External Philanthropy and Domestic Change in Colombian Health Care: The Role of the Rockefeller Foundation, ca. 1920–1950

The Rockefeller Foundation was active in health care and medicine in Colombia from the 1920s on.¹ In 1916 the Colombian government contracted the foundation to survey foci of yellow fever, and in 1920 invited it back to survey hookworm infection in Cundinamarca. The foundation had thereafter a permanent presence in the country. Before 1945 its first priority in Colombia was health care and medicine, after 1945 it was agriculture; but the impetus for health care programs continued.

This article, part of a larger project to investigate the contemporary history of health care in Colombia, sets out to clarify the Rockefeller Foundation’s impact and significance for that nation—embodying a little-studied element of the relationship between Colombia and the United States.² The intention is to relate changes at the international level to those at the national and local, and to explore connections between changes in science, technology, and education and those in the economy, society, and politics. These are examined for a three-decade period in order to relate secular trends to short-term phenomena.

This article begins by reviewing the international aims of the Rockefeller Foundation’s health-care activities, along with the foundation’s internal problems of strategy, personnel, and organization. Then it considers the nature and evolution of the foundation’s modus operandi in Colombia—negotiation and collaboration between Rockefeller officials and the Colombian authorities over the entire period—along with the practical setbacks, political resistance, and questions of disorganization that the foundation’s International Health Board (later Division) encountered in the wider society. The most common difficulties arose from the practice of funding projects for a period agreed on with the national government and then withdrawing, leaving Colombian officials to maintain them.

The focus then narrows to the campaigns against hookworm undertaken under IHB auspices in the 1920s and the sanitary units that succeeded them in the 1930s. During those years the IHB also encouraged the development of public health laboratories in Bogotá and Barranquilla. In the 1930s and 1940s, it promoted investigations into “jungle” yellow fever, undertaking long-term field research and complementary laboratory work connected to short-term campaigns of “eradication” and control.³ The foundation also contributed to education in the health sciences in Colombia. In the 1940s, it played an important part in the beginning of modern nursing education in Bogotá, and at midcentury, it was involved in a new school for public health specialists in Medellín and a proposed experimental school in Cali.⁴

In a recent article in this journal, Marcos Cueto explored the foundation’s rich archives to cast light on a four-year episode in Peruvian medical history.⁵ The purpose of this article is different: to assess the enduring significance of external philanthropic activities by adopting a long-term perspective. Because the hallmark of the foundation’s public health work was the demonstration program, by which a scientific and technological approach to disease control and eradication was transferred, Rockefeller officials’ correspondence analyzes public health issues mainly from a scientific and technical rather than a socioeconomic and political perspective. Nevertheless, even the correspondence between disease researchers in the countryside and laboratory personnel in the cities contains data on sociopolitical issues that transcend the merely anecdotal.

External Work and Internal Problems

The Rockefeller Foundation was built between 1906 and 1913 from a patchwork of philanthropic institutions that promoted public high school education for blacks and poor whites in the U.S. South, campaigned against hookworm, founded experimental farms, and developed medical education.⁶ John D. Rockefeller was a convinced Baptist layman whose entry into philanthropy was, contrary to some Roman Catholic and secular assumptions, motivated less by a desire to expiate guilt and buy public favor than by a Protestant ideology of voluntary giving, together with a determination that rational social progress achieved through the application of science should complement economic change. For the Rockefeller family, the ownership of wealth was not a matter for condemnation as long as it was managed intelligently and rationally. Resources should be allocated “according to the principle of scientific giving” and not subject to casual, intuitive impulses, because prudent stewardship was a divine responsibility.⁷

John D. Rockefeller and his associates drew a distinction between a desirable, organized philanthropy, such as the YMCA or the New York Society for the Condition of the Poor, and ineffectual almsgiving, such as ad hoc donations to particular local churches. The Rockefeller Foundation evolved as a smoothly operating, integrated combine, which was concerned with size, efficiency, economies of scale, and the risk of overcapacity and aimed to develop a corporate tradition and an esprit de corps among its employees.⁸ The foundation’s philanthropic activity was subject to the fluctuations of the world economy: when income from the Rockefeller empire fell during the World Depression, so too did its philanthropic spending, and its programs were reviewed, curtailed, or deferred.

From projects in the United States developed the foundation’s International Health Commission (later Board, and then Division), the stated aim of which was the “promotion of public sanitation and the knowledge of scientific medicine” throughout the world.⁹ The IHC undertook research, experiments, and fieldwork and promoted the institutionalization of public health in countries whose governments wanted “to forward the battle against disease.” To achieve these objectives, the foundation engaged in epidemiology and research toward cure, especially of diseases like hookworm that were amenable to treatment. It also instigated programs of prevention and control, and manufactured and distributed vaccines. By 1918 the IHB’s work had spread to include yellow fever studies, malaria control, and public health programs.¹⁰ The foundation’s international activities were animated by an ideology of liberal progressivism, particularly the belief that a spirit of cooperation, peace, and harmony would prevail over war, disease, ignorance, poverty, and factionalism.

Foundation officials proceeded from attitudes of racial and intellectual superiority, especially the assumptions that “civilized” peoples had obligations to the less fortunate and that U.S.-trained professionals had a superior understanding of the natural world, organizational methods, and scientific inquiry.¹¹ The IHD’s overall thrust in host countries was threefold: “to liberate ignorant populations from misery ”; to diffuse the benefits of modern science and technology; and to persuade receptive elements among national and regional elites that prudent spending on public health constituted an investment, not a drain on resources. The IHD identified specific areas in which it sought to achieve these objectives: promotion of the control of specific diseases by means of field investigations, practical demonstrations, and laboratory research; development of public health education; and aid to government, central and local, to place health work on a permanent basis. The outlook of senior officials was embodied in the view that the well-tested hookworm control measures constituted “one of the best single means of creating a widely understood concept of what modern health measures may accomplish.”¹²

The IHB’s international dimension was everpresent. In 1929, investigators of an urban yellow fever outbreak at El Socorro, Colombia, sent tissues for diagnosis to the Rockefeller laboratories in Havana.¹³ In 1931, scientists in Colombia consulted a pathologist at the University of Toronto who analyzed yellow fever tissues, and who in turn consulted a professor at the University of Liverpool with extensive research experience in Jamaica.¹⁴ During the mid- and late 1930s, the research results of the Colombian yellow fever studies were exchanged with reports from scientists in Rio de Janeiro on their experiences in Bahia and Ceará. Aviation made it possible in 1934 for laboratories in Bahia to receive yellow fever tissues for histological analysis from Quibdó (Colombia), Quiriquire (Venezuela), and Cuyaba and Cachocirinha (Mato Grosso). Also that year, a visiting U.S. specialist was vital in setting up jungle yellow fever studies in Muzo. He was accompanied by an Argentine from the Bacteriological Institute in Buenos Aires and a Brazilian entomologist from the Institute of Hygiene in São Paulo, whose assistant had made an entomological survey in Mato Grosso.¹⁵ In host countries such as Colombia, senior personnel from the United States and, on occasion, from Canada were complemented by Colombians, usually the recipients of IHB fellowships who had acquired training and work experience outside the country.

Most senior Rockefeller employees had a strong sense of teamwork, commitment to shared objectives, and conscientious adherence to their employer’s criteria. They maintained their official diaries regularly, recorded statistics systematically, drew up thorough and punctual reports of their work, sought advice from central and regional offices, and pooled data with their colleagues in other countries. Yet infirmity of purpose was a recurring fear. In Colombia, officials noted the risk that the IHB would violate its general policy of working intensively within the limits of its program and would dilute its impact by spreading resources too thinly over too large an area. They also anticipated the risk that an institution they established would deteriorate too soon into the routine performance of routine duties.

Personnel problems dogged the IHB projects. Senior officials expressed misgivings about the relationship between the central office, the national office, and field activities in 1924, when the Direction of Soil Sanitation in Bogotá and 48 employees were involved in the antihookworm campaign. In 1925, one national director rebuked his predecessor for failing to keep records of supplies furnished to each traveling laboratory or to take inventories at the end of each work stage, thereby preventing analysis of technicians’ relative efficiency. Senior officials worried about the inefficient supervision of assistant technicians, who were more interested in curative treatment with immediate, tangible results than in preventive soil sanitation and were poorly informed about legal procedures and the scope of their legal authority. Discipline among junior employees needed tightening, and employees at the local level were denied autonomy in the selection of purgatives and vermifuges.¹⁶ During Colombia’s economic boom of 1927–28, labor of all kinds, including physicians, was scarce because of opportunities in public works construction.

Personnel problems were linked with acute organizational problems. Transportation and communication posed major obstacles to coordinated field activities. Eight-day journeys to the field impeded proper supervision of employees in the antihookworm campaign. Time spent riding mules, much of it unavoidable in the Colombian Andes, reduced costeffectiveness.¹⁷ Supplying horses for sanitary inspectors incurred costs of foraging as well as purchase.¹⁸ Imports of drugs and equipment were held up in the customs houses by congestion or on stranded ships as the water level fell on the Río Magdalena. Although a coefficient of safety was established to assure security supply, this precaution failed to guarantee adequate stocks of essential goods.¹⁹ Supplies of yellow fever vaccine were at times damaged because they missed the air connection at Miami.²⁰ The use of surface instead of air mail delayed the delivery of drugs from Bogotá to Medellín.²¹ And before a satisfactory colony was set up in the Bogotá public health laboratories in 1936, mice ordered from New York for breeding were subject to heavy losses, probably from mouse typhoid contamination on the Río Magdalena.²²

New problems arose with the World Depression. Fiscal crisis in Colombia crippled port sanitation and paralyzed antimosquito measures and other public health activities.²³ In the mid-1930s, IHD officials noted the risks of creating an unwieldy and inefficient bureaucracy, and the danger that trained sanitarians would opt for private-sector jobs because of job insecurity caused by the politicization of the public sector. In 1935, Fred L. Soper held underfinancing and understaffing of the yellow fever studies section responsible for the failure to achieve a quality of analysis that met the foundation’s self-imposed standards.²⁴

Negotiation, Collaboration, and Resistance

The first Rockefeller Foundation officers to arrive in Colombia encountered little deepseated xenophobia. Memories of the excision of Panama in 1903 were receding. Because external economic penetration was shallow and regionally circumscribed, nationalism was mild and sporadic. The Colombian government was anxious to show that it was following international sanitary conventions and reporting notifiable diseases, because foreign investment and international commerce would otherwise be imperiled. The Yellow Fever Commission of 1916 concluded that the disease was not endemic in Colombia but that vigilance was needed in the Pacific port of Buenaventura, to which the disease had spread from Ecuador.²⁵ Favorably impressed by IHC work, the government of President Marco Fidel Suárez (1918–21) contracted the Uncinaria Infection Survey of 1920. Its aim was to determine the index of hookworm infection and the distribution and severity of the disease in Cundinamarca.²⁶ This project led to an executive decree establishing an Uncinariasis Department in the Ministry of Commerce and Agriculture, and decisively helped shape long-term attitudes.

In New York City before his inauguration, President Pedro Nel Ospina (1922–26) established a cordial relationship with Rockefeller officials by affirming that public health was an important priority.²⁷ In his 1925 presidential message, Ospina welcomed the foundation’s cooperation, arguing that its presence reassured Colombia’s trading partners of the nation’s determination to lower the Stegomyia index to the point where the extinction of urban yellow fever could be guaranteed. During the first presidency of Alfonso López Pumarejo (1934–38), some of whose supporters endorsed the Mexican Constitution of 1917’s commitment to health care, support for the IHD came from both the National Federation of Coffee Growers and Merchants and the National Association of Cattle Ranchers. In 1934, López commissioned a report on health care from the National Academy of Medicine, whose committee on rural sanitation and tropical diseases was composed of foundation allies.²⁸ Endorsement from radio commentators and Congressional leaders for sanitation and hygiene projects and for schemes of “infant protection” encouraged project officials.²⁹

By the mid-1930s, foundation officials had established a firm base and fluid working relationships in Colombia. By undertaking campaigns against “tropical” diseases such as hookworm, Rockefeller employees believed that they were equipping Colombians to fight for their own public health. By providing postgraduate fellowships in the United States for young Colombians to study subjects ranging from food bacteriology to pharmacology, and by financing trips by Colombian officials to visit projects such as a school for sanitary inspectors in Jamaica, the IHB was diffusing scientific and organizational knowledge and fomenting modern public health services.³⁰ By aiding the publication of specialized periodicals and pamphlets for schools, the foundation was taking an active part in raising public alertness to health issues.³¹

Serious negotiation problems crystallized only slowly. Seldom did the executive pose obstacles; more common were difficulties involving ministerial reorganizations, administrative weaknesses, minor officials, the relationship between the center and the regions, and the character of legislation. Overall responsibility for health care was shunted from ministry to ministry until the hygiene portfolio was established in 1946. The National Hygiene Department’s failure to issue vital statistics between 1929 and 1934 weakened the empirical basis for policymaking.³²

The early and mid-1930s and the mid- and late 1940s saw high turnover rates among ministers and senior officials. When regimes changed, priorities shifted; for instance, from child welfare and curative campaigns to sanitation and prevention in 1934. When foundation officials asked López to create a commission with sufficient autonomy to bypass junior bureaucrats, he replied tetchily that he confronted the same difficulties as they did and that his “pet peeves” were “American technicos [sic].”³³ In 1935, the transfer of the School of Sanitary Inspectors and the Rural Sanitation Section from the foundation to the government caused personnel instability that especially damaged the subsection responsible for health propaganda, which declined into merely routine activities.³⁴

Shifts of power and responsibility among national, departmental, and city authorities exacerbated delays. IHB officials argued that while it was desirable in the interests of efficiency to concentrate resources in one or perhaps two geographical departments, it was politically expedient to operate more widely, so that sympathizers could muster majorities to pass budgets through the Colombian Congress. Legislative procedures often deferred action instead of facilitating it; much public health legislation was too complex.

The premises of collaboration were established during the relative economic stability of the 1920s. In theory, cooperative activities were funded at an agreed level for an agreed period; the foundation progressively withdrew its financial support until control and responsibility were transferred to the Colombian authorities, and jointly purchased equipment and materials became the property of the Colombian government. In the year 1929–30, however, unpredictable economic downturns posed recurrent crises. Promised budgetary contributions for cooperative activities were not forthcoming; junior employees, such as sanitary inspectors, who were paid several months in arrears, had to travel to Bogotá to receive payment, covering their debts by selling their salary checks at a discount.³⁵ Rockefeller personnel feared that the high bureaucratic turnover, which left interim personnel unwilling to make long-term policy decisions, would thwart foundation aims, and that binding contracts would dissolve amid budgetary turmoil.

These were circumstances in which IHD officials set out to show understanding of Colombian dilemmas. They did at times renegotiate contracts, flouting the general principle of progressive withdrawal. Yet they also paused to reflect on whether they were over-accommodating Colombian governments when contracts were dishonored for fiscal reasons, and whether they were surrendering control of a project while continuing to supply financing or personnel. During the uneasy transition from Liberal to Conservative rule in 1946–47, IHD officials believed that the foundation was a stabilizing presence because it guaranteed some freedom from politicization of appointments, brusque cuts in financing, and abrupt personnel changes in areas it helped to fund.

The most important opposition came from Congress and the medical profession. Some political leaders wanted to use Colombian contributions to project budgets as leverage to obtain control of cooperative activities. Meanwhile, as the proportion of the total population resident in cities grew, and with it, pressure from newly enfranchised urban groups, Congressional leaders urged the central government to mount social policy initiatives in the cities—unlike the IHB, which in the 1920s and 1930s was active mainly in the small towns and the countryside. Some congressmen alleged that a nonaccountable external agency was dominating the health agenda and that a two-tier public hygiene apparatus—one tier well funded and invigorated by foreign expertise, the other poorly funded and denied external advice—was taking shape.

In the 1930s, exponents of alternative policies challenged the foundation. Senator Max Duque Gómez advocated in 1932 that ambulatory dispensaries should be established throughout Colombia to treat all classes of disease. An influential education minister, Luis López de Mesa, in 1934 expounded a general scheme for civic improvements in small towns as part of an alternative to campaigns against specific targets like hookworm. The main feature of his proposal was that each small town should have one doctor on the government payroll who would serve as local physician, sanitary inspector, health officer, and biology and hygiene teacher in the primary school. The foundation objected that most medical graduates did not recognize their own limitations in public health and disease prevention, and it argued that these tasks required highly technical public services, which village doctors could not provide.

Patterns of collaboration and resistance from regional elites, social classes, political parties, and foreign enterprises changed over space and time. Soil sanitation projects were often better received in the poorer departments—Norte de Santander, Narióo, Cauca, and Boyacá—than in the richer—Antioquia and Caldas. In the early 1920s, Cundinamarca’s large landowners, convinced that action against intestinal parasites would improve the labor force, supported the antihookworm campaign (except when inspectors demanded the right to examine their houses). But during the World Depression, hacendados resisted sanitation measures and tried to burden tenant farmers and squatters with the cost of building and maintaining latrines.

While in the 1920s both Conservatives and Liberals were sympathetic to the IHB’s goals, in 1933–34 the director of the Hookworm Department saw neither party as the leading ally of the rural campaign. Only Unirismo, a short-lived coalition of radical urban workers, tenant farmers, and rural laborers in Cundinamarca and Tolima led by Jorge Eliécer Gaitán, stressed public health in its program. Unirismo proved very cooperative in Fusagasugá once violence between Liberals and Uniristas there had been resolved.³⁶ Even the attitudes of U.S.-owned enterprises toward Rockefeller programs varied. In 1936, when a program of vaccination against yellow fever among oil company workers accomplished 2,573 vaccinations, the Colombian Petroleum and Engineers Limited displayed “irreproachable” cooperation, while South American Gulf was halfhearted in its help.³⁷

The systematic resistance the foundation had encountered in parts of Mexico in the late 1910s never surfaced in Colombia.³⁸ Some sustained resistance did appear, however, at the regional level in the 1930s. After initial support in 1927 from a sympathetic physician governor, resistance to Rockefeller antihookworm activity in Caldas grew. Controlling the most progressive departmental administration in Colombia and denouncing “parasitism”(!) in the national government, the Caldense elites were intensely regionalistic during the World Depression, and they used nationalist language against the foundation to disguise their opposition to Bogotá. A faction of physician-politicians, frustrated that it could not modify the foundation’s agenda and determined not to surrender control of hygiene policy to the capital, formulated an alternative program. It included a project to provide shoes for laborers and the creation of a competing set of health services managed by the regional coffee committee. Thus, for political reasons, the foundation’s work went more slowly in Caldas than in Norte de Santander. Dispirited, Rockefeller officials hoped in 1934 that the spread of urban sanitary units from Pereira to Armenia and Manizales would convert the Caldense elites to the foundation’s agenda.³⁹

Unhooking the Hookworm

The IHB defined its method in the U.S. South, Panama, Puerto Rico, Cuba, Jamaica, and Mexico before entering Colombia. The antihookworm campaign in Cundinamarca, its first major effort, combined treatment of peasants and rural laborers with preventive rural sanitation. By 1920, the political and intellectual milieu among the country’s ruling elite was propitious for the campaign. After the prominent, French-trained specialist in tropical diseases, Roberto Franco, reported the first Colombian diagnosis of hookworm in 1905, the medical profession had pressed the central government to undertake a campaign to treat and prevent the disease. Franco and another pioneering Colombian medical scientist, Jorge Martínez Santamaría, argued forcefully that more than 90 percent of coffee and sugarcane workers and their families were infested by the debilitating parasite. A medical publicist called for education in the use of privies. Legislation was passed in 1911 to organize a treatment campaign by means of dispensaries, but it achieved nothing.⁴⁰ Agricultural journals in the 1910s contained propaganda on the treatment of hookworm by thymol, which had only temporary effects without preventive measures. Legislation in 1919 authorized the executive to organize and regulate a campaign against hookworm.⁴¹ A Direction of Soil Sanitation was created within the Uncinariasis Department established in 1920.

The Department of Cundinamarca was selected because it was accessible to the national authorities and useful for demonstration, in that it comprised all climatic and most epidemiological zones. It was a Rockefeller Foundation axiom that a sound policy was based on an empirical knowledge of the selected localities. Therefore both quantitative and qualitative data were carefully assembled, some from official agencies and some by foundation employees. Employees assessed the level of hookworm infection, recorded health care spending patterns, outlined the disease profile, and drew maps. Data on the local population by sex, age, and ethnic group were collated, along with related information on, for example, the proportion of the population in the urban area and the number and proportion of children attending school. Foundation employees noted obstacles to launching a campaign, such as an epidemic of grippe or dysentery. The central government facilitated the analysis of data for outlying areas by providing offices in Bogotá and franking privileges for campaign employees.

The investigation concluded that the lowest rates of hookworm infection were in Bogotá and nearby municipalities on the Savannah. Coffee laborers had, at 93.0 percent, the highest rate among the 5,795 persons classified by occupation and diagnosed as infected. Sugarcane workers and ranch hands followed, while miners showed a low infection rate of 17.1 percent because the mines were located in the temperate uplands. The relatively high incidence among the police, 66.0 percent, astonished researchers, but the distribution pattern by ethnic group caused no surprise: 88.4 percent of blacks, mainly inhabiting the lowlands; 84.0 percent of mestizos; and 65.6 percent of whites. The correlation between geographic location, ethnic origin, and poverty was clear.⁴²

The main aim of the Cundinamarca campaign was to raise labor efficiency.⁴³ Treatment especially included migrant workers from the temperate uplands who fell victim to hookworm in the coffee-producing altitudes. At least 10 percent of the population was permanently incapacitated, and employers sent many invalids back to their communities of origin, where they spread the disease.⁴⁴

On launching the Cundinamarca campaign, IHB officials aimed to win over first the national elite, then the local elites, and finally the peasants and rural laborers. President Suárez, accompanied by prominent citizens, attended a lecture with lantern-slide illustrations presented to the department’s parish priests. The field director gave a talk to cabinet ministers, congressmen, and leading hacendados and bankers. Public conferences were held in La Mesa, attended by Bogotano physicians, and in Girardot.⁴⁵ The governor gave his unstinting cooperation, threatening to dismiss alcaldes who failed to enforce the legislation to build sanitary privies. (Various alcaldes did encourage the campaign; that of San Francisco even ordered the building of municipal privies.) The governor also took well-publicized coercive measures against curanderos who advocated resistance, such as a tegua (popular healer) without medical title or permit to practice in the town of Guaduas. Three teguas claiming to represent the Uncinariasis Department and selling “specifics” were sentenced to 30 to 60 days in jail.

Officials feared that the Catholic church would see the campaign as a challenge to its near-monopoly on philanthropy. But the archbishop of Bogotá, Bernardo Herrera Restrepo, gave cordial support, encouraging the clergy to give public conferences in the marketplaces on Sundays stressing the merits of rural sanitation. Herrera Restrepo publicly up-braided one parish priest who dissented. Other parish priests provided assistance; that of Viotá intervened to rescue the campaign when it was threatened after seven deaths occurred during antihookworm treatment.

Six Bogotá newspapers were warmly favorable in their coverage. One reminded its readers of the foundation’s positive role in China, Canada, Brazil, and Thailand and informed them that the teaching hospital of University College, London, short of financial resources during World War I, had accepted Rockefeller financial support.⁴⁶

Some hacendados furnished animals for inspectors’ use; provided food and lodging for sanitation employees working on their premises; and arranged for men, women, and children on their estates to be called by roll for treatment.⁴⁷ Junior campaign officials sought local authorities’ help in overcoming the reluctance of parents of large families to bring children naked to field dispensaries. It was suggested that the children alternate wearing one dress.⁴⁸

The initial campaign was so successful that community leaders, both lay and clerical, telegraphed petitions from small towns across the republic—Valledupar, Riohacha, Tenza, Utica, La Mesa, Girardot, Fomeque—pleading that a sanitary commission be hastily dispatched to them. Wickliffe Rose, IHB director-general, commented in 1921, “I am particularly interested in the fact that government and the people are giving much hearty cooperation. It would seem that in no country has the work had such cooperation from the beginning.”⁴⁹

IHB policy was re-evaluated in light of the Cundinamarca experience and then applied to other Colombian departments. Meanwhile, the government’s Uncinariasis Department expanded rapidly to include 7 field directors and 65 sanitary inspectors, divided into 7 squads operating in 7 departments. The main aim now was preventive: to inculcate hygiene habits and to sanitize houses, schools, official buildings, and, more generally, the countryside. Latrine construction was made obligatory for proprietors of habitable houses. Failure to build a latrine within 20 days of notification was punishable by fines of between 20 and 40 pesos, and all members of the sanitary department were empowered to impose fines.

The campaigns now also had an explicitly educational role, aiming to promote a detailed knowledge of intestinal diseases and their transmission. House-to-house talks were conducted, illustrated lectures were given in local cinemas, and public sanitary conferences were held on market days in town plazas. Foundation officials boasted that in 1926 alone, 850,000 persons attended the conferences. The officials met practical difficulties, however: a heavy rainy season in 1921 drowned the initial euphoria. Alcaldes, arguing that the privies they had built were now breeding grounds for mosquitoes, instructed local inhabitants to fill them in and compelled the foundation to respond quickly with supplies of crude oil.⁵⁰

Before it agreed to extend its geographical coverage, the Uncinariasis Department required regional governments to include compulsory hygiene instruction in the school curriculum and to create a permanent hookworm control organization, financed completely from regional funds, while the central office retained technical management authority.⁵¹ Nevertheless, by 1924 sanitary campaigns were operating in Tolima, Huila, Boyacá, Santander, and Antioquia, as well as in Cundinamarca. New persuasive devices were adopted, including the film Unhooking the Hookworm and wall posters on street corners. Pamphlets were circulated describing types of privies, septic tanks, and latrines. In 1925 more people in Colombia (285,925) received two or more hookworm treatments than in all of that year’s other IHB campaigns (the United States, Mexico, Jamaica, Puerto Rico, Guatemala, Nicaragua, Panama, El Salvador, and Peru) put together.⁵²

Senior officials’ concerns during this period centered on the criteria for evaluating the work and on cost-effectiveness. They assembled new data on the numbers and techniques of treatment, the number of dosages, and so on; they recorded meticulously the costs of treatments and cures (first treatments and total treatments). A reduction in these per capita costs between 1920 and 1924 was cause for self-congratulation.

When the sanitary campaign was extended to Antioquia, officials learned that the inhabitants of the plateau of Antioquia, unlike those of the Savannah of Bogotá, were infected with intestinal diseases. The foundation’s national representative, Frederick Miller, opted for mass treatment, in spite of the IHB’s inexperience with it. But his superiors insisted that mass treatment was acceptable only if conducted on a scientific basis, and demanded statistical evidence of local treatments to prove its costeffectiveness.⁵³ It was fallacious, they contended, to judge hookworm work by the number of treatments, because a limited number of scientifically controlled treatments would have more long-term value than a large number of less-controlled treatments. Officials rejected impressionistic evidence that was “largely a matter of opinion and testimony” and sought more logical methods of measuring the permanent benefits of sanitation and systematic treatment.⁵⁴

In the municipality of Palestina, Caldas, the foundation established a hookworm control demonstration area and opened a training school for employees in 1929–30. Officials made their habitual careful study of the area’s environment and statistical analyses of the levels and types of infestation. One finding was a lower level of infection among clerks, seamstresses, and other urban employees than among rural laborers. In 1929, IHB field director Carlos Franco formed an “almost military” organization of sanitary inspectors, who covered about five hundred houses each, supervised the installation of latrines in 95 percent of the dwellings, and prepared the first maps ever made of the entire district. Franco reported,

Support from local citizens for this campaign came gradually, especially regarding the building of latrines.⁵⁶

The Uncinariasis Department intended that the practices devised in Palestina should spread progressively to adjacent municipalities in the prosperous parts of Caldas until an efficient sanitary division was established. When funding contracted in 1930–31, the Palestina experiment was not touched. The campaign continued to operate in Caldas, Cundinamarca, Tolima, and Valle, but abandoned work in Norte de Santander because of distance, Antioquia for lack of cooperation, and Huila because of the area’s extreme poverty.⁵⁷

Out of the hookworm campaigns of the 1920s evolved, between 1932 and 1934, a Rural Sanitation Section of the National Hygiene Department, concerned with health education in homes and schools and the inspection of homes and adjacent premises. The Rural Sanitation Section decided to work mainly in coffee-producing areas because of their economic significance, demographic weight, and relative ease of access. The employees of the departmental committees of the National Federation of Coffee Growers and Merchants charged nothing for helping to persuade peasants to accept the changes, and the coffee economy was sufficiently buoyant to carry most of the costs of implementing them. The section’s priorities ranged over soil sanitation in backyards; the protection of wells, springs, and water sources; garbage and rural sewage disposal; corraling domestic animals; and controlling flies and their domestic breeding places. This broadening of activities aroused alarm among IHB officials that hookworm treatments were being neglected in favor of developing efficient sanitary inspection services.⁵⁸

For its part, the foundation extended its work in urban areas by creating sanitary units, such as a model unit in Pereira. In 1934 IHD officials reported how many dwellings they had inspected; the quality of water for domestic use, sewage, drainage, and garbage disposal; progress in corraling domestic animals; the mosquito population; soil sanitation; the numbers of sanitation conferences, house visits, and houses with and without sanitary latrines; and the increase or decrease between first and second inspections.⁵⁹ Foundation correspondence discussed the Pereira unit’s milk station, day nursery, well baby clinic, and school hygiene. Recommendations to municipal government ranged over such diverse issues as controls on the slaughterhouse, the marketplace, and garbage burning; the appointment of a municipal “poor” doctor; the prevention of venereal diseases and diffusion of VD information in the schools; and the opening of a municipal laboratory. Officials claimed in 1938 that the model unit had exceeded its founders’ most optimistic predictions.⁶⁰

Science, Research, and Public Health

The foundation expressed its commitment to science through support for laboratory development and research into “tropical” diseases in both the laboratory and the field. Like the antihookworm campaign, these initiatives began with government funding initially complemented by IHB assistance. In 1918 Rockefeller officials argued that Colombia needed a modern laboratory for general diagnostic services. They warned that national mortality statistics were unreliable, and that deaths from diseases like typhoid and paratyphoid were often concealed because no effective laboratory procedures existed to verify and report them. Officials proposed a laboratory that would expand the output of smallpox vaccine and manufacture biological products, such as diphtheria antitoxin and antivenin (for snake bites), not produced locally.⁶¹ With Rockefeller support a National Hygiene Laboratory was founded in 1926 when the government purchased the well-equipped private Laboratorio Samper Martínez.

By 1927 a wide range of injectable artificial and biological serums and vaccines was available.⁶² They proved unexpectedly valuable in one area, an urgent campaign against diphtheria in Bogotá. Defying the orthodoxy that it was a comparatively mild disease in the tropics, diphtheria proved, through bacteriological surveys, to be more common and virulent at high altitudes than previously thought. In the mid-1930s, however, senior officials of the National Institute of Hygiene hesitated to assume responsibility for supervising laboratories managed by the foundation because by law, the institute was required to supply equipment and make necessary inspections, neither of which it could afford in the straitened circumstances of that decade. Yet in spite of the foundation’s eventual withdrawal from direct responsibility for laboratory services, these continued to expand in Bogotá until, by the end of 1935, protection tests, mouse breeding, and pathology and entomology services were all functioning, and a room was ready to handle infected experimental animals.⁶³

The outcome of this sequence of innovations was the Carlos Finlay Institute. A cooperative activity of the Rockefeller Foundation, the Pan American Sanitary Bureau (PASB), and the Colombian state, the institute assumed responsibilities in the fields of epidemiology and control of yellow fever and other viral diseases, survey and control activities relating to typhus and typhoid fever and petechial fever, and the production of vaccines against both. The Finlay Institute also organized the coordination and direction of campaigns for the eradication of the vector of urban yellow fever, the Aedes aegypti mosquito; surveyed infected lands; and demonstrated insecticide. The founders envisaged it as the service laboratory for northwest South America. It exported vaccine along with free histological diagnosis—the examination of liver specimens obtained by viscerotomy (routine partial autopsy of persons dying from fevers) and mouse protection tests on serum specimens; and it conducted numerous field investigations.

In its early years, officials reported, the Finlay Institute made considerable progress, impeded only by temporary problems, such as the production of vaccine without an expiration date in 1944. But as it passed out of Rockefeller control, the institute’s scientific credentials were threatened. Subscriptions to essential scientific journals that published current research lapsed. By 1951, no staff member was competent to handle routine yellow fever control; and a youthful staff, interested in research but lacking other skills, was vulnerable to political pressures. Meanwhile, conflicts among U.S. -based bureaucracies threatened the institute’s viability. Foundation officials even accused the PASB of vacillating and failing to support the local staff.⁶⁴

These initiatives in Bogotá were complemented by a Rockefellerfunded laboratory in Barranquilla, founded with the intention that it would promote public health without competing with private initiative.⁶⁵ The laboratory was intended to perform citywide functions and then to assume responsibilities for the Caribbean coast and the islands of San Andrés and Providencia. Serving such local institutions as the military, port sanitation services, and the anti-tuberculosis dispensary, a diagnostic department undertook examinations for syphilis and other venereal diseases, tuberculosis, intestinal diseases, malaria, relapsing fever, and rabies.⁶⁶ A serological department produced injectable artificial and biological serums, vaccines, rabies treatments, and diphtheric toxin for immunizing horses. Laboratory personnel undertook vaccination campaigns against smallpox and typhoid; lectured on milk production, handling, and pasteurization; and ran courses for visiting nurses.⁶⁷ By pioneering a well-equipped public health laboratory, the IHD believed that it was demonstrating to the nation the value of upgrading existing laboratory facilities and the desirability of investing in new ones—even though senior government officials were wary of assuming responsibility for the laboratory when the Rockefeller contract terminated.⁶⁸

After these successful collaborations with the Colombian authorities, the IHB sought their cooperation in the drive to “conquer” jungle yellow fever.⁶⁹ In 1900 the Cuban physician Carlos Finlay had established that the bite of the infected Stegomyia mosquito transmitted urban yellow fever to susceptible humans; the commission led by Walter Reed had confirmed his findings with laboratory proof of the etiological link between the bacillus and yellow fever. Yet little further progress had been made between 1900 and 1927. The optimism associated with Hideyo Noguchi’s 1918 claim that Leptospira caused yellow fever had evaporated when his findings proved invalid.⁷⁰

In the mid-1930s, IHD officials, encouraged by the descending cost of controlling the mosquito vector of urban yellow fever, decided to allocate resources to study jungle yellow fever, and they set out to explore whether Stegomyia transmitted the virus. The Rockefeller Foundation financed yellow fever studies in the mid-1930s in Brazil, the Guianas, five Andean countries, and the Anglo-Egyptian Sudan, as well as the Pasteur Institute in Paris. Roberto Franco had identified jungle yellow fever in the Muzo area of Boyacá in 1907, so Colombia was an obvious location for further research. Yellow fever in Muzo had distinctive features, including contraction in the forest rather than around houses and inoculation during daylight hours. For the foundation, Colombia had the advantage over Brazil of faster air communications, which eased long-distance supervision of work and transmission of virus and serum specimens.⁷¹ As table 1 shows, Colombia received the second-largest budget appropriation in Latin America for yellow fever studies in 1938.

The 1933 plans for field and laboratory work in Colombia involved collecting and testing various suspected arthropod vectors, investigating possible animal hosts, and tracing the disease’s distribution by means of serum tests, viscerotomy, and field studies.⁷² Research in the mid-1930s by Fred L. Soper and his associates dispelled the orthodoxy that humans were the unique vertebrate hosts of yellow fever, and showed that the infective agent could be conveyed to some monkeys.⁷³

The Colombian government had good reason to welcome yellow fever research at this time. While the disease was not a leading cause of mortality, news of an outbreak could paralyze commerce and transport, provoke reprisals by trading partners, and divert purchases to trading rivals. The disease was characterized historically by sudden epidemic extensions far beyond any endemic foci, followed by periods of absence or relative quiescence.⁷⁴ Health officials therefore used the presence of yellow fever to persuade the government and Congress to build hospitals and organize treatment schemes. While the government took pride in living up to international agreements and reporting notifiable diseases, it was cautious about taking severe measures in ports, which would signal a panic in the public mind and might prompt Colombia’s trading partners to impose a quarantine.⁷⁵

Although the U. S. Public Health Service had recorded 57 cases in Colombia in 1929, it recorded none or but a few from 1930 to 1934 (see table 2). Some resurgence of the disease, however (probably reflecting an improvement in gathering statistics), caused recorded cases to rise for the next two decades. Not until 1949 did the figure fall again to zero. The trend was confirmed, with minor discrepancies, by statistics from the Health Section of the League of Nations between 1929 and 1935. These trends gave a spur to preventive action and assured scientific researchers of official collaboration.

Research was soon under way in the municipality of Restrepo on the genus Haemagogus, singled out as especially vicious by local inhabitants, who dubbed it the “blue mosquito.”⁷⁶ A laboratory in the town of Villavicencio, east of Bogotá, complemented the fieldwork. Yellow fever research in Villavicencio originated in an outbreak of the disease that puzzled scientists because up to that time, the only proven natural vector for the disease was Aedes aegypti, a species unknown in the town. A new road connecting Bogotá and Villavicencio in 1937 made possible the construction of the foundation-funded laboratory in 1938.

Both the fieldwork and the laboratory faced obstacles. In 1936, Restrepo’s parish priest opposed what he considered the barbaric practices of viscerotomy and punctures. These, he declared, were tantamount to mutilating and defiling the sacred remains of the dead, and could not be justified because yellow fever did not exist in his parish. Luis Patiño Camargo, director of the National Hygiene Department, raised the issue with the secretary-general of the archbishop of Bogotá, who agreed to suggest to the papal nuncio, immediate superior of the bishop of the Llanos Orientales, that Restrepo’s climate was prejudicial to the priest’s health and that he should be transferred elsewhere.⁷⁷ Other, more practical problems ranged from generating electricity to sustaining the “quality of monkey shipments.”⁷⁸

Yet the project went ahead. In Villavicencio, researchers sought a vector among mosquitoes and other insects, from termites to butterflies. The location was doubly excellent: perceived as a virgin biological paradise, the area was rich in anopheline species, culicids and other insects, mammals, birds, and reptiles. As the meeting point of three ecological zones—the Andean foothills, the Llanos Orientales, and the Amazon rain forest— Villavicencio was an ideal site for studying the interrelationship of the parasite, the host, and the environment.⁷⁹ Working on the assumption that sentinel animals were the simplest and most reliable means of determining the infection’s actual presence, researchers captured two thousand animals to see whether they acquired immunity to yellow fever or responded to inoculation with the virus. The research established that the opossum could be infected with yellow fever and identified temporary reservoirs of infection in other animals.⁸⁰

By 1943 the main research priority was to analyze variations in the basic mechanism of jungle yellow fever. Haemagogi were collected for examination from as far away as Brazil and northwest Argentina. The Colombian evidence, taken with the Brazilian and West African, gave rise to the hypothesis that the mechanism of yellow fever maintenance in the forest was probably the mammal-mosquito cycle, in which humans were only incidentally involved. In 1949 scientists corroborated that hypothesis. Yellow fever struck humans when they were bitten in the forest by infected tree insects, which occupied the forest canopy and ordinarily bit monkeys, but attacked woodcutters and road builders when they felled trees.⁸¹ Whereas humans were the main party in urban yellow fever, they were only fortuitous victims of the jungle version.

The yellow fever projects illustrated the significance, utility, and limitations of relating research in the field to that in the laboratory.⁸² In the town of Muzo and the nearby emerald mines, epidemiological study demonstrated the presence of a yellow fever virus in Haemagogus and its transmission to the rhesus monkey. In the different terrain of the coffeegrowing municipality of San Vicente de Chucurí, Santander, a similar study discovered two thriving species of Haemagogus, distinct from the one in the Llanos Orientales and hitherto unidentified in Colombia.⁸³ Further investigation indicated that the genus Haemagogus was more complex than previously thought: a colony of Haemagogus equinus propagated in a Bogotá laboratory demonstrated that it became domestic and played a similar role in rural areas to that of the Aedes aegypti in urban settings. Research in eastern Colombia showed that all species of marsupials tested were susceptible to the yellow fever virus.⁸⁴ These studies inspired support for expanded facilities. By 1946 an extensive viscerotomy service, a pathology laboratory, a unit for manufacturing yellow fever vaccine, commissions for giving vaccine in strategic areas, and a unit for performing mouse protection tests were all in existence.⁸⁵

Yellow fever studies were discontinued in the Villavicencio laboratory in 1945, but anopheline biology and malaria-related studies went on in what was now renamed the Institute Roberto Franco. In 1947 the IHD wished to withdraw from the cooperative arrangements, but the institute’s stability was a prime concern. The national hygiene minister preferred that the foundation remain to protect the autonomous agency from being subsumed by the government bureaucracy. Professional and personal ambitions among Colombian and U.S. personnel also posed a threat, but ultimately the institute’s position was salvaged in 1948.

While the laboratory maintained its role in disease control (“saving lives”), its goal of preserving a natural area for biological research uncontaminated by control measures was more problematic. Deforestation and a growing human population density, caused by natural growth and migration from the Eastern Cordilleras to the Llanos Orientales, had had an impact on wildlife, including mosquitoes. The commitments to a combination of exact observation and experiment under tropical field conditions, and to the juxtaposition of laboratory and field with complex equipment in a tropical environment, remained. Researchers tested new drugs, insecticides, and repellents, and pursued interdisciplinary studies of biology and tropical medicine in conjunction with applied research.⁸⁶

Action against yellow fever, made possible by the evolution of mouse brain vaccine by French scientists in the 1930s, complemented research. In 1940 the Colombian government established procedures for the rigorous control of the Stegomyia mosquito in all military and commercial airports as well as the main sea and river ports. Officials systematically vaccinated military and civil aviators, river navigation personnel, road and railway workers, and soldiers and policemen traveling from the temperate uplands to the tropical lowlands.⁸⁷ Between 1937 and 1942 more than six hundred thousand people in all parts of the country except the Guajira Peninsula were vaccinated against yellow fever, using serum vaccine manufactured in Bogotá.

Officials were encouraged to find populations anxious to be vaccinated. Poor peasants in the municipality of Jesús María, Santander, in the Río Minero lowlands, had learned from experience that permanent migration to the fertile valleys below 2,300 meters was lethal. They went down only briefly to plant maize each March and returned to harvest it in August. The scientist Jorge Boshell could find no one to accompany him as a guide in the valleys because, according to oral tradition, yellow fever had occurred there annually for at least 12 years. Learning that a cluster of German immigrants lived healthily in a neighboring area after being vaccinated in Bogotá, the Santandereano peasants, for whom opening up the lowlands was an economic imperative, requested vaccination.⁸⁸

The Diffusion of Education

The Rockefeller Foundation did not become involved in the promotion of health sciences education until the 1940s. In 1923, after thorough consideration, the IHB rejected the idea of supporting medical education in Colombia. Foundation officials confirmed Colombian physicians’ view that Bogotá possessed the best medical school in northern South America. The senior physicians, moreover, wanted to modernize the university hospital, because their wealthiest patients took advantage of the first airline services to travel to Panama City and Ancón, where operative technique, nursing facilities, equipment, and aftercare were said to be superior. But Rockefeller officials hesitated to collaborate; indeed, they believed it impossible, given the “high-strung individualism” of the medical elite.⁸⁹

By the early 1940s, however, the foundation had shifted its position significantly. While still keeping out of medical education, the foundation cooperated with the Pan American Sanitary Bureau and the central government to launch and manage a national nursing school in Bogotá.⁹⁰ Some discussion of founding a professional school had halted in 1930 with the onset of the World Depression. During the 1930s, various private ventures in nursing education, all but one of low quality, had foundered. By opening an institution that stressed the preventive and social aspects of medicine and that served as an example for the Colombian regions and a magnet for northern South America, IHD officials believed, they were performing a valuable service. They therefore set out to help professionalize nursing education and practice, and to help educate social workers and midwives.⁹¹

The National Nursing School opened with 43 students in 1944. Lectures, demonstrations, and practice took place at the San José Hospital, and microbiology studies in a laboratory attached to the National Department of Hygiene.⁹² Social conditions did indeed favor the professionalization of nursing: an interest among the upper middle class not generally found elsewhere in South America; the awareness of two generations of physicians and surgeons of the value of professional nursing; and a desire among the civilian elite to be identified with the West in the postwar era.⁹³ Furthermore, the new National University wished to develop new areas of study as well as traditional disciplines. It therefore provided an umbrella for innovation: to obtain official recognition from the Education Ministry, nursing schools were required after 1936 to adjust their curricula and regulations to those of the university.⁹⁴

The momentum the National Nursing School achieved in its early years was maintained largely by pressure from departmental hospitals to extend professional nursing services. The Municipal Hygiene Direction of Bogotá also decided to appoint a professional nurse on the grounds that a nurse would produce better results than a physician.⁹⁵ Further impetus came from the favorable image of the school imparted by student nurses in radio broadcasts, and from press coverage of a small group of Colombian nurses who, having gained field experience at the Cerro Barón Hygiene Center in Santiago, Chile, returned to establish a training program.⁹⁶ Success in Bogotá prompted the school to organize nursing courses in departmental capitals. Students reportedly worked harder in a course in Cali than in an earlier one in Bucaramanga because they realized that their political and personal connections would not help if they failed an exam.⁹⁷

Along with these successes, the new school encountered serious problems from the outset. The IHD’s senior staff, charged with appointing nursing consultants, was insufficiently bilingual and unversed in the complex relationships between official and philanthropic agencies, both domestic and foreign.⁹⁸ Foundation officials confronted legislative delays between 1943 and 1946; overly high student-teacher ratios on field trips and in practical classes; problems of registering enough students without lowering admission requirements; a “bolshevik element . . . calling so-called strikes”; low ethical standards among some student nurses, who stole medicines; and the task of keeping the curriculum out of the doctors’ control.” The school director reported that because parents discouraged “women of good families” from applying, the school was failing to obtain the national recognition it would otherwise secure. Status anxieties were similarly reflected in reports that student nurses were interested in nutrition theory as an intellectual activity but associated food preparation with menial work. The absence of a good, up-to-date nursing manual obstructed teaching until the Inter-American Cooperative Service (SCISP) published the nursing consultants’ Spanish translation of an English-language text.

Tensions between agencies involved in the school hampered its development. U. S. embassy personnel caused offense by giving the false impression that a nursing consultant would be allocated to the National Red Cross School of Nursing to teach dietetics, and another consultant to the private San José School to give a course in hospital administration. Both suggestions ran contrary to the joint decision reached by the three founding agencies to develop a national nursing program in the public sector. Tensions resurfaced when one member of the PASB team spoke of “luxury” in the nursing school, and when the SCISP business manager’s office delayed monthly expenditure statements without explanation, provoking Colombian comments about the “much talked-of American efficiency.”¹⁰⁰

Overtly sexist opposition to the professionalization of nursing posed few difficulties. The official police doctor’s assertion that “women were meant for the home, to produce and raise children, [to] make husband[s] happy, etc.” was an exception.¹⁰¹ Political identification presented more serious problems, especially when the Conservatives re-entered power in 1946. The school’s closest ally among health officials was an anticlerical Liberal, Luis Aconcha, who in 1947 was Secretary General of the Hygiene Ministry. A visit to the nursing school in 1950 by President-elect Laureano Gómez at the suggestion of U.S. Ambassador William L. Beauclac, however, went well. Gómez agreed with Beauclac that the nursing school was the best in South America and that no Colombian was yet ready to direct it, adding that the school should not leave U.S. hands. Beauclac also reported that the Laureanista newspaper El Siglo had warmly referred to the school director, Helen Howitt, as a “very expert American nurse.”¹⁰²

In the late 1940s and early 1950s, the main providers of preprofessional nursing services, the female religious orders, who were deeply hostile to the lay, professional challenge, stepped up their campaign to recover lost influence.¹⁰³ In 1951 the removal from office of Aconcha, an “archenemy of long standing” of the recently consecrated archbishop of Bogotá, Crisanto Luque, gave the women religious an opportunity to bid for control of the nursing school. That year, one consultant reported that nuns who had visited the school were circulating rumors that the school was atheistic, Protestant, and prone to perform abortions on students.¹⁰⁴ Howitt feared for her safety after routine authority slipped from her hands into those of nominally subordinate personnel. The school was failing to attract students from the “better families” because of its alleged Protestant direction and because some students converted to Protestantism while in attendance. Only the appointment of a Roman Catholic director quelled the hostility of the archbishops of Medellín and Bogotá.¹⁰⁵

While they remained cautious about the nursing school’s short-term future, Rockefeller officials were sufficiently confident about its long-term prospects to mount another effort, the National School of Public Hygiene. Set up in Medellín between 1949 and 1952, this enterprise aimed to produce health care generalists (that is, not specialists in particular diseases) who had attended courses in epidemiology, bio- and health statistics, public health administration, maternal and infant hygiene, entomology, parasitology, and sanitation. The main impetus for this school came from two quarters. One was the leading hygiene minister of the period, Jorge Bejarano. Impressed by similar schools in Mexico, Costa Rica, and Chile, Bejarano was determined to establish one in Colombia; but the project was shelved in 1946 because of administrative dislocations caused by the formation of the National Hygiene Ministry.¹⁰⁶

The other source of pressure was the Rockefeller Foundation itself, which had played a major role in founding the Chilean school and which believed Colombia to be an appropriate site for a comparable establishment in northern South America. The case for a school was argued in terms of public health professionalism, which was lacking among the 1,450 employees of the two hundred health centers that had grown out of the hookworm and sanitary campaigns of the 1930s. These workers also tended to opt for curative treatment, in which they were trained, and to attend only perfunctorily to preventive activities.¹⁰⁷ Finally, foundation officials hoped that the new school would extend its influence to adjacent countries.

Thus, in spite of the its overall policy to reduce operations and funding in South America after World War II, and the difficulties of maintaining routine activities because of contract delays, the foundation provided support for the school, even arranging the purchase of textbooks in Spanish from Buenos Aires.¹⁰⁸ The school’s first director already had a long association with the IHD, and spent several preparatory months visiting the hygiene schools in Mexico and Chile.¹⁰⁹

Various problems arose, but few proved insurmountable. The school had a strong nucleus of well-trained instructors but lacked faculty capable of teaching public health administration and salaries high enough to attract skilled professionals. The threat of political interference from both the Education and Hygiene Ministries loomed, and no suitable candidate appeared for the Rockefeller scholarships offered in 1952. Rockefeller officials expressed fears that red tape and conflict between the agencies involved in the school’s management—the Hygiene Ministry, the Office of the Rector at the National University, the dean, the Directive Council of the Faculty of Medicine, and that of the Hygiene School—would impair efficiency.¹¹⁰ In spite of renewed public discussion of forming a nonpartisan civil service, the school’s graduates still were likely to leave government employment because of political pressures and work conditions. Furthermore, by 1952 the school had failed to realize its aims of introducing an advanced hygiene course, incorporating sufficient field training, integrating all courses in detail, and admitting students from outside Colombia.

Yet the school proved to be no pipedream. It was confidently reported in 1952 that continuity of management had been achieved and that seven hundred students had been trained in three years. No professor had been selected on the basis of political affiliation because all had been appointed on part-time contracts, so none had required ministry approval. The school had made a positive contribution to the growth of interest in public health and hygiene. The balance favored optimism.¹¹¹

While the National School of Hygiene was being set up, IHD officials began to plan an experimental health sciences school in Cali, which took shape in the mid-1950s. The bitter professional rivalries that prevailed in the “older” cities, especially Bogotá, posed no obstacle to the initiative in Cali. This school aimed to stress public health in training for the health professions and to integrate the professions more closely. The first step was to modernize nursing education by opening a nursing school, based in a new children’s hospital. The foundation’s endorsement of this scheme proved useful to the city’s public health reformers: it validated what El Siglo called an “unaccustomed civic movement” and persuaded the regional elite in the Club de Leones to help fund the initiative.¹¹²

Conclusions

What were the achievements of the Rockefeller missions in Colombia from circa 1920 to circa 1950? Evidence from as early as 1928 indicates that the antihookworm campaign successfully nurtured a broader movement to control “filth” diseases, dispose properly of human waste, and inculcate the idea that community health could be improved by public health measures.¹¹³ In the mid-1930s, foundation officials plausibly claimed to have helped arouse a popular demand for health services and to have alerted interest groups to the importance of spending on rural sanitation and hygiene campaigns.¹¹⁴ Similarly, from the 1920s on, the foundation’s transfer of vaccine technology provided Colombia with access to supplies of essential products that it could not manufacture alone. Only in the late 1950s and 1960s did the ambiguous connotations of technology transfer become manifest as transnational corporations and their affiliates traded increasingly in pharmaceutical products and hospital equipment.

Despite disappointments, Rockefeller officials’ pessimism between 1947 and 1951 was qualified. They did not scale down operations in the face of an apparently unfavorable sociopolitical setting but instead reappraised the range, scope, and quality of their programs. The Colombian government had a good record of honoring contracts with international organizations; difficulties arose from electoral uncertainty, regime changes, and the bureaucratic disruption during the formation of the Hygiene Ministry, but not from a desire to create difficulties. Rockefeller officials claimed in 1946 that the hookworm campaigns of the 1920s had had an enduring impact on the attitudes of schoolchildren who became adults in the 1930s, and that the soil sanitation projects of the 1930s had aroused a permanent appreciation for better living and working conditions.¹¹⁵

By 1951, IHD officials were confident that for all its immediate problems, the National Nursing School could prove a success in the medium term, and that from its success could evolve radical changes in education in the health sciences more generally.¹¹⁶ Their confidence seemed justified by the decision of the World Health Organization and the United Nations International Children’s Emergency Fund to place their new midwife training and child health programs in Colombia under the school’s direction. A similar belief pervaded the planning discussions of the National School of Public Hygiene, an institution the foundation backed in the expectation that it would make a substantial contribution to scientific research and social change. Ironically, major decisions such as these were often based on conviction rather than the scientific observation and quantitative data on which officials relied heavily for lesser matters.

Rockefeller health-care activities in Colombia over these decades demonstrate both the possibilities and the limits of overseas philanthropic activity. Entering Colombia with a commitment to the diffusion of modern science, foundation officials were privileged outsiders. The intellectual environment was receptive to imported injections of science for specific purposes, but unwilling and probably unable to allocate either resources or prestige to sustained scientific education and inquiry. Visualizing a society in which health-care provision would be a majority right rather than a minority privilege, Rockefeller officials departed from orthodoxies that stressed private practice and curative medicine rather than public health measures and preventive action, thereby alienating many medical practitioners. Moreover, officials arrived with strong ideas of their own neutrality as scientists and experts. But they were unaware of the broader ideological consequences of their activities and unprepared for the political bargaining that was imperative to achieving their objectives; thus their effectiveness was impaired. Enjoying neither a domestic power base nor the active support of the U.S. Department of State, foundation officials felt vulnerable. They were isolated in a poor country, where successive governments proceeded from two social policy assumptions: that heavy social spending was unjustifiable and that incremental social improvements would best be achieved by combining charitable palliatives with economic strategies that facilitated some income growth.

In contrast to the accounts by the officials themselves, reaction to the foundation’s presence in the Colombian medical journals is scarce. Some contain reports by foundation officials, foreign and Colombian, but seldom include accompanying comment; when they do, such comment is polite and uncontroversial without being deferential. The medical journals leave the distinct impression that professional leaders in Bogotá and Medellín, though not enthusiastic about the foundation’s presence, accepted it pragmatically. They believed it expedient for fiscal and technical reasons to delegate to the IHB areas of influence where it had an acknowledged expertise, while retaining in national hands undisputed control in vital matters like the regulation of medical practice, hospital management, factory and food inspection, action against tuberculosis and measles, cancer treatment, and leprosy control.

How far is it appropriate to refer to Rockefeller activities as evidence of a “health” or “scientific” imperialism? The question is difficult to answer, partly because the literature on the subject lacks nuance. That literature has yet to address even such basic questions of periodization as whether the 1930s were a decade when “scientific imperialism” was in retreat or simply on hiatus.¹¹⁷ Rockefeller activities were “imperialistic” in several senses. Public health institutions shaped in one environment were transferred to another; technology, like vaccines, was transferred from a rich to a poor country. The foundation cemented international economic links through its antihookworm campaign, seeking to stabilize an amenable labor supply and raise its efficiency and acquiring allies among merchants and professionals. Officials played a salient role in conceptualizing disease, in organizing government and social reactions to disease, and in the internal and external power relationships of health personnel and institutions.¹¹⁸

Yet the Rockefeller Foundation was more concerned with opening Colombia’s economy to external influence, preserving the stability of the international economy, and protecting the health of U.S. personnel than with direct exploitation.¹¹⁹ Thus, although Colombia confounded the predictions of the early 1920s that it would soon become a major oil producer, Rockefeller health-care aid was maintained and directed to areas such as coffee production, where the Rockefeller empire had no business interests. IHR personnel played a role in defining and enforcing standards of professionalism and, by creating expertise, diffused standards to the broader Colombian society. As Colombia was made “safe” for metropolitan investment, science performed a function that was neither disinterested nor impartial.¹²⁰

The Colombian experience of Rockefeller advice was an important example of external penetration, but it did not, during the period studied, amount to hegemonic control. Colombian governments had various autonomous options. They could reject Rockefeller advice altogether; they could adapt Rockefeller-influenced institutions to locally perceived needs after the IHB withdrew. They could seek advice elsewhere and draw pragmatically on competing models. They did this in other areas during the same period, inviting British advice on the navy, Chilean on the national police, Belgian on primary education, and the Kemmerer missions on fiscal and tax policy, as well as, in the health sector, a French mission led by André Latarjet on medical education.¹²¹ There was no question of the IHB controlling public health policy because large areas remained over which it exerted no influence. Other understudied models were significant; especially the French, whose gouttes de lait (child welfare centers) inspired the opening of gotas de leche, and whose Pasteur Mission to Rio de Janeiro exported a model of bacteriological science and created “modern” scientific institutions that conformed to stringent professional criteria laid down in Paris.¹²²

How appropriate was the model that foundation officials espoused, given Colombia’s extreme poverty and income maldistribution? It is the contention of this article that while the foundation barely began to engineer the radical transformations that its most ardent advocates expected, it realized some tangible, beneficial, and enduring accomplishments that were consonant with the gradualist outlook of Colombian governments and the aims of reformist U.S. foreign policymakers.

In Washington, advocates of a liberal consensus welcomed the idea of conducting diplomacy through humanitarian aid and creating social policy institutions that did more than promote narrow partisan and sectional interests.¹²³ In Colombia, reformist elites endorsed ideas and techniques, filtered by the foundation, that posed no threat of revolutionary or counterrevolutionary violence, such as the application of scientific knowledge that improved the living conditions of the rural poor without challenging the interests of latifundistas. For Colombian policymakers the foundation was useful in three ways: it encouraged administrative rationality in the state medical apparatus, established the principle of state intervention in public health, and above all, enhanced the state’s authority. The state expanded its tutelary functions beyond primary education to new areas, where, like its Brazilian and Mexican counterparts, it projected itself as altruistic and “progressive.”¹²⁴

The foundation’s enduring significance for U.S.-Colombian relations was to shape a favorable image for the United States in areas that lay beyond the State Department’s formal concerns with diplomacy and trade.¹²⁵ Evidence that U.S. diplomats gave direct encouragement to the foundation’s health-care activities is slender, but this is not surprising; an understood confluence of interests did not require comment. External philanthropy between the 1920s and 1950s won allies for the United States in the Colombian government, public administration, professions, and universities, and among a broader electorate. And external philanthropy became more valuable to the U.S. government during and after World War II, when anti-U.S. feeling grew as Colombia’s opportunities to assert its autonomy through pragmatic bargaining with the United States and the European powers declined.

National conditions changed significantly during this period. The foundation’s initial projects prefigured many state institutions and anticipated modern social policy and development strategy. Far from distorting patterns of health-care expansion, the foundation in the 1920s and 1930s recognized that the demographic weight of the Colombian population was concentrated in the countryside and small towns, and it went some way toward rectifying an imbalance toward cities in official health care provision. In the late 1940s and 1950s, the foundation set out to identify areas of flexibility in a weak and brittle but nonetheless authoritarian Conservative regime, which aimed to delay and even reverse some features of social change and which ossified much administrative practice.

Grassroots programs that offended powerful supporters of the regime by awakening popular consciousness to poverty and misery were now absent from the foundation’s agenda. Its policy shifted markedly from schemes that directly served the poor and involved employees from modest backgrounds, such as sanitary inspectors, to projects stressing higher education initiatives and the creation of an elite professional stratum with a distinctive technocratic and meritocratic ideology.

These projects corresponded to the urban-focused, industrializing policies of the early postwar decades and to the priorities of Conservative governments in Colombia and conservative decision makers in Washington during the early years of the Cold War. Institutional innovations and health sciences education were useful to Colombian governments because they helped to contain pressures from the middle class and promised to meet some of the grievances of organized labor. The foundation’s active role in Medellín and Cali removed much of its risk of being overidentified with an unpopular central government when regionalism and localism were intermittently resurgent. Enjoying relatively elastic institutional structures, moreover, the cities of Medellín and Cali welcomed some public-sector innovations that central government stifled in Bogotá.

Foundation officials felt more instinctive sympathy for the exuberant Colombian Liberalism of the mid-1930s—which emulated the policy example, ideology, and material achievements of the U.S. New Deal—than for the authoritarian Conservatism of the 1950s. By the early 1950s, however, the policy framework in Colombia had changed radically. Innovative government agencies coexisted with inefficient ones; weak intragovernmental communications made for poorly synchronized strategies and patchily implemented programs.¹²⁶ Yet a Hygiene Ministry now existed, and it presided over the beginnings of a painfully slow transition from a fragmentary, selective policy approach to a more comprehensive one. An incipient sense of social rights was articulated in policies of social security; and a rhetorical commitment to preventive medicine that acknowledged the connections between the physical environment, the economy, and social conditions was translated, albeit incompletely and haphazardly, into policy. The Rockefeller Foundation and Colombian officials had established a record of cooperation; they observed a closer congruence of aims and language than they had 20 or 30 years earlier. If the immediate setting seemed unamenable to social reform, the long-term milieu seemed more promising.

The author wishes to express his gratitude to the director, Darwin H. Stapleton; the archivist, Thomas Rosenbaum; and the staff of the Rockefeller Archive Center for their generous help. A small research grant from the foundation helped in preparing this article. The author is also most grateful to Professor David Bushnell, without whose encouragement this article would not have been written.