Social Science & Medicine 49 (1999) 11971213

www.elsevier.com/locate/socscimed

Public health policy paradoxes: science and politics in the

Rockefeller Foundation's hookworm campaign in Mexico
in the 1920s
Anne-Emanuelle Birn a,*, Armando Solorzano b
a
Milano Graduate School, New School for Social Research, 66 5th Avenue, New York, NY 10011, USA
b
The University of Utah, 246 Alfred Emery Building, Salt Lake City, Utah 84112 USA

Abstract

The origins of US international health endeavors are intertwined with the Progressive Era's faith in science as
arbiter of humankind's secular problems. No agency better exemplies the period's condence in science than the
Rockefeller Foundation's International Health Board (IHB), which set out to export the new public health theory
and practice around the world. An examination of the IHB's hookworm program in Mexico in the 1920s
demonstrates that, notwithstanding the Rockefeller Foundation's (RF) self-conscious commitment to scientic
neutrality, its programs continuously engaged political criteria, exhibiting the competition, coexistence, and
inseparability of the worlds of science, politics, and international health policy. Analysis of the program's quotidian
decisions and larger strategies further reveals the protean quality of RF sciencepolitics, which enabled responses to
parochial and broadly-conceived needs at multiple levels. In the focus on hookworm, the selection of campaign
sites, hookworm diagnosis methods, treatment procedures, denition of cure, and the assignment of responsibility
for prevention, scientic and political considerations were inextricably bound. The sciencepolitics paradox was
molded by the hookworm program's constituencies in Mexico, including political leaders, health bureaucrats,
physicians, business interests, public health workers, peasants, and Rockefeller ocers. The multiple, often
contradictory, roles of the RF's hookworm campaign are characteristic of the policy paradoxes that emerge when
science is summoned to drive policy. In Mexico the campaign served as a policy cauldron through which new
knowledge could be demonstrated applicable to social and political problems on many levels. The repeated pledge
of scientic neutrality belied the hookworm program's inherent aim of persuading government ocials, the medical
community, business interests, and the populace of the value of investing in public health as a means to improve
social conditions, further a medical model of health and sickness, increase economic productivity, and promote
good relations between the US and Mexico. # 1999 Elsevier Science Ltd. All rights reserved.

Keywords: Public health history; Rockefeller Foundation; International health policy; Mexico; Hookworm; Philanthropy

Introduction
* Corresponding author Tel.: +1-212-229-5339; fax: +1-
212-229-5335. ``It is a comfort to realize that politics do not any
E-mail address: aebirn@newschool.edu (A.E. Birn) longer play an important part in public health work,

0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 1 6 0 - 4
1198 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
and that leads us to hope that some day politics may
be entirely divorced from public health so that cam-
paigns against disease can go forward systematically
and regularly regardless of political conditions.''
(Russell, 1924b)
``Our sanitary work is improving day by day and
we hope in two or three years we will have such a
ne Health Service as yours. Our motto by now is
the words you told us `Better health and less poli-
tics' and it runs quite well.'' (de la Garza Brito,
1925)
The origins of US international health endeavors are
intertwined with the Progressive Era's levitation of
science to arbiter of humankind's secular problems.
No agency better exemplies the period's condence in
science than the Rockefeller Foundation's (RF)
International Health Board, which set out to export
US-style public health theory and practice to dozens of
countries around the world. An examination of the
IHB's hookworm program in Mexico in the 1920s
demonstrates that, notwithstanding the Rockefeller
Foundation's self-conscious commitment to scientic
neutrality, its programs continuously engaged political
criteria, exhibiting the competition, coexistence, and
inseparability of the worlds of science, politics, and in-
ternational health policy.
This article explores the sciencepolitics paradox as
it played out among the hookworm program's consti-
tuencies in Mexico. Political leaders, health bureau-
crats, physicians, business interests, public health
workers, peasants, and the Mexico-based Rockefeller
ocers were swayed by the program's scientic de-
signs, and they simultaneously shaped and accommo-
dated its political underpinnings. Analysis of the
program's quotidian decisions and larger strategies
reveals the protean quality of RF sciencepolitics,
which enabled responses to parochial and broadly-con-
ceived needs at multiple levels.
In 1913 the Rockefeller Foundation (RF) was estab-
lished to promote ``the well-being of mankind''
through the funding, planning, and administration of
public health programs, research, and education
around the world (Birn, 1993, 1996; Solorzano, 1990).
This interest stemmed from the work of the
Rockefeller Sanitary Commission for the Eradication
of Hookworm, which uncovered the important part
1
For a persuasive argument regarding the importance of in-
ternational public health ventures in inter-imperialist compe-
tition, see Pyenson (1984). These rivalries took on more
urgency during World Wars I and II, when both sides
attempted to court Latin America.
played by public health in the economic development
of the South of the US and the potential role of indus-
trialists and philanthropic agencies in simultaneously
promoting development, mitigating some of its worst
eects, and earning kudos for doing so (Ettling, 1981;
Kunitz, 1988; Boccaccio, 1972; Cassedy, 1971; Link,
1988; Fosdick, 1989; Shaplen, 1964). The RF's self-
assured beacons of industrialization and their advance
team of public health doctors set out to prepare vast
regions for commerce, investment, and increased pro-
ductivity, motivated variously by economic, humani-
tarian, religious, scientic, and political goals (Abel,
1995; Birn, 1993; Solorzano, 1990, Cueto, 1988, 1994;
Hewa, 1995; Lowy, 1997; Ram rez de Arellano, 1981;
Williams, 1994; Franco-Agudelo, 1983; de Castro-
Santos, 1987). Along the way they befriended poten-
tially hostile peoples and governments, protected
Western Europe and North America from what were
believed the last of the great epidemic outbreaks, and
paraded the United States' newfound expertise in dis-
ease control to both recipient countries and European
rivals.1
For Frederick Gates, one of the RF's principal
architects, the mission of the new International Health
Board was threefold: to extend to other countries the
work of eradicating hookworm (and other ailments),
to promote public sanitation, and to spread the prin-
ciples of scientic medicine. Wicklie Rose, the IHB's
inuential rst director, more pointedly viewed hook-
worm control ``as a means to a greater end'' and as
the ``entering wedge'' to awaken grass roots interest in
disease control and enlist government participation in
public health activities (Williams, 1969; Acheson, 1992;
Hackett, 1960; Farley, 1995).
Following a costly but successful yellow fever cam-
paign from 1920 to 1923, the RF's International
Health Board (IHB) was eager to continue work in
Mexico. Through the inspection of hundreds of thou-
sands of homes and the chemical treatment of millions
of water receptacles and other breeding sites, the IHB
had gained the respect and condence of Mexico's fed-
eral government and the belated but cheerful co-
operation of the population of Veracruz (Solorzano,
1990), notwithstanding the historically tense relations
between Mexico and the US and ongoing insurrection
within Mexico. The eradication of yellow fever was an
important accomplishment for the protection of inter-
national commerce and the temporary generation of
goodwill (Carter, 1931; Coleman, 1987; Cueto, 1992),
but the militaresque campaign did not engage
Mexico's commitment to Gates's tripartite mission.
How would the IHB decide what public health cam-
paign would be a worthy successor to yellow fever era-
dication? According to reasoning of the period, public
health activities were to be guided by three rules. First,
the prevalence of the condition was to be assessed
 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
through surveys and analysis of mortality and morbid-
ity records. Next, activities were devised only when a
means of correcting the problem was available.
Finally, the ease of accomplishment and popularity of
the measures were considered (Janney, 1929).2 The
IHB decided to fund a hookworm campaign even
before considering the ailment's prevalence.
By the time a program had been arranged for
Mexico, RF hookworm campaigns had been carried
out in numerous settings in Latin America, the
Caribbean, and Asia, eventually reaching 52 countries
and 29 islands (Shaplen, 1964). In only three years, the
IHB had cured 76% of the population infected in the
West Indies, with 6.3% of the population opposing
treatment.3 In Malaya, Java, and the Fiji Islands, RF
doctors assessed their techniques to be 85% eective in
the reduction of anemia and other debilitating diseases
produced by hookworm (Darling et al., 1920). The
hookworm campaign in the Fiji Islands miraculously
transformed the inhabitants from ``a dejected, down-
cast, docile, uninterested people'' into one which was
healthy, alert, and mentally progressive (Heiser, 1936).
The Jamaica Hookworm Commission made evident
the monetary value of eradicating hookworm: workers
were ``healthier and capable of performing harder
work'' (Washburn, 1924). A 25% increase in ``average
working time'' was reported after treatment, and some
workers reported salary increases of 200%. These
achievements appeared to conrm the IHB's mantra
that ``prudent spending on public health constituted an
investment, not a drain on resources'' (Abel, 1995).
Campaign successes elsewhere made a hookworm
prevalence study in Mexico seem superuous.
The agreement
Following a rapid decision to oer a hookworm
program, Wicklie Rose pressed Department of Public
Health (Departamento de Salubridad Publica or DSP)
Director Alfonso Pruneda to request the IHB's collab-
oration, a prerequisite to RF participation in any pub-
lic health endeavor (Rose, 1922). Though this
2
Janney was an Indianola, Mississippi health ocer. These
priorities were established decades before the epistemological
critiques of science research priorities began to be made.
3
The countries comprising the West Indian colonies were
Antigua, British Guiana, Dutch Guiana, Grenada, St Lucia,
Saint Vincent, and Trinidad. The control of the disease was
carried out through the `intensive method' which consisted in
identifying all infected person within an area, providing them
with a treatment, and applying microscopic examination at
the end of the procedure to show that cure has been eected
(Howard, 1919).
1199
approach made the DSP defer to IHB overtures rather
than vice versa, Dr Frederick Russell, Rose's replace-
ment as IHB director, disingenuously proposed a more
equal relationship, averring, ``we also hope to learn
Mexican methods and apply them to the US'' (Russell,
1923). Mexican President Alvaro Obregon, pleased
with the outcome of the yellow fever campaign and
with the opportunity to distribute plum public health
positions, supported the program, hoping that it would
help quell continuing unrest in Veracruz. On 12
November 1923, the IHB Executive Committee
approved a joint hookworm campaign in Mexico.
Only after the Mexican government agreed to
absorb the majority of expenses was the formal operat-
ing budget launched. This 5-year budget, averaging
24,000 dollars annually (223,000 in 1998 dollars),
began with 80% nancing by the RF, which decreased
by 20% each year until the nal year, when the
Mexican government was slated to pay 100% of the
budget and incorporate the work of the project into
the DSP. The ``invitation'' by the Mexican govern-
ment, then, consisted not of a joint plan but rather of
the Mexican government's acceding to RF require-
ments.
This pattern of budget incentives, requiring increas-
ing levels of matching funds by participating govern-
ments, became standard practice for the RF and other
international funders. Even so, with the exception of
the yellow fever campaign, the RF investment was
lower (on a per capita basis) in Mexico than in most
other Latin American and Caribbean settings,
suggesting a dierent set of expectations for this bor-
dering country. At least initially, caution was war-
ranted given the volatility in USMexico relations and
within Mexico during the 1920s. Moreover, the RF's
administrative placement of Mexico in the division
overseeing activities in the US and Canada demon-
strated a belief that Mexico's public health develop-
ment more closely reected that of its northern
neighbors than its southern (Birn, 1993).
Although the Director of the Hookworm, Yellow
Fever, and Malaria Service, Dr Angel Brioso
Vasconcelos, was designated by the Mexican govern-
ment, the true project director (holding the title Sub-
director), Dr Andrew Warren, was an IHB ocer
selected by the RF. From a farming family in North
Carolina, Warren had helped the IHB set up health
demonstration projects in rural Kansas and Oregon
after he graduated from medical school. As he later
recalled, he was assigned to Mexico to show ``local
people that something could be done for their health
and [it] helped develop national interests and responsi-
bilities'' (Williams, 1963). The Mexicans had to cede
complete authority to the young Warren for the hiring
and ring of personnel, the assignment of responsibil-
ities for the entire campaign sta, book-keeping, and
1200 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
decisions on how best to allocate the program funds,
even after Mexico began paying more than 50% of the
operating budget.
Angel Brioso Vasconcelos, the hookworm service's
nominal director, was a career DSP physician who had
served as Sub-director of the yellow fever campaign.
Esteemed among his colleagues, Brioso Vasconcelos
served as director of the Gaceta Medica de Mexico, the
nation's leading medical journal. While he generally
adhered to Rockefeller goals and methods, Brioso
Vasconcelos did not shrink from criticizing the IHB
and complaining that Mexico received less funding
than other countries.
From outside the country, Alvaro Obregon's coup
and ensuing election to the Presidency in 1920 signied
the end of the Mexican Revolution. However, armed
opposition to Obregon's government persisted for sev-
eral years. Veracruz's resistance stemmed from its key
strategic location as the country's richest and largest
port and its continued nurturing of opposition leaders
and organized rebel movements. While Veracruz pea-
sants harbored the same antagonism towards wealthy
hacienda owners as did agricultural workers in the rest
of the country, laborers in the petroleum industry had
the additional grievance of working for foreign
employers under poor conditions. Because many
Veracruz industrialists also despised the foreign owner-
ship of Mexican oil, this merchant elite joined forces
with peasants and workers against Obregon, who was
accused of corruption and accommodation to foreign
investors (Smith, 1972). At the same time, the militant
Cristeros, who opposed the Constitution's separation
of Church and State, instigated open revolts through
the late 1920s, particularly in the state of Guanajuato
and surrounding regions (Bailey, 1974; Meyer, 1976).
In the face of this unrest, the IHB was surprisingly
intrepid, a sign of the importance of the Mexican pub-
lic health program to the RF.
4
The most labored point in the survey was that the micro-
scopic examination of fecal specimens for the presence of ova
was a faulty measure because not all persons with positive
stools had the disease, a discovery previously made by
Darling et al., (1920) (Warren and Carr, 1925).
5
This may have stemmed from the diering reliability of
quantitative measuring tools as compared to their qualitative
counterparts. A 1929 text recommended that the selection of
a survey population include both clinical symptoms of the dis-
ease, as measured from the hemoglobin index, and the aver-
age intelligence of each race, as ``determined through a few
leading questions from a person speaking the native language
uently, and acquainted with the psychology of the popu-
lation'' (Faust, 1929, p. 374).
The survey
According to medical understanding since the 1920 s
(Katz et al., 1982; Hegner and Taliaferro, 1924;
Langfeld, 1907; Faust, 1929), hookworm, or uncinaria-
sis, is caused by the infection of hookworms (Necator
americanus in the Americas) in the human digestive
track, especially in persons with malnutrition. Anemia,
stunted growth, fatigue, and weakness target children
in particular. Other symptoms include yellowed skin,
and swollen legs and bellies. The hookworm enters the
body where the skin is tender, often between the toes,
then migrates through blood vessels to the lungs,
where it is coughed out and swallowed into the alimen-
tary tract. There, it is nourished by blood sucked
through the wall of the duodenum; it reproduces and
is periodically expelled with feces. Persons walking
barefoot in places strewn with hookworm-ridden
human feces can come into contact with the ailment.
Though a survey was not carried out to determine
whether or not the IHB should sponsor a hookworm
campaign in Mexico, once approved, the campaign's
rst task was to survey hookworm prevalence and gen-
eral conditions around the country in order to select a
locale for a campaign. Notwithstanding its promise to
train Mexican physicians in modern public health
methods, the IHB designated its own ocerDr
Henry Carr, a recent Harvard medical school graduate
from rural Georgiato carry out the survey. In early
1924, the young Carr set out to examine the geo-
graphical distribution of hookworm, the demographic
make-up of the infected population, general living and
working conditions, the severity of the disease, the
source of the infection, the species of hookworm impli-
cated, and the overall ``eect of the disease upon the
individuals involved''.4 Only supercially alerted to
dangerous regions, Carr vowed to survey troubled
states as soon as they were free of conict (Carr,
1924b). Carr was warned that he would likely be asked
to provide medical care far beyond hookworm treat-
ment; his refusal could jeopardize cooperation with the
survey, but the provision of excessive free care would
frustrate his progress.
In other countries, surveyors had gauged the number
of persons infected with hookworm, but the Mexican
survey would also calculate the density of infection
and the clinical manifestations of the disease (Russell,
1924c). IHB ocer Wilson Smillie's work in Rio de
Janeiro had demonstrated that quantitative surveys
showed improvements due to hookworm programs
while qualitative surveys did not.5 Carr's quantitative
mandate led him to substitute a new method for
measuring hookworm infection. Previously, the popu-
lar WillysMolloy salt-otation technique, which deter-
mined the general presence or absence of hookworm
ova in the stool, had been used by most IHB ocers.
 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
Carr was instructed to use the alternative Stoll egg-
counting method, which purported to oer a more
accurate picture of the severity of infection through
the careful study of a random sample of fecal matter
(Stoll, 1923a,b; Warren, 1925d).
As he carried out the survey over several months,
Carr learned that, notwithstanding his instructions to
emphasize quantitative measures, the exact volume of
worms in a person's intestines was a far less valuable
indicator of infection than were physiological symp-
toms. He noted the importance of the geographic dis-
tribution of hookworm because of the rapid changes in
Mexican topology and climate. Most of all, the survey
revealed the relatively low level of hookworm infection,
especially when compared to the South of the US or
the West Indies (Carr, 1924a, 1926c). This observation
was overlooked by the RF home oce and was forgot-
ten following Carr's transfer back to Georgia in 1924.
Regardless of hookworm's epidemiological prevalence,
the RF was decided on a hookworm campaign;
because Mexicans were barred from the survey team
and therefore not privy to its results, the hookworm
arrangement was not contested by the DSP.
Carr ultimately surveyed only one third of the
Mexican states, for the IHB had pinpointed the desired
campaign locale before the survey was even begun.
Veracruz, the focus of the yellow fever campaign,
remained strategic for both the Mexican government
and the IHB. First, it was important to maintain the
state's support as a hub of oil and foreign commerce
and a key agricultural producer. Health activities
could increase popular morale, diminish the threat to
exports, and keep productivity high. Second, a power-
ful group of anti-Obregon rebels was based in
Veracruz. The federal government wished to heighten
its activities to gain the support of the general popu-
lation and counter the rebels (Solorzano, 1990). The
RF recognized the importance of maintaining contact
with both the government and the revolutionary
forces, should they gain national control.
The hookworm campaign's false start
In January 1924, Veracruz became the seat of an
attempted overthrow of Obregon's government, led by
Adolfo de la Huerta, who claimed that Obregon's suc-
cessor, Plutarco El as Calles, a one-time Revolutionary
turned landowner and nancier, had been fraudulently
elected. Fighting broke out around the state of
Veracruz and along a wide path to Mexico City, and
wire, steamer, and train services were cut o.
6
In 1932 Tlaxcala had a crude mortality rate of 31.2 per
1000, the fourth highest in Mexico (Bustamante, 1934).
1201
Veracruz's only route of communication were fruit
boats, which stopped en route from Central America
to the US Despite the danger and uncertainty, the IHB
saw that its work was ``appreciated by both parties to
the controversy and that either of them would prob-
ably support the program'' (Read, 1924a).
With hookworm sta selected and trained and
supplies arriving, the program was quickly relocated to
the state of Tlaxcala in April 1924. Rockefeller ocers
maintained that sites were selected for the scientic
and practical reasons of high disease prevalence and
cooperative local authorities, but Tlaxcala's selection
refuted these criteria. Because Tlaxcala was very poor,
agricultural, and populated by `pure-blooded' Indians,
Warren argued, ``There is every reason to believe that
hookworm infection is general in this state as the in-
habitants still live in the most primitive manner''
(Warren, 1923), a claim negated by Carr's recent sur-
vey. Carr had discovered that Tlaxcala's high, arid pla-
teau was ``not involved in the hookworm problem of
Mexico'' (Carr, 1926c, p. 50), yet it was the only
alternative site to Veracruz that was considered.
Tlaxcala, and its neighboring state Hidalgo, were
selected not because they were promising sites for a
demonstration project, but because they provided easy
access to Veracruz. These dry, mountainous enclaves,
topographically inoculated against hookworm, were
located part way from Mexico City to the Gulf of
Mexico, adjacent to the main artery to the port of
Veracruz. Carr's hookworm survey had shown the
states of Tabasco, Oaxaca, and Chiapas to have higher
rates of hookworm, but poor transportation made
these regions less accessible to Veracruz. Moreover, the
IHB would not be able to justify the campaign's sud-
den departure from one of these states once Veracruz
had calmed.
Thus, the rst phase of the RF's demonstration of
the value of public health measures in controlling
hookworm was carried out in a region known to be
hookworm-free. The team merely repeated Carr's
negative survey results, showing that while 72% of
those examined had intestinal parasites, only 8 of 1232
persons examined had hookworm. Even hookworm
education eorts at the silver mines appeared to dupli-
cate existing activities carried out by mine owners
(Vaughn, 1924c). Although Tlaxcala ranked among the
public health neediest states, the IHB quickly moved
on,6 predictably unable to demonstrate the value of
hookworm treatment on a large scale.
In the early summer of 1924, Veracruz was still not
suciently pacied, so the team moved to the silver
mining district of Pachuca, Hidalgo to see if it merited
a campaign. This time the IHB decided against work-
ing in Pachuca, however, because mine latrines, how-
ever decient, were ``under excellent medical
supervision. They have been doing and are doing anti-
1202 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
hookworm work and they do not especially appreciate
our appearance upon the scene'' (Warren, 1924d).
Further, Warren reported, ``the demand for a more re-
spectable showing in order to justify the campaign,
necessitated that the scene of activities be transferred
. . . to a more favorable area'' (Warren, 1925g).
Thus, the campaign quickly moved on to the coastal
plains of the state of Veracruz, beginning in the town
of Cordoba. Turbulent Veracruz was still deemed the
locale most in need of sanitation (Read, 1924c), even
though Carr's survey found hookworm to be prevalent
along the entire Gulf of Mexico coast.
By barring Mexican participation in the survey, the
selection of hookworm as a focus of the public health
work of the RFdespite Carr's survey results ques-
tioning the priority of hookworm control for
Mexicowas resolved internally by the RF and thus
shielded from scientic controversy. With no ability to
shape the subject of the program, the decision whether
to accept the hookworm program was made at the
highest diplomatic level, inhibiting debate over the sub-
stantive scientic merit of hookworm control. For the
early implementation of the program in hookworm-
free Tlaxcala, on the other hand, the Mexican govern-
ment was complicit in the scientically unsound site
selection process. Desire for implementation of a pro-
gram in Veracruz to legitimize the federal government
stilled DSP demands to extend the program to other
states. RF ocer Warren appeared agnostic about
these high-level political considerations, arguing that
demonstrating positive resultsin order to create sup-
port for modern public health activitiesshould take
precedence.
The early campaign in Veracruz
Warren was frustrated by the ambivalent reception
accorded the RF in the high plateau regions of the
country. As soon as the hookworm unit returned to
Veracruz, where the RF had won popular support
during the yellow fever campaign, Warren was grati-
ed to report, ``our initial eorts have been enthusiasti-
cally received by all classes of people'', and local
inhabitants desiring treatment had `mobbed' the unit
in Cordoba (Warren, 1924a).
Located at the heart of Veracruz's coee and fruit
growing region, Cordoba's 12,000 residents were an
economically important entity. Warren attributed the
success of the hookworm work to the cooperation of
the civil, church, and military authorities, a feat unim-
aginable during the early part of the year when the
7
Interview with Dr. Alberto P. Leon, 10 April 1991,
Mexico City Conducted by A.E. Birn.
same parties joined an ``attempt to overthrow the con-
stitutional government'' (Warren, 1925g).
The campaign pursued a two-pronged approach of
prevention and cure. Hookworm treatmentan oral
dose of chenopodium with a purgativewas adminis-
tered by uniformed IHB ocers. Prevention was pro-
moted through health education strategies to convince
peasants to wear shoes and construct latrines. As part
of this eort, RF ocers provided house-to-house il-
lustrated explanations of the life cycle of the hook-
worm and the biological mechanism of infectionto
generally baed audiences.7 RF administrator
Florence Read advised Warren to proceed slowly with
the campaign, starting new Veracruz units only if the
area had been surveyed, `sanitated', and if a successful
education program on the value of treatment and sani-
tation had been implemented. Personnel were not to be
added without DSP guarantees, for the ``wisdom of
slow and sound growth'' had been proven many times.
When Warren solicited specic advice, however, Read
retreated, insisting that the decisions and responsibility
went to the ``man on the ground'' (Read, 1924b).
In Cordoba, where infection rates exceeded 60%,
Warren advocated mass treatment to gain results more
quickly, even though mass treatment was generally
approved only in areas of high infection (over 75%),
where a lower per capita cost could be achieved. Mass
treatment forewent the preliminary diagnosis, treating
the entire population regardless of the actual fecal pre-
sence of hookworm. However, the occasionally unplea-
sant, or even fatal, after-eects of treatment meant
that up to one quarter or more of the population
would be faced with an unnecessary risk. This risk was
exacerbated by Warren's use of treatment doses ``not
advocated by the Board'' (Warren, 1924a). He justied
the high dose of chenopodium (2 cc at one time,
instead of 1 cc per hour during 3 successive hours) by
its eciency. Because the entire dose was taken in
front of unit personnel, he argued, its correct adminis-
tration was assured. Warren was so convinced of the
cost-eectiveness of his method that he failed to see its
potential dangers. A man believed to be heavily
infected with hookworm almost suocated under
Warren's care, but he proclaimed the absence of ``dis-
tressing consequences'' as a triumph.
Warren admitted that the ``rate and degree of infec-
tion in the area probably was not of sucient gravity
to absolutely justify'' the mass treatment procedure,
but he believed that by eliminating ``time-consuming
preliminary examinations'', the campaign could quickly
provide a large number of treatments, thus gaining
popular recognition (Warren, 1925g). Warren acknowl-
edged that ``making an impression with the campaign''
was of ``paramount'' importance, far greater than the
actual value of the treatments. Once again, political
ends eclipsed health priorities.
 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
Warren's joy at the campaign's reception in
Cordoba was not matched upon his departure for the
town of Alvarado in early 1925. Now pressured by his
superiors to move on as soon as it was clear that the
community had accepted the RF's public health mess-
age, Warren regretted not being able to stay until
every individual had been treated and a latrine built
for every home (Warren, 1925i). He believed that the
results of the rst year of work in Tlaxcala, Pachuca,
and Cordoba could not be stated numerically because
the new program's objectives of health education to
``change the intimate habits of a race of people'' and
of economic improvement could not yet be measured
tangibly. The challenge mounted because, ``The com-
munity must be convinced that the project is rst prac-
tical, second benecial, and third the cost must be
within the means of the tax-payers'' (Warren, 1925e).
For Warren, then, general community acceptance of
hookworm activity needed to be followed by universal
coverage and autonomous commitment. From the per-
spective of the RF in New York, popular approval of
public health was sucient; guaranteeing coverage and
enabling local implementation would be the responsi-
bility of the Mexican government.
Throughout 1924, Secretary of Health Pruneda
fretted that the IHB would pull its men from Mexico
because of the continuing disturbances (Vaughn,
1924b). After Calles became President in December
1924, Pruneda avowed that the new leader would fol-
low the policies of Obregon's government by improv-
ing living conditions through ``education, solving
agrarian problems, . . . and stimulating sanitary work''
(Pruneda, 1924).
With the change of administrations, Hookworm
Service Director Brioso Vasconcelos was replaced by
Dr Juan Solorzano Morf n, the chief quarantine ocer
for Veracruz, who had been extremely supportive of
the yellow fever campaign. Solorzano Morf n was one
of the best known physicians in Mexico, a brilliant lec-
turer, committed to public health and scientic
research, and a close associate of Obregon. Initially
the new Director was deemed ideal for Mexico's hook-
worm campaign, ``probably one of the most important
the IHB has ever undertaken'' (Vaughn, 1924a).
At the beginning of 1925, the RF's Mexico City
oce was shifted to Veracruz so that Warren could
8
In the IHB's campaign in Sri Lanka there was also tension
over the matter of reinfection, with IHB sta members sup-
porting the notion of prevention via latrine construction but
ultimately succumbing to pressure from plantation owners
and the government to administer large numbers of hook-
worm treatments which quickly and dramatically demon-
strated the eectiveness of curative medicine via reduced
absenteeism (Hewa, 1994).
1203
save money on travel and keep a closer eye on the
hookworm team. By this time, the campaign had dis-
continued the use of the dispensary methodwhich
required the population to come to the doctor
because patients could not be supervised during the
hours after they swallowed the medicine and because
many failed to return to the clinic for subsequent treat-
ments. The replacement intensive method required the
hookworm brigades to travel from house to house.
The anti-helminthic, but not the purgative, was admi-
nistered under the eye of a trained inspector in the
home of those being treated. Assistants returned
during the course of the day to monitor the condition
of patients. Preliminary fecal examinations were only
administered to individuals who refused treatment.
Positive results gave ``an added weight to [the inspec-
tor's] already heavy argument, and the individual
usually takes the medicine'' (Warren, 1925h). However,
there were sporadic instances of poisoning by anti-hel-
minthics. Young children were often the victims of
these overdoses, generally dying within hours of cheno-
podium administration. Rockefeller teams did their
best to muzzle publicity about these cases, lest the
hookworm campaign be jeopardized.
In its rst years, the hookworm campaign paid little
attention to concerns of reinfection, although latrine
and education eorts were at least implicitly designed
to prevent future infection with hookworm. Campaign
Director Solorzano Morf n's protests that reinfection
was not suciently addressed by the campaign despite
the obvious money-saving and persuasive value of the
prevention of reinfection were summarily ignored
(Solorzano Morf n, 1927a). The political ends of the
campaign to quell unrest by demonstrating the
value of government services in as many places as
possible overshadowed bona de scientic concerns
surrounding reinfection. In several countries, the RF
was careful to evaluate the eectiveness of its cam-
paigns by measuring infection levels after it had left an
area.8 In Mexico, however, it was only in the early
1930s, when political unrest diminished and the DSP
was fully in charge of hookworm control, that edu-
cational eorts to increase latrine use and prevent
ground contamination were specically tied to the risk
of reinfection through the monitoring of reinfection
rates (Hookworm Campaign, 1930). Though the RF
was partner to the reinfection duplicity, the contradic-
tions between scientic and political ends were played
out on Mexican turf, with a sophisticated medical elite
battling the federal government's power exigencies.
By the autumn of 1925, political conditions in
Veracruz once again jeopardized the Rockefeller pro-
gram. After municipal voters elected anti-Obregon lea-
ders, federal troops invaded the opposition Rojo-
Negro headquarters, killing 14 people and injuring
dozens more. Labor leaders responded by organizing a
1204 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213

Table 1
Hookworm campaign activities, 19241928; data missing for 1926 and 1927 costs; see Refs. corresponding to each year (Warren,
1924c, 1925f; Carr, 1926e, 1927a, 1928a)

Year Persons treated Number of treatments Number of latrines built Joint cost in dollarsa Cost in 1998 dollars

1924b 21,529 28,763 337 43,836 416,000

1925c 44,917 79,228 631 35,694 328,000
1926 53,527 97,660 6328
1927 61,877 126,799 5179
1928 32,557 78,420 2768 45,000 424,000

a
Includes US and Mexico contributions.
b
The per capita cost of the hookworm campaign was $1.03 (9.60 in 1998 dollars), which included the population of both persons
who received treatment and those not infested with hookworm (and not receiving treatment).
c
By the second year of the program the per capita cost dropped by more than half to 43 cents.

boycott against the 12 leading commercial houses.
With human barricades blocking the entrance to stores
and warehouses, many businesses had closed down;
with no imports arriving at the harbor, food supplies
were running low. Governor Heriberto Jara, a personal
friend of IHB Director Russell's, proposed expelling
all foreign merchants. Meanwhile, a strike against the
Aguila Oil Company had left water and sewage plants
without fuel. Warren, seemingly oblivious, assured
``work is progressing despite the rains'' (Warren,
1925a).9
Although concerned that strikes against oil compa-
nies might jeopardize Warren's work in Veracruz,
Russell argued to his colleagues in New York that it
was the ``disturbed conditions'' of other states, not
Veracruz, that ``makes our work impossible'' (Russell,
1925a). Yet hookworm was more severe in Chiapas
than in Veracruz, and Chiapas was relatively calm, but
the IHB paid little attention. Clearly Veracruz
remained strategically important to the RFand to
Mexico's federal governmentbecause other infected
areas were deliberately avoided. Admiring the value of
the Veracruz work, Russell contentedly remarked that
Mexico had become much more pro US since the
Revolution. ``During the next ten years'', he promised,
``we will have an opportunity to do pioneer work, and
one can reasonably expect big results in that time.''
RF public health, then, served at least two levels of
political interests: the ObregonCalles nexus seeking to
consolidate national power in Mexico and the US gov-
ernment searching for means of improving relations
9 5141 of which were without latrines (Warren, 1925f).
A letter written on 12 December 1925 described continu-
ing chaos, with squatters occupying newly built houses, the
ransacking of buildings, and unpaid teachers striking. As a
result Oaxaca was also going bankrupt too. Warren remained
surprisingly calm, noting, ``conditions barely aect [our] im-
mediate work''.
with Mexico following the turbulence of the
Revolution.
By January 1926 the ``crisis'' had passed, and
Warren reported that some brigades were building up
to 75 excusados per week (Warren, 1926c). Russell was
pleased that the hookworm work had been ``little
aected by the dicult conditions in Veracruz''. Now
that the conditions for the campaign had normalized,
Russell speculated:
``It may be that public health work will help to clar-
ify . . . a new relationship between the peon and the
state and federal governments, and help the peon to
understand and appreciate the duties and responsi-
bilities of government to the people and convince
him that the government has a real interest in his
welfare, health and happiness.'' (Russell, 1925b)
An increasingly explicit goal of the hookworm cam-
paign was to reinforce the principles of North
American democratic liberalism both through the
hookworm campaign in Mexico and via annual RF-
sponsored tours of US public health agencies for high
level Mexican health ocials (Warren, 1929).
Hookworm treatment and IHB policy
By the end of 1925, the hookworm brigades had
become highly ecient (See Table 1). That year 79,228
treatments were administered to 44,917 people at a
cost of 27 cents per treatment (2.50 in 1998 dollars).
Of 28,178 specimens, 18,494 were positive. The bri-
gades built 631 latrines and inspected 6371 buildings,
As the campaign gradually faced fewer conicts and
built up a track record, the interplay between science
and politics shifted from wartime and state-building
exigencies (which had also steered the yellow fever
campaign) to other priorities. With the RF's goal of
 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
instiling support for American-style liberalism in
Mexico as a backdrop, the hookworm campaign
became a vehicle for rival interests: promotion of a
model of scientic medicine; federal, state, and local
government commitment to scientic public health;
household responsibility for health; demands for better
social conditions; and the harnessing of improved
health to productivity and economic development.
These competing goals reected the diering power
and priorities of a series of actors: the RF home oce,
IHB ocers in Mexico, hookworm campaign workers,
ocials in the DSP, the Mexican government,
hacienda owners and other employers, peasants, and
local community leaders. The multiplication of clients
and shapers of Rockefeller public health greatly com-
plicated debates in the hookworm policy cauldron.
In one instance, Warren argued that the epidemiol-
ogy of hookworm infection in the small community of
Alvarado, Veracruz, was not inuenced by agricultural
occupation. This Mexican evidence contradicted the
earlier work of Wilson Smillie in Brazil, which had
concluded that hookworm was an occupational disease
of barefoot agricultural workers who became infected
in the elds. Warren's observations did corroborate
those of William Cort in Puerto Rico and Carr's initial
survey in Mexico, which found foci of human pol-
lution near homes to be the most important factor in
hookworm infection. Warren argued that because
hookworm infection occurred even in urban areas,
agricultural labor was ``not important at all'' (Warren,
1925b). By de-emphasizing hookworm's relation to the
work environment, Warren highlighted the role of indi-
vidual households in reducing their infection. The
responsibility of each Mexican family to build its own
latrine and wear shoes became a key element of the
campaign, while the obligation of hacienda owners,
who often owned and controlled housing, was de-
emphasized.
Warren noted that in the village of Tlacotalpan,
unlike sandy Alvarado, the soil was hard, black, sticky,
and hot, demanding some sort of protection for bare
feet. Warren insisted it was not these physical con-
ditions, but ``It is the culture and intelligence that
causes the people to wear shoes'' (Warren, 1925c),
suggesting that elsewhere lack of education and intelli-
gencenot lack of necessitydetermined shoe-wearing
patterns. The IHB also tried to promote the idea that
success in one locale would serve as a model for other
communities. At the end of several months, over 90%
of homes in San Andres Tuxtla had decent, self-con-
structed excusados with seats made of good lumber,
10
Indeed, Carr continued to write the Hookworm Campaign
reports several years after it had been turned over to the
Mexican government (Carr, 1930a,c).
1205
and the local people ``know they will protect against
reinfection'' (Warren, 1926e). Though ``one half the
Indians in the good agricultural area don't speak
Spanish they can see an improvement'', a sign of the
campaign's ``excellent propaganda''. Warren was opti-
mistic that these experiences would be repeated else-
where.
In June 1926 the organizational success of the cam-
paign led the IHB, with the DSP's approval, to place
Mexican doctors at the head of each of the hookworm
brigades. This change was also motivated by the resig-
nation of Solorzano Morf n, the campaign's nominal
director and the only Mexican physician directly
involved in it. Solorzano Morf n was displeased with
the administrative arrangement requiring Mexico to
contribute resources but yield technical control to the
RF (Solorzano Morf n, 1927a). This criticism was not
without merit: even after the Mexican government had
ocially taken over the hookworm campaign at the
end of 1929, the IHB representative continued to serve
as its chief scientic and administrative advisor (Carr,
1930a,c).10 Paradoxically, a campaign aimed at build-
ing national technical capacity only reinforced subser-
vience to RF expertise.
With Solorzano Morf n gone, Dr G. Garzon Cossa,
a one-time student at the Johns Hopkins School of
Hygiene and Public Health, Dr Bernardo Pena, a well-
known physician whose salary was entirely paid by the
DSP, and the recent graduate Dr Pilar Hernandez Lira
(who continued his collaboration with the RF for 25
years) each headed lab units and teams of 4 or 5
nurses and assistants. The brigades conducted house-
to-house censuses, hookworm lectures, treatments, and
furnished latrine construction advice. Under this more
ecient arrangement, 27,579 treatments were adminis-
tered and 1117 latrines were built in the second quarter
alone (Warren, 1926g). Warren was certain that the
expanded role of physicians would improve the health
units, combat program criticism, and increase public
condence in the campaign (Warren, 1926f).
Although pleased with Warren's desire to expand
services, RF administrator Russell urged him to limit
total spending for the hookworm campaign to 45,000
dollars annually (427,000 in 1998 dollars) in order to
``keep the work within the capacity of the Mexican
government to take over'' (Russell, 1924a). Warren
countered that treatment cheaper than 2.5 pesos per
capita (11.00 in 1998 dollars) would be ``at the expense
of thoroughness'' (Warren, 1924b). Sanitizing the area
was the most dicult problem because the work was
too slow to keep up with the treatment. Warren hoped
that local ocials could complete the hookworm work
and that members of the brigades would later conduct
inspections, but neither of these plans materialized, lar-
gely because these functions were not funded by the
campaign.
1206 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
After the federal government consolidated its mili-
tary superiority over rebels in much of the country in
1926, Warren traveled to Mexico City to revitalize the
IHB's relationship with the government and to secure
support for IHB projects in Veracruz and other parts
of the country. Bernardo Gastelum, the new Director
of the Departamento de Salubridad Publica, ``seems to
have just realized that we are a vital part of his organ-
ization and that we are in a position to be of further
service to him and to his people'' (Warren, 1926d).
Warren's visit with President Calles was also ``most
encouraging'', although the leader voiced jealousy at
the IHB's more extensive activities in other countries,
especially Brazil. Warren quickly reassured Calles that
the decline of turbulence made the RF much more
``kindly disposed'' to Mexico (Warren, 1926d).
After a short absence from Veracruz in early 1926,
Andrew Warren returned to the news that he had been
elected President of the local Anti-Tuberculosis
League. He informed Russell that he had refused the
position, arguing that it ought to go to a Mexican
physician, but the League's members insisted. When
Warren oered the excuse that the RF did not work in
the tuberculosis eld, the well-informed physicians
pointed to the case of France, where the RF had colla-
borated in TB control during the World War (Warren,
1926b).
Russell told Warren that it was best to ``formally
decline'' the invitation and to oer an ``explanation so
simple even laymen can understand'' (Russell, 1926).
The goal of the IHB was, Russell rationalized, ``to
improve public health organizations by demonstrating
what it is possible to do by co-ordinating intelligent
government eorts''. Yellow fever, hookworm, and
malaria provided eective examples of this work.
Tuberculosis, leprosy, and venereal diseases were never
to be used, however, because ``it takes too many years
to show results with chronic infectious diseases,
whereas with the others, particularly with hookworm,
it is possible to get results in a short time''. Thus, it
was ``improbable'' that the IHB would ``ever nance a
cooperative TB project''. Once the IHB's presence in
Mexico was accepted, demands multiplied and Warren
had to juggle interests that only partially coincided.
Warren was recalled to the US in the early autumn
of 1926 so he that he could study epidemiology at the
Johns Hopkins School of Hygiene and Public Health.
Towards the end of his stay, he proudly reported that
the campaign had rapidly become more scientic and
had achieved ``extraordinary co-operation between
State and National health departments''. In addition,
he boasted:
``the condence of the people is such that we can
kill a member of the family with chenopodium and
the other members will demand that they continue
to receive their treatment. And to throw this bou-
quet does not cause me the slightest embarrass-
ment.'' (Warren, 1926a)
For the rural population, then, the hookworm cam-
paign could kill or cure; moreover, its etiological ex-
planation both confused the population and
represented fulllment of revolutionary demands.
Henry Carr's experience conducting the Mexican
hookworm survey, together with Warren's condence
in him, facilitated his return to Mexico in the autumn
of 1926 to head the hookworm campaign. Though he
had been removed earlier from the campaign, Carr's
enthusiasm for hookworm work was tremendous.
Hookworm aected 1020% of the population of a
large area of Mexico, and it was ``capable of solution'',
he promised, ``and then [there is the] entirely virgin
eld of malaria control'' (Carr, 1926a). More indepen-
dent than his predecessor, Carr experimented with
treatment modalities and frequently deed the advice
of the IHB home oce.
Carr acknowledged that persons with an ``adequate
and balanced diet could resist a higher number of in-
testinal parasites'', but he held that nutritional status
played a ``secondary role to the actual number of para-
sites present and the symptoms exhibited by each indi-
vidual'' (Carr, 1932), revealing his conviction that a
technical, curative intervention was a far better sol-
ution to hookworm infection than was a preventive,
social intervention.
Hookworm, Carr believed, ``depends upon the insa-
nitary habits of night soil disposal and these customs
are very rmly xed in the instincts of the people''
(Carr, 1926d). Carr recognized the challenge in rapidly
changing defecation ``habits'', thus turning to treat-
ment as the IHB's ``best sort of propaganda for good
health''. Each cure of hookworm was ``a very obvious
and dramatic occurrence'', which became ``an adver-
tisement for better hygiene''. Carr believed that by
``curing'' cases of hookworm, rural inhabitants would
be convinced to take the individual measures of paying
for and building latrines in order to prevent the disease
in the future. That the IHB did not follow up to see if
this was actually the case did not temper his enthu-
siasm.
Only a few months after Carr had taken over the
directorship of the hookworm campaign, Russell com-
plimented him on the ``revolution you have brought
about in sanitation'' and for the ``good co-operation
from district peons'', which Russell jointly credited to
Carr and the DSP (Russell, 1927b). Even after two
peasants had died from carbon tetrachloride treatment,
Russell only gently recommended that it was contrain-
dicated in persons with calcium deciency, especially
malnourished children (Russell, 1927a).
As soon as Carr took over the leadership of the
 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
hookworm brigades, he learned that, ``Although the
Lucha (campaign) does not consider the treatment of
general diseases as a part of its function, it is occasion-
ally necessary, where no practicing doctor is available,
to give preliminary treatment (gratis) before antihel-
minthics'', most frequently for malaria (Carr, 1926b).
Carr was nervous that the DSP would soon request a
malaria program, so Russell counseled him to tell the
Mexican government that a campaign would only be
successful if it were preceded by a survey (Russell,
1927b), which would delay its inception. Russell gave
the determined Carr permission to carry out a malaria
survey as long as it did not interfere with the hook-
worm work. Subsequently, a malaria demonstration
was to be carried out in a locale where ``control would
be easy'' (Russell, 1927c). As a matter of policy, the
RF home oce was careful to avoid commitments that
were costly or that detracted from a rapid demon-
stration of the value of disease control, regardless of
the scientic or public health value of the activity.
The home oce and IHB ocers also battled over
more circumscribed treatment policies. One such
debate revolved around the question of when to end
the course of hookworm treatment. Russell had
advised Warren that the word ``discharged'' was to be
used in place of ``cured'' because the latter term could
be misleading and dicult to dene. Tropical disease
authority Samuel Darling had recommended the end
of clinical symptoms or the absence of hookworm ova
in the feces as appropriate endpoints (Russell, 1924d).
In 1928 Russell advised Carr that it was senseless to
``treat people to a cure'' when a small number of para-
sites ``do no real damage'' (Russell, 1928a). However,
not only would remaining worms continue to feed o
the intestinal wall, but expelled worms were likely to
lead to new infections. Like Warren before him, Carr
believed that preventing reinfection built legitimacy
among peasants, but the RF home oce's continued
lack of concern with reinfection underscored the
acknowledged goal of using the hookworm control
program for ends other than eradicating, or even per-
manently diminishing, hookworm disease in Mexico.
Carr disagreed with Russell's position, believing that
the hookworm campaign was responsible for prevent-
ing reinfection and for limiting treatment dosages. By
having the hookworm brigades recover specimens from
several persons undergoing treatment each day, Carr
saw evidence of chenopodium's variable antihelminthic
eectiveness. Carr believed that these results justied
making a microscopic examination of the worm count
before declaring a patient cured. Further, even though
the doses administered by the Mexican brigade were
11
The IHB also changed its name to the International
Health Division in 1927.
1207
lower than those recommended by Smillie in Brazil,
Carr explained, ``we have some toxic reactions which
are right worrysome'' (Carr, 1930d). Carr struggled
with achieving an optimal dose of chenopodium that
would eciently eliminate hookworm and prevent rein-
fection without jeopardizing the health of the persons
treated, and he also tested dierent combinations of
drugs (Carr, 1928c).
Although Widdie Rose's vision had called for
implementing only known public health measures in
the eld, the IHB became increasingly interested in
experimenting with new drugs and technologies, es-
pecially after 1927, when it embraced a more scientic
outlook (Russell, 1928b).11 Unfettered by patient con-
sent regulations, Carr was able to do a eld trial of tet-
rachloroethylene without informing the local
population. Finding it less toxic and more ecient
than chenopodium, Carr recommended the drug's use
starting in 1931 (Carr, 1931).
Impact and reception of the hookworm campaign
In 1927, the nal year of the RF's nancial partici-
pation in the hookworm campaign, the Annual Report
of the Lucha Contra la Uncinariasis, now published by
the Departamento de Salubridad Publica, boasted of
126,799 treatments given to 61,877 people and the con-
struction of 5179 latrines (see Table 1). Carr had
improved the eciency and coverage of the campaign
by not treating persons with very low worm counts
(who exhibited no other symptoms of hookworm).
While there was considerable resistance to the cam-
paign among some groups of peasants and rural
doctors in its rst years, by the late 1920 s hookworm
control had become extremely popular, reaching a
large number of people (Birn and Solorzano, 1997).
By this time, the elite academic wing of the Mexican
medical profession had established extensive ties with
the hookworm campaign, both through the direct par-
ticipation of several members of the Mexican Medical
Association and through discussions of the medical im-
portance of hookworm in Mexico in a series of semi-
nars and articles in the Gaceta Medica de Mexico
(Bulman, 1927; Solorzano Morf n, 1927a, 1927b;
Cervera, 1927). Dr Juan Solorzano Morf n, the former
director of the hookworm campaign, made a public
presentation on hookworm diagnosis and treatment to
the Mexican Academy of Medicine in a bid for mem-
bership. He attributed the awakening interest in the
research and control of this ``silent and draining plague
on tropical countries'' to government eorts, preven-
tive and curative measures put in place by doctors
working for mining and agricultural rms, and the col-
laboration of the International Health Board
(Solorzano Morf n, 1927a). According to the author,
1208 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
modern medicine had triumphed in its scientic under-
standing of the epidemiology, prevention, and treat-
ment of the disease, but the great task of eradication
remained.
While Solorzano Morf n acknowledged the role of
foreign investigators and the RF, his article empha-
sized the large part played by Mexican doctors since
the turn of the century.12 In 1902, Dr Ricardo
Manuell, a prominent military physician, discovered a
group of soldiers suering from hookworm in the
Military Hospital. Subsequently, hookworm was
encountered in a number of coastal and mining states.
In 1912, another physician conducted a meticulous sur-
vey of the nation's doctors to determine the extent of
hookworm infection among their patients, and, over
the years, more than a dozen Mexican physicians had
published articles about hookworm. Solorzano Morf n
ranked a long list of anti-helminthic treatments (all of
which were less toxic than chenopodium), including
traditional medicinal plants, which had not been tested
by the RF (Solorzano Morf n, 1927a).
He also condemned the pharmaceutical manufac-
turers for failing to provide a chest of medicine to help
treat the adverse reactions to their drugs. This was a
case the RF had not made, even though eld ocers
complained that their budgets did not cover thera-
peutic remedies. While Solorzano Morf n accepted the
explanations of the biological cause of hookworm, he
was concerned that the hookworm campaign paid
scanty attention to the likelihood that hookworm
infection would make individuals more susceptible to
other parasitic ailments, tuberculosis, or malaria.
Solorzano Morf n was also highly critical of the un-
necessary deaths caused by hookworm treatment. He
blamed these problems on the poor management of
the hookworm campaign, which remained entirely in
the hands of the RF representatives, even though the
DSP furnished the bulk of the budget (Solorzano
Morf n, 1927a).
Solorzano Morf n was awarded a prize for his pres-
entation, but his assessors did not acknowledge his dis-
12
Following the 1838 discovery by Italian physician Angelo
Dubini of hookworms in a human, Brazilian physicians were
perhaps the rst to debate the etiology of hookworm, with
old-school Rio de Janeiro Dr Jose Martins de Cruz Jobim
holding that climatic and meteorological conditions combined
with bad hygienic habits were the cause (and hookworms the
result) of the disease and upstart Dr Otto Wucherer of the
Bahian Tropicalista School, averring that hookworm parasites
together with secondary factors relating to diet and hygiene,
caused the ailment (Peard, 1996). It is interesting to note that
this controversy is overlooked by most standard accounts of
the history of hookworm, which generally focus on the role of
US scientists Bailey Ashford and Charles Wardell Stiles
(Ettling, 1993).
putes with the RF, and they criticized his ranking of
hookworm treatments (Bulman, 1927). In a subsequent
article, Solorzano Morf n was far more conciliatory
and accepting of medicine's technical orientation. He
optimistically pronounced that the arrival of micro-
scopes in the humblest of rural clinics marked the
``splendid future of scientic medicine in Mexico''
(Solorzano Morf n, 1927b). This time the article's eva-
luator declared that accepting Solorzano Morf n ``into
the bosom of the Mexican Medical Association has
been an act of justice, rewarding him who deserves''
(Cervera, 1927).
In the end, Solorzano Morf n's protest against the
RF was not generalized, although at least some of his
colleagues agreed that the Foundation wielded exces-
sive control over the hookworm campaign. It was ulti-
mately self-defeating for the medical profession to
oppose the RF, despite its violation of Mexican medi-
cal sovereignty. Not only did the physicians gain scien-
tic and technical knowledge and armamentaria
thanks to its presence, but they benetted from the
RF's promotion of an expanded medical purview, lead-
ing both the public and the government to accept a
wider societal role for medical practitioners.
Hooked on hookworm
In a report on modern methods for the eradication
of hookworm, Carr maintained that the mass treat-
ment method was helping to ``alleviate the suering of
the working class'' (Carr, 1927b). Carr acknowledged
that the campaign worked slowly, but he attributed
this to its newness and to the ``inertia in people's
habits''. The cure of even a single case of hookworm,
said Carr, was ``positive evidence . . . and as advan-
tageous for the person's neighbors as for himself''.
This served as the best propaganda for ``people who
are incapable of doing anything for so many diseases'',
by proving that disease results from ``poor hygiene and
that public health work can alleviate the suering of
the people''.
While the RF home oce continually stressed that
the importance of the hookworm campaign was to get
a foot in the door and swiftly convince rural people of
the value of public health work, IHB ocers in
Mexico could not remain suciently detached from
their work to regard its long term aims as more im-
portant than its immediate public health role.
Seasoned ocers soon forgot that hookworm was not
a leading cause of disease and death. Warren came to
regard hookworm as a root cause of poverty in
Mexico, and Carr, who witnessed the epidemiologically
secondary importance of hookworm when he con-
ducted a survey of the disease in 1924, became com-
mitted to the merit of controlling hookworm. After
 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
two years of hookworm work, Carr had become so
convinced of the value of hookworm control that he
contradicted his own ndings, judging it ``more im-
portant than malaria'' (Carr, 1928d).
The RF home oce was convinced that state and
local authorities need only be exposed to the hook-
worm campaign in order to ``create . . . a desire for a
local health service capable of dealing with the more
pressing public health problems'' (Ferrell, 1929). The
view that every jurisdiction would form a public health
unit as soon as the benets were demonstrated was
based on a vision of the inevitability of scientic
``truths'' to transform society. Thus, when the RF's
plans were stymied, ocers and administrators tended
to blame the problems on the character and purport-
edly less advanced intellectual level of Mexicans rather
than on the geopolitical and social landscape of
Mexican society.
The IHD's tendency to see all of its eorts as suc-
cessful (Farley, 1992) belied chronic battles over
Mexico's hookworm payments. Carr faced consider-
able diculty in collecting the monthly instalments for
the Lucha Contra la Uncinariasis, even when he told
Mexican Treasury ocials that theirs was an ``inter-
national obligation'' (Carr, 1928b). The home oce
was adamant that the Mexican government take
``entire nancial responsibility for continuing'' the
hookworm campaign, yet it urged Carr to prevent the
interruption of the work (Ferrell, 1930). Carr pushed
the DSP to incorporate the hookworm campaign into
its regular budget, but the higher salaries that the IHB
had fostered in order to recruit the best candidates
made it dicult to reintegrate the hookworm personnel
(Carr, 1930e). Finally, in June 1930, Carr wired the
home oce that the DSP would increase the budget
for the Lucha Contra la Uncinariasis by 20,000 pesos
(90,000 in 1998 dollars), ``in spite of budget cuts to
many dependencies'' (Carr, 1930b). Oblivious to the
sacrices made in Mexico's funding priorities, the
home oce succinctly expressed pleasure that the work
of the RF ``continues to merit the condence of the
ocials of the Mexican government'' (Warren, 1930).
Conclusions
Two decades after the joint RF-Mexican hookworm
program ended, the Secretar a de Salubridad y
Asistencia (the DSP's successor) launched a second
crusade against intestinal parasites, this time aiming at
long-term control. The RF had conducted one-time
hookworm control in each community, exposing entire
villages to the value of public health, but refraining
from providing follow-up to determine reinfection
rates after each area had been sanitized. Former RF
fellow Dr Pilar Hernandez Lira, who had held a var-
1209
iety of positions with the Lucha Contra la Uncinariasis
and the local sanitary units before becoming Director-
General of Health, observed in 1949:
``Experience acquired over twenty years has taught
us that hookworm clinics alone cannot signicantly
reduce rates of intestinal parasites, because treated
individuals who return to their former environment
which has not been appropriately sanitized are sub-
ject to levels of reinfection that make the results of
the hookworm clinics' work look very poor.''
(Hernandez Lira, 1949)
If evaluated according to a standard of hookworm
disease control through scientic methods, then, the
RF campaign in Mexico was a marked failure.
Paradoxically, if evaluated according to the goals of
stabilizing Mexico, transforming it into a valuable
commercial neighbor, and promoting modern medicine
and public health, the campaign was far more success-
ful. The hookworm campaign spawned further para-
doxes for its array of clients. For the Mexican
government, the campaign supported a modern state-
building endeavor and a tool to consolidate poweras
well as obliging commitment of funds to a foreign pro-
gram. For the DSP, the campaign functioned as a
patronage program that ignited interest in public
health and legitimized government services but also
challenged the DSP's control. For the medical estab-
lishment, the campaign expanded physician purview
and authority while impeding sovereignty. For pea-
sants, a dramatic hookworm control eort illustrated
the government's potential role in rural development,
but only limited services for a marginal ailment were
provided; hookworm control, moreover, could both
kill and cure.
RF ocers also conated the scientic and political
ends of the hookworm program. Warren predicted a
great future for the hookworm-free individual. More
productive due to his improved health and physical
condition, his newfound earning power would:
``result in more money in his pocket with which to
buy better food, better clothes, better homes, and
better schools. With better schools there will come
enlightenment. Intelligence will displace ignorance
and with intelligence there will come a true social
revolution and a better understanding between all
classes of men.'' (Warren, 1925j)
Warren inverted revolution in Mexico: rather than
setting the stage for government-led improvements in
social conditions, including relief from disease, it was
hookworm eradication that would lead to social revo-
lution.
The hookworm campaign set the terms of the re-
1210 A.-E. Birn, A. Solorzano / Social Science & Medicine 49 (1999) 11971213
lationship between Mexico and the RF which persisted
through subsequent programs including the develop-
ment of a network of local public health departments
(Birn, 1998). The Foundation maintained administra-
tive control even though its representatives were o-
cially placed in subordinate positions within the DSP;
it set budget incentives that assured Mexico's long
term commitment to the endeavors launched by the
RF; it promoted a public health orientation that
favored the control of diseases amenable to individua-
lized medical interventions; it encouraged the replace-
ment of traditional health practices and practitioners
with their ``scientic medicine'' counterparts; and it
began to stimulate the professional training and full-
time commitment of health personnel. These eorts
were challenged, reinforced, and resisted, remaining as
politicized as the RF's interest in promoting US demo-
cratic values and making Mexico a useful economic
and political neighbor through the hookworm pro-
gram.
The multiple, often contradictory, roles of the RF's
hookworm campaign are characteristic of the policy
paradoxes (Stone, 1997) that emerge when science is
summoned to drive policy. In Mexico the campaign
served as a policy cauldron through which new knowl-
edge could be demonstrated applicable to social and
political problems on many levels. The repeated pledge
of scientic neutrality belied the hookworm program's
inherent aim of persuading government ocials, the
medical community, business interests, and the popu-
lace of the value of investing in public health as a
means to improve social conditions, further a medical
model of health and sickness, increase economic pro-
ductivity, and promote good relations between the US
and Mexico.
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