12 
MAT.ARTA 
portance of malaria differed widely in the 
respective countries and that some rela¬ 
tively uniform method of evaluating data 
had to be provided. To this end a question¬ 
naire was addressed in February, 1940, to 
the chief of the public health service of each 
country in an attempt to obtain as much 
concrete information as possible. 
In several countries the desired informa¬ 
tion was not obtainable or only partially 
available. On the other hand, the reports 
obtained from some officials were fairly 
complete and bear evidence of relative accu¬ 
racy and reliability. In only three in¬ 
stances have repeated requests been ignored. 
It must be frankly stated, however, that 
much of this information is not wholly de¬ 
pendable, because it is based on clinical 
rather than survey records and is neither 
completely accurate nor representative. 
The most essential data are summarized 
by countries in Table I, while the average 
mortality rates are shown by countries and, 
wherever possible, by major political or geo¬ 
graphical subdivisions on the accompanying 
map (Fig. 3). 
With the probable exception of the Ba¬ 
hama Islands, malaria is endemic through¬ 
out the entire area covered in this portion 
of the report. In the highlands and essen¬ 
tially dry areas, the disease is usually much 
less intense than it is along the swampy 
coastal areas and in the tropical rain-for¬ 
ests. Nevertheless, highland malaria con¬ 
stitutes an important problem in parts of 
Mexico and Central America. Official gov¬ 
ernment reports indicate that the most 
highly malarious territory on the mainland 
begins in Southern Mexico and, with few 
interruptions, extends through Panama. 
The only comparably malarious countries 
of the West Indies are Haiti, Republica 
Dominicana, portions of Puerto Rico, St. 
Lucia and Trinidad. 
The range in malaria mortality in coun¬ 
tries with important political subdivisions 
may be very wide, as is seen when the rates 
for these subdivisions are compared with 
the averages of the country as a Vriiole 
(Table I, Fig. 3). Thus, the official figures 
indicate that Mexico has an average rate of 
140.7, although the Distrito Federal is 
stated to have the low rate of 6.16, Michoa- 
can, 9.43 and Chihuahua, 12.55. In con¬ 
trast, the rate for Tabasco is reported to be 
502.29 and that for Oaxaca, 563.02. Guate¬ 
mala, for which there is the official average 
rate of 414, has reported department rates 
ranging from 125 to 1671. Costa Rica, with 
an average rate of 152, has department 
rates ranging from 25 to 348. Cuba, with 
an average rate of 20.6, has a range from 
3.2 (Habana) to 88.5 (Camaguey). 
Attention is directed to the relatively low 
ratio of recorded morbidity rates compared 
with the mortality rates. This is explained 
by some reporting government officials as 
due to the extensive distribution of anti- 
malarials by local dispensaries. However, 
in only three of the countries surveyed— 
Nicaragua, Puerto Rico and the Virgin 
Islands (U. S. A.)—is malaria a reportable 
disease. With the exception of Guatemala, 
Jamaica, Puerto Rico, the Virgin Islands 
and possibly Nicaragua, routine diagnosis 
is based primarily on scanty clinical his¬ 
tories and on therapeutic tests, since many 
of the physicians and practicantes either 
have no immediate access to diagnostic labo¬ 
ratories or do not avail themselves of exist¬ 
ing services. Thus, it is highly probable 
that only a small percentage of malaria 
cases is included in the official figures. 
The computed average malaria mortality 
rate for all of the tropical countries con¬ 
sidered in this paper (with a reported popu¬ 
lation of 38,500,000) is 166 per 100,000 
population, a figure probably far too low. 
This means that approximately 63,900 
deaths in this area are caused each year by 
malaria and contrasts conspicuously with 
the average of 3,258 deaths (1933-1939) for 
the Southern United States, which has ap¬ 
proximately the same size population group 
(i.e.j a ratio of nearly 20 to 1). 
In several of the reporting countries ex¬ 
tensive malaria surveys have been con¬ 
ducted in recent years or are being carried 
out by health departments, at times in col¬ 
laboration with staff members of the Inter¬ 
national Health Division of the Rockefeller 
Foundation, and in Panama with the added 
