The Twentieth Century

The twentieth century has been a time of a tremen­dous mortality decline in the Caribbean as it has in much of the rest of the underdeveloped world. Im­proved nutrition, great strides in public health and sanitation, and the increasing sophistication of mod­em medicine have all played significant roles.

Yellow fever’s Caribbean career came to a close during the occupation of Cuba by the United States when the theory of Cuban physician Carlos Finlay that the disease was mosquito-borne was proved cor­rect by a Yellow Fever Commission headed by Wal­ter Reed. Ensuing mosquito control measures were successful in throttling the long-dreaded malady in Cuba, and, armed with this new epidemiological un­derstanding of the disease, William Gorgas was able to eliminate yellow fever in Panama where the canal was under construction. The disease flared up one last time in Cuba in 1905 but, after that, retreated from the whole of the Caribbean.

The public health activities of the U.S. Army also brought sweeping sanitary reforms to Cuba, which in Havana resulted in a decrease of “close to 30 percent in the crude death rate in that city by 1902” (Diaz-Briquets 1983). Similarly the annexation of Puerto Rico, and the occupation of the Dominican Republic and Haiti by the United States, although deplorable, nonetheless brought important health benefits to these countries in the form of cleaner water supplies, adequate sewage disposal systems, mosquito control, and medical treatment.

Just at the time when one African disease, yellow fever, was conquered, however, another African mal­ady was revealed. In Puerto Rico, the Puerto Rico Anemia Commission discovered a hookworm prob­lem estimated to be causing one third of all deaths on the island. War was declared on this disease, as well as on malaria and yaws, in much of the Carib­bean by the Rockefeller Sanitary Commission and later by the Rockefeller International Health Board.

Tuberculosis receded among Caribbean blacks as mysteriously as it had appeared, and it had ceased to be much of a health problem long before the end of World War II when medicine finally got its “magic bullet” against the malady. Yet the greatest gains in reduced mortality have taken place among the very young. Infant mortality rates, which were as high as 303 per 1,000 live births in Barbados earlier in the century, have plummeted in most places to rates of 20 per 1,000 or below. Exceptions are the Dominican Republic and especially Haiti, where age-old prob­lems of neonatal tetanus, malaria, yaws, and other African diseases still linger.

Less satisfactory have been improvements in the nutrition of the young, and it is quite possible that fully half the deaths that have taken place among the age group 1 to 4 years in Hispaniola and Jamaica in recent years are the result of PEM — the same disease that proved so devastating to the slave young of yesterday. Other problems or potential prob­lems left over from the disease ecology of that period also remain. Yellow fever is still very much alive in its jungle form in the treetops of South America and, with the present lax mosquito control measures, could easily return to the Caribbean as it in fact attempted to do in Trinidad during 1954. Indeed the ever increasing number of dengue epidemics that have taken place of late in the region show just how vulnerable the West Indies are to yellow fever, be­cause the same mosquito spreads both diseases.

Similarly the pockets of falciparum malaria that still exist may also suddenly expand, as happened in Cuba during the 1920s when tens of thousands of Haitian and Jamaican laborers entered the country bringing the illnesses with them.

Filariasis has not been completely eradicated. In fact, the people of Puerto Rico were found to have a surprisingly high rate of infection during a survey in the 1960s. In Barbados, however, where the disease was once notorious, the malady (or at least its most notable symptoms) has become rare. Schistosomiasis may still be found in some of the Lesser Antilles, and small endemic foci have been located in the Domini­can Republic as well, and intestinal parasites remain widespread across the Caribbean region. In addition, another new, seemingly African disease - AIDS - has surfaced in Haiti, although the extent to which this threatens the rest of the Caribbean remains to be seen.

One of the greatest assaults of late mounted on remaining health problems in the region has taken place in Cuba, where the government of Fidel Cas­tro has made improved health a top priority. The extension of health services to the countryside, mass vaccination campaigns, and important ad­vances in sanitation have allowed the Cuban people to attain a life expectancy considerably more favor­able than that enjoyed by those in most other devel­oping nations.

Yet it is ironic that today the greatest threat to the health of West Indian people is their own relatively good health. With the tremendous strides made in reducing infant and child mortality, populations have mushroomed in alarming fashion. In the past, much of the excess population of the region migrated to Great Britain or to the United States; that safety valve has been shut down by the recent restrictions both of these countries have placed on immigration from the islands. And they are islands, which by definition means a limited area of land. If, as is the case in so many of them, land is put into sugar instead of foodstuffs, then the latter must be im­ported. Thus, swelling populations can only threaten the level of their nutrition while placing perhaps impossible pressures on the ability of governments to continue to deliver essential medical and sanitary services.

Kenneth F. Kiple