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The island’s 1.8 million inhabitants had experienced an epidemiological crisis during the three-year-long Cuban insurrection against Spain, which lasted from February 1895 to August 1898. The vast majority of the estimated 290,000 Spaniards and Cubans who perished during that war, civilians and soldiers alike, died of starvation and infectious diseases. The most destructive force was the Spanish military policy called “reconcentration,” which set a deadly precedent for modern counterinsurgency warfare that the British and the Americans would find irresistible. Aiming to break up rural support for the Cuban Revolutionary Army, the Spanish general Valeriano Weyler ordered the forcible removal of Cuban civilians from the countryside to the urban centers, where the reconcentrados lived in close squalor under a form of martial law. Some 400,000 civilians, roughly one quarter of the island’s population, were forcibly concentrated into Havana and other cities already overrun with soldiers and refugees.39

“Hunger, starvation, and death were on every hand,” wrote Clara Barton of her arrival with the Red Cross in Havana in February 1898. In normal times, the population of nineteenth-century Cuba was too dispersed to support endemic smallpox. But the reconcentration of the rural population and the movement of soldiers and civilians across Cuba created a dense network of disease transmission that fostered the epidemic spread of smallpox, yellow fever, and enteric fever. According to The New York Times, smallpox was the single biggest killer among the reconcentrados. “The people were unable to keep clean, unable to be vaccinated, even if willing, and they died by [the] tens of thousands,” one longtime resident of Havana told the Times. During the lead-up to war with Spain, American newspapers inflamed the public with reports on Weyler’s disease-infested camps. And the escalating events of the U.S. war with Spain in Cuba from April to July 1898—the American blockade of Havana, the naval assault, and a ground war centered around Santiago de Cuba—had further strained the health of Cuba. Neither tropical climate nor simple Spanish incompetence nor the alleged backwardness of the Cubans could have wreaked such epidemiological havoc. Political decisions made these epidemics.40

Puerto Rico did not have its own war of independence, and the health situation there in the 1890s was less dire. Still, disease shaped the course of the U.S. invasion. Yellow fever had so disabled the U.S. regiments in Cuba that when Major General Nelson A. Miles landed at Guanica on the southern coast on July 25, 1898, he did so with a small initial force of 3,500 troops shipped in from the states. (U.S. troop strength later grew to more than 14,000 men.) Despite their superior numbers, the Spanish did not put up much of a fight. General Miles ordered three columns of men north to San Juan, but news of the armistice arrived before the soldiers reached their destination. An Army medical officer reported that malaria was “prevalent in all the valleys,” noting the “large pendulous abdomens and pale faces of the many little naked children.” During the long occupation, thousands of U.S. troops made their garrisons in the midst of local communities, spreading microorganisms wherever they went. By September 1898, one quarter of the troops were on the sick list, suffering from dysentery, malaria, venereal diseases, and a few cases of smallpox.41

The last brief battle of the Spanish War took place in the Philippines on August 13, 1898. The surrender of the Spanish garrison to the invading Americans at Manila had been scripted by both sides in advance, enabling the Americans to prevent Aguinaldo’s insurrectos from entering the city. In the Philippines, the U.S. troops marched into a health crisis that had been building for decades and which their presence and actions worsened.

An archipelago of seven thousand islands, most of them uninhabitable, distributed across a half-million square miles of ocean, the Philippines had been under Spanish rule since 1565. Roughly half of