How did smallpox and tuberculous force the Medial Corps Office of Indian Affairs to reform
By Clinton M. Sandvick
After its founding in 1824 within the War Department, the Office of Indian Affairs (OIA) became responsible for the health and welfare of Indians who were removed to reservations. While some treaties mandated providing tribes with medicines or physicians, Indian agents began to employ doctors in different reservations to treat the panoply of ailments afflicting the Indians.
Even though physicians were hired quite early in some situations, the OIA failed to create a formal medical corps to treat Native Americans for almost eighty years. Physicians were hired in a piecemeal and sporadic fashion by local Indian agents, superintendents, and Indian School administrators. By the end of the nineteenth century, the OIA employed only about 90 physicians for almost 200,000 Indians. Sometimes physicians were hired by agents as salaried employees; other times. They were contracted, workers. The OIA struggled to hire competent employees, and some of these problems were magnified in their pursuit of qualified physicians. The OIA lacked sufficient funds and was hampered by ineffective hiring practices.
While the OIA was slowly expanding its medical corps, Indians’ continued survival was threatened by smallpox and the advancing specter of tuberculosis. Under the stewardship of Commissioner Francis E. Leupp, the OIA attempted to reform its medical corps and create a more unified organization that could meet the needs of reservation Indians in response to the tuberculosis threat. While these reforms did not necessarily solve any of the problems Native Americans faced, they demonstrated that the OIA was cognizant of the health dangers Indians faced on reservation lands and showed they were willing to make coordinated efforts to protect Indians. The tuberculosis threat also provided the OIA with an opportunity to challenge Indian behavior but provide a rationale for how those behaviors threatened their lives. Even then, the OIA only considered reforming its medical corps after it was clear that tuberculosis threatened the survival of not only numerous Native Americans but whites who lived near reservations.
Even if an OIA commissioner had sought to improve the OIA’s ability to deliver competent health services before 1909, any potential reform could have been rendered meaningless because of its counterproductive hiring and appointment procedures. Essentially, the medical corps of the OIA could be reformed only after the OIA centralized its authority and was in a position to supervise and manage its various employees. Therefore, it is essential to examine the role the appointment process played in limiting OIA’s medical corps' effectiveness.
In addition to examining the OIA appointment policy and its role in limiting its medical corps' effectiveness, this paper will examine the role smallpox, and tuberculosis played in reforming the OIA medical service. Despite the constant specter of smallpox, the OIA did not fully commit to reforming its medical corps until it finally acknowledged the tuberculosis catastrophe's nature. This paper will examine how these crises differed and why they engendered such different responses. The OIA’s responses were not necessarily driven by a concern for the Indian’s health and safety. They may not have reformed the OIA earlier because it did not benefit the broader mission of implementing federal policy.
When the OIA created the Indian Medical Services, it did so because it advanced its broader policy objectives. This paper will focus more on the impetus and obstacles for reform than the reforms themselves. While the reforms did increase the number of physicians, nurses, and hospitals serving physicians, they were not particularly successful. Tuberculosis was still a problem in the 1950s for Native Americans. Throughout the twentieth century, the Indian Medical Services and the successor agency under the Public Health Service, the Indian Health Service, would undergo significant reforms to improve Indian health. Therefore, it may be more useful to understand why the OIA has finally instituted reforms instead of the efficacy or value of those reforms.
The Deeply Flawed Office of Indian Affairs
Starting in 1824, the OIA was charged with faithfully implementing federal Indian policy. Historian Paul Stuart described the OIA as “organizationally weak and ineffective in its first half-century.” The OIA was largely unsuccessful during its first five decades of existence because it could not effectively manage its agents and enforce Indian policy on its own. Before 1880, the OIA was decentralized and could not appoint personnel to its Indian agencies. Throughout the nineteenth century, the OIA’s policies for selecting Indian agents, superintendents and other employees were constantly changing, and each change limited the ability of the OIA to manage its employees. Throughout the nineteenth century, other organizations competed with the OIA to dictate and implement federal Indian policy including Indian Commissions, Congress, the Army, and various Christian Churches. Ultimately, the OIA was a weak, decentralized agency which was largely ineffective at lobbying Congress for the funds required to fulfill the United States’ treaty obligations.
Early in its history, the OIA was poorly situated to improve the health and welfare of agency Indians. Despite efforts by local agents to hire physicians, doctors were still fairly infrequent on Indian agencies in its early history. Agencies, especially early in the OIA’s existence, depended on missionaries, teachers, and Indian Agents to diagnose and treat Indians. In 1843, T. F. L. Verreyett stated that missionaries, not doctors, were responsible for administering medicine to sick Indians. In another report during that same year, a missionary to the Choctaw agency admitted that he was acting out of necessity as a physician for the Indians.
Indian agents began to request medicines, such as quinine because they believed that “a very small outlay for medicine” could save Indian lives. Before the Civil War, the OIA employed very few physicians for its tribes. By 1865, only 12 physicians were known to be employed by the OIA. Even by 1877, the agent for the White River Agency stated that his agency did not have a physician and that the agency’s teacher was forced to practice medicine. While these numbers would steadily rise over the next four decades to approximately 90 physicians, these doctors were responsible for the health and welfare of over 180,000 reservation Indians in approximately 150 agencies.
While the OIA was tasked with administering federal Indian policy, it relied upon the United States Army to fulfill its mission. The OIA’s dependence on the Army was emphasized during the Civil War. During the war, the Army’s role was dramatically reduced and chaos erupted on numerous reservations. Several tribes open revolted because the OIA could not fulfill its treaty responsibilities. The failure of the OIA to maintain peace and order during the Civil War led to a series of administrative reforms. These drastic reforms had a lasting impact on the agency’s physicians.
The impact of the patronage system on the OIA
During the first two decades of its existence, Indian agents and superintendents were presidential appointees. The organizational structure of the OIA placed agents under the Commissioner of the OIA, but agents were appointed by the President and confirmed by the Senate. After the OIA was reorganized under the Interior Department in 1848, the initial selection of the agent would be conducted by the Department of Interior, but the President ultimately decided who would be proposed to the Senate. Unsurprisingly, senators could both block or recommend candidates to the executive branch. While agents may have been organized under the Commissioner, they were essentially serving at the pleasure of the President. Stuart argues that the “political control of appointments” undermined the ability of the central office of the OIA to influence local decisions.
The Commissioner of Indian Affairs lacked the ability to hire and remove these agents and officials. Not only were agents presidential appointees, but they wielded complete control over the appointment of their subordinates. Indian agents had an extraordinary amount of autonomy to dictate the understanding of Indian policy on their reservation. Not only were Indian Agents political appointees, but they were approved by the Senate. Indian agents were a key component of the government’s patronage system.
Temporarily outsourcing appointments to OIA to Christian Churches
The Ulysses S. Grant administration tried to eliminate the patronage system and attempted to create a system which hired people for reasons other than political connections. Initially, the Grant administration tried to hire Army office, but various constituencies complained about these appointments. The Grant administration developed a novel solution to soothe competing interests. Instead of relying on a non-political appointment system or patronage, it decided that different Christian churches would be given the responsibility to not only appoint Indian agents and their subordinates but serve as missionaries on those reservations. Instead of agents hiring physicians, churches would be given the freedom to hire physicians who represented their values. Control over the OIA was essentially ceded to different churches.
While this system was approved, it created additional problems within the OIA by injecting various religious denominations’ goals and ideas into federal Indian policy. Instead of centralizing OIA authority, this move created additional strife within the OIA by allowing multiple church denominations to dictate federal Indian policy through their proxies. Attempts to eliminate the influence of medicine men among Indians became an increasingly important goal of Indian agents and agency physicians. Instead of consolidating its power, the OIA adopted several new masters which ensured that it would not be able to take a unified approach to improve Indian health. By 1880, the OIA revolted against church control and began to interfere with the selection of Indian agents by the religious organizations. After a decade of being pulled in different directions, the church appointment policy was abandoned and the practice was stopped.
Appointing Physicians under the Civil Service System
Even before the Rutherford Hayes administration abandoned appointment by churches of Indian agents, the OIA was finally allowed to appoint physicians to Indian Agency under the civil service system. Instead of relying on local agents or churches to select suitable physicians, the Commissioner could appoint physicians to agency positions. Instead of making these appointments subject to Senate approval, physicians were hired under the civil service system. By allowing the Commissioner to make appointments under the Civil Service Commission, the OIA was finally able to centralize its authority over agency physicians. Still, the OIA did not an administrator, such as a Surgeon General, in charge of agency physicians.
In 1886, Commissioner Adkins acknowledged that the OIA had had numerous problems with incompetent subordinate employees. Adkins indicated that new standards would be instituted for subordinate employees and promised that incompetent employees with the agency would not be eliminated. He argued that physicians should not only be graduates of medical school, but they should focus their undivided attention on the needs of the Indians and agency employees. He discouraged physicians from moonlighting and accepting payment for treating patients “not connected with the agency.”
By the end of the 1880s, the OIA had developed a list of criteria for people applying to become OIA physicians. In addition to being a “regular graduate of some reputable medical school,” physicians were expected to “be actually engaged in the practice of medicine.” In addition, to listing a physician’s minimum requirements, the OIA provided a job description for agency physicians. Considering the heavy patient load each agency physician faced, the OIA added a number of additional tasks, including eliminating “the influence of medicine men,” treating patients in their homes, reporting questionable sanitary problems to agency authorities, regularly visiting agency schools, organizing classes to teach Indians how to care for the sick, filing monthly reports, and working harmoniously with the Indian agent.
The State of Western Medicine was a Disaster
It is unsurprising, that the lack of centralized authority at the OIA prevented any organized approach to improving Indian healthcare. Since physicians were employed by the local Indian Agents they would not have been beholden to OIA bureaucracy in Washington. Therefore, it would have been impossible to effectively mandate minimum standards for physicians and promote health initiatives. Even if minimum standards for physician competency could be mandated, finding competent physicians in the United States during the nineteenth century was incredibly difficult. During the nineteenth century, American medical practice fragmented into multiple competing sects.
Before 1800, medical therapeutics had changed remarkably little over the previous two thousand years. At the beginning of the nineteenth century traditional physicians (or “regulars”) viewed themselves as learned professionals, their therapeutic methods were informed by Galen’s two-thousand-year-old “four humoral theory.” “The body was seen, metaphorically, as a system of dynamic interactions with its environment” and physicians believed that specific diseases played an insignificant role in the system.
During the nineteenth century, this understanding of the human body came under assault because it was ineffective in treating human illnesses. From the 1820s to the 1850s, the regulars’ dominance of American medical practice eroded dramatically. Several unorthodox or irregular medical sects, including Homeopathy, Eclecticism, and Thomsonianism, arose in opposition to the heroic medical practice of the regulars. 
Unsurprisingly, regular physicians were often seen as incompetent or ineffective. During the mid-nineteenth century, not only were regulars hampered by a fundamentally flawed understanding of medicine, but woefully inadequate medical schools sprouted like weeds throughout the country. These schools were staffed by poorly trained practitioners, who were focused on profit, not education. Admission standards for most American medical schools could be best described as non-existent. Ronald Numbers quoted a physician in “The Fall and Rise of the American Medical Profession” as saying, “[i]t is well understood among college boys that after a man has failed in scholarship, failed in writing, failed in speaking, failed in every purpose for which he entered college; after he has dropped down from class to class; after he has been kicked out of college, there is one unfailing city of refuge – the profession of medicine.”
It would have been even more difficult to locate competent physicians who would have been willing to relocate to the isolated and potentially dangerous Indian reservations. William Mitchell, agent for the Warm Spring Agency in Oregon, complained that for $1,000 per year “no physician of even ordinary ability” could be had. Not only was the pay insufficient, but few gentlemen of “education and ability” would be willing to live somewhere which completely lacked a “society.” Even if the OIA had instituted some standards, it is not clear that the medical profession could have provided physicians who could improve Native American health.
The Failure of the Medical Corps encouraged the use of Native American Medicine
While treating Indian disease was an auxiliary mission of the OIA, its primary goal was to control the Indian population and permit westward expansion. Unfortunately, several agents believed that this mission was severely compromised by the failure of the OIA to provide enough qualified physicians for Indian communities. In 1886, John S. Ward, the Indian Agent for the Mission Indians in California, complained that his physician could not adequately care for the 3,000 Indians under his care because the physician was required to cover an area the size of New England. Ward argued that his physician needed a horse and buggy and at least $1,000 a year in pay to treat his charges.
Because the OIA was unable to provide enough doctors, Indians continued to rely on their own medicine. Despite concerted efforts by the OIA throughout the nineteenth century to undermine and degenerate Indian medicine men, the influence of medicine men continued. The OIA believed that medicine men stalled the assimilation of Indians because they preserved not only their medical but religious traditions. While the OIA sought to eliminate their influence, they failed to understand the roles these individuals played in Indian society or provide Indians with medical alternatives.
Throughout the nineteenth century, Indian agents provided contradictory reports regarding the influence and reliance on medicine men by Indians. Whether or not these reports were accurate is difficult to ascertain. Due to the often contradictory nature of these reports, it appears that medicine men continued to play prominent roles tribes throughout the nineteenth century. Even though some Indian agents insisted that their Indians were not “superstitiously attached to their medicine men,” others reported that medicine played a prominent role in tribal life. Reports from the OIA agents during those years were often wildly inconsistent.
In 1860, B. W. Kimball, the physician for the Medicine Creek Treaty Indians stated the Indians’ trust in their medicine men was declining, but only after declaring that most Indians relied on their own “system of medicine” to treat health problems. Dr. Mills, agency physician for the Nebraskan Spotted Tail Agency claimed in 1877 that Indians in his agency had abandoned their own medicine-men and stopped performing their “superstitious and mysterious incantations.” In 1884, the Commissioner of Indian Affairs H. Price blamed Indian medicine men’s condemnation of western medicines as “poison” and “the almost universal belief in spirits…” for high the Native American mortality rate. Price argued that Indians could not be effectively treated by agency physicians because they sought treatment from their own medicine men first. In 1894, Frank C. Blackly the physician for the Southern Ute Agency minimized the importance of the tribe’s medicine men, but acknowledged that they were still able to “keep up the practice of their superstition…”
Whether or not agency physicians were better than medicine men is debatable. Western medicine had learned how to control smallpox, but most of the important parts therapeutic revolution would not occur until the twentieth century. Indian agents even blamed their physicians’ incompetence for the continued survival of medicine men. Some agency physicians simply hoped that Indians would stop using medicine men when the older generation of Indians died out. In 1860, Dr. A. Coleman acknowledged that it would take years before Indians would trust western medicine because their practice of medicine had not only been passed “to them by a succession of generations” but was “interwoven with their religion” and government. Throughout the nineteenth century, Indians relied on their native medical practices and, when available, agency physicians. This reliance on agency physicians was ultimately limited by both the number and quality of agency physicians and their unwillingness to reject their own traditions.
Adkins’ successor, T. J. Morgan acknowledged that OIA needed to reform its health services. Agency physicians could now be hired and fired by the Commissioner, but the OIA had not consolidated the physicians into an autonomous branch within in the OIA. Agency physicians were not organized under a chief administrator and they completely lacked supervision. Morgan argued that wretched working conditions and lack of supervision, agency physicians would be strongly tempted “to slight their work.” Additionally, Morgan criticized the OIA’s policy of appointing physicians without first examining them. Throughout the United States, states had created new licensing laws which required prospective physicians to pass examinations. The OIA only required that physicians be graduates of “some reputable medical school and submit testimonials as to moral character and correct habits.” Morgan realized that the OIA medical corps could soon become a haven for quacks. Agency physicians needed to be free from political influence, well compensated and thoroughly examined before their appointments.
It was fairly easy to demonstrate how poorly paid agency physicians were compared to their colleagues working in both the Army and Navy. In 1890, the agency physicians were paid on average $1,062 and Indian school physicians $813. Physicians in the Army and Navy were typically paid between $2,600 and $2,800 per year. Not only was the pay higher for military personnel, but they were required to treat far fewer patients. In the Navy, 160 physicians treated 9,955 sailors while 192 Army physicians were responsible for 26,739 army personnel. On the other hand, 82 agency physicians were responsible for 180,000 Native Americans in 1890. Each year agency physicians treated eight times as many patients. Some agency physicians were accountable for staggering numbers of Indians spread on far-flung reservations. One agency physician on the Navajo Reservation was in charge of the health and welfare of 18,000 Indians spread over 12,000 square miles. Despite the obvious problems within the medical corps of the OIA, major institutional reform was still decades away.
During the nineteenth century, Native Americans faced numerous health crises. Two of the most dangerous and disruptive diseases were smallpox and tuberculosis. Each of these diseases killed thousands of Indians. The different responses the OIA had to the smallpox outbreaks and the spread of tuberculosis may have also represented the central goals of federal Indian policy during this time.
Probably the most deadly danger faced by Native Americans was the nearly constant outbreaks of smallpox. Smallpox epidemics decimated Indian tribes throughout the nineteenth century. Smallpox outbreaks threatened not only Indians but posed grave dangers to neighboring American citizens. In 1832, as a result of this ongoing threat, an early smallpox program was created to vaccinate Indians. Unfortunately, even though over 3,000 Indians were vaccinated, the program was largely unsuccessful. Numerous tribes refused to be treated and eventually the program’s funding ran out. Soon after the program’s demise, the 1837 epidemic devastated the Blackfeet and Mandan tribes in the Dakotas. Lawrence Taliaferro, Indian Agent at St. Peter’s Iowa Territory, observed that during the smallpox epidemic of 1837 “upward of 60 (Sioux) lodges” had perished.
During the 1837 epidemic, some OIA employees attempted to stem the epidemic’s tide. In Wisconsin, T. T. Vandenbrock, Superintendent of the Mission on the Fox River, claimed that he had vaccinated hundreds of Indians during the epidemic without any financial support from the OIA. Fortunately for the Indians on the Fox River, Vandenbrock was willing to foot the bill because he believed that he was simply “discharging my duty to my fellow-creatures and to my Creator.”  While Vandenbrock may have been discharging his duty to his fellow creatures, he may also have also been attempting to get his expenses reimbursed from the $500 allocated to the Wisconsin superintendency out the $5,000 appropriated by the Twenty-Seventh Congress intended “to defray the expenses of vaccinating the Indians.”
The presence of smallpox both advanced and threatened American interests. While agency physicians could not always successfully stop these epidemics, successfully treating Indians helped smooth relations between Americans and Indians. Western physicians could reduce the deaths caused by smallpox through vaccination or inoculation. It was the most important way to demonstrate the superiority of western medicine. Of course, if smallpox epidemics culled the Indian population the OIA would have a much easier task of controlling Indian populations and advancing federal policy. Smallpox continued to be a danger to Indians throughout the nineteenth century.
In 1855, the Osages were faced with an outbreak of smallpox. The agency was required to hire a physician who administered the smallpox vaccine to the tribe to prevent further infection. Dr. C. W. Dean, from the Southern Superintendency, described a smallpox epidemic which killed approximately 400 Indians.  Additionally, the Arapahoes near Fort Laramie admitted to killing cattle and sheep because they were weakened by smallpox and unable to hunt.  In 1864, an outbreak of smallpox in The Dalles threatened the Warm Springs reservation and another outbreak in Colorado and Kansas forced a Special Agent H.T. Ketham to vaccinate over 1100 Indians.
In 1869, the OIA faced several additional occurrences of smallpox. Tule Indians faced a similar outbreak to the Arapahoes when smallpox appeared in Visalia. In order to prevent the spread of smallpox; the agent restricted the Tules to the reservation and vaccinated 190 of them. During the first year of an Indian school on the Nez Perces Reservation, it was closed after smallpox in Lewistown. After approximately 4 months the school was reopened. Another outbreak in 1877, threatened the Pima Indian Agency. This outbreak was worrisome because the Pima Agency did not have a physician and the disease spread widely. J. H. Stout, the Pima Indian Agent, was forced to temporarily hire a physician to vaccinate hundreds of Indians. Even though Stout indicated that it was a just mild form of the virus, it still proved to be a fatal outbreak.
Smallpox outbreaks continued throughout the nineteenth century and even as late as 1900, smallpox was still a threat. The Rosebud Agency reported a smallpox outbreak which was averted after the agency physician vaccinated the agency’s Indians and surrounding whites.  Aside from the Rosebud Agency, several other reported smallpox outbreaks. The continued smallpox scares motivated Congress in 1900 to allocate $50,000 to suppress smallpox in the Indian Territory, but it was not designated for Indians. The appropriation was solely intended for residents of the territory who were “not members of any Indian tribe or nation.” These outbreaks represent just a few of the examples of the continual nature of the smallpox threat.
Despite these constant smallpox outbreaks, the OIA did not develop a widespread program to vaccinate large numbers of Indians. Instead, the OIA shuffled physicians from one crisis to another. Agency physicians would only start vaccinating people once an outbreak or scare occurred. Even in the best circumstances, this strategy could endanger people’s lives, but on far-flung Indian agencies with possibly one physician it was often fatal. Oddly enough, it was not the constant threat of smallpox that convinced the OIA that it needed to take broader action to protect the lives of its charges, but the endemic disease of tuberculosis. Unlike smallpox, tuberculosis was essentially untreatable at the time. During the nineteenth century, tuberculosis was often referred to as scrofula (cervical tuberculosis) and consumption (pulmonary tuberculosis). It is difficult to determine when Indian agents became aware of the presence of tuberculosis.
By 1854, scrofula, a formerly a rare ailment among Indians, had become quite common among Indians in the Midwest.  Over the next 50 years, references to tuberculosis and scrofula by agency physicians and agents became increasingly common. Agency physicians pleaded for hospitals, sanitarium, and medicine. Other physicians argued that the OIA needed to quickly change Indian behavior because they firmly believed that Indians were primarily responsible for the diseases spread. Despite the growing number of reports from agencies regarding the alarming rates of tuberculosis, the OIA did not take any major steps to limit tuberculosis until in the first decade of the twentieth century.
Between 1865 and 1890, agency physicians increasing discussed tuberculosis’s grim toll. In 1865, Dr. A. Coleman, a physician for the Winnebago agency stated the tuberculosis was “their most frequent and destructive disease.” In 1875, the Fort Berthold agency physician remarked that tuberculosis and scrofula were still claiming victims, but he had that improved methods of providing fuel and “conveying the products of their agricultural labor” would improve sanitary conditions and limit the spread of tuberculosis. He failed to explain why he took these actions and how they could possibly control tuberculosis. Another physician simply claimed that there were not as many deaths from tuberculosis as he expected, but he makes no attempt to justify or explain his claims. The 1885 Annual Report showed that there were 875 cases of consumption and additional 1,809 cases of scrofula.  The commissioners would have been aware of the growing threat simply by reading the department’s Annual Report.
In 1894, Dr. A. E. Marden of the Pima Agency reported that tuberculosis was present with “fully half of the Pima families” and that “three-fifths of the deaths” in the agency were a result of either syphilis or tuberculosis. Another physician, C. H. Kermott of the Devils Lake Agency, claimed that Indians had strumous blood which caused high rates of tuberculosis and scrofula. Joseph R. Finney, the physician for the Fort Berthold Agency, claimed that the health of the Indians was essentially good, except for tuberculosis which had been “a veritable scourge” for a long time. Ambler Caskie, agency physician for the Lower Brule Subagency, acknowledged that tuberculosis “in one or another guise” was death’s “busiest factor.’
In 1901, the OIA sent out a circular to agencies physicians soliciting their opinions on the health and welfare of their Indians. Despite the sometimes “antagonistic” and contradictory nature of reports, the OIA believed that they convened an accurate impression of Indian health. The reports demonstrated that tuberculosis was “more widespread among the Indians” than whites. The OIA was confused by this response because it believed that the locations of most reservations and the Indians active, outdoor lifestyle should have reduced, not increased the incidence of tuberculosis. Tuberculosis appears to be the exception to the belief within the OIA that if done intelligently a “change from barbarous to civilized modes of life tends to improve health conditions.” The 1902 report pinpointed nine causes for the high rate of infection:
- Failure to disinfect tubercular sputum.
- Poor sanitation and lack of cleanliness.
- Improper and poorly prepared food.
- Intermarriage of Indians of the same tribe.
- Intermarriage of Indians and whites.
- Taking pupils predisposed to tuberculosis from camp life and confining them in school.
- Overcrowding dormitories.
- Lack of proper medical attention after infection.
- The use of alcohol.
The report focused blamed Indian behavior and culture for their high rates of tuberculosis. Physicians did not understand the nature of the tuberculosis threat at this time. Many physicians believed that tuberculosis could be controlled by sanitation and civilization. They did not understand the transmission or nature of the disease. Therefore, physicians delineated problems they saw with Indian culture which provided convenient explanations which shifted blame from the OIA and themselves. The 1877 report from the Red Lake agency physician blamed the Indians’ “habits” for the prevalence of such diseases as scrofula and tuberculosis.  The 1902 report even stated that Indians were primarily responsible for the lack of proper medical care because “ignorance and superstition” prevented Indians from following the proper courses of treatment.
While it was possible that agency doctors may have neglected tuberculosis patients, it acknowledged that any negligence was understandable under the circumstances. Aside from the overcrowding of dormitories, the OIA did not believe that it was responsible for tuberculosis on reservations. Whether or not there was an internal debate regarding what role the reservations system itself played is questionable. Physicians were more concerned with ventilation and climate than the potential problems posed by concentrating Indians on isolated and primitive reservations.
Despite the increasingly urgent reports from Indian agents and physicians regarding the prevalence of tuberculosis, the first comprehensive survey of Native American health did not occur until 1903. The results of the study were enlightening because it indicated that large numbers of Indians were infected with tuberculosis. Despite this evidence, it was not until Francis E. Leupp took over the OIA that someone within the organization took the danger of tuberculosis seriously. Part of the problem may have been caused the longtime belief that alcohol either caused or contributed to the tuberculosis epidemic. In 1905, Leupp took over as the Commissioner for Indian Affairs under Theodore Roosevelt. While Leupp did not take any immediate actions to reduce the number of tuberculosis cases, he did commission a study for the Sixth International Congress on Tuberculosis by Dr. Ales Hrdlicka, a prominent anthropologist, with United States National Museum.
Hrdlicka determined after an extensive study of five separate tribes that tuberculosis “threatens to exterminate before long whole units of the Indian race, and deteriorate much of the remainder.”
Hrdlicka argued that tuberculosis was only introduced to North America with the arrival of Europeans. This late introduction contributed to the high death rates among Native Americans. Data from the OIA, indicated that between 1907-1908, 641 Indian deaths were attributable to pulmonary tuberculosis and another 182 deaths resulted from other forms of tuberculosis out of 81,388 Native Americans. Hrdlicka’s study showed that in some tribes as a many a quarter of all Indians were infected with tuberculosis, but even more distressing is that in some cases, 40 percent of Indians lived a family group where someone was infected. 
Despite years of reports cataloging the high rates of tuberculosis infections, these new statistics finally caught the attention of the OIA and clarified the scope of the tuberculosis problem in the native population. David Jones accurately pointed out in Rationalizing Epidemics that the rediscovery of the tuberculosis problem among Indians by Leupp’s administration was just the latest attempt to understand the scope and nature of the tuberculosis crisis. Early twentieth century administrators either ignored or dismissed the validity of all the evidence that tuberculosis had been present for over a half-century.
The physicians and agents reports may have also played a factor in minimizing the tuberculosis risk. Physicians and agents often claimed that the health of the Indians on their agencies was essential good, but then acknowledge that tuberculosis was a constant problem. For the most part, unless an agency endured some type of deadly epidemic they would classify Native American health as good. The fact that Indians suffered from tuberculosis was not unexpected. Physicians and agents appear to have seen tuberculosis as just another aspect of Indian life. Like religion, alcoholism, or medicine men it was seen almost as a vestige of their Indian character, despite acknowledgment by some physicians that tuberculosis was a recent phenomenon among native populations. Jones argued that new physicians continually rediscovered the problem of tuberculosis and were “either oblivious to the existence of past health campaigns or dismissive of these past efforts.” 
Leupp tried to develop a new approach for controlling tuberculosis. First, Leupp acknowledged that there were simply not enough physicians to treat every tuberculosis patient. In 1897, there were approximately 86 physicians to treat over 180,000 Indians on the nation’s reservations. Instead of creating a centrally located sanitarium, Leupp proposed building sanitariums on reservations as needed. Various Indian agents, physicians and people who were affiliated with the Lake Mohonk Conference had repeatedly proposed establishing a central sanitarium for Indians in the Southwest. Leupp opposed creating a central facility because Indians were “simply unwilling to send their friends and families away from home.”  While Leupp did not intend “to rush into building camps on every reservation, regardless of the possibility of their success,” instead he sought to build a small number of experimental sanitariums to determine if they could be a success.
Additionally, he proposed developing a concerted program to educate all Indians regarding the dangers of tuberculosis and the possible ways to reduce the spread of the disease. A key component of these plans was the creation of the Indian Medical Services to centralize the management of the proposed sanitariums and establish education programs.
Leupp admitted that any reform of the Indian medical corps would be problematic. The following year, Dr. Joseph A. Murphy, the first medical supervisor for the OIA, blamed a litany of problems hampering the OIA efforts to reorganize the medical services including isolated populations, insufficient resources and the lack of trained workers. Murphy also argued the Indians compounded these problems because they were ignorant, lazy, unclean, indifferent, unhygienic, unwilling to reform and neglectful of the sick and the aged. Throughout the nineteenth, agency physicians often blamed Native Americans for their own ill health. Only occasionally did they acknowledge that most of the health problems faced by Indians were either a result of their interactions with Americans or their consolidation of them onto reservations.
Leupp left his position as commissioner at the end of Theodore Roosevelt’s administration, but the pressure to reform to improve Indian health continued. By 1912, Congress began appropriating money specifically to expand Indian medical service. This new money allowed for a dramatic expansion of the number of physicians working for OIA and contributed to a hospital building spree on reservations. Congressional appropriations continued to grow and by 1917 Congress was appropriating $350,000 a year for Indian health. At the turn of the century there approximately only 90 physicians in the OIA, but by 1918 there were 87 separate hospitals. Reform stalled during the First World War. After the start of American involvement in the war, the number of physicians in the Indian Medical Service decreased dramatically. At the start of 1917, the Indian Medical Services 186 physicians and 91 nurses. By 1918, those numbers had dropped dramatically; only 139 physicians and 55 nurses worked for Indian Medical Services. Unsurprisingly, the momentum that had been built up during the Taft administration was completely dissipated by the fall of 1918. The grossly understaffed IMS was little of no match for the 1919 influenza epidemic. A quarter of the 304,000 Indians came down with influenza and 6,270 died from the disease. 
The hope that Indian health could be improved diminished. Tuberculosis continued to rage on Indian reservations during the twentieth and it would even spread to Indians who had low incidence rates in 1905. The Navajos in Arizona had a lower rate of tuberculosis that was present in the United States general population, but during the first half, the century climbed dramatically. While the mortality rate for tuberculosis had declined by 1947 it was still seven to ten times higher than other American citizens. While tuberculosis mortality rates declined during from 1900-1950 it would be difficult to claim that reforms instituted during the Roosevelt and Taft administrations were primarily responsible.
Ultimately, these reforms did not have the intended effect, but they did demonstrate a shift in United States policy towards Native American health. While Smallpox epidemics wiped out large numbers of Indians in the nineteenth century; government agents, missionaries and physicians expressed concern and attempted to inoculate and vaccinate some Indians. But the OIA response was essentially reactive. Instead of preventing smallpox outbreaks, physicians would react to each and every outbreak. The failure of the OIA to develop a more proactive or extensive policy regarding smallpox was hampered the inherent weaknesses with institutional makeup of the OIA. Jones argued that the claims by agency physicians at the end of the nineteenth century that they effectively reduced the threat of smallpox are questionable. A number of complete reasons completely unrelated to OIA efforts could have played a larger role in reduced mortality rates including less virulent strains of the virus, increased immunity, or unreported deaths.
Unlike smallpox, the tuberculosis threat slowly crept up on the OIA. Unlike smallpox, tuberculosis did not sweep through reservations and kill thousands; it slowly integrated itself onto reservations and in Indian schools. While some Indians quickly succumbed after being infected, most victims lingered on for extended periods of time. By 1880, the OIA had become increasingly centralized and capable of managing its physicians, but its response to tuberculosis was hampered by its lack of institutional memory. Despite repeated warnings from its employees, the OIA did not remember that it had a problem. Instead, each new agent, physician, and the commissioner was surprised to discover the presence of tuberculosis among the Indians.
Leupp’s reform efforts gained traction because the tuberculosis threat to Native Americans could no longer be ignored, Roosevelt was interested in health and physical fitness, the OIA was sufficiently centralized to aid a broad reform effort and controlling tuberculosis dovetailed nicely with the OIA’s effort to integrate Native Americans into American society.  Leupp and Murphy not only sought to reform the OIA’s medical corps, but tuberculosis provided a powerful justification to change the behavior and culture of Native Americans. The OIA could increase its control over its charges under the guise of health reform and eliminate some of their more objectionable behavior. Not only could Indians be taught how to behave in civilized society, but if they failed to follow the OIA’s directives they could claim that their Indian behavior would kill them.
The effort at the turn of the century to reform the OIA’s healthcare was largely unsuccessful, but it is significant because it pinpoints a clear change in OIA and its policies. By 1900 the OIA was finally capable of implementing broad institutional reforms. Advances in medicine would have provided compelling reasons to expand its medical corps. It should not be ignored that these reforms occurred when the government’s relationship to Native Americans changed. By 1909, the United States wanted to control Native American behavior. Tuberculosis provided the OIA with a good reason to educate Native Americans about their potentially dangerous behaviors.
Office of Indian Affairs, Annual Report of the Commissioner of Indian Affairs to the Secretary of the Interior, (1831-1909)
Lake Mohonk Conference of Friends of the Indian and Other Dependent Peoples, Report of the Annual Meeting of the Mohonk Conference of the Friends of the Indian and other Dependent Peoples (1887-1904)
Leupp, Francis E., The Indian and His Problem, (New York, 1910)
Leupp, Francis E., In Red Man’s Land: A Study of the American Indian (New York, 1914)
Eds., Hildreth, Martha and Bruce T. Moran, Disease and Medical Care in the Mountain West: Essays on Region, History and Practice (University of Nevade - Reno, 1998)
Jones, David S., Rationalizing Epidemics: Meaning and Uses of American Indian Mortality since 1600 (2004, Cambridge and London)
Prucha, Francis Paul, The Great Father: The United States Government and the American Indians (Lincoln and London, 1984)
Stuart, Paul, The Indian Office: Growth and Development of an American Institution, 1865 – 1900 (University of Michigan, Ann Arbor, 1978)
- Article 11 of the 1887 Treaty with the Coeur d’Alene Indians mandated that the government furnish a competent physician to the Reservation. P. 421, Kappler, Charles Joseph, Indian Affairs: Laws and Treaties, Vol. 1 (Washington, 1904) Additionally, some unratified treaties, including an 1864 treaty with the Hoopa, South Fork, and Redwood and Grouse Creek Indian, provided for the appointment of a “competent physician.” P. 135-136, Report of the Commissioner of Indian Affairs for the Year 1864, (Washington, 1865.)
- Paul Stuart, The Indian Office: Growth and Development of an American Institution, 1865 – 1900 (UMI Research Press, 1978), 5.
- Stuart, 11-12
- Annual Report of the Commissioner of Indian (1843-1844): 58, 82.
- Annual Report of the Commissioner of Indian (1847-1848): 139.
- Stuart, Indian Office, 130.
- Annual Report of the Commissioner of Indian Affairs to the Secretary of the Interior for the Year 1877 (1877): 33.
- Sources, including the OIA, cite conflicting numbers regarding the number of Indians treated by agency physicians. While there were 300,000 Indians according to census numbers, the OIA sometimes does not include the Five Civilized Tribes in its calculations. I have not been able to determine why those tribes are not always included or if the OIA was not responsible for their healthcare.
- Stuart, Indian Office, 28.
- Stuart, Indian Office, 19.
- Stuart, Indian Office, 36-37.
- Annual Report of the Commissioner of Indian (1885): 13.
- Annual Report of the Commissioner of Indian (1885): 12-13.
- Annual Report of the Commissioner of Indian (1885): 13.
- Charles E. Rosenburg “The Therapeutic Revolution: Medicine, Meaning and Social Change in Nineteenth-Century America,” in The Therapeutic Revolution: Essays in the Social History of American Medicine, ed. Moris J. Vogel and Charles E. Rosenburg, (University of Pennsylvania Press, 1979), 3-6.
- Martin Kaufman, Homeopathy in America: The Rise and Fall of a Medical Heresy (Baltimore and London, The Johns Hopkins Press, 1971), 23.
- Numbers, Sickness, 226.
- Annual Report of the Commissioner of Indian (1869): 169.
- Annual Report of the Commissioner of Indian (1886): 45.
- Annual Report of the Commissioner of Indian (1843): 201.
- Annual Report of the Commissioner of Indian (1860): 201-202.
- Annual Report of the Commissioner of Indian (1877): 70.
- Annual Report of the Commissioner of Indian (1884): xxxv-xxxvi.
- Annual Report of the Commissioner of Indian (1894): 130.
- Annual Report of the Commissioner of Indian (1886): 76
- Annual Report of the Commissioner of Indian (1886): 59.
- Annual Report of the Commissioner of Indian (1860): 76.
- Annual Report of the Commissioner of Indian (1886): 111.
- Annual Report of the Commissioner of Indian (1890): xix-xxii.
- Annual Report of the Commissioner of Indian (1890): xxi-xxii.
- Martha Hilderth and Bruce T. Moran, Disease and Medical Care in the Mountain West: Essays on Region, History and Practice (University of Nevada Press,1998): 44.
- Annual Report of the Commissioner of Indian Affairs Transmitted with the Message of the President at the Opening of the 1st Session of the Twenty-Sixth Congress 1839-1840 (1839): 177.
- Annual Report of the Commissioner of Indian Affairs Transmitted with the Message of the President at the Opening of the 1st Session of the Twenty-Eighth Congress 1843-1844 (1843): 103.
- Annual Report of the Commissioner of Indian (1843): 103.
- Annual Report of the Commissioner of Indian Affairs (1839): 23.
- Annual Report of the Commissioner of Indian Affairs (1856): 10, 68.
- Annual Report of the Commissioner of Indian Affairs (1856): 122.
- Annual Report of the Commissioner of Indian Affairs (1856): 82.
- Annual Report of the Commissioner of Indian Affairs (1869): 191.
- Annual Report of the Commissioner of Indian Affairs (1869): 285.
- Annual Report of the Commissioner of Indian Affairs (1877): 33.
- Annual Report of the Commissioner of Indian Affairs (1890): 381.
- Annual Report of the Commissioner of Indian (1854): 60.
- Annual Report of the Commissioner of Indian Affairs Transmitted with the Message of the President at the Opening of the 1st Session of the Thirty-Fourth Congress 1860 (Washington, 1860): 76.
- Annual Report of the Commissioner of Indian (1877): 519.
- Annual Report of the Commissioner of Indian (1877): 140.
- Annual Report of the Commissioner of Indian (1885): 400.
- Annual Report of the Commissioner of Indian (1894): 107.
- Annual Report of the Commissioner of Indian (1894): 218, 223, 282.
- Annual Report of the Commissioner of Indian (1902): 36.
- Annual Report of the Commissioner of Indian (1902): 34.
- Annual Report of the Commissioner of Indian (1877): 128.
- Annual Report of the Commissioner of Indian (1902): 34-35.
- Francis Prucha, The Great Father: The United States Government and the American Indian (University of Nebraska Press, 1984): 846.
- Transactions of the Sixth International Congress on Tuberculosis In Six Volumes, Vol. 3: Hygienic, Social, Industrial, and Economic Aspects of Tuberculosis, (Philadelphia, 1908): 480.
- Transactions, Vol. 3 (1908): 481- 488.
- David Jones, Rationalizing Epidemics: Meaning and Uses of American Indian Mortality since 1600 (2004): 164-165.
- David Jones, Rationalizing Epidemics: 164-165
- Proceedings of the Twenty-Fifth Annual Meeting of the Lake Mohonk Conference of Friends of the Indian and Other Dependent Peoples 1907 (Lake Mohonk, 1907): 38.
- Transactions of the Sixth International Congress on Tuberculosis In Six Volumes, Vol. 5 State and Municipal Control of Tuberculosis, (Philadelphia, 1908): 430-31.
- Proceedings of the twenty-Sixth Annual Meeting of the Lake Mohonk Conference of Friends of the Indian and Other Dependent Peoples (1909): 23-24.
- Jones, Rationalizing Epidemics (2004) 170-171.
- Prucha, The Great Father, 854-855.
- Jones, Rationalizing Epidemics, 170-172.
- Jones, Rationalizing Epidemics, 121.
- Roosevelt served as the president of the 1908 International Congress on Tuberculosis in Washington D. C.