Variabel Umur Dan Gender Bagus Ini Resultnya Dalam Bagan Juga

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INTERNATIONAL JOURNAL OF LEPROSY

olume 55, Number 3Printed in the U S A

Social and Demographic Aspects of a

Leprosy Epidemic on a Polynesian Atoll:

Implications of Pattern

Michael D Lieber and Esther B Lieber 2

The authors, an anthropologist and a lin-guist respectively, agreed to help documentan epidemic of Hansen's disease on Ponapeand Kapingamarangi Atoll in Micronesiawhile conducting anthropological researchthere in 1982. Dr. Robert Worth informedus of the epidemic in the Kapingamarangi(hereafter Kapinga) population, and askedus to help document the probable paths ofinfection. We have had long experience inthe community, and speak the language withreasonable fluency. After a brief but inten-sive orientation to the more salient featuresof Hanscn's disease and its treatment,•Dr.Worth advised us to design our own meth-ods of data collection based on our knowl-edge of the community.

As our research proceeded, we were struck

by how highly patterned the spread of thisdisease was in this community. It quicklybecame clear that who could have infectedwhom was dependent on well known rulesof who can and cannot interact with whomand on the timing of interactions. Not onlydoes the spread of Hansen's disease in thiscommunity replicate patterns of personalmobility, which vary by gender and age cat-egories, but variations in demographic pat-terns between the two Kapinga communi-ties are reflected in variations in theirpatterns of infection, as we shall demon-strate.

The paths of infection are demonstrablynon-random—it is not the case that everylepromatous person has an equal probabil-ity of infecting every potential victim. Giv-en several possible means by which the dis-

' Received for publication on 12 January 1987; ac-cepted for publication in revised form on 5 May 1987.

M. D. Lieber, Ph.D., Department of Anthropology,University of Illinois at Chicago, Chicago, Illinois60680, U.S.A. E. B. Lieber, M.A., Department of En-glish, Wells Community Academy, Chicago, Illinois,U.S.A.

ease might be transmitted from one personto another, demographic patterning shouldrender some means more probable and oth-ers less probable. We follow this logic tooffer the hypothesis that the most likely av-enue of infection in this population is a skin-to-skin transmission and that the ubiqui-tous pandanus leaf mat is the most likelytransmission agent of the disease. We thentake advantage of the correlation of infec-tion with demographic patterning to showhow genetic inheritance of resistance to thedisease can be disentangled from the spe-cifics of demographic patterns of the pop-ulation.

The community. Kapingamarangi is a tinyatoll located 65 miles north of the equatorand 485 miles south and west of Ponape, a

high island that is the headquarters for bothPonape state and the Federated States ofMicronesia, of which Kapingamarangi ispart (Fig. 1). The atoll's 0.42 square milesof land area supports a population of about450 persons, who make their living by tend-ing groves of coconut, breadfruit, and pan-danus trees and growing taro. The bulk ofthe protein in their diet is from fishing. Al-though rice and tinned fish and meat arecommon on the atoll at present, traditionalsubsistence activities still provide much oftheir diet.

Effective colonial control of the atoll wasestablished in 1914 by the Japanese colonialadministration. Kapingamarangi was partof the Ponape administrative district whoseheadquarters continue to be in KoloniaTown on Ponape. Contact with Kapinga-marangi was maintained through regularvisits of a field trip ship, which linked theKapinga with Nukuoro, Ngatik, Pingelap,Mokil, and Kusaie (now Kosrae, a separatestate of the Federated States of Micronesia,hereafter FSM) as well as with Ponape. In1919, the Japanese administration gave the

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ieber and Lieber: Leprosy on a P olynesian Atoll

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Kapinga people a lease to a 21-acre site inKolonia Town which eventually becamePorakied Village, a permanent Kapinga set-tlement with a population of approximately600 persons today. Beginning as a Kapingacolony of Kapingamarangi Atoll, Porakiedhad become an autonomous political entityby the early 1960s. Contact between the atolland Porakied has been by ship, with a con-tinual stream of people moving both wayssince 1918 ( 4 ).

Kapinga people are Polynesian in lan-guage, physical type, and culture, and arequite distinctive in the Micronesian social

environment on Ponape. Their early ad-aptation to Ponape owes to the fact that theywere (until after World War II) practicallythe only deep-sea fishermen on Ponape.Thus, they were the major suppliers of deep-sea fish, particularly of yellow fin tuna, forboth the Japanese and the Micronesians.They were very desirable exchange partnersfor that reason, and Kapinga men and wom-en formed numerous friendships withMicronesian landowners, exchanging fish forvegetable foods. Among these many friend-ships, which connected the Kapinga villagewith Micronesians throughout Ponape Is-land, were several Pingelapese landownersliving on Sokes Island directly across thesmall inlet from Porakied Village. It wasthrough such friendships, both betweenadults and between school children, thatleprosy was first introduced to the Kapingapopulation.

Pingelapese people have experienced re-peated epidemic episodes of Hansen's dis-ease since 1918, when it was first introducedfrom Nauru ( 6 ). It was through visits byKapinga people to Sokes Island that twolepromatous cases were infected by Pinge-

lapese in 1962 and 1965. Two brothers werealso infected in 1963 and in 1967 with tu-berculoid leprosy contracted through friendsat school. As far as could be determinedthrough our research, all subsequent casesare ultimately traceable to one of the twoinitial lepromatous cases—a girl aged 8 yearsat first infection, her symptoms appearingin 1964, and a man about 47 years of ageat first appearance of symptoms in 1967.

The girl was the younger of two childrenwho had been adopted by a maternal auntafter the girls' mother's death. She lived with

her adopters on Ponape throughout most ofher childhood. Her adoptive father, a skilledfisherman, spent a good deal of time withMicronesian friends outside of PorakiedVillage, often taking his wife and adoptivedaughter along for extended stays. He wasparticularly close with two Pingelapese fam-ilies on Sokes Island, where he and his familyoften visited them. Given the high inci-dence of Hansen's disease in the Pingelapesepopulation and the large proportion of lep-romatous cases among those infected, it isnot surprising that sustained contact shouldhave resulted in infection. Although this girl

first noticed symptoms in 1964 and was re-peatedly examined by both Micronesian andAmerican physicians over an 11-year pe-riod, her symptoms were not diagnosed un-til 1975.

The second case is similar in pattern tothe first. A man in his forties was on Ponapebeing treated as an outpatient for tubercu-losis. He had Micronesian, especially Pin-gelapese friends, throughout Ponape. Hespent a good deal of time on Sokes Islandwith a Pingelapese family, who had one childwho was an active, untreated lepromatouscase in 1964 and 1965. The man noticedsymptoms in 1967, was diagnosed as havinglepromatous leprosy, and was isolated forabout 5 months at the Ponape hospital, re-turning to the atoll thereafter. Although hewas repeatedly brought back to Ponape bypublic health officials to check on his tu-berculosis, he was never subsequently treat-ed for Hansen's disease for over a decade.

MATERIALS AND METHODS

We first compiled a list of identified and/or suspected cases, using records from thepublic health department of the Ponape state

hospital. These records had recently beenupdated and organized under the directionof Dr. Worth, who organized surveys of theKapinga population in 1980, 1981, and1982. The records supplied 130 cases, andthese were supplemented by five more cases,discovered during June, July, and August of1982 by Ms Jeanne Windsor, by healthaides on Kapingamarangi and Ponape, andby the authors. A sixth case, that of a de-ceased man, was known to us previously.Our total number of cases was 136 as of 17September 1982.


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For each patient, we recorded name; dateof birth; parents' and/or guardian's names;specific diagnosis [indeterminate (I), tu-berculoid (T), borderline tuberculoid (I3T),lepromatous (L), etc.]; site of first lesions(when that information was available); anddate of diagnosis. Our research was de-signed to collect the following categories ofinformation: a) date of first notice of symp-toms and who noticed them, b) probabledonor and the place(s) where infectious con-tact occurred, c) relationship between prob-able donor(s) and the victim that would ex-plain the type and regularity of contact, and

d) the specific settings of infectious contactbetween (probable) donor and victim.

Given the starting assumptions, it seemedto us that the most productive researchstrategy would be to concentrate our datacollecting on identified patients and the na-ture of their contacts with people known tobe lepromatous and infectious in the yearsprior to the patients' first notice of symp-toms. We used two research strategies: in-terviews with patients and their families andobservations of various sorts of physicalcontact between persons of various age andsex categories.

We interviewed all 136 identified patientsand/or their families. For each patient, weidentified the date of first notice of symp-toms (month and year) and who noticedthem. Next, we elicited a biographical ac-count of all contacts with persons known tohave lepromatous leprosy over the previous5 years. We were careful in these biograph-ical accounts to ascertain the kind of rela-tionship between donor and victim (kins-man, friend, etc.) and the specific places(household, work place, the specific house,which island, etc.) in which the relationship

was enacted. What made this strategy fea-sible was that there were so few lepromatouscases to deal with. By September 1982, therewere only 17 people identified as being lep-romatous; 8 of these had exhibited symp-toms before 1980, but only 4 of these before1978. The possibilities for infectious con-tact, therefore, were quite limited. Becausea clear trend among the cases of a 2-3-yearincubation period emerged, we limited ourbiographical questioning to 3 years. Wecross-checked these data with ship passen-ger lists from 1977 onward, allowing us to

pinpoint at least which island people wereon during any given month of a given year.

We also conducted a series of observa-tions of people of various age and sex cat-egories in natural social interactions. Wenoted patterns of physical contact and thespecific physical settings in which the in-teractions took place. These included chil-dren's play groups, women's and men's workgroups, meetings, conversations, churchservices, drinking bouts, and the like.

Our demographic data were collected asfollows. We conducted household censuses,two each at 6-month intervals, in the Po-

nape and atoll communities, in 1978 and1979 and one each in 1980 and 1982. Wecompared these to two censuses (two percommunity at 5-month intervals) conduct-ed in 1965 and 1966 to ascertain any shiftsin pattern of residence over that 17-yearperiod. We cross-checked our census ma-terial with household censuses done in bothcommunities by the Protestant church (forfood assessments) and by the Kapingamar-angi municipal council for 1978, 1979, and1982. These cross-checks were further re-fined by reference to ship passenger lists be-tween 1979 and 1982. We also sampledmen's and women's work groups over pe-riods of 4-5 hours, noting comings andgoings (and places of origin and destination)over the periods of observation. We sam-pled adults' and children's play groups,e.g., card-playing groups, peer groups, bingohouses, and the like, noting place, person-nel, and changes in personnel over periodsof 1-3 hours. It is from these detailed ob-servations that we were able to construct aprofile of mobility patterns for people ofvarious age and sex categories.

RESULTSOf 136 people documented through in-

tensive questioning, all are seen to have hadsome contact and most seem to have beenin regular contact with at least one lepro-matous person. There are 25 people (19%of the total) in regular contact with morethan one lepromatous patient. Given theinformation on first notice of symptoms incombination with contact histories, the in-cubation period appears to vary between 2and 3 years, infants' incubation time beingless than 2 years. Figure 2 shows the cu-


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FIG. 2. Cumulative curve of new cases by year offirst appearance of symptoms.

mutative onset of new cases, acceleratingrapidly after 1976.

Of the 136 cases, 76% are 20 years of ageor less (the youngest being 14 months). Fig-ure 3 shows the distribution of cases by ageand sex through the combined atoll and Po-rakied populations. The ratio of male to fe-male patients is 3:2. This distribution, whilecertainly not uncommon in small Pacificpopulations, appears to us to be significantin that it is so highly patterned.

This pattern of disease faithfully repli-cates the patterns of personal mobility char-acteristic of this community: a) After theage of 4 years, males and females work andplay in geographically separate places, andmales are always more mobile than females.b) Females are most mobile up to puberty,after which they become decreasingly mo-bile (moving mainly between kin-relatedhouseholds) as their labor and sexualitycome under increasing parental control. c)Males are most mobile during their late teensand early twenties, after which they becomedecreasingly mobile as they acquire skillsneeded by their elders. d) Both sexes be-come least mobile after marriage whenmovement is restricted by the economic re-sponsibilities of household maintenance. e)Females of different age categories are inregular contact and communication with one

0 5 6 10 11 15 16 20 21 25 26 30 31 35 36 40 41 45 46 50 51 55 56 60 61

FIG. 3. Distribution of all leprosy cases by age andgender )̂ = female; ■ ) = male.

another through household work and con-versation. f) Males of different age cate-gories (e.g., boys, young men, married men,older men) are socially segregated, and donot maintain much contact with oneanother. Given our initial assumptions and

what we know about community demog-raphy, this distribution of cases might wellbe expected. The bulk of the cases occuramong that segment of the population thathas the most personal mobility with a cor-responding decrease in frequency of infec-tion in less-mobile categories of persons.

Figures 4 and 5 contain the same data asthose in Figure 3, but the cases are dividedby island where infection most probably oc-curred. Note that patterns of infectionamong people 20 years of age and youngerare almost identical in the two communi-ties. But there is a striking difference be-tween the Kapingamarangi and Ponapepopulations as regards infection among old-er men. While not one man over 30 yearsof age is infected on the atoll, six men be-tween the ages of 45 and 61 are infected onPorakied. One could contend that the casesare too few in number to be significant, andthis might be the case. But there is a re-markable correlation between the incidenceof infection in this age and sex category andan important, nontrivial demographic andsocial difference between males in these twocommunities.


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0 5 6 10 11 15 16 20 21 25 26 30 31 35 36 40 41 45 46 50 51 55 56 60 61

ears of age at first appearnre of symptoms

FIG. 4. Distribution of leprosy cases originating onKapingamarangi by age and gender (D) = female; (M) =male.

On Kapingamarangi, adult males rarelycome into regular social contact with boysand young men other than their own chil-dren. There is a tradition of separation ofadult males from younger males that is cod-ified in terms of respect that amounts toavoidance of elders by their juniors. Boystend to avoid contact with their elderswhenever possible. What contact there isoccurs at feasts and major work projects inwhich the participation of both is required.In Porakied Village on Ponape, this respectrelationship has been rapidly disappearing

as the village has shifted to a cash economy.The economic mainstay of the village hasbeen handicraft production since the early1970s. Men specialize in wood carving, askill that, unlike the traditional specialty offishing, can be learned quickly with far fewerand much-less-expensive tools. Boys of 13years of age are making full-time livingsproducing and marketing their carvings.Carving is done almost entirely in groupsat four or five craft houses, the modernequivalent of the men's house. The agerange of a typical craft house encompassesmales from 13 years to 60 or more. All ofthe males in a craft house do much the samework, cooperating in procuring wood, shar-ing tools, and in helping in production whenone of the group has a deadline to meet.Members of a craft house group also eat andsocialize together. Seven men, ranging inage from 18 to 59 years, appear to have beeninfected in this context. By way of contrast,one group of full-time fishermen have main-tained the age separation. They spend mostof their time at the lagoon shore, where theircanoe houses are located. These men alsomake handicrafts at their canoe houses.

0 5 6 10 11 15 16 20 21 25 26 30 31 35 36 40 41 45 46 50 51 55 56 00 61

Year s of age at first appearance of symptoms

FIG. 5. Distribution of leprosy cases originating onPonape by age and gender ^) = female; ■ ) = male.

Younger males are not specifically excluded

from this group, but only a few younger menoccasionally frequent the canoe houses. Onlyone man from this group has been infected(by a younger man who visits him regu-larly).

These data show a correlation betweenpatterns of infection and patterns of mo-bility by age and gender category, but theytell us little about who might have infectedwhom and by what means. The latter ques-tions demand finer discriminations of pat-terns of regular contact between specifiedcategories of persons. It should be hardly

surprising that patterns of regular contactare governed by well-known rules of kin-ship, friendship, and associations aroundcommon interests (such as work groups,church groups, peer groups, and card-play-ing groups). The contexts and settings inwhich these kinds of relationships are en-acted can be divided into domestic and non-domestic contexts.

The domestic setting is the compound, aplot of land that contains from 1-5 house-holds, a central house for cooking, and otheroutbuildings. Residents of a compound arethose with ownership rights inheritedthrough descent from a former owner andin-married spouses. Household member-ship is fluid, since people have rights in asmany compounds as they have recognizedancestors. Adoption, which is very common( 5 ), illness of a relative in another com-pound, quarrels within the compound, tem-porary needs of kin for one's labor, or leav-ing the island, all operate to cause periodicshifts of residence by individuals or wholefamilies. The frequency of these shifts in-dicates a regular circulation of persons be-tween compounds. Not all members of a


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compound actually sleep there. Adolescentmales move to a men's house or other quar-ters to sleep until marriage, eating and oc-casionally working at their natal com-pounds. Not all persons with rights tocompounds actually associate with their rel-atives there. People tend to associate witheither their father's or mother's kin de-pending on which compound they residedin as children. They remain at a respectfuldistance from kin on the distaff side. In-laws, even those residing in the same com-pound, avoid contact with one another.

A compound by day is inhabited by a core

of related women and their young children.Men and boys are there in the early morningand the early evening to eat and, for men,to occasionally entertain friends or visit-ing relatives. Women's female kin visitthroughout the day for various purposes. Acompound may also be a work place forwomen's craft groups, for a canoe-makinggroup, or for a women's card-playing group.

Domestic contexts can be viewed, then,as a set of specific locales —compounds —whose activities are organized by principlesof kinship and friendship and presuppose acontinual, regulated flow of persons be-tween compounds.

Nondomestic contexts are also specific lo-cales, including canoe houses, men's houses,craft houses (on Ponape), bingo parlors andpool halls (on Ponape), and church build-ings where people meet to work, transactbusiness, and socialize. Bingo parlors andchurch facilities involve both sexes, whilethe other locales are frequented by males.Principles of friendship and common inter-est regulate the circulation of people throughthese settings.

Table 1 summarizes the data on the prob-

able avenues of infection of people in eachcontext, specifying the relationship betweenprobable donor and victim. Note that about70% of infections appear to have occurredin domestic contexts.

For all its apparent neatness as a sum-mary, the results in Table 1 are ambiguous.Twenty-five cases involve more than onelepromatous contact in various contexts.More serious is the fact that in 19 cases (14%of the total) no regular contact with a lep-romatous donor could be established. In atleast 10 o these cases, no personal contact

whatever with any lepromatous person wasreported, although all 10 reported regularcontact with known tuberculoid cases.

These anomalous cases suggest two pos-sible explanations. Either tuberculoid casesmay show wide fluctuations in the numberof bacteria that are present over time orthere is some medium or media in the en-vironment that is extremely efficient intransmitting the bacteria in the absence oregular lepromatous contact. The secondpossibility, an effective medium of transfer,is realized in two possible ways. One is thepossible spread of bacteria through cough-

ing and sneezing. Micronesian populationsare well known for their low resistance torespiratory and bronchial infections, and theKapinga population is no exception. Com-mon colds, asthma, and tuberculosis havea long history in this population. Whileadults are careful about covering their faceswhen coughing or sneezing, very young chil-dren are not nearly so scrupulous.

Another, probably more effective, medi-um of transfer are the floor and sleepingmats universally used by Kapinga in theirsleeping houses, cook houses and, in somecases, in work houses. Their mats are madeof dried strips of plaited pandanus leaf intwo widths ('). The sleeping mat has a leafwidth of about '/2 and the floor mat 1/4 .With usage over time, the leaf fibers beginto fray, producing a surface that consits ofthousands of tiny needles. The frayed sur-face causes tiny skin punctures wheneverbare or thinly covered skin comes in contactwith the mat. For example, frayed fibers areperfectly capable of puncturing skin coveredwith the sarongs that Kapinga usually wear.Conceivably, the mat fibers puncturing theskin can release bacteria underneath the skin

and hold them, inserting them into anotherperson who later sits or lies on the infectedfibers. Mats are periodically but irregularlyaired in the sun.

Sleeping mats are made in various di-mensions, depending on the size of the per-son, and are kept rolled up during the dayand spread out in sleeping spaces at night.Each person has his or her own mat, butsmall children sleep with their mothers (orwith a woman who plays that role). Friendsof the same sex sometimes share sleepingmat space. However, siblings of the oppo-


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site sex (which includes cousins in this cul-ture) are forbidden from contact with oneanother's sleeping mats (as well as clothing).Siblings of the same sex may share sleepingmat space, but they rarely do this after theage of 8 years or so. Males particularly areless likely to share sleeping mats with theirbrothers, especially if there is a large age gapbetween them. When boys reach puberty,they remove their sleeping mats from theirnatal houses and sleep in the men's com-munal house, in canoe houses, or in friends'houses (not being used by adults). Males docontinue to eat and work at their natal

households. Thus, considering infectionthrough sleeping mats, young men are morelikely to be infected by their friends than bytheir brothers, unless they spend a lot oftime in and around their households.

Floor mats are found in sleeping housesand in work houses on the atoll, where theycover a floor of coral pebbles. In PonapeVillage, where houses are built on stilts orare (increasingly) made of cement block,floor mats are used in sleeping houses andcook houses. Cook houses in Ponape Villageare constructed much like sleeping housesbut are smaller, the thatch roof coveringboth floor space and fire pit areas. The cookhouses are used mostly by women for workspace and, when necessary, for sleepingspace. While women use cook houses, menand boys frequent them for various pur-poses. Children come there for meals. Whena family eats together (usually in the eve-ning), it is often in the cook house or on afloor mat spread outside the cook house.Cook houses are a very likely common pointof infection for adult women and for chil-dren and teenagers of both sexes. They arealso used for women's card-playing groups,

which meet once a week to play for up to12 hours.

Sleeping houses are used in both com-munities almost exclusively for sleeping andfor storing valuables, clothing, utensils, andthe like. Kapinga spend most of their wak-ing hours out of doors or in work houses,men's houses, canoe houses, or cook houses.Access to sleeping houses is restricted tomembers of the household and to close rel-atives, usually those in the same compound.Men's houses are much less used today thanin past times, and they have no floor mats.

Men who work in them (mainly on the atoll)bring their own small mats to sit on. Smallfloor mats (usually scraps of discarded housemats) are used in some craft houses (on Po-nape), canoe houses, and work houses inboth communities.

If we are to assign probabilities to sneez-ing/coughing and mats as the more likelymedium of transport of 11 ycobacterium lep-rae, that of mats seems higher. Spread ofbacteria through sneezing and coughing canoccur only: a) if the lepromatous person hasa cold; b) if the bacteria are not impeded intheir path, e.g., the person does not obstruct

sputum through holding a hand up in frontof his/her face and does not turn away fromothers during the sneeze or cough; and c) ifthe person to be infected is in close enoughproximity to the one sneezing or coughing.Reliance on this medium of transport as anexplanation encounters several difficulties.One must first assume that infectious con-tact is dependent on colds or other bronchialinfections that involve coughing and sneez-ing. One must also hypothesize that thoseincidents in which people do not cover theirfaces and/or turn away from others are re-sponsible for infection. The difficulty withthis second assumption is that one must as-sume infection to be the result o a rareoccurrence over the population or assumethat it is young children, who do not covertheir faces or turn away, who are respon-sible. The first assumption presupposes awhole series of coincidences—random oc-currences—as sufficient to explain a patternof infection. The second alternative, thatyoung children are responsible for spreadingthe infection, simply flies in the face of thefacts. Even a combination of both expla-nations still does not yield a high probability

of occurrence.We do not encounter the same problem

of assuming rare, random events to explainpatterned consequences in the case of mats.They are used and stored in dark, moistplaces that favor the retention of live bac-teria for several days. Their patterns of use,moreover, replicate the patterns of infec-tious contact delineated in Table 1. Whocan lie on or sit on a particular sleeping orfloor mat depends on the nature of the socialrelationships between those who share (orcannot share) its use. Moreover, the use and


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TABLE 1. ontexts of infectious contact

KAP PONS,Total

M F M F

Domestic

Lepromatous person infects:

Members of same household (eat, work, sleep) 7 13 6 9 35 25.9Person eating and working regularly at household 4 4 10 7.4Regular visitor to household (eats, works) 6 3 10 7.4Regular visitor to household (eats, converses) 8 5 12 30 22.2Occasional visitor to household (babysitter, kin) 3 2 - 2 9 6.7

Total 25 21 18 30 94 69.6

Nondomestic

Infected by a:

Playmate (children under 12) 2 9 3 8 12 16.3Friend 6 4 12 8.9Co-worker 0 7 7 5.2

Total 3 15 4 19 41 30.4

Totals 28 36 22 49 135 100.0

KAP = Kapingamarangi Atoll.b PON = Ponape Island.

sharing of mats is ubiquitous in this pop-ulation. Finally, direct contact between alepromatous person and a victim is not nec-essary for the effective spread of the bacteriagiven this medium. A lcpromatous personcan sit or lie on a floor mat, leaving bacteriabehind. Another person can sit or lie in thesame place one or more days later and beinoculated by means of the mat fibers. Withthese considerations in mind, let us returnto the 19 cases in which there is no regularcontact between an identified victim and alepromatous case.

In 1977, two new cases were discovered.One, a boy we shall call Pat, was diagnosedin 1977 as having tuberculoid leprosy. Hewas sent to Ponape for treatment, stayingwith his mother's brother, who was discov-ered to have lepromatous leprosy 2 yearslater. In 1980, four of Pat's playmates werefound to have lesions which were diagnosedas tuberculoid leprosy. None of these fivesubsequent cases showed any history of reg-ular or even occasional personal contact witha lepromatous case. Now, Pat's only contactwith a lepromatous person was an indirectone. The older man, diagnosed as a lepro-matous case in 1967, is said to have beenengaged in a long-term sexual liaison withPat's mother. This involved his visiting hereither in her house or in the cook houseadjoining it. These visits occurred late at

night, and the liaison was consummatedeither on the floor mat or on the woman'ssleeping mat (which Pat used on occasion).Pat and this man never had direct contact.Pat and several of his friends regularly vis-ited the cook house to cat or play. WhenPat's uncle accompanied him to the atoll in1977, he stayed in his sister's house and ateat the cook house, providing ample oppor-tunity for him to be infected through thefloor mats of both the house and the cook-house.

Five other cases, all women in their 40s,50s, and 60s living on Ponape and havingno personal contact with any lcpromatouscase, are similarly instructive. The one thingthese women had in common was mem-bership in a card-playing group that met inthe same cook house every Sunday. From

1979 through 1982, this cook house wasused as a work, study, eating, sleeping, andlounging place by three boys, all diagnosedas having lepromatous leprosy. We ob-served one of the boys at that house for a1-hour period as he lounged, in a sarongand naked from the waist up, alternatelysitting, lying on his back, lying on his side,and moving from side to side to scratch hisback on the old and frayed floor mat. Cardplayers similarly lounged on the same mat,sitting, lying on one side or on the stomachto play or to kibbitz. The likelihood of these


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women, all of whose symptoms appeared in1981, having contracted the disease in thiscontext is much higher than having, say,been in the way of a person sneezing inchurch.

Adding to the likelihood of mats as themost probable means of transmitting thebacteria is the fact that the sites of first le-sions, in those cases (93 cases or 68% of thetotal) where these data were available, in-clude only those skin areas that are in reg-ular contact with mats. The sites includearms, scapular area of the back, lower back,abdomen, thighs, shin, calf, buttocks, top of

the foot, flares, and cheeks, as shown in de-tail in Table 2.

There is no case of lesions in the crotch,upper medial thigh, neck beneath the chin,top of the shoulder, inner arm pit, or anyother site that never or rarely comes intocontact with the mats. But if there were norelationship between site of infection andsite of lesions, then we should expect byrandom chance at least a few lesions in areassuch as the neck, crotch, or elsewhere notin contact with the mats.

Hypothesizing pandanus mats as a me-dium of transmission of Al. leprae has theadvantage of being consistent with the de-mographic facts of population mobility andinfection patterns in this community. Weclaim no originality in presenting this hy-pothesis, since the possibility of mats as ameans of spreading Hansen's disease wassuggested to us by Michael Hamnett (Uni-versity of Hawaii) in 1982 and by Carl Tay-lor in 1984. C. K. Job and his associateshave found what is perhaps a similar patternof infection and mobility among infectedarmadillos in southern Louisiana ( 3 ). Themedium of infection in this case is hypoth-

esized to be thorns in the animals' environ-ment. Thorns have been found in the earsand noses of these animals and, in one case,there is no doubt that it is the thorn thattransferred the infection.

This sort of hypothesis can be tested. Onecould inoculate the mat in the laboratoryand develop techniques of recovery whichwould be effective to determine the presenceof M. leprae and to distinguish it from otheracid-fast bacteria that might also be present.This determined, it could then be replicatedboth in the laboratory with mats of known

TABLE 2. Site of first lesion(s).

Site Male Female

Face

Cheek

Nares Under lower lip

Thorax

Upper chest 7 3Lower chest 2Abdomen 5 2Pubis

ck

Scapular area 6 6Mid-back 1 1 8

Lower back 5 Buttocks 4 3

Arms

Upper arm lateral 5 8Upper arm medial Elbow _ Forearm 4 Ventral wrist Ventral hands 2

LegsThigh dorsal Thigh ventral 4 2Thigh, lower medial Knee ventral 2Shin 4

Calf 2Ankle distal Foot ventral

Genitalia

Penis ventral

There are 18 persons with multiple lesions that aredistributed as follows: 12 = 2 lesions, 5 = 3 lesions,1 = 5 lesions. Included in these 18 are 5 lepromatouscases; 3 with 2 lesions, and 2 with 3 lesions.

lepromatous patients and in the field. Ourexperiments with Kapinga mats should be-gin soon.

There is another implication of the cor-

relation between the pattern of leprosy in-fection and the pattern of social mobility inthe Kapinga population that is worth men-tioning—an implication for the inheritanceof susceptibility and resistance to the dis-ease. We arc fortunate in the Kapinga com-munity to have accurate genealogical doc-uments that reach back to about 175through the combined research of Dr. Ken-neth Emory ( ) and the authors. The dataare adequate for testing genetic hypothesesto account for the distribution of infection(and of noninfection).


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z _ \ •

,

A A

478


98 7

Fie. 6. Distribution of leprosy cases among descendants of an ancestral sibling set plotted against actualsocial contact between members of descendant sibling sets 6) = male; (A) = infected male; (0) = female; (•) —infected female; (—) = married; ( = wedlock; (h) = children; (: ) = boundary between noninteracting kin.

We have mapped the genealogical con-nections among the 136 victims by groupingsibling sets at each generation, treating themas units in the maps. Each map depicts anancestral sibling set and its descendant sib-ling sets in lower generations, displaying thegenealogical relationships between leprosyvictims as parts of the larger set. Obviously,with each patient, the number of possibleconnections doubles as one proceeds to se-nior generations. Yet it is already clear thatsome sets of related people show large pro-portions of leprosy patients while other suchgenealogical groups show relatively few pa-tients among its members, just as somecompounds have several patients and oth-ers none. It is significant for purposes ofgenetic analysis that the groupings of rela-tives that appear on our genealogical mapsform sets that arc quite independent of thecommunity's mobility and social interac-tion patterns. That is, people who are in factgenealogically related do not necessarily in-teract with one another on a regular basis,as already noted. Yet as a set of persons,they show much higher concentrations ofleprosy patients than sets of relatives who

do interact and are in regular contact withlepromatous persons. Figure 6 gives an ex-ample of this independence of genealogicalconnection and social interaction pattern.The dotted lines in the figure indicate thatthe group of persons set o do not regularlyinteract with the people on the other sideof the line.

The relative independence of genealogicalrelationship and demographic-social rela-tionship makes it likely that genealogicalhypotheses accounting for susceptibilityand/or resistance to leprosy can be applied

to the Kapinga data for both explanatoryand predictive purposes.

CONCLUSION

We have presented data on a leprosy ep-idemic in the Kapingamarangi populationsof Kapingamarangi Atoll and Ponape Islandin Micronesia. Our description has concen-trated on the patterning of the spread of thedisease and how the spreading of the infec-tion faithfully replicates the mobility pat-terns of age, sex, and kinship and friendshiprelations in this community. The concen-tration on the correlation between patternof infection and demographic patterns hasat least two major implications. It suggeststhat as we search for the most likely modesof transmitting M. leprac we must take intoaccount not only what is a possible meansof conveyance, but also that we be able todifferentiate between what is a more-prob-able or a less-probable means. We do notdeny that sneezing may be an effective meansof transmitting the disease. But when thismore random process of transmission iscompared with that of sleeping and floormats, the fit between the use of mats and

the demographic facts, added to the fact thatsneezing requires direct contact and matsdo not, clearly points to mats as a moreprobable mode of transmission. The de-mographic facts make the mat hypothesismore probable. As an hypothesis, it is alsomuch easier to test.

The second payoff of the correlation be-tween infection and demographic patternsis its implications for approaching the prob-lem of possible genetic inheritance of resis-tance to Hansen's disease. If the constraintsthat shape a genealogical grid were identical


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79

to those which constrain daily association,it would be difficult to disentangle demo-graphic from genealogical patterns. But thisis not the case in this population. Rules ofdaily association in fact prohibit people incertain genealogical categories from asso-ciating with one another. Genealogical re-lationship and social intercourse are rela-tively independent of each other, althoughthey do overlap where rules of associationpermit. The role ofgencalogical relationshipin the transmission of resistance, thus,emerges relatively clearly on a genealogicalgrid such as that in Figure 6. The data pre-

sented here, of course, represent an inci-dence whose rate was still increasing at thetime the authors left the field. This has itstheoretical advantage, however, in that pre-dictions oflikely subsequent infections basedon genealogical connection can be testedagainst the data on new cases after 17 Sep-tember 1982.

SUMMARY

This study reports the results of field re-search on a leprosy epidemic among the Ka-pingamarangi people, Polynesians living intwo communities on Ponape Island and Ka-pingamarangi Atoll in the Federated Statesof Micronesia. The patterns of infection inthe two communities are seen to replicatein detail patterns of personal mobility byage and gender and patterns of kinship andfriendship relations that order people's so-cial interactions in the communities. Thesepatterns of demographic and social rela-tionship form the context of infectious con-tact, enabling us to differentiate betweenmore- and less-probable means by whichHansen's disease is spread. We comparecoughing and sneezing with inoculation

through the frayed fibers of pandanus leaffloor mats and sleeping mats as alternativeways of spreading leprosy infection. We findthat frayed mats, because they are ubiqui-tous in the contexts in which people inter-act, are more likely to spread infection thancoughing and sneezing. Finally, we find thatdemographic patterns of the communitiesare not identical with genealogical relation-ships such that people with close genealog-ical relationships often do not interact on aregular basis. Thus, genealogical distanceand social distance are independent of each

other in this community. This makes ge-netic assessment of inheritance of resistanceand susceptibility to Mycobacterium lepraean enterprise unencumbered by a necessar-ily linked demographic variable.

RESUMEN

En este trabajo se presentan los resultados de unestudio de campo sobre una epidemia de lepra entrela genie Kapingamarangi, polinesios que viven en doscomunidades situadas en la Isla Ponape yen Ia isla oatolón de Kapingamarangi, en los Estados Federadosde Micronesia. Los patrones de infección en las 2 co-munidades rellejan tanto el patron de movilizaciónpersonal segfm edad y rata, como el patrón de las re-

laciones familiares y amistosas que rigen las interac-ciones sociales en esas comunidades. Estos patronesdemogrrificos y de relación social constituycn Ia basedel contact° infeccioso y nos permiten diferenciar lasformas mAs- y menos-probables de diseminación de laenfermedad de I lansen. Nosotros comparamos el es-tornudo y la cos, con la inoculación a través de lasfibras desgastadas de las hojas de Nndano que se usanpara hater tapetes de piso y tapetes de dormir comoun medio alternativo de dispersion de Ia infectionleprosa. Encontramos que los tapetes desgastados, dadasu ubicuidad y participación en las interacciones so-ciales de Ia comunidad, son vehiculos de dispersion deIa infección quiza mss importances que Ia misma cosy el estornudo de los pacientes. Finalmente, encontra-mos que los patrones demográficos de as comunidadesson independientes de las relaciones genealágicas yaque la genie con relación genealógica cercana rara-mente interacciona entre si. El hecho de que las rela-ciones genealógicas y las relaciones sociales scan in-dependientes en esta comunidad, permite que se puedaestablecer la genetica de Ia herencia de resistencia y/osusceptibilidad al Mrcolucterium /eprae sin el ob-stdculo do varibale demogrrifica.

RESUME

Cette etude relate les resultats d'une recherche men&sur le terrain, et porte sur une epidemic de lepre parmiles populations Kapingamarangi, des Polynésiens quivivent dans deux communautés sur l'ile de Ponape etsur l'Atoll de Kapingamarangi, dans les Etats Fédérésdo Micronésie. Les profits d'infection dans ccs deuxcommunautés relletent étroitement la circulation despersonnes, par age et par sexe, et les relations familialesou amicales qui y réglent les interactions sociales. Lesprohls démographiques et de relations sociales con-stituent le contexte du contact infectieux, cc qui permetde distinguer entre les moyens les plus probables et lesmoyens les moins probables par lesquels la =ladle deHansen est disséminee. On a compare Ia toux et reter-nuement, avcc ('inoculation par les fibres elfilochéesdes nattes de feuilles de pandanus qui recouvrent leplancher et les matelas, comme factcurs de transmis-


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4.

5.

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nternational Journal o Leprosy

98 7

sion de l'infection lepreuse. On a observe que Ics ma-tclas effiloches, qui se retrouvent putout la on les Bens

Sc recontrent, soot plus susceptibles de dissent iner l'in-fection que la toux ou l'eternuement. En lin, on a constate

que les profits demographiqucs de ces deux commit-nautes ne correspondaient pas parfaitement avec lesrelations genealogiques, car Ics individus ayant des re-

lations familiales etroites souvent ne Sc rencontrent pas

regulierement. Des lors, Ia distance genealogiquc et la

distance sociale sont deux parametres independants

run de l'autre dans cette communaute. II en resulte

que l'evaluation des facteurs genetiques d'heredite de

Ia resistance ou de la susceptibilite a MycobacteriumAiwa( Nut etre menee sans tenir compte (rune variabledemographique qui lui serait necessairement lice.

Acknowledgments. We arc grateful to Dr. RobertWorth, Dr. Kenrad Nelson, Dr. Carl Taylor, Dr. Vic-

toria Schauf, Dr. C. K. Job, Dr. Jeanne Windsor, Dr.

Georgeda 13uckbinder, and Dr. Timothy Holier for 6.

their valuable critiques, advice, and encouragement ofthe conduct of our research and in the preparation ofthis paper.

REFERENCES

1 3 u < kP. ,1 aterial Culture oilssapim,anuirangi. Ho-nolulu: Bernice Bishop Museum, 1950, pp. I05-116.

Emony, K. P. KapinKamaramn : Social and Reli-gious Li/i of a Polynesian Atoll. Honolulu: BerniceBishop Museum, 1965.JOB, C. K., I IARRIS, E. II, ALLEN, J. L. and I lAsTINGs,

R. C. Thorns in armadillo ears and noses and theirrole in the transmssion of leprosy. Arch. Pathol.

Lab. Med. 110 (1986) 1025-1028.LIEBER, M. D. Pornkicd. Kapingamarangi Colonyon Ponape Eugene: University of Oregon Depart-ment of Anthropology, 1968, pp. 10-21.LIEBER, M. D. Adoption on Kapingamarangi. In:

Adoption in Eastern Oceania, Carroll, V, ed. As-

sociation for Social Anthropology in OceaniaMonograph Series I. Honolulu: University Press of

Hawaii, 1970, pp. 158-205.WORTH, R., DOUGLAS, J. T., MURRAY, C., WINDSOR,J., LIEBER, M. and LIEBER, E. A virgin soil leprosy

epidemc in a Polynesian population. Int. J. Lcpr.

52 Suppl. (1984) 740.

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