‘To Awaken the Medical and Hygienic Conscience of the People’: Cultivating Enlightened Citizenship through Free Public Healthcare in Haiti from 1915–34

Abstract

This paper addresses the relative scholarly oversight of the history of public health in Haiti through a close examination of the colonial public health system constructed and operated by the United States (US) during its occupation of Haiti from 1915 to 1934. More than simply documenting a neglected aspect of Caribbean history, the paper offers the US occupation of Haiti as a remarkably clear example of a failed attempt to use a free public health service to cultivate a health conscientiousness among the Haitian citizenry through the aggressive treatment of highly visible ailments such as cataracts and yaws. I argue that the US occupation viewed the success of the Haitian Public Health Service as critical to the generation of a taxable, compliant and trusting citizenry that the colonial state could enter into a contract with. This idealistic programme envisioned by the US occupation was marred by financial mismanagement, racism, delusions of grandeur and contempt for Haitian physicians that resulted in the production of a far more precarious public health service and administrative state than the US occupation had hoped. By the time the Great Depression arrived in 1930 the Haitian Public Health Service was gutted and privatised, having successfully provided the majority of Haitians with free healthcare, yet failed to have persuaded them of the value of being governed by a centralised administrative state.

1 Introduction

The United States of America’s (US) colonial public health system in Haiti is a unique and noteworthy case of an imperial public health project. Midway through the US occupation of Haiti, the colonial government began to prioritise the construction of a centralised public health apparatus. The goal of this endeavour was to render the rural population of Haiti governable through cultivating trust between the state that provided a public health system and the Haitians who relied upon it for the provision of their health care. Both historians and anthropologists have noted that the formation and solidification of state power can be accomplished through the creation of a health-concerned population. ¹ Haiti is a notable case of this process because of the explicit priority the US occupation placed upon generating health conscious citizens as a part of enabling state formation. This process did not occur in a vacuum and was deeply influenced by the racialist beliefs held by the US occupation, and thus is suitable for a fruitful and critical interrogation of how US imperialism operated in a predominantly black environment unlike many of the other US imperial projects.

In 1915, following a revolt that culminated in the hanging of the then Haitian president Vilbrun Guillaume Sam by Haitian protestors, the US – citing the Monroe Doctrine as a pretext – invaded and occupied Haiti from 1915 to 1934 in a mission of what they described as peace-making or nation-building. ² However, several historical analyses have suggested that the occupation of Haiti by the US was more directly motivated by anxieties over growing German influence in Haitian politics, a desire for political stability in Haiti, and an attempt to liberalise Haiti’s protectionist economy to ensure reliable payments of its debts to US banks. ³ Despite having obvious commercial interests, members of the US occupation would frequently cite the occupation as humanitarian in nature because they considered the Haitian population ignorant of good governance structures, including a centralised state apparatus. This construction of incompetency was seen to be true by senior members of the US occupation, thus informing the Haitians’ requirement of American guidance for successful ‘development’.

The US invasion of Haiti was also framed in terms of enlightenment, with members of the US public explicitly invoking narratives of civilisation to justify and explain the success of the invasion:

Progress in what we call civilization takes a heavy toll from the simplicity of life and primitive habits. One misses now the silver voice of Haiti, laughing and calling with the freedom of children’s voices…The greatest change of an immaterial character now is the attitude of the people as a whole toward the whites…Generally [before the occupation] this attitude was good natured, rarely it was not, but one never found the attitude of deference or of anything approaching servility which the Negroes of the States have carried over from slavery days. Indeed, the feeling was just the reverse…the vast majority of these people…have not unnaturally come to feel instinctively equal and even superior [to whites]…Now that old attitude is in a flash changed, gone. It is a subdued people that greets you in towns or cities. Twenty-three hundred United States marines sweeping over the country like a human comb have left no part of this community unenlightened, unconvinced. They killed about a thousand Haitians who remained unconvinced. That was the price of peace. ⁴

During these early years, the US occupation exercised military power to secure the stability of their newly installed government and would violently put down resistance to their occupation. ⁵ Having secured the financial assets of Haiti, the US occupation saw its next task as developing Haiti into a market-based country with a population ‘convinced’ of the virtues of modernity. Accordingly, the US occupation would widely implement their preferred policies regardless of local opinion, including the redrafting of Haiti’s constitution. ⁶ The Haitian Public Health Service that was formed in the early 1920s by these policies was designed by the US occupation to be completely funded through taxes placed on trade and the Haitian people. As a result of this funding structure, the Public Health Service did not require any external investment to bring about its operation. When supplementary funds were required for projects or equipment that would otherwise exceed the budget of the Haitian Public Health Service, members of the US occupation would petition various non-governmental organisations to secure additional funding.

Similar to the US occupation of other tropical regions, creating an ideal commercial context for US interests were predicated upon the creation of a hygienic environment in which commercial activities could safely take place. ⁷ Practices of health and sanitation had already been enacted by the Haitian government or the Haitian physicians who had managed the hospitals for the 110 years prior to the US occupation. ⁸ Additionally, Haiti participated in existing regimes of international health. For example, the Haitian government was a participant in sanitation movements during the 1880s and had attended the International Sanitary Conference in 1881 to establish standards for quarantine and sanitation regulations for Haiti, and later in 1902 supported the formation of the Pan American Sanitation Bureau. ⁹ However, it was unclear to the US occupation to what extent these treaties were properly implemented; more likely, these treaties were formally signed to enable the continued participation of Haiti in international trade, because, given the lack of administrative and material infrastructure to properly implement sanitation standards upon the US invasion, the proper implementation of such policies was believed to be materially impossible. ¹⁰ Indeed, the US occupation, upon landing, suggested that Haiti was extremely vulnerable to epidemics such as smallpox, a prediction that proved true in 1920 when an epidemic of smallpox occurred. ¹¹ However, members of the occupation initially blamed ‘politics’ rather than the competency of the Haitian medical profession for the state of the medical system. ¹² Despite the presence of some public health infrastructure, the US occupation viewed the overall state of Haiti as chaotic and in urgent need of more comprehensive sanitation and public health infrastructure.

The view that the Haitian government had been unable to effectively implement public health policies affirmed the paternalism that characterised the US occupation and would sometimes lead to policies that appeared to contradict the values promoted by the public face of US occupation, such as freedom or justice. The most prominent example was the US occupation’s use of an archaic Haitian law to implement a policy of forced labour, leveraged in order to ensure the rebuilding of roads and other public infrastructure. ¹³ The internal tension between an ostensibly humanitarian mission and its often callous implementation became increasingly noted within the United States and prompted outrage at home, resulting in a Senate inquiry into the conduct of the occupation during the early 1920s. ¹⁴ Over the course of the occupation, apologists of the occupation would often point to the construction of infrastructure, increased numbers of cars and, most relevant for this paper, the Haitian Public Health Service as indicators of the benefits of the US military occupation, despite these departments being almost entirely funded by the Haitian state. ¹⁵

The US occupation never separated the US military from the Haitian government. The US occupation would staff the Haitian Public Health Service’s senior positions exclusively with US naval medical officers; there was an important integration and sharing of logistical and technical resources between the two. This often occurred at the local level with Haitian hospitals ‘borrowing’ from better-supplied navy hospitals or medical outposts. Therefore, I do not draw any sharp or ‘hard’ boundaries between the two and treat them both as part of ‘public health’ in Haiti while remaining focused on the Public Health Service.

The US occupation and its officers were meticulous record keepers, and produced monthly, annual and bespoke reports from all its departments (including the Public Health Service) on the state of the occupation. The US occupation was also full of prolific medical writers who would routinely publish papers on medical experiments and the public health status of Haiti in a variety of medical journals. Several sympathetic or hostile third parties audited the US occupation and provide another collection of sources to evaluate the occupation. Other documents following the US de-occupation of Haiti were submitted by Haitians to the Pan American Sanitation Bureau. Another source is the Rockefeller Foundation, which commissioned several investigations into the public health status of Haiti and scrupulously kept records of the results. It is from these documents that I form the basis of my argument for this paper. I also draw upon secondary sources that documented the US occupation and its ‘culture’ to help situate the context that public health operated in. There exist no accessible primary records of the rural Haitians who were often the subjects of a variety of medical interventions. Notably, the rural Haitians who spoke Haitian creole, which did not exist in a written form at the time, have had their voices silenced in this history, except through a few descriptions provided by American marines. ¹⁶ Thus, writing a history of Haiti is itself a problematic endeavour. Additionally, Haitians were not a homogeneous population and had a variety of colour and class-based factions. Recognising these important limitations, this paper does not attempt to provide a comprehensive history of public health in Haiti, but rather focuses on US conceptions of it and its goals relating to state-building.

I have structured this paper into four distinct sections that individually and cumulatively explore how ignorance was conceptualised by the US occupation and the implications of this particular articulation of it in Haiti. I first explore the conceptualisation by the director of the Public Health Service, Charles St John Butler. Butler’s account illustrates how he saw both highly educated Haitian physicians and poor, illiterate rural Haitian peasants as ignorant; in so doing, Butler articulated a justification for the US occupation and its explicit white supremacy. Drawing upon this broader framing of ignorance, I illustrate how the US naval officers looked for a performative approach to ‘educating’ suspicious rural Haitians of the value of ‘enlightenment’ through the public demonstration of the effects of a variety of medications. Next, I demonstrate how this performative approach to ‘education’ became institutionalised through the operation of the rural dispensary system that at one point provided free medicines and medical care to the majority of the population of Haiti and ultimately served the project of developing a compliant tax-paying citizenry. The final section takes a critical look at the practical operations of the Public Health Service and describes how budget constraints and funding priorities impaired its activities, while a market crash in the early 1930s resulted in the overall collapse of the rural dispensary system. Running through all of these sections I pay close attention to and highlight how ignorance and the meanings assigned to the term shifted over the course of the US occupation to argue that, by the end of the occupation, the US occupation had largely given up hope that their medicine or mentorship alone could ‘educate’ or ‘develop’ Haiti.

2 Ignorance in Haiti

When the US physician Captain Charles St John Butler took over the directorship of the Haitian Public Health Service in 1924, he imagined Haiti as a land of possibility; not only for the Haitian public but also for the US invaders, for whom it could be a transformative space of white redemption. C.S. Butler was a deeply moral man who viewed the roles of physicians as broader than the clinical treatment of patients: doctors were also gatekeepers of civilisation who have ‘failed to appreciate the enormous importance of our calling in helping governments to confer the benefits of civilization upon backward races’. ¹⁷ Butler also felt ‘convinced that it is a moral obligation of the white races of the new world to assist this little Caribbean republic to her feet and when once on her feet to give her the moral and material backing necessary to keep her there’. ¹⁸ Butler was an astute reader of history and had extensive knowledge of Haiti’s history post-contact with the Spanish and lamented the violence and cruelty practised by white slaveholders. Indeed, Butler believed that it was the brutal violence, economic extraction and anti-democratic practices of the previous whites who had occupied Haiti that had ‘taught’ the blacks of Haiti such ineffective modes of governance. It is from this historical debt that Butler felt a moral obligation to the people of Haiti, and the Caribbean more broadly, to ‘help her to her feet’. Butler, as director of the Haitian Public Health Service, would work to ensure that this service would support the Haitian populace in the way he thought served them best.

The framing of the Haitian public by Butler presumes several features, notably because they provide a context for how the notion of Haitian ‘ignorance’ featured in his account. Butler’s framing of the Public Health Service suggests that the US occupation occurred for purely altruistic reasons to help Haiti to develop and then stay developed. This humanitarian framing of the US–Haitian relation itself relies upon the belief that the Haitians are ‘backwards’ and that a paternalistic occupation would be able to help them develop. The relationship between that of a parent and a child is characterised by a profound asymmetry in power whereby the parent has almost complete control over all the aspects of the child’s life. When Butler used this concept metaphorically to describe the US–Haitian relationship, it enabled him to present Haiti as needing a ‘parent’ that would necessarily control all aspects of its development into a modern civilised nation. Most members of the US occupation’s medical corps accepted this paternalistic framing of the US–Haitian relationship. For Butler, ignorance was a core feature of the childish state that he imaged the Haitians inhabited. Butler found evidence for their ignorance by observing their sanitary habits, investigating their drinking water and experimenting on their water vessels. Examination of the Haitian leadership left Butler similarly disappointed because he believed that he had found evidence that Haitian elites were ignorant of effective US modes of governance.

Butler, like many of the other military medical men in Haiti, had spent significant time in other US colonies, notably the Philippines, and drew upon many of the same discursive practices during his time in Haiti in understanding Haitian sanitation practices. ¹⁹ Despite his seemingly compassionate and moral rhetoric, he could at times produce urgent and seemingly hyperbolic descriptions of Haiti and the Haitian inhabitants to illustrate the vital need for its domination by the US occupation. The framings used by Butler are similar to those deployed in the Philippines and illustrate a constancy in how US military physicians ‘turned their new tropical frontier into a desolate human-waste land’ that accordingly ‘called for massive, ceaseless disinfection; the Filipino [or in this case Haitian] bodies that polluted it required control and medical reformation’. ²⁰ Evidence for this colonial landscape in desperate need of white American domination and sanitary reform, while present in several of Butler’s writings, is exemplified clearly in a series of papers on water sanitation and hygiene that he wrote with the director of the Laboratories in Haiti, R.M. Choisser.

Following a ‘complete bacteriological examination of each spring supplying Port-au-Prince’, Butler and Choisser report, there was ‘heavy contamination with faecal bacteria of the entire water supply’. ²¹ While they do concede that most of the water that they examined was ‘crystal clear’ and that they had only examined several popular locations near the capital of Haiti, the new science of bacteriology, they believed, allowed them to produce a synoptic overview of the state of Haiti. Reflecting on the results of their bacteriological examination, Butler and Choisser conclude that the most pressing source of this faecal bacteria is from Haiti’s ‘intense and universal soil pollution by human and animal excreta’, which resulted in the ‘[t]he heavy contamination of every stream of running water and every lake in the Republic’. Likely relying on Butler’s travels (the text is unclear as to their source of information), Butler and Choisser state that in ’the high mountain regions of Haiti where water is obtainable only from water holes, there is intense contamination and gross pollution of the water by human and animal discharges. Many of these water holes simply reek with filth and yet the water is consumed by human beings without treatment’. ²² In this way, Butler and Choisser reconfigure Haiti into a literal latrine where both humans and animals alike create a toxic and infectious landscape as a result of their lack of retention and sanitation. ²³ Importantly, this biohazardous landscape produced by the careless defecations of animals and Haitians was imperceptible to Haitians themselves, as they consumed excreta contaminated water sources seemingly with indifference.

More than Butler’s disgust with the tendency of Haitians to drink water that would ‘reek with filth’, Butler was filled with anger towards the favoured drinking vessel used by rural Haitians: the Calabash. The Calabash – which he described as a ‘diabolical thing’ – was a gourd-like fruit of the common calabash tree that could be hollowed out to transport water in a wood-like jug. Butler noted that not only did the way that the Haitians handled the calabash encouraged the contamination of its water with their hands, but the Calabash bowls themselves appeared to resist the effects of chlorination, protecting the bacteria from the disinfectant’s toxicity. ²⁴ The capacity of this fruit to resist the activity of the American chemical treatments was interpreted by Butler as symbolically resisting techniques of American scientific control. That the ‘vile’ calabash failed to be cleaned by chlorination, and hence become chemically disciplined, served as an example of a practice that had to be eradicated in order to protect the health of the Haitians illustrated the importance of cultural adjustment in making a Haitian ‘healthy’. After laying out an impassioned jeremiad against the calabash, Butler is sombre in acknowledging that for apparently ‘obvious economical and social reasons the calabash will have to serve until we can get a better substitute. Perhaps the Agricultural Engineer may be able to recommend an improved method of carrying water for household use, be it by means of an earthen jar or a tin pail. Judicious propaganda is needed to convince the rural Haitian about the danger of the cheap calabash’. Rather than proposing viable strategies to modify unhealthy behavioural practices, articles such as these for Butler and his peers affirmed the difference and ‘ignorance’ of rural Haitians, and their need of US know-how.

The examples of the ‘ignorance’ of the Haitians that the US occupation found were not limited to the bacteria that circulated in the clear water they drank, but also included ignorance of administration. Butler believed that the construction of a new medical school that would be used to produce the next generations of medical students was critical for the development of Haiti and its healthcare system. However, he staunchly opposed the initial inclusion of Haitians in the design or the administrative aspects of the new medical school, stating:

It has been in the hands of the native profession for one hundred years and the final product is hardly an institution to be proud of. The fact remains, however, that it must continue to be a native institution. And it should be one to which the profession could point with real pride. The quickest way to accomplish this is to place the school under the direction of the Public Health Service. ²⁵

However, this proposal was met with criticism:

There were many Haitian doctors, not employed in the Public Health Service, who were very active in politics and these were constantly crying out against any American interference in connection with the medical school. They voiced their apprehensions in high flights of oratory, and many fiery editorials on the subject appeared in the newspapers. But no one took this group or their utterings very seriously. The real facts of the case were too apparent and too important. Dr Butler felt strongly on this question…He proposed to meet political obstacles with political tools,

ultimately placing the medical school under the control of the Public Health Service. ²⁶ That Butler would have opposed allowing the Haitian physicians to have control of the administration of the medical school could be explained by beliefs held by US medical officers that ‘Intimate association and unrestrained discourse with Haitian doctors’ resulted in the conclusion that while ‘they possess certain well defined and very laudable capabilities’, it has

also led to the conclusion that in the Haitian profession there is a pronounced and quite characteristic lack of capability in or promise of development in certain directions…the aspects of medical endeavor in which they are lacking are, unfortunately, aspects very essential to the successful execution of any national public health program. ²⁷

Indeed,

They have never shown any ability in organization and administrative activities. This may be due in large part to the fact that organization involves subordination. They are very disinclined to recognize superior authority in members of their own race; a Haitian resents subordination to another Haitian of a different shade (either lighter or darker, but especially when darker than his own) and tradition does not permit subordination to any one of a lower social caste (this situation frequently arises in hospital and public health administration). ²⁸

The Haitian’s administrative deficiencies were compounded, in the American view, that they also

are lacking in what might be termed ‘medical conscience.’ They have little or no consciousness of what we call medical ethics…A third lack is perhaps the most striking one. Their lack of the scientific viewpoint is absolute. Investigative work on a true scientific basis is apparently not possible for Haitians. ²⁹

It would only be through isolating medical students from the pernicious effects of their fellow senior doctors that they could hope to be as effective as their colonial administrators.

Wherever Butler and his fellow medical officers looked, they found ignorance and incapacity. Ignorance in Butler’s formulation could only be addressed by the US occupation through convincing both the rural Haitians and the Haitian elites of the value of US culture, its norms and its traditions. Representative of US perceptions of Haiti is Parsons’ quip, ‘American efficiency is one thing, Haitian culture is another’. ³⁰ Therefore, reconfiguring Haitian culture to promote a greater engagement with a centralised government would be as much a part of ensuring their health as the actual provision of medicines.

3 Medical Magic and Performances of Enlightenment in Militarised Malaria Control

In this section, I illustrate how the multiplicity of meanings attached to the notion of ‘ignorance’ were used by the US occupation to justify, implement and interpret various militarised public health activities. Concerns with the well-being of the occupying US troops constituted a primary concern for the US military, who would in times of stress willingly disregard the welfare of the Haitians who were too ‘ignorant’ to collaborate with in service of their own. These naval physicians positioned the health of their soldiers as the only priority and, by viewing the local Haitians exclusively as a means, enabled them to implement violent interventions on Haitian bodies. However, in the course of such violent experiments, they also discovered something unexpected from the Haitians: gratitude and, more importantly, compliance.

‘Ever since the landing of the marines in Haiti’, wrote Lieutenant Commander A.H. Allen in 1923 of the US Marine Corps, ‘malaria has caused a greater number of sick days and deaths…than any other disease.’ ³¹ Despite deploying the techniques of draining and oiling standing water developed in Panama in 1904 and Mexico in 1919, and novel ‘Haitian’ malaria drug dosing regimens, high rates of malaria persisted among the Marines who constituted the occupying forces. ³² Concerned with the risk of transmission back to the US and the apparent inefficacy of prophylactic quinine on the white bodies of his US Marines, Allen looked beyond the drained swamps to the Haitians that lived around the Americans as the next location to combat malaria. While pools were drained or oiled and Americans slept under mosquito nets, he felt the approaches he had used had failed to address the dangerous and malaria ‘ridden’ bodies of the black Haitians located near his camp. ³³ ‘During the seven years of occupation of Haiti much stress has been laid on protection against mosquitoes, but the actual source of the disease – i.e., the infected Haitian native – has gone unmolested.’ ³⁴

After optically examining blood samples extracted from asymptomatic Haitians with ‘healthy’ looking spleens near his marines, it was found that these samples contained malaria. ³⁵ This meant that the Haitians were in fact ‘sick’, contrary to their appearance of good health and their accounts. ³⁶ These asymptomatic Haitians, Allen concluded, were likely the source of malaria that plagued his vulnerable white troops. ³⁷ Between 1919 and 1920, Allen had read about ongoing malaria control campaigns in Mississippi and modelled his own after them in Haiti. ³⁸ These campaigns were conducted by Dr C.C. Bass, who, by treating carriers with ten grams of quinine sulphate daily for eight weeks, was able to reduce the malaria prevalence of African-Americans in the Mississippi delta from 50% to 5% in twelve months. ³⁹ However, Allen was sure to clarify that his adaptation of Bass’s experiments was not imagined to be a public health measure for the Haitians; instead, this was an experiment that was ‘necessarily limited to natives living within 1 mile of a marine camp’ and ‘was done solely as a prophylactic measure for the marines’. ⁴⁰ The results of this experiment were measured by Allen in the reduction of debilitating disease experienced by the white marines via counting the number of days they were admitted to hospital care. The results were ‘awaited with great interest’ by Allen and, upon the completion of the trial, he found that the campaign had cut in half the rate of admissions from 500 per 1000 to 250 in a span of eight months, which Allen viewed as a success. ⁴¹

In the end, there was a crucial difference in the implementation between Bass’s campaign and Allen’s. Allen, like his fellow American medical officers, believed that the epistemic and racial characteristics of the Haitian, namely being ‘100 per cent negroes [sic] who speak no English and who are ignorant and superstitious’, precluded the possibility of them being able to implement a curative regimen of quinine that had been implemented effectively without compliance issues in ‘American negroes’. Thus, Allen decided instead to provide the Haitians with a single, higher dosage of quinine (twenty grams) to be taken only with the onset of fever, which, Allen believed, while insufficient to cure malaria, would interrupt the transmission enough to protect American troops. ⁴² The single twenty-gram dose of quinine likely removed the Haitians’ acquired resistance and exposed them to a dangerous and debilitating reinfection with malaria. To conduct this experiment, Allen deployed a creole speaking doctor to communicate with the local villages and persuade them to use the medicine. In interacting with the Haitians, the doctor found that ‘To our surprise and gratification…[the Haitians] welcomed the examinations [which included extracting blood samples] and were anxious to take whatever medicine was prescribed’. ⁴³ Asymptomatic patients, of course, have been noted in contemporary and historical times as being particularly reticent to taking prescribed medicines; however, in this case, the participants did not appear to have any issues with compliance, given that the prescribing routine matched clearly along the lines of symptomatic presentation. ⁴⁴ Therefore, it appeared that the blackness of the Haitians guaranteed the assumption of their ‘ignorance’ and would preclude them not only from a ‘white’ standard of care but even the ‘African-American’ standard of care. They received a standard of care that was seen as simple enough that even the ‘unutterably stupid’ Haitian could understand. ⁴⁵ Ultimately, Allen’s racialist belief in the ignorance and incapacity of the rural Haitians to make informed decisions regarding their bodily sovereignty provided him the justification for designing interventions that materially stripped them of it.

The realisation of the Haitians’ willingness to collaborate surprised Allen, who had expected resistance and purposely designed his experiment to be implementable on a non-compliant population. Regardless of the appearance of a collaborative and engaged patient populace, there was no attempt to change the protocol. Instead, Allen seized upon the Haitians’ willingness to use quinine, and their gratitude over their experience of the curative effects of quinine, as a potential source of social control. He excitedly noted that, following treatment with quinine, the Haitians who were previously unwilling or unable to work managed to find their way back to ‘the near-by sugar plantation’. Not only did quinine improve productivity, it also appeared to educate Haitians wary of the benefit of the US invasion: ‘the Haitian peasant has learned to regard the military occupation as a boon to Haiti.’ ⁴⁶

A closer analysis of the reports from the creole speaking doctor, discussed earlier, is informative of how race affected US understandings of the Haitians, their diseases and the imagined effects of quinine. The doctor, American Lieutenant R.B. Storch of the US Navy Marine Corps, discovered that rural Haitians had a more or less complete understanding of the life cycle of malaria, its transmission and the use of cinchona (the plant from which quinine is produced) in its treatment. ⁴⁷ While this discovery ‘shocked’ him, his surprise did not last long as he rapidly found his way back to more traditional American views and gawked at the average rural Haitian, writing: ‘The average Haitian native appears so unutterably stupid at times as to be almost beyond belief…it is not hard to believe that a systematic and widespread effort to place natives under quinine medication where necessary would result in a transformation of the Haitian.’ ⁴⁸ Storch directly states in his account that quinine formed both a biological and subjective component of the American civilising process; moreover, he hoped that purging the Haitians’ bodies of malaria would purge them of their race’s ‘backwards’ or ignorant ways, civilise them into more traditional Western styles of medical care and solidify their beliefs in the value of a centralised governing authority. It was this insight into the relationship between the receipt of medical care and the resultant ‘compliance’ of the rural Haitian that became a core feature of the US occupation’s public health strategy.

4 The Emergence of the Rural Dispensary in Haiti: Ignorance of the State, Ignorance of Civilisation

The presumed ignorance of the Haitians and their corresponding incompetence to act in their own best interest was a position rapidly adopted by US medical officers in the early periods of the occupation and was solidified through surveys of their behaviour. In late 1916, N.T. McLean, a Naval Surgical Officer, was appointed lead sanitary engineer of the newly formed Public Health Service of Haiti and began implementing a new regime of sanitation and organisation for Haiti. ⁴⁹ The formation of the Public Health Service was the result of Article 13 in the treaty signed between the United States and Haiti in 1915 that granted the United States administrative control over Haiti and installed John H. Russell as its high commissioner. In McLean’s interpretation of Article 13, it had stipulated that the United States would ‘assist Haiti in bettering her health conditions’. ⁵⁰ However, the actual text of the treaty reads ‘The Republic of Haiti…to further the development of its natural resources, agrees to undertake and execute such measures…necessary for the sanitation and public improvement of the Republic’: from the outset of the US occupation, the establishment of a public health service was predicated on Haitian ignorance and intimately linked to the development of an efficient state, where health, economic development and ‘public improvement’ were tangled together rather than reflecting an exclusively altruistic interest in the health and well-being of the Haitians. ⁵¹

From the beginning of the US occupation, it was presumed that the US physicians had better knowledge, were more ethical and more altruistic than their Haitian counterparts, of whom they were suspicious and to whom they often attributed ‘unethical’ motivations. ⁵² This was part of a larger construction of Haitian physicians and the public as being less educated and less ethical as a result of not sharing white Western values. Differences in these domains (i.e. cultural) were frequently cited by prominent members of the US occupation as the reason for depriving Haitians access to managerial roles within the Public Health Service. This stance allowed for a notion of assistance and collaboration that in no way accepted equity, as equity would allow for the compromise of what were seen as universal moral values actively upheld by the US medical profession. ⁵³ During the formation of the Public Health Service of Haiti, McLean had extensive discussions with Haitian physicians, but found them to be an ‘impasse’ and subsequently requested that the Public Health Service be placed under US control. ⁵⁴ Thus, when McLean stated that he was ‘assisting’ the Haitians, he did not understand this to imply equity, rejecting the Haitian physicians’ proposed design for the development of a new public health service, while still relying on Haitian physicians and health workers to do the majority of the actual implementation of public health measures. ⁵⁵

Following their landing in July 1915, the Americans, under the auspices of the US Navy, began implementing a variety of programmes aimed at improving sanitation for the occupation and repairing and refurbishing existing health clinics. ⁵⁶ The lack of sanitation found in Haiti was viewed by McLean and other officers as an opportunity to educate Haitians in both the moral imperative to work and US hygiene standards. Sanitation was primarily accomplished through the removal of rubbish from the streets of Port-au-Prince and then placing it into swamps to fill them and prevent the reproduction of mosquitoes in the static water; this involved the US occupation hiring locals to do the labour, which in turn was celebrated as a form of economic development and consumed the majority of the budget for that year. ⁵⁷ Aid was not provided by the US government alone and, in 1915, the American Red Cross ⁵⁸ gave the US Navy funding to provide food aid to malnourished Haitians. However, aid such as the Red Cross’s was rapidly shut down by N.T. McLean in February of 1916 because it appeared to reward what he saw as the laziness and inefficiency of Haitian culture. He later justified his actions with the statement that ‘the Haitian never helps himself if he gets food without work’. ⁵⁹ With the remaining funds allocated to public health in Haiti, two navy surgeons, H.A. May and P.E. Garrison, surveyed the health and sanitation conditions of Port-au-Prince, a report of which was submitted to the Rockefeller Foundation by Garrison along with an ultimately unanswered request for aid. ⁶⁰ By 1924, several investigations found that the Public Health Service had failed to be effectively managed, which resulted in the appointment of the highly respected US naval medical officer Captain Charles St John Butler to take over the health care system. Upon taking over the system, Butler then approached the Rockefeller Foundation’s International Health Board to lead the reconstruction of the Haitian healthcare system, with Haitians eventually expected to take over the system following US withdrawal. ⁶¹

Ignorance as we have already encountered could be seen to imply many things, such as rejection or (violent) resistance to the US occupation, a lack of understanding of biomedicine or the science of hygiene, illiteracy or a lack of trust in the intentions of the US occupation. ⁶² Ignorance, whatever it was in a given context, was an obstacle to ‘development’. Nonetheless, one feature of the US occupation’s approach to the provision of public health care appeared to address, simultaneously, a plurality of the meanings attributed to the ‘ignorance of the Haitians’: the rural dispensary. The idea for the rural dispensary system was stated by the historian Parsons to have arisen from Dr Paul W. Wilson, a creole speaking doctor who frequently spent time with rural Haitians. In 1922 ‘He wanted to use some of the building fund for the construction of rural dispensaries in remote mountain villages so that the natives there could find all they needed in the way of antiluetics, quinine, and anthelminthics.’ ⁶³ This request was denied by the US occupation; however, Wilson was able to construct one rural dispensary, in Colline des Chênes, between 1922 and 1923, and it was there that the rural dispensary system was developed. ⁶⁴

Ideally, a functioning rural dispensary was a small building, either bought or built, that was run primarily by local Haitian physicians and nurses. The US Navy physicians that conducted rotating monthly visits for these clinics would provide care for the more severe cases that occurred there, and would resupply them. These dispensaries provided the rural Haitians with a free basic healthcare system, by diagnosing and subsequently dispensing any required medicines, such as salvarsan for yaws or quinine for malaria, or referring them for more intensive care at the hospitals that corresponded to their administrative region. ⁶⁵ By 1928, Haiti had been divided by the US occupation into ten administrative public health districts, each of which had either a new hospital built in its area or had an existing one refurbished, which would supply the 153 rural dispensaries operating across the country. ⁶⁶ Additionally, at the rotating rural clinics, visiting US naval physicians would conduct disease surveillance, collect tissues and blood for testing, perform rudimentary surgical or medical procedures and resupply the dispensaries. ⁶⁷

The rural clinics were a surprise success and the US occupation rapidly recognised the value that they could play through cultivating a positive relationship between a centralised state apparatus and the Haitians it ruled. Evidence for this possibility came from reports such as those provided by Allen from his malaria control experiments. Rather than constituting mere medical procedures or simple drug dispensation, the US occupation imagined that these clinics were performative spaces of enlightenment. For example, in 1927 the then high commissioner, Russell, notes

In the combating of ages of superstition and voodooistic beliefs few features of a doctor’s work are more productive of good than the medical miracle of making the blind see. The news of a recent case of a father again seeing his daughter after 11 years of blindness immediately spread far and wide. ⁶⁸

Indeed, the treatment of cataracts was viewed as the most persuasive of their treatments. ‘It is a pleasure to note the gratitude of these poor sufferers who have been blind for years and suddenly have regained their sight. These are worth-while apostles to send back to the hills.’ ⁶⁹ The expression ‘ignorance’ in these contexts would be used metaphorically by senior US administrators to link the chemical purification of malaria or salvarsan or the treatment of cataracts with an epistemological or ontological purification of the treated Haitian’s mind. The US occupation used this entanglement to allow for the funding of large-scale public health programmes in a tight budgetary condition. Indeed, both the Haitians receiving publicly funded treatment and the US occupation providing the funding via the Public Health Service responded positively to what they saw as effective and valuable interventions. For the Haitians, the ability of the salvarsan (a frequently toxic arsenical treatment for Yaws) ⁷⁰ , and later potassium bismuth tartrate, to radically reduce the visible symptoms of yaws provided sufficiently compelling evidence of its efficacy as to convince them of its value. From 1922 onwards, Haitians actively sought out and pursued treatment for Yaws using arsenical compounds, reaching over 600 000 treatments in 1929 alone, and with over 1 000 000 visits that year (in a population of almost 2 500 000). ⁷¹ Parsons, in writing the history of the US occupation in 1930, noted that ‘[Dr] Wilson went to remote mountain villages where he quickly gained the confidence of the natives who had feared the blanc. He poured arsenicals into this seething black mass and saw yaws lesions fade away, not in individual cases, but from a whole mountain side’. ⁷² Senior US officials, such as Haiti’s US director of health, viewed the uptake of treatments as exemplifying and ossifying US control by contributing towards ‘civilising’ the public: ‘If a kindly government attends to the to the bodily ills of these backwards peoples…the government wins the friendship of the masses and, by elevating the standard of health, it increases the earning capacity of the labourers.’ ⁷³ Indeed, this belief was also shared by Russell in his 1929 report where he said that the benefits were not ‘limited to human and economic benefit. The work of the rural clinics has been the single largest factor in destroying superstition among the country masses’. ⁷⁴ More than simply being a solution to a public health problem, the metabolism of pharmaceuticals acquired a symbolic meaning for the US occupier, which was utilised by them as a broad metaphor for purification or civilisation.

The success of the rural clinics, from the perspective of the US occupation, hinged on the Haitians’ recognition of the power of the US occupation’s medicines and their physicians to modulate their physiology. These performances were in effect theatrical displays of bio-power by the occupation to garnish the compliance of a suspicious and recalcitrant Haitian population. Following the Haitians’ recognition of the efficacy of the Americans’ antimalarial and yaws treatments, they would be forced to decide whether to receive treatment from their colonial occupiers, and thus partially participate in the colonial administrative system, or face debilitating disease and possible death. ⁷⁵ More deeply, members of the US occupation hoped that the rural dispensary system would provide a tangible illustration of the social contract required for the construction of the relationship between the state and the rapidly ‘civilising’ rural Haitian citizenry. As Butler and Peterson said in their 1926 report on public health in Haiti:

We are dealing with a rather primitive people who believe that they know more about government than they actually do…The peasant is to a large extent disease ridden, poverty stricken, superstitious and wholly illiterate…He is suspicious of strangers and does not want to have anything to do with the government…To force suddenly upon these people a modern Public Health organization would of course be preposterous. In order for an organization of this kind to be successful it has to be the outgrowth of an inborn or an artificially developed, but none the less sincere, demand for it. ⁷⁶

As the Haitians digested the quinine provided to them by physicians, it was hoped by Butler and Peterson that these cures would break their beliefs in traditional magic or an imagined god and, through interaction with the rural dispensary system, they would instead be convinced to place their faith in a new power: the state.

There has been developed an extensive rural clinical service through which the population receives medical attention at regular intervals, varying from one week to one month. The Public Health Service has staked it’s [sic] future on the successful carrying out of this scheme of taking modern medicine out into the bush and up on the mountain sides. It is by these means that our Service is trying to awake the medical and hygienic conscience of the people. ⁷⁷

Thus, compliance with a centralised state apparatus coded as ‘enlightenment’ was the cornerstone upon which this health service would either fail or succeed.

5 Tight Budget Cuts and the Gradual Collapse of the Rural Dispensary System

Within the final annual report submitted to the US State Department by the US military occupation, High Commissioner John Russell supplies his reflection on the US occupation. The pertinent section of his report is entitled the ‘Accomplishments of the National Public Health Service in the last ten years’. ⁷⁸ Russell is sanguine in his description of the National Public Health Service, writing that: ‘The work of the Department of Public Health since 1915, is an inspiring chapter in the history of Haiti.’ The rest of his summary charts an optimistic development narrative regarding the occupation’s impacts on the locals. ⁷⁹ While there had been significant progress in the implementation of public health programmes, such as the rural dispensary system, insufficient funding appeared to be a problem. Insufficient funding is noted by Russell, who stated that: ‘Public health work has been limited and handicapped here by insufficient funds…The fine record of achievement to date, however, constitutes only the first phase in the necessary program, final success in which can only be reached after many years.’ ⁸⁰

Upon solidifying their occupation, the US occupation restructured the Haitian budget and consolidated all foreign debt. Indeed, ensuring the repayment of foreign debts and US ownership of the debts was a motivating factor for the invasion of Haiti. From the beginning of the occupation, the Americans did not invest in Haiti; rather, Haiti’s development was self-funded: all its departments, including its public works department, police force and, importantly, the Public Health Service, were funded through tariffs (and some local taxation), which was dependent on the export of several cash crops. ⁸¹ The underfunding of the Public Health Service referenced by the high commissioner was a direct result of his budgetary priorities. One example of a questionable budgetary priority of his was the acquisition of Haitian foreign debt by the US occupation as a means to reduce the influence of the foreign debt holders in Haiti: notably, France. Importantly, the new US holders of this debt still expected the loans to be repaid, and thus, rather than eliminating Haiti’s substantial debt burden, they merely funnelled it into the coffers of US banks at a higher rate of interest than the previous loans demanded. ⁸² Averaging 33% of the budget per year, servicing debts was the single largest expenditure of the Haitian government. ⁸³ Servicing American owned debt occupied 25% of the budget, and specifically servicing the Series A Loan (i.e. the ‘independence debt’) took up, on average, 17% of the annual budget. ⁸⁴ In contrast, funds for the Public Health Service only occupied 9% of the annual budget on average, equivalent to about $800 000 (USD) at the time or $0.40 per Haitian. The US occupation, and later jointly with Haitian president Borno, dictated these funding priorities. In the face of chronic budgetary insufficiency, cost-intensive interventions that would promote Haiti’s economic and social development were impossible to implement. The US officers in charge of the various Haitian departments would frequently lament this, noting that this financial insufficiency would preclude the construction and operation of what they believed to be vital infrastructure.

A report conducted in 1926 by the Women’s International League for Peace and Freedom, following requests from its Haitian members, provides an example of this ‘handicapping’ of care; it reported that the ‘[i]nability to provide a living wage for Haitian physicians means, as already said, that rural communities are without resident physicians; lack of funds also means insufficient supplies, for instance of salvarsan; and other hindrances to effective service in the face of the dire need of the country’. ⁸⁵ Indeed, while the mainstay of routine care was provided by local physicians, the report concluded that their chronic underpay and lack of access to important medical resources, such as bandages, had resulted in an increasing level of privatisation of the Public Health Service. The Women’s League report concluded that this was a significant and widespread problem that undermined the effective provision of public health. ⁸⁶

However, because the directors of the US occupation took for granted the validity of their financial priorities, neither the inadequate funding of the Public Health Service nor a specific disease became the ‘number one’ public health priority during these final years of the US occupation. Rather, as is stated by Russell in 1930, and was held more broadly to be true among the prominent members of the US occupation, ‘[t]he reduction of tuberculosis, epidemic meningitis, hookworm, malaria, dysentery, and typhoid fever in Haiti can not be accomplished in a single generation’, because ‘[t]he ignorance of the people is a principal obstacle’. ⁸⁷ It was the ‘education’ of the ignorant peasants of the value of a large state apparatus that would secure their health; accordingly, ‘a campaign of unremitting intensity for which increasing funds are urgent and in which professional competency must be matched by devotion, must be waged’. Ignorance was ‘Haiti’s greatest public health problem’, as the then director of public health, Kent C. Melhorn, noted, and the solution to this was ‘overcoming the [Haitians’] woeful ignorance, superstition, and apathy with regard to the real meaning and value of health’. ⁸⁸

Ignorance in this context could be explained not through non-compliance, but rather through a refusal to participate in the US colonial ‘state’. Russell notes that one of the largest hindrances to the effective governance of the mountainous state of Haiti was that ‘[t]wenty per cent of Haiti’s population consists of ignorant peasants’ and that ‘[d]irect taxation is extremely difficult to enforce on such people’. ⁸⁹ Indeed, ‘[d]ue to [the] ignorance and primitive conservatism of this population, it is necessary to educate rather than to legislate’. ⁹⁰ What Russell began to touch on was a deep division between rural Haitians who were suspicious of the state previously run by those who lived in urban centres, noting: ‘The great hatred and suspicion which exists between town and country complicates the situation.’ ⁹¹ However, the refusal of rural Haitians to participant in the centralised system imposed on them was explained exclusively in terms of their ‘ignorance’ or lack of knowledge rather than any other plausible reason. Thus, garnishing their support was a simple matter of educating them. In this regard, however, the Public Health Service had failed to ‘educate’ the masses. Indeed, well over a million Haitians were using the rural dispensary system, yet this narrow intervention had failed to produce within them a favourable disposition towards the state, resulting in a largely untaxable population and a government dependent on the market prices of exports to support its operations.

The United States’ occupation was never intended to be permanent; the treaty ratified between Haiti and the United States in 1915 was set to expire in 1936 and, as the occupation wore on, its untenability became increasingly apparent. ⁹² In 1929, following growing discontent with the American occupation, Haitian students engaged with the then prominent decolonisation movement took to the streets and rioted, which in turn spread throughout Haiti and ultimately resulted in violent uprisings elsewhere. ⁹³ After the riots were put down in late 1929, United States President Hoover requested an inquiry into the American occupation of Haiti to be led by the former governor of the Philippines, W. Cameron Forbes. ⁹⁴ By 1930, the US occupation itself had begun to give up any hope of ‘developing’ Haiti, as the US Financial Adviser-General Receiver himself noted: ‘To be sure, the ambitious developmental program of recent years largely has been given up. Funds have been insufficient to extend the system of vocational education, to strengthen the police and constabulary, or to construct many badly needed improvements.’ ⁹⁵ Unfortunately, the Americans withdrew from Haiti during the height of the Great Depression, which had resulted in a substantial decrease in the value and quantity of exports during the early 1930s, resulting in a 30% budget reduction in 1932 from the high budget of 1928. This heavily reduced budget limited their ability to fully fund all the same health measures that they had earlier. ⁹⁶ As Patricia Lopez notes: ‘Further, as the [de-occupation] process began to unfold in 1931, the health systems infrastructure was slowly dismantled – the budget was slashed, prescriptions were watered down, and Haitians were expected to pay for or provide their own bandages and oils, by order of the Sanitation Engineer.’ ⁹⁷ A sentiment confirmed by Russell, who noted that: ‘The work of the service has necessarily been one of charity, but the service is now devoting especial attention to the lower of the volume of free care given by hospitals and sanitary units. This is in the interest of democracy and sound economics and will eventually result in proper medical and sanitation service for all the people.’ ⁹⁸ Correspondingly, the Haitian Public Health Service, which had already begun charging patients for medicines earlier in the occupation, expanded the practice and, due to the relatively high cost of medical treatment for rural Haitians, the 142 rural dispensaries that saw 1 134 156 patients during 1931–2 only saw 790 320 patients in 1932–3. ⁹⁹ This already taxed system was further strained by the loss of free goods from the US occupation that were no longer being provided to the Health Service by US marines. Following the budgetary adjustments in 1931, the Public Health Service’s budget, sustained on revenue from taxation and privatising the dispensaries, remained relatively stable. ¹⁰⁰ Haitianisation (the process of replacing white American administrators with Haitian administrators) also had a lasting impact on the Haitian medical school and in the Public Health Service itself through the selective placement of Haitians sympathetic to the goals of the US occupation – especially former members of the US-run gendarmerie – in positions of power. One example is the former president of the Haitian Medical Society, Dr Camille Lhérisson, a Rockefeller Foundation fellow and Butler’s protegé, who believed that the ‘diseases of the peasants of Haiti’ were primarily infectious, despite noting the substantial morbidity from cancer and other chronic illness, and also believed that they could be readily solved through ‘social medicine and hygiene’. He further believed, like his American predecessors, that the Public Health Service’s main task was ‘carrying out slowly and methodically a hard civilizing task, the medical education of the masses’ and thus that more than treating illness, the Public Health Service was central to building a modern developed state. ¹⁰¹

6 Conclusion

This paper addresses a gap in the history of colonial medicine in the Caribbean and adds to the historiography of late US imperialism by illustrating the construction of a primarily Haitian-funded health service. Apart from two French-language books written in 1980 and 1997 by Haitian historian and physician Ary Bordes, an unpublished Master’s thesis, a book chapter, a single paper and sporadic mentions in more general studies of health in Haiti, the history of public health and medicine in early twentieth-century Haiti has been neglected in histories of colonial medicine and public health in the Caribbean. ¹⁰² In contrast, there exists a growing body of excellent critical historical studies, written by Haitian scholars and historians of Latin America or the Caribbean, of the American occupation of Haiti in the twentieth century and its relationship with the United States. However, public health is either neglected or only discussed in detail either before or after the US occupation of 1915–34. ¹⁰³ By ensuring a broad coverage of the developments in early international health, late colonial medicine and early development programmes, this paper sheds light on how these concepts of statecraft, public health and colonialism became intimately linked.

This paper documented the trajectory of the Public Health Service of Haiti during the US occupation of Haiti. It documented the creation of a highly centralised administrative system that failed to complete its project of creating enlightened (tax-paying) rural Haitians. The resultant state was deeply dependent on external economic relations rather than on its internal economic activity for the generation of revenue. Thus, when the prices crashed during the early 1930s, the Public Health Service faced rapid cuts and was gradually dismantled. This paper also explored how the US occupation sought to simultaneously exploit, develop and heal Haiti through the development of a large public health service, which was to be accomplished through focusing on what was widely considered to be the greatest obstacle to its fruition: ignorance. The concept of ignorance was sufficiently vague and, over the course of the occupation, plastic to allow it to refer to a diverse range of problems or tensions; importantly, ignorance appeared to be the direct result of a lack of experience, knowledge of or trust in American forms of governance. In this way, ‘education’ or ‘enlightening demonstrations’ could become central to the US occupation’s project of developing a state. The Americans believed that for rural Haitians, this mistrust and lack of familiarity with US forms of biomedical practice could be overcome with performative demonstrations of curative biomedical practices – most spectacularly, curing blindness. The US occupation incorrectly believed that these treatments, which many Haitians did willingly take, would convince them not only of the efficacy of the drugs prescribed but also to participate in a larger administrative project to centralise and ‘modernise’ Haiti. However, in idealising their project, they neglected the violence perpetrated against rural Haitians by the occupation and their own inability to adequately fund the Public Health Service. Moreover, by the end of the occupation, the US administrators began to realise that people could easily take medications and experience curative effects of drugs without becoming ‘civilised’, meaning that the larger political project that free healthcare was meant to support had failed. Similarly, their project to develop efficient Haitian medical administrators appeared to have failed. Racial bias animated their assessments of Haitian physicians, suggesting that, as a race, the black Haitian physicians lacked a sense of ‘medical ethics’ and administrative prowess. What animated all these critiques of the Haitian people by the members of the US occupation was their seemingly endless depths of ignorance. Not only did the Haitians seem to lack the requisite knowledge, but they also lacked the right interpretation; indeed, their whole worldview was wrong. The US occupation’s perception of itself, however, was almost universally positive. Within the medical corps, there was never any expression of critical self-reflection. Doctors would not criticise their peers for being racist, but rather celebrated them for moments of ‘color blindness’. ¹⁰⁴ Ultimately, when faced with their failure, blame had to be assigned and the construction of the main obstacle to progress in Haiti – ignorance – could also be readily transformed into an explanation: the Haitians were simply too ignorant to be developed.