Hello again, beautiful people. It's Brandon Hewlett, infectious disease epidemiologist here at Vanderbilt University. And welcome to the Filth in America podcast, episode four. Today we're going to talk about an exciting chapter in American public health history. Really, one of the chapters when American public health truly changes the world. One of the first times that it really, really does this on a global level. One of the times when American public health really surges ahead of its European predecessors and does things that public health authorities in other parts of the world were not able to do. And that is the story of the building of the Panama Canal. Most people are familiar today with the Panama Canal, the small 50-mile or so strip across the Isthmus of Panama, which allows transit between the Atlantic and Pacific Oceans without going all the way around South America down, which really saves time and really enables a huge amount of transit. Of course, it wasn't always there. People had, since some of the earliest exploration of this area by Europeans, had dreamt of there being a passageway across the Isthmus of Panama and other locations in Central America to facilitate the commerce and the transport from ocean to ocean. Nobody had really made it happen until the early part of the 20th century when the Americans were able to complete the Panama Canal. Now, of course, that that isn't the first canal that the Americans had built, but the Americans, as we said, are not the first ones to try on the Isthmus of Panama. In fact, the biggest effort prior to the Americans taking over was the French. The French looked to take on construction of what is now the Panama Canal as early as 1881 and run into a whole host of problems. Now, the French at this time are not any stranger to large engineering projects. They'd done quite a lot around the world in the world of canals. Remember, the French had led the building of the Suez Canal, another fairly important, fairly remarkable engineering feat. So they knew what they were doing, but they kept getting bogged down in the Panama project. And money just kept going in and going in and going in, and there was really no progress. And there was a lot of attention both in France and globally as to what was going on. There was a lot of finger pointing about graft and corruption, and there certainly was some of that that was going on. There was a lot of fingers pointed at the leadership and saying that they were incompetent and so on. But the biggest factor, the biggest thing that stood in the way of the French completing the Panama Canal was disease. At the time, the French start referring to the section of Panama where they were digging as the pest hole of the world. Remember, this is Panama. It is an extremely dense jungle. It is not flat. It has both mountains and swamps. It has raging rivers that flood all the time. And with that comes a whole host of diseases, particularly mosquito-borne diseases. Things like yellow fever and malaria are hugely problematic. There is some smallpox, but there's also a good amount of typhoid and dysentery that plagues the French as they're going on. And even some plagues, mubonic plague pops up. The French, during the years that they were in charge of building the canal, ended up burying at least 20,000 workers in what is now the canal zone area. Now, that number probably underrepresents the total amount of people that were killed. The French were not always the best at recording the history of the Native peoples or the peoples from the West Indies that were brought to the area to work on the project. So it certainly, I think, is arguable that the 20,000 number, 20,000 deaths and the untold number of folks that fell sick really underrepresents the problems that the French were dealing with. The French effort ultimately goes bankrupt, falls apart. Chief engineer basically goes insane. Remember, this is the guy who had built the Suez Canal. So he's no slouch. And it was really thought by most in Europe to be an unsolvable problem, that the terrain was just too bad, the jungle too dense, the diseases and the mosquitoes too thick to solve this problem. And that is the background where the Americans enter. And now the Americans in the beginning of the 20th century are very optimistic. People on the world stage are really making their ascendancy, right? The U.S. economy is now the biggest economy in the world. You have Teddy Roosevelt as president who's really wanting to secure America's place on the world stage. They had accomplished quite a lot of huge engineering feats. And Roosevelt very much views this as another great opportunity for America to show its prowess. And so he thinks that building the canal would be of not only great benefit in terms of commerce to the United States, but also would be this way that they can prove America's prominence on the world stage. We can do anything. We can overcome the challenges that other nations haven't been able to overcome. Now, this is very much true not only of the engineering challenges of building the canal, which are, which are massive, but he also very much recognizes the health challenges. Remember, Teddy Roosevelt had been a reformer. He was interested in certain public health issues. He very specifically says that the sanitary and hygiene problems on the Isthmus are really of the first importance, he says, even coming before the engineering. He really very much believes that this problem has been solved. And as we'll see today, a lot of Roosevelt's Roosevelt's emphasis on addressing the public health concerns and putting the resources behind these public health folks that are there on the project are really one of the primary reasons that the engineering is able to happen. A lot of folks live in really unsanitary, squalor kind of conditions, particularly Native peoples and particularly the workers that were down there. There was no screening. Most water that folks got to use in Panama came from cisterns. It was rain-fed cisterns. Now, for a good bit of the year, it rains every day in Panama. So that made uh quite a lot of sense. But that's where most of the water came from. Now, during the French period, as we said, there was quite a lot of yellow fever and malaria, and not a whole lot was known about how those diseases were transmitted. Even though the germ theory of disease existed, people hadn't completely worked out how what we now know, mosquito-borne illnesses in this case were transmitted. But nonetheless, there wasn't a whole lot of attention paid to epidemic diseases among the French effort workers that were down there. There was almost no public health effort to protect the workers, or even the folks from Europe that came over to lead the project. There was really nothing. Now, there were some hospitals built at both ends. The city of Cologne's on one side and Panama City is on the other. Both of them had hospitals, about 500 beds. They were ward-type hospitals where you had different wards for different types of patients, which is actually a pretty good idea for a lot of reasons down there. So the hospitals were fairly good for the time. However, the hospitals, which were built largely by the French, didn't have much water. They did have some cisterns on the roof in some cases, but they didn't have bathrooms. They didn't have screens. There was a lot of open-air porches. Now remember, it's Panama, it's very, very hot, very, very humid. There is still some concern, even though the German theory of diseases around, of the miasmatic theory that bad air contributes to disease. And of course, you're in the middle of a swamp or a jungle, so there's quite a lot of that. So ventilation was important. But of course, with no screens, mosquitoes could get in. Anyone who's ever been to the jungle or some of these marshy, wet areas also knows you've got other mosquito-borne pests. You've got ants. Ants were a huge problem. And of course, when you have patients that are incapacitated because of disease or laying in the bed, they can't escape the ants. Ants would crawl in and crawl all over the thing. They would crawl up the bed, crawl up the legs, and accost the patients, bite them and sting them, and whatnot. It makes me itch just thinking about how bad that had to have been. It was customary that the feet of the beds were put in little pans of water, right? So they'd have a small little pan of water and they'd set the feet of the bed in that pan of water, and then the ants couldn't crawl up the bed to bother the patients. Of course, this puts a little area of standing water right at the foot of the bed of ill patients and makes a perfect environment for mosquito breeding, as we'll talk about later. So it really was a trade-off that was not necessarily a good one. The hospitals themselves were oftentimes run by charitable nuns groups. They were allowed to charge a dollar a day, but this was even expensive at the time by the Caribbean standards. In fact, some of the unskilled laborers didn't even make that much, so they didn't use the hospitals as much as perhaps they should. So their effectiveness from a public health standpoint was in fact limited. But it's just generally an overall problem. So in 1904, again, when the Americans decide to take over, they look at these hospitals and initially they're like, well, okay, but these may or may not be adequate to the amount of labor that it's going to take. Now, at first, they weren't looking necessarily at the quality of the care to as much as these are not big enough to manage what's going on, and certainly not everybody in this area is using them. So because of all these challenges, you have huge amounts of waste and filth problems, you don't have any sort of public health effort, you don't have any water and sanitation, you have huge amounts of mosquitoes, you have lots and lots and lots of tropical diseases. It is kind of understood, certainly by Roosevelt, that a sanitary officer had to be assigned. And when the bill passes Congress establishing the canal committee, which was going to be seven people, uh, they had various things that they had to represent. Uh, four of them at least had to be learned in science and engineering related to canals. You had to have an Army representative and a Navy representative. But none of the people initially appointed had any sort of medical background. They really looked at their charge as one to ensure that problems of efficiency, graft, corruption didn't take place. The money that was appropriated by Congress was really uh spent efficiently and on the project, which, of course, as we said, that was one of the biggest criticisms of the French effort. So there was a contingent from the Johns Hopkins University, which was a fairly notable medical institution at the time, as it is today. There was four well-known physicians, uh, including a guy by the name of Welch, and they go to see the president. And the president, as we said, has already expressed that he believes that these sanitation and hygiene issues are important. So they go to see the president, they get right in, uh, and the president uh s very much supports the appointment of a sanitary officer, and he says to Welch and this contingent from Johns Hopkins that they should definitely recommend a sanitary officer, preferably somebody from the Army, to the head engineer, guy by the name of Wallace, there, but he doesn't tell them who it is. He really wants to let them pick the best medical man for the job. So that's where we enter a guy by the name of William Crawford Gorgas. Gorgas really is the hero of our story today. He's an interesting guy. He had been a student of Welch. He was not really initially looking to be a physician as a younger man. He was in the Medical Corps of the U.S. Army. He was the son of a military officer that had served in both the U.S. and the Confederate Army, his father had. His father had also done some other jobs, including run the University of the South at Sowanee, where Gorgas received kind of the formal part of his education, a military officer moving around, of course. Uh the younger Gorgas education was kind of hodgepodge in different locations. Dr. Gorgas, as he wanted to be referred to, generally wanted to pursue a military career. So after he finished his what education he had there at Sowani, he applied to West Point, but he was not accepted to West Point. So he ends up going to medical school at Bellevue, New York, to get into the Army. He felt that being a physician was a surefire way to get into the Army. And in fact, it was by the time of the Panama Canal Project, he's a colonel. He had an interesting history that is very appropriate. You know, he was very much one of these right men at the right time in history situations. He had been mostly in frontier postings for most of his medical career, where he he performed uh adequately. He had worked several yellow fever uh outbreaks, he breaks he himself had contracted yellow fever, as has his wife. In fact, his wife, he and his wife actually met during a yellow fever outbreak. They were next door to each other. Um, his parents, the the elder Gorgas and his mother had also met during a yellow fever outbreak, and both had had a yellow fever. So after Dr. Gorgas recovers from one of these uh yellow fever epidemics that raged across the uh United States at various points, he dedicates his life to treating this disease. And since he was now immune, once you recover from yellow fever, if you do, which is uh at this point a pretty big if, but if you do recover, you are immune. So every time a yellow fever outbreak would pipe up or a larger epidemic, he was sent. So he had quite a lot of experience in dealing with yellow fever, but he doesn't uh ultimately understand at that point the causative agent. When he's in school, remember the germ theory disease is new and is still a subject of debate. He does, I think, accept germ theory for certain diseases, but he certainly doesn't have any inkling early on that mosquitoes play any role in the transmission of yellow fever or anything else for that matter. During the Spanish-American War, he is sent to Cuba and he is ultimately put in charge of a yellow fever camp. That is a place where both soldiers and civilians that were affected with yellow fever would go to convalesce. In Cuba in the late 1890s, yellow fever is rampant. It had been epidemic on the island for at least 400 years. It was really, really a problem. It's a really, really, really bad disease. You can bleed from the gums, uh, you vomit vile and actually kind of partially digested blood, uh, black vomit, uh, the dreaded vomito negro, as they called it. It was really a bad disease, very high fevers, you're very incapacitated, and quite a few people died from it. It was a huge problem for military forces who were out in the field in huge numbers would be stricken down by yellow fever and get really, really, really, really sick. Now, folks that were native to the Caribbean uh area had been exposed. So by the time they were of military age, oftentimes they had been exposed and recovered or died. But those that were still around obviously had recovered from yellow fever. So it was less of an issue for those native to the Caribbean than it was for people coming from either Europe or uh the United States. In the United States, it was a known disease. It had been a scourge epidemic disease, but it it but it remained exactly that. It was not endemic. It tended to happen in defined outbreaks that would flare up and then go away and flare up and go away, and it kept going. Uh so not everybody in the United States had been exposed, even though quite a few people had, not everybody had. And so when you're sending soldiers to this endemic area, huge numbers of them would get affected by this illness. Uh and it was really a military readiness problem. So he is looking, he ultimately takes care of the patients in this camp pretty well, but can't solve the transmission. He he looks at it more from a sanitary perspective, observing, as did others, that it tended to occur in areas where there was more filth and dirt. Now, of course, nowadays we would know the yellow fever being transmitted by a certain type of mosquito would certainly be associated with those filth areas because there'd be standing pools of water, right, in trash and refuse and things laying around that would that would facilitate mosquito breeding. But they don't know that at that time. He just does that. But the cleaning up doesn't work at the camp. Later on, he has put he is put in charge as the sanitary officer of Havana. Now, Havana at that time has a lot of the same filth-related problems. There's not a whole lot of trash collection, there's not good sanitation in Havana. And of course, there are ramp and uh yellow fever and other disease output, any number of tropical diseases. And again, Gorgas attributes these mostly to the filth, mostly to the cleaning. And for several years, even he sets about with military efficiency cleaning up the city, and he has the trash removed and he has the streets cleaned and a lot of these things that were that were going on, believing it would be the problem. And while it does improve the health of folks in Havana generally, it doesn't solve the yellow fever problem. Yellow fever is still rampant. Now, around the same time, now you know the discovery of the mosquito connection to yellow fever does take place over a period of time, but there was a Cuban by the name of Carlos Finley who had suspected that yellow fever was transmitted by mosquitoes. There was some precedent. By this point, Ronald Ross, an English physician, had proven that malaria was transmitted by mosquitoes, and he had put forth a treatise called Mosquito Brigades on how you go about remedying the mosquito problems in an area to deal with malaria, which of course was a huge problem all over the place, but particularly for the British in India. And so Finley was looking at this and looking at others, and he very much believed that yellow fever was the same way. However, they noted that it was probably going to be in a different mosquito species. There are uh we now know uh over a thousand different uh mosquito species. Species at the time they thought of about 800 or so, but they definitely honed in on a few species of mosquitoes then and now for control. And with malaria, they definitely focused on the Anopheles mosquitoes, which we still think about for mosquito control today as the causative agent or the causative vector, as we say epidemiologically, for transmitting malaria. And they believed that there was a separate mosquito that was common in the tropics, particularly in Cuba, that caused the yellow fever or facilitated yellow fever transmission. That mosquito is now known by a different name. So it is an 80s. It's now called 80s Egyptus, and you'll hear when they're doing mosquito control that that particular mosquito is one of the ones that they are really looking at. At the time they had different names for that particular mosquito. It was called Stegomia fasciata, other times were 80s colapus, different names for this mosquito, but it behaves fairly differently than the Anopheles mosquitoes do. And so there were going to be different things that are needed to deal with it. But Finlay conducts a series of experiments, including having mosquitoes bite malarial patients, and he just can't prove that yellow fever was transmitted by these mosquitoes. And so there was a good amount of skepticism about it, including our buddy Gorges. He is not subscribed to his theory. He thinks yellow fever, again, is a disease of filth, which is why he's trying to clean up Havana. There is another guy, Dr. Henry Rose Carter, who also is looking at the yellow fever problem. As many people were, he's a public health service associated guy, and he understands that it seems like when you have an isolated soldier or sailor on a ship that gets yellow fever, the other sailors on the ship don't immediately get it. So he didn't think it was contagious in the traditional sense. He also thought that there was probably an incubation period. And in fact, that turns out to be true. For mosquitoes to transmit the yellow fever disease, they have to bite an infected person within a fairly narrow window of about three days. Before that, the the uh pathogens are not in large enough quantities for them to go into the mosquito. After that, other things are going on physiologically and they're not there. So you really have to get in this three-day window. And then there's an incubation period. Once uh the mosquito has bitten somebody, drawn that um yellow fever blood up into their body, there is a an interval before they would transmit it again. So he figures this out, and it's Walter Reed, the well-known Walter Reed, the namesake of the large military medical center in the Washington, D.C. area, and quite a few other things, that puts the two together and definitively proves that mosquitoes are the vector. They are the cause of agent transmitting entity for yellow fever, just as we have seen with uh malaria. So you get rid of the mosquitoes, you can get rid of the disease. Now, again, we said Gorgas doesn't completely buy off on this. And he's riding back and forth in Cuba with Walter Reed, and he says, well, the only way to definitively prove this is to clear Havana of all the mosquitoes. You know, I cleared it of all the trash and all this other stuff. We still got yellow fever. If we clear it of all the mosquitoes, particularly this particular type of mosquito, and the yellow fever goes away, then we'll know it. And Walter Reed says, well, yeah, that's true, but I mean you can't clear a whole city of mosquitoes. And Gorgas sets about doing that. And so he actually studies the history and habits of the mosquitoes, and he understands their breeding in water. So he sets about ensuring that those issues are dealt with in Havana. And he gets rid of all the pools of standing water, those that he can't get rid of, he sprays with oil. When I say oil, I mean crude oil. He has guys walking around spraying oil on things. He screens in areas where patients were cared for that had yellow fever. He recommends screens on individual people's homes, in addition to the cleaning up that he recommended generally in the city. And as these efforts are going on, uh yellow fever is virtually eliminated in Havana. At the same time, although they were not targeting the malaria mosquito specifically, and the malaria mosquito, the Anopheles mosquito, can actually fly a little bit farther. They never completely eliminate malaria. It would actually, uh the mosquito might still breed outside the city, just fly in because it's at a longer range, but they definitely got rid of the yellow fever. And so Gorgas is convinced. So the time that he's appointed to take over the Panama Canal, he is a believer in this mosquito theory. And so, from his perspective, when he shows up in Panama, having been appointed the sanitary officer for the whole project, he really knows to his mind what needs to be done. Yellow fever was a scourge, a disease that everybody was afraid of because you were so sick and it was so obvious and it came in waves, particularly people from the United States associated with it, outbreaks and epidemics, and wouldn't work in that area. Malaria was actually more common in the canal zone at the time, but malaria was really more of a cause of morbidity, didn't necessarily directly kill people. Certainly in the short time, they would just have the recurring fevers and the other disability that came with malaria, whereas yellow fever was really what was feared. So he definitely prioritizes dealing with yellow fever. He's gonna have to deal with it anyway, and that's his area of expertise, right? That's what he's been dealing with. So he looks to set about what's going on, and he, in very military fashion, looks to organize his effort into a sanitary department of three divisions: the quarantine division, the hospital division, and the sanitary division. Now, the quarantine division, as the name implied, had uh entire charge of quarantine matters throughout the canal zone on both sides of the isthmus. If somebody was sick, particularly with yellow fever, they would be quarantined away. He also separated oftentimes groups of immune folks from non-immune folks so that there wouldn't be any contamination of the non-immune folks. He was very, very insistent on fairly strict quarantine rules. Laws ultimately were passed regarding quarantine and staying at home and so on there. His second division was the hospital division, which, again, as the name implies, at charge of the care of the sick, definitely expands the hospital footprint to a large hospital on the Pacific side that had a capacity of 1,600 beds. And then, of course, we still have the other hospital. He also has separate asylums built for, as you said, the insane, a separate facility from those built for the care of lepers so that his initial hospitals are not overwhelmed with these other chronic issues. He divides the canal zone into districts, which each had a small hospital or sick camp, again, where folks could be put under the care of a physician. Generally, there they could get emergency treatment. Some folks that didn't require more than one or two days wouldn't have to go back to the large hospitals. He develops a hospital train with a specially fitted hospital car that crossed the isthmus uh once or twice a day that would pick up the sick at each uh of these little stations and transmit them to the hospitals. So there's people that are ill that are all able to access hospital-level care. It's not necessarily just incumbent on them to seek out hospital care, uh. And they're definitely picked up even if they don't necessarily have means to pay. They're still taken care of in these military-run uh hospitals. They were also screened in largely, particularly the area where lot yellow fever patients were to be cared for, so mosquitoes could not get in and bite them. Now, this, of course, all has to be done. These are open-air facilities as he's building them, but this is what he proposes. And thirdly, his sanitary division itself was in charge of typical health department activities, street cleaning, garbage removing. There was a code of sanitary regulations that was drawn up for the canal zone, and health officers took charge of the enforcement. He also divides geographically the sanitary division. There was uh the one of Panama, which is based out of Panama City. There was one of Cologne, which is based out of Cologne, and then there was one for the rest of the Canal Zone. The Canal Zone itself was also in charge of a chief sanitary inspector and an assistant chief sanitary inspector. There are sub-districts in there where that there was uh a sanitary inspector in signs so they could go through the health codes and make sure they were being followed everywhere and all the cleanliness was being managed. There was an inspector entomologist, uh, an insect specialist, which as you might imagine is quite important when you're dealing with mosquito-borne illnesses and so on. And so, you know, when the large numbers of workers start arriving in 1904, this is the plan. And Gorgas submits it to this canal board. But remember what he said, the canal board does not have any medical folks on it. Engineer Wallace was supportive, uh, but it wasn't really his thing. And Gorgas says that his program to manage the health of the canal zone is going to cost a million dollars. Now, this is a million dollars in $1904. It's hugely expensive. They just they don't get it. And one of the problems of the early activities in the canal zone is that everything, every cart, every expenditure, every work detail, everything has to be approved directly by this committee. Remember, they said their charge was largely to ensure that the money was being spent efficiently and in a non-corrupt fashion. Of course, ironically, this has the effect of slowing down everything. Almost none of the equipment uh can be repaired, new equipment, carts, and so on can't be bought. The plans can't really be put into place of this million-dollar program that Gorgas proposes they allocate $50,000. I mean, they just don't get it. They absolutely don't get it. Uh and in fact, it is annoying to them that he keeps that gorgas keeps asking for these things and saying this is essential to get this canal built. Uh, and so they kind of quietly, some folks, start to try to have Gorgas fired. Uh, and the word gets up to the president. And uh around the same time, the chief engineer who's dealing with all these same problems, he can't do anything, he can't plan, he can't buy anything, he gets fed up. Now, this guy's only 51, was a pretty well-known Chicago engineer, uh, was thought to be inflatable, but he gets burned out and ultimately resigns uh with very little progress made uh on the initial activities leading to the Panama Canal. There are, again, these kind of grumblings and this groundswell from the uh from the committee to try to get this annoying Dr. Gorgas, Colonel Gorgas, fired from the canal project. And that word gets up to Roosevelt, who is considering the matter. And Roosevelt is visited by his personal physician, but you know, Oyster Bay, and and it's Roosevelt's personal physician says, Look, you've got a choice here. This is your project, this is gonna be your legacy, which really appeals to you know a Teddy Roosevelt type personality, right? And he says, Listen, you can either follow this committee and have this efficiency issue, or you can back Gorgas and get your canal. You can't get both. He said, You gotta do this. Roosevelt buys it. He very much sends forth the word to give Gorgas the resources that he wants and uh make sure that his recommendations are implemented. So now Gorgas has the backing. Ultimately, Roosevelt reorganizes the Panama Canal Committee. He's still got to work within the rules that Congress sets up, but he sets up an executive committee of just three of the seven members, um of which uh it only took two members to make these kind of basic decisions. So Gorgas could get what he wants. And as yellow fever starts to pop its head up in late 1904, at first it didn't, but again, with the with the workers' bog down, uh this new uh influx of non-immune folks from the United States coming in there, uh cases invariably appear and really start steadily increasing from November 1904 through December and into January 1905, and there are huge numbers, which ultimately uh by June 1905, there were uh 19 deaths and there were 62 active cases. And so they see this outbreak and it's really starting to rise. And there's a great fear. Remember, people are very afraid of this disease. They don't really understand it. Well, the medical folks do, the average people don't. You're really sick, you turn yellow, you're you know, black vomit. It was just horrible. Uh, and this, of course, had what had wiped out so many workers in the French effort. Um, and there are starting to be letters home, people saying, don't come. You know, even though you get paid these pretty great wages, it's not worth it to get yellow fever. You know, the administrators really start to have to quell this problem. About 500 or so workers leave. And you know, this is going to be a hugely labor-intensive thing. So if their labor force can't stay or they can't recruit a labor force, it is also not going to happen. So this really accelerates the emphasis on Gorgas' activities. And of this, his three areas, just as in Havana, right, he very much emphasizes the mosquito control. And here, too, he breaks it down into three different priorities. He's going to eliminate the breeding places of the Stegamaya fasciata mosquito. He's going to destroy infected mosquitoes wherever possible. And then he's going to prevent such mosquitoes that escape the other measures from becoming infected by screening the patients in the infected state. So he accelerates the building of the screens around the patient care areas in his hospital system. Again, remember, people can access this hospital system much more readily than the previous area. And of course, he divides areas into zones with an inspector in each zone so they could really try to get in there and do house-to-house level inspections to describe to discover cases of yellow fever as early as possible. People, uh particularly physicians, but but most everybody was required under a penalty to immediately report any suspicious case, anybody suspicious for having yellow fever. And as the number starts to go down later, they ultimately actually pay a bounty. They pay a reward for any number of cases that were reported. So by getting those patients to the hospitals and getting them cared for in screened-in areas, mosquitoes could not bite an infected person and therefore couldn't pick up yellow fever to transmit to someone else. So that starts going. The other measures, he starts introducing a piped water supply. So he really doesn't want and wants to get Panamanians away from the use of water containers. He actually prohibits the use of any sort of water container within 100 yards of a piped water supply, and of course, starts converting all the places where folks live to piped water. He starts looking for standing water. He removes, of course, what we talked about in the hospitals, but also he removes the pans of water under desks and beds in other places. He disallows them, he sends people in to get rid of them where the pipes weren't available yet, or cisterns were still needed, or water barrels were needed. They were screened in with a level of screening so that no mosquitoes could get in there. But when you had a patient discovered or an area where patients were being discovered, he would immediately fumigate or order that that room be fumigated to kill any mosquitoes that may have bitten that patient before they found them. Now we say fumigate, remember this is 1905, 1906. They're not necessarily using the eco-friendly uh pesticides that we have today. He would do things like burning sulfur for 20 minutes in there, which just had to be awful, but it had the effect of killing mosquitoes. He would also later burn things called uh pyrethans, which are derivatives of mums. We still use those insecticides today. They're a little less potent to doing the sulfur, but he does both of these things uh very, very promptly. Now, of course, this is gonna have the effect of killing not only the mosquitoes that transmit yellow fever, but also the mosquitoes that transmit malaria. There's so many cases of both malaria and yellow fever early on that he ends up ultimately fumigating almost every house in the Canal Zone and in Panama City and in Cologne. And of course, he very much recommends the screening in of porches and other open areas in the residences outside of the hospital and offers portable screens to folks to put around folks, uh, and it really starts having an impact. But you've still got all these other areas of standing water, right? There's water all over the place. I mean, again, this is Panama, it's the jungle, it's muddy where they've been digging. They um there still are certain areas where standing water uh is just unavoidable. And if they can't get rid of it, he starts spraying it with oil. And again, when we say spraying it with oil, what he really is doing is spraying crude oil on all standing water. If there was a puddle or a pond, he had sprayers come in, either man portable uh sprayers or larger machine-driven sprayers that would drizzle oil, crude oil, black, tarry oil, onto the standing water. Now, this has the effect of killing all the mosquito larvae that are in these uh waters. He called them Wrigglers, and he actually not only passed a law requiring the reporting of Wrigglers, he ultimately had a fine for having Wrigglers discovered on your property that you hadn't reported. So he's spraying oil all over the place. He requires brush around the area of the workers be cut down because it tended to hide smaller pools of water where the mosquitoes could breed or hide them from the prying eyes of the oilers that would go around. He has these folks spraying all the time. The canal ultimately starts going to 24-hour operations, and so too does Colonel Gorgas' spraying crew. He sprays water supplies everywhere. Again, large ponds he would spray, barrels he would spray. There would be oil on top of every bit of standing water. And of course, he had inspections going around apart from the sprayers to make sure that areas had been oilers, which poisoned the larvae. If there were areas, again, remember, part of Panama is mountainous, uh, so it's hard to get up to that. If there were areas in the canal zone that they really couldn't get up to oil, they tried to put fish in there that would eat the larvae. That was less successful. He said it really wasn't as successful as it had been in other places where he dealt with it. He also found that the fish didn't do pretty well, didn't do fairly well in the water that had been oiled, so you couldn't do both. He started putting out catching tubes and traps. To catch mosquitoes just generally around. He definitely became pretty rigid about segregating the non-immune and immune folks. Now, while today there is a vaccination for yellow fever, so immunization is possible in our modern world. At that time, there wasn't. But he did do a process of what's called what he called immunization by use of quinine. Now, it is not technically immunization, right? He's not stimulating an immune response by using a small dose of something like you would with immunization. Quinine, well known at the time as a treatment for malaria, is effective. Today we don't use regular quinine. We have other medicines that work a little better, and there's quite a lot of quinine resistance these days, but at the time there was less. And he not only uses quinine in the treatment of malaria patients, but he also recommends quinine be used prophylactically, so given to people that were not sick with malaria. And of course, malaria, like we said, is really, really, really common. So this has a pretty significant effect. And all this stuff goes simultaneously, and the disease rate plummets. Now, when I say this is a simultaneous thing that they're doing, I mean they're using as much as 65,000 gallons of oil per month in the canal zone, right? They are doing this everywhere. In places where they wanted to free up their sprayers to go look for more areas of standing water, they actually created these oil can drips where they would put a wick into a can of oil, let it just drip into streams that flowed in the drainage dishes. He would have the drainage ditches that were usually just mud pits, right? Either made out of concrete or tile. The French wanted to use the tile early on, but there just was only so much, which made them work better. And then he would drip oil, so there would be this oily sheen as the water flowed through, going down to wherever it went. He also would make sure that these wick cans were always going so that they would always have enough oil in there. Later they expanded the drainage ditches, and if they had to be made of dirt in certain areas, which they did as the construction moved, he would have those sprayed with tar. So you had kind of a tar ditch, which he said, you know, made the ditch last longer and less likely to wash out when they had flooding from all the rain. So really, he solves the mosquito problem and therefore the malaria and yellow fever problem almost immediately by oiling all this stuff, right? So he does trade one for another, and the the survivability of the workers goes up. Yellow fever basically was eliminated. The number of cases remains in the single digits per month in the canal zone. Very few workers get it. Malaria really starts being resolved as well. In all cases, the canal zone actually had lower rates than both Cologne and Panama City, the big cities with public health infrastructures that comes on. So he he is very successful in dealing with this particular uh scourge, which really helps deal with the workers' fear and the workers' health. And so ultimately, thousands of workers from both the United States and the West Indies come to the canal zone and work. Uh and the canal is able to progress on a schedule because the workforce was now healthy. Uh and when they weren't, they could be treated and get back to work fairly quickly. Now, this is fairly aggressive, fairly intrusive, mosquito control and other public health measures. Uh, but there are other issues that they also have to deal with. Typhoid, as we said, dysentery, right? A lot of the typhoid and dysentery problems are solved when they go to a piped water system, right? Water is brought to the residences through a piping system that is fed by water that is treated with sand filters and other filtration technology to remove pathogens. So you had clean drinking water that was coming in. And again, these drainage dishes, the sewers as they were, uh, were also upgraded and treated with oil. So that also begins to fall. And certainly, you know, you start seeing a pretty dramatic drop after the mosquito-borne illnesses start resolving. And in 1907, uh, the admission rate in the to the hospitals for typhoid fever among employees was about 14.45 per thousand employees. By 1913, as they're closing in on finishing the canal, it was down to 0.67, so less than one per thousand employees. And for uh disease classified as dysentery, just general diarrheal diseases, uh, same thing in 1907. It was 13.33 per thousand employees, and by 1913, it was only 2.07. And when you think about diarrheal diseases uh are the largest cause of morbidity in any sort of military operation or around the world and in developing uh areas to this day, uh, this is pretty remarkable in and of itself. Uh so they start uh building uh reservoirs for piped water all over the isthmus, and they uh the sanitary department under Gorgas starts conducting um laboratory surveillance of the water in the drinking water systems, a brief bacteriologic survey daily, uh, and then on a defined frequency on a larger chemical and bacteriological analysis of the drinking water to make sure that it was clean. Chlorine treatment of the filter to drinking water, the sand-filtered drinking water, was also implemented, and it was sent. The reports of these were sent to the to the chief health officer and to the governor of Panama, right? So the governor of the Canal Zone and the Panaminian authorities would see these things to make sure that they got the proper emphasis and were kept up. So the diarrheal diseases start going away fairly quickly after the mosquito-borne illnesses. Um flies were still a problem, you're still in the jungle, you got food. So a lot of effort was put into breeding and destroying them. Garbage pans, garbage cans and pails and all of these things had to be emptied daily, and the sanitary officer started inspecting that to make sure that they were. Most of the contents of these things uh were burned. The garbage cans themselves would oftentimes be disinfected, but the contents will be burned. Uh stable manure, remember, you got a lot of animals still uh running around, was disposed of by burning or burying or dumping at a sufficient distance, which and really every large site of workers or residential areas. They had a large crematory where they could burn garbage and manure. All kitchens were required to be screened to keep out flies, and they had to use fly traps. Again, this would be a standard thing today, and he implements all of this. Now remember, the whole project is moving. So they have, in addition to these permanent facilities, semi-permanent facilities, but they also required a lot of these measures to happen at the semi-permanent uh structures, so you didn't have areas where disease would pop up and not. It was really uniform across and very much centrally controlled by this Board of Health, all up to Colonel Gorgas, who's there the whole time. Uh he also does particular work around pneumonia. And while that wasn't a huge problem, one of the things that Gorgas does implement are changes to the housing of the workers, uh, particularly the low-end workers, which had been quartered in very tightly packed barracks. And they changed that rule and allow them to live in larger shacks that could be moved or torn down and rebuilt as the project moves. So pneumonia seemed to go away once those conditions were changed. Uh remember, this is really the pre-antibiotic area, so they can't, if you have bacteria, or uh they can't really treat it, but they can do these kind of living condition changes, which they do, and it has a pretty significant effect. Uh smallpox had been an issue for the French. Uh vaccination for smallpox was made compulsory in the canal zone, and the disease essentially disappeared. It was not there. Uh there were no cases among American employees that were there. Uh there was only, I think in the early days, three uh cases uh from folks coming from the West Indies in there. So they had huge efforts around all of these different activities to keep that canal zoned. So it tamps on all these different diseases, and it's all centrally controlled by Dr. Gorgas, who's really the hero of this particular story. As all these things are going simultaneously, you know, the workers are very healthy and they accelerate and ultimately complete the work ahead of time. Famously, Theodore Roosevelt becomes the only president or the first president at the time to leave the United States while in office. He comes down there to see for himself what's going on, and he's very impressed by Gorgas' activities and very much supports it. The subsequent engineers that come in just view these public health measures that are taken in the canal zone as part of doing business. And so it's all part of it or all rolls together. And this continues this way until the work on the canal is completed and the canal is in fact opened. Once the canal is opened, the public health activities are reorganized, but they continue on. There's still a good amount of effort. The hospitals continue. They become a general hospital for employees of the Canal Zone, members of the Army and the Navy that are there, the merchant marine, any sailor who is sick when they come to the Canal Zone and also be treated at these hospitals. There were an emergency hospital as well. There were hospitals under the direction of Panamania authorities in the city, the Panama City, that took care of all the same folks. The leper uh asylum, the place to take care of people with leprosy, uh, continued on and cared for all folks. It was ultimately taken over by the government of Panama and operated by them. The insane asylum was repurposed. It was like becoming a farm. And uh folks that uh were there for treatment of mental illnesses could work on the farm uh and supply things for Canal Zone residents. Uh they had very much an open-door policy, as they called it, which is extremely unusual at the time. So folks could self-admit for mental health issues and then could stay there until they felt recovered and could leave. They were not locked away or not warehoused in that sense. There were several smaller dispensaries in areas where folks lived. Uh, the Division of Sanitation uh was split again between Panamanian and uh U.S. authorities. The work continued on, and the success uh continued on, and the thoroughness uh continued, and there are many, many reports that come out where they continue all this work and they continue to see the success, right? And so Colonel Gorgas, in his last report, you know, really says that the cost of the sanitation effort properly ended up only being about one cent per capita per day for the total population. And once it was finished, it cost about $4 million, which is about uh $400,000 per year for the 10 years it took the U.S. to build the canal. That's just 1% of the total costs. There were other audits by the Canal Commission who said, well, it was closer to $6 million, but the difference comes in on what they called uh the sanitation effort, sometimes building the houses. You know, as Gorgas said, well, this is just the way you build houses, it's not sanitation per se. And they uh the the Panama Canal Commission says, well, that is we're doing it in the direction, it's not the way we would normally do it. So they put that $6 million figure. Either, though, when you look at it, it's not that much given the overall size of the project, the amount of money that was spent. You know, I mean, you're looking at $2.5 million that were spent for sewers and waterworks that goes on. So you have this out of this hundreds of millions of dollars that were spent, this really isn't that expensive. There are some upfront costs, as everybody points out, but he has tremendous success. And his success allows for the canal to be built, whereas others, like the French, who had not paid attention to public health, uh. So the Panama Canal at the time was hailed as this American triumph, really America coming onto the world stage. And it was American public health, not just know-how, but grit willingness and determination to scale up and do the things that were known to be effective, even when it incurred significant costs that allowed it to be. And those triumphs were heralded as much as the engineering triumphs. People looked at the doors and the locks and the ultimate final design of the canal, and that was heralded as was Dr. Gorgas' efforts and those uh uh that came behind him in Panama, both U.S. and Panamanian officials. It's kind of this is the greatness that humanity can achieve when you put all of your effort and your mindset into disease eradication. And so those efforts continued on for years and years and years. Obviously, today they don't spend the same amount of money uh on spraying oil on all the water in Panama. We have other ways to control mosquitoes and other ways to treat uh sick folks. But this was heralded, and so the Panama Canal only happens because of these public health heroes. Uh to this day, the equivalent of the Nobel Prize for uh preventive medicine or military preventive medicine given by the AMSIS Association of Military Surgeons of the United States is the Gorgas Award given annually. Dr. Gorgas goes on to do several other things, but very much considers uh the Panama Canal success one of his greatest triumphs. Uh, and he was at the at the end of his life, he was really thought of as the biggest uh um expert, the number one thinker in tropical disease control, especially after Walter Reed dies, all because of him reluctantly accepting this data-driven approach and then implementing the consequences of those data with military precision and aggressiveness. So that's uh the story of how the Panama Canal was built by public health efforts. I hope you enjoy it. I look forward to seeing you again on another episode of the Filth in America podcast.