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3. Health and sanitation among mangrove dwellers in Thailand

Puckprink Sangdee

Medical Care Available to the Residents of Mangrove Villages

This study of health and sanitation among the residents of mangrove communities in Thailand was carried out in conjunction with the research on Ko Lao and Had Sai Khao villages reported in chapter 2, above. The limited income and low level of education of the average villagers in both Ko Lao and Had Sai Khao affect their living style. Poor hygiene and sanitation create environmental and health problems, impairing the quality of their lives.

Only one household in Had Sai Khao (4 per cent) had a drug cabinet, compared with six Ko Lao households (27 per cent). The drug cabinet in Had Sai Khao was within reach of children and potentially dangerous to them, whereas those in Ko lao were not. None of the drug cabinets in either village were located in such a way as to be exposed to sunlight or other sources of heat.

Despite the existence of drug cabinets, the villagers still do not have enough of the drugs necessary for first aid (Department of Commercial Relations 1982). Drugs commonly found are analgesics, antipyretics, antacids, anti-inflammatory agents, drugs for cough, and antiseptic solutions. Some owners of drug cabinets never get rid of expired drugs, and this practice may be hazardous because the expired drug may become toxic or may have no therapeutic value (Martin and Martin 1978; Milford and Drapkin 1965).

Neither village has a government health centre, nor are there private clinics in the vicinity. A governmental mobile health-care unit makes a brief visit to each of the two villages once a month. The health team provides free primary-health-care services and drugs, including nonprescription medicines and contraceptive pills, and supplies some types of drugs to the principal of the village school, who dispenses them to any villager who needs them. The health team also gives school children basic dental services.

About 44 per cent of the villagers said they were not satisfied with the government health services offered to them. They wanted the doctor to visit more frequently and to investigate and treat of their diseases instead of simply distributing medicine, and they wanted the government to set up a clinic in each village.

One indication of the inadequacy of the health-care services provided by the government is that about twothirds of the villagers reported they have had to buy drugs from a drugstore to treat their illnesses. About 95 per cent of these said that they bought types and brands recommended by the salesman or the drugstore owner, people who are not trained pharmacists, and the remainder (4-6 per cent) bought drugs as a result of advertisements in various media. Some 23-30 per cent of the villagers have had to go to a private clinic or hospital in town for more serious health problems or for more rapid or frequent service, while the remainder simply neglected mild or tolerable illnesses. Some of them believe that the diseases will go away as easily as they come, and so they never treat their illnesses, and some do not have enough money to pay a doctor. Table 1 shows the amounts of money spent annually on health care.

TABLE 1. Annual household expenditures for health care

Traditional Healing

One Buddhist household in Ko Lao village believes in spiritual healing of illness. For example, the father worshipped his ancestors by offering them food in order to cure his son's illness. They believe that someone in the family may have done something to offend the ancestor spirit.

Some villagers (15-30 per cent) also seek additional help by using traditional medicines, especially medicinal plants which have been identified by Smitinand (1980) and Manoonpiju (1983) (table 2). The effectiveness of these medicines, as reported by the villagers, varies from poor to good, but their pharmacological activity has not been investigated. Villagers usually obtain information about traditional medicines from their relatives and friends. The information may be incomplete or misleading. If they use a traditional medicine incorrectly or misunderstand its therapeutic value, it may be harmful in two ways: first, the treatment may be ineffective or toxic, and, second, it may delay or prevent the patient from seeking more effective forms of treatment.

The four medicinal plants most commonly used are from the mangrove forest. These are two kinds of ngueak plea mo (Acanthus ebracteatus and A. ilicifolius), two kinds of samae (Avicennia officinalis and A. alba), thua shale (Bruguiera parviflora), and seng (Triumfetta rhomboidea). Two other medicinal plants are used by Ko Lao villagers. All these plants can be used in either fresh or dried form. Details of their use are as follows:
- Acanthus ebracteatus or A. ilicifolius is used for kidney stones. The whole plant is boiled in fresh water, and the patient drinks the solution instead of water, half a glass at a time, until the signs and symptoms disappear.
- Avicennia officinalis or A. alba is used for thrush in children. The heartwood is rubbed against a coarse stone into fine particles; lime juice is added; and the mixture is stirred vigorously to make a paste, which is spread on the child's tongue twice a day before meals (morning and evening) for three days.
- Bruguiera parviflora is used to relieve constipation. The whole plant is boiled in water, and a glassful of the solution is taken twice a day after meals. Jriumfetta rhomboidea is used for fever during menstrual peiods. The whole plant is boiled in a pot of water, and the solution is drunk instead of water, half a glass at a time. Water is added and reboiled until the solution becomes tasteless. This is repeated three times.

TABLE 2. Medicinal plants used by mangrove villagers

Drug abuse is a problem among divers. When they want to dive deeper than the limits their ears can normally tolerate, they take analgesics. They claim that they do not then experience pain in their ears during deep dives. This type of drug abuse is extremely dangerous to their ears, with damage varying from impaired hearing to total deafness.

Types of Illnesses Reported

Villagers were asked to report illnesses they had experienced. Common communicable diseases were reported in both villages with about the same frequency, except that skin diseases were not reported by Ko Lao villagers, whereas tuberculosis and whooping cough were not reported by residents of Had Sai Khao (table 3).

TABLE 3. Communicable diseases reported in Ko Lao and Had Sai Khao

Numbers and percentages of household heads reporting that the disease occurred in their household.

Malaria is a preventable and usually curable parasitic disease. A full course of drug treatment will usually eliminate the parasites and cure the disease. Patients in the two villages treat themselves symptomatically and inadequately. This practice is hazardous not only to their own health but also to others, since the Plasmodium organism will ultimately develop resistance to treatment if effective drugs are taken only sporadically. Consequently the inadequately treated patient will harbour resistant strains of malarial parasites that are much more difficult to destroy, and these resistant parasites may eventually spread throughout the community.

Although there is some question about the safety and efficacy of vaccination against whooping cough and tuberculosis (Fulginiti 1982, 134), vaccination programmes against whooping cough (DPT vaccine) and tuberculosis (BCG vaccine) are mandated by the Ministry of Public Health and should be administered to every infant. The occurrence of these two diseases in Ko Lao suggests either that the vaccination programme has failed or that there is a lack of cooperation of the parents, or both. The ineffectiveness of the programme in Ko Lao may be associated with religious faith; these two diseases are not found in Had Sai Khao, where the residents are all Buddhist.

A striking difference between the two villages is fungus disease of the skin, Tinea versicolor, which is commonly found in Had Sai Khao, where fresh water, obtained from a distant well, is usually saved for drinking and cooking (fig. 2). The disease is uncommon in Ko Lao, where fresh water is more plentiful. This disease normally occurs in people with poor skin hygiene and is generally found to be related to the lack of fresh water for washing and bathing.

Village Water Supplies

Each village school has a big reservoir to collect and store rain-water. However, this provides only enough for the children during the school day and for the teachers' families. In spite of the persistent long-term water shortage in both villages, they have not built public reservoirs big enough for everyone in the village. Only three households have one to three large earthenware jars for collection of rain-water for drinking and cooking.

The water supply at Ko Lao, where there are three fresh water wells, is far better than at Had Sai Khao. The first well belongs to the village school and is reserved for the school children and the teachers and their families. The second is privately owned, but the owner allows his neighbours to use it. The last is a public well. The privately owned well has plenty of fresh water all year round, but water from the public and school wells is scarce in the dry season and often has a salty taste. During the summer the owner of the private well limits the time when he allows his neighbours to use it.

Had Sai Khao households have to carry fresh water from a year-round source on nearby Ko Kew island. They transport it by boat in heavy, bulky containers, which is inconvenient and risky.

Birth Control

The birth control programme in Had Sai Khao is quite successful. Both oral and injectable contraceptives are used by housewives in both villages (table 4). The injectable form is more convenient, since only one injection is needed every three months, but a trained person is required to inject the drug. Sterilization has also been used in both villages. In some Moslem households birth control is not used because the family believe it is against their religion.

Sanitary Conditions

The average number of children per family is slightly higher in the Muslim families than in the Buddhist families. The average household income in the villages is quite low compared with the average wage of B 66 per day in Ranong Province (National Economic and Social Development Board 1984, 48), and therefore most parents can provide only inadequate care for their children's wellbeing. Most children do not have enough clothes to wear, and they play barefooted on the ground. They wear clothing, their school uniform, only when they go to school. These children are at risk for helminthiases because several kinds of worms, including hookworms, Strongyloides, and others, can penetrate the human skin (Krupp and Chatton 1982). Toddlers wander around the house and the village without supervision much of the time. They may pick up things from the ground and put them in their mouths, and thus, with poor sanitation throughout the villages, they are likely to swallow worm eggs or larvae. Helminthiases create various health problems, including anaemia, malnutrition, and liver diseases, which can impede the children's normal growth and development.

TABLE 4. Use of modern birth control methods

a. Households in which one or more women used the method.

None of the village houses, except the teachers' houses owned by the government, have either indoor or outdoor toilets or lavatories with septic tanks (fig. 3). The lack of facilities for the safe disposal of human wastes, along with the lack of fresh water, seems well correlated with diarrhoea, which is commonly reported in both villages. Poor sanitary conditions may cause epidemic diseases, especially those of the gastro-intestinal system, which can have dangerous consequences.

References

Department of Commercial Relations. 1982. A manual for public health workers. Office of the Permanent Secretary of Public Health, Bangkok.

Fulginiti, V. A. 1982. "Immunization." In C. Henry Kempe, Henry K. Silver, and Donough O'Brien, eds., Current pediatric diagnosis and treatment. Lange Medical Publications, Los Altos, Calif., USA.

Krupp, M. A., and M. J. Chatton. 1982. Current medical diagnosis and treatment. Lange Medical Publications, Los Altos, Calif., USA.

Manoonpiju, K. 1983. List of Thai plants and references to phytochemical research (in Thai). 2 vols. Department of Chemistry, Faculty of Science, Mahidol University, Bangkok.

Martin, E. W., and R. D. Martin. 1978. "Distribution and storage factors." In Hazards of medication, 2nd ed. J. B. Lippincott Company, Philadelphia, Pa., USA.

Milford, F., and A Drapkin. 1965. "Potassium depletion syndrome secondary to neuropathy caused by outdated tetracycline." New England Journal of Medicine, 272: 986.

National Economic and Social Development Board. 1984. Fact book on labour, employment, salaries and wages. Wages and Employment Planning Sector, Population and Manpower Planning Division, National Economic and Social Development Board, Bangkok.

Smitinand, Tem. 1980. Thai plant names. Forest Herbarium, Royal Forest Department, Bangkok.

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