Current Events and Philanthropy / Philanthropy and the State

The Return of Hookworm and the Limits of Public Health Philanthropy

Editors’ Note: HistPhil co-editor Benjamin Soskis reflects on a recent article in the Guardian on the return of hookworm to the American South.

There’s been no shortage of news stories over the last several months that delivered a punch to the gut of our national self-regard, challenging Whiggish notions of moral progression that still color some of our deepest beliefs about the United States and its place in the world. But a recent article in the Guardian landed a blow that fell particularly hard.

“Hookworm, a disease of extreme poverty, is thriving in the US South,” the headline read. It featured a study, conducted by the National School of Tropical Medicine at Baylor College of Medicine and the Alabama Center for Rural Enterprise, of residents of Lowndes County, Alabama, that found that more than a third of those sampled tested positive for traces of hookworm. Admittedly, the study is limited, relying on a small sample size (the researchers are preparing for a larger study). But hookworm, a parasite that latches onto the small intestine, and which can result in iron deficiency, anemia, lethargy and impaired mental function (especially in children), was thought to have been nearly wiped out in the US over the last century. Methodological quibbles don’t feel very reassuring.

It turns out the rates found in Lowndes—one of the poorest counties in the state, three-quarters of whose residents are African-American (as were all of those tested in the study)—have not improved much from levels a century ago. As the Guardian article makes clear, hookworm, which most often enters the body through the soles of bare feet, is a disease of dire poverty that, through its debilitating effects on the human body, perpetuates poverty. It also makes clear the role that failed public infrastructure investment plays in the story: much of Lowndes County lacks an adequate public sewage system, and so residents are required to provide their own (installing a private septic tank can cost as much as $15,000, nearly as much as many residents make in a year, and so many simply pipe raw sewage out of their homes to surrounding areas, helping hookworm to spread).

The images that the Guardian article conjured up are not those we prefer to associate with the citizens of our own country: they are more like those within lachrymose charity appeals to assist the unfortunate residents of some third-world country, who we can pity from the safe remove of our own relative comfort: “Children playing feet away from open pools of raw sewage; drinking water pumped beside cracked pipes of untreated waste; human faeces flushed back into kitchen sinks and bathtubs whenever the rains come.”

The fact that Lowndes County was also the site of some of the fiercest battles of the civil rights movement a half a century ago—Martin Luther King led protesters through Lowndes during the march from Selma to Montgomery—only underscores the sense of declension, of hard-won gains eroded by poverty, racism, and political disempowerment.

For students of the history of philanthropy, that sense of declension is even stronger because the defeat of hookworm in the US has long been considered one of the sector’s great, early success stories.

In 1909, John D. Rockefeller established the Rockefeller Sanitary Commission for the Eradication of Hookworm. At the time, researchers believed that as much as forty percent of Southerners had the ailment—it seemed to afflict poor whites especially severely—and the corps of agrarian reformers, seminary presidents and Progressive social scientists that congregated around the early Rockefeller foundations regarded it as a significant depressant to Southern productivity (it was termed the “germ of laziness,” which is also the title of a fantastic account of the Rockefeller hookworm campaign by John Ettling). Rockefeller committed $1 million for the Commission, which would ultimately work in states throughout the South to promote the treatment of hookworm and educate citizens about its prevention. Both were relatively straightforward tasks: the cure involved a purgative dose of thymol and salts and prevention mainly called for the increased use of latrines and the wearing of shoes.

But the Rockefeller Sanitary Commission had to contend with a wave of resentment directed against their work, with the suspicions that large-scale benefactions have often engendered in the United States now amplified through sectional antagonism. Many southerners didn’t appreciate the solicitude shown toward their “laziness,” and some suggested that hookworm was actually a malady invented by northerners to discourage investment in southern industry (another conspiracy theory held that the Sanitary Commission was just a ruse to convince southerners of the dangers of walking barefoot by Rockefeller, who was poised to capture the leather market and make a killing on shoe sales).

In the face of such opposition, the officials running the Sanitary Commission appreciated that they could not impose a solution on the hookworm epidemic in the South, and that they would need the active cooperation of southerners. Even more than this, they believed that the work would need to be done through public and not private institutions, if it was to receive public legitimation and sustainable support. So alongside the objective to eradicate hookworm, enshrined in its title, the Rockefeller Sanitary Commission had another aim: to build up the region’s faith in its barely existent public health infrastructure.

To this end, besides sponsoring traveling dispensaries that tested for hookworm and administered treatments to those found to be infected (some 700,000 individuals in all), the Sanitary Commission also ran education campaigns through state and county boards of health in order to improve sanitation standards. It trained and paid the salaries of doctors, scientists, health inspectors, and lab technicians that staffed these boards. And through this work, it helped to boost public appreciation for public health more generally in the region. Between its five years of operation, state appropriations for public health in the South increased by more than 80 percent.

In this respect, the Rockefeller Sanitary Commission could be deemed an enormous success, even if it did not strictly live up to its title. The Rockefeller Foundation claimed to have eradicated the disease from the US in 1926, but investigators found that it had persisted, and continued to do so, several decades later. There is no doubt, though, that it achieved a dramatic reduction in hookworm’s prevalence; as much as two-thirds by 1930.

Officially, the Sanitary Commission was shuttered well before then; Frederick Gates, the former Baptist minister who served as Rockefeller’s chief philanthropic advisor, closed it down in 1915, eager to shift the work overseas, to British colonies, through the newly formed Rockefeller Foundation’s International Health Division. Indeed, the Sanitary Commission’s successful campaign became a kind of template for much subsequent work. It was, as John Ettling has written, “the tiny acorn from which grew the Rockefeller Foundation itself,” inspiring RF trustees to seek to eradicate other communicable diseases in the developing world, such as yellow fever and malaria. These efforts, in turn, were a major inspiration for Bill Gates when he began to develop the focus and scope of his own philanthropic efforts.

The record of the Rockefeller Sanitary Commission could be especially instructive to Bill Gates and other contemporary philanthropists in two respects. It suggested the enormous potential that simple, well-designed interventions held in the realm of public health. As the Gates Foundation’s first CEO, Patty Stonesifer, noted, “A lot of people would say, ‘you’ve got to reduce poverty to get rid of hookworm.’ But the Rockefellers said, ‘You don’t need a 20-year intervention. You can use shoes.” What was attractive about this approach, besides the promise of speedier returns on investment, was that it allowed philanthropists to circumvent controversial social, political, and economic issues. In fact, public health was likely so attractive to Rockefeller and his associates precisely because it did not require them to engage in structural reform. Frederick Gates, for instance, insisted that “the evils of society are not fundamentally economic but are physical and moral.” This view enabled Rockefeller to position his philanthropy as striking at the root of social problems, without troubling the economic foundations of his wealth. Nor did Rockefeller seek to take on racism in the South. The Sanitary Commission purposefully avoided the issues, deferring to the public authorities. Its leaders did not urge improvement in blacks’ sanitary conditions, which were particular dire, or push the hiring of black field workers, or include racial categories in sanitary surveys.

The Rockefeller Sanitary Commission also helped set the terms of the role that philanthropy could play in building up state capacity. It provided an early model of philanthropic innovation giving way to public investment. As the Commission’s executive secretary Wickliffe Rose explained, “An outside agency can be helpful only in so far as it aids the States in organizing and bringing into activity their own forces.” Rose actually worried that Frederick Gates had initiated the dissolution of the foundation too precipitously, while there was still work to be done. But Gates insisted that once the Commission had demonstrated the value of its work, and “after a reasonable local enlightenment has created the local responsibility for self help and the means of self help exist,” philanthropy must yield place and remove itself from the scene. This view reflected a common concern among many of the early philanthropists about pauperizing the public. But it also placed enormous trust in the decency and resilience of a unitary “public enlightenment.”

We can appreciate now, more than ever, that such faith is not always warranted. We can see, too, with the benefit of hindsight, how the interaction of the two exemplary features of the Rockefeller Sanitary Commission actually undermined its own long-term impact, how together they helped set in motion the dynamics that led to the shameful revelations within the Guardian exposé. A philanthropy that looks to turn over programs to the state is ultimately at the mercy of that state and of the public that shapes it and of the deep power structures that undergird it. If those structures contain inequities of race, class, or gender, and if they are left to fester, they will sap the strength of those very programs, like a hookworm in the gut. The public health system in the South was being developed, with the aid of northern philanthropy, at the same time as Jim Crow, with its systematic disempowerment of the most vulnerable, and its disinvestment in their public good. We are still struggling with that legacy.

This is not to say that the Rockefeller Sanitary Commission for the Eradication of Hookworm should no longer be considered a philanthropic success story. It should; it improved the health of hundreds of thousands of southerners, and helped to boost public health infrastructure that no doubt helped many more. But it must also be considered a cautionary tale. All funders who invest heavily in public health systems without thinking clearly about the deeper political and cultural structures in which those systems are enmeshed run the risk of having their work undermined, much like the Sanitary Commission. They are setting themselves up for another punch in the gut.

-Benjamin Soskis

Benjamin Soskis is the co-editor of HistPhil and a research associate in the Center on Nonprofits and Philanthropy at the Urban Institute.

Image courtesy of Rockefeller Foundation, “Just Child’s Play,” 100 Years: The Rockefeller Foundation, accessed September 17, 2017,

2 thoughts on “The Return of Hookworm and the Limits of Public Health Philanthropy

  1. Ben, I really like this piece, and pretty much agree with its conclusions. My only quibble is that, as Ettling and the Guardian suggest, it really is too much for fans of philanthropy to claim, as they almost always do, that Rockefeller “eliminated” hookworm in the American south. The relevant foundation officials even warned at the time that what progress that had been made would be endangered by closing the program and moving on to the world scene. So it seems to have happened. Given my inveterate skepticism of philanthropic genius, I’m inclined to look at this and say that even in one of those rare instances when progressive philanthropy has finally found a problem to the root causes of which it can penetrate, it lacks the focus and discipline to finish the job.

    William A. Schambra


    • Bill,
      Thanks as always for your response. I tried to highlight in the post, as you do above, that though Rockefeller philanthropy officials believed that they had eradicated hookworm in the South, that was no in fact the case. And you are right that when to terminate the Commission was a matter of intense debate–so was, for that matter, whether eradication should really be the stated purpose. I do have my own quibble, though, with your comment on philanthropy lacking “the focus and discipline to finish the job.” Frederick Gates’ decision to shut the Commission down might be understood in these terms, but I think–as I suggest in the post–that it makes more sense to see this as a deliberate reflection of the policy of philanthropic evanescence–the objective of building up state capacity and public will. “Lack of focus” makes this seem more like it seemed from poor organization when it actually derived from core philanthropic principles. But, as I’m sure you’d note, the difference btw these principles and a lack of focus and discipline might be more difficult to tease apart than I’m allowing…


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