Misery and Death in the Pearl of the Pacific: Health Care in Guayaquil, Ecuador, 1870-1925

In 1875, U. S. Consul Charles Weile requested a leave of absence from his post in Guayaquil, due to the rapidly approaching rainy, “sickly” Guayaquil winter. When the State Department denied Weile’s request, he quit. He proved difficult to replace. Richard McAllister, Jr., politely refused the post, citing the city’s poor health reputation. Alexander McLean took the job, but he soon asked for a transfer. In explaining, he wrote, “I have had the fever here twice during my incumbency [of less than a year], and my family have all been afflicted.” One new U. S. minister to Ecuador, Thomas Biddle, never made it to his post in Quito, falling victim to fever soon after debarking in Guayaquil. Wrote the U. S. consul who was sending back the body, “it was a suicidal act to come here during the sickly season…”¹ Throughout its history, Guayaquil had dubious notoriety as one of the most disease-infested ports of the Pacific. Travelers stayed away, diplomats avoided assignment there. If people from other nations thought anything about Guayaquil, it was that it was a death trap that should be strictly avoided, no matter what one’s duties.

But while foreign visitors and sailors knew the port as the “pesthole of the Pacific,” civic boosters heralded Guayaquil as the glistening “pearl of the Pacific.” This essay will weigh these competing claims, examining the actual health circumstances in Guayaquil, the special problems the city confronted, and the efforts made to help the afflicted. Both perceptions of Guayaquil actually contained elements of truth. Nevertheless, the evidence reveals that, if the city did make some progress, it still could not overcome the extreme challenges imposed by its health conditions; and Guayaquil remained a truly dangerous place to live.

In recent years, the social history of Latin America has received much more attention, providing both a richer understanding and a more inclusionary vision of its collective past. Yet, serious gaps remain. Historiography on urban life during late nineteenth- and early twentieth-century Latin America is thin, especially regarding the working class. Even less has been written on health conditions—not just in Ecuador, but for Latin America as a whole. This is unfortunate, because to city dwellers of the era health conditions were of great importance, perhaps even utmost importance. We cannot claim to know much about their lives if we have but limited knowledge on this topic. A beginning must be made. This essay therefore offers a case study of health conditions in Guayaquil, with particular attention to the working class, in the hope that further research and comparison to other urban areas will ensue.²

The Setting

Guayaquil, like most cities, was at once beautiful and ugly. It was elegant: lovely colonial-style homes, immaculately groomed parks, and somber bronze statues peering out over the gently flowing Guayas River. It was squalid: hideous slums, beggars, a dearth of trees, legions of roaches and mosquitoes, and the intense heat and humidity of the equator. The city smelled wonderful: cacao drying in the streets, plantains frying, bread baking. And the city reeked: from the slaughterhouse; from men urinating by the riverbank; or from the ubiquitous garbage, manure, chickens, pigs, and raw sewerage.³

In the late nineteenth and early twentieth centuries, Guayaquil and its hinterland underwent a process of rapid economic growth. Responding to the pull of the expanding international economy, the port became the hub of a thriving cacao export trade. From the 1870s to the 1920s, the value of Ecuadorian cacao sales rose more than sevenfold, with three-fourths of the shipments coming from Guayaquil. The growth brought important social changes to Guayaquil and the coast. The city’s population increased from 26,000 in 1877 to 120,000 by 1925. Many people were drawn from the impoverished and increasingly crowded highlands to Guayaquil by the hope of finding a better life. Most did not find it, for the city’s development pattern did not create enough jobs for all waves of newcomers. Little industry appeared. Most people found only unsteady, loosely arranged service-sector employment. Women had jobs such as cooks, laundresses, and domestics; men typically were jornaleros, or day laborers, hauling ship cargo or working in construction, or else they hawked small items on street corners and worked in other odd jobs. Beyond the difficulties of trying to make a living, Guayaquileños had the added challenge of just trying to stay alive.

Guayaquil’s Leading Health Concerns

Respiratory diseases, such as tuberculosis, pneumonia, and bronchitis, and digestive disorders, such as dysentery and diarrhea, were the largest killers during this era, hospital directors and Sanitation Department heads agreed. Respiratory and digestive disorders together accounted for almost four of every ten deaths in Guayaquil from 1870 through 1925.⁴

Respiratory diseases were the more serious threat, causing more than one of every five deaths in the city during this period, with the number rising from just over 400 in 1893 (one of every six deaths in Guayaquil that year), to about 1,500, or one of every three deaths, in 1925. Respiratory illnesses usually claimed adults and left many families destitute. Tuberculosis alone causea roughly half of all respiratory disease-related deaths, with more than eight of ten victims adults. As the annual report of the Sanitation Service noted in 1913, tuberculosis was the single leading cause of death in Guayaquil.⁵

The city’s high risk of respiratory illness stemmed from several factors, but the leading problem was probably the city’s housing deficiency. In Guayaquil, urban growth was chaotic. Careful planning and strict zoning laws were unknown, and the city spread out into a maze of winding paths and makeshift hovels. As migrants overwhelmed the existing housing supply, people built cane and thatch homes on poles on the salt water estuary to the west, began to work up the sides of the Carmen and Santa Ana Hills to the north, and squeezed dwellings into vacant spaces in the city center. Others lived in balsas that crowded in along the west bank of the Guayas. The tubercle bacilli can live for a considerable time outside of the body, and the dirty or dusty homes of many of the poor provided conditions well suited to harboring this microorganism until it was inhaled by a new victim.

Digestive illnesses, especially dysentery and the various disorders that led to acute diarrhea, were responsible for one of every seven deaths in Guayaquil for most of this period. In 1925, the ratio had increased to one of every three deaths. Unlike respiratory-related illnesses, digestive diseases killed mainly children, who were nearly eight of every ten victims.

Certainly, the habits of the migrants contributed to the substantial threat of enteric illnesses. In their previous homes in the thinly populated countryside, most had followed the practice of disposing of garbage and wastewater wherever convenient. One might get away with this in the country; in the crowded city such habits were deadly. But the main source of the danger from digestive diseases was that the city quickly outgrew existing sanitation and water services.⁶ In working-class neighborhoods, families packed together in foul surroundings, and the crooked, narrow trails between the shacks too often served more as sewers than roads. In 1881 the city began construction of its first sewer lines, a project not completed until 1892. Even then, however, the sewer lines rarely reached the poorer districts. Typical was the complaint of Antonio Elizalde Najar, who wrote the City Council in 1893 demanding police action to stop people from using his yard as a toilet every evening after dark.⁷ Winter rains would flush out the slum roads, distributing their contents throughout the city. Already by 1896, the sewer lines were in obvious need of repair, and by 1903 the system had all but completely broken down. By 1914, wrote one visitor, filth continued to “accumulate… in the houses and patios, or courtyards, especially those of the poorer classes,” and wastewater from taverns, factories, laundries, and homes slopped out all over Guayaquil.⁸

In colonial times, people had traveled long distances just to bathe in or drink of the supposedly salubrious waters of the Guayas River.⁹ In the late nineteenth century, the poor still drank from the river, but only during the winter when heavy rains drove encroaching seawater downstream from the city. As Guayaquil grew and people polluted the Guayas, the water became much less desirable. Some took their water upstream or purchased barrels of it from those who did. The rich avoided the problem and favored bottled beverages.

In an attempt to augment the city’s inadequate supply of fresh water— too often fouled with garbage, offal, animal waste, or sewage—in 1886 the city council president, Dr. Francisco Campos, directed the newly created Public Works Department to undertake the construction of an aqueduct. Several foreign construction firms became involved in building the line, but the project went forward haltingly, with ruptured pipes, extended delays, and a great deal of bickering and bitter accusations by all involved. Piped water first flowed in 1891, and finally, by 1902, the Agua Clara Spring, only about 90 kilometers away, began to provide fresh drinking water directly to Guayaquil.¹⁰

Unfortunately, the new lines quickly proved insufficient for the steadily multiplying population. Those privileged homes with indoor plumbing found that the water ran infrequently, usually only a few hours a day. Most people had little choice but to keep drawing on the polluted waters of the Guayas. By 1918, the city again found itself debating how to expand potable water supplies, with the idea of pumping water directly from the nearby Río Daule and treating it with chlorine gaining some support. The city sent Drs. Miguel Martínez Serrano and Ricardo Aguirre Aparicio to Lima to study a similar program there. Yet, by 1921, Guayaquil still received only a fifth of the potable water it actually needed. As one observer put it, “Guayaquil, surrounded by water, nevertheless finds itself short….”¹¹

Inadequate supplies of pure water and improper sewerage disposal contributed greatly to the high incidence of enteric disorders. Other water-borne maladies, especially cholera and typhoid fever, also posed grave health hazards. Cholera was rarer, if deadlier when contracted, while typhoid fever afflicted more people, even if its victims stood a better chance of recovery. Typhoid fever became one of Guayaquil’s leading health risks, twice reaching well over 200 deaths in a year, and accounting for one of every 20 deaths in the city, claiming adults and children evenly. Intestinal worms, also associated with tainted water supplies and improper waste disposal, probably lived within most Guayaquileños. While worms seldom killed their host, they could leave one weakened and vulnerable to other maladies that would.

Since the death toll from respiratory and digestive diseases, Guayaquil’s leading killers, never really declined, residents tended to view their presence as almost inevitable. Guayaquileños expressed much more concern over the periodic arrival of epidemic diseases, in particular, yellow fever, which usually arrived aboard ships from afflicted ports (often Panama) but sometimes from the surrounding lowlands. Either way, it could be devastating. Spread by the bite of Aedes aegypti mosquitoes, yellow fever probably first hit Guayaquil in 1842, when half of the population fled in terror and over 4,000 died.¹² Another bad year was 1903, when yellow fever accounted for more than one in every ten deaths in the city, killing a third to half of those infected. During this and other epidemics (1890-1891, 1909, 1911, 1912, and 1913), nearly all victims were adult males. (See Table I). This is surprising, for urban yellow fever (as distinct from jungle yellow fever) is generally not considered gender selective.¹³ Perhaps typical outdoor occupations of men in the city—as construction workers, vendors, cacao handlers, or longshoremen—placed them at greater risk. Probably only further comparative research will help in understanding this unexpected finding.

The outbreak of a yellow fever epidemic could startle the city council into action, but until the origins and dissemination of the disease were discovered in 1900, governments everywhere were powerless to do much good. The Guayaquil authorities typically ordered a special religious ceremony (at taxpayer expense) or, as during the 1880-81 epidemic which claimed 472 lives, repeatedly fired cannons into the air, hoping to drive off miasmas but succeeding only in creating panic.¹⁴

By 1909, Guayaquil was one of the few cities in South America where yellow fever still presented a serious problem; by 1916 it was perhaps the only such city. Ultimately, the Rockefeller Yellow Fever Commission helped Guayaquil eradicate yellow fever in 1919. Guayaquil’s short supply of fresh drinking water had led people to store their supplies in tanks, cisterns, and barrels. However, the yellow fever vector, the Aedes aegypti mosquito, is a container breeder, especially preferring man-made ones. Guayaquil became the first city to use fish in its anti-yellow fever campaign, as people covered their fresh water containers and placed minnows (chalacos) into the tanks. The fish ate the larvae of the mosquitoes, thereby consuming the source of Guayaquil’s yellow fever.¹⁵

Another mosquito-borne disease, malaria, spread by anopheles mosquitoes, hit hardest when heat and rains peaked. While hospital and cemetery records seem to indicate that malaria became more prevalent after the turn of the century, it was almost certainly present before then. Before 1900, medical authorities did not keep separate tallies on malaria, simply grouping it with various maladies under the heading “other fevers.” Although malaria was not highly lethal—for every person who died of it, another 25 suffered from it but recovered—its threat never completely ebbed, and the yearly death toll seldom fell much below 200 lives, often reaching 500. Some years malaria accounted for more than 1 of every 9 deaths in the city. It was a particular danger to the young, as children made up three-fourths of its victims, a pattern typical for regions where malaria is endemic.

Guayaquil’s tropical equatorial climate provided excellent opportunities for illnesses to take hold and spread, and finding near-perfect breeding conditions, the disease-carrying mosquitoes flourished. The homes of Guayaquil’s poor, typically lacking glass or screen-covered windows, stood unprotected. Moreover, most Guayaquileños had a meager inheritance in natural immunities to disease. By moving to a crowded city, newcomers from isolated rural hamlets ran a high risk of contracting novel sicknesses. Yellow fever, which imparts immunity to previously exposed populations, never spread to the sierra; the disease-carrying mosquitoes only live in coastal regions. Malaria likewise was concentrated in lowland regions and killed a higher percentage in populations that had not yet experienced the disease.¹⁶

As a port city, Guayaquil took in travelers from other lands daily, placing itself in constant danger of infection with diseases from all over the globe. One such, bubonic plague, came from Asia and arrived in Guayaquil in 1908. It quickly established itself as a leading killer. Up to 1917, bubonic plague on several occasions accounted for one of ten deaths in the city (or over three hundred victims a year); it then gradually subsided, although it did not disappear. Unlike yellow fever, plague affected both genders equally, but it did afflict more adults than children. A particularly lethal disease, the plague usually killed one third or more of those infected (see Table I).¹⁷

The arrival of a bubonic plague outbreak could prompt action, not all of it wise or effective. During the 1909 epidemic, the national government learned that plague had spread inland to Huigra, and ordered the town completely leveled. Less ambitious, Guayaquil established a vaccination service. The program met only limited success. In 1913, when plague again appeared, nearly 20,000 people took the Linfa Haffkine anti-bubonic plague vaccine. Unfortunately, the shot afforded protection for only a few months, and 2 percent of those inoculated still contracted the disease.¹⁸

Given bubonic plague’s reputation, it is not surprising that officials either tried to deny its existence or shifted blame for the problem onto other towns. In 1910, for example, the police chief stressed that many plague victims came into the city from the surrounding rural districts.¹⁹ While no doubt true, this obscured the fact that the miserable sanitary conditions of Guayaquil and the generally dirty living circumstances of the poor helped bubonic plague to develop and spread within the city. In 1919, officials declared that bubonic plague no longer was a health concern in Guayaquil.²⁰ This claim was simply not true, as 59 people in 1920 would have gladly attested, had they been alive to do so.

Two highly communicable childhood diseases, measles and smallpox, also took many lives in Guayaquil. Measles, although not usually lethal, could at times become a serious threat, as in 1888 when over 550 fell victim to it. It reappeared periodically and in 1920 claimed the lives of more than 200 children, accounting for 1 of every 25 deaths in the city that year. Smallpox was likewise a sporadic disease, coming as an epidemic among children every few years. Deadlier than measles, the worst smallpox outbreak came in 1890 when more than 400 children died, representing 1 of every 7 deaths in the city.²¹

The city had a long-standing prevention program for smallpox. Usually, however, immunization campaigns came only after the disease had already begun to spread; too late then for many. By the 1890s, there was growing recognition in the Ecuadorian medical community of the drawbacks of the old “arm to arm” method for spreading immunization, but it was still used due to the lack of vaccine. Moreover, authorities typically found that when they needed the vaccine it had lost its potency through long neglect. Guayaquil often had to wait months before new serum arrived from Lima or Europe; by then, most outbreaks had already run their course. Guayaquil suffered smallpox epidemics in 1893, 1905, and 1908. After that, the vaccination program finally proved more effective, and the disease did not again return in force.

One other disease that presented a fairly steady low-level threat in Guayaquil was tetanus. This disease frequently claimed over one hundred lives a year, especially affecting the young. Newborns were at high risk when unsterile instruments were used during delivery, and older children faced danger as they were apt to go barefoot. It is probable that deaths from tetany—often confused with tetanus—may also have been added in the records to those caused by tetanus. Tetany, or severe muscle convulsions produced by extreme calcium and vitamin D deficiencies, often appeared at weaning. In any case, Guayaquil made almost no progress in quelling tetanus; the disease still was a significant health hazard in 1925.

Finally, deaths due to accidental or violent causes became a rising concern. More street traffic, especially trolley cars, inevitably brought more collisions. Murders also increased. Only 15 people died as a result of violence or accidents in 1892, but by 1911, 115 did, with many more suffering serious injuries. Most victims were men. In 1904 accidents or violence crippled or maimed about 500 people; of these, more than 80 percent were men.²²

In all, then, from dysentery and tuberculosis to yellow fever, malaria, and murder, there were many opportunities for an early grave in Guayaquil. Death haunted the city.

The State of Medicine

Until the late 1800s, even in the most advanced nations, let alone Ecuador, conventional thinking about the origin, spread, and treatment of disease continued to rely on centuries-old medical wisdom little improved by time.²³ Prevailing opinion had held that disease spread either by contagion or via infested airs—miasmas—tainted by putrifying organic material. Physicians commonly believed that all disease stemmed from a single cause—poisons in the system—which mandated the use of heroic measures to rid these toxins from the body. Treatments included blistering, daily bleedings of twelve or more ounces, enemas (and if bleeding from the anus resulted from repeated applications, so much the better), and harsh drugs to promote purging and sweating. Accepted theories of medicine consisted of little more than attempts to rationalize such measures. For much of the nineteenth century, then, medical care everywhere continued to be based on serious misconceptions; treatment too often proved to be ineffective or even harmful. Of course, some patients recovered despite the ministrations of doctors.

In nineteenth-century Western Europe, several critically important medical science breakthroughs led to a new understanding of the origins and prevention of disease. The application of this knowledge, both in Europe and the United States, soon fostered improvements in medicine and public health, bringing an end to the use of time-honored medical practices and a decline in the appeal of pseudoscientific fads. Research won increasing acceptance for the germ theory of disease. Advances came in surgery. Developments in the use of anesthesia—ether and later chloroform—allowed surgeons to control pain. Sterile methods came to be adopted in an increasing number of U. S. and European hospitals. With the introduction of asepsis and anesthesia, surgical death rates fell and physicians could attempt new types of operations. There were further advances in techniques and apparatus, as the stethoscope, thermometer, and microscope all came into widespread usage. X-rays, discovered in 1895, were already in use in U. S. hospitals by the late 1890s. After the early years of the twentieth century chemical examination of blood and urine also became common in the United States. The age of modern medicine had begun. News of all this progress spread unevenly, however, with older, outdated notions of treatment lingering on in places removed from the centers of intellectual and scientific advancement—that is, in places like Ecuador. In time, most of the advances in medicine would find their way south, but the pace of change was slow, and understanding and acceptance of new methods often incomplete.

In Ecuador, medical education centered in Quito, which had been producing graduates since the seventeenth century. The coast received its first medical school in 1867 with the founding of the medical school of the University of Guayaquil, although the seven faculty members were not formally inducted until 1877 and the dedication of a permanent building was delayed until 1888. By 1892, the Guayaquil faculty had grown to thirteen, but it did not increase after then. The university later opened a dentistry department in 1904, although there were no graduates until 1922. Still, there was some gradual progress in the medical profession in Guayaquil, as evidenced by the emergence of at least four medical societies, the publication of five medical journals, and the hosting of the first national medical congress in 1915. The doctor-to-patient ratio in Ecuador also showed improvement in these years. In 1863, there were 81 licensed doctors serving a population of about 893,000 (1 physician for every 11,025 people), and by 1909 there were 236 doctors caring for a population of 1,643,000 (a ratio of 1 to about 7,000).²⁴

Unfortunately, not all practicing physicians in Ecuador had formal training or licenses; many fakes dispensed dubious cure-alls, and some pharmacists sold tainted or unpure drugs. Even the medical school graduates were not always well prepared. The constant civil strife of politically unstable Ecuador frequently led to the closure of the universities and the declaration of “free study.” Even when in session, the universities did not always provide the basis for a sound education. Students suffered especially from the lack of adequate medical reference material; in late nineteenth-century Guayaquil, the public library had the only real collection, numbering but 266 books on medicine. In 1889, the national government hired a leading German medical bacteriologist, Dr. Gustavo von Lagerheim of Hamburg, to train Quito doctors in the latest European advances, following up on the pathbreaking work of Robert Koch and Louis Pasteur. Lagerheim brought the first microscope to Ecuador. It got little use, as Lagerheim received a chilly reception from the serrano medical community. Exasperated by the lack of interest in his work and upset by the hostility to his Protestantism, he packed and left in a huff in 1892.²⁵

But an awareness of new developments eventually came, especially to the port—historically less isolated and traditional minded than Quito— and medical practice began to modernize. Most leading Ecuadorian physicians traveled abroad to receive advanced medical schooling. The national government began to provide scholarships for foreign study in the last years of the nineteenth century, even if more of the scholarships went to students from Quito, not Guayaquil. Most students went to Western Europe, although some chose to go to the United States—at the time, a distant second choice.²⁶ By the 1890s, Ecuador’s universities were offering instruction in bacteriology and required hands-on training at the hospital, not just formal classroom lectures. In the field of surgery, ether was first used in Guayaquil in 1894, and, by 1898, aseptic surgical methods. X-rays were in use in Guayaquil in 1908. By 1907, Ecuadorian surgeons performed hysterectomies; by 1912, Caesarian sections on living mothers (such operations on mothers who had died in delivery had been used for some time); and, in 1919, in Guayaquil the first blood transfusion in Ecuador took place. As medicine came to be placed on a more scientific and rational basis in Ecuador, formally trained and licensed doctors began to increase in prestige.²⁷

Public Medical Facilities

In Guayaquil, as elsewhere, the traditional role of hospitals had been that of workhouse/warehouse for the aged, mentally retarded, insane, blind, or lame. By the late nineteenth century, the hospitals’ mission had evolved into one more singularly medical. Sadly, Guayaquil’s facilities overflowed with groaning, suffering, soon-to-die patients. Many of its poor chose to stay away from the public health facilities, although the service was usually free of charge. They preferred to take their chances with imported patent medicines or traditional folk remedies, rather than risk treatment at one of the city institutions.

Those who could afford the rising fees of private doctors received their medical attention at home. Public hospitals did not have rooms for paying customers, and private clinics were rare. (The first in Guayaquil, the Casa de Salud of Dr. Juan A. Cortez García, opened in 1905. Few followed.) For the privileged, even major surgery was often given at home, or, if the operation was not too urgent, in Europe. Even when stricken with a contagious epidemic disease, a wealthy patient could generally make arrangements with his private physician to avoid being sent to a city quarantine, as required by law.

During much of this time, the public health care facilities were exclusively for the poor, and then, perhaps, as a desperate last resort. But modern practices were gradually introduced toward the end of the period. Thus, conditions slowly improved, and the popular image of hospital as death house began to change. The introduction of modern medical machinery, often expensive and immobile, also meant that wealthy patients had to consider going to the hospitals to receive care.²⁸ Despite increased use of hospitals, however, Guayaquil cemetery records reveal that over two-thirds of deaths occurred at home. In 1914, for example, about 2,500 of the 3,500 deaths in the city occurred in one’s dwelling. In that year, 90 percent of the children died at home, while among adults only 50 percent died at home. Working-class parents probably paid for a doctor to come to their house to treat their gravely ill children.

In 1887, the city government authorized the recently formed Junta de Beneficencia to run most of Guayaquil’s city’s health care facilities and provide burials for those who died destitute. The Junta came to include many of the leading men of Guayaquil—including such notables as José Luis Tamayo, soon to be president of Ecuador, and Efrén Aspiazu, of the fabulously wealthy cacao-growing Aspiazus of Los Ríos province—as well as the wives of the city elite. Funds for its operations came from the municipal and national governments; lotteries; and charitable grants, including rents from donated properties. However, these sources did not provide enough money to cover costs, and, after only five years, the Junta lapsed deeply into a permanent state of debt.²⁹

Despite its limited resources, the Junta sought to respond to Guayaquil’s health concerns by opening several new facilities. Before the 1880s, Guayaquil had only two health care centers, the Hospital Caridad, operated by the city, and the military hospital, run by the provincial government. The Junta soon added a maternity hospital; insane asylum; tuberculosis center; quarantines for bubonic plague, yellow fever, and smallpox; a vaccination facility; and several orphanages. Catholic sisters working in these institutions, the Hermanas de la Caridad, won praise for their handling of patient care. The expansion of services brought benefits: more people received treatment, and city mortality rates showed a slow, if uneven, decline. Yet, despite all these efforts, very serious problems remained.³⁰

The busiest facility was the city hospital, known at different times as the Hospital Caridad, Civil, and General. The total annual number of patients rose from about 4,000 in 1881 to over 17,000 in 1925, a gain, however, that owed more to rapid handling of patients than to the increase in the number of beds (see Table I). At the end of 1875, there were 255 patients in the hospital. Fifty years later, the hospital counted 622 patients (see Table II). Therefore, while the annual number of people treated at the hospital increased more than fourfold, the ordinary daily patient population only about doubled. Doctors just treated patients with greater alacrity.

In 1881, the president of the city council, José María Urvina Jado, wrote that the hospital was in need of substantial renovation. The facility had particular need for special operating rooms; doctors had to perform surgery in full view of other patients.³¹ A fire at the military hospital in 1887 forced the transfer of patients to the Hospital Civil, resulting in extreme overcrowding.³² As the hospital filled up, administrators had little recourse but to send the overflow to the insane asylum. In 1893, the chief of the Hospital Civil, Dr. D. Federico Mateus, wrote an especially scathing report, complaining that the building was hot, overcrowded, understaffed, and had foul, disease-ridden air stagnating throughout. He called for the building of a special wing for those with infectious illnesses. Contagious diseases spread rapidly among the already weakened population, and many patients who arrived suffering only mild complaints soon contracted yellow fever at the hospital.³³

A citywide blaze in 1902 gutted the hospital, and patients had to be shifted to the already full Asilo de Maternidad Alejandro Mann. The Junta de Beneficencia quickly contracted a loan from the Banco del Ecuador (plunging yet deeper into debt) to build a new facility, and two years later opened the new Hospital General. With the gradual adoption of modern medical practices, mortality rates at last began to fall. In its 1905 report to Congress, the national Ministerio de Justicia y Beneficencia singled out this facility, unique in that it was supported by local not national funds, as the best in Ecuador.³⁴ Some progress was clear: in 1881 and again in 1883, almost 1 in 5 of those treated at the old hospital had died, but by the 1920s only 1 in 20 at the new facility died, a noteworthy improvement.

One of Guayaquil’s oldest health care institutions, although of declining importance, was the military hospital. When the new building opened in 1891 (following an earlier fire), the facility saw almost 3,000 men yearly; by 1909 it handled less than 1,000. Its usual daily patient population fell from over 200 at the end of 1891 to only about 70 in 1909 (see Tables II and III).

As the provincial government phased out the military hospital, Guayaquil opened several new small hospitals, auxiliaries, and annexes. One was the Hospicio del Corazón de Jesús, founded in 1892, and at the time probably the most modern medical institution in the city.³⁵ However, as with Guayaquil’s other hospitals, it too soon became overcrowded. The hospital saw about 120 people the year it opened, but in 1901 treated over 1,000. Eventually, the annual patient load fell to about 300. The number of patients in the facility at the end of each year—an indication of the daily patient load—rose from 80 in 1892 to a peak of over 370 in 1900, and then leveled out at about 200 in the 1920s (see Table II). For reasons that are unclear—perhaps related to the nature of the cases being treated—death rates jumped sharply at the Hospicio in these years. In the first year of operation, only 5 percent of the patients died, but soon the institution was losing more than 10 percent in most years, and 25 percent in 1919 (see Table I).

The Asilo de Maternidad Alejandro Mann, an annex to the Hospital Civil, operated principally as the maternity and children’s hospital beginning in 1903. Built with money from the Junta de Beneficencia (25,000 sucres) and a donation from Alejandro Mann (25,000 sucres), this institution handled more than 3,000 patients in 1914, increasing to between 5,000 and 9,000 patients annually by the 1920s (see Tables II and III). Hospital directors repeatedly declared the facility to be utterly inadequate and compiled a long list of shortcomings. For example, in his 1914 report the director noted that the entire building needed immediate repair: the annex lacked electric lights, adequate plumbing, private rooms for operations, separate quarters for contagious diseases, and a place to bathe patients.³⁶

The city also operated special tuberculosis centers, although doctors the world over could offer almost no positive treatment during this time. What the institutions really provided was community protection, isolating the highly contagious TB victims. The first tuberculosis hospital, Asilo Coronel, opened in 1902, but the city soon had to use the building as a quarantine for bubonic plague and yellow fever epidemic victims. In 1910, the city opened a new tuberculosis asylum, Asilo Calixto Romero.³⁷ The city tuberculosis asylums treated just over 300 people in 1902, and handled about 400 to 700 annually over the following two decades, typically housing about 30 patients at a time, the majority of them men (see Table II). Only with the deepest reluctance could one have entered one of these institutions, for in most years more than half of all patients died (see Table I).

The yellow fever and bubonic plague quarantines, functioning as permanent establishments after 1905, had perhaps the darkest reputation of all city institutions. Guayaquileños called them “Death’s Waiting Rooms.”³⁸ The yellow fever quarantine often had more than 200 patients a year, housing as many as 560 in 1912 (see Table I). Doctors could do nothing to help victims; even today there is no known cure for yellow fever. Hoping for the best was all doctor and patient could do. Busier was the bubonic plague quarantine, which often handled more than 400 patients a year and in 1909 over 900 (see Table II). The mortality rates at the quarantines rivaled even those of the tuberculosis asylum; in most years at least a third died; in bad years sometimes more than half were lost. Given these rates, people’s desperate efforts to ignore the law and avoid being sent to quarantine were quite understandable.

The city made efforts to provide facilities for the insane, but modern practices came slowly to this field of medicine, in Ecuador as elsewhere.³⁹ During this period the dominant view was that treatment would probably not help; the insane were incurable. Therefore, while at least the patients usually did not suffer the cruelties of the past (i.e., being chained up and beaten), they still received little actual treatment.

Before 1881, Guayaquil either kept mentally disturbed people in jail or housed them with the general patient population at the Hospital Civil. That year, however, Guayaquil opened its first insane asylum, the Manicomio Vêlez. Unfortunately, even this new institution soon encountered serious problems. In 1881, the city council president, Urvina Jado, noted that the just-opened asylum required a special area for the violently insane, a need underscored when several disturbed patients murdered one of the guards. Despite its limited space, the insane asylum also frequently doubled as a treatment center for overflow contagious patients from other health care facilities, contributing greatly to the high asylum death rates. Typically, the Manicomio lost about one in ten patients each year, but in 1903 more than one of every five patients at the insane asylum died. At last, in 1910, the city moved the patients to a new facility, the Manicomio Lorenzo Ponce, and conditions improved.⁴⁰ The patient population in city asylums held remarkably steady, given Guayaquil’s rapid rate of population growth; no doubt only the most visibly or violently insane were admitted to the Manicomio.

The Junta de Beneficencia operated some smaller special facilities. A leper quarantine, opened in 1880 in the hills by Guayaquil, had five rooms and beds for 60. The Junta also maintained three orphanages and a house of temperance. There was probably more philanthropic giving in commercially vibrant Guayaquil than in Quito or elsewhere in Ecuador, and a few small private charitable societies resulted: the Sociedad Filantrópica del Guayas, founded in 1849; the Sociedad Protectora de la Infancia, founded in 1905 which periodically distributed free drugs; the Sociedad de Puericultura, which took in orphans and sometimes provided needy mothers with free milk; and the Sociedad “Belem del Huérfano,” which sought to help orphans.⁴¹

Given the need for a reliable source of vaccines as well as the desire to provide accurate testing of foods and drugs, the city operated a chemical laboratory, first set up in 1905 at the Colegio Vicente Rocafuerte. In 1909, the city’s new Laboratorio Químico Municipal opened, under the directorship of Dr. Ramón Flores Ontaneda who had previously operated a private lab in the city. Flores Ontaneda fell victim to bubonic plague as a result of an accident while preparing a vaccine.⁴² The Sanitation Department, created in 1908 and with a staff of 71 by 1920 (administered as a branch of the police), handled other city hygiene matters, including quarantining vessels suspected of bringing in disease, rat control, most vaccinations, and public health care education, at times distributing free pamphlets printed at government expense (although probably one of every three Guayaquileño adults could not read).⁴³

Overall, Guayaquil had made some progress in health care, although clearly much remained to be done. As the City Sanitation Service noted in its 1914 report, Ecuador still lagged behind almost every other Latin American nation in providing public sanitation services, and the health facilities for the poor of Guayaquil could offer only the most minimal level of care.⁴⁴ For sick and dying working people in Guayaquil, options were grim indeed.⁴⁵

Death

Death rates for Guayaquil are difficult to determine exactly, for while it was possible to accurately number the dead, it proved much more difficult to count the living. People in Guayaquil moved so frequently, both within and to and from the city, that officials could offer only rough estimates of the total population. They completed very few census tallies. However, the Junta de Beneficencia carefully noted death totals in the burial records at the Catholic cemetery. Of course, not everyone was Catholic, some people doubtless received burial elsewhere (in their hometowns for example), and some nonresidents from the surrounding countryside came to the city seeking medical assistance and subsequently died in Guayaquil. Thus, the available data provide a general sense, but the numbers should still be used with caution.⁴⁶

It is clear enough that death rates in Guayaquil during this era showed a steady downward drift. In 1879, Guayaquil’s death rate was roughly 140 per thousand (see Table III). After 1880, the city’s death rate fluctuated between 50 and 80 per 1,000 until the turn of the century. After that, it usually reached about 40 per 1,000. However, the worst year of death was 1912, a year of civil war and its attendant epidemics, when Guayaquil lost more than 5,000 lives.

Children were at special risk, as infant mortality rates showed little improvement over the years. An infant born in Guayaquil stood only a 50 percent chance of celebrating a twelfth birthday. Children 1 year old or under accounted for one-fourth to one-third of all deaths throughout the period. Most people in Guayaquil, men or women, did not live to the age of 20.

The Problem of Comparison

Because the study of health care in turn-of-the-century urban South America is in its infancy, it is difficult to compare with certainty what is known about Guayaquil against the situation in other cities. Information is often frustratingly incomplete or unavailable for 1870-1925; it is especially deficient for the cities that most resembled Guayaquil, the other tropical port cities. Accordingly, while some tentative comparisons can be offered, final conclusions will have to await further comparative research.

Guayaquil’s death rates seem to compare very unfavorably with what is known of other Latin American cities of this era. Nineteenth-century Havana—like Guayaquil a tropical port city—had a death rate usually between the 30s and 40s per 1,000, though during the island’s struggle for independence, 1895-98, Havana’s death rate rose to 72 per 1,000. In the last quarter of the nineteenth century in Guayaquil, the death rate typically reached at least the 50s per 1,000 and was often higher, sometimes much higher. At least nine times during these years, Guayaquil equaled or surpassed the rate that Havana suffered during its worst years of chaos and war.⁴⁷

In the period 1908-11, Buenos Aires showed a death rate of 17.3; Rosario, Argentina, 23; and Mexico City (where typhus was a serious problem), 53.4. In those same years, Guayaquil averaged 42 deaths per 1,000 people.⁴⁸ Santiago, Chile had an average annual death rate of about 35 per 1,000 in the years 1900-24, and Rio de Janeiro from 1901 to 1920 showed a rate of 23 per 1,000.⁴⁹ Guayaquil in those years had an average annual death rate of about 45.

Even some populations that were at seemingly very high risk displayed death rates quite lower than those of Guayaquil in 1870-1925. For example, Rio de Janeiro in the years 1840 to 1851, a period when waves of African slaves poured into the city, had a death rate of between 28 and 42, averaging about 37, well below levels in Guayaquil.⁵⁰ In the warm, humid port city of Charleston, South Carolina the death rate among blacks, the poorest residents, averaged 44 in 1881-94.⁵¹ During that time in Guayaquil, the rate averaged about 62 for the entire population, not just the underclass.

Ecuador as a whole from 1915 to 1919 had an average annual death rate of 30, whereas Guayaquil’s rate averaged about 45. From 1920 to 1924, Ecuador had an average rate of 29; in Guayaquil it was 41. Ecuador showed a higher rate than eight other Latin American countries, but apparently a lower death rate than Mexico, Guatemala, El Salvador, and Chile.⁵² It would seem that it was not Ecuador that was especially unwholesome—just Guayaquil.

Some Final Observations

Unlike other South American cities that had some or many of the conditions that spawned deadly diseases, Guayaquil had nearly all of them, and many in the extreme. Climate was the most obvious single factor. The tropical environment was a friendly one for microorganisms, which could survive a long time outside of the body waiting for a new host to happen by. Some diseases, such as yellow fever, malaria, and cholera, are more prevalent in tropical regions (although of course by no means unknown elsewhere). Guayaquil also grew faster than most Latin American cities, from 1870 to 1920 recording an annual growth rate of 3.19 percent,⁵³ and this made it all the more difficult for health and other services to keep up with population. It further appears that the underclass in other cities may have had a stronger inheritance in natural immunities against disease. African descendants in such places as Rio de Janeiro probably enjoyed stronger biological defenses against yellow fever, typhoid fever, and malaria than the mestizo and Indian underclass of Guayaquil—and Guayaquil had a much higher death rate than did Rio.⁵⁴

But other circumstances in Guayaquil further contributed to the depressing state of its health conditions. The all-too-frequent civil wars of Ecuador typically brought unacclimated highland soldiers trooping down to the hot steamy coastal lowlands. Epidemic diseases followed. For example, in 1911 and 1912, a revolt broke out in Guayaquil and the army responded from Quito. As one observer wrote: “[A] violent yellow fever epidemic in Guayaquil is … inevitable, as the city is full of unacclimated hill people; troops and camp followers. All other diseases are also already prevalent.”⁵⁵ In the first part of 1912, government and rebel troops clashed at Yaguachi, a town just east of Guayaquil. Soon, “yellow fever had broken out at several of the intermediate stations where the troops from the highlands had camped.”⁵⁶ And again in 1913 and 1914, during the civil war centered in Esmeraldas, dysentery, typhoid fever, malaria, and yellow fever quickly spread around the squalid army camps, traveled to other coastal cities, and ultimately arrived in Guayaquil.

Another difficulty facing Guayaquil was that even though the busy commerce of the coast did create increasing tax revenues, this money had to be shared with the rest of the nation. Quito, the commercially isolated capital city, claimed a large portion. There remained no significant sierra tax after the abolition of the Indian tribute (1857) and the tithe (1889), and it fell to port duties collected in Guayaquil to generate from 53 to 81 percent of regular national tax revenues from 1895 to 1925. Most of this money came from Guayas (from 84 to 97 percent), with most of the remainder coming from the other coastal provinces.⁵⁷ The sierra, however, continued to demand and receive benefits from the national treasury. While many of the projects probably had merit enough, coastal politicians held that the sierra, not the coast, should pay for them. In some years, Guayaquil received nothing from the national government for public works. If Guayaquil often had trouble obtaining funds for needed construction, social programs, and sanitation, one reason was that the national government possessed, in the customs duties, the only major revenue source, and the sierra, especially Quito, siphoned off so much of the proceeds.⁵⁸ The assorted fees and nuisance taxes left to the city and province were wholly inadequate to meet the challenges of the fast-growing tropical port.

To make things worse, scarce government revenue was often wasted: lavished at the national level on excessive military expenditures, and at either the national or local level on poorly conceived development projects (many of them never completed) and on outlays dear to the favored elite—such as erecting elaborate bronze statues celebrating their forebears. Public health needs were left begging. Guayaquil took steps in addressing its problems, but the grand gesture of announcing the start of a project too frequently received preference over the more mundane task of seeing the work through to completion.

Whether one condemns or praises Guayaquil’s health record of the late nineteenth and early twentieth centuries depends on one’s frame of reference. In an absolute sense—that is, Guayaquil in 1870 compared to Guayaquil in 1925—there was notable improvement, as evidenced in the decline in city death rates. However, in a relative sense—that is, when compared against what is known about similar cities of the era—Guayaquil was a disgrace. While it is true that the most important factors in determining a city’s health situation—e.g., climate, geography, the natural immunities of the population—were beyond the immediate control of government, it is important to ask not only if death rates fell, but if they fell as far as was possible; that is, if everything that might be done, was being done.

In Guayaquil it was not. If it expanded existing hospitals and opened new ones, these steps did not come close to keeping pace with needs, as administrators from the city health care institutions so emphatically and repeatedly stressed. If some sanitation measures were taken, the city still remained appallingly filthy, as the reports of city officials and observations of foreign visitors so abundantly and vividly detailed.⁵⁹ The problem was that almost “no sanitary measures, however simple, can be enforced without compelling individuals to yield something of pecuniary interest or of personal convenience to the general welfare.”⁶⁰ That Guayaquil sanitary laws aroused neither anger nor opposition from business interests shows how little was even attempted. Ultimately, the private nature of its economy could not emphasize providing for public needs. In Guayaquil, “everybody’s business” was still mostly “nobody’s business.”⁶¹ Thus, the city earned and richly deserved its foul reputation.