Panama fever (54 page)

Gorgas, the son of a Confederate general, had become a doctor as the only way to secure an army commission after his rejection by West Point. Posted all around the frontier areas of the United States, Gorgas was on the Río Grande near the border of Mexico in August 1882. It was, wrote his wife whom he met that year, “yellow fever's first encounter with one who became its implacable foe, and whose life was to be concentrated on its extermination.” Gorgas caught the disease but survived and was therefore subsequently immune. Thereafter yellow fever epidemics became his specialty.

But for now, Gorgas was firmly with the majority about the cause of the disease: rotting rubbish and filth, together with “fomites”— everything the patient had touched while infected. Gorgas met and befriended Finlay in Havana but, he later wrote, “we were rather inclined to make light of his ideas, and none more so than I.”

Backed to the hilt by the city's military governor, he went to work. Streets were swept clear of dead animals and rubbish. Every house was cleaned and disinfected with “chlorinated lime,” essentially bleach. The exhaustive sanitation campaign was closely followed by the U.S. press. With plenty of “before and after” pictures the work made good copy and showed the American intervention in a good light. The cleanup also slashed the previously high rates of illnesses such as typhoid and dysentery. Furthermore, the yellow fever epidemic of the previous year showed no signs of returning.

But in August 1899 some 12,000 nonimmune Spanish workers arrived on the island. Within weeks yellow fever was back. It seemed that all Gorgas's hard work had not made the slightest difference. Worst of all, the disease seemed to hit hardest in the smarter “expatriate” areas of Havana (where, of course, the highest proportion of nonimmunes were living). The deaths of high-profile members of the U.S. community caused widespread panic.

Governor Leonard Wood ordered Gorgas to redouble his sanitation effort and made $50,000 available for the purpose. But the renewed round of sweeping and scrubbing had no effect. It was time for a new approach.

In June 1900, a special Yellow Fever Commission was appointed by Washington. Dr. Walter Reed, an expert bacteriologist as well as an experienced “frontier doctor” like Gorgas, was in charge, assisted by Drs. James Carroll, Aristides Agramonte, and Jesse W Lazear.

Reed seems to have landed in Havana with an open mind, amenable to persuasion by observed fact. The questions facing the Commission were simple: What agent causes yellow fever? How is it spread? How can it be stopped? On the first of these, the doctors drew a blank early on. They looked through the microscope at the blood of yellow fever patients but could not find the “germ” or “bacteria.” Viruses, of course, were unseen and unknown in 1900. On the second question, however, there was an early breakthrough. Soon after his arrival Reed was presented with a curious case. A soldier at the nearby military base had been locked in a cell following a disciplinary infringement. A month after having been imprisoned, he had come down with yellow fever and died six days later. But none of his eight cellmates had contracted the disease, even the one who had subsequently slept in the dead man's bunk. The men had remained sealed in the cell, but it did have a window. Reed concluded that something must have carried the infection in through the window, passed it to a single subject, and then departed: it had to be an insect.

The Commission turned to Doctor Finlay, whose theories were suddenly in favor at last. Finlay was happy to provide
Jëdes aegypti
eggs so that specimens could be bred for experiments. While several of the doctors tried to find out all they could about the insect's habits and life cycle, others attempted to achieve the demonstration of the theory that Finlay's experiments had failed to provide. For this volunteers were needed who were prepared to be bitten by infected insects. Although those selected would, of course, be the strongest and healthiest specimens, and the best care available would be ready for them, they would still run a heavy risk of death. Five hundred dollars was offered as an incentive, although the first U.S. Army volunteers nobly refused the reward, setting a precedent that was followed throughout the experiments. Reed's team of doctors also subjected themselves to the same tests.

Early results were disappointing, but after belatedly taking into account Carter's findings on “extrinsic incubation,” yellow fever was successfully transferred from one patient to another. Along the way both Carroll and Lazear became infected. Carroll narrowly survived, but Lazear, with what Gorgas called the worst case of yellow fever he had ever seen, died an agonizing death on September 25.

Reed was much chastened by the gruesome sacrifice of Lazear, a hugely popular member of the team, but was convinced that his experiments had yielded up yellow fever's secret. However, when Reed presented the mosquito theory to a Public Health Association meeting in Minneapolis in November 1900 he was greeted by a stony silence, followed by scathing criticism. The
Washington Post
was condemning in its report of the new theory: “Of all the silly and nonsensical rigmarole about yellow fever that has yet found its way into print—and there has been enough of it to load a fleet—the silliest beyond compare is to be found in the mosquito hypothesis.” The centuries-old, “common-sense” theory that yellow fever was caused by dirt was not to be moved.

Reed returned to Havana and set up a new base, named Camp Lazear, in an isolated spot outside Havana. Here it was possible to achieve a far higher level of control and scientific rigor over experiments. Reed was determined to provide data that even the most diehard believer in the filth theory would have to accept. At the end of November an experiment was started wherein a doctor and three volunteer soldiers were confined for twenty days to a mosquito-proof wooden shack. Inside, they slept on the soiled and
vomito negro
— plastered bedding of previous yellow fever victims. No one got ill, and the “fomites” theory, which had governed quarantine law for centuries, was demolished forever.

Other meticulous tests demonstrated again that
Aëdes aegypti
was the vector of the disease, but there remained doubters. One was Gorgas himself. Even if the insect did spread the disease, what was to say that this was the sole method of transmission, or even the most common one? The only way to demonstrate the theory for sure was to take it out into the field: to get Gorgas's sanitation squads to destroy the
A¨des aegypti
of Havana and see what happened.

This Herculean task was something of a last resort. But tests with inoculations had ended when a young American nurse died from her injection, and to screen all yellow fever patients—to keep the mosquitoes from becoming infected—was impossible as many cases went unreported. Therefore the only option left was to take on the mosquitoes themselves.

Called the “aristocrat of mosquitoes,”
A¨des aegypti
is distinctly marked. Its body has a series of silvery half moons, its legs are alternately black and white, and it has four brilliant stripes on its thorax. Only the female of the species is a bloodsucker—she needs blood to mature her eggs—and she has a marked preference for human blood to the extent that she knows where to attack a person: under the wrist or on the ankles, where the skin is thinnest, and never on the face or top of the hand as these places are easily slapped. Also, she is only very rarely found away from human habitation and always lays her eggs near a ready supply of human blood.

The researchers in Havana also discovered that she is very meticulous, preferring to lay her eggs in clean water in man-made containers, such as earthenware jugs or water butts. And this, they concluded, was her great weakness. So when Gorgas went to work in February 1901 on his new campaign directed entirely against
A¨des aegypti
, he started by directing that all such containers should be removed or screened. Where this was impossible, a layer of oil was poured on the surface of the water to suffocate any larvae, or “wrigglers” as they were commonly known, that might be lurking inside. At the same time, the entire city was divided into districts and meticulously fumigated by burning sulphur or pyrethrum, a dried flower used as an insecticide. The results were truly spectacular—a dramatic reduction in yellow fever from 1,400 known cases in 1900, to only 37 in 1901, none of them after October. The eradication procedures didn't just kill off
Aêdes aegypti
, but reduced the
Anopheles
population as well, thus decreasing malaria cases by more than half.

Havana had suffered some five hundred deaths a year from yellow fever for as long as anyone could remember. Now, quite suddenly, it was over. Furthermore, a controversial and important new theory had been proved correct, and the methods selected to exterminate the disease vector had worked. When the scale of the triumph began to sink in, Gorgas wrote to Reed, “When I think of the absence of yellow fever from Havana for a period of fifty days, I begin to feel like rejoicing that I was ever born!”

All of this hard-won knowledge and expertise was brought by Gorgas to his task in Panama. Indeed, most of the doctors who arrived with him in June 1904 were also veterans of the miracle in Havana. Yet by September, Gorgas would be utterly frustrated, despondent, and full of dread. “The Commission have their own ideas about sanitation, and do not seem much impressed with mine,” he wrote. Gorgas accurately predicted what was to come: “I fear an epidemic is inevitable. If only we could convince them! If only they knew!”

orgas had been confronted by many medical challenges at the start of the American effort in Panama. On his reconnaissance mission in April 1904 he had noted the filthy streets and the extraordinary prevalence of malaria. But he had selected yellow fever as the first of his enemies to be attacked. For a start, the defeat of the disease was an achievable goal; Gorgas had demonstrated in Havana that a spectacular and very press-friendly victory could be won. He had also seen enough yellow fever epidemics to know the disproportionate panic they could cause and how they were ignited by an influx of nonimmune personnel, just as was about to happen in Panama. Furthermore, yellow fever attacked the bosses and spared the workers, affecting in the main white outsiders, perceived to be the most valuable and least expendable of the canal workers. The health of this group would remain Gorgas's top priority. Writing in an American medical journal in 1909, and sounding more than a little like Alfred Mahan, he boasted, “our work in Cuba and Panama will be looked upon as the earliest demonstration that the white man could flourish in the tropics and as the starting point of the effective settlement of these regions by the Caucasian.”

Gorgas got to work within two weeks of his arrival, dividing Panama City up into districts and beginning house-to-house inspections, as he had done in Havana. But from the very start his efforts were severely hampered. The problem was that the gentlemen of the Commission simply did not believe the mosquito theory. The year before, a scientific congress in Paris had reviewed Reed's yellow fever work and proclaimed it “scientifically determined fact,” and Ronald Ross had received a Nobel Prize for his work on the mosquito transmission of malaria. Ross even visited Panama in mid-1904 and pronounced Gorgas's plans sound. Nevertheless, to Walker, the theory was “the veriest balderdash.” Gorgas should concentrate on cleaning up the filth and smells, the chairman of the Commission pronounced. The Zone governor, General Davis, concurred, saying to the doctor in a fatherly tone, “I'm your friend, Gorgas, and I'm trying to set you right. On the mosquito you are simply wild. All who agree with you are wild. Get the idea out of your head. Yellow fever, as we all know, is caused by filth.”

Ross himself wrote, “The world requires at least ten years to understand a new idea, however important or simple it may be.” Nevertheless, it is not hard to sympathize with Gorgas's frustration. Wallace was no better, sounding like old Jules Dingler when he announced that “clean, healthy, moral Americans” would not contract the disease.

So the Commission believed that Gorgas's efforts were a waste of time and money, and his requisitions for supplies suffered even worse than anyone else's, despite Roosevelt's express order that the medical effort be given top priority. Vital copper screening and medical supplies ordered in October 1904 had still not arrived the following April. Gorgas's department was also given the workers that no one else wanted and ordered to pay the lowest wages. “Consequently,” Joseph Le Prince complains, “only poor and unintelligent labour could be obtained … some of them could not even climb a ladder. This was the only class of labor allowed the sanitary department. We had to use it, and succeed or fail.”