Some Health Problems in Western Samoa
The mandated territory of Western Samoa consists mainly of two islands: one known as Savaii and the other as Upolu. There are also a few minor islets of no importance from the viewpoint of population. Savaii, though slightly the larger island, approximately 40 miles long by 20 miles wide, has rather a smaller population than the island of Upolu, where is situated the main township and port of Apia. The total population of the mandated territory was given as approximately 65,000 in 1943.
Although Samoa has been known to European navigators since the early eighteenth century, it is just over a hundred years since Europeans became established there, the real pioneers being, as usual, the missionaries These islands were for many years under German control, but have been governed by New Zealand under mandate from the League of Nations since 1921.
Medical services are under the control of the Samoan Administration. There is no private practice, not because this is prohibited in any way, but because a reasonably adequate service has in the past been provided by the administration. The medical services are centred around the main hospital, which is situated at the port of Apia and are under the control of a chief executive officer. The hospital is staffed by three medical officers and nine European nurses. This hospital is also a training school for Samoan nurses, of whom there are twenty-six employed on the hospital staff. The medical administration also employs twelve native medical practitioners who have received their training at the Central Medical School, Fiji. One or two native medical practitioners help to staff the base hospital, while others are allotted to various sub-bases and districts throughout the two islands. Periodically, on a rota system, the native practitioners return to the base hospital for what is in effect a refresher or post-graduate course. In a similar way throughout the two islands are distributed Samoan district nurses, who assist the native medical practitioners and also undertake maternal welfare work.
In passing, I would like to pay a tribute to the excellent work that these Samoans are doing, and I consider that the ultimate solution of many of the medical problems is the development and extension of the native medical practitioner system.
To glance now at some of the major medical problems of Samoa. It is quite impossible with the time at one's disposal to make a complete survey of health conditions in this field, which has been covered in various aspects by O'Connor and Buxton, of the London School of Tropical Medicine, and Lambert, of the Rockefeller Foundation. The most that one can do is to touch briefly on some of the major problems which appear to be the most urgent.
Resolutions adopted by the South Seas Conference at Canberra, in February, 1947, placed malaria prevention as one of the projects that should receive priority in the South Pacific. Samoa is fortunate in escaping this disease, as the anopheline mosquito does not penetrate past 170° of east longitude. How long this fortunate state of affairs will continue with the improved chances of the introduction of anophelines with airplane travel is a matter of conjecture.
The endemic diseases of Samoa are filariasis, yaws or frambaesia, and intestinal parasites, and these diseases have been considered by the South Seas Conference to be ones which require particular research. I have placed filarial disease first because it is one of the major diseases which causes much general ill-health and physical disability.
Many hospital admissions are cases of this disease, or at least are complicated by it. Filariasis may not cause obvious physical signs, but it does cause symptoms. Buxton, in his survey of 1924–25, found approximately one third of the population showing evidence of micro-filaria in the blood stream. This figure agrees very closely with the one I obtained after an examination of 1,000 bloods from natives of Niue Island. Buxton considered that on clinical grounds adult Samoans showed an infection rate of 70 per cent., as judged by the presence of enlarged epitrochlear glands. I think there can be little doubt that the whole adult population becomes infected. The figure which one obtains depends solely on the criteria adopted in diagnosing the disease.
The mosquqito vector of this disease, Aces varigatus, has been known for a long time. This mosquito breeds in coconut shells and coconut husks and also in the knot holes and steps which are often cut in the trunks of coconut palms. It will be appreciated that such breeding habits make the control of Aëdes varigatus an extremely difficult task. One can almost associate the incidence of filarial disease with the culture of the coconut palm. While some progress in the control of the disease might be possible by a concentrated anti-mosquito campaign, one cannot hold out great hopes here, as the energy that would have to be expended in reducing and controlling breeding grounds would be out of all proportion to the results obtained. Progress in the control of filariasis may have to await the discovery of a chemotherapeutic agent which will render the human carriers non-infectious.
Yaws has apparently been long endemic in the Samoan Islands, and the early lesions are seen in infancy and early childhood. Although accurate statistics are difficult to obtain, I think it would not be an over-statement to say that practically every Samoan child passes through an attack of yaws at some time. It is as common to the Samoan as chickenpox is to the European. The disease has been treated on an intensive scale for more than twenty years, ever since New Zealand took over the mandate, and enormous quantities of the organic arsenicals have been absorbed by the Samoan population, e.g., in 1923 over 32,000 injections of arsenicals were given. Off and on through the years large numbers of injections were given. In 1932 a really intensive campaign was begun. During that year over 74,000 injections were administered. Actually, at, that time 86.5 per cent, of Samoans were injecte, d and it was estimated at that time that 59 per cent, of the population were infected with yaws in one of its stages. Fairly heavy pressure of treatment has been kept up year by year, yet in 1939, the last year for which I have access to the statistics, it was necessary to administer over 17,000 arsenical injections.
There are many points which require elucidation with regard to this disease. While no one can deny the improvement in health and the disappearance of symptoms of this disease (if only temporary) since the introduction of this remedy, it is obvious that the optimism of the early workers, who considered the disease could easily be eradicated, was ill-founded. It would appear that further measures are necessary to control the disease and that wholesale arsenical injections are not the complete solution. Another point which must be considered is how many injections should be administered as a routine to each case. The usual procedure adopted is three doses of arsenicals at weekly intervals. My own figures showed that after arsenical treatment had been used for years, 50 per cent, of the population gave positive Kahn reactions. Working with the quantitative Kahn test, I found that few if any of the cases receiving the routine treatment had any reduction in the titre of their serum even after a lapse of two years. Further work is also necessary on the relationship between yaws and syphilis. Apparently yaws does give the population some immunity against the introduction of syphilis into the community, for to the best of my knowledge no case of native syphilis has been described from these islands.
Intestinal parasites, the chief of which are the hookworm, the round worm and the whip worm, are very widespread. The routine examination of patients admitted to Apia Hospital during 1936 showed that approximately 40 per cent. harboured appreciable numbers of hookworms, 25 per cent, harboured round worm, and 45 per cent, whip worm; this in spite of the fact that continuous mass treatments had been given to the population over preceding years. This state of affairs is, of course, only a reflection on the primitive sanitary practices of the Samoan. Real progress can only come in the control of these infestations by raising the sanitary and hygienic standards of the native villages.
In spite of careful attention to personal cleanliness by frequent personal ablution, the incidence of fungal disease of the skin is high. No doubt this is dependent to a large extent on climatic conditions which, causing excessive sweating, makes the skin more liable to disease of this nature. The diseases are caused probably by a great variety of fungi, on the identification of which little or no work has yet been done.
Besides such endemic diseases as measles and whooping cough, the occasional importation of which into Samoa causes widespread epidemics with high death rates in children, the main cosmopolitan diseases which have been imported into
Samoa are enteric fever and tuberculosis. One might also add leprosy. There appears to be little doubt that this disease, which continues to claim victims year by year, was brought to the Eastern Pacific from Hawaii, where it was introduced first by Asiatics.
The high incidence of enteric fever and occasional outbreaks of bacillary dysentery are an indication again of the poor sanitary standards under which the native Samoan is living. When hookworm disease and other intestinal parasitic infestations are brought under control we will see a drop in the incidence of the enteric group. The provision of safe water supplies to villages and proper disposal of excreta are the solution to both these problems.
The other imported disease is tuberculosis. The true incidence of this disease can only be guessed at, although from one's personal experience one would consider the incidence to be high. Bovine tuberculosis is widespread in such cattle as are on the plantations. But, as milk does not enter into the diet, of the Samoan, infection from this source is probably negligible. A valuable study which would throw some light on the incidence of tuberculosis is Mantoux testing in selected groups. This work still remains to be done.
What has been loosely termed malignant jaundice apparently made its appearance in Samoa about 1935. In 1939 there were 59 known cases of this disease and a further 51 in 1940. When the first cases appeared I happened to be resident in Samoa and saw some of them. There were during that time occasional cases that clinically could be considered to be catarrhal jaundice, what is now more correctly referred to as infectious hepatitis. These, however, ran a different course from the malignant cases which were mainly afebrile, of short duration and generally with a fatal termination. In spite of the fact that the clinical picture did not appear to be typical of Weil's disease, this possible diagnosis was entertained and an effort made to isolate the causative organism without success. Pathological specimens from cases have been examined by various world authorities in Australia, by the Rockefeller Foundation, and in South America.
Reports received at various times and from various authorities are conflicting. Leptospiral disease has been proved in Samoan rats. Some authorities have found agglutination against leptospira in recovered cases of the disease, while others have mentioned cell inclusion bodies in pathological specimens which could point to a virus as causative agent. The best summing up of the possibilities has been given, in my opinion, by Sir Raphael Cilento, who states the possibilities as: First, yellow fever, which was excluded by the definite opinions on specimens by yellow-fever experts in New York and Brazil. Secondly, Weil's disease or leptospirosis. There is some support for this diagnosis in certain cases from which specimens have been obtained. Sir Raphael's third suggestion was a chemical poison. When one considers the amount of toxic therapeutic material administered to the Samoan population both for the mass treatment of yaws and also hookworm disease, this is a distinct possibility, although in the particular cases with which I was familiar this possibility has been considered and excluded. Sir Raphael's final suggestion was an unidentified infection.
This last suggestion I feel merits very careful consideration. During the time (pre-war) I was interested and when most of the work was done on these cases, little if anything was known of homologous serum jaundice. This, I feel, is a distinct possibility. In those days one would not have considered the possibility of an incubation period extending up to, say, three months. The methods used in mass inoculations against yaws would without any doubt whatsoever favour the transfer of virus per medium of syringe and needles. I consider this suggestion merits a careful field study. Before leaving this very interesting problem, it seems only fair to remind you that jaundice after all is only a symptom, and possibly specimens from jaundice cases examined by different authorities were of different causation.
The medical problems of Samoa are not unique, but similar to those of many other countries at approximately the same level of development. The problem is not quite parallel with the Maori health problems in New Zealand. The Maori is in a minority in a European environment and sooner or later must adapt himself to it and become absorbed by it. The position in Samoa is quite different. The Samoan is still the predominant race in Samoa and is likely to remain so. His culture, social organization, and customs have been little altered in the one hundred years' contact with Europeans. The Samoan is proud
of his race and birth and tends to resist any attempt at europeanization. The best line of attack then appears to be to graft on to his culture such modifications and reforms as will influence his general health. To pass laws and regulations concerning health which run contrary to his established customs is just so much waste of time. There must be collaboration between anthropologist and medical administrator.
While some progress has been made along the lines of personal hygiene, the institution of district nursing services with advice to mothers on prenatal and infant care, the larger and more fundamental field of environmental hygiene remains practicaly untouched. Education required to raise the standard of health consciousness can and is to a limited extent being done by the native medical practitioner. I would recommend, however, that a greater bias towards preventive teaching be given in his training and that selected capable native medical practitioners be given special instruction in environmental hygiene.
The last figures to which I have access show that twelve native medical practitioners are providing preventive and curative services to sixty-odd thousand people, i.e., in the proportion of one practitioner to 5,000 population. If the practitioner is to assume any real responsibility with regard to preventive work, it will be necessary to increase the number of native practitioners at least threefold.
In what way can New Zealand help and guide the development of medical services to Samoa? First, by providing skilled personnel to direct the medical work and by assisting in the education of selected Samoan practitioners along the lines indicated, and, secondly, by co-operating with the Samoan Administration in providing assistance in surveys and research. Some of the major problems requiring further study have been indicated. New Zealand should be in a position to advise the most profitable lines along which the activities of the medical administration might be directed.
In conclusion, just a word of warning to enthusiasts. The Samoan is, to all intents and purposes, still in the Neolithic phase of culture. As from that phase it has taken European races some thousands of years of travelling along the road to reach their present vantage point, we cannot expect the Samoan to join us overnight. Progress will be slow, but progress there should be, and progress along the correct path.
Professor Richardson stated that work had shown that the intestinal parasites in native races varied with their amount of contamination with civilising influence, and asked if there were any record of this in regard to the Polynesians. He wished to know if there were any native villages which might be regarded as entirely uncontaminated with the influence of civilisation, where a complete picture of intestinal fauna of purely native type could be obtained. Dr. Dempster replied that he considered it unlikely that any such isolated community would be available for study in Samoa, as all showed similar degrees of admixture with civilisation, and differences in their intestinal fauna on this count would be unlikely.
Dr. F. S. Maclean disagreed with Dr. Dempster's pessimistic outlook regarding the possibility of the control of filaria through control of the vector, and considered too much weight was being placed on treatment of the host, to the neglect of eradication of the vector mosquito. He instanced work on the control of filaria in the Cook Islands by Amos, and the training of native boys in the eradication of mosquito breeding places in the immediate surrounds of villages. As the range of flight of the mosquito was so small, it appeared that intensive effort should be spent on cleaning up breeding places like coconut shells and empty meat tins in the neighbourhood of villages; this would yield satisfactory results if carried out with a high degree of efficiency. He regarded this method as being the essential and probably the only means of obtaining permanently improved control. Dr. Dempster replied wishing he could share in Dr. Maclean's enthusiasm over this.
Dr. Fischmann inquired regarding the incidence of rheumatoid arthritis and acute rheumatism in the Islands, stating that where such cases had been treated under tropical conditions, much improvement had been noted. Dr. Dempster replied that he had seen no cases either of acute rheumatism or rheumatoid arthritis in Samoa during his stay.