Pox

by Michael Willrich

  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 reconcentrados lived 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 D
r. 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 servi
ces 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