How did smallpox and tuberculous force the Medial Corps Office of Indian Affairs to reform

After its founding in 1824 within the War Department, the Office of Indian Affairs (OIA) became responsible for the health and welfare of Indians who were removed to reservations. While some treaties mandated providing tribes with medicines or physicians, Indian agents began to employ doctors in different reservations to treat the panoply of ailments afflicting the Indians.

Even though physicians were hired quite early in some situations, the OIA failed to create a formal medical corps to treat Native Americans for almost eighty years. Physicians were hired in a piecemeal and sporadic fashion by local Indian agents, superintendents, and Indian School administrators. By the end of the nineteenth century, the OIA employed only about 90 physicians for almost 200,000 Indians. Sometimes physicians were hired by agents as salaried employees, other times they were simply 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 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.” 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. Throughout the nineteenth century, the OIA’s policies for selecting Indian agents, superintendents and other employees were constantly changing and each change limited the ability of the OIA to manage its employees. Throughout the nineteenth century, other organizations competed with the OIA to dictate and implement federal Indian policy including Indian Commissions, Congress, the Army, and various Christian Churches. Ultimately, the OIA was a weak, decentralized agency which was largely ineffective at lobbying Congress for the funds required to fulfill the United States’ treaty obligations.

Early in its history, the OIA was poorly situated to improve the health and welfare of agency Indians. Despite efforts by local agents to hire physicians, doctors were still fairly infrequent on Indian agencies in its early history. Agencies, especially early in the OIA’s existence, depended on missionaries, teachers, and Indian Agents to diagnose and treat Indians. In 1843, T. F. L. Verreyett stated that missionaries, not doctors, were responsible for administering medicine to sick Indians. In another report during that same year, a missionary to the Choctaw agency admitted that he was acting out of necessity as a physician for the Indians.

Indian agents began to request medicines, such as quinine because they believed that “a very small outlay for medicine” could save Indian lives. Before the Civil War, the OIA employed very few physicians for its tribes. By 1865, only 12 physicians were known to be employed by the OIA. Even by 1877, the agent for the White River Agency stated that his agency did not have a physician and that the agency’s teacher was forced to practice medicine. While these numbers would steadily rise over the next four decades to approximately 90 physicians, these doctors were responsible for the health and welfare of over 180,000 reservation Indians in approximately 150 agencies.

While the OIA was tasked with administering federal Indian policy, it relied upon the United States Army to fulfill its mission. The OIA’s dependence on the Army was emphasized during the Civil War. During the war, the Army’s role was dramatically reduced and chaos erupted on numerous reservations. Several tribes open revolted because the OIA could not fulfill its treaty responsibilities. The failure of the OIA to maintain peace and order during the Civil War led to a series of administrative reforms. These drastic reforms had a lasting impact on the agency’s physicians.

The impact of the patronage system on the OIA

During the first two decades of its existence, Indian agents and superintendents were presidential appointees. The organizational structure of the OIA placed agents under the Commissioner of the OIA, but agents were appointed by the President and confirmed by the Senate. After the OIA was reorganized under the Interior Department in 1848, the initial selection of the agent would be conducted by the Department of Interior, but the President ultimately decided who would be proposed to the Senate. Unsurprisingly, senators could both block or recommend candidates to the executive branch. While agents may have been organized under the Commissioner, they were essentially serving at the pleasure of the President. Stuart argues that the “political control of appointments” undermined the ability of the central office of the OIA to influence local decisions.

The Commissioner of Indian Affairs lacked the ability to hire and remove these agents and officials. Not only were agents presidential appointees, but they wielded complete control over the appointment of their subordinates. Indian agents had an extraordinary amount of autonomy to dictate the understanding of Indian policy on their reservation. Not only were Indian Agents political appointees, but they were approved by the Senate. Indian agents were a key component of the government’s patronage system.

Temporarily outsourcing appointments to OIA to Christian Churches

The Ulysses S. Grant administration tried to eliminate the patronage system and attempted to create a system which hired people for reasons other than political connections. Initially, the Grant administration tried to hire Army office, but various constituencies complained about these appointments. The Grant administration developed a novel solution to soothe competing interests. Instead of relying on a non-political appointment system or patronage, it decided that different Christian churches would be given the responsibility to not only appoint Indian agents and their subordinates but serve as missionaries on those reservations. Instead of agents hiring physicians, churches would be given the freedom to hire physicians who represented their values. Control over the OIA was essentially ceded to different churches.

While this system was approved, it created additional problems within the OIA by injecting various religious denominations’ goals and ideas into federal Indian policy. Instead of centralizing OIA authority, this move created additional strife within the OIA by allowing multiple church denominations to dictate federal Indian policy through their proxies. Attempts to eliminate the influence of medicine men among Indians became an increasingly important goal of Indian agents and agency physicians. Instead of consolidating its power, the OIA adopted several new masters which ensured that it would not be able to take a unified approach to improve Indian health. By 1880, the OIA revolted against church control and began to interfere with the selection of Indian agents by the religious organizations. After a decade of being pulled in different directions, the church appointment policy was abandoned and the practice was stopped.

Appointing Physicians under the Civil Service System

Even before the Rutherford Hayes administration abandoned appointment by churches of Indian agents, the OIA was finally allowed to appoint physicians to Indian Agency under the civil service system. Instead of relying on local agents or churches to select suitable physicians, the Commissioner could appoint physicians to agency positions. Instead of making these appointments subject to Senate approval, physicians were hired under the civil service system. By allowing the Commissioner to make appointments under the Civil Service Commission, the OIA was finally able to centralize its authority over agency physicians. Still, the OIA did not an administrator, such as a Surgeon General, in charge of agency physicians.

In 1886, Commissioner Adkins acknowledged that the OIA had had numerous problems with incompetent subordinate employees. Adkins indicated that new standards would be instituted for subordinate employees and promised that incompetent employees with the agency would not be eliminated. He argued that physicians should not only be graduates of medical school, but they should focus their undivided attention on the needs of the Indians and agency employees. He discouraged physicians from moonlighting and accepting payment for treating patients “not connected with the agency.”

By the end of the 1880s, the OIA had developed a list of criteria for people applying to become OIA physicians. In addition to being a “regular graduate of some reputable medical school,” physicians were expected to “be actually engaged in the practice of medicine.” In addition, to listing a physician’s minimum requirements, the OIA provided a job description for agency physicians. Considering the heavy patient load each agency physician faced, the OIA added a number of additional tasks, including eliminating “the influence of medicine men,” treating patients in their homes, reporting questionable sanitary problems to agency authorities, regularly visiting agency schools, organizing classes to teach Indians how to care for the sick, filing monthly reports, and working harmoniously with the Indian agent.

The State of Western Medicine was a Disaster

It is unsurprising, that the lack of centralized authority at the OIA prevented any organized approach to improving Indian healthcare. Since physicians were employed by the local Indian Agents they would not have been beholden to OIA bureaucracy in Washington. Therefore, it would have been impossible to effectively mandate minimum standards for physicians and promote health initiatives. Even if minimum standards for physician competency could be mandated, finding competent physicians in the United States during the nineteenth century was incredibly difficult. During the nineteenth century, American medical practice fragmented into multiple competing sects.

Before 1800, medical therapeutics had changed remarkably little over the previous two thousand years. At the beginning of the nineteenth century traditional physicians (or “regulars”) viewed themselves as learned professionals, their therapeutic methods were informed by Galen’s two-thousand-year-old “four humoral theory.” “The body was seen, metaphorically, as a system of dynamic interactions with its environment” and physicians believed that specific diseases played an insignificant role in the system.

During the nineteenth century, this understanding of the human body came under assault because it was ineffective in treating human illnesses. From the 1820s to the 1850s, the regulars’ dominance of American medical practice eroded dramatically. Several unorthodox or irregular medical sects, including Homeopathy, Eclecticism, and Thomsonianism, arose in opposition to the heroic medical practice of the regulars.

Unsurprisingly, regular physicians were often seen as incompetent or ineffective. During the mid-nineteenth century, not only were regulars hampered by a fundamentally flawed understanding of medicine, but woefully inadequate medical schools sprouted like weeds throughout the country. These schools were staffed by poorly trained practitioners, who were focused on profit, not education. Admission standards for most American medical schools could be best described as non-existent. Ronald Numbers quoted a physician in “The Fall and Rise of the American Medical Profession” as saying, “[i]t is well understood among college boys that after a man has failed in scholarship, failed in writing, failed in speaking, failed in every purpose for which he entered college; after he has dropped down from class to class; after he has been kicked out of college, there is one unfailing city of refuge – the profession of medicine.”

It would have been even more difficult to locate competent physicians who would have been willing to relocate to the isolated and potentially dangerous Indian reservations. William Mitchell, agent for the Warm Spring Agency in Oregon, complained that for $1,000 per year “no physician of even ordinary ability” could be had. Not only was the pay insufficient, but few gentlemen of “education and ability” would be willing to live somewhere which completely lacked a “society.” Even if the OIA had instituted some standards, it is not clear that the medical profession could have provided physicians who could improve Native American health.

The Failure of the Medical Corps ecourages use of Native American Medicine

While treating Indian disease was an auxiliary mission of the OIA, its primary goal was to control the Indian population and permit westward expansion. Unfortunately, several agents believed that this mission was severely compromised by the failure of the OIA to provide enough qualified physicians for Indian communities. In 1886, John S. Ward, the Indian Agent for the Mission Indians in California, complained that his physician could not adequately care for the 3,000 Indians under his care because the physician was required to cover an area the size of New England. Ward argued that his physician needed a horse and buggy and at least $1,000 a year in pay to treat his charges.

Because the OIA was unable to provide enough doctors, Indians continued to rely on their own medicine. Despite concerted efforts by the OIA throughout the nineteenth century to undermine and degenerate Indian medicine men, the influence of medicine men continued. The OIA believed that medicine men stalled the assimilation of Indians because they preserved not only their medical, but religious traditions. While the OIA sought to eliminate their influence, they failed to understand the roles these individuals played in Indian society or provide Indians with medical alternatives.

Throughout the nineteenth century, Indian agents provided contradictory reports regarding the influence and reliance on medicine men by Indians. Whether or not these reports were accurate is difficult to ascertain. Due to the often contradictory nature of these reports, it appears that medicine men continued to play prominent roles tribes throughout the nineteenth century. Even though some Indian agents insisted that their Indians were not “superstitiously attached to their medicine men,” others reported that medicine played a prominent role in tribal life. Reports from the OIA agents during those years were often wildly inconsistent.

In 1860, B. W. Kimball, the physician for the Medicine Creek Treaty Indians stated the Indians’ trust in their medicine men was declining, but only after declaring that most Indians relied on their own “system of medicine” to treat health problems. Dr. Mills, agency physician for the Nebraskan Spotted Tail Agency claimed in 1877 that Indians in his agency had abandoned their own medicine-men and stopped performing their “superstitious and mysterious incantations.” In 1884, the Commissioner of Indian Affairs H. Price blamed Indian medicine men’s condemnation of western medicines as “poison” and “the almost universal belief in spirits…” for high the Native American mortality rate. Price argued that Indians could not be effectively treated by agency physicians because they sought treatment from their own medicine men first. In 1894, Frank C. Blackly the physician for the Southern Ute Agency minimized the importance of the tribe’s medicine men, but acknowledged that they were still able to “keep up the practice of their superstition…” Leupp and Murphy not only sought to reform the OIA’s medical corps, but tuberculosis provided a powerful justification to change the behavior and culture of Native Americans. The OIA could increase its control over its charges under the guise of health reform and eliminate some of their more objectionable behavior. Not only could Indians be taught how to behave in civilized society, but if they failed to follow the OIA’s directives they could claim that their Indian behavior would kill them.

Conclusion

The effort at the turn of the century to reform the OIA’s healthcare was largely unsuccessful, but it is significant because it pinpoints a clear change in OIA and its policies. By the 1900 the OIA was finally capable of implementing broad institutional reforms. Advances in medicine would have provided compelling reasons to expand its medical corps. It should not be ignored that these reforms occurred when the government’s relationship to Native Americans changed. By 1909, the United States wanted to control Native American behavior. Tuberculosis provided the OIA with a good reason to educate Native Americans about their potentially dangerous behaviors.

Bibliography

Primary Sources

Office of Indian Affairs, Annual Report of the Commissioner of Indian Affairs to the Secretary of the Interior, (1831-1909)

Lake Mohonk Conference of Friends of the Indian and Other Dependent Peoples, Report of the Annual Meeting of the Mohonk Conference of the Friends of the Indian and other Dependent Peoples (1887-1904)

Leupp, Francis E., The Indian and His Problem, (New York, 1910)

Leupp, Francis E., In Red Man’s Land: A Study of the American Indian (New York, 1914)

Secondary Sources

Eds., Hildreth, Martha and Bruce T. Moran, Disease and Medical Care in the Mountain West: Essays on Region, History and Practice (Reno, 1998)

Jones, David S., Rationalizing Epidemics: Meaning and Uses of American Indian Mortality since 1600 (2004, Cambridge and London)

Prucha, Francis Paul, The Great Father: The United States Government and the American Indians (Lincoln and London, 1984)

Stuart, Paul, The Indian Office: Growth and Development of an American Institution, 1865 – 1900 (Ann Arbor, 1978)