#11 Worth

Nepal
Health
Survey
1965 -1966
ROBERT M. WORTH
and
NARAYAN K. SHAH
UNIVERSITY OF HAWAII PRESS

HONOLULU 1969
A SURVEY CONDUCTED AS A JOINT PROJECT OF:
His Majesty's Government

Kathmandu, Nepal
The University of Hawaii
Honolulu, Hawaii
The Thomas A. Dooley Foundation, Inc.
San Francisco, California
The Bishop Museum
Honolulu, Hawaii
Copyright 1969 by the University of Hawaii Press
Library of Congress Catalog Card No. 72-76764

Printed in the United States of America
Acknowledgments
THE NEPAL HEALTH SURVEY of 1965-66 was the

product of the labors of many people. It was truly a team effort, and it
would not have been possible without the contributions of each member
of the team.
Dr. Narayan Shah together with Dr. Emmanuel Voulgaropoulos con-

ceived of the idea of a Nepal health survey in 1962 while both were
students at the Johns Hopkins University, School of Hygiene and Public
Health. Dr. Shah was instrumental in making the necessary contractual
arrangements with the Government of Nepal. He also helped in the survey
planning, served as its Medical Director, and filled in as its field physician
when illness struck those assigned to this task.
Dr. Robert Worth led the group at the University of Hawaii and was,
with the assistance of Dr. Myrtle Brown, responsible for the establishment
of the protocol, recruiting and training of personnel, selection of equip-
ment, supervision of field team activities, data analysis, and preparation of
the final report.
Dr. Verne Chaney, President of the Dooley Foundation, had the
monumental task of raising the $250,000 ultimately needed for the
survey, all of which funds came from public contributions in Hawaii and
the mainland United States. Freight costs were subsidized by the Agency
for International Development. Miss Zola Watson, Nursing Director of the
Dooley Foundation, assisted Dr. Chaney with the preliminary arrange-
ments in Nepal and handled personnel problems in addition to the
procuring and shipping of all supplies and equipment.
Mr. Robert Murphy had the difficult role of Administrative Director,
responsible for solving, with limited resources, the overwhelming logistical
v
vi NEPAL HEALTH SURVEY
problems in the field. Dr. Rosemarie Lenel served as field physician during
most of the survey, preceded by Dr. Virginia Singleton during survey of
the first four villages. Miss Carolyn McCue was in charge of the laboratory
group, and with the guidance of Dr. L. Poudyal, Bir Hospital, Kathmandu,
supervised the work of laboratory technicians Miss Dodie Stokes, Miss
Renda Lindley, and Mr. Richard Mitchell, all of whom spent a large part of
their time in the field. Miss Joan Butler served faithfully the multiple tasks
of nurse with the medical team.
Captain M. R. Thapa was the leader of the field team during most of
the survey, made local arrangements with village leaders and, along with
Rama K.C., Pampa K.C., Manik Tuladhar, and Sulochana Rai, served as
interpreter. Mr. and Mrs. Peyton Rowan were with the advance party,
serving as engineer and interviewer, respectively, both crucial roles. Miss
Diane Brown was with the team at the beginning of the survey, setting up
some sociologic interview schedules, and later did the data analysis and
preliminary draft leading to the section in this report on reproductive
practices.
Dr. Larry Quate of the Bishop Museum (Honolulu) and Mr. M.
Nadchatram of the Institute for Medical Research (Kuala Lumpur) each
accompanied the team for some time, collecting entomologic specimens.
These two entomologists, along with Dr. R. Traub, Department of
Microbiology, University of Maryland School of Medicine, did the neces-
sary taxonomic work. Thanks are also due to Dr. Charles Wisseman, Jr.,
Chairman of the above department, for undertaking the very laborious
task of serologic analysis of the filter paper blood discs.
Special appreciation is due to the several members of the team who
carried on admirably in spite of repeated illness, and special appreciation
should be expressed for the adaptability of all members in filling each
other's roles during illness in the field.
Special thanks are due to Dr. Robert Marks, Chief of the Tuberculosis
Division of the Hawaii Department of Health, who volunteered his services
in reading all chest x-rays.
It should be noted that the School of Public Health of the University of
Hawaii, with a grant (No. GM 15421) from the National Institutes of
Health, supplied computer time and programming services. Miss Sakiko
Okubo volunteered as supervisor of data processing and programming, and
she performed a monumental and tedious task with remarkable grace. Free
clerical services for data processing were obtained through the student
work-study program of the Office of Economic Opportunity.
Dr. Carl Taylor of Johns Hopkins University was kind enough to give
encouragement and advice during the entire process of planning, execu-
ACKNOWLEDGMENTS vti
tion, and analysis. We also wish to thank the many members of the faculty
at the University of Hawaii who have given valuable help in editing the
manuscript.
The U.S. Operations Mission Public Health staff in Nepal were most
helpful, especially Mr. Larry Cooper of the Malaria Control Program.
A special word of thanks should also be reserved for Ambassador Henry
E. Stebbins, then the U.S. Ambassador to Nepal, who was most cordial
and assisted immeasureably in getting the completed data forms forwarded
safely to Honolulu for data processing and analysis.
All ministries and departments of His Majesty's Government were
extremely cooperative and helpful in every stage of the planning and
execution of this survey.
Mr. Howard Kresge, Director of the Committee on Voluntary Foreign
Aid, U.S. State Department, was personally cooperative and helpful far
beyond any reasonable limits in making arrangements for air and sea
shipments of equipment and supplies to Nepal.
A volunteer committee of citizens of the state of Hawaii organized
itself to raise funds in that state for support of the Nepal survey. Their
invaluable help and confidence in the program and its principles was
deeply appreciated. This group certainly must include the newspapers,
radio and television stations, school children, university groups, churches
of all faiths, business groups, banks, and many wonderful individuals, all of
whom gave freely of their time and talents to make this program a success.
Contents
1 Introduction 1
2 Environmental Description 5
3 Estimates of Vital Statistics 18
4 Reproductive Attitudes, Beliefs, and Practices 32
5 Nutrition and Nutritional Deficiency Diseases 42
6 Diseases Transmitted by Direct Contact 58
7 Diseases Transmitted by the Respiratory Route 61
8 Diseases Transmitted by Fecal Contamination 72
9 Diseases Transmitted by Insect Vectors 79
10 Other Conditions 93
Eye 93
ENT, Dental 96
Lung 99
Cardia vascular 101
Diabetes 103
Bladder Stone 104
11 Summary and Specific Recommendations 106
12 General Recommendations 113
Appendix A - Sample Forms 117
Appendix B - Entomological Report 123
Bibliography 157
ix
CHAPTER ONE
Introduction
BECAUSE of its geographical isolation, suc-

cessful avoidance of foreign domination, and political isolation
until 1950, the rural parts of Nepal represent one of the few
areas of the world in which a traditional, pre-industrial ecologic
balance between man and his environment might be studied
with modern investigational techniques. With the very rapid
introduction into rural Nepal of schools, improved communica-
tions, transportation, agricultural and public health services in
the current decade, this is a vanishing opportunity. With the
modern tools of social and economic change now available to a
strong central government, there falls upon that government the
awesome responsibility of using these tools wisely and with
foresight. This book is dedicated to the assistance of those who
shoulder this responsibility.
The purpose of this book is not to be encyclopedic but to
give a concise, quantitative picture of the most important
current health problems of Nepal in order to assist in compre-
hensive health planning. This book does not pretend to give
definitive data on anyone topic but will add, it is hoped, a
significant and orderly increment of knowledge to that already
available, both from published sources (Taylor, Svensson, Mil-
lar, Dunn) and from the unpublished data available to the
Ministry of Health in its own files, in the U.S. Operations
Mission Public Health files, and in the store of practical
experience being rapidly accumulated by Nepalese physicians
2 NEPAL HEALTH SURVEY
working in the increasing number of small hospitals and dispen-

saries being opened in the remote, but populous, areas of the
country.
In August, 1963, a contract was signed between the
Ministry of Health, His Majesty's Government of Nepal, and the
Thomas A. Dooley Foundation, under the terms of which the
Dooley Foundation was to conduct a national health survey in
Nepal to supply baseline quantitative data to assist the Ministry
in its planning and to be useful in measuring future progress of
health work in Nepal. In September, 1964, the Dooley Founda-
tion reached an agreement with the School of Public Health,
University of Hawaii, under which the School (in cooperation
with the East-West Center of the University) was to develop the
general survey plan, work out a detailed survey protocol,
provide a list of equipment and personnel needed, assist in
recruiting and training personnel, provide continuing profession-
al consultation during the course of the survey, process the data
derived from the survey, and, together with representatives of
the Ministry, write up a final report to the Ministry.
During the fall and winter of 1964 preliminary planning
commenced at the School, assisted by the visit during February
and March, 1965, of Dr. Narayan Shah, who was designated by
the Ministry and by the Dooley Foundation to direct the
survey. It was decided to use the village as the sampling unit and
to use a sampling ratio of approximately 1/1500 (one village per
1500). On the assumption of a sample of 24 villages with an
average of 270 people per village, about 6,480 people would be
seen, or a sampling ratio of about 1 person seen per 1,500
Nepalese (assuming a national population of about 10 million).
Dr. Shah obtained a large-scale map based on aerial photographs
of Nepal. A small-square, numbered grid system was placed over
this map, and a random sample of 24 grid squares was selected,
with the village nearest the center of each selected square
designated as a sampling site. It was also decided to have a single
team in the field (a small advance party of 4 people and a
medical team of 7 people) supported by helicopter from a base
laboratory in Kathmandu (staffed by 1 administrator and 2
laboratory technicians). The plan was to spend about two weeks
INTRODUCTION 3
in each village in order to gather demographic, nutritional, an'd

sanitation data from each household, and to attempt to exam-
ine every person in the village to assess disease prevalence. The
survey was to be finished in about one year.
Dr. Shah then returned to Nepal with the map to make the
necessary arrangements with the government and to recruit the
Nepalese members of the team. Data-gathering forms were then
printed (Appendix A), final equipment lists made out, and the
American members of the team recruited (predominantly from
Honolulu). During the first week of June, 1965, the American
members of the team camped out near a small village on Oahu,
Hawaii, to test the equipment and to practice with the forms
and protocol. During this encampment, with the help of several
Nepalese students at the University of Hawaii, parts of a 16mm
color movie narrated in Nepali were made to show in detail the
exact procedure of the survey in a village. Arrangements were
also made for entomologists from the Bishop Museum, Honolu-
lu, and the Institute for Medical Research, Kuala Lumpur, to
accompany the team during part of the survey to make
collections of small mammals and medically related insects
(reports in Appendix B).
During July, 1965, the team members and supplies were
assembled in Kathmandu. During the first part of August,
training exercises were held in Kathmandu, with Dr. Worth
present, and the remaining parts of the 16mm color film were
made "on location," to be used in subsequent villages to allay
the suspicions and anxieties of individuals invited to participate
in the survey. The survey actually got under way during the
second half of August and proceeded more or less on schedule,
in spite of illness of team members and prodigious transporta-
tion problems stemming from the fact that the team never
obtained a helicopter fully committed to its support. In fact,
the survey would have ceased after the third or fourth village if
the Royal Flight, Ltd. had not made its helicopter available. By
a combination of part-time use of the Royal Flight helicopter,
DC-3, truck, jeep, bullock-cart, elephant back, and trekking on
foot, the team had completed 18 of the 24 selected villages by
the end of May, 1966.
At that time the wet monsoon was approaching. Three hill

villages in the west-central mountains and three higher hill
villages in the eastern mountains remained as yet unexamined.
Many of the team members had other commitments; so they
could not wait for the end of the monsoon to complete the six
remaining scheduled villages. Furthermore, funds to support the
survey were exhausted. It was therefore decided to apply the
survey procedure to all the occupants of one discrete village-
sized block in urban Kathmandu for comparative purposes, then
to terminate the survey.
In the following section on environmental description,
Table I shows the villages surveyed, giving for each village the
region, the order in which it was visited (numerical sequence),
the name of the village, the altitude, the total population at the
time of the survey, a brief summary of the principal occupation
of the adult men, and the proportion of youngsters in school.
Each village which was surveyed is identified by number on the
map (p. 7), while the six villages not surveyed are unnumbered.
CHAPTER TWO
Environmental Description
NEPAL is where the Indians from the south-

ern Asian plains have met the Mongoloid people of the central
Asian mountains and plateaus. The dominant geographical
feature is the Himalayan range, which forms the northern
border of Nepal and sends countless steep ridges irregularly
southward, creating almost impenetrable barriers to any easy
travel within the country. These ridges terminate in the Churia
Hills, a range of foothills that are fringed to the south by a
narrow, discontinuous segment of the northern Indian plains,
known as the Terai. It is in this narrow, warm, well-watered
strip (9,518 square miles) that about 2.8 million people live,
mostly Hindus of Indian stock (25 per cent of Nepal's approxi-
mately 10 million people). Another 600,000 people live among
the inner Terai foothills (4,749 square miles). The northernmost
40,296 square miles of the country consists of the Himalayan
range and its southern valleys, populated by 6.6 million people
')f mixed Indian and various non-Indian Mongoloid tribes. The
largest of the mountain valleys is Kathmandu Valley (209
square miles), the fertile, silted-in bed of an ancient lake, the
home of about 500,000 people, and the seat of the government
(Karan 1960).
Each June the warm, moist winds from the Indian Ocean
sweep northward and are raised and cooled against the southern
slopes, turning the rivers into raging torrents, the Terai into a
flooded lake, and obscuring the Himalayan ridges in constant
5
clouds. In the autumn the pattern reverses, and the cold dry
winds come down out of Tibet and central Asia, and cool
weather extends well down into the southern foothills. Both the
rainfall and the population are heavier in the eastern two-thirds
of the country, which is roughly in the shape of a rectangle,
extending 500 miles in an east-west axis and 100 miles in a
north-south axis (Karan 1960; Hagen 1961).
At each survey site the engineer in the advance party was
responsible for mapping and for gathering simple observations
about water supply and fecal disposal patterns, while the two
women doing the household interviews were also responsible for
filling out a household environment check list from observa-
tions made by them during their interview. These two sources
provided data for a brief standardized description of village
environments, which are summarized below by region in a
pattern corresponding to Table 1.
WESTERN MOUNTAINS
This region was represented by four villages:
No. 13 Bhawanipur (287 population, 50 households) a foothill
village bordering on the Terai at 1,1 Oo-foot elevation just south
of the Rapti River near Dang, about 30 miles east of Nepalganj,
is a Chetri* and lower caste Hindu village of subsistence
farmers. Schooling through grade 5 is available across the river.
No medical services are available locally. Water is obtained from
the river. This village is transitional in ecology between the
Terai and the foothills.
No. 15 Bajura (310 population, 59 households) at 4,500-foot
elevation about 25 miles northeast of Silgari is a predominantly
Chetri and lower caste Hindu village of subsistence farmers.
There are schools through grade 7 available within walking
distance. There is a Panchayat (local government) health office,
but without supplies. Water is obtained from a mountain
stream.
No. 16 Dandagau (352 population, 36 households) at 5,400-
*The Hindu caste system is still strongly felt in Hindu-dominated central and
southern Nepal. The major caste groupings are designated in this report as: Brahmin,
Chetri, Baisya, and lower castes.
Sampling sites (numbered in sequence visited), Nepal Health Survey, 1965-66
TIBET
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Unnumbered sites not surveyed.
Shaded areas indicate special entomologie survey sites.
-J
TABLE l. VILLAGES STUDIED IN THE NEPAL HEALTH SURVEY AUGUST 1965 - JUNE 1966
% of Persons
Age 7 - 16 Who
Population Occupation of Men Are Students
Altitude
Region, No., and Village in Feet Total Exam. % Majority Minority Boys Guls
WESTERN
MOUNTAINS
13 BhawanipurO IIOO 287 277 97 Farmers - 33 5
15 Bajura 4500 310 223 72 Farmers Wage/shopb 31 0
16 Dandagau 5400 352 3II 88 Farmers - 28 3
17 Talichaur 7600 343 296 86 Farmers Wage/shop 54 3
CENTRAL
MOUNTAINS
00 Larnatar (near 4700 219 163 74 Farmers Wage/shop 93 43
Kathmandu)
01 Pardidhan (near 2900 251 191 76 Farmers Wage/shop 64 14
Pokhara)
10 Piutar (cluster 3200 298 274 92 Farmers - 33 3
of three)
12 Brahmin Dada 4500 343 273 80 Farmers Wage/shop 33 5
EASTERN
MOUNTAINS
04 Debatar (cluster 4000 285 223 78 Farmers 14 4
of two)
07 Sakkejung 4400 329 255 78 Farmers - 46 29
EASTERN TERAI
(PLAINS)C
03 Godar 550 466 366 79 Farmers 4 6
05 Dulari 350 307 240 78 Farmers - 28 0
06 Jhapa Bazar 350 408 336 82 Wage/shop Farmers 45 24
08 Ramnagar 575 332 199 60 Farmers - 25 0
09 Kathariea Tola 400 267 206 77 Farmers - 0 0
MIDWEST TERAI
(PLAINS)C
02 Kathauti 500 345 297 86 Farmers Wage/shop 53 35
(cluster of two
near Bhairawa)
FAR-WEST TERAI
(PLAINS)C
14 Kailali 500 328 263 80 Wage/shop - 19 7
URBAN
18 Inbaha 4500 499 356 71 Wage/shop - 73 33
(in Kathmandu)
SUMMARY 6321 people in 957 households = 6.6 people per household

" 19 sites = 300 people per site
" 23 villages = 270 people per village
5011 people examined out of 6321 = 79.3% examined
~ Village No. 13 is borderline between western mountains and far-west Terai.
Wage-earner or shopkeeper.
C The Indian plains extend northward across the Nepal border in a narrow strip called the Terai, terminating in the foothills.
foot elevation about 25 miles south of Jumla is a predominantly

lower caste Hindu village of subsistence farmers. There is a
school through grade 5 in the village. No medical services are
available to this village. Water is obtained from an open spring
seepage pool in the hillside.
No. 17 Talichaur (343 population, 40 households) at 7,600-foot
elevation 1Y2 miles north of Jumla is a mixed Brahmin and
lower caste Hindu village of subsistence farmers. Schooling
through grade lOis available in Jumla. There is a physician in
Jumla, but no hospital is functioning as yet. Water is obtained
from the river and two tributary streams.
At each location maize, barley, and a wide variety of
vegetables and fruits are grown. In the three villages at higher
altitude wheat and rice are also grown, and occasionally pota-
toes. Beans are grown at all except the highest altitude village,
Talichaur.
The three higher villages have houses made of clay, with
rock and straw as supplemental material, while Bhawanipur
houses are made out of wood. More than half of the houses in
the three higher villages are attached (row houses with common
walls), while all of the Bhawanipur houses are detached.
One-story homes are the general rule, with very few two-story
structures in each village except Dandagau, which has none. The
structures tend to be in a moderate stage of deterioration,
except in Talichaur and Bhawanipur where about 20 per cent of
the homes are in a severe state of deterioration. The average
number of dwelling rooms per house is 1 in Bajura and
Bhawanipur, about 1Y2 in Dandagau, and 2Y2 in Talichaur.
Separate kitchens are the usual pattern in each village except
Dandagau. An attached shop is common only in Talichaur,
where there are frequently several rooms for each household,
and where there is moderately good ventilation in about half
the houses. Ventilation tends to be better in Bhawanipur than
in the mountain villages, where it is generally poor.
Only two latrines are present in these villages, both in
Talichaur, and only one of these is properly maintained. Animal
manure is piled near the houses for fertilizer, and human feces
are indiscriminately deposited. Refuse disposal is in general
ENVIRONMENTAL DESCRIPTION 11
poor but a bit better organized in Bhawanipur and Talichaur

than in the other two villages. Food is stored moderately well
protected in every village except Bajura. Talichaur has signifi-
cantly better food storage in many homes, but rodent and other
infestation (lice, fleas, flies) is universal. In each village there are
an average of two to six cattle per household, usually kept in or
under the house, along with a few chickens. A small number of
goats are also present (many houses have none), and pigs are
conspicuously absent, only three families having one pig each in
Bhawanipur and two families having one pig each in Dandagau.
Sheep and horses are also very seldom present.
CENTRAL MOUNTAINS
This region was represented by six villages in four sampling
sites:
No. 00 Lamatar (219 population, 34 households) at 4,700-foot
elevation 8 miles southeast of Kathmandu in the edge of the
valley is a predominantly Brahmin Newari village of rice
farmers. Primary school is available in the village. Medical
services are available in Kathmandu, but there is no public
transportation nearby. Water is obtained from streams which
flow through the rice fields and through the village.
No. 01 Pardidhan (251 population, 47 households) at 2,900-
foot elevation just south of Pokhara in Pokhara Valley is a
mixed-caste Hindu village of subsistence farmers. Primary
schooling is available. Medical services are available from a
nearby government health center, usually staffed by a nurse
only. There is a mission hospital with doctors and nurses in
Pokhara. Water is available from taps to the Pokhara water
system (stream water distributed at low pressure, no treatment).
No. 10 Piutar (298 population, 45 households) at 3,200-foot
elevation 20 miles south of Kathmandu is a cluster of three
small mixed-caste Hindu villages of Tamang subsistence farmers.
There is a local primary school through grade 5. No medical
services are available. Water is obtained from a stream or
irrigation ditches.
No. 12 Brahmin Dada (343 population, 47 households) at
4,500-foot elevation 30 miles northeast of Pokhara is a predom-
inantly Brahmin village of subsistence farmers. There is a

primary school through grade 5. Medical services are not
available. Water is obtained from spring water brought by open
ditch 100 feet into bamboo spouts near the village.
At each village, rice, maize, and a large variety of beans
and vegetables are grown. The houses are basically of clay-brick
construction in Lamatar and Pardidhan, and clay and wood in
Piutar and Brahmin Dada, with considerable use of bamboo in
the latter village. Virtually all houses are detached, with
two-story construction being the usual pattern, except at
Pardidhan, where most houses are one-story. Many houses are in
a slight or moderate state of deterioration. Most houses have
one dwelling room, except at Lamatar, which averages two.
Separate kitchens are found occasionally in Piutar and Brah-
min Dada, and separate cow sheds are common in all four
villages. Attached shops are very rarely found. Ventilation of
the houses is uniformly poor.
Sanitary latrines are commonly found only in Lamatar,
and there only four are adequately maintained. Human feces are
indiscriminately deposited in and around the villages. Animal
manure is usually heaped near the cow shed for use as fertilizer,
and household refuse disposal is generally poor. Food storage
practices are bad, except in Lamatar, where about half the
homes have moderately protected food storage. Rodent infesta-
tion is universal, and lice, flies and fleas were noted in all
villages. There were two to three cattle per household, usually
kept in or near the house, along with one or two buffalo, a few
chickens, one to three goats, but almost no pigs or horses.
EASTERN MOUNTAINS
This region was represented by four villages in three sampling
sites:
No. 04 Debatar (285 population, 32 households) at 4,000-foot
elevation about 65 miles southeast of Kathmandu is a pair of
two small Brahmin and Chetri Hindu villages of subsistence
farmers. A school through grade 5 is located 4 miles away.
There are no medical services. Water is obtained from poorly
protected seepage springs that provide (in November) about 4
gallons per day per person.
No. 07 Sakkejung (329 population, 41 households) at 4,400-

foot elevation about 8 miles west of Ham is a mixed-caste Hindu
village of Limbu and Rai subsistence farmers. Primary school is
available in the village. There are no medical services. Water is
obtained from unprotected springs or ditches and is occasional-
ly led to the house by bamboo pipes.
No. 11 Phulpaw (352 population, 59 households) at 3,500-foot
elevation about 35 miles east of Kathmandu is a lower caste
Hindu village of subsistence farmers. There is a nearby school
through grade 8. No medical services are available. Water is
obtained from a covered spring via a rock spout.
At each location, rice, maize, wheat, and sweet potatoes
are grown, along with a large variety of beans and vegetables.
The houses are of clay, wood, and rock construction, though
some at Sakkejung are made of bamboo. Virtually all are of the
two-story, detached type, with about half in a slight state of
deterioration and the other half moderately deteriorated. Single
dwelling rooms are most frequent, except in Debatar which has
several houses with two. Separate kitchens are rare in Debatar,
but common in Phulpaw and Sakkejung. Separate cow sheds are
common in all three villages. Attached shops are rarely found.
Ventilation is poor in all three villages. Sanitary latrines are
virtually absent in Debatar and Phulpaw, but are quite common
(though inadequately maintained) in Sakkejung. Human feces
are indiscriminately deposited and animal manure is stored in
heaps for use as fertilizer. Refuse disposal and food storage
methods are generally poor in all three villages, and rodent, flea,
fly and louse infestation is highly prevalent. Cattle and poultry
are found in or around many houses, with three or four cows
and one to three buffalos, along with several chickens and goats,
owned by most households. Pigs are present only in Sakkejung,
where 13 houses have one pig each. Horses are absent, except
for a small number in Sakkejung.
EASTERN TERAI
This region was represented by five villages:
No. 03 Godar (466 population, 79 households) at 550-foot
elevation 25 miles northeast of Jaleswar is a lower caste Hindu
village (two Muslim families) of subsistence farmers. There is a
primary school near the village. There are no local medical

services, but there is a health center, which often lacks medi-
cines, one hour's walk away. Water is dipped from two open
wells, only one of which has a concrete skirt and coping. This
village had experienced a cholera epidemic just two to three
months before the team visit.
No. 05 Dulari (307 population, 39 households) at 350-foot
elevation 20 miles north of Biratnagar is a lower caste Hindu
village of Tharu subsistence farmers. Primary school is available
in the village. A hospital is available at a distance of one hour's
walk plus one hour's bus ride. Water is obtained from two dug
wells with hand displacement pumps.
No. 06 Jhapa Bazar (408 population, 69 households) at 350-
foot elevation 1Y2 miles northeast of Jhapa is a mixed-caste
Hindu village of shop-owners or wage-earners, with a minority
of subsistence farmers. Primary school is available in the village.
No organized medical services are available, but a pharmacy is
present. Water is available from public or private open wells,
most of which have a concrete skirt and coping.
No. 08 Ramnagar (332 population, 63 households) at 575-foot
elevation 28 miles north of Jaleswar is a mixed-caste Hindu
village (two Muslim families) of subsistence farmers. School
through grade 6 is in the village, and through grade lOis 3 miles
away. There are no medical services available, but medicines can
be bought in a bazaar 3 miles away. Water is obtained from
three open wells with concrete or brick skirt and coping.
No. 09 Kathariea Tola (267 population, 45 households) at
400-foot elevation 8 miles north of Gaur is a lower caste Hindu
village of subsistence farmers and fishermen. No school exists in
the village, but there is one 2 miles away. There are no medical
services. Water is obtained from one drilled well with a hand
pump and no skirting, or by dipping from an open well with
insecure brick coping and skirt.
Rice, potatoes, beans, and a large variety of vegetables and
fruits are grown in all villages, and some jute is grown as a cash
crop at Dulari. Houses are made of clay and bamboo and are
virtually all of the one-story, detached type. They are generally
in a slight to moderate stage of deterioration, except for Godar,
where many are severely deteriorated. They have one or two

dwelling rooms, usually with a separate kitchen and separate
cow shed. There are very few attached shops except in Jhapa
Bazar, where more than half of the houses have attached shops
or businesses. Ventilation is generally poor except in Jhapa
Bazar, and latrines are virtually absent except in Jhapa Bazar,
where they consist of poorly maintained open pits. Human
feces are indiscriminately deposited and animal manure is stored
in heaps for use as fertilizer. Refuse disposal is generally poor,
but better than average at Jhapa Bazar. Food storage is
moderately safe in more than half the homes in all villages
except Dulari, where it is quite bad; and rodent and other
infestation is virtually universal. Two or three cows and one or
two buffalos are owned by most families. A few chickens and
goats are usually found in and around the houses, except at
Ramnagar and Kathariea Tola, where no chickens were seen.
Very few pigs are found, and only at Godar and Dulari. Horses
are found only at Jhapa Bazar.
MIDWEST TERAI
This region was represented by a pair of small villages on the
motor road 1Yz miles north of Bhairawa:
No. 02 Kathauti-Annapurna (348 total population, 59 total
households) at SOD-foot elevation is a mixed-caste Hindu village
(eight Muslim families) of subsistence farmers. A small hospital
and dispensary, together with several shops selling medicines,
are 1Yz miles away in Bhairawa. Schools through grade 10 are
available. Water is obtained from drilled wells with hand pumps
and no skirting. Rice, beans, and a variety of vegetables are
grown. Houses are of clay, one-story, detached construction,
and one-sixth of them are in a severe state of deterioration.
There are one or two dwelling rooms per house, and usually a
separate kitchen and cow shed. A few houses also have an
attached shop. The ventilation is reasonably good in about half
the houses, and six inadequate latrines are present. Human feces
are indiscriminately deposited, and animal manure is stored in
heaps for use as fertilizer. Refuse disposal and food storage are
better than in most villages, but rodent and other pest infesta-
tion are heavy. Two or three cows are owned by most families,
but few are kept in the house. There are a few goats in the
village, very few chickens, only one pig, and no horses.
FAR-WEST TERAI
This region is represented by one village 3 miles west of
Dhangari:
No. 14 Kailali (328 population, 41 households) at 500-foot
elevation is a mixed-caste Hindu village of Tharu subsistence
farmers. School through grade 5 is available in the village, but
the post of teacher is temporarily vacant. A small hospital and a
doctor are available in Dhangari. Water is obtained from one
drilled well with pump, and several open wells, one of which has
a secure coping and skirt. Rice, maize, wheat and a large variety
of beans, vegetables and fruits are grown. Houses are of clay and
straw construction, one- or two-story, detached type, with very
slight deterioration, and with one or two dwelling rooms. Most
have separate kitchens and separate cow sheds. Ventilation is
adequate in half the homes. There are no sanitary latrines.
There is indiscriminate human defecation, and animal manure is
stored in large piles for use as fertilizer. Refuse disposal is poor,
but food storage is moderately good. Rodent infestation is not
pronounced, but fleas, flies and lice are abundant. Chickens are
common in the houses. Most families own several cows and a
few goats. There are fourteen pigs in the village, but no horses.
URBAN ENVIRONMENT
This is represented by:
No. 18 Inbaha (499 population, 72 households), a discrete
block of row homes in the form of hollow squares five minutes
walk from Kathmandu bazaar, at 4,500-foot elevation. It is a
Newari Buddhist community of shopkeepers and wage-earners.
There are a few limited kitchen gardens. Schooling at all levels is
available. There is a private doctor's office in the neighborhood,
and several hospitals and pharmacies are available. Water is
distributed via twenty public taps from the Kathmandu urban
water system. One open well and a few tube wells are in the
area. Houses are of brick, two- to four-story, attached type, in a
moderate state of deterioration, averaging two dwelling rooms

per family, usually with a separate kitchen and without an
attached shop. Ventilation is moderately adequate. There are
four communal latrines and several inadequate private ones.
Many children defecate promiscuously, and their feces are
either eaten by dogs or collected by a sweeper for use as
fertilizer along with animal dung, some of which is used for
fuel. Refuse disposal is poor, but food storage is moderately
good. Few rodents were seen, but fleas, flies and lice are
plentiful. Half the families have some chickens. There are a very
few goats and no cows or pigs.
In summary, there is widespread fecal contamination of
the environment, with ample opportunity for a very large fly
population and transmission of disease via food and water.
Water supplies are mostly unprotected, however, an encouraging
beginning has been made in protecting the wells in some villages
in the Terai. There is a very high rat population in the villages,
with ample potential for the spread of plague, flea-borne
typhus, and leptospirosis. There is a fairly high degree of indoor
crowding (an average of 6.6 people per household in one or two
dwelling rooms with rather poor ventilation), providing an
optimum situation for transmission of diseases by the respira-
tory or contact routes within households.
CHAPTER THREE
Estimates of Vital Statistics
IN the absence of reliable birth and death

registration, it has been impossible until now to arrive at
measures of fertility and mortality in Nepal to serve as guides to
health and economic planning. One of the primary goals of the
Nepal Health Survey was, therefore, to make estimates of
fertility and mortality rates.
FERTILITY DATA
The fertility data gathered in each sampling site was done in
such a way as to allow several independent estimates, thus
allowing for a comparison of several rates to lend confidence in
the reliability of the information. Six types of information were
gathered:
1. an account of each married woman's total reproductive

history,
2. an account in detail, of each married woman's repro-
ductive history during each of the past three years,
3. an inquiry into current pregnancy,
4. a urine test to ascertain current pregnancy for every
woman age 15-49,
5. number of infants currently alive in each household,
plus number who were said to have died in the previous 12
months,
6. total number of births in each household during the
prior 12 months, and number of people in each household.
18
ESTIMATES OF VITAL STATISTICS 19
Data from the total reproductive histories are shown in

Figures 1-5.
Figure 1 shows a pattern of marriage at an early age,
usually pre-pubertal, with an onset of menses beginning at
about-age 14, * but with most of the women giving birth to their
first child at age 18 or older. These data indicate that age of
"marriage" really refers to a social event, and that the biological
event occurs sevenilyears later.
In six of the -_sampling sites there was a pattern of later
marriage, with at least 20 per cent of the marriages taking place
after age 16. These are all hill or foothill villages, and within
each of them the lower the caste, the later the age of marriage is
likely to be for the girls. Brahmin caste was strongly associated
with early marriage. The site with the highest proportion of
late-marrying girls is in urban Kathmandu, where they were
virtually all Newari Buddhists.
In both Table 2 and Table 3 the sources that probably
contain the least bias are also the ones that yield fertility
estimates most in agreement with each other-individual repro-
ductive histories covering the prior 12 months, the sum of living
infants plus the sum of infant deaths during the prior 12
months, and the adjusted estimate from the urine testing. One
would gather from these tables that fertility in Nepal is about as
high as could be observed anywhere in the world, with a crude
annual birth rate in in the neighborhood of 50 to 55 per 1,000
population, and an annual fertility rate of about 220 births per
1,000 women age 15-49. It should be remembered that these
estimates are based on a sample that excluded data from the
midwestern mountains and high altitude eastern mountains.
Figure 2 confirms the previous observation that just about
every Nepalese woman who is going to get married has done so
by age 20-24. Figure 3 shows estimated age-specific fertility
rates based on urine tests, revealing a very high peak in the
20-24 age group, with a continuation of moderately high levels
to age 49. A distribution of cumulative live births by the age of
the mother (not shown) confirms this, showing for women over
*All ages in this report have been transcribed to conform with the European system
of counting ages, and are only rough estimates at best.
800..---------------------,
= age at marriage
0--0
o
&----6
.. age at onset of menses
• age at birth of first child

A
,
I
I
I
700 I
I
I
I
I
I
I
I
600 I
1
I
.!I
I
I
,,
500 I
z
w
:2
t.
Xonset of menses
14.0 years I
I
0
:5: I
LL I
0 400 I
CC I
W
al I
:2 I
~ 1
z I
I
300 I
I
I
I
I
1
I
I
200 ,I
,I
I
I
, I
'{}.
OL..----JL--J..........kO..I--L--L-L-L-L-L..................-L--'--'--'-...L.......J
:!9 10 11 12 13 14 15 16 17 ~18
AGE IN YEARS
FIGURE I. Age at marriage, at onset of menses, and at birth of fIrst child, 1786
women, 19 sampling sites, Nepal Health Survey, 1965-66
300
r-
- • This irrqularitv is probably due to
uncertainty of okler women as to thai,
250 -
......
true age, and rounding to nearest 10
Z200 f-
w
:i:
o -
3:
u.
0150
a:
W
III
:i: -
:::> *
Z r-
100 f- -
*
r-
- -
50
--. nron
0< 10 10-14 15-19 20-24 25-29 30-34 3&39 40-44 45-49 50-54 55-51 8CHl4 65-69 70-74 75-79
AGE IN YEARS
FIGURE 2. Age distribution of 1780 women who have been married
age 50 a mean number of 6.0 live births, with a tri-modal curve,

showing some with relative sterility (0-1 live births), a major
peak at 5 live births, and a secondary peak at 8 live births.
Figure 4 shows the distribution of the number of surviving
children of women who have completed their reproduction (X =
3.02 surviving children), a figure only half that of the live
births, thus revealing a very heavy infant and child mortality.
These older women have reported that of their infants who
were born alive, only half survived until the time of the survey.
Figure 5 shows the age at the final pregnancy of this same group
of older women, revealing a relatively large number who ceased
reproduction quite young, due presumably to early widowhood,
absence of husband because of employment, or other reasons.
TABLE 2. ESTIMATES OF GENERAL FERTILITY RATES FROM SEVERAL DATA SOURCES
Estimated
Fertility
Source Formula Rate
Household :E births recalled in each household during prior 12 mos. 414 257/1000 a
history :E women age 15-49 in each household = 1614 = past yr.
:E infants alive in each household + infant deaths recalled in prior 12 mos. 290 + 63 219/1000
:E women age 15-49 in each household - 1614 past yr.
Individual :E births recalled for each married woman during prior 12 mos. 337 221/1000
reproductive -= past yr.
:E married women interviewed age";; 49 1522
history b
:E births for each married women during 12-23 mos. before interview 287 c 189/1000
:E married women interviewed age";; 49 - 1519 1 yr. prior
:E births for each married woman during 24-35 mos. before interview 207 c 136/1000
:E married women interviewed age";; 49 - 1519 2 yrs. prior
(history alone) No. currently -pregnant by historY alone 12 146 12 130/1000
(.;unent -- ·"[ND';'"2J1U InOS.
U'Jmeste~tt!"rr-:j:""NO;""2jf"cr-·+·Nlr."3r(f·· -- loo/l"OOO -
pregnancy 2 J . trimester trimester 12 mos. 185 12 current
history (adjusted) d X ---- --X - (adjusted)
2; married women interviewed age';;; 49 9 mos. 1489 9
(combined with No. tested positive + No. tested neg. but definitely preg. by history 163 l2mos. 243/1000
urine test) d 1006 = 0.162 X 8 mos. current
No. women tested
(adjusted)
Urine No. tested positive 12 mos. 147 12 219/1000

test X - X -= current
No. women tested 8 mos. 1006 8
alone (adjusted) e (adjusted)
a A significant number of births were from women under 15 (see Fig. 1); so there is an upward bias to this estimate perhaps made worse
by including infants born more than 12 months ago.
b Data from all married women under age 50 who responded to these questions.
c The downward trend noticed here is partly due to forgetting events that took place further in the past, and partly due to the fact that
the younger women interviewed had not entered full productivity during the previous two to three years (e.g. women now 19 were only
16 three years ago).
d Most women are not certain of pregnancy until nearly the end of the first trimester; so pregnancy by history alone is biased low and is
here adjusted upward on the assumption that there are as many 1st trimester pregnancies as the average of 2nd and 3rd trimester
pregnancies at any point in time.
e The urine test used (Gravindex, Ortho Co.) detects most pregnancies about 8 months prior to birth (Udry 1966). One would expect an
annual live birth rate derived from these data to be slightly high due to fetal losses that will take place.
TABLE 3 ESTIMATES OF CRUDE BIRTH RATES FROM SEVERAL DATA SOURCES
Estimated
Crude
Source* Formula Birth Rates
Household ~ births recalled in each household during prior 12 mos. 414 65/1000
history =-- past yr.
~ people in each household 6321
~ infants alive in each household + recalled infant deaths in prior 12 mos. 290+ 63 55.8/1000
~ people in each household 6321 past yr.
Individual ~ births recalled for each married woman during prior 12 mos. 337 53/1000
reproductive ~ people in each household 6321 past yr.
history
Current
pregnancy
[NO. 2nd trime~ter + No. 3rd trimester] + No. 2nd trimester + No. 3rd trimester
12 185 12 39/1000
history X -= --X
(adjusted) ~ people in each household 9 6321 9= current yr.
12 mos.
(Combined with (No. tested pos. + No. tested neg. but definitely preg. by history) X - - - -
urine test) 8 mos.
annual births = (147 + 16) X 12/8 = 244.5 births expected
current year from 1006 women + 362 births expected from 1489 married
57/1000
women in 6321 population = current yr.
Urine test No. tested positive X 12{8 = annual births expected from 1006 women = 220.5 + 51.5/1000
alone 326 births expected from 1489 married women out of 6321 population current yr.
400
• Numbers too small for reliability
,--
300
zw
:;
~
§ ,--
r--
r-
-* ,.....
* -*
~
o
15-19 20-24 25-29 30-3435-3940-44 45-49
AGE IN YEARS
FIGURE 3. Age-specific fertility rates estimated from urine testing
100
2
w
:; -x = 3.02
~ r--
.... 50
o
a:
w - - ,.....
III
:; -
:l
2
o n
o 1 2 3 4 5
NUMBER OF SURVIVING CHILDREN
nn6 7 8 9 10
FIGURE 4. Number of surviving children per woman among 249 women age 50
or older who had given birth at least once in their lives
40r---------------------------,
30
• This irr9gulerity is probebly due to
rounding of . . to nearest 5 yun.
1 . _-
,.~~
27
Z
w 26'
~
o
s:u.20 2"
o
a:
w
D:I
~ 13 '3'
12 12
~ 10' 11 10
10
7 7
1 1
0L..-==--1:='---'----l..---l..-l-....L.......L...-...L..-...l.-..I...-L.....JL.....I---l.---l.---'--L-l-....L.......L......l.-l
~26 27 2829 30 31 3233 343536 37 38 39 4041 4243 4445 46 47 48 49 50 51
AGE AT FINAL PREGNANCY
FIGURE 5. Age at final pregnancy of women age 50 or more
MORTALITY DATA
Data on mortality were gathered from the following sources at
each sampling site:
1. an account of infant mortality and number of surviving

children from each woman's total reproductive history,
2. an account of infant mortality and number of surviving
children from each woman's reproductive history during each of
the past three years,
3. total numbers of deaths in each household during the
prior 12 months, and age at time of death,
4, total number and ages of people currently alive in each
household,
Figure 6 shows the distribution of deaths by 5-year age
groups. Of the 171 deaths reported during the prior 12 months
in the 19 sampling sites, 55.5 per cent occurred prior to age 5,
and 67.3 per cent occurred prior to age 15.
Fi~ure 7 shows a detailed distribution of age at death of
the 63 infants who died during the 12 months prior to the
ESTIMA TES OF VITAL STATISTICS 27
100 , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
(/)
...J:
<l:
w
o
l1.
o
a:
w
!Xl
:E
:::>
z
5'9 10-14 15"19 2<Y.l4 25-29 30-34 35-3940-44~5(H;o455_!l96o_6465_6970+ ?

AGE IN YEARS AT TIME OF DEATH
FIGURE 6. Distribution of 171 deaths during prior 12 months by age at death
15
(/)
...<l:J:
w t-
o
... 10
Z
<l:
l1.
Z
-
l1.
o r-
,.-
a: 5 r-
w
!Xl - r- r-
:E -
:::>
z
o rr
2 3 456 7
v
-
2 3 4
v
2 3 4
~n- 'h-
Ii 6 7 8 9 10 11
days . first week week, - first month months
AGE AT TIME OF DEATH
FIGURE 7. Distribution of 63 infant deaths by age at time of death

survey. One notices the usual cluster of deaths during the first
four days of life, related to infants with congenital anomalies
and difficulty in establishing successful respiration and circula-
tion. There is another cluster of deaths between the sixth and
fourteenth days of life, almost certainly related to neonatal
tetanus of the umbilical cord. The deaths after that are very
likely related to weanling nutritional problems combined with
unsuccessful first encounters with infectious organisms.
Table 4 shows various estimates of infant mortality and
crude mortality rates. An estimated crude mortality rate of
27/1000 and an estimated crude birth rate double that would
give an annual increase of about 2.7 per cent, or about 270,000
additional Nepalese per year. * With an infant mortality ratio of
about 150/1 000 live births and with 37 per cent of all deaths
being infant deaths, plus another 19 per cent of all deaths
occurring after infancy and before the fifth birthday, it is clear
that infant and child mortality are the dominant features of the
current demographic picture in Nepal. The high risk to the
young child is revealed by the age-specific mortality rate for
those who are age 1-4 years, inclusive, which was estimated at
39/1000. The numbers of deaths over age 4 are too few in this
small sample to estimate other age-specific mortality rates.
Figure 8 shows the age distribution by sex, and by 5-year
age groups and also shows a comparison with the age distribu-
tion derived from 1961 census data from eastern hill districts
comprising 1,886,722 people. This fragment of the 1961 census
giving detailed age categories was the only part available to us at
the time of this writing. These curves are reasonably parallel to
each other, except for a marked deficit in the 0-4 age category
in the 1961 census data. The 1961 census was done through a
predominantly male line of communication, while our survey
census was made house-to-house, with women talking to wom-
en. It is reasonable to believe, both from medical and demo-
*This pattern of about 2 births per death was found in every sampling site except for
one east Terai village (No. 03 Godar), where there had been a recent cholera
epidemic, with a total of 46 deaths in the past 12 months and only 42 births during
the same period.
r-
TABLE 4 ESTIMATES OF MORTALITY RATES
Source Formula Estimates of Rates
Household ~ all recalled deaths 171 27/1000 crude mortality rate past year
survey 6321 past 12 mos.
~ people alive
~ recalled infant deaths 152/1000 infant mortality ratio past

~
.
recalled live births to date
=-41463 past 12 mos. year*
Total reproductive ~ all recalled infant deaths to date 1074 208/1000 infant mortality ratio
histories of - --= historical
~ all recalled live births to date 5164
women";;; 49
~
Reproductive history
for past 12 mos. of ~
recalled infant deaths in past 12 mos.
recalled live births in past 12 mos.
-m 49
past 12 mos. =
145/1000 infant mortality ratio past
year*
women";;; 49
1/ 12-24 mos. prior ~ infant deaths 12-24 mos. prior to interview 50 174/1000 infant mortality ratio 2 years
to interview -= prior
~ live births 12-24 mos. prior to interview 287
1/ 24-36 mos. prior ~ infant deaths 24-36 mos. prior to interview 27 130/1000 infant mortality ratio 3 years
to interview =--------------=-=
~ live births 24-36 mos. prior to interview 207 prior
* Considerable variability expected due to small numbers.

single arrows). The population "bulge" that is seen between the

highly productive ages of 15 and 34 is a fortunate demographic
feature from the point of view of economic development, if
these young adults can be fully employed and maintained in
sufficiently good health to be productive. It is also clear from
this figure that any sudden decrease in the currently high infant
and child mortality unaccompanied by a simultaneous decrease
in fertility would cause a disastrously rapid increase in non-
productive children dependent for economic support and educa-
tion during the next few years upon this same relatively small
group of adults, who even now must increase productivity at a
fairly large annual rate just to keep pace with the current rate of
population increase (estimated at 2.7 per cent per year).
The greatest psychological and physical stresses in this
situation of high fertility and high infant and child mortality are
borne by the mothers of Nepal. In the next section we shall
inquire, in a preliminary and superficial manner, into their
reproductive beliefs and attitudes.
CHAPTER FOUR
Reproductive Attitudes,
Beliefs, and Practices
DURING the course of taking the census in

each household and eliciting from the female head of the house
a 24-hour diet recall history for the household, the two inter-
viewers (one Nepalese unmarried girl and one American married
nurse) asked a few standard questions concerning the attitudes
about family planning of each married woman present. These
interviews were carried out in the relative privacy of the home
and tended to be a conversation among women. There was no.
attempt, however, to get private, independent interviews with
each married woman within each household. The first two
questions asked were:
1. If you were just now getting married, how many boys

would you like to have? how many girls?
2. For a couple just getting married in this village, how
many children would be ideal?
There was often difficulty in getting women to answer

these questions in any quantitative fashion, since their first
reaction tended to be, "It is a matter of fate." However, if
pressed for a number, they usually chose 2 boys and 2 girls for
themselves (see Figure 9) somewhat more than the mean
number of 3 surviving children actually observed in completed
families (see Figure 4). The "ideal" number of children chosen
for the model family in the village was 5, only slightly higher
32
REPRODUCTIVE ATTITUDES, BELIEFS, AND PRACTICES 33
30 0
,"
I \
I \
I \
I \
I
I \ X = 4.5 children = girls
250 I
I
\
I
, "ideal" for self ----- = boys
,
I
I \
I , \ -X = 5.0 "ideal"
z
2
z I
,
I
I
, \
I r--
for village
couple 0
I I
ii: 200
o ,
I I
I
Cl
z ,I ,
I
j:
~
,,
I
I
I
I
til / I
z 150 I
I
I
I
w I
:iE II I
I
~
u.
I
I
,
I
\ ,...-
o
ct
w
I
I
I ,
\
\
~ 100
t \
:::l \
-
Z \
\\
\
50 \
1\ \ ,
, -
r"\
o
,......,
"- r--.... ,
"', ,Jl
2 3 4 5 6 7 8 9 10
NUMBER OF CHILDREN
FIGURE 9. Number of children considered "ideal" as expressed by 687 married

women under age 50
than the number desired for oneself. This lack of a marked

difference between the ideal number of children chosen for
oneself and the ideal number chosen for others might well
represent a fairly consistent image of the social ideal of a family
and the acceptance of this ideal by the women as a goal for
themselves. It is interesting that the only sampling site where
L
almost no women chose "ideal" family sizes of more than 4

children was the only urban sample, Kathmandu.
Each woman was also asked during the course of the
interview if she had ever discussed with her husband the
question of the number of children they would like. Only 11
per cent of them said that they had. In five sampling sites a
significantly larger than average number of women stated that
they had discussed this matter with their husbands. Four of
these five places are near towns with airfields and hospitals, and
are villages where a relatively large proportion of girls go to
school. The other is a hill village northeast of Pokhara.
The women were also asked if they were interested in
learning about family planning methods. A majority, 61 per
cent, indicated that they would like to learn more. This was
true in almost every village except Lamatar (in Kathmandu
Valley), Pardidhan (near Pokhara), and Kailali (in the far-west
Terai), where less than one-third of the women expressed an
interest. The women were then asked if they knew of friends,
relatives, or other women in the village who might be using any
form of family planning. The response was an overwhelming
"No," except for some suggestion that there may be some use
by a very few women in Lamatar (Brahmin village near
Kathmandu) and Sakkejung (in the eastern mountains).
Finally, the women were asked if they on principle
disapproved, approved somewhat, or very much approved of the
idea of family planning. A comfortable majority, 66 per cent,
indicated strong approval, and another 4 per cent indicated
moderate approval, with a significant dissent in only three
villages-Lamatar (a village in which 22 per cent of the women
had indicated discussing family size with their husbands and. a
village in which there may have been some family planning
practiced), Piutar (a cluster of three small villages in the hills
south of Kathmandu, where there was no indication of family
planning being practiced but where an average amount of
interest had been expressed in learning more about it); and
Kailali (a lower caste Hindu village in the far-west Terai, where
the women had neither talked to their husbands about nor
. expressed an interest in learning more about family planning).
When the above expressions of beliefs and attitudes were

tabulated separately by caste or religion, no consistent or
significant patterns were revealed.
Thus, we have found evidence that there is a fairly widely
held view of an "ideal" family of 4 or 5 children. This is a little
higher than the average number of children per family (about 3)
who actually survive to maturity under present conditions of
high infant and child mortality. We also find that while there is
a fairly widespread interest in and general approval of the idea
of family planning, there is almost no family planning being
practiced at the present time-as one would expect in villages
with extremely high fertility rates.
During the survey a questionnaire was filled out on the
basis of interviews with women selected either because they
were currently pregnant or had delivered a baby within the
previous year. A total of 201 respondents were interviewed.
Fourteen villages were covered in this part of the survey,
representing a subsample of each region except for the midwest
Terai, which was missed.
Several types of villages ranging from simple, remote
hamlets to a bazaar town were covered, and patterns varied
somewhat among them.
Respondents' ages ranged from 15 to 49 years. The
majority of women interviewed were between 20 and 34 years
of age. Most of the women described themselves as farmers'
wives or housewives. In Jhapa (a bazaar town) several women
indicated that their husbands worked in non-farming occupa-
tions such as shopkeeping, government service, fishing, and
personal services (barbers, sweepers, etc.). All of the women
were married, with the exception of one woman who had been
recently widowed.
Most of the women were born in another village in the
same district as their present home. A few women came from
distant districts (those not bordering directly on the district in
which the survey village was located), and in the Terai several
women were born in India.
Most deliveries took place in the husband's house, but a
few women delivered in their mother's house. All of the
pregnant women said they would have the baby in the hus-
band's house. Only one respondent delivered in a hospital, and
this occurred while she was living with her husband in Bombay
(India).
Usually the mother-in-law or some other female relative
assisted during the delivery. Quite a few women, however,
claimed they delivered by themselves, and several said that only
their husbands helped. Most of the pregnant women said that a
female neighbor or relative would help them at the time of their
confinement.
Roughly 17 per cent of the respondents mentioned that
they had difficulties during delivery. The question was phrased
as whether there were any troubles at the time of delivery other
than those normally expected. Extreme pain before and after
delivery was the most common difficulty mentioned. Single or
compounded complications such as: excess bleeding, weakness,
retained placenta, body swelling, and secondary uterine inertia
were also described. The majority of women did not do
anything when these problems occurred. Two or three called
the dhami (local traditional medical practitioner) but took
no medicine from him. One woman took herbal medicine
from a midwife, and in Jhapa, several women took injections
from a compounder practicing there. A doctor was called to
Sakkejung from a nearby town to attend a case of secondary
uterine inertia. He performed an operation on the patient, but
the exact nature of it was not determined.
The umbilical cord was usually cut on the same day that
birth took place. Generally the cord was tied before cutting, but
half of the respondents in two villages said that the cord was
not tied before. In most cases, a coin was used on which to rest
the cord before cutting it, otherwise it was rested on wood,
bamboo, clay pots, or on the floor of the house. On occasion
the cord was held up for cutting rather than rested on
something.
Breast feeding was begun on the day of birth by almost
half of the women. Due to custom or lack of milk some started
breast feeding on the second or third day after delivery. Giving
mother's milk to the baby before three days was considered in
several villages to be harmful to the infant. With few exceptions

all respondents had begun breast feeding by the fourth day.
Mother's milk was usually the first milk given to a baby.
When this was not the case, goat's milk was generally given.
Only a few women mentioned giving cow's milk or a combina-
tion of cow's and goat's milk until breast feeding was initiated.
The process of caring for the newborn child was described
by the respondents and appeared to be fairly universal to all the
villages. The newborn infant was first washed with warm water,
then rubbed with oil, wrapped in cloth, and either fed or put
directly to sleep. Sometimes a respondent forgot to mention the
use of oil, but when a request for further details was presented,
oil was invariably mentioned. It was believed that oil kept the
baby warm.
The length of a mother's resting period after delivery
varied quite a bit within each village, as well as between villages.
Here individual circumstances were more likely to determine
the number of resting days. If a woman had no one in the house
to help her, her resting period was likely to be short. If she was
a member of a joint family she may have rested as long as one
month. About eight women rested for two months or more; this
was due to their having poor health or having had an extremely
difficult delivery.
Fewer than half of the respondents said they cele-
brated no special ritual during their resting period or connected
to the birth of a child. Of those who affirmed carrying
out a ritual after the birth of a child, most celebrated Narun
or called in friends to join them in food. Narun had no
consistent form with which it was carried out. It was generally
considered to be a naming ceremony and a priest mayor may
not have been called. Other ceremonies described were pujas to
various gods, and ritual washing of the mother. This was
usually done on the eleventh day, after which a woman was no
longer considered unclean and could mix with people.
Two-thirds of the respondents did not take any kind of
medicine after delivery. Medicines that were taken showed a
wide range of preparations. For example, included were: ayur-
vedic medici~e, vitamins, injections, one or more allopathic
medicines, a combination of allopathic and herbal medicines,

commercially prepared spice combinations, homemade spice
combinations and herbal preparations. Several other medicines
were also mentioned, but their exact classification could not be
determined.
Reasons for taking medicines after delivery were in the
main to regain strength or relieve pain. Other reasons given for
taking medicines were to cure excess bleeding, gastric trou bles,
infection, a combination of troubles related to delivery, for
milk production, to clean the blood, and to make the body hot.
Medicines were obtained from a number of sources, al-
though most were purchased from the bazaar. More exact
sources mentioned were: ayurvedic doctors, compounders, the
dhami, midwives, from relatives or home, allopathic doctors,
and a combination of these. One woman said she received some
medicine from a hill man passing through her village.
Usually medicines were purchased in the bazaar and mixed
at home or completely homemade. It was not possible to
determine the preparation of all the medicines taken, but some
were commercial and complete, others were prepared by the
dhami or the midwife, and a few homemade preparations were
taken along with commercially produced products. Oral types
of medicines dominated, followed by injections combined with
oral medicines, or injections only.
A majority of women ate special foods after delivery, that
is, foods not ordinarily eaten in their daily diet. Numerous
reasons for eating special foods were given. The most frequent
reason was to regain strength or build up blood. Custom, the
rule of the village, for milk, or for no particular reason were
other answers noted. One respondent humorously joked that
she ate special food because she was especially hungry. Ghee was
the dairy product mentioned most. Meat, poultry, or fish were
also important special food items. Sweets and spicy foods, oils,
fruits, various kinds of dahl (beans), and rice were also eaten.
The choice of special foods was usually dependent on the
economic condition of the family rather than on traditional
custom. Many women said they did not eat special foods but
would have liked to do so. Rice is often considered a special
food in non-rice-growing areas. Rakshi, a homemade alcoholic

beverage, was also taken by some women as a special food.
Almost half of the women drank boiled water after
delivery, and several drank rakshi in place of water. Boiled
water was usually consumed until the end of the resting period.
Joana jol, a spicy soup, or other spice mixtures were
considered helpful for increasing the amount of mother's milk.
Milk was also drunk occasionally in combination with spice
soups. Meat broth was another food item taken to increase
milk. A number of women felt that their milk was ample and
that there was no need to do anything to increase it. The dhami
was thought to have medicines which are helpful if lack of milk
occurs, and he supplied medicines to several women to cure
this.
Diet during the nursing period was given careful considera-
tion by more than half of the respondents. Sour things, such as
yoghurt and lemons, and leafy vegetables were the foods most
avoided during this time. Non-leafy vegetables like potatoes,
eggplant, pumpkins, onions, squashes and gourds, and raw
vegetables were avoided by some of the women. Dahl (a soup
made from beans) forms a part of the daily diet in Nepal. There
are many varieties and different properties are attributed to
each. The varieties most avoided were kesari dahl and kalo dahl,
although some individuals avoided yellow, urad, and masuur
dahl as well. This covers most of the common varieties used.
Other foods avoided were eggs, mangoes, fried foods, cold foods
(those considered to have cooling properties), oils, and sweets.
One woman did not drink fresh water in the morning and
mentioned this in answer to the question on avoidance of foods.
To keep either the mother or the baby from becoming ill,
to keep the milk from being affected, or a combination of these
were the main reasons given for avoiding foods. One belief
among the Tharus in Dulari was that certain foods caused the
child's navel to become infected, and these foods should not be
eaten by the mother during the time she is nursing.
Most respondents said they were nursing their infants
dUring the period the survey was being conducted. Nursing is
generally continued for several years or until 'the next child is
l
born. Food is introduced from about the age of 6 months or so

and is increased slowly in both quantity and variety until the
baby of its own accord stops taking breast milk. Most respond-
ent said, therefore, it was not necessary to do anything in
particular to discourage the child from breast feeding. The few
that wanted their babies to stop taking milk before they
naturally stopped either put quinine or a similar substance on
their nipples or gave the baby to another woman for a few days.
Respondents also said that their milk dried up naturally and
they did nothing special to stop the flow. Two women ate dry
types of foods to assist the drying, and two others put tumeric
on their breasts for this reason.
One-third of the infants were given medicine for a variety
of reasons. Fevers, diarrhea or other stomach troubles, breath-
ing trouble, coughs and colds, and skin growths were among
these. Other reasons mentioned were: to protect the infant or
to make it strong, for teething, for controlling the effects of
witchcraft which was believed to have been done, and, in one
case, because the infant did not take any milk. Two respondents
who gave medicine to their infants said it was for no particular
reason or due to custom. Medicines were either fed to the
infant, rubbed on, or hung around the body in an amulet.
Occasionally a combination of the above was done.
Water was not usually given to an infant during the first
few months. When water was introduced, it was generally
untreated. Only one respondent said she gave boiled water to
her baby during the cold season. Water is first given to an infant
about the same time that solid food is given. At the time of the
interview only one-third of the infants were taking solid food,
mainly rice and biscuits or sweets.
When asked what a woman can do if she does not bear any
children for a long time, most respondents said they did not
know what could be done, or it was up to God. A few thought
the dhami could help, and two said both a doctor and the
dhami might be able to alter this. One woman mentioned that
an operation could be performed, and another said prayers must
be offered. The majority of respondents did not know why this
occurred, but several mentioned that it could be due to
menstrual trouble, stomach trouble, witchcraft, or because the

husband has a second wife or is weak. When this question was
asked, several women expressed interest in this problem and
asked if a cure is available.
The respondents who were presently pregnant when inter-
viewed were mainly in their middle or third trimesters. Both
these women and those recently delivered generally did not eat
any special foods, nor did they avoid foods, during their preg-
nancies. Fruit, meat, dairy products, spicy foods, sweets, and
eggs were special foods eaten by a few women. Gardh (a kind
of dahl) and alcohol were foods avoided by some.
No medicine, generally, was taken during pregnancy, but a
couple of women took masala (spice) as a medicine for
increasing strength or heat. Other reasons for taking medicines
were for back pains or loss of appetite. Medicines were either
eaten or rubbed on the body.
About half of the respondents were nursing another child
when they became pregnant. No sharp pattern appeared regard-
ing discontinuation of this. Some stopped in early pregnancy,
some in the middle, and some continued nursing until the new
baby was born.
About half the women did not feel any different during
the time they were pregnant. The others felt weak, lazy, heavy,
or a combination of these, or had a few minor complaints such
as nausea, pains, fever, and burning sensations. Activity and
work were usually not avoided during pregnancy except in a
few cases where heavy work was temporarily suspended.
Several questions were asked concerning the development
of infants. Most respondents agreed that teeth first appeared
between 6 and 9 months, walking was begun between 1 and I Vz
years, and talking begun between I and 2 years.
On the whole, respondents were cooperative and interested
in the questions asked during the survey.
CHAPTER FIVE
Nutrition and Nutritional

Deficiency Diseases
THE nutritional status of a population reflects
a very important component of its economic status, has a
profound influence on the resistance against infectious diseases
of many kinds, and controls directly the appearance of nutri-
tional deficiency diseases. For these reasons considerable effort
was made to assess the dietary and nutritional status of the
people at each sampling site. This was done primarily through a
24-hour household dietary recall interview, carried out by the
two women interviewers at the same time they were gathering
demographic data from each household. This information was
also supplemented by observation of number and kinds of
livestock, plus the clinical impression of the physician at the
time of physical examination.
A 24-hour recall dietary interview often leads to errors of
omission and does not take into account important seasonal
variables, but it can give some crude quantitative information if
done with care. Table 5 shows the data from the 24-hour recall
dietary history of each household in each of the 19 sampling
sites. Roughly 11 per cent of calories are from proteins, 13 per
cent from fat, and 76 per cent from carbohydrates. About 82
per cent of calories are from grains. Table 5 reveals quite a wide
range of per capita daily nutrients, with calories ranging from
1923 to 3554 (both extremes in the eastern Terai) and proteins
from 45.4 to 98.0 grams. There are no very definite regional
patterns displayed, except that the higher altitude, western
42
NUTRITION AND NUTRITIONAL DEFICIENCY DISEASES 43
mountain villages seem consistently better off with regard to

both calories and proteins than does any other region.
Clinically diagnosed cases of calorie malnutrition were
quite rare. They are summarized in Table 6. There is no
correlation between the number of cases of calorie malnutrition
seen in a village and the mean calorie intake of that village. It is
clear from the above data that severe calorie deficiency is not a
characteristic of an entire village but of a small number of
individuals within certain villages. It appears to be especially
prominent in villages where a significant proportion of the
families are wage-earners, rather than subsistence farmers (see
Table I for reference). A look at the age and sex totals in Table
6 does not reveal an excess of starvation of very young females
which used to be found in certain hard-pressed families in India
and China, where female infanticide was practiced.
The number of obese persons seen in each village is clearly
not inversely correlated with the number of persons with
under-nutrition; both of these conditions were more prevalent
in Jhapa Bazar, where shopkeeping and wage-earning were the
usual occupations. This dual pattern was not seen in the
Kathmandu sample, where only one social group was included.
One view of the possible socio-economic implications of these
observations is shown in Table 7, which shows the prevalence of
cases of clinically diagnosed malnutrition by religion or caste.
The highest rate was found in urban Kathmandu Newari
Buddhists, in a setting devoid of subsistence farming. There are
too few Muslims to draw any conclusions about them. Among
the Hindu castes widely represented in the rural villages, there is
no statistically significant difference noted among the three
castes with higher social status, but the lowest Hindu castes do
show a significantly higher rate of malnutrition. This is further
evidence of the socio-economic basis of calorie malnutrition,
rather than any general regional or agricultural basis.
One may conclude that in times of normal harvest, calorie
deficiency is related to socia-economic status, is more likely
found among those who are wage-earners, and is seldom seen
among subsistence farmers except for those of lowest caste, and
even there it is an infrequent phenomenon.
TABLE 5 AVERAGE MINIMUM PER CAPITA DAILY NUTRIENT INTAKE
Region, No., and Protein Fat Carbohydrate Calcium Iron Vitamin A Thiamin Riboflavin Niacin Ascorbic
Village Calories Gm. Gm. Gm. Mg. Mg. t U. Mg. Mg. Mg. Acid Mg.
-
WESTERN
MOUNTAINS
13 Bhawanipur 2042 54.4 37.7 371 366 9.7 2615 1.7 0.7 10,6 2
IS Bajura 3248 92.7 39.6 620 414 14.5 371 2.5 0.8 28.3 3
16 Dandagau 3283 95.4 38.2 631 469 15.5 869 2.6 0.9 28.4 <1
17 Talichaur 2834 77.8 29.7 558 371 15.3 839 2.4 0.7 24.4 13
CENTRAL
MOUNTAINS
00 Lamatar 2403 58.4 26.6 478 328 11.5 2496 2.1 0.5 26.0 8
01 Pardidhan 1957 50.5 27.5 376 258 9.2 2380 1.6 0.5 12.1 1
10 Piutar 2036 52.3 32.7 382 280 9.6 2406 1.6 0.5 12.0 3
12 Brahmin Dada 2316 74.2 47.8 401 582 15.0 2950 2.3 1.0 19.6 6
EASTERN
MOUNTAINS
04 Debatar 2116 56.1 40.0 383 660 10.0 10643 1.6 0.8 13.4 15
01 Sakkejung
,."' """~,,'...,..«>- .....
2162
""> ..... ,-=>0
62.5
....,.""'.'>-
41.2 461 ~
...I
~
a: '7
W
I- ,.
-Z ,
W
Cl 14 rE)----@
<I: .-..
Z 13 o-c
W
> ••
Cl 11
I-
<I: ,.
~
i= •
.
<I:
...I 7
:::>
Do
oDo
U.
o •
w
Cl 3
cl:
I- •
Z
~ ,
a:
~ 0-4 a-I 10-14 16-18 20-24 25-28 30-34 3&"38 40-44 4&-.1
AGE IN YEARS
FIGURE 8. Age distribution by sex (compared with a fragment of 1961 census

data)
graphic points of view, that our survey census gave a more

accurate ascertainment of infants and children than did the
official 1961 census. It is inconceivable that mortality in
Nepalese villages is greater for adolescents than for infants and
young children or that a very sudden drop occurred in infant
mortality five to ten years ago; yet these would be the two
alternative conclusions forced upon one by the shape of the age
distribution seen in the official census. If our census is more
accurate, then one must also deduce that the actual population
of Nepal at the time of the 1961 census was about 3 per cent
larger than the official figure and that these additional people
were infants and children under age 5.
Figure 8 also shows that half the population is under age
19 (see area to the left of the double arrows) and also about
half the population is between 15 and 49 (see area between the
---_._ .•. _~~ ... -
EASTERN TERAI
03 Godar 1923 46.9 23.2 377 201 9.7 295 1.7 0.4 20.2 1
05 Dulari 2109 59.3 36.7 306 247 12.2 925 2.1 0.6 22.5 3
06 Jhapa Bazar 2644 77.6 43.0 480 406 14.4 962 2.4 0.8 26.9 4
08 Ramnagar 2908 76.7 44.5 549 365 15.0 700 2.6 0.8 28.6 1
09 Kathariea Tola 3554 98.0 47.9 679 363 19.6 510 3.3 0.9 37.5 1
MIDWEST TERAI
02 Kathauti-Anna- 2084 61.0 31.8 388 295 12.2 3247 2.1 0.6 22.8 7
puma
FAR-WEST
TERAI
14 Kailali 2267 45.9 20.4 470 194 9.8 3 1.8 0.3 25.7
URBAN
KATHMANDU
18 Inbaha 2029 45.4 26.0 389 203 9.1 534 1.6 0.4 20.8 7
AVERAGES 2442 66.3 35.0 463 357 12.6 1957 2.1 0.7 22.0 5
TABLE 6 DISTRIBUTION OF CASES OF CALORIE MALNUTRITION BY

VILLAGE, AGE, AND SEX
Under-nutrition * Obesity *
Region, No., and Male Female M&F M&F
Village 0-9 10-29 30+ 0-9 10-29 30+ All ages All ages
WESTERN
MOUNTAINS
13 Bhawanipur 2 3 2 7 1
15 Bajura 3 1 1 5 4
16 Dandagau 1 1 2 1
17 Talichaur 4 1 1 5 3 15 0
CENTRAL
MOUNTAINS
00 Lamatar 2 2 0
01 Pardidhan 0 0
10 Piutar 0 0
12 Brahmin Dada 4 2 8 6
EASTERN
MOUNTAINS
04 Debatar 0 0
07 Sakkejung 2 2 0
11 Phulpaw 0 0
EASTERN TERAI
03 Godar 1 2 1
05 Dulari 0 4
06 Jhapa Bazar 2 2 4 4 3 4 19 16
08 Ramnagar 1 1 0
09 Kathariea Tola 0 0
MIDWEST TERAI
02 Kathauti 0 3
FAR-WEST
TERAI
14 Kailali 6 3 7 3 20 0
URBAN
18 Inbaha 6 2 5 14
TOTAL 25 10 6 29 12 15 97 44
* Clinical impression at the time of examination.

TABLE 7 DISTRIBUTION OF CASES OF CALORIE MALNUTRITION BY

RELIGION OR CASTE
Hindu
Nutritional Lower
Status Brahmin Chetri Baisya Caste Muslim Buddhist Other
Normal or 1119 1091 2751 634 70 311 268

obese
Malnourished II 6 43 23 0 14 0
(clinically)
TOTAL POP. 1130 1097 2794 657 70 325 268
Malnutrition
rate per 1000 9.7 5.5 15.4 35.0 45.0
TABLE 8 AVERAGE DAILY NUTRIENT LEVELS AVAILABLE FROM BASIC

DIET
% of Villages With Per

Average of All Suggested Capita Intake at or
Nutrient 19 Villages Levels Above Suggested Level
Calories 2442 2400 a 42

Protein (gm) 66 74 a 42
Calcium (mgm) 357 450 b 21
Iron (mgm) 12.6 12 e 53
Vitamin A (I. U.) 1957 3500 e II
Thiamin (mgm) 2.1 l.oe 100
Riboflavin (mgm) 0.7 l.4 e o
Niacin (mgm) 22.0 12 e 95
Ascorbic Acid (mgm) 5 30 e o
a WHO
b FAO
e Selected as reasonable figures
Table 8 summarizes the average nutrients from all villages

as compared with World Health Organization and Food and
Agriculture Organization standards. The situation is favorable
with regard to calories, iron, thiamin, and niacin (as might be
expected where large quantities of unpolished rice are eaten).
There is a marginal situation with regard to proteins and

calcium. It is unfavorable with regard to vitamin A, riboflavin,
and ascorbic acid. It should be noted that the ascorbic acid data
are probably very unreliable due to seasonal variations in the
diet.
Beri-beri and pellagra were not found on clinical examina-
tion, as one would expect from the adequate dietary levels of
thiamin and niacin. Vitamin A deficiency signs were found,
however. While Bidot's spots were virtually absent, xerophthal-
mia was occasionally noted in older adults in the Terai and in
one person in the western mountains (village No. 15). Corneal
scarring (a possible residue of former xerophthalmia) was more
widely observed, appearing in 17 out of the 19 survey sites, but
in only a very small number of people except in village No. 14
in the far-west Terai, where it was seen in 17 people, and where,
according to the dietary history, vitamin A intake was the
lowest of any village studied. Of the eleven blind eyes found in
children under age 5, only one pair occurred in a place of very
low vitamin A intake (Kathmandu). Of the six blind eyes found
in children age 5-9, two (both unilateral cases) were found in
the eastern Terai in low vitamin A intake villages, and the other
four (two bilateral cases) were found in western hill villages
with a moderate intake of vitamin A (and probably a high
prevalence of gonorrhea-see below). From this one may con-
clude that, although vitamin A intake is low in Nepal and some
clinical evidence of vitamin A deficiency is widely distributed,
the situation at present is not so bad as to cause severe eye
damage except in a very few persons, if at all. The evaluation of
night blindness was not part of the survey protocol.
The clinical signs of riboflavin deficiency (angular lesions,
cheilosis, nasolabial seborrhea) were found in a very few adults
in a large number of villages. Clinical signs of vitamin C
deficiency were seen in only 13 people. These were children or
adolescents, and they were found in all regions. From the
above, one may conclude that although riboflavin and ascorbic
acid may be sub-optimal in the Nepalese diet, enough exists to
prevent severe or widespread deficiency diseases related to these
vitamins.
As far as proteins are concerned, the three higher villages

in the western mountains exhibit a good balance of milk
products, poultry products, and beans; but for the rest of the
country there is an irregular pattern, with hill villages doing, in
general, less well than the Terai, but with some Terai villages
also showing very poor protein levels. In any case, the clinical
examination of the people did not show widespread signs of
severe protein deficiency, so the ready availability of beans and
rice supplemented very often by small amounts of milk prod-
ucts or meat seems to give a marginal protection against frank
protein deficiency disease (kwashiorkor in the young or hypo-
protein edema in the adult), even if not optimum for growth or
resistance to infectious diseases.
Table 9 shows the overwhelming dependence on rice as a
source of calories, with other grains playing an important
dietary role only in the hills.
Table 10 summarizes types of foods used in all the villages
as compared with WHO recommendations. It shows an unbal-
anced excess with regard to cereals, a marginal situation with
regard to beans, milk products, fats and oils, and a very
unfavorable situation with regard to fruits and vegetables, meat,
poultry and eggs. The consumption of beef is forbidden for
religious reasons; fish are scarce for geographical reasons; vir-
tually no pork is produced; and although poultry are widely
present, they are usually in the form of a few low-yield
household scavengers, rather than being efficiently produced in
flocks for eggs or meat. Because of these cultural and agricultur-
al patterns, it would appear wiser to increase protein availability
thrOUgh a selective increase in the production of peanuts and of
beans of high quality protein value rather than depending
Primarily on animal sources.
It has been known for a long time that endemic goiter is
prevalent in Nepal. The hypothesis most widely accepted has
been that it is more prevalent the nearer one approaches the
northern border because salt from Tibetan mines contains less
iOdine than sea-salt imported from India. Current trade patterns
Would indicate about 15 per cent of the salt coming from Tibet,
with the remainder from India (Chandramohan 1966). In a
TABLE 9 AVERAGE MINIMUM PER CAPITA FOOD INTAKE (GM/DAY)
Other Beans Yellow/Green Other Other Meat, Fish, Milk

Region, No., and
Rice Grains Nuts Vegetables Veg. Fruits Ghee Fats Poultry Products Wine
Village
WESTERN
MOUNTAINS
472 23 2.5 9.4 213 23.8
13 Bhawanipur
15 Bajura 454 445 42 18 9 3.2 13.2 49.9 132
16 Dandagau 440 481 51 1.1 9.0 54.5 177 8.5
17 Talichaur 381 350 73 104 132 4.1 9.0 95 8.5
CENTRAL
MOUNTAINS
00 Lamatar 518 129 35 27 18 1.5 8.5 53
01 Pardidhan 50 45 8 1.0 2.5 13.6 123 20
10 Piutar 55 458 1.8 6.3 27.2 141 20
12 Brahmin Dada 277 200 78 5 14 13.4 0.4 22.7 245 3.4
EASTERN
MOUNTAINS
Q4 Deba;\.ax
~'~"""" ' M". 9S 4'2.7 S 91 .~ 1?;.~ :;"_. 1.8 345
r-~-~-----~---
EASTERN TERA~
03 Godar 427 28 45 1 9 1.5 11.0 5.4 33 17.0
05 Dulari 445 - 91 9 18 - 0.8 14.1 18.2 41 1.7
06 Jhapa Bazar 486 68 91 6. 27 - 4.8 15.0 63.6 145 25.5
08 Ramnagar 563 104 86 - 1 - 8.8 16.4 18.2 109
09 Kathariea Tola 740 41 132 - 2 - 9.4 17.9 45.4 54 5.1
MIDWEST TERAI
02 Kathauti- 400 21 103 32 45 - 1.1 13.0 18.2 73
Annapurna
FAR-WEST
TERAI
14 Kailali 599 9 - - 14 - 0.1 8.8
URBAN
KATHMANDU
18 Inbaha 418 81 9 5 104 - 0.6 12.3 13.6 27 62.9
TABLE 10 PER CAPITA FOOD SUPPLY OF SAMPLED VILLAGES AS COM-

PARED TO WHO TARGETS FOR THE FAR EAST
Average of 19 Villages WHO Long-term % Villages Above

Food in Nepal (grn/day) Target (grn/day) Long-term Target
Cereals 586 361 100

Beans and Nuts 54 80 32
Veg. and Fruits 41 315 0
Meat, Fish, Eggs,
Poultry 22 104 0
Milk 122 140 37
Fat and Oils 14 24 11
1959 survey of three Bhotian communities high in central Nepal

above the 9,000-foot level, 45 to 64 per cent of the people had
goiter (Dunn 1962), mostly grade I (according to the WHO
standards: I=palpable, but not visible; II=visible; III=visible at
some distance). Goiter was graded according to this same
scheme at all 19 sites covered in this survey, and the resulting
pattern somewhat disturbs the above hypothesis, since there are
plenty of low altitude villages with a very high prevalence of
goiter, especially in the west. It is true, however, that the hill
villages do tend in general to have more goiter than midwest or
eastern Terai villages. Table 11 shows the percentage of people
with goiter, and the Grade II or Grade III goiters in each village,
by sex.
Figure 10 show the distribution of the villages by percent-
age of people with Grade II or III goiters, revealing a very wide
range, falling into a trimodal curve.
Table 12 summarizes by region the data in Figure 10,
showing again that prevalence of visible goiter is not well
correlated with nearness to the Tibetan border.
Figure 11 shows the prevalence of visible goiter, by age
and sex of those affected, rising sharply to a peak between age
20 and 30, with a maximum preponderance of females at that
point and a moderate reduction in prevalence among older
people, especially among the women. This reduction in preva-
lence in the older age groups might represent either a regression
in the size of the goiter or an increased mortality rate after age
TABLE 11 PERCENTAGE OF PEOPLE WITH GOITER
WHO Grade II or III WHO Grade I, II or III

Region No., and
Village Male Female Male Female
WESTERN MOUNTAINS
I3 Bhawanipur 69% 76% 84% 84%
15 Bajura 85 92 96 98
16 Dandagau 73 86 84 87
17 TaIichaur 74 88 85 91
CENTRAL MOUNTAINS
00 Lamatar 3 23 15 39
01 Pardidhan 9 16 22 36
10 Piutar 4 9 9 20
12 Brahmin Dada 68 73 82 78
EASTERN MOUNTAINS
04 Debatar 13 43 36 57
07 Sakkejung 19 44 54 69
11 Phulpaw 2 6 7 11
EASTERN TERAI
03 Godar 42 61 71 78
05 Dulari 12 29 34 58
06 Jhapa Bazar 11 26 36 52
08 Ramnagar 42 56 51 68
09 Kathariea Tola 6 8 9 26
MIDWEST TERAI
02 Katha~ti 1 6 8 22
FAR-WEST TERAI
14 Kailali 72 78 86 91
URBAN
181nbaha 39 61 82 86
30 among those with goiters. This last possibility was examined

by looking at the six villages with lowest goiter prevalence (Nos.
00, 01, 02, 09,10,11) in comparison with the six villages with
the highest goiter prevalence (Nos. 12, 13, 14, 15, 16, 17) with
regard to age specific mortality rates and age distributions. No
difference was seen between these two groups of villages with
III
W
t:l
«
...I
...I
:>
u.
o
IX:
w
a:l
:E
~ 2
0-9 10-19 20-29 30-39 40-49 SO-59 60-69 70-79 80-89 90-99
PERCENTAGE OF PEOPLE WITH VISIBLE GOITERS
FIGURE ro. Distribution of villages by percentage of people with visible goiters
regard to mortality experience in the prior 12 months or with

regard to age distributions (reflecting an accumulation of
age-specific mortality experience over a number of years).
If this high prevalence of goiter is not related to any
apparent affect on mortality, what of morbidity? Only two
TABLE 12 DISTRIBUTION OF VILLAGES BY REGION AND BY PERCENT-

AGE OF PEOPLE WITH VISIBLE GOITERS
Percentage of people with visible goiters

Region <40 40-59 ~60
Western mountains 0 0 4 (incl. No. 13)

Central mountains 3 0 1 (No. 12)
Eastern mountains 3 0 0
Eastern Terai 3 2 (Nos. 03, 08) 0
Midwest Terai 1 0 0
Far-west Terai 0 0 1 (No. 14)
Urban Kathmandu 0 1 0
TOTAL VILLAGES 10 3 6
cretins were diagnosed as such by the examining physician (one

in village No. 06 and one in No. 12), but some of the physical
attributes of cretinism (deaf-mutism, mental retardation) were
more widely distributed. Mental retardation was diagnosed only
when so gross as to become apparent during a routine physical
examination, and hearing in each ear was routinely tested with a
tuning fork.
The differences in deaf mutism and mental retardation
between the low-goiter and high-goiter villages shown in Table
13 are teliab1e at the 5 per cent level of significance (Chi-square
== approximately 5). We do, therefore, have evidence of perma-
nent, severe disability associated with goiter in a large enough
number of people to be of economic importance in the affected
villages. Although we have no evidence to support it, there is
also a very strong probability that with such a large number of
people with diseased thyroid glands, many people in the
affected villages have only marginal levels of thyroid hormone
available-enough to prevent death or overt disease, but perhaps
not enough for full health and economic productivity.
A study of geological maps of Nepal (Karan 1960; Hagen
1961) does not show any definite geological correspondence
with the rather spotty distribution of goiter prevalence revealed
in this survey. The most reasonable hypothesis would seem to
be that there has been a leaching of the soil by glaciation in the
8o,.- ...,
70
60
III
a:
w
l-
e
e"
w SO
..J
III ", .. - - ---- ............."
Vi ,,
,,
~,
.~
:> "
~,
................ _------
J: 40 I
l- I
§: I
,,
w
e"
Cl: ,, "
I-
Z
W
30
," Female
,. Male
U
a:
w ,,
,
,
,,,
Q.
,
,,
I
0--S--1,a,,0---2'!-.0--~3~0---4....0 - - -...
S 0 - + - - - - - -. .
AGE IN YEARS
FIGURE 11. Percentage of persons with visible goiters, by age and sex of those
affected
extreme north and by heavy precipitation in central and

southern areas, leading to a widespread deficiency of iodine
available to man in food or water. In support of this hypothesis
is the observation that the Terai villages with the highest goiter
prevalence seem to be those with the lowest water tables. In this
situation one might expect a greater leaching effect of rainfall
than in villages where the water table is very close to the
surface. The actual development of goiter as a biological
TABLE 13 DISTRIBUTION OF DEAF-MUTISM AND MENTAL RETARDA-

TION BY PERCENTAGE OF PEOPLE WITH VISIBLE GOITERS
% of Deaf-mutism Mental Retardation

People with Rate per 1000 Rate per 1000
Visible Goiters No. Persons Examined No. Persons Examined
<40 12 4.9 4 1.6

(lO villages)
40-59 6 6.5 1 - (too few)

(3 villages)
>60 18 11.0 9 5.5

(6 villages)
compensatory mechanism probably relates to a combination of

host factors (thyroid hormone demand related to body growth,
pregnancy, lactation, etc.) and environmental factors (consump-
tion of goitrogens which block absorption of the meager
amount of iodine available in the diet). Although known
goitrogens (cabbage, cauliflower, etc.) are widely present in the
Nepal village diet, the proportion of families reporting these
items as part of their daily diet did not correlate well with the
observed distribution of goiter in the villages studied. It is,
therefore, unlikely that goitrogens in the diet play any impor-
tant role.
It is feasible to give enough excess iodine in an iodized salt
program to compensate for the lack of iodine in the food and
water, as has been demonstrated in many parts of the world.
CHAPTER SIX
Diseases Transmitted by
Direct Contact
THE transmission of infectious diseases by
one person directly touching another person is primarily gov-
erned by the social rules which determine such touching, and
secondarily by routes of travel that serve to spread such diseases
from one village to another. The data gathered in this survey
allow the use of leprosy, gonorrhea, and syphilis as illustrations
to give some insight into current patterns of transmission of this
type of disease in Nepal.
Leprosy is a disease transmitted primarily to children,
most likely in a household or family setting. It has some
limitations for illustrative purposes, because ascertainment of
early cases requires complete disrobing and careful examination
of each person. During this survey a very high proportion of
people in each village was examined (averaging 79 per cent), but
not everyone was examined, and those who were examined
were only partially disrobed. It is safe to say, therefore, that
ascertainment was incomplete and would be biased in favor of
older, more advanced, easily diagnosed cases. Out of 5,011
persons examined, 9 definite and 3 probable cases of leprosy
were diagnosed on clinical grounds (skin lesions, anesthesia,
palpable peripheral nerves) usually without confirmatory skin
smears or biopsies. Of these, 3 were female and 9 male. One was
a child under age 10, one was an adolescent, and the remaining
10 were adults. Differentiation between tuberculoid or lepro-
matous forms of the disease was not made in most cases. The
58
DISEASES TRANSMITTED BY DIRECT CONTACT 59
geographical distribution was most interesting, with cases found

in everyone of the five eastern Terai villages, one out of three
eastern mountain villages (Phulpaw), and two out of four
central mountain villages (Lamatar and Piutar). One cannot
conclude from this that the disease is absent in the western part
of the country, but if it is present, it is probably at a lower
prevalence and/or those in the west who have the disease are
less willing to come forward for examination. If one assumes
about 50 per cent ascertainment under the conditions of this
survey, then a leprosy prevalence estimate in the neighborhood
of 1 per cent of the population may be made for the eastern
part of the country, with the disease probably having been
introduced through the Terai, and now spreading up into the
adjacent mountains retarded somewhat by the geographical
barriers to travel.
Gonorrhea is a very difficult disease to diagnose accurately,
since there is no serological test, and bacteriologic diagnosis
is often inaccurate. For the purposes of this survey, the only
presumptive diagnostic data available were blindness under age
5 (as a possible consequence of gonococcal ophthalmia neona-
torum), in the absence of other evidence of vitamin A deficiency,
and current or recent history of urethal discharge or painful
urination in the adult male (without urinary blood that might
relate to bladder stone). Out of 884 children under age 5
examined, there were eleven blind eyes without other evidence
of vitamin A deficiency-one unilateral case and one bilateral
blindness case in the eastern Terai, three cases of bilateral
blindness in the western mountains and one case of bilateral
blindness in urban Kathmandu. We, therefore, have some
indirect presumptive evidence for the possible presence and
wide geographical distribution of ophthalmia neonatorum.
When the question was asked of adult males as to current or
recent urethral discharge and/or painful urination, positive
histories without concommitant evidence of blood in the urine
could be found in virtually every village, with much higher
numbers in the western mountain villages, where positive
responses to questions about current urethral symptoms ranged
from 6 per cent to 13 per cent in all males over 10 years of age.
Another village with a high per cent of current symptoms (10

per cent of males over age 10) was Debatar, in the eastern
mountains. From these limited data one may conclude that
gonorrhea probably is widespread throughout the regions sur-
veyed, with a higher prevalence in the hills than in the Terai. We
will discuss later the possible confusion of these symptoms with
bladder stone.
In the absence of yaws, syphilis lends itself to objective
ascertainment through a screening serological test. This is not
adequate alone for conclusive diagnosis (particularly where false
positives may occur due to leprosy or malaria) but is satisfac-
tory for survey purposes. The test is done on plasma in a
heparinized microhematocrit centrifuge tube and is read as
"non reactive," "questionable," or "reactive" (Worth 1964 a).
An attempt was made to obtain a blood specimen from every
person examined. Of the 5,011 persons examined, a serological
test for syphilis was done on 4,195 people. Of these 19 were
read as questionable, and 42 (or about 1 per cent of all
specimens) as reactive. The 42 reactive specimens were from 19
adult men and 23 adult women, representing all regions covered
in the survey; but the highest prevalence was in the hill villages,
particularly in the far west, and in Kathmandu valley, where 3
to 5 per cent of all persons over age 20 tested were definitely
reactive. From this one may conclude that, like gonorrhea,
syphilis is spread widely throughout the country at a relatively
low prevalence, but higher in the hills than in the Terai. This
pattern may well relate to regional differences in sexual customs
or to the fact that men from many hill villages spend some time
working in large cities in India.
CHAPTER SEVEN
Diseases Transmitted by the

Respiratory Route
THE transmission of infectious diseases by
..
I~
the respiratory route is primarily governed by the environmen-

tal variables of crowding within houses and ventilation of
houses, and secondarily by routes of travel. The data from this
survey allow the use of two diseases to illustrate this category-
one difficult to control, and one much easier to control.
Tuberculosis data were derived from tuberculin Tine Tests
(Lederle Laboratories, Inc.) done on everyone age 0-14 years,
chest x-rays· (full-sized films) done on everyone 14 years and
older, and direct sputum smears (not concentrated) done on
whomever the physician requested. Questions were also routine-
ly asked about chronic cough, production of sputum, and
bloody sputum. The chest was also routinely examined by
auscultation.
The Tine Test (four sharp metallic prongs 1.5mm long
coated with dried tuberculin material) was chosen in preference
to the standard Mantoux Test because of ease of performance,
less cause for anxiety (no syringe and needle), and uncertainty
of refrigeration in the field. A very carefully controlled compar-
ative triple study of the standard Mantoux Test, the Tine Test,
and the Heaf Test done in Hong Kong (Tsao 1965) on 448
children showed a good linear relationship between the diameter
of induration with the Mantoux Test at 10 TV and the Tine Test
(independently read). The results with the Heaf Test were poor.
All of the Tine Tests used in the Nepal Health Survey were
61
from a single production batch, kept refrigerated at the labora-

tory in Kathmandu until a week or two prior to use, and often
kept refrigerated in the field, A sample of this batch was
pre-tested on a small number of known tuberculin positive
(5 TV of RT-23 in Mantoux Test) and tuberculin negative
persons in Honolulu, and a further trial was made in Kathman-
du by performing the Tine Test (a sample of this batch) and the
Mantoux Test (5 TV of RT-23) simultaneously on 171 school
children. The Tine Tests were performed on one arm and read
by the same nurse who did the readings in the survey, The
Mantoux Tests were performed on the other arm and read by
the Tuberculosis Project nurse who performs most of the
tuberculin testing in Nepal. Independence was maintained in
reading, Figure 12 is a scattergram of the paired readings,
showing a good linear relationship between the two methods,
The three horizontal lines on the figure represent ~2mm,
~ 3mm, and ~4mm criteria for reading Tine Tests as positive,
'4,--------------------------,
'3
'2
a:
~11
w
:E '0
«
C9
:E 8
:E
vi 7
z
o 6
j:
:: ...
~ 6
"
W
a: 41- ':.:..'- --"-"-'_!--1
W
Z 3 "
j: 1--------------------------1
2
,. ii,li
0 .........iI:.-....2ii.......1i3~":O;4---J6L..-....
6 ---I- . L .--'-9-,1...
0 --'-"---I'2-'....
3---1'4L..-'.L.
6 -..l'6-'''-7--'-18-'9':--:'20
7 8
MANTOUX REACTIONS. MM DIAMETER
FIGURE 12. Paired Mantoux-Tine reaction comparisons in 171 Kathmandu

school children
DISEASES TRANSMITTED BY THE RESPIRATORY ROUTE 63
50
w
i 40/
i'"
\ Tine Test
5l I
Q. \
u. I
o 30 i
ffi
al
\ Mantoux 5 TU, RT-23
::E
:J
Z
20
1- 4,% P""'".
10
...--..... ...... -.......... . .. -_ .... _----_. .. ......

o 2 3 4 5 14 15 18 17 18 19 20
REACTION, MM DIAMETER
FIGURE 13. Tuberculin Test comparisons in 171 Kathmandu school children

Tine Test versus Mantoux Test.
These data were not analyzed prior to the survey, and no prior .c•
~
decision was made as to what would be called positive. The nurse
was simply instructed to record the diameter of the reaction
in each case. Figure 13 shows the diameters of reactions in the
two systems. The Tine Test curve closely approaches the I•
c
classical bimodal curve that one would expect. The Mantoux
curve shows a sharp deficit in 0 and 1mm readings, and a sharp
·
cleavage at and around the IOmm figure used customarily in
Nepal for the positive criterion, suggesting a subjective bias in
the reader. These two figures show that a ~2mm criterion for
the Tine Test would be quite sensitive and correspond well with
an 8mm criterion in the Mantoux Test. A ~3mm criterion
would be less sensitive, but more specific, and correspond with
about a 12-l3mm Mantoux criterion. These curves also show
that a reading error of 1 or 2mm is more likely to be crucial in
the Tine Test, since the distribution of diameters covers a much
narrower range than the Mantoux Test distribution. In conclu-
sion, although we chose the Tine Test for logistical reasons, we
have evidence that it is a technically satisfactory tool for the
purposes of this survey.
During the Nepal Health Survey 1,562 Tine Test readings

were obtained from all 19 sampling sites. The tests were
performed by the physician during physical examination, and
all readings were done 48-72 hours later by one nurse (usually
the same person at all 19 sites), who recorded the result in
millimeters of induration (maximum diameter). No child was
found with a history of having received BCG or with a BCG
scar, except for a few in Kathmandu. Up until the time of this
survey the giving of BCG had been largely limited to certain
schools in Kathmandu. The result of the Tine testing was a
bimodal curve shown in Figure 14. Figure 15 shows age and sex
specific tuberculin positive rates using ;;;'2mm, ;;;'3mm, and
;;;. 4mm of induration as the criteria for positive. The resulting
curves are practically linear, with very similar slopes. The main
difference is that a sex differential appears for the two older age
groups with the ;;;.3mm criterion, and increases with the ;;;'4mm
criterion. From the above, it would appear that with this batch
of Tine Tests in this. setting the ;;;'3mm criterion is a reasonable
compromise between sensitivity (a small diameter) and specific-
ity (a large diameter). The data for Figure 15 are shown in
Table 14. Using ;;;'3mm as the criterion and combining the data
from the two sexes to give adequate numbers, age specific
tuberculin positive rates for five geographical regions are shown
in Figure 16, the data for which are shown in Table 15.
TABLE 14 NUMBER OF POSITIVE TINE TEST READINGS BY AGE, SEX,

AND POSITIVE CRITERION
Diameter of Induration
Age Sex ;;;'2mm ;;;'3mm ;;;'4mm Total Read
0-4 Male 45 20 13 309

Female 38 19 11 312
5-9 Male 97 59 45 272

Female 68 42 33 235
10-14 Male 88 68 55 186

Female 101 68 47 213
700..__----------------------,
649
I = alternative criteria
for tuberculin positivity
w II:
..J
a.
:2
.~
0
p
W 1M
a. 'lit
:r::
II.
0
II:
-
W 300
III S
:i:
:::l
z 5
~
200
!
c::
;.
100
3 8
o 1 2 3 4 5 6 7 8 or more
MM OF INDURATION
FIGURE 14. Diameter of induration after Tine Test

50 ____Male
- - - - - Female
40
z
o
i=
CJ
<l:
w
a:
~ 30
i=
Vi
oDo.
::t:
I-
~
w
t:l
;: 20
Z
w
CJ
a:
w
Do.
10
O'-- --.L. ..L- -'- --'

0-4 5-9 10-14
AGE IN YEARS
FIGURE 15. Tuberculin (Tine Test) positive rates by age and sex, using alterna-
tive criteria
TABLE 15 NUMBER OF TINE TEST READINGS OF ~ 3MM BY AGE AND

GEOGRAPHICAL REGION
Age
Q-4 5-9 10-14
Region Pos. Total Pos. Total Pos. Total
Central Mts. 1 108 6 105 17 94

Eastern Tera! 13 201 28 143 34 86
Eastern Mts. 6 60 18 76 28 62
Western Mts.* 7 125 17 96 21 89
Mid- & Far-west Tera! 7 86 15 56 26 54
Urban Kathmandu 4 39 18 31 12 14
'The rates for the western mountain region are biased sharply upward by the inclu-
sion of village No. 13, a lower foothill village fringing on the Terai. The lower rates
for this region, with the data for village No. 13 excluded, are shown separately by
dotted lines on Figure 16.
From these data one can see three separate kinds of

slopes-a low slope in the western and central mountains
(roughly equivalent to tlult found in Hawaii), a very steep slope
in urban Kathmandu, and an intermediate pattern found in all
parts of the Terai and in the eastern mountains.
TABLE 16 CHEST X-RAY READINGS IN 14 SAMPLING SITES
Poor quality fIlm, probably normal 55

Good quality fIlm, normal 1326
Poor quality fIlm, probably tuberculosis 3
Good quality fIlm, advanced tuberculosis 10
Good quality film, minimal tuberculosis, probably active 60
Good quality fIlm, tuberculosis, probably inactive IS
Other lung disease (emphysema, chronic bronchitis, etc.) 52
Enlarged heart 57
Unreadable films 117 Readable films 1578
An attempt was made to take a full-sized chest x-ray (P-A,

32-inch tube to film distance) on everyone age 14 and over.
Because of severe logistical problems in receiving an air ship-
ment of fresh film from Hong Kong every month (interrupted
by the India-Pakistan war), and problems of film storage and
development in Nepal, about 7 per cent of the films were
unreadable, and out of the 19 sampling sites no films were
9 0 ~ - - - ~ --.
80
70
,r 60
z
0
j:
t.l
oct
w
a:
w lJO
>
j:
iii
0
a..
....J: 40
~
w
Cl
oct
....
Z
w 30
t.l
a:
w
a..
20
10
o 0-4 lJ-g
AGE IN YEARS
FIGURE 16. Tuberculin (Tine Test) positive rates (:;;;. 3mm induration) by age and
geographical region
taken in five (two in the eastern Terai, one in the eastern

mountains, one in the central mountains, and one in the far
western mountains). Table 16 shows the results.
These data reveal that 4 per cent of the chest films show
probably active tuberculosis, but with only one-seventh of these
showing other than minimal lesions. Due to the relatively small
number of positive films, it is not possible to draw any firm
conclusions about regional prevalence from these x-rays. One
can safely say, however, that these films showed that pulmo-
nary tuberculosis is widely disseminated in Nepal, and that a
high proportion of lesions is minimal. It should be noted here
that in western mountain villages with a considerable number of
chest x-rays suspected of showing minimal tuberculosis, there
were very low tuberculin positive rates, yet many people gave a
history of bloody sputum. This raises the question of paragoni-
miasis, which is discussed later in this report. .0(
Of the 157 sputum smears examined on clinical suspicion ..,c::

of tuberculosis, only one showed acid-fast bacilli (and that in a
village where no x-rays were taken). The occasional history of
bloody sputum was widespread except in the eastern hills. This
is a very non-specific sign, however, especially since paragoni-
miasis is known to occur, at least in the west-central hill area
not covered by this survey.
One may conclude from the' above evidence that tubercu-
losis, though widespread, is not nearly as serious as it is in
Kathmandu, where crowding is great and protein nutrition is
very poor. The western and central mountain regions are still
relatively free of disease, a fact presumably related to infre-
quent travel, assisted in the west, perhaps, by a rather good level
of protein nutrition.
Smallpox is much more easily transmitted than is tubercu-
losis and it tends to burn quickly through all available suscep-
tible people in a village, leaving all the survivors with good
immunity and a fair proportion of them with characteristic
scars. Data from this survey are based on the presence of
smallpox scars or vaccination scars. It should be remembered,
however, that the presence of a "vaccination" scar does not
necessarily mean that an immunologic event has taken place, as
the scar may have been produced by secondary bacterial

infection only. Questions were asked as to age when first
vaccination was performed. These questions were not answered
with enough completeness or precision to allow any rigorous
analysis, particularly the questions about the most recent
vaccination. In general, first vaccinations in rural areas tend now
to be given between 1 and 5 years of age, but in Kathmandu
they tend to be given in infancy. Vaccinations in Kathmandu
tend to be done by physicians, while lay vaccinators are quite
active in rural areas, particularly in the Terai. Table 17 summa-
rizes the range of percentages of people found with scarring.
These scarring data should be viewed with caution, because
smallpox epidemics in regions of limited travel might be quite
spotty in distribution and, therefore, subject to a very large
sampling error when only a small number of villages are visited
in each region. These data, however, show a rather limited
TABLE 17 PERCENTAGE OF PERSONS IN EACH VILLAGE WITH SMALL-

pox OR VACCINATION SCARS; BY AGE AND GEOGRAPHICAL
REGION
% of persons showing scarring (by age

Type of group)
Region Scarring 0-9 yrs. 10-29 yrs. 30+ yrs.
Western Mts. smallpox 0-16 3-27 0-27

vaccination 35-72 84-99 91-100
Central Mts. smallpox 0-1 0-3 1-5

vaccination 21-76 92-100 97-100
Eastern Mts. smallpox 0-1 0-3 0-5

vaccination 81-95 94-97 96-98
Eastern Terai smallpox 0-42 3-43 2-23

vaccination 29-85 53-91 73-93
Mid- & Far-west Terai smallpox 0-7 5-7 4-10

vaccination 21-75 41-80 68-93
Urban Kathmandu smallpox 6 13 24

vaccination 83 80 55
experience with smallpox in all three age groups in the central

and eastern mountains, with a much wider range of experience
in the western mountains (some villages with almost no experi-
ence, and some with a heavy experience). The eastern Terai,
with five villages studied, also shows a wide range of experience.
The vaccination data reveal a disturbing pattern in all rural
areas (except perhaps in the eastern mountains)-a relatively
low level of vaccination in the very numerous 0-9 age group.
This is very likely related to rather infrequent visits by the
vaccinator, which allows the accumulation of a large number of
unvaccinated children between visits, and allows the falling off
of immunity of previously vaccinated adults. The stage is
therefore set for a continuation of sporadic epidemics intro-
duced from across the border, with accompanying child mortal-
ity and interruption of the economic life of the village. It is
generally accepted that good vaccination status (within three
years), with live vaccine, of at least 85 per cent of the .,c:
population will lead to permanent and complete control of the
disease. The data would indicate that Nepal is approaching this
level only in the eastern mountains, judging from a very limited
sample of three villages, and the unreliable data of "vaccina-
tion" scarring.
CHAPTER EIGHT
Fecal Contamination
CaNTAMINAnON of the environment from
fecal deposits may lead to the infection of man directly from
the soil via skin or mouth (hookworm, Ascaris, Trichuris), from
the water supply (typhoid fever, poliomyelitis, amoebic dysen-
tery, cholera), or from food via hands or flies (amoebic
dysentery, salmonellosis, shigellosis, cholera).
Fecal smears were routinely made on a subsamp1e of all 4-,
.~
8-, and 12-year-01d children at each sampling site, then stained
III
m
and concentrated by the merthio1ate-iodine-formalin method
!!! (Kuntz, 1960). A total of 347 such smears were read, with the
'" results as follows:
Number of Per Cent of

Specimens Those Examined
Some parasites or ova 250 72

Hookworm 128 37
Ascaris 106 31
Trichuris 76 22
Entamoeba hystolytica 23 7
Hymenolepis nana 15 4
Giardia lamblia 7 2
Other or unidentified 17 5
No parasites or ova* 97 28
* Specimens with only Entamoeba coli cysts are included in this category.
72
DISEASES TRANSMITTED BY FECAL CaNTAMIN AnON 73
The percentages add up to more than 100, since multiple

infections were common, especially combinations of the first
three species. Due to the small numbers, no rigorous statement
can be made about regional distribution, but the species were
generally found in all regions studied, including urban Kathman-
du. This merely confirms the observation of a general fecal
contamination of the soil in all locations. The surprisingly low
prevalence of Ascaris (31 per cent compared to the 70-80 per
cent expected) is hard to explain except on the basis of freezing
winter temperatures, which might somewhat reduce the envi-
ronmentalload of eggs containing living larvae.
The presence of a small number of hookworms usually
does not cause disease. Hookworm disease is characterized by a
large number of worms per person (usually over 200) so that
there is enough daily blood loss to cause anemia (and thus lower
the work capacity of the anemic person and also lower his
resistance to other diseases). When blood was drawn into ..........
heparinized microhematocrit tubes during the examination, the
tubes were centrifuged at about 12,000 rpm for three minutes,
and the hematocrit was read. Over 4,000 microhematocrit
readings were thus obtained. The results for the males are
summarized in Table 18.
A comparison of fecal smear data and hematocrit data
showed no correlation between villages with many low hemato-
crits and villages with much hookworm. There is no evidence
here of a serious problem of hookworm disease, and we shall
have to look further for an explanation of low hematocrits in
certain villages.
The group of diseases transmitted primarily via the water
supply can be illustrated by two kinds of measurements. First,
unilateral muscular paralysis and wasting in the extremities
(without other nervous system involvement) was observed in a
small number of people (1 to 9) in virtually every village
studied, and these people represented both sexes and all ages.
This observation almost certainly represents the residual evi-
dence of a universal poliomyelitis infection at a young age,
giving rise to only a small percentage of people with neuromus-
=~~ :!!.!~~ !jI!~.!'='!, ~! !!'"l! ~! ff'V~ ~ Po.u"!
TABLE 18 DISTRIBUTION OF 2,214 MALES BY HEMATOCRIT READING, AGE, AND GEOGRAPHICAL REGION
Hematocrit Reading
Region Age No. read <20 20-24 25-29 30-34 35-39 40-44 45-49 50+ X % Low*
Western Mts. 0-4 38 1 0 4 1 11 17 5 0 0 35.1 13

5-9 60 0 0 1 I 12 34 12 1
1_ _ _ _ _ 0 35.4 2
10+ 388 4 4 13 33 1 82 133 100 19 44.9 13
r - - __ I
Central Mts. 0-4 34 0 0 1 1 4 22 5 1 1 38.0 3
5-9 66 0 0 2 1 9 36 18 1 0 39.5 3
1-----
10+ 289 0 0 9 10 I 59 127 79 5 42.5 6
r- - - __
I
Eastern Mts. 0-4 30 0 0 0 1 3 19 8 0 0 38.3 0
5-9 64 0 0 0 1 2 38 21 2 1 40.0 0
1-----
10+ 225 0 0 2 7 1 39 99 65 13 43.2 4
, _ - __ I
Eastern Terai 0-4 48 1 0 3 1 14 25 5 0 0 35.5 8

5-9 106 0 0 4 1 32 53 15 2 0 36.5 4
1-----
10+ 515 2 4 15 42 1 149 202 96 5 40.6 12
1- - - __ I
Midwest and 0-4 23 0 0 4 1 14 5 0 0 0 32.7 17

Far-west Terai 5 - 9 29 0 0 2 1 9 17 1 0 0 35.4 7
1-----
10+ 197 0 0 5 23 1 79 18
72 0 40.8 14
1 - - - - -I
Urban 0-4 3 0 0 0 1 1 1 0 1 0 - 0
Kathmandu 5-9 21 0 0 0 1 2 12 6 1 0 34.1
1- _ - - -
0
0 1 20
10+ 89 0 0 0 I
41 19 9 43.4 0
.... A 'Pa:\.ho\.o~\.c.a.\.\.y \.ovy heTna1:.oc.r\.1:. is arnh.ra.rily def"lned as on.e f"alling t.o t.he le£t. of' t.he dotted lines in this table.
DISEASES TRANSMITTED BY FECAL CONTAMINATION 75
cular damage. Here again we have presumptive evidence of

widespread contamination of water supplies.
Second, some of the plasma from heparinized microhema-
tocrit tubes was used to perform an agglutination test for
typhoid 0 antibodies (using Lederle Salmonella Group D
antigen) at a level roughly equivalent to a 1:80 titer in a
standard tube agglutination test (Worth 1964a). Preliminary
trials of this screening procedure in Hong Kong villages had
shown a very reliable correlation with the degree of potential
contamination of village water supplies. This method is useful
where typhoid immunization is rarely practiced. A total of
4,602 such tests were completed in Nepal (373 for the 0-4 age
group, and 4,229 for those age 5 or older). As may be seen in
Table 19, for the 0-4 age group 36 per cent showed agglutina-
tion, and 46 per cent for all those age 5 or more. This implies a
major prevalence of Salmonella typhi organisms in Nepal, with
water as the probable vehicle for infection early in life and for
frequent re-infection thereafter to maintain detectable levels of
this short-lived 0 antibody in almost half the population. The
percentage of agglutinating specimens from each village ranged
from a low of 22 per cent to a high of 85 per cent. The
percentage of agglutinating specimens in each village related
quite well with the potential contamination of the village water
supply detected by visual inspection as described in Chapter 2.
In general, villages with a municipal or a drilled-well supply had
positive agglutinations in the range of 22-27 per cent. One
village (No. 13) that also fell into this range got its water from a
large river, where the dilution factor must have played a role.
The highest percentage of agglutinations (45-85 per cent) were
found with poorly protected dug wells or irrigation ditches as
water sources. Mountain springs or streams were associated with
agglutinations in the intermediate range of 32-52 per cent.
Godar (village No. 03), which had experienced a recent cholera
epidemic and had suffered 46 deaths (8 in one household) out
of a population of 466 in the prior year, had two dug wells,
both of them poorly protected.
As long as village water supplies are poorly protected,
diseases transmitted by fecal contamination will contribute
iHi :ftt,~~ :fi;~,H ~ ~ !~ ~ ~ ft'V"; ~ f~fn
TABLE 19 DISTRIBUTION OF PERSONS SHOWING SALMONELLA GROUP D, 0 ANTIBODY TITERS AT 1:80
Age Q-4 Age 5+ All Ages

Persons with AggI. Persons with AggI. Number
Region, No., and Number
Neg. ? Pos. Tested Neg. ? Pos. Tested %Pos.
Village
WESTERN MTS.
13 Bhawanipur 16 0 8 24 170 2 61 233 22
15 Bajura 2 1 5 8 136 6 77 219 37
16 Dandagau 14 2 13 29 154 7 19 251 38
16 0 7 23 108 4 134 246 52
17 Talichaur
CENTRAL MTS.
00 Lamatar 2 4 6 12 20 19 94 133 70
01 Pardidhan 24 2 4 30 100 15 37 152 22.5
17 1 7 25 100 5 127 232 52
10 Piutar
12 Brahmin Dada 10 0 2 12 121 9 95 225 41
EASTERN MTS.
04 Debatax 14 0 4 18 114 10 61 185 32
'25 125 2 89 216 38
(}..' , ~~':':~~~~~g '2'2 0
~ 127 2~7 50
r b-.A.S-r.ER/V
TERAI
03 Godar 16 4 7 27 130 30 132 292 44
05 Dulari 2 0 10 12 59 7 123 189 66
06 Jhapa Bazar 20 0 7 27 140 4 144 288 48
08 Ramnagar 7 0 16 23 29 0 178 207 85
09 Kathariea Tola 4 0 8 12 41 3 139 183 76
MIDWEST TERAI
02 Kathauti 19 0 6 25 158 22 67 247 27
FAR-WEST TERAI
14 Kailali 12 1 4 17 160 7 53 220 24
URBAN
18 Inbaha 8 0 6 14 146 4 124 274 45
TOTAL 234 15 124 373 2120 162 1947 4229
liH1fr.·H! ln1MVH iU AliJO::;I\1i'iH

heavily to infant and child mortality, to some extent to young

adult mortality, to a continuing load of illnesses at all ages, and
will set the stage for periodic disastrous local epidemics of
cholera introduced from across the border. These epidemics can
lead to severe social and economic disruption of the life of the
village.
The data support the general contention that protection of
water supplies through engineering will probably yield quicker
(and more socially acceptable) results in disease prevention than
the socially difficult control of promiscuous defecation. The
soil-borne parasitic infections related directly to promiscuous
defecation are probably of less disease-producing importance in
Nepal than those infections mediated by contaminated water.
it'
This is not to imply that the gradual conversion to a proper
".. ~I
~~:: latrine system should not also be a long-range goal, but it should
have a lower priority than efforts to give direct protection to
r water supplies.
CHAPTER NINE
Insect Vectors
THE distribution of and severity of diseases

transmitted by insect vectors are governed by the distribution
of the specific vectors for each disease and by man's relation-
ship to them. The one disease in Nepal about which the most
accurate information is available is malaria, thanks to the very
good efforts of the malaria control program. It is not antici-
pated that the data from this general survey will add anything
to the knowledge of malaria in Nepal.
After the microhematocrit for each person in the survey
was read, a thick smear was made from the red cells just below
the buffy coat. The centrifugation produces at this level a very
good concentration of vivax-parasitized and a less good concen-
tration of falciparum or malariae-parasitized red cells (Worth
1964b). A village-by-village comparison of low-hematocrits and
malarial parasite rates (see Table 20 for the results of 4637
smears examined for malarial parasites) shows a good correla-
tion, except that there are a few eastern Terai villages where no
malaria was found and where there were many low hematocrits.
During physical examination each person was palpated for
enlargement of liver and spleen, which were counted as enlarged
if they extended one or more finger breadths below the costal
margin. Table 20 shows that enlargement of the spleen or liver
in children 0-4 years of age correlates very well with the
presence of smears positive for malarial parasites. The excep-
tions were in villages No. 08 and No. 09 in the eastern Terai,
79
!~v~~n !r~i~~li f,--'1 ~ tlr'¥1/Uf\ftl
TABLE 20 MALARIA FINDINGS FROM 4,637 SMEARS
% with % with
Enlarged Enlarged
Smears Liver Spleen
% with
Region, No., and P. falciparum P. falcipa- All All "Malaria"
Village Total Neg. p. vivax & P. vivax rum P. malariae 0-4 Ages 0-4 Ages History
WESTERN MTS.
13 Bhawanipur 253 205 20 8 20 12 18 24 45 85
16 Dandagau 282 281 1 1 11 0 1 45
17 Talichaur 267 266 1 3 11 2 1 25
CENTRAL MTS.
00 Lamatar 145 145 0 1 0 0 30
01 Pardidhan 178 168 0 0 2 1 6
10 Piutar 257 256 1 0 6 0 1 12
12 Brahmin Dada 233 233 0 1 0 2 18
EASTERN MTS.
04 Debatar 202 202 0 1 0 1 9
01 Sakkejung 231 229 2 0 1 0 1 15
'\- '\- 'P"hu."\.-paV>l 247 247
EASTERN
TERAI 0 1 6
0 1
03 Godar 318 318 20
0 1 0 3
05 Dulari 199 194 5
0 4 0 9 40
06 Jhapa Bazar 315 315
18 13 2 4 20
08 Ramnagar 219 219
3 4 0 2 20
09 Kathariea Tala 192 192
MIDWEST
TERAI 0
0 0 0
02 Kathauti 272 272
FAR-WEST
TERAI 64 71 91
133 32 15 54 3 34 45
14 Kailali 237
URBAN 0 8
1 4 0
18 Inbaha 270 270
id, ~fftfi! IfQ iT", n jV Ail JU~i lit ~i,

where one might consider other explanations, such as kala-azar

(visceral leishmaniasis), which is known to be present in that
area.
In each village the people were asked if they had experi-
enced the symptoms of malaria during the previous year. There
were positive replies to this question in every village, ranging
from just one person to as high as 91 per cent of the people
examined (Table 20). Where we found plenty of malaria by
smear, more than half the people responded affirmatively to
this question. There were several villages, however, where we
found no malaria, but where a considerable proportion (18-
40 per cent) said they had had the symptoms. These were
eastern Terai and central mountain villages, and the explanation
may either lie in a relatively small number of malaria cases, not
detected at the time of this survey, or, more likely, other febrile
illnesses with somewhat similar symptoms.
One may conclude from these data that malaria control
has progressed very well in the central parts of Nepal, but that
there is some remaining in the extreme eastern parts and quite a
lot left in the far west. Where it exists, malaria very likely
contributes heavily to the cases of anemia found, with hook-
worm contributing in a much less significant way.
I ARBOVIRUSES
There are a large number of arthropod-borne virus diseases, plus
some rickettsial ones, that can cause febrile symptoms mimick-
ing malaria to some extent. In order to ascertain the prevalence
and distribution of such arthropod-borne diseases, two filter
paper discs were soaked with finger-prick blood from each
person examined, allowed to dry overnight, and then stored
at-20° C (Worth 1964c; Brody 1963; Sever 1962; Adams 1956;
Karstad 1957). These discs were shipped to the Department of
Microbiology, University of Maryland Medical School, where
under the supervision of Dr. Charles Wisseman, Jr., a large
battery of serological tests using micro-methods were run on
their eluates.
The object of the arbovirus antibody study was to gain
information on the frequency of occurrence and distribution in
Nepal of arbovirus infections of man caused by members of

Group A and Group B arboviruses. The serological methods
employed were designed to give the broadest coverage possible
for these two important arbovirus groups, with reasonable
effort and cost. They were not designed to identify specific viral
members of the groups, a task far beyond the capabilities of the
hemagglutination-inhibition test. Indeed, without detailed
knowledge of the viruses that occur in the region, laboriously
established by isolation and characterization of the agents,
which is a long-term task for a well-staffed and equipped
medical-epidemiological-laboratory team, even the most sophis-
ticated tests available today could only give provisional results.
.0'
Hence, the objectives have been limited to studies on the w
occurrence or non-occurrence of infections caused by any

member of each group, insofar as the tests employed will
permit.
Because the number of specimens greatly exceeded the
capacity of the laboratory time and personnel that could be
devoted to this project without acquiring additional financial
assistance, the following sampling method was employed to
select discs for testing. It depended upon the following assump-
tions:
1. Hemagglutination-inhibiting antibodies to arboviruses

persist for long periods of time, and the serum of an individual
person bears a cumulative record of antibody responses to
arbovirus infections acquired over the years.
2. The family or household unit provides an unique
ecological unit in which members are exposed more uniformly
to a given arbovirus infectious environment than is a random
sample of the general population. Because arboviruses are
transmitted by insects and ticks, their distribution in an area
may not be uniform. Since family or household units tend to
sample the full range of distribution of age and sex in more or
less the proportion that they occur in the population, family or
household units would provide population samples exposed to a
wide variety of discrete arbovirus settings. Thus, age distribu-
tion of antibodies within a family unit might provide a clue to
the time in the past that there was arbovirus transmission in

that given locality. This does not, however, take into account
the fact that certain members of the household may actually
work more or less regularly in other areas or travel from time to
time to other regions. Since such travel and work is often a
function of the role of the sex, as well as age, of the individual,
analysis of antibody occurrence by sex would be expected to
reveal any marked influence of these factors.
On the basis of these assumptions, sampling was done on

a household basis, using the principle of the single immunologi-
cal sentinel, i.e., the person in each household who would most
likely show evidence of arbovirus infection, if it occurred in
that microhabitat. It was assumed that the older a person is, the
more likely that he would have been subject to arbovirus
"'''''I
infection over the longest period of time. Thus, insofar as
r'" possible a single person was chosen from each family, usually
"::~"i
the oldest member, which was often the husband or wife. Male
and female were alternated for sequential households of a given
area. All households for which adequate specimens existed were
tested. Because of certain technical difficulties, there was a
small amount of deviation from the principle of the oldest
person, but at least one member of each household for which
specimens were available was tested. Despite these minor devia-
tions from the ideal, analysis of the overall distribution of age
and sex of the household sentinels, recorded in Table 21, reveals
that over 97 per cent of the sentinels were 20 or more years old,
with some in their 70's and 80's, and that the sex distribution
was reasonably equitable in the various age groups.
Each sentinel was tested for antibodies with three
Group A and three Group B antigens. When a sentinel was
found to react positively to any antigen, it was assumed that his
household represented an area of arbovirus activity, and all
members of that household were then tested with all six
antigens to determine frequency of occurrence within that
microhabitat, and age and sex distribution. Members of the
households whose sentinel gave negative results were not tested.
Studies in the last few years have indicated that the early
TABLE 21 AGE AND SEX DISTRIBUTION OF HOUSEHOLD SENTINELS
Age Male Female Total Per cent
<10 3 0 3 0.3
10-19 6 14 20 2.3
20-29 74 74 148 16.8
30-39 118 121 239 27.2
40-49 112 93 205 23.3
50-59 71 54 125 14.2
~60 60 79 139 15.8
TOTAL 444 435 879
PER CENT 50.5 49.5

..I'.."
,
antibody response to certain, and presumably most, arbovirus
infections consists mostly of the 19 S or IgM variety, but that
this gives way within weeks to a dominantly 7 S, presumably
IgG, type of antibody. Very recent studies on the stability of
the various species of hemagglutination-inhibiting antibodies to
yellow fever virus, an arbovirus of Group B, have shown that
the early or IgM antibody is very unstable when stored dried on
filter paper discs but that the IgG antibodies, which develop
later, are relatively stable. Hence, in this study, IgM antibodies
would not likely be detected, and the method might fail to
detect infections which had occurred within the two to four
weeks prior to taking the specimen. This, however, is not likely
to influence the results of the present study to any great extent
(Wisseman 1967).
Sera were tested with hemagglutinating antigens prepared
from the following mouse brain-grown Group A and Group B
arboviruses:
Group A Group B
Sindbis (SBS) Edge Hill (EH)
Eastern equine encephalo- Murray Valley encephalitis
myelitis (EEE) (MVE)
Sernliki Forest (SF) Langat (LGT)
These viral antigens were chosen primarily to provide very

broad and sensitive group coverage and only secondarily to
represent agents of theoretical endemicity in the region. No

attempt has been made to identify infecting viruses beyond
their group. Thus, in Group A, Sindbis virus is endemic in India;
EEE virus represents another antigenic complex within the
group; and SF virus has been a sensitive Group A antigen in
other sero-surveys of Australasia. Chikungunya virus, which has
caused large outbreaks in the India plains, was not employed,
since it has a tendency to give many non-specific positive
reactions.
In Group B, Murray Valley encephalitis and Edge Hill have
in the hands of Dr. Wisseman shown the broadest cross-
reactivity and sensitivity and detect a wide range of Group B
arbovirus antibodies. Indeed, Edge Hill appears unusually sensi-
tive and may possibly yield some false positive reactions. Langat
virus represents the distinct sub-group of tick-borne viruses
within Group B.
Blood dried upon filter paper discs was eluted prior to
C
•..·11 testing by soaking overnight at 4° C in Tris buffer in a strong
conical centrifuge tube and then squeezing the disc with a metal
rod to express all possible eluate. In the same tube, the eluate
was treated with Kaolin to remove non-specific inhibitors of
hemagglutination and, finally, adsorbed with goose erythrocytes
to remove hemagglutinating antibodies for goose erythrocytes.
The hemagglutination-inhibition test, employing 4-8 units
of viral antigen prepared by the sucrose acetone method, was
carried out by the microtiter technique, using goose erythro-
cytes. Because of the very large numbers of tests involved, each
serum was tested at a single dilution of I :20 and was scored as
positive or negative. This dilution of serum was chosen as the
lowest dilution which distinguishes reasonably regularly be-
tween non-specific and specific inhibition of hemagglutination.
The sentinels of 868 households out of the 957 (90.7 per
cent) in all villages were tested for the presence of Group A and
Group B antibodies. The results from each village are summa-
rized in Table 22. It is readily apparent that antibodies which
reacted with any of the Group A antigens were very rare,
whereas antibodies which reacted with one or more of the
DISEASES TRANSMITTED BY FECAL CONT AMINA nON 87
TABLE 22 PREVALENCE OF GROUP A AND GROUP B ANTIBODIES

AMONG SENTINELS
Families Positive
Region, No., Altitude No. Families Group A Group B
and Village (ft) Listed Tested No. % No. %
WESTERN MTS.
13 Bhawanipur 1100 51 49 0 0 13 26.5
15 Bajura 4500 59 52 0 0 12 23.1
16 Dandagau 5400 36 26 0 0 4 15.4
17 Talichaur 7600 40 39 1 2.6 8 20.5
TOTAL 186 166 1 0.6 37 22.3
CENTRAL MTS. .
00 Lamatar 4700 34 33 0 0 5 15.1 "
:1:
01 Pardidhan 2900 49 45 0 0 0 0 :,
10 Piutar 3200 45 45 0 0 10 22.2 :1
''>
12 Brahmin Dada 4500 47 44 1 2.3 5 11.3
TOTAL 175 167 1 0.6 20 12.0 ~.
;:)
1'1
EASTERN MTS.
04 Debatar 4000 32 32 0 0 9 28.1 I::
il>
07 Sakkejung 4400 42 38 0 0 0 0
11 Phulpaw 12
IE
3500 58 50 0 0 6 :>
TOTAL 132 120 0 0 15 12.5 !::
.•
IE
EASTERN TERAI J"
tol-~
03 Godar 550 79 74 1 1.3 3 4.6 r·
05 Dulari 350 39 34 0 0 1 2.9 I'~
06 Jhapa Bazar 350 64 59 3 5.1 24 40.7
08 Ramnagar 575 64 60 0 0 13 21.7
09 Katheriea Tola 400 45 41 0 0 3 7.3
TOTAL 291 268 4 1.5 44 16.4
MIDWEST TERAI
02 Kathauti 500 59 57 1.8 20 35.1
FAR-WEST TERAI
14 Kailali 500 41 39 0 0 11 28.2
URBAN
18 Inbaha 4500 73 51 0 0 5 9.8
TOTAL 957 868 7 0.8 152 17.5

Group B antigens were relatively common, ranging from very

low to moderately high. Since conditions for the breeding of
mosquitoes and other arthropods and for the transmission of
viruses might differ between mountainous and plains regions, as
is the case in some other parts of the world, the distribution of
antibodies among sentinels from mountainous, low-lying Terai,
and urban areas were compared with one another. The results
are summarized in Table 23. It is evident that no great
differences existed between the mountainous and low plains
areas. The urban sample, which was from an altitude of 4,500
feet, was relatively small, and limited significance can be placed
on the fact that the frequency of reactors was somewhat lower
here than in the other two areas. Another analysis, not tabula-
ted here, in which the villages were divided into two groups on
the basis of altitude alone, failed to disclose any great difference
between the prevalence of antibodies in "highlands" and "low-
lands." In both categories, there were villages with very low to
zero prevalence of Group B antibodies, suggesting some unusual
ecological features. One possible explanation may lie in the
observation that the villages with low Group B prevalence
tended to be those that were several miles from the nearest large
river.
Failure to detect real differences in antibody frequency
between lowland and mountainous regions was somewhat sur-
prising. However, many of the villages in the mountainous
regions lie on the floors of valleys which gradually rise from the
plains along river systems, and they enjoy a moderate climate
due to this protected situation. Moreover, such villages are often
TABLE 23 PREVALENCE OF GROUP A AND GROUP B ANTIBODIES

AMONG SENTINEL GROUP, ACCORDING TO GENERAL CATE-
GORY OF HABITAT
Total Group A Group B

Region Tested No. Pos. % Pos. No. Pos. %Pos.
Mountains 453 2 0.4 72 15.9

Terai 364 5 1.4 75 20.6
Urban 51 0 0 5 9.8
DISEASES TRANSMITTED BY FECAL CONTAMINA nON 89
associated with irrigation systems which provide oases for the

breeding of mosquitoes in an otherwise inhospitable environ-
ment. Thus, conditions suitable for arbovirus transmission
probably exist well into the mountainous regions. It should be
remembered that the three highest altitude villages in the survey
sample (in the eastern mountains) were not examined due to
logistical problems in the field.
The extremely low prevalence of Group A antibodies
makes of limited value the detailed analysis of the distribution
of antibodies within the positive households. Nevertheless, it is
of interest that in five of the seven positive households, the
sentinel was the only person positive. This may be indicative of
the importance of travels out of Nepal as a source of these
infections. In the remaining two households, the incidence of
antibodies was 3 out of 4 and 6 out of 11. The youngest person
with antibody in any of the families was 5 years old. The
relative frequency with which the different Group A antigens
employed detected antibodies was: Sindbis, 13; Eastern equine,
2; Semliki Forest, 1.
When all members of the households in which the sentinel
showed Group B antibody reactivity were examined for Group
B antibodies, an unusually high prevalence was observed, with
an overall positive rate of 64.9 per cent as compared with 17.5
per cent positive rate among the more randomly selected
sentinels. This suggests that, indeed, this sub-population of
households was at greater risk of Group B arbovirus infection
than the population as a whole. The prevalence of positive
reactors in individual households ranged from 29-100 per cent.
No remarkable difference in the prevalence of antibodies was
found between the sexes. Antibody occurrence was not greatly
dependent upon age, suggesting that in these villages there has
been Group B arbovirus transmission rather generally within the
past five years, affecting all age groups. I
FILARIASIS
The centrifugation of blood in heparinized microhematocrit
tubes also serves to concentrate microfilariae in and just above
the buffy coat layer; thus any microfilariae in the specimen are
virtually all included in the thick smear made for malaria by

cutting the tubes just below the buffy coat (Worth 1964b).
Since most microfilariae in Asia demonstrate nocturnal perio-
dicity, and most of the blood specimens were taken during
daylight hours at the time of physical examination, the examin-
ation of these same smears for microfilaremia represented a
rather insensitive screening device for filariasis. Nocturnal
smears were made routinely in some villages, however, as
indicated in Table 24. For everyone examined it was also
recorded whether or not he had unilateral edema of the
extremities (presumptive elephantiasis).
The distributions of unilateral edema and of the 26
positive smears out of 4,528 smears reported would lead to the
conclusion that filariasis is present in the central mountains
around Kathmandu, extending into the eastern mountains and
down into the eastern and midwestern Terai. One could further
conclude that filariasis is not a major public health problem in
the areas surveyed, since this disease does not usually contribute
to mortality, and contributes significantly to morbidity only
with repeated reinfection and febrile attacks, eventually leading
to elephantiasis. The heaviest prevalence of either microfilare-
mia or of elephantiasis was in Kathmandu Valley itself, where
the prevalence was still relatively low.
The entomological collections made on the survey by
personnel of the Bishop Museum (Honolulu) and the Institute
for Medical Research (Kuala Lumpur) focussed primarily on the
ectoparasites of small mammals, to explore the potential distri-
bution of plague, flea-borne typhus, and scrub typhus. Their
reports are to be found in Appendix B. In summary, collections
were made from September, 1965, to January, 1966 in Kath-
Mandu Valley, Pokhara Valley, up the Trisuli Valley to the
Langtang Valley and along the Langtang Valley northward to
11,1 52-foot elevation near the border. Collectors then moved
with the medical team to Jhapa (No. 06) on the eastern Terai,
up to the Ilam-Sakkejung area (No. 07) in the foothills, and
there to the Rapti Valley, where collecting was discontinued.
We have, therefore, samples from eastern Terai and foothills,
central lower valleys, middle mountain, and northern valley
areas. We have no collections from western Nepal.
TABLE 24 MICROFILAREMIA AND ELEPHANTIASIS PREVALENCE IN

4,528 SMEARS TESTED
MicrofIlaria Smears* No. with

Region, No., and Unilateral Lymphedema
Village Total Neg. Pos. of Extremities
WESTERN MTS.
13 Bhawanipur 252 252
15 Bajura 217 217
16 Dandagau 282 282
17 Talichaur 267 267
CENTRAL MTS.
00 Lamatar 147 140 7 13
01 Pardidhan 178 178
10 Piutar* 257 257
12 Brahmin Dada 233 233
EASTERN MTS.
04 Debatar 202 201
07 Sakkejung* 230 230
11 Phulpaw* 247 247
EASTERN TERAI
03 Godar 319 319
05 Dulari 199 199 1
06 Jhapa Bazar* 307 302 5
08 Ramnagar* 220 220
09 Kathariea Tola* 192 192 1 '""I
i~:
MIDWEST TERAI
02 Kathauti 271 267 4
FAR·WEST TERAI
14 Kailali 234 234 1
URBAN
18 Inbaha 274 265 9 3
• All smears taken in daytime except those from villages marked with asterisk, where
nocturnal sampling was done.
The entomologists were delighted with the rich discovery

of small mammal ectoparasitic fauna. The trombiculid mite
vectors of scrub typhus were plentifully present on rats at
Virtually all collection sites, from the lowest Terai up to 11,152
feet in the Langtang Valley. Several new species were described
from this limited collection (from 305 hosts). Likewise, the rats
were liberally supplied with fleas, and several new subspecies
and species were described, and possibly a new subgenus and a
new genus. Xenopsylla cheopis, the very efficient vector of
plague and flea-borne typhus, was found in large num bers on rats
in Pokhara Valley, and much less frequently along the Trisuli
and Langtang Valleys. It was not found in fairly extensive rat
trappings in the Ham area in the eastern foothills, nor in
extremely limited rat trappings in the Rapti or Kathmandu
Valleys.
It should be noted that the medical team found a high
prevalence of lice in many villages, but they did not differenti-
ate in their reports between Pediculus capitis, Phthirus pubis, or
Pediculus corporis; and only the latter is a vector of louse-borne
typhus, which is reputed to occur in higher altitude, cold-winter
areas of Nepal. Complement-fixation tests were done for louse-
borne typhus antibodies in the eluates of the same filter discs
that were used for the arbovirus studies reported above. Due to
a laboratory delay, these results will have to be reported later.
CHAPTER TEN
Other Conditions
EYE
Specific nutritional conditions that relate to the eye have been
discussed above. In this section, summaries of investigations
into visual acuity, cataracts, and trachoma will be reported.
These data are based on a visual acuity test done with a ,'.,
standard "illiterate" chart at 20 feet, plus an inspection of the ...
~,
eyes during the routine physical examination. 0,

III"
Figure 17 shows the percentage of people, by three

age groups, at each of seven screening levels of visual acuity in
the right eye. The curves for the left eye are virtually identical
to the right but are not reproduced here. One sees a marked loss
of visual acuity over age 50 and a very high level (18 per cent)
of blindness in this age group. Even in the 20-49 age group,
one sees a figure of 2'l1. per cent blindness, which is enough to
cause a real economic impact, since this is the age group that is
mostly responsible for economic productivity. The percentage
of blindness reported here may well be somewhat biased
upward, since blind persons may be more likely to report for
examination than others. The minimum estimate of blindness
for those over age 50 would be the number found blind over the
total population of that age in the survey sites. This is 76/536,
or 14 per cent.
Table 25 shows a more detailed breakdown of blindness
according to age and sex of those persons affected. There were
139 blind right eyes, 135 blind left eyes, and 106 people with
bilateral blindness.
93
94 NEP AL HEALTH SURVEY
100r- "'\
90
~ 8-Gl = 5-19 years old

80
,
I
I br----il:> = 20-49 years old
\I 0--0 = 50+ years old
,
I
I
70 I
I
I
I
C
w
I-
..-"II",., til
w 60
~:~:: I-
...."1<
i;::n
W ,
1I!t:::U 1
til
0 ,
I
.1"::1
::::-~
:I:
I-
u. 50
,,
I
~
.",
•.r,;::
0 ,,
.....,.
""f'l
W
C'
,,
ct
~; I-
Z 40 ,
I
I
:f.
~:
w
t.l
a: ,,
I
W
CL
,,
t:::
~~:
30 , I
~ "
~I::
I ,
...
iI'"I('."
:
20
10
2Q'2O-25 20/30 20/50 20,.70 20/100 20/20 0

VISUAL ACUITY
FIGURE 17. Visual acuity right eye, by age

OTHER CONDITIONS 95
TABLE 25 DISTRIBUTION OF BLIND EYES ACCORDING TO AGE AND SEX

OF THOSE PERSONS AFFECTED
Age
All
Sex 0-4 5-9 10-19 20-29 30-49 50+ Ages
Male 6 3 9 16 23 55 112
Female 5 3 4 13 41 96 162
TOTAL 11 6 13 29 64 151 274
This distribution shows a preponderance of blindness

appearing in females after age 30-almost double the male
prevalence. One does not have to look far to discover cataract,
the cause of most of the blindness in older age groups. Out of
365 people over age 50 whose lenses are described in the data
sheets, clouding of both lenses was described in 104 people (66
of them women). This gives an estimate of 28 per cent with
Ii
bilateral cataract, undoubtedly biased on the high side by the 'I'
fact that those with cataracts are more likely to present '"'
,.'
themselves for examination. If the base figure of 536 is used (all ",,,,
",
persons over age 50 in the villages visited), and if one assumes
that none of those who were not examined had cataracts, then
19 per cent have bilateral cataracts. This is a minimum figure,
and approaches the 14-18 per cent estimated prevalence of :::1
l<'"
'"
blindness described in this age group. No significant regional
pattern was noted in the prevalence of blindness or cataracts in
older people except that an exceptionally high prevalence of
blindness and cataracts was noted in one eastern mountain
village (No. 11) and one central mountain village (No. 10).
Regional blindness patterns among the very young have already
been discussed under vitamin A nutrition and gonorrhea.
Although an etiologic diagnosis of trachoma was not
possible under the conditions of this survey, the chronic
conjunctivitis and conjunctival scarring often associated with
trachoma were observed at a fairly high prevalence (5-10 per
cent) in villages No. 14 through No. 17 (the three higher
elevation western mountain villages and the far-west Terai
village), and at a lower prevalence (1-2 per cent) in three out

of the four central mountain villages and in all five of the
eastern Terai villages. It was not noted in the three eastern
mountain villages or the one midwest Terai village (No. 02), but
it should be mentioned that there may have been an error of
recording this item in this last village. The infiltration and
scarring of the corneal limbus seen in the later stages of
trachoma were seen only in the same villages noted above, but
very rarely, and not associated with any significant degree of
youthful blindness. That is to say, the 13 people between ages
10 and 29 who were bilaterally blind were not clustered in the
same villages in which there was other evidence of trachoma.
From this one may conclude that while trachoma is almost
certainly present, and present with a higher prevalence in the
west than in the rest of the country, it is in a relatively mild
form, does not apparently contribute significantly to blindness,
and cannot be considered a major public health problem at
present. The prevalence of acute and chronic conjunctivitis
noted in the dryer, dustier, western part of the country is,
however, high enough to be a considerable nuisance to those
involved, and may lower productivity to some degree.
EAR,THROAT, DENTAL
Routine examinations of the ear and throat were made, and
hearing acuity was routinely tested with a tuning fork.
Diseases of the external ear and drum were not remarkable
in their prevalence, but evidence of current or prior otitis media
were occasionally seen. Chronic mastoiditis was seen in only 6
out of the 5,011 people examined.
Bilateral severe deafness was distributed as shown in Table
26.
The possible relationship between deaf-mutism and cretin-
ism has already been discussed. The age distribution in Table 26
indicates only minor problems, with the usual appearance of
presbyacusis in older age groups.
Harelip was noted in only one person-an adolescent boy.
Severe throat infections were seen in only a few people-most
of them children. Diphtheria was not diagnosed, although very
likely present in the population.
OTHER CONDITIONS 97
TABLE 26 DISTRIBUTION OF BILATERAL SEVERE DEAFNESS BY AGE

OF PERSONS AFFECTED
D-4 yrs. 5-9 yrs. 10-19 yrs. 20-29 yrs. 30-49 yrs. 50+ yrs.
No. deaf 4 7 8 5 21 19
A routine dental inspection was made, during which the

number of carious teeth were counted, and periodontal disease
was rated as complete, partial, or absent. Table 27 shows the
age-specific prevalence of carious teeth and reveals a pattern
strikingly more favorable than that found in almost any urban
society with a developed economy. Even the people in the
urban Kathmandu sample did not deviate from this pattern of
few carious teeth in childhood, with a very slow accumulation
during adolescence and adulthood.
Figure 18 shows the same data in graphic form. No
significant regional differences were found, except that about
one-third of all the edentulous adults found were in one
village-Jhapa Bazar (No. 06). There must have been someone
in that village who pulled teeth!
In his survey of three high-altitude Bhotia villages, DUl}n ."
1111
~n
reported that the teeth were usually clean and free of caries, but '"
::u
he also reported virtually universal presence of at least some ..
.,u
degree of periodontal disease in persons over age 5, with

"gingival tissues reddened, swollen, and often spongy. The gum
surfaces generally intact and spontaneous bleeding was not
observed" (1962: 135). Table 28 shows a rather different pat-
TABLE 27 DISTRIBUTION OF PEOPLE BY NUMBER OF CARIOUS TEETH

AND BY AGE
Number of Carious Teeth

None 1-5 6-11 12+ Edentulous
Age No. % No. % No. % No. % No. %
0-4 860 95 29 3 3 1 0 0
5-9 559 83 102 15 11 1 1 1 0 0
10-19 820 81 184 18 13 1 1 1 0 0
20+ 1168 47 737 30 323 13 189 8 49 2
100
90
l:r----A - age 0-4

a-----t:] = age 5-9
80
Q Gl = age 10-19
&------0 = age 20+
70
w
Cl
_1'1 Cl:
~~
zw
....u
> 60
',~'"
1n;
'::til
a
,/":il I-
::"'; Cl:
-<:; w
....I
:::)
"1"\1
D.
aw 50
D.
X::
~~l'
:IF.
u.
a
w
,.,,, I
1::", Cl , I
::::: Cl: 40 \ I
....--"
~:I
,
I-
Z
w
.., CJ
lii:;: a:
w
\
\
....
:~.,:;
D.
30
\
\
q,
\\
\
\
20 \\
""
"~
10 ..........."'t:).
........
...........'l:!>
o
none 12+ edentulous
NUMBER OF CARIOUS TEETH
FIGURE 18. Distribution of people by number of carious teeth and by age

OTHER CONDITIONS 99
TABLE 28 DISTRIBUTION OF PEOPLE BY DEGREE OF PERIODONTAL

DISEASE AND BY AGE
Degree of Periodontal Disease

None Partial Complete
Age No. % No. % No. %
Q-4 547 98 10 2 1 1
5-9 408 91 38 8.5 3 1
10-19 533 76 168 24 2 1
20-29 265 38.5 385 56 37 5
30-49 148 17 504 57 234 26
50+ 17 6 107 35.5 177 59
tern in this nation-wide survey, with a gradual appearance of the

condition with increasing age. The data for this table are from
all sites except villages Nos. 08, 09, 10, and 11, where there was
a defect in the data-recording system for this item, making the
results unreliable.
LUNG
Of the 1,579 chest x-rays of readable quality, taken of those age
14 or over, 49 were described as indicating lung disease other
than tuberculosis. The principal pathology probably giving rise
to the radiologic findings were as follows:
Basilar infiltrates, probably acute pneumonitis 7 cases
Basilar scarring, probably old or chronic pneumonitis 33
Chronic bronchitis, bronchiectasis,
generalized emphysema 5
Generalized nodular infiltrates, probably not tuberculosis 4
Total 49 cases
This distribution indicates a relatively high prevalence of

lung infections, as one would anticipate under housing condi-
tions of crowding and poor ventilation.
There is a known focus of paragonimiasis in the west-
central hills around Tansen, but its extent, severity, and inter-
mediate host patterns have not been worked out. Our village
No. 02 is in the Terai, 30 miles southwest of Tansen, and our
village No. 01 is near Pokhara, 35 miles northeast of Tansen. In

neither of these places was any unusual lung pathC?logy noted on
x-ray. The four cases of "generalized nodular lung infiltrates"
detected by x-ray were quite scattered geographically-l in the
eastern Terai, 1 in the eastern mountains, and 2 in the central
mountains. The usual ecology of paragonimiasis as described in
China and Korea requires the fresh water crustaceans usually
found in mountain and foothill streams, a wild host reservoir of
carnivores that eat these crustaceans, and a human population
that eats these same crustaceans raw. The dietary interview used
in this survey did not specifically ask about fresh water
crustaceans, and no useful data were obtained from this source.
...
~"
~,
' Every person was questioned, however, about the production of
bloody or blood-streaked sputum. This is certainly not an
r-t;
::.'r::t exclusive sign of paragonimiasis, of course, but if the disease is
::; present in a village, a higher than average number of persons
c:;
should respond positively to this question, if phrased in regard
to recent months to minimize the chance that they will have
forgotten.
Figure 19 shows each village plotted in terms of percentage
of persons reporting production of bloody sputum. These
figures show a fairly good dichotomy between a level of about 5
per cent or less, which might be accounted for by a combina-
tion of tuberculosis and other causes, and a clustering of four
mountain or foothill villages with over 7 per cent, which might
well relate to the presence of paragonimiasis in these villages. Of
the four villages with the highest proportion of people reporting
bloody sputum (Nos. 04, 12, 13, 15), chest x-rays were read in
all except No. 12. Village No. 04 showed very little lung
pathology and an average array of age-specific tuberculin posi-
tive rates. Village No. 13 showed a high level of lung pathology,
both the probably tuberculous and probably non-tuberculous
variety, and also showed high age-specific tuberculin positive
rates. Village No. 15 showed a high level of lung pathology
diagnosed as probably minimal tuberculosis, very little other
lung pathology, and low age-specific tuberculin positive rates.
In conclusion, we have fairly strong presumptive evidence
of the presence of paragonimiasis in the western and central
OTHER CONDITIONS 101
::i:
::J
I-
::J
c.
CIl
~ 10
o
ooJ
al
LL.
o 8
>
a:
~
CIl
:i: 6
J:
I-
~
w
oJ
C. 4
oW
C.
LL.
o
~ 2
~
2
w
U
~Ol- _ _-l.. .1..-_ _....lI.lI'--_ _Jl.IL_ _----=t::....-_ _....I.-_ _.;....J
c.
FIGURE 19. Distribution of villages (shown by numbers) by percentage of

persons reporting production of bloody sputum
hills, and somewhat less secure presumptive evidence that it also

may be in the eastern hills. We have shown again (village No.15)
that it is difficult to distinguish by x-ray between paragonimi-
asis and minimal tuberculosis.
CARDIOVASCULAR
Under the conditions of this survey three kinds of data are
available for a cursory review of the prevalence of cardiovascu-
lar disease-blood pressure determination, physical examination,
and an x-ray of the chest of adults in 14 out of the 19 study
sites.
A blood pressure reading was recorded for 4,965 out of
the 5,011 persons examined. Of these 157 (3.16 per cent) had a
moderate systolic hypertension (140-169/<90) and 13 more
(0.26 per cent) had a more severe systolic hypertension
(170+/<90). In addition, 30 (0.6 per cent) had moderate
systolic hypertension with a diastolic component
(140-169/90+), and another 15 (0.3 per cent) had severe
systolic hypertension with a diastolic component (170+/90+) for
a total of 187 (3.8 per cent) with moderate and 28 (0.6 per cent)
with more severe hypertension. These figures are quite distorted
by the fact that a majority of the people examined were quite
young. Table 29 shows the distribution of hypertension by age
.,
'
in older adults, which gives a more precise picture.
The only consistent regional finding was a definite excess
of hypertension in Jhapa Bazar (No. 06), among shopkeepers
and wage-earners, rather than subsistence farmers. This was also
the village with the maximum amount of obesity. An excess of
hypertension was not found in the urban Kathmandu sample,
where there was virtually no obesity.
In the 30-49 age group there was a large and significant
excess of females with moderate hypertension, but this sex
difference was not observed in the few cases of severe hyperten-
sion found. Among the group over age 50, the large significant
excess of hypertension in females was again found both in those
with moderate hypertension and in those with severe hyperten- .
sion. It should be noted that obesity was also found more often
in older females. The prevalence of hypertension found in this
survey is significantly lower than that found in surveys of
comparable age groups in Japan (ABCC) and Hawaii (Kagan).
Physical examination revealed that there were large num-
TABLE 29 DISTRIBUTION OF CASES OF HYPERTENSION IN OLDER

ADULTS
Total Moderate Hypertension Severe Hypertension

Age Examined 140-169 170+
30-49 1115 72(6.4%) 10(0.9%)

50+ 412 69(16.7%) 15(3.6%)
bers of people of all ages with systolic murmurs, usually in

persons with low hematocrits, especially prevalent in the malar-
ial villages in the west and among the relatively malnourished
people in the urban sample. These were very likely physiologic
murmurs related to the increased blood velocity in anemia.
Only a very few diastolic murmurs were recorded, and only
three youngsters were found with probable congenital heart
diseases. There were 23 persons for whom a clinical diagnosis of
heart disease was made, without any notable pattern with
regard to age, sex, or geographical region.
The chest x-rays (1,578 readable films), revealed 57 per-
sons, or 3.6 per cent, with enlarged hearts. These were almost all
in older adults, and there was a large and significant excess of
females, thus giving additional support to the hypothesis that
medically significant hypertension in Nepal is predominantly a
disease of obese older women.
DIABETES
In a country without the facilities in most areas for the
management of a disease like diabetes, one would expect a
relatively low prevalence of juvenile diabetics, since they do not
live long without treatment, plus a larger number of older
people with milder disease developing later in life. The only
data available in this survey are from the examination of 4,239
urine specimens (from virtually everyone over the age of 5)
by means of the Ames Laboratories "Hemocombistix"
screening test, in which a strip of material impregnated with
glucose oxidase is dipped into the urine, and a color indicating
system records the presence of glucose in the urine. This is a
highly specific test for urine glucose with three levels of
sensitivity. The age distribution at each of these screening levels
is shown in Table 30.
The number of urine specimens examined of children
under age 5 was too small for any reliable inferences. There
were no clear patterns with regard to sex or geographical region,
although 5 out of the 6 persons clinically diagnosed as probably
having diabetes were older males. The figures in Table 30 show
an exceptionally low level of "positives."
TABLE 30 AGE DISTRIBUTION OF PERSONS WITH GLUCOSE-POSITIVE

URINES, BY GLUCOSE CONCENTRATION
Total No. Glucose Concentration in Positive Urines "Positive"

Age Examined v..% v..-%% %% Total %
5-9 597 1 0 0 1 0.16

10-19 954 3 0 0 3 0.3
20-29 895 5 1 1 7 0.8
30-49 1127 8 1 1 10 0.9
50+ 402 2 2 I 5 1.2
TOTAL 3975 19 4 3 26
BLADDER STONE
In many parts of south Asia and the Middle East, a high
prevalence of bladder stones is found, particularly in young
:; males. This can lead to very severe urinary tract damage and
... great discomfort and disability for the person so unfortunate as
......... to be afflicted. There is no definite etiology known, although
..E
> nutritional hypotheses related to low protein, early infant
feeding practices are fairly popular at present. In the endemic
area in northeast Thailand, bladder stone has been correlated
with very early feeding of a high carbohydrate, low protein
supplement to infants, with an inadequate fluid intake (Hal-
stead, et al. 1967).
In this survey the data available are from the complaints of
the persons examined and the results of the urine examination
with Ames Laboratories "Hemocombistix," which includes
screening tests for protein and blood. The crucial findings
would be the determination of blood in the urine along with
moderate amounts of protein. In order to avoid the possible
confusion arising from the presence of menstrual blood in
women, or the complications of prostatic hypertrophy or
venereal disease in men, we have examined the question of
bladder stone by looking at the records of children under age
10.
Even though the data in Table 31 reveal a fairly high
proportion of younger children with slight amounts of hematu-
TABLE 31 DISTRIBUTION OF PRESUMPTIVE SIGNS OF BLADDER STONE

BY AGE AND SEX OF THOSE PERSONS AFFECTED
Proteinuria Hematuria
Age Sex More Than Trace Light Moderate-Heavy Urinalyses
0-4 M 0 22 I 157
F 2 16 3 123
5-9 M 0 13 4 329
F 3 2 7 268
ria, there are very few with large and definite amounts.
Proteinuria other than trace amounts was also very scarce. Of
the 5,011 persons examined, there were only 8 clinically
diagnosed as having probable bladder disease, and only 1 was a
young boy who was diagnosed clinically as possibly having
bladder stone. The remainder were adults with probable chronic
bladder infections. We, therefore, have no evidence, based on
this limited sample, that bladder stone is a significant wide-
spread public health problem in Nepal. This does not exclude
the possibility that it may be a serious problem in specific
localities not covered by this survey.
CHAPTER ELEVEN
Summary and Specific

Recommendations
ENVIRONMENT
Houses generally were overcrowded and poorly ventilated.
Disposal of waste was very poor; animal manure was heaped
.,
)
near houses for use as fertilizer. In some villages animals were
....
~
kept in houses, and cattle and poultry were found in many
.
~
houses. All villages were infested with rodents, flies, fleas, and
.... lice. Water supplies in all villages were poorly protected.
The environmental conditions in all villages were highly
favorable for the spread of communicable diseases. It is there-
fore recommended that certain improvements in environmental
sanitation be made. The highest priority is to assist the villages
to provide themselves protected and sufficient water supplies.
The second thing is to educate villagers to build houses with
better ventilation, to construct sanitary latrines, and to keep
animals in separate animal sheds. Last, but very important, is to
educate villagers in methods of proper disposal of both animal
wastes and human wastes without losing their agricultural value
for fertilizer, as outlined in the World Health Organization
monograph on composting methods (WHO 1956). A method of
disposal recently developed in China destroys pathogenic ova,
parasites, and bacteria in feces through the action of ammonia
released during the decomposition of urine. This system might
be adaptable to some parts of Nepal (Chinese Medical Delega-
tion 1955; Wong 1959).
106
SUMMARY AND SPECIFIC RECOMMENDATIONS 107
Some of the methods of improvement suggested above do

not require much finance but require changes in the habits of
the people which are very difficult to achieve.
ESTIMATES OF VITAL STATISTICS

The crude birth rate is estimated at about 52/1000 and the
death rate at about 27/1000. The population census taken
during the survey agrees well in age distribution with a portion
of the census done by the government of Nepal in eastern Nepal
in 1961, except in the 0-4 group, which seems abnormally low
in the official census data. One of the highlights of the
demographic data is that the proportion of the population in
the economically productive age group from 15 to 34 is
relatively high. If kept in good health and full employment
these people can be of great help in bolstering the economy.
The fertility rate in Nepal is very high (about 220), and if the
high infant mortality ratio of about 150/1000 is reduced
without an accompanying reduction in fertility, then surely
there will be a tremendous increase in population growth among
children, which would have a short-term detrimental effect on
economic growth.
REPRODUCTIVE ATTITUDES, BELIEFS, AND PRACTICES
The number of children born was usually attributed to fate or
God. There was no resistance or taboo against the idea of family
planning except in a few villages. The reproductive section of
the demographic data indicates that women show highest
fertility in the 20-30 age group. Therefore, a target population
for family planning with regard to child spacing should be this
group. The older women might be receptive to contraception
once they have achieved their "ideal" of 4 or 5 children.
Delaying the age of marriage will probably be a goal too much
at varience with social custom to be effective.
NUTRITION AND NUTRITIONAL DEFICIENCY DISEASES

The nutritional standard of the population was quite good. The
average nutrient levels available from the basic diet compared
well with suggested levels of the WHO and FAO except for
protein intake and vitamin A. Sources of protein food should be

made available at low cost. This could be done, with least
change of existing agricultural patterns in Nepal, simply by
laboratory identification of those commonly grown beans with
the highest protein and essential amino acid content, then
encouraging the systematic increase in production of those
beans. Additional sources might come from the development of
more efficient poultry production and the development of fish
ponds in the Terai. An additional rich source of vitamin A,
readily available in Nepal but not now used for food, is the
sweet potato leaf, 100 grams of which will provide roughly
6,000 International Units.
The commonest deficiency disease was goiter, produced by
iodine deficiency. The prevalence rate of goiter was high in all
villages, and extremely high in some villages. The best way of
controlling this disease is to supply ample amounts of iodine in
food. This is most conveniently done by providing iodized salt
.,:> as the only salt available in the markets. The cost and effort
.
~
that has to go into supplying iodized salt should be repaid many
E
I»
times through the rise in production capabilities of the popula-
:: tion. The degree of potential increase of productivity can be
estimated through special studies done prior to a general iodiza-
tion program.
LEPROSY
If we consider the eastern half of the country, the prevalence
rate of leprosy is estimated at about 1 per cent of the
population, with the disease probably introduced through the
Terai and spreading up into the adjacent mountains, retarded
somewhat by the geographical barrier. The prevalence in the
western half of the country was not well ascertained. If the goal
is to prevent further transmission of the disease to other people,
the only method presently available, economically practical,
and socially acceptable is to identify lepromatous cases as early
as possible through an active case-finding effort and to put them
under sulfone therapy at home for an extended period of time,
supervised from outpatient treatment centers. This kind of
program using oral medication is usually ineffective due to lack
of patient cooperation. Within the near future a new sulfone
derivative (DADDS, Parke-Davis) for intra-muscular injection

once every two and a half months will be released for general
use. This, for the first time, should allow the development of an
economic and effective control program through outpatient
chemotherapy. In addition to this, there are encouraging possi-
bilities of adding a chemoprophylaxis program for household
contacts of lepromatous cases, plus the now proven prophylac-
tic value of giving BCG to household contacts. The development
of this sort of program will depend on the development of local
health services.
VENEREAL DISEASES
Gonorrhea and syphilis have a low prevalence all. over the
country, but the prevalence rate is higher in the hills than in the
Terai. This might be explained by the fact that people from the
hills emigrate to big cities in India. They are separated from
their families for years, and it is probable that they contract
venereal diseases there and infect others after they come home.
The control of these diseases will depend on the development of
local health services.
DISEASES TRANSMITTED BY THE RESPIRATORY ROUTE

Readings of Tine Tests show that there are high age-specific
positive rates for tuberculosis in Kathmandu, intermediate in
the Terai and eastern hills, and low in the western and central
hills. This shows that the transmission of tuberculosis is very
high in Kathmandu and lower in rural districts, especially in the
remoter hills. From this, one may reasonably draw the hypoth-
esis that the disease has been introduced into Nepal fairly
recently (l 00-200 years ago), and due to bad communications it
has not been able to spread fully in the mountains. With the
opening up of the interior by new roads, there is an increasing
chance for spreading of this disease. It is advisable to increase
the immune status of the population by mass BCG campaigns.
The smallpox immunity status of the population as judged
by vaccination scars and smallpox scars is relatively low, even
assuming that vaccination scars are a sign of immunological
reaction rather than secondary infection.
This situation can lead to disastrous epidemics disrupting
both the economic and social life of the community. This

condition can be corrected by mass vaccination and revaccina-
tion campaigns, followed by vaccination of infants and revac-
cinations through local health services.
DISEASES TRANSMITTED BY FECAL CONTAMINATION

All the common species of intestinal parasites were found in the
regions studies, including urban Kathmandu. This merely con-
firms the observation of a general fecal contamination of soil in
all regions. The low prevalence of Ascaris (31 per cent com-
pared to the 70-80 per cent expected) might be attributed to
climatic conditions (freezing in winter). Serum agglutination
against typhoid 0 antigens was positive in 36 per cent of the
children age 0-4, also indicating the fecal contamination of food
and water. To improve this condition there should be improve-
ment in environmental sanitation, with improvement of water
supply taking priority.
DISEASES TRANSMITTED BY INSECT VECTORS

Malaria, which was an endemic disease in the Terai and deep
valleys, was found in this survey to be almost absent in the
central area, slightly prevalent in the eastern area, and highly
prevalent in the far west. This fits well with the progress of the
malaria eradication project in different areas.
Filariasis is present in the central mountains around Kath-
mandu, extending into the eastern mountains and down into
the eastern and midwest Terai. The highest prevalence was in
Kathmandu Valley, where it was still relatively low. Control of
this disease should take a low priority.
The arbovirus antibody studies indicate a fairly widespread
prevalence of Group B viruses in areas near the larger rivers,
with Group A viruses of negligible importance. No control
program is indicated without further studies to define the
specific Group B viruses involved, their specific epidemiology,
and their relative public health importance. Knowledge of the
distribution of and importance of louse-borne typhus awaits the
completion of further laboratory studies on the specimens we
obtained. The vectors for flea-borne typhus and mite-borne
scrub typhus are widely prevalent; so these diseases are proba-

bly at a high prevalence. They would pose a serious threat only
to adults (such as tourists without natural immunity acquired in
childhood) coming into village areas of high prevalence.
EYE
Blindness due to cataract was found to be highly prevalent in
the 30 and above age group. The cause for this has to be
investigated further before a public health solution to the
problem can be found. Trachoma, though probably widespread,
is mild and does not appear to present a serious health problem.
DENTAL
The dental health of the population in general is good. The
prevalence of carious teeth was low, as was that of periodontal
disease.
EAR
No special public health problems were discovered. Otitis media

and residual drum damage were at a low prevalence.
LUNGS
The non-correlation of Tine Test, x-ray film, and history of
bloody sputum suggests that paragonimiasis might be present
fairly widely in the hills. It has a known focus around Tansen in
the western hills. We do not have sufficient data to come to any
conclusion about the distribution or severity of this disease.
CARDIOVASCULAR
The chest x-ray revealed that 3.6 per cent of the persons
examined had enlarged hearts. These were almost all in the 30
and above age group. The percentage of persons showing
hypertension was quite low in this group, but females were
significantly in excess of males. This leads us to believe that
medically significant hypertension in Nepal is predominantly a
disease of older women; it is also strongly related to obesity.
DIABETES
By examination of sugar in urine samples, we can come to the
conclusion that diabetes is not a public health problem in Nepal
at present, the number of cases being very low.
BLADDER STONE
By testing for hematuria and proteinuria and getting histories of
urinary difficulties, we can say that we have no evidence to
show that bladder stone is a significant health problem in Nepal.
CHAPTER TWELVE
General Recommendations
IF the data gathered in this survey are viewed

from a traditional short-range public health perspective, inquir-
ing only as to which causes of mortality can be most efficiently
controlled with the minimum cost and minimum use of highly
trained personnel, one would obviously come up with a series of
priorities based on those groups now suffering the most severe
mortality rates-infants and young children. It has already been
shown in other parts of the world that through these relatively
simple measures infant and child mortality can be reduced by at
least half:
1. training and supervlSlon of traditional midwives, with

gradual introduction of better trained young women. This will
sharply reduce neonatal tetanus.
2. provision of rudimentary child health services based
predominantly on teaching local women certain nursing skills to
carty out immunization of children, and instruction of mothers
in child feeding techniques suitable to the local economy.
Supervision will be by a few physicians, who, assisted by trained
nurses, will offer some simple treatment services in rural health
centers. This will largely control smallpox, diphtheria, pertussis,
and tetanus, and will sharply reduce the mortality from cholera,
typhoid, and other gastro-intestinal infections, even if the
incidence of disease remains fairly high.
113
Due to transportation problems related to the geography

of Nepal, the programs outlined above would be more difficult
to carry out than in many countries, but could be gradually
developed over most of the country during the next decade.
This plan would be entirely within the capabilities of the nation
and would result in a dramatic increase in survival of children, a
rapidly accelerating population growth from its already high
level of 2.7 per cent per year, a rapid worsening of the already
severe crowding within homes (giving rise to an increase in the
transmission of leprosy, tuberculosis, and other diseases trans-
mitted predominantly within crowded homes), a rapid increase
in the consumption of foodstuffs in Nepal (increasing the
number of those with nutritional deficiency diseases), and a
rapidly rising pressure for more schoolrooms and more teachers.
An alternative strategy would be to focus on long-range
rather than short-range objectives, with the dual hope of:
1. reducing the fertility in a manner synchronized with

the reduction in infant and child mortality, and
2. reducing the young adult mortality and morbidity to
enhance the size and working capacity of the labor force during
the period of changing demographic patterns from those of high
child mortality to low child mortality.
Objective 2 is certainly being served by the current malaria

control program, which has been very effective in most of
central Nepal and which is being gradually extended into the
more remote regions. These qbjectives could be further served
by a continuation of the present program of developing local
health services, which should be designed to meet the following
objectives:
1. to offer rudimentary treatment services with para-medi-

cal personnel (having a moderate effect on mortality and
morbidity at all ages, and having a major psychological effect in
gaining the confidence of the people),
2. to offer family planning services, principally through
the insertion of intrauterine contraceptive devices (having only
a moderate effect on fertility, predominantly among those
GENERAL RECOMMENDATIONS 115
women who have already achieved their desired goal of 4 or 5

children),
3. to carry out and maintain a continuing BeG campaign
to control tuberculosis in the valleys and to retard its spread
into the hills (having a minor effect on child mortality and a
major effect on adult morbidity)-also serving as a partially
effective prophylaxis for leprosy,
4. to carry out a continuing smallpox vaccination program
(having a moderate effect on mortality at all ages, but a major
psychological effect on winning the confidence of the people),
5. to carry out cholera immunization programs every
spring in the Terai and along major travel routes into the hills
(having a moderate effect on mortality at all ages and a major
psychological effect in gaining the confidence of the people),
6. to carry out a continuing typhoid immunization pro-
gram (having a moderate effect on mortality and morbidity at
all ages),
7. to carry out a systematic program of improving com-
munity water supplies (having a moderate effect on mortality
and a major effect on morbidity at all ages, and some effect in
gaining the confidence of the people),
8. to carry out a home treatment program for leprosy
based on the injectable, long-acting sulfone DADDS, which
should be fully available in about two years (having a negligible
effect on mortality, but a significant effect on adult morbidity).
In addition to the above programs based on the local

health center, there should be a vigorous nation-wide program
of salt iodization to prevent goiter, along with some parallel
studies to measure the amount of hypothyroidism that may be
associated with the tremendous goiter prevalence in Nepal, and
to measure the changes in economic productivity that might be
associated with iodization. There also should be vigorous at-
tempts to find the cause of the very high prevalence of cataract,
since its control could prevent almost all of the blindness now
found in Nepal. This blindness due to cataract is at high enough
prevalence to have a significant impact on productivity at the
present time.
The plan suggested above would have a gradual, balanced
impact on mortality at all ages, would have a considerable

impact on morbidity in the labor force, and would gradually
gain the public confidence that children can survive. This would
create a psychological environment in which the number of
children desired might diminish somewhat. Meanwhile, during
the next decade as a larger and larger percentage of children go
to school, there must be built into the school curriculum some
concepts of the demographic realities for Nepal, so that the
boys and girls will emerge from school with newer ideas about
the necessity for spacing their children and having fewer of
them. When there is some indication that these ideas have
become living realities, then the infant and child health services
mentioned above can safely become high priority items. If,
during the next decade the economists in the government can
devise a system of taxation that would give differential rewards
to small families, the system might be introduced after the
general availability of family planning services, and in such a
way as not to punish those whose families were already large
before the services were available. Such a system might acceler-
ate the shift from high fertility to low fertility conditions and
would shorten the dangergus transitional period upon which
Nepal is just entering, during which the forces of mortality will
be decreasing at a faster rate than the lowering of fertility.
APPENDIX A
Sample Forms
NEPAL HEALTH SURVEY HOUSEHOLD CENSUS

FORM
Date Village No._ _ Household _
Gurung Maga Bhotia Tamang Limbu Rai Tharu M _
Hindu 1 2 3 4 Muslim 1 2 _
Name of Marital
person No. Sex Age Role Occupation Status
01 Head of house
02
03
04
05
06
(Include in above list those who are temporarily away-and where are they?)
(List below those who are temporarily living here-and from where?)
117
NEPAL HEALTH SURVEY DEMOGRAPHIC QUESTIONNAIRE
Date Village No._l,2 Household _ _ No._3,4

Since 5,6 how many babies have been born in this household?_ 7
(include any babies that have since died, but also list separately here_) 8
Since how many people of this household (incl. babies) have
died?_9
How old was each at the time of death? __ l0 __11 12
In this household, how many unmarried women are there over age 16 (never
been married)_13
(For female head of the household)
Name Age _ _ 14,15 Age at marriage 16

Age at end of first pregnancy_17 Age at 1st menses 18
Do you still have menses? O-Yes No Age when stopped 19,20
How many children have you had altogether (live births) 21
Of these, how many are living now? 22
(if any died) How many died before 1st birthday? 23
How many times have you had a miscarriage or stillbirth?_ 24
Are you pregnant now? D-No Yes Uncertain
(if yes) When due? (if uncertain) Why? 25
How old were you at the end of your last pregnancy? 26,27
Did that pregnancy end in I-livebirth 2-miscarriage or stillbirth
How many times have you been pregnant in the past three years? _
(end ofpreg.
in past 12 mos.) O-none I-miscar. 2-livebirth, ok 3-inf. death 29
(end of preg.
in yr. before that 0 2 3 4-child death 30
(end ofpreg.
in yr. before that 0 2 3 4 31
(if no preg. during 2 or more yrs) Was there any reason for not getting pregnant
during those_years? D-husband away I-illness 2-too old 3-don't know
why 4-sterilization of wife 5-sterilization of husband 6-contraceptive
7-didn't say 32
If you were just getting married now and could have just the number of children
you want, how many would be ideal for you? children 33
Boys _ _ 34 Girls _ _ 35 Either
SAMPLE FORMS 119
How many children do you think would be most ideal for a couple in your
village 36
Have you ever talked to your husband about not having more children than you
want? D-No I-Yes 37
Would you be interested in learning more about ways of keeping from having
more children than you want? O-No I-Yes 38
Among your friends or relatives is there anyone doing something to keep from
having more children than they want? D-No Yes l-don't know 39
(if yes) would you say 2-many such friends or relatives 3-some 4-few
In this village do you think many families are doing something to keep from
having more children than they want? D-none I-few 2-some 3-many
4-don't know 40
Do you approve of this sort of thing? D-not at all I-somewhat 2-very much
3-it depends (if depends, on what? ) 41
EXTRA REPRODUCTIVE HISTORY FORM FOR OTHER MARRIED WOMEN

LIVING IN THIS HOUSEHOLD
Name Age_42,43
Age at marriage _ _ 44
Age at end of 1st pregnancy_45
Age at Ist menses_46 Still menses? O-yes no Age when stopped 47,48
How many livebirths altogether? 49
How many still living? 50
How many died before 1st birthday? __ 51
How many miscarriages?_ _ 52
Is she pregnant now? D-no yes uncertain
(if yes) When due_ _ (if ") Why?
_ _ _ _ _ _ _ _ _ _ 53
How old at end of last pregnancy? 54, 55
Did it end in 1-livebirth 2-stillbirth 56
How many pregnancies in past 3 years? _
1 2 3 4
(past 12mos.) Omis lb ok infd ch d 57
(yr. before) o mis lb ok inf d ch d 58
(yr. before) Omis lb ok infd ch d 59
Reason for no preg. D-husb away I-ill 2-too old 3-? 4-w ster
5-h ster 6-eontr 7·didn't say 60
SAMPLE FORMS 121
HOUSEHOLD FOOD INTAKE PATTERN

Village No. _ _ Household No._
Food Usual Amount Consumed How Often Used

Item Preparation Yesterday Daily Occasionally Seldom
Cereals
Tubers
Nuts
Seeds
Vegetables
Fruits
Fat
Oils
Protein
Foods
Dairy
Beverages
Baby feeding practices

Usual age at weaning (in months)__ 67 When introduced
Supplementary foods 1st 68 (age in months) 71
2nd 69 _ _ _ 72
3rd 70 _ _ _ 73
What kinds of foods are best for baby when he fIrst starts eating? 74
What kinds of foods are especially good for you when you are pregnant?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 75
Salt sources 76 Amount used by family in a year _ 77

If you could get more of any kind of food, which would you get fIrst?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 78
After that, which second? 79

I
HOUSEHOLD ENVIRONMENT
Village No. _ _ l,2 Household No. _ _ 3, 4

House construction type I-clay 2-straw 3-brick 4-bamboo 5-wood
6-other 5
structure type I-one floor detached 2-one floor attached
3-two floor detached 4-two floor attached
5-3 or more floor detached 6-3 or more floor attached
deterioration I-slight 2-moderate repair needed 3-severe
rooms per house total 8
dwelling 9
separate kitchen _ _ 10
separate stable 11
storage 12
business (shop) _ _ 13
ventilation I-poor 2-moderate 3-good 14
Sanitary latrine O-not present I-present, not used 2-present, used,
inadequate 3-present, used, adequate 15
Refuse disposal Q-not acceptable I-poor 2-adequate 16
Food storage Q-not acceptable 2-moderately protected 3-adequate 17
Infestation Q-none seen 2-rodents 3-rodents and other 18
other _
Animals in house O-none l-eattle 2-poultry 3-eattle and poultry other __ 19
Number of animals owned Cows 20 Goats 25
Buffaloes 21 Dogs 26
Yaks 22 Sheep 27
Poultry 23 Pigeons 28
Pigs 24 Horses 29
APPENDIX B
Entomological Report
INTRODUCTION
A total of 612 animals and birds were collected during the

survey. At least 30 per cent of the time was spent on moving
camp or waiting in Kathmandu for local clearance to work in an
area. Of the 612 animals, 453 were infested with ectoparasites
-305 with chiggers; 224 with fleas; 358 with laelapid mites; 84
with ticks; 107 with lice. The fleas were sent to Dr. R. Traub,
the chiggers to Mr. Nadchatram, and the remaining parasites
were sent to Dr. Quate at the Bishop Museum.
Some 8,000 chiggers (Acarina, Trombiculidae) were pro-
cessed and studied at the Institute for Medical Research, Kuala
Lumpur. Fifty-seven species were determined from the 305
animals infested; 35 of them proved to be new species. This
is not surprising in view of the fact that this is the first time that
a survey of this nature was undertaken in the Kingdom of
Nepal. If one considers the short duration of the survey and the
small number of animals sampled, it can be seen that the chigger
fauna is rich.
Trapping was carried out in IS different localities in such
habitats as dwellings, wasteland, flood plains, millet and rice
fields, in plains and in terrace cultivations above 1500 m
elevation, in lowland forests, forests in hills, coniferous forests,
and alpine regions above timberline.
By far the commonest rats collected in houses, gardens,
123
rice and millet cultivations, wasteland, and lowland forests were

Rattus rattus brunneus (125 specimens) and R. brunneusculus
(l09 specimens), followed by R. tistae (54 specimens). Bandi-
cota bengalensis (31 specimens) and Suncus murinus caerules-
cens (19 specimens) were also collected from human dwellings.
The total number of animals collected in these habitats is 284
or 63 per cent of the 451 rodents collected during the entire
survey. Of the 284 animals, 77 per cent were infested with
chiggers.
Thirty species of chiggers were collected from Rattus
rattus brunneus; 39 from R. brunneusculus; 22 from R. tistae;
11 from Bandicota bengalensis; and 11 from Suncus murinus
caerulescens. Chiggers are habitat-specific, and the wealth of
chigger species from a single host animal indicates that the host
has a wide range of movement. For example, R. r. brunneus, R.
r. brunneusculus and R. r. tistae were collected in forest,
cultivation, and dwelling between 120 and 1450 m elevation.
R. nitidus was the common rat in dwellings and cultivation
between 3000 and 3300 m elevation.
The following chigger species were collected in abundance:
Leptotrombidium (Leptotrombidium) sp. C between 910 and
3400 m from a large variety of hosts; 1. (1.) puta between 230
and 1300 m; 1. (1.) deliense between 200 and 1450 m; 1.
(Trombiculindus) squamosa between 220 and 1950 m. Remain-
ing Leptotrombidium species were collected in very small
numbers. Microtrombicula buxtoni was the commonest species
in the genus collected between 1450 and 1950 m. Ascoschoen-
gastia (Laurentella) indica was the commonest species in that
genus at lower elevations. Of the 10 species of Gahrliepia
(Schoengastiella), 4 species proved to be very common-ligula,
punctata, sp. A and sp. C. At least 1 of the 4 occurred in the 15
localities surveyed. The remaining species of chiggers occurred
in very small numbers. Thirty species are represented by 5 or
fewer specimens of each species.
Species of the genus and subgenus Leptotrombidium are of
particular interest because the established vectors of scrub
typhus belong to this genus. It seems significant that Lepto-
trombidium was the dominant genus among the chiggers col-
ENTOMOLOGICAL REPORT 125
lected in Nepal. Sixteen species of the subgenus, including 10

new species, were collected in almost all the habitats in all the
localities, except one. The well-known vector of scrub typhus,
Leptotrombidium (Leptotrombidium) deliense (Walch) was col-
lected from 8 species of rats and shrews in 3 of the 15 localities
surveyed.
COLLECTING AREAS
POKHARA September 1965. W of Kathmandu, 910 m.
Farming community.
NAGARKOT October 1965. On edge of Kathmandu Valley,

30 km E of Kathmandu, 2200 m. Secondary scrub growth and
terraced fields.
TRISULI VALLEY November 1965. Collected at various

villages in the valley. Vegetation mainly secondary scrub and
cultivated terraced fields; few scattered, isolated secondary
forests. Terrain steep pitch of valley side. Inhabitants Tamang.
Village locations are in terms of distances from Trisuli
Bazaar, listed on many maps as "Nawakot," site of Indian
hydroelectric project, about 80 km W of Kathmandu.
Grang-ca. 20 km NE of Trisuli, 1850 m
Bokaikunde-23 km NE of Trisuli, 1900 m
Dunche-ca. 28 km NE of Trisuli, 1950 m
Syabrudens-ca. 35 km NE of Trisuli, 1450 m
LANGTANG VALLEY October 1965. 3300 - 3400 m. Just

south of the Tibetan border and north of Kathmandu Valley; E
of Trisuli Valley and joins it at Syabrudens. Most people are
Bhote. Lived in Langtang Village; collected in village, in fields,
and in scrub growth beyond fields. Vegetation high mountain
scrub, secondary growth, and cultivated fields.
TABLE 1 BROAD ECTOPARASITE INFESTATION OF BIRDS AND MAMMALS COLLECTED IN NEPAL BY L. W. QUATE AND
M. NADCHATRAM (November, 1965 to January, 1966)
Number of Specimens
with with
Trombi- Trombi-
culid culid with with
mites on mites in Laela- with Listro-
Total Total body nasal with pid with with Ascodip- phorid
Species of host collected infested and ear cavity fleas mites ticks lice teron mites
Alcedo atthis (kingfisher) 1 0 0 0 0 0 0 0 0 0

Cuculus varius (hawk-cuckoo) 1 1 0 0 0 0 0 1 0 0
Streptopelia decaccta (ring dove) 1 1 0 0 0 0 0 1 0 0
Streptopelia chinensis (spotted dove) 1 1 0 0 0 0 0 1 0 0
N
0\ Streptopelia tranquebarica 4 4 0 0 0 1 0 3 0 0
(red turtle dove)
Dove (undet.) 2 0 0 0 0 0 0 0 0 0
Lophophorus impejanus (grouse) 4 4 0 0 0 0 0 4 0 0
Man 1 1 0 0 0 0 1 0 0 0
Mustela sibirica 1 1 0 0 1 0 0 0 0 0
(Himalayan weasel)
Mustela kathiah (weasel) 1 1 0 0 0 1 0 1 0 0
Mongoose 1 1 1 0 1 1 0 0 0 0
Rattus nitidus 66 65 43 3 49 41 3 17 0 0
Rattus fulvescens 11 11 11 0 2 11 4 1 0 0
Rattus eha eha 8 8 7 0 5 8 0 0 0 0
Rattus rattoides 3 3 3 0 3 1 0 1 0 0
Rattus sp. (undet.) 16 11 7 0 4 1 0 1 0 0
Rattus rattus brunneus (commensal 125 99 58 9 59 63 27 14 0 1
and non-commensal forms)
Rattus r. brunneusculus
.. ,Ss2Ul''l'nmsa\. and non-conu'l\.ensal
109
- --~
99
-
80
---.
12 43 74 24 18 0 0
j
Dandi'cora bengalensis 31 27 20 0 0 14 :3 9 0 0
Mus cerllicolor 2 1 1 0 0 0 0 0 0 0
Mus sp. (30585 and 30587) 2 2 2 0 1 0 0 0 0 0
Mus musculus castaneus 15 2 0 0 1 1 0 1 0 0
(commensal)
Mus musculus (non-commensal) 1 1 1 0 0 0 0 0 0 0
Fauambulus pennanti 2 2 0 0 1 2 1 0 0 0
(five-striped squirrel)
Squirrel (undet.) skin lost 1 1 1 0 1 1 0 0 0 0
Ochotona roylei (mouse-hare) 4 4 3 0 2 0 0 0 0 0
Axis porcinus (hog-deer) 1 1 0 0 0 0 1 0 0 0
Anti/ope cervicapra (blackbug) 1 1 0 0 0 0 1 0 0 0
Domestic cow 4 4 0 0 0 0 4 0 0 0
Domestic buffalo 1 1 0 0 1 0 0 1 0 0
Domestic goat 1 1 0 0 1 0 0 1 0 0
Dicaem agUe (thick-billed flower 1 0 0 0 0 0 0 0 0 0
N peeker)
-J Muscicapa parva (flycatcher) 1 1 0 0 0 1 0 0 0 0
Prinia subflalla (wren babbler) 1 0 0 0 0 0 0 0 0 0
Scarlet minivet 1 0 0 0 0 0 0 0 0 0
Large Indian parakeet 1 1 0 0 0 0 0 1 0 0
Pigeon 10 0 0 0 0 0 0 0 0 0
Raven 2 2 0 0 0 0 0 2 0 0
Mynah 3 0 0 0 0 0 0 0 0 0
Sparrow 1 0 0 0 0 0 0 0 0 0
Hawk 1 0 0 0 0 0 0 0 0 0
Birds (undet.) 59 0 0 0 0 0 0 0 0 0
Tupaia gUs 1 1 1 0 1 0 0 0 0 0
Soriculus nigrescens (shrew) 1 1 0 0 0 1 0 0 0 0
Suncus murinus soccatus 2 2 0 0 0 0 0 2 0 0
Suncus murinus caerulescens 19 19 13 0 3 0 3 10 0 0
Rousettus leschenaulti 11 5 0 0 0 0 0 0 5 0
TABLE I-continued
Number of Specimens
with with
Trombi- Trombi-
culid culid with· with
mites on mites in Laeia- with Listro-
Total Total body nasal with pid with with Ascopid- phorid
N Species of host collected infested and ear cavity fleas mites ticks lice teron mites
00
Cynopterus ~phinx 5 0 0 0 0 0 0 0 0 0
Taphozous longimanus 6 0 0 0 0 0 0 0 0 0
Miniopterus schreibersi 1 1 0 0 1 1 1 0 0 0
Pteropus giganteaus 3 3 0 0 0 3 0 0 0 0
Bat (undet.) 1 0 0 0 0 0 0 0 0 0
TOTAL 612 453 305 30 224 258 84 107 5 1

TABLE 2 SUMMARY OF CHIGGER COLLECTIONS MADE IN NEPAL
HOST SPECIES
'".,l::
'" ~
~
.::'" E!
~
~
.~
a '"l:: <.>
~ ~
iii'"l:: iii'"l:: ~
l:: l::
'
ii"
'"l:: '"
~ ~ :;
.,
~
~ §l,
.,l:: .sa... .::'" '" :s'"
:s
.~ .~
'6--
~
i! i! .eg~ .~
...E!'" "'a" c a :s :s ...
"'..:" "'..:" ii'" ..: ~ ct .~
'"
.~
.'tl, t: t: '"
:s ...
<0:::, '" '-
l:: '" c
.~ t<.>:s
t: ~.s:; :;
l::
~ a:l
E!'" E!'" E!'" E!'" E!
'" E!'" E!'" E!'" E!'"
... ... ... ... ... ... ... ... ... ~
a~ ~
c .!3::s
l::
'" '" ii eo,
SPECIES OF CHIGGER '" '" '" c.::'" c.::'" c.::'"

c.::'" c.::'" c.::'" c.::c.::c.:: '"
<:l::l ~ ~ ~~J5J5 Cl 0"
til
tv --
'" j :1
I:
Leptotrombidium (Leptotrombidium) deliense + +
+ + +
Leptotrombidium
Leptotrombidium
(L.) macacus
(L.) puta + +
I +
Leptotrombidium (L.) rupestre +
Leptotrombidium (L.) villosum + +
Leptotrombidium (L.) wallacei +
Leptotrombidium (L.) A +
Leptotrombidium (L.) B + +
Leptotrombidium (L.) C + + + +1 + + +1 + + +
Leptotrombidium (L.) D +
Leptotrombidium (L.) E + +
Leptotrombidium (L.) F + + + +
Leptotrombidium (L.) G + +
Leptotrombidium (L.) H + +
TABLE 2-continued
HOST SPECIES
.,
~::s :i .,
.. ~
"§ .~ 8 "g
~ ~ ~ .§ ~ ~
~~ t~
s::::t::Iu"t:::s~~U'J
ci. ~
;;: .... ~
f.o)~.~
::::t;:s--
~~~a~i8; .,~~ Ss~
.J::).J::)t::I~t:·:::·af: .~8e .~33~
a.: ..:ii~~·i: ao.: ~ ~o'E:i .~E::::_
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ E ~ t::I ~ ~ 0 ~
aai!i:!i:!.2i:!i:!i:!:.su
~ ~ ~ ~ ~ ~ ~ ~ ~
U'J·~etIc.E
:: ~ ~ ~ ~ :: Ii:: ~ ~
~ ~ ~ ~ ~ ~ ~ ~ ~ cil ~ ~ ~ ~ Jl Jl 0 ~
-
W
o
SPECIES OF CHIGGER
Leptotrombidium (L.) I + + + I +
+
Leptotrombidium (L.) J
Leptotrombidium (Trombiculindus) squamosa + + + + + + + I++ +
Leptotrombidium (Trombiculindus) A +
Leptotrombidium (Trombiculindus) B + + I + +
Neotrombicula autumnalis +
Neotrombicula sp. A
Microtrombicula buxtoni + +
+
+ + +
I I I +
+
Microtrombicula sp. A +
Microtrombicula sp. B + + + + + + +
Walchiella sp. A + + + + +
Ascoschoengastia (Laurentella) indica + +
Ascoschoengastia (Laurentella) leechi + + I +I + +
Ascoschoengastia (Laurentella) roluis +
Ascoschoengastia (Laurentella) sp. A + + \ \+
Doloisia (Doloisia) sp. A + + + + +
Doloisia (Doloisia) sp. B + + + + +
,Q2JQ.ste:l_.J.p~Q~q.i.5:ial_s'Q.!!~ + - - " - - - - - -+-
- - " " -+- " - +
. _ - ~ ~ - - ' _._-_.,-~ .. _--_.-_ .. _-----"-"----"----~._---
~~ ....,r~~ ... -.r_ '-~£.I',,",-~I"'"I""~·""IJ'.~- LI -----
Doloisia (Doloisia) sp. E + +
Schoutedenichia sp. A + +
Helenicula kohlsi + + +
Helenicula lanius + + +
Helenicula miyagawai + +
Helenicula sp. A +
Helenicula sp. B +
Helenicula sp. C +
Helenicula (Euryphylla) sp. D + +
Gahrliepia (Walchia) enode +
Gahrliepia (Walch/a) ewingi lupella +
Gahrliepia (Walch/a) rustica + + + + +
Gahrliepia (Schoengastiella) ligula + + + + + + + +
Gahrliepia (Schoengastiella) gammonsi + + + +
Gahrliepia (Schoengastiella) punctata + + + + + +
Gahrliepia (Schoengastiella) sp. A + + + + + + + + + + +
w Gahrliepia (Schoengastiella) sp. B + +
Gahrliepia (Schoengastiella) sp. C + + + + + + + + + +
Gahrliepia (Schoengastiella) sp. D + + + + + +
Gahrliepia (Schoengastiella) sp. E + +
Gahrliepia (Schoengastiella) sp. F + + + +
Gahrliepia (Schoengastiella) sp. G +
Gahrliepia (Gahrliepia) plurisetae + + +
Gahrliepia (Gahrliepia) sp. A +
TABLE 3 SUMMARY OF CHIGGER COLLECTIONS BY LOCALITY IN NEPAL
E E E
°..".
o E g E ~
<"> o
o
<"> ° °E
..... V)
~
I
E E
o I'-s'?~'" ° 0
~ ~
'"
;;:: E E 1;; "";' 1 .....1 <">
'"1
o l-4.- t; .-;- ~ ... >.
E
Eo>.~E
'I ° o
0'>
cu Q .- ~ 4)
E-<F;O.~~ E ~ ~
o ..... ESOlF;O'" o
°~I';;.-
",:a 4) .....-l
IV)
0
a~ ~oo~bO~=t.:>
(1)V) .....
lo",=OlF;H
'-"-;j~
t;l ;;.-
;;:: -a ...
N "8 ~
a ].~ I ~ .[ 5 ~~ ~ I
I .... bll '" 1 C':S.-t
'" 0
t;l ~ ....
't:l
g '5'" bll '" t;l
'" .... aF; ~a ~....
:12 bll § .g ~ap..~~o~
8o~
I::
o ... ;l~.<::'<:: 0
SPECIES OF CHIGGER ~ ~ ...l ~ 8 ~,,_cncn""
W Leptotrombidium (Leptotrombidium) deliense + 1+ +

tv
Leptotrombidium (L.) macacus +
Leptotrombidium (L.) puta +1 + + +
Leptotrombidium (L.) rupestre +
Leptotrombidium (L.) villosum +
Leptotrombidium (L.) wallacei + +1 +
Leptotrombidium (L.) A +
Leptotrombidium (L.) B + +
Leptotrombidium (L.) C + + + 1+ + +1 +
Leptotrombidium (L.) D +
Leptotrombidium (L.) E +
Leptotrombidium (L.) F +
Leptotrombidium (L.) G +1 +
Leptotrombidium (L.) H + +
Leptotrombidium (L.) I + + 1+ + +
Leptotrombidium (L.) J +
Leptotrombidium (Trombiculindus) squamosa + + +1 + +1 + +
Leptotrombidium (Trombiculindus) A +
J'<-_....,..~~~_~~>~"";..;..;:' ~=
.. 9 '
N"eorrontb/cufa auruntnal/s +
Neotrombicula sp. A + +
Microtrombicula buxtoni + + +1 +
Microtrombicula sp. A +
Microtrombicula sp. B + + + + +
WalchieUa sp. A + + + +
+1
Ascoschoengastia (LaurenteUa) indica + I + +/ +
Ascoschoengastia (Laurentella) leechi + + +
Ascoschoengastia (LaurenteUa) roluis + +
Ascoschoengastia (Laurentella) sp. A + + + +
Doloisia sp. A + + + + + +
Doloisia sp. B + + + +
Doloisia sp. C + + +
Doloisio sp. D +
Doloisia sp. E + +
Schoutedenichia sp. A +I +
w Helenicula kohlsi + +
w Helenicula lanius + +1 +
Helenicula miyagawai + +
Helenicula sp. A +
Helenicula sp. B +
Helenicula sp. C +
Helenicula (EuryphyUa) sp. D +
Gahrliepia (Walchia) enode +
Gahrliepia (Walchia) ewing; lupeUa +
Gahrliepia (Walchia) rustica + + + + +
Gahrliepio (SchoengastieUa) ligula + + + + + + +1 + +
Gahrliepia (SchoengastieUa) gammonsi + + + +
Gahrliepia (SchoengastieUa) punctata + + + + + + +
Gahrliepio (SchoengastieUa) sp. A + + + + + + 1+
Gahrliepio (SchoengastieUa) sp. B + +
Gahrliepia (SchoengastieUa) sp. C + + + + + + + +
'\7£1
~.~ ~ ~ ~ ~
§. §. §. §. §. §.
~
(')trl
;;
t:rl
:::t :::t ::t :::t :::t:::t _ t""
~. ~. ~o ~. ~. ~o gJ trl
w
So S' S' S' S' S' 0 I
-...-...-..-...~t;; 'Tj '"::lo
~~~~""
:.- :.- :.- :.- :.-:.- (')
::c ~.
::t:::t~g~~ _
;;;. ;;;. ;:s ;:s ;:s;:s
1:!.1:!.~~~~
Cl
Cl
..
Q.
~..!:. ~ ~ ~ ~
f'1 "t::s ~.~.~. t\;'
m
~
"0 _;::;:::::::::;:::
. §.~~~~
>~V1V1V100
;.::. "Cl "Cl "Cl "Cl
I:l ••••
"'Cl"'l'ltrlO
+
I Pokhara-910 In
Nagarkot-2200 In
I + Langtang Valley-3310 - 3400 In
+ + Syabrudens-1450 In
+ + Dunche-1950 In
+ + + Bokaikunde-1900 In
Grang-1850 In
+ I Jhapa (Eastern Terai)-200 In
Sakkejung (Ham Dist.)-1300 In
+ + + I ShokteIn (Ham Dist. )-550 In
Ghorva (Ham Dist.)-220 In
Gokama Game Reserve-1240 In
Daman-2310 In
Chandranighar Pur-120 In
Rapti River Valley-230 In
TABLE 4 SPECIES OF LEPTOTROMBIDIUM OF NEPAL, REGIONS WHERE COLLECTED, AND THEIR USUAL HOSTS
Name of Chigger Region Habitat and Elevation Rat Mouse Squirrel Shrew Pika
Leptotrombidium Pokhara, Villages, cultivation and + I 1- 1+

(Leptotrombidium) deliense Syabrudens, Jhapa flood plain 200 - 1450 m
(Walch, 1922)
Leptotrombidium (L.) macacus Jhapa Plain (ricefield) 200 m + I 1 t+
Leptotrombidium (L.) puta Sakkejung, Shoktem, Hill forest, millet cultivation + 1 1 1+

(Womersley, 1952) Gokarna and game reserve 550 - 1300 m
Leptotrombidium (L.) rupestre Langtang Valley Coniferous forest, alpine and I I I I +

(Traub & Nadchatram, 1966) subarctic slopes 3310 - 3400 m
VJ
U1
Leptotrombidium (L.) villosum Rapti River Valley River flood plain 230 m +
Leptotrombidium (L.) wallacei Jhapa, Sakkejung, Cultivation in plain and hills, +

(Mitchell & Nadchatram, 1966) Shoktem wasteland
Leptotrombidium (L.) sp. A Rapti River Valley River flood plain 230 m +
Leptotrombidium (L.) sp. B Shoktem, Ghorva Secondary growth and +

disturbed forest 220 - 500 m
Leptotrombidium (L.) sp. C Pokhara, Nagarkot, Villages, cultivation, hill forest, + 1 1+ 1+ I +

Langtang Valley, coniferous forest, Alpine and
Syabrudens, Dunche, subarctic slopes 910 - 3400 m
Bokaikunde, Grang,
Sakkejung
TABLE 4-continued
Name of Chigger Region Habitat and Elevation Rat Mouse Squirrel Shrew Pika
Leptotrombidium (L.) sp. D Langtang Valley Field on hillside 3310 - 3400 m +
Leptotrombidium (L.) sp. E Syabrudens Rocky hillside 1450 m +
Leptotrombidium (L.) sp. F Syabrudens Rocky hillside 1450 m +
Leptotrombidium (L.) sp. G Bokaikunde, Grang Forest 1850 - 1900 m + +
Leptotrombidium (L.) sp. H Bokaikunde, Daman Coniferous forest 1900 - 2310 m + +
W
Leptotrombidium (L.) sp. I Pokhara, Nagarkot, Cultivation and forest in plain, + +
0\ Syabrudens, Jhapa, hill and mountain slopes
Sakkejung 200- 2200m
Leptotrombidium (L.) sp. J Jhapa Ricefield in plain 220 m + +
Leptotrombidium Syabrudens, Dunche, Villages, cultivation on plain + + +

(Trombiculindus) squamosa Bokaikunde, Grang, and hills 230 - 1950 m
(Radford, 1947) Sakkejung, Shoktem,
Ghorva
Leptotrombidium (T.) sp. AK Shoktem Disturbed forest 500 m +
Leptotrombidium (T.) sp. BK Daman Alpine slope and coniferous +

forest 2310 - 3400 m
TABLE 5 ECTOPARASITES COLLECTED BY 1. W. QUATE AND
R. MITCHELL
TICKS
Ixodes granulatus Supino

Involved in Langat Virus, natural infection (Hoogstraal, 1966, Ann. Rev. Ent.
11:264) and Russian spring-summer encephalitis in Malaya (Smith, 1956, Nature,
178-181).
Collected at Dunche and Bokaikunde, Trisuli Valley.
Boophilus microplus (Canestrini)

A widely distributed cattle tick. In New World involved in transmission of bovine
babesia.
Collected at Dunche, Bokaikunde, Syabrudens, Trisuli Valley, and Langtang
Valley.
Ixodes acutitarsus (Karsch)

Readily attacks man and may be responsible for persistent sore at site of bite
which is difficult to heal. Not known to be involved in disease transmission.
Collected in Trisuli Valley and Langtang Valley.
Haemaphysalis montgomeryi Nuttall

Syabrudens, Trisuli Valley, Kathmandu. Not involved in diseases.
137
TABLE 6 TENTATIVE IDENTIFICATIONS OF SIPHONAPTERA COLLECTED IN NEPAL BY FIELD TEAMS OF BISHOP
MUSEUM. PREPARED BY R. TRAUB, NEPAL HEALTH SURVEY, 1965-66.
Alcohol Mounted
Specimen
No. Host Region No. a No. C( No. a No. C( Flea
B-64837 Rat Ham District, 1 Peromyscopsylla himalaica ssp.

Sakkejung-4,400 ft. 1 Leptopsylla segnis (discarded)
B-64838 Rattus rattus Gokarna Game 1 Neopsylla stevensi?

brunneus Reserve 6 mi. N of 1 Nosopsyllus sp.
Kathmandu-4,500 ft.
B-64839 Rattus Kathmandu-1360 m 1 Nosopsyllus sp.

VJ 1 Xenopsylla astia ssp?
00
B-79186 Rat Ham District, 2 1 Leptopsylla segnis
Sakkejung-4,400 ft.
B- 79187 Rattus Ham District, 1 Peromyscopsylla himalaica ssp.

Sakkejung-4,400 ft.
B-79188 Mus Ham District, 3 1 Leptopsylla segnis

Sakkejung-4,400 ft.
B-79189 Rattus Ham District, 1 Peromyscopsylla himalaica ssp.

Sakkejung-4,400 ft.
B-79190 Rattus Ham District, 4 7 1 1 Leptopsylla segnis

Sakkejung-4,400 ft. 1 Nosopsyllus sp.
B-19191 Rattus llam District, 1 Leptopsylla segnis

\ 2
Sakkeiung-4,400 ft. 2 Nosopsyllus sp.
...".--._-"",,----.-
_._~ "--,
B- 79192 Suncus llwn District, 1 Srtvalius fertnus
Sakkejung-4,400 ft.
B-79I93 Rattus Ham District, 2 Peromyscopsylla himalaica ssp.

Sakkejung-4,400 ft. 1 Stivalius aporus
B-79I94 Suncus Ham District, 4 3 Stivalius ferinus

Sakkejung-4,400 ft.
B-79I95 Rattus Ham District, 1 2 Peromyscopsylla himalaica ssp.

Sakkejung-4,400 ft.
B-79I96 Rattus Ham District, 1 Nosopsyllus sp.

Sakkejung-4,400 ft.
B-79I97 Buffalo Ham District, I 1 Ctenocephalides felis orientis
-
Ghorva-200 m
w B-79I98 Goat Ham District, 1 Ctenocephalides felis orientis

\0
Ghorva-200 m
B-79I99 Rattus Gokarna Game 1 1 Neopsylla stevensi?

Reserve, 6 mi. from
Kathmandu-4,500 ft.
B-79200 Rattus Gokarna Game

Reserve, 6 mi. from
I 2 Neopsylla stevensi?
Kathmandu-4,500 ft.
B-7920I Bat Gokarna Game

Reserve, 6 mi. from
I 4 Ischonopsyllus indicus
Kathmandu-4,500 ft.
TABLE 6-continued
Alcohol Mounted
Specimen
No.
B-79202
B-79203
Host
Rattus
Rattus
Region
Daman-7,640 ft.
Daman-7,640 ft.
-----1---No. 0 No. « No. 0 No.
2
« Flea
Nosopsyllus sp.
Neopsylla stevensi?
2 Nosopsyllus sp.
B-79204 Rattus Daman-7,640 ft. 1 Neopsylla stevensi?

3 6 I2 1 Nosopsyllus sp.
-
-l::-
0
B-79205
B-79206
Rattus
Rattus
Daman-7,640 ft.
Daman-7,640 ft.
2 2
1
Nosopsyllus sp.
Neopsylla stevensi?
1 Nosopsyllus sp.
B-79207 Rattus Daman-7,640 ft. 1 Stenischia mirabilis
B-79208 Rattus Palung Village-6,000 ft. 1 Neopsylla stevensi?
B-79209 Mus Daman-7,620 ft. 1 Neopsylla stevensi?
B- 79210 Rattus Daman-7,620 ft. 2 Neopsylla stevensi?
B-79211 Funambulus Chandranighar Par.-400 m 1 Nosopsyllus n. sp.

pennanti
B-79212 Rat Chandranighar Par.-400 m 1 Xenopsylla astia ssp.?
B-79213 Rattus Rapti River Valley, 1 Acropsylla sp.

10 mi. W of Hitaura-750 m
- ~ ----
brunneus
~ ....._ ..... _-~.&"' ••• , ~ _.. , ......,.,-,.,.- ... , ... "',., ....
B-79336 Rattus r. Pokhara-910 m I 4 1 Xenopsylla cheopis

brunneus
B- 79337 Rattus rattoides? Pokhara-910 m 1 1 Xenopsylla cheopis
B-79339 Rattus nitidus? Pokhara-910 m 4 1 Xenopsylla cheopis
B-79340 Rattus nitidus? Pokhara-910 m 1 Xenopsylla cheopis
B-79344 Rattus r. Pokhara-91O m 1 Xenopsylla cheopis

.....- brunneus
~
.....- B-79344A Rattus r. Pokhara-91O m I 1 Xenopsylla cheopis
brunneus
B-79345 Rattus r. Pokhara-910 m I 1 2 Xenopsylla cheopis

brunneus
B-79345A Rattus r. Pokhara-910 m I 1 1 Xenopsylla cheopis

brunneus
B-79346 Rattus r. Pokhara-91O m I 2 3 Xenopsylla cheopis

brunneus
B-79347 Rattus nitidus? Pokhara-910 m Xenopsylla cheopis
B-79348 Rattus nitidus? Pokhara-910 m I: 2 Xenopsylla cheopis

TABLE 6-continued
Alcohol Mounted
Specimen
No. Host Region No.6 No. <;> No.6 No. <;> Flea
B- 79351 Rattus nitidus? Pokhara-910 m 2 6 3 Xenopsylla cheopis
B-79352 Rousettus
peschenaulti
Pokhara-910 m I: 1 Thaumapsylla breviceps ssp?
B-79353A Rattus nitidus? Pokhara-910 m 1 1 Xenopsylla cheopis

-
~
IV
B- 79356A Rattus r. Pokhara-910 m I 1 1 Xenopsylla cheopis
brunneus
B-79356B Rattus r. Pokhara-91O m I 1 2 Xenopsylla cheopis

brunneus
B-79357 Rattus r. Pokhara-910 m I 5 Xenopsylla cheopis

brunneus

brunneus
B·79360 Rattus r. Pokhara-910 m 3 2 I 1 1 Xenopsylla cheopis

brunneusculus
B-79360A Rattus r. Pokhara-910 m I 1 2 Xenopsylla cheopis

brunneusculus
~-_ . .------"~-:
~-- .._----.. .-~ __ ......... _ ... "",-,,"-1 ~ ••
- - , . --- -'''.~I-''''.Y''''~ e.-.,..--' ...... p.""
orunneus

brunneus
B-79364 Rattus r. Pokhara-910 m 4 9 I 3 3 Xenopsylla cheopis

brunneus
B-79369A Rattus r. Pokhara-910 m I 1 Xenopsylla cheopis

brunneus

brunneus
B- 79370A Rattus r. Pokhara-910 m I 1 Xenopsylla cheopis
--
.j::>.
w B-79373
brunneus
Rattus nitidus? Pokhara-910 m 6 1 2 2 Xenopsylla cheopis
B- 79373A Mouse Pokhara-910 m 1 1 Xenopsylla cheopis
B-79374 Rattus r. Pokhara-910 m 2 Xenopsylla cheopis

brunneus
B-79375A Rattus nitidus? Pokhara-910 m 2 Xenopsylla cheopis
B- 79377 Rattus nitidus or Pokhara-910 m 1 Xenopsylla cheopis

Mouse
TABLE 6-continued
Alcohol Mounted
Specimen
No. Host Region No. 0 No.9 No.O No.9 Flea
B-79378 Mongoose Pokhara-910 m 1 Ctenocephalides relis ssp.
B-79379 Rattus r.
brunneus
Pokhara-910 m I 1 Xenopsylla cheopis
B- 79379A Rattus r. Pokhara-91O m I 1 Xenopsylla cheopis

brunneus

+:- brunneus
+:-
B-79381 Rattus r. Pokhara-910 m 2 3 Xenopsylla cheopis
brunneusculus
B- 79384A Rattus r. Pokhara-910 m 1 1 Xenopsylla cheopis

brunneus
B-79384B Rattus r. Pokhara-91O m 8 8 3 3 Xenopsylla cheopis

brunneus
B-79387 Rattus r. Pokhara-910 m 2 3 1 1 Xenopsylla cheopis

brunneus
B-19381 A Rattus r. Pokhara-910 m \ 1 1 Xenopsylla cheopis

brunneus
______ __
...-~-._""". MM"""'""'_,.,,_,_,_.~"",,_,_"
::aw.
.L# 79J~J L«_rr_d" '17:r;;~_d-
~
~ ·O.oLJrL& ..
= ..
r-/_~~~ak....
,~_.-
" 8-J'1."'''.
p Illl<ll-i....:. ~ilIi=·~~_~w,,="."."'
.L
__ .__ ._:."~'''''''
fVe~psy~~a .:'>·~eve,.Uur
..... '"=~~'='~_~~'''~
20km NNE of
Trisuli-1950 m
B·79393 Rattus r. tistae?, Lapgtang Valley-3300 m 2 3 Frontopsylla (F.) spadix ssp.

R. r. brunneusculus, 3 Neopsylla stevensi?
R. nitidus
B-79398 Rattus nitidus? Langtang Valley-3300 m I 1 Neopsylla stevensi?

Neopsylla sp.
2 Paradoxopsyllus n. sp. (n. subgen.?)
1 Stenoponia n. sp.
1 new genus?
B-79401 Rattus nitidus,

R. r. tistae
Langtang Valley-3300 m I 1 Neopsylla stevensi?
~ B-79401A Rattus nitidus, Langtang Valley-3300 m 1 Frontopsylla (F.) spadix ssp.

VI
R. r. tistae 1 1 Neopsylla sp.
B-79403 Rattus nitidus? Langtang Valley-3300 m 3 Frontopsylla (F.) spadix ssp.?
B-79404 Rattus nitidus Langtang Valley-3310 m 1 3 Frontopsylla (F.) spadix ssp.

1 Neopsylla stevensi?
B-79409 Rattus nitidus Langtang Valley-3310 m I1 1 Frontopsylla (F.) spadix ssp.

Neopsylla sp.
B-79411 Rat Langtang Valley-3310 m I 2

2
A mphalius clarus
Paradoxopsyllus n. sp. (n. subgen.?)
TABLE 6-continued
Alcohol Mounted
Specimen
No. Host Region No.d No.<i' No.d No.<i' Flea
B-7941lA Rat Langtang Valley-3310 m I 1 A mphalius clarus

Neopsylla stevensi?
B-794l2 Rattus r. tistae? Langtang Valley-3310 m I 2

1
1
Frontopsylla (F.) spadix ssp.
new genus?
B- 79412A Rattus r. tistae? Langtang Valley-3310 m 1 Paradoxopsyllus n. sp. (n. subgen.?)

.j:::.
0\ 11 new genus?
B-79416 Rattus Langtang Valley-3310 m 1 Frontopsylla (F.) spadix ssp.
B-79416A Rattus Langtang Valley-3310 m 1 1 Frontopsylla (F.) spadix ssp.
B-79418 Rattus Langtang Valley - 3310 m 3 Neopsylla stevensi?
B-79419 Rattus r. tistae? Langtang Valley-33l0 m 1 Amphalius clarus

1 Frontopsylla (F.) spadix ssp.
B-79422 Rattus r. tistae? Langtang Valley-3100 m I5 4

4
Frontopsylla (F.) spadix ssp.
Neopsylla stevensi?
B-79429 Rattus nitidus Langtang Valley-3400 m I 1 Amphalius clarus
B- 79429A Rattus nitidus Langtang Valley-3400 m 1 1 Paradoxopsyllus n. sp. (n. subgen.?)
B-79430 Rattus r. tistae? Langtang Valley-3400 m 1 1 Neopsylla stevensi?
B-79431 Rattus eha eha Langtang Valley-3400 m 1 Paradoxopsyllus n. sp. (n. subgen.?)
B-79432 Rattus r. tistae? Langtang Valley-3310 m 1 Neopsylla stevensi?
B-79434 Ochotona roylei Langtang Valley-3400 m 1 A mphalius clarus
1 Paradoxopsyllus custodis
1 2 Paradoxopsyllus n. sp. (n. subgen.?)
9 5 new genus?
~
-...) B-79434A Ochontona roylei Langtang Valley-3400 m 1 new genus?
B-79436 Rattus r. tistae? Langtang Valley-3310 m I: 4 Frontopsylla (F.) spadix ssp.
1 1 Neopsylla stevensi?
1 Stenischia mirabilis
B-79437 Rattus nitidus Langtang Valley-3400 m 12 Amphalius clarus
2 Ctenophyllus (Geusibia) n. sp.
4 3 Neopsylla stevensi?
B- 79437A Rattus nitidus Langtang Valley-3400 m I 1 Neopsylla stevensi?
B-79441 Rattus r. tistae? Langtang Valley-3310 m I 1 Frontopsylla (F.) spadix ssp.
TABLE 6-continued
Alcohol Mounted
Specimen
No. Host Region No. 0 No.9 No. 0 No.9 Flea
B-79442 Rattus r. tistae? Langtang Valley- 3310m 17 4 Frontopsylla (F.) spadix ssp.
Stenischia mirabilis
B-79444 Mustela sibirica Langtang Valley-3400 m 13 1 A mphalius clarus

2 Ctenophyllus (Geusibia) n. sp.
+:>.
00
B-79445 Rattus eha eha Langtang Valley-3400 m I 3 Paradoxopsyllus n. sp. (n. subgen.?)
B-79448 Rattus eha eha Langtang Valley-3400 m I 2 Neopsylla stevensi?

B- 79448A Rattus eha eha Langtang Valley-3400 m 11 Neopsylla sp.

B-79450 Rattus nitidus Langtang Valley-3400 m 2 8 Paradoxopsyllus n. sp. (n. subgen.?)
B- 79450A Rattus nitidus Langtang Valley-3400 m 1 Neopsylla stevensi?

B-79451 Rattus r. Syabrudens, 35 km 1 Paradoxopsyllus custodis

brunneusculus NE of Trisuli-1450 m 1 Peromyscopsylla himalafca ssp.
B-19452A Rattus r. Syabrudens. 35 km 1 Neopsylla stevensi?

brunneusculus NE of Trisuli-1450 m 1 Paradoxopsyllus custodis
,----" '.~~";,;,m"'~"",;"·"m;"",~"",",m,,, "@.~·.'.".'_"'''~·"""",_""-,",,,,~'.',m ,,"" """"_ _ ,,m.",,,·,,~'M."""~, ~,='_m,;"~,,,,~," M ~."
13 11 ParadoxopiYll~S-custodis
1 Peromyscopsylla himalaica ssp.
B-79456 Rattus nitidus Syabrudens, 35 km NE 16 2 Paradoxopsyllus custodis

of Trisuli-1450 m
B- 79456A Rattus nitidus Syabrudens, 35 km 1 Nosopsyllus sp.

NE of Trisuli-1450 m 1 Paradoxopsyllus custodis
B-79458 Rattus r. Syabrudens, 35 km 1 1 Paradoxopsyllus custodis

brunneusculus NE of Trisuli-1450 m
B-79458A Rattus r. Syabrudens, 35 km 3 2 Neopsylla stevensi?

brunneusculus NE of Trisuli-1450 m 3 14 Paradoxopsyllus custodis
2 Peromyscops}'lla himalaica ssp.
...-
~
\0 B- 79460A Rattus r. Syabrudens, 35 km 11 1 Paradoxopsyllus custodis
brunneus NE of Trisuli-1450 m
B-79460B Rattus r. Syabrudens, 35 km Neopsylla stevensi?

11
brunneus NE of Trisuli-1450 m 5 12 1 Nosopsyllus sp.
14 13 Paradoxopsyllus custodis.
1 1 Peromyscopsyllus himalaica ssp.
B-79465 Rattus r. Syabrudens, 35 km I 2 Paradoxopsyllus custodis (discarded 19)

B-79467 Rattus r. tistae? Syabrudens, 35 km 2 Neopsylla stevensi?

NE of Trisuli-1450 m 1 1 Nosopsyllus sp.
4 3 Paradoxopsyllus custodis
1 Paradoxopsyllus sp.
TABLE 6-continued
Alcohol Mounted
Specimen
No. Host Region No. a No. <.? No.a No. <.? Flea
B- 79467A Rattus r. tistae? Syabrudens, 35 km I I Neopsylla stevensi?

NE of Trisuli-1450 m I Paradoxopsyllus custodis
B-79472 Rattus r. tistae? Syabrudens, 35 km I Neopsylla stevensi?

NE of Trisuli-1450 m 7 5 Paradoxopsyllus custodis
I Peromyscopsylla himalaica ssp.
B-79472A Rattus r. tistae? Syabrudens, 35 km II I Paradoxopsyllus custodis

,.... NE of Trisuli-1450 m
VI
0 Paradoxopsyllus custodis
B-79475 Rattus nitidus Syabrudens, 35 km I
NE of Trisuli-1450 m
B-79475A Rattus nitidus Syabrudens, 35 km I Paradoxopsyllus custodis

B-79476 Rattus r. Syabrudens, 35 km I I Neopsylla stevensi?

brunneusculus NE of Trisuli-1450 m 2 6 Nosopsyllus sp.
2 I Paradoxopsyllus custodis
B-79476A Rattus r. Syabrudens, 35 km I Paradoxopsyllus custodis

B-79480 Rattus r. Syabrudens, 35 km 2 Nosopsyllus sp.

B-19481 Rattus nitidus Syabrudens, 3S km 2 Neopsylla stevensi?

......,
NE of
~,- .
Trisull-14S0 m
' •. _, .," ..
.C~,..- .,~ ~, .. 3 3 _~a.rtld_o":?,,s)'l1us
custodis
- --r-"r - - - - -r-
2 2 2 1 Paradoxopsyllus custodis
B- 79482A Rattus r. Syabmdens, 35 km 1 1 Neopsylla stevensi?

B- 79486A Rattus rattus Syabmdens, 35 km 1 1 Paradoxopsyllus custodis

B-79486B Rattus rattus Syabmdens, 35 km 4 9 5 5 Paradoxopsyllus custodis

B-79487 Rattus rattus Syabmdens, 35 km 1 2 Nosopsyllus sp.

2 2 Peromyscopsylla himalaica ssp.
B-79489 Rattus r. Syabrudens, 35 km 1 2 Neopsylla stevensi?

..- brunneusculus NE of Trisuli-1450 m 4 5 2 3 Paradoxopsyllus custodis
VI
..-
B- 79492A Rattus t. tistae? Syabrudens, 35 km 1 Paradoxopsyllus custodis
B-79493A Rattus rattus Syabmdens, 35 km I 1 Neopsylla stevensi?

B-79495 Rattus r. Dunche, 28 km NE 1 2 Neopsylla stevensi?

brunneusculus of Trisuli-1950 m 3 5 1 1 Paradoxopsyllus custodis
B- 79495A Rattus r. Dunche, 28 km NE 1 Paradoxopsyllus custodis

brunneusculus of Trisuli-1950 m
B-79498 Rattus r. tistae? Dunche, 28 km NE 1 Paradoxopsyllus custodis

of Trisuli-1950 m
TABLE 6-continued
Alcohol Mounted
Specimen ---
No. Host Region No.6 No.9 No.6 No.9 Flea
B- 79498A Rattus r. tistae? Dunche, 28 km NE 1 Neopsylla stevensi?

of Trisuli-1950 m
B-79499 Rattus r. brunneus Dunche, 28 km NE 1 1 Neopsylla stevensi?

of Trisuli-1950 m 6 7 5 5 Paradoxopsyllus custodis
B- 79501 Rattus r. brunneus Dunche, 28 km NE 1 3 Neopsylla stevensi?

of Trisuli-1950 m 1 Nosopsyllus sp.
3 3 Paradoxopsyllus custodis
Vl
N 2 Stenischia mirabilis
B- 7950lA Rattus r. brunneus Dunche, 28 km NE 1 1 Neopsylla stevensi?

of Trisuli-1950 m
B-79503 Rat Dunche, 28 km NE 1 1 Paradoxopsyllus custodis

of Trisuli-1950 m
B-79505 Rattus r. tistae? Dunche, 28 km 3 Paradoxopsyllus custodis

B-79505A Rattus r. tistae? Dunche, 28 km 1 Neopsylla stevensi?

NE oiTrisuli-1950 m 1 Paradoxopsyllus custodis
B-79506 Rattus r. brunneus Dunche, 28 km 1 Stenischia mirabilis

NE of Trisuli-195 0 m
B-19501 Rattus r. tistae? Dunche, 28 km \ 2 Paradoxopsyllus custodis

+.><--.-,.• ~-~ NE of Ttisuli-19S0 m
NJ.:: o.t-Trisuli-1950 m
B-79509 Rattus r. brunneus Dunche, 28 km 1 Nosopsyllus sp.
B-79510 Rattus r. brunneus Dunche, 28 km 1 3 Neopsylla stevensi?

NE of Trisuli-1950 m 2 3 3 2 Paradoxopsyllus custodis
2 Stenischia mirabilis
B-79513 Rattus r. tistae? Bokaikunde, 23 km 12 2 Paradoxopsyllus custodis

B-79514 Rattus r. tistae? Bokaikunde, 23 km I 2 Neopsylla stevensi?

B- 79514A Rattus r. tistae? Bokaikunde, 23 km I 1 Neopsylla stevensi?

Vl
w
B-79515 Rattus r. tistae? Bokaikunde, 23 km 1 Neopsylla stevensi?
B-79516 Rattus r. tistae? Bokaikunde, 23 km 1 1 Paradoxopsyllus custodis

B-79516A Rattus r. tistae? Bokaikunde, 23 km I1 1 Paradoxopsyllus custodis

B-79517 Rattus r. tistae? Bokaikunde, 23 km I1 1 Paradoxopsyllus custodis

NE ofTrisuli-1900 m
B-79518 Rattus fulvescens Bokaikunde, 23 km I 1 Neopsylla stevensi?

NE 3f Trisuli-1900 m
TABLE 6-continued
Alcohol Mounted
Specimen ---
No. Host Region No.d No.9 No.d No.9 Flea
B-79519 Rattus nitidus Bokaikunde, 23 km 2 Neopsylla stevensi?

NE of Trisuli-1900 m 8 7 Paradoxopsyllus custodis
B-79519A Rattus nitidus Bokaikunde, 23 km 1 Paradoxopsyllus custodis

B- 79522A Rattus fulvescens Bokaikunde, 23 km I 1 Neopsylla stevensi?

NE ofTrisuli-1900 m
.....
VI B·79523 Rattus nitidus Bokaikunde, 23 km Xenopsylla cheopis
~
12
B- 79523A Rattus nitidus Bokaikunde, 23 km Neopsylla stevensi?

11
NE of Trisuli-1900 m 1 Paradoxopsyllus custodis (discarded)
B-79525 Squirrel Grang, 20 km NE 1 Macrostylophora sp.

of Trisuli-1850 m
B-79526 Rattus r. brunneus Kathmandu-1360 m 1 Nosopsyllus sp.

1 1 Xenopsylla astia
B-79527 Rattus r. brunneus Kathmandu-1360 m I1 Nosopsyllus sp.

1 Xenopsylla astia
B-79528 Rattus r. brunneus Kathmandu-1850 m I 21 Nosopsyllus sp.

Xenopsylla astia
__--_
.. .......""'_.-_., -----,.- \,
1
, Y".Mon.~"llln_nJt:tr·n
Xenopsylla cheopis
B-79531 Rattus r. brunneus Kathmandu-1850 m I1 Nosopsyllus sp.
B-79532 Suncus murinus Nagarkot, 30 km E 1 1 Paradoxopsyllus custodis

soccatus of Kathmandu-2200 m
B-79533 Canis Pokhara-91O m 3 Ctenocephalides felis orientis

1 Ctenocephalides felis felis
VI
VI
TABLE 7 DIPTERA PUPIBARA OF NEPAL, L. QUATE COLL., 1965
Ornithoica sp. n. (nr. stipituri Schin.)

1 BBM 30019
Ornithomya biloba Dufour from swallow
1 BBM 30059-62
1 BBM 30068-75
1 BBM 30092
Melophagus ovinus (Linn.)
1 1 ex yak, Langtang Valley
Eucampsipoda latisternum Sch. Stekn. & Hardbg. from Rousettus leschenaulti
8 13 BBM 30027
30029
30035
30036
30037
30085
30107
Bibliography
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Nepal

UNIVERSITY OF HAWAII PRESS

His Majesty's Government

Copyright 1969 by the University of Hawaii Press

Library of Congress Catalog Card No. 72-76764

THE NEPAL HEALTH SURVEY of 1965-66 was the

Dr. Narayan Shah together with Dr. Emmanuel Voulgaropoulos con-

BECAUSE of its geographical isolation, suc-

working in the increasing number of small hospitals and dispen-

in each village in order to gather demographic, nutritional, an'd

At that time the wet monsoon was approaching. Three hill

NEPAL is where the Indians from the south-

SUMMARY 6321 people in 957 households = 6.6 people per household

foot elevation about 25 miles south of Jumla is a predominantly

poor but a bit better organized in Bhawanipur and Talichaur

inantly Brahmin village of subsistence farmers. There is a

No. 07 Sakkejung (329 population, 41 households) at 4,400-

primary school near the village. There are no local medical

where many are severely deteriorated. They have one or two

moderate state of deterioration, averaging two dwelling rooms

Estimates of Vital Statistics

IN the absence of reliable birth and death

1. an account of each married woman's total reproductive

Data from the total reproductive histories are shown in

• age at birth of first child

FIGURE 2. Age distribution of 1780 women who have been married

age 50 a mean number of 6.0 live births, with a tri-modal curve,

Urine No. tested positive 12 mos. 147 12 219/1000

FIGURE 3. Age-specific fertility rates estimated from urine testing

AGE AT FINAL PREGNANCY

FIGURE 5. Age at final pregnancy of women age 50 or more

1. an account of infant mortality and number of surviving

5'9 10-14 15"19 2<Y.l4 25-29 30-34 35-3940-44~5(H;o455_!l96o_6465_6970+ ?

FIGURE 6. Distribution of 171 deaths during prior 12 months by age at death

AGE AT TIME OF DEATH

FIGURE 7. Distribution of 63 infant deaths by age at time of death

Source Formula Estimates of Rates

~ recalled infant deaths 152/1000 infant mortality ratio past

* Considerable variability expected due to small numbers.

single arrows). The population "bulge" that is seen between the

DURING the course of taking the census in

1. If you were just now getting married, how many boys

There was often difficulty in getting women to answer

FIGURE 9. Number of children considered "ideal" as expressed by 687 married

than the number desired for oneself. This lack of a marked

almost no women chose "ideal" family sizes of more than 4

When the above expressions of beliefs and attitudes were

several villages to be harmful to the infant. With few exceptions

medicines, a combination of allopathic and herbal medicines,

food in non-rice-growing areas. Rakshi, a homemade alcoholic

born. Food is introduced from about the age of 6 months or so

menstrual trouble, stomach trouble, witchcraft, or because the

Nutrition and Nutritional

mountain villages seem consistently better off with regard to

FIGURE 8. Age distribution by sex (compared with a fragment of 1961 census

graphic points of view, that our survey census gave a more

TABLE 6 DISTRIBUTION OF CASES OF CALORIE MALNUTRITION BY

* Clinical impression at the time of examination.

TABLE 7 DISTRIBUTION OF CASES OF CALORIE MALNUTRITION BY

Normal or 1119 1091 2751 634 70 311 268

TOTAL POP. 1130 1097 2794 657 70 325 268

TABLE 8 AVERAGE DAILY NUTRIENT LEVELS AVAILABLE FROM BASIC

% of Villages With Per