Part I
PURPOSE AND DEVELOPMENT OF PLANS
CHAPTER I
Problems of Civilian Health Under War Conditions-General Concepts and Origins
Thomas B. Turner, M.D., and IraV. Hiscock, M.P.H., M.D.
Section I. Concept and Development
Thomas B. Turner, M.D.
The complexities of modern war made it necessary for the U.S.Army in World War II to engage in many new and expanding activities to meet ademonstrated military need. Some of the measures appeared to be remote frommilitary operations at the outset of the war, and many of them were developedwith increasing experience and were adapted to changing and widely varyingconditions. Civil affairs and military government activities may be placed inthis category.
The development and practice of civil affairs and militarygovernment by the U.S. Army may be traced from George Washington in theRevolutionary War to World War II and beyond. Washington, interested in bothlogistics and rudimentary preventive medicine, was concerned with the mutualeffects of relations between troops and civilians. One example of hisadministrative action in this field was his appointment of Gen. Benedict Arnoldas military governor of Philadelphia in 1778 after the British, under Sir HenryClinton, withdrew from the city.
In a more practical way, the U.S. Army had been acquiringexperience in military government and civil affairs, including public health andpreventive medicine, for nearly a century before World War II. The history ofthis subject has been recounted by Gabriel and by Holborn, and set forth ingreat detail in an unpublished study by Daugherty and Andrews of the OperationsResearch Office (later known as the Research Analysis Corp.).1
For the United States, the earliest large-scale venture inthe field of preventive medicine and public health occurred during and after theMexican War (1846-48), with the occupation of New Mexico by Gen. Stephen W.Kearny and of Mexico City, Mexico, by Maj. Gen. Winfield Scott. In New Mexico,military government was not highly successful, principally because the occupyingauthorities failed to consider the customs
1(1) Gabriel, R. H.: American Experience With Military Government. Am. Political Sc. Rev. 37: 417, 1943. (2) Holborn, Hajo: American Military Government: Its Organization and Policies. Washington, D.C.: Infantry Journal Press, 1947. (3) Technical Paper (ORO-TP-29), A Review of U.S. Historical Experience With Civil Affairs, 1776-1954. Prepared by W. E. Daugherty and M. Andrews, Operations Research Office, Bethesda, Md., 1961.
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and problems of the inhabitants. In Mexico, on the otherhand, General Scott's administration of military government and publicrelations was conducted with intelligence, with liberality coupled withfirmness, and with fairness and understanding. It was responsible for theMexican people's opposition to General Santa Anna. In his scholarly article onthis subject, Gabriel has expressed the opinion that the friendly behavior ofthe population of Jalapa "is one of the outstanding civil affairs victoriesin American military history," and that General Scott's plans, orders,and operations put "into effect the principles which have subsequently beenfundamental to the American practice of military government and civilaffairs."2
In 1918, the Third U.S. Army was called upon to institutemilitary government in the Rhineland with less than 3 weeks of preparation forthis responsibility. Because time did not permit the formulation of detailedplans and the preparation of personnel, incoherence of policy and vacillation ofpurpose were observed especially in the early days of this occupation.Fortunately for the success of the mission, no destruction had preceded theoccupation, civil officials could be kept at their tasks, hostilities hadceased, and there was no serious shortage of essential civilian supplies.
Although these and other provisions had been made in the pastfor the administration of civil affairs in connection with military government,there was little concept, in 1939, of the potential scope and importance ofthese activities. The vastness and complexity of civil affairs and militarygovernment operations that developed in World War II were only partly envisionedin the early planning of the American effort.
By 1940, however, the civil affairs function began to berecognized as something more than military government, and the intelligent andinspiring influence of Lt. Col. (later Brig. Gen.) James S. Simmons, MC, newlyappointed chief of preventive medicine in the Surgeon General's Office,resulted in many important new developments. In these developments, the elementsof cultures, sociology, economics, and public health came into prominence.
On 30 July 1940, FM 27-5, the first basic Field Manual onmilitary government, was issued by the War Department,3and discussions then in progress led finally to the establishment, inMarch 1942, of the School of Military Government at Charlottesville, Va.
The invasion of North Africa on 8 November 1942 brought ahost of complicated problems of civil affairs, demonstrating that the militaryorganizations rather than the State Department were the inevitable and bestprimary agencies to deal with these matters. The problems increased in suchvolume and difficulty that the existing organization and staff of the
2Gabriel, R. H.: American Experience With Military Government. The Am. Hist. Rev. 49: 633, 637, July 1944.
3By the end of the war, Civil Affairs and Military Government came to be regarded as a grouping of terms employed for convenience to refer to either civil affairs or military government, depending upon the context. See Department of the Army Field Manual 41-10, Civil Affairs Military Government Operations, 2 May 1957.
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higher command in Washington could not cope with themeffectively. Therefore, on 1 March 1943, the Secretary of War created a CivilAffairs Division as a part of the War Department Special Staff. The firstdirector of this division was Maj. Gen. John H. Hilldring, GS, who took officeon 7 April 1943. The Civil Affairs Division acquired extensive responsibilitiesand became an influential section of the military staff as well as a center ofworldwide management of economic, social, public health, and governmentalaffairs in all countries liberated or occupied as the result of Allied militaryoperations. Additionally, both before and after the establishment of the CivilAffairs Division, an officer in the Operations Division of the War DepartmentGeneral Staff assisted with many civil affairs and military government matters.There was, however, no G-5 (or civil affairs) section forthis function in the General Staff in Washington. In May 1944, first in theheadquarters of SHAEF (Supreme Headquarters, Allied Expeditionary Force), a"fifth staff officer"4 was appointed with the designation"Assistant Chief of Staff, G-5" and assumed command of the G-5section. Similar arrangements were made in most of the overseas theaters ofoperations and in some of the armies.
Personnel problems were particularly acute, especially in thebeginning. Extensive efforts were made to secure and develop men competent to dothe required work. Civil affairs officers, especially selected on the basis ofcivilian experience in public administration, were trained in the language,history, governmental structure, and customs of the country to be occupied.
The pressure of events contributed to a steadily expandingrole for civil affairs in the various theaters of operations. World War II wastotal war in the most literal sense. Complex political questions had to bedecided quickly by the military commander. At the lower levels, the conduct ofmilitary government influenced the health and welfare of the individual civilianand, in turn, determined the cooperation and assistance which the Allied armiesreceived from the civil population. Moreover, events demonstrated again thatdecisions made during a campaign, largely on the basis of militaryconsiderations, may affect profoundly the foreign policy in the postwar period.To every extent possible, therefore, such considerations should be foreseen atthe time and balanced against military necessities.
DEFINITION
Military government may be defined as the supremeauthority exercised by an armed force over the lands, property, and inhabitantsof enemy territory, or Allied or domestic territory recovered from enemyoccupation. It is exercised when an armed force has occupied such territory,whether
4Mrazek, J. E.: The Fifth StaffOfficer. Military Review, U.S. Army Command and General Staff College, FortLeavenworth, Kans. 36: 48, March 1957.
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by force or agreement, and has substituted its authority forthat of the sovereign or previous government.
Situations frequently arise, however, in which an armed forceexercises control over civilians to a lesser degree than under militarygovernment, or a friendly nation may govern the territory in which the militaryforce is located, or a military force may be operating in areas controlled byits own nationals. To cover all of these relationships, the term "civilaffairs" is commonly used in referring to those manifold and complexactivities involving the government and the civilian inhabitants of such areas.
ROLE OF PUBLIC HEALTH
The field of responsibility broadly known aspublic health was a major component of civil affairs activities. Its importancerested on the following considerations:
1. Widespread disease in the civil populations can seriouslyimpede military operations, either through the spread of disease to the militaryforces or through disruption of community activities supporting militaryoperations.
2. Since public health is an integral part of government, thegoverning authority must assume responsibility for health programs directed tothe prevention of epidemics and to the provision of facilities for medical care.Standards were those existing before the war and were to be restored as far aspossible through the use of local personnel and facilities.
3. The character of World War II, with its aerialbombardment, rapid movement of ground troops, and bitter defense of cities,increased the danger to the civil population, which frequently sustained heavycasualties. Humanitarianism and the desire to secure the good will andcooperation of the civil population impelled the Allied military forces undersuch circumstances to render assistance in providing medical care for civilianswho came under their control.
The basis of the Medical Department's responsibilitytowards civilians under Army control was specified in Army Regulations No. 40-5,dated 15 January 1926, which stated that among the general functions of theMedical Department would be "the preservation of health and the preventionof disease among personnel subject to military control, including the directionand execution of measures of public health among the inhabitants of occupiedterritory."
GENESIS OF CIVIL
AFFAIRS HEALTH ACTIVITIES
IN WORLD WAR II
Beginning as little more than an idea in theminds of a few men in the spring of 1940, the civil affairs activities by theend of 1945, as an integral part of the operations of the victorious Alliedarmies, had en-
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compassed the Italian peninsula, most of Western Europe, the Philippines,Japan, Korea, the Chinese mainland to a limited extent, certain territories andpossessions of the United States, and numerous other areas. They were indeedglobal in scope. As with the master strategic plan for the war as a whole, it isinstructive to look back to the genesis of the civil affairs program and torespect the vision of those officers of the Regular Army and of the Reserves wholaid the groundwork for this major undertaking.
The fall of France to the German Army, in June 1940, broughta greater realization of things to come, with increasing perception that theU.S. Army, if involved in the war, would have heavy responsibilities for thehealth of both military and civilian personnel in liberated and occupiedcountries overseas. At this early date, Colonel Simmons began to formulate aplan for civil public health activities in relation to military government.5To assist in this work, he arranged, during May and June 1940, to call to activeduty Lt. Col. (later Col.) Ira V. Hiscock, SnC, and Lt. Col. (later Col.) AlbertW. Sweet, SnC, from civilian health positions. They were joined later by Lt.Col. (later Col.) William A. Hardenbergh, SnC, who, even in the 1930's, at theMedical Field Service School at Carlisle Barracks, Pa., had formulated andtaught in the military sanitation class a scheme of surveys, analysis, andrecommendations for the health phases of military government in Mexico. Thisplan comprised elements of what became known later, from 1940 onward, as medicalintelligence and civil public health affairs of military government.6On 26 June 1940, Colonels Hiscock and Sweet submitted to The SurgeonGeneral a plan for public health administration in occupied countries, whichformed the basis of the program subsequently developed.7
In preparing this plan, health conditions were surveyed in anumber of countries of the Western Hemisphere. As an outgrowth of thesestudies, what subsequently became the Medical Intelligence Division, PreventiveMedicine Service, was organized in April 1941. As one of its services, thisdivision provided essential medical and sanitary data on foreign countries foruse in civil affairs training and planning.8
During 1940, advice was also given by Preventive MedicineService of the Surgeon General's Office on the public health sections of amanual on military government then being drafted in the Office of the Chief ofStaff (p. 4). This manual outlined the fundamental principles and scope of
5(1) Unpublished diary, Col. JamesS. Simmons, MC. Entry dated 20 May 1940. (2) Simmons, James S., Whayne, Tom F.,Anderson, Gaylord W., Horack, Harold M., and collaborators: Global Epidemiology:A Geography of Disease and Sanitation. Volume I. Philadelphia: J. B. LippincottCo., 1944, pp. vii, x.
6Letter, W. A. Hardenbergh to Dr. Douglass W. Walker, 5 June 1951,enclosing memorandum covering some early developments in Army civil affairs (byW. A. Hardenbergh), dated 5 June 1951.
7Report, Lt. Col. Ira V. Hiscock, SnC, and Lt. Col. A. W. Sweet, SnC,to The Surgeon General, 26 June 1940, subject: A Plan for the MilitaryAdministration of Public Health in Occupied Territory.
8(1) OfficeOrder No. 87, War Department, Office of the Surgeon General, 18 Apr. 1941,subject: Further Reorganization of Professional ServiceDivision and Designation of New Divisions. (2) Anderson, Gaylord W.: MedicalIntelligence. In Medical Department, United States Army. PreventiveMedicine in World War II. Volume IX. Special Fields. Washington: U.S. GovernmentPrinting Office, 1969. pp. 251-340.
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public health. In 1943, on the basis of first experiences inNorth Africa, to expound a more rigid attitude toward the enemy, and to indicatenew concepts, the original field manual was superseded by a joint Army and Navypublication.9
EXTENT
OF CIVIL PUBLIC HEALTH ACTIVITIES
Geographically, Army civil public healthactivities were almost as farflung as the war itself. Whereas the varied terrainin different theaters of operations affected military tactics and thus broughtabout modifications in the operations of the fighting forces and of the attachedmedical components, civil affairs activities were less influenced by geographicfeatures than by the differing cultural patterns of the peoples with whom theywere concerned.
Differing languages, customs, and forms of governmentpresented varied problems to civil affairs officers, necessitated thedevelopment of different plans of operation for various countries, and requiredfrequent improvisation to cope with peculiarly local problems. On the otherhand, a pattern of disease phenomena which recognizes no language barriers and acontinuing thread of humanitarianism provided common denominators for civilaffairs health activities throughout the many regions of the world in which theprogram functioned.
The civil affairs program inherently served two functions: aprimary one in furthering strictly military operations, and a secondary one inlaying the basis for subsequent policies beyond the military phase. This dualfunction, from which stems the importance of civil affairs, created a dichotomyof objective which caused many of the difficulties and the conflicts thatplagued the civil affairs program throughout the war. These difficulties came tothe surface principally in regard to organizational and administrative questionsat higher echelons, but their effect was perceptible even at the lowestoperational level. These same conflicts were encountered in the civil publichealth programs and constituted one of the major problems of civil public healthin World War II.
In the chapters that follow, an account will be given of thehealth activities carried out by the U.S. Army, at times in collaboration withthe British Army, at other times in conjunction with the U.S. Navy, andsometimes with the participation of the American National Red Cross, the U.S.Office of Foreign Relief and Rehabilitation Operations (later United NationsRelief and Rehabilitation Administration), or with other appropriateorganizations. An effort will be made to evaluate the results of theseactivities in terms of the degree of success that attended the programinstituted to meet the principal problems. However, an ironic characteristic ofcivilian and military public health and preventive medicine is that only its
9War Department Field Manual 27-5 and NavyDepartment OpNav 50E-3, Army-Navy Manual of Military Government and CivilAffairs, 22 Dec. 1943.
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failures are spectacular, while its successes so often can begauged only by the things that do not happen.
PHASES OF MILITARY GOVERNMENT AND CIVIL AFFAIRS
The civil health program, together with themilitary government and civil affairs program as a whole, may be divided intothree principal phases: planning, combat, and occupation.A fourth phase, missions to friendly countries, may be recognized.
In addition, in several instances, as during maneuvers in theUnited States, during martial law in Hawaii, and in connection with theevacuation of the Japanese from California, civil affairs and public healthactivities were carried on by U.S. Army Forces that were operating in areas orpossessions of their own country. These episodes are described in chapterIV.
Planning phase .-Careful and farsighted planning to meetanticipated situations is necessary for all military operations.However, in laying the plans for the early military government operations inItaly, and later in the Philippines, little attention was given to the medicaland public health aspects of the problem. The emergencies that arose were met byimprovisation; only heavy reliance on Medical Department personnel and somereliance on supplies earmarked for the fighting troops saved the civil publichealth program in these areas from ineffectiveness. On the other hand, thecareful planning which preceded the invasions of Northwest Europe and Japan wasreflected in the more satisfactory manner in which the civil health programfunctioned.
Combat phase .-The combat phase is limited tothe period during and immediately following combat, and is territorially limitedlargely to the actual area of military operations. In this period, the medicalprogram was stripped to its bare essentials-for example, medical care forwounded civilians, the exposed, the seriously ill, and parturient women;provision of a few basic lifesaving medical items, such as morphine, ether,surgical dressings, antibiotics, tetanus antitoxin, and insulin; theconservation of locally available medical items; and the provision of arelatively unpolluted water supply.
In Italy and Western Europe, the medical problems of thisphase of the civil affairs operations were not excessive. Either the Army movedslowly and the civilians had time to evacuate the actual combat zone, orprogress was rapid and cities and towns were not badly damaged. The cellars andsubterranean passages, so common a feature of European buildings and towns,afforded good protection against shellfire. By contrast, in certain other areas,particularly the smaller islands of the Pacific, the flimsy houses offeredlittle protection against naval gunfire and aerial bombing, and civiliancasualties were high.
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Occupation phase.-The occupation phase can be divided intostages: the first, which may be designated as theorganization stage, extends from the combat stage to the period when authorityis turned over to its original government, or until it is succeeded by themilitary government stage.
No sharp line can be drawn between the combat and theoccupation phases of the civil health program for, in the early stages, thesituation is likely to be changing rapidly. In some operations, particularly inSouthern Italy, inaugurating the organization stages of the health program wasdelayed. This may be attributed to a combination of inadequate planning at lowerechelons, shortage of personnel, and some confusion arising from an uncertaintyas to relationship to more or less friendly peoples. When Germany and NorthernItaly were reached, the results of superior planning and experience were evidentin the rapidity with which the civil health program was converted from thecombat to the organization stage.
The second stage, military government, is that level in whicha relatively stable occupational government is established. Professionally, theproblems differ little from those of the preceding stage except that longerrange plans may be inaugurated. As will be noted later, the establishment of acommission form of government, in both Italy and Germany, was accompanied bysome organizational changes, by important changes in personnel, and by a partialreorientation of the overall civil affairs program. In Italy, the activation ofthe Allied Control Commission (later Allied Commission), while most of thecountry had yet to be taken from the Nazis, resulted in conflicts in questionsof authority and responsibility between representatives of the Allied ControlCommission on the one hand, and those of Allied Force Headquarters on the other.This situation was particularly true in several episodes involving the civilhealth program. In Germany, the transfer of authority from SHAEF to the U.S.Group Control Council was completed without a break in the continuity of thecivil health program; and the same was largely true in Austria. In Japan and inKorea, the entire civil affairs operation was confined to the militarygovernment phase.
Missions .-With the liberation of territory belonging toU.S. Allies, the governments of these countries immediately took over theirrightful function. Since most of these countries had suffered damage both frommilitary operations and from deprivation of food and medical supplies, theUnited States and Great Britain wanted to assist in providing an initial impetustoward rehabilitation. This was accomplished in Western Europe through thedispatch of missions, one to each country, which functioned under the policydirection of G-5 SHAEF. Each of these missions, which were numerically small,had one or more medical officers who were responsible for the health aspects ofthe missions' activities. Missions were sent to France, Belgium, theNetherlands, Denmark, Luxembourg, Romania, Bulgaria, and Greece. In the FarEast, there was a mission to China.
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GENERAL FEATURES OF THE CIVILIAN HEALTH PROGRAMS
The basic problems encountered in the Army civilian healthprogram in liberated and occupied areas during World War II were essentiallythose normally present in those areas but which had been magnified andintensified by destruction, civilian casualties, disorganization, and shortagesof medical personnel and supplies. In some instances, these problems occurred inareas, as in Northwestern Europe, where the level of sanitation and medical carehad been high; while in other areas, as on Okinawa, the general level of publichealth had always been low.
Although the civil affairs health problems differedquantitatively rather than qualitatively from peacetime health problems, theresponsibility of civil affairs health personnel was peculiarly one oforganization, administration, and supply. In addition, complex problems such asthe control of narcotic drugs and the control of typhus fever, where lack ofcontrol could be devastating for both civilians and troops, required the specialattention of all concerned.
To restore local health services following occupation of anarea, it was necessary frequently to go beyond what had existed before the warto provide adequate protection for military personnel. For instance, in a numberof areas, no satisfactory system for reporting infectious diseases had everexisted, yet reliable statistical data on where and how much disease isoccurring are an elemental requirement for any health program.
The entire civil affairs health program in World War II wassupervised by a small number of Medical Department officers, and necessarily so,because of the severe shortage of such officers available to meet the demands ofboth the Armed Forces and the homefront. Consequently, local health personnelhad to be relied upon almost entirely to implement the civilian health programin a particular area. Still, the Army civil public health officer provided afocal point around which local resources could be organized.
Depending upon the size of the area under control, the civilaffairs health officer served a function analogous to that of the chief medicalofficer of a ministry of health, or a State or city health officer. In thiscapacity, he had both a staff function, as the principal medical adviser to thechief civil affairs officer, and a supervisory function, as the rankingprofessional in the organized health services of that area.
The responsibility of each civil public health officer withinhis sphere of activity was to appraise a given situation, outline a few clearand practical objectives, organize and direct local health and medicalpersonnel, and assist in obtaining supplies and facilities essential to theprogram. Except in unusual circumstances, it can be regarded as a misdirectionof energy for the civil public health officer to attempt to treat patients or tooperate a clinic.
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Section II. Development and Organization of Civil Public
Health at War Department Level
Thomas B. Turner, M.D., and Ira V. Hiscock, M.P.H., M.D.
The civil affairs program was a comparatively newdevelopment, and those phases pertaining to civilianhealth underwent a natural growth process of organization. In retrospect, thisorganizational evolution seems at times to have had little rationale. The netresult, however, was the development, within the Army, of a group which did thejob required in a creditable manner. Since so many of the problems encounteredwere administrative, the pattern will be described in some detail (chart 1).
LIAISON WITH THE PROVOST MARSHAL GENERAL'S OFFICE
The initial responsibility for development of aprogram and for recruitment of personnel for civil affairs and militarygovernment was assigned to Maj. Gen. Allen W. Gullion, The Provost MarshalGeneral. In March 1942, the School of Military Government, under The ProvostMarshal General, was established at the University of Virginia atCharlottesville, Va. Colonel Hiscock (fig. 1), as a member of the preventivemedicine staff in the Surgeon General's Office, had been working since 1940 onplans for the administration of public health in occupied and liberatedcountries. In January 1943, he was placed on duty with the Provost MarshalGeneral's Office as a representative of the Medical Department.
In addition to helping select professional personnel for theSchool of Military Government at Virginia, of which he was a graduate, and forseveral newly developed civil affairs training schools elsewhere, ColonelHiscock served as liaison officer with 15 or more Government agencies thenengaged in studying problems related to public health in the war effort,including especially the Health Committee of the Office of Foreign Relief andRehabilitation Operations. This committee was comprised of The Surgeon Generalof the U.S. Public Health Service as chairman, representatives of The SurgeonsGeneral of the Army and the Navy, and other persons internationally prominent inpublic health.
CIVIL AFFAIRS DIVISION, WAR DEPARTMENT SPECIAL STAFF
When the Civil Affairs Division of the WarDepartment Special Staff was organized on 1 March 1943, provision was made for amedical section in its Civilian Relief Branch. The Civil Affairs Divisionoperated without a public health officer until 28 April 1943, when ColonelHiscock was transferred to assume charge of what subsequently was designated thePublic Health Section, which embraced health and medical services, hospitals,sanitation, and medical supplies.
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CHART 1.-Organizationof U.S. Army responsibility for Civil Public Health, 1943
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FIGURE1.-Col. Ira Vaughan Hiscock, SnC.
The following memorandum, prepared by Colonel Hiscock on 24July 1943, indicated the magnitude of the public health problem in occupiedterritories, as visualized at the time:
MEMORANDUM FOR THE CHIEF, CIVILIAN RELIEF BRANCH, CAD:
Subject: Planning for Public Health in Occupied Territory.
1. Policy and planning are so closely inter-related that theCivilian Relief Branch, Public Health Section, regards consideration of forwardplanning as essential.
2. The prevention of epidemics and the provision of emergencymedical services are primary functions of military government for which detailedcoordinated plans are essential. The first task in each area set free from theinvader presents the greatest challenge ever faced by medical and publicofficers, even with maximum use of local facilities.
a. As to epidemic disease, malaria is of firstimportance in Italy, the Balkans and the Pacific; dysentery and typhoid feverhave a high incidence in many areas occupied or to be occupied; gonorrhea andsyphilis increase under stress of war; all types of communicable diseaseincrease in an undernourished and economically handicapped population. Typhus,which decimated the troops of Napoleon, is not an isolated phenomenon, witnessthe experience following the last war in the Soviet Union, and rumors indicatean increase in various countries during the last two winters.
b. Other problems include loss of physicians killed ordriven into exile; systematic looting and destruction of hospitals; destructionof water supplies as in the Ruhr and at Bizerte and at Pantelleria; destructionby deliberate sabotage.
c. Of all tragedies of war and devastation, those relatedto mounting rates of mortality in maternity and infancy, affecting the healthand strength of future generations, are of appealing urgency. Infant mortalityrates in the Low Countries are soaring, and diseases of childhood will leavetheir mark on physique and morale.
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d. Detailed plans are necessary forproviding medical relief, sera and vaccines and other medical and sanitarysupplies immediately on occupation of an area.
3. Progress in planning to date has included the following:
a. Recruitment and training of public health personnelselected from the Army, the U.S. Public Health Service, and civil life, coupledwith the establishment of a Specialist Pool. This has given a list of about halfof the number of such technical personnel as may be required on a global basis.These steps were taken by the Office of the Provost Marshal General incooperation with the Office of the Surgeon General and with assistance from theCivil Affairs Division.
b. Preparation, under the auspices of the InternationalAid Division, ASF, with the participation of CAD, of basic lists of food,medical and sanitation supplies for use during the initial period of militaryoperations.
c. Preparation, by CAD in cooperation withrepresentatives of the Office of the Surgeon General, of a brief memorandumoutlining basic features of a program for occupied territory.
d. Participation, in a liaison capacity, of CAD officersin the planning by OFRRO of public health programs to be undertaken in foreignareas when responsibility is turned over by the military to the civilianauthorities.
e. Conferences, regarding public health plans andprograms, of CAD officers with representatives of the Inter-Allied Post-WarRequirements Committee (London) and of the British army.
4. Following the pattern which worked successfully in thepreparation of lists of supplies, the Office of the Surgeon General proposes toenlarge the scope of the activities of the small Board which was constituted onthe basis of the Directive of ASF, International Aid Division, to prepare listsof supplies in order to assist, as needed, in preliminary planning for thepublic health program and personnel required for effectivefunctioning of military government.
5. If approved, the Public Health Section will maintain closeand direct liaison with the above-mentioned Board of the Office of the SurgeonGeneral. Furthermore, this Board should prove useful to CAD in consideration oftechnical questions of policy, program and supply in the public health field,and should be utilized as needs arise.
IRA V. HISCOCK
Colonel, SnC
Close liaison was maintained with the Surgeon General'sOffice, particularly the Preventive Medicine Service; the Special PlanningDivision, Operations Service; Personnel Service; and the Supply Service.
CIVIL AFFAIRS DIVISION SUPPLY BOARD, SURGEON
GENERAL'S OFFICE
Beginning on 2 February 1943, Colonels Simmons and Hiscockdiscussed with the director of the Supply Division, Surgeon General's Office,the Army's responsibility for providing medical and sanitary supplies forcivilian use during early stages of military operations. A series of conferencesand interviews were held on the entire question of the Army's program ofessential medical supply for civilians. On 18 May 1943, in an informalmemorandum, the public health officer, Civil Affairs Division, recommended tothe liaison officer, International Division, Army Service Forces, that"necessary plans be instituted to insure that adequate medical and sanitarysupplies and such other items as may be required to meet
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essential civilian health needs available for emergency use inoccupied territory during the initial period of military operations." On 5June 1943, in response to a 31 May 1943 request from the International Division,The Surgeon General nominated Col. Howard T. Wickert, MC, director of PlansDivision, Operations Service, as the officer to be contacted by theInternational Division on matters pertaining to medical supplies for civilianpopulations. Finally, on 28 June 1943, under Office Order No. 419, The SurgeonGeneral appointed a board of officers "to prepare, develop, and implementthe medical portion of the War Department's program for aid to civilianpopulations in liberated countries." This board was later commonly referredto as the CAD Board, and consisted of representatives of Supply Service,Operations Service, and the various professional services. On 15 July 1943,Colonel Wickert was succeeded as president of this board by Col. Arthur B.Welsh, MC, who in turn was succeeded by Col. George M. Powell, MC, on 13 October1943.
CIVIL PUBLIC HEALTH
DIVISION, PREVENTIVE
MEDICINE SERVICE
Definitive plans for a public health program in occupied andliberated territory were initiated in the fall of 1942 at the School of MilitaryGovernment, and were developed further with the organization of the CivilAffairs Division, War Department Special Staff. This program was based largelyon the original plan written in the Preventive Medicine Division, in June 1940,by Colonels Hiscock and Sweet under the direction of Colonel Simmons.10Although constant informal contact was maintained between the Public HealthSection of the Civil Affairs Division, War Department Special Staff, and thePreventive Medicine Division, Office of the Surgeon General, it became evidentin the fall of 1943 that the responsibilities of The Surgeon General hadincreased to a point where it was necessary for his office to participate evenmore actively in the Civil Affairs Division public health program. On 6 November1943, a letter from the public health officer, with concurrence of the Chief,Civil Affairs Division, stated:
* * * it is understood that the function ofthe Civil Affairs Division is related primarily to policy. Furthermore, while itis essential that there be a public health officer on a regular basis in theCivil Affairs Division, it is also believed that the Office of The SurgeonGeneral is the logical agency for carrying forward plans for health organizationand service. An officer on duty in the Civil Affairs Division is in a keyposition to participate in these activities in a liaison capacity.
From the foregoing, it is evident that betweenearly 1940 and late 1943 detailed plans had been made for large portions of aprogram for the administration of civil affairs in connection with militarygovernment in occupied and liberated countries, and that several highlyimportant organizational steps had been taken by the General Staff; the CivilAffairs
10See footnote 7, p. 7.
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Division of the Special Staff; the Provost Marshal General'sOffice; and the Surgeon General's Office and several of its divisions, notablythe Preventive Medicine Division. During this time, President Roosevelt andcertain members of his cabinet were keenly concerned with these matters.Although experience, which took time, was needed to delineate clearly theessential role that the Army would play in civil affairs and militarygovernment, the Army's responsibilities and authority were definitelyenunciated by President Roosevelt in a letter to the Secretary of War on 10November 1943, which follows:
THE WHITE HOUSE
WASHINGTONNovember 10, 1943
Dear Mr. Secretary:
Although other agencies of the Government are preparingthemselves for the work that must be done in connection with the relief andrehabilitation of liberated areas, it is quite apparent if prompt results are tobe obtained the Army will have to assume the initial burden of shipping anddistributing relief supplies. This will not only be the case in the event thatactive military operations are under way, but also in the event of a Germancollapse. I envisage that in the event of a German collapse, the need for theArmy to undertake this work will be all the more apparent.
Therefore, I direct that you have the Army undertake theplanning necessary to enable it to carry out this task to the end that it shallbe prepared to perform this function, pending such time as civilian agenciesmust be prepared to carry out the longer range program of relief.
You may take this letter as my authority to you to call uponall other agencies of the Government for such plans and assistance as you mayneed. For all matters of policy that have to be determined in connection withthis work you will consult with the State Department for any political advice;and upon the Treasury for such economic and fiscal direction as you may need.
Very sincerely yours,
Franklin D. Roosevelt.
The Honorable
The Secretary of War
Washington, D.C.
On 14 November 1943, before the President's letter reachedthe Surgeon General's Office, General Simmons, in a letter to The SurgeonGeneral, recommended that a branch designated as the "Civil Affairs PublicHealth Branch" be established in the Preventive Medicine Division and thatthe purpose of this branch be to coordinate and handle for The Surgeon Generalall matters pertaining to the development of the public health program foroccupied territories subject to policy directives of the Civil Affairs Divisionof the Special Staff.11
The necessity for such an organization within the SurgeonGeneral's Office became clearer upon the receipt from the InternationalDivision of a memorandum, dated 7 December 1943, subject: Civilian ReliefRequire-
11Letter, Brig. Gen. James S.Simmons, USA, Director, Preventive Medicine Division, Office of the SurgeonGeneral, to The Surgeon General, 14 Nov. 1943, subject: Recommendation of theEstablishment of a "Civil Affairs Public Health Branch."
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FIGURE 2.-Thomas B. Turner, M.D., formerly Colonel, Medical Corps.
ments for Europe in the Event of Collapse. This memorandumenclosed a copy of the letter from President Roosevelt to the Secretary of War.
In response to General Simmons' recommendation, the CivilPublic Health Division was established as part of the Preventive MedicineService on 1 January 1944.12 Lt.Col. (later Col.) Thomas B. Turner, MC, was appointed as its first director(fig. 2).
Civil Affairs Branch, Special Planning Division, OperationsService,
Surgeon General's Office
As noted previously, The Surgeon General established, on 28June 1943, the Civil Affairs Division Board, which made extensive studies ofcivilian requirements for medical supplies. On 23 December 1943, a memorandumfrom the Commanding General, Army Service Forces, to the various technicalservices, directed the establishment of a full-time civilian supply unit. Thismemorandum stated:
1. It is becoming increasinglyapparent that the supply of civilian populations in combat areas, zones ofcommunications, and in liberated areas vitally affects operations andoperational plans.
12Office Order No. 4, Army ServiceForces, Office of the Surgeon General, 1 Jan. 1944.
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2. Estimating requirements for civilian populations undervarious operational plans and in the event of a collapse of Germany, pursuant tothe President's directive dated 10 November 1943 calls for special knowledgeof conditions within the various countries and a special technique of researchin order that estimated requirements can be made reasonably firm.
* * * * * * * *4. There is a need for the preparation of proper estimates ofrequirements on a country by country basis and proper plans for handlingcivilian relief supplies both in connection with operations and in the event ofcollapse. The problems involve study of the internal economy of each country,its industries and its distribution system. Study of proper export and importrelationships with other countries is also required. The need for solutions ofmany of the problems raised is pressing. Experience has shown that, while it maybe desirable to utilize personnel engaged in current requirement and procurementactivities, in the development of such plans, at least the supervision anddirection of the estimates of requirements and preparation of plans requires theundivided attention of competent personnel.
5. It is therefore directed that a civilian supply unit beestablished on the staff of each Chief of Technical Service mentioned above,unless such action has already been taken. It is desired that each such unithave initially assigned to it at least one qualified officer for full time dutywith the unit. * * *.
In response to this memorandum, a Civil Affairs Branch wasestablished in the Special Planning Division of the Operations Service on 5February 1944.
Assignment of Responsibility
According to the Manual of Organization and StandardPractices, dated 15 March 1944, the functions of the Civil AffairsBranch, Special Planning Division, Operations Service, and of the CivilPublic Health Division, Preventive Medicine Service, both of the SurgeonGeneral's Office, were:
Civil Affairs Branch. Operationallydirects and coordinates under the Chief of the Operations Service all activitieswithin the Office of The Surgeon General which relate to medical relief,including supplies, sanitation, training, personnel, and medical and veterinaryservice in occupied countries during the period of military responsibility.Maintains liaison with War Department offices and other agencies outside theOffice of The Surgeon General on civil affairs matters.
* * * * * * *Division. Formulates policies anddevelops plans for health programs in occupied and liberated territories.Assists in the selection of specialized personnel. Maintains contact with fieldoperations. Integrates programs with those of other agencies operating in thisgeneral field.
In view of the conflicting statement of functions in themanual, the director of the Civil Public Health Division forwarded a memorandum,on 13 April 1944, to The Surgeon General, requesting clarification as to whichdivision would assume the primary responsibility for:
(1) Recommendations pertaining to public health policy andpractice in occupied countries.
(2) Procurement, selection and assignment of MedicalDepartment personnel for civil affairs in conjunction with Personnel Service andother interested Services.
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(3) Training of Medical Department personnel for civil affairs activities inconjunction with Training Division.
(4) Preparation of guides and manuals pertaining to civil affairs inconjunction with Training Division.
(5) Matters pertaining to medical supplies for civil affairs in conjunctionwith Supply Service and the CAD Supply Board.
The director of the Civil Public Health Division recommended in thismemorandum that his division be responsible for the functions listed inparagraph (1), (2), (3), and (4), and that the Special Planning Division beresponsible for those listed in paragraph (5).
This matter was referred by the Deputy Surgeon General to Operations Service.On 25 April 1944, in a memorandum for the Deputy Surgeon General, the chief ofOperations Service outlined the following division of responsibility:
1. The Operations Service [Civil Affairs Branch of Special Planning Division]will be responsible for:
a. Overall coordination of Civil Affairs Activities for The Surgeon General.
b. Liaison with agencies outside the Office of The Surgeon General, except ascovered by paragraph 2e below.
c. Development and implementation of the program for medical and sanitarysupplies for the civilians of occupied and liberated areas utilizing the adviceand assistance of the C.A.D. Supply Board.
2. The Preventive Medicine Service [Civil Public Health Division] will beprimarily responsible for:
a. Recommendations pertaining to public health policy and practice inoccupied and liberated areas.
b. Procurement, selection and assignment of Medical Department personnel forCivil Affairs in conjunction with the Operations Service, Personnel Service andthe other interested services.
c. Training of Medical Department personnel for Civil Affairs activities inconjunction with the Training Division, Operations Service.
d. Preparation of guides and manuals pertaining to Civil Affairs inconjunction with the Training Division, Operations Service.
e. Liaison with agencies outside the Office of The Surgeon General on matterspertaining to the foregoing functions (Paragraphs 2a, b, c, & d above).
f. Coordination of matters of major importance and those likely to affectoverall planning with the Operations Service.
The Manual of Organization and Standard Practices was changed thereupon (1May 1944) to read-
Civil Affairs Branch. Coordinatesfor The Surgeon General, under the Chief of the Operations Service, allactivities which relate to medical relief, including supplies, sanitation,training, personnel, and medical and veterinary service in occupied countriesduring the period of military responsibility. Maintains liaison with WarDepartment offices and other agencies outside the Office of The Surgeon Generalon civil affairs matters, except as are specifically covered by the functions ofthe Civil Public Health Division, Preventive Medicine Service. Develops andimplements the program for medical and sanitary supplies for the civilians ofoccupied and liberated areas utilizing the advice and assistance of The SurgeonGeneral's C.A.D. Supply Board.
* * * * * * *Civil Public Health Division [Preventive MedicineService]-Develops plans per-
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taining to public health policy and practice in occupied andliberated territories. Assists in the procurement, selection, assignment andtraining of Medical Department personnel for Civil Affairs. Assists in thepreparation of guides and manuals pertaining to Civil Affairs public healthactivities. Maintains liaison with agencies outside the Office of The SurgeonGeneral on matters pertaining to the foregoing functions. Coordinates matters ofmajor importance and those likely to affect overall planning with SpecialPlanning Division, Operations Service.
Relationship of the Surgeon General's Office to CivilAffairs Division,
War Department Special Staff
As previously noted, there was a Public Health Section in theCivilian Relief Branch of the Civil Affairs Division. This section consisted ofone officer who maintained close liaison with the Surgeon General's Office,principally through the Preventive Medicine Service. On 10 August 1943, in amemorandum for the Chief, Civilian Relief Branch, Civil Affairs Division,subject: Provision for Control of Epidemics in Occupied Territory, this officerstated:
For continuing advice regarding policies, the Office of TheSurgeon General of the Army should be extensively utilized by the Civil AffairsDivision. To cope with the many problems of infectious diseases and to forecastneeds for the future, the Preventive Medicine Division, SGO, maintains acomprehensive program. This serves to safeguard the health of the Army on theone hand, and through the common sharing of scientific knowledge, to protect thepublic health generally.
Again, in an informal memorandum for the Chief, Economics andRelief Branch, Civil Affairs Division, subject: Planning for Public Health,dated 25 January 1945, Colonel Hiscock proposed:
When a project of planning for publichealth is initiated or received for action by the public health officer, of CAD,it is discussed with the Director of the Civil Public Health Division, SGO. Ifextensive research or work in preparation of a report or guide is required, theassistance of the Surgeon General's Office is requested, because of thespecial staff maintained for such a purpose and of the availability forconsultation of specialized personnel. Questions of medical supply planning arecoordinated with International Division and cooperation is obtained from theSpecial Planning Division, SGO. Likewise, questions of personnel are coordinatedwith Personnel and Training Branch, CAD, and cooperation is obtained from thePersonnel Division, SGO, working through the Civil Public Health Division, SGO.In a similar manner, assistance has been obtained from the Nutrition, theMedical Intelligence, and the Sanitary Engineering Divisions of SGO, to giveonly a partial list. For matters of joint interest with the Navy, excellentcooperation has been developed, in working with the Chief Medical Officer of theMilitary Government Section, Central Division, OCNO, with whom joint conferencesare frequently held, and, when indicated, include representation from theSurgeon General's Office of the Army.
It is recommended that this plan of referral of matters ofpolicy and planning related to public health to the Surgeon General's Officefor discussion and for assistance when needed be continued, inasmuch as suchcooperation insures sound technical advice, provides extensive service,facilitates coordination with plans for the military forces, and enables theCivil Affairs Division to function with a minimum public health staff.
In April 1945, when Colonel Hiscock was released from activeduty, no other officer was assigned to the Public Health Section, Economics and
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Relief Branch (formerly Civilian Relief Branch), to replacehim. However, arrangements were made for an officer (Maj. James B. Gillespie,MC) from the Civil Public Health Division, Preventive Medicine Service, todevote part of his time to the Civil Affairs Division to carry on the changingduties. This complied with a request in a memorandum dated 23 March 1945, fromthe director of the Civil Affairs Division to The Surgeon General, which stated:
Mutual benefit has accrued from cooperative workingrelationships developed between the Civil Public Health Division of PreventiveMedicine Service of The Surgeon General's Office and the Public Health Sectionof the Economics and Relief Branch of the Civil Affairs Division. In effect, theDirector of the Civil Public Health Division acts for the Surgeon General andthe Chief of Preventive Medicine Service in a consulting capacity to the CivilAffairs Division which arranges joint conferences, furnishes reports and otherinformation of direct concern to The Surgeon General.
In order to make this service more effective, it is requestedthat arrangement be made for an officer of the Civil Health Division ofPreventive Medicine, SGO, to spend part time in the Civil Affairs Division. Thisrequest confirms previous discussions between representatives of The SurgeonGeneral's Office and the Civil Affairs Division.
Necessary office and clerical service to facilitate the workof such officer will be provided by the Civil Affairs Division.
Relationships With Other Services and Staffs
Operations of civil affairs and military government at WarDepartment level included relations with the U.S. Navy, and at the highestmilitary levels with the Joint Chiefs of Staff and the Combined Chiefs of Staff.While it is not necessary to discuss these relationships here, they must bementioned to make the account complete. An excellent summary of the need forcivil affairs and military government, and of the higher staff relationships,was given by Gen. George C. Marshall, USA, as follows:13
Orderly civil administration must be maintained in support ofmilitary operations in liberated and occupied territories. In previous wars, theUnited States had no prepared plan for this purpose. In this war it wasnecessary to mobilize the full resources of both liberated and occupiedcountries to aid in defeating the enemy. The security of lines of communicationand channels of supply, the prevention of sabotage, the control of epidemics,the restoration of production in order to decrease import needs, the maintenanceof good order in general, all were factors involved. It was important totransform the inhabitants of liberated countries into fighting allies.
The Civil Affairs Division was created on 1 March 1943 toestablish War Department policies designed to handle these problems. In jointoperations, the Division works closely with a similar agency in the NavyDepartment, as well as with related civilian agencies to determine and toimplement United States policies. The Army and Navy are represented on the JointCivil Affairs Committee under the Joint Chiefs of Staff which is charged withplanning for civil affairs in both Europe and the Pacific. In combinedoperations, United States policies are coordinated with those of the Britishthrough the Combined Civil Affairs Committee of the Combined Chiefs of Staff.
13Biennial Report of the Chief ofStaff of the United States Army to the Secretary of War, July 1, 1943, to June30, 1945, p. 90.
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SUMMARY
Since the civilian health activities involved many differentelements in the organizational structure of the Army, it is not surprising that,in the evolution of this essentially new function, delegation of responsibilitywas not always clear and organizational paradoxes were at times encountered. Inan undertaking so vast as that required to wage World War II, confusingsituations are probably inevitable; fortunately, intelligent men of good willcan usually achieve an efficiently working pattern that transcends anorganizational chart.
In reviewing the evolution of the organizational pattern atWar Department level, apparently while the initial concepts of the role ofcivilian health activities in the Army's overall mission were formulated byGeneral Simmons, the early development of this specialized program was alongtwo, often largely independent, lines: (1) Problems pertaining to program,personnel, and training were handled largely by one individual stationed not inthe Surgeon General's Office but in the Civil Affairs Division of the WarDepartment Special Staff, led by an understanding general. Liaison between thisofficer and the chief of the Preventive Medicine Service, Office of the SurgeonGeneral, and the Army Service Forces, and many others was good on an informalbasis. (2) Problems pertaining to supply were handled largely by the SpecialPlanning Division of the Operations Service in the Surgeon General's Office;however, much broader functions were assigned to this division.
Only relatively late in the war was any officialresponsibility delegated to the Preventive Medicine Service and then in alimited and unclear fashion. From the vantage point of this experience, theessential nature of the civilian health activities apparently comprised, in themain, those elements commonly associated with public health and preventivemedicine. If this view is correct, it seems logical to place the mainresponsibility for the civilian health program on individuals who have specialknowledge of, and experience in, public health and preventive medicine. Suchpersonnel and points of view will most likely be found within the PreventiveMedicine Service.
The experience in World War II also emphasizes another point:the importance of fixing responsibility for the civilian health program longbefore combat operations are imminent. Much useful early planning can be done,especially with reference to personnel who must be drawn largely from amongReserve forces and civilian groups.
Typical command General Staff and specific medical CivilAffairs functions at various echelons, are delineated in chart 2 forHeadquarters, U.S. Army, Europe.
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CHART2.-Medical Civil Affairs relationships and functions European Theater ofOperations, U.S. Army, 1944
