Doctors and Peasants at the Intersection of Empires: The Hookworm Campaigns in Puerto Rico Francisco A.

Scarano University of Wisconsin-Madison

I do not believe that anything will bind these people more closely to us than the practical proof that we do not care to see a disease exterminate them. This is one good reason for our conducting the work. Another is this: if, as Secretary Taft would seem to desire, that the island be given a chance to engage in the canal work, such cured cases could be sent <to> the official in charge of the <illegible>barcation as would be fit to go without the well high certain chance of their becoming a future charge on the Canal Government on account of spreading an infectious disease. Another reason is that many most important scientific questions concerning the disease in particular and <illegible> to hemolysis are before us. In other words, a great field of work is opened up... ---Dr. Bailey K. Ashford

This paper examines key aspects of the manifold relationship between the Bailey K. Ashford, other American physicians, government and military figures, a deeply divided Puerto Rican medical establishment, and the peasant population in the immediate aftermath of the Spanish-Cuban-Filipino-American War. It seeks to answer the question of how the cloth of American hegemony in the new Caribbean colony was woven from a highly contingent process of political partisanship, struggles over the meaning of nationhood and citizenship, imperial ideologies laced with notions of Anglo-Saxon superiority, and class confrontation between the rural laboring groups and local and international capitalists. I claim that in order to fully understand the hegemonic process that affixed and normalized the U.S. colonial presence in Puerto Rico, of which the anemia campaigns were a central ingredient, we must understand a long precedent of peasant-hacendado conflictive patronage. Through a drawn-out process, generations old, of collaboration and resistance, Puerto Rican hacendados, especially in the highlands, and their literary and medical comrades had elaborated practices that combined benevolent, patriarchic interaction and guardianship with ruthless exploitation and cultural derisionthat articulated discourses of redemption and future nation-building, albeit with defective human raw material, with evolving, even intensifying, economic and social exploitation. These practices went along with, and were made part of, hegemonic discourses of concern and compassion for the jbaros. Thus, patronage as well as forms of labor exaction and exploitation bound the two groups together and sealed a strong bond of social cohesion, one that creole, liberal-reformist politicians strategically deployed to strengthen their hand in their confrontation with Spain over greater measures of self-rule. Some Americans, and no one more so than Ashford, recognized that this complex relationship involved
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a bond of interdependence that the U.S. would need to interrupt if it was to bind these people more closely to us. At one level, then, the anemia campaigns were about loosening the hacendados grip on peasants and laborers although in the discourse of some enthusiasts of the project they could also strengthen the hacendados by supplying them with stronger, healthier bodies to work. Both military and civilian representatives of the invading country, however, held the former objective to be foremost. Their often coded intentions lauded the superior economic possibilities of the island under the guidance of American investors in agriculture, industry, and utilities. In so doing, they expressed a desire to overturn social hierarchies inherited from the Spanish colonial era, and none more particularly than the one between coffee hacendados and highland peasants. U.S. officials were clear about the society they envisioned under the U.S. flag and the roles that certain key players would be summoned for: American capitalists would provide the energy and skill while Puerto Rican laborers would provide the hard work. Few expressed this more clearly than Charles H. Allen, the first civilian governor of the island under the Foraker Act, who noted that [w]ith American capital and American methods, the labor of the natives can be utilized to the lasting benefit of all parties and the general good of the commonwealth. This state of affairs evidently called for removing the hacendados from their predominant economic and social position. The anemia campaigns were many other things as well: novel state interventions in society with specific public-health goals; theatrical demonstrations of the superiority of American medical science; validation for a rapidly evolving world of American medical education and practice; explanations for the uniqueness of American intrusion in the Philippines, Hawaii, Puerto Rico, Cuba, the Panama Canal, and others, that could partially address the contradiction between democracy at home and imperialism abroad; and many others. It is highly instructive to read Ashfords paper trail on the campaigns in all of these lights. Ashford himself was acutely aware of the range of ideological and practical values that would accrue to the imperial enterprise if his campaigns were successful, as the epigraph to this paper suggests. The fact that these values and this symbolism were real, and that they bound many generations of Puerto Ricans to the American imperial project, if only to a limited extent, may be regarded as an allegory for the overall success of U.S. hegemonic penetration in Puerto Ricoan apparently successful venture that, 113 years after the fact, still engenders, in the deepening cultural-nationalist discourses of today, in parallel with politically assimilationist rhetoric, its most convincing demonstration of partial success and partial failure. II. By the second half of the century liberal-reformist creoles, many of them scions of peninsular Spanish families, had conceded that a weakened and degraded Spain and the colonial system it had sustained for decades were the cause of the islands ills. Prominent in this judgment were issues regarding public health, which observers linked to the entire fiberphysical, moral, and spiritual of the social body. While steeped in neo-Lamarckist ideas that made a complex set of factorsnot just race and heritage, but geography and other environmental featuresthe root causes of a countrys strength or weakness, the reformists also blamed Spain and its colonial mis-governance for the jbaro peasantrys deteriorating health, lack of vigor, and moral frailty. This was obviously a complex diagnosis, for it hinged not just on an ambivalent conception of local popular society and cultureit was both barbarous and potentially salvageablebut also
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on an uncertain admiration for Spain and the desire to remain politically linked to it, even as it disliked the local expression of Spanish institutions and the metropoles local representatives. Like other 19th. C. Latin American elites, but perhaps more so than most given the islands colonial condition, Puerto Ricos reformist liberals were caught between derision and admiration for both their superiors and their subalterns in the hierarchy of political and social power. During a long period of official censure and repression, roughly between 1823 and 1868, they had used various subterfuges to disguise their criticism of colonial policies and ridicule of officials, thus avoiding censure. But while they did not much conceal their racist condescension for a wretched, racially-mixed population incapable yet of becoming a democratic citizenry, they expressed hope that unusually white (for the Caribbean) but environmentally and congenitally degraded peasants and laborers would overcome all the flaws they had inherited from their nonwhite ancestors to finally be full participants in what Silvia Alvarez Curbelo has aptly termed un pas de porvenira country yet in the making. Most of these liberal reformist men (and a few women amongst them) had been educated abroad, for there were no universities in a colony whose Spanish governor-generals recurrently and aggressively blocked local initiatives to found even a modest one. Among the tiny minority of the university-educated, a significant number had received medical training in France and Spain, later returning to their homeland to sell their services primarily to the urban middle and upper sectors, and to the coffee and sugar landowners who either lived or kept homes in cities like Ponce. Not a few of those physicians in fact came from the same social strata. But whether raised in hacendado families or not, both groups, part of the same educated elite that considered itself the direct descendant of European immigrants, shared a similar need for cultivating the good will of the laboring classes while distancing themselves from them racially to a moderate extent, and socially to a much larger extent, even as they associated their own history as an group with the ethnic or cultural stamp left by multiple generations of the rural poor. It was only logical that one and the other since childhood had been in contact with peasants and laborers who were employed by members of their own social circle, or even by their own parents and relatives. Indeed, no matter how socially distant from their subalterns the hacendados and their educated relatives appeared, both groups were ensnarled in a social and political logic that bound them together in conflictive patronage. While the landowning groups in Puerto Rico and their professional cadre were not only eager and capable of stepping up their exploitation of and further marginalization of the rural labor force, and in the economically key coffee areas were definitely achieving that over the last two decades of the nineteenth century, they also strategically deployed forms of social and political patronage that gave them an important edge in their attempt to liberalize the political system and legitimize creole power. Conflict and patronage were not, therefore, contradictory; they coexisted and overlapped, to the advantage of both the dominant and the subaltern groups. An interpretive approach that allows us to consider recurring forms of contestation (and collective action as one subset of this) within the larger dynamics of patronage is pertinent to the case at hand. The politics and social dynamics of the anemia campaigns cannot be understood outside of this historical context. The U.S.-led public-health campaigns of the early years of the 20th. C. commandeered a hegemonic process under way in Puerto Ricos rural areas (and in cities, for that matter), led by liberal reformists. Like the creole reformists of an earlier age, the American and Puerto Rican doctors at the helm of these campaigns, too, tried to turn the jbaros into healthy (and worthy) citizens of the new nationbut this time, civilizing them with technologies of cure and prevention that their previous social superiors had not yet discovered
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nor deploy effectively once they did. Under the Americans, the work at hand was also much more clearly defined, for they had not just come upon a people unaccustomed to negotiating the limits and possibilities of colonial rule. Put in stark terms, they inherited a colonial system that needed to be reinvented, not built from scratch. This was not simply a case of initiating new conversations with the colonial subalterns, but of intervening in a multitude of existing conversations, some of them of quite long standing, and redefining the terms so that a new hegemony could be instated. In short, while an aging colonialism cried for an overhaul, one early and relatively economical part of it had involved a brief and bloodless military campaign. Spain had swiftly been removed from the conversation. A more difficult chapter, involving a peaceful and therefore more protracted process of obtaining the consent of the governed, had been inaugurated but was not yet concludedand perhaps could never be. For this, the new rulers needed to display their greater efficacy in running island affairs for the benefit of the countrys population while demonstrating why the more educated among the population could not be trusted to do so, in lieu of the government that had just been toppled in war. The old conflictive patronage of the liberal reformists and their planter allies needed to be delegitimized, even as the intent of erstwhile capitalist investors was to intensify the labor exploitation of the rural poor and even use people regarded as excess or surplus labor to work under American tutelage in distant landsHawaii, as it turned out in actual terms, and potentially Panama and other places about to be incorporated into the new American empire. Medicine was a crucial sphere in which to carry out the burden of this assay in colonial rule among a people who were profoundly disgusted by their old imperial masters, but as of 1898 had not turned their backs on negotiating consenta position that had become much more widespread in neighboring Cuba, where fierce fighting for independence had broken out for the third time in 1895. III. What is critical to understanding the hegemonic function of the anemia campaigns, then, is that enduring processes of domination and benevolence, estrangement and inclusion, needed to be replicated under the Americans, carried forth by a relatively inexperienced cadre of imperial agents. In 1898 the invading troops interrupted a political trajectory and, more broadly, a hegemonic process that had just yielded power to the creole liberal-reformist elite, deeply amalgamated with the landowning class and middle-sector farmers. For at least two decades before the U.S. invasion, those groups, liberal reformists for the most part, had cohered around a set of nation-building ideas whose main intellectual coordinates had been mapped by protonationalists, among whom stood physicians as the most prominent subset. When in 1899 Ashford observed for the first time the ancylostoma duodenale worms that infected many of his patients, a medical consensus existed on the origin of the jbaros problem and its solution. Regenerating the jbaros was not solely a medical problem, doctors had argued now for some time; it was a socio-medical one with political implications. A problem so overwhelming in scale required more than just medications or therapies. Moreover, the medical establishment was ill-equipped to handle a condition whose diagnosis and treatment only tangentially occupied physicians. Many of the rural sick did not visit doctors who lived in distant cities and whose services were expensive. Closer to mountain towns and especially in the peasant hamlets in the countryside, curanderos or medicine-men gave anemia sufferers brews and other preparations that depleted their pocketbooks without improving their health, and often
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made it worse. On the rare occasions when university-trained doctors were called on to treat people afflicted with anemia del pas (the countrys anemia), they suggested changes in diet, tonics, or improving hygiene in the home, all costly remedies that, according to Ashford and his team, did not address the underlying biological organism. In keeping with the tradition of conflictive patronage in which they were steeped politically, professionally, and personally, physicians like Francisco del Valle Atiles and Manuel Zeno Ganda called for a holistic intervention in the jbaross mundo enfermo. Del Valle Atiles had anticipated this characterization in his 1887 work on the jbaros as well: our white peasant is sick (enfermo) but this is due, we insist, to secondary circumstances that are easily remediable. And in a phrase that could well have come from the lips of the majority of doctors Ashford met when he began his anti-anemia crusade in 1899, Del Valle Atiles concluded that although climate and other forces were the cause of the peasants troubles, the organic poverty of the jbaro was due to those less fundamental causes that a more enlightened political and social order could address. Quickly persuaded that a parasite was at work and that a small dose of thymol was an effective treatment, Ashfords first reaction was to reveal it to Puerto Rican physicians and request them to confirm his discovery. In a long letter to the Surgeon General of the U.S. Army on November 25, 1899, the day after he had telegraphed his finding, Ashford reported that Ponce physicians had reacted well. They agreed with the diagnosis and were persuaded that until this time the existence of this parasite had not been proven on the island, or if proven, not within their knowledge. He wrote to the Surgeon General that he was now convinced of the appalling nature of the problem, the vastness of the infection among the people, and the general inaccuracy of their knowledgeignorance that patients and doctors shared, even in this heavily creole and progressive city, whose people correctly disdained the much more Spanish population center at San Juan. And in a not-so-veiled reference to Del Valle Atiless work and the prevailing medical consensus about the relative importance of malaria and hookworm, Ashford added: I know there is much malaria here in the lowlands [but] the testimony of the physicians coincides with mine that malarial organisms in the blood are not so often seen as would be supposed. Brilliant men had diagnosed malaria when it just wasnt there, adding that the disease he for which he now had evidence was curable and preventable. In this first letter to his superiors in Washington about his work with anemia patients in Ponce, Ashford pulled no punches about the material and ideological benefits the U.S. and its new clients would obtain from treating patients whose malady was caused by a worm. He couched his arguments about the larger significance of his work in a language of imperial legitimationa legitimacy that would accrue benefits to all the parties: laborers, local landowners, foreign investors, the American military, and the state. There is here in Puerto Rico, he wrote, a dense population in a small country. In a space of about 100 miles by 60 [sic for 35], we have probably over a million people. Of the working class it cannot be denied that a tremendous percentage have anemia and should the future prove my suspicion means are at hand to increase not only the wellbeing of those now suffering but to ensure to the owners of large haciendas of coffee and sugar a better class of labor, to ensure to the Army protection from the invaliding from anemia, to ensure to our American troops protection against its invasion, to unload from the hospitals here the expense to the state
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of a large number of anaemics who are now slowly but surely dragging on to a fatal end. At this early date, Ashfords conception of the American struggle to disown hacendados and their associated patrician class was still undeveloped. Only a year had passed since his arrival and the triumphal defeat of Spains forces. He no doubt harbored good feelings toward many persons in Puerto Ricos upper class, although those feelings would be tested over the next few years. Having fallen in love to and eventually married Mara Lpez Nussa, the daughter of Ramn Lpez, a prominent physician from Mayagez, the young Army physician must have been contemplating a long stay on the island, maybe even setting down roots there permanently. His marriage in February, 1900 had bonded him to an island he would eventually call home, and to which he would return several times over the course of the next 34 years, eventually settling there for good. He had begun to learn Spanish and always spelled the name of the island correctlyPuerto Rico, not Porto Rico, a corruption that became the preferred North American spelling and even the official island name for more than thirty years. It would seem consonant with this early identification with Puerto Rican society that near the end of his life Ashford referred to himself as Puerto Rican, although that did not prevent others from identifying him as an expatriate American. Because so many other North Americans no doubt experienced culture shock when they arrived on the island, one is surprised to discover, in going over Ashfords papers and printed materials, how speedily he accommodated to a society and culture that struck so many other North Americans as foreign, crowded, and hierarchical. That early report about his anemia findings in Ponce place him among the minority of North Americans for whom the imperial enterprise must have room for local expectations and desires to the largest extent possible. This group included Dr. Henry K. Carroll, President William McKinleys special Commissioner to Puerto Rico, whose 1899 Report on the Island of Porto Rico stands out for the evenhandedness of its observations and the sagacious quality of its political recommendations. For Ashford, as for Carroll, U.S. hegemony would be truly attained when the feelings of all classes of people on the island, but none more acutely than the common folk, were made part of the imperial project. IV. At this point, the historians pursuit of the story of the anemia campaign takes an unexpected turn. The Ashford papers at the Medical Sciences campus of the Universidad de Puerto Rico are abundant for the period between the first Commission against Anemia in 1904 and the end of the second, around 1906. Information for the years between 1899 and 1904 is scant, however, despite the fact that Ashford kept meticulous records, often storing carbon copies of letters he sent along with the original letters he received. In fact, it was this well-organized archive that allowed him, with the help of an assistant, to write his life memoirs in 1933, when he was already quite frail. Yet, this is an important chapter in which to gauge Ashfords evolution into a campaigner whose work was not just against a germ he had discovered, but also against what he came to regard as a recalcitrant medical establishment that resisted properly diagnosing patients with microscopic observation and then treating them, as opposed to hoping for a drastic change in the peasants economic and social conditions. After 1899, many of those physicians had joined the progressively resistant (anti-American) Partido Federal Americano under the leadership of the old Autonomist leader, Luis Muoz Rivera. Ashford and King, and
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eventually Gutirrez Igaravdez, the three original leaders of the anemia campaign, seemed especially peeved by those doctors whose resistance they came to regard derisively as the venting of anti-scientific and patriotic hot air. Not surprisingly, given the hegemonic import of public health, the confrontation that Ashford and his associates had with powerful figures within the existing medical and political establishment did not take long to develop. Available evidence suggests that soon after his Ponce work became public, Ashfords breakthrough, at first well received by the citys political establishment, became a point of contention. It came to rest on the charged political boundaries that were quickly congealing between some Puerto Ricans and the majority of U.S. administrators. Once the honeymoon with U.S. rulers passed, and especially when the contours of the U.S.-Puerto Rico relationship began to take shape in the Foraker bill, debated in Congress in the winter of 1900, many in the Federal campamong them numerous physiciansfor the first time openly questioned the colonial relationship being imposed against their will. Prominent in this group were some doctors who had agreed with Ashfords initial assessment of the anemia problem but now felt pushed into a colonial corner, forced to dig their heels in contrarian terrain. The opinions these doctors harbored of the new colonial authorities were already being tainted by the political confrontation over the extent to which the new regime would be a hybrid of integration and colonial disenfranchisementeconomically advantageous, as Muoz Rivera had pronounced when noting the adoption of nearly free trade conditions, but politically exclusionary, as it did not extend U.S. citizenship to the Puerto Ricans nor anticipate a process of territorial incorporation leading toward eventual statehood. Some U.S. military men in colonial authority contributed to this alienation by painting the countrys physicians with too thick a brush, as faithful representatives of the backward-looking culture and society to which they belonged. As Nicole Trujillo Pagn has lucidly argued, physicians had also clashed with the authorities over a series of issues during the period of military rule (13 August, 1898-1 May, 1900), in particular the question of much influence they would be allowed over a smallpox vaccination campaign begun in 1898. Although they had generally welcomed the Americans as potential allies in combating the misery and disease corroding the mundo enfermo, some insular doctors and American officials, particularly military medical officers, engaged in a protracted confrontation with the local physicians over issues of knowledge and enfranchisement. Trujillo Pagn details how the new colonial authorities sidelined these elite medical practitioners, debased their credentials, questioned their knowledge paradigms, and often lumped them with curanderos (medicine men), practicantes (medical and surgeon assistants), parteras (midwives), curiosos (persons curious or inquisitive), and other health practitioners of lower social extraction in a world not yet defined by the professionalization of the physicians craft. It is true that the dominance of university-educated doctors was upset in part by circumstances beyond anyones control, such as the arrival of numerous popular healers in lowland cities and towns after the San Ciriaco hurricane. But the new colonial authorities were clear in the need to supplant the health practitioners of all kinds, and it is therefore impossible not to see the anemia campaigns so zealously fostered by Ashford as an integral part of this. Within the new and developing institutions that Ashford influenced, writes Trujillo Pagn, Puerto Rican physicians sense of order and change was challenged by a shifting relationship to treating the islands poor. This shift in attitude toward the islands elite physiciansideologues, in many cases, of the liberal-reformist push of the late Spanish erasoured Ashfords initial optimism. Despite what he had described as the receptiveness of Ponces physicians to his method of diagnosing
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and treating anemia patients, it proved extremely difficult to put together a major effort that would involve the government, the military, and members of the medical establishment. The physicians were not yet convinced of the simplicity of the problem. And in 1900, there did not appear to be enough resolve on the part of the military government to launch the massive effort that would be required to treat the number of patients estimated to be infected. Still, in this uncertain environment, Americans oft-expressed disdain for the Spanish doctors became a central trope of the push for official action against anemiathe first shots of an extended battle between the two sides that eventually saw the American attitude toward anemia prevail, while it led to the increasing professionalization of the medicine. As early as January, 1900, Dr. George G. Groff, secretary and treasurer of the Superior Board of Health, wrote in the opinion journal The Independent that [t]he report of Lieutenant Ashford on this disease is the first paper ever written in Porto Rico on the subject and may give some idea of the activity of the American physician compared with the Spanish. In no uncertain terms Groff called into question one of the key principles undergirding the conflictive patronage that had evolved as an element of social cohesion and conflict in rural Puerto Rico: the elites claim that the improvement of the jbaros lot was to principally benefit the legitimate heirs of the land, which included the peasants, other laborers, the creole landowners, and their professional associates. Groff turned this logic around and argued that it was fortunate for the Americans that the island was getting healthier: With no small-pox, no yellow fever, and anaemia and dysentery under control, this island will have no terrors for Northern people. Thus, one by one, the causes of tropical diseases are being discovered. It is, indeed, a matter of germs and not of climate which we have to contend with in these regions, and the white man will yet conquer the tropics and make himself a healthful home there. The previous year, the Superior Board of Health (SBH) for which Groff spoke had replaced the Real Subdelegacin de Medicina (RSM), an ineffectual government body created by Spanish authorities to regulate the highly heterogenous healing occupations, from curioso to universitytrained physician. If, as Trujillo Pagn puts it, the RSM had become an obstacle for physicians professionalization and the standardization of medicine, the SBH began its existence as an institution in open combat against physicians and other Puerto Ricans who were disaffected with the new medical, public-health, and political orders. That disaffection may have had roots in the economic disruptions of war and invasion and in physicians own depressed personal economy, exacerbated by the San Ciriaco crisis. But its greatest challenge lay in the way that doctors like Ashford, even without outwardly opposing the physicians of old or relying on Groffs ethnocentricism, had begun to commandeer the hegemonic process they had launched several decades earlier and, thanks in no small measure to the Cuban insurgency, had begun to redefine the Spain-Puerto Rico relationship when war broke out in April of 1898. V. Ashfords returned to the island in 1901, after just more than a year in Washington, D.C. He asked for the transfer, perhaps because Maras fathers health had begun to deteriorate. In his memoir, he remembers a superior officer asking him if he wanting to go back and raise some more hell in Puerto Rico? To which he, the worm maniac as he referred to himself,
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answered affirmatively, and back to Ponce he went with a new commission to begin the reconquest of Puerto Rico for science. Ashford met W.W. King in Ponce, where the latter was stationed as the ports public health officer. More than three decades later, he remembered him in his memoir as honest to a fault, absolutely faithful always, and brave. It took a brave man to ostracize himself from his Spanish-speaking colleagues and furnish them with noisy amusement. Indeed, of the two original anemia campaigners it was King who most vocally expressed disdain for the Puerto Rican doctors and their socio-economic and nutritional approach to the jbaros anemia condition. In a letter to Ashford of December 31, 1901not long after the two had met, King relates having read Amadeos [possibly Lucas, the economist] diarrhea of words and constipation of ideas on ways to solve the laborers health problems. In a reference to the larger issue at hand, that is, the clash that had developed between the French-trained (and by implication, Spanish-trained) physicians and the Americans, King remarked about Amadeo: He ought to get back to that dear Paris he thinks so fine and get modernized. And continued: I am in favor of jumping all over him. We can easily tear down his arguments, but of course he will not admit it and immediately have to switch to another tack. We can get him so tangled up and force him to make denials and assertions that will make him the laughing stock of the island. Perhaps most revealing about this letter is what it implies about the alignment of forces confronting a projected campaign to combat anemia. For King, the opposing camps had lined up along ethnic and political, as well as medical and scientific, lines. He assumed, perhaps from a fount of earlier conversations between them, that Ashford saw the anemia business as a campaign against the Puerto Rican, or Spanish, doctors who did not regard the thymol treatment as the only effective therapy. Many of them were indeed skeptical about the worm theory, and those who rebutted it were clearly wrong. But others had a more nuanced interpretation that embraced the thymol treatment but felt strongly that in the new political order, the environmental, sanitary, and nutritional problems that surrounded anemia also had to be addressed. In conclusion, many of them thought, anemia was a political problem, and no amount of purgative would be able to tackle its root causes until the miserable condition of the rural masses were alleviated. In the memoir written near the end of his life, Ashford recognized that the more nuanced approach adopted by some of his first Puerto Rican critics was not all rhetoric without substance. Admitting he had gotten one part of it wrong, he reflected on lessons learned about the intricacies of anemia over several decades and many countries. There indeed was a nutritional anemia that complicated the clinical picture; some people with few worms displayed serious symptoms, while others with many worms seemed less affected by the condition. The concept of nutritional anemia implied that socio-economic conditions were profoundly responsible for the extent of the infection and the severity of its consequences. In 1901, however, Ashford was focused on ways to combat the anemia worm by itself, as the sole cause of the epidemic, and while he may have understood that the socio-economic challenges the laborers faced complicated the therapeutic picture, his goal was to treat as many people as possible, expecting that the rate of re-infection would decline over time as fewer worms were spread about the soil by sick people depositing their contaminated feces on the fields and around the bateyes or household yards. Interestingly, not all U.S. officials in Puerto Rico shared this view, a recognition that complicates our attempt to understand the axis of the conflict that seemed to pit many Puerto Rican physicians against some American ones. As late
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as 1904, after the first Anemia Commission had carried out part of its work, Governor William H. Hunt wrote in his annual report that cleanliness and hygienic conditions could still cure hookworm patients. In the orphan asylum of Bayamn, he noted, fully 90 per cent of the inmates were suffering from anaemia when admitted, yet, although no special medicines were used, when surrounded by proper conditions and educated to habits of personal cleanliness, the worm, owing to its inability to breed in the human body, with no chance for reinfection, gradually died out, and within three years 95 per cent of those originally infected have wholly recovered and the remainder are getting better. Certain that his discovery offered a much more efficient way to deal with the problem in a society that lacked proper sanitation controls, Ashford got on with his campaign to discredit local doctors. The zeal with which the young American approached the problem whose secrets he had unlocked in a tent hospital in Ponce two years earlier may explain why in 1901 King had felt comfortable to share openly with Ashford his ridicule of the Puerto Rican doctors trained in Europe. The contest to define the role of an American-style scientific medicine was on, and King, who had become hostile to the local physicians during his work at the Ponce port, evidently found just the perfect ally in the man just returned from the States, now widely lauded for a medical breakthrough that, in his own words many years later, could unlock the secrets of the jbaros soul, and hence that of all Puerto Ricans. The fact that Ashford had familial links to the local medical elite granted certain validity to his critique that most other foreigners could only envy. Over the next few years the two groups in contention, one favoring the American doctors and another their Puerto Rican critics, wrote articles in the press attacking each other and questioning their approaches to improving the health of the Puerto Rican people. They painted each others views as extreme and completely foolish, even though the two were somewhat compatible, as Ashford belated admission about the existence of a nutritional anemia suggests. Between 1902 and 1904, the balance tipped in favor of Ashfords and Kings ideas about using the power of the colonial state to directly diagnose and treat anemia patientsto use the microscope, not the improvement of workers socio-medical conditions, to return energy to the body and color to the faces of the exploited jbaros. Not long Ashford turned that corner, most of the physician-inspired critiques of American tactics died down as the prestige of the anti-anemia campaigners increased exponentially, both inside and outside Puerto Rico. While tropical-medicine loreand his own memoirslater credited Ashford and his collaborators with having shaped and carried out a crusade in the U.S.s new possession in the Caribbean that, once exported to similarly sickened but even larger countries, cleansed the tropical world forever, the record suggests a somewhat different story. Ashford was shrewd, articulate, and persuasivea great letter-writer, among other things, a man with an uncanny ability to win people over to his cause. He often wrote with modesty about how much credit he deserved and about how the glory should be shared by others, including the tenacious jbaros who sacrificed so much to visit the anemia clinics, often several times and under great duress. But it is evident that the passage of Ashfords (and later Kings and eventually Gutirrez Igaravdezs) anti-anemia effort from scientific novelty, without any obvious real-world application, to public-health policy was not due to individual will or enlightenmentand certainly not to the conquerors superior science. For it involved contingencies in the way that the U.S.-Puerto Rico relationship evolved, how certain institutions and professions adapted to the new conditions, and how important groups bought into the idea of sanitizing an entire population as a way of elevating them and shaping them into a modern, productive working class. For this
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papers conceptual framework, the implications are clear: commandeering the hegemonic process already under way before the U.S. invasion was not a simple act of willfulness on the part of any individual, even a medical scientist as capable as Ashford; not the successful intervention of a cadre of leaders even, but a propitious conjunction of policy-based factors (economic, military, political), social and ideological alignments, and scientific measures. The process was contingent and not pre-ordained, and at times it appeared as if it would be unlikely to succeed at all. VI. The details of how the stars aligned for Ashford and King between 1902 and 1904 to begin the anemia campaigns fall beyond the scope of the present paper. To conclude, however, I would like to mention three loosely interconnected events that were crucial to the earliest campaigns (1904) legitimation, and in the final analysis, to its elevation as a signal achievement of American imperialism. One was the founding of the Asociacin Mdica de Puerto Rico (AMPR) or Puerto Rico Medical Association in 1902; another, the launching two years later of a pilot project to treat anemia patients at a small number of rural clinics, an initiative widely credited to Ashford and King but one that actually involved significant Puerto Rican input; and the third, the recruitment that same year of two prominent Puerto Rican physicians as allies and collaborators of Ashford and King in this pilot project. The importance of the AMPRs embrace of the anemia-campaign model for its ultimate success as a hegemonic process cannot be underestimated. Trujillo Pagn has written persuasively that the American takeover of Puerto Rico precipitated elite Puerto Rican physicians to incorporate themselves into a professional organization, partly in opposition to the occupation governments policies and partly in defense of the groups economic interests. The AMPR was initially composed of physicians quite animatedly opposed to the governments takeover of medical and sanitation functions, as well as to the employment of less renowned and socially obscure small-town doctors as part of this effort. Under its main founder, Dr. Manuel Quevedo Bez, a member of the European-trained elite of doctors of the Spanish period, the AMPR upheld the that anemia patients needed to be treated as part of a broader campaign to reform societyto cure the mundo enfermo as a whole, not individual patients. Ashford, on the other hand, held to the diagnostic, microscopic view of anemia treatment, one patient at a time and, in every case, only after the presence of worms had been detected. Thus, the original idea behind the AMPR was to reflect national values, not American onesvalues, in other words, previously upheld by such as Del Valle Atiles and Zeno Ganda, who were still active leaders of the islands medical and political elite. But as its members began to see the benefits accruing to them from some of the health policies of the colonial government, and as they began to reap the benefits of a rapidly expanding agricultural economy, especially in the sugar lowlands, their opposition abated and the organization itself underwent what Trujillo Pagn dubs a radical about-face. It is possible that the idea of treating anemia patients in dedicated clinics across severely infested areas of the island had been brewing in Ashfords and Kings minds for some time. Still, the exact shape of the campaign and its sources of funds had probably not come together. The American physicians perhaps had an idea for a campaign that would be independent of the Superior Board of Health, then under local control and influenced by municipally appointed doctorshence subject to political influencebut at first such a notion did not carry much
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weight with island authorities. Neither Governor Allen nor Governor Hunt, the first two civilian executives of post-Foraker Act Puerto Rico, even mentioned anemia as a medical problem in their initial annual reports, which instead emphasized the healthful state of island inhabitants and the relative absence of diseases like yellow fever and smallpox. Not until Hunts 1904 account did the issue of the anti-anemia effort came up, when he described the launching earlier that year of a campaign directed by Ashford to combat the scourge, with $5,000 assigned by the legislature for that purpose. This demonstration or first campaign against anemia achieved unforeseen success and catapulted Ashford, King, and Gutirrez Igaravdez to international fame among tropical medicine practitioners the world over. Yet, while these men obtained the credit they deserved for their work, they may not have been solely responsible for its creation. Writing to Ashford on 4 December 1903, King credited the idea to Mr. Lugo Vias, an apparent reference to Eduardo Lugo Via, landowner in Guayama, financier, businessman, former independence supporter (under Spain), and later pro-American supporter and politician. Remarking that I have been thinking of something along the same line for some time, but tellingly not ascribing to Ashford joint intellectual authorship of the plan, Kings letter suggests that at least one Puerto Rican politician, and perhaps more in the pro-American camp had already begun to prepare the way for the adoption of a clinical approach to the anemia problem. Interconnected with the elite physicians change of mind toward American public-health and sanitation problems was the decision of two individual physicians to come on board and lend it their support. When Gutirrez Igaravdez and Agustn Stahl accepted to work for the first anemia campaign, and shortly thereafter the latter, who was AMPR president at the time, reported to the association on the inherent worth of treating anemia as a disease and not solely a socio-medical condition, they evidently creolized the campaign. This helped to convince skeptic members of the AMPR of the clinics value and facilitated the continuation and, in 1905, the expansion of this effort into Aibonito, in the heartland of the eastern Central Mountain Rangea place symbolically and deeply linked with jbaro society and culture. Both Gutirrez Igaravdez and Stahl were from the city of Bayamn, west of San Juan. The former was a highly respected doctor whom Ashford recalled in his memoirs as a perfect example of Spains impetuous nobility, handsome, with an almost abnormal sense of honor, chevalierly correct behavior, and, above all, loyalty. Gutirrez was a well-read man, ambitious in the field of investigative medicine. He had a good practice in the large town in which we were working, and a host of friends. To part with them, and go with us in our outlandish enterprise, meant an absolute severance of all those professional relations which would have made him to-day the wealthiest physician in San Juan. Such was the appeal of American-inspired scientific medicine to persons who, like Gutirrez, was already predisposed to see in it the utmost in modernity. A strong proponent of Americanizing the island, Gutirrez would be Ashfords closest Puerto Rican collaborator for more than a decade. He was a steady presence throughout the various campaigns, eventually becoming director of the Porto Rico Anemia Commission. He co-authored with Ashford the definitive report on the disease and its treatment on the island, Uncinariasis (Hookworm Disease) in Porto Rico: A Medical and Economic Problem (1911). By then, as the title clearly suggests, the campaigners were convinced of some of the things that the Puerto Rican elite
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physicians had been claiming all along: that the hookworm infestation on the island was not only a medical but also an economic problem. But by that time also the AMPR had undergone the kind of professionalization that made it less critical of American colonial methods and more receptive to U.S. medical and scientific influences. For his part, Stahl, who was sixty-two years of age when tapped for the campaign in 1904, was the dean of Puerto Rican men of science and a revered member of the elite physicians group. Born into an elite German immigrant family, Stahl had made a name for himself not only as a physician but as a naturalist, ethnologist, and archaeologist, having published important works on the natural history of Puerto Rico and its aboriginal inhabitants. In the Puerto Rican press and within the AMPR, he had initially spoken out against a public-health attempt that many saw as an American imposition that was contrary to Puerto Rican conceptions of the jbaro problem. As late as 25 June, 1904, with the first campaign in full swing, Governor Hunt told Ashford that he would hold Stahl at bay and would not implement his ideasa reference, perhaps, to Stahls and the AMPRs preference for the incorporation of anti-anemia remedies into Superior Board of Health functions. Stahl, however, was already undergoing a major sea-change in his thinking. In early 1904 he signaled to Governor Hunt that he was ready to persuade his colleagues in the AMPR to support the idea of a special campaign against anemia. While not fully convinced that the old man would support the American medical effort, Hunt tried to gain his trust by naming him director of the anemia clinic in his hometown of Bayamn, the first such clinic on the island, afterward moved to the interior (again, deeply jbaro) town of Utuado. Finally, the unforeseen success of a state-sponsored pilot project for the treatment of anemia victims in 1904 sealed the fate of the Ashford-King-Gutirrez Igaravdez model for anemia eradication. With the $5,000 the Legislature had appropriated, the anemia clinics in Bayamn and Utuado treated 5,500 patients. By then, the voices of opposition had begun to die down, and within months the government had assigned three times as much money for a larger effort, this one to be centered in Aibonitothe Puerto Rican jbaro heartland. The patients who recurrently attended the clinics suggested to Ashford and the other doctors there that the peasants, and not they, nor especially the exploiters of old who sold them useless brews and concotions, were in charge of their health and their fate. We believe that no more startling instance of the pernicious custom of trusting to patent medicines exists, wrote Ashford in his preliminary report on the 1905 campaign, than in the exceedingly interesting recovery in Porto Rico by Scientific Medicine, by the Doctor, of a territory exploited by commercialism, the innocent faith of the poor jbaro. An important page in the script that would establish American hegemony in Puerto Rico had been turned.

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