To Hoff and his staff, Puerto Rico was terra incognita. The smallest and easternmost island of the Greater Antilles, with a landmass three quarters the size of Connecticut, Puerto Rico lay roughly a thousand miles southeast of the recently incorporated U.S. city of Miami. A range of rugged mountains called the Cordillera Central divided the island’s wet Atlantic-facing northern half from its dryer Caribbean southern half. The climate was unmistakably tropical, with a rainy season that stretched from August to December. Getting around was hard. The island possessed few good harbors, most notably at San Juan on the north and Ponce on the South. But for the old Spanish military road that ran between those cities, there was, as one frustrated Army surgeon noted, “not a good road on the island.” In the wet season, the bridle paths and streams that connected the villages and barrios along the Cordillera Central flooded and became impassable for weeks.53
The Puerto Ricans confounded the Americans. “The laws, language, customs, institutions, and aspirations of the people were all strange, and in many respects, very difficult of comprehension,” said one military government report. American eyes puzzled over the island’s peculiar settlement patterns. Puerto Rico seemed to them a contradiction in terms: an overpopulated rural country. Fewer than one tenth of the people lived in cities, the rest in barrios, villages, and small farms. The chief industries centered on the land, especially sugar cultivation (along the coast), coffee growing (in the mountains), and cattle raising (along the southern plateaus). To the occupiers, the islanders’ problems resembled those the Americans associated with the tenement districts of their own industrial cities. The crowded palm-thatched huts were “entirely without any arrangements for the disposal of excreta.” Three quarters of the population lived in “miserable hovels,” subsisting upon “the merest apology for food.” Although the island had a small professional elite, including well-trained physicians, few Puerto Ricans could read. And the people suffered prodigiously from intestinal diseases as well as endemic tuberculosis, smallpox, and a deadly disease called anaemia.54
The multiracial population of the island defied the familiar American racial taxonomies. Major Ames described Puerto Rico uneasily as “the only ‘white’ island of the Antilles.” American racial norms had consolidated in recent years, with the Supreme Court recognizing the southern states’ peculiar “one drop” rule (which made a person with even a small amount of African “blood” black in the eyes of the law). Slavery had survived in Puerto Rico until 1873, and black laborers predominated on the sugar plantations. But Americans were uncertain how to classify the rest of the people. Assistant Surgeon General C. H. Alden reckoned that three fifths of the population was “pure white and almost entirely of Spanish descent.” But the Puerto Ricans did not subscribe to the American one-drop rule, and U.S. officials complained of “the natural tendency [of] the mulatto to deny the existence of negro blood in his veins.”55
Under military rule the Puerto Ricans inhabited an unstable political space within, but not of, the United States. During the invasion, General Miles had issued a proclamation to the inhabitants, assuring them that the American troops marching through their villages carried the “banner of freedom.” “This is not a war of devastation,” declared the old Indian fighter, “but one to give to all within the control of its military and naval forces the advantages and blessings of enlightened civilization.” As the Army built roads, opened schools, and cleaned cities, the military government said its duty was to protect and prepare the inhabitants for their “ultimate destiny” as “an autonomous, self-governing, and law-abiding people.” But the military governor lacked clear instructions as to whether the people ought to enjoy the guarantees of the U.S. Constitution. Practical political economy soon answered that question. In January 1899, President McKinley ordered the military authorities to collect customs duties on U.S. imports to the island. The commanding general reasonably concluded that the Constitution had not “followed the flag.” A divided U.S. Supreme Court later reached much the same conclusion.56
Smallpox was present on Puerto Rico in the best of times, but the rapid spread of the disease in late 1898 sent waves of alarm through the command. The influx of tens of thousands of Spanish and American soldiers and the hurried movements of displaced civilians had carried the disease far and wide. The exact scale of the outbreaks is uncertain. According to one report issued by Surgeon General Sternberg, from December 15, 1898, to February 11, 1899, sixteen villages and towns reported more than 550 cases. The volunteer surgeons Major Ames and Major Groff insisted that post surgeons had reported 3,000 cases during November and December alone. Army officials agreed that the epidemic constituted, in Sternberg’s words, “a constant menace to the people and to the material interests of the island.” “It steadily took on greater proportions,” Ames recalled, “no part of the island being free from it, until nearly all the country barrios (precincts) were infested.”57
Hoff kept a close watch on the emerging epidemic. His first response was to shore up the cordon sanitaire by ensuring that all troops were well vaccinated and keeping their garrisons clean. But with the soldiers living so closely with the native population, the line could not hold. Stateside newspapers ran stories on local boys who contracted smallpox in Puerto Rico; some of the soldiers died from the disease, others carried it back with them to infect American communities. The pressure rose for stronger measures. For Hoff, the turning point came when neighboring islands, including St. Thomas, Puerto Rico’s closest neighbor and a significant port of trade, quarantined against the island. Other ports, including New York, were considering the same action. For a colonial administration dependent on customs taxes, the situation was serious. If America’s largest port ceased doing business with the place, this tropical possession, funded largely by the flow of goods to and from the United States, would be in deep trouble. “[T]he success of our first effort in military government was hanging in the balance,” Hoff recalled. He paid a visit to the U.S. governor general, Guy V. Henry.58
According to the official Spanish legend, vaccine had first arrived on Puerto Rico in European bodies aboard European ships. If this were true, vaccine would have made much the same voyage to the New World as the variola virus itself. In 1518, a quarter century after the arrival of the Spanish, an epidemic of smallpox decimated the indigenous Tainos. Nearly three centuries later, on November 30, 1803, an expedition set sail from Corunna, Spain. Led by Dr. Francisco Xavier de Balmis, the Spanish court physician, its mission was to bring the new technology of Jennerian vaccination to the people of the vast Spanish empire in Latin America and the Pacific. On board were twenty-two foundlings, whose young bodies had never suffered the smallpox. Before setting sail, Balmis inoculated the first child with vaccine; as the expedition made its way across the seas, the doctor kept the “precious fluid” alive by vaccinating each child in succession, with pus from the vaccine sore of the previous child, in a continuous arm-to-arm relay. In this way, the Balmis expedition delivered “the beneficence of the King” to the Canary Islands, Puerto Rico, and Caracas, before breaking into two expeditions. One sailed to South America via Havana, the other to Vera Cruz and Mexico. Balmis picked up a fresh group of twenty-six children in Mexico before setting sail from Acapulco for the Philippines.59
In at least one respect, the official Spanish story cheated history. Balmis had arrived in Puerto Rico two months too late. With an epidemic of small-pox sweeping the island, a resourceful San Juan doctor named Francisco Oller (a military surgeon, no less) had procured some vaccine lymph from British St. Thomas. By the time of Balmis’s arrival, more than 1,500 residents of San Juan had already been vaccinated. The royal doctor promptly denounced Oller as a fraud and his vaccine as worthless.60
Under Spanish rule during the nineteenth century, Puerto Ricans grew accustomed to the occasional spectacle of public vaccinations. During smallpox epidemics, the public vaccinator would call the people of a barrio or village to assemble. Using virus secured from the Central Insti
tute of Vaccination at San Juan, the vaccinator would inoculate a calf or two, drive them to the center of each village or barrio at an appointed date, and set about vaccinating the people with fluid taken directly from the animal. In the final years of Spanish rule there still existed much popular opposition to the medical practice, not least because the vaccine orders seemed so arbitrary and the operation itself so often proved ineffective. In the 1890s the Spanish compulsory vaccination measures, according to Colonel Hoff, had been “honored in the breach more than in the observance,” especially in the rural areas. The greatest number of vaccinations performed in a single year was fewer than 25,000 (in a population exceeding 900,000 people). American officials may have exaggerated the defects of Spanish “misrule,” but Puerto Rico did suffer a high incidence of smallpox during its final decade under Spain. In 1890, smallpox killed 2,362 people—accounting for 9 percent of the island’s deaths that year. For the decade, deaths from smallpox averaged 620 per year. A far greater number were left scarred or blinded by the disease. Lacking an effective measure against the disease, many Puerto Ricans regarded smallpox with a fatalism that Army medical officials too readily interpreted as indifference.61
The incidence of smallpox on Puerto Rico at the start of 1899 was not dramatically out of proportion with that of the last years of Spanish rule. Smallpox killed an estimated 522 islanders in 1898, somewhat below average for recent years. What was new was the presence of a regime determined to bring its full might to bear in fighting the disease.62
On January 27, 1899, the American governor general Guy Henry issued General Order No. 7. “The inhabitants of this island must be protected from smallpox,” it proclaimed. “Every resident who has not had this disease will be vaccinated, and hereafter all infants must be vaccinated before reaching the age of six months.” Hoff took charge. The order parceled the island into five geographical areas of roughly 200,000 inhabitants, each presided over by an Army medical officer designated as a director of vaccination. Each director, including Major Ames and Major Groff, would command a staff of surgeons, inspectors, and Hospital Corpsmen. The directors would report any neglect by Puerto Rican authorities to carry out the order’s provisions.63
General Order No. 7 called for compulsory public health on a scale never before seen in Puerto Rico or, for that matter, any territory under the direct jurisdiction of the U.S. government. As the Army carried vaccination to the people, the Marine-Hospital Service ran a quarantine at the island’s ports, requiring all arriving passengers to show proof of vaccination and all travelers bound for the mainland to undergo the procedure. The vaccination campaign was all the more ambitious given the serious technological, geographical, and political obstacles that stood in the way. Dozens of centers of contagion existed, including barrios high in the mountainous interior whose people had little experience with sanitary authority. Most Puerto Ricans lived under crowded conditions, moving constantly between the countryside and the towns for trade and work. Like other Western physicians in colonial settings, the military doctors complained of the “indifference” of the “natives.” Ames noted the difficulty of delivering modern health to “hundreds of thousands of unregistered people, mostly ignorant and scattered, speaking foreign tongues, and unused to sanitary controls.” Unbeknownst to him, his complaint echoed those sounded by Kentucky health officials as they struggled to enforce vaccination in Appalachia.64
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.65
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.66
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.67
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.68
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.”69
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.”70
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