Cholera and the Origins of the American Sanitary  According to Worcester, the epidemic came soon
Order in the Philippines after the close of a long continued war
Reynaldo C. Ileto
Cholera is an acute diarrhoeal infection caused by
ingestion of food or water contaminated with bacterium
Vibrio cholerae(World Health Organization)
 Nationalist writers find it impossible to interrogate
the established notion that among the blessings of
American colonial rule was a sanitary regime that
saved countless Filipino lives.
 Filipino struggle to defend their independence
through blood and tears.
 Miguel Malvar continued the leadership of guerilla
warfare when Emilio Aguinaldo had been captured
until April 16, 1902.
 Educational System – originally established as
instrument of pacification
 The topic of health and welfare seemed to switch to
another register:
- Before 1900, ravages of cholera, smallpox,
dysentery, malaria, tuberculosis, and other deadly
diseases plagued the people untilthe Americans
came and immediately set to workto minimize the
spread of diseases and to improve the health of the
people.
- Epidemics that used to migrate to the Philippines
were either prevented or minimizedby the
establishment of the Quarantine Service
supervised by competent American doctors and
public health officers.
 It was difficult to educate the Filipinos the
“elementary principles of hygiene and
sanitation”because the they were:
- superstition-ridden and ignorant of the strange
power of the minute germs to cause deadly
diseases, and were not easily convinced by the
efficacy of medical methods in combating the cause
of death from various sickness.
 Two distinct series in Philippine historiography:
- The 1899-1902 war of resistances is a moment in
the epic struggle for independence from colonial
rule
- The 1902-1904 cholera epidemic was seen as
Philippine chapter in the saga of scientific progress.
 Jose Rizal – Father of nationalist historiography and
doctor of medicine
 Most Filipino intelligentsia order the past in terms of
the triumph of reason and science over superstition
and backwardness.
 The victory over the cholera in 1902-1903 is
assimilated into the universal history of medical
progress, torn from its original moorings in a colonial
war and pacification campaign.
 The most accessible accounts of cholera epidemics
during the first decade of American rule are authored
byDean Worcester (Secretary of the Interior) and Dr
Victor Heiser (Commissioner of Public Health).
- He knew that the rumor-mongering and the
popular resistance to his cholera
campaignformed some continuity with the recent
war
- However, since the health campaign is represented
in purely medico-sanitary terms– the issue of
colonial domination simply fades away.
 Worcester's representation of the war against cholera
is instructive to juxtapose.
- He could onlyperceive and describe the 'gallant
advance' and 'intrepidity' of American troops.
- He turned the Filipinos into almost impersonal
props in a drama whose theme was American
heroism and military skill.
 The fight against the cholera of 1902-1904 has been
represented in similar fashion: a drama whose theme
is American heroism and medico-sanitary skill, where
Filipino participants function as the anonymous
backdrop for the saga of progress.
 On 14 March 1902 – a vessel from Hong Kong
arrived in Manila with cholera on its bill of health
 Shortly afterwards the first cases of cholera were
discovered in a barrio called Farolanear the mouth of
the Pasig river
 From here the epidemic spread which devastated
the country up to November 1902, lingered on till
early February 1904, and ultimately claimed an
estimated total of 109,461 deaths, 4,386 of which
were in Manila.
 Upon confirmation of cholera, Secretary
Worcestermobilised both civilian and military
personnel to contain its spread.
- The Farola district was razed and its inhabitants
moved to a detention camp.
- The attempt to contain the epidemic in Manila
proved fruitless as people managed to escapeby
night or even by day through the rice fields.
 Cholera was certainly impossible to contain for even
American troop movements contributed to its spread.
 The cholera swiftly spread up the Pasig river
arteriesleading to the Mariquina valley and the
coastal towns of Laguna de Bay, until it arrived upon
the terrain of guerrilla resistance to American
occupation: the provinces of Laguna, Batangas and
Tayabas.
 Exigencies of war caused delay of about a month
before the lake towns of Laguna were infected.
- On 10 December of the previous year, all ports
had been closed as part of General J. Franklin Bell's
all-out effort to force Malvar's capitulation which
severely restricted the flow of supplies to the
guerrilla camps, and held back the cholera as well.
- On 19 April, three days after Malvar's surrender,
all restrictions to trade and travel in the region were
to be lifted, but the cholera forced the ports to
remain closed
 - As long as the ports remained closed, no cholera
appeared, until they opened it on May 1the disease
attacked first the ports and thence spread back into
the country.
 The coastal quarantine proved useless as infected
Filipinos and occasional Americans managed to land
surreptitiously, usually at night between ports.
 The disease once landed made universal progress,
especially through the barrios.
 Cholera claimed its victims from all levels of
society.
- However, the distribution of victims among the
races and social classes was unequal.
- Americans, Spaniards and Chinese had well-
equipped hospitals catering specially for them.
- At the Santiago cholera hospital, the vast majority
of patients belonged to the unintelligent class,
among whom the rate of recovery was as low as
5.32%, due tobad sanitary conditions and poor food
in their everyday lives the system was unable to
react from effects of the toxin produced by the
cholera organisms.
- Overcrowding, poor sanitation, and poor diet in
were the primary causes of the malignancy of the
cholera among the lower classes.
 In the provinces where guerrilla resistance had
been intense, the epidemic was especially severe.
 The 'sad and impressive' mortality figures were
attributed to the fact that both troops and natives had
been recently subjected to the demoralising and
debilitating influences of war.
 War, the cholera, and famine conditions came
together, at least in southwestern Luzon.
- The Commissioner of Public Health’s report for
August: In one or two instances it has been
necessary to send food, the scarcity of rice become
an important factor in the cholera situation.
- Any connection with the war is muted
- It was claimed that people in concentration
campshad never experienced better living
conditions
 According to Malvar, his decision to surrender was
forced by the reconcentration in zones, the extinction
of food supplies in the country.
- If he only knew that the deaths of the people who
petitioned his surrender were very certain in the
coming year, he should not have surrendered.
- April 7- cholera’s first appearance in Laguna.
- With thehorrors of the 1882 and 1889epidemics,
rumors of the cholera in Manila added to the local
elite's demand for an end to guerrilla resistance.
 The surrender was supposed to lead tothe break-up
of the zones of reconcentration, the re-dispersal of
peasants in their villages, the preparation of the rice
fields, and the reopening of the rice-trade networks.
 General Bell asserted that there was absolutely no
hunger and sufferingwithin the territorial limits of the
brigade,and admitted that rice was being imported
into the region.
- Search-and-destroy operations by the U.S.
Cavalry destroyed rice stocks which could not be
transferred into the zones.
- Rice aid would enable the people to eat until the
September harvest.
- Bell's optimism was also soured bycomplicating
factors such as the rinderpest, locusts, and cholera.
 The case of Calamba and its adjacent towns illustrates
the connection between the food problem and the new
round of restrictions occasioned by the cholera.
- Calamba had been the headquarters of the
republican Division of Southern Luzon.
- In 1899, there had been fierce battles resulting to
destruction of the irrigation works. Thus, no rice
had been planted around that town since 1900.
- In March 1902, work teams were given permission
to repair several dams giving hope that rice would
be planted that year.
- In the meantime, the town was rice-dependenton
Cabuyao and Binan.
- Even before Malvar's surrender, rice had been
allowed to enter from neighboring towns at regular
market prices but was suddenly cut off by
unexpected quarantine regulations because of
cholera.
- The border between Calamba and Binan was
assiduously guarded. The only rice available was
from the U.S. commissary which was sold to
wealthier Filipinos or distributed free to the poor as
required.
- May is the month of local feasts honoring patron
saints, infected food brought to a feast materially
assisted in the infection in Binan.
 Chief Quarantine Officer J. C. Perry noted that the
quarantine was absolutely uselessowing to the
smuggling of food.
- He attributed this to ignorance and wished he were
dealing with intelligent Americans or Europeans
instead
- For the inhabitants of the war-torn areas it was
ultimately a choice between dying of hunger or
dying of cholera.
 In 1902, the agricultural situation was still hopeless.
- Rinderpestdestroyed more than 90% of the work
animals.
- The work force was reduced by the ravages of the
cholera, and concurrent malarial fever and beriberi.
- Southern Tagalog peasants would certainly have
been debilitated and demoralisedwith the cholera
sweeping through and with reserve rice running out
- In mid-June, the mayor of San Juan Batangas
urgently telegraphed Bell begging for protection
since people are dying more of starvation than of
the cholera.
 Malvar's surrender and the increasing dependence
of the peasants on Americanseffectively ended the
war.
- However, the war was simply transposed from
the battlefields to the towns, the struggle
 continuedover the control of people's bodies, beliefs
and social practices.
- American military surgeons - standard bearers of
scientific medicine in the colonial world
 In December 1901, sanitary work came in.
- Heiser admitted that they decided that something
must be done because they had to protect their
troops.
- Cholera was the lesser problem compared to
ignorant and suspicious people making sanitation
workan extremely difficult task
- Purpose of Army's intervention- cleanse the
regions, eradicate the dual scourge of killer germ
and popular stubbornness framed by General Bell's
December program.
 Developments in 19th-century medicine
contributed to the convergence of colonial warfare
and disease control.
- By 1902, American physicians subscribed to the
germ theory or thedoctrine of specific aetiology of
disease which appeared about the same time as
Darwin' s theory of evolution.
- The germ theory gave rise to a kind of aggressive
warfare against disease-causing microbes which
had to be eliminated.
- Specific pathogenic micro-organisms were
discovered and viewed as the cause of specific
diseases.
- Towards the end of the 19th century, medical
thinking recognised the importance of a
patient's state of mind attributing disease to lack
of harmony between man and his environment.
- Europe and Americasearch for the specific germ
and the specific weapon against it.
 Between 1875 and 1900, French and German
bacteriologists identified the organisms involved in
many of the serious infections.
- Robert Koch, German doctor, discovered the
cholera bacillus in the 1880s
- Implications for preventive measures were apparent
even few cures were to be found
- By about 1905, control of water or food supplies
and onsect vectors had checked typhoid, cholera,
yellow fever and malaria.
 American surgeons and sanitation personnel had
just witnessed the glimmer of victory over disease in
their own countrywhen they confronted the cholera in
the Philippines.
- They were armed with the knowledge of Koch's
and others' discoveries, of the processes of taming
the disease and of its causes, means of prevention,
as well as, the treatments available at that time.
 The tropical environment, the war, and the
obdurate populace in particular-as petty obstacles
to the implementation of an unsullied knowledge
backed up by science and history.
- But since most of the natives had no faith in the
efficacy of these measures and opposed the
restrictions involved, 650 died of cholera before
they decided to report the situation to the
Americans.
 Army surgeons were armed with trial magic bullets
with which to shoot down the bacillus.
- Benzozone was one widely used drug; the ingestion
of which burns the mouth and stomach linings.
- Routine treatmentsusing different medical drugs
were really experimental in nature
- American doctors' methods of treatmentbrought
an aversion in Filipino cholera patients which
necessitate the use of force in the administering of
medicine.
- In the end,none of the medicine proved of any
value.
 Search and surveillance operations is the utmost
importance in the war
- Worcester organised platoons of inspectors led by
surgeons from the Army Volunteer brigades
- Initially,most of the inspectors were Filipinos but
were relieved owing to their inability to understand
that these measures must be enforced upon the rich
as well as the poor, and the strong as well as the
weak.
- Americans of all kinds were enlisted increasing
the popular opposition. Several of them were killed
as a result.
 The cholera introduced the stern figure of the
American army surgeon, less open than the regular
military officers to compromise with the local elite.
- As to Captain C. de Mey their job was ideally to
rule with a rod of steel.
- Health officer should be the commanding officer
of a citywhen that city is threatened with an
epidemic, and must be left free to act according to
his judgement.
- During an epidemic, the surgeon displaces the
military commander.
- As to Heiser, whatever the relative importance of
the medical man in other parts of the world, he, and
the profession he represented, stood first in the
Philippines
 Various combat zones can be identified in the
cholera war.Prominent among them was the issue of
confinement.
- When the epidemic was first discovered in Farola,
Worcester's platoons attempted to completely
cordon off the areaisolate the stricken and whoever
had contact with them.
- However, the disease spread rapidly among the
imprisoned people and the continuation of
quarantine would have been inhuman, so the
inhabitants were transferred to a detention camp.
 Uniformed men clattered up with ambulances without
ceremony lifted and carted the sick away from their
wailing families.
- Families could not understand why they were
forbidden to follow.
 - Four times out of fivethis was the last time they
ever saw of their loved ones until they received a
curt notice claim their dead.
- Confinement in hospitals and detention camps
were almost as feared as the cholera itself.
- Hospitals during the Spanish regime were
regarded as places where people so unfortunate as
to have no homes to die which makes cholera
victims sometimes had to be taken to the hospital
by force.
- Terrifying rumors of horrible abuses in the
detention camps and deliberate murder of patients
at the cholera hospitals added to the traditional
aversion.
 Strict confinement was premised on the then-
prevailing notion of disease as a purely biological and
physical entityin which Filipino public largely
refused
- Rumors, concealments and evasions were various
modes of resistanceto an imposed definition of
sickness and treatment.
- The conflict became so intense that a concession
had to be made to the ignorant classes
- Filipino doctors were also allowed in to practice
their mixed treatmentswhich involved keeping the
patient in an environment where his morale as well
as body was well attended.
 In mid-May, the removal of contacts to detention
camps has finally stopped in Manila
- On 1 July, detention in houses was scrapped.
- On May 23, Bell abolished forcible detention in
Batangas and Laguna.
 During the first few weeks of the epidemic in
Manila, the houses of those stricken household that
were sent off to detention camp wereto be burned if it
was constructed with a nipa-palm
- The cholera germ lay in the filth and vermin
associated with infected native dwellings which had
to be destroyed.
- The problems with such an efficient means of
destroying cholera germs is obvious.
 Many of the poor people see absolutely no way of
replacing their houses.
 Resistance to burnings took the form of widely
circulated rumorsthat houses of the poor were
burned to make room for the future dwellings and
warehouses of rich Americans. Hence, house
burning was quickly abandoned in Manila in
favor of thorough disinfection.
 In the provinces, Government Order 66 was
implemented which stipulated that nipa houses of
cholera cases were to be burned while houses
constructed of wood were to be disinfected.
- Since the burning of whole barrios created mass
resentment against the U.S. army, well-meaning
measures during the epidemic cannot have been
accepted passively.
- The threat of burnings figured largely in the
concealment of more than 50% of cholera cases in
the region.
- On 23 May, Bell sent out orders that no more
houses were to be burned if there were only a few
cases involved or where the cholera had already
disappeared.
 Infected houses were not as much of a problem as the
infected cadavers that piled up during a cholera
epidemic.
- In 1882, Manila experienced an estimated death toll
ranging from 13,000 to 34,000, bodies remained
unburied for days.
- The government finally intervenedwith a
battalion of engineers to help bury the dead in a
common pit.
- The same problem arose in 1902, the grounds of
Tondo cemetery were filled with cadavers and
further burials were banned.
 The American government preferred a more efficient
solution: cremationwhich was not directly
imposeddue to Filipino’s superstitious opposition
- The Insular board of health decreed that cadavers
must be placed in hermetically sealed metallic
coffins before being buried in seven-foot deep
graves. Otherwise, it would be sent to crematories
at government cost.
- Metallic coffins are expensive that the poor cannot
afford.
 In Manila hospitals, corpses left unclaimed after
twenty-four hours were cremated.
- In the crowded city slums, cholera victims were
so regarded with fear and horror to be abandoned.
- It became necessary to issue orders to deposit
bodies in shelters and leave them there for a few
hours before burial.
- In 1902, fear of cremation combined with fear of
house burnings and fear of detention forced
poorer families to bury bodies in backyards or out
in the rice fields at night or even to throw them into
the Pasig river.
 On 1 July, the board of health backed down on its
strict burial regulations.
- On the 29th, the board conceded that the graves
could be as deep as the condition of the ground
permitted, but not less than three feet in any case.
- However, only two individuals could accompany
the body and no services, funeral processions or
bands were to be allowed.
 In contrast, cremation in the provinces took place
although the Insular board of health did not
recommend.
- There were times when the board had to order it to
be stopped because none of the provinces had the
proper facilities for it.
- There were fewer horror stories in the provincial
towns than in Manila’s poor district.
 In the town of Pila, Laguna, the leading citizens were
ordered to supervise the digging of about twenty
 graves daily, ten for grown persons and ten for
children.
- In addition, they had to obtain burial permits from
the American commanders but the rules could be
broken.
- In Ibaan, Batangas, infected houses were required
to display a red flag, but the natives gave no heed
to this warning and view the presence of the flag as
a kind of joke. Observers saw this as a sign of
fatalism and ignorance.
 Trouble usually erupted when local officials were
accused of being incompetent or unco-operative.
- Provincial and municipal boards of health were
regarded as entirely incompetent to meet the
emergency of dealing with an epidemic
- Criminal laxity - not reporting cases to the army
surgeon.
 Major Isaac Brewer, was engaged in a bitter fight
with the mayor over the handling of the epidemic.
- Six months earlier the town church had been
occupied by U.S. troops and the parish priest
detained.
- Around May 17, occupation troops abandoned the
church in which the parish priest was freed.
 Father Alcantara, the detained priest, was a party to
the local opposition to interference by American
health authorities.
- This interference was great enough to provoke the
government to warn the highest church authorities.
- Priests had always taken charge in past
epidemics, they represented the notion that
sickness was both, a moral as well as a physical
state
 San Pablo suffered much during the reconcentration
- The town centre was transformed into one of the
three largest concentrationcamps in southwestern
Luzon.
- People were packed even closer together, making a
mockery of sanitation and vastly increasing the
chances of infection.
- None were left outside to attend to the rice fields.
Reconcentrationseverly cut back town’s revenue.
 Enormous mortality due to dysentery and
malarial feverwere attributed to the reconcentration
which gave rise to crowded conditions and limited
facilities that prevented sanitation and curative
measures from being enforced to lessen the mortality.
- Army surgeon recommended that the natives be
permitted to return to their barrios as soon as
conditions permitted.
 From the townspeople's point of view, the
American presence was as much a problem as the
cholera.
- Representations of the event as an epic struggle
against disease and ignorance only divert attention
from the wider colonial intervention
 Tensions were much reduced in towns where the
overseer of was the American garrison commander.
- Colonel RupertoRelova, former guerrilla hero,
was put in charge in all dealings with the people
such as explaining health measures, reporting cases,
and arranging burials.
 Militarily, Pila shows how a different tactic by the
Americans could lead to mutual accommodation
within combat zones.
 The new colonial order merely reproduced the
classic Philippine pattern of principalia-dominated
towns
 After Malvar's surrender, all forms of armed
resistance to the regime were labelled
ladronism(from the Spanish word ladron, 'bandit' or
'highwayman').
- Religious fanaticism - particular form of this
which incorporated religious beliefs and rituals
 At the end of July in the Mariquina valley,the
Filipino provincial medical officer and his American
counterpart appealed for easing
ofquarantinerestrictions because aside from poor
harvest and war conditions, thequarantine also
prevents peasants from tilling their fields and were
forced to pay their annual rent resulting for them to
join the ladrones as a means of earning a living
 The foothills of Mount Banahaw were in a state of
unrest in late 1902, to the extent that some Tayabas
towns had to be reconcentrated again.
- PopeRuperto Rios and the Katipunan chief
MacarioSakay, roamed these hills in late 1902 and
1903.
- A 1903 report on the religio-political movements
states that independence had become a religion
among them.
- In Tagalog, the word 'independence' is kalayaan,
derived from kaginhawaan: relief from pain, a life
of ease.
- Relief from the cholera would certainly have
registered in 1902-1903.
- The password among members of such movements
was the Ave Maria puiissima- the first line of the
prayer, posted on doors during the cholera
epidemic, imploring the Virgin Mary and Jesus
Christ for deliverance from the pestilence
 Banahaw and its foot-hills were the base of
operations of curanderos, curers who were the first
recourse of peasants in the region
- American doctor described them as men and
women who do not constitute a class or caste like
the medicine men of savage tribes, but are
somewhat akin to the barber surgeons of villages in
which doctors are not located.
- Curanderos commonly prescribed a cholera
medicine extracted from the manungal tree.
- They are particularly gifted curer combined
medicinal treatment with rituals involving the
intervention of a guiding spirit.
 As late as 1914, Worcester continued to lament the
unending supply of healers
 - Queen of Taytay, discovered during another
cholera outbreak in 1905, whose followers
threatened violent confrontation with the state
should harm befall their leader.
 In September and October, cholera cases and
deaths in southwestern Luzon declined.
- Strong typhoons were lashing the islands resulting
to volume of water flushed the streams and banks
- The virulence of the 1902 cholera strain had also
expended itself by that time; the population gained
increasing immunity
- Worcester and other health officials stated that the
decline of cases was due to American health and
sanitation measures
 In terms of preventing further serious outbreaks, such
measures were probably effective.
 But in 1902 their actual role was to close a chapter of
the Philippine - American war.