THE PREVALENCE OF CONTAGIOUS AND INFECTIOUS DISEASES AMONG THE INDIANS OF THE UNITED STATES.

INTRODUCTORY STATEMENT.

In the act approved August 24, 1912, making appropriations for the current and contingent expenses of the Office of Indian Affairs, for fulfilling treaty stipulations with various Indian tribes, and for other purposes, for the fiscal year ending June 30, 1913, there was included the following provision:

Provided, That the sum of ten thousand dollars, or so much thereof as may be neces sary, is hereby appropriated, out of any money in the Treasury not otherwise appropriated, to enable the Public Health and Marine-Hospital Service to make a thorough examination as to the prevalence of tuberculosis, trachoma, smallpox, and other contagious and infectious diseases among the Indians of the United States, full report to be made to Congress not later than February first, nineteen hundred and thirteen, with such recommendations as may be deemed advisable.

In accordance with the directions contained in this law steps were taken to make the necessary investigations, the work being conducted through the Division of Scientific Research and under the immediate supervision of Asst. Surg. Gen. J. W. Kerr, in charge of that division. The Indian population is widely scattered, persons of this race residing in practically every State, and Indian reservations are located in at least 25 States. According to official figures of the Bureau of Indian Affairs, the total Indian population in the continental United States is 322,715. It was determined to have visited and examined as large a number of these Indians as practicable and as would furnish data to show the prevalence of contagious and infectious diseases among them.

On account of the large area to be covered, it was necessary to divide the country into districts, and assign an officer to each district. The following were the officers detailed, and their respective districts by States:

Passed Asst. Surg. B. J. Lloyd: Washington, Idaho.

Passed Asst. Surg. W. C. Billings: Northern California, Oregon, Nevada.

Passed Asst. Surg. L. D. Fricks: Arizona, North Carolina.

Passed Asst. Surg. F. C. Smith: Colorado, New Mexico.

Passed Asst. Surg. M. C. Guthrie: Oklahoma.

Passed Asst. Surg. R. A. Herring: Kansas, Nebraska, Wyoming, Utah, southern California.

Surg. M. J. White: Iowa, Montana.

Passed Asst. Surg. J. W. Schereschewsky: North Dakota, part of South Dakota.

Passed Asst. Surg. Paul Preble: South Dakota.

Surg. Taliaferro Clark: Minnesota, Michigan, Wisconsin, Pennsylvania.

Asst. Surg. J. P. Leake: New York.

Surg. H. S. Cummings: Virginia.

Asst. Surg. Gen. W. C. Rucker: Florida.

1 The Bureau of the Census for 1910 gives 265,683 as the total Indian population. SD-62-3-vol 25--10

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Prior to undertaking the inspections each officer made a preliminary study of the situation in his territory in order to arrange his itinerary and survey so as to collect the greatest amount of data practicable within the time allotted, which was until January 1,

1913.

In the above-quoted law three diseases are specifically mentioned, namely, tuberculosis, trachoma, and smallpox. Special attention was accordingly devoted to these diseases with the view to determining their past and present prevalence, and data were also collected bearing on the incidence of other contagious and infectious diseases among the Indians.

While it was impracticable on account of varying local conditions to outline the extent of the investigations and the methods of making them in a particular district, instructions were issued that, in general, the studies should include: First, examinations of the morbidity and mortality records available at each general Indian agency visited; second, inspections of all pupils of nonreservation schools, boarding schools, day schools, and mission schools; third, visits to sanatoria, asylums, and other eleemosynary institutions within the reservations devoted to the care of Indians; fourth, house-to-house inspections of as many Indian families as practicable and representative of the general population to determine the prevalence of the communicable diseases mentioned and their character.

In letters of instructions the several officers were also directed to confer whenever practicable with the respective State health authorities, with a view to securing any information available, and particularly data in respect to cases of sickness and death and the occurrence of epidemics on or near Indian reservations.

During their inspections the several officers were required to observe and to inquire into the insanitary conditions and habits of life among the Indians that would have a bearing on the propagation and spread of contagious diseases, and provision was made for the taking of photographs which would convey some idea of the insanitary conditions met with.

Finally, each officer was instructed to consider carefully the public health problems presented, with the view to suggesting methods of handling them.

The investigations were begun in Oklahoma September 28, 1912, and as soon thereafter as possible in the other States. On account of the immense territory to be covered, the brief period of time available, and the limited number of officers that could be assigned to the duty, the inspections were necessarily somewhat restricted in character. Nevertheless, it is believed that a sufficient number of reservations were visited and Indians examined to determine the general prevalence of contagious and infectious diseases among them, and to observe the insanitary conditions that contribute to the spread of those diseases.

On completion of the field investigations December 30, 1912, it was found that a total of 39,231 Indians had been inspected. The results of these inspections are embodied in this report, all of the data collected by the several officers having been collated and condensed by Asst. Surg. Gen. J. W. Kerr, Surg. Taliaferro Clark, and Passed Asst. Surg. J. W. Schereschewsky, who acted as reporters.

The recommendations, in which I concur, are the sum of the recommendations of the several officers. They deal with conditions which in many instances are a serious menace to the welfare of the Indian, and should be vigorously met in his interest and in the interest of the public health.

ACKNOWLEDGMENTS.

Prior to undertaking the work, request was made of the Office of Indian Affairs for such cooperation on the part of its officers and employees as might be practicable. Acknowledgment is due and here made for the cordial assistance received from the Office of Indian Affairs and its personnel in the field. Without such assistance, particularly in respect to providing traveling facilities and the assembling of the Indians, the investigations would have been extremely difficult, if not well-nigh impossible.

JANUARY 23, 1913.

RUPERT BLUE,
Surgeon General.

SCOPE AND METHODS OF INVESTIGATION.

As pointed out in the introductory statement, the investigations herewith reported upon covered practically the entire geographical limits of the continental United States, field inspections having been conducted in 25 States. These States were grouped into districts to correspond with the number of officers assigned to the work. In so far as possible, these arbitrary districts comprised adjoining States, but this was not always practicable, other considerations, such as density of Indian population, facilities of transportation, and limitations of time, being necessarily taken into account. For the most part the data collected have been classified by States, but reference is occasionally made to districts because of varying climatic conditions, tribal customs, and the relations of Indians to white populations.

The investigations involved the visiting by the officers engaged in the work of many places where Indians were domiciled. Individual reference is made in the text to many of these places at which peculiar conditions were found.

DISEASES SUBJECT TO INVESTIGATION.

During the investigations inspections were made and data collected upon which to base estimates of the prevalence of contagious and infectious diseases, such as measles, scarlet fever, typhoid fever, and pneumonia. Such observations as practicable were also made to determine the prevalence of skin affections and venereal diseases. It soon became evident, however, that the two diseases most prevalent among practically every Indian tribe were tuberculosis and trachoma. These diseases and smallpox, accordingly, required most attention because they are specifically mentioned in the law authorizing the studies and because their presence on reservations is so intimately associated with the social and sanitary conditions of the Indians.

During the medical examinations lookout was also kept for other diseases which, while not considered infectious, are of great interest from an epidemic standpoint. Among these may be mentioned goiter and pellagra.

DIFFICULTIES ENCOUNTERED IN MAKING INSPECTIONS.

Considerable difficulty was experienced in collecting the data herewith submitted because of the season at which the investigations were undertaken, the wide areas over which the Indians are scattered upon reservations, and the inaccessibility of places where Indians are located. Long distances were traveled by the several officers on foot, on horseback, by teams, motor cars, and motor boats.

One obstacle to be overcome in connection with several tribes was their diffidence, distrust, or reluctance to submit to examinations. Certain Indians had a manifest objection to furnishing information about themselves, and were loath to permit physical examination, either because of prejudice against exhibiting bodily defects and diseases, or for fear of subjecting themselves to some malign influence. Nevertheless, there were examined a total of 39,231 Indians, and it is thought that this number is sufficient to enable correct inferences to be drawn as to the prevalence of contagious and infectious diseases among them.

It is altogether likely that more prolonged observations and repeated examinations would have resulted in the detection of additional cases, but under the circumstances this was impracticable. The percentage of disease stated for any particular group of Indians may therefore be accepted as a conservative one.

METHODS OF INVESTIGATION.

It was necessary to take advantage of every opportunity of making examinations. Upon arrival at an Indian reservation or school therefore, the officer engaged in the work conferred with the superintendent as to the best methods of reaching the greatest number of Indians in the short time available. As a result, Indians were either collected at the various subagencies or day schools on specified dates, and there examined, or they were visited in their camps and houses, the method varying according to the circumstances of the weather, the attitude of the Indian toward inspections, the density of population, traveling facilities, etc.

A considerable number were examined along the roadside as they were met, and advantage was also taken of the assembling of Indians at the various subagencies where rations were distributed, in order to examine relatively large numbers. All boarding schools and as many day schools as possible were visited and carefully inspected as to the incidence among the pupils of the diseases in question.

At all the reservations where Indians were collected for examination in the manner described, a certain amount of house to house inspection was also conducted in order to check the results arrived at by the collective examinations and to observe any conditions favoring the spread of disease. In some instances, however, local conditions rendered the extent of such inspections limited and even impracticable.