(A) EB15/VJP/1 19 January 1955 ORIGINAL

NATIONS UNIES UNITED

ORGANISATION MONDIALE WORLD HEALTH DE LA SANTÉ ORGANIZATION

EXECUTIVE BOARD EB15/VJP/1 19 January 1955 Fifteenth Session ORIGINAL: ENGLISH Provisional agenda item: 8.13 (a) RESTRICTED

PROGRAMME ANALISIS АШ Ш1ШШ

Sanples of Evaluation Reports

Under item 8.13 (a) of the Provisional Agenda, the Executive Board will examine a report on Programme Analysis and Evaluation (EB15/45). This document mentions (page 5) that, at the time of the completion of the report, the Regions had submitted 6Д "project evaluation reports",the distribution of ^ich is given in Table 1 on the same page. The present working paper is a reproduction of two evaluation reports as samples illustrating the process cf evaluation in specific cases.1

This document has been treated as a working paper, "restricted,« for the use of members of the Board during the discussion, but could not be treated as a formal Board document because it could not be published without consultation with the governments concerned and their agreement.

1 The reports attached are: I. Treponematosis Project in the Bechuanaland Protectorate II. Malaria Control Project in Taiwan EB15/WP/1 page 1 Bechuanaland.

EVALUATION REPORT

TREPONEMATOSIS PROJECT IN THE BECHUANALAND PROTECTORATE

1。 SHORT DESCRIPTION

The Extra Venereal Treponematosis Project was started in Bechuanaland Protectorate in November 1953. For carrying out the project a tripartite agreement was drawn up between the World Health Organization, the Bechuanaland Protectorate Government and the South African Institute for Medical Research, each of iAich undertook certain responsibilities. The first year waa to be one of intensive investigation using the Bakwena Reserve as a pilot area followed by a mass treatment campaign during the next two years.. The project is a UNICEF assisted one particularly during the second and third years e

2, PROJECT AREA

2,1 Technical

2.1.1 The Country

The Bechuanaland. Protectorate is a veiy sparsely populated country of some 300,000 square miles. The estimated population is about 270,000 people of who® only about 3,000 are Europeans. Much of the country consists of the bush veld of the Kalahari Desert。 Most of the population is gathered on the eastern side of the country. For the greater part of the year there is no surface water and the people rely for their drinking water on shallow wells and a few bore-holes. The territory- is divided into eight major tribal areas. Each tribe has its Paramount Chief with its native courts. The seat of the Government is in Mafeking, in the Cape Province, but in each tribal area there is a Government Representative knovm as the District Commissioner with his administrative Staff, The aim of the Government is indirect rule through the hereditary Chiefs and the Chiefs have great power over their people EB15/WP/1 page 2 Bechuanaland.

The Chief's word is absolute law for his people. The senior tribe in the Bechuanaland Protectorate, although not the largest numerically, is the Bakwena, whose capital is Molepolole, (see 4.2.1.1) i .•

2.1.2 The Treponematosis Position

For many years it has been known that a form of endemic syphilis exists throughout Bechuanaland. It is known also that the disease causes considerable morbidity amongst the people but there have never been any accurate investigations to show the exact incidence of the disease amongst the Bechuana. Most of the serological investigations, give a figure of about 30 per cent, sero-positivity.

2.1.3 Clinical Characteristics

The disease goes under different names in different parts of the country. For example in the Bakwena dialect it is called "Dichuchwa" whilst in others it is known as "Thosola". Its clinical manifestations are veiy sionilar to Bejel. It is non- venereal in spread and the earliest signs are aching legs, mucous patches in the throat and mouth, angular stomatitis and condylomata around the genitals, anus and axillae. If one child of a family is affected the parents expect that the other children will be affected also. These early lesions', vMch are teeming with spirochaetes, regress spontaneously. In a number of cases they are followed by tertiary lesions in anything from a few months? to a few years' time. The tertiary lesions particularly affect the long bones vhich, in some cases, show great swelling and deformity. Ulceration of the skin sometimes occurs over these deformed bones. Gxuranatous ulceration of the skin is especially common on the limbs and. buttocks. Nas o-Pharyngeal ulceration is common and at times extensive tissue destruction occurs » Keratitis is sometimes seen. Cardiovascular lesions arid involvement of the central nervous system are rarely, if ever seen. Congenital syphilis from mothers with a history of "dichuchwa" and with a positive serological reaction is also rare.

2.1.Д Epidemiology

The disease particularly^ affects the poorer members of the community and especially the dwellers in the Kalahari Desert where water is scarce and where direct and flies abound. Spread is direct from child to child, and common use of feeding bowls, spoons EB15/WP/1 page 3 Bechuanaland. and blankets is an important epidemiological factor。 Plies probably also play a part in the spread of the disease. The disease is rarely, if ever, seen in the well fed, well clothed and well washed better class families.

2.1.5 Laboratory Facilities in the Bechuanaland Protectorate

Before the commencement of the project there was no laboratoiy in Bechuanaland Protectorate where routine serological investigations could be carried out although, at the Government Hospital at Lobatsi, a small research laboratoiy has been functioning for a few years mainly for biochemical investigations. All hospitals in the Bechuanaland Protectorate send their sera by road and rail to the South African Institute for Medical Research in Johannesburg, a journey which may take a week or more.

2.1.6 Therapeutic Measures

For many years the Medical Department of the Bechuanaland Protectorate Government has been issuing to all Government and Mission Hospitals and to all Dispensaries supplies of arsenical and bismuth preparations for the free treatment of all cases of syphilis.

2.2 Functional

2.2.1 OrRanization of Health Services

The health services of the Bechuanaland Protectorate are under the direction and control of the Director of Medical Services stationed in Mafeking. In all the main centres of population there are either Govérament or Mission Hospitals and at many of the smaller places there are Government or Mission dispensaries in the charge of either trained Africans or European Nursing Sisters. At all these centres cases of extra-venereal treponematosis are diagnosed and treated with arsenicals and bismuth.

2.2.2 In the pilot area for the project, namely the Bakwena Reserve, there is an up-to-date Mission Hospital run by the United Free Church of Scotland which also has dispensaries in most of the villages of the Reserve. For twenty years the staff of this Hospital has been treating "dichuchwa" cases by means of arsenicals supplied by the Bechuanaland Protectorate Government^Medical Department. EB15/WP/1 page 4 Bechuanaland.

2.3 Social and Economic

2.3.1 The Bechuana are a pastoral people leading a semi-nomadic life. Theirs is a subsistence economy and they depend for their livelihood on satisfactory rains• The main crops are millet, mealies and beans• These are sown in areas known r 1 1 1 as lands or gardens Tdiich may be anything up to seventy, or even more, miles away from the village. Furthermore, each family owns cattle and these are kept at cattle 1 1 posts which are usually even further away than the lands . Each year, then, there is a cycle of movement between the village home, the lands where a poorer type of hut is built, and the cattle post. When the rains come in November the people scatter very widely to their ploughing lands and remain there with occasional breaks for visits of a few weeks to the cattle post or to home until after harvesting in July and August % From the end of August until November most people congregate in the towns and villages and this is the only time >iien the people can be easily reached and found in big numbers• There are no industries in the Bechuanaland Protectorate apart from a recently opened asbestos mine. Every year many hundreds of men from all over the Protectorate migrate to the gold mines in the Union of South Africa for contracts of four or nine months duration. Many parents send their children to school although often only one or two favoured children out of a fajnily are sent. If the rains are good and the crops plentiful these children may be removed from school to work in the lands of their parents, grandparents or other relatives. The result of all this is that for most of the year families are split up and the different members are scattered at widely separated places•

3. PROJECT PURPOSES

3Д General Purposes

11 The general purpose of the project is to investigate "dichuchwa from the clinical, serological, epidemiological and therapeutic aspects and then institute a mass treatment campaign to eradicate the disease from the Bechuanaland Protectorate,

3#2 Specific Purposes

3.2.1 Technical and Functional

During the current year an active system of case finding has been followed in conjunction with a "whole population" surv^r 此ich has been as complete as the EB15/WP/1 page 5 Bechuanaland.

constantly shifting nature of the population allows. All cases and all contacts are treated with РЛМ and serological examinations are carried out on as many as possible. As soon as the first experimental year is finished the Government intends to change over from the present standard arsenic and bismuth preparations to therapy with penicillin throughout the whole of the Protectorate。

During the second two years the main purpose will no longer be survey, but mass treatment of cases and contacts by teams of trained personnel who will, at ths same time, teach people how endemic syphilis can be prevented by simple hygiene and will also teach the importance of early treatment of cases.

3.2.1 Social and Economic

The Medical Department is actively advising the Government on many social and economic problems such as improved water supplies and housing in the territoiy whidi will lead to better hygienic conditions for the people. Village dispensaries are being increased in number and medical examination of school children is being introduced. Eventually these actions by themselves would tend to rid the territory of the disease.

4. METHODS

Д.1 General Methods

The general methods of fulfilling the project purposes and of eliminating "dichuchwa" in Bechuanaland are by mass treatment of the whole population with peni- ir ‘cillin and by seeking to improve the hygiene of the people. •.

4.2 Health Effort (During the Project)

4.2.1 Technical

4.2.1.1 Experimental Area The Bakwena Reserve has been chosen as an experimental pilot area for the first year of the project. This is an area of some 10,000 square miles with a population ..as far as can be guessed, of about 40^000 people. When the project commenced it was believed that the population was about 29,000 persons but the survey itself has shown EB15/WP/1 page 6 Bechuanaland. this figure to be inaccurate and that it is more likely to be in the region of 40,000. Most of this population is living in the South-Eastern part of the area around the capital town of Molepolole and so a triangular area with its base along the Rhodesian Railway and its apex at a large Kalahari village about 80 miles from the base line has been chosen for intensive investigation. This year an attempt is being made to interview and examine as many people as possible in that area and to take a blood sample from as high a proportion as possible. Details of each person seen are entered on a punched filing card and on this card is also made a note of the missing members of the 11 family. In this way a detailed picture of "dichuchwa in all its aspects is being built up and on this picture plans for the mass treatment phase can be based. In the pilot area cases and contacts are being treated as they are found. Towards the end of the year these will be assessed as regards their response to treatment.

4.2.1.2 The Technical Role of the Team and Staff

The Director of Medical Services of the Bechuanaland Protectorate Government is in close touch with the field medical officer and the team. All correspondence and reports from the field are sent to the Regional Office for Africa through his office. Dr. J.F, Murray, the Senior Consultant, is also in constant touch with the field team and pays frequent visits to the field.

A laboratory has been fitted up in Molepolole at the Mission Hospital at viiich is stationed a European laboratory technician with two African assistants^ appointed and paid by the South African Institute for Medical Research. The actual field team consists of the medical officer, appointed by World Health Organization. The African staff is paid by the Bechuanaland Protectorate Government and consists of a clerk, medical orderly, staff nurse, driver, lorry driver and cook. There is also a Chief's Representative paid from Tribal Funds.

4.2.1.3 Training Facilities

It was originally intended that a Government medical officer would be seconded to the team towards the latter end of the first year's working and that other medical officers would spend short periods with the team in the field. Similarly it was intended that African male orderlies and female nurses would be trained in ttie field EB15/WP/1 page 7 Bechuanaland. by spending short periods with the team. Staff shortages in the Government medical service have not permitted realization of this plan but the present team is well trained and should form a nucleus from which other teams can quickly be trained.

4.2,1.4 Supplies

All laboratory equipment has been supplied by the South African Institute for Medical Research under the control of Dr. Murray and there has never been any hitch in the laboratory arrangements. The metal identity discs have also been supplied by S.A.I.M.R. Three vehicles have been provided; a caboose has been loaned by the Medical Department of the Governmentj a 1-ton Ford truck has been supplied by the Deferred p t Fund of the Native Recruiting Corporation, and a Chevrolet light delivery aymen van has been supplied by UNICEF. РАМ; venules; and syr^ges have been supplied 欤 UNICEF. Unfortunate^ the of venules has ceased. UNICEF has also supplied sterilizers and Speed Graflex supp3y camera. Some of the equipment in anticipation of next year's mass therapy campaign has also been supplied by UNICEF but is in store and is not being used at present. ‘ This comprises further.sterilizers, camping equipment, tables, chairs, beds, bedding, a battery charger,, metal instrument dishes, kidney dishes, and cotton wool.

A 220-volt, autoniatic, 3 phase, 6 KVA Petter-Morrison electric power plant was supplied for the laboratory by the Deferred Payment Fund of the Native Recruiting Corporation.

4.2.2 Functional

4.2.2.1 Organization of the Project

During the past nine months the team гйг11е based upon Molepolole, and ccmencing its campaign there, has continually moved about the Bakwena Reserve surveying the population. The standard plan of action has been as follows: 厶.2.2.1.1 The Chief's representation is sent to the selected, centre at whic^h people are to be examined. He confers with the local headman and arrangements EB15/WP/1 page 8 Bechuanaland.

are made to have the people assembled in family groups on a specific date. If the numbers are too great for the team to cover the whole population in one day the representative is informed before his departure that the team will remain at the centre for two, three or more days according to the necessities of the situation.

4.2.2.1.2 On the arranged date the team sets up its equipment at a pre- determined spot (usually a hut set aside by the headman for the purpose). After a. preliminary stateroent by the Field Medical Officer in the presence of the headman, the population is examined in family groups.

4.2.2.1.3 Names, relationships, and a reference number for each person are entered on a punched card by the native clork. At the same time he ties on the wrist of each person a stamped metal disc bearing a number corresponding to his or her reference number on the card,,

4.2.2.1.4 The native orderly collects blood from as many as possible of the population the only limiting factor being inability to get into a suitable vein,

Д.2.2.1.5 The medical officer then examines each person and obtains a personal history which is entered in the appropriate portion of the record card. At the same time he determines whether an injection of РАМ is necessary, and, if so, entera the amount on the reference card^ and on a small blank card tóiich the patient takes to the native nurse. Dosages are determined on the basis of those recommended Ъу World Health Organization for extra-venereal tre- ponematos is teams in the field.

Д.2.2.1,6 The native nurse gives to each person the amount of PM indicated on the card and collects from the patient the reference and dosage cards.

Д.2.2.1.7 At the end of the day the total of the dosage cards is checked against the amount of РАМ used and the numbers of injections of each dosage are entered in a ledger book.

4..2.2.1.8 All blood specimens idiich have been collected are checked against the reference cards and then despatched at once by the lorry driver to the laboratory at Molepolole, FUNCTIONING CHART, SHOWING THE PERIOD OPERATIONS IN A KSIEN (PREFECTURE)

/ HSIEN \ MALARIA /(PREFECTURE)、 CONTROL \ HEALTH > HEAD- \ CENTRE / QUARTERS \

Headquarters• Personnel One hsien supervisor and his counterpart from the Headquarters Hsien Health are responsible for field opera- Pers

Township Personnel

One township supervisor is responsible for field operations in that township.

f One squad， com- ^posed of one I foreman^ fo\Xr I sprayinen and two I helpers, is res- I ponsible fcr I spraying 7,000 f j people s premises. EB15/WP/1 ‘ page 9 Bechuanaland

4,2.2.1.9 The following d^y the sera are examined by the VDRL and Kolmer

tests *

Д.2.2.1.10 Laboratory results are entered on the reference cards and in a

ledger book.

厶.2.2*1.11 The reference cards are filed under family, kgotla, and tribal headings.

Д.2.2.1.12 Once a month the amounts of penicillin issued from the central store are checked against the total administered in the field and that remaining in the hands of the field team.

Д.2.2.2 Administration

In the mass treatment campaign of the next two years considerable re-organization will be necessary. Intensive serological investigations will not be required} the main aim will be to find and treat all infectious cases. As already indicated the people can only be found easily in large numbers in the months of August to November and these are the months when the mass treatment campaign can most easily be carried out in an intensive way. If several teams of trained Africans are located, one in each main tribal area, it should be possible to find and treat the majority of cases. There will require to be intensive preliminary propaganda by Chiefs and local headmen to prepare the villages for the team's visit. It may be possible for tiie team to work under the supervision of the local Government medical officer with one Field medical officer to supervise the campaign over the whole Protectorate.

In order that the work of the next two years me¡r be carried out in this way it is most important that further African medical orderlies and nurses be trained, with the present team in the field. If this were done it would be possible to deal with two or three Reserves at a time, each under the supervision of the Government medical officer and all the teams under a field medical officer appointed for the purpose. This was the original intention of the Bechuanaland Protectorate authorities and we are confident that they will make every effort towards its achievement. EB15/WP/1 page 10 Bechuanaland.

Д.2.2.3 Finance

The following are the figures idiich are available to us regarding the cost of the survey to date:

4.2.2.3.1 S.Á.I.M.R. - Cost of equipping and running the laboratory from November 1953 to July 1954 • £2,375.

4.2.2.3.2 Bechuanaland Protectorate Gt们rnment • Costs of maintaining transport, African staff, postage and stationery to date + £350. .

Л.2.2.3.3 Native Recruiting Corporation - Donation towards purchase of. Ford lorry and its upkeep (1st year) - £1,700. Donation for purchase and installation of power p-lant - ££СО..

4.2.2.3.4 Ш0 and UNICEF - Expenditure for items and personnel indicated.

4,2.3 Social

The project has been enthusiastically received and supported by the Bakwena• No obstacles, social, religious, or superstitious, have been placed in the path of the team. The only social obstacle encountered has been the continual migratory- habits of the people with its consequent splitting of families and the difficulties resulting therefrom. As this is an integral, part of the life of the people we can see • # ' • no way of overcoming it entirely• It is our opinion that it would be best met by- concentrating future work in the months August to November when most of the people have 1 1 returned from the gardens to the major towns and villages• 4.3 Health Stratear .

4.3Д Technical

As already stated the Bechuanaland Protectorate Government has not found it possible to second medical officers or African orderlies and nurses regularly to the field team. If expansion is to be achieved over the next two years and familiarity with the extra-venereal treponematosis work is to be achieved amongst the African nursing personnel this remains the most urgent problem. EB15/WP/1 page 11 Bechuanaland.

4.3.2 Functional

The desirable organization for the next two years has already been outlined and depends upon the requisite personnel being available. It is our opinion, having had experience with Africans in the field and br-'r.g well aware of the difficulties of obtaining additional field medical officers that the best arrangements would be as indicated under 4.2.2.2.

4.3.3 Social

Apart from the continually shifting population no social difficulties are anticipated in a mass therapy campaign against extra-venereal treponematosis in Bechuanaland Protectorate,

4.3.Л Economic

Wiile it is true that 20-30 per cent, of the population show sero-positivity and the elimination of extra-venereal treponematosis will be cf benefit to the Bechuana, it is our opinion that the basic factor in determining the lack of "positive health" amongst them is that of malnutrition. This underlies all other disease processes in Bechuanaland Protectorate and is the basic factor in determining their lack of vitality and their poor есопов^г.

5• ACCOMPLISHMENTS

The foregoing refer mainly to health efforts and, at this stage it is not possible t¿ state what accomplishments will be achieved in health strategy. Such an assessment depends upon our findings when we resurvey villages within the next two or three months and also upon the extent to which the activities of the present team and other trained personnel is integrated, into the general health services of the Bechuanaland Protectorate Government,

5,2. Functional

The functional objectives of the project have, to date, been achieved in so far as organization, administration and finance are concerned. For details of costs refer to 4,2,2.3. EB15/WP/1 page 12 Bechuanaland 6. SUMMARY

As there are still some months to go before the first stage of the project is completed and resurveys have not yet been carried out, no final summary comparing accomplishments with objectives can be given. It can be stated, however, that the project has awakened wide interest in the subject, not only amongst Government medical officers, but also amongst the Government Administrative Service and the Bechuana people themselves.

The Bechuanaland Protectorate Government in Mafeking and the local District Commissioner have done all in their power to assist. The scheme was discussed at a recent District Commissioner's conference at which all District Commissioners expressed the greatest interest and are eager to assist in the mass therapy campaign in due course. Those members of the African nursing service who have been with the team have benefited greatly and will doubtless transmit their knowledge to their colleagues in the future. If circumstances permitted a constant flow of such orderlies and nurses through the team it would undoubtedly assist considerably in the control of the disease throughout the Bechuanaland. Protectorate.

The project has become widely known amonst the Bechuana and they show the greatest eagerness to benefit by the treatment. The demand amongst them for РАМ in such cases will undoubtedly be stimulated by the project. In addition to these benefits in Bechuanaland Protectorate there are additional scientifití -gains, e.g. splrochaete has been successfully transmitted to hamsters and is available in Boston for comparison with other strains. Also, various surveys have been made on batches of sera to determine the incidence of other infectious diseases. Change in lipo-protein content of the sera which could conceivably be associated with the high sero-positivity rate have been determined. These latter studies are being pursued by bi chemical and electrophoretic means at the South African Institute for Medical Research.

7. PREDICTIONS

It is not felt that long-range expected accomplishments can be discussed until a later stage when the extent to which the present campaign is incorporated into standard health programmes is known. EB15/WP/1 page 13 Bechuanaland.

CLINICAL AND SEROLOGICAL FINDINGS

E.V.T, Project Bechuanaland Protectorate

December 1953 - July 1954

Taking round figures the totals are as follows:

Patients seen 20,000

Clinically active or latent cases 6,000

Serological tests 15,000

Sero-positivity (including weakly positive) 6,œo EB15 AlP/1 page 1 China

CHINA - TAIWAN Chtao Chow Headquarters, 17 Sept. 1954

EVALUATION OF THE MAURIA CONTROL PROJECT IN TAIWAN

Project in Progress

1. SHORT DESCRIPTION ‘ China-7 (WHO/ТА). Province-wide malaria eradication project; assistance consisting of a WHO team of three experts, equipment and supplies, two fellowships during the academic year 1954 and three fellowships for 1955. Cost to WHO/ТА for four years: US $19,500 plus salaries of three experts. Cost to FOA/CUSA/JGRR for four years: NT $19,256,587 and US $516,500, Cost to Government for four years： NT 約，064，252. Cost to Prefecture and Township Governments for four years: NT ^12,592,482. Total cost from all sources: NT $40,913,321 and US 5-536,000 plus the services of three experts. Agreement signed in October 1951} expected duration of thé project four years, started in May 1952, at present in full operation.

2. PROJECT AREA

№e project area embraces the whole province of Taiwan by gradual expansion year year； the first year's programme (1952) involved a population of 156,217 by in southern Taiwan, the second year (1953) of 1,526,306 in the foothill regions of the central mountain chains and the third year (1954) reached the goal of the ‘ whole malarious area intended. 2.1 Technical

2ЛЛ Position of malaria problem in relation to the general health problem

in project area:. EB15 AlP/1 page 2 China

Vital statistics, regarding at least figures of births and deaths, are considered fairly accurate, except babies who have died within three months. No burial is permitted without a death certificate by an McD, or an authorized herb doctor. Accuracy as to the cause of death should be- however, taken under reservation. If Tb is the first killing disease with an annual death rate of 12,000, or one seventh of the total deaths in Taiwan, malaria is not in the first rank of the deadly diseases. It is however first in the rate of morbidity, with an estimated 800,000 sick cases, or 10 per cent, of the population per year.

Below in Table 1 is reported the malaria mortality in Taiwan for the last three -‘ .... years 1951; 1952; 1953.

Table 1

Malaria Mortality in Taiwan

Malaria Mortality Number of Total Number Mortality Year Population malaria of Deaths 1,000 100,000 Deaths

1951 7,618,942 83,431 10,95 2,659 34.90 1952 7,871,886 75,122 9.54 2,216 28.15 1953 7，904，142 70,981 8,98 1,320 16.70

Remarks: Records from Kee-Lung City and Peng-Ha Prefecture are not included in the above figures»

2.1.2 UNICEF Assistance

The participation of UNICEF in the malaria control project was relatively limited, for there was no agreement for such a bilateral support of the project. The offer however of three jeeps for three months and one jeep ceded for six months, at the beginning of the project, has proved a valuable contribution. Furthermore, 30,000 kgs of UNICEF milk powder for the babies of the routine infant surveys, and the continuous services of the UNICEFДШО Liaison Office in Tai-Pei.are much appreciated. EB15 AlP/1 page 1 China

2-1,3 The malaria situation prevailing at the period before the project started.

2Д.3.1 Project area description:

Taiwan, generally known as Formosa, is a province of the Republic of China, consisting of the proper island Taiwan with a land surface of 13,836 square miles or approximately 36,000 square kms and seventy-eight islands. Sixty-four of the isles located about 40 miles to the west of Taiwan constitute the archipelago of Peng-Hu or Pescadores. Taiwan bisected by the Tropic of Cancer lies between the East China Sea : and the South China Sea and is separated from the province of Fukien of the contin- ental China by the Strait of Taiwan of 90 miles in length and to the south is separated from the Philippines by the Bashi and Balingtang Channels, which are 230 miles wide. The eaat coast is bordered by the Pacific Ocean.

Shaped like a tobacco leaf physically Taiwan is intersected for almost its entire length by a mountain range, which is featured by five high peaks. In the western side 如 slope is characterized by numerous valleys and the west coastal plain，which contains the majority of the population. In the eastern side the mountain range . leaves a narrow strip between it and the Ocean and tremendous cliffs are formed above,the Pacific Ocean. The tydrographic picture of Taiwan is featured by many streams of mountainous origin, which are small during the.dry season, but may become raging torrents in the rainy season. ’ There are a few lakes of which the water is used for power and irrigation.

Considering the transmission of malaria there have been defined, more or less .safeDy, four sectors, each characterized by a seasonal peak of anopheles population and parallel peak of malaria transmission. A description of each sector follows.

Central. Starting from the sea, the region is a coastal plain, then a series of hilin^d narrow valleys, finally bordered by the high mountain of the main range running from north-northeast to south-southwest of the island.. This width from the western side to the base of the high mountains constitutes about three-fifths of the island. The so-called plain, really inclines at a gentle slope; the graded areas have been terraced for rice culture for generations. The hills are steep so during EB15 AlP/1 page 1205 China e rainy season the run-off is swift. As the soil is decidedly loose conglomerate, th erosion is very pronounced and landslides are common. The rivers and creeks have • ery wide beds, and during the rainy months are very swollen. In contrast the dry V gather flow is negligible, sometimes occurring only as standing water, except with large streams. Irrigation channels ramify the countryside, supplying the rice fields with water supporting two crops a year. Agriculture is varied; rice cultivation is the mainstay, with sugar-cane a close second. Rotation crops like Ъалапаз, sweet potatoes, tobacco and extensive truck farming abound. This region is also noted for citrus products, one of the exports of the island. Even bamboo is cultivated and one town, OHU-SHAN, meaning bamboo mountain, has really sufficient bamboos to merit no other name.

The Northern Sector. The region is more mountainous than the central, but numerous valleys separate the hills and lesser mountains. Agriculture is also widely practised with rice as the main crop. The rice fields are irrigated, although the channels are not as abundantly supplied with water as those in the Centre. Industrial activities include brick pottery and textiles. Mines are found in this sector. The people engaged in this industiy are concentrated in small

mountainous areas• The Eastern Sector. Every little narrow flat strip of arable land is cultivated for rice and sugar cane. Truck farming is practised, but the region is agriculturally very much poorer than the other three-fourths of the island. The mountains are very close to the sea so the rivers during the rainy months are very swift. Irrigation is also practised for the rice fields, but is even less extensive than in the north. Part of the inhabited portion of Tai-Tung Hsien is protected

• by a parapet consisting of a small.雜tain range parallel to the main north-south range. As a whole the sector is rocky.

T south. The plains are more pronounced in this region, with few hills ha until close to the bordering mountain range. In spite of this much wider plain， • e lofty and steep mountkin range has produced swift гшг-off which carved the th draining river beds In the same fashion, producing wide channels with very little EB15 AlP/1 page 1206 China flow during the dry season and a very swollen condition during the rainy months. Agriculturally this is the most productive part of the countiy. In fact the prices offerm lands in this area are about twice those of the other sectors. Being close to level, the area is the recipient of huimxs deposits. The region has an aquifer sea for self-flowing artesian water, when tapped. The irrigation channels are fed from the self-flowing wells supplemented by surface water from the large streams. As tapping of artesian water is taken for granted in this area, indiscriminate drilling keeps going on and so many areas are waterbound, with the result that there is no end to breeding places for mosqiitos throughout the year,

CHmate： The climate of Taiwan is both tropical and subtropical, but in areas of high altitude the climate may be frigid, although it never snows. In eight selected stations the monthty average temperature varies from 15.8°C. to 30.2°C. Warmest month is Julyj coldest months are Januaiy and Febmary. Tanperature rarely exceeds 100°F, (37.7°C.) The annual rainfall varies in the different parts of Taiwan from 3,700. лип to 2,700 mm, with an exception for the Pescadores where the annual rainfall is limited to 1,000 腿，The relative humidity is constantly high, with a monthly average of 80 per cent. The high percentage of cloudy days is apt e depressing to some people. Summer and winter seasons are well marked. In t0 b the central and north regions winter is rainy, foggy and cool； while in the south a nice sunny weather prevails from November through March. The typhoon season ex- tends from May to October. Earthquakes are recorded frequently, but are generally light and sectional. Table 2 Normal Annual And Monthly Average Temperatures In Various Localities in Taiwan r Recarc Monthly Ave age 'em]ier a игеГ(0 с Annual , Localities .1 .2 •cj ïrsr . 3 4 5 6 8 9 .0 6 8 262827282 27 效28 7 1818:18.1820:肌20.1 比 111 s18:1919:8 24 8 27á 5 28 3 93^191939203 5 參• «•»•• 23.3 2 2： 16.9 22.1 3 8••• 8 3 о 2 • о 8 22 о 23.23.22.24,2424:5 Han 3 568.8.8,3.9*4. 3 2 6 2 «•••• 2 _ 625.5 2 113 8 7 2 Taipei 16.2 22.2 6 2 7 4 8 4 2 3 2 2 6 1 61 16.9 22.5 6 2 9 324.7 2 3 3 Taichimg 2 2 4 6 2 8o 7 « 5 8 2 27-30282728 23.8 CNJ 5 Hwalien ю 8.8.8 17.2 3 21,7 7 4 88 ' 5 2 2 5 о 11 • 26.3 Cheluchien 18.7 24,7 2 2 t6 I о 1 7 2.5 о 6 о 2 口 (near Tainan) 2 8 2 28 2121:1 5 2 о. /и 9 9 2 丨 8 丨 о 8а 5 2 Taitung 19.5 9 23.5 27 2 г8 .2 8 25.0 2 о в 1 Chiaotsetou 19-5 25.2 28 27. С (nrKaohsiung) • 24.4 Hengchan 20.7 22.1 24.5 26.6 27.4 27.5 27.2 25.4 23.5 21.4 Source of Data: Sugar Handbook, 1952 Edition . Published by Taiwan Sugar Corporation EB15/WP/1 page 1207 China

Table 10 Normal Annual and Monthly Rainfall In Various Localities in Taiwan Monthly Total Rainfall (rnm ) Annual Recording， Localities Total Years 1 3 4 5 6 7 3 9 ilO ：XL . 02 (ram) Ilan 210 140 193 107 152 186 199 201 348 389 246 346 2,717 10 Taipei 94 129 209 158 166 329 251 270 164 105 35 75 2，035 13 Taichung 35 73 118 148 225 430 275 280 113 15 32 1,757 31 Hwalien 67 81 100 118 250 272 251 250 408 296 180 105 2,378 20 Cheluchien 11 28 47 89 188 459 541 420 156 44 11 24 2,018 • 19 (nr Tainan) Taitung 31 41 60 72 144 357 220 278 304 171 78 42 1,798 40 Ghiaotsetou 9 23 39 58 187 504 631 446 192 46 3 19 2,167 20 (nr Kaohsiung) Hengchun 20 29 23 40 166 393 589 526 316 142 47 19 2,310 38

Source of Data: Sugar Handbook, 1952 Edition Published by Taiwan Sugar Corporation.

Table 4 below shows the population in Taiwan since 1905 till 1940. During this period the Taiwanese population grew almost entirely through an excess of births over deaths.

Table 4 Population in Taiwan since 1905 till 1940 (in millions) Year Population 1905 3.05 1920 3.66 1930 4.59 1940 5.87

Since 1945 migration from the China mainland has brought about an abrupt increase of the Taiwanese population. Ignoring the migrants, the growth of the Taiwan population by only the difference between the number of births and the number of ldeaths in 1943 was near 25 per thousand» (Table 5 below.) According to G •W.Barclay s report on Taiwanese popúlala.on "the growth of the population at this rate is veiy rapid and it would take the people of Taiwan only a century and a half to produce the reputed 450 million of the whole of China, and less than 250 years to surpass the present population of the entire world". EB15/WP/1 page 9 China

Table 5 Annual Crude Birth Rates, Death Rates, and Rates of Natural Increase (Rates per 1,000 population)

Rates of Natural Years Birth Rates Death Rates Increase 4 C\\0 料糾 г Н О r- l ir \ M < > 權 1 H » O í .г Н и л 42.3 о о о г Ч i

41.6 о 〇 гН - « С Л vr \

45.5 寸 о о г Н 1 н S С Л « ① о 44^2 С о ^ From： G.¥ Barclay^ "A Report on Taiwan's Population" e

The growth of the population follows an upward trend during the post-war years, as Table 6 below shows: Table 6 Vital Statistics of Taiwan for the period 1947-1952

Death Rate Year Population Births Birth Rate Deaths c h O H 寸寸寸 I P v 114,192 17,57 t » H 6,497,734 241,001 37,09 c h 95,340 14.00 H 6,807,601 263^803 38.75 O ^ o ^ s 93,349 12.62 r~ l 7,396,931 300,843 40.67 0 О 85 737 11.35 7,554,399 323,643 42.84 г H s г Ч 89,259 11,34 i H 7,869,247 385,383 48 „97 0 Cv í 8,128,374 372,905 45.88 79,034 9.72

The Taiwanese population contains a high proportion of small and adolescent children, considerable.пшпЪегs of people in early adulthood, and rapidly declining proportion in advanced ages. Persons below 15 years of age make up 44 per cent, of the entire population, A relatively small portion, only one-fifth of the total, have passed thQ age of 40. The explanation of this age structure lies in Taiwan»s recent pattern of natural increase. There is a costly disproportion in. dependency. There are many people who are too young (or too old) to work, and the burden of their support falls on others. For eveiy 100 persons between 15 and 64. there are 88 others. By contrast, the corresponding ratio for Japan in 1950 was 68 for the United States 3 55，and for Swe.den 36. ‘ EB15 AlP/1 page 1209 China The population was found by computation 8,128,374 on 31 December 1952, 25.3 per cent, of the people live in cities of more than $0,000 inhabitantsi 31 per cent, live in towns of less than 50,000 people, and the remaining 43.7 per cent, live in rural areas. About 170,000 are aborigines, whose origin is not well known. Thçy live in small communities in the mountains. 87.75 per cent, of school- age children are registered in schools. The number of primary schools is 1,300, the number of school children 1,060,324 and that of school teachers 26,030. There are also 156,000 high school students in 222 schools and 12,000 students in nine colleges or univisities. For the majority of the people the nutrition is inadequate. Rice and vegetables are the ordinary food, with an estimated 2,200 calories per day for the average adult. As a rule one room plus some auxiliary space consists the family- home in urban and rural areas.

2.1.3.2 Malaria in the areas

On arrival of the WHO team in Taiwan' in May 1952，there were a great шацу malariometric and entomological data obtained by the Taiwan Malaria Research Institute. Numerous reports on spleen and parasite rates were available. Among them the first simultaneous parasite survey conducted in December 1951 by the Anti- malaria Stations, gave a general picture of the heavy infection level from malaria prevailing mostly in the rural people. About 13,500 blood smears were collected in one day from 140 locations in different parts of the province, from children below six years old. The average parasite rate was found 8.63 per cent, ranging from 0 to 30.36 per cent. In December 1952 a second simultaneous parasite survey was conducted from the same locations and about the same number of blood smears was collected. It showed an average parasite rate of 9.98 per cent, ranging from 0.50 to 36 per cent. The third simultaneous parasite survey of December 1953 yielded an overall parasite rate 4.76 per cent, but by this time a great part of the country had received the first spray coverage. The exact picture of the parasitic reservoir of the country therefore, might be better seen by splitting the .area in two parts, the one non-sprayed and the other sprayed in 1953, as in Table 7 below. EB15/WP/1 page 9 China

Table 7 Results of Three Simultaneous Island-wide Parasite Surveys

Area Sprayed in 1953 Area Unsprayed before 1953 Number of Number oi тогах rarasiw Number of Number of Total Parasite Localities Smears Posi- Rate Year Localities Smears Posi- Rate tiv . Surveyed Examined tive

i Examined f с о О C V 1Г \ с о »Г \ H O í 寸 и л 12.70 О H 739 as a t o « A о г Ч ч О ^ 5.53 О o c v с м с » - o ^ H 14,13

и л 847 1Г Ч V Û c v v O w С Л о o a 6Л8 < л N i < 3 w - о < л

VT N 3.73 та 5.57 233 О с о - о ^ o

above concentrating tabulation is fair^ descriptive of the dispersion of The alaria Plasmodium in the country and gives an ear]y indication of the speed the 迠让 which it can be reduced after spraying, The clarification, however, of every t of the country by the degree of endemicity has been based on a country-wide par reconnaissance by spleen and parasite surveys. Through a malaria survey conducted in 1952 was defined the t^erendemic area of 1,500,000 population, which has been the subject of the 1953 operations. The attached in the next page map of the alaria endemicity was completed after a second malariometric survey conducted during 1953, during which 820 primary schools including 147,000 school children surveyed. By this survey were checked both the malarious and non-malarious were areas. On the basis of the estimated population of Taiwan on 31 Deceiriber 1952 and the average spleen index of the schools the malaria status of Taiwan was using found to Ъе，the, following:.

The Malaria Endemicity in Taiwan

Spleen index 10-1 雄 Population Spleen index 15-1 诉 Population ^,161 Spleen index 20-50$ or more Population l^bl,^ 6rendemiC SPrayed ^ T "3 P^n.tion 1,509,904 Q Total malarious population 5,386,545

Itypoendemic rural area, spleen index below 10多 Population 1,622,975 City proper, non-malarious Population 1,118,854 Total non-malarious population 2^741,029 EB15 AlP/1 page 1211 China

Entomological Findings :

There are altogether 16 species of Anopheles recorded from Taiwan, namely A. minimus, A» hyrcanus sinensis, A. ludlowii, A, tessellatus, A. macvilatus, A, annularis, A. splendidus, A. subpictus indéfinitus, Д. leucosphyrus, A. candi» diensis, A. fluviatllis, A, lindesayi, A. gigas ballayi, A. barbumbrosus, A. aitkeni bengalensia and A. insulaeflorum. Of the 16 species only the first nine species were found in living houses and the remaining seven species are supposed to be the rare mountainous or zoophilous species.

Among the nine species of Anopheles found in living houses, A. minimus is the extraordtoartly predominant one occupying 78.9 per cent, of the total collections, and secondly A. hyrcanus sinensis occupies 16.1 per cent.

From the collections in animal sheds also nine species of Anopheles were collected but A. candldiensis was obtained instead of. A. leucosphyrus« By the species analysis A, minimus and A. hyr. sinensis are again the two predominant species showing 9.6 per cent, and 89.1 per cent, of the-total collections respectively. In the stables, therefore, A. h. sinensis is the far more predominant species.

Dissection of 83,737 wild-caught anophelines was carried out to determine the natural infection of local anophelines. Eight species； i.e. A. mln” A«h« ain»^ A»tess” A. lud., A. ann" A. spl” A. mac, and A, s. ind., were included but only the first three species were found infected with either gut or gland. As shown in the following table, A, minimus, especially those from living houses, gave much higher natural infection rate than the other two species： MALARIA ENDEMICITY IN TAIWAN

ENDÉMICITÉ PALUDIQUE À TAIWAN

1953

ж Ш

縫â

r.v.y

Spleen Rates

Indice splénique =-75 % 國 50 • 75 % 25 - 50 % [Т7Г| 10 - 25 % 0-10%

5 big cities 5 grandes villes

WHO 5071 ELEVATIONS OF LAND IN TAIWAN RELIEF DE TAIWAN

Elevations (metre)

Altitudes (en metres)

國 >1000 ill 100 - 1 000 I I -=100 EB15 AlP/1 page 11 China

Table 8 Results of Anopheles Dissection. Taiwan, 1947-1953

A. minimus i'U h. sin» • A. tes. Others TOTAL о • . H No, No.».' No. No. No. No. No. w No, Period Habitat о S ； • • dis. pos. pos. dis. pos. C L H . C O • pos. dis. pos. t o K î 寸 о с о Vf \ . 0

House Ч Л о

1947-1949 ю

• ч 0 4,168 0 60,915 19 O í M 办 cx > ,791 t o Stable О 9* 4 v n f v 办 0 3 o 厶 о с э 0 i Outdoor ^ _ с л H и л ¡ > г -

о L,810 0 с л 1950-1952 House 2,702 卜 Stable 538 ？,298 0 1,136 0 21,938 9 J с м а Outdoor 59 387 0 t o 1 0 34 0 House 11 0 ш 1953 655 о 884 11 ю

о 1 0 o a 0 Stable 2 0 G 0 TOTAL .House 7,613 24 2,317 Stable 2,398 4 53,521 ),827 1 5,339 0 83,737 39 о Outdoor 443 0 1,279 ！

Note: * Among 9 positive cases, 8 cases were reported Ъу Chpw et. al in 1950 for gland positive. Of the eight positive glands, the single slide now retained at the Gh'ao Chow Branch Laboratory of the Taiwan Malaria Institute was re- examined and was found to consist of crithidial forms of an unknown flagellate instead of the sporozoite identification previously reported. .

AH of the above-mentioned proved that in Taiwan A. minimus is the chief, vector of malaria transmission.

As well known, A. minimis breeds in streams, irrigation ditches and other clean running water and, on the other hand, A. hyr, sinensis breeds in rice-fields, ponds, swamps and other rather stagnant water collections. Under the local conditions of Taiwan, therefore, the former is generally prevalent in the foothill areas along the Central Taiwan Mountain Range and the latter in the western and other plain areas. The malaria parasite surveys also reveal highly malarious areas present in the foothills. .Looking at the malaria map of Taiwan we notice that the mountainous areas of 1,000 metres above sea level, where less than 1 per cent, of the entire population is living, the south-western coastal plain, the municipal centres in large cities, EB15/WP/1 page 12 China- and the arohipelago of Pescadores islands (Peng-Hu) constitute the hypoendemic zone of malaria. The highest degree of malaria endemicity has been found in areas located between 500-1,000 metres above sea level, with an average spleen rate 45#59 per cent, among 11,400 school children examined. The areas of 100-500 metres altitude give an average spleen rate of 29,96 per cent, among 18,625 school children examined. Below 100 metres elevation the spleen rate of 16,10 among 23,300 school children.

Demonstration and Check Area of Chi-Shan District

Two valleys separated by a mountain were selected for the demonstration and check area. The area is extensively cultivated with rice and sugar cane. The villages are accessible by roads and paths, but only the larger ones are reached by motor vehicles. The housing pattern is uniform and is expandable depending on the size of the family. This pattern of housing is the expression of the family ties in Chinese people. The nucleus of the house is a rectangle in shape, a structure which in plan contains the sitting room, bedroom, storeroom, kitchen. The toilet and bath may or may not be attached to the house. As the family increases, which is often the case, more rectangular structures are added at right angles forming the wings of the nucleus• The house, now really a unit, takes a U-shaped compound• In elevation the house unit is one storey and in most cases only three metres or / less in height• The materials are varied depending on the capability of the family # The better constructions are of brick, the medium of tiled roof and adobe walls, and the poorer ones are of plastered mud walls, bamboo walls and thatched rocfs. The furniture and furnishings of the people are all simple. The beds are mostly of wood surfaced with thick straw mats. Space under the beds is used as storage. Some articles are hung on the walls but these are very limited, apart from mirrors and pictures, where the walls are plastered or ara of mud and adobe. The houses are not painted, except in a few instances where dull tones are used. Since the windows are very small and mostly with grilles, the rooms are very dark. In the kitchens, where the excess smoke escapes from the chimney, the walls are well coated with soot. The people are indoor sleepers but mosquito nets are not universally used. From the dimensions of the structures, the surfaces required to be sprayed per capita exhibit uniformity in the villages. In the larger townships or large communities, the per capita surface areas required to be sprayed oscillate with the economic levels of the people # EB15 AlP/1 page 13 China

The demonstration area has a total population of 37,280; the check area has a total population of 21,370•

The Climate: The climate of the demonstration and check areas of Chl-Shan District is described as mild. For the eight consecutive years 1944-1951 the average annual rainfall 抓s 2,764 m. July, the rainiest month,.contributes 39.5 per cent, of the rainfall. 91,5 per cent, of the total rainfall is concentrated in the five consecutive months of May-September. During eight years, the rainfall oscillated from a lowest annual of 1,019 丽 to the highest of 5,268,9 mm. The lowest recorded temperature was 13°C which occurred in the month of Januaiy, while the highest of 35.5°C occurred in the month of May.

Table 9 Averages of Maximum, Mean, and Minimum Temperatures by Months Highest and Lowest Recorded Temperatures by Months of Eight Consecutive Years 1944-1951 in Demonstration and Check Areas of Chi-Shan District (In Centigrade)

Maximum Minimum Mean Highest Lowest Month Average Average Average Recorded Recorded 19.20.-23,2629:2829:2929:29.2618348828 ¿13.16X8:22.22.23.08592732052.0 : 礼24.21.17.14. 1415:¿2023:24.24.25.25,23.2114322621620.5,0-5 27.4 : January- 25.5 February 26.4 28.2 31.3 March 29.4 33*0 April 31.2 May 33.0 35.5 June 32.7 40J.7C^.O.8 34.5 July 33.3 34.3 August 33.0 34.9 September \ 33.0 34.2 October 31.8 33.8 November 30.0 32.5 December 23.4 28.7

More than 60 per cent, of the population over 12 years of age in the experimental area of Chi-Shan practise farming. EB15/WP/1 page 14 China

Table 10 Occupation of the Inhabitants in the Demonstration and Check Areas of Сhi-Shan District by Sex (1952)

Total Population Over 12 3rear s of Age Town- Sex Popu- Total Farm- Indus- Comm- Trans- Govt. Pro- Domest. Other ship lation ing try erce port, fess. Chia- Male 1,815 1,239 979 19 IS 5 35 27 68 5 Hsien Female 1,730 1Д92 809 2 13 0 0 5 36 2 Shan- Male 4,609 2,952 2,447 21 54 3 46 16 165 7 Lin Female 4,602 3,037 2,362 0 13 0 0 5 112 3 Chi- Male 15,740 LO,260 4,831 475 900 205 251 232 1,961 41 Shan Female 15,794 L0,408 3,617 9 • 137 6 3 79 1,097 14 tiei- Male 6,852 4,464 3,885 7 38 9 42 41 71 5 fen Female 6,709 4,354 3,889 0 13 0 0 11 47 0 Liu- Male 4,512 3,017 2,011 68 134 12 84 25 421 5 Kuei Female 4,300 2,843 1,961 1 54 0 2 5 302 0

Out of 26,466 females over six years of age in Сhi-Shan District 16,477 or 60 per cent, of the females are uneducated. Among males 30 per cent, are uneducated in Chi-Shan area. Table 11 Educational Level of the Inhanitants of the Demonstration •and Check Areas of С hi-Shan District (1951)

Total Over 6 Years of Age TowriT Sex Popu- Total Higher Sch. Middle ‘ Sch,Primar y Sch. Priv. Unedu- ship. lation Gradiin Sch. Grad, irj Sch, Grad.in Sch*. Sch, cated Chia- Male 1,815 1,457 0 0 54 42 431 421 64 445 Hsien Female 1,730 1,407 0 0 7 3 240 333 5 819 Shan- Male 4,609 3,643 4 4 133 72 1,185 946 182 1,117 Lin • Female 4,602 3,647 0 0 19 6 564 多62 8 2,488 • Chi- Male 15，740 12,472 80 14 778 •592 4,177 2,988 385 3,458 Shan Female 15；794 12,626 8 0 376 156 2,292 2,458 50 . 7,286 Nei- Male 6,852 5,501 0 2 224 (L21 1,657 1,543 199 1,755 Men Female 6,709 5,316 0 0 40 2.3 698 911 43 3,601 Liu- Male 4,512 3,662 7 0 111 60 1Д82 886 154 1,263 Kuei Female 4,300 3,470 0 0 27 1 527 710 22 2,183 ЕВ15А^Д page 15 China

Table 12 Land Utilization of the Chi-Shan District (All figures are in "Chia" a Chinese Unit equivalent to about 2.5 acres) ——————i Township Total Land Use --'Chia-Hsie" n Shan-Lin Chi-Shan Wei-Men Liu-Kuei 6,42^.2 Bice Fields 328.7 1,Ь66.2 2,229.5 1,585Л 814.6 2,983.6 Dry Crops 169.5 ^91.5 l^k-J.k 571.7 ^53.7 10,258.1 Other 190.I 1,988.2 - 3,599Л 3,124.6 1,355.8

Total 688.1 3,9^5.9 7,126.1 5,281.7 2,62k.1 19,665.9

Table 15 Vital Statistics Data in the Demonstration of Chi-Shan District Area in Five Years 19^7-1951

Infant Death Year Popu- Births Total Mala. Infant Birth Total Malar. Infant lat. Death Death Death 1,000 Death Death Mort. 1,000 100,000 1,000 Malaria 1,000 6.06 2,6kl 768 136 229 5紅 15.7 278 86.75

-1= - ^9,053 v o 288 175.5 lM M 1，7б7 838 1Л6 308 5M 16.55 O0- J 50,655 v o

M 12.0 2,169 7k6 1Л2 225 in.2 1、2 27O ^ O 52,7认 -p - v o 10紅 H » 5U，672 56紅 128 52 10.3 VJ l 1 О < 0 M 602 82 65 ^5.5 10,7 lÏ6 3.27 1- J b Ч Л v o 56，2红5 25.7

Tlie malariometric findings of the demonstration and check areas obtained in June-July 1952 illustrate the malaria situation of the area at the pre-operative time:

Demonstration Area；

E t s n3 Rt ae p a r a s i t e a e p б • 6 • 3 к- 5 9 5 12 2 5 • 6 •* 5 1 among 1,371 children 2Л years old； 2 k. 5 2 • among 565 children 5-9 years old； among b02 children 10脚ЗЛ years old; all three age groups coining from 19 villages and sampling a population of 11,000 inhabitants. EB15 AlP/1 page 16 China

Demonstration Area (continued)： Spleen Bate Parasite Rate among infants below 365 days old； 15.61 8 380 5 »-. 15 among 1，10紅 blood smears taken from persons with fever fótínd in house-to-house visits. The tvo latter parasite rates sample a population of 8 500 inhabitants. Л

Check Area： 3 5 9 6 k х^5 2. б 2I.96 among 559 children 2-紅 years old； 5 5 k- 19.^ among U32 children 5.9 years old； 18.93 ‘among lt-28 children 10-14 years old. These children coming from 7 villages sample a population of 8,000 inhabitants, 12.50 among 1UU infants below 365 days old; 51.91 among U67 blood smears taken from persons vith fever found in house-to-house visits. The two latter parasite rates sample 4 800 popula- > tion.

Chi-Shan is composed of five townships. There is one hospital in Chi-Shan tcjvmship with 30 beds and one Health Station in every township. In every Health Station is assigned a physician, one malaria technician, a sanitarian and one or two nurses. Chi-Shan is administratively a subdivision of Kao-Hsiung Prefecture; the health institutions of the area belong to the jurisdiction of the Prefectural Health Officer of Kao-Hsiung,

2.1.3.3 Insect-Ъогпе Diseases other than Malaria

(a) Fllarlasis： Another important mosquito-borne disease is Filariasis. The disease， however, is generally considered to Ъе present in Pescadores Islands only. The causative organisms are determined as Wuchererla bancrofti. . ' Several cases have Ъеап reported from the main island of Taiwan, but are accepted as the imported cases from Pescadores or China minland and other coastal islands.

In Pescadores, among 28 Culax fatigans dissected Ъу Professor Yokogava et al. a single specimen vas found harbouring Wuchereria bancroftiDue to thé coinmon appearance of the mosquitoes in the Ьшпап dwellings, it has Ъееп accepted as the mosquito vector in Pescadores. Several other anopheline or culicine mosquitoes are quite common domestic ories and suspected to Ъе vectors. This needs further con- firnation Ъу studies. EB15/WP/1 page 1220 China-

(Ъ) Dengue fever: The disease is reported in Taiván as incidental epidemic only. Among the recorded epidemics of dengue fever are those in 191^-15, 1922， 1951 and 19^2-^3. The last one occurred in the midst of the World War II which was first imported from the Southern Pacific Islands into Southern Taiwan and later swept the entire island. The epidemic was the severest one having been reported from the island because the two important Aëdes vectors, Aëdes aegypti and Aëâes albopictus, bred in large munbers in fire-fighting vater tanks vhich every household was forced to instal during the war.

There is an interesting fact observed regarding the distribution of the Aëdes mosquitoes. While Aëdes albopictus distributed throughout the island, Aëdes aegypti vas recorded from the Southern half of the island only. In Taiwan it is noted that most epidemics have occurred in Southern Taiwan. This is, of course, due to the close access or communication to the tropical endemic areas, but may Ъе also to the more important role played Ъу Aëdes aegypti.

(c) Japanese В Encephalitis: Some cases of the disease are usually reported from the island every year. No specific studies have been conducted in Taiwan on the moBquito vectors of the encephalitis. Culex tritaeniorynchus, the suspected vector in Japan, however, is also a popular domestic mosquito in Taiwan and considered as a possible vector. ( ) infectious Gastrointestinal Diseases Amoebic and bacillary dysentery, d ： typhoid and paratyphoid fever, and other fly-.Ъогпе diseases are prevalent in Taiván. These are mainly attributed to poor sanitation allowing the common house fly, Musca domestica vicim, to "breed profusely in garbage, vastes, excrements, etc., especially

during summer time. Cholera, partly regarded as a fly-borne disease, also has occurred as serious

epidemics in Taiwan.

( ) piague This was the most serious epidemic disease of Taiwan at the e ； beginning of this century. The endemic focus on the coast opposite the Chinese nland constitutes a constant threat of epidemics to Taiván. The disease ml 細 seemed to have disappeared from Taivan since 19П but recently we have experienced «other minor epidemic in 丄7 vith 15 cases and к deaths. Xenopeylla cheopis, the chief rat-to-шп vector, is quite prevalent in the island. EB15/WP/1 page 18 China-

(f) Scrub typhus (Tsutsugamushi Disease): The disease is endemic throughout Taiwan， especially in Pescadores, Eastern Taiwan and Tai-Chung. Usually 50-100 cases are reported from the island every year. Compared vith the serious attack in Japan, this is rather mild type in Taiwan but still results in about 10 per cent, mortality.,

The insect vector is the mite Trombicula akamushi, In the endemic areas, it is frequently found on sunny grassy fields, chicken, goats, rats, etc.

The rodent reservoirs are Hattus losea, Apodemus agrarius, and Battus rattus rufescens.

(g) Other Insect-borne Diseases： No definite records are available on the louse-borne typhus, murine typhus or relapsing fever. The "tvo-week fever" is fairly commonly reported and the transmission by insect vector is suspected. Pedicuius humanus capitis is common among children， and Ped, humnus corporis and Liponyssus nagayoi are frequently collected.

Despite the prevalence of Aëdes aegypti in Taiwan, no cases of yellow fever have been recorded•

Very few cases of kala-azar were reported, all being considered to have been imported from the Chinese mainland. Several specimens of sandflies were reported to have been collected in 1938 and 19红6， which needs further confirmtion. .

2.2 Functional

2.2Д Organization of public health, medical care and malaria services in the project area

In the Taiwan province of the Republic of China vhere the present malaria control project is being undertaken, there has been a good public health network organization developed during the last five years through the efforts of the Provincial Health Administration and the Joint Commission of Rural Reconstruction• At the provincial level, the Provincial Health Administration is responsible for over-all planning of various health projects for the island. Under the Provincial Health Administration, there are 22 Prefectural Health Centres which are responsible for health programmes of the 22 respective Prefectures• Under these Health Centres, there are 355 Health EB15/WP/1 page 19 China-

Stations (in 1953) which are the front-line health services and are responsible for the health programmes of the respective townships. One health station is provided for one township which has a population of 20,000 to 30,000 on the average. Each of •the Health Stations operating under the Health Centres has at least (B-class) one M.D. in charge, a nurse， a midwife and a sanitarian. Class A health stations have additional doctor, nurse and clerk. Their responsibilities include clinical an services (one-third of their time) and public-health services (two-thirds of their time)， such as routine immunization programmes, environmental sanitation programmes and incorporation vith special health projects directly sponsored Ъу the Provincial Health Administration, e.g. malaria control, VD control, ТВ control, MCH, traclÂ control and school health programmes. Apart from the above-mentioned health system, there are the following institutions directly sponsored by the Provincial Health Administration.

These are: Numъе532111112-1r 0 Name of Institution Provincial Hospitals Provincial Branch Hospitals Provincial ТВ Sanatorium Provincial Insane Asylum Provincial Leprosarium Provincial Taipei Health Ceiitre Provincial Hygiene Laboratory- Provincial Malaria Eesearch Institute and its Branch Station Quarantine Stations

There has been a malaria service on this island since 19Ю. Before World War II the Japanese Government had established mny anti-malaria stations over the island, the number being 2l6 in 19^1, and provided malaria services for mass blood-examinations followed by therapeutic treatment. This extensive malaria control activity had been conducted for 55 years until 19^5. These anti-mlaria stations vere closed down for a while after the War. However, with the establishment of health stations, the malaria control technicians were absorbed by the new organizations. The malaria services have been made available to the malaria patients visiting the health station clinics. There are 155 health stations at the moment which have trained malaria

techniciaxiB (195^). EB15 AlP/1 page 20 China

2.2.2 Administration

The central organization for miaría control project in the Tai^mn Province Js the Taiwan Provincial Malaria Research Institute which is one of the institutions directly sponsored by the Provincial Health Administration. It is responsible for over-all planning, standardization of formulations, training research and supervision of malaria control programmes for the province. It has 60 staff members including 5 malariologists, 3 entomologists, 5 engineers, ДЛ technicians for parasitological and entomologicil activities, 7 -administrative personnel, field supervisors plus in- service trainees, drivers and boys. It has its headquarters in Ch'ao-Chow (southern Taiwan) and two branch stations, one in Taichung (central Taiwan) and the other in Keelung (northern Taiwan). In the headquarters there are laboratories for parasitological entomological research activities, a small laboratory for chemical analysis, simple machine shop for repairing sprayers, storage space for DDT and insecticides, class-room and offices. In the branch station, facilities are rather limited to routine activities, such as mosquito collections and surveys. There are tvo or three technicians stationed in the branch stations who carry out the routine activities._ 1 In cases where experiments are to Ъе made in the branch stations, the headquarters personnel will move in. Insecticides 'and laboratory supplies for this project are mainly obtained through foreign aid (Foreign Operation Administration and the Joint Committee on Eural Foundation (the initiator of the Malaria Besearch Institute)) during 19红7—19^9. .

There is no other organization than the above Malaria Research Institute which is specifically constituted for mlarii control. At the local level, the malaria control project is integrated in the general public-health units, such as health centres and health stations. In case of necessity, the health personnel, especially those who received training in malaria control, can be mobilized for malaria control during the required length of time. The facilities in the local health units can be utilized for the control project. As a rule, supplies have been furnished by the Malaria Control Headquarters.

2.2.3 Before 19^5 when the island was under Japanese rule， there vere regulations relating to the implementation of mass blood examinations and therapeutic treatment. However, they are no longer valid. EB15/WP/1 page 21 China-

the island.wide malaria control programme started in 1952, there have been Since several provincial gazette orders indicating budgetary responsibilities of the island. mlaria control programme and pre- and post-caution of DDT spraying operations. wide It is contemplated to have malaria as one of the reportable diseases in the future.

2.2Л The sources and extent of financial support towards the programme is m the following table (for the current project only) shown ：

Salaries, maintenance, stationery, training, WHO team expenses, pur- Provincial 919,790 5,961,300 5，766，500 Government chase of insecticidal equipment and supplies etc. Supervision, training, $ printing, unintenance Prefecture от 2^,556 92,550 92,550 Government of sprayers. etc, Labour, per diem of foremen^ accessory Township 5,1+00,000 ктф 56,511 1，526，515 5,1+00,000 equipment, maintenance Government of sprayers 8,658,000 DDT sprayers and NT#^89,238 2，500,ООО 5,9^,000 FOA/CUSA 217,500 27^,000 76,000 Vehicles Travel, salaries of key 699,750 personnel^ training of 505，饵9 ？19,750 JCKR NT糾96，850 technicians, etc. Laboratory equipment, 9,000 1,500 US 懲 9,000 literature, supplies, salaries of salaries of salaries of WHO plus salaries 3 experts etc. of 3 experts 3 experts 3 experts 18,616,800 NT01>69,26l 5,2T6,U10 15,918,600 77,500 US$ 9,000 226,500 27^,000 salaries of TOTAL salaries of salaries of salaries of 3 experts 3 experts 5 experts 3 experts

Financial responsibility being transferred to FOA/CUSA. EB15 AlP/1 page 22 China

2.3 Social

2.3.1 The most common rural houses in Taiwan are baraiboo, adobe and aometimea brick structures with thatched or tiled (redtile) roofs. The house-pattern ie rather unique, having one main building in the centre and two wings facing each other, forming a U-shape ав a vhole. In the centre of the main building, there is a sitting room which is usually very bright and well ventilated. Next to the sitting room there are bedrooms on both sides. Next to the bedroom there is usually a kitchen on one side and a store-room on the other. In the two wings there are bedrooms, store-rooms, kitchen and very frequently animal sheds attached to the ends. Bedrooms and store- rooms are usually not well lighted, merely having two small windows, one in the front and the other in the Ъаск. The bedroone and store-rooms are found to make very goo'd harbourage for vector anopheles. During the evening hours, the families usually gather together in the front yard, gossiping until late in the evening. Bed-nets are not very popularly used.

The people are very much aware of the malaria problem since malaria control has Ъееп conducted on the island for over 紅0 years. They are very willing to co-operate. There have Ъееп no serious religious interferences observed in the malaria control activities except in the case when the family has а ЪаЪу. In such a case spraying squads are not welcomed to the baby's room for one month. The living standard is low in the rural families. Protein food is not sufficient. Compulsory education has been applied on the island for more than ten years.

2.k Economic

2Л.1 No studies have ever been made regarding the economic conditions related to nalaria except on one occasion vhen there vas a malaria epidemic. The study vas intended to investirte an economic loss due to the malaria epidemic. Altogether 5，256 people living in the epidemic area were contacted Ъу house-to-house visits. In the conventional vay of calculating such losses as to include the expenditures for treatment, the loss of labour and so on, the losses of this group of people during the epidemic period of four months totalled НТ$273,0б0.90. In terms of loss per capita, it amounts to HT$51.95. (The annual per capita cost for DDT residual spraying EB15/WP/1 page 23 China- averaged KT$2 73 in 1953.) Incidentally, in an over-populated area like Taiwan, it # my be difficult or almost impossible to investigate economic conditions related to malaria alone. In the first place, there is an excess of labour and there is almost no arable land left uncultivated. Secondly, there are many projects now being undertaken in the rural areas, and therefore it is difficult or impossible to separate the beiaefîts of malaria control from those of other projects now being undertaken, such as agricultural, industrial or public-health projocts other than malaria control,

5. PROJECT PURPOSES

3.1 General

The control of malaria and the eventual eradication of the disease from Taiwan, with modern methods and at the lowest possible cost, has been the fundamental purpose of this project, without however losing sight of the fundamental necessity of maintaining the achievements as the other no less important purpose.

3.2 Specific

Preventing malaria transmission by cutting short the life cycle of Anopheles minimus and A. hyrcanus sinensis, especially the former in habitations is the chief object. The current DDT residual spraying of houses is most essential to achieve this aim.

3*2.1 Residual DDT can do very little to control other insect-borne diseases such as filariasis, scrub typhus，fly-borne diseases, etc” in Taiwan, But it is quite an effective agent for controlling certain important house pests. Head, lice, bod bugs, fleas and cockroaches are among thoso posts e^p^^ted to be successfully controlled simultaneously.

3.2.2 Functional

3.2.2.1 The responsibilities of the malaria control operations in the current project have been gradually transferred from the central organization to the local health organizations. In the 1952 operations (the first year of the four-year malaria control project), the programme vas practically carried out Ъу the Malaria Control EB15 AlP/1 page 24 China

Headquarters, The headquarters personnel worked, at the twnship level, or^.nizing spraying squads and supervising the operations. In the 1953 operations, there was a network organization developed at the township level. The programme was conducted by the local health personnel who received training from the Milaria Control Head- quarters. The headquarters personnel were integrated into the work as instructors• In the 195红 operations， the programme was further decentralized. Even the supervisors vere provided by the prefectures or the townships themselves Through the % # 1 supervisors training courses, they were trained and developed to be the local super- vieors vho are responsible for spraying operations as well as supe?rvision. The headquarters personnel still remained in an advisory and supervisory capacity vorking together with the prefectural supervisor giving technical direction to the vork.

3.2.2.2 Despite the great expansion of population covered year by year (from 156,217 in I952 to 1，52б，30б in 1955 and further to approximately 5,^00,000 in 195^)， there has been no increase of personnel at the Malaria Control Headquarters. However^ the number of health workers including foremen, spraymen and helpers has increased in proportion to the extent of expansion： 207 in 1952 to 1,7^8 in 1953 and further to 6,118 in 195紅， Apart from the above operational personnel, there has been a group of local supervisory personnel added in the 195紅 operations; the number of this group being 186• In the 1952 operations almost all the administrative problems, such as distribution of DDT and sprayers, maintenance of equipment and provision of accessory equipment^ vere handled Ъу the headquarters personnel. In 1953, a greater part of the administration still remained at headquarters with limited assistance from the Prefect- ural Health Centres, However, in 195紅 the administrative problems related to the local operations were handled Ъу the Health Centres•

3.2.2.3 Beginning with the 1955 operations, there has been a provincial gazette order advising the local governments to provide malaria control "budgets of one New Taivan Dollar per capita. Another gazette order was issued in 1953 regarding pre- cautions to Ъе taken before, during aad after operations. It is contemplated that there vill Ъе a law or gazette order to have malaria as one of the notifiable diseases. EB15/WP/1 page 25 China-

3.2.2Л In the 1952 operations, the proportion of provincial and local funds contributed to the malaria control operations (excluding research and administrative overhead expenses of the headquarters), was 79.2 per cent»: 20•8 per cent. In the I953 operations the proportion became 7 per cent.: 37.3 per cent. This increase ， 62# of local contributions was attributed to the budgetary provision of one New Taiwan Dollar per capita at the township level. As indicated (in 2.2Л), the proportion of foreign aid between all the Government Funds, including provincial, prefectural and township, was 70 per cent.： JO per cent, in 1952， 72 per cent.: 28 per cent, in 1953 and 55 per cent. : 1+7 per cent, in 195^-

k. METHOD

k.l General method recommended to achieve the objectives

Spraying with vater dispersable DDT on the inside walls and ceilings and under- neath beds and furniture of all structures of the malarious areas, at the dose of 2 g of technical DDT per square metre. For experimental purposes， first a limited section within the demonstration area of Chi-Shan District, then in a much larger area of 2M^770 population in central Taivan, the selective spray method was tried. By this method only bedrooms (walls, ceiling, under the bed^ under furniture), store-rooms (walls ceiling, under furniture) sitting-rooms (under furniture), kitchens (under ， 9 furniture； food cabinets) and toilets, were sprayed.

ke2 The methods applied during the existence of the project

^.2.1 Technical

Training of the personnel of Taiwan №.laria Eesearch Institute^ graded training of recruits from the hsiens (Prefectures) and local townships where malaria is pre， valent.

Having the local government defray the expenses, gradually starting vith 1аЪоиг and minor auxiliary equipment for the spraying.

In training of personnel, stress has been laid on having the Malaria Institute as the technical centre/ with eventually an advisory and administrative role, shifting as much of the responsibility as possible to the hsiens. ЯЙ ��/WP/l page 26 China

扛.2.1.1 The project commenced in 1952 vith the establishment of an experimental area in Chi-Shan District including a population of 37,280 and an adjacent check area with 21,370 people. Lying in the tropical zone, the area is rural and had a high incidence of malaria.

In 195З, operations covered a population about ten times that of the 1952 campaign coverage. Selective spraying was also expanded to cover a highly malarious area of 24U,770 inhabitants. Similarly, in the expanded coverage there were still check areas chosen for comparison and an additional network of annual spleen-parasite surveys, monthly infant parasite surveys and routine entomological observations was organized.

In 195紅 the spraying operation was expanded to cover the vhole of the mlarious areas of Taiwan, including a population more than three times that of the 1953 coverage (5^00,000). . Thè 1955 data indicated not only a dramatic réduction in malaria incidence as a result of DDT spraying operations but also showed that selective spraying was effective, hence selective spraying was continued during the 195紅 operations in the same area.

Dieldrin was also tried in a limited area during I95U.

^.2.1.2 The technical role of the International team and the local staff :

The international team is composed of three members: namely, a malariologist, an entomologist and a public-health engineer. Each member of the team is seconded by a number of counterparts provided by the Government of China.

！The duties of the members as embodied, in the agreement are briefly stated as follows:

Malariologist： Serves as team leader and takes charge of the organization, planning, co-ordination, administration on behalf of the Government, the activities of the team including the opposite numbers. Other duties include organization of laboratory facilities, supervision, training of local personnel, collection of data and col- laboration in the treatment of malaria and in the control of insect-borne diseases. Reporting the activities of the team to the Begional Director is the team leader's responsibility. ' • EB15/WP/1 page 27 China-

Entomologist: The entomologist is in charge of investigations of the entomological problems related to the objective； carying out entomological surveys in the demonstration and check areas； assessment of survival of anopheles mosquitoes exposed to the insecticide； study of the bionomics of the vector； training the local personnel seconded Ъу the Government and keeping records of entomological observations.

Public-Health Engineer: The engineer is in charge of the administration and supervision of spraying operations and other measures necessary for the control of other insect-borne disease, gives assistance, in response to the request of the Government^ on environmental sanitation activities, compiles naps of the projects, checks chemical and biological methods of the procedures, supervises the maintenance of equipment, supplies and transport, trains local personnel seconded Ъу the Government as well as personnel from other countries， prepares and analyses reports on working costs of spraying operations； submits periodic reports to the team leader•

In the second year of the project, the leadership^ including administrative activities of the team, passed to the entomologist.

In view of the extent of the programme, which covers the iralarious areas of the entire island of Taiwan embracing the direct protection of 5^00^000 inhabitants^ training for the spraying operation has been formalized into classes. Elements of nalariology and entomology were integrated into the training. In other words the training not only covers the "hows" but also the "whys", which we feel is more lasting than merely demonstrating how. While the training of the operational personnel w^s principally the responsibility of the engineering section, the international, malariologist, entomologist, and the group of the national counterparts and staff members participated to give a broader background on malaria control. To achieve this it vas also necessary to conduct in-service training of these staff and counterpart members themselves.

To standardize the training and operations, training manuals were prepared by the engineering section supplemented by printed instruction^ prepared by the entomology section. The engineering staff made studies on the most efficient vays of carrying out the spraying work. Spraying is not merely routine mixing of suspensions and EB15/WP/1 page 28 China-

indiscriminate spraying of surfaces. Proper technique is involved so that DDT will Ъе distributed evenly on the surfaces and the unit data obtained (dose, etc.) is not a wild estimate taken for granted， or, the extreme of meticulous measurements which results in the loss of valuable man-hours which does not add to the quantitative accomplishments at all. With a good spraying job as the principal objective good data vas also obtained with the minimum loss of man-hours by teaching personnel constant convenient rate of spraying (20 square metres per minute in this case), rating the sprayers weekly, and taking measurements of typical structures to determine doses, and making suspensions accordingly.

With the director of TAMRI the team leader trekked the island to thrash out administrative problems in the field. Without this invaluable help, which, moreover, was only accomplished at the cost of tenacious efforts, the operations would not have been as smooth as they were. Agreement on paper is not very difficult but for implementation^ with timing and phasing involved, personal follow-up is indispensable. Contacts with bilateral agencies is another important aspect of the role of the international team. The project draws funds from several sources and aid from mny agencies； to get the material and supplies on time, contacts with these agencies other than the normal channel had to be resorted to by both the team leader and the director of TAMRI.

The National Staff： While the international team actively carried out their role both directly and in an advisory capacity, the national staff handled the details of the training of the supervisors, foremen and operators. In parasitology, surveys， taking of smear s ^ Qttd collection of data in the field and laboratory have Ъееп carried out by the local personnel. On the other hand the entomology personnel have been busy getting the field data and classifying them. The technicians of the engineering section have done a splendid job in repairing sprayers and putting them in working order to meet urgent needs in the field.

^.2.1.3 The Taiwan Provincial Malaria Research Institute is the organization which is responsible for the current malaria control programme in this province. It has its headquarters in Ch'ao-Chow (southern Taiwan) and two branch stations one in Tai-Chung (central Taiwan) and the other in Kee-Lung (northern Taiwan). At head, quarters^ there are laboratories for parasitology^ entomology and simple chemical EB15/WP/1 page 29 China-

analysis of insecticid.es, offices for administrative and engineering personnel, ‘ storage space for DDT and sprayers, facilities for Repairing sprayers and vehicles, anñ s, class-room.

, The two branch stations only have facilities for routine activities, such as routine observation of mosquito density, routine biological tests, monthly infant survey, and so on. In case programmes other than routine activities be carried out, the headquarters personnel will move in with necessary equipment and supplies. During the DDT operations in the central or in the northern region, the branch station in that region vill become the regional headquarters with supervisors and other necessary personnel, equipment and supplies moved in from the headquarters.

There are 60 staff members in the Malaria Besearch Institute Including those in the headquarters and its two branch stations. Among them, there are 5 malariologists, 3 entomologists, 3 engineers, 7 parasitological technicians, 7 entomologlcnl technicians, lH field supervisors, 7 administrative personnel such as clerks and typists, 6 drivers and 8 in-service trainees and laboratory boys.

The class-room at headquarters can admit 35 students at a time. There are no dormitory facilities； local hotels are to Ъе used in case of training at headquarters. In the current DDT spraying programme, the training' courses for supervisors and fore- ment were not held at headquarters but in the field using local facilities^ such as assembly halls as claas-rooms and local hotels for lodging. The instructors and ' lecturers moved în vith neo«esary teaching material's.

The training courses for spraymen and helpers vere held in the respective town» ships using tke facilities available at the health stations or other facilities in the respective towns；

Besides the facilities available at the Malaria Eesearch Institute, the facilities for general public-health activities as mentioned in.2.2.1.at the Health Centres and Tovnship Health Stations are all available for the malaria control programme. EB15/WP/1 page 30 China-

Ь.2.1Л The most important supplies of the programme are insecticides：

1952 1953 195k 1955 75 per cent, water-dispersaole DDT purchased through WHO from US 5 m.t. 0 through JCKR from US 10 m.t. 0 through. FOA from US 200 3ОО through FOA from local DDT plant • 150 350 500. DDT consumed 50 per cent. 5.67 m.t. - - DDT consumed 75 per cent. 13.61 m.t. 173.71 650 650 m.t. (esti- (estimated) mated)

The local DDT plant started to produce a good quality of 75 per cent, water- dispersable DDT in 1955. The products were tested Ъу the US laboratory and were found to meet the WHO standard specifications. As indicated in 2.2.1, there are 155 health stations which have trained malaria technicians. On an average, about 500,000 tablets of anti-malaria drugs (Atabrine or Paludrine) are needed for the treatment of out-patients. These drugs were purchased by and donated from the JCEE to the Malaria Research Institute for distribution among the health centres.

k.2.2 Functional

k.2.2.1 The Malaria Control Headquarters as mentioned in ^.2.1.5 is responsible for planning, training, research and standardization of equipment and formulations. As far as the malaria control operations are concerned, the responsibility for the work is borne by the local governments, Prefecttirál or Township organizations, as shown in the following chart.

2.2.2 The transmission of malaria in Taiwan is continuous through all the year. Analysis of malariometric and entomological data of the south part, showed that there were two pe&ks of transmission, the most active peak during fall through December, and a minor one in Jferch. So, the first cycle of spraying of the experimental (demonstration) area in the Chi-Shan District in 1952 vas timed in the middle of July . through the end of September. The following year it vas found more convenient that the spray time in the south be shifted to one month later, that is, middle of August through October.

* DDT purchased Ъу the Rockefeller Foundation in 19^9. EB15/WP/1 page 31 China-

Selective method of spraying vas tried within the demonstration area. From the standpoint of malaria transmission, Taiwan is divided into four operational sectors.

Central Sectors sprayed in February -他rch North Sectors sprayed in April - Шу East Sectors sprayed in June - July- South Sectors, including the demonstration area, sprayed in August - October. The delimitation of sectors was based on survey reports and personal information, which did not alvays agree in all respects. The above division of the country In four sectors, as shown Ъу the dramatic reduction in incidence, has not only Ъееп proved safe from the transmission of malaria aspect, but also as the most comrenient time to carry out the spraying operations vith the available equipment, transportation

and personnel on hand. Surveys： Spleen and parasite surveys have been made- at six-monthly intervals beginning vith June 1952. The first survey vas conducted in June 1952， before the initial spray, and the second survey in December 1952，after the spray. ,-Similar

surveys have been conducted in 1955 and 195^ and vill Ъе continued until the end of the four-year plan. About 1，500 children of 2丄 years old> 550 of 5-9 years and UOO of 10-llv years have been sampled at each survey in the 19 selected villages. Infant d morbidity surveys have Ъееп conducted Ъу house-to-house survey at eight villages an a population of 8,500. Number of.infants examined every month averages 300. havlng The positive cases of infants have Ъееп investigated on their history.

Similar surveys to those in the demonstration area have Ъееп made in the check About 600 children of years, of 5-9 ^d _ of 10-lH have been sampled area the seven villages in the check area. About 175 infants and ^800 inhabitants from been surveyed monthly for new infection and mlaria morbidity, respectively. have

For the measurement of anopheline density five collecting stations have been ted in the demonstration area for periodic collection and three collecting Belec stations in the check area. Besides, there are three catching stations each for larval collection in both the areas. EB15/WP/1 page 1235 China-

The estimated cost and financial responsibilities are outlined in 2 2Л. # As far as the present four-year malaria control programme (1952 through 1955) is concerned, all the parties concerned have committed themselves. The Provincial Govern- ment has approved the miarla control budget for 1955. There has been a provincial gazette order issued regarding the local budgeting of malaria funds. Following this gazette, there vill»be one New Taiwan Dollar per capita funds provided for 1955 at the local governments. As far as the government funds (provincial, prefectural or tovnship levels) are concerned, commitments can be implemented through provincial gazette order.

Technical

k^.1.1 The counterparts personnel are the permanent staff of the Taiwan Pro- vincial Malaria Eesearch Institute^ an organization directly sponsored by the Provin- cial Health Administration, These trained personnel vill be available in the future as long as the disease exists. There have been four fellowships given to the Malaria Besearch Institute Ъу the Rockefeller Foundation and the Foreign Operation Administra- tion (two fellws each) The fellows finished their studies in the United States in # engineering ancl general public health. In 195^， another tvo fellowships were given to the Malaria Eesearch Institute by WHO for a malariologist and entomologist to study in England in tropical disease and insect-borne disease. These trained personnel will be still available to the project in the future.

At the local level, there are 155 trained anti-malaria technicians scattered among the health stations located in the malarious area. These technicians will Ъе the key personnel for the future malaria surveillance programme• There vill,be re- fresher courses given to these technicians in order to have these technicians acquainted with the problems to be faced in the future• Operationally, the supervisors and foremen trained during the four-year malaria control programme are the permanent staff of the local health organizations, and vill therefore be also available for the malaria control operations in case of necessity.

、5二,2 The facilities of the Malaria Research Institute and its tvo branch stations will be still available in the future. For the future malaria surveillance programme^ it is contemplated that each health centre vill Ъе provided vith a laboratory for blood examination and a full-time technician. EB15/WP/1 page 33 China-

1^.5.1.3 Supplies

supply of insecticides will Ъе, a great problem in the future. It is planned The develop township financing to such an extent that the townships can purchase their to own insecticdes from the local DDT plant. However, it is realized that such expend!- ture may Ъе too heavy a load for the townships to bear. . In case the townships cannot bear the expenditures, the Provincial Government has to provide ШР in the future.

b.3.2 Functional

k.3.2.1 Methods of organization and development of a national malaria programme At national level, the Taiwan Provincial Malaria Research Institute (TAMEl) is the sole organization which handles malaria control work in the island, both research control work. The technical personnel with ^ride background experience from pre- and vious vork vith Rockefeller Foundation and others, is divided into three groups, parasitology, entomology and engineering. The first tvo groups handle the surveys other data collection while the third group is in full charge of the DDT residual and spraying operations. In the course of the progress of the work operation activities have Ъееп decentralized among the different hsiens vhich furnish supervisors, foremen, operators and helpers.

When the control work has reached the level where incidence of infant cases becomes practically zero, the role of the organization is expected to Ъе shifted to surveillance. In the surveillance stage the TAMEI with its few members vill constitute the nucleus in conducting the malaria eradication programme on the island Ъу maintaining a pool of lower echelon personnel in the hsiens vho will vatch under guid- ance any sign of the occurrence of malaria. Should an emergency situation srise in e form of an outbreak, the individual township, vith its organisation integrated in th the health station, can handle the control work.

k.^.2.2 Methods of administration

The Institute (TAMRl), with personnel designated as the counterpart to the team members of the WHO team, carried out the policy formulated for the control of malaria. Gradually the activities of the WHO team is shifted to the TAMRI so that in the fourth EB15/WP/1 page 1237 China-

year of the operation the team acts in an advisory capacity. TAMRI does liaison vork with the prefectural or hsien health centres which supervise the work in the townships. TAMRI also acts in consultative or referral basis.

红.5.2.5 Personnel and future roles

After the four years' work, that is at the beginning of 1956, it is proposed to retain the malariologist and entomologist in an advisory capacity. TAMRI will con- tinue to handle the surveillance -woric and also strive to exterminate malaria on the island。 Chosen stations or branches on the island will Ъе retained. The work on other insect-Lorne diseases will be given more impetus.

5. ACCOMPLISHMENTS

5.1 Technical

5Д.1 The technical objectives of the project were:

First year, 1952： Establishment of a demonstration and check area (156,217 population) and intensive training of the personnel of the Malaria Institute.

Second year, 1955： Expansion of the programme to 1,500,000 population and training of loce.l personnel of the Prefectural Health Centres and Township Health Centres.

Third year, 195^： Expansion of the programme to cover all the malarious areas of 5^00,000 population, training of local personnel.

Fourth year, 1955： Repeat the programme of 195I+ and organization of the Malaria Surveillance Plan.

Because A. minimus, the most active vector in Taiwan, vas found highly selective in its resting places in inhabited rooms (for instance 60 per cent, caught in the day time vere found in bedrooms), a selective sprnying method has been experimented with in south and central Taiwan.

Below are the mlariometric results obtained in the demonstration and check ai-eo.s for tiie first year's operations (1952) for both completely and selectively sprayed EB15/WP/1 page 35 China-

еав; further below are results observed in investigational areas established within аг 1955 operational areas. In the demonstration and check areas of Chi-Shan District the the malariometric investigation includes a semi-annual spleen ani parasite survey, monthly infant parasite, surveys and monthly fever case surveys^ In central, north and east Taiván the efféctiveness of the operational activities is measured Ъу investigations including annual spleen and parasite surveys and monthly infant parasite

surveys. The effect of both complete and selective spraying methods on morbidity rates ъееп.determined by monthly contacts with more than 11,000 persons in Chi-Shan has District, A blood smear is taken from any person who reports a fever during the preceding month and the malaria rate among these persons is determined from the ltant series of slides. The parasite rates found during the initial fever case resu survey of July 1942 ran 53.13 per cent., 31.73 Per cent” and 35.23 Per cent, for complete spray, selective spray, and check sectors, respectively The most recent the ve in the same sectors (August 195^) showed that the parasite rates among monthly sur y fever cases had dropped to 3.50 per cent” 2.22 per cent, and 5Л1 per cent, after a uai sprayings in the complete and selective spray sectorB and one spraying in two TO

the origiml check sector，respectively, monthly infant parante surveys included all infants less than days: of : The 鄉 the time of the survey. .Any infant found positive is treated and moved from. age at ,ester in subsequent surveys. Eesult, from the GM-Shan District infant parasite the

surveys are shown in table lb below. Table

Eesults of Infant Surveys in Chi-Shan District "Check Area Complete Spray Area Selects ve"Spray Area Survey- No, Total Para, No. Total Para, î'ôtâïPara, rate examd pos. rate period examd. pos. rate examd pos。 9„60 bOQ 38 9.50 U91 59 钭 June- 853 no spray Sept. 1952 -First spray completed 0Л江 1,997 '51 2„55 Oct. 1952 10 0Л0 丨 l，8j6 8 first spray— Oct. 1955 -Second spray completed— 0 0,00 I 1,236 0 0,00 1,596 2 0ДЗ Nov. 1955 1,725 ——eeconcL spray started- Aug. 195^ Third spray started EB15/WP/1 page 36 China-

Since November 1953 till August 195、 when this report was written, no positive infant has been detected in the demonstration area of Chi-Shan sprayed twice.

The results of spleen and parasite rates taken in five consecutive surveys in Chi-Shan District, reported belov in table 15， show very remarkable decreases of spleen rates and a dramatic fall in the parasite rates in both sectors, complete and selective spray. Number of examined is referred en masse to children 2攀ЗЛ years old.

Table 15 Spleen and Parasite Bates in Chi-Shan District (children 2-lk years old)

Survey Month Spleen Survey Parasite Survey Area and Year No„exam Spl.Eate (务)| A.E.S No.exam. Para.Ite.te [f>)

111191 5 2 11112 6 8 7 5 2 2 8 h, к- 8 7 2 2 11119 583»8 4 2311о5 9 5 2 夕夕 5 3 1 6 3 98 •4*4,, 111 1 б •••• 5 2 • 9 5 78 7о8 3 о 5 2 ^ 2 2 5 Completely 夕 76 1 5 6 3 1 о 9 2 3 2 к 73-88 зк о. 2 о 8 sprayed 9 5 1б4 о 6 7 1 1 7 8 7 1 3 夕 2

6 8 111191 5 2 12 8 2 915 4 2 6 7 8б 9 6 8 5 76 刃 5 2 вк о- « 9 16 8 к- 111 1 • t ^-к. 7 3 2 о 7 • 9 5 3 зк 2 5 . 985 5 Selectively 8 2 9 5 7 3 8 2 7^628^3038708 2 зк. • 9 5 0 5 3 2 • о sprayed 9 5 7 7 3 3 о к. 9 о 1 2 - • »

• • •• и 11119 51 >22 а996 8 ик1-748 9 ^ к- 3-й 5 12 11111 526 S25.53 2 8 June 9 5 • • о 9 •V 6 3 5U. 4 5 7 3 к• 7 . • 7 9 5 5 5 2 о k. > Former Dec. 5 2 38 « 64 7 9 9 5 5 3 в 1 36 2 5 # 9о6 夕 2 5k. Check June 5 6 11 5 9 5 k. 2 6 о 5 8 3 1 事參 с 夕 3 Dec, 6 2 June -ч

The monthly infant parasite surveys have been carried out in central Taiwan in the same manner as the surveys in the southern Taiwan. Infants, under 365 days of age are included, unless their blood is positive, in which case they are excluded from the roster for subsequent visits. Results are presented in table 16. EB15/WP/1 page 37 China-

Table 16

Infant Parasite Rates in Central Taiwan Investigational Areas

Complete Spray Sector Selective Spray Sector Check Sector Survey period No. Total Parasite No. Total Parasite No. Total Parasite examd pos. rate (实） examd pos. rate (实） examd pos. rate (关）

Feb.- 8仲 17 1,95 1,351 51 2.33 556 9 1.62 May 195З first spray completed no spray~~ ли June- 1,253 1 .08 2>290 10 651 7 1.08 Nov. 1953 Dec. 1953 8CA 0 1,630 0 .00 紅21 10 2.38 first spray Apr. 1妙 second spray completed May - 638 0 .00 1,290 0 .00 562 1 0.28 Aug. 19^

In the sector receiving complete spray treatment during №rch-May 1955, only one positive infant has been found in July, two months after spraying. In the selective spray sector, positive infants appeared through November six months after the ; spraying was completed. However, the complete spray sector has yielded no positive infants in the last 13 months and the selective spray sector has bean negative for nine months. Transmission in the check sector continued at a high rate until it was given complete spray coverage during February-April 195^.

In orth and eastern Taiwan the results showed remarkable decreases of the rates, n especially parasite rates, but the decrease is relative to the time since the spraying. North and east sectors were the last sprayed during 1953. In the north the parasite rate， vhich vas lU.76 per cent, among 210 schoolchildren in November 1952， vas found to be 3.63 per cent, among 358 schoolchildren in November 1953, four months after spraying. In the east area, which vas sprayed later than the north and central, the parasite rate two months after spraying was lk.29 per cent, against 36.96 per cent. one year ago. EB15 AlP/1 page 38 China

5.2 Functional

J % 2 1 The personnel of the Malaria Institute is divided into three technical 0 sections; parasitology, entomology and engineerings Increase of the permanent personnel of the Malaria Institute has been considered not a sound procedure. The initial training of Ik engineering technicians of the Malaria Institute enabled them to carry out supervisory work, starting first as foremen, overseeing and training the operators• The lb technicians contributed very much to the training of foremen, aid to the development of the new rank of supervisors, during the second and third years of the project. Most of the supervisors are malaria technicians of the peripheral anti-malaria stations, many of the foremen are personnel of the local health or township services. And one may now easily find very well trained personnel, including operators and helpers, in every community.

The Training Ъу Year

Supervisor Foremen Operators

1952 the lU technicians of the Malaria Inst. 31 126 1953 1U 25红 1,013 1妙 186 8扑 3^96

The spraying activities corresponded precisely not only to the requirements of the expansion of the programme year Ъу year, but also to a technique, fairly effect ive, of sustaining a steady spray pattern and ensuring a well organized job. 1 EB15 AlP/ page 39 China

The Spray Work by Year Accomplishments in DDT Residual Spraying

Description 1952 1955 1妙

Central Taivan only Sumber of structures 21,682 為655 21^,153

Population directly protected 156,217 1,526,306 1,781,251 dumber of villages 119 1,259 1,386 • Area of operation in square kilometres .. 629 Ю,05б.5 8,760 ！

The 1954 spraying operation coverage is the direct protection of a population of 5^00,000. As of the second week of Septeiriber^ the four-mill! on mark has been reached but the analysis of the data has to wait until the work is finished in the south,

5.2.2 In carrying out the operation beginning 195^, decentralization has Ъееп emphasized, to a point that each Prefecture should be handling its maximum activities. The self-sufficiency, on the other hand, of every township with technical personnel of trained supervisors^ foremei^ and operators, all coming from their own com- raunities, has strengthened the malaria services in both township and prefectural levels.

The dramatic decrease of the parasite rates in the people and the interruption itself of the transmission of the disease leave no doubt that the method of the residual spraying vith DDT is very effective in controlling malaria in Taiwan.

If the technical objectives of the project were to bring down the incidence of malaria and to eliminate or at least reduce the parasitic reservoir to a negligible point, these objectives have been achieved in most parts of the country, and as the project is still in full operation it is expected that parallel results will follow EB15/WP/1 page China

in the remaining parts. However， the best-organized campaign of residual spraying and even the best results achieved, still leave open the question of maintaining the achievements. The maintenance of the achievements constitutes the second log of the project, which is the organization of the surveillance plan to be applied when it is considered that residual spraying may be suspended,

5.2.3 In the matter of shouldering the cost of expenses, the yearly share has been analysed as follows： “

Year Total in _ Township and Other agencies Prefectures

1952 367Д55 Л2 20 M 79.2 实 jl953 4,088,9^0.8^ 37.3^ 62.7^ mb (for central Taiwan only) 今 5,3бб,0б1.7б 65.9^ i

At official rate,NT 415.60 equals ÜS $1.00. The cost analysis of the spray programme included all local costs, insecticides, depreciation on sprayers and vehicles, plus cost of Malaria Institute administration and engineering section supervision associated vith field operations. Not included are the overhead costs of malarionc-fcr£e and entomological investigations, nor the gross Malaria Institute overheads.

6. SUMMAEY

Since the four-year Malaria Control Programme began in May 1952, two years have passed. The project has been maintained in line vith the original planning and has been kept always on the go. The steady progress and the dramatic results in the control of the disease have bean very encouraging to international, national and local health workers. The programme today is in full operation and is one of the most active health activities on the island. The policy of having the programme integrated and incorporated into the over-all public-health activities has been carefully followed and consequently the project has bean becoming more and more de-centralized year by EB15/WP/1 page China

year< it is believed that the progranme in the future can be continued Ъу the local healt hvorkers and administered Ъу the local government with technical assistance and possibly a portion of financial assistance rendered Ъу the Central Organization, namely the Provincial Government；

(a) initiating national actions The malaria control programme had been fairly 'intensively carried out by the Japanese Government before the War, adopting therapeutic treatment vith anti-malarial drugs. Since 19阽，the programme hae Ъееп maintained Ъу

the Provincial Governiœnt, through the help of the Rockefeller Foundation and the joint Commission on Eural Eeconstruction, on a small scale in limited areas until the arrival of the WHO Alaria Control Team. After the arrival of the Team, a nation- wide malaria control programme has been initiated with some demonstration activities

in an area having a population of 156,217. Ths Provincial Malaria Eesearch Institute has been designated as the counterpart organization of the Team and its entire staff members have been working side Ъу side with the WHO personnel in organizing the local health vorkers. Through the efforts of Provincial Health Administration, the Foreign Operation Administration, the Joint Commission on Eural Reconstruction and the Team,

the commitment to carry out a four-year mlaria control programme was confirmed. • On

the other hand, the local governments vere informed of the programme and necessary arrangements vere made, Intensive ma].ariometric and entomological surveys were conducted to define the areas for coverage.

(b) Improving national action: A dramatic result of the control measures was

an intensive interest and enthusiasm emong the central and local government officials as veil as the people. Beginning with the second year's operation (1955), budgetary provision of one New Taiwan Dollar per capita has been made available for malaria control operations at the local level, On the other hand, the Provincial Government increased its 195.5 malaria control budget five times over that of 1952 and increased furthermore five times that of 1953 in 19哄。The Provincial Government is today pur- chasing spraying equipment in addition to the operational expenses of the Malaria Con- trol Headquarters. On the other hand, the military authorities started a parallel malaria control programme for military personnel, beginning 1955. EB15/WP/1 page 42 China-

(c) Expanding national action: The final project area is to include all the malarious areas in Taiwan. In 1952, a demonstration of malaria control measures vas applied to an area having a population of 156,217. Having received co-operation from the people and organizations at various levels, in 1953 the programme expanded ten times in conçjarison with the first year's population coverage. The population protected in 1953 was 1,526,306, living in highly malarious areas in Taiwan. In 1954, the programme was further expanded to include all the malarious areas on the island, having a population of approximately 5,400,000. There should be no diffi- culty in repeating these control operations in 1955.

(d) Improving personnel: Through four fellowships given by the Rockefeller Foundation and the FOA during 1950-1953, professional personnel have been trained in general public health, especially in malariology and public-health engineering. In 1954, two more fellowships were awarded by WHO to send a malariologist and an entomologist to England. On the other hand, auxiliary technical personnel have taken in- service training during the present active operations. Through an extensive training programme, 186 supervisors, 874 foremen, 3,496 spraymen and 1,948 helpers were trained in. 1954 for field operations.

(e) Increasing personnel: There has been no increase in the headquarters personnel. However, the number of trained workers at the local level has been increased proportionally with the expansion of the project, number of foremen being from 31 in 1952 to 254 in 1953 and further to 874 in 1954. In 1954, in addition to the foremen, there were 186 supervisors trained for the prefectures and townships. The number of spraymen and helpers increased from 176 in 1952 to 1,949 in 1953 and further to 5,244 in 1954.

(f) Improving physical facilities: The project in Taiwan has been carried out by the existing health organization using existing health facilities. At the Malaria Control Headquarters, there were facilities for parasitology, entomology laboratories, offices and class-rooms set up by the Rockefeller foundation before the arrival of the WHO Team. Since the start of the extensive malaria control programme, the existing facilities have been improved to facilitate biological tests, identification • ЕВ15АРД fík 、，、洩 Page M ¡¡^ China

and storage of insect specimens, simple chemical analysis,, repairing of sprayers and vehicie8 etc. However, the most remrkable improvement observed vas the development of mobile training facilities. This mobile unit can go anyvhere and set up а class-room in the field vherever a big hall is available. At the local health stations, there have Ъееп training facilities developed for training of spraymen and helpers.

(g) increasing physical facilities: nothing to report.

( ) Developing püblic demand: The programe has Ъееп so popular among the h people that the dennnd for DDT spraying has been developed. There is not a single

township шуог on the island vho can withstand the pr^niuô and fail to mke adequate township budget for the programe. There have been шпу requests sent an for DDT epraylng from those townships vhich vere not included in the Programme ln because of their lovr malaria endemicity. There vas a very serious dernnd from the eight townships on the sea-coast of the cotral Taivan. They even tried to raise funds themselves- to cover all the expenses including insecticides, labour per diem, .etc” vhen their requests had been turned down. •... � increasing individual participation or Ü) increasing scientific pledge： Besides the above-mentioned operational personnel, there have been groups of people

vh0 became interested in the programme - the local health personnel, township officials, nevrspapermen, etc. Furthermore, through every chance such as village

or iOTmship meetings, prefecture assemblies, schools and theatres, there have been eàucatioml programes carried out by local health workers.

7. ‘ PBEDICTIONS

The objective of the malaria control project in Taivan is not merely the demonstra tion of miarla control measures vithin a limited area of a country, but mtion-vide diaria control aiming at malaria eradication from the vhole province. Before

the participation of the WHO in the project, there wae organisa nalaria control service on the island. Hovever, because of the libations of technical Personnel

and because of some administrative difficulties, the nation-vide malaria services did EB15/WP/1 page China

not materialize imtil the arrival, of the WHO Malaria Control Team. Through the tech- nlcal directions as veil as the bilateral approaches of the Team to the relevant organizations, the programme was launched. There have been some problems encountered in the implementation of the malaria control strategy. However they have been solved vith the understanding and support of the people and the governmental organizations. In other words, in the initiation of the nation-wide malaria control the WHO served as a. catalyser administratively and as a, potential source of energy technically,

Once launched, the programme proceeded smoothly in line with the original planning. Technical improvements have been the method of training, efficiency of spraying squads, improvement of sprayers and DDT produced locally, survey methods for malariometric and entomological assessments, laboratory techniques etc., and administrative improvements integrating the malaria control programme into the general health activities, the de-centralized malaria control organizations, development of financial participation by local governmental organizations, etc.

With the excellent network of local ..health units, i.e. the local health stations, the project has been expanded year by year according to the original planning. In 1952 (the first year's operations) the population protected by DDT residual house spraying was only 156,217. In the second year the programme vas expanded to almost ten times and the population protected was 1，526,506, In the third year (195紅），the programme was further expanded to include all the malarious areas in Taiwan which have a population of approximately 5,400,000. There will Ъе no doubt that the programme will be conducted successfully in the fourth year (1955) because of enthusiasm shown Ъу the people and the organizations concerned. However, the end of the four-year Malaria Control Programme does not indicate the end of malaria transmission. Yet, there should be more attention paid to the project as the enthusiasm of the public and the governmental organizations may decline. A group of local nulari,. technicians is being organized to service the malaria surveillance programme through infant surveys after 1956» In-service training of this group of people is planned to Ъе given in 1955. Through the information obtained by the surveillance personnel, the programme can Ъе properly naintained with minimum efforts of DDT spraying operations„ EB15 AlP/1 page 5 China

It is felt that technically probably there should Ъе no difficulties in the future for local governments to carry on the spraying operations in case of necessity. Aâministrativelyr however, there may be some difficulties in obtaining sufficient funds for insecticides and sprayers entirely from the township governments. Although the local township governments are providing 3^.1 per cent. (195^) of the total operational expenses at the present, by raising one New Taiwan Dollar per capita, it may be the maximum contribution that townships can bear. It is, therefore, suggested that the Provincial Government can step in and give assistance to the townships so that their load can still Ъе 5紅 per cent, vhich is within their ability.

As far as the technical planning of the malaria control programme at the headquarters is concerned, it is felt that the participation of the WHO Team in the project through the end of 1956 is essential. Such an assistance is as important as the initial one vhich served as a catalytic effect administratively and a potential energy in the surveillance programme technically.

Signed Ev. A. Demos, M.D” D.P.H” Malariologist WHO Malaria Control Team in Taiwan, China