THE DARK SIDE OF SANITATION
By REAR ADMIRAL LUCIUS W. JOHNSON, (MC) U. S. Navy (Retired)
The opinions or assertions in this article are the private ones of the writer, and are not to be construed as official or reflecting the views of the Navy Department or the naval service at large.
The noblest efforts of mankind may produce disastrous results. Planned with the highest humanitarian ideals, carried out with devoted self-sacrifice and thoroughness, their accomplishments may threaten the peace of the world.
Take public health work, for instance. For more than two decades European colonial powers have enjoyed many a quiet snicker as they watched the effects of the beneficent policies of the United States in the islands it controls. Not that the programs for improving the health of the native populations were failures. No, on the other hand their very success has made them calamitous. Problems have been created that may well tip the balance in many future political and economic issues.
Nearly 18 years ago I listened to an evening’s discussion that I have never been able to forget. It took place in the Fortalesa, the palace of the Governor General in San Juan, Puerto Rice. Those who talked were Colonel Theodore Roosevelt, Jr., who was then the Governor General of the island, and Mr. Ernest J. Swift, disaster-relief expert of the American Red Cross.
Colonel Roosevelt was a fine gentlemen, of high ideals and purposes, who was concentrating his efforts on the objective of making Puerto Rico self-supporting. The Red Cross man’s name was Swift, but the speed of his mind was much greater than that, for it flashed like lightning to the very center of a problem, illuminating the kernel of fact which indicated the necessary action. With this he had a forceful yet pleasing personality which won everybody to his side, from peasants to presidents. He and I had been busy with relief work in Santo Domingo, capital of the Dominican Republic which had been visited by the disastrous hurricane of September, 1930. We had come by plane to San Juan to confer with Colonel Roosevelt on the valuable relief work being done by the Puerto Rico hospital unit.
It was part of Mr. Swift’s job to study political, economic and meteorological trends in all parts of the world, to predict when they would lead to war, famine or pestilence, and finally to plan the strategy of Red Cross relief work for the stricken populations. Naturally enough, conversation turned to the conditions that were causing so much unrest in Puerto Rico.
“Our population is now so great,” Colonel Roosevelt told us, “that the island cannot produce enough food to meet the demand. Poverty is widespread. Huge quantities of staple foods must be imported and the cost is so high that it is beyond the reach of those who need it most. That is the basic condition behind the agitation against the government.” Then he told us some of the facts that had been emphasized in a recent report to Washington. When we took over Puerto Rico in 1898 the population was less than 900,000. That was about the limit that could be supported under the Spanish feudal system, which kept a few families in luxury while the general mass of people existed close to the starvation level. Those rulers sternly suppressed any political activity or any show of interest in the government by the common people. Famine and devastating epidemics came almost every year to carry off great numbers of the peasants.
“But after Spain was defeated and our government moved in,” said Colonel Roosevelt, “all that was changed. With great energy and ambitious projects we set out to improve the condition of the oppressed people. The doctors started campaigns to abolish sprue, hookworms, malaria, yellow fever, pellagra, typhoid and the dysenteries. Soon the infant-survival rate was cut in half. In spite of emigration to the United States and to Caribbean areas the population has doubled and Puerto Rico has become one of the most densely populated lands of the globe.”
Economic conditions have gone from bad to worse in Puerto Rico since that time. Population pressure is forcing hundreds to emigrate to the mainland, where they can live in comparative comfort on unemployment relief. The problems caused by this concentration in large cities of the Eastern seaboard have been prominently displayed in illustrated magazine articles. Political agitation of the sort that is engendered by overpopulation has grown more harsh, so that our whole nation is painfully aware of the economic difficulties of this unfortunate island. Whenever I read about them I am reminded of Mr. Swift’s remark which closed that evening’s conversation:
“The European governments have a more practical attitude, as they like to think of it. They depend on the natural forces of nature such as famine, local wars, and epidemics to keep the population of their colonies within the limits that the other area can support. They look with a cold and fishy eye on our contributions of food and money to support the starving hordes of China and India, since they regard famine as a salutary and inexorable method which nature employs to correct an excess of one biologic group. They point to Guam, Puerto Rico, and the Philippines as impressive examples of the evil that we do with our humanitarian policies. Some day, they say, the American people must face the issue and answer the question: How much public health work?”
II
During the ensuing years I have often pondered that evening’s conversation. For a considerable part of that time I was engaged in observing and directing public health enterprises among primitive peoples. Is there any other field of human endeavor which gives such a lift to the ego, such a warm inner glow of worth-while accomplishment? I doubt it. The feeling of self-approbation which it creates is the reason why that glint never fades from the eye of the medical missionary or the worker in public health. It is the ample reward for all hardships and sacrifices, the spur that never allows one to retire or to lose his enthusiasm. But in spite of that self-gratification there were times when I could not fail to observe the dark side of sanitation. The force and truth of those comments by European observers were amply demonstrated. Sanitation does lead to overpopulation and its attendant evils.
Consider for instance the changes during the 40-odd years that we held Guam. When Captain Henry Glass, in the U.S.S. Charleston, entered Apra Harbor and captured the island in 1898, the Chamorro people there numbered less than 8,000. The drastic policies of the Spanish rulers, together with the prevalent yaws, gangosa, intestinal worms, leprosy, smallpox, dysentery and tuberculosis had kept the population down to the number that could be fed by the produce of the island.
School teachers and doctors followed the flag of our country into Guam. An ardent campaign was quickly begun against the diseases which had maintained such a high death rate. As a participant in that public health work for several years, I well remember the pride that all the medical men took in the lowered death rate and the improved living conditions of the Chamorro people. By the time the Japanese took the island the population had more than trebled, and huge imports of food had been necessary for several years. The pressure for government aid in feeding the people was too strong to be resisted.
In the Philippine Islands developments were similar. Sanitation was an important part of our benevolent occupation. Cholera, plague, smallpox, beri-beri and intestinal diseases were attacked with enthusiasm and soon placed under control. During our occupation the population increased from 7 millions to 17 millions. It is not necessary to recall the political agitation which was caused by the rise in population, for it is still with us. In spite of the so-called independence which the Filipinos have recently assumed, nobody who has read Mr. Bernard Seeman’s revealing article in the American Mercury for August, 1946, can doubt that their problems and their burdens must be borne largely by us for the foreseeable future.
The results of our policies in those island possessions are cited as examples of the dire consequences when public health work is intensive and successful. It is another angle of the law of compensations. Our triumphs in one field must be paid for by entanglements in another. With those object lessons in mind, let us consider what is being done in the lands which have recently come under our control. There it has been our national policy to duplicate the efforts which in the past have produced an excess of population over food supply.
After Guam was recaptured large areas of land were taken out of food production for roads, barracks, depots and other necessary military installations. The President has approved an appropriation of more than $1,600,000 to purchase additional acreage from the present owners for government use. This can only mean that even more land will be diverted from food production and that imports will have to be still further increased to feed the Chamorro population, who will be still further removed from the ideal of self-sufficiency. In fact, a further large appropriation has recently been sought to “support the economy” of the island.
In the Pacific islands which I had an opportunity to visit and observe during the late war, public health work for the benefit of the inhabitants was begun even before the fighting ended. Yaws, syphilis, typhoid, malaria, dengue, beri-beri, typhus, fluke diseases, the dysenteries and other killers were immediately attacked by our medical men with great success. One can state with confidence that those diseases will be virtually eliminated. Next, the native diet of fish, taro, yams and coconuts, with an occasional feast on pig, which had served the people for centuries was examined and compared with that enjoyed in the temperate zone. It was deemed to be deficient, and from some of the island governments came urgent demands for large shipments of food and vitamin products to supplement the diet of the natives.
The New York Times of 9 November, 1947, carried an item describing the medical census that was soon to be started, of all the territory in the Pacific which is in the trust of the United States. A floating laboratory will be provided and it will visit all the islands. “Each native will be brought out by boat for a complete medical and dental examination, including X-rays. Records obtained will be the basis on which to gauge success of the health program in later years.” It is further stated that while examinations are under way aboard ship, sanitation experts will check food and water supplies, garbage and sewage disposal, rodent and pest control. The Pacific Fleet’s medical officer is to be in charge of the program, which gives assurance that it will be intelligently directed and vigorously prosecuted. It is hardly necessary to point out the inevitable results of this work: the rapid increase of population, and the demands, augmented yearly, for food to be sent to support the hungry people.
In the past those islands were owned by or mandated to thrifty peoples such as the British, French, Dutch and Japanese. With few exceptions the colonies were governed frankly for the purpose of producing revenue and providing raw materials to be processed in the mother countries. What public health work was done had as its motive the realization that a certain level of public health would favor the greatest productiveness. Instances of food being sent out for free distribution to the natives, by governments other than ours, would be difficult to find. Medical officers who had been in the Gilbert Islands when they were turned back to the representatives of the British Empire told me that the first act of those practical men was to take away from the natives all the canned rations, money, clothing and miscellaneous gear that our men had so generously given them. In the future, the inhabitants were to earn their bread by useful work, as they had before the war. Any food they might get would be caught, raised or earned, but never handed out free.
III
The national policy of stimulating the growth of populations by public health work and then feeding the excess that it produces, undoubtedly meets with universal approval. It is evidence of the generous nature and kindly attitude of our people, and we are proud of it. Yet there have been a few who dared to invite attention to the long-range effects of such policies.
The English student, Thomas R. Malthus, was neither the first nor the last to worry over the dangers of excess population. Writing 150 years ago, he aroused a storm of protests against his belief that man and his governments should do something to prevent it. His critics insisted that the matter was obviously in God’s province and it would be blasphemous for mere man even to look into it. He was described as the most hated man of his day, and it is by no means certain that the matter can be discussed even now without arousing passion, prejudice and accusations of heresy—or worse. The Malthusian thesis was that there is a constant tendency for mankind to increase faster than his food supply, thus creating the twin dangers of overpopulation and starvation. Technological and other developments postponed the evil days that he predicted, but nobody can doubt the validity of his reasoning, for the same danger still looms ahead.
A great number of books and articles on the subject of population gives testimony that it is a matter of increasing interest. The most prolific of current writers is Mr. Warren S. Thompson, whose book, Population and Peace in the Pacific (University of Chicago Press, 1946), should be required reading for every officer in the Armed Services. Writing on population pressure as a fundamental factor in determining international relations, he refers many times to the effect of public health work on population pressure which “only waits the establishment of peace, the development of a moderately effective health service” to become dangerous. Also he observes that, “in a region where from 75 to 85 per cent of the people are agriculturists, when the population is already dense and when the standard of living is very low, any large and rapid increase of population at once raises the question of how these additional millions are to be fed, clothed and sheltered.” These conditions now exist in several of the colonial areas for which the United States is responsible, and in the others we are creating them as rapidly as possible.
C. Lester Walker, in Harper’s Magazine for February, 1948, states that Europe now has at least 21 million more people than when the war began, and even before the war two thirds of the people of the world were undernourished all the time. In terms of military strength, he states, the overpopulated nation is weakened by its extra people, for a modern army is fed and equipped by the surplus of foods and materials that its people can produce. He poses the question, “Isn’t food relief to grossly overpopulated countries an unsocial act in world terms?”, and answers, “Some food and population experts privately answer in the affirmative but, because of sentiment, publicly hold their peace.”
Sir John B. Orr, director general of the food and agricultural organization of the United Nations, recently emphasized the fact that millions of people in the world do not get enough to eat. The solution he offers is to place all the food problems of the world in the hands of a small committee who would have complete authority over production and distribution throughout the globe. This world-wide extension of the Marshall plan would take from us the right to decide what countries we would aid with our surplus food.
In India, it is estimated that 5,000,000 people must starve to death each year to keep the population at a level that can be supported by home production. It is stated that the Red Cross had given up famine relief in China before the war because its efforts led only to an increase of population, with added misery and starvation of even more people.
Here in the United States, the Metropolitan Life Insurance Company reports that the year 1947 was the fourth in succession to show a reduction in mortality, establishing a new all-time low. At the same time birth rates have zoomed to a new high. The figures indicate that more than 12,500,000 have been added to the national population since the census of 1940. Can it be doubted that this is one of the factors in the spiralling cost of food and other necessaries?
IV
What an be done to prevent overpopulation and its attending dangers? Many devices have been suggested and a few tried in the past. Primitive man employed abortion, infanticide, cannibalism, taboos against women, killing those too old or too feeble to support themselves, also banishment from the tribal area, all with indifferent success. Emigration, both forced and voluntary, were tried, but only rulers with absolute powers, like those of Hitler and Mussolini, could enforce it and regulate it so that it would be effective. Our Alaskan experiment at Matanuska still rises up as a warning that official attempts to create a paradise in a new land may fail to attract permanent settlers. Recent massacres along the border between Haiti and the Dominican Republic are reminders that serious international disturbances can be caused when people flee from starvation in a densely populated area to a region where population pressure is lower. Mr. Thompson’s book gives several examples of government-fostered migration that failed to produce more than temporary and local relief in overcrowded areas with food deficiencies.
He also comments on the effect of urbanization and industrialization in reducing the rate of population increase, and suggests the development of industries in those lands where uncontrolled population increase will shortly create a menace to international peace. But when we attempt to apply this means we find that political conditions in the lands where control is most needed are such that no consistent program can be started in the near future. It takes several decades for this influence to become effective. He alludes to birth control as a useful method of limiting population growth, but religion and tradition would be fanatically opposed to any attempt to limit births in this way. My personal observation of organized birth-control activities leads to the conclusion that those who practice it successfully must have patience, self-control and singleness of purpose far beyond those of any colonial native.
It has also been proposed that sanitary work be curbed, so that the death rate may rise and thus remove the excess. The director of the Office of Population Research of Princeton University comments on this point (Notestein, F. W., “The Facts of Life.” Atlantic Monthly, June, 1946): “People who propose that public health measures and efforts to improve living conditions be held in abeyance, pending a decline in the birth rate, have misread the history of population changes. Nowhere has the transition from high to low fertility been made in a welter of deepening misery. On the contrary, the transition has come in the context of improving health, rising levels of material well-being, growing literacy and new freedom from old taboos.” He also refers to the means of limiting fertility which Mr. Thompson seems to favor: “People who think a solution can be found in the widespread use of contraceptive knowledge are not much more realistic.…The population already has more knowledge of the means of controlling fertility than it uses.…”
There is a law of nature that is well known both to primitive and to educated people. An organism existing under difficult circumstances, or about to lose its power of reproduction, makes extraordinary efforts to perpetuate its kind before it is too late. The florist takes advantage of this by sticking pins or knives into his plants to hasten their blooming and to increase the number of flowers. Natives of tropical lands have brought me handfuls of bolts and rusty nails, asking me to load my shot gun and shoot them into the trunks of their mango trees just before the flowering season. Failing this, they would scarify the trunks with their machetes, to make the trees bear more heavily. In humans we note the excessive sexual urge of those with tuberculosis and other chronic diseases, also the increased fertility of those on relief in times of depression. Fertility does not decrease during a period of harsh living.
Suppression of tribal warfare is a factor in augmenting the population, and we carried it out zealously in the Philippines and other lands that we have controlled. To the observer in the remote ivory tower this might seem to be a laudable and beneficent action on our part, but residents of several primitive lands would disagree violently with them. Warfare, to certain large racial groups, is a much more desirable state than peace. In parts of the Philippines, for instance, interference with their marauding pursuits was regarded by the natives as inexcusable meddling with their long established customs, which had acquired a religious authority.
Our efforts to improve sanitation are looked on by the people of many backward lands as further evidence of the demented state which they regard as a universal attribute of the white man. They are little impressed when we tell them of the lives we have saved, for life seldom has the same importance to them that it does to us. They show little enthusiasm over the results of sanitation while deeply resenting the interference with their community customs. Where individualism is sternly suppressed, or where masses of people exist on the verge of starvation, the savior of life means little to the average man.
V
Overpopulation exists or is impending in most of the areas for which the United States is responsible. In the past it has been a fertile source of war, and it will continue to be so.
Can the problem be solved by withdrawing our sanitary specialists; allowing infant and maternal death rates to rise; permitting the epidemics of earlier times to return? Could our people be educated to the point where they would believe it right to relax our guardianship over public health; to stand by with a calculating eye while famine and pestilence corrected the population-pressure? Our huge contributions to prevent starvation throughout the world give a forceful negative answer to those questions. Adoption of such an attitude would require us to abandon our cherished benevolence and to endorse the doctrine of the superior race, which claims the right and the obligation to decide which of the subject races shall be allowed to survive and to what extent. We have just fought a war to correct that delusion.
To pose a problem without offering a solution leaves us in the realm of speculation. Many devices have been proposed but none promises really important help. Efforts to limit population by abortion, infanticide, continence or birth control are but puny subterfuges whose effects would be hardly noticeable. Urbanization and industrialization might be helpful after several generations of turmoil. Nature’s drastic methods of famine and pestilence we are determined to thwart. War, either tribal or national, we hope to avoid. Engineering projects which might improve the production or distribution of food would be helpful, but their extent is uncertain.
The United States now is helping to feed millions of persons in Europe, Asia, and the Pacific Islands. Other anxious claimants are striving to climb aboard the gravy train. The question, how long this can be continued, is causing grave concern. With constantly rising prices, how long will our people be willing to make the sacrifices entailed in feeding those in distant lands? The uncertain answer to this question would seem to make it unwise to create further problems of overpopulation in lands newly acquired.
This is an evil which we ourselves have created in Guam, Puerto Rico and the Philippines since we took charge of their destinies 50 years ago. It is a continuing and progressive evil, for which no satisfactory corrective has been found. We must continue to carry it but, if we are capable of learning by experience, this lesson is imperative: Do not repeat that same error in our newly-acquired dependencies. It will be no kindness to the simple people of those islands to replace the minor difficulties, to which they are accustomed, with the more harassing ones of overpopulation and possible starvation.
A graduate in Dentistry and Medicine of the University of Pennsylvania, Admiral Johnson entered the U.S. Navy Medical Corps in 1908 and served continuously until his retirement in 1946. His active service included many years of duty in home and foreign bases where sanitary problems were of great importance to the success of our policies.