Hookworm: Exporting a Campaign
In 1914 the International Health Division (IHD) applied the lessons learned from hookworm eradication campaigns in the southern United States on a global scale. Ten years later, hookworm campaigns had been adopted in 52 countries across six continents and 29 islands.
The IHD’s decision to undertake hookworm eradication as the first of its international projects was deliberate. Hookworm disease proved an ideal “wedge” that would allow for the creation or extension of public health organizations. Facts about hookworm disease were simple and easy to understand and could be clearly conveyed. IHD members saw hookworm as not only a disease but also as an opportunity for education. Illiterate populations could be educated through pictures, charts and health demonstrations that explained the dangers of the disease and the importance of sanitation.
The International Experience
The first hookworm campaigns outside of the United States began in British Guiana in 1914. Wickliffe Rose, director of the IHD, approached the British Colonial Office with his intentions in 1913 and quickly established a partnership between the two organizations. However, confusion over responsibilities prevailed. Disagreements between American and British staff were common, and the question of exactly which activities would be funded was a constant source of conflict. Following an established pattern, the Rockefeller Foundation (RF) had agreed to cover the costs of medical surveys, treatment and public education, while trusting that the local government would assume responsibility for funding the construction of privies and the establishment of a public health network. On the other hand, the colonial authorities of British Guiana saw the RF as an unlimited source of wealth that could and should assume all associated costs related to both treatment and preventative care.
As the numbers and locations of hookworm campaigns increased, so too did the problems that the RF encountered. However, the organization remained optimistic, writing in the 1920 Annual Report that:
Demonstrations in the control of this one disease, while bringing relief to hundreds of thousands of suffering people and increasing the economic efficiency of communities and countries, are having a more important effect in creating a popular interest in public health and in promoting the development of permanent agencies for the control of this and other preventable diseases.
Yet fueling interest in public health, and creating agencies to deal with it, was often more complicated than the report let on. For example, in the case of Madras Province in India, the numbers of infected persons overwhelmed staff and resources. The afflicted population was largely transient, and issues of poverty and caste stood in the way of privy construction. The local colonial government was also unwilling to fund sanitary initiatives. Intensive work began in Madras in 1922, but by 1928 the campaign had ended with mixed results.
While IHD initiatives increased public awareness of hookworm in India, the RF was not able to rid the region of the disease or to elicit local funding for initiatives in sanitation and public health. The experience caused a fundamental shift in IHD policy in favor of undertaking hookworm campaigns only in areas where latrines were already in place. This decision mirrored the programmatic decision to shift from the broader goals of sanitation and public health to medical research and treatment. This decision would echo in subsequent IHD-led initiatives.
By the end of the 1920s, almost all IHD hookworm eradication campaigns had ceased. Instead, the IHD directed its energy toward other serious health concerns, including the often fatal diseases of malaria and yellow fever.