SW MP-17 This paper is prepared for staff use.The views are those of the authors andnot necessarily those of the Bank.

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT

STAFF WORKING PAPER NO. 175

Iron Deficiency Anemia and the Productivity of AdultMales in Indonesia

April 1974

The health of the labor force is generally assumed to be an importantfactor in the productivity of labor. To investigate this more fully, the Bank

within the framework of its study on the use of labor and equipment in civilworks construction, is undertaking several studies to verify and quantify theimportance of this assumption.

Initial investigations of the labor force in Indonesia (see Working

Paper No. 152) revealed that a major factor likely to affect the productivity

of the labor force is the prevalence of iron deficiency anemia (1).. This preva-

lence of iron deficiency anemia is the highest ever recorded in any adult male

population during non-famine conditions. Eighty-five percent of the population

study suffered from hookworm infestation. This was largely responsible for

the finding that 45% of the adult male laborers suffered from iron deficiency

anemia.

In order to quantify the effects of anemia, a study was undertakenin which an attempt was made to correct this nutritional deficiency since it

was found that the productivity of non-anemic laborers was approximately 20%greater than the productivity of anemic laborers. Treatment was elemental iron

for a period of 60 days (at a cost of US$0.13 per laborer per day) and this

resulted in an increase in productivity of approximately 15% for tappers and

25% for weeders as compared to control groups.

These findings are highly significant. The benefit cost ratio interms of latex production alone, for example, of correcting this deficiency

could be 260:1. The high rate of anemia in the adult male population is

almost doubled in the population of females and children. The effects ofanemia on women and on the learning behavior patterns of school children is

documented in other studies.

In Indonesia it would cost approximately US$0.50 per year per person

to cure the anemia and US$0.75 per year per person to reduce hookworm infesta-

tion in a given area, including distribution costs. The evidence suggests

that an increase in the consumption of some local foods whose supply is

.plentiful, could lead to significant improvements in blood iron status.

Prepared By: S.S. Basta and A. ChurchillResearch DivisionTransportation and Urban Projects DepartmentCentral Projects Staff(Derived from Research Project No. 670-26 "Study of theSubstitution of Labor and Equipment in Civil Construction:Phase II Final Report")

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PREFACE

This working paper reports on a study by a nutrition survey team,formed under the auspices of the Nutrition Research Institutz.(Semboja Unit,Bogor), Directorate of Nutrition, Ministry of Health, Republic of Indonesia.The study was supported by the Transportation and Urban Projects Departmentof the World Bank and Bank staff members served as team advisers.

The authors would like to thank the members of the survey team fortheir work. The survey team also wishes to thank the following individuals,without whose help and cooperation the completion of the survey work and reportwould have been impossible:

1. Dr. Sulianti Saroso, Head of National Institute of MedicalResearch, Ministry of Health.

2. Dr. Sri Oemiyati, Head of Parasitology Department, Facultyof Medicine, University of Indonesia.

3. D)r. Utojo Sukaton, Head of Internal Medicine Dep'artment,Faculty of 'Medicine, University of Indonesia.

4. Dr. K.S. Gani, Dean, Faculty of Medicine, University Atma Jaya.

5. Dr. Teken, Head Social-Economic Department, University ofAgriculture, Bogor.

6. Mr. Dede Suganda Adiwinata, General and Commercial Director,Rubber Plantation XI, Ltd.

7. Mr. Hamin, Administrator, Rubber Plantation XI, Sukamaju, Sukabumbi.

S. Mr. Prawoto, Administrator, Rubber Plantation XI, Gibungur, Sukabumi.

Advisers

Nevin Schimshaw, Professor and Head, Department of Nutrition and Food Science,Massachusetts Institute of Technology.

Dradjat D. Prawiranegara, Director General of Medical Care, Indonesia.Clell G. Harral, Research Division, Transportation Department, IBRD.Leon H. Miller, Research Division, Transportation Department, IBRD.

Principal Investigators

Samir Basta, IBRD/MITbarwin Karyadi, Director, Nutrition Research Institute, Bogor.

Team Leader

Mr. Sukirman

Nutritionist Parasitology

Mr. Ignatius Tarwotjo Dr. Sri MargonoMr. Sukirman Mr. Henry IlahudeMr. Muhammad Enoch Miss Rochida Rasidi

Clinician Agronomics

Mr. Harto Husodo Nasrun Djuned, Eng. Agr.Mr. Hendra Budiman

Field Laboratory Statistics

Mr. Husaini Dr. Andi Hakim Nasoetion

Central Laboratory Administration

Mr. Saidin Mrs. NoermawanMiss Sukati Mr. Abdul MadjidMiss PudjihartiMiss Ina Supainah

Transportation

Mr. Robani

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TABLE OF CONTENTS

PREFACE i

I. INTRODUCTION 1

II. THE STUDY 1

A. Methods 1B. Characteristics of the Ponulation 2C. The Intervention Program 3D. The Productivity Measurements 4

III. CLINICAL RESULTS 4

IV. WORK OUTPUT RESULTS 6

A. Latex Output 6B. Weeding (Cultivation and Excavation) 7C. General 8

V. CONCLUSIONS OF WORK OUTPUT t1EASUREiENTS 8

VI. RECOMMENDATIONS 10

A. Nutritional Measures 10B. Public Health Programs 11

BIBLIOGRAPHY

TABLES

FIGURES

I. INTRODUCTION

1. Nutrition and health of a labor force are assumed to be importantfactors in the determination of the productivity of labor. The Bank, withinthe framework of labor substitution (see Working Paper No. 172), has under-taken several studies which attempt to illuminate and quantify the impact ofthese factors on labor productivity. This paper reports on the result of thesecond phase of the nutrition study in Indonesia.

2. The first phase of the study (Working Paper No. 152) revealed thatthe most prevalent single disease in Indonesian construction workers was irondeficiency anemia 1/. It far outranked any other disease in terms of distribu-tion and magnitude. The level of anemia in adult males in Indonesia is thehighest ever recorded under non-famine conditions for this disease. Fromavailable data, it is possible that the average male Indonesian low incomeworker suffers from anemia some four times more than his Indian counterpart.

3. Iron deficiency anemia occurs when losses of iron from the body arenot balanced by absorption of sufficient iron to compensate for both normaland abnormal losses. In the tropics the combination of bleeding from hook-worm infestation and a poor dietary intake of iron account for the most commoncause of iron deficiency anemia. It is estimated that some 600 million peoplesuffer from hookworm infestation (3).

4. Iron deficiency anemia affects physical capacity by reducing theavailability of oxygen to the tissues which in turn affects cardiac output andthe heart, eventually leading to death in severe cases. In addition, suscept-ibility to infection is also increased because iron containing enzymes whichplay a vital role in combating infections (e.g. myeloperoxidases) are alsoaffected.

5. Other probable effects of iron deficiency anemia are to increase themortalitv rate of women and to decrease thie learning ability of children (4).

II. THE STUDY

A. Methods

6. In the first phase of the study a sample of nearly 600 road andcanal construction workers were examined. A simple test was undertaken ofphysical capacity to analyze the effects of anemia on endurance. W4orkerswere asked to climb up and down a standard height (the Harvard Step Test) anda measurement was taken of the pulse as an indicator of cardiac function. Asignificant correlation was found between anemia and the results of the test.This established a relationship between anemia and physical capacity.

1/ The W4orld Health Organization considers that anemia is present whenlevels of the iron containing pigment in the blood (hemoglobin) is lessthan 13 grams per 100 ml of blood in adult males, and less than 12 gramsper 100 ml of blood in adult females (2).

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7. To relate physical capacity to labor productivity, a more complexstudy was required. The mobility of censtruction workers and the more casualnature of their employment made it difficult to establish the stable samplerequired for measuring the effects over time of increased iron intake on laborproductivity. Thus, the second phase of the study was undertaken using asample of plantation workers enjoying more stable conditions. Both the con-struction workers and the plantation workers had a similar incidence of hook-worm infestation and iron deficiency anemia. The general condition of bothsets of workers was also reasonably similar.

8. The health and nutritional status of the plantation workers dividedinto "tappers" and "weeders" 1/ was examined and prior to treatment, analysisof the results of our survey revealed that both tappers and weeders who wereanemic had average productivity outputs 20% below those recorded for non-anemicsubjects.

9. A random sample of 300 workers consisting of anemics and non-anemicswere treated with either 100 mg of elemental iron per day, or an inert tabletcontaining insignificant iron termed placebo. Neither the worker nor thoseconducting the test knew who were receiving the iron and who were receivinga placebo. The workers then performed their normal work task, in some casesunder a given set of incentives. The productivity of each worker was recorded.Within eight weeks significant increases in productivity were observed in thoseworkers treated.

B. Characteristics of the Population

10. Five hundred and seventy one road and canal construction workerswere examined in the first study and 379 plantation workers in the currentsecond study. Three hundred of the plantation workers were selected for theintervention program. The characteristics of both populations were similarin many respects:

(i) Both populations suffered from the same high prevalence ofiron deficiency anemia (42% and 45%) and hookworm infestation(85%). See Tables 1 through 4.

(ii) The severity of the anemia was related to the severity of thehookworm infestation. See Figure 1 and Tables 5 and 6.

(iii) The performance scores in the Harvard Step Test (HST) weresignificantly correlated to the degree of anemia. See Tables7 through 11.

1/ Each "tapper" is a plantation worker whose task is to collect latex from400 to 500 rubber trees per day. Each "weeder" is mainly responsiblefor clearing and digging jungle roots around the rubber trees and normallyexcavates an average of some 70 to 100 square meters of earth per day.

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:iv) No correlation was observed between caloric intake and theresults of both the HIST and the productivity studies. SeeFigures 2 through 4 and Tables 8 and 12.

(v) The clinical and nutritional status of both populations wasroughly similar. Anemia was by far the most prevalent disease.See Table 13 and 13(a).

(vi) Anemic subjects were much more likely to be suffering frominfectious diseases than were non-anemic subjects. Morbidityof clonical status was significantly correlated to blood ironlevels (i.e. hemoglobin and hematocrit levels). See Tables14, 15, and 22.

11. Some differences in the two populations were observed. The construc-

tion workers were slightly heavier and taller and had a thicker circumferencethan the plantation workers (Tables 16 and 17). These differences can becorrelated to higher intakes of calories and protein in the construction worker(Tables 18 and 19), combined with a working environment that insures that themigrant construction worker spends a larger proportion of his income on food.Furthermore, only those men who are stronger or look fitter are chosen byforemen for construction work.

12. On the other hand, the vitamin status of the plantation worker washigher than that of the construction worker. The plantation worker was ableto consume some of the multitude of edible leaves and fruits that were readilyavailable in the plantation environment. The construction workers surveyedwork on the arid plains in the northeast portion of West Java. Nevertheless,in both populations the clinical and nutritional status of the workers waswell below the desirable levels of health and nutrition (2) (5) (7).

13. The additional 4OO calories per day consumed by the average constructionworker raised his status to the accepteble Indonesian "norms" (5). These "nor-ms"however, are formulated solely from body weight maintenance requirements whichin turn are reflections of national "standards" or averages. These standardsdo not take into account the energy requirements of hard manual labor. Thuseven where the caloric intake of a worker was classified as adequate, theresults should be interpreted with caution. Energy requirements should notbe based on the perpetuation of existing body weights but should be basedmore on activity levels as well as international standards of "desirable"anthronometric (height/weight) measurements.

C. The Intervention Program

14. In the first phase of t}t . 'uuy tuvv=Lz11g construction workers, an

attempt was made to conduct an intervention program (i.e. to correct the irondeficiency) with a sample of 100 workers. Because of the high dropout ratesand the cessation of many work activities, due to heavy monsoon rains, only

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limited data were obtained. These data, however, were sufficient to indicate

that hemoglobin levels and performance in the Harvard Step Test could be

improved simultaneously by administration of 100 mg of elemental iron daily

for as little as four weeks.

15. This experience provided the basis for the intervention program

among the rubber plantation workers. A larger sample was used (300) and the

period of treatment lenghtened to 60 days. In addition, a small incomesupplement of 5% to 7% of the daily salary was given to each worker daily foreach pill taken. This insured that dropouts would be minimal.

16. The 300 workers selected were divided equally between anemic andnon-anemic subjects. Dropouts were 41 individuals and an additional 10 indi-

viduals were eliminated from the final analysis because they received other

medication which might have prejudiced the results. A "no treatment" subgroup

(no iron, no placebo, no income supplement) consisting of 51 individuals was

also tested hematologically before and after the intervention to establish

a further control group.

17. The intervention consisted of daily giving each worker a pill, some

of which contained 100 mg elemental iron and some of which were a placebo. The

observation and recording team was not aware who was or was not anemic, nor

which individual was receiving placebo or iron treatment. At the end of the

intervention period, clinical and hemotological tests as well as the Harvard

SteD Test were again repeated in all treatment groups. Hemotological tests

were also repeated again 40 days after the cessation of the intervention

program in the above groups, as well as the "no treatment" group (no placebo,

iron, or financial incentive subgroups).

D. The Productivity Measurements

18. Two standard tasks were selected (a) the collection of wet latex

by tappers and (b) the weeding or excavation of roots and weeds between the

rows of rubber trees. The output for weeders was measured in terms of the

area of the trenches dug in rows by each man, tappers were paid on the basis

of the weight of latex delivered to weighing huts and the unit productivity

used was Kg latex per man-day. In addition past records of latex payments

(income) provided a useful check on the data recorded during the intervention

program, and were also used independently as another index of productivity

since tappers are paid on a piecework basis. The age, size, and variety of

the trees was taken into account by analyzing only data from similar tree

areas.

19. Workers engaged in weeding were paid on a daily wage basis which

made productivity measurements more difficult. However, total area excavated

during the 5-hour work day was measured. To provide an incentive scheme,weeding excavation "races" were conducted. By these races financial incentives

were offered to those men (in groups of ten) who could "weed" the most area

in one hour. The winner would receive the equivalent of 100% of the dailywage with runners-up receiving decreasing portions of that sum. Each groupof ten men were selected on the basis of age, height, and eiperience. Qualitycontrol was established by foremen who inspected each area to be measured.Weeders were warned that if quality was not maintained they would be dis-qualified. Measurements were also conducted when weeders were not workingunder these financial incentives and were not aware that their output was tobe measured.

III. CLINICAL RESULTS

20. In the iron treated anemic groups, serum iron, transferrin satura-tion levels and TIBC levels changed dramatically, indicating that tissue ironstores (as distinct from hemoglobin levels) were significantly raised andreplenished by the period of iron treatment. In the placebo groups no signi-ficant changes were observed in these biochemical indices. (See Figure 7).

21. Certain therapeutic and ohysiological effects were observed in thegroups treated only with placebo. The clinical status of the anemics in thisgroup and the hemoglobin levels improved, although not as greatly as that ofthe iron treated group (Table 20 and Figure 6). Little change was observed,however, in the presence of infectious diseases per se in the placebo group,whereas a significant decline occurred in iron treated group (Table 21). Theplacebo group of anemics also improved their pre-intervention program scoresin the test of physical endurance (HST). The distribution of HST scores ofthe iron treated group was, however, significantly higher (P 0.05) than thatof the placebo group. (Table 22).

22. There are two possible explanations for the observed improvements inthe placebo group of anemics. First, there is the psychological and physiolo-gical impact of taking a pill. This possibility has been well documented (8).Second, there is the improvement in diet attributable to the small incomesupplement paid. A large part of this supplement went for the purchase offood, particularly leaves and fruit which are both rich in iron and vitaminC. 1/ These extra leaves consumed could well account for the small rise inthe hemoglobin levels of the placebo group of anemics (Tables 23 and 24).Thirty to forty days after placebo administration and the financial incentiveswere stopped, hemoglobin levels were re-measured and were found to have fallento pre-treatment levels in the placebo groups but were maintained in the irontreated anemic group. (Figures 8 and 9). There were no changes in thehemoglobin levels of the "no treatment" subgroup which received no incomesupplement nor increase in their consumption of edible leaves during thetreatment period (Figures 8 and 9).

1/ Vitamin C promotes the absorption of iron by 30% to 59% (9).

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23. The non-anemic groups treated with iron or receiving placebo showed

little change in either biochemical indices, morbidity, or HST performance.

Hemoglobin and hematocrit levels remained remarkably constafit over the whole

period. The additional iron (100 mg daily) was insufficient to raise most

hemoglobin levels above 14 grams/ml i.e. a "plateau" was reached at this

level. Iron stores in the non-anemic individuals are probably sufficient to

maintain hemoglobin levels constant over an extended period (Figures 8 and 9).

In addition, the non-anemic group suffered far less from the debilitating

effects of infections and high hookworm infestation.

24. The dietary intakes and nutritional status of the non-anemic workers

appear to be higher than in the anemic group. In the sample of construction

workers, during the first study, higher hemoglobin levels were positively

correlated with higher caloric and protein intakes (Table 8). In the case

of non-anemic plantation workers, no significant relationship was found

between caloric and protein intake and hemoglobin levels. However, significant

relationship was found between hemoglobin levels and intake of vitamin C.

25. The vitamin C intake of non-anemic subjects was almost double the

amount of that ingested by the anemic subjects. This greater vitamin C intake

is probably an important anemia prevention factor: one, because the sources

of vitamin C and iron are associated (leaves) and two, because vitamin C

appears to enhance considerably the absorption of iron (9).

IV. W4ORK OUTPUT RESULTS

A. Latex Output

26. Before treatment the work outDut (kilograms of latex collected) of

both anemic and non-anemics was measured. It was found that the output of

anemic tappers was on the average 19% below that of non-anemic tappers.

After iron treatment, the output of the anemic tappers reached the level of

the non-anemic tappers (see Table 25).

27. There was no difference in output among non-anemic workers regardless

of whether iron or placebo had been administered. That is, the non-anemic

tappers were not able to raise their output significantly with additional

iron treatment. This conforms with clinical tests which indicated that iron

levels in the blood reached a "saturation" level at around 14 to 15 grams of

hemoglobin.

28. Although both the iron anemic and placebo anemic groups raised their

productivity after treatment, only the iron treated group was able to raise

its output to the level of the non-anemics. Thus, although all groups raised

output, the placebo treated group's productivity was still approximately 15%

below that of their iron treated counterparts and the non-anemics, based upon

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the measurements taken at the end of the intervention program. In the absenceof any other restrictive variables this would imply a cost benefit/ratio interms of treatment costs (latex export earnings) of as high as 1:260, if weprojected that the yearly increase in the amount of latex obtained per hectareis 150 Kg (drv weight), that the market cost of this is an extra US$44 perhectare and that the cost of treatment per hectare (each tapper is assigned3 hectares) is US$0.17 per year.

B. Weeding (Cultivation and Excavation)

29. As described earlier (paragraph 19) two types of productivitymeasurements were carried out among the workers. The first measured theamount of earth cultivated during a normal 5-hour working day, with theweeders unaware that their output was being measured. The second involveda "race"' to see who could clear the most ground in one hour. Financialincentives were provided in the latter example and the grouns of weederswere selected in as homogeneous a sample as possible.

30. Prior to treatment the output of the anemic workers was approxi-mately 20% below that of the non-anemics (Figure 10). After treatment of theweeders no significant differences were found between the anemic iron andanemic placebo groups. Significant increases, however, in the hemoglobinlevels of many of the placebo groups were observed. This could be attributableto a higher consumption of iron rich foods made possible by the income sup-plement paid to those participating in the experiment. By separating theworkers on the basis of hemoglobin levels, a significant difference was, how-ever, found between these former anemics that experienced a rise in hemoglobinlevels (regardless of treatment) and the anemic placebo groups that experiencedno increase in hemoglobin levels. The group that was still anemic cultivatedapproximately 25% less area than the non-anemic groups, (77.39 m2 as comparedto 96.98 m2).

31. It has not been possible to calculate the benefit/cost ratioassociated with this particular task. The weeding cultivation of the treesobviously affects the latex production, but by how much under these particularcircumstances is not known.

32. In the weeding races undertaken for one hour by several groups often men each, no significant differences were found betweert anemic and non-anemic participants. Similarly, treatment in the different groups had noeffect on weeding performance; although it increased in all groups whencompared to pre-treatment levels. The (main) conclusion that can be reachedis that a one-hour race is too short a time span to detect differences,particularly when a large financial incentive is offered. It was not deemedprudent to extend the races beyond one hour, because at the end of that timenearly all performers were close to a state of collapse. Average output, forexample, in the one hour race was more than three times the first hour'soutput under normal weeding conditions.

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C. General

33. Many indirect observations supported the directly observable effectsof anemia on productivity. For example, foremen could identify anemic workerswith a high degree of accuracy, simply on the basis of their'knowledge of"lazy" or "weak" workers. They also indicated that there was a tendency toassign these weak workers to the least productive areas, thus reinforcing the

poor nutrition-income cycle. Tappers were asked if they could produce morelatex. The anemic tappers responded negatively to this question at twice therate of the non-anemic, indicating that they were "too tired".

34. The study also found a linear correlation between hemoglobin levelsand the monthly latex payments paid to tappers for outputs beyond the dailyquota. Based on a sample of 111 tappers chosen at random, the regressioncoefficient of 0.56 though suggestive of a wide variance is significant atp<0.000. Thus income for tappers clearly is related to their hemoglobinlevels. (Figure 5).

35. This finding is important because it reinforces the hypothesis that

income, health, nutrition, and productivity are deeply interrelated. In thisregard, mention must be made that the study found that non-anemic subjectswere consuming more calories, protein, iron and vitamin C than were anemicsubjects. There is no doubt that the relatively superior income, nutritionand health of the non-anemic subjects in this study are very much responsiblefor their lowered incidence of infectious diseases, and their higher product-ivity, as compared to the anemic subjects.

V. COUICLUSIONS OF WORK OUTPUT ?`EASUREMENTS

36. Differences between productivity levels of anemic and non-anemicworkers of approximately 20% were initially observed. The attempt to correctiron deficiency of anemic workers with an eight-week iron intervention programincreased their productivity relative to control groups by 15% for tappersand 2% for weeders. These increases in productivity were achieved at verylow cost -- about US$0.50 per man-vear to provide a worker with the required

iron supolement. In the case of the latex tappers, the resulting benefit/cost ratio is potentially as high as 260:1. This assumes, of course, thatadditional latex could be sold at existing prices and that there would not befurther supply constraints and that tree production would be a limitingfactor. V/

1/ The possibility remains, however, that under less favorable market condi-tions, were all plantations to attempt a similar program, the price oflatex and the resulting benefit/cost ratio could be adversely affected.Should this be the case, a project to correct this nutritional deficiencywould still show a very favorable rate of return since the costs are solow compared to the benefits, that the benefit would have to be alteredsubstantially before a benefit/cost ratio of one were reached.In some sectors, an increase in productivity would create employment. Anexample of this is road construction, where more productive labor-intensivemethods would reduce the requirements for capital-intensive methods -i.e.more men, working at full efficiency would enhance their competitive posi-tion with capital-intensive methods.

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37. The main factor determining whether an individual becomes anemicmust be the environment. The population examined was relatively homogenous,and it is doubtful that genetic inheritance could account for the differencesin hemoglobin levels. Also, the population was small and considerable inter-marriage had occurred which would tend to distribute genetic characteristicsevenly over the population. In addition to the nutritional parameters (e.g.iron and vitamin C intakes), iersonal hygiene and soil conditions undoubtedlyplay an important role. If population settlements around the home are denseand soil conditions humid and defecation there common, the more likely hook-worm infestation will occur. If children wear shoes or are restrained fromplaying near defecation areas, the chance of infestation can be lessened.

38. Once infestation or anemia occurs, the environmental, economic andnutritional factors are likely to enhance the debilitating effects of thedisease resulting in a vicious circle. An anemic individual will tend towork less, and thus earn less income if he is on a piecework or an incentivebasis. This in turn predisposes him to a poorer nutritional status (lessfood), aggravating further the anemia, and increasing susceptability toinfection. Increased absenteeism and lowered productivity Will thereforeresult, and he is trapped in a series of events in which he can neitherimprove his income, his nutrition, nor his health.

39. The benefits discussed above have been considered in strictlyeconomic terms. This no doubt understates total benefits. The resultspresented show quite clearly, for instance, that non-parasitic infections inanemic males are more than tuice those of non-anemic males, and that irontreatment abolished this difference in as little as eight weeks. Also thestudy has not calculated the effect or the cost of anemia on women and chil-dren, who traditionally show a much higher incidence for this disease thaneven the 45% figure found here for adult males. Indeed, the available literatureindicated that in Indonesian women, anemia prevalence approached the 80%level (10). Given the data from this study on the much higher rate of infec-tion in anemic individuals, it is not surprising that mortality rates aremuch higher in wTomen in the developing countries and invariably associatedwith this is a very high prevalence of anemia.

40. W4hat therefore is the benefit/cost ratio to the country concernedin reducing high mortality rates in women and reducing the risk of infections,hospital admission, loss of work days, and noor learning, in terms of curingiron deficiency in that population group. Dr. M4erril Read of the N.I.H.presents data which indicate that anemic school children are more apatheticand learn less than non-anemic school children (4). Loss of concentrationin the classroom, combined with increased absenteeism due to illness, shouldtherefore also be included in any calculations involving the benefit/costsof reducing the incidence of anemia in a particular country. It is clear thata large-scale program to reduce anemia in a population such as in Indonesiahas far more total benefits than the work output results reported herein.The study suggests that benefits could be quite substantial, and the costsalmost negligible if a treatment program is undertaken. Nevertheless, in

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many instances, as has been shown in Indonesia, iron rich foods are alreadypresent in the environment. What could a government do to increase consump-tion and production?

41. Anemia, unlike most diseases, is not dramatized by overt, clear-cutsymptoms which make it glaringly obvious to the untrained eye. Therefore,it has been relatively neglected in public health programs which invariablyhave political overtones. It's symptoms are subtle, additive, and for manypeople, lethal. It has been ignored because like most nutritional diseasesit is masked by infections and other diseases, which in most cases ariseprecisely because of a primary state of malnutrition.

42. This study is, in short, calculating the cost of maintaining adisease entity which is far more common than protein-caloric malnutrition,tuberculosis, malaria, cancer, leprosy or any other except possibly dentaldecay. Anemia is the most prevalent disease known to afflict man today.

VI. RECOMMENDATIONS

43. In view of the widespread occurrence of iron deficiency anemia inmany developing countries, and the impact of this disease on morbidity andproductivity, it is recommended that applied research programs to eradicatethis deficiency should begin as soon as possible. 1/ Investigations shouldinvolve educational, nutritional, and public health programs to reduce itsincidence. The attack on anemia can take several forms and many options areopen. They depend on the country and the population in question. In theIndonesian context, however, it is possible to briefly summarize certainapproaches:

1/ Hookworm eradication, even if feasible, would not lead to a significantreduction in anemia, since the anemia is due fundamentally to a dietarydeficiency of iron. If the hookworms were removed, body iron storescould not revert to normal levels without iron treatment. Hence, in thepresent study, the objective was to determine the benefits arising fromtreatment of anemia.

Hookworm infestation can be present in many people without causing anemia.Hookworm disease as the term is used here occurs when heavy worm burdensincrease the severity of the pre-existing nutritional anemia; or in somecases contribute to its formation.

Ideally, in tropical environments such as the one studied, both irontreatment and hookworm eradication should be carried out. However, giventhe difficulty of eradicating hookworm, the uncertainty of its role incausing anemia, and the fact that the main contributory cause of anemiain these localities is the low iron intake from inadequate diets,it is more realistic to attack the problem of anemia by nutritionalmeans.

A. Nutritional Measures

1. Confirmation of the results obtained in this study fridifferent population groups; in conjunction with:

a) Analysis of iron absorption from differentfoods in the Indonesian diet;

b) application of these results in the fieldso as to investigate the feasibility ofusing these foods to raise hemoglobin levels, and

c) the economics of producing and distributingthese foods on a large scale.

2. a) The economics and feasibility of producingiron supplements or iror enriched foods ona large scale; and

b) research in fortification of staples, and saltswith iron.

3. The cost and efficiency of using nutrition education onits own, or in conjunction with the above programs. Wlhatlimits are there, if any, to encouraging the consumptionof iron and vitamin C rich leaves, as well as some fermentedfoods? Can anemia be reduced by nutrition education alone?

4. Distribution and management problems:

a) Administration of iron tablets on a large scale. Forhow long, to whom, and what would be the actualcost; management problems in terms of distributionof, say, 100 million of these tablets on a weeklybasis, for 2 to 3 years? It is worth it? Can it bedone well?

B. Public Health Programs

1. The cost effectiveness, and management of different preparationsand methods used in hookworm eradication, as they would apply toa large-scale program.

2. Investigation of the type of public health education needed -

costs, effectiveness, etc.

3. Investigation of other public health measures needed.

4. The use and effectiveness of combining each of these public healthmeasures with any of the nutrition measures proposed above, todetermine the most effective, least-cost method to reduce anemiasignificantly in a given area.

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REFERENCES

(1) Karyadi D., Basta S.S., Nutrition and Health of Indonesian Construc-tion Workers: Endurance and Anemia - Staff Working Paper No. 152- Research Division, Transportation and Urban Projects Department -IBRD/IDA. (April, 1973).

(2) W.H.O. Technical REport, "Nutritional Anemias", Series No. 405,(1968).

(3) Stoll N.R. - Prevalence of Hookworm Disease - Journal of Parasitology33, 1, (1947).

(4) Read M.S. - Paper presented at International Symposium on Nutrition,Growth, and development - Valencia, Spain, May 1973.

(5) Manual for the Standarization and Evaluation of Data for theAssessment of the Nutritional Health of a Community Using a FieldSurvey Technique in Rural Areas - Directorate of Nutrition, Ministryof Health, Djakarta (1971).

(6) Manual for use in Nutrition Surveys - Interdepartmental Committeeon Nutrition for National Defense, Second Edition, U.S. GovernmentPrinting Office, Washington, D.C. (1970).

(7) Report of a Joint FAO/WHO Ad Hoc Expert Committee. "Energy andProtein Requirements", W.H.0. Report Series No. 522, (1973).

(8) Beecher H.K. - "The Powerful Placebo", Journal of American MedicalAssociation, 159, 1602 (1955).

(9) Callender S.T.E. - "Food Iron Utilization in Iron Deficiency",pp. 75-85. (Hallberg L. et al editors) - Academic Press-Londonand New York, (1970).

(10) VanVeen M.S. - "Some Ecological Considerations of Nutrition Problemsin Java", - Ecology of Food and Nutrition 1, 31, (1971).

(11) Basta S.S., Iron Deficiency Anemia in Adult Males and Work Capacity,Sc.D. Thesis - Department of Nutrition and Food Sciences - M.I.T.Cambridge, (1974).

(12) Indonesian Food Composition Tables - Direct. Gizi - DepartmentKesehatan-Djakarta (1967).

- 13 -

TABLES

1 Hemoglobin and Hematocrit Distribution (ConstructionSites)

2 Distribution of Hemoglobin and Hematocrit Values forTappers and Weeders (Pre-Intervention) (PlantationSites)

3 Incidence of Intestinal Helminths (Construction Sites)

4 Incidence of Intestinal Parasites (Plantation Sites)

5 Relation of Stoll Count to Hemoglobin and HematocritValues at Halim (Construction Sites)

6 Relation of Stoll Count to Hemoglobin and HematocritValues (Plantation Sites)

7 Harvard Step Test Scores of Anemic and Non-anemicRubber Plantation Workers (high cutoff point) BeforeIntervention (Plantation Sites)

8 Coefficients of Correlation for Dietary Subgroups inRentang and Saladarma (Construction Sites)

9 Correlation Matrix for General Analysis, Halim(Construction Sites)

10 Correlation Matrix (Pre-Intervention data) (PlantationSites)

11 Regression Statistics (Pre-Intervention) (Plantation Sites).

12 Correlation Matrix for Halim, including Dietary Analysis(Construction Sites)

13 NIutritional and Clinical Findings by Percent Prevalence(Construction Sites)

13a Clinical Findings by Percent Prevalence Before and AfterTreatments (Plantation Sites)

14 Prevalence of Acute and Chronic Infections in Anemicand Non-anemic Individuals (Pre-IP) (Plantation Sites)

- 14 -

TABLES

15 tMorbidity Scores of Anemic and Non-Anemic Individuals(Pre-IP) (Plantation Sites)

16 Average Ages and Anthropometric Measurements (ConstructionSites)

17 Average Ages and Anthropometric Measurements (PlantationSites)

18 Dietary Intake of Workers (Construction Sites)

19 Dietary Intake of Plantation Workers

20 Mean Morbidity Scores for Treatment Subgroups, Pre-Intervention and Post Intervention (Plantation Sites)

21 Percent Prevalence of Infections in Iron and PlaceboSubgroups Before and After Treatments (PlantationSites)

22 Mtean Harvard Step Test Scores for Treatment GroupsPre-Intervention and Post-Intervention (Plantation Sites)

23 Estimated Iron, Vitamin C, and Protein Intakes fromDietary Sources, Before and During Intervention (Planta-tion Sites)

24 Estimated Iron Balance Before and During Intervention(Plantation Sites)

25 Differences in Mean Outputs Between Anemic and Non-anemicTappers (Plantation Sites)

- 15 -

FIGURES

1 chematic Diagram of Relationship Between Hemoglobinnd Severity of IHookworm Infection (Plantation Sktes)

2 Qcatter Diagram of Area Weeded with "Race" Incentivevs. Caloric%.Intake (Plantation Sites)

3 Scatter Diagram of Incentive Wages vs. CaloricIntake for Latex Tappers (Plantation Sites)

4 Scatter Diagram of Latex Collected vs. CaloricIntake (Plantation Sites)

5 Hemoglobin vs. Latex Incentive Wages (PlantationSites)

6 ?ean Hemoglobin and Hematocrit Values Before andAfter Intervention (Plantation Sites)

7 Differences in Plasma Iron, TIBC, and TransferrinSaturation Levels for Iron and Placebo Anemic GroupsAfter Intervention (Plantation Sites)

8 HIean Hematocrit Concentration Before and After100 days Post-Intervention (Plantation Sites)

9 Mean Hemoglobin Concentration Before and After100 days Post-Intervention (Plantation Sites)

10 Daily Work Output (Weeding) for Anemic and Non-anemicSubjects (Plantation Sites)

- 16 -

Table 1: HEmOGLOBIN AND H1TATOCRIT DISTRBUTION (Constraction Site8)

Site Number Exarmined Rertang Saldardama i Fla. i-

1 31 j125 317

No. No. lio.

Hemoglobin (gA10 ml.)

>/ 15.0 11 84A 16 12.8 60 18.9

13.0 - 14.9 5S L1l.2 5h 43.2 157 LC9.6

Ul.0 - 12.91 45 3h.3 4O 32.0 76 23.9

9.0 - 10.9 / 16 12.3 8 6.14v 14 4 .h

< 8.9 l 5 3.8 7 5.6 10 3.2

Mean 12.7 13.0 13.5Standard deviati'on 2.2 1.2 1.3

Tlerat.ocri t (r )

>, hh 17 13.0 17 13.6 50 15.8

38 - 13 75 57.2 70 56.0 202 63.8

32 - 37 1/ 31 23.7 30 2h.0 5O 1-7.3

26-031 7 5.3 8 6.4 7 2.2

< 25 -/ 1 0.8 0 0.0 3 0.9

Mean 39.1 3°. 3 Lho.OStandard Deviatio 1n 5.1 4.5 4.2

1/ Below aner,mia cutoff point. He1 o,lobin of 22.9 gh/0 ml. (roulv equivalentto henatocrit ;nacked 5ellj v0o1u;,e) o' 3Y, or >3/ ) 1nd balow sigri" nemiaaccording to WH0 critoria,

2/ The nubehr examined at Halinr is higher here th-c.n the 308 cited eisewherebecause a small number of' workers ab the en'3 of the st'udy had only finger-prick samples taken to accelora-e selectiorn of' anerics.

- 17 -

Table 2: DISTRIBUTION OF HEPOGIOBIN AND HEM1ATOCRIT VALUES FOR TAPPERS ANDWEEDERS (PREINTERVENTION) (Plantation Sites)

Weeders Tappers

/fn % n do

Hemoglobin (g/100 ml)

above 14.9 7 5.0 12 4.8

13.0 - 14.9 76 51.2 122 48.8

11.0 - 12.9 53 35.8 103 41.2

9.0 - 10.9 10 6.7 12 4.8

below 9.0 2 1.3 1 0.4

Number examined 148 250

Mean 13.0 13.0

Standard deviation 1.4 1.4

Hematocrit (%)

above 43 15 10.1 28 11.1

38 - 43 88 59.14 167 66.7

32 - 37 42 28.6 52 20.7

26 - 31 1 0.6 4 1.5

below 26 2 1.3 - -

Number examined 148 251

Mean 39.5 40.2

Standard deviation 4.1 3.6

- 18 -

Table 3: INCIDDICE OF INTESTINAL HELMINTHS(Construction Sites)

Site Rentang Saladarma Halim

Sample size 102 75 168

No. % No. % No. %

Ancylostomiasis 89 87.3 63 84.o 143 85.1

(Hookworm)

Ascaris lumbricoides 77 75.5 50 66.7 98 58.3

Trichiuris trichura 65 63.7 44 58.7 98 58.3

(Whipworm)

- 19 -

Table 4W: INCIDENCE OF INTESTINAL PARASITES(Plantation Sites)

Sample size 1c2Nunber ofAffected

Individuals

ILncost' .isis / 142 87.7( Ho worm )

Ascaris lumbricoides 79 48.8(Round.wo mrn)

Trichuris trichziura 101 63.h

En'.acaba hirstcl y t,i^a 14; 8.6

Erft.=oeba coli 20 12.3

Giardia lar,bila 7 4.3

1/ Anpp1r, i ;1at(^y ,5DC-~ 6; cat-or Amuericanus

- 20 -

Table 5: RELATION OF STOLL COUNT TO HEKOGLOBIN (Hb) AND HEMATOCRIT (Ht)VALUES AT HALIM (Constraction Sites)

Intensity Grouping Ht(eggs per ml Clinical H __ __

Score of feces) no. Classification Mean + SD Mean + SD

0 100 25 Normal 13.7 + 1.06 4o.9 + 2.2

1 loo - 699 18 Very light 13.9 + 1.29 41.2 + 2.8

2 700 - 2,599 38 Light 13.6 + 1.79 41.6 + 4.7

3 2,600 - 12,599 48 Moderate 13.0 + 1.76 39.1 + 3.7

4 12j600 - 25,099 12 Heavy 11.9 + 2Z08 38.7 + 4.0Q

- 21 -

Table 6: RELATION OF STOLL COUNT TO HEMOGLOBIN (Hb) AND E>IATOCRIT (Ht) VALUES(Plantation Sites)

Intensity Grouping 1/ Clinical / Hb HtScore (eggs per mg of No. Classification

feces) Mean SD Mean SD

0 4 100 20 Normal 13.2 1.07 4o.6 2.9

1 100 - 699 20 Very light 13.6 1.05 40.8 2.3

2 700 - 2,599 50 Light 13.3 2.20 39.6 3.1

3 2,600 - 12,599 66 Moderate 12.9 1.40 38.9 3.0

12,600 - 25,099 6 Heavy 7.9 1.82 26.7 1.4

1/ No. refers to number of individuals.

2/ Classification according to Prof. Sri Oemiyati, Head, Dept, of Parasitology,University of Indonesia.

- 22 -

Table 7: HARVARD STEP TEST SCORES OF ANEMIC AND NON-ANEKIC RUBBER PLANTATIONWORKERS,(HIGH CUTOFF POINT), BEFORE INTERVENTION (Plantation Sites)

Hemoglobin fapper Weeder Total

13g% n 133 82 215

Mean 80.1 77.9 78.9

SD 15.2 14.5 14.8

below 13g% n 108 56 164

Mean 73.4 61.7 68.9

SD 17.1 20.7 19.7

Difference 6.7 16.2 2

1/ Difference significant (P <O.O1).

2/ Difference significant (P< O.OOl).

Table 8: COEFFICIENTS OF CORRELATION FOR DIETARY SUBGROUPS IN RENTANG AND SALADARMA (Construction Sites)

;iemorolobin (R) 1.0000(s) 1.0000

Hema-oocrit (R) .6959 1.0000(S) 7F23. 1.0000

HeigLt (R) .*2547 .1516 1.000(s) .1611 .2081 1.0000

Weig.It (R) .3285 .2304 .6329 1.0000(s) -.1 6o .1838 .66 i .oooo

Arm circ-amf. (R) .4853 .2691 .2691 .69'i 1.0000(s) .2637 .1935 .2275 6 1.0000

Calo:ries (R) .4319 .1531 .1684 .4195 •4927 1.0)OO(s) .U6B .0825 .2314 *1j51T .0606 1.0oo

Protein (R) .8503 .0063 .1551 .0651 .0040 .51 51 1.ooo0(s) .20148 .1521. .3601 .1132 .0512 FMiT i.oooo

Ca (R) .0898 .1951 .01143 .0415 .0196 .:2653 .7411 1.0000(s) .2138 .2040 -.3808 .2134 .1113 .o874 .25 & 1.0000

Fe (1) .0489 .0565 -.1147 .0536 .1044 .1360 .6587 .4651 1.ooo0(S) .0281 - .0302---.0784 .o8o6 .0681 > m 5 75 1.OOCO

Vit. A (R) .0683 .0142 .1765 .4852 .3922 .:398 .0387 .1345 .1433 1.0000(s) .2199 .1911 .0014 .23§ff .2632 .)983 .oo60 .2250 .1422 1.0000

Vit. B1 (R) .0957 .0323 .3161 .2754 .0565 .1370 .4549 .4354 .4132 .0211 1.0000(s) .0151 .0325 .0614 .0360 .0572 .7736 -. T6-5 7 7 .620 .1748 1.0000

Vit. C (R) .2123 .1664 .1595 .2673 .2971 .50Id .2043 .1303 .0007 . .9oo6 .0oooo(s) .1247 .0720 .0259 .1640 .2F15 .312 .0426 .1238 .0953 .o460 .5847 1.0000

Clin. Diagn (R) .1373 .1437 .0461 .2354 .1316 .2609 .1058 .1057 .0415 .1699 .1722 .0345 1.0000(s) .1730 .1360 .0905 .2502 .o538 .o,69 .0521 .0332 .0964 .0020 .0981 .0064 1.0000

Th.dtr. Diagn (R .2633 .1129 .0240 .4870 .3994 .3764 .1735 .1896 .1545 .4314 .0235 .3299 .4574 1.0000(s .1051 .o579 .2015 .3131 3§5T2 .j6Wi .0819 .2111 .0002 7.237 .0140 .1432 .6325 1.0000

PST (R) .4944 .3211 .2272 .4340 .3356 .2246 .o0o7 .0470 .0375 .0299 .1708 .1483 .0278 .0310(s) .01489 .0097 .1377 .1307 .2803 .)166 .2011 .2862 .0185 .1275 .2542 .1926, .3877 .og55

lib Ht H W Anm C1 Prot Ca Fe A B1 C Cd Nd

Significant at 10% level.

(R) Rentang(S) Sal.adarma

lfiunl.ber cases t 30

Table 9: CORREIATION MATRIX FOR GENERAL ANALYSIS, HALIM (Constraction Sites)

n = 252; p - 9

1. Height 1.000

2. Weight .610 l.ooo

3. Arm circumf. .200 .555 1.000

h. H.S.T. .001 .029 -.001 1.000

5. Hemoglobin .091 .090 .214 L31 1.000

6. Hematocrit .077 .073 .150 .320 .872 1.000

7. Clin. diagn. .038 .090 -.206 .148 .335 .317 1.000

8. Nutr. diagn. .153 .358 -.h27 .099 .200 .208 .420 1.000

9. Leg circumf. .128 .4h8 .350 .044 .025 .oL6 -.o80 -.272 1.000

1 2 3 4 5 6 7 8 9

Significant at 5% level

Table 10: CORRELATION MATRIX (PREINTERVENTION DATA) (Plantation Sites)

PRE-IP DATA FOR ANEKICS AND NON-ANBIICS, N-379

-VRIA-LE NO. 1 2 3 4 5 6 - 8 *9 0'- O0. WAA AGE HEIGT WEIGHT CLUaCAL NUTRITN HORBIDITY AN HB Hb L(MST

1 AGE 1,000? HEIGhT' .083 1,0003 v'lGHT .132 .639 1,0004 ci,liICAL .176 .083 -. 007 1,000o~5 fVfRlThV .1.42 .069 -.292 .096 1,0006 MC-PBIlrY .160 .132 -.068 .566 .201 1,0007 AFW -. 059 .014 -. 007 -. 001 .030 .105 1,0008 I-lB -.121 .010 .054 -.183 -.051 -.296 .021 1,0009 HST -. 247 -.005 .039 -.192 -.066 -.183 .084 .234 1,000

10 LGH:3T -. 266 -.028 .023 -.197 -.067 -.186 .085 .230 .983 1,000

Z-TRANSFORI1ATIONS SIGNIFICANCE MATRIX

VARIA-BLS NO. 1 2 3 4 5 6. 7 8 9 10NO. NkHE AGE IG1T WrEIGHT CLINICA, NUTRITN MORBIITY AN HB liST L.IIST

1 AGE .0002 HJlGHT .107 .0003 1EIOGHT .010 .000 .0004 CLINICAL .001 .105 .888 .0005 NUTRITN .co6 .178 .000 .063 .0006 ?'MCRBIDITY .002 .010 .184 .000 .000 .0007 AF.I .252 .790 .893 .988 .561 .040 .0008 n{B .018 .841 .297 .000 .321 .000 .690 .0009 HST .000 .916 .448 .000 .198 .000 .101 .000 .000

10 LGHST .000 °° .588 .659 .000 .192 .000 .099 .000 .000 .000.

HiJljFEiL OF OBSERVATIONS: 379.

Table 11: REGRESSION STATISTICS -- PREINTERVENTION (Plantation Sites)

_ _...__S.E.

Variables Sample Regression S.E. dep.constant/ correlation SignificancSsize equation .est indep.constant factor (r) of slope

1) Log HST, Hb, 379 IgHST = 3.58s .053 (Hb) 0-.28 0.151.011 0.23 -p < 0.001

2) Log HST, Hb. 233 LgHST_ 3.52+ 0.06 (Hb) 0.29 0.19/.014 0.24 p < 0.001 "

3) HST, Hb. 233 HST _30.64 +3.34 (Hb) 17.46 1.35/.87 0.24 p < 0.001

4) Latex payments, Hb. 111 LP =-580.304-211.80 (Nb) 382.74 398/30.50 0.55 p < 0.001

5)Latex payments (monthly) 81 LP= 1811.71+ 15.08 (L) 444.44 136.51/5.58 0.30 p < 0.001Kg latex (3 days).

Table 12: CORRELATION MATRIX FOR HALIM, INCLUDING DIETARY ANALYSIS (Construction Sites)

n = 63; p - 15

1. Height 1.000

2. Weight .587 1.000

3. Arm Circumf. .071 .409 l.ooo

4. H.S.T. .097 .033 .173 1.000

5. Hemoglobin -. 038 .023 .103 .359 1.000

6. Hematocrit -.082 - .063 -. o46 .301 .857 1.00 0

7. , Clin. Diagn. -. 025 .224 -. 344 .262 .180 .128 l.ooo

8. Nutr. Diagn. .222 .396 -. 367 .218 .016 .012 .443 1.000

9. Calories .093 .125 .140 .071 .024 .010 .106 .171 1.000

10. Protein .100 .081 .151 .051 .081 .o;6 .169 .oo6 .723 1.000

11. Ca -.010 -. 073 .109 .025 .090 .104 .310 -. o58 .245 .628 1.000

12. Fe .118 -. 022 -.032 .136 .120 .106 .009 .180 .369 .577 .539 1.000

13. Vit.A .080 -.149 -.081 .o56 .186 .1:3 .200 .246 .0o64 .069 .162 .109 l .ooo

14. Vit. B -.002 .011 .340 .186 .106 .096 .259 .283 .424 .412 .3Q5 .356 .09 l.ooo

15. Vit. C .123 .o56 -.033 .3214 .087 .082 .082 .002 .107 -. 213 -. 134 -. 125 .367 .060

H W Ac HST Hb H-t Cd Nd Cal Prot Ca Fe Vit.A Vit.B

Significant at 5% level

- 28 -

Table 13: NUTRITIONAL AND CLINICAL FINDINGS Br PERENT PREVALIENCE (Construction Sites)

Location Rentang Saladarma Halim

Number examined 129 12 305

Percent PrevalenceNYTITIO01

Nutritional. statusgood(score1) 24.8 19.3 25.9fair(score2) 31.8 L1.9 39.7poor(score3) 43.h 38.8 34.4

Souspected Vit. B complexdeficiency 2.3 3.2 2.6

SusDected Vit. C deficiency 1.6 4.0 3.9

CLMNICALHsalthy 36.4 35.5 51.5SusDected Anemic 40.3 32.?2 21.9General Dise3-.se PatternCardiovaz.cuiar near, aisease - .8 1.6Hiypertensive Heart disease 0.8 - -Hypertension 3.2 4.8 2.6

InfcctionsInfluenza 1.6 0.8 3.3Pulmcrnary tuberculosis 0.8Kihteijtis 0.8 0.3Malaria 0.3ConJunctivitis 1.6 - 0.3Perforated Otitis Media - - 0.3Cheilosis .8 -Pyoder2mia (fever) .8 -Cystitis .Ulcer o.6Wound - 0.8 0.3Firuncle 0.3,i scellaneousSusDected liver disease 0.8 1.6 -Gastriitis 4.6 14.5 5.9Hernia 0.8 -. 3Dermatitis/eczema - - 0.6Urticaria - 1.6 0.3Tinea Versicolor 13.2 2J..5 12.4Arthralgia - 0.8 0.9Fatigue 3.2 3.2 2.6Pter:7gium 0.8 0.3Invalid I- .8 0.3Ischialgia ' 0.8

1/ A general term denoting vague pains in lower back area.

- 29 -

Table 13at CLINICAL FINDINGS BY PERCENT PREVALENC3 BEFORE AND AFIER TREATMENT(Plantation Sites)

Fe Treatment Placebo

Anemic '_ Non-Anemic Anemic Non-Anemic(r.-58) (n-59) (n-56) (n'60)

1&Y Z7/ 1 2 1 2 1 2

CLINMICAL

Undenutrition 39.7 24e1 33.6 25.)4 26.8 28.6 26.7 B1.7HypertenAioin 6.7 - 4.8 - 2.4 2.4 3.3 3.3Asthma D-onc.'elale - - - _ 1.8 1.8 - -

In1luenza 15.5 5.2 - - 7.1 9.6 3.3 3.3Common co)d 3,4 - 5.1 _ 3.4 1.7 3.3 1.7Bronchitis - - - _ 1.8 1.8 - -Koch Pumonum - - _ _ 3.4 3.4 - _Tonsilitis 3.4 3.4 - - - - - -

bnterit4 s 6.6 1.8 5.1 1.7 5.1 3.4t 4.0 3.2Gingivitis 5.2 _ _ _ 1.8 1.8 - -

Stor"atit4 s 5.2 - _ _ - 1.8 - _Gloœsstis - - _ _ - 1.8 -

Gastriti3 31.0 20.7 28.8 22.0 1o.4 30.4 20.0 25.0Susrect. Liver r 4isease - - _ - - - - 1.7Conj=ctiAitis 3.!4 - _ 1.7 5.1 8.5 8.3Leucoma - -_ _ _ _ 3.4L 3.4Pterygiu - - _ _ 3.4 1.7 8.3Cataracta - - _ _ _ _ 1.7 1.7Pyocermia - _ _ _ 3.4 10.0 5.1 5.1Tirea Versi-color 39.7 37.9 33.? 30.5 28.6 25.0 33.3 33.3Dez'rrfatitis 3.4 - - - 3.4 - - 1.7Praiitis - - - _ 3.4 -

Keloid 1.7 1.7 -- - - -

Liporna - - 1.7 1.7 - _Atheroma - - -_ _ _ 1.7Ganglion - 1.?7 - _ _ _ - _Labioschizi6 1.7 1.7 _- - 34 3.4Arthritis - - _ _ 3.4 1.7 - 3.3

1/ Based on Hemoglobin below 13 g % according to WHO criteria.2/ Before intervention.

A/ fter intervention.

- 30 -

Table 14: PREVALENCE OF ACUTE AND CHRONIC INFECTIONS IN THE ANEMIC AND NON-ANEMIC INDIVIDUAL (PRE-IP) (Plantation Sites)

PERCENT PREVALENCENON-

DISEASE ANEMIC GROUP ANEMIC GROUP(n<H318-- (n=221)

Influenza 7.5% 4.8%

Bronchitis 2.5% 0.8%

Tuberculosis 1.7% none

Tonsilitis Chronica 1.7% none

Enteritis 3.3% 2.4%

- 31 -

Table 15: MORBIDITY SCORES OF ANEMIC AND NON-ANERIC INDIVIfUAIS(PRE-IP) 1/ (Plantation Sites)

Item Anemic Non Anemdc

Sample size: 181 221

Total Score: 296 226

Average morbidity score perindividual: 1.63 1.02

Sigificance: P< 0.01

1/ Preintervention.

- 32 -

Table 16: AVERAGE AGE AND ANTHROPOMETRIC MEASUREMENTS (Construction Sites)

Site Rentang Saladarma Halim

Number Examined 129 124 297

Age (years) 28.5 28.7 25.71/

(7.57)- (9.41) (8.17)

Height (cm) 160.6 160.5 159.8

(5.3) (5.4) (5.2)

Weight (kg) 51.2 50.5 49.2

(5.0) (4.9) (4.8)

Arm Circumference (cm) 25.9 26.7 26.6

(2.0) (1.6) (2.2)

1/ Standard deviation given in parentheses

Table 17: AVERAGE AGE AND ANTHROPOMETRIC MEASUREMENTS (Plantation Sites)

(number examined - 379)

StandardItem Mean Deviation

Age (years) : 29.3 7.5

Height (cm) 157.4 5.3

Weight (Kg) :46.9 4.9

Arm circumference : 24.3 1.7

- 33 -

Table 18: DIETARY INTAKE OF WORKERS (Construction Sites)

Rentang Saladanua HalimRating- n-31 n=33 nU71

2/ no. % no. % no. %

Calorie: 2500 - and over high 12 39 3 9 11 15

2200 - 2500 acceptable 9 29 6 18 18 251900 - 2200 low 8 26 8 24 28 39below 1900 deficient 2 6 16 48 14 20

Protein, gm/kg body weight:

1.5 and over high 0 0 0 0 0 0

1.0 - 1.4 acceptable 9 29 2 6 3 40.5 - 0.9 low 22 71 24 73 66 93below 0.5 deficient 0 0 7 21 2 3

Calcium, gm:o.8 and over high 0 0 O 0 0 0

0.4 - 0.7 acceptable 3 10 0 0. 1 10.3 - 0.4 low 28 90 2 6 2 3below 0.3 deficient 0 0 31 94 68 96

Iron, mg

12 and over high 12 39 1 3 21 309 - 11 acceptable 3 10 6 18 25 356 - 8 low 13 41 13 39 19 27below 6 deficient 3 10 13 39 6 8

Vitamin A, I.U.:

5000 and over high 1 3 0 0 0 0

3500 - 5000 acceptable 1 3 2 6 0 0

2000 - 3500 low 4 13 3 9 1 1below 2000 deficient 25 81 28 85 70 99

Vitamin C, mg:

50 and over high 2 6 3 9 1 1

30 - 49 acceptable 4 13 3 9 1 110 - 29 low 10 32 12 36 36 51below 10 deficient 15 48 15 45 33 46

Thiamine, mg/o1o cal.:

0.5 and over high 1 3 0 0 5 70.3 0.b9 acceptable 0 0 0 0 49 69

0.2 -0.29 low 4 13 4 12 13 18below 0.2 deficient 26 84 29 88 4 5

1/ These ratings foUow the ICNND Manual for Nutrition Survey 1963.2/ Caloric requirements are based here on body weights rather than on activity. (See discussion.)

3/ This rating does not adequately take into account the low absorption of iron from apredominantly cereal diet.

- 34 -

Table 19: DIETARY INTAKE OF PLANTATION WORKERS (SUKABUMI)

1/ Average intakeRating - per worker

NJ %

Calories: 2500-and over high 6 8.72200-2500 acceptable 13 18.81900-2200 low 28 40.6

below 1900 deficient 22 31.9 2078 Cal/day

Protein, gm/kg body weight:1 .5 and over high 0 0

1.0 - 1.4 acceptable 0 00.5 - 0.9 low 63 91.3below 0.5 deficient 6 8.7 30.5 gm/day

Calcium, gm:

0.8 and over high 0 0

0.4 - 0.7 acceptable 10 14.50.3 - 0.4 low 23 33.3below 0.3 deficient 36 52.2 294 gm/day

2/Iron, m. f

12 and over high 1 1.59 - 11 acceptable 7 10.2

6 - 8 low 16 66.7

below 6 deficient 15 21.7 7.2 mg/day

Vitamin A, I.U.:

5000 and over high 7 10.23500 - 5000 acceptable 11 15.92000 - 3500 low 15 21.7

below 2000 deficient 36 52.2 231k i.u/day

Vitamin B1 (Thiamine)mg/1000 Cal.

'o.5 and over high 0 00.3 - 0.49 acceptable 0 00.2 - 0.29 low 14 20.3below 0.2 deficient 55 79.9 0.32 mg/looo Cal.

Vitamin C, mg:

50 and over high 24 34.830 -49 acceptable 10 14.510 - 29 low 16 23.2below 10 deficient 19 27.5 80 mg/day

1/ The rating follows the ICNND Manual for Nutrition Survey 1963.2/ This rating does not adequately take into account the low availability of iron in pre-

dominantly cereal diets, nor does it relate caloric requirements to activity, but

rather to body weight.3/ B refers to number of individuals.

- 35 -

Table 20: MEAN MORBIDITY SCORES FOR TREATMENT SUBGROUPS, PRE-INTERVENTION AND

POST-INTERVENTION

Treatment n Pre-intervention Post-interventiongroup average average

x1 + S.D. xi + S.D.

Anemic, Fe 58 1,38 I 0.75 0.90 + 0.72 -

Anemic, Placebo 56 1.29 + 0.87 0.88 + 0.81

Non-anemic, Fe 59 1.36 +0.80 1.25 + 0.78

Non-anemic, Placebo 60 1.43 + 0.87 1.10 + 0.73

-I/Difference significant at (P< O.00l)

2/ Difference significant at (P< 0.02)

Table 21: PERCENT PREVALENCE OF INFECTIONS IN IRON AND PLACEBO SUBGROUPS

BEFORE ( PRE-IP ) AND AFTER ( POST-IP ), TREATMENTS(Plantation Sites)

ANEMIC NON-ANEMIC

IRON TREATMENT (58)1/ PLACEBO TREATMENT (56) IRON TREATMENT (59) PLACEBO TREATMENT (60)

PRE-IP POST-IP PRE-IP POST-IP PRE-IP POST-IP PRE-IP POST-IP

Influenza: 15.5 5.2 7.1 9.6 - _ 3.3 3.3Common Cold: 3.4 - 3.4 1.7 5.1 - 3.3 1.7Bronchitis: - - 1.8 1.8 - - -

Tuberculosis: - - 3.4 3.4 _ _

Tonsilitis: 3.4 3.4 - -

Enteritis:2/ 6.6 1.8 5.1 3.4 5.1 1.7 4.0 3.2Gastritis: Ai 31.0 20.7 10.4 30.4 28.8 22.0 20.0 25.0Susp.Liver Disease: - - - - - - - 1.7

Conjuntivitis: 3.4 - 1.7 5.1 _ _ 8.5 8.3Pyodermia (Fever): - - 3.4 10.0 _ _ 5.1 5.1

1 /Numbers in parenthesis indicates samples sizes2/ Enteritis and gastritis denote diarrhea, gas, and pain, in lower and upper half of abdomen respectively.

37 -

Table 22: MEAN HARVARD STEP TEST SCORES FOR TREAT qNT SUBGROUPS,

PRE-INTERVENTION AND POST-INTERVENTICN Y (Plantation Sites)

Treatmentgroup n _2 asa (t)

(Pre-IP) (Post-IP)

Anemic, Fe 58 69.41 82.20 12.78 2.330 5.49-

Anemic, Placebo 56 68.39 78.86 10.47 2.214 4.7

Non anemic, Fe 59 79.39 82.98 3.59 1.703 2.11

Non anemic,Placebo 60 78.10 77.48 0.62 2.145 0.29

1/ = Pre-intervention and Post-intervention.

2/ - difference significant (P 4' 0.001).

=/ difference significant (PC 0.01),

- 38 -

Table 23: ESTIMATED IRON, VITAMIN C, AND PROTEIN INTAKES FRCM DIETARTSOURCBE BEFORE AND DURING INTERVENTION (Plantation Sites)

IRON ABSORUED VITrIQN C PROTEIN

Habitual Diet s - 1.7 mg. 80 mg. 30.5 s

"Intervention" Diet s 3 to 5 mg. 50 mg. 10 g

TOTAL: 4.7 to 6.7 mg. 130 mg. 40.5 g

2/Table 24: ESTIMATED IRON BALANCE BEFORE AND DURING INTERVENTION

(Plantation Sites)

ENDOGENOUS HOOKWORMIRON LOSS BLOOD

LOSS DIET NET

Pre-intervention : -0.6 mg. -2.0 mg. -1.7 mg. -0.9 mg.

Intervention : -0.6 mg. -2.0 mg. +1.7+5 mg. +4.1 mg.-/

1/ Corresponding to an extra g. of edible leaves per average intake.(12)

2/ References for figures used in iron loss, hookworm blood loss, absorption etc.are found in Basta. (11)

3/ For the iron treated group we assume that another 25 mg of iron are beingabsorbed daily from the 100 mg of elemental iron that was given.

Table 25: DIFFERENCE IN MEAN OUTPUTS BETWEEN ANEMIC AND NON-ANEMIC TAPPERS (Plantation Sites)

1. BEFORE TREATMENT

_ .cference in Kg; % Difference BetweenNo. Latex Output/Mn DpaL Latex Output/Day Anemics & Non-Anemics

ANEMIC 42 20.94 4.83 Kg-

S.D. s 7.86 Kg. (F (0.01) 18.7%

NON-ANEMIC 35 : 25.77 Kg.

S.D. : 9.55 Kg.

2. AFTER TREATMENT

Difference in Kg.Latex % DifferenceNo. Latex Cut (XR Output/Day (Iron/PlaceDo) Iron/Placebo

ANEMiIC Iron 19 X : 29.78

S.D. : 8.47 4.32 Kg. 14.51%

Placebo 23 X 25.46 (PC 0.05)

S.D. : 10.58

NON'1-'Eu4IC (Cor.bined) 35 : 31.40

S.D. : 12.57

FIGURE 1 SCHEMA-lIC DIAGRAM OF RELATIONSHIP BETWEENHEMOGLOBIN AND SEVERITY OF HOOKWORM INFECTION

/5 (M EANS±SD)

814X

-4 -4 -- - -

72- 20 (6/o(2) (26) (23) 3

3E ( E4 G O(~~~~~~~~~~~)~~~(4

7-(6j

,<1400 /0oo 2000 %3000 4000 5000 10000 ?13000EGGS PER GRYAM OF FECES

FIGURE 2 . SCAT7TER DIAGRAM OF AREA WEEDED WITH RACEINGENTIVE VS CALORIC INTAKE (n=23)

601

LU 30La3

20- %~~~~~~~~~~~~~~

ki2O ..

10.10~ 0

1400 /600 1800 ?000 2200 2400X 2600 2800CALORIES

FIGURE 3 SCATTER DIAGRAM OF INCENTIVE WAGES 'I.S. CALORIC

INTAKE FOR LATEX TAPPERS (nhI15).4000

E 3500

L 3000

S ~~~~~~~~~~~S

2500.

LU 2~~~~~ 0

2000 0

1600 1800 2X0 2200 24C0 26X00 2800 30(

CALORIES

FIGURE 4 .'SCATTER DIAGRAM OF LATEX COLLECTEDV.S. CALORIC INTAKE (n=10).

45

1_ 35 e

-J-J030

i 25

20

/600 1800 2000 2200 2400 2600 2800 3000CA LORI ES

Fis 5-HEMOGLOBIN VS LATEX MONTHLY INCENTIVE PAYMENTS (PRE-1P)

4000

.

3500 _

3000 _

INCENTIVE WAGES 580.3 + 211.8 HB (SE = 3827)(r = 0.56) 0

z 0

2500 _

2000 _ * * j ; % ;|* * *

./ *~~~~~ t 0

1500 / 0~~~

*,i I I _I I l I I I I _ III

9.0 9.5 10.0 10.5 11.0 11.5 120 12.5 13.0 13.5 14.0 14.5 15.0 15.5

HEMOGLOBIN COUNT (9%)World Bank4268

FIGURE 6 MEAN±SE+5 E< HEMOGLOBIN AND HEMATOCRIr VALUESBEFORE AND AFTER INTERVENTION

(N-A-non-anernic A A,anertic; F:-iron FP: p(1acebo)

42 N.-A, PN-A.F~~~~~~~~~~~~~~~~~N-.F9 ~ ~ - 15 -

N-A0 F 40 1.-p

0 ~ ~ ~ ~ ~ ~~~~~~~~~~4

7: 2 / | * e ° M X , X Q~4 A. F.

-1

~38

before aftLer before afLer

The djfferenices 6eFore and ciLe-r inLeivevition for the arem'ic (iron, plccebo) groups are

highly signLficcntn (p<o.ool)) but are- not sugnifi%cjnt ror Ihe non.anervlic. (uron, p)acebo)hroups.

The- difference between Lle iron cand paelodo aneminc raoupss ofter interventUon are.signdficanL ciLE P<o.o8s;.

FIGURE 7:DIFFERENCES IN PLASMA IRON. TIBC AND TRANSfFERRINSA rURATION LEVELS FOR IRON ANID PLACEBO ANEMIC GROUPS AFTERINTERVENT/ON (MEANS ±S.E.,)

90-~~~~~~~~~~~~~~~~~~

u: Fe E- 430 4 P/acebo70 (POOS) 430, \ <O.-)

{PI4,Cebo CAK01

st60 <_~ W410

60- fi .40&

b6Sobre aof -er (60 days) .eforc afher-(60cozys)

r -

° t8- / ~~~~~~(P<,0.0l)

16 / Placebo

I)zj __ _ _

L 12- -

g b*4re oS;er6gOJof ays

FIWRRE 8: MEAN 1HEMATOC RIT CONCENTRATION BEFORE ANDAlF-TE'R INTERVENTION (I2E. )

42

- - - - - - - - - - - - - - - - - - - -……---4 NON ANEMIC Fe"I I F--

* '* -~.j* . ,IUNTREATED GROUP

Q 40f.,.,. ...* '''' -{ JNON ANEMIC Placebo

39-~ ~ ~ ~ ~ ~~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~-q 39 / ~~~~~~~~4 A N EMIC Fe

>~~~~~~__ ct'Lot r 38* < t *sx-.4 cutoff poirnt

3^ iA ANEAMC Place. bo

O DAY 60 DAAYS 90D. /00 DAYSBEFORE AFrER RE- ASSESSEMUENT

MEAN HEMOGLOBIN CONCENTRATION BEFORE AND AFTERINTERVENTION Lt S.E.

14 - .NON-ANEMIC Fe

:UNTREATED

->k::- --{NON-ANEMIC Placebo

Z ANEMIC Feo 13

-/

0~~~~~~~~~~~~6 DAS E 0tSEMN

ANEMIC Placebo12

0 Day ~ ~ ~~~~~~~0DAS90 DAYS 100 DaysBEFORE AFTER ~ ~~~~~~~~RE-ASSESSEMENT

- 49 -

Figure 10: DAILY WORK OUTPUT ( WEEDING ) FOR ANEMIC

AND NON-ANEMIC SUBJECTS

Square Meters Excavated

120-

Non-Anemics

100 _

/ Anemics

80 _

60 _'

40 _

20 -

20

0 I . I I

1 2 3 4 5

Hours Worked

Note: Each point or hour represents the cumulative mean for 46 observations in the non-anemic

grup and 15 observations for the anemic group..