Sanitation in Panama

by William Crawford Gorgas

It was known in the United States that yellow fever was always brought somewhere from the littoral of either the Gulf of Mexico, or the Caribbean Sea, and the city of Havana, located on the northern coast of the island of Cuba, was known to be the center of this endemic area.

Yellow fever in 1898 was looked upon as the example of a filth disease, par excellence, and it was thought that if Havana were put in a proper state of cleanliness, it might cease to be the great point of infection for the United States. It was known that yellow fever had existed in the city of Havana continuously for one hundred and fifty years. It is interesting to note that the endemic infection of Havana occurred in 1762, when Havana was besieged and captured by American troops. I say American troops, because the expedition was largely composed of men from the present United States, then colonies of Great Britain. It is also interesting to note that this infection was supposed to have been brought by a vessel from Vera Cruz.

Yellow fever peculiarly affects shipping, and time and again ships in the harbor of Havana have had every living soul of their crew die from this disease, and these vessels would have to lie there for months until another crew could be obtained.

When we went to Havana in 1898 we knew no more of the sanitation of yellow fever than we had known a century before. The army which went to Santiago suffered as severely from yellow fever and other tropical diseases as any military expedition into the tropics had suffered before that time, and its death rate, had it remained, would have been just as high as was that of the French army of similar size, which was exterminated in the island of Haiti just one hundred years before.

A very deep impression was made upon me by the condition of our army at the end of two months’ campaigning in this tropical region. It was utterly used up and of no value whatever as a fighting machine. Fully four-fifths of the men were having fever. This small army of sixteen thousand men was as fine a body of soldiers when they landed at Siboney as could probably be gotten together, but after two months’ campaigning in this tropical jungle, and after several weeks of fever from which no one was free, their stamina and morale were completely gone. After the surrender of the Spanish garrison there was a complete let-down on our side. Everybody wanted to go home. No one could see any need of staying in Cuba, and every individual was perfectly certain that he would die if he remained there a month longer. Officers and men became nervous and hysterical. I commanded the base hospital at Siboney, and it was my disagreeable duty to select from day to day those who would have to remain. Many times every day the poor fellows, officers and men, would break down and cry when told that they could not leave on the next ship. I could form some idea of what it must have been among the French at Haiti when they knew that they could not get away, but had to stay and die.

Being immune to yellow fever, I made application to go with the troops that took possession of Havana. We arrived there in December, 1898. The military authorities concluded that this was the opportunity which the United States had been awaiting for the past two hundred years. Thinking that yellow fever was a filth disease, they believed that if we could get Havana clean enough, we could free it from yellow fever. It was felt that if we could eliminate Havana as a focus of infection, the United States would cease to be subject to epidemics. This meant so much to the United States, financially and otherwise, that the authorities determined to make all other efforts secondary to this sanitary effort.

The city was cleaned as well as it was possible to cleanse it. This remark applies as well to the private premises as to the public highways. Energetic and capable Army officers were placed at the head of various municipal departments, and these departments were thoroughly organized and made as efficient as possible. By the middle of the year 1900 all the city governments were perfectly organized, and were accomplishing all that it was possible for them to accomplish. I believe that Havana was cleaner than any other city had ever been up to that time.

The health regulations of the Sanitary Department, such as the isolation and care of yellow-fever patients, were thoroughly and carefully carried out. But in spite of all this work and care, yellow fever had been steadily growing worse ever since we had taken possession of the city, and in 1900 there were a greater number of cases than there had been for several years. The Cubans twitted us with the fact that all our cleaning up and expenditure not only had not bettered things, but had even made them worse. They called attention to the fact that the very cleanest and best kept portions of the city were by far the worst sufferers from yellow fever, and the evidence was so staringly before our eyes that we had to acknowledge the truth of what they said.

The health authorities were at their wits’ end. We evidently could not get rid of Havana as a focus of infection by any method we then knew.

A few years before this period, an Italian savant had announced in Brazil that he had discovered the organism which caused yellow fever. This organism was known as the bacillus icteroides of Sanarelli, and it was quite generally accepted that Sanarelli had proved this to be the causative agent in yellow fever.