The Island of Porto Rico is more free from disease than the average tropical or semi-tropical country, due to the active efforts of the medical profession and of the special commissions and departments created for the elimination of disease within the last few years. Nevertheless, a great deal of sickness which might be avoided, part of which is responsible for death, and part of which merely incapacitates the sufferers or renders them less useful citizens, is to be found. The elimination of such diseases as smallpox and yellow fever, which formerly were responsible for a great number of deaths and which descended upon the Island as epidemics with considerable regularity, has been accomplished, and if similar care were taken in the case of less dreaded diseases, there is reason to believe that they could also be wiped out of existence in the Island.

For the year 1915-16 there was a total of 26,572 deaths in Porto Rico. Most of these deaths were from diseases classified as transmissible, and, consequently, from diseases which could be prevented by complete quarantine. Following is a list of the number of deaths from the diseases which took the heaviest toll in the Island:

The two diseases which are of most vital importance to the people of Porto Rico at present are undoubtedly tuberculosis and anemia. The ravages of tuberculosis are more noticeable in the cities, and it has been stated that in 1912, on one street in San Juan, 12 out of every 100 residents died of this disease. Anemia is prevalent throughout the Island, but is more noticeable in the country districts than in the cities, and while the death rate for anemia is not so high as the death rate of some other diseases, yet by reason of weakening the vitality of the sufferers it tends to offer a fertile spot for the incubation of germs of other diseases, and the working and producing power of the individual is lessened with the acuteness of the disease.

It has been claimed that anemia was introduced into Porto Rico by the negroes who were brought here as slaves in the sixteenth and seventeenth centuries, and the identity of the disease with the anemia existing in about 20 per cent of all the negroes of the Gold Coast has been determined. The disease was for a long time limited to the coast land and was propagated on the sugar plantations, but after the introduction of coffee, which has come to be the chief product of the mountain regions, the disease was propagated throughout the entire Island.

This disease has left its trace among the country people and they have been accused of laziness and idleness when it is probable that the cause of the apparent disinclination for work is due to the weakened physical condition which is a result of the anemia. In this connection, Drs. Gutierrez and Ashford in their work on Uncinariasis in Porto Rico quote Col. George D. Flinter, an Englishman in the service of Spain, who published in 1834 "An account of Porto Rico," as follows:

"The common white people, or lowest class (called jÍbaros), swing in their hammocks all day long, smoking cigars and scraping their native guitars.... Most of these colonists are inconceivably lazy and indifferent. Lying back in their hammocks, the entire day is passed praying or smoking. Their children, isolated from the cities, without education, live in social equality with the young negroes of both sexes, acquiring perverted customs, only to later become cruel with their slaves."

Commenting on this statement, Drs. Gutierrez and Ashford speak as follows:

"What if these people were merely innocent victims of a disease, modern only in name? What if the brand placed by the Spaniard, the Englishman, and the Frenchman in olden times upon the jÍbaro of Porto Rico were a bitter injustice? The early reports savor strongly of those touristic impressions of the Island which from time to time crop out in the press of modern America, in which 'laziness and worthlessness' of the 'natives' are to be inferred, if, indeed, these very words are not employed to describe a sick workingman, with only half of the blood he should have in his body."

"True, Col. Flinter, Field Marshall Count O'Reilly, and the rest of the long list of early 'observers' did not know what uncinariasis was. But is it necessary that we have a record of microscopic examinations of the feces of the people they describe to realize what can be read between the lines? Convicts, adventurers, and gypsies may have formed part of the element that colonized Porto Rico, but we cannot believe that these were all, nor that their descendants were 'lazy' and 'worthless.'

"We cannot believe that vicious idleness comes natural to the Spanish colonist, even in the Tropics, for the very reason that we have seen these descendants at their very worst, after the neglect of four centuries by their mother country, and after the laborious increase of an anemic population in the face of a deadly disease, whose nature was neither known nor studied, work from sunrise to sunset and seek medical attention, not because they felt sick, but because they could no longer work.

"We strongly feel that these writers have unconsciously described uncinariasis. Are the Spanish people considered 'lazy' by those who know them? Were those Spaniards who conquered Mexico, Peru, and all South America, who formed so formidable a power in the Middle Ages, a lazy people?

"Is it 'laziness' or disease that is this very day attracting the attention of the United States to the descendant of the pure-blooded English stock in the Southern Appalachian Range, in the mountains of Carolina and Tennessee, the section of our country where the greatest predominance of 'pure American blood' occurs, despised by the negro who calls him 'poor white trash'?"

During the year 1914-15 there were 6,644 deaths of children under two years of age, which constituted 28.8 per cent of the total mortality of the Island. Approximately 14 out of every 100 children born, died in infancy, and the death rate for the total population was 5.55 per cent for children under one year of age, and 7.71 per cent for children under two years of age. Diarrhea and enteritis were responsible for 33.8 per cent of infant mortality; congenital debility for 13.14 per cent; infantile tetanus for 10.32; while disease of the respiratory organs caused 16.17 per cent of the infant mortality.

It has never been definitely determined just what losses, from the point of view of days of labor, or from the point of view of vitality of the laborer, have been caused by malaria. Mr. D. L. Van Dine, in an article in the Southern Medical Journal for March, 1915, gives the result of some of his investigations among the laboring class in Louisiana. In this study, which was made on one of the large plantations and which covered 74 tenant families with a total of 299 individuals, he shows the losses which occurred from May to October 15, 1914. There were 970 days of actual illness of such a nature that the illness was reported to the physician. Forty-eight out of the seventy-four families were reported to the doctor for malaria. According to Mr. Van Dine, this does not take into consideration mild attacks of malaria which were not reported to the physician, especially in the cases of children. He has estimated that there were at least 487 days lost in cases which were not reported to the doctor. He also estimates that there was a loss of 385 days on the part of the adults who assisted in caring for the malaria patients. It is estimated that there was a loss in days of labor equal to nearly six days and a half for each case of malaria. It will easily be seen that this may be a serious loss of time as far as the production of crops is concerned, and even thus it does not fairly represent the loss, as it does not take into consideration the weakened energy of the man just before or just after the malarial attack.

Undoubtedly, there is as great a loss in Porto Rico from malaria as is indicated in the statements just made. It has been reported that in some sections of the Island, 85 per cent of the people were found to have malaria germs in their blood. Between the two diseases of malaria and anemia, there is no doubt that the physical condition of the Porto Rican countrymen is gradually debilitated.

Since the American occupation, stress has been laid upon the attempts to eliminate anemia, and this work has received special attention since 1906. During the year 1914-15 there were 32,278 new cases of anemia treated in different parts of the Island, and 15,497 cases were discharged as cured.

Undoubtedly a great deal of the illness in Porto Rico is the result of improper food, or food prepared in an improper manner. Malnutrition among children is frequent and leads to such diseases as rickets, which we find has an exceptionally high death rate. In the recent measurements given at the University among university students, it has been found that there was an average depth of chest of nearly half an inch more than is found in the American boy or girl of the same age, and this has been considered as an indication of malnutrition and general softening of the bones in early childhood.

A hemoglobin test which was given to the students of the University this year showed that the average among the men was 80.04 per cent, and only 77.6 per cent among the women. The average for Porto Rico should not fall below 85 per cent, and the anemic conditions indicated by the low average is an indication that the disease is to be found not only among the country people, but also among people of the best conditions of life.

It will be impossible to settle the economic and social problems of Porto Rico until the question of personal health has been more nearly solved than it is to-day. With a large proportion of the country people sick from anemia and malaria, and with tuberculosis as prevalent as it is at the present time, the weakened vitality will not permit strenuous or continued work sufficient to improve economic conditions to any great extent. Social conditions, depending as they do upon the economic situation, must also be slow of improvement, and the most important work facing the Government of Porto Rico at present is the elimination of such diseases as impair the physical condition of the people and thus interfere with economic and social progress.