Pox

by Michael Willrich

  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