improvements which go to make a city sanitary does not end here. Broad, well
paved market places; suitable play grounds; bright, well ventilated school houses;
in short, whatever the city has in the way of plant which goes to prevent the in-
juries to health which result from too densely segregated masses of people might
properly be comprised under the head of sanitation ; but in every-day parlance
they are not so included.

Yielding to works of sanitation are not only typhoid, dysentery and other
diarrheal diseases, but many other forms of sickness. To introduce a public supply
of pure water in place of a polluted one, or to build a sewerage system in a town
which has had no good way of disposing of excrement, is to reduce the prevalence
of nearly every disease from which men suffer and die. Nothing that can be done
is so certain to lessen the death rate.

It would ^ be interesting to know exactly the extent to which sanitation
decreases municipal death rates, but the effect cannot be stated in numerical figures.
Municipalities which are so backward as not to possess good sanitary works are
usually too backward to know how much preventable sickness and death they have.
And unless we know the sickness and death rates before and after the introduction
of a sanitary improvement it is impossible to say precisely how great the benefit is.



340 SECOND PAN AMERICAN COMMERCIAL CONFERENCE

Sanitary works possess a number of advantages as compared with other
measures for the prevention of disease. For one thing, they no not require as
high a degree of skill in their administration as do boards of health. For another,
they have an advantage over personal precautions in not being individual in applica-
tion and uncoordinated in action. Sanitary works have a wholesale application. A
water supply which is pure is wholesome for every person who has occasion to use
it. The street that is well paved and kept clean is of advantage to every one who
travels over it by vehicle or foot. And sanitary works do not hide their merits
under a bushel. Their good effects are in plain sight a constant recommendation
of the good sense of those who are responsible for the welfare of the community.

How the Sanitary Development of the Modern City Has Been Accomplished.
To trace the progress of ^anitation in Europe and North America is an instruc-
tive undertaking, for this history contains many useful lessons. In both continents
a deliberate intention exists to regulate the growth of cities along lines which
make for order, convenience, comfort, safety, health and beauty. From the first
sanitation has been a feature of many American cities. Sanitation, although long
delayed, when it came, came like a revolution to the continental cities of Europe.

The beginnings of municipal sanitation everywhere are due to European
initiative. Public water supplies, as we know them today, and sewers to carry
away the most offensive and dangerous part of a city's filth, are a recent European
contrivance. Street lighting, good pavements, adequate transportation, tenement
house reforms, the construction of parks and playgrounds, the regulation of
vehicular travel and street paving and cleaning having been developed more
recently. The American city which ignores foreign practice in these directions
fails to take account of experience which can save it a great deal of money.

The sanitary regeneration which European cities have experienced has had
no counterpart in the United States. There has been no necessity for such
revolutionary changes. American cities were small when the world began to learn
that sanitation was an indispensable feature of every municipality. There was
never such overcrowding, such slums to clean, such foci of filth to clear up and
eliminate, as existed abroad haljF a century ago. In 1860 there were only sixteen
cities in the United States with a population of 50,000 or more, as against one
hundred and forty-eight in Europe.

The significant feature of municipal growth in America as compared with
that in Europe has been less the reconstruction of cities already large than the
construction of a great number of small cities. Hundreds of these have passed
and are now passing through their periods of infancy, youth and ^ adolescence
toward a maturity which foreigh cities attained long ago. Their sanitation takes
place as they grow.

The first important sanitary improvement to be made in the growing village
is the public water supply. This leads to the use of water closets and, to accommo-
date the drainage from these, cess-pools are built. The privies, the original pro-
vision for the disposal of excrement, are then eliminated. Street pavements are
presently considered and the cleaning of the pavement and the collection of house
refuse by municipal" effort followed. At first garbage is collected by scavengers
at the private expense of the householders; later it is done at public expense.
The young city may now be said to have passed through its period of infancy and
entered that of youth.

A sewerage system is built later in the city's growth. During this period
the houses are gradually built closer to one another and in a more permanent
form of construction until they stand in a compact mass. More attention is given
now to pavements and to the cleaning of them. Parks are laid out, lighting is
improved, ordinances are passed regulating many sanitary matters. The city has
now reached its period of adolescence.

The period of maturity, that is, the period in which civic responsibility begins
fully to express itself, come last. The regulation of building construction, the con-
trol of traffic and the adoption of farsightect plans to insure public health and
safety are often taken up at this time. They should have been considered at a
much earlier period. It is always easier to carry out a plan which has been made
before-hand .than one which has had to be prepared after permanent constructions
and settled procedures have for some time been in existence.

How to Get Better Sanitation. It is instructive to observe how often it is
that a community owes its sanitary improvements to its business men. It might be
supposed that the principles of sanitation were more within the grasp of profes-



SANITATION 341

sional men than of those whose attention was chiefly occupied with manufacture
and trade and that doctors and lawyers and ministers would be foremost to see
that the health and welfare of the public were properly looked after. This is not,
however, always the fact. There is no disposition to belittle the help which pro-
fessional men can give, but an experience in public work which covers many years
and extends over many cities and states shows that when it comes to municipal
improvements it is the commercial element which usually exercises both the
initiating and sustaining influence.

The explanation of this is simple enough. The general subject of sanitation
is not so complicated as to be the exclusive province of any class or profession.
Certainly the need of sanitation and the benefits of it can be understood by every
intelligent person. Business men are accustomed to weigh returns against ex-
penditures and readily appreciate that sanitation is a sound investment. Moreover
they are accustomed to action and when they get together to obtain action for the
public welfare they are apt to get it.

Often the important thing to know is what to do in order to improve the
sanitation of a city. Why is the death rate high? What should be done to reduce
it under the particular circumstances which exist? In answering these questions
many technical and financial details may have to be considered. This is properly
the work of experts. An unprejudiced expert should be called on to make a
report based on a study of the local situation and on a knowledge of what other
cities have done and are doing under similar circumstances. This report should
serve as a program behind which the solid common sense -of the municipality can
array itself.

When a city needs a health program, as every city does, the best way to get
it is for the business men to demand it of the municipal administration through
their commercial organizations. If the municipality does not possess the talent
for the work an expert should be called in from outside. In many cases commercial
organizations have themselves employed experts to make 'investigations and reports
to serve as a guide to the citizens in demanding what is proper.

The question is often asked, what can a city afford to spend for sanitation?
The answer is that it can afford to spend whatever is necessary in order to make
it healthy. If it is already healthy it need spend but little ; if it is unhealthy it must
of course spend more. A city, like a man, must have health if it is fully to realize
its possibilities. Epidemics paralyze business and a high death rate is a reflection
upon the good business sense of a community. In many cases investments for
sanitation should be looked upon as insurance policies.

Every city and every village ought to have a program of development; a
plan to build to, a settled scheme of construction to refer details to. This program
should be prepared early in order to keep the growth properly proportioned and
prevent the excessive development of some relatively unimportant features at the
sacrifice of the essential. Paramount in such a scheme should be suitable pro-
visions for health.

Although a considerable investment of capital has to be put into sanitary
works, the maintenance charges are not excessive as compared with the adminis-
trative costs of hand labor which is often used as a substitute to accomplish the
same result. It must not be expected, however, that good sanitary works can be
built or that they can be effectively operated without care. Skill and attention in
design and construction and operation are indispensable to the best results.

Although no attempt will be made here to show what large investments
are made by every up-to-date city for the purposes of sanitation, it may interest
some to ^know what share of the total yearly outlay is devoted to this purpose
by the cities of the United States.

Among the 219 cities of 30,000 or more population in the United States for
every ten dollars put out each year for all purposes of administrative effort 'one
dollar and ten cents on the average is expended for health and sanitation. The
amount varies among the different cities according to the natural advantages of the
site with reference to water supply, drainage, kind of population and commercial
and industrial conditions, and according to the foresight and business ability with
which the work is planned and carried out. The percentage of the total yearly
expenditure which is devoted to health and sanitation sometimes runs as high as
twice the figure stated and occasionally falls to about one-half of it. The size of
the city does not affect the per cent.



342 S-ECOND PAN AMERICAN COMMERCIAL CONFERENCE

THE POPULATION AND SANITARY PROGRESS OF SOUTH AND CEN-
TRAL AMERICA AND THE WEST INDIES

BY FREDERICK L. HOFFMAN, THIRD VICE PRESIDENT AND STATISTICIAN, THE
PRUDENTIAL INSURANCE COMPANY OF AMERICA, NEWARK, N. J.

(Read at the Afternoon Session of Thursday, June 5)

The present address is in part an amplification of a previous discussion on
the "Significance of a Declining Death Rate," originally read before the National
Conference on Race Betterment, Battle Creek, Mich., January, 1914. Few seem to
realize the truly tremendous significance of mortality changes or the effect of a
declining death rate on population growth and development. Combining all the
statistics available for South and Central America and the West Indies, it would
appear that the population has increased from approximately 52,000,000 in 1886 to
89,000,000 in 1915, an actual increase of 37,000,000, equivalent to 70.2 per cent. The
annual rate of increase, however, for this period is not quite 2^ per cent, or
equivalent to an actual annual population growth of about 1,227,000. If this rate
of increase should continue for the next 50 years, there would be by 1965, on the
assumption of a geometrical ratio, a maximum population of 223,500,000, or, on a
much more conservative arithmetical ration, a minimum population of 150,500,000.
In neither of these estimates is proper allowance made for the affect of a further
and material decline in the general death rate, which, if taken into account, would
seem to justify the assumption that by 1965 the probable population of South and
Central America and the West Indies will not be less than 200,000,000.

Such a population growth must necessarily imply truly tremendous oppor-
tunities for trade and commercial intercourse. With the improvement in transpor-
tation facilities the enormous natural resources of this vast area will become avail-
able and will naturally offer a further inducement to population growth by immi-
gration. It is a reasonable assumption that in less than 25 years our foreign trade
with the countries to the south of us will be far in excess of the present amount,
which is out of all proportion to the opportunities for a highly developed com-
mercial intercourse.

The recent growth in population is in a large measure the result of favorable
mortality changes. Combining the available mortality statistics for 22 cities of
South and Central America and the West Indies, with a population of not quite
6,000,000 in 1913, it appears that the general death rate of this registration area
has progressively declined from 24-5 per thousand of population in 1904 to 23.2
in 1909, and to 20.1 in 1914. Dturing 1915 the rate was only 19.1 per thousand.
During the last two or three years the rate has been somewhat higher, but returns
for all the communities concerned are not as yet available.

The mortality rates, though relatively high, must nevertheless be considered
most favorable in view of the fact that the cities under consideration include a
large proportion of Indian, negro and mixed-blood population, subject to a higher
death rate than the native white element. In the southern States of the United
States, for illustration, the death rate of the white element is 13.0 per thousand, and
of the colored 19.0. The sanitary progress of practically all the principal cities of
South and Central America and the West Indies is therefore most gratifying
evidence of an aroused interest in sanitary reforms. The possibilities of a further
reduction are, however, extremely encouraging. The earlier excess was largely in
consequence of a high death rate from small pox, yellow fever and malaria and
its complications. Modern sanitary reform' concerns itself not only with acute
infectious diseases, particularly water-born or insect-born, but also with the larger
question of physical examination and the medical supervision of children and young
persons as best illustrated by the remarkable work of Dr. Louis Shapiro in Costa
Rica. Before enlarging upon the details for particular localities, attention may be
directed to the available mortality records of some 20 states of Central and South
America and the West Indies, though more or less incomplete for the earlier years.
The average death rate of this group, which in 1915 had an aggregate population
of 30,000,000, decreased from 30.7 per 1,000 of population in 1897 to 27.2 in 1902,
and 26.0 in 1907. The most remarkable decline, however, occurred during the last
ten years, when the rate was reduced to 20.0 in 1912 and to 18-8 in 1915. Granting
that the returns are merely an approximation, they are for too large an area and
too vast an aggregate of population not to be, in the main, sufficient for the present



SANITATION 343

purpose. The fact must not be overlooked that even for the United States we
have trustworthy mortality data for only two-thirds of the total population, and the
returns are chiefly for very recent years. The progress in the registration of vital
statistics, their accuracy and scientific classification, is commendable evidence of
the high degree of attained civilization in the countries and cities to the south of us.
The area of South and Central America and the West Indies is approxi-
mately 8,268,000 square miles, against not quite 3,000,000 square miles for the
United States and not quite 4,000,000 square miles for Canada and Newfoundland.
The approximate density of population in 1915 was about 11 persons per square
mile for South and Central America and the West Indies, against 2.1 for Canada
and 33.8 for the United States. It, however, is a safe assumption that a much larger
area in South and Central America and the West Indies is fit or useful for human
habitation than is the case with the waste spaces of northern Canada, reaching prac-
tically to the Pole. It is furthermore a self-evident conclusion that the area under
consideration in the countries to the south of us has vastly greater potential pos-
sibilities for future growth and development, all inter-dependent with a healthy
population growth. Further sanitary progress, in South and Central America and
the West Indies must enormously enhance the productive capacity of these countries,
which as yet have only commenced to contribute to the world's increasing need
for adequate food supplies. If, for illustration, the population of such an island as
Jamaica were entirely rid of malaria and related diseases, of ankylostomiasis,
syphilis and yaws, the productive capacity of that most beautiful island in the
West Indies would be enormously increased. In Costa Rica, under the direction of
Dr. Shapiro and the International Health Board, there has been a veritable physical
regeneration of the people due to the gradual elimination of ankylostomiasis,
malaria and kindred diseases. What is imperatively needed is more information
and such investigations as those of the Harvard School of Tropical Medicine, whose
report of a First Expedition to South America was issued in 1913, is a favorable
indication of substantial progress. First and last, however, the health problem
of South and Central America and the West Indies concerns malaria, and it is to
be hoped that the resolution adopted by -the Second Pan American Scientific Con-
gress, reading that:

The Second Pan American Scientific Congress, recognizing that
the education of the public in the elementary facts of malaria is of the
utmost importance, requests that

The. American Republics inaugurate a well-considered plan of
malaria eradication based upon the recognition of the principle that the
disease is preventable to a much larger degree than has thus far been
achieved,

will not be lost sight of, but made the corner-stone of a new and active health
propaganda throughout the countries concerned. During the year 1916 the average
death rate for the United States registration area was 14.0 per thousand of popu-
lation. For the city of New York for the same year the death rate was 13.9 per
thousand ; for Buenos Aires the death rate was 14.6 per thousand during the year
1916, against a rate of 22.1 in 1895. The city of La Plata decreased its mortality
from 18.0 in 1911 to 15.6 in 1916. The city of Rosario Santa Fe reduced its death
rate from 28.9 in 1900 to 18.9 in 1915. In Brazil exceptional progress has been
made, but the outlook for the future is particularly encouraging, due to the coop-
eration of the Brazilian government with the International Health Board of the
Rockefeller Foundation. Such reports as those on 'The Sanitary Conditions and
Diseases Prevailing in Manaos, North Brazil," by H. Wolferstan Thomas, of the
Liverpool School of Tropical Medicine, are evidence of sound scientific methods
which must needs lead to promising results. Superficial surveys and observations
like those, for illustration, contained in the Rice Expedition to Brazil, are more of
a hindrance than a help. A splendid report has been published on the Sanitary
Campaign in Brazil, by Dr. Theophilo Torres, Vice President of the National
Academy of Medicine, but unfortunately no translation in English thereof is at
present available. The same conclusion applies to the Memoirs of the Institute
of Oswaldo Cruz, which are available to the student of tropical medicine, but
which at the same time reflect the enormous sanitary and health progress of
Brazil as the result of strictly scientific investigations not surpassed by the re-
search work of any corresponding institute in the world. Amng the many illus-
trations of the useful \\ork of the Institute of Oswaldo Cruz, proper mention may
be made of a scientific investigation by two physicians, based upon personal inquiry



344 SECOND PAN AMERICAN COMMERCIAL CONFERENCE

in the states of Bahia, Pernambuco, Piauhi and Goiaz. The authors, for illustra-
tion, in discussing leprosy make the statement that this disease is particularly
prevalent in the southern part of Goiaz. Valuable observations and statistics on
leprosy are included in the reports of Dr. Mario da Silva Nazareth, made to the
sanitary authorities of Rio de Janeiro. What is true of Brazil is more or less true
of every other state of South and Central America, although, unfortunately, the
official evidence is rarely accessible to American investigators. The government
of Argentina has, for illustration, made public some extremely valuable researches
on Malaria Prophylaxis, and on the results of local efforts to eradicate malaria
in the most affected areas. If these reports were available in English they would
be most useful to the American Malaria Committee and other students of a health
problem of the first importance.

The sanitary progress of Brazil is reflected in the material improvement in
the health of the principal cities. In the city of Bahia there has been a decrease
in the death rate from 34.5 per thousand in 1897 to 13.6 in 1915. For the city of
Bello Horizonte, the death rate declined from 22.3 per thousand in 1908 to 16.8
in 1916. The city of Manaos reports a decline from 35.4 in 1903 to only 15.3 in
1907, and for the city of Pelotas the reduction is reported from 22.5 in 1899 to
18.3 in 1917. The most extraordinary decrease in the death rate, however, occurred
in the city of Rio de Janeiro, which in the period 1859-63 had an average mortality
of 58.2 per thousand of population. The rate declined to 30.5 during 1884-88 ; to
only 20.8 during 1914-17, and to as low as 18.8 during the year 1916.

Such evidences of progress are not the result of chance, or of natural causes,
but they are the consequence of a deliberate policy of sanitary reform and sanitary
control. Other illustrations could be given for practically all the states and cities
of South and Central America, including the West Indies; but additional details
would unduly enlarge the present discussion. There are, of course, exceptions, for
there remain a number of localities with decidedly unsatisfactory health condi-
tions. It is, however, a foregone conclusion that in a few more years these also
will be under reasonable control. Reference need only be made to the fact that
the city of Havana in 1898 experienced a death rate of 89.1 per thousand of popu-
lation, against a rate of 18.8 per thousand during 1916, and that the city of
Guayaquil experienced a decline in the death rate from 57.7 in 1897 to 42-1 in 1911
and 34.7 in 1917. It is sincerely to be hoped that the investigations which are now.
being made by a special commission of the International Health Board of the
Rockefeller Foundation, of which Major General Gorgas is the chairman, will
result in far-reaching benefits to the localities in the southern portion of the
Western Hemisphere which are still afflicted with yellow fever, plague and malaria
fever in a pernicious form. In view of the actual achievements in sanitary progress
it is safe to forecast a further material reduction in the general death rate. Such
a reduction if the birth rate should not suffer a corresponding decline would result
in a further increase in population, with the practical certainty that the previous
forecast of population growth would be exceeded during the next fifty years. The
people of the northern portion of the Western Hemisphere have therefore good reason
for a much more active interest in all that concerns the social and economic progress
of South and Central America and the West Indies. The Pan American Union,
the Pan American Scientific Congress, as well as other gatherings must needs
prove helpful in the direction of a broadening understanding of the problems of
mutual concern to all the countries of the Western Hemisphere. But the most