PUBLIC HEALTH BRIEFS
States House of Representatives Cost Containment Bill H.R.
6575; and California Cost Containment Assembly Bill 1156.
2. Cohen W: Current problems in health care. N Eng J Med
281:193-197, 1969.
3. Ford AS: The Physicians' Assistant: A National and Local
Analysis. New York: Praeger, 1975.
4. Lewis C, Resnick B, Schmidt G, et al: Activities, events, and
outcomes in ambulatory patient care. N Engl J Med 280:645-
649, 1969.
5. Lewis C and Resnick B: Nurse clinics and progressive ambula-
tory patient care. N Engl J Med 277:1236-1241, 1967.
6. Bystran SF, Knight CC, Soper MR, et al: An evaluation of
nurse practitioners in chronic care clinics. Int J Nurs Stud
11:185-194, 1974.
7. Spitzer WO, Sackett DL, Sibley JC, et al: The Burlington ran-
domized trial of the nurse practitioner. N Engl J Med 290:251-
257, 1974.
8. Galladay FL, Miller M and Smith KR: Allied health manpower
strategies: Estimate of the potential gains from efficient task del-
egation. Med Care 11:457-469, 1973.
9. Yankauer A, Connelly J, Andrews P, et al: The practice of nurs-
Operation of the Coconut Fiber/Burnt Rice Husks
Filter for Supplying Drinking Water to
Rural Communities in Southeast Asia
RICHARD J. FRANKEL, PHD
Rural water systems in developing countries around the
world have required investment capital of US $7 to 45 per
capita depending upon the extent and quality of services pro-
vided. For most such countries, the total costs of providing
water to rural inhabitants is far beyond the available devel-
opment budgets. The high costs of conventional systems do
not permit capital pay-back by the villagers themselves.
Thus in an effort to reduce overall system costs, ground wa-
ter supplies are preferred because such waters can often be
used directly for drinking without treatment. In many areas
of Southeast Asia, however, surface waters must be utilized
for community water supply. Conventional water treatment
for these areas is too complex to operate and too expensive
for most communities to afford. The older and cheaper slow
sand filters are also inappropriate because the filters cannot
handle the turbid waters without quickly becoming clogged
and properly graded filter sand is often difficult to obtain.
Both systems require skilled operation which is clearly lack-
ing in most rural areas. Accordingly, the World Health Or-
ganization and other agencies emphasized the importance of
adjusting technology to suit local conditions and needs.1-4
In 1972, the author worked on the development of a new
filter approach in Thailand which on a laboratory scale ap-
peared to have wide applicability for both water purification
Address reprint requests to Richard J. Frankel, PhD, President,
Seatec International, 87 Sukhumvit Road, Nai Lert Bldg., 6th floor,
Bangkok, Thailand. This paper, submitted to the Journal January
31, 1977, was revised and accepted for publication June 6, 1978.
AJPH January 1979, Vol. 69, No. 1
ing in pediatric offices: Challenge and opportunity. N Engl J
Med 282:843-847, 1970.
10. Kubala S and Clever LH: Acceptance of the nurse practitioner.
Am J Nurse 74:451-452, 1974.
11. Schoen EJ, Erickson RJ, Barr G, et al: The role of pediatric
nurse practitioners as viewed by California pediatricians. Calif
Med 118:62-8, 1973.
12. Yankauer A, Connelly JP and Feldman JJ: A survey of allied
health worker utilization in pediatric practice of Massachusetts
and in the United States. Pediatrics 42:733-742, 1968.
13. O'Dell ML: Physicians' perceptions of an extended role for the
nurse. Nurs Res 23:348-351, 1974.
14. Riddick FA, Bryan JB, Gershenson MI, et al: Use of allied
health professionals in internists' offices. Arch Intern Med
127:924-931, 1971.
15. Bates B: Doctor and nurse: Changing roles and relations. N
EngI J Med 283:129-134, 1970.
16. Sadler AM: The new health practitioner in primary care. J Med
Educ 49:845-848, 1974.
17. McCally M, Soren K and Silverman M: Interprofessional educa-
tion of the new health practitioner. J Med Ed 52:177-182, 1977.
and wastewater treatment in Southeast Asia. This appropri-
ate technology type filter consists of two stages. The first is
made up of the fibers from shredded coconut husks to filter
out the bulk of suspended solids from the water; the second
is a bed of burnt rice husks to "polish" the water removing
residual turbidity and other contaminants. The filter thus uti-
lizes local materials that are both widely available and in-
expensive enough to discard after use, thus eliminating back-
washing. The media are used in series so that filtration alone
can do the job in most cases without use of chemicals. In
addition, with burnt rice husks as a filtering medium, the
process includes significant absorption capability for taste,
odor, and color removal.
Community water projects utilizing filter plants ranging
in capacity of 0.25 to 15.0 cu.m. per hour were constructed
in the lower Mekong river basin countries and in the Philip-
pines. A typical design of a filter plant is shown in Figure I
for a community of 800 persons. Two-stage filtration, using
two separate gravity fed filters, was typical for all filter
plants. Total construction costs, including pump, filters,
storage jars, and public taps, amounted to less than US $2
per capita. The construction materials were generally wood
for the support structure, concrete jars for the filter boxes
(concrete pipe sections and galvanized iron tanks were used
also), PVC pipes, rubber ball valve controls, and gasoline
operated pumps for the power source. In the Philippines nu-
merous small units, costing less than US $1.00 per capita,
were built using hand operated "jet-o-matic" pumps.
75
PUBLIC HEALTH BRIEFS

FIRST STAGE FILTER sand filtration, does achieve removals of particulates to pro-
COCONUT FIBER
duce an effluent meeting recommended WHO International
SECOND STAGE FILTER Drinking Water Standards. The significant difference be-
BURNT RICE HUSKS -BALL VALVE CONTROL tween the two approaches is the fact that the two-stage proc-
ess can handle waters of high turbidity (usually the case for
CONCRETEOTER JAR Southeast Asia), whereas the slow sand filter is limited to
relatively low raw water turbidities. Also, the two-stage
BALL VALVE CONTROL PVC 0 UK process operates at 10 to 15 times higher filtration rates than
the slow sand filter, and incorporates significant absorption
capability for removing tastes and color. Moreover, by use
METER AND GATE VALVE of additional stages higher levels of removals can be
PVC 0/4 w In_io GAL\ANIZED PIPE achieved if desired. Effluent turbidities were generally below
5 JTU (Jackson Turbidity Units) from raw water turbidities
FILTERED WATER
which ranged from 15 to 150 JTU. Coliforms removals aver-
aged 60 to 85 per cent with individual samples ranging from
STORAGE STORAGE =|STORINGE zero to 100 per cent removal, but bacteriological removals
TANK TANK _|TAqK were insufficient to reach "potable" standards without the
PUBLIC TAPS 35HP GASOLNE addition of some simple disinfection. Iron removals varied
from 80 to 95 per cent. Filter media were changed only once
INTAKE
every three to five months at the various village installations.
SCALE 1: 50
It is believed the quality of effluent from the two-stage
process represents a reasonably good quality for most vil-
FIGURE 1-Two-Stage Filtration Unit Constructed at Ban Som, lages where investment in more expensive water treatment
Changwat Korat, Thailand, 1973 (side view) plants (rapid sand filtration or slow sand filtration) simply
cannot be afforded. The two-stage filter also serves as a
The objectives of testing the filter units used for village simple first stage investment in a multi-stage development
water supply were to seek design improvements involving process to improve water supply/sanitation services in rural
greater simplicity of construction, to oversee operational areas. Further information can be obtained from the author.
problems under actual village conditions, to quantify the fil-
ter performance in improving water quality, and to evaluate REFERENCES
1. World Health Organization, Community Water Supplies-A
villager acceptance of the treated water for drinking, cook- Critical Situation. WHO Chronicle 23, No. 8, 1969.
ing, and domestic purposes. 2. World Health Organization, Community Water Supply-The
Continuous testing of the coconut fiber/burnt rice husks Next Ten Years. WHO Chronicle 25, No. 2, 1971.
filter was carried out at a number of field installations from 3. World Bank, Issues in Village Water Supply. Public Utilities
1974 to 1977. The accumulated data, using turbidity, iron, Dept. Report No. 793, Washington, DC, 1975.
4. Feacham RG: Water supplies in low-income communities of de-
and coliforms as the main parameters, show that this type of veloping countries. Journal of the Environmental Engineering
two-stage filter, while not achieving results equal to slow Division, Proceedings ASCE 101, no. EE5, 1975.

Who Bought the Cars in Which People are Injured?

An Exploratory Study
SUSAN P. BAKER, MPH
An argument often made against requiring motor vehi-
cles to meet federal safety standards is that purchasers
Address reprint requests to Susan P. Baker, MPH, c/o Office of
the Chief Medical Examiner, 111 Penn Street, Baltimore, MD 21201.
Ms. Baker is also Associate Professor, Dept. of Health Services Ad-
ministration, Johns Hopkins School of Hygiene and Public Health.
This paper, submitted to the Journal April 3, 1978, was revised and
accepted for publication July 18, 1978.
should be free not to invest in their own protection. Since it
is their personal safety that is at stake, the argument runs,
safety features should be optional. This argument was used,
for example, by vehicle manufacturers, editorial writers,
members of the Congress, and others who opposed the "pas-
sive restraint" standard, which will require new passenger
cars to provide front seat occupants with automatic crash
protection, such as airbags or seatbelts that do not require
action by the occupant in order to be fastened.

76 AJPH January 1979, Vol. 69, No. 1