Immunization and Hygiene in the
Colonial Philippines
WARWICK ANDERSON*
ABSTRACT. Vaccination and the enforcement of stipulations of personal
hygiene can be viewed as different mechanisms of colonial government.
Immunization campaigns reach and register populations, but they may also
appear to obviate the need for behavioral reform. Hygiene education implies
the development of a disciplined, self-governing citizenry, although in the
colonial setting validation of such attainment is usually deferred. This article
explores the tension between mechanisms of security (immunization) and
drill (hygiene) in the Philippines, under the United States’ colonial regime, in
the early twentieth century. KEYWORDS: Immunization, vaccination, public health, state medicine, colonial, race, United States, Philippines.
Colonizing the Body, David Arnold called the introduction of mass
vaccination against smallpox during the late nineteenth century
a “remarkable demonstration of the interventionist ambitions
and capabilities of western medicine in India.” And yet, despite the
obvious efficacy and cheapness of vaccination, a general feeling
emerged that “vaccination was a distinctive form of medical activity
that did not provide a suitable base or blueprint for the wider development of state medicine and public health.” In the 1870s, efforts in
British India to merge vaccination departments with the newly
established sanitary departments failed, in part because vaccinators were
deemed ignorant of sanitation. Arnold thus points to a paradox: vaccination, whether as symbol or act, epitomized the interventionist
I
N
* Warwick Anderson, M.D., Ph.D., Department of Medical History and Bioethics,
University of Wisconsin-Madison, MSC 1440, 1300 University Avenue, Madison, Wisconsin
53706. E-mail: [email protected].
JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES, Volume 62, Number 1
© 2006 The Author(s)
This is an Open Access article distributed under the terms of the Creative Commons Attribution
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unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original
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Advance Access publication on July 28, 2006
doi:10.1093/jhmas/jrl014
[ 1 ]
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Journal of the History of Medicine : Vol. 62, January 2007
ambitions of the colonial state, even as that same state increasingly
displayed an “ambivalent or hesitant attitude” toward it.1 In this article I
intend to explore some of the tensions that can develop between intervention and government, ambiguities that are also expressed in the differences between vaccination and hygiene, or safeguard and discipline.
Arnold blames technical difficulties and widespread fears of a political backlash for the reticence of the British colonial state to vaccinate
widely. No doubt such concerns would make even the most aggressive
health officer think twice before urging compulsion. But we should
also consider the rising interest in the reform of personal and domestic hygiene that accompanies disinclination toward mass vaccination.
That is, we should recognize that the more effectively vaccination
appears to protect from disease, the fewer opportunities might be
offered to discipline a population. When a modern colonial state
attempts to frame civic identities through rituals of disease avoidance,
vaccination can provide an exemption—admittedly partial—from
the consequences of disobeying the laws of hygiene. If a vaccine were
available for typhoid, why would a disciplinary state, bent on reforming local customs and habits, want to make use of it? Take for example the American colonial state in the Philippines during the early
twentieth century. American health officers dedicated themselves to
altering local diet, toilet practices, housing, and clothing; they enjoined
native inhabitants to treat their bodies and their excreta with caution; contact increasingly implied risk. The new tropical hygiene
was predicated on limiting the transmission through local human
and insect populations of recently identified microbial pathogens.2
In the circumstances, then, automatic biological protection against
disease might have allowed locals to outmaneuver a “civilizing”
process based on disease avoidance. A vaccine, of questionable efficacy, was indeed available against typhoid for most of this period;
but until the 1920s it was used only for troops.3 The Philippines
1. David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in NineteenthCentury India (Berkeley: University of California Press, 1993), 121, 148, 157.
2. Warwick Anderson, “Excremental Colonialism: Public Health and the Poetics of
Pollution,” Critical Inquiry, 1995, 21, 640–69. On the difference between hygienists and
“vaccinologistes,” see Anne-Marie Moulin, Le dernier langage de la médecine: histoire de
l’immunologie de Pasteur au Sida (Paris: P.U.F., 1991), 129.
3. H. J. Parish, A History of Immunization (Edinburgh and London: E. & S. Livingstone
Ltd, 1965), 63–68. See also Anne-Marie Moulin, “Introduction: hasard et rationalité dans
l’approche vaccinale,” History & Philosophy of the Life Sciences, 1995, 17, 5–30. Frederick
F. Russell confirmed the effectiveness of the typhoid vaccine in a large-scale study of American
Anderson : Immunization and Hygiene in the Colonial Philippines 3
under the “progressive” and interventionist American regime thus
serves as another example of state reticence to vaccinate civilians,
but not for the reasons commonly adduced in histories of colonial
public health.
The emerging pattern of typhoid vaccination in the early years of
the twentieth century is especially revealing. A large-scale program
of British troop inoculation in the Boer War (1899–1902) appeared
to reduce the incidence of enteric fever among the vaccinated, but
the statistical analysis was flawed and contestable. It was also evident
that the vaccinated suffered severe side effects. In 1904, the British
army suspended the routine inoculation of troops heading for South
Africa and India and emphasized instead sanitary precautions against
the disease. But anti-typhoid immunization gradually became more
acceptable. In 1906 an improved version of typhoid vaccine was
reintroduced for soldiers in India; and inoculation became compulsory for all members of the Indian Civil Service in 1912, though its
use among civilians remained limited. During World War I, more
than 90% of the volunteer British force in France was immunized,
though anti-vaccinationists and liberal politicians ensured that it never
became compulsory.4 By 1911, all American troops were compelled
to submit to typhoid inoculation. The pattern becomes clear: biological protection where possible for state officers and military personnel,
with intensive hygiene reform of civilians or natives.
Yet it is vaccination—and not hygiene—that we continue to regard
as the most interventionist feature of state medicine. It is not hard to
understand why. Vaccination involves forcible restraint and handling
of the body; it may have perceptible physiological effect; and often a
scar will remain. Before bacteriologists expanded their understanding of the role of the body in the transmission of disease organisms,
vaccinators were the health officers most likely to track down and
inspect local populations. Health departments were sending inspectors into schools to check on unvaccinated children long before they
troops: The Results of Anti-Typhoid Vaccination in the Army in 1911, and its Suitability for Use in
Civil Communities (Chicago: American Medical Association, 1912). See also Frederick
F. Russell, “Anti-typhoid Vaccination,” Am. J. Med. Sci., 1913, 146, 803–33.
4. Anne Hardy, “‘Straight Back to Barbarism’: Antityphoid Inoculation and the Great
War, 1914,” Bull. Hist. Med., 2000, 74, 265–90. See also Derek S. Linton, “Was Typhoid
Inoculation Safe and Effective during World War I? Debates within German Military Medicine,” J. Hist. Med. Allied Sci., 2000, 55, 101–33.
4
Journal of the History of Medicine : Vol. 62, January 2007
sought to detect children with communicable diseases.5 So there are
plausible phenomenological and historical reasons to view vaccination
as an especially egregious state intervention. But in focusing on vaccination, we may miss other medical agitations of social life that are
more productive and lasting, though less obvious.
If the target of vaccination—revealed in references to “herd
immunity”—is primarily the social body, the goal of hygiene is
reform of the individual body. One practice thus biologically regularizes a population; the other produces an individuation.6 One is, in
a sense, a technology of security; the other, a technology of drill.
Vaccination therefore belongs to an older military model of the
campaign, while hygiene follows a military logic of occupation (in
effect, a missionary-military model, which Hubert Lyautey and other
promoters of “small wars” doctrine were doing much to make popular at the turn of the nineteenth century). One is more-or-less repressive in its power; the other, more-or-less disciplinary.7 But these
distinctions are, of course, far too absolute, and perhaps of no more
than heuristic value. I hope the rest of the article will complicate these
dichotomies, reveal their mutual articulation, and so make them
useful in understanding the ambiguous relationship between the state
and mass vaccination programs.
VACCINATION IN THE COLONIAL PHILIPPINES
For most of the nineteenth century, smallpox was an exception in
western disease theory; even in the early twentieth century, when in
many ways it offered a model for explaining disease etiology and
5. John Duffy, “School Vaccination: The Precursor to School Medical Inspection,”
J. Hist. Med. Allied Sci., 1978, 33, 344–55.
6. Mary Poovey, Making a Social Body: British Cultural Formation 1830–1864 (Chicago and
London: University of Chicago Press, 1995). On individuation through medical discourses,
see Michel de Certeau, “Des outils pour écrire le corps,” Traverses, 1979, 14/15, 5.
7. See Warwick Anderson, Colonial Pathologies: American Tropical Medicine and Race
Hygiene in the Philippines (Durham, N.C.: Duke University Press, 2006), chapters 1 and 2.
My use of the term “discipline” obviously derives from Michel Foucault, Discipline and
Punish: The Birth of the Prison, trans. Alan Sheridan (Harmondsworth: Penguin, 1991), and
“Body/Power,” in Power/Knowledge: Selected Interviews and Other Writings, 1972–77, ed.
Colin Gordon, trans. Colin Gordon, Leo Marshall, John Mepham, Kate Soper (Brighton:
Harvester Press, 1980). For an extended discussion of biopower and discipline, see Foucault,
“Society Must be Defended”: Lectures at the Collège de France, 1975–76, trans. David Macey
(New York: Picador, 2003). On the derivation of governmentality from the Christian pastoral and a “diplomatico-military model, or better, technics,” see Michel Foucault, “Governmentality” [1978], in Foucault, Power, ed. James D. Faubion, trans. Robert Hurley
(New York: New Press, 2000), 201–22, 221.
Anderson : Immunization and Hygiene in the Colonial Philippines 5
prevention, smallpox could still call forth unconventional responses.
From the European Middle Ages, it was known that the disease was
contagious—a disease of contact, not place—and that infection was
followed by increased resisting power of the tissues. Smallpox, or
variola, was mostly a disease of children, and appeared universal in
its distribution. The history of its prevention through inoculation or
variolation, and later by Jennerian vaccination, is well known.8
Vaccination evidently worked on the principle that a mild case of
disease protects an individual from further attacks. Smallpox was
exceptional in that the material that excited this resistance was available; for other diseases, despite repeated efforts to invoke the same
principles of immunity, no comparable material was found, though
many claimed some success in using morbilization to prevent measles.9 So smallpox seemed doubly extraordinary: first, as an indubitable contagion; second, as a disease that could be prevented through
biological means. By the 1870s, most European nations enforced compulsory vaccination laws; in Germany, revaccination at twelve years
also had been made compulsory, to prevent “varioloid,” or smallpox
of the vaccinated.10 In colonial India, the British passed compulsory
vaccination laws in 1880, but they proved difficult to enforce.11
Most of the northeastern states of the United States had compulsory
school vaccination laws at this time, though many midwestern and
southern states continued to resist moves to enact vaccination statutes
until the 1890s. Not until 1894 did Pennsylvania pass a compulsory
school vaccination law, soon after suffering a widespread smallpox
outbreak. But by 1900, according to John Duffy, Pennsylvania had
finally established an “effective statewide program of compulsory
vaccination.”12
In the late nineteenth century, compulsory vaccination statutes
were also passed in the Philippines under the Spanish colonial
regime, but their enforcement was generally perfunctory, except in
8. Edward J. Edwardes, A Concise History of Smallpox and Vaccination in Europe (London:
H. K. Lewis, 1902); Parish, History of Immunization.
9. George Rosen, A History of Public Health (New York: MD Publications, 1958), 327.
10. Edwardes, Concise History; Parish, History of Immunization. But in Britain, the 1907
Vaccination Act removed compulsory infant vaccination, which had been enforced since
the 1860s: see Roy MacLeod, “Law, Medicine, and Public Opinion: The Resistance to
Compulsory Health Legislation, 1870–1907,” Public Law, Summer 1967, 106–26, 188–211.
11. Arnold, Colonizing the Body.
12. Duffy, “School Vaccination,” 355.
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response to occasional smallpox outbreaks. The central board of vaccination had been producing and distributing lymph since 1806; by
1898, there were 122 regular vacunadores working in the provinces and
major towns. Even so, smallpox remained a serious and recurrent
threat to public health in the islands under the Spanish.13 Many
Filipinos shunned the vaccinators, who were in any case often underpaid
and disinclined to seek out the fainthearted. Moreover, the vaccine
was often ineffective, or variably potent.
Later a target for American criticism, the Spanish colonial health
system at the end of the nineteenth century was relatively modern in
its aspirations, even if its achievements were insubstantial.14 Provincial medical officers, the médicos titulares, had first been appointed in
1876; and the Superior Board of Health and Charity, equivalent to a
public health department, was established in 1883 and expanded in
1888. Since 1877, Filipino medical doctors had been able to graduate
from the University of Santo Tomás. An effective quarantine service
was in place, and provision had been made for the isolation of those
suffering from infectious diseases. Toward the end of the century,
health authorities began to press into service the new knowledge of
microbial causes of disease—but they were not far advanced in this
endeavor, and their innovations would soon be undone by war.
Nevertheless, in 1887 the government had created the Laboratorio
Municipal de Manila in order to examine food, water, and clinical
specimens.15
During the Philippine-American war of 1898–1902, the Spanish
health system broke down completely. As they advanced, American
forces established in its place a new stratum of public health institutions,
13. George Foy, “The Introduction of Vaccination to the Southern Continent of America
and to the Philippene [sic] Islands,” Janus, 1897–98, 2, 216–20; Reglamento de vacunacion para
las Islas Filipinas; aprobado por Superior decreto de 6 de febero de 1895 (Manila: Ramirez, 1895).
See Ken de Bevoise, Agents of Apocalypse: Epidemic Disease in the Colonial Philippines
(Princeton, N.J.: Princeton University Press, 1995).
14. The best source for the history of public health under the Spanish is J. P. Bantug, A
Short History of Medicine in the Philippines under the Spanish Régime, 1565–1898 (Manila: Colegio
Médico-Farmaceútico de Filipinas, 1953). See also Teodora Tiglao and W. L. Cruz, Seven
Decades of Public Health in the Philippines, 1898–1972 (Tokyo: South-East Asian Medical
Information Center, 1975); Enrico Azicate, “Medicine in the Philippines: An Historical
Perspective” (M.A. thesis, University of the Philippines, 1989); and Marcelo C. Angeles,
“History of the Public Health System in the Philippines,” typescript c. 1967, Department of
Health Archives, Manila, Republic of the Philippines.
15. Leoncio Lopez-Rizal, Annual Report of the National Research Council of the Philippines
(Manila: Bureau of Printing, 1934–35), 159.
Anderson : Immunization and Hygiene in the Colonial Philippines 7
based directly on a military model.16 The interim military board of
health for Manila, organized in September 1898, developed the fundamental arrangements for sanitation and health care delivery in the
city. It divided the city into ten districts and appointed a municipal
physician to each. During this period, separate hospitals for smallpox, leprosy, and venereal diseases were established, and a veterinary
corps was organized. In August 1899, the board added a bacteriological department to its municipal laboratory and set up a plague hospital. A municipal dispensary opened in late 1899. One of the principal
achievements of this military board was its vaccination program.
Although fortunate enough not to have to contend initially with
cholera, the board did need to contain the smallpox that had become
endemic in Manila. High temperatures had rendered inert the vaccine virus sent from the United States, so it was necessary to find a
local source for the immunizing agent. One of the military board’s
first decisions was to reopen the old Spanish vaccine farm and standardize its production in horses and caribao. A corps of carefully
supervised vaccinators soon roamed the streets: by the middle of 1899,
they had “properly” vaccinated almost 80,000 people.17
The health ordinance promulgated on 6 April 1901 became the
foundation of a new civil health organization: it was the basis of all
subsequent ordinances and of the sanitary code. The ordinance was
designed principally to control the spread of infectious disease among
the islands’ population. It provided, among other things, that a
physician called to visit or examine any case of infectious or contagious disease should immediately isolate the patient and notify the
health authorities by telephone or “postal card.” The term “infectious
or contagious disease” included smallpox; cholera; chicken pox;
plague; diphtheria; ship or typhus fever; typhoid; spotted, relapsing,
yellow, and scarlet fevers; measles; leprosy; and anthrax (but not the
16. Anderson, Colonial Pathologies, chapters 1 and 2.
17. Board of Health, Manual of the Board of Health for the Philippine Islands (Manila: Bureau
of Printing, 1911). See also John van Rensselaer Hoff, “Experience of the Army with
Vaccination as a Prophylactic against Smallpox,” Mil. Surgeon, 1911, 28, 490–503; Charles
R. Greenleaf, “A Brief Statement of the Sanitary Work Accomplished so far in the Philippine
Islands, and of the Present Shape of the Sanitary Administration,” Public Health Papers and
Reports: American Public Health Association, 1901, 27, 159; Louis H. Fales, “The American
Physician in the Philippine Civil Service,” Am. Med., 1905, 9, 515; and Mary Gillett, “U.S.
Army Medical Officers and Public Health in the Philippines in the Wake of the SpanishAmerican War,” Bull. Hist. Med., 1990, 64, 567–87.
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Journal of the History of Medicine : Vol. 62, January 2007
undoubtedly insect-borne diseases such as malaria or dengue).18 Any
building, locality, or ship infected by these diseases would be quarantined. The ordinance also regulated the selling of food by street
vendors, the condition of tenements, and night soil collection. A
system of sanitary inspectors—separate from the vaccinators—was
organized to check for violations of the regulations. Manila was
divided into ten districts—as it had been under the military board—
with an American medical officer, and subordinate Filipino inspectors, responsible for each division. Furthermore, the ordinance
contained a compulsory vaccination clause, which made it the duty
of everyone in Manila to be successfully vaccinated each year.19
Compulsory vaccination was later extended throughout the provinces, requiring everyone in the archipelago to present a certificate
of vaccination signed by the president of the municipal board of
health, a public vaccinator, or a qualified physician.
Victor G. Heiser, the director of the civil health service, was particularly proud of the rigor with which he enforced smallpox vaccination in the islands. The annual deaths from smallpox during the
Philippine-American war were estimated at 40,000; yet in 1913,
only 823 deaths were reported.20 What, the health authorities asked,
was responsible for “this almost unbelievable reduction”? Their answer,
quite simply, was vaccination. The chief vaccinator under the Spanish
regime had recorded 9,136 vaccinations in Manila between 3 November
1894 and 25 October 1898. In contrast, the American authorities—aware
of the “necessity for constant vigilance in this disease”21—performed
18. “General order no. 16,” Headquarters Provost Marshal General, 6 April 1901, RG
350/2394–3, United States National Archives and Records Administration (NARA), College
Park, Maryland.
19. Ibid. The board of health, through its vaccinators, would “inspect all persons” (section 8).
20. John E. Snodgrass, Smallpox and Vaccination in the Philippine Islands, 1898–1914
(Manila: Bureau of Printing, 1915), 15. Snodgrass was assistant to the director of health. For
accounts of similar methods of smallpox control, see Azel Ames, “The Vaccination of Porto
[sic] Rico—A Lesson to the World,” Pacific Med. J., 1902, 45, 513–32; and José G. Rigau-Pérez,
“Strategies that led to the Eradication of Smallpox in Puerto Rico, 1882–1921,” Bull. Hist.
Med., 1985, 50, 75–88, and “The Introduction of Smallpox Vaccine in 1803 and the
Adoption of Immunization as a Government Function in Puerto Rico,” Hispanic Am. Hist.
Rev., 1989, 69, 393–423. Soon after the American occupation of Puerto Rico, Governor
Guy V. Henry ordered a mass vaccination and barred anyone without a vaccination certificate
from school, employment, and public transportation. For Indochina during this period, see
Annick Guénel, “Lutte contre la variole en Indochine: variolisation contre vaccination?”
Hist. Philos. Life Sci., 1995, 17, 55–80.
21. Fernando Calderón, “Some Data Concerning the Medical Geography of the Philippines,”
Philippine J. Sci., 1914, 9B, 199–214, 204.
Anderson : Immunization and Hygiene in the Colonial Philippines 9
103,931 vaccinations in 1899 alone, and almost 18 million by 1914.22
Even so, the coverage of these campaigns was generally more limited
than their promoters admitted, with the exception, perhaps, of an
unusually thorough general vaccination in 1905. Probably not more
than half the vaccinations were successful. Smallpox remained endemic
in the archipelago, its incidence increasing again by the 1920s.23
Most Filipinos, mindful of the smallpox outbreak during the war,
came voluntarily to the vaccinators, but the few who did not were
tracked down. During the early vaccination programs, soldiers often
accompanied the vaccinators. Sometimes Filipinos actively resisted
their serological protectors. In Batangas in 1902, the teams would
“enter first the most crowded houses and drive the inmates to the
farthest room, then working at the doorway, natives are led out singly and each of any age not showing pock-marks, vaccinated.”24 But
in the pacified areas, where vaccinators depended more on the
cooperation of local officials, such military thoroughness was not
often achieved. Even after repeated sweeps of the archipelago, it was
still suspected that a low level of “smallpox infection apparently
exists everywhere in the islands, and it will make its appearance in
any community in which there are unvaccinated persons.”25 Control
of the disease, then, warranted constant inspection of every town
and barrio, along with recurrent mass vaccination—forced, if necessary.26 But it was, an army medical officer recalled, “no small problem to sanitate eight millions of semi-civilized and savage people,
inhabiting scores of islands with the aggregate area of a continent.”27
TOWARD A SANITARY IMMUNITY
Mass vaccination against smallpox was evidently an important activity of American colonial health authorities in the Philippines. These
22. Snodgrass, Smallpox, 15.
23. Vicente de Jesús, Director, Bureau of Health, to Gen. F. McIntyre, director, Bureau
of Insular Affairs, 3 March 1920, RG 350/3465–105, NARA, College Park, Maryland.
24. Medical History of Posts No. 528, San Pablo, Laguna, 16 January 1902, 4, RG 94/
E547, NARA, College Park, Maryland, quoted in Ken de Bevoise, “The Compromised
Host: The Epidemiological Context of the Philippine-American War” (Ph.D. diss., University
of Oregon, 1986), 235.
25. Calderón, “Medical Geography,” 204.
26. Heiser found that while he could force Filipinos to accept the “wholesale nature” of
vaccination, he was often unable to persuade Americans to submit to the same procedure
(Victor G. Heiser, An American Doctor’s Odyssey: Adventures in Forty-Five Countries [New York:
W. W. Norton and Co., 1936], 185).
27. Hoff, “Experience of the Army with Vaccination,” 493.
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campaigns, conducted with a military rigor, permitted the early
registration of the population of the archipelago and its continuing
surveillance. Smallpox vaccination was thus one of the first medical
means of intervening in Philippine social life. Vaccination had symbolic importance, too. For Heiser and his successors, the control of
contagious disease in the archipelago indicated the beneficence of
American occupation: health officers were saving the Orient from
itself, leading its people onto the path of science, progress, and health.
The heroic smallpox vaccination campaigns therefore required an
early expansion of the personnel of the health department; the sedimentation of health work over the whole archipelago; and reiteration of the need for efficient and scientific public health officers.
Smallpox vaccination had been a good way of growing a health
bureaucracy, but once grown, the organization dedicated itself to
civic programs.
In the early twentieth century, the enforcement of stipulations of
personal and domestic hygiene was by far the major concern of the
mature Philippines public health department. Heiser, for example,
imagined himself “washing up the Orient,” not just vaccinating it.
Sanitary engineering, especially the provision of clean water, was
not neglected, but Heiser and his colleagues generally regarded
major public works as extravagant and impractical in such an impoverished colony. Disease prevention increasingly involved education
and isolation, focusing on the regulation of social life as a means to
control the transmission of newly identified microbial pathogens.
But the “peculiar” and refractory social life of Filipinos supposedly
complicated the sanitary officer’s task. Heiser lamented the profusion of their “incurable habits.” He cited as obstacles the “unsuitable
dietary of the people, their peculiar superstitions concerning the
contraction of the disease, their almost unshakable fear of night air as
a poisonous thing, a fear which has kept their houses tightly closed
at night for generations past, their habit of chewing betel nut which
has made the custom of expectorating in public . . . universal.”28
Heiser declared that “they will have to be first cured of their superstitions, which is as great a task as converting them to new religion;
houses will have to be open at night, betel nut chewing gradually
28. Victor G. Heiser, “Unsolved Health Problems Peculiar to the Philippines,” Philippine
J. Sci., 1910, 5, 171–78, 174–75.
Anderson : Immunization and Hygiene in the Colonial Philippines 11
abolished, and then a gigantic anti-spitting crusade begun, and, last
of all, comes the Herculean task of rousing them out of their inertia.”29 Health authorities reached out to those who had not yet contracted disease, to emphasize that “they live in constant danger of
infection,” and to point out that “the path of safety lies in the maintenance of good general health through the observance of simple
rules of right living.”30 The major goal of the progressive colonial
public health department was the reform of pathological social
habits—not, primarily, vaccination, and rarely the improvement of
environmental, economic, or industrial conditions.
In developing programs to modify Filipino customs and habits—
whether through education or inspection—the Bureau of Health
attempted to inculcate a distrust of the body and its products, a dread
of personal contact, and a respect for American sanitary wisdom.31
Colonial authorities targeted toilet practices, food handling, dietary
customs, and housing design; they rebuilt the markets, using the
more hygienic concrete, and suppressed unsanitary fiestas; they
assumed the power to examine Filipinos at random, and to disinfect,
fumigate, and medicate at will. It was the hygienic state—more than
the immunizing state—that sanctioned, as never before in the archipelago, a reformation of everyday life and personal knowledge. To
engage in this enterprise during the first years of American occupation would have been futile: the new colonial authority was not yet
organized for persuasion, and its emissaries were too few to develop
a rigorous apparatus of inspection. Extension of American control
over the archipelago, and the early diffusion of an advance force of
vaccinators, soon permitted such intervention—which in itself would
further ramify colonial authority.
The crusade for “cleanliness” sharpened social divisions (and legitimated social categories) in the Philippines, further separating colonized
from colonizers, the sick from the healthy, native disease carriers from
non-immune foreigners. Strict enforcement of the rules of personal
and domestic hygiene promised multiple benefits: local populations,
29. Ibid., 175.
30. Annual Report of the Bureau of Health for the Philippine Islands, July 1, 1912- June 30, 1913
(Manila: Bureau of Printing, 1913), 61.
31. See Warwick Anderson, “Excremental Colonialism”; and “Immunities of Empire:
Race, Disease and the New Tropical Medicine, 1900–1920,” Bull. Hist. Med., 1996, 70,
94–118.
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Journal of the History of Medicine : Vol. 62, January 2007
less manifestly unwell, would be able to work more efficiently; and,
less likely to carry disease organisms, they would present fewer
dangers to Europeans (whose own disease-carrying capacity generally was ignored). Tropical public health was principally a localized
form of industrial hygiene, first for the colonizer, and then for the
laboring colonized. And clearly the policy of education and supervision had other advantages. Its goal of nurturing self-control among
Filipinos offered both to absolve the authorities from major environmental and social reform—so promising the great financial savings
never far from a colonial administrator’s thoughts—and to accord in
the most progressive style with the new science of disease causation,
transmission, and acquisition.
Elsewhere, I have linked the increasing emphasis on hygiene in
colonial medicine to the changing character of colonial warfare,
choosing to emphasize new styles of military deployment and management more than innovation in laboratory practice.32 Germ theory was a resource for new medical strategies, not their cause. A
public health system modeled on colonial warfare is considerably
different from any derived from notions of continental warfare:
colonial wars are fought in remote countries over large areas of
unknown territory with the aim not the destruction of the enemy,
but, as Jean Gottman has pointed out, the “organization of the conquered peoples and territory under a particular control.”33 The aim
is to occupy and organize subjugated territories. In 1900, Hubert
Lyautey announced a new principle of colonial strategy: avoid the
column and replace it with “progressive occupation.” (In fact, this
was a codification of what had already emerged in practice.) “Military
occupation,” he wrote, “consists less in military operations than in
an organization on the march.” The idea was to cover new territory
with a network of disciplinary structures, including a network of
hygiene. Colonial warfare at the turn of the century was recognized
as inseparable from administration. According to Lyautey, “the
occupation deposits the units in the soil like sedimentary strata”—it
32. Anderson, “Germs of Resistance.”
33. Jean Gottman, “Bugeaud, Galliéni, Lyautey: The Development of French Colonial
Warfare,” in Makers of Modern Strategy: Military Thought from Machiavelli to Hitler, ed. Edward
Mead Earle (Princeton, N.J.: Princeton University Press, 1952), 234–59, 235. See also Keith
Jeffrey, “Colonial Warfare, 1900–39,” in Warfare in the 20th Century: Theory and Practice, ed.
Colin McInnes and G. D. Sheffield (London: Unwin Hyman, 1988), 24–50.
Anderson : Immunization and Hygiene in the Colonial Philippines 13
creates a new, more favorable, terrain.34 As a historian of colonial
warfare has commented, “instead of bringing death to the theater of
operations, the aim [was] to create life within it.”35 In the early
twentieth century, hygiene thus moves out of the enclave or garrison,
and becomes an operational constituent of the military management
of colonial populations, a specified part of the new strategy of colonial
warfare. It is within this administrative structure—a colonial
amalgam of medicine and the military—that bacteriology and parasitology eventually are recognized as useful tools. In relation to vaccination, then, my point is this: it resembles an older continental
military operation—a remnant embedded in modern health
strategy—while the new hygiene, as an “organization on the march,”
does more to create a favorable terrain for the colonial state. Each
follows a different military model, with different consequences.
It is as easy to overstate this emerging concern with hygiene as it
has been to ignore it. Development of vaccines was, of course, as
much a part of the new bacteriology as was the prevention of disease
transmission through reform of personal conduct. Louis Pasteur,
assuming that cowpox was an attenuated form of smallpox (even
though he could isolate no microbe), had developed the principles
of active immunization with living, attenuated cultures. He experimented with immunization against anthrax and rabies, using infective
material of lowered virulence: even when attenuated, this material
appeared to retain the property of antigenicity. When Pasteur, in
1881, managed to produce immunity to anthrax in sheep, he called
the non-virulent antigenic material a “vaccine,” in honor of Jenner. In
1896, Almroth Wright produced active immunity to typhoid with a
killed bacterial vaccine. Trials on 4,000 volunteers in the Indian army
between 1898 and 1902, using broth cultures of bacilli killed by exposure to high temperatures and 0.4% Lysol, gave encouraging results
but also severe local and general reactions.36
34. Hubert Lyautey, “Du rôle colonial de l’Armée,” Revue des deux mondes, 15 February
1900, 157, 308–28. Lyautey, the major theorist of colonial warfare, was of course describing
French operations, but even Charles Callwell, in his influential contemporary publication
Small Wars: Their Principles and Practice, 3rd ed. (London: HMSO, 1906), makes a similar
argument for combining military action with political action. And from late 1899 in the
Philippines, the United States army provided a perfect example of the “new” principle of
strategy.
35. Gottman, “Bugeaud, Galliéni, Lyautey,” 246.
36. Parish, History of Immunization.
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By the end of the nineteenth century, it was evident that the
injection of germs in an attenuated state, or when dead, could confer a resistance to many communicable diseases. The list of candidate
vaccines might be expanded indefinitely. In 1896, Wilhelm Kolle
had prepared a heat-killed cholera vaccine that gained some epidemiological support but was not widely taken up. The next year, in
India, Waldemar Haffkine developed a plague vaccine, using a broth
culture of the organism (isolated by Yersin and Kitasato in 1894),
heat-killed and phenolized. Within a few weeks, over 8,000 people
were inoculated in Bombay; millions of doses were later produced
in the Plague Research Laboratory. During 1902–1903, over half the
military in the Punjab was vaccinated against plague, with an apparent reduction in case incidence and mortality. (But the Mulkowal
disaster, in 1902, when tetanus contamination killed nineteen recipients, helped to mute enthusiasm for plague vaccination.) During
this period, laboratory researchers also were adding a variety of
antitoxins—most significantly, against diphtheria and tetanus—to
these expanding serological resources.37
A large variety of sera and vaccines were developed and kept in stock
in the serum laboratory of the Bureau of Science in the Philippines.
In the laboratory’s early years, the preparation of anti-rinderpest
serum and of smallpox vaccine constituted the bulk of its work, but
it also issued diphtheria, plague, and tetanus antitoxins.38 By 1909, it
was offering tuberculin; vaccines for cholera, anthrax, gonococcus, and
Staph. aureus and S. albus; and sera for diphtheria, cholera, typhoid,
plague, and dysentery.39 In 1913, anti-meningococcic serum was added
to the list. Even carcinoma tissue from Filipino patients in the wards
of the Philippines General Hospital was dried and pulverized at the
serum laboratories to produce a vaccine against carcinoma.40 Of
course most of these products were experimental; their profusion
37. Ibid.; Rosen, History of Public Health; Paul Weindling, “The Immunological Tradition,”
in Companion Encyclopaedia of the History of Medicine, ed. W. F. Bynum and Roy Porter,
2 vols. (London and New York: Routledge, 1993), I, 192–204.
38. Paul C. Freer, Third Annual Report of the Superintendent of Government Laboratories,
1903–04 (Manila: Bureau of Printing, 1905), 12–14.
39. Paul C. Freer, Eighth Annual Report of the Director of the Bureau of Science, 1909 (Manila:
Bureau of Printing, 1910), 18.
40. Paul C. Freer, Tenth Annual Report of the Director of the Bureau of Science, 1911 (Manila:
Bureau of Printing, 1912), 16. See A. F. Coca and P. K. Gilman, “The Specific Treatment
of Carcinoma,” Philippine J. Sci., 1909, 4B, 391–403.
Anderson : Immunization and Hygiene in the Colonial Philippines 15
indicates more an enthusiasm for the potential of the new serology
than any confidence in its current efficacy. But all the same, a few
products were clearly effective. By 1918, the serum laboratory was producing annually enough vaccine virus to effectively vaccinate two
million people against smallpox.41
Serum development—fundamentally a service role—also provided
opportunities for creditable “original investigation.” Indeed, Paul
Freer, the director of the Bureau of Science, noted that “in the
Serum Laboratory as in any other the value of the research work is
apparent. The last word on the manufacture of serums and prophylactics has not by any means been rendered.”42 And yet, he continued, “so much of the time of the force is taken by the actual care of
the animals and in making serums for which at present there is a
demand,” that many worthwhile projects had been put aside. The
staff nevertheless found time to experiment with using glycerine in
the preparation of vaccine virus;43 Rüdiger investigated the etiology
of rinderpest;44 and a vast array of immunological agents continued
to be developed and tested in this period.45 The most notable local
innovation was Richard P. Strong’s production of a more effective
cholera vaccine.46 In 1918, sera and vaccines were displayed at the
Asamblea Regional de Médicos y Farmaceúticos to teach Filipino
physicians how to obtain and use a variety of immunological agents.
41. Alvin J. Cox, “Philippine Bureau of Science,” Bureau of Science Press Bulletin No. 87
(Manila: Bureau of Printing, 1918), RG 350/3466–38, NARA College Park, Maryland, 5.
See also Elmer D. Merrill, “Bureau of Science,” 11 October 1921, RG 350/3465–97,
NARA College Park, Maryland.
42. Freer, Third Annual Report, 1903–04, 14.
43. Paul C. Freer, Fifth Annual Report of the Director of the Bureau of Science, year ending
August 1, 1906 (Manila: Bureau of Printing, 1907), 19.
44. Paul C. Freer, Ninth Annual Report of the Bureau of Science, 1910 (Manila: Bureau of
Printing, 1911), 17. See E. H. Rüdiger, “Filtration Experiments on the Virus of Cattle
Plague with Chamberland Filters ‘F’,” Philippine J. Sci., 1909, 4B, 37–42.
45. See for example E. R. Whitmore, “The Inoculation of Bacterial Vaccines as a
Practical Method for the Treatment of Bacterial Diseases,” Philippine J. Sci., 1908, 3B, 421–30;
A. W. Sellards, “Immunity Reactions with Amoebae,” Philippine J. Sci., 1911, 6B, 281–98;
H. D. Bloombergh, “The Wasserman Reaction in Syphilis, Leprosy, and Yaws,” Philippine
J. Sci., 1911, 6B, 335–42; Rüdiger, “The Duration of Passive Immunity against Tetanus
Toxin,” Philippine J. Sci., 1913, 8B, 139–42; and idem., “The Preparation of Tetanus Antitoxin,” Philippine J. Sci., 1915, 10B, 31–64.
46. See Richard P. Strong, “The Investigations Carried on by the Biological Laboratory
in Relation to the Suppression of the Recent Cholera Outbreak in Manila,” Philippine J. Sci.,
1907, 2B, 413–41. Strong was later the first professor of tropical medicine at Harvard. See
also Paul C. Freer, Fourth Annual Report of the Superintendent of Government Laboratories, 1905
(Manila: Bureau of Printing, 1906), 17.
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Photographs on display there showed the serum stables, bleeding
house, and the process of obtaining blood from horses to make sera
and vaccines. (Many physicians later visited the Bureau itself, where
they were entertained by J. A. Johnston’s demonstration of the motility
of cholera vibrios, “showing the scintillating, darting movements” of
the organisms.47)
Clinical trials of the new immunological products at Bilibid
Prison were common in the first decade of the century. Early in
September 1905, for instance, one-half of the prisoners received
cholera vaccine: the resultant “herd immunity” seemed to reduce
the spread of the disease.48 But perhaps the most memorable—and
infamous—of these studies was Strong’s inoculation of twenty-four
inmates with a new live cholera vaccine that had somehow become
contaminated with plague organisms.49 A virulent plague culture had
been accidentally mixed with the cholera cultures. All the men sickened, and thirteen died. After an investigation, Strong was exonerated. Strong had, though, conducted the inoculations “in the
convalescent ward [where] he ordered all the prisoners there to form
a line . . . without telling them what he was going to do, nor consulting their wishes in the matter.”50 Neither cholera nor plague was
prevalent in the prison at the time. The investigating committee
suggested that Strong had forgotten “the respect due every human
being in not having asked the consent of persons inoculated.” It
enjoined the governor-general to order that no one would be subjected to “experiment without prior determination of the character
of that experiment by authorities . . . nor without having first gained
the expressed consent of the person subject to it.”51
Clearly vaccine development could be a creditable, if risky, field
of investigation even in a state increasingly dedicated to hygiene
47. Alvin J. Cox, 17th Annual Report of the Director of the Bureau of Science, for the year ending
December 31, 1918 (Manila: Bureau of Prining, 1919), 20.
48. Freer, Fifth Annual Report, 1906, 11.
49. See Eli Chernin, “Richard Pearson Strong and the Iatrogenic Plague Disaster in
Bilibid Prison, Manila, 1906,” Rev. Infect. Dis., 1989, 11, 996–1004.
50. “Report of the General Committee,” 1 March 1907, RG 4341/21, NARA, 11.
51. Ibid., 18. A. C. Ivy (“History and Ethics of the Use of Human Subjects in Medical
Experiments,” Science, 1948, 108, 1–5) claims that Strong was the first American to use prisoners for medical research. Chernin (1001) points out that Strong’s earlier study of plague
immunization, also conducted without consent, has been presented as a case study in
human experimentation in J. Katz, Experimentation with Human Beings (New York: Russell
Sage Foundation, 1972), 1014–15.
Anderson : Immunization and Hygiene in the Colonial Philippines 17
reform. But the new candidate vaccines were used primarily in the
military in the Philippines; even the expatriate American community
was allowed no automatic biological protection from local diseases.52
No one proposed any additional mass vaccination campaign; the
response to outbreaks of plague, typhoid, and cholera did not include
vaccination of Filipinos. Freer extolled experiments based on the
theory that “a natural immunity may be increased or one which is
scarcely existent may be rendered apparent and protective by the
introduction of cells, or the products of these cells.”53 But the actual
use of vaccines remained limited. Whether for technical, financial,
or governmental reasons, the health authorities continued to rely on
stipulations of personal hygiene to control the transmission of pathogens, rather than deliver an automatic immunological protection
that might render such rules of proper conduct medically unnecessary. Until the 1920s, smallpox vaccination was the only large-scale
program of biological protection for civilians in the archipelago.
CONCLUSION
The medical response to smallpox remained exceptional even when
it had become, in theory at least, paradigmatic. There are a number
of reasons for this singularity. Smallpox vaccine was cheaper than
most others, and, since the introduction of glycerinated lymph in
the 1890s, often more reliable. Its use was hallowed by long tradition. And smallpox itself was a notoriously contagious disease, not
likely to be contained by even the most stringent of hygienic stipulations. Just as importantly, smallpox vaccination had become an
effective means of building up a public health bureaucracy: Judith
W. Leavitt has observed that in the United States, too, the effect of a
smallpox outbreak was “typically to increase the power and effectiveness of the health department.”54 In his study of state vaccination
in Victorian Britain, R. J. Lambert argues that “technocrats,” not
52. The first attempt to vaccinate U.S. troops against typhoid took place in 1904, with
disastrous consequences. See W. D. Tigertt, “The Initial Effort to Immunize American
Soldiers with Typhoid Vaccine,” Mil. Med., 1959, 124, 342–49. By 1911, though, the U.S.
Army had made typhoid vaccination compulsory; see Russell, “Anti-typhoid Vaccination.”
53. Paul C. Freer, “A Consideration of Some of the Modern Theories of Immunity,”
Philippine J. Sci., 1907, 2B, 71–81, 75. For a typically confident account of the field’s potential,
see W. M. Haffkine, “On Preventive Inoculation,” J. Trop. Med., 1899, 2, 322–27.
54. Judith W. Leavitt, “Politics and Public Health: Smallpox in Milwaukee, 1894–95,”
Bull. Hist. Med., 1976, 50, 553–68, 553.
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politicians or the public, used compulsory vaccination to construct a
“medical department of state.”55 Although mass vaccination became
the symbol of an interventionist and repressive state, it more accurately indicated the state’s sensitivity to pressure from the medical
profession or public health bureaucrats. But in the early twentieth
century, vaccination fitted uneasily with a governmental discourse
increasingly committed to socialization. State support for vaccination
programs became more ambiguous. Smallpox prevention allowed a
government to reach, but not to grasp, the people: once it had reached
them, it would have them acquire a form of civility, not antibodies.
Hygiene, not vaccination, thus became the watchword of health
departments everywhere.56
In 1978 at Alma Ata, representatives of the member states of the
World Health Organization declared their support for primary health
care—indicating a concern to target health education and provision
at the level previously occupied by hygiene alone. In particular, the
conference emphasized the need for education concerning health
problems, promotion of proper nutrition and safe water supplies,
maternal and child health care, prevention and control of local
endemic disease, and the provision of essential drugs. Immunization
against major infectious diseases, previously approached “vertically”
as single-focus projects aimed at a specific disease, was to become
enmeshed in the delivery of general primary health care.57 But many
international health experts regarded such a comprehensive program
as impractical and too expensive: they promoted instead a more selective strategy, which underpinned the later universal child immunization
55. R. J. Lambert, “A Victorian National Health Service: State Vaccination, 1855–71,”
Hist. J., 1962, 5, 1–18, 14.
56. Clark H. Yaeger, a representative in the Philippines of the International Health
Division (IHD) of the Rockefeller Foundation, sometimes worried that a few nationalist
public health officers were tending to favor immunization over hygiene in the 1930s. He
urged Victor Heiser, by then the Director for the East of the IHD, to appeal again to politicians to emphasize education in personal hygiene and latrine building (Yaeger to Heiser,
23 February 1933, Rockefeller Foundation archives, RG 1.1, series 242, box 1, folder 9,
Rockefeller Archive Center, Tarrytown, New York).
57. World Health Organization: Declaration of Alma Ata. Report on the International
Conference on Primary Health Care, Alma Ata, USSR, Sept 6–12, 1978 (Geneva: WHO,
1978). In contrast, on the eradication of smallpox (the most successful example of a vertical approach), see F. Fenner, D. A. Henderson, I. Arita, Z. Jezek, and I. D. Ladnyi,
Smallpox and Its Eradication (Geneva: WHO, 1988); and J. W. Hopkins, The Eradication of
Smallpox: Organizational Learning and Innovation in Public Health (Boulder: Westview
Press, 1989).
Anderson : Immunization and Hygiene in the Colonial Philippines 19
program and specific disease eradication goals.58 The tension between
such “vertical” and “horizontal” programs, too often rendered simply
as a struggle between opposites, has generated considerable controversy among international health experts; it has also echoed, if faintly,
many of the earlier divergences in the approaches of vaccinologists
and hygienists. Debabar Banerji, for example, argues that the focus
on immunization in selective primary health care perpetuates the
“short-term technocentric approaches” that characterized the mass
BCG campaign and the malaria and smallpox eradication programs.
In contrast, through comprehensive primary health care, “the entire
edifice of the health services might be built with a mix of technology and administrative structure, tailor-made to serve the interests of
the people.”59 On the other hand, Peter Wright provocatively advocates a technical approach that does not become complicated by
educational efforts: although the smallpox eradication program often
resembled an old-fashioned military campaign, it did work (and it
did expand the international health services). He praises immunization,
for it is “a vehicle that runs independently of social customs and is a
means to improve health without being a mechanism for social
change.”60
In other words, the more effectively vaccination intervenes, the
less useful it is as a vehicle for social discipline. But perhaps the
response to AIDS provides the best illustration. Wright laments that
the prevention of HIV transmission currently depends on an “individualized educational component and understanding of cultures”
in order to change the “basic structures of social (and sexual)
58. Julia A. Walsh and Kenneth S. Warren, “Selective Primary Health Care: An Interim
Strategy for Disease Control in Developing Countries,” N. Engl. J. Med., 1979, 301,
967–74. See also William Muraskin, The War Against Hepatitis B: A History of the International Task Force on Hepatitis B Immunization (Philadelphia: University of Pennsylvania Press,
1995).
59. Debabar Banerji, “Hidden Menace in the Universal Child Immunization Program,”
Int. J. Health Serv., 1988, 18, 293–99, 293. See also Banerji, “Crash of the Immunization
Program: Consequences of a Totalitarian Approach,” Int. J. Health Serv., 1990, 20, 501–10.
See also the useful distinction between routinized vaccination and the vaccination campaign in Pieter Streefland, A. M. R. Chowdhury, and Pilar Ramos-Jimenez, “Patterns of
Vaccination Acceptance,” Soc. Sci. Med., 1999, 49, 1705–16.
60. Peter F. Wright, “Global Immunization—A Medical Perspective,” Soc. Sci. Med.,
1995, 41, 609–16, 615. Vicente Navarro criticizes both vertical and horizontal programs,
with their common emphasis on access to medical care, for ignoring the need for structural
economic and political changes, in “A Critique of the Ideological and Political Position of
the Brandt Report and the Alma Ata Declaration,” Int. J. Health Serv., 1984, 14, 159–72.
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intercourse.”61 A vaccine, to some extent, would make such social
reform unnecessary, but would its use, however “coercive,” promote
the interests of a modern state dedicated to the colonization of the
bodies of its citizens? Probably not so effectively as current stipulations
of sexual and social hygiene, delivered at the level of primary health
care.
“The modern state,” Paul Greenough writes, “is in a position to
demand that its citizens surrender their immune systems as a public
duty.”62 But such a submission is among the less exacting demands
that a modern state can make.
ACKNOWLEDGMENTS. I would like to thank Paul Greenough for advice on earlier versions
of this article, and Martin Gibbs and Kiko Benitez for research assistance.
61. Wright, “Global Immunization,” 615. See also Max Essex, “Strategies of Research
for a Vaccine Against AIDS,” Hist. Philos. Life Sci., 1995, 17, 141–49.
62. Paul Greenough, “Global Immunization and Culture: Compliance and Resistance in
Large-Scale Public Health Campaigns: Introduction,” Soc. Sci. Med., 1995, 41, 605–7, 606.