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====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. <ref>Stuart, <i>Indian Office</i>, 36-37.</ref> 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.” <ref> Annual Report of the Commissioner of Indian (1885): 13.</ref> 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.” <ref><i>Annual Report of the Commissioner of Indian</i> (1885): 12-13.</ref> In addition, to listing a physician’s minimum requirements, the OIA provides 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”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.<ref><i>Annual Report of the Commissioner of Indian</i> (1885): 13.</ref> ====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.<ref>Charles E. Rosenburg “The Therapeutic Revolution: Medicine, Meaning and Social Change in Nineteenth-Century America,” in <i>The Therapeutic Revolution: Essays in the Social History of American Medicine</i>, ed. Moris J. Vogel and Charles E. Rosenburg, (University of Pennsylvania Press, 1979), 3-6.</ref> 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. <ref>Martin Kaufman, <i>Homeopathy in America: The Rise and Fall of a Medical Heresy</i> (Baltimore and London, The Johns Hopkins Press, 1971), 23.</ref> 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.”<ref>Numbers, <i>Sickness</i>, 226.</ref> 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.”<ref><i>Annual Report of the Commissioner of Indian</i> (1869): 169.</ref> 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.
Whether or not agency physicians were better than medicine men is debatable. Western medicine had learned how to control smallpox, but most of the important parts therapeutic revolution would not occur until the twentieth century. Indian agents even blamed their physicians’ incompetence for the continued survival of medicine men. Some agency physicians simply hoped that Indians would stop using medicine men when the older generation of Indians died out. In 1860, Dr. A. Coleman acknowledged that it would take years before Indians would trust western medicine because their practice of medicine had not only been passed “to them by a succession of generations” but was “interwoven with their religion” and government. Throughout the nineteenth century, Indians relied on their native medical practices and, when available, agency physicians. This reliance on agency physicians was ultimately limited by the both the number and quality of agency physicians and their unwillingness to reject their own traditions.
Adkins’ successor, T. J. Morgan acknowledged that OIA needed to reform its health services. Agency physicians could now be hired and fired by the Commissioner, but the OIA had not consolidated the physicians into an autonomous branch within in the OIA. Agency physicians were not organized under a chief administrator and they completely lacked supervision. Morgan argued that wretched working conditions and lack of supervision, agency physicians would be strongly tempted “to slight their work.” Additionally, Morgan criticized the OIA’s policy of appointing physicians without first examining them. Throughout the United States, states had created new licensing laws which required prospective physicians to pass examinations. The OIA only required that physicians be graduates of “some reputable medical school and submit testimonials as to moral character and correct habits.” Morgan realized that the OIA medical corps could soon become a haven for quacks. Agency physicians needed to be free from political influence, well compensated and thoroughly examined before their appointments.
Unlike smallpox, the tuberculosis threat slowly crept up on the OIA. Unlike smallpox, tuberculosis did not sweep through reservations and kill thousands; it slowly integrated itself onto reservations and in Indian schools. While some Indians quickly succumbed after being infected, most victims lingered on for extended periods of time. By 1880, the OIA had become increasingly centralized and capable of managing its physicians, but its response to tuberculosis was hampered by its lack of institutional memory. Despite repeated warnings from its employees, the OIA did not remember that it had problem. Instead, each new agent, physician, and commissioner was surprised to discovery the presence of tuberculosis among the Indians.
Leupp’s reform efforts gained traction because the tuberculosis threat to Native Americans could no longer be ignored, Roosevelt was interested in health and physical fitness, the OIA was sufficiently centralized to aid a broad reform effort and controlling tuberculosis dovetailed nicely with the OIA’s effort to integrate Native Americans into American society.<ref> Roosevelt served as the president of the 1908 International Congress on Tuberculosis in Washington D. C.</ref> 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====