Medical Science Publication No. 4, Volume II
VENEREAL DISEASE PROBLEMS, U. S. ARMY FORCES,FAR EAST 1950-53*
COLONEL JOSEPH H.McNINCH, MC
Environmental Background
The principal factors contributing to the high incidence and spreadof venereal disease in military forces in the Far East Command are povertyin civilian populations and widespread prostitution, the former contributingsignificantly to the latter. Although prostitution exists in the absenceof poverty, economic conditions in Korea during the period 1950-53 undoubtedlydrove many women into this profession who would otherwise have married,raised families, or found other occupations.
Prostitution itself has long been a socially and legally accepted professionin the Orient. Japan, Okinawa, and Korea are not exceptions. Prior to theend of World War II prostitutes were licensed, organized, segregated intodistricts, and some medical examinations were done. Women had few rightsand girls were frequently sold for the purpose of prostitution by theirfathers to augment meager family incomes.
Following the occupation of Japan and Okinawa and the liberation ofKorea, reforms were initiated. In Korea a law was enacted that made allphases of prostitution illegal. In Japan a law was enacted outlawing prostitutionas an organized business and the licensing of prostitutes, but which didnot bar women as individuals from engaging in prostitution. In Okinawathe Military Government issued an order prohibiting prostitution with UnitedStates personnel, but not among the Okinawans. It is not known why Occupationauthorities did not impose stricter prohibitory measures, but it is assumedthat it was believed that there were limits to the degree and speed withwhich customs and tradition could be changed. In any event, prostitutionhas continued to flourish in Japan and in Okinawa. Even in Korea whereall phases of prostitution are illegal, since the onset of the war in 1950,the Government has taken the position that enforcement of the law is impractical.
In discussing the problem of prostitution as it exists today, it mustbe remembered that Japan and Korea are now sovereign nations, and
*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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United States military authorities are limited to requesting cooperationin application of United States policies regarding the suppression of prostitution.
Living conditions in all three countries also have a bearing on theincidence and variety of venereal diseases. Few houses in Okinawa havepiped water supplies, either hot or cold. Facilities for cleanliness ofthe prostitute or her clients are almost totally lacking. The situationin Japan is better, but many Japanese homes are without piped water, especiallyhot water.
Another factor having a bearing on the venereal disease problem in theFar East Command is the almost complete lack of moral, wholesome femininecompanionship for American servicemen. Important in this situation is thelanguage barrier. Few if any United States personnel learn more than afew words or sentences in Japanese or Korean. Few Japanese, Okinawans orKorean girls and women can speak English. The exception is the prostitutewho has learned through the practice of her profession. The inability tocommunicate effectively blocks the more wholesome mingling of young personsof opposite sexes. On the other hand, the language of the bedroom, if notof love, is universal. In addition to the language barrier, Japanese, Okinawanand Korean parents are naturally fearful of permitting their daughtersto associate with foreign males. The result is that with relatively fewexceptions, the American soldier in Japan, Okinawa and Korea in his searchfor female companionship is limited to the prostitute.
Venereal Disease Situation Prior to the War in Korea
Since prostitution is perhaps the most important factor in the spreadof venereal diseases and in view of the conditions in the Far East Commandas they have been described here, it was inevitable that control of venerealdisease presented a continuing and vexing problem prior to the onset ofhostilities in Korea. Total venereal disease rates for United States Armypersonnel in the Far East ranged from 100-160/1,000 per year throughoutthe period 1947-50. Some individual units reported rates in excess of 500/1,000per year.
Effect of the Korean War on Venereal Disease Problems
The principal manner in which the onset of hostilities in Korea affectedthe venereal disease problem was through the marked increase in the numbersand activities of prostitutes. The war resulted in the movement of largenumbers of troops through Japan to Korea and from Korea to Japan. Prostitutesfollowed concentrations of troops wherever such concentrations occurred.Sasebo, Japan, which is a port on the southern tip of the southern islandof Kyushu can be cited
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as an example. This port, during the first 2 years of the war, was astaging area for replacements en route to Korea. Normally these replacementsentered the Port of Yokohama, processed at Camp Drake near Tokyo, and thenwere sent to Sasebo by rail for transshipment to Korea. Troops rotatingto the United States from Korea were brought to Sasebo where they wereprocessed for return to the United States. Sasebo also is a United StatesNavy base and the number of Navy personnel arriving and departing increasedtremendously with the onset of the war.
In a letter dated 9 December 1950, the Commanding Officer of the ArmyCamp at Sasebo stated that the prostitute population had increased tremendouslysince the onset of the war and that the number was then estimated to bebetween six and ten thousand, most of whom were street walkers. To meetthe moral and disease problems posed by these prostitutes on the streetsof Sasebo, United States military representatives met with city officialsin mid-November 1950 and demanded positive action to drive the prostitutesout, threatening to place the entire city off limits if the situation werenot corrected. When a check on 29 November showed no evidence of correctiveaction the entire city was placed off limits the following day. This drasticaction resulted in the passage of an ordinance prohibiting solicitationon 8 December.
This ordinance was not enacted without considerable protest from Japaneseofficials, business men, and others among whom were representatives fromthe White Lily Association, which was the local organization ofprostitutes. Following the passage of this ordinance Sasebo was again placedon limits except for individual establishments which were previously offlimits for various reasons. The enforcement of this ordinance has variedfrom time to time, depending on the degree of pressure brought on Japaneseauthorities. The effect of the ordinance does not extend beyond the citylimits and there are many houses of prostitution in these outskirts. Similarproblems have existed at Camp Drake, near Tokyo, which is another replacementdepot.
Another activity in connection with the war which has increased theproblem of prostitutes has been the Rest and Recreation (R & R) leavefor troops in Korea. During the past 3 years thousands of men have beenflown from Korea to Japan for 5 days R & R. To process these men, so-calledR & R centers were established in Japan where the men were providedwith baths, clean, correct uniforms, and 5 days leave. Special Serviceshas provided hotels and other recreational facilities for the use of R& R personnel but servicemen are free to reject these facilities andfind their own recreation. One thing desired by most men returning fromKorea could not be provided by Special Services-namely, female companionship.However, in Ja-
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pan there are many prostitutes to provide such companionship and pimpsand prostitutes flocked to R & R centers. Despite continued attemptsto suppress their activities, sometimes with and sometimes without cooperationof local authorities, the problem has not been solved. In Korea the Governmentdoes not attempt to enforce the anti-prostitution law. In fact, legal recognitionof prostitution has taken place through the licensing of prostitutes, theinstitution of periodic physical examinations and the issuance of so-calledhealth cards. United States Army commanders of combat units through theirunlimited authority in the combat area have been able, with varying degreesof success, to keep prostitutes out of areas under their control. In Koreaparticularly, the factors of poverty and hunger have served to increasethe prostitute population tremendously.
Figure 1 shows the reported incidence of venereal disease in the ArmyForces Far East during the years 1951-53. It is evident that during 1951and the first half of 1952 there was a continuing rise in reported incidences.The decline during the second half of 1952 will be discussed in a latersection.
Figure 2 shows clearly the venereal disease problem created when newunits arrived in the Far East from the United States and when combat unitsrotated to rear areas. The first half of this chart shows the venerealdisease incidence in two divisions which arrived in Japan in the springof 1951. As prostitutes discovered the camps in which regiments were stationed,venereal disease rates rose progressively. In December 1951 these two divisionswere transferred to Korea and
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two combat-seasoned divisions rotated back to Japan. The second halfof this chart shows the venereal disease incidence in the rotated divisions.This time the prostitutes were already in the locations and the resultis indicated by the high rates in excess of 500-1,000 per year during thefirst month following their return.
Venereal Disease Control Measures in the Far East Command
At all times in the Far East Command, repression of prostitution incompliance with AR 600-900, has been the policy and has been enforced insofaras local conditions would permit. In education of personnel, continencehas been presented as the best method of avoid-
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ing venereal diseases and one that is consistent with American moraland religious concepts. To further this concept there have been characterguidance programs, health education programs, promotion of organized sports,construction and provision of recreational and educational facilities,and the promotion of religious activities. For personnel not acceptingcontinence as the method of choice, there has been free provision of chemicalprophylaxis, both sale and free provision of mechanical prophylaxis, andat times under certain restrictions, penicillin prophylaxis has been available.In Korea local health officials have at times used penicillin for periodicmass treatment of known prostitutes, entertainers, and waitresses. Contacttracing as a program has been encouraged at all times, but presents greatdifficulties in an Oriental country.
With reference to prevention of exposure of the individual or use ofprophylactic methods, there is little in the experience of the Far EastCommand that differs from experience elsewhere. Incidence of venereal diseasein the Command has indicated a fairly high degree of failure in both approaches.
Since prostitution is a particularly important element in the venerealdisease problem in the Far East Command more space will be devoted to adiscussion of this subject. The status of prostitution in the Far Easthas already been indicated. The declared policy of the United States Armythat all commanders will act vigorously to repress prostitution presentsmany grave difficulties in implementation in the Far East.
One approach in the repression of prostitution is the use of off limitsposting. This method is in liberal use in both Japan and Korea. In Koreaentire villages and large sections of cities and towns have been placedoff limits, and early curfews enforced almost everywhere during the periodsof combat. In Korea off limits areas can be and are indicated by appropriatesigns. This program, however, does not prevent the practice of prostitutionnor does it prevent constant movement of prostitutes from "off limits"areas to "on limits" areas, always one jump ahead of the ProvostMarshal. In Japan individual establishments and even entire areas are alsoplaced off limits as a venereal disease control measure. Before the endof the Occupation such houses and areas were plainly marked with signs.Since the end of the Occupation all signs have been removed and off limitsposting can be accomplished only by publication of the name and addressof the establishment or area. However, it is doubtful if at any one campin Japan many persons except the military police know the exact locationof all off limits establishments. Identification of areas or houses inan Oriental city by description is exceedingly difficult.
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The threat of off limits posting has been tried to force towns and villagesin Japan to eliminate prostitution. This has been fairly effective in someareas and totally ineffective in others. However, through efforts on thepart of military authorities, a number of municipalities and prefecturesin Japan have enacted anti-prostitution laws more restrictive than thenational law. At the present time, Tokyo, 9 prefectures, 28 cities, 6 townsand 4 villages in Japan have anti-prostitution ordinances. However, manyof these ordinances only prohibit solicitation on the street and do notprohibit operation of houses. Enforcement of these ordinances varies considerablyfrom place to place and in the same place from time to time. Japanese officialsare usually able to produce many reasons for lax enforcement which varyfrom an insufficient budget to difficulties in obtaining sufficient evidencefor conviction under the present Japanese Constitution.
There are widely divergent views in Japan on the subject of prostitution.Many Japanese desire a return to the "old days" in which prostitutionwas a well organized and regulated business operating in segregated districtswhere it was hidden from the eyes of Japanese wives, mothers, and children.Other Japanese, recognizing the fundamental evils of prostitution and itsdebasement of womanhood, are vigorous in demanding reform and the enactmentand enforcement of laws similar to those of the United States. It is notknown which of these groups constitute a majority.
However, it is my belief that increasing numbers of Japanese committeesare cooperating with United States authorities in at least partial suppressionof prostitution. Okinawa, although not a war-torn country as is Korea,is a country of poverty. The greatest source of income to Okinawans isthe United States Government and its military personnel. Of this incomea significant share is derived through prostitution. Some attempts havebeen made to repress prostitution completely in Okinawa, but such attemptshave usually succeeded in only scattering the prostitutes. Commanders arefaced with the very real problem of choosing between prostitution undersome sort of local government control or taking suppressive measures whichwould scatter the women so that they are under no control at all.
Physical Inspections and Contact Tracing
Identification and treatment of infected persons is an important elementin the control of any disease. It is particularly important in the venerealdiseases. In the control of venereal disease in the Army this involvesthe discovery of the infected soldier and identification of the femalecontact.
Current regulations provide for physical inspections only by specificorder of the Commander on recommendation of his surgeon. It is
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my belief that the indications for such inspections are knowledge orreasonable suspicion that there are concealed cases of venereal diseasein the unit. In units where an appreciable number of such cases are found,inspections should be frequent until men are convinced that concealmentis not desirable. Whenever there is punitive action against commandersfor high venereal disease rates, such commanders are loath to order physicalinspections because discovery of cases will increase their rate. Therehave been indications that commanders of some units in the Far East Commandhave at times avoided ordering physical inspections for this reason. Itis likely that in many areas lack of inspection of troops is a factor inmaintaining the reservoir of venereal infection in the civilian community.
Contact tracing in the Orient presents many problems. Identificationof persons and places is complicated by barriers of language and the useof Oriental symbols which have no resemblance to the Roman alphabet. InTokyo, one person in describing the advantages of a certain shop will usuallyend by saying "I can't possibly tell you how to find it, I will haveto take you there sometime." With the great movement of replacementsinto and rotatees out of the Far East Command during the war, the simpledevice of having the patient take the investigator to the place of exposurewas impractical in a large percentage of cases. Despite these difficultiesthere has been a contact tracing program at all times in the Command. Theeffectiveness has varied usually with the personnel making the investigation.Some camps in Japan claim to find a large percentage of contacts, othersfind almost none. In Korea the National Police assist military authoritiesin this program. The use of the patient to hunt down the contact improvesthe chances of finding the contact. However, in each area it is necessaryto determine whether the results justify the time lost from duty.
It is essential that the form used for the contact report in the FarEast Command be bilingual. The United States Navy operates a school ofcontact tracers at Sasebo, Japan. Army personnel are permitted to attendthis school and many have done so. We are grateful to the Navy for thisassistance.
One almost universal complaint of post and unit surgeons in Japan isthat after being located only a small percentage of contacts are foundto have venereal disease when examined by local health agencies. Indigenous,local diagnostic facilities in Japan, Okinawa, and Korea are poor at best.Also, the accurate diagnosis of gonorrhea or chancroid in females in theabsence of clinical manifestations may be difficult. A number of UnitedStates medical officers have rendered voluntary assistance to local healthagencies in improving their diagnostic technics. In Japan this has a doublehazzard: that of being
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accused of abetting prostitution by higher military authorities andalso that of being accused in the press of coercing Japanese health authorities.Diagnosis of chancroid in women presents an especially difficult problem.In Okinawa at one time when the ratio of gonorrhea to chancroid in militarypersonnel was 1 to 1 the ratio in routinely examined prostitutes was 22to 1.
Chemical and mechanical prophylactics have been both free and freelyavailable in the Far East Command. Many medical officers believe that chemicalprophylaxis is useless or worse than useless. If that is the consensusthroughout the Army, it is recommended that its use be discontinued, eventhough a replacement item is not available, and even if there is dangerof "loss of face" on the part of the Medical Service. In viewof the excessively high venereal disease rates in some units in the FarEast it would appear that neither chemical nor mechanical prophylacticswere ever used in those units. The reason for this is not known, but itseems most likely that modern treatment has resulted in lack of fear ofthese diseases.
Penicillin Prophylaxis
In July or August 1949 the Surgeon of the Eighth Army, then stationedin Japan, asked for authority to try out penicillin prophylaxis. This trialwas authorized and in October 1949 the Surgeon rendered a preliminary reportbased on the administration of oral penicillin in two units, one stationedin Yokohama and the other in Kobe, Japan.
Table 1 shows the data contained in that report. The results are striking.From available records it appears that based on these results the experimentwas broadened to include more units. The course of events afterward isnot clear from available records, except that the use of penicillin prophylacticallywas discontinued.
Table 1. Results of Test of Oral Penicillinto Prevent Gonorrhea, Eighth U. S. Army in Japan, 1949-Rates per 1,000per Year
| Incidence prior to test | Incidence during test | ||||
Cases | Rate | Period | Cases | Rate | Period | |
Yokohama Command | 18 | 376 | 8 weeks | 0 | 0 | 8 weeks. |
Kobe Base Command | 67 | 1,228 | 6 weeks | 3 | 55 | 6 weeks. |
Early in 1952 a number of officers in the Far East Command, both medicaland non-medical, requested authority to reinstitute oral penicillin prophylaxis.Since available records on this subject were meager a letter was dispatchedon 4 February 1952 to the Office of
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The Surgeon General asking for a restatement of policy. The reply tothe request stated current policy to be:
1. Oral penicillin prophylaxis could be used:
a. Only in overseas commands.
b. Only in areas of high gonorrhea incidence.
c. Only in selected units.
d. Only when leave periods would be less than 24 hours.
2. Oral penicillin tablets could be given:
a. Only in medical facilities.
b. Only on request of the individual.
3. The tablets must be taken in the presence of the person dispensingthem.
4. The use of penicillin must be emphasized to the individuals as effectiveonly against gonorrhea, and he should be told to apply other routine prophylacticmeasures.
After receipt of this letter, on the premise that all areas in the FarEast Command had a high gonorrhea incidence, the surgeons of all subordinatecommands were authorized to institute its use under the prescribed restrictions.Reactions of surgeons of subordinate commands varied. The surgeons of JapanLogistical Command and Eighth Army were opposed to its use and did nottake advantage of the authority granted. The Surgeon, XVI Corps, whichcontrolled combat units in Japan, instituted its use immediately.
Since that time, oral penicillin has been used periodically in manyArmy units in the Far East. The local policy has depended usually on theprofessional opinions of the current local surgeon. Records of the successor failure are generally not available. In units where the program hasbeen pushed, a lowering of the gonorrhea rate has almost always resulted.However, there have been no magic results apparent in the Army Forces FarEast. It is the belief of the writer that the Department of the Army restrictions,particularly the one that requires the tablets to be dispensed at a medicalfacility, effectively precludes the successful application of the method.
Evolution of Present Policy of Venereal Disease Control
It is apparent in figure 1 that there was a progressive increase inthe venereal disease incidence throughout 1951 and the early months of1952. This increase was especially marked in Japan because of the arrivalof two divisions from the United States in 1951 and rotation of two combatexperienced divisions from Korea in 1952. However, rates were also risingin Korea and in Okinawa. Commanders were showing increasing concern andthis concern was stimulated by published reports in United States newspapersabout narcotics, vice, prostitution and venereal disease in the Far EastCommand.
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In June 1952 a Command conference on the problem of venereal diseasewas held in Tokyo. Following this conference, strong letters were sentout directing commanders at all levels to intensify their efforts to repressprostitution and reduce the incidence of venereal disease.
To meet the demand for reduction in venereal disease rates all of theusual control measures were intensified. Punishment of the individual wasincluded among these measures despite regulations to the contrary. Suchpunishment was usually covert, but occasionally overt. One commander deviseda method in which he appointed all noncommissioned officers as venerealdisease control officers, then if the noncommissioned officer contracteda venereal disease he was reduced in grade for "inefficiency"as a control officer. Some punishment was not so subtle. One Corps commanderordered passes withdrawn from all men in the company having the highestvenereal disease rate in each large unit or each camp.
Figure 3 shows the trend of venereal disease following the command letterof 7 July 1952. In Japan the reported incidence, and I stress the word"reported," dropped 26 percent in July, 20 percent in Augustand 16 percent in September. A similar reduction occurred in Okinawa. InKorea, where opportunities for self-treatment or treatment by civilianswere limited, the decline was much more gradual.
It is difficult to determine the exact or even relative weight of thevarious factors involved in this reduction of reported incidence of venerealdisease. However, there was considerable evidence that concealment, self-treatmentand treatment by civilians existed and was increasing.
At every opportunity the Chief Surgeon pointed out to the Army HeadquartersStaff that lack of treatment and inadequate treatment were the real dangersof venereal infection and that the most important factor in causing concealmentof infection was the threat of punishment.
When finally converted to this point of view, the staff recommendedto the Commander that AFFE Circular 152 be published. There are some sentencesin this new circular that are believed to be worthy of quotation as expressinga new approach to the venereal disease problem in the Army.
The first paragraph of this directive points out that the venereal diseaserate is not necessarily identical with the true incidenceof venereal disease and that the former may be lower by certain commandactions without a reduction in the latter. It is also stated that the successof a commander in venereal disease control will be judged on the basisof his control program with due allowance for the environmentalsituation of his unit and the means at his disposal. It is em-
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phasized that the venereal disease rate of his unit is not anaccurate index of the control activities of the commander and that thereis no justification or authority for evaluating his efficiency solely onthe basis of the "venereal disease rate." It is finally pointedout that the control of venereal disease is but one of a myriad of commandresponsibilities and in the evaluation of the total efficiency of a commander,the problem of venereal disease control will not be given more emphasisthan it deserves.
These, we believe, are important principles in a military venereal diseasecontrol program. The publication of this directive has not resulted inthe acceptance of these principles by all unit commanders in the Far EastCommand. There is evidence that there is a fear by many unit commandersthat these principles will not be recognized in intermediate headquartersor that they will be rejected the next time a new directive is published.It is our hope that the passage of time will see acceptance of these principlesat Department of Army level
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and that subordinate commanders will realize that there has been a permanentmodification of former Army policy.
Before closing, there are several other problems concerning venerealdisease as encountered in the Far East Command which should be mentioned.
From 1949 to 1952 the percentage of all venereal disease reported aschancroid increased and that reported as syphilis decreased. This changingpicture is shown in figure 4.
Two problems are suggested here. First, the large incidence of chancroidpresents a difficult problem of control. Penicillin prophylaxis is noteffective against this disease. Diagnosis of the disease in women is difficultand identification of the bacillus of Ducrey is not easy or certain. Ithas been pointed out that in Okinawa, at a time when the ratio of gonorrheato chancroid in the military population was approximately 1 to 1, the ratiodiagnosed in prostitutes at routine examinations was reported as 22 to1. Some medical officers in the Far East Command have expressed the beliefthat clinical chancroid is caused not only by the bacillus of Ducrey butthat other agents might
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be implicated. Certainly there is reason for more study of the clinicalmanifestation, etiology and diagnosis of chancroid, particularly in thefemale.
The second problem concerns syphilis. The decrease in diagnosed casesof syphilis was both relative and absolute. In 1950 the rate in Japan was13/1,000, in 1953 the rate was 3.2. In Okinawa the rate dropped from 2.4to 1.0 during the same period. This has caused grave concern that diagnosesof primary lesions were being missed.
A recent survey of place of treatment of cases of syphilis has increasedour concern over this problem.
Figure 5 shows the percentage of cases of syphilis treated on a dutystatus compared with the percentage treated in hospital or quarters. Itwill be noted that the percentage treated in hospital and quarters is 52percent and 64 percent in Japan and Okinawa respectively. We believe thatthe great majority of these patients were not hospitalized for treatmentof syphilis per se, but were diagnosed while in hospital for treatmentof other conditions. This, of course, leads to the question of why a diagnosiswas not made at the time of admission. If the disease was contracted inthe Far East Command and missed, there
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is reason for much concern. It is planned to initiate a study of allcases routinely diagnosed in hospitals to determine the circumstances attendingthe diagnosis of the primary lesion. Until such study is made we can onlyspeculate on the significance of the last two charts.
Recently we conducted a survey to determine how uncomplicated gonorrheawas being treated in the Army Forces Far East. It was discovered that althoughthere were a great many variations in the dosage of penicillin used, thenumber of treatments and the length of treatment, in almost no instancedid we find the treatment to follow that prescribed in TB MED 230, Managementof Venereal Diseases. The Surgeon General has been informed of this fact.When a complete analysis of the result of this survey is completed it iscontemplated that an AFFE policy on treatment will be formulated and published,pending revision of the current policy by The Surgeon General.
