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__NOTOC__By Clinton M. Sandvick ====Beginnings====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 an 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 . 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 that 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 to supervise and manage its various employees. Therefore, it is essential to examine the role the appointment process played in limiting OIA’s medical corps' effectiveness. In addition to examining the OIA appointment policy and its role in limiting its medical corps' effectiveness, 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 tuberculosis catastrophe's nature. This paper will examine how these crises differed and why they engendered such different responses. The OIA’s responses were not necessarily driven by a concern for the Indian’s health and safety. They may not have 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 to improve Indian health. Therefore, it may be more useful to understand why the OIA has finally instituted reforms instead of 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. Before 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. 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 slowly expanding tasked with administering federal Indian policy, it relied upon the United States Army to fulfill its medical corpsmission. The OIA’s dependence on the Army was emphasized during the Civil War. During the war, Indians’ continued survival the Army’s role was threatened by smallpox dramatically reduced and chaos erupted on numerous reservations. Several tribes open revolted because the advancing specter of tuberculosisOIA could not fulfill its treaty responsibilities. Under the stewardship The failure of Commissioner Francis E. Leupp the OIA attempted to reform its medical corps maintain peace and create order during the Civil War led to a more unified organization which could meet the needs series of reservation Indians in response to administrative reforms. These drastic reforms had a lasting impact on the tuberculosis threatagency’s physicians. While these reforms did not necessarily solve any <dh-ad/> ====The impact of the problems Native Americans faced, they demonstrated that patronage system on the OIA was cognizant ====During the first two decades of the health dangers Indians faced on reservation lands its existence, Indian agents and showed they superintendents were willing to make coordinated efforts to protect Indianspresidential appointees. The tuberculosis threat also provided organizational structure of the OIA placed agents under the Commissioner of the OIA with an opportunity to challenge Indian behavior, but provide a rationale for how those behaviors threatened their livesagents were appointed by the President and confirmed by the Senate. Even then, After the OIA only considered reforming its medical corps after it was clear that tuberculosis threatened reorganized under the Interior Department in 1848, the initial selection of the agent would be conducted by the survival Department of not only numerous Native AmericansInterior, but whites the President ultimately decided who lived near reservations. Even if an OIA commissioner had sought would be proposed to improve the OIA’s ability to deliver competent health services before 1909Senate. Unsurprisingly, any potential reform senators could both block or recommend candidates to the executive branch. While agents may have been rendered meaningless because organized under the Commissioner, they were essentially serving at the pleasure of its counterproductive hiring and appointment proceduresthe President. Essentially, Stuart argues that the “political control of appointments” undermined the ability of the medical corps central office of the OIA could be reformed only after to influence local decisions.<ref>Stuart, Indian Office, 28.</ref> The Commissioner of Indian Affairs lacked the OIA centralized its authority ability to hire and was in a position supervise remove these agents and manage its various employeesofficials. Therefore it is essential to examine the role Not only were agents presidential appointees, but they wielded complete control over the appointment process played in limiting the effectiveness of the OIA’s medical corpstheir subordinates. In addition Indian agents had an extraordinary amount of autonomy to examining dictate the appointment understanding of Indian policy of the OIA and its role limiting the effectiveness of its medical corpson their reservation. Not only were Indian Agents political appointees, this paper will examine but they were approved by the role smallpox and tuberculosis played in reforming the OIA medical serviceSenate. Despite the constant specter Indian agents were a key component of smallpox, the government’s patronage system.  ====Temporarily outsourcing appointments to OIA did not fully commit to reforming its medical corps until it finally acknowledged Christian Churches====The Ulysses S. Grant administration tried to eliminate the nature of the tuberculosis catastrophepatronage system and attempted to create a system which hired people for reasons other than political connections. This paper will examine how Initially, the Grant administration tried to hire Army office, but various constituencies complained about these crises differed and why they engendered such different responsesappointments. The OIA’s responses were not necessarily driven by over Grant administration developed a novel solution to soothe competing interests. Instead of relying on a concern for non-political appointment system or patronage, it decided that different Christian churches would be given the Indian’s health responsibility to not only appoint Indian agents and safetytheir 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. They may have not reformed </ref> Control over the OIA earlier because was essentially ceded to different churches.  While this system was approved, it did not benefit created additional problems within the broader mission of implementing OIA by injecting various religious denominations’ goals and ideas into federal Indian policy. When the Instead of centralizing OIA authority, this move created additional strife within the OIA by allowing multiple church denominations to dictate federal Indian Medical Services it did so because it advanced its broader policy objectivesthrough their proxies. This paper will focus more on Attempts to eliminate the impetus influence of medicine men among Indians became an increasingly important goal of Indian agents and obstacles for reform then the reforms themselvesagency physicians. While the reforms did increase the number Instead of physiciansconsolidating its power, nurses, and hospitals serving physicians, they were the OIA adopted several new masters which ensured that it would not particularly successful. Tuberculosis was still be able to take a problem in 1950s for Native Americansunified approach to improve Indian health. Throughout the twentieth centuryBy 1880, the Indian Medical Services OIA revolted against church control and began to interfere with the successor agency under selection of Indian agents by the Public Health Service, the Indian Health Service, would undergo significant reforms in an attempt to improve Indian healthreligious organizations. ThereforeAfter a decade of being pulled in different directions, it may be more useful to understand why the OIA church appointment policy was finally instituted reforms as opposed to abandoned and the efficacy or value of those reformspractice was stopped.

Starting in 1824====Appointing Physicians under the Civil Service System====Even before the Rutherford Hayes administration abandoned appointment by churches of Indian agents, the OIA was charged with faithfully implementing federal finally allowed to appoint physicians to Indian policy. Historian Paul Stuart described Agency under the OIA as “organizationally weak and ineffective in its first half-centurycivil service system.” The OIA was largely unsuccessful during its first five decades Instead of existence because it could not effectively manage its relying on local agents and enforce Indian policy on its own. Prior or churches to 1880select suitable physicians, the OIA was decentralized and Commissioner could not appoint personnel physicians to its Indian agenciesagency positions. Throughout the nineteenth century<ref>Stuart, the OIA’s policies for selecting <i>Indian agentsOffice</i>, 36-37.</ref> Instead of making these appointments subject to Senate approval, superintendents and other employees physicians were constantly changing and each change limited hired under the ability of civil service system. By allowing the OIA Commissioner to manage its employees. Throughout make appointments under the nineteenth centuryCivil Service Commission, other organizations competed with the OIA was finally able to dictate and implement federal Indian policy including Indian Commissions, Congress, the Army and various Christian Churchescentralize its authority over agency physicians. Ultimately Still, the OIA was did not an administrator, such as a weakSurgeon General, decentralized in charge of agency which was largely ineffective at lobbying Congress for the funds required to fulfill the United States’ treaty obligationsphysicians.

Early in its history In 1886, Commissioner Adkins acknowledged that the OIA was poorly situated to improve 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 health and welfare of agency Indianswould not be eliminated. Despite efforts by local agents to hire He argued that physiciansshould not only be graduates of medical school, doctors were still fairly infrequent but they should focus their undivided attention on Indian agencies in its early history. Agencies, especially early in the OIA’s existence, depended on missionaries, teachers, needs of the Indians and Indian Agents to diagnose and treat Indiansagency employees. In 1843, T. F. L. Verreyett stated that missionaries, not doctors, were responsible He discouraged physicians from moonlighting and accepting payment for administering medicine to sick Indians. In the another report during that same year a missionary to treating patients “not connected with the Choctaw agency admitted that he was acting out .”<ref> Annual Report 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 Commissioner of Indian lives(1885): 13. Before </ref> By the end of the Civil War1880s, the OIA employed very few had developed a list of criteria for people applying to become OIA physicians for its tribes. By 1865 In addition to being a “regular graduate of some reputable medical school, only 12 ” physicians were known expected to be employed by “be actually engaged in the practice of medicine.”<ref><i>Annual Report of the OIACommissioner of Indian</i> (1885): 12-13. Even by 1877</ref> In addition, to listing a physician’s minimum requirements, the agent OIA provided a job description for agency physicians. Considering the White River Agency stated that his heavy patient load each agency did not have a physician and that faced, the agency’s teacher was forced to practice OIA added a number of additional tasks, including eliminating “the influence of medicine. While these numbers would steadily rise over the next four decades men,” treating patients in their homes, reporting questionable sanitary problems to approximately 90 physiciansagency authorities, regularly visiting agency schools, these doctors were responsible organizing classes to teach Indians how to care for the health sick, filing monthly reports, and welfare working harmoniously with the Indian agent.<ref><i>Annual Report of the Commissioner of over 180,000 reservation Indians in approximately 150 agenciesIndian</i> (1885): 13. </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 State of Western Medicine was emphasized during the Civil War. During the wara Disaster====It is unsurprising, that 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 lack of centralized authority at the OIA prevented any organized approach 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, improving Indian agents and superintendents were presidential appointeeshealthcare. The organizational structure of the OIA placed agents under the Commissioner of the OIA, but agents Since physicians were appointed employed by the President and confirmed by the Senate. After the local Indian Agents they would not have been beholden to OIA was reorganized under the Interior Department bureaucracy 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 SenateWashington. UnsurprisinglyTherefore, senators could both block or recommend candidates to the executive branch. While agents may it would 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 impossible to influence local decisions. The Commissioner of Indian Affairs lacked the ability to hire effectively mandate minimum standards for physicians and remove these agents and officialspromote health initiatives. Not only were agents presidential appointeesEven if minimum standards for physician competency could be mandated, but they wielded complete control over finding competent physicians in the United States during the appointment of their subordinatesnineteenth century was incredibly difficult. Indian agents had an extraordinary amount of autonomy to dictate During the understanding of Indian policy on their reservation. Not only were Indian Agents political appointeesnineteenth century, but they were approved by the Senate. Indian agents were a key component of the government’s patronage systemAmerican medical practice fragmented into multiple competing sects.

The Ulysses SBefore 1800, medical therapeutics had changed remarkably little over the previous two thousand years. Grant administration tried to eliminate At the beginning of the patronage 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 attempted to create a physicians believed that specific diseases played an insignificant role in the system which hired people for reasons other than political connections. <ref>Charles E. Rosenburg Initially“The Therapeutic Revolution: Medicine, the Grant administration tried to hire Army officeMeaning and Social Change in Nineteenth-Century America, but various constituencies complained about these appointments. ” in <i>The Grant administration developed a novel solution to soothe competing interests. Therapeutic Revolution: Instead Essays in the Social History of relying on a non-political appointment system or patronageAmerican Medicine</i>, it decided that different Christian churches would be given the responsibility to not only appoint Indian agents ed. Moris J. Vogel and their subordinatesCharles E. Rosenburg, but serve as missionaries on those reservations. Instead (University of agents hiring physiciansPennsylvania Press, 1979), churches would be given the freedom to hire physicians who represented their values. Control over the OIA was essentially ceded to different churches3-6. </ref>

While this system was approved, it created additional problems within During the OIA by injecting various religious denominations’ goals and ideals into federal Indian policy. Instead of centralizing OIA authoritynineteenth century, this move created additional strife within understanding of the OIA by allowing multiple church denominations to dictate federal Indian policy through their proxieshuman body came under assault because it was ineffective in treating human illnesses. Attempts From the 1820s to eliminate the influence 1850s, the regulars’ dominance of medicine men among Indians became an increasingly important goal of Indian agents and agency physiciansAmerican medical practice eroded dramatically. Instead of consolidating its power Several unorthodox or irregular medical sects, including Homeopathy, the OIA adopted several new masters which ensured that it would not be able to take a unified approach to improving Indian health. By 1880Eclecticism, the OIA revolted against church control and began Thomsonianism, arose in opposition to interfere with the selection heroic medical practice of Indian agents by the religious organizationsregulars. <ref>Martin Kaufman, <i>Homeopathy in America: After The Rise and Fall of a decade of being pulled in different directions the church appointment policy was abandoned Medical Heresy</i> (Baltimore and the practice was stoppedLondon, The Johns Hopkins Press, 1971), 23. </ref>

Even before the Rutherford Hayes administration abandoned appointment by churches of Indian agentsUnsurprisingly, the OIA was finally allowed to appoint regular physicians to Indian Agency under the civil service systemwere often seen as incompetent or ineffective. Instead During the mid-nineteenth century, not only were regulars hampered by a fundamentally flawed understanding of relying on local agents or churches to select suitable physiciansmedicine, but woefully inadequate medical schools sprouted like weeds throughout the Commissioner could appoint physicians to agency positionscountry. Instead of making these appointments subject to Senate approvalThese schools were staffed by poorly trained practitioners, physicians who were hired under the civil service systemfocused on profit, not education. By allowing the Commissioner to make appointments under the Civil Service Commission, the OIA was finally able to centralize its authority over agency physiciansAdmission standards for most American medical schools could be best described as non-existent. Still, Ronald Numbers quoted a physician in “The Fall and Rise of the OIA did not an administratorAmerican Medical Profession” as saying, such as “[i]t is well understood among college boys that after a Surgeon Generalman has failed in scholarship, failed in writing, failed in speaking, failed in charge 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 agency physiciansrefuge – the profession of medicine.”<ref>Numbers, <i>Sickness</i>, 226. </ref>

In 1886It 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, Commissioner Adkins acknowledged that agent for the OIA had had numerous problems with incompetent subordinate employees. Adkins indicated Warm Spring Agency in Oregon, complained that new standards would be instituted for subordinate employees and promised that incompetent employees with the agency would not $1,000 per year “no physician of even ordinary ability” could be eliminatedhad. He argued that physicians should not Not only be graduates of medical schoolwas the pay insufficient, but they should focus their undivided attention on the needs few gentlemen of the Indians “education and agency employees. He discouraged physicians from moonlighting and accepting payment for treating patients “not connected with the agencyability” would be willing to live somewhere which completely lacked a “society.” By <ref><i>Annual Report of the end Commissioner of the 1880s Indian</i> (1869): 169.</ref> Even if the OIA had developed a list of criteria for people applying to become OIA physicians. In addition to being a “regular graduate of instituted some reputable medical schoolstandards,” physicians were expected to “be actually engaged in it is not clear that the practice of medicine.” In addition, to listing a physician’s minimum requirements, the OIA provides a job description for agency medical profession could have provided physicianswho could improve Native American health. 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.

It is unsurprising, that ====The Failure of the Medical Corps encouraged the lack use of Native American Medicine====While treating Indian disease was an auxiliary mission of centralized authority at the OIA prevented any organized approach , its primary goal was to improving control the Indian healthcarepopulation and permit westward expansion. Since physicians were employed Unfortunately, several agents believed that this mission was severely compromised by the local Indian Agents they would not have been beholden to failure of the OIA bureaucracy in Washington. Therefore, it would have been impossible to effectively mandate minimum standards for provide enough qualified 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 difficultIndian communities. During the nineteenth centuryIn 1886, American medical practice fragmented into multiple competing sectsJohn S. Before 1800Ward, medical therapeutics had changed remarkably little over the previous two thousand years. At Indian Agent for 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, metaphoricallyMission Indians in California, as a system of dynamic interactions with its environment” and physicians believed complained that specific diseases played an insignificant role in his physician could not adequately care for the system. During the nineteenth century3, this understanding of the human body came 000 Indians under assault his care because it the physician was ineffective in treating human illnesses. From the 1820s required to cover an area 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 heroic medical practice size of the regularsNew England. Unsurprisingly, regular physicians were often seen as incompetent or ineffective. During the mid-nineteenth century, not only were regulars hampered by Ward argued that his physician needed 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 horse and buggy and Rise of the American Medical Profession” as sayingat least $1, “[i]t is well understood among college boys that after 000 a man has failed in scholarship, failed in writing, failed year in speaking, failed in every purpose for which he entered college; after he has dropped down from class pay to class; after he has been kicked out treat his charges.<ref><i>Annual Report of college, there is one unfailing city of refuge – the profession Commissioner of medicineIndian</i> (1886): 45.” </ref>

It would have been even more difficult Because the OIA was unable to locate competent physicians who would have been willing provide enough doctors, Indians continued to relocate rely on their own medicine. Despite concerted efforts by the OIA throughout the nineteenth century to the isolated undermine and potentially dangerous degenerate Indian reservations. William Mitchellmedicine men, agent for the Warm Spring Agency in Oregon, complained that for $1,000 per year “no physician influence of even ordinary ability” could be hadmedicine men continued. Not The OIA believed that medicine men stalled the assimilation of Indians because they preserved not only was the pay insufficient, their medical but few gentlemen of “education and ability” would be willing to live somewhere which completely lacked a “societyreligious traditions.” Even if While the OIA had instituted some standardssought to eliminate their influence, it is not clear that they failed to understand the roles these individuals played in Indian society or provide Indians with medical profession could have provided physicians who could improve Native American healthalternatives.

While treating Indian disease was an auxiliary mission of Throughout the OIAnineteenth century, its primary goal was to control Indian agents provided contradictory reports regarding the Indian population influence and permit westward expansion. Unfortunately, several agents believed that this mission was severely compromised reliance on medicine men by the failure of the OIA to provide enough qualified physicians for Indian communitiesIndians. In 1886, John S. Ward, the Indian Agent for the Mission Indians in California, complained that his physician could Whether or not adequately care for the 3,000 Indians under his care because the physician was required these reports were accurate is difficult to cover an area the size of New Englandascertain. Ward argued that his physician needed a horse and buggy and at least $1,000 a year in pay Due to treat his charges. Unsurprisingly, because the OIA was unable to provide enough doctorsoften contradictory nature of these reports, Indians it appears that medicine men continued to rely on their own medicine. Despite concerted efforts by the OIA play prominent roles tribes throughout the nineteenth century . Even though some Indian agents insisted that their Indians were not “superstitiously attached to undermine and degenerate Indian their medicine men, the influence of ” others reported that medicine men continuedplayed a prominent role in tribal life. The OIA believed that medicine men stalled <ref><i>Annual Report of the assimilation Commissioner of Indians because they preserved not only their medical, but religious traditionsIndian</i> (1843): 201. While </ref> Reports from the OIA sought to eliminate their influence, they failed to understand the roles these individuals played in Indian society or provide Indians with medical alternativesagents during those years were often wildly inconsistent.

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 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 same agent during the same years on the influence of medicine men could be internally inconsistent. In 1860, B. W. Kimball, the physician for the Medicine Creek Treaty Indians stated the Indians’ trust in the their medicine men was declining, but only after declaring that most Indians relied on their own “system of medicine” to treat health problems. <ref> Annual Report of the Commissioner of Indian (1860): 201-202.</ref> 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.” <ref><i>Annual Report of the Commissioner of Indian</i> (1877): 70.</ref> 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. <ref><i>Annual Report of the Commissioner of Indian</i> (1884): xxxv-xxxvi.</ref> 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…” <ref><i>Annual Report of the Commissioner of Indian</i> (1894): 130.</ref>

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. <ref><i>Annual Report of the Commissioner of Indian</i> (1886): 76</ref> Some agency physicians simply hoped that Indians would stop using medicine men when the older generation of Indians died out. <ref> <i>Annual Report of the Commissioner of Indian</i> (1886): 59.</ref> 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. <ref><i>Annual Report of the Commissioner of Indian</i> (1860): 76.</ref> Throughout the nineteenth century, Indians relied on their native medical practices and, when available, agency physicians. <ref><i>Annual Report of the Commissioner of Indian</i> (1886): 111. </ref> 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.<ref><i>Annual Report of the Commissioner of Indian</i> (1890): xix-xxii.</ref>

It was fairly easy to demonstrate how poorly paid agency physicians were compared to their colleagues working in both the Army and Navy. In 1890, the agency physicians were paid on average $1,062 and Indian school physicians $813. Physicians in the Army and Navy were typically paid between $2,600 and $2,800 per year. Not only was the pay higher for military personnel, but they were required to treat far fewer patients. In the Navy, 160 physicians treated 9,955 sailors while 192 Army physicians were responsible for 26,739 army personnel. On the other hand, 82 agency physicians were responsible for 180,000 Native Americans in 1890. Each year agency physicians treated eight times as many patients. Some agency physicians were accountable for staggering numbers of Indians spread on far -flung reservations. One agency physician on the Navajo Reservation was in charge of the health and welfare of 18,000 Indians spread over 12,000 square miles. <ref>Annual Report of the Commissioner of Indian (1890): xxi-xxii. </ref> Despite the obvious problems within the medical corps of the OIA, major institutional reform was still decades away.

Probably the most deadly danger faced by Native Americans was the nearly constant outbreaks of smallpox. Smallpox epidemics decimated Indian tribes throughout the nineteenth century. Smallpox outbreaks threatened not only Indians, but posed grave dangers to neighboring American citizens. In 1832, as a result of this ongoing threat , an early smallpox program was created to vaccinate Indians. Unfortunately, even though over 3,000 Indians were vaccinated, the program was largely unsuccessful. Numerous tribes refused to be treated and eventually the program’s funding ran out. Soon after the program’s demise, the 1837 epidemic devastated the Blackfeet and Mandan tribes in the Dakotas. <ref> Martha Hilderth and Bruce T. Moran, <i>Disease and Medical Care in the Mountain West: Essays on Region, History and Practice</i> (University of Nevada Press,1998): 44.</ref> Lawrence Taliaferro, Indian Agent at St. Peter’s Iowa Territory, observed that during the smallpox epidemic of 1837 “upward of 60 (Sioux) lodges” had perished. <ref><i>Annual Report of the Commissioner of Indian Affairs Transmitted with the Message of the President at the Opening of the 1st Session of the Twenty-Sixth Congress 1839-1840</i> (1839): 177. </ref>  During the 1837 epidemic, some OIA employees attempted to stem the epidemic’s tide. In Wisconsin, T. T. Vandenbrock, Superintendent of the Mission on the Fox River, claimed that he had vaccinated hundreds of Indians during the epidemic without any financial support from the OIA. <ref><i>Annual Report of the Commissioner of Indian Affairs Transmitted with the Message of the President at the Opening of the 1st Session of the Twenty-Eighth Congress 1843-1844</i> (1843): 103. </ref> Fortunately for the Indians on the Fox River, Vandenbrock was willing to foot the bill because he believed that he was simply “discharging my duty to my fellow-creatures and to my Creator.” <ref><i>Annual Report of the Commissioner of Indian</i> (1843): 103.</ref> While Vandenbrock may have been discharging his duty to his fellow creatures, he may also have also been attempting to get his expenses reimbursed from the $500 allocated to the Wisconsin superintendency out the $5,000 appropriated by the Twenty-Seventh Congress intended “to defray the expenses of vaccinating the Indians.” <ref> <i>Annual Report of the Commissioner of Indian Affairs</i> (1839): 23.</ref>

The presence of smallpox both advanced and threatened American interests. While agency physicians could not always successfully stop these epidemics, successfully treating Indians helped smooth relations between Americans and Indians. Western physicians could reduce the deaths caused by smallpox through vaccination or inoculation. It was the most important way to demonstrate the superiority of western medicine. Of course, if smallpox epidemics culled the Indian population the OIA would have a much easier task of controlling Indian populations and advancing federal policy. Smallpox continued to be a danger to Indians throughout the nineteenth century. In 1855, the Osages were faced with an outbreak of smallpox. The agency was required to hire a physician who administered the smallpox vaccine to the tribe to prevent further infection. Dr. C. W. Dean, from the Southern Superintendency described a smallpox epidemic which killed approximately 400 Indians. Additionally, the Arapahoes near Fort Laramie admitted to killing cattle and sheep because they were weakened by smallpox and unable to hunt. In 1864, an outbreak of smallpox in The Dalles threatened the Warm Springs reservation and another outbreak in Colorado and Kansas forced a Special Agent H.T. Ketham to vaccinate over 1100 Indians.

In 18691855, the OIA Osages were faced several additional occurrences with an outbreak of small pox. Tule Indians faced a similar outbreak to the Arapahoes when smallpox appeared in Visalia. In order to prevent the spread of smallpox; the agent restricted the Tules to the reservation and vaccinated 190 <ref><i>Annual Report of them. During the first year Commissioner of Indian school on the Nez Perces Reservation, it was closed after smallpox in Lewistown. After approximately 4 months the school was reopened. Affairs</i> (1856): Another outbreak in 187710, threatened the Pima Indian Agency68. This outbreak </ref> The agency was worrisome because the Pima Agency did not have required to hire a physician and who administered the smallpox vaccine to the disease spread widelytribe to prevent further infection. JDr. C. HW. StoutDean, from the Pima Indian AgentSouthern Superintendency, was forced to temporarily hire described a physician to vaccinate hundreds of smallpox epidemic which killed approximately 400 Indians. Even though Stout indicated that it was a just mild form <ref> Annual Report of the virusCommissioner of Indian Affairs (1856): 122. </ref> Additionally, it still proved the Arapahoes near Fort Laramie admitted to be a fatal outbreak. Smallpox outbreaks continued throughout the nineteenth century killing cattle and even as late as 1900, sheep because they were weakened by smallpox was still a threatand unable to hunt. The Rosebud Agency reported a smallpox outbreak which was averted after <ref> Annual Report of the agency physician vaccinated the agency’s Indians and surrounding whites. Commissioner of Indian Affairs (1856): Aside from the Rosebud Agency, several other reported smallpox outbreaks82. The continued smallpox scares motivated Congress in 1900 to allocate $50</ref> In 1864,000 to suppress an outbreak of smallpox in The Dalles threatened the Indian Territory, but it was not designated for IndiansWarm Springs reservation and another outbreak in Colorado and Kansas forced a Special Agent H. The appropriation was solely intended for residents of the territory who were “not members of any Indian tribe or nationT.” These outbreaks represent just a few of the examples of the continual nature of the smallpox threatKetham to vaccinate over 1100 Indians.

Despite these constant smallpox outbreaksIn 1869, the OIA did not develope faced several additional occurrences of smallpox. Tule Indians faced a widespread program similar outbreak to vaccinate large numbers of Indiansthe Arapahoes when smallpox appeared in Visalia. Instead, In order to prevent the spread of smallpox; the agent restricted the OIA shuffled physicians from one crisis Tules to anotherthe reservation and vaccinated 190 of them. <ref>Annual Report of the Commissioner of Indian Affairs (1869): Agency physicians would only start vaccinating people once 191.</ref> During the first year of an outbreak or scare occurred. Even in Indian school on the best circumstances this strategy could endanger people’s livesNez Perces Reservation, but on far flung Indian agencies with possibly one physician it was often fatalclosed after smallpox in Lewistown. Oddly enough, it After approximately 4 months the school was not the constant threat reopened.<ref> Annual Report of smallpox that convinced the OIA that it needed to take broader action to protect the lives Commissioner of its chargesIndian Affairs (1869): 285. </ref> Another outbreak in 1877, but threatened the endemic disease of tuberculosisPima Indian Agency. Unlike smallpox, tuberculosis This outbreak was essentially untreatable at worrisome because the Pima Agency did not have a physician and the timedisease spread widely. During J. H. Stout, the nineteenth centuryPima Indian Agent, tuberculosis was often referred forced to as scrofula (cervical tuberculosis) and consumption (pulmonary tuberculosis)temporarily hire a physician to vaccinate hundreds of Indians. It is difficult Even though Stout indicated that it was a just mild form of the virus, it still proved to determine when Indian agents became aware be a fatal outbreak.<ref> Annual Report of the presence Commissioner of tuberculosisIndian Affairs (1877): 33. </ref>

By 1854, scrofulaSmallpox outbreaks continued throughout the nineteenth century and even as late as 1900, smallpox was still a formerly threat. The Rosebud Agency reported a rare ailment among smallpox outbreak which was averted after the agency physician vaccinated the agency’s Indiansand surrounding whites. <ref> Annual Report of the Commissioner of Indian Affairs (1890): 381.</ref> Aside from the Rosebud Agency, several other reported smallpox outbreaks. The continued smallpox scares motivated Congress in 1900 to allocate $50,000 to suppress smallpox in the Indian Territory, had become quite common among but it was not designated for Indians in . The appropriation was solely intended for residents of the Midwestterritory who were “not members of any Indian tribe or nation. Over ” These outbreaks represent just a few of the examples of the continual nature of the next 50 yearssmallpox threat. Despite these constant smallpox outbreaks, references the OIA did not develop a widespread program to tuberculosis and scrofula by agency vaccinate large numbers of Indians. Instead, the OIA shuffled physicians and agents became increasingly commonfrom one crisis to another. Agency physicians pleaded for hospitalswould only start vaccinating people once an outbreak or scare occurred. Even in the best circumstances, this strategy could endanger people’s lives, sanitarium and medicinebut on far-flung Indian agencies with possibly one physician it was often fatal. Other physicians argued Oddly enough, it was not the constant threat of smallpox that convinced the OIA that it needed to quickly change Indian behavior because they firmly believed that Indians were primarily responsible for take broader action to protect the diseases spread. Despite the growing number lives of reports from agencies regarding its charges, but the alarming rates endemic disease of tuberculosis. Unlike smallpox, tuberculosis was essentially untreatable at the time. During the OIA did not take any major steps nineteenth century, tuberculosis was often referred to limit as scrofula (cervical tuberculosis) and consumption (pulmonary tuberculosis until in ). It is difficult to determine when Indian agents became aware of the first decade presence of the twentieth centurytuberculosis.

By 1854, scrofula, a formerly a rare ailment among Indians, had become quite common among Indians in the Midwest. <ref>Annual Report of the Commissioner of Indian (1854): 60.</ref> Over the next 50 years, references to tuberculosis and scrofula by agency physicians and agents became increasingly common. Agency physicians pleaded for hospitals, sanitarium, and medicine. Other physicians argued that the OIA needed to quickly change Indian behavior because they firmly believed that Indians were primarily responsible for the diseases spread. Despite the growing number of reports from agencies regarding the alarming rates of tuberculosis, the OIA did not take any major steps to limit tuberculosis until in the first decade of the twentieth century. Between 1865 and 1890, agency physicians increasing discussed tuberculosis’s grim toll. In 1865, Dr. A. Coleman, a physician for the Winnebago agency stated the tuberculosis was “their most frequent and destructive disease.” <ref>Annual Report of the Commissioner of Indian Affairs Transmitted with the Message of the President at the Opening of the 1st Session of the Thirty-Fourth Congress 1860 (Washington, 1860): 76. </ref> In 1875, the Fort Berthold agency physician remarked that tuberculosis and scrofula were still claiming victims, but he had that improved methods of providing fuel and “conveying the products of their agricultural labor” would improve sanitary conditions and limit the spread of tuberculosis. <ref>Annual Report of the Commissioner of Indian (1877): 519. </ref> He failed to explain why he took these actions and how they could possibly control tuberculosis. Another physician simply claimed that there were not as many deaths from tuberculosis as he expected, but he makes no attempt to justify or explain his claims. <ref>Annual Report of the Commissioner of Indian (1877): 140. </ref> The 1885 Annual Report showed that there were 875 cases of consumption and an additional 1,809 cases of scrofula. <ref>Annual Report of the Commissioner of Indian (1885): 400. </ref> The commissioners would have been aware of the growing threat simply by reading the department’s Annual Report. In 1894, Dr. A. E. Marden of the Pima Agency reported that tuberculosis was present with “fully half of the Pima families” and that “three-fifths of the deaths” in the agency were a result of either syphilis or tuberculosis. <ref> Annual Report of the Commissioner of Indian (1894): 107. </ref> Another physician, C. H. Kermott of the Devils Lake Agency, claimed that Indians had strumous blood which caused high rates of tuberculosis and scrofula. Joseph R. Finney, the physician for the Fort Berthold Agency, claimed that the health of the Indians was essentially good, except for tuberculosis which had been “a veritable scourge” for a long time. Ambler Caskie, agency physician for the Lower Brule Subagency, acknowledged that tuberculosis “in one or another guise” was death’s “busiest factor.’<ref> Annual Report of the Commissioner of Indian (1894): 218, 223, 282.</ref>  In 1901, the OIA sent out a circular to agencies physicians soliciting their opinions on the health and welfare of their Indians. Despite the sometimes “antagonistic” and contradictory nature of reports, the OIA believed that they convened an accurate impression of Indian health. The reports demonstrated that tuberculosis was “more widespread among the Indians” than whites. The OIA was confused by this response because it believed that the locations of most reservations and the Indians active, outdoor lifestyle should have reduced, not increased the incidence of tuberculosis. Tuberculosis appears to be the exception to the belief within the OIA that if done intelligently a “change from barbarous to civilized modes of life tends to improve health conditions.” <ref> Annual Report of the Commissioner of Indian (1902): 36. </ref> The 1902 report pinpointed nine causes for the high rate of infection:# Failure to disinfect tubercular sputum. # Poor sanitation and lack of cleanliness.# Improper and poorly prepared food.# Intermarriage of Indians of the same tribe.# Intermarriage of Indians and whites.# Taking pupils predisposed to tuberculosis from camp life and confining them in school.# Overcrowding dormitories.# Lack of proper medical attention after infection.# The use of alcohol.<ref> Annual Report of the Commissioner of Indian (1902): 34.</ref> The report focused blamed Indian behavior and culture for their high rates of tuberculosis. Physicians did not understand the nature of the tuberculosis threat at this time. Many physicians believed that tuberculosis could be controlled by sanitation and civilization. They did not understand the transmission or nature of the disease. Therefore, physicians delineated problems they saw with Indian culture which provided convenient explanations which shifted blame from the OIA and themselves. The 1877 report from the Red Lake agency physician blamed the Indians’ “habits” for the prevalence of such diseases as scrofula and tuberculosis. <ref> Annual Report of the Commissioner of Indian (1877): 128.</ref>The 1902 report even stated that Indians were primarily responsible for the lack of proper medical care because “ignorance and superstition” prevented Indians from following the proper courses of treatment.  While it was possible that agency doctors may have neglected tuberculosis patients, it acknowledged that any negligence was understandable under the circumstances. Aside from the overcrowding of dormitories, the OIA did not believe that it was responsible for tuberculosis on reservations.<ref> Annual Report of the Commissioner of Indian (1902): 34-35. </ref> Whether or not there was an internal debate regarding what role the reservations system itself played is questionable. Physicians were more concerned with ventilation and climate than the potential problems posed by concentrating Indians on isolated and primitive reservations. Despite the increasingly urgent reports from Indian agents and physicians regarding the prevalence of tuberculosis, the first comprehensive survey of Native American health did not occur until 1903.<ref> Francis Prucha, The Great Father: The United States Government and the American Indian (University of Nebraska Press, 1984): 846. </ref> The results of the study were enlightening because it indicated that large numbers of Indians were infected with tuberculosis. Despite this evidence, it was not until Francis E. Leupp took over the OIA that someone within the organization took the danger of tuberculosis seriously. Part of the problem may have been caused the longtime belief that alcohol either caused or contributed to the tuberculosis epidemic. In 1905, Leupp took over as the Commissioner for Indian Affairs under Theodore Roosevelt. While Leupp did not take any immediate actions to reduce the number of tuberculosis cases, he did commission a study for the Sixth International Congress on Tuberculosis by Dr. Ales Hrdlicka, a prominent anthropologist, with United States National Museum. Hrdlicka determined after an extensive study of five separate tribes that tuberculosis “threatens to exterminate before long whole units of the Indian race, and deteriorate much of the remainder.”<ref> Transactions of the Sixth International Congress on Tuberculosis In Six Volumes, Vol. 3: Hygienic, Social, Industrial, and Economic Aspects of Tuberculosis, (Philadelphia, 1908): 480. </ref>  Hrdlicka argued that tuberculosis was only introduced to North America with the arrival of Europeans. This late introduction contributed to the high death rates among Native Americans. Data from the OIA, indicated that between 1907-1908, 641 Indian deaths were attributable to pulmonary tuberculosis and another 182 deaths resulted from other forms of tuberculosis out of 81,388 Native Americans. Hrdlicka’s study showed that in some tribes as a many a quarter of all Indians were infected with tuberculosis, but even more distressing is that in some cases, 40 percent of Indians lived a family group where someone was infected. <ref> Transactions, Vol. 3 (1908): 481- 488.</ref>

In 1901Despite years of reports cataloging the high rates of tuberculosis infections, these new statistics finally caught the attention of the OIA sent and clarified the scope of the tuberculosis problem in the native population. David Jones accurately pointed out a circular in Rationalizing Epidemics that the rediscovery of the tuberculosis problem among Indians by Leupp’s administration was just the latest attempt to agencies physicians soliciting their opinions on understand the health scope and welfare nature of their Indiansthe tuberculosis crisis. <ref>David Jones, Rationalizing Epidemics: Meaning and Uses of American Indian Mortality since 1600 (2004): Despite 164-165.</ref> Early twentieth century administrators either ignored or dismissed the sometimes “antagonistic” and contradictory nature validity of reports, all the OIA believed evidence that they convened an accurate impression Indian healthtuberculosis had been present for over a half-century. The physicians and agents reports demonstrated that may have also played a factor in minimizing the tuberculosis was “more widespread among the Indians” than whitesrisk. The OIA was confused by this response because it believed Physicians and agents often claimed that the locations health of most reservations and the Indians activeon their agencies was essential good, outdoor lifestyle should have reduced, not increased the incidence of but then acknowledge that tuberculosiswas a constant problem. Tuberculosis appears to be For the exception to the belief within the OIA that if done intelligently a “change from barbarous to civilized modes most part, unless an agency endured some type of life tends to improve deadly epidemic they would classify Native American health conditionsas good.” The 1902 report pinpointed nine causes for the high rate of infection: (a) Failure to disinfect tubercular sputumfact that Indians suffered from tuberculosis was not unexpected. (b) Poor sanitation Physicians and lack agents appear to have seen tuberculosis as just another aspect of cleanlinessIndian life. (c) Improper and poorly prepared foodLike religion, alcoholism, or medicine men it was seen almost as a vestige of their Indian character, despite acknowledgment by some physicians that tuberculosis was a recent phenomenon among native populations. (d) Intermarriage of Indians of Jones argued that new physicians continually rediscovered the same tribe. (e) Intermarriage problem of Indians tuberculosis and whites.(f) Taking pupils predisposed were “either oblivious to tuberculosis from camp life and confining them in school.(g) Overcrowding dormitories.(h) Lack the existence of past health campaigns or dismissive of proper medical attention after infectionthese past efforts.(i) ” <ref> David Jones, Rationalizing Epidemics: The use of alcohol.164-165</ref>

The report focused blamed Indian behavior and culture Leupp tried to develop a new approach for their high rates of controlling tuberculosis. Physicians did First, Leupp acknowledged that there were simply not understand the nature of the enough physicians to treat every tuberculosis threat at this timepatient. Many In 1897, there were approximately 86 physicians believed that tuberculosis could be controlled by sanitation and civilizationto treat over 180,000 Indians on the nation’s reservations. They did not understand the transmission or nature Instead of the diseasecreating a centrally located sanitarium, Leupp proposed building sanitariums on reservations as needed. ThereforeVarious Indian agents, physicians delineated problems they saw and people who were affiliated with Indian culture which provided convenient explanations which shifted blame from the OIA and themselves. The 1877 report from the Red Lake agency physician blamed the Indians’ “habits” Mohonk Conference had repeatedly proposed establishing a central sanitarium for Indians in the prevalence of such diseases as scrofula and tuberculosisSouthwest. The 1902 report even stated that Leupp opposed creating a central facility because Indians were primarily responsible for the lack of proper medical care because “ignorance “simply unwilling to send their friends and superstition” prevented Indians families away from following home.” <ref> <i>Proceedings of the proper courses Twenty-Fifth Annual Meeting of treatment. While it was possible that agency doctors may have neglected tuberculosis patients, it acknowledged that any negligence was understandable under the circumstances. Aside from Lake Mohonk Conference of Friends of the overcrowding of dormitoriesIndian and Other Dependent Peoples 1907 </i> (Lake Mohonk, the OIA 1907): 38. </ref> While Leupp did not believe that it was responsible for tuberculosis intend “to rush into building camps on reservations. Whether or not there was an internal debate regarding what role every reservation, regardless of the reservations system itself played is questionablepossibility of their success,” instead he sought to build a small number of experimental sanitariums to determine if they could be a success. Physicians were more concerned with ventilation and climate than <ref> Transactions of the potential problems posed by concentrating Indians Sixth International Congress on isolated Tuberculosis In Six Volumes, Vol. 5 State and primitive reservationsMunicipal Control of Tuberculosis, (Philadelphia, 1908): 430-31. </ref>

Despite the increasingly urgent reports from Indian agents and physicians Additionally, he proposed developing a concerted program to educate all Indians regarding the prevalence dangers of tuberculosis, and the possible ways to reduce the first comprehensive survey spread of Native American health did not occur until 1903the disease. The results of the study were enlightening because it indicated that large numbers A key component of Indians were infected with tuberculosis. Despite this evidence, it these plans was not until Francis E. Leupp took over the OIA that someone within the organization took the danger of tuberculosis seriously. Part creation of the problem may have been caused the longtime belief that alcohol either caused or contributed to the tuberculosis epidemic. In 1905, Leupp took over as the Commissioner for Indian Affairs under Theodore Roosevelt. While Leupp did not take any immediate actions Medical Services to reduce centralize the number management of tuberculosis cases, he did commission a study for the Sixth International Congress on Tuberculosis by Dr. Ales Hrdlicka, a prominent anthropologist, with United States National Museumproposed sanitariums and establish education programs.

Hrdlicka determined after an extensive study of five separate tribes Leupp admitted that tuberculosis “threatens to exterminate before long whole units any reform of the Indian racemedical corps would be problematic. The following year, and deteriorate much Dr. Joseph A. Murphy, the first medical supervisor for the OIA, blamed a litany of problems hampering the remainder.” Hrdlicka argued that tuberculosis was only introduced OIA efforts to North America with reorganize the medical services including isolated populations, insufficient resources and the arrival lack of Europeanstrained workers. This late introduction contributed Murphy also argued the Indians compounded these problems because they were ignorant, lazy, unclean, indifferent, unhygienic, unwilling to reform and neglectful of the high death rates among Native Americanssick and the aged. Data from <ref> Proceedings of the OIA, indicated that between 1907twenty-1908, 641 Sixth Annual Meeting of the Lake Mohonk Conference of Friends of the Indian deaths were attributable to pulmonary tuberculosis and another 182 deaths resulted from other forms of tuberculosis out of 81Other Dependent Peoples (1909): 23-24. </ref> Throughout the nineteenth,388 agency physicians often blamed Native Americansfor their own ill health. Hrdlicka’s study showed Only occasionally did they acknowledge that in some tribes as a many a quarter most of all the health problems faced by Indians were infected either a result of their interactions with tuberculosis, but even more distressing is that in some cases, 40 percent Americans or their consolidation of Indians lived a family group where someone was infectedthem onto reservations.

Despite years of reports cataloguing Leupp left his position as commissioner at the high rates end of tuberculosis infections, these new statistics finally caught the attention of the OIA and clarified the scope of the tuberculosis problem in the native population. David Jones accurately pointed out in Rationalizing Epidemics that the rediscovery of the tuberculosis problem among Indians by Leupp’s Theodore Roosevelt’s administration was just the latest attempt to understand the scope and nature of the tuberculosis crisis. Early twentieth century administrators either ignored or dismissed the validity of all the evidence that the tuberculosis had been present for over a half century. The physicians and agents reports may have also played a factor in minimizing the tuberculosis risk. Physicians and agents often claimed that the health of the Indians on their agencies were essential good, but then acknowledge that tuberculosis was a constant problem. For the most part, unless an agency endured some type of deadly epidemic they would classify Native American health as good. The fact that Indians suffered from tuberculosis was not unexpected. Physicians and agents appear pressure to reform to have seen tuberculosis as just another aspect of improve Indian lifehealth continued. Like religionBy 1912, alcoholism, or medicine men it was seen almost as vestige of their Congress began appropriating money specifically to expand Indian character, despite acknowledgement by some physicians that tuberculosis was recent phenomenon among native populationsmedical service. Jones argued that This new physicians continually rediscovered money allowed for a dramatic expansion of the problem number of tuberculosis physicians working for OIA and were “either oblivious contributed to the existence of past health campaigns or dismissive of these past effortsa hospital building spree on reservations.” Leupp tried Congressional appropriations continued to develop grow and by 1917 Congress was appropriating $350,000 a new approach year for controlling tuberculosisIndian health. First, Leupp acknowledged that At the turn of the century there were simply not enough approximately only 90 physicians to treat every tuberculosis patient. In 1897in the OIA, but by 1918 there were approximately 86 physicians to treat over 18087 separate hospitals.<ref> Jones,000 Indians on <i>Rationalizing Epidemics</i> (2004) 170-171.</ref>Reform stalled during the nation’s reservationsFirst World War. Instead After the start of creating a centrally located sanitarium, Leupp proposed building sanitariums on reservations as needed. Various Indian agents, physicians and people who were affiliated with the Lake Mohonk Conference had repeatedly proposed establishing a central sanitarium for Indians American involvement in the Southwest. Leupp opposed creating a central facility because Indians were “simply unwilling to send their friends and families away from home.” While Leupp did not intend “to rush into building camps on every reservationwar, regardless of the possibility of their success,” instead he sought to build a small number of experimental sanitariums to determine if they could be a successful. Additionally, he proposed developing a concerted program to educate all Indians regarding physicians in the dangers of tuberculosis and the possible ways to reduce the spread of the diseaseIndian Medical Service decreased dramatically. A key component of these plans was At the creation start of 1917, the Indian Medical Services to centralize the management of the proposed sanitariums 186 physicians and establish education programs91 nurses. Leupp admitted that any reform of the By 1918, those numbers had dropped dramatically; only 139 physicians and 55 nurses worked for Indian medical corps would be problematicMedical Services. The following year, Dr. Joseph A. MurphyUnsurprisingly, the first medical supervisor for momentum that had been built up during the OIA, blamed a litany of problems hampering the OIA efforts to reorganize the medical services including isolated populations, insufficient resources and Taft administration was completely dissipated by the lack fall of trained workers1918. Murphy also argued the Indians compounded these problems because they were ignorant, lazy, unclean, indifferent, unhygienic, unwilling to reform and neglectful The grossly understaffed IMS was little of no match for the sick and the aged1919 influenza epidemic. Throughout A quarter of the nineteenth304, agency physicians often blamed Native Americans for their own ill health. Only occasionally did they acknowledge that most of the health problems faced by 000 Indians were either a result of their interactions came down with Americans or their consolidation of them onto reservationsinfluenza and 6,270 died from the disease. <ref> Prucha, <i>The Great Father</i>, 854-855.</ref>

Leupp left his position as commissioner at the end of Theodore Roosevelt’s administration, but the pressure to reform to improve The hope that Indian health continuedcould be improved diminished. By 1912, Congress began appropriating money specifically Tuberculosis continued to expand rage on Indian medical servicereservations during the twentieth and it would even spread to Indians who had low incidence rates in 1905. This new money allowed for The Navajos in Arizona had a dramatic expansion lower rate of tuberculosis that was present in the United States general population, but during the first half, the number of physicians working for OIA and contributed to a hospital building spree on reservationscentury climbed dramatically. Congressional appropriations continued to grow and While the mortality rate for tuberculosis had declined by 1917 Congress 1947 it was appropriating $350still seven to ten times higher than other American citizens.<ref> Jones,000 a year for Indian healthRationalizing Epidemics, 170-172. At </ref> While tuberculosis mortality rates declined during from 1900-1950 it would be difficult to claim that reforms instituted during the turn of the century there approximately only 90 physicians in the OIA, but by 1918 there Roosevelt and Taft administrations were 87 separate hospitalsprimarily responsible.

Reform stalled during Ultimately, these reforms did not have the First World Warintended effect, but they did demonstrate a shift in United States policy towards Native American health. After the start While Smallpox epidemics wiped out large numbers of American involvement Indians in the war the number of nineteenth century; government agents, missionaries and physicians in the Indian Medical Service decreased dramaticallyexpressed concern and attempted to inoculate and vaccinate some Indians. At But the start of 1917, the Indian Medical Services 186 physicians and 91 nursesOIA response was essentially reactive. By 1918Instead of preventing smallpox outbreaks, those numbers had dropped dramatically; only 139 physicians would react to each and 55 nurses worked for Indian Medical Servicesevery outbreak. Unsurprisingly, the momentum that had been built up during The failure of the Taft administration OIA to develop a more proactive or extensive policy regarding smallpox was completely dissipated by hampered the fall inherent weaknesses with institutional makeup of 1918the OIA. The grossly understaffed IMS was little Jones argued that the claims by agency physicians at the end of no match for the 1919 influenza epidemicnineteenth century that they effectively reduced the threat of smallpox are questionable.<ref> Jones, Rationalizing Epidemics, 121. </ref> A quarter number of complete reasons completely unrelated to OIA efforts could have played a larger role in reduced mortality rates including less virulent strains of the 304virus,000 Indians came down with influenza and 6increased immunity,270 died from the diseaseor unreported deaths.

The hope that Indian health could be improved diminishedUnlike smallpox, the tuberculosis threat slowly crept up on the OIA. Tuberculosis continued to rage on Indian Unlike smallpox, tuberculosis did not sweep through reservations during the twentieth and kill thousands; it would even spread to slowly integrated itself onto reservations and in Indian schools. While some Indians who had low incidence rates in 1905quickly succumbed after being infected, most victims lingered on for extended periods of time. The Navajos in Arizona By 1880, the OIA had a lower rate become increasingly centralized and capable of tuberculosis than was present in United States general populationmanaging its physicians, but during the first half the century climbed dramatically. While the mortality rate for its response to tuberculosis had declined was hampered by 1947 it was still seven to ten times higher than other American citizensits lack of institutional memory. While tuberculosis mortality rates declined during Despite repeated warnings from 1900-1950 it would be difficult to claim that reforms instituted during its employees, the Roosevelt and Taft administrations were primarily responsible. Ultimately, these reforms OIA did not have the intended effect, but they did demonstrate remember that it had a shift in United States policy towards Native American health. While Smallpox epidemics wiped out large numbers of Indians in the nineteenth century; government agents, missionaries and physicians expressed concern and attempted to inoculate and vaccinate some Indians. But the OIA response was essentially reactiveproblem. Instead of preventing smallpox outbreaks, physicians would react to each new agent, physician, and every outbreak. The failure of the OIA commissioner was surprised to develop a more proactive or extensive policy regarding smallpox was hampered discover the inherent weaknesses with institutional make up presence of tuberculosis among the OIA. Jones argued that the claims by agency physicians at the end of the nineteenth century that they effectively reduced the threat of smallpox are questionableIndians. A number of completely reasons completely unrelated to OIA efforts could have played a larger role in reduced mortality rates including less virulent strains of the virus, increased immunity, or unreported deaths.

Unlike smallpox, Leupp’s reform efforts gained traction because the tuberculosis threat slowly crept up on to Native Americans could no longer be ignored, Roosevelt was interested in health and physical fitness, the OIAwas 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. Unlike smallpox<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 did not sweep through reservations provided a powerful justification to change the behavior and kill thousands; it slowly integrated itself onto reservations and in Indian schoolsculture of Native Americans. While The OIA could increase its control over its charges under the guise of health reform and eliminate some Indians quickly succumbed after being infected, most victims lingered on for extended periods of timetheir more objectionable behavior. By 1880Not only could Indians be taught how to behave in civilized society, but if they failed to follow the OIA had become increasingly centralized and capable OIA’s directives they could claim that their Indian behavior would kill them. ====Conclusion==== The effort at the turn of managing its physiciansthe century to reform the OIA’s healthcare was largely unsuccessful, but it is significant because it pinpoints a clear change in OIA and its response to tuberculosis policies. By 1900 the OIA was hampered by its lack finally capable of implementing broad institutional memoryreforms. Despite repeated warnings from Advances in medicine would have provided compelling reasons to expand its employees, the OIA did medical corps. It should not remember be ignored that it had problemthese reforms occurred when the government’s relationship to Native Americans changed. InsteadBy 1909, each new agent, physician, and commissioner was surprised the United States wanted to discovery control Native American behavior. Tuberculosis provided the presence of tuberculosis among the IndiansOIA with a good reason to educate Native Americans about their potentially dangerous behaviors.

Office <i>Lake Mohonk Conference of Friends of the Indian Affairsand Other Dependent Peoples, Report of the Annual Report Meeting of the Commissioner Mohonk Conference of Indian Affairs to the Secretary Friends of the Interior, Indian and other Dependent Peoples</i> (18311887-19091904)

Lake Mohonk Conference of Friends of the Leupp, Francis E., <i>The Indian and Other Dependent PeoplesHis Problem</i>, Report of the Annual Meeting of the Mohonk Conference of the Friends of the Indian and other Dependent Peoples (1887-1904New York, 1910)

Leupp, Francis E., The <i>In Red Man’s Land: A Study of the American Indian and His Problem, </i> (New York, 19101914)

Eds.Prucha, HildrethFrancis Paul, Martha and Bruce T. Moran, Disease and Medical Care in the Mountain West<i>The Great Father: Essays on Region, History The United States Government and Practice the American Indians</i> (RenoLincoln and London, 19981984)

JonesStuart, David S.Paul, Rationalizing Epidemics<i>The Indian Office: Meaning Growth and Uses Development of an American Indian Mortality since 1600 Institution, 1865 – 1900</i> (2004University of Michigan, Cambridge and LondonAnn Arbor, 1978)