Part IV
EUROPE
CHAPTER XI
The United Kingdom
Pauline B. Vivette
* * * it must be recognized that the health of a military force is vitally affected by the health of the civil community in which it is stationed, whether stationed on a belligerent or a friendly basis. In many respects, the friendly basis favors closer contact with the civil population than does the belligerent so that the health problems of the civil community may be more readily reflected in military experiences.1
HISTORICAL NOTE
American citizens, including the President of the UnitedStates, had long been apprehensive about the state of affairs in Europe; but,when Adolf Hitler's forces invaded Poland on 1 September 1939, and France andthe United Kingdom of Great Britain and Northern Ireland2declared war on Germany 2 days later, Americanapprehension changed to simultaneous planning and action in many directions. Thehistory of public health activities in Civil Affairs/Military Government in theUnited Kingdom demonstrates again and again the value of careful planning andaction as it also demonstrates the power of negotiations and agreements at theconference table.
Foreign policy in the United States from 1933 to 1939 hadremained in a subordinate position to the reforms of President Franklin D.Roosevelt's New Deal. Neutrality legislation from 1935 to 1939 fulfilled theoverwhelming desire of the American people to stay out of war. PresidentRoosevelt called a special session of the 76th Congress, in July 1939, torescind the binding provisions of the neutrality acts, but the Senate declinedby marginal vote to consider any revision of the acts. It was not until afterwar came to Europe that President Roosevelt persuaded the Congress to lift theembargo on arms to make possible giving aid to the United Kingdom and othercountries fighting the Axis powers. By mid-1941, the United States
1This statement represents one of the basic principles underlying prewar planning for effective military and civilian health in areas where it was thought troops might be stationed; it is recorded in (1) the early working papers of Col. (later Brig. Gen.) James S. Simmons, MC, and published in (2) Simmons, James Stevens, Whayne, Tom F., Anderson, Gaylord West, Horack, Harold MacLachlan, and collaborators: Global Epidemiology; A Geography of Disease and Sanitation. Vol. 1. Philadelphia, London, Montreal: J. B. Lippincott Co., 1944, pp. vii-viii, x.
2Since 1927, the official name of this country has been the United Kingdom of Great Britain and Northern Ireland. The territory includes England, Scotland, Wales, and Northern Ireland. Popular terms used in this chapter (United Kingdom, Great Britain and Northern Ireland, Great Britain, and the British Isles) are used interchangeably. Formerly, from 1801, the official name of the country was the United Kingdom of Great Britain and Ireland.
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had become an "arsenal ofdemocracy," and ties between this country and the United Kingdom weregreatly strengthened.
The coalition between the United States and Great Britain inWorld War II, naturally attended by some controversy and differences of opinion,is generally agreed to have been "the closest and most effectivepartnership in war that two great powers have ever achieved." In anunbroken series of talks and agreements, both nations decided jointly what wasnecessary and desirable to do next to gain the maximum military advantage fromany future situation.3
Lend-Lease and American-British Staff Conversations
Early in 1941, two important developments strengthened anddrew the United States and the United Kingdom closer. The U.S. 77th Congressenacted the Lend-Lease Act on 11 March, initially allotting a fund of $7 billionto provide war materials for the democracies whose security was vital to that ofthe United States. Before the Lend-Lease measure passed, military leaders ofboth countries met in Washington in the first of several conferences which wereto have far-reaching effects on the future conduct of the war and to influenceall of the affairs of the two countries. Representatives of these conferencesinitiated a series of meetings called the American-British Staff Conversations;a joint planning staff was established in each of the other's capital; and thedecision was made to concentrate the principal effort in Europe should theUnited States be forced into a war with both Japan and Germany.4
Passage of the Lend-Lease Act resulted in Winston Churchill'sfamous and inspiring words:5
These two great organizations of theEnglish-speaking democracies, the British Empire and the United States, willhave to be somewhat mixed up together in some of their affairs for mutual andgeneral advantage. For my own part looking out upon the future, I do not viewthe process with any misgivings. I could not stop it if I wished. No one couldstop it. Like the Mississippi it just keeps rolling along. Let it roll. Let itroll on full flood.
The agreement to collaborate continuously andthe passage of Lend-Lease had a tremendous impact on all joint affairs. Withinthe framework of this design, the tone and style were set for Anglo-Americanpublic health activities in Civil Affairs/Military Government made necessary bythe presence of U.S. forces in the United Kingdom.
3Greenfield, Kent Roberts: American Strategy in World War II; A Reconsideration. Baltimore: The Johns Hopkins Press, 1963, p. 24.
4Ruppenthal, Roland G.: United States Army in World War II. The European Theater of Operations. Logistical Support of the Armies. Volume I: May 1941-September 1944. Washington: U.S. Government Printing Office, 1953, pp. 13-14.
5Reprinted in The Times, Times Publishing Co., London, England, 11 June 1942, p. 5b. These moving words of Mr. Churchill foretold in certain terms the intimacy developing between two nations joining their strengths to defeat a common enemy: he captured the spirit of the day and prophesied the tolerance with which either nation would accept inevitable impingements from the other in this unavoidable mixture of civil and military affairs. Desire to win the war outweighed cultural differences.
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Those actions taken by our military in theUnited Kingdom to protect the health of troops andcivilians were tempered by joint aims.
General Characteristics of Civil-Military Public HealthActivities
Operating a military base in a foreign sovereign country is acomplicated affair, but the British Government made every overture to theAmerican guests to reduce the disadvantages to a minimum.6The U.S. Army's preventive medicine service and command surgeons at allechelons struggled hard to avoid any impingement on British public healthdomains, but quite naturally, some problems and difficulties did occur.
Public health decisions in civil affairs and militarygovernment were reached by negotiation and agreement between the United Statesand United Kingdom military and civilian medical authorities. Their closeassociation from local to higher levels fostered the intimate exchange of ideasand information for the control of disease. Thus, military preventive medicinedid not function separately but was closely concerned and associated with theproblems of the civilian population where the Army was stationed.
This chapter describes public health activities in CivilAffairs and Military Government that arose because of the presence of U.S.troops,7 staging andtraining, in the United Kingdom; it also deals with the preliminary publichealth planning leading up to the landings of the troops on the Continent. Thegeneral story is told in some detail, and each pertinent problem or entity isdiscussed with some thought toward revealing how American troops in the UnitedKingdom might have impinged on the British rights, conveniences, resources,customs, practices, and requirements.8,9
Beginnings of World War II CivilAffairs
At the onset of World War II, the civil affairs program inthe War Department was a comparatively new development, and the civilian healthphases there underwent a natural growth process of organization (see p. 12). Theformal program in the United Kingdom, after the United States entered World WarII, evolved slowly from its inception at Belfast, Northern Ireland, in May 1942until mid-1944. On the larger scale of ETOUSA (European Theater of Operations,U.S. Army), this civil affairs activity attained success only when it came to berecognized by Supreme
6Ross, William F., and Romanus, Charles F.: The Quartermaster Corps: Operations in the War Against Germany. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1965, pp. 294 and 318.
7The terms "U.S. forces," "U.S. troops," and "American troops" refer to U.S. ground, air, and services of supply components.
8Conference on entire procedure for chapter with Dr. Stanhope Bayne-Jones (Brigadier General, Ret.), and Lt. Col. Frederick Bell, Jr., MSC, Chief, Special Projects Branch, The Historical Unit, U.S. Army Medical Service, 3 Aug. 1965.
9For civil affairs/military government activities on the Continent of Europe, see chapters XII and XIII, pp. 405, 431.
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FIGURE44.-Col. John E. Gordon, MC.
Headquarters, Allied Expeditionary Force, as aGeneral Staff function and an integral part of operational plans and commandresponsibility.10
In the combat zones, the General Board, U.S. Forces, ETOUSA,reported: "Military necessity is the determining factor in the execution ofCivil Affairs operations and the practice of Military Government control."11Early and continuous developments in the United Kingdom influenced the evolutionof public health activity of Civil Affairs/Military Government designed torestore and maintain order in the wake of advancing troops in Europe.
The ultimate bearing of the program on the management ofcivilian and military health problems occurred as a result of the presence ofU.S. troops in the United Kingdom. According to Lt. Col. (later Col.) John E.Gordon, MC (fig. 44), who, throughout the war, was chief of the PreventiveMedicine Division, Office of the Chief Surgeon, ETOUSA, and who had close andcontinuous association with British public health officials: "The tacticalproblems incident to contact of a home population and a foreign
10Bailey, John Wendell: An Outline Administrative History of Civil Affairs in the ETO, G-5, Appendix: Public Health, First U.S. Army, to July 1, 1944, pp. 175-199. [Official record.]
11Report, The General Board, United States Forces, European Theater. Civil Affairs and Military Government Organizations and Operations. Study Number 32, subject: The Organization and Operation of Civil Affairs and Military Government in the European Theater of Operations [1946], p. 3.
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army provided all manner of interesting and sometimesdistressing and trying situations."12
During staging of U.S. troops in the United Kingdom, thepublic health element of Civil Affairs and Military Government was seldom morethan a fragmentary and confusing attempt to clarify its position with respect tothe Office of the Chief Surgeon, ETOUSA, a factor not unusual, for "duringthe initial stages of military action there is usually no Civil AffairsDivision, as such; it develops gradually, and under Army guidance, as the troopsadvance."13However, formal relationships between the public health element of CivilAffairs and Military Government and the Office of the Chief Surgeon, ETOUSA,known to have been unsatisfactory, will not be explored here.14
Buildup in the United Kingdom
By D-day, 6 June 1944, the United Kingdom of Great Britainand Northern Ireland, smaller in area than the State of Oregon, was literallyteeming with Allied troops, refugees, displaced persons, and the hardware ofwar; each was so much in evidence that one reporter was led to say, "Theisland would sink if the barrage balloons were cut."
The buildup of U.S. forces in the United Kingdom had beengradual and steady, with strength figures interrupted briefly by the flow oftroops to North Africa for the TORCH operation in November 1942. From thebeginning of the buildup in January 1942 to its height in June 1944, contingentafter contingent of American troops arrived, day after day and month aftermonth, until a total of more than 1.5 million Americans were present by D-day.In addition to the British population of nearly 50 million, troops from most ofthe dominions and colonies of the British Commonwealth had been present almostsince the beginning of the war. Each successive defeat on the Continent broughtin waves of Poles, Free French, Norwegians, and other refugees in uniform.
In the beginning, threats of the spread of communicablediseases in the 94,279 square miles of the territories of England, Scotland,Wales, and Northern Ireland were sources of great anxiety. Despite risks,however, not a single epidemic disease got out of hand and the death toll frominfectious diseases was surprisingly low.15Except for small and controlled outbreaks
12Letter, John E. Gordon, M.D., Senior Lecturer, Massachusetts Institute of Technology, Department of Nutrition and Food Science, Clinical Research Center, Cambridge, Mass., to Brig. Gen. Stanhope Bayne-Jones (Ret.), Chairman, Advisory Editorial Board, History of Preventive Medicine in World War II, 28 Apr. 1966, subject: Civil Affairs Public Health Activities in World War II.
13See page 3 of footnote 10, p. 366.
14(1) Report, Col. Thomas B. Turner, MC, to The Surgeon General, U.S. Army, 9 Mar. 1944, subject: Report on Plans for Civil Affairs Public Health in the European Theater of Operations. (2) Bell, Lt. Col. Frederick, Jr., MSC, Memorandum for Record, 1 May 1964, subject: Conference With Dr. John E. Gordon on Chapter XI, The United Kingdom, History of Preventive Medicine in World War II, Volume VIII.
15Medical Department, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts. Washington: U. S. Government Printing Office, 1958, pp. 14, 25.
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of common infectious diseases, a troublesome incidence ofscabies, high venereal disease rates at intervals, sporadic occurrences ofinfectious hepatitis and postvaccinal serum hepatitis in situations wheredifferential diagnosis was especially difficult, the wartime health of civiliansand military personnel in the United Kingdom was good.16The record is even more remarkable when one considers the housingshortages, overcrowding, tremendous ebb and flow of the civil and militarypopulations, sanitation problems, water shortages, food restrictions,nutritional problems, and, in general, the contingencies of war.
Among these contingencies that had considerable bearing onthe health of civilians were a number of conditions and problems which occurredamong the population irrespective of the presence of U.S. troops. Gordon17has listed four main examples:
1. The evacuation of young children to thecountry from bombed and threatened cities, and the attendant hazards ofcommunicable and other diseases in the communities to which they went.
2. The unknown and unevaluated threat ofbiological warfare and necessary surveillance.
3. The health hazards of crowded air-raidshelters.
4. The infections and other aftereffects oftraumatic injury after bombing.
After deliberate analysis, one may say withconviction that the joint activities of the Ministry of Health, the preventivemedicine services of the military forces, and the good sense and cooperation ofthe British population were enough to establish reasonable control of theenvironment and to have been a real force in the prevention and control ofcommunicable diseases.
Prewar Planning and Activities in America
The United States became sharply interested in the problemsof civil health activities under war conditions shortly after the beginning ofWorld War II. When the United Kingdom declared war on Germany in 1939, theprobability of war for the United States became increasingly evident. Americaneffort to study public health in Europe's war zone developed simultaneously inmany directions.
On the military side, this effort represented an orderlydevelopment of the long term planning and preparation in OTSG (Office of theSurgeon General), U.S. Army. Col. (later Brig. Gen.) James S. Simmons, MC,appointed chief of the Preventive Medicine Subdivision in early 1940, initiatedmany new developments in the public health civil affairs function
16(1) MacNalty, Sir Arthur Salusbury, Editor-in-Chief: History of the Second World War. The Civilian Health and Medical Services. Volume I. London: Her Majesty's Stationery Office, 1953, pp. ix-x. (2) Medical Department, United States Army. Preventive Medicine in World War II. Volume V. Communicable Diseases Transmitted Through Contact or by Unknown Means. Washington: U.S. Government Printing Office, 1960, foreword, p. xi.
17See footnote 12, p. 367.
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and recognized it as something more thanmilitary government.18Under his intelligent and inspiring influence, civil public health,sanitation, sociology, economics, and other cultural elements gained prominenceand became integral constituents of the military preventive medicine program.General Simmons recognized medical intelligence as an important part of publichealth activities of Civil Affairs and Military Government and was an exponentof the scheme for reconnaissance surveys and analyses. To assist in thepreparation of firsthand surveys, in early 1940, he arranged for three SanitaryCorps officers to report for active duty in the Preventive Medicine Subdivision.Lt. Col. (later Col.) Ira V. Hiscock, SnC, Lt. Col. (later Col.) William A.Hardenbergh, SnC, and Lt. Col. Albert W. Sweet, SnC, reported in May 1940 andbegan the preparation of advance surveys on health and sanitary conditions incountries where U.S. troops might eventually be stationed. These officers alsoassisted in the preparation of the section on health and sanitation in theManual of Military Government, Field Manual 27-5, 30 July 1940, issued by theOffice of the Chief of Staff.
In the Preventive Medicine Service, OTSG, a comprehensive andextraordinarily effective Division of Medical Intelligence was developed throughthe vision and initiative of General Simmons, and supported by able assistants:Capt. (later Col.) Tom F. Whayne, MC, from June 1941 to March 1943, and Maj.(later Col.) Gaylord W. Anderson, MC, from 27 March 1943 to the end of the war.This division was highly serviceable to civil affairs and military government.19
Before his departure to serve as Military Attach? forMedicine at the American Embassy in London, Colonel Whayne had initiated anexpansion of the Medical Intelligence Division. After the establishment of hisoffice at the embassy in March 1943, he provided much valuable information andservice. Of particular value to public health activities were the relationshipsbetween representatives of the U.S. National Research Council and the BritishMedical Research Council, of the U.S. Public Health Service and other agencies,which contributed greatly toward the development of fruitful scientific medicaland administrative associations with the British. In addition, joint activitiesof the Military Attach? for Medicine and representatives of the NationalResearch Council, the U.S. Navy, and others who were engaged in exchanginginformation with the British, helped in every way possible the development ofpubic health activities of Civil Affairs/Military Government.
On the civilian side, authorities in preventive medicine andpublic health administration directed their attention both to a systematiccorrelation with efforts of medicomilitary authorities and to the means by
18(1) See footnote 1 (2), p. 363. (2) Diary (unpublished), Brig. Gen. James S. Simmons, USA, entry of 20 May 1940 (verified by Dr. Stanhope Bayne-Jones). (3) Medical Department, United States Army. Organization and Administration in World War II. Washington: U.S. Government Printing Office, 1963, pp. 30-31. (4) See ch. I, pp. 4, 7.
19For a full account of the organization, operations, and accomplishments of medical intelligence, see Colonel Anderson's chapter VI in Medical Department, United States Army. Preventive Medicine in World War II. Volume IX. Special Fields. Washington: U.S. Government Printing Office, 1969.
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which civilian staffs, equipment, andexperience could be converted to a wartime militaryorganization.20
Prewar Planning and Activities in the United Kingdom
The United Kingdom, much closer geographically toGermany and Italy than to the United States, and far more vulnerable to attack,began serious planning and preparation at least 2 years before the autumn of1939. Results of this planning were of significance to the United States whenDr. Gordon sailed for England in August 1940 to begin the earliest Americancivil affairs public health activity in the United Kingdom; and they wereequally important when American troops landed and staged there.
One of the first steps to be taken by the Ministry of Healthand local authorities was the organization of the Emergency Medical Service forthe treatment of casualties, the sick and wounded. During the spring of 1938, 16months before war was declared, plans were made to evacuate school children,expectant mothers, young children, incurables, cripples, and blind persons fromurban centers to hundreds of towns and villages less likely to be subjected toenemy air raids. A grave fear expressed by Great Britain at the outset of thewar was the possibility that the national health would be affected.21
By the time war was declared, all of Great Britain had becomeone gigantic placement agency. Evacuation went off smoothly; in less than 4days, more than 600,000 children and mothers were moved from London, and asimilar number from other large cities, to reception areas in small communities.Some movement of the evacuees between the reception centers and the cities wasexperienced, but the bulk of the evacuees remained in the centers. The next massevacuation took place after the fall of the Low Countries in May 1940. By then,satisfactory arrangements had been made to absorb the evacuees in villagecommunities.22
Thus, Great Britain's special arrangements for waremergencies and the evacuation of those who could not contribute to the wareffort represented important factors in the maintenance of civilian and militarypublic health and eased the burden for the reception of American troops.
PROGRESSION OF EVENTS
Reconnaissance Survey and Public Health
The Emergency Period, 1940-41, marked the actual beginning ofAmerican participation in civilian and military public health activities in
20Gordon, John E.: A History of Preventive Medicine in the European Theater of Operations, U.S. Army, 1941-1945. Volume I, Part I, p. 1. [Official record.]
21See footnote 16 (1). p. 368.
22(1) Jameson, Sir Wilson: War and Health in Britain. Am. J. Pub. Health 31: 1253-1262, December 1941. (2) Eliot, M. M.: Protection of Children in Great Britain in Wartime. Am. J. Pub. Health 31: 1128-1134, November 1941.
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the United Kingdom. These were formative years for America,investigative years, years of accomplishment, years in which this Nation notonly studied seriously the effects of war on the health of civilian and militarypersonnel alike in the United Kingdom, but also lent skills to the British inbuilding an imposing record in civil and military public health activity.Success in the prevention and control of diseases in the United Kingdom was sooverpowering, it almost completely obliterated the misfortune of what might havehappened. One factor remains outstanding. The excellent public health andmilitary preventive medicine record made in the United Kingdom stands in sharpcontrast to the frustrating experiences encountered in the NorthAfrican-Mediterranean theater where public health facilities were notfunctioning until 8 months after the landings there.
In summing up, the concurrent actions which evolved from manyparts of the United States among civilian and military health authorities, in1940 and 1941, arose from a genuine desire of Americans to aid Great Britain inthe prevention and control of diseases, and an urgent need23to acquire knowledge about the nature of civilian public health in anation at war; to learn of the policies of military preventive medicine from theBritish services; and to correlate the two in this kind of war. The British,long at war, had handled this well.
Early observers.-A few Army and Navy medicalofficers, together with medical representatives of the U.S. Public HealthService, went to the United Kingdom in 1940 to observe British public healthconditions. One of the Army officers, Col. (later Brig. Gen.) Raymond W. Bliss,MC, visited England briefly and reported his findings to The Surgeon General.Other military and civilian medical representatives set up headquarters at theAmerican Embassy in 1940 and collected information for later dissemination tothe U.S. Army, Navy, Public Health Service, and the National Research Council.These officers developed liaison with the British Ministry of Health and theMedical Departments of both the British and Canadian armies, navies, and airforces.24
National Research Council.-In the early months of1940, the National Research Council organized a large number of committees atthe request of The Surgeon General of the Army to advise on problems of medicalresearch. His request was concurred in by the Surgeons General of the U.S. Navyand the U.S. Public Health Service. The committees played an important role indeveloping new methods to be used in the control of wartime diseases. One of themost important steps taken by the council was the establishment of close andintimate liaison with the Medical Research Council of Great Britain and theNational Research Council of Canada. This resulted in the
23Letter, John E. Gordon, M.D., Department of Epidemiology, School of Public Health, Harvard University, Boston, Mass., to Brig. Gen. Stanhope Bayne-Jones (Ret.), Chairman, Advisory Editorial Board, History of Preventive Medicine in World War II, 7 Nov. 1963, subject: Civil Affairs Public Health Activities in World War II.
24Larkey, Sanford H.: Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, Vol. I. 1945, pp. 1, 11, 20. [Official record.]
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mutual pooling of all scientific medical knowledge. Inaddition to the exchange of information between the councils, there were manyvisits back and forth between the countries by military and civilian medicalexperts.
U.S. Public Health Service.-In February 1941,Surgeon General Thomas Parran of the U.S. Public Health Service spent 6 weeks inthe United Kingdom. With a group of five observers, he collected information oninfant and maternal welfare, air raid precautions, problems of evacuation, andother features of war which involved total military and civilian populations.
The American Red Cross-Harvard Field Hospital Unit-Atthe onset of World War II, a wave of sympathy for the welfare of the Britishpeople swept over the Harvard University community.25Harvard's attention naturally turned to the distinguished servicerendered the Allies, under similar circumstances, in the First World War. Dr.Harvey Cushing, under the university's sponsorship, had headed the firstAmerican medical service unit to enter the fighting zone of France in April1915; this unit, supported by voluntary contributions, became the nucleus of thefamous Base Hospital No. 5, served with the British, and was later transferredto the United States Army when this country entered the war.
During the remainder of 1939 and the first half of 1940, Dr.James B. Conant, president of Harvard University, Dean C. Sidney Burwell, Dr.John E. Gordon, Charles Wilder, Professor of Preventive Medicine andEpidemiology, Medical School and School of Public Health, and other members ofthe faculty conferred among themselves concerning what could be done to helpGreat Britain in the fields of nutrition, sanitation, epidemic prevention, orthe psychological treatment of shellshock and related war casualties.
After an exchange of views between the representatives ofHarvard University and the British Ministry of Health, the services of medicaland public health experts were offered to Great Britain. However, the practicaldifficulties of fitting United States medical and ancillary personnel into theBritish public health organization became evident. The concept of sendingmedical experts broadened to include plans to send a fully equippedepidemiologic unit including a small hospital to study communicable diseases andto assist British authorities, both military and civilian, in the control ofdisease.
After the unexpected swiftness of the German successes in1940, the fall of France, and the evacuation of Dunkirk, Harvard officialscabled the British Ministry of Health:
25(1) An excellent account of the activities of the unit appears in Dunn, Lt. Col. C. L.: The Emergency Medical Services. Volume I: England and Wales. London: Her Majesty's Stationery Office, 1952, pp. 435-437. (2) All of the quoted matter under this heading is published in The American Red Cross-Harvard Field Hospital Unit. Cambridge: Harvard University Printing Office, 1943, pp. 12, 13, 36-40. (3) In addition, copies of the letters from Sir Wilson Jameson to Dean C. Sidney Burwell are also on file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.
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Harvard ready tosend small advance group of expert field and laboratory workers including Gordonto lend technical assistance looking toward organization of comprehensive unit.Ready to finance these men for one year. If this offer acceptable, hope toenlarge group, lengthen period of service, and expand work along lines of yourcablegram provided we can raise necessary funds. Have given careful studyhospital project and find it involves considerable delay. Therefore believe ifneed urgent quicker features should be initiated at once. Fund raising for anypurpose increasingly difficult at this time; therefore assurances from Britishauthorities on two points would be of greatest assistance: First, urgency ofneed of entire project; second, actual extent of contribution British ready tomake to support of larger plan.
The British Ministryof Health replied: "Gratefully accept your generous offer. Consultationdesirable as to answers to your questions and development of future plans withsupport from this government. Therefore cordially invite Dr. Gordon to visit usimmediately and report to you."
Three steps were now before the university:
1. Making arrangements to send Dr. Gordon and an associate toEngland as the advance guard of the Harvard Public Health Unit.
2. Securing financial support for the Harvard part of theventure.
3 Finding an organization which might undertake the planning,construction, and staffing of a portable field hospital, stressed by the Britishas of vital importance to their plans as a citadel in state of siege.
With the invitation of the British Government and thecooperation of the U.S. State Department, Dr. Gordon sailed for England inAugust 1940 to negotiate with the British Ministry of Health. He was accompaniedby Dr. John R. Mote, Good Samaritan Hospital and Assistant in PreventiveMedicine and Epidemiology, Harvard Medical School and School of Public Health.They landed in Liverpool on 14 August, proceeded directly to London, and arrivedthere 15 minutes before the raid of the Luftwaffe signaled the opening of theBattle of Britain. Dr. Gordon returned to the United States briefly in September1940 and began detailed planning of the hospital and selection of its equipmentand staff. In the meantime, meetings were arranged by President Conant and DeanBurwell with Mr. Norman H. Davis, chairman of the American Red Cross, who gavehis enthusiastic cooperation and financial support to the building of a 125-bedhospital for shipment to England. Dr. Gordon returned to England after thesemeetings, empowered with the authority to discuss the proposed plan with theBritish.
In March 1941, the first shipment of the hospital was madefrom the United States to Salisbury in southern England, a site selected by Dr.Gordon and Dr. J. R. Hutchinson, Ministry of Health, at Combe Road on the city'sborder, and offered by the British Government for the building of the hospital.
The American Red Cross-Harvard Field Hospital Unit wasformally opened on 22 September 1941 and eventually numbered 85 physicians,nurses, and technicians; the installation included 22 prefabricated buildings,
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FIGURE45.-The American Red Cross-Harvard Field Hospital Unit, assembled inSalisbury, England, from 66,000 pieces of prefabricated building materialshipped from the United States. The hospital was used to study wartimeepidemics. (Photograph, courtesy American Red Cross.)
housed 125 beds for communicable diseases, anepidemiologic field unit, and several well-equipped laboratories (fig. 45).
Dr. Gordon headed the unit and, in addition, acted as adviserto the British Ministry of Health upon the epidemiologic aspects of publichealth and hospital care. He was also Liaison Officer of the Ministry of Health.Dr. Gordon was given an office in the Ministry of Health and placed as an extramember of the principal committees of that office. From the point of view of theorganization, this proved to be advantageous since this liaison providedinformation as to the current public health problems and activities throughoutBritain, and increased the possible fields of activity of the organizationtremendously. Dr. Gordon often referred to the Harvard Unit as a"freelance" group, mobile enough to move wherever an epidemic mightstrike, and based as a hospital for clinical study.
During the 13 months between Dr. Gordon's arrival in Londonand the final completion of the hospital, he and other American medicalauthorities worked with British military and civilian health authoritiesdedicated to the study and control of epidemic disease in the British Isles. Theincidence of communicable diseases in the first winter of war proved far
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less than anticipated. Nonetheless, there were the unusualconditions to be watched in air raid shelters, minor outbreaks in distantcommunities to attend before they became major ones, and a variety of servicesto be rendered. The unit, a particular American contribution, played an activepart in planning preventive medicine measures generally, particularly in theshelters, as well as on staffs of various emergency medical service hospitals.
The account of this fully organized American institution inGreat Britain before the United States entered the war, with its availabilityfor instant use by U.S. troops as they began to mass for the offensive againstGermany and Italy, is an intensely interesting record of American volunteereffort in the war.
For nearly 2 years, epidemiologic experts from Harvard andthe Field Hospital Unit formed an important part of theEmergency Medical Service. Sir Wilson Jameson, ChiefMedical Officer of the British Ministry of Health, was sohighly pleased with the work of these experts and the field hospitalunit that he wrote the following two letters of praise to Dean Burwell,Harvard Medical School:
New York, N.Y.
November 5, 1941
Dear Dr. Burwell:
I was indeed privileged to have theopportunity of delivering the Cutter Lecture at Harvard Medical School on thetwenty-second of October, and of paying public tribute to the work of theAmerican Red Cross-Harvard Field Hospital Unit, so ably directed by Dr. JohnGordon.
I leave New York in a day or two on my returnjourney to England and I should like before then to elaborate just a little whatI said in my Cutter Lecture. As you know, the Unit consists of three essentialelements never before brought together, in my own country at all events, as theyhave been in this instance. First of all, the hospital of some one hundredthirty beds provides us with the means of studying special groups of cases in amanner we should find it impossible to do with our present shortage of beds forcommunicable diseases. The hospital is so situated that it can admit eithercivilian or service patients, and Dr. Gordon has the complete confidence of allthe civilian and the service medical officers of the area. We expect that theresearch work undertaken in the wards of the hospital will contribute materiallyto our knowledge of the origin and spread of communicable disease. Indeed, someof the staff have already, elsewhere in England, thrown new light on such aprevalent condition as scabies-a disease about which many people thought nonew work remained to be done. I should like to make it clear that the hospitalis not meant to supplement our ordinarily existing hospital accommodations. Itis an integral part of a well-conceived scheme for the carrying out of research.
A hospital of this kind without a laboratorywould be bereft of its usefulness, so a first-class laboratory has beenincluded. This laboratory will not only do the work required of it in relationto the patients in the hospital; it will also form one of the units of our ownemergency public health laboratory service. It is not the intention that itshould be used for ordinary routine work, but that special problems involvinglaboratory research should be referred to it. This is readily accomplished, asit is situated at no great distance from Oxford, which is the headquarters ofour own laboratory service, and already a close relationship has beenestablished between the two places.
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Associated with the laboratory is a group ofmobile teams of field workers, consisting of medical officers, public healthnurses, and, when necessary, laboratory technicians. These teams have alreadyproved themselves of the greatest value to us. They have carried out fieldstudies on trichinosis, on paratyphoid fever, and on epidemic respiratorydisease, to mention only a few subjects, and have not only done their work inthe most competent manner but have at the same time really endeared themselvesto the health staffs and to the public with whom they have been associated. Letme tell you what happened in Bristol a few weeks ago. That city, which hassuffered severely from air raids and whose health department has been seriouslyoverworked, was visited by a widespread epidemic of paratyphoid fever. Theresources of the city proved inadequate to the occasion, and Dr. Gordon wasasked to help. He sent six of his nurses to the local isolation hospital to lenda hand there. Another six public health nurses, together with a doctor, tookcharge of the field work and two laboratory technicians undertook all thenecessary laboratory work. As a result, the situation was brought rapidly undercontrol, and Dr. Gordon earned the gratitude of the whole city. Indeed, theHealth Commissioner, whom I saw the last week I was in England, was unwilling tolet the mobile team depart, as he insisted he had other problems he wishedinvestigated but was quite unable to tackle with his own depleted staff.
Again, we dread the possible appearance oftyphus fever in England. Dr. Gordon, who has had special experience in thisdisease, is providing us with our Number One mobile team which will proceed atonce to any area where an outbreak of the disease is thought probable. And notonly so; Dr. Gordon himself has been of great help in assisting us to draw up aset of rules for the guidance of our health commissioners in relation to thisdisease.
I could go on multiplying instances of themanner in which this excellent unit is rendering us invaluable help, but I thinkI must by this time have indicated sufficiently clearly to you how much weappreciate all it stands for. I regard the unit as most original in itsconception and likely to modify our own general epidemiological practice inBritain. Even the type of hospital construction is novel and may well be thetype we would do well to adopt more generally after the war. There seems to meto have been no extravagance in the planning of the unit and I can vouch for theefficiency of all the members of the staff.
Finally, I should like to remind you onceagain of the service Dr. Gordon has given us in the Ministry of Health byacting, with your permission, as official U.S.A. Liaison Medical Officer. Heattends all our confidential staff meetings, and his opinions and advice havebeen wholly for good. I personally owe him a real debt of gratitude.
I hope it will be possible to maintain thewhole unit on its present lines. You may rest assured that the American RedCross, the Harvard Medical School, and all the foundations that have sogenerously assisted in the formation and maintenance of the unit, are making acontribution of the utmost value to us in our war effort.
Yours very sincerely,
WILSON JAMESON
Whitehall, S.W.1.
16th September, 1942
My Dear Dr. Burwell,
Now that the American Red Cross-Harvard FieldHospital Unit has been taken over by the United States Army authorities I feel Imust send you a letter of appreciation for all you and the Red Cross have donefor us through this admirable Unit.
You may remember that, when I was in theUnited States last October, I was privileged to give you some account of theearly work of the Unit before the hospital had really begun to receive patientsin any number. I was able to tell you of the great help we had received from themobile teams that were sent out to districts where epidemic
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disease of one sort or another was prevalent,as well as of the interesting studies that various members of the staff had beenconducting. During this year the demands on the Unit's bed accommodation grewsteadily until the hospital had its full complement of patients. At the sametime a large amount of field work was being undertaken. The field investigationscovered epidemic myalgia at Salisbury, mumps, meningitis "follow-ups"in London and Wales, typhoid fever in Devonshire, paratyphoid fever inWeston-super-Mare, jaundice in a number of areas, notably in Northern Ireland,as well as other subjects of epidemiological interest. The staff of the Unitsometimes worked side by side with members of the staff of the Ministry ofHealth; at other times they carried out independent investigations with the aidof the staff of the local public health departments. I have a list of nearlyforty important field studies made by the Unit's mobile teams between October,1941 and July, 1942, activities which carried them through England, Wales,Scotland, and Northern Ireland.
The staff of the Unit have come to be regardednot as a group of workers from America but more as part of the general publichealth staff of the country. Many of them have attended our meetings andcontributed in most helpful fashion to discussions on technical matters. Some ofthem have published papers in our medical journals and all of them have made thenumerous visitors to the Unit feel welcome guests. Indeed the Unit, whether fromthe point of view of the interesting nature of its design and construction or ofthe quality and specialized character of the staff, is looked upon as a modelfor the postwar development of epidemiological studies in this country. Theimportance of this can be realised in view of the announcement recently made ofthe generous intention of sponsors of the Unit-The American Red Cross andHarvard University-to present the buildings and equipment to the Ministry ofHealth after the termination of the war
Of Dr. Gordon's special services I cannotspeak too highly. He has kept in the closest touch with this Ministry and hisadvice and criticism have been sought on numerous occasions by officers of thedepartment-and indeed by persons and bodies quite unrelated to the Government.All these associations, so firmly established prior to July 15th, 1942, we hopewill remain even though the Unit is now under military control. Indeed, we havethe assurance of Colonel Hawley, Chief Surgeon, United States Army MedicalCorps, that it is the intention that the Unit should continue to give service tothe civilian population so long as the exigencies of the war permit.
I hope I have succeeded in giving you someidea of the great contribution the Unit has made to British public health duringits comparatively short life as a civilian organisation. It has created animpression that will long remain after the staff have returned to the UnitedStates. Your generous conception of making a gift of the premises to theMinistry of Health when the war is over enables me to believe that we shall bein a position to carry on the tradition of good work that has been so firmlyestablished by this joint Red Cross-Harvard venture.
Please accept my grateful thanks for your ownpersonal efforts to make a success of the scheme.
Yours very sincerely,
WILSON JAMESON
On 15 July 1942, the American Red Cross-Harvard Field HospitalUnit was transferred, with its personnel, to the U.S. Army tofunction as the central laboratory of the theater in support of preventivemedicine and hospital activities. The Secretary of War, Henry L. Stimson,accepted the unit with these words of acknowledgment:26
The transfer to the United States Army of theAmerican Red Cross-Harvard Field Hospital Unit at Salisbury, England, brings tothe Army the valuable services of an
26See page 11 of footnote 24, p. 371.
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FIGURE46.-Brig. Gen. Paul R. Hawley, MC.
establishment which is especially equipped inthe field of preventive medicine. Much effort and money have gone into thefounding of the Unit, and that the Army will be privileged to benefit from itduring the present emergency provides a source of great satisfaction to all whoare concerned with the maintaining of the health of our Forces. The WarDepartment extends its appreciation to those whose generous and voluntarycontributions have made the Unit possible.
The Harvard Unit was renamed "GeneralMedical Laboratory A" and functioned thereafter as the central laboratoryfor the theater, rendering the same efficient service to military and civilianpopulations.27 TheFirst Medical General Laboratory arrived from the Zone of Interior in June 1943,and the two units joined forces under the title of that organization. Thecombined facilities met the demands of an increasing troop strength and theapproaching cross-channel operations.
When Col. (later Maj. Gen.) Paul R. Hawley, MC (fig. 46),began to set up headquarters for the Office of the Chief Surgeon, ETOUSA, henaturally turned to Dr. Gordon to serve as chief of the Preventive MedicineDivision. When Dr. Gordon indicated that he believed his work was done, ColonelHawley replied, "Where else can I find a man who has had two years'experience in the particular problems we are going to face?"
27Report, 1st Medical General Laboratory, 23 Aug. 1942-21 May 1943.
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Dr. Gordon was commissioned lieutenant colonel, MC, on 7 July1942 and appointed Chief, Preventive Medicine Division, Office of the ChiefSurgeon, ETOUSA, the same day. He began immediately to build up his organizationto provide the best possible preventive medicine service for air, ground, andservice troops.
The American Red Cross-Harvard Hospital Field Unit, inretrospect, was an exceedingly important epidemiologic control unit for theBritish civil and military public health service for the British had indicatedthat they were weak in this one specialty of medicine. In serving the British,the unit served the best purposes of the United States in reconnaissance,survey, study, control, and reporting of communicable diseases.
Special Observers Group.-Foreseeing the possiblefuture involvement of the United States in the war in Europe, the War Departmentestablished a military SPOBS (Special Observers Group), under the command ofMaj. Gen. James E. Chaney, USA, in London, on 19 May 1941. Previously, GeneralChaney had been in England, from 12 October to 23 November 1940, to observe theBattle of Britain, and had predicted that Britain would not lose the war. TheSpecial Observers Group was more than an assemblage of observers. It was, infact, a miniature theater headquarters, and was one of the predecessor commandsof the European theater.28Although SPOBS had a number of sections in its organization, none wasspecifically designated "civil affairs/military government."Nevertheless, the group was interested in these matters and in public healthactivities, as evidenced by the presence among its staff officers of, first,Maj. (later Col.) Arthur B. Welsh, MC, and, after September 1941, ColonelHawley, who became Chief Surgeon of the European theater. Colonel Hawley was theonly officer of this group who remained throughout the span of the ETOUSA periodto continue the work he had started as a Special Observer.
Early in January 1942, after the United States had become abelligerent, the name "Special Observers Group" was changed to USAFBI(U.S. Army Forces in the British Isles). The organization, still under thecommand of General Chaney, was now able to work openly as an ally of GreatBritain instead of being in the delicate position of representing a professedneutral nation with a government that was engaged in a life and death struggle.In other ways, however, according to reports, the path of this force was rugged;its personnel was limited and its directives were both limited andcontradictory. "In the hectic days that followed America's entry into thewar they were forced to revise their plans again and again as one new crisisafter another forced the War Department to redeploy its troops again andagain."29 AlthoughUSAFBI operated until 8 June 1942, when
28Sprague, W. F., and Elliott, H. G.: The Administrative and Logistical History of the European Theater of Operations. Part I: The Predecessor Commands. The Special Observers Group and the U.S. Army Forces in the British Isles. [On file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]
29See footnote 28; comment by a reviewer of the cited document.
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the European theater was activated, it neverincluded a special section for civil affairs.
Colonel Hawley continued his work of reconnaissance,inspection, and medical intelligence reporting to The Surgeon General, U.S.Army. Colonel Hawley was particularly interested in preventive medicine. Withhis refreshing wit and optimism, he established excellent rapport and liaisonwith British health authorities. On the morning after Pearl Harbor was attacked,he said:
I was going down to Southern Command and I hadto catch a train out of Waterloo Station, in London, about six o'clock in themorning. And so I got up at five o'clock that Monday morning-it was inLondon-I walked over to Baker Street tube station to take a train down toWaterloo Station, and * * * headlines this high on the newsstand. I picked it upthere-Pearl Harbor has been attacked. I went right back to my apartment-wasabout a block away from the Baker Street tube station,-got into a uniform.That morning, Monday morning, was always conference in the [British] SurgeonGeneral's office-all of his department heads. * * * And I walked into thatconference room in uniform and they all got up and yelled and cheered.30
U.S. Army Forces in the British Isles andSubsequent Commands
The Special Observers Group was discontinued in January 1942,shortly after the United States entered the war. The U.S. Army Forces in theBritish Isles, created the same month, absorbed the staff of the Observers Groupand became the top U.S. command in the area. The same excellent liaisonrelations, established with the British, continued under the new command andunder the subsequent commands.
The term "U.S. Army Forces in the British Isles"endured for about 5 months and was superseded on 8 June 1942 by "EuropeanTheater of Operations, U.S. Army."
Landings of the Troops
The landings of large numbers of U.S. troops in rapidsuccession in the United Kingdom in 1942, 1943, and 1944 created sizableproblems for British military and civilian public health officials as well asfor their American military counterparts. Problems included traffic,transportation, housing, food, milk pasteurization, supplies, sanitaryengineering, and communicable diseases. Lend-Lease and Reverse Lend-Lease,inaugurated as early as June 1941 for the construction of bases in NorthernIreland and Scotland, became an important part of the public health picture and,like the buildup, reached their height just before the continental invasion.31
When the first contingent of troops arrived in NorthernIreland on 24 January 1942, hard on the heels of President Roosevelt'sannouncement that a U.S. force was to be sent to Britain, the United Kingdom washardly
30lnterview, Col. John Boyd Coates, Jr., MC, and others, with Maj. Gen. Paul R. Hawley (Ret.), at The Historical Unit, USAMEDS, Forest Glen, Md., 16 and 18 June 1962.
31See pages 20 and 257 of footnote 4, p. 364.
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in order to receive so many guests. A German invasion wasexpected any minute, the British Isles were already "crowded to theattic," and the British economy was hard pressed by shortages imposed byalmost 2? years of war.
Nevertheless, no nation in history ever appeared happier tosee the vanguard of friendly and grinning "Yanks" as they swarmed downthe gangplanks onto the quay at Belfast from each of the four successiveferrying tenders. The tenders, Canterbury, Maid of Orleans, Royal Daffodil, andPrincess Maud, had gone out early in the morning of 26 January to meetthe anchored transports, the Strathaird and the Chateau Thierry, whichwere too large to negotiate the Victoria Channel into the harbor. Thetransports, escorted across the Atlantic by British and American warships (and,much of the way, by air patrols), had made the journey safely and lay off theIrish Coast throughout the night at Belfast Lough.
General Chaney, Commanding General, USAFBI, and Maj. Gen.Russell P. Hartle, Acting Commanding General, U.S. Army Northern Ireland Force,stepped ashore first, while the band of the Royal Ulster Rifles played "TheStar-Spangled Banner." It was a great and festive day in Northern Ireland;the docks were gaily decorated, and the Stars and Stripes and the Union Jackfloated overhead. On hand to greet the generals were the Duke of Abercorn,Governor of Northern Ireland, Mr. J. M. Andrews, Prime Minister of NorthernIreland, and a number of other officials from the Northern Ireland Government. TheTimes, London, reported the arrival of the first contingent with lively andjoyful interest as it did each consecutive contingent thereafter.32It noted that "by contrast with its historic import, the occasionseemed curiously subdued in its mechanical efficiency."
After the first landings in Northern Ireland, U.S. troopslanded in every major port in the United Kingdom. The cumulative buildup of U.S.troops, beginning with the first contingent of 4,058, had reached 241,839 byDecember 1942, 918,347 by December 1943, and 1,671,010 by May 1944.33
By the end of 1943, five base sections were in operation inNorthern Ireland, Wales, Scotland, and England. The base sections, havingundergone several changes in name and boundary during 1942 and 1943, wereNorthern Ireland Base Section, Western Base Section, Eastern Base Section,Southern Base Section, and Central Base Section (map 11).
Maintenance of the health of the U.S. Army in the UnitedKingdom, in consultation with British authorities, was under the jurisdiction ofthe Office of the Chief Surgeon, ETOUSA, supported by components of his officeincluding chiefly the preventive medicine service. Responsibility was furtherdelegated to the base section surgeons who had staffs resembling those of theparent organization. As health of the command involved civilians, or
32The Times, Times Publishing Co., London, England, 27 Jan. 1942, p. 4b, and other issues, 1942, 1943, and 1944.
33See pages 100 and 232 of footnote 4, p. 364.
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MAP11.-United Kingdom base sections and surgeons' offices, December 1943.
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required joint negotiations and agreements, theOffice of the Chief Surgeon and its components down the line arrived atappropriate decisions with the comparable British military and civilianauthorities.
PROBLEMS OF THE CIVIL-MILITARY PUBLIC HEALTH
ACTIVITY
The cordial and cooperative relationships enjoyedwith the Ministry of Health and other civilian and military organizations, whilethe U.S. Army staged in the United Kingdom, had tremendous impact on solutionsto problems affecting military units and civilians. These relationships, havingbegun in August 1940 when Dr. Gordon and other civilian experts worked on thecontrol of epidemic disease throughout the United Kingdom, were continued duringthe existence of SPOBS, USAFBI, and the European theater.
Weekly meetings of the executive committee of the BritishMinistry of Health, headed by Sir Wilson Jameson, were of prime importance inthe civil and military public health activity. Colonel Gordon, then chief of thePreventive Medicine Division, Office of the Chief Surgeon, ETOUSA, and otherAmerican medicomilitary authorities were invited to attend these meetings asrepresentatives of the U.S. Army. Health problems affecting civilians and thestaging of military forces were thrashed out, and decisions were made on methodsof handling them.
From the Zone of Interior, General Simmons and his deputychief, Col. (later Brig. Gen.) Stanhope Bayne-Jones, charged with theresponsibility for almost global military preventive medicine, participated inmaking decisions affecting the excellent record of preventive medicine servicein the United Kingdom. In 1943, General Simmons made inspection tours of medicalfacilities in the theater and promoted further the spirit of good will betweenBritish and American medical officials. On completion of one of the tours ofBritish and American medical installations in 1943, General Simmons praised theeffective medical service and "excellent cooperation of British militaryand civilian medical authorities." "Working together," he said,"British and American medical authorities have developed many improvementsin military medicine."34
Health and Public Health Arrangements for U.S. Troops in
Northern Ireland
The following account consists essentially ofexcerpts from Sir Arthur S. MacNalty's publishedsummary,35 whichhe based mainly on notes supplied by Col. Joseph H. McNinch, MC, USA. ColonelMcNinch held various
34The New York Times, 5 Sept. 1943, p. 9:5.
35MacNalty, Sir Arthur Salusbury, Editor-in-Chief: History of the Second World War. The Civilian Health and Medical Services. Volume II. Part IV: Public Health in Northern Ireland. London: Her Majesty's Stationery Office, 1955, pp. 399-402.
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positions in the Office of the Chief Surgeon,ETOUSA, from 1942 to 1945, including the posts of Deputy and Assistant Surgeonof the theater.
The first contingent of U.S. troops, the VCorps consisting of the 34th Infantry Division and the First Armoured Division,arrived in Ulster, Northern Ireland, on 24 January 1942. From the beginning,invaluable assistance was furnished by the British authorities, both militaryand civilian. Liaison was established with British military commanders and theirRoyal Army Medical Corps representatives; with local health officers andEmergency Medical Service representatives; with leading local health authoritiesand surgical practitioners through the Ulster Medical Society and the NorthernIreland Branch of the British Medical Association; and with the heads of localBritish relief and hospital aid associations.
The Ministry of Home Affairs extended tomembers of the U.S. Forces stationed in Northern Ireland the same facilities fortreatment as were available to members of His Majesty's Forces.
The assistance of the Ministry of Home Affairsdid not appear to have been sought by U.S. military authorities at any time inregard to scavenging of camps, water supplies, et cetera. The U.S. authoritiesapproached the local authorities directly on these matters and obtained fromthem such assistance as was possible. In many instances, water suppliessufficient for small rural communities were inadequate for large camps. As aresult, the U.S. military authorities had to make their own provisions. Theengineering work entailed was done on behalf of the American Forces by the RoyalEngineers.
Camp Accommodation. Upon arrival,American troops were quartered in various districts. Nissen huts accommodatedmost of the troops although other types of shelter were utilised in someinstances. Arrangements for occupancy of camps and installations were madethrough British Army Authorities. Their Barracks Engineer Officer was chargedwith the responsibility for the care and issue of movable equipment such asfurniture, light-bulbs, coal and straw, and for conservancy service.
Each camp commander appointed a utilityofficer, who worked in close liaison with the local British Garrison Officer.The utility officer was the American agent; it was his duty to see that rulesand regulations on camp maintenance were carried out, and that needed fuel, campequipment, and waste disposal services were available.
Hygiene. Hygienic precautions receivedearly and careful consideration by the surgeon, U.S. Army, North Ireland Forces.Following a survey of the situation, detailed and comprehensive sanitaryregulations were published. These related to water supply, food, milk, disposalof waste, garbage and rubbish, personal hygiene, venereal diseases, and controlof rats and other vermin. Commanding officers of all grades were responsible forinitiating and enforcing sanitary measures within their organisations and theboundaries of areas occupied by them. In all cases where questions ofjurisdiction arose, the appropriate British medical officer or local healthofficer was consulted.
All existing water supplies were non-potableaccording to U.S. standards, and therefore all cooking and drinking water inNorthern Ireland had to be chlorinated. If community-chlorinated water wastested and found potable further chlorination was not practised.
Sewage disposal in the camps presented noproblems. Bucket latrines were used and were emptied daily by civiliancontractors.
Rat control was important. Units were directedto carry out a rat destruction campaign and were instructed as to theavailability of poisons and traps.
Health of the Command. This wassupervised by the Preventive Medicine Section, Office of the Surgeon, NorthIreland Base Section. In this work liaison was maintained with the Britishmilitary and civilian medical authorities. There was free and complete exchangeof information as to the prevalence of communicable diseases in the U.S.personnel and civilians in the environment of troops. The Assistant Director ofHygiene
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of the Royal Army Medical Corps gave advicethrough personal visits and by telephone on the problems that might affectAllied military personnel. Civilian authorities also furnished usefulinformation on disease that might affect U.S. Army personnel.
Venereal diseases. A Venereal DiseaseControl Officer was assigned to North Ireland Base Section on 22 February 1944.A number of existing VD control agencies and treatment clinics in Belfast and atother locations strengthened the efforts of the U.S. military to restrainvenereal infections. On 11 April 1944, two nurses were attached to the BaseSection headquarters as investigators of venereal disease contacts. The approvaland cooperation of the Northern Ireland health officials was obtained beforethese nurses were sent out to interview contacts.
Health and the V.D. rate for U.S. Army troopsin Northern Ireland compared very favourably with other sections of the BritishIsles, while the number of cases of respiratory diseases was slightly less thanin England.
U.S. Army operations in Northern Ireland werecompleted in August 1945.
Housing
Provision of housing taxed the joint efforts ofthe United States and the United Kingdom as soon as war appeared inevitable forthis country. The housing shortage in the United Kingdom was acute because ofthe heavy loss of buildings to enemy bombing, the cessation of building duringthe war, the influx of Dominion forces and refugees from the Continent, and anincreasing population. Provision of. adequate housing, which affected the civiland military government public health activity in the United Kingdom, was, afterfood, the most pressing need.
Preventive health measures on transports presented adifficulty which had to be overcome; housing for troops arriving in the UnitedKingdom involved further the same problems of overcrowding, proper spacingarrangements, heating, ventilation, and other factors which might affect health.36
Public health and military preventive medicine considerationsfor housing began in mid-1941, along with other facets connected with theprovision of housing. This country at that time, as stated previously,"walked a tightrope to avoid violating U.S. neutrality" with GreatBritain in developing a housing program for the reception of U.S. troops. InJune 1941, negotiation with the British Government had resulted in contractssigned by that government and an American firm for the construction of bases inNorthern Ireland and Scotland. The Special Observers Group made reconnaissancetours of Northern Ireland and Scotland to determine housing requirements andenvironmental factors (fig. 47). Since American volunteers in the United Stateswere not restricted from offering their services to a nation at war, severalhundred skilled technicians did so in June 1941, went to the United Kingdom,and, under the direction of the British Government, began the construction ofbases in Northern Ireland and Scotland.37
36Whayne, Tom F.: Housing. In Medical Department, United States Army. Preventive Medicine in World War II. Volume II. Environmental Hygiene. Washington: U.S. Government Printing Office, 1955, pp. 27-74.
37See pages 20-21 of footnote 4, p. 364.
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FIGURE47.-An old mansion served as quarters for the 2d Infantry Regiment, 5thInfantry Division, at Warren Point, County Down, Northern Ireland.
The speed with which forces were built up in theUnited Kingdom and the shortages of materials necessitated the waiving ofcustomary American building standards and also required the building services ofthe U.S. Army.
Housing consisted of hutments, barracks, billets, and tents.Hutments were of various types, from double-walled Nissen to tarred paper. Thesemade satisfactory, although overcrowded, quarters. Ventilation became worse inthe huts as nights grew longer and colder. Vertical walled huts were constructedof brick, concrete blocks, asbestos, wood, and tarred paper. Barracks loaned toAmericans by the British varied greatly. Billets consisted of castles and manorhouses, theaters, stores, armories, schools, churches, and any building havingwalls and a roof.38
Inherent in the housing of U.S. Army troops was theunavoidable problem of the Army's nearness to the civilian population.
Food and Nutrition
"In a dim steamy hut in Northern Ireland, a U.S. Armycook stirring a 40-gal. beef stew roared: 'We've gone back 20 years. Norefrigerators, no electricity, no mixing machines. No bread slicers even. Gee,what a backward
38Annual Report, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, 1942, pp. 21-24.
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FIGURE 48.-The"kitchen" during the routine preparation of a meal at the 10th StationHospital in Musgrave Park, Belfast, Northern Ireland.
country.' But generally the Yanks moving into Ulster havebeen so well behaved that they are a puzzle if not a disappointment to everybodybut their officers"39(fig. 48).
Troop rations-The first American convoy arrived inNorthern Ireland ahead of its rations. British rations were issued by the RoyalService Corps until the supply system, Navy Army Air Force Institute, was placedin operation under reciprocal Lend-Lease. British Army cooks were lent to theU.S. messes to familiarize American cooks with the stoves and other messequipment.
The British ration was found to be unsatisfactory largelybecause of the differences in national tastes. American soldiers griped; theypreferred beef over the staple British meat, mutton.
By March 1942, American inventories mounted in NorthernIreland, and troops were changed over from the strict British ration to anAmerican-British ration. The incorporation of British food in the Americanration permitted a considerable saving of shipping space.
The Nutrition Section-The program of the NutritionSection, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA,operated throughout the war on five constituent factors: (1) collaboration withBritish military and civilian agencies concerned with nutritional problems,
39Welsh, M.: U.S. Troops Set Up Housekeeping. Life 12: 39, 23 Feb. 1942.
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(2) collaboration with the Subsistence Division, Office of theChief Quartermaster, in developing all possible improvements of the ration, (3)participation in studies of the relation of the ration to the morale and thephysical efficiency of the troops, (4) participation in the instruction ofmilitary personnel in matters pertaining to nutrition and mess sanitation, and(5) observation and study of the composition and methods of issue, storage,preparation, and serving of the prescribed ration to recommend designimprovements in its nutritional adequacy and to minimize waste of foodstuff andnutrients.40
Food wastes-During November 1942, an extensive surveyof American units in the United Kingdom was made by representatives of theNutrition Section, the Quartermaster Subsistence Division, and the British ArmyCatering Corps. This investigation demonstrated that the issue of excess foodwas resulting in widespread wastage because of failure to use the rationeconomically and failure to return unused items to depots. The situation wasdistressing, not only because it represented financial loss and the futiletransportation of supplies across the Atlantic, but also because of theunfortunate effect it had on the British who were campaigning for the maximumprevention of waste. As a result of the investigation, the chief of theNutrition Section was ordered to recommend changes in the current directives onrations. A directive was issued on 14 January 1943 with adequate changes in thetroop-ration scale.
Gardening-To obtain some of the fresh fruits andvegetables desired, arrangements were made for American and British troops tocultivate gardens. About 8,000 acres were cultivated by U.S. troops in 1942, andmore than 15,000 acres in 1943. During 1944, the combined British and Americanmilitary agriculture was estimated at 50,000 ship tons.41
Food poisoning from powdered eggs.-Eggs werescarce in the British market. The United States supplied powdered eggs to theArmy and to British civilians. From May to September 1943, 78 British civiliansfrom seven different districts in the United Kingdom contracted food poisoningwhich was traceable to infected powdered eggs and to the consumption of uncookedpowder.42 Thelargest outbreak involved 26 civilians at a hotel, while the rest involvedcivilian families. Similar outbreaks occurred in the U.S. Army.
The strain of Salmonella causing the food poisoningwas not prevalent in Great Britain and Northern Ireland but did occur in theUnited States. British authorities concluded that bacteria belonging to the Salmonellagroup would be found in powdered eggs imported from America because of thefrequency of Salmonella infection among poultry in the United States andthe ineffectiveness of the drying process used to manufacture the product.
40See footnote 38, p. 386.
41See footnote 6, p. 365.
42See Part III, Sec. 2, No. 2, pages 15-20 of footnote 20, p. 370.
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The problem was investigated thoroughly byBritish and American health officials. Supporting evidence from theseinvestigations led to the belief that powdered eggs were a pertinent factor inthe food poisoning outbreaks. The difficulties related to powdered eggs wereattributed to unsatisfactory processing, badly infected birds, and contaminationby food handlers. Sir Wilson Jameson, however, decided to continue the import ofthe vital product and to suffer the risk of food poisoning.43
Milk pasteurization-According to Sir WilsonJameson, one of the finest examples of civilian public health activities toemerge from the joint British-American military and civilian efforts resultedfrom the order initiated by Colonel Gordon through the Office of the ChiefSurgeon, ETOUSA, prescribing a standard of milk which did not exist in Englandto any appreciable extent.44 One day in mid-August 1942, ColonelGordon observed American soldiers obtaining milk from carts in the street.Since British milk was not pasteurized nor cattle tested for tuberculosis inaccordance with U.S. standards, Colonel Gordon relayed this information toGeneral Hawley. He obtained General Hawley's approval to initiate an orderprohibiting the purchase of British milk in bulk and authorizing the purchase ofwhole milk only when delivered in bottles and pasteurized under the provisionsof Army Regulations No. 40-2230 from herds inspected and approved inaccordance with the regulation. The result was a main dependence by troops onimported powdered milk. This was a doubly daring order, with shipping space fromthe United States so limited at that time, but it was accepted. The day beforethe order was issued, Colonel Gordon visited Sir Wilson Jameson to inform him ofits contents. The next day British newspapers, according to Colonel Gordon,carried headlines- "British Milk Unfit for American Soldiers." SirWilson Jameson was most pleased for this action marked the start of a generalpasteurization of milk in Great Britain. He had the weapon that had long beenneeded. If British milk was not good enough for American soldiers, it was notgood enough for the British either. Full-scale pasteurization was not realizeduntil the end of the war, but this important event had set the wheels in motion.
Sanitary Engineering
During the staging period of U.S. troops in Great Britain andNorthern Ireland, sanitary engineering was an intricate responsibility,involving mutual agreements between British officials concerned with the problemand U.S. counterparts of the Office of the Chief Surgeon, the Corps ofEngineers, and the Quartermaster Corps, ETOUSA. As the problem concerned theChief Surgeon's office, sanitary engineering policy and procedure for thetheater were established in the Preventive Medicine Division, Sanitation Branch,through coordination with other branches as necessary.
43See footnote 14 (2), p. 367.
44(1) See footnote 14 (2), p. 367. (2) Circular No. 40,Headquarters, ETOUSA, 5 Sept. 1942, section II, Use of WholeMilk for U.S. Army in ETO.
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A major function of Col. Ralph R. Cleland, SnC, Chief,Sanitation Branch, was the responsibility for effecting liaison with British andcivilian military personnel and organizations in allied fields on sanitaryengineering problems. Colonel Cleland also inspected sanitary conditions at allU.S. facilities, gave technical advice, and made recommendations on problems.The actual practice of sanitation was done in the unit area by unit commanderswho, with the assistance of the unit surgeon, performed the necessary tasks.Water supply occupied first place in the field of sanitation, with wastedisposal and water purification running a close second and third.45
Water supply and purification.-Water had never beenabundant in the United Kingdom, but it had generally been adequate for the needsof the civilian population. The British public was not accustomed to the amountsof water supplied to the comparable American public. Increases in population andthe drought in England from 1942 to 1944 contributed to water shortages. WhenU.S. troops arrived, with their notoriously high requirements for water, thesituation became acute.
In the United Kingdom, water was drawn principally from oldestablished water supplies and from municipal sources that had existed foryears. The sanitary qualities of this water were well known.
Obtaining sufficient water for troops and civilians strainedexisting facilities so acutely that the United States and Great Britaindeveloped new sources and improved and enlarged old systems. Despite theseinnovations, General Hawley's office had to issue numerous directives andmemorandums to surgeons of base sections, hospitals, and hospital centers,urging them to practice water conservation and water discipline (fig. 49). Thewater shortage was so serious in late 1943 and in 1944 that General Hawleythreatened a complete shutoff of water supply during certain hours each day ifwater consumption were not reduced.
Scales of allowance for water supply were established throughmutual agreement and published in British Army Council Instruction No. 227 on 10February 1943, as follows:
For sanitary purposes, the amounts allowed were ample
Scale of allowance | Imperial gallons1 |
Where waterborne sewage systems existed: |
|
| 20 |
| 50 |
Where no waterborne sewage systems existed: |
|
| 10 |
| 40 |
| 5 |
11.20 U.S. gallons.
For sanitary purposes, the amounts allowedwere ample.
43Unless otherwise indicated, material on sanitaryengineering is based on (1) Cleland, R. R.: Sanitary Engineering in the EuropeanTheater of Operations. Mil. Surgeon 101: 36-40, July 1947. (2) Correspondence, reports,and directives, Office of the Chief Surgeon, ETOUSA,concerning Civil Affairs-Public Health, water supply and purification,sanitation, and sewerage and sewage disposal, 1942-44.
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FIGURE49.-A field demonstrationof pump and filter units of portable water purification apparatus in England, 1943.
Bacteriologic analyses were made by sanitary engineers fromAmerican and British facilities at monthly intervals to determine the potabilityof the water. Many of the analyses were made at the 1st Medical GeneralLaboratory.
Water was seldom chlorinated by British municipal authoritiesto the extent required by U.S. Army standards. Consequently, the British WarOffice agreed to the application of chlorine alone as the type of purificationto be furnished U.S. camps.
Damage to water mains by enemy bombs was extensive, and thetyphoid hazard was a real fear.46 Some instances of diarrheas anddysentery during 1943 were traced to impure water.
Hardness of water was encountered in all areas of the UnitedKingdom except certain parts of Wales, Northwest England, and Scotland. Washing,cleaning, and dishwashing became a serious problem not only because of thiscondition but also because of the shortage of soap and lye. Water softening, aspracticed in the United States, was relatively uncommon. Where hardness exceeded100 per million, and especially at specialized hospitals, zeolite softeners wereinstalled.
Waste disposal.-Food consumed by U.S. troops in the UnitedKingdom consisted largely of dehydrated foods and boned meats, materiallylessening the quantity of garbage and residual wastes. Conservation of food wasalso a
46See page 1256 of footnote 22 (1), p. 370.
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contributing factor. Garbage was sold to civilian contractorsfor use as animal food.
Disposal of human wastes was an aggravating problem becausethe use of pit latrines was not feasible in this country. Many sections of theland had chalk formation underneath, which, because of its fissured character,allowed direct connection with nearby water supply sources. Bucket or paillatrines were used in some areas and were emptied by civilian contract. U.S.troops considered this method highly unsatisfactory, and it was a source ofridicule. Because of the unsanitary conditions encountered in the use of bucketlatrines, the Corps of Engineers, on the recommendation of the Office of theChief Surgeon, installed sewerage systems whenever possible.
Requirements for large volumes of water for flushing andsewerage frequently exceeded amounts available in certain towns and cities.These requirements often raised the problem of either increasing available watersupply or decreasing installations to adjust to British capacity.
Sanitary Control at Ports
The closest liaison and cooperation were exercised at alltimes by U.S. port surgeons with British port medical officials. Procedureprovided for the examination of military personnel and for the distribution toport surgeons of weekly memorandums on ports of origin involved in ships comingto the principal ports of the United Kingdom.
Early varying interests of the military and civilianorganizations of British and American origin were correlated, with jointendorsement, by a directive on the sanitary control of ports. British quarantinediffered from that in the United States, where the control of maritime trafficis at the Federal rather than the local level. Similar arrangements were made toinspect incoming and outgoing air traffic.47 Established policyprovided for the inspection of the crew as well as for disinsectization ofplanes landing from areas where typhus, malaria, and other diseases werepresent.
Hospitalization
Through mutual Lend-Lease arrangements early in the war,provisions were made between the Medical Department of the U.S. Army and theBritish Emergency Medical Service for the emergency medical care of certain U.S.troops. Some Americans reported for sick call in British military and civilianhospitals. Later, British and Canadian Army, Navy, and Air Force personnel, inreturn, were accorded the privilege of medical service in U.S. militaryhospitals. For many reasons, the U.S. hospital program for its own forces laggedconsiderably behind the arrival of troops, but General Hawley did everythingwithin his power to push the
47(1) Minutes, EleventhConference of the Chief Surgeon, ETOUSA, with base section surgeons, 20 Dec.1943, p. 2. (2) See pages 240-247 of footnote 35, p. 383.
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FIGURE50.-A medical ward in the110th Station Hospital at Warrington, England, in July 1943.
rate of expansion of the American hospital service (fig. 50).As a result of the lag, many more U.S. troops were treated in British facilitiesthan British in U.S. facilities.48 Records substantiate the factthat, as late as 1944, some U.S. troops were still being treated in Britishhospitals.
Several incidents occurred which provoked General Hawley'scensure. For example: Two patients suffering from cerebrospinal meningitis wereinadvertently admitted to the Royal Masonic Hospital, a hospital whichprohibited the admission of those with communicable diseases. General Hawleydirected that the commanding officer of the U.S. admitting installation visitthe Honorary Secretary of the Royal Masonic Hospital to promote better relationsthrough the prevention of misunderstandings "This office," GeneralHawley wrote, "has been embarrassed upon several occasions by blunders inthe admission of patients and other infractions of the rules of the RoyalMasonic Hospital." Several reprimands, explanations, and apologies tookplace.
General Hawley also made it very clear that patients who wereunder the care of British physicians at the Royal Masonic Hospital were not tobe seen by American medical officers unless they were asked to do so by theBritish physician in charge of the case. "Naturally," Col. Elliott C.Cutler, MC, Chief Consultant in Surgery, Office of the Chief Surgeon, ETOUSA,wrote for General Hawley, "if the British physician in charge of the case
48(1) See pages 187-189 offootnote 25 (1), p. 372. (2) Hawley, Maj. Gen. Paul R., Chronological Files,1942-44, passim.
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asks a consultant to see his patient, the consultant groupshould respond, but under no other circumstances."49
Infectious Diseases
Malaria.-Because of the military seriousness of malaria,the disease had been made officially reportable in U.S. troops in the UnitedKingdom since January 1942.50 Although indigenous malarial infections had beeneither entirely absent or comparatively rare in the United Kingdom for most ofthe twentieth century, four species of anopheline mosquitoes were native to theisland. Only one of these, Anopheles labranchiae atroparvus, wasclassified as a dangerous vector of malaria. This species was consideredespecially dangerous because the adult habitually lives in close associationwith man, either in his dwellings or in animal houses.
British troops, returning home from the Middle East in WorldWar I, had introduced malaria in sufficient proportions in the population to bedescribed by the term "outbreak" by the Ministry of Health. Alertafter this experience, the Ministry of Health was also concerned because malariahad been introduced from time to time before and after World War I byindividuals returning from colonies where they had contracted the disease.
From 1942 forward, the following factors, experiencedpreviously in the spread of malaria in the United Kingdom, engaged the attentionof British and U.S. military and civilian health authorities: (1) the presenceof susceptible populations, (2) the presence of a suitable mosquito vector, and(3) the possible importation of malaria by returning and incoming troops andairmen.
During 1942, Dr. Gordon recorded 20 cases of malaria in U.S.troops and 51 cases of fever of undetermined origin, the clinical investigationsfor which showed the original infections to have been acquired in the UnitedStates.
An important development in malaria incidence in Americanforces occurred in October 1943 when 10 B-24 aircraft destined for the EighthAir Force arrived in England; 17 of 100 members of the crews subsequentlydeveloped malignant tertian malaria, caused by Plasmodium falciparum. Thecrews had flown the South Atlantic route from Florida to Puerto Rico, to BritishGuiana, and to Natal, Brazil. A few planes flew from Natal to Ascension Islandand on to Roberts Field, Liberia; but most of the planes flew directly fromNatal to Dakar, French West Africa, and then to Marrakech, French Morocco.Whether they flew directly or indirectly, all planes landed in Dakar andMarrakech, where living conditions offered a fertile source for infection. Onlyone of the aircraft crews escaped infection completely. Members of this crew hadbeen thoroughly indoctrinated in malaria prevention and practiced it fully.
49Letters and memorandums, Royal Masonic Hospital, 1942-43.
50See Part III, Sec. 5, No. 2,pages 1-21, of footnote 20, p. 370.
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In November and December 1943, recurrent malaria in U.S.troops returning to the United Kingdom from malarial regions in North Africaposed a problem of medical importance. The 1st and 9th Infantry Divisions, the2d Armored and 82d Airborne Divisions, and the 1st Engineer Brigade, withwell-established histories of primary vivax malaria, were responsible for thesharp rise in malaria rates in the United Kingdom in late 1943 and 1944.Recurrent rates reached the highest peak in the spring of 1944 and declinedsharply only after the four divisions and one brigade departed for theContinent.
A four-measure Anglo-American control program, intensified inlate 1943, included (1) prompt treatment of malaria patients to render themnoninfective to mosquitoes as quickly as possible, (2) use of Atabrine as asuppressive, (3) protection of patients in hospitals and troops of nearbyregions from contact with malaria-transmitting mosquitoes when patients withmalarial infection were under treatment, and (4) control of mosquitoes in thegeneral military area.
Scabies.-Scabies was a troublesome problem in the UnitedKingdom because of the proximity of military and civilian populations. By1942, scabies was found frequently among civilians and troops. Rates rosesharply in 1943, and by D-day, the European theater had one of the highest ratesamong theaters.
Scabies paralleled venereal diseases in several ways.Transmission depended on opportunities for contact and fraternization, and bothwere controlled to some degree (scabies to a lesser degree) by casefinding andcontact investigation at the base-section level.51 In fact, Dr. (formerly Major,MC) Theodore H. Ingalls pointed out that the most significant deficiency in thecontrol program for civilians and military personnel was the failure torecognize scabies as essentially a contact disease, in large part a venerealdisease.52 Not enough attention was devoted to civilian contactsofinfected soldiers. Indoctrination of the soldier lagged, and the realizationthat scabies was a joint command responsibility was somewhat lacking. Too mucheffort was expended in searching for a perfect scabicide when basic remedies onhand were already satisfactory.
Homologous serum hepatitis (yellow fever vaccine).-The"old and ugly camp follower," hepatitis, caused some strain on civilpublic health activity in Great Britain and Northern Ireland. British healthofficials, having encountered the disease earlier in the war, were far moreconcerned than Americans who gave little thought to a disease that had givenlittle trouble during the last war, or since. Up to 1942, there had been nogeneral realization, in America, of the dual character of hepatitis.53
The first real scare in the United Kingdom came on 13 May1942, when Dr. Andrew Davidson, Chief Medical Officer of Health for Scotland,
51Diary, Col. John E. Gordon, MC, Preventive MedicineDivision, Office of the Chief Surgeon, ETOUSA, 1942-45.
52See footnote 16 (2), p. 368.
53See footnote 16 (2), p. 368.
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informed Dr. Gordon, at that time in Wales on a fieldinvestigation, that 26 cases of jaundice had been found aboard ship amongincoming U.S. soldiers. The troop transport had stopped briefly at Glasgow andthen proceeded to its destination in Northern Ireland. Concurrently, informationconcerning the event was relayed to Colonel Hawley by Dr. Hugh H. Smith of theRockefeller Foundation, who had also been called by Dr. Davidson. On 14 May,Colonel Hawley called Dr. Gordon and asked him to begin an investigation withthe American Red Cross-Harvard Field Hospital Unit (later 1st Medical GeneralLaboratory). Dr. Gordon immediately dispatched 1st Lt. (later Lt. Col.) DeanFleming, MC, and two nurses from the Salisbury unit to Northern Ireland, andjoined them next day by plane. By this time, there were 83 American patientswith jaundice in hospitals. The Northern Ireland command placed full facilitiesat the disposal of the Harvard Unit. It was entirely evident, by now, that thedisease had started in the United States, that a number of the cases hadoccurred aboard ship, and that more occurred after arrival. From extensive andconclusive field studies, Dr. Gordon decided that the disease was not contagiousand that it had been caused by icterogenic lots of yellow fever vaccineadministered in the United States. Lot distribution indicated that the cause wasprobably related to human serum diluent used in the preparation of certain lotsof the vaccine. Simultaneously, outbreaks that were occurring in other theatersfurnished further proof of the cause.54
Once the British recognized that the disease was homologousserum hepatitis and not infectious hepatitis, they were greatly relieved. BySeptember, when the outbreak ended, 1,591 cases were recorded by Dr. Gordon forU.S. troops in Northern Ireland.55
Colonel Gordon made the following statement concerning theoutbreak of postvaccinal hepatitis: "Although the cause of this outbreak ofjaundice was already known in the United States, such information had not yetreached U.S. Forces in Great Britain, here the cause was ascertainedindependently."56
Venereal diseases.-A high venereal disease57 rate amongU.S. troops, with consequent increases in the rate within the British civilianpopulation, was one of the most taxing joint civil-military public healthproblems encountered in the United Kingdom in World War II. No other publichealth problem threatened or disturbed Anglo-American relations more; yet, noother problem received closer cooperation and collaboration between healthofficials and agencies of the two countries in a genuine effort, on the part ofeach, to control venereal disease rates.
One distressing paradox was apparent from the beginning.Although
54Reports, Lt. Col. John E. Gordon, MC, subject: HomologousSerum Jaundice Arising From the Use of Yellow Fever Vaccine, European Theater ofOperations, 1942. [Official record.]
55See page 452 of footnote 16 (2), p. 368.
56See Part I, page 5 of footnote 20, p. 370.
57The venereal disease situation in the United Kingdom isdealt with fully on pages 226-242 of footnote 16 (2), p. 368.
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the United States and Great Britain enjoyed culturalsimilarities in many respects, and consequently were a contributing factor to troop-civilian fraternization and increasedrates, each country had a distinctly different attitude toward methods to beused in handling and solving the venereal disease problem. From the beginning,joint civilian and military experience showed the futility of American effort toimpose certain restrictive public health methods, which had been successful inthe United States, in a country which had traditionally considered sex behaviora personal matter and not subject to legislation or regulation.58Also, any effort to effect restriction might have been misunderstood asreflecting an inclination on the part of Americans to meddle in affairs whichthe British considered strictly their own.
At the outset, the British were somewhat impressed with theusefulness of American venereal disease control methods including contactinvestigation and casefinding; but nothing of the sort had ever been practicedin Great Britain where very stringent libel laws rendered exceedingly precariousany action which might be interpreted as designating a woman as a source ofvenereal infection. The entire British approach to the control of venerealdisease, at the time of the arrival of the first U.S. troops, was based on theprovision of adequate free treatment facilities and voluntary application fortreatment of infection. The provisions of the Venereal Disease Act of 1916guaranteed the privacy of the individual by prohibiting physicians and clinicsin the United Kingdom from reporting the disease.
The existence of different racial and socioeconomic groupswithin each of the civilian and military populations of the two countries, withfurther differences in their understanding and attitude toward venerealdiseases, added fuel to an inflamed situation. These factors-coupled with thelack of educational materials, supplies, critical housing shortages forprophylactic stations, British sensibilities about the display of prominentsigns (fig. 51), and the rigid requirements of the total blackout-madevenereal disease the touchiest and knottiest of all medical problems. Theinfluence which large amounts of money in the pockets of U.S. troops had inpromoting promiscuity among some women was a source of bitterness in Britishcircles.
For the purposes of this section on venereal diseases,circumstances may be divided into two phases: (1) the early problems in theUnited Kingdom when the United States was preparing for, and creating, amilitary base of operations; and (2) the later situation in the European theaterwhen, with the building of a base well underway, major problems were caused bythe tremendous concentration of troops in the overcrowded British Isles.
During the first phase, 1940 to mid-1942, excellentcooperative relationships were established with British health officials by Dr.Gordon, first as a
58Gordon, John E.: A History of Preventive Medicine in theEuropean Theater of Operations, U.S. Army 1941-1945. Volume II, Part V, p. 6.[Official record.]
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FIGURE 51.-Two Army posters warning of the danger of venereal disease infection.
civilian expert in epidemiology on loan from HarvardUniversity, and, in time, head of the American Red Cross-Harvard UniversityField Hospital Unit and Liaison Officer to the British Ministry of Health.Later, when the Special Observers Group and the subsequent command, USAFBI, cameinto existence, Dr. Gordon introduced incoming medical officers to the properpersons in the Ministry of Health, to other health officials, and to members ofmilitary organizations. Sir Wilson Jameson proved from the beginning to beinterested in venereal disease problems and was most helpful. His interestassured easy access to all local medical officers of health, the level at whichit eventually becomes necessary to control disease.
During the second phase, mid-1942 to mid-1944, Colonel Gordonwas chief of Preventive Medicine, Office of the Chief Surgeon, ETOUSA, with theprime responsibility for venereal disease control. When U.S. troops began tobuildup in increasing numbers, many effective measures to control venerealdiseases began to take shape under the auspices of the Chief Surgeon and theBritish Ministry of Health; but venereal diseases were difficult to control fromthese top level offices before the base section surgeons' offices came intobeing. Many meetings took place between Colonel
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Gordon, other members of his staff including Maj. (laterCol.) Paul Padget, MC, chief of the Venereal Disease Control Branch, and theBritish Ministry of Health. Because of the basic differences in attitudes, someof these discussions were rather heated, but moderators were both intelligentand deft. British officials were highly concerned about public opinion amongtheir own people and feared that the techniques of contact investigation wereunsuitable for them and even dangerous.
By April 1943, the high venereal disease rates among troopsand civilians in the United Kingdom had aroused so much feeling that, underthe auspices of the British Home Office and the Ministry of Health, the JointCommittee on Venereal Diseases was established. Large numbers of representativesof the British, American, and Canadian forces held a series of 11 meetings, from25 June until 29 October, to discuss policies and procedures for resolving thevenereal disease problem.
In July 1943, upon the invitation of the British Ministry ofHealth, and with the authority of The Surgeon General, U.S. Army, Dr. JosephEarle Moore, chairman of the Subcommittee on Venereal Diseases, NationalResearch Council, made an extensive tour of Great Britain and Northern Irelandto study the problem firsthand and to gain a better understanding of theinterrelationships between military and civilian health officials. The survey,based on the advice of military and civilian authorities in preventive medicineand public health in the United Kingdom, was made in July and August 1943; and awritten report was submitted on 19 August 1943 to the Chief Surgeon, ETOUSA,The Surgeon General, U.S. Army, and the Secretary of War. Substantialquotations and excerpts from Dr. Moore's report follow.59
Unfortunately, there is a tendency on the part of manyEnglish people to whom I have talked, professional as well as lay, some of whomare of national prominence, to attribute the increased incidence of syphilis intheir own population to the influx of "foreign" troops and merchantseamen, rather than to the relaxation of public morals which, by experience,occurs in every country in wartime. Prominent, perhaps most prominent among the"foreign" troops are said to be those of the U.S. Army. Englishcomplaints from many sources (similar complaints were not heard in Scotland)cover several points:
1. That in general the attitude of American troops towardEnglish women is undesirably loose.
2. That personnel with already existing infectious venerealdisease are being sent from the United States to England, and that such menspread these diseases among the civilian population.
3. That Negro troops, because of their excessive sexual urgeand the unfamiliarity of a certain small group of women with their socialstatus, are a particularly potent source not only of venereal disease but ofillegitimate pregnancies.
4. That the rate of pay of American troops is excessivelyhigh in proportion to British Army pay, and that the American soldier's excessfunds leads him into increased sexual contacts.
59Report, Dr. Joseph Earle Moore, Consultant, Committee onMedical Research, National Research Council, to Brig. Gen. Paul R. Hawley, ChiefSurgeon, ETOUSA, 19 Aug. 1943, subject: Comments and Recommendations on VenerealDisease in the U.S. Army, ETOUSA. [Official record.]
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There are, however, similar complaints from U.S. Armysources, fully as justified as the British complaints, as follows:
1. The British are so far unwilling or unable to take anysteps to deal with the flagrant and blatant display of prostitution bystreet-walkers, which exists in the centers of all large cities, especiallyLondon.
2. The attitude of the British public in respect of venerealdisease control, largely led by the Church, is far behind modern public healthpractice, even as exemplified by the desires and tentative future programs ofresponsible British Health Officers.
3. The attitude of U.S. soldiers toward women is at least inpart attributable to the provocative and receptive attitude of some of the womenthemselves.
4. Entirely justifiable American efforts at newspaperpublicity concerning the local venereal disease situation in our own troops haveoccasioned such a storm of British protest as to have led to an unpleasantinternational incident.
These complaints from British and American sources areoffered sometimes soberly, sometimes with genuine bitterness. They seem to me toraise an issue far more important than the incidence of venereal disease in theU.S. Army, namely the maintenance of amicable Anglo-American relations.
In my opinion, the most important feature of the venerealdisease situation in the ETO is its impact on Anglo-American relations. * * * Itis agreed by thoughtful Americans and British that the winning of this war isovershadowed by the necessity of winning the peace to follow; and that toaccomplish this aim, the maintenance not only of friendly relations, but ofactive cooperation between our two countries is essential. Many factors tend todisturb those relations, most of them economic and not readily obvious to thegreat bulk of our two peoples. In the public health and medical fields, however,there is no other factor so disturbing to Anglo-American relations as thevenereal disease problem. The relations between the sexes which initiate thesediseases are readily visible for all to see. Social and sexual behavior, and theconsequences of the latter, can provoke, indeed already have provoked, seriousdifferences of opinion in each group.
* * * Every effort should be made by both countries toremedy, so far as possible, defects in their own venereal disease programs whichtend to contribute to international misunderstanding.
In respect to the British program, two encouraging factorsare already visible. These are: (1) the interest of capable and powerful MedicalOfficers of Health in England and Scotland, Sir Wilson Jameson and Dr. AndrewDavidson; (2) the Joint Committee on Venereal Diseases sponsored by the Ministryof Health and the Home Office.60
I recommend, therefore, that-
1. U.S. Army participation in membership on the JointCommittee on Venereal Disease be continued.
2. The U.S. Army program of epidemiologic case finding beexpanded.
3. A system of education of U.S. troops in British socialcustoms, Anglo-American relations, and so forth, be inaugurated in the U.S. Armyat home and continued in the ETO.
4. The policy of sending infectious venereal disease patientsfrom the United States to the ETO be discontinued.
5. Negro troops in the ETO should be transferred to othertheaters of operation, or alternately, their number held at its present level.
60The chairman of the committee was Sir WeldonDalrymple-Champneys, Bart., Ministry of Health, and the members were BrigadierT. E. Osmond, RAMC, War Office; Air Commodore T. McGlurkin, RAF, Air Ministry;Lt. Col. M. H. Brown, RCAMC, Canadian Army; Col. John E. Gordon, MC, U.S. Army;Mr. H. R. Hartwell, Secretary, and Mr. T. Lindsay, Ministry of Health; Mr. T.Mathew, Home Office; Chief Constable E. A. Cole, Metropolitan Police; Dr. M. M.Goodman and Mr. E. A. Hogan, Department of Health for Scotland; Mr. J. S. Munro,Scottish Home Department; and Surgeon Cdr. D. Duncan, RN, Admiralty.
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6. The responsibility for public health and clinical measuresas to venereal disease be centered in the Venereal Disease Branch of theDivision of Preventive Medicine.
7. Additional venereal disease control officers should beimmediately secured to a maximum of 9 for present strength, with continuedexpansion as strength increases.
8. The intensive treatment of early syphilis should beadopted as routine.
9. ETOUSAMD Form 313 (reporting form) should be adopted foruse by the entire U.S. Army.
10. All punitive measures, official and unofficial, for theacquisition of venereal disease should be discontinued.
11. Laboratory service with respect of serological tests forsyphilis should be brought to the highest possible standard.
12. Venereal disease control program among the W.A.C. shouldbe instituted.
I should like particularly to commend the venereal diseasecontrol activities of Col. John Gordon, MC, Chief of the Division of PreventiveMedicine, and of his venereal disease control officer, Lt. Col. Paul Padget, MC;also of the Dermatologic Consultant, Lt. Col. Don Pillsbury, MC.
Dr. Moore's report received the overwhelming support, withsome restrictions and recommendations, of the War Department, General Simmons inthe Surgeon General's Office, U.S. Army, and General Hawley, Chief Surgeon,ETOUSA.
Concurrently, the Preventive Medicine Division, Office of theChief Surgeon, ETOUSA, was delegating more and more responsibility for controlto the now well-organized base sections throughout the United Kingdom. Duringthe course of 1943, the Venereal Disease Control Branch became primarily acollection agency for the coordination and dissemination of information to thebase section level, where disease was ultimately controlled.
The diligent efforts of both countries resulted in (1) easingof restrictions in British law, (2) changes in the organization ofadministration of the program, (3) intensification of education, (4) provisionof prophylactic facilities and materials, (5) continued cooperation betweenmilitary and civilian agencies, (6) epidemiology study and reports, and (7)strengthening of the highly effective program of casefinding and contactinvestigation.
British and Americans were now better able to appreciate eachother's problems and, with better understanding, were in a position to developand carry out the improved mutually supported program of venereal diseasecontrol.
Contact investigation was by far the most effective measure. During the height of the buildup, eight U. S. nurses were engaged in theinvestigation. These nurses worked under the base section surgeons andmaintained liaison with the Chief Surgeon's Office. With the British laweased, the Ministry of Health influenced the organization of British contactinvestigation teams for full support of the program, and both countriesappreciated the rewarding results.
SUMMARY
The Anglo-American coalition in World War II, one of theclosest and most effective in the history of wars, served as a solid basis fromwhich
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the successful public health activity of Civil Affairs andMilitary Government grew from its early beginnings in 1940 to the end of the warin 1945. Prevention and control of diseases in the United Kingdom were sosuccessful, they almost completely eliminated the chances of epidemics. Toprove a point in context, one has only to compare the record made in the UnitedKingdom with the frustrating experiences encountered in North Africa wherepublic health facilities were not functioning until 8 months after the landingsthere.
The inherent desire of the United States and Great Britain towin the war by close alliance took precedence over any impingement which mightbe imposed upon either the British or American right of conveniences, resources,customs, practices, and requirements. That impingement did occur is evident inthe vast collection of published and unpublished writings of military andcivilian authorities. That impingement is inevitable in an alliance of nations,even in the face of relatively minor cultural differences, is reasonable andunderstandable.
The health of a military force is vitally dependent upon thehealth of the civil community where it is stationed, whether the force is inbelligerent or friendly territory. The friendly nation favors closer contactbetween civilian and military populations than does the belligerent one.Friendly nations with a common heritage, such as that shared by the UnitedStates and Great Britain, enjoy one asset which offsets the peril of much else.This asset is obviously the ability of representatives of each country tonegotiate with understanding and, in a series of talks and agreements, decidejointly what is necessary and desirable to do next to gain the maximum advantagefrom any future situation; success in the prevention and control of disease maybe attributed measurably to this very great advantage.
A published example, picked at random and representative ofthe feeling existing on both sides, is readily evident in the vivid andobjective account written by John W. Blake. Dr. Blake, a World War II historianfor Northern Ireland, described brilliantly and concisely the dramatic andperplexing effects of large numbers of military guests descending upon a nationand staging among its residents; his statement follows.61
The influx of so many Americans * * * spread over nearlyfour years, naturally created problems as difficult as they were numerous. Fromthe moment, in 1941, when a handful of technicians arrived in Northern Ireland,until the end of the war, the number and variety of these problems steadilygrew. No bare record now can do justice to the effort entailed in solving them,smoothing over differences and ensuring friendly relations between the visitorsand their hosts. The very intimacy which language permitted between Americanservicemen, British troops and Ulster civilians tended to multiply theopportunities of misunderstanding. All this the authorities foresaw, and it ledthem to apprehend some embarrassment. It was scarcely to be expected that scoresof thousands of servicemen, including coloured troops, drawn from every quarterof the U.S.A.,
61Blake, John W.: Northern Ireland in the Second World War.Belfast: Her Majesty's Stationery Office, 1956,pp. 289-290.
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could be suddenly brought into Northern Ireland and as suddenly removedwithout repercussions upon the Americans themselves, upon the British troops inNorthern Ireland, and especially upon the life of the province. Much of this wasimponderable. If some of the external and more concrete results might beforeseen, the inward surge, the excitement and the stimulation could not bemeasured. Whatever the authorities might try to do,and whether they looked backwards or forwards, they would be moving in deep andunknown waters. The impact would certainly be great, yet who could gauge itsstrength, still less its effect?
