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PUBLIC HEALTH IN THE PHILIPPINES
When U.S. soldiers arrived in the Philippine Islands in 1898, they encountered another green hell, another hot and humid country seething with disease. Malaria-bearing mosquitoes haunted the jungles, and the drinking water and fruits and vegetables carried organisms that inflicted dysentery upon the careless or unsuspecting. The Spanish had been quickly defeated, and the victory left "the Philippine Islands, with their teeming millions of inhabitants, . . . on our hands . . . ," a physician noted in the Journal of the American Medical Association. The resistance of Filipinos to occupying U.S. forces made it necessary to keep American soldiers in this hostile environment, where they were exposed to all the afflictions from which the native population suffered. Thus Army surgeons in the Philippines, inspired both by what has been termed an effort to "bestow the spiritual and material blessings of [America's] exceptional society on the new possession" and by a new understanding of disease, took up a sweeping challenge. To meet it, they began to study the health problems of the country and to use both traditional approaches and new methods suggested by their research to lower the incidence of disease. Following the pattern set in Cuba, however, those conducting research in the Philippines did not manage the public health campaign that attempted to put their discoveries to practical use.1
Research and Disease Boards
Research into the diseases of the Philippines was conducted by members of two tropical disease boards (see Table), as well as by other medical officers in the islands working independently of the boards. Except for the period 1902-1906, the two boards served through 1914, with many medical officers rotating through them. Unlike the scientists who worked with Major Reed, the members of the Philippine Tropical Disease Board investigated a wide range of diseases and health problems, those that posed a significant threat to the civilian population as well as to the military and those of interest principally because of their exotic nature. Members often worked separately, submitting individual reports. In at least one instance they investigated a disease that affected large animals rather than human beings. Their discoveries were not as spectacular as those of the Reed board. The value of their work lay principally in the accumulation of information rather than in any single discovery. Most of their research took place in Manila, where until 1902 laboratory space and equipment were available at the First Reserve Hospital and later at the Manila Board of Health as well. After that date, both the Army's and the Board of
Source: Based on Vedder, "Synopsis," in Army Medical Bulletin and WD, ARofSG, 1900, p. 21. The first board functioned from 1899 to 1902 and the second board from 1906 to 1914. Except where indicated, all members of these boards were medical officers.
Health's facilities were replaced by the Bureau of Government Laboratories, where separate chemical and biological facilities were established, together with a serum institute to handle the manufacture of immunizing serums.2
Although the facilities were adequate, the heat and humidity of the tropics imposed a considerable handicap on the work of researchers from the United States. The mental concentration possible in a temperate climate was unattainable in the Philippines, and the speed with which cadavers deteriorated made it difficult to obtain uncontaminated cultures from them because of the "rich and varied" nature of the thriving "bacterial flora" of the area. When rinderpest, or cattle plague, became so prevalent in the islands that researchers had to resort to water buffalo for cultures requiring milk, contamination of the culture medium also became a significant problem.3
First among the researchers' concerns was dysentery, a historic enemy of military forces whose cause was still a subject of controversy. It precipitated so many diffi-
culties for the soldiers fighting the Filipino guerrillas that two of the first members of the Tropical Disease Board, contract surgeon Joseph J. Curry and Lt. Richard P. Strong,4 started investigating it as soon as they arrived in the Philippines late in 1899. Although, unlike some in the medical profession at the time, both physicians had accepted the fact that dysentery could be caused by either a bacterium or an amoeba, they found the disease puzzling. Curry's research added to the confusion, for it apparently led him to the erroneous conclusion that the organism now known as Entamoeba coli, one of six species of nondisease-causing intestinal amoebas that parasitize man, and the amoeba causing dysentery (Entamoeba histolytica) were essentially identical. Under these circumstances, he could not account for the fact that E. coli could be found in healthy men as well as in those suffering from dysentery. Curry correctly concluded that E. histolytica could be present in drinking water and developed statistics that suggested the extent of the threat posed by amebic dysentery, which he maintained was responsible for 66 percent of the deaths caused by dysentery in cases that he had autopsied.5
In spite of Curry's interest, Lieutenant Strong was the board member initially assigned responsibility for the study of dysentery, although he resigned on 5 December 1902 to continue his research for another eleven years as a civilian working for the Philippine government. Assisting Strong was a talented hospital steward, physician, and pathologist, William E. Musgrave, who would soon sign a contract with the Army Medical Department to work as a contract surgeon. The First Reserve Hospital,6 where Strong and Musgrave worked, offered the two scientists a rich field in which to conduct their research, since in the ten months preceding the submission of their 17 June 1900 report to the surgeon general, more than 1,300 patients, almost 15 percent of the total number, had dysentery. Fewer than 600 of those who survived the disease were able to return to duty, and 125 died. Postmortems on 111 cases established that 79 deaths resulted from amebic dysentery. Although Strong and Musgrave were able to isolate bacteria in 19 more postmortems, they inexplicably did not look for bacteria in 56 cases. They noted, however, that the bacillus they found resembled that first recorded by the Japanese scientist Kiyoshi Shiga.7
The great difficulty experienced by Lieutenant Strong and Musgrave in isolating and precisely identifying the organisms that caused dysentery is a problem still experienced by scientists more than seventy-five years later. Unlike Curry, Strong con-
cluded that E. histolytica was not identical with E. Coli,8 which he described as "apparently harmless." He held in 1910 that even though the incidence of bacillary dysentery was at that time increasing, amebic dysentery was "by far the commonest form of the disease met with in the Philippine Islands" and that many other organisms could also be involved, including the malaria parasite. Simon Flexner and Lewellys F. Barker, leaders of a civilian team of scientists who brought their own equipment with them from the Johns Hopkins medical school to join the study of diseases in the Philippines, also experienced great difficulty in determining which of the hordes of organisms in the specimens they examined actually caused the problem.9
While Lieutenant Strong and Musgrave were seeking to gain a greater understanding of dysentery in Manila, in the general hospital at the Presidio in San Francisco, to which many of their patients were sent, contract surgeon Charles Craig, reassigned after his work at Camp Thomas during the typhoid epidemic in 1898, was beginning the research concerning this disease to which he would devote much of the remainder of his distinguished career. Craig, who joined the Medical Department as a lieutenant in 1903, noted that in four cases of dysentery he found large numbers of "pear-shaped organisms, possessing a nucleus and from 2 to 8 slender, hair-like flagella, which propel the parasites. . . ." He referred to these protozoa as "Cercomonas intestinalis," but they are all too familiar to modern travelers and backpackers as Giardia lamblia. Although Craig had never seen them in healthy patients, he was not entirely sure of their role in dysentery and concluded that "they apparently thrive in a diseased intestine and probably cause diarrhea and perhaps ulceration." He was sure, however, that they "aggravated the intestinal condition." Craig's interest in the subject inspired him to years of research and the publication in 1911 of The Parasitic Amoebae of Man.10
In March 1906, when Surgeon General O'Reilly succeeded in having the Tropical Disease Board reconstituted on a permanent basis with Lieutenant Craig and Capt. Percy M. Ashburn as its members, these physicians continued the board's study of dysentery, as did their replacements, Lt. Henry J. Nichols and Capt. James M. Phalen. Nichols and Phalen decided that they could not with confidence distinguish between the two varieties of Amoeba and that therefore all amoebas should be considered potentially harmful. Lieutenant Strong's conclusions concerning the identity and harmlessness of the E. coli was later confirmed by work undertaken by other scientists working in the Philippines, although even ten years later the role of this organism was still not completely understood.11
Research into the question of the identity of dysentery-causing organisms in the Philippines continued for many years. Initially, work with the bacterial form of dysentery proved more fruitful than that with the amebic type. Attempts to infect monkeys with amebic dysentery generally failed, but the discovery that the medium used in studying typhoid also favored the growth of the Shigella organism made bacillary dysentery research much easier. The examination of stool specimens in the attempt to detect typhoid carriers also revealed the possibility that bacillary dysentery, too, could be spread by healthy carriers.12
Because of the prevalence of dysentery, doctors in the islands gained experience with many types of treatment. Although ipecacuanha (ipecac) was to some degree successful in the treatment of amebic
dysentery when carefully used, the fact that it was an emetic made it difficult for the patient to retain. Since in the Philippines men with dysentery often had malaria as well and since falciparum malaria could cause dysentery-like symptoms, quinine was also widely used. Because even ipecac did not kill all amoebas in every part of the body, the medical treatment of dysentery remained frustrating for doctor and patient alike.13
The liver abscesses that could result from amebiasis occupied the attention of medical officers in the various army hospitals scattered throughout the Philippines. Although nine of the sixteen cases upon which he operated died, Lt. Edward W. Pinkham was satisfied by the autopsy results that indicated death had been inevitable in eight of them. He also concluded that none of the cases would have survived without surgery and that the true reason for the opposition of physicians who were not surgeons to surgical treatment for liver abscesses was the intrusion upon their domain.14
Among other insect-borne diseases studied by the Tropical Disease Board in the Philippines was dengue, a problem with which medical officers in both the United States and the Caribbean had become familiar. Also known as breakbone fever, dengue, while rarely fatal, was both painful and debilitating. Brig. Gen. George H. Torney, O'Reilly's successor as surgeon general, reported that it caused a "small constant non-effective rate" among troops in the island, serving as "an inconvenience" rather than "a sanitary danger." When the Tropical Disease Board renewed its work in 1906, a dengue epidemic was sweeping the garrison of Fort McKinley, located on a low damp site near Manila, and the study of this disease quickly be-
came part of the board's responsibilities. The erratic pattern characteristic of its spread at that post quickly convinced Captain Ashburn and Lieutenant Craig that dengue was mosquito-borne, but much remained to be learned.15
To conduct their research into the causes of dengue, Captain Ashburn and Lieutenant Craig, like Major Reed, resorted to human guinea pigs, although, because the disease was as a rule not fatal, the risk to the volunteers in their experiments was not serious. When all four corpsmen who volunteered had contracted the disease from the initial experiments and had thus become immune, Ashburn and Craig turned to volunteers from the line, encouraging their altruism with $25 gold pieces and the promise of favorable assignments. Unable to find parasites in dengue patients, the medical officers resorted to injecting their blood into the volunteers. Upon discovering that, whether filtered or unfiltered, the blood transmitted the disease, they assumed that dengue, like yellow fever, was caused by an "ultra-microscopic" organism. They also concluded that the minimum incubation period for dengue was three days and that the disease was carried by the Culex fatigans mosquito. The latter conclusion proved to be in error, however, since the principal vector for dengue is Aedes aegypti, the insect that also carries yellow fever.16
Except for the attempt to discover more accurate means of diagnosis, malaria did not inspire as intense a research effort in the Philippines as might have been anticipated in view of the fact that the disease had afflicted so many soldiers through the years. In writing the history of the Army Medical Department some years later, Ashburn reported that almost 300 soldiers of every 1,000 in the Army in 1902 were suffering from malaria. In fiscal year 1900, when Craig was assigned as a contract surgeon to the general hospital in the Presidio at San Francisco, he noted that the blood of 13 percent of the patients entering that hospital showed evidence of malaria, in most cases the tertian form, caused by the vivax form of the malaria parasite and characterized by a fever that returns every third day. Craig was obviously most interested in learning more about the appearance, behavior, and life cycles of the various malaria parasites and was developing improved techniques to use in this effort. In the Philippines the work of the Tropical Disease Board along these lines was limited to the use of mosquito netting to determine the size of the mesh that would exclude the Anopheles.17
In 1900 the officers of the Tropical Disease Board found themselves investigating plague, yet another insect-borne disease in the Philippines, without being sure that it was, indeed, insect-borne. Although the organism that caused plague had been discovered in 1894 and physicians were aware of a connection between the disease and rodents, the precise means by which it was spread would remain in the realm of conjecture for several years longer. Even such an authority as zoologist Charles Stiles was still convinced as late as 1901 that if rat fleas did play a role in the spread of the plague, it was not by biting. At this time, with his usual caution, Surgeon General Sternberg avoided actually taking a stand on the subject.18
Lieutenant Strong, Curry, and Lt. William J. Calvert, who replaced Lt. Jere B. Clayton,19 began studying the dread disease in the laboratories of the First Reserve Hospital in Manila in the first months following the appearance of plague, moving to the facilities of the Manila Board of
Health as soon as the laboratories there were properly equipped. Curry was particularly intrigued, as the epidemic continued, by the fact that while the death rate among Filipinos was 81 percent, it was only 72 percent among the Chinese who, because of the impoverished circumstances in which they lived, might have been expected to have a higher mortality. Lieutenant Calvert, however, credited what he called "racial immunity" to lifestyle, including clothing and cleanliness, but somewhat paradoxically blamed the Chinese for the spread of plague, both through their persons and their merchandise. He noted that "poverty, poor food and dwellings, and ignorance" were the breeding grounds for the disease and that ignorance was the most important factor.20
Lieutenant Calvert based these conclusions upon his study of plague both in the Manila laboratory and in Japan and Hong Kong. In Manila he carried out physical examinations of plague victims, grew cultures that proved capable of killing laboratory rats in three to five days, and conducted autopsies. When he was sent to Japan and Hong Kong to study the way in which plague was handled in nations long familiar with the disease, he visited a serum farm near Tokyo, where an antitoxin was being prepared. This type of serum impressed Surgeon General Sternberg more than Lieutenant Strong, who worked for months without notable success to develop a more effective means of immunization. In 1901 Calvert prepared a circular on the subject of plague that was promptly issued by the surgeon general. In it he covered all aspects of the disease, its history, its symptoms, its pathology, the climates where it was most prevalent, the types of people it most often afflicted, and the means by which it was transmitted. Because he had observed that it could appear where no rats were present, Calvert concluded that plague could be spread in two ways. The bite of an infected flea transmitted the bubonic form, while the inhalation of germs present in bedding, feces, and urine, or coughed up by bubonic plague victims with pneumonia as a complication spread the pneumonic type, which was particularly fatal.21
Unlike bubonic plague, an object of interest and study for centuries and a swift and legendary killer, one of the diseases that drew the attention of the Tropical Disease Board was relatively unknown, especially in the United States. In the Philippines, however, beriberi, now known to result from thiamine deficiency, soon became familiar to medical officers who were responsible for the health of Filipino scouts. Heart problems, edema, nerve pain, difficulties with gait and vision, weakness, mental deterioration, and paralysis severely reduced the effectiveness of scout and police units and thus limited the support they could provide the Army in its struggle with the insurgents. Very few American soldiers ever suffered from this disease, but in Bilibid prison, where many captured guerrillas were held, beriberi sickened more than 2,000 prisoners in a six-month period in 1902 and caused 77 deaths.22
Although vitamins as such were still unknown in the early 1900s,23 physicians knew that a deficiency of certain elements in the diet could seriously undermine the health. Scurvy, however, had been placed in the category of a deficiency disease long before the members of the Tropical Disease Board were born, and in their initial uncertainty as to the cause of beriberi, Medical Department researchers could only speculate, as their predecessors had speculated about scurvy, about the effects of ex-
posure to dampness, or to the cold, or to wide temperature changes. They also considered the possibility that "germs . . . in the soil," polluted water, or malaria was at the root of the problem. In 1901 a medical officer maintained confidently that "diet had little to do with the propagation" of beriberi, which he believed was most probably spread by germs. Even as late as 1911 some were still not convinced, but diet was increasingly regarded as a possible factor. Many experiments with different diets established that those who ate unmilled rice (rice from which the hulls had not been removed) did not get this disease. Largely because of the efforts of the Tropical Disease Board and in spite of difficulties experienced in persuading the scouts to abandon their customary diet, beriberi had almost entirely disappeared from among the native troops by 1911, when only three cases were recorded.24
U.S. medical officers conducted much research into the possible causes of beriberi, initially using animal subjects. In 1911 Capt. Edward B. Vedder and Maj. Weston P. Chamberlain, who became members of the Tropical Disease Board in 1910, began experimenting with the treatment of infantile beriberi with an extract of rice polishings. Other physicians had already tried feeding the polishings to nursing mothers; believing the problem to be a poison in the mother's milk, they required that each baby be exclusively bottle-fed until the mother's treatment had been completed. Vedder and Chamberlain cured fifteen infants whose mothers had symptoms of beriberi by supplementing each mother's milk with an extract of rice polishings and allowing nursing to continue. In every case, regardless of the seriousness of the baby's condition, the cure was rapid and complete. The experiment
demonstrated conclusively that beriberi was a deficiency disease rather than the result of a toxin in the mother's milk. In 1913 Vedder capped his work in this field with the publication of a book on the subject.25
A disease familiar to Filipinos and far more familiar to medical officers than beriberi was cholera, which struck the Philippines in 1902. In the course of their research Army surgeons tried new approaches to both prevention and treatment; results were disastrous in one instance, when a bottle of bubonic plague serum was mixed in with bottles of a cholera serum destined to be tested as a vaccine on prisoners at Bilibid prison, and the ten men who received the plague serum died. Strong, who was working with the cholera serum now in a civilian capacity, had been reserved in his reaction to the preparation of cholera vaccine from the outset because of questions about its safety and his belief that years might be required to produce a strain of the organism sufficiently attenuated for safe use. By 1903 the Japanese had developed both a vaccine to prevent cholera and an antitoxin to treat it, and the results achieved in a few tests of the antitoxin impressed U.S. Army contract surgeons whose patients received it on an emergency basis when they fell ill on a transport. But it was initially not for sale and was hard to obtain. Although the work of the Japanese had promise, that of the Tropical Disease Board was of little, if any, practical value to those responsible for attempts to stem the cholera epidemic in the Philippines.26
Attempts to cure cholera by injecting a saline solution under the skin or into the veins were more successful. A medical officer in charge of two cholera hospitals in the Manila area not long after the start of the epidemic reported to Surgeon General Sternberg that he was using a normal salt solution by vein, having learned that "in collapse it gave the most gratifying results." Many patients, however, were apparently so near death at the time they arrived at the hospital where this treatment was used that nothing could save them. Two physicians reported using intravenous injections to save 80 percent of their cholera patients when cholera again became epidemic in 1908.27
Skin diseases also drew the attention of the Tropical Disease Board while Captain Phalen and Lieutenant Nichols were members. Yaws, caused by an organism similar to that responsible for syphilis, was no threat to U.S. soldiers, but the huge skin ulcers it caused in many Filipinos, especially children, were hard to ignore. Although Captain Ashburn and Lieutenant Craig confirmed the identity of the organism causing this disease, first revealed in 1905, Strong discovered in 1910 that it could be successfully treated with a drug newly found effective with syphilis, arsphenamine, a compound of arsenic. Fungal infections, however, were often difficult both to diagnose and to cure. In the hope of preventing this type of problem, the board encouraged experiment with different types of clothing to reduce excess sweating.28
Organizing the Campaign
While the officers of the Tropical Disease Board continued their work, the remaining Army surgeons joined the effort to reduce disease rates in the Philippines. As far as could be ascertained from studying Spanish records, the occupying U.S. troops had come to a land where death rates had been averaging 50 percent or more above those in many major cities in the United States and usually more than 30 per 1,000
per year even in non-epidemic years. The attempt to devise practical means to improve public health could not wait for the new discoveries that might be made by the medical officers who were conducting laboratory research. Knowledge of the specific organisms that caused specific diseases was not at this point as important as an awareness of the fact that, as historian Ken de Bevoise has put it, "poverty, crowded and unhygienic living conditions, and lack of education" were associated with the spread of many diseases, among them cholera, plague, dysentery, and smallpox. Medical officers leading the effort to improve public health in the Philippines would soon discover that the spread of disease was also related to "the gregarious nature of the culture," which "required that those stricken by disease be attended constantly by family and friends."29
The Philippines "presented nearly ideal conditions for the propagation of all infectious disease." "A cycle . . . in which poverty was reinforced by undereducation, malnutrition, and disease" was already well under way when the Americans first arrived. Years of conflict between Filipinos and Spanish, then between Spanish and Americans, and finally between Americans and Filipinos only exacerbated an already tragic situation. The deprivations and dislocations accompanying the armed struggle contributed to the spread of disease. As far as sanitation was concerned, Manila resembled a fifteenth-century European city. Reconcentration policies aimed at gathering Filipinos, into communities that the occupiers could more easily control favored the spread of disease, and the customary diet of polished rice favored high rates of beriberi. Many Filipinos were especially vulnerable to epidemics because their resistance had been undermined by such endemic problems as chronic malaria, amebic dysentery, tuberculosis, and hookworm infection. What de Bevoise has described as the Filipino "dysfunctional concepts of health and illness" still further complicated the situation. Cholera, malaria, the diarrhea-like illnesses, and tuberculosis caused the greatest number of deaths, which in 1902, the first postwar period for which reasonably accurate statistics could be obtained, reached an annual death rate of 63.3 per 1,000.30
For U.S. physicians newly arrived in the Philippines, the discovery that even well-to-do Filipinos were not impressed by the value of sanitation came as a shock. By 1900 U.S. cities generally required, one observer maintained, "garbage collection, sewage disposal, street sweeping, universal vaccination, the proper disposition of fecal matter." In Manila, on the other hand, Army medical officer Lt. Col. Louis M. Maus, who had arrived in the Philippines in December 1899 to serve as chief surgeon of the 2d Division, VIII Corps,31 reported in 1902 that "until quite recently some of the best houses . . . were provided with a seat on the second story, on the outside of the house, and the deposit allowed to drop in the yard below, where it was finally scraped up and carried away" Other homes were equipped with indoor latrines located in a tower at the top of the building, whence the waste fell through a hole into a pit. After a century or so of use, "a solid column of . . . decayed filth" accumulated. Rich and poor alike built latrines over waterways, usually "above low-water mark, [so that] when the tide is out, the deposits are left high and dry, . . . being exposed to the action of flies and other insects for from eight to twelve hours daily." The surface of the ground occupied by many of the poorer houses was so badly drained that, Maus noted, "during heavy rains the accumulation of filth and
garbage is floated out into the streets and deposited over the district, thus spreading the germs of disease far and wide." The challenge that faced Army surgeons attempting to improve public health was still further complicated by the fact that it was difficult to make even the need for soap and hot water apparent to natives who spoke a multitude of dialects.32
The main responsibility for the effort to improve public health in Manila was borne by U.S. Army medical officers or former medical officers from the time of the Spanish surrender in 1898 until 1904. The military government created a board of health, composed of six Army surgeons assisted by two Filipino physicians as honorary members, making it responsible to the provost marshal general for the city's public health. The campaign "of cleaning and sweeping, so characteristic of the American sanitarian," that the Manila Board of Health initiated, doing "what it could in the face of an overwhelming problem," was limited for the most part to the city of Manila. To facilitate the board's public health efforts, the chief of the its sanitary division, Lt. Harry L. Gilchrist, worked from January to April 1901 to conduct what was probably Manila's first accurate census.33
Shortly after taking over the government in July 1901, the new civilian Philippine Commission created a second board of health, officially the Board of Health for the Philippine Islands and the City of Manila,34 to monitor health in all of the Philippines, requiring it to function as the board of health for Manila as well. The first two commissioners of public health who ran this new board and its chief sanitary officer were, once again, Army medical officers.35 Regulations required that officers serving the civilian government resign from the military, but the Army skirted the problem by making serving under the Philippine Commission a duty assignment. Other Army surgeons and even, on at least one occasion, a hospital steward, were detailed from time to time to assist the new organization in dealing with its mission, which was principally "the prevention and suppression of diseases." A laboratory that slowly grew in size was initially established on a small scale and managed for the board by Tropical Disease Board member Lieutenant Calvert. Medical officers were permitted to work with the Philippine Board of Health without examination if the commissioner of public health recommended their exemption and his decision was approved by the Philippine Civil Service Board. The qualifications of all others who wished to practice medicine in the Philippines had to be established before a board that the commissioner appointed for the purpose.36
The responsibility for sanitation in each area of the countryside was initially borne by the military officers stationed there. The challenge involved was great, for, according to a surgeon stationed three years in the provinces, "the people had no faith in preventive or any other medicine and relied solely on nightly religious processions and on prayer, fighting all our efforts tooth and nail. . . ." In 1901, under the organization devised by the new civilian government, a network of subordinate boards assumed the responsibility for health in all parts of the provinces not under direct military control, supported by the Bureau of Government Laboratories in Manila with former medical officer Richard Strong, who was already gaining considerable prominence in the field of tropical medicine, at its head. The provincial boards that worked under the Philippine Board of Health were composed entirely of civilians and headed by local doc-
tors, for whom the board established a training course in Manila in 1903. U.S. Army surgeons could advise the local boards but could not serve on them as voting members. Large communities were also permitted to form their own municipal organizations, subordinate to the provincial board of health. Finding an adequate number of "sufficiently intelligent" citizens and qualified civilian physicians interested in serving in the field of public health was often difficult, although Filipino and Spanish doctors were numerous. If needed, physicians serving in the U.S. Army could still be sent out into the provinces to check on sanitation, epidemics among either humans or animals, and economic conditions, a practice favored by the Medical Department because the experience gave these physicians a greater opportunity to study disease and the conditions that contributed to its spread.37
The military role in public health began to wane when the Philippine Board of Health was replaced by a bureau of health in 1904. The eleven divisions of the new organization were apparently all headed by civilians under the Army medical officer who was briefly detailed to run it until replaced by a medical officer of the Public Health and Marine Hospital Service. Steps were under way to abandon provincial boards of health in favor of a system of district health officers. Although the Medical Department's dominance of public health efforts in the Philippine Islands was thus brought to an end, in some areas, post surgeons often continued to function as the health officer of communities near their stations.38
The challenge faced by those involved in the campaign to improve public health in the Philippines was formidable from the outset. Although accurate figures were not available until many months after the U.S. occupation began, a review of the death rates of Manila conducted by medical officers revealed a dismal picture. Available Spanish figures for the twenty years preceding the war did not separate the city's figures from those of the surrounding province, but the statistics for both areas ranged from a low of 28.8 deaths per 1,000 per year to a high of 63.1, with a fifteen-year average of 38 per 1,000. In 1900, 44.5 of every 1,000 inhabitants of Manila died. In 1901 the rate was 42.6, while in the first nine months of 1902, when cholera began to rage in the city, the annual death rate rose to 64.81 per 1,000. Infant deaths formed the major part of the toll, however, even in cholera years; convulsions from unspecified causes killed 2,038 childeren from 1 September 1902 to 1 September 1903, during a period when a total of 894 men, women, and children died of cholera and 789 from pulmonary tuberculosis.39
Many of the fatal diseases, whether they afflicted adults or infants, could be linked directly or indirectly to the garbage and human wastes decaying in the hot and humid streets and the overcrowding that characterized Manila. The challenge involved in attempting to clean up the city was made all the greater by the fact that, in the fall of 1898, when presumably disease and death rates were high, the Manila Board of Health lacked adequate funding, the city had no municipal government with which the board could work, and conditions were generally unsettled.
Sanitation seemed a logical approach to reducing the inroads of disease in the Philippines. In the United States, where epidemics of such filth diseases as cholera were a thing of the past, the benefits of improved sanitation had become apparent on an empiri-
cal basis even before germs were accepted as the cause of so many devastating epidemics. The Manila Board of Health established fines for those who relieved themselves in the streets or failed to correct problems that had been pointed out to them, as well as a system of inspections to detect violations of sanitary laws and supervise their elimination. The first inspection apparently came in response to the specific threat of bubonic plague, first diagnosed late in December 1899. Once plague had been identified, a team of a hundred inspectors, most of them medical students, was quickly gathered with the aid of the chief of police and sent out on house-to-house inspection tours throughout all of the city, except for the Chinese sections, where community leaders of a population of more than 51,000 ran the inspections. A surgeon of the U.S. Volunteers assumed responsibility for a cleanup campaign that involved poisoning rats and for such markedly less useful efforts as whitewashing homes inside and out. The Marine Hospital Service inspected all those leaving Manila to ensure that no one who was coming down with the disease went out into the provinces.40
Recognizing that plague was by no means the only serious danger to public health in the Philippines, the Philippine Board of Health continued to refine the system of sanitary inspections when it assumed responsibility for the city of Manila. The inspections were the responsibility of one of the board's members, Franklin A. Meacham, who had resigned from the Army to serve as chief sanitary inspector. The board gave Meacham an interpreter and appointed a chief inspector to serve under him. Also part of Meacham's team were sixty inspectors, ten of whom were Chinese, with the balance Filipino. Each of the ten districts into which Manila was now divided was served by a district inspector, who was assisted by three subdistrict inspectors, and by a medical officer, usually a contract surgeon awaiting transportation back to the United States, who became responsibe for public health.41
Repeated frustrations greeted efforts in Manila to reduce disease rates significantly. The Manila Board of Health started its work with little equipment, having neither ambulances nor wagons equipped to handle disinfection on a large scale. Native inspectors, accustomed to the ways of their people, had to be closely supervised by Americans lest they ignore the very failings they had been hired to report. Because there was no better alternative immediately available, for a time the board had no choice but to allow the use of drainage ditches as latrines to continue, consoling itself by the fact that the heavy rains of the wet season
A SEWAGE-CLOGGED DRAINAGE DITCH, used by Filipino vendors and families
would eventually flush them out. The most fundamental problem, however, was the fact that inadequate funding threatened the much needed permanent solutions to the city's health problems: the construction of a city sewage system; the establishment of a safe and ample water supply; and the cleaning of the sewage-clogged moats and drainage ditches that crisscrossed the city, the breeding grounds of multitudinous mosquitoes. The challenge remained when the Philippine Board of Health assumed responsibility for Manila. Within a few months, Meacham's unceasing efforts to improve the health of the city's population in the face of these frustrations had completely exhausted him. In April 1902 he succumbed to heart failure after refusing to leave his desk despite the fact that he was running a high fever.42
Even as late as 1907, only eighteen miles of the new sewer system had been completed. Long before this point, the lack of a modern sewage network in Manila had forced the Philippine Board of Health to resort to the Chinese night soil system for removing excrement. Pails were provided to each household for this purpose, and indoor toilets were required to be emptied and cleaned twice a week. The contents of the pails joined all other forms of human wastes and garbage on barges, which dumped their unattractive cargoes in the bay at a spot where the current flowed away from the land. Since even after the pail system had been installed, the sanitation in poor homes was defective, the board decided to begin establishing public latrines where attendants would be responsible for cleanliness day and night.43
Other steps taken to improve Manila's sanitation early in the U.S. occupation included drawing up a sanitary map of the city and sanitary plans of each dwelling in
it as part of the census done early in 1901, in order to facilitate the work of the inspectors. The Philippine Board of Health also resorted to the prosecution of a few wealthy landlords for putting too many tenants in the tenements they owned, a step that inspired noticeable improvement in conditions in many similar buildings. The selling of food by vendors in the streets was also strictly regulated, with netting required to keep flies from the items for sale and forks required to avoid the handling of food with bare hands. By the fall of 1903 the system of sanitary inspection was in full operation, even though the size of the inspection force had been cut by 75 percent in June of that year with the discharge of inspectors hired to help with the cholera epidemic. Almost 2 million homes were inspected or reinspected in the twelve months following 1 September 1902. As a result, more than 241,000 houses and almost 162,000 yards were cleaned, and more than 11,000 cesspools and similar sewage systems were emptied.44
Since Manila took its water from a river often contaminated by the urine and feces of the 20,000 people who lived along it, either directly or through rain water that washed wastes into the river, the poor sanitary habits of some Filipinos who lived upriver continued to threaten the city's drinking water. Keeping these people entirely away from its banks was impossible, for traditionally they washed both themselves and their clothing in it and watered their livestock there as well. Furthermore, since they did not live in the city, they were little interested in changing their habits for the benefit of those who did. The river was also polluted by as many as 15,000 people who lived on boats and used it as both laundry and latrine, even though it was their only source of drinking water. The boat people were so hostile to interference that on occasion they attempted to avoid attracting visits from inspectors by throwing the bodies of their cholera dead, suitably weighted, into the river. Even within the city itself, hundreds of bamboo huts lay close to the water, where the occupant, "his carabao and his pigs, his hens, and his family bathed and often drank in the same stream. The few dishes and pots he possessed, together with the family wardrobe, his dutiful wife habitually cleaned in this common water, and as it saved labor, the nearer the shack was to the stream the better; and so it very often was placed right in it."45
Relying on the city's wells, however, was not the answer to the problem of polluted water, since they were shallow and their openings so badly encased that the run-off from the city streets drained into them after every rain. Thus when cholera hit Manila in 1902, the Philippine Board of Health had no choice but to close all of the city's shallow wells and have a few new ones driven to a depth of 700-1,000 feet. It had distilling plants set up to produce 10,000 gallons of pure water a day, but since more extensive measures were clearly called for, the board also made long-range plans to dam the river between its source and the area where people had located their homes so that water could be piped thence around the sources of pollution and into the city. The building of this new water system was almost complete by the end of 1906. Medical officers also urged, but with only partial success, that public lavatories and laundries be established in areas along the river near where the boat people were anchored and that good water be piped to locations where they could easily use it. These measures would both improve their health and reduce the threat to the city's water supply.46
Manila's hospital system was particularly important when the rates of communicable diseases were so high among the indigent, yet in 1898 apparently only one public hospital, one of the Philippines' two facilities for lepers, existed in the capital. Work had been started on a new general hospital for patients with noncontagious diseases, but the building was never completed within the lifetime of the Manila Board of Health. High smallpox rates, resulting from the fact that compulsory vaccination laws had been ignored here as in other Spanish colonies, necessitated the hasty erection of tents-the only type of shelter that could be afforded-to serve as a "pest hospital." The Chinese community, which had its own hospital, built a facility for contagious diseases as well. By the end of 1901, however, barracks with a capacity for 3,500 beds had been constructed and divided into two hospitals, where patients with plague or cholera could be isolated. Late in 1901 an 80-bed hospital was created for civil servants and their families. Nevertheless, the shortage of hospital beds continued; in 1903 the Philippine Board of Health was both urging the creation of more beds for the insane and deploring the closing of two women's hospitals.47
Initially when cholera invaded the city in March 1902, hospital space was available for its victims. Even though cholera patients could be treated in their homes if the proper precautions were taken to prevent them from infecting others, the Philippine Board of Health was soon experiencing considerable difficulty in supplying beds for those who could not be kept in their own houses and in finding adequate space in which to isolate those who had come in contact with them. When the 100 beds set up at Santa Mesa, along with a detention camp for 6,000 contacts, proved to be so far from Manila that the trip caused the condition of the patients moved there to deteriorate, a third hospital was opened in the city. Here it shared space with a privately operated facility for the Spanish community in buildings that had housed the Second Reserve Hospital. Medical officers were in charge of both the facility at Santa Mesa and that in the Second Reserve buildings.48
In 1903, with the need for beds for cholera patients still great, a rapidly spreading fire destroyed both the cholera hospital in Manila and the detention facility set up nearby for suspected cases. The corral for the Philippine Board of Health's horses and the buildings of the pail collection system that handled the city's night soil were also burned down. Although its facilities had been heavily damaged, the board had tents and temporary latrines erected for those rendered homeless by the conflagration, thereby avoiding the marked rise in disease rates that might otherwise have been expected to follow a disastrous fire in such an overcrowded and unsanitary city. Fortunately, the board was given a large increase in funds for the fiscal year 1904.49
One of the motivating factors for the creation of the Manila Board of Health had been the customary conviction that the maintenance of public health required the isolation of lepers from the rest of the public. The facility for these unfortunates had a capacity of 150-200 beds, but U.S. medical officers initially estimated that as many as 30,000 of them remained unsegregated in the islands, a figure later lowered to 6,000. One of the first duties of the board, therefore, was to locate an island that could be developed into a leper colony. While the investigations necessary to deal with this problem were being made, the board had a door-to-door search conducted to ascer-
tain who and where in Manila the lepers were. This inspection, started in January 1900, revealed more than 100 unhospitalized victims of this horrible disease in the city. By 1904 Culion Island (see Map 4) had been chosen for the leper colony and work to establish the facility was well under way. The Philippine Bureau of Health appointed a former medical officer as the colony's first director.50
The Most Dangerous Threats
In addition to the struggle to limit the spread of disease through improved sanitation and to create facilities where those with contagious diseases could be isolated, U.S. medical officers directed considerable effort against specific epidemic diseases that threatened the Philippines. Smallpox was a concern from the moment of the Spanish surrender in August 1898. The Filipinos took the disease casually. On the island of Luzon (see Map 4) it was prevalent in every village, yet no attempts were made either to isolate the victim or to disinfect his home. Despite the immunization that was mandatory for U.S. troops, American soldiers occasionally acquired the disease from the Filipinos, making its eradication doubly desirable. The Manila Board of Health promptly initiated a campaign later described by Colonel Greenleaf, then the Army's chief medical officer in the islands, as "forcible vaccination and revaccination, where that was necessary" The effort was eventually extended to all inhabitants of the islands over the age of three months. Medical officers in the provinces received authority to hire Filipinos and to send them from door to door within the city to perform the actual vaccinations, with the proviso that they supervise the procedure and consult local authorities to ensure their cooperation. The success of the board's efforts in this instance was marked. In March 1899 smallpox deaths numbered 75 in Manila alone; from October 1899 through July 1900, however, the disease killed only 7 in that city. In the provinces, where local boards of health were responsible for the immunization program, the campaign against smallpox was not under way until February 1900 and was handicapped by the fact that the insurgents occasionally kidnapped the vaccinators. Despite these problems, in the twelve months preceding 1 September 1903 almost 1.2 million units of vaccine were used in the effort to eradicate smallpox in the Philippines.51
The Manila Board of Health supervised the preparation of the smallpox virus for all of the Philippine Islands, but when the long trip seemed to be reducing the effectiveness of the vaccine sent to some of the islands, vaccine farms were also set up in the Visayas and on Mindanao (see Map 4). In Manila the board established a vaccine institute to prepare both smallpox vaccine and any other serums that might be called for to immunize or treat other diseases of man and beast. As the campaign progressed into the provinces and grew in both magnitude and complexity, developing a formal organization under a chief of vaccination to manage all aspects of the immunization program became necessary. Nevertheless, despite the care exercised, all too often the smallpox vaccine proved to be ineffective; in 1905 less than half of those vaccinated earlier were determined to have actually been rendered immune. In 1904, however, when no deaths from smallpox occurred among those who had been vaccinated, the problem appeared to be under control.52
The Manila Board of Health had scarcely launched the campaign against smallpox before it found itself confronted with the plague epidemic. Although U.S. medical officers were experienced in dealing with smallpox and vaccination and could manage the problems of the campaign against that disease with confidence, they were much less familiar with plague. Believing that the rat might be in some way connected with its spread, the board included within the generalized campaign to clean up the city a specific plan to eliminate rats by trapping or poisoning them. These rodents were killed at the rate of 5,000 to 10,000 or more a month and as many as possible were examined in the laboratory to determine if they were infected. Strenuous efforts were also made to detect and isolate plague victims and those exposed to them and to disinfect their homes and possessions. Whenever possible, those who died from plague were cremated, but if their families had religious scruples against this method of disposing of infected bodies, the board had the coffins filled with disinfectants and quick lime.53
Although the incidence of plague in Manila in 1900 officially dropped from a high of 49 identified cases in March to 11 by May, these statistics were not all-inclusive, since an average of 40 to 80 Chinese were apparently dying of the disease each month without medical attendance. Even after the epidemic ended in Manila in 1902, it continued to haunt the rest of the Philippines. From 1 January 1900 to 1 September 1902, 772 cases were identified and 646 deaths noted. In the following year 198 cases and 166 deaths occurred. The rate continued to drop, with 94 cases and 87 deaths from 1 September 1903 to 1 September 1904 and another 24 cases and 23 deaths in the eight months from 1 September 1904 to 30 April 1905. Moreover, by July 1902, only three American soldiers had contracted the disease and the rates in other cities in the Far East were far worse than in Manila.54
After the outbreak of plague had lasted two years, the epidemic of cholera, like plague most often found in communities with poor sanitation, diverted the attention of the harried and harassed Philippine Board of Health. This disease inspired growing concern from the moment it was first diagnosed in Manila in March 1902. Once again, the board had no weapon but a more extensive effort to improve sanitation. Going beyond the attempt to create safe sources of water, it also forbade the sale of fruits and vegetables that could be eaten raw. In addition, inspectors made house-to-house visits within the city at all hours of the day and night to make sure that no case of cholera went undetected, and a quarantine was placed on the city to limit the spread of disease. But the natives of the island, including Filipino physicians, were not always cooperative. As one Army surgeon noted, the Filipinos tended to take alarm only at the appearance of some spectacular disaster and otherwise accepted suffering and death with "a curious indifference." The board could take some consolation in the fact that few Americans contracted the disease, and those who did were usually men who had "visited or lived with native women" or who had made the mistake of assuming that adding alcohol to water would make it safe to drink.55
In spite of the efforts of the Philippine Board of Health, cholera soon escaped from Manila into the countryside, where it was more difficult to control. At the request of the commissioner of public health, Colonel Maus, thirty-one medical
officers were detailed to assist him in dealing with the epidemic. The board also asked to have medical officers placed on the municipal boards of health of the towns where their posts were located. The campaign included requiring medical officers to form municipal boards where they did not exist, to prevent the pollution of streams, and to report all cases of cholera to their division chiefs. The Philippine Board of Health urged American school teachers serving on the municipal boards to educate Filipinos on the nature of cholera and the steps to take to avoid its spread. It also encouraged the appointment of American civilians as inspectors so that soldiers would be given this assignment only as a last resort.56
Superstitions about the source of the disease were more widespread in the provinces than in the city, and the efforts of military authorities to stem the epidemic in the countryside were often thwarted. The hundreds of posts throughout the islands became centers from which medical help was rendered to the surrounding populations, but the opposition to the work of medical officers in some areas was so strong that they were accused of causing the epidemic by poisoning the water. Maj. Charles E. Woodruff, an Army surgeon serving in the Philippines in the summer of 1902, believed that the Filipinos were unable "to understand such abstruse matters. To their mystic minds," he noted, "the disease is carried by the air, and even the most intelligent are so fatalistic that they believe if their time has come to die it is futile to try to ward it off." Moreover, a pamphlet first issued by the Spanish in 1888 that maintained that cholera was an air-borne disease was still in circulation, reaffirming popular belief on the subject and encouraging Filipinos in their refusal to abandon the customs and habits of generations to cooperate with a campaign against a water and insect-borne disease.57
Shallow and easily polluted wells were the ordinary source of drinking water in the provinces, and crops were fertilized with human excrement. Natives relieved both bladder and bowel in the immediate vicinity of their homes, further facilitating the spread of disease. The Army surgeon working in one community reported that "everywhere there were carabao wallows and other pools of stagnant water, where the amphibious Filipino motive power [the water buffalo] lies dormant the greater part of the time, sunken up to his nostrils in the muddy water." Natives instructed to dig drainage ditches piled the earth on either side of the trenches they had just dug, thereby preventing water from entering. Run-off carried cholera to the drinking water, uncooked vegetables added the disease to the food, and flies transported the infection from fields and yards to food, water, and dishes, both within the native villages and at Army camps nearby. Women laundered the soiled linen from the beds of cholera victims in the stream whence came their drinking water. Guards posted around the homes and villages of cholera victims to guarantee their isolation, vigorous efforts to disinfect the premises, and the use of smudge pots to drive away flies and other insects were of no avail to stem the tide of the epidemic.58
Even where the local population seemed "peaceably inclined toward" the Americans and "disposed to obey the laws without questioning them," a basic problem remained in the form of what one Army physician regarded as a "lack of energy, improvidence and inability to ad-
minister public affairs" on the part of the Filipinos. A Philippine Board of Health publication on the subject of cholera was apparently largely ignored, and the efforts of medical officers to protect the civilian population too often came to nothing. "It is perfectly useless," one medical officer reported, "for any health officer to attempt to check an epidemic unless he can rule with a rod of steel." Furthermore, he added, "orders ought not to emanate from a central bureau. The officer in immediate command must be able to control his own movement. A chief cannot understand conditions in a town he has never visited." Sending medical inspectors to afflicted areas seemed to help, but these physicians were too few to reach all communities. Thus, because the rod of steel could not be used, people "died just as they used to die years ago and will continue to die for years to come."59
On 27 April 1904 the epidemic was declared to be at an end. A total of 166,252 cases had been officially reported, of which 109,461 had resulted in death. Perhaps as many as a third more victims had not been reported. Thanks to the military discipline that guaranteed adherence to preventive measures, only 305 U.S. soldiers died of cholera, in addition to 81 Philippine Scouts (their formal designation as of 1901), for whose health Army surgeons were also responsible. Mortality was highest among Filipino victims, their death rate being more than 80 percent, while fewer than 49 percent of the Chinese patients died, less than 56 percent of the Europeans, and barely more than 47 percent of all the Americans in the islands. Almost 96 percent of the infants under one year contracting cholera died. Few Chinese, it was remarked, even came down with the disease, a fact that was credited to their custom of cooking almost all of their food and drinking principally tea. One medical officer also noted that cholera seemed to grow more virulent with the passage of time. Significantly, however, despite the pronouncement that the epidemic was at an end, cholera had not been eradicated from the Philippines. Although it apparently no longer inspired panic, in the twelve months ending 31 August 1904 it killed 423 residents of Manila alone.60
In waging such a vigorous campaign to save lives from cholera, Army surgeons were indirectly waging a campaign to prevent disaster to the local economy. So many farmers died or neglected their fields and animals because of the need to minister to their sick families that crops were neither cared for nor harvested at the proper time. This neglect came just at the time when two epizootic diseases of much interest to medical officers-rinderpest, which affected cattle; and surra, nearly always fatal to horses and spread by the bites of flies-were sweeping through the Philippines, in some areas killing as many as 90 percent of the cattle and water buffalo and 60-75 percent of the horses and ponies. The very quarantine laws that were aimed at preventing the spread of cholera brought internal trade to a standstill, thereby further depressing the Philippine economy. While the Tropical Disease Board began experiments to develop a serum against surra, the Philippine Board of Health, responsible for the health of animals as well as humans, launched a campaign to immunize cattle against rinderpest. Both time and money were required to reach any substantial proportion of the islands' livestock, but by the fall of 1903 the death rate from that disease had fallen from 90 percent to 3 percent.61
Other Health Problems
Particularly distressing to U.S. physicians in the Philippines was the mortality among infants, who suffered not only from epidemic diseases but from infections and an inadequate diet. Those under a year of age died at a rate twice that found in the United States, although the rate in the islands might be less than that found among the infants of black Americans, who were almost uniformly very poor and whose overall mortality could be double that of whites. The infant death rate was particularly appalling in Manila, where in the cholera year of 1902 three-fifths died before they were twelve months old. Throughout the islands the annual death rate that year among children under five years old was 141 per 1,000, at a time when the comparable rate in the United States was 52 per 1,000 and 131 per 1,000 among blacks.62
Filipino children died of all the other ills afflicting the population, but Army surgeons soon realized that superimposed over these causes were problems stemming from poor nutrition and lack of cleanliness. All too often, neither midwife nor physician attended the mother in childbirth, and tetanus resulting from a lack of proper care in handling the newborn's umbilical cord caused many deaths, perhaps as many as 30 percent of the total. Meningitis also contributed to the mortality. The infant who was breast-fed exclusively by a mother suffering from poor nutrition might also develop beriberi. No safe alternatives existed for a mother who could not produce enough milk herself, especially after rinderpest had killed many of the cows in the islands. Because refrigeration was not available to the poor, infants might be given sour milk, and since the mothers knew nothing of how to modify cow's milk to make it more closely resemble that of humans, their babies often did not do well even if it was otherwise safe. Diluting cow's milk with water from polluted sources spread disease to the hapless offspring. In the attempt to keep them from starving to death, mothers might also feed their infants solid foods in a form they could not possibly digest. Statistics were difficult to obtain. Only physicians could record deaths, but few Filipinos called for medical assistance. Required to cite a cause of death for infants for whom they had not cared, doctors tended to list "infantile convulsions."63
Realizing that a reduction in infant mortality depended on the education of the mother, the Philippine Board of Health prepared a bulletin on infant care and had it translated into all the main dialects of the Philippines and distributed throughout the islands. The board also hired eight midwives to help poor women in the city of Manila with their deliveries, hoping thereby to reduce infection in newborns and to educate mothers in the need for cleanliness. The death rate from convulsions in those under twelve months of age stayed high, however, and infant mortality in general remained a problem for years to come.64
Many of the health problems that attracted researchers received little or no attention from officers on the various boards of health. No real campaign was ever made against hookworm or beriberi during the boards' lifetime, although the research of the Tropical Disease Board would prove invaluable to the Public Health and Marine Hospital Service officers when they became responsible for public health. Medical officers were concerned about dysentery and typhoid, but their concern centered about these diseases as threats to the health of troops. Malaria was not as
great a problem for the native population as might have been anticipated, even though screening was not often used, apparently because the predominant species of Anopheles mosquito did not breed in the coastal areas where most Filipinos lived. Although tuberculosis caused many deaths among the Filipinos and medical officers blamed its spread at least in part on poor hygiene, no campaign was undertaken against this disease. Mental illness in the civilian population concerned doctors principally because the lack of hospital beds for its victims resulted in their being imprisoned at Bilibid.65
When the Army relinquished its leading role in the attempt to improve sanitation and to lower disease rates in the Philippines, the work on sewage and water systems initiated at the urging of the various boards of health was not yet complete. Although infant mortality fell to 20 per 1,000 in 1920, in the earliest years of the twentieth century it remained great, and overall death rates in Manila continued to vary as epidemics waxed and waned. The city was definitely cleaner because of the Army's efforts, but the death rate of the Filipinos continued both high and fluctuating. The role cultural factors played in the spread of disease was demonstrated by the contrast in mortality rates between the Filipinos and the Chinese, who cooperated with the fight against disease and whose customs lowered their exposure to cholera. Chinese disease rates in Manila, like those among Americans and Europeans there, dropped markedly and consistently in the period 1902-1905. In the year ending 31 August 1903, when the Chinese rate was 28.26 per 1,000, that of Manila's Filipinos was 43.42. A year later the Chinese rate was 21.85, the Filipino 53.72. The year ending 31 August 1905 saw a Chinese rate standing at 16.15, the Filipino at 44.54.66
Victory over rats and insects proved to be far more easily achieved than victory over the customs, traditions, ignorance, and superstitions of a people accustomed to accepting disease and death without a struggle. The work of the disease boards was important to the understanding of such diseases as beriberi, dysentery, and dengue, and a campaign to reduce drastically the rat population of Manila contributed to the defeat of the plague, but the effort to reduce disease rates by improving standards of sanitation met with almost constant frustration. Discovering that a diet based on polished rice led to beriberi proved easier than inducing the people endangered by beriberi to adopt an unfamiliar diet, and the end of the cholera threat, like the end of the insurrection, was achieved by proclamation rather than by vanquishing the enemy. Nevertheless, sufficient progress had been made by 1913 to lead an American observer to comment that Manila was, "except in the matter of infant mortality, . . . about as healthy a city as any of its size in the warmer part of America."67
1. First quotation from David J. Doherty, "Medicine and Disease in the Philippines," p. 1526; second quotation from Stanley Karnow, In Our Image, pp. 196-97. See also Louis M. Maus, "Military Sanitary Problems in the Philippine Islands," pp. 1-2, 11; Edward L. Munson, "The Civil Sanitary Function of the Army Medical Department in Territory Under Military Control," p. 273.
2. Unless otherwise indicated, data concerning the work of the Tropical Disease Boards is based on Edward B. Vedder, "A Synopsis of the Work of the Army Medical Research Boards in the Philippines," in Army Medical Bulletin, and Percy M. Ashburn, A History of the Medical Department of the United States Army; idem, "The Board for the Study of Tropical Diseases as They Occur in the Philippine Islands," pp. 298-301; Richard P. Strong, "The Bureau of Government Laboratories for the Philippine Islands," pp. 665-67; War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1900, p. 21, 1908, p. 99, 1912, p. 140, and 1915, p. 131 (hereafter cited as WD, ARofSG, date); William J. L. Lyster, "The Army Surgeon in the Philippines," p. 31.
3. Joseph J. Curry, "U.S. Army Pathological Laboratories in the Philippine Islands," p. 176. See also p. 175.
4. Strong joined the Army Medical Department in 1898 and was appointed to the Tropical Disease Board when it was created late in 1899. He fell ill, however, on 25 December and was apparently unable to work until February 1900. At this time, he directed the Army's pathology laboratory in the First Reserve Hospital in Manila and continued in this position when the facility was reconstituted as the Government Biology Laboratory. Strong resigned from the Army in 1902. As a civilian, he remained as head of the Government Biology Laboratory until his resignation in 1913. His reputation as an expert on tropical medicine continued to grow after he left the Philippines to teach tropical medicine at Harvard. See Curry, "U.S. Army," p. 176; Who's Who in America, 1910-1911, s.v. "Strong, Richard Pearson"; War Department, [Annual] Report of the Secretary of War, 1903, 6(pt.2):39-40 (hereafter cited as WD, ARofSW, date); idem, ARofSG, 1900, p. 109.
5. Joseph J. Curry, "Dysenteric Diseases in the Philippine Islands . . . ," pp. 177-78. Although both organisms are commonly referred to as E. coli, Entamoeba coli should not be confused with Escherichia coli, which, unlike Entamoeba coli, does have pathogenic strains-in other words, strains that cause illness.
6. The First Reserve Hospital is discussed in Chapter 8.
7. WD, ARofSG, 1900, pp. 245-46, 251, 273; Curry, "U.S. Army," p. 176; Who's Who, 1910-1911, s.v. "Strong, R. P."
8. Entamoeba histolytica was then known as Amoeba dysenteriae and Entamoeba coli as Amoeba coli.
9. WD, ARofSG, 1900, pp. 246, 261, 267-68, 270-71, 273, 1901, p. 205 (first quotation), and 1909, p. 96; Richard S. Strong, "Tropical Medicine," p. 9 (second quotation); "Pseudo-outbreak of Intestinal Amebiasis," p. 1861; Curry, "U.S. Army," p. 175; Simon Flexner, "On the Etiology of Tropical Dysentery," pp. 415-17, 424; idem, "Bacillary Dysentery," p. 219; Charles F. Mason, "Bacillary Dysentery (Shiga)," pp. 242-43; Simon Flexner and L. F. Barker, "The Prevalent Diseases in the Philippines," pp. 525-26; Esmond R. Long, A History of American Pathology, pp. 153, 158-59, 413-14n5.
10. WD, ARofSG, 1900, pp. 66 (quotations), 67-71, 246, 250; Charles F. Craig, "Observations Upon the Amoebae Coli and Their Staining Reaction," p. 415; idem, "The Pathology of Chronic Specific Dysentery," pp. 353, 376, 378; idem, The Parasitic Amoebae of Man; Martha L. Sternberg, George Miller Sternberg, p. 210; Edward B. Vedder, "An Examination of the Stools of 100 Healthy Individuals . . . ," p. 872.
11. WD, ARofSG, 1906, p.130, 1907, pp. 40-41, and 1908, p. 98; James M. Phalen and Henry J. Nichols, "Tropical Diseases in the Philippines," p. 467; Ernest L. Walker, "Experimental Entamoebic Dysentery," pp. 254, 325.
12. WD, ARofSG, 1912, pp. 144-45, and 1913, pp. 131-32; Henry J. Nichols and James M. Phalen, "The Work of the Board for the Study of Tropical Diseases in the Philippines," p. 368; James M.
Phalen and E. D. Kilbourne, "The Bacteriology of an Epidemic of Bacillary Dysentery," pp. 433, 435-42.
13. "The Treatment of Acute Dysentery," p. 281; Gilbert E. Seamen, "Some Observations of a Medical Officer in the Philippines," p. 184; Richard P. Strong, Stitt's Diagnosis, Prevention and Treatment of Tropical Diseases, 1:72, 453; WD, ARofSG, 1900, p. 114, 1901, p. 204, 1904, pp. 87-89, and 1911, pp. 144-45; Alfred Alexander Woodhull, "The Value of Ipecac in Dysentery," p. 223; Henry I. Raymond, "Ipecacuanha in Amebic Dysentery," p. 46.
14. Edward W. Pinkham, "Tropical Abscess of the Liver," p. 309. See also pp. 312, 314, 316. This article was published posthumously.
15. WD, ARofSG, 1910, p. 96 (quotations); Percy M. Ashburn and Charles F. Craig, "Experimental Investigations Regarding the Etiology of Dengue . . . ," pp. 97, 102.
16. Percy M. Ashburn and Charles F. Craig, "Study of Tropical Diseases in the Philippine Islands," pp. 692-93; idem, "Experimental Investigations," pp. 102, 105, 123 (quotation), 136; Charles F. Craig, "On the Nature of the Virus of Yellow Fever, Dengue, and Pappataic Fever," pp. 363-65; Joseph F. Siler, M. W. Hall, and A. P. Hitchens, "Results Obtained in the Transmission of Dengue Fever," pp. 1163; WD, ARofSG, 1907, p. 41, and 1910, p. 96.
17. WD, ARofSG, 1899, pp. 289-90, 1900, pp. 53-60, 235, 1911, p. 145, and 1912, p. 147; Curry, "U.S. Army," p. 176; Frederick F. Russell, "The Results of Two Seasons Anti-malarial Work," p. 161.
18. WD, ARofSG, 1900, pp. 210-12; George M. Sternberg, "The History and Etiology of Bubonic Plague," p. 813; "The Mode of Spreading of Bubonic Pest," p. 1372; Arthur H. Moorhead, "Plague in India," p. 167; Charles W. Stiles, "Insects as Disseminators of Disease," p. 7; H. Harold Scott, A History of Tropical Medicine, 2:733, 735.
19. Clayton left the Tropical Disease Board soon after his appointment in 1899.
20. Quotations from William J. Calvert, "Plague in the Orient," pp. 60, 63. See also Joseph J. Curry, "Bubonic Plague," p. 278; idem, "U.S. Army," pp. 175-76.
21. WD, ARofSG, 1900, pp. 218-20, and 1901, pp. 202, 219-34; Sternberg, "History," pp. 813-14; Richard P. Strong, "Studies in Plague Immunity," pp. 157-59, 302, 324-27, 329; Charles F. Craig, "The Bubonic Plague From a Sanitary Standpoint," pp. 586-87.
22. WD, ARofSG, 1901, p. 236, 1903, p. 69, and 1911, p. 129; Richard H. Follis, Jr., "Cellular Pathology and the Development of the Deficiency Disease Concept," p. 295.
23. The term vitamine was introduced in 1911 by biochemist Casimir Funk, who in the course of his research into the cause of beriberi concluded that the necessary factors in the diet were all amine derivatives. See Henry A. Skinner, The Origin of Medical Terms, p. 365.
24. WD, ARofSG, 1901, pp. 237, 239 (first quotation), 1902, pp. 100 (second quotation), 101, 1903, pp. 69-70, 1905, p. 52, 1910, pp. 120-21, 1911, pp. 128, 130, 132, and 1912, pp. 130, 138; Rpt, Harry A. Littlefield, 1 May 1902, Ms 5000, Entry 52, Record Group (RG) 112, National Archives and Records Administration (NARA), Washington, D. C.; Weston P. Chamberlain, Horace D. Bloombergh, and Edward B. Vedder, "Report of the U.S. Army Board for the Study of Tropical Diseases as They Exist in the Philippine Islands," p. 446; Weston P. Chamberlain, "The Disappearance of Beriberi From the Philippine (Native) Scouts," pp. 514-15; Weston P. Chamberlain and Edward B. Vedder, "The Cure of Infantile Beriberi by the Administration to the Infant of an Extract of Rice Polishings. . . ," p. 30.
25. Chamberlain and Vedder, "Infantile Beriberi," pp. 26-27, 29; Scott, History, 2:892; Edward B. Vedder, Beriberi, pp. 257, 264; Edward B. Vedder and Robert R. Williams, "Concerning the Beriberi-preventing Substances or Vitamines Contained in Rice Polishings," p. 194; Robert R. Williams and N. M. Saleeby, "Experimental Treatment of Human Beriberi With Constituents of Rice Polishings," p. 118.
26. United States, Bureau of the Census, Census of the Philippine Islands. . . , 1:323 (hereafter cited as Philippine Census); WD, ARofSG, 1903, pp. 96-97; idem, ARofSW, 1902, 10(pt.1):359, 384, and 1906, 1:80-82; Richard P. Strong, "Vaccination Against Plague," p. 190; idem, "The Investigations Carried on by the Biological Laboratory in Relation to the Suppression of the Recent Cholera Outbreak in Manila," pp. 437-38. See also Kristine A. Campbell, "Knots in the Fabric," pp. 600-38.
27. WD, ARofSG, 1902, pp. 81 (quotation), 92; Henry J. Nichols and Vernon L. Andrews, "The Treatment of Asiatic Cholera During the Recent Epidemic," pp. 81, 91.
28. James M. Phalen and Henry J. Nichols, "Blastomycosis of the Skin in the Philippines," pp. 280-81, 285, 288, 292; idem, "The Work of the Board for the Study of Tropical Diseases in the Philippines," p. 467; WD, ARofSG, 1907, p. 41, 1908, p. 99, 1911, pp. 122, 141-42, and 1912, p. 140; Weston P. Cham-
berlain, Horace D. Bloombergh, and Edwin D. Kilbourne, "Report of the Board for the Study of Tropical Diseases in the Philippine Islands, Quarter Ending Sept. 30, 1910," p. 195; Nichols and Phalen, "Work of the Board," p. 370; Percy M. Ashburn and Charles F. Craig, "Observations Upon Treponema Pertinuis Castellani of Yaws and the Experimental Production of the Disease in Monkeys," pp. 443, 463; William E. Musgrave and M. T. Clegg, "The Etiology of Mycetoma," p. 499.
29. Ken de Bevoise, "Until God Knows When," p. 160 (quotations); Philippine Census, 3:17; John Duffy, The Sanitarians, pp. 146-47.
30. Bevoise, "Until," pp. 149 (second quotation), 150-54, 159-60 (first quotation); idem, "The Compromised Hosts," Ph.D. diss., pp. iv-v (third quotation), 280-81, 285; Philippine Census, 3:10, 23-24, 38-39; Reynaldo C. Ileto, "Cholera and the Origins of the American Sanitary Order in the Philippines," in Imperial Medicine and Indigenous Societies, pp. 128, 130-31, 140; Jose P. Bantug, A Short History of Medicine in the Philippines During the Spanish Regime, 1565-1898, pp. 26, 35-37, 70, 76, 109; William T. Sexton, Soldiers in the Philippines, p. 33.
31. Maus held the permanent rank of major when he arrived in the Philippines and later received his promotion to lieutenant colonel on 7 April 1902.
32. Frederick Chamberlin, The Philippine Problem, 1898-1913, pp. 116-17 (first quotation); WD, ARofSW, 1902, 10(pt.1):330 (second quotation), 371 (fourth quotation), 329 (fifth quotation), 1904, 12(pt.2):89, and 1907, 9(pt.3):281-82; G. J. Younghusband, The Philippines and Round About (New York: Macmillan Co., 1899), pp. 53-54, cited in Gaines M. Foster, The Demands of Humanity, p. 29 (third quotation); William T. Sexton, The Soldiers in the Sun, pp. 51-52, 104-05; Maus, "Military Sanitary Problems," p. 5; Duffy, Sanitarians, pp. 175, 178, 190, 199; Victor G. Heiser, "Unsolved Health Problems Peculiar to the Philippines," p. 171.
33. Victor G. Heiser, An American Doctor's Odyssey, p. 60 (quotations); Regulations of the Army of the United States, 1895, p. 11 (hereafter cited as Army Regulations, date). Maj. Frank S. Bourns of the U.S. Volunteers was the first president of the Manila Board of Health. He was succeeded on 28 August 1899 by Maj. Guy L. Edie, also of the U.S. Volunteers, who was followed in this office by Maj. Franklin A. Meacham, U.S. Volunteers. See WD, ARofSG, 1899, p. 119, 1900, p. 99, and 1901, p. 138.
34. This board will be referred to as the Philippine Board of Health to distinguish it from its predecessor, the Manila Board of Health.
35. Major Maus was detailed to serve as the first commissioner of public health for the Philippines on 26 July 1901. He was succeeded in 1902 by Maj. Edward C. Carter, U.S. Volunteers. The first chief health inspector was Major Meacham. His successor in April 1902 was Major Bourns, who resigned two months later. The position of chief health inspector was apparently vacant until September, when T. R. Marshall, presumably a civilian, became chief health inspector. See WD, ARofSW, 1902, 10(pt.1):310, and 1903, 6(pt.2):136, 143.
36. WD, ARofSG, 1900, p. 99, 1901, pp. 138, 141, and 1902, p. 46; idem, ARofSW, 1900, l(pt.10):283-84, 1902, 10(pt.1):261-62, 274, 309-10, 1903, 6(pt.2):66 and 8:9, 111, 567, 596, and 1904, 11:75-77 and 12(pt.2):83 (quotations); Army Regulations, 1901, p. 12; Digest of Opinions of the Judge Advocate General of the Army, 1912-1940, p. 115; Paul C. Freer, "Plague and Late Cholera Epidemic in the Philippine Islands," p. 346; Charles R. Greenleaf, "A Brief Statement of the Sanitary Work So Far Accomplished in the Philippine Islands . . . ," p. 159; Louis H. Fales, "The American Physician in the Philippine Civil Service," p. 515.
37. Wilfrid Turnbull, "Reminiscences of an Army Surgeon in Cuba and the Philippines," p. 48 (first quotation); WD, ARofSG, 1902, p. 46 (second quotation); idem, ARofSW, 1902, 2(pt.1):290a, 10(pt.1):263, 356, and 11:69-72, 1903, 6(pt.2):116-18, 1904, 12(pt.2):84, 134, and 1907, 9(pt.3):280; Samuel O. L. Potter, "Notes on the Philippines," p. 805; Fales, "American Physician," pp. 513-14, 516-17,
38. WD, ARofSW, 1904, 12(pt.2):132 and 14:406, 1905, 11(pt.2):63, 66-67, and 1907, 8(pt.2):96, 110; idem, ARofSG, 1911, pp. 104-05; John M. Gates, Schoolbooks and Krags, p. 59.
39. WD, ARofSW, 1903, 6(pt.2):68-70; idem, ARofSG, 1899, pp. 119, 135-36, and 1900, p. 99; Sexton, Soldiers in the Philippines, pp. 29-30, 33, 38; Philippine Census, 3:74.
40. Foster, Demands of Humanity, pp. 29-30; WD, ARofSG, 1900, l(pt.10):285, and 1901, l(pt.9):381-82; Greenleaf, "Brief Statement," p. 162; Richard H. Shryock, Medicine in America, pp. 126-27, 129-32, 138.
41. WD, ARofSW, 1902, 10(pt. 1):261, 272.
42. Ibid., pp. 262, 272, 274, and 1903, 6(pt.2):79, 81; idem, ARofSG, 1899, pp. 135-36, and 1901, p. 139; Sexton, Soldiers in the Sun, p. 56; Freer, "Plague," p. 346; Greenleaf, "Brief Statement," p. 161.
43. Sexton, Soldiers in the Sun, pp. 56, 59-60; WD, ARofSW, 1903, 6(pt.2):86-87 and 8:49, and 1907, 9(pt.3):285.
44. WD, ARofSG, 1901, pp. 138-39; idem, ARofSW, 1903, 6(pt.2):66-67, 74, 82-83, 93, 104, 137.
45. Maus, "Military Sanitary Problems," p.14; WD, ARofSW, 1903, 6(pt.2):75, 77, 91-92; Chamberlin, Philippine Problem, pp. 22-23 (quotation), 24-25.
46. WD, ARofSW, 1903, 6(pt.2):74, 76-77, 91-92, 1904, 12(pt.2):90, and 1907, 9(pt.3):284-85; idem, ARofSG, 1903, p. 44.
47. WD, ARofSW, 1900, l(pt.10):285 (quotation), 1902, 10(pt.1):277-78, 1903, 6(pt.2):96-97, 1904, 12(pt.2):150 and 13(pt.3):733, and 1905, 11(pt.2):94; idem, ARofSG, 1900, p. 215; Gates, Schoolbooks, pp. 57-58; Sexton, Soldiers in the Sun, pp. 55-56; Frank S. Bourns, "Some Notes on the Philippines," pp. 732-33; Freer, "Plague," pp. 346-47; Harry Morell, "A Brief Description of the Hospitals of Manila, With a Few Notes on the Plague," p. 261; Bevoise, "Until," pp. 155, 158.
48. WD, ARofSW, 1902, 10(pt. 1):264, 343-44.
49. Ibid., pp. 277-78, 1903, 6(pt.2):96-97, 101-02, 1904, 12(pt.2):150 and 13(pt.3):733, and 1905, 11(pt.2):94.
50. Ibid., 1900, l(pt.10):284, 1902, 10(pt.1):411, 1903, 6(pt.2):111, 1904,12(pt.2):94, and 1905, 11(pt.2):75; idem, ARofSG, 1900, pp. 100-101, 106, and 1901, pp. 140, 240-41; "Medical News," p. 437; Sexton, Soldiers in the Sun, pp. 55-56.
51. WD, ARofSW, 1900, l(pt.10):284, and 1903, 6(pt.2):110; idem, ARofSG, 1900, pp. 99 (quotation), 123-24, 143; John M. Banister, "Medical and Surgical Observations During a Three-Year Tour of Duty in the Philippines," p. 275; Bourns, "Some Notes," p. 732; Greenleaf, "Brief Statement," pp. 158-59.
52. WD, ARofSW, 1902, 10(pt.1):264, 1904, 12(pt.2):95-96, 101, and 1905, 5(pt.1):770, 819; idem, ARofSG, 1900, pp. 99, 106, 125, and 1901, p. 140; Greenleaf, "Brief Statement," p. 159; Freer, "Plague," p. 347.
53. WD, ARofSW, 1900, l(pt.10):285, 1902, 10(pt.1):275, and 1903, 6(pt.2):181-82, 186; idem, ARofSG, 1900, p. 214, and 1901, pp. 139, 230-31; Sexton, Soldiers in the Sun, pp. 56-57; James A. LeRoy, "The Philippines Health Problem," p. 779; Sternberg, Sternberg, pp. 210-11; Freer, "Plague," p. 347; Maxmillian Herzog, "Bubonic Plague in the Philippine Islands From Its First Outbreak in 1899 to 1905," pp. 652-54.
54. WD, ARofSW, 1903, 6(pt.2):181, 188; idem, ARofSG, 1900, p. 211, and 1902, p. 99; Freer, "Plague," p. 347.
55. William E. Musgrave, "Infant Mortality in the Philippine Islands," p. 466 (first quotation); WD, ARofSW, 1902, 10(pt.1):271, 1903, 5(pt.1):57 and 6(pt.2):109, and 1904, 12(pt.2):114 (second quotation), 115-16; Banister, "Medical and Surgical Observations," pp. 151, 162; Bantug, Short History, p. 35.
56. Henry du R. Phelan, "Sanitary Service in Surigao, a Filipino Town in the Island of Mindanao," pp. 1, 3; Banister, "Medical and Surgical Observations," p. 157; Gates, Schoolbooks, p. 136; Lyster, "Army Surgeon," p. 33; WD, ARofSW, 1904, 12(pt.2):121; idem, ARofSG, 1902, pp. 81, 94.
57. WD, ARofSG, 1903, p. 92 (quotations); idem, ARofSW, 1903, 6(pt.2):106, 115, and 1904, 12(pt.2):117-18, 123-26; Banister, "Medical and Surgical Observations," p. 151.
58. Phelan, "Sanitary Service," pp. 5 (quotation), 6, 9; Banister, "Medical and Surgical Observations," p. 152; Maus, "Military Sanitary Problems," p. 7; WD, ARofSW, 1902, 10(pt. 1):413.
59. Phelan, "Sanitary Service," p. 18 (first three quotations); WD, ARofSW, 1902, 10(pt.1):413 (next three quotations) and 411 (final quotation), and 1903, 6(pt.2):106; Banister, "Medical and Surgical Observations," p. 157.
60. WD, ARofSG, 1902, pp. 82-83, and 1910, p. 95; idem, ARofSW, 1903, 6(pt.2):107, and 1904, 12(pt.2):86, 114, 132; John M. Banister, "Army Sanitary Administration in the United States and in the Tropics," pp. 570-71; idem, "Medical and Surgical Observations," pp. 149-51; Elbert E. Persons, "Medical Service With Philippine Scouts," pp. 708-10.
61. WD, ARofSW, 1903, 6(pt.2):63-65, 112; Joseph J. Curry, "Report on Parasitic Disease in Horses, Mules and Caribao in the Philippine Islands," p. 512; Edwin D. Kilbourne, "Some Experiments With the Trypanosoma Evansi," p. 250; Paul G. Woolley, "Rinderpest," p. 577. Glenn A. May in Battle for Batangas suggests that by killing off so many of the animals upon which mosquitoes preferred to feed, the rinderpest epidemic and military operations led these insects to feed more frequently upon humans and thus indirectly contributed to rising malaria rates (see pp. 26, 266-67, 271).
62. Philippine Census, 3:28-29; Duffy, Sanitarians, p. 180
63. Louis Shapiro, "Umbilical Tetanus," p. 245; WD, ARofSG, 1901, p. 139; idem, ARofSW, 1903,
6(pt.2):71, 100, and 1904, 12(pt.2):85, 88; Fales, "American Physician," p. 513 (quotation); William E. Musgrave and George F. Richmond, "Infant Feeding and Its Influence Upon Infant Mortality in the Philippine Islands," pp. 362, 364-65, 385; Vernon L. Andrews, "Infantile Beriberi," pp. 85-86.
64. WD, ARofSW, 1903, 6(pt.2):100, 1904, 12(pt.2):85, 87, 1905, 2(pt.2):131 and 5(pt.1):58, and 1908, 8(pt.2):22; Musgrave, "Infant Mortality," pp. 459, 466; George Rosen, Preventive Medicine in the United States, 1900-1975, pp. 3, 5, 7, 42.
65. WD, ARofSG, 1900, pp. 126, 133-34, 1906, p. 109, 1907, p. 40, 1912, p. 140; idem, ARofSW, 1902, 10(pt.1):347, 1903, 6(pt.2):97-98, 110-11, 1904, 12(pt.2):93, and 1908, 8(pt.2):90; Sexton, Soldiers in the Sun, pp. 58-59; Gates, Schoolbooks, p. 136; "Health of Americans in the Philippines," pp. 700-701; Banister, "Medical and Surgical Observations," pp. 270, 272; Ltrs, H. E. Wetherill to SG, 13 Apr 1900, and W. F. Lewis to SG, 17 May 1900, Ms 4888, Entry 52, RG 112, NARA; Henry J. Nichols, "The Simple and Double Continued Fevers of the Philippines," p. 368; Rosen, Preventive Medicine, p. 4; Department of the Army, Office of the Surgeon General, Communicable Diseases: Malaria, p. 526; Chamberlain and Vedder, "The Cure of Infantile Beriberi," pp. 30, 32. The unexpectedly low rate of malaria in the Philippines might, however, have been related to a genetic resistance. See Andrew A. Skolnick, "Newfound Genetic Defect Hints at Clues for Developing Novel Antimalarial Agents," p. 1765.
66. WD, ARofSW, 1903, 6(pt.2):68-70, 1904, 12(pt.2):86, and 1905, 11(pt.2):124; Gates, Schoolbooks, p. 60.
67. LeRoy, "Philippines," p. 778; WD, ARofSW, 1903, 6(pt.2):65; Rosen, Preventive Medicine, p. 48; Chamberlin, Philippine Problem, p. 115 (quotation); Ileto, "Cholera," in Imperial Medicine, p. 125.