FOUR
Windswept and weather-beaten, the city of Iloilo stood upon unpromising marshland near the southeastern tip of Panay, in the vast Pacific waterworld of the Philippine archipelago. The center of the islands’ sugar trade, for decades the old Spanish port had sent forth from its deep harbor steamships bearing that prized commodity, as well as hemp, sapanwood, coffee, mangoes, and mother of pearl. The people of Iloilo were known for their habit of resistance to outside authority, be it the Kingdom of Spain, the Catholic Church, or, now, the United States. In December 1898, Emilio Aguinaldo’s Filipino independence movement set up a military stronghold there. By October 1899, when the Twenty-sixth U.S. Volunteers stepped ashore, Aguinaldo’s insurrectos had already been driven out, but they remained entrenched not far from the city.1
The Twenty-sixth was a regiment of New England militiamen. They had recently undergone a crash course in the geography of American expansion. Their journey began two months earlier in Boston. They traveled by train across the continental United States to San Francisco. Encamped in the late summer fog of the Presidio, they learned that smallpox had broken out in a neighboring regiment, which was swiftly quarantined on Angel Island. After a fresh round of vaccinations, the Twenty-sixth crowded aboard the Grant, a 454-foot transport ship that carried them across more than seven thousand miles of Pacific Ocean to Manila Bay, with a stopover for coal in Honolulu, the premier port of newly annexed Hawaii. Last, they steamed thirty-six hours from Manila to arrive here, in Iloilo. Their mission was to man the U.S. garrison and establish order.2
A Boston Globe reporter named J. N. Taylor had traveled with the Twenty-sixth all the way from Massachusetts. “The city was very dirty—oozy with it,” he recalled. Of pressing concern to the U.S. command, small-pox raged in the city, killing more residents every day. Prior to the arrival of the Twenty-sixth, smallpox, known by its local name, buti, seemed to be accepted as a fact of life. Few of the inhabitants had ever been vaccinated, and they made no effort to isolate the sick.3
On the advice of the U.S. health officer on the scene, the soldiers set about enforcing a “progressive policy” of sanitation, “giving Iloilo a bath and a scrubbing.” They set up a smallpox hospital outside the city and removed the sick from their families. Soldiers inspected homes, cleaned out decrepit privy vaults, and introduced a new system of dry earth closets. The troops moved with particular force upon an expanse of shacks that stretched a quarter mile from the old Spanish palace to the Jaro bridge. The district housed one thousand of Iloilo’s poorest residents, among whom, Taylor noted, “fully 700 were pock-marked.” The soldiers leveled the district.4
Risking fines or imprisonment, many Ilonggos resisted the American sanitary campaign, which, as Taylor had to admit, did require “a radical change in the sanitary conduct of their homes.” The Army’s effort to enforce vaccination proved so unpopular that the soldiers found it “necessary to round up the inhabitants with guns to inoculate them.”5
Within three months of the Twenty-sixth Regiment’s arrival, Iloilo seemed to Taylor a city transformed. The offensive odors had abated. Small-pox was disappearing. Even the attitude of the Ilonggos appeared to be softening. Many now called upon the health inspector’s office, children in hand, and asked to be vaccinated. Taylor could imagine a time when, with a little more sanitary work (draining the city’s swamps was the obvious next project), Iloilo might make a perfectly salubrious home for white men.
“There seems to be no good reason why Iloilo should not be as healthy as Boston,” he said.6
Where soldiers go, plagues follow. Since the age of Alexander, the annals of war had known no truer axiom. Mobilizing armies uprooted young men from great cities and remote villages, previously distinct epidemiological environments, and threw them together in crowded camps where the air reeked of waste and the water teemed with the unseen agents of cholera and typhoid. Across the millennia, seasoned generals had fairly expected diseases to take more lives than spears, swords, or guns. Rarely did those expectations go unmet. Beneath the staggering death toll of the American Civil War, in which some 620,000 Union and Confederate soldiers perished, lay the familiar but little understood handiwork of microbial pathogens: nearly twice as many soldiers had died from disease as from combat.7
When army camps grew up near centers of population, microbes circulated indiscriminately between soldiers and civilians. Soldiers on the march carried smallpox across continents, as the Spanish conquistadores had done in the Americas. The Franco-Prussian War of 1870–71 unleashed a European pandemic of pox that killed more than 500,000 people. Wars disrupted entire societies, causing famine and poverty, displacing populations, and destroying fragile systems of sanitation—all of which increased people’s vulnerability to disease. As catastrophic events, wars and the epidemics they made sometimes became indistinguishable from one another, making it hard for the soldiers and civilians caught in their crossfire to reckon which invasion was the defining one. After witnessing the plagues and carnage of the devastating Crimean War (1853–56), the Russian surgeon Nikolai Ivanovich Pirogoff concluded, “War is a traumatic epidemic.”8
And so it took some gall for Rudyard Kipling, well known to Americans as “the unofficial poet-laureate of the British Empire,” to imagine that a modern imperial army could be a force for public health, rather than an instrument of apocalypse. In his most famous poem, Kipling wrote:
Take up the White Man’s Burden
The savage wars of peace—
Fill full the mouth of Famine
And bid the sickness cease.
Published simultaneously in the London Times and the American McClure’s Magazine in February 1899, “The White Man’s Burden” was reprinted in newspapers across the United States. Even Kipling’s friend, New York governor Theodore Roosevelt, judged it “poor poetry” in a letter to Senator Henry Cabot Lodge of Massachusetts, though the “Rough Rider” added that Kipling’s lines “made good sense from the expansionist viewpoint.”9
At the moment of the poem’s publication, Lodge was exhorting his colleagues in the Senate to ratify the Treaty of Paris, a document that would officially end the Spanish-American War of 1898 and bring the former Spanish colonies of Puerto Rico, Guam, and the Philippines under U.S. rule. (In keeping with the Teller Amendment, enacted on the eve of war, Congress forswore annexation of Cuba; U.S. control of the island would end, officially, in 1902.) But even as the senators made their speeches, a new American war with Emilio Aguinaldo’s Philippine Republic was beginning in the suburbs of Manila, a city that, as American anti-imperialists pointed out, lay halfway around the world—five weeks’ voyage by steamship—from the U.S. mainland. Kipling appealed to a divided American people, urging them to “take up” their destiny as white colonial rulers in the Philippines. The purpose, he assured them, was noble: to deliver the blessings of Anglo-Saxon civilization, including freedom from want and disease, to that far-off archipelago and its “new-caught sullen peoples, Half-devil and half-child.”10
A native of British India, Kipling seemed at peace with the glaring ironies of colonial public health, with its frank uniting of idealism and violence. Some of his contemporaries were less untroubled. “It is a bad pedagogy to teach people at the point of a bayonet,” objected G. Stanley Hall, the eminent American psychologist and educator. But according to the expansionist viewpoint—informed by the long record of British colonialism and America’s own experience with westward expansion—sometimes bayonets were exactly what the situation required.11
In a previous story, “The Tomb of His Ancestors,” Kipling paid sardonic tribute to the British compulsory vaccination campaigns in nineteenth-century India. An industrious young British military officer, John Chinn, the latest in his family line to serve the Raj in central India, tricks the Bhil people—who “seemed to be almost as open to civilization as the tigers of [their] own jungles”—to bare their arms to “the vaccine and lancets of a paternal Government.” But it was hard work. The Bhils had kidnapped and beaten the first government vaccinator (an Indian) sent to do the job. The clever Englishman succeeded only by playing on the group’s superstitions. In “The White Man’s Burden,” Kipling cautioned the Americans to expect only heartache for their selfless efforts in the Orient:
And when your goal is nearest
(The end for others sought)
Watch sloth and heathen folly
Bring all your hope to nought.
Vaccinating U.S. troops aboard the Australia, bound for Manila in 1898. From Harper’s Weekly, July 16, 1898. COURTESY OF THE NATIONAL LIBRARY OF MEDICINE
The eyes of the Western world were upon the Americans. But the gazes of the Filipinos would haunt them more: those “silent sullen peoples . . . [s]hall weigh your God and you.”12
Whether or not they read Kipling, American leaders would come to accept the essential terms of his poem. The moral and political legitimacy of the entire colonial enterprise rested upon the capacity of the colonizers to deliver—not just natural resources, markets, and strategic ports to the metropole, but also freedom from ignorance, famine, and disease to the nation’s new subject peoples.
At the turn of the twentieth century, the United States of America, born of a colonial revolt against England, followed in Britannia’s wide wake and became, in the words of William Howard Taft, “a colonizing and colony-holding people.” Taft was in a good position to know. He served, in close succession, as America’s first “civil governor” of the Philippines, secretary of war, and president. In contrast to its long history of conquest and empire-building across North America, the United States had for the first time taken possession of foreign territories without any serious intention of incorporating them into the political nation as states. For Taft and other defenders of overseas expansion, the success of U.S. health interventions in the tropics proved, before all the world, the morally progressive and technologically superior character of American colonialism. Army surgeons and U.S. health officers in Cuba, Puerto Rico, the Philippines, and the Panama Canal zone labored mightily to reduce the incidence of many terrible infectious diseases, including yellow fever, malaria, bubonic plague, beriberi, leprosy, and smallpox.13
“We expended many lives and much money in the Spanish War, and in the discharge of the responsibilities that have followed that war,” President Taft told a rapt audience at the Medical Club of Philadelphia in 1911. “But they are as nothing compared with the benefits to the human race that have already accrued and will continue to accrue from the discoveries made under the conditions and necessities which the exigencies of that war and the governmental burdens following it presented.” Pointing to American “sanitary achievements” in the tropics, expansionists argued that the new possessions, rather than repudiating the values of self-determination expressed in the republic’s founding, demonstrated the nation’s desire to spread the blessings of liberty and modernity to dark corners of the globe. This belief has remained a touchstone in the ideology of American empire ever since.14
None of this, however, had been part of the original war plan. The celebrated American sanitary campaigns originated in a far more limited objective: to protect the health of U.S. troops. A cluster of historical factors raised the stakes involved in meeting even that objective. The Spanish War was the first American war to be fought in the era of the bacteriological revolution. The Medical Department of the U.S. Army was under considerable pressure to show how the scientific advances made in the field of medicine since the Civil War would benefit the soldiers under its care. Alas, the department had already failed the soldiers as they assembled for war. In a grotesque public scandal for the department and the McKinley administration, the mainland encampments had become centers of infection and death.15
The intensity with which U.S. military surgeons conducted their sanitary work in the Caribbean and Pacific was heightened, too, by deeply held cultural beliefs that the tropics posed untold hazards for civilized white men. A new discipline—“tropical medicine”—had risen up to address precisely this concern. As The Baltimore Sun opined, European and American physicians “look forward to a time when vast regions of the globe, now desert, or inhabited only by inferior races, will afford safe homes for the people of temperate climates.” Medical science seemed to hold the key to white settlement and further commercial exploitation of Latin America, Asia, and Africa. But American tropical medicine was still young in 1898, and, after the debacle of the assembly camps, military surgeons viewed their duties in Cuba, Puerto Rico, and the Philippines with deep apprehension.16
With great challenges, though, came unparalleled opportunities for the exercise of American health authority. While keeping infectious diseases at bay—including the virulent smallpox that broke out in all three areas after the landing of U.S. troops—the Americans acquired a new mastery of what the brigade surgeon Azel Ames called “the science and art of colonial government.” Like the mobile surgeons of the U.S. Marine-Hospital Service, who at that moment were fighting smallpox in the American South, the doctors of the Army Medical Department aspired to use the latest medical knowledge to fight disease. But unlike C. P. Wertenbaker and his colleagues, U.S. military surgeons in the new overseas domain possessed broad national authority and the resources of an army. For the occupying Americans, the vaccination campaigns in particular became a means to gather vital data on the local topography, political institutions, and indigenous peoples—making those exotic tropical places legible to their new rulers.17
In the American system of government, guarding the public health was the most elemental action a state could take under its police powers; the almost unlimited legal authority to ward off epidemics had often been compared by the courts to the right of any government to protect its own people from invasion. In the tropical possessions, that old analogy quickly became superfluous. Absent the institutions of popular sovereignty and due process (which the Americans planned to withhold until the indigenous peoples proved themselves fit for a measure of self-government), police power was military power. The Army’s sanitary campaigns far exceeded the normal bounds of the police power, which by a long American constitutional tradition had always been assumed to originate in sovereign communities of free people. In America’s overseas sanitary campaigns, the scale and scope of governmental power were greater, the colonial space was different, and the fact that an institution of the national government, the Army, was undertaking these measures was altogether revolutionary.18
By any honest measure, the achievements of U.S. military medicine in the overseas possessions were extraordinary, even when they did not meet the Americans’ own ever-rising expectations. Within just a few short years, the Army Medical Department could fairly boast that its surgeons had cleaned up the old Spanish colonial cities and made major discoveries in the etiology and prevention of yellow fever, beriberi, and other terrible diseases. These discoveries took place in Army camps, native villages, and colonial laboratories, using the full intellectual arsenal of the bacteriological revolution. But in the eyes of many Army medical men, it was the fight against smallpox—using the older technology of compulsory vaccination on a hitherto unimaginable scale—that showcased the full humanitarian promise of U.S. military medicine. For the Medical Department’s original mission, to protect the troops from disease, unexpectedly gave rise to the first glimmerings of a grander vision. Uninhibited American power might one day eradicate the ancient scourge of smallpox from entire regions of the globe.19
As the first major U.S. military action since the germ theory of disease gained broad acceptance in the medical profession, the war with Spain should have been a milestone in military medicine. And, in important respects, it was. The decades since the Civil War had witnessed the creation of modern health departments in the major U.S. cities, a greater recognition of the importance of aseptic practices in the treatment of wounds, and, in 1895, the discovery of X-rays. During the Civil War, Army surgeons had still probed bullet wounds with unsterilized instruments and unwashed fingers. By 1898, most Army doctors and volunteer nurses knew better. On the battlefield, they wrapped soldiers’ wounds in antiseptic dressings. In the field hospital, they used X-rays to locate bullets and assess damage to bones. At the operating table, they followed aseptic techniques. The results (aided by the introduction of small-caliber bullets) were extraordinary. The death rate of wounded U.S. troops during the Spanish War was the lowest in military history: fully 95 percent recovered. And blessedly rare in this war were the heroic amputations that had moved Walt Whitman to poetry during his stint as a hospital volunteer with the Union Army (“the smell of ether, the odor of blood”). As Army Surgeon General George M. Sternberg reported with pride after the Spanish War’s end, his surgeons had performed only thirty-four amputations in a wounded list of some sixteen hundred men.20
Notwithstanding these achievements, the record of the Army Medical Department during the Spanish War was a public disgrace. “Now that actual fighting is over,” wrote Dr. Carroll Dunham in the American Monthly Review of Reviews, “it is undeniable that failure adequately to safeguard the health of the American troops is the one blot on an otherwise fair account.” In an era of rising expectations about the power of preventive medicine, the department failed to conserve the health of the troops. Only 345 U.S. soldiers died from wounds of combat during the war; 2,565 men died from disease. The ratio of disease fatalities to combat deaths (more than 7 to 1) exceeded those of the Mexican-American War (6.5 to 1) and the Civil War (2 to 1). Tens of thousands of U.S. soldiers spent the Spanish War in the department’s ill-equipped hospitals, suffering from preventable infectious diseases. The vast majority of the men who died in this overseas war never left the mainland.21
Established in 1818, the U.S. Army Medical Department consisted during peacetime of a small corps of professional officers, reinforced during time of war or emergency by state-appointed surgeons from the volunteer militias and civilian physicians hired on contract. For centuries, medical men had marched with armies, but their status had always been less than heroic. In eighteenth-century Prussia, army doctors still shaved the officers of the line. The very title of “surgeon”—invoking both civilian status and the rough craft of stitching wounds and removing bullets and limbs from wounded soldiers—was viewed as a put-down by some nineteenth-century Army medical officers. The official duties of the U.S. Army surgeon did consist, first and foremost, of evacuating and treating troops wounded on the battlefield. But in the age of modern sanitary science, the duties did not stop there. America’s best-known citizen-soldier, Theodore Roosevelt, saluted the profession as a bastion of manly heroism in a feminized age, noting that the surgeons’ job required them to be not merely doctors and soldiers but “able administrators.” Responsible for the health of thousands of troops in camps and crowded transport trains and ships, the modern Army surgeon was necessarily a public health officer, charged with examining the recruits (rejecting those unfit for duty), vaccinating the line, securing pure food and water, and preaching modern hygiene to line officers and troops.22
Under Surgeon General George Miller Sternberg (1893–1902), an internationally recognized epidemiologist who published the first American textbook on bacteriology in 1896, the surgeons of the Army Medical Department aspired to a high degree of professionalism. Like many of the department’s senior officers, Sternberg, a Civil War veteran, had honed his medical skills in the late nineteenth-century campaigns against the Indians in the American West. By the 1890s, new candidates for the corps learned their trade in the classroom. They had to take a rigorous entrance exam; in 1897, only 6 out of the 140 applicants passed. The surgeons underwent a five-month program of postgraduate education at the Army Medical School in Washington, where they studied bacteriology, sanitary chemistry, pathology, and military hygiene under a faculty that included such leaders in the discipline as John Shaw Billings and Walter Reed. Reed’s academic title—professor of clinical and sanitary microscopy—captured the dramatic changes in military medicine since the Civil War. The microscope and bacteriological culture had taken their places alongside the scalpel and saw as tools of the trade.23
On the eve of the war with Spain, the professionalization of the Army Medical Department was still a work in progress. As was the case with practitioners in many other disciplines at the turn of the century, including law and civilian medicine, the military surgeons’ claims to the rigor and status of a science outpaced the workaday reality. Under U.S. military law, neither their medical credentials nor their commissioned ranks entitled medical officers to command in the line. The surgeons could only make recommendations regarding camp sanitation to the line officers, who decided whether to implement them. In the past, many line officers had shown little patience with regimental surgeons, insisting that their intrusions interfered with military discipline. During the Civil War, one Union Army colonel had shrugged off his medical officer’s complaint that the camp smelled of excrement, insisting the stench was “inseparable from the army. . . . [I]t might properly be called the patriotic odor.” (No wonder Whitman recalled that war as “nine hundred and ninety-nine parts diarrhea to one part glory.”) By 1898, many line officers and soldiers had grown more respectful of the surgeons’ expertise, and the medical corps consequently wielded greater authority over camp conditions. But the national military school still did not offer a course in hygiene. And the advance of scientific medical knowledge since the Civil War had eliminated neither the patriotic odor nor the old tension between line officers and their medical men.24
Even within the medical corps, the new knowledge of the microbe did not overthrow older ideas about disease causation that centered on the relationship between bodily constitutions and their geographical environments. Major Reed and two other senior department surgeons, who toured many of the training camps in 1898, found that even “intelligent medical officers” instinctively looked for the sources of camp epidemics in “intangible local conditions inherent in the place.” It was as if the old miasmatic theory of disease remained unchallenged. “There is apparent in man a tendency,” noted Reed and his colleagues, “to believe in the evil genius of locality.” Military surgeons still relied more on their senses than their microscopes, reflexively associating filth and foreign surroundings with pathogens.25
When Congress declared war against the Kingdom of Spain, on April 21, 1898, the U.S. Army consisted of just 28,183 men, stationed at eighty posts across the nation. Apart from the late-century campaigns against the Indians, in which many men of the current officer corps had participated, the Army had not fought a war in thirty-three years. By the end of May, the Army mustered in 125,000 Volunteers, men from all walks of life whose military experience was limited to service with their state volunteer militias, units of the National Guard. The regiments bound for Cuba and Puerto Rico assembled throughout the spring and summer in camps in the southeastern states. After Commodore George Dewey’s victory in Manila Bay, the Army mobilized an expedition in the western states to steam across the Pacific and take possession of the Philippines. By mid-August, when the fighting with Spain ceased, the Regular Army and the Volunteers had a combined strength of over a quarter million men—the great majority of them inexperienced volunteers.26
The War Department and its medical branch were unprepared for this sudden buildup. Like the Army itself, Sternberg’s Medical Department was a stripped-down affair during peacetime. The department had no stockpile of supplies and no ready reserve of field-tested surgeons. Many of the older surgeons had been serving at desk jobs and were in no shape to take the field. To the small corps of properly trained field surgeons were hastily added more than one hundred commissioned officers and nearly four hundred medical officers from the state militias. During the summer, the Army would add more than five hundred contract surgeons. The Medical Department suspended its rigorous examination requirement. Lieutenant Colonel John Van Rensselaer Hoff, a seasoned surgeon with the Medical Department, found among the volunteer surgeons “scarcely an officer who possessed the slightest knowledge of medico-military matters.”27
Some of the civilians, however, were seasoned public health officers who brought that experience to the Medical Department. If military discipline was new to these men, the police power was not. Several of them would play leading roles in staging the overseas campaigns against smallpox. Dr. Azel Ames, who served as a brigade surgeon with the U.S. Volunteers in Puerto Rico, had founded the board of health in Wakefield, Massachusetts. Dr. George G. Groff, who would serve with Ames as a director of vaccination in Puerto Rico, had a peacetime career as professor of organic science at Bucknell University and president of the Pennsylvania State Board of Health. Like many of the older surgeons of the Regular Army, Dr. Henry F. Hoyt was a veteran of the Indian campaigns—he called himself a “redhaired Indian fighter.” But he had also served as commissioner of health for St. Paul, Minnesota, where he enforced smallpox vaccination and established a bacteriological laboratory before receiving his wartime commission as chief surgeon of the Second Division, Eighth Army Corps, bound for Manila.28
Smallpox loomed on everyone’s mind as the troops and doctors streamed into the national assembly and training camps in Pennsylvania, Virginia, Florida, and Georgia. By the spring of 1898, the new mild type smallpox had spread across much of the South, shaping the War Department’s decisions about where to locate the encampments. C. P. Wertenbaker, dispatched to South Carolina just two days after the declaration of war, advised strongly against using smallpox-ridden Columbia as an assembly area.29
Since 1834, Army regulations had mandated that all U.S. soldiers submit to vaccination. The Volunteers had their arms scraped as they mustered into service. Army reports and soldiers’ letters home recounted the vaccine-induced fevers and inflamed arms that afflicted men in camps and aboard ships headed for the war zones. Lieutenant Colonel Hoff insisted the Army’s vaccine was sound, attributing the soldiers’ woes to the “hurry and turmoil” of the mobilization and the inexperience of the Volunteers’ medical staff. The virtue of compulsion seemed ably demonstrated by the remarkable absence of smallpox in the assembly areas, as tens of thousands of soldiers mobilized for war in the midst of an emerging regional epidemic. Among more than fifty thousand Regular Army troops, only one smallpox fatality occurred on the mainland.30
The real horror of the national encampments turned out to be typhoid. The infectious disease had haunted armies since time immemorial, earning the nickname “camp fever.”
By 1898, typhoid fever held few mysteries for Army surgeons. They knew its causative agent (Bacillus typhosus), its mode of transmission (“the transference of the excretions of an infected individual to the alimentary canals of others”), and the sanitary measures that would keep it at bay (keeping troops from fouling their own water, food, and personal effects). But the surgeons, particularly those serving with the Volunteers, proved incapable of preventing its spread. The hastily constructed camps provided ideal conditions for an epidemic: poor drainage, a dearth of pure water, and thousands of undisciplined recruits, who, disregarding the entreaties of their medical officers, preferred the nearby woods and streams to the newly dug latrines. Typhoid took hold almost everywhere.31
The camp epidemics made a deep impression on the surgeons who would soon accompany the American regiments overseas. Lieutenant Colonel Hoff witnessed the suffering up close; he may even have felt some responsibility for it. Assigned as chief surgeon with the all-Volunteer Third Corps at Camp Thomas, in Chickamauga Park, Georgia, he arrived at the camp in May 1898, after the Regular Army troops had pulled out. By the end of June, Camp Thomas teemed with nearly sixty thousand green recruits and fifteen thousand horses and mules. One line officer remarked how the Volunteers had turned the campground into “a mass of putrefaction.” No amount of quicklime could overcome it. For the American public, the typhoid horror stories told by the troops at Camp Thomas recalled the Confederate prisoner of war camp at Andersonville. “Bad Water, Unfit Food, Brutally Stupid Treatment,” read one New York Times headline. More than ten thousand soldiers contracted typhoid fever at Camp Thomas that summer; 761 of them died. Even more unseemly was Camp Alger, an assembly center just an hour’s ride from the Washington offices of the camp’s namesake, Secretary of War Russell A. Alger. With its drinking wells driven too close to the regimental sinks, Camp Alger had become a “nursery of typhoid.” Soldiers at the Florida encampments—Camp Tampa and Camp Cuba Libre—suffered, too. In all, nearly 21,000 American soldiers caught the disease in the national encampments during the summer of 1898, and 1,590 died. Most of the dead were Volunteers.32
Close on the heels of the camp typhoid epidemics came the highly publicized withdrawal from Cuba of the Fifth Corps, overwhelmed by typhoid, yellow fever, and malaria. With the fighting finished on the island by July 17, Colonel Roosevelt warned that 90 percent of the soldiers were incapacitated by disease and would, as The New York Times put it, “die like sheep if left in Cuba.” The plight of the Fifth Corps—compounded, some said, by Major General William Shafter’s refusal to cooperate with his medical officers—confirmed the public’s worst fears: America was sending its young men to do battle with tropical diseases more deadly than Spanish cannon.33
The health crises in the assembly camps and the Fifth Corps tarnished the reputation of the War Department and emboldened critics of the war. In September 1898, shortly after the cessation of hostilities, President McKinley appointed a presidential commission, headed up by General Grenville M. Dodge, to investigate the “charges of criminal neglect of the soldiers in camp and field and hospital.” The Dodge Commission’s report, released to the White House in February 1899 and made public the following year, concluded that the Army Medical Department, for all of the “good work” it had done during the war, had committed “manifest errors,” beginning with its failure to properly investigate the sanitary conditions of the assembly camps. Modern scientific knowledge and professionalism had not yet usurped the age-old dominance of disease over combat in the actuarial tables of warfare.34
The tragedy of the assembly camps would continue to haunt and motivate the surgeons of the Army Medical Department as they settled into new positions with occupying regiments and the U.S. military governments in Cuba, Puerto Rico, and the Philippines. The shame of the assembly camps heightened the Medical Department’s obsession with the health of the troops on the ground. It contributed to the intensity with which the Army prosecuted its sanitation and vaccination campaigns in all three places. And it gave additional motivation to the scientific work of the Army medical men as they pursued exciting new lines of research.
In 1901, Walter Reed and a team of colleagues in Cuba, in a bold and risky series of experiments, confirmed the Cuban physician Carlos Finlay’s theory that yellow fever was spread by the Stegomyia fasciata mosquito (now called the Aedes aegypti). Under the command of Major William C. Gorgas, the Army launched a campaign to destroy the mosquito’s breeding grounds in Havana. By the summer of 1901, the Stegomyia had virtually disappeared from Havana, and so had yellow fever. Reed expressed his relief in a private letter to Gorgas. “Thank God that the Medical Department of the U.S. Army, which got such a ‘black eye’ during the Spanish-American War, has during the past year accomplished work that will always remain to its eternal credit.”35
A strong desire to clear the good name of their institution only begins to describe the range of aspirations and interests U.S. military surgeons carried with them or discovered within themselves in the cities, garrisons, and villages of Cuba, Puerto Rico, and the Philippines. Military surgeons went to extraordinary lengths to protect the troops in those tropical places. Over time the surgeons would turn their medical gaze outward, from a narrow professional concern for the health of the troops—the maintenance of a continually shifting cordon sanitaire—to a broader interest in governing the health of the civilian populations of the newly subordinated territories. These agents of the American nation seized upon the vast and (to their eyes) exotic field of medicine, administration, and humanitarian intervention opened up by the Navy’s gunboats and the Army’s rifles. The worlds they entered would never be the same.
The lingering shame of the national encampments did not diminish the air of sanitary superiority with which American military men and civilians took in the sights, sounds, and smells of their new tropical surroundings. Disembarking from Army transports and commercial steamships, the Americans first encountered the old Spanish port cities. Judging the coastal population centers of Cuba, Puerto Rico, and the Philippines by standards of cleanliness only recently (and all too incompletely) achieved in American cities, the occupiers attributed the unsanitary state of affairs in equal parts to the incompetence of their Spanish predecessors and the indifference of “the natives.” “Nauseating odors” assaulted the nostrils of one American visitor to Havana: “dead animals abounded, garbage was encountered everywhere, and open mouths of sewers running in to the ocean and harbor were reeking.” Captain L. P. Davison of the Fifth Infantry, newly installed as president of the San Juan Board of Health, described the Puerto Ricans as “a poverty-stricken and extremely dirty and mixed population, living in absolute violation of all civilized rules.” In Manila, where residents reportedly thought nothing of relieving themselves at the side of the road or dumping chamber pots from windows, one American official advised his countrymen to walk in the center of the street and always carry an umbrella. To these Americans abroad, filth signified disease. And filth was everywhere.36
Wherever they went in these disorienting, humid cities, with their old Spanish churches and crude palm shacks, the Americans noted the traces of a disease they still associated with filth: smallpox. Army surgeons and U.S. health officials likened the epidemiological life of smallpox in these erstwhile Spanish colonies to eighteenth-century Europe, before the invention of vaccination. “[A]s was the case in Europe, so in the Philippines, it seems to be almost a disease of childhood,” said one report. “The explanation of this is that all natives who have reached adult age were exposed in their childhood to smallpox, and those who did not contract it may be considered immune.” If, as Captain Davison insisted, “Good sanitation is the visible sign of civilization,” the unmistakable sign of barbarism and misrule was the pockmarked face of a dark-skinned native.37
Like most first impressions, the Americans’ commentaries captured only the surface of things. To be sure, the Spanish colonial health systems had been halfhearted during the best of times; as The Boston Globe’s Philippine correspondent J. N. Taylor noted with contempt, they paled in comparison to the British sanitary measures in India. But the American occupiers failed to consider that the conditions they encountered might be anything out of the ordinary for these places. In fact, all three areas had suffered through mounting health crises during the late nineteenth century.38
Cuba, an island about the size of Pennsylvania that lay less than a hundred miles south of the U.S. mainland, had long been viewed by American health officials as a massive pesthole whose most notable export was yellow fever. The island’s 1.8 million inhabitants had experienced an epidemiological crisis during the three-year-long Cuban insurrection against Spain, which lasted from February 1895 to August 1898. The vast majority of the estimated 290,000 Spaniards and Cubans who perished during that war, civilians and soldiers alike, died of starvation and infectious diseases. The most destructive force was the Spanish military policy called “reconcentration,” which set a deadly precedent for modern counterinsurgency warfare that the British and the Americans would find irresistible. Aiming to break up rural support for the Cuban Revolutionary Army, the Spanish general Valeriano Weyler ordered the forcible removal of Cuban civilians from the countryside to the urban centers, where the reconcentradoslived in close squalor under a form of martial law. Some 400,000 civilians, roughly one quarter of the island’s population, were forcibly concentrated into Havana and other cities already overrun with soldiers and refugees.39
“Hunger, starvation, and death were on every hand,” wrote Clara Barton of her arrival with the Red Cross in Havana in February 1898. In normal times, the population of nineteenth-century Cuba was too dispersed to support endemic smallpox. But the reconcentration of the rural population and the movement of soldiers and civilians across Cuba created a dense network of disease transmission that fostered the epidemic spread of smallpox, yellow fever, and enteric fever. According to The New York Times, smallpox was the single biggest killer among the reconcentrados. “The people were unable to keep clean, unable to be vaccinated, even if willing, and they died by [the] tens of thousands,” one longtime resident of Havana told the Times. During the lead-up to war with Spain, American newspapers inflamed the public with reports on Weyler’s disease-infested camps. And the escalating events of the U.S. war with Spain in Cuba from April to July 1898—the American blockade of Havana, the naval assault, and a ground war centered around Santiago de Cuba—had further strained the health of Cuba. Neither tropical climate nor simple Spanish incompetence nor the alleged backwardness of the Cubans could have wreaked such epidemiological havoc. Political decisions made these epidemics.40
Puerto Rico did not have its own war of independence, and the health situation there in the 1890s was less dire. Still, disease shaped the course of the U.S. invasion. Yellow fever had so disabled the U.S. regiments in Cuba that when Major General Nelson A. Miles landed at Guanica on the southern coast on July 25, 1898, he did so with a small initial force of 3,500 troops shipped in from the states. (U.S. troop strength later grew to more than 14,000 men.) Despite their superior numbers, the Spanish did not put up much of a fight. General Miles ordered three columns of men north to San Juan, but news of the armistice arrived before the soldiers reached their destination. An Army medical officer reported that malaria was “prevalent in all the valleys,” noting the “large pendulous abdomens and pale faces of the many little naked children.” During the long occupation, thousands of U.S. troops made their garrisons in the midst of local communities, spreading microorganisms wherever they went. By September 1898, one quarter of the troops were on the sick list, suffering from dysentery, malaria, venereal diseases, and a few cases of smallpox.41
The last brief battle of the Spanish War took place in the Philippines on August 13, 1898. The surrender of the Spanish garrison to the invading Americans at Manila had been scripted by both sides in advance, enabling the Americans to prevent Aguinaldo’s insurrectos from entering the city. In the Philippines, the U.S. troops marched into a health crisis that had been building for decades and which their presence and actions worsened.
An archipelago of seven thousand islands, most of them uninhabitable, distributed across a half-million square miles of ocean, the Philippines had been under Spanish rule since 1565. Roughly half of the eight million inhabitants lived on the big northern island of Luzon, home of Manila, a city of a quarter million. The Filipinos had never known Edenic isolation. But prior to the mid-nineteenth century, geographic obstacles and dispersed settlement patterns had reinforced local communities’ separateness from one another and from the outside world. Even on a single island, villages were separated by the characteristic landscape of rugged, mountainous terrain rising up from broken coastal plains. Roads were few and travel arduous, particularly during the long rainy season. Local epidemics tended to remain local, running their course among the nonimmune inhabitants. The late nineteenth century brought population growth and an increasing connectedness: a proliferation of towns (pueblos), a stronger market economy, new steamship connections, and a rise in immigration to the coastal cities, mainly from China. As the long isolation of Filipino communities diminished, domestic and imported microbes circulated. By the 1890s, exposure to and mortality from infectious diseases had risen sharply, especially from malaria, dysentery, cholera, tuberculosis, and smallpox.42
The arrival of six years of war—first during the Filipino independence struggle against Spain of 1896–98, followed by the Spanish-American War of 1898 and the Philippine-American War of 1899–1902—caused the breakdown of the Spanish health system. Twenty-five thousand Spanish soldiers arrived in 1896. Between 1898 and 1902, roughly 122,000 U.S. troops would come, carrying microbial pathogens from North America and, more important, toting local disease agents from place to place in the islands. The U.S. Army reported nearly one-half million cases of illness in its ranks during the wars, roughly four sick reports per soldier. U.S. soldiers not only engaged the enemy; they fraternized with the civilians, drinking, gambling, having sex, and, all the while, spreading disease.43
As the four-month war with Spain gave way, in August 1898, to longer occupations in Cuba, Puerto Rico, and the Philippines, the responsibilities of the Army medical staff did not diminish. In the surgeons’ eyes, threats to the good health of the soldiers in the garrisons abounded. Heat exhaustion and sunstroke were perennial fears, leading some in the Philippines medical staff to shed their U.S. military blues and campaign hats for khaki clothes and the white cork helmets favored by the British in India. Army surgeons advised that Filipino or Chinese laborers, presumably accustomed to the oppressive heat, be used for the heaviest manual labor, lest white soldiers succumb to heat exhaustion. Most surgeons and soldiers took it as axiomatic that under tropical conditions a white man’s resistance to disease quickly deteriorated, making him especially susceptible to exotic microbes. Even diseases well known to North America seemed more threatening under such conditions. “[I]n this latitude and longitude,” reported Dr. Henry Hoyt from the Philippines, smallpox was “very fatal, especially to the white man.”44
The first American health interventions in Cuba, Puerto Rico, and the Philippines followed the territorial logic of the cordon sanitaire. As the British had done in India, the Americans aimed to create a kind of moving quarantine line, a zone of sanitary and immunological protection around the bodies of their soldiers. In the garrisons, this entailed frequent vaccinations of the troops, strict sanitation, and training the men in hygiene. But since the soldiers necessarily moved across spaces populated by indigenous (and thus “foreign”) people, eliminating filth and disease among the most proximate of “the natives” became a military imperative. Those natives with whom the Americans were likely to come into contact, such as the citizens of occupied Santiago, San Juan, or Manila, were the first local communities targeted for sanitary intervention. In the early phase of the occupations, the medical officers expressed no loftier purpose for their work. “From the day of the invasion,” said Lieutenant Colonel Hoff, chief surgeon of the U.S. Army’s Department of Puerto Rico, “great care was taken to improve the sanitary surroundings of the troops and consequently of the people.” Any sanitary benefits that might accrue to the people were incidental. As another Medical Department document put it, “[T]he health of the command depends on the health of the inhabitants.”45
Army medical officers and their admirers likened their work to that of Heracles in the Augean stables, “the cleanser of foul places and the enemy of evil beasts.” In all three of the territories, the Army and its medical staff took actions to sanitize the cities and towns where the Army located its garrisons. From the start, the measures blended police power and military force. “It is perfectly useless,” one Army surgeon observed, “for any health officer to attempt to check an epidemic unless he can rule with a rod of steel.” To clean up Santiago, Cuba, the U.S. military governor General Leonard Wood, himself a physician, named American businessman George M. Barbour as director of sanitation. “Major” Barbour’s sanitary corps impressed local residents into labor, cleaned up the slaughterhouses and markets, shot stray dogs, and horsewhipped inhabitants caught relieving themselves in the streets. Military surgeons still viewed sanitation as the first defense against disease. U.S. troops stumbled into the “dirty little town” of Siboney, Cuba, to find an outbreak of yellow fever. Under the direction of military surgeon Colonel Charles Greenleaf, the soldiers expelled the Spanish and Cuban refugees and conducted a “vigorous” cleanup campaign. Army doctors did not yet understand the role of mosquitoes in spreading yellow fever. When their sanitation measures failed to check the epidemic, the soldiers burned the town to the ground.46
From the beginning, Army medical officers claimed for their actions a precedent in the American legal tradition of police power, which allowed for broad governmental intrusions into the everyday lives of American citizens. As Lieutenant Colonel Hoff said of his experience in Puerto Rico, sanitation there “resolved itself down to its simplest form, ‘policing.’ ” How different were the Army’s actions really, these officers suggested, from the countless instances when American governments had walked over individual liberty and property rights in the name of the public welfare—whether by driving brothel-keepers and saloon-keepers from town or by regulating the operations of slaughterhouses, factories, and other noxious trades? But in the United States, the legitimacy of police regulations had always been closely tied to the sovereignty of the self-governing communities that enacted them. The very thinness of Hoff’s analogy suggests how far he and his peers were reaching for some foundation, other than military superiority, for their actions.47
Smallpox became epidemic in each of the three major theaters of the Spanish-American War during the fall of 1898. None of the epidemics involved the new “mild type” of the disease. All involved classic virulent smallpox (variola major), presumed to be all the more deadly because of its tropical origin. With thousands of U.S. troops, civilian personnel, and, increasingly, entrepreneurs and their employees settling into all three places, the Army surgeons were determined to bring the disease under control. Their first attempts were localized campaigns centered exclusively on protecting the troops, and those efforts revealed how entrenched in the thinking of the Army was the old idea of smallpox as a filth disease. In San Juan, Captain Davison reported, “From the class of people attacked it is believed that cleanliness of person, proper living and morals are at least equal to vaccination as a preventive of smallpox.” Smallpox became epidemic in the Holguin district of Cuba that November. Under Brigadier General Leonard Wood, the Second Volunteer infantry and its medical officers disinfected the towns, burning entire neighborhoods of thatched huts and vaccinating 30,000 residents. The Army also treated nearly 1,200 people with smallpox. By January, the epidemic had ended. Smallpox, though, would remain a “constant and increasing danger in Cuba” until the U.S. military government mandated universal childhood vaccination on the island in 1901.48
In all three tropical theaters, the Army Medical Corps responded to the first threats of smallpox by cleaning the troops’ immediate geographical environments and vaccinating the bodies of the natives who inhabited them. Gradually, the military surgeons would turn their attentions outward to the health of the native population as a whole. As they did, their campaigns would assume a scale and intensity they could not have anticipated when the war with Spain began. The most formidable efforts took place at the farthest reaches of the new American empire, in Puerto Rico and the Philippines.
Lieutenant Colonel John Van Rensselaer Hoff steamed into the port of San Juan in October 1898. It must have felt good to have the stench of Camp Thomas behind him; unlike most Army medical officers Hoff was struck by the natural beauty of this “fair isle.” The port had been churning all month, as ships off-loaded American goods and personnel and the last remaining Spanish soldiers and officials left the island. The incoming chief surgeon of the U.S. Army’s new Department of Puerto Rico had nothing but contempt for his predecessors. “Robbed of all superfluities,” Hoff declared, “the real reason we are in the Antilles today is because our people had determined to abate a nuisance constantly threatening their health, lives, and prosperity.” Of course, there had been “other factors of certain value, strategic, mercantile, humanitarian and sentimental,” Hoff conceded. But all these merely underscored the true casus belli: “Spain was maintaining a pesthole at our front door and we could no longer endure it.” Forget the Maine. In Hoff’s decidedly contrarian view, the Spanish-American War was at bottom a police action, taken against a delinquent neighbor that had allowed its properties to overflow with yellow fever and smallpox. Compared with Cuba, Puerto Rico was the lesser threat, but this island, too, “stretched a threatening hand toward our shore.” According to the police power tradition, the proper response to a nuisance was to abate it—kick out the bad neighbor and clean up the place.49
Fifty years old and full of vigor, Hoff had one of those nineteenth-century careers whose very contemplation induces in the modern mind a sharp sense of historical vertigo. In Hoff’s half century, industrial capitalism—with its steamships and telegraph wires and guns—had shrunk the seas, shortened the horizon, and accelerated time itself. Thus it was that Hoff, a Dutch-descended native of the Empire State, could serve during the 1890s in the last of the U.S. Army’s frontier Indian Wars, an imperialist venture in its own right, and the first of its modern overseas colonial wars. (The career-to-date of Hoff’s fellow New Yorker, Theodore Roosevelt, galloped across a similarly improbable canvas: from ranching in the Dakota Badlands to inspecting tenement sweatshops in Manhattan to storming San Juan Hill.)50
In an era when few American physicians had much formal training, Hoff, a second-generation Army medical officer, graduated from Union College and earned his medical degree from the College of Physicians and Surgeons in New York. He practiced surgery in western Army forts, lectured in college classrooms, and traveled in Europe, where he studied the medical services of the great European armies. Hoff distinguished himself on those battlefields Gilded Age America had to offer, the brutal and increasingly one-sided engagements with the western Indian tribes. In 1890, he led a detachment of Hospital Corps litter bearers in the Battle of Wounded Knee, the Army’s last major engagement with the Sioux, earning the Distinguished Service Cross for his “conspicuous bravery and coolness under fire.” A Protestant in a missionary age, he believed his sanitary work in Puerto Rico and later in the Philippines exemplified the duties of race and nation that his countrymen had taken up after the war with Spain. “Driven by fate we, as a nation, have ventured without our shores,” he wrote, “[and] accumulated our full share of the white man’s burden.”51
Hoff stepped ashore in San Juan, a city of 32,000 people, to find a big job waiting for him and no organization in place. “Nothing was and everything had to be,” he recalled, “not a record, nor a book in which to keep it.” In the coming months, Hoff and his medical staff would evolve into a de facto public health service for Puerto Rico. Under his command, the surgeons pursued health campaigns on a scale the U.S. government had never before attempted on the mainland. They enacted new sanitary codes based upon the police regulations of the American states. They studied diseases and taught modern hygiene to an impoverished rural people. By far the most ambitious of these efforts—“the first big sanitary undertaking of our Government in the tropics,” Hoff proclaimed—was the quixotic campaign to vaccinate the entire population of the island. It was “an immense task,” another Army surgeon agreed, “and possible only through military agency.”52
To Hoff and his staff, Puerto Rico was terra incognita. The smallest and easternmost island of the Greater Antilles, with a landmass three quarters the size of Connecticut, Puerto Rico lay roughly a thousand miles southeast of the recently incorporated U.S. city of Miami. A range of rugged mountains called the Cordillera Central divided the island’s wet Atlantic-facing northern half from its dryer Caribbean southern half. The climate was unmistakably tropical, with a rainy season that stretched from August to December. Getting around was hard. The island possessed few good harbors, most notably at San Juan on the north and Ponce on the South. But for the old Spanish military road that ran between those cities, there was, as one frustrated Army surgeon noted, “not a good road on the island.” In the wet season, the bridle paths and streams that connected the villages and barrios along the Cordillera Central flooded and became impassable for weeks.53
The Puerto Ricans confounded the Americans. “The laws, language, customs, institutions, and aspirations of the people were all strange, and in many respects, very difficult of comprehension,” said one military government report. American eyes puzzled over the island’s peculiar settlement patterns. Puerto Rico seemed to them a contradiction in terms: an overpopulated rural country. Fewer than one tenth of the people lived in cities, the rest in barrios, villages, and small farms. The chief industries centered on the land, especially sugar cultivation (along the coast), coffee growing (in the mountains), and cattle raising (along the southern plateaus). To the occupiers, the islanders’ problems resembled those the Americans associated with the tenement districts of their own industrial cities. The crowded palm-thatched huts were “entirely without any arrangements for the disposal of excreta.” Three quarters of the population lived in “miserable hovels,” subsisting upon “the merest apology for food.” Although the island had a small professional elite, including well-trained physicians, few Puerto Ricans could read. And the people suffered prodigiously from intestinal diseases as well as endemic tuberculosis, smallpox, and a deadly disease called anaemia.54
The multiracial population of the island defied the familiar American racial taxonomies. Major Ames described Puerto Rico uneasily as “the only ‘white’ island of the Antilles.” American racial norms had consolidated in recent years, with the Supreme Court recognizing the southern states’ peculiar “one drop” rule (which made a person with even a small amount of African “blood” black in the eyes of the law). Slavery had survived in Puerto Rico until 1873, and black laborers predominated on the sugar plantations. But Americans were uncertain how to classify the rest of the people. Assistant Surgeon General C. H. Alden reckoned that three fifths of the population was “pure white and almost entirely of Spanish descent.” But the Puerto Ricans did not subscribe to the American one-drop rule, and U.S. officials complained of “the natural tendency [of] the mulatto to deny the existence of negro blood in his veins.”55
Under military rule the Puerto Ricans inhabited an unstable political space within, but not of, the United States. During the invasion, General Miles had issued a proclamation to the inhabitants, assuring them that the American troops marching through their villages carried the “banner of freedom.” “This is not a war of devastation,” declared the old Indian fighter, “but one to give to all within the control of its military and naval forces the advantages and blessings of enlightened civilization.” As the Army built roads, opened schools, and cleaned cities, the military government said its duty was to protect and prepare the inhabitants for their “ultimate destiny” as “an autonomous, self-governing, and law-abiding people.” But the military governor lacked clear instructions as to whether the people ought to enjoy the guarantees of the U.S. Constitution. Practical political economy soon answered that question. In January 1899, President McKinley ordered the military authorities to collect customs duties on U.S. imports to the island. The commanding general reasonably concluded that the Constitution had not “followed the flag.” A divided U.S. Supreme Court later reached much the same conclusion.56
Smallpox was present on Puerto Rico in the best of times, but the rapid spread of the disease in late 1898 sent waves of alarm through the command. The influx of tens of thousands of Spanish and American soldiers and the hurried movements of displaced civilians had carried the disease far and wide. The exact scale of the outbreaks is uncertain. According to one report issued by Surgeon General Sternberg, from December 15, 1898, to February 11, 1899, sixteen villages and towns reported more than 550 cases. The volunteer surgeons Major Ames and Major Groff insisted that post surgeons had reported 3,000 cases during November and December alone. Army officials agreed that the epidemic constituted, in Sternberg’s words, “a constant menace to the people and to the material interests of the island.” “It steadily took on greater proportions,” Ames recalled, “no part of the island being free from it, until nearly all the country barrios (precincts) were infested.”57
Hoff kept a close watch on the emerging epidemic. His first response was to shore up the cordon sanitaire by ensuring that all troops were well vaccinated and keeping their garrisons clean. But with the soldiers living so closely with the native population, the line could not hold. Stateside newspapers ran stories on local boys who contracted smallpox in Puerto Rico; some of the soldiers died from the disease, others carried it back with them to infect American communities. The pressure rose for stronger measures. For Hoff, the turning point came when neighboring islands, including St. Thomas, Puerto Rico’s closest neighbor and a significant port of trade, quarantined against the island. Other ports, including New York, were considering the same action. For a colonial administration dependent on customs taxes, the situation was serious. If America’s largest port ceased doing business with the place, this tropical possession, funded largely by the flow of goods to and from the United States, would be in deep trouble. “[T]he success of our first effort in military government was hanging in the balance,” Hoff recalled. He paid a visit to the U.S. governor general, Guy V. Henry.58
According to the official Spanish legend, vaccine had first arrived on Puerto Rico in European bodies aboard European ships. If this were true, vaccine would have made much the same voyage to the New World as the variola virus itself. In 1518, a quarter century after the arrival of the Spanish, an epidemic of smallpox decimated the indigenous Tainos. Nearly three centuries later, on November 30, 1803, an expedition set sail from Corunna, Spain. Led by Dr. Francisco Xavier de Balmis, the Spanish court physician, its mission was to bring the new technology of Jennerian vaccination to the people of the vast Spanish empire in Latin America and the Pacific. On board were twenty-two foundlings, whose young bodies had never suffered the smallpox. Before setting sail, Balmis inoculated the first child with vaccine; as the expedition made its way across the seas, the doctor kept the “precious fluid” alive by vaccinating each child in succession, with pus from the vaccine sore of the previous child, in a continuous arm-to-arm relay. In this way, the Balmis expedition delivered “the beneficence of the King” to the Canary Islands, Puerto Rico, and Caracas, before breaking into two expeditions. One sailed to South America via Havana, the other to Vera Cruz and Mexico. Balmis picked up a fresh group of twenty-six children in Mexico before setting sail from Acapulco for the Philippines.59
In at least one respect, the official Spanish story cheated history. Balmis had arrived in Puerto Rico two months too late. With an epidemic of small-pox sweeping the island, a resourceful San Juan doctor named Francisco Oller (a military surgeon, no less) had procured some vaccine lymph from British St. Thomas. By the time of Balmis’s arrival, more than 1,500 residents of San Juan had already been vaccinated. The royal doctor promptly denounced Oller as a fraud and his vaccine as worthless.60
Under Spanish rule during the nineteenth century, Puerto Ricans grew accustomed to the occasional spectacle of public vaccinations. During smallpox epidemics, the public vaccinator would call the people of a barrio or village to assemble. Using virus secured from the Central Institute of Vaccination at San Juan, the vaccinator would inoculate a calf or two, drive them to the center of each village or barrio at an appointed date, and set about vaccinating the people with fluid taken directly from the animal. In the final years of Spanish rule there still existed much popular opposition to the medical practice, not least because the vaccine orders seemed so arbitrary and the operation itself so often proved ineffective. In the 1890s the Spanish compulsory vaccination measures, according to Colonel Hoff, had been “honored in the breach more than in the observance,” especially in the rural areas. The greatest number of vaccinations performed in a single year was fewer than 25,000 (in a population exceeding 900,000 people). American officials may have exaggerated the defects of Spanish “misrule,” but Puerto Rico did suffer a high incidence of smallpox during its final decade under Spain. In 1890, smallpox killed 2,362 people—accounting for 9 percent of the island’s deaths that year. For the decade, deaths from smallpox averaged 620 per year. A far greater number were left scarred or blinded by the disease. Lacking an effective measure against the disease, many Puerto Ricans regarded smallpox with a fatalism that Army medical officials too readily interpreted as indifference.61
The incidence of smallpox on Puerto Rico at the start of 1899 was not dramatically out of proportion with that of the last years of Spanish rule. Smallpox killed an estimated 522 islanders in 1898, somewhat below average for recent years. What was new was the presence of a regime determined to bring its full might to bear in fighting the disease.62
On January 27, 1899, the American governor general Guy Henry issued General Order No. 7. “The inhabitants of this island must be protected from smallpox,” it proclaimed. “Every resident who has not had this disease will be vaccinated, and hereafter all infants must be vaccinated before reaching the age of six months.” Hoff took charge. The order parceled the island into five geographical areas of roughly 200,000 inhabitants, each presided over by an Army medical officer designated as a director of vaccination. Each director, including Major Ames and Major Groff, would command a staff of surgeons, inspectors, and Hospital Corpsmen. The directors would report any neglect by Puerto Rican authorities to carry out the order’s provisions.63
General Order No. 7 called for compulsory public health on a scale never before seen in Puerto Rico or, for that matter, any territory under the direct jurisdiction of the U.S. government. As the Army carried vaccination to the people, the Marine-Hospital Service ran a quarantine at the island’s ports, requiring all arriving passengers to show proof of vaccination and all travelers bound for the mainland to undergo the procedure. The vaccination campaign was all the more ambitious given the serious technological, geographical, and political obstacles that stood in the way. Dozens of centers of contagion existed, including barrios high in the mountainous interior whose people had little experience with sanitary authority. Most Puerto Ricans lived under crowded conditions, moving constantly between the countryside and the towns for trade and work. Like other Western physicians in colonial settings, the military doctors complained of the “indifference” of the “natives.” Ames noted the difficulty of delivering modern health to “hundreds of thousands of unregistered people, mostly ignorant and scattered, speaking foreign tongues, and unused to sanitary controls.” Unbeknownst to him, his complaint echoed those sounded by Kentucky health officials as they struggled to enforce vaccination in Appalachia.64
The most pressing challenge at the start of the Puerto Rico campaign was to secure a reliable vaccine supply. Vaccine did not survive long in heat (a problem that would bedevil tropical vaccination programs until the invention of a heat-stable, freeze-dried vaccine in the 1950s). Vaccine tubes shipped from the mainland usually lost their potency by the time they reached Puerto Rico. The British imperial experience in India (as well as the Spanish record in Puerto Rico and the Philippines, assuming the Americans actually consulted it) taught that ineffective vaccines engendered popular resistance to vaccination in general. The solution the Army settled upon—to produce vaccine on the island itself—was, in keeping with colonial administrative imperatives, the cheapest. It was also the most ambitious. Governor General Henry put Major Ames in charge of the operation.65
Azel Ames was one of the hundreds of civilian physicians recruited, as he said, in “hot haste” for the war with Spain. Born in Chelsea, Massachusetts, in 1845, Ames had served in the Union Army and graduated from Harvard Medical School. The unifying theme of his career to date was the way it had blended seamlessly—and, on at least one occasion, scandalously—public service and private interest. As a physician in Wakefield, Massachusetts, he founded the town’s board of health. His résumé also included stints as a temperance crusader, state factory inspector, and administrator of U.S. government pensions. Ames had gotten himself embroiled in a national scandal in the 1880s, when he was indicted for abusing his position with the Boston board of medical examiners in the U.S. pension office by extorting bribes from claimants. The jury was hung, and Ames was never convicted. In none of his writings about his Puerto Rican experience did Ames mention any previous experience with vaccine production. But vaccine manufacture in the late nineteenth century remained a largely pastoral pursuit. And in Ames’s Wakefield it was not unknown for a physician to keep a calf on hand to meet his patients’ needs for lymph.66
The Puerto Rican vaccine farm was the capstone of Ames’s career, pulled off, if he said so himself, on a “grand scale . . . practically in the open air, in a new country, by unskilled hands.” Ames based his operations on rented fields at Coamo Baths, an area of “fine cattle country” on the dry coastal highlands near the island’s south shore. He supervised the construction of stables, corrals, and a camp large enough to sleep over a hundred men—Army surgeons, a pathologist, cattlemen, guards, cooks, couriers, and teamsters. Fresh meat, ice, and medical supplies from the United States were hauled almost daily up twenty-three miles of rough roads to the camp. Working through a native intermediary, a local cattleman named Simón Moret, Ames leased twelve hundred head of local cattle.67
The viability of the entire campaign depended on a few glass tubes of lymph imported from the United States. Army medical officers doubted that vaccine virus originating in a temperate climate could retain its “virility” in the moist heat of the tropics. Ames received his little supply, transported eighteen hundred miles by sea then hauled by pack animal up the dusty military road to the camp. An assistant inoculated forty cows with the lymph. The camp waited for the virus to incubate in the animals’ bodies. They waited the requisite six days, and then waited some more. Nothing. Ames would recall these hours as the “worst and most anxious” of his life. He and his assistants furiously searched the calves’ undersides for the telltale vesicles, the blister-like sores from which the vaccine lymph could be harvested. But there were none. It appeared that the entire shipment of American lymph was useless and that “the undertaking must be abandoned.” After twenty-four sleepless hours, Ames and an Army pathologist, Dr. Timothy Leary, took one last look. This time they discovered that many of the animals had scablike “crusts” and “cones.” Removing them, the physicians discovered bases flowing with lymph. The doctors realized their mistake. The animals at Coamo had not been confined in stables, as they would be on an American vaccine farm. The vaccine vesicles had been broken by the underbrush, grass, and the calves’ own rough tongues. From the ring-shaped bases on the calves flowed “the finest lymph.” The operation was soon producing sixteen thousand good-quality vaccine points a day.68
The Army’s next challenge was to get Major Ames’s vaccine to—and into—the people. For this, the Army relied on the Puerto Ricans. Native runners, on foot and pack animals, negotiated the narrow paths and mountain streams to deliver fresh vaccine to the villages and barrios. The Army vaccination directors determined that the population was so dispersed and difficult to reach that the common American method of house-to-house vaccination would be unfeasible. Instead, they would have to bring the people to the vaccinators. The directors set the schedule and secured the cooperation of the alcaldes, the local officials who served in the island’s seventy-one municipalities as “mayor, school commission, county commissioner, and sheriff, all in one.”69
The original plan envisioned using Army Hospital Corpsmen to vaccinate the people. But the medical officers decided to hire native physicians and their assistants, called practicantes, for the job, believing (no doubt correctly) that local vaccinators would be “more acceptable to the people.” Each director was allowed to hire ten vaccinators, who would be paid in gold. According to the Army’s instructions, the practicantes must conduct their business at specified hours, “wear white coats,” and “always be neat and clean.” The skin of the native physicians might be dark, but American medical authority would remain clothed in white. As the physicians and practicantes performed their vaccinations—scraping the arms of men, women, and children with the sharp edge of Dr. Ames’s points—native scribes recorded each person’s name, address, sex, age, and race. In this way, the vaccination teams produced for the U.S. military government its first record of the population. Major Groff found that a single vaccinator, “if hurried,” could vaccinate three hundred people in an eight-hour day. Some Army surgeons never overcame their low regard for the Puerto Ricans. S. H. Wadhams, a Yale Medical School graduate who served as an Army surgeon in Ponce, claimed American vaccinators could do “three to five times as much work as the natives.”70
The military government found it necessary to continually ratchet up the coercion in its vaccination campaign. No vaccination riots were reported, but physicians working for the military government had to take care. When one was asked why he had failed to vaccinate all the spectators at a cockfight near where he was working, he answered, “I feared a thrashing.” On March 18, Governor General Henry raised the pressure. He ordered the alcaldes to “use all their authority to secure prompt compliance on the part of the people.” The order, which Major Ames himself drafted, contained an important new provision. No one who failed to produce an official certificate of vaccination “shall be admitted to any school, public or private, shall travel by any public conveyance, visit any theater or any place of public resort, engage in any occupation related to the public, or receive employment.”71
Through the island vaccination campaign, Americans were indeed learning the art of colonial statecraft. Ames’s provision pulled a largely illiterate, rural population into a documented relationship with the U.S. military government. It also imposed a new discipline on local institutions, by holding public and private authorities—schoolteachers, managers, and employers—legally liable for enforcing the measure. The strategy worked. “From hills and valleys, hamlets and municipalities, young and old flocked to the vaccinators,” Ames recalled, “like John Chinn’s Wuddahs, in Kipling’s story of the vaccination of the Satpura Bhils. Often two or three hundred, old and young, would be still waiting, unvaccinated, when darkness closed the day’s work. . . . Sometimes the vaccination was continued by lamplight to relieve the pressure.” The metaphor of police power could no longer contain such ambitions. Like the Kipling character to whom he now compared himself, Major Ames saw himself as the vanguard of a civilizing mission, carrying into those overgrown hills and valleys the vaccine of a paternal American nation.72
Even then, some Puerto Ricans refused to cooperate. In June, the new governor general, George Davis, imposed new penalties for people who refused to be vaccinated: a $10 fine, plus $5 for each subsequent day in violation. Anyone who failed to pay the fine would “suffer ten days’ imprisonment and thereafter five days for each additional offense.” This penalty was harsh even by the toughest standards of vaccination measures in the United States.73
On June 25, 1899, Chief Surgeon Hoff received a telegram from Coamo Springs announcing that the vaccine farm had produced its one-millionth point. A week later he brought the campaign to a halt. The Medical Department’s vaccination program had carried vaccination to the people on an unprecedented scale. According to Hoff, the vaccinators had performed nearly 860,000 operations (742,062 vaccinations and 116,955 revaccinations) in a period of five months. And the vaccine produced at Coamo Springs was, by contemporary standards, good, with a reported success rate of 87.5 percent. Colonial administrators always kept the bottom line in view. Hoff noted with satisfaction that the entire vaccination campaign had cost only $43,000.74
By the end of June, the “head-fire of vaccination” had stopped variola in its tracks. In the decade before the arrival of the U.S. Army, the annual death rate from the disease had averaged 620 people. From January 1 to April 30, 1900, not a single death from smallpox was reported. And during the two years after completion of the eradication campaign, the annual death rate dropped to just two. Under the new superior board of health established under Colonel Hoff’s leadership in June 1899, the vaccination of infants continued. U.S. health officials continued to seek out the elusive people Hoff described as the “‘submerged’ 200,000 who escaped in the grand attack” of 1899.75
The new colonial civil administration installed by the Americans on May 1, 1900, would learn soon enough that the vaccination campaign had not permanently eradicated smallpox. The flow of people and goods from the mainland brought variola minor to the island. Still, American officials and journalists followed Ames’s lead in touting the Puerto Rican campaign as a “lesson to the world.” Ames hoped it would overthrow the “present belligerent skepticism” toward compulsory vaccination in America and Europe. “Small-pox still holds the first place in the list of preventable, readily-disseminated contagious diseases, common to all parts of the globe,” he wrote. And in Puerto Rico, the Army had shown how it could be eradicated. Surely, that colonial knowledge could be used to wipe out smallpox on the U.S. mainland.76
The question of exporting the Puerto Rican model—or importing it to the American mainland—hinged on how one felt about public health enforced by a form of martial law. Although the smallpox eradication effort had relied heavily upon local physicians to bring vaccination to the people, it had been a military operation through and through. No government agency on the United States mainland would have dreamed of securing a monopoly on vaccine production—in most parts of the United States, there were no regulations at all on vaccine production. To secure the cooperation of local officials, the Army wielded powers of influence and coercion that neither state nor federal authorities could have matched in a place like Middlesboro, Kentucky. That went double for the capacity to impose vaccination upon an unwilling people. When a Kentucky health inspector named W. M. Gibson visited the smallpox-afflicted mountain folk of Jackson County in August 1898, he sent word to his boss, Secretary J. N. McCormack of the state board of health. Dr. Gibson promised to vaccinate “all who willingly apply.” But he told McCormack that if he really wanted to see vaccination enforced in Jackson County, “you will find it necessary to send four battalions of four hundred soldiers each, well armed.” Gibson wasn’t joking.77
That Kentucky fantasy would become a reality in the Philippines. There U.S. health officials would have a good deal more than four battalions marching with them. The situation in the Philippines was different not only from Jackson County, but also from Puerto Rico. In the Philippines, the fighting was far from over when the vaccinators began their work.
If the Puerto Rico vaccination campaign deserved pride of place as America’s “first big sanitary undertaking . . . in the tropics,” the U.S. government’s fight against smallpox in the Philippines took place on an altogether grander scale. The Southeast Asian archipelago was both far more distant and far more expansive than the Caribbean island. The Army had many more men on the ground there. Some 125,000 U.S. Regular Army and Volunteer soldiers had arrived by 1902. And their mission proved far more dangerous, as the “splendid little war” against Spain gave way to a three-and-a-half-year guerrilla war with Aguinaldo’s republican forces. The people of the archipelago were eight times more numerous than the Puerto Ricans, and, in the eyes of the American occupiers, they inhabited a lower rung on the racial hierarchy. Lieutenant Colonel Hoff, who participated in both campaigns, sized up the Philippine challenge: “It is no small problem to sanitate eight millions of semi-civilized and savage people, inhabiting scores of islands with the aggregate area of a continent.”78
At their most open-minded, some U.S. officials envisioned a gradual process of “benevolent assimilation.” The indigenous elite would be fitted for eventual self-government while the political participation of the “wild” (and especially the non-Christian) masses would be deferred indefinitely. Typical of U.S. officials, most military surgeons regarded the Filipinos in general as racially inferior and indifferent to filth and disease. Not long after he supervised the hut-torching sanitation campaign in Siboney, Cuba, Colonel Charles R. Greenleaf served as chief surgeon of the Army’s division of the Philippines. “The native,” he wrote, “does not know how to take care of himself; not only is he ignorant of the first principles which govern the preservation of health, but he has never had anybody sufficiently interested in him to instruct him in these principles.” Above all else, the presence of endemic smallpox in the islands showed the Filipinos’ desperate need for a wise government to take them in hand.79
No doubt American military doctors believed their dispatches presented realistic accounts of the beliefs and practices of a backward “Oriental” people. In fact, these dispatches drew upon a common Western language of medical high modernism that had developed in the long nineteenth-century era of nation-state formation and colonial expansion. Within the ever widening world of cross-cultural contact, European and American physicians measured the civilization of subordinate groups along a scale of sanitary evolution. Although in this case U.S. surgeons were talking about Filipinos they encountered in the zones of combat and occupation, the nineteenth-century medical literature teemed with strikingly similar descriptions of the “primitive” health practices of Native Americans on the western reservations, Mexican Americans in the southwestern borderlands, African Americans in the rural South, Puerto Ricans of the Cordillera Central, and the “new” immigrants from Southern and Eastern Europe streaming into America’s industrial cities. European and American tropical medicine was embedded in a larger cultural and scientific process—one so homogeneous in its assumptions as to constitute a common project. Self-consciously modernizing nations used medical knowledge to comprehend, categorize, and govern the most marginal peoples within their territories. Tropical medicine was never merely a handmaiden of colonial domination, but it served that purpose exceedingly well.
Of course, for the Filipinos smallpox was not a figment of anyone’s colonial imagination. The disease stole children from families. It left thousands blind or scarred. In the absence of effective preventive measures, smallpox was an unavoidable fact of life—like the passing of the seasons. According to American estimates, forty thousand Filipinos died annually from smallpox during the final years of Spanish rule and the early years of the Philippine-American War. Army surgeons working in the provinces reported that between one third and one half of the inhabitants had already suffered smallpox. Greenleaf reckoned that the children of the islands were “practically the only susceptible persons, the adult population being as a rule immune and representing the ‘survival of the fittest.’” Although smallpox did the greatest harm to the islands’ poorest inhabitants, it did not spare the most elite. In March 1900, Aguinaldo’s own infant son died of smallpox while in U.S. captivity in Manila.80
The Filipinos were not indifferent to the many diseases that afflicted their families. Popular conceptions of health, disease, and medicine varied from place to place in the archipelago, combining indigenous traditions with Christian teachings and Western medical ideas acquired from the Spanish. Filipinos did not simply reject Western medical ideas; they incorporated those that seemed to work into their own systems of belief. According to commonly held Filipino medical beliefs, diseases could be caused by natural events: smallpox was known to be a disease of the dry months and was expected to wash away with the rains. Or diseases could be brought on by supernatural forces; if smallpox persisted through the rainy season, local healers used rituals to appeal to the spirits. Americans expressed dismay at the Filipinos’ practice of treating sickness and death as social events that required the close presence of friends and relatives. The occupiers used strong measures to compel Filipinos to remove the sick from their crowded huts, to promptly bury the dead, or destroy clothing contaminated with smallpox. Some Filipino practices must have fostered the spread of small-pox, but they also powerfully expressed the relationships of family to community and between the natural and supernatural orders.81
Many Filipinos had formed specific ideas about the various Western medical practices that the Spaniards had tried (usually halfheartedly) to introduce into their lives. Filipinos could be receptive to Western medical ideas and medicines—at least those that worked. Vaccination had not proven itself worthy of their confidence. In 1897, more than ninety years after Balmis first brought vaccine to the archipelago, the Spanish regime maintained a central vaccination establishment in Manila and employed 120 public vaccinators (vacunadores) in the various provinces. But many Filipinos spurned them. Traditional beliefs about the seasonal cycles of smallpox made vaccination seem unnecessary. Filipinos had all too often seen that even after the vacunadores did their work, smallpox returned. As Americans discovered, the tropical heat often rendered vaccine inert and thus ineffective. Filipinos had observed that vaccination sometimes spread skin diseases. In fact, the Spanish health authorities’ use of the arm-to-arm method for propagating vaccine carried the real risk that syphilis and other infectious diseases might be transmitted from person to person. Reports coming in to the Spanish authorities from the provinces during the 1890s indicated that vaccination had been “completely discredited.”82
From the outset of the U.S. occupation of Manila, on August 13, 1898, the Army’s top brass and medical officers were preoccupied with preserving the health of the troops. That in itself was a tall order. From 1898 to 1902, the Army reported a half-million cases of illness, more than four sick reports for every soldier who served. Every regiment suffered from dysentery, malaria, and venereal diseases. Typhoid fever and smallpox were continuing threats. While the Army’s sickness data documented the suffering of white American soldiers, they also showed the power of soldiers to carry infection across the archipelago, transmitting pathogens between local disease environments that had previously been isolated from one another.83
As the bustling base of operations for the U.S. command—not to mention for American business interests—Manila topped the Americans’ sanitary agenda. The first measures, as Colonel Greenleaf said, were “designed mainly with a view to the preservation of the health of the troops.” But the Army approached the cleanup of Manila with the determination of people planning to stay awhile. The commanding general established a board of health for the city, under the leadership of Major Frank S. Bourns, a surgeon with the U.S. Volunteers. The Atlanta physician possessed an exceptional knowledge of the Philippines, having spent four years there on two previous zoological and ornithological expeditions.84
By October 1898, Bourns’s health board had nearly eighty employees, including a number of European-educated Filipino physicians. A few of the physicians, such as Dr. Trinidad H. Pardo de Tavera, had been members of Aguinaldo’s government at Malalos. The board divided Manila into ten sanitary districts, appointing a local physician for each; hired eight municipal midwives; and established special hospitals for smallpox, leprosy, and venereal diseases. Working with the new American department of sanitation, the board cleaned streets, staged house-to-house inspections, and seized and burned the corpses of inhabitants who had died from contagious diseases. Bourns’s activities extended beyond purely sanitary matters.85
As relations with Aguinaldo’s independence movement deteriorated, late in 1898, Bourns began relying on the local physicians and his growing network of personal contacts to acquire, as he modestly put it, “a good deal of information not otherwise obtainable.” Bourns’s talents were not lost on the Army generals, who assigned him to investigate reports of insurgent activities in the city and suburbs. By the time the first shots were fired in the Philippine-American War in February 1899, Major Bourns had established within the health board what he called a “little spy system, by which we were enabled to keep track, especially in the city, of everything that was going on on the insurgent line.” Information-starved U.S. military governments in both Puerto Rico and the Philippines exploited the wealth of local knowledge produced by sanitary campaigns. But Bourns pursued that aspect of a health officer’s job with unusual intensity, blending epidemiological surveillance with outright espionage.86
The first scattered cases of smallpox had appeared among the U.S. troops in Manila in September. Surgeon General Sternberg reported that the men had been “visiting the huts of the natives, in many of which smallpox of a very malignant character was prevailing.” In November, as U.S. forces in the vicinity grew to 21,000 men, more cases appeared among them and also among the 2,000 Spanish prisoners in Manila. The Army’s first response was to “protect the command by vaccination.” All the Spanish prisoners were vaccinated, and Major General Elwell S. Otis ordered the revaccination of all enlisted men in the islands. After much of the vaccine sent from San Francisco to meet this demand proved inert, Major Bourns reestablished the old Spanish vaccine farm in the city and started harvesting fresh lymph by inoculating local carabao (water buffalo). The situation worsened in December when smallpox infected the Twentieth Kansas Volunteers, killing ten. An investigation traced the origins of the outbreak to a cluster of native inhabitants who lived across the street. By this time, as one U.S. soldier recalled, the rising incidence of smallpox “caused the Army Medical Corps to view the general health and living conditions of the civil population as being pertinent to the well-being of the American command.”87
Bourns established a corps of city vaccinators, starting with six men, then doubling their number, then increasing them further after the new year as smallpox became epidemic in Manila. On the eve of war, Major General Otis sent Secretary of War Alger a dispatch on the health of the troops: “Smallpox causes apprehension. Entire command vaccinated several times. Twelve physicians engaged several weeks vaccinating natives.” Soon the suburbs of Manila were in flames, and terrified residents poured into the congested central city. In the Tondo district, seventy-five Filipinos died of smallpox in March. Bourns’s corps aggressively enforced vaccination, meeting “considerable opposition” at first, applying force when necessary. In all, the corps vaccinated eighty thousand residents of Manila that winter. By the end of March, the danger appeared to be over. And by June, Bourns reported, “there were but 4 cases of smallpox in the entire city of Manila.”88
The Manila epidemic had demonstrated, to the satisfaction of the Army Medical Department, the importance of vaccinating not just the soldiers but the local inhabitants among whom they lived. It had been a costly lesson: from September 1898 through March 1899, the troops in Manila had suffered 236 cases of smallpox. Eighty-five of these were mild cases, reported as varioloid (smallpox modified by previous vaccination). But among the other 151 cases, more than half of the patients (77) had died, seeming to confirm that smallpox in this tropical zone was especially deadly to white men. The presence of any smallpox among the U.S. troops in Manila created a public relations problem for a War Department still reeling from the typhoid revelations. American newspapers reported the tragic deaths of young soldiers from the disease and advised parents to disinfect letters received from their boys in the islands. To Surgeon General Sternberg’s chagrin, English antivaccinationists seized on the news that smallpox had broken out among the U.S. troops to cast doubt upon the efficacy of compulsory vaccination.89
But to Army officials, a strategy of wholesale compulsory vaccination—of the troops and the most proximate natives—had proven its merits. For the people of Manila, the U.S. vaccination campaign far exceeded anything they had experienced under their previous rulers. The Spanish regime’s chief vaccinator had reported just 9,136 vaccinations performed in the city during the four years prior to October 1898. During the next five months, the U.S. military government vaccinated 80,000 inhabitants.90
The U.S. Army took the war beyond Manila to the provinces, across the central Plain of Luzon and to other islands. By 1900, Aguinaldo’s forces adopted guerrilla warfare, which the Americans derided as uncivilized. The Army countered with increasingly violent tactics, including interrogation of suspected insurgents and spies using a form of torture known, in an especially perverse marriage of medical metaphor and military technique, as the “water cure.” The Medical Department had its hands full, establishing military hospitals, caring for the wounded, and moving with the line. Controlling infectious diseases remained a high priority. During 1899, the most deadly year of the campaign for the Army, 475 soldiers and officers died from wounds of battle, another 139 died from “other forms of violence,” and 709 succumbed to disease, “principally diarrhea and dysentery, small-pox and typhoid.” During the same year, nearly two thousand soldiers were sent home due to sickness. Throughout the war, smallpox weighed heavily on the minds of the military surgeons. They vaccinated the troops with great regularity.91
Preserving the health of the troops called for measures to sanitize their environment and the peoples who inhabited it. Many of the soldiers were stationed in one of five hundred garrison towns, which soon grew overcrowded with migrants fleeing the war-torn countryside. Stationed indefinitely in garrison towns, the troops mixed promiscuously with the inhabitants, consuming palm wine, gambling, and fraternizing. “The most crying need in the early days of our occupancy of the Provinces was to check the ravages of smallpox,” Greenleaf recalled. He advised the U.S. military governor, General Arthur MacArthur, that each garrison should have an army surgeon designated as “health officer,” “special orders being given for the vaccination of the population of the towns and neighboring barrios as far as the people could be reached.” As one U.S. colonial official reported, the garrison surgeons “had great latitude, and under their direction compulsory vaccination was usually enforced.” The surgeons also used “arbitrary military compulsion” to enforce “simple regulations as to cleaning streets, putting dirty premises in order, [and] tying up pigs.”92
A comprehensive plan for vaccination in the provinces emerged. The idea appears to have originated with a military surgeon named Major Louis M. Maus. Major Maus knew how infection could rip through an army. He began the Spanish War as chief surgeon with the VII Corps in Miami and Jacksonville, bearing witness as more than 5,000 of the soldiers in his care were hospitalized with typhoid fever. Reporting from Bautista, Pangasia, in February 1900, he warned that smallpox prevailed among the people of the towns and was “not rare among our troops as a consequence.” It would be impossible, he said, to “stamp out this disease among our soldiers, in spite of the frequent and careful vaccinations among them, until the natives are themselves protected.” Not long after this report, the Army issued orders to vaccinate all people within the reach of the division of the Philippines, which at that time included seven provinces north of Manila. Within five months, more than 600,000 Filipinos certified by the medical department as protected from smallpox by vaccination or previous infection.93
For the remainder of the war, the Army enforced vaccination wherever it went. Sometimes that meant rounding up the inhabitants with bayonets in order to inoculate them. By 1901, the American vaccine farm in Manila was turning out a million points a year, and more farms were being established in the provinces. The U.S. Marine-Hospital Service established a quarantine station at the entrance to Manila Bay, vaccinating crews and passengers aboard ships approaching the principal harbor of the colonial government. On December 2, 1901, the Philippine legislature put its seal on this emerging American regime, mandating the compulsory vaccination of the entire population of the Philippines. The law ensured that the Army’s wartime policy would continue under the colonial regime long after the war’s end.94
The narrow military imperative of the cordon sanitaire was, during the course of the war, yielding something grander, a more far-reaching system of public health. As it did so, Army surgeons, U.S. officials, and other commentators began to publicize these measures as not merely efficient but humane. As early as 1901, Colonel Greenleaf declared that the Army’s sanitary measures were winning hearts and minds. “This object lesson in one of the most important characteristics of the American people, humanity in war, has made a deep impression on the Filipinos, and has been an important factor in winning their allegiance to our Government.” The following year, James LeRoy declared that the surgeons’ “little and big services to the natives . . . not only helped make the name ‘Americanos’ more acceptable” but “were also genuine responses to the call of humanity.” But as Greenleaf and LeRoy well knew, willing submission to vaccination remained far from universal in the pueblos and barrios. Understandably, Filipinos associated the vaccinators, even those who were native physicians, with the foreign army they served. The work of vaccinating the natives, conceded Greenleaf, was “by no means devoid of danger, and several instances occurred where the vaccinators were captured by insurrectos or kidnapped by the inhabitants and killed.”95
A fuller articulation of the humanitarian argument did not emerge until the final, brutal months of the Philippine-American War. The argument gained momentum at precisely the moment when the American public learned of the scale of atrocities carried out by the U.S. Army in the Philippines and the devastating effects, upon Filipino civilians, of the Army’s counterinsurgency policy of reconcentration. That policy would forever be associated with a single forsaken place: Batangas.
In the days before Christmas, 1901—as anti-imperialists in the U.S. Congress denounced the nation’s Philippine policy (“We have witnessed the spectacle of an American Army numbering over 70,000 men engaged in conquering a people struggling for independence,” thundered Representative Samuel W. McCall of Massachusetts)—the peasants of Batangas province made their way, by winding paths and rough roads, to the pueblos. Market towns in a prostrated agricultural region with precious little left to sell or barter, the pueblos were fast taking on a new kind of urban life as Army “reconcentration zones.” Traveling alone, with families, or alongside their entire uprooted barrios, the Batanguenos stepped past soldiers, through fences, and around garbage into the teeming camps. They carried rice, chickens, and the pieces of their bamboo and nipa palm huts. On the day after Christmas, by order of Brigadier General James Franklin Bell of the Third Separate Brigade, all property remaining beyond the perimeters would be subject to confiscation or the torch. Any man they found out there without proper papers would be arrested, or shot if he dared to run away.96
Located in southwestern Luzon, just a few hundred miles from the offices of the U.S. colonial government in Manila, Batangas province was one of the last strongholds of the Filipino resistance, the base of operations for insurgent leader General Miguel Malvar. The Army command had organized the Third Separate Brigade for this chief purpose: to “pacify” Batangas and thus bring an end to an increasingly unpopular colonial war.97
By the fall of 1901, that war had seemed all but over. Guerrilla bands laid down their arms in one province after another. Then came Balangiga. In a village on the island of Samar, guerrillas and villagers wiped out a U.S. infantry company. American newspapers likened the “Balangiga Massacre” to Little Big Horn. Dispatched on a punitive campaign against Samar, Brigadier General Jacob H. Smith ordered his men to kill everyone over the age of ten and turn the island into a “howling wilderness.”98
In Batangas, too, the customary distinctions between hostiles and civilians yielded to claims of military necessity. “Practically the entire population has been hostile to us at heart,” General Bell explained in a Christmas Eve circular to his officers. “To combat such a population,” the war must be made “insupportable.” By then Bell’s brigade had driven most of the province’s 300,000 inhabitants, already weakened by famine and disease, into the zones. American soldiers put the Batanguenos to work grading roads, digging latrines, and gathering rice in the countryside. With the rectitude of a Victorian charity official, Bell insisted “great pains” be taken not to “pauperize the people.” He told his men to exact respect in the camps for the American flag, the troops, and “the great nation to which they pertain.”99
A veteran of the late-century Indian Wars, General Bell did not invent the counterinsurgency tactic of reconcentration: the forcible removal of civilians from hostile areas into militarized towns in order to isolate guerillas from their base of support. The history of U.S.-Indian policy had been, in a sense, one long process of forcible removal. More recently, European armies had resorted to this specific tactic in colonial wars against indigenous, nonwhite populations. The Spanish general Valeriano Weyler’s brutal reconcentration campaign in Cuba during 1896–98 had failed to crush the independence movement, but it had caused the deaths of an estimated 100,000 Cubans and tilted American public opinion toward war. In 1900, the young Winston Churchill touted his nation’s forced reconcentration of rural South Africans in the Boer War. Still, the severity of the U.S. Army’s “concentration camps,” as some newspapers referred to them, shocked the American public. General Bell and his superiors defended the camps as a legal and necessary measure to protect the population from bandits and guerrillas. But within the United States the policy strengthened opposition to the war.100
Wherever it was undertaken, forced population concentration caused epidemics. In the British concentration camps for Boers and Blacks in South Africa, 42,000 civilians died. Public revelations of the policy’s human cost weakened public support for imperialism in England. Like rural people across the Philippine archipelago, the Batanguenos had already suffered mightily in recent years. The effects of the two successive wars—the collapse of the Spanish health system, the movement of troops about the provinces, the destruction of draft animals by rinderpest, and the dislocation and impoverishment of the rural population—intensified the health crisis that had been ongoing for some years. These events elevated the Filipinos’ susceptibility to disease while increasing their exposure to pathogens.101
The Batangas reconcentration zones seethed with disease and death. One Army officer described the camp he commanded as “some suburb of hell.” Vampire bats circled overhead awaiting the day’s supply of corpses. Thrown together with thousands of desperate strangers in the filthy zones, the Batanguenos suffered outbreaks of cholera, dysentery, and smallpox. With so many U.S. soldiers living in the camps, something had to be done.102
And so as U.S. infantrymen hunted down and killed General Malvar’s guerrillas in the coastal flatlands and rolling hills of Batangas, Army doctors enforced vaccination in the camps. The Army hired eighty Filipino vaccinators. According to the official “Directions for Vaccination of Natives,” sent in January 1902 to all station commanders in Batangas by Army Chief Surgeon William Stephenson, the vaccinators moved in pairs through the teeming reconcentration camps, each accompanied by an American soldier. As the vaccinating party entered the crowded huts and houses, they drove the inhabitants toward the rear walls. The vaccinators set to work at the doorway, scraping the arms of the men, women, and children as they were led, one by one, into the light. Only those showing recognizable pockmarks were exempt. General Bell himself took a special interest in the minute details of the compulsory vaccination effort. “It can easily be understood by all how serious the difficulty and detrimental to our plan of campaign [it] would be should an epidemic of small-pox break out in any protected zone,” he declared in an urgent telegram to his post commanders. “Whenever any opposition is met by vaccinators Commanding Officers will detail sufficient troops to round the people up and compel them to submit to vaccination.” While the Third Brigade “pacified” Batangas, the Army’s vaccinators performed 300,000 operations—a number roughly equivalent to the entire population of the province—in just two months.103
Along with General Smith’s Samar expedition, the Batangas military campaign led to Senate hearings on Army misconduct that sullied the Army’s reputation for years. Still, General Bell’s Third Separate Brigade accomplished its mission. By February 1902, several guerrilla bands had surrendered, some after killing their own leaders. On April 16, General Malvar, his wife seriously ill, surrendered, followed soon after by the remaining insurgents in Batangas and on Samar.
President Theodore Roosevelt chose the anniversary of the Declaration of Independence—July 4, 1902—to declare a formal end to the Philippine “insurrection.” More than 4,200 American soldiers died in the war, adding to the toll of 2,910 killed by combat and disease in the Spanish-American War. The death toll among the Filipinos reached a different order of magnitude. In addition to some 20,000 Filipino soldiers, hundreds of thousands of civilians perished from causes attributable in full or in part to the war, including killing by U.S. soldiers, famine, and especially diseases such as typhoid, tuberculosis, bubonic plague, smallpox, and a horrific two-year epidemic of cholera. All of which helps to explain why so many of the Filipinos interviewed for an oral history project during the 1950s would remember the first lethal years of the American colonial regime less for its battles or its atrocities than for its plagues.104
In the spring and summer of 1902, the U.S. Senate hearings and newspaper reports confronted the American public with shocking stories of Army misconduct in the Philippine War: interrogations by water torture, summary executions, and scorched-earth tactics. To many, the most disturbing revelation was that the U.S. Army had resorted to methods reminiscent of the “Weylerism” that had helped arouse American support for a war against Spain in the first place. In the end, General Bell survived with his reputation impugned but his career intact. At the height of the postwar debate, a veteran of the Army Hospital Corps named Edward Curran tried to set the record straight. In a letter to The New York Times, Curran praised General Bell for the “humane and meritorious concentration” in Batangas, where the corpsman had proudly participated in the strenuous effort to “vaccinate all of these people.”105
Curran’s letter was one small entry in a much larger argument unfolding in American public life, an argument that extolled the exceptional humanity displayed by the U.S. Army and colonial governments during and after the Spanish and Philippine wars. Beginning in 1902 and extending to President Taft’s 1911 Philadelphia speech and beyond, an outpouring of official commentary, newspaper and magazine editorials, books, and personal remembrances urged that the sanitary work of the Army Medical Department had shown that characteristic which Chief Surgeon Greenleaf had described as distinctly American—“humanity in war.” Arriving in San Francisco in June 1902, Major General Loyd Wheaton offered a humanitarian balance sheet of the Philippine War. “The devastations of war have cost many lives and the loss among the natives has no doubt been large,” General Wheaton said, “but when one takes into consideration the hundreds of thousands of lives that have been saved by reason of the sanitary precautions of the American Army and Civil Commission, that loss by war seems infinitesimal.” Wheaton referred specifically to the “compulsory vaccination [that] was held in every province, town, and throughout the country. In that way we saved thousands of lives.”106
The New York Times, a stalwart supporter of American expansion abroad and compulsory vaccination of the urban masses at home, applauded Wheaton’s speech. “The anti-imperialist, with his tender regard for the inclinations and preferences of all races except his own, will doubtless object that it is no favor to save the lives of people by forcing them to follow customs and endure Governments distasteful to them,” the Times noted. “[B]ut with the world as small as it is nowadays, this argument is decidedly weak. . . . The unsanitary have become public enemies, and modern war, with its enormous evils, does spread habits of clean living among ‘natives’ and the ‘unprogressives’ whom it leaves alive.” As American officials, commentators, and scholars praised the new levels of sanitation, hygiene, and health that the American efforts had brought to the peoples of Cuba, Puerto Rico, and the Philippines—from the old Spanish ports to the rural interiors—a new rhetoric of justification for military action crystallized. U.S. military medicine had preserved the health of the soldiers, protected American commercial interests, and saved the lives of countless natives.107
Health administration would remain an integral part of U.S. colonial rule in the Philippine archipelago—and also a principal means of justifying that rule. Americanized Manila stood as a model of the healthful city. In the 1904 fiscal year, the board of health had vaccinated 213,000 people in Manila and an additional 1,007,204 people in the provinces—well over one eighth of the entire population of the archipelago. American-made vaccine, packed for shipment in special boxes of ice, was reaching the people of the interior on horse-drawn carromatas, in water-borne bancas, and on the backs of Igorot runners. Local officials placed orders for vaccine over the telegraph wires the Americans had installed. Marine-Hospital Service surgeons vaccinated thousands of sailors each year in the harbors and pressed shipping firms to employ only persons holding the Service’s blue vaccination cards.108
By 1906, the Philippine Commission was boasting of the real possibility of eradication: “The day should not be far distant when smallpox will disappear from the Philippines.” The following year, Dr. Victor Heiser, the U.S. director of health, stated the argument in its baldest form. “During the year there has been unquestionably less smallpox in the Philippines than has been the case for a great many years previous.... In fact, if any justification were needed for American occupation of these islands, these figures alone would be sufficient, if nothing further had been accomplished for the benefit of the Filipinos.” Between the arrival of the U.S. troops in the summer of 1898 and 1915, some 18 million vaccinations were performed in the Philippines under American rule. The Filipinos, according to U.S. officials, had come to accept vaccination as an effective and necessary measure, suggesting, if true, a dramatic transformation of medical beliefs in a very short time.109
With the end of the war, the question of force became the greatest political liability of U.S. colonial health policy. Significantly, in 1904 the Philippine Commission ordered that public vaccinators would henceforth be “prohibited from using force in accomplishing vaccinations.” Individuals who refused to submit to vaccination would be tried in the courts. All of these ongoing efforts did not succeed in completely wiping out smallpox on the islands. The tropical climate continued to render much of the American-produced vaccine useless. But the efforts did dramatically reduce the incidence of smallpox there and laid the groundwork for the Philippines to become, in 1931, the first Asian country in which the disease was eradicated.110
At a time of pervasive opposition to compulsory vaccination at home and abroad, U.S. health officials presented the vaccination campaigns in Puerto Rico and the Philippines as evidence of the efficiency of compulsion. Azel Ames touted the Puerto Rico campaign as “A Lesson for the World.” Surgeon General Walter Wyman of the U.S. Public Health and Marine-Hospital Service declared, “No greater proof as to the efficacy of vaccination exists than in the Philippine Islands.” For Dr. John E. Snodgrass, assistant to the director of health in Manila, the truth of that proposition could be seen in the scarless faces of the rising generation of Filipinos. “The only argument necessary to explode the theories of the anti-vaccinationists,” he proclaimed before the Panama-Pacific International Exposition in 1915, “is to compare the visages of the children of today with those of their parents.”111