TED Case Studies

Ebola, Trade, and the Environment

CASE NUMBER:408
CASE MNEMONIC:EBOLA
CASE NAME:Ebola and Trade

I. Identification

1. The Issue

The Ebola virus is a rare and extremely deadly virus which has appeared in scattered places around the world, most often in Zaire. It is not known where this virus exists in nature, and Ebola is only obvious when had by humans and monkeys. The virus has affected our trade in monkeys and has also affected our trade in information--or lack of it, because the existence of the virus may be kept secret so it does not scare away tourism (another form of trade). The Ebola virus may also be traded for use in biochemical warfare, although there is no evidence of this. There is also no knowledge of where this virus naturally resides, but it can travel fairly easily.

2. Description

The Ebola virus is named after the Ebola River in northern Zaire, which flows a short distance north of Yambuku, a small town where the first person in whom this virus was spotted lived. This case study will first describe Ebola's victims, the virus in particular, and responses to the virus. It will go on to describe the history of the virus, and its relationship to trade. This case study also presents related cases, the type of environmental problem, and the economic impact of Ebola, among other topics.

Ebola's victims

The Ebola virus causes a severe hemorrhagic fever. This fever occurs most often 7-14 days after infection (with the range of 2-21 days).

Ebola is one of the most gruesome and deadly viruses in its effects on its victims. It often destroys its victim in less than ten days and it is spread through bodily fluids, most easily through blood to those who have close personal contact with the person who is acutely ill. For instance, family members and health care workers have caught it, the latter through reuse of hypodermic needles when treating infected patients. This is most common in developing countries such as Zaire and Sudan where healthcare is underfinanced.

Lack of sanitary conditions, including clean needles, syringes, water, and ways to sanitize an area after it comes into contact with the fluids of a victim are prime ways in which to spread the disease. We do not know what risks are associated with which body fluids because medical workers who have caught the disease were exposed to various body fluids. It is unlikely that there is airborne transmission in humans, although in monkeys this is more likely. There may be risk of spread of the disease through sexual transmission, although this is not likely through those who are infected but show no signs of infection. For persons who have been previously infected, the disease may spread through genital discharges for a brief period after recovery. The risk of transmission of the disease is more likely, of course, in the later stages of the disease, when body fluids are flowing more freely (for example, through vomiting, diarrhea, and hemorrhaging).

There is a great need for an increase in clean water, new syringes and better sanitation, especially in hospitals. In fact, hospitals are in such great need for these that two of the three outbreaks of Ebola in Zaire were in hospitals; for instance, in the university hospital in Kinshasa, several patients must share a single bed, and in a larger hospital, the Mama Yemo Hospital, corpses have piled up because of the lack of funds to dispose of them.(1)

In the 1995 Zaire Ebola outbreak, there were reports of transmission between people a few days after the onset of the fever. (Other symptoms in the primary patients and the level of exposure to bodily fluids which caused the secondary cases were unknown.)(2) It was asserted that "sharing a small, primitive, native hut with a patient was not a risk factor." But over one third of the secondary victims were either morgue workers or health care workers, which had "multiple contacts with multiple fluids."(3)

Symptoms which are evidence of the Ebola infection are fever, headache, and additional flu-like symptoms. Relatively soon after contraction of the virus, the blood congeals, and victims' capillaries, blocked by dead blood cells, collapse. The same thing happens to other blood vessels, and organs stop functioning normally. The organs, clogged with blood, in effect disintegrate, as the surrounding tissue bleeds uncontrollably.

Visual symptoms are bruised skin which blisters and then falls away, and uncontrollable bleeding, not only from surrounding tissue, but virtually wherever else possible, including the eyes, ears, nose. The victim becomes delirious and soon vomits disintegrating internal organs and tissues. Death often occurs in a week to nine days. It is not unsurprising that Ebola often creates crisis situations.

In response to the disease, health officials often attempt to control it by isolating the infected person. Hospital personnel isolate the sick person through "barrier technique:" (1) doctors and nurses wear gowns, masks, gloves and goggles when caring for a patient; (2) visitors are restricted; (3) disposable material is removed from the room and burned after use; (4) all reusable materials are sterilized before reuse; (5) all hard surfaces are cleaned with sanitizing solution.(4)

The Ebola outbreaks in humans cannot be attributed to association with monkeys. The Reston virus, named after the virus that broke out in Reston, Virginia (USA), was possessed by monkeys and was infectious to humans but did not cause serious human illness. In Italy, recently, a filovirus was found in cynomolgus monkeys imported from the Philippines. Human infections did not result from this virus, which is believed to be the Reston virus or closely related to it.

The Ebola virus, in particular

The Ebola virus is a filovirus, which may be able to warrant taxonomic status as a separate virus family because it is sufficiently distinct from the other non-segmented negative- stranded RNA viruses.(5) Viruses are shreds of genetic information, which are encoded as RNA or DNA that can insert themselves into a cell and use it to make copies of themselves. Interestingly enough, it may be that as Ebola spreads, it becomes more virulent, by undergoing genetic mutations. The fact that Ebola is a virus, makes it even more untreatable.(6)

Responses to the virus

There is a fear by scientists of the disease. They have classified it as a Level 4 pathogen, and allow it to be studied only in a super-sealed facility. In comparison, AIDS is Level 3.(7)

When informed of the existence of the virus, a team of experts often mobilizes and goes to the area of infection to study it, including characteristics such as how the virus was caught and methods of how to treat it. (For instance, CDC (Center for Disease Control) teams, at times with the U.S. Army Medical Research Institute of Infectious Diseases (in Fort Detrick, Maryland), go into the area.) The investigators often don protective suits and respirators to protect against the virus and take their temperature twice a day to check for any signs of a fever which might be the beginning of the Ebola virus.(8)

Another response to the virus is that the Zairian government has granted the Baptist Missionary Society a license to set up a satellite link with a hospital in Vanga (a town near the Zairian outbreak) to improve ties with international medical experts. The World Health Organization (WHO) has sent protective clothing, including gloves to medical workers in Kikwit.

History of the virus

The Ebola virus first broke out in Zaire and Sudan, almost simultaneously, in 1976. Mortality rates were 88% in Zaire and 66% in Sudan, with 500 cases. In one small village in Zaire, 274 out of 300 people infected in an Ebola outbreak died.(9) In 1977 in Zaire, a single case of the virus in isolation was reported. In 1979, Ebola appeared again in Sudan at the sight of the 1976 outbreak. Two other fatal and two other nonfatal cases had been reported.

On April 10, 1995, according to Zaire's Health Ministry, an Ebola outbreak began when a surgical patient infected medical staff at Kikwit's hospital.(10) The surgical team developed symptoms similar to a viral hemorrhagic fever (VHF) disease (of which Ebola is one). The Ebola disease was suspected by a Belgian doctor. This doctor reported it to the Zairian government. At request from the Zairian health officials, medical teams from CDC, WHO, and Belgium, France, and South Africa collaborated to investigate and control the disease in Zaire.

In response to this, also early in 1995, there were many newspaper and magazine reports on an outbreak of the Ebola virus in Zaire. The movie "Outbreak" underscored the horror of Ebola.(11) Tellingly, by May 14, 1995 the death toll was at least 64 people.(12)

Although nothing had been able to be done about Ebola, there was still hope to investigate and contain the outbreak in Kikwit (a city of 400,000 people, 400 kilometers East of Kinshasa, Zaire's capital city), Zaire, where, obviously according to other estimates, 170 people had died as of May 11, 1995. In response to people fleeing Kikwit and possibly spreading the virus, the government of Zaire attempted to cordon off the city to keep inhabitants from spreading Ebola across the countryside and possibly even into the slums of Kinshasa, Zaire's capital. Kikwit was put under a quarantine, but because the government of Zaire has not been adequately functioning for years, the announcement was rather ineffective. Therefore, international doctors were sent through the streets, pleading with citizens to stay home.(13) Even still, the Ebola virus spread to Musango, which is near Kikwit. There was fear had by experts that, like AIDS, the Ebola virus could quickly spread to the rest of the world.(14)

According to a transcript of a White House press briefing by McCurry, Kristoff, and Lord put out by the U.S. Newswire dated April 17, 1996, McCurry, when asked about the Ebola epidemic, replied that the President had an update on two monkeys that were in quarantine in Texas. McCurry said that the President was confident that Texas public health officials and federal public health officials from the Centers for Disease Control were working closely together, and that "they've seen nothing to indicate any cause for undue concern at this point."(15) This suggests that there may have been more Ebola cases at this point, but relatively little was known about it.

In general, population growth and people living in higher densities, may heighten the risk for spread of infections, and so, in this case, Ebola. Increased density of people and inadequate resources (in part due to mismanagement of resources) may cause political and social instability. "These multiple vulnerabilities often converge in a population or geographical region." New vulnerabilities may overcome technological change, with interventions having "unintended and unexpected consequences." In effect, "many interventions have been carried out with too narrow an understanding of their impacts."(16)

A cause of the Ebola virus could be in part that human stress has made the delicate ecological balance become unbalanced, adversely effecting the natural state of biodiversity. One source of this stress may be just blatant human mismanagement of the natural environment, which indirectly and, or inadvertently leads to destruction of it, and which causes public health concerns. In fact, "mismanagement of public resources which leads to poor management of the environment create opportunistic factors for the birth and spread of epidemics," an editorial in Le Palmares asserted.(17).

It is not known where the Ebola virus is naturally found, but some think it may be in the rainforests in central Africa, near the origins of the HIV. It is believed that there is an animal reservoir, but it is undetected.(18) In fact, these diseases are believed to be very ancient, but have attacked man as man has effected their natural habitat. (19)

It is not known what the natural reservoir for this virus is, how human epidemics start, and why they are so rare.(20) It seems that this virus is a response to deforestation and other man made influences on, and intrusions into, the environment. These influences (which change the environment) may often be for trade and commerce and other reasons. In order to reach trees which to cut and use commercially, loggers have made roads into the forests which now provide easier access to hunters who capture a variety of things which may have been off limits before. In fact, there are beliefs that the eating of bushmeat recovered from these forests are the cause of an outbreak of Ebola in Zaire in 1994. (It might not be surprising if hunters catch the virus because they are very exposed to the blood of the animals which they kill.) Karl Ammann, a Kenya-based photographer and environmental activist, who works with the World Society for the Protection of Animals, has affirmed that he has "seen hunters up to their elbows in blood." The chimp carcasses, after they have been dried, are then shipped to cities like Kikwit, where there have been cases of the Ebola epidemic.(21) There are traces of evidence here which are possible clues to where the virus lives in nature. There is speculation that forest -- dwelling bats are the home for the Ebola virus in Zaire.

The breakdown of these forests and of the resilience and resistance of ecosystems, are a reason for the spread of emerging diseases such as Ebola. Dr. Paul Epstein, calls this reaction a result of "the destruction of nature's defense mechanisms."(22) Further destruction by pesticide spraying can kill owls, wolves, snakes, birds, or lions which prey on pests that may carry Ebola. (This destruction is often done for economic gain. If the government helped provide alternative sources of economic gain, there possibly may be less need to encroach on these forests, and/or jungles.) Therefore, these pests affected (rats, mice, mosquitos, bacteria, etc. -- all potential vectors for the transmission of deadly viruses), increase. Dams and irrigation may also invade the environment, for instance, by wiping away the habitat of animals which prey on pests.

Modern transportation may also cause the spread of the Ebola virus to places it has not been before. For instance, the Ebola virus has shown up in Reston, Virginia, in Texas, the Philippines, Germany, the Ivory Coast, and Sudan, although the Ebola virus is indigenous to Africa. The Ebola virus that was found in Reston, Virginia, resided in monkeys originating from the Philippines.

The Ebola virus may be spread by people as they travel from one place to another, although it is very difficult to know this is being done. It is also highly unlikely, because, if a person does not have any of the symptoms, it is very difficult for the airport to detect the existence of the virus. It has been obvious that other diseases have spread through migration of people. "John Snow wrote in 1849: Epidemics of cholera follow major routes of commerce. The disease always appears first at seaports when extending into islands or continents."(23) It is necessary to be on the outlook for the possible spread of Ebola in this way. Also, because we do not know where the virus resides, we will not know if it is spread through airlines or any other form of transportation.

Ebola and trade

Trade can be increased in medical supplies that address Ebola, especially when Ebola is found, but also in those areas where the virus has hit in the past, so they may be prepared to react quickly and sufficiently to this virus if it arises in the future. Often the area in which Ebola shows up is poor and unable to purchase supplies let alone provide the sanitary conditions which are so desperately needed.

Other valuable forms of trade are to provide sufficient food and proper nutrition to people which might come in contact with the disease. A very real difference in situations of the Ebola Reston found in Reston, Virginia, and the Ebola Zaire found in Zaire, was that the people had adequate nutrition in Reston, but did not in Zaire.

Ebola would be a monstrous biochemical weapon, and, given that other viruses have been turned into lethal weapons, it may very well be that Ebola has been considered for use as a weapon. Laurie Garrett, in her book The Coming Plague, states that the Lassa virus had been shared with the Soviet Union, and there was fear that they might be developing this as a biological weapon.(24)

In the past, other diseases have been spread through organisms in the water in the bottom of ships which carry goods from one continent to another (for instance, Asia to North America). Another example is yellow fever. Yellow fever traveled with the slave trade through mosquitoes who had the virus and laid eggs on water barrels carried by the slave ships.(25) As in cases of other diseases, we could be spreading this virus in some unknown way through trade. This gives all the more reason to study the virus and find evidence of how this might happen.

A very real effect of the Ebola virus on trade is the import of monkeys for medical experiments in Japan has been curbed by at least three major airlines. Japan Airlines and All Nippon Airways, Japan's two major international carriers, in 1990 agreed to stop importing certain species of monkeys as protection from exposure to the disease. These types of monkeys were the rhesus, cynomolgus and African green monkeys from Africa and South-East Asia. A third major airline which has decided to follow this practice is Korean Airlines. As a result, there is only one major airline transporting monkeys to Japan.

This has visibly effected the price of research monkeys in Japan. For instance, in 1991, a cynomolgus monkey cost one hundred and fifty thousand yen in Japan (the equivalent then of US$1,500), and now costs nearly three times as much.(26) As a counter argument, researchers have asserted that monkeys grown in the wild are certainly much more likely to carry a virus like Ebola than monkeys which are grown in sanitary environments on which to do research. The researchers, as recourse, encouraged the government to study this industry more closely in order to potentially increase the supply of research monkeys and improve the safety standards.(27)

The airlines have decided to stop importing these monkeys into Japan after the scare of spreading the virus. This fear may be increased if more cases of the disease are found and it may reach extremely irrational proportions. For instance, in the movie Outbreak, there was consideration of bombing the infected area. Although studying the disease may be a better response to the presence of the disease, the disease may be so terrifying that extreme measures are, or will be, taken to deal with it.

The Ebola virus and the decision not to import the rhesus, cynomolgus and African Green monkeys into Japan not only directly effects trade in that there is less trade in these monkeys, but possibly indirectly effects trade in that helpful research is not being done and new products are not being made and traded because of the lack of monkeys. It has been speculated that medical advances are not being made because there are no monkeys to experiment on and with which to find cures and make progress in medicine. For instance, Japanese scientists have asserted that lack of monkeys has effected their research on HIV vaccines and vectors for gene therapy.(28)

The health ministry in Japan has notified the public that there may be risk of a disease residing in monkeys imported as pets. An example of trade in monkeys leading to importing a disease, although a different disease, is the still horrifying result of an import of one monkey. The result was that the pet shop owner who imported a monkey caught dysentery and later the monkey died of unknown causes. An official in Japan has said that there may be research into the import of diseased animals and the need to do biomedical research, and this may address the issue of the dearth of monkeys being imported because of the fear of the Ebola disease.(29)

A relevant quote from Mary E. Wilson, from the British Medical Journal is, "There is an urgent need to integrate knowledge about infectious diseases with knowledge of climate and environmental change, migration and population growth, demography, and the consequences of conflict;" and another relevant quote is: "a rise in infectious diseases is only one of the manifestations of global instability. Any meaningful response must integrate knowledge from multiple disciplines and approach the problem at the systems level. To be successful, we must apprehend infectious diseases in their evolutionary and ecological context."(30)

3. Related Cases

PRIMATE
AFRICA
AFRDOG
MALARIA
EUMEAT
HOOF

Key words 

(1): Trade Product = EBOLA
(2): Bio-geography = TROPICAL
(3): Environmental Problem = HABITAT LOSS

4. Draft Author: Angela Joy Moss (April 30, 1997)

II. Legal Clusters

5. Discourse and Status: AGReement and ALLEGEgation

Opposition commentators and independent journalists have also blamed corruption and mismanagement for the lack of resources to deal with the epidemic. Corruption is so pervasive in Zairian society and government that "even quarantine measures announced to keep the Ebola virus from the capital of five million people are being undermined by bribery," Kinshasa city officials have asserted.(31)

6. Forum and Scope: WHO and MULTIlateral

When the WHO and CDC are notified of a case of Ebola, they immediately send medical teams to the site of outbreak in order to investigate and control the disease.

7. Decision Breadth: Many

There are many countries (parties) affected by Ebola. The countries most relevant are those in which the disease has shown up. The countries where we know that the disease has shown up include Zaire, Sudan, Germany and Italy, the Ivory Coast, the Philippines, and the US (in particular, Virginia and Texas). At times the disease has shown up in experimental monkeys in these places.

8. Legal Standing: Law

III. Geographic Clusters

9. Geographic Locations

a. Geographic Domain: Africa

b. Geographic Site: Southern Africa

c. Geographic Impact: Zaire Various forms of trade are affected by Ebola. For instance, trade in the service of tourism is affected by the existence of Ebola in probable tourist destinations (in particular, in Zaire). Second, sending medical workers and other experts to the site of the disease in order to address it, could be termed "trade" in medical workers. Third, there is a ban on the import of monkeys into Japan by three airlines. Fourth, we may otherwise be unknowingly spreading the disease through trade. These four forms of trade are linked to the environment in that they are affected by Ebola, the existence of which may be due to human mishandling of the environment.

10. Sub-National Factors: No

11. Type of Habitat: TROPICAL

IV. Trade Clusters

12. Type of Measure: Import ban [IMBAN]

As a safety precaution, beginning in April, 1990, the cargo section of Japan Airlines does not carry Rhesus Monkeys into the US because of the threat of Ebola.

13. Direct v. Indirect Impacts: DIRect and INDirect

14. Relation of Trade Measure to Environmental Impact

a. Directly Related to Product: NO

b. Indirectly Related to Product: YES EBOLA

c. Not Related to Product: NO

d. Related to Process: YES HABITAT LOSS

15. Trade Product Identification: Many

The trade "products" involved are monkeys, the Ebola disease itself (both for research and possibly, although hopefully not, a biochemical weapon), medical workers who respond, and affected tourists. Indirectly trade in medical, sanitary and water supplies may be involved through the increase in their trade in order to treat the Ebola Disease.

16. Economic Data

The economic areas involved in this case include revenue lost through deaths of people who might have been able to work and therefore benefit their country's economy, especially in Zaire and Sudan. For instance, in Zaire a number of health workers have died from Ebola, health workers whose work was helpful for the economy, maybe by medically caring for other laborers in the Zairian economy. The Ebola which claimed these lives, therefore, made an impact on the Zairian economy, although the exact dollar effect is not known.

These events have also greatly increased the price of monkeys who are imported. For instance, five years ago, a cynomolgus monkey was 150,000 yen, (or $1500), but now is three times this amount.(32)

17. Impact of Trade Restriction: Low

18. Industry Sector: TOURism and Many

19. Exporters and Importers: Zaire and Many

V. Environment Clusters

20. Environmental Problem Type: Habitat [HABIT]

This case possibly involves deforestation [DEFOR] and bio- diversity loss [BIODIV] as well (both are under Habitat). The case may also involve land loss [SPLL] (under species loss). Environmental degradation is less of a problem in Zaire than elsewhere in sub-Saharan Africa.

In the early 1990s, when 86% of Zaire's forests were still in existence, it was projected Zaire's forests would be increasingly at risk, in light of contracts signed with foreign logging corporations. At that time, 37% of total exploitable area of Zaire's rain forest had been designated as timber concessions.

The most intense logging has been in the Bas-Zaire region, in the hinterlands of Kinshasa, the capital. Forest ecology has been disrupted by logging. Not just this, but the roads made for logging have allowed poor farmers to immigrate into the forest, who then clear and burn the forest for fields. It was reported in 1993 that "there was virtually no primary forest left in Bas-Zaire."(33) Forest destruction may have played a role in humans contracting Ebola because humans have exposed the disease which may have been largely hidden in the forest before. It is believed that this virus is relatively new, resulting from the increased stress that humans have put on the environment, particularly the jungles which are believed to carry the virus. It is unlikely, but it may be that the Ebola disease has been around for a long time, but simply was never reported. Also, Zaire is warm and has heavy rainfall and it is in this climate that hemorrhagic fevers, of which Ebola is one, flourish.(34)

21. Name, Type, and Diversity of Species

Name: Ebola

Type: Virus

Diversity: Many (Ebola Zaire, Ebola Sudan, Ebola Reston)

22. Resource Impact and Effect: HIGH and PRODuct

23. Urgency of Problem: HIGH and Unknown

We do not know where this virus exists naturally, and therefore we do not know its lifetime, although we know that in humans, it usually is deadly, and therefore, in humans, the lifetime of the virus would be from near the time symptoms appear in the human to the time the human dies, often 2-21 days. (In Zaire, the expectation of life at birth for males is 50.40 years and for females is 53.66 years. (35)

24. Substitutes: Conservation [CONSV]

Based on our current knowledge of the disease, conservation of the environment, and in particular, the jungles from which the virus is thought to originate, and preservation of these jungles' biodiversity, is the best way to guard against outbreak of the disease.

VI. Other Factors

25. Culture: YES

The rain-forest zone of Zaire is characterized by small-scale, segmentary societies. These societies are defined as societies which are divided into a number of units (i.e., lineage or clan groups), which were most widely distributed throughout the north and south of the great bend in the Congo River. Most of the peoples of the rain-forest were organized into village-like communities, led by chiefs or dominant clans or lineages.(36)

26. Trans-Boundary Issues: YES

27. Rights: NO

28. Relevant Literature

(1)Cowley et. al., "Outbreak of Fear," Newsweek (May 22, 1995), 55.

(2)"Update: management of patients with suspected viral hemorrhagic
fever-United States," Morbidity and Mortality Weekly Report Vol.
44, No. 25 (June 30, 1995): 475.

(3)"Ebola virus and other viral hemorrhagic fevers (VHFs),"
http://www.doveassoc.com/traveling_healthy/julaug96/ebola_vhfs.ht
ml

(4)Center for Disease Control Ebola Hotline 1-800-311-3435

(5)Klenk, Hans, Werner Slenczka and Heinz Feldman, "Marburg and
Ebola Viruses," http://www.bocklabs.wisc.edu/eov.ebola.html

(6)Cowley, et. al., 52.

(7)Highfield, Roger, "Plague worse than Aids turns bodies to
water," The Daily Telegraph (May 11, 1995), 13.

(8)Begley, Sharon and Alden Cohen, Christopher Dickey, and Dana
Lewis, "Commandos of Viral Combat," Newsweek (May 22, 1995), 50.

(9)Ibid.
 
(10)Ibid.
                  
(11)MacPherson, Peter, "They're back...; job security; infectious
disease specialists," Hospitals & Health Networks (November 5,
1995), 50.

(12)Chiahemen, John, "Virus refocuses world attention on Zaire,"
Reuters North American Wire (May 14, 1995) n.p. (no page).

(13)Cowley, et. al., 50.

(14)Highfield, Roger, "Plague worse than Aids turns bodies to
water," The Daily Telegraph (May 11, 1995), 13.

(15)"Transcript of White House Press Briefing by McCurry, Kristoff,
Lord," U.S. Newswire (April 17, 1996).

(16)Wilson, Mary E., "Infectious diseases: an ecological
perspective," British Medical Journal (December 23, 1995), 1681.

(17)Chiahemen, n.p.

(18)"Ebola."

(19)Highfield, 13.

(20)Cowley, et. al., 51.

(21)Crittenden, Jules.  "Why killer epidemics are on rise
worldwide."  The Boston Herald (May 28, 1995), 1.

(22)ibid. 

(23)Wilson, 1681.

(24)Garrett, Laurie, "N'zara: Lassa, Ebola, and the Developing
World's Economic and Social Policies," in The Coming Plague: Newly
Emerging Diseases in a World Out of Balance (New York: Farrar,
Straus and Giroux): 193-4.

(25)Highfield, 13.

(26)Nathan, Richard, "Ebola bar creates monkey shortage," Nature
Vol. 382 (August 29, 1996): 744.

(27)ibid.

(28)ibid.

(29)ibid.

(30)Wilson, 1681.
 
(31)Chiahemen, n.p.

(32)Nathan, 744.

(33)Meditz, 69.

(34)Gourou, 1039.

(35)Demographic Yearbook: 1994.  (New York: United Nations, 1996),
138.

(36)Meditz, 5-6.

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