Anemia in Puerto Rico at the Turn of the Twentieth Century | Ana Rita Gonzalez, ScD, and Elizabeth Fee, PhD

AT THE BEGINNING OF THE twentieth century, anemia was the principal cause of death in Puerto Rico. At that time, the disease was understood to be a rural health problem—whereas the mortality rate was 1 in 1000 people in the urbanized, coastal area of Ponce, it was 32 in 1000 in Adjuntas, a coffee-farming mountainous region.1 The Sanitation Board in Puerto Rico attributed the disease to malnutrition, malaria, and climate, but made no effort to address this public health problem.2 In 1898, Lieutenant Bailey K. Ashford arrived in Puerto Rico with the United States army. He was a physician who would devote his career to studying hookworm and hookworm disease, the leading cause of anemia.3 Upon his arrival, he began visiting towns in the island’s interior to study anemia, albeit without official support from the American government.4(p56) In 1899 he concluded that hookworm was caused by an intestinal parasite (Ancylostoma duodenale) that entered the body

Top: Entrance to dispensary, 1905. Right: Dr. Bailey K. Ashford.

through the feet when they came in contact with feces-laden soil. The American government refused to fund the building of sewage systems outside of San Juan, despite the fact that problems with sewage disposal had serious implications for many bacterial and parasitic diseases, including hookworm and the resulting anemia.4(p60) Ashford and a group of Puerto Rican physicians argued the need to put anemia on the public agenda, as it weakened the immune system (especially when coupled with tuberculosis and malaria) and diminished productivity. The results of Ashford’s study, when published in 1900, caused an uproar among US authorities as they believed that anemia in the Puerto Rican population was due to insufficient meat consumption. This controversy brought to light the need to establish priorities and to define the health problems in the Puerto Rican population. Health issues were now no longer seen as in the military domain—as they had been in the past—but

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rather issues for the government. The Puerto Rico Sanitation Board now became part of the Department of the Interior, with civilian health care part of its responsibility. In 1902, the newly established Puerto Rican Medical Association gave Ashford and his team a grant to establish health care clinics in the island’s interior. Ashford created an Anemia Commission in 1904 to diagnose, conduct research, and treat anemia. This was the first governmental effort to develop regionalized health services and to use laboratory diagnosis for any disease. When Ashford left Puerto Rico in 1906, the Puerto Rican legislature dissolved the existing Anemia Commission and created a more permanent body, the Second Anemia Commission. By 1907, 33 anemia control centers had been established across the island to test patients for the parasite, A. duodenale. At the same time, latrines were constructed to provide the needed sanitary control, resulting

in a very significant decline in both hookworm and anemia.5 This success laid the basis for hookworm control programs in many other countries.

About the Authors Ana Rita Gonzalez is with Policy Wisdom LLC, Miami, FL. Elizabeth Fee is with the National Library of Medicine, National Institutes of Health, Bethesda, MD. Correspondence should be sent to Ana Rita Gonzalez, 9981 SW 143rd St., Miami, FL 33176 (e-mail: [email protected] policywisdom.com) or Elizabeth Fee, Chief Historian, National Library of Medicine, 1W15, National Institutes of Health, 8600 Rockville Pike, Bethesda, MD 20894 (e-mail: [email protected]). Reprints can be ordered by clicking the “Reprints” link at http://www.ajph.org. This article was accepted on July 14, 2014. doi:10.2105/AJPH.2014.302225.

Contributors A. R. Gonzalez conducted the research and drafted the article. E. Fee advised and assisted with the editing. Both authors contributed to the image selection.

American Journal of Public Health | February 2015, Vol 105, No. 2


1. Puerto Rico First Annual Report of Health, 1900–1901. San Juan, Puerto Rico: Puertic Rico; 1901: 126.

proceso de Americanizacion. In: Silvestrini BG, ed. Politics, Society and Culture in the Caribbean. San Juan, Puerto Rico: Universidad de Puerto Rico; 1983.

USAID; 2010. Available at: http:// www.neglecteddiseases.gov/target_ diseases/soil_transmitted_helminthiasis/ hookworm.

2. Silvestrini BG. La politica de salud pública de los Estados Unidos en Puerto Rico, 1898–1913: consecuencias en el

3. United States Agency for International Development. Neglected Tropical Diseases Program. Washington, DC:

4. Ashford BK. A Soldier in Silence. An Autobiography. New York, NY: Morton and Co; 1934.


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5. Rivera de Morales N. Mortalidad en Puerto Rico: 1888–1967. Puerto Rico: Seccion de Bioestadisticas, Escuela de Salud Pública, Rio Piedras; Junio 1970:8.

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Anemia in Puerto Rico at the turn of the twentieth century.

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