Jakarta kampung morbidity variations: Some policy implications

0277-9536188 $3.00+ 0.00 Pergamon Press plc

Sot. Sci. Med. Vol 26, No. 6. PP. 641+49, 1988 Printed in Great Britain

JAKARTA

KAMPUNG MORBIDITY VARIATIONS: SOME POLICY IMPLICATIONS

RALPH LENZ Department of Geography, Wittenberg University, Springfield, OH 45501, U.S.A. Abstract-Urban growth in the developing world is likely to be accompanied by health problems in crowded zones where services are not available. Geographical analyses of aggregated data may prove interesting, but reliability and utility of spatial correlations are greater when microscale data are acquired. In this study data for households in 11 Jakarta neighborhoods were collected in interviews. Malaria and diarrhea1 disease patterns have been correlated with environmental and socioeconomic variables at the household level. Several environmental characteristics seem to he closely associated with the incidence of malaria and diarrhea1 diseases. F&J’wo&-Jakarta

households, malaria, diarrhea1 disease, sanitation, housing policy

Accelerating urbanization in the developing world has been accompanied by health problems in many urban zones. While cities have more health facilities and seem to exhibit lowered mortality rates, these improvements mask enormous intra-urban inequalities in income, access to health facilities and environmental conditions. Health differences between central city areas and the urban periphery, where poverty, squatting, and absence of urban services are most common, are likely to be acute. Spatial patterns of land use within Jakarta, Indonesia are similar to those in most very large cities in the developing world. This paper examines health problems among the inhibitants of Jakarta’s low income areas. SQUAITER SEITLEMENTS

AND URBAN HEALTH

Urban expansion in the tropics can create ecological conditions that favor the development of endemic diseases, especially mosquito-borne ones. There is likely to be an abundance of breeding sites for Anopheles [l-3] and Aedes aegypti [4-6], particularly in squatter settlements, which lack piped water and have inadequate sewage removal. Studies have indicated high rates of malaria

Mosquito-borne disease rates are lower in centrally located kampungs than in peripheral ones. (2) Disease rates within kampungs vary according to socioeconomic characteristics of the inhabitants. (3) House types affect the incidence of malaria. (4) The incidence of diarrhea1 diseases is affected by bathroom availability, source of drinking water, bathing facilities, and crowding. (5) Malaria incidence is higher for recent urban migrants and other mobile inhabitants. POLICY CONSIDERATIONS

RALPH LENZ

642

location is required. Are squatter settlements actually a creative response to the particular environments of tropical cities in the Third World? Appropriate planning responses depend on the extent to which health problems are associated with settlement characteristics. If location within the urban area rather than socioeconomic status is the primary indicator of health status, housing policy in Jakarta and other cities of the developing world may be able to make a difference. If local environmental conditions seem to exert a strong influence, perhaps minor improvements such as have been a part of Jakarta’s well-known kumpung improvement program [14] can produce health benefits. Additional services may well best be provided in the context of an area dominated by makeshift structures; multistoried products of urban renewal may not be necessary. DATA

CHARACTERISTICS

Geographical analyses of disease patterns are fundamental to the understanding of disease etiology. But whereas spatial studies are of obvious value in generating and, sometimes, eliminating hypotheses of disease causation, definitive cause-effect relationships are elusive. Not only are the generating processes of disease distributions probabilistic rather than deterministic, but they can also be very complex, and similar spatial patterns can often be generated by a variety of processes [ 151. Correlations that rely on data aggregated for macrospatial units can engender an ecological fallacy trap [ 16, 171,and must therefore be interpreted with extreme care. Data collected at the individual or household level allow sitespecific analysis, and the formation of more reliable conclusions. Data for this paper were obtained through the implementation of 559 questionnaires in 11 neighborhoods in various parts of Jakarta between January and April, 1985. Information was collected at the household level, primarily by students from Universitas Nasional, allowing maximum site specificity. The survey instrument was written in the Indonesian language, and respondents were asked about the health status of members of their household. Commonly recognized diseases were recorded if mentioned by respondents; otherwise descriptions of symptoms were requested and recorded. Medical diagnoses are far too expensive for large household surveys. The diagnostic advantage of aggregated data, which may be drawn from hospital admissions or mortality statistics, cannot be extended to such surveys. While Jakarta kampung residents may not be medically sophisticated, it is not unreasonable to assume that they can recognize the existence of health problems in their households and to specify symptoms which exist. The questionnaire approach does require interpretive caution. It is conceivable that respondents might misreport illnesses, although we are aware of no cultural predispositions on the part of Jakarta’s kampung populations to do this. The inclination to mislead, if present, would probably be influenced by socioeconomic, educational, or ethnic status, or perhaps by length of residence in the city. Indeed, these

factors do affect the likelihood that people will seek medical treatment; admissions data are even less reliable in this respect. There is little reason to expect that location-related variables or easily-altered environmental characteristics predispose Indonesians to respond deceptively. Another drawback is that similar complaints can be generated by different etiologic agents; Gesler has demonstrated that the use of broad disease categories such as ‘digestive’ and ‘respiratory’ can lead to acceptable levels of accuracy in reporting with a questionnaire approach [ 181. Malaria in Jakarta was frequently enough reported and distinct enough in its symptoms and etiology to be treated separately in this study. We were unable to distinguish symptoms of dengue hemorrhagic fever, an urban disease throughout Southeast Asia, in the Jakarta kampungs. Dysentery, typhoid fever, cholera, and muntaber (a local term for a combination of diarrhea and nausea symptoms) were aggregated into a single category called diarrhea1 diseases. Skin diseases, although distinct enough for separate treatment, were not frequently reported, and had to be grouped with a variety of maladies in an other diseases category. This latter category is far too general to allow serious interpretation, but has been included in this paper because it does supply additional information on health variations within Jakarta. HYPOTHESES

The first two hypotheses are concerned with the relationship between socioeconomic status and health in Jakarta kampungs. Epidemiologic theory suggests that the incidence of malaria declines with increases in socioeconomic conditions that accompany development [ 191, a process applicable to entire regions. A reasonable expectation would be that central zones of large cities should be the first areas to experience declining malaria rates in developing countries, and that the urban periphery would lag. Correlations within low-income zones could be expected only insofar as wealthier inhabitants are able to make improvements in their personal environments that limit the movement of Anopheles. Patterns of diarrhea1 diseases also seem to exhibit macro-scale correlations with level of development. Studies conducted within neighborhoods, however, rarely establish strong relationships between socioeconomic variables and diarrhea1 diseases [20]. Only weak inverse relationships between disease and indicators of socioeconomic status are hypothesized. Environmental variables may well bear closer scrutiny; they may indicate the likelihood of exposure to pathogens. Environmental conditions are also, to a much greater degree than socioeconomic conditions, susceptible to alteration by urban governmental policy. Environmental factors may influence health at a knmpung scale. With mosquito-vectored diseases, conditions suitable for breeding are likely to be present throughout entire neighborhoods, and exposure of populations will be determined by the presence of Plasmodium and the limited range of hopheles. With diarrhea1 diseases, contamination may also be present in rivers, well water, open drains,

Jakarta kumpung morbidity variations or roadside puddles throughout a neighborhood. The provision of piped water to squatter settlements in Zambia coincided with reductions in typhoid fever and diarrhea] cases [21], but increased water use had no effect on diarrhea in rural Panama [22]. Such diseases may also be spread by vectors or induced by the habits of the populace. Environmental factors may also be expected to operate at a household scale. Correlations of mosquito-vectored diseases with house types, for example, have been observed in the Caribbean [23], and several studies have examined variations in diarrhea1 diseases among households. The existence of in-house latrines has been found to be negatively correlated with amoebic dysentery in northern India [24], and flush toilets have been associated with lower infant mortality in Sri Lankan villages [25] and in Malaysia among nonbreastfed children [26]. Child deaths were also lower within households in Brazil with internally piped water [27], while the availability of tube wells in Bangladesh did not Seem to produce the desired effect on cholera and other diarrhea rates [28]. Strong kompung level variations in both malaria and diarrhea1 disease rates are hypothesized, and it is expected that environmental variations which coincide with disease variations can be identified, particularly for diarrhea1 disease. The third hypothesis suggests relationships at the household scale between malaria incidence and house types due to the potential effect upon exposure to Anopheles. Strong household level relationships between bathroom availability, source of drinking water, bathing facilities, crowding, and the incidence of diarrhea1 disease are predicted by the fourth hypothesis. Overlooking the fact that neither populations nor pathogens are immobile can lead to invalid interpretation of disease patterns. Activity patterns also affect potential exposures of populations [29]. The scope of the survey did not permit thorough treatment of population mobility, but data were collected on several variables which serve as indicators of mobility. Relationships are hypothesized between malaria and place of birth as well as years spent in place, since malaria is often described as a rural disease, and may be more likely to have been contracted outside the locale. SITES OF SURVEY

Eleven Jakarta neighborhoods were selected for the survey. All are of relatively low socioeconomic status,

643

but they differ markedly in environmental and locational characteristics. The sampled sites (Table 1 and Fig. 1) include two in the northern periphery, five with relatively central locations, and four kumpungs in the southern periphery. (The map encompasses most of the urbanized area of Jakarta; additional spokes of development extend outward along the major roads.) All of the sites except Karet Kuningan are immediately adjacent to rivers or canals, which abound in Jakarta. Makeshift structures, built with bamboo, zinc, and plastic, are absent only at Kebon Kacang, and are especially common at Kampung Bali, Karet Kuningan, Cipinang Besar, Kapuk Muara, and Glodok. Glodok and especially Mangga Dua Selatan, in the old city, have many structures built with permanent materials, more elderly populations, and many Betawi (Jakarta natives). As in Manggarai, which is located across from a train station, next to a vegetable market, and is somewhat similar in appearance, there seem to be fewer squatters. Characteristics of the sites for several other variables are summarized in Table 2. The two northern periphery sites, Kapuk Muara and Pademangan Timur, are very poorly drained. Many structures at the latter site are built on stilts over standing water, and as in the two old city sites, residents must purchase drinking water from vendors. The Tanah Abang sites, located near a longstanding market center and transportation hub south of the main business district, are unique. In Kebon Kacang, a cluster of four story concrete apartment structures have recently been built in a government project to rehouse the local, mainly Sundanese kampung population. The survey site is one of the first buildings to be completed, one in which the flats are smaller than the project norm, but it is fully serviced. Although monthly incomes above Rp 105,000 (about U.S.S98 in 1985) were more frequently reported there, the occupation types are not dissimilar from those in other kampungs surveyed. At the Kampung Bali site, under a bridge between a canal and railroad tracks, more makeshift structures are encountered than at any other site. Services are completely lacking, there are few children and elderly, and a majority of females (61 X), due partly to the large number of prostitutes who live there. The four southern sites all are characterized by typical Jakarta red tile roofs, and the use of pumps and deepwells for water and bathing. In Grog01 Selatan some permanent structures were sampled

Table I. Locations of sites for survey Kecamatan

Penjaringan Penjaringan Sawah Besar Taman Sari Tanah Abang Tanah Abang TCbel Kebayoran Lama Mampang Prapatan Seitia Budi Jatinegara

Kelurahan Kapuk Muara Pademangan Timur Mangga Dua Selatan Glodok Kebon Kacang Kampung Bali Manggarai Grogol Selatan Tegal Parang Karet Kuningan Cipinang Besar

RW

I I 4 3

I I 4 2;4 3 3 7

RT 2 17 14, I5 3.4 IS, I6 I 9.17 7,8;7, 17 17 8 8

Responses 63 so 53 50 41 50 50 52 51 52 47

RALPH LENZ

644

PAVED ROADS . ....w.. RIVERS OR CANALS

Fig.

2. Percent

variations

Kampung

Kapuk Muara Pademangan Timur Mangga Dua Selatan Glodok Kebon Kacang Kampung Ball Manggarai Grogol Selatan Tegal Parang Karet Kuningan Cminang Besar

m five indices of develooment

Literacy

Electrified

70 91 94 77 87 69 84 90 91 78 76

0 72 85 64 100 0 76 73 82 29 9

in Jakarta

Bathing R B B D B D D D D D D

64 90 73 59 100 64 74 56 65 90 87

kamowws

Walls B W C W c 2 w W W B B

51 82 62 56 100 62 60 48 76 46 79

Roof 42 0 II 2 0 32 4 0 0 23 0

Household percentages are listed for each index. For bathing facilites, R is river or canal, D is deepwell, and B is bathroom. For walls, B is bamboo, W is wood, C 1s concrete or brick, and Z is zinc or plastic combinations. The roof index refers to the incrdence of plywood or plastic combinations.

Jakarta

kampung

morbidity

as in Glodok, some of the makeshift structures were in the process of being removed at the time of the survey. In Tegal Parang, doubling up by single males who usually work as vendors is common, and males outnumber females by a wide margin (65:35). Karet Kuningan, near a garbage dump and with no river or canal, and Cipinang Besar both have many makeshift structures. The Cipinang Besar site has pools of stagnant water filled with debris from dwellings, which make it unattractive.

variations

645

because,

a household; a household

a disease a single

ANALYSIS

Disease rates

3. Disease rates and indicators of centrality for Jakarta kompungs Kampunz Kapok Muara Pademangan Timur Mangga Due Selatan Glodok K&on Kacang Kampung Bali Manggarai Grogol Satan Tcgal Parang Karet Kuningan Cipinana Besar

Malaria

Diarrhea

Other disease

Distance to CBD

Distance to sea

55 4 0

63 12 I2 0 5 19 0 0 8 5 5

17 54 36 14 19 125 39 56 I7 62 23

4.6 3.4 1.0 0.4 0.1 1.3 3.5 5.9 5.8 3.5 6.9

2.0 I.1 2.3 2.9 7.4 7.5 9.7 12.9 13.8 11.3 12.0

! 19 17 15 4 10 5

Disease rates are cases per 1000 people. Distances are measured in kilometers: CBD distances are measured from Jalan Gajah Mada or Jalan Thamrin. the two main business thoroughfares in Jakarta.

Table 4. Probability of chi square for socioeconomic variables Variable Ethnic group of male Ethnic group of female Number of children Number in family Occupation of head of household Employment status Self-employed Owner or renter Cooking facilities in house Radio in house Television in house Other major possessions Able to save money Income (expenditures plus savings) Years of school, male Years of school, female Male literacy Female literacy Number of children in school d/ are degrees of freedom.

l

Malaria

Diarrhea

0.376 0.770 0.420 0.778 0.747 0.857 0.416 0.155 0.729 0.240 0.710 0.718 0.255 0.564 0.948 0.745 0.999 0.990 0.932

0.967 0.675 0.163 0.474 0.061 0.088 0.991 0.679 0.436 0.999 0.895 0.042. 0.637 0.613 0.761 0.310 0.536 0.223 0.353

Other disease 0.690 0.372 0.948 0.206 0.157 0.399 0.879 0.556 0.690 0.768 0.704 0.969 0.936 0.649 0.237 0.908 0.08 I 0.558 0.31 I

Indicates statistical significance at the 0.05 level.

d/ 3 3 2 3 2 I I I I I

I I I 3 5 5 I I 2

RALPH

646

LENZ

Environmental variables do seem to influence disease rates within Jakarta households. The I1 study areas exhibit large variations in the incidence of disease (Table 3). One kampung, the Kapuk Muara site, housed far more cases than other areas of both malaria and diarrhea1 disease, with 45% and 52%, respectively, of all reported cases. Interestingly the other northern site, Pademangan Timur, which is even more poorly drained than Kapuk, reported only one case of malaria. The old city sites (Glodok and Mangga Dua Selatan) were malaria-free. While the northwest area of Jakarta was known to be malarious, the concentration of diarrhea cases in Kapuk was unexpected. Glodok, Manggarai, and Grog01 Selatan reported no diarrhea1 disease. Location also seems to significantly affect the incidence of other diseases; Kampung Bali, Grog01 Selatan, Karet Kunigan, and Pademangan Timur rates were high. Are there specific environmental characteristics that might account for these wide kampung scale variations in disease rates? Relationships of 10 environmental variables to morbidity throughout Jakarta are summarized in Table 6. Hypotheses about the influence of house types upon the incidence of malaria must be rejected for Jakarta kampungs, although small structures seem somewhat more likely to house malaria cases. Only one variable is significantly related to malaria. Households that bathe in rivers or canals exhibit very high malaria rates, while households with bathrooms have below average rates. The connection is unclear; the relationship could be due to residence in Kapuk Muara rather than river bathing, which is most common there. Malaria was not encountered among river bathers elsewhere, and Kapuk housed nearly 64% of all Jakarta households surveyed that bathed in rivers. Within Kapuk malaria was more frequently

these mainly low-income sites. There is a tendency for other diseases to occur in households headed by illiterate males, but it is not statistically significant. Both Plasmodium falciparum and P. vivax are considered widespread in Indonesia, particularly in rural West Jawa. Because of the likelihood of delayed attacks, and with P. vivax, relapse, the possibility exists that malaria in particular has been contracted outside the kampung of residence. Recently arriving migrants or people maintaining frequent village contacts could bring the disease with them. Six indicators of population mobility have been selected to assess the degree to which nonlocal conditions are responsible for ,disease patterns in Jakarta (Table 5). A consistent influence cannot be detected. Slightly higher rates of malaria do occur among recent arrivals for the three length of residence in locale variables, but they are not statistically significant, and the relationship is very weak for the residence in kampung variable. Place of origin seems to have little effect; malaria is actually slightly more common when household members were born in major cities of Jawa (Cirebon, Semarang, Jogjakarta, Surakarta, or Surabaya) rather than in rural areas. Length of residence has no effect on the incidence of diarrhea, although there is a tendency (statistically insignificant) for the households of rural Central and East Jawa-born males to show somewhat higher rates. Diarrhea does not seem to LX common in households which have remained in the same kampung during their tenure in Jakarta (a result significant at the 0.01 level), but these households differ in length of tenure in Jakarta as well as kampung and building of residence. The evidence drawn from mobility data seems to indicate that diarrhea and malaria in Jakarta have a predominantly urban origin.

Table 5. Probability of chi square for mobility variables Variable Birthplace of male Birthplace of female Years of residence in Years of residence in Years of residence in Number of kampungs df are

Malaria

Diarrhea

Other disease

0.126 0.109 0.096 0.333 0.145 0.306

0.103 0.498 0.999 0.910 0.962 0.009’

0.734 0.917 0.231 0.312 0.143 0.421

Jakarta kampung house of residence

degrees of freedom.

l

4 4 I

I 1 2

Indicates statistical significance at the 0.01 level.

Table 6. Probabililty of chi square for environmental variables Variable Study area Electricity available Toilet in house Bathroom m house Running water available Where household bathes Source of drinking water House area in square meters Space per person in house Wall materials Roof materials

Malaria o.ooOt 0.163t 0.517 0.107 0.942 o.oOOt 0.233 0.064 0.541 0.299 0. I78

degrees of freedom. *Statistical significance at the 0.05 level. tstatistical significance at the 0.01 level. df are

Diarrhea o.Ooot 0.027’ 0.999 0.337 0.999 o.Ooot 0.012’ 0.592 0.294 0.024. 0.OOOt

Other disease 0.037. 0.499 0.668 0.725 0.367 0.836 0.138 0.098 0.031’ 0.179 0.007t

d/

df 10

I I I I 2 3 I 2 3 3

Jakarta kampung morbidity variations

in households that bathed in the river (30.6%) than in those using other facilities (9.5%) but the difference is not statistically significant. Expected relationships between the various diarrhea] diseases and environmental variables are supported by the data. Contaminated water is an obvious mode of transmission for microorganisms that cause diarrhea1 diseases, and sources of bathing and drinking water do seem to affect the incidence of these diseases in Jakarta. Households that purchase drinking water from vendors exhibit higher diarrhea1 disease rates than those that rely on taps, pumps, or deepwells. The relationship is particularly strong in peripheral kampungs, where pump users have the lowest rates. Diarrhea1 diseases are heavily concentrated in the northern kampungs, where vendors are the primary suppliers; the four southern peripheral kampungs are outside the vendors’ territory. The vendors may not be agents of transmission, but their service areas may coincide with areas of polluted water. It is notable that the presence or absence of running water or toilets within the household has no effect upon the incidence of diarrhea1 diseases in Jakarta kampungs. A strong association with bathing patterns is evident; households using rivers or canals also have unusually high rates of diarrhea1 diseases. Most river bathers with diarrhea (91%) also resided in Kapuk Muara, but here there is an obvious mechanism for transmission of diarrhea1 diseases. Kampung Bali, the other area where river bathing is common, has relatively few children, and Shigella and other bacteria often infect children. Within Kapuk, diarrhea is not confined to households that bathe in rivers. But diarrhea1 diseases can be spread by insect vectors and other mechanisms, and many children in Kapuk were seen swimming in filthy canals. Suspicions of a cause-effect relationship seem to be justified. Several other variables indicating residence in makeshift structures not provided with basic urban services tend to be related to the incidence of diarrhea1 disease. Households lacking electricity and those living in houses built with bamboo walls seem to suffer higher diarrhea rates. An even stronger association exists for roof types; houses with combinations of plywood and plastic roofing materials were particularly likely to produce diarrhea reports, whereas the more common red tile or metal roofed houses contained healthier occupants. Again both bamboo walls and combination roofing are common in Kapuk Muara; within Kapuk diarrhea was 1.7 and 2.5 times more prevalent in structures built with these wall and roof materials, respectively, but makeshift structure data seem as closely associated with Kapuk as with the crtywide incidence of diarrhea. Reports of other diseases, which include a variety of ailments, were also associated with environmental variables. The association with living space per person is intuitive; perhaps with more data (there were only 106 observations on the two density varibles) a similar association of crowding with diarrhea would have been found. Residents of makeshift structures also exhibited higher rates of other diseases. Wall materials (houses with zinc or plastic combinations had higher rates) were less useful indicators of morbidity than roof materials; households using plastic encountered

647

or plywood roofing materials were significantly healthy.

less

CONCLUSIONS

Socioeconomic status seems to have little influence upon the incidence of malaria, diarrhea1 diseases, or other diseases among the residents of Jakarta’s low income neighborhoods. Local environmental conditions, on the other hand, seem strongly associated with disease rates. Wide variations in disease reports exist for the 11 study sites, and several environmental variables were strongly associated with the incidence of diseases at the household level. As expected, associations of diarrhea1 diseases with environmental variables were strongest. Lack of adequate bathing facilities and sources of drinking water seemed most closely related to diarrhea reports; variables distinguishing makeshift structures were also significant indicators. Malaria, which could be contracted outside the present neighborhood of residence, was closely related to location within Jakarta; Kapuk Muara housed a significant cluster of cases. The strong association with bathing facilities may suggest the synergistic effects of Pfasmodia and organisms responsible for dysentery, muntaber, or other diarrhea1 diseases upon their victims. The data also suggest that residents of makeshift structures, especially when living space per person is minimal, are more frequently infected by flu, stomach problems (maag), and other ailments in the general disease category. In one sense, the results of this study are encouraging. Whereas urban governments would be hardpressed to rapidly improve the socioeconomic status of their many millions of recent in-migrants, improvements in some environmental characteristics are feasible. The environmental associations with disease established here seem to indicate that widespread demolition of squatter areas accompanied by construction of modern, concrete, high-rise apartment buildings with running water and indoor toilets is not a prerequisite to improved urban health. Health patterns in most kampungs are comparable to those in the fully serviced concrete flats of Kebon Kacang; the availability of running water or toilets within households had no impact at all on morbidity in the 11 Jakarta kampungs. The construction of concrete flats for low-income residents is contra-indicated unless the potential exists to rehouse the entire low-income population of a city. Such is not the case in Jakarta or most other Third World cities. Minor improvements in temporary settlements could have a much more significant effect on morbidity rates. Yet recently built squatter settlements, where conditions are often most squalid, receive no benefits from Jakarta’s kampung upgrading programs [14]. While settlements along railways or under high-tension lines present safety hazards, and the city does need planned open spaces in some places, at most of the canal sites health hazards are the main difficulty. Better bathing facilities and drinking water sources should be extended as soon as possible to all kampungs where morbidity rates are high, unless strong evidence of safety hazards or immediate

planning

needs are indicated.

648

RALPH

Both drinking water and bathing improvements require increasing clean water flow to problem areas, but they do not necessitate the provision of running water to every dwelling unit. The installation of at least one and perhaps several standpipes (hydrants used in common by a group of families) to every RT (small neighborhood political unit) would apparently produce the desired health benefits, and at a much lower capital cost than house connections (see [30]). Standpipes, located close to every household, might be combined with small community bathing facilities where appropriate. Such improvements would also require increases in the city’s water supply capacity. The elimination of makeshift structures is not readily accomplished through policy directives; demolition results in relocation, probably to sites without standpipes, possibly isolated from economic opportunities. Perhaps improved health benefits along with the economic advantages anticipated by Rosser [13] in squatter settlements will lead to the improvement of makeshift structures through private initiative. These conclusions conflict with the findings of several studies in which flush toilets and piped water within the household were related to lower mortality [25-271. But the considerable socioeconomic variations among households in these studies were found to be more closely associated with mortality than environmental factors. A ‘threshold-saturation’ theory [31], in which socioeconomic level determines the effect of sanitation improvements upon health status, explains some of the contradictions among various studies, and suggests that sanitation strategies must be tailored to the needs of each locale. The 11 Jakarta kampungs surveyed here are of similar socioeconomic status, but they are unlike villages in Bangladesh or neighborhoods in Singapore, Rio de Janeiro, or even other parts of Jakarta. Interpretation of data in this study, which was preliminary in nature, has been hampered by the relatively small number of observations. Similar surveys of much larger areas could easily be implemented in Jakarta and other cities; not only could relationships of environmental variables to disease rates be more firmly pinned down, but also those areas most in need of neighborhood improvements throughout

the city

would

LENZ 5. Halstead

6.

7.

8.

9.

10. 11.

12.

13. 14. 15.

16.

17.

18.

19. 20.

be identifiable.

Acknowledgemenrs-Special gratitude is extended to Mimien Rachmat and Amrul Munif, Jaumat Dulhajah, Sutarno, and Dean Salim Usman of Universitas Nasional, who helped plan and supervise the survey. Opinions expressed in this paper are, of course. solely the responsibility of the author.

21.

22.

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