Diet & disease programme : coping with changes in food ... · 1 Diet & Disease Programme: Coping with changes in food supply among the Punan Tubu of Eastern Kalimantan by Edmond Dounias

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Diet Diet & & Disease Disease Programme:Programme:

Coping with Coping with changes inchanges in food foodsupply among the supply among the PunanPunan

Tubu Tubu ofof Eastern Eastern KalimantanKalimantanbyby

Edmond DouniasEdmond Dounias

(IRD-CIFOR)(IRD-CIFOR)

Travelling Workshop"Reconciling conservation and development in the forests of

East Kalimantan: prospects, problems and progress"Malinau, 19-21 April 2005

This presentation is entitled Diet and disease Diet and disease programme.programme. Coping with Coping with changes inchanges in food foodsupply among the supply among the PunanPunan Tubu Tubu ofof Eastern Eastern KalimantanKalimantan

The The data Idata I am going am going to to present present are part of aare part of a research research programmeprogramme conducted conducted by IRDby IRD(French(French Research Institute Research Institute forfor Development Development) in) in partnership with partnership with CIFOR (CIFOR (Center Center forforInternationalInternational Forestry Research Forestry Research) ) and the Health and the Health services of services of Malinau Malinau district.district.

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Anthropology of foodAnthropology of food

Comparative study of diet and health statusComparative study of diet and health statusbetween suburban and remote between suburban and remote Punan Punan of theof the

Tubu Tubu watershedwatershed

By using an anthropology of food approach that I'm going to describe later on, ourresearch team conducted a comparative study of the diet and health status ofcontrasted Punan communities.

During the early seventies, several Punan villagers of the Tubu watershed were invitedto settle down at Respen Sembuak near Malinau city. They have become suburbanfarmers and now benefit from all city facilities. They barely depend on forest resourcesfor their livelihood.

The rest of the Punan Tubu decided to stay in the forest. Nevertheless they acceptedto settle down in permanent villages. They practice upland rice shifting cultivation, andathough they are no longer nomadic, they keep on migrating into the forest on aseasonal basis. Therefore, their livelihood still highly depends on forest resources.

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Expected Expected outputsoutputs

•• Contribution of Contribution of NTFPs NTFPs to food and healthto food and healthintegrity of the integrity of the PunanPunan

•• To what extent differences in access and useTo what extent differences in access and useof of NTFPs NTFPs can explain the gap in healthcan explain the gap in healthconditions between remote and conditions between remote and periperi-urban-urbansettlementssettlements

•• Health consequences of development andHealth consequences of development andsocial changesocial change

Diet and health situations of the same ethnic groupDiet and health situations of the same ethnic group

compared in two contrasted social and ecological environmentscompared in two contrasted social and ecological environments

This comparison of the diet and health situations of the same ethnic group in twoThis comparison of the diet and health situations of the same ethnic group in twocontrasted social and ecological environments, provides ideal conditions to assesscontrasted social and ecological environments, provides ideal conditions to assesspeople/forest interactions in a changing environment.people/forest interactions in a changing environment.

With such comparison, we wish:With such comparison, we wish:

- to assess the contribution of - to assess the contribution of NTFPs NTFPs to food and health integrity of the to food and health integrity of the PunanPunan..

- to determine to what extent differences in access and use of - to determine to what extent differences in access and use of NTFPs NTFPs may explain themay explain thegap in health conditions between remote and gap in health conditions between remote and periperi-urban settlements.-urban settlements.

- to estimate the health consequences of development and social change- to estimate the health consequences of development and social change

(contrary to common assumption, social change may not necessarily have(contrary to common assumption, social change may not necessarily havepositive effects on peoplepositive effects on people’’s well-being. Social change may even sometimess well-being. Social change may even sometimescompromise defense mechanisms or present new challenges for which therecompromise defense mechanisms or present new challenges for which thereare no defenses, thus causing new disease and malnutrition).are no defenses, thus causing new disease and malnutrition).

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RESOURCE BIOLOGY & ECOLOGYRESOURCE BIOLOGY & ECOLOGY

ANTHROPOLOGYANTHROPOLOGY

HUMAN BIOLOGY & ECOLOGYHUMAN BIOLOGY & ECOLOGY

PHYSIOLOGYPHYSIOLOGY

ECONOMYECONOMY

HEALTHHEALTH

RESOURCE TEMPORAL AVAILABILITYRESOURCE TEMPORAL AVAILABILITY

TRANSACTION ON FOOD RESOURCESTRANSACTION ON FOOD RESOURCES

NUTRITIONNUTRITION

FOOD BEHAVIORFOOD BEHAVIORFood become meals, social attitudes, and symbolFood habits, food sharing, ritual foodFood avoidance and taboos, ostentatory food…Who eats what, where, when, how, and with whom

RESOURCE HARVESTINGRESOURCE HARVESTINGLand use system, production systemFrom techniques to rules of access

Seasonality of resources & activities

RESOURCE SPATIAL AVAILABILITYRESOURCE SPATIAL AVAILABILITYForest mosaic, agroecosystem, landscapeMobility, territory

Trade, market, bargain

FOOD TECHNOLOGYFOOD TECHNOLOGYTransformation of resource into food

Energetic balanceConsumption vs costsSocio-economic implications

Nutritive & energetic value of food

Food & medecineFood as medecineFood consumption by high riskindividuals

FOODFOOD

TOTAL SOCIAL FACTTOTAL SOCIAL FACT

Food is a central issue to study the interactions between man and their environment.

When you study food you need to get information on:

-Temporal availability of resources

-Spatial availability of resources

-Modalities of resource harvesting

-Transaction on food resources

-Food technology

-Food behavior

-Nutrition

-Physiology

-Health

Study of food requires integration of data on the biology and the ecology of both thepeoples and the resources, but also data on economy and anthropology.

It is what social anthropologists qualify as a "TOTAL SOCIAL FACT"

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RESOURCE TEMPORAL AVAILABILITYRESOURCE TEMPORAL AVAILABILITYSeasonality Seasonality ofof resources resources && activities activities


HEALTHHEALTH


NUTRITIONNUTRITION









FOODFOOD

Seasonality Seasonality ofof resources resources && activities activitiesRESOURCE TEMPORAL AVAILABILITYRESOURCE TEMPORAL AVAILABILITY

We are going to illustrate the links between these different aspects related to food bypresenting a few examples of our research results.

Let's consider first the temporal availability of resources by with the emblematic case ofwild boar hunting

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RESOURCE TEMPORAL AVAILABILITYRESOURCE TEMPORAL AVAILABILITYSeasonality Seasonality ofof resources resources && activities activities

Seasonality of wild boar capturesSeasonality of wild boar captures(Long (Long PadaPada, remote upper , remote upper TubuTubu, 11 hunters, 68 dogs), 11 hunters, 68 dogs)

December 2001 May-June 2002

Hunting expeditions per day 1.4 0.9Unsuccessful hunting expeditions 22% 68%Contribution of wild boars to total preys 83% 47%Most frequently captured Gravid/brood females (53%) Males (63%)

Average rate of wild boars captured daily in Long Pada

Wild boar is a very seasonal prey as this mammal migrates following patterns that arenot well understood sofar and that highly depend on the erratic mast fruiting ofDipterocarp trees.

-First figure shows that the number of catches varies significantly from one month toanother.

- Second figure shows that the type of wild boars captured varies also according toseasons (mainly gravid or brood females in December, mainly adult males 5 monthslater).

-So contribution of wild boar meat to the diet fluctuates both in quantity and quality.

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00,20,40,60,8

11,21,41,61,8

A M Jn Jt A S O N D J F M A M Jn

1984-1985

Wild

boa

r fa

t ra

te

Abundance of Dipterocarp

fruits

from data in Caldecott 1988

Seasonal fluctuation of meat qualitySeasonal fluctuation of meat quality

The nutritional value of meat also changes according to seasons:

This figure shows the variation of fat rate contained in wild boar meat.

For instance, the organoleptic characteristics of the meat are affected when thefemales are gravid, or during the season of reproduction (high concentrations of uricacid during mating periods, that compromise the palatability of male prey meat).

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HEALTHHEALTH



NUTRITIONNUTRITION










FOODFOOD

RESOURCE SPATIAL AVAILABILITYRESOURCE SPATIAL AVAILABILITYForestForest mosaic mosaic,, agroecosystem agroecosystem,, landscape landscapeMobilityMobility,, territory territory

Let's now consider the spatial availability of resources

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RESOURCE SPATIAL AVAILABILITYRESOURCE SPATIAL AVAILABILITYForestForest mosaic mosaic,, agroecosystem agroecosystem,, landscape landscapeMobilityMobility,, territory territory

•45 distinct locationsfor upland rice fieldsover 14 years

•Covering a 1,370 haperimeter

•Land characterized bymore than 200toponyms mainly basedon 65rivers/watercourses

Agroecosystem dynamics in Long Pada from 1989 to 2002

1 km

Long Pada

Pada Pada riverriver

Tubu Tubu riverriverTubu Tubu riverriver

0

200

400

600

800

1,000

1,200

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Year

ha

GaëlleLoutrel

In 2002, Gaëlle Loutrel and myself undertook a study of the agrosystem dynamic ofLong Pada since the date of creation of this village (1989).

We mapped the locations of the upland rice swiddens over 14 years (1989 to 2002)and we could estimate the surface of land used by the villagers of Long Pada topractice extensive but sustainable shifting cultivation.

Although the demography of the village remains stable, the extend of the agriculturallandscape varied between years from nearly 50 hectares to more than one thousandhectare

Gaëlle Loutrel is going to present her work more into detail during the seminar inRespen.

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HEALTHHEALTH



NUTRITIONNUTRITION










FOODFOOD

RESOURCE HARVESTINGRESOURCE HARVESTINGLand use system, production systemLand use system, production systemFrom From techniques totechniques to rules rules of accessof access

Now considering the modalities of resource harvesting…

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Time allocated to main activities among adults in Long Time allocated to main activities among adults in Long PadaPada

(n= 583 days)(n= 583 days) RESOURCE HARVESTINGRESOURCE HARVESTINGLand use system, production systemLand use system, production systemFrom From techniques totechniques to rules rules of accessof access

Over a period of 583 days, we monitored the time allocated to main activities by theadult villagers of Long Pada.

In these 2 graphs we compare the gender division of activities. These graphs revealthat time allocated to a particular activity changes according to season, and changeoccurs differently according to gender.

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HEALTHHEALTH



NUTRITIONNUTRITION










FOODFOOD

FOOD TECHNOLOGYFOOD TECHNOLOGYTransformation ofTransformation of resource into food resource into food

Food technology is another important component to assess, as it directly affects thenutritional value of food. For instance, directly cooked cassava tubers will not have thesame nutritional value with cassava tubers transformed into flour before cooking.

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Extraction of sagostarch

Calories Water(g)

Protein(g)

Lipid(g)

Carbohydrates

(g)

CelluloseFiber

(g)

Ashes(g)

Calsium(mg)

Phosphor(mg)

Iron(mg)

Sodium(mg)

Potassium(mg)

Mg(mg)

Mn(mg)

Zinc(mg)

Cu(ug)

Se(ug)

Vit A Vit B1(mg)

Vit B2(mg)

Vit B3(mg)

Vit B9(ug)

Vit B12(ug)

VitC(mg)

357 13.1 1.4 0.2 85.9 0.2 0.4 15 10 1.4 8 36 18 0.2 100 4 0 0.005 0 0 0 0 0

To illustrate this, these figures sum up the main steps of sago processing.

Sago starch used to be the staple food for the Punan Tubu before they gotsedentarized.

Extraction of sago starch is a long and complicated process which affects the nutrientcontent of the resource.

After cooking, the energetic value and caloric return of sago starch is very high.

Unfortunately repeated filterings of starch wash out the few vitamins contained in thestarch.

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HEALTHHEALTH



NUTRITIONNUTRITION










FOODFOOD


TRANSACTION ON FOOD RESOURCESTRANSACTION ON FOOD RESOURCESTradeTrade,, market market,, bargain bargain

Transactions concerning food resources are key factors to consider.

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TRANSACTION ON FOOD RESOURCESTRANSACTION ON FOOD RESOURCESTradeTrade,, market market,, bargain bargain

Socio-economic studiesPatriceLevang

SoaduonSitorus

These aspects were studied by Patrice Levang and Soaduon Sitorus were alreadydescribed in the previous presentation.

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NUTRITIONNUTRITIONNutritive &Nutritive & energetic energetic value ofvalue of food food


HEALTHHEALTH












FOODFOOD

Let us now introduce the nutritional aspects of food

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Food Consumption SurveyFood Consumption Survey


AudreySelzner

To assess the nutritional value of food among the Punan Tubu, Audrey Selzner andmyself undertook a food consumption survey.

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Seasonal protocol:• May-June 2003• September 2003• December 2003• March 2004• July 2004

•• Weight of ingredients beforeWeight of ingredients beforecookingcooking•• Weight of meals after cooking Weight of meals after cooking•• Weight of food distribution Weight of food distribution•• Weight of leftovers Weight of leftovers

1,200 weighed dishes1,200 weighed dishes

Comparatively in 3villages43 households

1- Quantivative FoodConsumption Survey

MiddleTubu

RemoteTubu

Sub-urban

A quantitative food consumption survey was carried out in 3 villages comparatively: 1sub-urban settlement near Malinau city, 1 settlement in middle Tubu, and 1 among themost remote settlements of the Tubu watershed.

Food consumption was considered on a quarterly basis, every 3 months from May2003 to July 2004 in order to assess the impact of seasons on food strategies. Sofar 4out of the 5 follow-ups were analysed.

We surveyed 43 households distributed over 27 houses.

Protocol consisted of weighing systematically during 4 consecutive days:

- ingredients before cooking;

- meals after cooking

- food distribution between consumers;

-leftovers.

-Nearly 1,200 meals were analyzed quantitatively over the 15-month period of study.

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400 meals monitored monthly from400 meals monitored monthly fromMay 2003 to December 2005 (nearlyMay 2003 to December 2005 (nearly9,000 meals), in 3 villages9,000 meals), in 3 villages

Calibration from the quantitative foodCalibration from the quantitative foodconsumption surveyconsumption survey

9,000 Calibrated meals

Comparatively in 3 locations2- Longitudinal Food Survey

LONG PADA

LONG RANAU

RESPEN SEMBUAK

Comparatively in 3villages54 households

As a complement of the quantitative and seasonal food consumption survey, we alsocarried out a longitudinal food survey. On a decade basis, the meals of all thehouseholds of 3 villages were systematically noted but without weighing as well as thelist and origins and ingredients, and the identity of the consumers. Nearly 400 mealswere monitored monthly.

Nearly 9, 000 monitored meals will be calibrated by using weight measurements duringthe quantitative food survey will give us a much accurate view of diet fluctuationthroughout the year.

The analyses of the huge amount of data collected during the food consumtion surveyare still in progress. What I'm going to present is just a few illustrations of the trends weobtained.

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Proportions of main ingredient categoriesComparison between locations, and according to seasons

Let's first have a look at the major categories of ingredients used in Punan meals.These 3 graphs recapitulate the proportion of use of the main categories of ingredients(Meat, fish, vegetables and starchy staple food) in each location (suburban, middleTubu, remote Tubu) and according to season (June'03, Sept '03, Dec '03 and March'04).

These graphs show:

1- significant differences between locations during the same season: for instance, if weconsider March '04, meat was rare in the diet of suburban Punans whereas it wasabundant in remote Tubu. By contrast, vegetable consumption was much higher nearcities, and less frequent in remote village.

2- significant differences as well between middle Tubu and remote Tubu. Thedifferences we observe can not always be explained by distinct accessibility to citiesbetween these two settlements. They also express different strategies among remotevillages, mainly based on time allocated to agricultural versus non-agricultural activities.

3- significant seasonal fluctuations of diet according to season.

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Seasonality of meat sources

Let's now have a closer look to proportions inside ingredient categories.

To do so, let's first consider the "meat" category.

As already mentioned, the Punan have a strong preference for wild boar meat. Butsince wild boar is a seasonal resource, the contribution of other sources of meat to thediet also fluctuates accordingly.

Wild boar meat is more difficult to obtain near the city (and this fat meat rapidelydeteriorates after a couple of weeks so possibilities for storage and delayed cookingare limited). On the other hand, the proximity to markets offers greater opportunities tofind other meat (from Sambar deer, monkeys, chicken), thus explaining that meatdiversity is higher in suburban village.

Again, disparities between the 2 remote villages are high and are caused by differentialpatterns of wild boar migration throughout the region.

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Distribution for carbohydrate staple foods

Let's have a look more closely to another category of food: the carbohydrate used asstaple foods. This category is composed of rice, arrow root, sago, and cassava roughtuber of flour.

After sedentarization, rice has rapidely replaced sago as the major staple food.However, the Punan are not true farmers, and remote villagers are far from being selfsufficient in rice. However, opportunities to bring rice back from the city are morefrequent in middle Tubu. During periods of rice shortage, the remote Punan haverescource to other starchy tubers. Again different food habit emerge between middleand remote Tubu villages. While middle Tubu villagers preferently eat cassava flour,those living more upriver predominantly eat cassava tubers.

Sago remains important only for the remote villager and only during seasonal migrationinto the forest for hunting and NTFP gathering. Sago has totally disappeared from thediet of suburban Punan.

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FOOD BEHAVIORFOOD BEHAVIORFood become mealsFood become meals, social attitudes,, social attitudes, and symbol and symbolFood Food habits,habits, food sharing food sharing,, ritual food ritual foodFood avoidance and taboosFood avoidance and taboos,, ostentatory food ostentatory food……Who eats whatWho eats what,, where where,, when when, how,, how, and with whom and with whom


HEALTHHEALTH



NUTRITIONNUTRITION










FOODFOOD

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Decreasing sharing of foodwith increased proximity to city

++

--

June '03 Sept '03 Dec '03 March '04

N 4042 255 374 486

Suburban 10 no data no data 17.4

Middle Tubu 20 19.2 18.7 27.8

Remote Tubu 25 40 33.1 28.9

Proportion of shared plates (%)

Food habits are also important to assess. For instance they may inform us on mother-child relations and on how mothers manage the weaning which is a critical nutritionalbreakthrough during childhood.

Collective activities and mutual aid for house building, swidden clearing, planting orharvesting, are social and festive occasions marked by food sharing. Food sharing iscommonly practiced by collectivist societies as an efficient adaptative response totemporary food scarcity. The frequency of food sharing is thus a relevant indicator orpersisting or degrading collectivist practices.

In this table we compare the frequency of shared plates between remote and suburbanplaces. Whatever the season, the proportion of shared plates is lower in suburbansettlements, thus expressing a severe regression of mutual aid near the city.

We observed the same tendency for gifts of food before cooking, like distribution ofbush meat.

“Nowadays if you want to eat you have to pay” is a popular lament in resettlementareas.

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Low frequency of snacks

Proportion of snacks Proportion of snacks exceed exceed 20% in Central 20% in Central Africa Africa ((Koppert Koppert et alet al. 1996). 1996)

June '03 Sept '03 Dec '03 March '04

Suburban 21.5 10.4 no data 0.1

Middle Tubu 1.7 2.8 1.5 0.4

Remote Tubu 0.8 1.5 1.3 1.2

Proportion of snacks (%)

++

--

Another remarkable aspect of food consumption among the Punan is the poorproportion of snacks compared to other forest dwellers.

Data also reveal significant differences between remote and suburban villages andmore frequent snacks among suburban villagers who can buy cakes and "fast food" tomobile vendors.

The types of snacks differ accordingly with location: hot drinks and fruits in remotevillages versus cakes and icecreams "fast food" and fatty and salty appetizers near thecity.

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HEALTHHEALTH



NUTRITIONNUTRITION







Energetic Energetic balancebalanceConsumption Consumption vsvs costs costsSocio-Socio-economic economic implicationsimplications



FOODFOOD

PHYSIOLOGYPHYSIOLOGYEnergetic Energetic balancebalanceConsumption Consumption vsvs costs costsSocio-Socio-economic economic implicationsimplications

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WeightWeight

SizeSize


Seasonal Seasonal fluctuations offluctuations ofbody fat body fat and nutritionaland nutritional

statusstatus

As aAs a complement complement toto food survey food survey, , we we mademade biometric measurements biometric measurements on on nearly nearly 400400people people every every 3 3 monthsmonths..

Measurements like weight and Measurements like weight and size serve for size serve for calculation calculation of of the the Body Mass Index, orBody Mass Index, orBMI BMI that is that is a a commonly used commonly used index to index to assess assess the nutritional status.

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SubscapularSubscapularskinfoldskinfold

TricipitalTricipitalskinfoldskinfold

SuprailiacSuprailiacskinfoldskinfold


statusstatus

99 anthropometric measurements anthropometric measurements

-- 8 on 8 on adults adults

-- 5 on 5 on children children

We also We also made 6made 6 different skinfold and perimeter measurements different skinfold and perimeter measurements are are necessary necessary totofollowfollow-up -up child growth and calculate the child growth and calculate the body fat body fat which is another which is another standard standard indicatorindicator..

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Male Female Male Female

May 2003 N 96 126 40 46Severe Underweight 0.0% 5.6% 7.5% 6.5%Underweight 4.2% 27.8% 22.5% 32.6%Normal 94.8% 65.1% 67.5% 54.3%Overweight 1.0% 1.6% 2.5% 4.3%Obese 0.0% 0.0% 0.0% 2.2%

September 2003 N 47 78 14 18Severe Underweight 2.1% 2.6% 0.0% 0.0%Underweight 25.5% 25.6% 35.7% 50.0%Normal 72.3% 71.8% 57.1% 44.4%Overweight 0.0% 0.0% 7.1% 5.6%Obese 0.0% 0.0% 0.0% 0.0%

December 2003 N 74 95 21 18Severe Underweight 1.4% 5.3% 9.5% 5.6%Underweight 8.1% 22.1% 23.8% 38.9%Normal 90.5% 70.5% 66.7% 44.4%Overweight 0.0% 2.1% 0.0% 11.1%Obese 0.0% 0.0% 0.0% 0.0%

March 2004 N 61 97 21 16Severe Underweight 0.0% 2.1% 14.3% 6.3%Underweight 9.8% 26.8% 19.0% 48.3%Normal 90.2% 69.1% 66.7% 25.0%Overweight 0.0% 2.1% 0.0% 18.8%Obese 0.0% 0.0% 0.0% 6.3%

Upper Tubu Respen Sembuak

•Body Mass Index Underweight: Women or more Underweight: Women or moreaffected than Menaffected than Men

No difference No differenceremote/suburbanremote/suburban

Obesity affects only suburban Obesity affects only suburbanWomenWomen


statusstatus

Body Mass Index values of adult respondents were organised according to 5categories: Severe underweight, underweight, normal, overweight, obesity.

This table shows that a fraction of the women population is exposed to chronicunderweight, whatever the location. Most of these women are relatively old aged"veuves" who highly depend on gifts from other villagers for their subsistance (theygenerally only cultivate small cassava garden and receive meat from other). Theseheads of household have a high sense for self sacrifice and as far as food sharing isconcerned, they give priority to the younger members of the family.

Such behavior seems deeply anchored into tradition, thus explaining that we observeno difference between remote and suburban locations.

On the opposite side, result also show that overweight and obesity remains rare amongthe Punan and affect only suburban women sofar. Emerging obesity in Respen in thiscategory of may be due to new social expressions of prosperity among "rich" familieswho are influenced by the wealthy chinese shop owners and traders.

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Seasonal fluctuations of adult BMI

In this graph we compare the evolution of Body Mass Index for Punan adult men andwomen from May 2003 to March 2004, between peri urban population (bold) andremote populations (thin).

Firstly, results show that the BMI of all Punan adult is good whatever the location asthey stand above the standard limit of 18.5 under which nutritionists consider that thereis chronic energetic defficiency.

However situation is different between men and women: Women fitness is on averagethe same in both locations (19.8). The fitness of women in remote areas appears morestable.

As for men, fitness is significantly better in remote villages (20.6 versus 19.9) but ismore exposed to seasonal fluctuation.

Sofar we still need to analyse these results in the light of contrasted activities betweenthe two locations, but also in the light of different exposure to diseases.

In July 2004 contagious trouble affected the city dwellers and not the remote villagers.As a consequence to this temporary sickness, the BMI dropped significantly.

I should mention that by the time the Punan were still nomadic hunter-gatherers, theywere poorly exposed to contagious diseases and during epidemics they practiced andefficient silent barter that prevented them from any direct physical contact withpotentially contaminated traders.

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•Body fat


statusstatus

I'm not going to describe into details the results concerning body fat.

Just keep in mind from these graphs that:

1- comparison between suburban and remote locations should nuanced according togender and according to age. Body fat is better in remote villages for men aged under30 year old, but advantage is for surburban settlement for elder men. This is thereverse for women.

2- against all odds, body fat fluctuates more significantly among suburban villagers,whereas it appears more stable for the remote villagers.

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HEALTHHEALTH



NUTRITIONNUTRITION










FOODFOOD

HEALTHHEALTH


Food Food && medecine medecineFood Food asas medecine medecineFood consumption Food consumption byby high risk high riskindividualsindividuals

HEALTHHEALTHFood Food && medecine medecineFood Food asas medecine medecineFood consumption Food consumption byby high risk high riskindividualsindividuals

Let's now consider the health issue in relation to the diet

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Clinical examination

Medical treatment BiomedicalBiomedical

SurveySurvey

HEALTHHEALTHFood Food && medecine medecineFood Food asas medecine medecineFood consumption Food consumption byby high risk high riskindividualsindividuals

•• Blood Blood

•• Urine Urine

•• Stools Stools

Biological sampling and analysing

As far as health is concerned, we undertook a biomedical survey in close partnershipwith the Health Services of Malinau disctrict.

This biomedical survey consists of 3 components:

-Detailed clinical examinations of the villagers by Dr Agung from Puskesmas PulauSapi.

-The Indonesian doctors who accompanied us upriver also provided medical care whenneeded (here Dr Boedhihartono who accompanied us for a few days in late 2002).

-Take away biological samples of blood, urine and stools for further analyses.

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Entomological monitoring

Mosquito night catchingusing a mini light (UV)trap

Malaria vectors on theTubu watershed:

Anophelesleucosphirus and A.babalacensis

Transmission ofPlasmodium falciparumand P. vivax

MOSQUITOES TICKS

Isolation of 2 newFlaviruses

Ticks captured oncarcasses of wild

boars and Sambardeers. Sent to

Mahidol University(Bangkok) for further

analyses

Anopheles leucosphirus

We also proceeded to seasonal night catching of mosquitoes by using mini light traps inorder to monitor the exposure to Malaria and to identify the vectors.

We found two species of Anopheles that are the main vectors of malaria in the Tubuwatershed. Both Plasmodium falciparum and P. vivax are transmitted in the area.

We also captured ticks (kutu) on carcasses of wild boars and Sambar deers. Tickswere sent to the University of Mahidol in Bangkok, where a research team from IRD isstudying new emerging viruses. They found 2 new flavivirus in the ticks we sent them.But further analyses are still in progress and we cannot say more at this stage.

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Parasitic load (n= 343)

pathogen non pathogen

Punan Tubu 35 9 60 5 6

West Kalimantan 60 90 76 10 34Semang 93 56 12 9 30

South-East Asian Temiar 78 23 2 3 18 Punan & Jahut 52 29 20 8 28

Orang Asli Semai 74 12 13 10 39Jakun 64 62 65 3 31Semelai 70 72 71 6 17Temuan 79 91 59 12 37

Mbuti Pygmies 85 70 57 36African Aka Pygmies 71

Pygmies Kola Pygmies 85 51Medjan Pygmies 83 90

Yanomami 59 80 86 49 85Ticuna 83 77 76 69 55Palikur 90 19 76 31 16Campa 45 20 28 21 37Xingu 81 18 61 87

Roundworms (Ascaris )

Amoeba

Ameridians

Hookworms (Ankylostoma and Necator )

Whipworms (Trichuris )

With the help of Misa Kishi in action on this picture, we took also samples of stools tosearch for intestinal parasites.

Stool samples were analyzed in Puskesmas Malinau (picture of Dr Victor Wairisal whois the Kepala Dinas puskesmas Malinau), and double checked by a privatelaboratorium in Jakarta. If we except 6 samples taken in Respen Sembuak, all of thesamples come from upper Tubu.

Results for the Punan are mentioned in red in this table, and are compared to resultspublished for other tropical forest hunter-gatherers of South-East Asia (mainly OrangAsli of Peninsular Malaysia), Central Africa (diverse Pygmy groups), and Amazonia.

The rates of infections we obtain for the Punan are significantly low compared to thoseobtained elsewhere. Fecal pollution among the Punan villages is very limited (even ifcompared with transmigrant villages of West Kalimantan) and this might be due to asanitary use of the river, and good conditions for the feces to be recycled byaquafauna.

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Urine analysis (n=405)

Respondents 47 44 103 118 9 10 36 38

Negative 44 23 89 55 9 4 25 17Positive 3 21 14 63 0 6 11 21Negative 47 44 101 117 9 9 35 38Positive 0 0 2 1 0 1 1 0Negative 47 43 100 111 9 10 33 37

Proteins Trace 0 1 2 4 0 0 1 0Positive 0 0 1 3 0 0 2 1Acid 46 38 96 105 9 9 36 37

pH Neutral 1 6 7 13 0 1 0 1Alkaline 0 0 0 0 0 0 0 0Negative 43 38 86 87 8 6 31 26

Blood Trace 3 4 11 13 0 3 2 6Positive 1 2 6 18 1 1 3 6Negative 42 44 87 105 7 9 31 32

Ketone Trace 4 0 13 8 2 1 4 5Positive 1 0 3 5 0 0 1 1Negative 47 44 102 118 9 10 36 38Positive 0 0 1 0 0 0 0 0

Respen SembuakUpper TubuChildren ChildrenAdultes Adults

Male Female Male Female Male Female Male Female

Glucose

Nitrites

Leucocytes

Urine analyses where processed on fresh early morning urine samples. We usedmedical urine tests strips, which enable a quick and easy check of the presence ofglucose, ketones, blood, protein, nitrite, pH, urobilinogen, bilirubin, leucocytes in urineas well as specific gravity.

Results presented in this table do not reveal particular problems for most of thecomponent tested. Only problematic are the high proportions of subjects with acidurines and significant positivity to leukocyte test. Combination of acid pH and positiveleukocyte test suggests frequent kidney infection, kidney stones and more importantlychronic urinary infection, especially among women of remote villages who show thehighest scores.

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Capillary blood analysis (n=810)

Epidemic phenomenon, rarely reported inEpidemic phenomenon, rarely reported inlitteraturelitterature

- Low immunity of the - Low immunity of the PunanPunan

- Occasional exposure to areas with endemic- Occasional exposure to areas with endemicmalaria (travels to Malaysia)malaria (travels to Malaysia)

Long Long TitiTiti

Long TamiLong Tami

Long Long RanauRanau

Long Long NyauNyau

2002: 26 Children died2002: 26 Children diedof malaria in 5 monthsof malaria in 5 months

We also took away a few drops of capillary blood from finger on a seasonal basis. Weused a lancing device which is totally painless.

Slides of smears and thick drops where colored with GIEMSA and fixed in ethanolimmediately after take away. Slides were analyzed by a private laboratorium in Jakarta.Blood samples were taken in 2 groups of villages : Long Nyau and Long Ranau inupper Tubu, versus Long Titi and Long Tami along the Kalun river.

In this figure, we compare the prevalences between the 2 groups during successiveseasons. Prevalences significantly differ between the two locations both in intensity andin frequency. The rates we obtain are consistent with the average reported throughoutKalimantan. Prevalences are much less important than in transmigrant villages of WestKalimantan. Seasonal fluctuations are more intense along the Kalun. In 2002, 26children died of malaria in these villages within a five month period of time. We areprobably confronted to an epidemic scenario, which is rarely reported in the litterature.

The high probability for such an epidemic scenario requires combination of severalfactors:

-Firstly, low immunity to malaria by the group studied. The nomadic Punan were poorlyexposed to malaria until they finally settle down into permanent villages.

- Secondly, it is necessary to be exposed occasionally to areas where malaria isendemic. This happens when some families migrate to Sarawak for a few months ofeven years, and possibly bring back malaria with them.

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Conclusion 1

• Diet: Remote Punan better than suburban Punan

• BMI / Body fat: remote villagers are better off

• Biomedical analyses: no serious problems– Prevalence of malaria: not higher than in other

places of Kalimantan, but more accute amongPunan

– Parasitic load is low

– Urine analyses: acid pH and positive leukocyte testindicate kidney troubles and urinary infection.

Studies on diet and disease among the Punan Tubu show that:

Diet of remote Punan villagers is much better than those of suburban Punan. Sourcesof proteins are more diversified. The problem the remote villagers face is thatthey are not self sufficient in rice and they need to shift to cassava as majorstaple food during several months preceeding new rice harvesting. They alsoseasonally depend on sago during occasional migrations into the forest ("mufut").

Body Mass Index and Body fat data reveal that fitness is also better in remote villages.Seasonal underweight affect women similarly in both locations, and the origin ofthis malnutrition is probably cultural as it affects elder people in priority. Rarecases of obesity were observed only among suburban women.

Biomedical analyses do not reveal serious problems among the Punan populations.

Prevalence of malaria is not higher than in other places of Kalimantan, but is moreaccute among the Punan who, as former hunter-gatherers, have not developedefficient immunity again vector-borne diseases.

Parasitic load is much lower than in any other groups of forest peoples living in similarconditions throughout the world. This proves that the forest and waterenvironments of the Punan are quite healthy sofar.

Urine analyses do not reveal serious problems, except high proportions of acid pH andpositivity to leukocyte test that may suggest frequent kidney infection, kidneystones and urinary infection.

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Conclusion 2• Remote Punan more exposed to seasonal fluctuations

• No possible regulation of this uncertainty by access to market

• Risks on health: not caused by malnutrition nor to insane/dangerous life in the forest

• Risks: infectious epidemics that are irregular and unpredictable

• Punan villagers can efficiently respond to INTRA-ANNUAL fluctuations:– diversified production system– seasonal mobility

• More problematic: irregular INTER-ANNUAL fluctuations– erratic resource scarcity– unpredictable epidemics: Vaccination campaigns

• INTER-ANNUAL fluctuations: methodological challenge for research

If, on one hand, the remote Punan are globally much better off in terms of diet andfitness than the Punan living near the city, on the other hand, they are moreexposed to drastic changes of seasons.

For them, access to market to compensate seasonal lack of resources from the forest,is very limited.

Risks on health are not due to malnutrition nor to insane/dangerous life in the forest.Major risk are due to infectious epidemics COMING FROM OUTSIDE THEIRFOREST, that are irregular and unpredictable.

Our study demonstrated high fluctuations between season within the same year.People respond to this INTRA annual fluctuations by a diversified productionsystem that combines agriculture-fishing-hunting-gathering, and by a seasonalmobility (migration into the forest when resources at the village are scarce).

But the Dipterocarp forests of this part of Kalimantan are also characterized by highfluctuations from one year to another. Such irregular INTER annual fluctuationsmay drastically affect resource availability during certain years and provokeunpredictable epidemics against which remote forest people have no immunity.One good answer to erratic epidemics would be systematic vaccinationcampaigns, but this requires a continued cold chain that is difficult to implementwhen conditions of access are difficult.

Inter-annual fluctuations a nearly impossible to assess without conducting fieldwork ona very long period of time. Such studies are not only costly and time consuming,they are also socially and ethically problematic as local peoples expect short termfeedbacks from research.

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Partnership between CIFOR-IRD-MDM-Dinas Kesehatan Malinauto contribute to better well-being of remote forest peoples

Drs Régis Garrigue and Isabelle Aguillera from Médecins duMonde, visiting the Puskesmas Malinau in October 2004

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Giving back results to Punan villagers: Health individual cards

Biomedical data for each respondent were compiled on individual cards.Some information are still lacking like blood pressure, "group sanguin", andserologic analyses to come from venous blood. These cards will beupdated and copy of the database will be given to local health service inorder to provide health care to those who need it. We will encourage thePunans to take this card with them each time they need to meet with adoctor.

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Giving back results to Punan villagers: Health individual cards

On the verso side of these cards we provide basic guidelines in indonesianlanguage on how to read the data provided on the cards, and hygieneinstructions on how to prevent parasitic load.

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THANK YOU FORTHANK YOU FORYOUR ATTENTIONYOUR ATTENTION

Research team

- Patrice Levang, IRD-CIFOR, France

- Edmond Dounias, IRD-CIFOR, France

- Soaduon Sitorus, CIFOR, Indonesia

- Iwan Kurniawan, CIFOR, Indonesia

- Ronal Siregar, CIFOR, Indonesia

- Audrey Selzner, CIFOR, France

- Gaëlle Loutrel, IRD-CIFOR, France

- Nicolas Césard, IRD-CIFOR, France

- Agni Klintuni Boedhihartono, IRD-CIFOR, Indonesia

- Dr Anak Agung Gde Dwipa Byantara,Puskesmas Pulau Sapi, Indonesia

- Dr Jan Susilo, Laboratorium Klinik"Exacta, Indonesia

Documents

Diet & disease programme : coping with changes in food ... · 1 Diet & Disease Programme: Coping with changes in food supply among the Punan Tubu of Eastern Kalimantan by Edmond Dounias