REPORT 
of 
SANITARY SURVEY 
of 
EL SALVADOR 
March 7-12, 1941. 
by 
V. H. CORNELL, LT. COL., M. C., U, S. ARMY. OUTLINE FOR SANITARY SURVEY OF PROPOSED MILITARY AREAS. 
I. INTRODUCTION. 
a. Location of country; district involved and areas actually 
surveyed. 
b. Other sources of information. 
c. Reason for suryey vrith type mission concerned. 
II. HISTORY. 
(Brief outline). 
III. TOPOGRAPHY AND GEOLOGY. 
Top and sub-soil. Drainage; swamps; streams; floods, etc. 
(with special reference as to effects on health, economics, acces- 
sibility, etc.) 
IV. CLIMATE. 
Temperature, rainfall, seasons; effect on health and conditions 
in general, 
V. POPULATION. 
Number; composition by races; educational social, health and 
economic status; cultural development. 
Urban; rural; manufacturing; agricultural. Recreation; types, 
availability. 
VI. GOVERNMENT, 
Form. Outline. Departments and other divisions. Place of Health 
Dept. 
VII. PUBLIC WORKS. 
a. Water, Sources; amount; treatment; quality; reserve; 
additional supply available; military vulnerability. 
General; and for cities and large towns. 
b. Sewage Disposal. Type. Efficiency. Dangers. Expansion. 
New developments in process, proposed or advisable. 
c. Garbage and Rubbish Disposal. As under (b). 
d. Manure disposal. As under (b). 
e. Insect Control. Flies. Mosquitoes. Ants. Termites, Ticks, 
lice and bedbugs. Others. 
f. Transportation. (Rail; roads; air.) 
g. Electric Power. (Type; distribution; reserve; expansion; 
availability). 
h. Gas (As under g).) 
i. Communications. (Mail; phone; telegraph; radio.) 
VIII. MEDICAL FACILITIES. 
a. Health Dept, Organizational outline (verbal or graphic). 
Personnel. Reports. Efficiency. Reliability. Cooperation. 
Laboratory. Prophylactic measures in use. Extent of control 
of health Activities. Deficiencies. 
b. Medical Practitioners. Number. Training, Relation to Health 
Dept. Others. Licensure* 
1 Sanitary Survey (Cont’d.). 
c. Hospitalization. Nominal and geographic list with capacity, 
both present and expanded. Extent of occupancy; adequacy for 
civil and military use. Efficiency of administration. 
Sanitary aspects. Other means for emergency hospitalization; 
buildings; schools, convents, etc. 
d. Medical Supplies, Source. Adequacy. Quality. Control. 
Excess. Emergency source. Deficiencies. 
IX. GENERAL HEALTH CONDITIONS. 
a. General:-climate; racial types; habits; economic status; 
health practices and control, 
b. Venereal Disease. (Syphilis; gonorrhea; chancroid; lympho- 
granuloma). Incidence; control; districts; clinics; case 
finding and following. 
c. Respiratory Group. Incidence by diseases: Influenza; 
Pneumonia; Diphtheria; Measles; Mumps; Meningitis; 
Poliomyelitis. Control: methods; efficiency; defects. 
Tuberculosis: Extent; control; trend; type. 
d. Intestinal Diseases; Typhoid-paratyphoid group. Dysentery; 
bacillary and amebic. Common Diarrhea. Sprue. Cholera. 
Trichinosis. Dot infestations. 
e. Insect Borne Diseases. Yellow Fever. Malaria. Dengue. 
Pappatacci. Typhus. Rocky Mt. Spotted. Filariasis and 
Elephantiasis. Relapsing Fever. Plague. (Rat control.) 
f. Other Communicable Diseases. Smallpox (elastrim?) Chicken 
pox. Leprosy. Yaws. Schistosomiasis, Tropical Ulcer. 
Trachoma. Anthrax. Rabies. Tetanus. 
g. Other Diseases. Rheumatic Fever. Bartonellosis. Snake and 
insect bites. Nutritional Conditions (Beri-beri; Pellagra, 
etc.) Tropical Ulcer and allied skin conditions. 
h. Quarantine Methods. Maritime and general. Laws; enforcement; 
efficacy; defects. 
X. HOUSING. 
General: Types, rural and urban. 
Available for use;-permanent; temporary; emergency. 
Suitability of available public and private building. 
Tents; barracks; new construction or reconstruction. 
Type advisable. Locality. Utilities available or absent. 
XI. CLOTHING. 
Used by natives. By resident Nordics. 
Advisable re climate and seasons. 
XII. FOOD. 
a. Meat: availability; types; source; condition; storage. 
b. Milk; dairies; control; number; adequacy of supply; treatment; 
epidemics, 
c. Vegetables: types; safety; availability. 
d. Fruits: types; safety; availability. 
2 Sanitary Survey (Cont’d.). 
e. Flour; source; abundance; period of safe storage. 
f. Beverages; coffee; tea; soft drinks; others. Source; 
availability; dangers. 
g. Cold Storage and Ice Plants. 
h. Markets. 
XIII. SUMMARY. 
3 REPORT OF SANITARY SURVEY OF EL SALVADOR* 
March 7 to 12, 1941. 
by 
Lt, Col, V, H. Comell> M* C*, U* S. Army* 
I. INTRODUCTION. 
El Salvador, the smallest of the Central American States is lo- 
cated approximately between the parallels of 13° and 14°24' N. latitude 
and the meridians of 87°391 and 90°08f W, longitude. It is bounded on the 
south by the Pacific Ocean, on the north by Honduras, on the west by Gua- 
temala and on the east by Honduras and the Gulf of Fonseca. Thus it is 
the only one of these Central American states which does not have a port 
on the Caribbean Sea. However, there is a railroad to the Caribbean 
through Guatemala. The Central American isthmus at this point is about 
200 miles wide, and this country about 75 miles wide at its broadest por- 
tion; its length is approximately 170 miles. It has approximately 10,000 
square miles in area. At the east end it borders upon the Gulf of Fonseca 
which is also surrounded on the other sides by portions of Honduras and 
Nicaragua. It is on the deeper side of that Gulf and hence has the only 
port to which fairly large ships can directly enter and tie up. 
This position, its roads, the distribution of population, the 
railroad terminals and the rail exit from the country make the coastal 
strip, varying from 40 to 50 miles in width, the important section of the 
country from a military viewpoint. The capital, the three ports of 
*(The original data is filed in the Office of The Surgeon General, United 
States Army, Division of Preventive Medicine. See list at the end of 
this report.) 
1 Acajutla, La Libertad and La Union with their connecting roads and rail- 
roads and the larger cities along them, together with the airfields are 
of prime interest in this zone. 
Consequently, this survey deals chiefly with that areaj the Cap 
ital, the road net to the west and east boundaries, two of the ports and 
the larger cities and towns along these routes being visited. One port, 
Acajutla, chiefly of importance for exports of coffee, is connected only 
by railroad. It is in a very unhealthy spot and due to poor connections 
and the fact that the customs and all other activities of the port are 
conducted at Sonsonate, the actual port was not visited. This is the 
third in importance, the first being La Union where imports and exports 
in 1938 were 32.5$ of the total and the second La Libertad with 27.9$; 
even the national statistics list the other port as Sonsonate which had 
20$ of the total. The rest entered or left the country by rail, road and 
air, at other points. 
Information obtained from other sources is chiefly from the 
statistical data collected with comments thereon by Dr. Sutter, Director 
General of Public Health, whose comments and information on many other 
details were relied upon for accurate information. Dr. H. W, Kumm of the 
Rockefeller Foundation is temporarily residing here and much valuable in- 
formation and opinion was also obtained from him. 
The survey of this country was begun without much knowledge as 
to its possible importance in a medico - military sense, as very little 
could be obtained from any source before entry. However, the survey has 
convinced the writer that there are some features which make it most im- 
portant. The railroad from Puerto Barrios in Guatemala to La Union in Salvador is an excellent means of communication between the Caribbean and 
Pacific with a branch line to Acajutla, The hard surfaced road from the 
Guatemalan border runs thru the capital, San Salvador, to near San Miguel 
and will probably be complete to the latter place within the year. The 
road from there to La Union is very bad but is only about 25 miles long 
and could probably be greatly improved in a short time. There is a good 
hard surface road from San Salvador to the port of La Libertad. The de- 
velopment of the larger cities is such that there are buildings available 
for military use and at Santa Ana there is a large 700-1000 bed hospital 
nearly completed except for equipment, this being on the road and railroad 
which extends across the country and connected by them to all three ports. 
It is not near a military objective other than these means of transporta- 
tion and not close to them. It is also connected by road to Guatemala 
City and to that city and the Guatemalan port of Puerto Barrios by rail, 
II. HISTORY. 
Like that of the other Central American countries, El Salvador 
is bound with them in early history (see Honduras report) and dates its 
independence from September 15, 1821. Like them too, it has passed 
through years of quarrels with the neighboring states, frequent and almost 
continual bickering between political, or rather, personal groups within 
the country and exploitation by the group in power, one after the other. 
There are listed about 99 governing officials for the country from 1830 
to date, with varying periods of government for each, and with many du- 
plications of the same name as men became President for a term then were 
removed for some reason or by one means or another. The present incumbent 
has been in office, except for a short period, since December 4, 1931. His term does not expire under the new constitution until January 1, 1945. 
It is generally admitted by natives and resident Americans alike, that the 
present is the best administration they have had. The new constitution 
was adopted January 21, 1939, and is deemed appropriate for this nation. 
Ill, TOPOGRAPHY AND GEOLOGY, 
Photographs of maps prepared by Dr. Sutter on field surveys to 
show the relation of malaria to density of population and altitude are 
filed which are considered much more accurate than the other colored large 
map which was purchased locally. This rather clearly outlines the chief 
topographic features of the country, namely, a shallow coastal strip along 
the west end of the country extending a slightly further distance inland 
near Sonsonate; a much broader or deeper zone of such lowlands in the 
eastern end of the country reaching through the entire country to its 
northern border along the river channels and even into the interior of the 
more eastern portion which would usually be thought of as highlands because 
it is beyond mountains or higher areas, and not apparent on most maps at 
first glance. Much of the rest of the country is in the area marked as 
between 300 to 900 meters (1,000 to 3,000 feet). These latter areas with 
the relatively small sections of higher elevation contain most of the pop- 
ulation. There are many hills and low mountains throughout the 300-900 
meter areas with rather deep gullies and much surface erosion but the soil 
is rich volcanic and there are many farms, extensive coffee plantations on 
the higher portions and considerable sugar and sisal cultivation. Some 
beans and sugar are exported to other Central American countries. The 
higher altitudes are rather limited to the peaks and sides of the numerous 
volcanic peaks, a few of which are still slightly active. One of these. Volcan San Salvador, erupted in 1917 causing some damage in the city of 
that name and leaving a broad bed of lava which is crossed by the rail- 
road en route to Sonsonate; there is another large bed in another portion 
of the country but this is very old and the date of its deposit not known. 
Of interest in this respect is the record (see Anuario Estadistico for 
1933) of seismologic disturbances in 1938 which records a total of 193 
quakes in that year, 4-3 of which were '’sensible"; 85 were local and 105 
diffuse. As stated much of the topsoil is volcanic in origin and in the 
hillsides where cuts have been made for roads layers of volcanic ash can 
be seen intermittent with layers of sand, gravel, larger stones of smooth 
round surfaces and some layers of clay. Some of this clay is quite light 
in color, other layers are more yellow. Apparently there was an old ocean 
bed with either layers of ash and lava laid down on the bed of the ocean 
or alternate rising and falling of the earth with periods of volcanic ac- 
tivity and later submersion and further deposit of silt, sand or gravel. 
The Navy (U. S.) has made extensive surveys of the Gulf of Fonseca and 
details of that region about La Union should be available in their files. 
About Acajutla and the Lempa river region the low lands are heavily in- 
fested by mosquitoes and the scarcity of population and industry would not 
justify any effort to eradicate them. The southern part of the Department 
of Usulutan, east of the Lempa River, is like these last-named areas in 
this respect. The Lempa River is the largest in the country and beginning 
in the western portion about 15-20 miles from the western border, flows 
southwest almost half way to the Pacific, then turns east to the Honduran 
border near the middle of the country then south and finally southeast to 
the sea. The Rio Goascoran is at the Honduran border on the east, the Rio San Miguel in the eastern province by that name, and several smaller 
rivers also flow to the Pacific. There are four fair sized lakes, 
Llopango near San Salvador in the center of the country, de Guija at the 
northwest edge bordering Guatemala, the Laguna de Coatepeque in Santa Ana 
Department and L. de Olomega in San Miguel near the eastern end. 
IV. CLIMATE. 
The climate on the coast and in the lowlands is tropical and in 
the higher regions semi-tropical with quite cool nights; as one goes to 
the higher elevations the nights are very cool and the days pleasant. 
Records of temperature for 1937 and 1938, together with those for humidity, 
barometric pressure, evaporation winds, rainfall, are given on pages 7 and 
9 of the Statistical report for 1938, and the rainfall records at several 
places in the article by Dr, Sutter; "Primer Infome” on pages 281-284, 
Further such data are given in the "Anales del Observatorio Nacional 
Meteorologico de San Salvador” and "Boletin Estadistico” for the year 1939 
which are filed. For a period of 26 years the normal mean was 23,1C, the 
maximum 32.8C and the minimum 16,3C. The dry season is generally Decem- 
ber to April with some extension into the months at either end or short- 
ening in a similar manner. The annual rainfall varies little over the 
country and averages 1835.5 mm. (73.4- inches) per year, with a range from 
1566 to 2283 mm, (39.2-57.1 inches) over a 28 year period, with an average 
of 121 days of rain. Very good tables of these two features, temperature 
and rainfall, are given on pages of the "Anales" with other data. 
The effect of these features on health is as elsewhere in such 
countries, namely great increase in malaria in the rainy season with some 
increase in respiratory diseases also at this time; in the dry season 
6 water becomes scarce in some areas and less safe, the plains become very 
dry and the roads extremely dusty. Food is less plentiful at the end of 
the dry season where irrigation is not, or cannot be practiced, 
V. POPULATION. 
The last census was taken in 1930 and recorded as 1,4-59,578 for 
the country; previous figures were adjusted to this and the following 
years computed from it. The present estimation of population (latest 
available) as of December 31, 1939, was 1,74-4-,535* These were classified 
as 655,127 urban and 1,089,408 as rural, but observation of "urban” areas 
leads one to agree with Dr, Sutter that the rural should be at least 10$ 
higher as they consider every capital of a Department as urban without 
regard to the conditions, and this might well apply to some other towns. 
The map prepared by Dr* Sutter shows the distribution of the population 
very well, each dot representing a thousand persons. It will be seen by 
reference to this that the population in general is on the higher areas 
and that aside from a few large cities the population is not greatly 
crowded in spite of the relative density of about 50 per square mile. The 
urban area of San Salvador has about one tenth of the population and 
nearly an eighth is in that Department, 
By races there is less variation here than in the other Repub- 
lics visited; they are of Spanish, mestizo or Indian blood with a very 
small admixture with other races. The city of San Salvador shows within 
itself extremes of culture and education seen throughout the country. It 
is a modern city in a great many respects but the market and other condi- 
tions about the outskirts illustrate the Indian manners and customs but 
little changed. The social and health conditions reflect the lower educational level of the general population though the higher intellectual 
groups have their own manners and customs strongly influenced by the Span- 
ish background of the country. Economically this country is far better 
off than many others, though at present in a slump due to loss of European 
coffee markets. But in normal times the country has developed in a way 
which, in spite of the difficult political vacillations, is a definite in- 
dication of the industriousness of the people. Yet there is a very defi- 
nite social status as between the more moneyed, higher educated, intellec- 
tual group and the peon class. Away from the cities, except for the few 
large plantation houses, the homes are of primitive type. There is but 
little manufacturing and none for export. One example indicates their 
industriousness - they now (in the last 6-7 years) raise their own 
hennequin (a type of sisal leaf) and make their own coffee bags instead 
of importing bags from India. The statistical publications referred to 
under IV give the distribution of the population by districts. 
In 1937 there were listed 1039 Government primary schools, 105 
municipal and 97 private. Secondary schools were numbered 44 of which 6 
were normal schools, 18 arts and letters and 20 commercial. Registration 
for that year was 89,839. A total of 4-4-6 were registered at the Univer- 
sities where courses in Jurisprudence, Medicine, Pharmacy, Dentistry and 
Engineering are conducted, 
VI. GOVERNMENT. 
This country is a constitutional republic with a new constitu- 
tion adopted in 1939. There are the usual three branches, executive, leg- 
islative and judicial. The President is elected for a period of six 
years. The National Legislature is composed of three representatives from each department whose term is one year. The Supreme Court, four lesser 
courts and the Justices at the chief municipalities exercise the law. 
The cabinet is composed of Ministers of fGovernment; Agriculture; Public 
Health, Public Works; Credit, Industry and Commerce; Foreign Relations; 
Justice; Public Instruction; and National Defense. Agriculture and Public 
Health are now under one Minister; also Foreign Relations and Justice are 
combined. 
VII. PUBLIC WORKS. 
(a) Water, Water is generally quite plentiful throughout the 
country and many springs and wells are used as sources for their water 
supplies. Electricity is generally obtained from water power. The fol- 
lowing table gives the data collected regarding the water supply of the 
larger towns; those marked with an asterisk (*) were visited; those marked 
with a number sign (#) have over 10,000 population; the others are between 
5,000 and 10,000; some other data is also entered here for convenience. 
("0.0." means an order and "C, & D." means collected and dumped.) 
WATER 
TREAT- 
CONDI- 
SEWAGE 
NAME 
SOURCE 
MENT 
TION 
PVT. 
SYST. 
GARBAGE 
Santa Ana*# 
Sprs. 
Chi. 
Safe 
Some 
80% 
Incin.. 
Chalchuapa # 
Sprs. 
No 
Safe 
Some 
85% 
Dump(Inc.0.0.) 
Ahuachupan # 
Sprs. 
No 
Safe 
Many 
10% 
C • & D * 
Atiquizaya 
Sprs. 
No 
Unsafe 
All 
None 
None 
Sonsonate*# 
Sprs. 
No 
Safe 
50$ 
50% 
C. & D. 
U0% 
Cesspool; 
10$ Privies) 
Nahuizalco 
Sprs. 
No 
Unsafe 
All 
None 
None 
Izalco 
Sprs. 
No 
Unsafe 
All 
None 
None 
Armenia # 
Sprs. 
No 
Unsafe 
All 
None 
None 
Juayua 
Sprs. 
No 
Unsafe 
All 
None 
None 
Santa Tecla*# 
Sprs. 
No 
Safe 
All(10$ Cesspool) 
C. & D.CEnc.0.0.) 
Quezaltepeque* 
Sprs, 
No 
Unsafe 
All 
None 
None 
Opico'* 
Sprs. 
No 
Unsafe 
All 
None 
None 
San Salvador*# Spr. and 
C • & D •, 
Well 
Chi. 
Safe 
Some 
80% 
(Inc, at D.) 
(Few 
Sept. Tks. 
& Cesspools.) WATER 
TREAT- 
■ CONDI- 
SEWAGE 
NAME 
SOURCE 
MENT 
TION 
PVT. 
SYST. 
GARBAGE 
MaJicanoS 
Sprsi 
No 
Unsafe 
All 
None 
None 
Villa Delgado 
Sprs* 
No 
Unsafe 
All 
None 
None 
Chalatenago 
Sprs* 
No 
Unsafe 
All 
Node 
None 
Acajutla(Port) River 
No 
Unsafe 
All 
None 
None 
LaLibertad # 
River 
No 
Unsafe 
Some 
805? 
None 
(Port) 
LaUnion #(Porb) Sprs. 
No 
Safe 
All 
None 
C. & 
D. 
Cojutepeque-*# 
Sprs. 
(QNS) 
No 
Unsafe 
All 
None 
None 
Suchitoto* 
Sprs. 
No 
Unsafe 
All 
None 
C. & 
D. 
Zacatecoluca* 
Sprs. 
No 
Unsafe 
655? 
35% 
C. & 
D. (Poor) 
San Juan Nonualco 
San Vicente-* 
Sprs. 
No 
Unsafe 
855? 
15% 
C. & 
D. 
Seusuntepeque 
San Miguel-*# 
Sprs. 
No 
Unsafe 
All 
None 
None 
Spr. 
No 
? 
90S? 
10% 
C. & 
D. 
(Chi 
. on order) 
Chinameca # 
Sprs. 
No 
Unsafe 
All 
None 
C. & 
D. 
Usulatan 
Sprs. 
No 
Unsafe 
90S? 
10$ 
Poor 
(Improving) 
Jiquilisco 
Spr.(QNS) 
Wells(Shallow 
)Unsafe 
All 
None 
None 
Jucuapa# 
Sprs. 
No 
Unsafe 
All 
None 
C. & 
D. 
Santiago de 
Maria 
Spr. 
(QNS) 
No 
Unsafe 
All 
None 
C. & 
D. 
In general it is observed that the water supplies are unsafe. 
This is due to the density of the population, the poor control of many of 
the water sheds, the minimal amount of sewage systems and the endemic ty- 
phoid and amebic dysentery. In San Salvador, though the supply is marked 
safe, all the better class boil their water and the hotels place bottles 
of water in the rooms for drinking, presumably boiled though mine smelled 
so strongly of chlorine it is safe to assume it had never been near a fire.1 
It is probably safest to be suspicious of all supplies. Sewage disposal 
is fair in the larger cities but on their outskirts there is no extension 
of the system and in many there are cesspools and privy vaults with a minimum of septic tanks. The privies are of a very elemental type. Most 
of the Indians prefer to squat and do so even on toilets when supplied, 
climbing up on them to assume their natural position. In some of the hos- 
pitals the toilets have a soapstone back wall, a trench along the rear 
and a stone floor with slightly raised foot steps thus affording a place 
for the favorite posture without complicated plumbing; a stream of water 
washes down the wall and trench. It was stated that San Salvador hoped 
to secure some deep wells nearer town for their supply of water. Sewage 
disposal units in course of construction or contemplated have been indi- 
cated. 
(b) Sewage. (See above). 
(c) Garbage and Rubbish Disposal, (See above). This is good 
in the cities and fair in the towns. Again the dogs and vultures assist. 
(d) Manure Disposal. Only so far as combined with rubbish. 
There is no apparent effort to conserve this material as fertilizer. 
(e) Insect Control. Efforts at fly control are nil other than 
the removals mentioned above. They are plentiful in some areas and a real 
menace about the food markets and hospitals. Screening is not used effec- 
tively except by Nordics resident here. Even where installed at some hos- 
pitals they have been permitted to deteriorate, or removed for air. 
Mosquito control is in its infancy. There has been no general 
survey of the types and breeding places though Dr. Sutter has made an in- 
tensive study of the incidence of malaria by spleen surveys and checked 
by blood smears. Dr, Kuram of the Rockefeller Foundation is now in this 
country for a survey of mosquitoes and has under way a demonstration con- 
trol project at San Miguel where they are manufacturing concrete drains and sidings. Both the Curry type of invert and one-third sections of 
large round pipe forms are being used with wall slabs. Maps (photos) are 
filed showing the general topography of the country, the distribution of 
the population, the results of the splenic index stocky and the department munic- 
ipalities, These will be published shortly in the Journal of Tropical 
Medicine and reprints will be secured. In Dr. Sutter's "Primer Infome" 
on this subject he classes the areas studied as to the degree of endemi- 
city (page 293). 
Ants and termites are active here as in other countries of this 
area and in construction of wood this should be borne in mind but no evi- 
dence of any general method of control was noted. Ticks are abundant but 
there is no evidence of their bearing any human disease. The lice and 
bedbugs of the lower class are present but not seen in the better classes. 
(f) Transportation. The International Railways of Central Amer- 
ica run from Cutuco and La Union at the eastern end across the flatter 
portion of the country south of the mountains to San Salvador, thence to 
Santa Ana and Metapan and then exits to Guatemala, being continued in that 
country to the Caribbean port of Puerto Barrios. A branch of this road 
goes southwest to the city of Ahuachapan. The main line actually runs 
from San Salvador to Texis Junction near Texistepeque, and a spur connects 
this junction with Santa Ana. This line has a total trackage of 314.5 
miles of which 2B5.5 miles are first track; 36" gage, 30 and 33 feet rails 
of 54 and 60 pounds; ties of native hardwood (pine and redwood) totalling 
768,225. The Salvador Railway Co., of English ownership, has 100 miles 
of first track and a total of 113*5 miles, 36" gage; rails 25 and 30 feet, 
weights 54.5 and 60 pounds; approximately 300,000 ties of native hardwood. principally balsam. This railroad runs from San Salvador to Sonsonate 
and Acajutla and another line from San Salvador to Santa Ana with a con- 
necting short line between Alcos and Silto del Nino, 
The road from the Guatemalan border west of Santa Ana to San 
Salvador and east to San Miguel is well paved and hard surfaced, with the 
exception of a few stretches to the east which are expected to be completed 
this year. This highway will branch northeast near San Miguel to enter 
Honduras east of Santa Rosa. The road from San Miguel to La Union is in 
very bad shape with holes and at this time of the year from 8 to 10 inches 
of dust. The road from Sonsonate to Santa Ana is poor but passable and 
was travelled by car. The road from San Salvador to Sonsonate is not good 
and was avoided. The road from Sonsonate to Acajutla is said to be even 
worse than that to La Union and no one cared to drive it even now in the 
dry season. The road from San Salvador to La Libertad is hard surfaced 
and good. Other roads are poor. The Pan American Airway makes one stop 
at the capital where the airport is good; data on other airports will be 
secured from Captain June in Guatemala, The Taca line is still operating 
here but what the results of the purchase of this line by American Exports 
will eventually be cannot be said, 
(g) Electric power, A list of the power plants with their ca- 
pacity and type current is being filed. They generally are of water power 
and yield a 110 volt, A.C., 60 cycle, 3 phase current. In general it may 
be said that electrification of the cities is good though at La Union the 
current is turned off in the day time as they use Diesel power; a kerosene 
refrigerator was in use in one shop visited, A list of cities supplied is 
also filed. (h) Gas. None available. 
(i) Communications. Mail is distributed by the trains, air, 
and from the points they reach by carts or muleback. The local service 
appears fairly good; air service is good. A list of telephone and tele- 
graph stations is being filed. The telephone service is fair and it is 
difficult to hear at distances. The list of amateur stations as complete 
as available is given in the general radio list. Government and PAA radio 
communication and the Western Union are used. Mail to other countries 
leaves by the three ports here and Puerto Barrios, Guatemala. Cable con- 
nections via La Libertad, 
VIII. MEDICAL FACILITIES. 
(a) Health Department. The Health Department is administered 
by the Director General of Sanitation under the Minister of Assistencia 
Social, It is administered under three divisions, Laboratory, Preventable 
Diseases, and Engineering, Statistics and Hospitals are not under this 
Department. There are four laboratories, including the one at the central 
office in San Salvador; the other three merely do such diagnostic work as 
is needed without determinative bacteriology or other extensive service. 
The central laboratory does most of the water analyses, prepares vaccines, 
does chemical analyses and general bacteriology. The Preventable Disease 
Division has five subdivisions, Malaria, Tuberculosis, Venereal Disease, 
Maternal and Child Health and Rural Districts, Malarial control has been 
mentioned and is under control of the central office. There are two tu- 
berculosis control centers, one in San Salvador and one in Santa Tecla; 
fluoroscopy is used primarily at San Salvador and a unit is to be installed 
at Santa Tecla. There are four Venereal Disease control clinics in the country where prostitutes are controlled more or less and other cases 
treated; prostitutes with open syphilitic lesions or gonorrhea are hospi- 
talized, The has Prenatal, Infant (well and sick). Pre-school and 
School Clinics, This is not too well established as yet but is function- 
ing in the larger cities and a real effort is being made to increase the 
work. In connection with the school clinics there are dental clinics. 
There are 4 prenatal, 4 infant, 1 pre-school and 14 school clinics, the 
latter being in the Department Capitals, There is one Sanitary Engineer 
in the central department and five field workers are used who vary in the 
locale of their work as needed. 
This organization is but about a year old having been revamped 
by Dr. Sutter, a graduate from Johns Hopkins School of Public Health, He 
has an excellent grasp of the needs of the country, is enthusiastic and 
honestly interested in the development of the service. His staff consists 
of the following: Chief Child Hygiene, and M.D., C.P»H, (Harvard), full 
time; Tuberculosis Division, M.D., part time; Chief Venereal Disease Di- 
vision, M.D,, part time; Chief Laboratory Division, M.D,, part time; Chief 
Engineering Division, Engineer, part time; General Secretary, M.D., part 
time; also five physicians on part time and five engineers on full time. 
There is a part time doctor in charge of the public health activities in 
the capital of every Department of the country and at each port including 
Ilopango airport (San Salvador). There is a Sanitary Inspector in each 
municipality of over 5,000 population and in six other important places of 
less than 5,000, 
There are three Sanitary Units established, one in San Miguel, 
one in Santa Ana and one in Santa Tecla, At each there is a physician as director on full time; in addition there are two assistant part time doc- 
tors at Santa Tecla. The rest of the staff at Santa Tecla consists of 
one Secretary, three Sanitary Inspectors, three Visiting Nurses, one Clinic 
Nurse and one Dentist, At each of the other two there are five Sanitary 
Inspectors, two Visiting Nurses (at San Miguel and four at Santa Ana), one 
Clinic Nurse and one Secretary. 
The Sanitary Unit at Santa Tecla is being run as a Demonstration 
Unit and much effort being placed there; the results as gaged by the re- 
action of the community are very favorable; they have arranged rental of 
a larger and better building and seem to like the idea. The houses in 
this community have been surveyed as to residents, sewage and water con- 
nections and these all mapped. 
There is much work to be done in this line throughout the coun- 
try and progress can be seen but it will take a long while to educate +he 
people of all classes as to the necessity and wisdom of the work. Proper 
methods to commence this are being used and the centers of population are 
first being approached with the idea of giving the greatest good to the 
most people. The present government seems to be well behind the idea. 
(b) Medical Practitioners. A list of Medical Practitioners is 
filed with those who have studied outside the country indicated thereon 
by Dr, Sutter. These total about 30$ of the whole. The Medical School 
was visited and, though small, was found quite complete. Their greatest 
need is more competent direction and a steadier, more interested staff of 
instructors. About ten to fifteen are graduated each year. The only re- 
striction on practitioners from other countries is that they pass the ex- 
amination. Osteopaths, chiropractors, etc, are not licensed. There are 
16 247 physicians listed, of whom 115 are in San Salvador, but this Depart- 
ment has only about 12$ of the population. Many of those who have been 
abroad have not studied too well but on the other hand there are many good 
men here. Some have lost considerable interest in the School and Hospital 
because of poor management of those institutions and here is a real need 
for improvement. 
(c) Hospitalization. In the August number (1940) of the Bulle- 
tin of the Pan American Sanitary Bulletin there appears an article review- 
ing the conditions existant in the hospitals of this country, which survey 
was made, at the request of the President, by Dr. Oswald D. Denney, of the 
Pan American Sanitary Office. A map shows the general concentration of 
population with respect to available hospital beds and the main hospitals 
are spotted thereon. The article gives the numerous deficiencies and 
recommendations for improvement of the service. His recommendation-tb-'14' 
a Director be appointed has been followed but the results have not been 
what were desired; most of the defects still exist.. The large hospital 
at San-Salvador is not in keeping with the progress of the city otherwise. 
The Bloom Hospital for Children, a philanthropic enterprise directed by 
the donor, Mr. Bloom, is a surprising contrast to the old hospitals, for 
it is a modern, clean, excellently equipped and managed hospital. The 
hospital at San Miguel was the best seen on this trip and is of the old 
style but cleaner, has been brought up to date and in many respects is en- 
tirely satisfactory though there are still some defects and some of the 
improvements have been allowed to deteriorate. There is a large 700 to 
1000 bed hospital practically completed at Santa Ana which is of steel 
beam construction with concrete walls, tile floors, and porches, heavy corrugated iron roof, high ceilings with ventilation beneath the over- 
hanging eaves, and all buildings needed for facilities. This hospital has 
been about ten years in construction and could be completed in a very 
short time. It is next to the old 500 bed hospital of that city which is 
in very poor condition. However, if needed, this new hospital could be 
utilized by military forces to great advantage. It is located in a city 
which is on the railroad, on the hard surfaced road through the country 
and connected by these to three ports in Salvador and one in Guatemala. 
Railroad connection with Guatemala City, San Salvador, Puerto Barrios, 
Guatemala, Acajutla, and La Union; hard surfaced road connection with San 
Salvador, and the port of La Libertad with hard surfaced road to within 
25 miles of La Union (this could be extended without too great difficulty, 
at least to be practical.) 
A list of Hospitals, Orphan Asylums, and other institutions is 
given below and some additional data regarding available buildings is 
filed which was secured for the writer by Dr. Sutter from the Department 
of Hospitals. (The number sign (#) means visited.) 
CITY 
HOSPITAL 
BEDS 
CONDITION 
Santa Ana 
# General 
500 
Fair 
# New 
700-1000 
New, unused 
# Orphan Asylum 
200? 
Fair 
Old Folks Home 
9 
Fair 
Chalchuapa 
Municipal 
10 
Bad 
Ahuachupan 
General 
60 
Fair 
Orphan Asylum 
200 
Fair 
Sonsonate 
# General 
300 
Fair 
§ Orphan Asylum 
200 
Fair 
Santa Tecla 
# General 
100 
Fair 
# Orphan Asylum 
? 
Fair 
San Salvador 
# General 
1000 
Good 
# Childrens 
135 
Excellent 
Venereal Dis.(Fenu) 
60 
Poor 
# Orphan Asylum 
Military Hospital 
400 
(700 Children) 
Good CITY 
HOSPITAL 
BEDS 
CONDITION 
Chalatenango 
General 
20 
Bad 
La Union 
# 
General 
20 
Bad 
Coiutepeque 
General 
25 
Bad 
Suchitoto 
General 
30 
Poor 
Zacatecoluca 
General 
30 
Bad 
San Vicente 
General 
120 
Fair 
San Miguel 
# 
General 
200 
Good 
Orphan Asylum 
? 
? 
Usulutan 
General 
5A 
Poor 
Jucuapa 
General 
100 
Fair 
Santiago de 
Maria 
General 
50 
Bad 
(See also list of Hospitals in Prontuerio Geografico in file.) 
In general it may be said that these hospitals are filled to 
capacity and are not available for military use, nor for that matter in 
general desirable. The one exception is the large new one at Santa Ana. 
In the cities of over 10,000 population (See VII) there are generally 
buildings which might be made available and these have been indicated on 
the list mentioned above which is filed. 
(d) Medical Supplies. As regards medical supplies, all are im- 
ported, and the same remarks as to their adequacy and prices as ..are given 
under the country of Honduras might apply. However, the drugstores are 
of good type, appear well stocked and there should be no immediate short- 
age of necessary items for small groups. 
IX. GENERAL HEALTH CONDITIONS. 
(a) General. The predominant Indian race in this country gov- 
ern to a great extent the economic and health conditions of the country 
and their habits, ingrained for centuries, are broken with difficulty. 
This makes it difficult to introduce new ideas or methods and education 
of the peon class is low. In the cities there are the Spanish families 
with higher planes of life who readily acquiesce to new ideas though some are necessarily modified to meet their living conditions and type of 
homes. Yet, except for San Salvador, many of the homes are dark, poorly 
kept and rather heart-breaking for a public health man to contemplate. 
One is struck that all these cities base their life about the family, the 
homes being constructed, even in the better class, on the "hollow square" 
type with the central patio where flowers and grass may be found but pre- 
senting a blank wall to the outsider on the sidewalk with no street im- 
provement and the only green spots to be seen in the few parks or plazas. 
And in the poorer homes these central patios are not so well kept but 
serve for laundry, animals and children alike. As sewer connections are 
few or absent in many places, the privy, cesspool and water wells may be 
clustered here also, though the well is usually outside this area. The 
climate along the low lands as described above is very favorable for the 
breeding of mosquitoes aided by the tropical rains and these ereas a~e ex- 
tremely unhealthy; this also applies to the low lands along the river ba- 
sins in the interior. The greater part of the population is on the some- 
what higher region where there is less malaria, and the climate is more 
pleasant. The abundant water supply is inadequately cared for to yield a 
good source of drinking water and is a regrettable but unavoidable situa- 
tion to be reckoned with by anyone entering the country, 
(b) Venereal Diseases, Venereal disease is a problem; the pro- 
stitutes are in houses to some extent but not by any means entirely so. 
They are controlled to some degree but this is so only in the larger 
cities and the venereal diseases are a menace to any entering force. The 
exact incidence is difficult to estimate and is probably about 10$ to 15$ 
for syphilis and unknown for gonorrhea. There is some granuloma. The clinics and case management have been discussed. 
(c) Respiratory Group. There have been no severe epidemics of 
influenza but pneumonia is frequent due to the poor housing and the heavy 
rains with added hazard due to late reporting to the physicians and long 
distances to hospitals. Diphtheria is endemic but rarely epidemic and is 
controlled by spot use of toxoid and serum. Measles is ever present and 
small epidemics occur nearly yearly; only in the better class of private 
patients is any effort at control made and the placental extract is used 
to a slight degree. Mumps is moderate in incidence and rather mild; men- 
ingitis rare and poliomyelitis very rare. 
Tuberculosis is a big problem and there is a large building of 
about 100 beds a short distance outside the city of San Salvador and a 
ward of the general hospital in the city for care of such cases; the man- 
agement of these has been in the hospital division but this tuberculosis 
work is to be turned over to the Health Department in the near future 
under a director of that Division. Definitive work in this line is being 
placed on a better plane and it is felt will soon be much more effective. 
The true incidence of this disease is buried to a great extent in the 
inaccurate diagnoses, wrong classification and lack of attendance. 
(d) Intestinal Diseases. Of the intestinal diseases amebic 
dysentery is quite prevalent but probably less so than generally supposed. 
Typhoid has occured in small epidemics and is endemic throughout the coun- 
try, Paratyphoid is likewise encountered but not in large numbers. One 
epidemic of 50 cases of so-called typhoid last year, on investigation, 
showed many cases sick only about 10 days. Hence the amount of this dis- 
ease is also hidden by incorrect diagnoses and inadequate laboratory checking. Bacillary dysentery is not reported* The other transmissable 
intestinal diseases are not troublesome or recognized. There is high in- 
fant mortality and much infantile diarrhea. 
- 
(e) Insect Borne Diseases. Malaria is the great scourge of 
this country as of the other Central American countries. The spleen and 
blood film surveys of Dr. Sutter in the "Primer Informe" give some indi- 
cation as to the prevalence and distribution of the disease. Work on the 
mosquitoes of the country is to be done by Dr. Kumm as mentioned above. 
In many of the areas concerned, as about the port of La Union, it is the 
opinion of authorities here that the condition can be easily controlled by 
drainage and oiling; but about Acajutla it is impracticable. About the 
larger cities it would be economically sound and feasible. Yellow fever 
has not appeared since 1923 but the Aedes egyptii are still present (3 - 5% 
of homes where search was made). Dengue not recognized; endemic typhus 
is present, there being only a few cases in San Salvador and Santa Ana. 
Other insect borne diseases not found. 
(f) Other Communicable Diseases. Smallpox occurs occasionally 
but all school children are vaccinated and all contacts when a case ap- 
pears; routine vaccination is used at varying periods of all people and 
about 50,000 are done each year; there have been no cases in the last 
three years. Chickenpox is fairly common. Leprosy is rare and there is 
no colory. Yaws is seen occasionally. There is some filariasis and a 
small amount of elephantiasis. There is a small amount of trachoma in 
the natives of Palestine and India but not in the natives of El Salvador, 
Anthrax occurs but not often; the serum is used* Rabies is rare. Tetanus 
is frequent but the majority of cases are umbilical in new born and efforts to enforce the use of sterile cord dressings are in progress. 
(g) Other Diseases. There is little rheumatic fever; snake 
bites are rare but occur; nutritional conditions in infants are numerous 
but the presence of sprue, pellagra and beri-beri are not recognized. 
Tropical ulcer of the leishmania type does not occur; other sores are fre- 
quent but of undetermined etiology. 
(h) Quarantine Methods. House quarantine in the contagious 
diseases is poor; ship and port quarantine are formalities only and de- 
pendence is placed on reports from Panama and San Francisco; more atten- 
tion is paid to ships from other ports. 
X. HOUSING. 
The city houses as mentioned above are generally of the Spanish 
type* cool and comfortable and when well kept, ideal for this climate but 
in the poorer classes often are dirty, closed and poorly ventilated. 
These houses frequently have no real patio but what amounts to a laundry 
and small farm in the rear. In the cities these homes have a common sit- 
ting and bedroom in front and a kitchen, etc., in one or two small, poorly 
ventilated rooms to the rear. In the towns with no pavement or only 
poorly kept cobblestone streets there is much dirt and dust, the animals 
and children, chickens, dogs, pigs and often birds mingle in the yard and 
houses alike. This is not the true picture everywhere but the poorer and 
dangerous class from the health standpoint. There are in every city and 
town, homes of similar form but kept neat and clean - these we do not need 
to worry about. 
The native homes are built of log frames with bamboo or board 
sidings and thatched roofs in general though there are also many with tiles of home manufacture. Many other houses are made of adobe bricks 
with straw between them and bamboo sticks. There are many of the adobe 
walled houses in the towns and cities too, and in San Salvador brick and 
reinforced concrete is used in the more modern buildings. 
For military use temporary wooden structures could be utilized 
as in Panama. 
XI. CLOTHING. 
In weight it is generally tropical; in quality it varies with 
the economic situation; the children of tender years do not worry about 
it. Clothing as used in Panama would be suitable and such has been worn 
continually by the writer in comfort while here in the dry season. Sun 
helmet is advisable in the middle of the day. The few higher regions are 
cooler, 
XII. FOOD. 
Meat is plentiful and good, but sold and consumed the same day. 
Honduras and Guatemala have additional reserve. Chickens and pork as well 
as beef are quite plentiful. There are no storage facilities for any 
quantity. (See page 22 of Beletin Estadistico.) 
There are no large dairies and the milk supply is limited. None 
is pasteurized and a case of Brucellosis has recently been bacteriologically 
confirmed. 
Vegetables are fairly abundant and good though all raw vege- 
tables should be well cleansed before eating. The personal habits of ven- 
dors and cooks are not to be trusted. The same remarks apply to the fruits. 
Both fruits and vegetables are more of the tropical variety and are good. 
Flour is imported though home ground corn tortillas are consumed in large quantities - they are quite good but here the handling enters 
again and they should be well cooked and eaten fresh* Storage periods 
should be limited* 
The local beer, coca-cola, orange bottled drinks and such are 
good. The stronger drinks are imported. Coffee is plentiful and good; 
tea is imported. 
Ice is manufactured at the following places; where known the 
capacity of the plants is given: San Salvador, 3 plants, (La Constancia 
Brewery, 5 tons; E.S.S.E. power plant, tons; C.A.E, power plant, 10 
tons); San Miguel, 5 tons; San Vicente, 2 tons; Zacatecoluca, 2 tons; 
Cojutepeque, 500 pounds; Suchitoto, 300 pounds; La Union; Ahuachapan; 
Santa Ana; Sonsonate; Usulutan. 
The markets are poorly policed, crowded by dry goods in the 
stalls about the sides and the vegetables and fruits sold from baskets on 
low boxes in the middle of wide aisles; the meats are piled on open un- 
protected counters or hung over racks above. The sanitary precautions (?) 
are almost nil. Food, both raw and cooked, is sold from tables about the 
market place. REPORT OF SANITARY SURVEY OF EL SALVADOR 
Original Data Filed in the Preventive Medicine Division, 
Office of The Surgeon General, U, S, Amy. 
1. Airport Photos. 
2* Blueprint - Map of City of San Salvador, 
3. List of Hospitals and Buildings Available for Additional Beds, 
(All of Buildings Specified not acceptable or truly available. 
List received too late to check all details,) 
4. Nominal list of Physicians by Localities. 
5. List of Ice Plants in El Salvador, 
6. General Information Sheet - American Legation. 
7. Colored Map of El Salvador. 
8. Electric Power Plants - El Salvador. Also Cities Serviced. 
9. Outline Maps of El Salvador (M.I.D., G.S. No, 112-B.) 
10. Report of Meteorological Observatory, San Salvador - 1939. 
11. Boletin Estadistico - January, 194-0 - Data of 1939. 
12. Graphic Bulletin of Statistics, 
13. Prontuario Geografico - General Data re El Salvador - 1939. 
14* Anuario Estadistico for 1938. 
15, Primer Informe (Malariologia), Dr., Sutter (1938). 
16. Boletin de la Oficina Sanitaria Panamericana - Ano 19:8, August, 
1940. (Article on Hospitals of El Salvador.) 
#727-SGO-4/lO/4l 
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