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for such materials as are on the Isthmus shall be promptly filled without reference to a higher authority.
There is nothing said about the sanitary department, and as that which is not included is excluded, it follows that the right very justly accorded to the Engineering Department is denied to the sanitary department as such. It is obvious, of course, that the sanitary department, being made subordinate to "the executive branch of the government of the zone,” can get supplies, but subject only to the judgment of the governor, who, by this resolution, is empowered to pass on the suitability of any or all supplies for the Medical Department or the Department of Public Health."
An example of the working of this rule was shown in the recent purchase of an x-ray outfit for the Ancon Hospital. The requisition went in several months ago and was pending before the commission, more especially Mr. Grunsky, when the expert who had been specially employed to do .r-ray work in Ancon, happened in Washington and requested the privilege of selecting the Crookes tubes ; the request was peremptorily refused; the expert urged that his knowledge would enable him to make better selections than would be probable of an unskilled purchasing agent, and went so far as to urge as an additional reason the distance to the Isthmus, the time involved in transportation, to say nothing of the expense involved, only, however, to be informed that if the tubes did not suit they could be returned. They came after a long delay, were found worthless and were returned; other ones have not yet been sent to replace them and, as a consequence, Ancon Hospital is today without x-ray service, while the salary of the expert goes on. In another instance objectives for a number of microscopes were carefully specified by the chief of the laboratory, who would naturally be presumed to know most about them, but the commission, more especially Mr. Grunsky, assumed to possess superior knowledge of the subject and substituted others, with the result that when they arrived on the Isthmus they, too, were found to be worthless.
The foregoing are but two examples of what is constantly occurring. The matter becomes really very serious when it involves questions of medicines, and in this particular furnishes a strange inconsistency with the laws laid down by the commission for the government of everybody else but themselves. Thus, by the laws of the canal zone, a severe penalty is imposed on druggists and purveyors in general for substituting one medicine for another that may have been ordered, yet instance after instance is coming to the front in which the commission, either through VIr. Grunsky or through an unqualified purchasing agent, is foisting on the medical service remedies Other than those specified in the requisitions. This, I believe, holds true in practically every requisition for medicine that has reached Ancon Hospital, and the same principle may probably account
for the fact that the majority of all of the requisitions for medical supplies have been either ignored or suppressed by the commission at Washington.
CHEAP PHYSICIANS FOR THE ISTHMUS.
The commission in every effort that it has made to secure service of any character on the Isthmus has tacitly acknowledged the unhealthfulness of the region by holding out as an inducement the fact that employes will be furnished free medical treatment, including the service of the hospitals. The fact that medical men in the zone would have much executive work to do, that they would have to deal with large bodies of workmen, and that their duties would require the exercise of trained judgment in a very broad sense, prompted Colonel Gorgas to advise that only relatively mature men be brought to the Isthmus in the capacity of physicians. He advised, furthermore, that the minimum salary to be paid to medical men in the zone be the same as the minimum salary paid in the Army for contract surgeonsnamely, $1,800. This plan did not, however, commend itself to the commission, more especially to Mr. Grunsky, who, in the interest of alleged economy, conceived the brilliant scheme of establishing interneships in the hospital of the zone, the incumbents to receive $50 per month, the same salary that is paid to nurses. The verbal justification of the plan offered by Mr. Grunsky, and subsequently adopted by the commission, is that young men will thereby receive a preliminary training in tropical diseases, which is to be accepted by them as part pay for their services, after which, that is, after a year, if they so desire, they will be at liberty to return to the states. But Mr. Grunsky takes pains not to say that the incidental service to be rendered by these internes is to represent the bone and sinew of the medical service on the Isthmus, and likewise fails to make clear how he expects to establish a stable medical service if, after the expiration of a year, his internes are at liberty to return to the North, which they would doubtless do in the absence of inducements to remain on the Isthmus. And what if they should desire to return before the end of a year?
This question brings us face to face with lfr. Grunsky's trap to get cheap medical service for the zone. Once on the Isthmus, these young men, finding themselves on the salaried basis of nurses with incidental expenses that cannot be evaded and that will eat up the last penny of their beggarly stipend, desiring to leave their humilating positions, will find the door closed against egress. It is even today easy for an employe to get to the Isthmus, but it is already exceedingly difficult for him to get away from it. And what is true today will be more emphatically true in the future, a fact that the commission, more especially Mr. Grunsky, takes great care to leave in the background.
But the commission, more especially Mr. Grunsky, holds up the prospect of promotion. This in any event, under Mr. Grunsky's rules, cannot be granted under one year, and then, if granted, which it may not be, the salary is placed at $125 per month, or $300 per year less than the minimum salary paid to contract surgeons in the Army. What is there about the medical service in the canal zone that should render it less entitled to compensation than the same medical service when rendered in the Army? What is there about the personnel of the zone government, about the employes, about the laborers, that they should be furnished with a cheaper grade of medical service than the officers, soldiers and enlisted men of the Army? Why should not the commission, more especially Mr. Grunsky, follow the example of both the Army and the Navy and accept men who have already served interneships in the hospitals of the states, give them decent salaries, and then, after sending them to the Isthmus, give them additional opportunities for the preliminary study of tropical diseases at the hospitals at Ancon and Colon? And why should this not be done at once, that a competent medical staff may be at the Isthmus when the large bodies of workmen shall have arrived? This could not but be gratifying to the chief sanitary officer, whose wishes, however, it would seem need only to be expressed to have them vetoed by the commission, more especially by Mr. Grunsky, in what seems to be a fatuous desire, regardless of consequences to give every detail the impress of his overpowering personality. THE UNITED STATES IN CHEAP COMPETITION WITH THE MEDICAL
PROFESSION OF PANAMA. The course of the commission in its endeavor to establish a cheap medical service, naturally enough made up of cheap doctors, which they hope in the future to send to the zone, is not limited in its influence and in its pernicious results to the zone itself. To make this clear, however, it is important to remember that under the truly remarkable plan of organisation of the sanitary department devised by Mr. Grunsky, adopted by the commission and duly engrossed in the laws of the canal zone, it is provided that all persons not employes of the commission, but who may be “sick in the canal zone and in Colon and Panama, should be admitted to the hospitals, but such persons shall pay according to their means.” This practically opens the hospitals of the zone as private pay hospitals to all the world, for it would be difficult for any sick persons to come from anywhere and to enter the zone at either end without being sick in Colon and Panama. As a matter of fact, it happens with increased frequency that patients, not only from Panama, but from various points along the coast and in the interior, are received and treated
in the hospitals at Ancon. I have no knowledge touching this point at Colon, but can see no reason why it should not be equally true there.
The thing, however, would not seem so bad if the provision that these patients should pay according to their means had been permitted to stand without qualification. Unfortunately, however, the commission, more especially Mr. Grunsky, with his fondness for prescribing details, proceeded to lay down a per diem charge for room and for nursing at Ancon, the rates being about the same as those charged for similar service in the better hospitals of the United States. He, however, did not stop at this point, but made it a part of the laws of the canal zone that "surgical operations shall be charged for according to their importance and the financial ability of the patient to pay, but no charge in excess of $50 shall be made without the approval of the director of hospitals.” As the office of director of hospitals has been abolished, the maximum rate to be charged for surgical operation, without reference to their gravity, stands at $50. is furthermore provided by Mr. Grunsky and made part of the laws of the canal zone, that physicians connected with the hospitals must visit the residences of persons "entitled to treatment at the hospital, at a fixed daily rate of pay," which visits “shall be charged for at the rate of one-half dollar ($0.50) for each visit, but no such charge is to be made for emergency calls nor in the cases of persons entitled to free hospital treatment until after the person has been ordered into the hospital." These rates which, in the instance of surgical operations, vary from one-fourth to one-tenth of the average charge in the United States and in the Republic of Panama, and in the instance of visits, less than one-fourth of the ordinary rates charged in either of the two countries, cannot but be disgusting to the medical profession in the states who are not in the least influenced by the belittling competition.
It is important, however, to bear in mind that the physicians at Ancon are in no sense the beneficiaries of the extra revenue that is derived from the extra service thus imposed on them. On the contrary, it is provided by the commission, more especially by Mr. Grunsky, and duly engrossed in the laws of the canal zone that:
The money realised in the hospitals from charges for board, medical attendance, surgical operations and the like, and from visits at residences as set forth, shall be considered public funds and turned over to the government of the canal zone.
It follows, therefore, that it is not the medical men sent to the canal zone, but the United States, our own great nation itself, that is engaged in this belittling business, which must be recognised as a personal insult to any decent practitioner of medicine in any country of the world.
In the Republic of Panama it amounts to more than an insult; it is an actual damage. This was brought to my attention by one of the most distinguished members of the medical profession of that country, who first made me aware of the situation, and who did so in terms of bitter complaint. He explained that under the operation of this order of things, and in spite of the existence of other hospitals in Panama, private patients, attracted by the cheap rates and the prestige of the medical staff at Ancon, are flocking to that institution to the present serious embarrassment and prospective ruin of medical practitioners.
I took the liberty to mention this matter in the course of a personal interview with President Amador, himself the most distinguished medical practitioner of the republic. As he is a friend of long standing, I had no hesitancy in broaching the subject and no difficulty in securing from him a very frank expression of fact that the situation had become so serious that he had been waited on by his colleagues of the medical profession, his constituents and fellow-citizens, by whom he had been requested to make formal representations on the subject to the American minister, but that he had desisted out of his great desire to avoid even the semblance of friction with the United States, and in the belief that a knowledge of so flagrant an injustice would sooner or later reach executive circles in Washington and would be corrected.
But a commission that is capable of thus busying itself with petty but, in their hands, annoying and obstructive details, would naturally enough be expected to forget matters of real importance. One cannot, however, even at the hazard of seeming impertinent, enquire: “Why is there yellow fever in Pana
WHY IS THERE YELLOW FEVER IN PANAMA? Yellow fever is demonstrably a preventable disease, and as a consequence all deaths resulting from that disease must at once raise the question of responsibility. Panama has long and justly been recognised as a seat of yellow-fever infection, just as was Havana before the brilliant sanitary achievements of Colonel Gorgas in that city,-achievements which resulted in his call to the Isthmus. The real campaign against the disease in Havana, more particularly against the disease-bearing mosquitoes, lasted from January to September, 1901. As Panama is but a village in comparison with the Cuban metropolis, it was naturally expected that similarly satisfactory results would be realised there in the same if not less time. But yellow fever is still endemic in Panama. Why is this true?
The dangers of the situation were thoroughly appreciated by Colonel Gorgas, even before he went to the Isthmus, and he laid before the commission a plan of campaign which embraced several distinct features-namely: