Eyes of the Beholder: The Public Health Service Reports on Trachoma in White Appalachia and Indian Country

In 1912, the United States Public Health Service (PHS) set out to survey trachoma rates among two populations: Appalachian Whites in Kentucky and American Indians. I knew about the American Indian survey from my dissertation research on Native health in the early twentieth century. But when I read the report from that study, I was surprised to find that PHS inspectors referenced problems with trachoma among Appalachian Whites. I couldn’t pass up the opportunity to compare the two reports.

To understand the history of these reports, we have to look at the PHS’s longer history with trachoma. But first, what is trachoma? It is a highly contagious eye infection caused by C. trachomatis. While not lethal, the infection causes granules to form on the under-eye which, if left untreated, scratch the cornea and cause blindness.

In the late nineteenth and early twentieth centuries, it was associated with immigrants, particularly from Asia and Eastern Europe and of Jewish descent. At the end of the nineteenth century, Surgeon General Walter Wyman warned that trachoma was “essentially an imported disease,” reinforcing American xenophobia and providing a good reason to keep out certain immigrants.

The disease also posed a diagnostic threat to the PHS: its symptoms presented like other, less serious eye infections and it naturally cycled through periods of remission, making it more difficult to catch at immigration stations. Also, the pathogen responsible for trachoma was still elusive. In 1910, laboratory advances in hookworm detection made that disease easier to spot. Along with a sense that trachoma had been successfully limited at the borders, PHS inspectors eagerly shifted their zealous immigrant inspections to focus on hookworm.¹

But the government’s trachoma panic did not end. It just shifted gears.

By the early twentieth century, health problems among American Indian communities had grown so bad that the Office of Indian Affairs (OIA) and Congress could no longer avoid them. In 1908, the commissioner of Indian affairs, Francis Leupp, commented on the “white plague” tuberculosis, very publicly acknowledging the growing health crisis. The following year, OIA physicians found that 65% of students at the Indian boarding school in Phoenix, Arizona had trachoma.² That number and increasing pressure from Progressive critics led Congress to set aside money for a PHS survey. Around the same time, concern for isolated Appalachian Whites developed as well. Surgeon General Wyman ordered a study of trachoma among Whites living in Kentucky’s Appalachian Mountains.³

The statistical results of the studies showed that both groups had elevated rates of trachoma when compared to the general population rate of 1.4%.⁴ Across Indian Country, thirteen PHS officials inspected 39,231 American Indians over three months in 1912. They calculated a trachoma prevalence rate of 22.7%. In eastern Kentucky, a single PHS inspector, John McMullen, examined 3,974 people, mostly students, and calculated a 12.5% prevalence rate.⁵ After years of touting trachoma as an “imported” disease, the PHS could not help but acknowledge that trachoma was deeply embedded within the country as well.

The similarities across the reports are striking. Health inspectors noted both groups were poor and their homes lacked basic sanitation and ventilation. In the Southwest and Appalachia, health inspectors feared railroads would increase contact between these unusually sick people and healthier White Americans. Inspectors also worried about the health consequences of endogamy or “in-breeding”: “Full blood” American Indians were found to have higher rates of trachoma than “mixed bloods,” while Appalachians were found to “intermarry quite closely” thus leading to a host of problems including “mental defectiveness” and susceptibility to disease.

But racial bias within the PHS led its officials to explain the circumstances, and the very people affected by trachoma, in contrasting terms: “Anglo Saxon” mountaineers of Kentucky were “good and honest” people living in “simple, small cabins” in a “beautiful region.” Unlike American Indians, “Many of these natives are unlettered, but not ignorant,” their flaws not inherent to their persons. To McMullen, they were “sturdy people [who] do not ask for charity … given the opportunity they will more than do their part.”

In contrast, his colleagues working on the Indian Country survey blamed indigenous peoples’ “improvidence and racial indolence and poverty” for their sickness. While McMullen took the time to differentiate between “unlettered” and “ignorant,” in order to present Kentucky Whites as wise, just lacking in education, PHS inspectors reported that American Indians were fundamentally “primitive” and so thoroughly nonwestern that they had to be “ignorant.”

These racial biases had lasting consequences. McMullen’s report prompted the Kentucky Board of Health and the PHS to open a hospital in Knott County, Kentucky between 1913 and 1916. During that time, and across eastern Kentucky into the 1920s, a mixture of surgical and medicinal treatments and public health lectures effectively eradicated trachoma in the region.⁶

The 1912 PHS report on American Indians had recommended health education, improvements to sanitation, and reorganization of the Office of Indian Affairs’ (OIA) medical service. But funding challenges, particularly during and after WWI, and bureaucratic inertia limited early interventions and failed to address underlying causes of poverty and poor health in Indian Country. In 1923, the OIA received its first increase in funding for Native health in several years. Officials poured a lot of the money into an anti-trachoma campaign in the Southwest.

John McMullen, satisfied with his work in Kentucky, actually advised the early stages of the OIA’s trachoma campaign. He and his successor, Dr. L. Webster Fox, advocated surgical remedies for indigenous patients. Unlike White Appalachians, McMullen, Fox, and other officials believed American Indians, “primitive” as they were, needed more than health education, they needed something permanent. The answer was radical and untested eye operations.⁷ The surgeries injured over three thousand American Indians and did not erase trachoma. The campaign ended following criticism in a 1928 government survey.

Race has influenced public health decisions in the United States across centuries and populations. Trachoma is a resonant example of how similar populations were expected to carry different amounts of guilt and blame for their suffering. The disease also showed the real and lasting consequences to nonwhite health. Lastly, it reminds us to critically evaluate the evaluators, look beyond their biases, and seek out comparisons between communities that may prevent unequal treatment in the future.

Juliet Larkin-Gilmore

Juliet is a PhD Candidate in History at Vanderbilt University. Her dissertation explores the relationship between public health policy and American Indian mobility along the Lower Colorado River in Arizona.

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