SampelaHealthProgram2007

(C.Crawford,J.Wallace,R.Watson,C.Young)

Introduction
Whentheearthissickandpolluted,humanhealthisimpossible....
Tohealourselveswemusthealourplanet,
Andtohealourplanetwemusthealourselves.
BobbyMcLeod(Kooriactivist,aboriginal)

Environmentalhealthcomprisesthoseaspectsofhumanhealthanddiseasethataredeterminedbyfactorsinthe
environment.Italsoreferstothetheoryandpracticeofassessingandcontrollingfactorsintheenvironmentthat
canpotentiallyaffecthealth.Inrecentyears,mystudiesinanthropologyhavemademequestionnotonlytherole
oftheenvironmentinhumanaffaires,butalsotheimpactofhumanactivityontheenvironment.Withinthe
developingworld,themajorityofinfectiousdiseasesaredirectlyrelatedtopeopleslifestylepracticesinthe
contextoftheirsurroundingenvironment.Forexample,leavingstagnantwateruncovered,whichthenbecomesa
vitalbreedingsiteformosquitolarvaeandapossiblehostfordiseasessuchasMalariaorDengueFever.The
prevalenceofdiseaseincreasesamongstmorerural,impoverishedanduneducatedsocieties.Thusthereisaneed
toinvestigateandunderstandthesecommunitieswithinthecontextofboththeircultureandtheirenvironment
toensurebetterhealthcaremethodsandapproaches.
Inthisaspect,IinvestigatedthemedicalbeliefsoftheBajau(arural,seafaring)societyinSoutheastSulawesi,
IndonesiaandthenanalyzedtheBajauperceptionsoftheirsurroundingenvironmentspurposeandimportanceto
theirhealthandwellbeing.Themajoraimsofmyprojectincludedthefollowing:
Fromahealthperspective

TounderstandperceptionsofhealthandcausationofillnessintheBajaucommunity.

TounderstandtheBajaucommunitiesknowledgeofmodernmedicine.

TostudythecontributionofculturalbeliefsinthechoiceofamedicalremedybymembersoftheBajau
community.

Fromanenvironmentalperspective

Toexplorecurrentattitudes,environmentalknowledgeandperceptionsheldbytheBajauonecosystem
structuresandfunctionsandhowtheyperceivetheirplacewithinthatenvironmentalsystem.

Fromanenvironmentalhealthperspective
Focus1:Toevaluatewater/wastewaterimpacts
Whatistherelationbetweendailylifestylepracticesbasedonthecontextoftheirsurrounding
environmentandtheincidenceofwaterbornedisease(Ex.AretheBajauusinglatrines?Whereisthe
freshwatersupply?Dotheyusecyanideinfishharvesting?Howmighttheprevalenceofdiseasediffer
betweenlandandseabasedcommunities?)

Focus2:Toinvestigatelocalusesofmarineresourcesforhealthrelatedpurposes
Towhatextentmightlocalmedicinalpracticesbeaffectingtheresourceabundanceordecline?(Ex.Are
theBajauharvestingaresourcewhichmightdisrupttheecosystemfortheirhealthneeds?Howmightthis
affectBajaulivelihoodneedsoffoodsecurityinthefuture?)
TheprojectwasconductedthroughOperationWallaceawhichhasbeenworkinginaremotecornerofSoutheast
SulawesiinIndonesiasince1995todevelopresearchcentersintheLambusangoforestinSouthButonIslandand
onHogaIslandintheWakatobiMarineNationalPark.WithintheWakatobiregion,IlivedintheBajauVillageof
Sampelafordurationofsixweekswhilecompletingmyresearch.Sincemytimeinthevillagewaslimited,only
Focus1ofmyabovepreresearchproposalwasinvestigated.Itwouldbestronglyrecommendedthatifthe
SampelaHealthProgramweretocontinueinthefollowingyear,thatresearchersalsolookintoFocus2.Interview
questionnairesaswellasrawdatahavebeenincludedwithinthisreporttoaidfutureefforts.Pleasefeelfreeto
contactmeifyouhaveanyquestionsorconcerns.
Whileconductingresearchwithinthevillage,Iwasalsosimultaneouslycreatingastudentorganizedgroup
betweenanthropologystudentsandmedicalelectivesatthesitetoanalyzeanddiscussprimaryhealthissuesin
SampelaandKaledupa.Inthefinalweeksbeforemydeparture,theSampelaHealthProgramwascreatedasa
responsetothelackofformalizedknowledgebetweenlocalgovernment,communityleaders,andresearchers.
CamiaCrawford
BrownUniversity,RI,USA
Anthropology08

Aimsandobjectives
TheaimsandobjectivesoftheHealthIssuesinSampelaandKaledupa(HISK)aspectoftheSampelaHealth
Program(SHP)aretoinvestigatetheprevalenceofhygieneandwaterqualityrelatedhealthissuesonKaledupa
andSampela,aswellasthemostimportanthealthissuestotheSampelacommunity,withrespecttowaterborne
illnessesandriskassociatedwithdailyactivities.Theaimofthesefollowingstudiesistoenableanunderstanding
ofthegapsinthecommunitysknowledgeofhealthybehavior,inordertocreateanddeliveran
education/informationprogramtoreducetheprevalenceofwaterbornediseases.Inadditiontothis,the
SampelaHealthProgramaimstocontinueannualcollectionsofhealthandwaterqualitydatabystudentsof
OperationWallacea.Eventuallytheprogramwillaimtoincorporatecommunitymembersandtraintheminthe
processofdatacollectionandfurtheradvanceindependentcommunitymonitoring.

Background
SamaBahari(otherwisereferredtoasSampela)isavillagebuiltupfromacoralreefflatofapproximately1300
inhabitantslyingtothenortheastofKaledupaIsland,intheWakatobiregionofSouthEastSulawesi,Indonesia.It
ispopulatedbytheBajaupeople,whoareknownastheseagypsiessincebeforeagovernmentsettlement
initiativeinthe1950stheylivedonhouseboatsandroamedtheopenseasaroundtheWakatobiregion.Their
religionismostlyMuslim,howeverthereisastrongbeliefinseaandlandspiritswhichtakealargeroleinmany
householdscentralbeliefs.
SamaBaharihas286householdssplitintothreesubdusuns(communities)withanaverageoffourchildrenper
household.Themajorityofthevillagepopulationisfemaleorunder20duetothemigrantworkernatureofthe
Bajaumen.Thevillageisgovernedlocallybyaheadman,theKepalaDesa,andhisfamilywithaclosenetworkof

influentialmothersandtraditionalhealers,theSandro/Sanjo.However,onamoreregionallevelthereisalocal
Camat(pronouncedchamat),equivalenttoacouncil,whichreportstovariousgovernmentofficialsontheisland
andregion.(putinsquarefootageorkilometerstoestimatepopulationdensity,somemoreondemographics,
numberofchildren,numberofpeopleperhousehold).
Thestructureofthevillageanditsbuildingsaremostlybuiltatopcoralplatforms,hackedfromthereefitself,oron
stiltsthatrise8feetabovethelowtide.Walkwaysspanacrossthecommonpathsbutindividualhousesarelinked
byplanksofwoodorbamboopoles.Howeveratlowtideonecanwitnesslocalchildrenplayinginamongstthe
coralplatforms.Theworryingfeatureofthisbuildingstrategyisthatthetoiletsandwashingfacilitiesperch
precariouslyabovechannelsflowingbetweenhouses,whichmeansthatduetotheflowsystemsandtidesonecan
regularlyseehumanwastecollectinginbottlenecksorevenfloatingouttosea.
TheseagypsynatureoftheBajaupeoplemeanstheirmainfoodandincomesourceistheseaandreefitself,and
inordertoutilizethisvastcommoditytheyfishbyboatusingnets,fences,gleaningatlowtideandattimesbomb
fishing.Anothergoodsourceofincomeisagarfishingtoselltomultinationalcorporationsforbiochemicaluse,as
wellasparticipatingasinformantsinresearchthroughtheOperationWallaceaprogram.
Itshouldalsobenotedthatthereisnofreshwatersupplytothevillage,thereforelocalsmustcollectitfromawell
orspringonKaledupaforasmallprice.Althoughfreshcleanwaterisnotarelativelyexpensivecommodity,itmust
betransportedfromthemainlandtothevillageoffshore.Thedifficultyintransportationresultsinlimiteduseof
cleanwaterforthingsotherthandrinking/cookingsuchaswashingplates/utensilsorbathing.
Thefollowingsectionsofthepaperwilllookatthethreemajorsourcesofdatacollectedbymyselfandothers
involvedintheHISKstudy.ItbeginsfirstwithananalysisifdatacollectedfromtheKaledupaMedicalCenter,
followedbyresponsesfromcommunityinformantinterviews,andfinallywaterqualitydatacomprisedwithin
spatialmapping.

HISKstudy1)KaledupaMedicalCenterreports

DatafromtheKaledupaMedicalCentersrecords,inatownhalfamilefromSamaBahari,wasenteredintoan
exceldocument,bymonthlypresentationsofeachillnessbyagegroups,whichwere04,514,1544and4559
yearsofage.FromMay2006untilJune2007thereportedillnesseswere
Diarrhea
Hypertension
Dysentery
TukakLambung(?)
Tuberculosis
Accidentalinjuries
Malaria
Skininfection
Worms
SkinAllergy
Respiratoryinfection
Bronchitis
Diabetes
Asthma
Anemia
Eyeinfections

Thisdatawasanalyzedby;
Annualdistributionofallillnesses
Annualdistributionbyagegroup,ofillnessesrelatedtowaterandhygiene
Diarrhea
Worms
Dysentery
Skininfection
Malaria
Skinallergy
Annualdistributionofthemostprevalentwaterandhygienerelatedillnesses

Analysis
Graph1.Agerangecomparisonofthe
totalnumberofpresentationsperillness,
totheKaledupamedicalcentrefromMay
2006untilJune2007.
Thisgraphshowsthatthehighestnumber
ofpresentationswasforrespiratory
infectionsacrossallagegroups,withthe
1544agegrouphavingthehighest
numberofpresentations.Thesecond
highestnumberofpresentationswasfor
skinallergyacrossallagegroupsbutwas
forTukakLambungfortheoldesttwoage
groups.Chronicdiseasesuchasdiabetes,
anemiaandasthmawerehighestamongst
theoldestagegroup.
Graph2.Annualdistributionofhygiene
relatedillnesspresentationsinthe04age
group.
Thisgraphshowsthatthemostsignificant
illnessinthisagegroupisdiarrheawitha
peaknumberofpresentationsin
November(12).Atthesametimethereis
acorrespondingincreaseinthesecond
mostprevalentillness;skininfections,
whichhavethreeannualpeaksinJune,
Novemberandthemostsignificantpeak
inFebruary(5).Overallthetrendisfora
steadyincreaseincasesofdiarrheafrom
JulytoNovemberandthenadeclineuntil
February.
Graph3.Annualdistributionofhygiene
relatedillnesspresentationsinthe514
agegroup.
Bycontrasttograph2,theillnesswiththe
mostpresentationsisskininfection,
howeverwithasimilartimecourseas
diarrheaingraph2.Therearethree
peaks,thefirstinJuneandJuly,andthen
anincreasetothehighestnumberof
presentationsinNovember(10)whichare
verysimilarinbothtimeandnumberto
diarrheacasesingraph2.Comparatively
diarrheahasfewcaseswiththehighest
numberofpresentationinDecember(3).

Graph4.Annualdistributionofhygiene
relatedillnesspresentationsinthe1544
agegroup.
Thisgraphshowsthatthemostprevalent
illnessisskininfectionthroughoutthe
year;howeverthereweremorecasesof
eyeinfectioninmay(4casescomparedto
3).Similarlytograph3therearethree
peaksofskininfectionpresentations,the
firstinSeptember(5cases)thesecond
hasasimilarbutlongertimecourseto
graph3fromNovemberuntilJanuary(5
cases).Howeverthehighestnumberof
caseswasatthesametimeasapeakin
graph3duringApril,howeverthenumber
ofcaseswas8comparedto5ingraph3.
Graph5.Annualdistributionofhygiene
relatedillnesspresentationsinthe4559
agegroup.
Thisgraphshowsthattheillnesswiththe
highestnumberofpresentationsisagain
skininfection.Similarlytograph4,thereis
ahighnumberofeyeinfectionsinMay(7)
cases,andtherearethreeannualpeaksof
skininfectionpresentations.Eachpeak
occursatverysimilartimesofyearto
thoseingraphs3and4,thehighest
howeverisatadifferenttime,occurringin
September(15cases)followedbya
secondinDecember(9cases).Withthe
lastpeakearlierthaningraphs3and4
occurringinMarch(7cases).
Graph6.Annualdistributionofthe
numberofdiarrheapresentationsacross
allagegroups
Graph6showsthatdiarrheaisthemost
prevalentintheyoungestagegroup(04
years)andhasapeaknumberof
presentationsinNovember(12).The
otheragegroupshaveapeakonemonth
laterinDecember,howeverthenumber
ofpresentationsismuchless(1,2and
threecasesinincreasingagegroups)

Graph7.Annualdistributionofthe
numberofskininfectionpresentations
acrossallagegroups
Thisgraphshowsthatskininfectionhas
varyingratesofpresentationamongstthe
agegroupsaswellasatdifferenttimesof
theyear.Thehighestnumberof
presentationsisinSeptember,December
andMarchintheeldestagegroupandin
NovemberandAprilbythetwomiddle
agegroups.Surprisinglytheyoungestage
groupdoesnothaveashighnumbersof
presentationsasotheragegroups.The
aretworoughpeaksduringtheyear,
betweenSeptemberandDecember,and
fromMarchtoMay.Thesecouldcorrelate
withchangesinseason,waterflowand
winddirectionalteringthetypeofpathogen/routeoftransmission.

Conclusions
Thedatacollectedshowsthatthetwomostsignificantwaterandhygienerelatedillnessesarediarrheaandskininfection.It
alsoshowsthattheprevalenceofeachdiffersbetweenagegroups,withdiarrheacasesbeinghigherinthe04agegroupand
skininfectionshavingsimilarnumbersofcasesintheotherthreeagegroups.
Thereisalsoapatternintheannualdistributionofillnessesthroughoutallagegroups,withpeaknumbersofpresentations
occurringbetweenSeptembertoDecemberandFebruarytoApril,formostwaterandhygienerelatedillnesses,butmore
specificallyfordiarrheaandskininfectionsacrossallagegroups.
Thereisnodefinitereasonwhythenumberofpresentationsdiffersbetweenagegroups,butonecanassumethatthe
youngestagegrouparemoresusceptibletopoorwaterqualityandrelyonothersfortheirpersonalhygiene,thereforethe
prevalenceofdiarrheaishigherbutskininfectionsislower.Converselyolderagegroupsaremoreselfreliantonhygieneand
areabletoobtaincleanerwater,thereforereducingthenumberofdiarrheapresentations.Howevertheyhaveamoreactive
lifestyleleadingtoahigherriskofinjurywithacomplicatingskininfection,givingahighernumberofskininfectionsinthe
oldestthreeagegroups.

Limitations
Thisstudydoesh avelimitations,astheKaledupamedicalcentreonlyhasasmallpercentageofpatientsfromSamaBahari,
andthereisalsomassiveunderreportingofillnessesamongsttheBajaupeople,notonlytotheKepalaDesabutalsoto
governmentandhealthcareofficials.
Howeveritisthelargestcollectionofh ealthrelateddatafromtheregionandisthereforeusefulinidentifyingmajordiseases
andtheireffectonhealthbyagegroupandseason,andowingtothecloseproximityandinteractionsbetweenSamaBahari
andAmbewa(wherethemedicalcentreislocated)wecanassumethatthesameseasons,tidesandreefstructureaffect
eachvillagesimilarly.

HISKstudy2)CommunityInterviews

ThesecondpartoftheHISKstudywasonaonetoonebasisinthecommunity.Itwasintheformofaninterview
andquestionnairewiththeheadofahousehold(usuallythewife/mother)usingseveralinterpreters.Indepth
interviewswereconductedwith39peoplethroughoutthevillageandtookapproximatelyonehourlong.The
structureoftheinterviewsandquestionnaireswereto:
1. Introduceourselvestothecommunity
2. Discussandrecordhealthbeliefsandbehavior
3. Identifydifferencesorunconventionalviewsonhealth,hygieneandrisktakingbehavior
Thequestionnaireincludedsectionsandquestionson

Waterandsanitation

Wheretheygetwaterfrom

Dotheyboilit,andwhy?

Sicknessanddisease

Recentillnessesbyseason

Whatcausesillness

Recentfamilydeaths

Medicaltreatment
Rankingwhatservicestheyuseby
illness

Governmenthealthprogram

Whattheyknowaboutit

Iftheyuseit,whyso/not

Attheendofthequestionnairewasariskassessmentofvariousdailyactivities,whicheachintervieweewasasked
torankashigh,medium,lowornoriskatall.Threesetsofintervieweesweresoughtoutforthissectionincluding
normalmembersofthecommunity,localexpertsbyprofessionandforeignexpertsbyeducationallevel(Opwall
volunteers/staff).Theareasassessedwere;

Collectingfirewoodin
themangroves

Walking/swimmingat
lowtide

Fallingfromabridge

Drinkingunboiled
water

Nightgleaning

Bombfishing

Drinkingalcohol

Walking/swimmingat
hightide

Smoking

Gettingavaccine

Eatingsweets

Drinkingcoffee

Eatingrawfish

Cookingameal

Disposingofwaste
aroundthehouse

Gettingmalaria

Havingdiarrhea

Socializingwithpeople
withdiarrhea

Results
WaterandSanitation
Graph8.Percentagedistributionof
intervieweeswaterrelatedbehaviors
Therearetwosignificantthingsto
observeinthisgraph.1.)Althoughthe
majorityofindividualsclaimtoalways
boiltheirwater,manyofthemareonly
boilingtheirwateruntiltheysee
bubbles(andnotfortherecommended
5minutesbyWHO).Additionally,
whileindividualsacknowledgethat
boilingwaterpreventsthemfrom
gettinggenerallysick,onlyafewwere
abletospecificallylistcommon
waterborneillnesses.
Sicknessanddisease
Graph9.Reporteddryseasonillnesses
Duringthedryseason,amajorityof
individualsclaimedthatheadacheand
fluwerethemostcommonillnesses.
Thismayduetooverexhaustionand
dehydrationfromdiarrhea.Increasein
Flucouldbeduetoevenlesssanitary
conditions.

Graph10.Reportedwetseason
illnesses
IncontrasttoGraph9,majorillnesses
ofthewetseasonwerediarrheaand
malariathussuggestingthattheremay
beacorrelationbetweenprevalenceof
specificillnessesandtypeofseason.

Graph11.Reportedfrequencyof
diarrheaperintervieweeandtheir
family
Duetoalackofinconsistencyin
answersandthepossiblesensitive
orembarrassingnatureofthe
question,therearenoconclusions
thatcanbeconcretelymade.

Graph12.Variouscausesgivenby
intervieweesfordiarrhea
Thetoptworeasonsforcausesof
diarrheagivenbyindividualswere
associatedwitheatinginvertebrates
orthewetseason.Interestingly,if
fecalmatterisbeingdisposedinto
thesurroundingreefflatwhere
Bajauvillagerscollectinvertebrate
speciesfrom,adirectlinkcanbe
identifiedbetweenpeopleswaste
andeatingpatternsinrelationto
diarrhea.

Graph13.Percentageoftotaldeaths
peragegroup,andthemaincauses
ofdeath.
Althoughthestudyfocuseddeeply
onwateranddiarrhealpatterns,
duringinterviewsitwasdiscovered
thatyellowsicknesswhichwas
linkedwithblackmagichad
symptomswhichcloselyrelated
HepatitisB(perhapsanevengraver
dangerandpublichealthconcernfor
thevillage).

MedicalTreatment
GraphW.FirstTreatmentChoice
perIllness

90
80
70
60
50
40
30
20
10
0

doctor/hospital
traditionalhealer

Ey
e

r
Fe
ve

e
in
fe
ct
io
ns

ac
h

ac
h

fe
ct
io
n

St
om

sh
es
ra

Ea
ri
n

in
Sk

Di

ar
rh

oe

ria

selfremedy

M
ala

Percentageofinterviewees

Firsttreatmentchoiceperillness

Thefollowinggraphdemonstrates
ahighpreferenceforselfremedy
forthemajorityofcommon
illnessesrelatedtopoorwater
quality.Whilepreferencefor
traditionalhealersanddoctors
varydependingonillness,they
aresoughtalmostequallyincases
ofdiarrhea.Apublichealth
programtargetedwillthereby
needtoincludebothpracticesfor
ittobeeffective.
GraphX.Combinedrisk
assessmentscoreofdailyactivities
bytheSampelacommunity
WhileDiarrheaiseasilyidentified
asahighriskamongstthe
community,behavioralactivities
whichmaycausediarrhea(i.e.
Walkinglowtide,wastedisposal,
rawfish,interactingwithpeople
whohavediarrhea)arenot
acknowledgeasmajorrisks.Thus
thelinkbetweendiseaseand
relatedcausalbehaviorarenot
identifiedinthepopulation.

GraphY.Combinedrisk
assessmentscore
Interestinglythisillustrateshow
cultureandeducationcan
influenceperceivedrisk.As
shown,localandwesternexperts
notedwastedisposalandwalking
inlowtidefarmoredangerous
thanthelocalnonexpert.

Conclusions
ThedatacollectedinthisaspectoftheHISKstudyrevealseveralimportantfindings.Mostimportantlywe
discoveredthatdiarrheawasmostprevalentduringthewetseasonandthatthereislittleunderstandingamongst
thecommunitybetweendiarrheaandotherwaterbornerelatedillnessesandthebehaviorswhichmayincrease
risksuchas,walkingthroughthechannelsatlowtidewhenfeceshaveyettobeflushed,notboilingwaterfora
longenoughperiodoftimeornotatall,andeatingrawinvertebratespecieswhichmaybecontaminatedwith
humanfecesintheenvironment.
Inadditiontothis,therewasnodefinitivesourceoftreatmentsoughtwhenpeopleexperiencedsignsofdiarrhea.
Sincethemajorityofwaterborneillnesssymptomswerereportedlytreatedbyselfremedy,itcouldmeanan
underreportingintheincidenceofdisease.Additionally,sincebothtraditionalhealersandKaledupandoctors
aresoughtbydependinguponafamilyswealthorculturalpreference,therecanbenoclearwayforapublic
healthapproachwithinthevillage.Tellingpeopletochangecertainbehaviorswillnotbetheanswer,sincethe
Bajau,anomadicpeople,haveneverlistenedtoanyoutsidebodyotherthanthespiritswhichtheyfeelakinto.

Limitations
Therewereseverallimitationswithinthisstudythataredifficulttoknowthedepthsof,butshouldsurelybe
acknowledged.Likeanyinterviewitischallengingtoknowwhethertheintervieweeisbeingcompletelyhonest
regardingsensitiveandpersonalquestions.Althougheveryeffortwasmadetoensureconfidentialityandcre atea
spacewhereintervieweestofeelcomfortable,nonetheless,ourmostinaccuracywasregardingthenumberof
timesanindividualexperiencessymptomsofdiarrheainthemonth.Itshouldalsobeacknowledged,that
althoughasensitivequestiontobeaskedbyaforeignstranger,theBajaupeopledonotquantifyexperiencesby
daysortimesasweinthewesternworlddo.Insteadtheymightclassifythingsintermsofhappeningmoregivena
certainseasonandhappeninglessinadifferentseason(asseeninthewet/dryseasongraphs).
Finally,theconceptofriskisdifficulttdescribeandalsotomeasurecrossculturallysinceeachculturewill
inherentlyplacedifferentriskvaluesondifferentthingsbasedupontheirfamiliaritywiththething/experienceor
theireducationalknowledgeofit.Forexample,theBajaumaynotcitemangroveharvestingasparticularly
dangerousbecausetheyarewellskilledintheartofusingaknifetochopdowntrees,whereasaforeignermight
findthistaskincrediblydangerous.Similarly,theBajaumightacknowledgemalariaasagreaterriskthandia rrhea,
becauseifanindividualcontractsmalariaevenjustonce,theymaydie.Yet,anindividualcancontractdiarrhea
numeroustimesthroughouttheirlifetimeandnotdieduetoit.Childmortality,commonandoftencausedby
diarrheaiswidelyacceptedamongstthecommunityandtherebyoftentobeexpectedamongonetoseveralofa
womansbirths.Theriskassessmenttherebyaidsusinunderstandingthesesocialandculturaldifferenceswhich
maydictatetheneedformultifacetedpublichealthapproaches.
*Note:Abasicquestionnairewasdistributedtoeachhouseholdineachofthethreesubdusunsthroughoutthe
villageaskingwhethertheyhadexperiencedMalaria,HepatitisB,Cholera,Flu,orDiarrheawithinthelastsix
months.ThiswasdoneunderinsistenceoftheKepalaDesa.Whileourteamattemptedtomaketherounds
amongthevillage,theKepalaDesainsistedtoorganizetheeventhimselfandgivemetheresults.WhenIwen tto
collecttheresult,allformswerefilledoutthesame,withalarminglyhighreportsofcholeraandmalaria,whic h
wouldassumeeveryoneinthevillagehadcholeraandshouldthereforebedeadorincrediblyill.Thedocuments
werefalsifiedforwhatreasonIamunaware.Mostlikely,Ibelieve,itwasaclaimofstrongdesireformore
medicalattentiontobebroughttothecommunity.Wedidnotusethisdatainourfinalsummaries.

HISKstudy3)WaterQualityandSpatialMapping

ThethirdaspectoftheHISKstudyisquantitativeincomparisontotheothercomponentsbutaidsinspatially
diagnosingenvironmentalhealthhazardswithinthelandscapeofthecommunity.Fortheperiodofmystay,there
wereseveralmainfactorsthatwerebeingmeasuredormonitoredonaregularbasis.Theywerethefollowing:

Recording%DissolvedOxygenonbothahighandlowtide

Mappingbridgesandmajorpathwaysthroughoutthecommunity

Newhouseswhichhaveyettoberecordedinthelasttwoyears

Areasoflargedebrisorbuildup

Surroundinglandscapearoundthevillage(deepchannel,reefflat)

Weatherpatternsindifferentseasons

Thecompilationofallofthesefactorsallowedustocreateaseriesofspatialmapswhichallowustocorrelate
increasingpopulationwithanalreadystrainedecosystemandthehealthconsequenceswhichariseduetothese
impacts.

Map1.SamaBahariVillage
Hereonecanseethe
existingvillageinbeige,
majorroadsandpathsin
gray,smallerpathsinnavy
aswellasnewhousesin
navy.Thepredominant
expansionofhousesnow
reachesfurtheroutontothe
reefflatinthenortheastern
andsoutheasterndirections.
(nottoscale,approximate
length)

Map2.TransectGrid
Thismapclearlydefines
thegridamongstwhich
theDOtransectstook
place.Bothredandblue
spotscorrelatetositesof
DOmeasurement.

Map3.PhysicalSightings
Thismapclearlyindicates
thelocationsofheavy
debrisbuildupwithin
certainchannelsas
indicatedbypinklines.
Largepresencesofupside
downjellyfishoftrash
builduparemarkedby
smallpinkdotsand
indicatestagnantpoolsof
water.Additionallylisted
arethecommon
swimmingareasfor
childrenandthepresent
winddirectionduringthe
wetandwindyseason.


Map4.DOResults
EachDOtestingsite
(indicatedbytheblue
dot)showsbothlowtide
andhightidetesting
results.Thedarkest
shadesofblueindicatea
healthy/normalDO
readingwhilethelightest
shadesofblueindicate
theworstareas.What
canbeinferredfromthis
dataarethelocations
whereareasofthevillage
areflushingonahightide
orduetowind,butwhere
toothercentralareasare
not(1.quadrantsC7C82.
quadrantsA6A7)
DOmonitorreading:
suboptimal
optimal
aboveoptimal

<6.0ppm
69.0ppm
>9.0ppm

Map5.FinalCompilation
Thisfinallapoverlaysthe
transectpoints,withdebris
sightings,winddirection,
andhighandlowtideDO
averagedresults.VisaVis
theoverlay,wecan
demonstratethatthewind
directionandchannel
locationonthewestern
borderofthevillagehelpto
flushitsoutermostsections.
Additionally,thereisadirect
correlationbetweendebris
buildupandtheworstDO
results,helpingusto
understandwhereproblem
areasexistwithinthevillage.

Limitations
Thelimitationsofthisresearcharemostlyinregardtothevaluationoferrorinthedissolvedoxygenmeterandits
abilitytomakeinferencesaboutthequalityofthewateralone.Typically,atraditionalanalysisofwaterquality
regardinghealthissueswouldincorporateDOmonitoring,Nitrogenmonitoringaswellasfecalcoliformtesting.
ThedatafromtheDOmeter,althoughincomplete,stillallowsustoidentifyareasofwaterwithinthechannels
thatareaeratedmorefrequentlyorlessfrequently.Withlessaerationwecanassume,thatwasteproductsare
notflushingcompletelyfromthevillageandarepresent.OnseveraloccasionsInotedfecalsightingswhilepursing
theDOmonitoringaroundthevillage.Additionally,whilewindanddebrisfactorsareidentifiedthrough
observationonlytheyhelptopaintthelargerscenarioandareimportantfactorsinunderstandingwaterqualityin
Sampela.

F indingsandRecommendations
BaseduponthedatacollectedandobservationsmadeduringmybrieftimeinSampela,thereareseveral
recommendationsIwouldliketomaketoboththecommunityandregionalgovernmentaswellastheOperation
WallaceaProgram.
1. Creatingadatabasewhichmoreaccuratelydocumentshealthincidentswithinthecommunity
ThiswillallowmedicalelectiveswiththeOperationWallaceaprogramtoincreasedatacollectionsskillsaswellas
buildadatabaseofmedicalhistory,whichthecommunitycanthenusewhenadvocatingforgovernmentaid.Ifthe
communitycannotshowevidenceofaneedformoremonetarysupportormedicalsupplies,thegovernmentdoes
notsponsorthemwithadetailedmedicaldatabase,thecommunitywillhavethetoolsnecessarytoadvocatefor
aid.OverallKaledupamedicalrecordsexist,butcomparablerecordsdonotexistforSampela.Ourteams
recommendationsincludethemonitoringofchild/infantmortalitydata,aswellastheincidenceofMalaria,
HepatitisBandDiarrhea.Opwallstudents/researchersshouldworkcollaborativelywithcommunitymembers
whovolunteertobehealthadvocatorstocollectthisdata.Itwouldbebestifcommunitymembersalsotookpart
inthecomparativedataanalysissothattheytoobegintounderstandtheimportanceandsignificanceofthisdata
andhowtouseit.
2. Establishingcommunityhealthworkerswhoareeducatedinbasicpublichealthtraining
Duringthecourseofthisstudywenoticedadistincteffectofwaterqualityanduseonnotonlycommunityhealth
butalsoahighinfantmortalityrate.Bytalkingtolocalofficialsandtraditionalhealersinconjunctionwithour
shortseasoninIndonesia,wefeelthatthemostproductivewaytoattempttoaddressthehighprevalenceof
waterbornediseasesistosetupacommunityeducationprogramthatisnotonlycommunityrunbutself
sustaining.Thusestablishingacommunityhealthcorpsisvital.Basichealthlessonsmightincludetraininginboil
timeaswellasbasichandandfoodsituation.ThosedesigningtheseprogramsshouldberespectfuloflocalBajau
cultureandnotonlysuggestwesterneducationaltechniques.
3. CoordinatewiththelocalhealthclinicinKaledupaaswellastraditionalhealersinSampela
Present ly,allthreefactionsofthehealthandsanitationworkinKaledupa/Sampelaremainseparatefromone
anothertheKaledupaHealthOffice,theGovernmentSanitationworker,thetraditionalhealersofSampela.
WhileallthreesectorsprovideservicetothepeopleofSampela,theirworkisnotoneofcollaboration.By
establishingaframeworkbywhichallthreesectorscancoordinateandcollaboratewithoneanotherwillgreatly
increaseefficiency,localmedicalknowledgeandaccesstoresources.

4. Supportanddevelophealthinfrastructureandgrowthwithinthecommunityaspartofthemedical
electivesprogram
WithOperationWallaceasvastwealthofresources,thisseemsliketheperfectopportunitytohaveafully
engagingmedicalelectiveprogramwithalocalcommunityaswellasanopportunitytoreturnvitalservicestothe
communitywheretheextractmuchoftheirresearchfrom.Itcouldbeginwithmedicalelectives,documenting
data,providingemergencyservice,andcommunityawareness.
5. Inviteteamofenvironmentalengineerstoconductresearchinflowinchannelsandmakepossible
recommendations/changestoexistingchannelsystem
Theissueofdebrisbuildupisonenottobeansweredbysocialscientistsofmedicalelectives.Instead,
professionalsareneededtoevaluateconsequentialrisksthatunblockingthechannelsmightduetotheadjacent
reefflataswelldesignamethodforincreasingwaterflowthroughthechannelsandpreventingdebrisbuildup.
Thismayposeasanattractivehandsonopportunitytofacultyandateamofstudentsatanengineeringuniversity.
6. DiscusshousingexpansionwithKepalaDesaanddevelopaplantodealwithincreasingpopulation
Therapidincreaseinpopulationinsuchadenselypackedareaisundoubtedlycausingdetrimentalaffectsonthe
peopleshealththatlivewithintheareaaswellasthefunctioningofthenearbyecosystem.Itwouldbewiseto
startplanningforalternativestocopewiththepressureofanincreasingpopulationwiththeKepalaDesaone
mightaskifanotherBajauvillagecouldbebuiltnearbyorperhapsabettersystemofcreatingchannelsbetween
housestoensurewaterflowthroughoutthevillage.
7. BuildfreshwatertapviachannelfromKaledupatoSampelaorstandingreserveincommunity
LimitedaccesstofreshwaterisoneofthemainreasonsthatthepeopleofSampeladonotusefreshwatertoclean
dirtydishes.Insteadtheyopttocleanthedishesinthesamesaltwaterthatfecesaredisposedinthereby
increasingchancesoffecalcoliformcontaminationwheneating.Afreshwatertaporbarrelreservemighthelpto
reducethisrisk.
8. Conducttestingofinvertebratesforconsumptionofhumanfecalmatter
Notingthatmanypeopleinthecommunityidentifiedeatinginvertebratesasasourceofdiarrheaitwouldbewise
andofgoodpurposetoconducttestingoftheinvertebratestheyareeating.Iftheytestpositiveforcoliform,the
communityshouldbenotifiedandadvisedofotherlocationstogleanorperhapscookinvertebratesthoroughly
beforeeating.
9. Createcompostingtoiletsbeneathstilthouses
Therehavebeenmanytacticsforcreatingcompostingtoiletstoensurebettersanitationwithinavillage.If
possible,onemightwanttolookintothepossibilityofdevelopingcompostingtoiletsbeneathhousesthathavea
coralreefplatformbuiltbeneaththem.Usingthecoralrockasamethodoffiltrationandcomposting,theamount
ofopenfecalsubstancesintotheenvironmentcanbedecreased.
10. Developreefplatformwherewastedisposalcanbeburned
Presently,themethodofdisposingoftrashandgarbageistodirectlythrowitintothesurroundingocean,posinga
majorthreattosurroundinganimalsandplantsintheecosystem.Althoughburningtrashisoftenpreventeddue
toitsoffsetofcarbonemissions,burningthetrashwithinthevillagewillhavesmalleffectsincomparisonto
directlydisposingofitintotheocean.Itwouldberecommendedthatfiresarewellcontrolledandtheplatformis
inadirectionthatwillnotbegreatlyaffectedbywinddirectionnorcauserisktoburningofneighboringhomes.

Appendixannotatedquestionnaire.
Survey Questionnaire (English)
Questionnaire No.______
Village:_________________
Interviewer:____________________
Number of Household Residents;__________
Socio-Economic Status
Roof
Nipa (thatched palm)_____ Tin____
Walls
Wood_____
Cement___
Floor Dirt____
Wood____
Cement_____

Other_____
Other_____
Other_____

Presence or absence of the following items in the House:

Electricity
Radio
TV
CD/DVD Player Y

Y
Y
Y
N

N
N
N

Water and Sanitation

5.) Do you have a toilet
Yes
No
If yes:
Indoor____
out house___
Water seal____ Pit latrine_____
6.) Where do you get water for bathing/washing from?
Well__

Pipe__

Spring__

Other___________(specify)

Must you buy it or pay a fee for water service

Yes
No
If yes, how much?_________ Rupiah (gallon/liter/jug) per specify water unit ______
7.) How far is the source from your home? ____ Kilometers
8.) Where do you get drinking water from?
Well

Pipe

Spring

Other

Must you buy it or pay a fee for water service

Yes
No
If yes, how much?_________ Rupiah (gallon/liter/jug) per specify water unit ______
9.) How far is the source from your home? ____ Kilometers
10.) Do you boil your drinking water?
Yes
No
11.) Why?_____________________________________________________________________

12.) Do you believe that boiling water keeps you from getting sick?
Agree __
Disagree__
Dont Know__
13.) How long do you boil water for? ____ minutes
Where/How do you dispose of your garbage/trash_____________________________________
______________________________________________________________________________

Sickness and Disease

14.) How often do you get intestinal diarrhea sickness in one month?
Frequently

Often

Seldom Never

(you may want to ask this differently and next question as well :
How often do you get intestinal diarrhea sickness
at least once a week
at least once a month
less than once a month never
15.) How frequently do members of your family get intestinal diarrhea sickness in one month?
Frequently

Often

Seldom Never

16.) In your opinion, what causes this sickness?

_____________________________________________________________________________________________
_______________________________________________________________
Medical Treatment
17.) Who do you see for treatment when you get sick?
Health worker

Traditional Healer

Family Member

18.) Do you take any medicines when sick?

Yes

Doctor

Other _______

Nobody

No

19.) If yes, what kinds? First response_______________________________________________

Second response_____________________________________________
Third response______________________________________________
Do you ever use traditional or herbal remedies instead of drugs from the pharmacy? Yes No
Why?__________________________________________________________________
20.) Do you harvest any creatures from the ocean for medicinal purposes?
Yes
No
If yes, What kind/names of creatures?_____________________________________
21.) Why?__________________________________________________________________
Optional/Additional Qs:
22.) Do you cover your food after cooking? Yes
No
Why?__________________________________________________
23.) How long do you leave your food out before you throw it away as spoiled? __________hrs
Personal information
1.) Age _____ years
2.) Gender
Male
3.) Ethnicity _______________________ (self identified)
4.) Educational level ____yrs formal schooling)

Female

Survey Questionnaire (Bahasa Indonesia)

NO kuisioner :______
Desa:_________________
Pewawancara:____________________
Jumlah anggota keluarga:__________
Status social dan ekonomi
Atap rumah
Nipah_____
Dinding rumah
Kayu_____
Lantai rumah
Kayu_____

Seng/Genteng____ Lainnya_____
Semen___
Lainnya_____
Semen___
Lainnya_____

Ada atau tidak hal-hal dibawah ini di dalam rumah:

Listrik
Radio
TV
CD/DVD Player Y

Y
Y
Y
N

N
N
N

Air dan Kesehatan

Apakah Anda mempunyai toilet (WC)?
Ya
Tidak
Jika Ya:
Di dalam rumah ____
di luar rumah___
Jenis:
Hilang dengan disiram air______
jumbleng (lubang tanah , ditutup setelah dipakai dan kotoran dibiarkan )_____
lubang tanah_____
Dimana Anda memperoleh air untuk mandi dan mencuci?
sumur__ pipa ledeng__

air sumber __

lainnya___________(jelaskan)

Apakah Anda harus membeli air atau membayar iuran untuk layanan air?
Ya

Tidak

Jika ya, berapa harganya?_________ Rupiah (gallon /liter /kubic ) tiap satuan unit air
Seberapa jauh tempat mengambil/membeli air dari rumah anda? ____ Kilometer
Dari mana asal air minum yang Anda dapatkan?
pipa ledeng

sumur

air sumber

lainnya___________(jelaskan)

Apakah Anda harus membeli air atau membayar iuran untuk layanan air?
Ya

Tidak

Jika ya, berapa harganya?_________ Rupiah (gallon /liter /kubic ) tiap satuan unit air

Seberapa jauh tempat mengambil/membeli air dari rumahmu? ____ Kilometer

Apakah Anda memasak air yang akan diminum?

Ya

Tidak

Mengapa?_________________________________________________________________

Apakah Anda percaya bahwa merebus air minum akan mencegah Anda dari sakit perut?
Setuju __

Tidak setuju__

Tidak Tau__

Berapa lama Anda mererbus air ? ____ menit

Dimana dan bagaimana Anda membuah sampah ? _____________________________________
______________________________________________________________________________
Sakit dan Penyakit
Seberapa sering anda mengalami diare perut dalam satu bulan?
Sangat sering ___ Sering___

Jarang____

Tidak pernah_____

Seberapa sering anggota keluarga Anda terkena penyakir diare perut dalam satu bulan?
Sangat sering ___ Sering___

Jarang____

Tidak pernah_____

Menurut Anda, apa sebab-sebab penyakit sakit perut (diare)?

_____________________________________________________________________________________________
_______________________________________________________________
Perawatan Medis
Bila Anda sakit, anda pergi ke siapa/kemana?
Pegawai kesehatan

Dukun

Anggota keluarga

Apakah Anda meminum obat bila sakit?

Ya

Dokter

Lainnya

Tidak kemana-mana

tidak

Jika iya, obat apa ? Tindakan pertama ____________________________________________

Tindakan kedua _____________________________________________
Tindakan ketiga _____________________________________________
Apakah Anda pernah menggunakan obat traditional atau obat dari tumbuh-tumbuhan dan hal tersebut lebih Anda
Sukai daripada obat dari apotik?
Ya
Tidak
Mengapa?__________________________________________________________________
Apakah Anda menggunakan jenis hewan/tumbuhan dari laut untuk obat (misal rumput laut)?
Ya

Tidak

JIka iya, Jenis /Apa nama hewan/tumbuhan tersebut _____________________________

Mengapa?__________________________________________________________________
Pertanyaan tambahan (tidak wajib)
Apakah Anda menutupi masakan anda setelah selesai memasak?

Ya

Tidak

Mengapa?__________________________________________________
Seberapa lama Anda membiarkan makanan Anda diluar sebelum Anda buang di tempat sampah (basi)?
__________jam
Informasi pribadi

Umur _____ tahun

Jenis Kelamin

Laki-laki_____

Perempuan______

Suku _______________________ (self identified)

Tingkat pendidikan _______tahun sekolah formal
( misal : tamat SD=6 tahun, SMP= 9 tahun, SMA = 12 tahun, Perguruan tinggi=16 tahun)