On the causes of death among infants, toddlers, and school-children in the D.I. Jogjakarta.
The official data of the causes of death among infants and toddlers were collected by the lurahs (village headmen), who registered deaths. In every case of a death notified, the name, age, and sex of the deceased is taken down, and besides the cause of death in the opinion of the relative who comes to notify it. The data obtained in this manner were later on collected ketjamatan-wise in a form like table VII-1, which distinguishes 29 causes of death.
No distinction is made between ages. The lack of this, and the doubtful value of these diagnoses, cause us to believe that these data are of no use for our purposes. The only source of data of causes of death we could dispose of were the archives of the children’s departments of the Jogjakarta hospitals: University hospital “Gadjah Mada” and “Bethesda Hospital”.
The children’s department of Gadjah Madah university was started on May 1, 1955. Chief of this clinic is doctor Ismangoen, lecturer in pediatrics. The data he was kind enough to place at our disposal relate to case-histories of child-patients that died during the period May 1, 1955 – July 1, 1958. The patients admitted to the children’s ward of the university came mainly from the policlinic. Admittance is very low : Rp. 2.-.
The policlinic is mainly frequented by indigent people. A number of patients is referred to the children’s ward by practising doctors in the city of Jogjakarta. The clinic has 45 beds.
The children’s department of Bethesda hospital is of older date.
Ever since the hospital was founded in 1901, children have been treated here. Mostly grown-up patients, however, came to the hospital in these early days for surgical,ophthalmological, and dermatological treatment.
In 1925 the hospital was enlarged from 190 to 380 beds, and a special children’s department with a capacity of 45 beds was opened, which was rebuilt again in 1934 and in 1956. The entire hospital has now 533 beds.
The method of admission of this Protestant Mission Hospital is the same as in the university clinic, viz. Via the policlinic. Admittance is also Rp. 2.- and a few children are sent by colleagues from the town.
The period for which we arranged the data of the children who died is from July 1, 1954 until July 1, 1958. From July 1,1954 the author was chief of the children’s department. Here, too, mostly children of indigent people were admitted. Table VII – 1.
Causes of Death according certificate of death during the period from to 196 .
The above two children’s clinics are the largest in the whole of the D.I. Jogjakarta, as will appear from the survey of hospitals and policlinics present in this area, arranged ketjamatan-wise in table VII-2.
At our request we also received data from other hospitals in the D.I. Jogjakarta about the children who died there in the years 1954-1956. It appeared that very few infants and toddlers die in the hospitals of the kabupatens Kulon Progo and Gunung Kidul, although mortality is likely to be rather high. Parents often shrink from taking a child to hospital, which appears from the small number of children admitted. This makes it difficult to study infant-mortality in these two kabupatens.
Table VII – 2.
Survey of the hospitals in the D.I. Jogjakarta per January 1, 1958.
The data of Wonosari hospital |(Gunung Kidul) were very scarce. The hospital doctor stated that the number of children’ aged less than 5, that died here in the years 1954-1956 did not amount to 15 per year.
From the data received from doctor Muljotaroena of the hospital at Wates (Kulon Progo) it appears that the children who died there were mainly infants. Chief causes of death were prematurity and malaria. The number of infants that died was very small again. In the north of the kabupaten Kulon Progo “Mardi Widajat” hospital is situated at Boro. It is a small Roman Catholic mission hospital, visited once a week by the doctor of the kabupaten Kulon Progo. Here, too, few children die. The head of the hospital R.Adj.Roebijah mentioned malnutrition as the chief cause of death of these children.
In the four general hospitals situated in the kabupatens Sleman and Bantul, Which have a capacity ranging between 20-75 beds, only few children were admitted during this period 1954-1956. These small hospitals have no daily supervision of a physician. Especially from the kabupatens Sleman and Bantul many sick children are taken to the hospitals in the city of Jogjakarta. In the city are seven hospitals.
In the eye-hospital “Rumah Sakit Dr Yap” no infants or toddlers died in the period 1954-1958.
From “Panti Rapih” a Roman Catholic mission hospital we received some data of children of Chinese families. Comparatively few child patients died here. It is an “open” hospital where and doctor can treat his own patients. In the children’s department more than twelve doctors work. Data were not full enough to make them suitable for our inquiry.
From “Rumah Sakit Penolong Kesingsaraan Umum” – chief doctor F’Moh. Saleh – we received some data of infants and children who died in the years 1954-1956.
From the Military Hospital we received detailed data from doctor Soebagija. They refer to children of soldiers stationed in the D.I. Jogjakarta. These people being temporary inhabitants, we left out of consideration.
From the data available to us concerning the patients of the Military Hospital we deduced the following:
Of the children of 1-10 years of age who died in these hospitals, 50% were infants, and in the case of both infants and toddlers enteritis was an important cause of death.
The data are collected in table VII-3.
The data of the children who died in the children’s clinic of the Gadjah Mada University and in Bethesda hospital are for several reasons so homogeneous and comparable that we thought fit to collect them in one survey. The chief causes are:
From August 1, 1954 the children’s ward of Bethesda hospital was supervised by Dr Franz E. Perabo (Associate professor of pediatrics, delegated to Gadjah Mada university by W.H.O.). This also applies to the university children’s clinic, until professor Perabo left in July 1956.
Table VII – 3.
Survey of the admitted children aged 0-9 during the period 1954-1956 in a number of hospitals in the D.I. Jogjakarta.
1) Concerns patients aged 0-10 years, admitted during 1955 and 1956.
2) Including newborn infants, born in hospital.
3) Concerns 1955 and 1956.
From October 1,1956 until January 1, 1958 the author assisted doctor Ismangoen in the university clinic. Intensive cooperation between the two clinics resulted in a great conformity in diagnosis.
The diagnostic aids at the disposal of the two clinics were practically the same viz.:
- A laboratory for clinical-chemical tests.
- The possibility of making bacteriological tests in the central laboratory of the city of Jogjakarta.
- The possibility of consulting specialists (in Internal medicine in Ear; Nose- and Throat-diseases, surgeon, dermatologist, and neurologist).
- X-ray examinations.
- Pathological-anatomical examinations in the laboratory for pathology of the University.
The child-patients admitted all belonged to the indigent class and were practically all Javanese.
In both clinics an extensive case-history was taken down of every patient admitted so that it was possible to call in a second opinion if so required.
In studying the causes of death we applied the scheme of age-groups indicated in chapter 6.
For infant-mortality we used the following classification into 5 groups:
- perinatal death.
- death within the other three weeks of the first month.
- death within the second and third month
- death within the second quarter of the year.
- death within the half of the first year of life.
Pre-school child-mortality is classified according to four year-groups viz.:
- death within the second year of life.
- death within the third year.
- death within the fourth year.
- death within the fifth year.
For death at school-age there is a classification into two groups viz.:
- death within the period of five and six years of age.
- death within the period of seven up to and inclusive of nine years.
Perinatal death.
Perinatal death should be taken to mean: the number of still-born children and those who die within seven days after birth per 1,000 confinements. This departure from ordinary usage, when it includes 10 days after birth, we allowed ourselves because Indonesian official registration distinguishes in the first month of life two categories viz.: deaths within the first week of life and in the other three weeks of the first month.
The second reason is the custom for women in child bed to be dismissed on the 7th or 8th day after confinement, so that only neonatal death within the first week could be studied in the maternity-ward.
The extent of perinatal death in this area could be estimated by means of registration-data of the kabupaten Wonosobo (Central-Jave).
Registration in the D.I. Jogjakarta is to our mind so defective that it is of no use to us to study perinatal death-rate. The kabupaten Wonosobo has had a proper registration of births and deaths for quite some time.
The number of still-born babies and of those succumbed within the first week registered in the kabupaten Wonosobo for the years 1952-1956 is mentioned in table VII-4.
Table VII – 4.
Data about fetal-, neonatal- and perinatal mortality in the kabupaten Wonosobo (Central-Java) during the period 1952-1956.
1) Fetal mortality : number of stillbirths per 1,000 births.
2) Neonatal mortality: number of infants deceased in the first week of life per 1,000 live births
3) Perinatal mortality: number of stillbirths and death in first week of life per 1,000 births.
The number of confinements is not known, but the number of children is. Therefore we did not use the number of confinements for computing foetal death together with perinatal death, but the total number of children born, both the living and the dead. The rate became slightly lower on account of this, since a number of twins and triplets were counted for a birth each.
Some remarks must still be made about these data. It is not sure that the definition of a still-born child (viz. A fetus of at least 28 weeks that does not show any signs of life on birth) has been taken into proper account in the registration. Besides, it is possible that notification of still-born children was defective in Wonosobo.
In view of the above data we estimate perinatal mortality in the D.I. Jogjakarta at 50% – 65% of the total number of births, which cannot be called particularly high, in comparison to European countries, when we consider that pre-natal care is in small demand. In 1950 the perinatal mortality was in England and Wales 38%, in the Netherlands 33%, in Sweden 32% and in New Zealand 35%.1
For our guidance in the matter of causes of death in the case f still-born children, and of mortality in the first week of life we depended on counts in the lying-in department of Bethesda hospital.
In the period January 1, 1955 – July 1, 1958 2,208 parturitions took place in this department. The number of children born was 2,260 among them 48 twins and 2 triplets. There was a total of 333 still born children, and 76 died within the first week after birth, so that perinatal death in this hospital amounted to 186 per 1,000 parturitions, which is quite high.
Of 2,208 parturitions 78% were spontaneous, whereas 500 were registered as abnormal. Perinatal death being so high can be explained from the circumstance that accouchement-practice in side as well as outside the city of Jogjakarta is in the hands of dukuns, women practising popular healing-art. Among them dukuns beranak specialize in aiding pregnant women and women in child-bed. They are mostly elderly women who according to their lights assist in ways practised of old.
Their ideas, naturally, differ considerably from more modern scientific views, which did not make themselves felt in the Jogjakarta area until 1897, when doctor G.J. Schreurer settled in Jogjakarta with the special intention to practise medicine in behalf of the native population.
The dukun is held in great esteem by the Javanese population and her help and assistance in child-birth is much appreciated. Her position is still assured, particularly in the country, because it is closely connected with the views of life held by the majority of Javanese. In the Javanese community she will probably be looked upon as indispensable for many years to come.
Modern medicine is only on aspect of Western culture. The process of acculturation, which is in full progress, particularly in the large towns, has only slightly affected the dukun’s position.
On tracing what women are admitted to the lying-in department for a normal delivery, we find that 75% of them live in the town, and 20% in nearby ketjamatans (Gamping, Mlati, Depok, Gondowulung, Sewon, Godean, Kalasan). Besides the lying-in departments of Bethesda hospital, of the University hospital, of Panti Rapih hospital, and P.K.U., there are some twelve lying-in clinics of 4-6 beds, where many women go to be delivered, and where they are assisted by midwives. These clinics do not occur outside the city.
Of the 500 patients admitted to Bethesda hospital in the period January 1, 1955 – July 1, 1958 whose delivery did not take place spontaneously, only 15% lived in the city. The others were mostly taken to hospital from the country, when delivery took a long time and the dukun’s skill failed. This decision is mostly made by relatives.
This leads to a concentration of abnormal parturitions in hospital. On these women the dukun’s methods were applied rather vigorously, which appeared from a great number of ruptured uteri, which were observed in these patients. In the period January 1, 1955 – July 1, 1958, 26 patients were admitted with a uterus ruptured at home in consequence of transverse lie, deep transverse arrest, malrotation, or hydrocephalus, when a dukun had assisted.
Reasons for admittance in these abnormal parturitions were the following arranged in order of frequency:
- Placenta praevia 114
- Breech delivery 28
- Tranverse lie 88
- Uterine inertia 26
- Deep transverse arrest 69
- Contracted pelvis 16
- Malrotation 44
- Toxemaia 12
- Gemelli parturition 31
- Hydrocephalus 11
- Retention of Placenta 28
- other reasons 33
It is quite understandable, therefore, that a high perinatal mortality occurs in this hospital.
The mortality among the women in child bed, who were admitted in the Bethesda-maternity ward was 15 per 1,000.
Table VII – 5.
Causes of death of stillbirths and of infants, who died in the first week of life. These data concerns birth in the maternity-ward of Bethesda hospital during the period January 1, 1955 – January 1, 1958.
The causes of death of the 333 still-born children and the 76 that died within the first week were traced as accurately as possible and collected in table VII-5. Where various factors were significant, we classified according to the most important cause.
Fetal mortality.
In judging the cause of death of still-born children we are aware of the selective factor introduced by the dukun. We shall less often see a still-born child in cases of spontaneous parturition than in cases of abnormal presentation, so that outside the clinic the ratio of the groups of causes of death will differ from that of this survey. Still-born children weighing less than 1,000 grams were left out of consideration.
Not a single obduction was possible, it being refused as a rule by the parents, The nomenclature we adopted for the causes of death is that agreed on by the 6th international conference for the nomenclature of the cause of death in 1948. We see from table VII-5 that the category “consequences of deliveries” is the most important in fetal mortality. Well over 57% of fetal deaths are caused by theses.
Next important is placenta praevia, the cause of 17% of fetal mortality. In 13 out of 18 cases of congenital deviations hydrocephalus had caused difficulties in parturitions and in 3 cases had even resulted in rupture of uterus.
Lues cannot be discriminated in this range of causes of still-birth, since pregnant women coming to the welfare-centre were checked on reactions on lues in the blood, but in emergency cases circumstances often prevented this. So it is possible some cases of lues are included in the group unknown fetal death. The five cases of still-birth caused by illness of the mother were no lues patients, but two cases of decompensatio cordis, one of malaria tropica, one coma e.c.i., and one of lung-deviation resulting in severe cyanosis.
During this period diabetes was not discerned as a complicating factor. It occurs very rarely with Javanese women. The number of eclampsia patients viz. 12 in 3½ years, is very low. There is no reason to expect these patients to be taken to hospital less often than cases of placenta praevia etc..
Neonatal mortality.
Here we see a strong concentration of mortality in the first few days of life.
- 23% occurred in the first hours.
- 24% occurred in the remaining hours of the first day.
- 22% occurred on the second day.
So a total of 69% was concentrated in the first two days of life.
The most important cause of death in the first week of life was prematurity viz. 52%. The average weight at birth is below viz. 2900 grams. As a criterion of premature infants we adopt the international definition recommended by the World Health Assembly 1948 and by the Expert-group on Prematurity (W.H.O.) 1950: any infant weighing 2500 gr. Or less at birth is regarded as a premature baby.
In the maternity department 25% of the babies born alive were born prematurely, a very high percentage. (See also chapter VIII).
Those who died mostly did so of breath-failure (apnea). Irregular breathing varying with breath-failure in most of these cases caused death in the course of the first week. Since we could not carry out post-mortem examinations, we do not know to what extent hyaline membrane disease affected premature babies who died on the first or second day. As this diagnosis durance vitae cannot be made with certainty and affects premature babies in particular, we presume it is of importance.
Edith Potter found that this deviation was the cause of death of 40% of the premature babies who had died in a Chicago lying-in hospital during the period 1939-1949.
Two children died of congenital atresia of the duodenum and of congenital volvulus of jejenum-ileum respectively.
We did not meet with any cases where Rhesus antagonism could be the cause of death. It is, however, in Djakarta only that it is possible to determine the Rhesus factor. Therefore it is seldom done.
As far as could be ascertained by clinical examination, the diagnoses: hydrops congenitus, icterus neonatorum gravis, and anaemia nenatorum were never made during the period of out enquiry.
Among those who died of other diseases there was one case of melaena neonatorum, and one of tetania neonatorum.
The main difference between parturition in the clinic and at home with the assistance of a dukun is the dukun’s non-sterile working method, resulting in an occasional tetanus or another mabilical-in-fection.
Among the causes of death of the neonati born in hospital, as compared to those of the ones admitted to the children’s department after birth, are less tetanus neonatorum, and congenital deviations. A very frequent congenital deviation is atresia ani. Prematurity is not looked upon by the mother as a sufficient reason for calling in medical aid.
Child-mortality.
For our guidance in the matter of mortality in the first year we used the data of patients who died in the University children’s department in the period May 1, 1955 – July 1, 1958, and of those who died in the children’s department of Bethesda hospital in the period July 1, 1954 – July 1, 1958. In the University clinic 1958 children under ten from the D.I. Jogjakarta were admitted from the opening on May 1, 1955 until July 1, 1958. Among them 478 deaths occurred (24%).
In the children’s department of Bethesda hospital 3901 children under ten from the D.I. Jogjakarta were admitted during the period July 1, 1954 – July 1, 1958, of whom 865 died, (22%).
Arranged according to sex and age the two groups are shown in table VII–6.
Table VII – 6.
Survey of the number of admitted patients and the mortality in the different age-groups in the University’ children’s ward during the period May 1, 1955 till July 1, 1958 and in Bethesda children’s ward during the period July 1, 1954 till July 1, 1958.
Mortality among the children admitted appeared to be unequal for the various age-groups In the clinic mortality among older children appeared to be lower than among infants and toddlers. On arranging the causes of death we used a classification of diseases mainly affecting these age-groups, based on the International Statistical Classification of diseases and causes of death (July 1948).
For the first year of life we chose 12, and for the other age-groups 10 groups of causes of death in the following manner:
Infants
1. The common infectious diseases
- measles measles
- diphtheria diphtheria
- malaria malaria
- poliomyelitis poliomyelitis
- tetanus tetanus
- typhoid fever typhoïd fever
2. Diseases of the respiratory tract.
3. Tuberculosis (all forms).
4. Intestinal disturbances.
5. Violent death.
6. Congenital abnormalities.
7. Malnutrition.
8. Prematurity.
9. Birth injuries.
10. Syphilis.
11. Non-specified or insufficiently specified and unknown causes of death.
12. All other causes of death.
Toddlers and school-children
1. The common infectious diseases
- measles measles
- diphtheria diphtheria
- malaria malaria
- poliomyelitis poliomyelitis
- tetanus tetanus
- typhoid fever typhoïd fever
2. Diseases of the respiratory tract.
3. Tuberculosis (all forms).
4. Intestinal disturbances
5. Violent death.
6. Congenital abnormalities.
7. Malnutrition.
8. Tumours.
9. Non-specified or insufficiently specified and unknown causes of death.
10. All other causes of death.
In the list of causes of death we gave a separate place to malnutrition (kwashiorkor). Since the most detailed data of infant- and child-mortality are from Europe and America, where malnutrition as a cause of death is of little importance,it had not yet been given a separate place in the international list of causes of death.
In the detailed list of the sixth decennial revision of the international lists of diseases and causes of death adopted by the first World Health Assembly in Geneva, July 1948, are mentioned as number 286: other avitaminoses and nutritional deficiency states; where other avitaminoses mean other than beriberi, pellagra, scorbut, and rachitis.
For a true presentation of the ratio of the causes of death it seemed better to us to include malnutrition as a separate cause of death in infancy- and childhood in the D.I. Jogjakarta. Determining the cause of death in a great number of deaths when a clinical examination had taken place beforehand, was not particularly difficult. In doing so, we followed the directions of the sixth Decennial International Revision Conference where it was agreed that the cause of death should mean the underlying cause, defined as: “the disease which initiated the train of morbid events leading directly to death”.
In cases of patients who suffered from malnutrition and from infections besides, this sometimes entailed difficulties in diagnosis.
The number of patients who died of malnutrition is an insufficient indication of the significance of deficiency in diet with regard to child-mortality, because under the heading intestinal disturbances, respiratory tract diseases, and diphtheria, are included deaths of child-patients who already suffered from malnutrition.
In only four cases was it possible to have an obduction, so that the clinical data are the almost exclusive basis of the determination of the cause of death.
In 139 cases of infants and toddlers, who died in Bethesda hospital it was possible to examine live-tissue obtained by punction post-mortem which appeared to be a valuable supplement of the diagnosis: malnutrition, tuberculosis, and hepatitis. We collected the results of our enquiry into the causes of death of all the children who died in both children’s clinics in the period 1954-1958 in table VII-7.
In order to be able to compare the ratio of the causes of death within the various age-groups, we computed the percentage division of the various groups of causes of death for every age-group. Although the number of infants deceased after the third year of life was less than 100, we yet expressed the ratio of the causes of death within these groups in percentages. The data are collected in table VII-8 and in fig. 15.
Table VII – 7.
Survey of the causes of death established in 1345 children, who died during the period July 1, 1954 till July 1, 1958 in the University and Bethesda children’s ward at Jogjakarta.
1) G.M. = Gadjah Mada University children’s ward
2) Beth. = Bethesda children’s ward.
Table VII – 8.
Proportional distribution of the causes of death in infancy and childhood according to the observations in the University- and Bethesda children’s ward at Jogjakarta during the period July 1, 1954 till July 1, 1958.
Fig. 15
Survey of the main causes of death is seven different age-groups expressed in percentages of the total number of deaths in each age-group. Jogjakarta, July 1, 1954 till July 1, 1958.
Fig. 16.
Survey of the main causes of death in five different age-groups of the first year of life, expressed in percentage of the total number of deaths in these age-groups. Jogjakarta, July 1, 1954 till July 1, 1958.
Table VII – 9.
Proportional distribution of the cause of death in 5 different periods of infancy, according to observations in the University- and Bethesda children’s ward at Jogjakarta during the period July 1, 1954 till July 1, 1958.
On looking over these data, we see that in the case of the infants three groups of causes of death stand out viz.: enteritis, prematurity, and tetanus neonatorum, while malnutrition already has a great significance.
With the toddlers the pattern of the causes of death is determined by malnutrition, enteritis and infectious diseases. At school-age it is infectious diseases and violent death.
Since a great number of infants died in both clinics, we further investigated the causes of death in relation to ages within this group of 706 infants. We traced the causes of death in the first week of life, in the remaining weeks of the first month, in the remaining months of the first quarter of the year, in the second quarter, and in the second half of the first year of life. The results are shown in table VII-9 and fig. 16.
In the first week and in the first month of life, it is especially tetanus neonatorum, congenital malformations, prematurity and enteritis which determine the spectrum of the causes of death. After the first month it is enteritis which dominates, in the second quarter it is after enteritis, respiratory diseases and malnutrition which are about equally significant.
In the second half of the first year the ratio is about the same, only after enteritis, malnutrition has become more significant than respiratory diseases.
Important factors in admitting infants to the clinic are the following: Distance, Seriousness of the disease, Income of the parents, and Customary law.
Distance.
In the University clinic, situated on the southern fringe of the city, mainly children from this neighbourhood and from the kabupaten Bantul, south of the city, are admitted together with a small number form sleman. Few patients come from Gunung Kidul and Kulon Progo. In the children’s ward of Bethesda hospital on the northern fringe of the city, about five miles from the University clinic, many patients are admitted from the northern part of the town and from the kabupaten Sleman together with a small number from Bantul. There are few patients from Gunung Kidul and Kulon Progo. As the distance from the other ketjamatans to the children’s clinic increases, there is a rapid decrease of the number of patients from these. The relation between the patients’ place of residence and frequency of admittance to the University clinic and to the Bethesda clinic are shown in fig. 17 and 18.
The results of this enquiry into infant-mortality refer therefore especially to the population of Sleman, Bantul and the city of Jogjakarta, but it is very probably that this is brought about mainly by the factor: distance.
Fig. 17.
Distribution of the patients, admitted in the Bethesda children’s ward during the period July 1, 1954 till July 1, 1958, according to place of residence in the D.I. Jogjakarta.
Fig. 18.
Distribution of the patients, admitted in the University children’s ward during the period July 1, 1954 till July 1, 1958, according to place of residence in the D.I. Jogjakarta.
Seriousness of disease.
Since the number of places for admittance to the clinic is small viz. 45 in both children’s clinics, and the number of children coming for treatment is great every day, it is obvious that as a rule serious patients only are admitted.
The University children’s policlinic is consulted annually by 6,000 – 8,000 new patients under ten.
The children’s policlinic of Bethesda hospital is consulted by 5,000 – 6,000 new patients under 10 annually.
From these patients and from those registered before, the ones are chosen that must be admitted. As the policlinic is not overwhelmingly busy, it has always been possible to admit serious patients, although policlinical treatment while waiting for admittance was sometimes necessary. The reason why a mother takes her child to the policlinic to have it examined is in most cases that she believes it to be seriously ill, and a number of children arrive in a moribund condition.
Of the children who died in the University clinic 39% did so within 24 hours on admittance.
In the children’s clinic of Bethesda hospital 41% of the children comprised in this investigation died within 24 hours on admittance, which goes to show that these chil-patients were taken to hospital in a very late stage of their illness.
A factor of great importance in the policlinic for grown-ups is that of incapacity to do work. Not until the complaints of a patient have become so bad that his daily work can no longer be done, and he becomes a burden on his relatives of the desa-community, is there any serious incentive for going to the clinic. Thus a tuberculosis patient will not come, until the process is very far advanced in both lungs. The patient with liver-cirrhosis and decompensatic cordis does not come, until oedema and tightness of the chest make any further work impossible.
The patient with Bürger disease does not come until some toes have become necrotic, and the patient with rheumatoid arthritis not until all important joints are swollen and painfull. This, of course, concerns the chronic diseases. In acute cases the seriousness cause medical aid to be sought, when it has become clear that the illness does not disappear of its own accord, or when dukun-aid has failed. Obviously, the factor of incapacity to do work does not influence admittance of children under ten.
The earnings of parents.
Charges in both children’s clinics being very low, and varying from nothing for the poor to a maximum of Rp.10-Rp.15 a day for those who can afford to pay, are one cause that it is particularly children of poor and indigent people and people who are not very well-t-do like lower officials that are admitted here.
Since rich and well-to-do people make up a very small part of the population, we expect the above factor to have had a favourable influence on our investigations in the sense that no financial obstacles were the cause of anybody going without medical aid.
Customary law (Adat).
During the first forty days of life the child is supposed to require special protection from surrounding dangers. That is why a mother in her anxiety is mostly not inclined to take her baby into the open air during this period. We expect that the number of patients less than forty days old who appear in the clinic, is particularly low for this reason.
Therapeutic action.
A factor possibly influencing the ratio between the causes of death inside the clinic and outside is therapeutic action. The group of children admitted to the clinic makes up a very small part of the total number of sick children among the population of the D.I. Jogjakarta. The well over 1,300 children that died under ten years old in the two clinics in the period 1954-1958 is a very tiny proportion of the total. On a basis of the data of table VI-18 we estimate the number of deceased children under ten years old in the period July 1, 1954 – July 1, 1958 at 90,000 and therefore put the 1,300 children who died that we comprised into our enquiry at 1.4% of this total.
Estimating on the basis of table VII-3 the number of children who died but received medical aid e.g. (in the hospital at Wates, at Wonosari, in the military hospital, P.K.U. Hospital, and Panti Rapih and also from general practitioners in the city of Jogjakarta), we should say this is 700-800 children. If all the assumptions of chapter 6 are correct, this would mean that of all the children who died well over 2% received medical aid, most of them in the children’s clinics of Gadjah Mada University and of Bethesda hospital. The group of children who died, which is comprised in our investigation makes up according to our estimate only 1.4% of all the deceased, and will because of the medical care they were given, show a ratio of causes of death somewhat different from that of the other 98% whose diseases took their course without any medical influence.
Considering the great similarity in the ratio between the diseases from which the patients suffered who died, and those from which those patients suffered who could be improved of dismissed from hospital on recovery, we do not believe that therapeutic intervention brought about any sizable changes. Particularly the fact that patients were often in a dying condition was important, because it left few possibilities for treatment.
We consider the pattern of causes of death in childhood, which was established among the children who died in the University-and Bethesda children’s ward at Jogjakarta during the period July 1, 1954 – July 1, 1958, of importance for the judgement of the dangers which threaten the life of the children living in the D.I. Jogjakarta. The great influence of the unsatisfying nutritional conditions is visible in this pattern of causes of death, and this influence will be discussed more detailed in the sections of the chapters. VIII , IX and X.
On looking for comparable data of other Asiatic countries, we found them to be very scarce. Only of Japan and Ceylon there appeared to exist some data of the causes of death of children under five. As the data concerned mortality owing to some “selected causes of death”, so that those of Ceylon concerning the age-group 1-4 year did not account for 59-69% of all deaths in this group, they are of limited value. Of the Japanese data, also for this age-group in the year 1954, 25-44% of all the deaths that occurred among the toddlers had remained out side these selected causes of death.
Egyptian data for 1954 coming from those parts of Egypt where Health Bureaus are available, were collected together with those of Ceylon and Japan in table VII-10.
In the Japanese data we notice how the factor accidents has become important in infant-mortality.
The Egyptian data show how in Egypt, too, enteritis is very significant both for the mortality of infants and toddlers.
Once they are dressed in the robe of officialdom, these data, which on behalf of the governments of these countries were placed at the disposal of the United Nations Statistical Office, still remain open to a number of questions.
How is it possible that only among the 81,000 infants who died in Egypt in 1954 the factor congenital malformations appeared to be non-significant?
Were the diagnoses made by doctors put together with those by the medical auxiliary staff, when the figures for this official survey were arranged?
Table VII – 10.
Survey of the causes of death in the first five years of life in Ceylon, Japan and Egypt in the year 1954.
Is the low mortality-figure of tuberculosis in Ceylon and Egypt an indication that occurrence of this disease is indeed low, or was no proper diagnosis made in many cases because of the doctors’ equipment being limited, so that enteritis, diagnosis of which can be made with less difficulty, were registered oftener than tuberculosis, which requires extensive bacteriological, clinical, and X-ray tests, before any diagnosis is justified?
In which groups would the patients who died of malnutrition have been registered? The occurrence of malnutrition in Ceylon, Japan, and Egypt is well-known from publications in medical literature.
In Ceylon malnutrition was described by Jayaskera et al. In 1951, in Japan by Arakawa et. al. In 1951, and in Egypt by Sheekry et al. In 1938, by Hanafy in 1951, and by Bado El Din in 1957.
In view of so many open questions comparison is only possible subject to many provisos.
____________________- The Netherlands: per 1,000 births, other countries: still-birth-rate + neonatal mortality-rate. [↩]