Changes

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 aliments ailments afflicting the Indians. <ref> 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, <i>Indian Affairs: Laws and Treaties</i>, Vol. 1 (Washington, 1904) Additionally, some unratified treaties, including a 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.)</ref> 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 piece meal 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 simply contract 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 which 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 supervise and manage its various employees. Therefore it is essential to examine the role the appointment process played in limiting the effectiveness of the OIA’s medical corps. In addition to examining the appointment policy of the OIA and its role limiting the effectiveness of its medical corps, 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 nature of the tuberculosis catastrophe. This paper will examine how these crises differed and why they engendered such different responses. The OIA’s responses were not necessarily driven by over a concern for the Indian’s health and safety. They may have not 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 then 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 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 in an attempt to improve Indian health. Therefore, it may be more useful to understand why the OIA was finally instituted reforms as opposed to the efficacy or value of those reforms.

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 supervise and manage its various employees. Therefore it is essential to examine the role the appointment process played in limiting the effectiveness of the OIA’s medical corps. In addition to examining the appointment policy of the OIA and its role in limiting the effectiveness of its medical corps, 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 nature of the tuberculosis catastrophe. This paper will examine how these crises differed and why they engendered such different responses. The OIA’s responses were not necessarily driven by over a concern for the Indian’s health and safety. They may have not 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 in an attempt to improve Indian health. Therefore, it may be more useful to understand why the OIA has finally instituted reforms as opposed to 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.” <ref>Paul Stuart, <i>The Indian Office: Growth and Development of an American Institution, 1865 – 1900</i> (UMI Research Press, 1978), 5.</ref> 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. Prior to 1880, the OIA was decentralized and could not appoint personnel to its Indian agencies. <ref>Stuart, 11-12</ref> 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.<ref><i>Annual Report of the Commissioner of Indian</i> (1843-1844): 58, 82.</ref> 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.<ref><i>Annual Report of the Commissioner of Indian</i> (1847-1848): 139.</ref> 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.<ref>Stuart, <i>Indian Office</i>, 130.</ref> 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.<ref><i>Annual Report of the Commissioner of Indian Affairs to the Secretary of the Interior for the Year 1877</i> (1877): 33.</ref> 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.<ref> 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. Needless to say, I have not been able to determine why those tribes are not always included or if the OIA was not responsible for their healthcare.</ref> 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.

Early in its history ====The impact of the patronage system on the OIA was poorly situated to improve ====During the health and welfare first two decades 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 agents and treat Indians. In 1843, T. F. L. Verreyett stated that missionaries, not doctors, superintendents were responsible for administering medicine to sick Indianspresidential appointees. In the another report during that same year a missionary to the Choctaw agency admitted that he was acting out The organizational structure of necessity as a physician for the Indians. Indian OIA placed agents began to request medicines, such as quinine, because they believed that “a very small outlay for medicine” could save Indian lives. Before under the Civil War, Commissioner of the OIA employed very few physicians for its tribes. By 1865, only 12 physicians but agents were known to be employed appointed by the President and confirmed by the OIASenate. Even by 1877After the OIA was reorganized under the Interior Department in 1848, the initial selection of the agent for would be conducted by the Department of Interior, but the White River Agency stated that his agency did not have a physician and that President ultimately decided who would be proposed to the agency’s teacher was forced Senate. Unsurprisingly, senators could both block or recommend candidates to practice medicinethe executive branch. While these numbers would steadily rise over agents may have been organized under the next four decades to approximately 90 physiciansCommissioner, these doctors they were responsible for essentially serving at the pleasure of the President. Stuart argues that the “political control of appointments” undermined the ability of the health and welfare central office of over 180the OIA to influence local decisions.<ref>Stuart,000 reservation Indians in approximately 150 agenciesIndian Office, 28. </ref>

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 lasting impact on the agency’s physicians. 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. <ref>Stuart, <i>Indian Office</i>, 19.</ref> 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 ideals 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 improving 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.