Panama: sanitary provisions and local conditions

Even in its name, the Sanitary Department of Panama is a landmark in medical history, and indicates an important change in the official attitude to disease. Hitherto the chief officer of the department which deals with health in a community has been styled a medical officer, and his first duty has been to care for the sick. It is true that he has been expected to have some regard for sanitation, doing as much as he could with the little voted for the purpose. Sanitation has been, however, regarded mainly as a “bottomless abyss” into which money could be poured, usually without much result. That it could be reproductive expenditure has not yet been grasped by most governments. This attitude was in no small way due to the failure of sanitary measures to control many of the most important diseases in the tropics.

It is true, cholera had almost been stopped by good water supplies in many places; but yellow fever and malaria fever defied all efforts of the sanitarian. But the American Government had, already by 1904, grasped the important fact that success in building the Canal depended on the success of the sanitarian in eliminating yellow fever and malaria, etc.; and to emphasise the importance of the preventative work, the department was called the Department of Sanitation.

The experiments which proved that yellow fever was conveyed by the Stegomyia mosquito were made as late as between June 1900 and February 1901. Yet by the 15^th February 1901 General Leonard Wood had issued an order, putting into force the regulations for fighting yellow fever by destroying the mosquito; and the last case of the disease in Havana occurred in September 1901. About three years later, when arrangements were being made to construct the Canal, President Roosevelt, who had been in Cuba and knew the value of the work done there, instructed the first Canal Commission to give special attention to sanitation, and to secure the best medical experts attainable for this purpose; saying further, in a letter to the secretary, that “it is the belief of those who have noted the successful results secured by our army in Cuba in the obliteration of yellow fever in that island, that it is entirely feasible to banish the diseases that have hitherto caused most mortality on the Isthmus.”

The promptitude with which General Leonard Wood utilised and profited by the scientific discovery made by the American Commission in Havana in 1901 is very extraordinary indeed, when compared with the attitude of many other governments towards similar problems. Within a couple of months of the conclusion of the experiments, the Americans had in full swing operations against the mosquito throughout the city; while when the critical moment in the history of the Canal came, the President of the United States at once brushed aside the engineer who was obstructing the sanitarian.

Colonel (now Surgeon-General) Gorgas, the head of the department, is called the Chief Sanitary Officer. Under him are Mr Le Prince, the Chief Sanitary Inspector, who is in charge of all the “preventive” work; Colonel Mason in charge of all the hospitals and dispensaries, i.e., of the treatment of the sick; and Dr Darling, Chief of the Board of Health Laboratory, who does most of the scientific work required by the other two sub-departments.

These three sub-departments are entirely independent of each other, but working in harmony. Mr Le Prince is an engineer, and all his staff are or may be composed entirely of laymen. Colonel Mason’s staff are physicians, surgeons, nurses, and all required for the hospitals. It is important, indeed of first importance, then, to grasp the fact that although inspired and directed by a medical man, the sanitary work which has made the construction of the Canal possible has been carried out by intelligent laymen, and not by medical men; and as will be seen later on, the success of the sanitary work has been due in no small measure to the keen interest taken in it by Mr Le Prince and his men, who have constantly striven to devise new and improve old methods of dealing with their foes.

While independent, the three sub-departments come into contact through the chief sanitary officer in the following ways: firstly, the hospital returns are sent to the chief sanitary inspector, who makes a special inquiry into the sanitary conditions if the amount of sickness in any station rises above the normal; and secondly, the district physicians make independent inspections of the sanitary conditions of premises, etc., and make recommendations, but are not allowed to give any orders to sanitary inspectors. Otherwise the sub-departments are distinct, and they work without the slightest friction. It is, consequently, possible to study each sub-department by itself.

Before going into details of the sanitary administration in the Isthmus of Panama, it will be convenient if I give a short description of the geographical conditions of the Canal zone and the Canal. A knowledge of this is essential to an understanding of the sanitary work.

Where the Isthmus is pierced by the Canal it runs almost east and west; and so the Canal, contrary to what one would expect, runs almost north and south, and its banks are always spoken of as the east or west bank, as the case may be. The latitude is approximately 9° north, and the longitude 80° west of Greenwich.

By the treaty with the Republic of Panama, the United States obtained in perpetuity a lease of a strip of land 5 miles wide on each side of the middle line of the Canal. This is called the Canal zone; and over it the Government of the United States has even greater control than it has over land in the States themselves, for the zone is really under the Department of War, which operates through the Isthmian Canal Commission. By the same treaty the capital of the republic, the city of Panama, on the Pacific coast, and the town of Colon on the Caribbean Sea, are expressly excluded from American control, except in regard to sanitation.

The town of Colon is close to the Atlantic end of the Canal, and is indeed the terminal town on the Canal. But in order to give the United States proprietary rights over the docks and other works at the end of the Canal, a portion of Colon has been brought within the Canal zone. This is called the town of Cristobal. The boundary between the two is a well-made street. Colon and Cristobal are really one town, although the administration of the two is in different hands. Similarly, at the Pacific end of the zone, the city of Panama, the capital of the republic, is separated from the American town of Ancon only by a street. The end of the Canal is about a couple of miles from the city of Panama, and opens on the ocean at a place called La Boca. This name has been changed to Balboa, in honour of the discoverer of the Pacific. There are thus three place names within a couple of miles of each other at the Pacific end of the Canal, namely, Panama, Ancon, and Balboa; and two at the Atlantic end, Colon and Cristobal.

Figure 9.1: Map of the Isthmus of Panama. This map was adapted from a modern one found on wikipedia.org. The map shown in the original edition of this book can be found in the Appendix (see Section 20.1).

The Atlantic end of the Canal begins in the swamps of Limon Bay, for here, as in the rest of the Gulf of Mexico, there is practically no rise and fall of the tide, and the land shades off into the sea by means of an extensive swamp. Running for some 7 miles through this low-lying land and swamp, and of course on sea level, the Canal reaches Gatun, where, by means of a flight of three locks, ships are raised to a lake 85 feet above sea level. The lake is formed by an immense dam nearly 11/2 miles long, 1/2 mile wide, and over 100 feet high. This enormous dam holds up the waters of several rivers, the chief of which is the Chagres. At Gatun the scenery changes: from a swamp, we pass to a lake 164 square miles in extent surrounded by hills, studded with islands, and with branches running for miles up the valleys of the submerged rivers. Not only have rivers been submerged, but so, too, have disappeared the old line of the Panama railway, and the villages of Tabernilla, Mitchelville, and old Frijoles. By means of this dam sufficient water has been obtained to operate the locks, and by its great extent the dangerous floods which swell the Chagres in the rainy season have been rendered harmless, indeed have been stored ready for use in the dry season.

Ships will be able to steam through the lake at full speed, until they reach the beginning of the Culebra Cut. The Cut begins at Gamboa, extends for a distance of 9 miles, and ends at Pedro Miguel. The Cut is really part of the Gatun Lake, the waters of which thus carry ships over the Isthmian divide or watershed: it has a minimum bottom width of 300 feet; the average depth of the excavation is 120 feet; while at Gold Hill, where the Cut crosses the watershed, the bottom of the Canal is 300 feet below the original ground level. Someone has called the Cut a great valley, and the idea is quite a happy one. Along the valley are a series of stations occupied by the Canal employees and others. They are called in order from north to south, San Pablo, Bas Obispo, Las Cascadas, Empire, Culebra, Paraiso, and Pedro Miguel. With the exception of the two last-named all are on the west bank of the Canal.

At Pedro Miguel ships will pass from the great Cut with its high banks, through one lock, into a lake formed by damming the Rio Grande. This lake when filled with water will be 2 miles long, and about 1 mile in width, and will be entirely artificial. When it is filled with water much of what is now Pedro Miguel will disappear. The hills round the lake run to about 500 feet in height.

Passing the Miraflores Lake (for that will be its name), steamers will descend by means of two locks to the Pacific level. The Canal here follows the valley of the Rio Grande, and for the most part runs through a mangrove swamp. At the locks is the station called Miraflores, and about 2 miles farther on is Corozal, situated, not on the Canal, but on the solid land forming the shore of the mangrove swamp through which the Canal runs. Another 3 miles brings the Canal to Balboa, the Pacific terminus, where the tidal range is 20 feet, a marked contrast to that at the Atlantic end of the Canal, where it is only about 20 inches.

The Canal thus passes through several different kinds of country; first, low-lying, almost undrainable swamp, then through a high-level lake, then through a deep cutting, and after a short distance in a second lake into a mangrove swamp, which, however, is much more drainable than that at the Atlantic end. The sanitary authorities had, therefore, a number of different conditions to deal with, and it was my object to ascertain how each of the different situations had been met.

Like other places near to the equator where the sea is not far distant, the Isthmus of Panama is not excessively hot. The maximum temperature recorded at Ancon is 97°F. The mean maximum, however, for the year 1911 was only 86.8, and the mean minimum 71.6. These records are from Ancon. The maximum temperatures are about 5° lower than in the Federated Malay States.

With some misgiving I abandoned my “topee,” and wore a felt hat (the inner part of a “double Terai”); for everyone wore felt hats, and topees are unknown. For a couple of days I was rather unhappy at times when in the full force of the sun; but the unhappiness was entirely due to the feeling that there was danger from abandoning the topee. There was no physical discomfort; indeed it was a great comfort to wear so light a hat in place of a heavy sun hat; and after a couple of days I felt the change was entirely for the better. As during my stay on the Isthmus I was walking about almost all day, stooping down searching for larvae, my exposure to the sun was almost as great as it could be, and was accompanied by considerable physical exertion. It may be prejudice, but I do not think I could do the same thing in Malaya. Certainly I have suffered from severe headache within a few minutes when exposed to the sun in the Federated Malay States.

I am inclined to think that, on the whole, the physical conditions as regards actual temperature, are more favourable to the white race in Panama than they are in Malaya; but as will be seen later on, the conditions which favour the breeding of malaria-carrying Anopheles are such that had the insects not been kept under control, the health of the labour would have been practically as bad as it could possibly be.

With regard to rainfall, the records show that the Atlantic side of the Isthmus is much wetter than the Pacific. The average rainfall per annum at Colon for forty-one years is 129.59 inches, while the average of four years for Porto Bello, which is about 20 miles along the coast, is 173.02. Porto Bello has a record of 2.48 inches in five minutes. There is a steady diminution of the rainfall from Colon to Ancon, where the average for fourteen years is 71.23 inches; while 10 miles out in the Bay of Panama, at the Island of Taboga, its amount has decreased, so I was informed, to between 40 and 50 inches.

The length of the Canal zone is approximately 50 miles, and its width 10 miles. As, however, only a portion of this whole area is occupied by the Commission employees, the Sanitary Department has confined its operations to the portions actually inhabited. For the purposes of sanitation, the whole zone except Cristobal is under Mr Le Prince, the chief sanitary inspector. It was divided originally into seventeen districts, but at the time of my visit Tabernilla and Mitchelville had been abandoned, having been covered by the rising waters of Lake Gatun. On the other hand, Monte Lirio and Frijoles were new stations on the relocated railway line.

Table 9.1 gives the number of sanitary inspectors in each district or station, the area of the station, the length of the ditches in miles, and the acreage of grass constantly cut in 1912.

Each of these districts is under a sanitary inspector, who has one or more assistant inspectors, according to the amount of work to be done. The districts are further grouped into two divisions, each of which is placed under a divisional inspector. His duty consists of inspecting, advising, and reporting; he has power to give an order to a sanitary inspector only in an emergency, and when he does so “a report must be made to the chief sanitary inspector covering the matter.”

For much of the following information I am indebted to Dr A. J. Orenstein’s paper, “Sanitary Inspection of the Canal Zone.”38 Dr Orenstein occupied for a time the post of assistant chief sanitary inspector.

The personnel of the division of zone sanitation is listed in Table 9.2. Each of the twenty-three inspectors on the zone has, therefore, an average of 2.16 square miles (or 1382.40 acres) under his care, and to carry out his instructions has 10.6 men under him. On his 2 square miles there are 11.1 miles of ditches to be oiled and upkept; and practically one-thirteenth of the area is under grass, which is constantly cut by the Quartermaster’s Department at the expense of the Sanitation Department.

The chief sanitary inspector and his deputies derive their powers from Act No. 8, section 20, of the Canal Zone Laws. It is:

The Chief Sanitary Inspector shall have direct charge, management, and control of all work performed or entered upon within the Canal Zone for the prevention or suppression of diseases. He shall be charged with the duty of securing the enforcement of all sanitary regulations, and perform such other duties appertaining to his position as may be required of him by the Chief Sanitary Officer, the Governor of the Canal Zone, of the Isthmian Canal Commission.

A Manual of Instructions for sanitary inspectors has been compiled. It …

… sets forth briefly the essential things necessary to the Sanitary Inspectors for the efficient performance of their work, such as methods of inspection, methods of making out the routine and special reports, building and screening regulations, construction of pit and pail closets, night soil disposal, fumigation, disinfection, etc. In addition the Inspectors are required to be familiar with the appearance, life-history, and habits of Anophelines, Stegomyia, and Culicines. They are expected to be able to distinguish these species in their larval and adult forms, and to be familiar with the methods of mosquito reduction in use here. Inspectors are also required to be familiar with the breeding habits of the house fly, and the usual methods of extermination of flies.39

The whole tone of the Manual is admirable, as will be gathered from the following sections in Chapter I on General Instructions:

The conditions of life and work on the Isthmus impose upon the Sanitary Inspector duties exceedingly varied in character. These duties embrace every phase of sanitation, involving not only the health, but the comfort, contentment, and general well-being of the people of his district. He must organise and carry on vigorously, persistently, and smoothly a work of vast importance to the community. His work must be carefully planned, his labours well disciplined, his office work promptly and accurately performed, his expenses closely scrutinized, and his property carefully used and guarded. In his relations to the people of his station he must sustain the dignity of his position by a gentlemanly bearing, universal courtesy, moderation, tact, and patience, which will enable him to carry out his duties with firmness, impartiality, and justice to all, with the least friction, and without incurrence of the ill-will of anyone.

He will obtain the confidence and respect of the people, seek the acquaintance and maintain amicable relations with the heads of all departments, and especially with the physicians of his district, to whom he will extend all the courtesies and facilities at his command in furtherance of their work.

No actual clash, or disagreement with, or inattention to the requests of the district physicians of this department will receive consideration in this office. Comply with requests, and enter protests later. The same holds good with the officials of other departments, to the effect that there will be no clash; the Inspector, however, is allowed a wider range of latitude in his judgment as to what course he should pursue.

It is the policy of this office to give District Sanitary Inspectors wide latitude in the administration of their districts, and the management of all affairs pertaining thereto. They will at all times have the support and full backing of this office in the faithful performance of their duties. Their recommendations and suggestions are sought, and will receive careful consideration.

Sanitary Inspectors should use every reasonable endeavour to secure compliance with the Sanitary Regulations by obtaining the cooperation and goodwill of the people. The advancement of sanitation is a matter of education rather than force. Sanitary Inspectors should also remember that sanitary regulations often cause considerable temporary inconvenience to the public, and they should endeavour to secure cooperation of the public by pointing out that the benefits to be derived from aiding the Sanitary Department are of far more importance than the inconvenience caused.

The supreme importance of the anti-mosquito work will be gathered from Chapter V. of the Manual. It deals with inspections:

1. (1)Inspectors in charge of districts may assign certain sections of the district to their assistants; but the Inspector in charge will be held responsible for the whole district, and must assure himself by personal inspection that conditions are satisfactory. It is directed that the Inspector in charge shall inspect every part of their district at least once a week.
2. (2)In the order of importance the sanitary inspections consist of:
   1. 1.Inspections to detect and remedy conditions favourable to Anopheles breeding.
   2. 2.Inspection to detect and remedy conditions favourable to Aedes (Stegomyia) calopus and Culicine breeding.
   3. 3.General sanitation.
3. (3)All streams, ditches, pools, marshes, and other areas where Anopheles might breed, should be inspected at least once a week, and the presence or absence of larvae noted. The inspection must include an actual search for larvae, and the desk diary must contain an entry showing when and where such search was made, and what was found. During these inspections the necessity for remedial works will be noted. More or less permanent breeding areas must be designated by a number, and this number must be used in all records and correspondence relating to the areas. The finding of pupae in a sanitary district will be considered as neglect on the part of the Inspector.
4. (4)District Sanitary Inspectors shall from time to time inspect the dwellings in their districts for the presence of adult Anopheles. They should also follow up the work of the mosquito catchers, to satisfy themselves that this very important work is being thoroughly done.
5. (5)District Sanitary Inspectors will make a weekly inspection of all premises for possible breeding places of the Aedes (Stegomyia) calopus. All rules regarding the screening of containers, prohibition of water storing within 300 feet of a public supply, and on premises supplied with water service, should be vigorously enforced. The carrying out of the regulation prohibiting eave gutters, except self-draining short gutters over doorways, must be insisted upon.
6. (6)Eave gutters on Government buildings found to be defective and holding water must be reported in writing to the Chief Sanitary Officer.
7. (7)There must be no Aedes (Stegomyia) calopus breeding in the Canal zone. Weekly inspections must be made of all Government quarters for defects in mosquito-proofing, methods of garbage collection, and general cleanliness of premises.

   Weekly inspections must be made of all native houses, shops, bakeries, hotels, stables, stores, slaughter-houses, markets, and all other places where conditions dangerous to health or life may exist.

   Weekly inspections must be made of all commissaries and Government messes, noting the sanitary conditions. Defects must be reported promptly in writing to the Chief Sanitary Inspector.

Section 8 deals with repairs to mosquito-proofed buildings; 9, with food unfit for use; 10, with the sale of beverages; 11, with building regulations; and the 12^th and last section, with the safety of buildings.

Dr Orenstein also gives the anti-mosquito work first place, saying:40

The work done by the Division of Canal Sanitation may be classified in the order of its relative importance and magnitude into:

1. (a)Anti-malaria work.
2. (b)Anti-yellow fever work.
3. (c)Anti-plague work.
4. (d)Anti-typhoid and dysentery work.
5. (e)General sanitation.

The work directed towards the control of malaria is relatively of most importance from the standpoint of the sanitary inspector, and it claims by far the largest portion of his time and effort, approximately two-thirds of the sanitary inspector’s time being devoted to this work.

It has been my experience, too, that where malaria is present in a severe form, its control is the most important sanitary work which can be undertaken, and that other sanitary work shows practically no result until the malaria is controlled. I was, therefore, much interested to find the orders to the sanitary inspectors in Panama so clear on this important matter.

The work of the Sanitary Department may perhaps be most easily realized by my giving a record of what I saw from day to day on the zone. I was particularly anxious to study the breeding places of the chief malaria-carrying mosquitoes, namely, A. albimanus and A. argyritarsis, and to see how the various conditions in which water is found were dealt with. My visits to the different stations were not made in regular order. Often I accompanied Major Noble when he happened to have special work at a station, and by doing so I had the advantage of seeing how he dealt with such special questions as had arisen. Afterwards he was good enough to show me the whole station. On other days I visited stations along with the divisional and sanitary inspectors. During my stay I visited and walked over a large part of every station on the zone.

I propose here to describe what I saw, taking each station in the order of my visit rather than in geographical order.