CHAPTER XVIII
Japan and Korea
Thomas B. Turner, M.D.
For the United States, the occupation of Japan came asthe great culminating phase of 4 years of global war. From the standpointof military government and, particularly, its public health aspects, thisoperation was also a culminating experience; the function represented bythe terms "civil affairs" and "military government" had finally been recognizedat all levels of command as an essential feature of military operations.In both planning and executing the military government program, the experiencesof other theaters of operation were liberally called upon, and commandsupport reached a high level of effectiveness.
It will be instructive, therefore, to consider the healthaspects of military government for Japan from two standpoints: first, withreference to plans for the invasion of Japan, an operation which fortunatelywas made unnecessary by Japan's surrender; and second, the occupationalphases of military government health activities as they evolved in Japan.
By way of contrast, it will be of interest, too, to considerthe analogous operation in Korea which took the form of civil affairs ratherthan military government, in which local officials enjoyed, at least inprinciple, a large degree of autonomy.
Section I. Japan
PLANS FOR INVASION OF JAPAN
In chapter XVI, brief reference was made to the groundstrategy which had as its objective invasion of the Japanese homeland.The great pincers that were to seize the main islands of Japan had alreadyextended out from Australia by way of New Guinea and the Philippines, thesouthern prong; and from Hawaii by way of the Marshall and the MarianasIslands and Okinawa to form the eastern prong. With superbombers flyingfrom Okinawa and the bases in the Marianas, and fighters from Iwo Jimaand aircraft carriers of the Third Fleet, the Japanese home islands weresubjected to heavy bombing as well as bombardment by the guns of heavynaval units during July and early August 1945.
The original plans called for two invasions of Japan.The first, designated Operation OLYMPIC, provided for a three-pronged assaulton south-
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ern Kyushu in the fall of 1945 by the Sixth U.S. Army,consisting of the I and XI Army Corps and the V Marine Amphibious Corps.Their mission was to land on the beaches, isolate the southernmost Japaneseisland, and destroy the defending forces there.
The second phase of the Japanese invasion, Operation CORONET,was to be carried out in the early spring of 1946. The Eighth and TenthU.S. Armies consisting of nine infantry divisions, two armored divisions,and three Marine divisions were to assault the Tokyo Plain of eastern Honshu;the First Army, redeployed from Europe, was to follow with 10 infantrydivisions. The three armies were to occupy the Tokyo-Yokohama area, destroythe Japanese home army, and fan out to occupy the whole of Honshu and Hokkaido.
These plans were shelved when Japan offered to surrenderon 10 August 1945, following the atomic bombings of Hiroshima, on 6 August,and Nagasaki, on 9 August.1
Military Government Planning
Planning for the invasion of Japan was begun by the CAD(Civil Affairs Division) of the War Department in August 1943, when Maj.Charles C. Hilliard was designated group leader forplanning for Japan at the School of Military Government in Charlottesville,Va. Planning was intensified in January 1944, and Col. David Marcus, JAGC,was designated chief planner for Japan in the Civil Affairs Division.
On 13 April 1944, a staff study by Col. William A. Boekel,which was presented to the Joint Chiefs of Staff, recommended that "Planningfor civil affairs (for Japan) be a U.S. responsibility pending determinationof other U.N. interests." Apparently, however, certain key decisions werenot made at this time and actual planning seems to have proceeded slowlyfor the remainder of 1944.
In January 1945, the tempo of planning again increased,coincident with the establishment of a State-War-Navy Coordinating Committeewhich provided a degree of policy guidance. Six topics were outlined forstudy as follows:
1. Fixing responsibility for military government in Japan.
2. Formulating civilian supply policy and advanced procurement.
3. Formulating surrender policy for Japan.
4. Preparing directives for military government in Japan.
5. Formulating U.S. views on the composition of forcesfor the occupation.
6. Determining the U.S. position on intergovernmentalconsultation on problems of the occupation of Japan.
Evidently, little planning for health and medical affairscould be accomplished until some of those basic decisions were made. Outof the fore-
1Marshall, Gen. George C.: Biennial Report of the Chief of Staff of the United States Army, July 1, 1943 to June 30, 1945: The Winning of the War in Europe and the Pacific, p. 86.
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going studies, however, came the decisions that (a) theCommander in Chief, Army Forces, Pacific (Gen. Douglas MacArthur) wouldbe charged with the responsibility of military government in Japan; (b)the Chief of Staff of the U.S. Army would be the executive agency for theJoint Chiefs of Staff regarding military government; (c) the War Departmentwould procure and train military government personnel and would also procure,ship, and distribute military government supplies.
In the meantime, however, supply problems in the Far Eastwere being considered by the International Division of the Army ServiceForces. Planning began in the summer of 1944. Supplies and equipment wereestimated as the minimum necessary to facilitate military operations bythe prevention of disease and civil disturbance. Such supplies were toinclude minimum quantities of food, fuel, clothing, materials for refugeeor internee camps, and medical and sanitary supplies. Maximum use was tobe made of indigenous supplies and stockpiles. No attempt at economic rehabilitationwas to be made. Insofar as practicable, supplies were to be limited tostandard Army items. The target for food requirements was set at 1,500calories of an average balanced diet per person which would be supplementedfor heavy workers employed on military projects.
The basic assumption for logistical planning was thatJapanese resistance would have collapsed at least 30 days before occupationby U.S. forces.
The Civil Affairs Division decided that military governmentwas to be exercised through the Emperor and his administrative machinery.Should imposition of direct military government be necessary, General MacArthurwas immediately to advise the Joint Chiefs of Staff. Institution of a policyof nonfraternization was left to General MacArthur's discretion. Therewas to be no "de-Nazification" program similar to that carried out in Germany,but members of certain supernationalist and aggressive organizations wouldbe excluded from office. Educational institutions were to be reopened assoon as possible.
Planning in the Office of the Surgeon General
Training activities were started as early as the springof 1943 by the Provost Marshal General's Office, with the assistance ofCol. Ira V. Hiscock, SnC, and personnel of the Preventive Medicine Serviceof the Surgeon General's Office.
At least 10 Civil Affairs schools in addition to the oneat Charlottesville, were established in July 1943, and a number of theseprepared various categories of officers for service in Japan.
In September 1944, further plans for campaigns in theFar East were made by the Preventive Medicine Service in the Surgeon General'sOffice. Among these were position papers relating to civil affairs andmilitary government. Several principles were enunciated at that time, amongwhich were the following:
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The health program of civil affairs was to be developedunder the Civil Affairs Section of any given headquarters rather than asa part of the Chief Surgeon's Office. On the basis of experience in theNorth African and European theaters, it was strongly proposed that publichealth should be a major subdivision of civil affairs and so representedin the organizational plan. It was further urged that the chief of thepublic health branch for a major theater be selected early and assignedto the staff during the operational planning phase. In this connection,it should be noted that Col. (later Brig. Gen.) Crawford F. Sams, MC, selectedby The Surgeon General to head civil affairs (medical and public healthactivities) in Japan, assumed these duties on 22 July 1945.
In the initial sketch of The Surgeon General's civil affairsplan for the Far East, the importance of close liaison in both the planningand operational phases between the Chief Civil Public Health Officer andthe surgeons was stressed to assure effective coordination of the civilaffairs medical plan with the military medical plan. Again the cardinalobjectives of the civil affairs public health program were restated tobe, "1. To re-establish and supervise the existing health organizationof occupied and liberated countries and 2. To provide minimum facilitiesfor medical care."
Standards of performance were to be based substantiallyon those existing before military occupation unless higher standards wererequired to prevent epidemics or civil unrest of an extent that might beprejudicial to the military effort.2
It was recognized that nutritional problems among thecivilian population might well pose difficulties for the invading armiessince a high incidence of deficiency diseases was present throughout thearea even before the war, and this situation was thought to have worsened.Recommendations were made, therefore, (1) to assign specialists in nutritionto civil affairs public health headquarters of theaters and major taskforces, and (2) to provide for epidemiologic studies to determine the incidenceof deficiency disease of an occupied area since such data would serve asa guide to determining the basic food requirements of a civilian population.3
PERSONNEL PLANNING
Expanded concept of military government health activities.-Untilthe spring of 1945, civil affairs personnel planning for Japan had beenbased on the use of a comparatively few highly qualified Medical Departmentofficers, who would be assigned to key positions from which they coulddirect civilian public health and medical matters with the aid of Japanesemedical personnel. While this plan was believed to be adequate for thepost-combat phase, reports from Guam, Tinian, Saipan, and other invadedis-
2Memorandum, Col. Thomas B. Turner, MC, for Chief, Preventive Medicine Service, Office of the Surgeon General, 18 Sept. 1944, subject: Civil Affairs Medical Plan for the Pacific Area. [Official record.]
3Memorandum, Col. John B. Youmans, MC, to Chief, Preventive Medicine Service, Office of the Surgeon General, 18 Sept. 1944. [Official record.]
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lands indicated that additional medical personnel shouldbe earmarked to care for civilian casualties during the combat phase toassure that facilities intended for the care of military casualties wouldnot also be burdened with the care of civilians. From experiences on theseislands, civilian casualties were expected to be high, with little helpinitially from native medical resources.
In a memorandum dated 20 March 1945,4The Surgeon General had outlined the plan for the Okinawa campaign, listingthe number and type of medical department personnel his office proposedfor the A, B, C, and D teams (later redesignated Teams CE, CF, CG, andCH). In addition, The Surgeon General proposed that one field hospital(Table of Organization 8-510, less nurse personnel) be attached to eachcorps for the care of civilian casualties, and that this organization asoutlined be used as a basis for future logistic planning. This was approvedby the Civil Affairs Division.
Estimation, procurement, and assignment.-Havingobtained CAD approval, the Civil Public Health Division, with the assistanceof Special Planning Division and Military Personnel Division, Surgeon General'sOffice, proceeded to estimate the number and type of Medical Departmentpersonnel required for military government for the Japan operation usingthe above basis. This estimate was forwarded to the Director, PlanningDivision, ASF (Army Service Forces), on 21 April 1945, with a recommendationthat the War Department troop basis for this operation be augmented toprovide for these personnel. This recommendation was studied in variousASF divisions until the early part of June 1945.
In the meantime, Brig. Gen. William E. Crist had beenchosen by General MacArthur as his chief military government officer andassigned to the Office of the Chief of Staff for CAD duty. This divisionwas requested by General MacArthur to make plans for military governmentin the Far East area.
On the advice of The Surgeon General, Public Health wasorganized as a major function of General Crist's staff, and Colonel Samswas designated as his chief medical officer. Colonel Sams was assignedto the Civil Affairs Division to work under General Crist in planning themedical program. The Surgeon General's Office assisted him in the selectionof his staff, and numerous conferences were held concerning all medicalphases of military government planning. Personnel needs in the event ofeither invasion or collapse were discussed. The estimate of 21 April 1945,having been referred by Army Service Forces to the Civil Affairs Divisionfor comment, was reviewed by General Crist and Colonel Sams. Upon reviewingthe SGO recommendation and later estimates based upon theater plans, astudy for the inclusion in the troops basis of all military governmentpersonnel requirements was forwarded by the Civil Affairs Division throughchannels. While this study was under consideration but before final actionwas taken, events
4Memorandum, The Surgeon General to Civil Affairs Division of the War Department, 20 Mar. 1945.
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transpired which caused the Commander in Chief, U.S. PacificOcean Areas, to authorize the diversion of personnel and troop basis tomeet the requirements for military government personnel. In view of this,the CAD study was returned without action.
Colonel Sams left for the theater about 15 August 1945.In a cable on 19 August 1945,5activation was requested in the Civil Affairs Staging Area of 18 Headquartersand Headquarters Detachments, Military Government Groups and 56 MilitaryGovernment Headquarters and Headquarters Companies.6The Surgeon General's Office was asked to procurethe needed medical officer personnel to fill these requirements, whichwere estimated as 74 Medical Corps officers and 56 Sanitary Corps officers(sanitary engineers). The table of organization for Headquarters and HeadquartersDetachment, Military Government Groups, included one Medical Corps officerwith the rank of lieutenant colonel. The Military Government Headquartersand Headquarters Companies included one Medical Corps officer with therank of major and one Sanitary Engineer with the rank of captain. Availableat the Civil Affairs Staging Area, Presidio of Monterey, were 23 MedicalCorps officers and 10 Sanitary Engineers who had been trained at the Schoolof Military Government at Charlottesville and the Yale University CivilAffairs Training School. In addition to these, the Surgeon General's Officerequested 46 Sanitary Engineers and 35 Medical Corps officers to reportto the Civil Affairs Staging Area to fulfill the requisition for officers.Information obtained from the theater indicated that the additional MedicalCorps officers to complete the needs could be furnished from theater sources.
THE UNOPPOSED OCCUPATION OF JAPAN-
MILITARY GOVERNMENT ASPECTS
The unexpected announcement by the Japanese Governmenton 10 August 1945 of its desire to surrender brought a new and sudden changein plans by those charged with future assault operations. What must beregarded as one of the great strokes of diplomatic history was the decisionthat the Japanese Government, under the moral leadership of the Emperor,and its armed forces be required to shoulder the chief administrative andoperational burdens of disarmament and demobilization, under policy directivesfrom General MacArthur's headquarters.
Operations Instructions No. 7 materially altered the missionassigned to the Army commanders. Instead of actually instituting militarygovernment, Army commanders were to supervise the execution of the policiesconcerning government functions assigned to the Japanese Government byGHQ, AFPAC (General Headquarters, U.S. Army Forces, Pacific).7
5Cablegram (IN 18292), Army Service Forces in the Pacific to the War Department, 19 Aug. 1945.
6Memorandum, Acting Director, Civil Affairs Division, to The Surgeon General, 22 Aug. 1945.
7Reports of General MacArthur. Vol. I (Supplement): MacArthur in Japan: The Occupation: Military Phase. Washington: U.S. Government Printing Office, 1966, p. 194.
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New plans had to be promulgated quickly for the occupation;troops, materials, supplies, and transportation had to be procured on thebasis of their availability rather than on that of fulfilling prime requirements.The Eighth U.S. Army was assigned the task of occupying northern Honshuand Hokkaido. Its mission was to occupy critical areas in those islandsand to establish control over the armed forces of the enemy and the civilianpopulation within the prescribed terms of the surrender.
Headquarters of the Eighth U.S. Army had moved from Leyteto Okinawa on 26 August. On 28 August, an advance group landed at Tokyoairfield (Atsugi), preceded by fighter planes overhead. The leading plane,bearing Col. Charles P. Tench of G-3 Section GHQ, commanding the advanceparty, was followed by 15 others-150 officers and enlisted men in all.Within 45 minutes after the lead plane landed, the field had been investedand communications with Okinawa established. The main airborne force arrivedon 30 August.
Under the supervision of Japanese Maj. Gen. Seizo Arisue,the field was put in order by dawn the next day for the accommodation oflarge planes which were to bring the 11th Airborne Division. Meanwhile,elements of the Third Fleet anchored in Sagami Bay. A "correct" attitudewas the keynote of individual relationships. By October, all of the Eighthand Sixth Armies were in Japan-a total of more than 460,000 men.
The Sixth Army occupied roughly the area south of Tokyo;and the Eighth Army, the area north of a line running across Japan justsouth of Tokyo and Sagami Bay (map 22).
Organization of Military Government
The occupation of Japan was theoretically under the FarEastern Commission, comprising representatives of the several Allied Powers,with the Joint Chiefs of Staff being the top military policymaking group.Reporting to the Joint Chiefs was SCAP (Supreme Commander for the AlliedPowers), General MacArthur, who was in operational control of the occupationand with whom originated most of the important policymaking decisions regardingJapan.
The Public Health and Welfare Section was one of 14 principalstaff sections under GHQ, SCAP; Colonel Sams (fig. 87), chief of this section,was responsible for all military government health activities of the occupation.The Eighth Army was the operational unit.
As noted previously, a Military Government section hadbeen established in GHQ, AFPAC, to administer occupied Japan. Militarygovernment teams were available to take over the government of Japan inevery phase of activity, but those teams assigned to the Sixth and EighthU.S. Armies were now used in the major cities of Japan to assure compliancewith SCAP's policy directives.
By a directive dated 28 August 1945,8military government activities
8See page 75 of footnote 7, p. 664.
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MAP22.-Occupation of Japan by the Sixth and Eighth U.S. Armies, fall 1945.
of Army and Corps commanders were limited to a few specifiedfunctions, and the following policies were set forth:
1. SCAP will issue all necessary instructions directlyto the Japanese Government.
2. Every opportunity will be given the Government andpeople of Japan to carry out such instructions without further compulsion.
3. The Occupation Forces will act principally as an agencyupon which SCAP can call, if necessary, to secure compliance with instructionsissued to the Japanese Government and will observe and report on compliance.
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FIGURE87.-Brig. Gen. Crawford F. Sams, MC.
On 6 September, a directive9stated that SCAP would exercise authority through Japanese governmentalmachinery and agencies, including the Emperor, to the extent that thissatisfactorily furthered United States objectives. A new Economic Sectionand Scientific and Civil information, and Education sections were createdin GHQ, AFPAC.
On 26 September, a directive10stated that there would be no direct militarygovernment in Japan; that a number of special staff sections would be establishedby GHQ, SCAP, to advise the Supreme Commander on nonmilitary matters inrelation to the occupation of Japan, and that the Military Government Section,GHQ, AFPAC, would be discontinued.
On 2 October, GHQ, SCAP, was established with generaland special staff sections of which Public Health and Welfare was one.These corresponded in general with the main technical branches of the JapaneseGovernment.
The Public Health and Welfare Section was required toinitiate policies
9See page 75 of footnote 7, p. 664.
10See page 75 of footnote 7, p. 664.
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relating to public health and welfare problems. The primaryaim was to achieve a level of health and welfare among the civil populationwhich would prevent widespread disease and unrest likely to interfere withthe occupation. The major problem was the lack of trained and experiencedJapanese personnel to conduct those programs at national, prefectural,and local levels.
The Eighth U.S. Army Military Government System
Military government in the Eight U.S. Army was organizedat three principal levels: a staff section at Army Headquarters, a staffsection at each of two Corps headquarters, and military government unitsstationed throughout Japan.11
Initially, military government was established in theEighth Army as a Civil Affairs section under G-1 in the Philippines. Immediatelyafter surrender, four Military Government companies were organized withpersonnel provided by GHQ and civil affairs units in the Philippines. Inanticipation of any emergency that might arise, selected members of tacticalunits were organized in military government staff sections at divisionaland regimental levels. In October, as trained military government unitsarrived in Japan, tactical units were relieved of this responsibility.
At Army level, military government continued under theCivil AffairsSection until 21 September, when this section was redesignatedMilitaryGovernment subsection, G-1, but shortly thereafter, it was reorganizedas aSpecial Staff section.
Military government units were formed into groups andsubordinate companies, each of which contained medical personnel. By mid-November,seven groups and eight companies had been assigned to the Eighth Army;three groups and two companies were directly under Army, and the otherswere attached to Corps and U.S. Army Service Command which operated atcorps level in Kanagawa Prefecture. A special detachment was set up formilitary government in Tokyo.
On 1 January 1946, all occupation duties in Japan wereassumed by the Eighth Army, to which were assigned at that time six groups,24 companies, and 28 detachments. Later, a new unit, designated a "team,"was formed to provide better use of specialist personnel. These teams wereidentified with each prefecture which, in turn, were grouped in seven regionalgroups. Three types of teams were created-a major, intermediate, and minor-tocorrespond to the importance of the prefecture.
Status of Public Health in Japan
Although Japan's introduction to Western culture beganonly as recently as 1853, the evolution, in theory at least, of Japanesehealth measures followed fairly closely that of the Western World and theirlevel of medical
11Unpublished manuscript, R. W. Komer: Civil Affairs and Military Government in the Mediterranean Theater, Office of the Chief of Military History, Department of the Army. [Official record.]
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and scientific sophistication approached that of the moreadvanced countries of the West.
In 1873, a medical bureau, which dealt with matters ofpublic health as well as medical education, was established in their Departmentof Education; and the following year, statutory authority was containedin a "Medical Code." In 1875, this bureau was transferred to the Ministryof Home Affairs, renamed the "Sanitary Bureau," and, from then on, dealtlargely with sanitation and epidemic diseases.
Fundamental weaknesses in the system, however, were thelack of authority at the national level and the absence of an analogousorganization at the prefectural and local levels for, here, health matterswere customarily under the authority of the police, with the national bureauhaving advisory powers only. Faced with growing problems induced by rapidindustrialization and a high incidence of malnutrition and tuberculosis,the Japanese Government in 1938 created the Ministry of Health and SocialAffairs (later called the Ministry of Welfare) which became responsiblefor the health and welfare of the civilian population, including laboradministration and social insurance. An attempt was made to reorganizethe health services at the prefectural and local levels as well; however,under the impact of war and the consequent domination of civilian affairsby the Japanese military, these changes scarcely came into being as functionalentities and, for all practical purposes, local health matters remainedunder the jurisdiction of the police. Moreover, there was tampering withmedical, dental, and nursing education and major diversion of professionalpersonnel and supply activities to military needs so that, by the end ofthe war, the Japanese civil health program had largely collapsed.
At the local level, such health and sanitation activitiesas existed were carried out by the police and the neighborhood associationswhich were influential in all phases of Japanese life. The health centers,established in 1932, were primarily advisory clinics for tuberculosis ormaternal and child health activities and were not directed to the supervisionof broader health programs in the more modern sense.
BROAD HEALTH PROGRAMS DEVELOPED
UNDER SCAP DIRECTION
Colonel Sams arrived in Tokyo on 30 August 1945. On 22September, SCAP issued a directive to the Imperial Japanese Governmentas follows:12
The Supreme Commander for the Allied Powers directs thatthe Imperial Japanese Government take the following action:
1. An immediate survey by agencies of the Japanese Ministryof Health and Welfare to determine:
a. Disease prevalence in each prefecture.
12SCAP Directive to the Imperial Japanese Government,22 Sept. 1945, subject: Public Health Measures.
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b. Medical, dental, veterinary and public health personnel available in each prefecture.
c. Hospital facilities, medical, veterinary and sanitary supplies present in each area with a comment in each instance as to its adequacy.
d. The adequacy of laws and regulations of the indigenous Japanese Public Health and Welfare authorities to meet current requirements.
2. Immediately inaugurate such measures as:
a. Weekly reports of communicable diseases by prefecture.
b. Examination, detention or hospitalization of cases or suspected cases of communicable disease.
c. Immunization, disinfestation and control of any disease which would be likely to seriously affect civilian health.
3. Restore all public water supply, sewerage systems and other human waste disposal means to the maximum civilian capacity with the least practicable delay through the use of civilian resources and labor.
4. Reopen or continue in operation civilian hospitals,sanatoria, leprosaria and clinics for use of indigenous population as rapidlyas conditions permit or require. Where civilian hospital space is inadequate,a survey of schools or other buildings will be made to locate facilitieswhich are suitable to be used as emergency hospitals and these buildingsso designated.
5. All civilian (wholesale) and Japanese Military andNaval medical, dental, veterinary, sanitation supplies and military foodstuffswill be distributed through indigenous Japanese agencies in accordancewith Military Occupational control plans on recommendation of the SupremeCommander for the Allied Powers for their conservation and distribution.
6. Inaugurate port quarantine control in cooperation withUnited States Naval Forces. Port quarantine will be established by Japanesecivilian control.
7. Reopen or continue in operation civilian laboratoryfacilities for public health work, for clinical diagnosis, and for themanufacture of sera and vaccines.
8. Expedite the reporting and analysis of vital statisticsdata in accordance with policies established by the Supreme Commander forthe Allied Powers.
9. Place special emphasis on adequate measures for thecontrol of all venereal diseases occurring in indigenous Japanese personnel.This will be accomplished by using existing Japanese agencies.
On 2 October, General Orders No. 7 establishing the PublicHealth and Welfare Section was issued by the Commander in Chief. Sincethis document set the stage for the program developed during the AlliedOccupation, it is quoted in its entirety.
1. The Public Health and Welfare Section is establishedas a Special Staff Section to advise the Supreme Commander for the AlliedPowers on policies relating to Public Health and Welfare problems in Japanand Korea.
2. The functions of the Section are:
a. Make recommendations to:
(1) Prevent disease and unrest in the civilian populationin accordance with objectives of the Allied Powers.
(2) Expedite the establishment or reestablishment of normalcivil health control procedures, in order to prevent the spread of anydisease likely to interfere with the success of the occupation mission.
(3) Provide for the early establishment of the essentialpublic health and welfare activities to meet the minimum humanitarian requirementsof the civil population and to protect the health and welfare and to furtherthe accomplishment of the mission of the Occupation Forces.
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(4) Require the various interested governments to establish such standards of health, sanitation and quarantine in connection with repatriation of displaced persons as will prevent danger to Occupation Forces.
b. Make recommendations for the disposal of existing stocksand for the control of production and traffic in narcotics in Japan andKorea.
c. Make recommendations relative to, and to direct theconduct of such surveys of public health and welfare activities as areessential:
(1) To keep the Supreme Commander for the Allied Powersfactually informed on public health and welfare conditions in Japan andKorea.
(2) To insure a factual and dependable basis for progressiveformulation and modification of policies and plans pertaining to publichealth and welfare requirements and activities.
d. Prepare instructions for the initiation, coordinationand development of such plans and programs as are required to meet thepublic health and welfare objective of the Supreme Commander in preventingserious diseases and distress in the civil population.
e. Coordinate such reports on the public health and welfaresituation and activities in Japan and Korea as are required.
f. Conduct all liaison with and coordinate the activitiesof all non-military missions, commissions, or agencies concerned with publichealth and welfare problems in Japan and Korea.
3. Liaison will be maintained with:
a. The Japanese Ministry of Health and Social Affairs (Welfare).
b. International Red Cross.
c. American Red Cross.
d. Japanese Red Cross.
e. Chief Surgeon.
f. The Economic and Scientific Section for the purpose of coordinating matters pertaining to the production and distribution of Japanese and Korean medical, dental, veterinary and sanitary supplies and equipment.
Under Colonel Sams' leadership, a modern health program was instituted in Japan within a relatively few months after the occupation began. This program was directed from SCAP but was implemented largely by the Japanese. The organization of public health activities at national and local levels conformed to the general reorganization of the Japanese Government in accordance with the new constitution adopted after the end of the war.
The Ministry of Health and Welfare, which was one of thecabinet ministries in the Japanese Government, was reorganized to integratefour fundamental aspects of health and welfare: Preventive Medicine, MedicalCare, Welfare, and Social Security. Labor activities formerly in the ministrywere transferred to a new Ministry of Labor.
At the same time, health and welfare departments wereestablished in all prefectural (state) governments on an equal status withother major departments of the prefectural governments. The same subdivisionswere created in the prefectural departments as at the national level.
Within each prefecture, health center districts were established,with one district for approximately each 100,000 population. Each districtcontained at least one organized and staffed health center, which mighthave one or more branches according to population distribution. In citieswith
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more than one health district, a city health departmentwas organized to supervise and coordinate the activities of the districthealth officers.
Under a new health center law, districts were to includethe following principal functions: public health nursing, maternal andchild hygiene, public health statistics, diagnostic laboratory services,dental hygiene, nutrition, sanitation and hygiene, health education, medicalsocial service, communicable disease control, venereal disease control,and tuberculosis control.
The sections that follow contain sufficient detail toconvey some idea of the magnitude of the problems of the health field thatconfronted the occupation forces and the people of Japan, and some of thesteps taken to meet those problems. It must be borne in mind that, duringthe period covered by this account, Japanese currency was not permittedas a medium of exchange outside Japan, and that virtually all the materialsneeded to implement a program of public health and medical care could beobtained only from Japanese sources-from industrial and pharmaceuticalplants that were, in many instances, badly damaged or antiquated.
SPECIFIC HEALTH PROBLEMS
General Measures
Japan, with a population of 80 million, was a truly nationallygoverned country with residual legislative power vested in the JapaneseDiet. One of the first measures, therefore, was to provide the appropriatenational executive group-in this instance, the Ministry of Health and Welfare-withthe authority and the executive mechanisms to fulfill its responsibilities.13
In turn, appropriate authority was vested in the PrefecturalHealth Department, the Health Center Districts, and, in metropolitan areas,the City Health Department.14
The successive steps in establishing this program on afirm legal basis in Japan were, first, to develop a basic plan which hadthe approval of the Supreme Commander and the concurrence of competentJapanese officials. This plan was then incorporated into a national healthact which provided an adequate legal basis to administer and procure personnel,equipment, and funds.
A second step was to establish a model health center inone area (Suginami-Ku) of Tokyo to demonstrate to the Japanese the intentof the law.
13Most of the statistical data for this section are taken from the following sources: (1) Report, Lt. Col. Wilson C. Williams, Chief of Preventive Medicine Subsection, SCAP, to Chief Public Health Officer, Public Health and Welfare Section, SCAP, 9 Oct. 1945, subject: Report on Preventive Medicine Organization and Activities in Japanese Ministry of Public Health and Social Affairs (Welfare), (Through September 1945). [Official record.] (2) Report, Brig. Gen. Crawford A. Sams, subject: Public Health and Welfare Organization and the Preventive Medicine Aspects of Public Health and Welfare in Japan, 1948. [Official record.] (3) Report, General Headquarters, SCAP, Public Health and Welfare Section, December 1949, subject: Mission and Accomplishments of the Occupation in the Public Health and Welfare Fields. [Official record.] (4) Report, General Headquarters, SCAP, Public Health and Welfare Section, subject: Public Health and Welfare in Japan. With provisional summary of health statistics for years 1945-48. [Official record.]
14See footnote 13 (2).
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This center also provided training opportunities for militarygovernment health officers who were to be responsible for overseeing thehealth program in Japan, and for Japanese professional personnel who wereto head the prefectural and local health department activities.
A third step was to establish a similar model in eachof the 46 prefectures of Japan and to inaugurate similar demonstrationcourses for local personnel. Continuing courses were offered also in specializedfields of public health.
The first phase of this ambitious program was completedby 1948, less than 3 years after the occupation, a truly remarkable accomplishment.
The fulfillment of this program was contingent upon thesubsequent activation of health centers in the remaining 780 districts,which was virtually accomplished before the end of the occupation.
To convey some idea of the acute shortage of trained personnel,at the end of the war Japan had only two trained sanitary engineers, bothfrom foreign schools, and no medical social workers. Moreover, there hadbeen no formal public health training in Japan; and only through the fellowshipprogram of the Rockefeller Foundation had a small nucleus of public healthofficers been trained abroad, mostly in the United States, before the outbreakof the war. This small group was, as might be expected, enormously helpfulin implementing the rejuvenated health program.
An Institute of Public Health had been built in 1939 withfunds from the Rockefeller Foundation, but its teaching program had scarcelybegun before its activities were curtailed by the war. Plans were quicklymade under the Military Government Program to reopen the institute andto reorient its program to provide greater educational opportunities inthe field of public health. This was accomplished in 1947. Indeed, becauseof the severe shortage of trained public health personnel, stress was placedon teaching preventive medicine and related subjects in many of the Japanesemedical institutions.
Included in this massive educational effort were successfulattempts to bolster educational facilities and opportunities in the fieldsof medicine, pharmacy, and sanitary engineering.
It is interesting to note that, by the end of the war,virtually all key positions in the various bureaus of the national andprefectural governments, including public health, were held by personswith a law degree. As a part of the occupation program, these individualswere gradually transferred-in the Ministry of Public Health and the Prefecturalhealth departments, to posts more commensurate with their training-andwere replaced as rapidly as possible with professionally qualified personnel.
Within the relatively few months after the occupation,a major revolution had been wrought in the national attitude toward publichealth and in the means for giving expression to it. For a country so thicklypopulated, where subsistence can be at a precarious level and where thereis potential
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for disaster in epidemic diseases, this new orientationmust indeed be regarded as a significant event in the life of the Japanesenation.
Health Statistics
While vital statistics, births and deaths, had for manyyears been reliably reported through police channels, the mechanisms forsecuring good health statistics were defective and, during the last yearsof the war, had deteriorated further. One of the first steps of the MilitaryGovernment health program was to establish health reporting on a weeklybasis throughout the nation.
The average mean crude annual death rate for the period1938 to 1945 was 18.3 per 1,000, with a high of 29.2 for 1945; this ratewas reduced to 14.6 in 1947. A substantial proportion of these reductionswas accounted for by a striking decline in infant mortality. The averagemean annual rate per 1,000 live births for 1938 to 1943 was 94.9 infantdeaths; for 1947, it was 76.2. In both adults and infants, the major reductionoccurred in deaths from enteric diseases and pneumonia.
Sanitation
Despite Japan's industrial and military sophistication,its standards of sanitation were far below those of most Western nations.Public water and sewerage systems existed only in the larger cities and,for the most part, sewage disposal was through the antiquated system of"honey buckets" in which disposal was from individual privy, to collectingcart, to gardens.
At the time of capitulation, while the water systems ofsome cities had been disrupted by bombing, the Tokyo water supply was largelyintact, and token chlorination was in effect. This was promptly bolsteredby supplies of chlorine from the occupation forces and, throughout thenation, water supplies were fairly rapidly put back into satisfactory operation.
Likewise, even the primitive sewage disposal systems commonin all but the largest cities had deteriorated because of the labor shortagedue to military demands. Again, the rehabilitation of these facilitiesto prewar standards was accomplished fairly quickly. Modernization wasaccepted as a long range objective.
Little attention had been given to insect or rodent controlexcept as it pertained to malaria control. A vast rat population was supportedon the comparatively meager diet of the Japanese people, and the numberof flies in a kitchen was regarded as a subtle tribute to the prowess ofthe cook. The incidence of louse infestation had increased and foci oftyphus fever cases were being brought to light (see p. 676).
Coal was practically nonexistent by the end of the war;this, together with crowding, water shortages, inadequate sewage disposal,and fuel shortages, led to a repitition of conditions encountered in Italy,Germany, and elsewhere under the impact of war, in which the incidenceof skin diseases,
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notably scabies, dysentery, and many other infectiousdiseases markedly increased.
The Public Health and Welfare Section assigned a highpriority to this problem. An intensive campaign of public education wasinaugurated, and strenuous efforts were made to rehabilitate whatever watersystems had been in existence. In addition, early in 1946, six-man sanitaryteams were organized, initially to deal with an outbreak of typhus. Theywere trained in elementary fashion and equipped with minimum facilitiesto deal with environmental sanitation, including insect and rodent control.By the spring of 1946, 9,000 such teams were in operation. Even assumingsome inefficiency, vacillation of purpose, and waste, the impact of theseteams, while impossible to measure, must have been enormous.
With the passage of time, too, the economy began to improve,the labor force increased; food, water, and fuel became more abundant-factorswhich, together with the specific health programs, brought fairly promptimprovement in the health of the nation.
Communicable Diseases
Only a few diseases were legally notifiable before theoccupation, and, by the end of the war, even these few were no longer beingreported. One of the first actions of Lt. Col. Wilson C. Williams on reachingJapan in late September 1945 was to assemble the available informationconcerning the prevalence of infectious diseases throughout Japan.
It was clear from these data that enteric diseases, includingtyphoid, had a high incidence throughout Japan, probably substantiallyhigher than the prewar level although valid statistical comparison couldnot be made. The data were qualitatively useful, however, in indicatingfoci of unusual incidence. Similar reports indicate that smallpox was presentin the country at a high endemic level, that typhus outbreaks were occurringin Hokkaido, the northernmost large island of Japan, and that tuberculosisand venereal disease were health problems of major importance.
The situation immediately after the surrender was complicatedfurther by the mass movement of people in and out of cities in search offood, by the return of thousands of Korean laborers to their native country,and by the anticipated return of Japanese soldiers from all over the FarEast and the Pacific Archipelago.
The enteric diseases.-The incidence of dysenteryis commonly regarded as a good index of the sanitary level of a communityalthough reliable data on incidence are not readily obtainable in manycountries. A few figures for Japan will be cited as broadly indicativeof the sanitary level.
In the period 1938-45, the reported average annual incidenceof dysentery, presumably both amebic and bacillary, was 101.6 per 100,000population, with peak rates of 138 in 1939 and 1945. The rate for 1946was 116.8. In 1947, the mean morbidity rate per 100,000 population haddeclined to 50.5, and in 1949, to 18.3, the lowest in the history of Japanto that time.
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Typhoid and paratyphoid fever cases reached a peak in1945, the greatest number occurring in the months immediately precedingand following surrender. The incidence remained high during the early monthsof 1946 and then sharply declined. Actual fatality rates per 100,000 fortyphoid and paratyphoid fever combined were 12.2 in 1945, 7.8 in 1946,4.2 in 1947, and 2.0 in 1948. During 1946, approximately 20 million personsreceived vaccinations against these diseases (fig. 88); and in 1948, theseimmunizations and reimmunizations were made obligatory for certain agegroups, a more questionable health procedure. Production of the large quantitiesof vaccine needed for this program was accomplished largely through Japanesefacilities.
Smallpox.-An old Japanese law required immunizationagainst smallpox, and the disease had been reasonably well controlled inthe past. However, enforcement had become progressively lax and, since1938, a higher endemic level had been noted. In the initial review by militarygovernment health authorities, vigorous steps were taken to rehabilitatefacilities for the production, assay, and distribution of smallpox vaccine;and a widespread immunization program was pressed.
By the end of January 1946, 60 million persons, three-fourthsof the population of Japan, had been vaccinated, which should have brokenthe epidemic. To the alarm of health authorities, the number of smallpoxcases continued to mount in the later months of 1945, reaching a peak of6,304 in March 1946, with 17,800 cases, or a rate of 23.7 per 100,000 population,being reported for 1946. It was discovered that, by the old regulation,alcohol or phenol was required to be used as an antiseptic; in actual practice,the vaccinia virus was place on the arm still wet with antiseptic, so thatsuccessful immunization was the exception rather the rule. When this situationwas discovered, a decision was made to revaccinate the entire populationof Japan by proper methods. This was accomplished in a few months-some75.3 million immunizations in all-surely one of the most stupendous healthoperations in the history of the world. Cases of smallpox progressivelydeclined to 3,850 in April, 1,746 in May, 1,057 in June, 114 in July, 41in August, and nine in September. In the following year, 391 smallpox caseswere reported, and in 1948, 29 cases, giving annual rates of 0.5 and lessthan 0.1 per 100,000 respectively. The smallpox rate remained at this lowlevel to the end of the occupation.
Typhus.-Early in the occupation, a conference ofrepresentatives of the Public Health and Welfare Section, the United Statesof America Typhus Commission, and Japanese authorities was held to discussthe typhus situation. This group concluded that the winter of 1945-46 promisedto be the most serious one for typhus in Japan and Korea, and also in Chinaand Manchuria, since 1942.
Based on recommendations of the Typhus Commission, theChief, Public Health and Welfare Section, GHQ, SCAP, arranged to importthe following essential typhus control supplies for civilian use: DDT insecticidepow-
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FIGURE88.-A Japanese civilian receives typhoid inoculation, Tokyo, 1946.
der and dusters, gasoline engine driven delousing outfits,and typhus vaccine.
A vigorous control program was outlined; for militarypersonnel, this was to consist of (1) a stimulatingdose of typhus vaccine for all troops on 1 November and 1 February, (2)monthly issue to each man of one can of louse powder, and (3) a trainingprogram for military typhus control teams.
A program directed to the civilian population was to consistof (1) immunization and monthly delousing in coal mines, labor camps, andsix of the major cities of Hokkaido which were the main typhus foci; (2)delousing all persons crossing Tsugaru Strait between Hokkaido and Honshu;(3) delousing all Japanese repatriates from the Asiatic mainland and Korea;and (4) appropriate control measures in the event of an epidemic.
There was no DDT or typhus vaccine in Japan, the solesource being the CAD supplies earmarked for Japan, or available in regularArmy supply channels, although the situation was such that it seemed unwiseto divert these latter supplies to civilian use.
A dusting and vaccination barrier was planned for theferry points between Hokkaido and the main island of Honshu; but this actionwas ineffective because the Korean miners in Hokkaido had revolted 2 weeksbefore the arrival of occupation forces and had dispersed widely throughJapan in an effort to return to Korea. In other words, typhus-infectedlice had been seeded throughout Honshu, and outbreaks occurred in someof the major cities, including Osaka, Kobe, Nagoya, and Tokyo, beginningin December
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1945. From 1 January to 1 July 1946, 29,939 cases werereported, with a total of 31,141 cases being reported for the whole of1946.
Problems were experienced in obtaining shipping spacefor DDT powder. When Japan capitulated, some 11 ships were being loadedin New Orleans and West Coast ports with relief supplies, including medicalsupplies and clothing, for Japan. The AFPAC headquarters then announcedthat Japan could not expect aid from the United States, and canceled dispatchof the 11 ships by AFPAC. This information, incidentally, first reachedthe War Department through the public press. The director of the TyphusCommission, Brig. Gen. Stanhope Bayne-Jones, MC, alert to the implicationof the cancellation, immediately arranged through Maj. Gen. (later Lt.Gen.) LeRoy Lutes, USA, to have the 75 CAD antityphus units earmarked forJapan, and possibly Korea, forwarded to Japan since he regarded such actionas essential to the protection of U.S. troops in those areas.15
The shipment authorized by Gen. Brehon B. Somervell, CommandingGeneral of the Army Service Forces, included 10-percent DDT powder anddusters in addition to the regular antityphus units. Shipping orders forthose supplies were issued on 8 October, and the shipment reached Japanin December 1945.
With the assistance of Col. Joseph F. Sadusk, Jr., MC,executive officer of the Typhus Commission Field Headquarters in Tokyo,an extensive program of DDT dusting and immunization was carried out duringJanuary 1946 in most of the trouble areas. The program followed much thesame pattern that had been successful in Italy and Northwest Europe. Themonthly buildup and defervescence of the epidemic on a national basis,from September 1945 through September 1946, were as follows:
| Number of cases |
1945: | |
| 117 |
| 44 |
| 285 |
| 153 |
1946: | |
| 272 |
| 2,036 |
| 10,435 |
| 8,486 |
| 5,298 |
| 3,412 |
| 507 |
| 213 |
| 67 |
Source: Report, General Headquarters, SCAP, Public Health and Welfare Section, subject: Public Health and Welfare in Japan, 1948. Statistical annex, table 25, p. 19. [Official record.]
During the winter of 1946-47, the number of cases increasedbut scarcely reached previous endemic levels (1,064 cases in 1947), andonly 429 cases were reported in 1948.16
15Memo for file, Brig. Gen. Stanhope Bayne-Jones, MC, Headquarters, United States of America Typhus Commission, 28 Sept. 1943, subject: Cancellation of Medical and Other Civilian Supplies for Japan. [Official record.]
16Medical Department, United States Army. Preventive Medicine in World War II. Volume VII. Communicable Diseases. Arthropodborne Diseases Other Than Malaria. Washington: U.S. Government Printing Office, 1964, p. 260.
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Tuberculosis.-Pulmonary tuberculosis had long beena leading cause of death in Japan. For several years, the death rate forall forms of the disease rose steadily, reaching 280 per 100,000 populationin 1945, one of the highest rates in the world.
Considered a shameful disease by the Japanese, cases alltoo rarely came under medical care until the late stages. Shortages offood and fuel, overcrowding, and the generally poor economic conditionsduring the later stages of the war had contributed to the increasing prevalence.At the time of occupation, many patients had left the tuberculosis sanatoriumsto seek food, and thus contributed to a further spread of the infection.
Japanese scientists had been conducting research on BCGvaccine since 1927; in 1943, the National Research Council of Japan hadrecommended that the use of this control measure should be encouraged.In 1944, more than 5 million individuals between the ages of 10 and 19who were tuberculin-negative were given BCG; and in 1945, more than 3 millionpersons between the ages of 15 and 24 were inoculated. Some doubt existsconcerning the potency of the vaccine used.17
Because of preoccupation with more acute health problems,the Public Health and Welfare Section did not tighten up the control measuresfor tuberculosis until the fall of 1946, at which time a major effort aimedat the eventual control of the disease was inaugurated. The essential elementsof this program were:
1. To encourage the return of patients with active tuberculosisto sanatoriums through public education and provision of adequate food,fuel, and facilities to these hospitals.
2. A program of professional education in diagnosis andtreatment for the medical and nursing professions.
3. Inauguration of a school lunch program for children.
4. Mass casefinding examinations in schools, factories,and among contacts of active cases.
5. A stepped-up program of BCG vaccination.18
Beginning in 1947, compulsory notification of tuberculosiswas required for the first time in Japan. Relying on the specific mortalityrates as an index of the trend of the disease, it should be noted thatthe rate per 100,000 population for 1946 was 264.2; for 1947, 187.5; andfor 1948, 181.1. It is difficult, of course, to determine those elementsof the program which were most effective in reversing the trend of tuberculosisin Japan, or to what extent the improvement in the general economy andsanitary level of the country was responsible.
Venereal diseases.-Fraternization of Allied soldierswith the Japanese was not forbidden and the venereal diseases were inevitablyof concern to the occupying forces. The Japanese, on the other hand, hadlong regarded this problem as one limited to prostitutes and, in general,the medical profession
17See page 8 of footnote 13 (3), p. 672.
18See page 8 of footnote 13 (3), p. 672.
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was ill-informed regarding clinical manifestations andepidemiologic patterns; methods of treatment were archaic. Licensed prostitutionwas legal and flourished widely since geographic limitations of brothelshad broken down during the war years.
In October 1945, syphilis, gonorrhea, and chancroid weredeclared reportable diseases; and in January 1946, the Japanese Governmentwas directed to annul laws pertaining to the legalization of prostitution.A program designed to revolutionize the psychological, epidemiologic, clinical,and legal approaches to these diseases was vigorously implemented, butwith uncertain success. In 1946, approximately 436,000 cases of syphilis,556,000 cases of gonorrhea, and 108,000 cases of chancroid were reported.
Treatment facilities were established, largely throughthe health centers referred to previously, and penicillin and the sulfonamideswere made increasingly available as the pharmaceutical industry swung intoproduction. A new venereal disease prevention law passed by the Diet in1948 included provision for premarital examination, prenatal examination,and examination of all contacts and suspects for evidences of venerealdisease.19
Diphtheria.-The incidence of diphtheria rose duringthe war years, with 94,274 cases reported in 1944; 90 percent of the deathsoccurred in children under 10 years of age. Diphtheria toxoid had neverbeen used as a control measure although antitoxin was available for treatmentand temporary prophylaxis.
The necessity of a nationwide immunization program wasrecognized immediately, but no toxoid was available. While waiting forthe production of this biological by the pharmaceutical industry, othercontrol measures such as quarantine and focal passive immunization wereinstituted. The number of cases reported in 1946 was 66,000.
During the latter part of 1946, a large-scale active immunizationprogram was begun, and 16 million children were inoculated. Deficiencieswere discovered, however, because of frequent confusion between toxoidand antitoxin, and it is not known what proportion of this number was properlyimmunized. A second large-scale immunization program was mounted in 1947.Case rates, per 100,000, were as follows: 1945, 122.8; 1946, 65.5; 1947,36.4; and 1948, 20.3.20
Cholera.-Only an occasional case of cholera hadbeen reported in Japan during the preceding two decades, and none was recognizedduring the early months of the occupation. Anticipating problems in thisrespect from the repatriation program, stringent quarantine measures wereinitiated in September 1945. In the spring of 1946, cases began to appearamong repatriates on ships from China and other areas of the Far East,and a few cases filtered into Japan through the smuggling in of non-Japanese.Cholera cases continued to increase, and a peak was reached in July andAugust; 1,229 cases were reported for 1946. Stringent control measures-isolation,
19See page 11 of footnote 13 (3), p. 672.
20See pages 24 and 26, and tables 23 and 24 of footnote 13 (4), p. 672.
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quarantine, disinfection, and focal immunization-whichwere applied to the areas where cholera cases occurred were probably responsiblefor limiting the epidemic. Approximately 34.5 million persons receivedcholera vaccine. No cases were reported after December 1946.21Control measures were less successfully applied insouthern Korea (see p. 696), where an epidemic of 15,642 cases occurred.
Other infectious diseases.-The early developmentof facilities for penicillin production in Japan was responsible for asharp reduction in the mortality from pneumonia. No cases of plague werereported during the occupation years or, indeed, in any year since 1926.
No large outbreaks of Japanese B encephalitis occurredsince 1935; sporadic cases were not uncommon, but the disease was not madeofficially notifiable until 1946. In the last 6 months of 1946, 259 caseswere reported, but in 1948, coincident with the delayed inauguration ofthe mosquito control program, an outbreak of 7,208 cases occurred.22
Malaria, which had been endemic in Japan for many years,was not made a notifiable disease until 1946. In 1947, reported cases numbered11,841; and in 1948, 4,940. It was determined, however, that most of thesecases were recurrent attacks among repatriated Japanese.23
In the 52 years between 1895 and 1947, life expectancyin Japan increased only from 42.8 to 50 years for men and from 44.3 to53.9 years for women. However, during the 3-year period under Allied MilitaryGovernment, 1947-50, the life expectancy for men increased from 50 to 58years, and for women from 53.9 to 61.5 years.24
MEDICAL CARE PROBLEMS
Medical Education
Before the war, Japan had 18 medical schools of universitycaliber and 10 second-class schools. For the most part, all of these schoolsfollowed the older German pattern of reliance principally on didactic lectures,with little practical experience in the clinic or laboratory being required.While only 10 second-class medical schools existed before the war, underthe pressure of necessity, 41 others had been started. The degree grantedby these poorer schools differed somewhat from that of the university schools,but the opportunity for such graduates to practice medicine was not limited.Approximately 60 percent of all medical graduates of 1945 were from thesesecond-rate schools. Understandably, therefore, the general level of medicalpractice in Japan was low despite the presence of some physicians trainedin scientific medicine. A small group of physicians in Japan had graduatedfrom European, chiefly German, or American medical schools.
21See page 27 and table 25 of footnote 13 (4), p. 672.
22See page 34 of footnote 13 (4), p. 672.
23See table 23 of footnote 13 (4), p. 672.
24Professional paper, Brig. Gen. Crawford F. Sams, dated 1 Nov. 1951, subject: American Public Health Administration Meets the Problems of the Orient in Japan.
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Under the impetus provided by the Public Health and WelfareSection, a Japanese Council on Medical Education, comprising physiciansrepresenting the better medical schools, was formed in early 1946 to considerthe reform of their medical education system. In 1947, the nonuniversity"technical" medical colleges were classified in A or B categories; membersof the latter group were either closed or put on probation, pending radicalimprovement. At the same time, changes in the curriculum were introduced,placing greater reliance upon practical work in the laboratory and theclinic.
As a part of these reforms, the Japanese Medical Associationwas reorganized to exclude direct governmental influence; new leadershipwas recognized; and a new constitution was formulated, dedicating the associationto the promotion of quality medical education, higher ethical standards,and the advancement of public health. Prefectural and local medical societieswere likewise formed.
At the same time, SCAP inaugurated national examinationsfor medical licensure. The first examinations were held in 1947, underthe auspices of the Council of Examinations for Medical Licensure of theJapanese Ministry of Welfare. One year of internship after graduation frommedical school was required for licensure.
The Medical Examiner System
Exaggerated Japanese press and radio reports on the numberof deaths attributed to starvation in persons found on Tokyo streets resultedin the Tokyo Metropolitan Health Bureau's being instructed to conduct anautopsy at the Tokyo University Medical School on each body subsequentlyfound. The system, first placed in effect on 24 November 1945, showed thatthese deaths, in fact, were caused by disease. In April 1946, this provisionwas enlarged to cover all deaths believed to have public health importance.This activity proved of such value that it was extended to include allthe large metropolitan areas in Japan, and legal authority for the systemwas established by direction in December 1946. This law also created authorityfor turning over to the medical school all unclaimed bodies for use ininstruction in anatomy. Up to this time, the use of cadavers for such teachingwas actually illegal.
Medical Literature
The international exchange of medical literature had virtuallyceased upon the outbreak of war. Early in the occupation, the great needfor modern medical literature was recognized, but currency restrictionscurtailed the purchase of such material. The situation was alleviated partiallyby loans and donations from the Surgeon General's Office in Washingtonand by textbooks and journals made available to each military governmentteam. The demand, however, far exceeded these meager resources.
After 2 years of effort and with the assistance of theCivil Information
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and Education Section of SCAP, the Public Health and WelfareSection succeeded in arranging for the republication of certain Americanjournals and textbooks in Japan. The Japanese Medical Association beganpublication of its journal in November 1948.
Hospital Care in the Early Occupation Period
Civilian hospitals deteriorated during the war becauseof the removal of equipment for other uses and because of the effects ofbombing; 1,027 hospitals with a total bed capacity of 53,000 were destroyed.Medical supplies had been diverted from civilian and military use, andthere was an overall shortage of drugs, X-ray films, and dressings.
At the time of surrender, 320 Army and Navy hospitalswith a bed capacity of 78,000 were in operation. These institutions wererapidly turned over to the Ministry of Welfare and gradually reorientedto civilian purposes.
Early in the occupation, a weekly reporting system wasestablished, which showed the bed occupancy of the hospitals of Japan.Initially, this report included all hospitals of more than 10-bed capacity,other than tuberculosis and mental hospitals and leprosariums. With thepassage of the Medical Service Law in July 1948, an institution was requiredto have a capacity of 20 beds before being classified as a hospital; andthe reports were made monthly.
At the same time, a program directed to the improvementof hospitals was inaugurated, but these changes were intimately relatedto medical and nursing education, and to age-old customs, so that progresswas inevitably slow. The First National Hospital in Tokyo was selectedfor development into a model institution. There were about 244,000 hospitalbeds in Japan, or one bed for each 328 persons in the population.
Model hospitals were established subsequently in eachprefecture following the pattern of the Health Center program for expansion.The First National Hospital became the site of the first School of HospitalAdministration in Japan.25
Atomic Bomb Casualties
Although one of the greatest military disasters of alltime to befall a civilian population occurred in Japan-the atomic bombingof Hiroshima and Nagasaki-the Allied occupation of these cities did notoccur for about a month so that military government was not importantlyinvolved, except indirectly. The bomb was dropped on Hiroshima on 6 August1945, and on Nagasaki on 9 August; some 64,000 deaths occurred immediatelyor within several weeks in the former city and 39,000 in the latter. Manythousands more were severely wounded. It is noteworthy that Japanese scientistsquickly deduced the essential nature of this new powerful destructive forceand demonstrated the presence of excess redioactivity in the soil withina few days after the initial explosion.
25See footnote 13 (4), p. 672.
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Since the first group of U.S. investigators did not arrivein the bombed areas until 8 September, the bulk of the rescue work fellupon the Japanese themselves. Working parties reached Nagasaki on 19 Septemberand, because of the intervention of a typhoon, they reached Hiroshima on12 October.26Theseworking parties, consisting of U.S. Armed Forces medical personnel, directedtheir energies primarily to investigation of the many different medicaleffects of the bombing although, in the process, much good medical carewas rendered to Japanese civilian victims.
Two stimuli for the scientific and medical evaluationof these extraordinary events came from Washington: one, a request to AFPACfrom Maj. Gen. Norman T. Kirk, The Surgeon General, and Lt. Gen. LeslieR. Groves, director of the Manhattan Project, that Col. Ashley W. Oughterson,MC, and Lt. Col. Averill A. Liebow, MC, be detailed to make an immediatesurvey of the situation. The other stimulus was the formation of a groupby the Manhattan Project under the command of Brig. Gen. Thomas Farrell,with the medical component under Col. Stafford L. Warren, MC; this grouparrived in Japan in early September. These two groups were integrated beforeproceeding to the destroyed cities.
Access to the bombed areas was difficult because of thedisruption of rail and air travel. Nagasaki was accessible by sea; Hiroshimawas not, because of the presence of large minefields. Three naval medicalunits organized under the supervision of Cdr. Shields Warren, MC, USN,were dispatched to Japan from the United States. On 12 October 1945, aJoint Commission for the Investigation of the Effects of the Atomic Bombin Japan was established, with Col. Elbert DeCoursey, MC, as the seniormedical officer. This Commission was composed of the following three groups:the Manhattan Project Group, under General Farrell; the GHQ group underColonel Oughterson, representing the Chief Surgeon's Office; and a JapaneseGovernment group, under Dr. Masao Tsuzuki of the Imperial University ofTokyo. Responsibility for longtime followup was eventually assumed by theNational Research Council. Studies carried out under the auspices of thesegroups have been published by the U.S. Atomic Energy Commission in a monumentalwork of five volumes under the general title of Medical Effects of theAtomic Bomb in Japan.27
Nutrition
Historically, Japan has always had a food deficit, andfood imports amounted to about 15 percent of her requirements. The dietbasically was composed of rice, fish, and fresh seasonal vegetables. Duringthe war, the Japanese were on a restricted ration which became more severeas the war progressed and imports were curtailed. For example, the usualmilitary daily allowance of 3,400 calories had fallen to 2,900 by the endof the war. The
26Oughterson, Ashley W., and Warren, Shields: Medical Effects of the Atomic Bomb in Japan. National Nuclear Energy Series, Manhattan Project Technical Sec. Division VIlI-Volume 8. New York: McGraw-Hill Co., Inc. 1956, pp. 3 and 7.
27For summary volume of this work, see footnote 26.
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average civilian allowance was only 1,300 calories daily,but most people averaged 1,600; and, while the nutrition of the civilianpopulation had suffered, no serious problem in this respect existed.28
Desiring more data on the nutritional status of the civilianpopulation, SCAP directed that a nutrition survey be made in Tokyo in December1945 since rumors then were rampant that deaths were occurring from starvation.Similar surveys were made early in 1946 in Nagoya, Osaka, Kure, Fukuoka,Sapporo, Sendai, Kanazawa, and Matsuyama. In addition, an equal numberof people were surveyed in the rural areas immediately adjacent to theseurban areas. The surveys were repeated at 3-month intervals, about 150,000persons being surveyed each time.
The surveys consisted of studies of representative householdsin each area, data being obtained on the physical condition of the individualand his estimated daily caloric intake. As might be expected, the foodintake varied according to season, being highest in the fall and winterafter the harvest of the rice and sweet potato crops, and these variationswere most pronounced in the large urban centers. During the late summerperiods of 1946 and 1947, the average caloric intake fell to 1,300 caloriesin some of the larger cities. This decline was accompanied by an increasein the proportion of persons with one or more deficiency symptoms, suchas inadequate lactation, delayed menstruation, hyperkeratosis, glossitis,and anemia. Large stocks of canned meat held by the military forces wereparticularly helpful in meeting hospital requirements during the food shortagein the summer of 1946.
One of the most important programs begun by military governmentwas the school lunch program which, in particular, added protein and calciumto Japan's school population. Powdered skim milk was the basis of thisdiet change, which resulted in increased stature and weight for the newgeneration of Japanese. This change in the dietary pattern, which includednew emphasis on meat eating, has probably had a lasting effect on Japanesehealth according to subsequent reports.
Nevertheless, a shortage of food persisted during theentire occupation. An effort was made to supply some of the deficienciesthrough imports. This was not a simple problem for not only were many importedfoods, such as wheat, unfamiliar to the Japanese, but also their preparationcalled for increased fuel which was also in short supply.
Dental Affairs
During the war, civilian dental practice virtually disappearedbecause of the shortage of personnel and materials. Eight dental schoolsremained after the war and served as the nucleus for improving dental educationin Japan.
The Council on Dental Education was established earlyin the occupa-
28Memorandum, Col. Bruce P. Webster, MC, 12 Sept. 1945, regarding conference with Japanese Minister of Health concerning "Current Health Problems in Japan."
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tion to recommend educational reforms. Three years wereadded to preliminary schooling as a requirement for entry into dental college,and the dental school curriculum was substantially changed. A NationalBoard of Dental Examiners was established for the first time, and the JapaneseDental Association was reorganized as a nongovernmental society.
Plans were made to provide dental service in each of the800 health centers in Japan.
Nursing Activities
In prewar Japan, nursing had never received professionalrecognition, and in only a few hospitals did nurses, in fact, achieve professionalstanding. Standards of education fell during the war.
Under SCAP guidance, a Nursing Education Council was formedand was very active in the inauguration of a modern nationwide nursingprogram. Based on the council's recommendations and with supervision andassistance from American nursing personnel, refresher and full-time trainingcourses were started, educational standards were raised, and registrationand licensure requirements were placed into law.
On 1 June 1946, a model demonstration school of nursingwas opened in the Central Red Cross Hospital in Tokyo. The student bodyfrom St. Luke's College of Nursing, hitherto about the only modern nursingschool in Japan, was merged with that from the Central Red Cross Hospital,and the faculties of both schools were used to instruct the combined totalof 420 trainees. Other demonstration schools of nursing were planned.
Shortly after the occupation, the existing government-controllednursing societies were dissolved; in their place, the National Nurses Associationwas established as an independent professional organization.
Veterinary Affairs
Under the Department of Agriculture, the prewar veterinaryprogram was concerned mainly with the eradication of certain diseases,notably infectious osteomalacia and tuberculosis. During the war, civilianactivities were sharply curtailed, and the program concentrated on thecare of military horses. Although monthly inspections of dairy plants continued,there was virtually no meat inspection.
In 1946, a Council on Veterinary Affairs was establishedunder the guidance of SCAP, and this group reorganized the Japan VeterinaryMedical Association along democratic lines. Veterinary education was improved,and a new program for the control of animal diseases was promulgated. Stepswere also taken to increase the production of biologicals used in the controlof these diseases. The eradication of bovine tuberculosis was acceptedas a long range objective. An expanded immunization program to controlcanine rabies was also begun.
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Medical Supply Problems
Some insight into medical supply problems may alreadyhave been gained from the foregoing sections. Much of the shortage wasin materials which, while essential for health, were not commonly regardedas medical supply items; for example, fuel, clothing, hot water, soap,and bedding. However, there were also real shortages in strictly medicalsupplies.
Before the war, the Japanese pharmaceutical and alliedindustries had expanded to develop a large export business throughout theOrient. Generally, these supplies were produced in relatively small factories;and at the time of surrender, about half of these factories had been destroyedor diverted to the production of war materials. The capacity of the remainingplants was only about 20 percent of prewar requirements, and about two-thirdsof the output went to the Japanese Army and Navy.
Immediately after the arrival of the occupation forces,surveys were made to determine the medical supply situation. It was foundthat considerable potential for production of pharmaceuticals and hospitalsupplies existed and that management was eager to reestablish production.
The decision was made, therefore, (1) to attempt to rehabilitateindigenous production rather than to rely on extensive and expensive imports,and (2) to supplement this production by importing only those materialswhich could not be produced in Japan. Through SCAP directives, the Ministryof Welfare was required to develop procedures to fulfill its supply responsibilities.Ministry officials were given guidance and training to enable them to increaseproduction and to establish effective distribution.
Japanese and U.S. military medical supplies.-Atthe time of surrender, all Japanese military supplies and equipment weretaken over by the occupation forces. Upon completion of an inventory, nonwarmaterials, such as food, clothing, and medical supplies, were returnedto the Japanese Government for civilian use. Distribution of medical suppliesto normal civilian channels was delayed, however, because most of thesesupplies were concentrated in large depots and dumps often in remote areas.
Essential medicines and biologicals were imported in themonths following surrender while indigenous production was being established.Also of great value were U.S. Army surplus medical supplies which weremade available to relieve this critical shortage.
Production.-An overall production plan was developedin the early months of the occupation. The most essential and criticalitems were to be produced first. The whole operation required sweepingchanges in the system of production, control, and allocation of raw materials.Responsibility for medical supply items was firmly placed on the Ministryof Welfare. In addition, an Economic Stabilization Board was establishedto allocate raw materials to various industrial groups.
At the beginning of the occupation, acceptable biologicproducts of various types were desperately needed to prevent and controlinfectious diseas-
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es. One of the first major projects undertaken which hada high priority was the production of vaccines for typhoid, typhus, cholera,and diphtheria, and tetanus toxoid. Facilities for standardization andquality control were lacking and many biologicals produced in the earlyphases of the occupation were of dubious efficacy.
In 1946, a Laboratory Control Section was establishedin the Japanese Ministry of Welfare and a national laboratory control programwas inauguarated. Official minimum standards for the various biologicalswere promulgated for the guidance of the production laboratories. Suppliesof laboratory animals were developed and the production of penicillin,sulfonamides, DDT, and BCG was later brought under surveillance.
During the early stages of the occupation, X-ray machines,X-ray films, and the chemicals necessary for their development were unobtainable.By the end of 1946, production of these items was increasing rapidly, withpriority being given to the requirements of the antituberculosis campaign.
Initially, the Ministry of Welfare strictly controlledthe distribution of some 365 medical supply items, notably drugs, surgicaldressings, and infant foods. By the end of 1948, only 79 items were controlled.The distribution system was altered radically to place primary responsibilityon local health departments for distribution to hospitals, physicians,clinics, and pharmacies rather than to leave this responsibility with themanufacturers themselves.
A program designed to raise the level of pharmacy educationand practice was also begun by the Ministry of Welfare, under the guidanceofSCAP.
Narcotics Control
No control over narcotics existed in Japan before theoccupation, in disregard of her obligation to international bodies chargedwith regulating the supply and distribution of narcotics throughout theworld.
Upon occupation, the Japanese Government was directedimmediately to prohibit the cultivation of narcotic plants as well as themanufacture and exportation of narcotics, to enact laws establishing strictcentralized control over narcotics, to establish a narcotics enforcementagency, and to destroy all heroin supplies.29
CONCLUSIONS REGARDING JAPAN
It is beyond the scope of this chapter to describe indetail the renaissance of the Japanese health services. Moreover, one canonly speculate to what extent the American occupation was responsible forthe vast rebuilding of these modern and essential functions which contributeso much to the human welfare-a development that went beyond anything previouslyknown in Japan. When General MacArthur and his staff entered Japan, notonly had the military forces been completely defeated, but also the civilian
29See footnote 13 (4), p. 672.
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economy and social structure had almost disintegrated.The U.S. occupation forces began the immense task of reconstruction.
General Sams and his competent staff were able to mobilizethe health and medical resources of Japan to benefit the people. With thesteadfast support of the Supreme Commander, General Sams and his groupmoved quickly and decisively to encourage and direct the Japanese to establisha health system and a health service capable of dealing with the manifoldproblems of first a defeated people and then a reconstituted industrialnation. The Japanese people without the occupation forces eventually wouldhave achieved a degree of stabilization of its public health situation,but it is unlikely that this could have been accomplished so quickly orreached so high a level without the grand pattern imposed by the occupationforces within a period of a few months. Nor could it have been accomplishedwithout the willing cooperation, hard work, and professional competenceof the medical and allied professions of Japan. After all, the whole purposewas to help Japan return to the community of democratic nations where respectfor human rights and human welfare was a guiding principle.
Section II. Korea
CIVIL PUBLIC HEALTH
Organization of Military Government Health Activities
Korea was regarded by the Allied Powers as a friendlycountry rather than as a defeated enemy like Japan. However, since Koreahad long been under the domination of Japan, there was no local governmentwith which the Allied Powers could work. Hence, the immediate pattern ofAllied occupation was in the form of a benevolent military government.30
When hostilities ceased on 14 August 1945, the XXIV Corps,which had been heavily engaged in Okinawa and was reequipping and retrainingfor the assault on Japan, was designated as the force to occupy Korea.Advance elements arrived in Korea on 8 September. Included in the partywas Lt. Col. Joseph Auerbach, MC, who served as acting surgeon in the absenceof Col. Laurence A. Potter, MC, the Corps Surgeon, who was on leave. Alsoincluded in the advance party was Capt. Virgil H. F. Boeck, MC, whose firstmission was to survey American prisoners, determine health and sanitaryconditions in Korea, and locate sites for hospitals and other medical installations.The main components of the XXIV Corps, including the 6th, 7th, and 40thInfantry Divisions and ASCOM 24 (Army Service Command-24), began to arrivein Korea on 15 September.
On 15 August, the 38th parallel was designated as theline dividing the
30Material for this section is taken from (1) Historical Summation, Headquarters, U.S. Army Military Government in Korea, undated, subject: History of the Department of Public Health and Welfare, September 1945-May 1947, and (2) a paper by Col. James P. Pappas, MC, subject: Civil Assistance to the Republic of Korea, Public Health, 1950 Through 1954. [Official record.]
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Soviet and U.S. zones of occupation in Korea. The areanorth of this line consists of approximately 46,500 square miles whilethe southern section has a land area of about 38,000 square miles. Beginningin August 1945, Russian troops entered Korea and accepted the surrenderof Japanese occupation forces above the 38th parallel; U.S. forces acceptedthe surrender of Japanese forces below this line. A joint commission fromthe two occupying powers was formed to develop a four-power trusteeshipthrough which the United States, the Soviet Union, the United Kingdom,and China would oversee a provisional government until the Koreans wereable to govern themselves. However, the Soviets blocked all efforts bythe Koreans to unite their country and, in May 1948, the North Koreansestablished the People's Democratic Republic of Korea, followed by theformation by the South Koreans of the Republic of Korea. This account describescivil affairs/military government public health activities in South Korea.31
U.S. Military Government in Korea operated under Lt. Gen.John R. Hodge, Commanding General, XXIV Corps, until August 1948. Headquarters,U.S. Army Military Government in Korea, was established in September 1945and continued until August 1948. By June 1949, the last U.S. troops, withthe exception of military advisers, were withdrawn from South Korea. Thechief medical officer for Military Government health affairs was Dr. WilliamR. Willard of the U.S. Public Health Service, serving in the grade of colonel,MC, with the Armed Forces in Korea.
Under the Japanese organization of the Korean Government,public health activities were under the direction of the national policeand consisted largely of inspection and licensing. Welfare activities werecarried on as a function of the Department of Education.
By Ordinance No. 1, signed on 24 September 1945 by GeneralHodge, the Military Governor of Korea, the Public Health Section of theBureau of Police was abolished and a Bureau of Public Health was established.On 27 October, welfare activities were added, and the name was changedto the Bureau of Public Health and Welfare. Shortly thereafter, an ordinancewas issued, establishing a Department of Public Health and Welfare in eachprovince.
At the national level, the Bureau was administered bya director and consisted of two principal branches, Public Health and Welfare,each under a deputy director. The Public Health Branch included the followingsections: Medical Services, Preventive Medicine, Vital Statistics, Sanitation,Laboratories, Dental Affairs, Veterinary Affairs, Nursing Affairs, andPharmaceutical Affairs. The Welfare Branch consisted of seven sections:Administrationand Policy, General Relief, Research and Analysis, Welfare Training, Institutionsand Agencies, Bureau Housing, and Bureau Employee Welfare.
At the end of 1945, approximately 50 officers and 30 enlistedmen had
31ROTC Manual No. 145-200. American Military History, 1607-1958. Washington: U.S. Government Printing Office, 17 July 1959, p. 492.
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been assigned to the Bureau of Public Health and Welfare,of whom about two-thirds were a part of the Public Health Branch.
The activities of the provincial Bureau of Public Healthand Welfare were predominantly in the field of health, and the followingsections were organized: Medical Services, Preventive Medicine and VitalStatistics, Sanitation, Veterinary Affairs, Pharmaceutical Affairs, andWelfare.
By an ordinance promulgated in October 1946, the nationalBureau was designated a Department with its various sections being designatedBureaus. Concurrently, the provincial health organizations were renamedBureaus.32
Medical Influences in Prewar Korea
Korea, over the years, had been subjected to three majorinfluences in the field of medicine and public health: Chinese, American,and Japanese. Since ancient times, treatment of the sick in Korea had beenbased largely on Chinese herb medicines and Chinese philosophy of "positive"and "negative" influences-the Yang and Yin theory. Herbs were prescribedchiefly to restore the balance between Yang and Yin, surgery was primitive,and modern medicine as brought in by the Americans and Japanese made slowheadway against this long heritage of the past; presumably today it isstill a potent influence.
Western medicine was introduced first into Korea by Americanmedical missionaries in the last two decades of the 19th century. Whilethe main purpose was propagation of the Christian faith, good medical carewas a powerful component of the missionary effort.
With the advent of the Japanese who established a protectorateover Korea in 1905 and annexed the country in 1910, the American missionariesgradually were suppressed. From then on, the principal medical influencewas Japanese which, on the whole, represented the then current Westernpoint of view. Fifty hospitals were erected, five medical schools werestarted, modern waterworks were constructed, and quarantine stations wereestablished.
However, not only did the organization of public healthfollow the traditional Japanese pattern of subservience to the police,but also opportunities for Korean nationals to become proficient in administrationwere exceedingly limited. Thus, at the time of Korea's occupation by theAmerican Army, there were virtually no experienced public health personnel.
Health Situation at the Time of Occupation
There had been no fighting in Korea and, consequently,no destruction of medical and sanitary facilities although, during thewar years, the facilities deteriorated as did the quality of medical services.Vital statistics pertaining to births, deaths, and marriages were collectedroutinely by the Department of Justice. Statistics on the occurrence ofdisease, however, were
32See footnote 30 (1), p. 689.
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meager. Malaria was endemic, tuberculosis was prevalent,typhoid and dysentery were common, and the infant mortality rate was high.
The repatriation of large numbers of Koreans from Japanand China, with attendant crowding in port cities, presented unusual opportunitiesfor the spread of epidemic diseases. While quarantine stations (map 23)were maintained at the principal South Korean ports-Pusan, Inchon, Mokpo,and Kunsan-the enforcement of regulations at times was lax. At other times,the services were inadequate to cope with the workload.33
HEALTH PROBLEMS AND PROGRAMS
Vital statistics.-The reports of births, deaths,marriages, and divorces obtained through the Justice Department were continued,but an early step in the health program was to devise and inaugurate modernhealth statistics reporting as an integral part of health services. Thisprogram met with doubtful success because of the dual system. At the sametime, an effort was made to begin a system of communicable disease reporting,a program which was limited by the paucity of physicians in many areasof the country, by the lack of laboratories where definitive diagnosescould be made, and by the generally inadequate state of communications.
Reports of communicable disease were made first by thedoctor to the local administrative office. These reports were then forwardedto the Provincial Health Department where they were consolidated and submittedto the national office, usually with a delay of 2 to 4 weeks. As mightbe expected, there was believed to be substantial underreporting of manydiseases, confusion of terms such as typhus and typhoid, and designationof dysentery as cholera during epidemics of the latter disease.
Medical services.-While there was no destructionof hospitals and sanatoriums, virtually all the key personnel of theseinstitutions were Japanese; with their departure, services largely collapsed.Before the war, there were 795 Japanese doctors in South Korea and an unknownnumber of Korean "regular" doctors (as contrasted to folk-medicine doctors).By 1947, there were 2,317 Korean "regular" doctors, giving a ratio of 1to 8,300 population, but more than 30 percent of these were practicingin Seoul which had only 5 percent of the population of South Korea.
The 46 government-owned and -managed general hospitalshad a total bed capacity of 4,128. These were formerly used principallyby the Japanese; and after the war, the bed occupancy varied from 60 percentto a low of 5 percent during the cold weather because of inadequate heatingfacilities. However, nearly every practicing physician had his own privatehospital which varied in capacity from 1 to 100 beds; these facilitiesprovided most of the general hospitalization. The military government healthofficer often found himself trying to resolve conflicting claims of Koreansfor the right to operate the many private hospitals previously owned andoperated by Japanese physicians before repatriation.
33See footnotes 30 (1) and (2), p. 689.
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MAP23.-Quarantine stations at principal South Korean ports, fall 1945.
By the end of November 1945, the larger provincial andmunicipal hospitals and private hospitals in and near Seoul surveyed bymilitary government officials were found to have adequate medical suppliesby Korean standards although coal and food supplies were inadequate. Problemsof price, procurement, distribution, and transportation still remainedacute. However, the outpatient departments were very active, and the firsthealth center in Seoul had been officially opened.
In addition, there were two mental hospitals of 50- and30-bed capacity, three tuberculosis hospitals with a total bed capacityof 300, and four leprosariums with a total capacity of 29,000 to care foran estimated 40,000 lepers in South Korea.
Infant and child mortality.-Infant mortality wasabout 300 per 1,000 live births, and approximately one-half of all childrenborn died before the age of 5 years. Infant nutrition was far below Westernstandards.
Pediatric clinics were established in the provincial capitals,but the work of these clinics was limited by inadequate supplies and personneland seemingly by the general apathy of the people.
Port quarantine.-Four major ports were used byforeign commerce
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-Pusan, Inchon, Mokpo, and Kunsan. Quarantine stationsin each of these ports were under the direction of an American quarantineofficer. All incoming ships were inspected routinely; all crew membersand passengers were vaccinated for smallpox, cholera, and typhoid beforecoming ashore; and any ship found to be carrying patients with communicablediseases was quarantined. Nevertheless, cholera was introduced throughPusan in 1946.
Nutrition.-A nutrition section in the Bureau ofPreventive Medicine was established during the early months of the occupation;but after abortive attempts at nutrition surveys among the Korean populace,the section was discontinued because of a lack of experienced personneland funds.
Public health education.-Efforts were made throughradio, newspapers, town meetings, and posters to disseminate informationconcerning the control of communicable diseases, especially those epidemicat the time. An educational film on cholera control was produced in Koreaand widely shown throughout the provinces by a portable unit. As usual,accomplishments of this program were difficult to evaluate.
Medical education.-One of the first governmentalacts after occupation was to establish the Korean Board of Medical Licensure,composed of prominent Korean physicians and representing the National KoreanMedical Society, the Korean Board of Medical Education, and the Departmentof Public Health and Welfare. It was decided early to discontinue licensingof "limited" doctors (those trained by apprenticeship to regular doctors)and herb doctors, and to permit only those previously licensed by the Japaneseto practice. By August 1945, most of the medical practitioners in SouthKorea had registered with the National Board. Graduate courses for physicianswere organized in Seoul in October 1946, about 1 year after the end ofJapanese control, and 5-day graduate courses by visiting lecturers werearranged in each of the provincial capitals.
In the seven recognized medical schools in South Korea,administration was delegated by military government to the Medical EducationSection of the Education Bureau. At the same time, a Board of Medical Educationwas organized to establish standards and define policies for these schools.
In August 1946, Seoul National University was establishedin an attempt to bring the existing university up to standards approximatingthose of universities elsewhere. Merged into the national university werevarious Seoul colleges including the medical college. By September 1946,official recognition had been given to the College of Medicine of SeoulNational University, Severance Union Medical College, Seoul Women's MedicalCollege, Taegu Medical College, and Kwangju Medical College.
A 6-week course in public health was organized at SeoulUniversity in November 1945. The first class was comprised of 22 Koreanphysicians.
Preventive medicine.-One ofthe largest and most diverse health programs was developed under the Bureauof Preventive Medicine. Trained native health personnel were in criticallyshort supply, and few Korean physicians had experience in administrativehealth activities. Moreover, commu-
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nication was poor, the social and political situationswere confused, and black marketing of medical supplieswas widespread.
Communicable Diseases
Smallpox.-At the time of occupation, a number ofminor smallpox epidemics were reported, and the disease appeared to beon the increase. During the winter of 1945-46, a nationwide epidemic ofsmallpox occurred, the epidemic peak being reached in April, during whicha total of 19,809 cases were reported.
A program of compulsory vaccination had been in operationunder the Japanese, the custom being to vaccinate children at 1 year, againat 6 years, and a third time at 10 years. However, the results of vaccinationwere not checked routinely, vaccination technique was often poor, and doubtlesslythe vaccine deteriorated because of improper handling. At any rate, therewere obviously many nonimmune individuals in Korea at the time of the epidemic.
A nationwide program of vaccination was inaugurated inOctober 1946 under the auspices of military government. Approximately 18million doses were distributed in South Korea during the next 3 months.This vaccine was produced in the National Veterinary Laboratory at Pusan.By May 1947, only 113 cases of smallpox had been reported. Most of thecases had been traced to a visitor to North Korea and occurred in one ofthe more isolated regions of South Korea (Kangnung area of Kangwon-Do).
Japanese B encephalitis.-Late in the summer of1946, three cases of Japanese B encephalitis occurred in U.S. troops inthe Kunsan area of Cholla-Pukto Province. No cases were found among thecivilian population at the time, but the mosquito vectors of the diseasewere found. Random survey of blood samples from Koreans showed a high frequencyof antibodies to this virus.
Typhus fever.-At the time of the Allied occupation,the United States of America Typhus Commission had begun a survey of typhusin South Korea and predicted that the incidence would probably be considerablyhigher than it was the preceding year. By November, a dusting program hadalready been started in Kyonggi Province, at the border stations alongthe 38th parallel, and at the Seoul Railroad Station. Casefinding and insectcontrol teams likewise were being trained in all provinces. Despite thesesteps, during the winter of 1945-46, a typhus epidemic occurred in SouthKorea, with a total of 5,869 cases being reported. The highest incidencefor any month was 1,064 cases reported in April. Delousing measures andvaccination programs were begun, but these measures seemed to have littleeffect on the course of the epidemic which ended in June.
During the winter of 1946-47, typhus recurred with 1,183cases being reported by 1 May. The picture was somewhat confused by thepresence of relapsing fever, which tended to be endemic with low mortality.
Typhoid fever.-This disease had a high endemicincidence in Korea throughout the early occupation period, 9,319 casesbeing reported during
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the first half of 1946. The disease was believed to havebeen transmitted by carriers since no explosive outbreak attributable tocontaminated water was encountered. Vaccination programs were conductedin areas of high concentration of the disease, but no nationwide programwas initiated because of the shortage of laboratory supplies needed toproduce vaccine.
Cholera.-An alarming epidemic of cholera occurredas the Koreans were being repatriated from China. The disease was introducedinto the province of Kyongsang-Namdo and spread to the whole of South Korea.The first case occurred in May 1946 and the peak incidence was observedin July, the epidemic being assisted by widespread floods in June. Altogether,15,642 cases of cholera were reported with 10,191 deaths; the actual numberwas believed to have been much higher since concealment of cases by familieswas common. No cases occurred in U.S. military or civilian personnel ortheir dependents.
A nationwide anticholera vaccination program was begunin June 1946, and by late August, almost all persons south of the 38thparallel had received cholera vaccine. The National Vaccine Laboratoryin Seoul produced approximately 30 million cc., and 10 million cc. werereceived from Japan. Quarantine measures and restriction of travel wereinvoked but were believed to have had only a limited effect. Most cholerapatients received little or no treatment because hospital facilities werelacking in many of the areas involved. Where it was possible to obtainand use intravenous fluids, the case fatality rate was greatly reduced.
Epidemiologic and bacteriologic studies indicated thatthe principal means of spread was through contaminated surface drinkingwater and through infected food consumed at large funerals, a common practicein Korea. The shortage of doctors in the provinces made prompt detectionand isolation of cases difficult. Eventually, teams of physicians and medicalstudents were dispatched to the provinces where they assisted in earlycase-finding, vaccination, and isolation of contacts, and in obtainingstool cultures on all suspected cases and immediate contacts. The policeand constabulary worked in coordination with public health officials inenforcing quarantine restrictions, establishing roadblocks, and restrictingcivilian traffic by rail and water. The highest incidence of cholera occurredin the provinces of Kyongsang-Pukto and Kyongsang-Namdo. A severe epidemicof cholera is believed to have occurred in North Korea at the same time,but no facts are available.
Diphtheria.-Diphtheria was a major cause of childhoodmorbidity in Korea during the years under discussion. In 1946, 864 caseswere reported; and 457 cases were reported from 1 January to 1 May 1947.Toxoid immunization had not been used in Korea, and facilities for itsproduction were not available. Diphtheria antitoxin was readily availablefrom the National Laboratory in Seoul.
Malaria.-The occupation troops had a high incidenceof malaria. Although the disease was not a major cause of disability amongKorean civil-
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ians, the spleen and parasite index was high, indicatingits endemic occurrence. Malaria control measures were conducted principallyby the Armed Forces (fig. 89).
Tuberculosis.-Tuberculosis was probably the mostwidespread and, in the long run, the most disastrous of all diseases inKorea although its occurrence was less spectacular than the epidemics ofsmallpox, typhus, and cholera. Tuberculosis was estimated to cause approximately45,000 deaths annually. By May, little progress had been made in institutinga civilian health program directed to the control of this disease. Lackof progress was attributable to the shortage of sanatorium beds and X-rayfacilities. A Korean Antituberculosis Association, formed in the fall of1945, was not effective because of lack of supplies. Construction of theMason Tuberculosis Sanatorium, in Kyongsang-Namdo, was begun under themilitary government; the sanatorium opened in June 1946. By December, 116beds were occupied, but months elapsed before the hospital was functioningeffectively. Deficiencies in tuberculosis control must be counted as oneof the more serious gaps in the civil public health program in Korea
Venereal diseases.-The accurate incidence of venerealdiseases was not known although the high rate among occupation troops wasclear evidence of high frequency in the civilian population. Prostitutionhad been legal in Korea for many years. There were no public clinics anddiagnostic and treatment facilities were inadequate. At the insistenceof the occupation forces, a program of venereal disease control was inauguratedby military government personnel in November 1946. Free clinics were establishedin all the provincial capitals, diagnostic facilities were provided, andadequate supplies of penicillin were made available. By May 1947, however,there was little tangible evidence of effective control among civilians.
Laboratory Program
When the State laboratories of Korea passed from Japaneseto Korean hands, they constituted a rundown physical plant which had neveradequately produced the volume or variety of biologicals needed for thehuman or animal population of Korea Moreover, essential phases of the relativelysmall-scale production had been entirely dependent upon skilled Japanesepersonnel since the few Koreans employed had occupied only positions demandingless skill.
During 1946, the following were produced: vaccines forcholera, pertussis, rabies, smallpox, typhoid, and typhus; also diphtheriaand meningococcus antiserums, diagnostic antigens for cholera, dysentery,typhoid, paratyphoid A and B, typhus, and tuberculin, as well as diagnosticantiserums for cholera, dysentery, typhoid, and paratyphoid A and B.
Since many of these biologicals were produced in smallquantities, the local supply was augmented through imports. In addition,various biologicals were produced for use in animals. Comparative costsof local production and importation of the same biologicals showed thatsubstantial sav-
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ings would result from increasing production capabilitiesin Korean laboratories.
Under military government, a National Chemistry Laboratorywas established as a part of the governmental laboratory system. This facilitycarried out synthesis and preparation of organic compounds required byother laboratories, such as purification of glycerin and phenol; synthesisof trichloracetic acid and preparation of peptone; toxicological studies;certain nutritional studies on selected population groups; preparationof certain drugs such as chaulmoogra oil; and the chemical analysis ofwater.
Sanitation Problems
Before military government took over the management ofinternal affairs in Korea, most of the sanitary work was under the Bureauof Police. Japanese personnel were responsible for water and sewage facilities.When military government was established, sanitation problems became aresponsibility of the National Health Services Bureau of Sanitation.
While the larger cities had reasonably efficient watersupply systems,
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most of the smaller towns and villages were supplied bywells, an estimated 240,000 in all. Sewage systems in the larger citiesfunctioned fairly well; garbage collections, however, were never satisfactory,largely because of the shortage of trucks and gasoline.
During the period of military government, an effort wasmade to develop programs of sanitary inspection of restaurants, hotels,and markets, and to establish some control over public toilets, burialgrounds, and the housing of animals and fowls in relation to public wells.These programs developed slowly and were only partially effective.
Nursing Services
Under the Japanese, Korean nurses had been little morethan servants. Most of the professionally trained personnel were Japanese,and these held all the key posts in the hospitals and schools of nursing.There was no public health nursing program, and midwifery was uncontrolled.When most of the Japanese nurses were removed during the war, trainingactivities ceased.
Under military government, a Nurses' Educational Committeewas formed to survey available personnel, curriculums of schools of nursing,lawsrelating to nurses and midwives, and methods of examination and licensure.
The 20 schools of nursing in Korea varied in quality fromthe high standards of Severance Union Hospital School of Nursing to verylow standards in some of the provincial hospitals. From the deliberationsof the Nurses' Educational Committee, a smaller study group consistingof three doctors and five nurses was formed; and on the recommendationsof this group, a program was begun to improve the nursing profession inKorea. Among the accomplishments under this program were the following:On 15 January 1946, a Nurse and Midwife Licensure Board was establishedwhose function was to prescribe curriculums and standards for nursing andmidwifery education and licensure. The board also proposed the establishmentof a National Korean Nurses' Association and provincial nursing associations.Four refresher courses of 2 months each for graduate nurses were organized,and 186 students graduated from them; four refresher courses in midwiferywere also completed with a total of 50 students in attendance; and fourcourses of 3 months each in public health nursing were completed by 69graduates. A 3-month course for training instructors and chief nurses wasbegun on 1 April 1947, with 22 graduate nurses enrolled. As of 1 June 1947,Korea had 746 recognized graduate nurses, 774 student nurses, 227 nursesaides, and 1,200 midwives.34
Textbooks on pediatrics, nursing arts, and nursing ethicswere translated and printed. Course outlines were prepared by the Koreanstaff for use in advanced nursing courses and in schools of nursing. Planswere also laid for a small-scale visiting nurse program. Four nurses wereselected for
34See page 11 of footnote 30 (1), p. 689.
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inservice training in the United States, under the auspicesof the Rockefeller Foundation, and an expansion of that program was envisioned.Plans were laid for the publication of a Korean journal of nursing.
Dental Services
The only dental college in Korea at the time of the Americanoccupation had been operated as a privately owned school by a group ofJapanese; at the end of the war, it was taken over by a group of Koreandentists. Responding to political pressure, the school subsequently wasturned over to the Government and became a part of Seoul National University.Its curriculum was converted gradually to the American pattern of dentaleducation.
No dental materials or equipment was produced in Korea;all came from Japan or the United States. At the time of American occupation,about 400 Korean and 900 Japanese dentists were practicing in Korea. Whenthe Japanese dentists were repatriated, their offices and equipment wereturned over to the Government for leasing to Korean dentists, especiallythose coming from North Korea.
Professional standards were low. No graduate of the KoreanDental College was required to pass a licensing examination although suchexaminations were required of graduates of foreign schools. A school dentalprogram which had been in operation before the war lapsed because of ashortage of dentists.
With the organization of the Department of Public Healthand Welfare, a Bureau of Dental Affairs was established, with both Americanand Korean directors. National laws pertaining to dental affairs were revisedto conform more nearly to the U.S. Code in these matters. A Board of Qualificationand Examination was set up and all dentists were subjected to relicenseprocedures. Authority was obtained from the Department of Finance for dentiststo purchase gold for professional use and, subsequently, about 135,000grams were released annually for this purpose.
Other dental materials and supplies, obtained from Armysurplus stores, were distributed to the dental college and to practicingdentists through the Seoul Dental Supply Co., which was privately operated.This company was also licensed to import dental materials and equipment.
Because of the extreme shortage of dentists, a plan wasevolved whereby experienced dental apprentices could take a course of lecturesin the dental school, followed by an examination, and be issued a limitedlicense to practice in the provinces for a period of 5 years.
As military government drew to an end, progress was beingmade slowly toward establishing school dental hygiene programs, organizinglow-cost dental clinics in hospitals and health centers, and improvingthe educational standards and equipment of the dental college.
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Veterinary Affairs
Before the establishment of military government in Korea,veterinary services, as such, did not exist as a governmental function.The relatively few Korean veterinarians practicing under the Japanese supervisionwere not well trained by modern standards. At the time of the occupation,an epizootic of rinderpest in North Korea threatened to decimate the livestockpopulation of the whole of Korea. Supplies and equipment for veterinarypurposes were limited to a small quantity of Japanese stocks.
A Bureau of Veterinary Affairs was established withinthe Department of Public Health and Welfare soon after the inaugurationof military government. During the Japanese control, animal treatment andrelated activities had been regarded as an agricultural function whilemeat inspection and other sanitary functions were under the supervisionof the police. A combination of these two activities into a single governmentalbureau was believed desirable, in part to make better use of scarce personnel.
The most urgent problem was to establish effective controlof the spread of rinderpest from North Korea. This involved securing laboratoryanimals, producing rinderpest vaccine, and sending teams into the fieldsto immunize all cattle in a zone 15 miles wide along the 38th parallel.Presumably this immune zone, which was rigidly maintained, created an effectivebarrier.
Rabies, which is enzootic throughout Korea, reached epizooticproportions on the island of Cheju-Do during the winter of 1946. A programof restraint and vaccination of the canine population was instituted, andthe outbreak was completely controlled within 3 months.
Attention was given concurrently to other veterinary programswhich included inspection and licensing of slaughterhouses, pasteurizingplants, fish and meat markets, and tanneries. Most important were measuresdesigned to increase the number of veterinarians and improve the qualityof their education. Formerly, veterinary education, such as it was, wasat the equivalent of American high school level and was under schools ofagriculture. Under military government, minimum requirements were raisedto include 4 years of college work, and plans were laid to establish aCollege of Veterinary Medicine in Seoul. In the interim, plans were madeto send students to veterinary colleges in America.
Census figures, even though only approximate, indicatethe serious decline in the animal population in South Korea from 1938 to1947 (table 5).
A national ordinance, designed to control the slaughterof animals and preserve the remaining livestock, was enacted; breedingof animals was encouraged; and production goals were established.
In September 1946, a new curriculum was introduced inthe College of Agriculture and Forestry, which established a School ofVeterinary Medicine in Seoul National University.
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Medical and Related Supplies
Most of the 72 major drug manufacturing plants in Koreaunder the Japanese were in the vicinity of Seoul. Immediately upon occupation,these plants were put under guard and their funds were frozen; after anaudit, military government officials invited bids for their operation.Successful Korean bidders were required to furnish cash bond covering 30percent of the appraised value of each concern. Considerable difficultywas experienced in finding the personnel required to operate these plants;by the end of November, only 20 plants were in operation, with productionranging from 5 to 60 percent of normal. Raw materials were available, butessential fuel was in short supply.
TABLE5.-Estimated animal population in South Korea, 1938, 1943, and 1947
| Animal | 1938 | 1943 | 19471 |
Cattle, draft | 1,717,000 | 1,062,000 | 661,141 |
Cattle, dairy | --- | 2,000 | 1,124 |
Horses | 51,200 | 35,000 | 34,142 |
Sheep | 27,000 | 48,000 | 3,546 |
Goats | 44,000 | --- | 25,663 |
Swine | 1,507,000 | 636,000 | 181,331 |
Poultry | 7,165,000 | 2,983,000 | 1,516,364 |
1As of 1 January 1947.
Source: Historical Summation, Headquarters, U.S. ArmyMilitary Government in Korea, undated, subject: History of the Departmentof Public Health and Welfare, September 1945-May 1947, p. 14.
No appreciable quantity of surgical instruments or oflaboratory, X-ray, dental, or veterinary supplies had ever been manufacturedin Korea. Upon occupation, estimates for a 6-month period called for deliveryof 360 basic medical units at the rate of 20 every 10 days, starting assoon as possible. By the end of March, some units had been received throughthe Port of Inchon. Each medical unit was designed to provide for 100,000persons for 30 days.
Before the American occupation, the Bureau of PharmaceuticalAffairs was controlled by the Bureau of Police, with three-fourths of itspersonnel being Japanese. Under the direction of an American military governmentofficer, three Koreans, remaining in the Bureau after discharge of theJapanese, inventoried Japanese medical supplies in the hands of drug wholesalers.Supplies uncovered amounted to approximately 664 items, plus 150 itemsof herb medicines.35
Shortly after occupation, the Korean Medical Supply Co.was named as the agent for the Department of Public Health and Welfareto inventory, receive, and distribute all recovered Japanese supplies andall medical supplies received from the United States. Distribution quotasfor each prov-
35See page 16 of footnote 30 (1), p. 689.
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ince were determined by the Bureau of Pharmaceutical Affairs,which was transferred to the Department of Public Health and Welfare. Provincialhealth departments controlled the allocation of supplies to hospitals anddoctors in their areas. To expedite distribution, one or more drug wholesalerswere designated in each province as distributing agents for the healthdepartment.
In January 1946, a Pharmaceutical Affairs Committee wasorganized to study existing laws and regulations pertaining to drugs andthe drug business. In March, a new ordinance36was published which, among other provisions, prohibited the sale of drugsby street peddlers, which had been the practice under Japanese rule. InMay, a further ordinance37promulgated by military government placed the control of all medical suppliesunder the Department of Public Health and Welfare; in July, Ordinance No.96, covering registration and licensing of pharmacists, drug manufacturers,wholesalers and retailers, was published. Immediately, 441 pharmacistswere licensed while 105 applications were disapproved.
The first of 360 CAD medical units were received in March1946, and additional units were delivered through November of that year.Early in 1946, the Korean Pharmaceutical Promoting Co. was organized bythe Bureau of Pharmaceutical Affairs to increase the output of locallyproduced pharmaceutical supplies. This organization, consisting of 70 to80 drug manufacturers in South Korea, controlled the allocation of rawmaterials to drug manufacturers. Among locally produced drugs were suchitems as alcohol, iodine, bismuth nitrate, sodium bromide, sodium chloride,dextrose, and a few insecticides. High-quality cod liver oil was beingproduced in North Korea and steps were taken to import it into South Korea.The military government attempted to increase the number and types of pharmaceuticalitems produced in Korea; in April, they published an official price-listestablishing ceilings on the retail prices of drugs.
In November 1946, responsibility for production and controlof narcotics was given to the Department of Public Health and Welfare.At that time, large quantities of narcotics, including 28 million gramsof opium, were turned over to the Bureau of Pharmaceutical Affairs. Anotherordinance38forbadethe growth or possession of poppy or poppyseeds in any form although itsenforcement continued to be a problem throughout the occupation period.Previously, large quantites of opium were processed in Korea; in the Seoularea alone were 10 narcotics manufacturing plants, one of which was reportedto be the largest in the world. Data indicated that the Japanese were producingenough opium in Korea to meet world needs.
36U.S. Army Military Government in Korea Ordinance No. 62, 29 Mar. 1946, subject: Regulation of Drugs, Medicines, Pharmaceuticals and Related Articles.
37U.S. Army Military Government in Korea Ordinance No. 90, 28 May 1946, subject: Economic Controls.
38U.S. Army Military Government in Korea Ordinance No. 119, 11 Nov. 1946, subject: Narcotics Control.
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Red Cross
Under the Japanese, the Korean Red Cross was, in effect,a branch of the Japanese Red Cross, and all of its senior personnel wereJapanese. Its program was largely medical and its activities included theoperation of a large modern hospital near Seoul and a tuberculosis sanatoriumat Inchon. Originally, supervision of the Korean Red Cross was placed bymilitary government under the Foreign Affairs Division but, in December1945, was transferred to the Welfare Division of the Department of PublicHealth and Welfare. Plans were made to expand its program to include suchfunctions as disaster relief and community organization.
In January 1946, the first American Red Cross civilianrelief team arrived in Korea and began to reorganize the local Red Crossservice. In July, the Korean Red Cross was recognized officially as a corporationunder the civil code although, because of internal frictions, completeautonomy was not gained until March 1947.
The Health of Occupation Troops
A major objective of the civil public health program inKorea-the protection of occupying troops-was accomplished. The XXIV Corpswas relatively free of epidemic disease during the last quarter of 1945and during 1946. Malaria, however, was a major problem; 1,868 new caseswere reported in troops in 1946, with 65 definitely established as havingbeen acquired in Korea.
EVALUATION OF PERSONNEL AND
ADMINISTRATIVE PROBLEMS
The key officers in health affairs of military government39wereColonel Potter, surgeon of the XXIV Corps, and Dr. Willard, the U.S. officialin charge of the civil health program. In April 1946, Col. William D. Willis,MC, replaced Colonel Potter as the Corps surgeon. A goal of the programwas to train Koreans for posts of responsibility as rapidly as possibleso that initially, in each major post in the health field, there were bothan American officer and a Korean civilian. However, not only were therefew trained Koreans in public health, but also the Army rotation policyreturned troops rapidly to the United States, so that few of the officersor enlisted men who entered Korea early in the occupation stayed more thana few months. Such rapid turnover made effective work difficult.
The problem was aggravated further by personnel shortages.Numerous officers trained for military government were retained in theUnited States and separated from the Service; many of those who subsequentlywere assigned to this duty had no understanding of the purpose of the occupationand little interest in anything except returning home. Of particular
39Much of the material in this section is taken from: Willard, W. R.: Some Problems in Public Health Administration in the U.S. Army Military Government in Korea. Yale J. Biol. & Med. 19: 661-670, March 1947.
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concern was the attitude of medical officers who wereassigned as health officers without preparation, some of whom displayeda feeling of resentment and helplessness. Fortunately, some of these officersadjusted well and used common sense and ingenuity in accomplishing theirvarious missions.
The shortage of trained professional personnel for militarygovernment health affairs was aggravated also by a scarcity of Servicepersonnel such as administrative assistants and stenographers. The lackof office supplies and motor vehicles was felt as keenly as were shortagesof medical supplies. All of this seriously impaired the efficiency of theprofessional personnel. For example, the officer in charge of laboratoriesspent much time in scrounging material from other Army units to rehabilitatelaboratory equipment or to make culture media; in waiting for a jeep totake him to the laboratory; in making out payrolls for his Korean employees;in negotiating with the finance office of the military government for expensemoney; and in typing his own reports rather than in directing the manufactureof biological products or in training Koreans to do the laboratory work.
Military Government Ordinance No. 1, and some succeedingordinances, created confusion among the various governmental agencies asto responsibility for public health administration. It was not realizedin how many different police laws public health matters were covered. Venerealdisease control among prostitutes, sanitation of eating establishments,public bathhouses, and other matters were retained under police controlby virtue of their coverage in the Peace Preservation Section of policelaws which were not broken down in the new ordinances with the appropriatetransfer of jurisdiction to the Department of Public Health and Welfare.Similar jurisdictional difficulties arose with the Department of Agricultureconcerning veterinary problems, with the Department of Justice concerningvital statistics, and with the Department of Commerce concerning drug manufacture.To secure additional legislation or administrative agreements with thedepartments concerned proved difficult and time consuming. The delays causeddissatisfaction in the field; despite them, some men established localrelationships which enabled them to solve pressing local problems.
Bureau Memorandum No. 1, issued in November 1945, directedeach province to organize a Bureau of Public Health and Welfare which,for all practical purposes, was a small-scale replica of the National Department.Because personnel were scarce, most provinces were only partially organized,with several consolidated sections, although some had an almost completeorganization. The provinces were given wide latitude in organizing theirsubordinate governmental units. At the same time, other national departmentswere directing the organization of their counterparts in the provincialgovernments, but it became apparent that overall direction and coordinationwere necessary to insure balance in the relative size of different agenciesof government and to put a ceiling on the number of employees.
Eventually, a Secretariat of Provincial Affairs was createdand directed to draw up a plan of organization for all echelons of Governmentas well
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as to approve budgets within its limit. This work progressedslowly because of the concept that Korea had always managed with very littlehealth work or organization, and now was no time to make an expensive expansionof the organization, particularly in view of the very limited trained personnel.In contrast, however, was the necessity of capitalizing on this uniqueopportunity to give Korea an effective public health organization. A skeletonorganization at all levels of government was believed necessary. Fleshcould be added to the skeleton later, but it might be difficult later tocreate the skeleton.
The problem was more complicated than this, however. Theprovincial departments of Public Health and Welfare were already organizedmore or less according to Bureau Memorandum No. 1. If the Department werereorganized with fewer sections as required, it would result in importantresignations because Koreans, more than Americans, will not accept a reorganizationwhich means a compartive loss of position in the administrative chain ofcommand. Personnel were too scarce to risk any loss.
The problem finally was solved, but only after considerabledelay, for the provincial personnel believed they could not go ahead withtheir organization and program until the organizational pattern was fixed.
Dr. Willard, in summary, stated, "A medical officer withno previous experience in Military Government cannot visualize clearlythe problems in the early stages of an occupation. Those who had theoreticaltraining in Military Government Schools acquired some familiarity withthe nature of the problems, although theory and practice differed widely.The time required for administrative work far overshadowed that devotedto medical work."
Although smallpox and typhus, for example, representedmajor epidemic control problems, the health officers soon found that theirprimary job was not vaccinating and dusting with DDT, but in making itpossible for others to do this work. This required the recruitment of personnel,not always an easy matter. Delays in defining organization patterns andpolicies handicapped some health officers in securing authorization toemploy the necessary help. Delays in establishing fiscal policies and procedurescaused some embarrassing delays in paying salaries. Procurement of suppliesrequired more than requisitions if supplies were to be expected; it requiredtelephone calls in a country where the service was exasperatingly poorwhen not impossible, or personal trips under difficult conditions. Afterprocurement, the task of arranging for delivery was not easy in a countrywith little public, and inadequate army, transportation. These were someof the problems of epidemic control for the health officers in the earlymonths of occupation.
The rehabilitation and maintenance of hospitals were muchgreater tasks than anyone anticipated. The hospitals needed coal, food,drugs, dressings, paint, window glass, soap, and instruments. Considerablescrounging
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was necessary to supply hospitals, and much effort wasrequired to make the Koreans keep the hospitals clean.
Rice became scarce and inflation developed, creating problemsfor the health officer. Special rationing arrangements had to be workedout for hospitals, and difficult problems of adjusting wages for nursesdeveloped. Strikes by nurses were narrowly avoided in several instances.The strike threat was usually related to the wage problem; occasionally,to political agitation.
These experiences provide lessons from which the UnitedStates may profit if the Nation again has to inaugurate military government.
Advance planning for public health administration in Koreawas clearly inadequate. The Army did not realize the magnitude, complexity,or technical nature of military government until too late.
Medical officers must have some training in military government,particularly in public health administration. This is more important thanspecial knowledge about disease conditions in a particular area.
