82 



sections in which it is really prevalent it is easily the most im- 

 poTtant sanitary problem we have there. It stands first on the 

 list for the injury it does the community. 



It does not give the highest, or even a high mortality. 

 Tuberculosis, pneumonia and typhoid run well above it. But 

 is recorded mortality an accurate measure of the comparative 

 injury done by disease? If so, tonsilitis and Rigg's disease 

 would do no harm at all. One of our southern health officers 

 says, ''We must direct our work against that group of diseases 

 which gives the heaviest mortality, because the reduction of 

 mortality is, in the last analysis, the measure O'f our success." 

 I count him wrong in his criterion of success, doubly wrong if 

 he understood "mortality" to be the same as "recorded mor- 

 tality." The recorded mortality of a disease frequently does 

 not indicate its true influence on the death rate. This is emi- 

 nently true of malaria. From its effects, direct and economic, 

 in lowering the general vitality of a community, it is a causal 

 factor in many a death in which it is not a terminal factor, the 

 one recorded as the "cause of death." Mortuary statistics do 

 not then give the proper weight of this disease as a cause of 

 death. 



It is not in its mortality, however, that the gravest injury 

 of malaria lies. It is in its morbidity; in the loss of efficiency 

 it causes rather than in the loss of life. One death from 

 pneumonia should correspond to about 125 sick days — days not 

 working; one of typhoid fever, 450 to 6001; one of tubercu- 

 losis to^ somewhat more among whites, decidedly less among 

 negroes. A death from malaria, however, corresponds to from 

 2,000 to 4,000 sick days. This loss of efficiency may really be 

 doubled or tripled, as the man infected with malaria is fre- 

 quently half sick all "the time. 



It is the extent of malaria when it is bad, the number of 

 people attacked as compared with other diseases, which appals. 

 If there is one per cent, of typhoid, it is an epidemic and a bad 

 one. Forty per cent, to 601 per cent, of a population per annum 

 is not uncommon for malaria, and I have seen outbreaks with 

 90 per cent. The injury to efficiency caused by malaria in the 



