Medical Science Publication No. 4, Volume II
TUESDAY AFTERNOON SESSION
27 April 1954
MODERATOR
COLONEL CHARLES L. LEEDHAM, MC
TUBERCULOSIS*
COLONEL CHARLES L.LEEDHAM, MC
Introduction
The theme of this discussion might well be stated to be: That in spiteof widespread exposure to tuberculosis in the Far East, American troopscame away practically unscathed. This statement becomes all the more amazingwhen one considers the extent of tuberculosis to which these troops wereexposed. In fact, consideration of the problem of tuberculosis in UnitedStates Forces in the Far East is inextricably bound with the problem oftuberculosis of the indigenous populations of Korea and Japan. A briefbackground discussion, therefore, of the Oriental problem must necessarilybe given in order to realize the full implications of the theme as it hasbeen stated. Let us turn our attention immediately to this background information.Let us consider the worst problem first-the Korean problem-then the Japaneseproblem and finally, as a pleasant comparison, the American experience.
The Problem in Korea
Every authority consulted in the preparation of this paper unequivocallystated that tuberculosis was and is the greatest health problem in Korea.Yet the problem of tuberculosis in Korea differs in no material sense fromthe problem of tuberculosis throughout the Orient. The problem of tuberculosisin the Orient differs from the problem in the Western countries only indegree and in the existence of certain adverse factors which exert a markedinfluence on the extent of the disease. These factors are poor sanitation,lowered resistance of the individual, the sociological reaction of theindividual to his disease and the effectiveness of therapy. Since in Koreathese factors are all demonstrably adverse, let us examine each factorbriefly.
Only one who has spent time in Korea can be fully aware of the extremelylow level of sanitation which exists in that country. By Western concepts,sanitation is shockingly absent. Paucity of sanitation inevitably resultsin high overall disease rates, or inversely translated, in very low levelsof general health. This of course has a marked influence on the generalsusceptibility to tuberculosis.
*Presented 27 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.
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To carry the point further, a low level of health in the populationas a whole when broken down to the intimate individual case means basicallya lowered individual resistance. This already low individual resistancewas aggravated in Korea by the inadequate diet and malnutrition createdby the war years. The multiple worm infestations, the avitaminoses andthe chronic upper respiratory infections existent in the general populationcompounded the problem. Add to this the starvation, exposure and hovel-typeexistence of the vast refugee group and one has built up a background remarkablyconducive to the spread of tuberculosis.
Another contributing factor is the attitude of the individual concerned.This attitude is in general based on ignorance of the condition, an indifferenceto the problem, and an all-pervading fatalism. These states of mind arepresent in varying degrees in all levels of the population, in all strataof society and in all echelons of authority. In fact, it is a rare individualand one unusually well educated-almost invariably one exposed to Westernthinking-who has any real concept of the threat of the disease. As a result,families tend to ignore or even conceal cases of tuberculosis. This concealmentcombined with communal living in small, poorly heated and ventilated buildings-whereas many as 20 persons may sleep in one room-further enhances the spreadof the disease. This attitude of indifference or ignorance or fatalism-whatevername you give it-adds to the problem tremendously.
Medical measures and management are in general much below Western standards.Case finding effectiveness is definitely hampered by indifference, neglect,lack of knowledge, lack of proper equipment, and family concealment. Whencases are found hospital facilities for the patients are at best poor.Institution sanitation is negligible, while isolation facilities are practicallynonexistent. Knowledge of therapy is apt to be inadequate and based onantiquated concepts. When medical knowledge is good it is usually hamperedby a woeful dearth of medication. Poor facilities, the distressing lackof drugs, and an inadequacy of professional knowledge contribute to thepoor outlook of the individual with tuberculosis and thus to the high overallrates.*
There has been delineated thus, in a few short paragraphs, some of thebackground of the tuberculosis problem in the Orient, which, I re-emphasize,has been compounded in Korea by the vicissitudes and hardships of the waryears. I might add anticlimactically that
*Dr. Yu Sun Yun (1) in his excellent report to the Pan Pacific Tuberculosis Conference in Manila in 1953 has emphasized the points made above most succinctly. In fact, in comparison I have been most diplomatic. His report should be required reading for any one more deeply interested in the problem.
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where progress has been made against the tremendous odds noted it hasbeen made with the help, impetus and stimulus of Western civilization andmedicine. It is here that hope for the future lies insofar as tuberculosisin the Orient is concerned.
But before delving into what is being done to alleviate these conditions,let us turn to some more or less specific statistics to illustrate themagnitude of the problem. Statistics concerning the disease in Korea aredesperately inaccurate-partly due to the facts previously noted and partlydue to the fact that as late as 1953 the disease has not been reportable.Dr. Bowditch (2) states that in 1950 mass radiographic surveys show2 percent active tuberculosis in the general population. Another authority(3) states that in 1952 there were 800,000 cases (4 percent) ina population of 20 million. An estimate of 60,000 deaths per year or arate of 200 per 100,000 population per annum is given by Dr. In Ho Chu(4) in a report to the UN in 1951.
Even more dramatic figures are furnished by Dr. Yu Sun Yun (1)in his presentation before the Pan Pacific Tuberculosis Conference in Manilain 1953. Dr. Yun estimates 1,300,000 cases or a 6.5 percent prevalenceof whom 500,000 (2.5 percent of the population) need sanatorium care. Healso reports that an x-ray study of 21,701 school-age children revealed7.7 percent active tuberculosis. Dr. Yun estimates 100,000 deaths per yearand a rate of 300 to 400 per 100,000 per annum. Somewhere in the rangeof these figures lies the real incidence of the disease.
In an effort to make comparisons with the extent of tuberculosis inthe United States one encounters two difficulties. First, Korean figuresare at best educated guesses and comparisons are thereby invalid. Secondly,Korean reports are given as prevalence figures whereas United States statisticsare given as incidence rates. However, by using death rates one can makea somewhat reasonable comparison. Accepting the median figure of 300/100,000per annum as the Korean death rate, and 16.1/100,000 per annum as the UnitedStates figure, one finds the Korean death rate almost 20 times that ofthe United States. The comparison, to say the least, is startling.
And what is being done to alleviate this situation? The first falteringsteps have been taken principally by the Korean relief agencies, limitedby a woeful lack of funds and lack of trained personnel. X-ray screeninghas been ambitiously planned for, but because of many difficulties hasmade a slow start. Using CRIK supplies KCAC (5) in 1952 administered533,976 tuberculin tests, while 292,174 negative reactors received BCGvaccine. Tuberculosis hospital facilities have been expanded from 300 bedsin 1950 to 1,536 in 1953. Fifteen ambulatory treatment centers have beenestablished, and handled 15,000 cases
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in 1953. Remembering that 1,300,000 patients need care-500,000 of thesesanatorium care-do you wonder I used the adjective "faltering"?
Private agencies and private charities are assisting in many ways. TheAmerican Korean Foundation presented $10,000 to the Ministry of Healthto support personnel for a tuberculosis control program, which is now headedby a competent Korean physician who has had 4 years' training in the UnitedStates. The official and unofficial contributions of U. S. Army personnelin funds and medical assistance are extremely noteworthy. All in all, asyou can see, a start is being made to sweep back the tide. When one considersthe extent of the problem and the start delineated above, future needsstagger the imagination.
The Problem Concerning Communist POW's
Let us turn now to another and more practical facet of the tuberculosisproblem as faced by the Military in the Korean campaign; the problem oftuberculosis in Communist Korean and Chinese POW's held by the U. N. Inthis group tuberculosis also ran rampant. The incidence rate for tuberculosisamong the captured Communists for the calendar year 1 September 1951-31August 1952 was 43 per 1,000 per annum (6). The incidence rate forU. S. Troops in Korea for a comparable period, the calendar year 1952,was 0.8 per 1,000 per annum (7). The rate, therefore, in Communisttroops on whom we were able to collect data was 53 times that of U. S.Army troops. You may draw any conclusions from these figures that you desire.
The problem of care which this mass of tuberculosis placed on the U.S. Army Medical Service was tremendous. The problem was met with characteristicallyaggressive fashion in the POW camp hospitals. Tuberculosis patients weresegregated as soon as detected, classified as to type and severity, andappropriate well-ordered plans of therapy were soon in operation. Therewere few U. S. Army professional personnel, physicians, nurses and paramedics,so in order to handle the problem captured medical personnel as well asfriendly Korean civilians were employed. All therapy was carried out underthe direction and guidance of the U. S. Army Medical Service. In orderto give you a sketchy picture of such an operation, I shall go into a bitof detail about one such hospital of which I have considerable personalknowledge. I am indebted to Dr. Robert W. Briggs (8) of Indianapolisfor much of the material contained in the next few paragraphs.
Imagine my surprise on my first visit as FEC Medical Consultant to POWCamp Number 1 to find a field hospital of 10,000-bed capacity. This 10,000-bedunit was actually operated by a combination of two field hospital unitsworking under a single commanding officer. The total patient load, allKoreans, ranged between 7,200 and 8,000. The
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hospital itself was divided into compounds accommodating from 1,500to 2,000 patients each. The medical service consisted of Compounds Number3, Number 5 and Number 6, and averaged at all times between 4,500 and 5,000total patients. Compound Number 3 was primarily for general medical problemsand cared for 800 to 1,200 patients. The other two compounds treated primarilytuberculosis.
Since we are dealing specifically with tuberculosis, let us look intothe operation of Compound Number 6. Here the average patient load variedfrom 1,800 to 2,000 patients. Five hundred of the patients had pleuraleffusions, the remainder had other types of tuberculosis. Approximately300 of the latter represented minimal disease and the remainder moderatelyadvanced and far advanced tuberculosis. There were 30 to 40 seriously illpatients at all times.
Physically, the compound occupied considerably more than an acre. Withinthe inclosing walls of barbed wire were rows of ward tents with appropriateareas for exercise, sanitary facilities and food preparation. A frame headquartersbuilding served as an American doctor's office and a nurse's station, aswell as a records center. As time passed and material became available,the tents were replaced by long low buildings of mud, adobe, rock and lumberwith thick walls and small windows high under the wide overhanging eaves.This type of structure, characteristic of the colder rural Orient, is surprisinglywarm and adequately suited for the purposes intended. Throughout the entireperiod one tent, later a frame building, was set aside as a therapy centerand assembly building for indigenous physicians. Here too, medical meetingswere held. Under these conditions and with the able assistance of the Koreannurses and POW hospital attendants, patients were given surprisingly goodcare. The fact that medical nursing and dietary care of these prisonerswas so good and, in fact, better than that available to the civilian populationwas the source of much adverse comment among the South Korean population.
As previously mentioned, the bulk of the work was done by indigenouspersonnel. Compound Number 6 had a staff of three American physicians andthree American nurses. There were 17 North Korean POW physicians, and twoSouth Korean civilian physicians. South Korean civilians were employedas nurses. Daily medical clinics were held and literature was reviewedon current problems of interest. Once weekly a CPC was held. The ChestSurgery Department collaborated in medical-surgical conferences twice weekly.The results of this training activity not only were evidenced in maintaininggood patient care, but also in raising markedly the level of medical educationof the Korean doctors. Cooperation among the various nationality groupswas excellent. Even during prison riots, when American medical personnelwere not permitted within compound limits, the Americans
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continued their supervision of medical care from stations outside thecompound fence. It is interesting to note two facts. To my knowledge noAmerican medical personnel were ever injured by POW's and to my knowledgenever has a propaganda barrage been released against American medical personnelin the tuberculosis compounds. The young American doctors and nurses usedthe opportunity presented to them to demonstrate to the enemy in theircare the great principles of our American democracy, both by means of goodmedical care and by personal example.
Therapy was based on the accepted American therapeutic regimen directedand supervised by the American physicians. Bed rest, nourishing diet, medicationand supplemental therapeutic procedures were the basis of medical care.Progress was followed by periodic laboratory work and chest x-rays. Bedrest schedules followed American sanatoria planning as much as possible.The Communist-indoctrinated Oriental mind of the patient frequently limitedcooperation. Diet was a minimum of 3,000 calories per day and consistedprincipally of rice, barley, vegetables, various types of meat stews, supplementedwith milk shakes and vitamins. Streptomycin was used at first, later supplementedby para-amino-salicylic acid as it became available. Selected patientswere given pneumoperitoneum therapy, even pneumothorax when warranted.When indications were present, excisional surgery was done. Results oftherapy compared quite favorably with those in the earlier phases of UnitedStates regimens, and were startingly good when one considers the handicapsof the poor physical and nutritional status of the patient, the numerousinherent infections and infestations, and the gross inability or indoctrinatedunwillingness of the patient to cooperate. Specifically, it is interestingto note that approximately one-third of the patients receiving pneumoperitoneumconverted from a positive to negative sputum in from 3 to 4 months.
The 500 cases of pleural effusions presented a problem of some magnitude.Many were simple effusions having the cytological appearance of an exudatein which even after assiduous search acid-fast bacilli were rarely found.Many were massive effusions with marked mediastinal shift, a few were mixedinfections due to bronchopleural fistula. Miliary tuberculosis and tuberculosismeningitis were much more frequent end results in this group than in similargroups seen in the Western Hemisphere. Likewise, there were more mixedinfection empyemas. The patients, because of their initial state of nutrition,low resistance and advanced disease, usually died in spite of surgicalprocedures. Some of the most successful surgery in the effusion group wasdecortication for the end results of massive effusions of long standing.
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Tuberculous peritonitis was seen in its most severe form. Mesentericlymph nodes were matted together in such a way that intestinal structuresin almost all of these cases could not be dissected at autopsy. In searchingfor a possible explanation, it is interesting to note that even the peritoneumof "healthy" Koreans is thick and fibrous. The mesenteric lymphnodes in these people were also enlarged, quite possibly because of theintestinal parasites which are the normal inhabitants of the intestinesof Koreans. When one states that not infrequently an Ascaris lumbricoidespassed through the walls of the intestine to produce an acute conditionin the abdomen, one realizes the magnitude of related problems.
Even though not tuberculosis, paragonimiasis must be mentioned. About5 percent of the POW's coming from coastal areas gave a 5- to 20-year historyof non-distressing hemoptosis. Sputum was anchovy paste in type and microscopicexamination invariably revealed paragonimiasis. Therapy was never successful,although emetine HCI and other measures were given extensive trial. Muchwork was done and many interesting x-rays of the chest resulted but thedisease was never conquered. However, the problem is not quite as severeas it might seem. The only direct death from paragonimiasis I have knowledgeof was that of a patient with a brain abscess, an unusually rare finding.
Of more than passing interest to those who in the future may be interestedin the problem is a tuberculosis case-finding project undertaken by theFar East Command. All prisoner-of-war camps were to be surveyed ultimately.This project was operating well in its initial phases until abruptly endedby prisoner-of-war riots. Among the difficulties encountered was a distinctlack of cooperation on the part of the examinees. The only explanationI can offer is that either they were carrying out party-line instructionsor in their ignorance regarded the project as an evil scheme. The resultsof this survey may someday be released from present security restrictions.
The Problem in Japan
But to move back to the broader aspects of tuberculosis in the Orient,the tuberculosis problem in Japan is very similar to that in Korea, althoughlesser in degree and severity. The country, although densely populated,is almost on its feet economically and has recovered to a large degreefrom its war damage. The U. S. Occupation gave great impetus to Japan'srecovery both in the economic and health fields, with great strides madebetween 1945 and 1952.
In spite of all of this, the same background factors noted in the Koreanproblem exist in Japan in varying degrees. Although sanitation in Japanis much better than in Korea, it is still far below that
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of Western countries. Nutritional levels are higher; in fact, consideringthe Orient, they are very high indeed. The attitude of the Japanese peopletoward the diseases is much the same as that of the Korean people, andit is still regarded as somewhat of a disgrace to the family, in spiteof much enlightenment generated by the Occupation Forces. Families stilltend to minimize, if not actually conceal, cases. This, combined with asomewhat similar type of communal living, where the average family of 8to 12 all sleep in one room, effectively sealed off in winter because oflack of heating, adds appreciably to the spread of the disease. However,case finding, immunization and therapy are all excellent as a result ofthe efforts initiated by the PH & W Section, GHQ, SCAP. So, allin all, the background factors contribute much less to case incidence thanin Korea.
During the period 1932 to 1951, tuberculosis was the leading cause ofdeath in Japan. In 1945 the death rate had reached a peak of 282.2/100,000(9). A gradual decline brought the rate down to 82.1/100,000 in1952, in which year it was at last no longer the leading cause of death.Although there are many other factors involved in this accomplishment,full credit must be given to the part played by the occupation leadership.
During the occupation, the PH & W Section of SCAP, under the leadershipof Brigadier General Crawford Sams, took aggressive action in the Japanesetuberculosis problem. Under SCAP guidance a tuberculosis control law wasenacted (9), a case-finding campaign organized, 800 health centersestablished, tuberculin testing carried out en masse and BCG vaccinationgiven to negative reactors. Three million vaccinations were given in 1945,and eight million in 1948. Three hundred eighty thousand new active casesof tuberculosis were discovered in the first year of the work, and an increasingnumber yearly thereafter. Five hundred ninety thousand cases were reportedin the year 1951. Tuberculosis beds were increased from 25,000 in 1945to 101,000 in 1951. Modern therapy on an ambulatory basis is presentlycarried out in the 800 health centers, while nutritional campaigns arean effective accompaniment. In 1951 the therapy program carried 1,300,000active cases uncovered in 25,500,000 persons surveyed under the age of30.
Compare these figures with those given above for Korea; 500,000 tuberculintests, 1,500 tuberculosis beds, 15 treatment centers, 15,000 patients undertreatment. Remembering that the Japanese population is a bit more thanfour times that of Korea, the comparisons indicate what aggressive leadership,absolute control of the population healthwise, and the passage of timewill do.
To get back to a more specific type of problem, there is a factor inthe exposure of American troops to tuberculosis in Japan that existed
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to a much lesser degree in Korea. That factor is the experience of theAmerican Army with war brides. In 1952 (10), approximately 5,200non-quota visas for dependents of American servicemen were issued. It canreasonably be assumed that the majority of these were wives of Japaneseextraction. The number of others rejected for entry is not available tothe author at present, but is undoubtedly large. Only the future will tellhow many cases of tuberculosis were contracted in the marital bond whichmight otherwise not have occurred. If one adds to this the extramaritaladventure in both Japan and Korea, one realizes the seriousness of thetuberculosis exposure problem when American troops are billeted amongsta friendly, receptive population harboring a high tuberculosis incidence.As will be seen later, there has been little immediate effect. However,only the future will tell. It is safe to conjecture at this time that onlythe magnificent physical resistance of the American soldier kept the problemfrom becoming a real tragedy.
But to get to the more practical aspects of the problem for future guidance;one aspect of this is the screening of Japanese wives for entry into theUnited States. The USPHS acting for the Immigration Service has absoluteand final decision on the physical fitness of any non-citizen applicantfor entry into the United States. Tuberculosis in any form or evidenceof past tuberculosis is a bar to such entrance. During the early phasesof the occupation, United States medical authorities permitted Japanesephysicians to certify to freedom from disease for those Japanese nationalsdesiring admission to the United States. It soon became apparent from thiswas an unsatisfactory procedure. The work then fell on the shoulders ofthe Medical Services of the Armed Forces. Even here, too frequent errorswere made and only when the greatest emphasis was placed on the problemby higher authority did the proper adjustments take place. What I shouldlike to recommend for future generations is that only those well or thoroughlytrained in tuberculosis be permitted to give entry clearances in questionablecases, and that a high index of suspicion be maintained, not only in regardto the tuberculosis itself, but also in regard to the identity of the individualsbeing examined. More need not be said.
The End Results in American Troops
In spite of all the dire things said about tuberculosis in the Orientto which American troops, because of their gregarious nature, were morethan exposed, the tuberculosis incidence rates (all types) in Americantroops in Korea and Japan are surprisingly low. In fact, there is no reallysignificant difference between rates in U. S. troops in the Orient, inthe Army as a whole, or in the U. S. civilian popula-
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tion. As an example (11), in the year 1952, the incidence ratefor all forms of tuberculosis for U. S. troops in Korea was 0.8 per 1,000per annum; for U. S. troops in Japan 1.0; for all overseas commands 1.0;for the Army as a whole 1.0; and for the civilian U. S. population 0.7per 1,000 per annum (12). The rates for previous years are entirelycomparable. As an example, the all-types tuberculosis rate for Americantroops in Korea for 1950 (13) was 0.90 per 1,000 per annum; for1951, 0.98; for 1952, 0.79; and for 1953, 0.68.
Another point to be noted is that neither the type nor the severityof tuberculosis seen in American troops in the Orient has varied significantlyfrom that seen in previous years, or from that seen in the Army as a whole,or in the Continental United States. In fact, except for tuberculosis inreturned American POW's, the disease was no more a problem in the Orientthan it is normally a problem in the Army as a whole. Only the passageof time will tell whether the statements just made are valid.
It must be acknowledged that tuberculosis contracted by exposure inthe Far East may not develop to clinically recognizable severity untillong after the return of the victim to the United States. When then discovered,if the victim has returned to civilian life, the case will presumably belost in the mass of U. S. statistics and its source be unrecognized. Withthis thought in mind, the Department of Defense, through Dr. Frank Berry,Assistant Secretary (Health and Medical) is seriously considering a case-findingproject for Far East Command returnees.
The Problem in American POW'S
Tuberculosis among Americans imprisoned by Communists is another storyentirely. We will perhaps never know the true morbidity and mortality ratesof the disease. Suffice it to say we can infer that the rates were veryhigh, that the care given was negligible, and that many deaths were contributedto or caused by tuberculosis. The only statistics available are on Americansrecovered in Operations Big and Little Switch (14). In these instances,4.1 percent either had tuberculosis or were under observation for it. Breakdownof these figures at once dissipates their apparent importance. Of the 4.1percent mentioned, only 17 percent of those had demonstrable pulmonarytuberculosis, 4.1 percent had tuberculosis unspecified, and the remaining78.9 percent were under observation. Further follow-up studies are notavailable at this time. However, because of the factors stated in the openingof this paragraph, no significance can be attached to these figures inattempting to assess the extent and severity of tuberculosis in Americansnorth of the combat line. As time goes on, perhaps more adequate data willbe published which may shed some additional light on the problem.
Conclusions
If conclusions are warranted, I should like to repeat as a preface myinitial statement: That in spite of widespread exposure to tuberculosisin the Far East, no significant increase in the incidence of the diseasehas occurred among American troops. If the future supports that statement,and there is much doubt among authorities, the conclusion I should liketo draw is that this miracle is in large part due to the magnificent physiques,the exceptionally high state of nutrition, and the inherited and acquiredresistance of the American soldier.
May the American soldier always be that fortunate.
References
1. Yu Sun Yun: Tuberculosis Problem in the Republic of Korea. Presentedat the Pan Pacific Tuberculosis Conference, Manila PI, 13-19 April 1953.
2. Bowditch, Sarah H.: South Korea Tuberculosis. Medical IntelligenceBranch, Preventive Medicine Division, OTSG, 18 June 1953.
3. FEC Surgeons Circular Letter, January 1952, Volume VII, No. 1.
4. In Ho Chu: Public Health Reports in Korea for the UN, 1951.
5. Extracts from Monthly Civil Affairs, Summary for Korea by HQ KoreanCivil Assistance Command, July 1953.
6. Unpublished data from Medical Statistics Division. OTSG.
7. Korea-A summary of Medical Experience, July '50-December '52. Reprintedfrom Health of the Army, Jan., Feb., Mar. 1953.
8. Briggs, R.W.: Personal communication.
9. Sams, Crawford F.: Experiences in Immunization against Tuberculosiswith BCG Vaccine in Japan. (To be published)
10. Data from Preventive Medicine Division, OTSG.
11. Health of the Army, May 1953.
12. Public Health Reports, November 1953.
13. Data furnished by Preventive Medicine Division, OTSG.
14. Data furnished by Preventive Medicine Division, OTSG.
