CHAPTER XVI
The Philippines and Okinawa
Thomas B. Turner, M.D.
Section I. The Philippine Islands
BACKGROUND
Preparation for the Invasion
In June 1942, Gen. Douglas MacArthur's forces began thelong push back to the Philippines. Landings were made at Buna in New Guinea,followed by landings, usually with relatively small forces, on numerousislands of the Solomons group, on New Britain, on the Admiralty Islands,and along the northern coast of New Guinea.1
In none of these areas were civil affairs activities,as such, carried out. Military forces had little contact with native populations,and the medical and health problems were largely ones of survival in malaria-riddenterritory. Captured Japanese medical supplies were sorted and classified,many of the more useful drugs and equipment being issued to the militarymedical units, while the bulk of the supplies were turned over to the civilauthorities.2
Detailed planning for the invasion of the Philippineswas begun by General MacArthur's headquarters on 12 March 1944.3The principal forces to be concerned with the invasion were the Sixth U.S.Army under the command of Lt. Gen. Walter Krueger, the newly activatedEighth U.S. Army under the command of Lt. Gen. Robert L. Eichelberger,USASOS (the U.S. Army Services of Supply), and the XIV Corps under thecommand of Maj. Gen. Oscar W. Griswold.
During most of 1943 and 1944, General MacArthur had, ineffect, two headquarters groups: The one designated "GHQ, Southwest PacificArea" was the headquarters of the Allied Commander in Chief, from whichhe directed all Allied Ground, Air, and Naval Forces; the other designated"Headquarters, USAFFE (U.S. Army Forces in the Far East)," was reactivatedon 26 February 1943 and served as administrative headquarters
1Accounts of the great contributions made by the Medical Department in the prevention of malaria andother diseases in these campaigns will be found in other volumes of this series of the History of Preventive Medicine in World War II, such as: Medical Department, United States Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government Printing Office, 1963.
2Quarterly History of Medical Activities, Sixth U.S. Army, 29 Dec. 1944, p. 29.
3Cannon, M. Hamlin: United States Army in World War II. The War in the Pacific. Leyte: The Return to the Philippines. Washington: Office of the Chief of Military History, Department of the Army, 1954, p. 2.
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for all U.S. Army forces in the Southwest Pacific theater.Although assigned to USAFFE, both the Sixth U.S. Army and the Eighth U.S.Army, after its activation in September 1944, were attached to GHQ, SWPA(General Headquarters, Southwest Pacific Area), which, therefore, exercisedoperational control over them while USAFFE merely provided administrativesupport.4
The chief surgeon of the Southwest Pacific theater, Maj.Gen. Guy B. Denit (fig. 76), and his staff organizationally belonged toUSASOS and were not a part of either General Headquarters or USAFFE. Indeed,for many months, the only physician attached to General Headquarters wasCol. Howard F. Smith, a commissioned officer in the U.S. Public HealthService, who for a number of years had been responsible for quarantineduties in the Philippines; Colonel Smith was officially designated ChiefMalariologist. On 26 September 1942, Col. George W. Rice, MC, was designatedSurgeon, GHQ,5 buthe was not allowed supporting personnel other than a secretary, and noreports were channeled through his office. Likewise, only a small medicalgroup was attached to HQ, USAFFE. In January 1944, the Chief Surgeon, USASOS,was also designated Chief Surgeon, USAFFE.
Thus, the principal staff concentration of competent medicalpersonnel was organizationally in a poor position to be effective in overallplanning or in the supervision of operational activities as they affectedmedical and health matters. Until late in the war, the Surgeons of thecomponent field armies functioned in a largely independent manner withoutmuch consultation with the Chief Surgeon of the theater. These organizationalarrangements imposed handicaps upon the medical activities in this theater.In particular, much of the early planning for civil affairs health activitiesin the Philippines was carried on without benefit of professional advicefrom the principal medical headquarters in the theater.
Planning for Civil Affairs Health Activities
As plans for the invasion of the Philippines developedin the summer of 1944, a Civil Affairs Section was established in GeneralHeadquarters. The section was initially under the direction of Brig. Gen.Bonner F. Fellers; the only medical officer attached to the group was ColonelSmith.6
During the planning period, scant liaison was maintainedwith the Civil Affairs Division, War Department General Staff, and essentiallyno liaison with the Chief Surgeon of the U.S. forces in the theater.7
On 22 September 1944, Lt. Col. Isaiah A. Wiles, MC, wasappointed the surgeon of Civil Affairs Service, ASCOM (Army Service Command),with the mission of planning medical activities for civil affairs. A planwas submitted and approved by higher authorities on 29 September 1944.Colonel
4Order of Battle of the United States Ground Forces in World War II; Pacific Theater of Operations. Washington: Office of the Chief of Military History, 1959, p. 35.
5General Order No. 36, General Headquarters, Southwest Pacific Area, 26 Sept. 1942.
6Memorandum, Brig. Gen. Bonner F. Fellers, for the Chief of Staff, 25 July 1944.
7Pincoffs, Col. Maurice C.: History of Preventive Medicine, Southwest Pacific Area (rough draft).
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FIGURE76.-Brig. Gen. Guy B. Denit, Medical Corps.
Wiles was joined by Lt. Col. Lorenzo L. Parks, MC, on9 October 1944. Further planning, however, was carried on at General Headquarters,and ASCOM seems to have had no further mission in respect to civil affairs.8
On 28 September 1944, an important revision of a previousstaff memorandum was issued by General MacArthur's Headquarters.9The underlying philosophy of the memorandumwas that the responsibility and authority of the Commander in Chief forcivil administration and relief were to be exercised as far as possiblethrough the Philippine Commonwealth Government, with the ultimate and primaryobjective of restoring the orderly and free democratic processes to theFilipino people.
Plans for civil administration and relief during the periodof military reoccupation anticipated two phases, combat and noncombat.During the combat phase, civil affairs were to be handled through U.S.military detachments recruited from available Philippine and U.S. Armypersonnel. They were to be known as PCAU's (Philippine Civil Affairs Units)and were to be under the direct command of Task Force Commanders.10Their
8Wiles, Lt. Col. Isaiah A., MC, Report of Medical Activities-Civil Affairs Service, Army Service Command, 12 Nov. 1944.
9Staff Memorandum No. 40, General Headquarters, SWPA, 28 Sept. 1944, subject: Civil Administration and Relief in the Philippines.
10Standing Operating Procedure No. 26, General Headquarters, Southwest Pacific Area, 9 Oct. 1944.
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duty was to execute plans and policies formed by GeneralHeadquarters in cooperation with the Philippine Government. Local governmentalorganizations were to be used as far as possible to avoid further dislocationof the lives of the people when they should become self-sufficient.
After the cessation of hostilities in an area, the CommonwealthGovernment, under the supreme authority of the Commander in Chief, wouldadminister civil government and relief. The seat of the Commonwealth Governmentwould be established at General Headquarters, Southwest Pacific Area. Asrapidly as was consistent with military operations, relief supplies wereto be provided to maintain health and working capacity and to alleviatethe effects of malnutrition. Stimulation of food production, fishing, andtransportation would, hopefully, hasten self-sufficiency of the people.
Financial and economic matters were to be handled so thatwage and price structures which could not be supported after the militaryperiod would not be established. Labor requirements of task forces andbases were to be recruited on a civilian basis. Punishment of Filipinocollaborators with the enemy was to be carried out by the CommonwealthGovernment.
The particular responsibilities for civil administrationand relief assigned to the Assistant Chief of Staff, G-5 (Civil Affairs),included the primary one of assisting the Philippine Government to carryout its tasks. The G-5 Section would (1) disseminate information to civiliansand handle legal and financial matters, (2) prepare plans for recruiting,training, and assigning PCAU's as well as plan and supervise health andsanitation measures, and (3) prepare technical and policy instructionsfor the task forces and units.
The Assistant Chief of Staff, G-4 (Logistics), would estimaterequirements for civilian relief and prepare directives for procuring,transporting, storing, and issuing relief requirements. He would make plansand implement directives to effect Philippine self-sufficiency as rapidlyas possible. These plans would include procurement and storage of suppliesand equipment. This section, in collaboration with the Chief Signal Officerand Chief Engineer, would prepare plans and directives for the restorationof transportation, communications, and utilities in furtherance of themilitary effort.
The Commanding General, USAFFE, was to be responsiblefor the recruiting and training of the PCAU's, for counterintelligenceactivities, and for censorship of civilian mail.
The basic philosophy was embodied more explicitly in StandingOperating Procedure Instructions.11Army or Area commanders were responsible for administration and reliefwork in their areas as consistent with the military situation. Coordinationof Civil Affairs policies was to be effected by General Headquarters inclose cooperation with Army or Area commanders and the Philippine CommonwealthGovernment. From the medical point of view, in addition to general healthand sanitation measures, these duties
11Standing Operating Procedure No. 27, General Headquarters, Pacific Area, 15 Nov. 1944, subject: Civil Administration and Relief of the Philippines.
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would include the control and isolation of communicablediseases among the civil population and the provision of hospitals anddispensaries for civilians not employed on military projects.
PHILIPPINE CIVIL AFFAIRS UNITS
These specially trained units were to be moved into thecombat areas as soon as the tactical situation permitted civil relief workto begin (fig. 77). Each unit normally contained 10 officers and 39 enlistedmen. The number of units to be attached to an area command would dependon the population and needs of the people; hopefully, each unit would beself-contained and would possess the necessary transportation and facilitiesfor distributing relief supplies.
While these units were not to be used as labor recruitingagencies, they were to be permitted to recruit labor for combat units andfor their own use in carrying out their normal duties. Otherwise, theywould notify the people of needs for civilian laborers and direct themto recruiting offices.
The War Department had already procured relief suppliesin the United States. These consisted of food (mainly rice), fuel, clothing,emergency shelter, and medical and sanitary supplies sufficient to preservelines of communication, to maintain health and working capacity, and topreserve order. Procurement of these supplies for Army and Area commandersaccording to General Headquarters estimates was a USASOS responsibility.Thesupplies furnished by the War Department for Philippine relief would besupplemented from excess military supplies, captured enemy material, andlocal produce. Army rations and medical supplies might be used until therelief supplies were available although troops were forbidden to issuethem to civilians unless specifically authorized. Wherever practicable,PCAU supplies would be segregated by Services of Supply from other suppliesand would be specially marked.
Maximum use was to be made of local products, for whicha fair price would be paid; wholesale ceiling prices were to be announcedfrom time to time. Emergency free relief was to be provided as necessary,but as soon as possible, stores were to be opened to sell relief suppliesto the public.
If necessary, a rationing system would be established,with each family receiving one ration book. To stimulate local productionof food, farm tools, fishing equipment, and seeds would be distributed.Since imported rice and corn will not grow in the Philippines, plans weremade to distribute seed rice by a system of exchanging Philippine palay(unhusked rice) for husked imported rice.
Personnel.-Initial personnel requirements of 100officers and 400 enlisted men were estimated for civil affairs activities.Maximum use was to be made of qualified Filipinos; in addition, 240 officersand 386 enlisted men trained in civil affairs were to be supplied by theWar Department. A limited number of officers were to be flown from theUnited States. Early plans of the estimated requirements for Medical Departmentpersonnel are not
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clear, but each PCAU was to include one medical officerand four enlisted medical assistants among the 10 officers and 39 enlistedmen assigned (table 4).
TABLE4.-Typical personnel complement, Philippine Civil Affairs Unit
| Sections | Officers | Enlisted men |
Administrative | 11 | 28 |
Medical | 1 | 4 |
Supply | 1 | 3 |
Relief and Welfare | 1 | 5 |
Labor | 1 | 1 |
Legal | 1 | 1 |
Engineer | 1 | 5 |
Public Safety | 1 | 10 |
Finance | 1 | 1 |
Transportation | 1 | 1 |
|
|
|
1Commanding officer of unit.
2Includes one master sergeant who served as chief administrative clerk and first sergeant.
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Although PCAU's were to accompany the Task Forces, underthe direct command of the commanding general of each task force, they wereassigned to various tactical units for administration.12
Training.-Training of civil affairs personnel forthe Far East had been instituted under War Department direction as earlyas 27 June 1944, when a Civil Affairs Staging Area was established at FortOrd, Calif. This staging area was moved to the Presidio of Monterey, Calif.,on 10 February 1945, and was known as CASA (Civil Affairs Holding and StagingArea). It served as the final advanced training center where teams of civilaffairs personnel were organized and given instruction just before shipmentto the Far East. Students came from other civil affairs schools, directlyfrom civilian life, or from other Army assignments.13
Coordination.-The General Headquarters Civil AffairsSection was to coordinate plans with the Civil Affairs Section, Sixth U.S.Army, and with representatives of the Philippine Commonwealth Government.Technical supervision and coordination of PCAU's were to be responsibilitiesof G-1, General Headquarters; on matters pertaining to Civil Affairs, directcommunication between G-1, General Headquarters, and PCAU's was authorized.The PCAU Medical Affairs Officers were to collaborate with the Task ForceSurgeon on matters relating to communicable diseases in occupied areas,and were to inform the PCAU commander and G-1, General Headquarters, ofthe medical situation among civilians, of the status of medical suppliesand equipment, and of other relevant matters.14In practice, these channels of communicationwere not particularly effective, partly because of the great distancesinvolved and the difficulties of communication.
Supplies.-For the Leyte operation, a food requirementof 20,000 tons was estimated for a population of 1.6 million with additionaltonnage for textiles, medical supplies, and transportation of equipment.
Transportation.-Profiting by the experience inthe Italian campaign, in which civil affairs personnel were severely handicappedby lack of organic transport, it was planned that, whenever possible, PCAU'swould be self-contained as regards transportation. That these plans weresuccessful is indicated by there being virtually no reference to a lackof transportation in reports of civil affairs operations in Leyte and Luzon.
THE LEYTE CAMPAIGN
The Leyte Operation, which began the campaigns for theliberation of the Philippine Islands, was divided into three tactical phases:first, an amphibious operation to secure the entrance to Leyte Gulf; second,major amphibious assaults to seize the eastern coastal strip from Taclobanto Dulag
12See footnote 10, p. 567.
13(1) Gillespie, Maj. J. B., MC: Training of Civil Affairs Public Health Officer, p. 11, (2) U.S. National Archives: Federal Records of World War II. Volume II. Military Agencies. Washington: U.S. Government Printing Office, 1951, pp. 150-151.
14Fellers, Brig. Gen. Bonner F., GSC, General Headquarters, Southwest Pacific Area: Tentative Plan for Civil Affairs in the Philippines, 22 Sept. 1944.
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and the Carigara Bay area on the north central coast,and to open the San Juanico and Panaon Straits; and third, the destructionof hostile forces remaining on the island and the clearing of the enemyfrom southern Samar (map 18).
Phase One, begun on 17 October 1944, was completed withrelatively small forces within a few days. On 20 October, the X and XXIVCorps of the Sixth U.S. Army landed abreast on the east coast of Leyte,and occupied Tacloban, Dulag, and the intervening area; simultaneously,elements of the 24th Infantry Division seized Panaon Island off the southeasterntip of Leyte and quickly gained control of Panaon Strait.
These forces rapidly moved inland and northwestward andcaptured Carigara on the north coast within a fortnight. Other elementsmoved southwestward to occupy Baybay on the west coast.
Despite heavy losses in the naval battle of Leyte Gulf,substantial Japanese reinforcements were landed. This fact, together withthe onset of the rainy season, led to a protracted Phase Three; and itwas not until 25 December 1944 that organized enemy resistance ceased andthe occupation of Leyte was given over to the Eighth Army, while the SixthArmy readied itself for the invasion of Luzon.15Meanwhile,elements of the 1st Cavalry Division landed on the Island of Samar on 24October, securing it toward the middle of December.
Organization for Civil Affairs
Coincident with the establishment of a Civil Affairs SectionGHQ, SWPA, the Sixth U.S. Army improvised a G-5 section, with the ArmyJudge Advocate General temporarily assigned as G-5 in addition to his otherduties; on 8 October 1944, an officer was assigned to this duty full time.Apparently, no medical officer was assigned to this section.
PCAU's Nos. 1 to 8, which had been organized and trainedunder GHQ, were attached to the Sixth U.S. Army for the Leyte Operation.PCAU's Nos. 5 and 6 were to be attached to X Corps, comprising the 24thInfantry Division and the 1st Cavalry Division; PCAU's Nos. 7 and 8 toXXIV Corps, comprising the 7th and 96th Infantry Divisions; and PCAU'sNos. 3 and 4 to ASCOM. PCAU's Nos. 1 and 2 were to be kept in reserve underthe Sixth U.S. Army. In addition, naval civil affairs units would accompanyXXIV Corps in the landing phase.
The Combat Phase
Because of his familiarity with advance planning, theSixth U.S. Army Judge Advocate General, Col. William P. Connally, Jr.,JAGD, landed with an advance civil affairs detachment on A+2 to coordinatethe activities of the civil affairs units.16PCAU'sNos. 3 and 4 landed on Red Beach,
15Letter, Headquarters Sixth Army, Civil Affairs Section, to Chief of Staff, 4 Mar. 1945, subject: Report of Civil Affairs Operation on Leyte-Samar.
16Letter, Headquarters Sixth Army, Civil Affairs Section, to Chief of Staff, 26 June 1945, subject: Report of Civil Affairs Operation on Leyte-Samar.
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MAP18.-Leyte, Philippine Islands.
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the X Corps Area, on A + 4. PCAU's Nos. 1 and 2, whilebeaching on A + 5, sustained a direct bomb hit on their landing craft andsuffered casualties. PCAU's Nos. 7 and 8 landed on A-day on X Corps beachbut, because of the absence of land communications, were unable to reachXXIV Corps beaches until A + 5; in the meantime, naval civil affairs unitswere carrying out the civil affairs functions in that area.
Naval bombardment of the beach areas had been heavy andthere were many civilian casualties. It was inevitable that the regularmedical installations would be called upon to render medical aid to woundedFilipino civilians. By A + 4, station hospitals were ready to receive patientson the beachhead. Because the large number of civilian wounded presenteda serious problem to the regular medical installations, the Surgeon ofthe XXIV Corps decided to assign the Corps clearing company as a civilianhospital.17 By A +5, this unit was able to relieve other military hospitals of all civilians.As fast as possible, civilian patients were moved for convalescence tocivilian medical facilities established under the supervision of PCAU.
A somewhat similar situation prevailed in respect to themedical units supporting the X Corps. On A + 2, the 36th Evacuation Hospitalwas on the beach treating mainly civilian casualties in an aid station,while Army battle casualties were evacuated to Navy vessels.18It should be noted, however, that PCAU's Nos.5 and 6 went ashore with the assault forces; but in view of the limitedsize of the medical section of a PCAU, they could do little more duringthe actual assault phase than work with the combat medical units in tryingto provide some care for wounded civilians.
The organizational medical supplies of PCAU's which wereexhausted in the early beachhead phase were augmented by captured Japanesemedical supplies. Generally, Army medical units provided necessary medicalsupplies as well as hospitalization for the civilians. The Civil AffairsSection of the Sixth Army recommended that PCAU's go ashore with at leasta 10-day supply of medical items.
The Chief Surgeon, USAF Western Pacific, described thesituation as follows:
On Leyte troops faced a serious civil public health problem.Civil affairs became the responsibility of tactical commanders and as nospecial medical facilities were provided for treatment and hospitalizationof civilians, their care placed a considerable burden upon the army medicalfacilities. The problem was not only one of personnel, but also one ofsupply. Not only did civilian wounded need care during the active combatphase but also large numbers of civilians required medical attention foracute and minor diseases. The combat division was specially hampered bythe presence of civilian casualties. The need was keenly felt for specialmedical civil affairs unit to be set up and operated by D-1 and capableof forward displacement in order to handle civilian casualties as theymight occur. The civil affairs problems on Leyte permitted a preview ofconditions later faced on Luzon. It was expected that in future operationsit could be taken for
17Quarterly Report, Headquarters XXIV Corps, 1 October-31 December 1944, dated 12 Jan. 1945.
18Quarterly Report, 24th Infantry Division, 1 October-31 December 1944, dated 16 Jan. 1945.
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granted that civilian sanitation would be inadequate andthat civil affairs units would have to be provided by army medical personneland equipment.19
As the tactical forces advancedacross Leyte towards the western and northern coasts, PCAU's attached todivisions continued to carry out their assigned functions. Resistance variedfrom area to area, but in essence, the civil affairs problems were thoseof the combat phase-dealing with civilian wounded, attempting to reestablishcivilian health services, which were rudimentary at best, and furnishingmedical supplies to hospitals and dispensaries. In this operation, PCAU'sfrequently were transferred as some units dropped off to join the occupationalphase of the operation, while others remained with their divisions. Someidea of these changes are contained in the following comments:
On 26 December [1944], Philippine Civil Affairs Units(PCAU) Numbers 14, 15, 17, 26 and 27 took over responsibility for civilaffairs * * *. These PCAUs relieved Numbers 4, 7, and 8 which had beenwith the Corps for some time but were relieved from their duties on Leytein order to make them available for duty on Luzon. Although the changein units resulted in some unavoidable confusion, the generally excellentservice performed by the PCAUs was continued.
At this time, civil conditions on the east side of theisland had become stable. On the west coast, however, thousands of civilianshad been driven from their homes by our advance. The town of ORMOC-thelargest in the area-and numerous smaller barrios had been destroyed.In addition, an estimated 2,000 natives of the Camotes Islands had lefttheir homes due to the atrocities committed by the Japs and were livingalong the beaches north of Baybay. The shortage of food and medical supplieshad resulted in seriously hazardous health conditions throughout the westcoastal plain, with the exception of the Baybay area which had been restoredto a reasonably normal condition.
The PCAUs operated directly under the Corps Commanderwith the mission of assisting the division commanders charged with tacticalcontrol of the particular area concerned. PCAU supplies of food, medicine,clothing and sundries were brought to the west coast as rapidly as spacein the convoys could be made available. An organized effort to reap theunharvested rice crop produced an appreciable addition to the importedfood supplies.20
The PCAU medical officer was instructed to "establishand operate hospitals and mobile and fixed dispensaries for the treatmentof civilians in liberated areas, prior to the establishment of facilitiesfor such medical care by the Philippine Commonwealth Government."21Accordingly, immediately upon arriving in Leyte in October 1944, the U.S.Army, principally through the PCAU Medical Sections, began restorationand operation of several previously used Filipino medical installationsand the establishment of many new ones to provide for the civilian population.
During the next 4 months, many of these original emergencymedical
19Annual Report of Chief Surgeon, USAF, Western Pacific, for 1945, Part I, Ch. 10.
20Operation Report, XXIV Corps (Leyte), for period 26 December 1944-10 February 1945, pp. 10-11.
21(1) General Headquarters, "Instructional Notes on Philippine Civil Affairs," 22 Nov. 1944, par. 2g (4). (2) USAFFE, "Instructional Notes on Philippine Civil Affairs," 13 Jan. 1945, par. 2d (3).
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installations were continued and expanded, and a few newinstallations were established. Simultaneously, a public health and sanitationprogram was being conducted by army agencies.
The Occupation Phase
On 26 December 1944, 11 PCAU's arrived in Leyte to takeover the responsibilities formerly discharged by PCAU's attached to theSixth Army. Organizationally, the former, which had been attached to theEighth Army, became a part of the SOS base on Leyte, Base K. Previously,various hospitals and dispensaries had been established for civilians,but were equipped to carry out only the most elementary medical care. Inthis area, Filipino physicians were scarce and much of the medical workwas performed by Filipino nurses. The only source of competent major surgeryand X-ray facilities for civilians on the east coast of Leyte was a stationhospital in Dulag which, shortly after the invasion, had been allocatedto civilians.
Following a well-defined policy,22assistance by U.S. agencies gradually diminisheduntil the Commonwealth Government assumed complete responsibility for alldispensaries and hospitals. Early in January 1945, the Medical Office ofthe Civil Affairs Section, USAFFE, recommended that all PCAU hospitals,clinics, and dispensaries be turned over to the Philippine Government.Certain unit commanders recommended that the changeover should not be abrupt,and that installations might operate without supervision if provisionswere made for necessary supplies and transportation. It was also suggestedthat supervision of sanitation and control of communicable diseases shouldnot yet be relinquished.
Before the end of February 1945, most of the medical installationswhich had been established and operated by PCAU's were either discontinuedor handed over to the Philippine Government through Dr. Arturo B. Rotor,Secretary of the Department of Health and Welfare. It was explained ineach instance that the U.S. Army accepted no more responsibility for theiroperation except to assist in securing relief medical supplies. Althoughtechnically the Army had no further responsibility, it continued to assistcivilian medical installations in every way possible. Until the end ofMarch 1945, eight hospitals, 25 dispensaries, and seven subdispensarieswere maintained in the Base K area by PCAU's.
Despite all the directives issued before the occupationthat military responsibility was to be limited to furnishing minimum emergencyassistance and supplies, many other, well-meant activities were carriedon which, in the long run, caused the Philippine Government problems whichwere at the time insoluble. The initial task of the PCAU's was to establishmedical installations rather than to set up a health organization. In retrospect,it is clear that the units were not given sufficient medical personnelto carry out their assigned tasks and, further, that the Philippine Governmentwas not
22Letter, USAFFE, "Civilian Medical Installations and Supplies for the Philippine Islands," 11 Jan. 1945, par. 1, sec. II.
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able to support the number of hospitals, clinics, anddispensaries which were established and which were considerably more numerousthan those which had existed before the war. The problem raised by thissituation began to appear as soon as control of the hospitals and dispensarieswas assumed by the Philippine Government. Personnel, transportation, andfinancial support were all lacking.
Before the war, 11 hospital-type medical installationshad been in operation in the Province of Leyte; seven of them were classedas maternity houses. During the occupation phase, 10 hospital-type dispensariesfor civilians had been in operation in Base K area. When the PhilippineDirector of Health assumed responsibility, he was able to include in hisbudget for fiscal year 1945 only four hospitals-the Leyte Provincial Hospital,Tacloban Maternity Hospital, and the San José and Baybay hospitals.
Before the war, dispensaries were operating in all 47municipalities of Leyte; during the military period,25 dispensaries were in use. On 1 May 1945, all dispensarieswhich had been under the control of the Supervisor of Hospitalswere placed under the care of the District Health Officer; by 1July 1945, only 10 were in operation in the Base K area.
Congested conditions.-Three main factors contributedto overcrowding in the hospitals: (1) patients stayed longer in the hospitalsbecause the physicians had no transportation to make followup calls inpatients' homes; (2) chronic and incurable cases were accepted in hospitalswhere, with the very limited facilities, space and effort should have beenconcentrated on doing the greatest good for the greatest number; and (3)the Filipino "companion" system was extended to the hospitals. Shelterand food had to be provided for one or more members of a patient's family.Sometimes these companions would be helpful in an understaffed hospitalin doing menial work, but the disadvantages of the system are clear, particularlywhen companions would sleep at night with a patient suffering from a communicabledisease.
Overcrowded conditions prevented the practice of idealpatient segregation according to age, sex, surgical and nonsurgical cases,and even communicable diseases; for example, the Supervisor of Hospitalsfound a case of diphtheria in a general ward. With the cooperation of thePreventive Medicine Section Officer, Base K, isolation wards were providedin the Tacloban Hospital, and a gradual improvement was seen.
Lack of mobile medical units.-Although the establishmentof mobile medical units was authorized and equipment, including transportation,had been available since the landing in October 1944, none was actuallyprovided. Maj. Charles W. Hall, Inf, Civil Affairs Officer, stated in hisreport23 that mobile units could have served a very useful purposein satisfying the needs of small villages, thus eliminating some of thesmall dispensaries. Their use would have extended the scope of the limitedmedical personnel and would have facilitated the work of the sanitationand public health sec-
23Hall, Maj. Charles W., Inf: Report of Medical Situation-Province of Leyte, as of 1 July 1945.
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tions of Civil Affairs. At the time this report was prepared,the establishment of the units was still desirable and had been recommendedto the Leyte health authorities.
Personnel.-Difficulties inherent in the situationon Leyte were increased by friction between those who were in charge ofthe civilian medical installations and the Supervisor of Hospitals. Theindividuals in authority lacked tact and good leadership. Since the salariespaid to professional medical personnel were low and they could obtain morelucrative work elsewhere, they would not accept arbitrary treatment. Relationsbetween the installations and local authorities and citizenry were oftenpoor and uncooperative. Lack of administrative ability among those in chargeof hospitals led to confusion and general laxity. In one hospital, forinstance, operations were performed without the permission of the physicianin charge, and even a "black market" in medical services, operations, andtreatment was reported. These factors, together with the overcrowding,inadequate facilities, and the fear that the Commonwealth Government wouldbe unable to give proper support to the installations, may have contributedto a lowering of morale among medical personnel. Nevertheless, despitethese problems, medical care was generally satisfactory. The majority ofthe personnel were loyal, devoted, conscientious workers.
Liaison between U.S. Army andCivil Government.-Coordination between Army andcivilian medical authorities after the installations were turned over tothe Commonwealth Government was not on an official basis except possiblyin the supply phase. Major Hall, in his report, stressed the need for adefinite official liaison to secure proper supervision of civilian medicalinstallations for both civilian and military interest.
MEDICAL CARE OF CIVILIANS IN U.S. ARMY INSTALLATIONS
The presence of the Army and, particularly, its use ofmany civilian laborers greatly taxed the normal civilian medical facilities.Furthermore, traffic casualties were numerous, and many civilians, includingchildren, were killed or injured by exploding ordnance materiel thoughtto be "duds."
Military hospitals were reluctant to accept civilian casesbecause our facilities were already overtaxed in caring for military personnel,and also because of the directive which stated that civilians would beadmitted to U.S. Army hospitals "only to save life or to prevent unduesuffering."24 Theywere to be transferred to civilian hospitals or otherwise released as soonas movement was no longer a hazard to their condition.
There were instances where admission to an Army hospitalwas necessary to save life or prevent grave suffering (where civilian facilitieswere unable to handle the cases) and yet admission was refused. On theother hand, some civilian hospitals turned away cases for lack of properfacilities without attempting to secure admission to a military hospital.Transfers from U.S. Army hospitals to civilian hospitals rarely occurred,in spite of
24Letter, Headquarters USAFFE, to various addressees, 19 Apr. 1945, subject: Filipino Patients.
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the directives. The unusually high death rate among thecivilian population seems to indicate that all that could have been doneto aid those requiring medical attention fell short of what might havebeen expected.
Major Hall believed that the various instructions regardingcivilians, both those who were employed by the Army and others, would havebeen carried out more satisfactorily and effectively if they had been publishedin one all-inclusive directive to the military.25
Health and Sanitation
Local organization.-The legal provision for healthand sanitation in the Philippines was based on the Administrative Codeof 1917. A system of municipal boards within the Health Bureau providedan excellent organization which would have accomplished a great deal hadit been adequately supported with funds and personnel. This system wasin operation at the time of the invasion and until 1946 when the CommonwealthGovernment achieved the independence which had been promised for that yearsince 1935. The Province of Leyte was designated as a Health District witha District Health Officer appointed by the Commonwealth Director of Health.The District was subdivided into 17 Sanitary Divisions, each supervisedby a president, usually a physician, who functioned as Health Officer andSanitary Inspector. Some sanitary divisions had Assistant Sanitary Inspectors.Securing satisfactory personnel for these positions was difficult becauseof the low wages.
When the U.S. Army landed on Leyte, investigation revealedthat household cleanliness, personal hygiene, and community sanitation,in most areas, generally did not meet the standards existing before theJapanese invasion. The Japanese occupation had seriously disrupted an alreadyinadequate system of public health supervision.
By July 1945, after 7 months of Allied occupation, littlehad been accomplished in Leyte by the District Health Officer, and themunicipal boards of health were almost inactive. Transportation, funds,and qualified personnel were all inadequate. Cooperation between the localpolitical leaders and the District Health Officer was poor and, althoughthe health officer's work was purely professional and advisory, he wasalso confronted with the operational problems referred to him by the municipalities.These problems were solely the responsibility of the local government,but they refused to act on them, either through lack of ability or unwillingness,or through both.
Under PCAU supervision, each municipality in the BaseK area had a sanitary inspector and an assistant sanitary inspector. Theirprincipal function was to supervise the construction of public latrinesand wells and to instruct the people in their use. These inspectors generallywere un-
25(1) See footnote 24, p. 578. (2) Regulations No. 50-40, USASOS, 17 Jan. 1944, subject: Medical Department, Medical and Dental Attendance and Hospitalization. (3) USAFFE, "Instructional Notes on Philippine Civil Affairs," 13 Jan. 1945, par. 2d (5).
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trained and unqualified, having been selected principallyon the basis of their previous doubtful experience as sanitary inspectors.
The responsibility for health and sanitation was not turnedover to the Commonwealth Government concurrently with the turnover of hospitalsand dispensaries. Since the chief concern of the PCAU's in this area wasthe establishment of hospitals and dispensaries, they achieved little insanitation.
The Base K Surgeon and his staff assisted local civilianmedical agencies wherever and whenever military exigencies permitted. Actingon the principle that the health of an army parallels the health of thesurrounding civilian population, the Base Surgeon incorporated a PreventiveMedicine Section in his staff. Through this section, unofficial liaisonwas maintained with the District Health Office.
Activities of malaria control units.-The MCU's(Malaria Control Units) might well be described as the backbone of theArmy public health projects among the civilian population after the reoccupationof Leyte (fig. 78). These units had certain advantages over the PhilippineCivil Affairs Units' medical sections: they were larger, having a trainedsanitation engineer and 11 enlisted men, and they were provided with eightvehicles of their own while the PCAU medical section had to share the vehiclesassigned to the whole team. As a general rule, the PCAU medical team establishedhospitals and dispensaries, and the MCU teams engaged in public healthrehabilitation.
Because of the absence of the malaria vector in Leyte,the MCU's operating in the area were able to concentrate on other phasesof health control and disease prevention. These included fly control measures,garbage collection and disposal, latrine construction, drainage, sanitarysurveys, cemetery rehabilitation, military camp installation inspections,operation of a mobile schistosomiasis laboratory and plague and rodentcontrol schools, setting up a model home exhibit, and assisting in thesurvey of sites and construction of civilian hospitals and dispensaries.
One of the finest health projects was carried out by the90th MCU in their public health inspection of Tanauan municipality usingcivilian public health workers. A checksheet including instruction wasfurnished to each worker in addition to an orientation lecture before inspectingthe house and grounds, toilets, and water sources. The object of the programwas to get the people of the community to do as many things as possibleby themselves to improve their own homes and surroundings and thus to raisethe level of health and hygiene of both the home and the whole community.
A survey conducted by the 32d Malaria Survey Unit of theschool children in Julita, Burauen, and Dagami revealed that, in Dagami,schistosomiasis had a high incidence rate (23 percent) which not only wasa serious local health problem but also threatened the troops. Julita (1.3percent) and Burauen (1.8 percent) had a relatively low incidence. Parasiticinfections and worms were found in the children. No record is availableon any follow-
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FIGURE78.-The 6th Malaria Control Unit, Tanauan, Leyte, Philippine Islands,December 1944.
up work; however, one report stated that no Fuadin (stibophen)was available for early treatment.
During February, the 98th MCU began an intensive sanitarycampaign covering Carigara and Capoocan, and Barrio Balud. Sanitary conditionsimproved markedly and an interested cooperative spirit was aroused in thepeople. On 12 February, following a conference with the community civicleaders of Capoocan, a mass meeting was attended by approximately 3,000civilians. Instructive talks were given and details of the coming sanitarycampaign were outlined by the mayor, the school supervisor, and the commandingofficer of the 98th MCU. Interestingly, the program provided for long rangecivic planning. Twenty-five female sanitary inspectors and 100 civilianlaborers assisted in carrying out the sanitation program.
A general program of sanitation was carried out in theTacloban area during March by the 97th and 92d Malaria Control Units. Theprogram started with a mass meeting attended by more than 3,000 peoplewhich was addressed by municipal authorities and Commonwealth Governmentofficials as well as the base surgeon and base malariologist. Next, a truckwith a mounted public address system carried the word to all sections ofthe town,
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and 500 posters, the results of a contest in the schools,were displayed. A model home was used as headquarters of the campaign.Posters and exhibits on schistosomiasis and rodent control were shown.A meeting of local doctors, nurses, teachers, sanitary inspectors, andcommunity leaders was held in the high school to plan for the details ofthe cleanup campaign. This included daily collection and removal of garbagefrom the city proper to an authorized dump for burning; weekly sprayingof all latrines, public and private; daily distribution of garbage collectioncans until a sufficient number were in use; construction of public latrines;cleaning of vacant areas within the city; and daily inspection of homesby a group of trained civilian employees. Neighborhood inspections werecarried out periodically by the local officials accompanied by MCU members.They visited homes and inspected yards, latrines, and adjacent areas. Wherevera dirty area was discovered, an order was issued from the Mayor's Officeand delivered by the Chief of Police, forcing the owner to clean the area.These measures stimulated property owners, especially since fines wereimposed upon a few lax individuals. A house-to-house canvass of the townwas conducted by 12 girls who had been trained as inspectors. They reportedall delinquencies to Unit Headquarters, and complaints were turned overto the local Sanitary Division. These girls also instructed each householdin sanitation and hygiene. By 31 March 1945, 1,974 homes had been visited.
In the town of Carigara, the 90th MCU found a similarhealth and sanitation program was necessary to control gastrointestinaldiseases among troops in that area. In collaboration with PCAU No. 5, acorps of 21 girls was hired and trained and, under joint supervision, conducteda complete public health survey. The training of the girls and their workwere carried on simultaneously. They were given mimeographed instructions,written in Visayan, which included directions on the construction of flyprooflatrines, and a copy of the PCAU Sanitary Bulletin No. 1.26The girls also attended a series of lectures outlining the general problem.Conferences were held and further instructions were given after they hadmade several visits. All persons who were employed on the project wererequired to build flyproof latrines and to maintain their homes and groundsin a sanitary manner, as an example to others. Data were obtained on pastand existing practices in public health matters and on the habits of thepeople.
Latrines.-Insanitary excreta disposal and diseasevectors were undoubtedly the fundamental causes of the high mortality andmorbidity rates in Leyte. The Commonwealth Government officially requiredevery house to have a sanitary toilet. Before the war, Government sanitaryinspectors told the people to build latrines; some complied, but mostlythey were not used, being kept only for inspection purposes. Flyproof latrineswere scarce in many areas of Leyte. The complacency of the Filipinos inthis respect presented a serious obstacle to the Army's efforts to educatethem in proper excreta disposal. Filth and disease were accepted as partof a normal existence.
26See annex No. 11 to footnote 23, p. 577.
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An energetic educational program by Army units stimulatedthe construction of latrines in the area. After 7 months, the use of latrinesby civilians in Base K was estimated to have risen from 10 percent to morethan 30 percent. The Preventive Medicine Officer of the Base recommendeda further program of instruction in building and using proper latrines,regular inspection by the local health officer, and enforcement of ordinances.An adequate and steady supply of disinfectants, especially diesel oil andchlorinated lime, was still needed.
Diseases.-A survey of the reports on disease prevalenceshowed that schistosomiasis, one of the special hazards in the Philippines,27wasoccurring among both civilians and Army personnel with some fatal cases.28Dengue- and malaria-transmitting mosquitoes were prevalent, the latteramong the foothills rather than in the coastal areas. In the Tacloban region,the high incidence of both yaws and influenza declined steadily with promptmedical attention and greater precautionary measures. Malnutrition wasuniversal and, of course, aggravated all diseases. Many sick people refusedproper medical care, preferring the home treatment given by "Dr.Laway,"the Visayan equivalent of the quack or "faith" doctor. Some of the moreoutstanding disease problems warrant attention here.29
Mental illness. No provision was made to care forthe mentally ill. For a time, cases of acute dementia were cared for inlocal military installations; however, the Provincial Supervisor of Hospitalsadvised that mental cases should not be accepted by military installations,but should be turned over to the local jail keepers for safekeeping. Laterinvestigations revealed that most mental patients did not remain in jaillong, either conveniently breaking away with no attempt at pursuit beingmade or actually being released by the jailer.
Tuberculosis. Tuberculosis was a major cause ofdeath in Leyte. One report estimated that 90 percent of the populationwas infected, and that pulmonary tuberculosis was still increasing. UntilJuly 1945, no arrangements were made for the examination, treatment, andcare of these patients. Those who reported to Army dispensaries were givensedative treatment and returned to their homes. Sanitariums and diagnosticfacilities were seriously needed as well as an educational campaign toteach the people the elements of personal hygiene in relation to the transmittalof the disease.
Leprosy. Before the war, lepers were isolated ina barbed wire enclosure behind the Provincial Capitol. During the war,they escaped to their homes and remained scattered throughout the province.When the U.S. forces arrived in Tacloban, seven lepers were discoveredliving under a school building in the swamp area behind the Capitol building.They made
27Circular No. 27, USAFFE, 27 Mar. 1945, subject: Disease Control in Philippine Islands.
28Memorandum, Headquarters Base K, to Commanding Officers, all units assigned or attached to Base K, 22 Jan. 1945, subject: Schistosomiasis.
29All of the disease problems are considered in greater detail in the other volumes of this Preventive Medicine Series and also in Volume II of the Internal Medicine Series.
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painful excursions late at night in search of food. Toisolate and provide care for lepers, a leprosarium was established by Armymedical authorities in a reconditioned building about 4 kilometers fromTacloban. All lepers brought to the attention of the Army were transferredthere. PCAU No. 25 furnished the necessary food and supplies and, later,the District Health Office assumed operation and control. Plans were madeto transfer all the patients to the Culion leper colony on Palavan Island.
Gastrointestinal diseases and parasitic worms.Infestationwas widespread throughout the area. People of nearly all ages had somedegree of anemia due to persistent infestation of parasitic worms. Thosewho were not acutely ill or recovering from illness were probably carriersof the various forms of gastrointestinal diseases-bacillary dysentery,amebic dysentery, and typhoid fever. Flies, contaminated water, neglectof hand-washing with soap and water, unsanitary preparation of food, lackof shoes, and direct fecal transfer between individuals were the chiefcauses of infestation.
Infant mortality. In some villages, the infantmortality rate rose as high as 40 percent. Causes of death, based on reportsby canvassers and by questioning the mothers, were the diarrheas of infancy,premature births, and obstetrical complications. The babies usually weredelivered in homes under unsanitary conditions with the assistance of neighborsand untrained midwives. Very few Filipino babies were delivered in hospitalseven when maternity care was provided.
Venereal diseases. Realizing the inevitabilityof a high venereal disease rate among military personnel on duty near populouscivilian areas unless drastic control measures were exercised, Army venerealdisease control officers conferred with the Tacloban Municipal Council.On the advice of these Army representatives, the council amended localcommunicable disease ordinances to include, under penalty of fine and confinement,isolation and treatment of venereal disease cases among civilians. Althoughprostitution was suppressed by Provincial law, the council, though notin agreement, judiciously elected to overlook the nuisance of a local "redlightdistrict." The district, established on the fringe of the business sections,flourished. As many as 40 women solicited, and Army visitors numbered upto 500 daily. Army representatives rigorously enforced venereal diseasecontrol measures and cooperated in laboratory tests and treatment. TheProvincial health representative examined prostitutes weekly at the localcivilian hospital. When the district proved to be offensive to neighbors,a hessian screen was erected.
Without warning, the Municipal Council directed the mayorto order the chief of police to arrest all prostitutes. Before this couldbe done, the "madame" closed her brothels and vacated the district, leavingthe Army with the task of locating the prostitutes and rendering treatment.
The Municipal Council, under pressure of some unenlightenedindividuals, voted to repeal the ordinance making venereal disease a communicable
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disease, subject to confinement. The matter was takento the Provincial Governor who adjudged that the Municipality had no authorityto repeal ordinances without approval from his office. This ordinance wasthe only instrument that could be used by the Army to control venerealdiseases among civilians.
The Public Health Service and the local police systemwere woefully inadequate to cope with the civilian contact problem. TheArmy formed a vice squad, composed of Army and Navy personnel, and actedon information supplied by military personnel who contracted a venerealdisease from civilian sources. Prostitutes were found in foodshops, emptybuildings, seashore shacks, and other places. After the "district" wasclosed, the military venereal rate rose more than 100 percent over theprevious month's rate. There was no method of determining the increasein the civilian rate.
Although venereal disease flourished, the Tacloban civiliangovernment showed its disinterest in the problem by suddenly closing acontrolled district and attempting to repeal the only instrument by whichcontrol was possible. It was unwilling to bring prostitutes and solicitorsquickly to trial, and did not provide sufficient jail space with sanitaryappointment for prisoners detained under the venereal disease and prostituteordinances. Little cooperation existed among members of the local governmentin carrying out planned venereal disease control. A strong educationalprogram was needed to explain the importance of treatment in the preventionof these diseases.
In summarizing the situation in Leyte with regard to communicablediseases, Major Hall emphasized the need for stricter observance of theexisting civil laws on the subject. Reporting was inadequate, almost nonexistent.Quarantine and isolation measures were not enforced. In outlying villageswhere medical care was inadequate, diagnoses for official reports in casesof death were made by ministers or civilian Public Health Department appointees.In many instances, no diagnosis was made; the corpse was simply buried.
Water supply.-In most areas, the water supply wasdependent upon shallow open wells. The water was undoubtedly contaminatedsince the ground water table had been subjected to massive deposits offeces for years. The people carried water from the wells in receptacleswhich varied from bamboo rods to salvaged tin cans. These containers, ofdoubtful cleanliness to begin with, often were set down in the muck, thenused to dip water from the wells, thus adding to the pollution of the water.Many homes had rainwater cisterns which were never clean since they remainedopen all the time and were contaminated by dirty dippers and passing animals.Several towns on Leyte had public water systems with pipeline service whichrequired rehabilitation before potable water could be made available tothe residents.
Disposal of garbage and refuse.-Under Philippinelaw, garbage and refuse collection and disposal were municipal functions.To protect the
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health of U.S. troops and to support the civilian publichealth program, however, Malaria Control Units provided cans for garbageand refuse and collection and disposal service for several municipalities.The Civil Affairs Section provided two trucks for Tacloban. Local officialswere expected to take over these duties eventually. In the more populatedareas, the only feasible method of disposal was by municipal collection.In less congested areas, disposal by burying or burning was feasible andadequate.
Restaurants and public food vendors.-Two purposesdecided the commanding officer of Base K to place all foodshops off limitsto military personnel-to reduce venereal diseases and to reduce gastrointestinaldiseases. The Preventive Medicine Officer of the Surgeon's Office had reportedthat foodshops were being used as introduction points for military personneland prostitutes. Not only were the prices exorbitant, but also there seemedto be no public awareness of cleanliness and no effective method of sanitarycontrol. As an example, dirty dishes and a dirty baby were seen being washedin the same water used in one of the foodshops. The order, placing allfoodshops off limits, while clearly displeasing to civilian authorities,did reduce the incidence of gastrointestinal diseases among military personnel.
Marketplaces and slaughterhouses.-Since U.S. Armyforces had commandeered the marketplace and slaughterhouse in Taclobanfor their own use during the early phase of the liberation, the civilianauthorities could not maintain even minimal sanitary standards for foodproducts in the makeshift locations they had to use. With no other accommodationsavailable, they slaughtered animals in backyards and empty lots, leavingentrails and other odorous remnants where they fell. When Base K returnedthe slaughterhouse to the municipality, the Civil Affairs Section providedtrucks to bring the meat to market and to carry away the refuse. Trucksof the Civil Affairs Section also carried livestock to the slaughterhouse.
Although representatives of the civil government requestedU.S. military authorities several times to return the marketplace to municipalcontrol, their requests were denied on the grounds of continuing militarynecessity. In the meantime, another marketplace would spring up next tothe municipal building. The municipal authorities and tradesmen disregardedsanitary codes, and the new, unplanned, and disorganized marketplace becamea festering sore of indescribable filth-a breeding ground for diseasesand disease vectors. Over the objections of the Provincial Health Officer,members of the town council closed their eyes to the alarming threat tothe health of the people. Representatives of the Base Surgeon informedthe councilmen that they must either close the marketplace or have it keptclean. The mayor then prevailed upon the vendors to clean it, and the U.S.Army command provided trucks for hauling away and disposing of the rottingrefuse. The municipal marketplace, which had concrete floors, adequatedrainage, latrines, and other sanitary facilities, was returned to municipalcontrol on 15 June 1945, thereby greatly alleviating this deplorable situation.
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Other municipalities in the area operated relatively cleanmarketplaces, having been instructed by the Malaria Control Units and thePhilippine Civil Affairs Units.
Comments and recommendations.-Summarizing the situationin the Province of Leyte, Major Hall wrote as follows:
Health propaganda by civilian agencies is almost completelylacking. Little or no effort by any government agency except the feebleattempts of the schools has been made to pursue a regular course of civilianeducation in health and sanitation matters. Like the father who insistson fixing his son's broken toy rather than telling him how or letting himdo it himself, so the army continues to do many things for the civilian-individuallyand collectively-rather than to show him how or let him do it for himself.This is an example of typical American impatience. One must not get theimpression that little or nothing has been accomplished in the line ofhealth improvement and health education here in Leyte-facts elsewhere inthis report prove otherwise. The army has done much to promote the feelingof need for "good health" and the desire for better living conditions amongthe people-the seed is planted-the Commonwealth Government must carry onwhere we have left off.* * *
In many cases the interest and cooperation of municipalofficers is evident, however their activity is generally unenergetic becausethey feel that in many cases the organization and funds for carrying onhealth work will cease almost simultaneously with the departure of thearmy. They know well that the number of army personnel and those employedby the army in addition to the almost unlimited equipment is impossibleto duplicate by the municipality and provincial governments to carry onthe work started. This condition is just as disheartening to the army personnelengaged in civilian medical activities as it is to the civilians who canrealize what is happening. Many have felt that it is actually cruel tocarry the health and medical work to such a high pitch and then have conditionsrevert to their former status. It is evident that certain supplies andequipment must be provided by the United States if the Filipinos are tobe expected to carry on. Unless these tools are provided, we must not betoo prone to condemn them, because neither could we accomplish our missionwithout the facilities at our disposal. To be honest we must admit thatwe have placed the government in an embarrassing position.
Ability and willingness are interdependent factors inhealth control and activities. A community may be very willing to supportan activity but lack the ability because of inadequate personnel, suppliesand funds. On the other hand the community may have the personnel, suppliesand finance enabling them to support the project but it isn't the natureof the people of that locality to be willing to expend the time and energyrequired to secure the necessary results. Examples of both cases are foundwithin the Base K area.30
Supplies
Instructions on distribution of civilian relief medicaland sanitation supplies were issued on 11 January 1945.31The furnishing of these supplies was limited to "emergency shelter, medical,sanitary and other essential supplies necessary to preserve lines of communication,to maintain the health and working capacity of the population, and to preservepublic order."32
30See footnote 23, p. 577.
31Letter, Headquarters, Advance Echelon to Commanding Generals of Sixth and Eighth Armies & USASOS, 11 Jan. 1945 (Annex No. 3), subject: Civilian Medical Installations and Supplies for the Philippine Islands.
32Circular No. 7, USAFFE, 13 Jan. 1945, subject: Civil Administration and Relief of the Philippines.
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As has been mentioned previously, when medical installationswere turned over to the Government of the Commonwealth of the Philippines,the Civil Affairs Section, USAFFE, had no further responsibility than thatof assisting the Government to secure relief medical supplies.33Accordingly, the Supervisor of Hospitals ofthe province was granted authority by Dr. Rotor, as of 3 February 1945,to requisition, receive, and sign for medical supplies and equipment turnedover by the U.S. Army for use in hospitals and dispensaries. After 18 April,the Supervisor of Hospitals continued to requisition supplies for hospitals,and the District Health Officer, for the municipal dispensaries.
Procedure.-In January, a letter from Advanced Headquarters,USASOS, indicated that thereafter civilian relief supplies were to be storedseparately by the respective services concerned until they were issued,and that separate stock records for relief supplies were to be kept bythe Depot Commander concerned.34Medical stocks, therefore, were transferredfrom the Base K quartermaster to the medical supply service, 34th MedicalSupply Depot Company.
Up to this time, no provision had been made to resupplycivilian medical relief supplies for Base K, and the original supplieswere so drained by continual PCAU requisition that the stock levels becamecritically low. Arrangements for replenishment were made eventually throughthe Eighth U.S. Army Civil Affairs Section.
Summary.-It is impossible to determine the actualquantity of civilian relief medical supplies distributed in the Base Karea. Accurate accounting of issue was maintained by the 34th Medical SupplyDepot Company, but this does not give a breakdown of supplies issued foruse in the Base K area alone. From certain available records which indicatethe quantity of medical supplies issued to civilian medical installationsin Base K by PCAU's and through the Base Civil Affairs Section, it is clearthat a large tonnage of medical supplies was distributed for civilian usein Base K.
The problem of civilian medical supplies was not generallyunderstood or handled satisfactorily by the U.S. Army. Advance planningdid not consider the whole civilian medical problem. The original intentionwas to inaugurate a program which would be supported adequately by a continuousflow of medical supplies until such time as the Commonwealth Governmentwould have access to normal commercial resupply agencies. The intricaciesof supply and resupply mechanisms required closer official liaison betweenthe Commonwealth Government and the U.S. Army.
Disposition of Civilian Patients
Civilian patients, other than U.S. Government employees,in military hospitals who required extended hospitalization were movedto civilian hos-
33Memorandum, Headquarters, Advance Echelon, USAFFE, to Commanding Generals, Sixth and Eighth Armies and USASOS, 11 Jan. 1945, subject: Civilian Medical Installations and Supplies for the Philippine Islands.
34See footnote 23, p. 577.
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pitals as soon as possible. Arrangements for their transferwere made with the base commander concerned.35
During the first few months after the liberation of Leyte,commanders of U.S. military hospitals experienced considerable difficultyin disposing of discharged civilian patients. Provisions for their dispositionproved to be inadequate, and some lingered in hospitals for as long asa month after their discharge before they were returned to their homes.
This problem was solved eventually but would have beensimplified by the issuance of a clear-cut statement authorizing bases toreturn, by the first available military transportation, civilians (nonmilitary,employees, and nonemployees) to the bases from which they had been originallyreceived. Undue hardships were imposed on released patients by the delayin securing transportation to their home areas.
Civilian Medical Personnel
Employment by the U.S. Army.-One of the dutiesof the PCAU medical officer was to obtain information as to the availabilityof local physicians, nurses, school teachers, midwives, pharmacists, andqualified assistants. He was further directed to allocate and coordinatethe activities of local physicians and nurses employed by PCAU's for thecare of the civilian population. Physicians, dentists, nurses, and pharmacistswere employed by the U.S. Army only if they were licensed to practice inthe Philippine Islands. In the Province of Leyte, no local agency, militaryor provincial, was able to compile a list of available civilian medicalpersonnel.
During February 1945, a plan, requested by the CommonwealthSecretary of Health and approved by the Chief Surgeon, USAFFE, was developedfor employing civilian physicians as "residents" in Base K general hospitals.Several young Filipino physicians enrolled for the 4-month refresher coursein general surgery and were most enthusiastic about it. Although they askedthat the course be extended, it was decided to place them at once in positionswhere they could serve the overwhelming civilian medical needs.
Private practice.-On occasion, it was found necessaryto draw attention to the regulations of the Commonwealth and of the PCAU'swhich forbade the private practice of physicians employed by these agencies.Patients were sometimes neglected because of the time the physicians wereexpending for private fees. This situation developed because of the lowsalary scale for doctors. The rates were based on the actual salaries paidby the Commonwealth Government,36but, even allowing for their limited professional training and local economicconditions, the salaries were inadequate. These low rates of pay tendedto attract only less qualified personnel to Govern-
35Regulations No. 50-25, Headquarters, USASOS, 15 Feb. 1945, subject: Medical Department-Hospitalization.
36Letter, General Purchasing Agency, USAFFE, to Commanding General, USASOS, and Commander, Service Forces, Seventh Fleet, 13 Apr. 1945, subject: Classification and Rates of Pay of Civilian Medical Personnel.
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ment positions and encouraged them to look for additionalsources of income.
Private practice by physicians, except for consultationand administration of homemade remedies, was almost entirely preventedby the lack of drugs and other medical supplies and equipment.
Technicians.-Few civilians were trained and qualifiedas medical technicians by Army standards. A plan was developed, therefore,to train selected personnel in local U.S. Army medical installations (fig.79). Individuals with high school training were selected for both theirenthusiasm and previous training and were placed in military installationsas laborers. When they could be spared from their regular work, they weregiven special opportunity to receive instruction in technical subjects.A dental laboratory technician, several medical laboratory technicians,and an X-ray technician were trained efficiently by this method. Undersuch special instruction, it was found that civilians spent many extrahours at work, did not shirk, and showed special interest which would nototherwise have been aroused.
Nurse's aides.-To establish a coordinated civilianservice in military hospitals and afford an opportunity for civilian womento receive training in basic nursing techniques, a "Nurse's Aide TrainingCourse" was organized in five major hospitals of the base. The course wasstarted at the 73d Field Hospital on 28 February 1945. Enrollees were givena thorough physical examination, including blood tests. In the five hospitals,110 young women were accepted for training in classes of 20-25 students.In one hospital, the aides were provided with both quarters and subsistence;in the other four, they were provided only with subsistence. They weregiven a minimum of 34 hours of class instruction followed by a writtenexamination. Those who successfully passed the 3-month training periodwere awarded a certificate. The first class graduated on 28 May 1945. Fromboth a training and assistance standpoint, this program was successful.Not only did these young women render valuable service, but also they learnedbasic nursing techniques and standards of cleanliness and efficiency. Unfortunately,the plan received a serious blow when the GPA (General Purchasing Agency),USAFFE, announced a wage scale so low that the course offered little attractionother than the certificate of efficiency awarded upon completion of thecourse. The nurse's aides were an integral part of a hospital personnelplan; to attract a high type of civilian personnel, the wage rate shouldhave been at least equivalent to the average rate being paid for similarwork in allied services. The base surgeon recommended that the wage ratefor trained nurse's aides be equivalent to the skilled clerical rate orto a rate paid to skilled laborers in a semihazardous occupation.
Drugs, Pharmacies, and Pharmacists
A few civilian pharmacists were employed through PCAU'sin the hospital dispensaries and some of them were retained in the sameservice by the Commonwealth Government. By July 1945, however, 15 to 20pharma-
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cists still were unemployed. Since the sale of reliefmedical supplies and equipment to individuals was prohibited, the absenceof pharmacies for civilian use precluded private practice by both pharmacistsand physicians. It was feared that the remaining stock of relief medicalsuppliesallotted to the area which was to be turned over the CommonwealthGovernment would be inadequate until the normal commercial flow of drugsand medical equipment could be resumed.
Occasionally, drugs intended for the use of the CommonwealthGovernment were sold for the treatment of patients by private practitioners,or for commercial resale. Some civilians also "begged" drugs from the Armymedical units on the basis of urgent need. Some of these drugs also reachedthe black market. The Supervisor of Hospitals and Dispensaries warned allphysicians that these were punishable, felonious acts. All medical unitswere notified to refuse unauthorized requests for drugs.
Occupation of Cebu, Samar, Mindanao, and Mindoro, 1945
Resisted landings were made on Cebu, Samar, Mindanao,and Mindoro. The pattern of civil affairs activities was much the sameas on Leyte.
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PCAU's went in with the invasion forces; medical unitssupporting tactical forces were responsible mainly for the care of civiliancasualties during the early combat phase, and malaria survey and controlunits assisted in developing civilian health service for the occupied areas,particularly those with large concentrations of occupation troops.
PCAU No. 9, for example, was located at San José,Mindoro, and was administratively responsible for the entire island andalso the nearby small islands of Marinduque, Tablas, Romblon, and Cuyo.Sanitary regulations were promulgated and put into effect through inspectionsby appointed civilians. Atabrine prophylaxis was administered to severalthousand civilians, and approximately 4,500 civilians were inoculated withtyphoid, dysentery, and cholera vaccines. Ten civilian dispensaries andthree hospitals were organized and kept fairly well supplied with medicinesand other items. Nearly 40,000 civilians received treatment in these facilitiesduring the 3-month period from April to June 1945. The hospitals and dispensarieswere staffed entirely by Filipino physicians and nurses appointed by thePCAU.37
Cebu.-As with other units, the mission of the medicalsection of PCAU No. 15 on Cebu was to organize medical installations forcivilian care to relieve Army medical units of that burden. Immediatelyafter landing, they set up an emergency civilian hospital at Pardo, adjacentto one of the field hospitals attached to the Americal Division. Civiliancasualties, cared for initially in the military hospital, were transferredpromptly to the emergency civilian installation. A few days after the invasion,the civilian hospital was moved to Cebu City and installed in one of thedormitories of San Carlos College; it ultimately became a 250-bed hospital,and preliminary steps were taken to organize it as a permanent governmenthospital. Eventually, an extensive system of dispensaries and civilianhospitals was established with a Filipino staff.
The Eversley Childs Leprosarium located at Mandawe wasgiven prompt PCAU relief, which led to the return of many of the leperswho had wandered off during the Japanese occupation.
Sufficient medical supplies to carry out the civilianprogram for 10 days accompanied the unit during the invasion; it was unnecessaryto call on the Medical Supply Officer of the Americal Division during thisperiod. Later, there was some delay in obtaining medical supplies sincethe original plan was to obtain them from the Division Medical Supply Officer,but this procedure was altered by an Eighth Army directive which requiredthat all PCAU medical supplies be requisitioned from Base K in Leyte. Thescarcity of medical supplies was alleviated by the use of captured Japanesemedical materials.38
Samar.-Mopping up operations were conducted byelements of the
37Report, Capt. Harold Grubin, MC, PCAU No. 9 Surgeon, 1 July 1945, subject: Medical History Report (Second Quarter).
38Report, Maj. Julian Wolff, MC, PCAU No. 15, 3 July 1945, subject: Quarterly Report for History of Medical Activities.
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Americal Division (X Corps). The civilian population wasfound to be fairly well cared for by small civilian hospitals adequatelystaffed by Filipino doctors and nurses.
Mindanao.-The 24th and 31st Infantry Division (XCorps) invaded the island of Mindanao near Parang on 17 April 1945. Atfirst, military casualties were light and civilian casualties offered noproblem. Later, however, both the 24th and 31st Divisions suffered heavycasualties.
PCAU No. 29 went ashore with the initial task force ofthe 24th Division on 17 April. Since civilian casualties were few, themedical section of the unit began its program by opening a dispensary inSanta Cruz, staffed with Filipino personnel, to care for civilians whohad returned from the hills and who were in need of food and medical attention.Later, the unit entered Davao and found that all four civilian hospitalshad been destroyed by heavy shelling. Within 2 weeks, one of these hospitals,with the aid of the Engineer section, had been repaired to the extent thatsome patients could be accepted. To cope with a continuing influx of liberatedFilipinos from the surrounding areas, a second hospital, the Davao GeneralHospital, with a bed capacity of 120 patients, was opened in an old constabularybarracks. A third hospital, with a bed capacity of 500, was opened in thecity of Davao by 1 July 1945. In addition, 10 dispensaries, each with aninpatient capacity of eight to 20 beds, were established in various partsof the island, mainly for the treatment of ambulatory patients.
Within 2 weeks after PCAU No. 29 reached Davao, the formercity health personnel had been located and the health services reestablished.Army Engineers established water points for civilians. The unit also begana venereal disease control program in an effort to stem the rising venerealdisease rates in military personnel. No epidemic of infectious diseasesoccurred. The total population under this PCAU's medical supervision wasapproximately 100,000, living in an area of 2,000 square miles. Approximately10,000 patients were treated weekly in dispensaries and 1,200 were in hospitals.
PCAU No. 23 was attached to the 41st Infantry Divisionwhich invaded Mindanao in the vicinity of Zamboanga on 10 March 1945. Headquartersof the medical detachment of the unit was established on the grounds ofthe Zamboanga General Hospital. Civilian medical personnel were plentifulin the area, and altogether 42 dispensaries and four hospitals for civilianswere maintained under supervision of the unit. The City Health Departmentcontinued to function with its regular personnel under the same supervision.39
Comments on the Leyte Operation
The principal need of the people was for clothing, shoes,and useful household articles. Some deficiencies in the items brought toLeyte became apparent. The sizes were too large, many shoes being sizes10 and 11,
39Report, Maj. John H. Graves, MC, PCAU No. 23, 4 July 1945, subject: Medical Historical Report.
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and there were not enough women's and children's garments.Some items were superfluous or were not adapted to normal civilian use.For instance, the people could not buy or use the 4,000 rattraps or therolls of toilet paper; nor would they accept canned or powdered milk. Themeat items came packed in 6-pound cans, a quantity that could not be usedat one time by the average Filipino family. In addition, the Filipinospreferred dried or canned fish to beef, so that canned meat was rarelypurchased. These items were frequently substitutes dictated by necessity;however, every effort should have been made to afford a basic ration andminimum clothing better suited to customs of the Filipino people.40
A tabulation shows that 10,000 tons of relief supply itemswere landed and 6,830 tons were distributed. A total of 1,102 tons of ricealone was sold or given away. More than 400,000 refugees were fed gratis,and 287,000 needy were cared for. By late December, the relief rolls werereduced to the aged, the infirm, and those families without a breadwinner-some2,500 families.
The relieving civil affairs units of the Eighth U.S. Armydid not land until 26 December 1944. By informal agreement with the EighthU.S. Army, the Sixth U.S. Army PCAU's remained in place and continued theirmissions under Eighth U.S. Army's operational direction. To attain thecontinuity of effort and to orient the relieving units, PCAU's Nos. 1 to8 remained under Eighth Army direction until the last possible moment beforeleaving for the Luzon operation. PCAU's Nos. 1 and 2 were relieved on 28December 1944, and the remaining six units 2 days later. The units thushad only the minimum of time in which to draw supplies and equipment andto move to their loading positions.
The relief went off smoothly. More than adequate storeswere left to the Eighth U.S. Army. Its civil affairs staff was fully informedas to the situation and the methods developed by Headquarters, Sixth U.S.Army.
The success of civil affairs activities during the Leyteoperation proved that the original plans were basically sound and thatPCAU training was adequate. The performance of all units was good, andthat of PCAU's Nos. 5, 7, and 8 was outstanding.
At the close of the period (25 December 1944), all areaswithin reach of the Sixth U.S. Army, with the exception of Ormoc-Palompon,were functioning normally in all civic activities. Order was excellent;health service and health conditions were probably above prewar levels;and the trade of the people, always limited, was substantially restored.
No person is believed to have starved or died for wantof medical assistance during the period of our operations. Adequate civilianlabor was at all times secured for the troops. The local government andschools were restored, and commerce was started on its way to normal activity.Tested by these standards, it can be said that the civil affairs unitsin the Sixth U.S. Army performed the mission given them by GHQ instructions.
40See footnote 15, p. 572.
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Experience in the Leyte operation showed that PCAU's attachedto assault divisions should go ashore early, and definitely not later thanD + 2. At Dulag, for example, the populace, in seeking to escape the enemy,concentrated behind our lines and seriously interfered with the militaryeffort. This could have been prevented had the PCAU's been landed earlier.
The landing of civil relief supplies should have beenassigned a higher priority than was assigned in the Leyte Campaign. Merchandisehad practically disappeared from the open market, and the civilian laborerwas unable to purchase anything with his wages. This condition destroyedthe civilian's incentive to work and created a difficulty in securing anadequate supply of labor for the military units. Delayed landing of civiliansupplies also caused an excessive demand on quartermaster supplies to preventactual suffering among the friendly inhabitants.
Prescribed medical supplies of the PCAU's proved inadequate.Several of these units exhausted their supplies within 2 days after comingashore, and thus unduly burdened the medical units and facilities of allechelons of the Sixth U.S. Army. A minimum of 10-days' supply for the estimatedcaseload should have been prescribed for each PCAU.
The organic vehicles of the PCAU's proved insufficientto distribute supplies promptly from the base warehouses and dumps. Becauseof the demands of the tactical situation, it was rarely possible to supplementthis transportation from other sources. Provision should have been madefor establishing a pool of vehicles under Army control to transport suppliesfrom the base to supply points in the respective areas assigned to PCAU's;a platoon of a quartermaster truck company could have been used for thispurpose.
Training of PCAU's was completed only a short time beforetheir loading dates. PCAU's Nos. 4 to 8 were shipped directly from OroBay to the objective area. Their first contact with the units they weresupporting was made when they landed on Leyte. This situation did not contributeto smooth functioning for the combat units had little appreciation of theduties, capabilities, and limitations of the PCAU's. Ideally, PCAU's shouldhave staged with the units to which they were attached, and orientationconferences on civil affairs should have been held in the corps and divisions.
THE LUZON CAMPAIGN
Planning
Civil Affairs planning for the Luzon Campaign41involved four separate operations with landings at the followingpoints (map 19): Lingayen Gulf-9 January 1945; Subic Bay-29 January; NasugbuBay-31 January; and Legaspi-1 April. Two of these operations, the landingsat Lin-
41Reports of the General and Special Staff Sections, Sixth U.S. Army. Volume III, Reports of the Luzon Campaign, 9 Jan. 1945-30 June 1945, pp. 175-182.
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MAP19.-Luzon, Philippine Islands.
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gayen Gulf and Legaspi, were mounted by the Sixth U.S.Army, and the other two by the Eighth U.S. Army.
The Civil Affairs Section of Headquarters, Sixth U.S.Army, consisted of 10 officers, organized in three main branches-medical,operations, and supply-under a chief of section and his executive officer.Initially, 13 PCAU's were attached to the Sixth Army for the Lingayen landing;one additional PCAU was made available for the Legaspi landing.
Planning for the Luzon Campaign began early in November1944. Many of the PCAU's earmarked for Luzon were still on duty in Leyteas late as 31 December 1944, so that little detailed planning with theseunits was possible. Standing Operating Procedure No. 27, dated 15 November1944, was used as the basis of planning.42
Throughout the entire campaign, civil affairs administrationwas to be of the operational (combat) rather than the territorial type.Supply planning for Luzon was for an estimated population of 8 million;50 percent of the population were expected to require assistance for 90days. Class I supplies aggregated 55,470 tons, the medical supplies beinga part of 7,000 tons which included clothing, shoes, cloth, soap, kitchenutensils, and hardware. Each PCAU was to land on Luzon with 10 tons ofrelief supplies, of which 1 ton was to be medical supplies.
The operational plans were essentially the same as thoseused for the invasion of Leyte; and in the combat phases, conditions encounteredon Luzon were similar to those encountered on Leyte. Except during thefirst few days, there was a shortage of PCAU's throughout the campaign.Despite the fact that PCAU coverage was entirely lacking for only briefperiods in any area, the total coverage nevertheless was inadequate becauseof the density of the population. A total of 61 PCAU's attempted to administeran island of 6.5 million people; the average population served by eachPCAU on Luzon was nearly seven times as large as those served on Leyte.
Influence of Tactical Situations on Civil Affairs Health Activities
As in most campaigns, the tactical situation differed from one unit to another and from one time to another in the same unit. For example, I Corps encountered stubborn enemy resistance in northwestern Pangasinan Province and moved slowly while XIV Corps moved rapidly through the central plain toward Manila, thus bringing large areas of Luzon under nominal control of PCAU's.
Because of the rapidly shifting tactical situation, Corpsboundaries changed quickly, necessitating frequent movement of PCAU's tomaintain coverage. With the rapid advance of XIV Corps through the centralplain, the liberated areas became too large for three PCAU's; three additionalunits (Nos. 6, 20, and 21) from Army reserve were assigned so that theoriginal units (Nos. 1, 2, and 8) might keep up with their divisions.
Plans for the administration of Greater Manila calledfor its division
42See footnote 11, p. 568.
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into eight zones with the assignment of one PCAU to each;these units were PCAU's Nos. 1 and 8 (of the XIV Corps); Nos. 4, 5, 6,20, and 21 (from Sixth Army reserve), and No. 27, which landed with XICorps at Subic Bay.
The systematic razing of towns and villages by the Japanesesouth of Manila created an unprecedented refugee problem and necessitatedthe shift of PCAU No. 2 to Laguna de Bay section. No PCAU had been attachedto the 11th Airborne Division for its operation at Nasugbu, and not untilsometime after the initial landing was PCAU No. 11 made available fromMindoro. Protracted fighting east and northeast of Manila made necessarythe detachment of PCAU No. 19 from I Corps and its reassignment to XI Corps.
These changes give some idea of the organizational andliaison problems confronting these civil affairs units. It is not surprisingthat, in the health field, liaison was inadequate and often ineffectivebetween the PCAU's and the surgeons of the tactical forces on the one hand,and the surgeons of the communication or base commands on the other.
Health and Medical Problems
After 3 years of Japanese occupation, much of Luzon'spublic health service had ceased to exist. Acute and chronic malaria, tropicalulcers, malnutrition, dysenteries, and tuberculosis were prevalent. Bythe time of liberation, many hospitals had been destroyed or looted oftheir supplies and equipment.
Civilian combat casualties added to the heavy medicalload normally present in most communities. Although the majority of civilianshad fled the path of some combat operations in response to our airdroppedwarnings, the rapid advance in other sectors produced many civilian battlecasualties. These casualties were in addition to those resulting from tamperingwith explosive projectiles and hand grenades, and bayonet wounds inflictedby the Japanese.
Throughout the campaign, all major surgery and, in theinitial phase of liberation, other types of health and medical serviceswere carried out by Army medical units. The first civilian medical serviceswere usually those afforded through dispensaries established and sponsoredby PCAU's. Immediately upon arrival in an area, a PCAU selected a location,hired medically trained personnel, provided medical supplies, and openeda dispensary for the treatment of the sick and wounded. Altogether, 185such dispensaries, operated under the supervision of PCAU's, gave approximately1,674,000 individual treatments.
The reopening of the former government hospitals and oftenthe opening of new hospitals followed closely upon the establishment ofdispensaries. Under PCAU supervision, buildings were repaired, beds wereconstructed, staffs were reassembled, and supplies and equipment were furnished.Considerable difficulty was experienced in providing a satisfactory hospital
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diet as there was a shortage of relief supplies. Militaryhospital rations could not be drawn for civilian hospitals. In the areasadministered by PCAU's, in addition to the military hospitals, there were45 civilian public hospitals where there had been only 15 before the war.
Measures to reestablish sanitary facilities were inauguratedwith the assistance of Engineer officers and Malaria Survey and ControlUnits. Latrines were constructed, wells repaired, garbage disposal provided,and programs of mosquito control (fig. 80) and health education instituted.To the extent that the supplies were available, vaccinations against smallpoxand typhoid were given. The government Serum and Vaccine Laboratory wasreopened under PCAU supervision, and a unit for clinical and public healthlaboratory services was established.
The medical supplies initially available were those mobile-loadedon PCAU transportation. Included for each PCAU was approximately 1 tonof dressings, sulfonamides, human plasma, and morphine. Despite procurementof some emergency supplies from medical supply stocks, there were seriousshortages of many items, especially anesthetics and tetanus antitoxin.
Civil Affairs basic medical units did not arrive untilabout3 months after the landings on Luzon. Many itemsin the basic medical units were not well adapted to the needs of the Philippinepopulation.
A serious shortage of organic transportation increasedthe difficulties of delivering medical supplies and of supervising thewidely spaced dispensaries. No satisfactory means of evacuation of civiliancasualties to civilian medical installations was available until earlyin February when one ambulance was issued to each of seven PCAU's.
The general lack of electric power, running water, gas,and sewerage systems added to the difficulties in operating civilian hospitalsduring the early phases of liberation. Many surgical operations were performedby candlelight and flashlight.
Special problems were created by large numbers of refugeeswho streamed out of combat areas, and it was frequently necessary to establishrefugee camps and to provide essential medical services and hospitalization.
In Manila, there was confusion as to the responsibilityfor civil administration both before and after liberation. Sixth Army hadthis responsibility initially, but it was supposed to revert promptly toGeneral Headquarters; Civil Affairs officers had no authority to appointofficials. PCAU No. 5 was designated to assist in the care of interneesat Santo Tomas University. The other seven PCAU's moved into the clearedportion of the city at an early date but waited until such time as theycould take over their specific assignments.
In the early phase of the liberation of Manila, PCAU'shandled more than 20,000 refugees a day; as many as 45,000 were fed insoup kitchens in 1 day. During February, when the PCAU's were under theSixth Army, more than 5,000 individual bed patients were handled in civilianhospitals,
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and about 99,000 treatments were given in dispensaries.Before relief ships were unloaded in Manila Bay in March, all relief supplieswere brought by truck from Lingayen Gulf; fortunately, a considerable amountof captured Japanese medical supplies was available for the civilian medicalservices.
On 2 March 1945, USAFFE relieved the Sixth U.S. Army andassumed full responsibility for administration of both civil affairs inManila and for PCAU's Nos. 1, 4, 5, 6, 8, 20, 21, and 27.
Assault Phase in the Lingayen Gulf
The initial assault waves of the U.S. I Corps and XIVCorps encountered little enemy resistance as they went ashore on 9 January1945, following heavy naval and air bombardment of the beaches and theirland approaches. Since our own military casualties were light, the evacuation,field, and portable surgical hospitals in support of our troops could handlethe many civilian casualties without difficulty. The Surgeon of the XIVCorps reported as follows:
Several hundred civilian Filipinos were wounded as theresult of the three day preliminary bombardment of the beaches and adjacentareas prior to the landing. The ma-
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jority of the large buildings were destroyed or badlydamaged. What few medical supplies that had been in the hands of civilianphysicians were also destroyed.
Because of the few Army admissions to clearing stations,it was possible to provide hospitalization and emergency medical care tocivilians, in division and shore party clearing stations. Civilian physiciansand nurses were hired through PCAU to assist Army personnel in the careof civilian casualties.
On the afternoon of 10 January 1945, civilian casualtieswere evacuated from division clearing stations to companies A and C, 264thMedical Battalion, in order to free them for possible movement inland.
During 11 and 12 January, civilian casualties were transferredto the 24th Field Hospital from Company A, 264th Medical Battalion, andto the 894th Clearing Company by Company C, 264th Medical Battalion. The24th Field Hospital thereafter received civilian casualties in the 37thDivision sector, and the 894th Clearing Company received those in the 40thDivision sector, until such time as improvised civilian hospitals underPCAU control were able to assume such hospitalization responsibilities.43
The XIV Corps moved rapidly toward Manila, but I Corpsencountered stiff resistance on the northern flank. Typical was the experienceof PCAU No. 18, which landed on S + 2 in support of I Corps. Its firstmission was in the town of Mangaldan, about a mile inland from the beaches;here, with the help of Army medical units, it dealt with a large numberof civilian casualties. A 100-bed civilian hospital was established within48 hours and staffed with Filipino doctors and nurses; this hospital handledthe less severely wounded civilians and received patients from Army hospitalsimmediately after major surgery. Within a few days, dispensaries were organizedin neighboring villages to relieve pressure on the hospital in Mangaldan.
A 75-bed hospital was established in the vicinity of Villasisto care for civilian casualties; major surgery for civilians was carriedout in Army hospitals. Cooperation between Army and civilian hospitalswas close; by 31 March, PCAU No 18 was supervising eight hospitals and20 dispensaries which, together, were caring for about 3,500 civiliansdaily.44
MANILA
Civil Affairs Plan
The Civil Affairs plan for the city of Manila and itssuburbs was contained in a letter of instruction from General Krueger,Commanding General of the Sixth U. S. Army, to the Commanding General ofthe 37th Infantry Division; the 37th, upon the occupation of Manila, wasto be detached from XIV Corps and become responsible directly under SixthU. S. Army Headquarters for the civil government of greater Manila.45
Eight PCAU's were to be made available, together withcertain spe-
43Report, Col. Robert E. Allen, MC, Surgeon, XIV Corps, to Surgeon, Sixth Army, 17 Apr. 1945, subject: Quarterly History of Medical Activities.
44Report, Maj. Donald H. Anderson, MC, PCAU No. 18, 31 Mar. 1945, subject: Medical History, Quarterly Report.
45Letter of Instruction, Commanding General, Sixth U.S. Army, to Commanding General, 37th Infantry Division, 5 Feb. 1945.
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cial headquarters personnel. Lt. Col. Albert M. Dashiell,MC, of Headquarters, Sixth U.S. Army, and one other officer, with two enlistedmen, were detailed to the 37th Division as Surgeons and were immediatelyresponsible for medical affairs in the city. Also available were one sectionof the 26th Medical Laboratory, two malaria control units, one malariasurvey unit, one medical clearing company, and one medical supply platoon.Medical care and sanitation were to be the responsibility of these unitsand personnel. Civilian hospitals were to be opened and civilian doctorsand nurses were to be employed as early as possible. Initial medical supplieswere to move forward with the attached units and resupplies were to beobtained from Army Medical Supply points and from captured stocks. A separatedetachment was detailed to give prompt attention to the 3,800 interneesat Santo Tomas University.
Civil relief.-Although the nature and full extentof civilian distress in Manila would depend upon the final enemy action,in the light of known conditions, approximately 200,000 inhabitants wereestimated to need immediate relief, and many others would be near starvation.During the initial phase, immediate objectives would be to provide directrelief in food, medical care, and shelter; to obtain labor, clerical, andprofessional assistance to aid the military and to develop civilian groupsto further relief; to maintain order, in conjunction with The Provost Marshal;and, with the Engineers, to restore emergency public utilities.
To accomplish these tasks, the Civil Affairs Officer wasto act as Director of Civilian Relief, and the eight PCAU's were assignedresponsibility for specific districts in which they would set up theirown headquarters and establish subdistricts as required. They were to followtheir normal operating procedure and employ all necessary doctors, nurses,medical technicians, relief workers, clerks, messengers, and laborers.Cooperation was expected from the civilians. PCAU No. 5 would act as Headquartersfor the units. Two quartermaster truck companies, under control of theTransportation Officer, would haul supplies for civilian relief into Manila.
With a view to the early assumption of responsibilityby the appropriate agencies of the city of Manila and the Philippine Commonwealth,the Director of Relief was to form an Advisory Council. This council, composedentirely of civilians, would represent the following activities: Healthand Sanitation, Labor, Food and Shelter, American Red Cross, PhilippineRed Cross, Utilities, Commerce, and Finance. Full use would thus be madeof the knowledge and experience of these residents of Manila. They wouldbe consulted and kept informed of developments. Their function was to bepurely advisory; the Sixth Army was responsible for administration of CivilAffairs in the city.
Supply.-Each PCAU was prepared to enter Manilawith its prescribed load of 10 tons of relief supplies. The Fred Galbraith,a relief supply ship, was waiting in the Lingayen Gulf with 7,000 tonsaboard; and two
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other ships with 1,500 tons each were expected shortlyin the Luzon area. Additional supply ships were loading or were en routeto the Southwest Pacific area. Supply dumps would be established in thecity of Manila as directed by Transportation and Civil Affairs representatives;one of these would probably be near the depot of the Manila Railroad Co.
Medical Plan
Hospitalization.-Three 400-bed Evacuation Hospitals(the 71st, 29th, and 54th) were to be moved to Manila by the Sixth U SArmy to support the XIV Corps, and to be established in suitable areasfor the prompt care of battle casualties. It was anticipated that theywould be able to care for a limited number of internees requiring hospitalization,but not for civilian casualties.
All possible assistance was ordered to be given to civilianhospitals to enable them to continue to operate and to increase their capacity.Every effort was also to be made to help inoperative civilian hospitalsto reopen. Evacuation routes to Army hospitals at Fort Stotsenburg, Tarlac,and Guimba were planned.
Care of liberated internees.-The 893d Medical ClearingCompany was ordered to Santo Tomas to classify the internees. Those whorequired hospitalization were to be cared for in Army hospitals. If thenumber of insane was high, such cases were to be treated in civilian hospitalsusing Army medical officers and civilian nurses secured through the ManilaHealth Department. Those who needed home care with outpatient medical attentionwere to be released to the Civil Affairs Section with the request thatthey be housed where medical care could easily be provided. Those who requiredonly domiciliary care were to be released to Civil Affairs for this care.
Rehabilitation of health and sanitary facilities.-On1 March 1945, the Chief Surgeon, HQ, USASOS, assigned Col. Maurice C. Pincoffs,MC, as director of the Manila Department of Health. He was instructed tocoordinate civilian health activities. These included the reestablishmentof the Manila Health Department so that sanitary inspections, health clinics,visiting public health nursing, and municipal hospitals might resume activitywithout delay; the provision of laboratory examination of water, milk,and foodstuffs, and serum agglutination for the diagnosis of infectiousdiseases; arrangement for the continued functioning of private and church-supportedhospitals for the care of civilian patients and for the opening of suchhospitals as were inoperative;initiationof quarantine proceedings for the control of contagious disease and immunizationsnecessary for epidemic control; and the resumption of collection and preservationof vital statistics. Also, he was to advise the Commanding General, 37thDivision, as to sanitary and communicable disease hazards within the cityas they were likely to affect American troops.
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The Combat Phase
The plan for the city of Manila and its suburbs to beadministered by eight PCAU's was put into effect during the initial periodof occupation. While each PCAU had a medical officer on its staff, therewas no coordinating Surgeon to whom these officers could look for an overallplan. Medically, each unit was on its own during the initial phase, whichlasted from 3 February until the control of health matters among the civilianpopulation became the responsibility of USAFFE on 2 March 1945. The fanaticalJapanese defense of Manila led to great destruction of the city.
Colonel Dashiell and Capt. Huron L. Vaughan, SnC, weredetached from Sixth Army Headquarters as part of a special staff assignedto XIV Corps for the emergency rehabilitation of Manila. While their dutieswere not clearly defined, their primary mission was to rehabilitate thehealth department and governmental hospitals to restore a public healthsystem. The PCAU's, meanwhile, were to provide medical care for the sickand wounded. Civilian medical facilities were believed to be adequate forthe civilian population, provided the Army issued medical supplies to PCAUSurgeons for distribution to their districts as needed. Since no Army hospitalscould be spared, none was detailed specifically to care for civilians inManila. Civilian internees liberated from Santo Tomas University and BilibidPrison and needing hospital care were sent to one of three evacuation hospitals.The 29th, 54th, and 71st Evacuation Hospitals were supporting XIV Corps,and they played no other role in caring for civilians.
The medical units assigned to assist the civilian medicalprogram were selected to provide technical service or transportation tocover anticipated civilian deficiencies. The units included the 26th MedicalLaboratory (Army), the 55th Medical Supply Platoon (Avn) (later replacedby the 15th Medical Supply Platoon on 16 February 1945), the 7th and 10thMalaria Control Units, and the 26th Malaria Survey Unit.
On 6 February 1945, Colonel Dashiell, accompanied by theG-4 and Transportation representatives, opened an office at 1955 RizalStreet, from which to administer a civilian health program. The followingday, the medical supply depot was established in an abandoned twine factoryon Aragon Street and began to issue medical supplies. The two malaria controlunits and the malaria survey unit were quartered in the same factory. On7 February, the 26th Medical Laboratory took over the laboratory at theSan Lazaro Hospital and opened for business the next day.
The civil affairs health problems of this early phaseare well described in a report by Colonel Dashiell:46
Due to the Japanese policy of destruction of Manila andatrocities committed against civilians by Japanese troops the civilianmedical facilities were unable to function in the manner that had beenexpected. Many hospitals were destroyed and civilian casualties were heavy,particularly from the destroyed area south of the Pasig River. Inas-
46Quarterly History of Medical Activities, Sixth U.S. Army, SWPA, 16 July 1945, Enclosure No. 3: Report of Rehabilitation of Civilian Health and Medical Facilities [in Manila], 28 Feb. 1945.
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much as the major surgical facilities were in the southarea, particularly in the Philippine General Hospital, it was necessaryto convert various institutions in north Manila into surgical hospitalsalthough they were originally intended for other purposes. As an examplethe San Lazaro Hospital, the city communicable disease hospital, was loadedwith 1,300 civilian battle casualties. This institution, like all hospitalsin the occupied area, had been taken over by the PCAU unit in whose districtit was located. The staff had been placed on the PCAU payroll and the institutionwas furnished medical supplies by the Surgeon of PCAU 20. However, thestaff of this institution was untrained in surgery and by 15 February itwas apparent that this staff was overwhelmed by the magnitude of the surgicalload thrown upon it. Meddlesome surgery was being done such as sewing upold infected wounds; thus increasing the risk to the patient. It was apparentthat a reorganization of this hospital was imperative. I requested of Lt.Colonel Meader, commanding officer of PCAU 20, authority to place MajorW. D. Tigertt, MC, commanding officer of the 26th Medical Laboratory, incomplete control of the San Lazaro Hospital. This was done at once. MajorTigertt accepted the responsibility and began the reorganization. TrainedFilipino surgeons were brought in from the outside and two U.S. Army surgicalteams were secured upon application to the Surgeon Sixth Army. The improvementin the institution from that time up to the present has been spectacular.Principles of war surgery were inculcated in the staff and the level ofcleanliness and efficiency in the care and feeding of the patients improvedbeyond all expectations. The service rendered by Major Tigertt has beensuperior and was carried out in addition to his regular duties as laboratorycommander and Manila epidemiologist. A somewhat similar measure was carriedout at the Psychopathic Hospital at Mandaluyong, this institution beingconverted into a surgical hospital for the care of patients evacuated fromthe Philippine General Hospital and other casualties from south of thePasig. Major Grounds from XIV Corps Surgeon's Office assumed supervisionover the institution and surgical teams were procured from the 54th EvacuationHospital. Personnel of the 26th Malaria Survey Unit assisted in sanitationwork in the area. Surgical personnel from the Philippine General Hospitalwere concentrated in this hospital with the idea of taking over from theAmerican surgical teams.
Regarding the critical medical supply situation for civiliansin Manila, Colonel Dashiell had this to say:
Medical Supply for civilians was taken from Army stocksand issued to PCAU Surgeons at the same depot from which army units weresupplied. No large stock level has been accumulated due to the heavy civiliandemands and the increasing number of army units which have drawn from thedepot. It was necessary to assure that army units were supplied and todistribute supplies to PCAU units on the basis of actual needs on a dayto day basis. This office kept the depot informed as to areas of casualtydensity in order that the PCAU units serving those areas should have specialallowances of medical supplies within the limits of depot stocks. It soonbecame apparent that the Commanding Officer of the 55th Medical SupplyPlatoon was unequal to this complex task. This unit was relieved by the15th Medical Supply Platoon commanded by Captain Messina, MAC. This officerhas displayed remarkable ability to "stay on top" of the situation andmake an equable distribution of available medical supplies. It should bepointed out that no "civil relief" medical supplies have yet reached Manilaand all supplies have come from stocks allotted to support Sixth Army'soperation. One hundred and fifty boxes of Red Cross supplies intended forinternees at Bilibid Prison were taken into the medical supply depot forissue to civilians through PCAU. Medical supplies for civilian interneeshave been furnished on the same high priority as for U.S. Army units. Atvarious times many items of medical supply have been critical but TetanusAntitoxin has been the outstanding shortage. Lack of this material hasresulted in the loss of a good many civilian lives that might otherwisehave been saved. This shortage persists up till the time of this
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report. Several small increments of Tetanus Antitoxinhave arrived at the depot, but the supply has never been enough to meetthe demand.47
Discussing preventive medicine activities in Manila duringthe period of Japanese occupation, Colonel Dashiell reported:
Early in the course of the Mission the various civilianhealth authorities were interviewed as rapidly as they could be located.No evidence of any epidemic could be discovered. The consensus was thatthe enteric infections had been rather infrequent during the Japanese regime,the record in this respect being better than during the pre-war years.This was probably due to heavy chlorination of the city water supply bythe Japanese coupled with a city wide immunization program against cholera,typhoid, and dysentery (bacillary-polyvalent vaccine) carried out in theFall of 1943. This immunization program was compulsory and the city wassaid to be over 98% immunized. Smallpox, plague, and cholera were saidto be completely absent during the Japanese regime. Diphtheria has beenmoderately prevalent. Gonorrhea and syphilis have increased apace duringthe Japanese period, many of the latter cases, particularly among prostitutes,being "serologically fast" due to inadequate treatment. Tuberculosis, alwaysa serious problem in the Philippines, was almost completely neglected bythe Japanese due in part to shortages of X-ray film and facilities forthe care of the patients. Crowding and malnutrition have undoubtedly greatlyincreased this problem which will be the major health hazard of Manilaand the Philippines for years to come. Sanitation suffered during the latterpart of the Japanese occupation due to lack of transportation for garbageand refuse although efforts were made to effect disposal through the mediumof the "neighborhood associations." In general it seems that the Japanesefirst approached Manila with a view toward permanent occupancy. They madereasonable efforts to maintain health standards and even effected someimprovements. One of the few bright spots in the functioning of totalitariangovernments is their ability to achieve success in preventive measuressuch as immunizations, sanitary handling of foodstuffs, etc. A man willreadily submit to immunization rather than lose his rice card and a foodprocesser will conform with sanitary laws rather than lose his licenseto engage in that or any other business. It will be observed thatthe Japanese effort was directed toward controlling those diseases immediatelyhazardous to Japanese troops. Tuberculosis was neglected and the insanewere gradually starved, particularly during 1944. The Japanese graduallyencroached upon the output of sera and vaccines prepared and distributedby the Institute of Hygiene of the Philippine Commonwealth. In September1944 the facilities of the serological laboratories of the Institute ofHygiene at Alabang (Rizal Pr.) were completely taken over and the civiliansupplies of antisera against diphtheria, tetanus, and gas gangrene werecut off. The Japanese removed much of the technical equipment of this institutionand the herds were not fed. The building and much equipment of this vitalinstitution are preserved and the nucleus of the herds remain.
In a discussion of the reorganization and resuscitationof Manila's health department, Colonel Dashiell noted that:
In the early days of February it was decided that in viewof the urgent need of medical care both in hospitals and in outpatientclinics it was not advisable to attempt to build a medical and nursingstaff for purely preventive services. Former health department medicalpersonnel were directed to the various PCAU units as the districts wereorganized and were employed on the staff of these units. By informal agreementwith Lt. Colonel Faust, Surgeon of PCAU 20, the director of health centers,Dr. [Lucerio] Ve-
47In the Annual Report for 1945 (Part I, p. 104), the Chief Surgeon, U.S. Army Forces, Western Pacific, estimated that 10,000 to 12,000 civilians were wounded in Manila. There were approximately 500 cases of tetanus among civilian wounded, of whom 389 or approximately 80 percent died. In contrast, there were no cases among U.S. Army personnel who had been immunized.
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lasquez, and the chief nurse, Mrs [Vicenta C.] Ponce,were employed in that unit but were permitted to work over all of northManila in reorganizing the health centers. These health centers when reorganized,were absorbed by the PCAU in whose district they fell and served as generaloutpatient dispensaries. This program met with varying success dependingupon the understanding of the PCAU Surgeon of the program attempted. Inthis matter, as in medical supply and many others, the lack of an overallPCAU Surgeon was keenly felt. It was necessary to hunt up each unit surgeonand explain to him the program attempted due to the lack of a responsiblehead with whom policy could be determined. By another informal arrangementwith PCAU 20 Dr. [Jose] Navarro, the former venereal disease control officer,began to examine prostitutes in the various houses in north Manila, submittinghis specimens to the 26th Medical Laboratory. Dr Navarro was permittedto work anywhere in north Manila without reference to PCAU districts.
The sanitation personnel of the health department weremore readily available than the medical personnel since their headquarterswas in north Manila. The staff of Mr. Emelio Ejercito, the former citySanitary Engineer, functioned under the control of Captain Vaughan. Thisstaff, which consisted of approximately 140 employees, was authorized towork anywhere in Manila that Captain Vaughan should direct. Malaria Controland Survey Units provided trucks and supervisory personnel and Capt. HenryM. Jones, SnC, the Commanding Officer of the 10th Malaria Control Unit,also furnished the sanitary group with technical supervision. Between 10February and 30 June, sanitation personnel accomplished the following:
a. Burial of 1,604 bodies from the city streets and hospitalmorgues-all buried in north cemetery.
b. Hauling and disposal of garbage and refuse.
c Unstopping and reconditioning public toilets.
d. Cleaning up and supervising sanitation of public markets.
e. Special sanitary details such as cleaning up the psychopathichospital at Mandaluyong.
f. Collection of water samples.
Colonel Dashiell concluded with a discussion of the watersituation and of the shortage of housing as follows:
The rehabilitation of the water system was carried outby the army engineers. Water was furnished to civilians first by the useof army water points and later through the regular water mains. At thetime of this writing the water supply was partially restored. The waterin the mains carried residual chlorine indicating its safety. Numerousexaminations were conducted by us on the water points and private wellsin the city. The sanitary quality of the water supplied to civilians bythe army water points was satisfactory whereas practically all of the privatewells, including the so called "artesian" ones, showed bacteriologicalevidence of fecal contamination. This was an uncontrollable health factorsince there was too great a shortage of firewood to permit boiling of thispolluted water even had the people been willing to go to the trouble todo so. In spite of this pollution of the private wells there is as yetno evidence of epidemic outbreaks of enteric diseases resulting from drinkingpolluted water.
The critical housing shortage due to the large numbersof destroyed dwellings has resulted in overcrowding in most of the remainingresidential area, and the construction of many shanties and temporary quartersin the ruins of former buildings. These latter establishments have noteven the most rudimentary sanitary facilities and are fast in-
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creasing the disease hazard. It is recommended that actionbe taken to remove the populace from the ruined areas in order that thewreckage may be cleared away to permit of adequate new construction.
Supplementary and supporting observations were recordedby numerous other medical and civil affairs personnel. For example, theSurgeon, XIV Corps, Col. Robert E. Allen, MC, noted various items of interest:48
During February and March, there was a critical shortageof tetanus antitoxin which was urgently needed for the care of woundedFilipino civilians, internees, and guerrillas. The venereal disease rateamong troops increased precipitously during February even though activefighting was in progress in the city; prostitution was widespread and,for many troops, this was the first contact with an urban civilizationfor 2 years.
Several thousand bodies of Filipino and Japanese deadwere scattered among the ruins throughout the city. The 37th Division employeda full-time civilian burial detail under the immediate supervision of theirmedical inspector, whose duty it was to follow the troops through the cityand dispose of the dead. The Manila Department of Sanitation under thesupervision of Civil Affairs disposed of the dead from civilian hospitalsand rear areas of the city.
The city water system, which had been seriously damagedby the enemy as well as by high explosives, was not in operation duringFebruary. Two Engineer Water Supply Companies and the portable water purificationunits of the Division served both Army troops and civilians. The only watersources available were sluggish and heavily polluted rivers and streamstraversing the city. Chlorine residuals were maintained at 2-4 ppm andthe water from all but three waterpoints satisfactorily passed bacteriologictests.
While Army troops disposed of kitchen wastes by burialand human excreta in slit trenches, civilians indiscriminately disposedof garbage and human wastes onto sidewalks, gutters, streets, and backyards.By the end of February, the resulting filth and fly breeding had increasedalarmingly and presented a serious menace to the health of both the commandand the civilians.
Specialized Functions in Relation to Civil Health
It will be instructive at this point to review brieflythe activities of certain specialized units which were assigned to civilhealth duties in Manila in March. None of these units had been designedprimarily for these activities, and indeed none had had special briefingfor the tasks ahead. Nevertheless, the evidence indicates that their assignedduties were carried out with imagination and timely improvisation.
The 26th Medical Laboratory (Army).-On 22 January 1945,the 26th
48See footnote 43. p. 601.
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Medical Laboratory (Army)49debarked at San Fabian and moved to a bivouacarea at Calasiao. The unit was alerted to proceed to Manila and establishits laboratory there in February. The advance section arrived on 6 Februaryand, the next day, set up in a laboratory building at San Lazaro Hospital,where it continued to function for several months. It operated as a stopgappublic health laboratory for the city of Manila and also provided laboratoryservices for various Army units in the area. The unit was quartered inthe attic above the laboratory itself because the concrete ceiling offeredprotection from shell fragments, shrapnel, and stray bullets. Originalplans were for the laboratory to provide only limited service, but it rapidlybecame evident that full laboratory facilities would be required. By 20February, when full laboratory facilities were available, it was necessaryto supplement the staff with civilian technicians. Considerable equipment,much of which was American make, was salvaged from captured Japanese supplies.
On 25 February, Headquarters, USAFFE, directed the Laboratoryto establish a Manila Public Health Department laboratory, which was toremain and continue to provide laboratory services for the civilian populaceafter the 26th Medical Laboratory left the area. The Public Health laboratorywas organized and almost completely set up by 20 March. The staff consistedof seven Filipino officers and 18 technicians.
Providing diagnostic tests for venereal diseases constitutedabout 50 percent of the work of the 26th Medical Laboratory. Water bacteriologyand analysis of alcoholic beverages also consumed much time and effort.
On 15 February, the unit was assigned the full responsibilityfor the care of the sick and wounded at San Lazaro Hospital, a civilianinstitution intended to care for contagious diseases, with an estimatedbed capacity of 1,200. At the time this assignment was made, no surgeonwas on the hospital staff; all public utilities were off; no sanitary measureswere enforced; and patients had had no food and little water for more than48 hours. The total number of patients in the hospital was about 1,750,of whom some 1,300 were battle casualties. Two Sixth Army surgical teamswere assigned to care for these casualties. An additional 500 PCAU employeeswere used to supplement the hospital personnel and to institute the muchneeded cleaning required for sanitary purposes. An operating room was setup using supplies found in the storeroom of the Bureau of Health. Necessarytemporary latrine facilities were constructed and the civilians were forcedto use them. Minimum food supplies were procured through PCAU. An auxiliarywater system was constructed using an artesian well on the grounds.
By 31 March 1945, when the laboratory was relieved ofthe responsibility for San Lazaro Hospital, an estimated 4,000 civilianwar casualties and an ever-increasing number of medical cases had beencared for.
49Reports, Lt. Col. W. D. Tigertt, MC, 26th Medical Laboratory (Army), 7 May 1945, subject: Quarterly Historical Report, From 1 January to 31 March 1945; and 18 Aug. 1945, subject: Quarterly Historical Report From 1 April to 30 June 1945.
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The quarterly report of the unit for the period 1 Aprilto 30 June 1945 indicates that, by 1 April, the work of the laboratoryhad settled into a grinding routine. The laboratory was covering all typesof medical installations, both military and civilian. Venereal diseasediagnosis accounted for about 55 percent of the work of the laboratorywith the daily average being about 500 Kahn tests, 110 dark field examinations,and 100 smears for gonococci. Enteric diseases accounted for the secondlargest amount of work, with a daily average of 70 stool cultures and 110stool examinations for ova and parasites. During April and May, the unitperformed laboratory work for some 10 large hospitals which were in theprocess of setting up in the Manila area and had received patients beforetheir own laboratories were in operation.
The supplies authorized for a medical laboratory of thistype were entirely inadequate to meet the demands made upon it. Only bysupplementing them with captured supplies and supplies given by the authoritiesof Santo Tomas University was the laboratory able to function. Fortunately,the section operating the Public Health laboratory in Manila was locatedin a preexisting laboratory building containing some of the necessary nonexpendableequipment.
The equipment authorization for this laboratory was basedon the assumption that it would function primarily for epidemiologic investigation.Actually, this was only a small part of the work, and the main functionof the laboratory was to carry out a large volume of routine work untilsuch time as the hospitals could establish their own laboratories. Furthermore,the laboratory was divided into three separate sections stationed in variousparts of Luzon, each functioning more or less as a complete laboratory.This situation demonstrated some of the deficiencies in the table of equipment.For example, some 8,000 test tubes were required whereas only 1,440 wereauthorized. Many other deficiencies of supplies were accounted for, inpart, by the division of the laboratory into three sections. One of thegreatest deficiencies was in the provision of power for the electricalinstruments which hampered work until Manila's municipal power was restored.
It is interesting again that this laboratory underwentmany administrative changes although, throughout this period, it was carryingout the principal function of providing laboratory services for almostthe entire armed forces and civilian population of Luzon. This unit wasfunctioning in an entirely different manner from any other such laboratoryunit in the SWPA; its duties were neither anticipated nor planned. Duringthe training period, no official information of any kind could be obtainedas to the method of operation of any similar unit either in the Europeantheater or SWPA, nor did any training program, as such, exist.
The 26th Malaria Survey Unit.-The 26th MalariaSurvey Unit50 departedfrom Sansapor in the SWPA on 8 January 1945, disembarked at
50Quarterly Historical Report, Headquarters, 26th Malaria Survey Unit, 1 Apr. 1945, subject: Case History of a Malaria Survey Unit.
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Lingayen Gulf, Luzon, on 27 January, and moved to Calasiaoon 1 February; left Calasiao on 5 February and arrived in Manila on 6 February.After several changes in assignment, including attachment to Sixth Army,I Corps, and USASOS, on 12 March, the unit was placed under control ofLuzon Base Section; and on 17 March, it was attached for duty with theDepartment of Health, Manila, which was then functioning under USAFFE.
The first duty assigned to the unit during this periodwas as a part of the Manila command, where it functioned as a general sanitationsurvey unit and not as a malaria survey unit since the area in which themission was assigned was nonmalarious.
The principal duties consisted of a survey of the watersupply, including the gathering of water samples for bacteriologic analysis,spotting of broken water mains and pipes, general surveys of mosquito breeding,fly population densities, human waste disposal, and garbage disposal inthe devastated areas of the city. During this period, the unit was housedin a well-lighted and well-ventilated school building which provided adequatelaboratory workspace, as well as office and storage space. Enlisted menof the unit were quartered in this same structure.
In a report dated 4 July 1945,51the commanding officer of this unit, Capt. Walter J. La Casse, SnC,stated that the unit had been functioning under the direction of the healthdepartment and had conducted several entomologic and parasitologic surveys.In addition, studies continued for several months to determine the effectsof DDT spray on fly population densities. Similar surveys were conductedon the larval and adult mosquito population to determine the effect oflarviciding programs and dengue control measures. Also, surveys were madeon the incidence of intestinal parasites in certain groups, including children,civilian food handlers, employees of civilian establishments, and civiliansemployed in Army messes. Systematic collection of water samples throughoutthe city for bacteriologic examination had also continued. An average ofabout 30 civilians had been employed on the various projects during theprevious months.
The 10th Malaria Control Unit.-The 10th MalariaControl Unit52 arrivedin Base M on the Lingayen Gulf on 28 January 1945. On 10 February, theunit was assigned the mission of supporting the Department of Health inManila. It performed a variety of duties while on this mission; such as,procuring civilian trucks for the disposal of accumulated garbage, procuringcivilian crews to man these vehicles, installing and supervising city garbagedumps, installing a motor pool for the Division of Sanitation, installingpublic latrines, pail systems collecting and disposing facilities for theselatrines, establishing a proposed budget for the Division of Sanitationof the Manila Health Department, and establishing garbage routes for nightand day crews.
51(1) Report, Capt. Walter J. La Casse, SnC, 26th Malaria Survey Unit, 4 July 1945, subject: Quarterly Historical Report of Medical Unit. (2) See footnote 50, p. 610.
52Report, Capt. Henry M. Jones, SnC, 10th Malaria Control Unit, 31 Mar. 1945, subject: Quarterly History Reports For Periods January-March 1945, and April-June 1945.
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During the succeeding 3 months, the unit functions wereextended to include sanitary inspections; installation and repair of publicplumbing facilities; disinfection and disinfestation of public marketsand garbage dumps, and of private homes where communicable diseases hadbeen reported; and supervision over all abattoirs. Some of the problemsencountered by the unit were the following: since the unit was permittedto pay garbage collectors only 1.45 pesos per day, it was difficult toobtain laborers for this job since they could make higher wages elsewhere.The unit experienced certain difficulties with the labor it did employ.For example, several crews had to be discharged for such offenses as haulingwood to their own homes, stopping work, and loitering around outside theirroutes. Despite these difficulties, however, from 10 February to 30 June1945, the unit had been responsible for collecting and burying 1,796 enemydead; collecting and burying 2,058 civilian dead, most of whom were casualties;and burying 3,073 civilian paupers. In addition, the unit had collectedand properly disposed of 11,981 truckloads of garbage and disposed of 19,464truckloads of garbage that originated in Army and Navy organizations. Thegarbage was distributed in three dumps and a system of sanitary fill wasdeveloped. This was operated so that no odor or fly nuisance occurred and,in addition, certain low-lying land had been reclaimed for buildings.
The 893d Medical Clearing Company.-The activitiesof the 893d Medical Clearing Company fell into three phases:53a period of preparation, including travel; a period of operation in Manila;and a period of operation at San Miguel, Tarlac Province, Luzon. The firstperiod ended and the second began when the company arrived at Santo TomasUniversity on 6 February 1945 to operate a hospital for liberated civilianinternees.
The unit, which had been operating a hospital of 125 bedson Leyte for American soldiers, boarded an LST on 21 January 1945, andsailed for Luzon. It arrived in the Lingayen Gulf on 27 January, and wentashore on 29 January (D+20).
Shortly after landing, it was learned that the 893d hadbeen selected to provide medical and surgical attention for the civilianinternees held by the Japanese at Santo Tomas University. Expensive additionalequipment and supplies were obtained to carry out this special assignment,particularly vitamins, vermifuges, calcium, extra food, and extra clothingsuch as bathrobes and pajamas. The Company traveled in convoy with PCAUNo. 5 which was also destined to go to Santo Tomas University. The hospitalwas established in the three-story education building on the hospital grounds.Hungry-looking liberated internees were wandering about aimlessly. Therooms assigned for the hospital were deplorably untidy. Quantities of paper,debris, and plaster lay all over the floors and furniture.
The operation at Santo Tomas lasted only 18 days, butthis was a very active period. On the first night, 320 people were fedat the kitchen, and by
53Report, Maj. Frederick H. Martin, MC, 893d Medical Clearing Company, 1 Apr. 1945, subject: Quarterly Report of Medical Activities, First Quarter, 1945.
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midnight, 97 patients had been admitted. Street fightingwas still going on just outside the compound, and many Filipinos and Americanswere brought into the hospital for surgery. No other station was preparedto treat these battle casualties; the surgical theater was in use day andnight almost continuously for the first week. PCAU No. 5, located in theadjacent main building of the University, had the job of feeding all theinternees and scores of news reporters, Red Cross workers, airmen, Filipinodoctors and nurses, and visiting military personnel. Approximately 3,800liberated internees were in the Santo Tomas Camp.
A problem of the first magnitude was sanitation. The buildingcontained six latrines, each with seven toilets, most of which did notwork. Moreover, the city water supply failed and the latrines could onlybe flushed with water brought from a brackish well by the Philippine laborers.This created a bad situation for the first week. Later, 6,000 gallons ofwater were hauled daily from scattered waterpoints, but even this supplywas dangerously small. Twenty-six 2½-ton truckloads of garbage,rubbish, and debris were hauled away from the education building duringthe first 3 days of operation.
Two factors influenced the activities of the unit duringthis period: the Japanese artillery shelling and the severe malnutritionof the liberated internees. Intermittently throughout the day of 7 February,shells hit many buildings on the University grounds. On that day, approximately100 Filipino laborers were hired by PCAU and placed on duty with the hospitalunit; but 3 hours later, four-fifths of them had disappeared.
The majority of the internees suffered from severe malnutrition,principally from a severe hypoproteinemia and avitaminosis. Most of themhad edema of the lower extremities and a few had wrist- and foot-drop.Many showed obvious signs of scurvy. Altogether, 544 civilian interneeswere hospitalized. In addition, 332 Filipino civilians and 49 Americansoldiers were hospitalized. Six Filipino patients had tetanus, two of whomdied.
The 55th Medical Supply Platoon (Avn).-The 55thMedical Supply Platoon (Avn)54was among the Sixth U.S. Army forces which invaded Luzon. The unit arrivedoff Lingayen Gulf on 13 January 1945, disembarked near San Fabian on themorning of 20 January, and moved the next morning to San Carlos, leavingsupplies under the guard of a truck company. From 24 January to 6 February,the unit stayed in Tarlac, in an area occupied by the 21st Medical SupplyPlatoon (Avn), and the personnel assisted in establishing a supply depot.
On 6 February, the 55th Medical Supply Platoon (Avn) enteredManila, unloading equipment and five truckloads of medical supplies onthe grounds of Santo Tomas University. The next day, the unit moved tothe George Washington School on Aragon Street near the Jockey Club andremained there until 18 February. The main units supplied were the 1stCav-
54Report, 1st Lt. Charles F. Rudolph, Jr., MAC, 55th Medical Supply Platoon (Avn), 1 Apr. 1945, subject: Quarterly Report of Medical History.
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alry and the 37th and 40th Infantry Divisions. In addition,the unit was responsible for supplying agencies treating civilian casualtiesalthough initial supplies were inadequate to meet these demands. Later,it was possible to make supplies available to civilian hospitals.
The Occupation Phase
On 1 March 1945, the administrative control of Civil Affairsin Manila came under USAFFE, with Brig. Gen. Courtney Whitney in chargeof the Civil Affairs Section. Lieutenant Colonel Dy (a native of the Philippines)and Lt. Col. Gottlieb L. Orth, MC, were also assigned to the Civil AffairsSection, Manila.
While some progress had been made during the combat phasetowards reestablishment of the Manila Health Department-the water systemhad been partially restored and most of the civilian dead had been buried-thenew Civil Affairs health personnel were confronted with tremendous problems.Among the more serious were the procurement and assignment of qualifiedcivilian personnel, the development of a system of garbage and sewage disposalincluding fly control measures, and the reopening of civilian hospitals.
The Department was organized into the following divisions:Communicable Disease Control, Medical Care (including hospitalization),Sanitation, and Supply and Procurement. In addition, eight Malaria ControlUnits and two Malaria Survey Units were attached to the Manila Departmentof Health for epidemiologic activities as well as malaria control.
By 20 April, 113 motor vehicles, including 74 U.S. Armytrucks and weapons carriers, and 25 bicycles were at the disposal of theHealth Department. During the period 1-20 April, the Sanitary EngineeringSection reported 542 blocks initially cleaned and 925 blocks recleaned,4,665 truckloads of garbage hauled to dumps, 7,408 pails of night soilcollected, and 1,270 human bodies buried. Seventeen markets were undersupervision and all had been recleaned and sprayed. Five abattoirs werebeing maintained in which 1,482 animals were slaughtered during this 3-weekperiod. More than 7,000 restaurants and other eating establishments hadbeen inspected, 130 ordered closed, and 623 approved for license. Of 177water samples tested, 14 were found nonpotable.55
On 14 April, a conference of representatives of the Departmentof Health, the Engineer Command, and the Commonwealth Government agreedupon the prompt provision of 10,000 pails for the collection of night soil.
The diarrheas and dysenteries were among the most prevalentdiseases among civilians and a sharp rise in the number of typhoid fevercases was reported; it was believed that this reflected an actual increase.Typhoid vaccination teams were organized and their activities concentratedin the dis-
55Report, Col. Maurice C. Pincoffs, MC, Director, Department of Health, 24 Apr. 1945, subject: Weekly Report, Health Department of Manila for 7-13 April and 14-20 April 1945.
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tricts of greatest prevalence. Active casefinding programsfor infectious venereal disease and tuberculosis were put into operation.In the 3-week period, 1,013 civilian patients were treated for syphilis;of approximately 3,661 persons examined for tuberculosis,614 were found to be positive with an additional 319 suspected cases; and75,550 typhoid and 3,461 smallpox immunizations were given.56
During this period, the Division of Medical Care inspected14 hospitals and attempted to correct some of the major deficiencies arisingfrom lack of supplies, equipment, food, and water. The excellent work beingcarried out in the former Children's Hospital under the direction of PCAUNo. 5 General Hospital was noted.
The procurement section of the Health Department distributedfresh vegetables to all hospitals and arranged for the requisition on anemergency basis of milk, eggs, butter, lard, and coffee from U.S. Armystocks. These were sufficient to supplement each civilian hospital rationfor 60 days with 4 oz. of milk, and 1.5 oz. each of eggs, butter, lard,and coffee. In addition, 4,000 bundles of firewood (for hot water and sterilizationof instruments) were procured for hospitals.
Two 40-bed hospital assemblies were delivered to the ProvisionalPhilippine General Hospital, two 40-bed assemblies to the Emergency Hospital(Psychopathic Hospital), and one 40-bed hospital assembly to the Children'sHospital (PCAU No. 5 General Hospital).
During this period, the most serious health hazard tocivilians and, indirectly through them, to the military forces, arose fromthe severely limited supply of water for both drinking and cleaning. ColonelPincoffs forcefully pointed out to command echelons the serious threatto the fighting forces because of a rise in enteric diseases from nonpotabledrinking water, lack of cleanliness in restaurants, and inability to disposeof sewage.
By 1 May, considerable progress had been made in reestablishingwater supplies, electric services to hospitals, and satisfactory sewagedisposal. Typhoid fever and tuberculosis continued at a high endemic level,but otherwise the health situation improved generally.57
Civilian hospital rations.-No special provisionhad been made for feeding civilian patients in civil hospitals in Manilaupon the entry of our troops.58 Distributionof relief food was under the supervision of the PCAU's. Since most patientsadmitted to these hospitals showed evidence of malnutrition, it becameclear that special food allowances would be needed.
Colonel Pincoffs requested a survey of the situation bya nutrition officer. Accordingly, Maj. William R. Bergren, SnC, spent severalweeks during March and April visiting hospitals and food supply installations,observing conditions, and gathering data for a definitive study of thesubject.
56See footnote 55, p. 614.
57See footnote 55, p. 614.
58Annual Report, Chief Surgeon, U.S. Army Forces, Western Pacific, 1945, Part I: USASOS, p. 114.
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He found that conditions varied considerably from areato area as each was administered by an independent PCAU. In all instances,the PCAU's had taken some measures to improve the patient ration; and insome instances, they furnished a limited amount of fresh vegetables. Actionhad been taken to reserve available milk stocks for young children andpregnant and lactating women. Despite the efforts made, however, the dietarywas found to be inadequate for complete recovery.
The patient ration improved considerably during the periodof PCAU administration. One step was the establishment of a centralizedprocurement agency for larger amounts of fresh fruits and vegetables fordistribution to all the PCAU districts. The most important factor, however,was the addition of a supplement to the hospital ration from stocks obtainedfrom the U.S. Army. Fats, milk products, and sources of ascorbic acid wereadded to bring the average dietary to an adequate standard and to furnishsufficient balance in the meals to encourage consumption over a continuedperiod. In the early stages of the liberation of Manila, variety and palatabilityin meals were of little importance for the preceding months under the Japaneseregime had been meager, sometimes almost to the point of starvation. Asthe weeks went by after liberation, however, the monotonous character ofthe relief ration made it distasteful. The supplementary ration obtainedby the director of Public Health was a big improvement.
During April, Col. John B. Youmans, MC, Chief of the NutritionDivision of the Office of the Surgeon General, visited this theater. Theprimary purpose of his visit was to make observations in connection withthe occurrence of atypical lichen planus, especially with respect to thepossibility of nutrition as a cause. He had the opportunity also to visitmost of the bases and to discuss current problems with the base nutritionofficers. Colonel Youmans also conferred with the Chief Nutrition Officerand other nutrition officers in the Manila area. Current problems werediscussed and various ways were outlined in which cooperation could bemaintained between the Office of the Surgeon General and the NutritionOfficers in this theater.
Release of control to the Philippine Government.-Bythe middle of May, the PCA units, which had been mainly responsible forthe supervision of various hospitals and dispensaries, both public andprivate, were being withdrawn; and on 19 May, Colonel Pincoffs was succeededas Director of Health by Lt. Col. Lorenzo L. Parks, MC.
On 1 July, all privately owned hospitals reverted to theirowners; arrangements were made to purchase drugs and supplies through wholesaledealers, and food through the PCA. One basic medical unit was sold to thePhilippine American Drug Co., wholesaler, for resale to private hospitals,and the plan called for two such basic units a month to be put into privatesupply channels for resale to hospitals and reputable drugstores. Publichospitals reverted to control of the Commonwealth Government. The lasttwo PCAU's (Nos. 5 and 27) turned over their responsibility on 19 June.The
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main administrative responsibility was assumed increasinglyby Filipino personnel. On 1 August, administration of the Health Departmentbecame the responsibility of civilian authorities except for an AdvisoryHealth Board consisting of Colonel Parks, Maj. Ray E. Trussell, MC, andCapt. Emil F. Vogt, SnC.
Summary of achievements to July 1945.-The weeklyreport of PCAU No. 27 for 31 July 1945 provides certain summary figuresfor the period, 2 March to 27 July. In all, 2,075 city blocks had beeninitially cleaned and 4,644 recleaned; 52,931 truckloads of garbage hadbeen hauled to the city dump; 88,615 pails of night soil had been collected;and 20,544 animals had been slaughtered in supervised abattoirs. More than16,000 restaurants had been inspected, 1,000 closed, and more than 8,000approved for license. Because of the abundance of "poison liquor," 650specimens had been analyzed for the presence of methyl alcohol. More than700 water specimens had been studied bacteriologically; and a total of68,000 gallons of DDT in oil had been sprayed for fly and mosquito control.More than 8,000 bodies had been buried.59
Diarrheal diseases had steadily declined over the 5-monthperiod, with typhoid falling to its previous low level. The high rate ofsyphilis and chancroid among prostitutes was reflected in excessively highrates in military personnel. Tuberculosis continued at a high endemic level.
During March through July, eight Army Medical Departmentofficers (of whom two were native Filipinos) headed by Colonel Pincoffs,one USPHS officer, and 10 Malaria Control and Survey Units had been assignedto Civil Affairs Health activities in the vital city of Manila, and militarypersonnel were assisted by many Filipino doctors and nurses. These menand women succeeded in bringing order out of chaos and starting Manilaback along the road toward being a modern city with all the health andsanitary safeguards that this implies. It should be noted that virtuallyall the Medical Department personnel upon whom these responsibilities fellcame to their assignments unexpectedly and without the benefit of priorplanning.
Little imagination, it seems fair to say, would have beenneeded to foresee the problems likely to be encountered in a city likeManila when the battle for liberation had rolled over it.
Within the limitation of their concept and organization,the PCAU's and their medical officers served adequately, some of them withdistinction. Always too few in number for the enormous job at hand, mostof them also lacked adequate training to cope with so many varied and complexproblems. Planning, organization, and manpower of a totally different orderof magnitude were required to rehabilitate a metropolitan area of 2 millionpeople. Moreover, restoration of health and sanitation in Manila in theshortest possible time was essential.
59Weekly Report, PCAU No. 27, 31 July 1945.
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Later Occupation Phase
From 1 August 1945 until late in the fall of that year,the Health Department of Manila operated under the direct supervision ofcivilian government personnel. The Advisory Health Board for Manila, consistingof three Medical Department officers, continued to serve in an advisorycapacity and to submit weekly reports to the Commanding General, AFWESPAC,concerning health matters in Manila. Venereal disease among prostitutespresented the most serious health problems confronting the Armed Forces.
On 18 September, Colonel Parks, the Chairman of the AdvisoryHealth Board for Manila, recommended that the Board be dissolved about15 October, and that its function be assumed by a liaison officer fromthe Army to the Manila Health Department. This action was taken in November.
Comments on the Luzon Campaign
The following comments and suggestions arising from theexperiences of the Sixth U.S. Army in the Luzon campaign are derived fromthe operational report of 9 January-30 June 1945. While all the commentsare not directly pertinent to health and medical concerns, they are, nevertheless,significantly related.
Policies and instructions from higher headquarters shouldhave been distributed earlier, in time for planning rather than after theinitial landings, as they were at Luzon.
A more adequate number of PCAU's should have been provided.For efficient operation, the units should have been displaced as littleas possible from their initial areas. Reserve units should have been athand to advance with the tactical units and replace those which were detached.Operations planning should have included sufficient medical units and transportationto enable Civil Affairs activities to be independent of tactical commands.
In an area which is evenly populated, such as the CentralPlain, the need for Civil Affairs units is normally related to the sizeof the operations. For operations in such an area, holding a large reserveof units under Army control is advisable. These units are then availablefor subattachment to Corps, based upon the extent of their zones of action.All forces for the Lingayen operation were landed in the same general area.This permitted free movement of PCAU's to any Corps at an early date. Wherelandings are made at more than one point and the forces may not join fora period of time, a much higher proportion of units should be subattachedinitially.
Regarding responsibility for civil administration, theSixth Army report recommended that, whenever an exception to directivesis made, the decision should be both early and final to prevent such uncertaintyas occurred in Manila.
Experience proved the importance of establishing definite,clear-cut wage scales and charges for rations as well as the amount ofsupplies allowed to be sold. The supplementing of authorized wages or suppliesto obtain laborers should be prohibited. Especially, service troops shouldnot be
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permitted to use these means to induce laborers to leavecombat troops as was done in areas near Manila. It was believed that, ifestablished wages are related to the ceiling prices of foodstuffs, a sufficientsupply must be available to civilians to permit them to support their families.
Supplies should be impartially allocated on the basisof the size, needs, and self-sufficiency of the population. The warehousingand issuing of PCAU supplies should be handled by trained service troops,not, as in Luzon, by the Civil Affairs Section, which had no personneltrained for the purpose. There were some difficulties with the suppliesthemselves: the sizes of the clothing had been planned for normal U. S.sizes instead of the smaller Filipino sizes; the food for civilian usedid not include the common items of the national diet, and, moreover, itwas issued in large containers more suitable for army than for family units.
The report included some criticism of the CAD Basic MedicalUnit and the comment that, if these units are to be used in the future,their composition should be governed by the needs of the area where theyare to be used. The units received in Luzon were poorly balanced, withexcesses of certain items and omission of such important ones as intravenousfluids, plasma, iodine, and hydrogen peroxide. Powders were furnished withoutmeans of converting them into sterile solutions or making them into capsulesor ointment. A system whereby requisitions may be submitted for requireditems, rather than for fixed units only, is believed preferable.
Trained Civil Affairs staffs should be made availablefor assignment rather than for temporary duty. Officers who have demonstratedabilities above the average, and whose status is other than that of assignment,subject the staff to which they are assigned to the inroads of higher headquarters,as was the experience of the Civil Affairs Section, Sixth Army.
Section II. Okinawa
BACKGROUND
Okinawa, the principal island of the Ryukyu group, issome 400 miles south of the southern tip of Japan itself. Conquest of Okinawa(map 20) was regarded as an essential step in the invasion of the Japanesehomeland. Under the overall command of Adm. Raymond A. Spruance, the TenthU. S. Army, under command of Lt. Gen. Simon B. Buckner, was given the missionof the capture of Okinawa, with, of course, close support of Navy and ArmyAir Forces. The Tenth U.S. Army consisted mainly of the XXIV Corps whichstaged on Leyte and the III Amphibious Corps, U.S. Marines, which stagedon Guadalcanal and the Russell Islands.
The offensive on the Ryukyus was launched on 26 March1945 with the landing of the 77th Infantry Division on the small approachislands of Kerama-retto. Within 3 days, the entire Kerama chain had beensecured
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and artillery commanded the western shores of Okinawa.Preceded by a realistic feint toward the southern tip of Okinawa and byintensive naval bombardment of the western beaches, landings were madeby the III Amphibious Corps and the XXIV Corps on 1 April. The Japaneseforces had been drawn toward the southern tip and offered little initialresistance to the landings. The Marines turned north and, against lightopposition, secured the northern portion of the island. The XXIV Corps,moving inland and southward, soon encountered the main Japanese force whichwas elaborately entrenched. Enemy resistance was fanatical both in fightingon the
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ground and in air attacks on our shipping. Eventually,the III Corps, U.S. Marines, and XXIV Corps pressed slowly southward andoccupied the two principal cities, Naha and Shuri, in mid-June; withina few more days, organized resistance ceased. Our casualties both amongground forces and naval personnel had been among the heaviest of the war;General Buckner himself was killed.
Planning for Military Government
It should be noted that the Okinawa operation was plannedand staged under CINCPOA (Commander in Chief, Pacific Ocean Areas) (FleetAdmiral Chester W. Nimitz), whose headquarters was on Guam. HeadquartersTenth U.S. Army was originally in Hawaii so that, from the beginning, twofactors influenced the evolution of military government developments: (1)joint planning with the Navy, whose outlook had been influenced by militarygovernment problems encountered in the Marianas; and (2) much closer liaisonwith the Civil Affairs Division of the War Department, with the resultthat the Okinawa planning group readily availed themselves of the experiencesof military government activities in the Italian campaign and the planningfor northwest Europe.
A staff memorandum,60dated 21 August 1944, pointed out the need foradequate planning, personnel, equipment, and supplies for military governmentin Okinawa. The staff section of the Tenth Army was augmented, on 15 August1944, by the addition of a Civil Affairs Section. Later, pursuant to adirective from CINCPOA that henceforth the term "Military Government" wouldbe used in lieu of "Civil Affairs" in all future Pacific operations, thename of the planning unit was changed to Military Government Section, HeadquartersTenth U.S. Army.61
The basic responsibility for military government in theJapanese Outlying Islands was placed on the Navy. Thereafter, CINCPOA requestedthat the Army assume this responsibility inasmuch as Army units would constitutethe larger portion of the expeditionary force and garrison troops.62
Planning for military government for Okinawa was madea responsibility of the Tenth U.S. Army, and Brig. Gen. William E. Cristwas assigned as head of the Military Government Section (G-5) on 3 November1944. Among the plans and directives prepared by this Section were thefollowing:
1. Operational Directive No. 7 for Military Governmentof the Commanding General Tenth Army, 6 January 1945 (Short title: Gopher).This
60Staff Memorandum No. 4, Headquarters Tenth U.S. Army, 21 Aug. 1944, subject: Concept of Organization of Civil Affairs Operations in Combat Areas.
61Crist, Brig. Gen. W. E., U.S. Army, Deputy Commander for Military Government, to Commanding General, ABF: History of Military Government Operations in Okinawa, 1 April to 30 April 1945 (L Day to L plus 29).
62Appleman, Roy E., Burns, James M., Gugeler, Russell A., and Stevens, John: United States Army in World War II. The War in the Pacific. Okinawa: The Last Battle. Washington: Historical Division, Department of the Army, 1948, p. 35.
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document outlined the basic concepts and principles forthe control of enemy population in the area of the Tenth Army.
2. Tenth Army Technical Bulletin on Military Government,25 February 1945. This bulletin contained detailed instructions for theconduct of military government operations within the framework establishedby Gopher to the Okinawa operation, and presented the attachment of militaryment operations.
3. Annex 15 to Operations Plan 1-45. This applied theprinciples of Gopher to the Okinawa operation, and presented the attachmentof military government units and the boundaries of military governmentdistricts.
It was contemplated that the Commander in Chief of thePacific Ocean Area would retain the title of Military Governor and proclamationswould be issued in his name. The Operations Plan provided that the MilitaryGovernment Section, Tenth U.S. Army, would function as Military GovernmentHeadquarters under the Island Commander; the Chief Military GovernmentOfficer would become Deputy Commander for Military Government.
As a result of military government experiences in otheroperations, four types of Civil Affairs units were organized:
A Teams, consisting of four officers and 11 enlisted men,were organized to accompany assault divisions and to conduct preliminaryreconnaissance as the troops advanced.
B Teams, consisting of eight officers and 19 enlistedmen, were designed to be attached to both corps and divisions, and theirmission was to organize military government activities behind the fightingfront.
C Teams, consisting of 10 officers and 26 enlisted men,were organized primarily to administer refugee camps.
D Teams, consisting of 22 officers and 60 enlisted men,were designed to administer the six districts into which Okinawa was divided.
Only D Teams included medical officers, although, in theOkinawa operation (see p. 629), many G-10 Navy dispensaries were attachedto all B and C teams to provide for emergency medical care.
For the Okinawa operation, there were to be six A Teams,eight B Teams, 13 C Teams, and six D Teams. In addition, regularly constitutedArmy and Navy units such as an MP battalion, a QM truck company, 20 NavyG-10 dispensaries (one officer and six enlisted men each), six Navy G-6hospitals (15 officers and 158 enlisted men each), and certain camp components(N-lA, N-4C, and N-5C) were assigned to military government.
Since the War Department was unable at this time to furnishthe necessary Military Government personnel for this operation, a planwas devised under which 182 Army officers, including a general officer(General Crist) would be made available for Military Government in Okinawa;the remaining officer personnel and all the enlisted personnel were tobe supplied by the Navy.
Personnel for Military Government headquarters were assembledat
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Tenth U.S. Army Headquarters, Schofield Barracks, Hawaii,while personnel for the detachments were staged and, to the extent permittedby the logistical timetable, trained at the Civil Affairs Staging and HoldingArea, which was located first at Fort Ord and laterat the Presidio of Monterey, Calif. It was most difficult to find Japaneseinterpreters, who were in short supply.
Military government detachments attached to XXIV Corpsand the 7th, 77th, and 96th Infantry Divisions staged with those unitson Leyte; those attached to the III Amphibious Corps and 1st Marine Divisionto units on Guadalcanal; and those attached to the 6th Marine Divisionto units on the Russell Islands. The teams attached to the two divisionsin the Army floating reserve staged with their respective divisions, the2d Marine Division on Saipan and the 27th Infantry Division on EspírituSanto. Some military government units, however, arrived on Okinawa directlyfrom the United States.
Special Planning for Military Government Health Activities
Special military government health plans for the invasionof Okinawa were contained in the Technical Bulletin of Military Government,dated 25 February 1945, prepared under the direction of General Crist.
The medical plans were prepared by the Chief Civil AffairsMedical Officer, Lt. Col. Glen W. McDonald. While these instructions followedin general outline those promulgated previously for other operations, theevolution of the whole concept of the role of military government can berecognized in these instructions, which were becoming more complete witheach new operation. The essential features of the medical plans were asfollows:
Medical officers of detachments, teams, and districtswere to make medical reconnaissance at such intervals as were necessaryto keep them informed of the situation in their areas. During the assault,MG (Military Government) medical officers were to maintain continuous liaisonwith the Surgeons of the tactical units to which they were attached while,during the garrison phase, they were to maintain liaison with the Surgeonsof the Island Command medical units. Wounded and sick civilians were tobe evacuated from MG dispensaries to MG hospitals wherever possible. Appropriatetags to identify patients as civilians were to be used.
Maximum use was to be made of native medical personneland facilities. As soon as possible, native physicians, dentists, pharmacists,midwives, veterinarians, and other related technical personnel were tobe registered and assigned appropriate duties. Civilian hospitals and othermedical facilities were to be rehabilitated if at all possible and providedwith sufficient supplies to operate. The qualifications of native practitionerswere to be investigated by MG medical officers, and licenses issued bynative government agencies were to be continued in effect as long as thelicensees performed their work satisfactorily.
Certain basic reports and records which are essentialfor planning, op-
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eration, and technical direction of the Public HealthProgram were to be kept and submitted to the proper authority. Among thesewere Communicable Disease Reports, Birth and Death Certificates, DailyRecord of Civilian Deaths, Vital Statistics and Treatment Summaries fromall MG hospitals, dispensaries, and camps which were to be submitted ona weekly basis. In addition, reconnaissance reports were to be submittedcovering the following subjects: (1) general health and nutritional statusof the population; (2) prevention and control of communicable diseases;(3) extent of civilian casualties; (4) information concerning native medicalfacilities, such as hospitals, laboratories, sanitariums, and others; and(5) the number, qualifications, and distribution of civilian medical personnel.All these reports were to be submitted to MG Headquarters, with copiesfurnished to the tactical units to which the medical unit was attached.
Concerning communicable disease control, military necessitydictated that priority should be assigned to the control of those diseasesor conditions which endanger the health of the occupying troops. Maintenanceof health and welfare of the civil population was assigned secondary attention.Attempts to raise the standards of public health above prewar levels werenot regarded as feasible because of the limitations of personnel and supplies.
Military government public health officers were to actin an advisory capacity to other MG officers who were responsible for providingand distributing food to civilians. A survey of local food supplies andof the nutritional level of the civilian population was to be undertakenas early as possible.
It was recognized that the extent and nature of the initialprogram for civilian medical care would depend upon the extent of hostilities,the number of civilian casualties, the amount of destruction of local medicalfacilities, the previous state of health in the area, and the availabilityof local medical facilities, supplies, and personnel.
The laboratories of the large MG hospitals were to bemade available to dispensaries and to the MG medical personnel locatedin civilian camps and communities. These laboratories were to be preparedto perform blood counts; bleeding and clotting time; blood-smear examinationsfor malaria; urinalysis; examination of stools for blood, parasites, andova; bacteriologic smears and cultures for common disease-producing organisms;tests for the serological diagnosis of syphilis; and appropriate agglutinationtests and post mortem examinations. Local facilities for producing biologicalswere to be appraised promptly and the manufacture of all biologicals essentialto epidemic control restored as promptly as possible. A special effortwas to be made to secure all antivenom serum and the facilities for itsproduction; if found, priority was to be granted to the use of such serumby troops.
Water supply for civilians, whether in collection points,temporary enclosures, or organized camps, was to be procured through thedevelopment
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of local resources wherever possible. If local sourceswere unavailable, troop waterpoints could be used, but arrangements fortheir use were to be made through the appropriate Engineer officer. Allwater from local wells, streams, ponds, or other surface sources was assumedto be contaminated with pathogenic bacteria and amebic cysts. The usualinstructions were given for the treatment of water for unit personnel.
Technical instructions were also issued for disposal ofsewage, for collection and disposal of garbage, and for control of flies,rodents, and mosquitoes.
It was recognized that the whole military government operationwould be influenced to a considerable extent by the supply situation, andit was pointed out that all military government personnel must be preparedto act in a supply capacity if the situation so demanded, particularlyduring the initial stages of the operation. Maximum use of local supplyresources would be made so that importation of supplies for civilians mightbe held to a minimum. The general scheme of supply was to be essentiallythat used by the line forces. Unloading, delivery, and storage of militarygovernment supplies were to be functions of the Army Supply service chargedwith handling comparable types of military supply. Liaison officers frommilitary government were to be sent to appropriate supply installations.In general, MG units were to draw civilian supplies from the regular militarydepots or dumps.
During the assault phase, MG supply requirements wereto be confined to a few essentials, such as food, water, tools, and medicalsupplies. Military government units, while attached to tactical units,were to draw all supplies, civilian or military, through the tactical units'supply channels. Captured stocks of food and clothing were to be reservedfor the use of military government unless urgently required by the militaryforces. Amounts, types, and location of captured supplies were to be includedin a daily MG report. In emergencies, water for civilians might be drawnfrom corps or division water distributing points by MG personnel. Duringthe early stages of the assault phase, no formal requisitions were to berequired, but proper stock control and other records would be establishedat the earliest possible date. The distribution of MG supplies was to followformal accounting procedures during the latest stages of the assault phaseand in the garrison phase. During these phases, a closely controlled supplysystem for military government would be in effect. Military GovernmentHeadquarters was to have responsibility for (1) planning the requirementsfor future overall MG supplies necessary to maintain area stocks at establishedlevels; (2) arranging for the delivery of supplies and their storage atproper depots or dumps; (3) establishment of necessary stock control andother records; and (4) allocation of supplies to MG units or installationsin accordance with availability and necessary priorities. Responsibilitieswere similarly fixed for district headquarters, camp headquarters, MG hospitalsand dispensaries, and Army and Navy units assigned to military government.
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Captured vehicles were to be turned over to MG units toreinforce organic transportation unless urgently required for combat operations.
All MG personnel were urged to report usable suppliesand equipment from civilian and captured enemy sources. The types of salvageablematerial regarded of greatest value were food, clothing, medical supplies,fishing gear and equipment, motor or animal transport, hand tools and agriculturalequipment, building material, and livestock and poultry. Guards were stationedto prevent looting or damage to dumps and other supply installations.
COMBAT PHASE
Tactical operations proceeded swiftly against light resistance,uncovering thousands of dazed civilians much more rapidly than had beenanticipated (fig. 81). Many villages were left in a relatively habitablecondition. Many civilians were really displaced persons who had fled northin advance of the invasion. However, thousands of civilians had to be assembledin large camps for security reasons.
An ample supply of food was available locally, althoughmuch of it was unnecessarily destroyed or dissipated because of the inabilityof Military Government to store and protect it for future use. Similarlosses were sustained in clothing, blankets, furniture, household utensils,farm implements, and building materials.
The medical situation was much more favorable than hadbeen anticipated. By and large, Okinawa has a healthful and equable climate,the incidence of malaria was low, and, with the exception of filariasis,no serious epidemics were encountered. Moreover, the number of civiliancasualties had been low and, with some assistance from a naval mobile surgicalunit which had no military patients, the MG medical units were adequateto meet all needs.
Many civilians had fled into the hillside caves wherethey led a crowded and unsanitary existence. The incidence of impetigo,scabies, and lice infestation was high, as was the incidence of pulmonarytuberculosis.
In the villages, the typical arrangement for sewage disposalwas an open pit a few feet deep close by or inside the native dwellings.Often the pit overflowed into a pool of feces and contaminated water inthe yard. Flies were numerous. Drinking water was obtained principallyfrom shallow wells, cisterns for the collection of rainwater, and springs;the widespread practice of tea drinking for which water is boiled probablyreduced the incidence of enteric disease.
In general, therefore, the medical facilities of MilitaryGovernment were adequate in this operation. It was observed, however, thatthe Navy G-6 and G-10 medical units were not sufficiently mobile to bewell adapted to field conditions.
The principal medical problem arose from the large refugeecamps
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(fig. 82). On 30 April (D + 29), approximately 125,000civilians were under Military Government care. For security reasons, thesecivilians were made to congregate in villages well to the rear of the combatzone, or were sealed off in wire enclosures. All ofthis necessitated large mass movements of refugees. On the Katchin peninsula,31,825 Okinawans were in one wire-enclosed camp. By native standards, healthin these camps was good and no epidemics were encountered, but scabiesand louse infestation were common.
The Japanese had deported, apparently for labor crews,a high proportion of the young adult population, both male and female,so that the camps were filled with elderly people and children There wasa curious absence of infants under 1 year and it was suspected that infanticidewas being practiced, possibly because of Japanese terror propaganda whichspread the notion that Americans were cruel to crying children
Despite the fact that the original plans called for thecollection of civilians in barbed wire enclosures, this proved impracticalbecause of the shortage of labor to construct the enclosures. For the mostpart, displaced Okinawans were relocated in villages and kept within themby Military Police with the aid of war dogs.
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XXIV Corps Activities
To examine some of the military government activitiesin more detail, the experiences of the XXIV Corps will be discussed briefly.63
This Corps, which was commanded by Lt. Gen. John R. Hodge,USA, completed its mission in the conquest of Leyte in February 1945, andbegan staging for the Ryukyus operation with the 7th, 96th, and 77th InfantryDivisions as its principal component units. The landing on Okinawa wasmade on 1 April; by the following day, the 7th Division reached the eastcoast to cut the island in two. Both the 7th and 96th Divisions turnedsouthward to meet fanatical Japanese resistance. On 9 April, the 27th InfantryDivision landed to reinforce the Corps; and on 30 April, the 1st MarineDivision moved in to relieve the 27th Infantry Division.
In the mounting area, the following number of MG unitswere attached to the Corps: three A, five B, and two C detachments, oneG-6 hospital, and nine G-10 dispensaries. The A detachments were assignedto divisions; their duties included posting proclamations, locating civilianfood and medi-
63Action Report of XXIV Corps for the Period 1 April-30 June 1945.
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cal supplies, establishing collecting centers, and evacuatingcivilians, with the assistance of Military Police.
Each division was also assigned one B Team to assume controlof collection centers established by A Teams, so that the latter couldmove forward closely behind the assault units. Corps B detachments wereprepared either to relieve the division B detachments or to leapfrog them,whichever the tactical and civilian situation might require.
The function of the C Teams, each with equipment to setup a 10,000-capacity camp, was to select and establish campsites to whichB Teams could evacuate civilians.
The G-6 hospital was prepared to operate a 500-bed hospital,and the G-10 dispensaries were equipped to operate 25-bed aid stations.The latter were attached to B and C detachments to provide emergency medicalcare. D Teams were to arrive on later echelons and take over in the rearareas.
A study of the activities of B and C Teams as given inthe Operational Report XXIV Corps shows that they were concerned almostexclusively with handling refugees on Okinawa. There was much movementof refugees from the combat areas to collecting stations and, thence, tomore permanent camps. For example, through 30 April, 32,098 civilians wereprocessed, of whom 363 died. On the whole, however, medical problems seemednot to have loomed large in the overall picture. Four rear area camps housedmore than 32,000 civilians; these reverted from Corps to Island Commandon 30 April. It was estimated that 10 percent were old men, 6 percent able-bodiedmen, 40 percent women, and 44 percent children. First aid and clinicalcare were given to approximately 13,500 persons by G-10 dispensaries, andapproximately 950 were hospitalized, mostly in the one G-6 installationlocated at Koza. The incidence of communicable diseases was surprisinglylow. A continuing educational program was directed toward the improvementof sanitation and personal hygiene.
When the final breakthrough into the southern peninsulaoccurred during the early days of June, 13,285 civilians were evacuated,many by water because of the almost impassable roads. These civilians werein much poorer physical condition than those encountered elsewhere on theisland. At least 30 percent required some medical care, and there werehundreds of stretcher cases. The regular B Teams were further augmentedby G-10 dispensaries and by medical officers and medical corpsmen fromthe D detachments under Island Command. More than 28,000 civilians wereevacuated from 10 to 30 June, most of them to camps on the Chinen Peninsula,Okinawa.
By using captured Japanese medical supplies and thosesupplies available to the G-10 and G-6 units, minimum standards of civiliancare were met without calling on the stocks of tactical units.
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Comments on the Okinawa Campaign
It seems clear that the Military Government activitiesof the Okinawa operation were handled very satisfactorily, and few criticismswere reported. The primary mission of Military Government, which was thatof relieving the fighting forces of responsibilities to civilians, wascertainly adequately accomplished. Moreover, there seems to have been betterrapport or, at least, less friction between the tactical forces and MilitaryGovernment detachments than had existed in many other operations.
This result probably stemmed mainly from two considerations:adequate planning well in advance of the operation by each headquartersof forces engaged in the operation, and due regard for the experience ofMilitary Government in other theaters.
It must be recognized, however, that in this operationour forces were in contact with a civilian population which was not onlyour enemy, but which was also on a low cultural and economic level. Itwas comparatively easy, therefore, to handle the Okinawan natives in asummary manner without evoking surprise or lasting hatred from them.
From a medical standpoint, several conclusions seem justified:
First, the large refugee operation must have been handledin such a manner as to avoid the development of serious epidemics or exceedinglypoor sanitary situations; the absence of evidence to the contrary is significant.This, in itself, indicates that the elements of good preventive medicinewere practiced.
Second, civilian sick and wounded were handled by theorganic medical facilities of military government and the hard-pressedArmy medical units were not burdened with this aspect.
Third, these results were accomplished by what appearsto have been the most economical use of scarce medical personnel by MilitaryGovernment up to that time. The assignment of regularly constituted medicalunits to work with Military Government detachments apparently was an eminentlysound development.
