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Chapter 3

Books and Documents > Table of Contents

CHAPTER 3

Emerging Missions: Combating Epidemics Abroad

The accomplishments of the, Army Medical Department in disaster relief between 1898 and 1917 surpassed not only its meager contributions in the nineteenth century but those of any subsequent era as well. The transformation of the department's role began as it combated epidemics in the tropical dependencies acquired by the United States as a result of the Spanish-American War. The spectacular success that resulted rested upon both the emergence of modern health science and the prewar reform of the Medical Department itself.

Between 1865 and 1890, Louis Pasteur and Robert Koch demonstrated that germs caused certain forms of infectious illness. Armed with that basic insight, other scientists soon implicated microbes as causal agents of many diseases- of typhoid, leprosy, and malaria in 1880, tuberculosis in 1882, cholera in 1883, diphtheria, tetanus, and bubonic plague in 1884, and dysentery in 1898. By 1901, the president of the American Public Health Association could proclaim: "We no longer talk vaguely of cosmic perturbations, aerial influences, noxious miasmas, and epidemic constitutions of the atmosphere, but have exact and definite knowledge of the characteristics, habits, and life-story of nearly all the organisms which are the cause of contagion."1

Relying on this "exact and definite knowledge," physicians cured more patients, and the status of the medical profession rose. Concurrently, sanitarians and engineers spurred municipal governments into forming new or strengthening existing boards of health with authority to enforce sanitary laws and regulations. Advances in medical knowledge and practice combined with these organizations for implementing them to make the two decades between 1890 and 1910, in the words of one historian of public health, a "period of scientific control of communicable disease by the application of bacteriology."2

    1Trattner, Poor Law to Welfare State, pp. 116-35, Quote from Benjamin Lee, "President's Address," Papers and Reports of the American Public Health Association 27 (1901): 13.
    2Rothstein, From Sects to Science, Lawrence H. Larsen, "Nineteenth-Century Street Sanitation A Study of Filth and Frustration," Wisconsin Magazine of History 52 (1969): 239- 47; Stanley K. Schultz and Clay McShane, "To, Engineer the Metropolis: Sewers, Sanitation, and City Planning in Late-Nineteenth-Century America," Journal of American History 65 (1978): 389-411; John Duffy, A History of Public Health in New York City, 1866-1966 (New York: Russell Sage foundation, 1974), passim, but especially pp. 70-280, Quote from C.-E.A. Winslow, The Evolution and Significance of the Modern Public Health Campaign (New Haven: Yale University Press, 1935), p. 49.


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The Army Medical Department was able to contribute to this age of' "scientific control" for it was a reformed service in a reformed Army. In common with many other segments of American society, the Army in the late nineteenth century strove to increase professional competency within its ranks- by the creation of special service schools, for example. The Medical Department, staffed by an unusually skilled, highly educated cadre of doctors who were frequently leaders in the revolution in medical knowledge, participated in this increased professionalism. The doctors also acquired specialized enlisted support in 1887 when Congress and the president approved the formation of the Hospital Corps. The corps strengthened the department by adding enlisted personnel who received training in elementary first aid, stretcher-bearing techniques, and other aspects of hospital and evacuation work.3

Unfortunately, all the weaknesses of the nineteenth century had not been corrected, as the Medical Department's performance in the Spanish-American War all too prominently revealed. The department did not have sufficient numbers of surgeons or corpsmen to support, the massive troop buildup, and when it expanded its ranks it did not always secure qualified or trained personnel. Problems of supply, organization, and line indifference to medical needs further contributed to a failure of health care for the armies. After the war, a specially appointed presidential commission headed by Grenville M. Dodge examined medical operations as well as the conduct of the entire War Department. Its report recommended reforms which, when enacted over the next few years, strengthened the Medical Department.4

    3For efforts at modernizing the Army, see Peter Karsten, "Armed Progressives: The Military Reorganization for the American Century," in Building the Organizational Society: Essays on Associational Activities in Modern America, ed. Jerry Israel (New York: Free Press, 1972), pp. 197-232; James E, Hewes, Jr. From Root to McNamara: Army Organization and Administration, 1900-1963 (Washington: GPO, 1975). For developments in the Medical Department, see Reports of The Surgeon General, 1887, p. 91, and 1888. pp. 141-42; Ashburn, History of the Medical Department, pp. 140, 142, and passim.
    4Graham A. Cosmas, An Army for Empire: The United States Army in the Spanish-Americon War (Columbia: University of Missouri Press, 1971), pp. 245-314. See also U.S. Congress, Senate, Report of the Commission Appointed by the President to Investigate the Conduct of the War Department in the War with Spain, S. Doc. 221, 56th Cong., 1st sess., 1900, 8 vols. All eight volumes include information on the Medical Department, but for the commission's findings and recommendations, see 1: 169-89.


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Even before these reforms, the Army Medical Department received an opportunity to demonstrate its new professionalism, in work that highlighted its members' medical expertise and abilities to administer public health programs. Army medical officers directed several campaigns against epidemics, with success that may, not have atoned for earlier failings but at least rehabilitated the Medical Department's public image. Maj. Walter Reed, one of the doctors most active in this work, wrote in 1901: "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."5

The Medical Department's opportunity for "eternal credit" resulted from a dramatic shift toward international activism in American foreign relations at the time of the Spanish-American War. Several of the motives that spurred early foreign disaster relief- humanitarian concern, national prestige, and commercial considerations- contributed to American imperialism as well. The practical result of the new policies was vastly expanded military involvement abroad, as the victorious United States replaced Spain as the ruler of Cuba, the Philippines, and Puerto Rico.6

In all three countries, the Army governed for a time, but the length and form of its administration varied in each. In Puerto Rico the Army quickly reestablished order and turned affairs over to a civilian government that ruled the island as a territory of the United States. In the Philippines an insurrection against occupying forces led to a long battle to pacify the island. Shortly after the subjugation of the rebels, the military government abdicated in favor of an American civilian Philippine Commission. In Cuba the military imposed stability and, after four years, withdrew when a newly elected government agreed to American terms. Four years later, the United States decided it had not complied and sent the Army back to support an American civil government. This time the troops remained on the island for almost three years before once again returning Cuba to the Cubans.7

    5Quote from Ltr, Walter Reed to William C. Gorgas, 29 Jul 01, in W.C. Gorgas Papers, University of Alabama Library.
    6For an introduction to the literature on the change in policy, see Daniel M. Smith, "Rise to Great World Power, 1805-1918," in The Reinterpretation of American History and Culture, ed. William H. Cartwright and Richard L. Watson, Jr. (Washington: National Council for the Social Studies, 1973), pp. 443-64.
    7See Edward J. Berbusse, The United States in Puerto Rico, 1898-1900 (Chapel Hill: University of North Carolina Press, 1966); John M. Gates, Schoolbooks and Krags: The United Stares Army in the Philippines, 1898-1902 (Westport, Conn.: Greenwood Press, 1971), but cf. Leon Wolff, Little Brown Brother (Manila: Erehwsa, 1961); David F Healy, The United States in Cuba, 1895-1902: Generals, Politicians, and the Search for Policy (Madison: University of Wisconsin Press, 1963); Allan R, Millett, The Politics of Intervention: The Military Occupation of Cuba, 1906-1909 (Columbus: Ohio State University Press, 1968).


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Several factors influenced the Army's decision to institute programs of sanitary reform in all three possessions. The nineteenth century legacy of Army medical aid on the frontier probably conditioned Army doctors to consider a civilian relief mission, but pragmatic considerations dictated a public health effort as well. Obviously, a reduction in the incidence of communicable disease in the civilian community would protect the health of the troops. It would also offer some protection to American civilians working in the countries and thereby facilitate the development of commercial relations.8

Finally, a few medical officers argued that the containment of contagious diseases, especially in Cuba and Puerto Rico, offered a means to reduce the likelihood of epidemics in the United States. Army surgeon John Van R. Hoff, in an article entitled "The Share of 'The White Man's Burden' That Has Fallen to the Medical Departments of the Public Services of Porto Rico," proclaimed: "Robbed of all superfluities, the real reason why we are in the Antilles today is because our people had determined to abate a nuisance constantly threatening their health, lives, and prosperity." "Spain," Hoff added, "was maintaining a pesthole at our front door and we could no longer endure it."9

The goals of protecting Americans and eliminating pestholes led the Medical Department to devote most of its attention to highly contagious diseases, though it did furnish some routine care and instituted minor programs to control tuberculosis and leprosy. But all three countries harbored various epidemic diseases- smallpox, plague, cholera, yellow fever- which with the sudden influx of nonimmunes during the war and its aftermath presented a situation of potential medical disaster. Driven by the possibility of such a calamity, the Army concentrated its efforts on the prevention or control of epidemics.

Sanitary and Organizational Reform

In 1899 doctors knew how to prevent smallpox epidemics and control cholera. The transmission of yellow fever and plague by insects had not yet been proven, even though the vectors for some other diseases had been recently established. Despite rapid advances, medical theory still held filth to be the leading cause of disease and organized sanitation the

    8On this point, see, RSW, 1903, vol. 6, The Philippine Commission, part 2, p. 64; Republic of Cuba, Report of the Provisional Administration from October 13, 1906 to December 1st, 1907, p. 47.
    9Quote from clipping from the Philadelphia Medical Journal, 7 Apr 1900, in the Jefferson R. Kean Papers, Alderman Library, University of Virginia. For evidence of popular support for this attitude in the States, see John H. Ellis, "Yellow Fever and the Origin of Modern Public Health in Memphis, Tennessee, 1870-1900" (Ph.D. diss., Tulane University, 1962), pp, 250-51.


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best means to prevent sickness. Cleanups reduced the incidence of "camp diseases" such as diarrhea and dysentery, may have helped prevent the spread of cholera, eliminated some breeding places of mosquitoes, and lessened the food supply of rats. Sanitation could not, however, have prevented or controlled the epidemics of plague and yellow fever which American officials so feared. Nonetheless, knowing what sanitation could accomplish and expecting- or perhaps only hoping- it could do more, the Army first cleaned occupied areas in all three countries and then established modern boards of health to maintain that cleanliness.

On all three islands, Army doctors encountered an environment reminiscent of America in the early nineteenth century, if not Europe in the Middle Ages. One American who arrived in Havana, Cuba, about the time the Army did recalled how "dead animals abounded, garbage was encountered everywhere, gutters were foul, and open mouths of sewers running into the ocean or into the harbor were reeking. Nauseating odors filled the air, and the condition of the public buildings was such that the American army officers practically refused to occupy them." With minor geographical variations, his description fitted cities the Army occupied in the Philippines and Puerto Rico as well. Most of the residents of all three countries still considered disease an act of God's will and apparently remained oblivious to the aesthetic as well as the medical benefits of sanitation. They drank from impure water supplies and made little provision for disposal of personal waste. So many people stopped by the roadside to relieve themselves or dumped chamber pots out of windows that one American official in the Philippines advised nighttime strollers in Manila to walk only in the middle of the street and to carry an umbrella.10

Since this tactic was unsatisfactory, particularly for soldiers who were not issued umbrellas, the Americans had to remove the accumulated filth and teach local civilians to maintain cleanliness through proper sanitation. At first the Army resorted to draconian measures. In the early days in Cuba, American troops entered the "dirty little town" of Siboney in which yellow fever was raging. Under the direction of Col. Charles R. Greenleaf, the surgeon in charge, the Army instituted a "vigorous" cleanup program and excluded all Cuban and Spanish refugees. When those measures failed to halt the epidemic, the Army burned the town.11

In Santiago, Cuba, the first American military governor, Gen. Leonard

    10Quote from Franklin Matthews, The New-Born Cuba (New York: Harper & Bros., 1899), pp. 95-96. Advice from Dean C. Worcester, The Philippines Past and Present, ed. Ralston Hayden (New York: Macmillan Co., 1930), p, 329, See also Joseph B. Van Hise, "American Contributions to Philippine Science and Technology, 1891-1916" (Ph.D. diss., University of Wisconsin, 1957), p. 14; L.P. Davison, "Sanitary Work in Porto Rico," Independent 51 (1899): 2128-29.
    11Quote from RSG, 1898, pp. 196, 216-17.


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Wood, employed less extreme tactics but still forcibly imposed cleanliness on the community. Wood, a physician himself, sought a general reduction in the city's death rate but also hoped to prevent yellow fever. He did not assign the cleanup task to Army medical personnel but appointed "Major" George M. Barbour director of sanitation. Barbour had simply assumed the title of major, he was a civilian, a former business partner of Buffalo Bill Cody, and an experienced free-lance sanitarian. Charged with cleaning the city, Barbour commandeered carts and drafted laborers, sometimes horsewhipping the recalcitrant. But local residents probably participated to receive the food and cash Wood's government offered as wages, rather than from fear of Barbour's lash. Wood added some of his own men to the sanitary force and organized soldiers and civilians alike in military fashion. Crew foremen exercised absolute control, and subordinates saluted superiors. To keep his eye on the troops, Wood rode, through the streets of the city on horseback several times a day.

This paramilitary sanitary force attacked filth with a vigor "as sharp and hot as the charge of San Juan Hill," according to one observer. Crews cleaned shops, bakeries, and slaughterhouses. And the streets became the main battle-front where workers shot stray dogs, buried trash, and began to clean what seemed to be the dirt of' centuries. They compiled an impressive body count: 1,100 corpses both human and animal were removed and burned in the first 68 days. At the height of the battle, crews


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carried off 200 loads of rubbish a day. The habits of the populace also came, under attack: "People making sewers of the thoroughfares were publicly horsewhipped in the streets of Santiago; [and] eminently respectable, citizens were forcibly brought before the commanding general, and sentenced to aid in the cleaning of the streets they were in the habit of defiling." Coerced if not convinced of the merits of sanitation, local residents started to cooperate. By the middle of the summer Wood proclaimed, "the old town is at last clean, and we are down, so to speak, to modern dirt which, while not attractive, is of a less offensive character than that of 1520."12

In other cities in the three countries, the Army relied not on a dramatic military assault but on a modern sanitation program that combined military authority with bureaucratic methods. In the capitals, San Juan, Manila, and Havana, the Americans formed crews composed mainly of local civilians to clean streets and public buildings, established inspection procedures to examine all residences, and attempted to force citizens to practice sanitation. Though Army medical officers did not always direct the cleanup efforts, they did oversee the establishment of new public health bureaucracies and often played a central role in their administration. Efforts in Manila illustrated how their attempts at sanitary reform proceeded in all three cities.

Cleaning the Philippine capital was no simple task; the Army drastically increased the size of the former Spanish sanitation force and hired many more carts and mules. The reinforced crews scoured the city, removing refuse and garbage which the Army then burned rather than dumping it into the ocean as had been Manila's practice. The disposal of personal waste posed a special problem because of the citizens' century-old habits. Many homes had picturesque towers housing a small room at the top with a hole in the floor that served as a wretched system of indoor plumbing, According to one observer, "this pit of iniquity is never cleared out" and "the excreta of fifty or one hundred years lie there" forming "a solid column of this decayed filth." A group of American soldiers, no doubt unwilling volunteers, took three weeks to clean out just one tower. After cleaning all of them, the Army instituted a night soil pail system and hired civilian contractors to remove the buckets and barrels but even so never

    12First two quotes from Robert P. Porter, Industrial Cuba Being a Study of Present Commercial and Industrial Conditions, with Suggestions as to the Opportunities Presented in the Island for American Capital, Enterprise, and Labor (New York: G.P. Putnam's Sons, 1899), p. 63. Hermann Hagedorn, Leonard Wood: A Biography (New York: Harper & Bros., 1931), 1: 187-202, Wood quote on p. 202, Matthews, New-Born Cuba pp. 127-35, 298-99, 302; for a cautionary note on Wood's achievement, see Albert G. Robinson, Cuba and the Intervention (New York: Longmans, Green, & Co., 1905), pp. 79-80.


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Once Manila became minimally free from foulness, the Army tried to institute modern public health practices to keep it so. The Board of' Health was created, directed by an Army medical officer and composed of six Army Medical Corps members and two local doctors. The board supervised clean up operations, compiled vital statistics, regulated medical practice, and, most important, promulgated sanitary regulations. These included a ban on using public places for toilets as well as rules that required householders to empty privies at least once a week, market vendors to use garbage cans, and slaughterhouses to burn carcasses. Unfortunately, since these and other rules sometimes conflicted with Spanish or local customs, many citizens remained unconcerned about or even hostile to sanitary measures. To stimulate their cooperation, the military adopted house-to-house inspections and street patrols.14

The Army medical officer who directed the inspections divided the city into ten districts, recruited workers from the local Filipino and Chinese populations, and organized them into a hierarchical staff of 10 district inspectors, 30 subdistrict inspectors, and 60 inspectors. The staff tried to check every house at least once a week, and at each the inspector posted a card with his signature, the date, and his findings. If he judged the premises unsanitary, he gave the householder a set of printed instructions explaining how to correct the problem. Householders who refused to make corrections could be fined, but those who agreed to cooperate were given time to perform the work. The hierarchy of inspectors coupled with the use of posted cards allowed thorough supervision, but as a further precaution the Army never fined a citizen without first sending an Army officer to reinspect the premises. Because the inspection system was judged to be fair, local cooperation improved.15

The populace responded less enthusiastically to the other method of enforcement, street patrols by American soldiers. Under the direction of the provost marshal, military details patrolled Manila to enforce compliance with sanitary ordinances. The soldiers not only fined people who broke

    13Quotes from G. J. Younghusband, The Philippines and Round About (New York: Macmillan Co., 1899), pp. 53-54, Gates, Schoolbooks, p, 60 Annual Report of Major General Arthur MacArthur, Military Governor in the Philippine Islands, 1901, 2: 8-15; Van Hise, "American Contributions," p. 14.
    14On the Board of Health, see Gates, Schoolbooks, pp, 57-60; RSG, 1900, p. 189; and 1901, pp. 138-40, R.C. Humber, "Military Government in the Philippines" (a study prepared in the Historical Section, Army War College, Jun 1943), Appendix FF, Charles R, Greenleaf, "A Brief Statement of the Sanitary Work So Far Accomplished in the, Philippine Islands, and of the Present Shape of the Sanitary Administration," Papers and Reports of the American Public Health Association 27 (1901): 157; Van Hise, "American Contributions," pp. 15-17.
    15MacArthur Report, 1901, 2: 11-13; Greenleaf, "Statement on Sanitation," p. 160; RSG, 1901, p. 139.


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the rules but also befuddled and angered many Filipinos accustomed to Spanish informalities by refusing bribes. One English traveler described how older local residents "male and female, who from time immemorial had been accustomed to perform the offices of nature in any convenient spot in the public streets, now found that the continuance of such habits was a luxury which, pecuniarily speaking, they could no longer afford for even the most opulent would hardly care to pay a couple of dollars on each occasion." The visitor added that "the custom of emptying slops out of windows was also severely discountenanced, and one Spanish officer who happened to hit an American sentry in this way spent the night in the guardroom, and, in addition, had to pay a handsome fine in the morning."16

As a part of its cleanup campaign, the Army attempted to improve Manila's water system and public market. Since 97 percent of the residents drew their drinking water from the public hydrants, immediately after occupying Manila the Army restored that service. Nevertheless, military authorities still worried about the system's efficiency and safety, so they thoroughly cleansed the reservoirs, constantly checked for contamination, and continually sought to maximize pressure and minimize waste. In the case of Manila's "unsightly and malodorous" market, however, the Army decided simply to abandon it and construct a new one. Beginning in November 1899, the military government built a new market, a wonder of modern merchandising with corrugated roof with iron supports, a concrete slab floor, and water hydrants for washing the entire structure.17

Manila's may have been the most thorough of the Army's sanitary campaigns, but programs in Havana and San Juan were nearly as comprehensive. In both cities the Army cleaned streets and buildings and created district staffs to ensure the cleanliness of every house. Outside the three capitals, however, Army sanitarians exerted less influence, and their message never reached the majority of small villages. Even in the handful of provincial towns where they did work, Army officials provided less structured, less thorough aid than in the capitals.

In the village of Malabon, to cite another example from the Philippines, the Army found filth everywhere since residents worried little about the cleanliness of either their houses or the village. Hogs served as the town' s "official scavengers," but unfortunately the job exceeded their appetites.

    16Quotes from Younghusband, Round About, pp. 52-53. Van Hise, "American Contributions," p. 17; Karl I. Faust, Campaigning in the Philippines (San Francisco: Hiels-Judd Co., 1899), pp. 111-12.
    17Gates, Schoolbooks, p. 59. Quote from Van Hise, "American Contributions," p, 47. Van Hise contends the improvements to the market were more to increase rentals than to ensure sanitary conditions.


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In attempting to improve the situation, the local Army commander initially tried persuasion. He sent through the village a drum-beating crier accompanied by a soldier who delivered a speech on the people's responsibility to clean their homes. The citizens remained unpersuaded, conditions worsened, and the Army resorted to regimentation. The commander dismissed dirty people from their jobs in the market. He appointed a corporal as sanitary inspector who, with the assistance of two local civilians, examined all the houses in the village. The corporal fined householders between fifty cents and a dollar for a first, offense of uncleanliness and twice as much for the second. When fine collections lagged, the Army started to double the fine after twenty-four hours, threatened uncompliant citizens with prison, and finally employed soldiers, as collection agents.18

Combating Epidemics

Despite the mammoth cleanup of major cities and lesser efforts in some smaller ones, epidemics still struck. Smallpox threatened areas of all three countries. In the Philippines, bubonic plague broke out during the military government, as did cholera, after the assumption of authority by American civilians. In Cuba, yellow fever threatened throughout the first and second occupations. These outbreaks provided dramatic testimony to the limits of sanitation as a means of disease, control and prompted Army Medical Department civilian disaster assistance on a unprecedented scale. To provide relief, Army medical officers mobilized the newly created boards of health and utilized the latest medical knowledge. For smallpox and cholera that knowledge proved sufficient, but with plague an effective campaign was not devised until the, Army acted on a then unproven theory of the disease's transmission. In the case of yellow fever, another malady that still perplexed epidemiologists, the Medical Department itself achieved the break-through upon which an eradication program was then based.

Fortunately, the state of medical knowledge, rendered Army medical personnel best prepared to control the first type of epidemic they encountered- smallpox. In November 1898 an outbreak, occurred in the Holguin district of Cuba's Santiago province. The American military Governor sent the 2d Volunteer infantry, composed of troops who had been vaccinated and revaccinated and augmented by several additional medical officers, to the affected area. Still influenced by the conviction of

    18Ltr, A, Millard to W.A. Kobbé, 31 May 1899, William A. Kobbé Papers, Military History Institute (MHI). For variations in another town, see James Parker, The Old Army: Memories, 1872-1918 (Philadelphia: Dorrance & Co., 1929), pp. 351-52


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a close relationship between filth and disease, the troops cleaned and disinfected the more permanent towns and burned (until Wood ordered the practice discontinued) the thatched hut communities. The medical officers vaccinated 30,000 people and, aided by the Cubans who actually provided most of the patient care, administered a hospital that treated 1,185 cases of smallpox with only a 10.1 percent death rate. The Army's efforts continued into January but then the epidemic had passed and did not, recur.19

In Puerto Rico the Army encountered a more, widespread smallpox epidemic. The outbreak began in October 1898; by the next February the disease had struck more than 3,000 people in almost all parts of the island. Since it spread from the countryside to the city, Army medical officers had no choice but to attempt to vaccinate everyone in Puerto Rico. But several factors made such a comprehensive program extremely difficult. The disease already had a firm hold in many part's of the country, the climate favored its survival, a huge number of people had to be vaccinated, and the Americans could not count on popular support since most residents discounted the danger. To counter their opposition, the Army had limited sanitary authority and few medical men to marshal for the crusade. The available Army doctors, met severe difficulties in traveling because of poor roads, which also intensified the problem of supplying fresh vaccine to isolated parts of the island.

Undaunted, the chief surgeon of American forces, Maj. John Van R Hoff, in December 1898 convinced the military government to authorize a plan to vaccinate all adults who had not previously had the disease and all infants under six months. Although in name a civil program, the vaccination effort actually was, according to its director, Maj. Azel Ames, "organized and directed wholly by medical officers of the army." Ames, also a member of the Medical Corps, both supervised the program and directed its implementation in the region around Ponce. In the four other administrative divisions designated by Hoff, medical officers also headed the project. In addition, doctors at all American Army posts inspected operations in their area, and at many vaccination stations, Hospital Corps personnel acted as orderlies, assistants, and recorders. The vaccinators, however, were usually Puerto Ricans.20

With the Army furnishing much of his staff, Ames's major problem

    19Ltr, R.S. Woodson to Leonard Wood, 23 Nov 1898, in Hammilton V. Bail, "The Military Government of Cuba, 1898-1902" (a study prepared in the Historical Section, Army War College, 1943), Appendix, HH; RSG, 1899, p. 245; Leonard Wood, "The Military Government of Cuba," Annals of the American Academy of Political and Social Science 21 (1903): 55.
    20Quote from Azel Ames, "The Vaccination of Porto Rico: A Lesson to the World," Journal of the Association of Military Surgeons 12 (1903): 302.


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became securing adequate supplies of potent vaccine. Vaccine sent from the United States tended to lose its potency before it arrived in Puerto Rico. At Hoff's suggestion and with the governor's approval, Ames built a vaccine farm on a site near Coamo and stocked it with cattle donated by local farmers. Its operators experienced considerable difficulty getting lymph brought from the States to grow, but eventually the farm's cows produced sufficient quantities of vaccine.

Ames then had to ensure the continued potency of the vaccine during shipment from the farm to the vaccinators. To do so workers at the farm placed 500 vaccine points in absorbent cotton, put them in specially constructed shallow tin boxes, wrapped the boxes in more cotton followed by, oiled silk, and finally placed fifteen of the boxes in, a pannier. With two panniers slung across the backs of their horses, riders immediately set off for the division vaccination stations. At the five division stations other laborers divided the packets into units of 100 points, placed them in quadruple wrappings, and mailed them to the vaccinators.

Once it had devised a way to deliver vaccine, to the stations, the Army had to convince people to be vaccinated. To secure their cooperation, the Americans employed a shrewd blend of political savvy and administrative fiat. The Army obtained the support of the alcaldes de barrio, the Puerto Rican equivalent of ward heelers, who knew or at least were acquainted with all the people in their neighborhood. The officials in charge, of vaccination had these men compile a list of all residents in their precincts. Shortly before the time scheduled for vaccination, the officials notified the, local alcalde who in turn summoned 225 people from his list to report to the station, usually located in a nearby school. Army authority, however, reinforced the influence of the neighborhood leader, since Ames convinced the military government to issue a decree that prohibited employment of anyone without a vaccination certificate.

Under Ames's program nearly 860,000 people were, vaccinated at a moderate cost of about $30,000. The United States supplied half of that sum, with Puerto Rico contributing the other half. Most of the money was paid to local physicians who served as vaccinators; the remainder defrayed the cost of operating the stations. The benefits of the, expenditure and the Army's efforts were readily apparent. In the, nine years before the program began, an average of 621 people died each year from smallpox. In 1899, the program's first full year of operation, total deaths dropped to 242; from 1 January to 30 April 1900, no one died of smallpox in Puerto Rico.21

    21RSG, 1899, pp. 191-92, 246-248: RSW, 1900, vol. 1, part 13, Report of the Military Governor of Porto Rico, p. 153; Ames, "Vaccination of Porto Rico," pp, 293-313; Henry K. Carroll, Report on the Island of Porto Rico: Its Population, Civil Government, Commerce, Industries, Productions, Roads, Tariff, and Currency, with Recommendations (Washington: GPO, 1899), pp. 212-16.


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Though it employed a similar program, the Army had more limited success eliminating smallpox in the Philippines, where the disease "was so common among the natives that one met them walking in streets all broken out, with great sores on faces and hands." Almost immediately after the Army's arrival, a near epidemic broke out among American troops and Spanish prisoners in Manila. The task of eradicating smallpox in the city fell to Maj. Frank S. Bourns. Bourns, a volunteer officer serving in the Medical Corps, had been in the Philippines twice before as a civilian, spoke fluent Spanish as well as a few local dialects, and had many friends in Manila. Fortunate in its director, the American program also benefited from the, fact that the Spanish colonial government earlier had undertaken a token vaccination effort. Therefore, some residents understood the process, and a pool of trained vaccinators existed. In addition, Spanish officials had built a vaccine farm that Bourns rapidly reactivated to produce vaccine from native carabao calves. With the head start provided by Spanish efforts as well as Bourns's own political and organizational abilities, the Army rapidly vaccinated 80,000 people, preventing a major disaster. As a further precaution the Americans treated infected Filipinos in. a smallpox hospital opened in a local church.22

As the American Army subdued the rebels and gained control of other parts of the Philippines, it extended its efforts against, smallpox to additional areas. For a time, local garrison surgeons vaccinated limited numbers of Filipinos when epidemics threatened. Lt. Col. Louis M. Maus, chief surgeon in the Philippines, considered that approach too haphazard and secured the military governor's approval for a systematic, compulsory vaccination plan. For adequate supplies of vaccine, Maus at first depended on the farm Bourns had used but when production fell behind demand started a second farm and, still later, three more. For his corps of vaccinators he recruited and hired Filipino medical students, taught them the fundamentals of vaccination and sterilization, and sent them throughout the islands. Maus assigned his own Army medical officers to supervise the program in their towns and neighboring villages. They hired people to keep the records and ensured that the students properly vaccinated the populace.

The program began in February 1900, and by the end of 1901 a

    22Quote from Mrs. L.M. Maus, "Old Army Days." manuscript in Halstead-Maus Family Papers, MHI. Van Hise, "American Contributions," pp. 134-35; Worcester, Philippines, p. 333; Gates, Schoolbooks, pp. 58, 64-65.


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million people had been vaccinated. After the Army had vaccinated adults and children, however, it entrusted vaccination of the newborn to the Filipinos, who neglected it. Outbreaks of smallpox recurred, forcing the Philippine Commission in 1904 and again in 1910 to launch other Vaccination programs.23

At the height of their efforts against smallpox, occupation forces in the Philippines faced the added threat of an outbreak of bubonic plague. In December 1899, two residents of Manila died, apparently from plague. When additional cases developed in January, alarmed Army medical officers decided to take precautions. In all the districts of the city, they established offices with direct telephone lines to the Board of Health and because of personnel shortages staffed them with Army doctors who were awaiting transportation to the United States. Each doctor received notification of every illness or death in his district and, when notified, hurried to the scene to investigate. If he found someone dead from plague, he took the corpse to be cremated. If the victim was still alive but appeared to be suffering from plague, the doctor accompanied the patient to a special hospital in an ambulance maintained solely for that purpose. When he left, another inspector assumed charge in the house until a disinfection crew arrived. The victim's personal belongings were sterilized or burned. Other residents received disinfectant baths and then were sent to a detention center for observation. Finally, the crew thoroughly washed and disinfected the premises, closed and placarded the house, then returned daily for twelve days to inspect it. Occasionally, if cleaning proved too cumbersome, the crew simply demolished the house.24

These measures failed to eradicate the disease. In 1900 Manila reported 271 plague causes and 200 more than that the next year. Early in 1902, Colonel Maus, now detailed to serve as president of the Board of Health in the new civilian Philippine Commission, escalated the attack. He continued the district office operation but expanded hospital service and instituted an inoculation program. Since the original plague hospital at San Lazaro had only tents, the board moved it to an old Spanish hospital where an Army surgeon directed its operation. The detention center remained at a site near San Lazaro, but now people admitted to it were inoculated against plague as were others considered likely to have had contact with the disease. Maus secured most of the vaccine used in the

    23RSG, 1900, pp, 122-25; Greenleaf, "Statement On Sanitation," p. 159; Maus, "Old Army Days," passim; Van Hise, "American Contributions," pp. 135-30; Gates. Schoolbooks, p. 217; Victor G. Heiser, "A Note on Smallpox and Vaccination in the Philippine Islands," United States Public Health Reports 26 (1911): 495.
    24RSG 1901, pp. 139-40, 214-15, Greenleaf, "Statement on Sanitation," p. 161: MacArthur Report, 1900, 2: 9-12; 1901, 2: 17.


37

program from one of the world's leading authorities on plague, Professor Shibasaburo Kitasato of Tokyo, and produced the rest in a local government laboratory. In all, the board inoculated more than 100,000 people- though the process probably provided at best temporary immunity.

Maus's major innovation, however, was to declare total war on the city's rat population. The role of the rat flea as a carrier of plague was not proved until 1905 by the Indian Plague Commission, but some scientists already suspected that rodents were involved in the transmission of the disease. Realizing the failure of the methods attempted so far, Maus decided to act upon this theory. The Board of Health organized a civilian "rat-catching, corps" with forty uniformed members divided into squads. Each squad distributed poison every night and at the same time collected dead rats, caught living ones when it could, and performed spot disinfection. Not content to depend totally on its professional rat catchers, the board also paid bounties to citizens bringing the animals to stations conveniently located throughout the, city.

At the stations, sanitary workers tagged each rat with the street number where it had been found, dipped it in a strong antiseptic solution, and sent it to the biological laboratory. There a staff examined the animal for plague, and cremated it. Of the 75,000 rats examined by the laboratory, 4 percent were diseased. Sanitary inspectors quarantined buildings where plague carriers had been found and followed the disinfection procedures applied to houses of human plague victims. Initially, the board simply burned all thatched houses but later discontinued that practice in the face of strong public opposition. It continued, however, to force homeowners to whitewash walls, lay cement ground floors, or make other improvements to their residences.

Many people remained hostile to the program, especially since opponents of American rule made use of a few mistakes by poorly trained workers for propaganda purposes. Even some Spanish and Filipino doctors refused to participate in the plague work, although many others rendered most valuable service. Community cooperation improved, however, when Maus returned to the United States in July 1902 and Dr, Frank Bourns, at that time a civilian, succeeded him. Increased support resulted both from Bourn's skill at public relations and the success of earlier efforts. In 1902 Manila reported only three cases of plague. Unfortunately, attempts to quarantine, the city had failed, and the disease spread to the provinces, obliging the government to institute similar programs there. The sporadic cases in the hinterland, though, presented less danger than would outbreaks


38

in the capital, where American efforts had all but eliminated plague.25

A two-year cholera epidemic that followed the plague was even more frightful and deadly. Between 1902 and 1904, 4,386 people died in Manila alone, while another 105,075 succumbed in the provinces. "The burial forces were all too slow to keep pace with the swath cut by the grim reaper," reported one American, "and the bodies were laid in rows in the trenches, the earth covering just reaching the corpses of the latest victims being constantly brought up in carts only to be covered in turn by a few shovels of earth." The rapidity with which death followed the first symptoms of the illness intensified the anxiety of the living. The same American who watched the burials commented how fear increased when "a friend who might have been perfectly well at noon, was stricken ill by mid-afternoon, and died during the night."26

If cholera terrified the Americans, it left the Filipinos singularly unconcerned- which of course made combating the epidemic considerably more difficult. Political distrust, differing cultural values, and ignorance of sanitary principles caused many nationals to oppose American efforts. Since the epidemic occurred shortly after the end of the war with the insurgents, tensions and antagonisms remained which hostile Filipinos exploited to portray American sanitary efforts as attempts at genocide. Even people unswayed by such charges obstructed measures that conflicted with local practices. Some tried to hide the sick in the belief that everyone should remain at home to die; others surreptitiously buried the dead because the burning of corpses violated religious beliefs.27

But most of those who ignored orders designed to check the spread of cholera probably did so simply through ignorance of modern sanitation. People took few if any precautions to insure the purity of the food or water that could transmit cholera. Residents of Manila bought vegetables that had been "refrigerated" on the way to market by being hung from the stem of boats in a polluted river. When someone reported seeing a patron saint rising from a well, people flocked to draw their water there, convinced it could not possibly, be infected. It was. In another place, water "miraculously" broke through the ground; many interpreted the event as a sure sign of purity and avidly drank from a broken sewer line.28

    25 Third Annual Report of the Philippine Commission, 1902, part 1, pp. 265-73, 336-37. Maus, "Old Army Days"; clipping from San Francisco Chronicle: both in Halstead-Maus Papers, MHI.
    26Statistics from Worcester, Philippines p. 337. Quotes from W. Cameron Forbes, The Philippine Islands (Boston: Houghton Mifflin Co., 1928), 1:336. See also Richard Johnson, "My Life in the United States Army," p. 63, manuscript in the Richard Johnson Papers, MHI.
    27Worcester, Philippines, pp. 335-36; RGS, 1903, p. 82; Van Hise, "American Contributions," p. 105; James A. Le Roy, "Philippine Health Problems," Outlook 71 (1902): 780.
    28John M,, Banister, "Medical and Surgical Observations during a Three-Year Tour of Duty in the Philippines," Journal of the Association of Military Surgeons 18 (1906): 151-53.


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Without public support or popular awareness that cholera was a waterborne disease, with Filipino officials generally "apathetic" and "native doctors . . . proverbially as scarce as hen's teeth," officials of' the Philippine Commission, which now controlled the country, had few resources to battle the epidemic. They turned to the Army Medical Department for assistance. Unfortunately, the Army itself had a very limited number of medical men in the Philippines, so initially the government concentrated its scarce manpower in Manila.29

Cholera first broke out in the capital in late March 1902, and civilian health authorities at once asked the commander of American troops in the Philippines to patrol the Marikina River, the source of Manila's water supply. The commander dispatched patrols to prevent bathing, washing of animals, and dumping of sewage. At the same time, authorities closed Manila's wells and distributed distilled water throughout the city.

Health officials at first thought they could restrict the outbreak to the Farola district, one of the capital's worst slums, but quarantine of the section failed miserably. Since the overcrowded and filthy neighborhood defied sanitary improvement, the head of the Philippine Commission ordered it burned. Colonel Maus hesitated to destroy a whole neighborhood but, after being commanded to do so three times, complied. Just before setting fire to the area, the Army removed to a detention camp all residents who had not already fled. Maus's compassion had been wise since surely the neighborhood's water supply was the source of the disease. Burning Farola accomplished little, while it prompted many inhabitants to flee to other sections of Manila where additional cholera cases soon appeared.30

Patrols along the river, distribution of water, and other precautions continued. Faced with an expanding epidemic, authorities detailed 31 Army physicians with a force of 1,500 workers to conduct daily house-to-house inspections. They also disinfected and closed for five days the residence of every known cholera victim. People exposed to the disease were sent to a detention camp near San Lazaro capable of handling 2,500 inmates. When it quickly became overcrowded, authorities set up a tent camp all Santa Mesa. To care, for the increasing number of victims, officials operated two cholera hospitals, both under the command of one Army medical officer. Unfortunately, the Filipinos often dreaded the detention centers and hospitals even more than the plague and tried to

    29First quote from RSG, 1903, p.79; second from Johnson, "Life in the Army," p. 63.
    30Third Annual Report of the Philippine Commission, 1902, part 1, pp. 267-69; Van Hise, "American Contributions," pp. 101-3.


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escape being sent to them.31

In late summer, after conspicuous courting by the Americans, local cooperation improved. Bourns assumed direction of the program and established better relations with civilians. More important, authorities repaired physical facilities in the detention centers and served better food prepared according to local customs. The directors even began to allow inmates under observation to leave the facility during the day for work. Finally, the program received a valuable endorsement when members of a few prominent families entered cholera hospitals and recovered. With greater local support and the continuation of the Army's sanitation efforts, the scourge passed in Manila by February 1903.32

The epidemic, continued in the provinces, however. Manila authorities had tried to seal off the city, but residents resented restrictions on their travel and took little-known paths to other parts of the islands. Cholera quickly appeared in several provinces and, by the end of May 1902, in all the islands. Since the Filipinos did little to halt its spread, American health officials depended on the aid of Army surgeons serving with small garrisons stationed throughout the country. Headquarters, Division of the Philippines, appointed the garrison surgeons to the boards of health in their towns and made them responsible for public sanitation. They were to check the purity of both foodstuffs and water supply, to ensure the removal of garbage and the proper burial of the dead, and to keep neighboring streams free of fecal matter. If their precautionary measures failed and cholera appeared in their town, the order directed surgeons to establish a detention camp and send to it all persons who had contact with the disease. They were also to ensure that townspeople boiled all drinking water and that vegetables that could be eaten raw were not sold.33

In, most areas Army medical officers strove to comply with this rather demanding order. Many not only directed efforts in their own cities but also visited and established anticholera programs in nearby towns. As the epidemic waned in Manila, Army doctors were freed for assignment to the larger provincial towns, where they supervised sanitation or directed cholera hospitals. Reforms took effect slowly, and for a time the disease continued to spread. Eventually, though, Army and civilian efforts contained the epidemic, and on 27 April 1904 the Board of health declared the Philippines free from cholera. Though the crisis had passed, as late as 1906 the civilian government still requested the aid of Army surgeons in

    31Fifth Annual Report of the Philippine Commission, 1904, part 2, p. 116; RSG, 1902, pp. 80-81.
    32Worcester, Philippines, p. 336; LeRoy, "Health Problems," p. 780.
    33RSG, 1902, pp. 81-83; 1903, pp. 78-79. An original copy of the order is in the Wilkinson File, Spanish-American War Archive, MHI.


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containing outbreaks of cholera in a few localities.34

In Cuba, too, the fight against epidemic disease- in this case, yellow fever- continued, for several years, as total victory proved elusive. The Army's extensive sanitary efforts in Havana had left the city cleaner than ever before, but yellow fever still appeared there during the winter of 1900. In the spring, more cases developed, and that summer, yellow fever spread to other parts of the island. The recurrence of the disease despite improved sanitation, lamented Gen. Leonard Wood, who had become military governor of all of Cuba, "compelled those who looked beneath the surface to realize that the spread of yellow fever could not be controlled simply by cleaning and disinfecting methods." In Washington, Surgeon General George M. Sternberg shared Wood's conclusion and concern. On 24 May 1900, the Surgeon General established the Yellow Fever Commission in Cuba to study the etiology of the disease. Maj. Walter Reed headed the commission, which also included Army contract surgeons James Carroll, Jesse W, Lazear, and Aristides Agramonte.35

Well before the Yellow Fever Commission began its investigation, other medical researchers had begun to look, "beneath the surface." As early as 1881 Dr. Carlos Finlay had hypothesized that the mosquito carried yellow fever. Between 1894 and 1898, Sir Ronald Ross and Sir Patrick Manson had proved that anopheline mosquitoes transmitted malarial fevers. And in 1899, Henry Rose Carter showed that approximately fourteen days passed between the introduction of yellow fever into an area and the time that area became infective. Carter's findings together with Finlay's theory and the research on malaria suggested the mosquito as a possible intermediate host.

Impressed by this evidence, Reed quickly decided to focus the commission's research on the mosquito. Early tests, one of which accidentally resulted in Lazear's death, revealed that the bite of an infected mosquito caused yellow fever. In October 1900, Reed disclosed the preliminary findings in an address to the American Public Health Association. At about the same time, he asked Wood for $10,000 and authority to conduct a series of experiments to prove that: the mosquito was the vector. Wood readily agreed. The commission then established an isolated camp named for Lazear and staffed by two medical officers and eleven nonimmunes from the Hospital Corps.

    34RSG, 1903, pp. 80-85; Fifth Annual Report of the Philippine Commission, 1904, part 2, pp. 118-31; Van Hise, "American Contributions," p. 106; J.R. Hatheway, "Teachers and Cholera in the Philippines," Nation 77 (1903): 278-80, 297-99; Worcester, Philippines, p. 337; Ltr, George W. Jean to Adjutant, 10 Jul 06, George W. Jean Papers, MHI.
    35Quote from Wood, "Military Government," p. 169, See also Hagedorn, Wood, p. 242; Gibson, Soldier in White, p. 221.


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The doctors first placed two courageous Hospital Corps volunteers in a poorly ventilated cabin filled with clothing and bedding from yellow fever wards. Sometimes wearing shirts taken from victims, the volunteers spent twenty nights in the rooms without contracting the disease, thereby destroying theories that yellow fever was contagious. Then Reed and his colleagues built another hut enclosed and divided in half by wire screens. On one side,, the commission ensured sanitary conditions but introduced several infected mosquitoes. There, a volunteer who had, been isolated to prevent previous exposure, spent a few hours on two successive days. Bitten several times by the mosquitoes, he soon developed yellow fever. Meanwhile two other nonimmunes slept on the other side of the hut, protected from the insects by the screen, for eighteen days without becoming sick. Such controls demonstrated conclusively that the mosquito spread yellow fever. The commission continued its study of the etiology of the disease, but Reed reported its proof to the world in February 1901.36

Even before the experiments removed all doubt, the Army in Cuba had acted upon Reed's preliminary findings. On 15 October 1900, the chief surgeon of the Department of Western Cuba published a circular warning that mosquitoes might carry yellow fever and directed the use of kerosene to control them. One Army wife in Cuba wrote that "everybody is crazy about the mosquito theory, the garrison hardly talks of anything else, and they all take such an interest in killing the mosquitoes with kerosene there is scarcely one on the post." In December, Wood's headquarters also issued an order directing the destruction of mosquito larvae.37

When the commission proved that yellow fever resulted from the bite of a Stegomyia mosquito (later renamed Aedes aegypti) that had previously fed on someone with the disease, the Army escalated its efforts. Reports

    36 This brief account is based on Wood, "Military Govenment," pp. 168-73; speech delivered by Jefferson R. Kean at the dedication of the Walter Reed Memorial in Belroi, Va., in the Kean Papers, University of Virginia (UVA); Russell H. Fitzgibbon, Cuba and the United States, 1900-1935 (Menasha, Wis.: George Banta Publ. Co., 1935), pp. 40-42; Aristides Agramonte, "The Inside History of a Great Medical Discovery," Scientific Monthly 1 (1915): 209-37; Francis A Winter, "The Romantic Side of the Conquest of Yellow Fever," Military Surgeon 61 (1927), 438-52, Reed gave, a report on his experiments in RSG, 190l, pp. 176-202. For more information, see Howard A. Kelly, Walter Reed and Yellow Fever (New York: McClure, Phillips, & Co., l906); Albert E. Truby, Memoir of Walter Reed: The Yellow Fever Episode (New York: Paul B. Hoeber, 1943); and the Walter Reed/Yellow Fever Archive compiled by Philip S. Hench, now at UVA.
    37The use of kerosene to control the breeding of mosquitoes was well known to Army sanitarians through the work of L.O. Howard. See Ltr, L.O. Howard to Jefferson R. Kean, 1 May 24, and copy of Ltr to New York Times by Kean, 27 Apr 24. Both in the Kean Papers, UVA. Quote from Ltr, Louisa Kean to Mumsie, 9 November 1900, Walter Reed/Yellow Fever Archive, UVA. General Order No. 6, 21 December 1900, Headquarters Department of Cuba, copy in Kean Papers, UVA.


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of yellow fever were investigated everywhere, but since most Cubans were immune, areas with few foreigners were unlikely sites for epidemics. The real danger lay in Havana, where, a sizable nonimmune population almost disappeared in the, mobility and anonymity of its urban environment. If the Army hoped to eradicate yellow fever in Cuba, it first had to rid the capital of the disease.

In February 1901 the campaign in Havana began under the direction of Maj. William C. Gorgas of the Army Medical Corps. His eradication program exploited the peculiar habits of Stegomyia, which prefer to live near its human food supply and lay eggs only on the walls of water-filled containers. If all such vessels could be sealed or destroyed, Stegomyia would be eliminated and with it yellow fever. While Gorgas concentrated on eliminating breeding places, be also devised a strategy to kill all mosquitoes that had an opportunity to bite a yellow fever sufferer and a system to observe visitors to the city to see if they became sick.

To accomplish the first task, the mayor of Havana issued an ordinance that required all residents to make water containers mosquito-proof, and Gorgas designated one group of his mostly Cuban staff to ensure that they did. Gorgas divided the city into districts and assigned an inspector and assistant to each. Visiting every house monthly, they taught the principles of mosquito eradication and assisted the householders in complying with the ordinance. Rain barrels were covered with planks, leaving only a wire screen for the water to come through, and other containers were either completely covered or doused with kerosene. The inspectors fined householders who refused to take the necessary precautions, and, if on their next visit the owners still had not complied, emptied and destroyed all vessels in which mosquitoes could lay eggs. After each visit the inspector submitted a detailed report, from. which Gorgas's office staff compiled, a card file on all premises in Havana, listing the location of water barrels, jugs, and other containers.

Through frequent inspections and detailed records, the Americans drastically reduced available breeding places. During the first inspection of the city, every house had at least a few larvae, and officials found a total of 26,000 infractions of the ordinance. The last inspection before the Americans left Havana uncovered only 258 violations. As an added precaution, Gorgas had another group drain ditches and canals or cover them with oil if draining proved impractical. Such efforts reduced the mosquito population and helped curtail malaria but, since such places provided no surfaces for Stegomyia to lay eggs, did little to eliminate yellow fever.


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More important was the work of a, third group which Gorgas divided into crews for dispatch to the scene of any reported case of yellow fever. Within an hour of Gorgas's notification, a crew placed the victim under a specially designed isolation screen and allowed only a doctor and four or five immunes to enter. Then the crew killed the mosquitoes that had already had an opportunity to bite the victim. Its members sealed one, room of the victim's house by papering over the cracks, burned pyrethrum powder in it, and after the fumigation swept up and burned all the insects that had fallen to the floor. They repeated the process in each room of the house, with the patient's room treated last.

In addition to mosquito control, Gorgas sought to monitor the flow of nonimmunes into Havana. On the roads leading to the city, the government posted officials to whom all nonimmunes reported their names and destinations. The officials in turn, notified the city's Sanitary Department, which on the third and sixth days of the visitor's stay in Havana dispatched an inspector to the given address to ascertain that the nonimmune had not fallen ill. In the summer of 1901 the department tried to improve its information on the arrival of possible disease carriers or victims by establishing contact with individuals in neighboring towns who reported anyone visiting Havana.38

Killing mosquitoes, isolating patients, and monitoring the visits of nonimmunes brought quick results. During February 1901, the first month of Gorgas's program, only five people died from yellow fever. From Match through September, only six more deaths occurred, and in the nine months after that no one succumbed. Cuba, declared Wood, had been freed from yellow fever. To help insure that it stayed free, in 1902 the military government issued a, civil order creating a Superior Board of Health with a chief sanitary officer who served as its president. The board consisted of eleven members, four active and seven honorary, representing the different parts of the island. The order charged the board with the responsibility of monitoring and studying epidemics and developing and lobbying for necessary sanitary laws. But Wood still feared that once the Americans departed, health conditions would degenerate and again endanger American ports with yellow fever. He urged the Secretary of' War to require Cuba to continue the Army's sanitation efforts.39

    38William C, Gorgas "A Short Account of the Results of Mosquito Work in Havana, Cuba," Journal of The Association of Military Surgeons 12 (1903): 138-39; William C. Gorgas, "The Results of Yellow Fever sanitation in Havana, Cuba, for the Year 1901 Up to September 1st, Carried on upon the Basis That the Stegomyia Mosquito Is the Sole Means of Its Transmission," Papers and Reports of the American Public Health Association 27 (1901): 130- 33; Gorgas and Hendrick, Gorgas, pp. 110-34.
    39Fitzgibbon, Cuba and U.S., pp. 39-43; Wood, "Military Government," p. 171. On the creation of the board, see Jose A, Lopez del Valle, The Development of Sanitation and Charities in Cuba during the Last Sixteen Years (Havana: La Moderna Poesia, 1914), pp. 11-14. On Wood's influence on continuing the program, see Ltr, Leonard Wood to Elihu Root, 19 Feb 01, Elihu Root Papers, Library of Congress; and James Hitchman, "Leonard Wood and the Cuban Question, 1898-1902" (Ph.D. diss., University of California, Berkeley, 1965), pp. 280-81, 310.


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In the Platt Amendment, a resolution that set conditions for the transfer of power to the Cubans, Congress included a clause calling for the new Cuban government to continue the Army's sanitation program. But the clause accomplished nothing. Soon after the Americans left in May 1902, sanitary conditions drastically worsened, for the Cubans cared little about sanitation and rarely caught yellow fever. Moreover, their government lacked cash to finance programs, and the representatives from the eastern provinces and Pinar del Rio opposed spending what little there was for yellow fever control in Havana. The United States repeatedly remonstrated with the Cuban government for its negligence, but to no avail.40

In 1906 political and commercial considerations prompted the United States to intervene in Cuba once more. President Theodore Roosevelt sent an Army of Cuban Pacification but established a civil government headed by Charles E. Magoon to govern the island. Although Magoon's administration emphasized reform of Cuban laws and regeneration of its economy much more than health reform, it did include a Department of Sanitation as one of its five major administrative branches. Maj. Jefferson Randolph Kean, an Army Medical Corps officer, directed its operations.41

Kean was chosen because of his experience in Cuba during the previous intervention; he functioned more as a public health officer than as a soldier. In the daily administration of his department he worked both with Magoon and with the Cubans themselves. In time he reorganized the Sanitation Department and, serving only as an adviser, set policy which the Cuban civilians implemented. Kean did, however, have four Army surgeons assigned to the department and could request temporary assistance from medical officers serving with the, occupying troops in thirty towns. Especially in the yellow fever campaign, he often relied on these Army doctors in the more troublesome provinces or in areas with high visibility.42

Yellow fever was the primary health concern of American officials

    40Lopez, Development, p. 13; Fitzgibbon, Cuba and U.S., pp. 103-4; David A, Lockmiller, Magoon in Cuba: A History of the Second Intervention, 1906-1909 (Chapel Hill: University of North Carolina Press, 1938), pp. 22-24; Dana G. Munro, Intervention and Dollar Diplomacy in the Caribbean, 1900-1921 (Princeton: Princeton University Press, 1964), p. 36. Munro maintains that much of this agitation actually concerned contracts with American firms for public works projects, not genuine concern for Cuban sanitation.
    41Millett, Politics of Intervention, pp. 148-53, 191-208.
    42Ltr, Kean to Provisional Governor, 1 Dec. 08; Decree No, 70 Prepared for Magoon, 1 Nov 06; Ltr, Kean to Dr. Agostini, 14 Jul 08; Ltr, Kean to Ireland, 16 Jan 08. All in Kean Papers, UVA. On reorganization, see Millett, Politics of Intervention, pp. 208-12.


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during the second intervention, as it had been in the first. Kean designed his eradication program along the lines formulated by Gorgas, employing house-to-house inspections, mosquito-killing crews, and disinfection procedures. But he added a few variations of his own. Kean recruited Cuban physicians to report all suspicious cases and tightened control over nonimmunes by requiring travelers both to carry passes and to report to local health officials upon arrival in a new town. More important, because of the tenacity of the fever in rural areas, Kean extended the techniques used in Havana to more cities.43

Kean's regime also introduced one significant procedural innovation. Previously, mosquitoes had often escaped while workers, taped the rooms in preparation for fumigation. By a change initiated in 1907, disinfecting crews covered the house itself with canvas and fumigated all of it at once, killing more insects more rapidly. Early in 1908, Capt. Henry D. Thomason, a medical officer serving with Kean, further improved the process when he covered an entire city block for fumigation all at once. Kean considered Thomason's procedure the most efficient yet developed, and it became standard procedure despite a $14,000 expenditure for canvas.44

Even with the help of other Army surgeons and the new procedures, Kean still had "the Devil's own time with yellow fever." When scattered outbreaks continued, Kean attributed them to increased Spanish immigration, greater movement within the island because of an improved road system built by the American government, shortage of people to discover and report cases, and lack of men trained in disinfection. The island experienced an epidemic in 1907 and again in 1908. Both were contained, but final victory never came. In January 1909, just before the Americans withdrew from Cuba, Kean wrote, "My soul is heavy within me because of those two cases of yellow fever from San Luis."45

The deterioration of health conditions in Cuba between the two interventions as well as Kean's failure to completely eradicate yellow fever indicated that the Army was better able to provide immediate relief than to institute long-term reform. Medical work during the occupation of Vera Cruz, Mexico, from 23 April to 23 November 1914 conformed to the pattern. There, Army doctors encountered sanitary conditions and disease rates similar to those in Cuba or the Philippines. Though the Army

    43Memo for Dr. Frederick C. Meyer, Mar 07, in Kean Papers, UVA; RSG, 1909, pp. 135-36, Fitzgibbon, Cuba and U.S., p. 128; Ltr, Kean to Provisional Governor, 9 Apr 07, Kean Papers, UVA.
    44 Rpt, Kean to Magoon, 5 Oct 07; Ltr, Kean to Ireland, 10 Mar 08; Memo for the Provisional Governor, 18 May 08. All in Kean Papers, UVA.
    45 First quote from Ltr, Kean to Ireland, 16 Jan 08. Second quote from Ltr, Kean to Thomason, 2 Jan 09. Paper entitled only "Yellow Fever in Cuba." All in Kean Papers, UVA. Report of the Provisional Administration, 1906-1907, pp. 457-59; Millett, Politics of Intervention, pp. 209-10.


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undertook a smallpox vaccination program, Army medical officers never faced an epidemic and were able to concentrate their efforts on cleaning the city, establishing sanitary practices, and treating victims of a few prevalent local diseases. They had stellar success, but shortly after their withdrawal, conditions returned to what they had been before the Americans came.46

Army medical officers proved more effective in relieving crises than in reforming local practices for many reasons, but two were crucial. First, the two arms often conflicted, and the doctors' responsibility to protect the health of the troops left them no choice but to concentrate on the former. To prepare local citizens to assume responsibility for maintaining health standards required a slow, laborious process of conversion and education. But in an epidemic, medical officers did not have time and resorted to fiat or force which residents usually resented and rarely learned from. Second, the Army brought a scientific, organizational society to countries where cultural development remained in a much earlier state. The Army- or anyone else, for that matter- simply could not impose modern methods on premodern societies. Unfortunately, Army medical men were not sensitive to the problem and tended to decry native barbarism rather than to try to understand and respect local culture- an attitude that limited their effectiveness and that, unfortunately, recurred in later missions.

Nevertheless, in Puerto Rico, the Philippines, and especially Cuba, their overall accomplishment was brilliant. The Medical Department demonstrated to the, world the capability of scientific medicine and modern organization to control epidemic disease. Moreover, medical officers displayed an ability to render casualty care and furnish effective preventive measures during a health emergency. Their achievements thereby suggested the Army Medical Department's value in other types of disasters as well. More, than any other single factor, the Army doctors' success in the tropics transformed the role of Medical Department personnel in relief.

    46Robert E. Quirk, An Affair of Honor: Woodrow Wilson and the Occupation of Vera Cruz (Louisville: University of Kentucky Press, 1962); Henry P. Birmingham, "Sanitary Work of the Army at Vera Cruz," Military Surgeon 36 (1915) 205-21; Charles Jenkinson, "Vera Cruz: What American Occupation Has Meant to a Mexican Community," Survey 33 (7 Nov 14): 133-41