To Cast Out Disease A History of the International Health

Division of Rockefeller Foundation (1913 1951)

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To
Cast Out
Disease
A HISTORY OF THE
INTERNATIONAL HEALTH DIVISION
OF THE ROCKEFELLER FOUNDATION
(1913-1951)

JOHN FARLEY

OXFORD
UNIVERSITY PRESS

2004
OXFORD
UNIVERSITY PRESS

Oxford New York

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Library of Congress Cataloging-in-Publication Data

Farley, John, 1936-
To cast out disease : a history of the International Health Division of
the Rockefeller Foundation (1913-1951)
/ John Farley
p. cm. Includes bibliographical references and index.
ISBN 0-19-516631-0 (cloth)
1. Rockefeller Foundation International Health Division.
2. Medicine—Research—United States—International cooperation.
3. Public health—Research—United States—International cooperation.
4. Medicine—Research—History.
5. Research—United States—International cooperation.
I. Title.
R852.F37 2003 610'.7'2073—dc21 2003048691

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
To Grace,
our family,
and our
perfect grandchildren

And, of course, to
Colonel Bob
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Acknowledgments

Living a few hundred yards from a shoreline washed by the frigid waters of the
Labrador Current has always presented a barrier to my interest in parasites, tropi-
cal diseases, and their histories. I was therefore pleasantly surprised to discover,
years ago, that an archive which catered to my interests was situated in Tarrytown,
New York, only two hours by air to the southwest; I no longer needed to take that
awful night flight to the British archives in London. The Rockefeller Archive
Center thus became the focus of my world for the long drawn out slog to uncover
the records of the International Health Division which, in the beginning, I believed
to be more or less the American equivalent of the British Colonial Medical Ser-
vice. Both organizations provided an outlet for young men who wished to com-
bine professional satisfaction with a life of adventure and sometimes danger.
I cannot begin to express my deep appreciation for the help I received from
Tom Rosenbaum and the other archivists at the center. I know with certainty that
had it not been for Tom, I would have given up in disgust many years ago, over-
whelmed as I often was by the sheer bulk of material in the archive. I would also
like to thank Dr. Darwin Stapleton, the archive's director, for his considerable
support, kindness, prompt answers to any queries, and for his multiyear loan of
the Health Division's annual reports. I need to thank also those with whom I stayed
during my many visits to the archive—particularly the lady, whose name I can no
longer remember, who introduced me to the historical and walking delights of

VII
Vlll ACKNOWLEDGMENTS

the Croton Aqueduct. Above all, I am indebted to the good ladies of Marymount
College, whose guest room became a second home to me and where the college
pool allowed me to indulge my passion for a hard morning swim; the only way I
could survive the rest of each day without falling asleep.
Most academic authors, if they are honest enough to admit it, will attest to the
fact that writing a manuscript and finding a publisher for it are vastly different
projects. This manuscript has had an extraordinarily long gestation period. Indeed,
had it not been for one very special person it never would have seen the light of
day. On hearing that I was about to toss the whole kit and caboodle into the At-
lantic Ocean, I received an order from Colonel Robert Joy, who had already read
some of the earlier drafts, to get back to work, although not in such polite terms.
As a former national serviceman in the British army I had no option but to obey
an order from a superior officer. The degree of thanks I owe "Colonel Bob" is
incalculable, and when, following his suggestion, I located the patient and pro-
fessional Jeffrey House of Oxford University Press, the tunnel suddenly began to
grow much shorter. I would especially like to acknowledge the extraordinarily
detailed and thoughtful critique I received from an anonymous reviewer at Ox-
ford University Press. I have since discovered that the reviewer was John Hutchinson
of Simon Fraser University in British Columbia, who sadly died suddenly before
he was able to read how I had reacted to his many suggestions. I would like to
acknowledge, too, the help asked of, and always given by, the physician and his-
torian, Dr. Margaret Humphreys of Duke University. I very much enjoyed work-
ing with my production editor, Lynda Crawford, particularly as I tried to make
sense of the American rules of capitalization. Americans are, as H. W. Fowler's
Modern English Usage makes clear, "anti-capitalists."
I am naturally grateful to the Social Science and Humanities Research Council
of Canada (who must be wondering where the book got to) for providing funding
for research and travel between Halifax and New York, which I sometimes did by
indulging my passion for trains, taking the 32-hour ride to Croton via Montreal. I
would also like to thank the Rockefeller Foundation for their generous grant which
will be used to allay publication costs.
While writing this book I took early retirement from the Biology Department
of Dalhousie University. I owe Grace, my wife, "she who must be obeyed," a heap
of thanks for constantly reminding me that retirement is not a time to retire, to
stop, but a time to increase the intensity of training for competitive masters swim-
ming, and to continue reading and writing.

Halifax, Nova Scotia J.F.

Contents

1. Introduction 1

I Rose's Vision
2. The First Stage: Means to an End 27

3. Tuberculosis in France (1917-1924) 44

II Disease Eradication
4. The First Hookworm Campaigns (1913-1920) 61

5. Retreat from Hookworm (1920-1930) 75

6. Yellow Fever: From Coast to Jungle 88

7. Malaria: Killing Mosquitoes and Anophelines (1915-1935) 107

8. World War II: DDT, Typhus, and Malaria 128

9. Malaria: The Ultimate Kill 138

ix
X CONTENTS

III A Research Program

10. Reorganization and Research Laboratories (1928-1940) 157

11. Yellow Fever Vaccines: A Slap in the Face 169

12. Diseases for Research 183

IV Training the Experts

13. Frustrations in Sao Paulo; The Wrong Step in Rio 203-

14. Northern Lights: London and Toronto 216

15. Rough Seas: Prague, Rome, Tokyo, and Calcutta 239

V Finale
16. Postwar Confusion: What to Do Next? 267

17. Conclusion: Swinging Pendulums 284

Glossary of Names 305

Index 313
To Cast Out Disease
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1
Introduction

In 1955 Paul Russell published his magnum opus, Man's Mastery of Malaria,
which told the story of how malaria was mastered.1 "The point is," he wrote, "that
malaria, after centuries of effort, is now universally controllable." And if with
malaria, why not with other communicable diseases? Yellow fever, for example,
was no longer the threat it had been and tuberculosis was continuing its long slide,
perhaps into oblivion. In Geneva members of the newly-formed World Health
Organization (WHO) had set up expert committees to declare a war to the finish
on malaria, venereal disease and tuberculosis, with other diseases close behind.
The medical world was awash with optimism.
Few doubted that these spectacular declines reflected the impact of modern
medicine, although malariologist Russell took care to point out that many other
factors had played a role. A growing choice of tools—chemical drugs, antibiot-
ics, vaccines and insecticides, none more famous than DDT—had become the
modern handmaidens of cure and prevention. Of course, there were problems on
the horizon that, if taken seriously, would undercut this optimism. Russell him-
self was aware of mounting insect resistance to DDT and of the malaria parasite's
ability to withstand the effects of antimalarial drugs. Others worried about the
impact that success in "death control" would have on mankind's lot—fewer people
dying, more mouths to feed; fewer dying of malaria, more dying of starvation.
Still, though Russell took pains to temper his optimism, one can appreciate how a
general reader would react to these words in the book's preface:

1
1 TO CAST OUT DISEASE

While keeping in mind the realities one can nevertheless be confident that malaria is well
on its way towards oblivion. Already as a malariologist, I feel premonitory twinges of
lonesomeness, and in my own organization I am now a sort of 'last survivor'.
To Cast out Disease is a history of the Rockefeller Foundation's International
Health Division (IHD), in which Russell spent most of his working life and where
he developed his ideas and his optimism. He came to believe that the expertise,
tools, and methods the organization had helped develop could, in the long term,
lead to the disappearance of many of the world's most feared diseases. Before
the founding of the WHO in 1948, it was arguably the world's most important
agency of public health work.2 The International Health Division went by slightly
different names at the beginning of its life: International Health Commission
(IHC) from 1913 to 1916, and the International Health Board (IHB) from 1916
to 1927. From 1927 until it closed down in 1951, it was the International Health
Division (IHD). In this book, it is referred to by its name at the time of the event
described, usually with the word "International" omitted.3 By the time it closed
its doors in 1951, its staff had worked in over 80 countries: the United States
and Canada, 25 nations in Europe, 15 in the Caribbean, every country in South
and Central America, 19 in the Far East, and several in Africa and the Middle
East. They began with an effort to control or eradicate hookworm as part of an
attempt to build up what today would be called a public health infrastructure;
but almost from the beginning they took on malaria and yellow fever and even
engaged in a high-cost tuberculosis campaign in France. For many years the
control or eradication of hookworm, malaria, and yellow fever was the IHD's
main focus of concern.
Similar efforts were directed toward the training of public health physicians
and, to a lesser extent, public health nurses. These physicians and nurses were
destined to become members of a new cadre of public health professionals, build-
ing up public health services where none existed or wrestling control of public
health matters from incompetent part-time physicians, untrained in public health,
who often owed their positions to political patronage rather than professional
expertise. Toward this end, the IHD endowed institutes of public health and pub-
lic health nursing, offering fellowships to study at these schools, located mostly
in North America and Europe. The IHD built several research laboratories, in-
cluding a very important yellow fever laboratory in New York City, supported
laboratory research, developed the yellow fever vaccine, and attempted to develop
vaccines for other diseases.
The IHD and its predecessors grew out of the Rockefeller Sanitary Commis-
sion, an earlier example of Rockefeller philanthropy, which had been founded in
1909 to strengthen up public health agencies and eliminate hookworm from the
American South. Hookworm was where it all started.
John D. Rockefeller Sr.'s Standard Oil Company, founded in 1870, had risen
to dominate the world oil markets with its control of wells, refining and oil trans-
INTRODUCTION 3

portation.4 In 1891, he appointed as his principal aide in philanthropy 38-year-

old Frederick Gates, who had played a major role in Rockefeller's endowment of
the University of Chicago. An astute businessman and former Baptist minister,
Gates turned the Rockefeller fortunes towards medicine. He had been pulled in
that direction after plowing through William Osier's 1892 text, Principles and
Practice of Medicine. To the surprised Gates, while the book was filled with di-
agnostic details, little was known about causes—and cures still rested on tradi-
tional medicines of questionable value. "When I laid down this book," he wrote,
"I had begun to realize how woefully neglected had been the scientific study of
medicine in the United States." What was needed, he concluded, was a research
institute given to "uninterrupted study and investigation, on ample salary, entirely
independent of practice."5 Rockefeller made his first move towards medicine by en-
dowing the Rockefeller Institute for Medical Research (after 1965 the Rockefeller
University). The institute was incorporated in 1901; Simon Flexner was appointed
director in 1902; work began in some converted houses in 1904; and in 1906 the
first laboratory building was erected at its present site in Manhattan.6 By 1970 it
had generated 16 Nobel Prizes. But it was only the initial step toward medicine
and public health.
In June 1909 John D. Rockefeller Sr. signed over a deed of trust to his son John
D. Rockefeller Jr., his son-in-law Harold McCormick, and Frederick Gates. Under
the trust, over 72,000 shares of the Standard Oil Company, worth more than $700
million in 1990 dollars, were to be given to a newly-created body, the Rockefeller
Foundation, whose mandate was "to promote the well-being and to advance the
civilization of the peoples of the United States and its territories and possessions
and of foreign lands in the acquisition and dissemination of knowledge, in the
prevention and relief of suffering, and in the promotion of any and all of the ele-
ments of human progress."7
In October of that year, Gates, John D. Rockefeller Jr., and 10 others met at
John D. Rockefeller Sr.'s offices in New York City, when it was agreed to found
the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease
in the U.S. South, to be funded for five years with up to 1 million dollars—nearly
14 million in 1990 dollars.8 Gates and Rockefeller Jr. realized that success de-
pended on cooperation across a broad spectrum in the South: the medical profes-
sion, public health officials, businessmen, schools, churches, and the press—and
that much effort would need to be expended on public health education. To this end,
they offered the post of executive secretary to Wickliffe Rose, a Tennessee-born
academic, dean of the Peabody Normal School and the University of Nashville, who
may never even have heard of hookworm.9 As Lewis Hackett, one of the IHD's
most eminent field workers, wrote, "many of those who got to know Rose well
have found i t . . . difficult to fathom why he should have been offered the job, and
why he should have accepted it."10 But accept it he did, opening the Sanitary
Commission's office in Washington on January 3, 1910.11 Three years later, he
4 TO CAST OUT DISEASE

was to become the first director of the newly-formed International Health Com-
mission (IHC).
During the four long difficult years it took to set up the Rockefeller Founda-
tion, hookworm and public health became priorities of the Foundation.12 In January
1913, just before the act to establish the Rockefeller Foundation was successfully
presented to the New York State Senate, the New York Times published an article
by Jerome Greene, secretary of the foundation, that suggested how important the
fight against hookworm was to become. The hookworm campaign needed to ex-
tend beyond the South, he wrote, "for its eradication must . . . be made a world
campaign—not for altruistic motives merely but because no one country can be
safe until all have been cleared of this pest.13
At the first meeting of the Rockefeller Foundation Trustees, held on May 23,
1913, Rockefeller Jr., the foundation's president, asked for opinions on possible
lines of work. The expansion of the work of the Rockefeller Sanitary Commis-
sion, which by then was well underway, beyond the South into other countries
was one obvious possibility. Indeed, in anticipation of this move, the Sanitary
Commission had ascertained that hookworm disease was "an international prob-
lem of serious proportions," prevalent in an equatorial belt from 36° north to 30°
south, and that hookworm carriers were a danger to the United States. "Every
Indian coolie already in California," the report noted, "was a center from which
the infection continued to spread throughout the state."14
Rose, Greene, and attorney Starr J. Murphy were asked to formulate a plan for
extending hookworm work beyond the South, and present it at the next meeting,
one month later. During this and a subsequent meeting at which the International
Health Commission received its formal name, the foundation agreed "to extend
the work of eradicating Hookworm Disease to other countries and other nations."
To that end, it divided the world into six geopolitical areas in each of which would
exist a distinct service. It was envisaged that the Sanitary Commission would
continue its work in the American South, while the Health Commission would
divide its work among Latin America, the Orient, and the empires of Britain, France,
and the Netherlands.15 In the end, they undertook work in only four areas: the
South, Latin America, and in British colonies in the Far East and in the West Indies.
And, in a final link to the Sanitary Commission, Rose became director of the
International Health Commission on June 27, 1913.
From the start, members of the Health Commission agreed on two premises.
First, philanthropy should not be confused with charity. They followed to the let-
ter the philanthropic principles of Gates and Rockefeller Sr. Philanthropy was an
investment. It should be offered to government agencies, not individuals; it should
be of limited duration so as to stimulate self-help, not dependence; and it should
be withheld unless recipients showed promise of continuing to work after aid had
ended. This was a golden rule that was rarely broken; charity and emergency re-
lief were alien concepts.