In the United States and around the world, public health has taken center stage in recent years to investigate how we treat infectious disease and, more importantly, how we contain its spread. However, less attention has been given to the development of the public health systems we benefit from today and the now-eradicated ailments that once affected large populations of Americans.
One such ailment was hookworm. Physicians deemed the hookworm, a parasite that thrived in damp and humid conditions, as responsible for the lethargic behavior that had come to characterize Southerners in the early part of the twentieth century. However, hookworm eradication efforts, along with the development of institutionalized public health, often neglected the health of the Black community.
What is Hookworm?
In 1902, Dr. Charles Stiles identified hookworm, an intestinal parasite, as the cause of the lethargy that had come to stereotype poor white Southerners. Stiles coined the scientific term for the parasite Necator americanus, meaning “the American Murderer,” which is a bit of a misnomer since it rarely was the direct cause of death. Hookworm became more popularly known as “the germ of laziness” due to symptoms of anemia, thin blood, and being “addicted to the habit of eating dirt.” Exposure to hookworm was most common through contact with human feces, often occurring while walking outdoors barefoot or while using unsanitary outhouses. Hookworm was so widespread across the southern region of the U.S. that it infected as much as 40 percent of the white population.
A 1909 McClure’s Magazine article, “The Vampire of the South,” claimed, “there are today two millions of these poor whites – our native born whites – suffering with anemia, and hardly one of those two million knows, or even suspects, that he is really suffering from an internal parasite.” The author’s attention to the prevalence of hookworm specifically in “our native born whites” reflects the development of viewing hookworm as particularly a problem for poor white communities, a view bolstered by white physicians and philanthropists.
However, investigations regarding the prevalence of hookworm in Black communities were neglected by physicians. White physicians like Stiles knew that hookworm also impacted Black communities, but deliberately chose to focus their eradication efforts on white populations. These physicians believed that “although their ancestors brought hookworms to North America, Southern Blacks proved less susceptible to hookworm,” mainly due to generational exposure to the hookworm in Africa. Southern doctors used this rhetoric as reasoning to exclude Black communities from eradication efforts.
In fact, some white people blamed Black Americans for the prevalence of the parasite itself. As a 1928 article in the Black newspaper The Chicago Defender noted, white officials like Navy Rear-Admiral E.R. Stitt were quick to blame Black people for hookworm, when he stated that “there was no doubt that Africans introduced hookworm” to the United States. Not only did white writers blame Black people for spreading these diseases, but they believed that white people suffered more from the illnesses. Even when white physicians did spread public health education to the Black community, it was self-interestedly and paternalistically aimed at protecting whites.
Eradication Efforts Begin
In 1909, John D. Rockefeller allocated a million dollars to the founding of the Rockefeller Sanitation Commission for the Eradication of Hookworm Disease, the first philanthropic public health effort in the United States. The Sanitation Commission sought to determine the prevalence of infection across the South, treat those who were infected, and educate communities on the importance of sanitation. Eradication efforts through proper sanitation included building outhouses and providing education about limiting the spread of the parasite. These eradication goals primarily focused on poor white communities. Sociologist Matt Wray suggests that “through the rhetoric of the hookworm campaign, poor white trash were partially refigured as pure white Americans, as a group that deserved higher status and greater prestige than that accorded to southern Blacks.” Physicians focused their eradication efforts on a specific group who they deemed worthy of a cure, while neglecting hookworm infection in Black communities.
The construction of hookworm as a problem physicians believed only directly affected poor white Southerners is evidenced in Dr. Stiles’s presentation at the 1909 “Negro Conference” at Hampton University in Virginia. Stiles spoke to a largely Black congregation about the dangers of hookworm even though he argued it was white people who were more likely to suffer symptoms of the parasite. Stiles then proceeded to explain what they could do to limit the risk of hookworm contamination to the white population.
Stiles noted that no studies had yet been conducted comparing the hookworm infection rate between white and Black people, despite the large sums of money the Rockefellers had allocated to the study of the prevalence of the disease. However, Stiles did present a study he completed on the number of sanitary outhouses based on race in lower Southern states. In total, three hundred and seventy farmhouses were surveyed, and 46.7 percent of farmhouses owned by whites had no privy, while 79.5 percent of Black-owned farmhouses had no outhouse. It is likely that regardless of physicians’ perceptions at the time, Southern Black communities were likely to encounter hookworm at the same rate if not more than Southern white communities, due to the lack of sanitary outhouses and therefore exposure to excrement.
In Stiles’s presentation, he lacked evidence of hookworm in Black people, but warned that they should practice sanitary habits to prevent further contamination of white people. He did this by relating hookworm to tuberculosis (TB), a disease that was three times more likely to kill Black people than white. Since hookworm causes severe anemia and weakens its victim, Stiles argued that hookworm doubled the chances of dying from TB. It is important to note here that Stiles appealed to Black self-interest by putting hookworm into the context of a disease that disproportionately affected Black communities. Stiles explicitly said that if “the Negro wishes to reduce his death rate from TB, one method of doing so is to eradicate hookworm disease not only by treatment but also by improving the sanitary conditions under which he is living.” This same sentiment was reflected in the 1910 Flexner Report, regarding the “Medical Education of the Negro” in the United States. This report stated,
Not only does the negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the ignorant and unfortunate white contaminates him. … The negro must be educated not only for his sake, but for ours.
This rhetoric directly aligns with the paternalistic attitudes of the Rockefeller Sanitation Commission and physicians, by establishing that whites were the principal concern as victims of hookworm, and that Black people had an obligation to prevent the disease from contaminating the white population even though every race was subjected to disease in poor areas.
Beyond the Hookworm
The Rockefeller Sanitation Commission and white doctors constructed hookworm to be an infection that only directly affected white Southerners. This rhetoric neglected the indirect effects of hookworm in Black communities who were also suffering from the parasite. In 1914, the Rockefeller Sanitation Commission ended without successfully eradicating the parasite. However, in 1933, twenty-four years after the Rockefeller Sanitation Commission began, the commission did claim total eradication. Dr. Stiles responded to this claim in an article, “Is It ‘Fair to Say That Hookworm Disease Has Almost Disappeared from the United States?’” In it, Stiles refuted the Rockefeller claim that hookworm no longer existed in the American South by stating that tracking the number of people treated is not a fair estimate of the disease because without proper sanitation or shoes, people could become reinfected. He noted that “the fundamental problem in hookworm control is not a question of bookkeeping or microscopic examinations, but requires a change in the daily habits of hundreds of thousands of rural whites, Indians, and negroes.” Here, Stiles argued that while attempts could be made toward public health education and sanitation, individuals must take it upon themselves to follow health guidelines to end the infection. Stiles stated that of 121,388 tests done in 1929, 28 percent were positive for hookworm.
Even though hookworm eradication was not completely successful in the American South, attention turned toward other preventable diseases specific to the South such as malaria and pellagra. Overall, examining hookworm eradication efforts in the early twentieth century shows the disproportionate focus on the health of white communities and the focus on health in Black communities only insofar as they could prevent the spread of disease to white people. Racial health disparities still affect minority communities in the United States today such as high infant mortality, heart disease, and access to healthcare, and even though hookworm is now considered eradicated in the United States, it is still prevalent in a few other countries. The question of who is deemed “curable” and given access to public health measures still remains.
- The geographic definition of the “South” used here as defined by George Tindall in The Emergence of the New South, 1913–1945: A History of the South (Baton Rouge: LSU Press, 1967), refers to “the eleven former Confederate states plus Kentucky and Oklahoma.” ↑
- Matt Wray, Not Quite White: White Trash and the Boundaries of Whiteness (Durham: Duke University Press, 2006). ↑
- Virginia Department of Health, The Virginia Health Bulletin 1–4 (1908–1912): 387. ↑
- John Ettling, The Germ of Laziness: Rockefeller Philanthropy and Public Health in the New South (Cambridge, Mass.: Harvard University Press, 1981). ↑
- Marion Hamilton Carter, “The Vampire of the South,” McClure’s Magazine 33, no. 6 (1909–1910): 617. ↑
- Ettling, The Germ of Laziness, 4. ↑
- “Blame Slaves for Diseases in America,” The Chicago Defender, 19 May 1928. ↑
- Wray, Not Quite White, 97. ↑
- Charles Stiles, Hampton University Negro Conference 1909 (Hampton University), 25. ↑
- Stiles, Hampton University Negro Conference, 26. ↑
- Abraham Flexner and Henry Smith, Medical Education in the United States and Canada (New York City: Carnegie Foundation for the Advancement of Teaching, 1910), 180. ↑
- Charles W. Stiles, “Is It ‘Fair to Say That Hookworm Disease Has Almost Disappeared from the United States?’” Science 77, no. 1992 (1933): 237–39. ↑
- Stiles, “Is It ‘Fair to Say?,’” 237. ↑
Ferrell, John A. The Rural School and Hookworm Disease Washington: G.P.O., 1914.
Hampton Negro Conference. Annual Report of the Hampton Negro Conference. Hampton, Va.: The Conference, 1905-1912.
Virginia Department of Health, v. 1-4, 1908-1912, Richmond, Virginia.