Public Health in the US and Global South - Southern Spaces

Stand & Witness: Art in the Time of COVID-19

Mary Ann Robertson — Tue, 11 Feb 2025 17:57:14 +0000

Introduction In many ways, artists are first responders—to repurpose a term often used in public health. Soon after COVID-19 shutdowns began in March 2020, artists took to their studios, desks, and Zoom to bear witness to the pandemic and the tragic experiences of morbity and mortality that upended millions of lives. Throughout the pandemic, artists … Continued

Encountering COVID

Allen Tullos — Mon, 14 Aug 2023 12:54:29 +0000

Michelle Fishburne and her dog Buddy outside of their RV. White Sands National Park, New Mexico. February 2021. Photograph courtesy of author.

Southern Spaces: Oh, here's Michelle now. Are you in your RV?

Michelle Fishburne: Yes, I am. As a matter of fact, I'm in the RV at Jordan Lake State Park near Chapel Hill. It's about ten minutes from where I raised the kids. I have a twenty-three-year-old who has struggled with long COVID, but has just graduated from UNC. And then we'll go up to Princeton, New Jersey, where I grew up. I'll be housesitting for two weeks.

Q: We've been intrigued by your book, Who We Are Now. It's an important project. The interviews hit powerfully with regard to the loss and heartbreak from COVID. Sometimes now, in the wake of the pandemic, it's possible to think it wasn't really that bad. Life goes on. But going back to the beginnings and to the following many months as you do, the power of this pandemic can't be avoided.

Let's start with what were you doing when it became evident COVID had arrived and was not going away. What were the early months of COVID in 2020 like for you? When was it evident that COVID was not going to be a two week, stay-home-and-then-go-back-to-life-as-normal situation? And how did you develop the project that ultimately became the book?

Fishburne: I think that moment when I realized this was going to last more than two weeks takes me into early April. In January, I had just gotten back from a wonderful vacation in Grand Cayman and I had told everybody all over holiday break how much I was enjoying my job and that I could just pinch myself. It was just a great job. I was a public relations partnership person for Inmates to Entrepreneurs, some people who really, really needed it. I was working on an event at the US Senate and the House of Representatives. We were talking to John Legend, who was working on something similar, about going into a prison with him.

And then on January 17, an unknown virus attacked my eighth cranial nerve and I lost my hearing in my right ear and my vestibular functioning. I began using a walker and learning to adjust to life without hearing in one ear. In February, I bought a prom dress for my senior in high school. She was very excited about the prom and we were waiting to hear back from colleges.

Then my boss, when he saw COVID coming, he was having some struggles. His doctor said to him, "You know, you can't go anywhere." And so he said to me, "I'm going to have to lay you off because I can't go do any of these things that you are preparing." So I was laid off and I thought, "No big deal. I have a law degree from UVA. I have had an illustrious career. I've done wonderful things. I'll find a job." I wasn't panicked. But I submitted eighty-six customized cover letters between the middle of March and the middle of July, and I had nothing.

The lease on the post-divorce house was coming up on July 31. I knew that on August 1 I would have no house, no spouse, no job, and no kids to take care of. And the big critical moment happened in a Target parking lot on June 15, when I had to decide where to have the movers put my stuff. I thought, "What doesn't make any sense for me is to rent a place because I have no idea where I'm gonna have to go to get a job. I've got the motorhome that I homeschooled my kids in for ten months once. All right, I can move into the motorhome." So I put everything in storage.

And then I thought, "Oh, what will I do? Well, I love the Outer Banks. Take the motorhome to the Outer Banks." But then I thought, "Michelle, you can be in hell while you're in paradise. And if you're waking up every day thinking what's your next job, you're kidding yourself. You need a project."

I could drive out to Yellowstone from North Carolina because I've done it before. Yeah, and then I will cry the entire time I go to national parks because I won't be with my little ones anymore and I'll be all by myself.

Then out of the blue came the idea of Humans of New York. And I thought, "Oh, Brandon Stanton interviewed thousands of people in New York, took their photo, got a little snippet of their story, put it on social media." I could do the same thing. I could do Americans of the pandemic. Who We Are Now—that was the name right from the beginning.

I know that when you focus on other people, it's easier not to be afraid. I also know now from somebody I met during the interviews that action is the antidote to fear.

Getting in the motorhome and doing a fast run helped with my fear. And focusing on other people helped with a different kind of fear. But I was also very naive. What made me think I could go out in the middle of the pandemic and find strangers to talk with?

Q: Your project started off the way interviews work. One person leads to another. But you say that your fear did not seem to have been pandemic related. We're wondering, weren't you concerned about catching the virus?

Fishburne: I wasn't. Once again, naivete really helped. I thought, "I'll just wear my mask and I'll be smart. I mean, I could be smart in Chapel Hill. Why can't I be smart in Saint Louis or New Mexico?" But what I found when I got out into parts of the country that were sparsely populated, I started to reconsider what critical thinking meant.

I did take some risks. I'd think, "Okay, this building is big enough and it's just me and this person. They're way over there and I'm way over here." Because if somebody is going to tell you a story, and they've just met you, and it's about their lives, especially since I only ask one question, what I really needed was for somebody to keep going and going, going and going, right in my face. Inviting them to continue and showing interest. The mouth is really important to that. As much as I tried to use just part of my face and some body language, there were times when I needed to take off the mask.

Q: That makes perfect sense. So you talk about how this book got started, but then you traveled a long road. How did you have the momentum to sustain the project?

Fishburne: It became something unto itself. I'm just a project person and I got in the groove. What sustained me was how surprised I was every single time I got to listen to somebody else. I mean, there were genuine moments of surprise in every single interview. For example, when I talked with Anne, who's the wedding planner in LA, I had in my mind all these questions I was going to ask her because I was interested in how weddings had changed. But when I asked her the one question, she went off in a completely different direction that surprised me.

I think the excitement of knowing I was going to hear somebody else's story is what sustained me.

Q: Who was most helpful in encouraging and supporting you?

Fishburne: My mother, who is now eighty-five, was my sounding board and supporter. She also is an editor. I would send her transcripts of the interviews. I would think, "Well, this person's got different parts of their story in different places in this transcript." So I would move it around then send it back to the person and ask, "Is this what you said?" Or they'd say, "Yes, that's pretty much what I said. Or, "I said 'like' too many times. Can you take that out?"

My mom has a PhD in sociology from NYU. I grew up knowing about qualitative and quantitative research. Knowing how you ask the question is so important. We talked about the question a lot. And I needed to have a grid, a mosaic, to do a representation of the US as best I could. We talked about that, too.

Q: How did you organize your project? And, to get a sense of the scale and the scope of all the interviews you did, how much is included? How much is left out? How did you edit?

Fishburne: I was conscious of what was going on geographically. Age, race, gender, class, they're all in the mosaic. Urban, suburban and rural. Religion of different kinds. There's New York City and there's Jackson, Mississippi. I used a reverse order of population of the top fifty cities to make sure that I got different types of urban places in different parts of the country.

One area I leaned into heavily was the performing arts because they rely on a live audience. And other vocations that really had a hard time. I overloaded those a bit because they were compelling.

I interviewed about three hundred people, but only a hundred are in the book. There are more on the website and there are more that never made their way into a story. One of the peer reviewers called the book "elegiac," not a word I had anticipated. He had seen the book without any photos. Originally the contract was for forty photos, but one hundred people. And I thought, "I don't know how I'm going to choose which forty people." This was December 2021. My editor at UNC, Lucas Church, said, "Maybe we shouldn't have photos in the book. Then it would be elegiac." So the book went without the photos; the way it's set up, it kind of tumbles.

In order to get that tumble feel, some of the stories had to be very short. For example, I spent two hours with Luke and Rodney and only used Luke's story about how he got more grief for wearing a mask than holding the hand of his partner. Lucas said the stories need to be between 250 words and about 1,200. The average interview was probably thirty-five or forty minutes. If the average story length is six-hundred words, which takes about three to five minutes to say out loud, the book has about five hundred minutes of material. And I recorded three-hundred times thirty minutes. A lot was left out.

When Who We Are Now was published—I'm just going to say the truth—it did not do very well. We think what happened is that it arrived during COVID exhaustion. Yeah. More recently, the couple of book clubs that have used it have really delighted in it because it helped them reframe what the pandemic was. I know that however-many-years hence everything that I gathered is going to have more value than it has today. I think in seven years, when I'm sixty-seven, I'm going to be a very popular lady at the ten-year anniversary.

Q: As a historical read as compared with a contemporary read, I think you may not have to wait that long.

Fishburne: Sometimes when I pick it up and I read it—like I just opened up to Tina, the grief counselor—it washes over me. It all just comes back and you think, "Oh, yes, we had to go through that. How do you grieve when you can't have the formal process?"

And then when I was re-reading Tina's story, Melissa's story in Corinth, Mississippi came flooding back. Her mom had died during COVID. And Melissa said to me, "I've always thought it odd when a family member passes and you go back to the home and you have the whole spread of food that people bring. I never understood the importance of it until now. Because now when I walk down the street, it can be a beautiful day, months and months after my mom has passed and I'm having a good day and somebody who hasn't seen me since my mom passed will say, 'Melissa, I am so sorry about your mom.' I didn't get the kind of closure you get with everyone there eating food, drinking, talking."

And in a way that's how it was with COVID itself. It came, peaked, and petered out, but we never had the "end," even though the federal emergency was over. But it's not the end. Especially for people with long COVID.

Q: You mention that Who We Are Now came out around the time of COVID fatigue. But how did these oral histories affect you? Did you compartmentalize them as research?

Fishburne: I didn't see the project as research. It was just my life. Even now, when people talk about the pandemic, most people talk about it in ways that are very foreign to me. And the way I talk about it is very foreign to most people. Before I got in the motorhome and drove around the country, I thought I knew the pandemic experience, but that was based on my own lived experience. When I left here in September 2020, I expected to find desolation, depression, and division. I expected it to be very, very negative. What really surprised me was the human tenacity. The pluck. And that's the word that I use now a lot, pluck, which is spirited and determined.

In doing the interviews, I settled on asking only one question: What was your 2020 supposed to be like and what did it end up being? And people could talk about what they wanted to. They talked about what really mattered to them, what really defined this period of time, and what made it very difficult, or challenging, or surprising.

People who were out in areas that are sparsely populated would say, "Oh, I just went on the same way." But I know having been there, that every person was changed during the pandemic. More than normally every person genuinely thought about other people and what they were going through. And then there were people who were not given anywhere near the support they needed.

Top, Michelle Fishburne. Bottom, Inside Fishburne's RV. Photographs courtesy of author.

Q: And what do you say now, with a bit of distance, in terms of the perspective that you have?

Fishburne: My mom keeps telling me that I'm a sociologist and I keep pushing back and saying, no, I'm a collector of stories because a sociologist goes back and looks writ large. And I don't feel qualified to do that. I centered the project on individuals and offered up each story.

Many people had very difficult experiences of having to go in and try to do their jobs under incredibly hard circumstances. Often, they didn't have the equipment, didn't have the guidance, didn't have the support. They were watching people die or people turned people away. They couldn't do the jobs that they had trained to do. Then people would come in and reject what they were trying to do or tell them they were wrong. That was head spinning. Or to walk into a store and nobody would have masks on because it was a state where you didn't need to have a mask. It was like a horror movie. They'd think, "Which one of you am I going to see next week?" A lot of the people that I talked with in the healthcare field felt like they went through a trauma.

I thought about various groups of people who were struggling. For instance, I talked with Emma, a director of a migrant farmworker nonprofit. She told me about how really nobody cared to protect migrant farmworkers and about one man who died alone in a motel room. That never should happen. In Birmingham, I interviewed Anne, who was running a homeless shelter. She said it got to a moment when she had to ask whether people were safer inside the building or outside.

I had just started eastward in Texas when Governor Abbott announced that you didn't need to wear a mask anymore. I'm like, "What the heck, Texas is a long state to have to go through no matter which way you do it, right up or down or sideways." I was going west to east and had to be in the state for four more days. It became very uncomfortable. I am a political animal so it was really hard for me to not lean into that. But I became so fascinated with each individual. And I thought, "We are all in this together."

But let's take Fox News, on cable all over America right now. And I was really angry at a big part of the country. I'm like, how can you think that way? How can you think that way? It's Fox News. People have had it in their homes for so long. Fox was pitting us against each other, making people angrier and angrier. Some really ugly parts of us came out. But when you actually get in and talk to people, that's not who they want to be. That's not what they want to be thinking about it.

The false narrative that COVID was not as serious as it indeed was really impacted our healthcare workers and public health officials. I interviewed people who had significant responsibilities, including top public health officials in major metropolitan areas, and they stepped away or are in therapy. And some decided not to deal with it affirmatively. One doctor I spoke with recently said, "I can't talk about it." She started the dialogue and then she said, "I can't. I've just put this away in a compartment. I just can't touch it. I just can't do it." But then, there was a nurse who cried at the end of the interview and said, "Oh my gosh, I just really needed to talk about that."

I saw and heard America in these different ways. People trying to get through. It was such an odd time. The challenges we faced were very unusual.

Luke, South Carolina

Mask Wearer—November 2020

We have felt more discriminated against for wearing masks than being gay. And that's crazy. In the United States of America, we are getting more nasty comments said to us in a grocery store, on the street, for the fact that we have a mask on than the fact that we're holding hands as two men. That's just hilariously tragic. Like, that's where we're at? You're really going to be angry that I have a mask on? So no shame or foul to people who don't want to wear a mask—just don't call me a sheep because I have a mask. That literally happened to me at the gas pump this week.

Valerie, North Carolina

State Senator—December 2020

Photograph of Senator Valerie Foushee courtesy of author.

On March 3, I was attending a conference in Charlotte, and I got a text message from Health and Human Services. It was, to put it mildly, surprising to get a text from DHHS out of the blue. They were alerting me that the first confirmed cases of coronavirus in the state of North Carolina were in my district. Two residents of Chatham County who had traveled to Italy had contracted the disease. I knew enough to know that this was huge and that we were on our way into something that was not going to be good. I left Charlotte that day rather than staying over the next night because I knew that if there were two cases, there certainly were more.

When I look back at 2020, coming from that point of entry into where we are now, with massive unemployment because of shutdowns, and then the blowback, the pushback, it has been very, very difficult. We knew the shutdowns were not the best thing for the economy, but having this juxtaposition of the economy versus overall healthy communities was hard. The governor was in a tough position.

And in the midst of all of that, we were waiting on the federal government to bring in aid. When people started to lose their jobs and people's rents and mortgages and car payments went into jeopardy, there was no help. And the state system was not equipped to handle the massive number of unemployment insurance claims. Before COVID, we usually had about 800 or so claims a week. Then all of a sudden, we went from 800 to 1,800 to 300,000.

Our constituents were coming to us saying, "I followed everything you told me, Senator. I filed my unemployment claim and I've waited for three weeks now. When I call, nobody answers the phone. When I go online, I get knocked off. When I do stay online, I keep getting the same thing saying I'm not eligible. I know I'm eligible. I can't pay my rent and my family is going to be out on the street. Can you help me?"

How many of those folks do you think I could help? Very few. And then the small businesses were calling and saying, "Senator, we're not eligible for PPP [Paycheck Protection Program]." Or "Senator, you can only apply through certain banks or lending institutions. I've never done this before. I need technical assistance in applying." Or "Senator, I don't have an established relationship with this bank, so they will not even talk to me. So where's our help?" That's so painful.

And then I got the call that brought everything really close to home. It went like this.

"Hey, Valerie, how are you?"
"I'm good, how are you?"
"Not so good. So-and-so died of COViD."
"No, can't be."
"Yes."
"What happened?"
"Well, you know he had surgery. After the surgery, he was sent to a convalescent center. He contracted COVID there and died in four days."

Two days later, his family asked me if I would eulogize him. The ceremony was on May 2. There was no church service, just a graveside service, because of course we had to be outside. Afterwards, my husband and I just drove around because I just was not ready to go inside. While we were driving, I got a phone call. I had noticed at the funeral that my friend's best friend was not there. Well, so I got the call from another friend who was at the funeral. This is how it went:

"Valerie, I know this is going to upset you, but they found Kenneth dead today."
"What do you mean?"
"That's why he wasn't at the funeral."

He was only two years older than me. Kenneth was the editor and publisher of the Carolina Times newspaper, one of the few Black newspapers in our state. So that's no more. That's the end of an era that started with his grandfather, Louis Austin, way back in 1927.

And so, when I quiet myself, those are the things I most vividly remember.

Frank, Louisiana

COVID-19 Ventilator Patient—January 2021

Photograph of Frank courtesy of author.

I was working for a nonprofit organization driving a bus. We would bring older people, people on Medicare, back and forth to doctor appointments, rehab centers. I come home from work, sit down, and watch TV, and all of a sudden, I can't breathe. I called my son and he took me to the hospital. They diagnosed me: "You have COVID." I said, "Man, I ain't got no COVID." The next morning, Dr. M. come and say, "What's the matter?" I'm telling him I come here last night, and the doctor told me I have COVID. I just couldn't breathe. He said, "Are you ready to go home?" I said, "Yeah." So they let me come home. Got home, next day, the same thing. Can't breathe.

They had an ambulance service come get me. They came in here and gave me a breathing treatment and took me to the hospital. And when I got there, on March 24, Dr. M. say he's going to put me in a medically induced coma. I went to sleep on March 24 and when I woke up, it was April 23. I'd been on a ventilator for almost thirty days. The hospital's head of infectious medicine told Dr. M. to unplug me earlier than that, but Dr. M. said, "Man, I'm in the business of saving lives. I'm not going to unplug that man and tell his family he is brain dead, which he's not." When I woke up, I asked my wife when was Easter, and she said, "Boy, Easter been gone." And I say, "Where I been?" And she said, "You been out, asleep." But I didn't remember nothing, and I didn't realize how sick I was until I called my wife and said, "When you come get me?" and she said, "Not right now." I had no idea that I couldn't walk. I had no idea. I couldn't go to the bathroom. I couldn't pull up in the bed. I couldn't use nothing on my body. Hands, legs, feet, nothing. I couldn't do nothing, period, in a vegetative state. I lost the use of everything, man.

They told me they would send me to a rehab center. When I got there, they put me in a room, and the next thing I know, they put me on a second floor by myself and told me that I got COVID again. So I stayed thirty days in there, with everybody masked up, aproned up, gloved up. And they just got me laying there in the bed, can't turn over, can't feed myself, can't do nothing. And nobody could come visit me because I was in isolation. Every time they come in the room, they'd say, "Why are you down in that hole?" "Man, I've been trying to get out of this hole, but I don't have the strength to pull myself up." And then they get mad with you, they'd bring three or four people in and take you out of the hole and then all of a sudden you're back in that hole. Yeah, I mean, I'm laying flat like this for three months. It was supposed to be a rehab center, but they did nothing for me.

I finally got out of there and back to the hospital to do rehab. In two weeks, I was able to stand at the parallel bars and sit in this wheelchair and push up. And then they started walking me, and it was amazing because I hadn't walked in ninety-something days. I got off-balance and never could get the strength. I would walk with a walker and then I would get tired. Like right now, I still get tired fast, I still don't have no balance, still can't taste every now and then, still can't smell every now and then.

I know there's a God 'cause it's a miracle that I am here. The guy's son who does the dialysis tell me, "Mr. Frank, you're a walking miracle." I say, "What are you talking about?" He say, "Frankie, everyone who
was on that floor that had COVID, all of them died but you." And he say, "I know there is a God, you blessed." Then Dr. V., the heart doctor, say, "Man, we really thought you was going to die." Dr. S., "Man, we really thought you was going to die." You know, it's a bad feeling when everybody coming to you, telling you that they really thought you was going to die. And they look at you, "Man, Frank!" and you don't remember. The doctor told me maybe it's good I don't remember. You know? And I'll be asking my wife, "What happened?" And she'll be telling me, and I don't remember. He said, "That's a part of your life that you will never be able to get back." That's fine, I'm here now. I don't wish this on nobody, man.

Emma, Arizona

Migrant Farmworker—February 2021

Photograph of Emma courtesy of author.

Our farmworker population start their days at 2:00 a.m., sometimes earlier. Approximately 15,000 to 20,000 of them cross every day, and the lines on the border can be two or three hours long. They leave early so they can make it here in time to get on the bus and be taken to the fields where they harvest the fruits and vegetables that America eats. This area around Yuma is called "America's Salad Bowl." Our organization provides services to our population, including immigration, housing, parenting, chronic disease prevention, and behavioral health. We're always very busy, so when we started hearing the news that this virus was impacting China and how bad it was, we didn't have a lot of time to think about it. We have a small, rural life, so you don't think a lot about whether something international will hit here. You don't think about how interconnected you are in reference to it. Then at the end of January, we had three cases. It was still not a pandemic at that point, and it was just three cases, so we were thinking, Okay, so three cases. We continued business as usual, no additional precautions, just basic hygiene and all that. When the governor issued a shelter-in-place order, we realized this was serious. Shops started closing and people were running around and piling up food and toilet paper.

After our agricultural season ended, a lot of our farmworkers migrated to California, particularly Salinas, San Joaquin, Santa Maria. Then we started hearing about the pandemic hitting them over there, and even some deaths. One man died in a hotel room by himself. The family knew he was very sick. Nobody was visiting him or giving him food or anything, according to the family. The only contact they had was just through the phone, and all of a sudden, he stopped answering. That's how they realized he had died.

During the stay-at-home order, I had a lot of thinking to do about our office here in Yuma. We have thirty employees, and it's important for personal and cultural issues to have direct, one-on-one contact with the individuals we serve. After the two weeks of stay-at-home, we opened the office back up. My husband used to work at the Health Department's emergency preparedness program and helped us understand the precautions we needed to take. We invested a lot of money in plastic safety barriers and hygiene equipment and products, and we had the offices fumigated every two weeks to sanitize them.

Then there was the question of whether to open the doors or lock them and make people knock. But I felt badly for the elderly or the farmworkers who just needed a form to be read or translated or just basic services like that. So I decided that we were going to have to take a risk and open the doors and do whatever we could and pray to God. We were going to face the threats and fight them because we could not be paralyzed; we have to continue serving our population. So we opened the doors. We let people in just two at a time or one at a time to keep as safe an environment for them and for us as possible.

When the agricultural season started back up again in October, the owners of the farms required the workers to wear masks and did temperature checks, but the buses were loaded just the same as before, everyone crowded in. We did two or three campaigns where we went to meet the loading area for the buses at three o'clock in the morning. We provided tote bags with masks, information, gloves, and everything. Our staff was wearing their gowns and PPE, like they were in a hospital. They were there, facing their fears, because what else could we do? One time we gave out about one thousand bags between 3:00 a.m. and 4:30 a.m.

At some point in the pandemic, we were ground zero in the world for the number of cases. The harvest season and the pandemic season collided. Many of the migrants were sick, but they wouldn't say anything. And a lot of them were young, between eighteen and thirty-six, and didn't show symptoms. Migrant workers don't get fringe benefits or sick leave or anything like that, so a lot of them, especially the H-2A temporary workers, didn't want to be quarantined for two or three weeks. So the sick workers wouldn't say anything and then the whole crew would get sick, but they would not say anything. The employers wouldn't say anything either. They wouldn't want the testing to be done for the workers and the workers wouldn't want to be tested, and so there was like this kind of silent agreement. "Don't ask, don't tell, because we need you and you need us." That is what I have been hearing.

Donna, Georgia

Senior Living Community Executive—July 2021

Donna inside senior living community. Photograph courtesy of author.

The coronavirus came to our campus on March 13. It was one employee and we sent them home. I then went to my boss, the CEO of our company, and said, "Our best strategy right now is to lock in. We'll ask employees to volunteer to live on campus and we'll reward them. And we will just live on campus with our members. It'll be over in two weeks, four weeks max." He never blinked. He was behind me 100 percent.

We didn't call it "lock out." We "locked in" with our members and we kept the world out. We kept coronavirus out. The gate was literally locked, and the only thing that came in and out of that gate was food deliveries, Amazon packages, and Instacart.

I asked for volunteers from our employee body, and sixty people raised their hands immediately.

They included our director of accounting, our moving coordinator, servers, housekeepers, maintenance, security. I took any volunteer who raised their hand. Ended up being seventy-five. The next step was figuring out where people were going to sleep, how we were going to feed employees, and how we were going to keep the operations of our 500-member community running with a staff of seventy-five instead of 300.

Some of the employees lived in model rooms, some lived in rooms on air mattresses, and some people, like me, lived in our health center, with memory care and skilled nursing. I lived in a tent in the community hall.

We left our titles at the door and we all took on different roles, whatever we needed to do to take care of members. Everybody at mealtime became someone that delivered meals. Everyone became someone who would disinfect our common areas. Everyone became whatever we needed them to be in the moment. I don't even know that some of my employees that I was serving with knew I was the COO. They just knew I was that girl that came and made French toast on Sunday mornings and vacuumed the hallways and helped do laundry. It didn't matter because it was all of us together, fighting a common enemy called COVID.

Each day, I would crawl out of my tent, put on my scrubs and ball cap, and go down to see who needed help with breakfast. I might be feeding a member, I might be cooking in the kitchen, I might be just engaging with members around a game of cards or a board game, or painting nails or giving a haircut. By the time breakfast was over, it was already lunchtime, and we were making sure that everybody was eating and getting their meals. Days were filled with making sure our households were clean, members' rooms were clean, laundry was done for everyone, and everyone received their medications. And spending time together, like sitting outside in the courtyard, soaking up the sun, talking and visiting. We did things to keep people entertained, too, like Zoom karaoke. They got such a hoot out of hearing me sing not well.

We were working twelve, fourteen, sixteen hours a day, doing what was needed and trying to keep everyone's spirits up. It was constant motion. I will admit that sometimes it was nice to retreat to my tent and just turn off the device and just be. I have an Energizer Bunny in my body, so it wasn't so much physically exhausting as much as just mentally exhausting. Retreating to my tent and just being by myself was a relief for me.

Two weeks went by and the coronavirus was a hot-fire mess in Georgia. Then four weeks. I got everyone together and said, "If you need to go home, you can. You did what I asked you to do. You committed for four weeks. But I still need you." That's the hardest thing I've ever had to do as a leader, to say, "You have given me what you promised, but I need more." And every time I did that, they would say, "You can count on me." And that's not about me, it's about what we do here. It's about our mission of loving and serving members. We make a promise to them that they never have to leave, that we will move them through the continuum of care as they progress in age, and that we will always take care of them.

This was a wonderful example of seeing people living our mission in action. It was about living it to the extreme. And it was a beautiful thing. Our employees talk about our members as their second family. We got to live that; we got to see it in action.

Employees made a commitment to leave their own families during this crisis so they could take care of the members of their second family. We have one director of nursing who has six kids, a husband, and her mom who lives with them. She talked to her family, and she said, "I feel like I need to do this." And the family said, "Don't worry about us. You go and do this and we will take care of home." I've got a picture of her standing in a window, looking at her family two stories down, waving up at the window. That's powerful commitment.

Growing up, my father was a soldier who went to Vietnam twice. You know, I was watching my father go off and hoping he would come back. With COVID, we knew we could lose members. If we didn't do extreme things like locking in, we could lose members, and we weren't willing to do that. That's what I learned from my father about mission and commitment.

We locked in for seventy-five days. When we did leave, it was because we had the processes in place, the PPE and testing in place, that we needed to make sure we could take care of our members and employees. But it was so interesting on that last day when everyone was leaving, and their families were meeting them in the parking lot. They all hung out in the parking lot talking, like they didn't quite know how to leave. They were a big family of seventy-three sisters and two brothers, needing to leave each other so they could be with their own families.

I was remembering that the other day when we finally were able to open up to family visits for our members. They had not seen their families in person, to be able to touch and hug each other, for over a year. Our staff, because they remember how emotional they were after the seventy-five days, were standing by the doors, crying, while the families were reuniting in the rooms. They knew.

We all walked away changed. You can't go through something like that and not be changed.

Michael, Texas

Bar Owner—January 2021

Photograph of Michael inside his bar courtesy of author.

Bars are places that people rely on in disasters. We're community hubs, a place where people go to be able to contextualize what's going on. So even people who you might not see in a bar regularly, you'll see them in times of crisis because it's a place to get news, it's a place to get out of your house, and it's a place to be around people in your neighborhood or community and reassure yourself that there's other people like you. That things are going to be okay. This particular disaster, though, was one that featured humans gathering as the disaster.

When we had to shut down, we wanted to find a way to be able to serve our clientele. We have a community of people that rely on us to be there for them for whatever reason they need us.

People don't go to bars because they want to get drunk. You can get drunk anywhere. People go to bars because of the basic human need to connect. Given the way modern society is going, there's more and more separation and less and less connection. As grocery stores have gone from local shops to big-box stores, there isn't anyone there to talk with anymore. Same with coffee shops. And now that everything is automated and delivered, you can sit in your home and order everything you need and have every interaction through a computer.

We were very cognizant of the fact that the people that needed us as bartenders were still going to need us, and probably more because they were stuck at home, so whatever drove them out of their house in the first place, that hadn't gone away. And more than that, their social outlet was gone; their community gathering outlet was gone.

We started livestreaming from the bar. We went on every night for an hour, and we did all kinds of crazy things, like we sang karaoke for them, hosted trivia nights, and sometimes made cocktails. I called it a virtual bar, and we were as interactive as possible with people. Sometimes we had guests come on from other places in the country. We ended up building a really, really strong following. Basically, virtual bar clientele would sit at home and have a beer, or they'd have a drink of their own, and they would come and talk to us and they would watch us do silly stuff. We put out a tip jar that they could put money in for the staff. It was surprisingly powerful.

That lasted for a while until Texas reopened again, very early and very unwisely. At the time, we were getting towards the end of whatever resources we had, so we tried to open as safely as possible. That lasted for a couple of weeks until one of my bartenders got COVID. Then I was furious. Furious that we'd been put in the position of even trying to let people in our place. And so, out of pique, I recorded a video that was basically addressed to Greg Abbott, the governor of Texas. It was a plea from a bar in a pandemic. It ended up getting something like half a million views on social media. What a lot of people didn't realize was that bars were excluded from a lot of the aid being offered to small businesses during the pandemic. We were placed in a position of needing to open as soon as we were allowed to, even if it was unwise.

Pretty much right after my video, Texas closed down again because there was a big spike in cases. It was a big spike at the time, but compared to where we are now, it was nothing. That big spike that closed Texas down in July was a fraction of where we are now.

Mike, Florida

Doctor—January 2021

Photograph of Mike courtesy of author.

We have knowledge we learned based on our experiences in past pandemics. Yet, over the last year, we've acted like we learned nothing. That's very disheartening. We have had a lack of direction, and that's been very frustrating. They say that tough times bring out the best in people. It also brings out the worst in people. I have seen benevolence and kindness that was just phenomenal. And I have seen selfishness and self-centeredness that I would never have expected. It's really been an eye-opening experience.

My grandmother used to say, "I've been alive long enough that I have a right to say what I believe, especially if it's true." I'm not even close to her age, but that being said, I also feel that I've been around long enough, and especially around the medical field long enough, more than thirty-five years, that I can be open and honest.

Over the last year, I've become extremely disappointed with people, from leadership all the way down. I've seen political leaders come out and say, "The doctors and the medical experts say this, but I'm going to do what I want to do." And they're supposed to be our leaders. When people say, "I'm not going to follow guidelines because it's an infringement on my rights," I want to ask, "At what point does it become not all about you but all about everybody else and all about society?" Rather than people uniting with a focused approach, which would have led to a lot less suffering and death for many people, many leaders took such a selfish and self-centered approach that it made a bad situation terrible.

And I'll be honest, I would never have foreseen this happening. Previously, I thought that if we had a worldwide pandemic and we knew it and we saw it daily, that we would take the right approach, follow the high road, a consistent approach. We have done none of that.

I work as a hospitalist and do critical care medicine as well as palliative care work. In the Florida panhandle, our COVID hospitalization numbers have been climbing rapidly. From the beginning in March through November, I would have twelve to fifteen patients to work with each shift, with somewhere between two to four COVID patients. Occasionally, I had up to eighteen patients, but that would be a heavy load. On my shift a week and a half ago, I had twenty-six patients, fourteen of which had COVID. COVID-positive patients take about 50 percent more time. So taking care of twenty-six patients was actually like taking care of thirty-nine regular patients. Four of those patients were in the ICU on mechanical ventilators, which takes even more time.

I truly try to provide the best care I can for each patient, but at some point, it's like something's got to give. That is very disheartening to the doctors and nurses and other members of the medical team because we try to give our all, but unfortunately, it doesn't always work. I've taken care of hundreds of patients with this disease, and I've seen dozens and dozens die from it. Yesterday, more than 4,000 people died from COVID nationally. Many of those dying are young, and even more are dying alone.

It's frustrating when the emergency room is packed with COVID patients, the ambulance bays are packed with COVID patients, and we have no ICU beds available for our critically ill patients. I had a patient come in who was not COVID positive, but he was bleeding out from the bottom, terribly, and he had dropped his blood count by two-thirds.

When a COVID patient died, we cleaned the room and then put this guy in there, but he was the only non-COVID patient in the entire ICU. We have other patients coming in who need ICU beds, like patients with acute strokes and severe heart failure. When these patients come in and the hospital tells them, "We don't have any beds, you've got to go to another hospital," that means more time before they're admitted. As they say, every second is brain tissue in a stroke; every second is heart muscle in a heart attack. And we're having to divert these patients because there's no room. And if we can fit them in the hospital but not in the ICU, then they are put on other floors without the equipment and staffing needed to give them the proper care.

I started during the HIV days, so I've been doing this a long time. Now, when I get home after working up to sixteen hours instead of what is supposed to be a twelve-hour shift, I just try to close my eyes, sleep, and let it go. Because I know that I have to go back tomorrow and do it again.

About the Author

Michelle Fishburne is a full-time digital nomad, splitting her time between her 2006 motorhome, Airbnbs, and the occasional housesitting gig.

Public Health in the US and Global South is a collection of interdisciplinary, multimedia publications examining the relationship between public health and specific geographies—both real and imagined—in and across the US and Global South. These essays raise questions about the origin, replication, and entrenchment of health disparities; the ways that race and gender shape and are shaped by health policy; and the inseparable connection between health justice and health advocacy.

Beginning in 2022, the series expands to include 1000-word blog posts, as well as longer commentaries, essays, articles and media productions that address the public health and political implications of the COVID-19 pandemic from multiple perspectives. The series editor for Public Health in the US and Global South is Mary E. Frederickson.

End of the Pandemic? A Grassroots Perspective

sevaa — Fri, 30 Jun 2023 14:41:01 +0000

Endstate ATL's solidarity gathering table offerings including COVID tests and readings on mutual aid. Atlanta, Georgia, January 2023. Photograph by and courtesy of Julian Rose.

In May of 2023, when the World Health Organization downgraded the coronavirus emergency from a global health pandemic to an "ongoing health crisis," the shift made sense in many ways. Most developed nations have made vaccines available for over two years. Shutdowns and enforced quarantines ended, even in holdout nations. The WHO's announcement signaled that other countries, including the United States, would follow suit if they had not already. This move, however, will have material consequences for grassroots charitable organizations across the US. Endstate ATL (ESA), a group I have worked with since 2021, is one of many non-profit groups that will be affected.

In Georgia, the COVID state of emergency officially ended in May 2022, even as it remained in place at the national level. This allowed organizations like ESA to continue our mutual aid work. But when the US announced the end of the Federal COVID-19 Public Health Emergency (PHE) Declaration on May 11, 2023, enhancements to public assistance and social safety net programs ceased. From this point on, groups like ESA once again will have to jump through multiple bureaucratic hoops to obtain the funding necessary to provide care.

Following the global outbreak of COVID in 2020 many governments created temporary measures to extend aid to vulnerable populations. In the US, these included extensions of unemployment benefits, a moratorium on student loan interest and payments, no-cost COVID testing and vaccinations, Medicare flexibility, and opportunities to provide nontaxable disaster relief funds. The national government also released relief funds to individual state governments, although often these funds did not reach the people who needed them.¹Rebecca Riess and Devon M. Sayers, "Alabama Governor Signs Bill to Use Covid-19 Relief Funds to Build Prisons," CNN, October 1, 2021, https://www.cnn.com/2021/10/01/politics/alabama-covid-relief-prison-bills-signed-governor-kay-ivey/index.html. Despite the uneven distribution of aid, many people, specifically children and elders, moved above the poverty line thanks to COVID assistance.²John Creamer, "Supplemental Poverty Measure That Accounts for Additional Government Benefits Lowest on Record at 7.8%," Census, September 13, 2022, https://www.census.gov/library/stories/2022/09/government-assistance-lifts-millions-out-of-poverty.html.

Members of ESA collecting water donations for crisis in Jackson, MS, Atlanta, Georgia, June 2022. Photograph courtesy of ESA.

The flexibility surrounding nontaxable disaster relief funds eased mutual aid work. Mutual aid has a long history in the US and Global South, and the onset of the COVID-19 pandemic witnessed an outpouring of community solidarity towards those in need. Mutual aid stands apart from other charity models because of its non-hierachal emphasis on mutualism rather than models that maintain divisions between givers and receivers. Mutual aid is rooted in reciprocity.

Endstate ATL took advantage of these temporary measures for the betterment and aid of our community members. Rooted in southwest Atlanta with a Black queer feminist politic, ESA's work aims to reach those most marginalized through community building, political education, and mutual aid. Through our Black Power Fund, which pays up to three months' worth of utility bills for Black queer households, and our Pack Provides Programs, which provide household supplies, COVID PPE, and infant essentials including formula, clothing, and sanitary products to caregivers of young children, we seek to step in where the state fails to provide support.

Mutual aid allows organizations to provide immediate care and relief to individuals in need without imposing the bureaucratic processes that often keep aid beyond reach. Under a state of emergency, disaster relief payments are not taxable. As such, ESA, and other groups like it, were able to provide direct aid through a less convoluted system of reporting and disbursement. This allowed us to move funds directly and rapidly to people in need and has been crucial to our ability to substantively support people in a timely way. ESA has covered bills for ten households in the past year, as well as covered a year of utilities for the BARRED Business house, which provides stable, community-owned housing for people recently released from prison. We have been able to report these funds as disaster relief.³"Mutual Aid Legal ToolKit," Sustainable Economies Law Center, Accessed June 22, 2023, https://www.theselc.org/mutual_aid_toolkit.

The efforts of mutual aid groups helped supplement aid where state and local leadership failed. Georgia governor Brian Kemp refused to take the COVID-19 pandemic seriously. In 2020, Georgia was the first state in the nation to relax quarantine restrictions, even as Kiesha Lance Bottoms, the mayor of Atlanta, sought to retain many protective measures. Initial reporting that the virus would largely impact the elderly and immunocompromised, combined with anti-fear government propaganda, engendered a sense of invincibility and an attitude of disregard among many Georgians. As of 2021, Georgia had one of the highest COVID mortality rates in the US, and those most impacted were poor, working class, and people of color.⁴"COVID-19 Mortality by State," CDC, Accessed June 22, 2023, https://www.cdc.gov/nchs/pressroom/sosmap/covid19_mortality_final/COVID19.htm. The refusal of Governor Kemp to implement mandated social distancing or mask requirements, even before vaccines were available, left the entire state population vulnerable to infection. The consequences were devastating, with thousands of unnecessary deaths and debilitating outcomes for those suffering from long COVID.

Pandemic relief payments meant to alleviate the burden of rising interest rates were out of reach for marginalized Georgians. In order to receive national stimulus checks and Kemp's own "special tax credit," individuals needed to have filed and paid taxes for the preceding two years, a barrier that left people who were unemployed or homeless without access to relief.⁵"Gov. Kemp Announces First Round of This Year's Special Tax Refund," Department of Revenue, May 1, 2023, https://dor.georgia.gov/press-releases/2023-05-01/gov-kemp-announces-first-round-years-special-tax-refund#:~:text=Single%20filers%20and%20married%20individuals,a%20maximum%20refund%20of%20%24500.

Free99fridge community food donation and pickup location, Atlanta, Georgia. Photograph by free99fridge.

In response to the pandemic, groups emerged such as Bed Stuy Strong, based in Brooklyn, which created a robust grocery delivery system by first relying on the resources at their disposal before evolving into a program that benefited thousands.⁶Haritha Kumar, "Four Key Takeaways from Mutual Aid Organizing During the COVID-19 Pandemic," Georgetown University Beeckcenter, October 4, 2022, https://beeckcenter.georgetown.edu/four-key-takeaways-from-mutual-aid-organizing-during-the-covid-19-pandemic/. Georgia has similar organizations. Community Movement Builders developed stabilization programs that include rent/mortgage payments as well as groceries in their efforts to impede the gentrification of southwest Atlanta, and Food4Lives a non-profit started by Georgia Tech and Emory students provides food and supplies for the unhoused in the greater Atlanta area.⁷Katie Burkholder, "Housing as a Human Right: Community Movement Builders Organize Against Gentrification," Georgia Voice, April 21, 2022, https://thegavoice.com/today-in-gay-atlanta/housing-as-a-human-right-community-movement-builders-organize-against-gentrification/; "Who are We?" Food4Lives, Accessed June 22, 2023, https://food4lives.org/about.html. Both organizations preceded the pandemic, but their work became much more indispensable in its wake.

The increase in groups doing this aid work was significant, especially in red states where Republican leadership champions laissez-faire government structures for almost everything but reproductive health, policing, and surveillance. Pandemic or no pandemic, people need help. However, smaller aid groups face difficulties in keeping the work going. ESA has primarily been funded by grants, a funding model that is not easily sustainable. According to one of our members, "A significant struggle we've faced since the end of the COVID-19 pandemic is the philanthropic and public perception that the conditions for folks have changed enough that mutual aid is not necessary even as we continue to field a significant number of requests." Further, all members participate on a volunteer basis, spending much of our time otherwise as graduate students, teachers, doulas, herbalists, and nonprofit workers. Over the last two years, many of us have faced our own destabilizing events, financial uncertainty, bouts of COVID, and family loss. The ability of small groups to come together and push to make a difference in their communities—despite personal difficulties and decreasing assistance from governing bodies—should inspire more activism. But the question remains, how can we continue this work when governmental policies have resumed restricting social safety nets while offering few, if any, alternatives?

Changing policy is one problem organizers face, burnout is another. Studies have suggested that we approach "burnout as a part of activism and as influenced by the organizational context, rather than as something that individual activists experience outside of activism."⁸Maria Fernandes-Jesus et al., "More Than a COVID-19 Response: Sustaining Mutual Aid Groups During and Beyond the Pandemic," Frontiers in Psychology 12 716202, October 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8563598/. However, as young Black people organizing in the South, my colleagues and I experience burnout from many directions. We deal with the stress of everyday life, as well as the difficulty of doing our solidarity work, with constant reminders from government leadership that our goals are at odds with theirs.

With the COVID state of emergency ending in the US, aid provided by organizations such as Endstate ATL becomes taxable, dramatically altering the way funds can be mobilized, as well as the process that recipients must go through to receive support. Charitable tax deductions are reserved for individuals and corporations who donate money to qualified charities.⁹Up until December 2021, entities meeting these requirements were able to claim as much as 100% of their AGI in charitable tax write offs. "CARES Act Charitable Benefits Not Extended For 2022," Stanford Giving, March 14, 2022, https://giving.stanford.edu/stories/cares-act-not-extended-for-2022/. Because ESA puts money "directly" in the hands of marginalized people, such direct contributions to individuals are not tax-exempt. The COVID state of emergency allowed groups like ESA to move funds to individuals more freely—on an emergency basis. The end of the state of emergency means we must restructure our aid programs. The beautiful thing about mutual aid is that even if one group burns out, another group can and likely will step up right behind to fill the gap. In this way, the work continues. We never stop.

About the Author

Ra'Niqua Lee writes to share her particular visions of love and the South. She earned an MFA in fiction from Georgia State University, and she is currently at Emory pursuing a PhD in late nineteenth/early twentieth century African American literature with a focus on spatial and Black queer feminist theories. Her fiction has appeared or is forthcoming in Cream City Review, SmokeLong Quarterly, Indiana Review, Passages North, Best of the Net 2023, Best Small Fictions 2023, and elsewhere. In 2021, the Georgia Writers Association awarded her the John Lewis Writing Grant for fiction. Her flash collection For What Ails You is forthcoming from ELJ Editions.

Acknowledgments

Many thanks to my colleagues. Without their collaborative support, I would not be able to do this work: Julian Rose, Britni Ruff, Christina Foster, Michelle, Jovan Julien, and extra thanks to Hugh Hunter for his early edits.

"Miking" Against Covid in Bangladesh

sevaa — Mon, 22 May 2023 11:41:39 +0000

Bangladesh. Map by Mysid. Courtesy of Wikimedia Commons. Creative Commons license: CC BY-SA 4.0.

As the world moves into its fourth year since the advent of COVID-19, the pandemic remains a broad public health concern. It is necessary to teach Covid-appropriate behaviors and build public confidence in vaccines and boosters to address new strains of the virus. Across the globe, localized Covid pandemic response projects should complement conventional approaches to preparedness. Community Support Team Dhaka (CST Dhaka) and Community Support Team Cox's Bazar (CST Cox's Bazar) are two projects implemented by the health program of BRAC, a Bangladesh-based NGO.

Bangladesh, the eighth-most populous country in the world (169.4 million people), is a developing country located in South Asia with a 2021 gross domestic product per capita of $2,458. The country has achieved significant progress in reducing maternal, infant, and child mortality rates, decreasing malnutrition, improving immunization coverage, and eliminating infectious diseases like polio. However, it faces emerging health challenges, including the growing burden of noncommunicable diseases, heightened vulnerability to disasters and environmental hazards, and the threat of health emergencies during disease outbreaks such as COVID-19. Bangladesh's health services are centralized and urban-centric.¹There are only 1.1 doctors per 10,000 people in rural populations in Bangladesh, while there are 18.2 doctors per 10,000 people in urban areas. Taufique Joarder, Lai B. Rawal, et al, "Retaining Doctors in Rural Bangladesh: A Policy Analysis," International journal of Health Policy and Management 7, no. 9 (2018): 847–858. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186485/. The country also faces shortages of well-equipped healthcare facilities and healthcare workers. The health financing system in Bangladesh suffers from a lack of adequate funding, absence of appropriate health insurance, and a large dependence (74%) on out-of-pocket payments.

A project volunteer showing a Covid-19 info card, Bangladesh. Photograph courtesy of Abdullah Al Kafi.

BRAC, founded in 1972, is the largest non-governmental organization in Bangladesh involved in a variety of sectors including public health, education, microfinance, and livelihood support. It currently employs over 100,000 people across Bangladesh and ten countries. Its Health, Nutrition, and Population Programme (HNPP) has been a global leader in developing and scaling up locally-based health worker programs for the rural population. With support from the Foreign, Commonwealth & Development Office (FCDO), the World Bank, and the United Nations Population Fund (UNFPA), the organization implemented two COVID-19 response projects in Dhaka and Cox's Bazar (two of the high-risk districts identified by the World Health Organization after analyzing infection rates in different districts of Bangladesh). BRAC initiated several creative approaches in these locations to tackle the spread of COVID-19 at the height of the pandemic.

"Miking" in Local Dialects

Loudspeaker announcements broadcasting messages on vaccination in Cox's Bazar city, Bangladesh. Photograph courtesy of Abdullah Al Kafi.

Playing health messages through mobile loudspeakers (locally known as miking) has been around for decades. After the initial round of miking in Cox's Bazar, however, the volunteers and area managers heard from local representatives that the messages in mainstream Bengali were not effectively reaching the people. Here, the Chatgaya/Chittaingya dialect is the primary oral language. Subsequently, the Cox's Bazar project engaged a local voiceover specialist to develop messages in Chittagonian dialect which enhanced the effectiveness of the 849 miking sessions conducted in the region, substantially improving the local population's understanding about vaccination.

Info Cards

A common request received by the field staff (community health workers, volunteers, and area managers) was for comprehensive materials to complement the messages disseminated verbally. In addition to the usual posters, stickers, and leaflets, BRAC designed tri-fold cards with detailed information on vaccination, handwashing, mask wearing and disposal, and instructions about taking care of people with comorbidities. Info cards were distributed to local change-agents such as market committee members or transport hub leaders to help sustain best practices. The cards garnered a positive response from the public.

Collaboration with Sisimpur

As schools in Bangladesh reopened after an eighteen-month shutdown, BRAC collaborated with Sisimpur—a local adaptation of children's television series Sesame Street—in creating an educational video about COVID-19 featuring the Sisimpur characters. Originally developed for the Dhaka project, this video ran on social media platforms and was shown at some three hundred schools. This intervention was entirely novel for many students and schools, and Sisimpur was also warmly received by parents and teachers. Unfortunately, this project began halfway through BRAC's wider Covid education initiatives, and needed more time and closer supervision.

Comics and Murals

Long perceived as reliable messengers in Bangladesh, local artists often translate crucial information into personable and understandable forms. Working with these artists, BRAC delivered COVID-19 information to schools in an engaging way. Renowned cartoonist Morshed Mishu developed wall murals in Dhaka and Cox's Bazar and 200,000 copies of a comic strip were distributed among schools and madrasas.

Faith Leaders' Endorsement

Faith leaders have addressed misinformation and influenced health behavior changes with a high degree of success. During the biggest Ebola outbreak in history, interfaith leaders were instrumental in delivering health messages in parts of West Africa that governments and NGOs could not reach. As credible sources of information, they worked actively on quashing rumors regarding Ebola and encouraged people to listen to government directives and the health workers.²A 2020 study by Afrobarometer revealed that across 34 countries in Africa, faith leaders are more widely trusted than any other public leaders. Brian Howard, "Religion in Africa: Tolerance and Trust in Leaders are High, but Many Would Allow Regulation of Religious Speech," Afrobarometer Dispatch no. 339 (2020), https://afrobarometer.org/sites/default/files/publications/Policy%20papers/ab_r7_dispatchno339_pap12_religion_in_africa.pdf. Early in the COVID-19 epidemic, BRAC teamed up with Islamic Foundation Bangladesh (IFB) and Bangladesh Baptist Church Fellowship (BBCF) to train their directors on best practices. Local representatives of UNICEF, who had previously engaged Muslim leaders in another health project, facilitated the IFB partnership. BRAC provided online training to IFB field supervisors and BBCF pastors via Zoom, addressing questions and rumors. This collaboration provided 3,400 faith leaders with awareness messaging, 860,000 reusable masks, and 350,000 leaflets.

Faith leaders and scholars such as Leor P. Sarkar (General Secretary of the BBCF), Gazi Sanaullah (Islamic scholar), and Pragyananda Bhikkhu (Assistant Director, Ramu Central Sima Bihar) endorsed preventive measures and appeared in short social media videos in support of wearing masks, maintaining social distance, washing hands, and taking vaccines.

While the Dhaka Community Support Team emphasized partnerships with selected faith-based organizations, Cox's Bazar sought to unite all the faith leaders from the intervention areas—Muslim, Buddhist, and Hindu—under one roof for knowledge sharing and collaboration. These meetings included a moderated session that provided equal opportunity to representatives of each religion to share the lessons they had learned. In Ramu, faith-based organizations overcame the silos between their work, meeting to formulate policies for combating the spread of vaccine misinformation. Volunteers working with faith-based groups increased both the reach and acceptance of the interventions.

Faith leader Reverend Leor P. Sarkar speaks on Covid,
Bangladesh. Translated from original Bengali.

Faith leader Gaji Sanaulla Rahmani speaks on Covid,
Bangladesh. Translated from original Bengali.

Interactive Popular Theater

BRAC's popular theater groups under its Social Empowerment and Legal Protection program (SELP), have performed about a wide range of topics such as gender equality, child marriage, violence against women, health, migration, and road safety across sixty-one districts since 1998. To raise COVID-19 awareness, the Cox's Bazar project organized 160 performances, despite dealing with some local challenges. For instance, the acceptance level of popular theatre was lower among the conservative Muslim population and the shows were more difficult to organize in hard-to-reach locations. Social distancing was more challenging when children made up the majority of the audience.

Popular theater groups singing about vaccination, Ramu, Bangladesh. Photograph by and courtesy of Abdullah Al Kafi.

Findings from surveys and focus group discussions indicated increased awareness about COVID-19 symptoms, modes of transmission, and prevention measures (handwashing, mask wearing, social distancing) and vaccination across all intervention areas. Local knowledge about the existence of the virus and its spreadability increased.³Compared to the baseline, 26% more people knew that both hands need to be washed, 11% more people knew not to use a damp or damaged mask, whereas 7% more people knew not to wear the mask loosely. 8% more people reported knowing that the Covid-19 vaccine improves the body's immunity against the virus. School surveys revealed that 10% more students reported that face-to-face communication with the infected was the mode of transmission and almost 4% more knew it could be transmitted through coughing and sneezing. Encouraging accessible, engaging, and equitable approaches to public health communications has led to an increase in the uptake of COVID-19 preventive practices, as well as a reduction in barriers to vaccine confidence.

COVID-19 continues to pose a significant public health concern for many countries, like in India. While Bangladesh faces various health challenges and lacks adequate healthcare facilities and workforce, local NGOs like BRAC have played a significant role in addressing the pandemic's impact through introduction of localized initiatives like miking, info cards, Sisimpur PSAs, comics and murals, and faith leaders' endorsement to strengthen COVID-19 response. Such programs are essential in complementing conventional approaches to pandemic preparedness and mitigating the virus's spread. While these initiatives may be unique to Bangladesh, their successes can provide important lessons for other countries in terms of pandemic response and preparedness.

About the Author

Monzur Morshed Patwary is a public health practitioner with over eleven years of professional experience. As a senior program manager at BRAC, he has led several large-scale projects involving COVID-19 response, maternal and child health, and digitalization of training for community health workers. He has also collaborated with UN organizations and international donors such as USAID, FCDO, DANIDA, and GAC and helped mobilize high-value grants through project design and proposal development. Monzur represents Bangladesh on global platforms such as ParisWHO, Global Leadership Forum and HPAIR Harvard Conference. He completed the Hubert H. Humphrey Fellowship at Emory University-Rollins School of Public Health and is currently pursuing his professional affiliation at The Task Force for Global Health.

CDC in the Pandemic's Wake

sevaa — Wed, 15 Mar 2023 13:34:45 +0000

Commentary

Multiple COVID-19 waves have left in their wake compelling evidence of long overlooked gaps in pandemic readiness and responsiveness. The primary lesson for the US public health and healthcare sectors is that this deep-rooted ignorance took a huge toll on their ability to contend with a novel, rapidly spreading, and lethal contagion. As historian Peter Burke recently noted: "Many vivid examples of the consequences of ignorance come from the history of diseases."¹Peter Burke, Ignorance: A Global History (New Haven: Yale University Press, 2023), 189. COVID-19 is a current case in point. What was missed or mismanaged in the run up to the pandemic and during its catastrophic course will, if left unexamined and uncorrected, lead to enormous suffering and loss in additional public health crises. In this commentary, I want to elaborate on how institutionalized ignorance affected the Centers for Disease Control and Prevention's (CDC's) response and what can and should be done to learn from the agency's mistakes, with the goal of avoiding a repetition.

Exterior view of the Tom Harkin Global Communications Center, known as Building 19, at the Roybal Campus of the CDC, Atlanta, GA, June 23, 2013. Photograph by James Gathany. Courtesy of Wikimedia Commons. Image is in the public domain.

A thorough and fully transparent probe of CDC's recent history is warranted, one that scrutinizes "institutional obliviousness, under a succession of agency directors and programmatic leaders, to basic gaps in readiness and responsiveness that became glaringly obvious during the pandemic and contributed to numerous missteps in the US response to COVID-19."²Daniel Pollock, "COVID-19 Lessons in Ignorance," Southern Spaces, April 28, 2022, the first in a public health series covering the pandemic: https://southernspaces.ecdsdev.org/2022/covid-19-lessons-ignorance/. Far too much had to be cobbled together on the fly in early 2020 largely because of prior organizational neglect. And far too little has changed three years later, even as CDC moves ahead with its latest—to date, largely upper echelon—reorganization.³Centers for Disease Control and Prevention, "CDC Moving Forward Reorganization: A Notice by the Center for Disease Control," Federal Register 88, no. 29 (2023): 9290, https://www.federalregister.gov/documents/2023/02/13/2023-02929/cdc-moving-forward-reorganization.

Yes, SARS CoV-2 is a novel pathogen that spread rapidly, wreaked extraordinary devastation, and evolved quickly. Lots of impromptu learning about the virus and measures to contain or counter was necessary. However, pandemic warning signals abounded for years, and many assets CDC needed to function optimally in public health emergencies—as well as in non-pandemic times—were long overlooked or chronically under supported by virtue of the agency's own strategic planning, programmatic priority setting, and discretionary funding decisions. In surveillance and data science, for example, CDC did not fully mind and mend critically important gaps in electronic case reporting, immunization information systems, forecasting and outbreak analytics, and tools and dashboards for data visualization.

Certainly, factors largely beyond CDC's control had major impacts on the agency's performance. Besides the virus itself, CDC had to contend with (1) a coterie of federal government executives, most notably the 45th President, who failed to respond effectively and exerted unprecedented political interference; (2) a legacy of outbreak responses in the United States that are highly decentralized and contingent on a variety of situational circumstances; (3) longstanding constraints on CDC's public health authorities; and (4) chronic underfunding of public health programs at all levels of government. Each of these factors helps explain limitations, gaps, and shortcomings in the agency's performance. However, to leave the matter there would mean overlooking the impact of internal organizational factors that remain largely under CDC's control. Whether the agency has fully reckoned and responded to its internal problems is an open question that warrants much more attention.

(Left to Right) Secretary of Health and Human Services Alex Azar, President Donald J. Trump, and Director of Centers for Disease Control and Prevention Dr. Robert R. Redfield listen as Dr. Stephan Monroe, CDC associate director, describes the upcoming tour of CDC grounds, Atlanta, GA, on March 6, 2020. Photograph by Shealah Craighead. Courtesy of Wikimedia Commons. Image is in the public domain.

"To be frank, we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications," CDC Director Rochelle Walensky acknowledged in August 2022. However, the full CDC Scientific and Programmatic Review report that prompted Dr. Walensky's critique remains under wraps and not publicly available. Many months after the report was completed, all that CDC has published is a high-level summary and set of recommendations.⁴"CDC Moving Forward Summary Report," Centers for Disease Control and Prevention, Last reviewed September 1, 2022, https://www.cdc.gov/about/organization/cdc-moving-forward-summary-report.html. What was covered in the review, its methods and findings, and how conclusions were reached are shrouded in secrecy. Sequestering the report does not bode well for efforts to learn from CDC's COVID-19 experience and improve the agency's performance. Instead, CDC leaders have opted for a form of knowledge concealment that serves to perpetuate institutionalized ignorance.

For those of us who are deeply concerned about where the agency is headed, this is a fraught moment, yet organizational dysfunctions, mishaps, setbacks, and downturns are not necessarily points of no return. Learning from the COVID-19 pandemic and CDC's response to it can lead to changes that help revitalize the agency. Concealing the recent scientific and programmatic review report is not a good start along the path of organizational learning.

The CDC's Emergency Operations Center (EOC), Atlanta, Georgia, 2020. Photograph by and courtesy of Jim Gathany. Image is in the public domain.

"Organizational learning," according to a leading researcher in the field and her colleagues, "is a process through which experience performing a task is converted into knowledge, which, in turn, changes the organization and affects its future performance."⁵Linda Argote, Sunkee Lee, and Jisoo Park, "Organizational Learning Processes and Outcomes: Major Findings and Future Research Directions," Management Science 67, no. 9 (2021): 5399–5429. The process should include gathering and moving information across organizational boundaries; eliciting and using multiple viewpoints; acknowledging hierarchies, policies, and practices that have not worked; and trying new approaches that have a higher likelihood of success. A prime example of an opportunity to learn from the COVID-19 experience is reckoning with how the agency organized, staffed, and operated its emergency response. From my perspective, the structure and process defects were profound and persistent, with the upshot that returns on the extraordinary time and effort so many CDC responders committed to their tasks fell well short of what would warrant use of all those precious resources. What purposes did the CDC response serve? Did the agency achieve those purposes? What was necessary to get the job done? Among the more specific questions about CDC's emergency operations is whether all the work involved with preparing, clearing, and presenting extensive PowerPoint slide decks in daily COVID-19 briefings was worthwhile. What were the benefits and at what cost?

Most of CDC's performance problems during the pandemic were the legacy of organizational neglect, not the exigencies of a novel corona virus or other external factors. The botched laboratory test rollout, flawed testing guidance, poorly prepared public health guidelines, confusing messaging, misguided mask recommendations, multiple data and analytic deficiencies, staffing shortfalls, and publication delays are traceable to assumptions widely held within the agency about institutional readiness coupled with longstanding inattentiveness by CDC directors and programmatic leaders to known or partially understood gaps. That CDC was not ready to go live sooner with a publicly facing, state-of-the art COVID-19 data display epitomizes what the agency had neglected. Instead, other data visualization websites, most notably Johns Hopkins University's dashboard, served as the go-to destinations for pandemic surveillance data. The reputational damage to CDC is severe and could have been avoided.

So much had to be launched or improvised by CDC in crisis mode because so much had been taken for granted or ignored for such a long time. Some additional examples from my own experience: When I joined the CDC response as Deputy Incident Manager for data and surveillance at the end of March 2020, I was surprised to learn that the agency had yet to introduce a process to enable secure data access and distribution of COVID-19 data sets to prospective data users who had been identity-proofed by the U.S. Department of Health and Human Services. Further, CDC had taken no steps to inventory and document relevant data sets and make provisions for sharing de-identified data with news organizations, one of which moved forward with a lawsuit to gain access to COVID-19 case data aggregated by CDC. The agency should have closed these basic gaps in data provisioning well before the pandemic, not during the throes of it. The only explanation of this blunder that I can think of is lack of forethought and follow through.

Becky Gonzalez, left, and her long-time friend, Mary Lou Samora, a 71-year-old COVID-19 patient at Providence Holy Cross Medical Center, Los Angeles, CA, December 17, 2021. Photograph by Jae C. Hong. Courtesy of the Associated Press.

SARS CoV-2 is not the first viral respiratory pathogen to emerge and spread across country borders in the twenty-first century. While each international outbreak has presented a unique mixture of causes and consequences, they also have had much in common. That commonality places a premium on learning from each event and applying take-away lessons in a thoroughgoing way. What's ahead epidemiologically can surpass what's happened already in terms of complexity and magnitude, and that only heightens the stakes for CDC's organizational learning and pandemic preparedness.

While there are many pockets of CDC excellence, the organization, most notably because of its COVID-19 response, has taken multiple hits—some reflect ignorance about the agency's mission, operations, opportunities, and constraints but others are knowledgeable, on target, and of high consequence. There is much to do—and soon. We need to know more about CDC's performance gaps and shortcomings, and how to remedy them. To that end, instead of treating the full details of CDC's COVID-19 mistakes as a sequestered resource, it behooves CDC leaders to build on, transfer, and most importantly, act on what has been learned.⁶Jeffrey Pfeffer and Robert I. Sutton, The Knowing-doing Gap: How Smart Companies Turn Knowledge into Action (Cambridge, MA: Harvard Business School Press, 2000): 261. In the pandemic's wake, a much stronger commitment to organizational learning by CDC will provide the quickest and most effective solutions to the institutionalized ignorance that placed the public and the agency at risk.

About the Author

After completing the CDC's Epidemic Intelligence Service training program in 1986, Daniel Pollock worked as a medical epidemiologist at the agency for 35 years. Dr. Pollock led the CDC unit responsible for national surveillance of healthcare-associated infections from 2004–2021, and he served in CDC's COVID-19 emergency response in the spring of 2020 as the Deputy Incident Manager for data and surveillance.

Covid Light and Darkness Alike

Allen Tullos — Wed, 05 Oct 2022 15:16:54 +0000

We can all remember when the Covid reality fully hit, that moment when we were forced to confront the stark news and the hard arrival of abrupt change. I remember exactly where I was standing when it all sunk in. I was photographing in Mississippi in early March 2020, on spring break from teaching at Duke, my near annual pilgrimage to get back to making pictures. I had been washing my hands incessantly as I drove from North Carolina to Mississippi, always keeping sanitizer close, trying to puzzle out how to respond to the invisible, infectious threats, and how to stay safe and productive. Like so many photographers, I was trying to make images of the visible and invisible viral effects of this unknown storm. Mostly photographing outside, I worked to try to understand and accept this gathering mystery. An email arrived announcing that spring break would be extended another week, all Duke classes would move on line, and with that began a collective retreat into the virtual and isolated refuge of distance. We would stay at six feet and farther, adapt and adjust, do whatever needed to be done.

There are no truly universal feelings about the shared experience of Covid, but there is, I believe, a collective impression that we’ve all experienced a tangle of time, a displacement from the normal markers and seasons, a confronting of the inequities that accompany a pandemic, a fuller view of vulnerability and mortality. Amidst the diversity of ways we’ve managed the many interruptions and anxieties, the unknowing and the seeming to know, there’s shared understanding of a narrowing and shortening of our movements, maps, and itineraries. Through it all I’ve photographed. Sometimes in direct response to covid—with a sense that there’s something rare and exceptional about the moment—and at other times just doing what I always do.

I’ve come to understand that any photograph made during Covid is a ‘Covid photograph.’ To be sure, I recognize that some images made over the last couple of years are directly observing a response to Covid. Images of health care workers, vaccine researchers, shuttered businesses and empty offices, empty stands at athletic events, all of those and more are deeply identified with the pandemic. But so are all the other images, photographs made with full recognition of our altered routines and attitudes, the lightness and darkness that we observe having shifted. There is no way to separate the act of making pictures from a recognition of the injuries caused by the weather that surrounds. The Covid weather tightened our geography, led to a perspective that sees closer and perhaps with more intimacy, intended or not. Anytime we find ourselves looking at a singular sameness, we hope for deeper clarity and precision of sight. If there is hopefulness here, it is in the realization that there’s forever more to see in the most ordinary; another way to compose, to transform the world into an image, to confront the temporal luminance before us in an otherwise dimming day.

There is a recognizable evil tyranny in assuming that our worlds never fall apart, in taking the day-to-day for granted. We like to think we know better (“Here today, gone tomorrow,” and all that). Whatever we know doesn’t prevent us from the familiar condition that when at home the protagonist so often wishes to be away, and when away the deepest wish is often to be at home. Making pictures throughout Covid has been energized by an acceptance of a shrinking physical daily terrain, of being isolated in smaller places. My reply was to busy myself by affirming through images the fullness of wonders and contradictions close to home.

Photographers—and photographs—get all they have from embracing the darkness and light equally, shadows adjacent to highlights, contrast next to flatness, what is present alongside what has gone, low fertile valleys juxtaposed with the dry peaks. The opposites are coequal and mutually dependent, elemental to how we see. The last line from Psalms 139:12 is “the darkness and the light are both alike to you.” Alike, I argue, in that both arrive daily, and perpetually offer us a frontier to explore, render, and move to reveal, a time and place to take full visual advantage of the mystery and the uknown.

About the Author

Tom Rankin is Professor of the Practice of Art and Documentary Studies at Duke University where he directs the MFA in Experimental and Documentary Arts. For fifteen years he was director of the Center for Documentary Studies at Duke. His books include Sacred Space: Photographs from the Mississippi Delta (Jackson: University Press of Mississippi, 1993); Deaf Maggie Lee Sayre: Photographs of a River Life (Jackson: University Press of Mississippi, 1995); Local Heroes Changing America: Indivisible (New York: W.W. Norton & Co., 2000); One Place: Paul Kwilecki and Four Decades of Photographs from Decatur County, Georgia (Chapel Hill: University of North Carolina Press, 2013); and Goat Light (Durham, NC: Horse and Buggy Press, 2021) coauthored with Jill McCorkle. His photographs have been collected and published widely and included in numerous exhibitions. A frequent writer and lecturer on photography, culture, and the documentary tradition, he is the general editor of the Series on Documentary Arts and Culture with the University of North Carolina Press.

Public Health in the US and Global South is a collection of interdisciplinary, multimedia publications examining the relationship between public health and specific geographies—both real and imagined—in and across the US and Global South. These essays raise questions about the origin, replication, and entrenchment of health disparities; the ways that race and gender shape and are shaped by health policy; and the inseparable connection between health justice and health advocacy.

Beginning in 2022, the series expands to include 1000-word blog posts, as well as longer commentaries, essays, articles and media productions that address the public health and political implications of the COVID-19 pandemic from multiple viewpoints. The series editor for Public Health in the US and Global South is Mary E. Frederickson.

COVID-19 Vaccine and the Right to Public Health

sevaa — Wed, 11 May 2022 15:10:33 +0000

Commentary

As a public health professor at the University of Michigan, I've encountered opinions about the Covid vaccine in my own family that reflect mistrust and hesitancy. I can understand this.¹Melissa Creary, "Bounded Justice and the Limits of Health Equity," Journal of Law, Medicine & Ethics 49, vol. 2 (2021): 241–256; Creary, "Legitimate Suffering: A Case of Belonging and Sickle Cell Trait in Brazil," BioSocieties 16 (2021): 492–513; Creary, "Biocultural Citizenship and Embodying Exceptionalism: Biopolitics for Sickle Cell Disease in Brazil," Social Science & Medicine 199 (2018): 123–131; Melissa Creary, Paul Fleming, Sheeba Pawar, and Amel Omari, "Leading with HEART: Working Toward Health Equity with Anti-Racist Teaching," The Pursuit, University of Michigan School of Public Health, April 29, 2021, https://sph.umich.edu/pursuit/2021posts/leading-with-heart.html; Creary, Paul Fleming, Trivellore Eachambadi Raghunathan, "The Impact of Race on Data." University of Michigan Population Healthy Podcast, February 16, 2021, https://sph.umich.edu/podcast/season3/the-impact-of-race-on-data.html; Creary and Anne Pollock, "How COVID-19 has highlighted racism as a health risk." King's College London Podcast, June 11, 2020, https://www.kcl.ac.uk/news/how-covid-19-has-exposed-racism-as-a-health-risk. Like many Black households in the US, my family had little reason to "trust the science," especially that produced during the presidency of Donald Trump, who consistently endorsed racist policies and spewed racist rhetoric.²Karen Grigsby Bates, "Is Trump Really That Racist?" NPR, October 21, 2020, https://www.npr.org/2020/10/19/925385389/is-trump-really-that-racist. While the public health response in the United States to COVID-19 was uneven across federal, state, and local entities, the narrative about disproportionate risk and mortality became apparent early and the public health establishment eventually sprang into action to make a case for health equity in the deployment of testing, prevention, and care.³Tasleem J. Padamsee, Robert M. Bond, Graham N. Dixon, et al, "Changes in COVID-19 Vaccine Hesitancy Among Black and White Individuals in the US," JAMA Network Open 5, no. 1 (2022), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788286. A survey published in January 2022, found that COVID-19 vaccine hesitancy had decreased more rapidly among Blacks than among whites since December 2020. Researchers found that Blacks "more rapidly came to believe that vaccines were necessary to protect themselves and their communities."

Even with these efforts, many of my family members initially could not be persuaded to take the vaccine. I was increasingly frustrated and wished they had more faith in science. Yet, even though I was vaccinated, I shared some of their concerns, and as I've written: "how can people who have never experienced equity be trusting of a supposedly new urgent call for equity when it comes to the vaccine?"⁴Fabiola Cineas, "Black and Latino Communities are Being Left Behind in the Vaccine Rollout," Vox, February 24, 2021, https://www.vox.com/22291047/black-latino-vaccine-race-chicago. If there were a culture that recognized a right to healthcare, would my family feel the same way? If we expected the state to have responsibility for our health and if we had a history of the public health system systematically and consistently providing preventative treatments and care, regardless of partisan politics, would it make a difference in vaccination rates in the present crisis?

In addition to studying health justice and equity in the United States, I have researched health policy development in Brazil. Segments of the Brazilian Black Movement in the 1990s, modeled to a significant extent on the 1960s US Civil Rights Movement, demanded the right to healthcare. Black participants in my Brazilian study deployed policy-based attempts to achieve full access to citizenship—most prominently as a right to health rights.⁵Creary, "Bounded Justice," 241–256. My work in Brazil explored how patients, non-governmental organizations, and the Brazilian government, at state and federal levels, have contributed to the discourse of sickle cell disease (SCD) as a black disease, despite a prevailing cultural ideology of racial mixture. Drawing on ethnography and oral histories from Rio de Janeiro, Salvador, Brasília, and Porto Alegre, this project charts the simultaneous constructions of race and science through SCD across Brazil. When I lived in Brazil in 2013, I was struck by just how much everyday people, within social movements and as part of civil societies, called on the Brazilian state to manage and provide healthcare access. With this in mind, I compare the public health systems in the United States and Brazil, the right to public health, and the COVID-19 vaccine.

Digital flyer for vaccine awareness by the Tennessee Department of Health as seen in "COVID-19 Vaccines: GOP Lawmakers Accuse State Health Chief of 'Peer Pressuring' kids," June 16, 2021, Tennessean. Image in public domain.

The rollout of Covid vaccines in the United States was painfully slow. The Trump administration's Operation Warp Speed broke records in vaccine development in 2020, but floundered badly when it came to distributing immunizations in early 2021. President-elect Biden set the goal of deploying 100 million vaccinations in the first 100 days of his administration, pledging to streamline delivery throughout the nation. Shots went into arms and by mid-March 2021, a quarter of the population had received at least one vaccine; six months later that number rose to 85 percent.

Although Black Democrats were vaccinated at a lower rate than white Democrats, the values associated with vaccine hesitancy follow the lines of partisan values and ideological orientation. A Michigan study in early 2021 found the following:

. . . in the initial wave of the outbreak in May 2020, Blacks experienced more severe direct impacts: they were more likely to be diagnosed or know someone who was diagnosed, and more likely to lose their job compared to Whites. In addition, Blacks differed significantly from Whites in their assessment of COVID-19's threat to public health and the economy, the adequacy of government responses to COVID-19, and the appropriateness of behavioral changes to mitigate COVID-19's spread. Although in many cases these views of COVID-19 were also associated with political ideology, this association was significantly stronger for Whites than Blacks.

The study found that Black Michiganders had more at stake, and more to lose. They were more likely to be infected with COVID-19, so they were also more likely to adopt behaviors of compliance. A history of racist mistreatment, however, affected their compliance. Those who perceived the impact of COVID-19 as less threatening were less willing to comply with mitigating behaviors. The Michigan study demonstrates how that state is a microcosm of the United States. According to data from mid-2021, the top twenty-two states with the highest adult vaccination rates voted for Joe Biden in the 2020 presidential election, and some of the least vaccinated states were the most pro-Trump. This partially explains the influence that Trump had (and arguably still has) on perceptions of vaccine validity and necessity.

But major resistance remained: in September 2021, 35 percent of the eligible US population remained unvaccinated and of that group, 83 percent said they did not plan to get the lifesaving shots. By the end of 2021, 73 percent of adults eighteen and older had received at least one dose of a Covid vaccine, however, 27 percent remained unvaccinated. Of those, 42 percent reported that they "don't trust the vaccine." Vaccine hesitancy, racial inequities in distribution, and state and local disparities in healthcare funding and facilities, continued to impede vaccine delivery as first the Delta variant and then Omicron took their deadly and debilitating toll.⁶Staff, "A Timeline of COVID-19 Vaccine Developments in 2021," AMJC, June 3, 2021, https://www.ajmc.com/view/a-timeline-of-covid-19-vaccine-developments-in-2021.

In contrast to the Covid geographies of the US, Brazilians appeared to "love vaccines," as Lucas Fontainha wrote in Undark, a digital magazine exploring the intersection of science and society. "They fight for vaccines," he continued, "they throw vaccine festivals, they kiss all the babies in the line waiting for vaccines, they camp overnight at the clinic to get a vaccine . . . even the anti-vaccination Brazilians vaccinate in secret."⁷Kiratiana Freelon, "Opinion: In Brazil's Successful Vaccine Campaign, a Lesson for the U.S," Undark, October 14, 2021, https://undark.org/2021/10/14/in-brazil-successful-vaccine-campaign-lesson-for-us/.

Bolsonaro with President Donald Trump, Washington DC, March 19, 2019. Photograph by Isac Nóbrega. Courtesy of Wikimedia Commons. Creative Commons license CC BY 2.0.

Unlike Americans in the US, Brazilians have benefitted from robust public health programs and a strong vaccine infrastructure since the 1970s. That said, throughout the pandemic, Brazilians have had to contend with Jair Bolsanaro, the "Trump of the Tropics," a man filled with authoritarian vitriol and disregard for vaccine science. Many worried that his influence would deter vaccine uptake, especially because 55 percent of the country voted for him. Bolsanaro's sphere of influence remains significant. His lukewarm stance on Covid vaccines and his refusal to pre-order them in 2020 and early 2021, resulted in many deaths. Nevertheless, a citizenry that believes healthcare is a basic right has countermanded Bolsonaro's failure of leadership. As the number of Brasilians dying from Covid increased to over 600,000 in 2021, citizens largely ignored their president, eschewed their free choice option to not vaccinate, and lined up for the shots.⁸Felicia Marie Knaul, Michael Touchton, Héctor Arreola-Ornelas, et al, "Punt Politics as Failure of Health System Stewardship: Evidence from the COVID-19 Pandemic Response in Brazil and Mexico," The Lancet Regional Health: Americas 4 (2020), https://www.thelancet.com/journals/lanam/article/PIIS2667-193X(21)00082-X/fulltext.

In 1973, Brazil created a national immunization program (Programa Nacional de Imunizações) that led to the near-eradication of polio and measles by 2000.⁹"National Immunization Program–Vaccination," Ministry of Health, accessed July 6, 2022, https://www.gov.br/saude/pt-br/acesso-a-informacao/acoes-e-programas/programa-nacional-de-imunizacoes-vacinacao. This successful program has been strengthened by the creation of a universal healthcare and public health system (Sistema Único de Saúde or SUS) that invested (in-part) in the delivery of free public healthcare, including vaccinations to every Brazilian, codified by the Brazilian Constitution of 1988.¹⁰Jairnilson Paim, Claudia Travassos, Celia Almeida, et al, "The Brazilian Health System: History, Advances, and Challenges," Lancet 377, no. 9779 (2011): 1778–97, https://pubmed.ncbi.nlm.nih.gov/21561655/. Vaccine delivery to Brazilian citizens is integrated into everyday life and normalized through informal connections, familiarity, and hyper-locality. Although Bolsanaro rejects the idea that the nation state owes a responsibility to its citizens, the state and local arms of the government (and the Constitution), disagree.¹¹Vincent Bevins, "Despite Bolsonaro, Brazil Has Barely Any Anti-Vaxxers," Intelligencer, November 10, 2021, https://nymag.com/intelligencer/2021/11/despite-bolsonaro-brazil-has-barely-any-covid-anti-vaxxers.html. Not only is the state obligated by law to distribute free services and pharmaceuticals, but citizens are mandated to be part of the process. Even those who choose private insurance must get their vaccines at SUS.

Even when an anti-science president such as Bolsonaro rails against vaccines, there is almost no way for the population to avoid receiving inoculations. In August 2021 in the city of São Paulo, the campaign Virada da Vacina reported that 99 percent of the adults in the city had been vaccinated (Bolsonaro won approximately 45 percent and 60 percent of the vote here in the run offs and general election respectively).¹²Isabella Menon and Paulo Eduardo Dias, "São Paulo Approaches 99% of Adults with the First Dose of the Covid Vaccine," Folha De S.Paulo, August 15, 2021, https://www1.folha.uol.com.br/equilibrioesaude/2021/08/sao-paulo-se-aproxima-de-99-dos-adultos-com-a-primeira-dose-da-vacina-contra-a-covid.shtml; "See the Calculation Map of all Cities in Brazil," Fohla De S.Paulo, October 7, 2018, https://www1.folha.uol.com.br/poder/eleicoes/2018/veja-o-mapa-de-apuracao-de-todas-as-cidades-do-brasil/?#/cargo/presidente/local/sao-paulo/turno/1/mapa/estadual/municipio/sao-paulo/3550308. Six-hundred locations dispersed the vaccine; sixteen of these were open for walk-in or drive-up around the clock. The state provided DJs, dancing, bands, and artists on stilts to create a carnivalesque atmosphere for those waiting hours in line.

Vaccine culture in Brazil is about accessibility. Locals become part of the campaign. That means you are likely to know and have some regard for the person who comes to you in the name of immunization—in the metro stations, on street corners, or in the park. Public displays boost the vaccine's image. It is harder to retreat into spaces of disinformation when the people you know, or even don't know, seem open to receiving a vaccination. A 2021 study showed that even among vaccine-hesitant individuals in Brazil (10.5 percent of the sample), only 2.5 percent did not intend to vaccinate at all.¹³Daniella Campelo Batalha Cox Moore, Marcio Fernandes Nehab, Karla Gonçalves Camacho, et al. "Low COVID-19 Vaccine Hesitancy in Brazil," Vaccine 39, no. 42 (2021): 6262–6268. Still, a June 2022 report from The Lancet found that municipalities that supported Bolsonaro in the 2018 elections were those that had the worst COVID-19 mortality rates, especially during the second epidemic wave of 2021.

Zé Gotinha at the Launch of the National Vaccination Operational Plan, Brazil, December 16, 2020. Photograph by Isac Nóbrega. Courtesy of Wikimedia Commons. Creative Commons license CC BY 2.0.

As of June 2022, 87.3 percent of Brazilians have received at least one dose of COVID-19 vaccine and 79 percent have been fully vaccinated, compared with 79.8 percent of US citizens having received one dose and 67.5 percent being fully vaccinated.¹⁴COVID-19 Vaccination Tracker, Reuters, last updated July 15, 2022, https://graphics.reuters.com/world-coronavirus-tracker-and-maps/vaccination-rollout-and-access/. While these numbers are not vastly different, it is of note that Brazil President Bolsonaro remains in power, regularly flouting vaccine regulations and bragging about his unvaccinated status, whereas since 2021 in the United States, President Joe Biden has worked tirelessly to get vaccines in arms, bolster public health, and eliminate health disparities.¹⁵Rodrigo Pedroso, "Brazil's Bolosnaro Says He Will Not be Vaccinated Against Covid-19," CNN, October 13, 2021, https://www.cnn.com/2021/10/13/americas/bolsonaro-no-vaccine-intl/index.html; Chuck Todd, Mark Murray and Carrie Dann, "Biden is True to a Key Promise: Getting More Shots in Arms," NBC News, March 19, 2021, https://www.nbcnews.com/politics/meet-the-press/biden-true-key-promise-getting-more-shots-arms-n1261531; HHS Press Office, "Biden-Harris Administration Provides $121 Million in American Rescue Plan Funds to Support Local Community-Based Efforts to Increase COVID-19 Vaccinations in Underserved Communities," HHS, July 27, 2021, https://www.hhs.gov/about/news/2021/07/27/biden-harris-admin-provides-121-million-in-arp-funding-to-local-communities-for-covid-19-vaccines.html.

Early in his tenure, Biden proposed a $1.6 billion increase for the Centers for Disease Control and Prevention to improve core public health capacities in states and territories, modernize public health data systems, train new epidemiologists and other public health workers, and build global capacity to respond to future health threats. Some of these efforts have worked. By August 2021, Pew research reported that around three-quarters of US adults (73 percent) had received at least one dose of a COVID-19 vaccine.

Despite these efforts, too many Americans see vaccine mandates, not as a way toward building public safety, but as extreme government overreach. Republicans and Libertarians have called repeatedly and loudly for "personal freedom" to be prioritized over public safety. Before the Supreme Court blocked the Biden administration's vaccine-or-test requirement for large private businesses in January 2022, there was an outcry for #massnoncompliance. Some scholars have called this political resistance to vaccines based on the tenets of choice and liberty, a "uniquely American predicament."¹⁶Alana Wise, "The Political Fight Over Vaccine Mandates Deepens, Despite their Effectiveness," NPR, October 17, 2021, https://www.npr.org/2021/10/17/1046598351/the-political-fight-over-vaccine-mandates-deepens-despite-their-effectiveness. And while the oppositional forces of conservatism and science have been noted as phenomenon elsewhere, including Brazil, the lack of a dominant US culture that trusts and respects public health and expects that the state can and should deliver it can be attributed largely to decades of right wing ideologues across many forms of media.

To date, an Omicron subvariant (BA-5) is the newest variant of concern, threatening a wave of infections and reinfections. As we continue to navigate this global pandemic, we must pay attention to the true influencers of public health. In Brazil, the public health system has a strong history of emboldening citizenry with a message of governmental duty and obligation. We'll see how this may play out in the polls come October for upcoming elections in this country. In the United States, anti-vax politicians, many of whom have themselves received the vaccine for COVID-19, have spread misinformation and anti-government rhetoric about public health. Although conservatism and evangelical religiosity has led to vaccine hesitancy, a Pew Report shows us that most Americans who go to religious services say they would trust their clergy's advice on COVID-19 vaccines. Some advocates of public health have historically prioritized local partnerships with religious leaders and institutions acknowledging this very important sphere of influence.

We must continue to undertake hard conversations about the tensions between individual freedoms and population health much as we did when H1N1 struck our collective shores. As families like my own navigate the implications of a mutating virus that generated a global pandemic, we need trusted resources that are sensitive to historical experiences and the collective common good.

About the Author

Dr. Melissa S. Creary is assistant professor in the Department of Health Management and Policy, School of Public Health at the University of Michigan and the senior director for the Office of Public Health Initiatives at the American Thrombosis and Hemostasis Network (ATHN). She assists ATHN in finding ways to leverage public health research and policy to make a broader impact within the bleeding and blood disorders population. Dr. Creary's areas of specialization include race and racism, genetics, identity politics, health policy, and health equity. She worked for a decade as a health scientist at the Centers for Disease Control and Prevention in the Division of Blood Disorders, has done extensive field work in Brazil, and has more than twenty years of bench, public health, and social science research experience.

Public Health in the US and Global South is a collection of interdisciplinary, multimedia publications examining the relationship between public health and specific geographies—both real and imagined—in and across the US and Global South. These essays raise questions about the origin, replication, and entrenchment of health disparities; the ways that race and gender shape and are shaped by health policy; and the inseparable connection between health justice and health advocacy.

Beginning in 2022, the series expands to include 1000-word blog posts, as well as longer commentaries, essays, articles and media productions that address the public health and political implications of the COVID-19 pandemic from multiple viewpoints. The series editor for Public Health in the US and Global South is Mary E. Frederickson.

COVID-19: Lessons in Ignorance

sevaa — Tue, 26 Apr 2022 15:38:48 +0000

Commentary

An online search using the keywords "COVID-19" and "lessons" turns up an astonishing volume and assortment of information: thousands of commentaries, news stories, scholarly articles, book chapters, and monographs. The lessons are intended for vast expert and general audiences: from pediatricians, public health professionals, and other specialized communities of practice to ordinary people and political leaders across the planet. What has been, can be, and should be learned? More lessons loom. Expect a deep dive Congressional investigation and blue-ribbon probes. Storytellers are weighing in with fictional chronicles. Booker Prize winner Ian McEwan's novel, Lessons (New York: Alfred A. Knopf, 2022), is scheduled for September 2022.

CDC Main Campus, Atlanta, GA. Image in public domain.

From my perspective as a recently retired Centers for Disease Control and Prevention (CDC) branch chief who served in the agency's COVID-19 response from late March through June 2020, the profusion of "lessons learned" reflects the magnitude of the knowledge gaps that impaired America's readiness and undercut its efforts to grapple with a new pathogenic peril, one for which danger signs were long evident. Failures in foresight were followed by fitful attempts at comprehending a lethal contagion's spread and knowing what to do about it.¹Cormac Bryce, Patrick Ring, Simon Ashby, and Jamie K. Wardman, "Resilience in the Face of Uncertainty: Early Lessons From the COVID-19 Pandemic," Journal of Risk Research 23, no. 7–8 (2020): 880–887.

The story of the nation's COVID-19 plight is as much an unfolding epistemological crisis as it is a once-in-a-century epidemiological catastrophe. Among the many lessons to be distilled are how and why ignorance in various forms and places accounts for so much of what went wrong. A thorough and wide-ranging exploration is needed, which calls for contributions from multiple disciplines and approaches. As historian of science Robert Proctor recommends: "We need to think about the conscious, unconscious, and structural production of ignorance, its diverse causes and conformations, whether brought about by neglect, forgetfulness, myopia, extinction, secrecy, or suppression."²Robert N. Proctor, "Agnotology: A Missing Term to Describe the Cultural Production of Ignorance (and Its Study)," in Agnotology: The Making and Unmaking of Ignorance, ed. Robert N. Proctor and Londa Schiebinger (Stanford, CA: Stanford University Press, 2008), 1–33. Further, as sociologist Scott Frickel suggests, we also need to focus on "how, where, and why ignorance, once produced, becomes institutionalized."³Scott Frickel, "Not Here and Everywhere: The Non-production of Scientific Knowledge," in Routledge Handbook of Science, Technology, and Society, ed. Daniel Lee Kleinman and Kelly Moore (New York: Routledge, 2014), 263–276. For example, studies of CDC's shambolic performance should include close scrutiny of institutional obliviousness, under a succession of agency directors and programmatic leaders, to basic gaps in readiness and responsiveness that became glaringly obvious during the pandemic and contributed to numerous missteps in the US response to COVID-19.

If the so-called Spanish influenza of 1918 was, in the words of historian Alfred W. Crosby, America's Forgotten Pandemic, then for the time being the bounty of lessons suggests that COVID-19 is America's Teachable Moment Pandemic.⁴Alfred W. Crosby, America's Forgotten Pandemic: The Influenza of 1918, Second Edition (New York: Cambridge University Press, 2003), 311–328. The largest public health cataclysm in a hundred years has put to the test assumptions, capacities, decisions, practices, and policies. In many ways, the United States has been found wanting, as evidenced by the exceptionally devastating and inequitable toll that COVID-19 has exacted, much of which was averted or more proficiently mitigated by other countries, including nations in the Global South. Vietnam is a prime example.

"U.S. Covid-19 Cases," October 25, 2020. Cartoon by and courtesy of Mike Luckovich.

Events turned US exceptionalism on its head; the nation's heralded public health preeminence ran aground against a novel corona virus. Remarkably, four months before the World Health Organization declared the worldwide spread of COVID-19 a public health emergency, preparedness experts convened by the Nuclear Threat Initiative and Johns Hopkins University reported that the United States was at the top of the heap internationally in terms of its readiness to contend with a pandemic. Scoring 83.5 out of 100 possible points, the US was deemed "best prepared" in the world.⁵Elizabeth E. Cameron, Jennifer B. Nuzzo, Jessica A. Bell, et al, Building Collective Action and Accountability, GHS Index, October 2019, https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf. Yet, when the virus began to spread throughout the nation, political and public health leaders overlooked or failed to respond promptly and effectively to signals of a mounting threat.

Myriad displays of ignorance in preparedness and response cast a spotlight on areas of knowledge, most visible in America's contributions to pathogen genomics and vaccine development, that were the rarity rather than the rule. As historian Peter Burke predicts, much will be said about ignorance when we look back on the pandemic.⁶Ana R. Rego and Marialva Barbosa, "Interview With Peter Burke: About Ignorance Nowadays," Revista Famecos—Midia, Cultura e Tecnologia 28 (2021): 1–7. The United States will provide many examples for review. "The coronavirus is very much under control in our country," President Donald Trump claimed without justification in February 2020.⁷"Trump Says Coronavirus Is 'Very Well Under Control' in U.S.," Bloomberg, February 25, 2020, Video, 1:26, https://www.bloomberg.com/news/videos/2020-02-25/trump-says-coronavirus-is-very-well-under-control-in-u-s-video. When cases and deaths surged, corporate America chimed in with commercials proclaiming "we are all in this together," a slogan that blithely disregarded systemic, inequitable differences in exposures, resources, and outcomes.⁸"Every Covid-19 Commercial is Exactly the Same," Microsoft Sam, April 15, 2020, YouTube video, 3:40, https://www.youtube.com/watch?v=vM3J9jDoaTA. As COVID-19 variants emerged and disease waves swelled, public health officials justified shifts in their response guidance with the catchphrase "follow the science," in effect denying knowledge gaps and glossing over judgment calls that informed their decisions.⁹Nason Maani and Sandro Galea, "What Science Can and Cannot Do in a Time of Pandemic," Scientific American, February 2, 2021, https://www.scientificamerican.com/article/what-science-can-and-cannot-do-in-a-time-of-pandemic/. Sports celebrities and other influencers joined in; some publicly declined vaccinations for spurious or unspoken reasons. In one widely publicized instance, a National Football League Most Valuable Player invoked vaccine misinformation to justify his decision to remain unvaccinated.¹⁰Ken Belson and Emily Anthes, "Scientists Fight a New Source of Vaccine Misinformation: Aaron Rodgers," New York Times, November 14, 2021, https://www.nytimes.com/2021/11/08/sports/football/aaron-rodgers-vaccine.html. These displays of ignorance, from the individual to the federal levels, almost certainly will be among the major topics covered when histories of America's recent past are written and discussed.

To a large extent, first drafts of our national COVID-19 history have been assembled, produced in near real-time amid an evolving pandemic. Among the lengthier accounts are books by Nicholas Christakis, Scott Gottlieb, Michael Lewis, Andy Slavitt, and Lawrence Wright.¹¹Nicholas A. Christakis, Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live (New York: Little, Brown Spark 2020); Scott Gottlieb, Uncontrolled Spread: Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic (New York: HarperCollins, 2021); Michael Lewis, The Premonition: A Pandemic Story (New York: W.W. Norton, 2021); Andy Slavitt, Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response (New York: St. Martin’s Press, 2021); Lawrence Wright, The Plague Year: America in the Time of Covid (New York: Alfred A. Knopf, 2021). Their narratives and additional reports, published across a wide variety of media platforms and outlets, recount a now familiar cascade of main events: warning signals missed or ignored. Contagion risks initially misunderstood or minimized. Testing bungled. Weaknesses in public health infrastructure and operations laid bare. Guidance delayed, shifted, and politicized. Mandates and masks applied, albeit unevenly. Healthcare stretched to the breaking point. Inequalities exposed. Supply chains disrupted. The economy slackened. Government spending skyrocketed, then dipped. Red-Blue divides widened. Vaccines produced in record time received mixed receptions. COVID-19’s impact surged, subsided, and swelled again—repeatedly. The pandemic dragged on and left its mark virtually everywhere and on everyone.

A bevy of initial accounts present a broad historical outline of what happened—to date. However, potential pitfalls arise when these first reports go beyond chronicling pandemic events and enter the realm of causal interpretations and lessons learned. There, the authors of quick-to-publication stories should tread particularly carefully, recognize uncertainties, and avoid unjustified or imbalanced explanations. Possible missteps include ignoring explanatory information or information sources and failing to acknowledge, or minimizing, the limits of their evidence. The risks of missing the mark are substantial. Causal interpretations skewed towards the unequivocal and unnuanced provide unreliable takeaway lessons and often obscure deeper etiologic factors. Revisions may be forthcoming, but inaugural versions can exert an outsized influence on what endures as the conventional understanding of what happened and why.

Cover of Michael Lewis's The Premonition: A Pandemic Story (New York: W.W. Norton, 2021).

A case in point and cause for concern is Michael Lewis's bestselling The Premonition: A Pandemic Story (New York: W.W. Norton, 2021), a fast-paced narrative—a Hollywood movie version reportedly is on the way—that tells the tale of several outside experts who tried to spur CDC insiders to recognize and respond rapidly in early 2020 to signals of the brewing COVID-19 calamity. CDC's performance leaves little doubt that the agency was ill-prepared for the pandemic and made multiple mistakes in its response, including its botched diagnostic testing roll out, guidance fiascos, and acquiescence to political pressures from the White House. The open questions that Lewis takes on are what accounts for these failures and, more broadly, the poor showing by the United States compared with its lofty, pre-pandemic preparedness ranking. His answers are uncomplicated and unequivocal: the talents and recommendations of experts, represented by a small but heroic crew of scientists and physicians whom he profiles, were ignored, and the underlying cause was a lack of public health leadership, exemplified by the failings of the Trump-appointed CDC Director. According to Lewis, Donald Trump himself bears little responsibility for America's anemic response. "As one of my characters puts it," Lewis reports, "Trump was a comorbidity."¹²Michael Lewis, The Premonition: A Pandemic Story (New York: W.W. Norton, 2021), xiv.

I read Lewis's book closely, concentrating on his account of CDC's poor performance and the lessons to be learned. Notwithstanding his mystifying minimization of Trump's baleful role, Lewis's The Premonition offers a glimmer of hope for revelatory explanations and guidance. "After a catastrophic season, management always huddles up to figure out what needs to be changed," he suggests in his introduction, invoking a football analogy that promises a line of sight into the gap between reputation and results.¹³Lewis, xv. However, the front office managers are the target rather than the truth tellers in Lewis's narrative.

"White House Press Briefing," March 16, 2020. Photo by D. Myles Cullen. Courtesy of Wikimedia Commons. Image in public domain.

To tell his story, Lewis mainly relies on a small coterie of outside experts, most prominently a retired Sandia National Laboratories senior scientist who studied the effects of social distancing on mitigation of pandemic influenza, a former assistant director of the California Department of Public Health who warned state officials about the mounting COVID-19 threat during the pandemic's initial phase, and two physicians who helped write a national pandemic preparedness and response plan during the George W. Bush administration and raised early alarms about COVID-19's potentially devastating impact on the United States. High among their recommendations for thwarting a rapidly spreading contagion were school closures, which Lewis describes as one of the "truths" that his informants had discovered long ago.¹⁴Lewis, 211. Yet, considering the downsides of school shutdowns and remote learning, cleaving to that plan and putting it into practice in the COVID-19 pandemic was far from an unequivocal success, an important lesson that eludes Lewis and warrants much further attention.

Lewis doesn't make clear whether he sought or used information from CDC responders about the agency's performance. Notably, he doesn't mention any contact efforts or interviews with insiders about CDC's emergency operations. The enormously harmful effects of Trump and his minions were clear to me and many CDC colleagues, as were major internal weaknesses in the agency's response, which Lewis largely ignores. Some of CDC's shortcomings were due to acute managerial and resourcing problems, often recurring or persistent despite multiple attempts at remediation; others reflected longstanding internal and external assumptions, refuted by the agency's woeful performance, about institutional readiness, proficiency, and sustainability in a pandemic. We need fuller accounts of what went wrong and why, including contributions by CDC insiders, to correctly cull lessons and put them to good use.

More broadly, the flaws in Lewis's assessment serve as a reminder that knowledge claims presented as takeaway lessons do not necessarily undo our ignorance. Some "lessons learned" ignore or minimize more compelling understandings of what went wrong and obscure what we ought to know better. The epistemological crisis that compounded the epidemiological calamity threatens to continue in new forms with the writing of pandemic histories and production of Hollywood dramatizations. Still, COVID-19 has the potential to propel high-value learning and positive changes at the individual, organizational, and societal levels.

Among the nation's earliest and most important pandemic lessons is the immense toll that ignorance can take on human lives. As I write this conclusion, American COVID-19 deaths are fast approaching the one million mark, and untold numbers of people who survived the acute phase of their infections are affected by long-term sequelae. Perhaps we now know better the enormity and implications of what was missing in the national efforts to contend with the pandemic, and we will address collectively what science and technology scholar Manjari Mahajan aptly describes as the "complex political and social determinants that anchor a country's public health response and that are critical in ensuring the sustained well-being of a population."¹⁵Manjari Mahajan, "Casualties of preparedness: the Global Health Security Index and COVID-19," International Journal of Law in Context 17, no. 2 (2021): 204–214. COVID-19's impact also has been evident in other, more individual lessons and actions. For many Americans, the pandemic has prompted a personal reckoning and welcome revisions in how they take care of themselves and other people in their lives. However, many COVID-19 lessons and changes are likely to fade, including some that are well worth preserving. America's Forgotten Pandemic of 1918 is a prime example of the finite limits on attention spans and memories. In our time, military conflict and other crises or preoccupations are likely sources of competition for mindfulness, efforts at sense making, and shifts in priorities and routines. "Information is no longer a scarce resource," notes sociologist Sheldon Ungar, "attention and interest are."¹⁶Sheldon Ungar, "Ignorance as an Under-Identified Social Problem," British Journal of Sociology 59, no. 2 (2008): 301–326. As a result, America's COVID-19 lessons, including those that are forthcoming, are at risk of diminution or disappearance regardless of their value.

The pandemic is a uniquely teachable moment in our history; we can learn from our ignorance and act accordingly. As political scientist Eric Stern reminds us, despite the formidable obstacles to learning from a crisis, great benefits can accrue from lessons that are deeply reflective, methodologically sound, and highly pragmatic.¹⁷Eric Stern, "Bridging the Crisis Learning Gap: From Theory to Practice," in Organizing After Crisis: The Challenge of Learning, ed. Nathalie Schiffino, Laurent Taskin, Céline Donis, and Julien Raone (Brussels: P.I.E. Peter Lang, 2015), 257–272. COVID-19 has made ignorance and its negative consequences more visible in America. Fortuitously, at least for the time being, our lessons in ignorance also provide an impetus for new knowledge and, hopefully, momentum towards a more equitable society, stronger commitments to public health and healthcare, and a much greater responsiveness to planet-wide threats.

About the Author

Public Health in the US and Global South is a collection of interdisciplinary, multimedia publications examining the relationship between public health and specific geographies—both real and imagined—in and across the US and Global South. These essays raise questions about the origin, replication, and entrenchment of health disparities; the ways that race and gender shape and are shaped by health policy; and the inseparable connection between health justice and health advocacy.

Beginning in 2022, the series expands to include 1000-word blog posts, as well as longer commentaries, essays, articles and media productions that address the public health and political implications of the COVID-19 pandemic from multiple viewpoints. The series editor for Public Health in the US and Global South is Mary E. Frederickson.

Before Tuskegee: Public Health and Venereal Disease in Hot Springs, Arkansas

Robert Billups — Thu, 01 Jun 2017 04:00:00 +0000

Introduction

U.S. Public Health Service Advertisements, ca. 1905. Photograph by Harris & Ewing. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/hec.20772/.

In the winter of 1936, Minnie Lee Ishcomer left home in Idabel, Oklahoma, and journeyed to Hot Springs, Arkansas. Thirty years old, white, poor, and the victim of a long-standing venereal infection, Ishcomer came to Hot Springs hoping to obtain treatment at the VD clinic operated there by the United States Public Health Service (PHS). Her experience was less than satisfactory. Because the clinic officially admitted only acute, infectious VD cases, Ishcomer was initially denied entrance—on the grounds that she was "not a danger to the public health." She passed her first few days in Hot Springs in search of food and shelter. Without money, she made her way to a bus station where a police officer found her "in a very serious condition." Taken back to the clinic, she received a few days' treatment. Soon after her release, a PHS official angrily wired the health officer in Ishcomer's home county that "such cases will not be treated in the future."¹H.S. Cumming, Surgeon General, to Charles M. Pearce, State Health Commissioner, Oklahoma, January 29, 1936, General Records of the Venereal Disease Division, 1918–1936, 203.4, in RG 90, Records of the Public Health Service, 1912–1968, National Archives, College Park, Maryland. Hereafter VD Division Records.

The treatment Minnie Lee Ishcomer received likely did little to improve her health.²Available federal census information indicates that in 1930, Ishcomer was married and had a least one son. Her husband appears to have been a mill hand but no occupation is listed for her. Exactly which of her conditions triggered resentment by clinic doctors is not clear. Nevertheless, her story sheds light on a relatively unexplored site of public health work in the early twentieth-century US South.³For a brief overview of the Hot Springs VD clinic, see Edwina Walls, "Hot Springs Waters and the Treatment of Venereal Diseases: The U.S. Public Health Service Clinic and Camp Garraday," Journal of the Arkansas Medical Society 91, no. 9 (1995): 430–7. The opening of the Hot Springs VD clinic in 1921 followed upon extensive anti-venereal initiatives carried out by the U.S. military during World War I. Closing in the 1940s, the clinic marked a transition in the federal government's campaign against syphilis and gonorrhea—including the Tuskegee Syphilis Study (1932–72) and the Chicago Syphilis Control Project (1937–40). Throughout the interwar period, Hot Springs sat on the front lines of the PHS's war against VD, and although its efforts were largely unsuccessful, the clinic's history points toward a more complex understanding of this moment of "venereal peril."⁴The term "venereal peril" was a staple of turn-of-the-century discourse around syphilis and gonorrhea. For a particularly good example of this, see William Leland Holt,The Venereal Peril: A Popular Treatise on the Venereal Diseases, ed. William Josephus Robinson (New York: The Altrurians, 1909). For historical studies on this, see Theodor Rosebury, Microbes and Morals: The Strange Story of Venereal Disease (New York: Viking Press, 1971); Allan Brandt, No Magic Bullet: Venereal Disease and American Society since 1880 (New York: Oxford University Press, 1987); Suzanne Poirier, Chicago's War on Syphilis, 1937–40: The Times, the Trib, and the Clap Doctor (Urbana: University of Illinois Press, 1995); Nancy K. Bristow, Making Men Moral: Social Engineering during the Great War (New York: New York University Press, 1996); Andrea Tone, Devices and Desires: A History of Contraceptives in America (New York: Hill and Wang, 2001); Marilyn Hegarty, Victory Girls, Khaki-Wackies, and Patriotutes: The Regulation of Female Sexuality during World War Two (New York: New York University Press, 2008); John Parascandola, Sex, Sin, and Science: A History of Syphilis in America (Westport, CT: Praeger, 2008).

We've fought in the open, New York, 1918. Print by H. Devitt Welsh. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/ppmsca.50577/.

The history of the Hot Springs clinic offers insights into racial, gendered, and class-based aspects of the federal government's campaign against syphilis and gonorrhea. The clinic treated all manner of patients—black as well as white, male as well as female. Some patients were chronically poor, and others—particularly with the onset of the Great Depression—had only recently fallen on hard times. How similar were the experiences of these different groups, and to what extent did their treatment reflect prejudices against the various "others" (such as prostitutes and African Americans) popularly associated with VD? While many historical VD studies examine population subsets, this article about Hot Springs offers a more comprehensive analysis, comparing the experiences of stigmatized groups along with those of Hot Springs's prototypical health-seekers: syphilitic white males. Although they accounted for the vast majority of the clinic's caseload, white men have not received significant attention in VD historiography. Including their experiences adds new depth to our understanding of the "venereal peril" while illustrating how forcefully eugenics pervaded the PHS's campaigns against syphilis and gonorrhea.

Eugenics, of course, figures prominently in scholarship on the infamous Tuskegee Study. This experiment, in which the PHS deliberately withheld treatment from four hundred syphilitic Alabama black men in order to study the disease's "natural" progression, was designed to provide evidence for the theory that (as the Johns Hopkins syphilologist Joseph Moore put it) "syphilis in the negro is in many respects almost a different disease from syphilis in the white."⁵Susan Reverby, Examining Tuskegee: The Infamous Syphilis Study and Its Legacy (Chapel Hill: University of North Carolina Press, 2009), 136. From 1932 to 1972 white PHS doctors attempted to prove that black syphilitics almost never progressed to the late, advanced stage of the disease characterized by disorders of the nervous system–including tabes (syphilis of the spinal cord) and paresis (syphilis of the brain). Blacks were seen as belonging to an uncivilized race with smaller, less developed brains that equipped them with a "racial resistance" to neurosyphilis; as a result, they were more likely to suffer from the disease's cardiovascular symptoms—including syphilis of the heart.⁶Christopher Crenner, "The Tuskegee Syphilis Study and the Scientific Concept of Racial Nervous Resistance," Journal of the History of Medicine and Allied Sciences 67, no. 2 (2012): 244–80. Doctors believed that this partial immunity to neurosyphilis was a hereditary trait. As the authors of a recent article on Tuskegee observe, the experiment's goal was to "prove the biological basis of racial difference by documenting race-linked pathology, consistent with prevailing eugenic theory."⁷Paul A. Lombardo and Gregory M. Dorr, "Eugenics, Medical Education, and the Public Health Service: Another Perspective on the Tuskegee Syphilis Experiment," Bulletin of the History of Medicine 80, no. 2 (2006): 313.

In providing an assessment of intellectual undercurrents circulating through the PHS in the 1920s and 1930s, this new literature successfully rebuts the claim that Tuskegee had little to do with scientific racism or eugenics.⁸For a recent article in the revisionist vein, see Thomas G. Benedek and Jonathon Erlen, "The Scientific Environment of the Tuskegee Study of Syphilis, 1920–1960," Perspectives in Biology and Medicine 43, no. 1 (1999): 1–30. Unanswered, however, is how eugenic theories informed aspects of the agency's anti-venereal work involving non-blacks. At Hot Springs, these theories found expression in a campaign designed to prevent the clinic's mostly white male patients from succumbing to the "racial poison" that was VD. Comprising traditional medical services and a variety of extra-medical measures (including financial assistance for food, shelter, and basic care), this campaign cost hundreds of thousands of dollars, with its budget increasing dramatically during the early years of the Great Depression—just as the PHS dismantled a number of pilot projects designed to provide mass treatment to syphilitic blacks. Although many of the initiatives undertaken in Hot Springs benefited patients regardless of race or sex, the clinic's white male health-seekers experienced a level of preferential treatment denied to both women and African Americans. Further, for the latter group, discrimination and hostility were part and parcel of the Hot Springs experience—both inside and outside the clinic. All of this represented the eugenic impulses coursing through the PHS facility, whose director—Oliver C. Wenger—declared syphilis and gonorrhea important "from the standpoint of race conservation."⁹O.C. Wenger, "The Need for Social Hygiene," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Hot Springs reveals a significant instance of the federal government's racist approach to public health policy. When dealing with white patients, Washington extended a taxpayer-supported hand. Because such a sizable gap existed between the experiences of Hot Springs's black and white health-seekers, the story of the city's VD clinic provides a further context for understanding the Tuskegee Study. But first, a more elementary question: why did the PHS decide to create a VD clinic at Hot Springs, Arkansas?

"Mecca for Syphilitics"

Excerpt from "The Advantages in the Treatment of Syphilis at the Hot Springs of Arkansas," 1897. Screenshot by Southern Spaces. Originally published in the Journal of the American Medical Association 28, no. 6 (1897): 251–253.

Hot Springs's selection as the site of the federal government's "model" VD clinic would not have surprised early twentieth-century Americans.¹⁰C.N. Myers, "Hot Springs and the Model Federal Venereal Disease Clinic," Medical Review of Reviews 28 (1922): 86. In 1832, Congress declared that the boiling waters of the Ouachita Mountains were to be forever set aside for the "benefit and enjoyment" of the general public.¹¹For more on the city's early history and the role of the Hot Springs Reservation, see Janis Kent Percefull, Ouachita Springs Region: A Curiosity of Nature (Hot Springs, AR: Ouachita Springs Region Historical Research Center, 2007). In 1877, Congress created the Hot Springs Reservation (HSR). Initially consisting of 2,529 acres, the HSR was public land managed by a federally-appointed commission, whose task was to maintain and control access to the 826,000 gallons of water that daily coursed through the site.¹²J.K. Haywood, Analyses of the Waters of the Hot Springs of Arkansas (Washington, D.C.: Government Printing Office, 1912), 5. Word of the area's therapeutic prowess spread across the country, and as the city began welcoming hundreds of health-seekers every year, its waters acquired a reputation for curing syphilis.¹³For evidence of this, see A.J. Wright, "Some Account of the Hot Springs of Arkansas," The New Orleans Medical and Surgical Journal (1860): 798–9, 801; R.M. Lackey, "The Hot Springs of Arkansas," Chicago Medical Journal 23 (1866): 9; J.L. White, "The Hot Springs of Arkansas," Chicago Medical Recorder 36 (1878): 311. During the late nineteenth-century, a growing belief in the springs' ability to "drive out syphilis completely" spurred a "Hot Springs craze" among venereal sufferers. Contemporaries began referring to the city as the "Mecca for syphilitics in America."¹⁴S.B. Houts, "Cases in Practice," The Medical World 5 (1887): 248–52; Edward L. Keyes, The Venereal Diseases, Including Stricture of the Male Urethra (New York: William Wood & Company, 1880), 107–8; E.R. Lewis, "The Hot Springs of Arkansas," The Kansas City Medical Index-Lancet 10, no. 7 (1889): 249. For references to Hot Springs as a "Mecca" for syphilitics during the late-nineteenth and early-twentieth centuries, see "Editorial: Syphilis of the Nervous System," The Hot Springs Medical Journal 3, no. 2 (1894): 51; A. Ravogli, "The Thermomineral Cure in the Treatment of Syphilis," The Medical Era 6, no. 8 (1897): 276; Bukk G. Carleton, A Treatise on Urological and Venereal Diseases (New York: Bukk G. Carleton, 1905), 741; Loyd Thompson, Syphilis (Philadelphia, PA: Lea and Febiger, 1920), 212.

While some of Hot Springs's health-seekers received treatment at the Free Government Bathhouse created by the HSR in 1878, increasing numbers did so at private enterprises.¹⁵Haywood, Analyses of the Waters, 5. Hot Springs was "fast becoming a fashionable resort."¹⁶J.L. Gebhart, "On the Therapy of the Waters of Hot Springs, Arkansas, and Their Relation to the Medical Profession at Large," St. Louis Medical and Surgical Journal 38 (1880): 634. Leasing land and water from the HSR, local developers began replacing the city's "miserable board shanties" with "palatial hotels."¹⁷Robert Heriot, "Letter to the Editor," Locomotive Engineers Journal 25 (1891): 919. The resort's clientele shifted: earlier the preserve of "poor, miserable paupers," it was increasingly visited by "very wealthy people from the Northern states."¹⁸E.B. Stevens, "Hot Springs, Arkansas," Transactions of the Ohio Medical Society 31 (1875): 197; Heriot, "Letter to the Editor," 919. See also H.M. Rector, "Then and Now," Hot Springs Medical Journal 4 (1895): 225; Henry Durand, "Uncle Sam, M.D., and His Great Sanitarium," The American Monthly Review of Reviews 16 (1897): 75–9. To ensure that its visitors remained a "people of leisure, with an abundance of money to spend," local officials forcibly uprooted the city's poorer health-seekers—those living in "shanties or tents" or found "encamped under the trees with no other shelter."¹⁹"Hot Springs, Arkansas," The Medical Visitor 20 (1904): 140; "Hot Springs, Arkansas, as a Health Resort," Hot Springs Medical Journal 3, no. 6 (1894): 173; William H. Deaderick, "The Development of the Hot Springs of Arkansas as a Health Resort," The Medical Pickwick 2 (1916): 265–6. One turn-of-the-century visitor reported on how "it was the policy of the municipality of Hot Springs to discourage the coming of the poor people to that place," which it did "by withholding all of the usual eleemosynary institutions from their use." Hal C. Wyman, "A Surgical Pilgrimage to Arkansas," Physician and Surgeon 28 (1906): 207. Medical authorities in other locales came to believe that "only the rich" could afford the "costly excursion" to Hot Springs.²⁰"Syphilitic Paresis," The Eclectic Medical Journal 50 (1890): 562. As a Chicago physician said of his city's syphilitic patients: "our rich people go to the great Mecca of medical wisdom, to Hot Springs," while "our poor people may go to—where they please."²¹Joseph Zeisler, "The Social Evil," Year Book (Chicago: The Sunset Club, 1894), 218.

Top, Entrance to the Government Reservation, Hot Springs, Arkansas, ca. 1896. Photograph by Detroit Publishing Co. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/det.4a08624. Bottom, Government Reservation building, Hot Springs, Arkansas, ca. 1895. Photograph by Detroit Publishing Co. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/det.4a16477.

The invention of Salvarsan (1910), a more effective drug, also prompted a decline in the city's voluminous traffic in syphilitic health-seekers.²²"Since the arsphenamines have justly become popular," the director of the Hot Springs VD clinic observed in 1921, "the number of syphilitics coming to Hot Springs has been decreased year by year." O.C. Wenger, "The Early Days of Hot Springs, Arkansas (1850–1900)," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. Nevertheless, neither new drugs nor the discrimination against impoverished health-seekers succeeded in severing the city's association with VD.²³"We see every day, here in Hot Springs," one local physician noted in a 1913 treatise, "from ten to a hundred persons" suffering from the "terrible disease" that was syphilis. Albert J. Whitworth and John M. Byrd, The Hot Springs Specialist (Memphis, TN: B.C. Toof & Company, 1913), 164. For more about Salvarsan, see Patricia Spain Ward, "The American Reception of Salvarsan," Journal of the History of Medicine & Allied Sciences 36, no. 1 (1981): 44–62. In 1920, the HSR created a new, expanded Free Government Bathhouse; its lower floor would soon become home to the PHS's VD clinic.²⁴Oliver C. Wenger, "The Early Days in Hot Springs, Arkansas (1850–1900)." Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. As its director put it upon entering the city that same year: "to the average layman, Hot Springs, Arkansas, means VD, and VD means Hot Springs."²⁵Oliver C. Wenger, "Results of a Study and Investigation of Venereal Disease at the United States Public Health Service Clinic at Hot Springs, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Hot Springs's status as federal land and as a "mecca" for syphilitics made the city an ideal site for the PHS's "model" VD clinic. But why would the government create such a clinic? The early twentieth-century was a time of profound anxiety over syphilis and gonorrhea, diseases said to be "undoubtedly on the increase."²⁶George P. Dale, "Moral Prophylaxis," The American Journal of Nursing 11, no. 9 (1911): 689. It is unknown whether the general prevalence of VD increased during the late nineteenth and early twentieth centuries. What changed was likely not the percentage of the population infected by syphilis or gonorrhea, but instead, the medical profession's awareness of how many illnesses originated in one of these two diseases. Medical authorities proclaimed that 80 percent of adult males living in large cities contracted syphilis or gonorrhea before the age of thirty, and that 80 percent of all operations performed on women for diseases of the womb and ovaries were the result of one of these conditions. Such figures, though highly suspect, engendered fears of a looming VD epidemic across the country.²⁷For these estimates, see G. Shearman Peterkin, "A System of Venereal Prophylaxis That is Producing Results," American Medicine 10 (1906): 328. A colleague named John Cunningham declared that "it is a fact worthy of consideration that every year in this country 770,000 males reach the age of maturity. It may be affirmed that under existing conditions at least 60 percent, or over 450,000 of these young men will sometime during life become infected with venereal disease, if the experience of the past is to be accepted as a criterion of the future." John C. Cunningham, "The Importance of Venereal Disease," The New England Journal of Medicine 168, no. 3 (1913): 77–8.

The sense that venereal diseases constituted "a menace to the national welfare" stemmed less from epidemiology than from social and cultural concerns—of "race suicide" attendant upon the declining fertility of native, white-born women and the influx of "new immigrants," of urbanization and its impact on sexual mores, of a "family crisis" prompted by the emergence of the "new woman," and of eugenic concerns tied to the rhetoric of social Darwinism and racial degeneration.²⁸Abraham L. Wolbarst, "The Venereal Diseases: A Menace to the National Welfare," Medical Review 62 (1913): 327–80. Reformers clamored for an attack on prostitution, artists luridly illustrated the consequences of untreated syphilitic and gonorrheal infections, and anxious legislators passed laws that ranged from the reporting of all professionally-handled VD cases to the bacteriological examination of immigrants and prospective spouses.²⁹For more on this, see Brandt, No Magic Bullet.

The climax of these fears came during World War I. With scientific diagnoses, doctors found that a surprisingly high number of prospective US military recruits suffered from VD. Hoping to head off a manpower shortage, in 1917 Congress created the Committee on Training Camp Activities—an organization that sought to curb the venereal scourge through the forced incarceration of prostitutes, the provision of medical services for infected soldiers, and the establishment of "wholesome" alternatives to the vice-ridden recreational opportunities commonly found in cantonment zones.³⁰See Bristow, Making Men Moral. See also Alexandra M. Lord, "Models of Masculinity: Sex Education, the United States Public Health Service, and the YMCA, 1919–24," Journal of the History of Medicine and Allied Sciences 58, no. 2 (2003): 123–52. The following year Congress passed the Chamberlain-Kahn Act, which created the PHS's Division of Venereal Diseases and allocated two million dollars for the establishment of free VD clinics across the country.³¹For the Chamberlain-Kahn Act, see Alexandra M. Lord, "'Naturally Clean and Wholesome': Women, Sex Education, and the United States Public Health Service, 1918–1928," Social History of Medicine 17, no. 3 (2004): 423–41. As the war came to a close, Washington followed up on these efforts by conducting a nationwide VD survey.

The US Public Health Service VD Clinic, Spring Street, Hot Springs, Arkansas, 1921. Courtesy of the University of Arkansas for Medical Sciences Historical Research Center and Elliott Bowen.

Each of these actions drew attention to Hot Springs. Throughout the war, military authorities fretted over Little Rock's Camp Pike, a training facility whose VD rates were reportedly "the [highest] by far of any camp or cantonment in the United States."³²Victor C. Vaughan, "Protection of American Army Against Social Diseases by More Rigid Health Laws," The Pennsylvania Medical Journal 22 (1918): 26. According to Vaughan, the venereal disease rate at Camp Pike was 568.7 per 1,000 soldiers. See also, "Disease Conditions among Troops in the United States: Extracts from Telegraphic Reports Received in the Office of the Surgeon-General for the Week Ending October 19, 1917," Journal of the American Medical Association 69 (1917): 1535–6; "Venereal Disease and Birth Control," Journal of the Switchmen's Union 20 (1918): 756. According to local commanders, Camp Pike's reputation as a hotbed of sexual sickness owed to its proximity to Hot Springs, where prostitution had been legal since the late nineteenth-century and where brothels enjoyed a reputation as home to the profession's "aristocrats."³³For evidence of this, see the letters of Archie C. Cowles, a syphilitic health-seeker who traveled to Hot Springs in 1905. In a letter dated December 10, 1905, Cowles wrote that "many of the women here seem to be on the courtesan order. Of course, it would not do to call them prostitutes," Cowles remarked, "for they are aristocrats in their profession." For Cowles' correspondence, see the Archie C. Cowles Papers, Garland County Historical Society Archives, Hot Springs, Arkansas. In August 1918, Camp Pike's commanders ordered the closure of Hot Springs's numerous "houses of immorality."³⁴"Commissioners Issue Order to the City Manager to Close the Houses of Immorality, Which Goes into Effect at Once," Hot Springs Sentinel-Record, August 2, 1918. Local businessmen and religious leaders rejected the association the military made between Camp Pike's high venereal disease rate and the "terrible conditions" in Hot Springs. See "Ministerial Men to Discuss Morals: Report from Washington of Bad Conditions Here Stirs some Enthusiasts," Hot Springs Sentinel-Record, August 9, 1918; "The Moral Condition," Hot Springs Sentinel-Record, August 10, 1918. Municipal authorities reluctantly complied, but the federal government's interest in Hot Springs did not end. While conducting their post-war VD survey, government officials grew increasingly anxious about the city's "serious medical and social problems," observing that Hot Springs was home to an increasing population of venereally afflicted "indigents" and an entirely "inadequate" public health infrastructure.³⁵Audrey Wenger McCully, "The United States Public Health Service Venereal Disease Clinic and Government Free Bathhouse, 1919–1936," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

From the federal perspective, syphilitic health-seekers represented an "interstate menace."³⁶"Proceedings of the Minnesota Academy of Medicine," Minnesota Medicine 5 (1922): 61. The PHS determined to "protect the rest of the country" from those who traversed it with a venereal infection.³⁷First Deficiency Appropriation Bill, 1921; Hearings before Subcommittee of House Committee on Appropriations, 66th Congress, 3rd Session (Washington, D.C.: Government Printing Office, 1921), 588. Opening a clinic in Hot Springs devoted to rendering the afflicted non-infectious seemed the best means of accomplishing this goal. Because patients traveled here from all parts of the country, constituted a diverse racial and socioeconomic makeup, and encompassed the full range of syphilitic infections, the PHS also found in Hot Springs an unprecedented opportunity for research. Establishing a long-term presence here would also allow the government to continue its wartime campaign against "houses of immorality," while transforming a parochial medical culture.³⁸This last point holds for all of the public health campaigns undertaken in the early twentieth-century US South. In the case of Hot Springs, the city was seen as a center of quackery, and in particular, of the country's VD patent medicine industry. See Excluding Advertisements of Cures for Venereal Diseases from the Mails; Hearings before the Committee on the Post Office and Post Roads of the House of Representatives, 66th Congress, 1st Session (Washington, D.C.: Government Printing Office, 1921).

Hot Springs Sanitarium, Hot Springs, Arkansas, ca. 1930. Photograph by the Tichnor Brothers. Image courtesy of Flickr user Boston Public Library. Creative Commons license CC BY 2.0.

In late 1920 the PHS drew up plans for the facility, obtained $300,000 in construction funds and selected Oliver C. Wenger, one of the country's leading venereologists, as director.³⁹During the war, Wenger—a native of St. Louis—served in the Medical Corps of the Missouri National Guard, and later focused his efforts on "venereal disease prophylaxis" as a member of Sanitary Squad #18, stationed in Camp Mills, a military camp in Long Island, New York. Afterwards, Wenger sought and obtained appointment as a "regional consultant" in the PHS, whereupon he assisted in the nationwide venereal disease survey (1919–20). See McCully, "The United States Public Health Service." Born in St. Louis in 1884, Wenger obtained his MD from St. Louis University in 1908. During the First World War, he served in the Medical Corps of the Missouri National Guard, later traveling to England and France as part of a sanitary squad involved in VD control.⁴⁰For more on Wenger's biography, see McCully, "The United States Public Health Service." His time in Europe convinced Wenger to devote all his efforts to venereology. According to a contemporary, Wenger's idea of heaven was a place containing "unlimited syphilis," and of course, "unlimited facilities to treat it."⁴¹Reverby, Examining Tuskegee, 141. In 1919, Wenger joined the PHS Division of Venereal Disease. Before becoming director at Hot Springs, his first assignment was the national VD survey.

Inside the Clinic

Salvarsan treatment kit for syphilis, Germany, ca. 1909. Photo by the Wellcome Trust Wellcome Images. Courtesy of Wikimedia Commons. Creative Commons license CC BY 4.0

With an inaugural budget of $40,000, the clinic opened in August 1921.⁴²Oliver C. Wenger to C.C. Pierce, March 16, 1921, Hot Springs National Park Administrative Archives, Subseries 25.1.4, File A7615[04]. Hereafter NPS Archives. In its first year, five hundred patients received treatment; a total of 61,930 patients—male and female, black and white—had wound their way through by 1936, receiving 1.2 million injections of mercury and Salvarsan. Who were these individuals? How did their circumstances, needs, and experiences differ? How did prevailing ideas about VD actions influence Hot Springs's response to syphilis? And how did the clinic's campaign develop over the course of the 1920s and 1930s?

On one level, the PHS's day-to-day work reflected the widespread belief that VD constituted the "wages of sin"—a sign of sexual immorality. In lectures given by clinic personnel, patients learned that their illnesses were the result of "ignorance and your own misconduct." This message of personal irresponsibility also extended to the clinic's official instructions, which warned patients not to "loaf downtown" between treatments. Above all other commandments stood one: "DON'T GET INTO TROUBLE." And because the minimum course of therapy lasted between twenty and thirty weeks, patients were "expected to make arrangements to pay [their] own room and board."⁴³Oliver Wenger, "Instructions" (1921), Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Figure 1: VD Cases Admitted to the Hot Springs Clinic, 1922–1936

VD Cases Admitted to the Hot Springs Clinic, 1922–1936. Graph courtesy of Elliott Bowen.

The PHS advised that "no patient should go to Hot Springs without at least a return ticket and $100 in cash." Such expectations clashed with reality. Wenger observed that "less than five percent of these indigent persons had funds with which to maintain themselves while receiving free treatment."⁴⁴McCully, "The United States Public Health Service." Many arrived "without one cent of money."⁴⁵O.C. Wenger, "The United States Public Health Service Clinic at Hot Springs National Park, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. In 1931, the average applicant carried not "$100 in cash" but $15.43. The following year, $8.76.⁴⁶Oliver C. Wenger, "A Comparative Study of the Amount of Money Each Applicant Declared Under Oath at the U.S. Government Bath House for the Years 1931–32," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. Resembling a "dumping ground of many indigents" during the 1920s and 30s, Hot Springs became the preserve of all sorts of "unfortunate people" who "slept out on the hillside or in alleys, begging food from door to door...or looking for food in garbage cans."⁴⁷ O.C. Wenger, "United States Conducts Clinics for Venereal Diseases," Nation's Health 8 (1926): 103; McCully, "The United States Public Health Service." As the clinic's director admitted, "the great majority left…before they could receive enough treatment to give them any real benefit."⁴⁸McCully, "The United States Public Health Service."

One of this "great majority" was Virgil Oren Adams. A native of Clovis, New Mexico, during the early 1930s Adams made several visits to the Hot Springs VD clinic. Each time, he "ran out of funds" after only a few weeks, and being "sick and weak from lack of food and sleep," was forced to leave. In 1934 he wrote to President Roosevelt seeking assistance for yet another clinic trip. "I have been fighting syphilis since 1927," Adams wrote, adding that he was "very much interested in…getting rid of this terrible disease." "[A]bsolutely broke," Adams entreated Roosevelt for a letter to take "as a recommendation for treatments at Hot Springs." "Anything you can do in my behalf," he pleaded, would be "highly appreciated."⁴⁹Virgil Oren Adams to President Franklin D. Roosevelt, September 27, 1934. Part of Adams's story also derives from a letter he sent to Captain Geoffrey, an officer at the Hot Springs clinic. For full texts, see VD Division Records.

Cases like Adams's were of "daily occurrence."⁵⁰Oliver C. Wenger to the Surgeon General, October 18, 1934, VD Division Records. While poverty hampered patients' chances of recovery, so did the advanced state of their ailments. Most venereal sufferers came to Hot Springs long after contracting syphilis or gonorrhea. Most had not received more than a few shots of mercury or Salvarsan, and many relied only on cheap, ineffective patent medicines.⁵¹For evidence of this, consider the case of James Gordon. A Michigan man, in 1926 Gordon wrote the PHS asking for help in getting to Hot Springs. "I have tried [sic] all kinds of medicines, which you know that it [sic] takes money." From a book he had read, Gordon surmised that "there is not mutch [sic] chance for a poor man there," but still he pleaded: Hot Springs was "the last chance I have got—I have every thing [sic] else until my money is gone." For this letter, see James R. Gordon to United States Public Health Service, August 17, 1926, VD Division Records. Their illnesses were chronic, and generally immune to existing remedies. With disease burrowed deep in their bodies, few had any hope of ever being free from VD.

The Salvarsan room, US Public Health Service VD Clinic, Hot Springs, Arkansas, date unknown. Courtesy of the University of Arkansas for Medical Sciences Historical Research Center and Elliott Bowen.

Realities such as these inspired a modicum of sympathy among clinic doctors. Particularly worrying to Wenger was the fate of ex-servicemen. Disappointed by the fact that during World War I, "our young American manhood" was often "unable to serve because of venereal diseases," Wenger observed hundreds of infected former soldiers seeking admittance to the Hot Springs clinic during the early 1920s. Like most patients, they were "nomads, seeking treatment here and there." Particularly troubling was the fact that these veterans were beginning to form families, and had entered "the best years [of their lives] from an economic standpoint." All of them needed medical attention; none were in a position to pay. Such matters made the treatment and control of syphilis and gonorrhea a national priority, he urged, especially "from the standpoint of race conservation."⁵²Wenger, "The Need for Social Hygiene."

Language such as this dovetailed with contemporary eugenic discourse. Like other eugenicists, Wenger's interest in "race conservation" stemmed from anxieties over white racial purity and integrity. Over the course of the nineteenth and early twentieth centuries, birth rates among native-born white women declined by approximately 45 percent, and this, coupled with the simultaneous arrival of millions of "new immigrants" from southern and eastern Europe, prompted fears of "race suicide" among the nation's political and cultural elite.⁵³For more on America's fertility transition, see J. David Hacker, "Rethinking the 'Early' Decline of Marital Fertility in the United States," Demography 40, no. 4 (2003): 605–20. Speaking to these fears, New York City gynecologist Abraham Wolbarst opined that "the flower of our land, the mothers of our future citizenship, are being mutilated and unsexed by surgical life-saving diseases, particularly gonorrhea."⁵⁴Wolbarst, "The Venereal Diseases," 373. Sentiments such as Wolbarst's were widely held by PHS officials, including Oliver Wenger—whose eugenic beliefs scholars have also observed in his later work in Tuskegee and Chicago.⁵⁵For more on this, see Reverby, Examining Tuskegee, 139–44.

The PHS sought means of accelerating the therapeutic process. Among the myriad venereological experiments conducted at Hot Springs, none loomed larger than those undertaken within the Salvarsan room. During the early 1920s clinic personnel began "the intensive and continuous plan of treatment."⁵⁶McCully, "The United States Public Health Service." In the typical VD clinic, patients received one dose of Salvarsan per week; in Hot Springs, they would receive twice that amount.⁵⁷J.R. Waugh and Elizabeth Milovich, "Severe Reactions to Arsphenamine among 3,050 Previously Untreated Patients," Journal of Venereal Disease Information 21, no. 12 (1940): 391. The Hot Springs clinic, it bears noting, was far from the only site where this experimental use of Salvarsan took place. In the medical literature of the time, many physicians reported success with an accelerated treatment regimen, and some recommended giving as many as three doses in a twenty-four hour period. One advocate advised colleagues to "give the largest possible amount of salvarsan in the shortest possible time." Faxton E. Gardner, "The Treatment of Syphilis," Medical Times 45 (1917): 63. For more discussions of the intensive and continuous treatment of syphilis with Salvarsan, see Frederick W. Smith, "The Modern Diagnosis and Treatment of Syphilis," Medical Record 91 (1919): 186–91; B.C. Corbus, "Prophylaxis in Cerebrospinal Syphilis," Journal of the American Medical Association 69, no. 25 (1917): 2087–9; Carlyle N. Haines, "Salvarsan in Syphilis," Pennsylvania Medical Journal 24 (1921): 839–41.

Top, Wax models showing the effects of syphilis symptoms on the face before and after Salvarsan, Germany, ca. 1910. Image courtesy of Wellcome Trust Medical Photographic Library. Creative Commons license CC BY 4.0. Bottom, Wax models showing the effects of syphilis symptoms on the extremities before and after Salvarsan, Germany, ca. 1910. Image courtesy of Wellcome Trust Medical Photographic Library. Creative Commons license CC BY 4.0.

Derived largely from arsenic, a highly toxic substance, Salvarsan was a frightening remedy. While more effective than mercury, its use was accompanied by a panoply of side effects—from the mild (dermatitis, gastro-intestinal distress) to the severe (ocular damage, cardiac distress, edema). In rare cases, death resulted. In a review of 6,308 syphilis patients admitted between 1922 and 1932, Wenger counted a total of 225 adverse reactions to Salvarsan—including three fatalities from arsenical poisoning.⁵⁸O.C. Wenger and Lida J. Usilton, "Notes on the Syphilis Clinic, United States Public Health Service, Hot Springs, Arkansas," Journal of Venereal Disease Information 15, no. 6 (1934): 210. It is impossible to verify these morbidity and mortality figures, as the clinic operated free from federal oversight. Because of this, and also because of the clinic's generally poor record-keeping practices, the number of "adverse reactions" may be higher than what Wenger reported. For more on the latter problem, see C.H. Waring to the Surgeon General, January 23, 1923, VD Division Records. It appears that severe reactions to Salvarsan were more common here than elsewhere.⁵⁹In a 1940 study, clinic personnel revealed that nearly 2.5 patients per thousand experienced "severe reactions" to Salvarsan—a rate higher than the 1.99 per thousand reported by the Cooperative Clinical Group's studies of syphilis. Waugh and Milosivic, "Severe Reactions." Cognizant of the fact that "the duration of anti-syphilitic treatment at the Hot Springs clinic is for a relatively short time," Wenger's staff rushed to experiment with untested modes of therapy. The adoption of an "intensive and continuous plan of treatment" contributed to the clinic's high rate of serious complications.⁶⁰Wenger and Usilton, "Notes on the Syphilis Clinic," 209. For further evidence of serious medical complications following upon the clinic's intensive plan of syphilis treatment, see George E. Tarkington, "Value of Liver Function Test in Arsenical Therapy," Journal of Venereal Disease Information 7, no. 1 (1926): 24–5. For details of a specific injury, see Paul S. Carley, "Infarction of Buttock from Intra-Muscular Injections of Mercury Benzoate," Journal of Venereal Disease Information 17, no. 10 (1936): 281–3. It bears noting here that during the 1920s and 1930s, the idea of "informed consent" had not become a universally recognized principle within medical ethics. Because of this, scientific investigators were not required to obtain patient permission before proceeding with experiments. Those housed within custodial institutions (public hospitals and clinics, asylums, prisons, orphanages, etc.) were especially targeted for human subjects research, with the justification often being that they owed society a debt in exchange for the free treatment they received. For more on this, see Susan Lederer, Subjected to Science: Human Experimentation in America before the Second World War (Baltimore, MD: Johns Hopkins University Press, 1997).

Such was certainly the case for Forrest LaPrade. A twenty-four-year-old Texan who arrived in Hot Springs in March 1930, LaPrade's original intention was to "boil out nicotine and malaria" through the city's "healing waters." Directed to Wenger's clinic for a physical, LaPrade was found to be syphilitic. Over the next few weeks he received seven shots of Salvarsan and eleven of mercury. His condition then worsened.⁶¹For the details of LaPrade's case, see G.L. Collins to the Surgeon General, October 11, 1932, VD Division Records.

On May 2, 1930, LaPrade complained of a "slight oedma" of the face, which his physician noted was "characteristic of arsenical poisoning." By the next day, he displayed a "face intensely swollen," along with a fever and an accelerated heart rate. After being diagnosed with erysipelas, LaPrade was transferred by a friend to a nearby hospital, where for twenty-eight days he experienced "untold agonies." Hoping to heal his swollen face, from which dripped "large drops of yellow corruption," LaPrade's doctors covered him with a white, glue-like paste, a remedy that produced a constant itching sensation that left the Texan "at the point of death." "I was actually skinned alive," LaPrade later said, describing how the itching left him "scaled like a fish." Unable to sleep, LaPrade's condition was so bad that his body "trembled like a leaf and even shook or quivered the bed." "I suffered, cried, and prayed as one who was in the doorway of Hell," he recalled with horror. "But for the Lord, I would have been six feet of earth."⁶²Forrest D. LaPrade to Mr. Wright Patman, June 10, 1930, VD Division Records.

Although few patients faced an ordeal like Forrest LaPrade's, the clinic's experiments failed to produce "new and better methods to fight venereal diseases."⁶³M.J. White, "Next Steps in the Field of VD Control from the Standpoint of the United States Public Health Service," Journal of Venereal Disease Information 7, no. 1 (1926): 173. A report from the PHS's Division of Venereal Diseases spoke in disappointed terms: "It was hoped that this clinic would prove useful from a research standpoint, but because of the transient character of the patients, results thus far have not been up to expectations."⁶⁴"Meeting of the Advisory Committee to the Division of Venereal Diseases, United States Public Health Service, May 16, 1927," Journal of Venereal Disease Information 8, no. 8 (1927): 303. And as late as 1936, clinic personnel were still reporting on the "comparatively small number of treatments given" to patients—a reference to how few individuals completed a full course of anti-venereal treatment.

Figure 2: Sex Differentials in Syphilis by Stage of Disease upon Arrival in Hot Springs, 1922–1932

Sex Differentials in Syphilis by Stage of Disease upon Arrival in Hot Springs, 1922–1932. Graph courtesy of Elliott Bowen.

Healing the "Other": Women and African Americans at the Hot Springs VD Clinic

Because their attempts to accelerate the curative process largely failed, Wenger's staff also investigated ways of keeping patients within Hot Springs for longer periods of time. This search for extra-medical means of disease control had a racial foundation, one that becomes clear through an examination of doctors' experiences with female patients. Initially, Wenger and his staff harbored quite negative attitudes toward women, who were seen as "uncontrolled spreaders of infection" and a "menace to the community at large."⁶⁵Wenger, "The Need for Social Hygiene"; Oliver C. Wenger, Annual Report for 1923, Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. With the passage of time, however, clinic personnel became increasingly sympathetic to the plight of female health-seekers—even those who supported themselves through prostitution while receiving treatment. From these sentiments (which extended only to whites) emerged a non-traditional disease control program, one rooted not only in testing and treatment, but also in socioeconomic measures—including financial aid for food and housing.

A woman at the VD clinic in Union Point, Green County, Georgia, 1941. Photograph by Jack Delano. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/fsa.8c05888/.

Wenger's first few years in Hot Springs were characterized by an intensive crackdown on the city's red-light districts, which had re-opened in the aftermath of World War I. Hoping to prevent local brothels from recovering their former strength, in January 1921 the PHS presented an ultimatum to municipal authorities, explaining that unless the city abolished its regulated district the agency would quarantine all individuals who came to Hot Springs seeking treatment for disease—venereal or otherwise. Recognizing that it would "prove a great financial blow to the city if this patronage were lost," the PHS argued that it was "absolutely inconsistent to permit men to go there for the cure and, at the same time be exposed to reinfection through the agency of an open red-light district." Women too would be subject to these measures, as some of the female patients in Hot Springs were prostitutes who "carry on their profession while under treatment."⁶⁶"Hot Springs Threatened With Loss of Patronage: Health Resort Must Eliminate Red-light District," The Social Hygiene Bulletin 8, no. 1 (1921): 8.

This seemed clear from a report Wenger received from the Interdepartmental Social Hygiene Department (ISHD) in 1922. A governmental entity tasked with investigating the relationship between prostitution and VD, the ISHD in 1921 sent an agent named Blanche Young to Hot Springs. Upon questioning a few girls "of the prostitute type" found within the city's public dance halls, she concluded that no progress against VD would be forthcoming unless the federal government abolished its system of regulated prostitution. One of the prostitutes Young met with informed her that "she had gone to the city for medical treatment and was under the care of a private physician." On another occasion, Young encountered a "very fast looking girl enter[ing] an automobile occupied by three young men who were obviously under the influence of liquor." "A little later," Young continued,

I saw this automobile stop and the men 'pick up' two girls. This was about 11:43 PM. The men talked to the girls on the street, inducing them to enter the car, immediately driving off. The next day I recognized in both the G.U. [genito-urinary] and syphilis clinics one of the girls who was present in the dance hall.⁶⁷L. Blance Young to O.C. Wenger, February 8, 1932, Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Prostitution spreads Syphilis and Gonorrhea, ca. 1943. Poster by the Office for Emergency Management, Office of War Information, Domestic Operations Branch, Bureau of Special Services. Courtesy of Wikimedia Commons. Image is in public domain.

Reports such as these inclined Wenger toward an all-out assault on the city's red-light district. As during wartime, Hot Springs's response to this federal ultimatum was regretful compliance. The death of the city's physician-mayor J.W. McClendon—"the leader of the wide-open town policy"—eased Washington's task. With the removal of this "obstacle," the PHS convinced local law enforcement officials to fall in line.⁶⁸O.C. Wenger to David Robinson, April 18, 1921, Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. By the summer of 1922, five brothels had been shut down; by 1923, their number had been reduced by half.⁶⁹ Information on brothel closures comes from my own analysis of police dockets from the City of Hot Springs, 1920–1923. These documents can be found in the Garland County Historical Society Archives, Police Department Records, Vertical Files, Garland County Historical Society, Hot Springs, Arkansas. In 1918, before the initial crackdown on prostitution, sex-workers accounted for almost one-fifth of all criminal arrests in the city. These results bore out the federal government's conclusion that local personnel had been "very successful" in "eliminating houses of prostitution" in Hot Springs.⁷⁰First Deficiency Appropriation Bill, 1921: Hearing before Subcommittee of the House Committee on Appropriations (Washington, D.C.: Government Printing Office, 1921), 568.

This assessment proved premature. The interwar years brought new life to prostitution. While initially complying with the PHS, steep declines in revenue from saloons and bawdy houses prompted municipal officials to change their minds.⁷¹"Hard Sledding for Bankrupt City," Yearbook of the City Managers' Association 6 (1920): 85–6. In the late 1920s, the city's mayor "[threw] the town wide open" to prostitution, and in the next decade, cases of "female patients street-walking or soliciting" were "almost of daily occurrence."⁷²Oliver C. Wenger, "The Transient-Indigent-Medical Problem at Hot Springs National Park, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. The clinic did little to oppose this challenge to federal authority. A 1934 visitor to the city remarked that Hot Springs was "the only national park where gambling, imbibing, and prostitution go unmolested."⁷³Ray Hanley, A Place Apart: A Pictorial History of Hot Springs, Arkansas (Fayetteville: University of Arkansas Press, 2011), 81; "Hot Springs Would Secede," Today 3 (1934): 23.

What explains this reversal? For one, it appears that clinic personnel had little appetite for prolonged conflict with the array of local forces (officials, doctors, and brothel owners) opposed to the abolition of prostitution. More important, however, were the interactions clinic personnel had with female patients—many of whom sold their bodies for sex while seeking VD treatment.

Consider the experience of a "young white woman" from Tennessee named "O.J." Orphaned since childhood, O.J. had grown up at the House of the Good Shepherd in Memphis. With "limited" opportunities, she then supported herself largely through prostitution—by which she contracted both syphilis and gonorrhea. Upon arriving in Hot Springs, O.J. found work as a boarding house maid. Subsequently accused by her landlady of "running around with men," O.J. found herself back on the streets. For the remainder of her stay, she supported herself through prostitution, a decision defended with three words: "I must eat." While concerned over the number of "boy friends" this "more than ordinarily attractive" woman had infected, Wenger sympathized with O.J.'s plight, explaining to his superiors that "she was a good patient and reported regularly for treatment." Summarizing her case, the PHS agent conceded that "it is hard to be chaste and hungry."⁷⁴Wenger, "The Transient-Indigent-Medical Problem."

Kettering Hypertherm used in the treatment of VD, Camp Garraday VD Clinic, Hot Springs, Arkansas, date unknown. Courtesy of the University of Arkansas for Medical Sciences Historical Research Center and Elliott Bowen.

Interactions with patients like O.J. had a dramatic impact on clinicians, who came to accept prostitution not as an indication of immorality, but as a consequence of the adverse circumstances many female patients faced.⁷⁵Wenger, Annual Report for 1923. In one of his earliest reports, Wenger spoke of the "large number of female patients" who arrived in Hot Springs with "no funds" and "no friends." With work "scarce" in the city, many of these women—in a "much discouraged" state—were "forced by dire necessity to support [themselves] by prostitution."⁷⁶Oliver C. Wenger, "History of United States Public Health Clinic, Hot Springs, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. The experiences of patients like O.J. were "not unique nor unusual, but exactly what goes on as these transients move across the country in their efforts to receive free medical service."⁷⁷ "Any person who engages in travel," Wenger maintained, "may be the carrier of a communicable disease." "Every health officer knows," he reminded his superiors, "of instances, when, from one single source, hundreds and thousands of new cases have developed." Oliver C. Wenger, "The Indigent, Transient Problem and Its Relation to Public Health," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. Criticizing those who argued that prostitution could not be tolerated, Wenger explained that "as social workers and health officers, we must change our own attitude and remember that we ourselves would become transients seeking medical services if they were not available at home. This is only natural."⁷⁸Ibid. In connection with Wenger's apparent acceptance of prostitution in Hot Springs, it is interesting to note that while overseeing a VD control program in Puerto Rico during the Second World War, the PHS official was privately reprimanded for proposing "methods of registration and identification of prostitutes which seem quite out of line" with the federal government's official policy of repression. For more on this, see Surgeon General Parran to Senior Surgeon O.C. Wenger, March 23, 1942, Thomas Parran Papers, Series 1, Box 5, University of Pittsburgh, Pennsylvania. Hereafter, Parran Papers.

Consistent with his new understanding of prostitution, Wenger's interactions with female patients displayed a lack of moralizing. In lectures on how to "prevent a second infection," he endorsed the use of condoms and taught women "the value of prophylaxis and also contraceptives, or birth control methods." A typical lesson began with a discussion of female anatomy and concluded with demonstrations of birth control techniques.⁷⁹In educating his patients on the use of contraceptives, Wenger was taking a risk. As he noted in a 1926 letter sent to Thomas Parran (the recently-appointed director of the PHS's Division of Venereal Diseases), "the whole subject of prophylaxis is T.N.T. at this stage of the game," and as such, advocating too forcefully on behalf of birth control measures "might innocently start some unwelcome comment"—particularly in the South. On account of this, Wenger generally advised that the PHS "let the State V.D. men do as they please"—another sign of the impact local forces had on the federal government's efforts. For more, see Oliver C. Wenger to Thomas Parran, October 23, 1926, Parran Papers. While initially concerned about how female patients would react to these frank methods, Wenger reported that "there has been no embarrassment on the part of the volunteer subjects or the patients looking on. The remarks and questions asked during the demonstrations are amazing."⁸⁰O.C. Wenger to Dr. White, January 13, 1925, VD Division Records.

The clinic's female patients also encouraged Wenger to search for economic solutions to the country's VD epidemic. Consider the 1933 case of "Mrs. W." A white, college-educated woman who "came here all the way from old Mexico" after having been deserted by her husband (who infected her with syphilis) and having "suffered losses in the general depression." Upon arriving in Hot Springs, Mrs. W. initially stayed with a "colored friend." When this woman's relatives moved in, Mrs. W. informed clinic personnel that she was "planning to 'hitchhike' her way back to Nogales, Arizona," where friends would take her home. Believing such a trip would be "practically impossible," Wenger turned to local welfare agencies, "who agreed to pay half of her fare." The remainder was "made up by clinic personnel." Discussing her case in a report to his superiors, Wenger noted that "this is just another instance, in which, if maintenance could have been arranged for a longer period of time, the patient could have probably improved sufficiently to take her place again among her friends and be self-supporting."⁸¹Wenger, "The Transient-Indigent-Medical Problem."

Like O.J. and Mrs. W., most of the women who made their way to the Hot Springs clinic in the 1930s were white.⁸²During the clinic's formative years, white women never accounted for more than one-fifth of the clinic's annual caseload. Between 1928 and 1936, however, their numbers steadily grew, reaching a peak of 2,353 in 1935—a year in which they represented nearly one-third of all patients treated. During the same period, African Americans' share of the clinic's annual caseload declined from 36.9 percent to 20.3 percent—a trend especially evident among females. O.C. Wenger, "Summary Statistical Data," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. They received a much more sympathetic response than did the city's black health-seekers. Consider the case of Charley Wade Bradshaw. Shortly after entering the clinic on September 3, 1927, Bradshaw—a twenty-five year old black man employed as a porter by the Oklahoma City Railway Power House—was diagnosed with neurosyphilis and placed on a regimen of mercury. For six weeks, Bradshaw's savings enabled him to rent a room at a colored hotel, but on October 19, he was reported "AWOL." One year later, an Oklahoma City law firm supplied the reason for this abrupt departure. Coming to Hot Springs after company doctors "advised him that he had bad blood," Bradshaw left after running out of money for room and board. As an attorney informed Wenger, Bradshaw was "in a bad condition physically," and because he had "no means whatever," anyone who tried to help him "will have to do so at their expense."⁸³Walter Martin to O.C. Wenger, March 2, 1928, VD Division Records.

Wenger apparently made no effort to pay for Bradshaw's expenses, despite his recognition of the socioeconomic inequalities that imperiled black health.⁸⁴Between 1922 and 1932, the number of African American visitors listed in the "unskilled labor" category was "nearly twice as high" as the comparable figure for whites. O.C. Wenger, "An Analysis of 10,000 Cases of Syphilis," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. While concurring that venereal diseases were "playing havoc within the Negro population of the country," he criticized those who interpreted these findings as evidence of African Americans' "absolute lack of morality." The observed differential between whites and blacks, commented Wenger, "does not mean that there is a considerable difference in the morals of these different groups." The critical variable was African Americans' "social economic status"—in particular, their "more limited" educational and employment opportunities. "When the social and economic backgrounds of the two races are considered," he concluded, "there seems to be little difference in the incidence of infection."⁸⁵Oliver C. Wenger, "Analysis of 10,000 Cases of Syphilis," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Syphilis: False shame and fear may destroy your future, have your blood tested, New York, 1938. Poster by Erik Hans Krause. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/ppmsca.38340/.

Improving black health-seekers' access to treatment required more than a rejection of the "syphilis-soaked negro" stereotype. When it came to removing institutional and economic barriers confronting African American VD patients, Wenger did little. He refused to challenge Hot Springs's adherence to Jim Crow, which confined African Americans to an "exterior observation" of all but two of the city's bathhouses. In addition to the "great disadvantage" they faced due to the "lack of proper accommodations in hotels and bathhouses," black patrons had fewer opportunities for securing therapeutic services than did whites. The Depression felled the one institution—the Woodmen of the Union Hospital—specifically catering to blacks.⁸⁶ A.W. Hunton, "The American Carlsbad," The Voice of the Negro 3, no. 5 (1906–7): 331; C. Melnotte Wade, "Hot Springs—Its People," Colored American Magazine 10, no. 1 (1906): xviii; O.C. Wenger, "The United States Public Health Service Clinic at Hot Springs National Park, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives; O.C. Wenger to Surgeon General, July 27, 1934, VD Division Records.

Black patients also faced the racial hostility of local physicians—some of whom worked in the PHS clinic. Believing that their higher rates of syphilis and gonorrhea stemmed from "the negro's almost absolute lack of morality and cleanliness," the resort's white doctors contended that southern blacks were "little better than animals with strong sexual passions."⁸⁷ Thompson, Syphilis, 52. Some believed that emancipation constituted the primary cause of syphilis's spread "among the negro population of the South," as rampant promiscuity created a situation in which "the very existence of the race is threatened."⁸⁸L.R. Ellis, "Address of the Chairman of the Section on Dermatology and Syphilology," Journal of the Arkansas Medical Society 6 (1909): 44; Loyd Thompson and Lyle B. Kingerly, "Syphilis in the Negro," American Journal of Syphilis 3 (1919): 396.

Racist attitudes were on display within the Hot Springs VD clinic. Admitted in July 1925, George Smith was a black man who came to the attention of local authorities after his arrest for "night prowling." While a judge ordered his release on the condition that he leave town, a Wassermann test revealed that Smith was infected with syphilis. Shortly after Wenger prevailed upon the city to permit his entrance into the PHS facility, trouble began. One day while receiving an injection of mercury, Smith reportedly became "impudent," and the doctor treating him "lost his temper and threatened to ruin" the man. Upon hearing of the incident, Wenger informed Smith to "remain away" from the clinic until the physician in question—a Dr. Abington—left. Though not expelling him, Wenger warned the doctor not to "cuss" the patients, and in his review of the case, the PHS official observed that Abington "was born and raised in the South, and [was] prejudiced toward all aggressive negroes."⁸⁹O.C. Wenger to the Surgeon General, July 20, 1925, VD Division Records .

With the advent of the Great Depression, fewer and fewer men such as Charley Bradshaw and George Smith entered the Hot Springs clinic. As the economic misery of the 1930s increased, the proportion of black men and women admitted to the clinic declined precipitously; whereas in the 1920s, roughly one-third of the city's health-seekers were African American, by the middle part of the 1930s, this figure had fallen to about one-fifth. Those able to pay for a stay came later in the course of their infections than did whites, and in addition to presenting less curable forms of illness, they left Wenger's clinic much earlier than did white men and women.⁹⁰On average, between 1922 and 1936, African American rates for tertiary syphilis were ten percentage points higher than those of their white counterparts, who also presented 8 percent more primary and secondary cases than did black syphilitics. O.C. Wenger, "Classification of Syphilis Cases, U.S. Public Health Service Clinic," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. A 1940 study revealed that the average white syphilitic received twelve shots of Salvarsan, and blacks only nine.⁹¹Waugh and Milovich, "Severe Reactions," 390. For further evidence of the unfavorable therapeutic outcomes for black patients, see J.R. Waugh and W. Burns Jones, "Genito-Urinary Survey of 1,625 Male Patients, United States Public Health Service Venereal Disease Clinic, Hot Springs, Ark.," Journal of Venereal Disease Information 13, no. 1 (1932): 9.

Instances of racial discrimination continued. In 1941, a PHS officer reportedly entered a number of "reputable Negro business places" in nearby Texarkana, arresting several "young ladies," and then transporting them to Hot Springs for treatment—all without testing them for venereal disease.⁹²"Officer Uses 'Gestapo' Methods: Texarkanians Terrorized, Business Houses Molested," Arkansas State Press, July 25, 1941, 1. Such tactics soured many black syphilitics on Hot Springs.⁹³For likely racial discrimination, see Paul Carley, "Infection with Syphilis Masked by Gonorrhea," Journal of Venereal Disease Information 18, no. 2 (1937): 21–4. For their part, black newspapers discouraged readers from journeying into central Arkansas, noting that northern health resorts and spas were "more attractive than Hot Springs" on account of the latter's "awful...Jim Crow cars and other uncivilized offerings to the colored visitor."⁹⁴"Negroes Can Bathe at French Lick Springs," The Michigan State News, Tuskegee Institute News Clippings File.

Clinic to Camp

From the beginning, clinic personnel were wary of attracting local citizens' ire. Hot Springs's patients frequently "[ran] into trouble with the police for housebreaking and robbing. " Local residents resoundingly objected to "the presence of such large numbers of indigent VD cases on the city streets."⁹⁵"Hot Springs Judge Wroth over 'Dumping' of Indigent Diseased Transients in City," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives; Wenger, "The Transient-Indigent-Medical Problem"; O.C. Wenger to Surgeon General, July 27, 1934, VD Division Records. As early as the mid-1920s, Wenger called on the federal government to provide "some means of housing these indigent patients, or at least of providing them with sufficient food while they are under our care."⁹⁶O.C. Wenger, "United States Conducts Clinic for Venereal Diseases," 103. Such aid never came.

During the Depression—as the city was "swamped with applicants seeking medical aid"—"begging, borrowing, and stealing" intensified.⁹⁷Oliver C. Wenger to Taliaferro Clark, August 29, 1931, NPS Archives. Many of these applicants, wrote Wagner, belonged to a "much higher type group," individuals who in normal times would not have had to avail themselves of free, government-provided services.⁹⁸O.C. Wenger, "The Transient-Indigent-Medical Program," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. Aware of the ways his clinic was "causing objection and criticism from certain groups of citizens," in 1933 Wenger again asked for federal housing of indigent patients. His next budget included monies courtesy of the Arkansas Transient Bureau (ATB), a branch of the Federal Transient Bureau, to provide "free room and board" at "$1.00 per day per patient," as well as funds for hospitalization, telegrams, minor emergencies, and transportation home.⁹⁹Ibid.

During its first month in operation, the ATB provided shelter, clothing, food, and medical attention to over 2,300 VD patients—black as well as white, female as well as male. The program reaped immediate dividends: according to state officials, only one year after implementing Wenger's "maintenance" plans, the number of venereal health-seekers leaving Hot Springs non-infectious increased by 38 percent.¹⁰⁰R.O. Brunk, "Some Interesting Facts," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. Echoing these sentiments, in January 1934, Wenger wired Washington praising the ATB for "giving out free room and board," noting that as a result of this "most of the old patients are remaining because they are getting free room and board and are taking more treatment."¹⁰¹Oliver C. Wenger to Dr. Vonderlehr, January 10, 1934, NPS Archives.

Figure 3: Salvarsan Injections Per Patient, 1922–1936

Salvarsan Injections Per Patient, 1922–1936. Graph courtesy of Elliott Bowen.

As diseased men and women descended onto Hot Springs, by early 1935 the ATB was providing for 4,000 diseased indigents.¹⁰²McCully, "The United States Public Health Service." City officials claimed that many patients were "irresponsible as to their personal conduct"; every day, one local paper reported, twenty-five health-seekers faced arrest on charges of drunkenness and disturbing the peace.¹⁰³Brunk, "Some Interesting Facts," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives; "Hot Springs Judge Wroth over 'Dumping' of Indigent Diseased Transients in City," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. "If the federal government continues to invite the scum of the earth here," complained a judge to the PHS, "I guess we'll just have to move out and give the town to you."¹⁰⁴"Hot Springs Judge," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Hot Springs officials began resisting calls for assistance, even refusing to admit dozens of children whose parents were receiving treatment into the public school system. Despite Wenger's "most vehement protests," and despite repeated assurances that it was "perfectly safe" for these children to mingle with local children, municipal leaders were adamant.¹⁰⁵Oliver C. Wenger, "A Plan for the Consolidation of all Medical Measures for Transient Relief in Hot Springs, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. They began to push for the removal of the clinic's "undesirable" indigent transients.¹⁰⁶"Council Approves New Transient Plan," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Conceding that patients "cannot be left to roam at will and get into difficulties on the streets of Hot Springs," federal officials and the ATB considered construction of a camp on the city outskirts to house clinic patients and "give them wholesome occupation and recreation."¹⁰⁷Antoinette Cannon, "Hot Springs Transient Program," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives. Initially, Wenger opposed these plans, but in order to "meet the needs of patients and the community," in 1934 the ATB began building a camp "for lone men who are under care in the United States Public Health Service clinic.¹⁰⁸Ibid.

Inside Camp Garraday, date unknown. Courtesy of the Garland County Historical Society and Elliott Bowen.

A year later, Camp Garraday opened on a thirty-three acre tract with a sixty-bed infirmary, nine barracks, kitchen, dining hall, and recreation building. During its first year, the ATB facility quartered five hundred white male transients.¹⁰⁹O.C. Wenger, "A Plan for the Consolidation of all Medical Measures for Transient Relief in Hot Springs, Arkansas," September 5, 1935, NPS Archives. While these men—whom Wenger labeled the clinic's "hardest problem"—benefited from the "good food," shelter, immediate medical attention, and recreational opportunities provided directly by the federal government, white women and African Americans of both sexes continued to subsist under the old plan, by which they were "maintained in rooming and boarding houses throughout the city."¹¹⁰O.C. Wenger, "The United States Public Health Service Clinic at Hot Springs National Park, Arkansas," Oliver C. Wenger Papers, Box 1, University of Arkansas for Medical Sciences Archives.

Camp Garraday embodied the PHS's eugenic understanding of VD. While Wenger labeled white male patients a "problem," they were central to his ideology of "race conservation" and thereby worthy of privileges. Other patients might receive very modest financial aid, but they had to find sources of food and shelter, and felt the full force of the city's loathing. By contrast, white male patients received care on site, in a domiciliary setting. And Wenger sought to expand the camp's capabilities. In his 1936 budget, he recommended $55,320 for additional forms of support—including a butcher, a recreational supervisor, a housing director, a nursery, and a children's school (with principle and one teacher)—for Camp Garraday's residents.¹¹¹Oliver C. Wenger, "A Plan for the Consolidation of All Medical Measures for Transient Relief in Hot Springs, Arkansas" (September 5, 1935), NPS Archives.

Wenger's plans never came to fruition. Local white citizens quickly and vehemently complained that Camp Garraday, "a Frankenstein monster," restored the "old stigma that Hot Springs is a place only for the treatment of venereal diseases." As the director of the Hot Springs Reservation explained, the PHS's efforts threatened to "ruin the results of the past hundred years of our history, to say nothing of the millions of dollars invested in the resort by private capital." The existence of Camp Garraday functioned to "make the place undesirable for pay patients."¹¹²As one local authority put it, developments of the early 1930s had given the health resort's more wealthy visitors the impression that "the transients being treated here were so numerous that [they] would overrun everything," and on account of this, the city had become "undesirable for pay patients." Thomas J. Allen to Arno B. Cammerer, July 23, 1934, NPS Archives.

Trailer-laboratory for the mobile syphilis control project, Washington, DC, 1937. Photographer unknown. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/hec.23247/.

Unable to overcome residents' objections to Wenger's maintenance program and the ATB's camp plan, the federal government terminated the Transient Bureau in 1936 and Camp Garraday ceased to house patients. Venereal health-seekers wishing treatment in Hot Springs were required to bring "sufficient funds available to pay their room and board over a period of at least ninety days."¹¹³John J. McShane to All Local Health Authorities, March 10, 1936, VD Division Records. For Oliver Wenger, who left Hot Springs in 1937 to take part in Chicago's Syphilis Control Program, it was a bitter ending. It appeared to him that Hot Springs was in no better shape than when he first arrived fifteen years earlier.

The same year Wenger left Hot Springs, Congress passed the National Venereal Disease Control Act. Allotting funds to the states, this legislation enabled a dramatic expansion in the nation's anti-venereal infrastructure. Arkansas soon felt the act's effects: prior to 1937 there were no state-run VD clinics here; by 1943, there were eighty-three. These new medical facilities treated fifteen thousand patients per year, far exceeding the heyday of the Hot Springs VD clinic.¹¹⁴"Venereal Disease Control," Arkansas Health Bulletin 1, no. 3 (1944): 6–9. In tandem with the mass production of penicillin in the 1940s, these developments led to a precipitous decline in the nationwide incidence of syphilis and gonorrhea. By the early 1950s, the country's VD "epidemic" had ended, and although rates for both syphilis and gonorrhea rose in subsequent decades, the government's model VD clinic would play no part in post-war developments.

Conclusion: Race, Hot Springs, and Tuskegee

The history of the Hot Springs VD clinic reveals how eugenics shaped the federal government's response to syphilis and gonorrhea. The facility's day-to-day operations show how the goal of "race conservation" structured patient experiences and outcomes. On account of the high volume of white syphilitics seeking admittance, clinic personnel became increasingly sympathetic to patients' circumstances and needs, and eventually, this sympathy manifested itself in a medical program that included free treatments as well as stipends for housing and food. While patients, regardless of race or sex, benefited from these extra-medical measures, it is unlikely the PHS would have launched such an approach to VD had not the primary beneficiaries been white males. The Camp Garraday transient center doled out special services to clinic patients because they were white men.

As old as creation Syphilis Is now curable, Hempstead, New York, ca. 1936. Poster by WPA Federal Art Project. Courtesy of the Library of Congress Prints and Photographs Division, loc.gov/resource/cph.3b48847/.

How did eugenics and scientific racism unfold at Hot Springs as compared with Tuskegee? As the failure of its venereological research program suggests, Hot Springs is a story about subjects becoming patients. In Tuskegee, the opposite occurred. What began as a series of mass treatment campaigns ended up as a horrific forty-year research program revolving around the denial of medical services. Tuskegee's creators tried to explain their complicity by invoking the Great Depression, claiming that their actions resulted from agency budget cuts that rendered additional funding for VD treatment impractical. However, just as the Depression deepened its hold, the PHS began pouring money into the Hot Springs clinic, whose patients were provided with drugs as well as with funds for food and shelter. The clientele at Wenger's clinic were primarily white; those enrolled in the Tuskegee study were black.

Race played a determining role in the PHS's attack on syphilis and gonorrhea. In broadening the scope of historical study beyond Tuskegee, and in particular by looking at the agency's policies toward white patients, the extent of the government's racialized response to VD becomes clearer.

About the Author

Elliott Bowen is a professor of history at Nazarbayev University and a historian of medicine and public health in the modern United States. His research explores the history of sexually transmitted diseases. Bowen is currently working on a book-length project about the history of Hot Springs, Arkansas.

Ungesund: Yellow Fever, the Antebellum Gulf South, and German Immigration

Madison Elkins — Mon, 12 Dec 2016 05:00:00 +0000

Introduction

During the antebellum era, New Orleans became the second largest port of US immigration after New York City, leading hundreds of thousands of Germans to begin new lives at the mouth of the Mississippi rather than the Hudson. ¹Carl Leon Bankston, ed., Encyclopedia of American Immigration, vol. 2 (Ipswich, MA: Salem Press, 2010), 476. New Orleans boasted one of the earliest and most vibrant German communities in North America, yet the German-born growth rate in Louisiana during these years pales in comparison to states such as New York and Pennsylvania, as well as that of other slave states such as Missouri, Kentucky, and Maryland. In fact, between 1850–1860 it exceeds that of only Vermont, Maine, and South Carolina.²For the history of the settlement of Louisiana’s Cotes des Allemandes (the German coast) near New Orleans, see: Ellen C. Merrill, The Germans of Louisiana (Gretna, LA: Pelican Publishing, 2005). Compiled from the Original Returns of the Eighth U.S. Census 1860a-04, 2–590; Compiled from the Original Returns of the Seventh U.S. Census 1850a-02, xxxvi. Could yellow fever and the imagined racial unsuitability of Germans to tropical climates help account for this phenomenon? A close examination of historical sources returns a resounding "Yes."

Mouth of the Mississippi, New Orleans, Louisiana, July 9, 2010. Photograph by Flickr user Adventures of KM&G-Morris. Creative Commons license CC BY-NC-ND 2.0.

European Bodies, Climate, and the Geography of Yellow Fever

As a catalyst for German interest in America, the Louisiana Purchase unleashed a flood of speculation regarding whether US stewardship of the Purchase territory could lead to the realization of the biblical "land of milk and honey." According to observations reprinted by Johann Friedrich Nonne, editor of the Neue Allgemeine Weltbühne, in 1804, "the eyes of all Europe…now focused on Louisiana." The author of the piece downplayed concerns regarding the city's unhealthy reputation, which he attributed to the neglect of its former French caretakers, and expressed confidence that the territory's new masters would fare better in realizing New Orleans's potential.³Johann Friedrich Nonne, eds. Neue Allgemeine Weltbühne Auf Das Jahr 1804, (Erfurt, Germany: Johann Friedrich Nonne, 1804), 499; Thank you to Alexander Cors for encouraging a more suitable translation and for clarifying Nonne’s role in reprinting this piece. Over the next half-century Germans wrote extensively about the United States, particularly about the Louisiana Purchase and its suitability for settlement.

Heinrich Schmidt, ca. 1850s. Photograph by unknown creator. Courtesy of Wikimedia Commons. Image is in public domain.

From 1815 onward, accounts of "travels in the New World became almost a mania among Germans."⁴Paul Weber, America in Imaginative German Literature (New York: Columbia University Press, 1926), 102–103. In 1836, for example, a single volume of the Jenaischen Allgemeinen Literatur-Zeitung reviewed twenty-one North American emigration guides.⁵“Neueste Colonisations-Schriften,” Ergänzungsblätter zur Jenaischen Jenaischen Allgemeinen Literatur-Zeitung 2, nos. 84–85 (1836): 281–295. Leading German newspapers began publishing weekly columns on culture and politics by Germans in America as well as observations on the relationship between climate and health.⁶Maria Wagner, ed., Was die Deutschen aus Amerika berichteten, 1828–1865 (Stuttgart, Germany: H. D. Heinz, 1985), x–xi. "In the most remote forest hut as well as in the middle-class dwelling," noted nineteenth-century German scholar Heinrich Julian Schmidt, "the only book that could be seen in the hands of a farmer or gentleman, was a book about America."⁷Julian Schmidt, Geschichte der deutschen Literatur von Leibniz bis auf unsere Zeit (1896; repr., Charleston, SC: Nabu Press, 2011), 271.

One of the most salient features of this writing was its demonstration of "Wissenschafts-popularisierung" (the popularization of science).⁸Andreas Daum, Wissenschaftspopularisierung im 19. Jahrhundert: Bürgerliche Kultur, naturwissenschaftliche Bildung und die deutsche Öffentlichkeit (München, Germany: Oldenbourg, 2002). German writers from different walks of life consumed and disseminated knowledge from the burgeoning field of medical geography: the post-Enlightenment amalgamation of geography and the rediscovery of classical theories that insisted on the interrelationship between climate, environment, and disease.⁹Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: W.W. Norton and Company, 1997), 302; Mark Harrison, Contagion: How Commerce Has Spread Disease (New Haven, CT: Yale University Press, 2013), 49. One result was an attempt to demarcate the southernmost limits of acceptable German settlement based upon a racialized discourse of "climate" largely informed by the susceptibility of European bodies to yellow fever.

German-American historian La Vern Rippley acknowledged in 1976 that Germans often cited "climate" as a major deterrent to settlement in the southernmost United States. Rippley, however, apparently didn't consider the term within the parlance of the era.¹⁰La Vern J. Rippley, The German Americans (Boston, MA: Twayne Publishers, 1976), 44–45. More recent scholars have unpacked nuances of words like "climate" to reveal that nineteenth-century European and American understandings of health and disease were inextricable from their environment. When nineteenth-century Germans referred to their suitability to certain climates, they were often speaking about the perceived health of the land.¹¹Conevery Bolton Valenčius, The Health of the Country: How American Settlers Understood Themselves and Their Land (New York: Basic Books, 2002); Linda Nash, Inescapable Ecologies: A History of Environment, Disease, and Knowledge (Berkeley: University of California Press, 2006). Environmental historians, such as Conevery Bolton Valenčius and Linda Nash, have demonstrated how depictions of the health of the land were invaluable to nineteenth-century settlers in the burgeoning American West. Some German observers spoke favorably of the weather in Louisiana while simultaneously deriding the climate as ungesund (unhealthy).

Drawing upon extensive observations published in the German-speaking states of northern Europe this article explores the collective medical geography of the Gulf South as produced through German travel and settlement writing. By collective medical geography, I refer to the gestalt of this literature within the minds of its readers. To get a sense of this perceived landscape, I have mapped the observations detailed in this work and laid them on top of each other, like transparencies on an old overhead projector (see figures below). Having mapped each author's medico-geographical observations, I juxtaposed them with immigration and settlement data from the seventh (1850) and eighth (1860) United States Censuses to demonstrate the effect of this discourse on German immigration and eventual settlement.¹²Both the census of 1850 and 1860 provide population statistics by nation of origin, providing the total number of German-born in each state. Compiled from the Original Returns of the Eighth U.S. Census 1860a-04, 2–590; Compiled from the Original Returns of the Seventh U.S. Census 1850a-02, xxxvi.

Top, The Mental Map of Yellow Fever, 1850. Bottom, The Mental Map of Yellow Fever, 1860. Maps provided by author.

The result suggests a strong correlation between the discourse of medical geography and German settlement patterns. It also raises questions about longstanding assumptions regarding slavery as the determining factor in German settlement, especially when one considers that slave states which received clean bills of health showed dramatic population increases. While some scholars have suggested that Germans avoided the US South almost exclusively due to their aversion to slavery, many German-American historians have cautioned against inscribing the beliefs of the outspoken Forty-Eighters on the entire German-American population, including the approximately 225,000 German-born citizens who lived in slave states on the eve of the Civil War.¹³For more on German-Americans and motivations for German-American settlement see: Merill, Germans of Louisiana, 9, 32–40; Walter D. Kamphoefner and Wolfgang Helbich, eds., Germans in the Civil War: The Letters They Wrote Home (Chapel Hill: University of North Carolina Press, 2006), 2–3; Rippley, The German Americans, 51; Andrea Mehrländer, The Germans of Charleston, Richmond and New Orleans during the Civil War Period, 1850-1870 (Berlin, Germany: Degruyter, 2011) 14; Patricia Herminghouse, “The German Secrets of New Orleans,” German Studies Review 27 (February 2004): 1–12; Wagner, Was die Deutschen aus Amerika berichteten, xi–xii.

While anti-slavery sentiment was not uncommon among Germans, other reasons more likely led to their near complete avoidance of the Gulf South: availability of land, access to cities, industrialization, etc. Closer scrutiny reveals the importance, often above all other concerns, Germans placed on settling in a salubrious climate. When combined with German laments that New Orleans's insalubrity offset its economic and cultural potential, this collective medical geography—based almost exclusively on the presence of yellow fever—was a deterring factor for German settlement in the Gulf South.

Consider as well the seasonal patterns of German immigration through New Orleans. Once its insalubrity was established in this literature by the late 1840s, German authors turned to questions of New Orleans as an economically viable port of entry to the American interior. Founded in 1847, the Deutsche Gesellschaft von New Orleans (a German-American society, DGNO) embraced this role, as is evident in annual reports and communications that dissuaded Germans from settling in Louisiana due in large part to the presence of yellow fever. The DGNO advised immigrants to utilize the port as an economical and German-friendly point of entry, but to time their arrival so that it did not fall within the yellow fever season (late May through early October). By charting the port records of the DGNO between 1847 and 1860 (see figure above) a clear correlation between their recommendations to newcomers and the arrival of German immigrants becomes apparent.

Why did Germans single out yellow fever among prevalent diseases? After all, as then American diplomat and naturalist David Bailie Warden wrote in 1819, "the ravages of yellow fever are confined to the crowded streets of the most commercial towns, and its victims are less numerous than those of the bilious putrid fever, or typhus, which sometimes runs over [all of Europe]."¹⁴David Baillie Warden, A Statistical, Political, and Historical Account of the United States of America (Edinburgh, Scotland: Hurst, Robinson, and Company, 1819), 281. While Americans attempted to downplay yellow fever against concerns abroad, what was important to consider when qualifying German fascination with the disease was not how many yellow fever killed, but whom it killed and how they died.

Top, Aedes aegypti mosquito, August 20, 2012. Colored drawing by A.J.E. Terzi. Image uploaded by Flickr user Wellcome Images. Creative Commons license CC BY-NC-ND 2.0. Bottom, Electron microscope image of the virus responsible for yellow fever, August 7, 2013. Photograph by Alain Grillet. Image uploaded by Flickr user Sanofi Pasteur. Creative Commons license CC BY-NC-ND 2.0.

Unbeknownst at the time, yellow fever is transmitted to humans through a mosquito vector, the female Aedes aegypti. The mystery of the disease's transmission confounded contemporary medical observers leading to theories ranging from domestic origination of miasmas to the direct importation of contagious persons and/or inanimate fomites. There was broad consensus on two points: first, that the affliction targeted strangers to tropical climates, hence its moniker as a "strangers' disease," and, second, the erroneous assumption that individuals of African descent carried an inherent racial immunity.¹⁵Margaret Humphreys, Yellow Fever and the South (Baltimore, MD: Johns Hopkins University Press, 1999), 6–7. Jo Ann Carrigan, The Saffron Scourge: A History of Yellow Fever in Louisiana (Lafayette: Center for Louisiana Studies, 1994), 10–11; Mariola Espinosa, “The Question of Racial Immunity to Yellow Fever in History and Historiography” Social Science History 38, nos. 3 and 4 (Fall/Winter 2014): 437–454. These two factors, whether real or imagined, carried tremendous weight for would-be German immigrants.

Beyond fears that they were more susceptible to yellow fever as strangers to the Gulf South, contemporaries suggested an underlying racial justification: the widespread belief that (white) Europeans and Americans could become acclimated over a period of years to regions otherwise hostile to their racial constitutions. Troubling to many observers, the process of acclimation suggested that the perceived immunity of slaves of West African descent confirmed a racialized climate theory often used to justify chattel slavery in the Trans-Atlantic South. That Europeans could acclimate to climates suitable for Africans raised concerns about whether the process led to racial mutability and/or degradation in whites.¹⁶David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Berkeley: University of California Press, 1993), 25–32. There is a lengthy historiography of racialized climate theory broadly conceived by Europeans in the nineteenth century. The following examples attest to American and European utilization of that theory within the American South: Mark Carey, “Inventing Caribbean Climates: How Science, Medicine and Tourism Changed Tropical Weather from Deadly to Healthy,” Osiris 26, no. 1 (2011): 129–130; A. Cash Koeniger, “Climate and Southern Distinctiveness” Journal of Southern History 54, no. 1 (February 1988): 21–44; and Humphreys, Yellow Fever and the South, 7. Not only would German bodies be extremely susceptible to this devastating affliction, becoming acclimated seemed to suggest that something inside them had changed.

The presence of tropical diseases, such as yellow fever, also shaped German conceptualizations of the Gulf South as a tropical place. Whereas the distinction between free and slave states has served to delineate between North and South in many US historical studies, it is evident from their descriptions and settlement patterns that nineteenth-century Germans viewed what political historians refer to as the lower South as being a part of a larger Gulf South: one that would include eastern Mexico and the Greater Caribbean. This is not to say that they did not appreciate the political distinctions between these places, but in terms of fitness for settlement words such as "tropical" and "West Indian heat," were often used to describe areas deemed ungesund.

This collective medical geography informed German imaginations, or cognitive mapping, of southern spaces such as the Gulf South's commercial center of New Orleans. Prior to photography and video—and before mass production of maps and illustrated books in the mid-nineteenth century—Europeans relied on the written or spoken word to inform their perceptions of places they had not visited. Settlement literature would influence the spatial imaginary. Writing that emphasized insalubrity and macabre scenes of epidemic yellow fever had a deleterious affect on German perceptions of New Orleans as a space.¹⁷Cognitive mapping has been utilized by a wide array of fields, but the most influential of these works are arguably those within environmental psychology and city planning. See: R.M. Kitchin, “Cognitive Maps: What are They and Why Study Them,” Journal of Environmental Psychology 14 (1994): 1–19; and Kevin Lynch, The Image of the City (Cambridge, MA: M.I.T. Press, 1960).

Development of yellow fever 1, 2, 3, 4. Illustration originally published in Etienne Pariset and André Mazet's Observations sur la fièvre jaune, faites à Cadix, en 1819. Courtesy of Wikimedia Commons. Creative Commons license CC BY 4.0.

In addition to concerns of their unique susceptibility and fears of racial degradation in regions unbefitting their racial stock, the way in which yellow fever victims died embellished the disease's exotic and macabre reputation for would-be German settlers. The accumulation of the virus in the lymph nodes and the associated immune response leads to high fever and the onset of chills. As the liver is compromised, jaundice sets in, giving the victim's skin the yellowish hue that names the disease. Hepatic congestion brought on by liver failure and the eventual "systemic dysfunction of the clotting system" leads to hemorrhaging of the lining of the upper digestive system. Partially digested blood is forcefully expelled through the nose and mouth, producing a black vomit by which also characterizes the disease. Combined with descriptions of seizures and fevered delusions, lay accounts testify to the horror of this progression upon the afflicted and its effect on their caretakers.¹⁸Humphreys, Yellow Fever and the South, 5–6. It is no wonder that Germans placed as much emphasis on yellow fever as they did.

Travel Tales: The "Unhealthy Cities" of the South, 1820–1830

After the Napoleonic Wars (1803–1815), the optimism that Johann Friedrich Nonne expressed in 1804 regarding New Orleans's future salubrity was scarce among German authors. This coincided with the environmental trend in Enlightenment-era medicine that suggested nature exerted powerful forces upon the land and European bodies. Yellow fever was perceived as a product of tropical climates that could not easily be mitigated.¹⁹Ibid., 18–19; Porter, The Greatest Benefit to Mankind, 302; Harrison, Contagion, 49. Germans who had traveled to tropical places during and after the Napoleonic Wars testified to the havoc these climates unleashed on German bodies. For many of these writers, the presence of endemic yellow fever was sufficient to designate a place as tropical and, therefore, ungesund.

Following his service as a Prussian artillery lieutenant in the Napoleonic Wars, Johan Valentin Hecke turned to "scientific pursuits and travel."²⁰J. Valentin Hecke, Reise durch die Vereinigten Staaten von Nord-Amerika in den Jahren 1818 und 1819, vol. 1 (Berlin: H. Pb. Petri, 1820), 1. In his 1820, two-volume Tour of the United States of North America in the Years 1818 and 1819, yellow fever figured prominently. Little is known of Hecke's life beyond his military service, but a reviewer of his Tour in the Allgemeine Literatur-Zeitung suggested that fellow Germans exercise caution in where they chose to settle.²¹“Vermischte Schriften,” Allgemeine Literatur-Zeitung (1821): 785–792. They would do "better to be poor at home" than die abroad.²²Ibid., 792.

A representation of the cholera epidemic depicting the spread of the disease in the form of poisonous air, or miasma, as Nonne and Hecke had observed. London, England, October 1, 1831. Lithograph by Robert Seymour. Courtesy of Wikimedia Commons. Image is in the public domain.

While, like Nonne before him, Hecke believed human agency—such as a lack of sanitation leading to pestilential miasma—could contribute to the unhealthiness of climate, the determining factor was "West Indian heat."²³Hecke, Reise durch die Vereinigten Staaten, vol. 1, 76. This heat, Hecke and others insisted, exacerbated miasmatic conditions present in many port cities and led to increased frequency and virulence of tropical diseases: most notably, yellow fever.²⁴Ibid., 166–67. Hecke's contribution lay in his detailed observations of major cities and their salubrity up and down the eastern seaboard and on the Gulf Coast.

Of all the diseases he encountered, Hecke devoted far more pages to yellow fever, dubbing it "the transatlantic plague," capable of striking "even among the hardened and seafarers accustomed to almost any climate." "Only a select few survive this terrible, nervous system-shattering disease," he wrote, and those who did would "never again reach their previous health."²⁵Ibid., 167–183. As for the uneven distribution of yellow fever between North and South, Hecke estimated that the absence of persistent West-Indian heat explained why "in the northern states yellow fever is restricted to the seaports." While he assailed the "pestilential swamps" of the South as a haven for the disease, he noted that Delaware and New Jersey were dotted with marshes, yet "not one person has been carried away" by yellow fever.²⁶Ibid., 166–67, 170

Bald cypress in Lake Drummond, Great Dismal Swamp National Wildlife Refuge, Virginia, August 2, 2006. Photograph by Rebecca Wynn, uploaded by Albert Herring. Courtesy of Wikimedia Commons. Creative Commons license CC BY 2.0.

The further south Hecke traveled, the more he remarked on the prevalence of yellow fever. While he lauded the mountains of Virginia for their cooler and healthier climate, he was none too kind to the coastal areas. Hecke remarked that the "especially unhealthy city" of Norfolk and its surrounding coastline were dotted with pestilential fever-producing swamps. These swamps, along with high temperatures, incubated yellow and other malignant fevers that seemed to "occur almost every year."²⁷Ibid., 161.

Of the Carolinas, Hecke was unabashedly critical. In Charleston, every summer the "burning West Indian heat" was "usually accompanied by the yellow fever."²⁸Ibid., 166 Hecke wrote of a girl whose German-immigrant family operated a farm not far from Charleston when, without warning, yellow fever struck. Within a few days, the disease had orphaned her. Hungry and alone, she was found wandering the road.²⁹Ibid., 167.

Yellow fever burial, Memphis, Tennessee, September 21, 1878. Illustration by unknown creator, published by Frank Leslie's Illustrated Newspaper. Courtesy of the Illustrations from Harper's Weekly Newspaper and Frank Leslie's Illustrated Newspaper collection, Digital Archive of Memphis Public Libraries.

"Despite all its glories," Hecke felt that New Orleans was "the unhealthiest place in the United States, and perhaps all of the Americas."³⁰Ibid., 170–171. He noted "every year the yellow fever calls for its victims" in the Crescent City and that in the previous summer "one day after another, 100 [bodies] were lowered into the ground."³¹Ibid. He referenced the affliction's reputation as a strangers' disease, "so very dangerous not only for Europeans, but for northern Americans as well."³²Ibid. Hecke's lament would be echoed in German settlement literature in the coming decades.

To emphasize the reach of the disease, Hecke wrote of a vessel anchored just outside of New Orleans during an outbreak. The ship carried "five young craftsmen who sought to take refuge [from yellow fever] in the northern states." After a short time removed from the port, each of the craftsmen fell ill. According to Hecke's informant, all five of them had fled only to perish before reaching their destination.³³Ibid., 171. "No one [could] count on a long life in New Orleans, much less a comfortable one."³⁴Ibid., 170–171.

Title page of Ignatz Hülswitt’s Tagebuch einer Reise nach den Vereinigten Staaten und der Nordwestküste von Amerika, (Münster, Germany: Coppenrathschen Buch und Kunsthandlung, 1828). Courtesy of Göttinger Digitalisierungszentrum.

Fellow Prussian artillery lieutenant Ignatz Hülswitt's portrayal of how yellow fever attacked and eventually killed its victims reads like a horror novel. Detailing the onset of this "fast-progressing and terrible disease," Hülswitt noted in the final stage, the victim could expect to endure "incessant vomiting and discharges of a black matter, which looks almost like tar" and "after a clear decline of all powers, strong jaundice, and maddening seizures, death usually comes on the seventh or eighth day." Hülswitt purportedly spoke from experience. Citing his own "irreplaceable loss," he claimed that during his time in Louisiana the disease had struck him down and robbed him of his "dear wife."³⁵Ignatz Hülswitt, Tagebuch einer Reise nach den Vereinigten Staaten und der Nordwestküste von Amerika (Münster, Germany: Coppenrathschen Buch und Kunsthandlung, 1828), 306, 308. Hülswitt warned German readers that yellow fever resided "in the cities of Louisiana and causes much suffering," especially "among the newcomers."³⁶Hülswitt, Tagebuch einer Reise nach den Vereinigten Staaten, 305–306. Despite praising the state as "indisputably one of the most beautiful in America," like Hecke, Hülswitt lamented his racial unsuitability for Louisiana.³⁷Ibid., 304.

In a review of Hülswitt's work in the Neue Allgemeine Geographische und Statistische Ephemeriden, prospective immigrants to Louisiana were cautioned that, despite attaining a "comfortably furnished home on 160 acres of land," yellow fever had taken Hülswitt's wife and ravaged his constitution to the extent that he spent a year rehabilitating "without being able to recover from the effects of the fever."³⁸Neue Allgemeine Geographische und Statistische Ephemeriden, (Weimar, Germany: Geographischen Institut und des Landes-Industrie-Comptoirs, 1830) 215. The affordability of land and the lure of prosperity came with dangerous consequences.

Title page of John R. Jewitt's Journal Kept at Nootka Sound (Boston, MA: 1807). Courtesy of Early Canadiana Online.

Unbeknownst to readers, Hülswitt may have fabricated the incident. Scholars have confirmed that he plagiarized much of his 1828 Diary of a Trip to the United States and the Northwest Coast of America from Englishman John R. Jewitt's Journal Kept at Nootka Sound: an account of Jewitt's abduction, enslavement, and eventual assimilation into the Nuu-chah-nulth tribe. While the portion of his book that dealt with his bout with yellow fever in Louisiana has not yet been attributed to any other author, there is no proof that Hülswitt traveled to America.³⁹Peter Littke, “Ignatz Hülswitt, the German ‘John R. Jewitt’ at Nootka Sound?” The Initiative for Russian American History, April 2002, www.irah.eu. It's possible that Hülswitt's narrative of his family's bout with yellow fever was an attempt to exoticize an already sensational tale.

In 1835, encouraged by the swell of interest in travel narratives, Duke Friedrich Paul Wilhelm, a naturalist, explorer, and nephew of the first king of Württemberg, published his First Travels in North America, 1822–1824.⁴⁰Friedrich Paul Wilhelm, Travels in North America 1822-1824, ed. Robert Nitske and Savoie Lottinville (Norman: University of Oklahoma Press, 1973), xiii. Having spurned the military life in pursuit of botany and other natural studies, "Duke Paul" set out to further the work begun by his idols, Meriwether Lewis and William Clark. As a self-styled expert of natural science, he believed himself an ideal candidate to report on the climate and ecology of Louisiana and its environs.⁴¹Ibid., xv, xiii–xx.

Paul Wilhelm of Württemberg. Image by unknown creator. Courtesy of Wikimedia Commons. Image is in public domain.

Landing in New Orleans, Wilhelm reports he was briefed on the recent yellow fever epidemic and felt blessed that a delay had kept him from arriving at its peak. "Many German countrymen who had not left," he reported, "had fallen victim to its plague."⁴²Ibid., 34. The following year he escaped another yellow fever epidemic as it swept through. Returning to the city from yet another trip to the "interior of North America," Wilhelm was "saddened by the news of the death of a highly valued friend." He consequently declared "all strangers [should] shun New Orleans from June to November."⁴³Ibid., 21, 34.

Like his counterparts, Duke Paul found much to appreciate in New Orleans. Enthralled by the city's commercial potential and the steamships that traveled the Mississippi, he wrote that "trade and population would increase enormously if the climate and unhealthful situation did not disturb both."⁴⁴Ibid., 34. He had little faith in New Orleans's measures to combat yellow fever, noting that a "quarantine station intended to protect the city from contagious diseases" was too far up river to prove effective. Ships could disembark early and circumvent quarantine, enabling those exposed to the disease to "go unhindered in the city."⁴⁵Ibid., 31.

Yellow fever quarantine camp, Louisiana, 1897. Photograph by Lyttle's Studio, Baton Rouge, Louisiana. Courtesy of Wikimedia Commons. Image is in public domain.

That Wilhelm traveled through Louisiana at this time appears to be corroborated by other accounts. He purportedly crossed paths with a young German named Max who had escaped a yellow fever epidemic that had decimated St. Francisville, Louisiana. Max's account comes from letters edited and published by his father in Ulm alongside those of his sister and uncle in Excerpts from Letters from North America (1833).⁴⁶Auszüge aus Briefen aus Nord-Amerika, geschrieben von zweien aus Ulm an der Donau gebürtigen, num in Staate Louisiana ansässigen Geschwistern (Ulm, Germany: E. Nübling Book Printers, 1833), 32–35, 51. Not to chance misinterpretation, Max's father emphasized his purpose for publishing his children's letters in an ominous foreword. He asked that "the youth and newly married couples who felt the impulse to emigrate to North America" heed this cautionary tale left behind, "especially the descriptions of the state of Louisiana and New Orleans."⁴⁷Ibid., foreword.

In writing of a steamboat trip from New Orleans to Baton Rouge, Max noted the well-developed land and beautiful plantations.⁴⁸Ibid., 22–23. He remarked on the affordability of life in Louisiana, adding that he and his uncle were able to rent their storefront, an African slave, and a wagon for only fifty-three Spanish talers per year.⁴⁹Ibid., 28. Max expressed fear, however, of the area's becoming "unhealthy" by summer due to the annual flooding of the river and the formation of swamps as it receded.⁵⁰Ibid., 25. That Max's unabashed participation in slavery and praise of Louisiana's economic accessibility is counterbalanced with fears of impending yellow fever presents a familiar theme.

Death of Aurelio Caballero due to yellow fever in Veracruz, 1892. Etching on zinc by José Guadalupe Posada. Courtesy of the Drawings and Prints department, The Metropolitan Museum of Art.

In a letter dated November 18, 1827, Max described an outbreak of yellow fever presumably brought by steamboat in September.⁵¹Ibid., 51. The disease initially spread among the unacclimated, "new arrivals and the older residents." Six weeks into the epidemic, Max reported that he had fallen victim. Suffering from inflamed eyes and a blackened tongue, he recalled feeling "an unusual accumulation" in his mouth, at which point he "pulled out a large piece of spalted black blood." Soon the blood poured out of his mouth and nose as doctors tried desperately to take his pulse. Max reported that he had "vomited about two sinks full of blood" that day and was failing fast. Miraculously, he made a full recovery, the lone survivor among those infected.⁵²Ibid., 52.

Max's expressed concern for fellow Germans seeking to land in New Orleans during the summer months is also telling. In June 1828, he lamented that during his time in New Orleans, a ship "brought about 120 Germans of diverse ages" who were ill prepared to travel to the interior. Without sufficient money, they were forced to beg while the "heat during and after the flooding of the river…will soon bring about the Yellow Fever." Disheartened, Max knew that his "countrymen, who have come here so hearty and strong from healthy Germany, will fall without a fight as its first victims."⁵³Ibid., 62–63.

When Max's sister Thekla came to America, he suggested that they meet in New York in the late fall and travel to New Orleans by steamship only after the fever season had ended. Despite their careful planning, Max reported the fever had lingered late that summer and was terrorizing New Orleans well into November. He noted that the twenty or so Germans on board decided to immediately travel north "for the sake of the preservation of their health." According to Thekla's account, she and Max retired to their quarters where they held each other and cried—praying the fever would leave them unscathed. Upon their arrival, Max and Thekla heeded the advice of "some experienced Germans" to remain onboard rather than risk entering the city.⁵⁴Ibid., 148. While they survived the ordeal, Max and Thekla's letters emphasized the danger posed to Germans by yellow fever in the Gulf South. The lesson Max's father intended comes through loud and clear—wanderlust had perilous consequences.

The authors of this first period of travel and settlement literature placed more emphasis on personal observation buttressed by hearsay than scientific analysis. Even self-styled naturalists, such as "Duke Paul" and Johan Valentin Hecke, offered little data, aside from notions of yellow fever's limited range from the sea. During the mid-nineteenth century, the "Wissenschafts-popularisierung" (the popularization of science) became more apparent. Just prior to the height of German immigration to the United States, writers would provide scientific evidence that explain earlier observations and explore the presumed relationship between southern climates and German bodies that made them more susceptible to yellow fever.

"Too Far South": Yellow Fever, Race, and German Fears, 1830–1845

Beginning in the 1830s, there was a perceivable shift from travel and adventure narratives towards settlement guides and treatises on medical geography. Of particular interest were the increasingly prevalent theories of acclimation, as well as the utilization of latitudinal coordinates to pinpoint unhealthy areas for German immigration. The shift in emphasis from dissuading settlement in New Orleans to debating its merits merely as a viable port of entry for Germans settling elsewhere suggests that the unhealthy nature of the climate was increasingly taken for granted.

Cover of Gottfried Duden's Report on a Journey to the Western States of North America (Columbia: University of Missouri Press, 1980).

The most well known German travel and emigration author of the nineteenth century, Gottfried Duden, extolled the virtues of the slave state of Missouri for prospective German immigrants in his Report on a Trip to the Western States of North America (1829).⁵⁵Gottfried Duden, Bericht über eine Reise nach den westlichen Staaten Nordamerikas (Elberfeld, Germany: S. Lucas, 1829). Reprinted three times, his Report became so popular that German authorities feared it might inspire a mass exodus to Missouri.⁵⁶Robyn Burnett and Ken Luebbering, German Settlement in Missouri: New Land, Old Ways (Columbia: University of Missouri Press, 1996), 10. Historians have long noted the significance of Duden's Missouri boosterism,⁵⁷Robert Frizell, Independent Immigrants: A Settlement of Hanoverian Germans in Western Missouri (Columbia: University of Missouri Press, 2007), 29; Conevery Bolton Valenčius, Health of the Country: How American Settlers Understood Themselves and Their Land (New York: Basic Books, 2002), 37; Richard O’Connor, The German-Americans: An Informal History (Boston, MA: Little, Brown, and Company, 1968), 68–70; Rippley, The German-Americans, 44. but his remarks on the southern limits of German settlement and yellow fever's role in establishing them have been largely ignored. Duden advised his readers to stay north of "settlements at the mouth of the Arkansas [River]," some 325 miles north of New Orleans, as they were "perhaps too far south." The main reason for his admonitions was yellow fever, which he claimed struck the Crescent City "almost every summer."⁵⁸Duden, Bericht über eine Reise nach den westlichen Staaten Nordamerikas, 165–166, 328.

Duden argued that the dangers of yellow fever and other tropical diseases kept Germans from areas in which slavery was most depraved. In the middle states, like Missouri, he contended, slavery was a relatively benign institution, comparing favorably to domestic servitude in Europe, and often in the best interests of the enslaved. The greatest obstacle slaves faced to freedom, Duden believed, was their racial inferiority. He asserted that no amount of education or betterment could undo thousands of years of being exposed to debilitative, and inferior, climates.⁵⁹Ibid., 142–143.

Duden maintained that Germans could not saunter into a tropical climate without prolonged seasoning.⁶⁰Ibid., 328. He cautioned readers not to be enticed by the availability of inexpensive tracts of land where their health would be imperiled. Germans, he argued, should settle in Missouri, preferably near St. Louis.⁶¹Ibid., 328, 330. While he recommended traveling there from New York or some other northeastern port, he conceded that traveling to Missouri by way of New Orleans was feasible, so long as one embarked from Germany no later than "December or January so that they arrive when there is no danger from yellow fever."⁶²Ibid., 332.

Observing that many Europeans survived in cities such as New Orleans seemingly unaffected by diseases such as yellow fever, Duden based his concepts of acclimation and seasoning on a version of racialized climate theory in which racial traits were somewhat mutable.⁶³Ibid., ix–xiv, 110. Seasoning or acclimation attempted to scientifically explain yellow fever's reputation as a strangers' disease. When his methods of acclimation failed and the promise of his Missouri boosterism went unrealized, Duden came to be known in many settlements of the mid- to upper Mississippi River Valley as "Duden der Lügenhund" (Duden the Lying Dog).⁶⁴T.S. Baker, “America as the Political Utopia of Young Germany,” Americana Germanica 1 (1897): 78.

Letter from Gustave P. Koerner to Abraham Lincoln, Springfield, Illinois, October 8, 1861. Courtesy of the Library of Congress Abraham Lincoln Papers, Manuscript Division, memory.loc.gov/cgi-bin/ampage?collId=mal&fileName=mal1/123/1235900/malpage.db&recNum=0.

A young Gustav Koerner took exception to Duden's proclamations. As an abolitionist fresh off the boat from Frankfurt in 1833, Koerner would become Illinois's most renowned German son as well as a political confidant and close friend of Abraham Lincoln.⁶⁵Jack Le Chien, “We Must Make Them Understand Lincoln is Our Man,” ed. Molly McKenzie (Bellville, IL: Koerner House Restoration Committee, 2011), 14. In his Illumination of Duden's Report on the Western States of North America, from America (1834), Koerner encouraged the German public to question Duden's observations regarding the health of St. Louis. In particular, he questioned how a city in constant contact with New Orleans, a locality known to harbor "diseases of all kinds, but especially yellow fever," could possibly be considered healthy. Koerner cited longtime residents of St. Louis who confirmed that the health of the city worsened since the advent of regular steamboat traffic to and from New Orleans.⁶⁶Gustav Koerner, Beleuchtung des Duden’schen Berichtes über die westlichen Staaten Nordamerikas, von Amerika aus (Frankfurt, Germany: Karl Körner, 1834), 28. It is important to acknowledge Koerner's role as a booster in Illinois. Both Duden and Koerner were selling the virtues of a place to prospective immigrants. Disagreements aside, they agreed on two principles: the universal condemnation of New Orleans as being host to endemic yellow fever (ungesund) and that Germans who settled too far south did so at their peril.

German-born academic and journalist, Francis Grund, echoed Duden's theory of acclimation in a piece for the Ausberger Allgemeine Zeitung, entitled "Die Colonisation von Liberia." Published in 1840, the article was sectionally biased. As the anti-slavery Grund lived in the North, his article about the colony of Liberia begun by the American Colonization Society offered few kind words for the South's peculiar institution. In his discussion of African Americans' perceptions of Liberia as a "morgue for the blacks," he made a corollary observation of yellow fever and the southern United States. Writing that blacks and "acclimated" residents of the South need not fear "this scourge of Mankind," Grund voiced another reminder that yellow fever was a strangers' disease and that those foreign to the South risked infection and their lives when this "yearly" affliction struck.⁶⁷Duden, Bericht über eine Reise nach den westlichen Staaten Nordamerikas, ix–xiv, 110.

The yellow fever scourge in Florida, September 8, 1888. Illustration by unknown creator, published by Frank Leslie's Illustrated Newspaper. Courtesy of the General: Reference collection, Florida Memory website, The State Archives of Florida.

So influential were Grund's opinions of the US that one scholar referred to him as "The Jacksonian Tocqueville."⁶⁸Holman Hamilton and James L. Crouthamel, “A Man for Both Parties: Francis J. Grund as a Political Chameleon,” Pennsylvania Magazine of History and Biography 97 (1973): 465–484. Alongside observations of culture and politics in his 1835 Die Amerikaner (The Americans), Grund offered a chastising observation of the climate in the Carolina Low Country. He warned that the region was "visited each year by the yellow fever" and insisted that even the interior or rural portions of the Carolinas and Georgia were not safe.⁶⁹Francis Grund, Die Amerikaner: in ihren moralischen, politischen, und gesellschaftlichen Verhältnissen (Stuttgart, Germany: J.G. Cotta’schen Buchhandlung, 1837), 363.

German observers often suggested what areas were "healthy" for German bodies. Friedrich Schmidt's Account of the Politics and Moral Condition of the United States of North America in the Year 1821 was published shortly after Hecke's first volume. Schmidt was quick to address the mania surrounding German emigration and in his use of medical geography and latitudinal coordinates, he was a pioneer. He offered five observations as to "which areas of North America are especially unhealthy and which states might be beneficial for Europeans."⁷⁰Schmidt, Versuch über den politischen Zustand der Vereinigten Staaten von Nord Amerika im Jahre 1821, 82.

Schmidt wrote that American climates were subject to rapid change and posed a potential threat, but that all areas south of "thirty-six degrees north latitude" were tropical and would "devastate European constitutions." He warned of uncultivated soils and "the reigning diseases" of the "southern and western states" that caused "exhaustion and death among Europeans and Americans." And significantly, he claimed that the "healthiest and most beneficial areas in North America for Europeans, are the states of Pennsylvania, New York, and around the southern parts of Ohio and Indiana."⁷¹Ibid., 82. As the maps accompanying this essay show, these states displayed high rates of settlement among German-born immigrants.

Ludwig Gottfried Blanc. Image by unknown creator. Courtesy of Wikimedia Commons. Image is in public domain.

Written fifteen years later by renowned preacher, philologist, and professor of Romantic Languages at the University of Halle-Wittenberg, Ludwig Gottfried Blanc's Handbook of Essential Knowledge of the Nature and History of the Earth and its Inhabitants (1837) was a comprehensive study intended for a broader audience of fellow Germans.⁷²Ludwig G. Blanc, Handbuch des Wissenswürdigsten aus der Natur und Geschichte der Erde und ihrer Bewohner Vol. 3 (Halle, Germany: C.H. Schwetschke und Sohn, 1837). In "The United States of North America" under the subheading of "Climate," Blanc summarized the health of the US landscape. "[T]he East Coast," he wrote, "particularly from 40° South [latitude] is, for the most part, unhealthy, and most so in the southern states." Blanc singled out the "terrible yellow fever" as the "main plague of these areas," adding that in the hotter southern states even the interior was susceptible to its devastation.⁷³Ibid., 471.

Blanc remarked favorably on the salubrity of New England, but claimed that the "interior states, between 36° and 42° are, by far, the most healthy."⁷⁴Ibid., 454. This area included Ohio, Indiana, Kentucky, Illinois, Iowa, Missouri, and the southern portions of Michigan and Wisconsin where, by 1860, over half of the German-born US population resided. If the western portions of Pennsylvania and New York were included as "interior states," the proportion would rise to roughly three-quarters.⁷⁵Compiled from the Original Returns of the Eighth Census 1860a-15 (Washington, D.C.: Government Printing Office, 1864), 621. For Blanc, the yellow fever zone extended down the eastern seaboard from New York City, with an increase in virulence and general unhealthiness the further south one traveled. He was especially critical of the coastal areas from Maryland southward, reserving particular scorn for Georgia, Alabama, Mississippi, and Louisiana.⁷⁶Blanc, Handbuch des Wissenswürdigsten, 479–492.

While differing in content and methods from earlier travel and adventure narratives, the settlement guides of 1830–1845 came to very similar conclusions, emphasizing the destructive power of yellow fever and its relation to southern geography. Rather than take a chance on acclimation, it was better to avoid the area altogether. On the eve of the greatest period of German immigration to the United States, prospective immigrants were inundated with warnings about the lower Gulf South, and particularly New Orleans. With the question of where to settle, one question remained: was New Orleans still a viable port of entry for Germans heading for California, Texas, and the upper Midwest?

Just Passing Through: New Orleans, 1845–1860

Death as a sailor bringing yellow fever to New York. Illustration by unknown creator, published by Frank Leslie's Illustrated Newspaper. Courtesy of the Civil War Profiles website.

The emphasis of German writings of the late 1840s and 1850s shifted to discussing the viability of New Orleans as a port of entry for immigrants planning on settling outside the Gulf South. Despite the threat of yellow fever, writers acknowledged New Orleans as an economical port for those heading to the US interior. Even here, there were stipulations, the most damaging of which dealt with the time of year to arrive to avoid yellow fever.

George M. von Ross, an American of German descent and a well-known booster of German immigration to central Texas, wrote several guides. While affirming New Orleans as an economical alternative to ports in the Northeast, Ross, in his 1851 The Emigrants' Handbook, warned that those who sought to immigrate through New Orleans "must avoid landing during the period of July to November" or they would "risk finding [the city] haunted by yellow fever upon their arrival."⁷⁷Ross, Die Auswanderers Handbuch, 404. Books by Gabriel Auguste van der Straten-Ponthoz and Traugott Braume shared Ross's concerns and warnings.⁷⁸Gabriel Auguste van der Straten-Ponthoz, Forschungen uber die Lage der Auswanderer in den Vereinigten Staaten von Nord Amerika (Augsburg, Germany: K. Kollman Publisher, 1846), 79–80. Braume, in particular, suggested that those headed for the interior of Texas were better off landing in Galveston which, despite being host to yellow fever on occasion, he deemed a safer alternative.⁷⁹Traugott Braume, Hand- und Reisebuch für Auswanderer und Reisende nach Nord, Mittel, und Süd-Amerika (Bamberg, Germany: Buchner Publishing, 1853), 612–613.

Auswanderer-karte und wegweiser nach Nordamerika, Emigration map and guide to North America, Stuttgart, Germany, 1853. Map by Gotthelf Zimmermann, published by J.B. Metzler'schen Buchhandlung. Courtesy of Library of Congress Geography and Map Division, loc.gov/resource/g3701e.ct000244/.

Established in 1847, the Deutsche Gesellschaft von New Orleans (DGNO) sought to increase German immigration through the Crescent City. It provided inexpensive or free services to those heading to the interior, and tried to protect German immigrants from fraudulent travel "brokers," false baggage handlers, and yellow fever. The organization did not actively recommend New Orleans as a final destination, but aspired to make the city the primary port of entry for German-speakers.⁸⁰Historic New Orleans Collection (HNOC), Deutsches Haus Collection 1847–1983 EL 1. 1984 Item 1—Die Deutsche Gesellschaft von New Orleans, Louisiana. 1848–1888.

The DGNO closed its first annual report with an unattributed quotation that eventually found its way into the Central Association of German Emigration and Colonization's 1852 circular "To all who want to emigrate!" It advised prospective German emigrants to:

...remain in the land that nourishes you fairly because you come to a country where climate, language, customs and traditions are quite different from your own. There have been many cases in which immigrants have befallen the bitterest price of woes, regretted the reckless step taken, and who, though often in vain, must beg for the means to return to the homeland.

The circular noted that those who sought "to improve their situation" were "only too often met by a terrible awakening." For "malignant fever is almost inevitable everywhere and is often fatal if the right care cannot be found."⁸¹Landeshauptarchiv Koblenz. Inventory: 441, No. 24, 215. www.t-stoffel.de/QUELL/Quellen/An%20alle%20die%20auswandern%20wollen%202.htm.

While originally conceived as an organization to protect German immigrants from false agents and travel brokers, the DGNO realized quickly that disease posed an even greater threat and understood their "special duty to advise immigrants to schedule their arrival during a time in which the city is free from yellow fever." Further it stressed that "no embarkation from Europe should proceed later than the beginning of May . . . [or] until the end of September."⁸²HNOC, Deutsches Haus Collection 1847–1983 EL 1. 1984 Item 1—Die Deutsche Gesellschaft von New Orleans, Louisiana. 1848–1888.

The data that the DGNO gathered between 1847 and 1860 when juxtaposed against the census figures of 1850 and 1860 explain the settlement patterns of Germans who landed in New Orleans. Of the 233,374 immigrants the society processed, sixty percent boarded steamships upriver upon their arrival. Seventy-five percent of that number chose St. Louis and its surrounding environs as their destination with just over twenty-three percent headed for the Ohio River Valley. The rest set out for Texas and, to a lesser extent, California. The remaining 63,665 were identified as either unsure of their final destination, withheld that information from the society, or had decided to remain in New Orleans for the time being. The society did not track those who migrated after their processing. Given that the German population of Louisiana was 24,614 in 1860—having only grown by 6,727 since 1850—it is safe to assume that the majority of the 63,665 who did not make immediate travel arrangements eventually migrated out of the region. Only five percent of the total German immigration occurred during the peak fever months of July, August, and September and sixty-five percent avoided arriving from the end of May to the first of November.⁸³Ibid.

A girl suffering from yellow fever. Watercolor by unknown creator. Courtesy of Wikimedia Commons. Creative Commons license CC BY 4.0.

The majority of German immigrants made arrangements in advance of their arrival to settle in areas deemed "healthy." The timing of their arrival suggests that they heeded the settlement literature's advice and almost unanimously avoided New Orleans during peak yellow fever months even in years when the disease was not epidemic. May, the month immediately preceding the yellow fever season, was the third highest month for German immigration to New Orleans. High numbers in November and December could be explained away by the avoidance of frozen rivers in the North, but seeing immigration peak immediately before and after yellow fever season suggests more. An even clearer picture becomes apparent when we combine data from the DGNO and U.S. Census with the gestalt of the geographic recommendations of the settlement literature (see "Mental Map of Yellow Fever" maps).

Cover page of J.W. McClung's Minnesota as it is in 1870, (St. Paul, Minnesota, 1870). Courtesy of the Library of Congress General Collections and Rare Book and Special Collections Division, loc.gov/resource/lhbum.01092/?sp=1.

Yellow fever and antebellum German perceptions of its hold on the Gulf and Atlantic Coastal South contributed significantly to their avoidance of these areas. Kindled by the vast expanse of the Louisiana Purchase, travel and settlement writing as well as the discourse of medical geography contributed to the popularization of scientific knowledge (Wissenschafts-popularisierung). The American frontier provided economic and scientific opportunity to observers and newcomers brimming with new ideas about the relationship between health and the land. The explosion of European immigration to the United States had an immediate and lasting effect, as German and Irish immigrants moved into US cities seeking a better life.

Germans, in particular, sought out the expanse west of the Appalachians and, if the extent of writing presented in this essay is any indication, they were considerably well informed as to the politics, economics, and health of the Gulf and Atlantic Coastal South. This is not to say that they came prepared. With published accounts of an unknown land in mind and far less money and resources than needed, they arrived in New Orleans by the hundreds of thousands: most of them promptly boarded a steamship and traveled up the Mississippi to what they hoped would be healthier country.

About the Author

Paul Michael Warden is a PhD candidate at the University of California, Santa Barbara and a visiting scholar in Harvard's Department of the History of Science. His dissertation focuses on how yellow fever shaped the medical imagination and development of antebellum New Orleans. His broader research examines how ecology and geography intersect with period medical and scientific theory within early American history.

Public Health in the US and Global South - Southern Spaces

Stand & Witness: Art in the Time of COVID-19

Encountering COVID

Luke, South Carolina

Valerie, North Carolina

Frank, Louisiana

Emma, Arizona

Donna, Georgia

Michael, Texas

Mike, Florida

About the Author

End of the Pandemic? A Grassroots Perspective

About the Author

Acknowledgments

"Miking" Against Covid in Bangladesh

"Miking" in Local Dialects

Info Cards

Collaboration with Sisimpur

Comics and Murals

Faith Leaders' Endorsement

Interactive Popular Theater

About the Author

CDC in the Pandemic's Wake

Commentary

About the Author

Covid Light and Darkness Alike

About the Author

COVID-19 Vaccine and the Right to Public Health

Commentary

About the Author

COVID-19: Lessons in Ignorance

Commentary

About the Author

Before Tuskegee: Public Health and Venereal Disease in Hot Springs, Arkansas

Introduction

"Mecca for Syphilitics"

Inside the Clinic

Healing the "Other": Women and African Americans at the Hot Springs VD Clinic

Clinic to Camp

Conclusion: Race, Hot Springs, and Tuskegee

About the Author

Ungesund: Yellow Fever, the Antebellum Gulf South, and German Immigration

Introduction

European Bodies, Climate, and the Geography of Yellow Fever

Travel Tales: The "Unhealthy Cities" of the South, 1820–1830

"Too Far South": Yellow Fever, Race, and German Fears, 1830­–1845

Just Passing Through: New Orleans, 1845–1860

About the Author

"Too Far South": Yellow Fever, Race, and German Fears, 1830–1845