ONCE UPON A TIME

PRESIDENTIALADDRESS

L. W. HACKETT

Justice Frankfurter has said there are twomyths which have always captivated the humanrace, that of a Utopia in the unforeseeable future,and that of a Golden Age in some remote epochof the past. In the dynamic field of world healthwe foster the same myths but shorten the timespan. To a Society like ours made up in itsmajority of young, imaginative and forwardlooking persons, the Utopia is just around thecorner—a happy if somewhat overcrowded worldfreed forever from malaria, tuberculosis, smallpox, yaws, leprosy and syphilis. But I, who havereached the age of retrospection, find pleasure inlooking back to a Golden Age no longer ago thanmy own youth, when public health, and especiallyinternational public health, were at the starting‘me,and progress was about to make a great

Jeap forward, as the Chinese say, into a new, richand virgin field. So I think it more appropriatetonight to review the record than to attempt toscan the future—more appropriate and morecircumspect.

My first chief, Wickliffe Rose, who in 1913organized the International Health Commissionof the Rockefeller Foundation, was impressivein action and endowed with extraordinary visionand courage, but he was modest and sell-effacingin his public relations, and disliked predictions.The sanguine neophytes on his staff, with all theconfidence of youth and inexperience, neverdoubted their ability to conquer yellow fever,suppress malaria, and purge the entire “wormyworld.―But Rose was prudent. “Weare onlysafe,―he would admonish them, “intalking aboutthe past.―Rose was forgetting that these youngdoctors fresh from medical school had no past;they had nothing to talk or think about but thefuture. I was one of those youths, among thefirst to be appointed to the staff of the International Health Commission, and since thatfateful conversation with Mr. Rose in April,1914, I have accumulated enough past to talkabout. My purpose tonight is to delve among theroots of the great, spreading international healthmovement to uncover its modest beginnings inRose's International Health Commission, the

IHC, known in successive epochs as the International Health Board (IHB) and the International Health Division (IHD).

Rose had a program for action so simple andso reasonable that it is astonishing it never hadbeen attempted before. The world had alwaysbeen defenceless against recurring invasions ofcertain great and destructive diseases whoseforays and infiltrations from their endemic seedbeds were a constant threat to every country onearth, in spite of all the barricades and quarantines which were erected in times of trouble, butwhich were always as ineffectual as they wereharsh and oppressive. Rose's design was to wagea coordinated mass attack on some of thesedangerous but preventable diseases on theirhome grounds, wherever they were found to beendemic and uncontrolled. Rose proposed tooffer any government in this situation the technical and financial collaboration of the IHC, aproposition without parallel in history, and onewhich had its remarkable aspects, consideringthe disparities in age, size and wealth betweenthe two parties. Dr. William H. Welch, in accepting a position on the Commission, said,“boththe purpose of the gift and the opportunityit creates are unique in the annals of preventivemedicine.―

Actually, the IHC was not without a prototype in its philanthropic plan to extend a helpinghand around the world to fight the aggressivediseases. Charles IV of Spain despatched a commission to disseminate the knowledge andapplication of Jenner's discovery of cowpoxinoculation for the prevention of smallpox. Thisprocedure had reached France, Spain and theU. S. by 1800, and Charles IV undertook to sendout a scientific mission to go completely aroundthe world carrying the protective virus “toallSpanish lands and all other races and peoplesen route.―The royal order was given August 3,1803, and a military surgeon, Dr. FrancescoJavier de Balmis set sail from La Corufia forAmerica on November 30, accompanied by 3doctors, 2 assistants, 3 male nurses and theDirectress of the local orphan asylum in charge

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of 22 nursing babies to conserve the virus duringthe long journey, passaging it from arm to arm.All arrived safely in Venezuela, where the expedition divided in two, one part going south tocover South America while de Balmis himself,after attending to the needs of the Caribbeanarea and Central America, crossed Mexico andsailed from Acapulco to the Philippines, wherehe arrived with the virus stifi alive and potent.Continuing on around the world he reachedUsbon August 15, 1806, two years and ninemonths after leaving La Corufia. The other halfof the expedition was not so fortunate. It wasshipwrecked at the mouth of the MagdalenaRiver, but all the babies were saved. The groupvisited Colombia, Ecuador and Peru, and waspreparing to go on to Chile and Buenos Aireswhen they learned in Lima that the vaccine hadalready reached the Rio de la Plata.

This story was given to me by Dr. RafaelSchiaffino, the medical historian of Uruguay,and I am sorry I cannot give you the furtherdetails we should all like to know about thispicturesque expedition—how the 3 male nurseswere able to provide nourishment for 22 nursingbabies, what happened to the little ship and itscrew as this gang of young delinquents reachedthe mobile and destructive age of three, and howthe virus was kept alive for almost 3 years withonly 22 passages. In any case, the factisthatascientific commission had encircled the globe topromote a general attack on one of the greatpestilential diseases of the age and to instructbackward and isolated peoples in the use of anew preventive measure of the first importance.

The great epidemics continued to ravageEurope and America, and often swept aroundthe world, but I cannot find that any coordinatedaction was ever again taken to curb them untilRose appeared on the international scene. Thegreat powers, including the U. S., did not, it istrue, suffer these blows in silence; after eachmajor visitation of plague, cholera, yellow fever,smallpox or typhus, they held an internationalsanitary conference, usually in Paris, and keptup this practice for over 50 years without visibleeffect on the incursions of the epidemics. It waslike the first installation of foghorns on the California seaboard, which the coastal inhabitantsare reputed to have called a futile gesture and awaste of money, since the fog kept rolling injust as before. The governments of the 19th

century could not agree on any effective plan fora joint campaign against these common enemiesbecause any suggestion that an internationalagency, even of their own creation, should bepermitted to make inspections and carry outmeasures behind their frontiers was consideredan intolerable derogation of national sovereigntyand an affront to national pride. But now aprivate organization, whom no one had everheard of, with no foreign experience and as yetwithout a staff, assumed that these same governments would invite it to enter their countriesand help them combat certain diseases whichthey had failed to curb, and thus establish aunited front against them all over the world.Rose was resolved to cooperate only with governments, and this was breaking ground in a numberof fields; it was new to philanthropy, to international diplomacy and to public health. Noone has ever accused Rose of being either naiveor foolhardy, but the prospect in 1913 was onewhich might have daunted any valiant soul. Fornot only, as it turned out, was there all tooscanty knowledge of the epidemiology of thediseases to be attacked, but as these graduallybecame better understood, the drugs and toolsand other measures available proved very ineffective to control, not to speak of eradicatingany of them.

But perhaps Rose's most serious handicapwas the lack of any trained and experiencedpersonnel, and this was so because there was nocareer in public health; practicing physiciansdoubled as health officers in their spare time.Rose had foreseen this major obstruction to hisprogram long in advance. When the IHC wasno more than a scheme presented to the Trusteesof the Rockefeller Foundation (RF) at their firstmeeting, he asked the General Education Boardto survey existing facilities in the U. S. for thepostgraduate education of doctors in the principles and techniques of hygiene, a training whichhe needed not only for his own staff, but for allthe countries where its work would lead to constructive developments in public health. Itturned out that there were no such facilities;evidently a new kind of professional schoolwas needed which did not exist. The RF offeredat once to assist universities to develop suchinstitutions for training and research in publichealth. The first of these, planned and organizedby Dr. Welch was the Johns Hopkins School

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of Hygiene and Public Health which enrolledits first class of 17 students in the fall of 1918.This was followed by grants to Harvard, Toronto,London and in time to a large number of schoolsall over the world. A majority of the studentsin the early years were foreign fellows sent bythe IHC and its successors, and this was one ofthe most acceptable and constructive forms ofinternational collaboration the RF ever undertook. The fellowship program acquired volumeas the projects multiplied, until in the end theInternational Health Division had spent some 7million dollars on what Rose called an investmentin leadership. These great schools and the thousands of health workers whom they trained,constituted an educational force which had aprofound influence on the well-being of mankind.The IHC thus set on foot a movement whichresulted in a new profession of full-time healthofficers, in the multiplication of health servicesto employ them, and in the creation of schoolsto train them. Rose had set his sights as highas this from the beginning and always obtainedthe support he needed from the RF, runninginto many millions of dollars. He wrote at theend, “Publicenlightenment, government machinery, and technical education and researchare bound up in a sure sequence.―

In 1914, when the work got started, thisevolution had not even begun. Finding personnelwas no small task. The U. S. was soon in the warand he had to scrape the barrel for candidates.These could be given at that time no proper fieldtraining in the U. S. to prepare them for a foreignprogram; they were equipped with only theconventional medical education of 50 years ago,before Abraham Flexner's report of 1910 hadhad time to improve it. Rose did not, for all this,slow down the expansion of his foreign program;within 5 years he had made agreements forprojects with 42 governments, and 3 years later,when he resigned to take up other work, thenumber had increased to 63. Recruitment of staffnever caught up in Rose's time with the invitations which came flooding in from all over theworld. Since he could not expect training orexperience, Rose chose his men for character andbent. They were sent overseas as soon as possibleand with a minimum of briefing to some previously established station, and then on to theirown destination in a land whose language, politicsand ways were no less strange to them than its

diseases. When I look back upon this picture, Imarvel at Rose's serene confidence both in hisballooning program which seemed always aboutto get out of hand but never did, and in his youngdoctors who knew very little of the world and itspeoples, or of tropical medicine and hygiene,but who rarely let him down.

The field staff learned by doing; education isthe accumulation of experience, not of facts,and as Oscar Wilde said, experience is the namewe give our mistakes. I feel now that our ignorance and inexperience were paradoxically anadvantage in the beginning when there was not agreat deal of existing knowledge to be drawnupon from any source. My early experience wasin Latin America, and when the local doctorswith whom we worked found out that we did notlook down upon them as ignoramuses but eagerlylistened to what they had to tell us, their suspicions and defense armor soon melted awayand a happy relationship of genuine and fruitfulreciprocity was established. They taught us theirlanguage, politics and folkways, and what theyknew about tropical disease; they got from usour kind of practical approach to problems, ourlack of frustration in the face of hypotheticaldifficulties, and the funds to carry out demonstrations and experiments on a significantlylarge scale. We were all empiricists, learningwhat we could from observation and experience,and Rose and the rest of us refused to be dismayed by presumptive obstacles.

For one thing, Rose started with hookwormdisease, a sound choice as it turned out—thebesthe could have made. The hookworm work neverled to such dramatic victories as malaria nor tosuch fruitful discoveries as yellow fever, but asan entering wedge for a long-term public-healthprogram, it was far superior to either. Therewere no mysteries about the nature of the hookworm or the way it spread; it was large enoughfor the victims to see without a microscope, itinfested an enormously wide belt, running cleararound the earth, which contained more thanhalf the population of the world, and it was vulnerable to treatment and sanitation. The OldWorld tropics were all colonial possessions in 1914except for Liberia, Ethiopia and Siam, and theBritish no sooner learned of Rose's programthan they invited him to begin in any or all oftheir tropical colonies. Thus the question as tohow the great Powers would react to Rose's

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initiative was answered at once to his satisfaction.Furthermore, he was not going into this thingblindly; he had just carried out from 1910 to 1914a sort of pilot experiment in hookworm controlon a large scale which had revealed both theobstacles he could expect to meet and the resultshe might hope to achieve. Wickliffe Rose, alayman and distinguished Southern educator,had been wisely chosen rather than a medicalman to organize the hookworm campaign of theRockefeller Sanitary Commission in the SouthernStates. The medical and sanitary problems wereso simple that they could be handled by youngdoctors and sanitary engineers with a minimumof special training, but the promotional andeducational aspects of hookworm control weresubtle and difficult, calling for a leader experienced in methods of teaching and in the waysof the South.

This campaign, which aroused so much indignation among its beneficiaries in the beginningand so much enthusiasm in the end, was due tothe propaganda and persistence of CharlesWardell Stiles, a zoologist in the Public HealthService, who in the early 1900's had uncoveredthe worm at the core of Southern backwardness.Having read in Hirsch's famous Hand&uchofthe prevalence of hookworm anemia in the WestIndies, Stiles wondered whether it might not bepresent in the southern part of the U. S. Theparasite had been reported once or twice as acuriosity in such unlikely places as St. Louis(1893) and Buffalo (1897), and in 1901 Dr. AllenJ. Smith of Galveston sent him a few hookwormsobtained from his medical students at the University of Texas. Stiles however found no specimens from man in the collections of the NationalMuseum, Army Medical Museum or Bureau ofAnimal Industry. He suspected that the hookworm, as a cause of anemia, was being overlookedand he lectured on the subject at Johns Hopkins,but he says that his good friend Dr. WilliamOsler took him roundly to task and maintainedthat a disease which could be so easily recognizedcould not have escaped detection if it werepresent. Stiles, however, persisted, and obtainedpermission from Surgeon-General Wyman ofthe Public Health Service to make a reconnaissance on his own account. He immediately setup a clinic in Columbia, S. C., and made excursions into Georgia and Florida. In a week hehad the confirmation of his suspicion; he foundto his excitement, that every anemic, listless,

pot-bellied child he examined was a victim ofthe hookworm. He had discovered the cause ofthe commonest disease in the Southern States.

Stiles reported this on December 4, 1902, tothe First Panamerican Sanitary Conference,which had met in Washington to organize aninternational health office for the Americas, laterto be called the Pan American Sanitary Bureau.By a curious circumstance, no speech he evermade caused such commotion or was fraught withsuch long-term consequences as this one. Stilessaid that the so-called “poorwhite trash―in ourSouth were not constitutionally lazy; their energywas being sapped by hookworms. A reporterfrom the New York Sun embroidered this inhumorous vein and sent in the story that a doctorin the South had discovered the germ of laziness;loafing was just a disease. This diverted his NewYork office, and the Sun of December 5 headlinedthe discovery. The ridiculous idea was caughtup by newspaper rhymesters and cartoonists,and swept the country. Stiles thought it a fortunate episode. “Thisreporter,―he wrote afterwards, “contributedan exceedingly valuablepiece of work in disseminating knowledge concerning hookworm disease. .. . It would havetaken scientific authors years of hard work todraw as much attention to this subject.―

Actually, the five-year campaign of the Rockefeller Sanitary Commission did not have muchimmediate effect on the hookworm. The taskwas not one which could be carried through toany conclusion by a six-weeks' campaign, whichwas all the time that could be devoted to anyone county. @Toget rid of the hookworm, thestandards of living and of education would haveto be permanently raised. But it had an enormouseffect upon the South; the Rockefeller SanitaryCommission had revealed the magnitude of thehealth problem, its social repercussions on thecommunity, and the feasibility of its solution.To the Trustees of the newly-created RF, Rose'ssuccess in mobilizing the health authorities ofeleven Southern States in a concerted driveagainst a common ill seemed capable of unlimitedapplication. Frederick T. Gates, one of the chiefarchitects of the Foundation and Mr. Rockefeller's personal adviser, determined to organize“anew and world-wide agency to attack hookworm and other curable and preventable diseases,and to promote universal health.―That was theorigin of the International Health Commission.

Although the word “eradication―had been

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rashly inserted into the title of the RockefellerSanitary Commission, neither Rose nor Stilesthought it possible within any given time. Evenbefore the Commission had begun its campaign,Rose wrote, “Theeradication of the disease is awork which no outside agency could do for apeople if it would, and one which no outsideagency should do if it could.―Nevertheless Rosehad earnestly desired at least one completedemonstration, even on a small scale—thatsomewhere cure and prevention might reach 100per cent of the inhabitants and serve as a modelof perfection after the Commission had withdrawn. In September, 1913, an attempt at eradication was begun on Knotts Island, a remotefishing village on the North Carolina coast whichhad little contact with the rest of the world. Theplan was to treat and sanitate until the job wasdone. Ninety-four of the 567 inhabitants hadhookworms and 90 were eventually declared tobe cured after many courses of thymol, a disagreeable and relatively ineffective poison whichhad to be given repeatedly, and administered tochildren by bribery or coercion. The other fourstubborn old people would have nothing to dowith the business. The sanitation campaign was,as usual, less successful. No inoffensive solutionof the rural latrine problem had been inventedby the doctors or engineers except expensiveseptic tank installations, and Knotts Island folkwent on using “nature'sway―in immutabledisregard of the calamity-howlers. Attempts topersuade the recalcitrants soon ran into the lawof diminishing returns and Rose was finallyconvinced that perfection was not worth theprice. He accepted defeat gracefully for his mainpurpose had been accomplished, to make hookworm prevention an essential part of publichealth work in the South. As we learned from apaper presented at this meeting, the hookwormstill prospers in many localities, and I doubtwhether it has ever disappeared from any areain which it has established itself.

But while Rose was organizing the IHC for ageneral attack on the hookworm, his attentionwas drawn in a compelling way to two otherdiseases, both of first importance as obstacles tohuman progress, and each peculiarly vulnerable,according to the highest authorities, to a welldirected attack, although none unfortunatelyhad ever been launched. These old, highly destructive enemies were malaria and yellow fever.Passing through London early in 1914 on his

way around the world to scout for projects forthe IHC, Rose met Sir Ronald Ross, who hadreceived the highest honors including the NobelPrize for discovering the mosquito transmissionof malaria, but who had been in a state of chronicindignation ever since because the knowledgehad not been applied on any large scale to controlthe disease. Gorgas had waged war on theAnopheles of the Canal Zone, but at a cost prohibitive to the ordinary community, so that hismethods had not been copied even in the U. S.Ross's only enthusiastic and competent disciplehad been Malcolm Watson in Malaya, who hadpersuaded the rubber planters to finance someexperiments in Anopheles control by drainage.Ross was becoming exceedingly unhappy overthe unprogressive attitude of malariologists ingeneral when suddenly here was Rose deliveredinto his hands, with what was reputed to be unlimited financial backing, and actually lookingfor a disease to attack. Ross was a very articulateperson and Rose was impressed with his grimpicture of malaria as a world problem and hisexposition of the practicable measures by whichit could be controlled. When Rose got to Malayahe took time out from his hookworm observations to visit Malcolm Watson, and came awayconvinced that the disease was one of the utmostgravity and that much could be done to preventit. The criteria which he thought should governthe selection of a disease suitable for attack bythe IHC were that it should be of global importance, that little was being done about it, andthat it could be prevented at a reasonable cost.Malaria satisfied the first two conditions; thequestion remained, as he wrote in his report,“whetherthe various known measures, such asquinine treatment, screening, and drainage operations, can be effectively employed.. . at a costwhich will not be prohibitive.―Rose set to workat once to find out.

Always anxious to involve government at alllevels in his projects, Rose asked the U. S. PublicHealth Service (PHS), which had been gatheringdata on malaria since 1912 but had no money,whether it would not like to invite the ifiCto collaborate with it and the state and localauthorities in some experiments in a few selectedlocalities to find out what it would cost to protecta rural community against malaria. Under thedirection of P118 officers, chiefly engineers, andat the expense of the IHC, these experimentswere begun in 1916 in several Arkansas and

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Mississippi villages, and succeeded beyond expectation. Malaria was greatly reduced by oneor a combination of measures at reasonable costand the villages were so pleased that they continued the work at their own expense. DuringWorld War I the same methods were used toprotect Army encampments and key industrialcenters from malaria, and by 1922 the antianopheline drive had been extended to 163counties in 10 states with very satisfactory results, even though no major drainage operationswere attempted. Rose was pleased. He hadprudently sent a young engineer to Nicaraguain 1920 to see whether the measures, so successfulin the Southern States, were adaptable to tropicalconditions, and finding that they were, he set upa training station in Leesburg, Georgia, underDr. Samuel T. Darling to instruct his young“malariologists―in the techniques of making amalaria survey and of applying the standardmethods of obstructing the transmission of theinfection. By 1922 he felt secure enough to acceptinvitations from Brazil and Italy to collaboratein solving malaria problems which had not yieldedto the classical method of quinine prophylaxisand cure, and soon he had made similar agreements with malarious countries all over the world.

As long as we were fighting the hookworm,it took no great amount of training or epidemiological insight on the part of the staff to circumvent the parasite with its simple mode of spread;it was human nature, not the hookworm, thatdefeated us. Malaria proved to be a differentsort of problem altogether, as I began to suspectwhen I was transferred to Brazil. Our principalscout in the foreign field was Dr. Mark Boyd,who was sent down to me to survey the malariasituation in the State of Rio de Janeiro. WhenBoyd, accompanied by the Brazilian entomologist Antonio Peryassil, disappeared into themarshes of Magé,there were only three recognized Anopheles in the whole region, but whenthey emerged months later, no one knew howmany there were. They had begun that processof multiplication and division of species whichhas enriched entomological nomenclature andfrustrated the malariologist ever since. For noone was able to tell the variants from the truespecies, and specimens submitted to more thanone systematist would come back with morethan one name, so that we cannot say even nowhow many species of Anopheles there are. Theaberrant forms were all given names, usually

those of persons, like rooti, evansi, 8trodei, oswakkietc., which was considered to be an honor to theeponymous individuals. Dr. Peryaasd, in afriendly gesture of hospitality and homage,created a new species, Anopheles rockefeUeri, nospecimen of which has ever been captured. Whatwas most confusing was that the same mosquitowould appear to be a notable vector of malariain one area but quite inoffensive in another, aphenomenon which was to puzzle us later inEurope. In spite of all this, the tactics of mosquitocontrol remained the same as in Arkansas: putthe water in motion if you can't get rid of it, andAnopheles breeding will stop. This “secret―wasour main weapon against malaria.

The thing that had made Ronald Ross indignant and had surprised Rose was that theEuropean malariologists did not seem to knowthis. Rose determined to find out why, and tothis end I was rapidly converted in a few weeksat Leesburg from a helminthologist to a malariologist and sent to Italy. My qualifications werethat I knew my anophelines through associationwith Boyd, and my malaria by personally contracting a vivax infection in Leesburg and afak@iparuminfection in Panama. I had thus beenafforded a splendid opportunity to study atfirst hand Dr. Bass's standard quinine treatmentin various formulations and dosages, though Inever got to like it. Dr. William James of theCanal Zone used to double and triple it in obstinate cases like mine and add calomel.

I think I was supposed, when I got to Italyin 1924, to talk rather severely to Grassi,Marchiafava, Bastianeffi and other renownedmalariologists, and show them lantern slides ofthe work in Arkansas. What I did of course wasto keep my mouth shut and sit at the feet of themasters. What I learned was that the vectoranophelines of the Mediterranean countries weremore versatile than those of Arkansas—theycould fly farther, they were more prone to bitehuman beings, and would breed in almost anykind of water—brackish or sweet, standing ormoving—sothat the great drainage canals themselves were a prolific source of mosquitoes. Nowonder the Italians had failed to adopt thesimple American measures. Their Anopheleswere more dangerous by far than ours, and muchmore difficult to reduce in number below thethreshold density required to maintain malariatransmission. Considering how best to spend theirlimited funds, the Italians had fallen back on

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intensive quinine therapy, a time-honored resource with a history of 300 years of continualdefeat. There were good years, as always in themalaria cycle, which they attributed to thequinine program, and there were bad years whichthey attributed to acts of God, but the fact wasthat the death rate from malaria in Italy in 1924was higher than it had been a decade earlier. Theoutlook was therefore pretty discouraging to afellow with my limited experience. There wereevidently no easy victories to be won either overthe Anopheles or over the plasmodia, and I hopedI could make the people in our New York officeunderstand this.

However, I had another weapon up my sleevein Paris green, which Dr. Marshall A. Barberhad just discovered to be an effective anophelinelarvicide. I had brought a small supply with meto Italy and tried it out on the quiet in Sardinia.Barber had experimented with it on a small scaleat his laboratory in Louisiana, but this was thefirst time it had been used in actual combat. Itworked splendidly on the Italian larvae andwas an enormous improvement over anythingthat had ever been tried before against anophelinemosquitoes. We had no doubt from the first thatit would put quinine out of the running as anantimalaria measure.

This was not immediately conceded by someof the European malariologists who were lookedup to as authorities. The Second Report of theMalaria Commission of the League of Nations,appearing in 1927, still called for more intensivequininization, and contained the extraordinarystatement (and how Ross must have gnashedhis teeth!) that the knowledge of the mosquitotransmission of malaria had, contrary to allexpectation, not helped us in the struggle againstthe disease, and may in fact have led us awayfrom the right path. The reported success of antimosquito measures in our South was considereda typical American exaggeration if not pureinvention, and a commission was sent to the U. S.in 1927 to investigate the matter. It reportedthat no conclusions could in fact be drawn fromthe American experience, since malaria was obviously dying out for social and economic reasonsunconnected with any specific measures takenagainst it. Nor was Col. James, the medicaladviser to the Colonial Office, impressed by ourlittle show in Sardinia; he wanted a more permanent solution, and thought of malaria as asocial disease, perpetuated by bad housing, mal

nutrition and inadequate medical care, andbelieved it would tend to disappear spontaneouslyif the standard of living could be significantlyimproved. Prof. Marchoux, the leading Frenchmalariologist, held that malaria was a diseaseof backward peoples and would gradually beeliminated as civilization advanced. (He politelyrefrained from pointing out that France had theleast malaria and America the most, of the socalled advanced nations.)

I thought it would be instructive to stage acompetition between quinine and Paris green.My Italian colleague, Prof. Missiroli, and I chosetwo neighboring small villages in Sardinia, whichwas the most malarious region of Italy, andinstituted a treatment campaign in one andantilarva measures in the other, providing equalbudgets for the two experiments. The first townhad about 1,000 inhabitants and, employing adoctor and a nurse, we succeeded in treatingvirtually every case of malaria or of parasitemiaas soon as it was detected, and we continuedthis therapeutic campaign for three years. Thesupply of quinine was unlimited and it waspressed upon the patients in quantities unnecessarily large. In fact, the average consumptionper case treated was over 31 grams, three timesthe amount generally considered ample. Itreminded me of old times in Panama. Nevertheless, the amount of malaria actually increasedover the three years; the parasite rate went upfrom 22 to 36 per cent and the spleen rate from75 to 94 per cent. In the last year we treated915 individuals, almost everybody in town. Thequinine did a great deal of good; it relieved suffering and reduced the death rate, but there was noevidence that it had suppressed endemic malariain the slightest degree. In contrast, malariadiminished rapidly in the village protected frommosquitoes, and before long there developed anemigration of anemic children from the firsttown to the second during the worst of the summer months. The Sardinian demonstration putour modest Malaria Experiment Station on themap, nationally and internationally. I was appointed Vice President of the Malaria Commission of the League of Nations, a purelyornamental job if there ever was one, but indieating their change in attitude, and Prof.Missiroli was at last able to obtain the ear ofhis government, whose authority was thenconcentrated in the person of Mussolini. Ittransformed the official malaria-control measures

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in Italy, and the use of Paris green spread aroundthe world. The attack on the mosquito now hada decided edge over the attack on the parasite,which it has never lost.

It was Paris green which Drs. Soper and Wilsonof the IHD used in Brazil to eradicate Anophelesgambiae in 1939-40. This led to another mutationin our thinking about malaria. Long before thattime, eradication of malaria had been discussed,but without conviction. Dr. Frederick L. Hoffman, statistician for the Prudential Life InsuranceCo. procured in 1916 the formation of the National Malaria Committee as a catalyzing agentfor the eradication of malaria from the U. S. andpossibly from the Western Hemisphere. It wasestimated at that time that more than a millioncases and 15,000 deaths occurred annually in theU. S. due to malaria, causing an economic losswhich ran into the hundreds of millions of dollars.Virtually nothing was being done about this, andin 1917 Dr. Hoffman read a paper before theCommittee entitled “Aplea and a plan for theeradication of malaria.―He was soon led to theconclusion that this would entail the eradicationof the malaria vectors, for he said in 1918, “Anyeffort must fail to rid the community of malariaif the Anopheles mosquitoes are not entirely doneaway with.―That seemed an extravagant proposal in the days of quinine and minor drainage,and the nation was not stimulated to action untilSoper's and Wilson's spectacular feat in Brazil.Here was an achievement, accomplished with thetools we all had, which aroused first this countryand then the world to revolt against payingannual tribute in lives and fortune to the brutalityand exactions of malaria. Dr. Wilbur A. Sawyer,then Director of the IHD, a man of cool andbalanced judgment not apt to be carried away bya wave of over-optimistic enthusiasm, became anadvocate of mosquito eradication as the safestand most economical way of getting rid ofmalaria. “Thesuccess beyond all predictions,―hewrote, “ofthe major strategy in the exterminationof A. gatnbiaein Brazil has fired the imaginationof malariologists everywhere.―and Dr. L. L.Williams, Jr., began to elaborate the NationalMalaria Eradication Program which was put intoeffect by Congress in 1947, and which in turninfluenced the WHO to enter upon its presentglobal effort. So in malaria as in hookworm, theIHC set in motion a chain of events which we candescribe, in Rose's words, as “boundup in a suresequence.―

The gambiae campaign in Brazil had a curioussequel which caused consternation for a briefperiod throughout South America, but which asfar as I know, has never been reported. The lastadult gambioe was caught in Brazil on November9,1940, and continued surveillance for almost twomore years failed to turn up a single larva oradult. It was practically certain that every lastgambiae had died.

But on September 5, 1945, I received a letterat the regional office of the IHD in Buenos Airesfrom the Rio de Janeiro office calling my urgentattention to an article in the Journal of theMuseum of Natural History of Asunción, Paraguay, by a Russian entomologist named Podtiagin, the Curator of the Museum. Podtiaginstated that among some mosquito larvae collected at Colonia Independencia during a veryserious epidemic of malaria, he had identifiedlarvae of A. gambiae. Podtiagin had worked inAfrica and knew the species well. The letter saidthat he had sent an adult specimen bred out fromone of the larvae to the Oswaldo Cruz Institutein Rio, where it had been confirmed by NelsonCerqueira as undoubtedly A. gambiae. Dr. RenéRachou of the Brazilian Malaria Service hadgone at once to Asunciónand I lost no time ingetting the news to Dr. Carlos Alvarado who wasDirector of the Malaria Service of NorthernArgentina. Both Brazil and Argentina sent commissions immediately to examine the entire lengthof their frontiers with Paraguay, but no gambiaewere found. A joint Brazilian and Argentinecommittee was then sent to Asunción to interview Podtiagin and review the evidence. Podtiagin suggested at least four routes by whichgainbiae might have entered Paraguay. A planefrom North-East Brazil during the gambiae invasion might easily have continued its flight toAsunción.The Botanic Garden of Asunciónhadrecently received jars of tropical plants fromAfrica which might have contained larvae. DuringWorld War II a visiting entomologist namedJorgensen, who called himself a Dane but whoPodtiagin suspected might have been a German,had been studying the possibilities of “adaptingexotic mosquitoes to Paraguay.―He died and hiswidow sold his collections to Podtiagin who foundgambiae among his live larvae. But in Podtiagin'sopinion the most likely means of transport oflive gambiac from Africa to Paraguay was in oneor both of the two gunboats which Paraguay hadbought in Italy just before the war and which had

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stopped to take on water ballast in Senegal. ADr. Alexander Ladkovsky, contracted by theParaguayan government, had boarded one ofthese gunboats in Algiers and later, in midAtlantic, had caught a gambiae mosquito on theboat. He also found larvae in the bilge and wrotean article entitled “Mosquitoesof Paraguay―forthe Revue de l'Universitéde Nancy (Vol. I, pp.68—85,1938) in which he mentioned this fact.

Podtiagin thought that gambiae was ratherwidespread in Paraguay. Dr. Schenone, a wellknown Paraguayan physician, was bitten by astrange-looking mosquito in the Park in Asunción;he caught it and took it to Podtiagin, whorecognized it as gambiae. But Schenone, a bitskeptical, sent another specimen to his brotherwho was Military Attachéin Paris asking him tohave it classified at the Pasteur Institute. Hereceived a report signed J. Bedoc identifying it asA. gambiae. In the meantime an American namedSchneider, who collected for North Americanmuseums, had sent Podtiagin some adult mosquitoes from the north of Paraguay, some ofwhich were gambiae.

Podtiagin, however, had no gambiae material toshow the Joint Committee, since it had all beendestroyed or lost in various ways except the onemosquito sent to the Oswaldo Cruz Institute. Thevarious witnesses too were unavailable. Dr.Schenone had died and Schneider had returned tothe U. S. There had been several violent deathsamong the group which struck a rather sinisternote; Jorgensen was found dead in the junglewith his head bashed in, and Ladkovsky had beenassassinated.

The Joint Committee soon found that Podtiagin was not much of an entomologist, but wasan expert at intrigue. He spread stories about theArgentines among the Brazilians and about theBrazilians among the Argentines, and set theParaguayans against them both, with such successthat the Joint Committee almost broke up, andDr. Barbero, President of the Sociedad Cientfficadel Paraguay (which ran the Museum) refused togive the Committee any information. The Committee then got busy running down the secondaryclues in this singular affair. Dr. Schenone'sbrother, the Military Attaché,was traced toBuenos Aires, and his testimony was a shock tothe Committee; he had never heard of A. gambiae,his brother had not sent a mosquito to him inParis, and he had never set foot in the PasteurInstitute. The Captain of the gunboat was found

and he said he had not picked up anybody namedLadkovsky in Algiers, nor had he taken on waterin Senegal. In any case, both gunboats had beenlaid up for weeks in dry-dock in Buenos Aires tohave their bottoms scraped, and could not havetransported any mosquitoes to Paraguay. TheBotanic Garden had received only dried plantsfrom Africa. What then of the specimen sent byPodtiagin to the Oswaldo Cruz Institute andidentified as gambiae? Dr. Rachou rememberedthat Dr. Cesar Pinto of the Brazilian MalariaService had distributed specimens of gambiae toall the South American countries to help themidentify any possible invaders from Brazil. Herushed to the Museum, but this specimen couldnot be found; it had undoubtedly been sent toRio. The entire business in all its impressivedetail had been a carefully prepared hoax. Butwhen the Committee in a body went to chargePodtiagin with fraud, he could not be found; hehad eradicated himself from Paraguay. And whydid he indulge in this elaborate deception? Ithink he planned to put himself at the head of acampaign to exterminate a nonexistent Anophelesgambiae and to go down in history as the Soperof Paraguay.

I am afraid I have dwelt overlong on malaria,because this is a story I know at first hand. ButRose also selected a third disease against whichto wage a war of extermination. While he was inSingapore in 1914, after his visit to MalcolmWatson, he learned that there was apprehensionin India and the Far East over the opening of thePanama Canal, which was to take place in Augustof that year. It was feared that the shortening ofthe sea route from the Caribbean and Brazilianseed-beds of yellow fever would place the entireOrient at risk, where Aedes aegypti was prevalentin many areas. Col. James suggested establishinga quarantine station in some selected port of theFar East such as Hong Kong or Singapore, whereall ships from the Canal would be rounded up forinspection before being allowed to proceed to theirdestinations. Rose knew that the person to seeabout this was Gen. William C. Gorgas who hadjust left the Canal Zone to become SurgeonGeneral of the Army. Immediately upon hisreturn Rose got in touch with Gorgas, a consultation which had momentous consequences, forit marked the inception of the largest projectwhich the IHD ever undertook. To Gorgas, theBritish alarm must have seemed nothing less thanprovidential, if it should lead to a great campaign

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throughout the Western Hemisphere, a thingwhich he had dreamed of but had not thought itpossible to realize. He was convinced that yellowfever could remain endemic only in a very fewlarge seaports—not more than five or six perhapsin the American tropics—wherebabies and immigrants would be numerous enough to providea constant supply of new fuel. Whenever yellowfever broke out elsewhere in epidemic form, it wasa blaze which always rapidly burned itself out.Gorgas's experience had been that the disease,though occasionally able to spread for thousandsof miles along routes of travel, could not longwithstand a well-directed attack on its “keycenters.―Thus the campaigns in Havana, Panamaand New Orleans had freed the entire Caribbeanarea from yellow fever. “TheIHC,―he told Rose,“couldnot undertake a better piece of work thanthis. . . . The eradication [of yellow fever] wouldcommand the attention and gratitude of theworld—andthe thing can be done!―In fact, theIHC was the only agency which could wage suchan international campaign, for the Pan AmericanSanitary Bureau at that epoch was an intelligenceoffice without authority or funds. After threeweeks of reflection, the Commission resolved toundertake the task. Rose thought it might take atleast two years, but Henry Rose Carter, thedistinguished epidemiologist of the Public HealthService, wise and cautious as he was, wrote toRose: “Ithink you have rather exaggerated thedifficulty of getting rid of yellow fever when youput two years as the time required. We know justwhat to do. There is no uncertainty in it.―It hadonly taken Dr. Joseph H. White six weeks to endtransmission for all time in New Orleans in 1905.The prudent Rose however set up the project fora five-year period. The dangers of unconditionalprophecy are well illustrated by the fact that ittook the IHD 34 years to complete its yellowfever program; 76 staff members were associatedwith it at one time or another, and it cost theRockefeller Foundation almost 14 million dollars.

Gen. Gorgas made a survey of the yellow feversituation in South America in 1916, and while hewas in Bogota, Colombia, with his Commission,inquiring in vain about outbreaks of acute diseasein the interior which might be yellow fever, atelegram was received by the National Healthauthorities reporting an epidemic of yellow feverin the town of Muzo, an isolated spot near someemerald mines, 2,700 feet above the sea and 100miles northeast of Bogota. This was very pat

indeed, and the General and three of his companions got on horses and rode for several daysup the mountains to Muzo. When they arrivedthey found no very sick people and no cases thatsuggested yellow fever; more than that, theyfound no adults or larvae of “Stegomyia―(the oldname of Aede.eaegypti), which clinched the caseagainst there having been any yellow fever there.The Committee's report went on to say: “TheAlcalde of the town franidy admitted that histelegram had been without foundation; that hehad received a number of communications fromhigh officials in Bogota asking about yellow fever;that for some reason his superiors wished to havethe disease in Muzo; and that it was his duty as asubordinate appointed by Government to meetthe demand of his superiors; if the Governmentwanted yellow fever in Muzo, the Alcalde mustfurnish it. The Commission believes that thismining region may be dismissed from the area requiring consideration.― However, jungle yellowfever was surely endemic in Muzo at that verytime as later outbreaks proved. Probably theepidemic was not purely an invention of theAlcalde, but was over before the General arrived.As it was, the possibility of yellow fever in theabsence of Stegomyia was not entertained, and theCommission came to the conclusion that in allSouth America the only endemic center at thetime was Guayaquil.

Dr. M. E. Connor of the IHC cleaned yellowfever out of Guayaquil and all of Ecuador in sixmonths. Unfortunately, that did not ring theknell of yellow fever in the Hemisphere. He hadhardly recorded the last case in Guayaquil inMay, 1918, when an epidemic was reported fromGuatemala, and soon it was cropping up all overthe map. In 1919 there were outbreaks in Peru,Brazil, Honduras, Salvador and Mexico, followedwithin a year or two by epidemics in Nicaraguaand in Colombia without known antecedent casesand at points completely isolated from any possible sources of infection. Thus perished the keycenter concept, but what was wrong with it wasnot known for many years, until finally in 1932 arural epidemic, materializing out of nowhere, occurredintheValledoChanaan,inBrazil,inthecomplete absence of the Aede.saegypti mosquito,and it was discovered that yellow fever was notonly a disease of man but of monkeys too, spreadby forest mosquitoes not vulnerable to any conceivable method of attack

Thus the hope of banishing yellow fever from

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the earth was sunk by jungle yellow fever, butmuch was salvaged when that ship went down. By1937, a vaccine had been perfected which protected people from infection by jungle mosquitoes,and a blood test for immunity—the mouse-protection test—had been evolved in 1930 whichrevealed past infections with the virus in man ormonkey. This made it possible to map theendemic areas of yellow fever and even localizeprevious epidemics in time and place if they hadoccurred within the lifetime of the people examined, thus giving intelligence of the enemy. Asurvey of the world for yellow fever immunity inman was at once instituted by Dr. Sawyer in1931, which revealed a much wider distributionof the virus in South America and Africa thanhad been suspected. This survey took five years,and since it led the yellow fever staff into the rainforests of both continents and among primitiveand even savage peoples, it was attended byhardship and danger. Some of the stories whichcame out of the jungle have acquired by multiplepassage from mouth to mouth happy accessionsand incrustations of myth which give them almosta legendary quality.

There is one I prize about Dr. Allen M. Walcott, the dependable troubleshooter of the yellowfever crew. One of his missions took him over thewind-swept Andes of Ecuador by mountaintrails into the Amazon jungle between thePastaza and the Napo rivers, a rugged trip ifthere ever was one. This is the country of thewarlike Jibaros, the notorious head-hunters ofthe Upper Amazon, some of whose blood hehoped to obtain for the test, along with that ofany of the fabled Amazons he might meet, thebeautiful nude warriors on horseback. As his colleagues wrung his hand at his departure and said

goodbye, it crossed their minds that one of them,idling some day in a shop in Belémdo Pará,might come upon a shrunken head as small asyour fist and cry, “Goodheavens, that's Walcott!―But Walcott turned up in Iquitos with hishead on his shoulders and the blood of the Jfbarosin his bag. I wrote Walcott the other day to tryto confirm this story, but he said it was mostlyinvention—that is, he had made the trip andcollected a lot of blood, but had run across onlythree teen-age Jfbaros, who put up no resistance.He was silent on the subject of the Amazons. Hisversion and mine are at variance only statistically,as you see, and I do not regard the difference assignificant.

I will close on this note of modest claims andsuccessful accomplishment, which was characteristic of Wickliffe Rose and in some measure, Ilike to think, descended to his staff, who admiredand were loyal to him. It is ironical, as I lookback on the three diseases selected for demonstrations of control, that hookworm disease, chosenfor its simplicity as target for the first eradicationcampaign of them all, has turned out through defects of the human temperament to be the mostintractable, and that yellow fever, which Dr.Carter gave two years to live, now appears to beimmortal. But malaria, protean and tenacious,the endlessly adaptable and resourceful foe, maywell be on the way to extinction. I have sketchedfor you the earliest flowering of internationalpublic health, the tentative efforts of a privateorganization to stir oppressed peoples to work fortheir own salvation. To paraphrase the poet, allthis I saw and no small part of it I was. TheInternational Health Division, its task as acatalyst accomplished, isno more; but its soul goesmarching on.