History

Part II

THE AMERICAS

CHAPTER IV

The United States, Its Territories and Possessions,and the Panama Canal Zone

Stanhope Bayne-Jones, M.D., Ira V. Hiscock,M.P.H., M.D., and
Major General Morrison C. Stayer, MC, USA(Ret.)

Section I. The United States

Stanhope Bayne-Jones, M.D.

In the continental United States, from 1939 through 1945,there were two main types of operations in civil affairs and military governmentand its associated public health activities. One type was the deliberative,policymaking, planning, and directive activity carried on at the highest levelsof the Government and its principal agencies, among which the War Department andthe U.S. Army were especially important. This type constituted the centralsource and authority where ideas and requirements were received and from whichoperational directives were sent to all appropriate Army services throughout theworld, wherever U.S. and Allied military organizations were either directly orindirectly engaged. The other type was represented by the civil affairs andmilitary government public health activities which took place on an operationallevel within the continental United States, and its territories and possessions,because of the Nation's military activities at home. Although not always solabeled, these operations had many of the characteristics of civil affairs andmilitary government public health activities, and they furnished valuableinformation and experience for similar work overseas. The purpose of thissection, and the two succeeding it, is to present examples of what might becalled domestic civil affairs and military government public health activities,which developed somewhat unexpectedly to fairly large dimensions in someinstances. As in foreign countries, so also on the homefront, these activitiesinvolved collaboration among military and civilian authorities and agencies;liaison between military and private organizations; public relations; legal,economic, and social questions, and logistics They also imposed somerestrictions upon individual liberties.

Turning first to those examples that occurred in thecontinental United States, consideration is given in this section to: (1)extra-military area sanitation and disease control, (2) maneuvers, and (3) enemyalien supervision and control, including the evacuation of Japanese fromCalifornia and other areas along the West Coast.

SANITATION AND DISEASE CONTROL OUTSIDE
MILITARY AREAS

Since ancient times, potential health hazards have beenshared mutually by a military post and its surrounding civilian community. Thenatural environment, if it contains endemic diseases or is the habitat ofvectors of infectious agents, is a source of sickness among soldiers andcivilians. Furthermore, the environment may become contaminated by eitherelement of its human population. Hence, the application of general and specificmeasures of preventive medicine and public health, routine in peacetime, becomesurgent in wartime.

The extraordinary conditions that developed in regions andcommunities in the vicinity of both old and new Army posts and camps, and aroundinduction centers, training centers, and maneuver areas, required not only theenforcement of routine measures for health protection but also the invention anduse of novel methods and new types of organizations. In response to these needs,a high degree of collaboration, based upon World War I experience, developedbetween the Army and the U.S. Public Health Service; the public health officialsof States, counties, and municipalities; and private civilian organizationsconcerned with the health and welfare of both citizens and soldiers. All workedtogether in the system which became known as extra-military area sanitation orextra-cantonment sanitation.

Accounts of this system have been published by tworepresentatives of the Army, Col. (later Brig. Gen.) James S. Simmons, MC,¹chief of the Preventive Medicine Service, and Lt. Col. (later Col.)William A. Hardenbergh, SnC,²chief of the Sanitary EngineeringDivision, Surgeon General's Office; and by the historian and Assistant SurgeonGeneral of the U.S. Public Health Service, Ralph C. Williams, M.D.³

In areas surrounding the usual military reservations and bothwithin and outside the vast maneuver areas, sanitation and sanitary engineeringunder this system accomplished prodigies despite conflicts involving divergentpersonalities, interests, jurisdictions, and philosophies. Water supplies wereimproved, enlarged, and purified. Sewerage disposal systems and waste disposalplants were installed. Food supplies and food services were inspected, cleanedwhere necessary, and supervised. Insect and rodent control was effectivelycarried out. All the usual methods, plus some new ones, were applied for theprevention and control of communicable diseases. Accident prevention wasattempted on roads and highways. Military police, as an arm of militarygovernment, affected the behavior of soldiers and

¹Simmons, J. S.: The PreventiveMedicine Program of the United States Army. Am. J. Pub. Health 33: 931-940, August 1943.
²Medical Department, United StatesArmy. Preventive Medicine in World War II. Volume II. Environmental Hygiene.Washington: U.S. Government Printing Office, 1955. ³Williams, Ralph Chester: The United States Public HealthService, 1798-1950. Washington: Commissioned Officers Association of theUnited States Public Health Service, 1951, pp. 322-326, 625-629.

their companions outside Army installations. New legislationwas enacted, notably the May Act, for the control of venereal diseases. Of allthese undertakings, three deserve special consideration because they brought tobear upon the problems most of the elements of domestic civil affairs andmilitary government public health activities: (1) venereal disease control, (2)malaria control in war areas, and (3) extra-cantonment environmental sanitation,especially as related to establishments serving food and beverages.

Venereal Disease Control

The closest possible cooperation and collaboration among theArmy, the U.S. Public Health Service, civilian agencies and organizations, andthe communities were required to attain a measure of control over venerealdiseases among troops in the continental United States. The activities andachievements of these organizations are discussed frankly and in detail by Lt.Col. Thomas H. Sternberg, MC, and associates in another volume of the history ofthe Medical Department in World War II.⁴

During 1939-40, as the probability of U.S. involvement inthe European war increased, the military services, the U.S. Public HealthService, and the American Social Hygiene Association, recalling their jointaction in World War I, met to revive their collaboration for the control ofvenereal diseases. Out of their conferences emerged a joint resolution, formallytitled, "An Agreement by the War and Navy Departments, the Federal SecurityAgency, and State Health Departments on Measures for the Control of the VenerealDiseases in Areas Where Armed Forces or National Defense Employees areConcentrated." The resolution was more commonly known as the Eight-PointAgreement. Its main objective was the suppression of commercializedprostitution. This agreement was adopted by the Conference of State andTerritorial Health Officers, held from 7 to 13 May 1940, and was promulgated tothe Army by The Adjutant General on 19 September 1940. "Throughout the war,with minor exceptions, the close liaison and cooperative relationshipestablished by this agreement between the Army, the U.S. Public Health Service,the American Social Hygiene Association, and, later, the Social ProtectionDivision of the Federal Security Agency [under the direction of its initiator,Mr. Charles P. Taft (and the State Health Departments)], operated effectively toproduce an integrated civilian venereal disease [control] program."⁵

Suppression of prostitution was the policy of the WarDepartment throughout the war. But it was often difficult, sometimes impossible,to bring some of the commanding officers and certain medical and public healthofficials into line with the official policy. In addition, its requirements were

⁴Medical Department, United StatesArmy. Preventive Medicine in World War II. Volume V. Communicable DiseasesTransmitted Through Contact or By Unknown Means. Washington: U.S. GovernmentPrinting Office, 1960, pp. 139-331.
⁵See pages 140-141 of footnote 4.

resisted by soldiers, prostitutes, pimps, panderers, andother moneymaking exploiters. Despite much effort, it became evident by late1940 that local law enforcement facilities were inadequate in many communities.

This deficiency of enforcement became conspicuous when Armymaneuvers became more frequent, deployed larger and larger forces, and occupiedmore and more land. To strengthen the means for enforcement, a bill wasintroduced on 20 January 1941 by Congressman Andrew J. May, chairman of theHouse Committee on Military Affairs. This bill, H.R. 2475, was passed on 11 July1941, and was officially known as the May Act. It was designed "to prohibitprostitution within such reasonable distance of military and/or navalestablishments as the Secretary of War or the Secretary of the Navy or bothshould determine to be needful to the efficiency, health, and welfare of theArmy and/or Navy, it became more than the policy of the armed services: it wasnational policy."⁶

In practice, however, many differences of opinion had to becompromised and a number of legal, political, and economic questions had to beresolved before pressures for the invocation of the May Act became strong enoughto push it into effect. It was invoked in only two areas during the war. Thefirst, on 20 May 1942, was in the region surrounding Camp Forrest, Tenn., andthe second, on 31 July 1942, was in the area around Fort Bragg, N.C. As aresult, some prostitution was suppressed; how much is uncertain. Thereafter, thethreat of Federal intervention was sufficient to cause local communities to takepositive action.

During the first 2 years of increasing military activity,1939-41, the preventive medicine organization (under various designations) inthe Surgeon General's Office was engaged constantly in strengthening itsVenereal Disease Control Division and in working through corps area surgeons andpreventive medicine officers in tactical units to develop and implement acomprehensive control program. At the same time, the advantageous liaison withthe U.S. Public Health Service expanded. Dr. Thomas Parran, the Surgeon Generalof that Service, and Dr. Raymond A. Vonderlehr, his Assistant Surgeon General,detailed very able public health service officers to many Army organizations toconduct special sanitary surveys, to report on conditions and performance, andto serve as links between the Army and State health officers. In the ArmySurgeon General's Office, there was a sense of progress.

Unexpectedly, however, the working relationship between theArmy and the U.S. Public Health Service was seriously disturbed in 1941by the publication of a book by Drs. Parran and Vonderlehr⁷ in which they criticized the Army for what they regardedas its failure to take sufficiently drastic action against commercializedprostitution around cantonment areas. "Charges and countercharges weremade, and eventually, on 27 November

⁶See page 143 of footnote 4, p. 61.
⁷Parran, Thomas, and Vonderlehr,Raymond A.: Plain Words About Venereal Disease. New York: Reynal & Hitchcock, Inc., 1941.

1941, Mr. [Paul V.] McNutt [Federal Security Administrator]wrote to the President about the matter. Shortly afterwards, however, the attackon Pearl Harbor occurred. With the American declaration of war, what hadthreatened to precipitate a serious break in mutual confidence between the Armyand the U. S. Public Health Service faded into insignificance in the face of thenew responsibilities and problems facing both services."⁸

The effects of this book were felt in several directions.Undoubtedly, its publication expedited and enlarged efforts to suppresscommercialized prostitution around military areas. The passage of the May Actand its subsequent invocation in Tennessee and in North Carolina were hastened.Several new governmental committees were established, one of which was theInterdepartmental Committee on Venereal Disease Control, formed early in 1942 byan agreement between the Federal Security Administrator, the Secretary of War,and the Secretary of the Navy, to meet informally and consider condensed overallreports from competent advisers and establish closer liaison between variousdepartments concerned with venereal disease control problems. In addition to thethree cabinet officers and other members, two War Department representativeswere designated to serve on the committee. It is of special interest that therepresentative from the Surgeon General's Office was Colonel Simmons (fig. 6),Director, Preventive Medicine Division, who, in collaboration with Lt. Col.(later Col.) Ira V. Hiscock, SnC, and Lt. Col. (later Col.) Albert W. Sweet, SnC,had already prepared a plan for the administration of a civil affairs andmilitary government public health program. On 7 February 1942, Colonel Simmonswas replaced by Lt. Col. (later Col.) Thomas B. Turner, MC, Chief, VenerealDisease Control Subdivision. The representative from the War Department GeneralStaff was Brig. Gen. (later Maj. Gen.) John H. Hilldring.

The effort sustained from 1940 through 1945 to prevent andcontrol venereal disease among U.S. Army troops in the Zone of Interior wasclearly zealous and intensive, and it brought to bear upon the problems manyelements and powers characteristic of civil affairs and military governmentpublic health activities although the program was not so designated.

During the war, and afterward, the question was asked: Whatwas accomplished? Despite strenuous exertions for control, the incidence (totalcases acquired after induction) and rates (per 1,000 average strength per annum)were high. For troops in the continental United States, the figures were asfollows:⁹

Gonorrhea-1942-45: a total of 464,962 cases, with anannual rate per 1,000 average strength of 31.52 (maximum rate, 43.21 in 1945;minimum rate, 23.91 in 1943).

Syphilis (including neurosyphilis)-1942-45: a totalof 230,405 cases, with an annual rate per 1,000 average strength of 15.63(maximum rate, 20.04 in 1944; minimum rate, 7.19 in 1942).

⁸See page 158 of footnote 4, p. 61.
⁹See page 473 of footnote 4, p. 61.

F IGURE 6.-Brig. Gen. James StevensSimmons, USA. (Photograph, courtesy of National Library ofMedicine.)

Admittedly, it is difficult to state exactly how much wasaccomplished through the program of prevention and control. Nevertheless, thegeneral and reasonable opinion of those who administered the program is that ifsuch a program had not been in operation there would have been a much higherincidence of venereal disease among troops in the continental United States.

Malaria Control in War Areas

Activities for the control of malaria in areas surroundingmilitary and defense-production installations in the continental United Statesfrom 1940 to 1945 were vast, both in scope and in benefits attained. While theyhave been described in several publications by a number of authors,¹⁰ some

¹⁰(1) Williams, Ralph Chester: TheUnited States Public Health Service, 1798-1950. Washington: CommissionedOfficers Association of the United States Public Health Service, 1951, pp. 308-309,397-399, 648-655. (2) See pages 201-202, 333-334 of footnote 2, p. 60. (3)Medical Department, United States Army. Preventive Medicine in World War II.Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government PrintingOffice, 1963, pp. 73-112, 202-240.

discussion of malaria control in populated areas surroundingmilitary and defense establishments in the United States and in Puerto Rico isessential here because it comprised a number of elements common to all civilaffairs and military government public health activities. Because the operationtook place in the continental United States, it was not officially regarded as acivil affairs and military government undertaking although it furnishedexperience and trained personnel which were useful later in carrying out similarcivil affairs and military government public health activities in overseastheaters of operations.

Continental United States-Malaria preventionand control around military areas in the United States proceeded simultaneouslywith venereal disease control efforts and employed, in general, most of thebasic methods, principles, authorities (such as the Eight-Point Agreementbetween the War Department and the National Security Administration), and meansof collaboration among various agencies. The resulting malaria control programwas a joint product of the remarkably close and effective collaboration betweenthe Army and the U.S. Public Health Service.

The pattern had been set as early as March 1927, when Dr.Louis L. Williams, Jr., malariologist and medical director in the U.S. PublicHealth Service, began to devise and supervise programs which contributedimportantly to the development of the South by anticipating and findingsolutions to civilian problems which had much in common with military problemsof malaria control encountered later. By 1937, Dr. Williams was advocating thatState health departments in the malarious South organize malaria control unitscomposed of physician-entomologist-engineer teams, and that the final attacks ofsingle group teams be pressed against malarious foci, using all appropriatebiological, clinical, sanitary engineering, logistical, and educational meansand methods. This general type of organization and plan of operation, adopted bycivilian, U.S. Public Health Service, and military agencies, did much to breakthe hold of malaria upon the South and ultimately contributed to the virtualeradication of malaria from the United States. Furthermore, as World War IIprogressed, the malaria control units became malaria survey and controlorganizations in the military preventive medicine program. They were used inoverseas theaters of operations where malaria was a problem throughout the war.The basic concept has persisted in the preventive medicine company.

In the spring of 1941, Dr. Williams, who had been detailed asU.S. Public Health Service liaison officer to Headquarters, Fourth Corps Area,Atlanta, Ga., drafted the plan for malaria control in extra-military areas andassisted in the formulation of military policies for local malaria control.

At the end of 1941, when U.S. Public Health Service funds formalaria control had been curtailed by the Congress and the Bureau of the Budget,it became clear that the Work Projects Administration could not meet the needs.Early in 1942, with the backing of the deeply concerned War De-

partment, advised by the Preventive Medicine Service,SurgeonGeneral's Office, the U.S. Public Health Service received an appropriation for anindependent malaria control program in areas surrounding military and defenseestablishments in 15 southeastern States, Puerto Rico, the Virgin Islands, andin other Caribbean areas controlled by the United States. The resultant office,established in the States Relations Division of the U.S. Public Health Serviceto administer the program, was first designated as Malaria Control in DefenseAreas, and later as Malaria Control in War Areas. Although the latter implied aconcern with malaria in combat areas overseas, it was not so intended.

The policy of the Malaria Control in War Areas organizationwas to undertake operations only where the prevalence of malaria-transmittingmosquitoes indicated a risk of the spread of malaria. Mosquito-free zones, 1mile wide (the flight range of Anopheles quadrimaculatus), were set upand maintained around each military and war industrial establishment. No controlof pest mosquitoes was undertaken except upon special military request. Thebasic objective was vector control by ditching, draining, oiling, larvicidingwith paris green, and later by spraying with DDT(dichlorodiphenyltrichloroethane)to kill adult mosquitoes. By agreement, these teams were to remain outside themilitary installations and the military sanitarians were to remain within theirposts, camps, and stations. However, some overlap in responsibility wassometimes necessary. Colonel Hardenbergh stated:

While the military reservation boundary was usuallymeticulously observed as the dividing line between Army mosquito control workand Public Health Service operations, there were numerous local adjustmentswhereby the areas in which work was necessary were allotted, irrespective oflocation, to the organization best fitted to accomplish control. The aim was toinsure effective mosquito control at the lowest cost. In a few instances, theservices of Army sanitary engineers and entomologists were made available toMalaria Control in War Areas, and the converse was equally true. The closecooperation and the excellent personal relationships that existed between bothorganizations were of great value in insuring effective work.¹¹

A good idea of the scope and complexity of the program, andan intimation of the civil affairs aspect of it, can be derived from thefollowing listing, compiled by Dr. Justin M. Andrews.

* * * In the States where malariahad been endemic in the past, there were in 1942 some 900 so-called warestablishments to be protected; by January 1945, the total had risen toapproximately 2,000. These included military posts, camps, stations, bases,hospitals, depots, airfields, Navy yards, other military port areas, stagingareas, prisoner-of-war camps, maneuver areas, access highways, extramilitaryrecreational centers, shipyards, airplane factories, ordnance works, otheressential war industries, and housing developments for war workers. These warestablishments were grouped, according to location and the nature and extent ofthe problem into some 250 war areas, and an area supervisor, usually anengineer, was placed in charge of the malaria control activities to be carriedon around each group of war establishments. He worked closely with

¹¹See pages 201-202 of footnote 2, p. 60.

the sanitation officers on adjacent military installationsand with the local health officers. Thus, the war area was the geographic unitof operations * * *.¹²

Puerto Rico.-Among the war areas of concern to the MalariaControl in War Areas group, Puerto Rico, as an American possession, wasnaturally the center of the military organization and administration of theAntilles Department (map 1). The Army had installations at Borinquen Field, CampTortuguero, Fort Buchanan (where the Antilles General Depot was located), FortBrooke, Camp O'Reilly, Losey Field, Henry Barracks, and Fort Bundy, togetherwith a large number of lesser installations used largely for coastal defense orantiaircraft batteries. Camp Ensenada Honda was an example of the latter. In1942, malarious conditions in all areas ranged from unsatisfactory to"distressingly bad." In April 1942, the malaria rate among Armypersonnel in Puerto Rico was 73 per 1,000 per annum. There were manycontributory factors. Within the Army units, there were poor organization formalaria control and prevention, assignments of personnel unsuited for controlwork, and a lack of proper planning of campsites. Environmental factors wereunseasonable rains, flooded fields, blocked ditches, poor drainage, and anincrease in native troops drawn from an infected population. During the criticalperiod, 1942-43, Malaria Control in War Areas groups rendered highly importantcorrective services both to military personnel and civilians. The Army did notachieve a proper organization for malaria control until late in 1943, andpreventive medicine units did not move into action in Puerto Rico until 1944.Later, malaria rates among troops decreased until they were of secondaryimportance while rates among the civilian population remained high.

Experts who evaluated the malaria control program within andnear military areas in the continental United States, as well as in Puerto Rico,from 1942 through 1945, concluded that a capable job was done by both themilitary personnel concerned with the former and the civilian organizationdeveloped for the latter. Among trainees and troops, malaria morbidity was heldto unprecedented low levels during the last 3 years of the war. In addition,great benefits accrued to civilians both in the United States and overseas.

MANEUVERS

Inherent Civil Affairs andMilitary Government Elements

Although a vast amount of thought and effort was devoted byGen. George C. Marshall, Brig. Gen. (later Lt. Gen.) Lesley J. McNair, theGeneral Headquarters Staff, and hundreds of officers to the planning, conduct,and critique of Army maneuvers in the United States from 1939 to 1944, littleattention was paid directly to the elements of civil affairs and militarygovernment public health activities which were inherent in those

¹²See page 91 of footnote 10 (3), p. 64.

M AP1.-Antilles Department, 1944.

operations. As these elements were not identified as such,they either were not generally recognized at the time of their appearance orwere noted by only a few specially informed persons. Inevitably, however,activities in this category occurred in exercises simulating warfare because thetroops involved moved through homeland territories, occupied large public andprivate lands possessed by their own people, and committed acts which impingedupon the behavior of their own national kinsmen, sometimes taking or destroyingproperty, occasionally restricting liberties, and often conferring sanitarybenefits upon communities. Army maneuvers in the continental United States,creating in a domestic setting a situation somewhat similar to that of a theaterof operations, resembled the type of military occupation of friendly orliberated countries that occurred overseas as the war progressed. An analysis ofthese activities distinguishes them clearly from those of routine preventivemedicine programs.

As the usual military preventive medicine programs arecovered in other volumes in this series, this section will discuss some of thepublic health activities having characteristics appropriate to civil affairs andmilitary government as they were carried out in certain Army maneuvers. Themaneuvers to be considered here were those that took place in Wisconsin in 1940,in the Carolinas in 1941, in Louisiana and Texas in 1940-41, and in Tennesseein 1942.¹³

Background and Concomitants

Because of their bearing upon the development and conduct ofArmy maneuvers in the United States, it is well to recall the following events:

(1) On 8 September 1939, in view of the state of war inEurope, the President proclaimed a limited national emergency, and on the sameday, by Executive Order No. 8244, he increased the strength of the Army by17,000 men. These additional troops, bringing the total strength of the RegularArmy to about 190,000, made it possible to rearrange a number of units and tocreate a standard Army Corps and a field army. Their creation, and certain otherauthorizations, permitted a few months later the first genuine corps and armymaneuvers in the history of this nation. Before the end of 1941, theorganization of the four armies had been brought to a point which made itpossible to put all of them through maneuvers and in September of that year topit two of them [the Second and Third], fully organized, against each other inthe field.¹⁴

¹³(1) Greenfield, Kent R.,Palmer, Robert H., and Wiley, Bell I.: The Organization of Ground Combat Troops. United States Army in World War II. The Army GroundForces. Washington: U.S. Government Printing Office, 1961. (2) Palmer, RobertR., Wiley, Bell I.,and Keast, William R.: The Procurement and Training of Ground Combat Troops. United States Army in WorldWar II. The Army Ground Forces. Washington: U.S. Government Printing Office, 1948.
¹⁴(1) Watson, Mark S.: Chief of Staff: Prewar Plans and Preparations. United States Army inWorld War II. The War Department. Washington: U.S. Government Printing Office,1950, pp. 156-159. (2) See page 10 of footnote 13 (1).

(2) Extra-military area sanitation anddisease control were established formally in May 1940 bythe Eight-Point Agreement (p. 61) which was the basis for extensive cooperationbetween the Army and the U.S. Public Health Service in carrying out preventionand control of venereal diseases in areas around Army and defenseestablishments, Malaria Control in War Areas, and many joint undertakings in thefield of public health. As a further means for enforcement of regulations andprocedures for venereal disease control among civilians, Public Law 163 (theso-called May Act) was passed by the 77th Congress on 11 July 1941.

As a major contribution to this work, the U.S. Public HealthService detailed a large number of its high-ranking specialists as liaisonofficers to the Army. These liaison officers made useful, broad surveys;prepared detailed reports on conditions and events of public health significancein the maneuver areas; and greatly assisted both civilian and military publichealth organizations in those areas.

The relationships among the cooperating organizations, andtheir fields of special concern, varied from place to place. In all, however,the focus of interest was in the commingling of activities of military andcivilian preventive medicine and public health.

(3) In 1939 and 1940, Colonels Hiscock andSweet, working under the direction of Colonel Simmons, initiated studies whichresulted in "A Plan for the Military Administration of Public Health inOccupied Territory."¹⁵ The interest of these and other officers,and of the Preventive Medicine Division, in the public health aspects of civilaffairs and military government, both in the United States and overseas, wasintense and continuous from the beginning. Their early ideas, policies, andplans were applied later during maneuvers. The Provost Marshal General'sSchool of Military Government, Charlottesville, Va., and the Civil AffairsDivision, War Department Special Staff, included sections for dealing with thepublic health aspects of civil affairs and military government, and drew uponthe experiences gained, and observations made, in Army maneuvers.

Wisconsin, 1940

During August 1940, the Second U.S. Army held maneuvers ina 1,000-square-mile area of southwestern Wisconsin, La Crosse, Monroe, Juneau,Jackson, and Wood Counties, with headquarters at Camp McCoy, near Tomah. Thetroops engaged numbered 59,750, with a mean average strength of 32,950 for themaneuver period. There was excellent cooperation between the Second U.S. Army;the commanding general of the Sixth Corps Area (Lt. Gen. Stanley H. Ford), whothoroughly supported the chief surgeon of the Sixth Corps Area (Col. Paul W.Gibson, MC); the Wisconsin

¹⁵A Plan for the Military Administration of Public Health inOccupied Territory, submitted to The Surgeon General, 26 June 1940, by Lt. Col.Ira V. Hiscock, SnC, and Lt. Col. A. W. Sweet, SnC.

State Board of Health (Dr. C. A. Harper, State HealthOfficer); the U.S. Public Health Service (Dr. Vonderlehr); and the State,county, and municipal governments. A sound pattern was set in this and otherearly maneuvers as the sanitary and medical plans adopted and the policingarrangements devised were found to be equally effective where local authoritiescould be organized to work with military authorities.

Surgeon General Parran and Assistant Surgeon GeneralVonderlehr regarded the venereal disease control measures taken during thismaneuver period as one of the few praiseworthy examples of coordinated attack bythe Army and local health and police authorities which had occurred up to thetime of the writing of their book, "Plain Words About VenerealDisease." From their commendation, which includes some historical details,the following is quoted:¹⁶

Wisconsin gave an effective demonstration last year of whatcan be done to protect the troops from venereal disease. A thousand square miles* * * were designatedfor August [Camp McCoy] maneuvers of 60,000 regulars and national guardtroops. The Surgeon of the Sixth Army Corps Area, being a competent andexperienced medical officer, realized the need of advance planning forprevention of disease among the troops. In a letter addressed to the PublicHealth Service, he requested certain measures to be taken having to do withsanitation of food and water, disposal of sewage, control of flies andmosquitoes, and control of all communicable diseases with a specific requestfor repression of prostitution, especially of the expected influx of itinerantprostitutes.

Financial assistance and technical consultation was offeredthe State Health Department by the Public Health Service and a meeting wascalled at Sparta early in June to which were invited to meet with the ProvostMarshal and Chief Corps Area Surgeon, not only the state and local healthofficers having responsibility for conditions in the area, but also the judges,mayors, police officers and city attorneys of the larger cities. Wisconsin is astate in which the problem of venereal disease has been under constant attackfor more than 20 years, as evidenced by its low prevalence. Consequently, themeeting was well attended and its purpose thoroughly understood. Plans toprotect both soldier and citizen from infection were drawn up well in advance ofthe maneuvers and approved by the Governor.

Making use of a relatively new type of medicolegal agent, theWisconsin Board of Health appointed additional deputy health officers who werealso commissioned as deputy sheriffs. They remained under the State HealthDepartment but were also under the sheriff's jurisdiction; however, theirduties were medical, not of a law enforcing nature. Their main purpose was toassist in the control of communicable diseases, especially venereal diseases, byarresting and detaining infected prostitutes. These agents were called"deputies of the Board of Health instead of special investigators becausethe law [of Wisconsin] outlines fully the duties and powers of deputy healthofficials."¹⁷Later, in other maneuver areas, somewhat similaruse was made of health department deputies with certain medicolegal powers.

¹⁶See pages 153-154 of footnote7, p. 62.
¹⁷Letter, Dr. C. A. Harper, State Health Officer, Wisconsin,to Surg. Gen. Thomas Parran, USPHS, 9 Aug. 1940, and reply to Dr. Harper from Asst. Surg. Gen. R.A. Vonderlehr, 16 Aug. 1940.

The Carolinas, 1941

The First U.S. Army opposed the IV Corps (reinforced by the IArmored Corps) in a General Headquarters directed free maneuver in the Carolinasfrom September to November 1941. The maneuver area, about 60 miles wide,extended from Columbia, S.C., to Southern Pines, N.C. Area headquarters was atMonroe, N.C., and Corps headquarters were at Columbia and Fort Jackson, S.C.Many problems of public health and civil affairs were encountered by large troopunits "fighting" through this region, which contained sizable moderncities and thinly populated rural districts. A few excerpts from the report ofthe medical inspector, Lt. Col. Isadore Schayer, MC, will illustrate some ofthe pertinent relationships, problems, and events.¹⁸

4. Cordial and valuable contact was made with the especiallyassigned Representative of the South Carolina State Board of Health at Chester,South Carolina. This contact was maintained throughout the Maneuvers for thepurpose of obtaining:

(a) daily reports of prevalent infectious diseases amongcivilians in the Maneuver Area

(b) information about the various municipal water-supplies

(d) cooperation in the control of venereal disease.

Supervision of locally purchased foodstuffs and of publiceating places, in an effort to prevent or check outbreaks of diarrhea anddysentery, involved military inspection and sanitary policing of stores, cafes,and restaurants in towns in the maneuver area. Obviously, when it becamenecessary either to put unsanitary eating places "off limits" or toclose them, the resulting military-civilian relationship had jurisdictional,commercial, political, and personal implications.

In an unexpected and disturbing manner, the depressedeconomic status of civilians in impoverished districts in the maneuver areadirectly affected intertroop relationships and the military sanitation ofcampsites. In referring to the policing of campsites and to the scavenging byhungry animals and humans, the medical inspector reported:

In many instances, almost immediately upon the departure oftroops [from an encampment], dogs and hogs would enter, dig and up-root hastilycovered garbage pits, cans, turning up and scattering about, can, particles offood, etc. in a manner that upon a hastily drawn conclusion by an inspector,would be a great discredit to troops concerned. This Inspector, himself, onseveral occasions, when going into a site just evacuated by troops, would findnegro men, women and boys with sticks etc., digging up garbage pits, hoping tofind some edibles or other usable materials. Such incidences would also be notedby other units entering such upturned and defiled places, causing, to an extent,the attitude in the troops of-discouragement and discontent concerning"policing."

¹⁸Report of Medical Inspector on First U.S. Army Maneuvers,September-November 1941, Headquarters, I Army Corps, Office of the Surgeon, FortJackson, S.C., to Surgeon, I Army Corps, Columbia, S.C., 9 Dec. 1941.

As usual, the program for the control of venereal diseaseamong troops involved the most extensive coordination of military and civilianauthoritative actions. In the maneuvers in the Carolinas, "venerealinfections * * * were reduced to a surprisingand gratifying minimum * * * byeliminating or restricting the sources of infection and, by strategicallyestablishing prophylactic stations in many communities within the maneuver area ** * and also by offering the men an easily obtainedsupply of rubber protectives.^" Colonel Schayer's report continuesgraphically:

The State of South Carolina possesses no specifically aimedlaw against prostitutes, nor does it have any specifically assigned structurefor the detention and treatment of diseased individuals. With the great influx,in "trailers", by railroad trains, in private cars, etc., of anappalling large number of itinerant prostitutes, the grave potential menace ofsuch influx was realized and the Commanding General advised of this problem.Upon the representation of this problem by the Commanding General to the SouthCarolina State authorities, the latter promptly afforded all available aidpossible. These authorities authorized the use of a woman's building, part ofthe State Penitentiary, as a house for detention and treatment of diseasedwomen, and the Chief of State Constabulary visited Headquarters I Army Corps atChester, South Carolina for further consultation. A conference was then held, inthe office of the South Carolina State Board of Health in Chester, SouthCarolina, composed of the acting State Health Officer, the Chief of StateConstabulary, the acting Chief of South Carolina State Highway, the Corps'Provost Marshal and Corps Medical Inspector. The Medical Inspector stated thatwhile this I Army Corps appreciated the higher ethical phase of educational andmoral prevention of sexual-promiscuity, this was a problem of an emergency, andthe I Army Corps was chiefly concerned with the prevention of venereal disease among its men. The law authorizingthe detention and isolation of any person having or, suspected of having, acommunicable infectious disease was invoked and carried out according to thefollowing plan:

All Sanitary Inspectors (additional ones were placed on duty)of the South Carolina State Board of Health were sworn in as DeputyConstables and they with the regular Constabulary and members of the SouthCarolina State Highway, would apprehend any diseased or apparently diseasedprostitute, have her physically, microscopically and serologically examined and,if she proved to be diseased, sent to the temporary house of detention fortreatment and cure. This plan proved very effective ** * and, together with other methods mentioned above,produced the low total of venereal disease in this Corps.

It is interesting to note that, as in the Wisconsin maneuversin August 1940, Board of Health sanitary inspectors were commissioned also asdeputy constables with certain police powers. As sanitary policemen, theydefinitely strengthened the joint military-civilian effort to prevent andcontrol communicable diseases in the maneuver area.

Louisiana and Texas, 1940-41

In the 2 years immediately before the United States enteredWorld War II, there were two extensive Army maneuvers in the Sabine River areain northwestern Louisiana and northeastern Texas-one in April-May-June 1940and the other in August-September 1941. This great "Louisiana maneuverarea" was a part of the domain of the Third U.S. Army, which,

with headquarters at Fort Sam Houston, Tex., became thelargest training Army in the United States. Its zone, extending from Mississippito Arizona and from Arkansas to the Mexican border, included hundreds of units,from corps to small detachments; numerous posts, camps, and stations; andseveral maneuver areas. At times, its monthly troop strength averaged more than750,000.

The Sabine River maneuver area, lying between the Sabine andRed Rivers, was "a 40- x 90-mile sparsely settled, chigger- andtick-infested bayou and pitch-pine section," sandy, denuded, and rugged.¹⁹

Before the 1940 maneuvers began, health conditions weresurveyed by Army medical officers and by U.S. Public Health Service liaisonofficers. Cooperation was secured from the Louisiana and Texas State HealthDepartments and from the public. The majority of the parishes and counties hadno full-time health services. The major problems were venereal diseases,malaria, and diseases transmitted through milk, water, and food. Plans were madeto devise the direct control measures against these diseases in the civilianpopulation, and to attempt to advance a general health program throughout thearea which would afford maximum protection to the military and civilianpopulations. Obviously, such an attempt involved programs in the general fieldof civil affairs and military government public health activities although theywere not specifically termed as such.

Of the two maneuvers in the Sabine River area, the second,held in August-September 1941, in which the Second U.S. Army was pitted againstthe Third U.S. Army, involved more than 350,000 men and was the largest everconducted in the United States in peacetime.²⁰

Many strategic, tactical, logistical, and professionallessons were learned from this large maneuvers-exercise, and the experiencegained in the practice of military preventive medicine under field and simulatedcombat conditions was extremely valuable. On the other hand, not much that wasnew or highly important from the point of view of civil affairs and publichealth was developed. Nothing was lost, but the groundwork had been laid in themaneuvers in Louisiana and Wisconsin in 1940. Since the development ofinterested and competent personnel is on a par with plans and operations, itshould be noted that two military commanders who had great influence insucceeding years upon civil affairs and military government rose to nationalprominence during these maneuvers. One was Lt. Gen. (later Gen.) Walter Krueger,who, in 1943-45, was to command the Sixth U.S. Army in its drive from theeastern tip of New Guinea to Luzon, in a campaign frequently concerned withproblems of civil affairs and military government, particularly in thePhilippine Islands. Commanding the Third U.S. Army, General Krueger drove theSecond U.S. Army, under the com-

¹⁹Allen, Robert S.:Lucky Forward-The History of Patton's Third U.S. Army. New York: TheVanguard Press, Inc., 1947. ²⁰See page 45 of footnote 13 (1), p. 69.

F IGURE 7.-Maj. Gen. George C. Dunham, USA.

mand of Lt. Gen. Ben Lear, out of Louisiana into Arkansas,and "became a national figure overnight in the great Louisiana war games ofSeptember, 1941." The other was General Krueger's Chief of Staff, "athen unknown, newly made Brigadier General, Dwight D. Eisenhower."²¹General Eisenhower, recognizing the problems and responsibilities, set in motionthe activities of the Army as the primary agent for the conduct of civil affairsand military government in North Africa in 1942. As Supreme Commander, AlliedExpeditionary Force, in 1944, he provided for and expanded the work in thisfield in Europe.

As a source of ideas and new practices, the maneuvers in theSabine River area in April-May-June 1940 were more important than the largermaneuvers of August-September 1941, chiefly because one of the most eminent andthoughtful military preventive medicine leaders of that time, Lt. Col. (laterMaj. Gen.) George C. Dunham, MC (fig. 7), was the medical inspector of the ThirdU.S. Army and participated in the Louisiana-Texas maneuvers. He was directlyconcerned with military and civilian public health activities in the maneuversarea and, on 24 June 1940, wrote a

²¹See page 9 of footnote 19, p. 74.

characteristically perceptive report, recording hisobservations, opinions, and recommendations, as follows:²²

2. In a maneuver area, the senior medical inspector, eitherArmy or Corps, is concerned with the public health activities of a large area.This area will consist of several counties containing a number of small townsand villages. The tactical methods used in training at the present time are suchthat sanitation on the military reservation, or reservations, within themaneuver area, plays a relatively minor role in protecting the health of thetroops.

The public health conditions in the towns, villages and ruraldistricts of the maneuver area outside the military reservations are, on theother hand, of major importance in their effect on the health of the troops. Asthe Army medical inspector has no jurisdiction outside the military reservationhe must, in order to protect the health of the troops, obtain the fullcooperation of and work with the state, county and municipal health and policeauthorities.

3. It is recognized that the Office of The Surgeon General ofthe Army, being a Federal agency, can deal directly only with another Federalagency, which in this case is the U.S. Public Health Service. This is being done[according to the cooperative relationship established in 1940 between the U.S.Public Health Service and the Office of The Surgeon General of the Army] and, onrequest from the states concerned, the U.S. Public Health Service is placingofficers in the maneuver areas. It can be assumed that requests by the statesfor officers of the U.S. Public Health Service will always be forthcoming,because the Federal Government is in a position to grant certain funds to thestates for health work. Theoretically, the U.S. Public Health Service officerwill act as a liaison agency between the Army or Corps surgeon, as representedby the Army or Corps medical inspector, and the local civilian health agencies.In practice, if the Army or Corps medical inspector is trained in public healthwork, and is willing and capable of cooperating with the civilian officials, thestate, county and municipal health officers will work directly with the medicalinspector, rather than through an officer of the U.S. Public Health Service. Theofficer of the Public Health Service functions as an advisor to the civilianhealth officers and cooperates with the medical inspector in coordinatingcivilian and Army health activities, and in this connection he rendersinvaluable service. However, an officer of the U.S. Public Health Service cannotbe held responsible by the Army or Corps surgeon for obtaining quick andefficient action on the part of civilian officials or for coordinating the workof the latter with the activities of the Army. As a matter of fact, the Army orCorps medical inspector becomes the leader of a group of civilian healthofficers which includes the U.S. Public Health Service officer, provided, ofcourse, that he has the necessary qualifications. Actually, the Army or Corpsmedical inspector, within the sphere of his health activities-that is, inconnection with the local water supplies, food establishments, control ofvenereal diseases, etc.-becomes the health officer of the maneuver area forthe duration of the maneuver.

4. * * * allthe civilian health officers of the state or states concerned and the county andmunicipal health officials of the maneuver area are imbued with a desire to helpthe Army to protect the health of the troops. ** * they quite naturally look to the Army medicalinspector for instructions regarding the health work that the Army wishes tohave done in their respective communities. In Louisiana, the state assignedsanitary engineers, an entomologist, a director of a parish health unit, and anumber of sanitary inspectors to the maneuver area to work with the Army in theexecution of health measures throughout the area. These workers, together withthe local public health personnel asked for, and followed, instructions given bythe Army medical inspector.

²²Letter, Lt. Col. G. C. Dunham, MC, Medical Field ServiceSchool, Carlisle Barracks, Carlisle, Pa., to Col. Albert G. Love, MC, Office ofthe Surgeon General, U.S. Army, Washington, D.C., 24 June 1940, subject: HealthWork in Maneuver Areas.

5. The Army or Corps medical inspector in a maneuver areawill work with county officials, the mayors of towns concerned, and with themunicipal and state police. In Louisiana all of these officials were found to beanxious to do anything the Army desired to protect the health of the troops butthey wanted, and it was necessary to give them, instructions as to just what theArmy did want them to do.

6. In large maneuver areas such as the Louisiana-Texas area,Minnesota-Wisconsin area, or the New York area, the health work of the medicalinspector and his staff can be of great educational value in demonstrating tocivilian health officials the nature of the work that would be required of themin the event of mobilization. Furthermore, the maneuvers now being carried out,because of the large areas utilized, and the number of troops involved, offer asplendid opportunity for developing methods and procedures of coordinating Armyand civilian health activities.

7. * * * itis urgently recommended that a regular Army officer who has had some specialtraining in public health work be assigned as medical inspector to each of theArmy or Corps maneuvers to be held in the future. It is further recommended thatin each instance this officer arrive in the maneuver area at least two weeksbefore the beginning of the maneuvers in order that he may be able to work withthe local health officials, and become familiar with the public health situationin the area, before the maneuvers begin.

The Third U.S. Army maneuvers in the general area of theSabine River continued throughout 1942, 1943, and early 1944, and the conceptsexpressed earlier by Colonel Dunham were carried out.

Camp Forrest Area, Tenn., 1942

Of the numerous field training exercises held from 1940 to1943 in the Camp Forrest area in central Tennessee, the Second U.S. Armymaneuvers, commanded by General Lear, during the period September to December1942, were most significant as a demonstration of military and civiliancooperation in public health work under simulated warfare conditions. In thefollowing description and commentary, attention is focused on the early patternsof civil affairs and military government public health activities developed bythese maneuvers.

The impressive finished product of the 1942 maneuvers had anearlier smaller model that was fashioned in the 2-28 June 1941 maneuvers ofthe Second U.S. Army held in a portion of the Camp Forrest area. This region,southeast of Nashville, was centered on Camp Forrest and Tullahoma and boundedby Shelbyville, Murfreesboro, Manchester, Cowan, and Lynchburg. Apparently, theneed to institute new methods and a new type of organization to solve theproblems of controlling food sanitation led to original, comprehensive, andeffective developments. These developments are described in a paper presentedbefore the Food and Nutrition Section of the American Public Health Associationat its October 1944 meeting by three former civilian health officials.²³Thefollowing is quoted from their paper:

With the inauguration of the Second Army Maneuvers in MiddleTennessee, the sanitation of food handling developed as a public healthresponsibility of primary im-

²³Morgan, H. A., Jr.,Muse, T. B., and McKellar, A.: Making Food Handlers Health Conscious. Am. J. Pub. Health 35: 28-34, January 1945.

portance. This importance was emphasized by five factors: 1.The large number of troops served in public eating places 2. The increase in warworkers eating out, due to both husband and wife working in defense plants 3.The number of transients either directly or indirectly related to the war effort4. The necessity for adjustment of small establishments to be able to handlelarge increases in patronage 5. The large number of novices in the business offeeding the public.

In order better to meet the problems posed by thisoverwhelming demand on public eating places, as well as other public healthproblems of the maneuvers, a district health department was organized by theTennessee State Health Department in the area immediately surrounding CampForrest [italics added]. Six counties with organized health units werecombined with one unorganized county into one large district with about 113,000population. Since the district organization is unique in its arrangement andlends itself well to the solution of the problem to be solved, it will bear abrief description. A district director is in charge of the program planning andexecution for the district as a whole, assisted by a nursing supervisor,sanitation supervisor, health educator, venereal disease investigators, andclerical supervisor. The six organized counties are divided into threetwo-county units, * * *. Theexistence of the district staff in addition to the regular county staffs is oneof the important factors in making our approach to the control of foodsanitation possible.

In carrying out the food sanitation control program and otherpublic health connected programs during maneuvers, preventive medicine officersand other military personnel collaborated with the civilian health authorities.

During the next year, several important changes occurred. Themaneuver area was enlarged, and in an even larger portion of the Statesurrounding Camp Forrest, the May Act (p. 62) was invoked on 20 May 1942 tolimit prostitution near Army establishments.²⁴The area in which thislaw took effect in Tennessee comprised 27 counties; and in these counties,Federal agents, including military units and personnel, reinforced localcivilian law enforcement agencies in efforts to prevent and control venerealdisease.

The next maneuvers of the Second U.S. Army in the CampForrest area were held during the period September-December 1942 in a roughlyrectangular area of 3,400 square miles-40 miles in an east-west direction and85 miles in a north-south direction. The maneuver headquarters was at Lebanon,about 30 miles east of Nashville. The phases of this operation that wereconcerned with matters relating in principle and fact, if not in name, to civilaffairs and military government public health activities greatly impressed oneof the chief participants, Dr. W. Carter Williams, who was then commissioner ofhealth of the State of Tennessee and coordinator of State services in the SecondArmy maneuver area. His summary and comments were recalled in a letter to Col.John Boyd Coates, Jr., MC, in 1961.²⁵

* * * Historically, perhaps one of themost extensive and successful programs of military, state and local governmentcooperation in all aspects of preventive medicine

²⁴War Department Bulletin No. 24, 20 May 1942.
²⁵Letter, W. C. Williams, M.D., Director, Veterans'Administration Hospital, Nashville, Tenn., to Col. John Boyd Coates, Jr., MC,Director, The Historical Unit, U.S. ArmyMedical Service, Walter Reed Army Medical Center, Washington, D.C., 9 May 1961.

was developed in the * * *[27] counties included in the maneuver area. The liaisonbetween all military units through Second Army Headquarters (Major General BenLear Commanding) and an established office for all state and local services wasdirect and most effective. All state and local services were coordinated underone person (the writer), designated by the Governor of Tennessee as"Coordinator of State Services in the Second Army Maneuver Area."Personnel included Public Health physicians, nurses, sanitarians, highwaypatrol, food and restaurant inspection, welfare, and other concerned local andstate activities. As I recall, this was the first area in the U.S. where the MayAct was invoked-and quite successfully. The low incidence of communicablediseases, including venereal diseases, justified the efforts ** *

* * * Dr. G. Foard McGinnis representedthe Commissioner of Health for the State of Tennessee as "Deputy Directorof the Maneuver Area Program" and did an outstanding job ** *. This particular project represented exceptionalorganization, cooperation and accomplishment by all agencies concerned and atall levels of government.

Dr. Williams, in his letter, also cites the contributionsmade by Dr. G. Foard McGinnis. Additional information about the remarkablefunctions of Dr. McGinnis is given in a report by one of The Surgeon General'smaneuvers observers, Capt. (later Lt. Col.) Francis B. Carroll, MC:²⁶

On September 22, we had a conference with Dr. G. F. McGinnis,Liaison Officer between the State governmental agencies and the Army. Dr.McGinnis is not only an employee of the State Department of Health and a UnitedStates Public Health Service consultant, but he is actually a coordinator of allState agencies, such as secret service, state police, agriculture, conservation,labor and industry, etc., with considerable authority vested in him by theGovernor. Dr. McGinnis' staff functions almost as a small state government inthe twelve counties involved in this maneuver area. The Federal Security Agency,recreational agencies, and all other civilian agencies are housed in the samebuilding.

Shortly after the end of these maneuvers, W. Carter Williamswas commissioned a lieutenant colonel in the Medical Corps of the Army of theUnited States. It was natural that his interests, talents, and experience shouldlead to his assignment in the field of civil affairs and military governmentpublic health work overseas. In 1943-44, Colonel Williams served withdistinction as a staff member of the Public Health and Welfare Division, AlliedMilitary Government (later Allied Commission (Italy), in Italy, in theMediterranean Theater of Operations, U.S. Army.

Sanitary and Epidemiological Surveys

Experiences during maneuvers in the United States from1939 to 1943, from the first maneuvers at Pine Camp, N.Y., to the last inLouisiana and Tennessee, revealed that medical, sanitary, and demographicproblems in civilian communities were related to the domestic economy, toshortages of medical, laboratory, and sanitary personnel, and to limitations inhealth and hospital programs. These experiences suggested problems that would beencountered in overseas theaters of operations. They were small prototypes oflarge problems of civil affairs and military government public

²⁶Letter, Capt. F. B. Carroll, MC,to The Surgeon General, 2 Oct. 1942, subject: Report on Observations Made onSecond Army Maneuvers in Tennessee, September 21 to September 27, 1942.

health activities that had to be faced and solved. Theyemphasized the importance of surveys, of estimates of situations, and of plansgeared to local and emergency conditions.

To gain knowledge of conditions, and to make such informationavailable, a new type of survey and report was needed. A few Army medicalofficers and the liaison officers of the U.S. Public Health Service readilyperceived the characteristics of this new requirement and respondedappropriately. As previously mentioned (p. 76), Colonel Dunham, in a report tothe Surgeon General's Office, pointed out that the current "tacticalmethods used in training" were not broad enough to cover civiliansituations that were much larger and more complex than those of militaryreservations. The matters to be examined and reported upon according to therequirements of Army Regulations No. 40-275 (Medical Department-SanitaryReports, 15 November 1932) were important but not sufficient for the kind ofreport that was developing, unofficially, for civil affairs and militarygovernment purposes. Colonel Dunham emphasized also the need to study suchcomprehensive reports as existed and for on-the-spot inspections, when possible,in advance of a maneuver. Later, overseas, it was found essential for all suchinformation to be checked by personal inspection and for a limitedsanitary-epidemiological survey and medical intelligence report to be madewithin the first few hours after the entrance of medical and nonmedical civilaffairs officers into an area.

Incidentally, while problems of this nature were underconsideration in maneuvers, the first forerunner of a comprehensive medicalintelligence program in the U.S. Army was initiated in May 1940 by an oralrequest to The Surgeon General for information about the general functions of ahealth department. This information was to be incorporated in a War Departmentbasic field manual on military government, then being prepared by the JudgeAdvocate General's Office.

Although this information was readily furnished by Lt. Col.(later Brig. Gen.) James S. Simmons, MC, then chief of the Preventive MedicineSubdivision (later Preventive Medicine Service), the task called attention tothe need for detailed planning for civil public health in such areas and fordata regarding local health problems and facilities. Accordingly, two Reserveofficers, Colonel Hiscock, professor of public health at the Yale UniversitySchool of Medicine, and Colonel Sweet, of the New Jersey State HealthDepartment, were called to active duty * * * toprepare a more detailed plan. The finished report, submitted on 26 June 1940entitled "A Plan for the Military Administration of Public Health inOccupied Territory," was general in scope, attempting to delineateprinciples applicable to all countries. A suggested sanitary code containingdetailed regulations was appended.²⁷

While participating in maneuvers in the United States, Colonel Hiscock noted the inadequacy of theordinary military sanitary survey to meet the needs of possible future publichealth activities in connection with civil affairs and military government. Hethereupon attempted to broaden the

²⁷Medical Department, UnitedStates Army. Preventive Medicine in World War II. Volume IX. Special Fields.Washington: U.S. Government Printing Office, 1969, pp. 252-253.

scope of survey methods and the content of the reports. Heassisted in expanding the scope of the teaching along these lines at the Schoolof Military Government at the University of Virginia and at the Civil AffairsTraining Schools at the University of Pittsburgh and at Yale University in 1943.Changes proved difficult, however, and pressures to follow established patternsin meeting "military necessity," as more generally understood andapplied, left much to be desired for civil affairs and the office of the newlyestablished Assistant Chief of Staff, G-5, in theaters of operations. In fact,the goal had not been reached even after the end of World War II and shortlybefore the beginning of the action in Korea. As a member of an Army advisorycommittee, Colonel Hiscock observed that the older insufficient survey andreport procedures were used in Operation PORTREX, the large Army-Navy amphibiousexercise held from 25 February to 11 March 1950 on Vieques Island 9 miles offthe southeastern coast of Puerto Rico.

Although no official War Department form of survey or report was adopted generally for thepublic health phases of civil affairs and military government, models wereavailable in the comprehensive reports issued by the Medical IntelligenceDivision, Preventive Medicine Service, in 1943-44. These reports, in the formof summaries of medical and sanitary data about various countries, werepublished as War Department Technical Bulletins, Medical. Information on thetypes and content of these reports can be gained by consulting any of thechapters in the three volumes of "Global Epidemiology."²⁸Recognizingboth the military and civil aspects of these situations, the authors of thiswork stated in the Introduction to Volume I:

The information assembled has been primarily that which wouldbe valuable in planning for the health protection and medical care of troops.Secondarily, information of essentially civil value has been included, as themilitary force so often must furnish care to the civil population. Moreover, itmust be recognized that the health of a military force is vitally affected bythe health of the civil community in which it is stationed, whether stationed ona belligerent or a friendly basis. In many respects, the friendly basis favorscloser contact with the civil population than does the belligerent so that thehealth problems of the civil community may be more readily reflected in militaryexperiences.

Time is a limiting factor with regard to thecomprehensiveness of initial surveys. Therefore, those items that requireimmediate attention, those that may be left for a short time, and those that maybe delayed for later consideration must be determined.

As a result of experience on maneuvers and familiarity withsituations in theaters of operations, a "sanitary-epidemiological surveyoutline" was developed by Colonel Hiscock and others. Their adaptation wasbased upon the discussion and outline of sanitary surveys presented by ColonelDunham

²⁸Simmons, James S., Whayne, TomF., Anderson, Gaylord W., Horack, Harold M., and collaborators: Global Epidemiology: A Geography of Disease and Sanitation (3volumes). Philadelphia: J. B. Lippincott Co., 1944, 1951, and 1954.

in his volume entitled, "Military Preventive Medicine."²⁹Invarious versions, it was used by Dr. Davenport Hooker in the Civil AffairsTraining School at the University of Pittsburgh, and by Colonel Hiscock at theCivil Affairs Training School at Yale University and at the School of MilitaryGovernment at the University of Virginia. The outline suggests the coverageneeded, as well as a rating of items which, under emergency conditions, may beconsidered chronologically as of primary (**), secondary(*), and tertiary (unmarked) importance on the basis of what can and cannot bedone in the time available. Although tentative and unofficial, the followingoutline is a useful guide in the conduct of sanitary and epidemiologicalsurveys.

SANITARY EPIDEMIOLOGICAL SURVEY OUTLINE
(Adapted to civil affairs and military government public health activities.)

A. Population.

1. Density.
2. Social and racial status.
3. Principal occupations and industries.
*4 Living conditions.
*5 Funds, sources, amounts and availability.
6. Vital statistics (birth and death rates, causes of death, etc.).
7. Transportation and communication facilities, etc.

B. Environmental features.

1. Topographical and meteorological conditions.

**a. Nature of terrain.
**b. Character of topsoil and subsoil.
**c. Water table.
**d. Amount of rainfall and snowfall.
e. Mean temperature and humidity.
f. Winds, fogs, and seasonal variations in climate; earthquakes.

**2. Water supply.

a. Sources (such as, dug wells, springs, driven wells, etc.).
b. Methods of purification (chlorination, boiling, fixed or portable purification units, etc.).
c. Methods of distribution.

3. Waste disposal.

a. Kinds of wastes.
b. Methods of disposal and salvage.

**(1) Human and animal dead (burial, cremation, etc.).
**(2) Human excreta (treatment plants, sewers, septic tanks, cesspools, privies, latrines, collection, etc.).
*(3) Animal wastes (composting, sanitary fill, etc.).
*(4) Garbage (sanitary fill, feeding, incineration, etc.).
*(5) Rubbish (burning, sanitary fill, etc.).
(6) Tin cans (perforation, etc.).

4. Housing.

*a. Kinds of shelter.
b. Ventilation, heating, and lighting.
c. Persons per room, etc.

²⁹Dunham, George C.: Military Preventive Medicine. 3d edition. Harrisburg,Pa.: Military Service Publishing Co., 1940, pp. 1052-1058.

5. Food supplies (including milk).

a. Sources.
b. Effectiveness of inspection methods.
c. Storage and protection.
d. Methods of distribution.
e. Operation of bread lines, soup kitchens, bakeries, etc.
f. Training and supervision of foodhandlers.
g. Character of public restaurants and their operation.
h. Adequacy of diet available.

*6 Insect control.

a. Kinds of disease-bearing insects.
b. Control methods employed and their effectiveness.
c. Civilian groups active in control measures.

C. Disease prevalence, hospital and medical facilities, and health agencies.

1. Morbidity rates.

a. Average total sick rate, specific diseases, geographic distribution.
b. Average daily incidence for communicable disease.
c. Prevalence of deficiency diseases.

2. Communicable disease.

**a. Epidemics existing.
*b. Epidemic, endemic, or sporadic prevalence.
**c. Foci of infection.
*d. Control measures.
*e. Venereal diseases and prostitution.

(1) Extent and control
(2) Laws relating to prostitution and their enforcement.

3. Hospital and medical facilities.

*a. Capacity of local hospital installations.
*b. Availability of additional space and equipment for emergencies.
*c. Facilities for segregation and isolation.
**d. Physicians, nurses, midwives, sanitarians and related personnel available, and facilities for training.
*e. Medical supplies, chemicals, drugs, etc., sources and availability.
*f. Laboratories, etc., available.
*g. Maternal and child welfare facilities.

4. Local health agencies, health laws, and regulations.

*a. Nature, operation, availability and distribution.
b. Laws and regulations.

(1) Character and adequacy.
(2) Enforcement in general.
(3) Enforcement in regard to food, foodhandlers, restaurants, etc.
(4) Enforcement in regard to crowding of public facilities, etc.

c. Type of health department of municipalities.
*d Health centers and administration.
e. Welfare organizations, Red Cross, etc.

* *Primary: May require immediate attention.
* Secondary: May be delayed for a short time.
Unmarked: May be delayed for later consideration.

EVACUATION OF THE JAPANESE FROM THE WEST COAST, 1942

Alien Control Program

In the continental United States and its Territories, fromearly 1940 to the end of hostilities in 1945, the supervision and control ofpotentially dangerous aliens (called "enemy aliens" in wartime)involved the Military Establishment in civil affairs and in civilian publichealth activities. The enforcement of the enemy alien control program requiredthe assertion of military authority in domestic situations, resulting in theregulation of some civil affairs. To serve joint interests, such as protectingthe health of both aliens in custody and civilians in adjacent communities,military and civilian organizations worked together. Other examples ofcooperation were anti-sabotage measures to protect sources of drinking water andto safeguard foodstuffs, both raw and processed. These activities were notspecifically identified as pertaining to civil affairs and military governmentexcept in two important instances. The first occurred under the conditionscreated by the invocation of martial law in the Territory of Hawaii in 1941; thesecond developed in March 1942 in the Western Defense Command evacuation of theJapanese from the West Coast, when the first Civil Affairs Division in the Armywas established on a staff level at a military headquarters-a year before theestablishment of the Civil Affairs Division of the War Department Special Staff.

In April 1940, The Adjutant General became responsible forproviding through local Army commanders for the custody of aliens ordered by theDepartment of Justice to be interned. The arrests were made usually by theFederal Bureau of Investigation. During the years 1941-43, The Provost MarshalGeneral and the Corps of Military Police exercised administrative supervisionover this program.

In the early stages of the war, before the arrival of largenumbers of prisoners of war from overseas, the chief internment function of theProvost Marshal General's Office was staff supervision over the detention, inWar Department internment camps of more than 4,200 civilian internees, most ofwhom had been arrested in the continental United States and a minority of whomhad been received from Alaska, Hawaii, and the Panama Canal Zone. In 1941-42,the section of The Provost Marshal General's organization which was concernedwith these matters was called the "Aliens Division." With the greatinflux of Italian and German prisoners of war from the North African Theater ofOperations, U.S. Army, the attention of The Provost Marshal General turned fromcivilian internees to prisoners of war, and the name of this unit was changed to"Prisoners of War Operations Division." In 1943, all civilianinternees, except the Japanese who were under the control of the War RelocationAuthority of the

Office of Emergency Management, were turned over to theDepartment of Justice.³⁰

Western Defense Command and Fourth U.S. Army, 1941-43

Since 1932, the Fourth U.S. Army had been stationed in theSeventh and Ninth Corps Areas, with a mission "to deal with the PacificCoast." In 1940, under the command of Lt. Gen. John L. DeWitt, this Armywas deployed throughout the Ninth Corps Area, which, also under the command ofGeneral DeWitt, encompassed Washington, Oregon, California, Idaho, Montana,Nevada, and Utah. Arizona was added to this group in 1941. On 17 March 1941,this region and its military organizations became the Western Defense Command,with General DeWitt as commander. Its main troop component was the Fourth U.S.Army, and its primary mission was: "Responsible in peacetime for planningall measures against invasion of area under command, and in case of invasion ofarea, responsible for all offensive and defensive operations until otherwisedirected by War Department.^" On 11 December 1941, the Western DefenseCommand, with Alaska included, became the Western Theater of Operations. Itsheadquarters, combined with those of its major constituent units, was at thePresidio of San Francisco. It was under the command of General Headquarters, WarDepartment, and General DeWitt was theater commander. Actually, in 1942, the topstaff of the Western Defense Command, in conjunction with certain officers inthe G-1 section of the General Staff, influenced the development of thenational policy governing the dealings with aliens on the West Coast, and theFourth U.S. Army furnished troops and support that carried out the WarDepartment's alien control program in that area, including the evacuation ofthe Japanese.

In 1941, the Fourth U.S. Army conducted highly instructivecommand post exercises at the Hunter Liggett Military Reservation, Calif. (withtroops which included the III Corps under the command of Maj. Gen. (later Gen.)Joseph W. Stilwell), and army maneuvers in Washington and Oregon. Thesemaneuvers, as well as the static disposition of units, involved all the elementsof extra-military area sanitation and control of communicable diseases, exceptmalaria, that have been discussed previously. Aspects of civil affairs andmilitary government public health activities, conspicuous and prophetic in themaneuvers conducted in the eastern, northern, and southern regions of the UnitedStates, were equally notable in the Fourth U.S. Army maneuvers.³¹

³⁰(1) Historical Monograph, Prisoner of War Operations Division, Office of The Provost MarshalGeneral, 1945. [Official record.] (2) Lewis, George G., and Mewha, John: Historyof Prisoner of War Utilization by the United States Army, 1776-1945. Department of the Army Pamphlet No. 20-213, 24 June 1955.
³¹(1) See footnote 13 (1), p. 69.(2) History of the Fourth Army, Study No. 18, Historical Section, Army GroundForces, 1946. [Official record.] (3) The status of the Western DefenseCommand as a theater of operations was terminated on 27 October 1943, and theWestern Defense Command was discontinued on 6 March 1946. The Fourth U.S. Armymoved its headquarters from the Presidio of Monterey, Calif., to Fort SamHouston, Tex., on 7 January 1944, to assume duties of Headquarters, Third U.S.Army which in turn proceeded to the European theater. Continuing as a greattraining Army, the Fourth U.S. Army formed two combat armies in 1944, the Ninthand Fifteenth U.S. Armies; and late in 1944, it was supplying at least half ofthe combat units shipped overseas.

Through its location in the Pacific Coast States, the WesternDefense Command, since late 1941, had been concerned in activities whichinvolved the Army with various civilian and governmental agencies. Theseinterests were represented by the war disaster relief plans, which were aresponsibility of the Ninth Corps Area. The plans included such matters as bombdisposal, camouflage, shelters, antisabotage, and general disaster relief. InApril 1942, this responsibility was transferred from the Ninth Corps Area to theWestern Defense Command, which soon prepared a "War Disaster Relief Plan-WesternTheater of Operations, 1942." In this plan, provision was made forcooperative effort by troops of the Western Defense Command and Fourth U.S. Armywith local, State, and other Federal agencies. Detailed plans were prepared foreach geographic subdivision of the command. In 1943, these responsibilities werereturned to the Ninth Service Command, and the Western Defense Command wasrelieved of them.³²

Civil Affairs Aspects of the Japanese Evacuation

During the period from 2 March to 3 November 1942, theWestern Defense Command and Fourth U.S. Army gradually became engaged in anoperation which has been characterized as "one of the Army's largestundertakings in the name of defense during World War II." This undertakingwas the relocation of approximately 110,000 persons of Japanese ancestry fromCalifornia, southern Arizona, and the western halves of Oregon and Washington.Some persons of Japanese ancestry were removed from Alaska, and a beginning wasmade on a proposed transfer of such persons from Hawaii to the continentalUnited States. German and Italian residents of these areas were allowed toremain there. Only the Japanese, regardless of American citizenship and withoutbenefit of legal trials, were evacuated. They were moved first to assemblycenters under control of the Western Defense Command, in California, Washington,Oregon, and Arizona, and thence transferred to relocation centers under thecontrol of the War Relocation Authority, in dispersed places throughout thecountry. Mass exclusion was directed and continued until late in 1944. Nearlyall the interned Japanese were held in custody until the last months of 1944when a few were allowed to return to the "restricted areas." Themajority were retained at the relocation centers and were to be released betweenJanuary and June 1945.³³

This mass evacuation of the Japanese was a controversialissue from the start, and continues to be criticized. Conflicting opinions as toits

³²History of the Western Defense Command, 17 Mar. 1941-30Sept. 1945, vol. II. Prepared under the direction of Maj. Gen. H. C. Pratt, U.S.Army. On file, Office of the Chief of Military History, Special Staff, U.S.Army. [Official record.]
³³(1) Conn, Stetson, Engelman, Rose C., and Fairchild,Byron: The Western Hemisphere. Guarding the United States and Its Outposts. United States Army in World War II.Washington: U.S. Government Printing Office, 1964. (2) See footnote 32.

"military necessity" were held by both individualsand agencies. The War Department was convinced that it was essential to thenational security; the Department of Justice, on the other hand, wished toprotect the civil rights of individuals within reasonable provisions fornational security. Economic and political factors influenced decisions. Publicopinion was manipulated, and the fact that the Japanese in the Pacific States,and especially in California,had been targets of hostility and restrictive action for several decades was afactor that unquestionably influenced the measures taken against them followingthe attack on Pearl Harbor.

After much debate and maneuvering had occurred among hisadvisers, President Franklin D. Roosevelt, on 19 February 1942, signed ExecutiveOrder No. 9066, which authorized the Secretary of War to exclude "any orall persons" from areas to be designated by him, and to use the Army andother agencies of the Government to carry out the edict. This Executive orderprovided for the acceptance of assistance of State and local agencies, as wellas for the use of Federal troops. It further authorized and directed "allExecutive Departments, independent establishments and other Federal Agencies, toassist the Secretary of War or the said Military Commanders in carrying out thisExecutive order, including the furnishing of medical aid, hospitalization, food,clothing, transportation, use of land, shelter, and other supplies, equipment,utilities, facilities, and services." This laid the foundation for the massevacuation of the Japanese from the West Coast.

On 20 February 1942, the Secretary of War authorized GeneralDeWitt to exercise all the powers which the Executive order conferred upon himand upon any military commander designated by him. General DeWitt's firstevacuation proclamation, putting these powers into effect, was issued on 2 March1942. Congress passed Public Law 503 on 19 March 1942, and the President signedthe act 2 days later, thus, in an ex post facto manner, giving the programlegislative authority. Two years later, in the midst of the war, the evacuationof the Japanese was tested in the courts as an unconstitutional invasion of therights of individuals. On 18 December 1944, the Supreme Court of the UnitedStates upheld the constitutionality of the evacuation by its decision renderedin the case of Korematsu v. United States.³⁴

Among the individuals concerned with this unprecedentedundertaking were General DeWitt, a vigorous and versatile commander who,although originally not in favor of evacuating Japanese-American citizens,yielded to this demand in the end. Another was the able Maj. (later Col.) KarlR. Bendetsen, GSC. Major Bendetsen, with the Office of the Assistant Chief ofStaff, G-1, War Department General Staff, and Chief of the Aliens Division ofthe Provost Marshal General's Office, and later Assistant Chief of Staff forCivil Affairs, Headquarters, Western Defense Command and Fourth

³⁴(1) Final Report: JapaneseEvacuation From the West Coast, 1942. Washington: U.S. Government PrintingOffice, 1943, pp. vii-x, 522-525. (2) Grodzins, Morton: Americans Betrayed.Chicago: The University of Chicago Press, 1949, pp. 274-322.

U.S. Army, had such a strong influence upon events that hisbiographical sketch in "Who's Who in America," 1944-45³⁵,contained the statement: "* * * organized Civil AffairsDivision and Wartime [Civil] Control Administration of Western Defense Command;conceived method, formulated details and directed evacuation of 120,000 personsof Japanese ancestry from military areas." This statement was shortened inthe 1950-51 edition to: "Directed evacuation of Japanese from West Coast,1942." According to the analysis by Dr. Stetson Conn:³⁶ "The decisionto evacuate the Japanese was one made at the highest level-by the President ofthe United States acting as Commander in Chief."

Civil Affairs Division, Western Defense Command

In American history, neither pattern nor precedent existedfor an undertaking of this magnitude and character, and European precedents wereunsatisfactory. Among the many qualities of leadership required for thesuccessful conduct of the operation were firmness, foresight, energy, ingenuity,administrative creativity, and as much humane mitigation of the harshness of thedislocation as circumstances permitted. From the start, particular attention waspaid to the hitherto unexperienced relation between the civil affairs of thelocal Japanese and American populations and the military government to beexercised by the Western Defense Command and the Fourth U.S. Army. Among the newadministrative organizations invented to deal with the consequent problems was aCivil Affairs Division, established at the combined headquarters.

Although policy contemplated that a staff section chargedwith the responsibility for civil affairs would be created only when militaryforces were in actual occupation of enemy territory, or in other instancesinvolving full military government, a novel and unexpected situation confrontedthe commanding general of the Western Defense Command. To cope with the newdevelopments, General DeWitt, on 10 March 1942, issued General Order No. 34, bywhich the Civil Affairs Division of Western Defense Command and Fourth U.S. Armywas created. The Assistant Chief of Staff for Civil Affairs was made fullyresponsible for the formulation of policies, plans, and directives pertaining tocontrol and exclusion of civilians. These new functions of the Assistant Chiefof Staff were in addition to any other duties and responsibilities which mightbe assigned to him and would be performed within the directives and generalpolicies of the commanding general.

Next day, 11 March 1942, General DeWitt issued General Order No. 35, establishing the Wartime Civil Control Administration as the operating agency of the Civil Affairs Division. This also was placed under the direc-

³⁵Who's Who in America. Chicago: The A. N. Marquis Co., vol. 23, 1944-45; vol. 26, 1950-51.
³⁶Conn, Stetson: The Decision toEvacuate the Japanese From the Pacific Coast. In Command Decisions. NewYork: Harcourt, Brace and Co., 1959, p. 88.

tion of the Assistant Chief of Staff for Civil Affairs.Thus the Assistant Chief of Staff for Civil Affairs performed a dual function.As a general staff officer and agent of the commanding general, he was empoweredto issue appropriate directives pertaining to the control and exclusion ofcivilians in the name of the commanding general. As director of the WartimeCivil Control Administration, he was authorized to carry such directives intoexecution.

The Assistant Chief of Staff for Civil Affairs, who heldthese multiple offices simultaneously, formulated policies, and issueddirectives for their implementation was Colonel Bendetsen, recently transferredfrom the Office of the Assistant Chief of Staff, G-1, War Department GeneralStaff, in Washington, to Headquarters, Western Defense Command and Fourth U.S.Army, at the Presidio of San Francisco. Later, in 1943-44 in London, ColonelBendetsen played an influential role in shaping some of the policies andorganization of the G-5 Section of Headquarters, European Theater ofOperations, U.S. Army, and Supreme Headquarters, Allied Expeditionary Force.

The designated exclusion areas were those in which aircraftmanufacturing plants and other war industries, ports, depots, and militaryinstallations were located; namely, Seattle, Portland, San Francisco, LosAngeles, Sacramento, and the vicinity of each. Obviously, practically the wholeWest Coast constituted the "vicinity" of those great cities.

As an initial step to facilitate voluntary migration of theJapanese, numerous Wartime Civil Control Administration offices wereestablished, one in each important Japanese population center in the affectedarea. Later, when forced evacuation was put into effect, some of these and otheroffices became known as Wartime Civil Control Administration service centers,where the processing, examination, and medical care of evacuees were handled.

In the course of the next several months after March 1942, asmass evacuation of the Japanese proceeded, assembly centers were established inCalifornia at Fresno, Manzanar, Marysville, Merced, Pomona, Sacramento, Salinas,Santa Anita, Stockton, Tanforan, Tulare, and Turlock; in Arizona, at Mayer and Pinedale; in Oregon, at Portland; and inWashington, at Puyallup. At the assembly centers, various health procedures werecarried out, including vaccination against smallpox and typhoid.

After varying periods of detention at assembly centers, theJapanese were evacuated to relocation centers in the intermountain Statesfollowing difficult negotiations with governors and local officials who hadagreed reluctantly to receive them. These relocation centers were to be theirhome for the duration of their internment.

On 18 March 1942, President Roosevelt, by his Executive OrderNo. 9102, established the War Relocation Authority in the Office of EmergencyManagement and, at about the same time, appointed Mr. Milton S. Eisen-

hower as director. The director was given broad powers torelocate evacuees in appropriate places, to provide for their needs, and tosupervise their activities. Although there were separate jurisdictions overevacuation and relocation, by agreement dated 17 April 1942, the War Departmentand the War Relocation Authority worked together in administrative, operational,medical, and public health affairs.

Mr. Eisenhower became director of the War RelocationAuthority at a time when consideration was being given to the possibility thatsimilar plans for the removal of persons of Japanese ancestry might have to beinstituted on the East Coast. This was not done. Therefore, the problems fallingto Mr. Eisenhower were those of taking over from the Western Defense Command theJapanese evacuated from the West Coast, moving them to relocation centers,providing for their care, and later returning them to their homes. The workinvolved many medical care, public health, and preventive medicine activities tobe carried out in rather primitive but, on the whole, salubrious environments.These relocation centers were situated mostly in remote and thinly populatedareas in California (Tule Lake and Manzanar), Colorado (Amache), Arizona (Postonand Gila

F IGURE8.-Brig. Gen. Condon C. McCornack, USA.

River, both on Indian Reservations), Arkansas (Rohwer andJerome), Idaho (Minidoka), Wyoming (Heart Mountain), and Utah (Topaz).³⁷

On matters pertaining to medical and sanitary aspects of theevacuation, Col. (later Brig. Gen.) Condon C. McCornack, MC (fig. 8), surgeonof the Western Defense Command and Fourth U.S. Army, and his successors, Lt.Col. (later Col.) Harold V. Raycroft, MC, and Lt. Col. Melvin Mark, Jr., MC,acted throughout in the capacity of general advisers to the commanding generaland his Assistant Chief of Staff for Civil Affairs, who was also director of theCivil Affairs Division and of its operating agency, the Wartime Civil ControlAdministration. Actual direction and operation of medical service, sanitation,and preventive medicine activities at assembly centers were conducted by theU.S. Public Health Service, using its own officers, State and county healthofficers, and civilian volunteer physicians. Daily health reports and reports ofinspections were made to the Wartime Civil Control Administration which imposeda multitude of rigid requirements, in accordance with U.S. Army regulations andpractices. The medical and sanitary results were excellent. Morbidity was low,and no serious outbreaks of communicable disease occurred at either the assemblycenters or the relocation centers. The death rates from all causes were aslow as those in the civilian population outside the centers.

Section II. Alaska

Stanhope Bayne-Jones, M.D.

HISTORICAL NOTE

The purchase of Alaska by the United States was sealed bytreaty with Russia on 30 March 1867, and the United States assumed formaljurisdiction over Alaska on 18 October 1867. For the next 45 years, this vastnorthern region, one-fifth the size of the continental United States, wasgoverned by an ill-defined combination of local and Federal authority. On 18March 1868, 5 months after the beginning of the American regime, the MilitaryDistrict of Alaska was created by the U.S. Army and the War Department becameone of the chief Federal agencies to be concerned with both civilian andmilitary government in the area. Even after Alaska became an organized territoryand with the establishment of a limited Territorial government in 1912, the WarDepartment, together with the Office of Indian Affairs of the Department of theInterior and the U.S. Public Health Service, continued to have influentialpractical connections. From 1868 to the outbreak of the war in Europe in 1939,many episodes occurred which in retrospect may be classified as civil affairsand military government activities arising under a system of limited militarycontrol exercised by

37Girdner, Audrie, and Loftis,Anne: The Great Betrayal: The Evacuation of the Japanese-Americans During WorldWar II. New York: The Macmillan Co., 1969, pp. 216ff.

agreement or convention.³⁸For example, the influxof miners during the gold rush in the late 1890's necessitated an extension ofmilitary control, preservation of law and order among civilians, and someconcern for the protection of their health.

During the 71 years from 1868 to 1939, both the militaryforces and the civilian population of Alaska remained small and the militaryimplications were considered to be minimal. As expressed by recent reviewers ofthe situation:³⁹

* * * in prewar years the likelihood of military action in ornear Alaska had appeared so remote that the Army had taken little more than anacademic interest in America's huge northern continental territory and itsisland appendages extending far out into the Pacific. In fact, the only Armytactical force in Alaska in September 1939, when the German attack on Polandprecipitated a new world war, was a garrison of 400 men-two rifle companies-atChilcoot Barracks near Skagway, a relic of the Gold Rush days.

This academic interest was changed to urgent concern by theneed in 1939 to strengthen the Alaskan outpost and to prepare its coasts,harbors, islands, and interior for defense against possible attacks from thePacific. The process was greatly accelerated by the Japanese attack on PearlHarbor and by the subsequent advance of the Japanese in the Pacific whichculminated with the alarming occupation in June 1942 of Attu and Kiska in theAleutian Islands. Driving the Japanese out of the Aleutians made Alaska the onlyarea in the Western Hemisphere in which U.S. Army ground and air forces werebattle-tested in World War II.

THE ARMY BUILDUP AND ITS RESPONSIBILITIES FOR PUBLIC HEALTH

The story is one of strenuous work in the construction of newbases and improvement of old bases and posts, of increase in the garrison bytens of thousands of troops, and of the importation of many thousands ofcivilian laborers, assistants, and technicians, greatly increasing thepopulation and aggravating the problems of public health.⁴⁰

An army, whether stationary or mobile, generates its ownproblems of public health and preventive medicine, wherever it may be. At thesame time, it both intensifies existing health problems and initiates new ones,which easily spread to any neighboring civilian communities. Consequently, theArmy has a responsibility, in its own interest and in the interests of localcommunities, to improve sanitation and to control all communicable diseases andother disabling conditions through appropriate measures. The desired result canbe achieved only by collaboration between military and civil elements, and bysome degree of military control over civil affairs.

³⁸War Department Field Manual 27-5(Navy Department OpNav 50E-3), United States Army and Navy Manual of MilitaryGovernment and Civil Affairs, 22 Dec. 1943, p. 2.
³⁹See pages 223-300 of footnote 33 (1), p. 86.
⁴⁰According to the 1940 census, the total population ofsparsely settled Alaska was 75,524, scattered over an area of approximately584,000 square miles. Only eight towns had a population of more than 1,000;Juneau, the capital and largest, had 5,748.

Frontier characteristics-The frontier characteristicsof Alaska made the solution of health problems more difficult in some respects,easier in others. There was relatively slight development of urban life, and thesmall population of the country was widely dispersed. Natives were inducted intothe Army in fairly large numbers, and many of the Army posts were situatedadjacent to native communities and communities to which natives had migratedrecently. Thus, opportunities for contacts were provided. For many years, thehealth of the native Eskimos, Indians, and Aleuts was a matter of concern toGovernment officials. Although there was no malaria, typhus, cholera, or plague-diseaseslargely of temperate and tropical zones-sanitary conditions among the nativeswere poor, tuberculosis and venereal disease rates were high, and the nativeswere extremely susceptible to the common communicable diseases of the whitepeople. The Office of Indian Affairs, concerned with the medical care of thenatives, had provided eight hospitals and a number of field physicians andnurses. The Army Medical Department, in addition to providing medical servicefor native inductees, was called upon frequently for emergency assistance inhandling disease outbreaks, and to care for many sick and injured personsbecause civilian authorities lacked personnel or transportation. Furthermore,the Medical Department had to consider the possibility of nutritionaldeficiencies among civilians as well as among the military, and periodicallyfurnished supplies of vitamins. Fortunately, no serious cases of deficiencydiseases or malnutrition were reported to the Alaskan Defense Command.

The American National Red Cross-The program of theAmerican National Red Cross in Alaska was determined by both War Department andRed Cross directives. Its activities, like some of the activities of militaryunits, were limited by the cold wet climate, weather, fogs, williwaws,isolation, and the small and transient populations in the station hospitals.After 1942, the Red Cross activities became an important part of the programs ofthe larger hospitals in the Alaskan theater.

Civilian employees.-The large number of civilianemployees brought into the area by the Army and by civilian contractors placedan additional burden on the Army Medical Department which had to compensate forthe lack of civilian medical facilities at the worksites. For example, the totalnumber of employed civilians rose to more than 17,000 during 1944. Frequently,they represented a third of the population of an isolated post and,occasionally, greatly exceeded the military, as at Shemya in December 1944.Hospital personnel had to be diverted for their care because an increase ofpersonnel was not provided to meet the increased demands.

Army medical reports-The surgeons of military units inAlaska from 1941 to 1945 have provided valuable reports and histories.⁴¹These docu-

⁴¹(1) McNeil, Gordon H.: History of the Medical Department in Alaska in World War II, 1946. [Official record.] (2) Report, Lt. Col. Luther R. Moore, MC, Surgeon, Headquarters, Alaska Defense Command, subject: Medical Problems to be Considered for All Areas, 1 January 1943. (3) Annual Report, Surgeon, Headquarters, Seventh Infantry Division, 1943.

ments contain medical and technical dataconcerning the routine professional, sanitary, and administrative experiences oflarge and small organizations, but they have little to say about the publichealth activities associated with civil affairs and limited military government.Inevitably, however, unit surgeons participated in such activities through theircollaboration with the semiterritorial, semitactical Alaskan authorities; and attimes, they were actually local health officers of civilian settlements orvillages.

The Territorial Department of Health-The chiefcivilian contribution to the joint work in public health was made by theTerritorial Department of Health, under the Commissioner of Health, Walter W.Council, M.D. In a series of reports,⁴²Dr. Council described the organization of the department, summarized theactivities of its six divisions, and stressed the fact that the work of thesedivisions increased greatly during the war as the result of the innumerable,varied, and widespread activities of the large military forces in the Territoryof Alaska. Military authorities collaborated particularly with the Division ofPublic Health Engineering and Sanitation, the Division of Public HealthLaboratories, and the Division of Communicable Disease Control. The other threedivisions were Central Administration, Office of the Commissioner; the Divisionof Maternal and Child Health and Crippled Children's Services; and theDivision of Public Health Nursing.

WAR-PERIOD ACTIVITIES AND DISASTER RELIEF PLANS
AND PREPARATIONS

The possible disruption of ordinary civilian activities inAlaska by enemy action was a prominent factor in planning the public healthprogram. The "probable" destruction of cities and towns and theirsanitary facilities, together with the threat of epidemics under such conditionsand circumstances, made it necessary to anticipate problems and to prepare tomeet them on a territory-wide basis. Almost all civilians living in accessibleplaces in Alaska were immunized against smallpox and typhoid, and, to someextent, recommended immunizations against whooping cough and diphtheria werecarried out. Shortages of personnel interfered with the immunization program asthey did with other public health activities. In addition, the problems ofcommunicable disease control were made more difficult by overcrowding, shiftingpopulation, and inadequate sanitation. With respect to this phase of the work ofthe Health Department, the commissioner reemphasized, in 1943:"Ever-increasing problems of sanitation due to the influx and relocation ofcivilian population were evident. Addi-

⁴²(1) Annual Report, Territorial Department of Health, to the Governor of Alaska, 1 July 1941 to 30 June 1942. (2) Annual Report, Territorial Department of Health, to Governor of Alaska, 1 July 1942 to 30 June 1943.

tional soldier personnel in nearby camps, as well as newcamps, threw an extra load on the already crowded sanitary facilities."⁴³

Laboratory facilities and services were made available on awider scale than ever before. The commissioner noted: "Laboratoriescontinued to provide an excellent service to the private physicians and themilitary services. In a few instances they were particularly valuable to thearmed forces, due to the fact that they did essential laboratory work for thevarious camps while they were in the process of setting up their ownlaboratories."⁴⁴A new branch laboratory was opened in Ketchikan Health Center, and theHealth Centers at Juneau and Fairbanks were enlarged and improved.

Public health nursing programs were expanded to provide newand increased services for the families of civilian defense workers as well asfor the families of members of the Armed Forces.

A blood typing program was put into effect to provide atleast the first step in the procedure of blood transfusion should civiliancasualties occur.

Furthermore, the Territorial Department of Health togetherwith other agencies was actively engaged in planning a territory-wide programfor emergency first aid and medical services. First aid supplies, surgicalequipment and supplies, and drugs were collected, to be made available to theprincipal towns in the event of an emergency or enemy attack. The other agencieswere chiefly the American National Red Cross, the National Resources PlanningBoard, and the Office of Civilian Defense. Naturally, Army units in Alaska wereprepared to aid civilians who might be harmed in an enemy raid or larger attack,and to assist in repairing sanitary facilities and in maintaining law and order.

Communicable Diseases

Respiratory infections, including tuberculosis, venerealdiseases, and the diarrheas and dysenteries, were endemic in Alaska.Overcrowding accompanied the preparations for defense, and sanitary facilitiesbecame more inadequate than ever. The military forces usually improved thelocation in which they were stationed, but not always. To build airfields,bases, and camps, forests were cut down, trees and stumps were uprooted, tundrawas bulldozed and churned into mud, and some sources of fresh water werecontaminated. Waste disposal was difficult. Viewing this aspect of the situationin March 1944, the surgeon at Adak wrote that this island "had regressedfrom virgin nature to the pollution of modern civilization."

In dealing with communicable disease control in itsenvironment, the military force in Alaska participated in broadly conceivedextra-military area sanitation.

⁴³See footnote 42 (2), p. 94.
⁴⁴See footnote 42 (1), p. 94.

Respiratory infections.-For theperiod 1942-45, the average rate of respiratory diseases (203 per 1,000average strength) was higher in the Alaskan Department than in any other majorregion. In the first 2 weeks of April 1943 and, again, beginning on 2 December1943, there were explosive outbreaks of sickness regarded as influenza. The mostserious threat among the respiratory diseases was pulmonary tuberculosis.Although this was prevalent among the native Eskimos, Indians, and Aleuts, itdid not spread among U.S. military personnel.

Venereal diseases.-Venereal diseases, although prevalentamong native women and white prostitutes, were a much smaller health hazard totroops in Alaska and on the Aleutian Islands than in any other area ofcomparative size in which U.S. troops were stationed. Explanations given forthis were: (1) reduction of contacts by the geographic isolation of manymilitary posts; (2) good working collaboration between the militaryorganizations and the Territorial Department of Health which, among otherhelpful actions, forced the deportation of infected prostitutes; (3) the easeand thoroughness with which houses of prostitution and the "line"(red-light district) in the main cities and towns could be kept "offlimits"; (4) thorough application of rules of chemical prophylaxis; and (5)sanitary and health disciplines enforced by all commanding officers on ordersfrom the commanding general.

Diarrheas and dysenteries-With low endemicity andvariable severity among the aboriginal natives, intestinal infections in thesecategories were less of a problem than expected. The lowest rates for diarrheasand dysenteries, lower than for troops in the continental United States, wereattained by troops stationed in the Alaskan Department. Factors contributing tolaw incidence were (1) climate and cold environment; (2) good control over watersupplies for all bases in Alaska; (3) low endemicity among the natives, withonly occasional epidemics; (4) adequate screening against flies and lowprevalence of Musca domestica; (5)rapid installation of water-carriage sewage disposal units; (6) decrease ofaverage troop strength after 1943; (7) use of military foodhandlers; (8)frequent sanitary inspections with emphasis on mess sanitation; (9) isolationand lack of contact with natives in many areas; and (10) practical public healtheducational programs especially with regard to sanitation.

Other serious communicable diseases among troops and nativesincluded mumps, measles, and infectious hepatitis. Diseases of minor prevalence,however, raised few problems.⁴⁵

Veterinary Activities

As described in detail by Lt. Col. Everett B. Miller, VC, inanother

⁴⁵(1) Medical Department, UnitedStates Army. Preventive Medicine in World War II. Volume IV. CommunicableDiseases Transmitted Chiefly Through Respiratory and Alimentary Tracts.Washington: U.S. Government Printing Office, 1958, pp. 65, 405-409. (2) Seepages 319-324 of footnote 4, p. 61.

volume of the World War II Medical Department historicalseries,⁴⁶ veterinary activities brought the military and civilianagencies concerned with food and feeding into numerous contacts involving closecollaboration. These activities included procurement and inspection of fish,reindeer meat, eggs, dairy products, and vegetables.

Evacuation of Japanese From Alaska

Concurrently with the evacuation of the Japanese from theWest Coast, the Army in Alaska engaged in the same kind of"protective" activities as those of its controlling authority, theWestern Defense Command. After the attack on Pearl Harbor when the AlaskanDefense Command was made responsible for controlling enemy aliens in its area,it interned those it regarded as potentially dangerous. "On 6 March1942," as recorded by Conn and his associates,⁴⁷"theSecretary of War extended his authority under Executive Order No. 9066 to theArmy commander in Alaska. By the end of May, he had evacuated not only his alieninternees but also the whole Japanese population of Alaska-230, of whom morethan half were United States citizens."

Antibiological Warfare

During the last year of the war, the Surgeon, AlaskanDepartment,⁴⁸ announced on 18 April 1944 that he had been appointedantibiological warfare officer in addition to his duties as surgeon, and thathis activities as antibiological warfare officer were "limited to thepreparation of precautionary measures and procedures." These measures andprocedures might have involved civil affairs and military government publichealth activities. "Balloons of Japanese origin ** * carrying various types of explosive charges"had been found "and the possibility was considered that these balloonsmight be used as a means of biological warfare." The surgeon organized andinstructed the balloon recovery teams which included medical or laboratorytechnicians "to inspect balloon landing sites and recover all possiblebacteriological warfare specimens." These teams were not put to practicaltrial as there were no serious alarms over possible sabotage of health resourcesand facilities.

Section III. Hawaii

Ira V. Hiscock, M.P.H., M.D., and Stanhope Bayne-Jones, M.D.

Annexed by the United States on 12 August 1898, the HawaiianIslands became an organized territory by act of Congress on 14 June 1900, in the

⁴⁶Medical Department, United StatesArmy. United States Army Veterinary Service in World War II. Washington: U.S.Government Printing Office, 1961.
⁴⁷See pages 115-149 of footnote 33 (1), p. 86.
⁴⁸See footnote 41 (1), p. 93.

opening years of American expansion into regions of thePacific Ocean. These years saw the beginning of the territory's contact withFederal military forces which exerted varying degrees of influence upon itscivil affairs. These years also contained the seeds of the fated conflictbetween the United States as a new world power and Japan's moving, in 1940-41,into its so-called Greater East Asia Co-Prosperity Sphere. The militaryinfluences upon many civilian affairs, including public health activities, beganto be especially notable in February 1913, when the Hawaiian Department,including Pearl Harbor on the island of Oahu, was established by the WarDepartment to garrison and defend the territory and to serve as the main base inthe line of support of U.S. forces in the Philippines, Guam, and other Pacificislands.

The strategic significance of the Hawaiian Islands as themost important Pacific outpost of U.S. defense was recognized from the firstdays of their possession. From 1900 onward, under the rule of the United States,Oahu and several adjacent islands were fortified increasingly. Organizations ofthe Army and Navy stationed there increased in number, strength, and localinfluence. The territory's civilian economic, political, and cultural growthtook place under a paternalistic, friendly, military "occupation."Eventually, from 1941 to 1945, the strategic estimates became realities whenHawaii served as the main base for the hemiglobal counteroffensive against theJapanese Empire.⁴⁹

DEFENSE PREPARATIONS AND PUBLIC HEALTH

The outbreak of war in 1941, and the emergency defensepreparations which had preceded it, imposed new and additional duties andresponsibilities upon the Board of Health of the Territory of Hawaii andnecessitated considerable extension and expansion of the "normal"public health program. Fortunately, the territory, including the city ofHonolulu, had one of the better programs of services in public health. It wassuperior in some respects to the programs of several States on the mainland,partly as a result of local initiative in periodic appraisal of needs andresources following a comprehensive health survey made in 1929. A resurvey wasundertaken in 1935, which resulted in further constructive action. There was afirm basic structure for public health, with many members of the professionalstaff technically prepared, and a growing public interest in health affairs. Thehealth department recognized not only the need for expanding its regularfunctions but also the necessity for preparing for any type of emergency.

From 1940 to the end of the war, increased demands were madeupon the Department of Health, especially on Oahu, as a result of the nationaldefense program. There was a rapid and continuous increase in population

⁴⁹(1) Allen, Gwenfread: Hawaii's WarYears, 1941-1945. Honolulu: University of Hawaii Press, 1950. (2) Anthony, J.Garner: Hawaii Under Army Rule. Stanford, Calif.: Stanford University Press,1955. (3) See pages 150-222 of footnote 33 (1), p. 86.

from 368,336 on 1 April 1930 to 423,333 on 1 April 1940, andan estimated 502,122 on 1 July 1945, when 261,023 military personnel also werestationed on the islands. As a result of the increased population alone,additional public health services, medical and sanitary supplies, and personnelwere required in environmental sanitation, communicable disease control, foodsanitation, public health nursing, supervision of water supplies and wastedisposal, and problems related to housing.⁵⁰

In providing these services, the Board of Health was joinedby a number of other governmental and civilian agencies, including theDepartment of Institutions and its Bureaus of Hospitals and of Mental Hygiene,the local medical associations, the Junior Chamber of Commerce and the Chamberof Commerce of Honolulu, the American National Red Cross, and many others.Constant working liaison was maintained with the military medical establishmentof the Hawaiian Department for joint undertakings and formulation of policies,especially in relation tosanitation, control of communicable disease, and disaster relief.

The lowest crude mortality and lowest infant mortality in thehistory of the territory were reported during the years immediately precedingthe war, with a decline in the mortality from tuberculosis. The 1941 AnnualReport recorded that "a receptive and public health minded community was agreat assistance to the department [of Health] in helping to produce suchresults," while "military defense has precipitated many healthproblems."

President Roosevelt's proclamations of a limited and anunlimited national emergency, issued on 8 September 1939 and 27 May 1940,respectively, were followed by increasingly thorough planning and heightenedefforts to prepare the public health services for meeting the needs that wouldarise in the event of an enemy attack from without, or sabotage from within, theterritory. Anxiety about possible sabotage, an old obsession, was keener, atthat time, than the fear of a possible overt enemy attack by air or sea. Thislong-held dread of sabotage was responsible, after the attack on Pearl Harbor,for repressive actions against the resident Japanese, aliens and citizens, andfor stringent military antisabotage and antibiological warfare measures, both ofwhich had an impact upon civil affairs.

When the Disaster Relief Council was organized after itsestablishment by an ordinance passed in April 1941, the Territorial Commissionerof Public Health was named chairman of the Health and Sanitation Committeecomposed of representatives of various related health, medical, and welfareagencies. The committee pointed out that its function would be almost identicalwith the normal functions of the Board of Health except for the expansion ofspecific activities to meet needs as they developed. All of this was carried onwith an air of confidence in the impregnability of Oahu.

⁵⁰(1) Annual Reports of the Boardof Health, Territory of Hawaii, Honolulu, Fiscal Years 1940-1946. (2) Health Department Service in War Emergency. The HawaiiHealth Messenger, vol. 1, No. 6, December 1941.

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F IGURE 9.-Brig. Gen. Edgar King, USA.

ATTACK ON PEARL HARBOR

The material damage inflicted by the Japanese attack on PearlHarbor upon the military targets was enormous and casualties among militarypersonnel were heavy. Honolulu was not deliberately bombed, but certain sectionswere strafed with machineguns. Several fires were started by Navy antiaircraftshells which had failed to explode in the air. The city suffered some damage anda number of civilians were killed or injured.⁵¹

The medical establishment of the Hawaiian Department, ofwhich Col. (later Brig. Gen.) Edgar King, MC (fig. 9), was surgeon, treatedcasualties at aid stations and at various Army hospitals, particularly TriplerGeneral Hospital. Civilian hospitals also were used by the military incooperation with physicians and surgeons of Honolulu.⁵²Many reliefmeasures, including the restoration of sanitary facilities and procedures, wereundertaken at once.

⁵¹See footnote 33 (1), p. 86.
⁵²Mason, Verne R.: Central PacificArea. In Medical Department, United States Army. Internal Medicine inWorld War II. Volume I. Activities of Medical Consultants. Washington: U.S.Government Printing Office, 1961, pp. 625-693.

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Military control of civil affairs in Hawaii began on the dayof the Pearl Harbor attack when Gov. Joseph B. Poindexter invoked the HawaiiDefense Act and proclaimed martial law at the request of Lt. Gen. Walter C.Short, commanding general of the Hawaiian Department. General Short thenproclaimed himself "Military Governor of Hawaii." (The invocation ofmartial law and the suspension of the writ of habeas corpus were approved byPresident Roosevelt on 9 December.) The Military Governor asked that alldepartments of the Territorial government continue their special functions untilotherwise ordered.

Within an hour after the first bombs fell, the executiveheads of the civilian Department of Health were in conference, the well-laidplans were reviewed, and arrangements were made for carrying out the serviceswhich seemed to be required at the moment. An inventory was taken of thebiologicals on hand at the health department and at the pharmaceutical supplyhouses in the city. All members of the health department in Oahu were placedimmediately on 24-hour call. Day and night service was established at the Officeof the Board of Health and was maintained for 2 weeks following the attack.

Close liaison was established and maintained with the medicaldepartments of the Army and the Navy, the medical director of the first aidstations, the medical officer in charge of the Emergency Hospital, and municipalauthorities, particularly those in charge of the water supplies, the seweragesystems, and garbage collection. All were urged to use the facilities of theDepartment of Health to the greatest possible extent.

On 8 December 1941, the United States declared war on Japanand formally entered World War II in alliance with Great Britain. This meantthat the military representatives of the nation at war would, in the name ofsecurity and military necessity, exercise increasing authority over civilaffairs, especially in a territory under martial law. However, medicine andpublic health in Hawaii were preempted less by martial law than were thejudiciary functions and individual civil rights.

Further Public Health Activities After Pearl Harbor

Although the Hawaiian Islands were not attacked again, thewar affected intimately the life of each individual there and was a constantfactor in the responsibilities, plans, and everyday work of the Department ofHealth. So that appropriate measures for the prevention and control ofcommunicable diseases might be instituted at the earliest possible moment, theDepartment of Health requested all physicians to report communicable diseases bytelephone. An order from the Office of the Military Governor followed, directingphysicians to comply with the request.

New public health problems were created by the forcedevacuation of large numbers of civilians from residential districts close tomilitary

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establishments to sections of Oahu distant from likelytargets of possible renewed attack by the Japanese.

In Honolulu, a previously organized community health councilproved useful. Routine sanitary, food, water, milk, and other inspectionservices were intensified. The outer-islands health department representativestook similar steps to meet local conditions.

The passage during the war period of various social securitylaws resulted in a flood of requests for copies of birth, death, and marriagecertificates for such purposes as proof of citizenship, age, insurance,expatriation, passports, employment, school enrollment, social security, andwelfare benefits. The demands upon the Bureau of Vital Statistics exceeded thecapacity of the limited personnel, and the regular staff was increased withassistance from the Governor's contingent fund and other sources. The healtheducation program was amplified, with special emphasis on nutrition.

Early orders of the Military Governor dealt with the economicuse, control, and distribution of available medical supplies to meet the needsof both the military forces and the public during the emergency.

During the war period, while the territory was in a"theater of operations," the Board of Health continued to cooperateclosely with the military authorities and other agencies for the mutualprotection of civilian and military health. It collaborated with the surgeon ofthe Hawaiian Department in preparing a number of military orders relating tothese matters. Two of those orders were especially noteworthy. The first orderrequired the immunization against typhoid fever and smallpox of the civilianpopulation of the territory who had not been vaccinated since 1 January 1941.The second order made venereal disease control measures more stringent.

Immunization program.-The immunization program of theterritory's population against typhoid and smallpox was organized andadministered by the Department of Health with the cooperation and assistance ofthe Army Medical Department, the Office of Civilian Defense, and voluntaryorganizations. Immunization against diphtheria, with toxoid, was not requiredbut was recommended. Diphtheria toxoid was furnished by the Board of Health;typhoid and smallpox vaccines and incidental supplies were provided by the Army.As of 30 July 1942, records on file at the Department of Health covered 301,567persons vaccinated against typhoid fever, 308,406 against smallpox, and 11,634children injected with diphtheria toxoid. These numbers were exclusive of thoseon the large island of Hawaii, where the program was still in progress at theend of the fiscal year.

Venereal disease control-The venerealdisease control order strengthened and supplemented existing communicabledisease control regulations. It required that all cases of venereal diseases bereported to the Department of Health within 24 hours after diagnosis by medicalofficers of the Army and the Navy, as well as by civilian physicians. Itprovided for the naming of

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contacts and the reporting of delinquent cases. It made theDepartment of Health responsible for immediate examination of all suspectedsources of infection and for the quarantine of infected individuals.

Many aspects of the situation in Hawaii were unique. A systemof organized prostitution existed in the Territory. Houses of prostitution hadattending physicians who examined the operators at regular intervals. ** * the practice was lucrative. ** * There were strong forces in the civilian communityfavoring the presence of organized prostitution. These forces included both alarge group who obtained handsome financial support from a reportedly10-million-dollar business and others who felt that the prostitution system hadcontributed to the low venereal disease incidence in the islands and was aprotection to respectable women and girls of the community.

Efforts were made by the military authorities to close thehouses of prostitution in Honolulu.

In September 1944, after many conferences with localauthorities, the houses of prostitution in Honolulu were closed. Similar housesin other places in Hawaii had been closed previously. After this action, therewas no increase in sex crimes or other criminal practices and there was anadditional decrease in the already low venereal disease rate among Armypersonnel.

From this experience, it may be concluded that the proponentsof organized prostitution were mistaken as to its benefits.⁵³

Dengue.-After an absence of more than 30 years, dengueappeared in epidemic form in Honolulu in July 1943; apparently it wasintroduced by commercial airline pilots flying in from the Fiji Islands, wherean epidemic had been reported. After several cases appeared in civilians and inmilitary personnel about 3 to 4 weeks following the arrival of the pilots,vigorous measures were taken by the Territorial Board of Health in collaborationwith the Army Medical Department and the U.S. Public Health Service. Although1,498 civilian cases were reported through June 1944, only 56 occurred inmilitary personnel. The disease reached its peak in October and did not spreadfrom Oahu to the other islands.

Of the two proved vectors of dengue, Aedes albopictus andAedes aegypti, A. albopictus was the more important-a persistent biteronly during daytime. Protective measures consisted of (1) citywide inspectionsat 10-day intervals to eliminate mosquito breeding places, (2) selectivespraying to kill adult mosquitoes, (3) mandatory screening for patients inhospitals and in homes, (4) placing large areas of Honolulu "offlimits" to troops, and (5) educating the residents in how to preventmosquito breeding on their premises.

Assistance in dengue control was given freely by the Army tocivilian agencies because effective control in military establishments was notpossible without adequate control in civilian areas. A medical officer wasattached to the Territorial Board of Health to make an epidemiological study ofall new cases. Fifty enlisted men were assigned to spray the buildings andeliminate mosquito breeding places in houses in which there

⁵³See pages 139-331 of footnote4, p. 61.

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were cases of dengue. Trucks, ladders, and spraying equipmentwere made available to civilian agencies.

As an aftermath, in 1944-45, Lt. Col. Albert B. Sabin, MC,of the Commission on Neurotropic Virus Diseases of the Army EpidemiologicalBoard, recovered seven strains of dengue virus (which became known as theHawaiian strain) from serum specimens drawn from Americans stationed in Hawaii.⁵⁴

Plague.-After an absence of 3 years, human plague was againreported from the Hamakua District on the Island of Hawaii: seven cases, allfatal, in 1943; and seven cases, five fatal, in 1944. From May 1943 to April1944, the flea index of rats rose from 0.17 to 0.61, and infected dead rats werefound increasingly. The Territorial Board of Health attacked the problem ofcontrol vigorously. Some 5,000 persons were vaccinated with the Army plaguevaccine. Air Force personnel and employees entering the Hamakua District alsowere injected with plague vaccine. Rat-free zones in and around infected areaswere established by poisoning and gassing operations and by communitysanitation. The rodent population was held at a low level in the epizootic area.Trapping was used primarily to determine whether or not the infection wasspreading. This limited outbreak affected only civilians. The Army treated it"expectantly," cooperating with the Territorial Board of Health asindicated.⁵⁵

Martial Law

The administration of martial law, particularly on Oahu from1941 to 1944, and the activities that took place in this clearest of allinstances of military government of civil affairs, included certain publichealth activities, in an internal domestic situation in a territory of theUnited States. During its enforcement, there was a period, beginning on 8February 1943, in which partial restoration of civil authority prevailed. Onthat day, mitigating proclamations were issued by Gov. Ingram M. Stainback andby Lt. Gen. Delos C. Emmons who had succeeded General Short as commandinggeneral of the Hawaiian Department and as Military Governor of the Territory.From June 1943 to August 1944, Lt. Gen. Robert C. Richardson, Jr., held thetitle of Military Governor. These three Military Governors administered martiallaw according to the pertinent field manual and army regulations.⁵⁶They applied the authorizations strictly in matters having a direct bearing onthe prosecution of the war, particularly with regard to curfew, blackout, foodcontrol, and controls over a multitude of individual civil liberties. Their

⁵⁴(1) Medical Department, UnitedStates Army. Preventive Medicine in World War II. Volume VII. Communicable Diseases: Arthropodborne Diseases Other ThanMalaria. Washington: U.S. Government Printing Office, 1964, pp. 29-62. (2) Gilbertson, W. E.:Sanitary Aspects of the Control of the 1943-1944 Epidemic of Dengue Fever in Honolulu. Am. J. Pub. Health 35:261-270, March 1945.
⁵⁵See pages 79-100 of footnote 54 (1).
⁵⁶(1) War Department Basic FieldManual 27-15, Military Law: Domestic Disturbances, 6 Feb. 1941. (2) Army Regulations No. 500-50, Employment of Troops: Aidof Civil Authorities, 5 Apr. 1937.

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orders bore heavily upon judicial proceedings. For example,military courts replaced civil courts, which were suspended. All schools wereclosed for a period. Practitioners of medicine and public health were subjectedto severe controls in some matters, but were largely left to conduct their ownaffairs. The Office of the Military Governor included a controller of civilianmedical supplies, and orders were issued regulating some phases of medicalpractice, the handling of drugs and poisons (including insecticides), garbagedisposal, public health hospitals, insane asylums, water supply control, and soforth.

President Roosevelt arrived in Honolulu for a militaryconference on 21 July 1944, and the overbearing title, "Office of MilitaryGovernor," was changed to "Office of Internal Security." On 24 October 1944, the President ended martial law and restored the writ of habeascorpus by Proclamation No. 2627.

Throughout this long period, the public health activities ofcivil affairs and military government were aided considerably by the existenceof martial law, through orders issued by the Military Governors and throughcollaboration between the Territorial Department of Health and the militaryestablishments, both of which were endowed with wider powers.

Nevertheless, opinions differed as to the values of martialrule and its prolonged tenure in Hawaii. Criticisms have been expressed byAnthony⁵⁷ and Biddle.⁵⁸However, more moderate statementssummarize the case well, as an anonymous historian wrote:⁵⁹

When the Japanese attacked Pearl Harboron 7 December 1941, asituation unprecedented in American History came into being. Martial law wasproclaimed in the Territory of Hawaii, subjecting the community to strictcontrol by the Commanding General of the Army forces in Hawaii in his capacityas the Military Governor. This rule was destined to last for nearly three years.Previously, martial law had been used on numerous occasions in the United Statesto subdue riots, labor disorders, and other internal violence, but never beforehad it attained such proportions, so completely pervaded the community life, orremained in effect so long. * * * The daily life of each individual in the Territorywas vastly and often rather suddenly changed by the emergency measures whichfollowed the attack.

Finally, Conn, Engelman, and Fairchild⁶⁰assessed the situation as follows:

* * * By and large, at the outset[of martial law], civilians accepted these and other measures with understandingand good spirit. Later, both Hawaiians and agencies of the federal governmentother than the War and Navy Departments registered a good many complaints aboutthe continuation of martial law; but the Army kept a tight control of civiliansand civilian affairs until after the Battle of Midway in June 1942 erased anythreat of invasion.

⁵⁷See footnote 49 (2), p. 98.
⁵⁸Biddle, Francis: In Brief Authority. Garden City, N.Y.:Doubleday & Company, Inc., 1962.
⁵⁹History of U.S. Army Forces,Middle Pacific and Predecessor Commands, During World War II, 7 December 1941-2September 1945. [Official record, Office of the Chief of Military History.]
⁶⁰See footnote 33 (1), p. 86.

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Evacuation of Japanese.-From the beginning of the emergencyin 1939, the authorities of the Territory of Hawaii and manyimportant citizens had been fearful of injury to persons, installations, publicutilities, offices, and property by acts of sabotage that might be committed byresident aliens, particularly by the Japanese. Many precautions were taken,notably a suspicious watchfulness over their activities. After the attack onPearl Harbor, strict control of Japanese, both aliens and citizens, wasincreased, stimulated by the proclamations and actions of the central governmentconcerning control of aliens living in the West Coast States.

Although there was much suspicion of the Japanese, there wasno evidence that they committed sabotage of any kind at any time. During thefirst few days after the attack on Pearl Harbor, rumors were current that thewater supply of Honolulu had been contaminated or poisoned. Upon investigationand examination, this rumor was shown to be without foundation; other similarrumors also were found to be false.

Of 160,000 Japanese in the territory, 1,450 were taken intocustody during the war and, of these, 1,000 were evacuated to the mainland. Theywere interned for the duration in the relocation centers at Jerome, Ark., andPoston, Ariz.⁶¹

Antisabotage and antibiological warfare.-To further protectthe health and safety of civilians, military personnel, and installations in theTerritory of Hawaii, an extensive effort was directed against possible sabotageand biological warfare that might be carried on by Japanese or other residentsof Hawaii.⁶²This effort was centered in the Office of the Surgeon,Hawaiian Department, as Colonel King was designated antibiological warfareofficer early in 1942. From 1942 until the end of the war, his special staffconsisted of a number of departmental antibiological warfare assistants. Theyconducted many surveys of water supplies, food processing and servingestablishments, drugstores, chemical supply houses, and bacteriologiclaboratories. They supervised hundreds of chemical and bacteriologicexaminations of all kinds, and Colonel King's detailed scientific andpractical reports contributed much to the effectiveness of precautionarymeasures. No instance of sabotage or biological warfare occurred.

SUMMARY

The public health program existing in Hawaii before theoutbreak of war in 1941 made it possible to carry out unusually effective andwell-administered military and civil public health operations in World War II. Inconcluding this section, it is appropriate to quote from an article by RichardK. C. Lee, M.D., Director of Public Health, Territory of Hawaii, published inthe January 1944 issue of The Hawaii Health Messenger. Dr.

⁶¹See footnote 49 (1), p. 98.
⁶²(1) See footnote 59, p. 105. (2) Personal information ofthe authors.

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Lee's summary and opinion of the health program in Hawaiiduring the early war years follow:

From December 7, 1941, until March 11, 1943, the Territory ofHawaii experienced health administration under civilian and military control.During this period, the Military Governor's office exercised generalsupervision over all health problems relating to the civilian and militarypopulation. The civilian health department continued to carry out health lawsand regulations, while the military superimposed or added new regulations tomeet the changed conditions of the community, and in several respectsstrengthened existing regulations.

Public health under military rule in wartime Hawaiidemonstrated the value of a well organized health program and the possibilitiesof its expansion wherever it was needed. Instead of organizing and developingwartime health department services for the maintenance of public health,military authorities were able to utilize the Territorial health departmentpersonnel, supplementing their activities, where necessary, with additionalpersonnel. The close cooperation between the military and the civilianauthorities responsible for the maintenance of health in Hawaii has been verygratifying. The results of such a relationship have been adequately demonstratedin the low morbidity and mortality figures in the Territory during the past twoyears. And among the gains which have been made in public health can beprominently listed wider public acceptance of certain progressive communityhealth measures, such as mass immunization and more stringent venereal diseasecontrol, which were initially imposed by military order and later promulgatedand continued under civilian authority.

Section IV. U.S. Possessions and Bases in theCaribbean Area

Major General Morrison C. Stayer, MC, USA (Ret.)

HISTORICAL NOTE

The concern of the United States with the security anddefense of the Caribbean area was a part of the Nation's instinctive sense ofthe need to defend the entire Western Hemisphere. This precautionary attitude,assumed at the beginning of the country's independence, was first formallyasserted in President James Monroe's annual message to the Congress on 2December 1823. The Monroe Doctrine, modified and expanded from time to time, asone of the basic foreign policies of the United States, admonished againstEuropean political or military intrusion into the affairs and territories(including coasts, islands, seas, and adjacent ocean areas) of North America andSouth America. During the succeeding 80 years, the doctrine stood as a warningto foreign powers, and it was invoked several times with deterrent effect.However, no permanent defenses were created by the United States in theCaribbean area until after the Panama Canal Zone was acquired in 1903.

After the acquisition of the Panama Canal Zone, somedefensive preparations were made to protect the canal and its approaches. Littlewas done, however, to plan and create the military means for the United Statesto engage in a defense of the Americas. A philosophy of isolation and adisinclination to maintain sufficient military strength to sustain defense on

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a hemispheric scale persisted from the end of World War Iinto the 1930's. In addition, by about 1936, newinternational agreements, and the displeasure of a number of Latin Americancountries, had forced the virtual obsolescence of the Monroe Doctrine. Towardthe end of the 1930's, startling events immediately preceding World War IIcaused a radical change in outlook and a quickening of military and politicalactivities to safeguard the Western Hemisphere.

These events have been summarized by Conn and Fairchild⁶³as follows:

Immediately after the Munich crisis of September 1938, theUnited States moved toward a new national policy of hemisphere defense. * * *The rise of aggressive dictatorships in Europe during the pre-World War IIdecade found the United States Army in condition to do no more than defend thecontinental United States, Oahu, and the Panama Canal Zone. The Navy, relativelymuch stronger than the Army, was tied down in the Pacific by Japan's navalexpansion and aggressive action in China. Therefore, when President Franklin D.Roosevelt declared, six weeks after the Munich settlement, that "the UnitedStates must be prepared to resist attack on the western hemisphere from theNorth Pole to the South Pole, including all of North America and SouthAmerica," the Army and Navy were presented with a much bigger mission thanthey were then prepared to execute.

Less than a year after President Roosevelt's pronouncementthat the United States must be prepared to defend the entire Western Hemisphere,World War II began in Europe with the German invasion of Poland on 1 September1939. The United States began at once to strengthen its continental perimeter onland and in the bordering seas and oceans. Great arcs of defensive installationswere projected from Alaska through Hawaii to the Panama Canal Zone and, fromthere, eastward along the northern shores of Colombia, Venezuela, and theGuianas, and northward through the Antilles to Newfoundland, Greenland, andlater Iceland.

One of the measures taken by the United States to strengthenits defense position was the acquisition of base sites on British territory inthe Caribbean. The Destroyer-Base Agreement with Great Britain of 2 September1940 secured additional base facilities, and "although the Army played acomparatively minor role in the actual negotiation" of the exchange ofdestroyers for bases, its Medical Department inherited major additional civilaffairs and military government public health activities in a large portion ofthe Caribbean area.⁶⁴

GENERAL CHARACTERISTICS OF CIVIL AFFAIRS AND
MILITARY GOVERNMENT PUBLIC HEALTH ACTIVITIES

Although the 1940 leased-base agreement did not confer uponthe United States sovereignty over British territory on Caribbean islands and

⁶³Conn, Stetson, and Fairchild,Byron: The Western Hemisphere. The Framework of Hemisphere Defense. UnitedStates Army in World War II. Washington: U.S. Government Printing Office, 1960,p. 3.
⁶⁴See page 45 of footnote 63.

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on the mainland of British Guiana, it did endow U.S. Army andNavy forces and certain agencies with some degree of authority over theinhabitants. Many problems that arose under this agreement, as well as underthose with the Latin American countries which were not partners to thedestroyer-base deal, called for serious and intricate negotiations betweenrepresentatives of civil governments and U.S. military authorities to arrangefor necessary sanitation and public health control over civilians living nearmilitary facilities. The development of programs of sanitation, preventivemedicine, and public health was necessary in conformance with the limitingprovisions, agreements, and conventions. This type of relationship betweencivilians and military forces under a form of mixed civilian and military rulewas not new to the Caribbean area. It had been experienced in the Panama CanalZone since 1904 and, to a lesser extent, in Puerto Rico since 1898.

This section deals with the joint civil and military aspectsof public health activities in thatportion of the Caribbean Defense Command that included U.S. possessions; namely,Puerto Rico, especially the islands of Saint Thomas and Saint Croix in theVirgin Islands, and the Panama Canal Zone. The Panama Canal Zone was not apossession of the United States, but was a portion of the Republic of Panamawherein the United States has perpetuity control.

THE CARIBBEAN DEFENSE COMMAND

According to war plans adopted in 1940 (Rainbow 4),⁶⁵a Caribbean theater was contemplated, with territoriallimits consisting of "the islands in or bordering on the Caribbean Sea, theGuianas, Venezuela, Colombia, Ecuador, and the countries of Central America(except Mexico)." Althoughthe theater concept persisted throughout the next several years, the actualdesignation of the area and its military organization was Caribbean DefenseCommand.⁶⁶

The Caribbean Defense Command⁶⁷ wasauthorized by the War Department on 9 January, officially activated on 10February, and its organization was completed on 29 May 1941, under the commandof Lt. Gen. Daniel Van Voorhis who was also commanding general of the PanamaCanal Department. Its primary mission was "to meet any threat by air orwater by European powers, coming directly from the East into this area or froman established base in the northeastern part of Brazil, and further,

⁶⁵(1) A History of MedicalDepartment Activities in the Caribbean Defense Command in World War II, vol. I,May 1946. (2) See footnote 63, p. 108.
⁶⁶General Orders No. 8, Headquarters, Caribbean DefenseCommand, Quarry Heights, Canal Zone, 29 May 1941.
⁶⁷(1) See footnote 63, p. 108. (2) Francis, Marion D.:History of the Antilles Department. Sec. II, Ch. I. War Plans and Defense Measures Prior to Organizationof the Caribbean Defense Command (1 July 1939-29 May 1941), passim. [Official record, Office of theChief of Military History.] (3) See pages 301-441of footnote 33 (1), p. 86.

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to provide a more readily available force for augmenting thedefense of Panama Canal from the above directions or from the Pacific."⁶⁸

The area of the Caribbean Defense Command was more than afourth the size of the United States. It extended eastward as far as planescould fly, fight, and return, without refueling; westward 800 miles into thePacific to the Gal?pagos Islands; southward to Peru; and northward to encompassCuba and Puerto Rico in the Greater Antilles, and thence eastward and southwardthrough the Lesser Antilles to the northern coast of South America throughFrench Guiana. The Caribbean Defense Command included British Honduras,Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Panama, Ecuador,Colombia, Venezuela, and a portion of Peru, Cuba, Haiti, and the DominicanRepublic (map 2).

Command Organization

The military medical organization in the Caribbean area beganwith the establishment of the Panama Canal Department, with headquarters atQuarry Heights, C.Z., on 1 July 1917. The Caribbean Defense Command wasactivated in the Panama Canal Department on 8 May 1941. However, in the courseof prewar defense preparations, the Puerto Rican Department, which included theU.S. possessions in the Virgin Islands, was activated on 1 July 1939, withheadquarters at San Juan, P.R.

On 29 May 1941, the Caribbean Defense Command was organizedinto three major sectors with lesser commands, as follows:

1. The Puerto Rican Sector (included the Virgin Islands inthe Puerto Rican Department) and the Bahama, Jamaica, and Antigua Base Commands.

2. The Panama Sector absorbed the Panama Canal Department.

3. The Trinidad Sector was divided into the Trinidad, SaintLucia, and British Guiana Base Commands.

When the Antilles Department was established as the northeastsegment of the Caribbean Defense Command on 1 June 1943, the Puerto RicanSector, which had absorbed the Puerto Rican Department in 1941, was transferredto the Antilles Department, with headquarters still at San Juan, P.R.

The purpose of outlining the organization of the CaribbeanDefense Command is not to immerse the reader into the pool of jurisdictionalcomplexities of 1941 but rather to indicate the intricacy, variety ofterritorial arrangements, and the many different peoples and national intereststhat were involved in the civilian and military administration of the CaribbeanDefense Command. Diverse as were the elements, there were many common interestsin problems of sanitation, preventive medicine, and public health. These peoplesand their economic standards were united

⁶⁸The Army Almanac. Washington: U.S. Government PrintingOffice, 1950, pp. 305-306.

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M AP 2.-Location of departments and major U. S. Army bases, Caribbean DefenseCommand.

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by two common afflictions, malarial fevers⁶⁹and venereal diseases. Civil affairs and militarygovernment public health activities were intimately intermingled in efforts tocontrol and prevent these afflictions.

Medical Department Organization

In May 1941, the three separate health and medicalorganizations in the Caribbean area were Health Department, Panama Canal; Officeof the Surgeon, Panama Canal Department; and Office of the Surgeon, Puerto RicanDepartment. These, with the addition of sector medical establishments, werecontinued after the Caribbean Defense Command was activated. Their chiefsurgeons, according to different arrangements, reported directly to The SurgeonGeneral; to the Office of the Chief of Staff, War Department; or to First U.S.Army through Headquarters, Second Service Command. In planning for the CaribbeanDefense Command, provision had been made for an overall medical staff. Forvarious reasons-strategic, tactical, and conceptual-the establishment of theOffice of the Surgeon, Caribbean Defense Command, was postponed until 13 October1943. This delay of more than 2 years took place despite the strongrecommendation of a War Department inspection team under the command of Col.(later Brig. Gen.) Frederick A. Bless?, MC, Surgeon, General Headquarters, U.S.Army. On 11 February 1942, this team reported that the headquarters of theCaribbean Defense Command was only partially organized and had no medicalsection, and that such a section should be established without delay.⁷⁰

In the meantime, from 29 May 1941 to 13 October 1943,requests for expert professional advice and information on medical and healthproblems by Headquarters, Caribbean Defense Command, were dealt with chiefly bythe informal assistance of Brig. Gen. (later Maj. Gen.) Morrison C. Stayer, MC,chief health officer of the Panama Canal since 1939 and acting chief surgeon ofthe Caribbean Defense Command since 1941 (fig. 10). In responding to theserequests, General Stayer exercised unofficially some of the functions he waslater to perform officially; General Stayer was not designated surgeon of theCaribbean Defense Command until 13 October 1943, when the Office of the Surgeonwas established.⁷¹

Assignment of venereal disease control officer.-With theinflux of troops into the Caribbean area in 1942, the incidence of venerealdiseases rose rapidly. In September 1942, the Anglo-American CaribbeanCommission requested the assignment of a U.S. Public Health Service officer toassist in directing a control program. At the same time, The Surgeon General wasdeeply concerned with this problem. The matter was taken up

⁶⁹West, LutherS.: The South Atlantic and Caribbean Areas. In Medical Department, UnitedStates Army. Preventive Medicine in World War II. Volume VI. CommunicableDiseases: Malaria. Washington: U.S. Government Printing Office, 1963, pp. 113-247.
⁷⁰(1) Seepage 155 of footnote 65 (1), p. 109. (2) Medical Department, United States Army.Organization and Administration in World War II. Washington: U.S. GovernmentPrinting Office, 1963.
⁷¹(1) See page 167 of footnote 10 (3), p. 64. (2) See page 159 of footnote 65 (1), p. 109.

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F IGURE 10.-Maj.Gen. Morrison C. Stayer, MC, USA.

also by the Interdepartmental Committee on Venereal DiseaseControl, especially at its meeting on 17 November 1942. As a result of thediscussions, the chief of the Venereal Disease Control Division, Surgeon General'sOffice, strengthened the Army venereal disease control program in the Caribbeanarea, assigning Maj. (later Col.) Daniel Bergsma, MC, an officer speciallytrained for this work, to headquarters of the Caribbean Defense Command, toinitiate and promote the necessary control measures.⁷²

Assignment of surgeon-There was no official surgeonof the Caribbean Defense Command when Major Bergsma began his duties as venerealdisease control officer on 14 June 1943. This created an anomalous situation inthe Command's Special Staff structure as Major Bergsma was the first medicalofficer to be assigned to the staff. Nevertheless, the Assistant Chief of Staff,G-1, held that the assignment of both a chief surgeon and a venereal diseasecontrol officer to Command headquarters was unnecessary. On 13 October 1943, 28months after the Command had been organized, General Stayer was appointedSurgeon, Caribbean Defense Command, in addition to his regular assignment asChief Health Officer, Panama Canal.

After the establishment of the Office of the Surgeon,Caribbean Defense

⁷²See page 169 of footnote 4, p. 61.

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Command, most of the medical reports from both the PanamaCanal and Antilles Departments were routed through headquarters for review andconsolidation before being sent to Washington. This procedure was advantageousto the Caribbean Defense Command as many decisions involving policy could berendered by the surgeon and necessary action could be taken without waiting fordirectives from Washington, where practical field conditions were not alwayscompletely understood.

General Stayer held his dual positions until 1 November 1943,when he was succeeded as Chief Health Officer, Panama Canal, by Col. (laterBrig. Gen.) Henry C. Dooling, MC. General Stayer was then able to devote histime entirely to the duties of surgeon, and held that position until March 1944.

Assignment of assistant surgeon.-On1 January 1944, Colonel Bergsma, the venereal disease control officer, wasdesignated assistant surgeon and held that position until 22 October 1945. Asassistant surgeon, Colonel Bergsma was responsible for the administration of allsubordinate medical and health units in the Caribbean Defense Command. He alsosupervised research activities as a part of the preventive medicine program. Inconjunction with the surgeon, he was active in coordinating all civilian and WarDepartment agencies engaged in public health work in the area. During 1944,Colonel Bergsma also served as antibiological warfare officer for the Command,an activity which involved reviewing departmental plans and reports andtransmitting directives from Washington.

Coordination of Military Government and CivilPublic Health Activities

Although there was no specifically designated division ofcivil affairs and military government in the Caribbean Defense Command, thesurgeon, as coordinator for all American military, civilian, and foreign healthagencies within the Command, worked closely with civil health experts toestablish overall health policies. The surgeon was called upon to advise, tomake special investigations, and to consolidate selected medical reports on thehealth of troops and on the status of civil health on each of the islands thathe visited.

The surgeon and his staff assumed a major responsibility forthe supervision of the health, sanitation, and foreign quarantine problems ofthe many islands and land bases of the Caribbean area. For the benefit of bothtroops and civilians, the surgeon developed excellent liaison with leaders ofthe British, French, and Dutch Governments which controlled most of theseislands and territories.

THE PANAMA CANAL DEPARTMENT AND THE
HEALTH DEPARTMENT OF THE PANAMA CANAL

For obvious reasons, the concern of the United States in theCaribbean area was centered upon the Panama Canal. It was "a focal point ofnational

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defense, a base of operations for the protection of theHemisphere, [and] an instrument of national influence."⁷³Withinthe Canal Zone-the 5-mile strip on each side of the waterway-were locatednumerous military and civilian agencies. Among these were the headquarters andchief operational units of the two health and medical organizations.

The two health and medical organizations-Thefirsthealth and medical organization was the Health Department of the Panama Canal.It was established in 1914, and replaced the Department of Sanitation, whichCol. (later Maj. Gen.) William Crawford Gorgas, MC, created in 1904 when hebegan his epochal sanitation and disease control work as Chief Sanitary Officerof the Panama Canal Zone-work which made possible the building of the PanamaCanal by the U.S. Army Corps of Engineers. The second organization was thePanama Canal Department, established by the War Department, on 1 July 1917, asthe overall local operational military agency. The former was essentially acivil health department; the latter predominantly a military medicalorganization. The structure and functions of the two were different as may beseen from a comparison of their organizational charts (charts 3 and 4).

These two health and medical organizations had much in commonand worked together whenever their independent interests merged. From theirannual reports,⁷⁴however, it is difficult to identify their acts ofmutual collaboration. One rarely mentions the other because, apparently,collaboration was taken for granted and because the respective commandingmedical officers had similar viewpoints, traditions, and standards.

U.S. jurisdiction over public health in Col?n and Panama City.-Underthe terms of treaties and conventions between the United States and the Republicof Panama, the former's jurisdiction covered the Canal Zone and extended intoadjacent towns and cities. A Sanitary Code, prepared by the zone's chiefhealth officer and promulgated officially by decree of the President of theRepublic, constituted the authorization for the application of public healthmeasures in the terminal cities of Col?n and Panama, and in certain other areasof the Republic. This code dealt with all the important phases of sanitation,quarantine, and disease control. It involved many relationships between militaryand civilian authorities. In the cities of Panama and Col?n, the chief healthofficer was represented by two members of his staff who functioned as municipalhealth officers. At first, the two deputies were civilian physicians; after theUnited States entered the war, they were commissioned as lieutenant colonels inthe Medical Corps. Their reports emphasized indigenous diseases-namely,enteric infections, malaria and a variety of parasitic infections, and venerealdiseases-and included sanitary measures appropriate

⁷³Padelford, Norman J.: The PanamaCanal in Peace and War. New York: The Macmillan Co., 1942, p. v.
⁷⁴(1) Reports, Chief Health Officer, Health Department of PanamaCanal, 1939-44. (2) Annual Reports, Surgeon, Panama Canal Department, 1940-44.

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C HART3.-Organization of the HealthDepartment, Panama Canal, 1940

Source: Report, Chief Health Officer, HealthDepartment, of the Panama Canal, 1940.

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C HART 4.-Organization of the Office of the Surgeon, Panama Canal Department, 1944

¹Activated as the Panama Canal AirForce on 20 November 1940. Redesignated the Caribbean Air Force on 5 August1941, and redesignated the Sixth Air Force on 5 February 1942.

Sources: (1) Annual Report, Surgeon, Panama Canal Department, 1944, enclosure 4.(2) The Army Air Forces in World War II. Volume I. Plans and Early Operations,January 1939 to August 1942. Chicago: The University of Chicago Press, 1948, pp.160-166. (3) Annex No. 2 to Field Order No. 2, Headquarters, Sixth Air Force,Albrook Field, 1 Dec. 1944, subject: Missions of Commands, Air Bases, Airdromes,and Installations Under Sixth Air Force Jurisdiction.

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to a tropical environment. An effective public health programwas developed and maintained which benefited Army personnel, zone employees, andothers living in sanitated areas, and the Panamanian people within its reach.⁷⁵

Disease control through negotiation.-Even in the presenceof statutory authority based upon the Isthmian Canal Convention of 26 February1904, The Judge Advocate General advised that careful negotiations shouldprecede the prescription of sanitary ordinances that would place restrictionsupon the people of Panama. This matter came up for consideration in January1942, when an opinion was requested by the Assistant Chief of Staff, G-1,concerning the authority of the chief health officer of the Panama Canal tocontrol venereal diseases in the cities of Panama and Col?n. After reviewing thelanguage of the Convention, and after citing precedents, The Judge AdvocateGeneral issued the following opinion accompanied by a wise suggestion on theprocedure for carrying on public health activities under a permissivearrangement for civil affairs and military government in a friendly country.⁷⁶

I believe * * * that the United States may prescribeordinances with reference to the control of venereal diseases in the cities ofPanama and Colon, and I suggest that the representatives of the United Statestake that position in negotiations on the subject with the authorities of theRepublic of Panama. It seems preferable in any event for the matter to behandled by such negotiations rather than for the health authorities to prescribeordinances without previous notice to the government of Panama of an intentionto do so. It should also be noted that, according to paragraph 2 of Article VII,* * * when such ordinances shallhave been prescribed by the United States, enforcement of them will in the firstplace be the responsibility of the government of Panama; and it is only if thatgovernment is unable or fails in its duty to enforce them that the officers ofthe United States may themselves do so.

Increased U.S. military authority over civilian affairs.-Anincrease in military authority over civilians in the Canal Zone was imposed byPresident Roosevelt under Executive Order No. 8232, dated 5September 1939. Under authority derived from the Canal Zone Code, and inaccordance with the precedent set during World War I, the President placed theCanal Zone and all its appurtenances, including its Government, under theexclusive jurisdiction of the Panama Canal Department. Normally, the CommandingGeneral, Panama Canal Department, and the Governor of the Panama Canal sharedthe responsibility for the security of the Canal. In wartime, however, orwhenever the President believed that war was imminent, the Governor was to besubordinate to the military commander. The Executive order did not bring aboutthe invocation of martial law, nor was it intended to do so. Its chief effectwas to further unify Army command.

⁷⁵Francis, Marion D.: MedicalDepartment, United States Army. Preventive Medicine in World War II. Draftmanuscript. Volume I, Organization and Administration. Chapter XVIII, TheOff-Continent Defense Commands and Base Commands, 1941-45, pp. 2793-2864.[Official record.]
⁷⁶Memorandum, Maj. Gen. Myron O. Cramer, The Judge AdvocateGeneral, for Assistant Chief of Staff, G-1, 27 Jan. 1942, subject: Authorityof the Chief Health Officer of the Canal Zone to Control Venereal Disease in theCities of Panama and Col?n.

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Apparently, the two chief medical organizations under thisenlarged military jurisdiction carried on as usual, as did the Panama Canalauthorities.

Enlargement of the Panama Canal Department.-Beforethe President's declaration of a "Limited National Emergency" on 8September 1939, the Panama Canal Department was limited territorially to thePanama Canal Zone and to certain areas in the Republic of Panama occupied,with the consent of that Republic, for reasons of mutual defense. During WorldWar II, from 1 January 1940 to 1 October 1945, the Panama Canal Department wasexpanded enormously. Extending south from the eastern tip of Cuba, itencompassed nearly all of Central America, Panama, and portions of the coastalterritories of Colombia, Ecuador, and Peru, and the Gal?pagos Islands. (See map2, p. 111, and charts 3 and 4, pp. 116, 117.)

Sanitation and public health-In all of these areas,the Office of the Surgeon, Panama Canal Department, was engaged in improving thesanitary conditions among the inhabitants of cities, towns, and plantations, andother areas. The primary purposes were to protect the health of troops and tosupport the general military effort.⁷⁷This activity involved theapplication of public health measures by military medical and sanitary officersin collaboration with civilian officials, as exemplified by extra-military areasanitation and disease control, and by malaria control in war areas (fig. 11). Purification of water supplies, drainage, insect androdent control, housing, and foreign quarantine were familiar parts of theprogram.⁷⁸ In addition, militaryveterinary activities improved and safeguarded food supplies and built up localsources of meats and other foodstuffs, thus aiding the civilian economy andreducing shipping.⁷⁹

Control of communicable diseases-The three chiefcategories of diseases common to both civilians and troops in all segments ofthe Panama Canal Department were the enteric infections, venereal diseases, andmalaria. The methods employed for the control and prevention of these diseaseshave been recorded in three earlier volumes in this historical series.⁸⁰Whilethe locales and episodes were characteristic of the Panama Canal Department, theprinciples of the practices in these public health activities were the same asthose in other tropical and temperate areas.

The outcome of all of these activities was highly beneficialfor both civilians and troops. Of particular value were the personal andofficial contacts that fostered understanding and encouraged collaboration.⁸¹

⁷⁷(1) The Prevention of Disease in theUnited States Army During World War II. The Panama Canal Department, 1 January1940 to 1 October 1945. [Official record.] (2) See pages 193-201 of footnote 65(1), p. 109.
⁷⁸See pages 299 and 304 of footnote 2, p. 60.
⁷⁹See pages 220-224 of footnote46, p. 97.
⁸⁰(1) Medical Department, United States Army. PreventiveMedicine in World War II. Volume IV. Communicable Diseases Transmitted ChieflyThrough Respiratory and Alimentary Tracts. Washington: U.S. Government PrintingOffice, 1958. (2) See footnote 4, p. 61. (3) Seefootnote 10 (3), p. 64.
⁸¹See footnote 77 (1).

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F IGURE11.-Medical personnel dipspecimen jars in a drainage ditch along Madden Road, Canal Zone, December 1942, as part of the malaria controleffort.

THE PUERTO RICAN DEPARTMENT

Puerto Rico

During World War II, Puerto Rico was a possession of theUnited States. Ceded by Spain by the treaty signed in Paris on 10 December 1898,this island, one of the larger land masses in the Greater Antilles group, washeld under military government until 1900 and thereafter under civil government.Through the Organic Act of 2 March 1917 (the Jones Act), it became a territoryof the United States, organized but not incorporated. Puerto Rico remained inthis status until 25 July 1952 when, in accordance with the provisions of aresolution of the Congress signed by President Harry S Truman, it was proclaimeda Commonwealth and no longer was considered a colonial territory by the UnitedStates. On 1 July 1939, the War Department established within this territory thePuerto Rican Department, with headquarters at San Juan. By this action, theisland of Puerto Rico and the adjacent U.S. possessions in the Virgin Islands(chiefly

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F IGURE 12.-Military hospital,Borinquen Field, P.R., where U.S. military personnel and some civilians were treated.

Saint Thomas and Saint Croix) were grouped under a single WarDepartment administrative organization. The Puerto Rican Department continued asan administrative and operational unit of the War Department until 1 July 1943when it was absorbed by the Antilles Department, created on that day.

Characteristics of civil and military public healthactivities-From 1939 to 1945, Puerto Rico was in the same general territorialstatus as Alaska and Hawaii. At the same time, it had a representativesystem of civil government which resembled State governments in the continentalUnited States. An Insular Health Department and a commissioner of healthfunctioned side by side with a military post and departmental surgeon and adepartmental medical establishment (fig. 12). In addition, the U.S. PublicHealth Service, several U.S. governmental agencies, and certain voluntaryorganizations such as the Rockefeller Foundation carried out public health workamong the civilians which helped to protect the health of troops. Consequently,many aspects of the joint military and civilian public health activities weresimilar to activities carried out under civil affairs and military governmentalthough they were not so named.

Puerto Rico was in a chronic state of economic depression.Most of the poverty-stricken people in overpopulated areas were undernourished.Housing was indescribably bad. Sanitation of water supplies, food preparationand eating places, waste disposal, and sewerage were woefully deficient.

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Incidence of tuberculosis, hookworm infestation,schistosomiasis, malaria, and enteric infections was high. There was some murinetyphus fever, but no epidemic typhus although louse infestation was common.Venereal disease was widespread in the population and caused an enormous amountof sickness and mortality. The Army collaborated with civilian agencies toimprove all of these conditions by methods which involved education, regulation,and support of civilian inhabitants as well as military personnel.⁸²

An additional element of self-protection was essentialbecause the U.S. Army drew many of its troops from the Puerto Rican reservoir,thus bringing infections as well as manpower into its units and installations.The Puerto Rican components of the U.S. forces on the island were the RegularArmy's 65th Infantry Regiment and the National Guard's 295th and 296thInfantry Regiments, many of whose recruits were infected by variousmicro-organisms.

Reorganization of the Puerto Rican Department of PublicHealth-To coordinate activities better and to emphasize therepresentative character of the administrative units, the Puerto RicanGovernment reorganized its Department of Public Health in July 1942. Three maindivisions were established, each with a director who was responsible to thecommissioner of health. The reorganized Department of Public Health consisted ofa central office, the Office of the Director, and several bureaus, each with abureau chief. The scope and interests of some of the bureaus are exemplified bytheir names: Nursing; Sanitary Engineering; Epidemiology, with a section for thecontrol of venereal disease; Tuberculosis; Malaria Control; Education andResearch; and General Inspection and Sanitation.

U.S. Government assistance in local public health matters-Atthe onset of the national emergency, the U.S. Government assisted the PuertoRican Government through several agencies, notably the Works ProjectAdministration and the Federal Works Agency. This assistance encouraged many ofthe 76 municipalities, with a population of some 2 million people, to submitprojects for the expansion and improvement of their water and sewage systems,and for the construction and improvement of their treatment plants.⁸³

In 1943, when the civilian program was hampered by a shortageof sulfonamide drugs, the U.S. Army sold 100,000 sulfathiazole tablets toinsular health authorities.

Sanitation of public establishments serving food andbeverages-A helpful act of sanitary diplomacy in Puerto Rico in 1943 wasdescribed by Col. Clyde C. Johnston, MC, Surgeon, Antilles Department, asfollows:⁸⁴

Post surgeons have undertaken the inspection of the publiceating and drinking establishments most likely to be frequented by soldiers, inan attempt to insure that

⁸²(1) See pages 17-25 and 105-106of footnote 65 (1), p. 109. (2) Annual Reports, Department Surgeon, Puerto RicanDepartment, 1941-43.
⁸³Annual Report, Commissioner of Health, Puerto Rico, 1942-43,San Juan, Puerto Rico.
⁸⁴Annual Report, Surgeon, AntillesDepartment, 1943, p. 89.

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minimum sanitary standards are fulfilled. The percentage ofsuch establishments meeting these standards is small in Puerto Rico, and smallerelsewhere in the Sector. This necessitated the monthly publication ofconfusingly long lists of "Off Limits" places. In Puerto Rico, thisquestion has been approached recently from a positive, rather than negative,point of view, a system of "On Limits" being adopted instead of"Off Limits" with respect to eating and drinking establishments.Establishments which are found, upon inspection, to meet those minimum sanitarystandards to which the Army subscribes, are marked with a sign reading:

"On Limits for members of the Armed Services."

(The Army and the Navy work jointly in these matters.) Thisis a help to the soldier seeking a bar or a restaurant, and he can enter, withconfidence, an establishment displaying the "On Limits" sign, whereasunder the old system he could never be quite sure whether a place was or was noton the "Off Limits" list. * * *

The "On Limits" signs are a sort of freeadvertisement, highly prized by restaurant proprietors and more and more of themare requesting inspection. This adds to the work of the Medical Department, butis worthwhile.

Malaria control measures.-The Department of Public Healthand the Bureau of Malaria Control of the Puerto Rican Governmentworked closely with the U.S. Army Medical Department in and around Army camps toprotect the health of troops. The malaria control work consisted of treatment ofall persons having a positive blood smear living within a 2-mile radius of Armyinstallations. Larviciding of all mosquito breeding places within a 2-mileradius of posts and camps was carried out by dusting foliage with paris green orspraying small water areas with oil. Open ditches were constructed and old oneswere cleaned and reconditioned to facilitate drainage of stagnant water. Lowareas were filled with earth. The subsoil was drained with concrete pipes, whichinvariably resulted in reducing to a minimum the potential mosquito breedingareas. During 1941-42, under the supervision of the U.S. Public HealthService, the U.S. Army and the Insular Health Department sponsored joint WorksProject Administration projects for the permanent eradication of mosquitobreeding areas.

Russell-Boyd survey and recommendations-In September1942, Lt. Col. (later Col.) Paul F. Russell, MC, chief of the TropicalDisease Control Subdivision, Epidemiology Division, Preventive Medicine Service,Surgeon General's Office, and Dr. Mark F. Boyd, of the International HealthDivision, Rockefeller Foundation, both experienced malariologists, surveyed themalaria situation in troops in Puerto Rico. The malaria attack rate there hadreached 114 per 1,000 average strength by the end of July. They found manydeficiencies in the activities required for effective malaria control and made anumber of important technical and administrative recommendations. The mostsignificant administrative recommendation was that a full-time malaria controlofficer, with suitable assistants, be appointed to the Puerto Rican Departmentand that he be placed on the staff of the surgeon. A malaria control officer wasappointed to the surgeon's staff on 4 December 1942.⁸⁵

⁸⁵(1) See page 86 of footnote 70(2), p. 112. (2) See pages 216-218 of footnote 10 (3), p. 64.

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Malaria control in war areas.-In February 1942, followingthe Army's request for information concerning future plans of the U.S.Public Health Service regarding extra-military mosquito control activities, theOffice of Malaria Control in War Areas (generally referred to as "MCWA")was created by the U.S. Public Health Service "to direct and coordinate theefforts of Federal, State, and local health agencies near militaryestablishments and to help integrate on an area basis the malaria mosquitocontrol activities of military and civilian workers."⁸⁶ Thisnewly created special organization was organized by Dr. Williams, specialist inmalaria control research and investigations for the U.S. Public Health Service.When MCWA began operations in Puerto Rico, it was agreed with the Insular HealthDepartment that all mosquito control projects around posts, camps, and stationswould be carried out directly by the U.S. Public Health Service. Local fundswere then applied chiefly to malaria control in rural areas and civilianpopulation centers, with special emphasis on the provision of antimalarialdrugs. The work of MCWA contributed greatly to the remarkable reduction ofmalaria, which became evident among the troops in 1943. The incidence of thisdisease progressively decreased through 1944 and 1945.

Venereal disease control measures.-The control ofvenereal disease was a major health problem for the military forces in PuertoRico. Prostitution was firmly established and accepted on the island, andinfection was widespread. Frequently, prostitution was the only means oflivelihood for individuals and families. The Puerto Rican Department of Health,the U.S. Army, and the U.S. Public Health Service attempted many times to copewith the situation.

After his arrival in Puerto Rico in early 1942, Dr. Oliver C.Wenger, of the Venereal Disease Control Section of the U.S. Public HealthService, instituted a vigorous effort known as "the Wenger Plan forVenereal Disease Control." Dr. Wenger embarked on a program to educateprostitutes in antivenereal-infection methods. He conducted conferences withlarge groups of prostitutes throughout the island, and acquainted them withapproved methods of personal hygiene and with preventive measures to be appliedby their patrons. His plan met with enthusiastic response and appeared to beproducing good results. At that time, however, the cardinal tenet of thevenereal disease control policy emanating from Washington was the suppression ofprostitution. As a result of the implementation of the new policy designed tosuppress prostitution, the prostitutes who were recognized as such were arrestedand detained by the police. Soon the promising work accomplished by the Wengerplan was lost. The prostitutes on the island continued their activities butquickly abandoned the use of personal hygiene and individual protection fortheir patrons and themselves.

⁸⁶See page 74 of footnote 10 (3), p. 64.

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During 1943, venereal disease control was made a commandfunction. The U.S. Army developed a stepped-up educational sex hygiene programconcerning the nature of venereal disease, the mode of its spread, the dangersattendant upon sexual promiscuity and excessive indulgence in alcohol, and thevalue of venereal disease prophylaxis. It must be emphasized that, in the topmanagement activities for venereal disease control among troops, hundreds ofdifficult and important military and civilian relationships were involved.⁸⁷

The Virgin Islands

The U.S. possessions in the Virgin Islands are the islands ofSaint Croix, Saint Thomas, and Saint John. Of these, Saint Croix and SaintThomas were of major military significance during World War II because of theirgeographic location in the northeast segment of the Caribbean defense perimeter.

The public health standards of these islands were below thoseof the States in the continental United States but, in general, were higher thanthose of other Caribbean areas. The Department of Health was operated by thelocal government. A limited number of physicians were furnished directly by theFederal Government. Hospital facilities were available and satisfactorilyorganized.

Venereal disease was prevalent, but the rates amongcivilians were lower than they were in other Caribbean populations.Nevertheless, the chief medicomilitary problem encountered in the Virgin Islandswas the control of venereal disease among troops. The U.S. Public HealthService, with the aid of the U.S. Army, attempted to eradicate venereal diseaseby searching for every contact and treating every case.

There was little endemic malaria. The dryness of the climateand the land reduced mosquito breeding.

The most important environmental sanitation problem was metby the development of an adequate water supply.

THE ANTILLES DEPARTMENT

The Caribbean Defense Command was divided into two largedepartments in mid-1943 by the establishment of the Antilles Department in itsnortheastern half. The Panama Canal Department remained unchanged. The AntillesDepartment absorbed the Puerto Rican and Trinidad Sectors, and consisted of sometwo dozen U.S. Army installations in Puerto Rico, the Virgin Islands, theBritish and Netherlands West Indies, Cuba, Trinidad, and Saint Lucia, and thecoastal regions of Venezuela and the British, Dutch, and French Guianas on theSouth American mainland.

⁸⁷History of Medical Department Activities, AntillesDepartment, Preventive Medicine (Venereal Disease and Malaria), pp. 13-22.[Official record.]

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The Antilles Department contained all the naval and airbasesites for military operations in the Caribbean area which the United States hadacquired the right to lease from Great Britain in the history-makingdestroyer-base agreement of 2 September 1940. Additional base sites wereacquired, by an exercise of protective custody or negotiation, from othergovernments as military necessity arose.⁸⁸

Because the leased-base agreement did not confer sovereigntyover the base sites acquired through it, occasionally difficult and intricatenegotiations were required to secure permission and concurrence from the localgovernments (1) for the installation of U.S. Army, Navy, and Air Force unitsupon the islands, and (2) for the occupation and use of land and properties forcantonments, airfields, and docks, as well as territory for maneuvers. The sametype of negotiations were required with Dutch, French, and Venezuelanauthorities regarding stations on the South American mainland. Consequently,civil affairs arrangements had to be adjusted by agreement and convention,rather than by command, to the degree of U.S. military authority regarded asessential to carry out the mission of the Antilles Department-one of the maindivisions of the Caribbean Defense Command.

Except for the civil public health activities of the ArmyMedical Department on the island of Trinidad, there was generally a minimum ofcontact between U.S. military and civil groups on the leased bases. The generalpolicy of the base command surgeons and of the commanding officers of hospitalsand dispensaries on the various islands and other sites was to comply with anyreasonable requests for supplies and professional consultations. For their part,the local British, Dutch, and French doctors were uniformly courteous,informative, and cooperative.

It can be said emphatically that the period of construction atthese bases was as notable for effective sanitation as it was for the buildingof military facilities. As medical adviser and later as Surgeon, CaribbeanDefense Command, from 1941 to 1944, General Stayer visited all of these basesand collected and consolidated an immense amount of information about theirmedical and sanitary condition. During these years, General Stayer, acting uponthe basis of this accumulated information, directed public health activitiesthat were as beneficial for civilians as for troops.

COMMUNICABLE DISEASES AND THEIR CONTROL

Malaria

Malaria⁸⁹was the leading cause of death, the mostdebilitating illness, and the chief deterrent to economic development among thenative population in the Antilles islands. The highest incidence of malaria wasconcen-

⁸⁸(1) See pages 51-62 of footnote 63, p. 108.(2) See pages 354-408 of footnote 33 (1), p. 86.
⁸⁹See footnote 69, p. 112.

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trated chiefly in the coastal plains where the most importantmosquito vectors (Anopheles albimanus and the Anopheles aquasalis-Anophelestarsimaculatus complex) breed in a wide range of habitat, includingtemporary accumulations and saline waters.

Malaria Control

It was not possible to impose upon the civilian populationsliving outside military posts the same extensive and rigorous malaria controlmeasures that were enforced within the cantonments. Nevertheless, the exerciseof a certain amount of military authority over civilians living in areasadjacent to Army installations was required for necessary ditching, drainage,and larviciding. In the operation of extra-cantonment malaria control projects,the U.S. Public Health Service rendered valuable assistance, particularlythrough the supervision provided by its MCWA in Puerto Rico and Jamaica. AMalaria Control Board was formed in the Office of the Surgeon, AntillesDepartment; it consisted of the Antilles Department Malaria Control Officer, arepresentative of the U.S. Army Corps of Engineers, and the Chief of Operations,MCWA. This board instituted and supervised extra-cantonment malaria control onseveral islands and on the South American mainland. Services important to civilpublic health undertakings in malaria control were rendered by the AntillesDepartment medical research laboratory at San Juan, P.R., and by the MalariaControl Detachment at Fort Read, Trinidad.

Because some native communities appeared to be potentialreservoirs of human infection, at times it was thought desirable to relocate anative village for more effective malaria control if U.S. forces were not givencomplete jurisdiction over its sanitation. The most notable example of this wasthe recommendation made by Lt. Col. (later Brig. Gen.) Leon A. Fox, MC, when hesurveyed the U.S. Army base area on Parham Harbor, Antigua, in 1941. A villagecontaining some 300 Negroes jutted into the center of the base. General Foxrecommended that the village be relocated about 2 miles away. Carefulinvestigation by a representative of the MCWA failed to confirm General Fox'ssuspicions. "The daily tidal character of the great mangrove swamp nearbyapparently rendered its water unsuitable for any significant breeding of A.albimanus."⁹⁰

Venereal Disease

Venereal disease was widespread among the natives of theCaribbean area as few had inhibitions regarding sexual promiscuity. For manyyears, these people had been living under regimes which made little or no effortto prevent or control venereal infections. Syphilis and gonorrhea were the

⁹⁰(1) See page 203 of footnote10 (3),p. 64. (2) Report, Lt. Col. Leon A. Fox, MC, U.S. Army, subject: Sanitary Surveyof Antigua, British West Indies, 17-21 February 1941.

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most prevalent and serious forms. During the early years ofWorld War II military operations in the Caribbean, venereal disease was themajor cause of sickness and disability among both troops and constructionworkers. The civilian public health authorities of the colonial governments werenot especially concerned with the situation and, except for some members of thehealth department staffs in Jamaica and Trinidad, they were of little assistanceto the venereal disease control officers of the Army units in their areas. Inspite of these difficulties, a vigorous venereal disease control program wascarried on, and, by 1944, the venereal disease rates had been greatly reduced.

Sanitation and Public Health

The supervision of local establishments serving food andbeverages was another activity which brought military preventive medicine intoauthoritative contact with native civil affairs. In the Antilles Department,medical, sanitary, and veterinary officers inspected foodstuffs and theirhandling and serving. They exercised some degree of control over the cleanlinessand sanitary standards of eating places and restaurants. As in Puerto Rico, thesalutary device of labeling satisfactory eating places "On Limits forMembers of the Armed Services" was more effective than listing theunsatisfactory places as "Off Limits."

The control of water supplies sometimes carried militarypersonnel further into civilian public health affairs. As Colonel Johnstonreported:⁹¹

In most cases the water supplies at the posts were developedand operated by the U.S. Army. However, in some cases it was more economical toobtain water from sources already developed by local municipal or governmentalagencies, whenever these agencies could provide sufficient quantities of waterof the required quality. These local plants are inspected by Army personnel inorder to insure the safe quality of the water supplied to the posts.

COOPERATING ORGANIZATIONS

In the Caribbean Defense Command-including its two maindivisions, the Panama Canal Department and the Antilles Department-influentialmedical, sanitary, and political organizations carried on activities in whichcivilian and military personnel and interests were mingled. These were not apart of any formal civil affairs and military government division, but theyserved some of the ends that such a division would have sought had it existedthere.

The Anglo-American Caribbean Commission was created on 9March 1942 to encourage and strengthen social and economic cooperation betweenthe United States, Great Britain, and the Caribbean possessions of the twocountries. The Caribbean Research Council carried out research activities

⁹¹Annual Report, Surgeon, Antilles Department, 1945.

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for the commission, which also took an important part inpublic health affairs in the Caribbean area. Commission headquarters werelocated at Port of Spain, Trinidad. Its advisory group consisted of threemembers from each of the two countries.

The Institute of Inter-American Affairs, incorporated on 31March 1942, was set up by the Coordinator of Inter-American Affairs to aid inimproving the health and general welfare of the people of the WesternHemisphere. It was an important force affecting indirectly the health of bothtroops and civilian laborers in the American Tropics. Key defense areas andthose producing critical war materials received particular attention.⁹²

SUMMARY

The U.S. Army and the Caribbean Defense Command did notpursue a planned public health program at the various Allied bases where troopswere assigned during World War II. There was no special organization concernedwith civil affairs in the Caribbean area; the joint civil and military affairswere conducted through agreements and conventions. This was especially true inpublic health activities.

The extent of U.S. Army Medical Department assistance to thehost government of each island base in matters of sanitation, malaria control,venereal disease control, and the prevention of communicable disease generallywas directly equated with its importance to the safeguarding of the health ofU.S. troops assigned to these bases.

Because of the poverty, illiteracy, overpopulation, economicunder-development, local customs, and lack of material and monetary resources,much of the civil public health activities undertaken by the local governmentsstressed curative rather than preventive measures.

The Army medical organizations and installations committed tothe Caribbean area were chiefly (1) offices of surgeons at headquarters ofdepartments and base commands; (2) sanitary units such as those used for malariacontrol; (3) station hospitals and dispensaries; and (4) laboratorieswith broad capabilities. During World War II, medical activities expanded andcontracted in accordance with the varying missions and status of the CaribbeanDefense Command. Regardless of the limited medical capabilities at some Armybases, the surgeons and their staffs, together with the Army Medical ResearchLaboratory (Malaria) at San Juan and the Malaria Control Laboratory at FortRead, maintained continuous liaison and cooperation with the local British,French, Dutch, and Venezuelan public health authorities in efforts to safeguardthe health of local civilian populations.

⁹²Dunham, G. C.: Malaria Control Activities of the Instituteof Inter-American Affairs. J. Nat. Malaria Soc. (No. 1) 3: 31-38, March 1944.

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