Pox (25 page)

The most pressing challenge at the start of the Puerto Rico campaign was to secure a reliable vaccine supply. Vaccine did not survive long in heat (a problem that would bedevil tropical vaccination programs until the invention of a heat-stable, freeze-dried vaccine in the 1950s). Vaccine tubes shipped from the mainland usually lost their potency by the time they reached Puerto Rico. The British imperial experience in India (as well as the Spanish record in Puerto Rico and the Philippines, assuming the Americans actually consulted it) taught that ineffective vaccines engendered popular resistance to vaccination in general. The solution the Army settled upon—to produce vaccine on the island itself—was, in keeping with colonial administrative imperatives, the cheapest. It was also the most ambitious. Governor General Henry put Major Ames in charge of the operation.
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Azel Ames was one of the hundreds of civilian physicians recruited, as he said, in “hot haste” for the war with Spain. Born in Chelsea, Massachusetts, in 1845, Ames had served in the Union Army and graduated from Harvard Medical School. The unifying theme of his career to date was the way it had blended seamlessly—and, on at least one occasion, scandalously—public service and private interest. As a physician in Wakefield, Massachusetts, he founded the town's board of health. His résumé also included stints as a temperance crusader, state factory inspector, and administrator of U.S. government pensions. Ames had gotten himself embroiled in a national scandal in the 1880s, when he was indicted for abusing his position with the Boston board of medical examiners in the U.S. pension office by extorting bribes from claimants. The jury was hung, and Ames was never convicted. In none of his writings about his Puerto Rican experience did Ames mention any previous experience with vaccine production. But vaccine manufacture in the late nineteenth century remained a largely pastoral pursuit. And in Ames's Wakefield it was not unknown for a physician to keep a calf on hand to meet his patients' needs for lymph.
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The Puerto Rican vaccine farm was the capstone of Ames's career, pulled off, if he said so himself, on a “grand scale . . . practically in the open air, in a new country, by unskilled hands.” Ames based his operations on rented fields at Coamo Baths, an area of “fine cattle country” on the dry coastal highlands near the island's south shore. He supervised the construction of stables, corrals, and a camp large enough to sleep over a hundred men—Army surgeons, a pathologist, cattlemen, guards, cooks, couriers, and teamsters. Fresh meat, ice, and medical supplies from the United States were hauled almost daily up twenty-three miles of rough roads to the camp. Working through a native intermediary, a local cattleman named Simón Moret, Ames leased twelve hundred head of local cattle.
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The viability of the entire campaign depended on a few glass tubes of lymph imported from the United States. Army medical officers doubted that vaccine virus originating in a temperate climate could retain its “virility” in the moist heat of the tropics. Ames received his little supply, transported eighteen hundred miles by sea then hauled by pack animal up the dusty military road to the camp. An assistant inoculated forty cows with the lymph. The camp waited for the virus to incubate in the animals' bodies. They waited the requisite six days, and then waited some more. Nothing. Ames would recall these hours as the “worst and most anxious” of his life. He and his assistants furiously searched the calves' undersides for the telltale vesicles, the blister-like sores from which the vaccine lymph could be harvested. But there were none. It appeared that the entire shipment of American lymph was useless and that “the undertaking must be abandoned.” After twenty-four sleepless hours, Ames and an Army pathologist, Dr. Timothy Leary, took one last look. This time they discovered that many of the animals had scablike “crusts” and “cones.” Removing them, the physicians discovered bases flowing with lymph. The doctors realized their mistake. The animals at Coamo had not been confined in stables, as they would be on an American vaccine farm. The vaccine vesicles had been broken by the underbrush, grass, and the calves' own rough tongues. From the ring-shaped bases on the calves flowed “the finest lymph.” The operation was soon producing sixteen thousand good-quality vaccine points a day.
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The Army's next challenge was to get Major Ames's vaccine to—and into—the people. For this, the Army relied on the Puerto Ricans. Native runners, on foot and pack animals, negotiated the narrow paths and mountain streams to deliver fresh vaccine to the villages and barrios. The Army vaccination directors determined that the population was so dispersed and difficult to reach that the common American method of house-to-house vaccination would be unfeasible. Instead, they would have to bring the people to the vaccinators. The directors set the schedule and secured the cooperation of the alcaldes, the local officials who served in the island's seventy-one municipalities as “mayor, school commission, county commissioner, and sheriff, all in one.”
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The original plan envisioned using Army Hospital Corpsmen to vaccinate the people. But the medical officers decided to hire native physicians and their assistants, called
practicantes
, for the job, believing (no doubt correctly) that local vaccinators would be “more acceptable to the people.” Each director was allowed to hire ten vaccinators, who would be paid in gold. According to the Army's instructions, the
practicantes
must conduct their business at specified hours, “wear white coats,” and “always be neat and clean.” The skin of the native physicians might be dark, but American medical authority would remain clothed in white. As the physicians and
practicantes
performed their vaccinations—scraping the arms of men, women, and children with the sharp edge of Dr. Ames's points—native scribes recorded each person's name, address, sex, age, and race. In this way, the vaccination teams produced for the U.S. military government its first record of the population. Major Groff found that a single vaccinator, “if hurried,” could vaccinate three hundred people in an eight-hour day. Some Army surgeons never overcame their low regard for the Puerto Ricans. S. H. Wadhams, a Yale Medical School graduate who served as an Army surgeon in Ponce, claimed American vaccinators could do “three to five times as much work as the natives.”
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The military government found it necessary to continually ratchet up the coercion in its vaccination campaign. No vaccination riots were reported, but physicians working for the military government had to take care. When one was asked why he had failed to vaccinate all the spectators at a cockfight near where he was working, he answered, “I feared a thrashing.” On March 18, Governor General Henry raised the pressure. He ordered the alcaldes to “use all their authority to secure prompt compliance on the part of the people.” The order, which Major Ames himself drafted, contained an important new provision. No one who failed to produce an official certificate of vaccination “shall be admitted to any school, public or private, shall travel by any public conveyance, visit any theater or any place of public resort, engage in any occupation related to the public, or receive employment.”
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Through the island vaccination campaign, Americans were indeed learning the art of colonial statecraft. Ames's provision pulled a largely illiterate, rural population into a documented relationship with the U.S. military government. It also imposed a new discipline on local institutions, by holding public and private authorities—schoolteachers, managers, and employers—legally liable for enforcing the measure. The strategy worked. “From hills and valleys, hamlets and municipalities, young and old flocked to the vaccinators,” Ames recalled, “like John Chinn's Wuddahs, in Kipling's story of the vaccination of the Satpura Bhils. Often two or three hundred, old and young, would be still waiting, unvaccinated, when darkness closed the day's work. . . . Sometimes the vaccination was continued by lamplight to relieve the pressure.” The metaphor of police power could no longer contain such ambitions. Like the Kipling character to whom he now compared himself, Major Ames saw himself as the vanguard of a civilizing mission, carrying into those overgrown hills and valleys the vaccine of a paternal American nation.
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Even then, some Puerto Ricans refused to cooperate. In June, the new governor general, George Davis, imposed new penalties for people who refused to be vaccinated: a $10 fine, plus $5 for each subsequent day in violation. Anyone who failed to pay the fine would “suffer ten days' imprisonment and thereafter five days for each additional offense.” This penalty was harsh even by the toughest standards of vaccination measures in the United States.
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On June 25, 1899, Chief Surgeon Hoff received a telegram from Coamo Springs announcing that the vaccine farm had produced its one-millionth point. A week later he brought the campaign to a halt. The Medical Department's vaccination program had carried vaccination to the people on an unprecedented scale. According to Hoff, the vaccinators had performed nearly 860,000 operations (742,062 vaccinations and 116,955 revaccinations) in a period of five months. And the vaccine produced at Coamo Springs was, by contemporary standards, good, with a reported success rate of 87.5 percent. Colonial administrators always kept the bottom line in view. Hoff noted with satisfaction that the entire vaccination campaign had cost only $43,000.
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By the end of June, the “head-fire of vaccination” had stopped variola in its tracks. In the decade before the arrival of the U.S. Army, the annual death rate from the disease had averaged 620 people. From January 1 to April 30, 1900, not a single death from smallpox was reported. And during the two years after completion of the eradication campaign, the annual death rate dropped to just two. Under the new superior board of health established under Colonel Hoff's leadership in June 1899, the vaccination of infants continued. U.S. health officials continued to seek out the elusive people Hoff described as the “‘submerged' 200,000 who escaped in the grand attack” of 1899.
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The new colonial civil administration installed by the Americans on May 1, 1900, would learn soon enough that the vaccination campaign had not permanently eradicated smallpox. The flow of people and goods from the mainland brought variola minor to the island. Still, American officials and journalists followed Ames's lead in touting the Puerto Rican campaign as a “lesson to the world.” Ames hoped it would overthrow the “present belligerent skepticism” toward compulsory vaccination in America and Europe. “Small-pox still holds the first place in the list of preventable, readily-disseminated contagious diseases, common to all parts of the globe,” he wrote. And in Puerto Rico, the Army had shown how it could be eradicated. Surely, that colonial knowledge could be used to wipe out smallpox on the U.S. mainland.
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The question of exporting the Puerto Rican model—or importing it to the American mainland—hinged on how one felt about public health enforced by a form of martial law. Although the smallpox eradication effort had relied heavily upon local physicians to bring vaccination to the people, it had been a military operation through and through. No government agency on the United States mainland would have dreamed of securing a monopoly on vaccine production—in most parts of the United States, there were no regulations at all on vaccine production. To secure the cooperation of local officials, the Army wielded powers of influence and coercion that neither state nor federal authorities could have matched in a place like Middlesboro, Kentucky. That went double for the capacity to impose vaccination upon an unwilling people. When a Kentucky health inspector named W. M. Gibson visited the smallpox-afflicted mountain folk of Jackson County in August 1898, he sent word to his boss, Secretary J. N. McCormack of the state board of health. Dr. Gibson promised to vaccinate “all who willingly apply.” But he told McCormack that if he really wanted to see vaccination enforced in Jackson County, “you will find it necessary to send four battalions of four hundred soldiers each, well armed.” Gibson wasn't joking.
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That Kentucky fantasy would become a reality in the Philippines. There U.S. health officials would have a good deal more than four battalions marching with them. The situation in the Philippines was different not only from Jackson County, but also from Puerto Rico. In the Philippines, the fighting was far from over when the vaccinators began their work.

 

 

I
f the Puerto Rico vaccination campaign deserved pride of place as America's “first big sanitary undertaking . . . in the tropics,” the U.S. government's fight against smallpox in the Philippines took place on an altogether grander scale. The Southeast Asian archipelago was both far more distant and far more expansive than the Caribbean island. The Army had many more men on the ground there. Some 125,000 U.S. Regular Army and Volunteer soldiers had arrived by 1902. And their mission proved far more dangerous, as the “splendid little war” against Spain gave way to a three-and-a-half-year guerrilla war with Aguinaldo's republican forces. The people of the archipelago were eight times more numerous than the Puerto Ricans, and, in the eyes of the American occupiers, they inhabited a lower rung on the racial hierarchy. Lieutenant Colonel Hoff, who participated in both campaigns, sized up the Philippine challenge: “It is no small problem to sanitate eight millions of semi-civilized and savage people, inhabiting scores of islands with the aggregate area of a continent.”
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At their most open-minded, some U.S. officials envisioned a gradual process of “benevolent assimilation.” The indigenous elite would be fitted for eventual self-government while the political participation of the “wild” (and especially the non-Christian) masses would be deferred indefinitely. Typical of U.S. officials, most military surgeons regarded the Filipinos in general as racially inferior and indifferent to filth and disease. Not long after he supervised the hut-torching sanitation campaign in Siboney, Cuba, Colonel Charles R. Greenleaf served as chief surgeon of the Army's division of the Philippines. “The native,” he wrote, “does not know how to take care of himself; not only is he ignorant of the first principles which govern the preservation of health, but he has never had anybody sufficiently interested in him to instruct him in these principles.” Above all else, the presence of endemic smallpox in the islands showed the Filipinos' desperate need for a wise government to take them in hand.
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