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WEANING OFF BABIES FROM A DISEASE:

INFANTILE BERIBERI, COLONIAL PUBLIC HEALTH, AND AMERICAN


TUTELAGE IN THE US-OCCUPIED MANILA
(1901-1928)

A Thesis
Presented to
the Faculty of the History Department
De La Salle University

In Partial Fulfillment
of the Requirements for the Degree
Bachelor of Arts in History

By
Orestes C. Magdaraog III
2014

ACKNOWLEDGEMENT
.
Finishing this thesis had not been easy. At the time I was completing this thesis,
being a double-degree major I was also finishing my subjects in my business degree
which forced me to delay Thesis Writing 1 and 2 for several times. It took me two years
to finally finish writing this thesis and successfully defend it before the panel. I would
say that this thesis is not only a product of my own. I have a lot of people to whom I
should give credit to and express my sincere gratitude for making this product of
academic research successful.
To my former professors in La Salle especially to Dr. Florina Orillos-Juan, Dr.
Rene Escalante, and Sir Joey Jimenez, it was a great experience to be trained to be a
great historian under the tutelage of these three amazing professors. In my stint as a
history student, I and my co-majors would call these three professors as the great triad
because they were our usual line-up of professors in all our major classes every term. I
would never have the skills needed to be a history student without the proper guidance
their proper guidance. Sir Joey first taught me research methodology in my Historical
Methodology class or HISMETH. Dr. Escalante trained me to become a great critic
because of his numerous book review requirements in his subjects. Dr. Orillos-Juans
classes taught me different perspectives in the discipline of history. It was one of her
classes where I was introduced to the conceptual framework I used to write this thesis.
Her teaching style pushed me to my limits and made me realize the significance of
leaving a contribution to historical studies.
I would also want to thank Dr. Ronaldo Mactal who shared to me the content of
his book, Kalusugang Pampubliko sa Kolonyal na Maynila (1898-1918): Heograpiya,
Medisina, Kasaysayan in one of my history major classes, SPECHIS or Special Topics
in History. I gained interest in the study of diseases and public health during the colonial
period because of his work and lectures. To my thesis panelists, Dr. Arleigh Dela Cruz
and Dr. Lars Ubaldo, I sincerely extend my gratitude for giving feedbacks and criticisms
to my work. This thesis would not be polished without their extreme scrutiny. Even if I
never had the chance to be a student of these two professors, I am still grateful that they
spent their time to read my work. I will always appreciate their praises about my thesis
during the final defense.
Again, I would want to express more of my gratitude to Dr. Orillos-Juan for
giving me an opportunity to be her advisee. I really feel honored that I chose her to help
i

write this thesis. It was because of her expertise and care that I was able to put up a
complete academic research. I will always appreciate her generosity of sharing to me her
materials and mailing me online copies of sources that I used to complete this thesis. She
had been an amazing critic to make sure that my thesis would be more than ready before
I sat before the thesis panel. The painful process of making revisions was made easy
because of her suggestions and comments. I will appreciate her kindness and support
every time that I consulted with her.
My whole stay in La Salle would not be memorable without the great friendship I
made during my first three years in La Salle. I would like to thank my blockmates and
my co-majors in history: Myca Lleander, Mico Ignacio, Lawrence Aguinaldo, Lorenzo
Velasco, Desi Tolentino, Kaye Garcia, Steve Lee, and Lovely Narciso, Rodrigo Wong,
Steven Tan, John Paumig, and Jhenice Alana. I spent most of my time in school with
these people. I will always remember those moments when we helped one another by
sharing photocopies of readings and books we needed to write our term papers. College
life would not have been easy if I did not have a group of supportive friends.
To my Liga Historia family, it had been an incredible journey to take this college
life with all of you. Although there had been many challenges that threatened the
existence of the organization, I would say that we still came out strong and happy with
all the activities that we made. Even if the organization had come to an end, I will still
bring with me the experiences and learning I gained from this organization whose
members all have extreme passion as I do for the study of history.
To my family, I will always be grateful that you allowed me to pursue the
academic program that I wanted which was very far from the degree program that you
wanted for me. I will always be thankful for all the support and assistance that you gave
to me. I will remember the time that my father would always remind me of finishing
every chapter of the thesis before the deadlines. I am very lucky to have my mother with
me who was forever generous when I needed financial support for the photocopying,
printing, and hard-bounding of my thesis. I will always keep in my heart all those
encouragements that you gave to me while I was doing this thesis. This work could not
have been finished without my loving parents.

ii

TABLE OF CONTENTS

Page

Acknowledgement

Table of Contents

iii

Abstract

vii

Glossary

ix

I. Introduction
A.
B.
C.
D.
E.
F.
G.
H.

Background of the Study


Statement of the Problem
Significance of the Study
Scope and Limitation
Review of Related Literature
Methodology
Conceptual Framework
Thesis Organization

1
4
5
8
10
15
17
23

II. Mapping the City and Its Diseases:


The City of Manila during the Early American Period (1901-1910)
A.
B.
C.
D.

Colonial Pilot Site: The Organization of the City of Manila


Births and Population
Deaths, Mortality Rates, and Causes
Sanitation is the Key: Public Health Programs and Policies
In the City
E. Beriberi: A Growing Menace
F. The Problem of High Infant Mortality in Manila
G. Care of the Infants
iii

26
27
34
40
46
64
79
89

III. Conquering a New Disease: The Discovery of the Nature of Beriberi,


Its Infantile Form, and the Colonial Health Policies (1910 -1918)
A.
B.
C.
D.
E.
F.

Etiology of Beriberi
White Rice as the Root of All Evil
Colonial Response Against Beriberi
Discovery of the Infantile Beriberi
Etiology of Infantile Beriberi
Developing a Cure

101
102
108
121
130
138
144

IV. Rearing Babies Towards Self-Government: The Challenge of Infant


Mortality and Beriberi under a Filipino-Run Government
(1918-1928)
A.
B.
C.
D.
E.
F.

A New Era: The Policy of Filipinization


Working for the Ultimate Independence
Infant Mortality as a Flaw to Self-Rule
Training Nurses and Establishing Puericulture Centers
Filipinos Capacities to Control Infantile Beriberi
Beriberi Committees

159
161
169
175
180
193
202

V. Conclusion

209

List of Tables
Table 1 - Population of Manila by district and sex (1902)
Table 2 - Population of Manila by age and sex (1902)
Table 3 - Deaths by percentages in Manila during different months (1902)
Table 4 Death rate of different age groups in Manila and Archipelago (1902)
Table 5 Deaths by age including transients (1903-1904)
Table 6 - Deaths, by districts including transients (1903-1904)
Table 7 - Deaths and Population by health districts, including transients (1904-1905)
Table 8 Death rate from Beriberi by provinces (1902)
Table 9 - Death rate by age groups (1902)
Table 10 Causes of deaths among prisoners in Bilibid Prison (1902-1903)
Table 11 - Rate of infant mortality to total number of deaths
Table 12 - Death rate by age groups in Manila and Archipelago (1902)
Table 13 Causes of deaths in Manila and Archipelago (1902)
Table 14 Causes of deaths among children under 12 months of age

iv

36
37
40
42
42
43
44
67
69
73
82
83
83

in Manila (1903)
Table 15 Leading causes of deaths of infants below 1 year and 5 years in Manila
Table 16 Importation of Condensed and Fresh Milk into Manila (1903-1910)
Table 17 Total deaths and deaths from beriberi in Culion Leper Colony
by months (1910)
Table 18 - Phosphorus Content of Different Varieties of Philippine Rice in Manila
Table 19- Imports and Exports of Rice into Manila, in kilos (1859-1908)
Table 20 - Sources of Imported Rice in Manila, in kilos (1899-1908)
Table 21 Causes of Deaths in Convulsion Cases
Table 22 - Number of cases of infants investigated by clinical diagnoses and
necropsy findings
Table 23 Annual and Monthly Incidence of Infantile Beriberi
Table 24 - Number of breastfed infants in different causes of deaths in Manila
(1910)
Table 25 - Age incidence of Infantile Beriberi Cases
Table 26 - Total number of Treatments of Public Health Nursing in all Stations
in Manila (1920)
Table 27 - Reports of the Public Health Nursing about Beriberi cases (1921-1922)
Table 28 Tikitiki extract distributed by the Office of Public Welfare
Commissioner (1921-1927)
Table 29- Number of Infants below one year admitted in Puericultures in Manila,
Total number of Infantile Beriberi cases, and Number of Tikitiki Extract
Distributed (1923-1927)
Table 30 Infant Mortality due to Beriberi in Manila, 1918-1927
Table 31- Total Admission of Infantile Beriberi cases in pediatrics ward of
Philippine General Hospital, College of Medicine, University of the Philippines
Table 32 Number of deaths from beriberi in the in Manila and in the Provinces
(1918-1925)

85
88
96
111
113
117
118
133
134
140
142
143
184
187
191

192
201
202
205

List of Figures
Figure 1 Factors of the Vulnerability of Infants to Infantile Beriberi
Figure 2 Floating Vessels as Houses in Port of Manila, Entrance of Pasig River
Figure 3 Street of Nipa Houses in Manila
Figure 4 Composition of a Rice Grain
Figure 5 Governor-General Wood and Party at the First National
Conference on Infant Mortality Public Welfare

21
58
72
106

Bibliography

217
v

176

Appendices
Appendix A - Health Bulletin No. 12, Beriberi and How to Prevent It
Appendix B The Treatment of Infantile Beriberi with the Extract of Tiqui-Tiqui
By Jose Albert
Appendix C - The A, B, C, of Filipino Nutrition
Appendix D Common Diseases of Babies causing High Infant Mortality
By Jose Albert
Appendix E Infantile Beriberi: Its Causes and its Remedies
By Joaquin Quintos

vi

226
235
241
246
250

ABSTRACT

This study examines the progress of vulnerability of infants to infantile beriberi in


the city of Manila through the historical development of the disease. The study is divided
into three time periods discussed in three separate chapters. The three chapters are
arranged in chronological order, thematically narrating the historical development of
infant mortality from infantile beriberi. The discussion of the study starts in 1901 with
the organization of the city of Manila through a charter and the start of the official efforts
of the colonial government to establish a public health service in the city. The discussion
ends in 1928 when the last Beriberi Committee published its official report on their
investigation of beriberi condition in the Philippines.
Chapter 2 discusses the organization of the city of Manila and its districts in
1901. After the creation of the Charter that established the city of Manila as the colonial
pilot site for the Americans experimentation of their public health policies and
programs, the chapter then discusses the vital statistics of the city including its birth,
population, and deaths. One of the focal point of the chapter is not only to map the city of
Manila but also to provide its complete health situation. As the Americans observed the
prevalence of ravaging epidemics and diseases in the city, they were prompted to initiate
their public health policies and programs to control the spread of communicable and
dangerous diseases. Apparently, the colonial public health streamlined their health
policies and efforts only to the sanitation of the city having been influenced by their
theory that all diseases were brought by germs and unclean environment. With their
attitude of treating all diseases as infectious in nature, the Americans had overlooked
other important public health concerns which had posed more threats to thousands of
innocent livesinfant mortality and beriberi.
As the colonial public health became aware of the growing concern of the high
infant mortality of Manila in 1910, many efforts were spurred to discover the real cause
of the deaths of vulnerable and helpless infants. Starting from 1910, Chapter 3 discusses
the medical breakthrough of the discovery of the nature of beriberi and its connection to
the deaths of infants. After beriberi was proven to be not a disease of infection but a
cause of nutritional deficiency, the colonial public health reoriented their health policies
by giving more importance to the human body than their sanitation policy. Consequently,
the colonial public health had realized the existence of a type of beriberi that caused loss
of thousands of infant lives. Since then, infant mortality was taken as a serious public
health matter and a lot of programs and policies were directed to the control of infantile

vii

beriberi among infants. To end the malady of infants, the important mission was to find
the cure of it all.
Chapter 4 continues the thesis starting in 1918 which was the year that marked
the complete take-over of the Filipinos of the public health service. As the Filipinos
enjoyed the partial autonomy they received from the policy of Filipinization of US
President Francis Burton Harrison, the Americans did not see the democratic policy as
fitting to the country. For them, such policy only brought a disastrous experience under
the control of the Filipinos. By 1921, infant mortality continued to be a national issue.
The Americans saw the high infant mortality as an obvious flaw of the Filipino capacities
for self-rule. During this period of tutelage and preparation for self-government, infant
mortality, especially from infantile beriberi, became a point of evaluation of the Filipino
capacities. It was apparent that the Americans politicized the social issue of high infant
mortality to criticize the Filipinos aspiration for self-government. This chapter discusses
the development of public health policies of the Filipinos to control infantile beriberi in
the city of Manila through the creation of voluntary organizations, investigation
committees, nursing schools, and clinics. It is an important question in this chapter
whether the Filipinos had proven their worth to run their nation by decreasing the
vulnerability of infants to infantile beriberi.

viii

GLOSSARY

Acute Bronchitis - inflammation of the main air passages of the lungs due
to infection
Amoebic Dysentery infection of the intestines caused by the parasitic
amoeba
Arsenic poisoning condition caused by ingestion of high level of arsenic
Autopsy a post-mortem surgical examination of the body to determine its
cause of death
Beriberi a disease brought on by a VitaminB-1 or Thiamine deficiency
Bubonic Plague a form of plague in humans, characterized by fever,
delirium, and the formation of buboes (inflamed lymph node).
Cerebral Congestion swelling of the brain
Cerebral Hemorrhage a type of stoke caused by the bleeding of a brain
tissue
Cerebro-Spinal Fluid - a clear colorless bodily fluid found in the brain and
spine
Cholera an infectious bacterial disease of the small intestine causing
severe vomiting and diarrhea (see definition of diarrhea)
Diarrhea - a condition of having loose and watery bowel movements
(stool)
Congenital Debility a disability or loss of strength present at birth
Convulsion similar to a seizure where body muscles shake rapidly and
uncontrollably
Cyanosis - a symptom of the appearance of a blue or purple color of the
skin
Dengue a mosquito-borne tropical disease caused by the dengue virus
Diphtheria a bacterial infection that affects the membranes of the throat
and nose
Dropsy a swelling of soft tissue due to the accumulation of excess water
Dry Beriberi a type of beriberi that affects the nervous system and causes
muscle paralysis
Dysentery an inflammatory disorder of the intestine resulting to severe
diarrhea
Dysphagia a symptom of difficulty in swallowing.
Eclampsia a severe condition that causes seizures during pregnancy
Empyema a collection of pus (dead cells and infected fluid) inside a body
cavity
ix

Enteritis inflammation of the small intestine caused by virus and bacteria


Enterocolitis inflammation of the digestive tract, involving enteritis of the
small intestine and the colitis of the colon
Epidemic a widespread occurrence of an infectious disease in a
community at a particular time
Etiology - the study of the causes of diseases
Gastro-duedenal Mucosa a dynamic barrier restricting entry of gastric
acid
Hemorrhages a condition where a person bleeds uncontrollably
Icterus also known as jaundice which is a condition in newborns
associated with the yellow color of the skin and the whites of the eye
Infantile Beriberi beriberi appearing in a breast-fed infant whose mother
has beriberi resulting from thiamine deficiency
Insomnia a sleep disorder characterized by difficulty in falling asleep
Intestinal Parasites parasites that populate the gastro-intestinal tract in
humans
Leprosy an infectious disease that causes severe, disfiguring skin sores
and nerve damage in the arms and legs
Lesion an injury to the living tissue of the body
Malarial Fever a fever produced by malaria (a serious infectious disease
from mosquito bite)
Meningitis - an acute inflammation of the thin tissue that surrounds the
brain and spinal cord
Metabolism is the physical and chemical process in the body that convert
or use energy
Microorganism living organism too small to be seen with naked eye
Multiple Neuritis degeneration of nerves of peripheral nerves which
supply the muscles of extremities
Necropsy see definition on autopsy
Nephritis a chronic inflammation of the kidney caused by infection or
disease
Nerve Lesions - a damage of nerve tissues
Neuritis inflammation of one or more nerves
Night Soil human excrement or feces collected at night and sometimes
used as fertilizer
Nitrogenous containing nitrogen which is essential for healthy immune
system and for producing antibodies
Oedematous an excessive accumulation of fluid in the body tissue
Oliguria a symptom characterized with low excretion of urine
Pathology a study of the origin, nature, and course of diseases

Pericarp - the outer layer component of rice which is present in brown rice
(see figure 4)
Phosphorus an essential component of living systems and is found in
nervous tissue and bones
Phosphorus Pentoxide phosphorus chemical used as food additives
Pneumonia an infection of the lungs that is usually caused by virus or
bacteria
Polished Rice/White Rice milled rice where the husk, bran, and germ are
removed
Polyneuritis Gallinarum the bird counterpart of human beriberi
Polypnea a symptom characterized with rapid breathing
Puerperium - the period beginning immediately after the birth of a child up
to about six weeks
Rice Bran/Rice Polishings - the product from the outer layer of the rice
which contains pericarp
Rinderpest an infectious viral disease of cattle and buffalo
Sclerema a skin condition characterized by diffuse hardening of tissue
with inflammation
Senile Disability showing a decrease of mental function
Smallpox a contagious fatal disease caused by infection with a virus
known as variola
Spleen the organ responsible for purifying the blood as well as storing
blood cells
Tetanus a bacterial disease marked by rigidity and spasms of the
voluntary muscles
Tikitiki the extract obtained from rice polishing and used to cure infantile
beriberi
Toxin a poisonous substance produced within living cells or organisms
Tropical Disease diseases that are prevalent in or unique to tropical and
subtropical regions
Tuberculosis an infectious disease caused by bacteria called
Mycobacterium tuberculosis which affects the lungs
Typhoid Fever fever produced by the bacterial infection of the intestinal
tract
Unpolsihed/Brown Rice - a type of rice which only the husk has been
removed and pericarp has been retained
Vitamins organic compounds which are needed in small quantities to
sustain life
Wet Beriberi a type of beriberi that affects the cardiovascular system and
causes heart failure

xi

CHAPTER 1
Introduction

A. Background of the Study


The turn of the new century in the Philippines had carried many lives as
Americans implemented their ways of pacifying the resisting natives.

As the new

colonizers realized the end of the war, they became quickly aware that numbers of deaths
still remained to be high because of the prevalence of tropical diseases like malaria,
cholera, smallpox, and plague. After a formal government was established in the islands,
Americans carried out their own public health in the country. As a miniature of their
health experiment, the city of Manila was chartered in 1901 and was chosen as the pilot
site of the colonial public health. To protect the city from ravaging infectious diseases,
the Americans first assigned high priority in transforming the city into healthy and
habitable city.1 By about 1905, sanitary reforms were narrowly concentrated only for
cleaning the city through the control of water and food supplies, purge of insect and pest
vectors, and eradication of epidemic diseases like cholera, smallpox, plague, yellow
fever, leprosy, and malaria.2

Ronaldo Mactal, Kalusugang Pampubliko sa Kolonyal na Maynila: Heograpiya, Medisina,


Kasaysayan (1898-1918) (Quezon City: University of the Philippines Press, 2009), 26-27.
2
Reynaldo Ileto, Cholera and the origins of the American Sanitary Order in the Philippines in
Imperial Medicines and Indigenous Societies, ed. David Arnold (New York: Manchester University Press,
1988), 133.

As the Americans implemented their sanitation policies, other public health


concerns like beriberi, tuberculosis, and infant mortality only received attention after the
more dangerous diseases mentioned above had been managed. Apparently, the
oversimplification of the culture of the different diseases in the city tended the
American health officials to generalize that all the diseases could be solved by their
sanitary measures.3 Their efforts to decrease the mortality rate in the city fell short as all
death statistics showed that the highest mortality rate was not from any infectious
diseases that the Americans feared, but from the most vulnerable group in the society
the infants. The unremarkable high rates of infant mortality merited relatively little
discussions in early American reports. It was clear that Americans devoted their
attentions to control infectious diseases which could imperil more important human lives
than, for them, worthless infants. 4
As more infants below five years old perished, Americans still had not realized
the relation of beriberi, a disease that developed from nutritional deficiency, to the high
deaths of infants. They thought that Filipino body was not different from the western
body studied by them in treating their own diseases. In fact, they heavily relied on their
own medical theories that they imprudently forgot that Filipino bodies were unique and
more vulnerable to diseases only peculiar to natives.5 Dealing with this problem to save

Mactal, Kalusugang Pampubliko sa Kolonyal na Maynila, 100.


Ken De Beviose, Agents of the Apocalypse: Epidemic Diseases in the Colonial Philippines
(Quezon City: New Day Publishers, 2002), 185.
5
Mactal, Kalusugang Pampubliko sa Kolonyal na Maynila, 141.
4

infants from death, Americans sought the help of the Filipinos to address infant
mortality. Together they focused on the effect of human participation in the creation of
their own diseases. Being trained under the tutelage of the colonizer, Filipinos later on
assumed high positions in the public health service as a measure for their eventual selfrule. In 1918 onwards, Filipino physicians and nurses had generally administrated
medical institutions of the Philippine government. Unfortunately, no matter how much
Filipinos worked to save young and innocent lives, the colonizers still believed that
letting Filipinos to take over the colonial bureaucracy was nothing but a premature
decision.6
As a whole, history of infant welfare created an axis of health and politics. More
often than not, childhood has been considered as a discursive symbol than as the subject
of colonial policy. 7 However, there is more to tell about infants in history than only as
numbers in population and death statistics. For this, the study of childhood in
imperialism offers an interesting undertaking in finding a shortcoming in the objective of
the American colonizers to transform the Philippines to a civilization in their own image.
The combination of infants, diseases, and colonialism are interesting research to give a
new discussion of the colonial experience of the Philippines during the American
occupation. After all, Philippine colonial history is not only written from the experiences
6

Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in
the Philippines (Quezon City: Ateneo De Manila University Press, 20006), 184-185.
7
Bonnie McElhinny, Kissing a Baby Is Not at All Good for Him: Infant Mortality, Medicine,
and Colonial Modernity in the U.S.-Occupied Philippines, American Anthropologist 107, no. 2 (2005):
183.

of those dissidents who died from wars and those who co-opted with the American
because aside from them babies also had struggling stories to be told.

B. Statement of the Problem


The study examines the vulnerability of infants to infantile beriberi by discussing
the historical development of infant mortality and infantile beriberi in the city of Manila
from 1901 to 1928. The study aims to answer the following questions:
1. How did the Americans solve the health and sanitary problems in the city
during the early American period?
1.1 What were the geography, population, mortality, and causes of death
of the city?
1.2 What health programs and sanitary orders did the Americans
implement to control the diseases in the city?
1.3 How did the Americans view and address beriberi during the early
American period?
1.4 What was the general condition of infants in the city?
2. How did the Americans and Filipinos discover the real nature of Beriberi
and its impact to infants?
2.1 What was the nature and origin of Beriberi?

2.2 What were the factors contributed to the vulnerability of the Filipinos
to the disease?
2.3 How did the Filipinos and Americans discover infantile beriberi?
2.4 What was the etiology of infantile beriberi?
2.5 What were the measures taken by the colonial public health to address
infant mortality from beriberi?
3. How did Filipinization of the Philippine Health Service affect the problem
of infant mortality in Manila?
3.1 What was the Filipinization policy and how was it taken?
3.2 How did Filipinos solve infant mortality under the colonial
government?
3.3 How did Filipino nurses contribute to address infant mortality?
3.4 What were puericulture centers and its contribution to infant health?
3.5 Did the Filipinos succeed in controlling infant mortality from beriberi
as part of the measure for their self-government?

C. Significance of the Study


This study has several contributions to historical learning. First, the prevalence of
diseases in the country has been an important national issue. Diseases and epidemics are
important matters that demand immediate solutions from the government and other

sectors. During the American period, beriberi was a disease that recorded very high death
rate because of the lack of knowledge of the Americans about the nature of the disease.
Although this disease had long been cured, it is still very interesting to learn how
Americans and the Filipinos struggled to solve this disease that killed the most lives in
the early colonial period. This study will give insights on how to manage the threat of
unknown diseases in the future.
Second, another important contribution of this study is its discussion of infants.
Infants were not a common topic of imperialism in historical studies. During the early
American period, infants were perceived to be useless to national development as the
Americans argued that the deaths of babies could eventually be compensated by a high
birth rate. It was only at a later time that Americans had realized the tremendous impact
of loss of infants on Philippine society. There are only a few scholarly works that have
studied the experiences of infants in Philippine colonial history. This study is therefore a
great addition to a few studies that have undertaken researches about infants as a subject
of history.
Third, many of the old and contemporary books and journals that discuss human
diseases in the Philippines during the colonial period only focus on more familiar
diseases like cholera, smallpox, tuberculosis, and malaria. There are very few written and
published materials that discuss beriberi as a dangerous disease in history. Moreover,
infantile form of beriberi has not been popularly discussed in scholarly works. No work
so far has critically studied infantile beriberi and its impact to infant mortality during the
6

Philippine colonial period. Many of the present studies about infant mortality only
discuss the social aspect of the issue but rarely look at the medical dimension of the
problem. This research attempts to trace the problem of infant health through the
historical development of beriberi and its infantile form. This study hopes to contribute to
Philippine historiography by making a study about infants and beriberi.
Fourth, this study is also anchored on a nationalist perspective. Part of this study
discusses the policy of Filipinization of the colonial bureaucracy wherein Filipino
leaders, doctors, and nurses held administrative positions to address the infant mortality
in the country. The perspective of nationalism in the study of diseases in the country is
rarely used in historical studies. Reynaldo Iletos work is one example which applies a
nationalist perspective in discussing the stories of Filipinos during the colonial years.
More often than not, elitist view is always used in research that limited the scope of
historical studies to stories of resistance, protests, and insurrections. This study can be
viewed in parallel to Iletos works. Filipinos struggle to independence is not only about
brutal resistance and wars. Some of them co-opted with the Americans while working on
to achieve the independence for the country. This study will discuss the role of the
Filipino authorities, physicians, and nurses in the colonial public health.
Lastly, the present study generally endeavors to contribute to social history,
public health history and institutional history during the American period. It aims to be
an additional material to social history because the research discusses a specific group of
people in the society that is always overlooked by historians. They are the infants who
7

could not write history of their own during the colonial period for obvious reasons. In
addition, the present work will also give a social and local history of Manila as the
geographical scope of the study. The study also contributes to public health history
because it will primarily engage in a discussion colonial health policies and programs
against epidemics and diseases. Finally, it will also serve as a contribution to institutional
history of the country because government agencies and non-government sectors of the
Philippines played significant roles in this study.

D. Scope and Limitation


This study discusses the historical vulnerability of infants to beriberi. It covers the
periods between 1901 up to 1928. Its time frame starts in 1898 because it was the year
Manila was chartered as a city during the American period and the year when the
Americans began their colonial public health in the city. The study ends in 1928 after the
last Beriberi Committee submitted its last report about the beriberi condition in the
country. The study does not aim to provide a general survey of the effect of beriberi to
the whole archipelago. Thus, it only limits itself to the city of Manila covering its several
districts as defined in the charter of the city.
This study focuses on the impact of beriberi to infants. However, in the
discussion of beriberi, the adult type of beriberi will be an unavoidable discussion. At
first, American reports had generally thought of beriberi as an adult disease and was not

related to infants during the early American period. It will be a big mistake not to give a
background discussion of the general knowledge of beriberi before the Americans and
Filipinos discovered that beriberi had an infantile form.

One major limitation to this study is that all sources and materials used are mostly
the official government records and publications of the American colonial government.
These documents include the annual reports of the Philippine Commission,
Commissioner of Public Health, which was replaced by the Board of Health, which
shortly became the Bureau of Health, the annual reports of the Secretary of Interiors,
Philippine Health Service, and official reports of the American officials. Therefore, it is
to be expected that the discussion of the study is anchored mostly on the perspective of
the Americans experience in their colonial experience in the Philippines.
As a scope, the present work provides a description of the city of Manila, its
geography, population, and mortality from diseases. It discusses the organization of
public health and the implementation of the early American public health measures and
sanitary orders in the control of the deadly diseases in the city. It also provides a
discussion on the discovery of the true nature of beriberi in 1910 and analyzes the
vulnerability of the Filipino bodies to the disease. Also, this study gives weight to the
discussion of the infantile form of beriberi and assesses the effectiveness of the
government actions to curb infant mortality. Furthermore, it gives a discussion of the
Filipinization policy and the experiences of Filipinos in answering the problem of infant
health and welfare.
9

E. Review of Related Literature


In the book, A Short History of Medicine in the Philippines during the Spanish
Regime, 1565-1898,8 Jose P. Bantug provides an archival narration of the development
of medicine in the Philippines from the pre-Spanish period to the end of the three
centuries of Spanish Regime in the country. Bantug says that no authentic monuments
have come down to us that indicate with some certainty early medical practices. In the
pyramid of progress, Bantug describes the pre-colonial medicine as the lowest point of
development of the medical practice in the country. In his book, Bantug says that
colonialism improved the medical practices in the Philippines. As the Spanish
colonialism transformed the Philippines, it brought superior medical practice and public
health service in the Philippines and changed the mythical and superstitious medicines in
the pre-colonial period.
Similarly, Enrico Azicates thesis of the history of medicine in the Philippine
entitled, History of Medicine: A Historical Perpsective,9 expands the framework of the
history of medicine in the Philippines. Azicate categorizes the history of medicine in the
Philippines in three periods: pre-colonial, Spanish period, and the scientific period under
the American regime. Akin to the framework of Bantug, Azicate describes the pre8

Jose P. Bantug, A Short History of Medicine in the Philippines During the Spanish Regime,
1565-1898 (Manila: Colegio Medico-Farmaceutico de Filipinas, 1953).
9
Enrico Azicate, History of Medicine in the Philippines: Historical Perspective (thesis,
University of the Philippines, Diliman, 1988).

10

colonial medical practices of the Philippines as traditional and unscientific. The medical
practices only began to move from its primitive state to scientific stage when the
Americans brought in the Philippines their western idea of medicine. The so-called
traditional and conservative state of medicine was commonly attributed to the preAmerican because of its superstitions and mysticism and its lack of exact science. The
work of Azicate implies that the history of modern medicine in the Philippines was only
existent during the American period. However, I will argue that despite of the excellent
knowledge of the Americans in medicine and epidemics, their first decade in the country
showed that they still had more to learn in the realm of medicine. Their knowledge of
diseases was purely influenced by western science which was not applicable to the
vulnerability of the naives to their own diseases. This explains the success of the
Americans in their warfare against infectious diseases and their downfall in their battle
against beriberi in adult and infants.
The book written by Ken De Bevoise entitled, Agents of the Apocalypse:
Epidemic Disease in the Colonial Philippines,10 describes the various epidemics that
ravaged the Philippines in the late 19th century and linked it to the economic, political,
social, and cultural factors through a historical process. The general thesis of the book
will help in applying the studys conceptual framework to the thesis topic since De
Bevoise book technically uses the same conceptual framework. One limitation of this

10

Ken De Beviose. Agents of the Apocalypse: Epidemic Disease in the Philippine. (Quezon City:
New Day Publisher, 2002).

11

book to the present study is that the discussion in beriberi epidemic concentrated to the
late Spanish period and described only a little explanation during the early American
period. Nonetheless, De Bevoises book provides a good context of the relation of socioeconomic conditions and beriberi epidemic during the early American period. The
present study will further expound the context of the disease during the American period.
Ronaldo Mactal wrote a book entitled, Kalusugang Pampubliko sa Kolonyal na
Maynila: Heograpiya, Medisina, at Kasaysayan (1898-1918),11 that analyzes the
formation of the public health policies of the American colonial government in the city of
Manila. The author relates the influence of the environment and geography to the
colonial public health of the city. This material will be helpful in describing the general
colonial public health in the city of Manila during the first two decades of the American
occupation. Although the book did not specifically provide a discussion for the beriberi
epidemic in Manila during the American colonial period, its chapter about the infant
mortality offers a great overview for the thesis. The present study will further expound
on this matter.
Kenneth Carpenter in his book, Beriberi, White Rice, and Vitamin B: A Disease,
a Cause, and a Cure,12 comprehensively traces both the historical and medical research
about beriberi in a global context. It provides a concise chapter about the relation of rice

11

Ronaldo Mactal. Kalusugang Pampubliko sa Kolonyal na Maynila (1898-1918): Heograpiya,


Medisina, Kasaysayan. (Quezon City: University of the Philippine Press, 2009).
12
Kenneth John, Carpenter. Beriberi, White Race, and Vitamin B: A Disease, a Cause, and a Cure
(Berkeley: University of California Press, 2000).

12

to beriberi and describes a historical process of the discovery of the disease. In the
present study, this will help in discussing the historical explanation of the discovery of
the beriberi in the Philippines. Again, the study will only focus on the beriberi experience
in the city of Manila.
The article written by Bonnie McElhinny entitled, Producing the A-1 Baby:
Puericulture Centers and the Birth of the Clinic in the U.S.-Occupied Pilippines, 19061946,13 published in Philippine Studies Journal, gives a history of the practices and
initiatives of the Americans on maternal and child health, particularly the creation of
puericultures. This article provides a concrete example of the Americans policies to
reduce the infant mortality. Although it never focuses on the beriberi epidemic, the
article nevertheless gives a thorough description of the initiatives of the Americans to
solve the mortality of children. The present study relates colonial health programs to the
eradication of the beriberi cases among infants.
The book, Toward the Conquest of Beriberi,14 written by Robert R. Williams
clearly explains the etiology of the beriberi as a deficiency disease and provides inquiries
about practical experiences of different parts of the world in conquering the disease.
However, its details regarding the Philippines are not comprehensive. As a limitation, the
book only reveals a more scientific and chemical understanding of the disease.

13

Bonnie McElhinny, Producing the A-1 Baby: Puericulture Centers and the Birth of the Clinic in
the U.S.-Occupied Philippines, 1906-1946. Philippine Studies 57, no. 2 (2009): 219-260.
14
Robert Williams. Toward the conquest of Beriberi (Cambridge: Harvard University Press,
1961).

13

Nonetheless, this book can still be helpful in studying the nature of the beriberi disease
and its implications to the human body. The present study can employ the scientific and
chemical interpretations of beriberi and contextualize it into a historical narrative.
The dissertation, Prerequisites to a Civilized Life: The American Colonial Public
Helath System in the Philippines, 1901-1907,15 submitted by Ma. Mercedes Planta to
the National University of Singapore examines the rationale of the civilizing mission
of the Americans wherein Filipinos were monitored for their preparation for self-rule in
the aspect of public health. The study focuses on sanitation, health, hygiene, medical,
scientific institutions, and medical and health professions of the American colonial state.
This dissertation formulates the background of the paper in discussing the political
aspects of public health in the country. However, the study takes a narrower approach
because the focus is only the disease of beriberi in infants.
Reynaldo Iletos article, Cholera and the Origins of the American Sanitary Order
in the Philippines,16 attacks the cloaked mission of American benevolence in public
health and how medicine was made to accomplish Americas pacification of the islands.
Ileto describes that the military origins of the American colonial public health was made
as a means not only to eliminate cholera virus but also to subdue the continuing war in
the years 1902 to 1904. This work is pertinent to the present study because it offers a
15

Ma. Mercedes G. Planta, Prerequisites to a Civilized Life: The American Colonial Public
Health system in the Philippines, 1901-1927, (PhD diss., National University of Singapore, 2008).
16
Reynaldo Ileto, Cholera and the origins of the American sanitary order in the Philippines in
Imperial Medicines and Indigenous Societies, ed. David Arnold (New York: Manchester University Press,
1988).

14

contextual background of the other side of the benevolent mission of the Americans.
This will be another insight to the paper in the discussion of the rift between the Filipinos
and the Americans during the progress of Filipinization policy.
Warwick Andersons Colonial Pathologies: American Tropical Medicine, Race
and Hygiene in the Philippines,17 critically illustrates the development of colonial public
health and medicine in the country and categorically identifies in each phase of
development the perceptions of the Americans about the Filipinos. The book discusses
relevant topics like the control of malaria, sanitations of human excrements, and the leper
colony. But none is mentioned about beriberi in infants which this study will focus on.
Nevertheless, its chapters about the military basis of the American public health and the
Filipino mimicry of the late colonial public health are considerably a great contribution
to this study with regard to the political developments of the colonial public health.

F. Methodology
This study uses library, archival and online library research. All the sources and
material are gathered from De La Salle University Library, National Library of the
Philippines, and the online library of University of Michigan, The United States and its
Territories, 1870-1925: The Age of Imperialism.

17

Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in
the Philippines (Quezon City: Ateneo De Manila University Press, 2007).

15

The study uses primary sources and secondary sources. Most primary sources in
this study are taken from the American government publications such as the Philippine
Commission, Commissioner of Board of Health, Board of Health, Secretary of Interiors,
Philippine, and Annual Reports of the Governor-General and Secretary of Wars, and
Philippine Health Service. Journal articles produced during the American occupation like
the articles written by Dr. Edward Vedder and Dr. Albert Jose are also important primary
sources pertinent to write this study. Furthermore, this study uses related literatures as
secondary sources such as the books of Ken De Bevoise, Ronaldo Mactal, Robert
Williams, and Ken Carpenter, the thesis of Ma. Mercedes Planta and selected academic
journal articles.
This study applies the descriptive-analytic method as a research design. A
descriptive-analytic design provides a comprehensive analysis of the historical
information used in this study. The proponent of the study not only describes the
narrative events of the thesis but also provides a critical evaluation of the materials in
order to create an analysis of the historical information. As applied in this study, the
thesis constructs a descriptive narrative of the historical development of beriberi in the
city of Manila. From the descriptive historical information about the events, the study
uses analysis in order to answer the critical questions presented in the thesis. The study
analyzes the vulnerability of infants through the historical development of beriberi. As a
research design, descriptive-analytic method allows the proponent of the thesis to write
an in depth study of the subject.
16

G. Conceptual Framework
The present study uses the concept of vulnerability in understanding disasters
through the interplay of different variables in the environment and their relationship to
human societies. The discussion regarding this concept materialized from the interests of
sociologists, anthropologists and geographers to study the development of disasters in the
social systems. In tradition, disasters had been variously defined in terms of physical
agents such as earthquakes, tornadoes, storms, and droughts and the physical impact of
these to people. However, the focus of disaster from the natural environment, described
by Kenneth Hewitt as the hazards paradigm, loses the attention of the important
connection of social nature to disasters.18
A new perspective in the social scientific study about disasters emerged in which
disasters are not only characterized as entirely natural events but much more as functions
of an on-going social order in a structure of human-environment relations. Hewitt says
that disasters are seen as more of characteristics of societies than they are simple physical
environments. In this sense, disasters are more appropriately explained to be caused
rather than simply a normal order of things that simply happen in time. 19 Disasters thus
become defined as failures of human systems to understand the relation of humans and
18

Susanna Hoffman and Anthony Oliver-Smith ed, The Angry Earth (New York: Routledge,
1999), 21-24.
19
Anthony Oliver-Smith, Perus Five Hundred Year Earthquakes: Vulnerability in Historical
Context.in Disaster, in Development and Environment, ed Ann Varley (London: John Wiley and Sons,
1994), 31.

17

environment, producing a failure of human to cope with disasters and protect themselves.
In anthropology, disasters are conceptualized in terms of an interrelated system that links
society (composed of the organization, individuals and groups), environment (the
physical world in which people and groups are both constituted), and culture (values,
norms, beliefs, and attitudes).20
On one hand, Anthony Oliver-Smith describes disasters in relation to the behavior
of people and groups at a temporally and spatially specific moment. He says that disaster
is a behavioral phenomenon where community perception and response become crucial
issues for defining disasters. In this approach, disasters become a function of social
effects.21 Michael Barkun also supports the same idea that disasters are expressed
through behavior of human beings and groups in a specific context of disruption and
damage. He defines disasters to be a mental construct imposed upon human
experience. Furthermore, he notes that studies on disasters have neglected the symbolic
aspect of it which deals with the manner in which stress brought by disasters is perceived
by those who have felt it. For him, it is not enough to know the number of deaths, the
value of property destroyed, and the decrease in per capita income resulting from
disasters. The symbolic aspect of disasters essentially requires the knowledge of the
sense of vulnerability.22

20

Hoffman and Oliver-Smith, The Angry Earth, 28-29.


Ibid., 24.
22
Michael Barkun, Disasters in History, Mass Emergencies 2 (1977):219-221.
21

18

However, some researchers would reject the concept of vulnerability as relevant


in understanding disasters. For them, the concept of vulnerability is more related for
explaining the origin and causes of disasters. However, other researchers have
emphasized that disaster has history in itself. The societys progress of vulnerability is an
essential element of disaster and this is expressed through historical developments.
Oliver-Smith adds that disasters are made inevitable by the historically produced pattern
of vulnerability of a society. Vulnerability will form the behavior of individuals and
organizations throughout the life history of a disaster than will the physical impact that
these destructive agents create.23
In the same light, Greg Bankoff shares also a similar opinion saying that,
awareness of time constructs vulnerability. He also adds that vulnerability is regarded
as difficulties some social groups have in accessing certain resources over time. In other
words, peoples circumstances and their pasts have brought them to that state at that
particular time and place. As Oliver-Smith says, life history of a disaster begins prior to
the appearance of a specific event-focused-agent.24 Therefore, the study of disasters is
not only to be undertaken by geographers and sociologists, who have been very active in
this area of research. For this, Ted Steinberg strongly encourages historians to engage in
research about natural disasters as a part of historical studies. The discipline of history as

23

Hoffman and Oliver-Smith, The Angry Earth, 28-29.


Greg Bankoff, Time is of the Essence: Disasters, Vulnerability and History, International
Journal of Mass Emergencies and Disasters 22, no. 3 (2004): 23-42.
24

19

a social science can be used to interpret natural disasters by bringing human dimensions
of the problem.25
In this study, the concept of vulnerability is specifically applied to a disease.
Before it was used to disasters, the concept of vulnerability has already been disguised as
a discourse during the seventeenth to early twentieth century that categorized disasters as
tropicality and western intervention was known as colonialism. Bankoff describes
these tropics as the abode of dangerous diseases that justified the establishment of high
colonialism clothed under the humanitarian slogan of western medicine. This was the
rationale behind the western rhetoric of white mans burden.26 The study presents
factors that coordinated to form the historical progress of vulnerability of the people,
especially infants, to beriberi which includes changes in political environment, economy,
natural environment, population, medical science, poverty, and other socio-cultural
variables.
In theory, Americans traditionally based their health and sanitary programs in the
elimination of germs which for them were the dwelling of different infectious diseases.
Even diseases, whose scientific nature was yet to be known, were associated to the
unsanitary condition of the environment. The colonial public health during the early
American period treated diseases as only a physical agent in the environment. Departing
from that point of view, in this study, the framework of vulnerability discusses the
25

Ted Steinberg, The secret history of natural disaster, Environmental Hazards 3 (2001): 35.
Gregory Bankoff, Rendering the World Unsafe: Vulnerability as Western Discourse,
Disasters 25, no. 1 (2001): 27-28.
26

20

relationship of human elements and environmental changes leading to the appearance of


a disease. It is very important that the study of diseases, as a form of disaster, needs to be
explained from the social perspective of its emergence. Applying the concept of
vulnerability, the study gives more emphasis on human actions in creating their own
diseases. The diagram below illustrates the concept of vulnerability in the study:

Figure 1 Factors of Vulnerability of Infants to Infantile Beriberi

In the study, infantile beriberi is discussed as a function of the imbalance of


environment and human actions and not simply as a result of natural disorder of the

21

human body alone. Beriberi became an epidemic because of the history of vulnerability
of the Filipino in the past that progressed to the appearance of the disease. The shift from
the subsistence agriculture to colonial export agriculture gave a way to the prevalence of
beriberi. The heavy importation of rice from other Asian countries resulted to the
shortage of local rice, forcing the people to consume nothing but imported polished rice
from Saigon. The coincidence of cholera epidemic and other viral diseases compounded
by poverty and nutritional imbalance made people particularly susceptible to beriberi.
This pattern of historical events determines the progress of vulnerability of the people to
the beriberi.
The result of these historical developments during the early American period was
very disastrous to infants who were the most vulnerable victims of beriberi because of
their young age and physical condition. Unfortunately, as a new disease to the
Americans, the lack of scientific study about the true nature of beriberi even exacerbated
the vulnerability of infants to the disease. As soon as Americans had known of the origin
of beriberi and the relation of the mothers milk to the disease, high infant mortality
became a leading social problem upon the discovery that infantile beriberi was the cause
of death of many infants in Manila. Throughout the process of the control of beriberi,
cultural resistance also arose and further exacerbated the progress of vulnerability of
infants to beriberi.
Furthermore, the challenge of the high infant mortality rate from beriberi was
made an argument against the Filipinos capacity for self-rule.
22

As a part of the

determination of the pattern of vulnerability of the infants to the beriberi, this study also
looks at the trend of political development in the Philippine government during the era of
Filipinization. It is important to note that childhood welfare became a subject of
American evaluation in the preparation of the Filipinos for self-government. In the end,
the success to curb the high infant mortality depended on the competence of the leaders
who occupied the government.

H. Thesis Organization
This thesis is divided into five chapters. Chapters 2, 3, and 4 are arranged
thematically in chronological order. It starts in year 1901 and ends in 1928.
The first chapter introduces the thesis. It comprises of the background of the
study, the statement of the problem, the objectives, significance, scope and limitation of
the thesis, the conceptual framework, the methodology, and the organization of the
thesis.
The second chapter begins in 1901 when the Americans formally began their
efforts to establish the colonial public health in the city. This chapter briefly describes the
organization of the city of Manila in 1901, including the political development of the
local government of the city. The chapter discusses the general health profile of the city,
showing the population, birth, death rates, and cause of deaths. This chapter covers initial
views and records of beriberi epidemic and infant mortality during the American period.

23

It must be noted that beriberi was not known yet to be the cause of the very high rate of
infant mortality until 1910. Thus, this chapter ends in that year prior to the year when the
colonial government had realized the real cause of deaths among infants.
The third chapter narrates and explains the discovery of the etiology of beriberi,
both the adult and infantile form, its impact to people, and the several factors that
contributed to the vulnerability of the people to beriberi. The chapter starts in 1910,
which as mentioned, marked the discovery of the colonial public health that the beriberi
was related to polished rice and was transferred to infants through the mothers milk. The
chapter also discusses colonial response against beriberi and the health policies and
programs instituted to the control of infantile beriberi among infants. The chapter ends in
1918 as the year when the Filipinos completely took over the administration of the public
health in the country.
The fourth chapter covers the continuing problem of the infantile beriberi and the
high mortality of infants in the city. It continues the year 1918 as the year when Filipino
administrators, doctors, and nurses dominated the public health in Philippine
government. Around this period, serious public welfare programs were instituted to curb
the increasing problem of infant mortality. Many nurses were trained for maternal and
child welfare as a solution to control the problem of infant mortality. It was also around
this time that baby clinics called puericultures were widely established in Manila. The
chapter gives a discussion of the Filipinization policy and the initiatives of the Filipinorun government in the control of the infant mortality. This chapter ends in 1928 when the
24

last Beriberi Committee submitted its report on its investigation of the beriberi condition
in the country.
The fifth and final chapter provides a summary and a conclusion.

25

CHAPTER 2
Mapping the City and Its Diseases:
The City of Manila during the Early American Period
(1901-1910)

Existing with the resistance of the natives in the provinces, the growing number
of deaths from epidemic diseases in Manila became the greatest public enemy of the
colonial government in the city. As part of their proclaimed Benevolent Assimilation,
the Americans saw the possibility to save lives being destroyed every year by dangerous
diseases. As the Americans developed Manila as their pilot site for their public health,
they primarily exhausted their efforts in waging warfare against diseases that were
dangerous not only to the locals but also to their own health. To make Manila
invulnerable to the threat of deadly diseases, the Americans narrowed their programs
mainly to the sanitation of the city. An enormous work was done only to transform the
city to a beautiful and habitable place that was free from the destruction of viral diseases.
This chapter discusses the apparent disparity in the attention of the colonial
government in curbing different public health concerns upon the formal organization of
the city of Manila in 1901. The chapter narrates how sanitation, in an effort to eliminate
dangerous diseases, received the highest concern from the Americans and other public
health concerns such as beriberi and infant mortality were attended only after the more
dangerous diseases were managed. The chapter ends by introducing the much overdue

26

discovery of the real causes of beriberi and infant mortality, and the possible connection
between the two.

A. Colonial Pilot Site: The Organization of the City of Manila


For three years since 1898, the City of Manila was under a military rule. By the
end of the Philippine-American War, Americans began changes incident to the
reorganization of a military government to a civil government. One of the last official
acts of Brigadier-General George W. Davis, the last provost marshal of Manila, was to
craft a charter for the city to be presented to the incoming Philippine Commission.27 The
draft had been drawn after consultation with Judge William Howard Taft, who was later
to become the first president of the Philippine Commission, and in accordance with US
President William McKinleys instructions to provide the locals a municipal government
wherein they were given an opportunity to manage their own local affairs to the fullest
extent of which they are capable and subject to the least degree of supervision and
control...consistent with the maintenance of law, order, and loyalty.28 On July 31, 1901,
after the enactment of Act No. 183, the Philippine Commission promulgated the Charter

27

Philippine Commission, Third Annual Report of the Philippine Commission to the Bureau of
Insular Affairs, War Department (Washington: Government Printing Office, 1903), 77. [hereafter Third
Annual Report of the Philippine Commission]
28
US War Department, Report of the Philippine Commission, the Civil Governor, and the
Executive Departments of the Philippine Islands, 1900-1903 (Washington: Government Printing Office,
1904), 5-6. [hereafter Reports of the Philippine Commission to the Civil Governor (1900-1903)]

27

incorporating the city of Manila.29 On August 7, 1901, the Charter officially went into
effect by the proclamation of Taft after he became the Civil Governor.30
Among other local governments under the US administration, the cities of Manila
and Baguio were the only chartered cities in the Philippines. The organization of
governments and the management of affairs of these chartered cities differed from those
of municipalities. Unlike municipalities which were governed and organized under the
provisions of the Municipal Law, chartered cities were created by special acts of the
Legislature and were governed by their respective charters. 31 Upon the promulgation of
the Charter, Manila was no longer limited to the confines of the city walls of Intramuros.
The arabales or the suburbs, located outside of the walled city, during the Spanish
colonization were incorporated into the city of Manila as its individual districts. In 1901,
11 districts originally composed Manila. It included the districts of Intramuros, Binondo,
San Nicolas, Tondo, Santa Cruz, Quiapo, San Miguel, Sampaloc, Ermita, Malate, at
Paco.32
Under section 4 of the said charter, Manila was classified as a municipality
governed by a Municipal Board consisting of three members and a secretary, all of whom
were appointed by the Civil Governor by and with the consent of the Philippine

29

Philippine Commission, Public Laws Passed by the Philippine Commission (Manila: Bureau of
Public Printing, 1903), 336-338.
30
Jose P. Laurel, Local Government in the Philippine Islands (Manila: La Pilarica Press, 1926),
138.
31
Ibid., 135-142.
32
Nick Joaquin, Manila, My Manila: A History for the Young (Manila: City of Manila, 1990),
137.

28

Commission.33 The Board possessed legislative powers vested by the Charter. It was also
endowed with executive authority to be exercised through the different departments to
which the city government was organized. These included Engineering and Public
Works, Police, Law, Fire, Assessments and Collections, and Sanitations and
Transportation.34 Many of the heads of the departments who had been army officers
during the military government were still retained as officials under the civil government
and were of great assistance in the work of reorganization because of their knowledge of
the work of the departments in the past.35
Contrary to what was intended, the new charter did not successfully establish
Manila as an autonomous government entity. Under the charter, the people of the city
were given only a little share in the administration of their affairs because members of
the Board were responsible to the Governor-General and the Philippine Commission.36
Most of the functions of the Municipal Board were closely linked with those of the
Insular Government of the Philippine Islands. For example, revenues of the city were
required to be kept by the insular treasurer and the warden of Bilibid Prison was given
jurisdiction to receive city prisoners. With both the Municipal Board and the Insular
Government concurrently existing in the city, almost all government functions which had

33

Municipal Board of Manila, Report of the Municipal Board of the City of Manila for the Period
from August 7, 1901 to June 30, 1902 (Manila: Bureau of Public Printing, 1903), 7-8.[hereafter Report of
the Municipal Board (1901-1902)]
34
Philippines, Handbook on the Executive Departments of the Government of the Philippine
Islands (Manila: Bureau of Printing, 1912), 25.
35
Report of the Municipal Board of Manila (1901-1902), 8.
36
Laurel, Local Government in the Philippine Islands, 140.

29

been entrusted by the Charter to the city government were transferred to the central
government by passing legislative laws and orders.37
Following the District of Columbia model, power was conferred exclusively to
federal executive and legislature. Local people did not exercise political rights except the
powers of petition which they could exercise either through the executive or legislative
branch of the insular government. The centralized political arrangement of the city
government, in effect, disenfranchised the residents of Manila of the power to determine
their own affairs.38 To give the residents a fair share in the affairs of the city, the original
charter of Manila provided, besides the Municipal Board, an Advisory Board. It was
composed of representatives from all districts into which the City of Manila was divided
under the Spanish Government. At first, the Advisory Board had 11 members from the
all original districts of the city. Since the organization of this body, two new districts,
Santa Ana and Pandacan, had been added to the city. In 1902, the number of members of
the Board was increased to 13 under Act 447 to represent the inclusion of the two new
districts. The members of the advisory body were appointed by the Governor-General
with the consent of the Commission.39
The addition of the advisory body had been a great help to the Municipal Board
in the government of the city as it had brought to the attention of the Municipal Board the
37

Bennett Rich, The Development of Self-Government in Manila, The Western Political


Quarterly 11, no. 3 (1958): 586. (583-597)
38
Christina Evangelista Torres, The Americanization of Manila: 1898-1921 (Quezon City:
University of the Philippines Press, 2010), 50.
39
Laurel, Local Government in the Philippine Islands, 140.

30

special needs of the city and its inhabitants. It forwarded suggestions and
recommendations relating to conditions within the city for consideration of the board. All
the members of advisory body being Filipinos, they had come in close touch with the
native population, and conveyed their petitions and necessities before the Municipal
Board in such a way as to simplify the matter of legislation on their behalf. Before the
final action by the Municipal Board, all ordinances of the city had to be passed by the
members of the Advisory Body, and before all large expenditures amounting to $10,000
and over could be disbursed, they had to be first submitted to the body for approval.40
Albeit the little democratic participation of the Filipinos in the local government
of the city, the relationship between the Municipal Board and the Advisory Board was
not always harmonious. Whereas the Advisory Board represented more the concerns of
the local people in the city, the Municipal Board inclined more to reflect Americas
interest. The Commission even belittlingly viewed the Advisory Board as an obstruction
and a hindrance instead of an aid to the development and improvement of the city. The
American authorities criticized the formulation of the advisory body as a mere formality
because the law only so required for it.41 The American authorities did not agree to the
idea of giving up control of the affairs of the capital city to the locals. With the locals
only enjoying an advisory function of administration, the structure of the city

40
41

Report of the Municipal Board of Manila (1901-1902), 8.


Laurel, Local Government in the Philippine Islands, 141.

31

government still remained a disappointment to Filipinos as they did not enjoy basic
political rights given to other municipalities despite Manilas status as prime city.
As Filipinos became more exposed to democratic processes, they criticized the
discrimination of the local political structure and the obvious pro-American tendency of
the city government. In 1905, such increase in the political consciousness among the city
people led to a review of the city charter. Those who found the political system
unfavourable appealed that the city government charter be modified in favour of a more
popular type of government.42 As provided in the Philippine Civil Government Act of
1902, in 1907, the Philippine Commission passed the Philippine Election Law which
paved way to the opening of the Philippine Assembly whose members were to be elected
by the people. In accordance with the apportionment of representation by the Act, there
should have 80 delegates, two of whom would represent the city of Manila, which was
then considered as a province within the meaning of the said Act and was intended to be
reduced from 13 districts to a division of two districts.43
While the law opened opportunities for a nationally-represented assembly, the
people of Manila did not enjoy the right to elect their local officials. This only further
reinvigorated their political clamour to effectively democratize the government of the
city. The Committee on Reorganization therefore recommended a bill for the abolition of
the Municipal Board to be replaced by a Municipal Council made up of 13 members,
42

Torres, The Americanization of Manila, 53.


Bureau of Insular Affairs, Report of the Chief of the Bureau of Insular Affairs to the Secretary
of War, 1907 (Washington, Government Printing Office, 1908), 5-6.
43

32

eight to be elected and five to be appointed by the Governor-General. The eight elected
officials were expected to represent Filipino interests while the appointive officials were
expected to represent business and foreign interests. Americans thought of the
suggestions to be too radical for it would significantly change the original charter of the
city. In the end, the bill failed to meet the approval of the Commission and was therefore
not enforced.44
After the initial bill was rejected, the Philippine Legislature sought to pass a law
to reorganize the Municipal Board. Act No. 1869 was passed on June 18, 1908 which
would abolish the advisory board which was generally controlled by Filipinos and further
provide for a less radical reorganization of the Municipal Board than the one initially
suggested. The rearranged Municipal Board was to be made up of six members, three to
be appointed by the Governor-General, two to be elected from the two assembly districts
of Manila, and the City Engineer as the ex officio member. A seventh member may be
appointed by the Governor-General to break a tie in case of a deadlock.45
As instituted by the said Act, the city was subsequently divided into two districts.
The first district was located north of the Pasig and composed of Tondo, Binondo, San
Nicolas, and Intramuros, including the transient residents of boats and cascoes by the
Pasig River. The second district was located south of the Pasig and included the districts
of Ermita, Malate, Paco, Pandacan, and Santa Ana, and territories, north of the Pasig,

44
45

Torres, The Americanization of Manila, 54.


Laurel, Local Government in the Philippine Islands, 141.

33

such as Quiapo, Sampaloc, San Miguel, and Santa Cruz.46 In the implementation of this
substitute measure after the initial recommendation was vetoed, the reorganization of the
city government was accomplished without any radical change of the Charter. This,
however, did not soften the friction between American authorities and the Filipinos
occupying government positions in the city. For the Americans, the reorganization of the
Board and the transfer of political power to the locals was a surrender of the city to
demagogues.47

B. Births and Population


After the insurrection was reported to have officially ended on September 8,
1902, the Bureau of Census carried out a census of the Philippine Islands. During the
year 1903, the census was wholly taken by Filipino officials under the direction of
General J.P. Sanger and his skilled assistants, Mr. Henry Gannett of the U.S. Geological
Survey and Mr. Victor Olmstead of the Bureau of Statistics. It was proclaimed and
published on March 27, 1905.48 In taking the census, the bureau had a difficulty in
establishing the precise number of inhabitants in Manila. The census originally taken by
the Board of Health of the city showed a population of 244,732. However, the board
raised the figures to 250,000 and later to 302,154 because of the fluctuation in the
46

Torres, The Americanization of Manila, 54-55.


Laurel, Local Government in the Philippine Islands, 141-142.
48
David P. Barrows, A Decade of American Government in the Philippines, 1903-1913 (New
York: World Book Company, 1914), 39.
47

34

population caused by the intermittent flocking of people into the city for safety when the
provinces were in a disturbed state, and returning again to their provincial homes as the
rural conditions improved. The recent official census of 1902 showed that there was a
population of 219,928 in the city. The director of the census had stated of the accuracy of
the census. The figures showed that the population of the city was made up of 185,351
Filipinos and 29,491 foreigners.49
Being near to Binondo, the commercial district of the city, Tondo, Santa Cruz,
and San Nicolas were the three most populous districts in Manila. In these districts were
the poor workers in Binondo residing because of the efficient transportation and short
travel from home to their work. Those districts which were far from Binondo recorded
the least number of inhabitants: Pandacan, Santa Ana, and Paco.50 The census returns for
the city of Manila also showed that the floating population of Manila consisted of about
15,000 people. They usually resided upon cascos, lorchas, launches, and other small
vessels plying on the river, the esteros, and the bay.51 One reason for the large number of
people living on the river and esteros was the proximity of the location of the bodies of
water to their place of work and people had no properties and lands where they could

49

Report of the Philippine Commission to the Civil Governor (1900-1903), 553.


Bureau of Census, Census of the Philippine Islands Taken under the Direction of the Philippine
Commission in the Year 1903, volume 3 (Washington: Government Printing Office, 1904), p. 230-233.
[hereafter 1903 census] See also Mactal, Kalusugang Pampubliko sa Kolonyal na Maynila, 12.
51
Philippine Commission, Fourth Annual Report of the Philippine Commission to the Bureau of
Insular Affairs, War Department, 1903 (Washington: Government Printing Office, 1904), 11.[hereafter
Fourth Annual Report of the Philippine Commission]
50

35

build on their house in the city.52 The considerable difference between the male and
female in the floating population explained that the laborers in the district of Binondo
were the residents on vessels in Manila. 53 Refer to the table below:
Table 1 - Population of Manila by district and sex (1902)
District
Total population
Male
Female
Binondo
16,657
11,706
4,951
Ermita
12,246
7,199
5,047
Intramuros
11,460
7,149
4,311
Malate
8,855
4,668
4,187
Paco
6,691
3,408
3,283
Pandacan
2,990
1,489
1,501
Quiapo
11,139
5,954
5,185
Sampaloc
18,772
9,862
8,910
San Miguel
8,834
4,944
3,890
San Nicolas
29,055
18,130
10,925
Santa Ana
3,255
1,631
1,624
Santa Cruz
35,030
20,859
14,171
Tondo
39,043
20,706
18,337
Vessels
15,871
13,954
1,917
Total (Manila)
219,898
131,659
88,239
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3
In the next reporting year of the Board of Health, from September 1, 1903 until
August 31, 1904, the total population of the city increased a little, from 219,928 to
219,941. Of this figure, 189,782 were Filipinos, 22,125 were Chinese, 4,389 were
Americans, and 3,645 were foreigners. The districts of Tondo (39,045), Santa Cruz
(35,040), and San Nicolas (29,059) still recorded the most number of inhabitants. The

52

Mactal, Kalusugang Pampubliko sa Kolonyal na Maynila, 12.


1903 census, 230-233. See also discussion in Mactal, Kalusugang Pampubliko sa Kolonyal na
Maynila, 12.
53

36

population of other districts were: Sampaloc (18,779), Binondo (16,663), Ermita


(12,226), Intramuros (11,463), Malate (8,858), San Miguel (8,838), Paco (6,725), Santa
Ana (3,255), and Pandacan (2,990). The transient residents or those inhabitants not
permanently residing in the city totalled 15,901.54
In terms of age, the largest population in Manila came from the age groups
ranging from 21 to 34 years. Another prominent observation was the very small number
of population of infants under one year and children ages one to four. 55 Refer to the table
below below:
Table 2 - Population of Manila by age and sex (1902)
Age
Total Population
Under 1 year
3,533
1-4 years
13,751
5-9 years
15,368
10-14 years
17,291
15-17 years
14,553
18-19 years
11,586
20 years
8,617
21-24 years
20,069
25-29 years
31,875
30-34 years
24,243
35-39 years
17,069
40-44 years
13,094
45-49 years
7,990
50-54 years
7,385
55-59 years
4,001
60-64 years
4,419
65-69 years
1,756
54

Male
1,738
6,688
7,686
9,705
8,374
6,935
4,827
12,793
21,033
16,231
11,615
8,289
5,027
4,003
2,299
2,197
885

Female
1,795
7,063
7,682
7,586
6,179
4,651
3,790
7,276
10,842
8,012
5,454
4,805
2,963
3,382
1,702
2,222
871

Bureau of Health, Annual Report of the Commissioner of Public Health from September 1, 1903
to August 31, 1904 (Manila: Bureau of Public Printing, 1905), 94. [hereafter Annual Report of the
Commissioner of Public Health (1903-1904)]
55
1903 census, 366-67.

37

70-74 years
1,729
760
969
75-79 years
536
219
317
80-84 years
612
210
402
85-89 years
151
56
95
90-94 years
171
51
120
95-99 years
59
19
40
100 years and over
70
19
51
Source: Source: Bureau of Census, Census of the Philippine Islands Taken under
the Direction of the Philippine Commission in the Year 1903 volume 3
In 1903, the total number of births reported in Manila was 3,387, with a rate of
15.39 per thousand on a total population of 219,941. As the Chinese population was
almost entirely composed of adult males, who intermarried largely with Filipinos, the
children of mixed blood were usually report as Filipinos. With regard to Americans and
other white population of the city, a large number of this class were generally unmarried
and composed of adult males, thus explaining the small birth rate occurring from these
classes. It was expected that as conditions had became more settled and the American
residents and officials in the city had been joined by their families and established
homes, there would be a gradual increase in the number of births occurring in the white
population. 56
In reporting the births, the Board of Health mentioned that there were
inconsistencies and inaccuracies in establishing the actual number of births. One problem
in securing reliable returns was the unwillingness of the natives to employ the services of
municipal midwives and physicians. Therefore, the health board made efforts to secure

56

Fourth Annual Report of the Philippine Commission, 72-73.

38

more reliable statistics of births by requiring all vaccinators to make report of births.
However, the efforts were unsatisfactory as the results were often incomplete. 57 In 1904,
there had been a great improvement in reporting birth rate by the information obtained
from the baptismal records of the Catholic churches, but since the organization of the
Independent Catholic Church under the leadership of Se or Gregorio Aglipay, the names
of many children did not appear upon records of the churches of Manila.58
In January of 1907, the Bureau of Health carried out a new census of Manila. It
showed a population of 223,542, as against 219,941 given by the official census in 1903.
An increase of 18% was recorded in the number of Americans, 2% increase in the
number of Filipinos, 14% increase in the number of Spaniards, and 27% in other
nationalities, while the a 15% decrease was recorded in the number of the Chinese
population.59 The sudden decrease in population of the Chinese in the city could be
accounted for by the large immigration of groups of Chinese to the provinces where the
conditions were more peaceful. There was only a few numbers of births because of the
small number of the wives of Chinese living in Manila. Furthermore, many of the
Chinese decided to settle in mainland China and the decrease of the Chinese population

57

Ibid.
Philippine Commission, Fifth Annual Report of the Philippine Commission to the Bureau of
Insular Affairs, War Department, 1904 (Washington: Government Printing Office, 1905), 85. [hereafter
Fifth Annual Report of the Philippine Commission]
59
War Department, Office of the Secretary, Eight Annual Report of the Philippine Commission to
the Secretary of War 1907 (in three parts) part 2 (Washington: Government Printing Office, 1908), 12.
[hereafter Eight Annual Report of the Philippine Commission]
58

39

in Manila could be accounted for by the operation of the Chinese exclusion law, which
prohibited the coming of the Chinese to the country. 60

C. Deaths, Mortality Rate, and Causes


According to the 1903 census, in 1902, there were 15,223 total deaths which was
equivalent of a 69.2 death rate in every 1,000 persons in Manila.61 In the past two years,
from 1900 to 1901, the death rates kept from the municipal registration since the
American occupation of the city figured to 44.5 and 42.6 per thousand respectively. It
was very overwhelming that in the next year, in 1902, the death rate ballooned to an
extreme rate. This was because the condition in 1902 was too extreme that the more
deaths were lost because of the appearance of the cholera virus which had its origin in
Manila before it propagated in other provinces.62 In the table shown below, the largest
proportion of deaths in Manila occurred in May, June, July, and August, while in the
archipelago, the most fatal months were July, August, September, and October. The
difference of the critical months of deaths was due to the fact that cholera invaded
Manila first before it affected the rest of the archipelago during the year.63
Table 3 - Deaths by percentages in Manila during different months in 1902
Manila
Archipelago
Month
(percent)
(percent)
60

Eight Annual Report of the Philippine Commission, 63-64.


Ibid., 73.
62
Ibid., 74.
63
Ibid., 78.
61

40

January
5.7
5.4
February
5.3
5.4
March
5.7
5.8
April
7.4
6.4
May
11.8
7.2
June
10.0
9.0
July
15.4
12.4
August
11.7
12.3
September
7.9
12.3
October
6.7
10.1
November
7.2
7.0
December
5.2
6.7
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3
The census returns of 1902 also showed that the number of deaths among the
males was 8,667, with a death rate of 65.8 per thousand for this sex, while the number of
deaths among the females was 6,556, with a much larger rate of 74.3 per thousand for
this sex. The proportion of deaths among the two sexes was 56.9% for males and 43.1 for
females.64 By race, the deaths of the brown people recorded 14,173. Deaths among the
yellow people numbered 746. Among the whites, the total number of deaths was 293.
Meanwhile, the comparison of the proportion of deaths of the city with the whole
archipelago revealed the excessive proportion of deaths among children five years of age
below in the city. New-born infants and very young children had the largest proportion of
deaths during the year. Deaths from the infants below five years had a 45.5 death rate. 65
Refer to the table below:

64
65

Ibid., 75.
Ibid., 76.

41

Table 4 Death rate of different age groups in Manila and Archipelago (1902)
Age group
Manila (percent)
Archipelago
(percent)
Under 5 year
45.5
33.6
5 to 19 years
9.2
21.4
20 to 39 years
24.9
20.0
40 years and over
20.4
25.0
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3
The excessive mortality rate among infants and young children subsisted as a
perennial problem in the city in the next reporting year of the Board of Health. From
1903 to 1904, out of the total deaths of 11,357, 4,901 came from the age groups of under
30 days and one month to one year. 66 Refer to the table below:
Table 5 Deaths by age including transients (1903-1904)
Age
Number
Age
Number
Under 30 days
1,213
40 years to 50 years
599
30 days to 1 year
4,901
50 years to 60 years
451
1 year to 2 years
549
60 years to70 years
306
2 years to 5 years
450
70 years to 80 years
192
5 years to 10 years
151
80 years to 90 years
96
10 years to 15 years
105
90 years to 100 years
42
15 years to 20 years
313
100 years and over
20
20 years to 25 years
442
Unknown
44
25 years to 30 years
604
Total
11,357
30 to 40 years
379
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3
During the year, the district of Ermita, where a large population of whites and
Filipinos of the better class resided, had been the healthiest district of the city only
recording a death rate of 19.22 which was about that of the most healthful modern cities
66

Annual Report of the Commissioner of Public Health (1903-1904), 94.

42

at that time. On the other hand, districts with a large Chinese population showed a much
lower death rate than those chiefly populated by the poorer class of Fiipinos. Paco, with a
death rate of 88.32, was the unhealthiest district and the board of health for the city
recommended an early investigation of the cause of high mortality in the said district.67
The district of Tondo, with a death rate of 78.14, was practically as bad as that of the
district of Paco but the board believed that the high death rate of Paco was too erroneous
and possibly had an error in the census returns. The board, instead, regarded the district
of Tondo as the unhealthiest district in Manila.68 Refer to the table below: 69
Table 6 - Deaths, by districts including transients (1903-1904)
District
Population
Deaths
Rate per 1,000
Walled City
11,468
509
44.40
Binondo
16,618
762
45.86
San Nicolas
29,059
855
29.42
Tondo
39,045
9,051
78.14
Santa Cruz
35,040
1,619
46.20
Quiapo
11,149
604
54.17
Sampaloc
18,779
1,213
64.59
San Miguel
8,838
418
47.29
Paco
6,725
528
78.51
Ermita
12,226
287
23.47
Malate
8,858
528
59.60
Pandacan
2,990
192
64.21
Santa Ana
3,255
177
54.87
Transient residents
15,901
576
36.22
Unknown
38
Total
219,941
11,357
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3
67
68

Fourth Annual Report of the Philippine Commission, 6.


Fifth Annual Report of the Philippine Commission, 6.

43

In the next reporting year, from 1904 to 1905, the original 13 districts of the city
were identified as individual health districts, except for some which were merged into
one. During the year, health district no. 1 which comprised of the lone district of Tondo
still ranked first to have the largest proportion of deaths in the city with an annual rate of
67.28 per thousand. Health district no. 2 consisted of the district of Santa Cruz was not
far behind with total deaths of 2,248, giving an annual rate of 52.23 per thousand. Health
district no. 7 which was a consolidation of the districts of Ermita, Paco and possibly San
Miguel, Santa Ana, Pandacan, and Malate, totalled 1,524 numbers of death with an
annual death rate of 54.32. The other three health districts consisting of the districts of
San Nicolas, Quaipo, and Sampaloc, and Intramuros had smaller proportion of the
number of average deaths of the city.70 Refer to the table below:
Table 7 - Deaths and Population by health districts, including transients (19041905)
Health districts
Population
Deaths
Annual rate
per 1,000
No. 1 San Nicolas
58,573
844
15.75
No. 2 Tondo
39,045
2,625
67.28
No. 3 Quiapo
18,437
860
46.51
No. 4 Santa Cruz
48,040
2,248
52.23
No. 5- Sampaloc
20,279
1,077
53.10
No. 6 Intramuros
17,463
563
31.66
No. 7 Ermita, Paco, etc.
28,054
1,524
54.32
Total and average
219,941
9,731
44.24
Source: Fifth Annual Report of the Philippine Commission, 1904

70

Ibid., 102.

44

As a commercial center where most of business activities occurred, the city of


Manila had a large population of non-residents. In 1903, there were 502 deaths occurring
among transients. As the transient population was not permanent inhabitants of the city
and did not enter into the census returns for the city, the death occurring in this class
were listed separately. A large population of this class was males of the working period
of life, thus diseases of childhood and old age and those of chronic character naturally
were not reported as causes of death among transients. The most important causes of
deaths among this population were beriberi (132), Asiatic cholera (61), pulmonary
tuberculosis (61), dysentery (23), convulsions of children (13), plague (11), and organic
disease of the heart (11).71 In 1905, deaths of transients in the city of Manila were
eliminated from the city death rate as the Board of Health found it irrelevant and
misleading for the actual death rate of the city. Manila was the hospital center for the
entire archipelago which was a fact why there was a large number of deaths coming from
transient people. Notwithstanding the practice of counting out transients in recording the
mortality rate of the city, there were still many deaths of this class recorded. From the
statistics recorded, deaths among transients were generally due to acute disease.72
In 1903, out of a total of 9,394 deaths and stillbirths occurring among residents
and transients in Manila, it was unfortunate that 4,541 or 48.3% were reported to have

71
72

Fourth Annual Report of the Philippine Commission, 72.


Sixth Annual Report of the Philippine Commission, 108.

45

occurred without medical attendance by a qualified physician.

73

One factor was the

prevailing idea that physicians were not to be disturbed during meal time, the afternoon
siesta, or at night after the hour of retirement. There was also the common trait called the
ma ana habit, which was the tendency to put off things until a more convenient time.74
On the other hand, the colonial government insisted the fault of the poorer classes in
latters disbelief of the medicines or physicians and faith of supernatural means in
relation to their diseases. To remedy the ignorance among the poorer classes, the colonial
government sought to educate the people and make them appreciate the value of modern
scientific medical practice. The government saw the importance of securing the
confidence of the people first before the poorer classes could be free of suspicions and
apprehensions in undergoing the modern medical practice. In addition, the government
also planned to disseminate information as to where the medical treatment could be
secured with cost to hose indigent who were unable to pay.75

D. Sanitation is the Key: Public Health Institutions and Programs in Manila


The site of the city, situated on Manila Bay and along the low banks of the
overflowing Pasig River, was very low and flat. At times, the city was always submerged
at high tide. The Pasig River flowed through the middle of it, and on both sides were

73

Fourth Annual Report of the Philippine Commission, 72.


Sixth Annual Report of the Philippine Commission, 108.
75
Fourth Annual Report of the Philippine Commission, 72.
74

46

esteros, or the narrow tidal canals, traversing the city and opening to the river. As the
Americans formally organized the city, they first described it as very unkempt and
impossible for habitation. There was no proper sewer system and the numerous esteros
were open, sluggish, filthy water courses. All garbage, household waste, and night soil
(human excreta) were disposed in the crudest possible manner. The city also had no safe
water for domestic use. The water supply of the city was mostly being drawn from the
Mariquina River where majority of the people used the waters from the river for every
purpose for which a water supply should not be used. This deplorable sanitary condition
of the city, as the Americans said, made it as a dwelling for disease-breeding virus and
germs.76
Concerned of the public health not only of the capital city but also of the other
islands, colonial government heavily prioritized sanitation and hygiene above anything
else. An initial step to accomplish this was to create a health board that would take
measures of cleaning the archipelago. On 1July 1901, such a board was created by Act
No. 157 and was named as the Board of Health for the Philippine Islands. It consisted of
a commissioner of a public health, a sanitary engineer who was also the city engineer of
Manila, a chief health inspector, a secretary of the board, and superintendent of
government laboratories, while the chief surgeon of the US Army in the Philippine
Islands, the chief officer of the US Marine-Hospital Service, and the president and vice

76

Charles Burke Elliott, The Philippines (Indianapolis: The Bobs-Merrill Company Publishers,
1917), 187.

47

president of the Association of Physicians and Pharmacists of the Philippine Islands were
honorary members. 77 Within 1901, a series of appointment of members of the board was
made: Lieut. Col. L. M. Maus, the deputy surgeon-general, U.S. Army, was detailed as a
commissioner of public health on July 26, 1901; Maj. Franklin A. Meacham was
appointed chief health inspector on August 9, 1901; Dr. Paul C. Freer was appointed as
superintendent of government laboratories on August 9, 1901; Dr. Manuel Gomez was
appointed secretary of the board on August 9, 1901; Capt. C.W. Mead, city engineer of
Manila, was by virtue of his position, was appointed as the sanitary engineer of the
board.78
The Insular Board of Health for the Philippine Islands had been vested with wide
powers to safeguard the public health in the provinces and municipalities. The powers
were believed to be already adequate so as to cover also the administration of the public
health of the city of Manila. Hence, the Insular Board of Health for the Philippine Islands
served also as the local health board for the city for Manila, absorbing the preceding
military public health board of the city created in 1898.79 Consequently, almost all
offices of the city government of Manila were placed under the supervision of the Insular
Board. The enactment of Act No. 22 on September 6, 1901 placed within the executive
control of the Department of the Interior, among others, the Board of Health and the
77

Department of the Interior, Report of the Secretary of the Interior to the Philippine Commission
for the year ending August 31, 1902 (Manila: Bureau of Public Printing, 1902), 6.
78
Third Annual Report of the Philippine Commission, 261-262. See also in Reports of the
Philippine Commission to the Civil Governor (1900-1903), 321-322.
79
Ibid.

48

Quarantine Service of the marine-hospital corps. The Civil Hospital in Manila and the
Board of Medical Examiners, even established before the passage of Act No. 22, were
also transferred under the jurisdiction of the Department of the Interior.80 The Philippine
Commission said that in order to insure efficiency and render impossible any clash of
authority, which might result harmfully for the public interest, the Insular Board of
Health for the Philippine Islands should also act as the local health board for the city of
Manila. With this, the Commission noted that the consolidation of public health duties in
the city to the Insular Board resulted to a more efficient work.81
At the moment the Insular Board of Health was organized, the board already
recognized a heavy burden of work rested upon them. Act No. 157 required the Board of
Health to draft and recommend to the central legislative body of the islands suitable
sanitary laws. Because of the presence of bubonic plague in Manila in 1901, the
Philippine Commission instructed that there be no lapse in the health work upon the
turning over of the city government to the civil authorities. One measure they adopted
was to transfer all the old employees of the Board of Health of Manila to the Insular
Board of Health to dispense with the time of recruiting new employees.82
While the merging of duties worked well from the start, clashes of authority
between the insular board and the municipal board did from time to time occur because
of the contradicting provisions in the Manila charter and in the laws defining the powers
80

Ibid.
Reports of the Philippine Commission to the Civil Governor (1900-1903), 176.
82
Ibid., 322.
81

49

and duties of the board of health. This lapse of authorities in Manila became a subject of
careful consideration. In 1904, Act No. 1150 was adopted which further defined the
powers and duties of the board of health for the Philippine islands and of the municipal
board of health of Manila in connection with the preservation of the public health of the
city. The new arrangement gave the Insular Board of Health to determine the sanitary
matters to be done, and the municipal board of the city had the decision to implement the
ordinances legislated by the insular board, either independently or under the general
supervision of officers of the insular board of health. Since the passage of this act, the
sanitary works had been carried on with less friction and more efficiency than before.83
In 1905, the Board of Health for the Philippine Islands was later changed into the
Bureau of Health by Act No. 1407 or the Reorganization Act. Under the said law, the
Director of Health was made as the legal successor of the Board of Health for the
Philippine Islands and of the Commissioner of Public Health. He thus assumed the
powers and duties of the former board and the Commissioner. The Director of Health
was given authority to revoke or modify any public health order, regulation, or order of a
local board of health of any municipality, except in the city of Manila. The Act also
abolished the Civil Hospitals and the Civil Sanitarium in Benguet as separate Bureaus
and merged them into the Bureau of Health as divisions. The Bureau was also charged to
supervise care for the health and sanitation of the prisoners of Bilibid Prison and other

83

Fifth Annual Report of the Philippine Commission, 12.

50

penal institutions in the archipelago.84 On April 27, 1905, on account of a failing health,
Maj. E.C. Carter retired as the commissioner of public health after assuming the duties of
the office on September 9, 1902. He was then succeeded by Dr. Victor G. Heiser, of the
U.S. Marine-Hospital Service, who made an admirable record as chief quarantine officer
of the Philippines.85
Since the Insular Board of Health acted as the health board for Manila, given this
capacity, it recommended to the Municipal Board of the city many health ordinances.
Nearly all of what the Insular Board had suggested was adopted in the city. The Insular
Board had been prescribed by law to have a general supervision over all interests of the
public health in the Philippine islands. Among any other public health concerns,
prevention and suppression of diseases, especially those of epidemic character, were
given preference by the health officials. The health board was especially tasked to
investigate the cause and means of preventing epidemic diseases including those of
domestic animals. Maj. Carter reported that the prevention of disease would give two
important results: good health and economic prosperity. Sanitation, Maj. Carter said, was
the answer to the prevention of epidemic diseases from which too much economic lives
and properties had been destroyed. He said that economy would start in the creation of a
sanitary department and promulgation of sanitary laws. The Americans were fully

84

Bureau of Health, Annual Report of the Bureau of Health for the Philippine Islands, July 1,
1905-June 30, 1906 (Manila: Bureau of Printing, 1906), 7-8. [hereafter Annual Report of the Bureau of
Health (1905-1906)]
85
Sixth Annual Report of the Philippine Commission, 4.

51

convinced that sanitation and hygiene were important vehicles in improving the
economic condition of the city of Manila.86 Maj. Carter said that:
The fact should be emphasized that in any
community, and especially in these Islands, the
governmental economy should begin elsewhere than in
the sanitary department, and improved sanitary
conditions should not be an occasion for decreased
appropriations. Improvement in health conditions is
permanent only while proper sanitary measures are being
applied... Sanitary efficiency is the key to the prosperity
of these Islands, and this to the success of their
administration; in its absence every walk in life will be
unfavourably affected and the work of every other
department of the Government will be curtailed for lack
of revenue. The interest of humanity, industry, and
commerce thus unite to bespeak of the authorities a most
liberal, financial, and moral support for the sanitary
department.87
In his annual report in 1903, Maj. Carter was disappointed that the laws for the
sanitary government of the city of Manila were incomplete, inconsistent, and irrelevant
with the present situations. The functions and powers of the board of health and its
officials were also unclear and confused by the provisions of acts 157 and 183 of the
Philippine Commission. In this regard, the Board of Health for the Philippine Islands,
being attentive of the local needs of the city, had been suggested to draft necessary
sanitary legislatures for submission to the Commission. Some of the legislations drafted
by the Board and submitted to the municipal board of Manila were an ordinance
regulating plumbing, issuance of plumbers licenses, house drainage, making of the
86
87

Annual Report of the Commissioner of Public (1903-1904), 7-8.


Ibid., 8.

52

openings in the streets, and an ordinance relating to the period of detention of smallpox
and plague cases and suspects.88
Since there was no existing law prohibiting bathing or washing of clothing in the
river and esteros, Maj. Carter, in his report, strongly recommended the establishment of
public bath houses and laundries. The Board of Health learned of the bad results of
bathing and washing clothing in the Pasig River and the esteros in time of epidemic
disease. Even when there was no epidemic disease infecting the public water in the city,
the Board suggested that the use of water still be prohibited because of it produced itch
and other ailments. To take the place of the unclean water from the river and esteros,
public baths and wash houses would be established by the municipal authorities at
convenient places with significant number of people.89 Driven by fear of contaminated
water drawn from a stream as demonstrated by the recent cholera epidemic, Maj. Carter
also urged the necessity of putting up a new water supply for the city. The need for an
immediate water supply became even more critical when the town of Mariquina was
destroyed by fire. As a result of the conflagration, four thousand homeless people
crowded among the trees on the river bank and erected temporary shelters for
themselves. As there was no sanitary facilities to control contamination of the river at
that time, cholera inevitably spread in neighboring towns. The present water supply
system was also found to be unfit for drinking purpose unless it was boiled or filtered.

88
89

Fourth Annual Report of the Philippine Commission, 14-15.


Ibid., 6-7.

53

Furthermore, the pressure of the pumping water stations was insufficient, and in many
parts of the city the water could not be drawn from the antiquated pumping stations.90
A serious sanitary problem experienced by the Board of Health in Manila was the
lack of a sewer system or of any adequate means for the disposal of human excreta or
waste. With this concern, the Board of Health, upon the direction of the Commission,
took responsibility of the disposition of the night soil (see glossary) of the city.

91

In

absence of sewer facilities in the city, the Board introduced the sanitary pail
conservancy system for the collection of night soil. The system was used until the
construction of the sanitary sewer system for the city.92 The work was partly performed
by employees of the pail conservancy system and partly by private contractors. Vaults
and latrines were emptied by employees only at night, and odourless excavators were
used for this purpose. Night soil was then disposed of by dumping it into the bay. In the
collection of night soil among the poorer class, the pail conservancy system preferred to
group the pails for a number of houses in a latrine open to the general public instead of
individual installations. In 1903, the scavenger barge, Pluto, especially constructed to
serve as a dumping boat, had been received by the system. The vessel carried 285 tons of
night soil and disposed the load at a point sufficiently distant from the shore to prevent
foul matter on the beach. Since the installation of the system, the problem of human
90

Ibid., 7.
Third Annual Report of the Philippine commission, 264.
92
Bureau of Health, Sanitary Achievements in the Philippine Islands, 1898-1915, written for the
Panama-Pacific International Exposition in San Francisco, California on February 20, 1915 to December 4,
1915.
91

54

waste had been greatly relieved.93 Furthermore, the dirty practice of the Chinese market
gardeners in Manila of sprinkling a solution of night soil over growing vegetables
prompted the Board of Health to pass Act No. 1226, which prohibited farmers and
market gardeners from using human waste as a fertilizer for crop. The law aimed to
prevent the possible spread of cholera virus in vegetables being fertilized by night soil.94
Having no sewer system around the city, the Board pushed for an installation of
adequate sewer facilities as the citys greatest sanitary need. The sewer system proper
would be, in two separate systems, for the removal of excreta and liquid waste from
houses and factories. Serving as a natural sewer system of the city, the esteros or tide
creeks would be retained and further improved. Dr. E.L Munson, assistant to the
commissioner of public health, in 1903, suggested a plan for the flushing of the esteros
during the dry season by building gates to facilitate a constant movement of water of the
Pasig River.95 It was only in 1907 when the construction of the water and sewer system
was actively initiated. The Bureau positively hoped that, upon the completion of the
construction of the system, it would eventually decrease the sanitation problem of the
city as against epidemic diseases.96 In the meantime, until the sewer system had been
constructed, the sewage was being disposed of by a system of septic tanks, which had

93

Fourth Annual Report of the Philippine Commission, 10.


Philippine Commission, Report of the Philippine Commission to the Secretary of War 1908 (in
two parts) part 2 (Washington: Government Printing Office, 1909), 85. [hereafter Reports of the Philippine
Commission to the Secretary of War (1908)]
95
Fourth Annual Report of the Philippine Commission, 9.
96
Eight Annual Report of the Philippine Commission, 21.
94

55

been very effective and helped maintain the city free from foul odor. 97 In 1910, the
sanitary sewer system had been operated and available for service. On July 1, 1910, the
number of houses connected with the sewers was 516. As a new improvement in the city,
however, many people were not in sympathy with the new system. The municipal board
therefore passed an ordinance to compel more house owners to make connections with
the sewer system.98
Maj. Carter mentioned that the Filipinos possessed many habits of cleanliness by
being fond of bathing and of the use of perfumes and cosmetics. He said, however, that
this was not a popular practice among the lower classes who were accustomed to many
unsanitary habits which were the result of their absolute lack of knowledge of the nature
and cause of diseases. A greater number of houses were not fortunate to have facilities
for heating water, thus dishes that were used at one meal were left over until the next
before any attempt was made to wash them. Among the better classes and in the homes
of many Americans, the muchachos or house helpers were even idle to wash the
dishes. The tolerance of this habitual condition was responsible for the appearance of
amoebic dysentery in the city. The Board of Health had higher hopes in eliminating these

97

Report of the Philippine Commission to the Secretary of War (1908), 67.


Philippine Commission, Report of tbe Philippine Commission to the Secretary of War 1910
(Washington: Government Printing Office, 1911), 90-91. [hereafter Report of the Philippine Commission
to the Secretary of War (1910)]
98

56

racial habits and customs through a work of education in public schools rather than upon
the direct efforts of the sanitary officials.99
To educate the natives of a proper solid waste collection, in 1903, the Department
of Streets and Parks, under the direction of the city engineer, performed the collection
and disposal of garbage. If and when the said department failed to properly conduct the
work, the sanitary inspectors of the Board of Health would take administration of the
work. Property owners were required to deposit their garbage in water-tight metal
containers. The containers, together with receptacles for other refuse, were instructed to
be set out on the streets in front of the premises for collection not earlier than 9:30 p.m.
or later than 5:00 a.m.100 The Department of street cleaning and collection and disposal
of city refuse conducted street cleaning around the city. In the meantime before modern
equipments were applied, the work was carried on principally by hand labor.101Another
dirty habit among the Filipinos was spitting in public places, prompting the board of
health to pass an ordinance, in 1905, in which spitting in public places was forbidden in
order to prevent the spread of pulmonary tuberculosis and other infectious diseases.102
The question of sanitation of the floating population living upon cascoes, lorchas,
launches, and other small vessels floating in the Pasig River and esteros were also
attended by the Board of Health. (See figure 2) This so called boat population was a

99

Fifth Annual Report of the Philippine Commission, 90.


Fourth Annual Report of the Philippine Commission, 10.
101
Sixth Annual report of the Philippine Commission, 84.
102
Ibid., 105.
100

57

subject of stricter sanitary measure because it was almost impossible to prevent the
pollution of the river and esteros by excrement and refuse of people living on water
crafts. The people living in vessels were also difficult to be restrained from using the
polluted waters for purposes of drinking, cooking, laundering, and bathing. It was feared
that if cholera occurred on board the vessels and the river became eventually infected, the
floating population were expected to suffer at a larger extent than the rest of the city
population. The Board therefore recommended installing potable water pipes to places
near the river front where the boat population could readily procure a supply of pure
water. In 1903, a launch was placed on the river and maintained by the Board to facilitate
the sanitary work over other water vessels in the river and harbor. In line of this work,
the Board of Health had been rendered of assistance by the Marine-Hospital Service and
by the sanitary inspectors of the army.103

Figure 2 Floating Vessels as Houses in Port of Manila, Entrance of Pasig River


103

104

Fourth Annual Report of the Philippine Commission, 92.


University of Michigan, Special Collections Library, Manila-Port Entrance from Pasig River
in Manila, photography, 1900, http://quod.lib.umich.edu/s/sclphilimg/x-893/*.
104

58

Meanwhile, the heavy congestion of people in populous districts, especially those


inhabited by the working class was also seen as a factor in the unsanitary condition of the
city. Aside from the natives, the Chinese especially preferred to crowd together in the
darkest, dampest, and worst ventilated buildings in the city.105 The Board explained that
the convenience of living near ones place of employment was the reason why many
workers chose to reside in already congested districts of the city. Many of the working
class could not afford of a horse and vehicle or a daily expenditure for even hiring
carriage to commute to work. It was not easy for the Board to decongest the
overpopulated districts and compel the inhabitants to find homes at a distance from their
place of work.106 This problem was answered by the installation of an electric street-car
system to control the further unsanitary overcrowding of people in populous districts.
The street-car system, extending to every portion of the city, would render the life in the
suburbs much more comfortable and enable them to be reached in a few minutes from
any part of the city.

107

However, a greater part of those who lived in overcrowded

districts were unable to patronize cars. Thus, a system of municipal tenement houses,
rented at the lowest cost, was found by the Board as the most feasible solution.108
In containing the epidemics of contagious and infectious diseases in Manila, the
Board of Health emphasized the fundamental importance of prompt and thorough

105

Fifth Annual Report of the Philippine Commission, 16.


Fourth Annual Report of the Philippine Commission, 11.
107
Ibid., 88-89.
108
Sixth Annual Report of the Philippine Commission, 83.
106

59

sanitary inspection and disinfection as the most effective and economical means of
preventing the spread. First organized on September 29, 1898, the inspection division
was restricted in its operation until 1901 when the plague epidemic destructively
appeared in Manila. With the appearance of cholera in April of 1902, the division was
enlarged by the employment of a large number of emergency inspectors estimated to be
about 7,000. In 1907, the Bureau of Health organized five sanitary districts in Manila,
conforming to the number and boundaries of the police districts. Each of the sanitary
districts was under the supervision of a district health officer and a group of inspectors,
disinfectors, and sanitary police. These sanitary districts were responsible for supervision
of household sanitation, detection of public nuisances, and removal of special causes of
disease.109 During that year, the inspection division consisted of 35 district health
officers, five of whom were on duty in Manila, 7 sanitary inspectors, six of whom were
on duty in the city, and 12 assistant sanitary inspectors, all on duty in the city. When the
Pure Food and Drugs Law was passed and the Sanitary Code called for a larger work of
sanitary inspection, the responsibilities of the inspection division was changed to include
a regular inspections of the necessary public health concerns in the city.110
Prior to the organization of sanitary districts, in 1904, there was already a division
of disinfectors, under a chief disinfector, that had been organized and was thoroughly
equipped with facilities and materials. The work of this division simply covered the

109
110

Eight Annual Report of the Philippine Commission, 83.


Ibid., 108.

60

disinfection of everything that could be a medium of conveying germs or disease such as


any premises, bed clothing, wearing apparel, and cooking utensils 111 In 1905, the number
of disinfecting squads was reduced by the last appropriation act to three. Nonetheless, the
number was still practically sufficient for the needs in the city. It was found necessary
that some of the disinfectors be sent at some distance from Manila.112 In 1907, there were
5,331 disinfections made.113 To prevent the ravage of plague as experienced in 1901, the
board of health had maintained a permanent body of rat catchers for the city. During the
seven months ending March 31, 1905, there were 113,015 rats caught. This sanitation
project was brought about by the discovery that some of the rats sent to the bureau of
government laboratories were, aside from carrying bacilli, important factors in the
propagation of several diseases in the city.114
To limit the spread of cholera and other diseases in the city, in 1903, the
Americans constructed sanitary markets for an easier inspection and maintenance of
quality of food. In this way, the sanitary inspectors would not have a difficult time to
keep in a proper state the 1,100 shops or tiendas where a large number of poor people
habitually took their meals. The sanitary conditions of these shops had been constantly
improved by the sanitary inspectors. During the cholera epidemic, the work of inspecting
food and drinks and establishment for their sale and preparation had been extremely

111

Fifth Annual Report of the Philippine Commission, 15-16.


Sixth Annual Report of the Philippine Commission, 86.
113
Eight Annual Report of the Philippine Commission, 83.
114
Sixth Annual Report of the Philippine Commission, 84.
112

61

difficult because of the insanitary habits among the lower-class Filipinos.115 The Board
of Health noticed that the poor Filipinos were unwilling to purchase an article food
without first handling it and the infection of cholera had been easily spread in this
manner. Therefore, touching of foods was disallowed, and vendors were required to
supply forks for the use of possible purchasers. Placing of proper fly screens in covering
of foods was also encouraged to keep away flies carrying cholera bacilli. The use of
some 40 articles of food was strictly prohibited. Included in the prohibited list were fruits
not of an acidic character and usually eaten raw and unpeeled, and vegetables used for
salads, molluscs, and a number of mixed foods used by Chinese and Filipinos which
were likely to carry cholera infection.116
In 1904, the number of tiendas in the city increased to about 1,200. The most
dangerous of all foods and drinks were being sold by the tienda vendors, and the sanitary
inspectors had difficulty to keep the shops in a decent state. The Board also could not
simply abolish the insanitary shops because they were a great convenience to the
working people. The new sanitary code being drafted would deal with the sanitary
considerations of the foods and drink sold by the vendors to the poorer classes.117 On
November 1, 1906, the work of market sanitation was transferred to the Department of
Sanitation and Transportation. Two markets were selected for trial measures by the
department. One was the Divisoria market in Tondo which was one of the largest
115

Ibid., 11-12.
Ibid.
117
Fifth Annual Report of the Philippine Commission, 16.
116

62

markets in the city and the other was the Quinta market in Quaipo, both were in a very
unsatisfactory condition when turned over to the department for sanitation work.118
In 1905, the Board of Health drafted a sanitary code.119 Finally, on October 20,
1906, the code was enacted, and on January 1, 1907, it officially went into effect.120
Provisions had been made for the cleansing and sanitary maintenance of buildings,
prevention of overcrowding, regulation of plumbing, house drainage, and the removal of
night soil.121 The code also made ample provisions for the sanitary maintenance of
dairies and for the inspection of dairy products. It specifically prohibited persons
suffering from infectious diseases from working in dairies or even in assisting in any
stage of the preparation of dairy products.122 The code was also too broad enough to
encompass also a chapter dealing with the prevention, reporting, and suppression of
dangerous infectious diseases, the question of water supply and sanitation of the harbour,
rivers, esteros, canals, and other waterways of Manila, and even the subject of disposal,
transfer, and exhumation of the dead.123
For a stricter compliance of all of the sanitary laws in the city, the Board of
Health had received assistance in the enforcement of the laws from the courts of Manila.
There was a belief that the sanitary laws could not be enforced against wealthy and
influential persons because of the lack of teeth in implementing the laws in the city. Such
118

Eight Annual Report of the Philippine Commission, 95.


Ibid., 80.
120
Eight Annual Report of the Philippine Commission, 85.
121
Ibid.
122
Ibid, 78.
123
Ibid, 85.
119

63

judicial support for the sanitary work of the city had been helpful for the success of the
project.124 In 1904, the courts of Manila and the city prosecuting attorney had been
zealous in their enforcement of laws and ordinances relating to sanitation. Adequate
punishment had been prescribed to offenders regardless of their social position, wealth,
or influence. This fair treatment of the law did not exist in Manila prior to American
occupation.125 In 1906, a new sanitary legislation, the Act No. 1457, was passed making
it possible to proceed against municipal officials who would not enforce health
ordinances. The passage of the said act reminded the offending officials of their duty
enjoined to them by law.126

E. Beriberi: A Growing Menace


In the report of the Philippine Commission to the U.S. President in 1900, they
observed the prevalence of beriberi in the islands, but the disease had been confined
entirely to the natives and Spaniards during their occupation. Dr. Simon Flexner and Dr.
L.F. Barker were assigned by the Philippine Commission to investigate the occurrence of
beriberi. The medical doctors had the opportunity to study the death of prisoners from
beriberi in Cavite, wherein the chief outbreak of the disease was believed to have started.

124

Fourth Annual Report of the Philippine Commission, 14.


Fifth Annual Report of the Philippine Commission, 19.
126
Philippine Commission, Seventh Annual Report of the Philippine Commission, 1906 in three
parts, part 2 (Washington, Government Printing Office, 1907), 13. [hereafter Seventh Annual Report of
the Philippine Commission]
125

64

Among roughly 1,200 prisoners, they found out 200 cases of the beriberi. The number of
deaths had been between 30 and 40.127
By studying the nature of the beriberi, medical doctors observed that the disease
appeared in several forms. One was what was known as the oedematous form in which
the persons body became swollen and dropsical. Then second, in the paralytic form, in
which the loss of power in the legs and arms was the chief symptoms. The last was the
mixed form, where both of the first two identified forms were combined. They also noted
that the most fatal form of the disease was probably the oedematous form. In this form of
beriberi, the disease ran a chronic course, last days, weeks, or even months, but rarely
acute. Being unknown to the Americans, they simply believed that the disease had to do
with the unfavourable hygienic conditions. As such, the Americans thought that the
squalor condition of the natives, under which the food was improper in kind and
insufficient in amount, was responsible for the disease. With proper food and clean
surroundings, they firmly believed that the danger of the disease would diminish.128
Another evident observation of beriberi was it attacked persons especially in the prime of

127

Philippine Commission, Report of the Philippine Commission to the President Vol.2, January
31, 1900 (Washington: Government Printing Office, 1900), 232-233. [hereafter Report of the Philippine
Commission to the President II]
128
Philippine Commission, Report of the Philippine Commission to the President Vol.1, January
31, 1900 (Washington: Government Printing Office, 1900), 160. [hereafter Reports of the Philippine
Commission to the President I]

65

life, even in their best physical condition. According to the report, persons under 40
were the ones generally attacked.129
Asked if there were already cases of beriberi in Manila, the doctors revealed
before the commissioners that there were already cases of the disease in the city. Among
the natives of the city, beriberi was very serious and constantly present. There were cases
reported in the hospitals in Manila. As the Americans expected, all cases of the disease at
San Juan Hospital were all from Manila. Despite the alarming outbreak of beriberi in the
city, the Americans announced that it was a disease that should not be feared among the
white people if conditions of hygiene were favorable.130 Inasmuch as beriberi was
recognized as prevalent, the doctors remarked that there could be errors in recording the
disease. Because of only little knowledge of the nature of the tropical disease, other
diseases which were thought of to be as beriberi were not really beriberi. From the
autopsies upon the beriberi cases in the San Juan Hospital, the doctors explained that the
lesions of the people afflicted of beriberi were not closed, which was a characteristic
peculiar to beriberi. It was suspected that all the persons were subject to tuberculosis as it
was apparently very common among the natives. The doctors believed that the
prevalence of beriberi in and around Manila had been exaggerated because of the
confounding symptoms constituting the disease. In the paralytic form, there as a great
deal of trouble in locomotion, and in the final stages of the disease, there was also
129

Ibid. See also Aretas W. Thomas, The Philippines and the Purpose (Washington D.C.: The
Jeffersonian Democrat Publishing Company), 138.
130
Ibid.

66

dropsy. It was possible that people only accounted for the manifest symptoms of beriberi
without depending on an autopsy and anatomical examinations. Since then, beriberi was
very obvious in health records with no clear pathology of the disease.131
In 1902, while the civil board of health began its work to control the ravaging
epidemics of cholera, plague, and smallpox over the whole archipelago, beriberi slowly
became a huge public health concern in Manila. In the classification of tropical diseases,
the Americans divided it into two classes: the serious or fatal and the non-serious.
Beriberi was classified as part of the first class together with Bubonic plague, cholera,
smallpox, dysentery, leprosy, and pernicious malarial fever. The second class included
typhoid fever, Malta fever, estivo-autumnal and malarial fevers, diarrhea, intestinal
parasites, dengue, and parasitical skin infections.132
According to the census for the Philippine islands in 1902, the total number of
deaths from beriberi was 5,666 or 1.3% of all deaths. The death rate from this disease
was 0.8 per thousand. The number of male victims was 3,503, being 61.8 of deaths from
this cause, and of females 2,163, being 38.2% of the total deaths from the same. 133 Refer
to the table below:
Table 8 Death rate from Beriberi by provinces (1902)
Province
Death rate
Province
Manila City
4
Leyte
Mindoro
2
Marinduque
Tayabas
2
Misamis
131

Report of the Philippine Commission to the President II, 233.


Third Annual Report of the Philippine Commission, 344-345.
133
1903 census, 56-57.
132

67

Death rate
1
1
1

La Laguna
2
Nueva Ecija
1
Ambos Camarines
2
Paragua
1
Albay
1
Paragua Sur
1
Bataan
1
Rizal
1
Batangas
1
Romblon
1
Bulacan
1
Samar
1
Capiz
1
Sorsogon
1
Cavite
1
Surigao
1
Cebu
1
Source: Bureau of Census, Census of the Philippine Islands Taken under the Direction of
the Philippine Commission in the Year 1903 volume 3
Of all the provinces, the highest death rate per thousand of beriberi was found in
the city of Manila recording a rate of 4 per thousand. Of all the deaths from this disease
in the whole archipelago, 542, or 9.6%, occurred in Manila. The census report in 1902
attributed such a high mortality rate to the fact that the disease was very much prevalent
in Bilibid Prison, which was the general place of confinement for offenders for all parts
of the archipelago. The presence of a large body of Chinese in the city was cited as
another reason by the census report for the heavy death rate of beriberi. Chinese were
discriminately believed to be especially carrying the disease in Manila.134
On one hand, the average at death of victims of beriberi was 35.2 years. This was
due to the fact that beriberi was generally a disease of maturity or among adults.
According to age groups afflicted of beriberi, the maximum death rate occurred in the
prime of life, between 20 and 40 years of age. Among children and in old age as well,

134

Ibid., 57.

68

however, the proportions of death were relatively very small.

135

Refer to the table

below:
Table 9 - Death rate by age groups (1902)
Age Group
Percent
Age Group
Percent
Under 1 year
1.0
40 to 44 years
7.8
Under 5 years
5.8
45 to 49 years
6.9
5 to 9 years
4.8
50 to 54 years
5.7
10 to 14 years
3.1
55 to 59 years
4.7
15 to 19 years
6.3
60 to 64 years
6.0
20 to 24 years
8.7
65 to 69 years
2.8
25 to 29 years
12.3
70 to 74 years
2.6
30 to 34 years
10.1
75 to 79 years
0.8
35 to 39 years
9.5
80 years and over
2.1
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3
Prior to September 1, 1903, there were 313 deaths from beriberi in the city. A
severe outbreak of this disease occurred among the prisoners confined in Bilibid Prison.
Of these 313 deaths, there were no cases of deaths among whites.136 In 1905, less beriberi
cases in public institutions and other places under government control occurred than the
previous years since the American occupation. The number of cases occurring at the
light-house stations was practically reduced to normal during the said year.137 In 1906,
the mortality from beriberi in Manila was about the same as 1905, there being 403 deaths
reported from this cause as against 378 for the previous year. From 1906-1907, there had
been a most marked reduction in the deaths from beriberi in public institutions. At
Bilibid Prison, the number of cases dropped from 21 in 1905 to nine in 1906. The Bureau
135

Ibid., 57-58.
Fourth Annual Report of the Philippine Commission, 112.
137
Seventh Annual Report of the Philippine Commission, 90.
136

69

of Health observed the consistent decrease of the spread of beriberi in jails and other
places where the inmates were under the direct control of the Bureau. The Bureau then
focused their attention only in dealing with cases of beriberi victims who were afflicted
with the disease upon their admission to prisons.138
Since the nature of beriberi was still in doubt, the health officials could not take
further steps to control the disease because of the absence of definite knowledge of the
cause of beriberi. The appearance of beriberi in public institutions in Manila left the
government dumbfounded of the real cause of the disease. Henceforth, they started
studying the pattern of the epidemics and the victims of beriberi. In other Asian
countries, beriberi was seriously studied. There were already literature about the nature
of beriberi available in other Asian countries but these were contradictory from one
another, leaving the study of the disease still unresolved. Hamilton Wright, in the
introduction to his monograph on beriberi, said:
Probably there is no disease whose etiology is so
much a matter of speculation at that of beriberi.
Certainly there is no disease whose literature when
read leaves one in so great a state of mental
confusion. Nitrogen starvation, pernicious anaemia,
infected fish and raw fish diet, arsenical, carbon
dioxide, and miasmatic intoxication, bacterial and
plasmodial infection are amongst the many direct
causes put forward to account for it. They are largely
speculative or founded on superficial or one-sided
observation. No one of them is generally accepted.
138

Bureau of Health, Annual Report of the Bureau of Health for the Philippine Islands for the
fiscal year ended June 30, 1907 (Manila: Bureau of Printing, 1907), 6. [hereafter Annual Report of the
Bureau of Health 1907]

70

Many of them may and ought to be excluded as chief


pathogenic factors.139
While completely clueless of the cause of beriberi, meanwhile, the colonial
government decided to adopt measures in improving the standard of living of the general
population to increase the vital resistance from the disease.140 The Board of Health
thought that beriberi might be infectious in nature and therefore could be disinfected. The
Americans sustained the view that in treating cases of beriberi, the conditions of living
among the natives and the Chinese population must be improved. The absence of sanitary
measures was also considered a factor in the development of beriberi. Americans
described the low, damp nipa houses (See Figure 3 below) as a good dwelling of germs
and must be replaced with dry tenement houses with living rooms high above the
ground.141 At Santiago Cholera Hospital, H.A. Lindley, the physician in charge, reported
in the month of July, 1902 that beriberi attacked the Filipino convalescent ward, three
cases occurring within 24 hours of each other. The quick spread of the beriberi in the
ward indicated that beriberi might be viral. The cases were, therefore, immediately
segregated from the other patients of the ward. Believing that beriberi could be treated
like cholera, the hospital personnel thoroughly disinfected the ward with bichloride
solution and since then, there was no further appearance of the disease.142

139

Maximilian Herzog, Studies in Beriberi, The Philippine Journal of Science 1, no. 7 (1906):

709.
140

Fourth Annual Report of the Philippine Commission, 112.


Ibid., 346.
142
Third Annual Report of the Philippine Commission, 390.
141

71

Figure 3 Street of Nipa Houses in Manila143

The behavior of beriberi in the islands confirmed the general observations


reported by physicians from all tropical countries that it was a disease of prisons,
lighthouse, and ships, of dampness and heat, of overcrowding and poverty. Dr. Heiser
also confined the beriberi epidemics only in jails and public institutions where the
disease was responsible for large number of deaths.144 Such an observation was true in
Bilibid Prison in Manila which was probably the largest and one of the cleanest in the
Philippines and yet it suffered with over 2,000 cases in 1901. Dr Loius Fales, the prison
surgeon of Bilibid Prison, believed that the cause of beriberi resided outside of the food.
The prison diets had been liberal and varied under American regime, and yet a large
143

University of Michigan, Special Collections Library, Street of nipa huts: Manila, P.I.,
photographs, 1900, http://quod.lib.umich.edu/s/sclphilimg/x901/PHLC012?lasttype=boolean;lastview=thumbnail;resnum=12;size=20;start=1;subview=detail;view=ent
ry;rgn1=ic_all;q1=phlc*.
144
Victor G. Heiser, American Sanitation in the Philippines and Its influence on the Orient,
Proceedings of the American Philosophical Society 57, no. 1 (1918): 61.

72

portion of the prisoners contracted beriberi. Dr. Fales, instead, found the removal to new,
dry, sunshiny quarters as the best means of curing prisoners suffering from beriberi. The
wards were also regularly disinfected to prevent more appearance of the disease among
the prisoners. In spite of these measures, Dr Fales reported 2,470, with 77 deaths, cases
in Bilibid Prison from January to May in 1902.145
In the report of Dr. William Moulden, the acting resident physician of Bilibid
Prison, covering the twelve-month period prior to September 1, 1903, the total number of
prisoners admitted to sick reports were 2,986. Of these cases, 2,961 were male and only
25 were female. 146 The important causes of deaths among the prisoners incarcerated in
Bilibid were presented below:
Table 10 Causes of deaths among prisoners in Bilibid Prison (1902-1903)
Diseases
Male
Female
Male
Male
Deaths
Filipino Filipino Chinese American
Amoebic Dysentery
152
17
Beriberi
1,692
10
107
Cholera asiatica

17

12

Malarial Fever

339

Plague, bubonic, and


pneumonic
Pneumonia

16

35

28

Tuberculosis

39

24

Source: Fourth Annual Report of the Philippine Commission, 1903

145
146

Third Annual Report of the Philippine Commission, 346.


Fourth Annual Report of the Philippine Commission, 177-178.

73

The report in 1903 showed that beriberi was the dominant disease among Filipino
prisoners in Bilibid prison. Beriberi recorded 1,702 sick cases, 1,692 of which were male
and only 10 were female. Of the total sick cases reported from this disease, 107 were
recorded as deaths. Dr. Moulden noted that since 1892, all of the cases of prisoners
suffering from beriberi in the penal institution were contracted previous to their
admission, possibly having acquired the disease in smaller provincial jails. Prisoners who
were afflicted of beriberi were treated in a special ward.147
Even on vessels reaching the port of Manila beriberi was apparently present. In
1906, of the actual diseases observed on vessels other than diseases quarantinable such as
cholera and smallpox, beriberi headed the list: beriberi recorded 79 cases, dysentery (22),
diphtheria (1), tuberculosis (7), typhoid fever (2), and malarial fever (24). The crew of
sailing vessels was disabled because of the epidemics of beriberi on ships. For an
instance, the entire crew of one sailing vessel, the Minerva II, was completely disabled.
The said vessel was bound from Saigon to Manila and reached the port of the city only
after several months that was ordinarily completed in eight or nine days. To prevent the
ravage of beriberi among sailors, it had been a practice of the crew to disinfect the living
quarters of all vessels on which beriberi was found on arrival.148
The case of certain diseases prevalent in the tropics was ascribed to the ignorance
of the inhabitants and their violation of sanitary laws. The Americans blamed also the

147
148

Fourth Annual Report of the Philippine Commission, 179.


Sixth Annual Report of the Philippine Commission, 218.

74

filthy surroundings of the natives and their superstitious belief of treating diseases as
divine dispensations.149 Sunlight, fresh air, cleanliness, and a nitrogenous diet were
regarded to exert a curative effect in many cases of beriberi.150 The government believed
that this improvement in the control of the disease in public institutions was solved by
disinfecting the premises in which cases occurred, providing more light and air in the
quarters, and changing the diet which contained more nitrogenous constituents such as
mangoes.151 The health division of the Philippine Commission reported that beriberi was
easily eliminated by change of ration, burning of infected buildings, and draining or
filling of damp places.152
The colonial government had a little insight of beriberi as the epidemic of the
disease that occurred in Bilibid Prison showed that the cause of the disease was greatly
favoured by a diet sufficient in nitrogen. Such insight might not be the leading factor but
was regarded as a powerful predisposing factor in treating beriberi.153 They also noticed
that with the substitution of bread for rice in the native rations beriberi had almost
disappeared.154 Dr. Fales added that a lack of fresh vegetables, rather than the small
proportion of nitrogenous food, was the cause of beriberi. From his study of the epidemic
of beriberi in Bilibid prison during his connection with that institution, Dr. Fales
explained that those prisoners who had access to the preparation of the vegetables and
149

Third Annual Report of the Philippine Commission, 345.


Fifth Annual Report of the Philippine Commission, 94.
151
Seventh Annual Report of the Philippine Commission, 90.
152
Report of the Philippine Commission to the Secretary of War 1908, 886.
153
Fourth Annual Report of the Philippine Commission, 112.
154
Fifth Annual Report of the Philippine Commission, 10.
150

75

had the opportunity to take more than their share of them had no beriberi. When the
vegetables were discontinued as a part of the ration, the mortality from beriberi became
higher. Dr. Fales also noticed that prisoners who were sent to work on the Benguet road
had beriberi because of the scarcity of vegetables in their diet. On the addition of
vegetables to the diet of the prisoners, most of them recovered.155
Dr. Maximillan Herzog investigated a number of cases of beriberi occurring in
Manila between February, 1904 and August, 1905.156 In 1906, Dr. Herzog had an
opportunity to proceed to Japan to study the large amount of beriberi material which had
been collected in that country from the soldiers suffering from the disease. When Dr.
Herzog returned in Manila, he continued his studies with the material which was
available in the country and demonstrated that the specific organism of the disease had
not yet been identified. His assumption repudiated the claims in prior studies of Okata
and Kokubo of Japan concerning beriberi, or what they called kakke, that the organism
that caused beriberi had already been isolated. The result of his studies was published in
Philippine Journal of Science.157
From his studies, Dr. Herzog concluded that beriberi was neither a nutritional
disturbance nor a simple intoxication, but was an infectious disease. He defined beriberi
as an acute, or chronic infectious disease, characterized clinically by disturbances of the

155

Report of the Philippine Commission to the Secretary of War 1908, 94.


Herzog, Studies in Beriberi, 710.
157
Bureau of Science, Fifth Annual Report of the Director of the Bureau of Science to the
Honorable Secretary of the Interior (Manila: Bureau of Printing, 1906), 12.
156

76

motion, circulation, and sensation of the body, and associated with the degeneration of
the heart, peripheral nerves, and voluntary muscles.158 He further believed that while
there was an absence of evidence or proof of the real nature of beriberi, the disease was
due to an unknown organism which entered into the human body, either directly or
through food, and there produced a toxin which gave rise to the associated symptoms of
beriberi such as disturbances of circulation, of motion, and of sensation.159
Similarly, Dr. Patrick Manson, a Scottish physician serving in China, defined
beriberi as a specific form of multiple and peripheral neuritis, a disorder of the nerves,
occurring as an epidemic in most tropical and sub-tropical climates.160 This was
supported by Dr. Fales in his observations of the symptoms of beriberi among the
prisoners in Bilibid prison. He described that there was a gradual loss of strength, the
gums became red, spongy, and swollen, and there were extensive hemorrhages into the
muscles usually of the leg. The hemorrhages would be followed by hardening of
muscles. The muscles became almost board-like in their consistency, and the patient
could barely walk.161
Dr. Herzog conducted several autopsies to find recurring symptoms of beriberi
among victims. In one case, Donoso Coronel, a native Filipino of 45 years, light-house
keeper in Manila Bay, became sick after seven days from assuming his position in the

158

Herzog, Studies in Beriberi, 710.


Ibid., 761.
160
Third Annual Report of the Philippine Commission, 346.
161
Report of the Philippine Commission to the Secretary of War (1908), 94.
159

77

light house. On admission in the Civil Hospital, the patient could not walk on account of
partial paralysis of the legs; his expression was heavy and he complained of pain in the
abdomen, lower eyelids, lower extremities, and pitting on pressure.162 Hamilton Wright
believed that the incubation period of beriberi was between 10 and 15 days, although
extreme paralysis and other more marked effects of the virus might not manifest
themselves until several days after the first demonstrable symptoms of nerve lesions had
occurred. An earliest symptom experienced by the patient affected of beriberi was
palpitation of the heart on slight exertion; next was pain in the legs which soon became
tender on pressure and later the patient had difficulty in walking. Together with the
problem of locomotion, a disturbance of sensation simultaneously developed. After those
changes had endured for some time, severe paralysis became obvious163
In 1906, the Bureau of Health had suspected another possible cause of beriberi.
Upon the appearance of beriberi, the nitrogenous constituent of the ration was
immediately increased by adding more meat and mongoes, and the amount of rice was
correspondingly reduced. This was substantiated by the results achieved by William
Fletcher at the Kuala Lumpur Lunatic Asylum in using rice which was boiled before
being husked, in which no cases of beriberi appeared among inmates who were kept on
this diet. The Bureau considered that the success of the management of beriberi had been
due to the withdrawal of a portion of the rice. During the past year, the Bureau had an

162
163

Herzog, Studies in Beriberi, 747.


Ibid., 750-751.

78

impression that beriberi was very much less common among persons who ate only
Philippine rice which was not husked until shortly before using than among persons who
ate imported Chinese or Indian rice, which had often been husked for a year or more
before being used. However, no scientific investigation had been made to prove the
observation. In the meantime, the Bureau aimed to reduce the amount of rice in the ration
in public institutions and replace it with a more varied diet.164

F. The Problem of High Infant Mortality in Manila


Beginning in the 20th century, public interest had been aroused by the shocking
high infant mortality among Filipino children of the city of Manila. A striking feature of
all reports of deaths occurring in the city was the high mortality rates of infants. The
unremarkable deaths of babies convinced the Americans during their occupation that the
environment of the city was very deadly to young children. At the start of the American
civil regime, in 1902, about four out of five of the babies in the city were believed to
have died before they even reached the age of one year.165 This estimate was proven from
the census carried out in 1903 indicating that the very high death rate among infants was
the chief factor of the total deaths of the city. Infants under one year constituted 41% of
the total deaths.166 Death rate of children under one year of age in Manila in 1902 would

164

Annual Report of the Bureau of Health (1907), 7.


Serafin Egmidio Macaraig, Social Problems (Manila: The Education Supply Co., 1929), 180.
166
Fourth Annual Report of the Philippine Commission, 6.
165

79

not fall less than an average deaths of 1,515. In fact, the actual reported deaths in this age
group in that year were 5,394, while the surviving population in this age group reported
on March 2, 1903 was only 3,532. Comparing the two records, the obvious trend
revealed that in Manila more infants under one year of age died than those who
survived.167 In the general results of the census for the Philippine Islands, Manila ranked
first in the country to have recorded the highest death rate of infants from birth until the
age of one year. The recorded deaths of 1,515 of infants below one year old were more
than twice as large as the recorded deaths of the same in some other provinces including
Laguna (600 per thousand), Sorsogon (595), Rizal (587), Marinduque (572), Tayabas
(523), Bengeut (500), Iloilo (497), Albay (494), and Batangas (469).168
Meanwhile, deaths among children under the age of five years registered a 35.3%
of the total deaths of the city in 1902. Its actual cases numbered 6,587 and showed a
death rate of 399 per thousand.169 The death rate of Manila under this age bracket still
ranked number one but was not far enough to the death rates of other provinces:
Batangas (362 per thousand), Laguna (269), Lepanto-Bontoc (222), Bataan (216), Iloilo
(216), Rizal (215), Cagayan (207), Nueva Vizcaya (200), Cavite (193), and Isabela
(190).170 Above the latter age, the death rate rapidly diminished. Deaths among children
between five and nine years numbered 559, with a death rate of 36, a little more than

167

1903 census, 77.


Ibid., 29. See also Mactal, Kalsuguang Pampubliko sa Kolonyal na Maynila, 82.
169
Ibid.
170
Ibid.. See also Mactal, Kalsuguang Pampubliko sa Kolonyal na Maynila, 82
168

80

one-half of the average death rate of the city.171 A prominent observation of all the
reports of mortality of different age groups in the Manila was that the greatest number of
deaths, the greatest proportion of all deaths, and the greatest death rate in the city were all
from infants under one year and very young children from age of one until five years.
The following year, in 1903, the very high death rate among infants was still the
same and constituted the largest proportion of the total deaths of the city. According to
the results of that year, 41.23% of the total number of deaths occurred in infants under 1
year of age.172 The Bureau of Health still recorded the same result in year that followed.
In 1904, there were 1,213 deaths of infants under 30 days of age and 4,901 of infants 30
days to 1 year of age. The total number of deaths, including transients, in the city for the
year ending August 31, 1904 was 11,357, of which 6,029 were infants under one year of
age. Deaths among young infants were therefore 53.8% of all deaths.173 From 1904 until
1908, records of death clearly reflected that young children of age of five below were the
primary victims of death in the city. In those years mentioned, infants from early birth up
to one year old stayed as the leading mortality rate among other age groups. Combining
all deaths of infants and young children from birth up to five years of age, almost 60% of
the total deaths of the city came from this age bracket.174

171

Ibid.
Fourth Annual Report of the Philippine Commission, 5.
173
Fifth Annual Report of the Philippine Commission, 5-6.
174
See full discussion in Mactal, Kalsuguang Pampubliko sa Kolonyal na Maynila, 82-83.
172

81

High mortality of children still had an enormous death rate in 1909. Of 9,307
deaths among the population of the city, 6,041, or 64.9%, were of children under five
years of age, and 4,512, or 48.8%, of the said death toll were of infants under 1 year of
age. 175 Refer to the table below:
Table 11 - Rate of infant mortality to total number of deaths (1909-1910)
Total number of deaths, all ages
9,307
Total number of deaths under 5 years
6,041
Total number of deaths under 1 year
4,542
Rate of deaths under 1 year to total number (in 48.8
percent)
Source: Annual Report of the Bureau of Health (1909-1910)
. Dr. Fernando Calderon, a professor of obstetrics in the Philippine Islands
Medical School, encouraged for a thorough investigation of the loss of lives among
infants below five years of age. In his address on the subject of Infant Mortality in the
Philippines at the 26th annual meeting of the Lake Mohonk Conference, Dr. Calderon
said:
This small population of the Philippines is not
increasing, not because of race suicide in its different forms
as in other countries, or revolution against Spain in 1896,
or war against the United States, or epidemics of cholera,
bubonic plague, etc. These causes are removed today. The
revolution and war are over. The epidemics are checked by
the excellent sanitary measures taken, and if cholera breaks
out now and then, it is controlled with a very few victims.
It is therefore necessary to search deeper for the true cause
of this nonincrease of the Philippine population. The true

175

Annual Report of the Bureau of Health (1909-1910), 60.

82

cause you will find to be the alarming mortality among


children under 5 years of age. 176
Comparing the condition of infant mortality in Manila to the rest of the provinces
of the archipelago, there was an excessive proportion of deaths among children under one
year of age, and in a lesser degree under five years of age in Manila than in the total
deaths of all provinces. Between five and nine years, the deaths were nearly one-third of
those of the archipelago at large, while in ages between 10 and 20 years the proportion
was small. In ages between the years of 20 and 40, the proportion of deaths was greater
in Manila than in the archipelago. Above the latter ages, records of death in Manila were
less numerous than in the provinces. 177 Refer to the table below:
Table 12 - Death rate by age groups in Manila and Archipelago (1902)
Percent
Age Group
Manila
Archipelago
Under 5 years
45.5
33.6
5 to 19 years
9.2
21.4
20 to 39 years
24.9
20.0
40 years and over
20.4
25.0
Source: Bureau of Census, Census of the Philippine Islands Taken under the
Direction of the Philippine Commission in the Year 1903 volume 3

For the month of June of year 1902, the deaths reported from convulsions of
children alone exceeded the combined mortality rates of Asiatic cholera, bubonic plague,
smallpox, malarial fevers, typhoid fever, and beriberi.178 Refer to the table below:
Table 13 Causes of deaths in Manila and Archipelago (1902)
176

Annual Report of the Bureau of Health (1908-1909), 43.


1903 census, 76.
178
Fourth Annual Report of the Philippine Commission, 5.
177

83

Disease

Number
of
deaths

Death
rate
for
Manila

Death
Rate for
the
Archipela
go
2.3
20.0
4.0

Proportion
total
deaths for
Manila
(percent)
24.1
22.5
6.5

Proportion
total deaths
for
Archipelago
(percent)
3.6
31.1
6.6

3,674
16.7
Convulsions
3,428
15.6
Cholera
993
4.5
Tuberculosis of
the lungs
833
3.8
0.4
5.5
Bronchitis
709
3.2
2.0
4.7
Diarrhea
413
1.9
2.0
2.7
Dysentery
378
1.7
0.2
2.5
Meningitis
320
1.5
17.0
2.1
Malarial Fever
828
3.8
1.0
5.4
Beriberi
281
1.3
0.9
1.9
Senile debility
29
2.0
Smallpox
Source: Fourth Annual Report of the Philippine Commission, 1903

0.7
3.2
3.7
0.2
26.8
1.3
0.1
3.4

From the results in 1902, the greatest numbers of deaths and the biggest
proportion of all deaths were due to convulsions, which were confined to young children.
According to the mortality report of all diseases occurring in the city, convulsions
recorded a total of 3,674 numbers of deaths. This disease among infants shared 24.1% of
the total deaths for Manila. The proportion of this cause of deaths among infants in
Manila had an inverse relationship with its proportion of deaths in the archipelago as a
whole. The report indicated that there were fewer deaths of infants from convulsions in
the archipelago as a whole than in Manila. 179 Despite the ongoing epidemic of cholera
virus in Manila in 1902, cholera was listed only second to convulsions as the cause of the
largest number of deaths of the city, whose victims were apparently recorded more in
179

1903 census, 77.

84

other provinces.180 The other listed causes of deaths for Manila had a significant
difference from convulsions and cholera: Tuberculosis of the lungs ranked third with 993
deaths, Bronchitis with 833, Diarrhea with 709, Dysentery with 413, Meningitis with
278, Malarial fever with 320, Beriberi with 828, Senile Disability with 281, and
Smallpox with only 29.181
The Board of Health for the Philippine Islands and the city of Manila for the
month of November of 1903 reported the following principal causes of mortality with the
total number of deaths from the diseases and the number of deaths occurring from the
same under the age of 12 months.182 Refer to the table below:
Table 14 Causes of Deaths among children under 12 months of age (1903)
Deaths among
Cause
Total deaths children under 12
months of age
342
312
Convulsions of children
68
0
Pulmonary tuberculosis
65
62
Acute Bronchitis
58
58
Eclampsia, nonpuerperal
41
29
Chronic Bronchitis
35
0
Beriberi
33
33
Meningitis
28
28
Congenital debility
25
8
Chronic diarrhea and enteritis
24
8
Dysentery
23
0
Asiatic Cholera
16
2
Malarial fevers
12
0
Peurperal septicimia
10
0
Cerebral hemorrhage
180

Mactal, Kalsuguang Pampubliko sa Kolonyal na Maynila, 85.


1903 census, 77.
182
Board of Public Health, Monthly Report of the Board of Health for the Philippine Islands and
City of Manila for November, 1903 (Manila: Bureau of Public Printing, 1904), 2.
181

85

8
Typhoid Fever
7
Tetanus
2
Smallpox
2
Bubonic plague
1
Leprosy
1
Diphtheria
Source: Monthly Report of the Board of Health, 1903

0
4
0
0
0
0

In the above table, a total of 404 deaths among children had not lived to complete
the first year of their lives from causes reported as convulsions of children, eclampsia,
and tenatus. Of these deaths, 158 occurred within only 30 days after birth.183 From the
mortuary report from year 1903 until 1904, convulsions among children below five years
still ranked first as the leading cause of deaths of Manila with 3,541 cases of deaths.
Within a year, the gap between convulsions and the other causes of diseases became
more distant compared from results from 1902. The other diseases that followed were
tuberculosis of the lungs (1,153), acute bronchitis (549), eclampsia (534), chronic
diarrhea and enteritis (526), chronic bronchitis (489), Asiatic cholera (423), simple
meningitis (416), congenital debility, icterus, and sclerema (379), dysentery (319), and
beriberi (318).184
From September 1, 1904 to August 31, 1905, deaths of children below five years
from convulsions did not reduce from the high number of its recorded deaths from the
report of last year. From the report of deaths with causes occurring among residents in
Manila during the reporting year, convulsions of children below five years recorded
183

Ibid.
Annual Report of the Commissioner of Public Health (1903-1904), 97-99. See also in Mactal,
Kalsuguang Pampubliko sa Kolonyal na Maynila, 85.
184

86

2,363 out of 8,925 total deaths. The margin of difference was very large compared to
tuberculosis of the lungs which ranked second with 971 deaths. The other diseases were
as follows: chronic bronchitis (403), congenital debility, icterus, and sclerema (359),
acute bronchitis (388), simple meningitis (359), dysentery (313), chronic diarrhea
entiritis of children two years and below (302), and diarrhea enteritis of children two
years and below (297).185
In the two next reporting periods of the Board of Health specifically from 1905 to
1906, and from 1907 to 1908, convulsions among young children barely moved from the
first spot as the leading cause of deaths of the city. Tuberculosis consistently ranked
second to convulsion during the three consecutive periods. The other specified diseases
had varying results over the three courses of period including acute bronchitis, congenital
debility, simple meningitis, and dysentery.186 In 1909, the Bureau of Health finally began
to undertake health investigations to determine accurately what diseases really
constituted the greatest factors in child mortality of the city. According to the statistics
for the fiscal year 1908 to 1909, it validated the facts from the previous reports that
convulsions of children 5 years and below were the principal cause of deaths of children.
Out of a total of 4,542 death cases of infants and young children, there were 1,615 cases
recorded for convulsions of infants age one year and below, while exactly 1,615 cases
185

Bureau of Health, Annual report of the Bureau of Health for the Philippine Islands period from
September 1, 1904 to August 31, 1905 (Manila: Bureau of Printing, 1906), 103-105. [hereafter Annual
Report of the Bureau of Health (1904-1905).
186
Annual Report of the Bureau of Health for the Philippine Islands (1905-1906), 65-68. See also
Mactal, Kalsuguang Pampubliko sa Kolonyal na Maynila, 86.

87

were also recorded for convulsions of young children below five years and below.

187

Refer to the table below:


Table 15 Leading causes of deaths of infants below 1 year and 5 years in Manila
Number of deaths of children under
Cause of death
1 year
5 years
1,615
1,615
Convulsions
596
596
Congenital debility
595
629
Beriberi
569
689
Acute Bronchitis
287
510
Acute Meningitis
286
745
Enteritis
594
1,257
All other causes
4,542
6,041
Total
Source: Annual Report of the Bureau of Health (1909-1910)
As a summary, some of the diseases exclusively attributed to children such as
convulsions, congenital debility, icterus and sclerema, and chronic diarrhea and enteritis
of children two years and below were undeniably the leading causes of deaths in statistics
of mortality report. Of all these infantile diseases, convulsions were the most alarming
because of the consistently high number of deaths it recorded. Even if compared from
other diseases of all ages, convulsions recorded more death cases with a considerable
margin of difference from the combined deaths of diseases which were infectious in
nature like cholera, bubonic plague, and smallpox.188

187

Bureau of Health, Annual report of the Bureau of Health for the Philippine Islands period from
July 1, 1909 to June 30, 1910 (Manila: Bureau of Printing, 1910), 60. [hereafter Annual Report of the
Bureau of Health (1909-1910)]
188
Mactal, Kalsuguang Pampubliko sa Kolonyal na Maynila, 88.

88

G. The Care of the Infants


In the early decade of colonial public health, there was no scientific basis and
research that could give light to the cause of deaths of infants. To explain the
unbelievable deaths of infants, in 1902, the municipal physicians of the city were called
upon by the Board of Health to submit a report as to the cause of such a large death rate
from convulsions among infants. Dr. Cavanna stated that a large majority of the deaths
reported from this cause were certified to by physicians who first saw the case after death
and made a diagnosis from questioning the mother or friends of the deceased infants. He
believed that many of the cases were improperly diagnosed. More often, mothers blamed
the deaths of their infants to convulsions because of the convulsive movements
manifested by the infant upon death. He believed that gastric disturbances were the prime
cause of infantile convulsions.189
On one hand, Dr. Gabriel Ageo, municipal physician of Intramuros, believed that
convulsions among infants were due to changes in atmospheric pressure and temperature,
lack of hygienic care, and deficient nutrition and general lack of development. The
municipal physician of Quiapo, Dr. Valeriano Pantojo, was of the opinion that lack of
nutrition, overcrowding, scrofula, enteritis, meningitis, and dentition were the principal
causes of infantile convulsions. Dr. Canuto Reyes, municipal physician from the health
district of Northern Tondo, added that mothers milk and food given to infants were
189

Bureau of Public Health, Monthly Report of the Board of Health for the Philippine Islands and
City of Manila, December, 1901 (Manila: Bureau of Public Printing, 1901), 2.

89

frequently bad. He also suspected that cerebral congestion was brought about by humid
surroundings and damp floors in the houses in which the family lived. Dr. Candido Mora
of Ermita and Malate further explained that many of the nipa houses where the natives
usually dwelt were built over swampy and damp places explaining the exposure of the
infants to germs. Dr. Francisco Castaneda of the district of Sampaloc and San Miguel, on
the other hand, believed that the deaths from convulsions were due to irregularity in
feeding and that the milk of the mothers was frequently affected by their habit of
drinking alcoholic beverages (bino) while nursing their babies.190
The excessive infant mortality in Manila had also been the subject of special
study by the district medical inspectors. They explained that the possible cause of high
infant mortality was the ignorance of the Filipinos in treating a new-born child after
delivery from the mothers womb. The municipal midwives of the city discovered certain
causes to the death of new-born infants which they thought could be remedied at least
when cautions of newly born infants were properly performed. First, it was found out that
improper treatment of the umbilical cord by the natives could be attributed to the large
percentage of deaths. Second, exposure of the new-born infants to atmospheric changes
without proper protection also contributed to the sudden death of infants.191 Furthermore,
Dr. Fernando Calderon believed that the overwhelmingly high rate of mortality of infants
under five years of age was due to the ignorance of the Filipina mothers as to the proper

190
191

Ibid.
Annual report of the Commissioner of Public Health (1903-1904), 136.

90

care of their babies. He added that it would be difficult to educate the Filipina mothers
because of the absence of charitable institutions in the city where mothers and girls could
apply for instruction and help in order to carry out properly their duty of raising the baby
properly.192
Although high death rate among infants was common to all tropical countries,
Americans did not only ascribe the problem to the climatic condition alone. With all the
possible reasons that could provide explanation for the enormous deaths of infants in the
city and the real cause of convulsions among children, the Bureau of Health specially
focused their attentions to two causes. From the report of the Commissioner of Public
Heath in 1904, the first cause was the extreme lack of knowledge of the proper care and
feeding of young children and the second cause was an ineffective artificial feeding when
they could not be nursed by their mothers. The Commission on Public Health exactly
said: In the Philippine Islands the primary cause seems to be due to lack of knowledge
of the proper care and feeding of young children, and to the difficulties of obtaining
suitable food in cases where it is necessary to supplement the natural food by resorting to
artificial feeding. 193
The Board of Health investigated the great mortality among children and believed
that a large percentage of the cases were ascribed to the poor methods of nursing

192

Annual Report of the Bureau of Health (1908-1909), 43.


Annual Report of the Commissioner of Public Health (1903-1904), 13.

193

91

practiced among the Filipino mothers of the lower classes.194 The common practice by
the poorer classes of allowing children to remain practically unclothed during the first
few years of life could result in chilling at night or during stormy weather. The health
officials therefore attributed the deaths of infants from the financial incapacity of the
parents to procure suitable clothing for the proper protection of the infants against
exposure during the first few months of life.195 To resolve this malpractice, the board of
health furnished cloth for wrapping the new-born infants of the poor of Manila to prevent
chilling.196 The germ-infected nursing bottle was also seen as a factor to the death of
infants. Filipinos normally washed their dished in cold water, and the nursing bottles, if
in use, were also treated in the same way if it was fortunate enough to be washed at all.
Americans also blamed the cause of intestinal disorders of infants to the ignorant classes
for using water taken from a stream or estero in which people took their bathe and
washed their cloths to dilute milk. The use of unclean cloth in dressing the umbilical cord
at the time of birth also caused infection to the child.197
In ordinary circumstances, mothers were encouraged of breastfeeding their babies
instead of bringing them up on the bottle. Mothers were reminded by the doctors to
employ breastfeeding in preference to artificial feeding whenever possible. However,
under special conditions, it became necessary and justifiable to have recourse to artificial
194

Bureau of Public Health, Monthly Report of the Board of Health for the Philippine Islands and
City of Manila for October, 1901 (Manila: Bureau of Public Printing, 1901), 2.
195
Bureau of Public Health, Monthly Report of the Board of Health for the Philippine Islands and
City of Manila for November, 1903 (Manila: Bureau of Public Printing, 1904), 2-3.
196
Fifth Annual Report of the Philippine Commission, 5.
197
Annual Report of the Commissioner of Public Health (1903-1904), 13.

92

feeding as when the mother lacked sufficient milk or because the milk was harmful, or
because the mother was afflicted with diseases that might be dangerous to the child like
syphilis, leprosy, tuberculosis, and beriberi which, under such cases, must prohibit
nursing.198 The Filipina mother was often unable to suckle her child, and as a result it
was common to see a child of a few days fed on rice or bananas as alternative foods.
There were even some extreme cases where the infants were being fed of cooked rice,
sauces, potatoes, sweets, shellfish, fruits, bits of meats, and other things which the infants
could hardly digest.199
W.E Musgrave and George F. Richmond from the Biological and Chemical
laboratories of Bureau of Science indicated several reasons for resorting to artificial
feeding by the mother. In some cases, the mother was seriously injured at childbirth and
unable to nurse immediately the infant. Artificial feeding was thought to be a better way
to feed infants due to the lack of sufficient and proper food for the mother during
puerperium and might affect the milks nutritional value to the infant. The hereditary
characteristic of a Filipino woman was considered also a reason for artificial feeding. The
average Filipino woman was poorly developed and usually had small breasts, so her
milk-giving capacity was at a minimum. These several conditions and many others

198
199

Annual Report of the Bureau of Health (1908-1909), 45.


Ibid.

93

brought about the necessity of instituting artificial food for breast milk in infant
feeding.200
In one of his reports to the President of United States, Taft mentioned the absence
of pure milk for babies as one of the most important factors responsible for the excessive
death rate among infants. For a while, fresh milk from cows received from the United
States saved lives of many infants. Unfortunately, many of the cows died and the supply
of fresh milk became very limited. Dean Worcester accounted the destruction of the
horned cattle by rinderpest for the reduction of the supply of milk in the city.201
Nevertheless, it was still almost impossible for the poorer class to purchase fresh cows
milk because of its high price. In absence of cows milk, carabaos milk was extensively
used as an infant food among the poorer people.202
The use of carabaos milk was identified however to be bad to infants and should
never be employed as foods. For the Americans, the carabaos were naturally dirty
animals and the milk that the animal produced was believed to be already infected by the
time it reached the infants stomachs. The carabaos habit of wallowing in the mud,
together with the neglect of the milkman to observe sanitary measures, were likely to
result in milk contamination by forms of bacteria other than those normally found in

200

W.F. Musgrave and George F. Richmond, Infant Feeding and its influence upon infant
mortality in the Philippine Islands, The Philippine Journal of Science 2, no. 4 (1907): 365.
201
William Howard Taft and J.M. Dickinson, Special Reports on the Philippines to the President
(Washington: Government Printing Office, 1919), 50.
202
Annual Report of the Bureau of Health (1905-1906), 14.

94

milk.203 More often than not, the poor people could not buy ice in order to preserve the
milk in a fresh state and the unpreserved milk was often fed to infants after it had become
spoiled.204 Charles L. Bliss of the Bureau of Science found out from an experiment he
conducted that carabaos milk obtained and marketed in Manila was dangerous and dirty.
Such milk was excessively contaminated and could not be fed to infants.205 As an
alternative, the Bureau of Health decided to invest a portion of its appropriated budget in
encouraging the purchase of goats as these animals were not likely to be affected by
rinderpest, and besides being less expensive to keep than cows.206
Discouraging the use of poor quality animals milk, the substitute for mothers
milk was thus confined to various imported canned milks and prepared infant foods to
meet the lack of milk supply for the country. The poor quality of most of the fresh milk
which was offered for sale in the market had been compensated by the importation of an
excellent quality of natural whole milk which could be bought for large quantities in the
Manila market. But most of the milk imported with voluminous quantities into the
country was condensed milk. In Manila, a great variety of preserved milks in enormous
quantities were imported into the city. During the year 1906, the records of the Bureau of
Customs showed that 4,041,703 pounds of condensed milk, with an approximate value of
P800, 000 and 59,809 gallons of fresh milk, with an approximate value of P147, 000
203

Jose B. Uichanco, The Methylene Blue Reduction Test: Its Efficiency and Interpretation
under Philippine Condition, The Philippine Journal of Science 57, no. 3 (1935): 300.
204
Annual Report of the Commissioner of Public Health (1903-1904), 13.
205
Musgrave and Richmond, Infant Feeding and Its Influence upon Infant Mortality in the
Philippine Islands, 371.
206
Annual Report of the Bureau of Health (1908-1909), 26.

95

were imported into the city.207 The Insular Collector of Customs furnished a statistical
table showing the constant increase of the use of imported canned milks in the country.
In 1904, $251,261 amount of money was allocated for the importation of condensed milk
while only $2,494 was spent for natural milk. Until 1910, there had been a large
importation of condensed milk into the country.208 Refer to the table below:
Table 16 Importation of Condensed and Fresh Milk into Manila (1903-1910)
Condensed
Fresh
Year
Quantity
Quantity
(in pounds)
Value
(in
Value
gallons)
1903
3,070,028
$247,366
1904
3,233,052
$251,261
8,804
$2,494
1905
3,018,376
$233,667
8,537
$3,778
1906
3,776,761
$284,495
34,879
$11,428
1907
3,646,264
$289,789
69,030
$27,435
1908
4,147,413
$349,307
81,669
$36,627
1909
4,752,733
$406,607
113,397
$47,233
1910
6,371,129
$475,882
149,656
$49,314
Source: Bureau of Health, 1914
In the market, a prevalent practice was the adding of water and any other
substance to milk. The small vendors who sold milk were the principal offenders in the
mixed milk in the market. The vendors frankly admitted that they added water, coconut
oil, rice flour, and sugar in order to cheapen it.209 One of the provisions of the provostmarshal-generals Ordnance No. 15, dated July 15, 1901, entitled, An ordinance

207

Musgrave and Richmond, Infant Feeding and its Influence upon Infant Mortality in the
Philippine Islands, 372.
208
Bureau of Health, Report of the Bureau of Health for the Philippine Islands for the fiscal year
from January 1 to December 31, 1914 (Manila: Bureau of Printing, 1915), 9.
209
Eight Annual Report of the Philippine Commission, 80.

96

regulating the manufacture and sale of food and drink, was to illegalize the bringing into
the city, or to sell or offer for sale any milk that was not fresh and wholesome, or that had
been watered, adulterated by the addition of water or other substance or removal of the
cream.210 To further ensure the quality of milk of animals being sold in public markets,
the sanitary code for the city of Manila provided that all milk dealers should register at
the Bureau of Health, and that all vessels or receptacles used by them as containers for
milk shall be made of smooth, impervious material capable of being thoroughly sterilized
by heat or other improved means, and that such container should be provided with a
suitable cover for protection against dust and should be sterilized each time before use.
The code also provided that all milk sold or offered for sale should at all times be subject
to examination and analysis by the Bureau of Health and that diseased animals used for
milk production would be condemned and destroyed.211
The ignorance and malpractice of the midwives were also regarded by the Bureau
of Health to have caused much deaths of infant. In a paper read by Dr. Calderon on The
Health of a Mother and Child, in the city, he explained many barbarous practices he
observed among ignorant mothers of which were mostly advised by unqualified and
superstitious midwives and curanderos. The remedies applied for the sick child
consisted of certain medicines made up of certain leaves, roots, salt, and other substances
which were ordinarily harmless. During childbirth, the procedure employed by the

210

Third Annual Report of the Philippine Commission, 1183.


Annual Report of the Bureau of Health (1905-1906), 15.

211

97

midwives was very dangerous such as strong and brutal application of pressure upon the
abdomen of the mother, which might cause lesions on her sexual organs and injuries to
the child inside the womb. As the baby was expelled by force, the mother obtained big
laceration of her organ, or what is worse, the womb of the woman was ruptured and both
the mother and the baby died.212 Because of the deaths of infants during birth, the health
reports showed that of the total number of deaths in Manila, approximately one-half
occurred in the absence of any treatment of a qualified physician.213
The bureau therefore acknowledged an urgent need of a large maternity hospital
for Filipino women and of a training school for Filipino nurses and midwives. In 1903,
municipal midwives were assigned as part of the personnel of the health stations under
the direction of the district medical inspectors and the municipal physicians to provide
free service for poor women of the city. The result had been satisfactory as the number of
births reported had increased to several hundred in some districts, and the number of
births actually attended by midwives had also increased. This free service rendered by
the municipal physicians served as an opportunity to study the causes leading the
excessive infant mortality in Manila.
The Bureau of Health believed that the best and most permanent results in
reducing the infant mortality could be obtained along the lines of education. In order to
curb the increase of deaths of infants, the Board of Health began a campaign of education
212

Macaraig, Social Problems, 182.


Bureau of Insular Affairs, Report of the Philippine Civil-Service Board for the year ended June
30, 1905 (Washington: Government Printing Office, 1906), 722.
213

98

against the causes which were responsible for the loss of childrens lives. In 1902, Health
Bulletin No. 3, on the Care of Infants, was prepared by a committee of physicians
appointed by the Board of Health composed of Juan Miciano, Ariston Bautista, Mariano
Martin, and Manuel Gomez. The native physicians displayed great interest in the
circulation of the guidelines to influence the native parents to properly take care of their
babies.214
The copies of the instruction for proper nursing of the infants were written in a
more understandable manner for the poorer natives to comprehend. More than 60,000
copies translated in Spanish and in Tagalog were circulated throughout the whole city to
reach the majority of families for which it was intended rather than the medical
practitioner.215 The Bureau of Health also coordinated by furnishing data to the Bureau
of Education which was used in the school system particularly in domestic science
courses.216 In 1908, the Bureau of Education established a class in the subject of infant
feeding in connection with the Meisic Intermediate School to teach the Filipina mothers
proper infant feeding for the benefit of their babies. The class was taught by a specialist
under the supervision of the Bureau of Health.217 In the domestic science department of
the Meisic Public School, mothers were invited to bring in their children, and in the

214

Annual Report of the Commissioner of Public Health (1904-1905), 145.


Ibid.
216
Annual Report of the Bureau of Health, (1908-1909), 46.
217
Ibid.
215

99

presence of the class, the subject of infant feeding was demonstrated like the value of a
balanced diet and the care of the containers of the milk.218

218

Annual Report of the Philippine Commission to the Secretary of War (1908), 93.

100

CHAPTER 3
Conquering a New Disease:
The Discovery of the Nature of Beriberi, Its Infantile Form, and the Colonial Health
Policies (1910-1918)

In the early years of American regime, beriberi was only a disease of speculation.
There had been many causes assigned for the disease, as for instance, overcrowding and
poor ventilation in ships, jails and asylums, bacteria which grew on rice and left a toxin
to the human body, and to many other causes. All of these theories were just products of
mere observations. With no medical explanation of the nature and cause of beriberi, the
colonial public health treated it with no difference to other infectious diseases like
cholera and smallpox. By 1910, the cause of beriberi had finally interested the colonial
public health. As beriberi became a popular topic of research in medical science, many
theories were presented to prove that the disease could be caused by infection,
intoxication, or nutritional deficiency.
The American colonial public health was put in a test as it conquered a relatively
new disease. All the while the Americans had thought that their sanitation measures and
policies were successful in the elimination of diseases of Manila. The campaign against
beriberi was not an easy task at all as the colonial public health was confronted with
cultural resistance from the natives. As the Americans figured out the cause of beriberi,
their policies to control the disease were deemed to be too invasive of the Filipino body.
Resistance was therefore a big hurdle on the part of the colonial public health to pacify
101

the mortality from beriberi. The campaign against beriberi experienced more challenges
as a new type of the disease was discovered. As investigations revealed that the high
mortality rate of infants was from beriberi, the colonial public health gave more efforts to
control infant mortality from the disease by finding the possible cure. This chapter
discusses the discovery, experiences, and responses of the colonial public health with
regard the true cause of beriberi and its infantile form.

A. Etiology of Beriberi
There were medical scientists who supported the view that beriberi might be
infectious in nature. C.M.E. Dubruel said that beriberi was caused by an infection
through a microorganism contained in polished rice. According to him, the germ
penetrated the human body and released a toxin which destroyed the spinal nerves and
other organs. Schubert considered that beriberi was infected by insects like malaria.219
Heinrich Botho Scheube adhered also to infection theory although the nature of the virus
was unknown. His reason was that beriberi attacked strong and well-nourished
individuals and virus would deteriorate their body immediately.220 Meanwhile, Wilhelm
John van Gorkom articulated that beriberi was an infectious disease which was caused by
a food and spread through human feces on the ground, in rooms, jails, and ships.221 In
219

C.M.E. Dubruel, Le beriberi (Paris Taffard, 1905).


Heinrich Botho Scheube, Die Beriberi-Krankheit: Eine Geographish-medicinische Studie
(Jena: Gustav Fischer, 1894).
221
Wilhel John van Gorkom, De beriber quaestie Vergiftiging of infectie? (Amsterdam: J.H. de
Bussy, 1897).
220

102

support of the infectious theory, Hamilton Wright believed that the disease was caused
by a specific bacillus. He illustrated the procedure by which the bacteria was taken into
the human body and therein caused a local injury. The organism left the body through
the feces. The whole process of infection would take seven to twenty days.222
Rejecting the belief that beriberi was epidemic and viral, J. De Haan said that no
one had ever succeeded in proving beriberi to be caused by a specific microbe and should
be classed among the infectious diseases. All kinds of experiment had already been tried
to prove the microbe origin of beriberi but all had turned unsuccessful.223 In the
experiment of Hunter and Koch, they attempted to infect animals by feeding them blood,
spleen, gastro-duodenal mucosa, brain substance and cerebro-spinal fluid from human
body diagnosed to have beriberi. Their conclusions showed that it was impossible to
convey beriberi to any of the animals.224 Henry Fraser and A.T. Stanton, from the
Institute for Medical Research in Kuala Lumpur, also performed human experiments to
demonstrate the possibility of transmission of beriberi from man to man. They tried to
infect healthy individuals from beriberi patients. The experiments turned out to be all
negative. For there was no organisms shown to be the cause of infection, Edward B.

222

Edward B. Vedder, Beriberi (New York: William Wood and Company, 1913), 130 and 137-

138.
223

J. De Haan, On The Etiology of Beriberi, Philippine Journal of Science 5, no. 1 (Manila,


Bureau of Printing, 1910): 65.
224
Vedder, Beriberi, 142.

103

Vedder of the U.S. Army Medical Corps in the Philippines dismissed the idea that
beriberi was an infectious disease.225
Aside from infection theory, intoxication had also been the basis of several
theories of the etiology of beriberi because similar forms of neuritis (nerve disorder)
were produced by alcohol, arsenic, and some other poisons and a few toxins.226 Patrick
Manson considered in his article in 1902 that beriberi was a disease contracted through
absorption of a poison which was produced by a microorganism. He said that nerve
disorder in beriberi was produced by a toxin, a product of a germ operating in some
culture located outside of the human body. Further, he held that the said toxin entered the
body neither in food nor in water, and therefore led him to conclude that it was
introduced through the skin or that it was inhaled.227
Leonard Braddon, who served as a government surgeon in the Federated Malay
States, posited his poison theory specifically to the consumption of bad rice. In his book
published in 1907, Braddon convincingly explained his rice poison hypothesis. He
articulated that beriberi attacked only those people who were rice eaters and precluded
those who did not eat rice. He added that among these rice-eaters, the incidence of
beriberi would vary with the quality of the rice they consumed. The mortality from
beriberi among these rice-eaters would again vary with the amount of poison taken from

225

Ibid., 144.
Robert R. Williams and John A. Johnston, Miscellaneous Notes and Comments on Beriberi,
Philippine Journal of Science 10, no. 5 (1915): 338.
227
Vedder, Beriberi, 106.
226

104

the rice.228 Other authors like Christiaan Eijkman, a Dutch physician, regarded the white
rice as poisonous, and the antidote was contained in the rice bran or the polishing. 229
Fraser and Stanton reported that the poison hypothesis failed to substantiate
with evidence the theory that poison existed in rice produced beriberi and that the outer
layer of the rice which was removed from it contained an antidote.230 If beriberi was
caused by a poisonous toxin in the food, Vedder said that it would be possible to extract
this toxin by chemical procedure. All attempts to perform this process were unsuccessful.
Vedder concluded in his discussion of beriberi in his book that toxin in beriberi had
never been discovered despite the earnest efforts of various scientist to find such poison
that caused the disease. No advocate of the intoxication theory of beriberi had
scientifically proven its accuracy. Vedder therefore dismissed the consideration that
beriberi was produced by toxins from eating rice.231
Since the discovery of vitamins, there had been a tendency to disregard the
hypothesis that beriberi was a simple result of intoxication. As the poison hypothesis
became more obscured, certain results from the study of rice brought attention to the
possibility of an explanation of a defect of nutrition. Recent development welcomed the
idea that beriberi might be a deficiency of vitamins. As the theory of the cause of beriberi
was narrowed to the problem of nutrition, rice was implicated to be as the food
228

Ibid., 115.
Hans Aron, Phosporus Starvation with Special Reference to Beriberi I, Philippine Journal of
Science 5, no. 1 (1910): 84.
230
Henry Fraser and A.T. Stanton, The Etiology of Beriberi, The Philippine Journal of Science
5, no. 1 (Manila, Bureau of Printing, 1910): 55-56.
231
Vedder, Beriberi, 124.
229

105

responsible for producing beriberi in humans. Having observed that the white rice as
prepared in the mills in the Philippines was associated with beriberi in 1907 and 1908,
Fraser and Stanton supported further the hypothesis that beriberi was a deficiency of
nutrition. To prove this nutritive hypothesis, the two made an experiment of adding to
white rice the substance residing in the pericarp (See Figure 4 below) which was
polished away from the rice.232 According to their study, beriberi was a disorder of
metabolism that was associated with a diet in which white rice was the principal
constituent. They firmly rooted the cause of beriberi in the milling process which made
the rice lose most of its substance essential to maintain the normal metabolism of nerve
tissues. This substance was found in the original grain and in the pericarp from the
rice.233

Figure 4 Composition of a Rice Grain

232

234

Fraser and Stanton, The Etiology of Beriberi, 58.


Ibid., 61.
234
Fortivia, Composition of a Rice Grain, photopraphy, http://www.fortivia-nature.fr/indexenglish.html (Accessed on March 29, 2014).
233

106

In order to prove that polished rice was associated with beriberi, Fraser and
Stanton in the Straits Settlement and Hans Aron of the Philippine Medical School in the
Philippines conducted made an experiment to a series of chickens. The experiment aimed
to show that same causes developed the polyneuritis gallinarum among chickens and
beriberi in humans. As demonstrated in the experiment, the chickens were placed in
cages wherein some were fed only on water and polished rice and the rest were given
only water and unpolished rice. In a few weeks, the chickens which consumed the
polished rice showed evidences of illness which proved to be polyneuritis and soon died
upon the continuous consumption of the same rice. On one hand, all of the chickens
which were fed unpolished rice remained healthy. When the experiment was reversed,
those chickens which were previously fed of polished rice began to improve upon` the
use of unpolished rice and those which were healthy became sick with the use of
polished rice.235
Fraser and Stanton tried the experiment on chickens to a large number of men.
The men were sent to the interior of the Straits Settlements to build a railroad. Just like
the experiment on chickens, one half of the men were completely subsisted on polished
rice and other half upon unpolished rice. The result consistently turned out the same as
the findings in chicken. Those who lived on polished rice became ill with beriberi, while
those who consumed unpolished rice showed no signs of the disease. To clear the doubt

235

Philippine Health Service, Beriberi and How to Prevent It, Health Bulletin No. 12 (Manila:
Bureau of Printing, 1913), 4.

107

that beriberi was conveyed by infection, the people who ate unpolished rice and showed
no symptoms of beriberi exchanged clothing and houses with those were eating the
polished rice. None of them had beriberi and remained healthy. Again, the experiment
was reversed and those who had eaten polished rice were given unpolished rice and vice
versa. Those men who were ill with beriberi because of eating polished rice recovered
rapidly upon eating unpolished rice while those who were given polished-rice diet began
to show signs of beriberi.236

B. White Rice as the Root of All Evil


Having read the contribution of Stanton and Fraser to the etiology of beriberi,
Highet Campbell, principal medical officer in Bangkok, was not very keen to the idea of
the two that rice polishing be added to the diet of those using white rice. Although
beneficial, the suggestions might not be too practical. Campbell reasoned out that unless
the rice polishing was carefully prepared, it would not be a good addition to ones diet
because rice polishing was more or less mixed of debris from the grinders, dust, and filth.
Furthermore, in a country like the Philippines where most rice was imported, supplying
rice polishing would be a challenge. The ordinary natives could not also gauge the
proportion of the polishing required to make up for the deficiency of the white rice.
Campbell thought that a better was idea was to drastically force the people who ate rice

236

Ibid., 5.

108

to use nothing but undermilled rice. Although this action would be too harsh, Campbell
urged the Government to consider this question in their legislation to control the number
of cases from beriberi.237 Before returning to Manila, Campbell carefully studied the
condition of beriberi in Siam. Similar to what had been observed in Manila, beriberi was
also prominent disease in places established for public services like hospitals, the army,
the navy, and the police. His experience in Bangkok led him to confirm the opinion
earlier expressed by Fraser and Stanton that beriberi had a connection with the
consumption of white, steam-milled rice. He summed up his observation that the large
number of cases of beriberi in Bangkok was a result of eating white rice and could be
prevented by substituting white rice by parboiled rice or hand-milled rice.238
Following the terms Fletcher used to label different types of rice in relation to
beriberi, Aron termed the rice that produced beriberi as polished and the rice that did
not produce beriberi as unpolished. There were also local names such as red rice
which referred to the harmless or the unpolished rice and white rice which pertained to
the harmful rice which had undergone the process of polishing and milling. 239 De Haan
differentiated white rice and red rice. The distinction between the two kinds of rice was
only apparent until they were husked. The grain (endosperm) in the red rice had retained
its pericarp thus giving the rice its red color. Red rice was commonly used as feed for
animals. When the pericarp was removed from the grain, the rice became clean and
237

Highet H. Campbell, Beriberi in Siam, The Philippine Journal of Science 5, no. 1 (1910):79.
Ibid., 73-75.
239
Ibid., 83.
238

109

polished, thus being called as white rice. The practice of polishing the rice was to clean it
so as to render the grain suitable for the table.240
As more studies were made about the relation of polished rice to beriberi, it was
becoming more apparent that beriberi could be prevented by the use of undermilled rice
or the addition of other articles of food to a diet. In consideration with all the new
evidences about beriberi, the theory that the disease was of dietary origin was becoming
more possible. However, many people in Manila were still doubtful of this fact. To prove
these people wrong, Richard Strong, the head of Philippine Biological Laboratory, and
Crowell, from the Department of Pathology and Medical Zoology of the University of
the Philippines, decided to perform another experiment in 1912 in Bilibid Prison to
determine definitely whether beriberi was an infectious disease or was due to a
nutritional deficiency caused by a prolonged use of polished rice as a staple article of
diet. The subjects were divided into four groups and placed in rooms separated by stone
walls. The groups ate same ration of food except with the kind of rice. From this
experiment, Strong and Crowell concluded that beriberi was produced by the continuous
consumption of white rice. In addition, the experiment also satisfied the conclusion that
beriberi was not an infectious disease.241
Same experience about eating white rice was observed in civil institutions in the
Philippine Islands. In Culion Leper Colony, Dr. Heiser stated that since the opening of

240
241

De Haan, On The Etiology of Beriberi, 66.


Vedder, Beriberi, 181-182.

110

the leper colony in 1906 rice, which was either Saigon rice No. 2 or local polished rice,
had bad become the principal diet of people. Apparently, beriberi had been continuously
present in the colony until 1910. In February 1910, all the inmates of the leper colony
were compelled to use unpolished rice.242 After the implementation of this measure in the
colony, beriberi cases completely disappeared among the inmates in 1910. Refer to the
table below:
Table 17 Total deaths and deaths from beriberi in Culion Leper Colony by
months (1910)
Before the use of unpolished rice, After the use of unpolished rice,
1909
1910
Average population of 1,537
Average population of 1,952
Month
Total deaths
Deaths from
Total Deaths
Deaths from
Beriberi
Beriberi
February
39
14
66
20
March
54
15
36
0
April
52
17
29
0
May
47
15
22
0
June
48
8
27
0
July
57
9
15
0
August
61
9
24
0
September
63
21
12
0
October
43
4
13
0
November
80
30
15
0
December
188
69
58
0
January
164
98
52
0
Total
898
309
369
20
Source: Edward Vedder, Beriberi, 172.
Major Weston Chamberlain of the U.S. Army Medical Corps in the Philippines,
in his paper, investigated the relation of polished rice with beriberi and tried to eradicate
242

Victor G. Heiser, Practical Experiences with Beriberi and Unpolished Rice in the
Philippines, Philippine Journal of Science 6, no. 3 (1911): 243.

111

the disease in among the Philippine Scouts. Prior to 1910, polished rice constituted the
ration for the Filipino scouts. On September 30, 1909, Captains Phalen and Kilbourne
recommended changes in the ration issued to the scouts. Some of the important changes
were the reduction of quantity of daily rice supplied, addition of mongo, and the
substitution of overmilled Sagon rice with undermilled Filipino No. 2 rice. The
authorities in Washington undertook the recommendations and issued an order modifying
the diet of the scouts. For many reasons, the Filipinos however were dissatisfied with the
new ration. The Filipino no. 2 rice contained many unhusked kernels and broken grain
and insects. By pursuing this change in ration, the army board observed the great
reduction in beriberi. From September to December, 1910, undermilled rice contributed
an important share in the eradication of beriberi. The change in ration of the Filipino
scouts with the eradication of beriberi indicated with certainty that the disease had
something to do with the diet and not with the sanitary condition.243
In his article in the Philippine Journal of Science, Aron presented a new view to
the etiology of beriberi. He believed that a constant lack of phosphorus in rice
contributed to the development of beriberi. He stated that with insufficient phosphorous
in the body, those tissues in the body which were rich in phosphorus rapidly degenerated.
In his study of the phosphorus content of different classes of Philippine rice sold in the
Manila market, he noted that different classes of rice consumed in the city had varying

243

Weston Chamberlain, The Eradication o Beriberi from the Philippine (Native) Scouts by
means of a Simple Change in their Dietary, The Philippine Journal of Science 6, no. 2 (1911): 135.

112

content of phosphorus depending on their milling process.244 The study showed that the
total amount of phosphorus in unpolished rice was considerably higher than in polished.
From his study of rice using animals as experiment, Aron proved that those varieties of
rice which had low content of phosphorus caused beriberi, whereas the other rice with
high content caused no signs of beriberi. The hypothesis of the lack of phosphorus
became an important factor in the etiology of beriberi.245 Refer to the table below:
Table 18 - Phosphorus Content of Different Varieties of Philippine Rice in Manila
Variety of Rice
Phosphorus content
Protein
Laguna rice,
55.7%
9%
unpolished
Laguna rice, polished
31.4%
7.87%
Macan`, from
34%
Bulacan Province,
machinery type
Macan from
45.5%
Bulacan Province,
native made, freshly
husked rice
Valenciana rice,
19.7%
highly polished
Average Manila rice
33%
Source: Philippine Journal of Science 5, no. 1 (1910)
In a separate analysis of rice sold in Manila, Saigon rice No. 2 and locally
polished rice contained less than only 40% phosphorus pentoxide, whereas unpolished or
slightly polished rice was found to contain 50 to 75% of phosphorus pentoxide.246 As a
result of experiment of Aron conducted in the Chemical Laboratory of the Bureau of

244

Aron, Phosporus Starvation with Special Reference to Beriberi: I, 85.


Ibid., 86.
246
Heiser, Practical Experiences with Beriberi and Unpolished Rice in the Philippines, 229-230.
245

113

Science in Manila, a rice was safe when it contained 45% of phosphorus pentoxide and
unsafe if it contained less than 35%. Therefore, Heiser said that for purposes of
convenience rice containing less than 40% of phosphorus pentoxide was regarded as
polished and that which contained a greater percentage of phosphorus pentoxide was
unpolished rice.247 However, Heiser made it clear that the amount of phosphorus in rice
was only used to determine the degree of polishing that given rice had undergone. The
estimation of the amount of phosphorus was only to ascertain whether much or little of
the pericarp had been removed, but the lack of phosphorous in the human body should
not be translated as a cause of beriberi. What was only proven at this point was that the
phosphorus amount of rice would indicate its degree of polishing and too much polishing
was proven to cause beriberi. 248
As more studies progress, rice became more implicated as the cause of beriberi.
As far as 1882, physicians cited the consumption of white rice as a factor in the outbreak
of epidemic of beriberi in Manila. Dr. M. Koeniger, a German resident physician in
Manila, gave a detailed account of the nature of epidemic of beriberi in the city in 1882.
He said:
From August to October, 1882, Manila was
visited by a severe cholera epidemic which found there a
fertile soil and carried off between 15,000 and 20,000
victims. (The population of Manila was estimated at
400,000) A panic occurred among the native as well as
among the European population, because cholera had not
247
248

Ibid., 232-233.
Ibid., 230.

114

been present since 1865 and the mortality was more than
75 per cent. After the epidemic had subsided, on October
20, a terrible typhoon visited the city and province, and
destroyed all the suburban houses built of light material.
As a consequence, almost the while native population of
Manila and its surroundings was without shelter. Nor was
it possible to rebuild the destroyed houses and huts,
since, following the typhoon flood occurred and all the
lower parts of the city and province were under water for
several weeks. By this time, while the cholera epidemic
was still smoldering, a new disease, which killed its
victims in a few days or weeks, was noticed among the
inhabitants. The native and Spanish physicians did not
recognize the malady and the terror of the population
increased. In some cases the disease was connected with
a swelling of the glands and it, therefore, was believed by
some to be a variety of bubonic plague.
As soon as I saw the first cases I had no doubt
that I was dealing with a particularly malignant epidemic
of beriberi, of which I had seen some cases in Japan....
The probable explanation of this epidemic of beriberi is
as follows: There was an epidemic of cholera and the
people were in terror. As a result the ceased using fresh
fruits and vegetables, and ate nothing except what could
be boiled, naturally chiefly rice. But most of these people
were eating hand-pounded or undermilled rice, and were
therefore protected from beriberi. Then came the typhoon
and the flood, which swept away houses and accumulated
supplies of rice. Thereafter the people were compelled to
purchase their rice in the open market, and many of them
bought white rice or overmilled rice. Since they were
impoverished and subsisted almost entirely upon this
rice, after the incubation period had elapsed they all
succumbed to beriberi at about the same time. Very
similar circumstances would undoubtedly explain all the
epidemics of beriberi that have occurred in the past, and
should be sought for to explain any that may occur in the
future.249

249

Vedder, Beriberi, 186-187.

115

Contrary to the fact that beriberi only began to appear in 1882, Capt. Edwin D.
Kilbourne, a member of the Philippine Tropical Disease Board, disagreed with Dr.
Koeniger that beriberi only existed among the natives in 1882. He mentioned that
beriberi had probably existed in the Philippine Islands since the very early times although
it was rarely common than it was when the Americans took over the Islands. Kilbourne
too was convinced that beriberi had a relation with polished rice. It was a requisite,
Kilbourne noted, for the study of the history of beriberi to involve the history of the
culture of the use of rice in the country. According to Kilbourne, inhabitants of the
islands used different kinds of rice being influenced by their geographical location. The
inhabitants of the interior used irrigated rice whenever practicable, and in absence of
water, they used mountain or upland rice. Those in the lower lands consumed irrigated
native rice which was commonly used for the greater part of the Islands. The inhabitants
of the coastal plain which included the city of Manila were accustomed to eat a different
kind of rice. People from these coastal plains used imported rice brought principally from
the British and French East Indies and from Siam.250
For 21 years preceding the American occupation and during the early American
occupation, there had not been enough native rice produced to supply the population of
the city of Manila. Before 1877, this lack of supply of local rice was not a problem. In
1877 onwards, the city had been tremendously importing rice from other countries. Since

250

E.D. Kilbourne, Food Salts in Relations to Beriberi, Philippine Journal of Science 5, no. 1
(1910): 127-128.

116

the American occupation, the city was not producing local rice and became too much
dependent on imported rice.251 It was also important to note that rice imported was
entirely white rice or had been completely milled. The sudden increase of imported rice
into the city was believed to have a direct effect to the growing number of beriberi cases
since the American occupation. Refer to the table below:
Table 19- Imports and Exports of Rice into Manila, in kilos (1859-1908)
Year
Imported
Exported
Year
Imported
Exported
None
Not known 1884
108,431,626
1,609
1851-1857
1,393,040
772,920
42,440,640
749
1858
1885
746,460
820,440
61,798,722
18,585
1859
1886
1,758,240
6,313,428
79,987,973
32,337
1860
1887
16,218
2,443,500
82,445,441
374
1861
1888
Not known
Not known 1889
85,417,158
905
1862-1863
1,046,100
20,396,300 1890
71,166,714
13,426
1864
253,257
21,396,300
72,664,363
None
1865
1891
4,788
6,000,054
62,709,137
254
1866
1892
480,804
2,306,696
41,000,503
62,492
1867
1893
Not known
Not known 1894
44,870,685
1,513,658
1868-1872
7,311,002
13,278
Not known
Not known
1873
1895-1897
10,811,589
101,371,178 1898-1899
55,817,073
None
1874
2,910,847
1,594,855
110,141,537
None
1875
1899-1900
239,589
3,571,931
178,605,867
None
1876
1900-1901
23,005,946
86,800
216,812,362
None
1877
1901-1902
23,670,099
265,285
307,835,856
None
1878
1902-1903
58,818,165
89,848
330,518,006
None
1879
1903-1904
13,555,647
366,241
256,037,430
None
1880
1904-1905
5,558,047
203,077
138,341,469
None
1881
1905-1906
8,971,305
840
112,985,635
None
1882
1906-1907
54,414,683
50,361
162,515,826
None
1883
1907-1908
Source: Philippine Journal of Science 5, no.1 (1910)

251

Ibid., 128.

117

The various sources of rice imported since the American occupation were given
in the records compiled by the Bureau of Customs. In the annual records of the rice
imported in the country, most of the supply of the imported rice originated from French
and British East Indies. Rice from the French East Indies significantly had the highest
number of imported rice in Manila. Beginning in 1901, the city imported rice from Siam.
From 1904 to 1906, the rice from Siam was categorized under rice coming from Other
Asia.

252

Among the numerous commercial varieties of white rice, Stanton and Fraser

considered the Siam rice to have stronger beriberi-producing effect than any other rice
the country imported from Asia. It was shown that the pericarp of the Siam rice had been
almost completely polished away.253 Refer to the table below:
Table 20 - Sources of Imported Rice in Manila, in kilos (1899-1908)
Year

Spain

Japan

Dutch
East
Indies
-

French
East Indies

Siam

Other Asia

5,727

British
East
Indies
3,172,052

1899

859,272

6,774,902

1900

6,619

129

5,589,964

149,999,369

1901

136,405

147

4,624,958

7,500

161,647,368

12,188,900

1902

16,713

85,421

22,819,860

1,919

179,719,833

13,414,080

700,780

1903

42,040

8,258

27,687,089

262,930,276

16,481,171

630,354

1904

30,859

38,443,895

29,547

264,317,216

26,519,980

1905

19,381

7,287

18,432,723

198,35

208,772,632

28,606,778

1906

25,872

9,837

8,412,494

1,376

120,312,056

9,988,451

252
253

Ibid.
Fraser and Stanton, The Etiology of Beriberi, 57-58.

118

1907

17,901

11,616

971,600

106,673,410

5,311,105

1908

35,773

31,398

1,209,207

2,739

152,799,236

8,427,425

Source: Philippine Journal of Science 5, no.1 (1910)

To explain the appearance of beriberi from the consumption of polished rice,


Aron believed that the cause of the disease was rooted in the processes of producing the
polished rice. The most probable explanation to the connection of rice with beriberi was
in its preparation such as milling, sterilizing the food, and other processes. This
assumption directly contradicted the earlier theories which blamed the white rice to have
inherent element to produce beriberi.254 How the rice was prepared became a primary
question by many medical scientists in order to understand the cause of beriberi from
eating rice. Aron gave a short description of the preparation of rice for consumption:
At first, the rice husk must be removed from the
grain (in Spanish and native dialect, palay). This husk (ipa) is
never eaten. The grain (pinaoa) as it now appears when the
husk was broken and thrown away is surrounded by a second,
thinner skin of a more or less red or brownish color, which
does not render the appearance of the rice very appetizing.
This second skin can also be cleaned off by a process of
milling between rotating stones which removes it, together
with the outside layer of the rice grain; and after this process
of milling or polishing, the grain is white and clean and now
has the form which the European usually knows as rice. The
first rice, which still contains the second skin is that which
usually does not cause beriberi; while the grain which is
deprived of this skin by the process of polishing must be
regarded as quite liable to produce the disease. There are
different degrees of polishing, for we find on the market rice
254

Aron, Phosporus Starvation with Special Reference to Beriberi: I, 84.

119

which is only slightly polished and grain which has been very
highly treated. There are, in addition, certain processes,
usually practiced in India and elsewhere (parboiling) which
seem to prevent the thorough removal of the outer parts of the
rice, but I am unable to judge of them, since they are not in
use in these Islands. The native rice prepared by hand is
pounded in a large mortar (Tagalog, lusong), and even if
milled by a hand mill is never deprived of its outer layers to
as great extent as that milled by large machinery.255
As regards the preparation of rice, there were three most common procedures
before rice was ready for consumption: first was that grown at home and pounded out by
hand in large wooden mortars, second was that grown at home and submitted to milling
of varying degrees of thoroughness, and the last was the imported rice that had been
milled and polished abroad. Kilbourne had an assumption that those rice that were
husked at home using hand pounding did not contribute to the appearance of beriberi and
was true enough because of the absence of the disease in rural areas where such
procedure of preparing the rice was applied. At Taytay in Rizal Province, a small town
about 15 miles from Manila, beriberi was not common because the rice being sold in the
tiendas there were all of the home-grown qualities and incompletely milled. This was
different in the coast towns like Manila and those towns which were along the lines of
the railroad system where polished rice was extensively eaten. Beriberi was proven to be
found only in places principally along the coasts or rivers where polished rice was
used.256

255
256

Ibid., 82.
Kilbourne, Food Salts in Relations to Beriberi,129.

120

All observers of the cure of beriberi agreed that people who had a diet that was
not based almost entirely on white rice but diversified with sufficient amount of fresh
meat, fresh vegetables, and special kinds of beans had a high resistance from the disease.
Having a diversified diet was proved to be the best cure for beriberi. 257 Stanton and
Fraser showed in their study that the disease polyneuritis gallinarum in chickens was
similar to beriberi in man as they observed the etiology, clinical manifestations, and
pathological effects of rice to both diseases.258 When the diet consisted of rice alone, the
question was whether the rice was polished or not. According Aron, it was wrong to say
that those who subscribed entirely to rice were more vulnerable to contract beriberi than
were others. Citing the study of Eykman, Aron mentioned that it was not the rice which
must be regarded as the cause of beriberi, but that certain kinds of rice and how it was
prepared were the cause of the disease.259 As remarked by Stanton and Fraser, the root
of the evil lies in the milling process itself.260

C. Colonial Responses against Beriberi

From March 5 to 14 in 1910, the first biennial meeting of the Far Eastern
Association of Tropical Medicine was held in the cities of Manila and Baguio. Many far
eastern countries sent their delegates to the meeting including Japan, China, Hongkong,

257

Ibid., 82.
Fraser and Stanton, The Etiology of Beriberi, 57.
259
Aron, Phosporus Starvation with Special Reference to Beriberi: I, 81.
260
Campbell, Beriberi in Siam, 78.
258

121

Strait Settlements, India, Siam, Ceylon, Federated Malay States, German New Guinea,
Tsingtau, and the Netherlands East Indies. The Philippine government provided for the
entertainment of the delegates during their stay in the islands. At the meeting, medical
men read some of the important study papers about tropical diseases, and men designated
to do sanitary work in their respective countries were afforded an opportunity to compare
methods and results in combating tropical diseases. In a session on March 11, an
important paper presented at the meeting was about the recent discovery of the cause of
beriberi. At the end of the session held in on March 14, 1910, the Philippine Congress
passed a resolution dealing with the problem of beriberi.261 The immediate legal action
was a response to the discovery of the Association regarding the possible cause of
beriberi. In the session, the Association produced sufficient evidence to show that
beriberi had a direct connection with the continuous consumption of white rice. In
support of this matter, the Association called international action with the view to
devising ways and means by which the ravages of beriberi might be prevented.262
Recent work of Fraser and Stanton in the Straits Settlements and that of Aron of
the Philippine Medical School showed that outbreaks of beriberi could be caused by the
continuous consumption of polished rice. This was probably due to the fact that much of
the phosphorus reposed in the pericarp was polished away in the milling process and

261

Reports of the Philippine Commission to the Secretary of War (1910), 93.


Bureau of Health, Annual Report of the Bureau of Health for the Philippine Islands from July
1, 1909 to June 30, 1910 (Manila: Bureau of Public Printing, 1910), 45. [hereafter Annual Report of the
Bureau of Health, (1909-1910)]
262

122

thus people who ate this type of rice were deprived of a requisite amount of this element.
An experiment in Manila confirmed that those who consumed polished rice developed
beriberi and only recovered from the disease by eating rice polishing during treatment
except when the disease was too far advanced. The foregoing discovery of the treatment
of beriberi was presented by Heiser to Thomas Cary Welch, the acting Executive
Secretary, with a recommendation to Governor-General William Cameron Forbes to
issue an executive order prohibiting the use of polished rice as a staple article of diet in
government institutions. On May 4, 1910, Governor-General Forbes immediately acted
upon the recommendation by issuing Executive Order No. 37. As quoted from the
executive order, the law thus ordered that:263
... upon the recommendation of the Director of Health and
the honourable the Secretary of the Interior the use of
polished rice in all public institutions is hereby forbidden. All
Insular, provincial, and municipal physicians having control
of public institutions, such as workshops, prisons, and so
forth, are hereby to see that the provisions of this executive
order are complied with in the institutions under their
control.
The Bureau of Science conducted an extensive series of experiments at Bilibid
Prison in 1912 to know the different influence of various diets on beriberi. Since rice was
believed to be the direct cause of the disease, the Bureau of Science experimented with

263

Ibid., 69-70.

123

different varieties of rice as the chief component of these diets. 264 The next year, in 1913,
the extensive experiments made by the Bureau supported the earlier belief that beriberi
was a disease of nutrition and not an infection as believed by many when it first called
the attention of health officials. They also demonstrated the white or decorticated rice, a
staple article of diet of Filipinos, was the chief cause of the spread of beriberi in the
country. The findings turned out to be very significant and from this the Bureau
recommended to the Government that the use of unpolished rice in all government
institutions would help eradicate the spread of the disease.265
The fruitful research made by the Bureau of Science had been practically used by
the Bureau of Health in controlling the spread of beriberi. . For many years, beriberi had
defied all efforts of possible treatment using the advantages of modern science. The
colonial government only discovered later that the remedy was just as simple as a proper
diet or merely the use of unpolished rice. A campaign of education was then begun. To
prove that rice could be polished in a way that was not harmful, Dr. Aron personally
visited the rice mills to demonstrate to them the safe way of cleaning the husks of rice.266
It was also proven that rice which was hulled by hand in the Philippines was practically

264

Bureau of Science, Eleventh Annual Report of the Bureau of Science to the Honorable the
Secretary of the Interior for the year ending August 1, 1912 (Manila: Bureau of Printing, 1913), 8.
[hereafter Eleventh Annual Report of the Bureau of Science]
265
Bureau of Science, Twelfth Annual Report of the Bureau of Science to the Honorable the
Secretary of the Interior for the year ending June 30, 1913 (Manila: Bureau of Printing, 1913), 21.
266
Heiser, Practical Experiences with Beriberi and Unpolished Rice in the Philippines, 232.

124

always a safe rice to use. It was only the machine-milled rice of extreme whiteness that
was dangerous when used as a staple article of diet.267
The Bureau of Health spent publicity works to engage the public in preventing
beriberi epidemics by preparing more health literature for public distribution. A pamphlet
was published containing information of the fact that beriberi occurred among those who
used polished rice as a staple article of diet.268 The Health Bulletin Vol. 1, No. 12 (See
Appendix A) of the Philippine Health Service (PHS) in 1913 was published for the
people to be informed of the prevention of beriberi.269 The Health Bulletin No. 12 aimed
to bring awareness to the harmful effect of polishing the rice. The health bulletin
explained upon the investigation of rice grain that the chemistry of the outside of the rice
grain differed from that of the inside. There were essential elements that were only found
in the outer layer of the rice grain that were absent in its inner part. These essential
elements of the pericarp or the outer coat were important in order that rice could supply
the proper nourishment for the human body. If the hull or the pericarp was polished
away, it would be apparent that the persons who principally subscribed to rice as the
staple article of diet were being deprived of an essential substance which might
subsequently lead to beriberi. This practical knowledge was being imparted to the people
through the circulation of the health bulletin about the prevention of beriberi.
267

Philippine Health Service, Beriberi and How to Prevent It, 8.


Bureau of Health, Annual Report of the Bureau o f Health for the Philippine Islands for the
fiscal year July 1, 1912 to June 30, 1913 (Manila: Bureau of Printing, 1913), 10. [hereafter Annual Report
of the Bureau of Health (1912-1913)]
269
, Philippine Health Service, Beriberi and How to Prevent It, 7-8.
268

125

Furthermore, the same substance in the outer layer of the rice grain was also present in
other foods like beans, mongoes, and yeast. It was therefore advised that people should
practice eating diversified diet other than eating only polished rice.270
As the colonial government recognized beriberi as disease connected with the
lack of nutrition in the ordinary diet of the Filipino, especially in the form of rice, they
focused their programs through educational propaganda knowing that ordinary sanitary
measures were not a direct answer to the disease and therefore beyond the immediate
control of health officers. The PHS believed that the lack of nutrients in rice can be
compensated with both fats and proteins from other foods. In consideration of this idea,
the PHS made a campaign for home gardens in which leguminous vegetables were to
occupy a principal place.271 Aside from encouraging each family to maintain a kitchen
garden, the PHS also forwarded the idea of farming a small area as a community
garden.272 This measure, however, only resulted to a decrease in the percentage of deaths
from beriberi among adults which improved their physiological condition and made them
less vulnerable to the disease.273

270

Ibid., 5-6.
Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1916 (Manila: Bureau of Printing, 1917), 100. [hereafter PHS 1916]
272
Ibid., 110.
273
Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1917 (Manila: Bureau of Printing, 1918), 101. [hereafter PHS 1917]
271

126

The Bureau of Science had a proactive approach in treating people with beriberi.
As long as the ignorant274 people continued to eat polished rice as a staple diet even
despite the encouragement to use unpolished rice, the Bureau of Science would have to
direct their efforts to maintaining the rice at a standard sufficient for the physiological
requirements of the humans body.275 However, the application of this knowledge was
not a simple task to implement at all. That was the experience of the Bureau of Health in
their attempt to regulate the peoples diet. For the Filipinos, the administration of their
diet was a further colonization of their lives. On the part of the government, this
resistance from the people was just sheer ignorance. For instance, in government
institutions, when unpolished rice was furnished, ignorant Filipinos perceived that the
Government was attempting to substitute a cheap form of rice for the polished rice.
Thinking that this berated their dignity, Filipinos staunchly refused to eat it.276
Much opposition had resulted from the attempt of the government to introduce
unpolished rice to people. When the Army and the Insular Government tried to enter the
market to purchase large quantities of rice so that they could sell it unpolished, the rice
dealers were unable to supply them because the managers of rice mills refused to adjust
their process of manufacture. Because of this, large quantities of rice still came from the
mills which were already husked. Commissary officers, prison wardens, and others who

274

The descriptive words ignorant and intelligent in this chapter are being quoted verbatim
from its original text. See Appendix A, Beriberi and How to Prevent It, 7-8.
275
Review, Philippine Journal of Science 5, no. 1 (1910): 142.
276
Philippine Health Service, Beriberi and How to Prevent It, 7-8.

127

directed to implement the order received complaints among those people who were
required to eat unpolished rice because the rice was not very clean and contained many
husks. The people who were compelled to eat unpolished rice alleged that the husks
tickled their throats and often caused gastritis. For economic reasons, managers of rice
mills complained that unpolished rice, when stored in bulk, was easily spoiled although
investigation regarding this matter proved there was no truth to this rumor.277
To help the ignorant Filipinos realize the value of eating unpolished rice, the
government sought the assistance of the intelligent persons in the dissemination of the
knowledge that beriberi could be prevented by consuming unpolished rice. Many people
thought that white rice was more appetizing than the unpolished rice, which was
naturally darker. There were still those who objectively attested to the greater taste of the
unpolished rice than the white rice. The ignorant Filipinos were only accustomed to
eating white rice so the Government encouraged those people who had come to
knowledge of the taste of the unpolished rice to influence other people who still preferred
eating white rice. Even those whose diet was diversified to keep them from beriberi were
encouraged to join the movement by using unpolished rice in order to set an example to
those who were not capable to have a proper diet.278
Finding it hard to change the peoples diet through information and persuasion,
the Government decided to find a more forceful means to make people eat unpolished

277
278

Heiser, Practical Experiences with Beriberi and Unpolished Rice in the Philippines, 232.
Philippine Health Service, Beriberi and How to Prevent It, 8.

128

rice. The Government thought of imposing a tax of four centavos a kilo of polished rice
and making unpolished rice duty free. This measure would accomplish the purpose by
making white rice too expensive for the mass market, and that the sale of this kind of rice
was limited to the rich, who could prevent themselves from beriberi by a diversified
diet.279 Finally, in 1911, after considerable discussion with Heiser and physicians,
lawyers, and legislators, a bill was introduced in the Philippine Assembly imposing a tax
of five centavos per kilo on all polished rice sold.280 Commissioner Worcester made the
following statement regarding report of the Committee on Finance about the imposition
of tax:
The report of the committee states that the great
majority of the Filipinos eat polished rice and that the tax
would therefore eat polished rice and that the tax would
therefore fall heavily upon the masses. If this statement be
true, then the great majority of the people are eating a
dangerous food and the necessity for remedying the
existing condition is imperative. The object of the bill is to
create conditions such that great majority of the people will
eat unpolished rice. If its object is achieved, this majority
would then not pay a tax and there would be no burden on
the masses whatever.281
Vedder stated that the imposition of taxes appeared to be more practical than the
gradual education of the people about the benefits of the use of unpolished rice. He
articulated that oriental habits and ways of thinking of the people who were eaters of rice
279

Ibid., .8.
Vedder, Beriberi, 318.
281
Philippine Legislature, Journal of the Philippine Commission being the first session October
16, 1912 to February 3, 1913 and special session February 3, 1913 to February 11, 1913 of the Third
Philippine Legislature (Manila: Bureau of Printing, 1913), 438.
280

129

would take at least a generation to be changed. Educational propaganda was therefore an


impractical consideration. The Government was left with a choice to levy upon the riceeaters the burden of taxation. However, the people raised objection to the tax contending
that it would be difficult to enforce among rice mill dealers. Such tax would also derange
commerce in the country considering that most of the rice imported and traded into the
Islands was polished rice. More especially, the Philippines was under a shortage of local
rice and none of the exporting countries were producing undermilled rice. The tax on rice
was also feared to cause native discontent.282

D. Discovery of Infantile Beriberi


By the end of 1909, the Bureau of Health attempted to confirm, by necropsy, the
clinical diagnoses appearing upon the death certificates of infants in Manila. The results
were published in a paper under the title, Studies in Infant Mortality, written by Dr.
Allan J. McLaughlin, Assistant Director of Health, and Dr. Vernon L. Andrews, assistant
professor of pathology at Philippine Medical School, in July, 1910 and was presented at
the first biennial meeting of the Far Eastern Association of Tropical Medicine held in
Manila in March, 1910.283 In the study, the doctors examined carefully important
diseases that constituted the greatest factors in infant mortality. Unsatisfied with the
statistics of deaths of infants, the doctors expressed that there could probably large
282
283

Vedder, Beriberi, 319-320.


Vernon L. Andrews, Infantile Beriberi, The Philippine Journal of Science 7, no. 2 (1912):

69.

130

discrepancies in the clinical findings of most of the diseases of infants recorded in their
death certificates. Many questions were raised as to the truthfulness of the death statistics
and the causes of deaths entered in most cases of infant deaths. With this, the Bureau
started investigations by necropsies of bodies dying of infant diseases to check the
obscure causes of deaths of infants of Manila.284
Despite the Bureaus positive goal of validating the diagnosis of infant death,
several practitioners objected to the autopsies on the ground that it was an affront to their
diagnostic ability. They filed an elaborate protest with the government and caused delay
with the ongoing investigations of the Bureau with respect to the autopsies. To reconcile
the desire of the Bureau to finish the investigation and the protest of the Filipino
physicians, a circular was issued to the medical officers of the Bureau and others
concerned. Under the circular, the practice of verifying diagnoses on death certificates by
autopsies should be notified to the attending physician and to the family or relatives of
the deceased so that no misconception of the investigation would arise. The circular
ensured that every precaution would be taken to inform the people especially the families
of the deceased that the autopsies were not held as a reflection on the attending physician
but as a public health measure for the benefit of the people through better knowledge of
disease.285

284

Annual Report of the Bureau of Health (1909-1910), 59.


Bureau of Health, Annual Report of the Bureau of Health for the Philippine Islands for the
fiscal year ended June 30, 1911 (Manila: Bureau of Printing, 1911), 7-8.
285

131

As illustrated in the table showing the different factors in the mortality of children
in Manila from 1908 to 1909 (See table 13), convulsions of children below one year and
five years recorded a significant number of deaths but the doctors doubted the accuracy
of the record and recommended for a verification of the statistics. They did not question
the correctness of the total number of deaths but raised doubts in the truthfulness of the
causes recorded in the death certificates of infants.286 From the very beginning,
convulsions were the recorded as the leading cause of deaths among infants and this
continued to be a practice for the lack of knowledge of the specific disease that the doctor
could attribute the deaths to. However, Dr. Andrews and McLaughlin rejected infantile
convulsions as a cause of death among infants. 287
The Bureau of Health saw the importance of securing the correct diagnoses in the
cases reported as dying of infantile convulsions for the reason that 35% of the total
mortality less than one year was attributed to this cause on the death certificates of
infants in Manila. With convulsions being entered as a cause of death, said the doctors,
the real cause of the 35% of the mortality of infants below one year in the city was
absolutely unknown. As only a symptom of some specific diseases like fever or chills,
the Bureau of Health believed that convulsions therefore had no definite place in
statistics and could be a cause of confusion to many people. Curious to discover the real
disease that killed many infants of the city, the doctors revealed in their studies the

286
287

Ibid., 60.
Ibid., 62.

132

results obtained from investigations by necropsy of cases of alleged infantile


convulsions. The table below showed the suspected diseases mistaken to be convulsions
supported with clinical data and pathological finding:288
Table 21 Causes of Deaths in Convulsion Cases (1908-1909)
Cause of deaths
Cases
Beriberi
31
Cholera
4
Pneumonia
1
Enterocolitis
1
Empyema
1
Cerebral hemorrhage
1
Undetermined
1
Total
40
Source: Bureau of Health, 1911
As the findings in the convulsions showed inaccuracy in cases entered as some
other diseases, the Bureau took pains in finding other flaws in other prevalent diseases of
infants. True enough, it was not only the pathological findings in infantile convulsions
that gave an idea of the possibility that beriberi was the real cause of infant mortality in
the city. The series of pathological findings from the autopsy of bodies of infants dying
of bronchitis gave the same result; beriberi was found as the real cause of deaths of
infants in most of the cases entered as acute or chronic bronchitis.289 There were also a
number of cases some other diseases such as congenital debility, pneumonia, acute
enteritis and other diarrheas that suggested the possibility that beriberi might be present

288
289

Ibid., 62.
Ibid., 63.

133

in the infants who died of these causes.290 Since then, the Bureau of Health considered
the idea that a special form of beriberi, a disease commonly attributed to adults, could be
killing large number of infants. Subsequently, starting in the annual reports of the Bureau
of Health from 1909-1910, beriberi in infants made its debut as an official cause of
deaths of infants. At first, the doctors were doubtful of the existence of beriberi in infants
but further study showed a large number of infants died of a disease which resembled a
pathological picture of beriberi. 291 See the study of the cases below:
Table 22 - Number of cases of infants investigated by clinical diagnoses and
necropsy findings
Clinical Diagnoses
Necropsy Findings
Meningitis
37
Cholera
40
Enteritis
22
Beriberi
97
Convulsions
40
Pneumonia
14
Beriberi
50
Enterocolitis
7
Bronchitis
27
Meningitis
4
Nephritis
2
Empyema
2
Acute tonsillitis, paryngitis and 1
bronchitis
Cerebral hemorrhage
1
Undetermined
8
Total
176
Total
176
Source: Bureau of Health, 1911
In the number of cases investigated to uncover the real causes of deaths of
infants, 50 out 176 cases studied under clinical diagnoses were found to be beriberi,
whereas 97 out 176 of the same cases were registered as beriberi when autopsied. The

290
291

Ibid.
Ibid.

134

large number of discrepancy between the clinical diagnoses and the autopsy findings
could be explained by the fact that in many instances the native doctors were not called
to see the patient until the latter was about to die without the cause of death being
checked carefully by the doctors. In some cases, it was common that the family wanted
the death certificate to be signed immediately after death without securing the real cause
of death of the deceased. Nonetheless, the findings under both methods agreed that
beriberi, among other diseases, was the largest factor in the infant mortality of Manila. 292
For a lack of a better name, the newly-discovered disease came to be termed as
infantile moist beriberi or simply infantile beriberi. Andrews believed that the
pathology of the infantile beriberi was similar in many aspects to the beriberi in adults.
He also noticed that many of the infants were children of mothers who apparently
showed symptoms of beriberi. He described from the cases he diagnosed that those
infants inflicted of infantile beriberi apparently had a well-nourished body, or even
described as plump or chubby but the skin was usually pale and anemic. The face of the
infants appeared to be fully swollen, pits on deep pressure, and the flesh of thighs and
legs were soft and flabby. Occasionally, the skin had a tough, leathery feel, a leaden
color, and a slight goose-flesh appearance 293
While the outward physical symptoms could easily be determined, the internal
nature of infantile beriberi in infants was harder to be identified because many of the

292
293

Ibid., 64.
Ibid.

135

bodies of the babies who died of the disease were not subjected to autopsy until 24 or 36
hours after death. The doctors and the families of the deceased failed to transport the
bodies to the morgue at an early time and the decomposition of the bodies rapidly set in
making it difficult to establish an autopsy. Clinically, medical inspectors said that the
patient was sick for a few hours, or at most, for a day or two. The parents, however, did
not recognize that the child was ill until the condition became very serious or until the
child was almost dead. There was a suspicion that the baby had already been sick since
its birth. Dr McLaughlin and Dr. Andrews did not attempt to give the etiology of the
disease because of the length of time elapsing between the death of the patient and the
time of necropsy which might render false results.294
In April, 1912, Andrews attempted again to contribute to the study of infantile
beriberi by undertaking a series of cases clinically and subjecting those that died to
necropsy as he commented that the past papers by different men only focused entirely on
clinical or pathological but not a combination of the two. He thought that it was best to
study the cases of infants all at the same time so that comparisons and differences could
be made. The largest number of these cases came from the district of Tondo. In the
district of Tondo, sick infants were met with on almost any street. From the study, the
summary of the clinical observations was that symptoms of sickness were not
conspicuous at first glance, but a closer inspection would change this opinion. The
symptoms were around cyanosis around the mouth and nose, slight dyspnea, periodic
294

Ibid., 66.

136

restlessness, insomnia, rarely a slight cough, occasionally vomiting, and a change in the
childs voice. They observed that the child would probably had been sick for a long time
already and the mother had noticed nothing abnormal until the infant began crying and
died of an attack of heart failure. In the necropsy performed after death, Andrews found a
pathological picture of beriberi to be present.295 Andrews had a close encounter with the
mothers whom he believed suffered from beriberi while they nursed their infants. He
described that:
In nearly all cases the mother shows some
symptoms of beriberi; numbness and pains in the legs,
anaesthetic areas on the legs, formication, tachycardia,
dyspncea on slight exertion, lack of coordination in
walking, palpitation, possibly distinct heart murmurs,
loss of knee jerks and other reflexes. In two cases we
found the mother suffering from such pain in the legs
that she could not walk, but sat on the floor and
shuffled herself along. On inquiring as to the mothers
diet we found that it consisted entirely of white rice,
and fist or meat; rarely were any vegetables or fruit
eaten.
The disease is just as apt to manifest itself in the
first infant of a girl 18 years old as in the infant of an
older woman with her third or later pregnancy. Indeed
one of the severest cases we saw in both mother and
child was exhibited in a girl barely 18. The child died 6
weeks old and at this time the mother could hardly
stand. She sat on the floor and pushed herself along as
best she could. The pains in the legs were severe. Areas
of anaesthesia, numbness, and formication were
present.
It is not unusual to obtain the history that the first
and second children have died each at about 2 months
of age from taon. With the third child the doctor
295

Ibid., 71.

137

advises artificial feeding, and if the little one escapes


the gastro-enteritis which usually follows, it survives.
With the fourth child the mother resumes the breastfeeding with the result that the infant dies of taon in
about 2 months. Occasionally the mother starts the
infant on artificial feeding. In about a month, gastroenteritis has become severe, and she returns to breast
feeding; two months later the child dies of beriberi.296

E. Etiology of Infantile Beriberi


In the experiment of rice polishing of Vedder and Chamberlain, Vedder said that
his observation of infantile beriberi nullified the idea that a toxin was the cause of the
disease. Having excluded the intoxication theory, Vedder asserted that infantile beriberi
was due to a deficiency in the diet of the babies. Once again, polished rice was
implicated to be the source of the disease in infants. The cases of infantile beriberi
appeared for the most part in families where polished rice was almost the exclusive diet.
These cases could all be cured by proper feeding. Vedder also argued that majority of the
these cases were among the poorest class of natives, who were left with no choice but to
subsist on eating rice alone with a little fish or meat. Among the well-to-do families who
were able to purchase a varied diet, cases of infantile beriberi were practically none.297
Andrews observed that before several of the families moved to Manila, their first
and second children having been born in the provinces showed no evidence of beriberi.
After they settled in the city, the subsequent children of the families carried the disease.
296
297

Ibid., 74.
Ibid., 258-259.

138

Andrews articulated that it might be because the daily rice outside of Manila was
pounded out by the family themselves and the pericarp of the rice was not completely
polished. The families in the provinces also subscribed to a diversified diet by eating
both vegetables and fruit. This was not the case in of a normal diet in Manila where only
polished rice imported from abroad and highly milled from rice mills was available to the
people. This fact enforced the idea that rice was the cause of both adult and infant forms
of beriberi.298
The records of death certificates furnished by the Bureau of Health showed that
infantile beriberi was more prevalent in the wet season. Andrews though that this could
have a relation to the growing crops. After the rainy season, usually in November,
vegetables and fruits were supplied abundantly in the markets of Manila. People
including the poorer classes were able to purchase these commodities in cheaper price
because of the increasing quantities of these goods in the market. Beginning of the rainy
season, the supply of fruits and vegetables began to dwindle and therefore the price went
up with a consequent loss of goods at affordable price to the poorer classes.299
The only months when infantile beriberi was more or less absent were May, June,
and July. (See table 23) It was only around this season when rice or palay began to be
planted, thus people were compelled to consume food other than rice. With this more
diversified diet, people were believed to be less vulnerable to beriberi. Meanwhile, the

298
299

Andrews, Infantile Beriberi, 74.


Ibid., 85.

139

behavior of infantile beriberi every year showed that the disease started to decrease after
1910the year when infantile beriberi was first largely recognized in Manila. The
infrequency of the disease in the latter years might be attributed to the success of the PHS
in disseminating information of its symptoms to the poor mothers and the benefits of
giving artificial feeding to their infants.300
Table 23 - Annual and Monthly Incidence of Infantile Beriberi
Month
1910 1911 1912 1913 1914 1915 1916 Total
January

12

14

February

35

37

March

29

31

April

11

11

May

June

July

August

11

September

October

10

November

17

December

95

20

17

Total

Source: Philippine Journal of Science 12, no. 2 (1917)

300

Maria Paz Mendoza-Guason, Study of the Anatomicopatholigic Lesions in One Thousand


Filipino Children under Five Years, The Philippine Journal of Science 12, no. 2 (1917): 73.

140

As the direct link between the consumption of polished rice and beriberi was
firmly established, the PHS attempted to trace the connection of the rice to the beriberi in
infants. One question that bothered many medical scientists was how unpolished rice
could be responsible for deaths among infants who were incapable of digesting rice and
other foods. There was still no scientific answer to clarify the connection of the
unpolished rice and the deaths of infants from beriberi but there were considerable
evidence to show that made many people believe that such was likely to exist. The PHS
wrote in one of its health bulletins in 1913 that the very high death numbers of infants
born in the city of Manila due to beriberi could explain the relation of infantile beriberi to
unpolished rice. Since these infants died during the period of their lives when they were
still entirely dependent upon their mothers milk for nourishment, the mothers diet was
incriminated to be responsible for the infants death. The Health Bulletin No. 12
theorized that if the mother subsisted almost entirely on white rice, she was deprived of
essential nutrients that affected the nutritive value of her milk. As a result, the milk that
the mother passed on to her infant most likely produced beriberi.301
To uncover the cause of beriberi in infants from the mothers milk, the colonial
public health suspected the practice of breastfeeding as the source of the disease. One
striking consideration in the infant mortality of Manila was that the high number of the
total deaths of infants was breast-fed. The deaths of breast-fed children constituted
73.74% of the total infant mortality. The Bureau of Health compiled statistical data for
301

Philippine Health Service, Beriberi and How to Prevent It, 6-7.

141

the year ending February 25, 1910 showing the figures of deaths among breastfed infants
below one year. Around 87 to 88% of the total deaths of infants from beriberi and
convulsions were breast-fed.302 Refer to the table below:
Table 24 Number of breastfed infants in different causes of deaths in Manila
(1910)
Number of
Number of
Percent of
Disease
certificates
breast fed
breast-fed to
stating how
infants
total reports
fed
Beriberi
473
417
88.1
Convulsions
872
768
87.5
Acute bronchitis
615
469
76.2
Congenital debility
381
218
57.2
Meningitis
134
75
56
Enteric disease
201
70
34.8
Other diseases
722
494
68.4
Total
3,398
2,505
73.74
Source: The Philippine Journal of Science 5, no. 2 (1910)
Since infantile beriberi was encountered in infants who were nursed by their
mothers suffering from beriberi, it would seem possible that the disease was transmitted
through the mothers milk. There were other theories presented to explain what was in
the mothers milk that was responsible for the transfer of beriberi from the mother to her
infant. Professor Hirota of Japan concluded in his study of the beriberi attacking the
infants that the disease was a in a form of intoxication produced by the digestion of
beriberi milk. Since the infants were hugely dependent of the mothers milk, Hirota
recommended that maternal feeding be discontinued and encouraged instead the

142

substitution of artificial feeding for the babies. The professor said that there was no other
treatment to save the infant from beriberi but to stop the mother from breastfeeding her
offspring as early as possible before the disease became far too advanced.303
Studying the age of the infants at which infantile beriberi appeared, it would be
observed that the disease mostly likely attacked infants during the first three months of
life and sometimes appeared soon after birth. (See table 25) In explaining this condition,
Vedder said that it was during the first few months of life that infants subsisted entirely
on milk of their mothers. After the fifth or sixth month, cases of infantile beriberi were
less numerous. Vedder explained that the decrease of infantile beriberi cases after the
infants sixth month of life was because the infants were given in many cases some other
food which compensated the existing deficiency of nutrients from the mothers milk.
Furthermore, Vedder noted that the high incidences of infantile beriberi in the first few
months of life were expected because the mothers were already lacking in particular
vitamins and therefore were incapable of supplying their fetus with vitamins which
would prevent the disease. The child was already ailing from infantile beriberi when it
was born and was continued to be fed on milk from the same mother who was also
deficient in this important substance.304
Table 25 - Age incidence of Infantile Beriberi Cases
Age
Cases
Age
0 to 1 month
6
8 to 9 months
303

Cases
3

Jose Albert, The Treatment of Infantile Beriberi with the Extract of Tiqui-Tiqui, Philippine
Journal of Science 10, no.1 (1915): 81. See Appendix B.
304
Vedder, Beriberi, 259-260.

143

1 to 2 months
2 to 3 months
3 to 4 months
4 to 5 months
5 to 6 months

56
44
12
6
10

6 to 7 months
4
7 to 8 months
2
Source: Philippine Journal of Science (1917)

9 to 10 months
10 to 11 months
11 to 1 year
1 to 1.5 years
2 years and
months
Total

2
0
2
1
7 1
150

From all the following considerations, infantile beriberi was concluded to be of


dietary problem because of the deficiency of some substance in the milk of the mother.
There had been attempts to find out the exact nature of the substance that was lacking in
the mothers milk but most of these attempts were unsatisfactory. However, Andrews had
reported 11 cases of milk obtained from women whose infants had just died of beriberi.
The milk was collected cautiously and the analyses were made by competent chemist.
Based on the findings, infantile beriberi was not caused by a deficiency in fat, protein,
inorganic salt, or phosphorus. Since the deficiency was not of these elements, it simply
appeared that the disease in infants was caused by the same deficiency of vitamins which
produced adult beriberi.305

F. Developing a Cure
In the opening session of the eleventh annual meeting of the Philippine Islands
Medical Association held in Manila on November 4, 1914, Governor-General Francis

305

Ibid., 261-262.

144

Burton Harrison applauded the hard work of the Bureau of Health and the cooperation of
the members of the Philippine Island Medical Association in maintaining the high
standard of health programs. Harrison emphasized in his address that the Filipinos had
come to realize the value of the governments health service which had been proving its
efficiency and showing progress in many lines of health care. Speaking in the same
meeting, the president of the Philippine Islands Medical Association, Dr. Najeeb
Saleeby, addressed that although the general health welfare of the Islands had been going
steady, beriberi still remained as widespread as it had been before. The President was
very anxious of the extensive existence of beriberi in mild form which though not as fatal
as the other forms of the disease could lower the resistance of the victim from other more
dangerous diseases like tuberculosis. Dr. Saleeby also stressed the greater vulnerability
of new-born child of mothers affected by beriberi. Weaned infants and children of all
ages were also as vulnerable to contract beriberi. He, therefore, encouraged immediate
treatment of cases of young children suffering beriberi.306
At the final meeting of the Philippine Island Medical Association on November 7,
1914, the association presented resolutions before the committee on public policy and
legislation. One of the significant resolutions was the direct relation of the occurrence of
beriberi between the mother and the infant. Members of the association were of the same
opinion that beriberi occurred frequently in women during their nursing life, and through

306

Philippine Islands Medical Association, Minutes of the Eleventh Annual Meeting, held at
Manila November 4-7, 1914, Philippine Journal of Science 10, no. 1 (1915): 87-88.

145

them, the disease was transmitted in their infants. This condition could explain the
excessive mortality of infants in the Islands as many mothers did not know that they had
beriberi while nursing their babies. Accordingly, the association recommended for the
establishment of special hospital facilities under the control of the Bureau of Health for
beriberi victims and urged for the further study of the disease and its treatment.307
Among the physicians who had practical experience with beriberi, they believed that
beriberi was highest among those people who had faster metabolisma process in the
body that converts or uses energy. Thus, it was commonly observed that beriberi was
usually present in women during the period of puerperium or six weeks after childbirth.
Infants of beriberic mothers were anticipated to be just as vulnerable of carrying the
disease in their early weeks.308
With the very high infant mortality of breast-fed children, the Filipino mothers
were impugned to be the source of the malady of their children. The Bureau of Health
believed that average Filipino mother was in poor physical condition and many of them
had beriberi and subsisted upon a diet favourable to beriberi. They considered the fact
that there seemed a probability that there was an intimate relation between beriberi of
infants and a mothers milk poor in quality and lacking certain necessary elements which
were absent in the mothers diet. A possible solution of the problem was to supplant the
infants diet with artificial food to replace the mothers poor quality milk. It was also

307
308

Ibid., 92.
Williams and Johnston, Miscellaneous Notes and Comments on Beriberi, 337.

146

noted that the physical condition of the Filipino mother and of the quality of the milk was
an economic question which might be a result of poverty.309 Andrews once again
articulated in his other paper the significance of improving the health of the mothers first
before the infant mortality in Manila could be solved. He saw this as the solution to the
economic question of infant mortality of the city. He said:
In this connection I want to emphasize again that
the improvement of the physical condition of the
Filipina mother and of the quality of her milk is an
economic question of the highest importance to Manila.
Fifty per cent of the total number of deaths of Filipinos
in Manila is of infants 1 year of age and under. Over
fifty per cent of these is due to infantile beriberi. Since
the recent advances in our knowledge of the etiology of
beriberi indicate that this appalling condition may be
stopped or at least checked by the substitution of
undermilled rice for white rice in the daily diet of this
people, it certainly behooves us to become active in
some measures of relief. Just the modus operandi for
bringing this about would have to be determined. It
might be possible, perhaps, to require all dealers
handling rice to keep a stock of the undermilled variety
on hand, and then, by the introduction of a campaign of
education among the people with especial reference to
pregnant women, it may be possible to do considerable
to relieve the situation.310
Musgrave focused his study of infantile beriberi on the nutritional deficiency of
infants without going to the question of the influence of special varieties of rice upon
infants health. As he had seen from the reports of the Bureau of Health, Musgrave

309

Annual Report of the Bureau of Health (1909-1910), 68.


Vernon Andrews and Allan McLaughlin, Studies on Infant Mortality, The Philippine
Journal of Science 5, no. 2 (1910): 159.
310

147

emphasized the greater mortality in breast-fed children than the artificially fed children.
This condition was very peculiar to the Philippines as other countries showed the
opposite. Musgrave believed that the root of evil of infantile beriberi was the quality of
the mothers milk. In the cases he studied from the clinics of the Philippine General
Hospital (PGH) in Manila, he noticed that the mothers produced only small quantities of
milk to their babies. The lack of natural milk was a result of the undernourishment of
most of the mothers from beriberi. He concluded that the bad nutrition of the mothers
was the principal element of the high infant mortality of breast-fed children from this
disease. In solving this problem, however, Musgrave thought that substituting artificial
feeding to natural breastfeeding was an unwholesome policy. Convincing the mothers
to desist from doing their maternal duty of nursing their infants had been very difficult.311
Although the idea of prohibiting the mother from breastfeeding her infant
appeared to be simple, Jose Albert, of the College of Medicine and Surgeon of University
of the Philippines, called into question the plan because of serious inconveniences
inherent in the sudden and untimely discontinuance of maternal feeding. The procedure
of allowing a wet nurse (a woman who breastfeeds for anothers child) was too
expensive and mothers of the poorer class were not able to afford it. Substituting
artificial feeding for breastfeeding was dangerous to the infants for they were exposed to
gastrointestinal and other nutritional disturbances. Purchasing of fresh milk and canned

311

W.E. Musgrave, Infant Mortality in the Philippine Islands, The Philippine Journal of Science
8, no. 6 (1913): 460-462.

148

milk were also not viable foods because of pecuniary reasons. 312 The quality of milk sold
in Manila was found to be dangerous to health and should never be used as infant food.
There was even a report that milk sold on the streets of the city was from 26 to 30 hours
old, and some had been diluted with tap water and contaminated by unclean containers.
Certainly, there was no other better solution than to depend upon the improvement in the
nutrition of the mothers.313
The effort of the government to reduce the number of children suffering from
beriberi was slightly hindered by the lack of cooperation from rice mill dealers. The
Director of Education requested medical inspectors of schools to investigate and report
upon the occurrence of beriberi among pupils at the School of Household Industries. In
the report of the special investigation furnished to the Director of Education on February
21, 1916, the inspectors found out that the rice mill dealers were not marketing rice with
sufficient pericarp remaining on it to prevent beriberi. This was due to the fear of most
rice dealers of the loss of market because students had a lack of appetite for unfamiliar
foods such as unpolished rice. The medical inspectors recommended that the
Government make an arrangement with the rice mill dealers to maintain a demand for
reasonable quantity of this grade of rice especially for families where cases of beriberi

312
313

Albert, The Treatment of Infantile Beriberi with the Extract of Tiqui-Tiqui, 82.
Musgrave, Infant Mortality in the Philippine Islands, 460-462.

149

occurred. The suggestions were carried out and since then, all of the students recovered
and no subsequent cases developed.314
As the Liga Nacional para la Proteccion de la Primera Infancia (Liga Nacional)
had been carrying extensive work with infants, Robert Runnels Williams and Najeeb
Saleeby from the Laboartory of Organic Chemistry of Bureau of Science in Manila
worked to experiment rice polishing in the hope that it might lead to some practical
suggestions for the treatment of beriberi.315 Meanwhile, the Bureau of Health undertook a
study whether tikitiki from the rice mills could be used as a palatable food. A sample of
the tikitiki product was taken from the rice mill near the Tondo railroad station and
submitted to the Bureau of Science for a test in order to determine the safety of the use of
the rice polishing as food without having to undergo a purifying process. Despite of a
few human hairs, beetles, and grits and hulls found in the sample, a chemist who partook
in the test noted that tikitiki, if cleaned, was probably as edible as any other commercial
products such as corn.316
In 1912, Major Weston Chamberlain and Capt. Edward Vedder reinforced the
idea that the extract made from rice polishing could be a possible cure to save infants
from suffering infantile beriberi. They obtained the cure by mixing 90 or 95% alcohol
in the fine power of tikitiki extract. To each kilogram of tikitiki extract, Vedder and

314

PHS 1916, 86.


R.R. Williams and N.M. Saleeby, Experimental Treatment of Human Beriberi with
Constituents of Rice Polishings, Philippine Journal of Science 10, no. 2 (1915): 99-100.
316
Annual Report of the Bureau of Health (1912-1913), 20.
315

150

Chamberlain recommended that three liters of alcohol should be added. They further
experimented on different mixtures of alcohol and the tikitiki extract to determine the
best protective and curative substance. In their final method of preparation of extract of
rice polishing, Vedder and Williams described:
Rice polishing or tiqui-tiqui may be obtained from any
rice mill, but should preferably be from a recent milling. The
finest grade of polishing should be carefully selected, since
some of this product is very coarse and consists mostly of
hulls. The tiqui-tiqui is first sifted to remove hulls and
weevils. Gauze of about seven meshes and mixed with 90 per
cent alcohol in the proportion of three liters of alcohol to
each kilo of polishing. It is then allowed to macerate for 24
hours. A glass of jar or white enamelled receptable [sic]
serves for this purpose, and the mixture should be repeatedly
stirred or shaken, since the tiqui-tiqui sinks rapidly to the
bottom, forming a densely packed mass which the alcohol
penetrates with difficulty.
During the extraction the alcohol becomes of a deep
green color, due to the fat that has been dissolved out. At the
end of 24 hours the alcohol is siphoned off and filtered until
absolutely clear. Since a very considerable quantity remains
in the tiqui-tiqui, this should be squeezed in a press, or
washed with fresh alcohol, and the residuum filtered and
added to the alcoholic filtrate already obtained. The
extraction should then be repeated several times, again using
three liters of alcohol to each kilo of polishing. This is
necessary because the neuritis-preventing substances are
only slightly soluble in cold 90 per cent alcohol, and
experience has shown that if the polishings are not repeatedly
extracted in full therapeutic action of the polishing is not
obtained. The combined alcoholic filtrate is then placed in a
water bath provided with a thermometer, and an electric fan
is so arranged as to throw a strong current of air on the
surface of the alcohol. As a result of the heat and the
movement of air the alcohol rapidly evaporates. It is essential
that the temperature of the extract should not be permitted to
rise above 80C... Whenever the temperature of the extract
151

approached [sic.] 80C., the fire should be extinguished until


the temperature drops.
This process is continued until all the alcohol is
evaporated. The residue is poured into a separating funnel
and allowed to stand for about an hour, when it will be
observed that the liquid has separated into two layers. The
upper and larger portion is of a deep green color and cosists
of the fat. The lower and smaller layer is brown in color, of
syrupy consistency, and contains a number of substances that
have been extracted by the alcohol. This lower layer is
carefully drawn off, leaving the fat behind. The brown
syrupy fluid so obtained from kilo of polishing is diluted to
60 cubic centimeters with distilled water, whereupon a heavy
precipitate is formed. This precipitate consists of substances
that were soluble in alcohol, but are insoluble in water. After
allowing the mixture to stand for a while the precipitate
settles and the clear fluid is filtered off. This filtrate
constitutes the extract as we have used it. Each 60 cubic
centimeters contains the substances that have been extracted
by this method from one kilo of polishing.317
Moreover, Vedder and Chamberlain articulated that beriberi in infants could be
prevented by tikitiki while maternal feeding was still being continued. Previously,
breastfeeding was utterly disregarded because of the high deaths of many breastfed
infants from beriberi. Chamberlain and Vedder introduced that mothers need not stop
their nursing while tikitiki was being administered. In one case, Chamberlain and Vedder
described:
The mothers have all had symptoms of incipient
or marked beriberi...The children have all been
breastfed. The infants were all given twenty drops of the
extract of rice polishing every two hours while awake,
and the results have been truly marvelous. Improvement
317

A.H. Wells, The Preparation of tikitiki extract for the treatment of beriberi, The Philippine
Journal of Science 19, no. 1 (1921): 70-71.

152

is immediate. The vomiting stops in 24 or 36 hours. The


child, who has not passed any urine for several days,
urinates five or six times freely. The oedema disappears
in the course of a few days. Usually on the first night
after treatment is begun the infant falls into a deep sleep,
although it may have been practically sleepless for
several weeks. At the end of a week, or in less time, the
patients are completely cured with the exception of the
aphonia. The mother assures us that the baby is well,
and that she would be completely satisfied if only it
would recover its voice... It can be said that this extract
is a cure in the true sense of the word, just as lime
juice is a cure for scurvy, and that it acts with as great
promptitude as does fruit juice in infantile scorbutus.318
While the treatment of the extract to infants obtained considerable success,
beriberi cases of adults showed otherwise. In their report of three adult cases, Vedder and
Williams believed that the administration of the preparation of extract of the rice
polishing was capable of eliminating the dropsy and controlling the attacks of cardiac
insufficiency which were very apparent in cases of infantile beriberi. But this extract was
not capable of curing the paralysis in the case of adult beriberi especially the dry type. As
observed in the beriberi cases in PGH, the treatment of adult patients of beriberi using
rice polishing was not followed by satisfactory results similar to infantile beriberi
cases.319 Williams and Saleeby also concurred that that constituents of rice polishing or
tikitiki were very beneficial in infantile beriberi, but the treatment had failed to be of

318

Vedder, Beriberi, 257-258.


Edward B. Vedder and Robert R. Williams, Concerning the Beriberi-preventing Substances or
Vitamins Contained in Rice Polishings, The Philippine Journal of Science 8, no. 3 (1913): 190-191.
319

153

service in most adults.320 One of the cases demonstrated this challenge. Vedder and
Williams reported:
A woman in the Philippine General Hospital who
was very kind referred to us for treatment by Dr. A.G.
Sison. This woman had been in the hospital for some
time and was suffering from typical dry beriberi. Her
muscles were much wasted and exquisitely tender, and
she was completely bedridden. This woman was given
the unhydrolized extract from 1 kilogram of polishing
daily for two weeks with no improvement except
possibly a slight alleviation of the tenderness of the
muscles. She remained completely paralyzed. It may here
be stated that we have been informed by several
physicians that they have been similarly disappointed in
the treatment of cases of dry beriberi with the extract of
rice polishings.321
Knowing the curative actions of tikitiki in beriberi among infants which was
caused by a deficiency in the diet, Jose Albert admitted that the extract gave the infants
vitamins which were very deficient in beriberic milk. Albert was of the same opinion that
the extract was of immense value in the treatment of infantile beriberi. In the tests that
Albert conducted in many of his cases of infants affected by beriberi, he noted that the
administration of tikitiki when given in time to the sick infants and in proper doses was
followed by mark improvements. Many physicians were surprised of the positive result
that the medicine showed to the sick infants. The effects of the extract to infants
happened very quickly that at the end of only 24 hours, symptoms like vomiting,
320

Saleeby and Williams, Experimental Treatment of Human Beriberi with Constituents of Rice
Polishings, 99-100.
321
Vedder and Williams, Concerning the beriberi-preventing substances or vitamins contained in
rice polishings, 189.

154

whining, restlessness, insomnia, dysphagia (see glossary), polypnea (see glossary), and
oliguria (see glossary) all disappeared. At the end of three days, the doctors were
confident to say that the beriberi of the infants disappeared. Albert, however, still
suggested that it was still necessary for mothers to continue the treatment for at least
three weeks after the apparent cure to avoid relapses.322
Because of the astonishing results of using tikitiki in infants, both the Committee
for the Investigation of Infant Mortality and the Segunda Asamblea Regional de Medicos
y Farmaceuticos requested the Philippine Legislature to pass measures enabling the
preparation of the extract to be made available to the poorer class. Hearing the requests,
the Philippine Legislature, in 1914, immediately enacted Act No. 2376 designating the
Bureau of Science as the one in charge of the duty of preparing extract of tikitiki for the
treatment of infants from infantile beriberi. The chief of the division of general,
inorganic, and physical chemistry of the Bureau led the preparation of tikitiki and
initiated measures to further modify and improve the process of preparation. At the end
of 1914, despite losses of some products under preparation from fire in June, the Bureau
had prepared 58 liters of tikitiki extract which were probably sufficient enough to treat
700 infants.323 In the next year that followed, in 1915, the Bureau continued its work of
preparing more extract of tikitiki. The level of production of the extract was greatly

322

Albert, The Treatment of Infantile Beriberi with the Extract of Tiqui-Tiqui, 83-84.
Bureau of Science, Thirteenth Annual Report of the Director of the Bureau of Science to the
Honorable the Secretary of the Interior for the year ending December 31, 1914 (Manila: Bureau of
Printing, 1914), 9.
323

155

increased up to the close of the year. From only 58 liters of last years preparation, the
Bureau had prepared 200 liters of extract sufficient to treat 3,500 infants with only
slightly half of the fund appropriated for the work being expended.324
The Act No. 2376 also provided that the Liga Nacional would supervise the
distribution of the extract among the poorer class. Accordingly, the law also instructed
Liga Nacional to present a written report of the results of the experiments of the extract
on infants through the Secretary of Public Instruction at the beginning of each regular
session.325 On October 15, 1916, Liga Nacional submitted its evaluation of the use of
tikitiki extract among infants. According to the report, the mortality of infantile beriberi
among children below one year of age in the city of Manila continued to be what it had
always been based on the statistics of the PHS; this was despite of the increase of tikitiki
extract manufactured by the Bureau of Science. The Bureau could not give concrete
reasons why their efforts to decrease the mortality rate of children from beriberi did not
yield fruitful results.326
The officers of the Liga Nacional even commended the management of the
Bureau of Science in solving the problem of sterilization of the preparation of the extract

324

Bureau of Science, Fourteenth Annual Report of the Director of the Bureau of Science to the
Honorable the Secretary of the Interior for the year ending December 31, 1915 (Manila: Bureau of
Printing, 1917), 10-11.
325
Albert, The Treatment of Infantile Beriberi with the Extract of Tiqui-Tiqui, 83.
326
Bureau of Science, Fifteenth Annual Report of the Director of the Bureau of Science to the
Honorable the Secretary of the Interior for the year ending December 31, 1916 (Manila: Bureau of
Printing, 1917), 16. [hereafter Fifteenth Annual Report of the Bureau of Science]

156

amidst the departure of Mr. R.R. Williams who had personal charge of the work.327
Meanwhile, the Bureau blamed the negligence of mothers to call the doctor for the
proper treatment of their beriberi children and the malpractice of the doctors themselves
to diagnose infantile beriberi correctly or the extracts they used to treat it did not possess
the qualities that the Bureau of Science prepared. The report further said: Theoretically,
no children suffering from beriberi that are treated in time with a sufficient dose of
extract of tikitiki should die. As a matter of fact, our mortality does not reach 1.5 per cent
and even this small percentage of mortality is due to the fact that little patients do not
reach us until it is too late, almost at the dying stage, when the medicine has no time to
exert its beneficial influence. 328
In 1916, the Bureau of Science furnished only few of tikitiki extract to outside
agencies because the Liga Nacional demanded more distributions of the extract.329 Since
there were more infants being afflicted of beriberi than adults, the Bureau of Science
decided to balance the distribution of the tikitiki extract in proportion to the need of the
beriberi patients. The Liga Nacional received almost all the bottles of tikitiki extract
recorded to be 8,034 of 8,268 bottles prepared by the Bureau, and only 234 of the bottles
were sold or delivered to the general public.330 In order to accommodate the high demand
of the extract, the Bureau of Science revised its method of preparation and increased its

327

Ibid., 35.
Ibid., 16.
329
Ibid., 35.
330
Ibid., 67.
328

157

production. During 1916, more production of tikitiki extract was obtained because of the
larger still, which had been used for essential oil work, was put into operation for the
distillation and substituted the only one small copper being previously being used for
concentration.331
Since there were times that the supply of tikitiki extract was not enough, Andrew
Cox, the Director of the Bureau of Science, said that the Bureau had to refuse the
requests for tikitiki of other agencies. Cox lobbied that provision should be made to
ensure that all requests for the extract would be complied with by the Bureau. He added
that the work of preparing tikitiki extract would have to be enlarged in order to
accommodate the need of supply of tikitiki of other institutions and agencies of the
government.332 The improvements sought by Cox were immediately carried out in 1917
when new installations were placed in the laboratories of the Bureau for the manufacture
of tikitiki extract. Supply of the tikitiki slowly went with its very high demand. Many
practicing physicians and large corporations also received, upon their request, tikitiki for
the treatment of beriberi among their patients and employees.333

331

A.H. Wells, The Preparation of tikitiki extract for the treatment of beriberi, 71.
Bureau of Science, Sixteenth Annual Report of the Director of the Bureau of Science to the
Honorable the Secretary of the Interior for the year ending December 31, 1917 (Manila: Bureau of
Printing, 1918), 85.
333
Fifteenth Annual Report of the Bureau of Science, 67.
332

158

CHAPTER 4
Rearing Babies towards Self-Government:
The Challenge of Infant Mortality and Beriberi under a Filipino-Run Government
(1918-1928)

It had always been a pledge of the Americans to withdraw their sovereignty over
the Philippine Islands and to recognize the independence of the Filipinos as soon as a
stable government had been established in the country. The policy of Filipinization
was first inaugurated by President McKindley. In the instruction of McKinley to the First
Philippine Commission, he clearly announced that municipal officers who would
administer the local affairs were to be selected by people and offices would be given to
the natives of the Islands if they were competent to perform the required duties. President
McKinley said that the government they were establishing in the Philippines was not for
their satisfaction, but for the happiness, peace and prosperity of the people of the
Philippine Islands.334 The First Philippine Commission under Taft assured the Filipinos
that the US was willing to establish in the Philippines a government under which the
Filipinos people would enjoy liberty of governance. After he became the first GovernorGeneral of the Philippines, Taft endorsed self-governance to Filipinos in his famous
slogan, Philippines for the Filipinos.

334

William McKinley, Instruction to the Taft Commission, April 7, 1900 in

159

However, the matter of promoting Filipinos to high positions had been one of the
problems during the American rule. As they were given larger measure of autonomy,
Filipino leaders took advantage of that enhanced political power to build the foundation
for a greater and better Philippines. Filipinization of the government was an evidence of
political success and progress of the Filipinos towards their goal of independence. For the
Americans, this was a total sign of regression. While keeping their eye on the Filipinos
fitness for self-government, Americans expressed over the fact that the Filipinized
government failed to formulate a definite plan of nation-building which was in its power
to create. The poor showing of the Filipinos in the protection of infant mortality was seen
as a flaw to their ambition of an independent nation. The Americans had always pointed
out that the growth of population was an essential factor in national progress. As the
Filipinos held positions in public health and general welfare, they attempted to prove
themselves that they had been successful in controlling the deaths of infants.
This last chapter narrates the showcase of Filipino leadership from the time
Governor-General Francis Burton Harrison opened a leeway for Filipinos to occupy high
positions in the government. It continues in 1918 when Filipinos had taken over the
administration of public health from the American hands. Since then, Filipinos
performance in public health and welfare had been a keen subject of evaluation by the
Americans. By 1921, infant mortality was seen as a national concern and therefore called
into question the Filipinos readiness for independence. Infant mortality from beriberi
had been a focal point of Filipinos capacities in maintaining an acceptable population
160

for the country. Many conferences were convened to discuss the main issue of infant
mortality. To mitigate the increase of infant deaths, more nurses and health clinics were
established to take care of the poor infants. However, it was an apparent evaluation that
the success of the Filipinos crusade against infantile beriberi in the country was
concentrated only in the capital. It was a question whether the change to a Filipino-run
government made the infant mortality of the country even worse.

A. A New Era: The Policy of Filipinization


Since 1900, the question of Philippine Independence had been a leading issue in
the US. The Democratic Party assailed in their campaign the imperialistic tendency of
US in the administration of her colonies. The election of President Woodrow Wilson in
1912 with a democratic congress marked the end of the imperialistic policy and the
beginning of a democratic administration in the Philippines. On October 6, 1913,
Governor-General Harrison arrived in Manila. He was welcomed by the Filipino crowd
at Luneta to hear his general line of policy. In delivering US President Woodrow
Wilsons message, Governor-General Harrison said that every step of his administration
would be taken with a view of the ultimate independence of the Philippines. Harrison
realized that the Filipinos really desired to have a full control of their government. The
new Governor-General acknowledged the claim of the people for self-rule. In his
concluding remarks, Harrison said:

161

We shall eagerly await convincing proof that you are


capable of establishing a stable government of your own. Such
a government may not necessarily denote an entire
reproduction of our institutions but one which guarantees to its
citizens complete security of life, of liberty, and of property.
We not invite you to share with us responsibility for such a
government here. Every Filipino may best serve his country
who serves us in this endeavour. And to that end I call upon
every good citizen of these islands and all who dwell therein,
whether of native or foreign birth, for assistance and support.
People of the Philippines! A new era is dawning! We place
within your reach the instruments of your redemption. The
door of opportunity stands open and, under Divine Providence,
the event is in your hands.335
As part of his promises, Harrison was very open that his administration would
give to the natives a majority representation in the upper and lower houses of the
Legislature. To gain the trust of the Filipinos for his democratic policies, Harrison
initiated his administration by giving to the Filipinos of the Islands a majority of the seats
in the upper house, or the Philippine Commission, which had been comprised in majority
by Americans. Harrison thought that his policy of Filipinization would be easily
carried out with Filipinos ruling both the two Houses of the Philippine Legislature. This
reorganization of the Legislature in favor of Filipinos who came forward to represent and
to lead their people in affairs was received with great enthusiasm. Before the
reorganization, serious conflict arose between the five appointed Americans in the
Philippine Commission and the Philippine Assembly, the lower house composed entirely
of Filipinos. With the Philippine Commission and Philippine Assembly being controlled
335

Maximo M. Kalaw, The Development of Philippine Politics (1872-1920) (Manila: Oriental


Commercial Company, Inc.), 350-351.

162

by Filipinos, the dead-lock between the two houses which often delayed the process of
legislation was finally broken.336
One of the first actions of Harrison was to Filipinize the civil service of the
Philippine government. He found out that since 1907, there was no increase of Filipino
employees in the colonial government which was contrary to the instruction of President
McKinley to the Taft Commission that Filipinos should be preferred to serve in
government positions. Although there had been legislation about the civil service
requiring that public offices and appointments should be made in preference to qualified
Filipinos, material reduction of American employees in the government did not take
place until the democratic administration of Harrison. 337 The first step taken was to give
a majority of the positions of the Municipal Board of the City of Manila to Filipinos. In
the bureaus of the Insular Government, Americans were still retained as chiefs in most of
the bureaus and Filipinos were first appointed as assistant chiefs as a preparation for
greater responsibilities. This was done in the Bureaus of Internal Revenue, Prisons,
Agriculture, and Health.338
As the nationalization of the government continued, many Americans chose to
resign or were asked to resign from their positions. The American Assistant Director of
the Bureau of Lands resigned for the reason that he would not serve under a Filipino

336

Francis Burton Harrison, The Corner-Stone of Philippine Independence: A Narrative of Seven


Years (New York: The Century Co., 1922), 50-51.
337
Kalaw, The Development of Philippine Politics, 354.
338
Harrison, The Corner-Stone of Philippine Independence: A Narrative of Seven Years, 77-78.

163

Director. For political reasons, a Republican Chief of an important bureau was asked to
resign because Harrison believed that it would be difficult to carry out the new policy
with an American leader from a different party running that influential position.
Meanwhile, the resignations of the Chief of Police of Manila and of the prosecuting
attorney of the city were asked for purely administrative reasons. For the first time,
Filipinos were appointed as prosecuting attorney and city attorney of Manila. Other
Bureau Chiefs resigned for voluntary reasons.339 President Wilson, in his message to
Congress on December 2, 1913, praised the progress of the filipinization of the
colonial government. He said:
I believe that in this way we shall make proof of
their capacity in counsel and their sense of responsibility
in the exercise of political power, and that the success of
this step will be sure to clear out view for the steps which
are to follow. Step by step we should extend and perfect
the system of self-government in the Islands, making test
of them and modifying them as experience discloses their
successes and their failures; that we should more and
more put under the control of the native citizens of the
Archipelago the essential instruments of their life, their
local instrumentalities of government, their schools, all
the common interests of the communities, and so by
counsel and experience set up a government which all the
word will see to be suitable to a people whose affairs are
under their own control at last. I hope and believe that we
are beginning to gain the confidence of the Filipino
peoples. By their counsel and experience rather than by
our own we shall learn how best to serve them and how
soon it will be possible and wise to withdraw our
supervision. Let us once find the path and set out with

339

Ibid., 79-80.

164

firm and confident tread upon it and we shall not wander


from it or linger upon it.340
As the policy continued to gain grounds in the colonial government, in 1914, the
percentage of Americans in the service decreased to 23% from 29% in 1913. More than
600 Americans left the service in the same year and 920 Filipinos were ushered in.
Regarding the share in the salary appropriation, in 1915, the Filipinos in the service
received 51% of the total salary appropriation. This was already significant since the
American employees received larger share of the salary appropriation in the previous
years. By 1918, the Americans constituted only 9% of the public service and Filipinos
constituted 76% of the total number of employees with an average salary of 1,047.79
pesos a year.341 However, while Harrison pushed through his own policy, he was
denounced in the eyes of his own people. While the Filipinos praised Harrison as the
Messiah who had come to liberate the Filipinos from oppression, the American press in
the Philippines criticized the new administration for its radical policy in favor of the
Filipinos. American employees blamed Harrison and his policy for all the inefficiencies
of the reorganized government controlled by Filipinos.342
As Harrisons policy continued to give access to Filipinos in the colonial
government, the Bureau of Health was later reorganized as PHS on July 1, 1915.
Officers, who were Filipino in majority, of the former health bureau were transferred to
340

Ibid., 81-82.
Victoriano D. Diamonon, The Development of Self-Government in the Philippine Islands (Iowa
City: 1920), 75.
342
Ibid., 86.
341

165

the new organization. For twelve years being a staff in the Bureau of Health, Dr. Vicente
De Jesus was promoted to assistant directorship under Dr. John D. Long, Surgeon of U.S.
Public Health Service, who substituted Dr. Heiser as the Director of Health when the
latter resigned in 1915. On December 31, 1918, Dr. Long tendered his resignation as the
Director of Health for the Philippine Islands. To fill the vacated position, Dr. De Jesus
became the first Filipino director of the PHS. Together with the resignation of Dr. Long
were seven other commissioned officers. During this time, after World War I broke out,
more officers of the PHS chose to resign and served the U.S. Army which included ten
men from the commissioned personnel and six presidents of municipal sanitary divisions
from the provincial organizations. The loss of high-ranking men in the PHS caused a
serious handicap in the routine of health work since those people who resigned were
the ones who supervised the work in the eradication of infectious diseases.343
Meanwhile, Harrison with the cooperation of Nationalist leaders moved to create
a definite legislation from Congress which would finally settle the independence problem
of the Philippines. The question of Philippine independence was brought in the halls of
the US Congress when Congressman William Jones proposed the legislation of what was
called as the Jones Bill. According to Jones, the bill was to give to Filipinos an
opportunity to show that they were capable to run a government. An important feature of
the bill was the broad delegation of powers to Philippine Legislature. As the law-making

343

Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1918 (Manila: Bureau of Printing, 1919), 4.

166

body of the government, the Legislature would have the power to pass laws governing
properties and rights acquired by the US in the Philippines. The Legislature would also
have the power to fix the salaries of the officials except the salaries of the Secretary of
the Public Instruction, the justices of the Supreme Court, the auditor, the deputy auditor,
and the Governor-General. Another important feature of the Jones Bill was to give the
power of framing the budget for the year to Filipinos. In matter of appointments, the
Philippine Senate would have a voice with the Governor-General.344
Despite the radical tendencies of some groups in the US Senate, the Conference
report presented to the two houses was adopted and the Jones Bill became a law on
August 18, 1916.345 Congressman Jones cabled Speaker Sergio Osmea to convey his
messages for the most important step for the countrys road to independence. He said: I
congratulate the Philippine people through you upon the final enactment by Congress of
the fundamental legislation giving to them the substance of the fundamental and the
solemn assurance that in due time complete independence will be theirs. It practically
confers upon the Filipinos the power to determine when they shall take their place among
the independent nations of the world. All other advocates of independence in the United
States believed that a great step of the national aspiration of the Filipino people had been
taken.346

344

Ibid., 100.
Ibid., 359-361.
346
Harrison, The Corner-Stone of Philippine Independence: A Narrative of Seven Years, 195.
345

167

The Jones Law was the ultimate vehicle of Governor-General Harrison to his
policy of Filipinization. In explaining the meaning of the Jones Law to the Filipino
people, Governor-General Harrison, on September 1, 1916, said: it should never be
possible, and it will now never be so here, for an executive to ride ruthlessly over the
people he is sent here to govern, with due regard for their sentiments and due
consideration of their wishes. From here on, the Filipino people enjoyed the largest
measure of autonomy under the tutelage of the Americans. The preamble of the Jones
Law explicitly promised that as soon as when the Filipinos could show that a stable
government was established in the country, independence would be granted to them.
This clause, however, was a point of contention between the Filipinos and the
Americans.347
Even if the Filipinos were to have their independence in the future, what was a
stable government prescribed the Jones Law was to be determined by the Americans.
Harrison explained that the intention of the Jones Law was to promise independence
when the new form of government prescribed by the law had proved itself as stable. That
stability was then to be judged by the US Congress which had the constitutional right to
determine the final status of the Philippines. However, during the period of waiting, the
meaning of a stable government became even more ambiguous as it seemed.348 In
defiance of the devolution of the colonial government to Filipinos, the Manila Times

347
348

Kalaw, The Development of Philippine Politics (1872-1920), 363-364.


Harrison, The Corner-Stone of Philippine Independence: A Narrative of Seven Years, 197.

168

condemned the preamble of the Jones Law which gave extension of the control of
government to Filipinos. As more Filipinos continued to control not only the insular
service but also the Philippine Legislature, the Americans criticized the creation of an
elective Senate and its added power to make appointments with the Governor-General.349
A Filipino majority on the Commission was described by Americans in the service as a
weapon aimed straight at them. At an instance, Americans realized that they had lost
their power in some positions in the government.350

B. Working for the Ultimate Independence


To prove that they were capable of establishing that stable government, the
Filipino representatives in the Legislature expressed their desire for the final settlement
of the question of independence of the Philippines. On November 7, 1918, the Philippine
Legislature passed a concurrent resolution creating a Commission for Independence to be
composed of the presiding officers of the Legislature and its other members. The
members of the Commission of Independence would report to the Legislature regarding
the ways and means of negotiation for the recognition of the independence of the

349

The Manila Times, March 28, 1915, p. 1, April 23, 1915, p. 1, September 25, 1915, p. 4 cited
in Diamonon, The Development of Self-Government in the Philippine Islands, 87.
350
Harrison, The Corner-Stone of Philippine Independence: A Narrative of Seven Year, 75.

169

country, guarantees of the stability of the said independence and territorial integrity, and
ways of organizing a constitutional and democratic government.351
On March 7, 1919, the Philippine Legislature passed a Declaration of Purposes
which articulated the position of the Filipino people to the question of independence. The
Philippine constitutional representatives had made it clear in public documents the
declarations respecting the national aspirations of the Filipino people. They reiterated
that the only aim of the Independence Commission was to achieve nothing but
independence. As one of the first actions of the Commission of Independence, its
members recommended the sending of a special Philippine Mission to the United States.
This recommendation was approved by the Philippine Legislature in Joint Resolution No.
11. On April 4, 1919, the Philippine Mission was officially received by U.S Secretary of
War, Newton Baker. Senator Manuel Quezon, the President of the Philippine Senate and
the Chairman of the Mission, presented the claim of the Filipinos in their mission.352 In
his statement to the Secretary of War, Quezon said:
The Philippine Mission, Mr. Secretary, is here
charged with a high and solemn obligation. It is enjoined
with a noble and sacred trust. It is instructed to present the
great cause so essential and necessary to the happiness and
existence of the entire Filipinos. I refer to our national
birthright to be free and independent. We, therefore,
formally submit hereby the vital and urgent question of
Philippine Independence to you, and through you, to the
Government of the United States, in the confident hope that
351

Maximo M. Kalaw, Self-Government in the Philippines (New York: The Century Co., 1919),

352

Ibid., 147-148.

144.

170

it shall merit a just, righteous, and final settlement.


Independence is the great national ideal of the Filipino
people. The members of the Philippine Mission here,
representing all elements of Philippine life, are, one and all,
ready to testify to the absolute truth of this assertion. We
believe that this is the proper time to present the question,
looking to a favourable and decisive action, because of the
declared and uniform policy of America to withdraw her
sovereignty over the Philippine Islands and to recognize our
independence as soon as a stable government can be
established.353
In 1920, Warren Harding, a republican, won the U.S. election. When the news of
the election of the republican US president reached the Philippines, Filipino leaders did
not hopelessly see the change of president as a threat against their impending
independence. In fact, both houses of the Philippine Legislature sent President Harding a
resolution of congratulations. The message of the Philippine Legislature to the newlyelect president expressed their confidence that their repeated demands for independence
would finally be resolved. Senator Quezon commented that the Filipinos believed that
Americans had always dreamt a national policy for the Philippines. He was confident that
the success of the republicans in the US election would not hamper the progress of
Filipinization in the Philippines. He concluded: We have reasons, therefore, to hope
that, under the administration of President-elect Harding the advancement attained by the
Filipino in their liberties under the present regime will continue, and we hope that his

353

Instructions from the Commission of Independence to the Philippine Mission, Manila, March

17, 1919.

171

administration will, with respect to the Philippines, be guided by the same lofty spirit and
patriotic inspiration displayed by his predecessor in power.354
Following the democratic policy of his predecessor, President Harding recognized
that it was one of the duties of his administration to settle the independence issue of
Philippines. On the issue of granting independence to the Philippines, President Harding
referred to the condition of establishing a stable government set forth in the preamble
of the Jones Law. Reading the reports about the situation in the Philippines, President
Harding could not act upon the important issue of independence because the evidence
available to him was not of the same tenor. These contradicting views on the
Philippines readiness disturbed President Harding that he deferred his judgment until he
had an adequate evidence to base his decision whether to hand over the control of the
Philippine government to Filipinos.355
To help gather more evidence on the subject of Philippine independence, on
March 20, 1921, President Harding appointed General Leonard Wood and former
Governor-General of the Philippines Cameron Forbes in a special mission tasked to make
a survey of the entire Philippine situation. The special mission arrived in Manila on May
4, 1921. Their travel to the whole Islands took four months. In the first week, the
Mission stayed in Manila where they held conferences with officials of the Central

354

Francisco M. Africa, Who is Warren Gamaliel Harding?, The Philippine Review 5, no. 12
(1920): 848-849.
355
Letter to the Secretary of War, Warren Harding, War Department, Washington, March 23,
1921 in Report of the Special Mission on Investigation to the Philippine Islands, 7.

172

Government with representative Americans, Filipinos, and foreigners of every walk of


life. During the time of their travels to every province and municipality, General Wood
and ex-Governor-General Forbes were accompanied by an experienced correspondent of
the Associated Press, a special correspondent of one of the leading American dailies
committed to giving independence to the Filipino people, and one of the editors of the
leading Manila Journal.356
After months of survey of the whole Islands, Wood and Forbes report to the
President Harding reflected the deplorable situation of the Philippines. They concluded
that the situation in the Islands was unfavorable to the grant of Philippine independence.
The report confirmed that the period when the country was under the Filipino hands was
a disaster which brought a lot of inefficiencies in the colonial government. They
recommended that Americans should continue their supervision. In the report submitted
to President Harding on October 8, 1921, Wood and Forbes concluded:
We feel that with all their many excellent
qualities, the experience of the past eight years during
which they have had practical autonomy, has not been
such as to justify the people of the United States
relinquishing supervision of the Government of the
Philippine Islands, withdrawing their army and navy,
and leaving the islands a prey to any powerful nation
coveting their rich soil and potential commercial
advantages.
In conclusion we are convinced that it would be a
betrayal of the Philippine people, a misfortune to the
American people, a distinct step backward in the path
356

United States, Report of the Special Mission on Investigation to the Philippine Islands to the
Secretary of War (Washington: Government Printing Office, 1921), 11.

173

of progress, and a discreditable neglect of our national


duty were we to withdraw from the islands and
terminate our relationship there without giving the
Filipinos the best change possible to have an orderly
and permanently stable government.
We recommend that the present general status of
the Philippine Islands continue until the people have
had time to absorb and thoroughly master the powers
already in their hands.357
In the end, Wood-Forbes mission intensified the idea that the general condition in
the Philippines showed the unfitness of the Filipinos for independence. As a result, the
mission emphasized the need to increase the authority of the Governor-General by
bestowing him more power over the Filipinos. As explained in the report, under no
circumstance should the American government permit to be established in the Philippine
islands a situation which would leave the United States in a position of responsibility
without authority.358 While Filipinos in the government petitioned against the
conclusion of the report saying that it was an indictment to their competency, on October
15, 1921, President Harding appointed General Wood to become the Governor-General
of the Philippines. He took over the office from Vice-Governor and Judge Charles E.
Yeates who assumed the Governor-General position after Francis Burton Harrison left on
March 5, 1921. As the head of the Special Mission, Wood was found to be the best man
to accomplish the recommendation he articulated in his report.359

357

Ibid., 46.
Ibid.
359
Ibid.
358

174

Thereafter, Woods acceptance of the Governor-General position changed the


tone of Philippine politics after 1921. With the conclusion of the report against the grant
of independence and the political change in the United States-from Democratic to
Republican controlthe idea of Filipinization policy of Harrison received even more
pessimistic views. In an interview, Governor-General Wood affirmed that Filipinos were
still premature to rule an independent country. According to Wood, excessive and rapid
Filipinization from 1914 to 1921 eliminated experienced Americans and installed
incompetent Filipinos in the government. He was afraid that self-rule in the hands of the
Filipinos would bring nothing but a disastrous experience.360

C. Infant Mortality as a Flaw to Self-Rule


Starting in 1921, the Americans were continued to be alarmed by the condition of
infant mortality under the Filipino control. Seeing that the problem on infant mortality
could not get any better after his tour of the Islands, Governor-General Wood initiated
the idea of convening a national conference on infant mortality. Wood was very wary of
the Filipino efforts in decreasing the number of infant deaths in the country. He was very
particular to the lack of coordination among the government and other social
organizations, mostly under the Filipino control, in ending the crisis among Filipino

360

Edward Price Bell, Future of the Philippine: Interviews with Manuel Quezon, President of the
Philippine Senate; Sergio Osmena, Senator and ex-Speaker of the Philippine Lower House, and Maj-Gen.
Leonard Wood, Governor-General of the Philippines (The Chicago Daily News, 1925), 21.

175

infants. He said that this conference would discuss matters pertaining to infant
mortality, health and sanitation and other public welfare activities, and to bring about
closer cooperation and coordination of work done by various agencies.361 By the
initiation of Wood, the First National Conference on Infant Mortality and Public Welfare
was held in Manila from December 6 to 10 in 1921. At the Conference, a total of 1293
delegates attended: 113 represented womens club, 41 represented puericultures, 63
represented provincial boards, and the remainder represented schools and other
institutions.362

Figure 5 Governor-General Wood and Party at the First National Conference on Infant
Mortality and Public Welfare363

361

Office of the Public Welfare Commissioner, Proceedings of the First National Conference on
Infant Mortality and Public Welfare (Manila: Bureau of Printing, 1922), 7. [hereafter Proceedings of the
First National Conference on Infant Mortality and Public Welfare]
362
Frank Charles Laubach, The People of the Philippines: Their Religious Progress and
Preparation for Spiritual Leadership in the Far East (New York: George H. Doran Company, 1925), 425.
363
Office of the Public Welfare Commissioner, Governor-General Wood and Party at the First
National Conference on Infant Mortality and Public Welfare, photography, 1920, printed in Proceedings
of the First National Conference on Infant Mortality and Public Welfare.

176

Since the start of the tutelage of Filipinos under the critical eye of the Americans,
the problem of high death rate of infants became a big challenge for the Filipino leaders
to prove that they were fit to run an independent country. The Americans saw the serious
infant mortality as a direct blow to the competency of the Filipinos. For them, a country
that was progressive would have a good size of population which was to be supported by
a high birth rate. Unfortunately, the Philippines could not be proud of this mission.
Teodoro M. Kalaw, the Secretary of the Interior, attested to the awful infant mortality of
the country and described it as serious initial obstacle to the Philippines goal of
independence. He addressed:
Out of every thousand children born in the
Philippine Islands, three hundred and twenty die under
the age of one year. What eloquent and distressing
figure! The practices of our mothers, who are ignorant
as regards the care of infants before and after
confinement, are deplorably backward and are
tantamount
to
infanticide
considering
their
consequences. Thousands and thousand of infants die
because they have not received any medical attendance
nor even the care counseled by the most elementary
precepts of hygiene. The result is that the population of
the Philippines has not increased as much as it ought to,
and the development of the Filipino race, which has a
potential faculty for expansion and advancement, is
thus prevented by a serious initial obstacle.364
Hon. Sergio Osme a, the Speaker of the House of Representatives, was slightly
upset with the bad impression of Governor-General Wood towards the work of Filipinos
on the problem of infant mortality. In his address in the First National Conference on
364

Proceedings of the First National Conference on Infant Mortality and Public Welfare, 15.

177

Infant Mortality, Speaker Osme a clarified that Filipinos had done much in improving
the health of their own men especially the infants. He cleared that the conference was not
the first in fighting infant mortality and the similar line of efforts had already been
introduced before. He said: this (the First National Conference) is the natural result of
the tremendous progress of the Filipino people along the line of sanitation and public
hygiene. The campaign is part of the health activities of the Government since its
establishment.365 Osme a traced the beginning of the Filipino campaign against infant
mortality in 1903, when the Government launched rigorous efforts against diseases that
claimed big toll of deaths every year. The establishment of Gota de Leche, through a
private initiative, and a Liga Nacional was another gradual step to help the children of
the poor.
In an article of Manila Daily Bulletin, Speaker Osme a was firm on its
declaration that public health and sanitation in the Philippines had gradually developed.
He gave comments against the sentiment of Governor-General Wood towards the loss
of lives in the country. Osme a took this as a negative evaluation of the Filipinos
competence in handling the problem. He was quoted saying: No impartial critic of our
institutionsof the administration of justice, of public works, of public instruction, of
public ordercan say that we have not progressed along these lines. You are here not for
the purpose of creating a sentiment against infant mortality and lack of sanitation, for that

365

Address of the Hon. Sergio Osmena, Speaker, House of Representatives in Proceedings of the
First National Conference on Infant Mortality and Public Welfare, 21.

178

sentiment already exists and has existed in the past, but rather to coordinate scattered
forces in order that our work may be more effective.366 All commentaries of Osme a
pointed out that the Filipino Government had not taken a blind eye to the need of a
campaign that would conserve the Filipino race. At the organization of the government
under Filipino control, public health was among the first thing to be attended to by the
Philippine Legislature. Osme a said that the Filipinos had always been ready to launch a
national campaign for saving children. He added: The idea (national campaign against
infant mortality) having been accepted by the people through past activities can now be
pushed in a general campaign managed by a central office in Manila.367
Apart from Speaker Osme a, other Filipino politicians, scientists, and physicians
believed that the topic of the conference was a challenge to their political autonomy.
Talking about infant mortality as serious public issue was a diminution of the Filipinos
level of leadership in the eyes of the Americans. However, this did not stop Filipinos
from completely controlling the entire colonial government. Filipino legislators
attempted to counter the power of Governor-General Wood by preparing a bill which
was to create an independent Department of Public Health. The PHS had been under the
Department of Public Instruction which was then supervised by an American vice
governor. Not only did the Filipino want to sever the PHS from the supervision of an
American, but also hoped to increase the efficiency of the health department. The
366

Manila Day Bulletin, 1921, cited in Proceedings of the First National Conference on Infant
Mortality and Public Welfare, 21.
367
Proceedings of the First National Conference on Infant Mortality and Public Welfare, 21.

179

Department of Public Instruction embraced two bureausthe PHS and the Bureau of
Education. Filipinos thought that the separation of the two bureaus and the formation of
an independent Department of Public Health would speed up health services in the
country. Governor-General Wood, however, did not agree to the idea and vetoed the
proposed bill.368

D. Training of Nurses and Establishing Puericulture Centers


As emphasized in the Wood-Forbes report on the investigation of the Philippines,
the Filipinos had not been successful in improving the health condition. Wood
particularly mentioned the shortage of medical facilities. He reported that the average
Filipino died without medical attendance or nursing. The excellent health service that the
Americans worked hard to maintain had become inert after the Americans abdicated
their positions to Filipinos. Wood said that most of the personnel who remained at
service had lost the zeal to continue their health works. As the Filipinos assumed the
government, the appropriations for sanitary work and medicines were always not
sufficient. Wood referred to the statistics of the PHS showing that diseases, especially
beriberi, malaria, and tuberculosis, which could have been prevented became even worse
during the period of the Filipino control. With infant mortality still showing a steady

368

Dr. Jose P. Bantug, Progress in Public Health Work in Occidental Negros, Monthly Bulletin
of the Philippine Health Service 6, no. 10 (1926): 481. See also Frank Golay, Face of Empire: United
States-Philippine Relations, 1898-1946 (Manila: Ateneo de Manila University Press, 1997), 244.

180

increase, Wood attributed the failure of the Filipino government to the shortage of good
nurses. He explained that: wherever you find good nurses you find lowered infant
mortality and improved sanitary conditions.369
On 1 May 1919, Public Health Service was one of the new activities introduced
in the Division of Sanitation in Manila. Although this service had been started in 1915,
the activities of the nurses from this institution only began to fully take effect after its
reorganization in 1919 which increased its number of personnel and the scope of
activities.370 In September, 1915, the work of the district nurses in Manila was started
with one American nurse, one Filipina nurse, and one dietist. The district nurses planned
to extend their work to the provinces but decided to launch their two-month course in
instruction and practice in Manila. They sent letters to different hospitals to ask for their
cooperation. Later on, several nurses had applied to take the course in Public Health
Nursing and were thereafter appointed to positions in Manila.371
The reorganization of the Office of Public Health Nursing in Manila had been
made with the main objective of reducing the infant mortality. As the Public Health
Nursing carried out its work, infant mortality had been reduced within only a short period
of time. From the time of its reorganization in 1919, infant mortality showed a reduction
in 1919 from a high number of deaths in 1918. One of the duties of the Public Health

369

Report of the Special Mission on Investigation to the Philippine Islands, 31.


Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1919 (Manila, Bureau of Printing, 1920), 89. [PHS 1919]
371
PHS 1916, 169.
370

181

Nursing in Manila was to control beriberi among infants. The promising work of the
public nurses resulted to a decrease in the number of deaths from infantile beriberi in
Manila. In 1918, there were 597 cases of deaths among infants from infantile beriberi.
The number of cases went down to 354 in 1919 and the PHS owed this improvement
largely to the impressive work of the nurses.372
To educate the public nurses about the nature of infantile beriberi, a set of
instructions were distributed among them and illustrated by oral explanation and
discussion by a trained instructor. The instructions concisely described the nature of
infantile beriberi together with its signs and symptoms. In addition, the instruction also
contained information on prevention of infantile beriberi by the use of tikitiki extract. As
written in the instructions, the nurses would manage the infantile beriberi cases by giving
them tikitiki extract. The mother diagnosed to have beriberi was also treated as well. The
nurses were also instructed to take care of the hygiene and proper diet of both mother and
infant. In administering the tikitiki extract, the nurses would give three teaspoonfuls of
the extract every day until the baby reached four months. 373
In case after-effects would appear after the administration of tikitiki, which was
usually diarrhea, the nurses would refer the case to the physician for proper advice and
treatment. Under the instruction of the physician, the public health nurse would continue
to attend the patients. Mrs. Carmen R. Leogardo, chief nurse of the Public Health
372

PHS 1919, 88-89.


Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1920 (Manila, Bureau of Printing, 1921), 159. [hereafter PHS 1920]
373

182

Nursing, emphasized the need of continuing with the practice of distributing tikitiki for
free to those who needed it especially the poor whose mode of living made them more
vulnerable to contract the disease. Mrs. Leogarda further reported the success of the
tikitiki treatment under their administration:
The distribution of tiki-tiki and the giving of
instruction in connection with its use, form one of the
most important activities of the Public Health Nursing
Division. The treatment is administered at once to those
babies whose mothers have shown symptoms of the
disease during the period of their pregnancy or any
history of beriberi either in themselves or in previous
children. That the treatment has been productive of the
highest results is shown conclusively by the following
facts and figures: Out of 491 cases of babies without
symptoms of beriberi by those mothers were affected
with the diease, 485 or 98.77 per cent developed no
symptoms of beriberi. In the cases of babies showing
symptoms of beriberi, 415 were reported as cured and
138 as improving out of a total of 553 cases.374
In the clinics, public nurses gave lectures and made practical demonstrations on
Sundays between 8 and 10 a.m. to mothers concerning the health and welfare of their
babies and best preparations of artificial food with the ordinary home facilities. Babies
were weighed to determine if there was any progress on their health condition. To those
pregnant, mothers, and babies who could not come to the clinic or health station during
work days, the public nurses gave them treatment. All nurses were also called to
participate to the Carnival Exhibit of the PHS where they distributed bulletins and
placards dealing on prenatal and postnatal care to the public. There were also important
374

Ibid., 160.

183

duties outside of the clinics the nurses had to attend. The nurses regularly went to the
homes of babies to register their birth in case they were not yet registered. They also
visited the home of mothers and prospective mothers to give them instructions as to
proper care of pregnancy and of babies. To families with history of beriberi or when their
babies showed signs of the disease, the public health nurses would come to their home to
bring and supply them with tikitiki extract and give instruction on how to use it.375 The
table below summarized the treatments of infants by tikitiki extract in the city of Manila:
Table 26 - Total number of Treatments of Public Health Nursing in all Stations in
Manila (1920)
Health Stations

Treatment in
Clinics
Station No. 1- Intramuros
379
Station No. 2 Meisic
775
Station No. 4- Sampaloc
104
Station No. 5 Tondo
209
Station No. 6 Paco
402
Total
1,879
Source: Philippine Health Service (1920)

Treatment in
Homes
179
1,202
503
996
446
3,345

Meanwhile, in 1921, Wood especially mentioned the urgent need for professional
nursing. He wished that more nurses could be trained to do special work of his
campaign.376 Believing to the ability of women in their maternal duties, Wood called on
the help of women in his campaign against infant mortality. In his address, he mentioned:
The needless of loss lives in the Philippines must
be terminated. The percentage of infant mortality is onethird of all born, very much greater than it should be, very
375
376

Ibid., 161-162.
Proceedings of the First National Conference on Infant Mortality and Public Welfare, 18.

184

much greater than is necessary. We look especially to the


women of the Philippine Islands to bring about better
conditions. The men are going to help also, but the work
will concern women mostly. Their natural instinct will be
touched by this unnecessary loss of lives which no people
can stand. The campaign is going to be largely one of
general education, and we want all the women of the
Islands as well as the men to take up this work. Education
is not a very difficult thing. We want you to teach ignorant
mothers how to take care of their children. We need better
centers everywhere in which all that is good for children is
taught, one of them being the matter of proper diet. We
have the means in the Islands for preparing a diet at little
cost.377
Kalaw also recognized the important role of women in the care of infants. He noted:
And, lastly, most especially and in a way which appeals most strongly to our heart and
our patriotism, we need the cooperation of the woman, be she a Filipina, an American, or
a foreignerthat a cooperation which she has already accorded to us in the past and
which constitutes an achievement and one more glory for the Filipino woman. We need
the cooperation of women particularly because the purpose of this campaign, the goal
towards which we are striving, is but one: the education of our mothers.378
Assisting the PHS in improving the nursing education in Manila, the International
Health Board of the Rockefeller Foundation in the Philippine Islands stayed in Manila
and extended their stay over a period of nine months. Through the efforts of Miss Alice
Fitzgerald, formerly in charge of the division of nursing of the League of Red Cross
Societies, the standard of nursing in various hospitals of Manila became satisfactory.
377
378

Ibid.
Ibid., 16.

185

Miss Fitzgerald won the confidence of her Filipino Colleagues and served as an advisor
in the PGH. As part of her mission, Miss Fitzgerald succeeded to establish a school for
public health nurses. This school graduated its first class of 30 nurses in January, 1923.
Moreover, through her efforts, the Filipino Nurses Association and registry of nurses
were organized. Inspired to continue the work of Miss Fitzgerald, the PHS also exerted
their efforts for the establishment of the school for public health nursing. The PHS,
through a readjustment of certain items in the budget, provided a financial support of an
amount of P25, 000 solely for this purpose.379
In 1922, there was a greater demand of tikitiki extract. From 1,457 tikitiki bottles
distributed in 1921, the Office of the Public Health Nursing distributed 5,298 bottles of
tikitiki extract, of which 3,473 were distributed at the Health Center and 1,825 were
supplied by nurses at the home of the patients. The nurses delivered tikitiki extract to the
homes of only those who were unable to go to the Health Center for some other reason.
To prevent patients from seeking advice from their ignorant neighbors, the nurses
encouraged them to go to the Health Center to personally receive their tikitiki extract so
that nurses could also give them consultation of their sickness380
Table 27 - Reports of the Public Health Nursing about Beriberi cases (1921-1922)
Findings
1921
1922
Mothers found without signs of beriberi during pregnancy
2,490
4,802

379

Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1922 (Manila, Bureau of Printing, 1923), 126-127. [hereafter PHS 1922]
380
Ibid., 110.

186

Mothers found without signs of beriberi during previous


pregnancies but with signs during last pregnancy

2,531

712

Mothers found with signs of beriberi during present pregnancy


but with signs during the previous pregnancies

2,883

783

Mothers found with signs of beriberi in every pregnancy

1,367

349

Babies found without signs of beriberi born to mothers without


signs of beriberi
Babies found with signs of beriberi born to mothers with a
previous history of beriberi
Babies under tiki-tiki treatment given as prophylactic

2,301

4,575

1,547

1,265

2,424

1,725

Babies under tiki-tiki treatment given as curative

2,043

373

Babies recovered by tiki-tiki treatment


Babies that died of beriberi during the tiki-tiki treatment

1,660
403

660
279

Source: Philippine Health Service (1921-1922)


The Health Center also submitted its report about the work it accomplished. As
the physicians and nurses in the Health Center continued its work of providing medical
treatments on mothers and on babies under two years of age, they noticed that mothers
and expectant mothers showed more enthusiasm in health education. Even on slight
illnesses, mothers would seek medical advice from the Health Center. Those mothers
who were far from Intramuros requested the service to hold at least one day clinic every
week in the health station of their respective districts. To extend the service of the Health
Center to poor people, the request was submitted to Dr. S. V. Del Rosario, the Assistant
Director of the Public Health Nursing Office. The request was finally granted on October
15, 1922 and afternoon clinics established in each health station of the city. Among the

187

districts of the city, Paco and Tondo had the most attendance. To babies with beriberi,
tikitiki extract was given by the Health Center for free.381
In 1925, the four health centers were maintained, one in the central office in
Intramuros, one in Meisic, one in Paco, and one in Sampaloc. In these centers
consultations were held mainly to attend maternity cases and child welfare. During the
year, a total of 307 consultations were on record. The attendance of people was 11,129,
of which 7,734 were children, 282 prenatal cases, 2,894 postnatal, and 219 cases other
than maternal and children.382 Infantile beriberi was still present in most of the infants
brought in the health centers. Symptoms of the disease were found in 46 of cases, 4 of
which were of the severe type. Infants were given tikitiki extract until they were six
months old or over.383
The Government made an extensive propaganda on the importance of maternity
and child care through the establishment of puericulture centers. These institutions were
organized and managed in accordance with the provisions of Department of Interior
Order No. 10. The puericulture centers are required to meet certain standards prescribed
in the Department Order No. 10. Those puericultures that complied with the set standards
were provided with financial aid from the Insular Government.

384

Dr. Tranquilino

Elicano, medical officer of the Public Welfare Commissioner, defined the purpose of a
381

Ibid., 112-113.
Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1925 (Manila, Bureau of Printing, 1926), 110. [hereafter PHS 1925]
383
Philippine Health Service, Report of the Philippine Health Service for the fiscal year from m
.January 1 to December 31, 1926 (Manila, Bureau of Printing, 1926), 13. [hereafter PHS 1926]
384
PHS 1922, 117.
382

188

puericulture center as a place or station where mothers and expectant mothers can take
their bazzbies and children in order the condition of their health and development may be
ascertained and in order to secure such advice as is necessary for the proper care and
prevention of the common ailments of infancy and childhood. He said that the objective
of puericulture center was to take care of babies by educating the mothers of prevention
of infant sickness. The clinics also provided education for a proper diet of babies and
children as well as the nursing mother as it was recognized in the past that improper
feeding of infants was one of the chief causes of illness.385
Schools cooperated with the Office of the Public Welfare Commissioner by
teaching their students about the aim and activities of the puericulture centers.
Schoolgirls of the proper age were instructed of basics in infant care and were
encouraged to visit neighboring homes to assist mothers in the care of their babies. The
Office of the Public Welfare Commissioner gave many of the schools health posters with
colors and appropriate health statements that appealed to school children. 386 As a way to
stimulate the interest of the mothers in exercising good care of their infants, puericulture
centers held baby contests or baby shows once a year. Through these celebrations,
mothers were attracted to the work of the center and its activities. To supervise the

385

Dr. Tranquilino Elicano, How to organize and operate a puericulture center, in Proceedings
of the First National Conference on Infant Mortality and Public Welfare, 44.
386
Bureau of Education, Twenty-third Annual Report of the Director of Education from January
1, 1922 to December 31, 1922 (Manila: Bureau of Public Printing, 1923), 51-52.

189

events, representatives of the Office were sent to cooperate with the puericulture centers.
In 1927, 49 baby contests were held.387
On August 30, 1923, De Jesus issued Circular V-72 which instructed the health
officers and public health nurses of PHS to coordinate with the Office of the Public
Welfare Commissioner. This was to have a better understanding between the two offices.
De Jesus saw the coordination between the two offices would distribute the work of
nurses and physicians to a greater number of people through the puericulture centers.388
Seeing the necessity of defining the work of each office, in 1924, the PHS and the Office
of the Public Welfare Commissioner made an arrangement to avoid duplication of work.
The two offices designated that nurses of the puericulture centers would be on duty in
certain districts of the city and nurses of the health centers in other districts and health
stations. The health centers of the PHS covered the districts of Intramuros, Ermita,
Malate, Meisic, Sampaloc, Santa Mesa, San Miguel, and Paco. 389
To train the workers of puericulture centers especially the nurses, the Office held
training for nurses for one month. Most of the trainings were held in Manila. The city
maintained five training centers and one maternity house which were located in the
districts of Tondo, Sampaloc, San Nicolas, Santa Ana, and Singalong. Even those nurses
who were taking up post-graduate work in the School of Public Health Nursing attended
387

Office of the Public Welfare Commissioner, Sixth Annual Report of the Office of the Public
Welfare Commissioner from January 1, 1926 to December 31, 1926 (Manila, Bureau of Printing, 1927),
177. [Sixth Annual Report of the Office of the Public Welfare Commissioner]
388
PHS1923, 683.
389
Philippine Health Service, Report of the Philippine Health Service for the fiscal year from
January 1 to December 31, 1924 (Manila, Bureau of Printing, 1926), 16. [hereafter PHS 1924]

190

trainings in the centers. In 1926, 43 graduate norses for puericulture centers, 11 for the
American Red Cross, and 35 post-graduate students of the School of Public Health
Nursing were trained by the training centers of the city. The Office also had a special
work of establishing a school of midwifery for the proper training of midwives to replace
the old and ignorant manghihilot. The maternity house offered training to students of
midwifery and conducted demonstrations in the University of the Philippines.390
To assist in the control of infantile beriberi, puericulture centers were also
entrusted by law to administer in the distribution of tikitiki extract manufactured by the
Bureau of Science. By Act 2744, tiktiki was distributed without charge among the poor.
Since 1921, the Office of Public Welfare Commissioner, through the puericulture
centers, had been one of the main distributors of tikitiki extract. It was a consensus
among hospital workers, medical officers, of the PHS and puericutlures in Manila that
the administration of tikitiki contributed to the decrease of infantile beriberi in the city. 391
Refer to the table below:
Table 28 Tikitiki extract distributed by the Office of Public Welfare
Commissioner (1921-1927)
Year
Number of bottles
1921
17,381
1922
46,730
1923
53,625
1924
54,253
1925
52,344
1926
49,790
1927
52,208
390
391

Sixth Annual Report of the Office of the Public Welfare Commissioner, 173.
Ibid., 172.

191

Source: Office of the Public Welfare Commissioner (1927)


Dr. Traquilino Elicano observed in the various puericulture centers located in
different parts of Manila that there were positive results in the condition of infant
mortality from infantile beriberi since 1923. In the statistics he furnished, Dr. Elicano
remarked: the number of admissions in the puericulture centers (in the city) increases
yearly, while the beriberi cases decrease notably and are proportional to some extent to
the number of bottles of tikitiki extract distributed; the same technical personnel
continued in charge of those puericulture centers, so that the factor of appreciation from
the point of view of diagnosis is eliminated practically. The private medical
practitioners in Manila agreed that their observation of the frequency of infantile beriberi
became rarer every day.392 Refer to the table below:
Table 29- Number of Infants below one year admitted in Puericultures in Manila,
Total number of Infantile Beriberi cases, and Number of Tikitiki Extract
Distributed (1923-1927)
Year
Admissions under 1 Infantile Beriberi
Bottles of tikitiki
year
Cases
extract distributed
1923
3,735
1,127
9,960
1924
5,097
837
12,128
1925
5,644
434
12,153
1926
6,634
124
13,553
1927
6,501
165
15,932
Total
27,611
2,687
63,726
Source: Office of the Public Welfare Commissioner (1927)
One challenge against the huge campaign against infant mortality in the country
was the lack of trained personnel that could be trusted to manage the puericulture centers.
392

Jose Albert, Studies in Infantile Beriberi, 308-309.

192

The higher rate of infant mortality in the Provinces could be explained by the irregular
distribution of physicians in the Islands. In Manila alone, there were not less than 250
physicians which was a lot for only one city. The other Provinces experienced a shortage
of physicians and as a result, many infants in the towns died without the attendance of
medical men.393

E. Filipinos Capacities to Control Infantile Beriberi


As the Americans casted more doubts on the Filipinos administration of child
health and welfare, the alarming case of infantile beriberi in the Philippines was a point
against the Filipinos. The problem of infantile beriberi was opened up in the Conference
and was noted as an important factor in infant mortality. Filipino politicians and
physicians saw the topic of the Conference as a public declaration of their negligence to
take care of infants. To give a lie to the bad impression, Filipinos presented their
successful work against infant mortality through the persistent dedication of Filipino
voluntary organizations. In the first decade of American regime when many infants were
observed to have died of a disease resembling beriberi, it was not the Bureau of Health
but the Colegio Medico-Farmaceutico de Filipinas which tried to finally settle the
ambiguous nature of beriberi by appointing a committee to study the matter. The
committee was entirely composed of Filipinos: Dr. Jose Albert, as the chairman, Manuel
393

Fernando Calderon, Obstetrics and its Relation to Infantile Mortality, The Philippine Journal
of Science 17, no. 1 (1920): 19.

193

S. Guerrero394, as secretary, and Ariston Bautista, Benito Valdes, Galicano Apacible,


Joaquin Quintos, and Fernando Calderon, as members. The decision in the formal
meeting led to the organization of La Liga Nacional Filipina para la proteccion de la
Infancia whose aim was to protect the life and health of Filipino infants. The
organization carried out their humanitarian mission through the following means:395
1. Publicity: lectures, publications, etc.
2. The union of kindred associations for the purpose of easy coordination but
without the unnecessary loss of individual freedom of action.
3. The organization of provincial branches
4. The collection of all printed matter, as pamphlets, books, treatises, by-laws,
reports, etc. Which in general carry information relative to institutions
concerned directly with childhood.
5. The study of all protective measures which may be proposed to charitable
institutions, public offices, organizations, and patrons of public interests, with
a view to safeguarding children against all the numerous factors which
threateningly beset infant life. And for the purpose of lowering the infant
mortality rate, the league proposes likewise to aid whole-heartedly in the

394

Manuel S. Guerrero was a medical doctor who graduated from University of Santo Tomas in
1902. His had interests in the study of cholera and infantile beriberi. His paper on infantile beriberi earned
him admission into the Colegio Medico-Farmaceutico de Filipinas in 1905.
395
Manuel Artigas Cuerva, Beri-beri from a Historico-Bibliographical Point of View, Monthly
Bulletin of the Philippine Health Service 3, no. 12 (1923): 531-532.

194

foundation and organization of all associations whose aim is to protect


effectively children in the first year of existence.
The association submitted its report wherein it was concluded that infantile
beriberi was considered to be the principal cause of infant mortality in the Islands.
Filipinos of the association were entrusted to distribute safe milk and tikitiki extract to
infants with beriberi. In 1918, Liga Nacional submitted its fifth report to the Legislature
with this conclusion:
For all that has been presented this body believes
and thinks that the period of trial and experimentation in
the treatment of infantile beriberi with the extract of
tikitiki, can be said to have concluded, and that this
remedy discovered in 1911 by the American doctors,
Chamberlain and Vedder, administered in convenient
doses is the drug most effective and sure which
medicine counts on to-day to combat this terrible
disease which pays a high toll of innocent breast-fed
infants yearly in Manila and which is responsible for
about 30 per cent of the infant mortality. In this respect
it can be affirmed that the resolution presented by the
Segunda Asamblea Regional de Medicos y
Farmaceuticos de Filipinas,: converted into Angeles
Bill... is one of the most beneficial laws and is of
immense significance for the future of the Filipino
people since that law tends to solve in part the problem
of infant mortality and depopulation.396
Despite the shortcomings such as the unequal distribution of tikitiki to the poor
and the shortage of nurses and doctors, Dr. Joaquin Quintos, a member of the Board of
Directors of the Gota de Leche and Liga Nacional, said in his address in the conference
396

Jose Albert, Studies in Infantile Beriberi, 306.

195

that the Filipinos had contributed immensely to the knowledge of infantile beriberi. He
challenged the medical superiority of the Americans by emphasizing that it was a
Filipino who first discovered the cause of infant mortality. He clarified that it was a
Filipino who first noticed infantile beriberi in the Philippines.397
At the time when many American practitioners and medical experts were
completely clueless with a certain disease that killed many infants in Manila, Dr. Quintos
gave by right the undisputable credit to Manuel S. Guerrero for having been the first man
in the Philippines to have made known that a local disease known as taon was the same
as infantile beriberi. In a memorandum he read before the Colegio Medico Farmaceutico
of the Philippines on October 10, 1904, Professor Guerrero affirmed that the taon was the
beriberi of breast-fed infants that Hirota discovered in Japan.398 In his paper entitled,
The Etiology, Symptomatology, Clinical Forms, Diagnosis, and Pathogenesis of
Beriberi in Children, Guerrero related his observations of 103 clinical cases of the
disease called taon to the disease occurring in children nursed by mothers suffering from
beriberi and called by Hirota as infantile beriberi. In this paper read before the Colegio
Medico-Farmaceutico de Filipinas, Guerrero produced revolutionary ideas surrounding
the disease taon.399

397

Joaquin Quintos, Infantile Beriberi: Its Causes and Its Remedies, in Proceedings of the First
National Conference on Infant Mortality and Public Welfare, 87. (See Appendix E)
398
Joaquin Quintos, Infantile Beriberi: Its Causes and Its Remedies, 87.
399
Vedder, Beriberi, 156.

196

Since Guerreros findings were only supported by clinical observations and no


necropsies, the Americans and his other colleagues were not convinced of his study and
ignored the possibility of the existence of beriberi in infants. Guerrero, later on, would
underline the grave mistake of the Americans in disregarding his study. In an article in
Revista Filipina de Medicina y Farmacia, Guerrero wrote: This disease (infantile
beriberi), which constitutes a factor of the first order in the excessive infant mortality in
these Islands, was completely unknown in the annals of Tropical Pathology, and the
practitioners here following the medical profession mistook the illness for infantile
enclampsia, convulsions, or epilepsy, or even nervous exhaustion as caused by gastralgia
or colic.400 In 1905, there was a few numbers of native doctors who believed to the
disease introduced by Guerrero and began attributing death of infants to infantile beriberi
even with autopsy.401 On November 19, 1905, at the program given by the Philippine
Feminist Association at the Liceo De Manila, Dr. Fernando Calderon noted the high
mortality of children and suggested the need for the Municipal Board of Manila and the
Bureau of Health of furnishing clean and cheap dwellings believing that this could
eliminate deaths of children from taon.402
The delegations in the First Biennial Meeting of the Far Eastern Association of
Tropical Medicine revealed their scepticisms in accepting the conclusion that taon was
the cause of the high infant mortality. They were not convinced of the Filipinos idea that
400

Cuerva, Beri-beri from a Historico-Bibliographical Point of View, 526-527.


Vedder Beriberi, 156.
402
Cuerva, Beri-beri from a Historico-Bibliographical Point of View, 528.
401

197

taon was the same as infantile beriberi. Dr. Musgrave did not believe that infantile
beriberi was identical with taon. Disregarding the contribution of Filipinos discovery,
Dr. Musgrave said that the term taon be suspended in the medical field until there was a
study describing the etiology of the local disease. Dr. Clark of Hongkong also said that it
was premature for the Filipino doctors to conclude that the taon and infantile beriberi
was nutritional in nature.403
Before the discovery of Guerrero, the disease taon had never been fully
explained. Some doctors regarded taon as sane as eclampsia and a form of nervous
exhaustion. Guerreros work was therefore a huge undertaking for the Filipinos to
unravel an unknown tropical disease that even the Americans failed to study. It was
Guerrero who arduously studied and discovered that it was infantile beriberi that caused
the excessive number of deaths of nursing children who died during their first year. As
Manuel Cuerva, member of the Royal Academy of History, said: To him is due the
discovery that what was formerly the dim and unrecognizable taon is now a known
nosological specimen, seeing that it was he, through his investigations, who classified it
thus and described, in the masterly manner he so well knew, its etiology and pathologic
and treatment, including the exact rules to be observed in order to preclude the increase
of its victims.404

403
404

Jose Albert, Studies on Infantile Beriberi, 303.


Cuerva, Beri-beri from a Historico-Bibliographical Point of View, 528.

198

After Guerreros splendid study of the disease taon, other Filipino doctors
became interested to study further the nature of the local disease. In 1908, Jose Albert
attempted to confirm the clinical diagnosis of Guerrero by necropsy. Albert reported a
case of infantile beriberi with autopsy findings and from this time on, the disease called
taon had been more properly called as infantile beriberi. He ascertained that the
pathological findings from necropsy confirmed the clinical observations and even
demonstrated the degeneration of the nerves. Alberts contribution cleared all doubts of
other people regarding the possible manifestations of beriberi in infants by substantiating
the clinical observations with autopsy.405 Having confirmed that the taon was in fact a
case of infantile beriberi, other medical men of the Philippines were thankful of the
unique opportunity of knowing for the first time the autopsy of a case of infantile
beriberi. The College of Medicine and Surgery had an archive of the autopsies of
infantile beriberi cases.406
With the contribution of the Filipino physicians, Cuerva took pride to say that the
success of the Filipino doctors in studying the nature of taon and infantile beriberi was a
proof of Filipinos competencies to achieve a free and sovereign nation. It was on the
strength of this achievement that Filipinos could belie the Americans low impression of
their capacities. Through the discovery of beriberi in infants by native doctors, Filipinos
showed that they were skilled enough to take care on their own the entire Filipino race.

405
406

Vedder, Beriberi, 241.


Cuerva, Beri-beri from a Historico-Bibliographical Point of View, 529.

199

This was clear-cut evidence of the capacity of Filipinos in solving the problem of their
country without leaving for training and education abroad. Cuerva said:
To take the case of beriberi as a concrete instance,
every effort we have put forth to solve the riddle evinces our
patent interest in a worthy cause, and may even place us
above the level of other peoples. The spectacle of our
children dwindling away by the thousands was of public
knowledge and of regrettable occurrence; and our inherent
love for the flesh of our flesh and our fundamental love for
humanity in general made us all knuckle down to the grim
task so as to end once for all a holocaust we could not
behold without anguish. The creditable accomplishments so
excellently performed by Dr. Manuel Guerrero blazed new
trails through the jungles of uncertainty and surmise, and
Dr. Jose Albert proposed the investigation of mortality from
infantile beriberi in order to determine more securely its
causes and recommend the proper remedies.407
To confirm if the efforts of the PHS to increase the population of the country
were successful, the number of registered births must have increased since 1918. The
statistics of the PHS showed that the number of births in Manila had considerably
increased from 1918 up to 1927. From 9,083 total registered births in the city, it went up
to 15,386 in 1927. The continued increase in number of infants in the capital was taken
as a sign of improvement of Filipinos in their administration of the public health and
welfare. (See Table 30) Since infantile beriberi had taken a huge toll in infant deaths in
Manila, the PHS gave a special attention to the control of the disease. The figures of the
PHS showed that despite all their efforts and other institutions to eliminate infantile
beriberi, the number of deaths from this disease had increased in 1920 and 1921 and had
407

Ibid., 529-530.

200

only decreased a little in 1922. The PHS noted that their failure to decrease the number
of deaths from infantile beriberi might be from the lack of unpolished rice in the markets.
The increase number of deaths was also partly caused by the poor nutrition of the
indigent mothers.408 Since 1924, however, deaths from infantile beriberi gradually
showed a considerable decreased from the 739 deaths in 1923. In 1927, only 280 cases of
deaths from infantile beriberi were recorded. Refer to the table below:
Table 30 Infant Mortality due to Beriberi in Manila, 1918-1927
Year
Total Births
Death from Infantile
Beriberi
1918
9,083
597
1919
10,029
354
1920
12,614
555
1921
12,261
722
1922
13,092
671
1923
14,598
739
1924
13,969
664
1925
15,046
616
1926
14,813
538
1927
15,386
280
Source: Philippine Health Service (1918-1927)
In the PGH, it was also observed that infants suffering from infantile beriberi
showed a decrease in number of cases admitted in the childrens ward. In 1918, there
were 40 cases of infantile beriberi admitted in the pediatrics ward of PGH. Since 1918,
number of cases of the disease in the hospital fluctuated until it consistently showed a
decreasing number since 1924. In 1927, only six cases were admitted. Refer to the table
below:
408

PHS 1922, 116.

201

Table 31- Total Admission of Infantile Beriberi cases in pediatrics ward of


Philippine General Hospital, College of Medicine, University of the Philippines
Year
Total admission of
infantile beriberi
1918
40
1919
24
1920
37
1921
39
1922
37
1923
46
1924
19
1925
18
1926
9
1927
6
Source: Office of Vital Statistics, Philippine Health Service (1927)

F. Beriberi Committees
In 1923, another conference was convened at the last Biennial Congress of the
Far Eastern Association of Tropical Medicine in Singapore. At the conclusion of the
conference, the Congress passed resolutions for the purpose of encouraging different
countries to take further studies and investigations on beriberi. The Congress reaffirmed
the opinion that beriberi was a disorder of nutrition and that the consumption of white
rice as a stable diet caused the disease. Filipino delegates to the conference showed in
the conference their superior knowledge as they showed before the international
convention their success in the elimination of beriberi in the Philippines. They convinced
the Congress of their proposal for the control of beriberi. Seeing the worth of Filipino
efforts in curbing beriberi, the Congress primarily considered the proposals of the

202

Filipino delegates to the conference as it had seen the excellent development of the
control of beriberi in the Philippines.409
Following the resolutions of the conference, Filipinos became more dedicated to
investigate beriberi in the country. With the view of taking further investigation of
beriberi, an administrative order was enacted on November 20, 1923 creating the
Committee on Beriberi Investigation in the Philippines. It was composed of nine
members with Filipinos as majority: Dr. Leoncio Lopez-Rizal as Chairman, and Dr.
Felipe G. Calderon, Capt. W.D. Fleming, Dr. Jose Albert, Mr. A.H. Wells, Dr. Jose
Fabella, Dr. Joaquin Quintos, Prof. F.O. Santos, and Dr. P. Gutierrez as members. Later,
Drs. Quintos and Capt. Fleming resigned as members and Dr. I. Concepcion and Col. J.
F. Siler were appointed. Major A.P. Hitchens was later appointed as the last member of
the Committee.410
After the Committee was organized, it faced serious financial constraints because
there was no appropriation set aside to meet the expenses of the studies and
investigations to be made. The limitation of money was a handicap in carrying out the
investigation of the Committee. It had prevented the Committee from extending its
investigations and studies. The PHS, under which the members were working, had
defrayed such expenses to be able to finish the work. To meet the costs of the
investigation, the Beriberi Committee approved a resolution and submitted it to the
409

Department of Public Instruction, Report of the Committee on Beriberi Investigation,


Monthly Bulletin of the Philippine Health Service 5, no. 11 (1925): 593.
410
Ibid., 593-594.

203

proper authorities asking for an appropriation for the necessary expenses. This, however,
did not receive a favorable action. For an efficient organization of the work, the Beriberi
Committee appointed members under three subcommittees: subcommittee on
standardization of rice, subcommittee on effects of transportation and storage, and
subcommittee on clinical investigation.411
The Beriberi Committee saw the important use of educational campaign to inform
people of the basic knowledge concerning beriberi. This was a faithful response to one of
the resolutions of the Congress of the Far Eastern Association of Tropical Medicine
which stated: the Association considers that educational methods of control on the basis
of the available scientific knowledge should be vigorously applied in all countries.412
The Committee began their educational campaign among school-children. To achieve
this purpose, the Committee created a subcommittee to prepare a pamphlet informing the
elementary knowledge of beriberi and food requirements of the body to prevent the
disease. Professor Santos, one of the members of the Committee, prepared the pamphlet
which was entitled, The A, B, C, of Filipino Nutrition. (See Appendix C) The
pamphlet educated children about the value of Filipino foods and vegetables and their
vitamin content necessary to prevent beriberi.413 Seeing the worth of the pamphlet, the

411

Ibid., 594-595.
Ibid.,
413
Ibid., 654.
412

204

Committee recommended that the material should be published and used as the basis of
reading lessons, lectures, and conferences in public schools.414
Table 32 Number of deaths from beriberi in the in Manila and in the Provinces
(1918-1925)
Years
Manila
Province
Total
1918
731
11,866
12,597
1919
406
11,981
12,387
1920
555
12,481
13,036
1921
705
15,311
16,016
1922
648
16,241
16,889
1923
698
17,417
18,115
1924
600
18,331
18,931
Source: Report of the Committee on the Investigation of Beriberi (1925)
From the table above, it appeared that although beriberi in Manila continued to
decrease, beriberi in the provinces ballooned to a greater extent. In the last five years
from 1924, beriberi decreased to 40% of its prevalence during the period of 1910 to
1914. Based on the statistics of Manila, 91% of deaths from beriberi were still infants.
The Beriberi Committee speculated what seemed to be as a challenge to the success of
the control of beriberi. The Committee figured out that the tikitiki extract, which was the
main cure for infantile beriberi, was only used in Manila and were hardly distributed in
the Provinces. Since 1917, with the increase of rice-mill machinery in the Provinces,
there was a coincidence of an increase of beriberi in the Provinces and a reduction of the
disease in Manila. Seeing that beriberi in the Provinces continued to grow, the Beriberi

414

Ibid., 656.

205

Committee admitted that the beriberi situation in the Philippines had been getting worse
despite the success achieved in Manila.415
The Beriberi Committee was not satisfied enough with the result of the first
investigation and recommended that another committee be made to continue the study
started by the body.416 It did not take too long before another committee was formed for
the same purpose of studying beriberi. The second Committee had been created on
October 18, 1926only a year after the report of the first Committee was published in
1925. Compared to the previous Committee created in 1923, the latest Beriberi
Committee received more than enough of financial support to continue further the
investigation about beriberi. An appropriation of P5,100 had been approved for the
investigation and propaganda work. The International Health Board also contributed
money to the investigation. Dr. Lopez-Rizal remained as chairman of the Committee and
Dr. Calderon, Colonel Edward Vedder, Major A. Parker Hitchens, Dr. Luis Guerrero, Dr.
Liborio Gomez, Dr. Jose Fabella, Mr. A.H Wells, Dr. Isabelo Concepcion, Dr. Jose
Albert, and Professor F.O. Santos as members.417
Since 1924, the new Committee had not seen a change in the last report published
in 1928 regarding the beriberi situation in the Philippines. The beriberi in Manila
continued to decrease while it increased in the provinces. From 600 cases of beriberi in

415

Ibid., 597-598.
Ibid., 658.
417
Department of Public Instruction, Report of the Committee on Beriberi, Monthly Bulletin of
the Philippine Health Service 8, no. 10 (1928): 514.
416

206

Manila in 1924, it decreased to 587 in 1925 and 526 in 1926. In the Provinces, beriberi
increased to 19,204 cases in 1926 from 18,931 cases in 1925. Similar to the initial report
of the first Committee, 91% of deaths from beriberi were ascribed to deaths of infants
under one year from infantile beriberi.418 This time, the Committee was curious of the
lopsided success of the Filipino Government to eliminate beriberi. The members of the
Committee believed that the figures of the PHS on mortality from beriberi were
unreliable. They claimed that there were cases misdiagnosed as beriberi in Manila and
that the same mistake might have occurred in the Provinces. To settle the issue, the
Committee passed a resolution appointing a clinician to conduct an investigation on the
diagnosis of cases entered as beriberi in the Provinces. Dr. Agerico Sison was appointed
to perform the work with the following instructions:
In order to have a more dependable basis on
which to judge the beriberi situation in the
Philippines, especially in the provinces, the
diagnosis of beriberi in as many municipalities of
several provinces as possible, where beriberi
prevails should be verified. Verification of the
diagnoses will be made on (a) cases of beriberi
found in the dispensaries and puericulture centers,
both adults and infants; (b) deaths from beriberi as
stated in the death returns, both adults and infants;
(c) verify the errors in diagnoses separately in both
cases; and (d) make a separate survey to see actually
whether or not the disease is really increasing.419

418
419

Ibid., 514-515.
Ibid., 528.

207

Apparently, the Committee attempted to disguise the worsening beriberi situation


in the whole country with the success of the beriberi condition in the city of Manila. In
the investigation of the accuracy of beriberi cases in the provinces, the Committee
appeared to be correct with their speculation that there was misinterpretation in the
diagnosis of infants in the Provinces. However, no matter how much they made it appear
that there were errors in the diagnosis of the death returns, the Beriberi Committee could
not discard the fact that the beriberi problem in the Philippines had become a more
serious health problem because of the consistent increase of the beriberi cases in the
Provinces.

208

CHAPTER 5
Conclusion

As the Americans developed Manila as their colonial pilot site in 1901, they were
stunned by the prevalence of epidemic diseases and the high mortality of deaths. While
they implemented their colonial works in the city, the Americans were reminded of the
Benevolent Assimilation in their mission to save lives from the ravage of killing
diseases. To transform Manila to their colonial ideals of a civilized city, the colonial
public health exhausted their efforts in combating dangerous diseases such as, among
others, cholera, smallpox, and bubonic plague. The statistics of the Board/Bureau of
Health confirmed that these diseases were taken seriously by the Americans. This was a
proof that Americans turned their attention only to the elimination of these diseases. As
the colonial public health put in place their health programs, they invested so much time
and efforts in cleaning the entire city during the first decade of their colonization.
Apparently, the Americans saw sanitation as the key to make the city beautiful and
habitable based on their colonial standards.
On the other hand, while the Americans implemented their best strategy in
preventing dangerous diseases, they seemed to have forgotten other public health
concerns of the city. The colonial public health was not attentive of the high mortality of
infants. In spite of the clear official reports that showed mortality of infants from

209

convulsion constituted the highest death tolls in Manila, Americans were not too
concerned as to convince them to initiate prompt actions to discover the cause behind the
high infant mortality. During the first decade of American rule in Manila, infant
mortality received nothing but indifference from the colonial public health. No
immediate response was even made to reduce the high deaths of infants. This was
evident from the attitude of the Americans towards the elimination of what for them were
more important diseases. Compared to their focus on the eradication of diseases like
cholera, smallpox, and bubonic plague, infant mortality was off the radar to be an
important public concern of the city. For them, infants were not to be considered as an
economic resource. The Americans believed that the high death rate of infants could
eventually be offset by a high birth rate. This lethargic attitude towards infants would
explain their high death rates without any clear picture of the cause of their deaths.
As the Americans disregarded the significance of the loss of lives of infants,
the cause of infant mortality in Manila remained a nebulous topic in medicine. During
the first decade of the American rule in the city, the vulnerability of infants to contract
the unknown disease, which was only identified as convulsion, had no clear picture.
Thus, thousands of innocent infants perished every year because of the short of
knowledge of the Americans about the cause of peril among Filipino infants. It was
evident that the colonial public health narrowed their public health policies and programs
to infectious diseases such as cholera and were unconcerned of the problem of infant
mortality. In their first decade in the Philippines, the colonial public health were first
210

concerned of the health of their own officials and army in order to successfully pacify the
natives and transform Manila to fit their colonial ideals of a habitable and beautiful city.
Being spared from the tropical diseases such as beriberi, the early colonial public
health did not see these diseases, which had killed more native lives, as an important
health hazard. Since beriberi was only a disease of no interest to the Americans, it did not
merit a considerable interest in the colonial public health until it was discovered that
beriberi, a disease which was only confined to prisoners, was the one responsible for the
deaths of many infants in the city. Thus, a factor for the vulnerability of the infants was
the bereft of scientific knowledge of the nature of beriberi. It was discussed in the first
chapter of the thesis that beriberi was initially regarded as an adult disease. Being fond of
their western science and their germ theory, Americans treated beriberi as another type
of infectious diseases like cholera and smallpox. For the Americans, all diseases were
caused by unclean environment and thus, the first decade of American public health was
only about keeping the city as clean as possible through their stringent sanitation
measures and policies. With a misinterpretation of the cause of beriberi by the
Americans, infants remained unknowingly vulnerable from the disease. It was already
too late for the Americans to realize that beriberi, a disease they initially suspected to be
infectious, was the disease that had killed many infants. At the time when the Americans
did not spend time to discover the relation of beriberi to the death of infants, many babies
died while they could have been saved had the Americans put some of their efforts to the
problem of infant mortality of the city.
211

As the Americans learnt that beriberi was not a disease caused by germs and
infection but by a lack of nutrition of people whose staple diet was polished rice, they
implemented harsh measures to control Filipinos from eating polished rice. As the
Americans attempted to intervene with the lives of the Filipinos in their mission to
eliminate beriberi, tensions between the colonizer and the natives arose because of
polarizing cultural views of the public health policies against the disease. One factor that
increased the level of vulnerability of infants to beriberi was the resistance of the
Filipinos to the policies of the Americans. While the Americans forcibly intrude into
Filipino lives, the latter interpreted the health policies in a wrong way. Filipinos felt that
most of the policies of the Americans to control beriberi were only parts of a larger
measure of pacification. Many Filipinos were indecisive to participate with the
Americans campaign of the use of unpolished rice as against white rice which had been
their staple food for a long time. For some Filipinos, the forced use of unpolished rice
was a derogation of their racial status. Filipinos literally found the unpolished rice as a
bitter food to swallow since this type of rice had a bad flavor and was often unclean.
Because of the cultural resistance of the Filipinos against the colonial policies which they
perceived as a tool of superiority, infants became the most helpless victims as they
unknowingly suffered deaths from beriberi.
As they finally bridged the connection of beriberi and infant mortality, Americans
blamed the mothers as the prime suspect of the death of their infants. Being only young,
weak and vulnerable, the infants were only dependent to the care of their mothers. It was
212

at this point that the vulnerability of the infants was attributed to the nursing mothers.
Mothers were believed to contribute the most to the vulnerability of the infants to
beriberi because of their improper care and nursing method. The third chapter of the
thesis has explained that there was a direct connection between the mothers milk and the
vulnerability of the infants to beriberi. If the mother subsisted to a diet with polished rice
as a staple food, she was likely to be carrying beriberi. The milk of the mother, which
was deprived of a particular nutrient that her infant should get, caused the latter to
develop infantile beriberi. The health of the mother, therefore, was very crucial to the
vulnerability of their infants to infantile beriberi.
As the mothers milk was implicated to be the source of beriberi in infants, the
colonial public health turned their attention to the proper care and nursing of the mothers.
To a greater extent, colonial health policy was very critical against the maternal duty of
the mothers to breastfeed their babies. Seeing it as intrusion to their natural right to nurse
their babies, Filipino mothers resented to the unwholesome policies of the heath service.
Although the high vulnerability of infants to beriberi was partly to be blamed to
Americans lack of attention to the problem, their discovery of the cure of infantile
beriberi cannot be disregarded. Chapter three of the thesis has discussed that tikitiki was
discovered by American doctors Chamberlain and Vedder. The recognition of the
discovery of the cure therefore cannot be discredited from the Americans. Their study of
the cure of infantile beriberi had taken a great leap in the reduction of infant mortality.

213

Apparently, at the time when many infant lives were lost, the question on who
should take over the problem of infant mortality was an issue in the city. At the onset, the
Americans passed on the duty to take care of infants to Filipino doctors. While the
Americans busied themselves in cleaning the city from infectious diseases, they left to
the Filipino doctors and voluntary organizations the job to discover the cause of deaths of
infants. Thus, when the problem of infant mortality of the city was discussed, there
seemed to be a blame game among the Americans and the Filipinos. Americans did not
take responsibility of the high death rate of infants because for them infants were not
even an important subject of a colonial policy. Subsequently, it had become a duty of the
Filipino doctors to discover the cause of deaths of infants in the city. They took over the
natural duty to conserve their own race when the colonial public health seemed to have
forgotten the problem of infant mortality.
As the Filipinization policy radically changed the colonial public health into a
service controlled by Filipinos, the issue of infant mortality and infantile beriberi became
part of colonial politics. As Filipinos capacity for self-government was evaluated by the
Americans, the issue of infant mortality became a focus of criticisms. Filipinos were
aware that in the eyes of the Americans their claims for autonomy were flawed by their
lack of experience in improving the infant care in the country. As Filipinos moved to
prove that they were capable of solving the high infant mortality from beriberi, their
initiatives seemed to never meet the standards of the Americans. Despite the large
contributions of Filipinos in the discovery of infantile beriberi among infants and the
214

great efforts of Filipino doctors, nurses, and voluntary organizations to curb infant
mortality, the Americans criticized that the administration of public health and child
welfare in the country deteriorated under the control of the Filipinos.
On the contrary, chapter four of this thesis has proven that Filipino efforts to
control infant mortality especially from beriberi in Manila were very significant contrary
to the negative evaluation of the Americans. Filipino politicians and doctors challenged
the impression of the Americans against their competency for self-government.
Throughout their challenge to show their capacity for self-rule, Filipinos had always
emphasized the medical superiority of Filipino doctors through the discovery of infantile
beriberi as the cause of high number of deaths in Manila. The use of the local term of
infantile beriberi, the taon, suggested the undeniable contributions of Filipinos in the
study of the disease. Furthermore, it was the Filipinos who conducted the most extensive
research and committees which led to the discovery of infantile beriberi as a disease of
vitamin deficiency. Most of these efforts to study the infantile beriberi in Manila
flourished without the support of American education or research. The Filipino voluntary
organizations also had performed tremendous work in distributing safe milk and tikitiki
to infants.
It can therefore be concluded that the Filipinos had proven that they were
competent in dealing with the problem of infant mortality. While Americans saw infants
as only objects of their colonial policies, the Filipinos had already embraced the idea that

215

infants were important members of the nation. The Filipinos had even showed that they
were more superior to their colonizer in discovering infantile beriberi as the cause of
infant mortality in Manila. As they witnessed the crux of many infants in the city,
Filipinos initiated actions to put light to the vulnerability of infants to beriberi. With the
joined efforts of Filipino doctors, nurses, and politicians, infants were spared from the
threat of beriberi. Since its deplorable infant mortality at the start of American
occupation, it can be said that Manila progressed to a city which could be described to be
a good cradle for Filipino babies.

216

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(2009): 219-260.
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_______. Kissing a Baby is not at all Good for Him: infant Mortality, Medicine, and
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Thesis and Dissertation


Azicate, Enrico. History of Medicine in the Philippines: Historical Perspective
Masters Thesis, University of the Philippines, 1988.
Planta, Ma. Mercedes G. Prerequisites to a Civilized Life: The American Colonial
Public Health System in the Philippines, 1901-1927. PhD diss., National
University of Singapore, 2008.

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APPENDIX A
Health Bulletin No. 12
Beriberi and How to Prevent It

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APPENDIX B
The Treatment of Infantile Beriberi with the Extract of Tiqui-Tiqui
By Jose Albert

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APPENDIX C
The A, B, C of Filipino Nutrition

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APPENDIX D
Common Diseases of Babies Causing High Infant Mortality
By Jose Albert

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APPENDIX E
Infantile Beriberi: Its Causes and Its Remedies
By Joaquin Quintos

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