Palmer

Palmer, Stephen. Launching Global Health: The Caribbean Odyssey of the Rockefeller Foundation. Ann Arbor, Mich.: The University of Michigan Press, 2010. Pp. xi + 301. Hardcover, $70.00.

In 1913, The Rockefeller Foundation began a campaign to eradicate hookworm in six countries of Central America and the Caribbean, the first campaign of a US based philanthropic foundation to improve health internationally.  Six efforts were started, in British Guiana first, then in Costa Rica, Guatemala, Nicaragua, Panama, and Trinidad.  The basic guidelines were similar for each effort: to eradicate the disease, to ensure sustainability by educating the populace about the relevant science, to catalyze local efforts, and to be a laboratory for further programs in larger countries such as Brazil, Egypt, and Sri Lanka.  Before starting internationally, the Rockefeller people had experience with hookworm eradication in the US South, where the basic strategy, the “intensive method,” was developed.  Leaders of the international programs, before deployment, were sent for several months training in North Carolina and Mississippi. The method consisted of identifying every resident, sending teams house-to-house to collect fecal specimens from each person, examining each specimen under a microscope, and then treating those infected with a massive dose of a “vermifuge.” The approach borrowed much from ideas of assembly line production. The registration/treatment strategy was complemented by education about germs and building latrines.

The campaigns met with varying degrees of success in the six countries.  A major contribution of the book is comparing the outcomes and teasing out the differences. The work in Costa Rica built on an existing government hookworm programs and worked with a heterogeneous population speaking basically the same language.   The legacy was a strong Ministry of Health.  British Guiana and Trinidad were British colonies with strong colonial heritages.  The British collaborator there had his own hookworm treatment strategy based on treating plantation workers who could be forced to take small daily medicinal doses.  The multi-ethnic aspect of the intensive approach, as well as of the teams implementing it, probably made the colonial powers nervous. In any case, neither host country renewed the program.  When efforts started in Guatemala, a major problem was reaching the indigenous population, which spoke little Spanish and did not work on the large plantations.  A hero of the book is Dr. Alvin Struse,who first worked to overcome plantation owners’ resistance to putting resources toward the native people.  The hookworm effort was interrupted by a major earthquake and then by a yellow fever epidemic.  The erratic national dictator appointed Struse to be top medical officer in the country.  Struse contained the yellow fever but tragically died when the 1918 influenza epidemic arrived in Guatemala, probably originating in the local US military camps.

The scientific message of germs and sanitation, an important part of the Rockefeller strategy, was not always easy to convey.  An especial problem was the presence of low-level infection, forcing people who did not feel sick to be treated. In British Guiana, where a major target population was indentured plantation workers from India, the field officer authored and distributed a tale, “The Demons that Turned into Worms,” based on popular Hindi stories. Use of such parables, especially when presented by a local Brahmin holy person, was a long way from sending disciplined health worker teams into every household. 

The outcome suggests lessons about how to bring new technology to unfamiliar cultures.  The specific examples give credibility.  I am surprised by the lack of numbers, certainly in a work based on the Rockefeller archives, showing at least short-term effectiveness of the campaign, although the author states such would be misleading.  The writing is lively and accessible, and overall the book is well done.