Though both infections cause broadly similar symptoms – fever, headaches, vomiting – they follow different courses. Malaria, a parasitic invasion of the red blood cells, recurs constantly. Adults with malaria often survive, and if exposed to it over a long period, patients will build up some limited immunity. Yellow fever, by contrast, is caused by a virus that kills very fast. But patients who recover are then completely immune for the rest of their lives.
By December 1884, just a month after his arrival in Panama, Philippe Bunau-Varilla could see signs of illness all around him. ‘Never had the yellow fever been more deadly,’ he wrote in his journal. ‘Some fathoms from my house at Colón, ships were anchored in the Company’s harbour with not a single soul on board. All the crew had died.’
At first, it was inevitable that Bunau-Varilla, who counted himself blessed to be a Frenchman and who regarded survival as a sign of godliness, put a moral slant on the disease. ‘The chief accountants of the two divisions placed under my orders were intimate friends,’ he wrote.
They had come together to the Isthmus, they lived in the same house and ate at the same table. One of them was an irreproachable character, while suspicions clouded the other’s reputation. Public rumour, when I arrived, imputed to him certain reprehensible acts. They concerned the payment for some heads of cattle bought for feeding our workmen, when the interruption of the train service by the insurrection nearly caused a famine in Colón. People spoke of fraudulent payment to the purveyors with the complicity of the accountant. A rapid inquiry strengthened the accusation in my mind. I ordered the incriminated man to appear before me on the following morning at seven o’clock. His no doubt heavily burdened conscience, as well as the certainty of finding no mercy from me for a breach of honour, so troubled him that he fell ill with fever and was taken to the hospital.
Eight days later he was carried to the cemetery. His comrade and friend, who was unaware of the cause of his disease, was terribly frightened when he left him to go to the hospital. ‘If he dies,’ said he, ‘it will be my turn next.’ But in the event he did not succumb.
Many a time I went to see the ships as they arrived from Europe filled with employees. Many a man on them had been happy to enlist, but felt his heart sink at the sight of the warm, low and misty shores of the deadly Isthmus. Some bore on their faces the obvious mark of terror. I often took note of their names to see how they would stand the trial. Without exception they were dead within three months, if they had not fled the Isthmus.
For every eighty employees who survived six months on the Isthmus one could say that twenty died.
Bunau-Varilla’s observations were harsh, and his conclusions hardly scientific. By the end of 1884, more than a hundred workers were dying each month in the two main hospitals. This was ten times the death rate two years earlier, but given that many more men died at home or on the construction site, the real figure was much higher. William Gorgas, the army doctor who would take over running the medical programme while the canal was being built by the Americans in the early twentieth century, reckoned that for every death recorded in French hospitals there were at least two more outside that were not counted. De Lesseps, le grand français, began to be called ‘The Great Undertaker’.
The months after their arrival were terrible for the Dingler family who crossed the Atlantic with Bunau-Varilla. Their daughter was the first to succumb, to yellow fever. A dark-haired, pretty girl of eighteen, she liked riding side-saddle into the hills wearing a full skirt and a little Panama hat. ‘My poor husband is in a despair which is painful to see,’ Madame Dingler wrote to de Lesseps’ son Charles. ‘My first desire was to flee as fast as possible and carry far from this murderous country those who are left to me. But my husband is a man of duty and tries to make me understand that his honour is to the trust that you have placed in him and that he cannot fail in this task without failing himself. Our dear daughter was our pride and joy.’ Jules Dingler, his twenty-one-year-old son and his daughter’s fiancé rode at the head of a long procession to the cemetery.
A month later, Dingler’s son showed signs of the disease. Within three days, he too was dead. Presently, the fiancé died, also of yellow fever. And on 1 January 1885, at the height of the epidemic, Madame Dingler too succumbed. Ever the public servant, the Chief Engineer was at his desk by seven the next morning. But Dingler’s grief finally caused him to lose his mind, and he sailed back to France. In the absence of anyone else available, Bunau-Varilla was appointed in his place.
Within a few months, though, it was Bunau-Varilla’s turn to fall ill. At the end of March, he lunched with a group of French officials from the Quai d’Orsay who had come to view the progress of the canal. Arrangements were made to meet the following morning to begin the tour of inspection. That night, Bunau-Varilla’s valet, George Octave, was awakened by the sound of his master tossing feverishly in bed. Octave ran to the nearest cottage, where some of the canal’s technicians slept, yelling: ‘The calentura! Master Philippe has the calentura.’ Within half an hour, a doctor and a retinue of attendants had arrived.
Bunau-Varilla had seen from his hospital visits how few patients recovered from the dreaded yellow fever or malaria. To prevent the former he swallowed a concoction given to him by a local curandero, or healer, while for the latter he took regular doses of quinine. If he fell ill, he instructed his servants, under no circumstances was he to be moved from his quarters. On the third day of his confinement in his room he was visited by a French doctor. Sitting up, Bunau-Varilla observed: ‘I am doing as well as a man can do when approaching the cemetery.’
‘Why do you say that, Monsieur le Directeur?’ asked the doctor.
‘Because at the start, my pulse was sixty to the minute, the following day it had fallen to fifty, yesterday to forty … and today it is thirty. In three more days I will not be here to make any more observations about myself.’ Knowing that Bunau-Varilla was in the habit of taking quinine and the treatment prescribed by the curandero, the doctor suggested the dosages of both be increased. Before long, the patient fell asleep, and by the following morning the decline in his pulse rate had been reversed. Within days, Bunau-Varilla was up and about.
My great-grandfather’s self-prescribing, though it may have worked, casts little light on the practice of medicine in nineteenth-century Panama. The French established two main hospitals, one in Ancón, close to Panama City, and the other on Limón Bay, which surrounds Colón, the port on the Atlantic side where Bunau-Varilla arrived in Panama. Other than that there were small medical outposts and dressing stations at various posts along the railway line that crossed the isthmus. Sponging and bloodletting were still the favoured treatments for fever even as late as the 1880s, though there were people who swore by bourbon and mustard seed as an ‘infallible specific’ for yellow fever. Fever was regarded as an ailment in its own right, caused by an imbalance of the humours, rather than as a symptom of disease. Malaria, or intermittent fever as it was called, was said to be caused by the miasma. Yellow fever, or the vómito negro, for its black vomit, was considered to be directly contagious, and anyone diagnosed with it could be certain to have his bedding and belongings burned within a few hours. The true nature of parasitic disease and the role of the mosquito in transmitting both malaria and yellow fever were completely unknown, and the insects were allowed to flourish unchecked. There were no screens at the windows, and no attempt was made to isolate patients with contagious diseases – hospital patients were allotted beds by nationality rather than by illness.
De Lesseps’ Compagnie did not place a premium on keeping its workers healthy, and although the price of quinine had begun to slide a little after the American Civil War, it still traded at nearly five hundred French gold francs a kilo. The management believed it was cheaper to replace sick or dying workers with fresh men than to spend a lot of time and money treating them with quinine in hospital. It thus instituted a policy of ignoring quinine altogether, and refusing to dose its workers. The only qu
inine available was what the engineers, usually the most senior among them, had brought with them for personal use. My great-grandfather’s supplies were sent to him regularly from Paris by his mother.
In 1889 Ferdinand de Lesseps’ Panama Canal project collapsed, and the Compagnie Universelle du Canal Interocéanique was declared bankrupt. The last straw was a bond issue that failed. On the morning of the subscription a bogus report swept the globe announcing that de Lesseps had died in his sleep. De Lesseps himself describes its effect: ‘Lying rumours and false telegrams announcing my death were circulated all over the world! The scoundrels had chosen their time well; for a denial could not be issued until too late … A complaint has been lodged with the public prosecutor, who has started an investigation into these criminal acts.’ The culprits were never found, and de Lesseps’ last-ditch attempt to save his company, a whirlwind tour of France to drum up support for the bond issue, ended in an impassioned plea: ‘I appeal to all Frenchmen. I appeal to all my associates whose fortunes are threatened. I have dedicated my life to two great works which have been called impossible: Suez and Panama. Suez is completed and France has been enriched. Do you wish to complete Panama? Your fate is in your hands. Decide!’ Only half the bonds were taken up. The public had decided.
By the time the Americans took over the building of the Panama Canal in 1903, much had changed. Panama itself, which had formerly been only a province of Colombia, had seceded. Its revolution was protected by American warships ordered there by Theodore Roosevelt, for Washington had been offered the canal and a strip of land on either side, the canal zone, in return for its backing. The Americans had been prompted to become involved after one of their ships, the Maine, was blown up in Havana harbour at the start of the Spanish-American war in 1898. The only ship that could come to its rescue, the Oregon, had been forced to sail twelve thousand miles around Cape Horn for lack of a Central American canal. The journey took sixty-seven days, and the Oregon arrived as hostilities were coming to an end.
‘If we are to hold our own in the struggle for naval and commercial supremacy,’ Roosevelt later told a Chicago business club, ‘we must build up our power without our borders. We must build the Isthmian canal, and we must grasp the points of vantage which will enable us to have our say in deciding the destiny of the oceans of the east and west.’ His bravado notwithstanding, Roosevelt was denounced in the press for not having consulted Congress more before supporting Panama’s secession. He turned to one of his more humorous cabinet colleagues for support:
‘Have I defended myself?’
‘You certainly have, Mr President,’ came the reply. ‘You have shown that you were accused of seduction and you have conclusively proved that you were guilty of rape.’
Philippe Bunau-Varilla set out early on to enlist Roosevelt’s help. He saw off a rival claim to build another canal across the isthmus in Nicaragua, by sending a postcard with a Nicaraguan stamp to every member of Congress and anyone else he could think of besides. The stamp showed the Nicaraguan volcano Mount Momotombo in full eruption. On the card he wrote, ‘An official witness of the volcanic activity on the isthmus of Nicaragua.’ If there was one thing a trans-isthmian canal did not need it was a live volcano nearby; any hint of one was bound to frighten off potential investors.
In November 1903 a treaty formalising the annexation of the canal zone was drawn up in Washington. John Hay, the American Secretary of State, signed it on behalf of the United States, Bunau-Varilla for the French. In a letter to his eleven-year-old daughter, my grandmother, he described his life’s work as ‘the struggle I kept up for the defence and triumph of the greatest moral interest which the French genius has ever had abroad’.
French genius there may have been, but the US Army applied different methods to making the Panama Canal project succeed. Where there was chaos, it instituted order; it upgraded the technology, rationalised the machinery used on site and carefully marshalled thousands of workers. But nowhere did the army make more difference than in the methods it deployed for fighting disease.
This was no straightforward or easy task. Colonel George W. Goethals, who took charge of the canal works after Panama’s secession, was aghast at the cost of maintaining the health of his workers. Much of the sanitary work being done was on the basis of the newly propounded theory that malaria and yellow fever were spread by mosquitoes.
‘Do you know,’ Goethals once asked the head of the sanitary department, William Gorgas, ‘that every mosquito you kill costs the United States government ten dollars?’
‘But just think,’ Gorgas replied. ‘One of those ten-dollar mosquitoes might bite you, and what a loss that would be to the country.’
Despite Goethals’ efforts at thwarting him, Gorgas had the support of President Roosevelt, who had appointed him with the instruction that he should do whatever was necessary to wipe the isthmus clean of disease.
William Crawford Gorgas was born in Mobile, Alabama, in 1854, the son of a Confederate Chief of Ordnance. He followed his father into the army, and throughout his life he remained a doctor first and an army officer second. During the Spanish-American war he served in Cuba, initially assisting on the experimental work which established the connection between fever and mosquitoes, then on the constantly developing precautions for eliminating malaria and yellow fever. In Havana he worked closely with Carlos Finlay, a doctor of Franco-Scottish extraction living in Cuba, who as early as 1881 first put forward the theory of a link between yellow fever and the mosquito. Gorgas carried out a number of experiments in an effort to turn Finlay’s inspired guess into proven fact. He had volunteers bitten by mosquitoes, injected with parasites and toxins, and made to sleep in vomit-covered bedding surrounded by bowls of excreta donated by yellow-fever patients. Some of these selfless volunteers contracted yellow fever; some even died. But their sacrifice was not in vain. Early in 1901 the Army Medical Board was able to state categorically that yellow fever was transmitted by the Aedes mosquito, that this mosquito must previously have fed on the blood of an individual sick with fever, that an interval of at least twelve days after feeding on the blood of a yellow-fever victim was needed before the mosquito could pass on the disease, that the period of incubation after a bite was between forty-one and 137 hours, and that infection could not be passed on by clothing, bedding or vomit.
In March 1904, Gorgas was appointed Chief Sanitary Officer to the Isthmian Commission, at the instigation of President Roosevelt. He was based at the hospital in Ancón, from where he was determined ‘to do what I could to prevent the enormous loss of life which had attended the efforts of the French’.
Gorgas was initially hampered in his work by bureaucracy, lack of funds and deep scepticism about the mosquito theory. ‘The whole idea of mosquitoes,’ the chairman of the Isthmian Commission told him, ‘is the veriest balderdash.’ The Governor of Panama was, if anything, even more direct: ‘I’m trying to set you straight, Gorgas. On the mosquito you are simply wild. Get the idea out of your head. Everyone knows that yellow fever is caused by filth.’
It was not until 1905, nearly two years after the Americans took over the canal, that Gorgas was given the go-ahead he needed to carry out Roosevelt’s instructions. What had changed the climate of opinion was yet another outbreak of yellow fever in the winter of 1904. Although it killed no more than eighty-four people, the epidemic showed how very easily the American-run canal zone could be threatened by the same disease that had seen off the French. A new Chief Engineer, John Stevens, was appointed, and on 2 August, just a week and a day after his arrival, he told Gorgas that he could have all the money, supplies, equipment and men that he needed. Ten years later, after the canal was opened, Gorgas, by then the US Surgeon-General, wrote privately to Stevens:
I have a very clear and grateful recollection of the support and friendship you always gave me on the isthmus. I knew very well that you were the only one of the chief officials who believed in the sanitary work we were doing, and who was not taking active mea
sures to oppose us. The fact is that you are the only one of the higher officials on the isthmus who always supported the Sanitary Department, and I mean this to apply to the whole ten years, both before and after your time, so you can understand that our relations, yours and mine, stand out in my memory of the very trying ten years I spent on the isthmus as a green and pleasant oasis.
The first task Gorgas set himself was to eliminate malaria and yellow fever from the isthmus. He used many of the methods he and Carlos Finlay had worked on in Havana. In the late summer of 1905 he attacked the breeding grounds of the mosquito. The use of water containers within a hundred yards of any piped supply was prohibited. Ponds, cisterns and cesspools were to be coated with oil once a week. Where water barrels had to be used, they must be screened. It was made a punishable offence to harbour mosquito larvae, even if done inadvertently. Inspectors made house-to-house searches for the larvae, and a poor report would quickly be followed by a visit from commission carpenters, who repaired sagging gutters, put up screens of copper-wire mesh, and emptied out infected tinafas, stoneware jugs, and the bowls of water that helped protect hospital patients from enthusiastic spiders.
The inhabitants of Panama City submitted with good-humoured, if bewildered, resignation, though they were less amenable to the second plank of Gorgas’s campaign: fumigation. Initially, only those houses in which a case of yellow fever had been diagnosed were fumigated. Gorgas knew from first-hand experience that a mosquito had to have fed on the blood of a yellow-fever carrier to become a carrier itself. But it was only when it was seen how effectively fumigation destroyed mosquitoes and hampered further breeding that fumigation was extended to all houses in Panama City and Colón. By the summer of 1906 every building in both cities had been meticulously sterilised.
The Miraculous Fever-Tree Page 19