Yellow Fever in Panama

Yellow fever is a viral disease endemic to many tropical and subtropical areas of Africa and Central and South America (Centers for Disease Control and Prevention, 2019). The disease is concentrated in these regions because it is spread by mosquitoes that breed in standing water and have adapted to urban areas. The disease also has a primary reservoir in monkeys, meaning that the virus can pass between monkeys and from monkeys to humans, as well as passing solely between humans. Though there are several species of mosquito that transmit the disease, public health officials have historically concerned themselves with the Aedes aegypti mosquito, which most often facilitates the spread of the virus among humans. Once infected, many people do not experience symptoms or only experience mild flu-like symptoms; however, about 15 percent of patients develop a more severe form of the disease that leads to death about half the time (World Health Organization, 2018; Brink, 2016). Symptoms of this more severe form of the disease include the jaundice, or yellow skin, that gives the disease its name, recurring fevers, vomiting, abdominal pain, kidney failure, liver failure, and hemorrhage (Nordqvist, 2017). Those patients that survive, or individuals who have been vaccinated, then have lifelong immunity to yellow fever, which makes outsiders to areas where the disease is endemic especially vulnerable to infection (McNeill, 2010). With no known cure, treatment is limited to supportive care for dehydration, liver and kidney failure, and fever (World Health Organization, 2018).

Eradication of yellow fever has been historically difficult, due in large measure to its natural reservoir in monkeys. Given this difficulty, scientists and public health officials have focused on controlling or eradicating the Aedes aegypti mosquito to prevent the spread of the disease. A Cuban physician and scientist, Carlos Finlay, first hypothesized the importance of the mosquito vector in the spread of yellow fever in the late 1800s (Severo, 1956). Finlay’s theory was proven with the help of Walter Reed, a US Army physician, in 1901. Following this discovery, an immediate attempt was made by William Gorgas to eradicate yellow fever from Havana using vector control techniques (Leonard, 1991). Gorgas was skeptical at first that his campaign would be successful—he doubted the validity of Finlay and Reed’s discovery—but he achieved success within just a few months of beginning his campaign (Faerstein & Winkelstein, 2011).

Now a strong advocate for vector control, Gorgas shifted his attention to Panama after recognizing that, following the US takeover of construction of the Canal from the French, workers and administrators would be combating both yellow fever and malaria during the project (Guardia, 1983). Gorgas thus requested to be put in charge of a mosquito elimination campaign in the area (Severo, 1956). His request was approved, and Gorgas arrived in Panama in 1904 to assume his role as Chief Sanitary Officer for the medical arm of the Isthmian Canal Commission (Guardia, 1983; Stern, 2005). By this point, the US had been given quasi-military authority with respect to sanitation and health measures in the Canal Zone and within the city limits of Panama City and Colón (Guardia, 1983; Stern, 2005). Yellow fever was also already claiming the lives of thousands, and canal workers harbored fears of the disease that were fed by a long history of susceptibility of white outsiders to tropical diseases like yellow fever and malaria (Brink, 2016; McNeill, 2010).

Gorgas began his project by focusing on yellow fever. He built a network of inspectors who would inspect homes for potential mosquito breeding grounds. His team mosquito-proofed rain barrels, removed or treated other standing water sources, and fumigated the homes of yellow fever patients (Leonard, 1991). He also moved forward with plans to provide piped water to residents of Panama City and Colón, thereby eliminating the need for open water-collection systems (Leonard, 1991).

However, Gorgas’ initial work in Panama was limited because he was attempting to carry out his plans in the face of surprising apathy and lack of interest on the part of the engineers and government officials who made up the Isthmian Canal Commission to which Gorgas was subordinate. President Theodore Roosevelt had initially placed very little weight on biomedical science, and as such the Chief Engineer of the project, Admiral John G. Walker, never really supported Gorgas and his team. The Commission frequently denied supply requests and ignored the request made by the American Medical Association that Gorgas be placed on the Commission (Guardia, 1983).

Eventually, President Roosevelt became so frustrated with the Commission and the slow progress that had been made in building the Canal that he replaced the entire Commission. The new Chief Engineer Roosevelt appointed was John Stevens, who supported Gorgas and his efforts. Following this change, Gorgas was essentially given free reign; requisitions were filled immediately, and his team was able to fumigate Panama City and Colón house by house, oil cisterns and cesspools once a week, and provide running water to Panama City, Colón, Cristóbal, Ancón, La Boca, Empire, and Culebra (Leonard, 1991). Thanks to Gorgas and his team’s efforts, the last victim of yellow fever on the Panama Canal died in 1906. Unfortunately, the disease reemerged later in and around the Canal, but construction had ceased by then (Brink, 2016).

Gorgas’ yellow fever elimination campaign was the largest public health intervention the world had seen up to that point, and was revolutionary in its scope and success. The scale of the project and the control that the US had in the Canal Zone also allowed Public Health Service (PHS) officials who were working in the Canal Zone to gather data for the first time on patterns of health and disease. These professionals were able to study sewage infrastructure and water systems, demographic and vital statistics, and the architecture and capacities of local hospitals (Stern, 2005).

However, the campaign also highlights some of the challenges that public health interventions face both externally and internally. One example is Gorgas’s struggle against apathy and lack of attention, as major concerns in public health are frequently funding, supplies, and public interest. Another example can be found in the attitudes of many of the public health officials present during the campaign who frequently saw patterns of cleanliness and disease as reflections of racial differences. They assumed that darker-skinned locals were more inclined, or predisposed, to being dirty and thus saw it as their duty as cleaner, whiter men to lift up, sanitize, and civilize them (Stern, 2005).

In general, the US viewed the construction of the Panama Canal as a heroic triumph over a tropical environment that was inherently hostile to white men. Gorgas’s sanitation efforts and successes were particularly associated with the opening up of the “uncivilized” tropics to settlement by the “civilized” white man, thereby furthering the expansionist goals of the US and realizing its dream of bringing development to the tropics (Sutter, 2007). Unfortunately, these colonialist, white savior views still exist today, though they are generally subtler and less frequent than they were at the beginning of the 20^th century. And while many public health lessons can be drawn from the efficiency and impressive scale of Gorgas’s campaign, the imperialist and racist undertones of the program, and of the Canal construction in general, should not be overlooked.

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Additional Resources

Bosch, A. (Writer), & Chin, M. (Director). (2006). The Great Fever [Television series episode]. In A. Bosch, American Experience. PBS.

Ives, S. (Filmmaker). (2011). The Panama Canal [Motion picture]. USA: PBS.

Packard, R. (2016). Colonial Training Grounds. A History of Global Health: Interventions into the lives of other people (17–31). Baltimore: Johns Hopkins University Press.

References

Brink, S. (28 August 2016). Yellow Fever Timeline: The History of a Long Misunderstood Disease. Retrieved from https://www.npr.org/sections/goatsandsoda/2016/08/28/491471697/yellow-fever-timeline-the-history-of-a-long-misunderstood-disease

Centers for Disease Control and Prevention. (2019). Yellow Fever. Retrieved from https://www.cdc.gov/yellowfever/index.html

Faerstein, E. & Winkelstein Jr., W. (2011). William Gorgas: Yellow Fever Meets Its Nemesis. Epidemiology, 22(6), 872.

Guardia, C. A. (1983). Salud publica y saneamiento en la zona del canal de Panama: Un recuento histórico, 1880–1950. Boletín de la Oficina Sanitaria Panamericana, 95(1), 62–73.

Leonard, J. (1991). William Gorgas, Soldier of Public Health. Bulletin of the Pan American Health Organization, 25(2), 166–185.

McNeill, J. R. (2010). Mosquito Empires: Ecology and war in the Greater Caribbean, 1620-1914. Cambridge University Press.

Nordqvist, L. (2017). What’s to know about yellow fever? Retrieved from https://www.medicalnewstoday.com/articles/174372.php

Severo, O. P. (1956). La erradicación del aedes aegypti en las Americas. Boletín de la Oficina Sanitaria Panamericana, 40(6), 485–498.

Stern, A. M. (2005) The Public Health Service in the Panama Canal: A Forgotten Chapter of U.S. Public Health. Public Health Reports, 120, 675–679.

Sutter, P. S. (2007). Nature’s Agent or Agents of Empire? Entomological Workers and Environmental Change during the Construction of the Panama Canal. Isis, 98(4), 724–754.

Pan American Health Organization. (n.d.). Control of Yellow Fever in the Panama Canal Zone. Retrieved from https://www.paho.org/hq/index.php?option=com_content&view=article&id=2676:2010-control-yellow-fever-panama-canal-zone&Itemid=40275&lang=fr

World Health Organization. (2018). Yellow fever. Retrieved from https://www.who.int/news-room/fact-sheets/detail/yellow-fever