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THE TUBERCULOSIS PROBLEM IN PUERTO RICO

      In Puerto Rico, tuberculosis stands unrivalled as Public Enemy Number One. It causes nearly one-half of all deaths of persons between nineteen and thirty-five years of age. Because it is responsible for widespread disability and loss of life among young parents and breadwinners, it constitutes an economic as well as a public health problem.
      After twenty years of steadily increasing tuberculosis mortality, the rate in 1933 reached 337, one of the highest in the civilized world; and it seemed that the disease was becoming epidemic. The alarmed Public Health authorities launched an intensive campaign against it, and in 1934 tripled the number of beds for open cases, bringing the total to 1,500. This number was still extremely inadequate, since our average of more than 5,000 tuberculosis deaths annually called for more than 10,000 beds, according to the standards of the National Tuberculosis Association.
      The urgent need was then, and is now, isolation of open cases. In the homes isolation is impossible. Puerto Rico is an agricultural country, densely populated and poverty stricken. Most of the inhabitants live in slums where huts are crowded together, families are crowded within the huts, sanitary facilities are meager in the extreme, and everything favors the spread of contagious diseases. Without hospital beds it is foolish to preach isolation, when, in the home, five or six persons, including the patient, must of necessity live in one small room.
      In the hope of controlling spread of tuberculosis from the open cases who could not be isolated, the next step undertaken was the application of artificial pneumothorax to ambulant patients. Simultaneously, the early diagnosis campaign was greatly intensified, especially through the examination of contacts of open cases. The first pneumothorax dispensaries were opened in 1935. By the end of the fourth year nearly 2,000 patients were receiving pneumothorax while living at home. Also, 147,000 persons had been examined for tuberculosis in Health Department Clinics.
      For the first time since reliable statistics were available, the mortality curve started on a sustained downward course, and in six years after the beginning of the campaign, the mortality rate dropped twenty per cent.
      It is disheartening to report, however, that after such an effort our tuberculosis death rate in Puerto Rico is still 245 (in 1941), five and one-half times the rate in continental United States. Pneumothorax can control a certain number of open cases, but the majority remain a public health menace unless hospitalized.
      Were we to provide the required number of beds, the cost for the first five years would run into some fifty millions of dollars—an impossible undertaking, considering our limited means and other pressing needs of the island. Our only hope is to obtain Federal aid. The Puerto Rico Chapter of the American College of Chest Physicians has made an appeal for such help to Senator Dennis Chavez, president of a Congressional Committee recently sent to the island to investigate social and economic conditions. We hope that this plea will be effective.
      Even in the midst of a desperate struggle for the survival of democracy, we cannot help but think that the tuberculosis problem of Puerto Rico could be solved with less cost than building one battleship. Perhaps it is a sinful thought at this moment, since the objectives of the war are so much more desirable than life; but it is a good thought to keep in mind until after the war, when human needs will have a new perspective and human values will rise to higher levels.