be able to use smallpox as a weapon against the continental army. among wars with high death tolls from disease is the civil war where an estimated 224,000 soldiers died from all diseases combined. american soldiers in other countries have spread diseases that ultimately disrupted entire societies and healthcare systems with famine and poverty. spanish–american war the spanish–american war began in april 1898 and ended in august 1898. during this time the united states gained control of cuba, puerto rico, and the philippines from spain. as a military police power and as colonizers the united states took a very hands-on approach in administering healthcare particularly vaccinations to natives during the invasion and conquest of these countries. although the spanish–american war occurred during the era of "bacteriological revolution" where knowledge of disease was bolstered by germ theory, more than half of the soldier casualties in this war were from disease. unknowingly, american soldiers acted as agents of disease transmission, fostering bacteria in their haphazardly made camps. these soldiers invaded cuba, puerto rico, and the philippines and connected parts of these countries that had never before been connected due to the countries sparse nature thereby beginning epidemics. the mobility of american soldiers around these countries encouraged a newfound mobility of disease that quickly infected natives. military personnel used rudyard's kipling's poem "the white man's burden" to explain their imperialistic actions in cuba, the philippines, and puerto rico and the need for the united states to help the "dark-skinned barbarians" reach modern sanitary standards. american actions abroad before, during, and after the war emphasized a need for proper sanitation habits especially on behalf of the natives. natives who refuse to oblige with american health standards and procedures risked fines or imprisonment. one penalty in puerto rico included a $10 fine for a failure to vaccinate and an additional $5 fine for any day you continue to be unvaccinated, refusal to pay resulted in ten or more days of imprisonment. if entire villages refused the army's current sanitation policy at any given time they risked being burnt to the ground in order to preserve the health and safety of soldiers from endemic smallpox and yellow fever. vaccines were forcibly administered to the puerto ricans, cubans, and filipinos. military personnel in puerto rico provided public health services that culminated in military orders mandating vaccinations for children before they were six months old, as well as a general vaccination order. by the end of 1899 in puerto rico alone the u.s. military and other hired native vaccinators called practicantes, vaccinated an estimated 860,000 natives in a five-month period. this period began the united states' movement toward an expansion of medical practices that included "tropical medicine" in an attempt to protect the lives of soldiers abroad. adverse event reporting there are several programs for monitoring the safety of vaccines in the united states. chief among these is the vaccine adverse event reporting system (vaers), which is co-managed by the u.s. centers for disease control and prevention (cdc) and the food and drug administration (fda). vaers is a postmarketing surveillance program, collecting information about adverse events (possible harmful side effects) that occur after administration of vaccines to ascertain whether the risk–benefit ratio is high enough to justify continued use of any particular vaccine. in addition to vaers, the vaccine safety datalink, and the clinical immunization safety assessment (cisa) network are tools by which the cdc and fda measure vaccine safety. vaccine injury compensation the national vaccine injury compensation program (vicp or nvicp) was established pursuant to the 1986 national childhood vaccine injury act (ncvia), passed by the united states congress in response to a threat to the vaccine supply due to a 1980s scare over the dpt vaccine. despite the belief of most public health officials that claims of side effects were unfounded, large jury awards had been given to some plaintiffs, most dpt vaccine makers had ceased production, and officials feared the loss of herd immunity. the u.s. department of health and human services set up the national vaccine injury compensation program (vicp) in 1988 to compensate individuals and families of individuals injured by covered childhood vaccines. the office of special masters of the u.s. court of federal claims, popularly known as "vaccine court", administers a no-fault system for litigating vaccine injury claims. these claims against vaccine manufacturers cannot normally be filed in state or federal civil courts, but instead must be heard in the u.s. court of federal claims, sitting without a jury. compensation covers medical and legal expenses, loss of future earning capacity, and up to $250,000 for pain and suffering; a death benefit of up to $250,000 is available. if certain minimal requirements are met, legal expenses are compensated even for unsuccessful claims. since 1988, the program has been funded by an excise tax of 75 cents on every purchased dose of covered vaccine. to win an award, a claimant must have experienced an injury that is named as a vaccine injury in a table included in the law within the required time period or show a causal connection. the burden of proof is the civil law preponderance-of-the-evidence standard, in other words a showing that causation was more likely than not. denied claims can be pursued in civil courts, though this is rare. the vicp covers all vaccines listed on the vaccine injury table maintained by the secretary of health and human services; in 2007 the list included vaccines against diphtheria, tetanus, pertussis (whooping cough), measles, mumps, rubella (german measles), polio, hepatitis b, varicella (chicken pox), haemophilus influenzae type b, rotavirus, and pneumonia. from 1988 until 8 january 2008, 5,263 claims relating to autism, and 2,865 non-autism claims, were made to the vicp. 925 of these claims, one autism-related (see previous rulings), were compensated, with 1,158 non-autism and 350 autism claims dismissed; awards (including attorney's fees) totaled $847 million. as of october 2019, $4.2 billion in compensation (not including attorneys fees and costs) has been awarded over the forty-three year history of the program.