I read with considerable interest Ronn Pineo’s article on health care in Guayaquil, Ecuador, between 1870 and 1925 (HAHR, November 1990). Pineo provides a succinct discussion of the institutional difficulties in providing health care in a rapidly growing and overcrowded urban center in the tropics. However, the author’s characterization of medicine and his notions of the social history of disease control are incomplete and provide only a partial understanding of the causes and responses to the unhealthy conditions in the city.

Medicine in the eighteenth and early and middle nineteenth centuries was, as Pineo points out, still based on the humoral and miasma theories (p. 620). However, despite a lack of understanding of the origin of disease, doctors and public officials developed effective measures to control the two greatest killers in preindustrial Europe, bubonic plague and smallpox. According to historical demographer Michael Flinn, evidence from Europe in the seventeenth and eighteenth centuries suggests that quarantine measures gradually eliminated bubonic plague by limiting its spread. In the early eighteenth century smallpox accounted for some 10-15 percent of all deaths in Europe. The use of inoculation by variolation and later the Jenner cowpox vaccine reduced the impact of smallpox. For example, between the late eighteenth century and the 1810s smallpox mortality in Sweden dropped from 278 per 100,000 population to 15 per 100,000 population.1

Control of disease, either through quarantine measures or vaccines, took effect gradually. One of the most important aspects of the social history of disease control is popular resistance to new methods, and thus the uneven application of prophylaxis. Between 1900 and 1904 and again in 1907 and 1908, bubonic plague broke out in San Francisco’s Chinatown. Efforts at plague control by public health officials were undermined by businessmen who didn’t want to lose business or tourism and by opposition from Chinese residents. Anonymous leaflets circulated in Chinatown warned against the Haffkine vaccine.2 Similarly, British efforts at plague control in colonial India after 1890 met considerable resistance, largely because of cultural factors such as Hindu and Muslim controls over and sensitivity to female seclusion. Between 1891 and 1921, some 1,916,000 people died of bubonic plague in British India.3

In Latin America there is evidence of both opposition to new disease control measures and government inability to implement them. Government officials first introduced the use of inoculation by variolation to control smallpox in Mexico in 1779 during a major epidemic.4 Two years later smallpox reached the Baja California missions in northwestern New Spain. Missionaries at three of the missions substantially reduced death rates through the use of inoculation by variolation, whereas death rates at missions where inoculation was not used remained high—at one mission, Santa Gertrudis, 296 people, some 40 percent of the population, died.5 Between 1803 and 1805 the Spanish government mounted an expedition to introduce the Jenner cowpox vaccine to the Americas, and officials as far north as New Mexico vaccinated children against the disease.6 However, smallpox control efforts broke down during the independence war in Mexico between 1810 and 1821. For example, smallpox killed hundreds of people, mostly children, in Sonora in 1816 and 1817, including 212 at Nacameri alone in 1816.7

Contrary to the impression given by Pineo, some disease control methods do appear to have been effective to a certain degree. For example, Pineo implies that the use of the new Haffkine bubonic plague vaccine was unsuccessful since 2 percent of those vaccinated apparently contracted the disease (p. 618). Even a 2 percent morbidity rate was an improvement for a disease that could infect a substantially larger percentage of an unvaccinated population. Moreover, the figures on the mortality from the bubonic plague quarantine center are somewhat misleading. Mortality rates of 25 percent to 47 percent for people unfortunate enough to have been taken to the facility and the decline in the mortality rate between 1912 and 1925 (Table 1, pp. 616-617) indicate that plague treatment for advanced cases did help and improved with the passage of time. The bubonic form of the plague causes 60-70 percent mortality if untreated, and the pneumonic and septicemic 100 percent mortality if untreated.8 Moreover, figures from the quarantine center were not necessarily representative of the total population. Similarly, smallpox, the great killer of the eighteenth century, had apparently been brought under control in Guayaquil, although there continued to be periodic outbreaks of the disease (p. 619) that most likely killed the children of recent migrants to the city or the unvaccinated children of Guayaquil residents.

The effectiveness of disease prevention measures depended not only on the ability of the doctors and the resources available to public health officials, but also on the attitudes of the public. Pineo alludes to a common reaction to disease control in Guayaquil, a widespread impression that hospitals and quarantine facilities were places where the sick went to die (pp. 623, 630). It was no coincidence that, as the author reports, the majority of deaths occurred in the home and not hospitals (p. 623). The public frequently rejected vaccines that it feared might be as deadly as the disease they were designed to prevent. Inoculation by variolation and the jenner cowpox vaccine did not gain universal acceptance. The complacency that set in once it appeared that smallpox had been brought under control in the nineteenth century allowed smallpox to return, because parents neglected to have their children vaccinated. The failure of smallpox vaccination in Guayaquil most likely resulted from a shortage of funds, parents who did not have their children vaccinated, and men who may have refused to take female family members to public hospitals, in order to protect them from what they may have seen as certain death. Pineo’s use of hospital records to document his claim that more adult men died from yellow fever does not support his interpretation that the disease was gender selective, because of different types of employment (pp. 614-615). A more plausible explanation may be that many women were not taken to hospitals or the yellow fever quarantine facility and hence did not enter the records that Pineo consulted.

Class attitudes may well have been a factor in the apparent underfunding of public health measures in Guayaquil. The wealthy could afford the best medical care available in Ecuador or Europe, but what of the poor? Did the interpretation of the causes of poverty articulated in Social Darwinism influence Guayaquil elites to invest little money in health care? Pineo implies that the uneven distribution of national government revenues between Guayaquil and the sierra (pp. 635-636) was the major fiscal limitation on public health measures, but might not ideological factors have influenced decisions made on the allocation of resources?

Pineo attributes the high mortality rates in Guayaquil to several fundamental factors (pp. 634-657): (1) a tropical climate favorable to the survival and spread of some disease organisms; (2) uneven regional distribution of fiscal resources; and (3) frequent civil wars that absorbed scarce government revenues. Although these factors provide an adequate explanation of institutional limitations on public health, they do not necessarily expand our understanding of the social history of disease control, especially for the working class—a stated objective of Pineo’s article (p. 610). Pineo’s description of Guayaquil indicates that poverty was an important factor: the overcrowded living conditions that facilitated the spread of disease and harbored the rats that spread bubonic plague when it arrived in the city; polluted water; and unbalanced diets that enhanced susceptibility to disease. The author alludes to the unreliability of employment for the urban poor (p. 611) but does not make a strong connection with health conditions. He outlines patterns of mortality (total numbers) (pp. 628-629) but does not clearly indicate patterns of infant mortality, an indirect index of poverty.

Pineo provides a good description of the institutional development of medicine and public health measures in Guayaquil, but not of the social context. The question that Pineo poses and answers in the article relates to Guayaquil’s reputation, deserved or not, as a hellhole of rampant disease or the Pearl of the Pacific. An equally important and informative question might be what impact poverty and underdevelopment have on public health and public health measures.


Michael Flinn, The European Demographic System, 1500-1820 (Baltimore, 1981), 58-61 (plague), 63 (smallpox), 99 (Sweden).


Philip Kalisch, “The Black Death in Chinatown: Plague and Politics in San Francisco, 1900-1904,“Arizona and the West, 14:2 (Summer, 1972), 113-126.


Michelle Burge McAlpin, Subject to Famine: Food Crisis’ and Economic Change in Western India, 1860-1920 (Princeton, 1983), 80.


Donald Cooper, Epidemic Disease in Mexico City, 1761-1831 (Austin, 1965), 66.


Robert H. Jackson, “The 1781-1782 Smallpox Epidemic in Baja California,” Journal of California and Great Basin Anthropology, 3 (1981), 138-139; and Jackson, “Epidemic Disease and Population Decline in the Baja California Missions, 1697-1834,” Southern California Quarterly, 63 (1981), 326-330.


A series of documents in the Spanish Archives of New Mexico in Santa Fe records the vaccination of hundreds of children in New Mexico.


Jackson, “Causes of Indian Population Decline in the Pimería Alta Missions of Northern Sonora,” Journal of Arizona History, 24 (1983), 413.


Kalisch, “The Black Death” 114.