government health service in 1946 for the systematic study of the disease and effective measures for control. OtuHER HELMINTH INFECTIONS. In many regions from 50 to 100 per cent of the in- habitants harbor one or more species of in- testinal worms ; multiple infections are fre- quent. Ascariasis, trichuriasis and strongy- loidiasis are common at both high and low altitudes. Taeniasis occurs sporadically. Taenia saginata is widely distributed in the cattle- raising districts of the eastern highlands. In- fections with 7. solium and Hymenolepis nana are reported occasionally. Other Infections. Brucellosis is endemic in the dairy districts of Ruanda-Urundi and in the adjacent Kivu Province. Sporadic cases are also recorded among Europeans and Congolese in Oriental and Leopoldville provinces. Both Brucella melitensis and B. abortus are encountered. Cholera has not been present in this area within the period for which records are available. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. The actual prevalence of tuberculosis is not known, but it appears to be increasing in the industrial areas of Kasai, Katanga, Kivu and Leopoldville provinces. Active foci exist in the larger centers of population, from which the in- fection is carried into the villages of the in- terior by workers returning to their homes. From 4,000 to 6,800 cases are reported an- nually, the majority probably advanced in- fections. Approximately 30 to 50 Europeans and from 1,100 to 1,900 Congolese are treated each year in the government insti- tutions alone. Pulmonary cases predomi- nate, accounting for 75 to 80 per cent of the total infections. The disease frequently fol- lows a rapid, fulminating course in native patients, with fatality rates of 35 to 40 per cent. However chronic cases are becoming more and more prevalent in the large popu- lation centers. Measures for the control of tuberculosis have been carried on in Leopoldville and in certain mining areas for a number of years, but facilities for diagnosis and treatment are inadequate in all parts of the country. In 1947-48 the Colonial health organization initiated a tuberculosis-control program, with services in the cities of Leopoldville, Elisabethville, Stanleyville, Luluabourg and Costermansville. The program is based on tuberculin testing, supplemented by x-ray examinations and immunization with BCG vaccine, where indicated. The service began to function in Leopoldville early in 1949. In over 20,000 Mantoux tests in adults, the positive reactions averaged 75 per cent. In the surrounding villages they ranged from 45 per cent in females to 60 per cent in males. In Elisabethville, where the labor is generally derived from more sparsely set- tled areas, the tuberculin-positive rates are usually lower. The immunization of in- fants with BCG vaccine is undertaken in Leopoldville and a few other cities, and the 350 Belgian Congo extension of the program to include children in the schools is contemplated. Smallpox. Localized epidemics of small- pox are reported annually from all parts of the Colony. From 1,500 to 6,500 cases are recorded each year. The majority are mild infections, but from 100 to 400 cases of severe smallpox are usually included. Ex- tensive outbreaks occurred in Kivu and Katanga provinces in 1945 and in Leopold- ville, Oriental and Katanga provinces in 1946. The general situation improved in 1947 and 1948, although over 600 cases of variola major were reported from the Katanga area during 1947. In outbreaks of mild smallpox the recognized cases probably constitute a fraction of the total incidence. Although mass vaccination is carried on in the affected districts, extensive areas remain inadequately protected. Vaccination is fre- quently unsuccessful, due to the difficulty in maintaining the potency of the virus under tropical conditions. Moreover, it is opposed by many tribes. The provincial laboratories not only prepare smallpox vaccine for use in the Colony but also undertake considerable research in connection with the disease. Meningitis. Localized outbreaks of men- ingococcus meningitis are common, partic- ularly in the Leopoldville, the Ituri and the Katanga areas. From 100 to 300 cases are reported each year among the Congolese, with occasional cases among the Europeans. The fatality rates still range from 30 to 80 per cent but have decreased appreciably since the introduction of “sulfa therapy.” Strains of meningococci isolated in Ruanda- Urundi and the Congo have been found to be immunologically distinct from those en- countered in Europe, and attempts at im- munization with antimeningococcus vaccine, prepared from local strains, have been prac- ticed in the control of epidemics. Other Infections. Diphtheria is rare, but occasional cases occur among both Euro- peans and Congolese. An isolated outbreak of 187 cases in the native population was re- ported from Leopoldville Province in 1941. Scarlet fever is reported infrequently, but sporadic cases are observed in both races. Dick test surveys indicate that 93 per cent of the children acquire immunity by 2 years of age.5® Measles, whooping cough, mumps and influenza are endemic and at times epidemic. Poliomyelitis is sporadic but localized out- breaks have been recorded. Pneumonia is prevalent, especially in the labor camps. Fatality rates average from 8 to 14 per cent in the Colony as a whole, but exceed 18 per cent in the Katanga region, where conditions are peculiarly unfavorable. Primary pneu- mococcus meningitis is not unusual. Respir- atory infections are responsible for a large proportion of the infant deaths. Pulmonary spirochetosis is sometimes reported. DiseASES SPREAD OR CONTRACTED CuIerLy THROUGH CONTACT Venereal Diseases. Venereal diseases are prevalent. Endemic foci exist not only in the industrial centers but also among the tribes of the interior, primarily along the historic trade routes. Between 75,000 and 85,000 cases are reported annually by the various medical agencies, but, as in other colonies, the treated cases probably consti- tute a small portion of the total incidence. In the years 1942-46, from 475 to 600 Euro- peans and from 35,000 to 45,000 Congolese were treated annually for venereal infections in the government hospitals and dispensa- ries. Syphilis was responsible for from 22 to 29 per cent of the cases, gonorrhea for from 60 to 66 per cent, chancroid for from 2 to 4 per cent, lymphogranuloma venereum for from 5 to 8 per cent and granuloma in- guinale for from 0.08 to 0.3 per cent. Both syphilis and gonorrhea influence adversely the birth and the infant mortality rates in many tribes. Treatment is provided in the various hospitals and dispensaries and at special antivenereal disease centers oper- ated by the Croix Rouge du Congo in Leo- poldville, Matadi, Stanleyville and Elisa- bethville. Control is difficult, however, since few natives continue attendance after the acute symptoms have subsided. Belgian Congo 351 Leprosy in the Belgian Congo Leprosy. Leprosy is widespread, partic- ularly in the northern and in central prov- inces. In 1948 approximately 68,000 known cases of leprosy were under treatment by the Colonial medical services and the various mission and private agencies. About 39 per cent were located in Equator, 27 per cent in Kasai, 12 per cent in Oriental and 7 per cent in Leopoldville provinces, with the remainder about equally distributed be- tween Kivu and Katanga provinces. The numbers vary from year to year with the activity of the medical services in the dif- ferent areas but are consistently high in Equator and Kasai provinces. From 8,000 to 12,000 new cases are reported annually. On the basis of preliminary surveys in Stanleyville and in the Ango territory on the northern frontier in 1946, the Colonial medi- cal authorities estimated that there were at least 200,000 lepers in the country.!! The in- fection rates vary from 0.2 to 0.3 per cent in the Bas-Congo and the Kwango sectors to from 5 to 10 per cent among certain prim- itive tribes in both savannah and forest re- gions. A survey in the Kibale-Tturi district in 1939 showed rates ranging from 4.4 to 6.2 per cent in three “chefferies” and from 3.4 to 8.9 per cent in four tribes of Pygmies. Statistics collected by a special leprosy commission appointed by the Ministére des Colonies in 1937 suggest that the prevailing infection is mild in type. Lepromatous cases probably do not exceed 10 to 15 per cent of the total. Moreover, the incidence in chil- dren is low, except in certain highly infected villages. In 1948 over 16,300 lepers were segregated in leprosaria or agricultural vil- lages maintained by the Colonial medical services, the missions or the Croix Rouge du Congo in different parts of the country. The segregation units range in size from 3 to 1,955 patients and vary in the amount of medical supervision provided. Both the treatment and the social rehabilitation of the lepers are stressed in the principal cen- ters, such as Pawa, Tschumbe, Ste. Marie, Wafania and Bibanga. The Croix Rouge du Congo maintains a special research labora- tory at Pawa. Occasional cases are encoun- tered among Europeans. Yaws. Yaws is widely distributed, and probably from 2 to 3 per cent of the popula- tion is affected. Mass treatment is carried on in many areas by the provincial medical services and by various mission and phil- anthropic agencies, with a marked reduc- tion in incidence. Between 250,000 and 350,000 cases are treated each year. The disease is particularly active in Equator Province, where a recrudescence of yaws was experienced among the tribes of the northern savannah in 1946. Other important foci are found in the tropical regions of Kivu Province and in parts of Leopoldville and Oriental provinces. From 35 to 50 per cent of the cases reported from Leopoldville Province in 1945-46 were attributed to the Mayumbe territory, north of the Congo estuary. Diseases of the Eyes. Trachoma is sporadic among the native peoples, pri- marily in Kasai, Katanga and Leopoldville provinces. From 75 to 120 cases are treated each year in the provincial hospitals and dispensaries. Diseases of the Skin. Phagedenic, or tropical, ulcers are common, from 150,000 to 200,000 cases being reported annually. This condition was formerly prevalent among 352 Belgian Congo the laborers, but the incidence is now par- tially controlled by protective measures in many camps. Fungus infections of the skin are frequent. Cases of Madura foot, caused by Actinomyces madura, and “mossy foot,” a condition in which the etiology is obscure, are also present. Human myiasis is occa- sionally seen. In the savannah country it is caused most frequently by the tumbu fly, Cordylobia anthropophaga; in the forest country, by C. rodhaini. Sarcoptes scabiei and Tunga penetrans are widespread and produce sores which readily become infected. Other Infections. Cases of human rabies are reported from time to time from various parts of the country. From 50 to 100 cases of tetanus are treated annually in the gov- ernment and FOREAMI hospitals and dis- pensaries. Puerperal infections and cases of tetanus neonatorum predominate. Cases of leptospirosis are sometimes observed. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is present in all por- tions of the Colony, except in the eastern highlands at elevations over 5,500 feet, where the anopheline vectors are not present. The infection is hyperendemic in the lowland areas and frequently epidemic at the higher altitudes. Statistics compiled by the Colonial medical services from 1937 through 1948 reveal a rise in incidence in Europeans from 1,737 cases in 1937 to a maximum of 4,159 cases in 1945, due pri- marily to the increase and the shifting na- ture of the white population during the war years. Among the Congolese the recorded cases are not indicative of the extent of in- fection, but a comparable advance from 47,- 316 cases in 1937 to 142,348 cases in 1948 is demonstrated. Extensive outbreaks of malaria have occurred in recent years among the laborers recruited by industries in en- demic areas from upland regions which are more or less free from the disease. The in- termingling of populations with varying degrees of susceptibility has been responsi- ble for an increase in incidence. Malaria is transmitted throughout the greater part of the year in most sections of the country, with minor fluctuations in areas of greater or lesser rainfall. Almost 100 per cent of the native children in endemic re- gions acquire the infection before 10 years of age. The average index of infection for the entire Colony has been estimated at 75 per cent for children under 3 years and slightly less than 50 for children 3 to 15 years of age.3® In endemic and hyperendemic areas the disease constitutes an important pri- mary and contributory cause of death in infancy and early childhood. The general fatality rates for children up to 3 years of age range from 12 to 24 per 1,000; for chil- dren 3 to 15 years of age, from 0.5 to 5 per 1,000. In the epidemic zones all ages are equally affected. Plasmodium falciparum is the predomi- nating species found in both white and in- digenous populations. P. malariae is com- mon among native children in the endemic areas but is rarely encountered in the white residents. P. vivax occurs irregularly and less frequently. P. ovale is seen occasionally. In areas characterized by a high incidence of malaria, as the Mayumbe territory and part of the Kilo-Moto mining region, two and sometimes three species are found. The relative proportion of P. malariae infections decreases with the reduction in incidence, while P. vivax may be completely absent. Anopheles gambiae is the principal vector in most sections of the Colony. A. funestus is also an important vector and the domi- nant species in some areas. A. moucheti and A. nili may be implicated in the transmis- sion of malaria in localized regions. Programs for the control of anopheline mosquitoes are undertaken in the urban and the industrial areas. Since 1947, residual spraying with DDT preparations has been introduced in some localities, with varying degrees of success. In Elisabethville, a re- duction in incidence from 35 to 45 per cent to 12 to 18 per cent was demonstrated among groups of children examined in 1947- 48.55 Prophylactic treatment with quinine Belgian Congo 353 and other antimalarial drugs is carried on in certain infant welfare centers and schools and occasionally in labor camps located in highly endemic regions. In some infant wel- fare centers, it has been responsible for a 50 per cent reduction in infant mortality. Blackwater fever is recorded sporadically in the white population; rarely, in the na- tive. Trypanosomiasis. Trypanosomiasis is a disease of primary importance in the Bel- gian Congo and affects both the health and the economic welfare of the people. The human infection was formerly widespread throughout the greater part of this region. Today in spite of an intensive treatment campaign extending over 20 years or more, it remains endemic in areas totaling over half of the Colony. During this period, how- ever, the incidence has been reduced mark- edly, and the individual areas of endemicity have been restricted in size. The average infection rate among over 2 million per- sons examined in 1928 was 3.3 per cent, while in some localities it reached from 10 to 30 per cent. In contrast, the average in- fection rate among some 474 million persons examined in 1948 was 0.77 per cent, and the index of new infections was 0.21 per cent. New infection indices of 2.5 per cent or more were limited mainly to foci in the Bas- Congo region of Leopoldville Province, along the western border of Equator Prov- ince and near Kasongo in Kivu Province. Human trypanosomiasis in the Belgian Congo is caused by Trypanosoma gam- biense, transmitted by Glossina palpalis. The control program adopted by the Direc- tion Générale des Services Médicaux is aimed at the elimination of the infection in the human reservoir. Periodic surveys and mass treatment are carried on by special mobile units. The movement of the native population in and out of the endemic zones is controlled by means of a passport and permit system. In limited areas antitsetse- fly measures constitute an accessory part of the program. In spite of continuous inten- sive efforts to eradicate the disease, the Zo, y Ns 0 5~C_ 70% 2, Z AoStanleyville , p “ olan TH) SEK... 78 7 4 2 : Distribution of Human Trypanosomiasis in the Belgian Congo, 1948 index of endemicity has become more or less stabilized within recent years. This is thought to be due to the development of strains which are resistant to tryparsamide and other arsenical compounds used in treatment. Since 1942, the government medi- cal service has conducted field experiments employing prophylactic injections of Bayer 205, Pentamidine or Propamidine (isethion- ate) for the protection of the people in cer- tain highly endemic areas. Research is also carried on for the discovery of new drugs and more effective methods of treatment and prophylaxis. : Following the international trypanosomi- asis conference at Brazzaville in 1948, a permanent Inter-African Bureau of Tsetse and Trypanosomiasis was created. The Bureau will maintain its headquarters at the Institut de Médecine Tropicale Prin- cesse Astrid in Leopoldville. Rickettsial Infections. Outbreaks of rickettsial disease occur sporadically in scattered foci throughout the Colony. Rare cases of suspected typhus fever were re- ported between 1934 and 1940, but the presence of the disease was not confirmed until 1939-40, when an epidemic of 200 or more cases was reported among the natives in Maniema district on the eastern border. Though mild and slightly atypical, the in- 354 Belgian Congo fection was diagnosed as epidemic typhus on the basis of clinical and serologic evi- dence. Since then, cases have been encoun- tered among Europeans and Congolese in this area almost every year. Louse-borne typhus is probably endemic in the Lake Kivu region, as well as in Ruanda-Urundi. Murine typhus is endemic, and from 100 to 500 cases are reported almost annually from widely separated foci throughout the country. The presence of the infection has been demonstrated in numerous foci in the Congo basin below Stanleyville and in the Kasai, Katanga, Lake Kivu and Ituri River regions. Tick-borne typhus is relatively rare. Oc- casional cases of fievre boutonneuse have been reported, in which Rhipicephalus san- guineus was the vector. The term “Congolese red fever” has been employed for many years to describe cer- tain febrile conditions common in Leopold- ville and along the banks of the lower Congo and Ubangi rivers. Studies initiated in 1940 indicated that many of the cases were murine typhus. At the International Rick- ettsial Conference held in Brazzaville in February, 1950, it was agreed that “Con- golese red fever” did not represent a clinical entity and that the use of the term should be discontinued. Plague. Sylvatic plague is enzootic in several foci located in two separate areas in the northeastern part of the colony : west of Lake Albert and northwest of Lake Edward, between the Semliki River and the Ituri- Kivu road. From 10 to 70 human cases are recorded annually, with an average fatality rate of 80 to 100 per cent. Bubonic, pneumonic and septicemic cases are represented. From 1928, when the Ituri focus was first recog- nized, through 1947 a total of 382 cases was reported from the Lake Albert region. Ap- proximately 107 cases were observed in the Lake Edward area from the time of its dis- covery in 1938 to the end of 1947. An in- crease in the number and the size of the endemic foci has been noted recently. The semidomestic rats, Arvicanthus abys- sinicus and the multimammate Mastomys coucha wugandae, are the most frequent rodent reservoirs in the native villages. Rattus rattus alexandrinus is an important reservoir in the Lake Edward area but is completely absent around the Lake Albert focus. R. rattus kijabius has been found infected in some localities. Numerous wild rodents are potential accessory reservoirs. The rat flea, Xenopsylla brasiliensis, is the principal vector, but X. ckeopis is also im- plicated in the Lake Albert region. A continuous control program is carried on by antiplague units in the government health service. Antirodent measures include the periodic destruction of field and domes- tic rodents and the elimination of breeding places in the villages. The systematic im- munization of the population in the affected areas with Girard’s antiplague vaccine is undertaken by mobile teams from the plague research laboratories at Blukwa and Lubero. Yellow Fever. Sporadic cases of yellow fever are encountered in widely scattered areas throughout the Colony. The disease was formerly confined to the port towns of Matadi and Boma, but within recent years the majority of cases have been reported from rural districts in the interior. From 1940 through 1946, 15 fatal cases were ob- served in Leopoldville, Equator and Ori- ental provinces. The principal vector, Aedes aegypti, is abundant in all sections of the country. Since the epidemic in Matadi and Boma in 1927-28; Aedes-control measures have been enforced in Leopoldville, the ports on the lower Congo and the larger cities in the interior. ‘Evidence of endemicity among the native populations is furnished by protection test surveys in representative areas. In an in- vestigation undertaken by members of the staff of the Rockefeller Foundation in 1932- 33, immune antibodies were demonstrated in 8.8 per cent of 1,746 sera from 43 villages in various parts of the country? Positive results were obtained in 10 of the 28 towns in which samples were collected from chil- dren. Within recent years successive surveys have been carried on by the Colonial medical services in collaboration with the Rocke- feller Foundation, and a special yellow fever section was organized in the laboratory at Stanleyville in 1938. Protection test surveys in Oriental Province in 1939-41%* showed from 7.4 to 16 per cent positive reactions among children and from 20 to 40 per cent among adults in the northern districts where the savannah was broken by galleries of forest. In 11 localities in the equatorial forest area, immune antibodies are present in 6.8 per cent of the adults and in 0.7 per cent of the children examined. In the vil- lages in the southeastern highlands the tests were uniformly negative. Subsequent sur- veys by the government medical staff have revealed varying percentages of immune individuals among adults in scattered areas in all 6 provinces and particularly in the Bas-Congo and Ubangi and Uélé regions. Immunity has been demonstrated among children chiefly in Oriental, Equator and Leopoldville provinces. Viscerotomy studies in 1938-41 also disclosed unrecognized cases in these same 3 provinces. The southern limit of the endemic zone is recognized as 10° S. latitude by the World Health Organ- ization. Immunization against yellow fever is compulsory for all white residents in the Colony, both permanent and temporary. The regulations of the International Conventions are enforced at all sea and airports. Filariasis. Filariasis is reported from many parts of the country. From 3,000 to 11,000 cases are treated annually among the natives by the provincial and FORE- AMI medical services. An average of from 100 to 300 cases is observed among Euro- peans. Wuchereria bancrofti is distributed irregularly although Culex quinquefasciatus (= C. fatigans), Anopheles gambiae, A. funestus and other vectors are abundant. Occasional cases are reported from Matadi, Banana Island and localities near the mouth Belgian Congo 355 of the Congo River. The infection is gen- erally absent in the interior, but several foci are found in the neighborhood of the Kwango and the Kasai rivers? as well as in other parts of the Colony. Infections with Acanthocheilonema pers- tans are widespread. A. streptocerca has also been reported. Loa loa is common in low wooded regions, particularly in the northern provinces. In many localities 25 per cent or more of the inhabitants harbor the parasite. The vectors, Chrysops dimi- diata and C. silacea, are prevalent. Onchocerciasis is present in numerous foci below 1,500 feet in Equator, Leopold- ville, Oriental, Katanga and Kasai prov- inces, conforming to the distribution of the vector, Simulium damnosum. Multiple nodules and ocular manifestations are frequent. A survey of the Bas-Uélé region, reported in 1935,' revealed cutaneous onchocerciasis in 88 per cent of the adults and in 61 per cent of children from 6 to 12 years of age. Ocular lesions were apparent in 2.1 per cent, with blindness in 0.4 per cent. In some communities along the San- kuru and the Lubilash rivers in Kasai Prov- ince from 80 to 85 per cent of the in- habitants are infected. An important focus in the Leopoldville area was suppressed in 1948, when S. damnosum was eradicated from the banks of the Congo river in the vicinity of Stanley Pool by means of DDT sprayed from an airplane.®® Relapsing Fever. African tick fever, caused by Borrelia duttoni, is widely dis- tributed in the southern and the eastern dis- tricts, particularly in the Kwango district of Leopoldville Province and in the plateau regions of Kivu and Katanga provinces. It does not occur in the forest areas. From 300 to 1,200 cases are reported each year, but the infection is undoubtedly more extensive in many tribes. It is transmitted by the tick, Ornithodorus moubata. The fatality rates are low, rarely exceeding 0.3 to 2.5 per cent. Other Infections. Dengue fever is en- demic. Kala-azar has not been reported from the Colony, but the existence of cu- 356 Belgian Congo taneous leishmaniasis has been suspected on several occasions. NvurtrITIONAL DISEASES Various forms of avitaminosis occur; from 100 to 200 cases are reported each year among the white residents, and from 1,000 to 3,500 among the Congolese. Major de- ficiencies in thiamin, riboflavin and related vitamins of the B complex are common in many areas. Beriberi and pellagra are re- ported occasionally. Xerophthalmia and other signs of vitamin A deficiency are fre- quent. “Mbuaki,” a condition comparable with the malignant malnutrition, or kwa- shiorkor, found in neighboring territories, is prevalent in Kwango district, as well as in other regions. Approximately 4,500 cases were treated annually by the FOREAMI medical services in 1945-46, with a fatality rate of from 3 to 4 per cent. Sporadic cases of mild scurvy are re- corded. Indications of iron and calcium de- ficiency are common among many tribes. Goiter is endemic in scattered centers throughout all the provinces, the most prom- inent being in Kwango district, in the Lodja and the Tschofa areas of Kasai Province, in the regions north of Stanleyville spreading toward the Ubangi River, and on the Luapula plateau in Katanga Province. From 1,200 to 3,800 cases are recorded annually. MisceLLANEOUS CONDITIONS Sporadic cases of infectious hepatitis are reported each year in both European and native communities. Cases of suspected rat- bite fever are recorded from Banana Island, but the nature of the infection has not been established. Silicosis is discovered occasionally among the workers in the mines in Katanga and Kivu provinces. Acute polyarticular arthri- tis is widespread. SUMMARY The Belgian Congo is a territory of over 910.000 square miles, with a population of about 51,600 whites and more than 10.5 mil- lion natives. Health standards and living conditions vary markedly in diverse sections of the Colony and among peoples in different stages of cultural progress. The health and medical services are ad- ministered by the Direction Générale des Services Médicaux in close co-operation with several unofficial organizations, nu- merous “national” and “foreign” missions and various large industrial concerns. In 1948 the Colonial medical services operated 36 hospitals for Europeans and 59 for Con- golese. Approximately 135 to 185 hospital units were maintained by mission, philan- thropic or private organizations. In addi- tion, over 1,000 dispensaries were scattered throughout the Colony. The estimated total of hospital beds under private and govern- ment auspices was 59,400, or roughly 5.4 per 1,000 of population. Water supplies are derived from rivers, lakes and streams. Treated municipal water supplies are available in the larger towns and cities. Rural supplies are usually unpro- tected and frequently polluted. Septic tanks are employed by the European communi- ties, but facilities for sewage disposal are generally primitive in the native areas. Hy- gienic controls over food supplies are en- forced in the urban areas, but low levels of sanitation prevail in other regions. Malaria, leprosy, yaws, venereal diseases and tuberculosis are prevalent. Trypano- somiasis and schistosomiasis are widespread. Tick-borne relapsing fever, epidemic typhus fever, murine typhus, onchocerciasis and Wuchereria bancrofti infections are reported from localized areas. Sylvatic plague is en- zootic in the region of lakes Albert and Ed- ward. Cases of yellow fever are reported oc- casionally, and the infection is apparently endemic in all parts of the country with the exception of the southeastern highlands. Frequent epidemics of smallpox, meningitis and pneumonia occur. Intestinal and skin infections are common. Diphtheria and scarlet fever are relatively rare. Measles, mumps and whooping cough are sometimes epidemic. Avitaminosis, beriberi, “mbuaki,” 1. 10. 11. 12. 13. 14. Belgian Congo 357 endemic goiter and other deficiency condi- tions are present. BIBLIOGRAPHY Barlovatz, A.: Typhus exanthématique de forét au Congo, Ann. Soc. belge de méd. trop. 20:23-40 (Mar. 31) 1940. Baudart, M.: Le goitre endémique dans la région de Ebola, Ann. Soc. belge de méd. trop. 19:129-142 (June 30) 1939. 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Congo belge 2:97-123 (Jan.) 1944. ——, Rousseau, E., and Courtois, C.: Com- plément d’enquéte sur la distribution d’im- munité antiamarile naturelle chez les in- digénes du Congo belge, Ann. Soc. belge de méd. trop. 28:247-267 (June 30) 1948. Mabhaffy, A. F., Smithburn, K. C, and Hughes, T. P.: The distribution of immu- nity to yellow fever in Central and East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. Marvel, Tom: The New Congo, New York, Duell, Sloan & Pearce, Inc., 1948. Mouchet, R.: Le probléme de la tuberculose humaine en Afrique tropicale et spéciale- ment au Congo belge, Ann. Soc. belge de méd. trop. 17:509-554 (Dec. 31) 1937. Neujean, G.: Recherche de la réaction de Schick chez les indigénes de la région de Kitega, Ann. Soc. belge de méd. trop. 17: 351-352 (Sept. 30) 1937. Ruel, R., and Eeraerts, W.: Une épidémie de “dengue-like fever” dans la province de I’Equateur, au Congo belge, Ann. Soc. belge de méd. trop. 29:153-175 (June 30) 1949. Schwetz, J.: Considerations sur la future lutte antianophélo-paludéenne au moyen du D.D.T. au Congo belge, resp. en Afrique centrale, Ann. Soc. belge de méd. trop. 28: 51-83 (Mar. 31) 1948. ——: Sur Détat sanitaire de la région du Lubilash et tout spécialement sur la bilhar- ziose dans cette région. Rapport sur une 43. 44, 45. 46. 47. 48. 49. 50. 51. 52, 53. 54. reconnaissance effectuée en janvier-février 1946, Inst. Roy. Colon. Belge. Bull. des Sciences 18:519-577, 1947. ——: Sur un cas myiase intestinale pro- voquée par les larves de Chrysomyia putoria, wied, Ann. Soc. belge de méd. trop. 14:469-471 (Dec. 31) 1934. Sur une nouvelle classification des planorbes du Congo belge. Resp. de Afrique éthiopienne, Ann. Soc. belge de méd. trop. 29:37-65 (No. 1) 1949, ——, Baumann, H., and Fort, M.: Nouvelles recherches sur la répartition des anophéles et du paludisme endémique au Congo belge. I. Région du Lubilash-Sankuru, Ann. Soc. belge de méd. trop. 27:289-313 (Sept. 30) 1947. , : Nouvelles recherches sur la répartition des anophéles et du palu- disme endémique dans diverses régions du Congo belge. II. L’entre Kundelungu et Kibara (territoire de Sampwe, province du Katanga), Ann. Soc. belge de méd. trop. 27:315-331 (Sept. 30) 1947. , and Dartevelle, E.: Sur les mollusques gastéropodes pulmones et la schistosomiase de lest du Kivu-Ituri et spécialement dans Pagglomération de Kasenyi au Lac Albert, Ann. Soc. belge de méd. trop. 22:123-156 (June 30) 1942. Strong, Richard P.: Onchocerciasis in Africa and Central America, Suppl. Am. J. Trop. Med. 18:1-57 (Jan.) 1938. Van den Berghe, L.: L’'immunité amarile de sérums prélevés chez des ictériques en Ubangi (Congo belge), Ann. Soc. belge de méd. trop. 17:577-579 (Dec. 31) 1939. ——: Recherche sur 'onchocercose au Congo belge. Ier mémoire. La transmission d’On- chocerca volvulus par les simulies, Ann. Soc. belge de méd. trop. 21:63-76 (Mar. 31) 1941. : La schistosomose humaine dans la pro- vince de Stanleyville (Congo belge), Ann. Soc. belge de méd. trop. 19:573-594 (Dec. 31) 1941. ——: Les schistosomes et les schistosomoses au Congo belge et dans les territoires Ruanda-Urundi (Mémoire couronné au concours annuel de 1939) Institut Royal Colonial Belge, section des sciences natu- relles et médicales, Mémoirs 8:1-154 (No. 8) 1939. ——: Les schistosomiases humaines et ani- males au Katanga (Congo belge), Ann. Soc. belge de méd. trop. 14:313-371 (Sept. 30) 1934. : L'immunité amarile de sérums pré- levés chez des ictériques en Uélé (Congo Belgian Congo 359 33. 56. 5%. 58. 59. 60. 61. 62. belge), Ann. Soc. belge de méd. trop. 15: 561-566 (Dec. 31) 1935. ——: Sur lexistence d'une immunisation amarile récente chez des enfants du Bas- Congo, Ann. Soc. belge de méd. trop. 17: 581-582 (Dec. 31) 1937. Van Hoof, L. M. J. J.: Observations on trypanosomiasis in the Belgian Congo, Tr. Roy. Soc. Trop. Med. & Hyg. 40:728-761 (July) 1947. Van Riel, J.: Etude épidémiologique et clinique d'un foyer de maladie de Weil au Kivu, Ann. Soc. belge de méd. trop. 19: 253-277 (Dec. 31) 1939. ——: La leptospirose en Afrique, Rec. trav. sc. méd. Congo belge 1:7-22 (Jan.) 1942. ——, and Mol, G.: La peste dans le nord du Kivu, Ann. Soc. belge de méd. trop. 19: 453-473 (Sept. 30) 1939. Van Slype, W.: La réaction de Dick au Congo belge, Ann. Soc. belge de méd. trop. 15: 269-272 (June 30) 1935. ——: La réaction de Schick au Congo belge, Ann. Soc. belge de méd. trop. 15:117-118 (Mar. 31) 1935. , and Bouvier, G.: Sur existence de la fievre boutounneuse dans les régions de 63. 64. 65. 66. 67. 68. 69. Luputa et de Port-Franqui, Ann. Soc. belge de méd. trop. 16:143-148 (Mar. 31) 1936. Van Wymeersch, H.: Contribution a l'étude du paludisme dans un groupe de collecti- vités indigenes du Congo belge, Rec. trav. sc. méd. Congo belge 1:81-85 (Jan.) 1942. Vincke, I. H.: Note sur la biologie des anophéles d’Elizabethville et environs, Ann. Soc. belge de méd. trop. 26:1-97, No. 4, 1946. ——: Rapport sur la lutte anti-adults par le DDT dans la province du Katanga. Un- published. ——, and Devignat, R.: Le foyer de peste du Lac Albert, Ann. Soc. belge de méd. trop. 17:87-122 (Mar. 31) 1937. Wanson, M.: Sur la biologie des phlébotomes congolais, Rec. trav. sc. méd. Congo belge 1:23-43 (Jan.) 1942. ——, Courtois, L., and Lebied, B.: L’éradi- cation du Simulium damnosum (Theobald) a Léopoldville, Ann. Soc. belge de méd. trop. 29:373-423, No. 3, 1949. ——, Richard, P., and Toubac, M.: Les ron- geurs et insectivores de Léopoldville et leurs ectoparasites, Rec. trav. sc. méd. Congo belge 6:3-38 (July) 1947. 24 Ruanda-Urundi GEOGRAPHY AND CLIMATE Ruanda-Urundi, a small territory of about 21,000 square miles, comprises the indige- nous kingdoms of Ruanda and Urundi, which were assigned to Belgium under a mandate from the League of Nations in 1924. It is situated along the eastern border of the Belgian Congo and is administered independently under United Nations trus- teeship in conjunction with that Colony. The territory is united into two residencies under a Vice Governor-General who is re- sponsible to the Ministére des Colonies in Belgium. The country is predominantly mountain- ous. The western frontier includes Lake Kivu and the northern part of Lake Tan- ganyika, both of which lie in the Albertine Rift Valley. The mountains of the eastern escarpment rise abruptly above the narrow, broken coastal plain of Lake Tanganyika and the valley of the Ruzizi River between the lakes. They form part of the Congo-Nile divide and contain peaks of from 7,000 to 9,000 feet, both in the south and in the Lake Kivu region. In Urundi the rolling uplands east of the mountains have an average alti- tude of from 3,500 to 5,000 feet and are bisected by numerous well-watered and fer- tile valleys. In Ruanda the mountains are more rugged, and the eastern slopes are characterized by undulating terraced pla- teaus, traversed by deep valleys. The north- ern plains provide excellent pasturage but lack the abundance of perennial streams found in the south. The climate is tropical in the coastal plain and the Ruzizi River basin, but it is tem- perate in the higher altitudes. Wide daily fluctuations in temperature are encountered in the mountainous regions, particularly during the rainy season. In general, the rainy season extends from October through May. In some mountainous areas, however, precipitation may occur throughout the year, while on the Lake Tanganyika coast the season usually is divided by a short dry interval in December or January. The rain- fall averages from 35 to 55 inches but varies markedly in different regions and from year to year. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLATION The population in 1947 was a little over 3,780,000, including 2,349 whites, 267 mu- lattoes and 1,439 Asiatics. About 68 per cent of the white residents were Belgians; 955 of the total were settled in Ruanda and 1,394 in Urundi. The Asiatic community contained 573 Arabs, about equally divided between the two areas, and 866 Hindus, 74 per cent of whom were located in the Urundi region. The indigenous inhabitants belong to three ethnologic groups. The Bahutu, a homogeneous people of Bantu origin, make up about 90 per cent of the population. Another 5 to 6 per cent are Batutsi, pas- toralists of Hamitic stock who are the aris- tocracy and ruling class of the territory. The Batwa, comprising the smallest racial group, represent the aboriginal inhabitants of the region. They probably are closely related to the Pygmies of the Belgian Congo. Small 360 Ruanda-Urundi 361 numbers of Swahili, of mixed Arab and Negro blood, have penetrated from the East African coast and are settled along the shores of Lake Tanganyika. Two Bantu dialects are spoken in differ- ent parts of the country: Kinyarwanda in Ruanda, and Kirundi in Urundi. The Batwa and the Swahili employ their respective lan- guages, while French is extensively used in the official and commercial centers. The in- digenous religions are pagan. Catholic and Protestant missions are active in the terri- tory, however, and almost one third of the inhabitants have been converted to Chris- tianity. The Swahili and many of the Asiatics are Moslems. The country is thickly settled, with a population density of almost 200 per square mile, as contrasted with an average of 12 in the Belgian Congo. It ranges from 100 per square mile in Kibungu district to about 425 in Ngozi. The majority of inhabitants live in small scattered villages. Usumbura, at the head of Lake Tanganyika, is the ad- ministrative center and principal city. In 1947 its population totaled 913 Europeans, 790 Asiatics and 12,346 natives. Other towns of importance are Kitega in Urundi, and Astrida, Kisenyi and Kigali in Ruanda. Overcrowding in the urban and the indus- trial areas and the exodus of natives from their tribal villages are regulated by means of a permit system. Educational facilities are conducted by the various mission organizations, with gov- ernment control through grants to qualify- ing schools. The Groupe Scolaire d’Astrida, the foremost secondary school in the terri- tory, has branches for the training of ad- ministrative, medical, veterinary and agri- cultural assistants. VITAL STATISTICS The vital statistics in Ruanda-Urundi are calculated on the basis of census returns in representative population groups. In 1947 the population studied totaled 133,690: 106,951 in Ruanda and 26,739 in Urundi. The estimated birth rate for the territory was 40 per 1,000 population, and the death rate, 22. No statistics are available for deter- mining the infant mortality. In the more primitive communities it probably exceeds 100 per 1,000 live births. Sociar Economy Colonization and concessions to large in- dustrial and agricultural concerns have con- tributed to the economic development of Ruanda-Urundi. A large proportion of the white residents are representatives of vari- ous mission societies or of European busi- ness firms. The indigenous peoples are primarily agriculturalists or pastoralists. Livestock constitutes a major source of wealth. Cattle, goats, hides and butter are exported. The cultivation of industrial crops on European and native plantations is fostered by the government. Coffee, cotton, oil seeds and pyrethrum are the principal products. Ex- perimental work for the promotion of a sound agricultural economy is carried on in local stations by the Institut National pour Etude Agronomique du Congo Belge. The Bahutu are the primary source of labor. Among some 29,400 workers regis- tered in 1944, about 71 per cent were em- ployed in industry, 8 per cent in commercial enterprises and 21 per cent in agriculture. Large numbers of Bahutu leave their homes each season, however, to work for short periods on the European or Batutsi planta- tions. Many also migrate to the mining areas of the Belgian Congo and the neigh- boring British colonies. The local mineral reserves are worked by Belgian companies. Gold, cassiterite and wolframite are ex- ported. Extraterritorial traffic is chiefly by means of steamer across Lake Tanganyika from Usumbura to Albertville in the Belgian Congo, or to Kigoma in Tanganyika Terri- tory. Steamers are also operated on Lake Kivu. A system of motor roads links the principal towns in the territory with the commercial centers on Lake Victoria. Air services are maintained between Usumbura 362 Ruanda-Urundi and Leopoldville and Elisabethville in the Belgian Congo. Foop AND NUTRITION The nutrition of the people varies some- what in the different regions. In general, their diets are largely vegetarian and are deficient in fats and in animal proteins. Grains, sweet potatoes and legumes are the basic foods in the uplands; cassava and bananas, in the tropical districts. The culti- vation of food crops is scarcely adequate to provide for the needs of the population, and in periods of drought famine conditions pre- vail in many areas. A serious famine oc- curred in 1944. Attempts to raise the stand- ards of nutrition include the promotion of diversified crops and the education of the people in better methods of agriculture and animal husbandry. The areas under cultiva- tion have been increased within recent years by the drainage and the utilization of the marshy lands in the valleys and by the curtailment of pasturage. Beef and milk are consumed by the Ba- tutsi and to a slight extent by the other indigenous peoples. Cattle and smaller live- stock are regarded as forms of wealth, rather than as sources of food. Goats, and occa- sionally sheep and pigs, are used for meat by the Bahutu. The supply of fish is inade- quate. Creameries have been established in several localities, but butter is an important commodity of exchange with other coun- tries, and the local consumption is variable. The cultivation and the use of peanuts, palm oils and soya beans are growing in popu- larity. Housing The typical native dwellings, both in Ruanda and in Urundi, are dome-shaped structures made of poles, overlaid with straw. The huts and the surrounding kraals vary in size, depending upon the affluence of the individual. In the larger towns the houses of the native workers usually are made of brick, cement or adobe, with tile or corrugated iron roofs. The construction of modern homes by the more prosperous urban communities and the provision of substantial dwellings for their workers by the larger industrial concerns are gradually promoting a demand for improved standards of housing. In some areas the tick-infested straw huts of the villages on the periphery of the towns are being abolished. ENVIRONMENT AND SANITATION WATER SUPPLIES Water supplies are obtained from wells and from the numerous streams and lakes throughout the territory. In sections of Ruanda water may be scarce during the dry season, particularly on the plains of the northeast and on the slopes of the volcanic mountains of the Lake Kivu area. Usum- bura has a central water supply, with dis- tribution to individual houses in the Euro- pean section and to community outlets in the native areas. The water is treated with ozone and is tested regularly for purity by the government laboratory at Astrida. Small wells now furnish water to the inhabitants of Astrida, but the construction of a piped supply is under consideration. Both urban and rural supplies are frequently contami- nated. WasTE DisposaL In Usumbura and in the administration and the mining centers, septic tanks are em- ployed in connection with the modern build- ings. In the native sections, pit latrines con- stitute the usual method of sewage disposal. Contamination of the soil is the general practice in the primitive rural areas. Usum- bura and Astrida are provided with storm sewers but have no sanitary sewerage. Fauna anbp Frora Climatic conditions in Ruanda-Urundi are comparable with those found in adjacent parts of the Belgian Congo, and the insect and other vectors of disease are essentially the same. Anopheles gambiae and, to a lesser extent, A. funestus are responsible for the Ruanda-Urundi 363 transmission of malaria, which is prevalent in the lake plains, the marshy lowlands and the river valleys. A. funestus is the primary vector around Astrida at elevations of from 5,000 to 5,500 feet. Malaria vectors are rarely found at higher altitudes. Mosquito- control measures, involving the treatment of breeding sites with oil or DDT sprays, are undertaken in the urban areas. Glossina palpalis is encountered in nu- merous foci adjacent to rivers, lakes and marshes. It is the vector of human trypano- somiasis on the Lake Tanganyika plain and in the Ruzizi River valley. In some areas trypanosomiasis is common among the cat- tle. Tsetse flies are not present in the higher altitudes, but infection is acquired during the dry season when the cattle range the lowlands in search of water. The tampan tick, Ornithodorus moubata, infests the straw of the native huts, and relapsing fever is widespread. A variety of other species is also present, some of which are responsible for the transmission of East Coast fever and other tick-borne infections among the cattle. Fleas and lice are abun- dant, and both flea-borne and louse-borne typhus occur. Foop SANITATION The inspection of abattoirs and meats is carried out by the veterinary services in the larger towns and by the medical officers in the smaller communities. The dairies and the food-manufacturing establishments are inspected periodically by the local health authorities. Laboratory examinations of foodstuffs are performed in the‘government laboratory in Astrida at the request of indi- vidual merchants or firms. HEALTH SERVICES AND MEDICAL FACILITIES HeaLTH ORGANIZATIONS The Direction de Service Médical at Usumbura is responsible for the administra- tion of public health in Ruanda-Urundi. The activities and the technical services of the territorial medical organization are co- ordinated with those of the six provinces of the Belgian Congo through the Direction Générale des Services Médicaux in Leopold- ville. The functions of the department are divided into three branch services: medical care, hygiene, and laboratories and research. They include the operation of hospitals and dispensaries for the care of the European and indigenous populations, the institution of measures for the control of communicable diseases, the conduct of special sleeping sickness and malaria control programs, the supervision of conditions pertaining to na- tive labor, and the enforcement of sanitary regulations in urban and rural areas. In- vestigations relating to the epidemiology and the prevention of specific diseases are undertaken by the staff of the laboratory division. Catholic and Protestant missions operate medical programs in various parts of the country in co-operation with the Direction de Service Médical. Medical and health services are also conducted by the larger mining and agricultural concerns for the benefit of their employees. The Oeuvre pour ’Enfance et la Mater- nité Indigéne operates subsidized clinics and supplementary material and child welfare services. MEepicAL INSTITUTIONS Hospitals and Dispensaries. The Direc- tion de Service Médical maintains major hospitals at Usumbura, Kigali, Kitega and Astrida, with an approximate capacity of 525 beds, and 7 smaller hospitals in the rural areas, with a total of about 350 beds. Facili- ties for the care of the white population are provided in a separate hospital unit of 40 beds in Usumbura and in pavilions of 4 beds each at Kigali and Kitega. A total of 20 beds is reserved for Asiatics in the hos- pitals at Usumbura, Kigali, Kitega and Nyanza. In 1947 there were 10 mission hospitals, which ranged in size from 29 to 132 beds and had an aggregate capacity of 591 beds. 364 Ruanda-Urundi There were also 5 private hospitals with a total of 273 beds, belonging to industrial concerns. In addition to the government hospitals, facilities for the care of white residents are available in the mission hos- pital at Kabgaye and in the industrial hospital at Rutongo. In 1947, 72 dispen- saries were established in various parts of the country; 48 were maintained by the government, 23 by the missions and one by a private organization. A small leprosarium is located at Buhonga in the Usumbura area. Laboratories. The Direction operates a laboratory at Astrida for the performance of chemical, bacteriologic, serologic and bio- chemical examinations. The laboratory also prepares bacteriologic vaccines and other biologicals and participates in studies for the control of diseases epidemic in the territory. Diagnostic and sometimes research facili- ties are available in the larger hospitals. The veterinary service of the territorial government has established a laboratory at Kisenyi for the production of smallpox vac- cine and of vaccines against anthrax and other diseases affecting the domestic ani- mals. It carries out microscopic examina- tions in connection with the control of trypanosomiasis in cattle, and research on various animal diseases of economic im- portance. The Institut pour la Recherche Scien- tifique en Afrique Centrale, which was created by the Belgian government in 1947 to provide facilities for research in the social and the physical sciences, has recently de- veloped a nutrition center at Astrida. Schools. Theoretical and practical train- ing for medical assistants and male nurses is provided in conjunction with the mission school at Astrida. Courses for the training of nursing aides are conducted in the hos- pitals at Usumbura, Kitega, Kigali and Kabgaye. PERSONNEL Physicians. A total of 35 physicians was practicing in Ruanda-Urundi in 1947. Nine- teen were employed by the government medical service, 13 by “national” and “for- eign” missions, and 2 by industrial concerns, while 1 was in private practice. Reports for 1948 indicate an increase in doctors to 48, 28 of whom were in government services. Others. In 1947 there were 2 dentists and 15 sanitary agents in the territory; also 28 European nurses connected with religious orders. The auxiliary staff of native per- sonnel included medical assistants, nurses and nursing midwives and sanitary aides. DISEASES Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. The standards of sanitation are low in all parts of the country, and outbreaks of intestinal infections, caused by contaminated food or water supplies, are frequent. Typhoid fever and paratyphoid fevers A, B and C are en- demic. Epidemics of typhoid fever occur sporadically in towns and other centers of population, affecting both the white and the native communities. In 19427 a major out- break was reported from the gold-mining camp at Nyongwe in Ruanda. Immuniza- tion with antityphoid, or sometimes anti- typhoid-dysentery vaccine, is undertaken among exposed populations. Dysenteries. Bacillary and amebic dysen- tery are prevalent. At least from 2,000 to 3,000 cases of each type of infection are reported annually; these totals probably give little indication of the actual incidence. Epidemics caused by Shigella dysenteriae are frequent. Immunization with antidysen- tery vaccine, prepared from local strains, is sometimes employed in the control of out- breaks of the Shiga type of bacillary dysen- tery. Helminthiases. ANcyLosToM1AsIS. Hook- worm infection is widespread, with the high- est incidence in the villages on the coastal plain of Lake Tanganyika. Infection rates, as shown by special studies,” 1® range from 10 to 20 per cent on the plateau country Ruanda-Urundi 365 around Kitega to from 60 to 70 per cent among the fishermen at Usumbura. Ancylo- stoma duodenale is apparently the prevail- ing species. ScuisTosoMIASIS. Schistosoma mansoni is endemic in localized areas, particularly in the Lake Tanganyika region. A focus cen- tered around Usumbura is gradually disap- pearing with the drainage of the marshes along the lake shore, and only sporadic cases have been reported within recent years. S. haematobium also occurs, but recognized infections are comparatively rare. The fresh water snail, Planorbis ( Biomphalaria) alex- andrina pfeifferi, is the intermediate host of S. mansoni; and Physopsis africana globosa, of S. haematobium. Oraer HerminTa INFECTIONS. A large percentage of the inhabitants harbors intes- tinal worms. Ascariasis is encountered in about 20 to 40 per cent of the population; trichuriasis and strongyloidiasis are also common. The beef tapeworm, Taenia sagi- nata, is highly enzootic among the native cattle, and human infections are frequent. Trichinosis is reported occasionally. Brucellosis. Brucellosis is present among the native cattle and in the human popula- tion. The infection is apparently caused by a variant of Brucella abortus, which Pergher and Noel'® have provisionally named B. abortus africana. Diseases SPREAD CHIEFLY THROUGH THE REspiraTORY TRACT Tuberculosis. No evidence is available regarding the prevalence of human or bovine tuberculosis. The infection is probably ex- tensive among the indigenous population, particularly in the urban areas. In the decade from 1938 to 1947 an average of 1,076 cases was diagnosed annually in the course of routine hospital and dispensary examinations. About 80 per cent were pul- monary infections. Smallpox. Outbreaks of smallpox are re- ported sporadically, in which variola minor has predominated within recent years. Spe- cial vaccination centers have been estab- lished, and campaigns are undertaken for the control of epidemics. Other Infections. Epidemics of menin- gococcus meningitis are recorded at fre- quent intervals, usually during the dry sea- son. The respiratory diseases characteristic of this area are essentially the same in type and relative incidence as those of the Belgian Congo. DiseaSES SPREAD OR CONTRACTED CuIerLy THROUGH CONTACT Venereal Diseases. All forms of venereal infection are recorded, but their prevalence is not known. Syphilis and gonorrhea pre- dominate ; gonococcal infections are usually twice as numerous as syphilitic among hos- pital and dispensary patients. Leprosy. The number of lepers in the territory was estimated in 1947 at about 527, roughly 1.4 per 10,000 population. A small mission colony is located at Buhonga in Usumbura district. Other Infections. Yaws is widespread. Anthrax is present among the herds, and human infections occur from time to time. Human cases of foot-and-mouth disease have been reported during epizootics in the Lake Kivu region. Trachoma, various my- cotic skin infections, myiasis and rabies are recorded with about the same relative fre- quency as in the Belgian Congo. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is highly endemic in the lowland areas of the lake plain and in the river valleys. Transmission takes place throughout the year, and the inhabitants, who acquire the infection early in child- hood, develop considerable tolerance to the malaria parasites. In the highlands malaria is epidemic during the rainy season. The in- cidence has increased markedly within re- cent years. Workers from the nonendemic hill areas have been engaged in the drainage and the cultivation of the marshes at the foot of the plateaus, and the introduction of large numbers of susceptible individuals into highly malarious regions has lead to 366 Ruanda-Urundi serious epidemics among them. Plasmodium falciparum is the predominating species. As in the Belgian Congo, P. malariae is com- mon in young children, while P. vivax is relatively rare. Anopheles gambiae is the major vector; A. funestus is an important secondary vector in certain areas. Blackwater fever is reported occasionally, most frequently in the white and the Asi- atic populations. Trypanosomiasis. Infection with ZT7ryp- anosoma gambiense is prevalent among the inhabitants in the region adjoining Lake Tanganyika and in the Ruzizi River basin. The Mission Maladie du Sommeil of the protectorate medical service carries on an active treatment program in this area. In a population of 146,429 surveyed in 1947, the incidence averaged 2.3 per cent; the new in- fections, 0.87 per cent.! The disease is most active in the sectors west and north of Usumbura. The case rate in the section in- cluding the region around Usumbura was 3.5 per cent, and the new infections 1.38 per cent. Comparable estimates in the hills east of the city were 1.1 per cent and 0.29 per cent, respectively. Field experiments on the prophylactic use of Pentamidine and Pro- pamidine were in progress in 1947 among limited population groups in the districts west and south of Usumbura. Rickettsial Infections. Intermittent out- breaks of typhus fever are reported from scattered foci, primarily in Urundi. The most recent epidemic occurred in 1945-46 when almost 3,800 cases were recorded within a period of 15 months, and the actual incidence probably reached several times that figure. The fatality rates averaged from 10 to 12 per cent. The epidemic infec- tions are apparently all louse-borne. A permanent focus of epidemic typhus, from which strains of Rickettsia prowazeki have been isolated, is located in the mountains above Usumbura. Murine typhus is also en- demic in many areas. The presence of “Q” fever has recently been established, and rare cases of fievre boutonneuse may occur. Other Infections. Relapsing fever is widespread, conforming to the distribution of the tick vector, Ornithodorus moubata. In highly infested districts control measures consist in the construction of sanitary dwell- ings of durable materials to replace the typical straw huts. Yellow fever has not been reported. Pro- tection tests performed on samples of blood taken from individuals at Kitega (Urundi) indicate an absence of immunity to the yellow fever virus; at Kigali (Ruanda) im- mune antibodies were found in one in- stance.!! The forms of filariasis found in the east- ern provinces of the Belgian Congo are common to this area. Plague has not been reported. NuTrITIONAL DISEASES The standards of nutrition in the popula- tion are low. Food shortages are recurrent, and undernutrition is general. Localized epidemics of beriberi occur from time to time. Rickets, scurvy and pellagra are fre- quently encountered. Goiter is endemic in certain mountainous areas. SUMMARY Ruanda-Urundi is a small but densely populated territory administered by Bel- gium under United Nations trusteeship, in close co-operation with the adjoining colony of the Belgian Congo. The health services, incorporating public health, medical, and laboratory and research branches, are oper- ated by the Direction de Service Médical. Its activities and technical services are co- ordinated with those of the provinces of the Belgian Congo through the Direction Gén- érale des Services Médicaux at Leopold- ville. The health and medical programs of the Catholic and the Protestant missions and of the industrial concerns function in close co-operation with the official services. In 1947, 4 major and 7 rural government hospitals, 10 mission hospitals and 5 in- dustrial hospitals were established in the territory. Approximately 72 government, Ruanda-Urundi 367 mission and private dispensaries were lo- cated in various parts of the country. Water supplies and methods of sewage disposal are primitive. The standards of nutrition are low, and famine conditions are recurrent in many areas. Malaria, typhoid fever, dysentery, typhus fever, meningococcus and smallpox are fre- quently epidemic. Helminthiasis, leprosy, yaws, brucellosis and relapsing fever are endemic. Human trypanosomiasis and Schis- tosoma mansoni infections are prevalent in localized areas. Yellow fever and plague are not reported. BIBLIOGRAPHY [= . Belgium: Rapport sur 'administration belge du Ruanda-Urundi pendant l'année 1947, Bruxelles, Etablissements généraux d’Im- primerie, 1948. 2. Congo Belge: Congo Belge, 1944, édite par le Service de I'Information et de la Propa- gande du Congo Belge, Léopoldville, L’Im- primerie du Gouvernement général de la Colonie du Congo belge, 1944. 3. ——: Direction Générale des Services Médi- caux, Rapport annuel 1948. 4. ——: Rapport sur l’hygiéne publique au Congo belge pendant l'année 1946. 5. de Beve, F.: La bilharziose en Ruanda- Urundi et spécialement a Usumbura, Ann. Soc. belge de méd. trop. 15:3-18 (March) 1935. 6. Dubois, A., and Noel, G.: Essais d'immunité avec la souche de typhus examthématique de I’Urundi, Ann. Soc. belge de méd. trop. 15:349-359 (Sept.) 1935. 7. Geubel, J. L.: La fiévre typhoide au Ruanda, Ann. Soc. belge de méd. trop. 28:21-27 (March) 1948. 8. Jadin, Jean: Les rickettsioses du Congo Belge et du Ruanda-Urundi, Louvain, Edi- tions Nauwelaerts, 1951. 9. ——, and Fain, A.: Anopheles funestus Giles transmetteur de paludisme en pays d’alti- tude (Astrida 1750 m., Ruanda-Urundi), Ann. Soc. belge de méd. trop. 29:145-149 (No. 2) 1949. 10. Liber Jubilaris J. Rodhain: Société Belge de Médecine Tropicale, December, 1947, Bruxelles, Ad. Goemaere, 1947. 11. Liegeois, P., Rousseau, E., and Courtois, C.: Complément d’enquéte sur la distribution d’immunité antiamarile naturelle chez les indigénes du Congo belge, Ann. Soc. belge de méd. trop. 28:247-267 (June) 1948. 12. Mahaffy, A. F., Smithburn, K. C, and Hughes, T. P.: The distribution of immu- nity to yellow fever in Central and East Africa, Tr. Roy. Soc. Trop. Med. & Hyg. 40:57-82 (Aug.) 1946. 13. Marvel, Tom: The New Congo, New York, Duell, Sloan & Pearce, Inc., 1948. 14. Mattingly, P. F.: Notes on a collection of mosquitoes (Diptera: Culicidae) from Ruanda Urundi, Ann. Soc. belge de méd. trop. 29:29-35 (No. 1) 1949. 15. Neujean, G.: Enquéte sur une epidémie de typhus exanthématique, 1939-40, Rec. trav. sc. méd. Congo belge 2:7-46 (Jan.) 1944. : Le parasitisme intestinal chez les in- digénes des Hauts-Plateaux (environs de Kitega), Ann. Soc. belge de méd. trop. 17: 343-349 (Sept.) 1937. 17. ——: Recherche de la réaction de Schick chez les indigenes de la région de Kitega, Ann. Soc. belge de méd. trop. 17:351-352 (Sept.) 1937. 18. Pergher, G., and Noél, G.: Note sur la fievre ondulante au Ruanda-Urundi, Ann. Soc. belge de méd. trop. 16:217-225 (June) 1936. 19. ——, and Portois, F.: Note sur I’épidémi- ologie et la prophylaxie de la méningite cérébro-spinale au Ruanda-Urundi, Ann. Soc. belge de méd. trop. 16:343-366 (Sept.) 1936. 20. Pergher, J., and Casier, J.: Le typhus exan- thématique au Ruanda-Urundi, Ann. Soc. belge de méd. trop. 15:305-347 (Sept.) 1935. 21. Schwetz, J.: Considérations sur la future lutte anti-anophélo-paludéenne au moyen du DDT au Congo belge, resp. en Afrique centrale, Ann. Soc. belge de méd. trop. 28: 51-83 (March) 1948. 22. Van den Berghe, L.: Les schistosomes et les schistosomoses au Congo belge et dans les territoires du Ruanda-Urundi (mémoire couronné au concours annuel de 1939), Institut Royal Colonial Belge, Section des Sciences naturelles et médicales, Mémoires 8:1-154 (No. 8) 1939. 16. 25 French Equatorial Africa GEOGRAPHY AND CLIMATE French Equatorial Africa is a federation of four territories : Gabon and Middle Congo in the south, Ubangi-Shari in the center and Chad in the north. With a total area of some 900,000 square miles and a coastline of approximately 800 miles on the Atlantic Ocean, the Federation extends from the lower reaches of the Congo River to the Libyan frontier and is bounded on the west by the Cameroons, French West Africa and Rio Muni, on the east by the Anglo-Egyptian Sudan and on the east and south by the Bel- gian Congo. The French mandated territory of the Cameroons is closely associated with French Equatorial Africa and in 1940-45 was joined with it under the administration of the Free French. French Equatorial Africa is a land of sharp contrasts, ranging from primeval rain forest in the south to desert in the north. The coastal plains of Gabon and Middle Congo are backed by a series of mountain ranges from 2,000 to 4,000 feet in height, which form the edge of a great undulating plateau separating the Congo and the Lake Chad basins. The plateau, which has a gen- eral elevation of from 1,500 to 2,500 feet, slopes gently in the east to the valleys of the Congo and Oubangui rivers, and in the northwest to the depression of Lake Chad. Tropical forest covers the greater part of Gabon and Middle Congo and projects into the savannah country of the plateau along the banks of the larger rivers. The region north and east of Lake Chad is principally desert, broken by scattered oases and by the rugged Ennedi plateau (5,000 feet) in the northeast and the Tibesti Mountains, with peaks of 11,000 feet, in the northwest. The rivers conform to three systems: the coastal streams, the tributaries of the Congo, and the Chari and the Logone rivers of the Lake Chad basin. The climate of the southern territories is essentially tropical, with high humidity and little variation in temperature. There are two rainy seasons, corresponding to the northerly and southerly course of the sun across the Equator, but the short inter- vening period in January is often hard to distinguish. The heaviest rainfall occurs between September and December and be- tween February and April. Frequent severe storms are experienced, particularly at the beginning and the end of the rains. A “dry” season, associated with minimum rainfall and lowered temperature, extends from June through August. The rainfall varies in different localities but averages from 60 to 100 inches a year in the coastal region. The mean temperature approximates 76° to 82° F. with a range of 10°-15° F. In Ubangi-Shari and southern Chad there are two distinct seasons: a rainy and a dry. The dry season extends from November to February in the south but becomes pro- gressively longer in duration toward the interior. In the Lake Chad region the rain- fall is concentrated in the months from June to October. Correspondingly, the an- nual precipitation decreases gradually from 40 to 60 inches to from 20 to 40 inches. The mean temperature approximates 80° to 82° F., with a mean maximum of 88° to 92° F. and a mean minimum of 65° to 70° F. The daily range increases in the north, 368 French Equatorial Africa 369 approaching 30° F. in some areas. North of Lake Chad the rainfall varies from a few inches annually to negligible amounts over several years in the desert country. An increase in temperature is experienced, with marked seasonal and daily fluctuations. The mean maximum temperatures range from 82° to 110° F.; the mean minimum, from 50° to 65° F. The greatest daily variations are encountered from November to March when the dry, dust-laden karmattan winds blow from the northeast. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTioNn In 1946, the population was estimated at 4,130,000. The white residents, who are pre- dominantly French, increased in number from 4,749 in 1936 to 10,942 in 1946. Almost 50 per cent are settled in Middle Congo, principally in the vicinity of Brazzaville. About 22 per cent are located in Ubangi- Shari, and the remainder are about equally distributed between Gabon and Chad. Three ethnic divisions are represented among the native inhabitants. The people of the coast, the forest and the Congo basin belong to various groups of Bantu tribes, among the most numerous of which are the Fangs, the Batékés and the Bakotas. In Ubangi-Shari and Chad the indigenous peoples belong to the Sudanic family, among which the Bayas and the Sanghas are the largest groups. Tribes of Arabs and of various Negroid ad- mixtures are found in the north. Highly developed tribal organizations, or ‘“Sul- tanates,” exist among the Kanuri, the Kamen, the Ouadaiens and other islamized tribes of the Chad basin. Communities of Hausas are settled along the major trade routes in all parts of the country. Scattered bands of Pygmies are also found in the tropical forest. The greatest concentrations of population are encountered on the coast, along the banks of the Congo and the Oubangui rivers and south of Lake Chad, in the Logone and the Chari river valleys. The rest of the coun- try is sparsely settled. The average popu- lation density is 10 per square mile in Chad, from 8 to 9 in Middle Congo, about 3 in Ubangi-Shari and 2.5 in Gabon. There are few large towns. Brazzaville, the capital of the Federation, had approximately 25,000 inhabitants in 1944. Bangui, the administra- tive headquarters of Ubangi-Shari and the second largest town in the Federation, had a population of 22,800. Pointe Noire is the principal ocean port, and Fort Lamy is the commercial center of the Chad region. The languages employed in the different areas reflect the racial origins of the people. A diversity of Bantu languages and dialects is used in the south, and Sudanic tongues in the north. Arabic is spoken by the Arabs and certain Negroid tribes in close association with them. Few of the natives outside of the administration and the business centers have any knowledge of French, the official language. The Arabs and many Negroid tribes in the north are Moslems. Most of the Bantu peoples adhere to their traditional animistic beliefs, but the influence of Mo- hammedism is slowly spreading in Ubangi- Shari and the northern part of Middle Congo. Numerous Catholic and Protestant mission organizations are established in the Federation, chiefly in the southern terri- tories. The largest numbers of converts to Christianity are found in the coastal dis- tricts. The development of education has re- ceived little impetus until recently, with the result that the majority of the natives are illiterate. Elementary and technical educa- tion, adapted to the mores and the needs of the people, is provided in the larger towns by the territorial governments, but the school attendance is small and is made up chiefly of boys. French is the medium of in- struction. Facilities for secondary education are available to all races in Brazzaville and to Europeans, in Bangui and Pointe Noire. Schools are also maintained by various mis- sion organizations, some of which are sub- sidized by the government. 370 French Equatorial Africa VITAL STATISTICS Accurate vital statistics are not available for French Equatorial Africa. However, a comparison of estimates for 1936 and 1946 indicates that the population is decreasing in Gabon and Middle Congo and increasing in the Moslem territories of Ubangi-Shari and Chad. The mortality in childhood is high in all parts of the country. In 1938 it was estimated that about one third of the children die before the age of puberty.? In sample surveys in six subdivisions of Gabon in 19333! the birth rates ranged from 7 to 16.7 per 1000 population; the death rates from 28.6 to 44.4. The infant deaths aver- aged between 20 and 35.9 per cent. The mor- tality in infancy varied among different tribes, approximating 35 per cent among the Massangos and 50 per cent among the Pahouins. Tribal customs and venereal dis- ease influence the low birth rates. Poor nu- trition, disease, and ignorance of obstetric and infant hygiene contribute to the high infant mortality. Social Economy The economic development of the terri- tories has been retarded by their inaccessi- bility, lack of adequate transportation facili- ties and shortage of labor supply. Their early growth was dominated by large con- cessions, and a period of relative stagnation followed their liquidation in 1930. Interest in French Equatorial Africa was revived during the war years, 1940-45, when it served as a base for the Fighting French forces. The principal products of the forest zone are palm oils, coffee, cocoa, rubber and tropical woods. A few plantations are oper- ated by European concerns and colonization societies. Most of the natives live under primitive conditions by means of subsistence agriculture. However, cotton is cultivated by peasant farmers in the Congo River basin. Stock raising is the major occupation of the people in the north. The settled tribes engage in both agriculture and stock breed- ing, but the nomadic tribes are purely pas- toralists. The presence of the tsetse flies over extensive areas restricts large-scale cattle production to the grasslands of Chad and small sections of Ubangi-Shari. Sheep and camels are raised by the nomadic tribes in northern Chad. Livestock, meats and hides are potentially valuable exports. In 1942 a long-term agricultural program was initiated by the territorial administra- tions which embodies the promotion of na- tive agriculture through education in modern methods of cultivation, and the in- auguration of research stations in the dif- ferent climatic zones for the improvement of food and commercial crops. The govern- ment veterinary services also conduct cam- paigns for the immunization of cattle against rinderpest and contagious pleuro- pneumonia and for the control of other dis- eases among the livestock. There are no large industries, but plants for the processing of palm oils, coffee, tapi- oca, skins and rubber have been developed recently. Small deposits of copper and gold have been worked, and reserves of lead, iron, zinc, salt and tin are known to be present in certain sections. Transportation is mainly dependent upon a limited network of motor roads and on river navigation. The Congo River is not navigable below Stanley Pool, but access to the Atlantic Ocean from the interior is af- forded by a railroad from Brazzaville to the port of Pointe Noire. Air services link the administrative headquarters with each other and with France. Foop AND NUTRITION The nutrition of the people varies with the climatic and the physiographic conditions in different parts of the country. Except for a limited number of tribes engaged in hunt- ing or fishing, the indigenous peoples sub- sist largely upon a vegetarian diet. In the south cassava is the staple food crop; in the north it is millet or rice. The use of legumes, greens and other vegetables as supple- mentary foods differs among the tribes. Plantains are abundant and an important item of food among the people of the coastal region, particularly in Gabon. Palm oils, peanuts and sesame constitute the principal sources of fat. Fish are available to the river tribes, but meat is usually scarce. Major deficiences in protein and in vitamins, es- pecially the B complex, are said to be gen- eral but most acute among the cassava- eating tribes. Moreover, the supply of food is frequently inadequate, due to the methods of cultivation and the lack of suitable means of distribution and storage. The nomads, and to a lesser extent the seminomads of the north, live chiefly on milk and milk products, miscellaneous wild greens and grains. Dates are produced in some sections of northern Chad. Beef, sheep, goats and camels are raised by different tribes, depending upon pasturage conditions, but meat is rarely consumed except on cere- monial occasions. The domestic animals are regarded as a measure of wealth rather than a source of food, and quality is sacrificed for quantity. Housine In the administrative centers, many of the homes are modern in architecture and con- struction, while others are small, over- crowded and dilapidated. In the native sections, the majority are huts comparable with those found in the tribal villages. Pro- grams for the erection of model native set- tlements around the urban areas were initiated by some of the territorial govern- ments in 1942. Except for a few moderately large towns, the indigenous peoples live in small villages built around the chief’s dwelling. The huts vary in size, design and composition among the various tribes. Circular mud huts are characteristic of some, while rectangular structures of clay, straw, poles or bark are typical of others. The roofs are usually of thatch and are distinctive in shape. The least substantial dwellings are the matting tents of the nomads; the most complicated, French Equatorial Africa 371 the walled communities in the “Sultanates” of the Chad area. ENVIRONMENT AND SANITATION WATER SUPPLIES The availability of water supply varies in different territories. Streams, lakes and shallow wells provide sources of supply for the towns and the villages in the southern and the central regions. In the more arid country of the north, water is scarce in many districts. Community supplies are de- rived frequently from waterholes or from wells ranging from 10 to 100 feet in depth. Treated water supplies are found only in the larger urban centers where they are supervised by the local Services d’Hygiéne. Where transportation facilities permit, labo- ratory examinations are conducted by the Institut Pasteur de Brazzaville. In spite of treatment by filtration or chlorination most water supplies are contaminated from time to time. The water for Brazzaville is ob- tained from pumping stations in the Ravin de la Mission and the Ravin de la Glaciére. It is chlorinated at the source, but, due to imperfections in the distribution system, subsequent contamination often occurs dur- ing periods of heavy rainfall. Low standards of sanitation prevail in the tribal areas, with the result that the village supplies are gen- erally polluted. WasTE DisposaL The methods of sewage disposal are prim- itive. Septic tanks and pit latrines are em- ployed for the disposal of sewage wastes in the larger communities. In the tribal vil- lages, pollution of the soil and of near-by streams is common. Fauna anp Frora Arthropods. Mosquitoes. A dozen or more species of anopheline mosquitoes are encountered in French Equatorial Africa, but only four, Anopheles gambiae, A. fu- nestus, and possibly A. kargreavesi and A. 372 French Equatorial Africa pharoensis, are considered important as vectors of malaria. 4. gambiae is abundant and probably responsible for a large per- centage of the malarial transmission in the region. A. funestus is also a prominent vector, especially in the savannah country of the plateau. A. pharoensis and A. har- greavesi may transmit the infection in lo- calized areas. A. gambiae breeds prolifically in the numerous natural and artificial col- lections of water, free from vegetation and exposed to the sunlight. 4. funestus breeds along the shaded edges of shallow pools or streams and in swampy areas. Numerous species of Aedes are found, in- cluding Aedes aegypti, a significant vector of yellow fever in this area, and 4. africanus and A. vittatus, potential vectors. Culex quinquefasciatus (= C. fatigans) and other species of Culex are widespread. Species of Taeniorhynchus (Mansonia) and Eretmo- podites are also present. Some mosquito-control work is carried on in the urban communities by the local health services. Drainage projects and antilarval measures are undertaken in the vicinity of Brazzaville, Pointe Noire and other centers. Fries. Little is known regarding the dif- ferent species of flies in this region. At least 8 species of tsetse flies have been identified, several of which are of primary importance from the standpoint of disease transmission. Both human and animal trypanosomiasis are endemic. Glossina palpalis, the chief vector of the human infection, inhabits the banks of the rivers and streams from the coast to about 10° N. latitude. However, G. tachinoides predominates in the north where it breeds in the bush along the rivers of the Lake Chad basin. G. morsitans and G. submorsitans are widely distributed in the savannah country, while G. fusca is com- mon in the forest. TABANIDAE are numerous, including Chrysops dimidiata and C. sila- cea, which are implicated in the transmis- sion of Loa loa in the southern territories. Cordylobia anthropophaga is the chief myia- sis-producing fly affecting man. Awuchme- romyia luteola is present, and its larvae, known as “Congo floor maggots,” are an- noying pests. Simulium damnosum occurs in numerous scattered foci. It is especially prevalent in the vicinity of Stanley Pool where eradi- cation experiments have been carried on re- cently by the Belgian health authorities. Various species of Phlebotomus are found, some of which may be responsible for the transmission of leishmaniasis in the Lake Chad region. Culicoides austeni and C. grahami are common. Lice. Pediculus humanus corporis and P. humanus capitis are prevalent among the native populations in the northern terri- tories. The former has been implicated in the transmission of louse-borne relapsing fever in occasional foci in Chad. FrEas. Xenopsylla cheopis and X. brasili- ensis are widely distributed. X. ckeopis is the vector of murine typhus in the savannah country and in the vicinity of Brazzaville. Plague is transmitted by this species in the neighboring colonies but has not been re- ported from French Equatorial Africa. Ctenocephalides canis and Pulix irritans are common. The chigoe flea, Tunga pene- trans, is found in many areas. BepBucs. The bedbugs, Cimex lectularis and C. hemipterus, are indigenous. Ticks AND Mites. Ornithodorus moubata is present in numerous foci from which cases of tick-borne relapsing fever are some- times reported. Species of Amblyomma, Dermacentor, Haemaphysalis and Rhipi- cephalus are common. R. sanguineus is responsible for the transmission of a form of fievre boutonneuse in the districts around Brazzaville. The itch-mite, Sarcoptes sca- biei, is widespread. ScorpioNs AND SPIDERS. Spiders and scor- pions are indigenous throughout this re- gion, and several species are poisonous. Buthus quinquestriatus, which inflicts a painful sting, is one of the most dangerous of the scorpions. OTHER ARTHROPODS. Beetles, ants and other pests are abundant. The cannabalistic driver ants of the genus Dorylus are French Equatorial Africa 373 found in the forest region; also the stinging ants, Paltothyreus tarsatus and Macro- mischoides aculeatus. Reptiles. Numerous poisonous snakes are present in this area. The water cobra, Boulengerina annulata, occurs in many sec- tions of Gabon, and people are sometimes attacked while fishing. It has a highly toxic venom and is considered one of the most dangerous snakes in the territory. The black cobra, Naja melanoleuca, is present in Mid- dle Congo and Gabon, and the spitting cobra, N. nigricollis, in the savannah coun- try. Dendroaspis jamesonii is found in many regions. This species and the puff adder, Bitis arietans, are responsible for a large proportion of the deaths from snake- bite in Central Africa. B. arietans and B. gabonica inhabit the savannah zone; B. nasicornis, the forest. Causus rhombeatus is found frequently near human habitations. Atheris squamiger is common in the forest, while species of A¢ractaspis are encountered in the desert region. Crocodiles and the crocodilelike Varanus niloticus infest many of the rivers. Rodents. The rats, Rattus rattus rattus and R. rattus alexandrinus, are prevalent in all parts of the country, while R. norvegicus is present in the port towns. The multimam- mate rat, Mastomys coucha, and several species of wild rodents and gerbils are po- tential hosts of sylvatic plague, but locally they have not yet been found infected. Mollusks.* The fresh-water snails, Pky- sopsis africana globosa and Bulinus (Pyr- gophysa) forskalii, are widely distributed. They are potential intermediate hosts of Schistosoma haematobium, which is en- demic in numerous foci. S. mansoni also occurs, but the intermediate host has not been identified. Foop SANITATION The markets and the food establishments in the population centers are supervised by the local Services d’Hygiéne. The inspec- tion of meats and of slaughtering places is * See footnote, p. 10. carried on in the larger cities by the terri- torial Services Zootechniques. Little fresh milk is sold, and no sanitary regulations are in force pertaining to its production. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The four territories of French Equatorial Africa have independent Services de la Santé Publique, the activities of which are coordinated by the Direction Générale de la Santé Publique of the Federation, at Braz- zaville. The federal and the territorial or- ganizations function under the supervision of the Direction du Service de Santé Colo- nial of the Ministére de la France d’Outre- Mer in Paris. The territorial headquarters are located at Bangui (Ubangi-Shari), Fort Lamy (Chad), Brazzaville (Middle Congo) and Libreville (Gabon). The Service de la Santé Publique in each territory is responsible for the maintenance of hospitals, the establishment of medical (Assistance Médicale Indigéne) and ma- ternal and child welfare facilities for the care of the native populations, the direction of the public health services in the adminis- trative subdivisions, the supervision of the Services d’Hygiéne in the urban centers, the control of epidemics and the enforce- ment of quarantine regulations. Special programs for the control of spe- cific diseases in all four territories are con- centrated in the Service Général d’Hygiéne Mobile et Prophylaxie, an autonomous or- ganization under the Direction Générale de la Santé Publique. The activities of the Serv- ice include the operation of mobile units and treatment centers, and the conduct of field investigations on special problems af- fecting the health of the indigenous popula- tions. It contains sections dealing with trypanosomiasis, leprosy, malaria, syphilis, tuberculosis and nutrition. The Institut Pasteur de Brazzaville, which is affiliated with the Institut Pasteur in Paris, functions in close co-operation with 374 French Equatorial Africa the Direction Générale de la Santé Publique. Several Catholic and Protestant mission societies carry on educational and health activities in various parts of the country. Maternity and child health work is con- ducted by branches of the Berceaux Afri- cain, the Croix Rouge and the Gouttes de Lait. MebpicAL INSTITUTIONS Hospitals and Dispensaries. In 1948 the territorial health services operated cen- tral hospitals at Brazzaville, Libreville, Pointe Noire, Bangui and Fort Lamy, with an aggregate capacity of 172 beds for white residents and 848 for natives. The largest, located at Brazzaville, had a capacity of about 600 beds. They also maintained 3 rural (regional) hospitals with a total of 33 beds for whites and 250 for natives. Forty- four medical centers, providing 2,446 beds, and 182 rural dispensaries were scattered throughout the territories. Altogether, 35 maternity units, attached to the hospitals or medical centers, and 2 child welfare clinics were conducted in the different territories. A hospital for the treatment of communica- ble diseases is established in Brazzaville. Institutions for the care of lepers included, in 1948, 31 leprosaria, with 2,789 beds, and one agricultural colony with accommoda- tions for 670 patients. Dr. Albert Schweitzer’s hospital at Lam- beréne in Gabon is the principal mission hospital in this region. Both the Catholic and the Protestant missions maintain scat- tered dispensaries in the tribal areas. Laboratories. The Institut Pasteur de Brazzaville is the central laboratory and re- search center of the Federation. It is a well- equipped, modern institution with divisions in bacteriology, chemistry and entomology. The laboratory carries out various diag- nostic and analytical examinations, prepares vaccines and serums and conducts extensive research on tropical diseases, particularly trypanosomiasis, yaws, leprosy, yellow fever and various intestinal infections. Clinical diagnostic laboratory facilities are located in the larger hospitals. The Institut d’Etudes Centrafriques, which was created in 1946 for research on entomologic and other problems of medical or veterinary importance, is situated in the Institut Pasteur in Brazzaville. Schools. There are no schools for medical auxiliaries in French Equatorial Africa. Candidates for diplomas in medicine, phar- macy and midwifery are sent to the Ecole de Médecine Africaine at Dakar. Native men and women are trained for various types of medical work, including nursing, in the larger hospitals. PERSONNEL Physicians. With a few exceptions, all of the doctors in French Equatorial Africa are connected with federal or territorial health services. In 1948 the total European staff consisted of 9 army officers, 68 army officers with civilian status, and 6 civilian doctors under contract to the territorial govern- ments; the African staff, of 19 graduates of the medical school in Dakar. There are no physicians in private practice, but a few are affiliated with mission organizations. Others. The roster of European personnel in the government health services in 1948 listed 1 dentist, 60 army or civilian nurses, 6 midwives and 30 sanitary agents. The na- tive auxiliaries included 773 nurses, 2 mid- wives and 79 sanitary agents. DISEASES Generalization regarding the incidence of specific infections in French Equatorial Africa is difficult in view of the size of the territories, the marked differences in cli- matic and physiographic conditions, and the diverse ethnologic composition of the indigenous populations, the majority of whom are superstitious and more or less re- sistant to change. A large proportion of the people adhere to traditional forms of tribal medicine, centering around the “witch” doctors and medicine men. Current esti- French Equatorial Africa 375 mates of disease prevalence are based upon the records of the government hospitals and dispensaries, and. special mobile treatment units. The reported morbidity is probably low, due in part to the reluctance of the natives to seek assistance and in part to the shortage of medical facilities, trained per- sonnel and means of communication. How- ever, the recorded data serve as criteria for evaluating the spread of certain endemic and epidemic diseases which affect the social and economic welfare of the country and threaten the health of the populations in the adjoining areas. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. The standards of sanitation are low, and dysentery infections are wide- spread among both white and native popula- tions, particularly in the early part of the rainy season. Amebic dysentery is most prevalent in the northern territories. The highest incidence is encountered in the southern part of Ubangi-Shari and in the thickly settled areas in the Lake Chad and the Chari River regions. Epidemics of bacil- lary dysentery are numerous, but the in- cidence cannot be determined, since most cases are not seen by medical officers. Mixed bacillary and amebic infections are com- mon. Shigella paradysenteriae is apparently the predominating organism in the small percentage of cases in which the diagnosis is confirmed by laboratory examinations. The relative frequency of observed amebic and bacillary infections is suggested by the fact that 10,220 cases of amebic dysentery were reported from French Equatorial Africa in 1946, as against 844 cases of bacil- lary dysentery. Typhoid and Paratyphoid Fevers. Ty- phoid fever is endemic, but only sporadic cases are reported. An average of from 5 to 15 cases is diagnosed annually by the Insti- tut Pasteur de Brazzaville. Immunization by means of typhoid-paratyphoid vaccine is employed extensively among the white resi- dents. Salmonella infections are widely dis- tributed. Shellfish and other foods are fre- quent sources of infection. Helminthiases. ANcyLosToMIasIs. Hook- worm infection is encountered in all parts of the country, except in the northern desert regions. The prevalence averages 30 per cent but reaches 100 per cent in many villages. Ancylostoma duodenale and Necator amer- icanus exist simultaneously in most areas. In heavily infected localities, hookworm in- fections probably contribute to the high mortality among young children. ScuisTosomiasis. Schistosomiasis occurs in numerous foci, primarily in the territories of Chad and Ubangi-Shari. The infection rates range from 25 to 80 per cent. Schis- tosoma haematobium is widely distributed, and predominates in the Lake Chad region and in the basins of the Chari and the Logone rivers. S. mansoni is also present in Ubangi-Shari and Chad but absent in the other territories. Important foci are found in the vicinity of Fort Archambault and N’dele and in the basin of the Gribingui River. Intestinal schistosomiasis, apparently caused by S. haematobium intercalatum, is encountered along the Ogooué River in Gabon, especially between N’djole and Achouka. Of 4,887 cases of schistosomiasis treated in government institutions in 1946, 2,933 were recorded from Ubangi-Shari, 1,886 from Chad, 34 from Gabon and 15 from Middle Congo. The freshwater snails, Physopsis africana globosa and Bulinus (Pyrgophysa) forskalii, are probably the intermediate hosts of S. haematobium. Those of S. mansoni have not been identi- fied. OruErR HELMINTH INFECTIONS. From 50 to 100 per cent of the indigenous population harbors one or more species of intestinal parasites. Multiple infections are frequent, particularly among the tribes of the coast and the forest regions. In general, infec- tions with Ascaris lumbricoides are most numerous, and the incidence averages at least 30 per cent. Strongyloidiasis, enterobi- asis and trichuriasis are also recorded. The 376 French Equatorial Africa beef tapeworm, T'aenia saginata, is prevalent among native cattle, and human infections occur sporadically in the cattle-raising areas. The pork tapeworm, 7". solium, is restricted to the pig-raising areas, which are usually closely associated with the European settle- ments. Other Infections. Undulant fever is re- ported occasionally. Brucellosis is enzootic among the goats and the cattle in many areas, and human infections are probably frequent. Cholera has not been reported from French Equatorial Africa. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Little is known concerning the incidence of tuberculosis. The reported cases are those observed in the course of routine dispensary and mobile clinic ex- aminations and obviously do not represent the extent of infection. The disease appears to be increasing, particularly among the in- digenous populations in close contact with European civilization. It is most prevalent among the tribes along the coast and in the Congo and the Oubangui river valleys; it is least prevalent in the Lake Chad region. Pulmonary infections predominate, but bone lesions are observed frequently in the north. The insanitary and overcrowded living con- ditions, and poor nutrition and unhygienic habits of the people are conducive to the spread of the disease. A program for the im- munization of newborn infants with BCG vaccine is carried on in connection with the maternity services in Brazzaville. Tuberculosis is present among the cattle in some regions. Tuberculous lesions are found in roughly from 2 to 8 per cent of the cattle slaughtered in the abattoirs in Ubangi- Shari and Middle Congo. However, the hu- man infections of bovine origin are not thought to be extensive. Smallpox. Epidemics of smallpox break out at frequent intervals. Major epidemic foci exist in the Lake Chad region, which usually account for from 85 to 95 per cent of the total cases from the territories. Serious epidemics were recorded from Chad and the adjacent areas of Ubangi-Shari in 1944-45, in which almost 3,000 cases were reported, with a fatality rate of 27 per cent. Vaccination campaigns are undertaken by the different Services de la Santé Publique. Their success is limited by the difficulties of transportation and the opposition of the people in many areas. Meningitis. Widespread epidemics of meningococcus meningitis occur almost an- nually in scattered foci in Chad and Ubangi- Shari. Outbreaks normally coincide with the dry season and subside with the onset of the rains. The recorded cases, which fre- quently total several thousand, do not re- flect the true size of the epidemics, since the majority of cases are diagnosed in the late stages of the disease, and the mild in- fections are rarely brought to the attention of the medical officers. Extensive epidemics were reported in 1938 and 1943. In the former year over 5,000 cases were recorded with fatality rates of from 30 to 100 per cent in different localities. In 1943 the known cases totaled 2,440, or several times the normal incidence. Immunization of the populations in affected areas has been at- tempted by means of an antimeningococcus vaccine, prepared from local strains at the Institut Pasteur de Brazzaville. Other Infections. Pneumonia is preva- lent and may assume epidemic proportions in the period between the dry and the rainy seasons. Primary pneumococcus meningitis is common. Measles, whooping cough and mumps are endemic and sometimes epi- demic. Poliomyelitis and diphtheria are sporadic. Scarlet fever is relatively rare. DiseasEs SPREAD OR CONTRACTED CHIEFLY THROUGH CONTACT Venereal Diseases. Venereal diseases are widespread among both white and native populations. The incidence is not known but, based on the composite statistics of dis- eases treated in government institutions, the rate of venereal infections ranges from 4 to 15 per cent in different areas. Syphilis pre- 377 French Equatorial Africa dominates, being responsible for from one half to two thirds of the cases reported. Gonorrhea accounts for a large percentage of the remaining cases, but soft chancre and lymphogranuloma venereum are also com- mon. The highest incidence of syphilis is found among the. peoples of the coast and of the Lake Chad region. The customs and the traditions of many tribes promote the spread of the disease, which contributes to the high abortion and infant mortality rates. All types of venereal infections are preva- lent in the urban centers, where considerable promiscuity exists. Control measures are rendered ineffective by the fact that native patients seldom continue treatment after the most severe symptoms have subsided. Leprosy. Leprosy is widely distributed throughout this area. In recent years an attempt has been made to determine the extent of infection by means of village counts taken in the course of trypanosomi- asis surveys. The compilation of an accurate leper census is difficult, however, due to the lack of co-operation of many tribal chiefs and the fear of detection on the part of the individuals. In 1946 there were 32,750 known lepers in French Equatorial Africa. The incidence varied among the different tribes. The infection rates averaged 0.43 per cent among the population visited in Chad; 0.8 per cent in Gabon; 1.6 per cent in Ubangi-Shari; and 2.1 per cent in Middle Congo.® In Gabon leprosy is highly endemic among the Bakobas and the Pahouins set- tled in the villages along the main road and the Ogooué River. The southeastern districts of Ubangi-Shari are also severely affected, and in some areas the incidence approxi- mates 8 per cent. In 1948 the government facilities for the isolation and the treatment of lepers in- cluded 31 leprosaria and one agricultural colony, which accommodated 2,789 and 670 patients, respectively. Leper colonies are also maintained by mission organizations. Yaws. Yaws is one of the principal dis- eases affecting the indigenous populations of the forest and the Haut Chari regions. The infection rates are highest among young children. The disease is relatively infrequent among the sedentary tribes of the Lake Chad area and is absent among the pastoral peoples in the north. Diseases of the Skin. Tropical ulcers are common among the natives, particularly in the humid forest regions. The lesions are sometimes serious; when neglected, they may result in fatalities due to septicemia or gangrene. Fungus infections of various types are numerous. Infestations with Tunga penetrans and with Sarcoptes scabiei, which is often associated with a condition known locally as craw-craw, are wide- spread. Outbreaks of impetigo sometimes spread among the residents of port towns from passengers infected on coastwise vessels. Other Infections. Cases of human rabies are reported frequently. Antirabic vaccine, prepared according to the method of Fermi at the Institut Pasteur de Brazzaville, is distributed through depots at Bangui, Fort Lamy, Fort Archambault, Pointe Noire, Libreville and Port Gentil. Trachoma is prevalent in the Lake Chad area and in the settlements along the main trade route from the Congo River through Bangui. Conjunctivitis, due to the effect of the dry, sand-laden winds, is general in the north during the kiarmattan season, and serious complications are frequent. Tetanus is reported occasionally; the majority of cases are umbilical infections of the newborn. Anthrax is enzootic among the livestock, and human infections are prob- ably numerous. Cases of leptospirosis are observed from time to time. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is pre-eminent among the causes of sickness and death. It is hy- perendemic in the lowlands of the coast, in the forest region and in the valleys of the larger rivers. It varies in intensity in the plateau country and is absent only at eleva- tions of over 4,000 feet. Probably 50 per cent of the children are infected before two 378 French Equatorial Africa years of age, and from 90 to 100 per cent before the age of ten. Many adults develop a high degree of resistance to the disease, but under conditions of poor nutrition re- currences are common. In studies reported in 1942 of representative population groups, the parasite indices ranged from 57 to 85 per cent in Gabon; from 53 to 99 per cent in Middle Congo; and from 31 to 84 per cent in Ubangi-Shari; and approxi- mated 39 per cent in southern Chad. Clas- sification by age showed an average parasite index of about 59 per cent among children under 2 years of age; 71 per cent in chil- dren from 2 to 5 years; 55 per cent in chil- dren from 5 to 10 years; and 44 per cent in children from 10 to 15 years. In the north in the Kamen region, where conditions are less favorable to anopheline breeding, the parasite rates average from 4 to 10 per cent, and the spleen rates, from 20 to 40 per cent. Plasmodium falciparum predominates and is responsible for at least three quarters of the total infections. P. vivax accounts for from 5 to 22 per cent of the infections, de- pending upon the locality. It is encountered most frequently in the region around and north of Lake Chad. The proportion of P. malariae infections is relatively low. They are observed chiefly among young children in limited foci in the south. Malaria-control programs are carried on in the urban centers and among certain re- stricted agricultural and industrial groups. Chemical prophylaxis is extensively em- ployed. Antianopheline measures are un- dertaken in Brazzaville, Pointe Noire and the larger cities but are impractical outside of the urban areas. Anopheles gambiae and A. funestus are the principal vectors. Blackwater fever occurs sporadically, primarily in the white populations. Trypanosomiasis. Human trypanoso- miasis, caused by Trypanosoma gambiense, is prevalent in the regions south of Lake Chad, where the tsetse fly vectors breed abundantly along the banks of the numerous rivers and streams. It was formerly epi- demic over extensive areas, but active con- trol programs within the last two decades have been effective in controlling the spread of the infection and in reducing the level of endemicity. However, scattered foci of high incidence persist. The disease is distributed irregularly. In 19468 the infection rates varied in different villages but averaged 4 per cent in Middle Congo, 2 per cent in Gabon, 1 per cent in Ubangi-Shari and 0.5 per cent in Chad. A survey of old foci in Epena, Impfondo and Dongou districts along the lower Oubangui River in 19472 showed infection indices which ranged from 7 to 13 per cent. In Gabon the greatest prevalence is found in the district of I’Estuaire and in the region traversed by the Ogooué River. In Chad, the territory least affected, the disease was con- fined to the settlements along the banks of the Chari and the Logone rivers. The treatment of the human reservoir is the basis of the sleeping sickness control program, which was started as an independ- ent service (Mission permanente de pro- phylaxie de la maladie du sommeil) in 1925-26 and eventually was incorporated in the Service Général d’Hygiene Mobile et Prophylaxie. The villages are visited at fre- quent intervals by survey and treatment teams, and the serious cases are transferred to special segregation camps. In 1948 the Service maintained 40 sleeping sickness hos- pital units with an aggregate capacity of 3,415 beds. The trypanosomiasis-control program has been most successful in the savannah areas where the tsetse fly popula- tion is restricted by the development of agricultural clearings around the native villages. Glossina palpalis is the principal vector, but G. tachinoides predominates in the Lake Chad region. A conference of tech- nical representatives of the major colonial powers was held at Brazzaville in 1948, in which plans for collaboration in sleeping sickness and tsetse fly control between the different colonies were projected. Yellow Fever. Scattered cases of yellow fever are reported almost annually, pre- dominantly among the white residents. Eight cases were diagnosed in Gabon in 1941, two in Chad in 1943, and four in the mining areas of eastern Ubangi in 1946. Protection test surveys have demonstrated immunity? 3% against yellow fever virus in a large percentage of the individuals tested in widely separated areas in French Equa- torial Africa. Protective antibodies were found in the blood of children in some local- ities, particularly in the coastal region and in the Oubangui River basin. Outbreaks ap- parently have occurred from time to time among the indigenous populations, the most extensive being along the main traffic routes to the east. Immunity has also been dem- onstrated among monkeys in the Mouyondzi region. Campaigns for immunization against yel- low fever are carried on each year. Immuni- zation of the white population was made compulsory in 1944. Vaccine is prepared for distribution in the French territories at the Institut Pasteur at Dakar, according to the method introduced by Peltier and his col- laborators. The urban vector, Aedes aegypti, is widespread, and anti-Aedes measures are enforced in the larger cities. In 1946 the Aedes indices ranged from 0.4 per cent at Brazzaville to 14 per cent at Port Gentil. Rickettsial Infections. Present evidence suggests that several rickettsial fevers may be endemic in this region. Both murine and tick typhus are known to be present. Spo- radic cases of murine typhus are reported from the Congo River area. Formerly many of these were undoubtedly classified as “Congolese red fever.” Seasonal outbreaks of an apparent murine typhus are also re- corded each year among certain Moslem tribes of the savannah region. The epi- demics are associated with periods of maximum contact between man and the field rodents, namely, during the weeks de- voted to the burning of the bush and to planting. Rodents are regarded as a food delicacy by these tribes, and some infections may result from contact during the dressing of diseased animals. The fatality rates of French Equatorial Africa 379 this infection, known locally as “maladie des bougbous,” are relatively high. Occasional cases of tick-borne typhus are observed in the Congo River basin which are probably transmitted by the dog-tick, Rhipicephalus sanguineus. They are usually seasonal in distribution and appear during the rainy season between November and June. The disease differs in minor respects from the classical fiévre boutonneuse and the designation ‘“‘congolaise” has been sug- gested by the workers at the Institut Pasteur de Brazzaville.?¢ Epidemic louse-borne typhus has not been reported. Cases of “Q” fever have been de- scribed from Bangui. Relapsing Fever. Tick-borne relapsing fever exists in numerous foci along the major traffic routes where the tick vector, Ornithodorus moubata, infests the native huts and “rest houses.” The reported cases vary in any one year from 30 to 1,500 or more, and the actual incidence is probably several times greater. Epidemics of louse-borne relapsing fever have been recorded from the Lake Chad area, but none within recent years. Filariasis. Filariasis is prevalent. All forms are encountered with a characteristic geographic distribution. Infections with Wuchereria bancrofti are common in the coastal region and in limited foci in Chad. Acanthocheilonema perstans and Loa loa are apparently widespread, the latter pri- marily in Gabon, Middle Congo and the Chari basin. Onchocerca volvulus is found in scattered foci in Middle Congo, Gabon and Ubangi-Shari where the vector, Simu- lium damnosum, breeds abundantly in certain swiftly flowing streams. Other Infections. Dengue fever is en- demic. Sandfly, or pappataci, fever is re- corded occasionally. Cutaneous leishmania- sis occurs sporadically in the region north of Lake Chad. Guinea worm, or Dracunculus medinensis, infections are frequent in the Chad region. Plague has not been reported, and rat-control measures are enforced in the port towns. 380 French Equatorial Africa NuTtriTiIONAL DISEASES The standards of nutrition are low, and chronic undernutrition and avitaminosis are more or less general. Outbreaks of beriberi are reported sporadically, but evidence re- garding the relative incidence of other nutri- tional diseases is lacking. Serious vitamin B deficiencies are most numerous among the cassava-eating tribes. Goiter is encountered in some localities in the Lake Chad region, particularly near the Mayo-Kebbi and the Logone rivers. SUMMARY French Equatorial Africa is a federation of four territories characterized by marked differences in climatic conditions, in natural resources and in the racial composition of the populations. It is a thinly settled coun- try in which development has been retarded by lack of communication facilities and capital resources. Health and medical facili- ties are provided by the territorial Services de la Santé Publique and are co-ordinated by the Direction Générale de la Santé Pub- lique, with headquarters in Brazzaville. The federal and territorial services are super- vised by the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer in Paris. The services for the control of specific diseases are centralized in the Service Général d’Hygiéne Mobile et Prophylaxie, an autonomous organization under the Direction Générale de la Santé Publique. In 1948 the government operated 5 central hospitals, 3 regional hospitals and 44 medical centers with a total capacity of 219 beds for white residents and 3,530 beds for the native populations. It also main- tained 182 rural dispensaries and infirma- ries, and various special medical facilities scattered throughout the territories. Nu- merous Catholic and Protestant missions carry on medical work in the southern terri- tories. Water supplies vary in distribution but are usually adequate in the south and scarce in the north. Community sources are derived from streams, lakes and wells and differ widely in purity and potability. The methods of sewage disposal are primitive, and the standards of sanitation are generally low. Undernutrition and nutritional defi- ciencies are common. Malaria, trypanosomiasis, dysentery, hel- minthiases, leprosy, yaws, tuberculosis and venereal diseases are prevalent. Outbreaks of smallpox, meningococcus meningitis and pneumonia are frequent. Relapsing fever, schistosomiasis, rickettsial infections, mea- sles and whooping cough are endemic. Dra- contiasis, onchocerciasis and brucellosis are common in localized areas. Yellow fever occurs sporadically, and immunity is ap- parently widespread. Human rabies, tra- choma, diphtheria and poliomyelitis are encountered occasionally. Scarlet fever is rare. Plague has not been reported. BIBLIOGRAPHY 1. Beaudiment, R.: La protection de la mater- nité et de 'enfance dans les colonies fran- caises en 1936, Ann. méd. pharm. col. 36: 148-240, 1938. 2. Beeuwkes, Henry, Mahaffy, A. F., Burke, A. W., and Paul, J. H.: Yellow fever pro- tection test surveys in the French Came- roons, French Equatorial Africa, the Bel- gian Congo and Angola, Tr. Roy. Soc. Trop. Med. & Hyg. 28:233-258 (Nov.) 1934. 3. Bruel, Georges: La France Equatoriale Africaine. Paris, Larose Editeur, 1935. 4 Cartron: Le pian et sa répartition dans les colonies francaises, Ann. méd. pharm. col. 35:5-73 (Jan.-Mar.) 1937. Davey, T. H.: Trypanosomiasis in British West Africa, London, Colonial Office, H.M. Stationery Office, 1948. 6. Eboué, Felix: Discours en conseil d’adminis- tration, Afrique equatoriale francaise (Afrique francaise libre), November, 1942, Trop. Dis. Bull. 40:412 (May) 1943. 7. France. Ministére de la France d’Outre-Mer, Direction du Service de Santé Colonial: Situation sanitaire de l’empire francais, tableaux statistiques 1941-1945, Marseille, Imprimerie LeConte, 1947. wn French Equatorial Africa 381 8 10. 11. 12. 13. 14. 13. 16. 17. 18. 19. 20. 21. 22. 23, _ : Rapport sur la situation sanitaire dans les territoires francais d’outre-mer pendant année, 1946. Gaud, Maurice: The rickettsioses in Equa- torial Africa: Congolese red fever, Bull. W.H.O. 2: No. 2, 257-271, 1949. Grosfilez and LeFevre: Les maladies trans- missibles observées dans les colonies fran- caises et territoires sous mandat pendant Pannée 1938, Ann. méd. pharm. col. 38: 183-359 (Apr., May, June) 1940. Kolochine-Erber, B., and Stefanopoulo, G. J.: A propos d'une enquéte sur les leptospi- roses en Afrique équatoriale francaise, Bull. Soc. path. exot. 32:919-923 (Dec. 13) 1939. Lalonel, J.: La trypanosomiase dans le Bas- Oubangui de 1907 a 1948, Bull. Soc. path. exot. 42:229-238 (No. 5-6) 1949. Lavier, G.: La lutte contra les glossines, Ann. méd. pharm. col. 37:27-40 (Jan.) 1939. La pathologie des bilharzioses a Schistosoma haematobium et S. mansoni a la lumiére des travaux récents, Ann. méd. pharm. col. 37:5-26 (Jan., Feb., Mar.) 1939. Ledentu, Médecin colonel: Le paludisme en Afrique équatoriale francaise, Bull. Office Internat. d’hyg. pub. 34:24-51 (Jan.-Mar.) 1942. Le Fuente, M.: Les parasites intestinaux au Gabon, Bull. Soc. path. exot. 41:588-591 (Oct.) 1948. Le Gac, P.: Etude préliminaire sur les typhus de I'Oubangui-Chari (Afrique équatoriale francaise), Ann. méd. pharm. col. 38:5-13 (Jan., Feb., Mar.) 1940. ——: Recherches sur les typhus de savanes de 'Oubangui-Chari. La maladie des Boug- bous, Bull. Soc. path. exot. 39:97-103 (Mar.-Apr.) 1946. Margat, C.: Note sur l'alimentation de la population indigéne dans le departement de I’Ogooué-Maritime, Bull. Soc. path. exot. 38:163-173 (May-June) 1945. Marque: Le trachome dans les colonies fran- caises, Les grandes endémies trop. 10: 98-114, 1938. Montagne: La bilharziose urinaire, Les gran- des endémies trop. 5:94-110, 1933. Moustardier, G.: Sur un cas de fiévre typho- exanthématique observé en A.E.F., Rev. sci. méd. pharm. vét. de I'Afrique fran- caise libre (Brazzaville) 1:21-28 (Oct.) 1942. Pales, L.: Geographie médicale du Tchad, Les grandes endémies trop. 9:33-54, 1937. 24. Pons, René: L'ulcére phagédénique des pays chauds, Les grandes endémies trop. 7: 135-146, 1935. 25. Protection de la maternité et de l’enfance indigenes dans les colonies francaises en 1938: Ann. méd. pharm. col. 38:46-95 (Jan., Feb., Mar.) 1940. 26. Rapport sur le fonctionnement technique de I'Institut Pasteur de Brazzaville en 1945, Brazzaville, 1946. 27. Rapport sur le fonctionnement technique de I'Institut Pasteur de Brazzaville en 1946, Brazzaville, 1947. 28. Rapport sur le fonctionnement technique de I'Institut Pasteur de Brazzaville en 1947, | Laval (France), Imprimerie Barneoud, 1950. 29, Saleun, G., and Ceccaldi, J.: Epreuves de | séro-protection en Afrique équatoriale francaise. Contribution a I’étude de la spécificité du test, Bull. Soc. path. exot. 30:49-57 (Jan.) 1937. , and Palinacci, A.: Un cas de fiévre exanthématique en A. E. F. Bull. Soc. | path. exot. 31:555-550 (July) 1938. Sorel, F. P. J.: Essai de démographie des colonies francaises, Bull. Office internat. | dhyg. pub. 30:1-21, Suppl. 2, 1938. 32. : Prophylaxie de la léepre dans les colo- | nies francaises, Bull. Office internat. d’hyg. pub. 30:1-21, Suppl. 6, 1938. 33. : La méningite cérébro-spinale dans les | colonies frangaises d'Afrique en 1937, | Bull. Office internat. d’hyg. pub. 30:1546- 1555 (July) 1938. 34. | ——: La méningite cérébro-spinale dans les colonies francaises d’Afrique. Epidémie de 1935-1936 en Afrique équatoriale fran- | caise, Ann. méd. pharm. col. 35:144-156 (Jan.-Mar.) 1937. 33, Stefanopoulo, G. J.: Resultats fournis par | Papplication du test de séro-protection contre le fievre jaune sur les indigenes de l'Afrique équatoriale francaise (juillet il 30. 31. 1932-janvier 1936), Ann. méd. pharm. col. 35:74 (Jan.-Mar.) 1937. Terrier, Auguste: Histoire des Colonies Fran- | caises et de 'Expansion de la France dans le Monde. Afrique Equatoriale Frangaise, Paris, Libraire Plon, 1931. 37. Vogel, E., and Riou, M.: Les maladies epi- démiques, endémiques et sociales dans les | colonies francaises pendant l'année 1937, Ann. méd. pharm. col. 37:257-551 (Apr.) 1939. 36 26 Spanish Guinea (Rio Muni and Fernando Poo) GEOGRAPHY AND CLIMATE The territories collectively known as Spanish Guinea incorporate two main divi- sions: Rio Muni, an enclave of some 9,500 square miles between Gabon in French Equatorial Africa and the Cameroons; and Fernando Péo, an island of approximately 800 square miles in the Bight of Biafra, off the coast of Nigeria. Four lesser islands, Annoboén, Corisco, Elobey Grande and Elo- bey Chico, which range in size from 20 to 30 acres to 7 square miles, are included with continental Guinea. In Rio Muni, branches of the Crystal Mountain chain rise from a narrow coastal plain to a general elevation of 4,500 feet and form the western edge of the central pla- teau, which extends inland toward the Congo basin. The Rio Benito, the largest of several rivers flowing to the Atlantic, drains at least two thirds of the colony. The entire continental area lies within the tropical rain forest. The vegetation is luxuriant, while dense mangrove swamps border the coast. Fernando Péo, which forms an integral part of the Cameroon Mountain range, contains volcanic peaks of from 4,000 to 10,000 feet. The island is densely forested and includes some of the most fertile country on the west coast of Africa. The climate of Rio Muni is equatorial. The mean temperature is 88° to 92° F. with minor seasonal and daily variations, and the relative humidity is 85 to 95 per cent. Rain and cloudiness are common throughout the year, but the maximum pre- cipitation is concentrated in two rainy sea- sons, from September to December and from February to May. The annual rainfall aver- ages 100 inches. On Fernando Pdo the mean temperature approaches 78° F. with fluctu- ations from 65° F. to 98° F. The main rains occur in the months from May to Novem- ber, but occasional heavy rains are ex- perienced during the rest of the year. The rainfall approximates 120 inches a year in the north and 200 inches in the south. Tor- nadoes occur frequently during September and October, toward the end of the rainy season, POPULATION AND SOCIO-ECONOMIC CONDITIONS PorPuLATION No complete census has been undertaken in the Colony. The resident population in 1942 was estimated at about 170,600: 134,000 in Rio Muni proper, 34,000 on Fer- nando Pédo, 1,460 on Annobdén and 900 on the lesser islands. The European residents totaled 3,319 on Fernando Pdo and 805 in continental Guinea. They are chiefly gov- ernment officials, planters and traders and vary in number from year to year. The majority are Spanish, with Portuguese pre- dominating among the foreign nationals in the territory. The indigenous population of Rio Muni is composed of several different tribes, all of Bantu origin. The Pamtes, members of the Fang group, known as Pahouins in the neighboring French territories, comprise 382 Spanish Guinea 383 nearly 90 per cent of the total. The Bengas, the principal tribal division of the coastal region, also inhabit the smaller islands. Small communities of aboriginal Pygmies persist in the northern forests near the Campo River, where they dwell in a primi- tive state, untouched by civilization. In addition to the native dialects, a small per- centage of the inhabitants speak Spanish. Relatively few, however, are literate. On Fernando Péo, various half-caste peoples, locally known as “Portos,” inhabit the coastal region, while the less civilized abo- riginal tribes, the Bubis, dwell in the interior. The Portos are largely descendants of liberated slaves or of imported laborers from Sierra Leone, Gold Coast or Liberia and show strong admixtures of Spanish or Portuguese blood. Spanish is the official language, but a form of pidgin English is widely used as a medium of trade. The native tribes are predominantly pagan. Roman Catholic and Protestant missions are established in Rio Muni and Fernando Pé6o, and small percentages of Christians are found in both areas. The population density of Rio Muni aver- ages from 11 to 15 per square mile, while that of Fernando P6o approximates from 35 to 40 per square mile. The small islands of Annobé6n and Elobey Grande have den- sities of from 175 to 200 per square mile. Santa Isabel, on Fernando Pdo, is the seat of government for the Colony. It is a com- mercial center with roughly 4,000 inhabit- ants, including about 1,000 white residents. Bata, the chief town and administrative headquarters of Rio Muni, has a popula- tion of about 3,000, of whom less than 100 are Europeans. Schools providing elemen- tary and agricultural education are main- tained in the population centers by the Spanish government and by Catholic and Protestant mission organizations. VITAL STATISTICS No valid vital statistics are available for Rio Muni or Fernando Péo. Birth and death rates are computed annually for the white residents, sections of the population which are small and not representative in composi- tion. In 1943 the European birth rate was 24.1 per 1,000 on Fernando Péo and 17.5 in continental Guinea; the death rates were 9.6 and 13.7, respectively. Statistics are almost completely lacking for the indige- nous populations. The estimated mortality rates approximate from 50 to 60 per 1,000 population. In general, the superstitions and the unhygienic habits of the people and the prevalence of malaria and various social diseases contribute to high infant mortality and death rates. Sociar Economy The economy of both Fernando Péo and Rio Muni is essentially agricultural. Large plantations have existed on Fernando Péo for many years, but until the second decade of this century, only a few were established on the coast in continental Guinea. In 1943 about 26 per cent of the land in Fernando Péo was planted in commercial crops, while in Rio Muni less than 0.2 per cent was simi- larly cultivated. Cocoa, the principal crop on Fernando Pdo, is grown on estates lo- cated chiefly around Santa Isabel and San Carlos. Secondary exports include coffee, palm oils and insignificant amounts of bananas, latex and copra. Coffee is the most valuable crop of Rio Muni. It is produced both on European-owned plantations and by the peasant farmers. Cocoa is grown by the Pamues in the northeast corner of the terri- tory. Palm oils, yucca, coconuts and kola nuts are minor products. Tropical woods constitute an important source of wealth in Rio Muni. Industrial development is handicapped, however, by a shortage of labor supply and by lack of transportation facilities. Rich reserves of minerals have been located in the mainland but have not yet been worked. Communication facilities are poor in Rio Muni, except in the districts along the coast and the main rivers. Large portions of the interior are relatively inaccessible. The ports of Santa Isabel and San Carlos on 384 Spanish Guinea Fernando Pdo, and Bata on the continent have steamer connections to Europe and the adjacent African territories. Air service is also available from Bata and Santa Isabel to various continental points. Foop AND NUTRITION The diets of the various tribes consist largely of bananas, cassava and malanga (a farinaceous root), supplemented by nu- merous wild fruits and vegetables. The methods of cultivation are primitive and generally destructive. Few cattle or other domestic animals are kept in Rio Muni, due to the prevalence of tsetse flies and trypano- somiasis. Meat forms a negligible part of the average dietary. However, good grazing lands are found on Fernando Péo. Housing The native villages are built in clearings in the jungle and usually consist of from 30 to 40 huts surrounding a central palaver house. The individual huts are rectangular and are constructed of palm branches, bamboo, bark or clay, depending upon the region and the tribe. All are primitive and they are apt to be infested with vermin and rodents. The white residents live apart in homes which resemble, in many respects, those found in Europe. On the plantations the laborers are housed in compounds, but con- ditions vary in different areas. ENVIRONMENT AND SANITATION There are no modern sanitary facilities, either on Fernando Po or in continental Guinea. Water supplies are obtained from wells, streams or springs and are all subject to pollution. The vectors of disease and the reservoir hosts are identical with those found in the adjacent areas of the Came- roons and Gabon. Anopheles gambiae is the principal vector of malaria. 4. funestus and, on the coast, A. gambiae melas are impor- tant secondary vectors. Glossina palpalis is prevalent and is the chief vector of human trypanosomiasis. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS The health and medical services in Spanish Guinea are operated by the Direc- cién del Servicio Sanitario Colonial, which functions under the Direccién General de Marruecos y Colonias in Madrid. The head- quarters organization, which is located at Santa Isabel on Fernando Podo, includes three branches: administrative, technical and pharmaceutical. The Colony is divided into 14 sanitary districts, served by 28 Colonial physicians who are responsible for the medical care of the populations, the control of communicable diseases, the con- duct of child welfare work and the supervi- sion of the health of immigrant laborers. MepicAL INSTITUTIONS Hospitals and Dispensaries. In 1950 the Direccion del Servicio Sanitario Colo- nial maintained 4 hospitals: 2 on Fernando Péo and 2 in Rio Muni. The largest, at Santa Isabel, had a capacity of from 200 to 230 beds and had medical, surgical, infec- tious disease, leprosy, mental and maternity sections. A smaller hospital, with a capacity of 50 beds, was located at San Carlos. The present hospital at Bata, the capitol of Rio Muni, was constructed in 1945 and has a capacity of from 100 to 150 beds. A hos- pital with about 50 beds is situated at Kogo, but also serves Benito. Dispensaries, with a few beds each for the care of serious cases, are established in the chief towns of each medical district. A hospital and village settlement for the care of lepers is located at Mikomeseng, and a hospital at Ebebiyin. Small hospitals are maintained by some of the plantation companies for the benefit of their workers. Laboratories. The technical branch of the Direccion del Servicio Sanitario Colonial, which is housed in the Instituto de Higiene in Santa Isabel, undertakes research investi- gations and chemical, bacteriologic and pharmaceutical examinations for the hos- Spanish Guinea 385 pitals on Fernando Pdo. Clinical laboratory facilities are also available in the hospitals and the dispensaries in Rio Muni. The construction of a hygienic laboratory and research institute, to be affiliated with the Instituto Espanol de Medicina Colonial in Madrid, is planned for the near future and will replace the present outmoded In- stituto de Higiene. PERSONNEL In addition to the 28 physicians of the Colonial health services, medical assistants and male nurses are employed in the hos- pitals and the rural dispensaries. The hos- pitals are managed by nursing sisters of religious orders. DISEASES The hospital and dispensary statistics give little indication of the actual incidence of specific diseases in Spanish Guinea. Ex- cept in the case of special investigations, the proportion of cases seen by the medical officers is relatively small, due in part to the lack of medical facilities in the more remote districts and in part to the influence of the tribal medicine men. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Dysentery. Amebic dysen- tery is one of the most prominent diseases reported from the hospitals and the regional dispensaries and apparently predominates among the recognized intestinal infections. Specific reports regarding the prevalence of bacillary dysentery and typhoid and para- typhoid fevers are lacking, but infections are undoubtedly common, in view of the low standards of sanitation prevailing through- out the country. Helminthiases. ANcyrLosToMmIasis. Hook- worm infection is widespread and affects the entire population in many villages. The majority of cases are caused by Ancylo- stoma duodenale, but Necator americanus occurs concurrently in many areas. The dog hookworm, Ancylostoma brasiliensis, is common. OtuER HELMINTH INFECTIONS. Ascariasis is prevalent, and severe, massive infections are frequent. Strongyloidiasis is next in im- portance, although trichuriasis and entero- biasis are also encountered. Schistosomiasis has not been reported. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. The incidence of tubercu- losis is not known. The infection is widely distributed, particularly among the tribes in the European plantation areas. Cases of tuberculosis are reported from all the dis- tricts, with the greatest number from the Niefang area of northwestern Rio Muni. Pulmonary infections predominate, but other forms of tuberculosis are also encoun- tered. A tuberculosis-control program has recently been undertaken in Santa Isabel, which incorporates the immunization of the population with BCG vaccine. Preliminary studies indicate that about 50 to 60 per cent of the inhabitants react negatively to tuber- culin. Smallpox. Sporadic outbreaks of small- pox are reported. A systematic vaccination program is carried on by the health author- ities among the indigenous populations and the laborers imported for the plantations. The incidence is normally low. Other Infections. Pneumonia and upper respiratory infections are prevalent, partic- ularly on the islands of Fernando Péo and Annobén. Epidemics of meningococcus men- ingitis occur sporadically, most frequently in the labor camps. Epidemics of measles and chickenpox are common. Diphtheria and poliomyelitis are endemic, and occasional cases are reported. Scarlet fever is rare. Diseases SPREAD OR CONTRACTED Cuierry THROUGH CONTACT Venereal Diseases. A large proportion of the native population suffers from vene- real infections. Gonorrhea, the most gen- eral, is an important cause of sterility among 386 Spanish Guinea both men and women.? Syphilis is also wide- spread. It is foremost among the diseases treated in regional dispensaries, both on Fernando Pdo and on the continent. Lym- phogranuloma venereum is reported occa- sionally. Leprosy. Leprosy is endemic in Rio Muni and sporadic on Fernando Péo. In 1949 the number of lepers in the colony was estimated at between 4,000 and 5,000. A modern leper settlement and hospital is established at Mikomeseng, with facilities for the care of 850 patients. A second hos- pital has also been started at Ebebiyin, near the Gabon border, which will form the nu- cleus for a future leper colony. Yaws. Yaws is widely distributed, with infection rates approaching 90 to 100 per cent in many parts of continental Guinea. Diseases of the Skin. Mycotic infections and phagedenic, or tropical, ulcers are prev- alent. Cases of Madura foot are observed occasionally. Scabies and craw-craw, a skin disease of uncertain etiology, are general. Creeping eruption, caused by the larvae of the dog hookworm, Ancylostoma brasilien- sis, is frequent in many areas. Human myiasis occurs sporadically. Other Infections. Tetanus is common. A few deaths are recorded each year among the native laborers, especially on Fernando Péo. Tetanus neonatorum is not reported but is undoubtedly frequent. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is hyperendemic in most portions of the Colony, and the ma- jority of inhabitants acquire the infection in early childhood. Splenic indices of almost 100 per cent have been demonstrated among infants under one year of age in Santa Isabel and other localities on Fernando Péo. A high degree of immunity is encountered among the adults, but relapses are experienced from time to time. Plasmodium falciparum infec- tions predominate, while P. vivax and P. malariae are of minor importance. Anoph- eles gambiae and A. funestus are the prin- cipal vectors. Trypanosomiasis. African sleeping sick- ness, caused by Trypanosoma gambiense, was formerly prevalent throughout the Colony, particularly on Fernando Péo and in the southwestern part of Rio Muni. How- ever, an active treatment program has been carried on by the health authorities over a period of almost 20 years, with an apprecia- ble decline in incidence. In 1949 about 205 cases were reported, in contrast with 6,000 to 7,000 cases in 1930-31. The infection rates on Fernando Pdo in 1944 averaged 0.9 per cent and ranged from 0.4 per cent in the Basakato Este sector to 1.7 per cent in that of Conception. In continental Guinea the infection rates approximated 0.15 per cent but were negligible in all the sectors except Rio Benito and Kogo, where they averaged 0.3 and 0.7 per cent, respectively. Filariasis. Filariasis is endemic. The rela- tive incidence is uncertain, but both Wuche- reria bancrofti and Loa loa infections are frequent. Acanthocheilonema perstans is widely distributed. Onchocerciasis exists in limited foci. Yellow Fever. Cases of yellow fever are reported occasionally. Following an out- break in the Bata, the Benito and the Kogo sectors of Rio Muni in 1941, an immuniza- tion campaign was initiated by the health authorities among the European residents and the native populations in the affected areas. Aedes aegypti and other potential vectors are abundant throughout this region. Other Infections. Dengue fever is en- demic. Dracontiasis, or guinea-worm infec- tion, is encountered sometimes. SUMMARY The colony of Spanish Guinea consists of two divisions: the island of Fernando Pdo, and the territory of Rio Muni, which with several lesser islands comprise continental Guinea. It is administered from Santa Isabel in Fernando Péo, under the jurisdiction of the Direccién General de Marruecos y Colo- nias in Madrid. Responsibility for the health and medical care of the inhabitants resides in the Direccién del Servicio Sanitario Colo- Spanish Guinea 387 nial, with headquarters in Santa Isabel. In 1950 the Direccion operated two hospitals with a combined capacity of from 250 to 280 beds on Fernando Pdo and two hospitals with a capacity of from 150 to 200 beds in Rio Muni. Small private hospitals are also established on the larger plantations for the care of the employees. Sanitary conditions are primitive in all parts of the colony. Malaria and hookworm infection, amebic dysentery, syphilis, gonorrhea and skin dis- eases are the most frequent causes of illness. Yaws and leprosy are widespread, especially on the continent. Pneumonia and tubercu- losis are prevalent. Filariasis and human trypanosomiasis are endemic, although the latter infection is partially controlled by an active treatment program. Outbreaks of smallpox, meningococcus meningitis and yellow fever are sporadic. BIBLIOGRAPHY 1. Arbelo Curbelo, A.: La reaccién de Dick en los indigenas de los territorios espafioles del Golfo de Guinea, Med. colon., Madrid 1:280-281 (April) 1943. 2. Corada Redondo, Angel: Fiebre amarilla en Kogo (abril, ano 1941), Med. colon., Madrid 1:243-279 (April) 1943. 3. Denecke, Karl: Betrachtungen ueber Hiu- figkeit und Uerlauf von Krankheiten bei den Eingeborenen der Guineabucht (West- afrika), Arch. f. Hyg. u. Bakt. 126: No. 5-6, 331-348, 1941; Abst., Trop. Dis. Bull. 39:348-349 (May) 1942. 4. Fontan y Lobe, Juan: El Servicio Sanitario Colonial, Africa (Madrid), Rev. de accién espafiola, Ano 1 (Terca Epoca), Num. 8 (Aug.) 1942. 5. Gonzalez Vicente, D.: Estado actual de la tripanosomiasis humana en la zona sani- taria de San Carlos, Fernando Péo, Med. colon., Madrid 12:283-323 (Nov.) 1948; Abst., Trop. Dis. Bull. 46:124 (Feb.) 1949. 6. Lalinde Del Rio, E.: Organizaciéon sanitaria en los territorios espafioles del Golfo de Guinea, Med. Colonial (Madrid) 1:53-59, (Jan.) 1943. Abst., Trop. Dis. Bull. 41: 514-15 (June) 1944. 7. Spain: Boletin de Informacién, suplemento de la Revista “Africa,” No. 2, June, 1943. Secciéon Legislativa. III. Organizacién de los territorios espafioles del Golfo de Guinea. XII. Servicios sanitarios, Africa (Madrid) 18: (June) 1943. 8. ——: Direccion General de Marruecos y Colonias. Excmo. Sr. D. Juan Bonelli y Rubio. Notas sobre la geografia humana de los territorios espafoles del Golfo de Guinea. Geografia economica de la Guinea espafiola, Madrid, Teléf, 1944-45. 9. ——: Direcciéon General de Marruecos y Colonias. Prof. Dr. Valentin Matilla y Gomez. Una expedicién cientifica a la Guinea, Madrid, Imprenta, J. Cosano, 1945. 10. ——: Direccién de Marruecos y Colonias. Correspondence. (Dr. Ricardo Teresa Ro- bles, Medico de los Sanitarios de la Zona.) 11. ——: Negociado de estadistica del gobierno general de los territorios espafioles del Golfo de Guinea. Anuario estadistico de los territorios espafioles del Golfo de Guinea, 1942-1943, Madrid, Selecciénes Graficas, 1945. Patronato nacional antituberculoso. Benitez Franco, Bartolome. Tuberculosis. Estudio de la lucha contra esta enfermedad en Espafia (1939-49), Madrid, Saéz-Buen Suceso, 1950. 13. ——: Presidenta del gobierno. Instituto Nacional de Estadistica, Anuario estadis- tico de Espafia, 1948-49, Madrid, 1950. 14. Teran, Manuel, and Menendez-Pidal, Gon- zalo: Geografia histérica de Espaia. Marruecos y colonias, Madrid, Libreria Enrique Pbieto, 1943. 12. PPP PP PI »” ¢ rr PrP 27 Cameroons Cameroons (French) GEOGRAPHY AND CLIMATE The French territory of the Cameroons includes some 162,000 square miles of the former German colony, which were assigned to France under a mandate from the League of Nations in 1921. Since 1946 it has been administered by France under United Na- tions trusteeship. Except for a coastline of about 120 miles on the Gulf of Guinea, and common frontiers with Nigeria and the British Cameroons in the northwest, and with Rio Muni on the south, it is bounded by French Equatorial Africa and forms part of that geographic unit. Tropical forest covers the southern third of the country and projects northward in spurs along the banks of the larger rivers. The western frontier is dominated by a chain of volcanic mountains, which reach heights of from 4,000 to 5,000 feet in French territory and include the 13,353-foot peak of Mt. Cameroon in the British-mandated area. The mountains form the northern edge of the central plateau, which rises abruptly from a narrow coastal plain and slopes in terraces to the lowlands of the Congo River basin. The plateau has an average altitude of 2,000 to 3,000 feet and is traversed by numerous rivers, among which the Sanaga and the Nyong are the largest. Beyond the valley of the upper Benoue River, the highlands rise to the Mandara Mountains (4,000 feet) on the British border, and in the north and the east they slope to the plains of the Lake Chad basin. The climate is as varied as the physio- graphic character of the country. In general, it is subequatorial in the south, with two rainfall seasons, from September to Decem- ber and from February to May, interspersed by periods of relative dryness. However, in the northern coastal region which is domi- nated by Mt. Cameroon, there is only one long rainy season, with maximum precipi- tation from June to September, and a short dry period in December and January. The annual rainfall varies from about 155 inches in the vicinity of Douala to from 62 to 104 inches on the plateau. The severe storms which commonly precede and follow the rains are rarely encountered in the Mt. Cameroon area. The mean annual tempera- ture approximates 75° to 80° F., with vari- ations of 5° to 10° F. in the forest and the coastal regions, and of 10° to 30° F. in the savannah country. In the north the rainfall becomes concentrated into one season, which decreases gradually in duration to- ward the interior. In the Lake Chad region it averages from 30 to 50 inches annually, with the greatest precipitation in the months from June to October. The mean tem- peratures range from 70° to 90° F., while the daily variations are frequently marked, particularly during the karmattan season from November to March. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuULATION The population in 1946 was estimated at 2,816,000, including about 3,980 white resi- 388 Cameroons 389 dents. About two thirds of the white popula- tion, which is predominantly French, is settled in the districts around Douala and Yaoundé. The native inhabitants are divided into several ethnologic groups. The peoples of the forest region in the south are of Bantu origin and belong to numercus tribes among which the Doualas, the Yaoundés, the Bakokos, the Bamilékés and the Fangs are the most important. The indigenous tribes of the north are largely of Sudanic Negro stock, but many are dominated by groups of Bamouns or of Foulbés (Fulani). The country north of the Adamaoua high- lands is inhabited by Kirdis, Foulbés and Schoa Arabs. Small communities of Hausas are found in the larger towns throughout the country. Scattered bands of Pygmies also dwell in isolated portions of the equatorial forest. In general, the Bantu tribes of the forest and the pagan tribes of the north are the most primitive, while the Bamouns and the Foulbés control highly organized states or native “Sultanates.” Catholic and Protestant missions are es- tablished in the southern Cameroons and have exerted a considerable influence on the social development of the various tribes. In the north the Foulbés, the Arabs and the Sudanic peoples of the plains are Moslems, while the tribes of the mountains are pagans. Elementary and intermediate edu- cation is provided by the government in the larger towns. Schools are also operated by the missions, many of which are subsidized by the government, but the rate of illiteracy is high, and probably less than 15 per cent of the children are enrolled in schools of any type. The density of population averages about 17 per square mile but it exceeds 110 per square mile in some areas. The most thinly settled portions of the country are the forest regions of the southeast and the grasslands of the Adamaoua highlands. The highest population density is found in the north- west corner, in the region between Douala and Dschang. The plateau country around Yaoundé and the fertile plains of the Logone River basin in the north also support popu- lations of moderate density. The principal cities are Douala, the chief port and com- mercial center, and Yaoundé, the adminis- trative capital. Both have populations of from 45,000 to 60,000, including sizable communities of white residents. The seats of the native “Sultanates,” as Ngaoundéré, Foumban, Banyo, Galim and Tinguéré, are important towns and trading centers with permanent populations of from 10,000 to 20,000. VITAL STATISTICS No reliable vital statistics are available, although sample surveys have been made from time to time to assess the mortality rates in infancy and childhood. Theoreti- cally, registration of births and deaths has been compulsory since 1930, but the sta- tistics are incomplete and of little value in the absence of accurate knowledge regard- ing the size of the various population groups. In an analysis of surveys covering an aggregate population of 430,548 in 1936, the birth rate was calculated at 46 per 1,000 population, and the death rate at 42. The mortality in early childhood varies markedly among the individual tribes. In a demographic study published in 1938! the infant mortality in different racial groups was estimated at 18.6 per cent among the Bantu, 22.6 per cent among the Sudanic Negroes and 30.2 per cent among the Foulbés and the Hausas. The stillbirth rates were given as 6.7, 5.7 and 2.3 per cent, re- spectively ; the deaths before 3 years of age as 31.2, 36.7 and 40.2 per cent. The factors governing infants and maternal mortality are the same as in the adjoining territories: tribal customs, ignorance, undernutrition and disease. Polygamy is common to from 20 to 25 per cent of the population in the various racial groups. Sociar Economy The economy of the French Cameroons is primarily agricultural. The plantation sys- tem is highly developed, due partly to the 390 Cameroons favorable climatic and soil conditions in the coastal mountain regions of the northwest and partly to its promotion by the Germans in the early part of this century. Within recent years the French have encouraged native production and have introduced co- operative organizations to facilitate research and marketing, particularly among the cocoa cultivators and the cattle breeders. The more primitive peoples live by sub- sistence farming, but the Doualas and the tribes of the savannah country are active agriculturalists. Cocoa, coffee and bananas are grown extensively by both Europeans and natives in the northern coastal areas, frequently on large commercial plantations. Oil palms and wild rubber are found abun- dantly in the forest zone, where a few estates have been developed under Euro- pean ownership. Kola nuts also flourish in certain forest districts. Cotton is cultivated in the Benoue, the Faro and the Mayo Kebbi river valleys, while stock raising is a major industry on the Adamaoua plateau and in the Lake Chad region. Species of Cinchona are grown in extensive areas under the direction of the government’s agricul- tural services. Lack of transportation facili- ties has retarded the development of the timber resources of the equatorial forest. The mineral reserves have not been fully investigated, but as yet no economically rich deposits have been discovered. The communication facilities are limited outside of the coastal region. Trunk roads radiate from Yaoundé, linking the popula- tion centers with the larger towns in north- ern Nigeria and in the territories of French Equatorial Africa. Two short railway lines from Douala serve the principal agricultural areas: one to N’Kongsamba near the British border, and the other to Yaoundé and Mbalmayo on the plateau. Many of the rivers are navigable to small craft. Douala is the principal port for ocean traffic with the neighboring colonies and Europe, and air services are available both from Douala and Yaoundé. Foop AND NUTRITION The standards of nutrition vary among the different tribes. In general, cassava, sweet potatoes, yams, bananas, plantains and rice are staple articles of diet in the south; maize, millet, peanuts and legumes, in the savannah country. These are supple- mented by indigenous fruits, roots and leafy vegetables to a variable extent. Cattle are raised only in the northern districts, but goats and fowl are found in most villages. Pigs are common in the coastal region. Live- stock represent wealth, however, and are rarely used for meat by the poorer peoples. Game and fish, when available, provide the most frequent sources of animal proteins. Milk is scarce outside of the cattle-raising areas. Red palm wine is popular with many tribes and has considerable dietary value. Undernutrition and vitamin deficiencies are prevalent, but serious nutritional diseases are rare. Housine Primitive thatched huts of wood laths or mud are characteristic of the forest and the savannah regions. They vary in design ac- cording to the individual tribes; some are round, but the majority are rectangular with overhanging roofs. Long houses, partitioned off for several families, are found in some Bantu settlements. Some of the more pro- gressive tribes are gradually adopting Euro- pean ideas, and two-story dwellings of per- manent construction are frequently built by the chiefs and the wealthy natives. The lowland peoples dwell in small iso- lated communities, and the savannah tribes in large villages surrounded by cultivated fields. Fortified towns with houses of sun- dried brick, grouped in compounds, are common in the Sultanates of the north. The nomadic Bororos and Schoa Arabs live in tents, but many are settled in villages where they practice agriculture with the aid of irrigation. In the larger towns, as Douala, the Europeans dwell apart in modern resi- Cameroons 391 dential areas. Stucco, brick and tile are common building materials. ENVIRONMENT AND SANITATION WATER SUPPLIES Water supplies are derived from streams, lakes, wells and waterholes. They are ade- quate in the high rainfall areas of the south but frequently scarce and seasonal in the Lake Chad region. Urban water supplies serve Douala, Dschang and Yaoundé. The supplies of Douala and Dschang are treated by chlorination. The degree of supervision of the treatment plants varies, however, and the purity of the water is often unreliable. All village supplies are subject to pollution. WasTE DisposaAL The methods of sewage disposal are usu- ally primitive. Septic tanks are employed in the European quarters of the larger towns. Communal pit latrines are common in the native population centers, but sani- tary facilities are generally lacking in the tribal villages. Fauna AND FLorA The vectors of disease are essentially the same as those encountered under similar climatic and physiographic conditions in the adjacent territories of French Equatorial Africa and Nigeria. Anopheles gambiae is the principal vector of malaria. A. funestus is widespread and second in importance to A. gambiae in the transmission of the dis- ease. A. gambiae melas is a significant vector along the southern coast. Aedes aegypti is present in all parts of the country. Tsetse flies are widely distributed. Glos- sina palpalis, the principal vector of human trypanosomiasis, is found south of the Ada- maoua highlands, and G. tachinoides in the north. G. morsitans and G. longipalpis are present in scattered foci. All four species are responsible for the transmission of ani- mal trypanosomiasis in this area. G. fusca is reported from the forest region. Tsetse fly control measures are carried on in lim- ited areas. They consist primarily of bush clearance at the intersections of roads and infested streams and around important water places. Antitsetse fly measures have been most successful in the savannah coun- try where the villages are protected by fields under cultivation. Foob SANITATION Sanitary regulations are enforced in the larger towns. The supervision of markets and food establishments is the responsibil- ity of the local Services d’Hygiéne. The inspection of meats and slaughter houses is carried on by the veterinary services. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS The Direction de la Santé Publique ad- ministers the public health and medical services of the territory. Its activities are supervised by the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer in Paris. During the war period, 1940-45, the French Cameroons and the territories of French Equatorial Africa were united under the Free French, and their health services were combined under the Direction Générale de la Santé Publique in Brazzaville. The headquarters of the Cameroons health organization is located at Yaoundé. It is responsible for the control of epi- demics, the supervision of urban and rural sanitation, the conduct of the hospitals in Douala and Yaoundé, the maintenance of laboratory and educational facilities, and the institution of measures for the protec- tion of the health of children, laborers and other special population groups. Subordi- nate medical units (Assistance Médico- Sociale Indigéne) operate rural hospitals, health centers and other facilities for the care of the native populations in the admin- istrative divisions throughout the territory. In Douala and Yaoundé, public health 392 Cameroons measures are enforced by the municipal Services d’Hygiéne. Special services for the control of leprosy and trypanosomiasis are centralized in the Service d’Hygiéne Mobile et Prophylaxie, which functions under the Direction de la Santé Publique. Several Catholic and Protestant mission organizations support medical and mater- nity and child welfare programs and carry on extensive work among the lepers. MEepICAL INSTITUTIONS Hospitals and Dispensaries. The gov- ernment medical facilities are administered by the Direction de la Santé Publique. In 1948 it maintained 4 central hospitals, of which the institutions at Douala and Yaoundé were the largest. The aggregate capacity totaled 85 beds for Europeans and 695 beds for natives. Thirty-four regional hospitals were located in the different ad- ministrative divisions, which varied in size from 40 to 100 beds, depending upon the density of the population, and provided a total of 15 beds for white residents and 1,498 for natives. Mobile teams of doctors and nurses, based on the regional hospitals; tour the villages periodically for the treat- ment of the natives in their home commu- nities. The Direction also conducted 60 infirmaries and dispensaries and 54 treat- ment centers in the rural areas. Its mater- nity and child health facilities included maternity wards in 34 hospitals, with a combined capacity of 1,136 beds, 3 chil- dren’s dispensaries and 7 midwife stations. The Service d’Hygiéne Mobile et Prophy- laxie operated 25 leprosaria, caring for 5,840 patients, and 12 sleeping sickness treatment centers with facilities for 558 patients. The medical missions maintain hospitals and dispensaries in various parts of the country, as well as child welfare centers and leper settlements. Laboratories. The Institut d’Hygiéne at Douala is the official laboratory of the Direction de la Santé Publique. It includes four divisions: a microbiology section, equipped for the performance of bacterio- logic, serologic and parasitologic examina- tions and for the preparation of biologic products; an entomology section, engaged in research on trypansomiasis; a bureau of hygiene; and a disinfection and disinsecti- zation unit. The Direction de la Santé Pub- lique also operates a diagnostic laboratory at Yaoundé. Clinical laboratory facilities are found in the larger hospitals. The veterinary service of the government maintains a laboratory at Maroua for the preparation of vaccines used in the control of rinderpest, pleuropneumonia and other diseases prevalent among the livestock. Schools. There are no medical schools, but qualified students are sent to the Ecole de Médecine Africaine at Dakar. Nurses and other medical assistants are trained in the central hospitals and the Centre d’In- struction at Ayos. PERSONNEL Physicians. Most of the doctors in the territory are French army officers engaged in government service. In 1948 the medical staff of the Direction de la Santé Publique numbered 32 military surgeons and 3 civil- ian doctors. Several physicians are also con- nected with the mission hospitals. As of 1936, there were 11 missionary doctors in various institutions. Others. In 1948 the European military and civilian personnel in the government health services included 2 dentists, 20 nurses, 9 midwives and 14 sanitary assist- ants. The auxiliary native staff incorporated 41 doctors and medical assistants, 362 nurses and 535 aides, and 29 sanitary assistants. DISEASES The disease statistics of the French Cameroons are derived from reports of the government hospitals and dispensaries and of special units for the control of specific diseases, such as trypanosomiasis and lep- 393 Cameroons rosy. Due to the inaccessibility of many areas and the diversity of tribal medical practices, the information available is nec- essarily incomplete. With certain qualifica- tions, however, it serves as a useful basis for evaluating the incidence of disease in the territory. In general, the diseases en- countered in the different regions are the same as those existing under similar envi- ronmental conditions in French Equatorial Africa. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or UriNArRY TRACTS Typhoid and Dysentery. Typhoid fever is endemic. Sporadic cases are reported, but they undoubtedly represent only a small percentage of the total infections. Amebic dysentery is prevalent in all parts of the territory. The highest incidence occurs during the rainy season in the south, but in the more arid northern districts it corre- sponds to the dry season when the people use readily polluted surface pools as sources of water supply. From 1,600 to 3,500 cases are treated each year. Abscesses of the liver are frequent in some areas. Outbreaks of bacillary dysentery are common in all parts of the country. Helminthiases. ANcyLosTom1asts. Hook- worm infection is widespread, particularly in the southern part of the country. In sur- veys conducted in different regions in 19468 the infection rates, based upon single rou- tine stool examinations, averaged 29 per cent and reached 50 per cent in some re- gions. The prevalence was highest among the women, who are exposed to infection to a greater extent than the men through their work in the fields. The disease is relatively rare in the younger children, but the rate of infection increases steadily in the age groups from 5 to 15 years of age, when it attains the level found in adults. ScHIsTosom1asis. Schistosomiasis is en- demic in limited areas in the northern part of the country. Schistosoma haematobium infections are found in the Lake Chad re- gion, primarily in the Logone River basin. S. mansoni is less localized in distribution, and several foci exist in the Benoue, the Adamaoua and the M’Bam sections of the plateau country. In 1946 a total of 493 cases of infection with S. mansoni and 346 with S. haematobium were recorded. The intermediate snail hosts have not been de- termined. OtHER HELMINTH INFECTIONS. Ascariasis predominates among the round worm infec- tions, and in many villages the infection rates exceed 50 per cent. Enterobiasis and strongyloidiasis are also encountered with considerable frequency. Infections with the beef tapeworm, Taenmia saginata, are spo- radic in the cattle-raising areas, and with the pork tapeworm, 7. solium, in the pig- raising districts of the coastal region. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is prevalent, but the actual incidence is not known. An average of from 400 to 500 cases of pulmo- nary and from 100 to 200 of nonpulmonary tuberculosis is treated each year in the gov- ernment hospitals. Since the majority of cases are in the advanced stages of the dis- ease before hospitalization, they provide poor criteria for estimating the extent of infection. A program for the immunization of infants, using BCG vaccine, is carried on by the maternity services in Douala. Smallpox. Epidemics of smallpox occur almost annually, especially in the northern frontier districts. Mass vaccination cam- paigns have been conducted within recent years by teams of the Service d’Hygiéne Mobile et Prophylaxie. Major epidemics de: veloped in 1943-45, but only 106 cases were reported in 1946. Meningitis. Seasonal outbreaks of men- ingococcus meningitis are reported almost every year. The southwestern part of the country along the British frontier is usually most severely affected. The disease was epi- demic in this region in 1945, when a total of 2,280 cases was recorded, as against 619 394 Cameroons in 1944 and 641 in 1946. This outbreak was the most extensive experienced in the decade 1937 to 1946. Other Infections. Pneumonia ranks high among the causes of death in the native populations. Whooping cough and measles are endemic and frequently epidemic. Diph- theria, scarlet fever and poliomyelitis are sporadic. Diseases SPREAD OR CONTRACTED CHIEFLY TurOUGH CONTACT Venereal Diseases. Both gonorrhea and syphilis are widespread, but the latter dis- ease probably predominates in the coastal region and among the Moslem tribes of the interior. The relative incidence of the differ- ent venereal infections is not known, but 5 per cent of the total cases treated in government installations in 1946 were at- tributed to syphilis, and 4.4 per cent to gonorrhea. Syphilis is one of the principal diseases contributing to the high infant mortality, while gonorrhea is regarded as a major factor underlying the low birth rates in many tribes. Special clinics for venereal diseases are conducted at the Institut Vernes in Douala. Leprosy. Leprosy is endemic in all parts of the territory and especially in the forest and the southern savannah districts. The highest incidence is found in the M’Bam, the Haut-Nyong, the N'Tem and the Noun regions. In 1946 the total number of lepers was estimated at 22,850, or 8 per 1,000 pop- ulation.® Less than one third are segregated. In 1948 the government health services maintained 25 agricultural colonies, organ- ized in tribal groups, with 5,840 lepers in residence. Yaws. Yaws prevails throughout the forest and the coastal regions. In 1946 over 135,700 cases were treated by mobile teams of the Service d’Hygiene Mobile et Pro- phylaxie. The disease accounts for from 9 to 14 per cent of the total cases treated by the government health services each year. Other Infections. Trachoma is prevalent among the Moslem tribes in the north. Tetanus infections are common ; about one half are usually cases of tetanus neonatorum. Rabies is enzootic among the dogs, and human infections occur sporadically. Anti- rabic treatments are provided through the Institut d’Hygiéne at Douala. Mycotic infections, craw-craw, scabies and other skin conditions are widespread. Tropical ulcers are frequent among the agricultural workers in the forest country. Occasional cases of human myiasis are en- countered. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is present in all parts of the country below 4,500 feet in elevation. It is endemic in the coastal region, in the forest zone south of Cameroon Mountain, in the Lake Chad region, and in the Benoue River valley, while on the plateau it occurs in seasonal outbreaks coincident with and after the rains. The splenic indices range from about 18 per cent in the hill country to 70 per cent in the lowlands. Approxi- mately 20 per cent of the cases reported each year are in children under 5 years of age. Plasmodium falciparum, the predomi- nating species, is usually responsible for approximately 90 per cent of the infections. Anopheles gambiae is the principal vector. Trypanosomiasis. Trypanosomiasis, caused by Trypanosoma gambiense, is en- demic in the southern half of the country, where the rate of infection is highest in the Nyong and Sanaga, the Lom and Kadei and the Haut-Nyong regions. The disease was formerly epidemic in many foci throughout this area, but the incidence has been reduced as the result of an active treatment program carried on by the government. The infection rates in the populations surveyed in 1946 averaged less than 1 per cent, in contrast with 11 to 18 per cent in 1926. Foci of higher incidence still exist in some localities, chiefly in the upper Nyong Valley, and minor out- breaks are recorded from time to time. The trypanosomiasis-control program was initiated by an independent governmental unit, the Mission Permanente de Prophy- Cameroons 395 laxie de la Maladie du Sommeil in 1926 and was assimilated by the health services in 1932. The program is based upon surveys and the follow-up treatment of infected individuals in their home villages by spe- cially trained medical teams. Only the most serious cases are transferred to sleeping sickness treatment centers. In a few in- stances, villages have been moved from highly infected sites. In 1946 trypanoso- miasis-control units of the Service d’Hygiéne Mobile et Prophylaxie operated 5 mobile units and 12 permanent treatment centers. Yellow Fever. Cases of yellow fever were not officially reported from the Cameroons until 1941, but the infection is probably endemic throughout the greater part of the country. In a protection test survey in 1933, in which blood sera were collected from 496 individuals and 9 scattered localities, the presence of immunity was demonstrated in 18 per cent of the adults and 3.6 per cent of the children. The findings were irregular, however, and negative tests were obtained in 4 of the towns visited. Evidence of more widespread infection was indicated in sub- sequent surveys by workers from the In- stitut Pasteur at Dakar in 1936.8 A wide- spread immunization program is carried on by the governmental health services. Filariasis. Loa loa and Acanthocheilo- nema perstans infections are prevalent in the southwestern part of the country. Wuchereria bancrofti is not reported but may also be present. Onchocerciasis occurs in localized foci, particularly in the M’Tem and the M’Kam regions in the south. Other Infections. Occasional cases of dermal leishmaniasis are observed in the Lake Chad area. Infections with the guinea worm, Dracunculus medinensis, are endemic in numerous foci in the Logone and the Mandara regions, south of Lake Chad. Tick-borne relapsing fever is sporadic. Cases of typhus fever have been reported from time to time, but whether they were tick-borne or flea-borne infections has not been determined. Epidemic typhus has not Human Trypanosomiasis in the Cameroons been recorded. Dengue fever is present throughout most of this area. Plague has not been reported within re- cent years. Antirodent campaigns are car- ried on in Douala and other towns. NuTtriTioNAL DISEASES Evidence of protein and vitamin deficien- cies is common, but frank nutritional disease is rarely reported. Cases of beriberi are seen occasionally. Goiter is endemic in the vicin- ity of Yaoundé and N’Kongsamba. SUMMARY The Direction de la Santé Publique, with headquarters at Yaoundé, is responsible for the administration of the health and medi- cal services of the territory. Its activities are supervised by the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer in Paris. Measures for the control of trypanosomiasis, leprosy and other diseases are conducted by the Service d’Hygiéne Mobile at Prophylaxie, under the Direction de la Santé Publique. In 1949 the Direction operated 4 central hospitals and 34 regional hospitals, which provided an aggregate of 100 beds for Europeans and 2,193 beds for natives. 396 Cameroons Water supplies are derived from streams, wells, springs and waterholes and are fre- quently contaminated. The water supplies of Douala and Dschang are treated by chlo- rination. The methods of sewage disposal are primitive. The standards of nutrition vary among the different tribes. Major de- ficiencies are common, but frank nutritional disease is rarely encountered. Malaria, trypanosomiasis, dysentery, hookworm infection, venereal disease, lep- rosy, yaws, tuberculosis and pneumonia are prevalent. Schistosomiasis and trachoma are common in the north. Loaiasis and oncho- cerciasis occur in the south; guinea-worm infection, in the north. Outbreaks of small- pox and meningococcus meningitis occur almost annually. Typhoid fever, rabies, yel- low fever, dengue fever, measles and whoop- ing cough are endemic. Scarlet fever, diph- theria, poliomyelitis, tick-borne relapsing fever, typhus fever and dermal leishmaniasis are sporadic. Cameroons (British) GEOGRAPHY AND CLIMATE The western part of the Cameroons, com- prising roughly one sixth of the former German colony, was mandated to Great Britain by the League of Nations in 1921. Since 1946 it has been administered as a Trust Territory under the United Nations. The territory includes two separate strips of land with a total area of approximately 34,000 square miles along the eastern bor- der of Nigeria and is governed as an integral part of that colony. For administrative pur- poses, it is divided into two portions: Cameroons Province in the south, which is incorporated in the Eastern Provinces of Nigeria, and three divisions in the north, which form parts of Benue, Adamawa and Bornu provinces of the Northern Provinces. In the south the volcanic mountain ranges along the French frontier terminate in Mt. Cameroon, which rises to an elevation of 13,353 feet scarcely 14 miles from the coast. This peak dominates the geography and the climate of Cameroons Province and the con- tiguous districts of the French Cameroons. The hill country is bordered by low-lying tropical forest in the southwest, and in the north it extends to the plains of the Lake Chad basin. The annual rainfall ranges from 350 to 400 inches on the western slopes of Mt. Cameroon to 20 to 30 inches in the vicinity of Lake Chad. POPULATION AND SOCIO-ECONOMIC CONDITIONS The population in 1947 was estimated at slightly over 1,027,500. The white residents totaled less than 500, of whom about one half were Germans. The indigenous peoples of the coastal and the forest regions belong to heterogenous tribes of Bantu origin, while Fulani, Hausas and Kanuri form the principal racial groups in the north. As in Nigeria, highly organized Moslem states, designated as “Emirates,” are encountered among the peoples of the Adamawa high- lands and the Lake Chad area. The popula- tion density, in 1937, averaged 24.4 per square mile, but approached from 30 to 40 in the Victoria and the Bamenda divi- sions of Cameroons Province, and from 40 to 50 in Dikwa district in the north. Vic- toria, the administration center, is the largest city and principal port. Except in the eastern part of Cameroons Province, where large plantations have been developed on the slopes of the mountains, the social economy of the people is compara- ble with that of related groups in Nigeria. In this area, bananas, cocoa and rubber are extensively cultivated by individual farm- ers, as well as on plantations owned by large industrial concerns. One tract of 394 square miles is leased to the Cameroons Develop- ment Corporation, a government-sponsored concern created in 1947, which is required to invest its profits in enterprises for the benefit of the native inhabitants. Timber and palm oils are also valuable products of the forest region. Cameroons 397 ENVIRONMENT AND SANITATION As in Nigeria, water supplies are obtained from streams, springs, wells and waterholes. Piped supplies are available in Victoria and Buea. The methods of sewage disposal are primitive. Pit latrines are commonly em- ployed in the towns, while limited numbers of septic tanks are in use in the European centers. The standards of sanitation are low in most parts of the country. The fauna of the region is the same as in adjacent sec- tions of Nigeria. Anopheles gambiae and A. funestus are the principal vectors of malaria. Aedes aegypti is widespread. Mosquito-control measures are carried on in the larger towns and on some of the plan- tations. Glossina palpalis, the most impor- tant vector of human trypanosomiasis, is widely distributed in the south and in parts of the northern districts. G. tachinoides and G. morsitans are found in scattered areas throughout the north. Tsetse fly control measures are undertaken in important foci. Chrysops silacea and C. dimidiata are abundant in the south where Loa loa is endemic. HEALTH ORGANIZATIONS AND MEDICAL FACILITIES There is no independent public health organization in the British Cameroons, but responsibility for the health and medical care of the people devolves upon the Medi- cal Department of the Nigerian govern- ment. In Cameroons Province the health services are developed on a provincial basis and are supervised by the Deputy Director of Medical Services for the Eastern Prov- inces of Nigeria. The headquarters is lo- cated at Victoria. In the northern districts they are administered by the regional of- ficers of the three Nigerian provinces of which they form a part. Hospitals are main- tained by the Medical Department and by most of the plantation companies. Govern- ment hospitals are located at Victoria, Kumba, Mamfe, Bamenda and Banso, with a unit for the treatment of white residents in Victoria. In addition, there are from 15 to 22 small hospitals on the various plantations, which provide from 250 to 500 beds for the care of the native workers. The populations of the northern districts are served by the hospitals at Maiduguri, Yola and Wukari in Nigeria. In 1947 a total of 40 rural dis- pensaries were scattered throughout the territory: one was operated by the govern- ment, 25 by the Native Administrations and 12 by the Cameroons Development Corpo- ration, while 2 dispensaries and 3 maternity homes were maintained by mission organ- izations. Maternity and infant welfare centers are conducted both by the govern- ment and by several religious missions which function in the southern part of the territory. There are no leper colonies, but lepers are treated at Garkida near the bor- der in Nigeria and in several small Native Administration and mission settlements. A field research unit, supported in part by the British Colonial Medical Research Committee, is established at Kumba. It carries on investigations on loaiasis and onchocerciasis, with the co-operation of the Liverpool School of Tropical Medicine. DISEASES Separate statistics of disease incidence are not available for the British Cameroons, since they are incorporated with those from Nigeria. In general, the health problems are comparable with those found in the adja- cent districts of eastern Nigeria. Malaria is widespread. Sleeping sickness, caused by Trypanosoma gambiense, is a major prob- lem, especially in the southern districts. Yaws is widely distributed in the forest re- gion, and the incidence is probably higher than in comparable areas in Nigeria. Lep- rosy is common, with the greatest number of cases in Bamenda and Mamfe divisions. Filariasis is endemic, and foci of high inci- dence occur in Cameroons Province. Epi- demics of meningococcus meningitis and smallpox are frequent in the northern dis- tricts. The incidence of tuberculosis is not known, but the infection rates probably are 398 Cameroons not high. Pneumonia, dysentery, skin infec- tions, venereal diseases and helminthiases are prevalent. Schistosomiasis and guinea- 10. {i 12. 13. worm infection are common in the northern part of the territory. Rabies, yellow fever, measles and whooping cough are endemic. BIBLIOGRAPHY CamEeRrooNs (FreENcH) Beeuwkes, Henry, Mahaffy, A. F., Burke, A. W,, and Paul, J. H.: Yellow fever pro- tection test surveys in the French Came- roons, French Equatorial Africa, the Bel- gian Congo and Angola, Tr. Roy. Soc. Trop. Med. & Hyg. 28:233-258 (Nov.) 1934. Bruel, Georges: La France Equatoriale Afri- caine, Paris, Larose Editeur, 1935. Campourcy: Recherches sur linfection de Glossina palpalis par Trypanosoma gam- biense au Cameroun, Rev. sci. méd. pharm. vét, de Afrique francaise libre (Brazza- ville), 1:59-75 (July) 1942. Cartron: Le pian et sa répartition dans les colonies francaises, Ann. méd. pharm. col. 35:5-73 (Jan.-Mar.) 1937. Chazelas, Victor: Territoires africains sous mandat de la France. Cameroun et Togo. Commissaire des territoires sous mandat a lexposition coloniale internationale de Paris, Paris, Société d’Editions, 1931. Commission de la Maladie du Sommeil: Compte-rendu de la lutte contre la trypa- nosomiase, Ann. méd. pharm. col. 38:360- 381 (April, May, June) 1940. France. Ministére de la France d’Outre-Mer, Direction du Service de Santé Colonial: Situation sanitaire de l’empire francais. Tableaux statistiques 1941-1945, Marseille, Imprimerie LeConte, 1946. . ——. ——: Rapport sur la situation sani- taire dans les territories francais d’outre- mer pendant année 1946. Grosfilez et la Févre: Les maladies trans- missibles observées dans les colonies fran- caises et territoires sous mandat pendant Pannée 1938, Ann. méd. pharm. col. 38: 183-359 (April, May, June) 1940. Hervé: Note sur la leishmaniose cutanée au Cameroun, Ann. méd. pharm. col. 35:928- 1034 (July-Sept.) 1937. Kuczynski, Robert R.: The Cameroons and Togoland. A Demographic Study, London, Oxford, 1939. Moustardier, G.: Sur un cas de fievre typho- exanthématique observé en A.E.F., Rev. sci. méd. pharm. vét. de ’Afrique francaise libre (Brazzaville), 1:21-28 (Oct.) 1942. La protection de la maternité et de ’enfance indigénes dans les colonies francaises en 14. 13: 16. 17. 18. 19. 20. 21, 22. 1938: Ann. méd. pharm. col. 38:46-95 (Jan., Feb., Mar.) 1940. Sorel, F. P. J.: Essai de démographie des colonies francaises, Bull. Office internat. d’hyg. pub. 30: Suppl. 2, 1-154, 1938. Vaucel, M.: La maladie du sommeil au Cameroun, Rev. sci. méd. pharm. vét. de l'Afrique frangaise libre (Brazzaville), 1: 100-112 (July) 1942; 88-110 (Oct.) 1942. Vogel, E., and Riou, M.: Les maladies epi- démiques, endémiques et sociales dans les colonies francaises pendant l'année 1937, Ann. méd. pharm. col. 37:257-551 (Apr.) 1939. , and Rouzic, J.: Les maladies trans- missibles observées dans les colonies fran- caises et territoires sous mandat pendant Pannée 1936, Ann. méd. pharm. col. 36: 352-520, 1938. Wilbois, J.: Le Cameroun, Paris, Payot, 1934. CAMEROONS (BrITISH) Gordon, R. M., Chwatt, L. J., and Jones, C. M.: The results of a preliminary ento- mological survey of loaiasis at Kumba, British Cameroons, together with a de- scription of the breeding places of the vec- tor and suggestions for future research and possible methods of control, Ann. Trop. Med. 42:364-376 (Dec.) 1948. Great Britain. Colonial Office: Report by His Majesty’s Government in the United Kingdom of Great Britain and Northern Ireland to the Council of the League of Nations on the Administration of the Cameroons under British Mandate for the Year 1937, London, H.M. Stationery Office, 1938, Colonial No. 153. —— ——: Report by His Majesty’s Gov- ernment in the United Kingdom of Great Britain and Northern Ireland to the Coun- cil of the League of Nations on the Administration of the Cameroons under British Mandate for the Year 1938, Lon- don, H.M. Stationery Office, 1939, Colonial No. 131. ——, ——: Report of His Majesty’s Gov- ernment in the United Kingdom of Great Britain and Northern Ireland to the Cameroons 399 United Nations on the Administration of the Cameroons under United Kingdom Trusteeship for the Year 1947, London, H.M. Stationery Office, 1948. 23. Kuczynski, Robert R.: The Cameroons and Togoland. A Demographic Study, London, Oxford, 1939. 24. Sharp, N. A. Dyce: Filariasis in the Came- roons, with special reference to skin in- fections by microfilariae, Trans. Roy. Soc. Trop. Med. & Hyg. 21:413-416 (Feb.) 1928. 25. Simpson, T.: Yaws—and its treatment in the Bamenda division of the Cameroons under British mandate, West African M. J. 10:14-34 (Oct.) 1938. 28 Sido Tomé and Principe The Portuguese colony of Sido Tomé and Principe consists of two small islands in the part of the Gulf of Guinea known as the Bight of Biafra, which together have an ap- proximate area of 320 square miles. Both are mountainous, while peaks of from 6,000 to 7,000 feet are found on the larger island, Sao Tomé. The temperature is uniformly high and humid, and the rainfall heavy, except during a relatively dry period from June to September. In 1950 the population of Sao Tomé was estimated at 58,000, in- cluding about 1,000 Europeans, 30,000 na- tives and 27,000 Negroes from other African territories. The population of Principe totaled 3,444, with 56 Europeans, 1,123 na- tives and 2,265 foreign Negroes. The European residents are almost en- tirely Portuguese officials, planters or mis- sionaries. The native population is made up largely of descendants of escaped slaves or of laborers from the mainland. Cocoa and coffee plantations represent the principal in- dustry of the islands, while cinchona, coco- nuts and palm oils are minor products. Most of the estates are dependent upon the re- cruitment of contract labor from the Portu- guese and other African colonies. The public health facilities in the Colony are administered by the Servicos de Saude, which functions under the jurisdiction of the Servigos de Saude e Higiene in the Direccdo Geral de Administracdo Politica e Civil of the Ministerio das Colonias in Lisbon. The headquarters of the Servigos is located in the town of Sdo Tomé, with a branch in Santo Antonio on the island of Principe. It operates a hospital, with a capacity of 232 beds, and 16 sanitary posts on Sdo Tomé, and an infirmary with 16 beds on Principe. Hospital facilities are also furnished by the owners of the larger estates for the benefit of their workers. In 1950 there were 17 pri- vate farm hospitals, providing an aggregate of 1,690 beds, on Sao Tomé; 4 hospitals, with 181 beds, on Principe. The medical per- sonnel of the Servigos de Saude, in that year, included 6 physicians, 1 part-time dentist, 2 nurse-midwives, 3 nurses, 10 nursing aux- iliaries and 1 pharmacist. Sanitary conditions are primitive, and vectors of disease are numerous. The dis- eases indigenous to the islands are essen- tially the same as those encountered on the adjacent mainland of French Equatorial Africa and Spanish Guinea. Malaria, dys- entery and other intestinal infections, tuber- culosis, pneumonia and influenza are the principal causes of death. Trypanosomiasis was epidemic on Principe until 1914, when the vector, Glossina palpalis, was eradi- cated as the result of a comprehensive con- trol program undertaken by the govern- ment authorities in co-operation with the plantation owners. Tsetse flies have not been reported from Sao Tomé. 400 SECTION SEVEN West Africa 29. 30. 31. 32. 33. 34. 35. 36. 37. NIGERIA Gorp CoAST . Toco: French Togoland British Togoland LIBERIA SIERRA LEONE . PorTUGUESE GUINEA . Tue GAMBIA FreENca WEST AFRICA CAPE VERDE ISLANDS . . 403 . 423 . 436 . 438 . 441 . 455 . 466 . 474 . 482 . 508 DI84[y 159M ; 3 4 v 34 py COOINY ILS, 3 REE ; $1onog AMO Ad) NOI 7 Bumoysy a ; ~ 0? 3 gt EA ouoy 0 - Fa | § 3 ry | bi: ry \ an 1yonog DunpDY ossojnoiq : 4 n ON /) s3dN1AOYd N¥3IHLY 0qog / WW Qossig | VININGS 330018042 29 Nigeria GEOGRAPHY AND CLIMATE Nigeria, the largest British possession in Africa, is situated on the Gulf of Guinea and bounded on the north and the west by French West Africa, and on the east by the French-mandated Cameroons. Roughly 34,- 000 square miles of the former German colony of the Cameroons is administered under United Nations trusteeship as an in- tegral part of Nigeria. The total territory comprises approximately 373,000 square miles. Politically, it is divided into the Colony, an area of 1,500 square miles around Lagos, and the three administrative groups of provinces, the Northern, the Eastern and the Western, which constitute the Protec- torate. The southern part of the Cameroon segment forms one of the Eastern Provinces, while the remainder is incorporated into three of the Northern Provinces. Although, in general, the elevation rises gradually from the coastal plains to the highlands of the interior, the country may be differentiated into four distinct physio- graphic regions. The entire coast is lined, to a depth of 3 to 60 miles, by dense mangrove swamp, intersected by numerous rivers and creeks and bordered by frequent lagoonal strips. The second zone, which is charac- terized by tropical “rain” forest, rich in oil palms, extends across the country in a belt from 50 to 100 miles in width and merges into a third zone of deciduous forest. North of the Niger and the Benue rivers, the country rises to the high central plateau. The general elevation averages from 2,000 to 3,500 feet but decreases gradually toward the Sahara. The greater part of the Northern Provinces is essentially a vast undulating plain of open savannah country. There are few mountains, but the Bauchi Plateau, which dominates the central uplands, reaches an elevation of 5,000 feet, while the Cameroon range and associated spurs along the eastern border attain an altitude of from 4,000 to 8,000 feet. This volcanic range cul- minates in Cameroon Mountain, which rises to 13,353 feet and projects through the forest to the sea. Except for the numerous small streams along the coast and the rivers of the Lake Chad basin in the northeast, the greater part of Nigeria is drained by the Niger River and its tributaries. The Niger enters the terri- tory from the northwest, receives the Benue from the east at Lokoja, and then flows south through broad plains, which are flooded periodically during the rainy season. About 140 miles from the sea, it fans out into numerous branches, forming a delta over 100 miles in width. The climate is tropical, with variations governed by the physical features of the country, and by the amount and the distri- bution of the rainfall. Under normal condi- tions rain occurs at all seasons in the south, the heaviest precipitation being in July and again in September. However, except for certain mountainous areas in the Cam- eroons, the months of December and Jan- uary are relatively dry. The annual rainfall ranges from 140 to 150 inches in Owerri and Warri provinces to 70 to 75 inches at Lagos. On the western face of Cameroon Mountain, which is one of the rainiest spots in the world, it reaches from 350 to 400 inches. Toward the north, the dry season becomes 403 404 Nigeria clearly defined, the duration increasing pro- portionately with the distance from the coast. The rainy season extends from March to October, with peaks of precipitation in May or June and again in September in the central provinces, in August in the northern. The rainfall approximates from 40 to 50 inches a year at Lokoja, from 30 to 35 inches at Kano and from 20 to 25 inches at Sokoto. Short but violent electric storms, known locally as “tornadoes,” usually precede and follow the rains. The northeast karmattan winds dominate the dry season but blow with decreasing frequency from north to south. Conditions of temperature and humidity are more tropical in southern Nigeria than in the north. The mean temperatures are relatively uniform: 75° to 80° F. in the coolest months, from July to September, and 80° to 85° F. in the hottest, March and April, with slight elevations inland. In the Northern Provinces the mean annual tem- peratures are higher, while the differences between maximum and minimum tempera- tures increase with the distance from the coast. Maximum temperatures of 105° to 110° F. are not uncommon. The daily range is considerable during the karmattan season, when fluctuations of 40° F. or more may be experienced. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruLATION No census has been published since 1931, when the population of Nigeria approxi- mated 19,928,000, including 5,440 whites and 27,200 Africans from the surrounding terri- tories. Of the total, about 375,000 resided in the Cameroons. The population of the Northern Provinces exceeded 11 million, while that of the Eastern and the Western approached 4.7 million and 3.8 million, re- spectively. In 1946 the native population was estimated at almost 24.4 million; the non-native, at 10,900. The population is ex- tremely heterogeneous. The people of the Niger delta are predominantly “Sudanese Negroes,” while Bantu and semi-Bantu tribes are found in the southeastern districts and in Cameroons Province. The Fulani, a Negroid-Berber people of obscure origin, are widely scattered throughout the North- ern Provinces, and a small group of Shuwa Arabs is concentrated in the Lake Chad re- gion. However, the majority of the inhabit- ants represent various Negroid races. A prolonged and extensive intermingling of Berber, Bantu and Nilotic Negro stock has produced variations in physical type, culture and language which are not readily classified ethnologically. For convenience, 10 major and numerous minor groups are recognized, on the basis of language affiliations. The most numerous are the Fulani, the Hausas in the northwest, the Kanuri in the north- east, the Yorubas in the southwest, and the Ibos in the southeast. The Hausas comprise about 18 per cent of the total population; the Yorubas, 16 per cent; the Ibos, 16 per cent; the Fulani, 10 per cent; and the Kanuri, the Ibibio and the Munshi, 12 per cent. Hausa is now extensively employed as the language of trade in the Northern Provinces. The inhabitants of the north are largely Moslems, the Fulani and the Hausas being found chiefly in the “Emirates” of the former Fulani empire. Animism prevails in the south and in scattered areas on the pla- teau, but large numbers of converts have been made, both to Christianity and to Mohammedanism. Nigeria is essentially a rural country. However, it contains a number of large towns and cities, the majority of which are in the southwest. The population density averages 55 per square mile but reaches from 200 to 300 per square mile in the Colony and in the delta provinces. Through- out the north it ranges between 10 and 55 per square mile, with extensive areas ap- proaching 200 per square mile in the vicinity of Sokoto, Katsina and Kano. In 1947 the population of Lagos, the political and com- mercial capital, was estimated at 178,700. That of Ibadan, the largest city in the south, is about 250,000. Kano, the principal city in the north, has a population in excess of 60,000 and is the center of a congested agricultural district. Culturally, all gradations are encountered between the primitive tribes and the wealthy, educated and Europeanized natives resident in some of the larger cities in the south. Educational facilities vary markedly. Schools are maintained by the Native Ad- ministrations, by Protestant and Catholic mission groups and by the Nigerian govern- ment. Some degree of co-ordination between the different agencies is effected through the medium of government subsidies. Postsec- ondary school education is provided at the University College of Nigeria, which was established at Ibadan in 1948. University College is an autonomous institution, affili- ated with the University of London and supported in part by grants from the Ni- gerian government. It has faculties in agri- culture, arts, science, medicine and educa- tion. The extension of education at all levels, for both men and women, is a promi- nent feature of Nigeria’s development pro- gram. VITAL STATISTICS The only complete statistical records are found in Lagos, where the registration of births and deaths has been in operation since 1867. Local registration is gradually being extended in the larger townships and in some rural areas in the Northern and the Western provinces. Since 1945, partial sta- tistics have been available from the towns of Enugu and Port Harcourt, and from Katsina Emirate in the Northern Provinces. Even in Lagos, however, vital statistics can- not be regarded as reliable, due to the fluc- tuating character of large sections of the population. In Lagos the birth rate in 1947 was 48.6 per 1,000 population; the death rate, 21.7 per 1,000 population. The infant mortality rate was 126 per 1,000 live births, a de- crease of almost 100 per cent within the last quarter of a century. The infant mortality Nigeria 405 rates in other parts of the country are not known but probably reach 300 per 1,000 live births in many areas. In 1946 the infant mortality rate for Katsina was estimated at 173. SociaL Economy Sociologic and economic conditions vary markedly among the different population groups, with the Yorubas and the Hausas attaining, in general, somewhat higher standards of development than the other races. The Nigerians are predominantly small peasant farmers. Palm oil and palm kernels, which represent the major wealth of the country, are produced abundantly in the forest areas. The second major export crop is peanuts, which are grown through- out the territory, but especially in Kano Province. Cocoa and rubber are important products of the south, while cotton is widely cultivated, particularly in the north. Sesame, kola nuts, maize and gums are minor trade crops. Goat and sheep skins and hides are valuable exports, the famous Morocco leather having originated in Sokoto. The development of the cattle industry is limited by the presence of the tsetse fly and tryp- anosomiasis over extensive areas. The mineral resources of the territory have been only partially explored. Tin is mined from alluvial deposits, located chiefly on the Bauchi Plateau. Some gold is also found in Oyo Province, but prospecting is restricted by the government. Coal de- posits near Enugu are worked under gov- ernment ownership. The quality is poor, however, and fuel represents a considerable problem throughout West Africa. Manufac- turing is limited to small local and home industries operated largely by hand labor. The most important is the textile industry, the expansion of which is fostered by the government. The curing of fish is a family trade of widespread local significance. Al- though a large percentage of the people are engaged in agricultural pursuits, the con- centration of labor in the urban areas is in- creasing rapidly. At present over one half 406 Nigeria of the wage-earners are probably employed by the government or by the Native Ad- ministrations. The communication facilities are well developed. The government maintains a network of trunk roads which is rapidly being extended to link all of the centers of population. The country is also provided with an elaborate system of waterways, the use of which varies with the season. The Niger is navigable to flat-bottom craft as far as its confluence with the Kaduna. A 2000-mile government-owned railway has eastern and western divisions from Lagos and Port Harcourt to the interior, but no direct interconnecting services. Air transport is maintained between some of the major towns in the territory and between Nigeria and the neighboring British, French and Belgian colonies; also to South and East Africa, the United Kingdom and Europe. Foop AND NUTRITION The standards of nutrition vary among the different peoples of Nigeria, depending upon their manner of living and the climatic conditions governing the cultivation of food crops. Poverty and malnutrition are fre- quent in the congested areas of the south, while in the north, periods of semistarvation are experienced before each harvest, partic- ularly during the years of low rainfall. The staple foods of the north are grains, includ- ing several varieties of millet and maize. The principal food crops in the south are yams and other root vegetables, but in the forest mountain areas of the Cameroons the plantain replaces the yam in the dietary of the people. Subsidiary foods are numerous. Except in the extreme north, cassava, sweet potatoes, coco-yams, beans and peanuts are used to a varying extent. Plantains and bananas are common in the south. Wheat is grown under irrigation in some of the north- ern districts, and rice is cultivated in the northwest and in the Niger delta. Fruits and green leafy vegetables become increasingly scarce toward the north, particularly during the dry season, although irrigated gardens are found near water courses and wells in many areas. Various meats are obtainable, but the amount consumed is usually small except among the nomadic Fulani. Goats, sheep and chickens are kept by the peasants in most areas, although cattle and large-scale stock raising are largely restricted to the Northern Provinces. Fish are abundant in the coastal and the river regions. In the man- grove forests of the delta fish is the staple food of the people, and smoked fish is the principal article of trade. Milk constitutes a major item in the dietary of the nomadic Fulani and of the tribes in the Bamenda re- gion of the Cameroons, but is scarce and sea- sonal in other portions of the country. Shea- butter, made from the indigenous shea-nuts, is widely used ; also palm oil in the southern provinces. The average diet is deficient in animal proteins and fats, in calcium and iron, and in vitamins, especially A, the B complex and C. The government departments of agriculture and education are co-operating with the medical services in an effort to promote better nutrition among the people. The education of the peasants in improved methods of agriculture and of stock breeding is also undertaken. An active program for the control of enzootic diseases among the livestock, particularly rinderpest and trypanosomiasis, is carried on by the government’s Veterinary Department. Housine The housing problems are diverse. The standards are generally low, except among the prosperous and educated residents of the larger communities. In Lagos the housing facilities vary from the large concrete or stucco homes of the wealthy to the primitive bamboo or galvanized iron shacks of the poorer families. Extensive areas of over- crowded and insanitary dwellings exist, al- though considerable progress has been made in the demolition of slums since 1930. Com- prehensive programs of town planning and rebuilding are being carried out, not only in Lagos but in many other large townships. Nigeria 407 The native dwellings differ in size and design among the various peoples. In the rural areas the majority are constructed of mud, or wattle and daub, with palm-thatch roofs. In the towns, mud blocks or bricks and corrugated-iron roofing are frequently employed. In some parts of the south and in the Moslem areas of the north the inhabit- ants live in compounds which include huts for various family groups and for livestock. In the Northern Provinces the village com- pounds and the larger two- and three-story houses in the towns are sometimes enclosed, the former by a fencing of trees, cactus, or grass matting, and the latter by high, mud walls. Housing conditions among the Hausas of the far north and the animist tribes of the plateau are generally inferior. The huts are small, and overcrowding is almost universal. Flimsy, beehive huts of grass or skins con- stitute the typical dwellings of the nomadic Fulani and certain tribes of Bornu Province. A concerted effort is being made, through the Native Administrations, to raise the standards of housing and village planning to conform to modern ideas of health and sanitation. In some sections of the Northern Provinces propaganda has been supported by the construction of model compounds at public expense. The housing provided for the laborers in the minefields and on the plantations is generally poor, although im- provements are being made continuously. ENVIRONMENT AND SANITATION WATER SUPPLIES Water for human consumption is avail- able from wells, springs and streams in most parts of the country. The close network of rivers and streams in the south provides sources of water throughout the year, al- though during the dry season they may be seriously depleted. In the north many of the streams are seasonal, but subsurface sup- plies are frequently available from shallow and deep wells in the vicinity of the dry stream beds. In the more arid regions the provision of water for livestock and for irri- gation may constitute a major problem. The permanent pools which persist after the floods of the rainy season are common sources of water supply in many areas. Varying degrees of protection and control are exercised over the water supplies in the larger townships. The water for Lagos is derived from an underground stream-fed reservoir at Iju, 18 miles from the city, and is piped to an open service reservoir before distribution. Over 600 dug wells are also scattered throughout the area. At Ibadan the major water supply is obtained from a large impounded reservoir, but secondary river sources are also available. The town of Kano is served by a water supply collected in 5 infiltration wells in the bed of the Challowa River. The municipal supplies are treated by filtration, chlorination, or both. Bacteriologic examinations are performed in the laboratories of the government’s Chemical Department at regular intervals. Distribution is usually to community pumps in the native areas, but private connections are provided in certain residential and com- mercial sections. The Colonial government has undertaken an ambitious program for the construction of wells and dams in the rural areas, partic- ularly in the Northern Provinces, and for the extension of treatment facilities for the urban supplies. As a result of the low level of sanitation in many rural areas, small vil- lage supplies are subject to contamination. Waste DisposaL No modern systems of sewage disposal are found in Nigeria, although the development of water-borne sewerage is incorporated in the rebuilding plans projected for Lagos. Bucket and pit, or trench, latrines are in use in most of the towns. The sewage is disposed of by burial, composting or dumping into the sea and adjacent streams. In a few lo- calities incineration is undertaken on a small scale. Installations for the composting of refuse and night soil are gradually being introduced in urban communities through- out the country. Shallow trenching is em- 408 Nigeria ployed in many areas; pits or silolike concrete towers are used in others. In some regions the night-soil compost is utilized to maintain soil fertility. Septic tanks are used in the European quarters and in many of the government and commercial buildings in the larger towns. In the rural areas the methods of disposal are universally primi- tive. Fauna anp Frora Arthropods. Mosquitoes. At least 30 species of anopheline mosquitoes have been reported from Nigeria, among which Anoph- eles gambiae, A. gambiae melas and A. fun- estus are of major significance in the trans- mission of malaria. 4. gambiae, the principal vector, is widely distributed, breeding in various exposed collections of water, such as ditches, ponds, pools, footprints, and slowly moving shallow streams. 4. gambiae melas breeds along the coast, in the Avicennia (white mangrove) orchards and the grass- covered mud flats of the tidal lagoons and islands. At least 95 to 99 per cent of the anophelines collected in the coastal area are a variety of A. gambiae * A. funestus is an important vector, especially during the first half of the dry season. It is abundant in the rain forest zone and in certain localities may be more dangerous than A. gambiae. It breeds among the vegetation of clear streams and ponds and sometimes in swampy areas. In the northern savannah 4. gambiae again becomes the most prominent vector. A. hargreavesi, A. nili, A. hancocki, A. phar- oensis, A. moucheti nigeriensis and A. rufipes are also important vectors in local- ized areas. A. gambiae, A. funestus and A. nili may be implicated in the transmission of Wuchereria bancrofti. Aedes aegypti is prevalent in many areas and is a vector of yellow fever in both north- ern and southern Nigeria. Numerous other species of Aedes mosquitoes are present, in- cluding A. africanus, A. pseudoafricanus, A. simpsoni, A. apicoargenteus, A. luteoceph- alus, A. stokesi and A. vittatus; all are potential vectors of yellow fever. Numerous species of Culex mosquitoes are found, but the majority are of no known medical significance. However, Culex quin- quefasciatus (= C. fatigans) is a presumed vector of Wuchereria bancrofti. Taeniorhyn- chus (Mansonia) africanus and T. (M.) uni- formis constitute major pests in some areas. Eretmopodites is also reported. Active programs for mosquito control are carried on in the larger towns. Comprehen- sive anti-Aedes measures have reduced the Aedes index in Lagos to a fraction of one per cent. Within recent years extensive malaria-control projects, financed with the assistance of British Colonial Development and Welfare funds, have been conducted in the vicinity of Lagos township. Up to 1946 approximately 4,000 acres of swamp had been drained by means of tidal gates which are operated in accordance with the high and the low tides. Supplementary antilarval measures include the treatment of collec- tions of water with Paris green, oil or DDT, and the stocking of certain pools and dug wells with larvivorous fish. A Malaria Service has been created by the Nigerian health authorities to facilitate the standard- ization of antianopheline measures in various parts of the country and to carry out research and survey programs. Fries. The tsetse flies are of major im- portance, both from a medical and a veter- inary standpoint. About 79 per cent of the territory is infested, the Bamenda highlands, the higher altitudes of the Jos plateau and the artificially cleared ‘“Anchau corridor” being the only sections which are free. Glos- sina palpalis, G. tachinoides and G. morsi- tans are the principal vectors of trypanoso- miasis, but G. longipalpis, G. caliginea, G. pallicera and several species of the Fusca family are also present. G. palpalis and G. tachinoides are the species chiefly concerned in the transmission of human infections. They breed in connection with dense riverine vegetation: G. palpalis from the coast to latitude 10° N., and G. tachinoides in the central region with spurs to the northern frontier. G. palpalis is widely Nigeria 409 though sparsely distributed in the swamp forest zone, but it is found abundantly in the fringing “Kurmi” forest along the rivers and streams of the savannah country. G. morsitans is present in scattered foci in northern and central Nigeria. It is the most dangerous vector of bovine trypanosomiasis but is of little significance in the transmis- sion of the human infection. Tsetse fly control measures are carried on co-operatively by the medical, veterinary and forestry services of the Nigerian gov- ernment. They include discriminative or “protective” clearings in the dense vegeta- tions along the banks of the streams and complete “barrier” clearings, from 500 to 1,000 yards in length, at points of maximum man-fly contact. Barrier clearings are em- ployed to protect the roads and to guard the partially cleared areas from reinfesta- tion. Numerous species of Muscipae and Tas- ANIDAE are found. The majority are annoy- ing pests, but they may be involved in the spread of intestinal infections. Stomoxys and some of the MuscipaE probably are im- plicated in the mechanical transmission of animal trypanosomiasis. Chrysops silacea and C. dimidiata are vectors of Loa loa in the southern provinces. Several species of myiasis-producing flies are present. The tumbu fly, Cordylobia anthropophaga, is frequently responsible for cases of human | 1] |-G. palpalis — =G tachinoides 3B {& palpalis and G.tachimoides Z =G.morsitans Distribution of Principal Species of Tsetse Flies in Nigeria myiasis. Auchmeromyia luteola is wide- spread ; its bloodsucking larvae, known as “Congo floor maggots,” produce wounds which readily become infected. Species of Phlebotomus also occur; P. argentipes is a probable vector of cutaneous leishmaniasis in the Lake Chad region. Numerous species of SIMULIIDAE are re- ported. Simulium damnosum, which breeds in clear streams of flowing water, is responsi- ble for sporadic cases of Onchocerca vol- vulus infection in scattered foci, particularly in the southern Cameroons. The biting midges, Culicoides austeni, and possibly C. grahami, are encountered in many areas where they serve as vectors of Acanthocheil- onema perstans. Lick. Infectation with Pediculus humanus corporis is general, particularly in the Northern Provinces. P. humanus capitis and Phthirus pubis are also common. Louse- borne typhus has probably been endemic in this region for a long time, but the first out- break was recorded in 1945. Freas. The rat flea, Xenopsylla cheopis, is prevalent. Plague has not been reported since 1927 when it occurred in Lagos, but the presence of this potential vector and a large rodent population necessitates con- stant vigilance, particularly in the port towns. Numerous other rat fleas are found, but none is of medical importance. The dog and cat fleas, Ctenocephalides canis and C. felis, are abundant. The chigoe flea, Tunga penetrans, is in- digenous. Bepsucs. The usual bloodsucking bedbug of this region is Cimex hemipterus, but C. lectularis is also found. Ticks anp Mites. Numerous ticks occur, including species of Rhkipicephalus, Booph- ilus and Amblyomma. The dog tick, R. sanguineus, is found in many areas. The tampan tick, Ornithodorus moubata, is not known to be present. The itch mite, Sar- coptes scabiei, is widespread. OtHER ARTHROPODS. The scorpion, Buthus quinquestriatus, is common to this area. Its sting is painful but rarely fatal to adults. 410 Nigeria The poisonous centipede, Scolopendra mor- sitans, is also encountered. Biting ants of the genus Dorylus and the stinging ants, Megaponera foetens and Paltothyreus tars- atus, are found; also Macromischoides aculeatus. The tiger beetle, known locally as “fura,” is present as far south as Enugu. Its bite produces lesions closely resembling crab yaws. Reptiles. A large number of venomous snakes is encountered. The cobras are repre- sented by the spitting cobra, Naja nigri- collis, as well as N. goldii, N. haje and N. melanoleuca; the mambas, by Dendro- aspis viridis, D. jamesonii and Elapechis guentheri. The most deadly vipers are the puff adder, Bitis arietans, which is widely distributed in the savannah country, and B. gabonica and B nasicornis, which inhabit the heavy forest. At least two species of night vipers exist, Causus rhombeatus and C. lichtensteinii. Atheris chlorechis, Echis carinatus, Aspis cerastes (= Cerastes cornutus) and 4 species of burrowing vipers of the genus, Atractaspis, are also reported. Several species of poisonous rear-fanged snakes have been identified, the most im- portant of which is the boomslang, Dispholi- dus typus. Crocodiles are numerous in the rivers of the south and may occasionally attack human beings. Rodents. Rats are abundant, particularly in the congested communities. Rattus rattus rattus is probably the most prevalent, but R. norvegicus abounds in the port towns. R. rattus frugivorus and R. rattus alexandrinus are also present. Other species of MURIDAE are widespread, including the gerbils in the north. The giant rat, Cricetomys gambianus, is common. Mollusks.* The fresh water snail, Phy- sopsis africana globosa, the intermediate host of Schistosoma haematobium, is widely distributed, particularly in the Northern and the Western Provinces where both uri- nary and intestinal forms of schistosomiasis are common. Planorbis (Biomphalaria) * See footnote, p. 10. alexandrina pfeifferi is the intermediate host of S. mansoni. Plants. Numerous species of poisonous plants grow in Nigeria, many of which are employed by the different tribes in the prep- aration of medicinal compounds. Several species of Euphorbia are present. The sap produces severe local reactions and was em- ployed frequently as an ingredient of arrow poisons. The latex of Croton lobastus is also irritating but is used by some primitive tribes to protect against witchcraft. Other plants valued for arrow poisons include Strophanthus hispidus, S. sarmentosus, S. gratus, Adenium hongkel, Acocanthera triesiorum and A. longifiora. Prominent among poisonous plants utilized for medic- inal or homicidal purposes are Erythroph- leum guineense, Jatropha gossypiifolia, Physostigma venenosum and Calotropis procera. The bitter cassava, Manihot util- issima, which often serves as a food, contains cyanogenetic substances and may be toxic unless properly prepared. The coco- yams, Colocasia esculenta and C. anti- quorum, are reported to produce forms of chronic poisoning. Foop SANITATION The sanitary control of meats and other foods for human consumption is the respon- sibility of the Nigerian health authorities. In the Northern and the Western Provinces, and to a lesser extent in the Eastern Prov- inces, regulations governing the sanitation of markets, slaughter houses and various eating establishments are enforced by the constituted Native Administrations. Condi- tions vary in different areas, depending upon the degree of authority retained by the Nigerian government, the adequacy of su- pervisory personnel and the progressiveness of the individual local authorities. Milk is usually scarce outside of the cattle-raising areas in the north. Pasteurized milk is not available, except in one dairy operated by the government’s Agricultural Department at Kano. The Department also conducts small dairies at Agege, near Lagos, and at Nigeria 411 Ibadan. Small producers supply milk in other localities, but no system of control is in force. Meat inspection is carried on only in the larger centers of population. Ante- mortem examinations of slaughter animals are made by veterinary officers. At present, postmortem examinations are undertaken by sanitary inspectors of the government health organization, but this responsibility will eventually be assumed by the Veter- inary Department. HEALTH SERVICES AND MEDICAL FACILITIES HeartH ORGANIZATIONS The Medical Department is responsible for the public health and medical program in Nigeria and the British Cameroons. It is a major department of the Nigerian govern- ment, which is advised on matters of gen- eral policy by the medical staff of the Colo- nial Office in London. The Department is administered by a Director of Medical Services with headquarters in Lagos. In accord with the constitution of 1947, the health and medical services are organized on a regional basis. Deputy Directors of Medi- cal Services are located at the regional head- quarters at Ibadan in the Western Prov- inces, at Kaduna in the Northern Provinces and at Enugu in the Eastern Provinces, while a Senior Medical Officer directs the health activities in Lagos and the Colony. Co-ordination is effected through the central organization, which also controls the train- ing of medical personnel and 7 ancillary branches: Leprosy, Malaria, Sleeping Sick- ness, Laboratory, Dental, and Maternal and Child Health Services, and a Medical Field Unit Service, which consists of mobile teams equipped for the control of epidemics and the conduct of special investigations. The functions of the Department and of the regional divisions include the development and the maintenance of hospitals and dis- pensaries, the control of sanitation and the prevention of certain communicable dis- eases. In the larger towns public health measures are carried out by local health authorities. To a varying extent, depending upon their autonomous development and financial re- sources, the Native Administrations assume responsibility for the enforcement of sani- tary and other preventive measures and for the maintenance of maternity hospitals and dispensaries in their respective areas. Su- pervision and technical or professional staff is provided by the government services. Maternity, infant welfare and school clinics are operated by the government and by many Native Administrations. In 1950 a comprehensive maternal and child health program was initiated by the Medical De- partment. In 1948 the first two of a proposed series of rural health centers were estab- lished at Ilaro and Auchi in the Western Provinces. Numerous mission societies operate hos- pitals and dispensaries and make considera- ble contributions to public health in Nigeria through their educational, maternity and child health activities, as well as their work with lepers. MEebpIcAL INSTITUTIONS Hospitals and Dispensaries. Hospitals are maintained by the Medical Department, by the various Native Administrations and by mission organizations. In 1947 the gov- ernment operated 59 hospitals with a total capacity of 3,724 beds. The hospitals at Lagos and Kano have a capacity of from 200 to 300 beds, but the majority range in size from 16 to 135 beds. Special maternity hospitals are located in certain centers in the south, notably Lagos, Calabar and Aba. Small infectious-disease hospitals are estab- lished at Yaba (near Lagos), Enugu, Cala- bar and Port Harcourt in the south, and at Maiduguri, Makurdi, Sokoto and Jos in the north. In the same year 15 hospitals and 56 maternity homes were supported by the Native Administrations, many of which were served by medical officers and nurses of the government staff. They provided a total of 1,928 beds. The field dispensaries in 412 Nigeria the mining areas and the hospital at Barakin Ladi are operated by government medical personnel, but they are subsidized by the mining concerns on a per capita basis. Rural dispensaries are maintained by the Native Administrations, In 1947 they numbered 510, and in 1948, 558. Other medical facili- ties conducted by the government included a tuberculosis hospital at Yaba, mental hospitals at Calabar and Abeokuta and an orthopedic hospital at Igbobi, near Lagos. The various missions operated 34 hos- pitals and 59 maternity homes in 1947, which contributed a total of 2,850 beds. In addition, there were 18 private nursing homes with an aggregate of 225 beds. There are 22 leper settlements, 17 of which are mission institutions. Since the organization of the Leprosy Service within the Medical Department in 1945, most of the settlements have come under its jurisdic- tion. The mission settlement at Itu in Cala- bar Province accommodates approximately 4,000 lepers and is the largest institution of its kind in the country. Laboratories. The Medical Research In- stitute at Yaba, near Lagos, is operated by the Laboratory Service of the Medical De- partment. It has well-equipped bacteriologic and pathologic laboratories for the per- formance of routine investigations and re- search and the production of biologicals. The pathologic laboratory in the General Hospital in Lagos carries out routine diag- nostic examinations for the government medical services. Diagnostic laboratory ex- aminations are also performed in the hos- pitals at Kaduna, Port Harcourt, Calabar, Kano, Zaria, Jos, Maiduguri, Enugu, Ilorin, Victoria and other centers. The Sleeping Sickness Service operates its own laboratory section. A West African Institute for Trypanosomiasis Research was established in 1949, with laboratories at Kaduna and Vom. It will undertake investi- gations on animal and human trypanosomi- asis, in association with the field services of the Veterinary Department. The Malaria Service has a laboratory at Yaba. A research station for the study of leprosy was organ- ized at Uzuakoli in 1945. The Yellow Fever Research Institute was established at Yaba in 1943 to provide a center for the study of the epidemiology and the control of yellow fever. It was started as a co-operative project, supported by the International Health Division of the Rocke- feller Foundation and the four British West African colonies. Since the withdrawal of the Rockefeller Foundation in December, 1949, the direction of the laboratory has been taken over by the Colonial Medical Re- search Service. It will be conducted as a Tropical Diseases Research Institute. A unit devoted to research on hot climate physiology and sponsored by the Medical Research Council of Great Britain is located at Oshodi near Lagos. The government’s Veterinary Department maintains a laboratory at Vom for the pro- duction of vaccines and other prophylactic agents for the control of animal diseases enzootic in the territory. The Chemistry De- partment has facilities for the conduct of chemical and hygienic examinations at Lagos and other centers. Schools. The Medical Faculty of Uni- versity College at Ibadan, which was opened in 1948, provides a full course of medical training with recognition by the General Medical Council of Great Britain. Nurses’ training schools are established at Lagos, Kano, Ibadan and Aba, while supplementary practical training is given in 23 teaching hospitals. Some Native Administration and mission hospitals also provide training courses which meet the requirements of the Nigerian Nursing Council. Schools for mid- wives are conducted in the maternity hos- pitals in Lagos, Aba and Calabar. Other government, Native Administration and mission hospitals are approved for the train- ing of midwives (Grade II), but their graduates are not eligible for certification. Schools of Pharmacy are located at Yaba and Zaria. Training centers for sanitary in- spectors are situated at Lagos, Kano and Aba, and a shorter course of instruction for Nigeria 413 assistant inspectors is given at Ibadan. A special school for the training of staff for the Sleeping Sickness Service is conducted at Kaduna, and for the Medical Field Unit Service, at Makurdi. Courses are also avail- able for the training of medical assistants, dispensary attendants, laboratory assistants and other medical personnel. PERSONNEL Physicians. About 333 physicians were registered in Nigeria in 1948. Of these, 201 were connected with the Colonial medi- cal services and 90 with various mission or- ganizations, while 42 were engaged in pri- vate practice in Lagos, Ibadan and other urban centers. Dentists. From 10 to 15 dentists are located in Nigeria. In 1947, 6 dentists were employed by the government and 6 by mission or other organizations. Nurses. The nurses registered in Nigeria in 1948 totaled 929, while 515 were in train- ing. In addition, 75 British nursing sisters with midwife qualifications were attached to the Medical Department. Others. In 1947 about 203 certified mid- wives were connected with the medical mis- sions, and 64 with the government services. There were also 795 midwives (Grade II) with limited licenses. The roster of the Med- ical Department included 38 sanitary super- intendents and 201 sanitary inspectors, as well as assistants in all the services. Various professional laboratory personnel and at least four medical entomologists are affili- ated with the various divisions of the De- partment. DISEASES The differences in topography and cli- mate, in population complexes and in eco- nomic and social development between northern, eastern and western Nigeria must be considered in evaluating the health and disease conditions of the country. Reporting is incomplete even in Lagos and the larger towns in the Protectorate. Official morbidity and mortality statistics are based upon gov- ernment hospital and outpatient dispensary reports and give little indication of the true incidence of infection. However, in a few diseases, as trypanosomiasis and lep- rosy, area surveys provide criteria for esti- mations of prevalence. Native superstitions and religious fanaticism vitiate the recog- nition and the control of communicable dis- eases in many areas, but the increasing ac- ceptance of preventive regulations and the growing demand for hospital and dispensary services reflect the changing outlook and health consciousness of the people. DiseASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL OR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fever is endemic in all parts of the country. The reported incidence is relatively low, and available evidence suggests that a high degree of immunity exists among the native populations. Approximately 55 to 60 cases of typhoid fever and 5 to 10 of para- typhoid fever are treated each year in gov- ernment institutions. Dysenteries. Dysentery ranks high among the causes of illness due to com- municable disease in all portions of the country and particularly in the plateau and the eastern provinces. From 1945 through 1947 an average of 14,600 cases was reported annually, of which roughly 30 per cent were listed as amebic and 6 to 7 per cent as bacil- lary. In the group of unclassified cases, a large porportion were undoubtedly bacillary infections. In view of the generally low level of sanitation, the cases seen in the govern- ment hospitals and dispensaries probably represent but a small fraction of the total incidence. In cases where laboratory diag- nosis is attempted, Skigella paradysenteriae (Flexner) seems to predominate. S. dysen- teriae is encountered occasionally. Diarrheas and enteritis are prevalent among individuals of all ages. Helminthiases. ANcyLosToMIAsIS. Hook- worm infection is widespread, but the clini- cal manifestations are generally mild. In 414 Nigeria most areas the degree of soil infestation is relatively low. Surveys in 1947, including over 20,000 laboratory examinations, indi- cate a probable infection rate of 15 to 30 per cent.*? A rough estimate of the incidence of ancylostomiasis in the vicinity of Lagos is derived from a study of 114 routine autop- sies in the General Hospital during four months in 1937-38:1% 47 showed infection with Necator americanus and 22 with An- cylostoma duodenale. N. americanus is the principal species in foci around Lagos and in some sections in the north, but 4. duo- denale apparently predominates in many areas. ScuisTosom1asis. Schistosomiasis is widely distributed throughout northern Nigeria. It is especially prevalent in Adamawa and Plateau provinces, where infection with Schistosoma haematobium frequently exceeds 50 per cent among the children examined in school surveys. Scat- tered foci are also found in the southern part of the country. The infection, which is known locally as “dog gonorrhea,” is often confused in the public mind with true gonor- rhea. In a field study*’ in 11 different locali- ties in the Northern Provinces, reported in 1934, ova of S. haematobium were demon- strated in 31.6 per cent of urine specimens from 7,109 persons of all ages, and S. mansoni in 15.2 per cent of fecal specimens from 7,136 persons. The infection rates of S. haematobium in children ranged from 16 per cent in Bida to 72 per cent in Kano and averaged over 50 per cent in Bauchi, Birnin Kebbi, Kano, Katsina and Zaria. Compara- ble rates for S. mansoni ranged from 9 per cent in Maiduguri to 39 per cent in Yola, with rates of over 25 per cent in Bauchi, Jos, Sokoto and Yola. In both species the highest incidence was found in individuals from 10 to 15 years of age. The height of infection occurs toward the end of the rainy season. The intermediate host of S. kaema- tobium is probably Physopsis africana globosa; of S. mansoni, Planorbis ( Biomph- alaria) alexandrina pfeifferi. Oraer HermintH INFECTIONS. Ascari- asis is common. Infections are numerous in the south, where in many localities the prev- alence approximates 30 to 50 per cent. In the survey in the Northern Provinces cited above?’ the examination of fecal specimens from 7,136 persons of all ages revealed Ascaris lumbricoides ova in 6.1 per cent, Trichuris trichiura in 2.8 per cent, Hyme- nolepis nana in 3.5 per cent and T'aenia in 10.2 per cent. Infection with the beef tape- worm, Taenia saginata, is unusual in the south, but prevalent in the cattle-raising areas of the Northern Provinces. 7. solium does not occur in the Moslem districts but the infection may be encountered sporadi- cally elsewhere. Other Infections. Sporadic cases of un- dulant fever are reported, most frequently from the Northern Provinces. Brucellosis is enzootic among the goats, especially in Sokoto Province, while infection with Bru- cella abortus is thought to exist among the cattle. The incidence of B. abortus and B. melitensis infections in man is not known. Occasional cases of human anthrax are observed, due to the consumption of meat from infected animals. Cholera is not recorded from this area. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is prevalent in the urban areas and also in many rural districts. From 1,200 to 1,700 cases of pul- monary and from 500 to 900 of nonpulmo- nary tuberculosis are reported each year from the government hospitals and dispen- saries, but such totals give little indication of the actual incidence. The majority of cases show slight resistance to the infection and seek treatment only in the advanced stages. In a small study in 194742 of children around 13 years of age at Bida, in central Nigeria, about 20 per cent gave positive re- actions to tuberculin. Poor nutrition and crowded living conditions, together with an acute shortage of diagnostic and treatment Nigeria 415 facilities, serve to promote the spread of the infection. The organization of a special Tuberculosis Service is planned by the Medical Department. Bovine tuberculosis is not known to be present in southern Nigeria, and the extent of infection in the north is uncertain. Smallpox. Sporadic outbreaks of small- pox are frequent. The most extensive epi- demics within recent years occurred in 1945- 47, with Bauchi and Sokoto provinces most severely affected. The peak of incidence was noted in 1946, when 7,620 known cases were recorded. The fatality rates ranged from 12 to 17 per cent. In 1948 the disease was prev- alent in the Lagos area. Mass vaccination campaigns are undertaken in all parts of the country and especially in the affected regions. Meningitis. Serious outbreaks of menin- gococcus meningitis are reported almost an- nually, primarily from the northern and the eastern provinces. Outbreaks usually occur in the latter half of the dry season and sub- side with the onset of the rains. Major epi- demics resulted in 1937-38, in 1944-45 and in 1948-50. In the most recent epidemic, the reported cases increased from 8,500 in 1948 to over 40,000 in 1949, while in 1950 the number rose to 56,185, the largest then on record. The outbreaks centered around Sokota, Katsina and Kano provinces. The fatality rates averaged 19 per cent in 1948, and 12 per cent in 1950. Control measures include the quarantine of infected villages and, when necessary, the organization of treatment camps. Other Infections. Pneumonia is reported to be one of the major causes of death in all parts of the country. The infant mortality from respiratory infections is especially high. The pneumonias were responsible for the deaths of almost two thirds of the 500 children under 3 years of age autopsied in the Lagos Hospital in 1940.20 Clinical diphtheria is rarely encountered. Less than 100 cases were reported by the Nigerian medical services in the period from 1927 through 1946. Subclinical infec- tions are apparently general. In a Schick test survey of 1,753 natives in Lagos in 1934,% positive reactions were demonstrated in 33 per cent of 46 infants under one year; in 22 per cent of 1,409 children from 1 to 10 years of age, and in only 2 per cent of 298 individuals from 10 to 20 years of age. Wound diphtheria is probably com- mon. Measles and whooping cough are fre- quently epidemic. Scarlet fever is rare, but occasional cases are reported. Poliomyelitis occurs sporadically; from 10 to 30 cases are observed each year. Diseases SPREAD OR CONTRACTED CuierLy THROUGH CONTACT Venereal Diseases. Venereal diseases are prevalent, and all forms of infection are encountered. In almost 47,000 cases re- ported in 1947 approximately 36 per cent were attributed to syphilis, 51 per cent to gonorrhea and only 6 per cent to other venereal diseases. However, recorded cases bear little relation to the actual incidence. Venereal diseases occur with greatest fre- quency in the districts along the major trade and pilgrim routes in the north, and in the large urban centers in the south. The rate of venereal infection is probably from 3 to 4 times greater in the northern provinces than in the southern.?” Syphilis, in particular, is common among the Hausa peoples. The dis- ease is found most extensively in northern and western Nigeria, while gonorrhea is highly endemic in all parts of the country. Surveys by the field units of the Medical Department in 1947, calculated on the basis of the male population only, suggested gonorrhea infection rates of 25 per 1,000 in Benue Province and of 125 per 1,000 in the Cameroons. Leprosy. Leprosy is a major endemic disease in large sections of the country. Spread originally along the slave trade routes, the disease is now established in the Niger, the Benue and the Cross River val- 416 Nigeria Leprosy in Nigeria leys. The greatest concentration of cases is found in the densely populated delta region, and in Ogoja and Calabar provinces in the south ; and in southern Plateau Province in the north. Scattered foci of high incidence are also encountered in Onitsha, Benin and Cameroons provinces, as well as throughout the Northern Provinces. Little leprosy is present in the southwestern part of the country where the Yorubas have enforced extreme measures against lepers for genera- tions. In 1947 the number of lepers was estimated at 400,000, of whom probably 100,000 were in infective stages of the dis- ease.*> The infection rates, based upon epidemiologic surveys, range from 2 per cent in Bornu Province to 6 per cent in Warri Province. The lowest rates are found in the large towns and in Lagos Colony where the prevalence is estimated at about 0.1 per cent. With the inauguration of a Leprosy Serv- ice within the Medical Department in 1945, the Nigerian government embarked upon a co-ordinated program for the control of leprosy on an area basis. In 1947 the Service was operating in three areas, Onitsha, Owerri, and Warri and Benin provinces, and it is expected that the balance of the North- ern and the Western Provinces will even- tually come under its control. In 1947 the Service had jurisdiction over all mission settlements, except those at Itu and Ogbomosho, and numerous small camps in the north, operated in association with the Native Administrations. A total of 76,293 lepers was under treatment in government-controlled leprosy settlements or subsidiary segregation villages and treat- ment centers. The most important settle- ments, at Uzuakoli, Oji River and Ossiomo, each has facilities for the care of from 1,000 to 1,600 lepers. Itu, the largest colony in Nigeria and the principal nongovernment unit, cares for approximately 4,000 lepers. Research on the efficiency of various sulfone drugs in the treatment of leprosy is being carried on at Uzuakoli in co-operation with the British Empire Leprosy Relief Associa- tion. The Medical Department hopes soon to establish a West African Institute for Leprosy Research at Ibadan. Yaws. Yaws is prevalent in the south- eastern provinces of Nigeria and the Came- roons. The incidence decreases gradually toward the north and the west and is said to be negligible in sections of the country where syphilis predominates. An average of 30,000 cases is reported an- nually from the government hospitals and dispensaries, but treatment statistics pro- vide inadequate estimates of actual inci- dence. The disease is encountered primarily in the remote villages and less frequently in the towns. Surveys among certain tribes in the Cameroons in 1935-374¢ revealed in- fection rates of from 6.7 to 16.5 per cent in the bush and of 0.1 per cent in Bamenda. In most areas the disease occurs predomi- nantly among children from 2 to 5 years of age, with a gradual decline in incidence up to puberty. Among some tribes, as the Tiv in the Benue Valley, at least 95 per cent of the children suffer from yaws, and about 5 per cent of the adults. Roughly 75 per cent of the recruits examined for army service at Ogoja and Okigwi in the Eastern Provinces in 1942 were rejected, the majority because of yaws.37 The disease is seasonal to a large extent. A high percentage of primary and secondary cases is seen during the rainy sea- son when the confinement of the children indoors provides increased opportunities for infection. Treatments are given locally by specially trained villagers in many areas and Nigeria 417 also at the dispensaries of the Sleeping Sick- ness Service. Diseases of the Skin. Human myiasis, produced by the larvae of Cordylobia anthropophaga and other flies, is seen some- times. Scabies is widespread. Lesions, simu- lating crab yaws, frequently result from the bites of caterpillars of the tiger beetle. They are encountered as far south as Enugu. Various types of mycotic infections are ob- served. Tropical ulcers are prevalent, and almost 100,000 cases are treated each year in the Native Administration dispensaries. Infestation by the chigoe flea, Tunga pene- trans, is frequent. In 1932-35 a serious epi- demic was recorded among the pagan tribes on the Jos plateau, where it had been intro- duced by itinerant laborers. Other Infections. Trachoma is common, particularly in the north. Canine rabies is enzootic in all parts of the country, and sporadic human cases are reported each year. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is hyperendemic in the southern provinces, and endemo-epidemic throughout the rest of the country. In the coastal and the rain forest zones transmis- sion takes place during a large part of the year, with the peak of incidence between July and September. In the lower rainfall areas of the north severe outbreaks may occur during and after the rainy season. Over 100,000 cases of malaria are reported each year, which probably represent a small part of the actual incidence. Malaria constitutes a major cause of death, particularly among infants and young children. The infections in the south reach a maximum at from 2 to 4 years of age and decline gradually in the older age groups. Except in certain urban areas, the spleen rates among children, from 2 to 10 years of age, average 65 to 80 per cent. In the central savannah region where the trans- mission period covers 6 to 8 months, they approximate 55 to 75 per cent at the end of the rainy season. In the more arid north- ern districts transmission is restricted to less than 5 months, and the spleen rates drop to 40 to 50 per cent. In the course of population surveys in 194742 a spleen rate of 72 per cent and a parasite rate of 74 per cent were found among children under 12 years of age in 17 villages around Lagos. Corresponding rates among children under 12 years of age in 17 Lagos schools were 69 per cent and 71 per cent. The parasite rates vary with the local- ity and the season. In general, they range from 15 to 50 per cent in infants under one year; from 65 to 90 per cent in children, 1 to 10 years of age, and from 11 to 28 per cent in adults. Plasmodium falciparum is the predomi- nating species in all sections of the country. P. malariae infections are found chiefly in young children, with the highest incidence between 5 and 8 years of age. The rate of infection usually ranges between 3 per cent and 15 per cent. P. vivax is encountered infrequently. P. ovale is reported sporadi- cally, particularly from a focus near Lagos. Anopheles gambiae and A. funestus are the principal vectors. A Malaria Service was organized recently within the Medical Department. Extensive field surveys and research in anopheline control are in progress. From 20 to 50 cases of blackwater fever are recorded annually. Trypanosomiasis. Human trypanoso- miasis is widely distributed in northern and southeastern Nigeria. The main belt of endemicity is located in the central portion of the country, involving Zaria, Niger and Benue, the southern districts of Katsina and Kano and parts of Bauchi and Plateau prov- inces. Secondary areas of sporadic incidence are found along the edges of this region. In the south scattered foci exist in Owerri and Ogoja provinces and in the Tiko and Mamfe areas of the Cameroons. The Oyo gold-mining region is seriously infected, but little, if any, trypanosomiasis occurs else- where in the Western Provinces. Since 1925, extensive outbreaks of trypa- 418 Nigeria tt od +// Endemic or epidemic UL ,-“Localized or sporadic R Restricted mining areas Human Trypanosomiasis in Nigeria nosomiasis have been recorded, influenced by several factors: the dispersal of the populations into small, isolated hamlets; the increase in communication facilities; and the concentrations of laborers in the mining areas. Regional surveys and mass treatment measures were initiated by the Sleeping Sickness unit of the Nigerian medical services in 1930. In the initial sur- veys infection rates of from 5 to 25 per cent were common, while in certain districts, par- ticularly in Zaria Province, they reached 50 per cent. The spread of the infection was arrested by 1936-40. In 1946 the examina- tion of over half a million persons in scat- tered areas throughout 8 provinces?” re- vealed an average reduction in incidence to less than 1 per cent. Intensive resurveys the following year showed average infection rates of 0.5 per cent. Residual foci of greater prevalence exist, however, primarily in Bauchi, Plateau, Zaria and Katsina prov- inces. A localized outbreak with a total of 2,000 or more cases occurred in Galadima district, Katsina Province, in 1946, in which the infection rates in individual villages ranged from 2 to 20 per cent. Pockets of high incidence with rates up to 40 per cent were also discovered in villages in Yandaka district (Katsina) in 1947. The alluvial tin and gold fields are located in highly infected areas. Control measures, based on a permit system and examinations at 6-week inter- vals, were introduced in the tin-mining region of southwest Plateau Province in 1935 and in the Kabba-Ilorin and the Niger gold fields in 1940. The annual infection rate among the workers in these “restricted” areas was from 1 to 1.5 per cent in 1947, as against previous rates of from 40 to 60 per cent. The government control program is car- ried on by its Sleeping Sickness Service, supported by liberal grants from the British Colonial Development and Welfare funds. It incorporates the following: mass surveys and treatment; various measures for the eradication of the vectors, Glossina palpalis and G. tachinoides; and in some instances the concentration of populations in tsetse- free localities. Permanent dispensaries, where treatment is provided on a voluntary basis, have been established in the surveyed areas. They function as general clinics and centers for the development of public health activities. In 1946 the Sleeping Sickness Service operated 51 dispensaries, besides a number of temporary units, and co-operated in the work of 38 Native Administration dispensaries. Treatment facilities are also provided in the government and mission hospitals. An experimental control project was in- itiated in the Anchau district of Zaria Province in 1937. An area of 600 square miles, 60 to 70 miles in length, had been rendered tsetse-free by 1946, and about 50,000 inhabitants resettled in the corridor. The development has broad social and pub- lic health aspects, with the promotion of higher standards of living among the people. Model villages and demonstration farms have provided means for education in village sanitation and in improved methods of agriculture. The Sleeping Sickness Service also conducts field investigations on the efficiency of new drugs, as compared with the standard antrypol and Tryparsamide, and on the use of pentamidine isethionate as a prophylactic agent. A Trypanosomiasis Research Institute was established at Ka- duna and Vom in 1949 for research on both human and animal trypanosomiasis. It will Nigeria 419 serve all of the British colonies in West Africa. Rickettsial Infections. The first known epidemic of louse-borne typhus fever was reported from Jos on the central plateau in 1945. The outbreak involved a section of the “native town,” in which a total of 126 cases and 32 deaths was recorded. Due to the mild and slightly atypical character of the infection, however, the recognized cases are not indicative of the extent of the out- break. Control measures were promptly en- forced, including mass dusting of the in- habitants and the impregnation of the clothing and bedding in the compounds with DDT powder. During 1945 also a minor outbreak of louse-borne infection ap- peared in the city of Kano. Epidemic con- ditions recurred in Kano and in Jos in 1946; 90 cases with 31 deaths were recorded dur- ing the year. Mass delousing measures, using DDT powder, were carried out, imple- mented by pyrethrum spraying in the in- fected areas. Thirty-one cases were reported in 1947. Murine typhus is sporadic. Tick- borne typhus is known to be present, par- ticularly on the Bauchi plateau, but only a few cases have been observed. Yellow Fever. Small localized urban out- breaks of yellow fever occur at irregular intervals. In the decade 1934-44, a total of 30 to 40 cases was recorded from various parts of the country. In 1946 the disease appeared in epidemic form in numerous towns around Ogbomosho, in southwestern Nigeria. A total of 49 cases was reported, and the rate of unrecognized infections was believed to be high. Immunization of the population with yellow fever vaccine, and the destruction of adult Aedes in the dwell- ings by means of DDT and pyrethrum sprays were effective in bringing the epi- demic under control. Although clinical yellow fever is rela- tively infrequent among the indigenous populations, the infection is known to exist both in man and in monkeys throughout the southern forest region. Protective antibodies were demonstrated in the blood of adults in most of the communities visited in the course of protection test surveys in 120 towns and villages in 1931-32.2 Some degree of immunity was found among the children under 15 years of age in 80 per cent of the 99 localities in which samples were col- lected from children. Explosive outbreaks apparently have been experienced from time to time in all portions of the country, but the areas of highest endemicity are prob- ably centered in the southwestern provinces. A sampling of scattered areas in southern Nigeria by the staff of the Yellow Fever Research Institute in 1945-47 confirmed the existence of widespread immunity to the yellow fever virus in young children and in wild monkeys. Mass immunization with yellow fever vaccine is carried on in Lagos and various parts of the Protectorate. Aedes aegypti, the principal urban vector, is widely dis- tributed but most abundant in the southern provinces. A. africanus and A. pseudo- africanus are potential forest vectors, but the species involved in the transmission of jungle yellow fever and in the spread of the virus from the forest to the neighboring villages have not been identified. Filariasis. Wuchereria bancrofti infec- tions are prevalent in the north and fre- quently are associated with elephantiasis. Loa loa is endemic in the Kumba region of the Cameroons and the adjoining provinces. The incidence is not known, but in a survey undertaken in 1945% infection was demon- strated in 3.7 per cent of the children and 23 per cent of the adults examined. Calabar swellings predominate, but ocular loaiasis is not unusual. Foci of infection are also found in the Western Provinces. Acanthocheilo- nema perstans is widely distributed. Infec- tion rates approximate 50 per cent in the southern Cameroons. In highly infected areas this species may produce lesions which simulate Calabar swellings. A. streptocerca is frequently found in the Mamfe district where the infection rates range from 10 to 40 per cent. Onchocerciasis is common in many localities and particularly in Camer- 420 Nigeria oons Province and the adjacent districts of Adamawa and Benue provinces. Cases are also recorded from scattered areas as far north as Kano. A filariasis research unit was established at Kumba in 1949 by the Colonial Medical Research Committee, in association with the Liverpool School of Tropical Medicine. Relapsing Fever. Louse-borne relapsing fever is reported occasionally. In 1947-48 extensive outbreaks spread through the northern border provinces, coincident with epidemics in French West Africa. Katsina and subsequently Kano and Plateau prov- inces were affected. A total of 4,000 cases was reported from multiple small foci. Sta- tionary and mobile DDT dusting units were employed for the control of the outbreaks. Other Infections. Guinea-worm infec- tions, caused by Dracunculus medinensis, are widespread. In the north the highest incidence is found in Katsina, Benue and Adamawa provinces. In Katsina Province the infection rate was estimated at 16 per cent in 1947. Rates up to 10 per cent are also common in certain areas in the south- west, especially in the vicinity of Ibadan. Rare cases of plague are reported from residual foci in Lagos and the surrounding provinces. One case of bubonic plague oc- curred in 1947, the first since 1938. The last outbreak was recorded from Lagos in 1927. Leishmaniasis is sporadic in the Lake Chad region. Dengue fever is endemic. Un- recognized cases of Bwamba fever are ap- parently frequent. NutriTioNAL DISEASES Malnutrition and avitaminosis are com- mon, both in the Northern Provinces where food shortages are experienced annually toward the end of the dry season, and in the congested delta region of the south. Deficiencies in protein, in vitamin A and in vitamins of the B complex predominate. Night blindness is sometimes widespread in the north. Frank beriberi and pellagra are most prevalent during poor crop years, but from 1,000 to 2,000 cases may be treated annually in government hospitals and dis- pensaries. Scurvy is reported occasionally. Rickets is rare. Goiter is endemic in sections of Bornu, Benue and Plateau provinces and in cer- tain areas in the Cameroons. MisceLLaANEOUS CONDITIONS Infectious hepatitis is probably common. An extensive epidemic occurred in the Eastern Provinces in 1944, with the peak of incidence in August. Investigation revealed that the disease had been present in the area for some months, the first cases being ob- served in the vicinity of the Cross River. Almost 1,000 cases were reported, but only a small percentage were actually diagnosed by the medical officers. The death rates were extremely low. Pneumokoniosis occurs in certain rice- growing districts in the Cameroons. SUMMARY Marked differences in economic and social development and in the standards of living and of nutrition are encountered among the various peoples of Nigeria. The white popu- lation is small; the native population, ex- tremely heterogeneous. Public health is the responsibility of the Medical Department of the Nigerian government. It is admin- istered by a Director of Medical Services, with headquarters in Lagos. The medical and public health services are organized on a regional basis and are augmented by those of the Native Administrations and the vari- ous mission organizations. In 1947 there were 59 government, 15 Native Administra- tion, 34 mission and 18 private hospitals. In addition, 510 rural dispensaries were supported by Native Administrations. Water supplies are obtained from wells, springs and streams. Permanent streams abound in the south. Surface supplies are seasonal in the Northern Provinces, but subsurface sources exist in most areas. Vary- ing degrees of treatment are provided for the water supplies of the larger towns. Primitive methods of sewage disposal are Nigeria 421 employed in both urban and rural areas. The standards of sanitation are varied. Sanitary controls over meat, milk and other food supplies are enforced in Lagos and in the larger cities. Malaria, trypanosomiasis, yaws, leprosy, tuberculosis and venereal diseases are the major disease problems. Severe epidemics of smallpox and meningococcus meningitis occur almost annually. Intestinal infections and helminthiasis are prevalent. Schistoso- miasis is endemic in Northern and Western Provinces. Yellow fever is widely distrib- uted, but clinical infection is limited to sporadic cases and infrequent outbreaks. Murine and tick typhus are present. The first epidemic of louse-borne typhus was re- ported in 1945, Filariasis and trachoma are common. Rabies occurs sporadically. Mea- sles and whooping cough are frequently epi- demic. Pneumonia is prevalent. Scarlet fever and diphtheria are relatively rare. BIBLIOGRAPHY 1. Barber, M. A., and Olinger, M. T.: Studies on malaria in southern Nigeria, Ann. Trop. Med. 25:461-501 (Dec.) 1931. 2. Beeuwkes, Henry, and Mahaffy, A. F.: The past incidence of and distribution of yel- low fever in West Africa as indicated by protection test surveys, Tr. Roy. Soc. Trop. Med. & Hyg. 28:39-76 (June) 1934. 3. Blacklock, D. B.: Water supplies in the British Colonies, Ann. Trop. Med. 37: 211-220 (Dec.) 1943. 4. Briercliffe, R.: Leprosy in Nigeria, Leprosy Rev. 11:84-89 (Apr.) 1940. 5. Bruce-Chwatt, Leonard Jan: Recent studies on insect vectors of yellow fever and malaria in British West Africa, J. Trop. Med. 53:71-79 (April) 1950. 6. Cauchi, J., and Smith, E. C.: An analysis of 1758 Schick tests in Nigerian natives, Lancet 2:1393 (Dec. 22) 1934. 7. Clark, Alfred: Report on the effects of cer- tain poisons contained in food plants of West Africa upon the health of the native races, J. Trop. Med. 39:269-276, 285-291 (Dec.) 1936. 8. Davey, T. H.: Trypanosomiasis in British West Africa, London, H. M. Stationery Office, 1948. 9. Elmes, B. G. T.: The isolation of virulent strains of Corynebacterium diphtheriae in Nigeria, Ann. Trop. Med. 35:3-4 (Oct.) 1941. 10. ——: Undulant fever in Nigeria, Ann. Trop. Med. 35:1 (Oct.) 1941. 11. Findlay, G. M., and Elmes, B. G. T.: Typhus in northern Nigeria. II. Laboratory in- vestigations, Tr. Roy. Soc. Trop. Med. & Hyg. 41:339-352 (Dec.) 1947. 12. Fisk, Guy H.: Helminthiasis in Lagos, Ni- geria, Tr. Roy. Soc. Trop. Med. & Hyg. 32:645-652 (Feb.) 1939. 13. Gilroy, A. B.: Malaria control by coastal swamp drainage in West Africa. London, Ross Institute of Tropical Hygiene, Lon- don School of Hygiene and Tropical Medi- cine, 1948. Abst., Trop. Dis. Bull. 45: 1043-1045 (Nov.) 1948. 14. ——, and Chwatt, L. J.: Mosquito control by swamp drainage in the coastal belt of Nigeria, Ann. Trop. Med. 39:19-40 (May) 1945. 15. Gordon, R. M., Chwatt, L. J., and Jones, C. M.: The results of a preliminary en- tomological survey of loaiasis at Kumba, British Cameroons, together with a de- scription of the breeding places of the vector and suggestions for future research and possible methods of control, Ann. Trop. Med. 42:364-376 (Dec.) 1948. 16. Great Britain: Colonial Office. Annual Re- port on Nigeria for the Year 1946, Lon- don, H. M. Stationery Office, 1947. 17. ——: Economic Advisory Council, Commit- tee on Nutrition in the Colonial Empire. Summary of Information Regarding Nu- trition in the Colonial Empire, first re- port, part II, London, H. M. Stationery Office, 1939. 18. Hall, G. Norman: Tuberculosis in cattle— Its occurrence in northern Nigeria, West African M. J. 4:69-71 (Jan.) 1931. 19. Irvine, F. R.: West African Botany, London, Oxford, 1942. 20. Kuczynski, R. R.: Demographic Survey of the British Colonial Empire. Vol. I. West Africa, London, Geoffrey Cumberlege, Oxford, 1948. 21. Leper Institutions in Nigeria: Leprosy Rev. 7:172-181 (Oct.) 1936. 22. Leprosy in Nigeria: Leprosy Rev. 9:53-70 (Jan.) 1940. 23. Lester, H. M. O.: Further progress in con- trol of sleeping sickness in Nigeria, Tr. Roy. Soc. Trop. Med. & Hyg. 38:425-444 (July) 1945. 24. ——: The progress of sleeping sickness work 422 25, 26. 27. 28. 29. 30. 31. 32. 33. 34. 33. 36. Nigeria in northern Nigeria, West African M. J. 10:2-10 (Oct.) 1938. Maegraith, B. G.: The identification of the poisonous snakes of British West Africa. II. Details of genera and species, Ann. Trop. Med. 38:119-139 (Sept.) 1944. Mayer, T. F. G.: The distribution of leprosy in Nigeria with special reference to the aetiological factors on which it depends. Part I, West African M. J. 4:11-15 (July) 1930. McLetchie, J. L.: The control of sleeping sickness in Nigeria, Tr. Roy. Soc. Trop. Med. & Hyg. 41:445-470 (Jan.) 1948. Montgomery, T. H. L., and Budden, F. H.: Typhus in northern Nigeria. I. Epidemio- logical studies, Tr. Roy. Soc. Trop. Med. & Hyg. 41:327-337 (Dec.) 1947. Nash, T. A. M.: The Anchau Rural De- velopment and Settlement Scheme, Lon- don, H. M. Stationery Office, 1948. : The probable effect of densification of woodland upon the distribution of tsetse in northern Africa, West African M. J. 10:10-13 (Oct.) 1938. ——: Tsetse Flies in British West Africa, London, H. M. Stationery Office, 1948. Naudi, J.: Two cases of tropical typhus, West African M. J. 10:34-36 (Oct.) 1938. Nigeria: Annual report sleeping sickness service, 1944, 1945, 1946, Abst., Dis. Bull. 44:971-978 (Nov.) 1947. ——. Medical Department: Report on the Medical Services for the Year 1939, Lagos, Govt. Printer, 1941. —— ——: Report on the Medical Services for the Year 1940, Lagos, Govt. Printer, 1941. —— ——: Report on the Medical Services for the Year 1941, Lagos, Govt. Printer, 1942. Trop. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. . ——. —: Report on the Medical Services for the Year 1942, Lagos, Govt. Printer, 1944. : Report on the Medical Services for the Year 1943, Lagos, Govt. Printer, 1945. ——. ——: Report on the Medical Services for the Year 1944, Lagos, Govt. Printer, 1946. ——. —: Report on the Medical Services for the Year 1945, Lagos, Govt. Printer, 1946. , : Report on the Medical Services for the Year 1946, Lagos, Govt. Printer, 1947. ——. ——: Annual Report of the Medical Department for the year 1947, Lagos, Govt. Printer, 1949. Pasqual, J. R. H.: Field guide to the com- mon colubridae and viperidae, West Afri- can M. J. 10:36-39 (Oct.) 1938. Platt, B. S.: The nutritional status of the indigenous peoples of the colonies, Roy. Soc. Empire Scientific Conference Report 1:587-607, 1948. Ramsay, G. W. St. C.: A study of schisto- somiasis and certain other helminthic in- fections in northern Nigeria, West African M. J. 8:2-11 (Oct.) 1934. Simpson, T.: Yaws—and its treatment in the Bamenda division of the Cameroons under British mandate, West African M. J. 10: 14-34 (Oct.) 1938. Smith, E. C., and Howie, J. W.: A yellow fever protection-test survey of one hun- dred African children in Ibadan, Nigeria, Ann. Trop. Med. 36:176-178 (Dec.) 1942. Thomson, R. C. Muirhead: Recent knowl- edge about malaria vectors in West Africa and their control, Tr. Roy. Soc. Trop. Med. & Hyg. 40:511-536 (May) 1947. 30 Gold Coast GEOGRAPHY AND CLIMATE The British dependency known as the Gold Coast comprises three divisions: the Gold Coast Colony, Ashanti and the pro- tectorate of the Northern Territories. In addition, a section of Togoland is adminis- tered under United Nations trusteeship, the northern part with the Northern Territories, and the southern part with the Colony. An oblong country of some 91,690 square miles, the Gold Coast has a coastline of 354 miles on the Gulf of Guinea and is completely surrounded inland by French territory, by Ivory Coast and Upper Volta on the west and the north and by French Togoland on the east. Topographically, the country, which has a general elevation of less than 1,000 feet, may be divided into three zones: coastal plain, forest and savannah. The rolling scrub plain along the coast increases in width from one mile at Takoradi, to about 60 miles on the eastern frontier. The western part of the Colony and southern Ashanti are character- ized by dense forest and are separated from the eastern plains by groups of moun- tains. These run northwest from Accra, through Mampong to the western border and contain peaks rising to 2,500 feet. All of northern Ashanti and the Northern Terri- tories is undulating open woodland, inter- spersed by areas of treeless plateaus. The entire country is watered by numerous small rivers and streams, but, with the ex- ception of the Volta and its major tribu- taries and the larger rivers in the forest zone, the majority are seasonal and flow only during the rainy season. The climate is tropical, with variations conforming to the physical features of the different regions. The country south of Kumasi has virtually two rainy seasons: rains from March to July and from Sep- tember to November, with an interval of relative dryness during July or August. In the north, rain falls from March to No- vember, with a maximum in August and September. The annual rainfall averages 40 to 60 inches over a large part of the terri- tory, with heavier precipitation in the south- west and lower along the coast and in the far north. The humidity is high in the south, but from 15 to 25 per cent lower in the northern areas. The mean maximum tem- peratures range from around 82° to 88° F. at Accra to 92° to 95° F. at Tamale. Corre- sponding mean minimum temperatures are about 74° to 75° F. and 64° to 69° F., re- spectively. The daily range is usually slight, but increases with the distance from the coast and with the season, being greatest during January and February when the harmattan blows from the Sahara. POPULATION AND SOCIO-ECONOMIC CONDITIONS PorurAaTION Provisional estimates based on the census of 1948 place the population at 4,473,942. Probably one half of the inhabitants live in the Colony, and one tenth in Togoland (British), with the remainder divided be- tween Ashanti and the Northern Territories. The non-African population, which totaled 5,609 in 1948, is predominantly British and + Syrian and is settled chiefly in the Colony. 423 424 Gold Coast The indigenous population is made up of 50 or more tribes. The peoples of the Colony and Ashanti are of pure Negro origin and belong to two main groups: the Akans, west of the Volta River, and the Ewes in the east. The principal languages are the Chi (or Twi) of the Akans, the Ewe language, and the Ga, which is spoken by the tribes of the Accra and the Volta River areas. The inhabitants of the Northern Territories and of Togoland are Negroid peoples and employ a wide diversity of dialects which may have a common root—Mossi. Large colonies of Hausas and of Fulani are scattered through- out the country, particularly in the north, where a corrupt form of Hausa has become the language of trade. English is widely used in the larger towns and in the mining centers of the Colony and Ashanti but less fre- quently in the Northern Territories. Most of the tribes are pagans, but roughly 10 per cent of the inhabitants have been converted to Christianity, and a small proportion, in- cluding the Hausas, are Moslems. The population is unevenly distributed, with centers of concentration in the coastal towns, in the cocoa-producing districts, in the mining areas and in the northeast corner of the Territories. The population density averages from 65 to 70 per square mile in the Colony and about 25 in the rest of the country. The people are primarily agricul- turalists, and there are few large urban com- munities. Accra, the capital, had a popu- lation in 1948 of 135,456. Kumasi, the administration headquarters in Ashanti, had a population of 70,705; Sekondi-Takoradi of 44,130; and Cape Coast, Winneba, Tamale and Koforidua of between 15,000 and 25,000. Education is more advanced than in some of the neighboring territories of West Africa. However, the rate of literacy is low in the Northern Territories and does not exceed 25 per cent in the Colony and Ashanti. Schools are conducted by Protes- tant and Catholic missions and by the Native Administrations, the majority of which are subsidized by the government. Achimota College, an independent, govern- ment-endowed institution near Accra, is the largest secondary school in the country. In 1948 the University College of the Gold Coast was established at Achimota, with financial assistance from the British Devel- opment and Welfare funds, the Gold Coast government and the local Cocoa Marketing Board. It is affiliated with the University of London. VITAL STATISTICS Vital statistics for the Gold Coast are based upon the reports from 35 registration areas, which cover roughly 11 per cent of the total population. They are largely urban in composition, however, and are not repre- sentative of the country as a whole. In 1948 the birth rate was calculated at 29.4 per 1,000 population, and the death rate at 21.4. From 1942 to 1948 the infant mortality rate ranged from 110 to 124 per 1,000 live births. Regional differences are shown by the esti- mates of 1931, which indicate infant mor- tality rates of 143 to 171 in the Colony, 145 in Ashanti, 188 in Togoland and 224 in the Northern Territories. In 1948 the maternal mortality was 20.3, and the stillbirth rate 87 per 1,000 live births. SociaL Economy Agriculture is the chief occupation of the people, most of whom are small farmers. Cocoa, the major export crop, contributes about 50 per cent of the total income of the country. It is grown in the forest zone be- tween the main mountain ranges and the ocean, where roughly one million acres are under cultivation. Since 1938, a disease known as “swollen shoot” has threatened the existence of the industry, but the gov- ernment’s agricultural department has been making a strenuous effort to combat it. A West Africa Cacao Institute has been organ- ized recently at Tafo with facilities for research on methods for controlling the disease. Secondary agricultural products include palm oil and palm kernels, copra, coffee Gold Coast 425 limes and rice. In the northern areas pro- duction is limited by unfavorable rainfall conditions, but in some districts cattle are raised for shipment to the population cen- ters in the south. Small amounts of seed cotton are grown in southern Togoland (British), but attempts to establish the industry in the Northern Territories have not been successful. The major mineral exports are gold, in- dustrial diamonds, manganese ore and baux- ite. Mining is carried on by European com- panies, except in a few areas, chiefly in Tarkwa district, where the diamond fields are worked by native producers. The allu- vial gold deposits for which the Gold Coast has been celebrated from earliest times are no longer profitable. About one third of the country is covered with dense forest; mahogany and other luxury woods are ex- ported. Industrial development consists pri- marily in small plants for the processing of cocoa butter, palm oil, soaps, rice and other agricultural products. Communication facilities are generally adequate in the Colony and in southern Ashanti but poor in the northern part of the country. Motor roads connect the principal towns and the established industrial and agricultural communities. A system of government-owned railways traverses the mining and the cocoa-raising areas. One section connects Takoradi and Kumasi, with a branch from Huni Valley to Kade, while a second line links Accra and Kumasi. Ship- ping and air services are maintained be- tween Takoradi and Accra and the United Kingdom, Europe and the neighboring terri- tories in Africa. The Volta River and for short distances its tributaries, the Black Volta and the White Volta, are navigable for small craft and provide important means of travel into the interior. Foop AND NUTRITION The food habits of the people are influ- enced by the climatic and soil conditions which govern the type of crops cultivated in the different zones. In the south cassava, maize, plantain, yams and palm oil are the principal foods, supplemented by peanuts, shea-nut butter, rice, legumes and various indigenous greens and fruits. Coconuts are plentiful along the coast. The forest zone is capable of producing a diversity of tropical foodstuffs, but cultivation is frequently neg- lected in favor of the cash crop, cocoa. Fish is an important food in the coastal and the river regions. Cattle are raised only in sec- tions of Eastern Province, but sheep, goats, pigs and poultry are common in most villages. However, little meat is usually consumed, except in the more prosperous families. In the Northern Territories, recurrent droughts and primitive methods of agricul- ture limit the quality and the quantity of foodstuffs. Millet, guinea corn, cow peas and peanuts are dietary staples in the extreme north; maize, yams, peanuts and certain vegetables, in the basin of the Volta River. Shea-nut butter is used extensively. Fruits and green vegetables are scarce, except dur- ing the rainy season. Extensive cattle-raising areas are located in the Northern Terri- tories, but the supply is inadequate to meet the needs of the country. Milk is available only in a few districts. The average Gold Coast diet is poorly bal- anced, but nutritional diseases are observed mainly among the children and the migra- tory laborers. The chief deficiencies are in protein, calcium and vitamins, particularly the B complex and A. Malnutrition is most prevalent in the urban centers, where pov- erty and local food shortages due to trans- portation difficulties are important factors. The government is attempting to improve the standard of nutrition through the pro- motion of diversified crops and mixed farm- ing. Programs for the control of the common animal diseases and the improvement of cattle and other livestock are carried on by its Department of Animal Health. Experi- mental farms and demonstration stations serve as centers for the education of the people in modern methods of agriculture and animal husbandry. 426 Gold Coast Housing Standards of housing, and types and ma- terials of construction differ in the various sections of the country. Sand or concrete blocks are commonly employed in the urban areas; sun-dried brick or wattle and daub, in the rural. In the Northern Territories, the housing is generally more primitive than in the south. The native dwellings are usu- ally round, with thatch roofs which vary in type according to tribal customs. In some areas they are high-pitched and in others flat. Throughout the Colony and southern Ashanti improvements have been introduced within recent years, but in the larger and older towns considerable congestion and a high percentage of overcrowded, insanitary dwellings exist in many sections. Ambitious housing programs are being sponsored by the Gold Coast government in Accra, Tako- radi, Sekondi, Cape Coast and Kumasi. ENVIRONMENT AND SANITATION WATER SUPPLIES Water supplies are abundant in the heavy rainfall areas of the western part of the Colony and Ashanti, but they are scarce and seasonal in the Accra plain and southern Togoland and in the Northern Territories. Water is obtained from rivers and streams, from wells and, particularly in the more arid regions, from rain storage tanks and reser- voirs. In many areas the principal sources are shallow waterholes or small ‘“hand- scrapes” in the dried river beds, which readily become polluted through human and animal usage. Within the last decade an active program for the provision of sanitary water supplies in the rural areas has been undertaken by the government in co-opera- tion with the Native Authorities. New wells and impounded reservoirs are being con- structed, primarily in the Northern Terri- tories where the seasonal shortages are most acute. The water supply of Accra is taken from the Densu River, while river-fed reservoir sources are available in Kumasi, Sekondi- Takoradi, Cape Coast, Winneba, Tamale and Koforidua. All are treated by filtration and chlorination. The municipal supplies are subject to sanitary supervision, but the small rural supplies are usually contami- nated. WasTE Di1sposAL Bucket and pit latrines are the most fre- quent means of sewage disposal, but septic tanks are common in the business and the residential sections of the larger towns. Facilities for the disposal of sewage are in- adequate in the congested areas of the cities, particularly in Accra. Incineration is em- ployed in some mining regions and to a limited extent in Accra. Communal trench latrines are found in many villages in the south. Borehole latrines are also being intro- duced on an experimental scale in certain rural districts. In most areas indiscriminate pollution of the soil is a general practice. Fauna anp Frora Arthropods. Mosquitoes. Sixteen or more species of anopheline mosquitoes are found in the Gold Coast, but only Anopheles gambiae, A. gambiae melas, A. funestus, A. hargreavesi, A. nili and A. hancocki, have been incriminated as vectors of malaria. A. gambiae is the principal vector, but A. funestus is also important in most sec- tions of the country. A gambiae melas is abundant in the coastal region, where it breeds along the edges of the small lagoons. About 38 species of Aedes mosquitoes have been recorded from the territory. Aedes aegypti probably plays a major role in the transmission of yellow fever. A. simpsoni, A. africanus, A. vittatus, A. luteocephalus and other potential vectors are also found. A variety of Culex mosquitoes is present. The majority are considered to be merely annoying pests, but Culex quinquefasciatus (=C. fatigans) may be of importance in the transmission of Wuchereria bancrofti. Taeniorhynchus (Mansonia) africanus and T. (M.) uniformis are widely distributed. Mosquito-control measures, which are Gold Coast 427 largely limited to the more populous centers in the Colony, include the drainage of coastal lagoon areas, the drainage or filling of pools and swamps, the clearing of vege- tation along the banks of the streams, and the antilarval treatment of bodies of stand- ing water with oil, Paris green or DDT. Difficulty is encountered in the control of A. gambiae, due to its tendency to invade recently cleared sections of forest. Wide- spread Aedes control is carried on in com- munities where yellow fever is known to be endemic. Fries. At least nine species of tsetse flies have been reported. Glossina palpalis, which breeds along the banks of the water courses, is found irregularly in the dense forest and more extensively in the drier por- tions of the forest and the savannah region. G. tachinoides breeds along the rivers and the streams as far south as 8° N. lati- tude. It is probably the most important vector of animal trypanosomiasis and ranks with G. palpalis as a significant vector of human trypanosomiasis. G. longipalpis in- habits the transition zone encircling the forest and extends eastward into Togoland. G. morsitans is present in the savannah country of the north. G. fusca and G. nigro- fusca are encountered occasionally. Control measures, including “aggressive” and “dis- criminative” bush clearings, are carried on by the government under the direction of its medical and veterinary departments. Species of Musca and Stomoxys are prob- ably implicated in the mechanical transmis- sion of intestinal and other infections. Vari- ous species of the genera T'abanus, Chrysops and Haematopota are widespread. Chrysops dimidiata is responsible for the transmis- sion of occasional cases of loaiasis. Myiasis- producing flies are numerous, the “tumbu” fly, Cordylobia anthropophaga, being one of the most important. The bloodsucking maggots of Awuchmeromyia luteola fre- quently infest the floors of native huts. Eight species of Simuriae have been identified ; Simulium damnosum transmits Onchocerca volvulus in many localities. The midges, Culicoides austeni and C. grahami, are vectors of Acanthocheilonema perstans. Lice. The human lice, Pediculus humanus corporis, P. humanus capitis and Phthirus pubis, are common among certain tribes. The first is sometimes implicated in the transmission of typhus and relapsing fevers among the Moslem tribes of the north. Freas. Xenopsylla cheopis is the most abundant of the rat fleas. The human flea, Pulex irritans, and particularly the dog flea, Ctenocephalides canis, are troublesome pests. The chigoe flea, Tunga penetrans, is prevalent. BebBucs. The bedbugs, Cimex hemipterus and probably C. lectularis, are present in most areas. Ticks anp Mi1tTES. Various species of ticks infest domestic and wild animals, including Rhipicephalus sanguineus and Haemaphy- salis leachi. The tampan tick, Ornithodorus moubata, the vector of relapsing fever in other parts of Africa, is not reported from this region. The human itch mite, Sarcoptes scabiei, is widely distributed and frequently pro- duces severe skin lesions. Scorpions AND SpipErs. Both large and small scorpions are common. Pandinus im- perator, in particular, has a severe sting. Numerous species of spiders are found. The large, hairy spider, Scodra brachypoda, in- flicts painful bites. Reptiles. A number of venomous snakes exist in the territory, but the reported fatal- ities from snake bite rarely exceed 25 to 35 a year. The cobras, Naja nigricollis, N. melanoleuca and N. goldii, are fre- quently found near human habitations. Bitis arietans and B. gabonica are probably the most dangerous of the vipers, but B. nasi- cornis, Atheris chlorechis, Causus rhom- beatus and several species of the burrowing Atractaspis are also present. The mambas, Dendroaspis viridis and D. jamesonii, are reported from many localities. Several spe- cies of rear-fanged snakes are encountered, the most dangerous being the boomslang, Dispholidus typus. Species with a relatively 428 Gold Coast weak venom include Leptodira hotamboeia, Psammophis irregularis, Dromophis prae- cornatus and D. lineatus. The crocodiles, Crocodilus cataphractus, C. niloticus and Osteolaemus tetraspis, in- habit the banks of the Volta River and its tributaries. Rodents. Rattus rattus rattus, R. rattus alexandrinus and R. norvegicus are preva- lent, particularly in the coastal towns. Wild rodents, including the giant rat, Cricetomys gambianus, are widely distributed. Rickett- sial infections have been demonstrated in specimens of R. rattus rattus and C. gam- bianus captured in the Accra port area. Mollusks. Physopsis africana globosa is probably the intermediate snail host of Schistosoma haematobium. Infections with S. mansoni are recorded from some areas, but the intermediate host has not been determined. Plants. Large numbers of poisonous plants are found, many of which are used by the natives for medicinal purposes or for killing fish or arrow poisons. Several species of Euphorbia and at least one of Croton are present. The latex produces a severe local irritation of the skin or the eyes. Strophanthus hispidus and S. sarmen- tosus are frequent ingredients of arrow poi- sons. Infusions of the bark of the sasswood, Erythophleum guineense, have often been employed in tribal ordeal ceremonies. Other important poisonous plants include E. mi- cranthum, S. gratus, Jatropha multifida, Melia azedarach, Gloriosa virescens, G. su- perba, Datura metel and D. stramonium. The shrub, Dichapetalum flexuosum, grows on the Accra plains and may be dangerous to livestock. The seeds of Hilleria latifolia are sometimes responsible for the death of sheep and goats in the southern part of the country. Foop SANITATION The markets and the slaughter houses in the larger towns are controlled and inspected regularly by the government or municipal health services. Animals are inspected before and after slaughtering. Supervision is also maintained over the cold storage plants and the aerated water factories. Facilities for the steam steriliza- tion of cysticercus-infected meat are op- erated in connection with some abattoirs, and the subsequent sale of treated meat is permitted if the infection is not extensive. Restaurants and bakeries are licensed in the principal towns and are inspected when sufficient staff is available. Little fresh milk is used. It is produced in limited quantities in some areas, but sanitary controls are not enforced. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The health and medical services of the Gold Coast government are centralized in its Medical Department, which is adminis- tered by a Director of Medical Services, with headquarters at Accra. The Depart- ment is a major unit of government, and the Director of Medical Services functions as a member of the Executive Council. It is advised indirectly on matters of policy by the medical officers of the Colonial Office in London. The Medical Department is organized on a regional basis, with the headquarters for the Colony at Cape Coast; for Ashanti at Kumasi; and for the Northern Territories at Tamale. The regional divisions, under Assistant Directors of Medical Services, are responsible for the maintenance of govern- ment hospitals and dispensaries, the super- vision of sanitation and the control of com- municable diseases. The central organiza- tion includes laboratory, personnel training and leprosy control sections, and a Sleeping Sickness Service which operates in the Northern Territories. Municipal health services are established in Accra, Kumasi, Cape Coast and Sekondi- Takoradi. Local government in the smaller communities is the function of designated Native Authorities, to whom certain health Gold Coast 429 services, such as village sanitation, are dele- gated. Several mission organizations carry on medical and health programs in the terri- tory in co-operation with the Medical De- partment. The British Red Cross Society has an active branch in the Gold Coast which works in close association with the Department. Maternal and child welfare work is conducted by the government, the missions and the Red Cross. A public health museum in which models and pos- ters on sanitary and health subjects are displayed is sponsored by the Red Cross at Accra. MEepicAaL INSTITUTIONS Hospitals and Dispensaries. In 1950 the Medical Department maintained 32 gen- eral hospitals with an aggregate capacity of 1,348 beds and 201 cots. The largest, located in Korle Bu (Accra) and in Kumasi, had 282 and 213 beds, respectively. The re- maining hospitals ranged in size from 12 to 84 beds. A maternity hospital with facili- ties for 132 patients and a children’s hos- pital with 12 cots for serious cases are estab- lished in Accra. The Department also operates hospital units with a total of 89 beds for paying patients, which are used chiefly by Europeans, at Accra, Cape Coast, Sekondi-Takoradi, Kumasi and Tamale. Special facilities include communicable dis- ease hospitals, a mental hospital and a leprosy settlement at Ho. The number of hospital beds per 1,000 of population was estimated in 1946 at 0.4 in Gold Coast Colony, 0.32 in Ashanti and the Northern Territories and 0.35 in British Togoland.?® Only the larger hospitals are equipped with x-ray and laboratory facilities. Village dispensaries or dressing stations are scattered throughout the rural areas, many of which are supported by the Native Authorities. The Department also operates three mobile dispensaries. Child welfare centers, with home-visiting services, are established at Accra, Kumasi, Cape Coast and Sekondi. The Basel Mission maintains a well- equipped hospital at Agogo in Ashanti. Achimota College has a small hospital for the benefit of its students, and several of the mining companies provide hospital serv- ices for their employees. Laboratories. The Medical Research In- stitute in Accra is the central laboratory of the Medical Department. It is equipped for the performance of routine bacteriologic, pathologic, parasitologic, serologic and chemical examinations for the Colony, as well as a limited amount of research. Diag- nostic laboratory facilities are also available in connection with the hospitals at Sekondi- Takoradi, Cape Coast, Kumasi and Tamale. The government’s Veterinary Department maintains a small laboratory at Pong- Tamale for the preparation of vaccines against various animal diseases. Schools. There is no medical school in the Gold Coast, but students are sent on government scholarships to Great Britain for training in medicine and dentistry. Plans are underway for the expansion of the Medi- cal Faculty at University College, Ibadan (Nigeria), to receive students from all the British West African colonies. A Nurses Training College is established at Korle Bu (Accra). It is the only insti- tution which meets the standards required for certification. Nurses training schools are also operated in connection with the govern- ment hospitals at Accra, Kumasi, Tamale, Sekondi and Cape Coast, with the mission hospital at Agogo (Ashanti) and with a few mine hospitals. Male nurses are trained to assume charge of the village dressing sta- tions in the larger hospitals and at the Native Authority Center in Kintampo. Schools for midwives are located in the maternity hospital in Accra and at Kumasi. Courses for health visitors are given at the Princess Mary Louise (children’s) Hospital in Accra. A school for dispensers is con- nected with the Gold Coast Hospital at Accra. Training courses for sanitary inspec- tors are conducted in Accra, and for sani- tary “overseers” in Tamale. 430 Gold Coast PERSONNEL Physicians. In 1950 a total of 121 physi- cians was licensed in the Gold Coast, but all were not present in the territory. About 75 to 85 members of the Colonial Medical Serv- ice were employed in the Medical Depart- ment. A few doctors are connected with the mission hospital at Agogo and with the mining companies. Others are engaged in private practice in Accra and Kumasi. Dentists. In the same year 6 dentists were located in Accra and Kumasi. One or more dental surgeons are usually attached to the Medical Department. Nurses. The European staff of the De- partment included 34 nurses, and the native nursing personnel totaled over 475 nurses and 10 health visitors. Others. The roster of the Department also listed 36 midwives, 11 sanitary super- intendents and 148 sanitary inspectors. At least 2 pathologists and 2 medical entomol- ogists are connected with the service. DISEASES Statistics regarding the prevalence of communicable disease are derived largely from the records of admissions to the gov- ernment hospitals and outpatient dispen- saries and give little indication of the total incidence. Primitive forms of medicine per- sist in many areas, and a large proportion of the inhabitants attend the established clinics only as a last resort, after their tra- ditional methods of treatment have failed. The reports of special surveys furnish in- formation which is applicable to limited areas and may or may not reflect condi- tions in the country as a whole. DiseAsES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UriNARY TRACTS Typhoid and Paratyphoid Fevers. Enteric fevers are endemic. Approximately 200 to 400 cases of typhoid, 10 to 30 cases of paratyphoid and 10 to 150 cases of un- defined fevers are treated each year in the government hospitals. Paratyphoid fevers A and B are common, but group C is relatively rare. Dysenteries. Amebiasis predominates among the dysenteries listed in the hospital reports, but the statistics are probably mis- leading, since laboratory diagnoses are not made in a large proportion of the cases. Both bacillary and amebic infections are prevalent, and localized outbreaks occur frequently. From 250 to 800 cases of bacil- lary, from 800 to 1,200 cases of amebic and from 1,500 to 3,500 cases of unclassified dysentery are treated annually in the gov- ernment hospitals and dispensaries. Shigella dysenteriae is relatively rare, but paradys- entery infections are numerous. Other intes- tinal diseases, many of which are probably undiagnosed bacillary dysenteries, are wide- spread. Over 6,000 cases of diarrhea and enteritis are recorded each year in persons under two years of age, and from 5,000 to 14,000 in persons over two years. Helminthiases. ANcyLosTomiasis. Hook- worm infection is widely distributed, partic- ularly in Mamprusi district in the Northern Territories. The prevalence usually averages between 40 and 50 per cent and may reach 70 to 80 per cent in some areas. Ancylostoma duodenale apparently predominates in many localities, but Necator americanus is also widespread. From 3,000 to 8,000 cases are treated each year in government institutions throughout the country. Severe infections are rarely observed, however, and the re- ported cases do not represent the true in- fection rates. Scuistosomiasis. Schistosomiasis, caused by Schistosoma haematobium, is endemic in the Oda, the Volta River and the Accra districts of the Colony and in numerous foci in Ashanti and the Northern Terri- tories. The prevalence averages about S per cent in the forest and the coastal regions. Physopsis africana globosa, the probable intermediate snail host, is found in the pools and the permanent streams. Infections with S. mansoni are reported from limited areas in Ashanti and the Northern Territories, but the responsible intermediate snail host is Gold Coast 431 not known. From 3,000 to 6,000 cases of schistosomiasis are treated each year in the government hospitals. Oraer HrrmiNnTH INFECTIONS. Other forms of intestinal helminthiasis are prev- alent; ascariasis and strongyloidiasis are the principal worm diseases in most sections of the country. Taenia saginata, Hymeno- lepis nana and Echinococcus granulosus oc- cur primarily in the Northern Territories. Other Infections. Brucellosis is enzootic among cattle and goats, and occasional human cases are recorded. These infections probably result from the consumption of goat’s milk, since little cow’s milk is con- sumed in the Colony or Ashanti. Cholera has not been reported from this region. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Pulmonary tuberculosis is widespread, especially in the congested coastal towns and in the mining areas. The disease constitutes one of the most serious public health problems in the Gold Coast. An average of 2,500 known cases is treated annually, while the deaths due to tubercu- losis represent from 8 to 12 per cent of the total deaths reported from government insti- tutions throughout the country. A large pro- portion of the cases occurs among the transient laborers from the rural areas. The disease was formerly rare in the Northern Territories but is spreading rapidly with the return of infected workers to their home villages. In the mining regions tuberculosis is sometimes associated with silicosis. No special facilities for the diagnosis and the treatment of tuberculosis exist, and the actual extent of infection is not known. Other forms of tuberculosis are common but comprise only 15 to 20 per cent of the total cases reported. Smallpox. Smallpox is endemic, and scat- tered outbreaks are recorded almost annu- ally. The most extensive epidemics usually develop in the Northern Territories where the disease is readily introduced from across the border. In case of an outbreak control measures, including widespread vaccination, are rigorously enforced in the affected areas by the government health authorities. When the disease was epidemic in 1942, a total of 1,995 cases was reported, of which 1,649 were from the Northern Territories. In most areas the fatality rates averaged less than 5 per cent, but in two localized outbreaks they reached 20 per cent. Major epidemics were again recorded from the north and from Keta district in southern Togoland in the period 1946-48. The fatality rates ranged from 10 to 20 per cent. During the last few years repeated vacci- nation campaigns have been undertaken, especially in the Colony and in Ashanti. In 1948 a drive was initiated in conjunction with the French authorities in the frontier districts of Togoland. Meningitis. Epidemics of meningococcus meningitis are frequent in the Northern Territories, and scattered cases are reported annually from various parts of the country. The outbreaks usually start between Janu- ary and March, at the time of the karmat- tan, and subside with the onset of the rainy season. The most extensive epidemics of recent years occurred in 1945 and 1948 in the Northern Territories. The disease ap- parently had died out in this area around 1908, following a series of devastating out- breaks, but began to reappear in 1941. In 1945 a total of 9,863 cases and 1,056 deaths was recorded, and in 1948, 11,002 cases with 868 deaths. In the intervening years the incidence averaged from 700 to 1,200 cases annually. In 1947 there was a localized out- break in Accra in which 225 cases were observed. Other Infections. The infection rates for pneumonia are usually high and reach a peak during the harmattan season. Lobar infections are more numerous than bron- chial among the reported cases, but a large proportion are unclassified. Measles, whooping cough and influenza are endemic and often epidemic. Diphtheria and poliomyelitis are sporadic, but scarlet fever is relatively rare. 432 Gold Coast DiseasES SPREAD OR CONTRACTED CuierLy THROUGH CONTACT Venereal Diseases. All types of venereal disease are prevalent, the incidence being highest in the coastal towns. Gonorrhea is the predominating infection, but the actual incidence is not known, since only the most severe cases register for treatment in the government hospitals and dispensaries. In 1948 approximately 20,200 cases of gonor- rhea were reported, as against 2,621 of syph- ilis. Syphilis is rarely encountered in the rural districts where yaws is endemic. A special venereal disease clinic is operated in connection with the Gold Coast Hospital in Accra. Yaws. Yaws is widely distributed, par- ticularly in the rural areas in the forest and the southern savannah zones. The number of cases treated in the hospital dispensaries increased from 78,819 in 1941 to 144,400 in 1947, partly as the result of the inaugura- tion of free treatment facilities by the Medical Department. Since 1943, a mass- treatment campaign has been carried on in the Northern Territories, which in 1947 was combined with the trypanosomiasis-control program. The mass-treatment measures will gradually be extended into the most remote rural communities. In a medical survey of a village on the southern fringe of the forest zone in 1949¢ about 38 per cent of the in- habitants showed clinical signs of yaws, while 76.5 per cent gave a history of infec- tion. Leprosy. Leprosy is widespread through- out this region. The incidence is highest in the eastern part of the Colony; in Ashanti, especially around Lake Bosumtwi, Kumasi and Kintampo; and in the Northern Terri- tories. It is lowest in the central and the western portions of the Colony, particularly in the coastal area. It was estimated in 1938 that there were over 8,000 lepers in the country, but the present incidence is not known. In 1948 about 2,750 lepers were under treatment in government institutions. There are 5 treatment centers. The settle- ment at Ho (Togoland) accommodates 521 patients, but those at Yendi, Lake Bosum- twi, Accra and Kumasi are merely camps providing simple therapy. Other Infections. Cases of tetanus are reported frequently. Canine rabies is en- zootic, and human infections occur sporadi- cally. Various skin conditions—tropical ulcers, fungus infections and scabies—are common. Anthrax is reported occasionally. DISEASES SPREAD BY ARTHROPODS Malaria. The entire Gold Coast is highly malarious, and infection is almost universal among the native populations. At least 60,000 persons are treated annually in the government hospitals and dispensaries, but this figure represents only a fraction of the total number of infections. Splenic indices vary in different parts of the country, being higher in the western coastal region than around Accra or Kumasi. In a survey of a forest village 60 miles from Accra in 1949.8 spleen enlargement was observed in 25 per cent of the individuals under one year of age; in 86 per cent between 1 and 5 years; in 62 per cent between 6 and 15 years; in 24 per cent between 16 and 45 years; and in 17 per cent over 45 years. Infections with Plasmodium falciparum predominate. P. vivax and P. malariae are identified in a small percentage of cases, with the latter infection found primarily in young children. P. ovale is occasionally re- ported. Amopheles gambiae is the most frequent vector, but A. fumestus and A. gambiae melas are of major significance in certain areas. Little malarial control work is undertaken outside of the larger centers, primarily Accra and Sekondi-Takoradi. Blackwater fever is sporadic, with from 40 to 80 cases recorded each year. Trypanosomiasis. African sleeping sick- ness, caused by Trypanosoma gambiense, occurs in the Northern Territories and Ashanti but is absent from the coastal re- gion except for minor foci in the western dis- Gold Coast 433 tricts. The highest infection rates are found in the Northern Territories, where they average between 1 and 2 per cent but reach 10 to 50 per cent in scattered vil- lages.” The Sleeping Sickness Service of the Medical Department carries on an active antitrypanosomiasis program, based upon the mass treatment of cases in special centers and the clearing of bush along rivers and streams where the vectors, Glossina palpalis and G. tachinoides, are encoun- tered. The Sekondi-Takoradi area is mildly infected; in a survey completed in 1942 about 15,000 persons were examined, with an infection rate of 0.16 per cent.’ Surveys in 1947-48 showed that the incidence was also trivial along the eastern Togoland frontier, except in part of Krachi district where it approaches 1 per cent. An average of 2,500 to 4,000 cases is treated annually in the government hospitals. Yellow Fever. Cases of yellow fever are reported almost every year. A total of 10 cases was recorded during the period 1940 through 1947, and subsequently 37 cases in 1948-50, with 18 in 1949 and 16 in 1950. The last major epidemic was experienced in 1937, when at least 75 cases occurred in Eastern Province. Evidence that the infec- tion has existed at intervals in widely sepa- rated areas throughout the country has been revealed by immunity surveys. In an in- vestigation in the Northern Territories in 1932, protective antibodies were found in the sera of 8 to 52 per cent of adults and children examined in three towns in which the disease had been epidemic the previous year, and also in seven towns from which .no cases had been reported. In 1932-33 immune antibodies were found in the blood of 4 per cent of the persons examined in Sekondi and Saltpond, in 8 per cent in Accra, in 24 per cent in Koforidua and in 28 per cent in Cape Coast. Rickettsial Infections. Louse-borne typhus fever may occur sporadically, but no epidemics have been reported within recent years. Murine, or flea-borne typhus, has been encountered near Accra and in the vicinity of Kumasi. Occasional cases sug- gestive of tick-borne infection have also been observed in northern Ashanti. Filariasis. Infections with Wuchereria bancrofti, Loa loa and Acanthocheilonema perstans are endemic. Elephantiasis is en- countered occasionally. In the village sur- vey cited above® A. streptocerca was found in 21 per cent of the individuals examined, and 11 per cent showed a mild degree of “presbyderma.” Onchocerciasis is prevalent in numerous foci along the upper reaches of the Red Volta and the White Volta rivers. In certain areas where the incidence of blindness is high, a large percentage probably is caused by infection with Onchocerca volvulus. Other Infections. Plague has not been reported since 1924, but an old focus exists in the Ashanti region. There is constant danger of its introduction into the con- gested coastal towns where rat-control measures may be lax. Louse-borne relapsing fever occurs spo- radically among the tribes of the north. A few cases are reported each year, but the incidence is seldom high. Cases of kala-azar and dermal leishmaniasis are recorded from time to time. Dracontiasis, or guinea-worm infection, is widely distributed in the Northern Terri- tories where acute water shortages are ex- perienced in the dry season and the inhabit- ants sometimes travel long distances to obtain water from communal pools. NuTrITIONAL DISEASES Undernutrition and various forms of sub- clinical avitaminosis are common, but the incidence of frank deficiency disease is rela- tively low. Beriberi is frequent among the Krus who subsist largely on rice rations. Pellagra occurs sporadically in some areas. Occasional cases of scurvy are reported. Riboflavin and vitamin A deficiencies are common. The syndrome of kwashiorkor is observed in the forest villages where, in the 434 Gold Coast absence of milk, children are weaned on starchy foods. It also occurs in a mild form in Accra and other cities. Deficiencies in protein, minerals and vitamins are thought to be important factors underlying the sub- normal standards of health common among all classes of the population. MisceLLANEOUS CONDITIONS Silicosis is a major problem among the underground workers in the mines. Tubercu- losis is observed in association with silicosis in a large percentage of the cases. Infectious hepatitis is endemic throughout this region. SUMMARY The British territory of the Gold Coast comprises three administrative units—the Colony proper, Ashanti and the protectorate of the Northern Territories—in which dif- ferences in physical environment and acces- sibility are reflected in the economic and cultural development of the people. The provision of medical and health services is the responsibility of the Medical Depart- ment of the Gold Coast government, which is administered by a Director of Medical Services, with headquarters at Accra. Vari- ous mission organizations and the Red Cross Society carry on health activities in close co-operation with the Department. The gov- ernment maintains 33 hospitals with a total capacity of 1,348 beds, and small hospitals with facilities for Europeans at Accra, Cape Coast, Sekondi-Takoradi, Kumasi and Tamale. A mission hospital is located at Agogo in Ashanti, and company hospitals in the mining areas. Village dispensaries are maintained in various parts of the coun- try by the government and the Native Authorities. Water is abundant in the southwestern districts but scarce on the eastern plain and in the Northern Territories. Communal sup- plies are obtained from rivers and streams, from wells and in the more arid regions from shallow waterholes. Treated municipal supplies are available in the eight largest towns. Waste disposal is primitive, and sanitary controls over food supplies are en- forced only in the urban areas. The stand- ards of nutrition vary in the northern and the southern provinces, but deficiencies in important dietary constituents are of fre- quent occurrence. Malaria, intestinal infections, respiratory infections, venereal diseases, hookworm in- fection and leprosy are widespread. Yaws and trypanosomiasis are prevalent, particu- larly in the Northern Territories. Tubercu- losis is common, with the highest incidence in the coastal towns and in the mining centers. Smallpox and meningitis are en- demic, and scattered outbreaks occur fre- quently. Schistosomiasis exists in localized areas. Louse-borne relapsing fever, typhus fever, filariasis, yellow fever and leishman- iasis are sporadic. BIBLIOGRAPHY 1. Beeuwkes, Henry: Clinical manifestations of yellow fever in the West African native as observed during four extensive epidemics of the disease in the Gold Coast and Ni- geria, Tr. Roy. Soc. Trop. Med. & Hyg. 30:61-86 (June) 1936. , and Mahaffy, A. F.: The past inci- dence and distribution of yellow fever in West Africa as indicated by protection test surveys, Tr. Roy. Soc. Trop. Med. & Hyg. 28:39-76 (June), 1934. 3. Blacklock, D. B.: Methods of disposal of human excreta and refuse in the British colonies, Ann. Trop. Med. 37:66-72 (Apr.) 1944. 4. ——: Water supplies in the British colonies, Ann. Trop. Med. 37:211-220 (Dec.) 1943. 5. Brown, M. P., Waddy, B. B., and Tudor, R. W.: Cerebrospinal meningitis in the Gold Coast, Lancet 1:741-743 (May 31) 1947. 6. Colbourne, M. J., Edington, G. M., and Hughes, M. H.: A medical survey in a Gold Coast village. In Press. 7. Davey, T. H.: Trypanosomiasis in British West Africa, London, H. M. Stationery Office, 1948. 8. Dixey, M. B. D.: Some observations on leprosy in the Gold Coast and British Gold Coast 435 10. al, 12. 13. 14. 13. 16. 17. 18. 19. 20. Togoland, West African M. J. 5:3-5 (July) 1931. . Findlay, G. M., and Elmes, B. G. T.: Typhus in northern Nigeria. II. Laboratory in- vestigations, Tr. Roy. Soc. Trop. Med. & Hyg. 41:339-352 (Dec.) 1947. ——, Reid, R. D., and Maegraith, B. G.: Typhus in Gold Coast, J. Roy. Army M. Corps 80:134-141 (Mar.) 1943. Gold Coast: Annual Report on the Social and Economic Progress of the People of the Gold Coast, 1938-39, Accra, Govt. Printer, 1939. Gold Coast Colony: Report on the Medical Department for the Year 1936, Accra, Govt. Printer, 1937. ——: Report on the Medical Department for the Year 1937, Accra, Govt. Printer, 1938. : Report on the Medical Department for the Year 1938, Accra, Govt. Printer, 1939. ——: Report on the Medical Department for the Year 1942, Accra, Govt. Printer, 1943. ——: Report on the Medical Department for the Year 1944, Accra, Govt. Printer, 1945. ——: Report on the Medical Department for the Year 1947, Accra, Govt. Printing Department, 1948. : Report on the Medical Department for the Year 1948, Accra, Govt. Printing Department, 1949. Gold Coast Government: The Gold Coast Handbook, 1937, London, Ebenezer Baylis and Son, 1937. Great Britain. Colonial Office: Annual Re- port on the Gold Coast for the Year 1946, London, H. M. Stationery Office, 1948. 21. 22. 23. 24. 23, 26. 27. 28. 29. 30. 31. 32. Irvine, F. R.: Plants of the Gold Coast, London, Oxford, 1930. Kuczynski, R. R.: Demographic Survey of the British Colonial Empire. Vol. I. West Africa, London, Geoffrey Cumberlege, Oxford, 1948. Leprosy in the Gold Coast: Leprosy Rev. 7:182-190 (Oct.) 1936. Maegraith, B. G.: The identification of the poisonous snakes of British West Africa. II. Details of genera and species, Ann. Trop. Med. 38:119-138 (Sept.) 1934. Morris, K. R. S.: Planning control of sleep- ing sickness, Tr. Roy. Soc. Trop. Med. & Hyg. 43:165-199 (Sept.) 1949. Murray, A. J., and Crocket, J. A.: Report on Silicosis and Tuberculosis among Mine- Workers in the Gold Coast, Accra, Gold Coast Colony, 1946, Abst. Bull. Hyg. 21: 744-746 (Nov.) 1946. Nash, T. A. M.: Tsetse Flies in British West Africa, London, H. M. Stationery Office, 1948. Platt, B. S.: Colonial nutrition and its prob- lems, Tr. Roy. Soc. Trop. Med. & Hyg. 40:379-398 (Mar.) 1947. Russell, Helen: Human and experimental re- lapsing fever, Accra, Gold Coast, 1929-30, West African M. J. 4:59-66 (Jan.) 1931. Saunders, G. F. T., and Morris, K. R. S.: The distribution of human trypanoso- miasis, West African M. J. 5:62-64 (Jan.) 1932. Selwyn-Clarke, P. S.: Yellow fever in West Africa, Bull. Health Organ., League of Nations 5:69-78 (Mar.) 1936. Thomson, R. C. Muirhead: Recent knowl- edge about malaria vectors in West Africa and their control, Tr. Roy. Soc. Trop." Med. & Hyg. 40:511-536 (May) 1947. 31 Togoland Togoland (French) GEOGRAPHY AND CLIMATE The former German colony of Togo is partitioned between France and Great Britain, in accordance with mandates from the League of Nations, established in 1922. French Togoland is now administered as a United Nations Trust Territory, in close co-operation with the Federation of French West Africa. It consists of a narrow corridor of approximately 21,800 square miles be- tween British Togoland and Dahomey, which extends from the Gulf of Guinea to Upper Volta. The low, sandy coastal re- gion is characterized by a series of lagoons, the largest of which, Lake Togo, receives the seasonal flow of the Sio and the Haho rivers. Inland, a broad, undulating plateau rises to the Togo and the Karo mountain ranges which occupy the central portion of the country. The highest elevations are found in the south, where the peaks of the “Fetiche” mountains average from 3,100 to 3,300 feet in height. Northern Togoland is largely savannah tableland. It is traversed by the Oti River and its tributaries, which frequently flood during the rainy seasons. The Mono, the principal river in the east, marks the southern part of the bound- ary with Dahomey. The climate is essentially tropical. The monthly mean temperatures range from 68° to 86° F., while the daily variations average 6° to 8° F. The highest tempera- tures are encountered in February, March and April; the lowest, in the coastal region in August. There are two rainy seasons, from March to July, and from September to November in the south, but in the extreme north the intervening dry period is usually absent. The annual rainfall in the coastal region is lower than in corresponding areas along the Guinea coast. It averages from 20 to 25 inches at Lomé, but increases to from 60 to 80 inches in the mountains. In Mango district, in the north, it approxi- mates 40 inches. The Aarmattan, which blows intermittently during the dry season, decreases gradually in intensity and dura- tion from north to south. POPULATION AND SOCIO-ECONOMIC CONDITIONS The population in 1948 was estimated at 943,400, including 1,082 Europeans. The non-native residents are predominantly French and, except for a small contingent of Syrian traders, rarely establish perma- nent homes in the territory. Over 75 per cent are settled in Lomé district. The native populations belong to diverse ethnic groups and are divided into 30 to 40 different tribes, showing varying degrees of European influ- ence. The Ewes are the dominant peoples in the coastal region; the Akpossos, in the central mountains; and the Colocolis, the Cabrais and the Mossi tribes in the north. The Ewe language is used exten- sively throughout southern Togoland, while Twi, Bariba, Gourma and Hausa are the principal tongues in other regions. The ma- jority of the inhabitants are animists or fetish worshipers. Roughly 100,000 converts to Christianity are found in the coastal dis- tricts, while certain northern tribes and the scattered Peuhls (Fulas) and Hausas are Moslems. The population density averages 45 per 436 Togoland 437 square mile. It ranges from 100 to 200 in the coastal region, where roughly one quar- ter of the population is concentrated, and in portions of the Cabrais country in the northeast, to 16 in the central mountain districts. There are few large towns. Lomé, the administration and business center, had a population in 1948 of 763 Europeans and about 29,300 natives. It is the principal port and the terminus of the three railway lines which run to Anécho, Bliba and Palimé. The economy of the territory is compar- able with that of Dahomey, but the agri- cultural resources are more limited, due to the excessive deforestation and lower rain- fall. The Togolese are primarily peasant cultivators. Stock raising is largely re- stricted to the north, although small num- bers of cattle and hogs are found in the coastal region. The nutritional habits of the tribes vary according to the climatic and soil conditions in the different areas. The principal foods in the south are maize, manioc, yams, legumes, bananas, palm oil and fish. The staples in the north are millet and peanuts, supplemented by meat, milk and shea-nut butter. Outside of the port towns the living conditions are generally primitive. As in the adjoining territories, the typical dwellings are square or round mud huts with thatch roofs. No comprehensive vital statistics are available, but a demographic study based on the analysis of over 118,000 births, pub- lished in 1938,!5 estimates the mortality of infants 0 to 1 years of age to be 14 to 20 per cent in the southern districts, 13 to 19 per cent in the central and 4 to 30 per cent in the northern. ENVIRONMENT AND SANITATION The water supplies are generally ade- quate but may be scarce during the dry season in some parts of the country. Do- mestic supplies are derived from streams, springs or wells and are usually subject to pollution. The methods of waste disposal are primitive, and the standards of sanita- tion are generally low. The insect vectors of disease found in this area differ little from those of Dahomey and the Gold Coast. Anopheles gambiae, A. gambiae melas and A. funestus are the principal vectors of malaria. Glossina palpalis is widespread in the south, while G. tachinoides predominates along the banks of the northern rivers. G. morsitans is also present in many scattered foci. Both human and animal trypanoso- miasis are common. HEALTH SERVICES AND MEDICAL FACILITIES The responsibility for public health in the French mandated territory of Togoland is invested in the Direction de la Santé Publique, with headquarters in Lomé. The functions of the Direction include the provi- sion of medical care for the European and the native populations, supervision of sani- tation in urban and rural areas, control of epidemics and of endemic diseases of social importance and protection of the health of mothers and children. Prior to 1947, when it was organized as an independent service, the Direction functioned in close co-opera- tion with the territorial health service of Dahomey under the authority of the federal health organization of French West Africa in Dakar. The activities of the Direction are controlled by the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer in Paris. The enforce- ment of sanitary and malarial control meas- ures in the town of Lomé is carried out by the local Service d’Hygiene. Protestant and Roman Catholic mission organizations maintain dispensaries and maternities in the southern districts. The Comité Togolais de I’'Union des Femmes de France, an affiliate of the Croix Rouge Francaise, operates a child welfare center in Lomé, with branches in other administra- tion posts. The local Berceau Africain also supports infant welfare work in various parts of the country. The Direction de la Santé Publique main- tains a central hospital at Lomé, which in 438 Togoland 1948 had a capacity of 16 beds for Euro- pean and 65 for Togolese. In addition, it operated 7 small regional hospitals, with an aggregate capacity of 3 beds for Europeans and 303 for natives, and 31 dispensaries scattered throughout the territory. Mater- nity care was available in 10 of the above institutions. Special facilities included 2 agricultural leper colonies, with provision for 520 lepers, and 7 infirmaries with beds for 598 sleeping sickness patients. The gov- ernment laboratory is operated in connec- tion with the Lomé hospital. No medical school is located in this area, but Togolese students are admitted to the Ecole de Méde- cine Africaine in Dakar. Training courses for native nurses are conducted in the hos- pital at Lomé. In 1948 the French medical personnel in the Togoland health services totaled 13: the Director, 10 doctors (7 mili- tary and 3 civilian), 1 pharmacist and 1 midwife. The African staff included 17 doc- tors, graduates of the school at Dakar, 19 midwives, over 100 nurses, and sanitary and medical assistants. DISEASES In view of the similarity between the health problems existing in French Togo- land and in Dahomey, and the fragmentary nature of the medical statistics available, the specific diseases of this region have been considered with those of the federation of French West Africa. The epidemic and endemic diseases affecting the populations of French Togoland are essentially the same as those encountered under com- parable physiogeographic conditions in Dahomey and the Gold Coast. Malaria, yaws, syphilis, gonorrhea and helminthiasis are widespread. Tuberculosis, pneumonia, dysentery, leprosy, trachoma, purulent conjunctivitis and tropical ulcers are prev- alent. Sporadic outbreaks of smallpox, men- ingococcus meningitis, measles and whoop- ing cough are frequent. Numerous active foci of human trypanosomiasis exist in the central and the northern sections of the country. Schistosoma haematobium infec- tions are common in the lagoon region. Onchocerciasis and dracontiasis occur in limited foci. Tick-borne typhus fever is re- ported occasionally. Yellow fever is en- demic. Plague has not been recorded within recent years. Togoland (British) GEOGRAPHY AND CLIMATE British Togoland was mandated to Great Britain by the League of Nations in 1922 and has been governed under a United Nations trusteeship since 1946. It consists of a narrow strip of territory along the eastern border of the Gold Coast which averages 40 miles in width but does not extend to the Gulf of Guinea. It is adminis- tered with the Gold Coast: the northern section of approximately 10,600 square miles with the Northern Territories, and the southern, totaling 2,464 square miles, with the Colony. Topographically, the country is relatively flat, except for low hills in the south, and the Gambaga scarp which trav- erses the northern corner and has an average elevation of 1,300 feet. Tropical forest covers a portion of southern Togoland, but the northern section is largely parkland and savannah. The chief rivers are the Volta, which marks part of the western frontier, and the Oti, one of its major tributaries. The annual rainfall approximates 40 inches in the north and 80 inches in the hilly dis- tricts of the south. There is a double rainy season, from March to July, and from September to November, over most of the country, but a single season from March to November in the extreme north. The #Aar- mattan blows intermittently during the dry season. The mean monthly temperatures range from 68° to 86° F., but the daily vari- ations rarely exceed 6° to 8° F. The hottest months are February, March and April. POPULATION AND SOCIO-ECONOMIC CONDITIONS The population for 1947 was estimated at 382,000. The European residents are mainly British officials and usually number less than 50. As in French-mandated Togo- land and in the adjacent sections of the Gold Coast, the peoples of the south are predominantly Ewes. In 1946 they peti- tioned the United Nations Trusteeship Council for the consolidation of the Ewe nation under a single administration. Het- erogeneous tribes, belonging to several ethnic groups, are found in the north. The most prominent are the Mamprusi, the Kusasi, the Mossi, the Dagombas, the Gonjas and the Karchi. The majority are animists or fetish worshipers. However, a considerable portion of the inhabitants in Krachi and Ho districts have adopted Christianity, while some groups, as the Hausas, are Moslems. Schools are operated by the missions and by the constituted Na- tive Authorities, with financial support from the government, but the facilities are limited, and probably less than 15 per cent of the inhabitants are literate. The population density approaches 50 to 60 per square mile in Ho district in the south. In the north it averages 16 but varies from 98 in the Kusasi region to 5 in Kete-Krachi district. There are no large urban settlements. Ho, the administrative center and one of the largest towns, had a population of 4,000 in 1947. Agriculture is the major industry, and over 95 per cent of the people are peasant farmers. Cocoa is the principal export crop, but palm oils also contribute to the native economy in the south, and rice and peanuts in the north. As in the Gold Coast, the food crops are varied and normally adequate, except in the pastoral districts of the north. ENVIRONMENT AND SANITATION Water supplies are obtained from streams, wells, storage tanks and under- ground cisterns. Natural sources of water are meager in many areas, but community supplies have been developed by the Gold Coast government or by the Native Authori- ties in all of the villages along the major traffic routes. No piped water supplies are available except in Ho. The methods of waste disposal are universally primitive. Bucket latrines are frequently used in the Togoland 439 towns, and pit latrines in the smaller vil- lages. The standards of community hygiene are low among all of the native peoples. The vectors of disease are similar to those encountered in the Gold Coast. Anopheles gambiae is of primary significance in the transmission of malaria, with A. funestus next in importance. Glossina palpalis and G. tachinoides are the principal vectors of human trypanosomiasis. Anopheline and tsetse fly control measures are carried on in limited areas. HEALTH SERVICES AND MEDICAL FACILITIES The responsibility for the public health in British Togoland resides in the Gold Coast Medical Department, which has its headquarters in Accra. Medical officers, who are also health officers, are stationed at Ho and at Hohoe, in the southern district, but the northern section of the country is de- pendent upon the services of a visiting medi- cal officer from Tamale. The activities of the Medical Department include the opera- tion of hospitals and dispensaries for the medical care of the populations, the institu- tion of measures for the prevention of epi- demics, the management of mass-treatment campaigns for the control of yaws and sleeping sickness, and the supervision of water supplies and village sanitation. In the northern districts the Native Authori- ties frequently administer the dispensaries and discharge other public health functions within their areas. Small hospitals are located at Ho, Hohoe and Yendi, and dispensaries in the rural population centers. In 1947 there were 5 antenatal and child welfare clinics in the ter- ritory. Leper settlements are established at Ho and Yendi, with facilities for 450 and 40 patients, respectively. A trypanosomiasis dispensary is situated at Nakpanduri in the Mamprusi country. In 1946 the total hos- pital facilities were estimated at 0.35 beds per 1,000 population.!® Roman Catholic mission organizations carry on child welfare work in Ho, Hohoe and Kpandu. 440 Togoland DISEASES No separate medical statistics are availa- ble for British Togoland, since the reports of attendance in the government hospitals and dispensaries are incorporated with those from the Gold Coast. In general, the health status of the people is the same as in comparable sections of both territories. The principal diseases are malaria, yaws, tuber- culosis, trypanosomiasis, syphilis and gonor- rhea. Leprosy, helminthiasis, dysentery, pneumonia, mycotic skin infections, tropical ulcers and conjunctivitis are also prevalent. Outbreaks of smallpox are frequent in spite of extensive vaccination. Localized epi- demics of meningococcus meningitis occur sporadically. Yellow fever, dracontiasis and the common respiratory infections are en- demic. BIBLIOGRAPHY 1. Bunche, Ralph Johnson: French Administra- tion in Togoland and Dahomey, Thesis, Faculty of Arts and Sciences, Harvard University. Thesis Collection, Harvard University, 1934. 2. Kuczynski, Robert R.: The Cameroons and Togoland. A Demographic Study, London, Oxford, 1939. TocorLaND (FRENCH) 3. Chazelas, Victor: Territoires Africains sous mandat de la France. Cameroun et Togo, Paris, Société d’Editions, 1931. 4. France. Ministére de la France d’Outre-Mer: Direction du Service de Santé Colonial. Situation sanitaire de l’empire francais. Tableaux statistiques 1941-1945, Marseille, Imprimerie LeConte, 1946. : Direction du Service de Santé Colonial. Rapport sur la situation sani- taire dans les territoires francais d’outre- mer pendant l'année 1946. . Secrétariat d’Etat aux Colonies: Direc- tion du Service de Santé. Médecin Colonel Giordani. Protection de la maternité et de Penfance indigenes pendant l'année 1940, Paris, Charles-Lavanzelle & Cie, 1943, 519-71. 7 , : Direction du Service de Santé. Médecin Colonel Le Gall. La situation sanitaire de l’empire francais pendant Pannée 1940, Paris, Charles-Lavanzelle & Cie, 1943, 1-516. 8. Grosfilez and LeFevre: Les maladies trans- missibles observées dans les colonies fran- caises et territoires sous mandat pendant lannée 1938, Ann. méd. pharm. col. 38: 183-359 (Apr., May, June) 1940. 9. LeGac, P., and Borjeix, L.: Premier cas de fievre boutonneuse au Togo, Bull. Soc. path. exot. 38:247-250 (Oct.) 1945. 10. LeGall, R.: Les bilharzioses en Afrique occi- dentale francaise, au Togo et a Mada- gascar de 1939 a 1941, Bull. Office in- ternat. d’hyg. pub. 36:116-126 (No. 3-4) 1944. 11. Maroix, Général: Le Togo. Pays d’influence francaise, Paris, Larose Editeurs, 1938. 12. Pechoux, L.: Le mandat francais sur le Togo, Paris, Editions A. Pedone, 1939. 13. La protection de la maternité et de I’enfance indigénes dans les colonies francaises en 1937: Ann. méd. pharm. col. 37:97-149 (Jan., Feb., March) 1939. 14. La protection de la maternité et de ’enfance indigénes dans les colonies francaises en 1938: Ann. méd. pharm. col. 38:46-95 (Jan., Feb., March) 1940. 15. Sorel, F. P. J.: Essai de démographie des colonies frangaises, Bull. Office internat. d’hyg. pub. 30:41-49 (Togo); 1-154 Suppl. 2, 1938. 16. ——: Prophylaxie de la lépre dans les colonies francaises, Bull. Office internat. d’hyg. pub. 30:1-21, Suppl. 6, 1938. 17. Vogel, E., and Riou, M.: Les maladies épi- démiques et sociales dans les colonies frangaises pendant année 1937, Ann. méd. pharm. col. 37: Suppl, 257-551 (Apr.) 1939. TocoraND (BrITISH) 18. Great Britain. Colonial Office: Annual Re- port on the Gold Coast for the Year 1946, London, H. M. Stationery Office, 1948. . ——: Report by his Majesty’s Gov- ernment of Great Britain and Northern Ireland to the Trusteeship Council of the United Nations on the Administration of Togoland for the Year 1947, London, H. M. Stationery Office, 1948. : Report by His Majesty’s Gov- ernment in the United Kingdom of Great Britain and Northern Ireland to the Coun- cil of the League of Nations on the Ad- ministration of Togoland under British Mandate for the year 1938, London, H. M. Stationery Office, 1939. 21. Kuczynski, R. R.: A Demographic Survey of the British Colonial Empire. Vol. I. West Africa, London, Geoffrey Cumber- lege, Oxford, 1948. 19. 20. 32 Liberia GEOGRAPHY AND CLIMATE Liberia, an independent republic since 1847, is situated on the west coast of Africa between Sierra Leone and the Ivory Coast, French West Africa. The territory includes some 43,000 square miles of land area, with a coastline of approximately 350 miles on the Atlantic Ocean. The coast is flat except for a few isolated rocky headlands. It is in- dented by numerous creeks and lagoons, the largest of which, known as Fisherman Lake, is partially enclosed by the promontory of Cape Mount. The country rises gradually from a low coastal plain, with an average depth of 20 to 30 miles, to the interior pla- teau which attains a general elevation of 1,800 to 2,000 feet at the French frontier. The wide central zone is largely undulating terrain characterized by dense tropical forest and broken by occasional groups of hills with a more rugged aspect. The forest projects in irregular spurs into the savan- nah country of the inland plateau. There are few mountainous areas. The most im- portant are the Waulo Mountains, which dominate the northeast corner between Sierra Leone and French Guinea, and the Nimba Mountains, along the central fron- tier. The former contain peaks of 4,500 feet, or more, while the latter reach 4,000 feet in Liberia and higher elevations across the border. Numerous small rivers and streams dissect the country, flowing in a general southwest direction. The Mano on the Sierra Leone frontier, the Cavally, on the south- eastern border, the St. Paul, the St. John and the Cess rivers are the most important. The climate of Liberia is essentially trop- ical, while the rainfall and the humidity are 441 generally higher than in the neighboring territories. There are two seasons: a rainy season, dominated by the southwest mon- soon, from March to November, and a dry season covering the rest of the year. In the coastal region, the rainfall ranges from 140 to 200 inches annually. Rain falls through- out the year with frequent periods of almost continuous precipitation at the height of the rainy season. Roughly 90 to 95 per cent of the total rainfall occurs between May and October, often with peaks of precipitation in June and September, and a short interval of relative dryness around the last of July and the first of August, which is known lo- cally as the middle dries. Severe storms accompany the opening and the close of the rainy season. Comparatively little rainfall is experienced in the middle of the dry season, during January and February, when the influence of the harmattan is felt. Toward the interior the demarcation be- tween the seasons becomes more pro- nounced, with a gradual decrease in pre- cipitation, except in the areas that are mountainous. The seasonal variations in temperature are relatively slight in the coastal region. The lowest temperatures are encountered during the rains, and the highest at the time of the /Zarmattan. The yearly mean temperatures average 76° to 80° F., with a seasonal range of approximately 15° F. The maximum monthly means range between 77° to 83° F. in July and August and 86° to 98° F. in January and February; the minimum monthly means, between 70° to 74° F.in July and August and 69° to 72° F. in January and February. Few meteorologic observations have been recorded in the in- 442 Liberia terior, but in general the mean temperatures decrease slightly with the altitude, while the daily and the seasonal fluctuations be- come greater. The maximum daily range occurs during January and February at the time of the karmattan. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoPULATION The population of Liberia is variously re- corded at between one and two million. In the absence of a census, estimations of popu- lation are based upon the number of villages and of taxable dwellings and are subject to major inaccuracies. The most widely ac- cepted reports place the number of inhabit- ants at slightly less than two million. The population, which is almost exclu- sively of Negro origin, may be roughly divided into two groups: the Americo- Liberians and the tribes of the coast and the hinterland. The white population, which fluctuates around 200 and 300, is made up largely of official representatives of foreign governments, missionaries and employees of American organizations and industrial con- cerns. Roughly 25 to 30 Syrian traders are also established in the larger towns. The Americo-Liberians are the descendants of liberated slaves settled in this region in the early part of the nineteenth century under the auspices of various colonization socie- ties and with the protection of the United States government. They are concentrated, to a large extent, in the country around Monrovia and probably do not exceed 15,000 to 18,000 in number. The inhabitants of the coastal region, many of whom have adopted the customs and the civilization of the Americo-Liberians, total in the neigh- borhood of 50,000 to 100,000. From its in- ception, the Republic has been governed by the Americo-Liberians, who have dominated the indigenous peoples. The native inhabitants belong to from 20 to 30 or more separate and independent tribes but may be roughly divided into three ethnologic groups.?? Heterogeneous tribes of mixed racial stock, located in the northern and the central parts of the coun- try, are frequently classified with the Man- dingos. The most important are the Vais, the Kpelles and the Manos. The Krus, the Bassos, the Grebos and related tribes of “Sudanese Negro” origin constitute a second group, settled chiefly in the south between the St. Paul and the Cavally rivers. A third division includes the Golas, in the St. Paul River basin, and the Gissis, on the north- western border. The languages and the dialects of Liberia are almost as numerous as the tribes. The most extensively used are the Mandingo, the Kpelle and the Kru. English is the of- ficial language of the Republic. It is em- ployed by educated Liberians, while a colloquial form is sometimes spoken among uneducated Krus and other tribes. Pagan religions predominate, but probably from 5 to 6 per cent of the Liberians are Moslems, and from 25 to 30 per cent Christians. The Mandingos and the Vais are the only wholly Moslem tribes, but the influence of Islam is spreading, particularly among the Golas and the Mendis. The Americo-Liberians, as well as scattered tribes on the coast and around the missions in the interior, have adopted Christianity. The population is distributed unevenly. Regions of comparative density are found along the coast between the St. Paul and the Farmington rivers and in the moun- tainous areas of the north, while large por- tions of the interior remain virtually unin- habited. Most of the people live in small scattered villages, but towns of 300 to 3,000 inhabitants are found on the coast and in the interior along the St. Paul River and the segments of arterial road between Monrovia and the French border. Mon- rovia, the capital and the only town of any size, has a population of from 10,000 to 15,000. Education is poorly developed, except in the region around Monrovia. A large pro- portion of the inhabitants is illiterate, al- Liberia 443 though the demand for education is spread- ing rapidly. The Liberian government and various religious missions maintain schools in the towns along the coast and in scattered communities in the interior, but few extend beyond the elementary level. The govern- ment-supported Liberia College (Monrovia College) provides some postsecondary school courses, while several mission insti- tutions offer advanced vocational training. Numerous Koranic schools are found in the northwestern part of the country. VITAL STATISTICS No vital statistics are available for Liberia. The first census of any part of the population was undertaken in the vicinity of Monrovia in 1945, but the results were considered unreliable. Notification of births, deaths and cases of communicable disease has been required in Monrovia since 1947, but enforcement is incomplete. The infant and the maternal mortality rates are gen- erally high; among some tribes the infant mortality is believed to approximate 50 per cent. Sociar Economy Liberia is potentially a rich agricultural country, but native production has been re- tarded by the attitude of former govern- ments toward the indigenous tribes of the interior. The Americo-Liberians have tended to congregate in Monrovia and other coastal towns, where many are employed in govern- ment service. Industrial and agricultural developments have been assisted largely by American capital. The Firestone Plantations Company has been active in Liberia since 1924, when it obtained a 99-year lease on a maximum of one million acres from the government of the Republic. Two Hevea rubber planta- tions are in operation; the main plantation lies on the Farmington River, southeast of Monrovia, and a smaller unit is located near Cape Palmas on the Cavally River. The company employs a large volume of native labor, which is recruited with the co- operation of the tribal chiefs and the Liberian government. Within recent years it has also encouraged independent farmers to develop Hevea groves under its supervi- sion. Estimates for 1945 indicate that about one half of the land under cultivation is planted in rubber ®® whereas the whole rep- resents only a small part of the total land area. The Liberia Company, which was created in 1947, obtained an 80-year concession from the Liberian government, authorizing it to develop the agricultural, mineral and forest resources of the country and to or- ganize modern financial and communication facilities. The mineral resources of Liberia include one of the richest deposits of iron ore in the world, which is now being developed by the Liberia Mining Company. Commercial de- posits of gold, industrial diamonds, mica and minor minerals have also been located. In 1945 rubber constituted 95 per cent of the total exports, with gold, piassava fiber, coffee and palm oil making up most of the remainder. Rich reserves of tropical hard- woods exist in the forest areas but have not been exploited. Small amounts of sugar, lumber and cotton goods are processed lo- cally for home consumption. Communication facilities are meager, fully two thirds of the country being inac- cessible except by foot paths. A single motor road links the population centers around Monrovia with Ganta and the towns near the French frontier. Also, modern roads have been constructed by the Firestone Planta- tions Company and other industrial con- cerns to serve their installations and to pro- vide the necessary connections with the port towns. There are no good natural harbors, but Monrovia was developed as a deep-water base by the United States Navy during World War II. Steamer transporta- tion is available to the United States and Europe. Air services are also maintained from Roberts Field, southeast of Monrovia, to other West African colonies and to Europe and America. 444 Liberia Foop AND NUTRITION The nutritional standards of the people are generally poor. Large numbers of the inhabitants suffer from undernutrition and chronic deficiencies in protein, calcium, iron, vitamin A and vitamins of the B com- plex. The basic foods are rice and cassava, supplemented by yams, sweet potatoes, plantains, red palm oil and incidental vege- table greens. Indigenous fruits and vegeta- bles are used to a varying degree by the different tribes. The consumption of animal proteins is low in all parts of the country. Goats and chickens are kept in the villages, but milk and eggs are used infrequently. Meat is always scarce and prohibitive in cost for the average family. Cattle are found only in limited areas in the southwest and in the mountainous regions of the north. Fish constitute a major source of protein, but, due to primitive methods of procure- ment, the supply is inadequate even in the coastal villages. The wild game, which formerly provided ample supplies of meat, is rapidly becoming depleted. Local food shortages are common, partic- ularly toward the end of the dry season. A large proportion of the food supply of Monrovia and other Americo-Liberian towns is imported. Research in the develop- ment of better and more diversified crops is carried on continuously by the staff of the Firestone Plantations Company. Also, nu- trition studies have been undertaken by the United States Economic Mission and the United States Public Health Service Mis- sion to Liberia. Housinc The architecture of the homes of the Americo-Liberians is distinctive, with a tendency toward the use of wide overhang- ing balconies and high-pitched roofs, both supported by pillars. Wood, brick and occa- sionally concrete are the usual building materials. Roofs are commonly made of corrugated iron or tile. Many of the homes in Monrovia are well constructed and com- modious, but neglect, overcrowding and in- sanitary surroundings characterize the poorer sections. The dwellings of the indigenous tribes vary in size, design and structure. In gen- eral, the villages are built around a central nucleus, consisting of a community or pa- laver house and the chief’s residence. The huts are round or square and are con- structed of poles, mud or clay, with peaked thatched roofs. A diversity in tribal customs is reflected in the appearance and the degree of cleanliness of the individual villages. The laborers on the rubber plantations are housed in modern brick buildings or in model villages in which the traditional housing arrangements of the tribal groups are observed. ENVIRONMENT AND SANITATION WATER SUPPLIES The water supplies are obtained from local streams or springs and from shallow wells. Deep wells are impractical in most parts of the country because of the nature of the underlying strata. There is no central water supply in Monrovia, but water is pro- cured from 150 to 200 individual and com- munal wells. The water is generally poor in quality and inadequate during the dry season. Rain-water tanks are employed in connection with a few houses. Most of the wells are poorly constructed and are subject to pollution due to the proximity of the privies. The installation of a modern water- supply system is under consideration. Treated water supplies have been de- veloped for the Firestone plantations, Roberts Field and certain industrial units. The supply for the main plantation of the Firestone Plantations Company is derived from the Farmington River at Harbel and is subjected to filtration and chlorination. Waste DisposaL The methods of sewage disposal are prim- itive. Septic tanks are installed in connec- Liberia 445 tion with a few of the public buildings and homes in Monrovia and on the Firestone plantations, but pit privies are the usual means of sewage disposal. The facilities in Monrovia are inadequate, and the pollution of the ground and the thoroughfares is com- mon in some sections. Communal pit latrines are found in the villages in close contact with civilization but are rarely en- countered in the interior. The disposal of excreta on the ground or in near-by streams is a general practice among the indigenous tribes. Fauna anp Frora Arthropods. Mosquitoes. Anopheline mosquitoes are prevalent. The data re- garding the species found in various parts of the country are incomplete, but at least 12 have been identified. The most numerous are Anopheles gambiae and A. funestus, both of which are active vectors of malaria. A. gambiae melas may be present along the coast. Other species which may transmit malaria in localized areas are A. mili, A. hancocki, A. hargreavesi, A. marshalli and A. pharoensis. A. gambiae, the most im- portant vector, breeds prolifically in shallow bodies of water more or less exposed to the sunlight. It is most abundant from March to July and from September to December. In a survey of Monrovia, Katata and Roberts Field, reported in 19482 A. gam- biae accounted for 98.6 per cent of the mos- quitoes aspirated from inhabited areas. Studies undertaken in 1947? also indicate that this species is of considerable impor- tance in the transmission of Wuchereria bancrofti. Seven species of Aedes are reported. Aedes aegypti, the usual vector of yellow fever, breeds abundantly in the numerous small collections of water around dwellings and in tree holes and other nondomestic sites, particularly at the beginning and the end of the rainy season. A. vittatus, a potential vector, is common. Several species of culi- cine mosquitoes are found. The majority "are annoying pests, but Culex quinquefasci- atus (= C. fatigans) is a potential vector of Wuchereria bancrofti. Eretmopodites chrysogaster and Taeniorhynchus (Man- sonia) uniformis are also present. An active antimosquito program has been carried on by the Malaria Control Division of the United States Public Health Service Mission to Liberia in Monrovia and Bush- rod Island and at Roberts Field since its arrival in 1944. The measures employed in the vincinity of Monrovia and Bushrod Island have included the draining and the filling of swamp land, the antilarval treat- ment of breeding areas with DDT and oil and the residual spraying of dwellings with DDT preparations. In 1947-48 the index of female anophelines per square yard was estimated at 0.86 in controlled areas, in con- trast with 7.54 in the uncontrolled. Maxi- mum indices of 2.2 were recorded in April in the controlled areas; of 25.3 in March in the uncontrolled.? Fries. Five species of tsetse flies occur, Glossina palpalis, G. fusca, G. nigrofusca, G. pallicera and G. medicorum. Glossina pal- palis, the chief vector of animal trypanoso- miasis and the only vector of the human dis- ease, is common in swampy forest regions of the interior, where it breeds along the banks of the larger rivers. It also infests the densely wooded areas fringing the streams in the savannah country of the north, par- ticularly in Western Province. It is rare in the coastal region, but is encountered in limited numbers in a few localities. Few clearings have been attempted, except in sections of the Harbel plantation of the Firestone Plantations Company. Current knowledge regarding the species of flies in Liberia is incomplete. At least 14 species of Tabanid flies have been identified, including Chrysops longicornis, Haemato- pota guineensis and 12 species of T'abanus. Musca domestica and at least 5 species of Stomoxys are abundant. Cordylobia anthro- pophaga, which is responsible for cuta- neous myiasis, is apparently rare, except in 446 Liberia the northwestern part of the country near the border with Sierra Leone. Auchmero- myia luteola is present in the interior where its larvae, known as “Congo floor maggots,” are sometimes found in the huts. Simulium damnosum breeds in numerous swift-flowing streams in the interior, es- pecially in the primary rain forest. It is the vector of Omnchocerca volvulus, which is prevalent in localized areas. Phlebotomus flies are present, but the species have not been determined. Culicoides grahami and possibly C. austeni occur. Both are vectors of Acantho- cheilonema perstans. Lice. Pediculus humanus corporis and P. humanus capitis are present but are rela- tively uncommon. Louse-borne infections, such as typhus fever and relapsing fever, are rarely observed. Freas. Numerous species of fleas, includ- ing those of the genus Xenopsylla, infest the rat population. Plague has not been re- ported, however, and only occasional cases of flea-borne typhus have been described. Ctenocephalides canis is frequently found on human beings, as well as on dogs. The chigoe flea, Tunga penetrans, is prev- alent in the coastal region. BepBuces. The tropical bedbug, Cimex hemipterus, is widespread. C. lectularis is also present in Monrovia. Ticks AND Mites. A variety of ticks is found, including Haemaphysalis leach, Boophilus decoloratus and species of Der- macentor, Ixodes, Amblyomma and Rhipi- cephalus. The tampan tick, Ornithodorus moubata, has not been reported. Infestation with Sarcoptes scabiei is gen- eral. It is frequently associated with a skin condition, known locally as craw-craw. ScorPIONS AND SPIDERS. Severe stings are produced by two common scorpions, Pand- inus imperator and the thew hip scorpion, Titanodamen bassemensis. The latter spe- cies sometimes attains a length of 6 inches. The large hairy spider, Scodra brachy- poda, and species of Nephilla are present. Tarantulas of the genus Lycosa are found "in regions away from the forest. All have poisonous bites. OrHER ArTHROPODS. Predatory driver ants, species of Anoma and Dorylus, are encountered frequently. They devour all forms of life and may inflict severe injuries to human beings who are unable to get out of the path of their advancing column. The tree ants, Oecophylla, attack when their nests are disturbed. Their bites are ex- tremely painful. The cockroach, Periplaneta americana, is found in most Americo-Li- berian settlements and is a troublesome pest during its period of flight, from November to January. Reptiles. Various species of venomous snakes occur, including the mamba, Den- droaspis viridis, and the cobras, Naja goldii, N. melanoleuca and N. nigricollis. The most important vipers are Cawusus rhombeatus, C. lichtensteinii, Bitis gabon- ica, B. nasicornis and Atheris chlorechis. Atractaspis corpulenta and A. irregularis are also found. Several species of Dipsa- DpOMORPHIDAE and COLUBRIDAE are known to be present. The python, Python sebae, al- though not venomous, is occasionally dan- gerous to man. The crocodile, Crocodilus niloticus, is common near the coast, while C. cataphrac- tus is found in inland rivers. The monitor lizard, Varanus niloticus, may be vicious when cornered. Rodents. The roof rat, Rattus rattus alexandrinus, is prevalent in the tribal vil- lages, where the thatch of the huts provides favorable conditions for nesting. R. rattus rattus is encountered less frequently. R. norvegicus is relatively rare, but may be found in the port towns. The most frequent semidomestic rodent in all parts of the country is the multimam- mate rat, Mastomys coucha erythroleu- cus. The giant rat, Cricetomys gambianus liberiae, is encountered occasionally. Mollusks.* The fresh-water snails, Pky- sopsis africana globosa and Planorbis (Bi- omphalaria) alexandrina pfeifferi, are * See footnote, p. 10. widely distributed in the streams of the interior and in the northern coastal region. Both Schistosoma haematobium and S. mansoni are endemic in localized areas. Plants. Numerous indigenous plants are employed by the tribal medicine men in compounding native medicines. Among the plants used by the various tribes in making poisonous arrows, the most important are species of Acanthocera and of Strophanthus, namely S. gratus, S. sarmentosus and S. hispidus. Preparations of Erythrophleum guineense are sometimes given to test the guilt of the accused in native “trials by ordeal.” Foop SANITATION Sanitary measures for the protection of food supplies are enforced only in Monrovia and a few other towns. The eating establish- ments in the city are visited regularly by inspectors of the Liberian Bureau of Public Health and Sanitation. Foodhandlers are examined and licensed annually, and in- dividuals found to be infected with intes- tinal parasites or with one of the venereal diseases are treated in the government clinics. Meats offered for sale in Monrovia are inspected by agents of the Bureau. Limited facilities for the storage of meats and other perishable foods are available in Monrovia and on the plantations of the Firestone Plantations Company. HEALTH SERVICES AND MEDICAL FACILITIES HEALTH ORGANIZATIONS The Liberian Bureau of Public Health and Sanitation is responsible for the organ- ization of health services in all portions of the country. It is administered by a Direc- tor, appointed by the President of the Re- public, with headquarters at Monrovia. Authority for the enforcement of public health measures, in their respective areas, resides in the Superintendents of the four counties and one territory of the coastal region and in the District Commissioners of Liberia 447 Western, Central and Eastern provinces in the interior. Prior to 1943 the activities of the Bureau were largely political. In that year Presi- dent-elect Tubman requested the assistance of the United States in the reorganization of the health services of the Republic. A 5- year plan of co-operation was approved by the War and the State Departments and the Public Health Service of the United States, and in 1944 a special health mission was dispatched to Liberia under the direction of the United States Public Health Service. A general health program, incorporating medical, sanitary, laboratory and educa- tional services, was developed by the Mis- sion in conjunction with the Liberian Bureau of Public Health and Sanitation. The Bureau has gradually assumed respon- sibility for various phases of the program, and in 1948 it took over the operation of all of the clinics established by the Mission. The stimulation of interest in public health may be gauged by the increase in the budget of the Bureau from $20,000 in 1942, to $400,- 000 in 1947. A Public Health Council has been organized with a representative mem- bership from Monrovia and the tribal areas to advise with it on the promulgation and the enforcement of public health meas- ures. Medical and educational work is carried on by several mission societies in various parts of the country. The Firestone Planta- tions Company and other industries also conduct health services for the benefit of their employees. MEebpICAL INSTITUTIONS Hospitals and Dispensaries. Before 1944 a small 40-bed hospital in Monrovia was the only institution operated by the Liberian government, and this had been closed for a period because of lack of equip- ment. The facilities for the medical care of both the indigenous and the white popula- tions consisted in this hospital, a mission- supported maternity hospital in Monrovia, 5 mission hospitals in various parts of the 448 Liberia country, the hospitals of the Firestone Plan- tations Company and a few government and mission dispensaries. Shortly after its arrival in Liberia, the United States Public Health Service Mission assumed the responsibility for the reorgan- ization of the government hospital in Monrovia, adding wards for the care of maternity and pediatric cases. At this time the Carrie V. Dyer Memorial Hospital, the local mission maternity hospital, became an affiliated institution, specializing in ma- ternity care. The United States Public Health Service Mission established a dis- pensary, with general outpatient services and maternal and child health clinics, in Monrovia, which it operates in conjunction with the Liberian Bureau of Public Health and Sanitation. It also organized a dispen- sary at Tchien in Eastern Province, which was turned over to the Liberian government in 1947. In 1950 there were about 14 hospitals in the country, including 4 operated by the government, 6 by religious missions and 4 by industrial concerns. The majority range in size from 25 to 40 beds, but the Monrovia (government) Hospital has a capacity of 80 beds, and the Firestone Plantations Com- pany’s hospitals at Harbel and Harper, of 120 and 100 beds, respectively. A total of approximately 700 beds were available, or, on the basis of an estimated population of one and three-quarter million, roughly one to 2,500 inhabitants. In the same year there were about 52 dis- pensaries scattered throughout the country. In addition to the joint government and United States Public Health Service Mis- sion dispensary in Monrovia, 16 dispensa- ries were operated by the government, 28 by religious mission organizations, 4 by indus- trial concerns and 2 by private individuals. A mission-supported leper colony with accommodations for 250 lepers is located at Ganta, near the northern frontier. The government also maintains isolation colo- nies at Cape Mount and Webo, in which no treatment is provided. Laboratories. Except for clinical labora- tories in the Firestone and the mission hos- pitals, there were no laboratory facilities in Liberia until the establishment of a laboratory, in Monrovia, by the United States Public Health Service Mission in 1945. This laboratory is equipped for the performance of routine examinations in clinical pathology, bacteriology, mycology and chemistry, and for the conduct of re- search on medical problems. It receives co- operation and some financial support from the Liberian Bureau of Public Health and Sanitation. Technicians are being trained in the laboratory to assume charge of diag- nostic centers for the Bureau in other parts of the country. In 1947 a Liberian Institute of Tropical Medicine was established as a center for in- ternational research on medical and asso- ciated problems pertaining to tropical re- gions. It is partly supported by a gift from Harvey Firestone, Jr., to the Republic of Liberia and will be operated under the di- rection of the American Foundation for Tropical Medicine. The Technical Coopera- tion Administration of the United States Department of State is also providing finan- cial assistance for the maintenance of the Institute, which is located near Roberts Field, a few miles inland from the town of Marshall. Its facilities will be available to co-operating institutions in the United States and Europe. : Schools. The Tubman National Institute of Sub-Professional Medical Arts was or- ganized in Monrovia in 1946 under the joint supervision of the United States Public Health Service Mission and the Liberian Bureau of Public Health and Sani- tation. Schools for the training of nurses, technicians and subprofessional medical and dental personnel are included within the Institute. The incorporation of courses for sanitary inspectors is also contemplated. The government of Liberia provides a limited number of fellowships to qualified students for study in medical and nurses’ training schools in the United States and Europe. Training courses for nurses, dress- ers, or medical assistants, and laboratory technicians are conducted in the Firestone hospitals. PERSONNEL Physicians. The number of doctors has increased appreciably within the last few years. Except for the 4 to 7 doctors em- ployed by the Firestone Plantations Com- pany, there were only 6 qualified physicians in the entire country in 1944. In 1949 there were from 17 to 20 private, mission and in- dustrial physicians practicing in the Re- public, while from 15 to 20 more were employed by the Liberian Bureau of Pub- lic Health and Sanitation. Unlicensed herb doctors have a large fol- lowing among the Liberians. The so-called “Bush devils,” both men and women, prac- tice traditional forms of native medicine in their respective tribes and exert considera- ble authority over the people. Others. In 1944 there were two dentists and a small number of European or Ameri- can nurses in the Republic. With the recent expansion of the medical services, from 20 to 40 foreign nurses and an increased num- ber of locally trained nurses have been em- ployed in the hospitals and dispensaries. DISEASES The inadequacy of reporting, errors in diagnosis and the lack of exact knowledge regarding the size of various population groups must be considered in evaluating the incidence of specific diseases in Liberia. Available statistics, based upon studies in localized areas, are incomplete but sugges- tive of the health status of the inhabitants in different parts of the country. Diseases SPREAD oR CONTRACTED CHIEFLY THROUGH INTESTINAL oR UriNARY TRACTS Dysenteries. Both amebic and bacillary dysentery are common. Amebic dysentery is probably more prevalent in the coastal re- Liberia 449 gion than in the interior, but serious mani- festations are rarely encountered, and the true incidence of infection is not known. Outbreaks of bacillary dysentery and diar- rhea occur with greatest frequency during the early rainy season. Typhoid and Paratyphoid Fevers. Ty- phoid and paratyphoid infections are spo- radic, but cases are recorded chiefly among the white residents. Helminthiases. ANcyLosToMmIasts. Hook- worm infection is widespread in the coastal region and in the interior. Repeated surveys in the Monrovia area have revealed infec- tion rates of 59 to 80 per cent, both among children and adults. Comparable studies in various localities in the northern part of the country show rates ranging from 33 to 85 per cent. Ancylostoma duodenale is ap- parently the predominating species around Monrovia, but identification is seldom at- tempted, and Necator americanus may be equally prevalent in other areas. Scuistosomiasis. Foci of Schistosoma haematobium infection are frequent in the northern coastal region and in the hinter- land of Western and Central provinces. S. mansoni is also present in limited areas. The highest incidence of known infection is en- countered in the interior of Central Prov- ince and particularly in Sanoquellie district. Physopsis africana globosa, the principal in- termediate snail host of S. kaematobium, is widely distributed. Planorbis (Biomph- alaria) alexandrina pfeifferi is the inter- mediate host of S. mansoni in the localities which have been investigated. Oruer Heuminta INFECTIONS. A large percentage of the population harbors one or more types of intestinal worms. In a medi- cal survey of six representative areas in 194717 the infection rates (including hook- worm) averaged 98 per cent among children and 27 per cent among adults in the vicinity of Monrovia and ranged from 35 to 94 per cent in other localities. Individual infections are not heavy, however, and severe clinical symptoms are unusual. Ascaris lumbricoides predominates, but Trichuris trichiura, 450 Liberia Strongyloides stercoralis and Enterobius vermicularis are also found. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. The incidence of tubercu- losis is unknown, but the disease apparently does not constitute a major public health problem at present. It is common among the Americo-Liberians and inhabitants of the coastal towns but decreases in prom- inence among the tribes of the interior. In the course of over 10,400 tuberculin tests performed between 1947 and 1950%° the rate of positive reactions averaged 8.3 per cent. The groups tested were composed primarily of school children, but included 1,868 adults, chiefly from the interior, who gave positive reaction rates of from 3 to 9 per cent. The proportion of positive reac- tors was approximately the same under urban and rural conditions. Pulmonary infections predominate among the reported cases of tuberculosis, but other forms of the disease are also observed. Most of the cases follow an acute and fulmi- nating course. Smallpox. Epidemics of smallpox occur sporadically but, due to the lack of rapid transportation, tend to remain more or less localized. Following a few years of relative quiescence, outbreaks of mild smallpox developed in multiple foci in 1946 and 1947. A nationwide program was initiated in 1947 which, by the end of 1950, would pro- vide for the vaccination of the majority of the inhabitants over 4 years of age. For- merly, little vaccination was attempted, ex- cept in certain limited areas. Other Infections. Pneumonia is preva- lent. Epidemics of measles and whooping cough appear periodically. The latter is particularly serious among children who acquire the infection at the beginning of the rainy season, as recovery is usually delayed. Meningococcus meningitis, mumps and chickenpox are endemic. Sporadic cases of poliomyelitis are reported, but diphtheria and scarlet fever are rare. DiseASES SPREAD OR CONTRACTED CuIerLy TuroucH CONTACT Venereal Diseases. All forms of vene- real diseases are encountered; syphilis, gonorrhea and granuloma inguinale are the most prevalent. Gonorrhea is common in all parts of the country, but syphilis exists chiefly among the Americo-Liberians and the coastal tribes in close contact with other civilizations. The infection is ap- parently rare among the inhabitants of the interior, where yaws is widespread. The marriage customs of most tribes favor the spread of venereal infections. A national venereal disease program was instituted by the Liberian Bureau of Public Health and Sanitation in 1946, which makes provision for periodic examinations for syphilis and free treatment for indigent cases. Yaws. Yaws is endemic in all parts of the country, but the infection rates vary in different localities. In observations made in 1935-36,! in Central and Western provinces, the rates ranged from 3 to 12 per cent in the coastal plains to from 70 to 83 per cent in certain mountainous districts. Primary infections are found almost exclusively among young children. Crab yaws, a condi- tion characterized by cutaneous lesions of the feet, is prevalent. Gangosa and goundou swellings, considered by many to be mani- festations of tertiary yaws, are not infre- quent. Leprosy. Leprosy is widespread, but the distribution and the prevalence are not ac- curately known. The number of lepers has been variously estimated at from 1.2 to 50 per 1,000 population. The lepers often hide in the bush when visitors approach the vil- lages, and their presence may be concealed by the inhabitants. The extent of infection is apparently greater in the interior than in the coastal region. There are three leper colonies in Liberia, but the mission colony near Ganta, in Sanoquellie district, is the only one which provides facilities for treat- ment. Diseases of the Skin. Tropical ulcers Liberia 451 are an important cause of disability among porters and plantation workers. Mycotic dermatoses are frequent among both the white and the indigenous populations. From 14 to 18 per cent of the persons treated at the dispensary in Monrovia have some form of ringworm infection. Blastomycosis, spo- rotrichosis and moniliasis are also encoun- tered. A highly contagious skin condition of disputed origin, known locally as craw- craw, is widely distributed. It is sometimes associated with Sarcoptes scabiei infections. Occasional cases of cutaneous myiasis are reported. Other Infections. Rabies is relatively rare. Tetanus infections occur sporadically. Tetanus neonatorum is common, but the incidence has declined within recent years with the introduction of better methods of maternity and infant care. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is hyperendemic throughout the Republic, but the rate of infection is probably higher in the interior than in the coastal region. Transmission takes place throughout the year but most abundantly during the rainy season, when a sharp rise in incidence may be noted. The infection rates approximate 60 to 70 per cent in children under 5 years of age and decrease progressively to 15 to 50 per cent at 15 years of age. Adults develop a high degree of resistance, but reinfection is fre- quent. In the examination of blood films from over 10,000 individuals in 194831 malarial parasites were found in 21 per cent of the persons living in the coastal region, in 34 per cent in scattered localities in the central part of the country, in 49 per cent in three localities near the northeastern frontier of Central Province and in 40 per cent in towns near the northern border in Western Province. Blood films examined from 2,579 persons residing in the vicinity of Monrovia showed infection rates of 19 per cent. Plasmodium falciparum was present in 84 per cent of the cases in which diagnosis was established, P. malariae in 14 per cent and P. vivax in 2 per cent. P. ovale was en- countered in one instance. P. falciparum pre- dominates at all ages, but P. malariae in- fections are most numerous among children under 5 years of age. Mixed infections are common. Malaria-control programs are carried on by the United States Public Health Service Mission and by the Firestone Plantations Company. They include anopheline control measures in localized areas and the distri- bution of antimalarial drugs. Free drugs are dispensed by the Mission through its dis- pensary at Monrovia, by the medical cen- ters of the Liberian Bureau of Public Health and Sanitation and by voluntary organizations. Anopheles gambiae is the principal vector, and 4. funestus is an im- portant secondary vector. Blackwater fever is occasionally re- ported, usually among the white residents. Trypanosomiasis. Human trypanosomi- asis, caused by Trypanosoma gambiense, is prevalent in the northern part of the coun- try in a belt covering a large portion of Western Province and the frontier districts of Central Province. The highest incidence is found in the northwestern corner along the borders of Sierra Leone and French Guinea and in Sanoquellie district, near the frontier in Central Province. Infection rates of 19 to 23 per cent have been reported from localized areas. However, treatment surveys Human Trypanosomiasis in Liberia 452 Liberia give erroneous estimates of incidence, since the figures are frequently enlarged by an influx of cases from the surrounding regions. In the course of a survey in the Kolahun- Vonjama area in 1941-43 ,%% trypanosomiasis was detected in 14 per cent of the 90,980 individuals examined. The widespread dis- tribution of infection throughout Western Province was shown in a second survey among the various tribes in 1943-44, during which 32,617 persons were examined in 31 widely scattered villages. The average inci- dence was 2.2 per cent, including areas in which the infection rates were known to be low, and also areas previously covered by treatment units. In 13 towns in the Kolahun- Vonjama-Zorzor area the infection rates ranged from 0.6 to 8.09 per cent. Series of treatments with Tryparsamide and antrypol were carried out by both survey teams, but no general program has been developed. The vector, Glossina palpalis, is prevalent. Filariasis. Four types of filariasis are en- countered in Liberia. Wuchereria bancrofti is endemic in all parts of the country. Ob- servations by survey teams of the United States Public Health Service Mission to Liberia, reported in 1950,'% indicate infec- tion rates of 14 and 15 per cent in the Tchien, the Webo and the Greenville dis- tricts of Eastern Province, and of 20 per cent in the lower Buchanan area along the coast of Central Province. Elephantiasis oc- curs with greatest frequency in the coastal region. Scrotal and breast enlargements pre- dominate, but cases with involvement of the lower extremities are also seen, especially near Monrovia. Anopheles gambiae and Culex quinquefasciatus (=C. fatigans) are both considered significant vectors. Infections with Acanthocheilonema per- stans and Loa loa are observed occasionally. Onchocerca volvulus is found in localized foci in the interior, conforming to the dis- tribution of the vector, Simulium dam- nosum. Yellow Fever. In the past, outbreaks of yellow fever were reported from Monrovia at irregular intervals, but no cases have been recorded since 1929. Protection test studies indicate that the infection is en- demic in many parts of the country. In 1932 mouse protection tests were performed on the bloods of 47 Liberians employed on the Firestone plantations. Yellow fever anti- bodies were demonstrated in 6 individuals from northern and central districts. How- ever, subsequent tests on the sera of 25 per- sons from the Ganta region and on 24 from Cape Palmas showed no evidence of immu- nity.* In a series of protection tests in 1935- 36 on the blood sera of 20 individuals in scattered localities in Central and Western provinces, positive reactions were obtained in 2, or 10 per cent.! Aedes aegypti and other potential vectors are widely dis- tributed. Other Infections. Murine typhus is en- demic, but louse-borne and tick-borne fevers have not been reported. Cutaneous leishman- iasis is encountered occasionally. Plague, dengue fever and sandfly fever are not re- ported, but the vectors are prevalent. The tick, Ornithodorus moubata, apparently is not present, and relapsing fever has not been recognized. Dracontiasis, or guinea-worm infection, is common in the northwestern part of the country. NutritioNAL DISEASES The majority of Liberians subsist on diets which are deficient, both in quantity and quality. Undernutrition is general, and cases of extreme emaciation are not un- usual. Beriberi occurs occasionally, but pellagra is not reported. Lesions character- istic of deficiencies in riboflavin and in vita- min A are common. Endemic goiter is prevalent in the moun- tainous regions. At least 8 to 10 per cent of the population, primarily women, are af- fected in certain areas. SUMMARY Liberia is a republic with a population of roughly two million. Interest in public health and social welfare has developed rapidly within the last decade. The Liberian Bureau of Public Health and Sanitation is responsible for the health and medical care of the population in all parts of the country, but prior to 1943 its activities were largely political and were confined to Monrovia, the capital. Since 1944, the United States Public Health Service Mission in Liberia has co-operated with the Bureau in the organization of health and medical facili- ties and in the development of long-range plans for the Republic. In 1950 there were 14 hospitals in the country, 4 of which were operated by the government, 6 by religious missions and 4 by industrial concerns. The number of hospital beds totaled about 700, or roughly one per 2,500 of population. The largest institutions are the government hos- pital at Monrovia and the hospitals of the Firestone Plantations Company at Harbel and Harper. In addition, 52 dispensaries were scattered throughout the territory, the majority of which were conducted by the government or by different religious mis- sions. In 1947 an Institute of Tropical Medicine was established under sponsorship Liberia 453 of the American Foundation for Tropical Medicine which will provide facilities for international research in medical and allied fields. Water supplies are derived from streams and springs and from shallow wells. Monrovia has no central supply but de- pends upon from 150 to 200 shallow wells which are seriously depleted during the dry season. Methods of sewage disposal are gen- erally primitive. Ignorance, superstition and lack of adequate nutrition are major prob- lems, affecting the health standards of the people. Malaria, helminthiasis, yaws, venereal diseases and various dermatoses are wide- spread. Leprosy and tuberculosis are preva- lent, but the infection rates are not known. Human trypanosomiasis and schistosomiasis are common in localized areas. Smallpox, measles and whooping cough are frequently epidemic. Filariasis, yellow fever, murine typhus, typhoid fever and meningococcus meningitis are endemic. Pneumonia is gen- eral, but diphtheria and scarlet fever are rare. Plague, relapsing fever and tick and louse-borne typhus fever are not reported. BIBLIOGRAPHY 1. Anigstein, Ludwik: Medical exploration in Liberia, Quart. Bull. Health Organ., League of Nations 6:93-127 (Feb.) 1937. 2. ——: Medical Survey. Report on the Medi- cal Survey of Liberia, Monrovia, Govt. Printing Office, 1936. 3. Barber, Marshall A., Rice, Justus B., and Brown, James Y.: Malaria studies on the Firestone rubber plantation in Liberia, West Africa, Am. J. Hyg. 15:601-633 (May) 1932. 4. Beeuwkes, Henry, and Mahaffy, A. F.: The past incidence and distribution of yellow fever in West Africa as indicated by pro- tection test surveys, Tr. Roy. Soc. Trop. Med. & Hyg. 28:39-76 (June) 1934. 5. Bequaert, Joseph C.: Tsetse flies in Liberia: Distribution and ecology; possibilities of control, Am. J, Trop. Med., Suppl 26: 57-94 (Sept.) 1946. 6. Brown, George W.: The Economic History of Liberia, Washington, D. C., The Asso- ciated Publishers, Inc., 1941. 7. Buell, Raymond Leslie: Liberia: A Century of Survival. 1847-1947, Philadelphia, Univ. Penn. Press, 1947. 8. Davey, T. H.: Trypanosomiasis in British West Africa, London, H. M. Stationery Office, 1948. 9. Diller, William F.: Notes on filariasis in Liberia, J. Parasitol. 33:363-366 (Aug.) 1947. Harley, George May: Native African Medi- cine, Cambridge, Harvard, 1941. Johnston, Sir Harry: Liberia, vols. T and II, London, Hutchinson and Co., 1906. Kittrell, Flemmie P.: A preliminary food and nutrition survey of Liberia, West Africa, December, 1946-June, 1947. Un- published. Loveridge, Arthur: Report on the Smith- sonian-Firestone expeditions collection of reptiles and amphibians from Liberia, Proc. of the United States National Mu- seum 91:113-140, No. 3128, 1941. Maass, Edgar W. H.: Notes on the infant 10. 11. 12. 13. 14. 454 15. 16. 17. 18. 19. 20. 21. 22: 23, Liberia mortality rate among an indigenous tribe in the Liberian hinterland, West African M. J. 3:34-36 (Oct.) 1929. Mann, Lucile Q.: Smithsonian-Firestone ex- pedition to Liberia, Scient. Monthly 51: 482-485 (Nov.) 1940. Maugham, R. C. F.: The Republic of Li- beria, New York, Scribner, 1920. Poindexter, Hildrus A.: A laboratory epi- demiological study of certain infectious diseases in Liberia, Am. J. Trop. Med. 29:435-442 (July) 1949. : Studies on Filaria bancrofti in Li- beria, Am. J. Trop. Med. 30:519-523 (July) 1950. ——: Tropical ulcers, Arch. Dermat. & Syph. (In press). : Tuberculin patch test survey among school-aged children in Liberia. Unpub- lished. Smith, H. F. Résumé of report on sanitation and yellow fever control in Liberia, Pub. Health Rep. 46:1353-1359 (June) 1939. Strong, Richard P.: The American Republic of Liberia and the Belgian Congo, vols. I and II, Harvard African Expedition, 1926-27. Cambridge, Harvard, 1930. United States. U. S. Public Health Service, 24. 25. 26. 27. 28. 29. 30. 31. Office of International Health Relations: First Annual Report of the United States Public Health Service Mission to Liberia, for the Period ending June 30, 1945. : Annual Report of the United States Public Health Service Li- berian Mission, Fiscal Year, 1947. : Annual Report for the Fiscal Year 1948, United States Public Health Service Mission in Liberia. : Annual Report of the United States Public Health Service Mis- sion to Liberia, 1949-50. United States Public Health Service Mission in Liberia, Labo- ratory Section, Research Activities, 1947. Veatch, Everett P.: Human trypanosomiasis in Liberia, 1941-44, Suppl.,, Am. J. Trop. Med. 26:5-56 (Sept.) 1946. West, John B.: United States Health Mis- sions in Liberia, Pub. Health Rep. 63: 1351-1364 (Oct. 15) 1948. Wilson, Charles Morrow: Liberia, York, William Sloane Associates, 1947. Young, Martin D., and Johnson, Thomas H., Jr.: A malaria survey of Liberia, J. Nat. Malaria Soc. 8:247-266 (Dec.) 1949. New Inc., 33 Leone Sierra GEOGRAPHY AND CLIMATE Sierra Leone, on the west coast of Africa between French Guinea and Liberia, is ad- ministered by Great Britain—part as a colony, and part as a protectorate. The Colony covers barely 270 square miles and consists of the peninsula of Sierra Leone, a small portion of Sherbro Island and several other island groups. The remainder of the territory, which was declared a Protectorate in 1896, has a total area of approximately 27,670 square miles and is divided into three provinces, incorporating some 214 separate and independent chiefdoms. The Peninsula, which protects the deep, natural harbor at the mouths of the Rokel and the Sierra Leone rivers, is largely moun- tainous, with heights up to 2,500 feet in elevation. The rest of the coast, however, is a low-lying plain, varying in width from 30 to 50 miles and intersected by creeks and estuaries, which in places are bordered by dense mangrove swamps. The greater part of the Protectorate consists of a series of plateaus with an average altitude of 1,500 feet, which are broken by hills in the north and by mountains reaching 6,000 feet along the northeastern borders. The country to the south is dense bush; to the north, thinly wooded grassland. Six rivers, with their tributaries, traverse the territory in a gen- eral southwesterly direction. The single rainy season extends from April to November, with the heaviest rain- fall between July and September. Violent thunderstorms and tornadoes are frequently experienced at the beginning and the end of the rains, but the months between De- cember and March are practically rainless. During this period, the dry, dust-laden northeast harmattan winds blow intermit- tently. The rainfall averages from 145 to 152 inches a year at Freetown on the north- eastern coast of the peninsula, but decreases inland; it is around 114 inches at Bo, toward the center of the Protectorate, and 90 inches at Kabala in the northeast. Dur- ing the rainy season the humidity reaches 90 to 95 per cent in the coastal area. The temperature at Freetown fluctuates between a mean maximum of 85° to 87° F. and a mean minimum of about 75° F. The mean annual range is 15° F. or less at Freetown but is somewhat greater in the interior. The largest daily variations are encountered dur- ing the karmattan season. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopurLATION According to the census of 1947, the pop- ulation of Sierra Leone was approximately 1,858,300: 124,700 in the Colony and 1,733,600 in the Protectorate. The popula- tion of the Colony included 608 Europeans, 873 Asiatics, and 28,114 non-native Africans. Corresponding figures for the Protectorate were 356 Europeans, 1,201 Asiatics and 2,078 non-native Africans. The designation “non-native African” is applied to the de- scendants of the original colonists, “Lib- erated Africans” from the Americans who were settled on the Peninsula in 1782-1800. These peoples, commonly called “Creoles,” make up about a quarter of the inhabitants of the Colony, while the native fraction in- 455 456 Sierra Leone cludes the aboriginal tribes of the area and immigrants from the various tribes of the Protectorate. The indigenous races are largely of Negro origin, with varying de- grees of Hamitic infiltration. There are from 15 to 30 different tribes in the Pro- tectorate, two of which, the Mendes and the Temnes, comprise almost two thirds of the total native population. The Mendes, which are the most numerous, occupy large por- tions of the central and southern Protec- torate, while the Temnes are widely dis- tributed in the Colony and in the Northern Province. The native peoples are essentially pagan. However, certain small tribes in the north are traditionally Moslem, while other large and influential tribes are rapidly becoming converted to the Islamic faith. Several Protestant and Catholic missions are established in the country, but, although over 50 per cent of the inhabitants of the Colony, including the majority of Creoles, profess Christianity, the percentage of con- verts in the Protectorate is small. Each tribe has its own language or dialect, but the Mende tongue is used extensively in the south, and the Temne in the north. English is employed by the educated Creoles and natives, while a form of pidgin English, which incorporates words and phrases of Portuguese, French and African origin, is spoken throughout the Colony and in some parts of the Protectorate. The majority of the peoples of Sierra Leone live in small permanent towns and villages which are more or less self- contained. The population density averages 66 per square mile and varies from 105 in the fertile Pendembu area along the eastern terminus of the railroad to 15 in Koinadugu district on the northeastern border. Free- town, situated on the peninsula at the mouth of the Sierra Leone River, is the capital and only large city. The population was 54,700 at the time of the census in 1931, but about 80,000 in 1949. Bo is the largest and most important town in the Protectorate. Educational facilities are reasonably ad- vanced in the Colony and are gradually being developed in the Protectorate. The government maintains schools and subsi- dizes mission institutions in both areas. In the Protectorate, education is conducted largely by the missions. A few schools are also supported by the Native Administra- tions. In 1946 approximately 55 per cent of the children of the Colony were enrolled in primary schools, and 4 per cent of the chil- dren in the Protectorate. Fourah Bay Col- lege, the only institution offering a post- secondary school education, is affiliated with the University of Durham in England. VITAL STATISTICS The registration of births and deaths is compulsory only for residents in the Colony and for non-natives in the Protectorate. Vital statistics are available for Freetown, but the absence of recent census data and the mobility of certain groups of the popula- tion detract from their validity. In 1947 there were 2,265 births and 1,510 deaths in the city, giving on the basis of an estimated population of about 80,000 a birth rate of 28.3 per 1,000 population and a death rate of 18.9. Within recent years the infant mor- tality rate has fluctuated between 243 per 1,000 births in 1937 and a low of 153 in 1944. It was 208 in 1946, and 182 in 1947. Over one half of the infant deaths occur during the first month of life. Low standards of living and malnutrition are important contributory factors. The infant mortality rates among the tribes in the Protectorate probably average between 25 and 35 per cent. SociaL Economy Sierra Leone is primarily an agricultural country, with abundant natural resources in the indigenous trees found in the central and the southern portions of the Protecto- rate. Palm kernels and palm oil constitute the major wealth of the territory. Together with piassava and kola nuts, they comprise from 70 to 80 per cent of the total exports. Ginger, which is cultivated in the Colony, is also exported. Stock raising is of minor Sierra Leone 457 importance, being confined largely to two small pastoral tribes in the northern part of the country. Mining is the principal indus- trial development ; iron ore, diamonds, gold and chrome ore deposits are worked on a commercial scale. The Creoles constitute the artisan, clerical and professional classes of the Colony. The Syrian community and a limited number of European firms have a virtual monopoly of trade. Steamer and air transport services connect Freetown with the United Kingdom and with other west African ports, while the Sierra Leone Government Railway links that city with the interior. It has branches to Makeni and to Pendembu, with a junc- tion at Gibina. Communications in the Pro- tectorate are poorly developed, but motor roads connect the major population centers. Because of the presence of the tsetse fly and the shortage of draft animals, transport on the smaller local roads is largely by means of human carrier. Foop AND NUTRITION The staple food of the country is rice, supplemented by palm oil, cassava and fish. Other foods which are used in varying amounts by different peoples are maize, pea- nuts, millet, legumes, sweet potatoes, yams, greens and a variety of indigenous fruits. Meat and dairy products are scarce and are rarely consumed by the poorer natives. Few cattle are raised, but goats are common. Pig breeding is becoming increasingly pop- ular in some areas. In spite of primitive methods of “shift- ing” cultivation, with the consequent de- terioration of vast areas, the territory is normally self-supporting, and acute food shortages are rare. However, the dietary of most tribes is usually deficient in animal proteins and in vitamins of the B complex and A. The Sierra Leone government is at- tempting to raise the standards of nutrition and, through education and research on its experimental farms, to promote modern methods of cultivation and animal hus- bandry. Recently, rice has been cultivated successfully in the swamp area of the Great Scarcies River, and the drainage and the utilization of the swamplands in that region for growing “wet rice” is now encouraged by the government. It is anticipated that these former waste areas will contribute materially to the rice supply of the country. Housine The typical village homes are round or square huts of wattle and daub with palm- tile or grass thatch roofs, but in some of the larger towns more permanent dwellings made of mud blocks with palm-tile or cor- rugated iron roofs are gradually being intro- duced. In Freetown and the towns of the Colony the better-class homes are constructed of concrete or stone, typically with upper stories of timber, but most of the people live in small one-story dwellings of frame or mud-block. Overcrowding is general, and larger houses converted into tenements, wooden shanties and mud and wattle huts are common. Town planning and improved housing are important features of Sierra Leone’s development program. ENVIRONMENT AND SANITATION WATER SUPPLIES Ample water supplies are derived from surface streams, wells and springs during the greater part of the year, but seasonal shortages occur in many areas. The rain- fall, although heavy, is concentrated to a large extent in the period from June to September, with the result that water is frequently scarce in the months just preced- ing. Impounded reservoirs are the chief source of supply for the towns and the vil- lages of the Peninsula. The water supply for Freetown is taken from streams in the surrounding hills. There are 27 sources of supply, most of which feed into reservoirs on Tower Hill or Babadori Saddle. About 95 per cent of the water is treated by chlorination in 8 separate treat- 458 Sierra Leone ment plants. In 1946 water was distributed to about 1,200 private buildings and to 250 communal outlets. The present water supply is inadequate from February to June, and the construction of a new 100-million gallon reservoir is under consideration. Most of the untreated water supplies are polluted. Waste DisposaL The bucket system is the common method of sewage disposal in the towns of the Colony and the Protectorate. In Freetown, a few septic tanks are employed in connec- tion with business buildings and the homes of the European residential quarter, but the seasonal shortage of water prohibits their use on a large scale. The sewage is disposed of in cesspits and, in spite of a restrictive ordinance, by dumping into the harbor. The city is built on hard laterite rock, and the construction of a sewerage system is not considered feasible. Septic tank latrines are gradually being introduced in Bo and Bonthe. The pollution of the soil is general in the rural areas. Fauna AnD Frora Arthropods. Mosquitoes. At least 14 species of anopheline mosquitoes are found in Sierra Leone, but only Anopheles gambiae and A. gambiae melas are of major impor- tance in the transmission of malaria. A. fu- nestus also occurs but is of secondary and local significance. In the neighborhood of Freetown, A. hancocki, A. hargreavesi and A. nili have been shown to be efficient vec- tors; the two former species play a minor role in transmission during the malaria sea- son, while the latter, a stream breeder, is important in certain limited areas during the dry season. A. rkodesiensis is common throughout the territory but is of little con- sequence in malaria transmission. A. smithi is found in Freetown district and other localized areas. A. gambiae breeds abun- dantly in exposed rock pools, drains, seep- ages and other accumulations of water and, during the dry season, in the numerous shallow streams. A. gambiae melas breeds along the coast in the brackish waters in the Avicennia (black) mangrove orchards and paspalum grass swamps, which are flooded by the spring tides. Numerous species of Aedes and Culex are recorded. Aedes aegypti is widespread. Culex thalassius is a frequent pest. Eretmo- podites quinquevittatus is also common. An extensive antianopheline program is carried on in Freetown and certain areas in the Colony by the Malaria Control Unit of the government health services. It in- cludes swamp drainage, canalization of streams, antilarval measures employing oil or DDT, and house spraying with various insecticides. Drainage operations are also undertaken at Bo and other populous cen- ters in the Protectorate. A considerable reduction of A. gambiae melas has been effected in the Bonthe area since the reclam- mation of the tidal swamps for rice cultiva- tion was initiated in 1939. Fries. Various species of tabanid and muscoid flies are present in Sierra Leone, as in the adjacent areas of West Africa. The most important, from a medical standpoint, are the tsetse flies, which are widely though unevenly distributed throughout the Colony and the Protectorate. Only parts of Port Loko, Bambali and Koinadugu districts are entirely free. Glossina palpalis, the domi- nant species, is found in the vicinity of creeks, streams and rivers in the forest and the parkland savannah country. G. longi- palpalis occurs in the extreme north where it is a significant vector of bovine trypano- somiasis. G. fusca was formerly abundant, but with the devastation of the forests its range has become restricted. Animal trypa- nosomiasis is of considerable economic im- portance in the territory, but the human dis- ease is largely restricted to Sherbro Island and to the eastern part of the Protectorate near the borders of French Guinea and Liberia. Lice. Pediculus humanus corporis and P. humanus capitis are widespread. Phthirus pubis is sometimes present. FrEas, Xenopsylla cheopis and X. brasili- ensis parasitize the domestic and wild ro- dents. No evidence of plague infection has been discovered within recent years, but sporadic cases of murine typhus are re- ported. Ctenocephalides felis is common. Ticks. Species of Rhipicephalus, Bo- ophilus, Hyalomma, Amblyomma and Apo- nomma infest the domestic animals. Haema- physalis leachi is also found. The tampan tick, Ornithodorus moubata, has not been reported from the territory. OTHER ARTHROPODS. Venomous scorpions and spiders are encountered occasionally. The juices of the Paederus beetle cause severe blisters. Reptiles. The cobras, Naja mnigricollis, N. melanoleuca and N. goldii, and the tree mambas, Dendroaspis viridis and D. jame- sonii, are found in different regions. The most dangerous viper is the puff adder, Bitis arietans, but B. gabonica, B. nasi- cornis, Echis carinatus and Causus rhom- beatus are also present. Atheris chlorechis and Atractaspis irregularis have been re- corded from some localities. Other species which have been identified include Lepto- dira hotamboeia, Dipsadomorphus pulveru- lentus, D. blandingii, Dipsadoboa unicolor, Psammophis sibilans, P. elegans, Thelotor- nis kirtlandii, Calamelaps unicolor, Miodon acanthias, Aparallactus niger, Elapops mo- destus, Dromophis praeornatus and D. line- atus. The pythons, Python sebae and P. regius, are not venomous but may cause the death of the smaller animals. Mollusks.* The freshwater snails, Pky- sopsis africana globosa and Bulinus (Pyrgo- physa) forskalii, are widely distributed in the northern and the eastern portions of the Protectorate, where numerous foci of Schistosoma haematobium infection occur. Planorbis (Biomphalaria) alexandrina pfeif- feri, the intermediate host of S. mansoni, is also found in the mountain streams along the northern border, particularly in Koina- dugu district. Occasional cases of schistoso- miasis, caused by S. mansoni, are reported from scattered foci. * See footnote, p. 10. Sierra Leone 459 Plants. Numerous poisonous plants are found throughout West Africa which are used by the various tribes for medicinal purposes or in the preparation of fish and arrow poisons and of potions employed in tribal ordeal ceremonies. Plants specifically reported from Sierra Leone include, among others, Strophanthus gratus, S. hispidus, S. sarmentosus, Jatropha gossypiifolia, Calo- tropis procera and Erythrophleum guine- ense. Foop SANITATION Sanitary controls over meats and other foods are enforced only in Freetown and other large towns. Local meats are subjected to antemortem and postmortem inspection by sanitary inspectors, but imported sup- plies are not examined. Fresh milk is scarce, and canned or dried products constitute the principal source of supply. The standards of cleanliness in the rural areas vary but are generally low. . HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The Medical Department of the Colonial government is responsible for the protec- tion of the health of the people. It is advised on matters of general policy by the medi- cal officers of the Colonial Office in London. The Department is administered by a Direc- tor of Medical Services, with headquarters in Freetown, while assistant directors are in charge of its medical and health activities in the Colony and in the Protectorate. The responsibilities of the Department include the maintenance of hospitals and dispen- saries, of laboratories and of facilities for the training of medical personnel; the or- ganization of school health and dental serv- ices; the supervision of sanitation; the enforcement of port and quarantine regu- lations; and the conduct of programs for the control of communicable diseases. Ma- laria Control, and Yaws and Sleeping Sick- ness Units constitute subsidiary services 460 Sierra Leone which are financed in part by British Colo- nial Development and Welfare funds. Maternity and infant welfare work is car- ried on in connection with the larger hos- pitals. Co-operation between the Medical Department and the Bundu, a secret tribal society of women, has been effective in pro- moting health education and child welfare work in some areas. Many of the chiefdoms which are organized as Native Administra- tions support various health and sanitary services. The expansion of the activities of the Department, featuring the establishment of health centers throughout the country, the improvement of water supplies, the exten- sion of the campaign for the control of yaws and sleeping sickness and the organization of a leprosy survey is contemplated under a development program initiated by the Sierra Leone government in 1946. Several mission organizations carry on important medical work in the Colony and the Protectorate and through their educa- tional activities contribute materially to the promotion of higher standards of health among the native peoples. MEepICAL INSTITUTIONS Hospitals and Dispensaries. In 1947 the Medical Department operated 2 general hospitals with a total of 237 beds in the Colony and 8 hospitals with 238 beds in the Protectorate. The Connaught Hospital in Freetown has a capacity of 205 beds and is the largest and best equipped hospital in Sierra Leone. Other hospitals in the Colony include the Hill Street Hospital, with 32 beds, and a maternity hospital, with 43 beds, in Freetown ; a mental hospital at Kissy and an infectious disease hospital at Lakka, both near Freetown. The hospital at Bo is the largest in the Protectorate. It has a capacity of 68 beds, while the remaining institutions vary in size from 12 to 45 beds. A tuber- culosis section with an annex for white pa- tients was opened in connection with the Bo hospital in 1947. Five rural dispensaries, in charge of qualified native medical assist- ants, are maintained in the Colony, and 17 in the Protectorate. There are 4 mission hospitals, one in Free- town and 3 in various parts of the Protec- torate. The institution in Freetown, which specializes in the care of women and chil- dren, was closed temporarily in 1947. Laboratories. The Medical Department conducts a Pathological Laboratory in Free- town, which performs the pathologic, bac- teriologic and serologic examinations for the territory. It was opened in 1940-41, follow- ing the closing of the Sir Alfred Jones Re- search Laboratory, formerly operated in association with the Liverpool School of Tropical Medicine. Clinical laboratory fa- cilities are available in the larger hospitals. Schools. Courses for the training of medi- cal assistants and nurses are provided in the government hospitals in Freetown. It is anticipated that the hospital at Bo will eventually become the training center for the Protectorate. Midwives are trained at the maternity hospital in Freetown and in the mission hospitals at Segbwema and Rotifunk. A school for native sanitary over- seers is operated at Bo. PERSONNEL Physicians. In addition to the Director of Medical Services and the Assistant Directors assigned to the Colony and the Protectorate, from 25 to 30 members of the Colonial Medical Service were employed on the staff of the Medical Department in 1948. A few physicians are also connected with the mission hospitals and are engaged in private practice in Freetown. Others. In 1949 two dentists were work- ing in the government services, and one was practicing independently in Freetown. The British professional staff of the Medical Department also included, in 1948, 2 path- ologists, 1 entomologist, 5 sanitary superin- tendents and 16 nurses. Native medical assistants, nurses, midwives, sanitary in- spectors and laboratory assistants are em- ployed in the different branches of the department. Sierra Leone 461 DISEASES The incidence of disease among the people of Sierra Leone is not accurately known. Except in the case of certain infections, such as yaws and trypanosomiasis, which are the subject of special investigations, the avail- able information is compiled from the gov- ernment hospital and dispensary statistics. In most areas these cannot be considered as representative, since a large percentage of the inhabitants conform to their traditional forms of medical practice, while others live beyond reach of the medical services. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or URINARY TRACTS Typhoid and Paratyphoid Fever. Typhoid fever is common in all parts of the country. The level of sanitation is low, and the water supplies are frequently pol- luted. From 100 to 150 cases are reported annually, with an average fatality rate of from 20 to 30 per cent. Paratyphoid fever also occurs, but the recorded incidence does not exceed 4 to 10 cases a year. Dysenteries. All forms of dysentery are prevalent. Amebic dysentery appears to pre- dominate among the reported cases, but laboratory confirmation is usually lacking. Moreover, the hospital figures probably rep- resent but a small fraction of the total inci- dence. Among the 1,929 cases treated in 1946 and 1947, about 39 per cent were recorded as amebic dysentery and 8 per cent as bacil- lary, while the remainder were unclassified. In 123 cases of bacillary dysentery diag- nosed at the Pathological Laboratory in Freetown over a period of 36 months in 1946-47, all types of Shigella were isolated except S. dysenteriae. Shiga dysentery is relatively rare and had been identified on only one occasion since the reopening of the Laboratory in 1940.22 Diarrheal infections are widespread, and many are undoubtedly unrecognized bacillary dysenteries. Helminthiases. Scuistosomiasis. Infec- tions with Schistosoma haematobium are common in the central and the northern provinces, particularly in the eastern dis- tricts, where the intermediate hosts, Phky- sopsis africana globosa and possibly Bulinus (Pyrgophysa) forskalii, are abundant in the streams and the swamps. No foci of infec- tion have been found in the southern part of the country, but nonindigenous cases are reported occasionally. S. mansoni is also en- countered in isolated areas along the north- ern border. Surveys in 1932-34,% following an outbreak in Kabala, revealed infection rates of 10 to 35 per cent among different tribes in the mountainous portions of north- ern Koinadugu district. The host is Pla- norbis (Biomphalaria) alexandrina pfeifferi, which abounds in the streams and the wash- ing pools. A total of 162 cases of schistoso- miasis was reported in 1947. Ancvrostomiasis. Hookworm infection is prevalent in most parts of the country. From 300 to 900 cases of ancylostomiasis are treated in the hospitals and the connecting dispensaries each year, but the infections are rarely severe, and the actual incidence cannot be accurately estimated. Both Neca- tor americanus and Ancylostoma duodenale are encountered. The former species pre- dominates in the vicinity of Freetown. Oruer HELMINTH INFECTIONS. Ascariasis is widely distributed. Trichuriasis, strong- yloidiasis and enterobiasis are undoubtedly present, as in the neighboring territories. Other Infections. Cholera has not been reported from this region. The presence of brucellosis is uncertain. Diseases SPreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. All forms of tuberculosis are common. The 150 to 300 cases of pulmo- nary and 30 to 60 cases of nonpulmonary tuberculosis treated annually in government institutions do not give a true index of its prevalence. The treatment facilities are in- adequate; beds are available in the Con- naught Hospital in Freetown; and a tuber- culosis pavilion has been opened recently in connection with the hospital at Bo. The malnutrition, the poverty and the ignorance 462 Sierra Leone of hygienic measures prevailing among a large percentage of the population are major factors in the spread of the infection. There is considerable evidence that a degree of resistance to the disease, comparable with that usually found in urban populations in Europe, exists among the Creole inhabitants of Freetown. Smallpox. Outbreaks of smallpox occur sporadically. After several years of com- parative freedom from the disease, an epi- demic of smallpox involving 343 cases was reported in 1944 from Kailahun district along the northern border with Liberia. Small outbreaks also appeared in other parts of the country, bringing the total inci- dence to 484 cases, with a fatality rate of 20 per cent. The incidence continued to increase in the form of sporadic outbreaks in various parts of the Colony and the Pro- tectorate. Approximately 650 cases were re- ported in 1945, and 750 in 1946, with fatality rates of 6 per cent and 15 per cent, respec- tively. In the latter year, 134 cases were recorded in Freetown, and the port was de- clared “infected” for a short period. In 1946 an intensive vaccination campaign was in- itiated in the districts bordering on French Guinea and Liberia and later was extended to the eastern chiefdoms. An active immu- nization program was also carried on in Freetown and other parts of the Colony. The disease persisted in localized outbreaks in 1947, but the incidence declined to a yearly total of 200 cases by 1948. Other Infections. Pneumonia is preva- lent, and the fatality rates are generally high. Epidemics of meningococcus menin- gitis are reported at irregular intervals. They coincide with the dry season and abate with the onset of the rains. Measles and whooping cough are endemic. Occasional cases of scarlet fever, diphtheria and acute poliomyelitis are recorded. DiseasES SPREAD OR CONTRACTED CuierLy TaroucH CONTACT Venereal Diseases. All forms of vene- real disease are widespread. Gonorrhea pre- dominates and averages roughly 70 to 80 per cent of the venereal infections treated each year in the government hospitals. Cases of syphilis usually account for 6 to 10 per cent. A center for the treatment of venereal diseases is maintained by the Medical De- partment in Freetown. Yaws. Yaws is highly endemic in all portions of the country, particularly the rural areas. In 1947 a total of 27,697 cases was treated in the government hospitals and dispensaries. In addition, over 21,270 cases were treated at special treatment centers established by the government’s Yaws and Sleeping Sickness Unit. In the chiefdoms in Kono, Kenema and Kailahun districts, surveyed in 1942-46, the infection rates ranged from 4 to 34 per cent.!® The inci- dence is seasonal, with a recrudescence of active lesions during the rainy season. Con- trol measures include mass diagnosis and treatment, the establishment of permanent and mobile centers or dispensaries, and in some areas the employment of itinerant workers to search out cases to be referred to the centers for treatment. Leprosy. Leprosy is widely distributed in the Protectorate, but the actual prevalence is not known. In a survey reported in 1936,'¢ the number of lepers ranged from 0.3 to 4.6 per 1,000 population in different districts. However, the 3,656 lepers enumerated at that time were thought to represent only a small part of the actual number. The disease is most frequent in Kono, Kailahun and Koinadugu districts, in the southwestern portion of Kambia district and in the west- ern part of Port Loko district. There are no special facilities for the treatment of leprosy, but the cases treated in the govern- ment hospitals average from 100 to 225 a year. Other Infections. Trachoma is common in the Protectorate. Rabies is enzootic in the dog population, and human cases are ob- served occasionally. Tetanus is sporadic. Numerous mycotic infections of the skin are encountered. Scabies is prevalent and often associated with a vesicular pustular dermatitis locally known as craw-craw. Sierra Leone : 463 DISEASES SPREAD BY ARTHROPODS Malaria. A large proportion of the terri- tory is malarious. Government hospital sta- tistics record from 10,000 to 30,000 cases annually which afford a low estimate of the extent of infection. Malaria transmis- sion takes place throughout the year, with a peak of incidence between May and Sep- tember when the rainfall conditions favor maximum breeding of anopheline mosqui- toes. The principal vectors are Anopheles gambiae and in the tidal swamp areas, A. gambiae melas. An intensive anopheline control program has been conducted in the vicinity of Free- town since 1940-41, with an appreciable reduction in malaria. Surveys of school children in 1944 revealed parasite rates of 21.3 per cent in urban Freetown, 42.7 per cent in the suburbs and 47.4 per cent in the adjacent rural areas. Corresponding find- ings for 1947 were 7.6 per cent, 14.4 per cent and 27.5 per cent, respectively. Plasmodium falciparum is the predomi- nating species and has been demonstrated in roughly 98 to 99 per cent of the blood films examined in the government labora- tory since 1941. During this period, P. ma- lariae was responsible for less than 0.5 per cent of the infections. The P. malariae parasite rate varies considerably in different surveys. P. vivax infections have been en- countered infrequently within recent years and probably never exceed 6 per cent of the total. P. ovale is seen sometimes. Cases of blackwater fever are reported sporadically. Trypanosomiasis. Human trypanoso- miasis, caused by Trypanosoma gambiense, occurs chiefly in the eastern part of the country. The disease was epidemic in the Kissi and the Luawa chiefdoms, which oc- cupy the tongue of territory between Liberia and French Guinea, in the late 1930’s. As the result of an intensive campaign carried on by the Yaws and Sleeping Sickness Unit, the incidence was reduced from 20 per cent in 1940 to 1 per cent in 1945.2° Control measures include mass diagnosis and treat- ment (with antrypol and Tryparsamide) in the affected villages. In Kono district, a symptomless type of trypanosomiasis with a relatively severe blood infection is en- countered. The greatest prevalence is found between the Meli River and the towns of Koardu, Fuero and Laome. The incidence persists at a high level in spite of treatment measures; in some areas it appears to be increasing. The infection rates in Fuero rose from 8 per cent in 1941 to 14 per cent in 1944. Since 1946, an experimental program of mass prophylaxis, using single injections of pentamidine isethionate at 6-month inter- vals, has been carried on with considerable success. In 1947, 5 permanent dispensaries and 7 treatment centers were being operated in regions covered by the Unit’s diagnosis and treatment teams. A new endemic focus was discovered on Sherbro Island in 1942, with an average infection index of from 2 to 3 per cent. In a survey in 1945, the prevalence was esti- mated at 2.1 per cent in Bonthe and 0.5 per cent in the surrounding areas.?’ Bonthe is a trading center for the eastern districts of Sierra Leone and is continually exposed to the introduction of new cases from the mainland. Sporadic cases of trypanosomiasis have been recorded from the Colony penin- sula and from the country south of Moy- amba. Yellow Fever. Yellow fever was formerly epidemic in Freetown. The city has been relatively free from the disease since the in- stallation of a piped water supply in 1910, but occasional cases are reported. The most recent outbreak occurred in 1942, when three cases were recognized among the white military personnel stationed at Allen Town, 8 miles from Freetown. Mass im- munization of the local population against yellow fever, and the intensification of Aedes-control measures were instituted im- mediately. The infection is endemic in the interior, where epidemics apparently de- velop from time to time. A protection test survey in 19322 revealed some evidence of immunity to yellow fever virus in the Segbwema and the Makeni areas and 464 Sierra Leone widespread immunity in the vicinity of Moyamba. Rickettsial Infections. Murine typhus occurs sporadically and in occasional local- ized outbreaks. Cases of suspected louse- borne typhus have also been recorded. The presence of tick-borne infections has not been established. Other Infections. Filariasis is endemic, but the incidence of Wuchereria bancrofti, Loa loa and Acanthocheilonema perstans has not been determined. Plague has not been reported within recent years, and the routine examinations of rats in Freetown and other urban areas have disclosed no evidence of infection. Relapsing fever has not been recorded. NuTrITIONAL DISEASES Malnutrition and avitaminosis are com- mon, particularly in Freetown. During the examination of 1,626 school children in 1946, marked avitaminosis was found in 29.4 per cent of the primary school group and in 17.9 per cent of the secondary. Con- ditions due to deficiencies in vitamins of the B complex and vitamin A are prevalent. Various skin lesions are common. Beri- beri is reported sporadically, but scurvy is rare. Rickets is encountered sometimes among young children. Goiter is endemic in localized areas. MisceELLANEOUS CONDITIONS Infectious hepatitis is endemic. Recog- nized cases occur most frequently during the rainy season. SUMMARY The Colony and the Protectorate of Sierra Leone differ in history, administra- tion and cultural development. The health of the inhabitants is the responsibility of the government’s Medical Department, which is administered by a Director of Medical Serv- ices with headquarters in Freetown. In 1947 the Department operated 2 general hospitals and 5 rural dispensaries in the Colony; 8 hospitals and 17 dispensaries in the Pro- tectorate. Several mission organizations also carry on medical services in various parts of the country. The standard of sanitation is low. Water supplies are derived from streams, wells and springs but are frequently scanty toward the end of the dry season. Few supplies are treated. Facilities for waste disposal are primitive. Malnutrition and avitaminosis are common. Malaria, intestinal infections, helminthia- sis, venereal diseases and tuberculosis are prevalent. Yaws is widespread, and human trypanosomiasis is epidemic in the eastern part of the Protectorate. Schistosomiasis is common in all but the southern districts. Outbreaks of smallpox and meningitis occur sporadically. Yellow fever is reported occa- sionally. Murine typhus, leprosy, trachoma, tetanus and the ordinary respiratory infec- tions are endemic. Plague, relapsing fever and cholera are not reported. BIBLIOGRAPHY 1. Aylmer, G.: The Snakes of Sierra Leone. Sierra Leone Studies, No. 5 (Jan.), 1922, Freetown, Govt. Printer. 2. Beeuwkes, Henry, and Mahaffy, A. F.: The past incidence and distribution of yellow fever in west Africa as indicated by pro- tection test surveys, Tr. Roy. Soc. Trop. Med. & Hyg. 28:39-76 (June) 1934. 3. Blacklock, D. B., and Wilson, Carmichael: Notes on Anopheles gambiae and Anoph- eles gambiae var. melas in Freetown and its vicinity, Ann. Trop. Med. 35:37-42 (Oct.) 1941. 4. Davey, T. H.: Trypanosomiasis in British West Africa, London, H. M. Stationery Office, 1948. 5. Goddard, T. N.: The Handbook of Sierra Leone, London, Grant Richards, Ltd. 1925. 6. Gordon, R. M,, and Davey, T. H.: An ac- count of trypanosomiasis at the Cape Lighthouse Peninsula, Sierra Leone, Ann. Trop. Med. 24:289-319 (July) 1930. : : The occurrence of tropical typhus in Sierra Leone: a preliminary re- port, Ann. Trop. Med. 30:203-209 (July) 1936. ~I Sierra Leone 465 8. 10. 11. 12. 13. 14. 13. 16. 17. 18. 19. 20. ——, ——, and Peaston, H.: The trans- mission of human bilharziasis in Sierra Leone, with an account of the life cycle of the schistosomes concerned, S. mansoni and S. haematobium, Ann. Trop. Med. 28:323-418 (Oct.) 1934. , and Macdonald, G.: The transmission of malaria in Sierra Leone, Ann. Trop. Med. 24:69-80 (Apr.) 1930. Great Britain. Colonial Office: Annual Re- port on Sierra Leone for the Year 1946, London, H. M. Stationery Office, 1947. ——. ——: Annual Report on Sierra Leone for the Year 1947, London, H. M. Sta- tionery Office, 1949. Harding, R. D, and Hutchinson, M. P.: Sleeping sickness of an unusual type in Sierra Leone and its attempted control, Tr. Roy. Soc. Trop. Med. & Hyg. 41:481- 512 (Jan.) 1948. ——: A yaws campaign in Sierra Leone, Tr. Roy. Soc. Trop. Med. & Hyg. 42:347-366 (Jan.) 1949. Irvine, F. R.: West African Botany, London, Oxford, Humphrey Milford, 1942. Kuczynski, R. R.: Demographic Survey of the British Colonial Empire. Vol. I. West Africa, London, Geoffrey Cumberlege, Oxford, 1948. Leprosy in Sierra Leone: Leprosy Rev. 7: 191-199 (Oct.) 1936. Lourie, E. M.: Treatment of sleeping sick- ness in Sierra Leone, Ann. Trop. Med. 36:113-131 (Sept.) 1942. Maegraith, B. G.: The identification of the poisonous snakes of British West Africa, Ann. Trop. Med. 38:21-34 (Apr.) 1944. Mattingly, P. F.: New keys to the West African Anophelini, Ann. Trop. Med. 38: 189-200 (Dec.) 1944. Nash, T. A. M.: Tsetse Flies in British West Africa, London, H. M. Stationery Office, 1948. A, ry 23: 24. 23. 26. 27. 28. 29. 30. 31. 32. Peaston, H., and Renner, E. A.: Report on an examination of the spleen- and parasite- rates in school children in Freetown, Sierra Leone, Ann. Trop. Med. 33:49-59 (Mar.) 1939. Reid, John D., and Gosden, Minnie: A short account of the types of dysentery in Sierra Leone: with report of a case of infection with Shigella shigae, Tr. Roy. Soc. Trop. Med. & Hyg. 43:683-685 (May) 1950. Sierra Leone: Medical Report for the Year 1941, Freetown, Govt. Printer, 1942. : Report of the Medical and Health Services, 1942, Freetown, Govt. Printer, 1944. ——: Annual Report of the Medical and Health Services for the Year 1944, Free- town, Govt. Printer, 1946. : Annual Report of the Medical and Health Services for the Year 1945, Free- town, Govt. Printer, 1946. ——: Annual Report of the Medical and Health Services for the Year 1946, Free- town, Govt. Printer, 1947. ——: Annual Report of the Medical and Health Services for the Year 1947, Free- town, Govt. Printer, 1949. : Medical Department. Report on Ma- laria in Freetown and District, Freetown, Govt. Printer, 1946. Thomson, R. C. Muirhead: Recent knowl- edge about malaria vectors in West Africa and their control, Tr. Roy. Soc. Trop. Med. & Hyg. 40:511-536 (May) 1947. : Studies on Anopheles gambiae and A. melas in and around Lagos, Bull. Ent. Res. 38:527-558 (Feb.) 1948. Walton, G. A.: On the control of malaria in Freetown, Sierra Leone. I. Plasmodium falciparum and Anopheles gambiae in re- lation to malaria occurring in infants, Ann. Trop. Med. 41:380-407 (Dec.) 1947. 34 Portuguese Guinea GEOGRAPHY AND CLIMATE Portuguese Guinea, an enclave of some 14,000 square miles between Senegal and Guinea in French West Africa, has a coast- line of approximately 240 miles on the At- lantic Ocean and incorporates several small offshore islands and the Bijagos Archipelago. The major portion of the territory is flat and low, with a gradual slope inland toward the Fouta Djallon highlands of French Guinea. The maximum elevations in Portuguese ter- ritory are found in the hills along the south- eastern frontier, which, however, rarely exceed 600 to 700 feet in height. The coast is deeply indented by wide estuaries and is lined throughout most of its length by ex- tensive tracts of mangrove swamp. The islands and the coastal region are thickly forested, but in the interior the country changes to open grassland, with dense forest galleries bordering the banks of the major rivers. The climate, which is essentially tropical, is characterized by two seasons: the rainy, from May to November, and the dry, from December to April. The highest tempera- tures are recorded in the transitional months between the seasons. In Bolama the mean monthly temperatures range from 74° to 77° F. in January to 82° to 85° F. in May. The maximum-minimum fluctuations nor- mally average 10° to 12° F., but in the dry season, when the Zarmattan blows almost daily, they may approach 20° to 32° F. The annual rainfall approximates 85 to 90 inches, and the relative humidity 66 to 80 per cent. No reliable meteorologic data are available for the mainland. 466 POPULATION AND SOCIO-ECONOMIC CONDITIONS PorurATION The Colony is divided into 9 ill-defined administrative districts, 2 of which include the islands of Bolama and Bissau, on which towns of the same name are located. At the time of the census in 1940, the population was estimated at slightly over 351,000 in- cluding 1,419 white residents, 2,200 half- castes and a small number of Asiatics. All but 391 were Portuguese subjects. The white residents are primarily government officials, missionaries and business repre- sentatives. The native inhabitants belong to from 16 to 20 separate tribes of diverse ethno- logic origin. The tribes of the interior repre- sent different Negroid groups, including the Balantas, the Fulas and the Mandingos. The peoples of the coastal region are pre- dominantly of Negro stock. They are divided into several tribes with varying degrees of civilization, the most numerous of which are the Manjacos and the Papeis. The Bijagos, who inhabit the islands of the Archipelago, are the most primitive. The indigenous peoples employ a multiplicity of languages, but the Mandingo dialects are understood over wide sections of eastern Guinea. A large percentage of the half- castes are Capverdians. They take an active part in business and in government, and the Creole dialect of the islands is rapidly becoming the lingua franca of the country. In general, the Fula, the Mandingo and the Biofada tribes, representing roughly 40 per cent of the population, are Moslems. The remainder are pagans, with the exception of about 10,000 Christians around the mis- sion centers, chiefly Bissau, Bolama and Cacheu, Education is poorly developed. Schools are maintained by the government and by Roman Catholic mission organizations, but the influence of education among large seg- ments of the population is negligible. According to the 1940 census, the group designated as “civilized” consisted of the non-native communities and 2,190 natives, scarcely 0.6 per cent of the indigenous population. The territory is sparsely settled, with a population density of 10 to 15 per square mile. There are no large towns. Bolama, the former capital, and Bissau, the capital since 1942, have populations of only 2,500 to 5,000. In 1947 almost 65 per cent of the total white residents were settled in the town of Bissau, which is also the principal commercial center of the Colony. Bafata is the largest town in the interior and is a prosperous trading headquarters for that region. VITAL STATISTICS No valid vital statistics are available for Portuguese Guinea. The registration of births and deaths is not attempted among the primitive tribes. Moreover, the data obtained from the birth, the morbidity and the mortality statistics for the groups classi- fied as “civilized” are fragmentary and of doubtful value. Social Economy The economy of the Colony is almost ex- clusively agricultural, the majority of the inhabitants being peasant farmers or pas- toralists. Peanuts and palm oil and kernels are the most valuable commercial products, but beeswax, coconuts, hides and skins, and smaller amounts of rubber, kapok, oil seeds and kola nuts are also exported. Industrial development is slight and consists primarily in the processing of materials for local con- sumption. Although the coastal towns are Portuguese Guinea 467 readily accessible, communications with the population centers of the interior are fre- quently difficult. A network of roads links the mainland towns, but many are not suit- able for motor traffic during the rainy sea- son. Bissau is the chief port for commerce with Europe and the neighboring colonies, while Bolama and Cacheu are ports of local importance. Air services are available from Bissau, with connections to Lisbon. Foop AND NUTRITION Rice is a staple food in all parts of the country, while maize, millet, peanuts, leg- umes, bananas and numerous indigenous fruits and vegetables are used to a varying extent by the different tribes. Cattle are found throughout the area, particularly in the Gabu region of the interior. Milk forms an insignificant part of the native dietary. Some butter is produced in the vicinity of Bissau, but palm and other vegetable oils constitute the principal sources of fat. Little beef is consumed, since the cattle are prized as a measure of wealth and are slaughtered reluctantly. However, sheep, goats, pigs and poultry are raised in large numbers. Fish are abundant in the coastal region. The nutrition of the people differs from tribe to tribe, but serious deficiencies in essential elements are rarely noted. HousiNne The native dwellings conform to different types, characteristic of the various tribal groups, but all are primitive in construction, with walls of mud or poles, and straw roofs. In the towns concrete, stone and corrugated iron are the customary building materials. Bissau and Bolama have modern sections, but the sanitary conditions in the native settlements are generally poor. Old Bissau was formerly a walled town. ENVIRONMENT AND SANITATION WATER SUPPLIES Wells, streams and rainwater cisterns provide the chief sources of water supply. 468 Portuguese Guinea There are no water works in the Colony, and no established facilities for the treat- ment of domestic supplies. In 1945-48 an extensive program was undertaken by the Portuguese government for the construction of community wells in the towns and the villages. Large numbers of concrete wells were built in various parts of the country. Waste DisposaL The methods of sewage disposal are prim- itive. In towns, such as Bissau and Bolama, septic tanks or cesspools are sometimes em- ployed in connection with the modern dwellings. In the native areas indiscrimi- nate pollution of the soil is a general practice. Fauna anp Frora Arthropods. The vectors of disease, as well as the pests, are essentially the same as those encountered in the adjacent por- tions of French West Africa. Anopheline mosquitoes are abundant. Anopheles gam- biae is the species most frequently found in human habitations. It is the principal vector of malaria and probably of Wucher- eria bancrofti. Aedes aegypti is widespread and a vector of yellow fever, which occurs at irregular intervals. Species of Culex and Taeniorhynchus are numerous. Glossina palpalis, the vector of human and animal trypanosomiasis, breeds abundantly in the extensive mangrove swamps along the tidal estuaries in the coastal region and in the brush along the banks of the inland rivers. G. morsitans, G. longipalpis and G. fusca are present in smaller numbers. Flies, lice and fleas, including the chigoe flea, Tunga penetrans, are prevalent. The large scor- pion, Pandinus imperator, and several spe- cies of ButuipAE have been identified. Sarcoptes scabiei is indigenous. Reptiles. Numerous species of reptiles are found. The mambas, Dendroas pis viridis and D. jamesonii, and the cobra, Dipsado- morphus blandingii, are the most dangerous snakes in the forest zone. The spitting cobra, Naja nigricollis, the puff adder, Bitis arietans, the night adder, Causus rhom- beatus, and several less venomous species are common in the savannah areas. The boomslang, Dispholidus typus, is also pres- ent. Crocodiles of the species Crocodilus niloticus and Osteolaemus tetraspis and the crocodilelike Varunus niloticus, inhabit the rivers and the coastal waters. Rodents. Rattus rattus rattus and Mas- tomys coucha are the most frequent do- mestic rodents. Wild rodents are abundant, as in the adjoining territories. Foop SANITATION Regulations for the sanitary control of foodstuffs are enforced only in the larger towns. Cattle and other livestock are sub- ject to inspection at five slaughtering cen- ters—provided that a doctor or a nurse happens to be in the vicinity. Milk offered for sale is tested periodically for adultera- tion but not for sanitary quality. No facili- ties for pasteurization exist in the Colony. Refrigeration plants are available in Bissau and Bolama. HEALTH SERVICES AND MEDICAL FACILITIES HeAaLTH ORGANIZATIONS The Direccio dos Servicos de Satde is re- sponsible for the protection of the public health in Portuguese Guinea. It functions under the Governor of the Colony, who is directed on matters of health by the Ser- vicos de Saude e Higiene in the Direccio Geral de Administracdo Politica e Civil of the Ministerio das Colonias in Lisbon. The headquarters of the colonial organization are located at Bissau. It has divisions re- sponsible for the operation of hospitals and dispensaries, the maintenance of laboratory facilities, the control of epidemic diseases, the institution of measures for social assist- ance and child welfare, and the distribution of medical and pharmaceutical supplies. Subordinate units, Delegacidos de Saude, Portuguese Guinea 469 administer the health and medical services in each of the districts. Since 1945, the Instituto de Medicina Tropical in Lisbon has maintained a perma- nent trypanosomiasis-control mission in the Colony, the Missdo de Estudo e Combate da Doenga do Sono, which functions in co- operation with the Direc¢io dos Servicos de Saude. It has three subdivisions: research, treatment and tsetse-fly control. The survey and treatment program is organized in five sectors which cover the country. In certain regions its units undertake the investiga- tion of other endemic diseases, as ancylosto- miasis, dracontiasis, filariasis and schistoso- miasis. The Instituto de Medicina Tropical also advises with the Ministerio das Colo- nias on colonial health problems. Roman Catholic mission organizations carry on educational activities in Bissau, Bolama, Cacheu, Bula and Bafata, which contribute materially to the improvement of the standards of living among the surround ing populations. MebpIcAL INSTITUTIONS Hospitals and Dispensaries. The Direc- ¢io dos Servigos de Satde maintains hos- pitals at Bissau and Bolama, with 80 to 100 and 72 beds, respectively. The former insti- tution has x-ray facilities. The Direccdo also operates native-hut infirmaries in the dis- trict headquarters and sanitary posts or dis- pensaries in the rural areas. In 1950 there were 36 sanitary posts scattered throughout the country, and 8 mobile units. Maternity centers function in connection with the hos- pitals and the infirmaries and some of the larger dispensaries. Separate infirmaries and treatment centers are conducted by the anti- trypanosomiasis unit. Laboratories. The Laboratorio Central de Analises in Bissau is the official labora- tory of the health services. It has two divisions, medicobiologic and chemicophar- maceutical, equipped for the performance of chemical, clinical, bacteriologic, toxico- logic and pharmaceutical examinations. It also houses the headquarters and the labo- ratory sections of the recently organized antitrypanosomiasis unit, the Missdo de Estudo e Combate da Doenca do Sono. Schools. The Escola Técnica de Enfer- magen was established in the hospital at Bissau, in 1946, for the training of nurses. It aims primarily to prepare native male nurses for the management of the rural dis- pensaries. PERSONNEL Physicians. In 1950, 14 physicians were connected with the Direc¢io dos Servicos de Saude, including the port health officer at Bissau. In the Missdo de Estudo e Combate da Doenga do Sono, physicians are in charge of each of the headquarters divisions and the mobile treatment units. According to reports for 1944, only one private physician was practicing in the Colony. Dentists. One dentist was employed in the government health services in 1950. Others. The same year the Direcgio staff comprised 29 male nurses, 10 nursing sisters, one nurse-midwife, 15 nursing assistants and 13 assistants in midwifery. A small per- centage were Portuguese, and the remainder were Capverdians or natives. The directors of the laboratory, one chemist and three pharmacists were also included among the personnel of the health services. DISEASES Little information is available from which to evaluate the health status of the peoples of Portuguese Guinea. Morbidity statistics, based upon hospital and dispensary records, are inconclusive. The medical facilities and personnel are thinly distributed through- out the territory, and large sections of the population live beyond reach of medical at- tention. Moreover, most of the indigenous peoples adhere to their own tribal practices, while local prejudices against Capverdian personnel and members of other tribes cur- 470 Portuguese Guinea tail the effectiveness of the health services to a considerable degree. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Dysentery. Both amebic and bacillary dysentery are common, but the infection rates are not known. The re- ported cases usually average less than 100 a year, totals which are obviously low. Moreover, the majority of recorded cases are not differentiated as to type. Typhoid and paratyphoid fevers are en- demic. The reported cases are relatively few in number, but localized outbreaks are known to occur. Diarrhea and enteritis rank first among the causes of death in children under 5 years of age. Helminthiases. ANcyLosTomI1asts. Hook- worm infection is widespread. The incidence reaches 90 to 95 per cent on the island of Bissau. Both Necator americanus and An- cylostoma duodenale are present in highly infected areas. Scuistosomiasts. Infection with Schisto- soma haematobium is endemic in Cacheu district in the northwestern part of the country and possibly in other regions. The incidence is particularly high in the Cole- quisse area. An infection rate of 2 per cent was found among 6,227 individuals exam- ined in the region north of Canchungo in 1946.14 Oruer Hrerminta InrecTiONs. Infec- tions with Ascaris lumbricoides, Trichuris trichiura and Enterobius vermicularis are widely distributed, particularly on Bolama and the other islands of the Bijagos archi- pelago. Taeniasis, caused by the pork and the beef tapeworms, Taemia solium and T. saginata, is sometimes observed. Diseasks SPreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is prominent among the diseases treated in the govern- ment hospitals and dispensaries. No evi- dence is available, however, from which to assess the extent of infection. Pulmonary in- fections predominate, but other forms also occur. Smallpox. Smallpox appears in localized outbreaks, most frequently in the frontier districts of the interior. Widespread vacci- nation against smallpox is carried on by the government health services. Other Infections. Pneumonia is one of the major causes of death among all age groups. The infection rates for pneumonia are highest in the transition periods be- tween the rainy and the dry seasons. Measles and whooping cough are some- times epidemic. Meningococcus meningitis may occur in sporadic outbreaks. Diphtheria and poliomyelitis are relatively rare, but occasional cases are reported. DiseAsES SPREAD OR CONTRACTED CuierLy TuroucH CONTACT Venereal Diseases. Venereal diseases are prevalent. Among almost 1,900 cases of ve- nereal infection treated by the government medical personnel in 1943, 56 per cent were attributed to syphilis, 36 per cent to gonor- rhea and 8 per cent to chancroid. Leprosy. Leprosy is endemic in most sec- tions of the Colony. Roughly 200 to 300 cases are reported each year, but the actual incidence has not been determined. A total of 327 lepers was discovered among the 81,000 persons examined by the survey teams of the Missdo de Estudo e Combate da Doenga do Sono in 1947.5 These repre- sented only the advanced cases, however, since the majority hide in the bush before the approach of the medical units. No spe- cial facilities for the segregation of lepers are maintained by the health services. Yaws. Yaws is widespread among the indigenous populations, particularly in the humid coastal regions. Other Infections. Epidemic conjuncti- vitis and trachoma are common. Scabies, mycotic skin infections and phagedenic ulcers are frequent. Tetanus is sporadic. Rabies is enzootic among the dogs, and anthrax among the livestock. Human infec- tions are not reported, but undoubtedly exist from time to time. Cases of human myiasis are encountered occasionally. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is one of the most serious disease problems in Portuguese Guinea. Infection rates of from 60 to 100 per cent are found in the coastal region and around the estuary of Biafada, and of from 20 to 30 per cent in the interior. Transmis- sion takes place throughout the year in all portions of the Colony, but predominantly during the latter part of the rainy season, in October and November. Plasmodium falciparum is the principal species, with P. malariae next in importance. In the sur- vey of 709 children from O to 12 years of age in the vicinity of Bissau in 19477 splenic and parasite rates of 57 and 58 per cent were encountered. The blood examina- tions showed P. falciparum in 59 per cent, P. malariae in 32 per cent and P. vivax in 9 per cent. The incidence of P. vivax and P. malariae infections varies in different age groups, and from season to season. Blackwater fever occurs sporadically. Trypanosomiasis. Trypanosomiasis, caused by Trypanosoma gambiense, is endemo-epidemic throughout the major part of the Colony, conforming to the distribu- tion of the vector, Glossina palpalis. Treat- ment surveys were initiated in 1945 by the Missdo de Estudo e Combate da Doenca do Sono. The rate of infection among 15,689 individuals examined on the islands of Bis- sau, Bolama and Galinhas, in 1946, aver- aged from 2 to 2.5 per cent. In surveys of other areas in 1947 a total of 81,042 persons was examined. The incidence of trypanoso- miasis approximated 0.7 per cent in the Gabu region in the interior, 0.5 per cent along the northern border, and 0.9 in the Canchungo-Bissau area. Filariasis. Wuchereria bancrofti is en- demic in the coastal region, being most prominent among the Manjacos tribe in the northwestern districts. Elephantiasis Portuguese Guinea 471 and hydrocele are encountered in a signifi- cant percentage of the cases. Surveys to de- termine the relative incidence of filariasis have been undertaken in Cacheu district by the mobile units of the Missdo de Estudo e Combate da Doenca do Sono. In the exami- nation of 986 individuals in a hyperendemic focus around Costa de Baixo, north of Can- chungo, in 1946'* microfilariae were found in 49.2 per cent, irrespective of clinical evi- dence of infection. About 68.2 per cent showed no apparent signs of filariasis. Ele- phantiasis was present in 10.1 per cent of the individuals examined. Anopheles gam- biae probably is primarily responsible for the transmission of the infection, although Culex quinquefasciatus (= C. fatigans) and other potential vectors are present. Acantho- cheilonema perstans is also prevalent. Yellow Fever. Yellow fever is reported from Portuguese Guinea at irregular inter- vals. Within this century outbreaks have ‘occurred in 1911, 1932 and 1943-44. In the latest instance the infection was introduced from Senegal. A total of 8 to 10 cases was recorded from widely scattered regions: 5 from Canchungo, 2 from Bafatd and one each from Farim and Bissoram. Quarantine and Aedes-control measures were enforced in the affected areas. In addition, an inten- sive immunization program was undertaken, employing yellow fever vaccine prepared at the Institut Pasteur in Dakar or at the Yellow Fever Research Institute in Lagos. The results of a small and inconclusive pro- tection test survey, reported in 1947,1° sug- gest that the yellow fever virus may have been present in the interior within the life time of the present generation. Other Infections. Minor outbreaks of plague have occurred from time to time, usually following the introduction of the infection from Senegal. Serious epidemics were recorded in 1921, when 76 cases were diagnosed in Cacheu and 54 in Bissau. No cases have been reported within recent years. Dracontiasis, or guinea-worm infection, is endemic in scattered foci. The S. Domingo 472 Portuguese Guinea region, in the northwestern corner of the Colony, was surveyed by one of the sleep- ing sickness survey units in 1947% and infection with Dracunculus medinensis was found among 23.5 per cent of the popula- tion in 5 villages in the Suzana area. In- capacitating secondary infections were fre- quent, particularly during the rainy season. The cyclops, Mesocyclops leukarti, was identified as the intermediate host. Sandfly fever and tick-borne relapsing fever are sporadic. Dengue fever is not notified, but Aedes aegypti is found in all parts of the territory, and the infection is undoubtedly present. Rare cases of undiffer- entiated typhus fever are reported. The presence of tick-borne infection is reported. NurtritioNAL DISEASES Little information has been compiled re- garding the nutritional status of the dif- ferent tribes. A large variety of foods is available, and major deficiencies are not apparent. Occasional cases of beriberi are treated in the government hospitals, but no other nutritional diseases are reported. SUMMARY Portuguese Guinea is a small, undevel- oped territory, with approximately 351,000 inhabitants, including 1,419 white residents. The Direccdo dos Servicos de Satde is re- sponsible for the administration of the pub- lic health and medical services in the Colony. It operates under the health division of the Ministerio das Colonias in Lisbon. The headquarters of the Direccdo are lo- cated at Bissau, while subordinate bureaus function in each of the administrative dis- tricts. It maintains hospitals in Bissau and Bolama, infirmaries in the district centers, and rural dispensaries scattered throughout the Colony. A permanent sleeping sickness mission of the Instituto de Medicina Tropi- cal in Lisbon operates in the territory in conjunction with the Colonial health serv- ices. Sanitation is primitive. Water supplies are derived from wells, streams and rain- water cisterns. No water works exist, and the majority of supplies are unprotected from contamination. Malaria, trypanosomiasis, yaws, leprosy, tuberculosis, pneumonia, enteric diseases. skin infections and venereal diseases are widespread. Filariasis and hookworm infec- tion are prevalent in the coastal regions. Schistosoma haematobium infection and dracontiasis are endemic in localized foci. Smallpox and meningococcus meningitis occur in sporadic epidemics. BIBLIOGRAPHY 1. Ferreira, F. S. da Cruz: As tripanosomiases nos territérios africanos portugueses. Africa ocidental (Angola e Guiné) Africa oriental (Mocambique), Abst. Trop. Dis. Bull. 46:530-531 (June) 1949. 2. ——: Relatério do chefe da missdo de estudo e combate da doenca do sono na Guiné portuguesa referente de 1945, An. Inst. med. trop. 4:713-749 (Dec.) 1947. 3. : Relatorio do chefe da missdao de estudo e combate da doenga do sono na guiné referente a 1946, An. Inst. med. trop. 4: 751-789 (Dec.) 1947. 4. : Sobre o grau deinfestacdo por tri- panosomas da Glossina palpalis da Guiné portuguesa, An. Inst. Med. trop. 4:91-97 (Dec.) 1947. 5. ——: Relatério do chefe da missdo de estudo e combate da doenga do sono na Guiné referente ao ano de 1947, An. Inst. med. trop. 5:407-445 (Dec.) 1948. , and Lopes, M. Rodrigues: Aspectos clinicos e epidemiolégicos dum foco en- démico de dracontiase na Guiné portu- guesa, An. Inst. med. trop. 5:71-86 (Dec.) 1948. 7. ——, Pinto, A. R., and de Almeida, C. L.: Alguns dados sobre a biologia do Anoph- eles gambiae da Cidade de Bissau e Arredores (Guiné portuguesa), em relagio com a transmissio da malaria e filariase linfatica, An. Inst. med. trop. 5:223-250 (Dec.) 1943. 8. Fraga de Azevedo, J., Cambournac, F. J. C., and Pinto, Manuel R.: A doenca do sono na Guiné em 1944 e observagdes sobre 9. 10. 11. 12. 13. ofideos, culicideos e Phlebotomus da co- 16nia, An. Inst. med. Trop. 2:7-47 (Dec.) 1945. _— : Observagoes sobre a inci- déncia do sezonismo na Guiné portuguesa (nota preliminar), An. Inst. med. trop. 4:7-15 (Dec.) 1947. _— : Resultados de um in- quérito sobre febre amarela na Guiné portuguesa, An. Inst. med. trop. 4:17-24 (Dec.) 1947. Guiné, Colénia da: Orcamento geral para o ano econémico de 1950, Bolama, Imprensa Nacional, 1950. Lyall, Archibald: Black and White Makes Brown, London, Heinemann, 1938. Pinto, A. R.: O recenseamento dos doentes do sono (extracto dos relatérios semestrais 14. 1s, 16. 17. Portuguese Guinea 473 referentes ao ano de 1946), An. Inst. med. trop. 4:791-810 (Dec.) 1947. , and de Almeida, C. Lehmann: Con- tribuicio para o estudo das filariases da Guiné portuguesa, An. Inst. med. trop. 4:59-89 (Dec.) 1947. Portugal: Anuario da Guiné portuguesa, 1946, Lisboa, Sociedade Industrial de Tipografia, 1946. ——: Anuirio da Guiné portuguesa, 1948, Publicagdo do Governo de Colénia, Lisboa, Imprensa na Sociedade Industrial de Tipo- grafia, Lda., 1948. ——: Instituto Nacional de Estatistica. Anuério estatistico do império colonial, 1946, Lisboa, Tipografia Portuguesa, Lda., 1947. : CECLEOCLEEOLG CESGESHEEHECEEESY 35 The Gambia GEOGRAPHY AND CLIMATE The Gambia, the smallest British de- pendency on the west coast of Africa, com- prises two administrative divisions, the Colony and the Protectorate. The Colony consists of the Island of St. Mary and the district of Kombo St. Mary, at the mouth of the Gambia River, and MacCarthy Island, almost 200 miles upstream. The Protectorate is a narrow strip of about 4,000 square miles, which lies wholly within the valley of the Gambia River and projects for nearly 500 miles into Senegal, French West Africa. On both sides of the river, the territory stretches inland to a depth of 10 miles in an undulating plain, broken by isolated hills, which rises to an elevation of 150 feet in the east. The temperature at Bathurst, on the Island of St. Mary, ranges from a mean maximum of 90° to 95° F. to a mean mini- mum of 55° to 65° F. In the inland dis- tricts the variations are 15° to 25° F. greater. The rainy season occurs from June to October and is usually preceded by heavy showers during May. The rainfall aver- ages 50 inches a year at Bathurst, but from 35 to 45 inches in the eastern part of the Protectorate. The humidity is high through- out the rainy season. During part of the dry period, usually from December to March, the harmattan blows intermittently. At this time, daily temperature fluctuations of 50° F. or more are frequent. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLaTiON In 1948 the total population of Gambia was slightly in excess of 248,000, including approximately 300 British and French and 300 Syrians, most of whom resided in the Colony. The population density was esti- mated at 56.9 per square mile. The most numerous among the pure and mixed tribes in the territory are the Mandingos, the Jollofs, the Jolas and the Fulas. The first two are Negroid peoples belonging to the Sudanic language group. The Jolas are Bantu-speaking, while the Fulas are a hybrid people of Hamito-Semitic origin. Except for a few pagan tribes, as the Jolas, the inhabitants are predominantly Moslems. About 5,000 Christian converts are found in the Colony. There are few large towns. Bathurst, on St. Mary’s Island, is the capital and the only community of any size. According to a census taken in 1944, its population was 21,152, an increase of more than 50 per cent over that of 1931. Georgetown, on Mac- Carthy Island, is the principal center in the interior. The various portions of the Colony, outside of the town of Bathurst and the adjacent Kombo St. Mary, are administered as parts of the Protectorate. There are 5 divisions with 36 districts, in each of which a Native Authority is appointed for pur- poses of local government. Except for Armitage, a government boarding school, which provides elementary and vocational training for the sons and the relatives of the tribal chiefs and subchiefs, and a few small Native Authority and mis- sion schools, the educational facilities of the territory are concentrated in Bathurst. The government operates primary schools in Bathurst and subsidizes secondary schools conducted by the missions. Opportunities for advanced education are provided through scholarships to Achimota or Free- 474 town. The census of 1944 revealed that only 40 per cent of the population of Bathurst was literate—approximately 20 per cent in English and 20 per cent in Arabic. VITAL STATISTICS The registration of births and deaths in the native population is not compulsory, ex- cept on the islands of St. Mary and Mac- Carthy. While the registration of deaths may be regarded as reasonably accurate, that of births is incomplete and unreliable. In the years 1941 to 1948 the birth rates per 1,000 population in Bathurst ranged from 25.8 to 40.8 ; the death rates from 18.9 to 35.8. Because of the small size of the population, the infant mortality statistics show even wider fluctuations. In 1944-48 they ranged between 103.0 and 153.8 per 1,000 live births ; the stillbirth rates between 78 and 137.5. A large percentage of the still- births are probably erroneously reported and should be classified as infant deaths. Malaria, malnutrition and venereal diseases are primary factors influencing the high infant mortality. In the course of a nutri- tion survey of a representative rural village, undertaken in 1947,' it was estimated that fully half of the children died before reach- ing 12 years of age. SociaL Economy The economy of the Gambia is completely dependent upon the cultivation of one crop —peanuts. Other agricultural resources have not been developed to any extent, although negligible amounts of palm nuts and hides are also exported. The country is lacking in mineral resources. The majority of the na- tives are peasant farmers who raise both food and cash crops according to a primi- tive system of “shifting” cultivation. Ex- periments with mechanized crop production are now being carried on by the Agriculture Department of the Gambia government. A unique feature of peanut cultivation in the Protectorate is the seasonal influx of “strange” farmers from the neighboring territories, namely French Sudan and The Gambia 475 Guinea, who as tenant producers contribute materially to the size of the crop. Communications are largely dependent upon the Gambia River, which is navigable throughout its length within the territory. Good roads are found in the vicinity of Bathurst. A trunk road circles the lower districts of the Protectorate from Bathurst to Brumen Ferry on the south shore and from Barra to Illiassa on the north, but the major portion is closed to motor traffic dur- ing the rainy season. Steamer and air serv- ices are maintained with the neighboring territories and with Great Britain and Europe. Foop AND NUTRITION The food habits of the different tribes vary markedly. Rice is the staple food in most sections of the country, although millet and maize are frequent substitutes. Common supplementary foods are yams, coco-yams, cassava, peanuts, okra, peas, pumpkins, tomatoes and citrus and other indigenous fruits. Large herds of cattle are raised by the semipastoral tribes of the Pro- tectorate. Milk and butter are used when available, but the supplies are inadequate and seasonal. Chickens are found in most villages. Sheep and goats are also raised, but the average consumption of meat is negli- gible. Fish are plentiful. The diet of the majority of the people is deficient in animal fats and proteins, in calcium and in vitamins of the B complex, A and C. Moreover, the production of food crops is variable, and “hungry seasons” customarily precede each harvest. The government is attempting to pro- mote mixed farming and improved meth- ods of agriculture and animal husbandry. Trypanosomiasis is enzootic, but the local cattle normally show a high degree of re- sistance to the infection. Extensive areas of swampland bordering the river have been reclaimed for rice cultivation, and in limited regions small-scale irrigation has been intro- duced. On the basis of a comprehensive nutrition survey among the tribes of the 476 The Gambia Protectorate, a long-term experimental and educational program was initiated in 1946 by the Human Nutrition Unit of the British Medical Research Council. The headquar- ters of the Field Working Party is estab- lished at Genieri, a representative village in the Middle River division. The research station is located at Fajara. A local com- mittee co-ordinates the activities of the Working Party with those of the various governmental departments. Housing The congestion in Bathurst constitutes a major housing problem. The town is situ- ated on a low island surrounded by swamps and, though originally well planned, is not adapted to the accommodation of a rapidly expanding population. The density of popu- lation in 1944 was 193 persons per acre. Development plans, initiated in 1946, in- clude the drainage of the town itself and the construction of model suburban villages about ten miles distant on the mainland of Kombo St. Mary. The standard of living throughout the Protectorate is generally low. Typical na- tive dwellings have walls of mud plaster on a supporting framework of bamboo and rhum palm, and roofs of thatch or corru- gated iron. Improvements in village plan- ning and in building construction are grad- ually being introduced. ENVIRONMENT AND SANITATION WATER SUPPLIES Water supplies are obtained from surface sources and from shallow wells and springs and are generally adequate in all parts of the territory. Bathurst is the only town with a piped water supply. It is derived from a small reservoir formed by damming an ad- jacent stream; the water is treated by chlo- rination in the waterworks at Abuko. Most of the village water supplies are unprotected and are subject to contamination. The Gambia River itself is tidal for 100 miles or more from its estuary. Waste DisposaL Sanitation is generally primitive. In Bathurst, the bucket system is the common method of sewage disposal, although septic tanks are used in connection with the larger houses. Public septic tank latrines are grad- ually being built and eventually will replace the bucket installations. Sewage is dumped in swamp areas selected for reclamation and is covered with other refuse and sand. The introduction of water-borne sewerage has been proposed, but it has been delayed be- cause of the cost of construction. Pit latrines are employed in many areas in the Protec- torate. The government is endeavoring to promote the construction of pit latrines in the individual compounds and to encourage other improvements in village sanitation. Fauna anDp Frora The arthropod vectors of disease and the animals and the plants dangerous to man are essentially the same as those encoun- tered in the adjacent territories that border this dependency. Anopheles gambiae is widespread, while A. gambiae melas breeds prolifically in the mangrove swamps along the lower river. A. funestus is present but is usually of sec- ondary importance. It is estimated that three quarters or more of the malaria on the Island of St. Mary and the adjacent Kombo mainland is transmitted by A. gambiae melas; most of the remaining by 4. gam- biae.'> Numerous other Anopheles, Aedes and Culex mosquitoes are found. Aedes aegypti is prevalent in the rural areas, but an active anti-Aedes program has been car- ried on in Bathurst since the outbreak of yellow fever in 1934, with the result that the Aedes index in the town has been re- duced to a fraction of 1 per cent. Mosquito- control measures are conducted routinely in Bathurst and in the Kombo area. These in- clude filling and drainage, where possible, and the antilarval treatment of all collec- tions of water with oil or DDT, particularly the shallow earth drains of the town. In 1946 the control of A. gambiae melas was The Gambia 477 accomplished on an experimental scale by the drainage and reclamation of 600 acres of swamp in the Bakau area. The extension of the project to the Kombo mainland is contemplated. The most important fly vector is the tsetse fly, Glossina palpalis. It is prevalent throughout the Protectorate, but especially in the districts west of MacCarthy Island, where the low-lying swampland surrounding the numerous creeks provides favorable con- ditions for breeding. G. morsitans is widely distributed in the region north of the Gambia River and in a belt between Ban- sang and Bruma to the south. G. longipalpis may be present on the north bank from Niumi district to the eastern border. Both human and animal trypanosomiasis are widespread. Foop SANITATION The inspection of premises where food is sold is carried on routinely in the town of Bathurst. In the larger towns meat animals are inspected before and after slaughter by sanitary inspectors of the Medical Depart- ment. There are no organized milk supplies in the urban areas. Small supplies are some- times available, but production is uncon- trolled. Local milk is generally dirty and contaminated. In one area the government operates a dairy for the manufacture of butter, and some of the milk collected is offered for sale. The cream used in the gov- ernment’s plant is pasteurized, but no other pasteurization facilities are available. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS The Medical Department of the Gambia government is responsible for the provision of curative and preventive services in the Colony and the Protectorate. The Depart- ment is administered by a Senior Medical Officer stationed at Bathurst. It functions with the advice of the medical staff of the Colonial Office in London. The activities of the Medical Department include the op- eration of hospitals and dispensaries, the supervision of environmental sanitation, and the enforcement of measures for the control of epidemic and certain other dis- eases. In Bathurst certain functions pertain- ing to sanitation and the control of com- municable disease are undertaken by the township council. In some districts, also, re- sponsibility for the administration of local health measures is gradually being dele- gated to the established Native Authorities. Several mission societies carry on educa- tional and medical work in the country. MEepIicAL INSTITUTIONS Hospitals and Dispensaries. In 1948 the Medical Department maintained two general hospitals: Victoria Hospital at Bathurst and the Bansang Hospital on MacCarthy Island. They provided a total of 156 beds. In addition, it operated 21 dis- pensaries and branch dispensaries in vari- ous parts of the Protectorate and a mobile medical unit in the Western division. A ma- ternity hospital is situated in Bathurst, and an infectious disease hospital about two miles outside of the town. A small leper settlement for advanced cases is conducted by the government near Bathurst, as well as special treatment centers at Bathurst, at Bwiam and at Allatento, near Bansang. Health centers are established at Bakau in Kombo St. Mary’s division and at Basse in the Protectorate, and maternity and infant welfare clinics, in Bathurst and in 5 towns in the Protectorate. Laboratories. Clinical and pathologic laboratories for the performance of routine examinations are available in the hospitals at Bathurst and Bansang. The government’s Veterinary Department also operates a laboratory for the manufacture of vaccines for use in the territory. Laboratories are connected with the nutrition research sta- tion at Fajara. Schools. Training courses for dressers. nurses and nurse-midwives are conducted at Victoria Hospital in Bathurst. A course for 478 The Gambia the training of sanitary assistants was or- ganized in 1945. PERSONNEL Physicians. There were 8 physicians in the territory in 1948. Seven were connected with the Colonial Medical Service and were employed in the Medical Department. One was engaged in private practice. Others. The nursing personnel included 8 European nurses and 45 trained at the local hospitals. About 30 midwives were practicing in the country. Four sanitary supervisors and 26 sanitary inspectors were employed by the government or by the township authorities. DISEASES Geographically, the Gambia is a long, narrow corridor projecting into French ter- ritory, and no distinction can be drawn between the health problems of its people and those of related tribes along the border. Statistics of disease incidence are not nec- essarily representative, since a large propor- tion of the inhabitants conform to tribal systems of medical practice. Moreover, the fact that subjects of the adjacent territories frequently seek treatment in the dispen- saries of the Protectorate modifies the local value of their records. Diseases SPREAD oR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Dysentery. The standards of sanitation are low throughout the terri- tory, and intestinal infections are common. Typhoid fever occurs sporadically. Rela- tively few cases are reported, but there is little reason to believe that these reflect the true incidence of infection. Both bacillary and amebic dysentery are prevalent. The differential diagnosis is recorded in a com- paratively small number of cases; among over 300 reported in 1946, only 36 were designated as amebic dysentery and 17 as bacillary. However, a larger percentage of the cases of unclassified dysentery and of diarrhea probably should be ascribed to bacillary infections. Cases of diarrhea are numerous both in children under two years of age and in the older age groups. Helminthiases. ScHisTosomIasis. Schis- tosomiasis, caused by Schistosoma haema- tobium, is common in eastern Gambia. In recent surveys, infection rates of 25 to 36 per cent have been found in the MacCarthy Island and the Upper River areas. The inci- dence is particularly high among the young children. The intermediate host is probably Physopsis africana globosa, which decreases in prevalence in proportion to the proximity to the mouth of the river and the degree of salinity in the water. OtaER HELMINTH INFECTIONS. Ascariasis is the predominating helminth infection, especially among the children in the rural areas along the lower river. Hookworm in- fection is widespread throughout the coun- try. Taeniasis, due to the beef tapeworm, Taenia saginata, is also prevalent but more restricted in distribution. The pork tape- worm, T. solium, occurs in a few districts where pigs are raised. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is prevalent, but no special diagnostic or treatment facili- ties exist in the territory, and the actual incidence is not known. Between 300 and 400 patients are treated annually in the government hospitals. These represent only the advanced cases and provide a poor index of the extent of infection. Pulmonary tuber- culosis predominates, but other forms are also encountered. Smallpox. Smallpox is endemic, and minor scattered outbreaks are reported an- nually. The highest infection rates within recent years were recorded in 1944, when a total of 177 known cases was reported, pri- marily from Bathurst and from MacCarthy and Upper River divisions. Widespread vac- cination is carried on each year in Bathurst and in the affected areas in the Protectorate. Meningitis. Localized epidemics of men- ingococcus meningitis are frequent, partic- ularly in the Protectorate. The fatality rates average 20 to 25 per cent; a large proportion of the cases is seen too late for effective treatment. Major outbreaks were reported in 1945, when 424 cases were treated in contrast with 138 cases in 1946, and 47 cases in 1948. Other Infections. Pneumonia is preva- lent. The common respiratory diseases of childhood are endemic. Measles, which is sometimes epidemic, usually takes a mild form, but in the outbreaks of 1946 compli- cations with gastro-enteritis and broncho- pneumonia were general, contributing to a high mortality in the lower age groups. DiseAsES SPREAD OR CONTRACTED CuierLy THROUGH CONTACT Venereal Diseases. All forms of vene- real disease are present, but their relative incidence is uncertain. Gonorrhea is wide- spread in the Colony ; less so in the interior. In the three years, 1946-48, from 1,895 to 3,617 cases of gonorrhea were reported, from 118 to 835 of syphilis, and from 316 to 182 of other venereal infections. Treat- ment for syphilis, gonorrhea and soft chancre was made compulsory in 1944, but the lack of adequate facilities limits the application of the ordinance in the Protec- torate. Free treatment for venereal diseases was made available in Bathurst in 1945. Leprosy. Leprosy is widely distributed. In a medical survey covering over 17,400 persons in 1947!! an average infection rate of 2.5 per cent was found; 1.3 per cent in the Kombo area; 2.9 per cent in MacCarthy Island division; and 3.2 per cent in the Upper River districts. On the basis of these findings the prevalence for the territory was estimated as at least 3.3 per 1,000 popu- lation. A small settlement for advanced cases is maintained at Bathurst, and there are special treatment centers at Bathurst, Bwiam and Allatento, near Bansang. Yaws. Yaws is endemic, with the highest incidence in the Upper River districts. From 3,000 to 6,000 cases are treated each year, The Gambia 479 but these provide a low index of infection. Treatment is available at all of the govern- ment medical centers and was made com- pulsory in 1944. Other Infections. Trachoma is com- mon, but severe infections are relatively infrequent. Tetanus is endemic, particularly in the vicinity of Bathurst. In the years 1944-48 an average of 28 cases of tetanus, exclusive of tetanus neonatorum, was re- ported annually. Human rabies is sporadic. Scabies, craw-craw, a skin condition often associated with it, and various mycotic skin diseases are prevalent. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is the most important disease in the Gambia. Major epidemics occur annually during and immediately after the rainy season. The incidence is high even in Bathurst, where anopheline control measures are undertaken. The majority of infections are presumably caused by Plas- modium falciparum, but only a small per- centage of the diagnoses are confirmed by microscopic blood examination. P. vivax and P. malariae are reported irregularly. The major vectors are Anopheles gambiae and A. gambiae melas. Trypanosomiasis. African sleeping sick- ness, caused by Trypanosoma gambiense, is a major problem in all parts of the country, with the exception of the Island of St. Mary. The cases treated by the government medical service, which number from 1,500 to 3,000 annually, represent only the most severe infections. The infection rates aver- age between 1 and 6 per cent but may reach 25 per cent in certain villages.? In the medi- cal survey of 1947'! the prevalence was esti- mated at 2.5 per cent in Kombo, 4.2 per cent on MacCarthy Island and 6.0 per cent in the Upper River areas. Previous surveys of towns along the north bank showed infec- tion rates ranging from 1 to 5 per cent in 1937; from 2 to 6.9 per cent in 1939; and from 0.4 to 3.6 per cent in 1942. In the South Bank division, on the opposite shore of the river, the prevalence varied in 1942 480 The Gambia from 0.3 to 6.6 per cent, with an average of 2.2 per cent in the Bintang-Bwiam area, and from 4.2 to 6.6 per cent, with an average of 5.5 per cent, in the Kanfinda-Sintet area. Special treatment facilities have been or- ganized in various localities in these highly infected districts. Yellow Fever. Yellow fever is endemic throughout the country, but clinical cases of the disease have not been encountered, except in the vicinity of Bathurst. Out- breaks have occurred periodically in the town, the most recent being in 1934. Since that date an intensive 4edes aegypti control program has been successful in reducing the Aedes index from 50 to 60 per cent to almost zero. Immunization against yellow fever is compulsory in Bathurst, and a large majority of the residents are immune, al- though the shifting population renders com- plete protection difficult. No outbreaks have been recorded among the natives in the Protectorate, but immunity surveys? follow- ing the 1934 outbreak revealed protective antibodies in the blood sera of from 18 to 33 per cent of the inhabitants of the villages visited. Immunity to the virus has also been demonstrated in forest monkeys. Other Infections. Plague has not been reported within recent years, although its introduction was feared at the time of the outbreak in Senegal in 1944-45. Filariasis, caused by Wuchereria bancrofti, occurs sporadically. Guinea-worm infection, or dra- contiasis, is reported occasionally. A few cases of murine typhus have been recorded, chiefly from the town of Bathurst. NuTrITIONAL DISEASES The standards of nutrition are low. Mal- nutrition is general. Widespread deficiencies in animal protein, calcium, and vitamins of the B complex, A and C are encountered, but clinical diseases are seldom reported. Pellagra occurs sporadically, but beriberi and scurvy are relatively rare. The most frequent symptoms of nutritional deficiency are mild neuritis, chalky and carious teeth, and various skin and mouth lesions. Fatty liver disease is common in infancy. Famine edema is prevalent among adults. Goiter is endemic in the Fula-Bintang area. SUMMARY The Gambia is a small British depend- ency, administered partly as a Colony and partly as a Protectorate. The Medical De- partment, with headquarters in Bathurst, is responsible for the maintenance of medi- cal and health facilities in the territory. It operates a general hospital, a maternity hos- pital and a small infectious disease hospital in Bathurst; also a general hospital on MacCarthy Island. A limited number of dis- pensaries and subdispensaries are estab- lished in various parts of the Protectorate. The water supplies are adequate but derived from surface and shallow subsurface sources and are liable to contamination. Sanitation is primitive. Malnutrition and mild defi- ciency conditions are common. Malaria and sleeping sickness are epi- demic. Venereal diseases, yaws, leprosy and tuberculosis are widespread. Smallpox and meningococcus meningitis occur annually in small, scattered outbreaks. Dysentery and diarrhea are prevalent. Intestinal helmin- thiasis is general, while urinary schistoso- miasis is common in the eastern districts. Yellow fever is endemic, but the clinical disease is restricted to Bathurst, where the last outbreak occurred in 1934. Filariasis and murine typhus are encountered sporadi- cally. Plague is not reported. BIBLIOGRAPHY 1. Beeuwkes, Henry, and Mahaffy, A. F.: The past incidence and distribution of yellow fever in West Africa as indicated by pro- tection test surveys, Tr. Roy. Soc. Trop. Med. & Hyg. 28:39-76 (June) 1934. 2. Davey, T. H.: Trypanosomiasis in British West Africa, London, H. M. Stationery Office, 1948. 3. Findlay, G. M., and Davey, T. H.: Yellow fever in the Gambia. II. The 1934 out- break, Tr. Roy. Soc. Trop. Med. & Hyg. 30:151-164 (July) 1936. The Gambia 481 10. 11. 12. The Gambia: The Annual Medical and Sani- tary Report for the Year 1937, Bathurst, Govt. Printer, 1938. ——: Annual Medical and Sanitary Report for the Year 1938, Bathurst, Govt. Printer, 1939. . ——: Annual Medical and Sanitary Report for the Year Ended December 31, 1942, Bathurst, Govt. Printer, 1943. ——: Annual Medical and Sanitary Report for the Year Ended December 31, 1943, Bathurst, Govt. Printer, 1944. ——: Report on the Medical and Health Services for the Year 1944, Bathurst, Govt. Printer, 1945. ——: Report on the Medical and Health Services for the Year 1945, Bathurst, Govt. Printer, 1946. : Report on the Medical and Health Services for the Year 1946, Bathurst, Govt. Printer, 1947. ——: Report on the Medical and Health Services for the Year 1947, Bathurst, Govt. Printer, 1949. ——: Report on the Medical and Health Services for the Year 1948, Bathurst, Govt. Printer, 1949, . Gray, J. M.: A History of the Gambia, London, Cambridge Univ. Press, 1940. 14. 15. 16. 17. 18. 19. 20. 21. Great Britain. Colonial Office: Annual Re- port on the Gambia for the Year 1946, London, H. M. Stationery Office, 1948. . Economic Advisory Council: Commit- tee on Nutrition in the Colonial Empire. Summary of Information Regarding Nu- trition in the Colonial Empire. First Re- port, Part II, London, H. M. Stationery Office, 1939. Kuczynski, R. R.: Demographic Survey of the British Colonial Empire. Vol. I. West Africa, London, Geoffrey Cumberlege, Oxford, 1948. Nash, T. A. M.: Tsetse Flies in British West Africa, London, H. M. Stationery Office, 1948. Nutrition Field Working Party in Gambia Protectorate: Unpublished Reports. Colo- nial Office, London. Platt, B. S.: Department of Human Nutri- tion, Extract from Report. London School of Hygiene and Tropical Medicine, 1947- 48. Selwyn-Clarke, P. S.: Yellow fever in West Africa, Quart. Bull. Health Organ., League of Nations 5:69-78 (Mar.) 1936. Thomson, R. C. Muirhead: Recent knowl- edge about malaria vectors in West Africa and their control, Tr. Roy. Soc. Trop. Med. & Hyg. 40:511-536 (May) 1947. 36 French West Africa GEOGRAPHY AND CLIMATE French West Africa is a federation of 8 territories: Senegal, Guinea, Ivory Coast, Upper Volta, Dahomey, Sudan, Niger and Mauritania, which together occupy most of the region from the Gulf of Guinea to the Spanish Sahara, southern Algeria and Libya, and from the Atlantic Ocean to French Equatorial Africa, Nigeria and Lake Chad. The territories along the coast are separated by Portuguese Guinea, Liberia and the British dependencies of the Gambia, Sierra Leone and the Gold Coast, but join inland with Upper Volta, Sudan and Niger to form a political unit of over 1.8 million square miles. They range in size from Dahomey, with an area of 43,000 square miles, to Sudan which covers over 590,000 square miles. The French-mandated area of Togo is administered independently, but geo- graphically and culturally is closely allied to Dahomey. The major part of French West Africa is an undulating plateau with a general eleva- tion of from 1,000 to 2,000 feet, which rises from a narrow coastal plain and slopes in- land toward the Sahara Desert. The coast, particularly along the Gulf of Guinea, is edged by lagoons and stretches of dense mangrove swamp. The principal mountain- ous region parallels the coast from Portu- guese Guinea to the Ivory Coast. It includes the high plateaus of Fouta Djallon in Guinea and the chain of mountains along the borders of Sierra Leone and Liberia, in which Mt. Nimba (4,995 feet) is the highest peak in French territory. Lesser highlands, rising to from 2,400 to 3,200 feet are located in northern Dahomey, and isolated groups with massifs approaching 5,900 feet are seen in the desert country of Niger and Sudan. The Niger, the third largest river in Africa, flows for almost three-quarters of its length through French West Africa. It runs northeast from its headwaters in the Fouta Djallon highlands and makes a wide bend in the plains of Sudan before turning in a southeasterly direction to reach the Gulf of Guinea in Nigeria. The middle stretches of the Niger and of its chief tributary, the Bani, form a broad inland delta, dotted with numerous ponds and lakes, which is inundated during the flood season. The Senegal, the second river of importance, also rises in the Fouta Djallon plateau and takes an irregular course, north and west, to the Atlantic Ocean. From the standpoint of climate and vege- tation, French West Africa may be divided into three or four more or less parallel zones —of forest, savannah and desert. The region bordering the Gulf of Guinea and including the southern portions of Guinea, Ivory Coast, Dahomey and Togo is equatorial forest. The climate is essentially tropical, with relatively uniform temperatures and high humidity. The mean minimum tem- peratures average 72° to 77° F.; the mean maximum, 86° to 95° F. There are two rainy seasons, extending from March to July and from August or September to November, which are separated by an in- definite interval of lower precipitation. The period from December to March is rela- tively dry. The rainfall approximates from 150 to 200 inches annually in most localities. The savannah zone includes about two 482 French West Africa 483 thirds of Senegal; the inland portions of Guinea, Ivory Coast and Dahomey ; Upper Volta ; southern Sudan; and part of Niger. There are two distinct seasons: a rainy sea- son from June to October and a dry season extending over the remainder of the year. The annual rainfall ranges from 20 to 100 inches, decreasing gradually inland, and toward the north, with a corresponding in- crease in the length of the dry season. The temperature also rises toward the interior, with proportionately greater seasonal and daily variations. The lowest temperatures are recorded in the early part of the dry season, from November to February, and the highest, toward the end, from March to May. Along the western coast in the vicinity of Dakar, the climate is moderated by the Canary Current, however, and the highest temperatures coincide with the rainy season. The mean minimum tempera- tures (January) are about 65° F. at Dakar, 62° F. at Bamako and 57° F. at Niamey; the mean maximum temperatures, 88° F. (October), and 105° F. and 108° F. (April), respectively. Severe storms usually precede the monsoon or rainy period. The hot, dust- laden karmattan winds blow intermittently from January to March or April, affecting the entire territory to a greater or lesser degree. Mauritania and the northern portions of Sudan and Niger are incorporated in the desert or sakarien zone. The climate is hot and dry, with daily fluctuations reaching 40° to 60° F. The rainfall ranges from 4 to 10 inches a year in the steppe region bor- dering the savannah to negligible amounts over long periods in the desert to the north. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTiON In 1948 the population of French West Africa was approximately 16,377,000; over 3 million each in Sudan and Upper Volta; over 2 million each in Senegal, Guinea, Ivory Coast and Niger; almost 1.5 million in Dahomey and 524,000 in Mauritania. The non-native population, which is made up of government officials, traders, industrialists, planters and missionaries, is concentrated to a large extent in the urban centers. Almost 50 per cent are located in the imme- diate vicinity of Dakar. The European resi- dents, who totaled over 50,200 in 1943, are predominantly French. Large numbers of Syrian traders are also found in the towns and the villages throughout the country. The native inhabitants belong to two di- verse groups: the tribes of Berber and Semitic stock and the Negroes, who make up the major part of the population. The former are represented by the Maures, the Touaregs and the Peuhls (Fulas). The Maures and the Touaregs, nomadic peoples related to the Arabs and the Berbers, roam the northern steppe: the Maures in Mauri- tania and Sudan, and the Touaregs from the bend of the Niger to Lake Chad. The Peuhls, a Negroid race of uncertain origin, are widely dispersed throughout this area. Over 2 million are settled in French West Africa, chiefly on the Fouta Djallon pla- teau, in eastern Senegal and in the delta region of Sudan. The Negro peoples comprise a medley of tribes, conforming to numerous, more or less, distinct ethnologic divisions. The most numerous are the Mandingos, found along the upper and the middle reaches of the Niger River, and the Mossi, in Upper Volta. Both total between 2 and 3 million, but the Mandingos represent a complex family of tribes, while the Mossi are a relatively homogeneous people with a highly devel- oped feudal organization. The principal tribes of Senegal are the Ouolofs (Wolofs) and the Séréres, with a scattering of Man- dingos in the interior. Other large groups are the Sénoufes of Ivory Coast; the Songhai, located in Sudan in the area en- circled by the bend of the Niger; the Tou- couleurs (Tukolors), divided between east- ern Senegal and Sudan; the Hausas, found throughout the territory but predominantly in Niger territory; and the heterogeneous 484 French West Africa tribes of the Guinea coast, the Baoulés, the Aquis, the Dahomeans and the Krus. Among the characteristic languages and dialects of the various racial groups those of the Peuhls, the Songhai, the Toucouleurs, the Mossi, the Mandingos, the Ouolofs and the Hausas are the most widely distrib- uted. The four latter tongues are increas- ingly recognized as languages of trade throughout their respective areas. Arabic, the only written native language, is used by the nomadic tribes of the desert region. French is spoken by a small percentage of the population, primarily the residents of Dakar and other urban centers. Mohammedanism predominates in the north, and paganism in the south. About 60 per cent of the inhabitants are animists, with the largest proportion in Upper Volta, Ivory Coast, Dahomey and Sudan, and smaller communities in Guinea, Senegal and Niger. However, the different tribal religions vary somewhat in external charac- teristics. Secret societies are encountered in some areas, which exert an important in- fluence in the life of the people. The Touaregs, the Maures and the Peuhls and the majority of the Hausas are Moslems. Mohammedanism is gradually infiltrating among the tribes of Senegal and Sudan but is most strictly observed by the peoples on the fringe of the desert. The converts to Christianity, both Catholic and Protestant, probably do not exceed from 2 to 3 per cent of the total population. The majority are Catholics; the largest numbers are found in Ivory Coast and Dahomey. The social structure of the territories is complex, with the primitive tribes of the forest and the desert nomads at one extreme, and the educated, Europeanized residents of Dakar or Saint Louis at the other. The concentration of populations varies mark- edly, not only between the territories but in the different climatic regions. In 1943 the population density of Mauritania, Niger and Sudan ranged from 1.2 to 7.5 per square mile. In Senegal, Guinea Coast, Ivory Coast and Upper Volta, it averaged from 22 to 27 per square mile, and in Dahomey it ap- proached 35 per square mile. The most populous areas, outside of Dakar district, are found in the Mossi country of Upper Volta and in the coastal regions of Dahomey. A feature of the social and economic de- velopment of French West Africa within recent years is the increasing urbanization, particularly along the west coast. In Dakar, the capital of the Federation, the popula- tion increased from about 32,000 in 1921 to over 110,000 in 1943, when the white resi- dents numbered 11,767 and the natives 98,661. Official statistics are not available, but reports indicate that the non-native pop- ulation of Dakar approximated 35,000 in 1949. Other cities with white populations of 1,200 to 3,000 and indigenous populations of from 24,000 to 43,000 in 1943 were Saint Louis, Thiés and Kaolack in Senegal; Bamako in the Sudan; Conakry in Guinea; Abidjan in Ivory Coast; and Bobo Diou- lasso in Upper Volta. Port cities with equally large native populations, but less than 700 whites, were Rufisque in Senegal, Grand Bassam in Ivory Coast, and Porto- Novo in Dahomey. Tombouctou (Tim- buktu), an ancient trade center on the Niger River, and the largest wholly native town, has a population of over 10,000. The majority of the sedentary peoples live in small, scattered villages, and the urban pop- ulations probably do not exceed 5 per cent of the total. Schools are maintained by all the terri- torial governments, but the proportionate enrollment of children of school age is rela- tively low. Probably the greatest number of literate persons is found in Senegal, the first territory to confer French citizenship on the native inhabitants. The ability to read and write in French is one of the basic re- quirements determining eligibility for citi- zenship. In 1936 there were about 81,000 native citizens in the Federation, 96 per cent of whom were Senegalese. Essentially two types of education are offered in the government schools. In the larger cities, as Dakar, educational facilities, patterned after those of France, are provided to equip both whites and blacks for responsible positions in the administration and in business. How- ever, the standard schools combine ele- mentary instruction in French with a prac- tical curriculum adapted to the needs of the different communities. Primary schools are established in the rural and the urban areas; the more advanced and vocational schools, in the capital cities of each territory. Koranic schools are located in the Moslem areas, and a few mission institutions in the coastal territories. The creation of a West African university at Dakar is a major fea- ture of the Federation’s program for the promotion of education among the native population. VITAL STATISTICS No vital statistics are available for French West Africa. Even in Dakar and other principal cities where the registration of births and deaths is enforced, the records are incomplete and unreliable. In 1940,'8 2,898 births and 2,146 deaths were reported in the district of Dakar. Approximately 25.8 per cent of the total deaths were among children under 1 year of age, and 40 per cent among children under 5 years. The infant mortality averaged 190 per 1,000 live births. A study of the infant mortality in the principal Cercles, or districts, in Senegal in 1934.5" showed that only 58.4 per cent of the children lived beyond 3 years of age. Roughly 9 per cent of 17,436 pregnancies terminated in abortions or stillbirths. The infant mortality (0 to 1 years) was 265 per 1,000 live births. Intestinal infections, bron- chopneumonia, malaria, tetanus and syph- ilis are among the major diseases responsible for the high death rates among children 0 to 5 years of age. : Sociar Economy The economy of French West Africa is based primarily on agriculture. Production varies in the different territories, the inten- sity and the type of cultivation being gov- erned not only by climatic conditions but French West Africa 485 by the social development of the tribes in- digenous to the area. The inhabitants of the forest and the savannah zones are predomi- nantly peasant farmers, engaged in the cul- tivation of subsistence and cash crops. The plantation system is restricted largely to Ivory Coast and Guinea, where some large concessions are operated by European own- ers and agricultural societies. The principal exports, in order of importance, are: pea- nuts, cocoa, palm oils and kernels, coffee, bananas and cotton. Peanuts are grown in Senegal and to a lesser extent in the savan- nah regions of Sudan, Upper Volta, Ivory Coast and Niger. Cocoa is the major prod- uct of Ivory Coast. Oil palms are cultivated throughout the forest zone but particularly in Dahomey, which is one of the most con- gested agricultural areas in the Federation. Coffee, a relatively recent crop, is grown by the natives in Dahomey, Guinea and Ivory Coast, and on European plantations in the Ivory Coast. Bananas are cultivated in Guinea and Ivory Coast. Cotton for local use has been raised for many years in the Niger delta and Upper Volta regions, but the crop has reached export proportions only within the last few decades. The expansion of the industry is largely dependent upon the extension of irrigation facilities, espe- cially in the Niger River valley, and on the promotion of modern methods of processing and transportation. Cattle, sheep, horses and camels are raised by the pastoral tribes of the northern territories, but the volume of exports in animals and hides is relatively small. The breeding of cattle is restricted, however, by the presence of trypanoso- miasis and its fly vectors over extensive areas. Most of the territorial governments main- tain research stations and educational facil- ities for the promotion of improved methods of agriculture. They also encourage the or- ganization of co-operative societies. These agencies, which are most highly developed in Senegal, assist the government organiza- tions in popularizing new crops and modern technics of cultivation. The veterinary serv- 486 French West Africa ices of the territories, the Services Zootech- niques, operate laboratories for the produc- tion of vaccines and sera to combat anthrax, pleuropneumonia, rinderpest and other en- zootic diseases, and in some areas they carry on experimental programs for the im- provement of the quality of the livestock. The forest zone is a rich source of tropical timbers, the principal areas of exploitation being in Ivory Coast, Guinea and the Casa- mance area of Senegal. The mineral wealth of French West Africa is negligible. Small supplies of gold are derived from alluvial deposits in Senegal and in the basin of the upper Niger. Minor veins have also been located in Dahomey and in Ivory Coast. Diamonds are found in Guinea, and zircon and titanium ores in Senegal. Salt is pro- duced from deposits in Mauritania and in northern Sudan and Niger and by evapora- tion in shallow lagoons in Dahomey and Senegal. Small native industries are established in the urban areas, especially in Senegal. Within recent years, also, numerous indus- tries have been organized, chiefly under Eu- ropean auspices, for the processing of agri- cultural and: other products. Prominent among these are plants for the extraction of peanut oil and for the drying of fish and of bananas. Communication facilities between the coast and the interior are generally poor. Four unconnected railway lines link the coastal ports with the Niger basin: lines from Dakar, in Senegal, to Bamako and Koulikoro in Sudan; from Conakry to Kankan in Guinea; from Abidjan in Ivory Coast to Bobo Dioulasso in Upper Volta; and from Cotonou to Parakou in Dahomey. The Senegal and Niger rivers are the prin- cipal water routes. The Senegal is navigable to Podor throughout the year, and to Kayes during the rainy months. Three sections of the middle Niger are also navigable during the flood season. Networks of roads link the larger population centers but many are not serviceable for motor traffic during the rains. Dakar is one of the major ports of West Africa, with steamer connections to Europe, the Americas and the other African colonies. Saint Louis, Kaolack, Conakry and Abidjan are important secondary ports. Air services are also available between the territories, and from Dakar to various cen- ters in Africa, South America and Europe. Foop AND NUTRITION Conservative estimates indicate that less than 5 per cent of the total population of the French West African territories obtains an adequate and balanced diet. Except in the urban centers and in certain peanut- growing areas, the food habits of the people are determined by the availability of local foodstuffs, the variety being governed by climatic conditions and by the customs and the occupations of the tribes. A large pro- portion of the inhabitants of the forest and the savannah regions subsist upon vege- tarian diets which are deficient in protein, fats and vitamins. Bananas and cassava (manioc) are staple foods among the tribes of the Guinea Coast, while millet (sorghum) is the basic article of diet in the north. Sup- plementary foods, which are used to varying degrees in different regions, are legumes, peanuts, yams and other tubers, and numer- ous herbaceous fruits and vegetables. Rice is grown in Senegal, Guinea, Sudan and Ivory Coast; maize in northern Dahomey and parts of the Niger basin. The fats are almost exclusively of vegetable origin and consist of peanut oil, palm oil or shea-nut butter. Small domestic animals are kept in most villages, but the consumption of meat is usually low, except among the more prosperous town dwellers. Fish are plentiful in the coastal and the river regions, where they contribute materially to the protein ration of the people. Game is also found in some areas. The nutrition of the nomadic Maures, Touaregs and Peuhls is based upon the con- sumption of milk and milk products and grains and is low in caloric value. Cattle, sheep, goats and camels are raised by the different tribes, but meat is used only on special occasions. The Peuhls, in particular, regard their cattle as evidence of wealth, rather than as a source of food. Undernutrition is general among most of the tribes. The majority live from harvest to harvest and make little provision for periods of drought, when famine conditions may prevail in many areas. Among some peoples, religious and social customs aggra- vate the recurrent seasonal shortages. Overt vitamin deficiencies are not common under normal conditions, but the different diets are frequently inadequate in protein, in vitamin C and in vitamins of the B complex. The latter deficiencies are most often ob- served among the cassava-eating tribes of the south. Nutritional defects are also en- countered among the poorer inhabitants of the larger towns and cities. HousinG Housing conditions vary markedly throughout the territories, ranging from the comfortable masonry dwellings of the pros- perous inhabitants of the urban centers to the simple grass or mud huts in the tribal areas. The design and the construction of the native huts are characteristic of the dif- ferent tribes. Circular dwellings with con- ical straw roofs predominate in Senegal and in western Sudan. Dome-shaped huts of straw are typical among the Peuhls in Guinea, while in the south and in the middle valley of the Niger River, square or rec- tangular huts of sun-dried bricks, with straw roofs, are encountered most fre- quently. Most of the villages are small, with the huts concentrated around the dwelling of the chief. In a few areas, as in “upper” Dahomey, they are enclosed within circular walls. The nomadic tribes of the north commonly live in simple tents made from hides. The larger cities are becoming increas- ingly overcrowded. Except in certain parts of Dakar and in Saint Louis and Conakry, the European sections are distinct from the native. Although the newer dwellings are well constructed and modern in design, the French West Africa 487 usual native quarters comprise a miscel- laneous assortment of primitive huts and wooden shacks. The overcrowded and in- sanitary native villages in and around the urban centers constitute important foci for the spread of communicable diseases. In Dakar, the largest and most prosperous city in the Federation, the Medina or old native section, houses over half of the population. Housing programs have been undertaken by the urban authorities in most of the larger cities to relieve the congestion among the rapidly expanding populations and to promote higher standards of living among the people. ENVIRONMENT AND SANITATION WATER SUPPLIES The availability and the quality of water supplies vary markedly in the different terri- tories of French West Africa. In general, surface sources of water are plentiful in large portions of Guinea, Ivory Coast and Dahomey, and village supplies are derived from streams, springs, lakes or ponds and shallow wells. In the northern territories where barren steppe and desert predomi- nate, the settlements are located to a con- siderable extent in the coastal region, in the Senegal and the Niger river basins and around the occasional oases in the desert. Surface water supplies are ample during the rainy months but negligible in the dry season, when acute shortages may be ex- perienced due to the lack of facilities for storage. In northern Senegal and sections of Sudan, Niger and Mauritania, water is sometimes obtained from deep wells. The available supplies are not only inadequate but frequently of questionable potability. The water obtained from the numerous small streams of the Niger delta is heavily sedimented during the flood seasons, while the artesian supplies are often highly min- eralized. The public water supplies in the cities and the larger towns are supervised by the terri- torial or local health services. The degree of 488 French West Africa surveillance and treatment varies, however, and contamination is frequent. In most cities the water is piped to a limited number of houses and buildings and is distributed to the remaining inhabitants from com- munity fountains or standpipes. In Dakar the water supply is derived from wells sunk to a depth of 20 to 30 feet at Fann and M’Bao and to a depth of 100 to 150 feet at Point B and on the Route d’Ouakam. The water is collected in two series of interconnected reservoirs and is treated by chlorination. The quality and the purity of the supply are checked at reg- ular intervals by the chemical division of the Institut Pasteur at Dakar. The system serves about 80 per cent of the population of Dakar itself, as well as the surrounding suburbs. The supply is inadequate during the dry season, and nightly shutdowns are enforced periodically. Other urban centers having water sup- plies which are treated by chlorination or filtration include Rufisque, Saint Louis and Thiés in Senegal; Segou and Markala in Sudan; Conakry in Guinea; and Niamey in Niger. Untreated public supplies serve the population centers of Kaolack in Sene- gal; Bamako and Kayes in Sudan; Abidjan and Bouaké in Ivory Coast; Bobo Diou- lasso and Ouagadougou in Upper Volta; Kankan in Guinea; and Porto-Novo and Cotonou in Dahomey. In most instances the water is pumped from wells, but in Saint Louis, Bamako and Kayes it is obtained from adjacent river sources. Small installations for the purification of water supplies are found in labor camps and other industrial or state facilities. The sup- plies in the rural areas are not protected and are subject to serious pollution. Irrigation is carried on in the delta region of the Niger River and in the vicinity of Podor in the valley of the Senegal River. The completion of the barrage at Markala on the Niger in 1947 was an important feature of a large-scale irrigation scheme sponsored by the French government. The project will open up extensive areas in the Niger delta area for the cultivation of rice and cotton. WasTE DisposaL Most of the larger cities have sewerage systems which serve at least part of the community, but the methods of sewage dis- posal are primitive in the towns and vil- lages. Where water-borne sewerage is not available, septic tanks are customarily em- ployed in connection with European dwell- ings. Pit latrines are found in some of the native villages, but pollution of the soil is a general practice. Moreover, human excre- ment is frequently utilized as fertilizer on the farms and the gardens. In Dakar a water-borne sewerage system covers most of the modern city. In the Medina and in the surrounding villages, drainage is effected by a network of open drains and canals, which in some areas re- ceive the overflow of septic pits. The sewers and the night soil collections from the native quarters are emptied into the ocean without treatment. A separate seawater distribution system provides water for flushing the sewers and the drains during the dry season and for street cleaning and fire protection purposes. Fauna anp Frora Arthropods. Mosquitoes. Numerous spe- cies of anopheline mosquitoes exist in the various sections of French West Africa, of which 20 or more are potential vectors of malaria. Anopheles gambiae, the most effec- tive vector, is widely distributed. In the coastal regions and in the forest and plateau country of the southern territories, it consti- tutes, at times, roughly 80 per cent of the total anopheline population. This species breeds prolifically in sunlit collections of water, both natural and artificial, partic- ularly in the shallow pools and marshes formed by the heavy rains. Anopheles funestus is also of primary importance in the transmission of malaria. It breeds along the grassy margins of slow-flowing streams French West Africa 489 and is found most abundantly in the savan- nah regions. Potential vectors of significance in localized areas are: A. nili, A. pharoensis and A. coustani, with its varieties paludis, ziemanni and tenebrosus. Other species which may be implicated in the transmis- sion of malaria in limited regions are: A. marshalli, A. hancocki, A. rufipes, A. squa- mosus, A. longipalpis, A. splendidus, A. smithi, A. moucheti, A. obscurus and A. har- greavesi. A. gambiae and A. funestus are also efficient vectors of Wuchereria ban- crofti. Aedes aegypti is widespread throughout the southern half of French West Africa, where it is a vector of yellow fever and of dengue fever. Various other species of Aedes are present, a few of which may be of some importance in the epidemiology of yellow fever. A. africanus and A. simpsoni are po- tential vectors, while A. luteocephalus and A. vittatus are known to be capable of trans- mitting the virus under experimental condi- tions. Numerous Culex mosquitoes are annoy- ing pests. Culex quinquefasciatus (= C. fatigans) and C. pipiens are abundant, par- ticularly in the coastal regions. The former is an important vector of Wuchereria bancrofti. Taeniorhynchus (Mansonia) africanus, T. (M.) uniformis and Eretmopodites chrys- ogaster are present. Mosquito-control programs are under- taken by the local health authorities in the larger cities, especially in Senegal. The measures employed include the draining and the filling of swamps and unused garden wells; the antilarval treatment of breeding sites with oil, Paris green or DDT; and the stocking of pools, wells and streams with larvicidal fish, usually Girardinus guppyi. Residual spraying of native habitations with DDT solutions is carried on in the Medina and the villages surrounding the airport in Dakar, in Conakry and in Bobo Dioulasso. The elimination of domestic accumulations of water favorable to the breeding of Aedes aegypti or Anopheles gambiae is enforced in all the cities and adjoining villages. The nature of the terrain and the heavy pre- cipitation during the rainy season make mosquito control difficult and largely inef- fective, except in the population centers. Fries. Flies are prevalent in all parts of the Federation, but the species character- istic of the different areas have not been completely studied. The most important, from a health standpoint, are the tsetse flies, which are widely distributed in the regions south of 14° to 16° N. latitude. Glossina palpalis and G. tachinoides are the principal vectors of human trypanosomiasis (African sleeping sickness). G. morsitans plays an insignificant role in the transmission of human infections but is an important vector of animal trypanosomiasis. Other species implicated in the transmission of tryp- anosomiasis among game and domestic ani- mals are G. longipalpis, G. fusca, G. nigro- fusca, G. tabaniformis and G. medicorum. Glossina palpalis is found near the rivers and the streams in the forest zone and in the forest galleries bordering the rivers in the savannah regions, in a belt extending from the Gulf of Guinea to 10° to 11° N. latitude in Dahomey in the east and to Dakar in the west. G. tachinoides inhabits the riverine bush from 9° to 16° N. latitude but probably is not found to any extent as far west as Senegal and lower Guinea. It is the predominating tsetse fly in Sudan, where it breeds along the borders of the swamps and the rivers, and disperses during the rainy season to invade the more distant vil- lages. G. morsitans is limited to scattered islands in the sparsely settled sections of the savannah, including parts of Guinea, Casamance (Senegal) and Upper Volta. G. longipalpis is common in the transitional zone between the forest and the savannah, while G. fusca abounds in limited foci in the equatorial forest. G. pallicera and G. caliginea are also present. The control of trypanosomiasis in French West Africa is based largely upon the treat- 490 French West Africa ment of the human reservoir. Organized antitsetse fly measures are undertaken in limited areas by the government health services. They consist primarily in the elimi- nation of breeding sites adjacent to major lines of communication and in the protec- tion of villages in the savannah regions by selective clearings. The extensive work nec- essary for effective control is not considered feasible in the forest zone. Several species of flies of the genera Stomoxys and Musca are widespread. Al- though essentially pests, they may be active in the mechanical transmission of intestinal and other infections. Cordylobia anthro- pophaga, the most frequent cause of human myiasis, is found throughout the southern part of French West Africa. Other blowflies which may be responsible for occasional cases of myiasis in man include species of Cynomyia, Lucilia, Chrysomyia and Sar- cophaga. Auchmeromyia luteola is common in the tropical and the semitropical regions, where its bloodsucking larvae, known as “Congo floor maggots,” infest the floors of the native huts. Numerous species of TaB- ANIDAE are encountered. Chrysops dimidi- ata and C. silacea are vectors of Loa loa in some sectors along the coast. Gnats are prevalent. Species of SimuL- 1pAE are recorded from all of the territories, exclusive of the desert and steppe regions. Simulium damnosum is a vector of the filarial worm, Onchocerca volvulus, in local- ized foci. Culicoides austeni and C. grahami are widely distributed and implicated in the transmission of Acanthocheilonema perstans. Numerous Phlebotomus flies are known to be present. Phlebotomus papatasii is found in the vicinity of Tombouctou and elsewhere in Sudan, but sandfly fever has not been reported from the area. Lice. Pediculus humanus corporis, P. humanus capitis and Phthirus pubis are common, particularly among the peoples of the plateau country. The body louse, P. humanus corporis, is responsible for the transmission of louse-borne relapsing fever and typhus fever, both of which are re- ported occasionally from the northern terri- tories. Freas. Xenopsylla cheopis is the pre- dominating rat flea. X. brasiliensis and X. astia are encountered less frequently. Cten- ocephalides canis, C. felis, and Echidnoph- aga gallinacea are common. X. cheopis is the principal vector of plague, which is en- demic in the coastal region of Senegal. Synosternus pallidus is abundant in the na- tive houses and may be implicated in the transmission of the infection from man to man. Pulex irritans is relatively rare. The sandflea, Tunga penetrans, is a trou- blesome pest in many areas. It burrows into the skin, usually around the toes, causing sores which readily become infected. BepBucs. Cimex hemipterus is indigenous throughout this region. C. lectularis is present in Senegal, Guinea, Ivory Coast and Dahomey and possibly elsewhere. Ticks anp Mites. Species of Ambly- omma, Rhipicephalus, Ixodes, Haemaphy- salis and Boophilus are found on the do- mestic animals in most sections of the country. Rhipicephalus sanguineus is the probable vector of fiévre boutonneuse in Senegal and other territories. Ornithodorus erraticus is prevalent in sections of the northern savannah country. It is the vector of tick-borne relapsing fever in the vicinity of Dakar. O. savignyi is found in the Lake Chad region, but O. moubata has not been reported. The itch mite, Sarcoptes scabiei, is wide- spread among the populations. ScorpPIONS AND SPIDERS. Scorpions are numerous, especially in the western part of the country around Dakar, and many are poisonous. Species of Buthus, Scorpio, Pan- dinus and other genera are recorded. The venomous spider, Latrodectus indistinctus, is present in some areas. Its bite may pro- duce a serious toxemia. Scodra brachypoda is reported from the Guinea coast. OTHER ArTHROPODS. Blister beetles are French West Africa 491 plentiful. The body juices of many species, and sometimes simple contact, may produce blistering of the skin. Species of the family PaussipaE are present in all of the terri- tories. Cylindrothorax dusaulti is found in Senegal, Sudan and Niger. Species of the genera Mylabris and Psabydolytta are widespread, while Paederus is indigenous in Guinea, Ivory Coast and Dahomey. Anthia (Thermophilia) sexmaculata is found in Sudan and Mauritania. The cockroach, Periplaneta americana, is common in Senegal. The driver ants, Anomma, are encoun- tered in the forest. They are destructive and dangerous to individuals unable to get out of their path. Reptiles. Numerous species of poisonous snakes have been identified in French West Africa. The cobras are widely distributed: Naja nigricollis throughout the territories; N. haje in Senegal, Sudan and Niger; N. goldii in Ivory Coast and Dahomey; and N. melanoleuca in the coastal areas. The mambas, Dendroaspis jamesonii and D. viridis, are found in various regions south of the desert. Elapechis guentheri is com- mon to all the territories. The puff adder, Bitis arietans, is widespread. The vipers, B. nasicornis and B. gabonica, are found in the forest regions of Guinea, Ivory Coast and Dahomey. The night viper, Causus rhombeatus, is present in all of the terri- tories, while the tree viper, Atheris chlor- echis, is found throughout the south, and A. squamiger, in Dahomey. Echis cari- natus is common in the desert and steppe regions of Senegal, Sudan, Niger and Mauri- tania, and Aspis cerastes (= Cerastes cornutus) in the latter territories. Species of Atractaspis are widely distributed: A. dahomeyensis in Dahomey and Upper Volta; A. microlipholis in Senegal; A. corpulenta, A. irregularis and A. aterrima along the Guinea coast; and A. watsonii in Sudan and Mauritania. The rear-fanged Disphodilus typus is reported from all the territories. The nonpoisonous constrictors, Python sebae and P. regius, ave also widely distrib- uted. Eryx muelleri is found in Upper Volta and Sudan, and E. thebaicus in Niger. Crocodiles frequent the rivers and some- times attack man. Rodents. Rats are prevalent, particularly in the port cities. Rattus rattus alexandrinus is most frequently encountered, but R. rattus rattus and R. norvegicus are also common. Plague is endemic in the coastal littoral of Senegal but has not become es- tablished in the interior. The domestic rats and a variety of field rodents are potential reservoirs of the infection. The giant rat, Cricetomys gambianus, the semidomestic Mastomys coucha and the shrew mouse, Crocidura stampflii, are most intimately as- sociated with man. Wild rodents found infected with plague in nature are Arvi- canthus rufinus, Golunda campana, Pelomys campanae and the palm rat, Xerus ery- thropus. The various species of Rattus, C. gambianus and A. rufinus may also harbor the spirochetes of relapsing fever in the endemic areas of Senegal. Rat-control measures are carried on in Dakar and other large cities. These include the destructicn of rodents by trapping and poisoning, ratproofing in new buildings, and occasionally the demolition of dwellings in which cases of plague have occurred. Mollusks.* Foci of infection with Schis- tosoma haematobium exist in all of the ter- ritories. Physopsis africana globosa is an intermediate snail host in Guinea, Sudan and Ivory Coast; Bulinus truncatus, in Mauritania and Sudan; and Bulinus (Pyr- gophysa) forskalii, in Senegal and Sudan. The snail hosts in other territories have not been identified. Planorbis (Biomphalaria) alexandrina is an intermediate host of S. mansoni in Guinea ; and P. (B) alexandrina pfeifferi, in Guinea and Sudan. Foci of the disease also occur in Ivory Coast and Dahomey, but the snail hosts are not known. * See footnote, p. 10. 492 French West Africa Plants. Numerous species of poisonous plants are found in the forest and the savan- nah regions. Some are employed medici- nally. Others are used by primitive tribes for the purpose of poisoning arrows, killing fish, or inflicting punishment or revenge. Poisonous plants reported from different parts of French West Africa include: the sasswood, Erythrophleum guineense; sev- eral species of Strophanthus, particularly S. hispidus, and S. sarmentosus; Jatropha gossypiifolia, Adenium hongkel, Calatropis procera, Strychnos densiflora; and species of Dichapetalum. Many of the wild grasses and common cereals are potential allergens, but no stud- ies have been made to determine those of major importance. The pollen of the kapok tree, Ceiba pentandra, sometimes produces allergic symptoms in susceptible individ- uals. Foop SANITATION The standards of food sanitation vary but are generally low in the native towns and villages. In the urban centers the markets and the food-processing establishments are supervised by the local health authorities. Little attempt is made to protect the market produce from dirt and flies, which are abundant. The inspection of meats and of slaughter houses is the responsibility of the local veterinary services in the cities and of the district medical personnel in the rural areas. Meat inspection is usually limited to the gross examination of carcasses. While the diseased parts are condemned, the re- maining portions may be sold on the open market. Cysticercosis and anthrax are com- mon among the native herds; bovine tuber- culosis and brucellosis are also present ; but the extent of infection is not known. Fresh milk is rarely available in the urban areas, and no sanitary regulations covering the production and the sale of milk are enforced in any of the territories. Munic- ipal refrigeration facilities have been estab- lished in Dakar. HEALTH SERVICES AND MEDICAL FACILITIES Heart ORGANIZATIONS The administration of the public health and medical services in French West Africa is centralized in the Direction Générale de la Santé Publique de I’Afrique Occidentale Francaise, with headquarters in Dakar. The department functions under the direct au- thority of the Governor-General of the Federation who, in turn, is advised on matters of public health by the Direction du Service de Santé Colonial in the Ministére de la France d’Outre-Mer, in Paris. The medical activities in each territory are operated by a territorial Service de la Santé Publique and co-ordinated through the federal organization. The headquarters of the Service de la Santé Publique for Senegal are located in Saint Louis; for Sudan, in Bamako; for Ivory Coast, in Abidjan ; for Upper Volta, in Ouagadougou ; for Dahomey, in Porto-Novo; for Guinea, in Conakry; for Niger, in Niamey ; and for Mauritania, in Saint Louis, Senegal. They are responsible for the maintenance of hos- pitals and subsidiary medical facilities, the operation of laboratories, the organization of itinerant services in the tribal areas (As- sistance Médicale Indigene), the supervision of urban and rural sanitation and the en- forcement of quarantine measures. The preventive services are concentrated in the Service Général d’Hygiéne Mobile et Prophylaxie, a branch of the federal organ- ization, which is based at Bobo Dioulasso (Upper Volta). The Service functions in all the territories in close co-operation with the local Service de la Santé Publique. It maintains special treatment, research and training centers, and itinerant field units for the control of trypanosomiasis, leprosy, ma- laria, plague, syphilis and tuberculosis. The Service also incorporates branches dealing with nutritional and housing problems. Services d’Hygiéne, dependent upon the territorial health administrations, are es- tablished in the larger cities and towns. French West Africa 493 They are charged with the control of epi- demic diseases and the performance of various sanitary functions, including Anoph- eles, Aedes and rodent control. Maternal and child health work is carried on by the Service de la Santé Publique in each territory. Prenatal and infant health clinics, with staffs of visiting nurses and midwives, are maintained in the larger cities, in addition to the regular facilities for maternity care (see Hospitals). A limited degree of supervision over the health of the children in the schools is also provided, par- ticularly in Dakar. Branches of the Croix Rouge Francaise, the Berceau Africaine and the Association des Dames Francaises carry on infant and child welfare work in co-operation with the territorial health organizations. Several Catholic and Protestant mission groups operate small hospitals and dispensaries in the non-Moslem areas, all of which are sub- sidized by the territorial governments. Plan- tation and industrial groups and the semi- official enterprises, such as the Société des Travaux Irrigation du Niger, maintain medical facilities for the benefit of their employees. MEepicAL INSTITUTIONS Hospitals and Dispensaries. Most of the hospitals in French West Africa are operated by the Service de la Santé Pub- lique in each territory, under the super- vision of the Direction Générale in Dakar. There are 8 central hospitals located in the capital cities, which provided 820 beds for non-natives and 1,710 beds for natives in 1948. Hospital facilities for the care of the white population are available in Dakar, Saint Louis, Bamako, Abidjan, Conakry, Niamey and Porto-Novo and in a few in- firmaries and medical centers in various parts of the country. The largest and most fully equipped hospitals are found in Dakar. The Hopital Colonial has a capacity of about 250 to 300 beds, roughly two thirds of which are reserved for white residents. The Hopital Central Africain has about 500 beds for natives ; in addition to the usual medical and surgical services, it maintains oph- thalmology, dermatology, psychiatric and communicable disease divisions. The Poly- clinique Roume, the leading dispensary in French West Africa, is connected with the medical school at Dakar. The central hos- pitals in the other territories vary in size, with 10 to 80 beds for non-natives and 100 to 250 beds for natives. In 1948, there were also 19 regional hos- pitals with subsidiary ambulance units, located in the administrative centers, and 152 rural infirmaries, which provided a total of 216 beds for non-natives and 3,741 beds for natives. In addition, 232 dispensaries and 21 special clinics were scattered throughout the territories. In the same year the different Services de la Santé Publique maintained 13 maternity hospitals, 93 maternity wards in hospitals or infirmaries and 75 rural maternity clinics with a combined capacity of 75 beds for white women and 2,523 beds for natives. Special medical facilities include 18 units for the isolation of communicable diseases, 9 units for the care of mental patients and 82 hospital camps for the treatment of tryp- anosomiasis. Provision for the treatment of lepers is available in 37 agricultural villages, with accommodations for about 2,450 resi- dents, and at the Institut Central de la Leépre at Bamako, which has a bed capacity of 450 to 500. A few small private nursing homes are located in Dakar. The mission hospitals and dispensaries in the southern territories are supervised and frequently subsidized by the territorial health organizations. In 1948, 23 private dispensaries were operated by in- dustrial concerns. Laboratories. The Institut Pasteur de PAfrique Occidentale Francaise in Dakar, which is affiliated with the Institut Pasteur in Paris, is one of the foremost diagnostic and research laboratories in West Africa. It maintains 5 divisions: microbiology and serology, pathology, chemistry, rabies and yellow fever. The Institut carries on re- 494 French West Africa search on the major endemic and epidemic diseases of the region; prepares vaccines and other biologic products for distribution in the various French African territories and performs microbiologic, serologic, chemical and pathologic examinations in co-operation with the health services of Dakar and of the Federation. Field investigations on tryp- anosomiasis, malaria, yellow fever, plague and other diseases are undertaken from time to time by the staff of the Institut. The Institut Pasteur at Kindia (Guinea) conducts research in veterinary microbi- ology and prepares vaccines and sera for the control of enzootic diseases in the terri- tories: namely, anthrax, pleuropneumonia and rinderpest. It also offers facilities for research on human diseases. The Institut Francais d’Afrique Noire de Dakar includes research in the fields of entomology, physiology and nutrition among its various activities. Government laboratories are maintained by the territorial health services of Senegal and Mauritania at Saint Louis; by the health service of Sudan at Bamako and by the health service of Ivory Coast at Abidjan. These laboratories are equipped for the con- duct of bacteriologic and serologic examina- tions, and at Saint Louis and Bamako for the preparation of smallpox vaccines. Research laboratory facilities are avail- able at the Institut Central de la Lépre, which was established by the federal health services at Bamako in 1933-34 as a center for the study of the epidemiology of leprosy and the efficiency of new therapeutic methods. Microscopic equipment is availa- ble also at the trypanosomiasis treatment centers. Bacteriologic and chemical diagnostic laboratories are incorporated in all of the larger hospitals. Schools. The Ecole de Médecine Afri- caine in Dakar, is operated by the French colonial medical services for the training of African auxiliary personnel: doctors, phar- macists and midwives. The school receives qualified students from the territories of French West Africa and French Equatorial Africa and from French-mandated Togo and the Cameroons. Practical instruction is pro- vided in the Hopital Central Africain, the Polyclinique Roume and the maternity hos- pital, in Dakar. Plans are being developed for the incorporation of the medical school in the proposed Université de Dakar. It is expected that by 1951 graduates in medicine will receive degrees equivalent to those of the French universities and that the present regulations restricting their practice and employment to the territorial health serv- ices will be removed. Nurses and medical assistants are trained in the larger hospitals in each territory. Spe- cialized training is provided for the subordi- nate medical staff in the trypanosomiasis division of the Service Général d’Hygiéne Mobile et Prophylaxie, in its school at Bobo Dioulasso (Upper Volta). PERSONNEL Physicians. Most of the European doc- tors in French West Africa are connected with the different territorial services. The majority are members of the Medical Corps of the French Army, with civilian status. In 1948 from 170 to 200 French physicians and 300 Africans, graduates of the Ecole de Médecine Africaine, were employed in the federal or territorial health organizations. Small numbers of physicians are asso- ciated with the Pasteur Institutes in Dakar and Kindia and with industrial or mission enterprises. A few are engaged in private practice ; about 8 to 10 in Senegal and 3 in Ivory Coast. Dentists. In 1948, 6 military and 3 civil- ian dentists were employed in the territorial health services. Two or three private dentists also practice in Dakar. Others. The roster of the European staff of the various government health services in 1948 listed 17 pharmacists and 98 nurses with army status, and 24 health or sanitary agents, 2 laboratory assistants and 47 mid- wife-nurses among the civilian personnel. The native staff totaled 29 pharmacists, 279 French West Africa 495 midwives, 53 visiting nurses, about 3,500 military and civilian nurses, 274 sanitary agents and numerous assistants in other medical categories. DISEASES The diseases characteristic of the different territories of French West Africa are in- fluenced by the physiographic conditions and by the manner of living and the social development of the people. Estimations re- garding the extent of specific infections among rural and urban populations are necessarily inaccurate in view of the dif- ficulties of reporting and the lack of precise information, even in the larger cities. More- over, the mobility of the pastoral tribes, the increasing migration of transient laborers to and from the urban and industrial areas, and the perpetual traffic across international boundaries invalidate the compilation of morbidity statistics. Also, a large percentage of the people in each racial group conform to their traditional forms of medical prac- tice and do not come within the scope of the existing government facilities. In gen- eral, the factors which influence the pres- ence of epidemic or endemic disease in the French-mandated territory of Togo are comparable with those found in Dahomey ; Togo is included in the following discussion. Summaries of disease incidence are based upon records of government hospitals and dispensaries, the reports of special programs for the control of specific diseases and the research and epidemiologic studies of the Instituts Pasteur in Dakar and in Paris. Although the data provided are incomplete, they serve as useful indices for determining the relative distribution and the circum- stances governing the spread of different infections. Except for trypanosomiasis and a few other diseases which have been the subject of special surveys, the reported cases probably constitute but a small frac- tion of the total incidence. Considerable confusion exists regarding morbidity and mortality data from Ivory Coast and Upper Volta. In 1947 Upper Volta was re-established as a separate territory, with the restoration of the boundaries it had before it was abolished in 1932. In the in- tervening period most of its area was in- cluded in Ivory Coast, but small portions were allotted to Niger and Sudan. There are no separate statistics for Upper Volta for the period 1932-47, but reference is fre- quently made to the ‘Haute Volta” region of Ivory Coast. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fever and paratyphoid fever B occur sporadically and sometimes in small local- ized outbreaks. Paratyphoid fever A is less frequent. The incidence is relatively low compared with that of other intestinal in- fections, which may be attributed, in part, to incomplete reporting. In the opinion of the staff of the Institut Pasteur at Dakar, the typhoid fevers contracted in that area are more benign than cases seen in North Africa or in France.?¢ Dysenteries. Amebic and bacillary dys- enteries are prevalent. Infections are asso- ciated with contaminated food and water supplies, in which the low standards of sani- tation, the prevalence of flies, and a general ignorance of the basic principles of per- sonal hygiene are contributory factors. Of- ficial medical reports generally include only the most severe cases and give little idea of the actual incidence. Amebic dysentery is reported with greatest frequency, but the differential diagnosis is seldom established, and in many areas all dysenteries are auto- matically classified as amebic. Moreover, a large percentage of the cases recorded as diarrhea and enteritis probably should be attributed to bacillary dysentery. Amebic dysentery is widespread in all of the territories, especially in the valleys of the Niger and the Senegal rivers. Abscess of the liver is relatively rare. Localized epi- demics of bacillary dysentery occur almost annually, usually in the dry season. In the 496 French West Africa Dakar area outbreaks are normally concen- trated in the months from July to Novem- ber. Infections with Shigella dysenteriae and with the Flexner, Hiss, Strong, Sonne, Cas- tellani, d’Herella and Morgan strains of the Shigella group are reported. Outbreaks of diarrhea are common and are responsible for a high mortality among young children. Cholera. Asiatic cholera has not been re- corded from this region. Epidemics of an intestinal infection, designated as ‘“choler- ine” have been reported occasionally from the St. Louis and Senegal River area. The last outbreak was noted in 1911-12, but an epidemic of a similar mild infection was described in 1943. The etiology is un- certain. Helminthiases. ANcyLosTomiasis. Hook- worm infection is widespread in the savan- nah and the forest zones. Cases are reported from Senegal, Sudan, Niger, Guinea, Ivory Coast (including Upper Volta), Togo and Dahomey, with a relative prevalence ranging from 10 to 40 per cent in Sudan to 30 to 90 per cent in the coastal territories. Both Ancylostoma duodenale and Necator ameri- canus are encountered. The exact geographic distribution has not been determined, but Ancylostoma duodenale probably predomi- nates in the northern territories. Several lo- calized outbreaks of severe ancylostomiasis among young children have been reported from Ivory Coast, which were attributed to the practice of geophagy, or earth eating. Heavy infections which predispose to inter- current disease are frequent in infancy. The dog hookworm, Ancylostoma brasiliense, is common in the coastal area in Senegal. ScuisTosoM1asIs. Schistosomiasis is wide- spread throughout French West Africa in the regions south of the desert. Cases are reported from all the territories, but in 1946 roughly 58 per cent of the total, including both Schistosoma haematobium and S. mansoni infections, were attributed to Sudan, and 11 per cent each to Senegal and Ivory Coast (including Upper Volta). Evi- dence regarding the geographic distribution of the two species is still incomplete. Five major foci of S. haematobium infection are recognized : along the Niger River and its tributaries, the Milo, the Baoule and the Bagoé, from their headwaters to Tom- bouctou ; the upper basin of the Volta River and its tributaries; the Senegal River and its tributaries, the Bafing and Falémé; the Gambia, Casamance and Saloum rivers in Senegal ; and the district of Dakar.’ Other areas of high incidence occur in the moun- tainous sections of southern Guinea and in the coastal and the forest zones of Dahomey and Togo. The infection rates vary, but in general they are uniformly high among children and persistently higher among women than among men. They range from 17 per cent in Dakar and 35 per cent in Kaolack, in Senegal, to 60 to 70 per cent in certain localities in Sudan and Dahomey. Schistosoma mansoni occurs irregularly over more limited areas. It is endemic in the Niger basin in Sudan and Guinea and in limited foci in Dahomey and Togo. The zones of greatest prevalence are found in the high valleys of Guinea, around Macenta, and in the Sokodé region of northern Togo. Infections are also reported sporadically from Senegal, Niger, Ivory Coast and Upper Volta. Potential intermediate snail hosts of both species are abundant in the streams and the pools in the different areas. Otruer HELMINTH INFECTIONS. Ascaris lumbricoides is prevalent, particularly in Dahomey and Guinea. Strongyloides ster- coralis and Trichuris trichiura are also com- mon. Enterobius vermicularis is less fre- quent. Infections are usually multiple, es- pecially in children. Echinococcosis is some- times encountered. The beef tapeworm, Taenia saginata, is widely distributed in the cattle-raising areas. The pork tapeworm, 7". solium, is rare in the north but appears occasionally in the southern territories. The dwarf tapeworm, Hymenolepis nana, also occurs. Brucellosis. Brucellosis is enzootic among the cattle and the goats, and human French West Africa 497 cases are sometimes observed. Numerous foci are known to exist in the pastoral areas of the northern savannah region. Since 1938, when malta fever was first diagnosed in French West Africa, confirmed cases of Brucella melitensis infection have been re- ported almost annually from Senegal and Sudan. The disease is transmitted hoth by the consumption of goat’s milk aud cheese and by contact with infected animals. Other Infections. Outbreaks of human anthrax occur sporadically in association with epizootics among the livestock. Infec- tion often results from the consumption of the flesh of diseased animals. Acute and chronic infections caused by Balantidium coli are observed frequently in Guinea and Niger. Diseases SpreAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is believed to be increasing in the territories of the Fed- eration, as in other sections of Africa. The infection is common in the coastal regions around the European settlements and is gradually infiltrating in the interior with the repatriation of tuberculous laborers and soldiers to their home villages. The inci- dence is particularly high in Sudan, Ivory Coast (including Upper Volta) and Senegal. The disease follows a rapid, fulminating course among peoples from the tribal areas but tends to become chronic in residents of the cities. Pulmonary tuberculosis pre- dominates, but all forms are encountered. Overcrowding and lack of ventilation in native dwellings, undernutrition and primi- tive concepts of personal hygiene and sani- tation favor the spread of the infection, both in the congested quarters in the urban areas and in the rural villages. In 1927 a survey in Dakar of the school children between 7 and 10 years of age showed that 43.3 per cent were tuberculin- positive.*® A more recent survey of 11 dis- tricts in Ivory Coast in 19407 indicates positive tuberculin reactions in from 42 to 45 per cent of the population tested in the coastal towns and in from 22 to 35 per cent in the forest villages. The rates increased proportionately with age, the highest being found on the settlements along the major traffic routes. Immunization of infants and young chil- dren with BCG vaccine is carried on in Dakar. Within recent years the program has been gradually extended to include school children in other population centers throughout the Federation. The vaccine is prepared at the Institut Pasteur de Afrique Occidentale Francaise in Dakar. Bovine tuberculosis is present in the na- tive cattle in some regions, and human in- fections probably occur. Lesions due to tubercle bacilli of human origin are fre- quent among the garbage-fed pigs in Dakar. Smallpox. Localized outbreaks of small- pox occur sporadically. The highest inci- dence is reported from Sudan and second- arily from Senegal, Guinea, Niger and Ivory Coast (including Upper Volta). Roughly 400 cases are recorded each year from Senegal, the infection being introduced usually by migratory laborers from Niger and Sudan during the peanut harvest. In 1945 a minor epidemic was experienced in Dakar. Vaccination against smallpox is re- quired but frequently is evaded by the in- habitants of the more sparsely settled dis- tricts. A persistent, endemo-epidemic focus exists in Dahomey, where all attempts at control are frustrated by the attitude of the people, who regard the disease as sacred.® Smallpox vaccine is prepared locally and also is imported from Paris. Simultaneous immunization against smallpox and yellow fever has been practiced in some areas since 1940. The mixed vaccine is prepared at the Institut Pasteur in Dakar. Meningitis. Since 1937 epidemics of greater or lesser intensity have been re- ported from all of the territories but most frequently from Senegal, Sudan, Niger and Upper Volta. The epidemic zone extends from the northern desert to the humid forest and coastal areas of the southern terri- tories. Outbreaks normally start in Niger 498 French West Africa and spread progressively from east to west. The most extensive and severe are recorded from the regions east of the Niger River. They occur primarily during the dry season from January to May, with the peak of in- cidence in March or April. The cold, dry, sand-laden winds which cause the inhabit- ants to congregate in the huts and other shelters may increase contact and facilitate the spread of the infection. The epidemics usually subside with the onset of the rains, but sporadic cases continue throughout the year. In 1946 over 26,000 cases of meningo- coccus meningitis were reported from French West Africa and 48 from Togo, with an average fatality rate of from 20 to 25 per cent. The local strains isolated at Dakar are predominantly Type A, although Type B is occasionally encountered. Attempts to immunize the affected populations by means of an antimeningococcus vaccine, prepared from local strains, have been abandoned recently. The present methods of control include isolation of cases and contacts, treatment with “sulfa therapy,” and quar- antine of infected areas by the use of sani- tary cordons. Sulfapyridine prophylaxis is sometimes employed in labor camps and in other selected groups. Pneumonia. Pneumonia is prevalent, often reaching epidemic proportions among the native populations of Senegal, Sudan, Niger and the savannah regions of Upper Volta, Ivory Coast, Togo and Dahomey. Serious outbreaks occur repeatedly among laborers living under overcrowded and un- hygienic conditions. The highest incidence occurs in the cool months at the beginning of the dry season and during the karmattan, when the simple dwellings provide inade- quate protection against the sharp fluc- tuations in day and night temperatures. Primary pneumococcal septicemias and meningitis are frequent. The fatality rates averaged from 70 to 80 per cent before the introduction of specific: drug therapy and still are abnormally high. Pneumococcus, Types I, ITI, VII and XII have been re- ported in from 55 to 60 per cent of the cases confirmed by bacteriologic diagnosis at the Institut Pasteur in Dakar. Among 283 pneu- mococcus strains isolated from 1939 to 1945, Type I was identified in 16.3 per cent, Type IIT in 9.5 per cent, Type VII in 17.3 per cent, and Type XII in 15.1 per cent.” Pneumonia is prominent among the diseases contributing to the high mortality among children. Minor upper respiratory tract diseases of undetermined etiology are widespread. Other Infections. Measles, mumps and whooping cough are endemic and frequently epidemic. Scarlet fever, diphtheria and poliomyelitis occur sporadically. DiseEASES SPREAD OR CONTRACTED Cuierry TaroucH CONTACT Venereal Diseases. All forms of venereal disease are encountered, the greatest num- ber of cases being reported from Senegal, Ivory Coast (including Upper Volta) and Guinea. The prevalence in the general popu- lation is not known, but venereal infections comprise from 4 to 14 per cent of the total cases treated in government hospitals and dispensaries in the different regions. Syphilis and gonorrhea are widespread, while chan- croid and, to a lesser extent, lymphogranu- loma venereum also occur. Syphilis predomi- nates, the infection rates being especially high among the Peuhls (Fulas). In some areas from 70 to 100 per cent of the popu- lation is infected with a mild form of syphilis. Promiscuity is customary among many tribes, and prostitution is widespread in the urban areas. Special dispensaries for the treatment of venereal diseases are main- tained in Dakar and other cities. Treatment is also provided at the maternity centers and by the medical units in the rural areas. Control efforts are handicapped by the gen- eral failure of the natives to return for treatment after the acute symptoms have subsided. Leprosy. Leprosy is one of the major en- demic diseases in this area. In 1946 ap- proximately 112,000 lepers were known to exist in French West Africa and the French West Africa 499 French-mandated territory of Togo. The observed cases, estimated at 6.38 per 1,000 population in French West Africa and at 10.2 in Togo probably represent a low index of the actual prevalence. A leper census is gradually being compiled as part of the leprosy program of the federal Service Général d’Hygiene Mobile et de Prophy- laxie, but lack of co-operation from lepers, their families and the tribal chiefs in many areas makes an accurate enumeration dif- ficult. The distribution of leprosy in the ter- ritories of the Federation in 1946, based upon an enumeration of 102,200 lepers at that date,'® was as follows: roughly, 45.5 per cent in Ivory Coast (including Upper Volta), 23.6 per cent in Sudan, 14.5 per cent in Guinea, 8.8 per cent in Dahomey, 49 per cent in Senegal, 2.5 per cent in Niger and 0.2 per cent in Mauritania. The Institut Central de la Lépre at Bamako is a center for research on methods of prevention and treatment. The Institut hospital and associated convalescent colo- nies have facilities for the care of from 450 to 550 lepers. A small leprosarium is located at Sor in Senegal. Elsewhere the lepers are isolated and treated in agricultural colonies or villages. In 1948 there were 37 such colo- nies in French West Africa with 2,422 lepers in residence and 2 in French Togo with 520 lepers. Yaws. Yaws is widespread among the na- tive peoples in the regions south of 15° N. latitude. In 1946 cases were reported from all of the territories: roughly 63 per cent of the total from Ivory Coast (including Upper Volta), 20 per cent from Guinea and 13 per cent from Dahomey. The highest in- fection rates are associated with the densely populated forest areas. In 1940'7 yaws rep- resented 13 per cent of the total recorded morbidity in Ivory Coast, 7 per cent in Dahomey, 5 per cent in Guinea and 9.6 per cent in Togo. In Senegal the infection is limited to the Casamance and the upper Gambia river regions. Goundou, which is regarded by many as a form of tertiary yaws, is common. Rabies. Rabies is endemic throughout this region. Human cases usually occur as the result of dog bites but occasionally of cat bites. The Institut Pasteur at Dakar maintains facilities for the preparation of antirabic vaccine and for the treatment of human cases. Phenolized vaccine, prepared by the Fermi technic, is shipped by air to desig- nated stations in all the territories of the Federation and in French Togo. Diseases of the Skin. Phagedenic ulcers are prevalent, particularly in Senegal and Ivory Coast. They are frequently extensive, with serious complications. Mycotic infec- tions are numerous and widely distributed. Madura foot and ringworm of the skin and the scalp are encountered repeatedly. Rare cases of human infections with Histoplasma capsulatum have been reported. A creeping eruption, caused by the larvae of the dog hookworm, Ancylostoma bra- siliense, occurs in the vicinity of Saint Louis and Dakar. The condition, known locally as “larbish,” is contracted on the beaches, primarily during the bathing season, from June to November. It is also common among garden laborers and young children. Scabies is widespread. Craw-craw, a vesic- ular dermatitis of uncertain etiology, may be associated with Sarcoptes scabiei infec- tion. Cases of human myiasis occur sporad- ically. The majority are caused by the larvae of Cordylobia anthropophaga. The lesions produced by the sandflea, Tunga penetrans, generally become secondarily in- fected. Diseases of the Eyes. Trachoma is en- demic, and serious complications are com- mon. The highest incidence is reported from Guinea, Sudan, Senegal and Niger. In Togo the infection is common among the Moslems in the north. The communal use of pieces of antimony, employed in blackening the eye- lids, probably facilitates the spread of the disease. Gonococcal and other forms of con- junctivitis are frequent. Severe irritation of the eyes, caused by dust and sand, is ex- perienced during the karmattan season. 500 French West Africa Other Infections. Tetanus is sporadic, a large percentage of the cases being due to umbilical infections. Tularemia is occasion- ally reported from Dakar and Senegal. In most instances the infection is transmitted by the bite of the palm rat, Xerus ervthro- pus. Leptospirosis, or Weil's disease, is en- demic, especially in the vicinity of Dakar and St. Louis. Cases of human anthrax are frequently acquired from contact with in- fected animals or hides. Diseases SPREAD By ARTHROPODS Malaria. Malaria is highly endemic in all parts of French West Africa and Togo, ex- cept the more arid portions of the northern territories. It is especially prevalent in the coastal regions and in the proximity of river valleys. The infection rates vary, but splenic indices of 20 per cent to 50 per cent and parasite indices of 40 per cent to 80 per cent are more or less general. Transmission takes place throughout the year but primarily dur- ing and immediately after the rainy season, when the infection may reach epidemic pro- portions. The incidence is uniformly high among infants and young children. In 1946 over 38 per cent of the total reported cases were attributed to children under 5 years of age. In the same year'® a survey of nearly 12,000 children in the vicinity of Porto- Novo (Dahomey) revealed spleen rates of 13.4 per cent at from 2 to 5 years, 68 per cent at from 6 to 10 years, and 50 per cent at from 11 to 17 years. The plasmodium in- dex averaged 40.7 per cent, and the gameto- cyte index 5.1 per cent. The seasonal distribution is shown in a study of 2,500 children in the vicinity of Dakar in 1922-23.%> The parasite indices were 36 per cent in January, 45 per cent in June and 63 per cent in October (at the end of the rainy season) in the city ; 40 per cent, 60 per cent and 72 per cent, respectively, in the adjoining native areas of the Medina. In spite of an active malaria-control program in the city the parasite index approximated 100 per cent in the near-by Parc des Sports in 1944.7 Tt is persistently 90 to 100 per cent in the suburbs from June to December. Infections with Plasmodium falciparum predominate and normally are responsible for from 50 to 95 per cent of the total cases. The relative proportions of P. vivax and P. malariae infections fluctuate from season to season and from region to region. P. vivax usually accounts for from 2 to 20 per cent of the cases but may approach P. falciparum in frequency. The P. malariae infections average from 3 to 15 per cent and occa- sionally exceed 50 per cent of the total. Anopheles gambiae is the principal vector of malaria in all the territories, while A. funestus is an important secondary vector. A. pharoensis, A. nili and A. coustani are re- sponsible for some transmission in localized areas. Anopheline control programs are un- dertaken in the urban centers but are im- practical in the rural districts, where the breeding places are numerous and often in- accessible. Quinine prophylaxis is employed for the protection of the white residents. It has also been introduced among selected groups of the native population, particularly in cer- tain infant or child welfare clinics, in the schools in Dakar and other cities and among the labor crews in various industries. The incidence of malaria has increased materi- ally within recent years in all the population centers, due to the shortage of supplies and trained personnel, which reduced the effec- tiveness of the control programs, and to the influx of nonimmune laborers from non- malarious regions. Blackwater fever occurs sporadically, most frequently in the white population. Trypanosomiasis. Trypanosomiasis (African sleeping sickness), caused by Tryp- anosoma gambiense, is widespread in the area south of an arbitrary line from Dakar to Lake Chad. The infection occurs most extensively in Ivory Coast (including Upper Volta), but foci are also found in Guinea, Dahomey and Togo; in the basins of the Black Volta, the Bani and the Niger rivers in Sudan; in Casamance and the “Petite Coté” in Senegal; and in southwestern Niger. The incidence in the northern terri- tories tends to be more seasonal and irregu- lar in distribution than in the forest zone. The average infection indices among the populations surveyed in the different terri- tories fluctuate from year to year with the discovery of new foci and the degree of con- trol in the infected areas. In 193917 the in- fection rates were estimated at 8 per cent in Ivory Coast (including Upper Volta), 9.4 per cent in Dahomey, 8.2 per cent in Sudan, 5.0 per cent in Senegal (chiefly Casamance), 3.9 per cent in Guinea, 3.1 per cent in Niger and 15 per cent in Togo. In active foci they ranged from 5 to 20 per cent but reached 50 to 60 per cent in individual villages. The campaign against human trypano- somiasis was initiated in 1931-32 in Ivory Coast. In 1939 the Service Général Auto- nomie de la Maladie du Sommeil was cre- ated for the purpose of co-ordinating the work in the territories of French West Africa and Togo. The program now con- stitutes a major division in the Service Gén- éral d’Hygiéne Mobile et Prophylaxie which was created in 1945. The headquarters are located at Bobo Dioulasso (Upper Volta) where the Service maintains a special train- ing center for its personnel. The work is undertaken by mobile teams, divided into survey and treatment units, which visit the native villages in designated sectors. Serious and arseno-resistant cases are evacuated to sleeping sickness hospitals or ‘“hypnosaries.” In 1948 there were 82 hypnosaries with 9,568 patients in French West Africa and 7 with 598 patients in Togo. Field research in the use of new drugs is carried on continu- ously by the treatment teams. The number of individuals examined annually increased from approximately 900,000 in 1935 to from 4 to 5 million in 1946. Correspondingly, the average index of new infections dropped from 2.7 in 1935 to 0.34 in 1946. In the savannah country of Sudan, Upper Volta, Ivory Coast and Togo, where the treatment program has been augmented by the clear- ance of tsetse fly areas for agricultural pur- poses, the incidence of active infectious French West Africa 501 cases has been reduced to 0.1 per cent. In the forest zone, where antitsetse fly meas- ures have been restricted to a few definite points, it probably exceeds 2 per cent in numerous foci. Since 1946-47, chemoprophy- lactis, employing single injections of Penta- midine, has been carried out experimentally in selected villages in Casamance, Guinea and Ivory Coast. The vectors of human trypanosomiasis are Glossina palpalis and G. tachinoides. The former species is responsible for the transmission of the infection in the coastal and the forest areas, while the latter pre- dominates in savannah regions. Plague. Epidemics of human plague oc- cur at irregular but frequent intervals in Dakar and the coastal regions of Senegal. The zone of greatest endemicity lies be- tween the Atlantic Ocean and the main traffic routes linking Dakar and Saint Louis. Dakar, Saint Louis, Tivaouane and Thies are prominent endemo-epidemic centers. Only occasional authenticated cases have been reported from other territories. From 1912, when plague was first recognized in French West Africa, to 1946 over 45,000 cases were recorded, with an average fatal- ity rate of 70 per cent. Workers at the In- stitut Pasteur in Dakar have established the presence of an active focus of sylvatic plague in the coast littoral of Senegal. The appearance of human cases of the disease parallels epizootics among the wild and the domestic rodents. The overcrowding in the Medinas and the native villages, poor sani- tation and the abundance of rats and fleas are factors conducive to the perpetration and the spread of the infection. Following a period of quiescence from 1936 to 1941, plague broke out in Dakar in 1942. It soon reached epidemic proportions, with 32 cases reported from the city and 266 from the surrounding villages in 1943; 570 cases from the city and 69 from the villages in 1944. Moreover, the number of hidden and unidentified cases was probably high. The majority of infections were of the bubonic type, although septicemic and 502 French West Africa sometimes pneumonic forms were also en- countered. In addition to the usual control measures, a comprehensive DDT program was introduced late in 1944. The entire population and their dwellings were treated with DDT compounds. Immunization with antiplague vaccine was made compulsory in Dakar and the neighboring regions of Sene- gal, and certificates of immunization were required of persons entering or leaving the district.?” As a result of these control meas- ures only 4 deaths were reported from the city in 1945. Moreover, the focus in rural Senegal was rapidly extinguished. Rat-control measures are undertaken by the Services d’Hygiéne in Dakar and Sene- gal; also in port cities in other territories. Rickettsial Infections. Murine typhus is endemic. Sporadic cases are reported each year, particularly from the congested native quarters of the port cities. The causative organism, Rickettsia mooseri, was isolated from rats in Dakar in 1936.*> Human infec- tions are usually mild, but occasional deaths occur among the workers on the rat-infested docks. Epidemic foci of a rickettsial infection, presumably murine typhus, exist in the sa- vannah regions of Ivory Coast (and Upper Volta). The disease, which is known locally as “Maladie de la Chasse,” is prevalent among certain tribes at periods when rats are normally captured in large numbers ; in February when the fields are burned over; and during the rainy season in the course of cultivation operations. The infection is transmitted by the rat flea, Xenopsylla cheopis, and also by contact during the preparation of rats for food.?¢ Louse-borne typhus is relatively rare, but suspected cases are reported sporadically from the plateau districts. Louse infesta- tion is general in many areas where un- hygienic and overcrowded living conditions may facilitate the spread of the infection. Cases diagnosed as epidemic typhus have been recorded from Guinea and Upper Volta. Fiévre boutonneuse is occasionally pres- ent in Dakar and neighboring districts of Senegal. The vector is Rhipicephalus san- guineus. Tick-borne infections, presumably transmitted by species of Rhiipicephalus, Amblyomma or Haemaphysalis, have been reported from time to time from Guinea and Togo. “Q” fever has been described from the Saharan regions. Yellow Fever. Yellow fever is endemic in all portions of French West Africa south of the Sahara desert. Sporadic cases are re- ported from widely separated areas and, prior to the introduction of widespread im- munization, localized outbreaks were ex- perienced at frequent intervals. Major foci are found in the densely populated region between the Saloum and the Gambia rivers and in the forest zone of Ivory Coast. In a total of 313 cases of yellow fever reported from the Federation in the period from 1931 to 1946, 32 per cent were from Senegal, and 28 per cent from Ivory Coast (including Upper Volta). The disease is largely sea- sonal, cases being recorded in the period of greatest Aedes intensity, from September to November. Seroprotection test surveys un- dertaken by staffs of the Rockefeller Foun- dation and of the Institut Pasteur in Dakar indicate that foci of endemicity exist in all of the territories. A protection test survey was made in 1939 of over 900 school chil- dren, from 5 to 15 years of age, in four villages in the Sine-Saloum district near the Gambia border, and immunity to the yellow fever virus was demonstrated in from 35 to 60 per cent. Comparable tests in 1940% in- dicated 11.5 per cent immunity in 200 chil- dren, from 6 to 12 years of age, in Ivory Coast, and 12.5 per cent immunity among the children of Bamako, Kayes and Segou in Sudan. A sharp decrease in the incidence of yel- low fever has been recorded since the in- auguration of an immunization campaign in Senegal in 1939 and in Sudan and Ivory Coast in 1940. Immunization by means of a scarification technic developed by Peltier, Durieux and their collaborators at the In- stitut Pasteur in Dakar was extended in French West Africa 503 1940 to all of the territories. In 1941 im- munization was made compulsory for both white and native populations. In many areas a mixed yellow fever and smallpox vaccine is employed. Between 1939 and 1948, almost 15 million persons were im- munized. Within recent years only sporadic cases have occurred among unvaccinated in- dividuals in the population centers along the major trade routes and also in isolated vil- lages. The yellow fever division of the In- stitut Pasteur at Dakar prepares yellow fever vaccine for use in the French terri- tories, maintains diagnostic services, con- ducts immunity surveys and carries on ex- tensive research on yellow fever. Rural (jungle) yellow fever exists in both the savanah and the forest regions, and the presence of an animal reservoir is suspected. Specific immunity to the yellow fever virus has been demonstrated in several species of monkeys captured in scattered localities in French West Africa and in the neighboring colonies. In 1944'% immunity was also dem- onstrated in 29 of 33 young baboons, Papio papio, collected along the Gambia River. Aedes aegypti, the principal vector of yellow fever, is widespread. Anti-Aedes measures are enforced by the local Services d’Hygiéne. In 1940 the Aedes index in Dakar was about 0.01 per cent. Filariasis. Filariasis is prevalent in French West Africa and in Togo. Wucher- eria bancrofti, Acanthocheilonema perstans, Loa loa and Onchocerca volvulus infections exist, but since the cases are usually grouped in the medical reports, the geographic dis- tribution of the individual species is not clear. A. perstans is widely distributed. WW. bancrofti is common in the coastal regions and in the basins of the upper Senegal and Niger rivers. In studies published in 19124% relatively high infection rates for W. ban- crofti were recorded both in Senegal and in the region within the bend of the Niger River. Anopheles gambiae, A. funestus and Culex quinquefasciatus (= C. fatigans) are important vectors. Loa loa infections are re- ported specifically from Dakar and Togo and presumably occur in the intervening coastal regions, where the vectors, Chrysops dimidiata and C. silacea are abundant. Onchocerciasis is widespread, particularly in Sudan, Guinea, Upper Volta and Ivory Coast. In Sudan the infection rates range from 4 to 5 per cent in the vicinity of Bamako to from 30 to 45 per cent in the Kolokani region. In the Mossi district, in Upper Volta, the infection rates average from 10 to 20 per cent, but are considerably higher in many villages. Cutaneous nodules and ocular lesions with accompanying blind- ness are common. Simulium damnosum is considered responsible for the transmission of the infection. Relapsing Fever. Borrelia recurrentis is occasionally responsible for localized out- breaks among the louse-infected native populations of the northern savannah areas. In 1921-29 an extensive epidemic of louse- borne relapsing fever occurred in “Upper” Ivory Coast and Sudan, which spread along the lines of communication to Senegal and eastward to the Lake Chad region. The in- fection rates averaged 10 per cent in the areas affected; the fatality rates from 5 to 25 per cent. Apparently French West Africa was subsequently free from louse-borne in- fection until 1945, when it was introduced into Dakar by Senegalese troops repatriated by boat from Morocco. About 60 to 65 cases were reported over a period of 6 months, The imposition of rigid control measures prevented the spread of the infec- tion to the civilian populations. The out- break was secondary to the major epidemic which swept across North Africa in 1943-46. Tick-borne relapsing fever, caused by Borrelia duttoni, is endemic in Senegal, especially in Dakar and the surrounding suburbs. It is transmitted by Ornithodorus erraticus. In Dakar the infection is more prevalent in the European quarters than in the Medina. Differences in the nature of the soil and in the character of the buildings, which favor the presence of the tick vectors and the rodent hosts, probably explain the discrepancies in infection rates. Numerous 504 French West Africa domestic and field rodents have been found infected in nature. The recognition of the shrew mouse, Crocidura stampflii, as a po- tential reservoir formerly led to the designa- tion of the Dakar strain as Spirochaeta duttoni crocidurae.*® Relapsing fever is also reported sporadi- cally from Togo and the southern territories. O. moubata, a vector elsewhere, is believed to be rare or absent throughout this area. Other Infections. Dengue fever is en- demic, particularly in the coastal regions where the common vector, Aedes aegypti, is most abundant. Cutaneous leishmaniasis occurs in Sudan, where the existence of both classical and unusual forms with nodular lesions has been described.?* Sporadic cases are reported from the neighboring territories, primarily Niger, Senegal, Ivory Coast and Dahomey. Visceral leishmaniasis is rarely, if ever, ob- served. Specific instances of sandfly fever have not been recorded, although various species of Phlebotomus flies are present. Rift Valley fever is thought to be present in the Sudan region. Guinea-worm infection, or dracontiasis, is found in most parts of the savannah zone. NUTRITIONAL DISEASES Undernutrition and subclinical deficien- cies, especially in vitamins of the B com- plex, are prevalent. Clinically evident de- ficiency diseases are encountered primarily among the natives residing in the cities, where the dietary standards are influenced by the economic status of the people and are generally lower than in the rural areas. Beriberi is reported most frequently from Dakar and the urban districts of Senegal and Sudan. Scurvy occurs in the towns and among the tribes of the steppe and the desert regions. Rickets is reported sporadi- cally. MisceLLaNEoUus CONDITIONS Tropical pyomyositis, caused by Pas- teurella bouflardi, is common in Guinea, Ivory Coast and Sudan, in the basins of the upper Niger and Senegal rivers. The disease is seasonal, occurring in the latter part of the dry season and the early part of the rainy season. Outbreaks of infectious hepatitis are re- ported sporadically from Senegal, Upper Volta and Ivory Coast. SUMMARY French West Africa is a Federation of 8 territories which extends from the Guinea Coast to the Sahara and incorporates zones of forest, savannah and desert. The total population is slightly over 1624 millions, in- cluding a small percentage of white resi- dents concentrated largely in the urban centers. Responsibility for the public health is centralized in the Direction Générale de la Santé Publique de DI’Afrique Occidentale Francaise, with headquarters in Dakar, the capital of the Federation. The health and medical services are administered by the local Service de la Santé Publique in each territory. The federal and territorial health organizations are supervised by the Direc- tion du Service de Santé Colonial in the Ministére de la France d’Outre-Mer, in Paris. The control of certain diseases of socio-medical significance, as malaria, lep- rosy, trypanosomiasis, tuberculosis, plague and syphilis is concentrated in the Service Général d’Hygiéne Mobile et Prophylaxie under the direction of the central health or- ganization. Local Services d’Hygiéne are charged with the enforcement of sanitary measures in the larger towns and cities. In 1948 there were 8 central hospitals, pro- viding a total of 820 beds for non-natives and 1,710 beds for natives. The largest and best-equipped institutions are located in Dakar. There were also 19 regional hos- pitals with rural ambulance services, 13 maternity hospitals, 152 health centers and 232 dispensaries in various parts of the country. Most of the medical facilities are operated by the territorial health services, but a number of hospitals and dispen- saries are maintained by mission organiza- tions and industrial concerns. The Institut Pasteur at Dakar is one of the outstanding research centers of West Africa. Water supplies are plentiful in the south- ern territories but variable and frequently scarce in the northern. Community sup- plies are derived from surface sources, from shallow wells and, in many sections in the north, from artesian wells. The water sup- plies in some of the cities and towns are treated by chlorination and other methods of purification, but the degree of supervision varies, and contamination is frequent. Mod- ern sewerage systems serve the European and business sections of the larger cities, but the methods of sewage disposal in the smaller towns and villages are generally primitive. Standards of nutrition differ among the tribes, but undernutrition and serious deficiencies in protein, vitamins and minerals are general. The major diseases in French West Africa are malaria, trypanosomiasis, dysentery, French West Africa 505 helminthiasis, leprosy, tuberculosis, syphilis and gonorrhea. Epidemics of meningococcus meningitis, pneumonia and smallpox are reported annually. Outbreaks of louse-borne relapsing fever have been recorded from time to time among the tribes of the plateau country. Murine typhus is endemic, and tick-borne typhus is sporadic. Tick-borne relapsing fever is encountered primarily in Senegal. Foci of sylvatic plague exist in the coast littoral of Senegal, and epidemics are frequent, particularly in the congested urban centers. Yellow fever is endemic, but within recent years immunization has been compulsory, and human cases few in num- ber. Schistosoma haematobium infections are widely distributed, while those due to S. mansoni are limited in extent. Yaws is prevalent among the tribes of the forest zone. Typhoid fever, dengue fever, tra- choma, brucellosis and rabies are endemic. 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Kartman, Leo: A note on the anopheline vectors of Wuchereria bancrofti in West Africa, J. Parasitol. 32:91-92 (Feb.) 1946. ——: A note on the problem of plague in Dakar, Senegal, French West Africa, J. Parasitol. 32:30-35 (Feb.) 1946. Kervran, P.: Les hotes intermédiaries de bilharzioses humaines a Bamako (Soudan francais), Bull. Soc. path. exot. 40:349- 352 (Sept.-Oct.) 1947. ——, and Aretas, R.: Deux cas d’histoplas- mose observée au Soudan francais, Bull. méd. de DP'Afrique occidentale frangaise 30. 31. 32. 33. 34. 35. 36. 37: 38. 39. 40. 41. 42. 43. 44, 3:127-133, 1946; Abst. Trop. Dis. Bull. 44:1018-19 (Nov.) 1947. Labouret, Henri: Paysans d’Afrique occi- dentale, Paris, Librarie Gallimard, 1941. La protection de la maternité et de ’enfance indigénes dans les colonies frangaises en 1937: Ann. méd. et pharm. col. 37:97-149 (Jan.-Feb.-Mar.) 1939. La protection de la maternité et de 'enfance indigénes dans les colonies francaises en 1938: Ann. méd. et pharm. col. 38:46-95 (Jan.-Feb.-Mar.) 1940. Lefrou, G.: Considérations sur 1’étiologie de la fievre bilieuse hemoglobinurique a pro- pos de 123 cas observés au Soudan, Bull. Soc. path. exot. 41:176-187 (March-April) 1948. : La leishmaniose cutanée au Soudan francais, fréquence de la forme séche papulo-tubercolose, Bull. Soc. path. exot. 41:622-627 (Sept.-Oct.) 1948. ——: Presence de Bullinus dybowskyi au Senegal. La diagnose des bullinidae afri- cains, Bull. Soc. path. exot. 26:1099-1105 (July) 1933. Le Gac, P.: Etude sur le typhus tropical des savanes de la haute Cote d'Ivoire, Bull. Soc. path. exot. 39:86-94 (Mar.-April) 1946. ——, and Borjeix, L.: Premier cas de fievre boutonneuse au Togo, Bull. Soc. path. exot. 38:247-250 (Oct.) 1945. ——, Foubert, A., and Aihonnou, L.: 81 cas de charbon humain observés en haute Cote d’Ivoire. Resultats remarquables de la sul- famidothérapie, Bull. Soc. path. exot. 38: 252-255 (Oct.) 1945. Le Gall, R.: Les bilharzioses en Afrique occi- dentale francaise, au Togo et a Madagas- car de 1939 a 1941, Bull. Office internat. d’hyg. pub. 36:116-126 (Nos. 3-4) 1944. : La méningite cérébro-spinale dans les colonies francaises au cours des derniéres années, Bull. Office internat. d’hyg. pub. 36:27-40 (Nos. 1-2) 1944. : La paludisme en Afrique occidentale francaise, au Togo et a Madagascar en 1941, Bull. Office internat. d’hyg. pub. 36:203-224 (Nos. 5-6) 1944. : La parasitose intestinale en Afrique occidentale francaise, au Togo et a Mada- gascar en 1941, Bull. Office internat. d’hyg. pub. 35:35-47 (Nos. 1-2) 1943. : La variole en Afrique occidentale fran- caise et au Togo de 1935 a 1941, Bull. Office internat. d’hyg. pub. 34:228-249 (Nos. 7-8-9) 1942. Mathis, C.: Application de la vaccination par le B.C.G. en Afrique occidentale fran- 45. 46. 47 48. 49, 50. 51. 52. 53. 54. 33. 56. 57. 58. caise, Premier Congrés International du B.C.G., 18-23 Juin, 1948, Supplement p. 286-287, Paris, Institut Pasteur, 1948. ——: L’oeuvre des Pastoriens en Afrique noire, Paris, Presses Universitaires de France, 1946. ——, and Durieux, C.: Fréquence a Dakar de la spirochétose recurrente a tiques, Bull. Acad. de méd., Paris 3:528-532 (April) 1934. Muraz, G.: Resultats thérapeutiques obtenus en trypanosomiase humaine en A.O.F. et au Togo, Bull. Soc. path. exot. 35:367- 383 (Nov.-Dec.) 1942. Nash, T. A. M..: Tsetse Flies in British West Africa, London, H. M. Stationery Office, 1948. Parrot, L., Mornet, P., and Cadenat, J.: Notes sur les phlébotomes. XLIII. Phlébotomes de ’Afrique occidentale fran- caise. 1. Sénégal, Soudan, Niger, Arch. Inst. Pasteur d’Algérie 23:232-241 (Sept.) 1945. ——: Notes sur les phlébotomes. L. 2. Guinee, Cote d'Ivoire, Dahomey, Arch. Inst. Pasteur d’Algérie 23:281-289 (Dec.) 1945. Plague in Dakar: Bull. U. S. Army M. Dept. 87:13-16 (April) 1945. Puyuelo, R.: Note préliminaire sur 1'épidé- miologie et le traitment de I'onchocercose humaine a O. volvulus en pays Mossi. Le 3799 R.P. (Notezine), Bull. Soc. path. exot. 42:558-563 (Nov.-Dec.) 1949. Rapport sur le fonctionnement technique de I'Institut Pasteur de I’Afrique occidentale francaise en 1938. Dakar, Grande Im- primerie Africaine, 1939. Rapport sur le fonctionnement technique de I'Institut Pasteur de Dakar en 1939. Dakar, Grande Imprimerie Africaine, 1940. Rapport sur le fonctionnement technique de IInstitut Pasteur de I’Afrique occidentale francaise en 1940. Dakar, Grande Im- primerie Africaine, 1941. Rapport sur le fonctionnement technique de P'Institut Pasteur de I'Afrique occidentale francaise en 1941. Dakar, Grande Im- primerie Africaine, 1942. Rapport sur le fonctionnement technique de I'Institut Pasteur de I’Afrique occidentale francaise en 1945. Dakar, Grande Im- primerie Africaine, 1947. Rapport sur le fonctionnement technique de I'Institut Pasteur de UAfrique occidentale 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71, French West Africa 507 francaise en 1946. Dakar, Grande Im- primerie Africaine, 1948. Rapport sur le fonctionnement technique de I'Institut Pasteur de I’Afrique occidentale francaise en 1947. Dakar, Grande Im- primerie Africaine, 1949. Répartition des schistosomiases dans les pays africains de l'union francaise—mollusques vecteurs. Unpublished. Courtesy of Dr. Jean Gaud, Institut d’Hygiéne du Maroc. Richet, P.: La volvulose dans un cercle de la haute Céte d'Ivoire. Ses manifestations cutanées et oculaires, Bull. Soc. path. exot. 32:341-353 (Mar.) 1939. Sicé, A.: La prophylaxie de la trypano- somiase humaine et le traitement des trypanosomés au Soudan frangais, Ann. méd. et pharm. col. 37:879-918 (Oct.- Nov.-Dec.) 1939. ——, and Brochen, L.: Les manifestations sporadiques du typhus amaril au Soudan francais et leur expression épidémiolo- gique, Bull. Soc. path. exot. 33:266-271 (April) 1940. ——, Robin, C., and Brochen, L.: Considéra- tions épidémiologiques sur la méningococcie au Soudan francais, Bull. Soc. path. exot. 33:5-9 (Jan.) 1940. ——, and Torresi, F.: Considérations sur I’épidémiologie, 1’évolution clinique et la prophylaxie de la trypanosomiase humaine au Soudan francais, Bull. Soc. path. exot. 32:88-93 (Jan.) 1939. ——, and ——: Répartition de la trypano- somiase humaine au Soudan francais, Bull. Soc. path. exot. 32:560-565 (May) 1939. Sorel, M.: Essai de démographie des colonies francaises, Bull. Office internat. dhyg. pub. 30:Supplément 2, 1-154, 1938. Sorel, F. P. J.: Prophylaxie de la lépre dans les colonies frangaises, Bull. Office inter- nat. d’hyg. pub. 30:Supplément 6, 1-21, 1938. Stefanopoulo, G.: Sur la détermination des foyers d’endémicité amaril. Afrique occi- dentale francaise, Bull. Acad. méd., Paris, 109:26-34 (Jan.) 1933. Vaucel, M.: Etat actuel du paludisme dans les colonies frangaises, Bull. Soc. path. exot. 39:29-36 (Jan.-Feb.) 1946. Vogel, E., and Riou, M.: Les maladies épidémiques, endémiques et sociales dans les colonies francaises pendant l'année 1937, Ann. méd. et pharm. col. 37: Supp., 257-551 (April) 1939. 37 Cape Verde Islands GEOGRAPHY AND CLIMATE The Cape Verde archipelago, consisting of 10 islands and 5 small islets, is located from 300 to 400 miles west of Cape Verde, the westernmost point in the African Con- tinent. It has been a Portuguese possession since its discovery in 1456. The islands, which are grouped in an irregular sicklelike pattern, have an aggregate area of 1,475 square miles. They are divided into two groups with respect to the prevailing north- east winds, the barlavento (windward) and to sotavento (leeward) islands. The former include Santo Antdo, Sido Vicente, Santa Luzia, Sao Nicolau, Sal and Boa Vista; the latter, Maio, Sido Tiago (Santiago), Fogo and Brava. The islands vary in topography. The majority are rocky and barren, but some, as Sao Nicolau, Sido Tiago and Santo Antido, are mountainous, with deep, fertile valleys in the interior. The volcanic peak of Pico do Cano on the island of Fogo reaches 9,300 feet in height. It is still active but has not erupted since 1857. The climate ranges from tropical or sub- tropical at sea level to temperate, at eleva- Lam Antio sio Pe sioncony fo 4 VICENTE e- V- CAPE VERDE Boa Vista ISLANDS shoTuco__ BRAVA == “Picodty rE —~ AntO tions of over 1,500 feet. The mean tempera- tures at Mindelo (Sao Vicente) and Praia (Sao Tiago) average 74° to 76° F.; the maximum, 90° to 94° F.; and the minimum, 48° to 50° F. The highest temperatures are experienced during the rainy season, from July to October. The annual rainfall ap- proximates 10 to 20 inches, being greatest on the windward side of the mountains. The relative humidity fluctuates around 62 to 72 per cent. The northeast karmattan winds which blow intermittently from October to June, are felt most forcibly on the island of Sal. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTION Differences in development and lack of communication between the islands are re- flected in the racial composition and customs of the inhabitants. The descendents of the early white settlers and imported Negro slaves, locally known as “Creoles,” consti- tute the predominating group. In 1945 the aggregate population of the colony totaled 165,530, including 5,732 whites, 55,475 Negroes and 104,326 Creoles. Roughly 44 per cent of the population lives on Sido Tiago, 20 per cent on Santo Antéo, from 5 to 10 per cent each on Sio Vicente, Sio Nico- lau, Brava and Fogo, and less than 6,000 on the remaining islands. The white residents are mainly Portuguese, with a sprinkling of other nationalities, while the Negroes stem from numerous different mainland tribes. In general, Santo Antdo, Sdo Tiago and Maio 508 Cape Verde Islands 509 have proportionately the greatest number of inhabitants of primitive Negro stock; Sao Vicente and Brava, the highest percentages of whites. The majority of Capverdians are Roman Catholics, but many retain the superstitions and the beliefs of African fetishism. About 50 per cent are literate in Portuguese, while the remainder speak the Creole dialects, compounded of Portuguese, English and Bantu, which are peculiar to the different islands. The Portuguese government maintains primary schools in the population centers, and one secondary school at Mindelo (Sdo Vicente). The population density of the Colony averages 100 per square mile which, in view of the extensive areas of barren wasteland, means serious congestion on the more fertile regions. The highest population densities are found on Brava, Sdo Tiago and Sido Vicente; the lowest on Sal, Boa Vista and Maio. There are no large towns. Porto da Praia, the colonial capital, is located on the island of Sdo Tiago. In 1945 it had a population of 33,200, including less than 1,000 whites and about 15,000 Creoles. Mindelo, or Porto Grande, on Sido Vicente, is the principal sea- port and a prominent coaling station. It had a population of 15,886, with 1,348 whites and 12,845 Creoles. VITAL STATISTICS In the decade 1934-43, the birth rate for the Colony varied from 23.1 to 48.0 per 1,000 population. In the same period the death rate ranged from 20.3 in 1934 to 107.1 in 1942, the second year of a famine crisis on the islands. The infant mortality rate varied between 137.3 and 223.4 per 1,000 births from 1934 up to 1941 and averaged from 31 to 40 per cent of the total deaths. In 1941 it rose to 435.9, and in 1942 to 510.3. In the latter year the infant deaths were only 11.6 per cent of the total mor- tality. The rate declined to 317.9 in 1943, but the percentage index rose to 24.7. In 1941-43 infant mortality rates of less than 346 were recorded on only two islands, Sal and Boa Vista. Sociar Economy The fortunes of the Colony have depreci- ated steadily within recent years. They were originally linked with the slave trade and later with the establishment of an interna- tional coaling station at Sido Vicente and with emigration to America, especially from Brava and Fogo. Portugal maintained a penal settlement on the islands until the end of the nineteenth century; a new sta- tion was started on the island of Sido Tiago in 1936. Salt is the only product derived from the rocky islands of Sal, Boa Vista and Maio. The majority of the inhabitants on the remaining islands are agriculturalists, but production is restricted by primitive methods of cultivation and recurrent droughts. The standards of living are gen- erally low, particularly on Santo Antdo, Sao Vicente and Sdo Tiago. Most of the islands are dependent upon the importation of foodstuffs, even during years of adequate rainfall. The greatest acreage of cultivatable land is found on Santo Antdo, Sdo Nicolau and Sido Tiago. In addition to salt, coffee and negligible amounts of castor-oil seeds, aquardente (from sugar cane), fish meal and hides are exported. Local industry is poorly developed, but there are a few small plants for the processing of fish, sugar cane and textiles. Steamer services are available between the islands and Portugal, or the Portuguese colonies on the mainland, but the schedules are usually irregular. Foop AND NUTRITION The level of nutrition among the Cap- verdians is low, as the result of widespread poverty and the scarcity of indigenous food- stuffs. Devastating famines, affecting one or more of the islands, occur at frequent in- tervals. The most serious famine within this century was experienced in 1941-43. The staple foods are maize, rice, beans, fish, goat’s milk and cheese. Fruits and vegetables are scarce and seldom accessible to the poorer inhabitants. Goats are the usual domestic animals, but sheep, pigs and 510 Cape Verde Islands poultry are also raised in some areas. How- ever, fresh meat is rarely consumed by the average individual. Undernutrition is prev- alent, but little information is available re- garding the incidence of specific deficiency diseases. Housine As elsewhere, the type of housing is gov- erned by the financial status of the family. The typical Capverdian dwellings are con- structed of stone, with thatch roofs and dirt floors. They are generally small and over- crowded, but, except during the rainy sea- son, the cooking and other work of the household is customarily carried on out- doors. ENVIRONMENT AND SANITATION WATER SUPPLIES The scarcity of water is a major problem in the Cape Verde Islands. Although sub- surface water is reported to be available on all of the islands, the present supplies barely meet the minimal requirements of the peo- ple, while during periods of drought, the shortage of water may be acute. The diffi- culty in securing water is, in part, respon- sible for the low standards of personal hygiene which prevail among the popula- tion and for the high incidence of intestinal infections. Sanitary control of community water supplies is lacking, and contamina- tion is frequent. Santo Antdo has the most abundant water supply. Water is derived from rivers and springs. A good supply is piped from spring- fed inland reservoirs to the region of Tarra- fal Bay. On Sido Vicente water is obtained from three main sources. Those who can afford it purchase spring water, which is im- ported from Santo Antdo by a private con- cern and is certified as pure. Most of the in- habitants of Mindelo are provided with an unpalatable supply of questionable purity, which is piped into the town from springs on Mt. Madeiral in the center of the island. Beach holes and shallow wells are also used along the shores of Sio Pedro Bay. The water for Sao Tiago, the most populous of the islands, is derived from springs and streams. That for the town of Praia is piped from inland springs and stored in a floating reservoir on the bay. Water is scarce on Sal, which is depend- ent upon local supplies from shallow wells, springs and rainwater tanks or on water im- ported from Santo Antdo. Shallow wells and a single spring are the sources of water sup- ply on Maio; streams and springs on Fogo, Brava and Boa Vista. Sao Nicolau has fresh water bays. Waste DisposaAL There are no sewerage systems in the Cape Verde Islands. In the towns a few houses have individual disposal facilities by which the sewage is treated chemically in underground tanks. The usual method of disposal in Mindelo (Sdo Vicente) consists in dumping the sewage at night at stipu- lated points on the edge of the bay. The burial of sewage in loose soil at the town limits is also common practice. Elsewhere in the islands, the sewage is frequently dumped directly on the surface of the ground. Fauna AND FLora Little precise information is available re- garding the vectors of disease on the islands. Anopheles gambiae is widespread and the principal vector of malaria. 4. funestus may also be present but is probably of secondary importance. A. pretoriensis is reported as responsible for the transmission of the dis- ease on Sido Nicolau. Aedes aegypti is found on all the islands. Numerous culicine mos- quitoes are present, but only Culex pipiens has been identified. The common housefly, Musca domestica, is abundant. Failure to dispose properly of human and animal wastes, together with the generally insanitary conditions in both urban and rural areas, accounts for the Cape Verde Islands 511 swarms of flies which are reported. Indi- vidual species which have been found on one or more of the islands include flies of the genera Hippobosca and Gasterophilus, Sarcophaga haemorrhoidalis, Oestrus ovis and Auchmeromyia luteola. All forms of human lice and the human flea, Pulex irritans, are common. The bur- rowing flea, Tunga penetrans, is prevalent in tropical and subtropical areas. Sarcoptes scabiei is widely distributed. Species of ticks probably exist on all the islands. Am- blyomma variegatum is known to occur on Boa Vista. Rats and other rodents are found, but re- ports concerning their numbers are con- tradictory. Specific information as to species is lacking. Foop SANITATION The local health authorities are charged with the sanitary control of meats, milk and water supplies and with the supervision of markets and other food establishments. The level of sanitation is generally low, and regulations are enforced only in the larger towns. HEALTH SERVICES AND MEDICAL FACILITIES HeArTH ORGANIZATIONS The Direccdo dos Servicos de Saude ad- ministers the public health and medical serv- ices on the islands. It is responsible to the Governor of the Colony and functions under the authority of the Servicos de Saude e Higiene of the Direc¢ido Geral de Adminis- tracdo Politica e Civil in the Ministerio das Colonias in Lisbon. Local health units, Delegacoes de Saude, are established on each of the islands except Maio. They supervise the health of the people and pro- vide medical care, directly or through sub- ordinate rural dispensaries. In Praia (Sdo Tiago) and Mindelo (Sdo Vicente) the directors of the hospitals officiate as health officers. A port physician is stationed at Sido Vicente. The doctors of the Colonial health services hold this position in rotation. The Instituto de Medicina Tropical in Lisbon maintains a permanent research mission on the islands which carries on an experimental program for the eradication of mosquitoes and co-operates in the investi- gation of various endemic diseases. MEebpICcAL INSTITUTIONS There are three government hospitals operated by the health services: one at Mindelo on Sdo Vicente with 170 beds, one at Praia on Sdo Tiago with 130 beds, and one at S. Filipe on Fogo, with 24 beds. Ma- ternity wards and child welfare clinics are connected with the two larger hospitals. Facilities for the treatment of mental and tuberculous patients are also available in the hospital at Praia. In 1947 four infir- maries were established in other population centers, and ten sanitary posts or dispen- saries in the rural areas. A government lep- rosarium with beds for 25 to 30 patients is located at Barbasco on Santo Antdo. The hospitals at Mindelo and Praia have laboratories equipped for the performance of bacteriologic and chemical examinations. PERSONNEL Sixteen physicians were connected with the Direc¢éo dos Servigos de Saude in 1950; 7 were located on Sido Tiago, and 3 on Sido Vicente. Other medical personnel included 1 medi- cal analyst, 4 pharmacists, 39 male nurses, 7 female nurses and 8 sanitary inspectors. DISEASES The unsatisfactory health conditions on the Cape Verde Islands are reflected in ab- normally high mortality rates. Disease sta- tistics which are compiled from the reports of the hospitals and other medical units are probably incomplete but give a general pic- ture of the incidence of specific diseases. The extreme poverty and undernutrition of the people, and the inadequacy of treatment 512 Cape Verde Islands facilities contribute to high fatality rates from malaria, intestinal infections, syphilis and tuberculosis, all of which are prevalent in the Colony. DiseASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid and paratyphoid fevers are endemic. The annual incidence of typhoid fever aver- aged 3.1 per 10,000 population in the period 1933-43. The rates varied on the different islands; they approximated 10.8 on Brava and 22.7 on Sal. Paratyphoid fevers are reported less fre- quently, but the known cases provide a poor index of the extent of infection. Dysenteries. Both amebic and bacillary dysentery are widespread, but their relative prevalence is not known. The incidence is particularly high in the cities of Praia (Sido Tiago) and Mindelo (Sido Vicente). In 1933-43 the annual dysentery infection rate for the Colony was 13.3 for 10,000 popula- tion, but it reached 33.2 on Brava, 53.5 on Sao Vicente and 104 on Sal. Diarrhea and enteritis are major causes of death at all ages. They are usually re- sponsible for from 30 to 40 per cent of the deaths in children under 5 years of age. The pollution of water supplies, the abundance of flies and the unhygienic habits of the people contribute to the high incidence of enteric infections. Cholera. Cholera was epidemic in 1857 but has not been reported since that date. Helminthiases. ANcyLosTom1as1s. Hook- worm infection is of recent origin on the islands. It probably was introduced on Sido Nicolau from Sao Tomé. An infection rate of 79 per cent was found among 117 individ- uals examined on that island in 1946-47.1° Both Ancylostoma duodenale and Necator americanus are encountered. OraeEr HELMINTH INFECTIONS. Ascaris lumbricoides, Enterobius vermicularis and Trichuris trichiura are common. Human infections with the pork tapeworm, Taenia solium, are sporadic. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is a major problem and ranks high among the causes of death in the Colony. Reports for 1933-43 indicate an annual infection rate of 21.8 per 10,000 population. The greatest prevalence is found on Sao Vicente, where the infection rate averaged 133.7 in the same period. There are no sanitaria for the care of tuber- culous patients, but a few cases receive treatment on a special ward in the hospital at Praia. Smallpox. Smallpox occurs in localized outbreaks. The reported cases, the majority of which are variola minor, average from 25 to 80 a year. Vaccination against small- pox is carried on in the population centers. Other Infections. Pneumonia and influ- enza are prevalent. Respiratory infections, reported as grippe, average from 2,300 to 7,100 cases annually, with fatality rates of 0.4 to 4 per cent. Measles and whooping cough are endemic and sometimes epidemic. Diphtheria is ob- served sporadically. Scarlet fever is rare, but streptococcus infections, including ery- sipelas, are relatively frequent. DiseAsES SPREAD OR CONTRACTED CurerrLy THroUGH CONTACT Venereal Diseases. Venereal diseases, and particularly syphilis, are widespread. Cases are most numerous in Praia (Sido Tiago) and in the port of Mindelo (Sido Vicente). In the latter area at least half of the native population has some form of venereal infection. No measures are under- taken by the local authorities to control the spread of these diseases. Leprosy. Leprosy exists on all of the islands except Boa Vista, Maio and Sal. The actual prevalence is not known, but a total of 209 cases was reported in the 11 years from 1933-43. Of these 80 were from Cape Verde Islands 513 Santo Antdo, 48 from Fogo, 41 from Sido Tiago and 21 from Sido Vicente. A lepro- sarium is operated by the Colonial health services at Barbasco (Santo Antdo) for the isolation and the treatment of cases. It has accommodations for from 25 to 30 lepers. Diseases of the Skin. Tropical ulcers and mycotic skin infections are common. Cases of “mossy foot” have been recorded from Sido Nicolau. Scabies and cases of in- festation with Tunga penetrans are widely distributed. Diseases of the Eyes. Trachoma is not normally endemic in the Colony, but an epidemic was reported in 1943 among the military and the civilian populations on the island of Sal. The infection subsequently spread to other islands, and a total of 426 cases was recorded. The tardy enforcement of control measures and the universally poor sanitary conditions were responsible for the spread of the condition. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is both endemic and epidemic. The incidence varies from island to island, depending upon the terrain, the amount of vegetation and climatic condi- tions. It is highest on Sdo Tiago where ex- tensive marshes provide favorable condi- tions for anopheline breeding. Transmission occurs throughout the year, with a peak of incidence from July to October or No- vember—during and immediately after the rainy season. The mean annual infection rates for the seven years 1937-43 were 1,201.8 per 10,000 population on Sido Tiago; 991.7 on Sido Vicente, 761.6 on Maio, and 614.4 on Boa Vista. On Sal and Sao Nicolau the average incidence is relatively low, but outbreaks of greater or lesser severity are frequent. On Fogo, Brava and Santo Antdo the disease is sporadic, and the infection rates average less than 20 per 10,000 popu- lation a year. Plasmodium falciparum is prevalent in all highly endemic foci. In in- vestigations conducted by members of the staff of the Instituto de Medicina Tropical (Lisbon) from November, 1946, to January, 1947.2 P. vivax was found to be the pre- dominating species on Sal and Sao Nicolau, and P. malariae on Boa Vista. Blackwater fever is reported from Sao Tiago but rarely from the other islands. Filariasis. Wuchereria bancrofti infec- tions occur on Sao Tiago and probably on most of the other islands. Elephantiasis is not uncommon. Culex pipiens and Anoph- eles gambiae, both potential vectors, are widespread. Other Infections. Yellow fever has not been reported from the archipelago since 1873, when an outbreak involving 300 cases was recorded from Sal. The fatality rate averaged 5.1 per cent. The infection was introduced from Brazil. The disease was also epidemic during the nineteenth cen- tury in Praia (Sdo Tiago) and on Boa Vista. Aedes aegypti is abundant, and the prox- imity of the islands to mainland areas where the infection is endemic makes the intro- duction of the disease by infected persons or mosquitoes a potential hazard. Passen- gers from endemic ports are required to dis- embark at Praia while the vessels are sub- ject to quarantine. Plague has not been reported within re- cent years. NuTrITIONAL DISEASES Deficiency diseases are common. Extreme poverty is general, and famines occur from time to time. Detailed information regard- ing the more frequent manifestations of malnutrition is lacking, but all reports em- phasize the low dietary standards of the people and their adverse effect on the mor- tality rates. Beriberi is said to be the most prevalent deficiency disease. SUMMARY The Cape Verde archipelago is a Portu- guese colony of 10 inhabited islands and several small islets. The islands vary in physiographic features, but on all of them the standards of living of the inhabitants 514 Cape Verde Islands are relatively low, and the mortality rates high. Water supplies are generally scarce, except in a few well-watered areas. Supplies are most frequently obtained from streams, springs or rainwater tanks and are subject to pollution. Sanitation is primitive. The Direccdo dos Servicos de Saude is re- sponsible for the public health in the Col- ony. It functions under the Servicos de Satde e Higiene in the Ministerio das Colonias in Lisbon. The Direccdo operates hospitals at Praia on Sdo Tiago, at Mindelo on Sdo Vicente and at S. Filipe on Fogo, with an aggregate capacity of 324 beds. Health bureaus or rural dispensaries are established on each of the islands. Malaria, tuberculosis, intestinal infec- tions, venereal diseases, pneumonia and various skin conditions are prevalent but vary in incidence on the different islands. Leprosy is endemic on all but three. Fila- riasis is common on Sdo Tiago and prob- ably on other islands. Smallpox occurs in sporadic outbreaks. Whooping cough and measles are frequently epidemic. Plague has not been reported within recent years, nor yellow fever and cholera within the present century. BIBLIOGRAPHY 1. Cabo Verde, Colénia de. Servicos de Estatis- tica: Anuario estatistico, 1941, Imprensa Nacional de Cabo Verde, Praia, 1944. 2. : Anuério estatistico, 1942, Im- prensa Nacional de Cabo Verde, Praia, 1944. 3. : Anudrio estatistico, 1943, Im- prensa Nacional de Cabo Verde, Praia, 1945. 4. ——. ——: Anuario estatistico, 1944, Im- prensa Nacional de Cabo Verde, Praia, 1945. 3, : Anudrio estatistico, 1945, Im- prensa Nacional de Cabo Verde, Praia, 1946. ‘ 6. Cape Verde Islands: Boletim Oficial de Governo da Colonia de Cabo Verde, No. 28 (Sept. 20) 1941. 7. Firmino Sant’anna, José: Demografia e noso- necrologia do arquipélago de Cabo Verde, An. Inst. med. trop. Suppl. to 5:1-387 (Sept.) 1949. 8 Lengyel, Emil: Dakar, Outpost of Two Hemispheres, New York, Random House, 1941. 9. Lyall, Archibald: Black and White Make Brown, London, Heinemann, 1938. 10. de Meira, Manuel T. V., Pinto Nogueira, J. F., and Serras Simées, T.: Contribui¢iao para o estudo do parasitismo intestinal nas Ilhas do Sal, Boa Vista e S. Nicolau (Cabo Verde), An. Inst. med. trop. 4:239-255 (Dec.) 1947. 11. ——, Serras Simdes, T., and Pinto Nogueira, J. F.: Observagoes sobre a fauna ento- mologica das Ilhas do Sal, Boa Vista e S. Nicolau (Cabo Verde), An. Inst. med. trop. 4:257-267 (Dec.) 1947. 12. , ——, and ——: Observagdes sobre sezonismo nas Ilhas do Sal, Boa Vista e S. Nicolau (Cabo Verde), An. Inst. med. trop. 4:213-238 (Dec.) 1947. 13. Portugal: Instituto Nacional de Estatistica. Anuério estatistico do império colonial, 1946, Lisboa, Tipografia Portuguesa, Lda., 1947. 14. ——: Colénia de Cabo Verde. Orcamento geral para 0 ano econémico de 1950, Cabo Verde Imprensa Nacional, 1950. SECTION EIGHT Northern Africa 33. 39. 40. 41. 42. 43. 44. 45. CANARY IsLANDS SPANISH SAHARA AND IFNTI . Morocco . Spanisa Morocco TANGIER . ALGERIA TuNisIA LiBva . +517 +:528 .%530 . 548 +556 .- 558 . 1573 . 1595 DIU U4IY140 NI A OIE Sat NS. 2 Yauhuogsuoy SVE ° 34g, 1 / 4542161y 38 Canary Islands GEOGRAPHY AND CLIMATE The Canary Islands, located about 60 miles off the coast of Southern Morocco, comprise 7 islands and several uninhabited islets, with a total area of about 2,890 square miles. They are politically part of Spain and constitute two provinces: Santa Cruz de Tenerife, which incorporates the western islands of Tenerife, La Palma, Gomera and Hierro, and Las Palmas, which includes the eastern islands of Gran Canaria, Lanzarote and Fuerteventura. Gran Ca- naria and the western islands are moun- tainous, with peaks rising to 7,746 feet on La Palma and to 12,162 feet on Tenerife. They are generally rugged, with precipitous cliffs bordering fertile valleys and verdant slopes. In contrast, the islands of Lanzarote and Fuerteventura are sandy and arid, resembling the adjacent mainland. The Canary Islands are volcanic in origin, and disturbances are experienced at irregular intervals. The most recent eruption oc- curred on La Palma in 1949. Santa Cruz de ZF E_ = = Lgl = * Palmas _ C.Yubi 4 Gy The infections were sporadic; only 76 out of a total of 1,579 cases were attributed to localized outbreaks. They were also predominantly urban, a factor which is influenced by the overcrowded living condi- tions in and around the larger cities. Sub- ject to inequalities of reporting, the ratio Morocco 539 of urban to rural cases was five to one. The highest incidence was recorded from the city and the province of Casablanca. The infec- tion rates among the different races in that area were about 30 per 10,000 for the Euro- peans, 9 per 10,000 for the Israelites, and 1 per 10,000 for the Moslems, who undoubt- edly acquire a high degree of immunity as the result of repeated exposure. Immuniza- tion with antityphoid-paratyphoid vaccine is encouraged by the government health authorities. Localized outbreaks, caused by Salmo- nella suipestifer, occurred among the in- habitants of the upper Sebou Valley in 1931 and in Meknés in 1943. Dysenteries. Both amebic and bacillary dysentery are widespread. From 15,000 to 50,000 cases of amebic dysentery and from 300 to 5,200 cases of bacillary dysentery are reported each year. The incidence in the interior exceeds that of the coastal region, with a predominance of cases in the northern districts and especially in the Mekneés-Fés area. The peak occurs in October and No- vember, with an apparent minimum of cases between February and April. The fatality rates approach 8 per cent among the Mos- lem populations in urban communities. Considerable confusion is associated with the differentiation of bacillary and amebic infections. Diagnosis is made most fre- quently on the basis of clinical findings, and many physicians tend to attribute all cases of dysentery to amebic infection. Diarrhea and enteritis are prevalent, and a large pro- portion of the cases probably are unrecog- nized Shigella infections. Cholera. Cholera has not been reported within the present century, but epidemics were recorded in 1848-55 and in 1868. Pre- cautionary measures against the introduc- tion of the disease include the immunization against cholera of all pilgrims to Mecca. Helminthiases. ScuHisTosoMm1asis. Schis- tosomiasis, caused by Schistosoma haema- tobium, is prevalent in numerous scattered foci, primarily in the Sous Valley and along the slow-flowing, seasonal oweds of the Schistosomiasis in Morocco southeast, particularly the Dra and the Ziz. Isolated foci also exist in the vicinity of Marrakech, Fés and Quezzane. The infec- tion rates are generally high, but the dis- ease itself tends to be benign. Different observers have demonstrated rates ranging from 5 to 100 per cent in the villages in the Dra, Tafilalet and Bani areas, around 82 per cent near Souk el Arba du Gharb, and from 10 to 86 per cent in the Sous region. Fluctuations in incidence, charac- terized by recurrent outbreaks in areas of normally low endemicity, are suggested by investigations undertaken in four foci in 1940-44 1* The intermediate snail host, Buli- nus truncatus, is widely distributed, and the existence of unidentified centers of infection is probable. No indigenous cases of S. man- soni infection have been reported. Ancyrostomiasis. Hookworm infection is relatively rare. A focus of Ancylostoma duodenale has been established in the phos- phate mines at Khouribga, where the envi- ronmental conditions are unusually favor- able for the development of the larvae. A survey in 1938% showed infection rates of 40.5 per cent and 68.9 per cent in two sepa- rate areas. The institution of control meas- ures resulted in a reduction in incidence; only 0.2 per cent of the workers were found to be infected in 1945. OtuerR HELMINTH INFECTIONS. Ascariasis is widespread, especially among young chil- dren. In a survey of 391 Mohammedan school children in the vicinity of Fes, re- 540 Morocco ported in 19437 from 60 to 75 per cent were found to be infected with Ascaris lum- bricoides, from 40 to 50 per cent with Trichuris trichiura, 1 per cent with Taenia saginata and 2 per cent with Hymenolepis nana. Hydatid disease, caused by Echino- coccus granulosus, is common. Human in- fections with Fasciola hepatica are observed occasionally. Brucellosis. A few sporadic cases of undulant fever are recorded each year. The - disease is enzootic among the goats and the cattle of the country, and human infections with Brucella melitensis and B. abortus are undoubtedly more numerous than the known cases would seem to indicate. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is known to be prevalent, but the actual distribution of the disease has not been determined. In the decade 1938-47 from 6,700 to 12,000 cases were reported annually from all parts of the country. In 1942-47 the specific death rates per 100,000 population in the urban areas averaged 222 for the Moslems, 130 for the Jews and 59 for the Europeans. Mortality statistics for the Moslem populations are misleading, since a considerable number of cases die from intercurrent acute infections. Pulmonary tuberculosis usually predomi- nates, but glandular and other forms are prominent in certain areas, notably Mar- rakech, Meknés and Mogador. Tuberculin test studies in individual cities indicate a relatively high degree of infec- tion in childhood. In 1945 the examination of 1,431 individuals in Fés revealed 16 per cent positive reactors in the group from one month to one year of age; 27 per cent at from 1 to 3 years; 47 per cent at from 3 to 5 years and 51 per cent at from 5 to 10 years.** Similar tests in 976 children under 10 years of age in Casablanca in 194443 showed 47 per cent positive reac- tors among the Moslems, 39 per cent among the Jews, and 31 per cent among the Euro- peans. An active tuberculosis-control program is carried on by the Direction de la Santé Publique et de la Famille. Special dispen- saries are operated through the tuberculosis service of the Institut d’Hygiéne in Casa- blanca, Rabat, Marrakech, Meknés, Moga- dor and Feés. Treatment facilities are avail- able in the larger hospitals and in the sanatorium at Azrou. In 1948 a large-scale survey and immuni- zation program was initiated under the auspices of the United Nations Interna- tional Children’s Emergency Fund organi- zation. The project included the immuniza- tion with BCG vaccine of all individuals giving negative reactions to tuberculin in three groups: children and adolescents under 20 years of age in the cities and the important rural communities; children in mining and industrial areas; and the semi- nomadic population of southern Morocco. It was expected that approximately 3 mil- lion persons would come within the scope of the program. ‘Bovine tuberculosis is enzootic among the dairy cattle. It is more prevalent among the imported breeds than among the do- mestic stock. Smallpox. Epidemics of smallpox occur at irregular intervals, with sporadic cases in the intervening periods. Outbreaks were re- corded in 1927, 1932, 1941-43 and 1945-46, in which the aggregate known cases ranged from 1,500 to 2,700 a year. In the latter years localized epidemics were reported from widely scattered foci, predominantly in the rural districts. The fatality rates varied from 2 to 6 per cent in individual outbreaks. Widespread vaccination is under- taken, but the nomadic character of a large segment of the population complicates the problems of control in both urban and rural areas. Smallpox vaccine is prepared at the Institut Pasteur in Casablanca for use throughout the country. Other Infections. Measles is frequently epidemic. Serious complications are common and contribute to the high infant mortality. Diphtheria is endemic, an average of from Morocco 541 200 to 350 cases being recorded each year. A large proportion of the cases is usually reported from the coastal cities, especially Casablanca and Rabat. All races are af- fected, but the known cases are always more numerous among the Europeans than among the Jews or the Moslems. From 30 to 70 cases of scarlet fever are reported annually, chiefly from the cities and predominantly among the Europeans. Meningococcus men- ingitis, poliomyelitis and encephalitis occur sporadically. Pneumonia is prevalent, par- ticularly on the plateaus where the tradi- tional habitations provide inadequate pro- tection against storms and daily fluctuations in temperature. Diseases SPREAD OR CONTRACTED CuIerLy TurouGcH CONTACT Venereal Diseases. Syphilis and gonor- rhea are widespread. Chancroid and lym- phogranuloma venereum are also common. The real incidence of venereal infections is not known, but in general they represent from 18 to 20 per cent of the total hospital and dispensary admissions, and from 27 to 30 per cent of the cases treated by the rural mobile units of the Direction de la Santé Publique et de la Famille. In many areas the infection rates average 13 per cent among the European populations and 45 per cent, or more, among the Moslem. A large proportion of the infants seen in some child health centers suffer from congenital syph- ilis. Special venereal disease clinics are located in Casablanca, Rabat, Mekneés, Fes, Oujda and Marrakech, in which the number of cases treated for syphilis annually fluc- tuates between 15,000 and 20,000. The surveillance of professional prostitutes is undertaken by the Bureaux d’Hygiéne. Diseases of the Eyes. Trachoma is one of the principal public health problems of French Morocco. The reported cases, which in 1943-47 averaged approximately 72,600 a year, probably represent a small part of the actual incidence. Most infections are acquired in early childhood. All manifesta- tions of the disease are encountered, in- cluding a high percentage of blindness. On the basis of a survey of representative re- gions in 1948* the trachoma infection index was estimated at from 0 to 25 per cent in the coastal area, from 25 to 40 per cent in the interior and from 60 to 100 per cent in the semiarid regions in the south. Marrakech is a major focus. Rates of from 75 to 100 per cent were found among the children in the Moslem schools and of from 64 to 81 per cent in the Jewish schools. In Casablanca the rates range from 6 per cent to 25 per cent, depending upon the social environment of the students. Purulent conjunctivitis is prevalent, par- ticularly in the late summer and the early autumn. Hemophilus conjunctivitidis and H. lacunatus are said to be responsible for the majority of cases, but from 8 to 10 per cent are normally of gonococcal origin. The wide distribution and the severity of eye infections are indicative of the low stand- ards of hygiene prevailing throughout the country. The severe irritation caused by the sirocco winds, and the abundance of flies which swarm on the eyelids of the children are factors conducive to the spread of these conditions. Special ophthalmologic centers are op- erated by the government health services in 8 of the larger cities. Mobile surgical units also conduct treatment clinics in the schools at regular intervals. Leprosy. Only fragmentary evidence is available regarding the extent of leprosy in Morocco. Several endemic centers are known to exist, the most prominent being the districts between Fés and the Spanish frontier and the region inhabited by the Doukkala tribe to the west of Marrakech. In 1937-41 an average of 365 cases was re- ported annually; in 1942, 155 cases. A large proportion of the recorded cases are from the Feés-Taza region. Diseases of the Skin. Favus and ring- worm infections are prominent in all parts of the country. Phagedenic ulcers are fre- quent, and cases of Madura foot are encoun- tered occasionally. Rare cases of sporo- 542 Morocco trichosis have been recorded. Scabies is widespread. Other Infections. Canine rabies is en- zootic, and human infections frequently occur. Between 600 and 1,500 persons, both Europeans and natives, are treated each year at the Institut Pasteur in Casablanca. Dog bites are responsible for the majority of cases, but cats, asses, camels, rats and other animals, as well as man, are impli- cated in a small percentage. Antirabic vac- cine, prepared at the Institut by Pasteur’s or Fermi’s method, is employed in treat- ment. From 20 to 110 deaths from tetanus are recorded each year among all racial groups in the urban centers. Reporting is not oblig- atory, and the prevalence in the rural areas is not known. The incidence of tetanus neo- natorum is apparently high among certain sections of the Moslem population. Anthrax is sometimes epizootic among the sheep and the goats. Occasional human cases result from contact with infected ani- mals. Leptospirosis is reported occasionally. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is widely distributed throughout Morocco, and indigenous cases may be found at elevations up to 6,000 feet. The most seriously affected areas are the wide marshy basin of the lower Sebou and the valleys of its major tributaries, and the oases of the southeastern desert. Malaria is also highly endemic on the coastal plain and in the agricultural regions on the western slopes of the Moyen Atlas chain. Localized epidemics are frequent, the regional vari- ations in incidence being correlated with the amount of the late winter and the early spring rainfall. Within recent years the re- ported cases, which provide a rough index of the extent of infection, have ranged be- tween 162,000 in 1944 and 1945 and 325,000 in 1947. Spleen rates of from 20 to 30 per cent are common, both along the coast and in the interior, while in epidemic years, they reach from 50 to 60 per cent in many vil- lages. The fatality rates are particularly high among infants and young children. The peak of incidence fluctuates with local climatic conditions in the different areas. Regional epidemics may be experienced from March to November, but the maxi- mum cases for the country, as a whole, usually are recorded between August and October. Plasmodium falciparum and P. vivax are encountered in varying proportions through- out the year. P. falciparum is the dominant species under epidemic conditions. The sea- sonal curve of P. vivax infections usually reaches its height in August or September ; that of P. falciparum, one or two months later. P. malariae is present, but little infor- mation is available regarding its relative distribution. Infections are most frequent in the late winter months and are of negligible importance in the summer. Anopheles la- branchiae labranchiae is the principal vec- tor in northern Morocco, but A. sergenti and A. multicolor may be significant vectors in the south and the southeast. A malaria-control program is conducted under the direction of the Service Anti- paludique of the Institut d’Hygiene, which incorporates treatment of the population with antimalarial drugs and anopheline control measures. Mass prophylaxis is car- ried on from June to October in many of the major endemic centers. Measures for the control of the anopheline vectors are restricted largely to the cities and to peri- urban and rural areas in close proximity to European communities. Rickettsial Infections. Louse-borne typhus fever is continuously present and reaches epidemic proportions at irregular intervals, usually coincident with periods of drought or social stress. Within the last few decades severe epidemics have occurred in 1927-28, in 1937-39 and in the wartime years of 1942-46. In the recent outbreak the multiplication of contacts and the shortage of clothing, soap and insecticides created conditions which fostered the spread of the infection among the habitually louse- infested populations. In 1942 alone the re- Morocco 543 ported cases totaled almost 29,000. The incidence declined gradually to about 3,000 cases in 1944 but, due to a recrudescence in the southern districts, rose again to 8,200 cases in 1945. In 1947 a low level of 126 cases was attained, the smallest number ever recorded in the Protectorate. Typhus is endemic in all parts of the country. It attacks all population groups, both sedentary and nomadic, but reaches its greatest intensity in the overcrowded urban centers. Casablanca, Rabat, Fes, Mekneés and Marrakech are major epidemic foci. The peak of incidence usually falls between March and July, with occasional minor recrudescences from September to November. The infection varies in severity in different outbreaks. The fatality rates average from 10 to 20 per cent among the Moslems and the Jews and from 20 to 30 per cent among the Europeans. Typhus-control measures instituted by the Moroccan health authorities include the enforced isolation of cases and contacts, the deverminization of individuals and dwell- ings in the affected districts, and the im- munization of the exposed populations. Delousing stations are established along the major traffic routes, while mobile units op- erate in the infected areas. Antityphus vac- cines, prepared at the Institut Pasteur in Casablanca, are used extensively by the French authorities. The precipitous reduc- tion in incidence in 1947 was attributed to the systematic use of DDT powders. Fiévre boutonneuse is relatively common during the summer months and is usually transmitted by the dog tick, Rkipicephalus sanguineus. The known cases occur chiefly among the European communities. Murine typhus is reported sporadically from widely scattered localities. The infection has been demonstrated in rats in Casablanca and in other port cities. Cases of “Q” fever have been encountered in the Goulimine area of southern Morocco, and in the vicinity of Casablanca. The gerbil, Meriones shawi, is regarded as an important reservoir of infec- tion in the southern foci, by the workers of the Institut Pasteur in Casablanca. Several species of ticks of the genus Hyalomma are potential vectors. Plague. Plague has been endemic in Morocco since its reappearance in 1909, following a lapse of almost a century. The major foci are associated with the port cities, especially Casablanca and Rabat, but localized epidemics also occur in the urban centers of the interior and in the rural dis- tricts. In general, the regions south of the Atlas ranges remain relatively free from infection. No cases were reported in 1935-39, but, beginning in 1940, outbreaks were ex- perienced in several areas, with an aggre- gate of 1,099 known cases in 1940 and 2,337 in 1941. In the three subsequent years the annual incidence declined to from 200 to 580 cases, but in 1945 a major epidemic de- veloped in the Casablanca region, with an aggregate of 828 cases in scattered foci. The fatality rates averaged 70 per cent among the Moslems and 50 per cent among the Europeans. The outbreak was suppressed promptly, and no further cases were re- corded from 1946 through 1948. Rattus norvegicus and R. rattus rattus are the recognized reservoirs of plague in the port cities, with Xenopsylla cheopis the principal vector. The human flea, Pulex irritans, has also been implicated in the transmission of the infection from man to man. The presence of foci of sylvatic plague has not been established, but the frequent occurrence of rural outbreaks suggests their existence. An active rat-control program is carried on in the major ports by the Service de la Santé Maritime. Measures employed in the event of an outbreak include the isolation of cases, the rigorous disinsectization of con- tacts and dwellings, rodent extermination and the immunization of the population. Relapsing Fever. Up to 1945 no serious outbreaks of louse-borne relapsing fever had been reported from the Protectorate. Minor epidemics occurred prior to 1917, but in the subsequent period the infection remained relatively quiescent. An epidemic which 544 Morocco swept across North Africa in 1943-46 reached Oujda, near the Algerian border, in January, 1945. It spread rapidly south and west, attained its maximum level in the fall and the early winter of 1945-46 and died out in August, 1946. Major foci of infection were established in Oujda, Fes, Meknés, Rabat, Casablanca and Marrakech. In general, the epidemic followed a uniform pattern in the different regions. The out- breaks originated in the urban centers, with the development of secondary foci in the surrounding areas, and faded out after from 5 to 6 months’ duration. All races were affected, but the cases among the European populations did not exceed 1 per cent of the total. The fatality rates ranged from 2 to 10 per cent, being highest in Fés and Marrakech. Approximately 43,900 cases were reported, a figure probably much less than the actual number. Overcrowding, poverty and vermin infestation, aggravated by the war conditions, facilitated the rapid extension of the infection, while the poor nutrition of the people, intensified by suc- cessive years of mediocre harvests, was re- sponsible for the high mortality. Isolation of cases and disinfestation of the popula- tion were undertaken by the health author- ities. The systematic use of DDT powder proved to be effective in suppressing the individual foci. Tick-borne relapsing fever, caused by Borrelia hispanica marocanum, occurs in the northern provinces as far south as Mar- rakech. It is transmitted by Ornithodorus erraticus. The exact distribution of this in- fection has not been determined, but spo- radic cases are reported annually. Cases of relapsing fever, caused by Borrelia duttoni and transmitted by O. erraticus, are encoun- tered occasionally in the south. Leishmaniasis. Kala-azar is rare, but sporadic cases have been recorded in the vicinity of Fes and Marrakech and from the southwestern Atlas region. The infection is observed most frequently among children and only occasionally in adults. The dis- tribution of canine leishmaniasis is un- known, but infected animals have been found in Casablanca and in Fes. Cutaneous leishmaniasis, or oriental sore, is endemic over a wide area from the south- ern oases to Fes. Other Infections. Yellow fever has not been reported from French Morocco within recent years. The vector, Aedes aegypti, is prevalent in the region from the coast to the mountains, and precautions against the introduction of the infection by means of air traffic are enforced by the Moroccan health authorities. No mouse protection test surveys to determine the presence of the virus have been made. Dengue fever is endemic, but major out- breaks have not been recorded. Rare cases of filariasis, due to Wuchereria bancrofti, have been reported. Occasional cases of ele- phantiasis are encountered, but their origin has not been determined. NUTRITIONAL DISEASES Undernutrition is widespread, but specific deficiency diseases are not common under normal conditions. From 1940 to 1947 the nutritional status of the population de- clined, however, as the result of the export of foodstuffs to occupied France, the in- creased poverty and the near-famine con- ditions arising from successive years of drought and poor harvests. Vitamin A and C deficiencies are general and have increased within recent years. Scurvy and rickets are observed in many areas. Pellagra and nutri- tional edema are encountered periodically in the southwestern oases. As in Algeria and Tunisia the percentage of fluorides in the natural waters is exces- sively high in the regions containing large phosphate deposits. Cases of mottled enamel and exostoses are frequent among the in- habitants of these areas. Goiter occurs among the natives of certain villages in the Grand Atlas and the Anti-Atlas mountains. MisceLLaNEOUS CONDITIONS Infectious hepatitis is reported occasion- ally. Lead poisoning is common among the Morocco 545 workers in the lead mines and smelting works. Drug addiction is prevalent. The drug most widely used is hashish (Cannabis indica). SUMMARY Morocco is a French protectorate in which sovereignty is divided between the Resident- General, the representative of the French Republic, and the Sultan, the head of the Sherifian monarchy. The Protectorate gov- ernment functions under the Ministére des Affaires Etrangéres in Paris. Responsibility for the public health and for the medical care of the population is concentrated in its Direction de la Santé Publique et de la Famille, with headquarters in Rabat. The department is organized on a regional basis, with urban and rural divisions. Bureaux d’Hygiéne are established in each of the 18 cities constituted as municipalities. The Institut d’Hygiéne at Rabat is the technical arm of the Direction, while the Institut Pasteur at Casablanca functions in close co- operation with it. The hospitals are op- erated or controlled by the government health services. In 1949 there were: 25 hos- pitals, ranging in size from 80 to 560 beds; 74 regional infirmaries with 12 to 50 beds each; 25 special dispensaries ; and 207 rural clinic centers. The capacity of the urban and the rural hospitals totaled 1,495 beds for Europeans and 5,008 beds for Moroc- cans. The largest hospitals, European and Moroccan, are established in Casablanca. A few small hospitals are conducted by private physicians in the European com- munities. Water supplies are obtained from streams, springs, wells, rainwater cisterns and sub- terranean galleries. Potable supplies are relatively scarce in many areas. Most of the municipal water supplies are treated by chlorination, but the degree of supervision and of treatment varies in different com- munities. Simple sewerage systems serve all or part of the larger cities. In general, how- ever, the methods of sewage disposal are primitive in other sections of the country. The majority of the people live in over- crowded, insanitary environments favorable to the spread of intestinal, respiratory and contact infections. Undernutrition is com- mon, and nutritional deficiency conditions have increased within recent years. Malaria, trachoma, tuberculosis, venereal diseases, typhoid fever, dysentery, intestinal helminthiasis and various skin infections are prevalent. Louse-borne typhus fever and louse-borne relapsing fever occur in devas- tating epidemics. Plague, smallpox and measles are epidemic at irregular intervals. Numerous widely scattered foci of Schisto- soma haematobium infection are found. Leprosy is endemic in two small centers in the north, and oriental sore in the regions between the southern oases and Fes. Rabies, fievre boutonneuse, diphtheria and tick- borne relapsing fever are endemic. Scarlet fever, poliomyelitis, meningococcus menin- gitis, murine typhus and kala-azar are spo- radic. Yellow fever has not been reported within recent years. BIBLIOGRAPHY 1. Barnéoud, J.: La bilharziose vésicale dans le sud marocain. Arch. Inst. Pasteur d’Algérie 9:476-479 (Sept.) 1931. : Note sur I'endémie lépreuse dans la région de Marrakech, Internat. J. Leprosy 3:327-331, 1935. 3. Becmeur, A.: Situation de l'ankylostomiase de centre minier de Khouribga en 1945, Bull. Inst. d’hyg. du Maroc 5:75-83, 1945. 4. Blanc, Georges, and Baltazard, Marcel: La vaccination contre le typhus exanthe- matique par virus vivant. Son applica- tion au Maroc. Rev. d’hyg. et de méd. prév. 61:593-610, 1939-40; Abst. Trop. Dis. Bull. 37:580-581 (August) 1940. , Martin, L. A., and Maurice, A.: Le mérion (Mériones shawi) de la région de Goulimine est un réservoir de virus de la Q. fever marocaine, C. R. Acad. Sci. L, Paris 224:1673-1674 (June 9) 1947; Abst. Trop. Dis. Bull. 44:898-899 (Oct.) 1947. 6. Carrosse and Barnéoud: Enquéte sur la bilharziose vésicale & Marrakech (Schisto- 3. 546 Morocco 10. 11 12. 13. 14. 15. 16. 3. 18. 19. 20. 21. 22. 23. soma haematobium), Arch. Inst. Pasteur d’Algérie 7:51-78 (Mar.) 1929. Célérier, Jean: Le Maroc, Paris, Colin, 1931. Chevaliér, Louis: Le probleme démographi- que nord-africain, Institute National d’Etudes Démographiques, Paris, Presses Universitaires de France, 1947. Colombani, M.: L’'importance respective du rat et de la puce de 'homme dans les epidémies de peste au Maroc, Bull. Soc. path. exot. 26:562-566 (Apr. 5) 1935. Delanoe, E.: Trente années d’activité médi- cale et sociale au Maroc, Paris, Maloine, 1949. Delanoe, P.: L’importance de la puce de homme, Pulex irritans L., dans les épi- démies de peste au Maroc, Bull. Soc. path. exot. 25:958-960 (Nov. 9) 1932. Desportes, C.: Recherches sur la bilharziose vésicale au Maroc, Thesis, Paris, 1936. Gaud, J.: Fréquence au Maroc et role vec- teur possible d’Anopheles sergenti, Theo., Bull. Soc. path. exot. 41:498-501 (7/8) 1948. ——, Fauré, and Solé: Variations dans le temps des index d’infestation humaine dans la bilharziose vésicale marocaine, Bull. Inst. hyg. du Maroc 6:55-60, 1946. , and Maurice, A.: Foyers de bilharziose vésicale dans le Sous, Bull. Inst. hyg. du Maroc 6:61-62, 1946. , Méchali, D., and Clier, J. L.: Emploi et avénir des insectides de contact au Maroc dans la prophylaxie des maladies épidémiques, Bull. Inst. hyg. du Maroc 8:35-89, 1948. , Salm, G., and Fassi, F.: Parasitisme intestinal chez les écoliers de Fes, Bull. Inst. hyg. du Maroc 3:87-113, 1943. Gaud, M.: L’alimentation indigéne au Maroc, Rabat, Forin-Moullot, 1933; Extrait du Bull. Inst. d’hyg. du Maroc, No. 1-2, 5-64, 1933. ——: La leishmaniose viscérale au Maroc, Bull. office internat. d’hyg. Pub. 27:533- 535 (Mar.) 1935, ——, and Charnot, A.: Note sur le “Dar- mous” fluorose chronique des zones phos- phatées, Bull. Office internat. d’hyg. pub. 30:1280-1293 (June) 1938. ——, Khalil Bey, Mohammed, and Vau- cel, M.: The evolution of the epidemic of relapsing fever, 1942-1946, Bull. W.H.O. 1:93-101, 1947-1948. ——, and Morgan, M. T.: Epidemiological study of relapsing fever in North Africa, 1943-45, Bull. W.H.O. 1:69-92, 1947- 1948. ——, and Sicault, G.: L’habitat indigéne au 24, 28. 26. 2% 28. 29. 30. 31. 33. 34. 33. 36. 37. 38. 39. 40. Maroc, Rabat, Editions F. Moncho, 1937; Extrait du Bull. Inst. d’hyg. du Maroc 4:5-102, 1937. Goulven, J.: Le Maroc, Paris, Emile Larose, 19109. Hardy, Georges, and Célérier, Jean: Les grandes lignes de la géographie du Maroc, Paris, Emile Larose, 1922. Jude, A., and Le Minor, L.: Fréquence de certain types de Salmonella (bacilles typho-paratyphoidiques) au Maroc et en Algérie, en milieu vaccine, Bull. Soc. path. exot. 41:124-129 (3-4) 1948. Liebesny, Herbert J.: The Government of French North Africa, African Handbook No. 1, Philadelphia, Univ. Penn. Press, 1943. La lutte antipaludique au Maroc en 1947: Bull. Inst. d’hyg. du Maroc 7:119-124, 1947. Maroc Médical: Numéro spécial consacré a la santé publique au Maroc, No. 296 (Jan.) 1950. Maroc. Direction de la Santé Publique de la Famille au Maroc: Statistiques médicales annuelles, Année 1948, Rabat, Fortin- Moullot, 1949. Melnotte, P.: Les affections typhoides au Maroc. Statistiques générales et épidémio- logie, Bull. Soc. path. exot. 25:447-460 (May 11) 1932. . ——: Contributions a l'étude de la patho- logie intestinale du Maroc, Bull. Soc. path. exot. 21:440-452 (June 13) 1928. Messerlin, A.: Epidémiologie de paludisme au Maroc, Maroc médical 233:54-57 (Mar.) 1943. ——: La lutte antipaludique au Maroc en 1941, Bull. Inst. d’hyg. du Maroc 1:1-14, 1941. , and Couzi, G.: Epidémie infantile grave a Salmonella suipestifer, Bull. Inst. hyg. du Maroc 2:15-33, 1942. Nain, M.: Note sur les indices d’endémicité de deux foyers de bilharziose vésicale marocaine, Bull. Soc. path. exot. 30:237 (Mar. 10) 1937. Pouhin: Bilharziose vésiculaire dans la Vallée du Draa, Maroc médical 201:96- 105 (March) 1939. Rapport annuel de Service Antipaludique en 1945: Bull. Inst. d’hyg. du Maroc 5:85-95, 1945. Rapport sur lactivité des Services de la Direction de la Santé et de I'Hygiene Publiques pendant l'année 1940: Bull. Inst. d’hyg. du Maroc 10:77-111, 1940. Rapport sur lactivité des Services de la Direction de la Santé Publique et de Morocco 547 41. 42. 43. 44. 45. 46. I’Assistance pendant l'année 1941: Bull. Inst. d’hyg. du Maroc 1:1-53, 1941. Rapport sur lactivité des Services de la Direction de la Santé, de la Famille et de la Jeunesse pendant l'année 1942: Bull. Inst. d’hyg. du Maroc 2:93-142, 1942. Rapport sur lactivité des Services de la Direction de la Santé Publique et de la Famille pendant I’année 1943: Bull: Inst. d’hyg. du Maroc 3:123-187, 1943. Rapport sur lactivité des Services de la Direction de la Santé Publique et de la Famille pendant l'année 1944: Bull. Inst. d’hyg. du Maroc 4:115-191, 1944. Rapport sur lactivité des Services de la Direction de la Santé Publique de la Famille pendant I'année 1945: Bull. Inst. d’hyg. du Maroc 5:98-190, 1945. Rapport sur lactivité des Services de la Direction de la Santé Publique de la Famille pendant l'année 1946: Bull. Inst. d’hyg. du Maroc 6:121-183, 1946. Rapport sur lactivité des Services de la 47. 48. 49. 50. i 52. 53. Direction de la Santé Publique de la Famille pendant année 1947: Bull. Inst. d’hyg. du Maroc 7:133-194, 1947. Rodier, J.: Etude du saturnisme dans les mines de plomb marocaines, Arch. mal. profess. 9:539-545 (No. 6) 1948. Sainte Marie, P. E. Flye: La léepre au Maroc. Revue générale, Internat. J. Leprosy 3: 315-326 (July-Sept.) 1935. Sicault, G.: Epidémiologie de la variole au Maroc, Bull. Inst. d’hyg. du Maroc 2:5-15, 1943. Stuart, G.: Relapsing fever in North Africa and Europe, 1943-45, Epidemiol. Inform. Bull. 1:453-464 (July) 1945. Terrier, Auguste: Le Maroc, Paris, Larousse, 1931. Vachon, Max: Etudes sur les scorpions, Arch. Inst. Pasteur d’Algérie 28:152-216 (June) 1950. Violatte, Ch.: La bilharziose vésicale au Maroc. Le foyer d’Erfoud, Arch. Inst. Pasteur d’Algérie 10:157-158 (June) 1932. 41 Spanish Morocco GEOGRAPHY AND CLIMATE Spanish Morocco constitutes that part of the former Sherifian Empire which has been administered by Spain since the partition of the territory by the Franco-Spanish Con- vention of 1912. The Sultan, who is the nominal civil and religious head of the Sherifian monarchy, is represented in the Spanish zone by a Khalifa, while the au- thority of the Spanish government resides in a High Commissioner, responsible to the Direcciéon General de Marruecos y Colonias in Madrid. In addition to the Protectorate territory there are 5 presidios, old Mediter- ranean garrison towns which have been con- trolled by Spain more or less continuously since the sixteenth century. Politically, they are regarded as part of Spain and do not come under the jurisdiction of the Khalifa. The most important are the cities of Melilla and Ceuta. The Spanish zone of Morocco consists of a narrow semicircular strip of mountainous country covering roughly 8,500 square miles in the northeast corner of the continent. It is characterized by a chain of almost im- penetrable mountains, designated as the Er Rif, which extends eastward in an arc from Tangier to the Moulouya River, and con- tains numerous peaks over 7,000 feet in height. A narrow plain borders the Atlantic coast, but the Mediterranean shores are rugged, except for stretches of lowland be- tween Ceuta and Tetuan in the west and between Alhucemas Bay and Melilla in the east. Several rivers drain to the Mediter- ranean, of which the most important is the Moulouya on the eastern frontier. The climate is typically Mediterranean along the coast but is modified by the alti- tude in the interior. The mean temperatures average from 63° to 65° F. at Larache, from 60° to 68° F. at Tetuan and from 62° to 69° F. at Melilla. The variation between the summer and winter temperatures usually approximates from 18° to 20° F. The rain- fall, which is concentrated in the months from October to May, is greatest in the western Rif mountains and decreases grad- ually toward the east, being lowest on the plains south of Melilla. It averages from 28 to 32 inches annually at Larache, from 26 to 28 inches at Tetuan and from 14 to 16 inches at Melilla. POPULATION AND SOCIO-ECONOMIC CONDITIONS PopuLATION The population of the Protectorate was enumerated at slightly in excess of one mil- lion in 1945, including 995,329 Moslems, 72,096 Spanish, 14,196 Jews and 388 of other nationalities. The city of Ceuta had a population of 63,062 in 1947, and Melilla of 89,073. Both are essentially Spanish cities, in which the native and other non- Spanish communities totaled 3,947 and 11,- 881, respectively. The majority of the inhabitants of Span- ish Morocco belong to two racial groups, the Arabs and the Berbers, which show less evidence of admixture than in other parts of North Africa. The Berbers predominate and may be divided into two main branches: the Rifs of the central and eastern moun- tains and the Berber-speaking tribes of the 548 Spanish Morocco 549 west. Large numbers of Berbers who have . assimilated the language and many of the customs of the Arabs are found in the cities and in the lowlands of the Yebala peninsula in the northwest. Tribal variations and dialects exist among the Berbers, while a large percentage are bilingual and employ Arabic as a medium of religion and educa- tion. Pure Arab tribes occupy the region between the two divisions of Berbers. Other communities include the Jews, most of whom are Sephardic Jews of early Spanish origin, and the Andalusians, or Moors, de- scendents of Moslem refugees from Spain in the sixteenth and the seventeenth cen- turies. The Moroccans tend to live in small scat- tered villages, and few large towns are found outside of the coastal region. In 1945 over three quarters of the population of the Protectorate was classified as rural. The population density varies from about 70 per square mile in the central mountain region and the eastern plains to from 100 to 150 per square mile in the country around Tetuan and in eastern Rif Province. Tetuan, the capital and the largest city in the Pro- tectorate, has a population of over 70,000, and the Atlantic ports of Larache and Alcéazarquivir, of between 33,000 and 40,000. The development of Spanish Morocco has been retarded by the intermittent Rif rebellions from 1912 to 1927 and by the up- risings associated with the Civil War in Spain in 1936-39. Schools are maintained by the government and by private and religious organizations in the larger towns and vil- lages. The educational facilities are not ade- quate, however, to provide for more than a small proportion of the school-age popula- tion. VITAL STATISTICS Vital statistics are compiled for the Span- ish and the Jewish communities in the Pro- tectorate but are lacking for the Moslem. For the two years, 1941-42, the birth rate in the Spanish population averaged 24.2 per 1,000, and the death rate 19.4. The mortality among the children 0 to 5 years of age was 250 per 1,000 births in 1941, and 202 in 1942. The specific birth rates for the Jewish population averaged 15.7, and the death rates, 10.2 per 1,000. The relatively small size of the Jewish communities, which are almost exclusively urban, influences the validity of such statistics, as shown by the fluctuation in the mortality rates among children under five years from 91 per 1,000 births in 1941 to 215 in 1942. SociaL Economy Agriculture is the principal occupation of the people, but it is poorly developed com- mercially, and the majority of the inhabit- ants produce little beyond the needs of the region. Barley, wheat, fruits, olives, nuts and legumes are cultivated, while cattle, sheep and camels are raised by the tribes of the eastern plains. Natural resources consist of the scattered cork oak forests, the esparto grass which grows in the steppe regions, and a variety of minerals, chiefly iron, copper, zinc, magnesium and salt. Iron ore and small amounts of other minerals, cork, cattle, hides, eggs and esparto grass are ex- ported. Manufacturing is still in an elementary stage. Local industries include the process- ing of olive oil, soap and fish, as well as textile, leather and metal crafts. An ambitious program for harnessing the rivers and the mountain streams was ini- tiated by the Spanish government in 1946. The projects will provide water for hydro- electric and irrigation purposes and will facilitate the promotion of agriculture in many areas. The construction of water- works on the Moulouya River was under- taken in 1947 in co-operation with the French authorities. The numerous ports on the Atlantic Ocean and the Mediterranean Sea provide facilities for communication with Spain and the adjacent colonies in North Africa. How- ever, the mountainous nature of the coun- try makes access to the interior difficult and, in many areas, almost impossible. In 550 Spanish Morocco addition to the international railway from Tangier to Fes, short lines connect Ceuta and Tetuan, and Larache and Alcazarquivir. Industrial railways also serve some of the mining districts. Air transport is available between Tetuan and Melilla, and Spain. Foop AnD NUTRITION The food habits of the Moroccans are simple and are based primarily upon the consumption of cereals, dried fruits, legumes and soured milk. Barley is the principal grain cultivated by the Rif tribes, while wheat and sorghum are grown in the west. Little meat is used, except in the homes of the more prosperous families, where mutton and fowl are common ingredients of the couscous, a staple dish prepared with a base of coarsely grained flours. In many mountainous regions two crops a year are possible, and the villages are self- sustaining. In other areas, however, the people live at subsistence levels, and serious food shortages occur during years of low rainfall. When the crops fail, the villagers frequently resort to the use of acorn flour and the indigenous wild vegetables. Housine The rural villages are small and more or less isolated, particularly in the mountain- ous districts of Rif Province. The individual houses are constructed of stone, or of dried earth or clay bricks, depending upon the region, and usually consist of one or two rooms on the ground floor, with an upper chamber approached by an exterior stair- case. The living conditions are universally primitive. The nomads of the eastern plains live in tents made of mats or skins, which are grouped in encampments. With the exception of Ceuta and Melilla, the towns of the coastal region differ little in appearance from those of French Mo- rocco. In the larger cities modern European sections adjoin the old native quarters. Tetuan is cosmopolitan in character, while Ceuta and to a lesser extent Melilla are definitely Spanish. ENVIRONMENT AND SANITATION Mountain streams, springs and wells pro- vide adequate sources of water supply, ex- cept in the semiarid districts of the eastern steppes. Water is frequently deficient, how- ever, due largely to the lack of facilities for the storage and full utilization of available supplies. Piped water systems exist in the modern sections of the larger cities. The water sup- ply of Tetuan is obtained from a spring-fed reservoir at Torreta del Mers. Recently the construction of a dam on the Rio Martin has furnished a supplementary supply for domestic and irrigation purposes. The Rio Martin water is pumped to Torreta, where it is filtered and chlorinated before distri- bution. A large-scale project based upon a reservoir on the Najla River was initiated in 1942; it will incorporate the present system and provide water for Tetuan and Ceuta. The cities of Ceuta and Melilla rely upon water supplies from springs, collected in reservoirs, or in the case of part of the Melilla supply, in underground cisterns. Wells, rainwater tanks and water carts serve the portions of these cities which are not connected with the distribution sys- tems. The degree of sanitary supervision varies in different localities. Contamination of the water supplies is frequent, partic- ularly in the smaller communities. Outside of the larger cities the standards of sanitation are generally low. Mosquitoes, flies, lice, fleas and other insects are abun- dant, while the species responsible for the transmission of disease are, in most in- stances, the same as those encountered in the French zone and in Algeria. HEALTH SERVICES AND MEDICAL FACILITIES HearLtH ORGANIZATIONS The health and medical services in Span- ish Morocco are administered by the Inspec- cién de Sanidad de la Zona, with headquar- ters in Tetuan. The department, which is Spanish Morocco 551 connected with the Delegacion de Asuntos Indigenas (Native Affairs) in the Protec- torate government, functions under the supervision of officers in the Direccion Gen- eral de Marruecos y Colonias in Madrid. The present health organization in Morocco has been developed since the termination of the Rif rebellions in 1927 and, to a large extent, since the end of the Spanish Civil War in 1939. It incorporates sanitary, medi- cal, laboratory and pharmaceutical branches and is responsible for the control of com- municable diseases, the maintenance of medical facilities, the distribution of phar- maceutical supplies, the compilation of sta- tistics and the enforcement of other public health measures. Special malaria, venereal diseases and trachoma control services are included within the department, as well as infant and child welfare and school health sections. Municipal health organizations, subordinate to the central administration, exist in Tetuan, Larache, Alcazarquivir, Villa Nador and Villa Sanjurjo. In each district, medical officers are charged with the direction of the local sanitary and medi- cal services. The health of the populations in the cities of Ceuta and Melilla and the minor presidios does not come within the scope of the Inspecciéon de Sanidad de la Zona but is the responsibility of municipal depart- ments under the control of the Direccion General de Sanidad of Spain. As in Spain, the services for the control and the treat- ment of tuberculosis, both in the Pro- tectorate zone and in the presidios are concentrated in the Patronato Nacional Antituberculoso, an organization recently created under the Ministerio de la Gober- nacion in Madrid. The Patronato operates tuberculosis centers and sanatoria through- out Spain and the colonies. The Spanish Red Cross also maintains hospitals and other health services in both areas. MEepicAL INSTITUTIONS Hospitals and Dispensaries. The hos- pital division of the Inspeccién de Sanidad de la Zona operates hospitals at Tetuan, Larache, Alcazarquivir, Villa Nador and Villa Sanjurjo, and a 60-bed infirmary at Xauen. The hospital at Tetuan has a capac- ity of 400 beds, including maternity and private pavilions. The four other hospitals have an average capacity of from 170 to 200 beds. A small provisional leprosarium is located at Larache. Special facilities sup- ported by the Patronato Nacional Tubercu- loso include a tuberculosis sanatorium with 200 beds at Ben Karrich and a 25-bed tu- berculosis infirmary for the care of bone infections at Arcila. A hospital with about 80 beds is also conducted by the Spanish Red Cross at Larache. Many of the medical centers in the rural districts have a few beds for the care of emergency cases preliminary to their transfer to the regional hospitals. In 1948 the Inspeccion maintained 18 medical centers or dispensaries in the cities and the larger towns and 41 in the rural areas. Special clinics with women physicians for the treatment of Moslem women and children are also located at Tetuan, La- rache, Alcazarquivir, Villa Nador, Villa Sanjurjo and Xauen. The principal institutions in Ceuta and Melilla are under military control, but hos- pitals are operated by the Red Cross in both cities. The hospital at Ceuta has a capacity of 100 beds, and that in Melilla of 300 beds. A 40-bed tuberculosis sanatorium has been opened recently at San Amaro near Ceuta, under the auspices of the municipality and the Patronato Nacional Antituberculoso. Laboratories. The laboratory services of the Inspeccion de Sanidad de la Zona are centralized in the Instituto de Higiene in Tetuan. The Instituto has sections for the conduct of bacteriologic, parasitologic, his- topathologic and chemical examinations and for the preparation of smallpox and rabies vaccines. It functions in close asso- ciation with the Instituto Espanol de Medi- cina Colonial in Madrid. A mobile disinfec- tion unit is also attached to this division. Clinical laboratory facilities are availa- ble in the larger hospitals. 552 Spanish Morocco Schools. A school for the training of mid- wives is connected with the hospital at Tetuan. PERSONNEL Physicians. In 1943 about 106 doctors were employed by the Inspeccion de Sani- dad, 16 in the hospitals, 43 in the urban medical centers and 47 in the rural areas. Private physicians are located in the larger towns and staff the Red Cross hospitals in Larache, Ceuta and Melilla. Others. Nursing sisters of religious orders serve in the hospitals. Subordinate medical personnel attached to the health services included 112 medical auxiliaries, 49 Spanish assistants and 265 native assistants. DISEASES Little information is available regarding the incidence of specific diseases in Spanish Morocco. Reporting is incomplete, and in many areas the existing health services have functioned for little more than a decade. In general, the diseases associated with the French territory are common to the Spanish zone, while the intermittent disruption of the civilian facilities undoubtedly has fos- tered the spread of epidemic diseases, par- ticularly among the impoverished and un- dernourished urban populations. Unless otherwise specified, the reports cited below apply only to the Protectorate. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Dysenteries. Both bacillary and amebic dysentery are prevalent. The actual inci- dence is uncertain, but in the 9 years from 1939 to 1947, from 352 to 1,013 cases of amebic dysentery and from 13 to 278 of bacillary were reported annually. Facilities for laboratory diagnosis are lacking in many areas, and the discrepancies in recording are suggested by the fact that 1,226 cases of unspecified dysentery were treated in government hospitals and dispensaries in 1943, as against 271 cases of amebic dys- entery and 27 cases of bacillary. Typhoid and Paratyphoid Fevers. Lo- calized outbreaks of typhoid fever are fre- quent. The reported incidence is relatively low in view of the poor standards of sanita- tion prevailing throughout the country, but unrecognized infections are undoubtedly common. In 1939-46 from 101 to 198 cases of typhoid fever were reported annually. Statistics for 1943 record 89 cases of ty- phoid fever and 50 cases of paratyphoid fever treated in the hospitals and dispensa- ries. Helminthiases. Helminth infections are widely distributed. Ascariasis predominates, but strongyloidiasis and trichuriasis also occur. The beef tapeworm, Taenia saginata, is present among the cattle, and human in- fections are encountered occasionally. Hy- datid disease is sporadic. Ancylostomiasis and schistosomiasis are not reported. Other Infections. From 2 to 18 cases of undulant fever are recorded each year. Bru- cella melitensis is enzootic among the goats and the cattle, and human infections may be more numerous. Cholera has not been re- ported within this century. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is wide- spread throughout this region, but partic- ularly in the urban communities. The inter- mittent strife from 1912 to the end of the Civil War in 1939, and the overcrowded living conditions and poor nutrition of the people have contributed to the spread of the infection. From 600 to 1,000 cases of pulmonary tuberculosis were reported each year until 1945, when a gradual decline in incidence was noted as the result of the in- auguration of a national antituberculosis program. Only 220 cases were recorded in 1947, but the actual incidence was not cer- tain. Special tuberculosis dispensaries are established in the larger cities, while treat- ment facilities are available in hospital Spanish Morocco 553 clinics in Tetuan, Larache and Villa Nador. It is planned to increase the capacity of the sanatorium at Ben Karrich from 200 to 400 beds in the near future. The new sanatorium at San Amaro, near Ceuta, is the only insti- tution for the care of tuberculosis patients from the presidios. Pulmonary tuberculosis predominates, but other forms of the disease are also re- ported. In 1943 a total of 983 cases of pul- monary tuberculosis were registered in the government dispensaries, and 234 cases of nonpulmonary infections. Smallpox. Sporadic outbreaks of small- pox are recorded, chiefly among the nomadic tribes. In the period 1939 through 1947 the incidence ranged from 14 to 269 cases a year, with peaks in 1940 and 1946. Wide- spread vaccination is carried on by the health authorities. Other Infections. Whooping cough, measles and chickenpox are endemic and frequently epidemic. Outbreaks of diph- theria and meningococcus meningitis occur sporadically. Cases of scarlet fever and poliomyelitis are reported occasionally. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH CONTACT Venereal Diseases. Syphilis is one of the major causes of illness. Congenital syphilis and other forms of nonvenereal infection are prevalent. The incidence is not known, but 12,879 cases, including 1,451 of con- genital syphilis, were treated in the regular dispensaries in 1943. Gonorrhea and soft chancre are also common; in the same year 2,545 cases of gonorrhea and 1,044 cases of soft chancre were recorded. A venereal disease control program is car- ried on by the health authorities, which in- cludes the supervision of prostitution, the isolation of infectious individuals and the provision of facilities for the free treatment of cases. Special venereal disease clinics are established in Tetuan, Larache, Alcazar- quivir, Xauen, Villa Nador, Villa Sanjurjo and Bab Taza. Leprosy. Leprosy is endemic, and occa- sional cases are recorded. However, no surveys have been made from which to esti- mate the probable incidence. The number of new cases reported each year ranges from zero to 31. Lepers are treated in the regional hospitals, and in a temporary leprosarium, with 25 beds, at Larache. The disease is common in the vicinity of Ceuta and to a lesser extent around Melilla. Diseases of the Eyes. Trachoma is prev- alent, and from 500 to 1,200 cases are treated annually in government institutions. A service for the control of trachoma is in- corporated within the central health organ- ization, and clinics are conducted in the larger cities. A decreased incidence has been noted within recent years, especially in the region around Villa Sanjurjo. Purulent conjunctivitis is widespread, and gonococcal infections are common. Diseases of the Skin. Ringworm and other fungus infections are general, and sev- eral thousand cases are treated each year in the dispensaries. Serious mycoses are also common. Scabies is widely distributed. Cases of human myiasis are sometimes encountered, a large percentage of which are produced by the larvae of Woklfahrtia magnifica. Other Infections. Rabies is endemic. In the period from 1939 to 1947, from 2 to 15 human cases were reported annually. Anti- rabic vaccine is prepared at the Instituto de Higiene in Tetuan. DiseaSES SPREAD By ARTHROPODS Malaria. Malaria is endemic in all parts of the country, exclusive of the mountain- ous areas. The highest infection rates are found in the lowlands of the coastal region, on the Mghoura plains and on the plateau of Sharf el Akab. The incidence usually varies with the extent and the volume of the spring rains, and in the decade 1940-49 the reported cases ranged from 3,000 to 18,000 a year. During years of heavy rainfall abun- dant pools form in the clay soil in many 554 Spanish Morocco regions, and they provide favorable condi- tions for the breeding of the principal vector, Anopheles labranchiae labranchiae. Malaria occurs throughout the year but reaches a peak between July and October, when the recorded cases exceed two or three times the total for the remaining months. Plasmodium vivax infections apparently predominate, but P. falciparum and P. ma- lariae are also common. Rickettsial Infections. Louse-borne typhus fever is prevalent, both in the coastal towns and in the inland villages. Sporadic outbreaks are frequent, particu- larly during the spring and early summer months. Epidemic conditions prevailed in many areas in 1941-43 and in 1946. The reported cases give little indication of the extent of infection, but from 380 to 739 cases were recorded annually in each out- break. The incidence ranged from zero to 91 cases in the intervening years within the period 1939-47. Murine typhus is endemic. Fievre bou- tonneuse is common in the summer when the tick vector, Rhipicephalus sanguineus, is abundant. Relapsing Fever. Louse-borne relapsing fever was epidemic in 1945-46, concurrently with the spread of the disease across all of North Africa. A total of 1,796 cases was re- ported in 1945, and 4,418 in 1946, but, as in the adjacent territories, the recorded cases probably represented only a small fraction of the actual infections. Tick-borne relapsing fever, caused by Borrelia hispanica morocanum, occurs spo- radically. From 7 to 40 cases are reported each year. It is transmitted by the tick, Ornithodorus erraticus, which is found in numerous foci, especially in the highland areas. Other Infections. Plague has not been reported within recent years, but the dis- ease has been epidemic in the port towns from time to time. Kala-azar and cutaneous leishmaniasis are rare, but occasional widely distributed cases are recorded. Dengue fever is endemic. NUTRITIONAL DISEASES Although the diet of the average Moroc- can is meager, nutritional diseases are rare, except during periods of prolonged food shortages. Little detailed information is available, but it may be assumed that sub- clinical deficiency conditions are common, as elsewhere in North Africa. SUMMARY Spanish Morocco, part of the former Sherifian empire, has been administered by Spain as a protectorate since 1912. Five presidios, or old garrison towns, form an integral part of the country, although po- litically they are part of Spain and do not come under the authority of the Khalifa, the representative of the Sultan. The largest are the cities of Ceuta and Melilla. Respon- sibility for the health and medical care of the people in the Protectorate is centralized in the Inspeccion de Sanidad de la Zona, with headquarters in Tetuan. The Depart- ment is connected with the Delegacion de Asuntos Indigenas, under the Direccion General de Marruecos y Colonias in Madrid. The civilian health and medical services in the presidios come under the juris- diction of the Direccion General de Sani- dad of Spain. There are 5 government hospitals and 1 infirmary in the Protecto- rate, with an aggregate capacity of about 1,200 beds, as well as urban and rural medi- cal centers and dispensaries. Civilian hos- pitals are operated by the Spanish Red Cross in Ceuta and Melilla. The country is as yet poorly developed, and the living conditions and standards of nutrition of a large proportion of the inhabitants are rela- tively low. Water supplies are obtained from wells, springs and streams. Piped water supplies and sanitary facilities are available only in the larger cities. Malaria, syphilis, tuberculosis and intes- tinal infections are the most important dis- ease problems. Louse-borne typhus fever is frequently epidemic. Louse-borne relapsing fever is epidemic at irregular intervals. Skin diseases, trachoma and gonorrhea and other Spanish Morocco 555 venereal diseases are prevalent. Outbreaks of smallpox occur sporadically. Leprosy, murine typhus, fievre boutonneuse, brucel- losis, rabies and the common respiratory infections are endemic. Leishmaniasis is re- ported occasionally. Plague and cholera have not been recorded from this area within recent years. BIBLIOGRAPHY 1. Amaro Fernandez, J. M.: Contribucién al estudio de la lepra en Marruecos. El subfoco Jaldi, Med. colon., Madrid 8:127-45 (Aug.) 1946. 2. Hardy, Georges, et Célérier, Jean: Les grandes lignes de la geographie du Maroc, Paris, Emile Larose, 1922. 3. Spain. Direccion de Marruecos y Colonias: Correspondence. Dr. Ricardo Teresa Robles, Medico de los Sanitarios Servicios de la Zona. 4. ——. Ministerio de Trabajo, Direccion Gen- eral de Estadistica: Zona de Protectorado y de los Territorios de Soberania de Espana en el Norte de Africa. Anuario estadistico 1944, Madrid, Graficas Sanchez, 1945. 5. ——. Patronato Nacional Antituberculoso: Benitez Franco, Bartolome. Tuberculosis. Estudio de la lacha contra esta enfermedad en Espana, 1939-49, Madrid, Saez-Buen Suceso, 1950. . Presidenta del Gobierno: Instituto Na- cional de Estadistica. Anuario estadistico de Espafia, 1948-49, Madrid, 1950. 7. Teran, Manuel, and Menendez-Pidal, Gon- zalo: Geografia historica de Espafia. Mar- ruecos y colonias, Madrid, Libreria Enrique Pbieto, 1943. 6. 42 Tangier Tangier, at the entrance to the Straits of Gibraltar, is geographically a part of Spanish Morocco but has been accorded international status under the nominal sov- ereignty of the Sultan of Morocco since the Act of Algeciras in 1906. The zone comprises an area of about 160 square miles surround- ing the city of Tangier. It was occupied by Spain and incorporated within the political structure of Spanish Morocco for a brief period from 1940 to 1945, when its inter- national position was restored. A provi- sional administration was established at a conference in Paris in August, 1945, pend- ing the subsequent action of the interested powers. No census has been taken, but in 1949 the population was estimated at 130,000, including 95,000 Moslems, 10,000 Moroccan Jews and 25,000 Europeans, of whom about 18,000 were Spanish. Almost all of the non-Moslems reside in the city of Tangier, which has a population of from 70,000 to 80,000. The majority of Moslems are Berbers, closely related to the tribes in the western part of the Spanish protecto- rate. The Moslem and the Jewish com- munities are subjects of the Sultan, who is represented in Tangier by a Mendoub. The administration of the city and the zone resides in an Administrator-General and an International Legislative Assembly, subject to the approval of a Committee of Control, composed of the Consuls General of the different nations signatory to the Act of Algeciras. Until recently the development of the zone has been retarded by international frictions and by its relative inaccessibility. It is connected by ferry with Algeciras and Gibraltar and by steamer with Mediter- ranean ports in France and Spain. A rail- way links Tangier with the principal cities of Morocco and Algeria, while air services now unite it with Lisbon, Madrid, Rabat and Tetuan. Tangier is a cosmopolitan city, with many of the aspects of other urban centers in northern Morocco. The municipal water supply, which is obtained from a spring-fed reservoir at Sharf el Akab, is piped to indi- vidual houses in about one third of the city and to public fountains in the remainder. Supplementary supplies are derived from wells and rainwater cisterns. A health department is organized under the jurisdiction of an Assistant Adminis- trator. It is responsible for the maintenance of sanitary services, the operation of port quarantine regulations and the control of communicable diseases. It exercises super- vision over water, milk and meat supplies and conducts inspection and laboratory services. There are four modern hospitals: French, Italian and English hospitals which range in size from 30 to 50 beds, and a new Spanish hospital with a capacity of 250 beds, which was opened in 1947. The zone also has a small isolation hospital. Dis- pensaries are operated by the Spanish Red Cross and by the municipality. The Institut Pasteur de Tangier has facilities for the conduct of research and various routine laboratory examinations in co-operation with the local health authorities. The disease conditions in Tangier are comparable with those of northern and western Morocco. Tuberculosis, venereal diseases, intestinal infections and skin dis- 556 Tangier 557 eases are the most prevalent causes of ill- ness. Malaria is endemic, especially in the southern and the eastern portions of the zone; helminthiasis and trachoma are less frequent than in the adjoining territories. Louse-borne typhus fever and other epi- demic diseases of North Africa are also present. 43 Algeria GEOGRAPHY AND CLIMATE Algeria, the largest French possession in North Africa, incorporates 847,500 square miles, extending from the Mediterranean Sea to the frontiers of French West Africa, and from Morocco on the west to Tunisia and Libya on the east. It is divided into two unequal parts, which are distinct ad- ministratively, although both are under the authority of the Governor-General of the territory. The departments of Oran, Alger and Constantine, covering approximately 80,100 square miles along the coast, are technically part of metropolitan France, while the remainder of the country is in- cluded within the semimilitary organization of the Territoires du Sud. The government functions under the jurisdiction of the Sous- Direction d’Algérie et des Departements d’Outre-Mer of the Ministére de 'Interieur in Paris. On the basis of climate and topography, the country falls naturally into four major divisions: the Tell, the Hauts Plateaux, the mountains of the Saharan Atlas and the desert. The coastal region, designated as the Tell, is an area of hills and mountains, with intervening fertile plains and valleys. The sections of the Tell Atlas chain vary in character from low hills in Oran to peaks of over 7,000 feet in the mountains of Grande Kabylie in Constantine. To the south the grassy tableland of the Hauts Plateaux stretches to the slopes of the Saharan Atlas (4,000 to 7,000 feet), except in the east where the Tell is backed by the Aurés Mountains. The desert country, a complex of rocky plateaus, mountains, sand 558 dunes and oases, occupies roughly 84 per cent of Algeria. The Ahaggar Mountains in the south contain massifs of over 9,000 feet, the highest elevations in the territory. Scat- tered depressions, or ckotts, which are con- verted into extensive salt lakes and marshes during the rainy season, are found in the Hauts Plateaux region and the northern Sahara. There are few perennial rivers, and the majority of streams, or oueds, flow only during periods of heavy rainfall. The largest is the Cheliff, which parallels the coast north of the Ouarensis Mountains for about 125 miles and empties into the Mediterranean near Mostaganem. Numerous fertile oases occur in the vicinity of the oueds, particu- larly in the northern desert. The climate of the Tell is essentially Mediterranean, with modifications due to the proximity of the desert and to differ- ences in altitude. In general, the mean tem- peratures average 50° to 54° F. in the winter months from December to February, and 75° to 79° F. from April to October. The maximum and the minimum means range from 43° to 59° F. in the winter; from 68° to 85° F. in the summer. The temperatures increase progressively toward the south while the seasonal variations become more pronounced. At Laghouat and at Ghardaia in the northern desert, the mean temperatures are 62° to 64° F. and 70° to 72° F., respectively. The minimum temperatures (absolute) range from 20° to 32° F.; the maximum, from 104° to 122° F. The daily fluctuations average 21° to 36° F., in contrast with 14° to 16° F. in the coastal region. The rainfall is irregular, with variations Algeria 559 in time of onset and in amount, from year to year. North of the desert, the maximum precipitation usually occurs in December and January, while the months from June to September are practically rainless. In the coastal region the annual rainfall ranges from 16 to 24 inches in the west to from 24 to 32 inches in the east and approaches 40 inches around Bougie. It decreases steadily in volume toward the interior, although snow is common in the winter at the higher altitudes. On the Hauts Plateaux, the rain- fall averages from 16 to 18 inches a year, but on the Saharan slopes of the Atlas Mountains it rarely exceeds 8 inches. It is capricious in the desert and is characterized by localized storms at intervals of months or years. The prevailing winds are east or northeast in summer and west or northwest in winter, while the hot, sand-laden sirocco blows across the desert for irregular periods, most frequently between February and September. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoPULATION In 1948 the population of Algeria was slightly in excess of 8,676,000. Roughly 89 per cent of the inhabitants were settled in the departments of Alger, Oran and Con- stantine, and 11 per cent in the Territoires du Sud. The European population, which is concentrated to a large extent in the north- ern departments, totaled about 965,000. It is composed primarily of western Mediter- ranean peoples, the majority of whom are French of metropolitan or colonial origin. Colonists of Spanish, Italian and Maltese descent are also numerous. The Spaniards are found predominantly in the west; the Italians and Maltese, in the east. The Algerian Jews were naturalized en masse by the Crémieu decree of 1870 and are enumerated in the European segment of the population. They numbered about 117,000 in 1936. Although ethnically the native popula- tions of Algeria are made up largely of Arabs and Berbers, they belong to heter- ogenous groups with widely different cus- toms, traditions and social organizations. Representatives of the aboriginal Berbers are found among the Kabyles of the moun- tainous districts of the eastern Tell, the Chaouias of the Aurés Mountains, the Mzabites of the Mzab oases and the Toua- regs of the central and southern Sahara. People of Berber stock, showing varying degrees of Arab influence, comprise roughly 40 per cent of the population. The Arab contingent includes numerous admixtures, the true Arabs being found chiefly among the nomadic tribes of the Sahara. Negroes dwell in scattered groups in the larger cities, especially Oran, and throughout southern Algeria, while inhabitants of Arab-Negro blood, descendents of former slaves, pre- dominate on certain oases. Mohammedanism is the prevailing re- ligion among the indigenous peoples. Arabic is used by the Arabs and by a large per- centage of the Berbers. However, the un- educated classes employ an Arab-Berber dialect peculiar to the region. Different Berber tongues are spoken by the Kabyles, the Mzabites and the Touaregs; the last group has conserved the written language. French is widely used, particularly among the inhabitants of the north. The white population of Algeria is pre- dominantly urban. In 1936 roughly 67 per cent resided in cities and towns of over 10,000 population, and over 45 per cent in the municipalities of Algiers, Oran and Constantine. However, an extensive rural element is found in the departments of Oran and Alger, and in scattered localities in the Department of Constantine. A large per- centage of the Arabs and the Berbers live in the Tell region, the mountainous areas in many districts being more densely popu- lated than the plains. The Kabylie high- lands and the northern slopes of the Aurés and the Ouarensis mountains are among the most thickly settled sections of the country. In 1936 the population density 560 Algeria averaged 81.4 per square mile in the north- ern departments and 0.83 per square mile in the Territoires du Sud. It approximated from 130 to 250 per square mile in the coastal region between Algiers and Con- stantine and reached from 375 to 635 per square mile in certain mixed communes in Grande Kabylie. Numerous oases support- ing relatively large sedentary populations are found in the Sahara, particularly in the north. The remaining inhabitable portions of the desert are sparsely peopled by nomadic tribes. The population densities of the four divisions of the Territoires du Sud—Touggourt, Ghardaia, Ain Sefra and Oases—approximate 4.7, 3.1, 0.8 and 0.1 per square mile, respectively. Several large and populous cities are found in the Tell region. Algiers, the capital and a historic port, had a population, in 1947, of almost 370,000. Oran, the principal port along the western coast, had a popula- tion of over 253,000. Constantine numbered about 121,000 inhabitants, and Bone, the chief port of that department, 82,000. Two systems of education exist in Algeria —the French and the Koranic. Educational facilities, corresponding to those in France and supported by the Algerian government, are available to Europeans and Moslems. Primary schools are widely distributed but are inadequate to provide for the mass of the population. Secondary, technical and professional schools are maintained in the urban centers. The Université d’Alger has faculties in law, medicine, science and letters. Koranic schools are found in all Moslem communities. The advanced Mosque schools, or medersas, furnish courses in administration, economics and the French-Arab humanities, as well as in Moslem law. ViraL STATISTICS No reliable vital statistics are available, except for the European residents. Even in the major cities, where the systematic re- porting of births and deaths is attempted, the records are incomplete for the Moslem populations. In 1948 and 1949 the Euro- pean birth rates averaged 21.8 per 1,000 population; the death rate, 10.8. The re- corded birth rates for the Moslem popula- tion were 44.3 per 1,000 in 1948 and 41.8 in 1949. The death rates were 20 and 19.6, respectively. The infant mortality rates for the Euro- pean population are given as 74 per 1,000 live births in 1948 and 71 in 1949. The true infant mortality among the Moslems is not known. In the 30 largest cities the Euro- pean infant mortality rate was 85 per 1,000 live births in 1947 and 79 in 1948. Com- parable rates for the Moslem communities, as estimated by the health authorities, were 191 per 1,000 live births in 1947, 178 in 1948 and 201 in 1949. SociaL Economy Agriculture is highly developed. Extensive farms and vineyards totaling over 4 million acres are operated by European colonists and agricultural syndicates. A large propor- tion of the sedentary Arabs and Berbers are peasant farmers. Many of the large land- owners have adopted modern methods, but the majority of natives adhere to their tra- ditional primitive methods of cultivation. Under normal conditions, wines and cereals represent over 60 per cent of the total ex- ports of the country. In 1939 Algeria ranked as one of the leading wine-producing areas in the world. Other important agricultural exports include market vegetables, citrus fruits, olives and figs, grown in the sub- littoral regions, and dates, produced on the irrigated oases, particularly in southern Constantine and the northern Sahara. To- bacco and, in many areas, cotton are also cultivated. The cork oak forests of Con- stantine and the esparto grass of the Hauts Plateaux are valuable natural resources. Stock raising is carried on by the nomadic and seminomadic tribes, primarily on the grassy steppes of the plateaus and in the drier portions of the Tell region. Sheep and goats are the principal livestock, but some cattle, horses, mules and camels are also Algeria 561 raised. Limited numbers of dairy cattle and pigs are bred by the European farmers. However, probably from 90 to 95 per cent of the total livestock in the country are owned by the Arabs and the Berbers. The promotion of agriculture and animal husbandry is fostered by the Algerian gov- ernment. Experimental farms, agricultural and horticultural schools, and other special- ized services are provided for the benefit of European and Moslem farmers. Co-opera- tive organizations are sponsored by the government, particularly in the viticulture, tobacco, cotton and sheep-raising industries, while many credit societies receive financial support. A variety of minerals is found in different parts of the country, especially in the de- partment of Constantine. The most valuable deposits are iron ore and natural phos- phates. Numerous industries have been es- tablished in the larger cities, but the major- ity are restricted to the processing of local raw products. Native industries which have survived the competition of manufactured goods include the making of carpets, pot- tery, leather articles and embroideries. Modern roads serve the northern depart- ments, while well-defined motor tracks link the population centers in the Territoires du Sud. The railway system includes the trunk line skirting the coast from Casablanca to Tunis, and several branch lines from the Mediterranean ports to agricultural and mining districts in the interior. The unit from Oran to Colomb-Béchar may even- tually be projected to terminals in French West Africa. Oran, Algiers and Bone are among the largest ports under the French flag, with services to Europe and other parts of the world. Air lines operate between Oran and Algiers and various points in Europe and the African colonies. Foop AND NUTRITION The nutritional standards of the people differ according to their race, place of resi- dence, economic status and occupation. The diet of the poorer peasants and wage-earners is largely vegetarian and barely adequate even in normal years. It is highly deficient during periods of drought and economic stress. A form of bread (galette) and couscous, made with barley, hard wheat, millet, maize, or in the Kabylie region, with acorn flour, are staple articles of diet among both Arabs and Berbers. Couscous is aug- mented by vegetables and occasionally by meat. The use and the types of vegetables and fruits vary in the different regions. The average individual, irrespective of race, consumes little meat, except on market and feast days. Sheep and goats are the com- monest sources of meat, and in many areas cattle are sacrificed for food only on certain ceremonial occasions. Fish are abun- dant near the coast. The milk of sheep, goats and camels is a basic food of the nomadic tribes and forms an important part of the diet of most peasant farmers. It is fre- quently utilized in the curdled form and sometimes for the production of cheese. Olive oil is used extensively, but butter and animal fats are scarce and expensive. Undernutrition and subclinical nutritional disorders are common and constitute an im- portant factor in determining the health status of the people. Major deficiency dis- eases are rarely encountered, however, ex- cept under abnormal conditions. In 1943-45 Algeria experienced a severe drought, which accentuated the poverty and the nutritional problems of the people. Housine The prosperous residents of all races live in substantial houses of modern construc- tion and design. The average native dwell- ings, however, are picturesque but fre- quently insanitary and overcrowded. In most Algerian cities the European and the Moslem quarters are distinct, while in some all of the various races tend to be segre- gated. Algiers is divided into the old Moor- ish city and the modern; in the latter even the poorer homes are well constructed, usu- ally of stone with flat roofs adapted for utilitarian purposes. The ancient Arab and 562 Algeria Berber cities and many of the rural villages are enclosed within high walls, while the streets are narrow and often vaulted alleys. The homes of the rural peoples vary char- acteristically in type and building materials, depending on the region. The houses of the Arabs are commonly built around courts. Those of the Kabyles are generally crude huts of whitewashed stone, or mud and clay bricks, with thatch and sometimes tile roofs. The families live under primitive conditions in rooms without windows or chimney, in close association with their livestock. The dwellings of the nomadic tribes are tents made of woolen cloth or skins. On some oases, many families abandon their homes in the summer for temporary grass shelters near the palm gardens. In the early 1930s the Algerian government undertook a pro- gram for the demolition of unhealthy slum areas and the construction of modern low- cost homes in many localities, but the proj- ect was interrupted during World War II. ENVIRONMENT AND SANITATION WATER SUPPLIES Sources of water for domestic and irriga- tion purposes are normally adequate in northern Algeria, although subject to sea- sonal fluctuations in rainfall. There are few perennial rivers, but in many districts sup- plies are assured by the construction of reservoirs for the storage of rain and sur- face waters. Small domestic supplies are derived from shallow, deep or artesian wells, depending upon the locality. In the Terri- toires du Sud water is obtained primarily from underground sources. Community sup- plies are usually from springs, deep wells operated by primitive mechanisms or arte- sian wells. In the oases of Gourara, Touat and Tidikelt, foggeras or shafts tapping underground passages are the traditional means of supply. The waters in many parts of southern Algeria have a high mineral content. The urban water supplies are supervised by the health services of the different de- partments, or, in the case of the larger cities, by the municipal Bureaux d’Hygiene. The majority are treated by chlorination, but the degree of supervision varies, and con- tamination is frequent. Bacteriologic and chemical examinations are made at regular intervals in the public health laboratories of the departments and sometimes at the Institut Pasteur d’Algérie. The water sup- ply of Algiers is obtained from springs in three different localities, from a subterra- nean source at the Ravin de la Femme Sau- vage, and from artesian wells in the Maison- Carrée and Baraki regions. The supply of Oran is taken from springs at Raz-el-Ain and from wells at Pont-Albin and Messer- ghin, while that of Constantine comes from springs at Bou-Merzoug and from wells at Fesgnia. The present supply of Oran is saline, and the construction of a dam at Beni-Bahdel on the Tafna River was pro- jected in 1948. Numerous small-scale irrigation projects are scattered throughout the Tell region and the oases, many of which are primitive in design and construction. At least 8 major irrigation works are located in the Tell, with dams on the Tafna, the El Hamman, the Mina, the Fodda, the Cheliff and other oueds ; also two at Oued Ksob and Foum el Gueiss in the Hauts Plateaux. These sys- tems will eventually provide water for the irrigation of over 300,000 acres. Barrages have been erected at numerous points for the diversion of streams into the adjacent agricultural areas. Waste Disposal Water-borne sewerage systems serve parts of the larger cities and towns. The sewage is usually discharged into the sea or into an adjacent water course. In many cases it is treated by sedimentation, and sometimes by digestion, the sludge being utilized for fertilizer. In sections where no sewerage is available, and in the rural areas, pit or bucket latrines are commonly employed. Pollution of the soil is a general practice in many localities. Algeria 563 Fauna anp Frora ~ Arthropods. Mosquitoes. Anopheline mosquitoes are found in all parts of Algeria, except possibly on the oases of El Oued, Mecheria, Ghardaia and Laghouat, where the absence of surface collections of water restricts breeding. Anopheles labranchiae labranchiae (= A. maculipennis labran- chiae) is the predominating species and the principal vector of malaria throughout northern Algeria from the coast to the edge of the desert. It breeds from April to No- vember in swamps, sluggish and weedy rivers, garden wells and stagnant irrigation pools, many of which become mildly brack- ish as the result of evaporation. Its preva- lence varies from year to year, correspond- ing to fluctuations in the amount and the distribution of rainfall. A. hispanola is widespread, although probably not an important vector of ma- laria. It breeds most abundantly in moun- tain streams but is found throughout the Tell and the Hauts Plateaux regions, as well as in the northern Sahara. A. sergenti and A. multicolor are the principal species in southern Algeria. Both species breed in irrigation pools, swamps and unused wells —the former in fresh waters, and the latter in brackish. Both are potential vectors of malaria. Other species reported from vari- ous parts of the country include 4. algeri- ensis, A. bifurcatus, A. sacharovi, A. cou- stani tenebrosus, A. marteri, A. d’thali and A. brousseri. Mosquito-control measures are organized in each department by the Service Anti- paludique, a unit of the Algerian public health organization. Extensive drainage and swamp-reclamation programs have been car- ried on in the vicinity of Algiers, Bone and other large cities. One of the most produc- tive experimental projects, started in 1927 under the direction of the Institut Pasteur d’Algérie, was the conversion of the swamp of Ouled Mendil in the plain of Mitidja into rich agricultural land. Antilarval meas- ures employed by the Service Antipalu- dique and by the mosquito-control branches of the governmental Services d’Hydraulique and de la Colonization include the use of larvicide sprays as oil, Paris green or DDT; the clearance of streams and irrigation ditches; and the stocking of ponds and other permanent waters with Gambusia holbrooki. Aedes aegypti is abundant during the summer months in the coastal area. It is also reported from the Hauts Plateaux re- gion and from the Mzab oases at Ghardaia. Other Aedes of no known medical impor- tance are present, among them A. caspius, A. echinus, A. geniculatus, A. mariae, A. rusticus, A. vexans and A. vittatus. Numerous species of Culex are found, including C. pipiens. Theobaldia longiareo- lata and possibly other species of Tkeo- baldia, as well as one species of Uranotaenia, have been identified. Fries. A wide variety of flies is found in Algeria, many of which are suspected as mechanical vectors of intestinal and skin infections. Myiasis-producing flies are nu- merous. Human infections are occasionally reported, most frequently with the larvae of Wohlfahrtia magnifica or Oestrus ovis. Hypoderma bovis, Rhinoestrus purpureus, Anthomyia pluvialis, Fannia canicularis and several species of Sarcophaga, especially S. haemorrhoidalis and S. tuberosa, are also present. Musca domestica, Muscina stabu- lans and species of Stomoxys are abundant. At least 59 species of TaBANIDAE have been identified, including several of Tabanus and smaller numbers of Chrysops, Chrysozona and Pangonia. Numerous species of Simu- LIIDAE are found. Ten or more species of Phlebotomus occur, but only P. papatasii, P. sergenti and P. perniciosus are of particular medical sig- nificance. The first two species are regarded by many as vectors of cutaneous leishman- iasis, which is endemic in numerous foci from the coast to about 30° N. latitude. P. papatasii is widespread throughout this area, being replaced in the south by P. pa- patasii bergeroti. P. sergenti is absent from 564 Algeria the oases of the northern Sahara but is found in the central region. P. perniciosus is also widely distributed and may be re- sponsible for the transmission of occasional cases of Mediterranean kala-azar in the lit- toral. P. longicuspis is a potential vector in some of the northern oases. Lice. Infestation with lice is almost uni- versal among the native populations. Pedic- ulus humanus corporis is widely distributed and is responsible for the epidemic spread of typhus fever and relapsing fever, partic- ularly in northern Algeria. P. humanus capitis and Phthirus pubis are compara- tively rare. Fras. Xenopsylla cheopis is prevalent on rats in the coastal region and probably else- where. It is the usual vector of plague and murine typhus, both of which are sporadic. Ctenocephalides felis, C. canis, Ctenopsyllus musculi and Ceratophyllus fasciatus are also numerous. The human flea, Pulex irri- tans, is common in the Tell but is absent in the Sahara and infrequent in the Hauts Plateaux country. BepBucs. The bedbug of temperate cli- mates, Cimex lectularis, is indigenous. Ticks anp Mites. Numerous species of ticks are encountered. Rhipicephalus san- guineus is found abundantly from April to October and is involved in the transmission of occasional cases of fievre boutonneuse. Ornithodorus erraticus is widely distrib- uted. It is the most frequent vector of tick- borne relapsing fever, which occurs sporadi- cally in the Tell and the ckotts and northern Saharan regions. O. savignyi is found in some arid localities. Boophilus annulatus calcaratus, Rhipicephalus bursa, Hyalomma mauritanicum, Argas persicus, Margaropus calcaratus and Ixodes ricinus are among the other species present. The mite, Pediculoides ventricosus, is re- sponsible for cases of “grain itch” in some areas. The human itch mite, Sarcoptes scabiei, is common in the north but rare in the southern oases. Scorpions ‘AND SpipErRS. Numerous spe- cies of venomous scorpions are found, par- ticularly on the Saharan slopes of the Atlas mountains and along the northern fringes of the desert. Prionurus australis, Buthus occitanus and Scorpio maurus are the pre- dominating species. P. australis is the most dangerous, but occasional serious cases of stings by P. amoreuxi, P. liouvillei, P. quin- questriatus, P. hoggarensis and B. occitanus are reported. Species of Buthacus are also widespread. In the decade 1936-46 over 2,100 persons were treated by antivenom serum prepared at the Institut Pasteur d’Algérie. Among 531 severe cases, 59 deaths were recorded. The poisonous black spider, Latrodectus, occurs in some localities. OruEeRr ArTHROPODS. Blister beetles of the family Merompae and rove beetles of the family STAPHYLINIDAE are present in many areas. Reptiles. The puff adder, Bitis arietans, is the most widely distributed poisonous snake in Algeria. Aspis cerastes (= Cerastes cornutus) and A. vipera (= C. vipera) are common in the desert region. Vipera ammo- dytes, V. latastei, V. lebetina mauritanica and V. lebetina deserti are found in their respective habitats. The cobra, Naja haje, is present throughout the northern and the central Sahara regions, while N. tripudians has been recorded from localities in the south. Rodents. Rattus norvegicus is the pre- dominating species in the port cities. R. rattus rattus is prevalent in all parts of the country; R. rattus alexandrinus and R. musculus are encountered somewhat less frequently. Many varieties of wild rodents, including rats and gerbils, are found in the interior. Both wild and domestic rodents are hosts of plague and murine typhus, which are reported sporadically from vari- ous foci. Active antirodent campaigns are conducted by the health authorities in the principal cities. Mollusks.* Bulinus and Physopsis snails are found in the irrigation canals, and in swamps and lakes in numerous sections of * See footnote, p. 10. Algeria 565 northern Algeria from Mostaganem to Bone, as well as in the spring-fed lakes of Oasis Djanet in the southeast. Bulinus truncatus is the probable intermediate host of Sckisto- soma haematobium in localized foci. Plants. Little exact information is avail- able regarding the allergy-producing plants in Algeria. Poisonous plants which may inadvertently contaminate human foods include Datura stramonium and D. metel. Battandiera amoena, Androcymbium punc- tatum and Hyoscyamus muticus (— H. falezlez) have been reported as responsible for occasional deaths in southern Algeria. Foop SANITATION The production and the sale of milk and food supplies is supervised by the health services of the three administrative depart- ments, and in cities of over 50,000 popula- tion by the municipal Bureaux d’Hygiéne. Meats are inspected before and after slaugh- ter by qualified veterinary officers. The pasteurization of milk is compulsory in the larger cities, but volumes of less than 600 liters are exempted by law, and a large proportion of the supply probably escapes pasteurization. Fruits, milk and market produce are subject to contamination by polluted soil, insanitary handling and flies, which are particularly abundant during the summer months. HEALTH SERVICES AND MEDICAL FACILITIES HeALTH ORGANIZATIONS Responsibility for the public health in the departments of Alger, Oran and Constan- tine is concentrated in the Direction de la Santé Publique et de la Famille, a major department of the central government. It has authority over all activities relating to the health and medical welfare of the peo- ple. The Direction is advised by a Comité Superieur de la Santé Publique and by vari- ous technical commissions. The headquar- ters organization at Algiers has divisions responsible for the administration of medi- cal assistance and the maintenance of tech- nical sevices, including the prevention of epidemic diseases, the control of malaria, and the management of certain endemic diseases, such as trachoma, tuberculosis and syphilis. It also incorporates sections dealing with quarantine and port health services, the education of medical personnel and the supervision of social welfare activities. Directions départementales de la Santé, with headquarters in the capital cities of each department, carry out the functions of the central organization and exercise con- trol over the medical and technical services in their respective areas. The three depart- ments are divided into 13 sectors and 257 subordinate medical units, each of which is in charge of a physician responsible for all phases of public health in his district. In towns of over 50,000 population the enforce- ment of sanitary and health measures is delegated to municipal Bureaux d’Hygiéne. The health services in the Territoires du Sud are administered by a Service de la Santé under the Direction des Territoires du Sud of the Algerian government. Branches of the Croix Rouge Francaise carry on tuberculosis, maternity and child health and home service programs in vari- ous parts of the country. Medical and health work is conducted by religious orders in some areas. Numerous charitable organizations operate nurseries, maternity and child welfare centers, milk stations and other facilities contributing to the health of the people. In northern Algeria most of the philanthropic and other private organiza- tions are subsidized by the government, and their work is supervised by the depart- mental health services. MEepicAL INSTITUTIONS Hospitals and Dispensaries. In 1949 the regional hospitals in the three depart- ments, under the jurisdiction of the Direc- tion de la Santé Publique et de la Famille, numbered 17 with an aggregate capacity of 6,515 beds in Alger; 11 with 4,646 beds in Oran; and 16 with 5,218 beds in Constan- tine. All had maternity and outpatient serv- 566 Algeria ices. In addition there were 77 auxiliary hospitals, ranging in size from 10 to 40 beds, which provided a total of 1,967 beds. The Mustapha Hospital in Algiers, with its an- nexes, has a capacity of over 2,000 beds and functions as an educational and research center. The hospitals in the cities of Oran and Constantine have capacities of 2,010 and 1,190 beds, respectively. Special insti- tutions include the psychiatric hospital at Blida-Joinville (Alger) with 1,534 beds; the children’s tuberculosis hospital at Beni- Messous (Alger) with 170 beds; and a tuberculosis preventorium at La Calle (Con- stantine) with 90 beds. In the Territoires du Sud, hospitals with a combined capacity of 160 beds were lo- cated at Colomb-Béchar and Ouargla in 1949. Scattered infirmary-dispensaries, each with several beds for the care of emergency cases, brought the beds available in this region up to 510. Hospitals operated by religious orders and subsidized by the government are established at St. Cyprien-de-Attafs and Michelet in Alger, and at Biskra in Con- stantine. Other private institutions include two small hospitals supported by the Croix Rouge, a 189-bed tuberculosis sanatorium at Rivet and a 100-bed hospital operated by an agricultural concern at El-Affroun. The bed capacity in government and private in- stitutions totaled 21,789 in 1949. Sanitary posts in the outlying villages and from 140 to 200 infant welfare clinics supplement the hospital facilities of the health organization. Laboratories. The Institut Pasteur d’Al- gérie is one of the foremost research insti- tutions in North Africa. It is subsidized by the Algerian government and functions in close co-operation with the Direction de la Santé Publique et de la Famille. The main laboratories are located in Algiers. An annex for the preparation of vaccines and serums for the control of certain animal dis- eases is situated at Kouba, near Algiers, and an experimental station at Birtouta in the Mitidja plain. The Institut staff carries on research in bacteriology, parasitology, my- cology, immunology and entomology. It also performs routine bacteriologic and chemi- cal examinations; prepares various vac- cines, serums and ferments; and conducts field studies for the governmental health services. Hygienic Laboratories are maintained by the three department health organizations and by the Bureaux d’Hygiéne in Algiers and Oran. Clinical laboratories are operated in the larger hospitals. Research labora- tories are also connected with the Mustapha Hospital and the annex El-Kettar in Algiers. Schools. The Université d’Alger has schools of medicine and pharmacy. The medical faculty is affiliated with the Mus- tapha Hospital. Schools are established for the prepa- ration of medical personnel for the health services. Medical assistants of all races are trained in the Ecole des Adjoints Techniques de la Santé Publique at El-Biar. The Ecole Nationale d’Infirmieres in Algiers offers courses for nurses and visiting nurses which meet the State registration requirements. Three other schools for the training of nurses and medical auxiliaries are located in Algiers, Constantine and Oran. A school for visiting nurses is also conducted at Sétif. PERSONNEL Physicians. In 1949 a total of 1,567 physicians was registered in the three de- partments of northern Algeria. Of this num- ber 237 were connected with the Direction de la Santé Publique et de la Famille, and 37 were army officers. Thirty-five doctors were settled in Terri- toires du Sud, including 6 employees of the Service de la Santé and 20 army officers in charge of medical services for the civilian population. The ratio of physicians to 1,000 popula- tion in 1947 averaged 18.4 in the northern departments and 3.9 in the Territoires du Sud, but 81.2 in the city of Algiers, 39.7 in the city of Oran and 10.1 in the city of Constantine. Dentists. In 1949, 336 dentists were Algeria 567 practicing in the northern departments. Two health department dentists were lo- cated in the Territoires du Sud. Others. In the same year there were 1,137 nurses and 431 midwives in the north- ern departments; 45 nurses, of whom 41 were connected with mission societies, and 10 midwives in the Territoires du Sud. The pharmacists totaled 541 in northern Algeria and 7 in southern. DISEASES Morbidity statistics are incomplete even in the larger towns of Algeria. Many of the inhabitants adhere to superstitious beliefs and traditional tribal practices and seek the attention of the medical authorities as a last resort. Cases of communicable disease frequently escape observation until the numbers reach epidemic proportions. The spread of infection is facilitated, not only by the wanderings of the nomadic popula- tions and seasonal migrations of agricultural and other workers, but also by the numerous religious pilgrimages. Less than 2,000 Al- gerian Moslems make pilgrimages to Mecca and Medina each year, but large numbers congregate at local shrines in various parts of the country. DiseEASES SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL or UriNARY TRACTS Typhoid and Paratyphoid Fevers. Typhoid fevers are prevalent in northern Algeria, particularly in the departments of Oran and Alger. The reported cases range from 1,000 to 2,500 or more annually and are only roughly indicative of the extent of infection. Localized outbreaks, caused by contaminated water supplies, shellfish and other foodstuffs, are frequent. A large per- centage of the cases are attributed to the coastal region where the pollution of the beaches is considered an important factor in the spread of infection. Cases occur throughout the year but are most numerous from July to February. Typhoid fever pre- dominates among the known cases, but paratyphoids A and B are reported occa- sionally. Immunization with typhoid-para- typhoid vaccine is carried on by the health authorities. Authentic cases of typhoid fever are apparently rare among the native peo- ples of southern Algeria, a fact which is attributed by local observers to immuniza- tion resulting from infections in childhood.!? Dysenteries. Little information is avail- able from which to evaluate the prevalence of bacillary and amebic dysentery. Rela- tively few cases are reported, but the inci- dence is undoubtedly high, in view of the insanitary conditions prevailing throughout the country. Diarrhea and other intestinal disorders are common, and a large percent- age are probably Shigella infections. The presence of widespread chronic infection with Endamoeba histolytica has been estab- lished in many areas. Helminthiases. ANcyLosTomIasts. Hook- worm infection is extensive in the highly irrigated districts of northern Algeria. Foci of infection are encountered in many areas, notably Hodna, Mostaganem, Biskra and Touggourt. The infection rates are particu- larly high in the oases, where they fre- quently reach 50 to 100 per cent. Ancylos- toma duodenale is the prevailing species. Scuistosom1asis. Three distinct areas of infection with Schistosoma haematobium have been established: Saint-Aimé on the Oued Djidiouia, a tributary of the Cheliff ; the Djanet oasis on the Libyan frontier; and Fondouk, near Algiers, a focus which was discovered in 1947. At Saint-Aimé the disease is associated with an extensive irri- gation system. Bulinus snails are abundant in the subsidiary earth canals, and infec- tion is thought to have originated from migratory Moroccan laborers or from Sene- galese troops stationed at Orléansville. In the course of an investigation in 19392 eggs of S. haematobium were found in the urines of 42 individuals among 96 men and boys suspected of having the disease. In the Djanet focus, which is probably secondary to that of the Gat region in Libya, the in- fection rates average from 25 to 45 per cent. 568 Algeria Bulinus and Physopsis snails are widely distributed in the irrigated districts of northern Algeria, and the spread of schisto- somiasis by migratory workers from Tu- nisia or Morocco represents a serious threat to the populous agricultural communities of the area. With the exception of one apparently in- digenous case, reported from Saint-Aimé in 1939,* S. mansoni infection has not been recorded. Oruer Herminta Infections. Infec- tions with Ascaris lumbricoides, Trichuris trichiura and Enterobius vermicularis are prevalent. The beef tapeworm, Taenia saginata, is common among the native cat- tle, and human infections are relatively fre- quent. T'. solium infections are observed occasionally in the European populations, but rarely among the Moslems and the Jews, to whom the use of pork is prohibited. The dwarf tapeworm, Hymenolepis nana, is frequently found in children, especially in southern Oran and Alger. Hydatid disease, caused by Echinococcus granulosus, is wide- spread, particularly among the nomadic tribes of the Tell, the Hauts Plateaux and the chotts regions. It is rare on the Saharan oases. Infection with Fasciola hepatica is enzootic among the sheep and the cattle on the Hauts Plateaux, and human infec- tions are sometimes encountered. Cholera. Serious outbreaks of cholera have occurred in the past in Biskra, Toug- gourt, Ziban and other localities, but the disease has not been reported since 1893. During the 1947 outbreak in Egypt, special precautions were taken by the Algerian health authorities, in co-operation with the health services of Morocco and Tunisia, to prevent its spread in North Africa. Stringent quarantine regulations were imposed against traffic across the frontiers and especially from Egypt and Fezzan. All pilgrims to Mecca were immunized against cholera and were detained in quarantine upon their re- turn, pending the result of laboratory ex- aminations for evidence of infection. Brucellosis. Early in this century brucel- losis was enzootic among the goats through- out the country, but since the imposition of restrictions upon the importation of animals from Malta, the disease has been almost eradicated from the departments of Alger and Constantine. However, persistent foci of Brucella melitensis exist among the herds in the Department of Oran. B. abortus is also reported as present among the cattle. The extent of human infection is not known. Diseases Spreap CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis constitutes a serious problem in Algeria. Although the actual morbidity rates are not known, the incidence is generally believed to be high and to have increased progressively within the last decade. The disease occurs more frequently among the Arabs and the Berbers than among other races. It is most preva- lent in the population centers of the north and is relatively rare among the nomadic Touaregs of the southern Sahara. Pulmo- nary infections predominate, but glandular and bone lesions are also numerous. The poverty, overcrowded living conditions and poor nutrition, which prevail among large sections of the population, are conducive to the spread of the infection. Many observers also regard as important factors the disturb- ances of the North African campaign in 1940-43 and the return to their homes of laborers and soldiers who had acquired the disease in Europe. The Institut Pasteur d’Algérie has carried out extensive investigations since 1910 on the geographic distribution and the inci- dence of infection. Tuberculin tests have been performed on over 45,000 individuals. The accumulated results of successive sur- veys™ show 80 per cent positive reactors among persons over 15 years of age in the crowded mountain villages of the Kabylie region, from 55 to 72 per cent in the Tell, from 55 to 70 per cent in the steppes of the Hauts Plateaux, from 50 to 78 per cent on certain oases of the northern Sahara, 45 per cent in the Ahaggar area and 10 per cent Algeria 569 in the Ajjer section of the southern desert. The largest number of positive reactors among children less than 5 years of age, which averaged 30 per cent, was found in the Mzab oases and in the Hauts Plateaux country. In a small series of tuberculin tests in the Souf region of southern Constantine, recorded in 1939,°% infection rates in indi- viduals over 15 years of age, in different population groups, averaged 85 per cent among the sedentary Arabs, 83 per cent among the Jews, 80 per cent among the Negroes and 71 per cent among the nomadic and seminomadic Arabs. Since 1928 the Institut has undertaken considerable experi- mental work on the use of BCG vaccine in the immunization of children of all ages. In 1946-47 the Direction de la Santé Publique et de la Famille embarked upon a systematic campaign against tuberculosis, involving an increase in the number of tuberculosis dispensaries, the expansion of sanatoria and hospital facilities for the iso- lation and the treatment of cases, the de- velopment of mobile units for radiologic surveys in the schools and the immunization of children under 15 years of age, in both urban and rural communities, with BCG vaccine. The number of beds available for the care of tuberculosis patients in govern- ment institutions totaled over 2,000 in 1948, in contrast with 800 in 1939. An intensive BCG immunization program was initiated in 1949, with the co-operation of United Nations International Children’s Emergency Fund units. Smallpox. Serious epidemics of smallpox were formerly common, but as the result of vaccination campaigns the incidence de- clined to an annual average of from 10 to 20 cases in 1932-40. Since 1941 numerous sporadic outbreaks have been reported each year. In the three northern departments the peak of incidence was observed in 1943, when 1,800 cases were notified. The number of cases subsequently dropped to 334 in 1945, and from 400 to 565 annually in 1946-48. In the Territoires du Sud, the maximum incidence was recorded in 1944 and 1945. The reported cases increased from 33 in 1943 to an average of 485 in 1944-45 and then declined to an average of 175 in 1946-47. Intensive vaccination programs were carried on in all the affected districts. Other Infections. Measles is endemic and an important contributary cause in the high infant mortality. Severe and explosive outbreaks are frequent. In southern Algeria two peaks of incidence are noted— January to April, and July to August. Whooping cough is prevalent, sometimes occurring in widespread epidemics. The greatest numbers of cases usually fall in the months from December to March. Mumps is common at all seasons of the year. Meningococcus meningitis, diphtheria, poliomyelitis and scarlet fever are sporadic. Diphtheria and scarlet fever are reported primarily among the European residents. A high rate of im- munity to diphtheria has been demonstrated in Algerian natives. Pneumonia is a major cause of morbidity, particularly in the desert and semidesert regions, where wide fluctuations in daily temperatures are experienced. Broncho- pneumonia is often a complication of mea- sles and whooping cough in children. DiseAsSES SPREAD OR CONTRACTED CurerLy THROUGH CONTACT Venereal Diseases. Syphilis and gonor- rhea are widespread. Chancroid and lym- phogranuloma venereum or climatic bubo are also encountered. The actual infection rates of syphilis and gonorrhea are not known. Both are taken as a matter of course by the indigenous populations, and only advanced lesions are usually seen by the Colonial physicians. In a total of 56,170 cases treated in venereal disease dispen- saries in 1947, almost 49,000 were due to syphilis, and only 6,484 to gonorrhea. Syph- ilis, in particular, is an important factor influencing the high abortion and infant mortality rates in all parts of the country. A venereal disease control program is con- ducted by the Direction de la Santé Pub- lique et de la Famille, with the support 570 Algeria of several unofficial organizations. Special venereal disease services are maintained in the larger hospitals. Clinics are located in all of the major population centers in the three northern departments and in the Ter- ritoires du Sud. Control measures are ren- dered ineffective, however, by the fact that few natives persist in treatment after the acute symptoms have subsided. Diseases of the Eyes. Trachoma is widely distributed throughout Algeria. All races are affected, but predominantly the Moslem populations. According to the re- gion, the prevalence ranges from 40 to 83 per cent among the Arabs and the Berbers and from 7 to 20 per cent among the Euro- peans. The index is highest among young children, from 50 to 75 per cent of the cases being acquired before two years of age. Serious corneal and other complica- tions, which may result in blindness, are frequent. The disease is apparently more ex- tensive in southern Algeria than in the northern departments. Studies in the Terri- toires du Sud!’ indicate infection rates of from 74 to 100 per cent among the settled populations and of from 7 to 8 per cent among the nomads in the region south of Oran. The prevalence among the nomadic tribes varies considerably in different areas. In a survey of three communities in the Souf district of Touggourt territory in 1934-37%% about 86 per cent of 343 individ- uals were found to be trachomatous. The government health services conduct an intensive antitrachoma campaign, in- cluding not only the provision of special treatment facilities, but also the promotion of preventive and educational measures. Ophthalmologic services are maintained in all of the hospitals and dispensaries, while special eye clinics, Bit-el-Ainins, are organ- ized in the rural areas. Mobile units also undertake treatment surveys in the most seriously affected areas. Infectious conjunctivitis is common in both sedentary and nomadic populations. Hemophilus conjunctivitidis or H. lacu- natus are responsible for a large proportion of the cases. The peaks of incidence occur in May and June and in October and No- vember. Gonococcal conjunctivitis is wide- spread and sometimes epidemic in family or community groups. Diseases of the Skin. Various types of mycotic infections occur. The incidence ranges from 1 to 10 per cent in different localities, depending upon social and cli- matic conditions. In general, skin infections are most numerous among the Moslem chil- dren in the native quarters of the cities and in the congested communities on the north- ern edge of the Sahara. Favus predominates among the skin lesions, the majority of cases being caused by Achorion schoenleini. Ringworm infections of the scalp are promi- nent. Most of the cases among Moslem chil- dren and about four fifths of the cases in Europeans are due to Trichophyton gla- brum or Tr. violacewm. Infections with Ctenomyces mentagrophytes are often found among adults. Lesions of the buccal membranes from which Candida albicans, C. tropicalis, C. pseudotropicalis, C. krusei or C. brumpti may be isolated are frequent. Actinomycotic infections are also seen. Phagedenic ulcers were formerly rare, but in 1943-44 epidemic foci developed among the dock workers and the agricultural labor- ers in the vicinity of Algiers and spread throughout northern Algeria. A total of 7,935 cases was recorded; 857 were Euro- peans. Almost 80 per cent were from the Department of Alger. The actual incidence among the native populations probably ap- proached 57,000.2¢ The lowered resistance and poor nutrition of the people, resulting from the war conditions, were undoubtedly contributory factors. Secondary outbreaks appeared in 1946 and 1947. In the latter year a total of 311 cases was reported, pre- dominantly from the departments of Oran and Constantine. The epidemics are usually concentrated in the period between October and December, but sporadic cases are ob- served during the remainder of the year. Scabies is indigenous. Occasional cases of Algeria 571 human myiasis are encountered, in which Wohlfahrtia magnifica or Oestrus ovis are most frequently implicated. Other Infections. Rabies is endemic throughout northern Algeria but is rare in the Saharan regions. Antirabic vaccine is prepared by the Institut Pasteur d’Algérie. From 2,500 to 3,500 treatments are given annually. The majority of infected individ- uals are bitten by dogs; a few by cats, rodents, asses and other animals. The negli- gence and the indifference of the natives, together with the large number of stray dogs, are important factors in promoting the spread of the disease. Leprosy is reported from time to time. A small isolated focus exists among the Kabyles. Rare cases are also recorded from the department of Oran. Weil’s disease, or leptospirosis, is en- demic. Tetanus occurs sporadically in the north. Cases of tetanus neonatorum are unusual, however, in southern Algeria in spite of primitive tribal customs practiced at childbirth. Anthrax is enzootic among the sheep, but human cases are seldom re- ported. Cases of psittacosis have been described, and the importation of parrots from South America is now prohibited. DISEASES SPREAD BY ARTHROPODS Malaria. Malaria is widely distributed, but the epidemiological factors governing the spread of the infection vary in different parts of the country, particularly as be- tween the coastal and the desert regions. Marked local and yearly variations in inci- dence exist throughout northern Algeria. Recrudescences of the disease occur in cycles, usually at intervals of from 7 to 10 years, depending upon meteorologic condi- tions. The rate of breeding of the principal vector, Anopheles labranchiae labranchiae, and the intensity of infection is largely governed by the amount and the duration of the winter and the spring rainfall. Differ- ences in the terrain, the presence or the absence of irrigation, and seasonal increases in the volume of migratory labor from non- malarious areas influence the local fluctua- tions in incidence. According to the nu- merous scattered surveys among the native populations, the splenic indices range from 3 to 50 per cent in the diverse sections of the Tell. In the extensive epidemic of 1946 the splenic index in the Sebaou valley rose from 53 per cent in the spring to 83 per cent in the late autumn. In the Isser valley, a major hyperendemic area, it remained con- tinuously at from 90 to 94 per cent.'* The infection rates are normally low in the larger cities but increase materially in the suburban districts. Malaria is endemic in most of the oases of the Territoires du Sud. However, it is not reported from Mecheria, Ghardaia, EI Oued and possibly Laghouat, where the absence of surface collections of water limits the opportunities for anopheline breeding. In contrast with northern Algeria, the inci- dence remains relatively constant from year to year, although occasional epidemics are experienced in localized areas. In some highly irrigated regions, as the Ziban, hyperendemic conditions prevail. The dis- ease is most prevalent in the settled popula- tions, but high infection rates are found among nomadic tribes which take up resi- dence near the oases at certain seasons, or pasture their flocks periodically in malarial districts. Anopheles sergenti and A. multi- color are probably the principal vectors in the southern territories. Throughout the greater part of the coun- try, Plasmodium vivax is associated with endemic malaria, while P. falciparum pre- dominates under epidemic conditions. In the northern departments, P. vivax is usu- ally responsible for almost 100 per cent of the infections from February to May. P. falciparum infection is sporadic until June or July, when the parasite rate in- creases gradually. The proportionate inci- dence fluctuates between 20 and 30 per cent throughout the summer and the fall months and drops to almost zero in January, as the P. vivax curve again approaches 100 per cent.’ P. malariae infections are sporadic 572 Algeria and usually comparatively rare. Foci of in- creased incidence exist in Colomb-Béchar, El Goléa, the Ziban, the oasis of Zousfana as far as Beni Abbés, and the Oued Rihr region up to Touggourt.'® Malaria-control measures are carried on by the Service Antipaludique of the Direc- tion de la Santé Publique et de la Famille. Anopheline control and prophylactic drug therapy constitute important parts of its program. Supplies of antimalarial drugs are distributed by the government authori- ties during the malaria season, from May and June to November and December. Rickettsial Infections. Louse-borne typhus fever is endemic throughout north- ern Algeria. Widespread epidemics, extend- ing over two to four years, tend to recur at irregular intervals, separated by periods of relative quiescence during which sporadic cases and small localized outbreaks are re- corded. The infection is most frequently spread by groups of nomads, itinerant la- borers or pilgrims. Persistent foci appar- ently exist around Ammi Moussa and Télagh in the Department of Oran; in parts of the Kabylie country and the valley of the Cheliff, and near the southern border in the Department of Alger; in southern Con- stantine, especially in the Aurés Mountains; and in the Laghouat, Ziban and Chellala regions in the Territoires du Sud. Major epidemics are associated with years of famine or social upheaval, accom- panied by poverty and misery. The peaks of incidence usually coincide with the winter and spring season (February to May), when climatic conditions favor the dissemination of lice, but serious outbreaks have occurred during the summer months, from June to September. All races are affected, although the incidence is always proportionately greater among the Arab and the Berber pop- ulations. The fatality rates are usually considerably higher among the Europeans than among the native peoples who are con- tinuously exposed to infection. The Euro- pean fatality rates average from 30 to 50 per cent; the native, from 10 to 20 per cent. Within recent years serious epidemics were experienced in 1919-23, in 1936-38 and in 1941-44. The last outbreak was the most severe recorded since 1868. Over 38,000 cases were reported officially during the peak year of 1942, and the actual infec- tions probably totaled five or six times that number. Subsequently, the incidence de- clined progressively from 11,362 cases in 1943 to 2,409 in 1944, and to 99 in 1949. The preventive measures undertaken by the Direction de la Santé Publique et de la Famille include the disinfestation of the clothing of exposed individuals with DDT powders in permanent stations and by mobile units, and the mass immunization of the inhabitants in the infected areas. Antityphus vaccines, prepared at the In- stitut Pasteur in Algiers, are used exten- sively throughout the country. Sixteen mobile disinfestation units, which can be dispatched to combat an outbreak in its initial stages, were created in 1947 to com- plement the regular departmental and mu- nicipal organizations for the control of typhus. It is interesting to note that in 1943 field studies on methods of applica- tion of insecticide powders were under- taken near Algiers by the International Health Division of the Rockefeller Founda- tion, in collaboration with Algerian health authorities, the Institut Pasteur and the U. S. Army. The dusting of persons, fully clothed, with DDT powder was successfully practiced. Murine typhus is known to be present. Recognized cases are relatively uncommon and usually occur among individuals work- ing in a rat-infested environment. Xenop- sylla cheopis is the chief vector. Fievre bou- tonneuse is widely distributed. Sporadic cases, transmitted by the tick, Rhkipicepha- lus sanguineus, are reported between April and October. Occasional cases of “Q” fever have been recorded from the vicinity of Algiers. The cattle tick, Hyalomma mauri- tanicum was the vector. : Relapsing Fever. The epidemic of louse- borne relapsing fever, which involved all Algeria 573 North Africa in 1943-46, was the first major outbreak to attack Algeria since 1912-15. In the interim only occasional cases were re- ported, although unrecognized infections undoubtedly existed in many localities. The 1943-46 outbreak originated in the Fezzan region in Libya and penetrated to Algeria by two routes, west and north. A minor wave of infection invaded the Touggourt and Biskra region late in 1943. Over 2,700 cases were reported, but they probably rep- resented a small part of the total incidence. The principal spur of the epidemic spread through Tunisia to northern Algeria. It reached the Department of Constantine in November, 1944, and progressed westward through the Departments of Alger and Oran to Morocco. The incidence rose rap- idly, reaching its peak in March and April in the east and in July in the west, and sub- sided to a relatively low level by the end of 1945. The official reports list over 16,000 cases in the three departments. However, the actual incidence was estimated at 160,000, or more probably 400,000. The wide- spread undernutrition and the high degree of louse infestation, together with a paucity of soap and clothing, accelerated the spread of the infection. The fatality rate averaged between 3 and 10 per cent. Secondary spo- radic outbreaks were recorded in 1946, with 3,156 cases reported from northern Algeria and 9,991 from the Territoires du Sud. Sys- tematic disinfestation of the populations was employed in the epidemic areas to curb the spread of the disease. Tick-borne relapsing fever, “fiévre recur- rente hispano-nord-africaine,” occurs in mild sporadic outbreaks in the Tell, the chotts regions and the northern Sahara. It has not been reported from the southern oases. The infection usually is transmitted by Ornithodorus erraticus, but O. savignyi is a potential vector in the arid regions of the northern Sahara. Leishmaniasis. Cutaneous leishmaniasis, known locally as “clou de Biskra” or “bouton d’Orient,” is common in many lo- calities from the littoral to the desert. Major foci exist in the vicinity of Biskra and among the foothills of the Saharan Atlas mountains. The infection is frequent in the northern oases, particularly along the Moroccan frontier from Oasis Figuig to Beni Abbés. It occurs sporadically in the Tell, the cases being more numerous in Con- stantine than in Oran. Only rare instances of infection are recorded from the steppe region of the Hauts Plateaux. The disease is apparently absent from the Sahara, south of 30° N. latitude. Phlebotomus papatasii and P. sergenti, the most probable vectors, are widely distributed. Kala-azar is occasionally reported from the coastal region. The disease is of the Mediterranean type, caused by Leishmania infantum, and is found primarily in young children. P. perniciosus is a probable vector. Plague. Small localized outbreaks of plague develop at irregular intervals, usually originating in the port cities. From 1927 through 1945, a total of 235 cases was re- corded. The epidemics within recent years include 86 cases in the Department of Con- stantine in 1931; 16 cases in Algiers in 1940 and 67 in 1944; and 11 cases divided be- tween Algiers and Oran in 1945. In the 1931 epidemic and in the Oran outbreak of 1945, the cases were predominantly pneumonic in type. Vaccination of the exposed popula- tions is undertaken in all outbreaks, in combination with rat extermination meas- ures. Antiplague vaccines prepared at the Institut Pasteur are employed. Xenopsylla cheopis is the most important flea vector. Pulex irritans was tentatively implicated in a neighborhood outbreak in Aumale in 1921, which involved 185 cases and 97 deaths.” Other Infections. Yellow fever has not been present in Algeria within recent years. However, Aedes aegypti is widely distrib- uted throughout the coastal region, and precautions are enforced by the Algerian health authorities against its introduction from central Africa. Dengue fever is en- demic. Sandfly fever is not specifically re- ported, but the Phlebotomus vectors are 574 Algeria prevalent. Tularemia has been described from Tunisia and may exist in adjacent por- tions of Algeria. Filariasis is not indigenous, but occasional cases of Wuchereria ban- crofti infection are recorded among the migratory laborers. Elephantiasis, of un- known origin, is sometimes found among the Arabs of the south. Dracontiasis, or guinea-worm infection, may be encountered among the Touaregs in the Ahaggar region. The infection probably is acquired during visits to adjacent areas in French West Africa. NUTRITIONAL DISEASES Undernutrition is widespread among the native populations, but statistics regarding the prevalence of specific deficiency diseases is generally lacking. Mild scurvy is frequent among certain nomadic tribes. Mottled enamel, exostoses and general osteopetrosis occur among the inhabitants of the phosphate-mining areas. The water supplies of the regions in the vicinity of the phosphate deposits have an excessively high fluoride content. Fluorine poisoning is some- times responsible for fatalities in sheep and other animals. Goiter is found in numerous foci on the Mediterranean slopes of the Atlas moun- tains in Constantine, on the Mitidja plain and in western Oran. MiscerLLaNEoUSs CONDITIONS Infectious hepatitis is endemic, and local- ized outbreaks are reported sporadically. Drug addiction is common; hashish (Can- nabis indica) and other drugs are widely used. SUMMARY Algeria has a complex administration under the authority of a Governor-General. The three northern departments of Alger, Oran and Constantine, which include three quarters of the population, are overseas provinces of France, while the southern ter- ritories, comprising 85 per cent of the total land area, have a semimilitary government. The public health services of the three departments are administered by the Direc- tion de la Santé Publique et de la Famille, with headquarters in Algiers. The Direction is responsible for the medical care of the European and the Moslem populations, for the control of communicable diseases and for the institution of sanitary and preventive measures. The latter are enforced through departmental Services and municipal Bu- reaux d’Hygiéne. The Service de la Santé in the Direction des Territoires du Sud car- ries on a comparable program in southern Algeria. The Institut Pasteur d’Algérie, one of the foremost research organizations in North Africa, co-operates with the Algerian government in the investigation of human, animal and plant diseases. Medical and health work is also conducted by subsidized religious and philanthropic organizations. Well-equipped hospitals are located in all the larger population centers. In northern Algeria, in 1949, there were 44 major hos- pitals with an aggregate capacity of 16,379 beds, and 77 regional auxiliary hospitals with a capacity of 1,967 beds. In the Terri- toires du Sud there were two hospitals and scattered infirmary-dispensaries which pro- vided a total of 510 beds. The water supplies in northern Algeria are ample but dependent on rainfall condi- tions. There are few perennial rivers. Com- munity supplies for domestic and irrigation purposes are derived from storage reservoirs or wells. Rainfall is precarious in the south- ern territories, and water is generally scarce. Supplies are largely obtained from subter- ranean sources, by deep and artesian wells or, on some oases, by underground channels. Many of the larger cities have modern water and sewerage systems. Sanitation is primi- tive in the native and the rural areas, how- ever, and local supplies are frequently con- taminated. The distribution of the diseases of pri- mary importance in Algeria is governed not only by physiogeographic and environ- mental factors but also by the economic, occupational and nutritional status of the individual. Malaria, trachoma, tuberculosis, venereal infections, helminthiasis and en- Algeria 575 teric diseases are prevalent. Louse-borne typhus and relapsing fevers occur in wide- spread epidemics. Sckistosoma haematobium infections are frequent in limited foci. Cu- taneous leishmaniasis is common in exten- sive areas, while kala-azar is occasionally re- ported from the littoral. Mycotic skin infec- tions are numerous. Pneumonia, measles and whooping cough are often epidemic. Smallpox is controlled by systematic vac- cination, but localized outbreaks are re- ported almost annually. Small outbreaks of plague occur from time to time, usually in the port cities. Meningococcus menin- gitis, diphtheria, scarlet fever and poliomye- litis are sporadic. Rabies, infectious hepati- tis, murine and tick-borne relapsing fever are endemic. Leprosy is rare, but a few limited foci exist. Yellow fever and cholera have not been reported within recent years. BIBLIOGRAPHY 1. Aiguir, C.: Djanet (pays Ajjer), étude géo- graphique et médicale, Arch. Inst. Pasteur d’Algérie 16:533-587 (Dec.) 1938. 2. Alcay, L., Marill, F., Musso, J., and Castryck, R.: Découverte d'un foyer de bilharziose vésicale autochtone en Algérie, Bull. Soc. path. exot. 32:608-612 (June 14) 1939. 3. , ——, ——, ——: Premiére enquéte sur le foyer de bilharziose vésicale de Saint-Aimé-de-la-Djidiouia (Oran), Arch. Inst. Pasteur d’Algérie 27:421-428 (Sept.) 1939. 4. Bernard, Augustin: L’Algérie, Paris, Lib- rairie Renouard, 1931. 5. Bodley, R. V. C.: Algeria from Within, Indianapolis, Bobbs, 1927. 6. Casserly, Gordon: Algeria Today, New York, Stokes, 1923. 7. Catanei, A.: Etude des caractéres morpho- logiques et biologiques de champignons levuriformes isolés chez ’homme en Al- gérie, Arch. Inst. Pasteur d’Algérie 23: 45-49 (Mar.) 1945. 8. ——: Nouvelles observations sur les teignes en Algérie et dans les colonies francaises, Arch. Inst. Pasteur d’Algérie 24:116-121 (June) 1946. 9. ——: Sur la répartition de différentes espéces de champignons des teignes de ’homme en Afrique, Arch. Inst. Pasteur d’Algérie 17:613-624 (Sept.) 1939. 10. Collignon, E.: Liste des localités d’Algérie ou le paludisme est endémique avec indi- cation du taux d’endémicité, Bull. Office internat. d’hyg. pub. 34:131-139 (Mar.- Apr.-May) 1942. 11. ——: Zones paludéennes en Algérie et prin- cipes généraux de la prophylaxie, Bull. 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Office internat. d’hyg. pub. 38:622-644 (July., Aug., Sept.) 1946. : Notes sur la peste en Algérie, Bull. Office internat. d’hyg. pub. 37:419-444 (July, Aug., Sept.) 1946. , and Carle, Dr.: Le fonctionnement de la santé maritime d’Alger de 1937 a 1945, Bull. Office internat. d’hyg. pub. 37:29-46 (Jan.-Apr.) 1945. Imbreaux, et al.: Annuaire statistique et descriptif des distributions d’eau et égouts de France, Algérie, Tunisie, Maroc et Colonies frangaises, Belgique, Suisse et 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53, 54. Grand-duché de Luxenbourg, Volume II, 3rd ed., Paris, Dunod, 1931. Institut Pasteur: L’oeuvre de [IInstitut Pasteur en Algérie. Documents algériens. Service d’Information du Cabinet du Gou- verneur Général de I’Algérie 9: (Sept. 15) 1946. Jude, A., and Le Minor, L.: Fréquence de certains types de Salmonella (bacilles typho-paratyphoidiques) au Maroc et en Algérie, en milieu vaccine, Bull. Soc. path. exot. 41:124-129 (3-4) 1948. Lartigue: La lutte contre la trachome en Algérie, Bull. Office internat. d’hyg. pub. 31:486-487, 1939. Lasnet: La lymphogranulomatose inguinale en Algérie, Bull. Office internat. d’hyg. pub. 27:1970-1971 (Oct.) 1935. ——: Organization administrative et sani- taire des pélerinages algériens aux lieux saints de IIslam, Bull. Office internat. d’hyg. pub. 27:2192-2201 (Mar.) 1935. : La lutte contre les maladies vénérien- nes en Algérie, Bull. Office internat. d’hyg. pub. 35:129-143 (Mar.-Apr.) 1943. Lespés, René: Pour comprendre 1’Algérie, Alger, les Presses de I’Ancienne Imprimerie Victor Heintz, 1937. Ouvrage publié sous les auspices du Gouvernement Général de Algérie, 1937. Manya: Note sur une endémo-épidémie de bilharziose, Bull. san. d’Algérie 34:159-160 (June) 1939. Marill, F. G.: La bilharziose vésicale en Algérie. Programme de prophylaxie. Cahiers méd. union francaise, Algiers 2: 677-691 (Nov.) 1947; Abst., Trop. Dis. Bull. 45:798-799 (Sept.) 1948. , Alcay, L., and Musso, J.: Un cas algérien de bilharziose intestinale autoch- tone, Bull. Soc. path. exot. 32:822-823 (Oct.) 1939. ——, Hofman, M., and Bertozzi, P.: Le foyer de bilharziose urinaire de Fondouk (Algérie), Arch. Inst. Pasteur d’Algérie 27:110-127 (June) 1949. Meunier, R.: Le laboratoire de la peste de la santé maritime d’Alger, Bull. san. de Algérie 35:507-509 (Mar.) 1940. Monfort, R.: Le parasitisme intestinal chez les indigénes sédentaires de Beni Ounif (Sud Oranais), Arch. Inst. Pasteur d’Al- gérie 14:62-65 (Mar.) 1936. Montagny, J.: Le probléme de l'alimenta- tion des indigénes en Algérie, Bull. san. de I’Algérie 33:1721-1724 (Nov.) 1938. Nevou-Lemaire, M.: Etude des culicides africains, Arch. Parasit. 10:238-288, 1906. 58. 56. 37: 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. Pallary, M. P.: Les scorpions du Sahara cen- tral, Bull. Soc. Hist. Natur. de I'’Afrique du Nord 20:133-141, 1929. Parrot, L.: Les espéces algériennes du genre Phlebotomus (Psychodidae), Bull. Soc. Hist. Natur. de I’Afrique du Nord 26:145- 149, 1935. La Pasteurisation des laits de consomma- tion, Bull. san. de I’Algérie 34:1-18 (Jan.) 1939. Piana, L.: Essai médical sur le Souf (annex d’el Oued, Sud Constantinois), Arch. Inst. Pasteur d’Algérie 17:530-569 (Sept.) 1939. Rames, C.: Sur lexistence du bouton d’Orient a Beni Abbés (Sahara Oranais), Arch. Inst. Pasteur d’Algérie 17:482-483 (Sept.) 1939. Raynaud, M.: Foyer de bilharziose humaine dans la région de Saint Aimé, Bull. san. de Algérie 34:291-307 (Oct.) 1939. , Colonieu, L., and Hadida, E.: L’or- ganisation de la lutte anti-vénérienne en Algérie, Alger, Imprimeries la Typo-Litho et Jules Carbonel Reunies, 1938. Roumagoux, J.: Un cas de bouton d’Orient autochtone a Mecheria (Hauts Plateaux Oranais), Arch. Inst. Pasteur d’Algérie 25:196-198 (Sept.-Dec.) 1947. 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Inst. Pasteur d’Algérie 23:183-223 (Sept.) 1945. Velu, H.: Le darmous (ou dermes) fluorose spontanée des zones phosphatées, Arch. Inst. Pasteur d’Algérie 10:41-118 (Mar.) 1932. Vachon, Max: Etudes sur les scorpions, Arch. Inst. Pasteur d’Algérie 28:152-216 (June) 1950. Wilson, J. H.: Malaria in North Africa, 1944, J. Roy. Army. M. Corps 85:33-40 (July) 1945. 44 Tunisia GEOGRAPHY AND CLIMATE Tunisia, officially known as the Regency of Tunis, has been a French protectorate since 1881-83. The smallest of the Barbary states of North Africa, it has an approxi- mate area of 48,000 square miles and is sur- rounded on the north and the east by the Mediterranean Sea, on the southeast by Libya, and on the west and the south by Algeria. It is divided into the five provinces of the Regency proper and the military Ter- ritoires du Sud, which incorporate roughly 17,000 square miles of desert country to the south. French and Beylical systems of ad- ministration exist side by side, except in the southern territories, which come under the direct jurisdiction of the Resident-General, the representative of the authority of France. The topography is varied. Northern Tunisia is a highly mountainous region, with a rugged coastline containing bold promontories which shelter some of the finest harbors along the Mediterranean. Commonly designated as the Tell, it em- braces two Atlas chains which terminate at Cape Blanc and at Cape Bon and are sepa- rated by the wide fertile valley of the Medjerda river. Inland the massifs of the High Tell and Dorsale Mountains rise to from 4,000 to 5,200 feet. To the south they merge with the high steppe of central Tu- nisia which slopes eastward to the broad coastal plain of the Sahel, extending from the Gulf of Hammamet to the Gulf of Gabeés. Southern Tunisia is predominantly desert. The region along the edge of the central plateau is studded with c/kotts, salt 578 lakes and marshes, which lie partially below sea level. Some, like the extensive Chott el Djerid, are fringed by numerous oases in which date palms are grown under irriga- tion. The southern desert contains a few scattered oases but is largely uninhabitable. The coastal plain from Gabes to the Libyan frontier is narrow. The adjacent Ile de Djerba, separated from the mainland by a narrow strait, is the most prominent feature of this area. The Tell is bisected by numer- ous rivers which flow to the Mediterranean. However, the water courses of the central plateau and the Sahel plain drain toward the numerous closed, inland basins. The streams, or oueds, of the central and the desert regions are seasonal and flow only during periods of heavy rainfall. The climate, which ranges from Mediter- ranean in the north to Saharan in the south, is modified by the proximity of the sea and by the variations in altitude. There are es- sentially two seasons: summer from May to September, and winter from October to April with brief transitional interludes. With the exception of occasional local storms, the rainfall is concentrated in the winter months. It fluctuates appreciably in amount from year to year. In general, the annual precipitation decreases from 50 to 60 inches in the western highlands to from 20 to 26 inches at Bizerte and around 16 inches in the basin of the Medjerda and on the plains of Tunis. In the Sahel region it ranges from 12 to 15 inches at Sousse to about 8 or 9 inches at Sfax. The rainfall in the south is slight and variable. It approxi- mates from 4 to 8 inches in the chotts area, but becomes almost negligible in the desert. Tunisia 579 Along the Mediterranean littoral the mean monthly temperatures range from 51 to 53° F. in January and February to 77° to 79° F. in July and August. Mean maximum tem- peratures of 106° to 108° F. are recorded in midsummer, and mean minimum tempera- tures of 36° to 40° F. in winter. The sea- sonal and daily fluctuations become more pronounced toward the Sahara. The humid- ity averages from 65 to 75 per cent in the coastal region. The hot, sand-laden sirocco winds, which blow spasmodically from the southwest, affect all parts of the country. They decrease in frequency and duration with the distance from the desert and may be slight in the districts protected by the Dorsale mountain chain. POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTion According to the census of 1946, the popu- lation of Tunisia was slightly over 3.2 mil- lion, including about 239,600 Europeans, enumerated as 143,980 French, 84,900 Italians, 6,500 Maltese and 4,200 of other nationalities. The French classification in- cludes individuals of French or colonial origin and naturalized citizens. The Italian contingent represents a strongly national- istic group, with independent social and economic interests, which has persistently resisted assimilation. Over half are settled in Tunis, while the remainder cultivate small farms in the fertile plains of the east- ern Tell. The Tunisian Jews totaled about 70,900 in 1946. They live in scattered com- munities throughout the country but have never been accorded mass citizenship as in Algeria. The native population, which is predominantly Moslem, is a mixture of Arabs and Berbers. Their distinguishing characteristics, however, have been largely eradicated by centuries of contact, political and social. The purest Arab peoples are found among the nomadic tribes of the plateaus and the desert, while groups of Berbers inhabit the Ile de Djerba and some of the southern oases. Both Arabic and French are employed as official languages. The Italians and the Jews cling to their native tongues, but, except in the few cen- ters where Berber culture and languages survive, Arabic is almost universally used by the Moslems. The population density averages 79 per square mile in the northern provinces and 10 per square mile in the Territoires du Sud. In the vicinity of Tunis, Bizerte, Béja and Zaghouan, in portions of the coastal plain near Sousse and in back of Sfax, on a large part of the Ile de Djerba and on some of the oases around Chott el Djerid, it exceeds 250 per square mile. Over half of the total population is concentrated in the provinces of Bizerte, Tunis and Le Kef, which repre- sent roughly one sixth of the total land area. Outside of the major cities, the sedentary populations are found largely in the agri- cultural areas of the Tell, in the Sahel and in the oases. Nomadic and seminomadic tribes inhabit the central plateaus and desert. The native population is almost 80 per cent rural, although the trend toward urbanization has increased within recent years. A large proportion of the Europeans reside in the coastal area; about 90 per cent, in urban communities. Tunis, the capital and the only metropolis in the Regency, had a population in 1946 of about 347,000, including 120,000 Europeans, or about one half of the total white population of the country. Sfax, the second city and the center of the olive industry, had a popula- tion of over 55,000. The ports of Bizerte and Sousse, Kairouan, a religious center of the Tunisian Moslems, and M’Saken are the only other towns of appreciable size. Three systems of education flourish in Tunisia—French, Franco-Arabic and Moslem. Primary and secondary schools, modeled after those of France, and trade schools are operated by the Protectorate government for the benefit of all races. Private schools are also maintained by Catholic orders and by Italian and Jewish organizations. Postsecondary school educa- 580 Tunisia tion is available in the Institut des Hautes Etudes, which is affiliated with the Uni- versité de Paris. The Tunisian government not only encourages the development of Moslem education but also subsidizes modernized Koranic schools and medersas, such as the Collége Sadiki in Tunis. The Université Ez Zitouna, connected with the Great Mosque in Tunis, ranks with the El Azhar in Cairo. Statistics for the city of Tunis in 1946 indicate that 62 per cent of the Moslem population were illiterate, and 28 per cent of the Jewish. VITAL STATISTICS No reliable vital statistics are available, except for the European inhabitants. The birth rates for the country as a whole, in 1945-47 ,*6 were estimated at 24.7 per 1,000 population for the Europeans, 38.9 for the Moslems and 38.3 for the Jews. The death rates were 11.9, 16.0 and 16.2, respectively. The infant mortality rates in the city of Tunis in 1945-47 were calculated at 92 per 1,000 live births for the Europeans, 209 for the Moslems and 105 for the Jews. Com- parable rates for 1948 were 68, 193 and 77, respectively. The mortality rates among the Moslem children, in both rural and urban areas, are reputed to be high, due to under- nutrition, ignorance and the prevalence of syphilis, malaria and intestinal diseases. SociaL Economy The resources of Tunisia are primarily agricultural, with mining second in im- portance. A large percentage of the Euro- peans and over 90 per cent of the Moslems are engaged in agricultural pursuits. In the early days of the Protectorate, the French promoted the development of large estates by individuals or commercial companies, and a considerable proportion of the land is cultivated according to a system of “meta- yage,” a form of tenant farming. Within recent years, however, there has been a growing trend toward the division of the larger holdings and a redistribution among French and Italian proprietors. In general, French capital is invested in the major projects, while the small farmers and the agricultural laborers are predominantly Italian or Moslem. Native methods of cul- tivation are primitive, except in areas de- veloped under European influence. The leading export crops are olives, grown in the eastern plains, and dates, produced on the oases in the ckotts and the desert re- gions. Other important exports include citrus fruits, garden produce, wheat and wines. Alfa (esparto) grass, used in the manufacture of paper, grows in the steppes of the central plateaus, and cork oaks grow in the mountainous regions of the north- west. Large herds of sheep and goats are raised by the nomadic tribes. Limited num- bers of cattle are produced in various areas; also horses, camels, donkeys, mules and pigs. The mineral wealth of the country cen- ters around the phosphate deposits, which are located largely in the vicinity of Gafsa and north of the Chott el Djerid, and the iron ore of the northwestern highlands. Tunisia is normally one of the largest pro- ducers of phosphate rock in the world. Lead, zinc and other minerals are mined in small amounts. Industrial development is re- stricted by the paucity of natural fuels to the processing of olive oil and other local products. Tunisia was one of the major battle grounds in the African campaign of 1941-42 and suffered considerable destruction of buildings, machinery and lands under cul- tivation. Ambitious reconstruction plans in- clude the promotion of extensive irrigation projects, particularly in the central plains. Communication facilities are reasonably well organized. The network of roads which radiates from and connects Tunis, Bizerte, Sousse, Sfax and Gabés includes trunk roads to the neighboring colonies. A gov- ernment-owned railway, with terminals at Tabarka, Bizerte and Tunis, links Tunisia with the Morocco-Algerian system. Private lines also provide outlets from the mining areas to the shipping centers. Tunis, Tunisia 581 Bizerte, Sousse and Sfax are major ports for steamer traffic, while Tunis is a cehter for air services to Europe, the Near East and other African territories. Foop AND NUTRITION The nutritional status of the people is variable. In the cities it is essentially an economic problem; in the rural areas it is also governed by local environmental and climatic conditions. The basic diet of the sedentary Moslems consists of grains, barley, olive oil and divers fruits and vege- tables. Couscous, prepared from coarse flour with the addition of vegetables, meat or milk, is a staple dish. Meat is consumed ir- regularly. Fish are plentiful near the coast. Milk from sheep and goats is used when available, both in the form of milk and un- salted cheese. Soured milk is preferred by all except the Berber tribes. Cow’s milk is utilized by the Europeans but rarely by the Arabs and the Berbers, except for butter. Milk, cheese, cereals, vegetables and dates are the regular constituents of the diet of the nomadic tribes. It is supplemented oc- casionally by meat, most frequently mutton and game. The nutrition of the different peoples has been the subject of numerous investigations conducted by the staff of the Institut Pas- teur in Tunis. A diversity of food habits exists among the various racial and social groups. The diet of the average Tunisian, however, appears to be deficient in calories, in proteins and in vitamins A and C. The Moslem religious observances and the re- current crop failures are factors which must be considered in evaluating the nutritional status of the people. Housine Housing conditions throughout the coun- try are influenced by racial and social customs, by tribal traditions and by the economic and educational status of the in- dividual. The larger cities and towns are divided into European and Moslem quar- ters. They resemble the cities of the Near East more closely than those of Algeria and Morocco. The building materials are typi- cally stone, brick, concrete or mud. The Arab houses in the towns are two-storied and are built characteristically around courtyards. The interiors are usually dark, poorly ventilated and {frequently over- crowded. Throughout the Tell and the northeastern steppes the rural dwellings consist of one or two rooms in which narrow doors constitute the only opening. The roofs are low and are made of thatch or branches. In the eastern plains, flat tile roofs facilitate the collection of water, while the courtyards shelter the livestock. Many of the villages of the oases are surrounded by high walls which formerly served for forti- fication. Distinctive forms of construction are found in certain areas: cave dwellings in Matmata and many-storied ghorfas in Médenine, Matameur and the surrounding country. Large sections of the population of south- ern Tunisia are migratory, at least part of each year. Most of the cereal farmers move to tents or huts near their fields from plant- ing to harvest. The nomads and semino- madic pasturalists live in tents which are grouped in family encampments of varying size. ENVIRONMENT AND SANITATION WATER SUPPLIES In northeastern Tunisia, where rivers and streams are numerous, storage reservoirs and wells constitute the principal sources of water supply. Subsoil collections of water are small and unreliable, however, and it is frequently necessary to pipe urban supplies over considerable distances. More- over, the water in many localities has an ob- jectionably high mineral content. Potable subsurface sources are generally scarcer in the north than in the south, in spite of the greater rainfall. Water is furnished to the city of Tunis by aqueducts from spring-fed reservoirs at Zaghouan, Djouggar and Bargou and from a large reservoir con- 582 Tunisia structed in 1927-31 on the Oued Kébir. Auxiliary supplies are obtained from wells at Khledia and in the valleys of the Oueds Kébir and Bakbaka, and more recently from a reservoir on the Oued El Lil. In the southern and the central parts of the country there are no perennial rivers, and water supplies are derived from subter- ranean sources or in some cases from small catchment basins. Wells, sunk in or near stream beds, and artesian borings provide water for domestic and irrigation purposes. The flow varies but is relatively independent of rainfall conditions. In 1939 government-controlled water sup- plies were available to about 90 per cent of the urban population. The municipal sup- plies in the larger cities are supervised by the local health authorities and are treated by chlorination when the results of bacterio- logic examinations appear to warrant it. Contamination is frequent in both urban and rural areas. Major projects to furnish water for irri- gation and electric power and in some cases for drinking purposes have been developed on the Medjerda river and its major tribu- taries and on the Oueds Zeroud and Miliane. The irrigation of extensive areas in the eastern plains is also contemplated as part of the reconstruction program of the Tuni- sian government. Waste DisposaL Modern systems of sewage disposal are found only in certain sections of the larger cities. In the old Arab quarters and in the rural villages the methods employed are generally primitive. The sewage of the city of Tunis is treated in a disposal plant at Montplaisir. Part of the effluent is used on the land, and the remainder is piped to the lake. Fauna AnD FrLora Arthropods. Mosquitoes. As in Alge- ria, Anopheles labranchiae labranchiae (= Anopheles maculipennis labranchiae) is the principal vector of malaria throughout northern Tunisia, while A. sergenti and A. multicolor transmit the infection in the Saharan regions. 4. kispanola, A. algeriensis and A. coustani are encountered in the northern part of the country. 4. super pictus has been reported from the Sahel. Other species are probably present, but none is of medical importance. A. labranchiae labranchiae is widely dis- tributed from the littoral to the ckotts re- gion. It breeds abundantly from April to November in swamps, slow-flowing and weedy streams, irrigation canals, wells and various collections of water containing vegetation. It may become adapted to waters with a salinity up to one per cent. A. sergenti is found both in the Tell and in the southern territories. It breeds in fresh water, while A. multicolor prefers brackish. The latter species is particularly prevalent in the vicinity of Kebili, Tozeur, Gabés and Tatahouine and on the Ile de Djerba. Anopheline control measures are carried on by the antimalarial branch of the Tuni- sian health service in co-operation with the - governmental departments of agriculture and public works. A few major drainage projects have been undertaken, especially in the northwest and in the vicinity of Tunis. In most areas, however, antilarval measures constitute the principal means of control. Oil and DDT sprays are used ex- tensively, while large bodies of water are frequently stocked with the larvivorous fish, Gambusia. Aedes aegypti is prevalent during the summer in the coastal area. Numerous other species, including 4. caspius, A. detritus and A. pulchritarsis asiaticus, are also known to be present. Six species of Culex have been specifically recorded: C. quinquefasciatus (=C. fatigans), C. apicalis, C. hortensis, C. pipiens, C. impudicus and C. latricinctus. Fries. Flies are abundant. Many species are predominantly pests, but some are im- plicated in the mechanical transmission of intestinal and other diseases. Myiasis-pro- ducing flies are numerous. Woklfahrtia magnifica, Oestrus ovis, Rhinoestrus pur pu- 583 Tunisia reus, Sarcophaga haemorrhoidalis, S. beck- eri, S. fertoni and S. tuberosa exuberans are responsible for occasional cases in man. Sev- eral species of Phlebotomus are reported, including P. papatasii, P. perniciosus, P. sergenti, P. fallax and P. minutus (= P. africanus). Various species of MuscCIDAE, and TaBanipaAE are found; also species of SimuLnpAE in the Tell area. Lice. Pediculus humanus corporis is wide- spread. It is the vector of louse-borne ty- phus fever, which is endemic throughout this region, and of louse-borne relapsing fever, which occurs sporadically in devastat- ing epidemics. P. humanus capitis and Phthirus pubis are also common. Freas. Xenopsylla cheopis is abundant and probably is the most important vector of plague in both urban and rural areas. It is the species most frequently found on cap- tured rodents. Ctenopsyllus segnis, Cera- tophyllus barbarus, C. fasciatus, C. londini- ensis, Ctenocephalides felis and C. canis are likewise prevalent. Pulex irritans is encoun- tered sometimes. BepBucs. The bedbug, Cimex lectularis, is found in all parts of the country. Ticks AND Mites. Ornithodorus erraticus is widely distributed from the Mediterra- nean to the chotts region; O. savignyi, on the oases. The former is the principal vector of tick-borne relapsing fever which occurs in small localized outbreaks. Rkipicephalus sanguineus is common and is responsible for the transmission of occasional cases of fievre boutonneuse. Other species of Rkip- icephalus and of Hyalomma, Haemaphysa- lis, Amblyomma and Argas are found in various parts of the country. The common itch mite, Sarcoptes scabiei, is widespread. Pediculoides ventricosus, the grain itch mite, produces skin eruptions on workers handling barley and straw. SCORPIONS AND SPIDERS. Scorpions are numerous, and fatalities from scorpion stings are sometimes recorded. Prionurus australis and Scorpio maurus are the most important species. Several species of Buthus and Buthacus are also reported. Therapeutic antiserums are obtained from the Institut Pasteur in Algeria. The black widow spider, Latrodectus tredecimguttatus, may be present. OtHER ArTHROPODS. Dangerous beetles include Lytta (Cantharis) vesicatoria and others of the family MeroipaE, which exude irritating vesicant substances. The ground beetle, Anthia (Thermophila) sexmaculata, is capable of ejecting an acid secretion for several feet. Reptiles. The Egyptian cobra, Naja kaje, is widely distributed in central and south- ern Tunisia. The sand vipers, Aspis cerastes (= Cerastes cornutus) and A. vipera (= C. vipera), are encountered on the northern fringe of the Sahara. Vipera lebetina mauritanica and V. latastei are found in mountainous areas of the north- west. Rodents. Numerous species of domestic and wild rodents are present. Rattus norvegicus is prevalent in Tunis and the port cities but is almost entirely absent from the rural districts. R. rattus rattus and R. rattus alexandrinus are widespread. Plague is enzootic among the rats in Tunis and other areas, and sporadic outbreaks of human infection are frequent, both in the coastal region and in the interior. Psam- monys, one of the most common wild rodents in the south, is particularly suscep- tible to plague. Rat-control measures are undertaken by the local health authorities in Tunis. Thousands of rats are captured each year and examined for evidence of murine infection. Mollusks.* Bulinus snails are present in many localities, particularly in areas under irrigation. Bulinus truncatus is widely dis- tributed throughout Tunisia, but most abun- dant in the oases around Chott El Djerid and in the vicinity of Gafsa and Kairouan. It is the intermediate host of Schistosoma haematobium which occurs in limited foci. Planorbis snails are found in a few locali- ties on Cape Bon peninsula, but S, mansoni has not been reported. * See footnote, p. 10. 584 Tunisia Other Animals. The leech, Limnatis nilotica, is of some medical importance. Oc- casional instances of ingestion of the almost invisible, small forms in drinking water have been recorded. The worm may become at- tached in the pharynx, tonsils, vocal cords or nasal cavity, producing symptoms of aphonia or epistaxis. Foop SANITATION The supervision of markets, restaurants and other food establishments is undertaken by the municipal health authorities in the larger cities. The sanitary quality of the meat and the milk supplies is controlled by inspectors of the government veterinary services in the cities and by the medical of- ficers in the rural areas. The standards of sanitation are low among the native popu- lations. The insanitary habits of the peo- ple, the frequent use of human excrement as fertilizer and the prevalence of flies are responsible for the contamination of foods sold by vendors or in markets and eating establishments. HEALTH SERVICES AND MEDICAL FACILITIES HEALTH ORGANIZATIONS Authority for the protection of the public health and the medical care of the popula- tions in Tunisia resides in the Ministére de la Santé Publique, which was created in 1947. The Ministére, which has its head- quarters in Tunis, is organized in two divi- sions—administrative and technical. Incor- porated under the latter are Services de I’Hygiéne Publique and Services de I'Hy- giéne Sociale. The Services de I'Hygiéne Publique are charged with the supervision of environmental sanitation, international quarantine and the control of epidemic and endemo-epidemic diseases, particularly ma- laria, typhus fever, smallpox and typhoid fever. The Services de I’Hygiéne Sociale are responsible for the conduct of special pro- grams for the control of tuberculosis, vene- real diseases and trachoma and the protec- tion of the health of infants and children. Subsidiary to the central organization are services concerned with the maintenance of hospitals, polyvalent or multiple dispensa- ries and rural medical facilities, and the dis- tribution of pharmaceutical supplies. The Regency is divided into 57 sectors, each of which is administered by a medical of- ficer who directs the activities of the Minis- tére in his respective area. Municipal Bu- reaux de I’Hygiéne are responsible for the enforcement of public health measures in Tunis and the larger cities. The medical care of the inhabitants in the Territoires du Sud is undertaken by French army personnel. French, Italian, Moslem and Jewish re- ligious and philanthropic organizations carry on public health and welfare work among their respective communities. The Comité Central de Protection et d’Assistance de I’Enfance operates child welfare programs throughout the Regency. The Societé de Secours aux Blessés Militaires, a compo- nent of the French Red Cross, maintains dispensaries, milk stations and nurseries and conducts courses in nursing. The Ligue Antituberculeuse supports tuberculosis dis- pensaries and preventoria in co-operation with the Ministeére. MEepicAL INSTITUTIONS Hospitals and Dispensaries. In 1948 the Ministére de la Santé Publique controlled 7 hospitals with an aggregate capacity of about 2,600 beds. Four hospitals, ranging in size from 230 to 770 beds, were located in Tunis, as well as a mental hospital at Manouba. Two hospitals, each with a capac- ity of from 230 to 300 beds, were estab- lished in the provinces, at Sousse and Sfax. The Ministére also maintained the follow- ing: 33 regional infirmaries, with a total of about 1,046 beds and subordinate dispensary services; “polyvalent” dispensaries at Bi- zerte, Sousse, Sfax and Le Kef, with special facilities for the treatment of tuberculosis, trachoma and venereal diseases; 22 oph- thalmologic dispensaries; and 162 rural clinics. In the Territoires du Sud, infirma- ries operated by military personnel are es- tablished at Tataouine, Ben Dardane, Zarzis, Médenine, Matmata and Kebili. In the same year 24 small private hos- pitals and clinics, providing approximately 294 beds, were conducted by French, Italian, Moslem and Jewish societies in the urban centers. A private sanatorium for tubercu- losis patients is located at Kram. Tuber- culosis preventoria are operated by the Ligue Antituberculeuse at Bizerte and Zaghouan, and by Jewish philanthropies at Ariana near Tunis. Laboratories. The Institut Pasteur de Tunis, which is affiliated with the Institut Pasteur in Paris, functions in liaison with the Ministére de la Santé Publique. It per- forms chemical, bacteriologic, serologic and parasitologic examinations for the medical and the veterinary services of the govern- ment ; manufactures vaccines, serums and other products used in the prevention and the treatment of human and animal dis- eases; conducts special rabies, vaccination and fermentation services; and carries on research in the epidemiology and the con- trol of plague, malaria and other diseases. It maintains regional laboratories in Sousse, Sfax and other centers, and co-oper- ates in the work of the malaria laboratory of the Services de I’'Hygiene Publique. Research laboratories are also located in the Institut des Hautes Etudes. Diagnostic laboratories are available in the larger hos- pitals. Schools. There are no medical schools in Tunisia. Nurses and other medical person- nel are trained in the larger hospitals. The Hopital Sadiki for Moslems in Tunis main- tains a training school for visiting nurses. PERSONNEL Physicians. Approximately 472 physi- cians were registered in Tunisia in 1948, 297 of whom were practicing in the city of Tunis. A total of 91 doctors was employed in the health services of the Ministére de la Santé Publique, and from 69 to 90 in the hospitals. i Tunisia 585 Dentists. In the same year 59 dentists were registered in the country. Others. The roster of medical personnel on the staff of the Ministére in 1948 in- cluded 21 midwives, 364 nurses and 13 nursing aides. In addition, about 160 phar- macists, 28 veterinarians and 120 midwives were reported as working independently in the Regency. DISEASES Estimates of disease incidence based upon hospital and dispensary statistics are grossly inadequate. The cases treated by the gov- ernment medical officers represent but a fraction of the total morbidity. Moreover, the mortality statistics are frequently faulty, due not only to incomplete reporting but to lack of differential diagnosis. The nomadic and migratory habits of fully half of the native population, and the pilgrim- ages to Mecca and the numerous local shrines or Zaouia are important factors in the spread of infectious diseases, while the lack of personal hygiene and insanitary living conditions of the people facilitate transmission in both urban and rural envi- ronments. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fevers are prevalent. The incidence is highest at the beginning of the rainy season, reaching a peak between September and December. From 300 to 900 cases are re- corded each year, and the actual infection rates are presumably much greater. Im- munization with typhoid-paratyphoid vac- cine is carried on in many parts of the country. The incidence was unusually high in Tunis in 1941-43, and immunization against typhoid fever was made compulsory for the inhabitants of the city and suburbs in 1943. Paratyphoid fevers A and B are observed less frequently. Among 230 strains isolated in the laboratories of the Institut Pasteur in Tunis from 1936 to 1940, all but 586 Tunisia two were Eberthella typhi® The Institut maintains a special service for the promo- tion of immunization against typhoid and paratyphoid fevers, diphtheria and tetanus in the vicinity of Tunis. Dysenteries. Both amebic and bacillary dysentery are common. The reported cases number from 150 to 300 annually—a total obviously not indicative of the true extent of these infections. No differentiation is made between cases of amebic and bacillary origin. Diarrhea and enteritis are wide- spread and are important causes of infant mortality. Insanitary methods of sewage disposal, which result in contaminated water sup- plies, shellfish and garden produce, the abundance of flies and the unhygienic prac- tices of the people contribute to the high incidence of intestinal infections. Helminthiases. Scristosomiasis. Nu- merous localized foci of Schistosoma hae- matobium infection exist in southern Tunisia, especially in the low-lying region Schistosomiasis in Tunisia of the chotts. Occasional cases are recorded from Kairouan, but the country north of that point is apparently free from the dis- ease. The most heavily infected areas are found in the vicinity of Gafsa, Kebili and Nefzaoua and on the Djerid oasis of El Oudiane. Bulinus snails, the intermediate hosts of S. haematobium, are abundant in the irrigation canals and the bathing pools in these regions. In the examination of 964 specimens of urine at Gafsa in 1932,°¢ ova of S. haematobium were identified in 58 per cent. Surveys of three villages on El Oudiane, reported in 1941,% showed that the infection rates among the men ranged from 20 to 86 per cent; and among the boys under 15 years of age, from 42 to 80 per cent. In the case of the women and the girls, they were from 0 to 55 per cent and 72 per cent, respectively. Differences in infection rates among adults are largely occupational. S. mansoni has not been reported. Ancyrostomiasis. Hookworm infection, caused by Ancylostoma duodenale, is prev- alent among the cultivators in the densely populated, irrigated areas of southern Tu- nisia. Infection rates of from 10 to 30 per cent have been demonstrated? in the vicin- ity of Gabes and Gafsa, and on the oases around Chott el Djerid. Soil pollution, com- bined with the barefoot habits and the ritualistic practices of the people provide favorable conditions for the dissemination of the larvae, Otuer Herminta INFECTIONS. Ascaris lumbricoides and Trichuris trichiura are widely distributed. Echinococcus infections are frequent among the nomadic and semi- nomadic tribes. The tapeworm, Taenia saginata, is present among the cattle, and human infections are observed occasionally. Cysticercosis is found in from 2 to 3 per cent of the animals slaughtered in the abattoir at Sousse.'® Fasciola hepatica is common among the sheep, and a few human cases have been described. Cholera. Cholera has not been present in Tunisia within recent years, but several out- breaks were recorded in the last century. Tunisia 587 The last epidemic occurred in 1911, when 733 cases were reported from Tunis and the surrounding suburbs. The fatality rate was between 60 and 65 per cent. Brucellosis. Brucellosis is enzootic among the goats and cattle. Both Brucella melitensis and B. abortus are reported as present. Less than 30 human cases are re- corded each year, but unrecognized infec- tions are undoubtedly numerous, resulting from the ingestion of milk or milk products, as well as from contact with infected animals. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is a major public health problem in Tunisia. The actual incidence is not known, but ap- parently it is highest among the Moslems and lowest among the Tunisian Jews. From 500 to 800 cases are reported each year. The annual death rates, which ranged between 175 and 275 per 100,000 population before 1939, have risen within recent years as the result of the social and economic disloca- tions associated with the war years of 1940- 43. The poverty, poor housing, inadequate nutrition and ignorance of personal hygiene existing among the native populations pro- mote the spread of the disease. Its control is hampered by the fact that sufferers are stigmatized and hence hidden whenever possible. Pulmonary infections predominate, but other forms of tuberculosis are fre- quent. A large proportion of the reported cases are ascribed to Tunis and the larger cities, but the infection is increasing in the rural areas. Tuberculin tests made in con- nection with a school survey initiated by the mobile x-ray unit of the Services de 'Hy- giéne Sociale in 1947 indicate that from 60 to 70 per cent of the children under 10 years of age in Tunis give a positive reaction to tuberculin. The reactivity rate is also high in the rural areas. A tuberculin test survey, reported in 1938,*2 revealed from 50 to 58 per cent positive reactors among Moslem children, from 10 to 18 years of age, at Zarzis, an isolated community southeast of Gabes. The diagnostic and treatment facilities are inadequate, particularly as regards the Moslem population. Separate tuberculosis dispensaries for Europeans, Jews and Mos- lems are established in Tunis, and spe- cial tuberculosis sections are incorporated in the “polyvalent” dispensaries in Sousse, Sfax, Le Kef and Bizerte. Wards for the treatment of tuberculous patients are avail- able in two hospitals in Tunis and in the hospital in Sousse. A private sanatorium for Europeans at Kram is subsidized by the government. Preventoria for European chil- dren are located at Bizerte and Zaghouan, and for Jewish children at Ariana. An intensive immunization program, using BCG vaccine, was started in October, 1949, under the auspices of the United Nations International Children’s Emergency Fund organization. Smallpox. Vaccination against smallpox is compulsory, and only rare sporadic cases are normally reported. The government pro- gram provides for the vaccination of all young children and approximately one fifth of the population in the older age groups each year, with the result that the majority of inhabitants are protected by repeated immunizations. Effective control of the in- fection among the nomadic tribes is diffi- cult, however, and outbreaks occasionally occur in the border districts. In 1944-45 the disease was introduced by nomads from Al- geria, encamped in southern Tunisia during the date harvest. About 190 cases were re- corded in 1945, the majority of which origi- nated among the visiting Algerians. Mass vaccination was carried on among the border populations, and the surveillance of migrations across the frontier was at- tempted. Nevertheless, the incidence in- creased; 797 cases were reported in 1946, and 1,203 cases in 1947. Further outbreaks, with 524 cases, were reported in 1948. Other Infections. Epidemics of measles and whooping cough are frequent. In both, the fatality among the young and poorly 588 Tunisia nourished children is high. Scarlet fever, diphtheria and poliomyelitis are endemic. Outbreaks involve primarily the European and the Jewish communities. Immunization against diphtheria is promoted in some cities by the school health services, and in the city and the suburbs of Tunis by a spe- cial unit of the Institut Pasteur. Menin- gococcus meningitis is sporadic. Pneumonia is a frequent cause of death; in 1941-47 it was responsible for from 7.9 to 8.5 per cent of all deaths reported in the city of Tunis. DiseAsES SPREAD OR CONTRACTED CuIerLY THROUGH CONTACT Venereal Diseases. Syphilis and gonor- rhea are prevalent, but little is known re- garding their actual incidence. Chancroid and lymphogranuloma venereum also occur. Centers for the treatment of venereal dis- eases among the different racial groups are established in Tunis, Bizerte, Sousse, Sfax and Le Kef, but no facilities are available to the rural Moslems, comprising almost 80 per cent of the total population, outside of the regular infirmaries and dispensaries. Venereal infections are regarded as com- monplace by the majority of the inhabit- ants. Poverty, ignorance and associated low standards of living are important factors governing their spread. Gonococcal oph- thalmia is particularly common among the children in the southern districts. Prostitution is widespread, especially in the port towns. No supervision is exercised by the health authorities, except in the European sections of the larger cities. Diseases of the Eyes. Trachoma is widely distributed. All races are affected, but primarily the rural Moslem popula- tions. The prevalence increases from north to south, averaging 10 per cent in the Tell region and from 80 to 100 per cent in the coastal plain near Gabés and on the Saharan oases. Infection usually occurs in early childhood. Ophthalmologic services are connected with the hospitals in Tunis, Sousse and Sfax, and 22 regional dispensaries are lo- cated in various parts of the country. A special trachoma center has been started re- cently on the outskirts of Tunis. Other Infections. Rabies is enzootic among dogs and other animals, and human infections are numerous. The Institut Pas- teur in Tunis maintains services for the treatment of human cases, and for the pro- motion of preventive immunization of dogs. Tetanus is common. Mycotic skin infec- tions are prevalent. Occasional cases of human myiasis occur, in which the larvae of Wohlfahrtia magnifica are most frequently implicated. A few cases of leprosy are re- ported each year. Di1SEASES SPREAD BY ARTHROPODS Malaria. Malaria is highly endemic in most inhabited sections of Tunisia but varies in intensity in different localities and from year to year, depending upon climatic conditions. Areas of high incidence exist in the well-watered districts of the western Tell, on the Cape Bon peninsula, on the central steppes, around the salty marshes of the Sahel plain in the vicinity of Sousse and Kairouan, and on the oases of the chotts region. Widespread epidemics appear periodically. Severe outbreaks were reported in 1947 and 1948, when an annual average of 14,500 confirmed cases was re- corded, as against 7,855 in 1946. In the north, transmission takes place throughout the year, with a marked re- crudescence in infection from June to the end of November. The peak of incidence usually comes at the end of the summer or in the early autumn, when the infections are almost exclusively due to Plasmodium falciparum. The comparative incidence of P. falciparum and P. vivax fluctuates. The latter is usually less extensive but persists throughout the winter, with a seasonal in- crease from April to June. P. falciparum is responsible for epidemic malaria. P. mala- riae is encountered in small foci which are frequently sharply demarcated. The most prominent are found on Cape Bon penin- sula, at Tabarka, and at Ouchtata in Tunisia 589 ol nN C2778, 3 \.. Chott Djerid \ \ , \ od yr y L i Malaria in Tunisia Kroumirie. The total incidence is relatively low. P. ovale is rare. Studies of malarial prevalence have been largely confined to northern Tunisia. In most areas from one third to one half of the children are probably infected at an early age. At Ain Draham in the western littoral, the splenic index among children less than 12 years of age was found to be 69 per cent in 1931.37 The parasite indices averaged 32 per cent in children and 29 per cent in adults. Epidemics may extend to the mountainous regions of the High Tell. In 1933 the splenic indices in children in the Thala area varied from 40 to 80 per cent, and in adults from 23 to 60 per cent. The parasite indices were from 13 to 66 per cent and from 5 to 71 per cent, respectively. In different localities on Cape Bon penin- sula, the spleen rates may range from 25 to 80 per cent.?” On the southern oases, anoph- eline breeding is independent of rainfall conditions, and malarial transmission is relatively constant. Little information is available regarding incidence, but equally high splenic indices have been found at Gabeés, Tozeur and Kebili. Anopheles labranchiae labranchiae is the major vector of malaria in northern Tuni- sia, from the littoral to the chotts region. A. sergenti and A. multicolor are responsi- ble for its transmission on the Saharan oases. A malaria-control program is sponsored by the Services de 1'Hygiéne Publique. Anopheline control measures are under- taken primarily in the vicinity of the prin- cipal cities and in the endemic areas of the northwest. The promotion of drug prophy- laxis constitutes a major part of the pro- gram among the European communities and other limited groups. The nomadism of the Arab tribes, the seasonal migrations of the semisedentary cultivators, and the continu- ous movements of agricultural and other laborers play an important role in the spread of the disease and render the control of the human reservoir almost impossible. Blackwater fever is relatively uncom- mon. Rickettsial Infections. Outbreaks of louse-borne typhus fever, which involve all sections of the population, occur almost an- nually. The disease is most prevalent in the north, but probably no part of the country is completely free from infection. Within recent years the regions around Tunis, Sousse, Sfax and Le Kef have been seriously affected. The incidence usually reaches a peak between March and May and drops to a minimum in September to November. The reported cases, which represent a small part of the total incidence, increased from an annual average of approximately 400 in 1922-33 to almost 860 in 1934-36. In 1937 and 1938 the number rose precipitously to 3,778 and 2,376, respectively. The poverty and the widespread louse-infestation of the inhabitants facilitate the spread of the in- fection. In 1939-44, these factors were augmented by crop failures, which pre- cipitated migrations of the people from the 590 Tunisia rural villages to the towns, and by the gen- eral shortage of food, clothing and soap oc- casioned by the war. The morbidity rose from 3,600 to 7,000 cases a year in 1939- 1941 to a peak of 16,335 in 1942. The epi- demic spread throughout North Africa in 1941. In Tunisia alone the reported cases in the four years, 1941-44, totaled 11.3 per 1,000 population. Subsequently, the mor- bidity declined abruptly to from 300 to 700 cases a year in 1945-48. Measures employed by the Tunisian health authorities in the control of typhus outbreaks include not only the isolation and the disinfestation of cases and contacts but also the conduct of large-scale immu- nization campaigns in infected areas. In view of the difficulties encountered in the wholesale delousing of migratory peoples, considerable reliance has been placed upon immunization. Antityphus vaccines are pre- pared at the Institut Pasteur in Tunis. The use of DDT preparations as insecticides has facilitated the control of the infection within recent years. Occasional cases of murine typhus are reported from various parts of the country. The infection has been demonstrated in rats in Tunis and Bizerte. Fiévre boutonneuse occurs sporadically during the summer months. The tick, Rhipicephalus sanguineus, is the usual vector. Relapsing Fever. Louse-borne relapsing fever was epidemic in North Africa in 1912- 18. The infection then subsided, and only sporadic cases were reported until the out- break of 1943-46. This epidemic, which originated in the Fezzan region of Libya, attacked Tunisia in October, 1943. Scat- tered cases among soldiers and civilians were recognized in Sfax, Gabeés, Kairouan and other widely separated localities in 1943, but the epidemic did not gain mo- mentum until 1944. It spread rapidly through the southern and the western dis- tricts, reached a peak in 1945 and declined abruptly in 1946. At least 17,500 cases were reported in 1944, and 34,000 in 1945. The true morbidity was probably from five to ten times greater than the official reports, based upon microscopically controlled cases, would indicate. Competent authori- ties estimate that the incidence totaled ap- proximately 400,000 cases, roughly 20 per cent of the population.®® The fatality rates averaged between 10 and 12 per cent. The shortage of medical facilities, destruction of equipment and social disruption occa- sioned by the African campaign created con- ditions conducive to the rapid spread of the disease among the habitually louse-infested inhabitants. Mobile units were organized for the treatment and the deverminization of cases, but control measures were inade- quate to forestall the ravages of the epi- demic. Tick-borne relapsing fever, caused by Borrelia hispanica, occurs sporadically in the northern Tell, on the Cape Bon penin- sula and in the suburbs of Tunis. The vec- tor, Ornithodorus erraticus, is widely dis- tributed throughout northern and central Tunisia. O. savignyi, which inhabits the semiarid regions, may be a potential vector. Plague. Since its reappearance in North Africa in the late 1890’s plague has been present almost continuously in Tunisia. Outbreaks have occurred from time to time, both in the port cities and in the rural areas. Major epidemics were experienced in 1926 and 1927, when 424 and 250 cases were re- corded, respectively. In 1929 also, 64 cases of pneumonic plague were reported from Tunis. From 1932 to 1944 the infection was relatively quiescent, but in 1944-45 local- ized outbreaks were reported from the Ferryville-Bizerte-Tunis region. In addition to the usual isolation, disinfestation and rodent extermination measures, widespread immunization with antiplague vaccine was undertaken among the populations in the affected areas. Probable foci of sylvatic plague exist in the vicinity of Kairouan, on the Sahel plain between Sousse and Sfax, in the region of the Great Chotts, and in the southeast, around Gabes, Zarzis, Médenine and the Ile de Djerba. Human cases are found sporadically among both the seden- Tunisia 591 tary and the nomadic populations. The rodent reservoir has not been definitely established, but many wild rodents, as well as domestic, are susceptible to infection. A rat-control station is maintained in the city of Tunis, where a low rate of infection is persistently noted among the animals cap- tured. Leishmaniasis. Kala-azar occurs at rare intervals in northern Tunisia, as far south as Thala, Kairouan and Sousse. From 1906 to 1936 a total of 131 cases was recorded. It is essentially a disease of childhood, but occasional cases are encountered among adults. A large proportion have been at- tributed to the Italian population. Cutaneous leishmaniasis, or oriental sore, is widespread in the south, particularly on the mountainous oases. Important foci exist at Gabeés, and at Gafsa, where the lesion is known as “bouton de Gafsa.” Nu- merous species of Phlebotomus are present. The specific vectors of leishmaniasis have not been identified, but P. papatasii, P. per- niciosus, and P. sergenti are most fre- quently implicated. Other Infections. Onchocerciasis has re- cently been described from La Goulette, near Carthage. Dengue fever is occasionally epidemic. Yellow fever has not been re- ported. NutriTioNAL DISEASES No precise information is available re- garding the extent of specific nutritional diseases. Undernutrition is general, how- ever, and major deficiencies, particularly in protein and in vitamins A and C, are common. The soil and the water supplies in the phosphate mining areas of central and southern Tunisia have an excessively high fluoride content. Mottling of the dental enamel, localized exostoses and osteopetro- sis are encountered among the inhabitants. MisceELLANEOUS CONDITIONS Infectious hepatitis is reported occa- sionally. Drug addiction is a major problem. The drug most frequently employed is hashish, derived from hemp (Cannabis indica). The cultivation of this plant is now controlled by law. SUMMARY Tunisia is a French protectorate with a diarchic form of government. Beylical and French administrations parallel each other. The southern territories, outside of the Regency proper, have a semimilitary organi- zation. The Moslem population, which represents almost 92 per cent of the total, is predominantly rural. A large proportion is migratory, at least part of each year. The responsibility for the public health resides in the Ministére de la Santé Pub- lique, with headquarters in Tunis. It has administrative and technical divisions. The latter incorporates Services de I'Hygiéne Publique and Services de I’'Hygiéne So- ciale. In 1947 the Ministére operated 7 hospitals—S5 in Tunis (including the mental hospital) and 1 each in Sfax and Sousse —and 33 regional infirmary-dispensaries, with a total capacity of 3,612 beds. In addition, it maintained 4 dispensaries with facilities for the treatment of venereal diseases, tuberculosis and trachoma, 22 oph- thalmologic dispensaries and 162 rural clinics. Medical and welfare work is also conducted by French, Italian, Moslem and Jewish philanthropic organizations. The In- stitut Pasteur in Tunis carries on routine investigations and research in co-operation with the Ministére de la Santé Publique. Water supplies are obtained from wells, and from numerous streams which flow from the mountains to the Mediterranean, and are dependent upon rainfall conditions. In the Saharan regions, water supplies are derived mainly from subterranean sources. Municipal supplies are available in the larger cities. Modern methods of sewage disposal are found only in certain sections of the larger cities. Sanitation is primitive in the native quarters of the towns and in the rural communities. 592 Tunisia Malaria, tuberculosis, syphilis and other venereal diseases, typhoid fever, dysentery, trachoma and helminthiasis are prevalent. Louse-borne typhus fever and relapsing fever occur in widespread epidemics. Occa- sional cases of plague are reported, both from the port cities and the rural areas in the central and the southern sections of the country. Vaccination for smallpox is com- pulsory, but extensive border outbreaks have been recorded recently. Measles, whooping cough, diphtheria, scarlet fever, poliomyelitis and meningococcus meningitis are endemic. Hookworm and Schistosoma haematobium infections are common in lo- calized foci in the irrigated regions of the south. Kala-azar is sporadic in the northern littoral ; oriental sore, in Gabeés, Gafsa and other semidesert localities. Human cases of brucellosis and rabies are frequent. Fiévre boutonneuse, murine typhus and tick-borne relapsing fever are reported occasionally. BIBLIOGRAPHY 1. Anderson, C.: Sur la présence d’'O. erraticus infecté par Sp. hispanicum dans la banlieu de Tunis, Arch. Inst. Pasteur de Tunis 24:483-492 (June) 1935. , Brun, G., and Coursiéres, H.: Note sur le XXTII¢ cas de pied de madura observé a Tunis, Arch. Inst. Pasteur de Tunis 26: 156-159 (Mar.) 1937. , and Lehucher, P.: Premier cas d’oncho- cerose cutanée observé en Tunisie, Arch. Inst. Pasteur de Tunis 29:105-112 (Mar.) 1940. 4, ——, Berge, Ch. Fauconnier, H., and Runacher, A.: Etude d'un foyer de fievre recurrente hispano-africaine dans la région de Bizerte-Ferryville-Mateur, Arch. Inst. Pasteur de Tunis 30:118-128 (June) 1941. : Chronique du kala-azar en Tunisie, Arch. Inst. Pasteur de Tunis 27:96-104 (Mar.) 1938. 6. Balozet, L.: Etat actuel de nos connaissances sur la rage dans les contrées tropicales et sub-tropicales et sa prophylaxie. La vac- cination préventive des chiens, Arch. Inst. Pasteur de Tunis 27:450-469 (Dec.) 1938. , and Reynal, J.: La fievre ondulante d’origine bovine a Tunis, Arch. Inst. Pas- teur de Tunis 21:273-275 (Dec.) 1932. 8. Baugé, R.: Sur un foyer de bilharziose vési- cale dans le sud tunisien, Arch. Inst. Pas- teur de Tunis 30:291-301 (Dec.) 1941. 9. Berge, Ch.: Sur la vaccination antitypho- paratyphoidique préventive, Arch. Inst. Pasteur de Tunis 31:270-286 (Dec.) 1942. 10. ——, Audoyne, H., and Fauconnier, J.: Présence du typhus murin dans la région de Ferryville, Arch. Inst. Pasteur de Tunis 31:185-193 (Dec.) 1942. 11. Bloch, E.: La peste en Tunisie, pp. 142-143, These de Paris, 1929. 12. Bouget, J.: Notes sur l'alimentation dans le sud tunisien, Arch. Inst. Pasteur de Tunis 28:350-355 (Sept.) 1939. 13. Broc, R.: Chronique sur la fievre médi- terranéenne, Tunisie méd., 25:459-469 (Sept.-Oct.) 1931. 14. Burnet, E.: L’alimentation en Tunisie, Arch. Inst. Pasteur de Tunis 27:85-95 (Mar.) 1938. 15. Callot, J.: Contribution a I’étude des mous- tiques de Tunisie et en particulier de sud de la Régence, Arch. Inst. Pasteur de Tunis 27:133-183 (June) 1938. 16. ——: Trématodes du sud tunisien en par- ticulier du Nefsaoua, Ann. de parasitol. 14:130-194 (Jan.) 1936. 17. Cambon, Henri: Histoire de la Régence de Tunis, Paris, Berger-Levrault, 1948. 18. Conseil, E.: L’épidémie de choléra de Tunis et de sa banlieue pendant l'année 1911, Arch. Inst. Pasteur de Tunis 7:144-191, No. III, 1912. 19. Coussi, D.: La cysticercose bovine en Tu- nisie, Rev. Vet. et J. de Méd. Vet. et de Zootech. 85:121-130, 1933. 20. Cuenod: Le trachome en Tunisie, Rév. in- ternat. de trach. 7:124-215, 1930. 21. Dupoux, R., Barthas, R., Antoine, A., and Garali, T.: Nouveaux résultats des expé- riences de prophylaxie collective antipalu- dique en Tunisie, Bull. Acad. de méd., Paris (3 ser.) 121:591-595 (Apr. 25) 1939. 22. Eparvier, Jean: Tunisie vivante, Paris, Edi- tions du Pré aux Clercs, 1945. 23. Espie, A.: L’ankylostomiase dans le sud tunisien, Arch. Inst. Pasteur de Tunis 19: 59-65 (Feb.) 1930. 24. : L’ankylostomiase en Tunisie dans les terrains cultivés et les campagnes, Bull. Office internat. d’hyg. pub. 29:778-783 (Apr.) 1937. 25. ——: Parasitisme intestinal infantile en Tunisia 593 26. 27 28. 29. 30. 31. 32. 33. 34. 38. 36. 37. 38. 39, 40. 41. 42. Tunisie, 5¢ région, Arch. Inst. Pasteur de Tunis 24:368-370 (Apr.) 1935. Exanthematic Typhus in Tunisia from 1939 to 1946: Bull. Office internat. d’hyg. pub. 38:253-254 (Apr.-June) 1946. Fabiani, G.: L’ictére infectieux de Tunisie, Bull. Soc. Path. Exot. 36:126-128 (March and April) 1943. Fonctionnement des Services de I'Institut Pasteur pendant I'année 1938, Arch. Inst. Pasteur de Tunis 28:272-291 (June) 1939. Fonctionnement des Services de I'Institut Pasteur pendant l'année 1939, Arch. Inst. Pasteur de Tunis 29:324-358 (Sept.) 1940. Fonctionnement des Services de IInstitut Pasteur pendant l'année 1940, Arch. Inst. Pasteur de Tunis 30:302-331 (Dec.) 1941. Galliard, H.: Contribution a I’étude des races d’Anopheles maculipennis en Tunisie, Arch. Inst. Pasteur de Tunis 24:343-351 (Apr.) 1935. Gaud, M., Khalil Bey, Mohammed, and Vaucel, M.: The evolution of the epidemic of relapsing fever, 1942-1946, Bull. W.H.O. 1:93-101, 1947-48. ——, and Morgan, M. T.: Epidemiological study of relapsing fever in North Africa, 1943-45, Bull. W.H.O. 1:69-92, 1947-48. Gesselin: L’hydraulique en Tunisie, Arch. Inst. Pasteur de Tunis 28:360-394 (Sept.) 1939. Gobert, E.: Le controle permanent de la peste en Tunisie, Arch. Inst. Pasteur de Tunis 20:456-469 (Mar.) 1931. : Note sur la bilharziose en Tunisie, Arch. Inst. Pasteur de Tunis 23:349-359 (Aug.) 1934. Henry, Charles: La lutte antipaludique en Tunisie, Paris, LeGrand, 1935. Lapie, Paul: Les civilizations tunisiennes, Paris, Ancienne Libraire Germer Bailliére et Cie, Alcan, 1898. Laurent, Ch., Barge, P., Berge, C., Audoye, H., and Fauconnier, J.: Deux nouveaux cas d’infestation par la grande douve du foie (Fasciola hepatica), Arch. Inst. Pas- teur de Tunis 31:154-158 (June) 1942. Le Mer, G., and Chauzy, M.: Musulmans tunisiens et diphtérie, Arch. Inst. Pasteur de Tunis 24:114-118 (Jan.) 1935. Liebesney, Herbert J.: The Government of French North Africa. African Handbook No. 1, Philadelphia, Univ. Penn. Press, 1943. Michel, M. et Mme. J. and H.: L’indice tuberculinique en milieu scolaire dans le sud tunisien, Arch. Inst. Pasteur de Tunis 27:311-314 (Sept.) 1938. 43. 44, 45. 46. 47. 48. 49. 50. 31. 82, 53: 54. 83. 56. 57. Mosauer, W.: The reptiles and amphibians of Tunisia, Univ. California Publ., Biol. Sci. 1:49-64, 1934. Nicolle, C., and Giroud, P.: Etude des rapports du typhus exanthématique his- torique et du typhus murin en Tunisie. Résultats d'une enquéte sur l'existence du virus murin chez les rats foyer de typhus historique invétérés eteints ou en activité, Arch. Inst. Pasteur de Tunis 24:8-28 (Jan.) 1935. Régence de Tunis. Secretariat Général du Gouvernement Tunisien, Service Tunisien des Statistiques: Annuaire statistique de la Tunisie, années 1940-46, Tunis, Impri- merie S.A.P.I., 1948. : Annuaire statistique de la Tunisie, année 1947, Tunis, Imprimerie S.A.P.I, 1948. , ——: Annuaire statistique de la Tunisie, année 1948, Tunis, Imprimerie S.A.P.I, 1949. Répartition des schistomiases dans les pays africains de l'union francaise. Mollusques vecteurs. Unpublished. Courtesy of J. Gaud. Reynal, J., and Wassilieff, A.: Prophylaxie de la peste a Tunis, Arch. Inst. Pasteur de Tunis 22:122-136 (July) 1933. Scemama, Robert: La Tunisie agricole et rurale et oeuvre de la France, Paris, Librairie Générale de Droit et de Juris- prudence, 1938. Sicart, Marcel, and Villain, Georges: Con- tribution a l'étude du paludisme dans le Cap Bon, Tunisie méd. 26:429-446 (Jan.) 1932. Smallpox in Tunisia, from 1939 to 1946, Bull. Office internat. d’hyg. pub. 38:447- 448 (July-Sept.) 1946. Sparrow-Germa, Héléne: Endémie typhique sur la population murine de Tunis. Apti- tudes vaccinales d'un virus murin isolé a Tunis, Bull. Office internat. d’hyg. pub. 29:719-729 (Apr.) 1937. Speder, E.: L’ostéopetrose de la fluorose phosphatique de I’Afrique de nord, Bull. et mem. Soc. radiol. méd. de France 24: 200-207, 1936. Vachon, Max: Etudes sur les scorpions, Arch. Inst. Pasteur d’Algérie 28:152-216 (June) 1950. Wassilieff, A.: La lutte antilarvaire en Tunisie, doit-elle étre saisonniére ou con- tinue?, Arch. Inst. Pasteur de Tunis 27: 31-41 (Mar.) 1938. ——: La peste murine en Tunisie, Bull. 594 Tunisia Office internat. d’hyg. pub. 29:2097-2105 (Oct.) 1937. : Les rongeurs et puces de Tunisie et leur réle dans la propagation de la peste. La receptivité comparée des divers ron- geurs tunisiens vis a vis de la peste, Arch. Inst. Pasteur de Tunis 22:443-475 (Nov.) 1933. 58. 59. , and Ristorcelli, A.: L’anophélisme dans la région du Nefzauoua, Arch. Inst. Pas- teur de Tunis 26:269-287 (June) 1937. 60. Worsfold, W. Basil: France in Tunis and Algeria, London, Brentano, 1930. 61. Zachert, M.: Le trachome en Tunisie, Arch. Inst. Pasteur de Tunis 16:391-396 (Dec.) 1027. 45 Libya GEOGRAPHY AND CLIMATE The former Italian colony of Libya, com- prising the historic territories of Tripoli- tania, Cyrenaica and Fezzan, and a large portion of the eastern, or Libyan, desert, has an approximate area of 680,000 square miles and a coastline of 1,400 miles along the Mediterranean Sea between Tunisia and Egypt. From the conquest of the coun- try by the Allied Armies in 1943 until the establishment of an independent federal government late in 1950, Tripolitania and Cyrenaica were administered by the British military, and later civilian, authorities; Fezzan was administered by the French. Except for narrow stretches of fertile land along the coast, Libya is almost en- tirely desert, made up of rocky uplands and sandy wastes, interspersed with oases. In the north the plateaus of Tripolitania and Cyrenaica are separated by the Sirte de- pression, which is largely desert to the shores of the Gran Sirte. Fertile coastlands and semiarid steppes characterize the coast region of Tripolitania. A chain of oases lines the coast from Misurata to the Tunis- ian border and is backed by a low, sandy plain which rises gradually to elevations of from 2,000 to 3,000 feet in the Jebel Nefusa range, part of the northern scarp of the great Saharan plateau. To the east the Jebel el Achdar highlands, which form the prom- ontory of Cyrenaica, rise abruptly from a narrow, broken coastal plain. The foothills and the coastal uplands contain extensive areas which are fertile under irrigation, 595 while oases mark the edge of the plateau from El Agheila to Siwa in Egypt. There are no perennial rivers, except the Wadi Derna, which flows almost continuously for a few miles near the port of Derna. The desert region to the south contains two large groups of oases: the Kufra oases in the east, and the oases of Fezzan in the west. Along the southern frontier the desert stretches to the Tibesti Mountains, which rise to peaks of over 11,000 feet in Chad territory. The climate of Libya is dominated by the winds from the desert. The mean tempera- tures in the coastal region average from 67° to 70° F., but range from 75° to 82° F. in the months from June to October, to from 52° to 60° F. from December to March. The daily variations are frequently considerable, particularly in the summer when the tem- peratures may rise to from 100° to 110° F. in the heat of the day and may fall as low as 40° F. at night. The rainfall is erratic, ranging from 5 to 17 inches in different localities and from year to year. Most of the rain falls during the winter months, par- ticularly between January and March. The heaviest precipitation is found on the sea- ward slopes of the Tripolitanian and the Cyrenaican plateaus. The mean tempera- tures and the daily fluctuations increase to- ward the interior. In the Fezzan region the mean monthly maximum temperatures ap- proximate 105° F. between June and Sep- tember and 20° F. in the winter. High winds charged with sand are frequent, but the rainfall is negligible on the southern and the central oases. 596 Libya POPULATION AND SOCIO-ECONOMIC CONDITIONS PoruraTiON The population of Libya was slightly in excess of 1,153,500 in 1947. The population of Tripolitania was estimated at 803,900; that of Cyrenaica at 309,600; and that of Fezzan at 40,000. The Italian residents totaled about 40,500 in Tripolitania, but less than 200 in Cyrenaica due to the large- scale evacuation of civilians in 1943-44. The non-Moslems also included about 28,000 Jews in Tripolitania and 4,600 in Cyrenaica. The majority are being re- settled in Israel under the auspices of the American Joint Distribution Committee, and it is anticipated that by the end of 1950 only a few thousand will be left in the towns of the coastal region. The native inhabitants are predominantly Arab-Berbers, with a small percentage of pure Berber or Arab stock. Arabic is used by most tribes, although dialectal variations are found in different areas. The Berber- speaking tribes are located primarily in western Libya, around Nalut, Jefren, Gada- mes, Socha and Gat. Numerous Negroid peoples, descendents of the early slaves or traders from Central Africa, are scattered throughout the country, with the greatest numbers in the Misurata region of the coast and on the southern oases. Touaregs from the vicinity of the Tassali-n-Ajjer moun- tains occupy western Fezzan; and Toub- bous, the southeast. Except for the Jewish communities, Mohammedanism is the uni- versal religion among the various native races of Libya. Educational facilities are meager outside of the larger towns. The schools have been reorganized since 1943, but they are inade- quate in number, and few furnish instruc- tion beyond the elementary levels. Separate schools are established for Moslems and Italians in Tripolitania, and schools open to all races in Cyrenaica. Elementary schools, providing a practical education with em- phasis on improved methods of agriculture, have also been started in Fezzan. A few schools are operated by religious and pri- vate organizations. Although almost two thirds of the popula- tion is settled in the northern agricultural areas, there are few large towns. Tripoli, the administrative headquarters of Tripolitania and the colonial capital of Italian Libya, had a population of 125,240 in 1947, while that of Bengasi, the administrative head- quarters of Cyrenaica, was about 50,000. The towns of the southern oases are usually small; Sebha, the center of the Fezzan ad- ministration, has a population of less than 10,000. Vital Statistics There are no vital statistics for Libya. However, statistics have been collected, for a few of the larger towns, which represent rough approximations of the actual figures. For the two years 1948 and 1949 the birth rates in Bengasi averaged 21.4 per 1,000 population, and the death rates 10.9. The infant mortality rates ranged from 213 per 1,000 live births in 1948 to 305 in 1949; the stillbirth rates, from 48.6 to 6.4. Reports for Tripoli in 1944 give specific birth rates of 26.8 per 1,000 population for the Europeans, 23.8 for the Moslems and 41.7 for the Jews; specific death rates of 12.7, 15.2 and 13.6, respectively. The infant mortality rate in the European population was 61.7 per 1,000 live births, in the Moslem 175.4, and in the Jewish, 111.4. Sociar. Economy Agriculture is the principal occupation of the inhabitants of northern Libya, while in the south a large percentage are nomadic pasturalists. The agricultural resources of the country are most highly developed in the regions settled by the Italians, particu- larly in Tripolitania, where colonization had reached a more advanced stage before the beginning of hostilities in 1940 than in Cyrenaica. The chief commercial crops Libya 597 grown by both Italians and Moslems are olives, dates, citrus fruits, almonds, wheat and barley. Esparto grass is a valuable na- tural product of the subdesert regions. Live- stock, mainly goats, sheep and camels, and hides are also exported. Sponge and tunny fishing are major industries along the coast. There are no important minerals except salt, which is extracted from salt pans, chiefly in the Bu Kemash region. Manufacturing de- velopment is limited by the lack of cheap sources of fuel supply, but numerous small plants catering to local needs are located in Tripoli, Bengasi and the port towns. Communication facilities are relatively poor. Roads connect the important popula- tion centers, and a modern highway extends along the coast, linking Tripoli, Misurata, Bengasi and Derna with Egypt and Tunisia. There are no railways, except short lines from Tripoli to Zuara and Garian, from Bengasi to Barce and Soluch, and from Tobruch to Bardia. Caravan routes and tracks constitute the principal means of reaching most of the Saharan oases. Tripoli, Bengasi and Tobruch are important ports for steamer traffic with Europe and the Near East while air services are available from Tripoli, Bengasi and Sebha. Foop AND NUTRITION Grains, usually wheat or barley, dates and milk products are the staple foods of the Moslem populations. The milk from camels and goats is frequently used, and fermented milk and cheese are common ar- ticles of food among most tribes. Meat forms a minor part of the diet of the aver- age Libyan, but the flesh of sheep, goats and camels is consumed in small quantities. Fish are plentiful in the coastal region. Various fruits and vegetables are grown under irri- gation in the agricultural areas, but dates constitute the only fruits of the desert nomads. Undernutrition is general and may reach serious proportions during periods of drought. The grain harvest was deficient in Tripolitania in 1947-48, and semifamine conditions prevailed in many areas. Housine Housing conditions vary in different parts of the country. The villages of the settled tribes are usually small and are divided into groups of flat-roofed huts enclosed within a walled court. The nomadic peoples, on the other hand, live in tent encampments. Communities of cave-dwellers are found in the hills in the Garian and the Nalut re- gions. In Tripoli and Bengasi modern-type dwellings are characteristic of the newer de- velopments. However, the native sections are typical of other old Arab cities, with flat-roofed houses and narrow, tortuous alleys. Bengasi, and to a lesser extent Tripoli, suffered considerable damage dur- ing the campaign in 1941-43, and a shortage of housing is common among all sections of the population. Overcrowding is particu- larly acute in the poorer quarters. ENVIRONMENT AND SANITATION WATER SUPPLIES In most localities water supplies are ob- tained from dug or driven wells, which range in depth from 20 to 1,500 feet. Springs are numerous in the highlands and in some of the eastern oases, but perennial stream sources are almost completely lacking. The Wadi Derna, which is fed by springs in the hills in back of Derna, flows for a short dis- tance and irrigates an extensive area near the coast. In Tripolitania the majority of towns and larger villages have deep well supplies which are frequently pumped to community standpipes. The city of Tripoli has a piped supply derived from deep wells. In the vicinity of Misurata the water is saline and sulphurous, and the people are dependent upon supplies brought in by tank wagons, except in the town itself, where a satisfactory well source was obtained in 1949. All town supplies are subjected to 598 Libya bacteriologic examination by the sanitary services at regular intervals, but treatment by chlorination usually is restricted to the imported tank supplies. In Cyrenaica wells and collecting galleries at Fueihat and El Menastir provide water for Bengasi, while that of Derna is obtained from springs. The supplies are treated by chlorination before distribution to individual buildings and community outlets and are tested for purity periodically. Few small water supplies are protected, however, and surface contamina- tion is common. Irrigation is extensively employed in the cultivated coastal regions and on the oases. Primitive methods are in use in most areas outside of the large farm- ing projects of the coastal region. WasTE DISPOSAL Small water-borne sewage disposal sys- tems, with outlets to the Mediterranean, serve parts of Tripoli, Bengasi and other coastal cities. Septic tanks are connected with many of the buildings in other sections, and in Bengasi the contents are collected by municipal sullage wagons. Bucket or pit latrines are employed in the Moslem quar- ters. Pit latrines are also found in a few rural villages, but in most regions pollution of the soil is a general practice. Fauna AND FLora Arthropods. MosquitoEs. Several anoph- eline vectors of malaria are reported. Anopheles labranchiae labranchiae (=A. maculipennis labranchiae) is the most im- portant vector in the coastal region of Tripolitania, but apparently it does not ex- tend far into Cyrenaica. A. sergenti and A. multicolor probably are responsible for the transmission of the infection on the Saharan oases. A. sergenti breeds in fresh and vege- tated waters, and A. multicolor in brackish. The two species are found together, although the latter is usually more numerous. 4. superpictus, A. algeriensis and A. coustani are also recorded from the northern part of the country. Anopheline control measures are carried on in the endemic areas and include the canalization of swamplands and the treat- ment of other bodies of water with oil or DDT. In 1948-49 residual spraying pro- grams were initiated in the larger towns of Tripolitania and in some communities in Cyrenaica for the purpose of controlling both flies and mosquitoes. The larvivorous fish, Gambusia, is used extensively in per- manent pools on certain oases of the Fezzan. Aedes aegypti is prevalent in the coastal ‘belt, especially between March and Decem- ber. In some localities in Cyrenaica it may account for up to 25 per cent of the mos- quitoes found in human habitations. Species of Culex, including Culex pipiens, are widely distributed. Fries. Numerous species of TABANIDAE are found, many of which are common pests. Stomoxys calcitrans and Musca domestica are widespread and with other species of Muscipak may be implicated in the mechan- ical transmission of intestinal and skin in- fections. The fly larvae of a variety of species produce myiasis in man and animals. The most dangerous, as regards man, are Wohlfahrtia magnifica and Lucilia sericata. Fannia canicularis and species of Sarco- phaga, Oestrus and Calliphora are also present. Several species of Culicoides and Simu- lium occur. Sandflies are rare, but both Phlebotomus papatasii and P. perniciosus have been recorded. Lice. All species of human lice are found, and infestation is widespread among the native inhabitants. Freas. The rat flea, Xenopsylla cheopis, is abundant and is the usual vector of plague, which is endemic in the coastal re- gion. With Ctenopsyllus segnis, it may ac- count for a large percentage of the fleas encountered. Ceratophyllus fasciatus, and the cat and dog fleas, Ctenocephalides felis and C. canis, are common. The human flea, Pulex irritans, is also present. Bepsucs. The bedbug of temperate re- Libya 599 gions, Cimex lectularis, is widely distrib- uted. Ticks AND MrtEs. A large variety of ticks exists in this region. Ornithodorus moubata and O. savignyi are found in the southern oases. Both are potential vectors of tick- borne relapsing fever, which is reported occasionally. Several species of Rhiipiceph- alus occur, including R. sanguineus, the vector of fievre boutonneuse in the coastal area. Other ticks which have been reported include Hyalomma aegyptium, Argas persi- cus and Ixodes ricinus. The human itch mite, Sarcoptes scabiei, is prevalent. The straw mite, Pediculoides ventricosus, and the chicken mite, Der- manyssus gallinae, may attack man and cause severe skin eruptions. Scorpions AND SPIDERS. Numerous species of scorpions are found, among which Pri- onurus australis is possibly the most impor- tant. It is active during the hot weather, and its sting produces systemic reactions which may prove fatal to young children and very old persons. The poisonous spiders include Latrodec- tus tredecimguttatus, L. lugubris and Choe- topelma olivacea. Reptiles. The Egyptian cobra, Naja haje, is widely distributed and is probably the most dangerous snake in this area. The sand vipers, Aspis cerastes (= Cerastes cornutus) and A. vipera (= C. vipera), are common in the desert regions. Echis carinatus has been recorded from many localities. Rodents. Rattus rattus alexandrinus is the principal house rat, but other species of Rattus are undoubtedly present. Wild ro- dents, and particularly a giant field mouse known locally as jerboa, are abundant in the rural areas. Mollusks.* The freshwater snail, Bulinus truncatus, is present. In the coastal region of Cyrenaica and in Fezzan it probably serves as an intermediate host of Schisto- soma haematobium. Planorbis (Biompha- laria) alexandrina pfeifferi may be an * See footnote, p. 10. intermediate host of S. mansoni on the oasis of Gat. Foop SANITATION The supervision of food, milk and meat supplies is carried on by the local health organizations in the municipalities, but the standards and the degree of enforcement vary considerably. Meats are inspected by veterinary officers in the slaughter houses, and a stamp of approval is required on meats offered for sale. In the smaller towns, the supervision of foodstuffs is undertaken by the sanitary inspectors and nurses of the government administrations. Sanitary con- ditions are generally poor in the Moslem quarters of the towns and in the rural areas. HEALTH SERVICES AND MEDICAL FACILITIES HeaLTH ORGANIZATIONS Since the occupation of Libya by the Allied Armies in 1943, the responsibility for the public health has been divided between the British administrations in Tripolitania and Cyrenaica and the French in Fezzan. British Military Administrations functioned until 1949, when the territories were trans- ferred to the Foreign Office and the govern- ing agencies acquired civilian status. The health and medical services have necessarily been conducted on a temporary basis in anticipation of the changes in government and unification of the country, which will become effective in 1950-51. As of November, 1950, interim health services were functioning in each of the territories. In Tripolitania, the health serv- ices are administered from Tripoli by the Medical Department of the British Admin- istration, under the direction of a Principal Medical Officer. Senior medical officers, who also serve as health officers, are in charge of the services in the four provinces into which the territory is divided. In Cyrenaica, a Ministry of Health was created under the new government formed in September, 1949. 600 Libya The headquarters organization of the Min- istry is located in Bengasi, while medical officers are responsible for the health and medical facilities in the districts of Ben- gasi, Jebel and Derna. Due to the disruption of the pre-existing services, the health es- tablishments in Cyrenaica have been com- pletely reorganized since 1943. In Fezzan the protection of the health of the inhabit- ants devolves upon a Councillor for Public Health and Education, appointed under the new administration in the fall of 1950. Municipal public health departments func- tion in Tripoli and Bengasi. Several voluntary and mission organiza- tions conduct clinics and child welfare services in co-operation with the govern- mental services. The Italian Red Cross Society carries on an active program in Tripolitania, while the Italian Health In- surance Society supports special clinics in Tripoli and meets the costs of medical care for its members. The British Red Crescent Society functions in Cyrenaica and main- tains child welfare clinics in Bengasi and Derna. MEepicaL INSTITUTIONS Hospitals and Dispensaries. In 1949 there were three general hospitals in Tripo- litania, under the control of the Medical Department. The Colonial Hospital in the city of Tripoli had a capacity of 1,200 beds and separate facilities for the care of Euro- peans, Moslems and Jews. In the provinces a 120-bed hospital was located at Misurata, and a 50-bed hospital for Moslems at Zavia. Special institutions included a mental hos- pital, an isolation hospital and a venereal diseases hospital for women in Tripoli, and a new 25-bed tuberculosis hospital at Busetta. In addition, 70 dispensaries were scattered throughout the territory; 25 were staffed by Italian physicians, and 45 by Italian or Moslem nurses. Four dispensaries were conducted by the municipal health or- ganization in Tripoli, as well as ophthalmo- logic, children’s, antenatal and dental clinics. There was only one small private nursing home in Tripoli. In Cyrenaica the medical services oper- ated hospitals at Bengasi, Barce, Messa (Luigi Razza), Derna and Tobruch, with an aggregate capacity of 541 beds, and 34 dispensaries in various parts of the terri- tory. The hospital at Bengasi was the largest, with accommodations for over 200 patients. Special institutions included a 30- bed tuberculosis hospital at el Marj (Barce) and a small mental home at Messa. In Fezzan infirmary-hospitals were estab- lished at Sebha, Brak and Mourzouk, and 17 dispensaries in villages on the different oases. Laboratories. The Medical Department in Tripolitania maintains a central labora- tory in Tripoli, with chemical and bacterio- logic divisions. The laboratory performs all the public health examinations for Tripoli- tania and makes analytical investigations for Cyrenaica. A clinical laboratory is lo- cated in the hospital at Misurata. A small pathologic and bacteriologic laboratory is operated by the governmental medical services at Bengasi. Schools. In Tripolitania, nurses training schools are conducted in the hospitals at Tripoli and Misurata. Programs are offered for the training of male and female nurses of all races. A more advanced school for medical assistants is connected with the hos- pital in Tripoli. Courses for the training of midwives and sanitary inspectors are also given in Tripoli. A school for dispensary orderlies and tribal dressers was opened in Bengasi in 1947. Courses for the training of nurses, midwives, health visitors and sanitary in- spectors were started in 1950. In Fezzan the nursing personnel receive instruction in the hospital infirmaries. PERSONNEL Physicians. As of 1949, the staff of the Medical Department in Tripolitania in- cluded 5 British medical officers and from Libya 601 65 to 74 Italian physicians. Thirteen British medical officers served the Cyrenaican health and medical services, while the or- ganization in Fezzan was in charge of 3 French army medical officers. Reports for 1947-48 indicate that 4 phy- sicians were engaged in private practice in Tripoli, and 2 in Bengasi. Dentists. Four dentists were connected with the government medical organization in Tripolitania in 1949, and one with the municipality of Tripoli. Two dentists were employed in the health services of Cy- renaica. Nurses. Nursing sisters of Italian re- ligious orders serve in the hospitals in both Tripolitania and Cyrenaica. In addition, there were 34 Italian and 39 Libyan male nurses, and 50 Italian, 1 Libyan and 6 Jewish female nurses in Tripolitania in 1949. Besides the nursing nuns, 7 British nurses were attached to the medical institu- tions in Cyrenaica. About, 21 male nurses served with the French organization in Fezzan. Others. Midwives are employed by the health services in both Tripolitania and Cyrenaica and, so far as possible, are located in the larger towns. Sanitary assistants and health inspectors are connected with the services in both territories. DISEASES The incidence of disease in Libya is not known. Reports from the hospitals and out- patient dispensaries give a rough indication of the prevalence of certain diseases, but the percentage of the population covered is relatively small. Moreover, the majority of the patients attending government institu- tions are men and boys, and in the absence of an adequate home-visiting staff, reports of disease among the women and the chil- dren are necessarily fragmentary. The dis- ruption of the medical services during the war years and the division of responsibility since 1943 have made the compilation of | valid statistics difficult. Diseases SPREAD OR CONTRACTED CHIEFLY THROUGH INTESTINAL oR URINARY TRACTS Typhoid and Paratyphoid Fevers. Ty- phoid fevers are mildly endemic among all sections of the population. The cases are usually sporadic, but small localized out- breaks sometimes occur. In the four years, 1946-49, from 62 to 378 cases were reported annually from Tripolitania, and from 4 to 30 cases from Cyrenaica. A limited amount of immunization with typhoid-paratyphoid A and B vaccine is carried on by the health - authorities. Dysenteries. Both amebic and bacillary dysentery are common, particularly in the towns of the coastal region, but the extent of infection is uncertain. The recorded cases of amebic dysentery in Tripolitania in 1943-49 were largely associated with the Moslem population and did not exceed 95 in any one year. Cases of bacillary dysentery are not reported but are known to be.numer- ous. Comparable reports from Cyrenaica for 1947-49 list from 25 to 41 cases of amebic and from 18 to 57 of bacillary dysentery yearly. Enteritis and diarrheas of undeter- mined etiology are prevalent, and a large percentage are undoubtedly Shigella in- fections. Helminthiases. ScuistosoMmiasis. Foci of Schistosoma haematobium infection exist in the coastal districts around Bengasi and Derna and on the oases of the Fezzan re- gion, especially Sebha, Brak, Mourzouk and Gat. In the latter area infection rates of from 60 to 80 per cent among hoys and from 15 to 20 per cent among adults have been observed in some localities. In 1947-49 from 3 to 14 cases were treated annually in the hospitals in Cyrenaica. S. mansoni infec- tions are rare, but occasional cases have been recorded from the Gat oasis. The inter- mediate snail host of S. haematobium is Bulinus truncatus; that of S. mansoni is Planorbis (Biomphalaria) alexandrina pfeifferi. 602 Libya AnNcyrosToMmiasis. Reports regarding the extent of hookworm infection are conflict- ing. The disease is present on some of the Saharan oases, but its prevalence has not been determined. Two cases were reported from Tripolitania in 1944, but infection is believed to be rare in that area. OrHeEr HELMINTH INFECTIONS. Ascaria- sis, trichuriasis and enterobiasis are widely distributed. The beef tapeworm, Taenia saginata, is present among the native cattle, and sporadic human infections undoubtedly occur. Echinococcosis may be encountered among the sheep-raising tribes. Other Infections. Undulant fever is en- demic in all parts of the country. The dis- ease was frequently recorded among the Italian colonists prior to 1943. More recent reports indicate an annual incidence of 20 to 36 cases in Tripolitania in 1947-49 and of 3 to 25 cases in Cyrenaica. Brucella melitensis infection was epizootic among the goats in some districts of Tripolitania in 1946 but was controlled through the slaugh- ter of infected animals. Cholera was epidemic in Tripoli during the pandemic of 1846-51, but the disease had not been reported from the Libyan coast within the present century. Diseases SPREAD CHIEFLY THROUGH THE RESPIRATORY TRACT Tuberculosis. Tuberculosis is prevalent and is increasing in the urban areas, where the overcrowded and insanitary living con- ditions are conducive to the spread of the infection. Pulmonary tuberculosis predom- inates, but other forms of the disease are frequent. The fatality rates are high, due to the poor nutrition and the low resistance among the native populations and to the fact that the majority of cases admitted to the hospitals are in advanced stages of the disease. From 412 to 625 cases of pulmonary tuberculosis were reported annually from Tripolitania, and from 118 to 210 from Cyrenaica in 1947-49, but the known cases are not indicative of the extent of the in- fection. Smallpox. Localized outbreaks of small- pox are common. Vaccination is carried on in the larger towns and villages, but spo- radic epidemics occur among the inhabitants in the outlying areas. Two epidemic foci developed in Tripolitania in 1946, in the Sirte region and in the vicinity of Tripoli. The former was of short duration, but the latter spread over the entire territory. Over 1,450 cases were reported in 1946, with a fatality rate of about 9 per cent. An increase to 2,400 cases was recorded in 1947, with a subsequent decline to 236 cases in 1948. Vac- cination teams toured the country, covering the entire population with the exception of certain nomadic tribes. An intensive vac- cination campaign was also undertaken in Cyrenaica, with the result that only occa- sional cases were reported, the majority of which were among immigrants from Tripo- litania. Small foci of infection persist in the Fezzan region, where a large percentage of the people are nomadic. Other Infections. Meningococcus men- ingitis, influenza, pneumonia, measles, whooping cough and mumps are endemic and sometimes epidemic. Diphtheria is sporadic. Occasional cases of scarlet fever and poliomyelitis are reported. DiseAsES SPREAD OR CONTRACTED CuierLy TaroUGH CONTACT Venereal Diseases. Gonorrhea and syph- ilis are widespread among all groups of the population, both in the coastal region and on the Saharan oases. Chancroid and lym- phogranuloma venereum are encountered less frequently. Diseases of the Eyes. Trachoma is a major public health problem in all parts of the country. At least from 70 to 90 per cent of the population is affected in Tripolitania and Cyrenaica and probably in Fezzan. Acute infections are most frequent during the summer months. Corneal complications with resultant blindness are common. Various types of purulent conjunctivitis are also prevalent, including gonococcal in- fections. Special ophthalmologic clinics are Libya 603 established in Tripoli and Bengasi. Tra- choma and conjunctivitis are almost uni- versal among the children, and systematic treatment programs are carried on in the schools in Tripolitania, Cyrenaica and Fezzan. Diseases of the Skin. Septic sores, which are often diphtheritic in origin, are numer- ous among the desert tribes. Phagedenic ulcers are a prominent cause of disability among the undernourished workers in agri- cultural areas. Mycotic infections are widespread. Cases of human myiasis are occasionally seen, most of which are caused by larvae of Wohlfahrtia magnifica or Lucilia sericata. Scabies is widely distributed. Other Infections. Occasional cases of leprosy are observed. In the 3-year period, 1947-49, a total of 22 cases was reported from Tripolitania, and 30 from Cyrenaica. A few cases of human rabies are recorded each year. Tetanus and human cases of an- thrax are sporadic. DiSEASES SPREAD BY ARTHROPODS Malaria. Malaria is endemic in the irri- gated coastal regions of Tripolitania, but, due to the restricted rainfall, the incidence is relatively low. Outbreaks occasionally occur in areas where the swamps and the pools formed by the winter rains provide abundant breeding places for the vector, Anopheles labranchiae labranchiae. Little malaria is encountered in the more arid littoral of Cyrenaica, but outbreaks are fre- quent in the oases. In 1947-49 an average of 147 cases of malaria was reported annually from Tripolitania. In Cyrenaica the re- corded incidence ranged from 7 cases in 1948 to 79 cases in 1946. Little precise information is available regarding the spe- cies. Plasmodium vivax apparently predomi- nates in most localities, but P. falciparum and P. malariae are also common. The oases of Fezzan are highly malari- ous, and P. falciparum infections are more prevalent than in the coastal region. A. ser- genti and possibly A. multicolor are the vectors on the Saharan oases. Blackwater fever is reported from Fezzan, but its inci- dence is uncertain elsewhere. Rickettsial Infections. Outbreaks of louse-borne typhus fever are recurrent among the Moslem tribes, particularly dur- ing the winter and the spring months. Data regarding the extent of infection during 1940-42 is meager, but it is probable that epidemic conditions prevailed in Libya, as in Tunisia and Egypt. In Tripolitania, 947 cases were reported in 1943, followed by a decline to from 52 to 168 cases a year in 1944-47. A rise to 481 cases in 1948 was pre- cipitated by widespread crop failures and the influx of the rural inhabitants to the cities. DDT powder was used extensively in the disinsectization of the people and the infected areas, with a resultant drop in inci- dence to 171 cases in 1949. The infection is also endemo-epidemic in Cyrenaica and Fez- zan. In the latter area the entire population was immunized with antityphus vaccine prepared according to the method of Durand and Giroud when an outbreak occurred on the oasis of Edri in 1947. Murine typhus is endemic in the coastal region. Sporadic cases of fievre boutonneuse are recorded from Tripolitania, where the dog tick, Rhipicephalus sanguineus, is the principal vector. Relapsing Fever. Foci of both louse- borne and tick-borne relapsing fever exist in Libya. The outbreak of louse-borne infec- tion which swept across North Africa in 1942-46 originated among the nomadic tribes in the Fezzan region and spread northward to Tunisia and Algeria. Over one half of the population of the Fezzan is reported to have suffered from the disease in 1942-44, with a fatality rate of from 8 to 10 per cent. At the same time, the infec- tion spread to Tripolitania and eastward to Egypt. Sporadic cases of tick-borne relapsing fever are recorded from various parts of the country. The principal focus is in the Kufra oases in the southeastern desert. Plague. Plague is endemic, and occa- 604 Libya sional outbreaks have been reported from the port areas. Other Infections. Dengue fever and sandfly fever are endemic along the Medi- terranean littoral. Sporadic cases of kala- azar and cutaneous leishmaniasis also occur. Yellow fever has not been reported within this century, but the vector, Aedes aegypti, is prevalent along the coast. NuTtriTIONAL DISEASES Little information is available concerning the nutritional diseases of this area. The majority of Libyans are undernourished, and during drought years, as in 1947, the mortality among the semistarved, debili- tated peasants may reach serious propor- tions. Pellagra, beriberi and scurvy are re- ported from the entire region. MisceLLANEOUS CONDITIONS Infectious hepatitis is endemic, and spo- radic outbreaks are not unusual. SUMMARY The former Italian colony of Libya has been administered by the British and the French authorities since its occupation by the Allied forces in 1943. Pending the or- ganization of an independent federal gov- ernment, to become effective in 1950-51, the territories of Tripolitania and Cyrenaica have been under British jurisdiction, and Fezzan under French. The health and medi- cal services are operated by the medical or- ganizations of the different administrations. In 1949 there were 3 government hospitals with an aggregate capacity of 1,370 beds in Tripolitania, 5 hospitals with 541 beds in Cyrenaica, and 3 hospital-infirmaries in Fez- zan, Numerous rural dispensaries were scattered throughout all three regions. The sanitary services disrupted during the hos- tilities of 1940-43 have been restored. Water supplies are derived from wells ranging from 20 to 1,500 feet in depth, and in some areas from springs. Sanitary piped water supplies are available in the larger cities. Small sewerage systems are found in Tripoli, Ben- gasi and a few coastal cities, but the meth- ods of sewage disposal in other localities are primitive. Widespread poverty and under- nutrition exist among the native popula- tions, and during periods of drought semi- famine conditions occur in many parts of the country. Intestinal infections, trachoma, tubercu- losis, skin diseases and venereal diseases are the major public health problems. Out- breaks of louse-borne typhus fever and smallpox are frequent. Malaria and schisto- somiasis are prevalent in localized areas. Foci of both louse-borne and tick-borne re- lapsing fever exist in all the territories. Meningococcus meningitis, measles and the more common respiratory infections are en- demic and sometimes epidemic. Typhoid fever, undulant fever, infectious hepatitis, rabies and leprosy are endemic. Dengue fever, sandfly fever, kala-azar, cutaneous leishmaniasis and plague may occur in the coastal region. BIBLIOGRAPHY 1. Broderick, Alan Houghton: North Africa, London, Oxford, 1943. 2. Casserly, Gordon: Tripolitania, T. Werner Laurie, Ltd., 1943. 3. Castallani, Pr. Aldo: Histoire et developpe- ment de la tuberculose en Tripolitaine, Bull. Office internat. d’hyg. pub. 31:86-87 (Jan.) 1939. 4, ——: Le pian dans les colonies italiennes, Bull. Office internat. d’hyg. pub. 31:291- 295 (Feb.) 1939. 5. Dixon, C. W.: Smallpox in Tripolitania, London, 1946, J. Hyg. 46:351-377 (Dec.) 1948. 6. France. Ministére des Affaires Etrangéres: Notice sur le Fezzan, 1948. 7. Gaud, M., and Morgan, M. L.: Epidemio- logical study of relapsing fever in North Africa, 1943-45, Bull. W.H.O. 1:69-92, 1947-48. 8. Giordano, M.: La febbre esantematica del littorale mediterraneo in Tripolitania, Arch. ital. sci. med. col. 16:161-185 (Mar.) 1935. 9. Great Britain: British Military Administra- Libya 605 10. 11, 13. 14. tion, Tripolitania, Libya. Handbook on Tripolitania, Government Press, Tripoli- tania, 1947. : Foreign Office, Administration of Afri- can Territories. Excerpts from the annual reports on the medical services in Cyre- naica, 1947, 1948, 1949. ——: Foreign Office, Administration of Afri- can Territories. Excerpts from the annual reports on the medical services in Tripoli- tania, 1947, 1948, 1949. . Lord Rennell of Rodd: British Military Ad- ministration of Occupied Territories in Africa during the years 1941-1947, Lon- don, H. M. Stationery Office, 1948. Italy: Instituto Centrale di Statistica. An- nuario statistico italiano, 1939, 4th ser., Vol. 6, Rome, 1939. ——: Ministero della Guerra, Dir. Gen. di Sanita Militare. Relazione medico—sta- 18, 16. 17. 18. 19. 20. tistica sulle condizioni sanitaire delle forze armati nelle colonie, 1935-36, Rome, 1939. Manson-Bahr, Philip: The prevalent dis- eases of Libya, Lancet 240:253-255 (Feb. 22) 1941. Medulla, C.: Le malattie del gruppo tifo esantematico che si osservano in Cirenaica, Arch. ital. sci. med. col. 16:7-39 (Jan.) 1935. ——: Sulla dibattuta questione della presenza della ricorrente da Spiromema duttoni in Cirenaica, Arch. ital. sci. med. col. 16:755- 759 (Oct.) 1935. Pani, A.: Sulla bilharziosi vescicale (studio di 114 casi), Acta. med. ital. 5:133-138 (May) 1950. The Italian Empire. Libya: New York, Italian Library of Information, 1940. Zavattari, E.: Ambiente fisico e schistoso- miasi vescicale in Libia, Riv. di. Biol. colon. 1:5-27 (Feb.) 1938. ‘ . I ' ‘ I } ‘ ' ‘ \ 1 £ | ‘ ' \ ' Appendix Maps Showing Distribution of the Principal Tropical Diseases Ted R SOMALILAND BRITISH | OMALILAND o AFRICA SOUTHWEST} Distribution of Foci of =) [BECHUANALAND AFRICA] EPIDEMIC TYPHUS FEVER i 1935-1950 609 i i i \ \ \ i ; i tramp: £3 \ BRITISH i SOMALILAND o ~ A AFRICA Distribution of T i SOUTHWEST! : 3 BECHUANALAND, Known Endemic Foci of HUMAN PLAGUE 1930-1950 610 ~_ Equator. AFRICA Distribution of Known Foci of SCHISTOSOMA HAEMATOBIUM Infection 611 AFRICA Distribution of Known Foci of SCHISTOSOMA MANSONI Infection AFRICA! 612 dir {BECHUANALAND R SOMALILAND TISH | LILAND) o Seapia Se LX y Zz Ne Wn 0 Q <4 9, 9, a » ~ o m 2 > — A \/ / ; | 3% 4 > n Ed oa > / whey a e CANGLO-EBY PTA aS NS De i FRITISH + N Wnt ly ~~ Noes AFRICA A 3 \sourwean { . 3 Fawerts AA : SOUTHWEST) Distribution of ci TOECHUANALAND N AFRICA' - ' HUMAN TRYPANOSOMIASIS : mail} ~ i WS 0 vv wt caused by Trypanosoma gambiense ~ Np 613 R SOMALILAND 4 A, SH SOMALILAND) +} A 2 7 AFRICA SOUTHWEST} 2 Distribution of | [8EcHuaNaLAND AFRICA' \ HUMAN TRYPANOSOMIASIS sR 7d ; Wo wT wy caused by Trypanosoma rhodesiense ~ Nena 614 % 72 R SOMALILAND p \ X Rif ~~ SOMALI Sey SH | LAND) of y fem] Distribution of YELLOW FEVER AFRICA willy, Boundary of Endemic Yellow Fever Area, as defined by the World Health Organization, 1950" “ws Area to be included, I95I1 r 1 [ i SOUTHWEST! "BECHUANALAND, Regions from which cases of yellow (1) Source: Informe Epidemiolégico Mensual (Monthly Epidemiological Report). Regional Office of the World Health Organization; Woshington AC. July 1950. fever were reported, 1930-50 615 ro x Freefow i, . — So. Abidjan iW ~ Takoradi..- OCEAN Pointe Noire ATLANTIC Kano i {or red Yaoundé Port Gentil \ Brazzaville \ \ Lobito Benguela.> Baia dos Tigres Linge 1 | \ | \ \ \ Fort Lamy (Victoria le \ El Geneina Juba > Dovels Libenge hs O Entebbe gv Sf Léopoldville N7/ : Dar es Saleam re AA Pt. Bell AV \itisemo Mombasa y: Zanzibar Nachingwes 3 \ Ridold ye. J 0\ Zomba | Diégo Suarez Lusaka ; tone mw 0 / \ Windhoek Noor] Walvis Bay \ \ Keetmanshoop rif ! Lideritz er \ b ie \ Bloemfontein AFRICA AIRLINES STEAMSHIP ROUTES RAILROADS MAP COURTESY TRANS WORLD AIRLINES COPYRIGHT, GENERAL DRAFTING CO., INC. \ \ A] Pt. Elizabeth Cape Town = . be te n A Noocaues Beira J x Horsrpive INDIAN OCEAN 616 Health Hints for the Tropics’ By Dr. GEORGE K. STRODE, CoL. THOMAS F. WHAYNE, Dr. Louis L. WiLL1AMS, JR., CAPT. JAMES J. SAPERO, AND DR. JonnN C. SNYDER INTRODUCTION It is well for travelers to the tropics to be neither too romantic nor too cynical about their destination. Those who consider the tropics a glamorous place where people live in exotic surroundings are likely to be lulled into a careless state of mind in which they do not give sufficient thought to health haz- ards. On the other hand, pessimists who re- fer to Africa as “the white man’s grave” go much too far in the other direction. They think only of danger, disease and bad cli- mate. Both of these extreme groups have the wrong attitude and both have been mis- informed. The truth, as usual, lies in be- tween. The right attitude is the common sense one which seeks out the facts and then makes the proper adjustment to these facts. Let it be emphasized right at the start that life can be safe, comfortable and pleas- ant under most tropical conditions. There is no need for undue apprehension or concern because some of the conditions encountered may be new or unknown to the traveler. Tropical diseases in general are well under- stood, are preventable, are for the most part susceptible to cure by modern methods, and are not the mysterious maladies or unknown fevers so often referred to in popular fiction. In the tropics as elsewhere, if proper at- tention is given to personal hygiene and cer- tain elementary safeguards, there is remark- ably little reason why health should be jeopardized. To get along well in the tropics, * Published as a Supplement to Tropical Medicine News, The American Society of Tropical Medicine, 1949. it is necessary to be alert and intelligent enough to follow simple rules of hygiene, to cultivate certain health habits, and to take a few extra sanitary precautions hav- ing to do chiefly with the preparation of food, purification of water, and protection from the bites of certain insects. All this may require moderate changes in one’s way of life, but the day-by-day application of these simple rules can make tropical living both a salubrious and a happy experience. It is always well to start by consulting a physician to be assured that there is no medical defect present which will jeopardize one’s well-being while traveling or residing in the tropics. Minor illnesses and physical defects which may be relatively unimpor- tant in temperate climates may become causes for major disability in tropical re- gions. Next, the prospective traveler should acquire reliable and specific knowledge of the tropical area to be visited and take the time to make careful plans, especially in the way of obtaining necessities not readily available in the tropical area concerned. Once there is assurance of physical well- being and once the necessary items and sup- plies have been secured, the next thing is to get acquainted with some of the simple rules and principles for tropical living. CLIMATE Generally speaking, the effects of a tropi- cal climate are not drastic. For those who are accustomed to temperate climates, how- ever, humidity and temperature and the seasonal rainfall in a tropical environment do influence certain physiological and psy- 617 618 Health Hints for the Tropics chological processes. It is unlikely that climate has any mysterious psychological effect. On the other hand, the enervating influence of excessive heat, light, and humidity and the monotony of tropical climate, together with the relative paucity of the recreational and cultural stimuli to which we are accustomed, the lack of chal- lenge of the type of work usually available, and the different social conditions encoun- tered are all factors in the psychological problems that sometimes arise. Physiological changes which result from residence in the tropics are chiefly adjust- ments to heat, light, and humidity. The average individual requires a period of ac- climatization in order to develop a toler- ance to tropical conditions including heat. Appropriate clothing, carefully selected at the outset, adequate rest, reasonable work- ing hours and a balanced diet, including intake of sufficient fluids and salt, are of great aid both during this initial period and for daily living later on. Other obvious es- sentials to adjustment in a tropical climate are some form of recreation, an intellectual interest or hobby, mild exercise and par- ticipation in the activities of the people with whom one lives. In addition, it is well to adopt an attitude of acceptance toward both the monotonous heat, humidity and high rainfall which characterize the rainy sea- son, and the heat, wind and sun glare which are features of the dry season, and to re- member, above all, that moderation in all things is the keystone of successful living in the tropics. WATER Opportunities for the contamination of water are unusually great in tropical com- munities. One of the most frequent sources of intestinal diseases among tropical resi- dents is contaminated drinking water. These diseases include the common diarrheas, amebic dysentery, bacillary dysentery, typhoid and paratyphoid fevers, and in some areas, cholera, schistosomiasis and guinea-worm infections. Some of these yield to modern therapy and have thus lost most of their terror, while others are prone to develop into chronic diseases for which the cure is difficult or uncertain. All of them can be prevented if suitable precautions are taken with regard to water and food. In many tropical cities adequate water purification facilities do not exist, and in others the operation of facilities is such as to discourage confidence in the final result. Unless one is assured that centrally dis- tributed water is constantly safe water, it is wise to boil or “treat” with some approved method all water used for human consump- tion, brushing the teeth, and other personal purposes. Contrary to popular assumption, ice made from impure water and used in beverages is dangerous, and it is not purified by the amount of alcohol used in alcoholic drinks. Ordinary carbonation does not kill most disease-producing organisms; thus carbonated drinks in general are unsafe. Uncarbonated soft drinks are even more dangerous. The safest purification procedure avail- able to the individual is boiling. Water boiled from 3 to 5 minutes may be con- sidered entirely safe. Also acceptable for human consumption without treatment are freshly prepared hot tea or coffee and fresh undiluted citrus fruit juices when prepared by oneself. “Halozone” or other chlorine preparations when used in the ordinary way are not sufficient to kill the disease agent of amebic dysentery. Various kits such as those made up of “Aqua-Tabs” provide for over-chlorination with subsequent removal of the chlorine by a harmless chemical. This procedure kills the amebic cysts, but is somewhat complicated to use. An iodine preparation, “Globaline,”! is the simplest and safest chemical means for water puri- fication thus far developed and is the agent of choice. Reliance in the “candle” filter so widely used in some parts of the tropics is largely misplaced. These devices are useless unless 1 Wallace and Tierman Products, Inc. Belleville, N.J Health Hints for the Tropics 619 they are carefully cleaned and boiled daily and they are far inferior to boiling or the chemical treatments described above. Water used for bathing and laundering also should come from a treated source. Salt water bathing is usually safe except in the case of beaches which are contaminated by fresh water streams or sewage outlets. In some parts of the tropics salt water beaches of the latter type are the source of infec- tions by intestinal bacteria and by the blood flukes which cause schistosomiasis, a chronic disease which is difficult to cure completely. In areas where schistosomiasis is present, fresh water streams, lakes, marshes, rice paddies and similar bodies of water may be sources of this serious dis- ease. Wading, bathing, or swimming in such waters is dangerous and should be strictly avoided. Foop Most of the diseases caused by contami- nated water also may be acquired from foods. Foods contaminated with disease- producing-organisms are the principal source of the simple diarrheas, food poison- ing, and bacillary and amebic dysentery. Other food-borne diseases are tuberculosis, undulant fever, trichinosis and many para- sitic diseases. In fact, food in which exces- sive bacterial growth has occurred is one of the chief causes of poor health and loss of time in the tropics, the resulting group of in- testinal diseases ranking second only to ma- laria as a tropical scourge. The uninitiated or the careless are even more likely to be afflicted in supposedly sanitated zones be- cause of the hidden dangers in palatable food served in pleasant surroundings. All such infections are nonetheless preventable. Foods spoil rapidly in tropical climates, especially foods of animal origin such as meat and dairy products. Refrigeration, in- spection and storage services, and other safeguards largely taken for granted in tem- perate climates often are inadequate or lacking in the tropics. Most foods are ex- cellent culture media for the growth of bac- teria that cause disease. It is, therefore, obvious that slight contamination of these foods with disease-producing bacteria may, by rapid bacterial growth, result in gross and dangerous contamination within a few hours. Sources of contamination usually are discharges from the respiratory or intestinal tracts of human beings. Food handlers who are not sanitary in their habits and who do not practice good personal hygiene are therefore a menace. Meats slaughtered from infected animals often contain parasites which may, unless destroyed by cooking, cause disease in man. In many countries human excreta is widely used as fertilizer. Contamination of ground and leafy vegetables, under these circumstances, is to be taken for granted. In other countries where direct soil con- tamination may not be so likely to occur, the practice of “freshening” root and leafy vegetables in surface water, often drainage or sewage ditches, just prior to arrival at the market is a source of real danger. Houseflies and other insects also may me- chanically transfer disease-bearing organ- isms in filth which they carry from human and other wastes to foods in the kitchen or dining room. Canned foods ordinarily are safe. After opening they are subject to the same spoil- age and bacterial contamination as other foods. “Blown tins,” “swells,” that is, cans with swollen ends in which there is obvi- ously gas pressure, often are sources of botulinus toxin and should always be dis- carded. Rusty cans may develop minute leaks through which contamination may take place. There is an old tropical food maxim of much merit which states: “Eat no fruit or vegetable raw that does not have an un- broken skin, and which has not been well- washed and peeled or skinned by oneself immediately prior to eating. Boil or bake all others.” These rules hold true at home, when visiting other homes, and in hotels and restaurants, however well-selected. Food which may be considered safe for con- 620 Health Hints for the Tropics sumption includes thoroughly cooked food, freshly prepared, and fresh fruits that have not been exposed to contamination. Raw vegetables and salads are especially dan- gerous because of their probable contact with grossly contaminated soil or water and the impossibility of cleaning them thor- oughly. Milk is safe only if boiled, or if in the form of canned evaporated milk, con- densed milk, or powdered milk. In diluting the latter milks, boiled or treated water should be used. Like fresh milk, ice cream and other creams sold locally are likely to be contaminated. Cold pastries, custards, meringues, many cheeses and other such delicacies, however attractive, should be avoided likewise. Dietary requirements in the tropics do not differ greatly from those in the tem- perate zones. If fresh foods, meat, eggs, dairy products and other vitamin-containing foods are not always readily available, it may be advisable to supplement the diet with a multi-vitamin preparation. Again the price of health is moderation in a well- balanced diet of native and imported foods which have been carefully selected and care- fully and freshly prepared. Cooks, nursemaids, and all other servants should be examined by a physician before they are accepted into the home, to avoid the possibility of their transmitting chronic intestinal diseases, tuberculosis, skin dis- eases, or other communicable diseases. Re- examination at regular intervals where fea- sible is a good practice. Cooks and food handlers are rarely well trained in the sani- tary care of food, to say nothing of personal hygiene. The housewife who spends time in training and regularly supervising them in food handling, care of children, sanitation, personal hygiene, and general cleanliness will be well repaid by a more consistently healthy family. INsEcTs AND INSECT VECTORS OF DISEASE The insects of greatest medical impor- tance throughout the tropics are the anoph- eline mosquitoes which transmit malaria. Other species of mosquitoes may carry dengue fever, yellow fever and filariasis in areas where these diseases are present. Houseflies are pests throughout most of the tropics and are important in the mechanical spread of intestinal diseases. Various spe- cies of flies may deposit their larvae (maggots) in minor skin lesions such as abrasions, cuts, insect bites, etc. Under other circumstances, the larvae may invade natu- ral body orifices or other organs. Tissue destruction and secondary infection are the rule. The ear canal, nasal passages, or intes- tine may be involved. Larval infestations of this type are known collectively as the myiases. Sandflies, fleas, ticks, mites, lice, tsetse flies and the reduviid or “kissing” bug are responsible for serious diseases in certain parts of the great tropical zone. Many of these insects infest native habitations, espe- cially in the poorer sections of the cities and in the rural areas. In those parts of the world where plague, typhus fever, relapsing fever, or Chagas’ disease are endemic, peo- ple who find it necessary to visit native homes of the lower classes should take every precaution to protect themselves. Local in- quiry of the health officer or a responsible physician should always be made where possible concerning the presence or absence of these insect vectors and the prevalence of the diseases which they carry. Spiders are found in many tropical areas. The bite of the black widow species is dan- gerous, but tarantulae cause only mild toxic symptoms. The centipede is a great nuisance in many parts of the tropics. It has a pain- ful sting which sometimes seriously affects infants. The scorpion, or native ‘“cran,” is distributed throughout the tropics; its sting also is painful and sometimes dangerous. It lives close to man and often is found in beds, in personal clothing, and especially inside shoes. A thorough inspection of rooms, beds and clothing should be made each day. The common bedbug, although prevalent, is not known to be a carrier of Health Hints for the Tropics 621 disease. There is some evidence that the common roach, large and small varieties of which are often seen in great numbers in the tropics, may carry the amebae of amebic dysentery. Mosquitoes and Malaria. Most malaria mosquitoes breed in water of streams, ponds, or marshes. Other species, both an- noying and dangerous, prefer small amounts of water which accumulate in various types of household utensils, vases, urns, eave troughs, septic tanks and other water recep- tacles. All such breeding places in or near dwellings must be detected and every effort made to eliminate them or to treat them regularly with DDT, Paris green, or oil. It is also important to sleep under mosquito nets or in screened bedrooms, and to make regular, frequent inspections of screens or nets to search out holes or imperfections through which mosquitoes may enter. As a rule in the tropics it is wise to stay indoors in screened buildings after nightfall. In the open after sundown it is advisable to move about constantly. Particularly hazardous are such pleasant evening recreations as picnics, beach parties, outdoor movies and garden parties held in unscreened patios or pavilions after dark. If night exposure can- not be avoided, it is best to wear protective clothing and mosquito boots and use the newer types of repellents containing di- methylphthalate. Insecticides, especially of the residual DDT types, applied to walls are of great value in controlling house mos- quitoes. With regard to prophylaxis or suppres- sive treatment for malaria, quinacrine (Atabrine), chloroquine (Aralen), palu- drine, or other drugs should be used as routine protection only upon local medical advice. Suppressive treatment with an antima- larial drug may be advisable for trips into the jungle or across country in areas where the malaria hazard is particularly great. Any qualified physician will advise as to the type of treatment and the dosage needed. In the absence of such advice, how- ever, Atabrine may be taken daily in doses of one tablet of 100 mg. This treatment should begin several days before starting on a trip into a malarious area and should be continued for a period of 4 to 6 weeks after returning. More recently developed drugs— chloroquine and paludrine—may have sev- eral advantages over Atabrine. Chloroquine (Aralen) thus far seems to be the drug of choice. It should be taken in a 0.5 Gm. dose (Chloroquine diphosphate) once weekly during the period for which suppressive treatment is advisable. Responses to these drugs differ somewhat according to the variety of the malaria parasite. Infections with the “vivax” or benign tertian variety as a rule are only “suppressed” and active malarial attacks may occur upon cessation of suppressive treatment. Vigorous curative therapy by a physician is then required. Even so, relapses may occur weeks, months, or even years later. With the “falciparum” or malignant tertian variety suppressive treatment usu- ally prevents attacks of the disease provided it is continued for 4 to 6 weeks after leaving the malarious area. Flies and Intestinal Diseases. Flies breed in decaying organic matter and filth. They frequently feed on similar materials and may later spread to exposed food the organisms which cause intestinal diseases. Protective measures include the elimination of all potential breeding places in and about the home, the meticulous protection of food from flies, and destruction of the adult in- sect. Thorough screening and regular appli- cation of DDT residual sprays to walls and screens of kitchens and dining rooms and other places likely to serve as resting places for flies are the best protective measures. It is particularly important to provide for prompt sanitary disposal of garbage and night soil. Garbage cans should be kept clean and covered while in use. Garbage racks should be so constructed as to be easily cleaned and to permit easy access around and under the stand for the sanitary handling of wastes. Cans, racks, screens and 622 Health Hints for the Tropics a small area of ground about the rack should be sprayed with DDT residual spray at regular intervals. DDT. DDT has already been recom- mended as an agent for the control of mos- quitoes and flies. It is also effective in the destruction of lice, fleas, sandflies, bedbugs, roaches, ants and other insects. Since the traveler or resident in the tropics is sub- jected not only to the dangers of disease- bearing insects but also to the annoyance of pest insects, many of which are suscep- tible to DDT, it seems apropos to point out briefly the various uses and methods of ap- plication of this highly effective insecticide. Ten per cent DDT in an inert powder is excellent protection against lice, fleas, bed- bugs and other crawling insects when dusted into clothing or placed on floors and other areas habitually used as runways by insects. Similarly, this powder has a wide use in the control of ants outside or around buildings. Five per cent DDT in kerosene or other suitable oily base may be used as a general residual spray for the control of insects in and about the home. It is sprayed directly onto walls, screens, ceilings and other: sur- faces and not into the air. One quart per each 250 square feet is recommended. The oily base evaporates leaving a residue of crystalline DDT. Insects which come into contact with the treated surfaces are de- stroyed. Residual spraying should be re- peated at intervals of 3 to 6 months. Watery emulsions or suspensions of DDT also have been used successfully. To achieve immediate knockdown and destruction of insects, the most effective weapon is the aerosol bomb which dispenses pyrethrum and DDT into the air as an aerosol produced from a liquefied gas (freon) under pressure. Aerosols are so finely divided that the particles remain sus- pended in the air and are therefore effective for a relatively long period—from a few minutes to a few hours, depending upon air exchange. This method is most effective in a room or a closed space. Where aerosol bombs are not available hand sprays of pyrethrum and DDT-in-oil are effective in- side buildings against flying or still insects with which the coarse spray droplets may come in contact. Travelers should include in their luggage an aerosol bomb and several cans of the 10 per cent DDT-in-powder for personal protection in hotels or other places where pest or disease-bearing insects may be found. A bottle of insect repellent contain- ing dimethylphthalate also may be found most useful in discouraging biting by mos- quitoes and other flying insects. IMMUNIZATION Most people now accept certain immuni- zation procedures as normal measures for the protection of health. In the case of adults, however, it is not uncommon to dis- cover that an immunization has not been repeated since childhood or adolescence. In their home environments, the majority of these adults, although they risk illness, re- main free from the diseases against which vaccines have been developed. It is a dif- ferent matter when they move to a com- pletely new environment such as a tropical country, where exposure is probably greater and where resistance to disease may be modified. To insure good health it is essen- tial to obtain immunizations against several serious diseases. It must be stressed, how- ever, that artificial immunity produced by a vaccination or by an attack of the disease itself is not absolute security. Vaccination should never be considered as an excuse to neglect strict health, hygienic, and sanitary precautions. All persons going to tropical areas should be vaccinated against smallpox and against the typhoid and paratyphoid group. Immu- nization against tetanus may also be advis- able. Other diseases with a limited geo- graphical distribution for which vaccines are available are plague, cholera, epidemic typhus fever, and yellow fever. Persons traveling to areas in which these diseases are endemic should receive the appropriate vaccine. Plague vaccine is an exception in Health Hints for the Tropics 623 TABLE 1. ROUTINE IMMUNIZATIONS INITIAL SERIES STIMULATING DOSE Agent Yea: of Interval oses ivi i Individual Dose Beicaeon Doses When Indicated Amount Smallpox vaccine 1 Contents 1 cap- Every 3 years; Contents 1 cap- illary tube within 1 year illary tube prior to de- parture for overseas areas; and in pres- ence of the disease* Typhoid-para- 3 1st dose, 0.5 cc.; 7 to 28 days Annually, and in ~~ One dose, 0.5 cc. typhoid vac- 2nd 10 cc. presence of the cine and 3rd 1.0 cc. disease Tetanus toxoid 3 Each dose, 1.0 Minimum of 21 One year after 1.0 cc. a “booster (Plain) cc. days initial series, dose” and upon oc- currence of wounds or burns, as di- rected by the medical officer (Editor’s Note) : *It is advisable in traveling in areas where cases of smallpox are actually occurring and the risk is therefore great, to be revaccinated almost irrespective of the time of the last vaccination. This is particu- larly true if the course of the previous vaccination has not been carefully observed by the vaccinating physician for several days after vaccination. If within a previous 6-months period the individual has had a positive “take” or a well-defined “accelerated” reaction, the traveler is safe. If the physician states that the previous reaction was “immune,” he will probably advise a repetition of the vaccination to ensure against the possibility that an impotent vaccine had been used previously. that it is usually indicated only in the presence of known cases, or when exposure is probable or suspected. Immunization against influenza is not recommended as a routine procedure. Although diphtheria is not ordinarily considered a tropical disease, it occurs frequently, and immunization is indicated. This protection is especially im- portant for children and young adults. Routine vaccinations such as typhoid- paratyphoid, smallpox and diphtheria, com- monly practiced in the temperate zones, ordinarily can be done by one’s family physician. Other vaccines may not be read- ily available to him, and vaccination may have to be carried out at the nearest United States Public Health Service medical instal- lation or quarantine station. An example is yellow fever vaccination which is required for most of South America and Africa. By international conventions certain im- munization procedures are mandatory if quarantine detention is to be avoided. Prior to travel an internationally recognized and accepted immunization form, appropriately certified to by competent authority in the country of origin should be procured. In- formal certificates, signed by one’s physi- cian usually will not suffice. Inquiry should be made at time of securing or validating passports as to immunization requirements, periods of validity and the periods of time which must elapse after vaccinations before entry into foreign country is permitted. In regard to these matters it is well to know that U. S. Public Health Service representa- tives will provide expert advice, either to one’s physician or the traveler himself. One’s record of vaccination or immuniza- tion certificate should be safeguarded and the vaccinations repeated as necessary for international travel requirements, as well as for the maximum protection of health. See previous pages for tables which sum- marize immunization procedures and specify the dosage and time required for basic 624 Health Hints for the Tropics TABLE 2. IMMUNIZATIONS REQUIRED FOR TRAVEL TO CERTAIN OVERSEAS AREAS (in Addition to Routine Immunizations) INITIAL SERIES STIMULATING DOSE No. of Agent “: Interval : Doses Individual Dose Between Doses When Indicated Amount Typhus vaccine 2 1.0 cc. each 1 week At 4- to 6-month 1.0 cc. intervals in presence of danger of epi- demic (louse- borne) typhus Cholera vaccine 2 1st dose, 0.5 cc.; 1 week At 4- to 6-month . 1.0cc. 2nd dose, 1.0 intervals in cc. presence of danger of cholera Yellow fever 1 0.5 cc. of the Every 4 years, if 0.5 cc. of the vaccine proper dilu- in yellow proper dilution tion fever endemic area Diphtheria 4 0.1, 0.5, 1.0, 1.0 2 days between If Schick reac- 1.0 cc.in divided toxoid (Plain) cc. tion becomes doses if neces- positive; usu- sary ally not re- quired Plague vaccine* 2 1st dose, 0.5 cc.; 1 week At 4- to 6-month ~~ 1.0cc. 2nd dose, 1.0 CC, intervals in presence of danger of plague * Indicated in the presence of known cases. TABLE 3. DOSAGE OF IMMUNIZING AGENTS, AND AGE OF ADMINISTRATION, FOR CHILDREN TRAVELING OUTSIDE THE UNITED STATES, WHEN INDICATED FOR AREA OF DESTINATION Immunizing Agent Dosage Age Limit Smallpox vaccine Typhoid-paratyphoid vac- cine Typhus vaccine Cholera vaccine Yellow fever vaccine Diphtheria toxoid As for adults All children, regardless of age Usual number and interval between inocula- tions; volume of each dose reduced accord- ing to weight (e.g., one-half adult dose for 50-1b. child) Usual number and interval; dosage reduced according to weight Usual number and interval; dosage reduced according to weight Usual full dose Usual full dose (either alum precipitated or fluid toxoid may be used; alone or in com- bination with other agents such as tetanus toxoid or pertussis vaccine) Children over 1 year of age Children nver 1 year of age Children over 3 months of age Children over 3 months of age All children between 3 months and 15 years of age Health Hints for the Tropics 625 series, as is prescribed in the United States Army which in general meet international requirements. MiscerLANEOUS HINTS Skin Diseases. Certain types of skin dis- eases are more likely to occur in the tropics than in temperate climates. Daily bathing is essential to the maintenance of health and the prevention of skin diseases. Likewise, thorough and careful drying of the skin, par- ticularly between folds of the skin such as in the armpits, the crotch, underneath the breasts, and between the toes is fundamental to the prevention of fungus infections. The use of mild dusting powders after bathing, especially between the toes, always is ad- visable. The skin should be observed daily for early evidence of fungus infection. Early treatment with a mild fungicide should be initiated at once whenever lesions of fungus infections (athletes foot, dhobie itch, crural itch, ringworm, tinea cruris, epidermiphy- tosis, etc.) appear. For mild infections a salve made up with 5 per cent undecylenic acid or a dusting powder containing 20 per cent zinc undecylenate and 2 to 5 per cent undecylenic acid is recommended. If the in- fection fails to respond promptly, one should see a physician. Self-treatment with strong ointments such as Whitfield’s ointment, strong alcoholic solutions of salicylic acid and phenol and similar preparations should be strictly avoided. Heat Exhaustion, Sunstroke, Sunburn. In most tropical regions, the effects of sun exposures are more intense than is usual in the United States. It is possible to acquire serious skin burns and to suffer heat exhaus- tion after relatively short exposure to the tropical sun, or following only moderate ex- ertion in the tropical heat indoors or on cloudy days. Persons with light skins are especially susceptible. Sun glare may pro- duce eye irritation, and it is therefore well for one to invest in a good pair of dark glasses. Excessive sun bathing is never wise in the tropics. Sun tan should be acquired gradually and without exposing too much of the body at one time, preferably in the early morning or late afternoon. The direct heat and penetrating rays of the midday sun may be quite dangerous. In addition to light, well-ventilated clothing, protective headgear of the sun helmet type which per- mits free flow of air inside the headgear is a wise precaution against heat-exhaustion and sunstroke. If exercise or physical labor are necessary, it is advisable to drink large quantities of water and to take additional salt on food or dissolved in drinking water to replace body salt losses. Two 10 grain tablets of salt (sodium chloride) dissolved in a quart of drinking water is palatable and efficacious. Salt tablets swallowed whole - may cause brief nausea and discomfort. The early symptoms of heat exhaustion are dizziness, faintness, headaches, blurring of vision, and sometimes nausea and vomit- ing. Persons experiencing any of these symptoms should cease physical exercise, obtain rest immediately, and seek medical care if the symptoms persist. Rest. Tropical climates are enervating, and restful nights of 8 hours’ sleep or more are important to good health. Although not indispensable, the almost universal tropical custom of taking a short siesta after the midday meal is well founded and worthy of adoption. It should not, however, be abused as an excuse to keep late hours. Exercise and work should not be carried to the point of exhaustion, but mild exercise as a daily habit is a wise precaution. Alcohol. Alcohol should be used in mod- eration if at all and preferably in the form of well-diluted drinks. Overindulgence is common in the tropics and should be avoided as one of the first indications of maladjustment to tropical conditions. Clothing. The best type of clothing for the tropics is light in weight and color, porous, and loosely fitted to permit a flow of air about the body and allow ready evapo- ration of perspiration. Frequent change of clothing is imperative. Underclothing, and socks in particular, should be changed at least once a day, for soiled materials encour- 626 Health Hints for the Tropics age skin diseases. As mentioned above, spe- cial precautions must be taken against mosquitoes. In certain parts of the tropics temperatures may drop several degrees nightly. In these areas light blankets may be required for comfortable sleeping and even lightweight topcoats and jackets for comfortable evening wear. Housing. Excellent principles of design, construction and materials have been devel- oped in the tropics and should be followed in planning tropical dwellings. A house should be constructed so as to permit con- stant ventilation in all parts, preferably from the four directions. It should be pro- tected from the sun by large porches and by overhanging roofs, awnings, or shades over windows. The installation of adequate and sanitary sewage disposal facilities is es- sential. Construction for protection against insects involves complete screening and spe- cial underpinning and step-construction to prevent the entrance of both flying and crawling insects. Sufficient bathing facilities should be provided so that each member of the household may bathe daily. Ample, dry closet space is needed to protect clothing, linen, and other effects from mold and mil- dew. Most tropical houses are constructed with adequate dry closet space equipped with protected electric outlets for large (100-200 watt) electric bulbs or infra-red heating units. These bulbs or units must be kept burning constantly day and night. Fire precautions require mesh wire hoods for the light bulbs or infra-red units. Air conditioning has proved successful in parts of the tropics where the heat is unduly oppressive and unbroken. Snakes and Dangerous Fish. In general, cleared and inhabited areas are not particu- larly dangerous from the point of view of poisonous reptiles; however, the hazard varies greatly according to the tropical area. Most snakes are nocturnal in their habits and bite in the daytime only upon provoca- tion or when surprised. In the jungle or open country, substantial leather or canvas boots with loose-fitting trousers worn inside the boots are usually sufficient protection. It is particularly important, however, to avoid leaning against tree trunks, branches, ledges, rocks, logs, and other objects with- out first examining them closely. First-aid measures in the case of snake bite are simple but must be carried out at once. Where the risk of snake bite is appreciable a simple snake-bite kit should be carried. Essential items are a tourniquet, rubber gauze or dam, a sharp blade, and a suction bulb or syringe. Suction may be applied by mouth through the rubber gauze placed over the incised bite area or by the suction bulb. A number of excellent commercially produced kits are on the market. Directions are included. Snake-bite victims should receive the appro- priate antivenom as early as possible, pref- erably to be given by a physician. Sharks and barracuda abound in many tropical waters and may be dangerous to swimmers at unprotected beaches. In the water of some parts of the tropics carnivo- rous fish are abundant. The piranha of cer- tain South American rivers is an example. These fish have been known to completely destroy large animals and even man, espe- cially when thousands are attracted by even minor blood loss into the water. Miscellaneous. Tropical residents should have physical and dental examinations at regular intervals. Even minor illnesses or injuries should receive the earliest medical attention to obviate the possible develop- ment of serious disease or complications. Many questions remain to be answered con- cerning allergy to tropical plants. Persons with severe hay fever or other allergic mani- festations should proceed to the tropics only upon the advice of their physician. Local inquiry should be made as to poisonous or harmful plants. Of these, some are danger- ous if eaten, while others may cause serious skin and eye irritations. In hot and humid areas residents should spend a few weeks each year at a “hill station” and if possible return to the tem- perate zone for 2 months or longer at least every 3 years. Health Hints for the Tropics 627 CONCLUSION Any attempt to summarize the health precautions for the tropics as a whole must of necessity be broad in nature so as to take into account the potential hazards of the average tropical zone. It should be empha- sized therefore that the wise application of health protective measures in a given area depends upon specific knowledge of the country or area concerned and the exercise of common sense and good judgment. Some of this knowledge can be acquired prior to travel ; the rest must be obtained from local health authorities and by experience. It is in the tropics that the old adage, “An ounce of prevention is better than a pound of cure” has its greatest application. The emphasis must be on preventive hygiene and sanitation, for public health and sani- tary procedures can never be taken for granted in tropical regions. New conscious- ness must be cultivated. At home we have become conscious of certain daily perils and habitually observe appropriate precautions. We are traffic-conscious and look left and then right before leaving the curb; we heat our houses and wear appropriate clothing to avoid the hazards of winter cold. In the tropics we must become water-conscious— never drink fluid of unknown origin; food- conscious—never eat foods that have not been freshly prepared and are not safe from bacterial contamination; heat-conscious— never work or play to the point of fatigue and exhaustion ; insect-conscious—use DDT repellents, nets and screens. The essentials of good health in the tropics are the un- remitting application of simple preventive health measures and above all moderation in everything. BIBLIOGRAPHY 1. Manson-Bahr, P. H.: Symposium of Tropi- cal Medicine, ed. 1, London, Cassell. 2, Craig, C. F.,, and Faust, E. C.: Clinical Parasitology, ed. 4, Philadelphia, Lea, 1945. 3. Kagy, Edwin S.: A medical program for prospective residents in the tropics, Bull. Tulane M. Fac. 6:1, 1946. 4. Mackie, T. R., Hunter, G. W., and Worth, C. B,, III: A Manual of Tropical Medi- cine, Philadelphia, Saunders, 1945. 5. Strong, R. P.: Stitt’s Diagnosis, Prevention and Treatment of Tropical Diseases, ed. 7, Philadelphia, Blakiston, 1944 6. Napier, L. Everhard: Principles and Practice of Tropical Medicine, New York, Mac- millan, 1946. 7. Simmons, J. S., Whayne, T. F., Anderson, G. W., and Horack, H. M.: Global Epi- demiology. A Geography of Diseases and Sanitation. Vol. I. India and the Far East; the Pacific Area, Philadelphia, Lippincott, 1944. 8. Manson-Bahr, P. H.: Manson’s Tropical Diseases, ed. 12, Baltimore, Williams & Wilkins, 1945. 9. Russell, P. F., West, L. S., and Manwell, R. D.: Practical Malariology, Philadel- phia, Saunders, 1946. 10. Immunization: War Department Technical Bulletin 114, Washington, D. C., War De- partment, 1947. 11. Health Precautions for Far East (Southern Asia, Eastern Asia, and Netherlands East Indies): War Department Pamphlet No. 8-4, Washington, D. C., United States Government Printing Office, 1943. 12. Health Precautions for African and Asiatic Countries along Southern and Eastern Mediterranean Sea, Red Sea, and Persian Gulf: War Department Pamphlet No. 8-3, Washington, D. C., United States Govern- ment Printing Office, 1943. 13. Health Precautions for Central and South Africa and West Coast of Africa: War De- partment Pamphlet No. 8-1, Washington, D. C., United States Government Printing Office, 1943. 14. Health Precautions for Central and South America and Caribbean Area: War De- partment Pamphlet No. 8-2, Washington, D. C,, United States Government Printing Office, 1943. 15. DDT Insecticides and Their Uses: War De- partment Technical Bulletin 194, Washing- ton, D. C., War Department, 1945. 16. Health Precautions for Personnel on De- tached Duty: NAVMED 193, Washing- ton, D. C., Navy Department, 1944. 17. Military Sanitation: War Department Field Manual 21-10, Washington, D. C., War Department, 1945. | I pep \ £ E : g ; : : : : | : iw iN : 8 “ : : : : = = = EE van SERN ie 2 3 Su : : = : § ¢ en g Ti Jnl od = ; 2 : ig | ‘ Fis Boy seam eed nk eh ; ; 5 eZ a PRS 2 : : : : “So 2 5 “ : Se : SS £2 4 i$ ada : : 3 F & a = - = Ye Gk EE : % as m= pe : : ~4 w= = ah re is Re : : or : i 7 Topas : : 3 : : Eo : HE 3 Ea : Le ) 2 ign - : : AS LS a aide LE nian, Acanthocheilosomiasis, Anglo- Egyptian Sudan, 42-43 Angola, 333 Belgian Congo, 355 Cameroons, French, 395 French Equatorial Africa, 379 French West Africa, 503 Gold Coast, 433 Guinea, Portuguese, 471 Spanish, 386 Kenya, 125 Liberia, 452 Nigeria, 419 Rhodesia, Northern, 191 Sierra Leone, 464 Tanganyika, 164 Uganda, 145 Zanzibar Protectorate, 232 Actinomycosis, Algeria, 570 Basutoland, 306 Somalia, 99 Somaliland, British, 82 Union of South Africa, 284 African tick fever. See Relapsing fever Alcoholic beverages, restricted use in tropics, as health meas- ure, 625 Allergic manifestations from plants. See Plants Amebiasis. See Dysentery, amebic Ancylostomiasis, Algeria, 567 Anglo-Egyptian Sudan, 36 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 348 Cameroons, French, 393 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 16 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 496 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 470 Spanish, 385 Kenya, 118-119 Liberia, 449 Libya, 602 Madagascar and Comores ar- chipelago, 242 Mauritius, 255 Index Ancylostomiasis— (Continued) Morocco, French, 539 Spanish, 552 Mozambique, 217 Nigeria, 413-414 Nyasaland, 175 Réunion, 261 Rhodesia, Northern, 188 Southern, 202 Ruanda-Urundi, 364-365 Sierra Leone, 461 Somalia, 98 Somaliland, French, 88-89 South West Africa, 297 Swaziland, 316 Tanganyika, 159 Tunisia, 586 Uganda, 140 Union of South Africa, 281 Zanzibar Protectorate, 230 Anthrax, Algeria, 571 Anglo-Egyptian Sudan, 40 Angola, 331 Basutoland, 306 Canary Islands, 523 Egypt, 19 French Equatorial Africa, 377 French West Africa, 497 Gold Coast, 432 Guinea, Portuguese, 470-471 Kenya, 119, 122 Libya, 603 Madagascar and Comores ar- chipelago, 245 Morocco, 542 Mozambique, 218 Nigeria, 414 Rhodesia, Northern, 188, 190 Southern, 202 Ruanda-Urundi, 365 Somaliland, British, 82 South West Africa, 298 Swaziland, 317 Tanganyika, 160 Uganda, 140-141 Union of South Africa, 284 Ants, Belgian Congo, 343 driver, French Equatorial Africa, 372-373 French West Africa, 491 Kenya, 114 Liberia, 446 Uganda, 136 Egypt, 10 French Equatorial Africa, 372 Liberia, 446 629 Ants— (Continued) Nigeria, 410 safari. See Ants, driver Zanzibar Protectorate, 228 Ariboflavinosis, Bechuanaland Protectorate, 313 Union of South Africa, 288 Arthritis, polyarticular, acute, Belgian Congo, 356 Arthropod-borne diseases. See Malaria, Rickettsial infec- tions, Plague, Relapsing Fever, Filariasis, Leish- maniasis, etc. Arthropods. See Mosquitoes, Flies, Lice, Fleas, Bedbugs, Ticks, Mites, etc. Ascariasis, Algeria, 568 Anglo-Egyptian Sudan, 37 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 349 Cameroons, French, 393 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 16 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 496 Gambia, 478 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 119 Liberia, 449 Libya, 602 Madagascar and Comores ar- chipelago, 242 Mauritius, 255 Morocco, French, 539-540 Spanish, 552 Mozambique, 217 Nigeria, 414 Nyasaland, 175-176 Réunion, 261 Rhodesia, Northern, 188 Southern, 202 Ruanda-Urundi, 365 Sierra Leone, 461 Somalia, 98 Somaliland, French, 89 Swaziland, 316 Tanganyika, 159-160 Tunisia, 586 630 Index Ascariasis— (Continued) Uganda, 140 Union of South Africa, 281 Zanzibar Protectorate, 230 Avitaminosis. See Nutritional dis- eases Bacteriologists, Sudan, 35 Ethiopia, 68 Balantidiasis, French West Africa, 497 Bedbugs, Algeria, 564 Anglo-Egyptian Sudan, 32 Angola, 328 Belgian Congo, 343 Egypt, 9 Ethiopia, 66 French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Kenya, 114 Liberia, 446 Libya, 598-599 Madagascar and Comores ar- chipelago, 239 Mauritius, 253 Morocco, 535 Mozambique, 214 Nigeria, 409 Nyasaland, 173 Rhodesia, Northern, 184 Southern, 198 Somalia, 95-96 Somaliland, British, 78 Tanganyika, 155 tropics, 620-621 Tunisia, 583 Union of South Africa, 274 Zanzibar Protectorate, 228 Beetles, Algeria, 564 Anglo-Egyptian Sudan, 32 Belgian Congo, 343 Canary Islands, 520 French Equatorial Africa, 372 French West Africa, 490-491 Kenya, 114 Mauritius, 253 Mozambique, 214 Nigeria, 410 Rhodesia, Northern, 185 Southern, 198 Sierra Leone, 459 South West Africa, 296 Tanganyika, 155 Tunisia, 583 Uganda, 136 Union of South Africa, 274 Beriberi, Angola, 333 Bechuanaland Protectorate, 313 Belgian Congo, 356 Cameroons, French, 395 Cape Verde Islands, 513 Egypt, 22 Eritrea, 59 French Equatorial Africa, 380 Anglo-Egyptian Beriberi— (Continued) French West Africa, 504 Gambia, 480 Guinea, Portuguese, 472 Kenya, 126 Liberia, 452 Libya, 604 Madagascar and Comores ar- chipelago, 248 Mauritius, 257 Mozambique, 220 Nigeria, 420 Nyasaland, 178 Réunion, 263 Rhodesia, Northern, 191 Southern, 206 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 101 Somaliland, British, 83 French, 90 South West Africa, 299 Swaziland, 317 Tanganyika, 166 Uganda, 146 Union of South Africa, 288 Zanzibar Protectorate, 232 Biochemists, Kenya, 118 Birth rates. See Statistics (vital) Blackwater fever, Anglo-Egyptian Sudan, 41 Angola, 332 Belgian Congo, 353 Cape Verde Islands, 513 Egypt, 20 Ethiopia, 71 French Equatorial Africa, 378 French West Africa, 500 Gold Coast, 432 Guinea, Portuguese, 471 Kenya, 123 Liberia, 451 Libya, 603 Madagascar and Comores ar- chipelago, 246 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Rhodesia, Northern, 190 Southern, 205 Ruanda-Urundi, 366 Sierra Leone, 463 Somalia, 100 Somaliland, British, 83 Tanganyika, 163 Tunisia, 589 Uganda, 143 Zanzibar Protectorate, 232 Blastomycosis, Liberia, 451 Madagascar and Comores ar- chipelago, 245 Blindness, Algeria, 570 Anglo-Egyptian Sudan, 43 Egypt, 18 Eritrea, 57 Kenya, 122 Blindness— (Continued) Libya, 602 Morocco, 541 night. See Night blindness Rhodesia, Northern, 189 Sudan. See Onchocerciasis Swaziland, 317 Union of South Africa, 284 Bouton d’Gafsa. See Leishman- iasis d’Orient. See Leishmaniasis Boutonneuse fever, Algeria, 572 French West Africa, 502 Libya, 603 Morocco, French, 543 Spanish, 554 Ruanda-Urundi, 366 Tunisia, 590 Bronchitis, Mauritius, 256 Egypt, 18 Bronchopneumonia, Algeria, 569 Madagascar and Comores ar- chipelago, 244 Uganda, 141 Brucellosis, Algeria, 568 Anglo-Egyptian Sudan, 37-38 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 349 Canary Islands, 522 Egypt, 16-17 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 376 French West Africa, 496-497 Gold Coast, 431 Kenya, 119 Libya, 602 Madagascar and Comores ar- chipelago, 243 Mauritius, 255 Morocco, French, 540 Spanish, 552 Mozambique, 218 Nigeria, 414 Nyasaland, 176 Rhodesia, Northern, 188 Southern, 202 Ruanda-Urundi, 365 Sierra Leone, 461 Somalia, 98 Somaliland, British, 81 South West Africa, 298 Swaziland, 316 Tanganyika, 160 Tunisia, 587 Uganda, 140 Union of South Africa, 281-282 Zanzibar Protectorate, 230 Bwamba fever, Nigeria, 420 Uganda, 146 Caterpillars, Kenya, 114 Centipedes, Anglo-Egyptian Sudan, 32 Index 631 Centipedes— (Continued) Belgian Congo, 343 Egypt, 10 Nigeria, 410 tropics, 620 Uganda, 136 Zanzibar Protectorate, 228 Chancroid, Algeria, 569 Anglo-Egyptian Sudan, 39 Belgian Congo, 350 Canary Islands, 522 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 498 Gambia, 479 Guinea, Portuguese, 470 Kenya, 121 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 541 Spanish, 553 Réunion, 262 Rhodesia, Northern, 190 Southern, 203 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Tunisia, 588 Union of South Africa, 283 Chemists, Anglo-Egyptian Sudan, 35 Ethiopia, 68 Guinea, Portuguese, 469 Mauritius, 254 pharmaceutical, Somalia, 97 Uganda, 139 Union of South Africa, 279 Chickenpox, Anglo-Egyptian Sudan, 39 Canary Islands, 522 Egypt, 18 Ethiopia, 70 Guinea, Spanish, 385 Liberia, 450 Morocco, Spanish, 553 Rhodesia, Southern, 203 Somalia, 99 Somaliland, 81 Spanish Sahara and Ifni, 528 Uganda, 141 Chigoe (sand) flea (Tunga pene- trans), Anglo - Egyptian Sudan, 32 Angola, 328 Belgian Congo, 343, 352 Cape Verde Islands, 511, 513 Eritrea, 53 Ethiopia, 66, 70-71 French Equatorial Africa, 372, 37 French West Africa, 490, 499 Chigoe (sand) flea— (Continued) Gold Coast, 427 Guinea, Portuguese, 468 Kenya, 114, 122 Liberia, 446 Madagascar and Comores ar- chipelago, 239, 245 Mozambique, 214 Nigeria, 409, 417 Rhodesia, Northern, 184 Southern, 198, 204 Somalia, 95, 99 Somaliland, British, 78, 82 Tanganyika, 155, 162 Uganda, 135 Union of South Africa, 274 Zanzibar Protectorate, 228, 231 “Chiseye,” Nyasaland, 178 “Chlorosis, Egyptian.” See Ancy- lostomiasis Cholera, Algeria, 568 Anglo-Egyptian Sudan, 36 Angola, 331 Belgian Congo, 349 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 15 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 376 French West Africa, 496 Gold Coast, 431 Kenya, 118 Libya, 602 Madagascar and Comores ar- chipelago, 243 Mauritius, 255 Morocco, French, 539 Spanish, 552 Mozambique, 217 Nigeria, 414 Réunion, 261 Rhodesia, Northern, 188 Southern, 201 Sierra Leone, 461 Somalia, 98 Somaliland, British, 81 French, 89 Tanganyika, 159 Tunisia, 586-587 Uganda, 140 Union of South Africa, 282 Zanzibar Protectorate, 230 Chromoblastomycosis, Union of South Africa, 284 Climate. See Geography and climate Clinics. See Health organizations, Hospitals and dispensaries Clothing, tropics, 625-626 “Clou de Biskra.” See Leish- maniasis Cockroaches, French West Africa, 491 Liberia, 446 Cockroaches— (Continued) Rhodesia, Northern, 185 tropics, 621 Comores archipelago. See Mada- gascar and Comores archi- pelago Congo floor maggots, Anglo- Egyptian Sudan, 31 French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Kenya, 113 Liberia, 446 Mozambique, 213 Nigeria, 409 Nyasaland, 172 Rhodesia, Northern, 184 Tanganyika, 155 Congolese red fever, Congo, 354 French Equatorial Africa, 379 Conjunctivitis, Algeria, 570 Angola, 332 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 499 Guinea, Portuguese, 470 Kenya, 122 Libya, 602 Morocco, French, 541 Spanish, 553 Somaliland, British, 82 French, 89 Spanish Sahara and Ifni, 528- 529 Tanganyika, 162 Togoland, British, 440 French, 438 Uganda, 142 Craw-craw, Cameroons, French, 394 French Equatorial Africa, 377 French West Africa, 499 Gambia, 479 Guinea, Spanish, 386 Liberia, 451 Sierra Leone, 462 Crocodiles, French Equatorial Africa, 373 French West Africa, 491 Gold Coast, 428 Guinea, Portuguese, 468 Liberia, 446 Nigeria, 410 Tanganyika, 156 Uganda, 136 Cysticercosis, Basutoland, 305 Kenya, 119 Tunisia, 586 Union of South Africa, 281 Cysts, hydatid. See Echinococcosis Belgian 632 Index Death rates. See Statistics (vital) and individual diseases Dengue fever, Algeria, 573 Anglo-Egyptian Sudan, 43 Basutoland, 306 Belgian Congo, 355 Cameroons, French, 395 Canary Islands, 523 Egypt, 22 Eritrea, 59 Ethiopia, 72 French Equatorial Africa, 379 French West Africa, 504 Guinea, Portuguese, 472 Spanish, 386 Kenya, 125-126 Liberia, 452 Libya, 604 Madagascar and Comores ar- chipelago, 247 Mauritius, 257 Morocco, French, 544 Spanish, 554 Mozambique, 220 Nigeria, 420 Rhodesia, Southern, 205 Somalia, 101 Somaliland, British, 83 French, 90 Tanganyika, 165 Tunisia, 591 Uganda, 146 Union of South Africa, 287 Zanzibar Protectorate, 232 See also Mosquitoes Dentists, Algeria, 566-567 Anglo-Egyptian Sudan, 35 Bechuanaland Protectorate, 310 Belgian Congo, 347 Cameroons, French, 392 Egypt, 14 French Equatorial Africa, 374 French West Africa, 494 Gold Coast, 430 Guinea, Portuguese, 469 Liberia, 449 Libya, 601 Mauritius, 254 Morocco, 538 Mozambique, 216 Nigeria, 413 Nyasaland, 174 Réunion, 261 Rhodesia, Northern, 187 Southern, 201 Ruanda-Urundi, 364 Sdo Tomé and Principe, 400 Sierra Leone, 460 Somaliland, French, 88 Tanganyika, 158 Tunisia, 585 Uganda, 139 Union of South Africa, 279 Zanzibar Protectorate, 229 Dermatitis. See Skin diseases from plants. See Plants Desert sores, Egypt, 18 Diarrhea, Algeria, 567 Angola, 330-331 Basutoland, 305 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 15 Eritrea, 56 Ethiopia, 69 French West Africa, 496 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 470 Libya, 601 Mauritius, 255 Morocco, 539 Mozambique, 217 Nigeria, 413 Nyasaland, 175 Sierra Leone, 461 Somaliland, British, 80 South West Africa, 297 Swaziland, 316 Uganda, 140 Union of South Africa, 280- 281 Zanzibar Protectorate, 230 Diphtheria, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Cameroons, French, 394 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 17 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376 French West Africa, 498 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 540-541 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Southern, 203 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Swaziland, 316 Diphtheria— (Continued) Tanganyika, 161 Tunisia, 588 Uganda, 141 Union of South Africa, 283 Zanzibar Protectorate, 231 Dipylidiasis, Kenya, 119 Diseases. See individual diseases Dispensaries. See Hospitals and dispensaries Dracontiasis, Algeria, 574 Anglo-Egyptian Sudan, 43 Bechuanaland Protectorate, 313 Cameroons, British, 398 French, 395 Egypt, 22 French Equatorial Africa, 379 French West Africa, 504 Gambia, 480 Gold Coast, 433 Guinea, Portuguese, 471-472 Spanish, 386 Kenya, 126 Liberia, 452 Nigeria, 420 Nyasaland, 178 Somalia, 101 Somaliland, British, 83 South West Africa, 299 Tanganyika, 165 Togoland, British, 440 French, 438 Uganda, 146 Drug addiction, Algeria, 574 Morocco, 545 Tunisia, 591 Dysentery Cameroons, British, 398 Sado Tomé and Principe, 400 Togoland, British, 440 French, 438 amebic Algeria, 567 Anglo-Egyptian Sudan, 36 Angola, 330-331 Basutoland, 304 Bechuanaland Protectorate, 310-311 Belgian Congo, 347-348 Cameroons, French, 393 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 14-15 Eritrea, 55-56 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 495-496 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 470 Spanish, 385 Kenya, 118 Liberia, 449 Libya, 601 Index 633 Dysentery— (Continued) amebic— (Continued) Madagascar and the Co- mores archipelago, 241-242 Mauritius, 255 Morocco, French, 539 Spanish, 552 Mozambique, 217 Nigeria, 413 Nyasaland, 175 Rhodesia, Northern, 187 Southern, 201 Réunion, 261 Ruanda-Urundi, 364 Sierra Leone, 461 Somalia, 97-98 Somaliland, British, 80 French, 88 South West Africa, 297 : Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 159 Tunisia, 586 Uganda, 140 Union of South Africa, 280 Zanzibar Protectorate, 230 bacillary Algeria, 567 Anglo-Egyptian Sudan, 36 Angola, 330 Basutoland, 304 Bechuanaland Protectorate, 310-311 Belgian Congo, 347-348 Cameroons, French, 393 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 14-15 Eritrea, 55-56 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 495-496 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 470 Spanish, 385 Kenya, 118 Liberia, 449 Libya, 601 Madagascar and the Co- mores archipelago, 241-242 Mauritius, 255 Morocco, French, 539 Spanish, 552 Mozambique, 217 Nigeria, 413 Nyasaland, 175 Rhodesia, Northern, 187 Southern, 201 Réunion, 261 Ruanda-Urundi, 364 Sierra Leone, 461 Somalia, 97-98 Somaliland, British, 80 French, 88 Dysentery— (Continued) bacillary— (Continued) South Africa, 297 Spanish Sahara and Ifni, 528 Tanganyika, 159 Tunisia, 586 Uganda, 140 Union of South Africa, 280 Zanzibar Protectorate, 230 Echinococcosis (hydatid disease), Algeria, 568 Anglo-Egyptian Sudan, 37 Basutoland, 305 Eritrea, 56 French West Africa, 496 Gold Coast, 431 Libya, 602 Mauritius, 255 Morocco, French, 540 Spanish, 552 Mozambique, 218 South West Africa, 297 Tanganyika, 160 Tunisia, 586 Economy, social. See Social econ- omy Edema, malignant. See Kwash- iorkor nutritional, Basutoland, 306 Gambia, 480 Rhodesia, Southern, 206 Union of South Africa, 288 Elephantiasis, Algeria, 574 Anglo-Egyptian Sudan, 42 Cape Verde Islands, 513 Egypt, 21 Gold Coast, 433 Guinea, Portuguese, 471 Kenya, 125 Liberia, 452 Mauritius, 257 Morocco, 544 Mozambique, 220 Nigeria, 419 Tanganyika, 164 Uganda, 145 Zanzibar Protectorate, 232 Enamel, mottled, Algeria, 574 Morocco, 544 Tunisia, 591 Encephalitis, Morocco, 541 “Africana,” Union of South Africa, 287 Endamebiasis. See Dysentery Enteritis, Angola, 331 Basutoland, 305 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 15 Eritrea, 56 Ethiopia, 69 Gold Coast, 430 Guinea, Portuguese, 470 Libya, 601 Enteritis— (Continued) Mauritius, 255 Morocco, 539 Mozambique, 217 Nigeria, 413 Nyasaland, 175 Réunion, 261 Somaliland, British, 80 Swaziland, 316 Uganda, 140 Union of South Africa, 280-281 Zanzibar Protectorate, 230 Enterobiasis, Algeria, 568 Cameroons, French, 393 Cape Verde Islands, 512 Egypt, 16 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 496 Guinea, Portuguese, 470 Spanish, 385 Kenya, 119 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 242 Mauritius, 255 Mozambique, 217 Rhodesia, Northern, 188 Southern, 202 Sierra Leone, 461 Somalia, 98 Tanganyika, 160 Union of South Africa, 281 Entomologists, Anglo-Egyptian Sudan, 35 Angola, 330 Gold Coast, 430 Kenya, 118 Mauritius, 254 Mozambique, 217 Nigeria, 413 Rhodesia, Northern, 187 Southern, 201 Sierra Leone, 460 Uganda, 139 Erysipelas, Cape Verde Islands, 512 Eruption, creeping. See Skin dis- eases and Ancylostomiasis Etiologic agents. See individual diseases Exostoses, Algeria, 574 Morocco, 544 Tunisia, 591 Eye diseases, Algeria, 570 Anglo-Egyptian Sudan, 40, 44 Belgian Congo, 351 Canary Islands, 522 Cape Verde Islands, 513 Egypt, 18 Eritrea, 57 Ethiopia, 70 French West Africa, 499 Kenya, 122 634 Index Eye diseases— (Continued) Libya, 602-603 Mauritius, 256 Morocco, French, 541 Spanish, 553 Rhodesia, Southern, 204 Somaliland, British, 82 French, 89 South West Africa, 299 Spanish Sahara and Ifni, 528- 529 Swaziland, 317 Tanganyika, 162 Tunisia, 588 Uganda, 142 Union of South Africa, 284 Zanzibar Protectorate, 231 See also Blindness, Conjuncti- vitis, Flies, Ophthalmia, Trachoma Fascioliasis, Algeria, 568 Mauritius, 255 Morocco, 540 Tunisia, 586 Union of South Africa, 281 Favus, Algeria, 570 Morocco, 541 See also Tinea Fernando P6o. See Spanish Guinea Fever, blackwater. See Black- water fever boutonneuse. See Boutonneuse fever Bwamba. See Bwamba fever Congolese red. See Congolese red fever dengue. See Dengue fever paratyphoid. See Paratyphoid fever Q. See Q fever ratbite. See Ratbite fever relapsing. See Relapsing fever Rift Valley. See Rift Valley fever sandfly. See Sandfly fever scarlet. See Scarlet fever tick, African. See Relapsing fever tick-bite. See Typhus fevers typhoid. See Typhoid fever typhus. See Typhus fevers yellow. See Yellow fever Fiévre, boutonneuse. See Bouton- neuse fever recurrent hispano-nord-afri- caine. See Relapsing fever Filariasis, Algeria, 574 Anglo-Egyptian Sudan, 42-43 Angola, 333 Basutoland, 306 Belgian Congo, 355 Cameroons, British, 397 French, 395 Filariasis— (Continued) Canary Islands, 523 Cape Verde Islands, 513 Egypt, 21-22 Eritrea, 59 Ethiopia, 72 French Equatorial Africa, 379 French West Africa, 503 Gambia, 480 Gold Coast, 433 Guinea, Portuguese, 471 Spanish, 386 Kenya, 125 Liberia, 452 Madagascar and Comores ar- chipelago, 247 Mauritius, 257 Morocco, 544 Mozambique, 220 Nigeria, 419-420 Nyasaland, 177-178 Réunion, 263 Rhodesia, Northern, 191 Southern, 205 Ruanda-Urundi, 366 Sierra Leone, 464 Somaliland, French, 90 Tanganyika, 164 Uganda, 145 Zanzibar Protectorate, 232 See also Mosquitoes, Flies Fleas, Algeria, 564 Anglo-Egyptian Sudan, 32 Angola, 327-328 Basutoland, 303 Bechuanaland Protectorate, 310 Belgian Congo, 342-343 Canary Islands, 519-520 Cape Verde Islands, 511 Egypt, 9 Eritrea, 53 Ethiopia, 66 French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Guinea, Portuguese, 468 Kenya, 114 Liberia, 466 Libya, 598 Madagascar and Comores ar- chipelago, 238-239 Mauritius, 253 Morocco, 535 Mozambique, 213 Nigeria, 409 Nyasaland, 173 Rhodesia, Northern, 184 Southern, 198 Ruanda-Urundi, 363 Sierra Leone, 458-459 Somalia, 95 Somaliland, British, 78 South West Africa, 295 Tanganyika, 155 tropics, 620 Fleas— (Continued) Tunisia, 583 Uganda, 135 Union of South Africa, 274 Zanzibar Protectorate, 228 See also Skin Diseases, Typhus, Plague Flies, Algeria, 563-564 Anglo-Egyptian Sudan, 31-32 Angola, 327 Basutoland, 303 Bechuanaland Protectorate, 309 Belgian Congo, 342 Canary Islands, 519 Cape Verde Islands, 510-511 Egypt, 9 Eritrea, 53 Ethiopia, 66 French Equatorial Africa, 372 French West Africa, 489-490 Gold Coast, 427 Guinea, Portuguese, 468 Kenya, 112-114 Liberia, 445-446 Libya, 598 Madagascar and Comores ar- chipelago, 238 Mauritius, 253 Morocco, 535 Mozambique, 213 Nigeria, 408-409 Nyasaland, 172-173 Rhodesia, Northern, 184 Southern, 197-198 Sierra Leone, 458 Somalia, 95 Somaliland, British, 78 South West Africa, 295 Tanganyika, 153-155 tropics, 613-615, 620, 621-622 Tunisia, 582-583 Uganda, 134-135 Union of South Africa, 273-274 Zanzibar Protectorate, 228 See also Myiasis, Tsetse flies, sandflies, etc. Fluke infection. See Fascioliasis, Heterophyiasis, Schistoso- miasis Fluorosis, Algeria, 574 Morocco, 544 Tunisia, 591 Union of South Africa, 288 Food and nutrition, Algeria, 561 Anglo-Egyptian Sudan, 29 Angola, 326 Basutoland, 302-303 Bechuanaland Protectorate, 308-309 Belgian Congo, 340 Cameroons, French, 390 Canary Islands, 518 Cape Verde Islands, 509-510 Egypt, 6-7 Eritrea, 52 Index 635 Food and nutrition— (Continued) Ethiopia, 64-65 French Equatorial Africa, 370- 371 French West Africa, 486-487 Gambia, 475-476 Gold Coast, 425 Guinea, Portuguese, 467 Spanish, 384 Kenya, 109-110 Liberia, 444 Libya, 597 Madagascar and Comores ar- chipelago, 237 Mauritius, 252 Morocco, French, 532-533 Spanish, 550 Mozambique, 211 Nigeria, 406 Nyasaland, 171 Réunion, 260 Rhodesia, Northern, 182 Southern, 196 Ruanda-Urundi, 362 Sierra Leone, 457 Somalia, 94 Somaliland, British, 77 French, 86-87 South West Africa, 294 Spanish Sahara and Ifni, 526- 527 Swaziland, 314-315 Tanganyika, 151-152 tropics, 619-620 Tunisia, 581 Uganda, 132-133 Union of South Africa, 270- 27% Zanzibar Protectorate, 226-227 Food sanitation, Algeria, 565 Anglo-Egyptian Sudan, 33-34 Angola, 328-329 Basutoland, 303 Bechuanaland Protectorate, 310 Belgian Congo, 344 Cameroons, French, 391 Canary Islands, 520 Cape Verde Islands, 511 Egypt, 11 Eritrea, 54 Ethiopia, 67 French Equatorial Africa, 373 French West Africa, 492 Gambia, 477 Gold Coast, 428 Guinea, Portuguese, 468 Kenya, 115-116 Liberia, 447 Libya, 599 Madagascar and Comores ar- chipelago, 239 Mauritius, 253 Morocco, 536 Mozambique, 214-215 Nigeria, 410-411 Food sanitation—(Continued) Nyasaland, 173 Rhodesia, Northern, 185-186 Southern, 199 Ruanda-Urundi, 363 Sierra Leone, 459 Somalia, 96 Somaliland, British, 79 French, 87 South West Africa, 296 Tanganyika, 156 Tunisia, 584 Uganda, 137 Union of South Africa, 276 Zanzibar Protectorate, 228 Foot-and-mouth disease, Ruanda- Urundi, 365 Fungus infections. See Mycotic skin infections, Skin dis- eases Gastro-enteritis. See Diarrhea and Enteritis Geography and climate, Algeria, 558-559 Anglo-Egyptian Sudan, 26-27 Angola, 323-324 Basutoland, 301 Bechuanaland Protectorate, 307 Belgian Congo, 336-337 Cameroons, British, 396 French, 388 Canary Islands, 517 Cape Verde Islands, 508 Egypt, 3-4 Eritrea, 49-50 Ethiopia, 62-63 French Equatorial Africa, 368- 369 French West Africa, 482-483 Gambia, 474 Gold Coast, 423 Guinea, Portuguese, 466 Spanish, 382 Kenya, 107 Liberia, 441-442 Libya, 595 Madagascar and Comores ar- chipelago, 234-235 Mauritius, 250 Morocco, French, 530-531 Spanish, 548 Mozambique, 208-209 Nigeria, 403-404 Nyasaland, 169 Réunion, 259 Rhodesia, Northern, 180 Southern, 194 Ruanda-Urundi, 360 Sdo Tomé and Principe, 400 Sierra Leone, 455 Somalia, 92-93 Somaliland, British, 75 French, 85 Geography and climate—(Cont.) South West Africa, 292 Spanish Sahara and Ifni, 525 Swaziland, 313 Tanganyika, 149 Tangier, 556 Togoland, British, 438 French, 436 tropics, 617-618 Tunisia, 578-579 Uganda, 130 Union of South Africa, 267-268 Zanzibar Protectorate, 225 Goiter, Algeria, 574 Angola, 333-334 Belgian Congo, 356 Cameroons, French, 395 Egypt, 22 French Equatorial Africa, 380 Gambia, 480 Liberia, 452 Morocco, 544 Nigeria, 420 Rhodesia, Northern, 192 Southern, 206 Ruanda-Urundi, 366 Sierra Leone, 464 Union of South Africa, 288 Gonorrhea, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Belgian Congo, 350 Cameroons, French, 394 Canary Islands, 522 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 498 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 385-386 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 541 Spanish, 553 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Swaziland, 316 636 Index Gonorrhea— (Continued) Tanganyika, 161 Togoland, British, 440 French, 438 Tunisia, 588 Uganda, 142 Union of South Africa, 283- 284 Zanzibar Protectorate, 231 Granuloma inguinale, Anglo- Egyptian Sudan, 39 Belgian Congo, 350 Egypt, 18 Liberia, 450 South West Africa, 298 Union of South Africa, 284 Grippe, Canary Islands, 522 Cape Verde Islands, 512 Spanish Sahara and Ifni, 528 Guinea-worm infection See Dracontiasis Hashish addiction, Algeria, 574 Morocco, 545 Tunisia, 591 Health centers. See Hospitals and dispensaries Health hints for the tropics, 617- 627 alcoholic beverages, 625 climate, 617-618 clothing, 625-626 fish, dangerous, 626 food, 619-620 general 617-626 heat exhaustion, 625 housing, 626 immunization, 622-625 additional for certain areas, 624 children, 624 routine, 623 insects, 620-622 intestinal diseases, 621-622 malaria, 621 rest, 625 skin diseases, 625 snakes, 626 sunburn, 625 sunstroke, 625 water, 618-619 Health organizations, Algeria, 565 Anglo-Egyptian Sudan, 34 Angola, 329 Basutoland, 303-304 Bechuanaland Protectorate, 310 Belgian Congo, 344-345 Cameroons, British, 397 French, 391-392 Canary Islands, 520 Cape Verde Islands, 511 Egypt, 11-12 Eritrea, 54 Ethiopia, 67 Health organizations—(Cont.) French Equatorial Africa, 373- 374 French West Africa, 492-493 Gambia, 477 Gold Coast, 428-429 Guinea, Portugese, 468-469 Spanish, 384 Kenya, 116-117 Liberia, 447 Libya, 599-600 Madagascar and Comores ar- chipelago, 239-240 Mauritius, 353-254 Morocco, French, 536-537 Spanish, 550-551 Mozambique, 215-216 Nigeria, 411 Nyasaland, 173-174 Réunion, 260-261 Rhodesia, Northern, 186 Southern, 199-200 Ruanda-Urundi, 363 Sao Tomé and Principe, 400 Sierra Leone, 459-460 Somalia, 96-97 Somaliland, British, 79-80 French, 87-88 South West Africa, 296 Spanish Sahara and Ifni, 527 Swaziland, 315 Tanganyika, 156-157 Tangier, 556 Togoland, British, 439 French, 437 Tunisia, 584 Uganda, 137 Union of South Africa, 276-278 Zanzibar Protectorate, 228-229 Health services. See Health or- ganizations, Hospitals, Laboratories, Schools, Physicians, Dentists Nurses Heat exhaustion, tropics, 625 Helminthiases, Algeria, 567-568 Anglo-Egyptian Sudan, 36-37 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 348-349 Cameroons, British, 398 French, 393 Canary Islands, 521-522 Cape Verde Islands, 512 Egypt, 15-16 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 375- 376 French West Africa, 496 Gambia, 478 Gold Coast, 430-431 Guinea, Portuguese, 470 Spanish, 385 Helminthiases— (Continued) Kenya, 118-119 Liberia, 449-450 Libya, 601-602 Madagascar and Comores ar- chipelago, 242-243 Mauritius, 255 Morocco, French, 539-540 Spanish, 552 Mozambique, 217-218 Nigeria, 413-414 Nyasaland, 175 Réunion, 261 Rhodesia, Northern, 188 Southern, 201-202 Ruanda-Urundi, 364-365 Sierra Leone, 461 Somalia, 98 Somaliland, British, 81 French, 88 South West Africa, 297 Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 159 Tangier, 557 Togoland, British, 440 French, 438 Tunisia, 586 Uganda, 140 Union of South Africa, 281 Zanzibar Protectorate, 230 Hepatitis (infectious), Algeria 574 Anglo-Egyptian Sudan, 44 Belgian Congo, 356 Egypt, 22 Ethiopia, 72 French West Africa, 504 Gold Coast, 434 Libya, 604 Morocco, 544 Nigeria, 420 Sierra Leone, 464 Somalia, 101 Tunisia, 591 Uganda, 146 Heterophyiasis, Egypt, 16 High Commission Territories of South Africa. See Basuto- land, Bechuanaland Pro- tectorate, Swaziland Histoplasmosis, French West Africa, 499 Union of South Africa, 284 Hookworm infection. See Ancy- lostomiasis Hospitals and dispensaries, Al- geria, 565-566 Anglo-Egyptian Sudan, 34-35 Angola, 329 Basutoland, 304 Bechuanaland Protectorate, 310 Belgian Congo, 345-346 Cameroons, British, 397 French, 392 Index 637 Hospitals and dispensaries — (Continued) Canary Islands, 520-521 Cape Verde Islands, 511 Egypt, 12-13 Eritrea, 55 Ethiopia, 67-68 French Equatorial Africa, 374 French West Africa, 493 Gambia, 477 Gold Coast, 429 Guinea, Portuguese, 469 Spanish, 384 Kenya, 117 Liberia, 447-448 Libya, 600 Madagascar and Comores ar- chipelago, 240 Mauritius, 254 Morocco, French, 537 Spanish, 551 Mozambique, 216 Nigeria, 411-412 Nyasaland, 174 Réunion, 261 Rhodesia, Northern, 186-187 Southern, 200 Ruanda-Urundi, 363-364 Sao Tomé and Principe, 400 Sierra Leone, 460 Somalia, 97 Somaliland, British, 80 French, 88 South West Africa, 296-297 Spanish Sahara and Ifni, 527- 528 Swaziland, 315 Tanganyika, 157-158 Tangier, 556 Togoland, British, 439 French, 437-438 Tunisia, 584-585 Uganda, 137-138 Union of South Africa, 278 Zanzibar Protectorate, 229 Housing, Algeria, 561-562 Anglo-Egyptian Sudan, 29 Angola, 326 Basutoland, 303 Bechuanaland Protectorate, 309 Belgian Congo, 340-341 Cameroons, French, 390-391 Canary Islands, 518 Cape Verde Islands, 510 Egypt, 7 Eritrea, 52 Ethiopia, 65 French Equatorial Africa, 371 French West Africa, 487 Gambia, 476 Gold Coast, 426 Guinea, Portuguese, 467 Spanish, 384 Kenya, 110 Liberia, 444 Housing— (Continued) Libya, 597 Madagascar and Comores ar- chipelago, 237 Mauritius, 252 Morocco, French, 533 Spanish, 550 Mozambique, 211-212 Nigeria, 406-407 Nyasaland, 171-172 Rhodesia, Northern, 182-183 Southern, 196 Ruanda-Urundi, 362 Sierra Leone, 457 Somalia, 94 Somaliland, British, 77 French, 87 South West Africa, 294 Spanish Sahara and Ifni, 527 Swaziland, 315 Tanganyika, 152 tropics, 626 Tunisia, 581 Uganda, 133 Union of South Africa, 270-271 Zanzibar Protectorate, 227 Humidity. See Geography and climate Hydatid disease. See Echinococ- cosis Hydrocele, Anglo-Egyptian Su- dan, 42 : Egypt, 21 Guinea, Portuguese, 471 Kenya, 125 Mozambique, 220 Tanganyika, 164 Uganda, 145 Hydrophobia. See Rabies Hymenolepiasis, Algeria, 568 Anglo-Egyptian Sudan, 37 Belgian Congo, 349 Ethiopia, 69 French West Africa, 496 Gold Coast, 431 Kenya, 119 Mauritius, 255 Morocco, 540 Nigeria, 414 Rhodesia, Northern, 188 Southern, 202 Somaliland, French, 89 Union of South Africa, 281 Hypovitaminosis. See Nutritional diseases Ifni. See Spanish Sahara and Ifni Immunization, for tropics, 622- 625 additional for certain areas, 624 children, 624 routine, 623 See also individual diseases Impetigo, French Equatorial Africa, 377 pemphigoid, Somaliland, French, 89 Infections. See Mycotic skin in- fections, Rickettsial infec- tions, Skin infections, etc. Influenza, Anglo-Egyptian Sudan, 38 Basutoland, 305 Belgian Congo, 350 Cape Verde Islands, 512 Eritrea, 57 Gold Coast, 431 Libya, 602 Mauritius, 256 Mozambique, 218 Nyasaland, 176 Réunion, 262 Sao Tomé and Principe, 400 Somalia, 99 Somaliland, British, 81 Swaziland, 316 Union of South Africa, 283 Zanzibar Protectorate, 231 Inoculation. See individual dis- eases Inspectors, health, sanitary. See Food sanitation, Health organizations, Personnel Institutions, medical. See Hos- pitals and dispensaries, Laboratories, Schools Intestinal diseases. See individual diseases and also under Flies Itch, “Dhobie,” Tanganyika, 162. See also Tinea Kala-azar (Visceral leishmania- sis), Algeria, 573 Anglo-Egyptian Sudan, 42 Belgian Congo, 355-356 Egypt, 22 Eritrea, 58 Ethiopia, 72 Gold Coast, 433 Kenya, 125 Libya, 604 Morocco, French, 544 Spanish, 554 Somalia, 100-101 Somaliland, British, 83 Tunisia, 591 Uganda, 146 Kwashiorkor, Belgian Congo, 356 Gold Coast, 433-434 Kenya, 126 Rhodesia, Northern, 192 Southern, 206 Tanganyika, 166 Uganda, 146 Laboratories, Algeria, 566 Anglo-Egyptian Sudan, 35 Angola, 330 638 Index Laboratories— (Continued) Belgian Congo, 346 Cameroons, British, 397 French, 392 Canary Islands, 521 Cape Verde Islands, 511 Egypt, 13 Eritrea, 55 Ethiopia, 68 French Equatorial Africa, 374 French West Africa, 493-494 Gambia, 477 Gold Coast, 429 Guinea, Portuguese, 469 Spanish, 384-385 Kenya, 117 Liberia, 448 Libya, 600 Madagascar and Comores ar- chipelago, 240 Mauritius, 254 Morocco, French, 537 Spanish, 551 Mozambique, 216 Nigeria, 412 Nyasaland, 174 Réunion, 261 Rhodesia, Northern, 187 Southern, 200 Ruanda-Urundi, 364 Sierra Leone, 460 Somalia, 97 Somaliland, British, 80 French, 88 South West Africa, 297 Spanish Sahara and Ifni, 528 Swaziland, 315 Tanganyika, 158 Tangier, 556 Togoland, French, 438 Tunisia, 585 Uganda, 138 Union of South Africa, 278-279 Zanzibar Protectorate, 229 Language. See Population Lead poisoning, Morocco, 544- 545 Rhodesia, Northern, 192 Leech, Tunisia, 584 Leishmaniasis, Algeria, 573 Anglo-Egyptian Sudan, 42 Angola, 333 Belgian Congo, 355-356 Cameroons, French, 395 Egypt, 22 Eritrea, 58 Ethiopia, 72 French Equatorial Africa, 379 French West Africa, 504 Gold Coast, 433 Kenya, 125 Liberia, 452 Libya, 604 Madagascar and Comores ar- chipelago, 248 Leishmaniasis— (Continued) Morocco, French, 544 Spanish, 554 Nigeria, 420 Somalia, 100-101 Somaliland, British, 83 Tunisia, 591 Uganda, 146 See also Sandflies Leprosy, Algeria, 571 Anglo-Egyptian Sudan, 39 Angola, 331-332 Basutoland, 305-306 Bechuanaland Protectorate, 312 Belgian Congo, 351 Cameroons, British, 397 French, 394 Canary Islands, 522 Cape Verde Islands, 512-513 Egypt, 18-19 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 498-499 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 121 Liberia, 450 Libya, 603 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 541 Spanish, 553 Mozambique, 218-219 Nigeria, 415-416 Nyasaland, 176-177 Réunion, 262 Rhodesia, Northern, 190 Southern, 204 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Somaliland, British, 82 French, 89 South West Africa, 298-299 Spanish Sahara and Ifni, 529 Swaziland, 316 Tanganyika, 162 Togoland, British, 440 French, 438 Tunisia, 588 Uganda, 142 Union of South Africa, 284 Zanzibar Protectorate, 231 Leptospirosis, Algeria, 571 Belgian Congo, 352 Egypt, 19 French Equatorial Africa, 377 French West Africa, 500 Madagascar and Comores ar- chipelago, 245 Leptospirosis— (Continued) Morocco, 542 Union of South Africa, 285 Lice, Algeria, 564 Anglo-Egyptian Sudan, 32 Angola, 327 Basutoland, 303 Belgian Congo, 342 Canary Islands, 519 Cape Verde Islands, 511 Egypt, 9 Eritrea, 53 Ethiopia, 66 French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Guinea, Portuguese, 468 Kenya, 114 Liberia, 446 Libya, 598 Madagascar and Comores ar- chipelago, 238 Mauritius, 253 Morocco, 535 Mozambique, 213 Nigeria, 409 Nyasaland, 173 Rhodesia, Northern, 184 Southern, 198 Ruanda-Urundi, 363 Sierra Leone, 458 Somalia, 95 Somaliland, British, 78 South West Africa, 295 Tanganyika, 155 tropics, 620 Tunisia, 583 Uganda, 135 Union of South Africa, 274 Zanzibar Protectorate, 228 See also Relapsing fever, Ty- phus Liver disease, fatty, Gambia, 480 Loaiasis, Angola, 333 Belgian Congo, 355 Cameroons, French, 395 French Equatorial Africa, 379 Gold Coast, 433 Guinea, Spanish, 386 Liberia, 452 Rhodesia, Northern, 191 Sierra Leone, 464 Lymphogranuloma venereum (in- guinale), Algeria, 569 Anglo-Egyptian Sudan, 39 Belgian Congo, 350 Canary Islands, 522 Egypt, 18 Eritrea, 57 Ethiopia, 69 French Equatorial Africa, 377 French West Africa, 498 Guinea, Spanish, 386 Kenya, 121 Libya, 602 Lymphogranuloma venereum (in- guinale) —( Continued) Madagascar and Comores ar- chipelago, 244 Morocco, 541 Réunion, 262 Rhodesia, Northern, 190 Southern, 203 Somalia, 99 Somaliland, French, 89 South West Africa, 298 Tunisia, 588 Union of South Africa, 283 Madura foot. See Mycetoma Malaria, Algeria, 571-572 Anglo-Egyptian Sudan, 40-41 Angola, 332 Basutoland, 306 Bechuanaland Protectorate, 312 Belgian Congo, 352-353 Cameroons, British, 397 French, 394 Canary Islands, 523 Cape Verde Islands, 513 Egypt, 19 Eritrea, 57-58 Ethiopia, 71 French Equatorial Africa, 377- 378 French West Africa, 500 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 471 Spanish, 386 Kenya, 122-123 Liberia, 451 Libya, 603 Madagascar and Comores ar- chipelago, 245-246 Mauritius, 256-257 Morocco, French, 542 Spanish, 553-554 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Réunion, 262-263 Rhodesia, Northern, 190 Southern, 204-205 Ruanda-Urundi, 365-366 Sao Tomé and Principe, 400 Sierra Leone, 463 Somalia, 99-100 Somaliland, British, 82-83 French, 89-90 South West Africa, 299 Spanish Sahara and Ifni, 529 Swaziland, 317 Tanganyika, 162-163 Tangier, 557 Togoland, British, 440 French, 438 tropics, 621 Tunisia, 588-589 Uganda, 143 Malaria— (Continued) Union of South Africa, 285 Zanzibar Protectorate, 231-232 See also Mosquitoes Malnutrition. See diseases Massawa fever. See Dengue fever “Mbuaki,” Belgian Congo, 356 Measles, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Cameroons, British, 398 French, 394 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 17 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376 French West Africa, 498 Gambia, 479 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 540 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 161 Togoland, French, 438 Tunisia, 587 Uganda, 141 Union of South Africa, 283 Zanzibar Protectorate, 231 Nutritional Medical institutions. See Hospi- tals and dispensaries, Lab- oratories, Schools Meningitis, meningococcus, Al- geria, 569 Anglo-Egyptian Sudan, 38 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Index 639 Meningitis, meningococcus — (Continued) Cameroons, British, 397 French, 393-394 Canary Islands, 522 Egypt, 17-18 Eritrea, 56 Ethiopia, 70 French Equatorial Africa, 376 French West Africa, 497-498 Gambia, 478-479 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 120-121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 243 Morocco, French, 541 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Swaziland, 316 Tanganyika, 160-161 Togoland, British, 440 French, 438 Tunisia, 588 Uganda, 141 Union of South Africa, 283 Zanzibar Protectorate, 231 pneumococcus, Belgian Congo, 350 French Equatorial Africa, 376 Kenya, 120 Uganda, 141 Midge, biting. See Flies Midwives, Algeria, 567 Anglo-Egyptian Sudan, 35 Angola, 330 Bechuanaland Protectorate, 310 Belgian Congo, 347 Cameroons, French, 392 Egypt, 14 French Equatorial Africa, 374 French West Africa, 495 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 469 Libya, 601 Madagascar and Comores ar- chipelago, 241 Mauritius, 254 Morocco, 538 Mozambique, 216 640 Index Midwives— (Continued) Nigeria, 413 Nyasaland, 174 Réunion, 261 Rhodesia, Southern, 201 Ruanda-Urundi, 364 Sao Tomé and Principe, 400 Sierra Leone, 460 Somalia, 97 Somaliland, French, 88 Togoland, French, 438 Tunisia, 585 Uganda, 139 Missionary (religious) medical work. See Hospitals and dispensaries, Schools (med- ical), Physicians, Nurses, Midwives Mites, Algeria, 564 Anglo-Egyptian Sudan, 32 Angola, 328 Belgian Congo, 343 Canary Islands, 520 Egypt, 9-10 Eritrea, 54 Ethiopia, 67 French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Kenya, 114 Liberia, 446 Libya, 599 Morocco, 535 Mozambique, 214 Nigeria, 409 Nyasaland, 173 Rhodesia, Northern, 185 Southern, 198 Somalia, 96 Somaliland, British, 79 Tanganyika, 155 tropics, 620 Tunisia, 583 Uganda, 136 Union of South Africa, 274 See also Skin diseases, Scabies Mollusks, Algeria, 564-565 Anglo-Egyptian Sudan, 33 Angola, 328 Basutoland, 303 Bechuanaland Protectorate, 309-310 Belgian Congo, 343-344 Egypt, 10-11 Eritrea, 54 Ethiopia, 67 French Equatorial Africa, 373 French West Africa, 491 Gold Coast, 428 Kenya, 115 Liberia, 446-447 Libya, 599 Madagascar and Comores ar- chipelago, 239 Morocco, 536 Mollusks— (Continued) Mozambique, 214 Nigeria, 410 Nyasaland, 173 Rhodesia, Northern, 185 Southern, 199 Sierra Leone, 459 Somalia, 96 Somaliland, British, 79 Tanganyika, 156 Tunisia, 583 Uganda, 136 Union of South Africa, 275 Zanzibar Protectorate, 228 See also Schistosomiasis Moniliasis, Liberia, 451 Mortality rates. See Statistics (vital) and individual dis- eases Mosquitoes, Algeria, 563 Anglo-Egyptian Sudan, 30-31 Angola, 327 Basutoland, 303 Bechuanaland Protectorate, 309 Belgian Congo, 341-342 Cameroons, British, 397 French, 391 Canary Islands, 519 Cape Verde Islands, 510 Egypt, 8-9 Eritrea, 53 Ethiopia, 66 French Equatorial Africa, 371- 372 French West Africa, 488-489 Gambia, 476-477 Gold Coast, 426-427 Guinea, Portuguese, 468 Spanish, 384 Kenya, 111-112 Liberia, 445 Libya, 598 Madagascar and Comores ar- chipelago, 238 Mauritius, 252-253 Morocco, 534-535 Mozambique, 212-213 Nigeria, 408 Nyasaland, 172 Rhodesia, Northern, 183-184 Southern, 197 Ruanda-Urundi, 362-363 Sierra Leone, 458 Somalia, 95 Somaliland, British, 78 South West Africa, 295 Spanish Sahara and Ifni, 527 Tanganyika, 153 Togoland, British, 439 tropics, 620 Tunisia, 582 Uganda, 134 Union of South Africa, 273 Zanzibar Protectorate, 227-228 See also Dengue fever, Filaria- sis, Malaria, Yellow fever Mossy foot. See Fungus infec- tions Mumps, Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Belgian Congo, 350 Egypt, 18 French Equatorial Africa, 376 French West Africa, 498 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Rhodesia, Southern, 203 Somaliland, British, 81 French, 89 Spanish Sahara and Ifni, 528 Tanganyika, 161 Mycetoma (Madura foot)’, Anglo- Egyptian Sudan, 40 Belgian Congo, 352 Egypt, 18 French West Africa, 499 Guinea, Spanish, 386 Madagascar and Comores ar- chipelago, 245 Morocco, 541 Somalia, 99 Somaliland, British, 81-82 Mycotic skin infections, Algeria, 570 Anglo-Egyptian Sudan, 40 Angola, 332 Bechuanaland Protectorate, 312 Belgian Congo, 352 Cameroons, French, 394 Canary Islands, 522 Cape Verde Islands, 513 Egypt, 18 Eritrea, 57 Ethiopia, 70 French West Africa, 499 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 122 Liberia, 451 Libya, 603 Madagascar and Comores ar- chipelago, 245 Mauritius, 256 Morocco, French, 541 Spanish, 553 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Réunion, 262 Rhodesia, Northern, 190 Southern, 204 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Mycotic skin infections—(Cont.) Somaliland, British, 81 French, 89 South West Africa, 299 Spanish Sahara and Ifni, 528 Tanganyika, 162 Togoland, British, 440 Tunisia, 588 Uganda, 143 Union of South Africa, 284 Myiasis, Algeria, 571 Anglo-Egyptian Sudan, 40 Angola, 332 Bechuanaland Protectorate, 312 Belgian Congo, 352 Cameroons, French, 394 Canary Islands, 522 Egypt, 18 Eritrea, 57 French West Africa, 499 Guinea, Portuguese, 471 Spanish, 386 Kenya, 122 Liberia, 451 Libya, 603 Morocco, Spanish, 553 Mozambique, 219 Nigeria, 417 Rhodesia, Northern, 190 Ruanda-Urundi, 365 Somaliland, British, 82 South West Africa, 299 Spanish Sahara and Ifni, 528 Tanganyika, 165 Tunisia, 588 Uganda, 143 Union of South Africa, 284 Zanzibar Protectorate, 231 See also Flies, Skin diseases Night blindness, Egypt, 22 Nigeria, 420 Rhodesia, Southern, 206 Tanganyika, 165 Nurses, Algeria, 567 "Anglo-Egyptian Sudan, 35 Angola, 330 Basutoland, 304 Bechuanaland Protectorate, 310 Belgian Congo, 347 Cameroons, French, 392 Canary Islands, 521 Cape Verde Islands, 511 Egypt, 14 Eritrea, 55 Ethiopia, 68 French Equatorial Africa, 374 French West Africa, 494 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 469 Spanish, 385 Kenya, 118 Liberia, 449 Libya, 601 Nurses— (Continued) Madagascar and Comores ar- chipelago, 241 Mauritius, 254 Morocco, French, 538 Spanish, 552 Mozambique, 216 Nigeria, 413 Nyasaland, 174 Réunion, 261 Rhodesia, Northern, 187 Southern, 201 Ruanda-Urundi, 364 Sao Tomé and Principe, 400 Sierra Leone, 460 Somalia, 97 Somaliland, British, 80 French, 88 South West Africa, 297 Swaziland, 316 Tanganyika, 158 Togoland, French, 438 Tunisia, 585 Uganda, 139 Union of South Africa, 279 Zanzibar Protectorate, 229 Nutrition. See Food and nutrition Nutritional diseases, Algeria, 574 Anglo-Egyptian Sudan, 43-44 Angola, 333-334 Basutoland, 306 Bechuanaland Protectorate, 313 Belgian Congo, 356 Cameroons, French, 395 Cape Verde Islands, 513 Egypt, 22 Eritrea, 59 Ethiopia, 72 French Equatorial Africa, 380 French West Africa, 504 Gambia, 480 Gold Coast, 433-434 Guinea, Portuguese, 472 Kenya, 126 Liberia, 452 Libya, 604 Madagascar and Comores ar- chipelago, 248 Mauritius, 257 Morocco, French, 544 Spanish, 554 Mozambique, 220 Nigeria, 420 Nyasaland, 178 Réunion, 263 Rhodesia, Northern, 191-192 Southern, 205-206 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 101 Somaliland, British, 83 French, 90 South West Africa, 299 Swaziland, 317 Index 641 Nutritional diseases—(Cont.) Tanganyika, 165-166 Tunisia, 591 Uganda, 146 Union of South Africa, 287-288 Zanzibar Protectorate, 232 See also Beriberi, Goiter, Kwashiorkor, Pellagra, Rickets, Scurvy Obock fever. See Dengue fever Onchocerciasis, Anglo-Egyptian Sudan, 40, 43 Angola, 333 Belgian Congo, 355 Cameroons, French, 395 Egypt, 22 Ethiopia, 72 French Equatorial Africa, 379 French West Africa, 503 Gold Coast, 433 Kenya, 125 Liberia, 452 Mozambique, 220 Nigeria, 419-420 Nyasaland, 178 Rhodesia, Northern, 191 Tanganyika, 164 Togoland, French, 438 Tunisia, 591 Uganda, 145 Onyalai, Angola, 334 Southern Rhodesia, 206 Ophthalmia, gonococcal, Basuto- land, 305 Egypt, 18 Kenya, 122 Tanganyika, 162 Tunisia, 588 neonatorum, Swaziland, 317 Oriental sore. See Leishmaniasis Osteomalacia, Egypt, 22 Osteopetrosis, Algeria, 574 Tunisia, 591 Oxyuriasis. See Enterobiasis Pappataci fever. See Sandfly fever Paralysis, tick, Union of South Africa, 287 Parasitologists, Kenya, 118 Paratyphoid fever, Algeria, 567 Anglo-Egyptian Sudan, 36 Angola, 330 Basutoland, 304 Belgian Congo, 347 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 14 Eritrea, 55 Ethiopia, 68-69 642 Index Paratyphoid fever— (Continued) French Equatorial Africa, 375 French West Africa, 495 Guinea, Portuguese, 470 Gold Coast, 430 Kenya, 118 Liberia, 449 Libya, 601 Madagascar and Comores ar- chipelago, 241 Mauritius, 254-255 Morocco, French, 538-539 Spanish, 552 Mozambique, 217 Nigeria, 413 Nyasaland, 175 Réunion, 261 Rhodesia, Northern, 187-188 Southern, 201 Ruanda-Urundi, 364 Sierra Leone, 461 Somalia, 98 Somaliland, British, 80-81 French, 88 South West Africa, 297 Tanganyika, 158 Tunisia, 585-586 Uganda, 140 Union of South Africa, 280 Zanzibar Protectorate, 230 Pathologists, Anglo-Egyptian Su- dan, 35 Gold Coast, 430 Kenya, 118 Mauritius, 254 Nyasaland, 174 Rhodesia, Northern, 187 Sierra Leone, 460 Somaliland, British, 80 Uganda, 139 Zanzibar Protectorate, 229 Pellagra, Anglo-Egyptian Sudan, 44 Basutoland, 306 Bechuanaland Protectorate, 313 Belgian Congo, 356 Egypt, 22 Gambia, 480 Gold Coast, 433 Kenya, 126 Liberia, 452 Libya, 604 Mauritius, 257 Morocco, 544 Mozambique, 220 Nigeria, 420 Nyasaland, 178 Rhodesia, Northern, 191 Southern, 206 Ruanda-Urundi, 366 Somalia, 101 South West Africa, 299 Swaziland, 317 Tanganyika, 166 Pellagra— (Continued) Uganda, 146 Union of South Africa, 288 Zanzibar Protectorate, 232 Personnel. See Health organiza- tions, Physicians, Dentists, Nurses, Midwives, Veter- inarians, Pharmacists, Chemists, etc. Pharmacists, Algeria, 567 Angola, 330 Belgian Congo, 347 Cape Verde Islands, 511 Egypt, 14 French West Africa, 494 Guinea, Portuguese, 469 Madagascar and Comores ar- chipelago, 241 Morocco, 538 Mozambique, 217 Nyasaland, 174 Réunion, 261 Rhodesia, Northern, 187 Southern, 201 Sao Tomé and Principe, 400 Somalia, 97 Somaliland, British, 80 French, 88 Togoland, French, 438 Tunisia, 585 Uganda, 139 Union of South Africa, 279 Physicians, Algeria, 566 Anglo-Egyptian Sudan, 35 Angola, 330 Basutoland, 304 Bechuanaland Protectorate, 310 Belgian Congo, 346-347 Cameroons, French, 392 Canary Islands, 521 Cape Verde Islands, 511 Egypt, 14 Eritrea, 55 Ethiopia, 68 French Equatorial Africa, 374 French West Africa, 494 Gambia, 478 Gold Coast, 430 Guinea, Portuguese, 469 Spanish, 385 Kenya, 117 Liberia, 449 Libya, 600-601 Madagascar and Comores ar- chipelago, 241 Mauritius, 254 Morocco, French, 538 Spanish, 552 Mozambique, 216 Nigeria, 413 Nyasaland, 174 Réunion, 261 Rhodesia, Northern, 187 Southern, 201 Ruanda-Urundi, 364 Physicians— (Continued) Sdao Tomé and Principe, 400 Sierra Leone, 460 Somalia, 97 Somaliland, British, 80 French, 88 South West Africa, 297 Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 158 Togoland, French, 438 Tunisia, 585 Uganda, 139 Union of South Africa, 279 Zanzibar Protectorate, 229 Pinworm infection. See Entero- biasis (Oxyuriasis) Pityriasis vesicolor, Tanganyika, 162 Plague, Africa (map), 610 Algeria, 573 Anglo-Egyptian Sudan, 43 Angola, 333 Basutoland, 306 Bechuanaland Protectorate, 312 Belgian Congo, 354 Cameroons, French, 395 Canary Islands, 523 Cape Verde Islands, 513 Egypt, 20-21 Eritrea, 59 Ethiopia, 72 French Equatorial Africa, 379 French West Africa, 501-502 Gambia, 480 Gold Coast, 433 Guinea, Portuguese, 471 Kenya, 123-124 Liberia, 452 Libya, 603-604 Madagascar and Comores ar- chipelago, 246-247 Mauritius, 257 Morocco, French, 543 Spanish, 554 Mozambique, 220 Nigeria, 420 Nyasaland, 177 Réunion, 263 Rhodesia, Northern, 191 Southern, 205 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 100 Somaliland, British, 83 French, 90 South West Africa, 299 Swaziland, 317 Tanganyika, 164-165 Togoland, French, 438 Tunisia, 590-591 Uganda, 144-145 Union of South Africa, 286-287 Zanzibar Protectorate, 232 See also Rodents, Fleas Index 643 Plants, allergy-producing Anglo-Egyptian Sudan, 33 Egypt, 11 French West Africa, 492 Kenya, 115 tropics, 626 Union of South Africa, 275- 276 poisonous Anglo-Egyptian Sudan, 33 Angola, 328 Belgian Congo, 344 Egypt, 11 French West Africa, 492 Gold Coast, 428 Kenya, 115 Liberia, 447 Mozambique, 214 Nigeria, 410 Rhodesia, Northern, 185 Southern, 199 Sierra Leone, 459 Somaliland, British, 79 South West Africa, 296 Tanganyika, 156 tropics, 626 Uganda, 136-137 Union of South Africa, 275- 276 Pneumokoniosis, Nigeria, 420 Pneumonia, Algeria, 569 Anglo-Egyptian Sudan, 38 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Cameroons, British, 398 French, 394 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376 French West Africa, 498 Gambia, 479 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 119-120 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, 541 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Sao Tomé and Principe, 400 Sierra Leone, 462 Somalia, 98-99 Pneumonia— (Continued) Somaliland, British, 81 French, 89 South West Africa, 298 Swaziland, 316 Tanganyika, 161 Togoland, British, 440 French, 438 Tunisia, 588 Uganda, 141 Zanzibar Protectorate, 231 Poisoning, fluorine, Algeria, 574 lead, Morocco, 544-545 Rhodesia, Northern, 192 from plants. See Plants Poliomyelitis, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Cameroons, French, 394 Canary Islands, 522 Egypt, 18 Eritrea, 57 French Equatorial Africa, 376 French West Africa, 498 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 255-256 Morocco, French, 541 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Sierra Leone, 462 Somaliland, British, 81 French, 89 Tanganyika, 161 Tunisia, 588 Uganda, 141 Union of South Africa, 283 Population, Algeria, 559-560 Anglo-Egyptian Sudan, 27-28 Angola, 324-325 Basutoland, 301-302 Bechuanaland Protectorate, 307- 308 Belgian Congo, 337-338 Cameroons, British, 396 French, 388-389 Canary Islands, 517-518 Cape Verde Islands, 508-509 Egypt, 4-5 Eritrea, 50-51 Ethiopia, 63-64 Population— (Continued) French Equatorial Africa, 369 French West Africa, 483-485 Gambia, 474-475 Gold Coast, 423-424 Guinea, Portuguese, 466-467 Spanish, 382-383 Kenya, 107-108 Liberia, 442-443 Libya, 596 Madagascar and Comores ar- chipelago, 235-236 Mauritius, 250-251 Morocco, French, 531 Spanish, 548-549 Mozambique, 209-210 Nigeria, 404-405 Nyasaland, 169-170 Réunion, 259-260 Rhodesia, Northern, 180-181 Southern, 194-195 Ruanda-Urundi, 360-361 Sao Tomé and Principe, 400 Sierra Leone, 455-456 Somalia, 93 Somaliland, British, 75-76 French, 85-86 South West Africa, 292-293 Spanish Sahara and Ifni, 526 Swaziland, 313-314 Tanganyika, 149-150 Tangier, 556 Togoland, British, 438-439 French, 436-437 Tunisia, 579-580 Uganda, 130-131 Union of South Africa, 268-269 Zanzibar Protectorate, 225-226 Principe. See Sao Tomé and Prin- cipe Prostitution, Anglo-Egyptian Su- dan, 39 Egypt, 18 French West Africa, 498 Morocco, 541 Mozambique, 218 Rhodesia, Southern, 203-204 Somalia, 99 Somaliland, French, 89 Tunisia, 588 Union of South Africa, 284 Psittacosis, Algeria, 571 Pyomyositis, tropical, French West Africa, 504 Q fever, Algeria, 572 French Equatorial Africa, 379 French West Africa, 502 Morocco, 543 Ruanda-Urundi, 366 Union of South Africa, 286 Quarantine. See individual dis- eases 644 Index Rabies, Algeria, 571 Anglo-Egyptian Sudan, 40 Angola, 332 Bechuanaland Protectorate, 312 Belgian Congo, 352 Cameroons, British, 398 French, 394 Canary Islands, 523 Egypt, 19 Eritrea, 57 Ethiopia, 71 French Equatorial Africa, 377 French West Africa, 499 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470-471 Kenya, 122 Liberia, 451 Libya, 603 Madagascar and Comores ar- chipelago, 245 Morocco, French, 542 Spanish, 553 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Rhodesia, Northern, 190 Southern, 204 Ruanda-Urundi, 365 Sierra Leone, 462 Somaliland, British, 82 South West Africa, 299 Tanganyika, 162 Tunisia, 588 Uganda, 143 Union of South Africa, 284 Zanzibar Protectorate, 231 Racial groups, divisions, statis- tics, etc. See Population Rainfall. See Geography and climate Ratbite fever, Belgian Congo, 356 Rats. See Rodents Reduviid bugs, Canary Islands, 520 Kenya, 114 Madagascar and Comores ar- chipelago, 239 tropics, 620 Relapsing fever, Algeria, 572-573 Anglo-Egyptian Sudan, 41 Angola, 333 Basutoland, 306 Bechuanaland Protectorate, 313 Belgian Congo, 355 Cameroons, French, 395 Canary Islands, 523 Egypt, 21 Eritrea, 58 Ethiopia, 71-72 French Equatorial Africa, 379 French West Africa, 503-504 Gold Coast, 433 Guinea, Portuguese, 472 Kenya, 124 Relapsing fever— (Continued) Liberia, 452 Libya, 603 Madagascar and Comores ar- chipelago, 247 Mauritius, 257 Morocco, French, 543-544 Spanish, 554 Mozambique, 220 Nigeria, 420 Nyasaland, 177 Réunion, 263 Rhodesia, Northern, 191 Southern, 205 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 100 Somaliland, British, 83 French, 90 South West Africa, 299 Spanish Sahara and Ifni, 529 Swaziland, 317 Tanganyika, 164 Tunisia, 590 Uganda, 144 Union of South Africa, 286 Zanzibar Protectorate, 232 See also Lice, Ticks Religion. See Population Religious (missionary) medical work. See Hospitals and dispensaries, Schools (med- ical), Physicians, Nurses, Midwives Reptiles, Algeria, 564 Anglo-Egyptian Sudan, 32-33 Angola, 328 Belgian Congo, 343 Canary Islands, 520 Egypt, 10 Eritrea, 54 Ethiopia, 67 French Equatorial Africa, 373 French West Africa, 491 Gold Coast, 427-428 Guinea, Portuguese, 468 Kenya, 114-115 Liberia, 446 Libya, 599 Madagascar and Comores ar- chipelago, 239 Mauritius, 253 Morocco, 536 Mozambique, 214 Nigeria, 410 Nyasaland, 173 Rhodesia, Northern, 185 Southern, 198-199 Sierra Leone, 459 Somalia, 96 Somaliland, British, 79 South West Africa, 296 Tanganyika, 155-156 tropics, 626 Tunisia, 583 Reptiles—(Continued) Uganda, 136 Union of South Africa, 274-275 Zanzibar Protectorate, 228 Research, in disease. See Labo- ratories in nutrition. See Food and nu- trition Rest, requirements in tropics, 625 Rheumatism, ‘‘acute,” Anglo- Egyptian Sudan, 44 Rickets, Basutoland, 306 Egypt, 22 French West Africa, 504 Kenya, 126 Mauritius, 257 Morocco, 544 Mozambique, 220 Nigeria, 420 Nyasaland, 178 Rhodesia, Northern, 191 Southern, 206 Ruanda-Urundi, 366 Sierra Leone, 464 Somaliland, British, 83 Swaziland, 317 Union of South Africa, 288 Zanzibar Protectorate, 232 Rickettsial infections, Algeria, 572 Anglo-Egyptian Sudan, 43 Basutoland, 306 Belgian Congo, 353-354 Canary Islands, 523 Egypt, 20 Eritrea, 58 Ethiopia, 71 French Equatorial Africa, 379 French West Africa, 502 Gold Coast, 433 Kenya, 124-125 Libya, 603 Madagascar and Comores ar- chipelago, 247 Morocco, French, 542-543 Spanish, 554 Mozambique, 220 Nigeria, 419 Rhodesia, Northern, 191 Southern, 205 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 100 Somaliland, British, 83 South West Africa, 299 Tunisia, 589-590 Uganda, 145 Union of South Africa, 285-286 See also Typhus fevers Rift Valley fever, Anglo-Egyp- tian Sudan, 43 French West Africa, 504 Kenya, 126 Uganda, 146 Ringworm infection. See Tinea Rio Muni. See Spanish Guinea Index 645 Rodents, Algeria, 564 Anglo-Egyptian Sudan, 33 Angola, 328 Basutoland, 303 Bechuanaland Protectorate, 310 Belgian Congo, 343 Canary Islands, 520 Cape Verde Islands, 511 Egypt, 10 Eritrea, 54 Ethiopia, 67 French Equatorial Africa, 373 French West Africa, 491 Gold Coast, 428 Guinea, Portuguese, 468 Kenya, 115 Liberia, 446 Libya, 599 Madagascar and Comores ar- chipelago, 239 Mauritius, 253 Morocco, 536 Mozambique, 214 Nigeria, 410 Nyasaland, 173 Rhodesia, Northern, 185 Southern, 199 Somalia, 96 Somaliland, British, 79 South West Africa, 296 Tanganyika, 156 Tunisia, 583 Uganda, 136 Union of South Africa, 275 Zanzibar Protectorate, 228 See also Plague, Typhus Roundworm infection. See As- cariasis 4 Sand flea. See Chigoe flea Sandflies, Algeria, 563-564 Anglo-Egyptian Sudan, 32 Angola, 327 Canary Islands, 519 Egypt, 9 Eritrea, 53 Ethiopia, 66 French Equatorial Africa, 372 French West Africa, 490 Kenya, 113 Libya, 598 Madagascar and Comores ar- chipelago, 238 Morocco, 535 Nigeria, 409 Somalia, 95 Somaliland, British, 78 Tanganyika, 155 tropics, 620 Tunisia, 583 Zanzibar Protectorate, 228 See also Sandfly fever, Leish- maniasis Sandfly fever, Algeria, 573-574 Anglo-Egyptian Sudan, 43 Sandfly fever— (Continued) Egypt, 22 Eritrea, 59 Ethiopia, 72 French Equatorial Africa, 379 French West Africa, 504 Guinea, Portuguese, 472 Kenya, 126 Liberia, 452 Libya, 604 Madagascar and Comores ar- chipelago, 247-248 Somalia, 101 Somaliland, British, 83 Uganda, 146 See also Sandflies Sanitation. See Water supplies, Waste disposal, Food sani- tation environmental. See Environ- mental sanitation Scabies, Algeria, 570-571 Angola, 332 Basutoland, 306 Bechuanaland Protectorate, 312 Belgian Congo, 352 Cameroons, French, 394 Canary Islands, 522 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 499 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 122 Madagascar and Comores ar- chipelago, 245 Liberia, 451 Mauritius, 256 Morocco, French, 542 Spanish, 553 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Réunion, 262 Rhodesia, Northern, 190 Southern, 204 Sierra Leone, 462 Somalia, 99 Somaliland, British, 82 South West Africa, 299 Spanish Sahara and Ifni, 528 Swaziland, 317 Tanganyika, 162 Union of South Africa, 284 Zanzibar Protectorate, 231 See also Mites Scarlet fever, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Scarlet fever— (Continued) Belgian Congo, 350 Cameroons, French, 394 Canary Islands, 522 Cape Verde Islands, 512 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376 French West Africa, 498 Gold Coast, 431 Guinea, Spanish, 385 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Morocco, French, 541 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Tanganyika, 161 Tunisia, 588 Uganda, 141 Union of South Africa, 283 Zanzibar Protectorate, 231 Schistosomiasis, Africa (maps), 612-613 Algeria, 567-568 Anglo-Egyptian Sudan, 36-37 Angola, 331 Bechuanaland Protectorate, 311 Belgian Congo, 348-349 Cameroons, British, 398 French, 393 Canary Islands, 522 Egypt, 15-16 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 496 Gambia, 478 Gold Coast, 430-431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 119 Liberia, 449 Libya, 601 Madagascar and Comores ar- chipelago, 242 Mauritius, 255 Morocco, French, 539 Spanish, 552 Mozambique, 217 Nigeria, 414 Nyasaland, 175 646 Index Schistosomiasis— (Continued) Réunion, 261 Rhodesia, Northern, 188 Southern, 201-202 Ruanda-Urundi, 365 Sierra Leone, 461 Somalia, 98 Somaliland, French, 88 Swaziland, 316 Tanganyika, 159 Togoland, French, 438 Tunisia, 586 Uganda, 140 Union of South Africa, 281 Zanzibar Protectorate, 230 See also Mollusks Schools (medical, nurses’ train- ing, etc.), Algeria, 566 Anglo-Egyptian Sudan, 35 Angola, 330 Basutoland, 304 Bechuanaland Protectorate, 310 Belgian Congo, 346 Cameroons, British, 397 French, 392 Canary Islands, 521 Egypt, 13-14 Eritrea, 55 Ethiopia, 68 French Equatorial Africa, 374 French West Africa, 494 Gambia, 477-478 Gold Coast, 429 Guinea, Portuguese, 469 Kenya, 117 Liberia, 448-449 Libya, 600 Madagascar and Comores ar- chipelago, 240-241 Mauritius, 254 Morocco, French, 537-538 Spanish, 552 Mozambique, 216 Nigeria, 412-413 Nyasaland, 174 Rhodesia, Northern, 187 Southern, 200-201 Ruanda-Urundi, 364 Sierra Leone, 460 Somalia, 97 Somaliland, British, 80 Swaziland, 315 Tanganyika, 158 Togoland, French, 438 Tunisia, 585 Uganda, 138-139 Union of South Africa, 279 Zanzibar Protectorate, 229 Scorpions, Algeria, 564 Anglo-Egyptian Sudan, 32 Angola, 328 Belgian Congo, 343 Canary Islands, 520 Egypt, 10 Eritrea, 54 Scorpions— (Continued) French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Guinea, Portuguese, 468 Kenya, 114 Liberia, 446 Libya, 599 Madagascar and Comores ar- chipelago, 239 Morocco, 536 Mozambique, 214 Nigeria, 409 Rhodesia, Northern, 185 South West Africa, 296 Sierra Leone, 459 Tunisia, 583 Uganda, 136 Zanzibar Protectorate, 228 Scurvy, Algeria, 574 Anglo-Egyptian Sudan, 44 Angola, 333 Basutoland, 306 Bechuanaland Protectorate, 313 Belgian Congo, 356 Egypt, 22 French West Africa, 504 Gambia, 480 Gold Coast, 433 Kenya, 126 Libya, 604 Mauritius, 257 Morocco, 544 Mozambique, 220 Nigeria, 420 Nyasaland, 178 Rhodesia, Northern, 191 Southern, 206 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 101 Somaliland, British, 83 French, 90 South West Africa, 299 Swaziland, 317 Tanganyika, 166 Uganda, 146 Union of South Africa, 288 Sewage disposal. See Waste dis- posal Sewerage. See Waste disposal Silicosis, Belgian Congo, 356 Gold Coast, 433 Rhodesia, Northern, 192 Southern, 206 Tanganyika, 166 Uganda, 146 Union of South Africa, 288 Skin diseases, Algeria, 570 Anglo-Egyptian Sudan, 40 Angola, 332 Belgian Congo, 351-352 Cameroons, British, 398 French, 394 Canary Islands, 522 Skin diseases— (Continued) Cape Verde Islands, 513 Egypt, 18 Eritrea, 57 Ethiopia, 70-71 French Equatorial Africa, 377 French West Africa, 499 Gold Coast, 432 Guinea, Spanish, 386 Liberia, 450-451 Libya, 603 Madagascar and Comores ar- chipelago, 244-245 Morocco, French, 541 Spanish, 553 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Réunion, 262 Rhodesia, Northern, 190 Southern, 204 Somalia, 99 Somaliland, British, 81-82 French, 89 Spanish Sahara and Ifni, 528 Tanganyika, 162 Tangier, 556-557 tropics, 625 Uganda, 143 Union of South Africa, 284 Zanzibar Protectorate, 231 Sleeping sickness, African. See Trypanosomiasis Smallpox, Algeria, 569 Anglo-Egyptian Sudan, 38 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Cameroons, British, 397 French, 393 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 17 Eritrea, 56-57 Ethiopia 70 French Equatorial Africa, 376 French West Africa, 497 Gambia, 478 Gold Coast, 431 Guinea, Portuguese, 470 Spanish, 385 Kenya, 120 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 243-244 Mauritius, 255 Morocco, French, 540 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Index 647 Smallpox— (Continued) Rhodesia, Northern, 189 Southern, 203 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 98 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 161 Togoland, British, 440 French, 438 Tunisia, 587 Uganda, 141 Union of South Africa, 282-283 Zanzibar Protectorate, 231 Snails. See Mollusks Snakes. See Reptiles Social economy, Algeria, 560-561 Anglo-Egyptian Sudan, 28-29 Angola, 325-326 Basutoland, 302 Bechuanaland Protectorate, 308 Belgian Congo, 339-340 Cameroons, British, 396 French, 389-390 Canary Islands, 518 Cape Verde Islands, 509 Egypt, 5-6 Eritrea, 51-52 Ethiopia, 64 : French Equatorial Africa, 370 French West Africa, 485-486 Gambia, 475 Gold Coast, 424-425 Guinea, Portuguese, 467 Spanish, 383-384 Kenya, 109 Liberia, 443 Libya, 596-597 Madagascar and Comores ar- chipelago, 236-237 Mauritius, 251-252 Morocco, French, 532 Spanish, 549-550 Mozambique, 210-211 Nigeria, 405-406 Nyasaland, 170-171 Réunion, 260 Rhodesia, Northern, 181-182 Southern, 195-196 Ruanda-Urundi, 361-362 Sao Tomé and Principe, 400 Sierra Leone, 456-457 Somalia, 93-94 Somaliland, British, 76-77 French, 86 South West Africa, 293-294 Spanish Sahara and Ifni, 526 Swaziland, 314 Tanganyika, 151 Tangier, 556 Togoland, British, 439 Social economy— (Continued) French, 437 Tunisia, 580-581 Uganda, 132 Union of South Africa, 270 Zanzibar Protectorate, 226 Soft chancre. See Chancroid Spiders, Algeria, 564 Belgian Congo, 343 Canary Islands, 520 Egypt, 10 French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Liberia, 446 Libya, 599 Madagascar and Comores ar- chipelago, 239 Morocco, 536 Mozambique, 214 Rhodesia, Northern, 185 Southern, 198 South West Africa, 295 Sierra Leone, 459 tropics, 620 Tunisia, 583 Union of South Africa, 274 Spirochetosis, bronchopulmonary, Eritrea, 57 pulmonary, Belgian Congo, 350 Sporotrichosis, Angola, 332 Liberia, 451 Morocco, 541-542 Union of South Africa, 284 Statistics (vital), Algeria, 560 Anglo-Egyptian Sudan, 28 Angola, 325 Belgian Congo, 338-339 Cameroons, French, 389 Canary Islands, 518 Cape Verde Islands, 509 Egypt, 5 Eritrea, 51 Ethiopia, 64 French Equatorial Africa, 370 French West Africa, 485 Gambia, 475 Gold Coast, 424 Guinea, Portuguese, 467 Spanish, 383 Kenya, 108-109 Liberia, 443 Libya, 596 Madagascar and Comores ar- chipelago, 236 Mauritius, 251 Morocco, French, 531-532 Spanish, 549 Mozambique, 210 Nigeria, 405 Nyasaland, 170 Réunion, 260 Rhodesia, Northern, 181 Southern, 195 Ruanda-Urundi, 361 Statistics (vital)— (Continued) Sierra Leone, 456 Somalia, 93 Somaliland, British, 76 French, 86 South West Africa, 293 Tanganyika, 150-151 Togoland, French, 437 Tunisia, 580 Uganda, 131 Union of South Africa, 269-270 Zanzibar Protectorate, 226 Statistics on population. See Pop- ulation Strongyloidiasis, Anglo-Egyptian Sudan, 37 Belgian Congo, 349 Cameroons, French, 393 Egypt, 16 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 496 Gold Coast, 431 Guinea, Spanish, 385 Kenya, 119 Liberia, 450 Madagascar and Comores ar- chipelago, 242 Mauritius, 255 Morocco, Spanish, 552 Réunion, 261 Rhodesia, Northern, 188 Southern, 202 Ruanda-Urundi, 365 Sierra Leone, 461 Somalia, 98 Somaliland, French, 89 Tanganyika, 160 Union of South Africa, 281 Zanzibar Protectorate, 230 Sunburn, tropics, 625 Sunstroke, tropics, 625 Syphilis, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311-312 Belgian Congo, 350 Cameroons, French, 394 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376- 377 French West Africa, 498 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 121 Liberia, 450 648 Index Syphilis— (Continued) Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 541 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 161 Togoland, British, 440 French, 438 Tunisia, 588 Uganda, 141-142 Union of South Africa, 283-284 Zanzibar Protectorate, 231 Taeniasis, Algeria, 568 Anglo-Egyptian Sudan, 37 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 349 Cameroons, French, 393 Cape Verde Islands, 512 Egypt, 16 Eritrea, 56 Ethiopia, 69 French Equatorial Africa, 376 French West Africa, 496 Gambia, 478 Gold Coast, 431 Guinea, Portuguese, 470 Kenya, 119 Libya, 602 Madagascar and Comores ar- chipelago, 243 Mauritius, 255 Morocco, French, 540 Spanish, 552 Mozambique, 218 Nigeria, 414 Nyasaland, 176 Réunion, 261 Rhodesia, Northern, 188 Southern, 202 Ruanda-Urundi, 365 Somalia, 98 Somaliland, British, 81 French, 89 South West Africa, 297 Swaziland, 316 Tanganyika, 160 Tunisia, 586 Taeniasis—( Continued) Uganda, 140 Union of South Africa, 281 Zanzibar Protectorate, 230 Tapeworm infection. See Taenia- sis, Echinococcosis, Hy- menolepiasis, Dipylidiasis Temperature. See Geography and climate Tetanus, Algeria, 571 Anglo-Egyptian Sudan, 40 Angola, 332 Belgian Congo, 352 Cameroons, French, 394 Canary Islands, 523 Egypt, 19 Ethiopia, 71 French Equatorial Africa, 377 French West Africa, 500 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 122 Liberia, 451 Libya, 603 Madagascar and Comores ar- chipelago, 245 Morocco, 542 Mozambique, 219 Nyasaland, 177 Réunion, 262 Rhodesia, Southern, 204 Sierra Leone, 462 Somalia, 99 Somaliland, French, 89 South West Africa, 299 Spanish Sahara and Ifni, 529 Swaziland, 317 Tunisia, 588 Uganda, 143 Zanzibar Protectorate, 231 Tetanus neonatorum, Algeria, 571 Belgian Congo, 352 Ethiopia, 71 Cameroons, French 394 Gambia, 479 Guinea, Spanish, 386 Liberia, 451 Morocco, 542 Réunion, 262 Rhodesia, Southern, 204 Tick fever, African. See Relapsing fever Tick-bite fever. See Typhus fevers Ticks, Algeria, 564 Anglo-Egyptian Sudan, 32 Angola, 328 Basutoland, 303 Belgian Congo, 343 Canary Islands, 520 Cape Verde Islands, 511 Egypt, 9 Eritrea, 53-54 Ethiopia, 66-67 Ticks— (Continued) French Equatorial Africa, 372 French West Africa, 490 Gold Coast, 427 Kenya, 114 Liberia, 446 Libya, 599 Madagascar and Comores ar- chipelago, 239 Mauritius, 253 Morocco, 535 Mozambique, 214 Nigeria, 409 Nyasaland, 173 Rhodesia, Northern, 184-185 Southern, 198 Ruanda-Urundi, 363 Sierra Leone, 459 Somalia, 96 Somaliland, British, 78-79 South West Africa, 295 Spanish Sahara and Ifni, 527 Tanganyika, 155 tropics, 620 Tunisia, 583 Uganda, 136 Union of South Africa, 274 Tinea, Algeria, 570 French West Africa, 499 Kenya, 122 Morocco, French, 541 Spanish, 553 Somalia, 99 Somaliland, British, 81 Spanish Sahara and Ifni, 528 Tanganyika, 162 See also Favus Torulosis, Union of South Africa, 284 Trachoma, Algeria, 570 Anglo-Egyptian Sudan, 40 Angola, 332 Basutoland, 306 Bechuanaland Protectorate, 312 Belgian Congo, 351 Cameroons, French, 394 Canary Islands, 522 Cape Verde Islands, 513 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 499 Gambia, 479 Guinea, Portuguese, 470 Kenya, 122 Libya, 602 Madagascar and Comores ar- chipelago, 245 Morocco, French, 541 Spanish, 553 Nigeria, 417 Nyasaland, 177 Rhodesia, Northern, 190 Southern, 204 Trachoma— (Continued) Réunion, 262 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Somaliland, British, 82 French, 89 South West Africa, 299 Spanish Sahara and Ifni, 528 Swaziland, 317 Tanganyika, 162 Tangier, 557 Togoland, French, 438 Tunisia, 588 Uganda, 142 Union of South Africa, 284 Zanzibar Protectorate, 231 Trichinosis, Canary Islands, 521- 522 Ruanda-Urundi, 365 Trichophytosis, Angola, 332 Trichostrongylosis, Egypt, 16 Trichuriasis, Algeria, 568 Anglo-Egyptian Sudan, 37 Belgian Congo, 349 Cape Verde Islands, 512 Egypt, 16 Ethiopia, 69 French Equatorial Africa, 375 French West Africa, 496 Guinea, Portuguese, 470 Spanish, 385 Kenya, 119 Liberia, 449 Libya, 602 Madagascar and Comores ar- chipelago, 242 Mauritius, 255 Morocco, French, 540 Spanish, 552 Mozambique, 217 Nigeria, 414 Réunion, 261 Rhodesia, Northern, 188 Southern, 202 Ruanda-Urundi, 365 Sierra Leone, 461 Tanganyika, 160 Tunisia, 586 Union of South Africa, 281 Zanzibar Protectorate, 230 Tropics, health hints. See Health hints for the tropics Trypanosomiasis, Africa (maps), 613-614 Anglo-Egyptian Sudan, 42 Angola, 332-333 Basutoland, 306 Bechuanaland Protectorate, 312 Belgian Congo, 353 Cameroons, British, 397 French, 394-395 Ethiopia, 72 French Equatorial Africa, 378 French West Africa, 500-501 Trypanosomiasis— (Continued) Gambia, 479-480 Gold Coast, 432-433 Guinea, Portuguese, 471 Spanish, 386 Kenya, 123 Liberia, 451-452 Madagascar and Comores ar- chipelago, 248 Mozambique, 219-220 Nigeria, 417-419 Nyasaland, 177 Rhodesia, Northern, 190-191 Southern, 205 Ruanda-Urundi, 366 Sao Tomé and Principe, 400 Sierra Leone, 463 Somalia, 101 South West Africa, 299 Swaziland, 317 Tanganyika, 163-164 Togoland, British, 440 French, 438 Uganda, 143-144 Union of South Africa, 287 Zanzibar Protectorate, 232 See also Tsetse flies Tsetse flies, Anglo-Egyptian Su- dan, 31 Angola, 327 Bechuanaland Protectorate, 309 Belgian Congo, 342 Cameroons, British, 397 French, 391 Ethiopia, 66 French West Africa, 489-490 Gambia, 477 Gold Coast, 427 Guinea, Portuguese, 468 Spanish, 384 Kenya, 112-113 Liberia, 445 Mauritius, 253 Mozambique, 213 Nigeria, 408-409 Nyasaland, 172 Rhodesia, Northern, 184 Southern, 197-198 Ruanda-Urundi, 363 Sao Tomé and Principe, 400 Sierra Leone, 458 Somalia, 95 South West Africa, 295 Tanganyika, 153-154 Togoland, British, 439 tropics, 620 Uganda, 134-135 Union of South Africa, 273-274 Zanzibar Protectorate, 228 See also Trypanosomiasis Tuberculosis, Algeria, 568-569 Anglo-Egyptian Sudan, 38 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Index 649 Tuberculosis— (Continued) Belgian Congo, 349-350 Cameroons, British, 397-398 French, 393 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 17 Eritrea, 56 Ethiopia, 69-70 French Equatorial Africa, 376 French West Africa, 497 Gambia, 478 Gold Coast, 431, 434 Guinea, Portuguese, 470 Spanish, 385 Kenya, 120 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 243 Mauritius, 255 Morocco, French, 540 Spanish, 552-553 Mozambique, 218 Nigeria 414-415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 202-203 Ruanda-Urundi, 365 Sao Tomé and Principe, 400 Sierra Leone, 461-462 Somalia, 98 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Swaziland, 316 Tanganyika, 160 Tangier, 556 Togoland, British, 440 French, 438 Tunisia, 587 Uganda, 141, 146 Union of South Africa, 282 Zanzibar Protectorate, 230 Tularemia, Algeria, 574 French West Africa, 500 Typhoid fever, Algeria, 567 Anglo-Egyptian Sudan, 36 Angola, 330 Basutoland, 304 Bechuanaland Protectorate, 310-311 Belgian Congo, 347 Cameroons, French, 393 Canary Islands, 521 Cape Verde Islands, 512 Egypt, 14 Eritrea, 55 Ethiopia, 68-69 French Equatorial Africa, 375 French West Africa, 495 Gambia, 478 Gold Coast, 430 650 Index Typhoid fever— (Continued) Guinea, Portuguese, 470 Spanish, 385 Kenya, 118 Liberia, 449 Libya, 601 Madagascar and Comores ar- chipelago, 241 Mauritius, 254-255 Morocco, French, 538-539 Spanish, 552 Mozambique, 217 Nigeria, 413 Nyasaland, 175 Réunion, 261 Rhodesia, Northern, 187-188 Southern, 201 Ruanda-Urundi, 364 Sierra Leone, 461 Somalia, 98 Somaliland, British, 80-81 French, 88 South West Africa, 297 Swaziland, 316 Tanganyika, 158 Tunisia, 585-586 Uganda, 139-140 Union of South Africa, 280 Zanzibar Protectorate, 230 Typhus fevers, Africa, louse- borne (map), 609 Algeria, 572 Anglo-Egyptian Sudan, 43 Angola, 333 Basutoland, 306 Bechuanaland Protectorate, 312-313 Belgian Congo, 353-354 Cameroons, French, 395 Canary Islands, 523 Egypt, 20 Eritrea, 58 Ethiopia, 71 French Equatorial Africa, 379 French West Africa, 502 Gambia, 480 Gold Coast, 433 Guinea, Portuguese, 472 Kenya, 124-125 Liberia, 452 Libya, 603 Madagascar and Comores ar- chipelago, 247 Mauritius, 257 Morocco, French, 542-543 Spanish, 554 Mozambique, 220 Nigeria, 419 Nyasaland, 178 Réunion, 263 Rhodesia, Northern, 191 Southern, 205 Ruanda-Urundi, 366 Sierra Leone, 464 Somalia, 100 Typhus fevers— (Continued) Somaliland, British, 83 French, 90 South West Africa, 299 Spanish Sahara and Ifni, 529 Tanganyika, 165 Tangier, 557 Togoland, French, 438 Tunisia, 589-590 Uganda, 145 Union of South Africa, 285-286 Zanzibar Protectorate, 232 See also Fleas, Lice, Ticks Ulcers, chronic, Egypt, 18 phagedenic. See Ulcers, trop- ical tropical, Algeria, 570 Anglo-Egyptian Sudan, 40 Angola, 332 Bechuanaland Protectorate, 312 Belgian Congo, 351-352 Cameroons, French, 394 Cape Verde Islands, 513 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 377 French West Africa, 499 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 122 Liberia, 450-451 Libya, 603 Madagascar and Comores ar- chipelago, 244-245 Mauritius, 256 Morocco, 541 Mozambique, 219 Nigeria, 417 Nyasaland, 177 Réunion, 262 Rhodesia, Northern, 190 Southern, 204 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 299 Tanganyika, 162 Togoland, British, 440 French, 438 Uganda, 143 Union of South Africa, 284 Undulant fever. See Brucellosis Vaccination. See individual dis- eases Vectors. See individual diseases and arthropods Venereal diseases, Algeria, 569-570 Anglo-Egyptian Sudan, 39 Venereal diseases— (Continued) Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311-312 Belgian Congo, 350 Cameroons, British, 398 French, 394 Canary Islands, 522 Cape Verde Islands, 512 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376- 377 French West Africa, 498 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 385-386 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, French, 541 Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189-190 Southern, 203-204 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 South West Africa, 298 Spanish Sahara and Ifni, 528 Swaziland, 316 Tangier, 556 Tanganyika, 161 Tunisia, 588 Uganda, 141-142 Union of South Africa, 283-284 Zanzibar Protectorate, 231 See also Syphilis, Gonorrhea, Chancroid, Lymphogranu- loma venereum, Granu- lomainguinale, Prostitution Veterinarians, Angola, 330 Bechuanaland Protectorate, 310 Canary Islands, 521 Egypt, 14 Ethiopia, 68 Mozambique, 217 Somaliland, French, 88 Swaziland, 316 Tunisia, 585 Union of South Africa, 279 Waste disposal, Algeria, 562 Anglo-Egyptian Sudan, 30 Index 651 Waste disposal— (Continued) Angola, 326-327 Basutoland, 303 Bechuanaland Protectorate, 309 Belgian Congo, 341 Cameroons, British, 397 French, 391 Canary Islands, 519 Cape Verde Islands, 510 Egypt, 8 Eritrea, 53 Ethiopia, 66 French Equatorial Africa, 371 French West Africa, 488 Gambia, 476 Gold Coast, 426 Guinea, Portuguese, 468 Spanish, 384 Kenya, 111 Liberia, 444-445 Libya, 598 Madagascar and Comores ar- chipelago, 237-238 Mauritius, 252 Morocco, 534 Mozambique, 212 Nigeria, 407-408 Nyasaland, 172 Réunion, 260 Rhodesia, Northern, 183 Southern, 197 Ruanda-Urundi, 362 Sierra Leone, 458 Somalia, 95 Somaliland, British, 77-78 French, 87 South West Africa, 295 Spanish Sahara and Ifni, 527 Swaziland, 315 Tanganyika, 153 Togoland, British, 439 French, 437 Tunisia, 582 . Uganda, 133-134 Union of South Africa, 272-273 Zanzibar Protectorate, 227 Water supplies, Algeria, 562 Anglo-Egyptian Sudan, 29-30 Angola, 326 Basutoland, 303 Bechuanaland Protectorate, 309 Belgian Congo, 341 Cameroons, British, 397 French, 391 Canary Islands, 518-519 Cape Verde Islands, 510 Egypt, 7-8 Eritrea, 52-53 Ethiopia, 65-66 French Equatorial Africa, 371 French West Africa, 487-488 Gambia, 476 Gold Coast, 426 Guinea Portuguese, 467-468 Kenya, 110-111 Water supplies— (Continued) Liberia, 444 Libya, 597-598 Madagascar and Comores ar- chipelago, 237 Mauritius, 252 Morocco, French, 533-534 Spanish, 550 Mozambique, 212 Nigeria, 407 Nyasaland, 172 Réunion, 260 Rhodesia, Northern, 183 Southern, 196-197 Ruanda-Urundi, 362 Sierra Leone, 457-458 Somalia, 94-95 Somaliland, British, 77 French, 87 South West Africa, 295 Spanish Sahara and Ifni, 527 Swaziland, 315 Tanganyika, 152-153 Tangier, 556 Togoland, British, 439 French, 437 tropics, 618-619 Tunisia, 581-582 Uganda, 133 Union of South Africa, 272 Zanzibar Protectorate, 227 Weil's disease. See Leptospirosis Whooping cough, Algeria, 569 Anglo-Egyptian Sudan, 39 Angola, 331 Basutoland, 305 Bechuanaland Protectorate, 311 Belgian Congo, 350 Cameroons, British, 398 French, 394 Cape Verde Islands, 512 Egypt, 18 Eritrea, 57 Ethiopia, 70 French Equatorial Africa, 376 French West Africa, 498 Gold Coast, 431 Guinea, Portuguese, 470 Kenya, 121 Liberia, 450 Libya, 602 Madagascar and Comores ar- chipelago, 244 Mauritius, 256 Morocco, Spanish, 553 Mozambique, 218 Nigeria, 415 Nyasaland, 176 Réunion, 262 Rhodesia, Northern, 189 Southern, 203 Sierra Leone, 462 Somalia, 99 Somaliland, British, 81 French, 89 Whooping cough— (Continued) South West Africa, 298 Swaziland, 316 Tanganyika, 161 Togoland, French, 438 Tunisia, 587 Uganda, 141 Zanzibar Protectorate, 231 Xerophthalmia, Belgian Congo, 356 Yaws, Anglo-Egyptian Sudan, 39-40 Angola, 332 Bechuanaland Protectorate, 312 Belgian Congo, 351 Cameroons, British, 397 French, 394 Eritrea, 57 Ethiopia, 71 French Equatorial Africa, 377 French West Africa, 499 Gambia, 479 Gold Coast, 432 Guinea, Portuguese, 470 Spanish, 386 Kenya, 121 Liberia, 450 Madagascar and Comores ar- chipelago, 244 Mozambique, 219 Nigeria, 416-417 Nyasaland, 177 Rhodesia, Northern, 190 Ruanda-Urundi, 365 Sierra Leone, 462 Somalia, 99 Tanganyika, 161-162 Togoland, British, 440 French, 438 Uganda, 142 Union of South Africa, 284-285 Zanzibar Protectorate, 231 Yellow fever, Africa (map), 615 Algeria, 573 Anglo-Egyptian Sudan, 41-42 Angola, 333 Basutoland, 306 Bechuanaland Protectorate, 312 Belgian Congo, 354-355 Cameroons, British, 398 French, 395 Canary Islands, 523 Cape Verde Islands, 513 Egypt, 22 Eritrea, 58-59 Ethiopia, 72 French Equatorial Africa, 378- 379 French West Africa, 502-503 Gambia, 480 Gold Coast, 433 652 Index Yellow fever— (Continued) Yellow fever— (Continued) Yellow fever— (Continued) Guinea, Portuguese, 471 Nigeria, 419 South West Africa, 299 Spanish, 386 Nyasaland, 178 Swaziland, 317 Kenya, 125 Réunion, 263 Tanganyika, 165 Liberia, 452 Rhodesia, Northern, 191 Togoland, British, 440 Libya, 604 Southern, 205 French, 438 Mauritius, 257 Ruanda-Urundi, 366 Tunisia, 591 Madagascar and Comores ar- Sierra Leone, 463-464 Uganda, 145-146 chipelago, 248 Somalia, 100 Union of South Africa, 287 Morocco, 544 Somaliland, British, 83 Zanzibar Protectorate, 232 Mozambique, 220 French, 90 See also Mosquitoes C. BERKELEY LI Nii (029424151