Medical report by Jonathan Hodges
2015 Korowai
This report details the findings of the second expedition to the Korowai people of West Papua following the assessment of healthcare needs conducted by Dr Maryke Nielsen & Dr Nicholas Fazakerley in 2014.
Preparing for Travel
Recommendations from the last expedition had focused on potential areas for improvement and looking at sustainable programmes that might benefit the local population beyond that which could be achieved through the running of annual primary care clinics without the current resources to provide ongoing follow up. The interventions focused on long-term goals and potential improvements in field diagnostics and included advocating for the Korowai living in traditional settings to be included within the scope of the current mass drug administration programme for the eradication of Lymphatic Filariasis identifying this as a cause of considerable morbidity amongst the population. Diagnostic provision was improved through the availability of a limited number of BINAX NOW rapid diagnostic tests to be used in the diagnosis of Malaria and also attempts were made to try to gain a greater insight into the potential causes of Gastrointestinal symptoms through the use of a small portable microscope for reviewing stool samples.
Dr Nielsen was integral in liasing with representatives of the World Health Organisation within Indonesia both prior to and during our travel. This allowed Tribal Survival to act as a distribution network providing a means by which hard to reach populations within the Korowai could access the Lymphatic Filariasis Mass Drug Administration Programme. Already available to many of those living in village settlements the combination of Mebendazole and DEC given annually for 4-6 years was beyond the reach of traditional families living within the jungle tree houses and it was felt that the coverage this may provide could be important in the overall future success of the programme within this region.
The Expedition
On this expedition myself and Dr Nielsen were present as members of the medical team and were accompanied by the Trustees of Tribal Survival Mr & Mrs Montanaro who had also travelled from the UK to oversee the work being done by the charity with the Korowai people. The logistics of the expedition had been planned in advance with the help of the team on the ground in Papua & the UK including many of the staff who were familiar with the work of the charity based on the previous year’s efforts. Thanks must again go to Eleanor, Andreas & Fenilon for their hard work in organising the itinerary, recruitment of guides and also roles in clinic triage and translation.
This year thirteen days were spent within the Korowai region with six locations chosen for clinic using Yaniruma as a starting point for the expedition and with agreement to see a limited number of patients at the start and end of the trip at the request of local residents.
With limited detailed mapping available of the Korowai region and only approximations of population size and densities, locations were chosen based upon previous knowledge from the past expedition and the guidance of local Korowai as to the areas of need as well as those requesting assistance from the charity. Estimates of population size from existing sources prior to travel suggested a total number of Korowai in the region of 4000 people distributed between village settlements on the ground and traditional tree-houses. As part of this expedition it was hoped to gain a more realistic perspective as to the numbers of Korowai and also to try to ascertain from local guides the number of traditional settlements remaining and to work towards producing a more detailed map of the area for use in the future.
In total 170 clinical contacts took place during the expedition split between the chosen sites. As a result of some unrest amongst one of the villages chosen to visit (Lano-lano), difficulties noted during the expedition in managing to set up and dismantle clinic and camps within the pre-planned time frame and concerns that the target population was not being reached it was agreed that the programme would be slightly changed to allow longer stops at fewer locations. This meant more time being spent at Levilhari & Hamai with clinics at Yafofla and Lano-lano being sacrificed to allow for longer clinic time and we hoped also larger patient numbers to be treated. Messages were relayed ahead to the villages to explain the change in itinerary and to update patients as to revised schedules so as to allow arrangements to be made to intercept the clinic at some point along the proposed route. A traditional feast had been organised at Hamai in advance of our travel in the hope of attracting large numbers of the Korowai to a single location where they could access medical care should they wish and it was thought that with this in mind a greater length of time spent at this location in the preceeding days would allow the greatest exposure to those in need.
Clinical Data & Demographics
Each patient had their name, age and where they live recorded at the time of registering at the clinic. Of the 170 patients seen in clinic 150 were from the surrounding ground settlement villages with the majority from Hamai and Sela possibly indicative of the extended time period spent in close proximity to these villages. 16 of the patients seen stated that they were from traditional treehouse dwellings and we have no recorded data for at least four of the remaining patients. Whether this is indicative of a change in the living circumstances of the Korowai, the message not getting to those in more remote areas, clinic locations, inaccurate record keeping, varying health needs or differing belief systems surrounding western practices amongst those favouring a more traditional way of life is unclear but at least from the data collected on this expedition it would appear that only approximately 10% of patients were recorded as hailing from traditional treehouse dwellings.
Presenting complaints of the patients seen in clinic as stated at triage were rarely in isolation and frequently multiple, often containing a suspected diagnosis or symptoms across a wide variety of body systems. This is not perhaps surprising given that we see patients in the developed world with multiple opportunities to see a clinician presenting with a number of ailments at a single appointment. As this maybe the only opportunity many of these patients have had to discuss their symptoms and to receive treatment in a limited time frame it is understandable that a number of problems are discussed at any one time and that many more chronic conditions may have gone untreated for many years.
The presenting complaints have been grouped according to systems and are expressed in percentages of patients reporting symptoms in that domain bearing in mind that many patients reported more than one symptom at triage.
In comparison with those diagnoses made one year previous the most commonly seen problems were similar in some aspects in that the majority of patients were presumed to have a diagnosis of lower respiratory tract infection and a significant proportion were affected by forms of infective diahorrea which could not be accurately identified as well as fungal skin infections. There appeared to be a greater number of cases of Malaria which may have been explained by our use of Rapid Diagnostic Testing (RDT’s) on this expedition. A limited number of tests were available and it quickly became clear that we did not have sufficient resources to test all of those describing symptoms of fever as part of their presenting complaint. Presumptive treatment was occasionally used in the event of pyrexia of unknown origin or significant splenomegaly with 60 patients tested using the available RDT’s of whom 4 were diagnosed with Falciparum Malaria & 7 with Non-Falciparum Malaria. Chronic gastrointestinal problems were frequently postulated to be related to Helminth infections although no samples were provided for microscopy to be performed to better differentiate parasite infections from other causes of GI upset.
On this expedition myself and Dr Nielsen were present as members of the medical team and were accompanied by the Trustees of Tribal Survival Mr & Mrs Montanaro who had also travelled from the UK to oversee the work being done by the charity with the Korowai people. The logistics of the expedition had been planned in advance with the help of the team on the ground in Papua & the UK including many of the staff who were familiar with the work of the charity based on the previous year’s efforts. Thanks must again go to Eleanor, Andreas & Fenilon for their hard work in organising the itinerary, recruitment of guides and also roles in clinic triage and translation.
Clinic patients by gender
Of the patients treated 91 were male and 79 were female
No Data Found
Age distribution
Number of pages by age
No Data Found
Home Settlement
Patients were seen across all age groups with the vast majority being children or between the ages of 31-60 years. The age range was from two months of age to 68 years.
No Data Found
Presenting complaint
Symptoms by category
No Data Found
Presumptive Diagnosis
Of the patients on whom data was collected 77 had a single diagnosis only, 68 had two diagnoses recorded and 7 had three diagnoses. Below is a breakdown of these diagnoses of which a large majority are presumptive and based upon the clinicians combined opinions, physical signs, described symptoms and the illnesses felt likely to affect the population of a tropical environment based on extrapolation from available resources.
No Data Found
Mid-Upper Arm Circumference (MUAC)
Mid-Upper Arm Circumference (MUAC) was recorded in 20 children with the following results:
No Data Found
Cultural Preservation & Community Mobilisation
It appeared from the observations of those familiar with the Korowai region and the comparisons made from previous visits to the area that the number of Korowai choosing to live a traditional existence are declining in number. The reasons for this are not clear and are no doubt complex & multi-factorial in nature. It was discussed that future directions for the involvement of Tribal Survival might involve looking towards recruiting volunteers more skilled in community mobilisation techniques to empower local Korowai to promote their own traditions, skills and values that might lead to preservation through future generations and thus be more directly attuned to the central aims of the charity.
