Contents

The fall of France in June 1940 and the establishmentof the Vichy government brought the war closer to the continent of SouthAmerica, and especially to Brazil, whose "bulge" juts far out into theAtlantic Ocean and is only 1,619 nautical miles from Dakar, French WestAfrica. Vichy control of Dakar gave the Axis Powers easy access to theSouth Atlantic sea and airlanes, of which they took full advantage andseriously menaced South American security.¹

The U.S. Government, in July 1941, agreed to cooperatewith Brazil in the protection of her vulnerable northeast coastline. Acontract was made with a Pan American World Airways subsidiary, the AirportDevelopment Program, to build and operate airbases at Natal, Bahia, andSão Luís. Airbases had already been built in Africa underthe Airport Development Program so that the South Atlantic air route fromthe United States to Africa, Great Britain, and the Far East was establishedthrough Brazil. In conjunction with the operation of these bases and equallyimportant to the Allied cause was the permission granted by the BrazilianGovernment to use them for refueling and servicing American-built Lend-Leaseaircraft, manned by civilian crews, bound for the British Royal Air Force.Shortly after the United States declared war, unrestricted ferrying ofpersonnel and materiel by the U.S. Army through these bases was allowed.

The Lend-Lease Act, passed in March 1941, authorized theWar Department to supply war materiel to Allied countries. Approximately$25 billion worth of supplies and equipment was forwarded under this program,the majority of which went to the British.²

In view of improvement of the air-ground defense of Braziland its acknowledged assistance to the prosecution of the war, the UnitedStates-Brazilian Mutual Pact Agreement was approved on 27 May 1942. Oneof the important provisions of this pact was for the United States to cometo the assistance of Brazil if the latter were attacked by the Axis Powers.On 22 August 1942, Brazil declared war on Germany and Italy, the firstSouth American country to do so.

¹Unless otherwise indicated, all material in this chapter is from "Medical History, World War II, U.S. Army Forces, South Atlantic, 24 Nov. 1942-31 Oct. 1945." [Official record.]
²Department of the Army ROTC Manual No. 145-20, American Military History, 1607-1958, 17 July 1959, p. 400.

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As soon as the Brazilian airbases were completed, theArmy Air Forces Ferrying Command assumed refueling and servicing duties.The pace of operations increased. By June 1942, the Ferrying Command wasreorganized as the South Atlantic Wing of the Air Transport Command; itoperated from the U.S. Army Base in British Guiana and moved to Natal whenBrazil joined the Allies as a cobelligerent. The South Atlantic Wing functionedas the operational agency of all U.S. Army activities in Brazil until theactivation of U.S. Army Forces, South Atlantic, on 24 November 1942, atRecife.

The South Atlantic Command included Brazil, Uruguay, andParaguay, and extended from Amapá (Brazil) on the north to Montevideo(Uruguay) on the south and from Asunción (Paraguay) on the westto Ascension Island (British territory) on the east. There were no U.S.facilities south of Rio de Janeiro. The South Atlantic Command had responsibilityfor military missions only. Its stations were located at Belém,Amapá, São Luís, Fortaleza, Natal, Bahia, and on Fernandode Noronha and Ascension Islands. Its principal ferrying route bases ofoperations were Natal, Belém, and Ascension Island (map 3). Commandstrength, excluding the Composite Force on Ascension Island, was less than1,000.

Since this area clearly would be one of growing activityand importance, the first medical officers selected to proceed to Brazilin May 1942 were prepared to assist in selecting and establishing basescapable of expansion for larger forces than those needed by the FerryingCommand. First as Surgeon, South Atlantic Wing, Air Transport Command,and later as Surgeon, U.S. Army Forces, South Atlantic, Col. George E.Leone, MC (fig. 13), with his staff, developed plans for the theater medicalsupport of the U.S. Army Air Forces in Brazil.³

Soon after activation of U.S. Army Forces, South Atlantic,on 24 November 1942, at Recife, Colonel Leone established liaison withthe Health and Sanitation Division, Office of the Coordinator of Inter-AmericanAffairs. The Institute of Inter-American Affairs, under the directorshipof Brig. Gen. (later Maj. Gen.) George C. Dunham, MC, was established asa separate corporation on 31 March 1942 by the Office of the Coordinatorof Inter-American Affairs to carry out that office's health and sanitationprograms in Latin America. The Office of the Coordinator of Inter-AmericanAffairs, originally created in August 1940 "to combat German, Italian,and Japanese commercial and propaganda efforts in Latin America," ultimatelywas given responsibility for "most aspects of Latin American relationshipsnot directly under the control of the State, War, or Navy Departments."⁴

³Medical Department, United States Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government Printing Office, 1963, pp. 139-142.
⁴Conn, Stetson, and Fairchild, Byron: The Western Hemisphere. The Framework of Hemisphere Defense. United States Army in World War II. Washington: U.S. Government Printing Office, 1960, pp. 196-197.

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Colonel Leone conducted frequent liaison visits with Drs.George M. Saunders and B. McD. Krug of the Health and Sanitation Division.They assisted the theater surgeon by familiarizing him with the individualsand agencies of the Brazilian Government with whom he would have to cooperatein civil public health matters of mutual benefit to the health and safetyof both the Brazilian population and U.S. troops stationed in Brazil. Conferenceswere held in Belém and Rio de Janeiro in August and September 1942.

The groundwork and liaison having been prepared, ColonelLeone and his staff began their series of conferences with representativesof the various health services of the Brazilian Government, particularlywith the Serviço Nacional de Málaria, Serviço Nacionalde Febre Amarela (yellow fever), and a multitude of public health officersof the local, State, and governmental agencies. Vital statistics were obtainedfrom cities adjacent to U.S. Army airbases. Brazilian medical authoritieswere helpful and cooperative.

The medical organization of the South Atlantic theaterwas based upon the principle of furnishing the best possible medical servicewith the least

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personnel to conserve both Medical Department personneland equipment. To this end, every effort was made to develop a single compactorganization, avoiding overlapping, duplication, and overspecialization.Emphasis was placed upon establishing medical service at each base, station,airfield, or post which would be equally available to all Army personnel,permanent and transient, as well as to U.S. Navy personnel and authorizedcivilians. Most important, the division of responsibility was scrupulouslyavoided and the old established principle of making the senior medicalofficer responsible for all medical service and sanitation in a particulargeographic location was maintained.

There was ample opportunity for confusion since authorizationexisted for separate medical organizations in several commands; namely,the South Atlantic Wing of the Air Transport Command, Army Air Forces units,Army Ground Forces, and Army Service Forces units.

Medical directives issued by War Department, Army AirForces, and Air Transport Command headquarters in Washington were receivedat each base. Each service was anxious to implement its own policies withrespect to health and sanitation. Confusion and misunderstanding were evidentby medical officers of each service in rendering reports and compilingstatistical data for medical purposes. Air Transport Command headquartersat Natal at first was exempt from theater control, but with one commandinggeneral in dual command, several difficulties which might have resultedwere avoided. To bring all medical activities under single supervision,the theater surgeon, Colonel Leone, having qualified as a

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flight surgeon, was appointed, in addition to his otherduties, as Surgeon, South Atlantic Division, Air Transport Command, inNatal, and as Surgeon, U.S. Army Forces, South Atlantic, in Recife. Asthe theater surgeon, he acted in a dual capacity until 28 July 1945, whena separate division surgeon was appointed and assigned to Natal by theAir Transport Command, upon the urgent request of its headquarters in Washington.

Under this arrangement of dual capacity, the theater surgeon,with the consent of the theater commander, acted as chief surgeon for allactivities, including the Army Service Forces and the Air Transport Command.Medical Department personnel, equipment, and buildings were used wherepossible, resulting in considerable economy and improved medical service.All military personnel within the theater were required to adhere to theadministrative policies of the theater commander at Recife on all MedicalDepartment matters. The office of the South Atlantic Division surgeon withminimal personnel was maintained at the division's headquarters at Natal.The office of the chief surgeon for U.S. Army Forces, South Atlantic, wasat Recife.

The theater surgeon's staff consisted of the followingpositions: surgeon, medical inspector, venereal disease control officer,sanitary engineer, veterinarian, malariologist, dental surgeon, medicalsupply officer, laboratory officer, and nutrition officer. Because so fewofficers were assigned to the medical section, several duties were necessarilyassigned to each. Military exigencies required that the various sectionsbe staffed to the fullest extent.

Preventive Medicine Sub-Section.-Inthe office of the chief surgeon, the Preventive Medicine Sub-Section facedthe most difficult and important health and medical problems. The chiefof this section acted as theater medical inspector, theater venereal diseasecontrol officer, and deputy chief surgeon. Capt. (later Lt. Col.) EverettW. Ryan, MC, occupied this position from the time the theater was activated.At first, he was placed on detached service with Headquarters, U.S. ArmyForces, South Atlantic, in Recife, to occupy the position of medical inspectorfor the theater, in addition to his duties as medical inspector for theSouth Atlantic Division, Air Transport Command. Later, on 8 May 1944, hewas transferred to U.S. Army Forces, South Atlantic, but he continued towork in this dual capacity. This was done in the interest of a unifiedmedical service and the arrangement was satisfactory.

Disinsectization of aircraft and quarantine unit. Aspecial organization consisting of one officer and 11 enlisted men wasactivated at the Natal base to meet the new problems encountered in thedisinsectization of aircraft returning from Africa to Brazil. The medicalinspector of the theater surgeon's office was responsible for the supervisionand function of this service. The function of the organization was to preventthe reimportation of the Anopheles gambiae mosquito as a resultof air traffic between Africa and Brazil. This became a major problem whichnecessitated close cooperation

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by the U.S. Army in liaison with the International HealthDivision, Rockefeller Foundation, in Brazil, and the following civil publichealth agencies: the Brazilian National Malaria Service,the Office of the Coordinator of Inter-American Affairs, and the BrazilianPort Health Service.⁵

Malaria control unit. To bring widespread malariacontrol activities within the theater under single supervision, a specialorganization for malaria control was activated.⁶The57th Malaria Control Unit (later designated detachment) which had arrivedin Belém on 8 February 1944 was made responsible for all controland survey work in northern Brazil.

Venereal disease control unit. As an integral partof the Preventive Medicine Sub-Section, venereal disease control was supervisedby a Medical Corps officer. Although the total theater strength did notexceed 10,000 men, the stations were scattered and the operation of anefficient and coordinated program required considerable effort. Difficultywas experienced with venereal disease at Natal, and intensive efforts weredirected at that base. The important task of preventing disease among combatcrews en route to active fronts required constant vigilance by all commanders.Liaison was maintained with Brazilian authorities concerned with controlwork, but results were discouraging.

Sanitary engineers unit. The sanitary engineerfunctioned under the Preventive Medicine Sub-Section insofar as his dutieswere related to preventive medicine. Specifically, he investigated andrendered technical advice concerning procurement and treatment of water,disposal of sewage and refuse, control of insects and rodents, and sanitationof barracks and mess facilities. A complete coverage of the problems inwater purification, waste disposal, control of insects, and foreign quarantineconfronting the sanitary engineers in the South Atlantic theater can befound in another volume of this historical series.⁷Anadditional duty of the sanitary engineer was that of assistant theatermedical inspector.

Medical laboratory service. To meet the growingneed for laboratory service within the command, a laboratory officer wasrequisitioned from the Air Transport Command before activation of the SouthAtlantic theater. This officer arrived on 6 January 1943 and immediatelybegan setting up a laboratory service for the command; as an additionalduty, he acted as theater laboratory officer and epidemiologist. The laboratorywas established at Ibura Field, physically attached to the 200th StationHospital but under the direct supervision of the theater surgeon's office.In April 1944, it was designated as the theater medical laboratory andalso the histopathologic center for the theater (fig. 14).

Veterinary Sub-Section.-Maj. James R. Karr, VC,who previously had served with the Air Transport Command in Natal, wasplaced on detached

⁵Medical Department, United States Army. Preventive Medicine in World War II. Volume II. Environmental Hygiene. Washington: U.S. Government Printing Office, 1955.
⁶See page 143 of footnote 3, p. 132.
⁷See footnote 5.

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service with the theater surgeon's office upon its activation.In addition to serving as staff veterinarian, he functioned as a full-timeveterinarian at Recife. Veterinary officers were assigned to the followingstations: Ascension Island, Natal, Belém, Recife, Fortaleza, andRio de Janeiro.

The theater veterinarian was available as an adviser toBrazilian governmental agencies, to the International Health Division ofthe Rockefeller Foundation, and to the U.S. Navy. Major Karr rendered invaluableservice through his professional visits to the local Brazilian slaughterhouses,meatpacking facilities, pasteurization plants, and pig and chicken farms.

Supporting medical service units.-Four stationhospitals and two malaria detachments assisted in the all-important preventivemedicine program.

Station hospitals. Medical service for U.S. militaryand civilian personnel was furnished by four station hospitals-the 193dat Val de Caens Field near Belém, the 194th at Parnamirim Fieldnear Natal, the 175th on Ascension Island, and the 200th at Recife. Inaddition to providing hospital service for the Armed Forces in their areas,these hospitals also accommodated air evacuation patients en route to theUnited States. The 175th received several victims of sea disasters duringthe period of submarine

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activity. The 200th Station Hospital served as the theaterhospital, providing medical service for troops in the Recife area and fortransient U.S. Army personnel, U.S. merchant marines, U.S. nationals, dependentsof U.S. military personnel, U.S. Navy personnel, and for Brazilian civiliansemployed by the War Department. Patients were received from all other medicalinstallations in the command when prolonged hospitalization or ultimateevacuation to the United States was recommended. They were evacuated byboth air and sea. For practical purposes, the 200th Station Hospital furnisheddefinitive treatment similar to that offered by any general hospital. Chiefsof sections and specialists on duty there were available through the theatersurgeon's office for consultation throughout the theater, including Riode Janeiro and Ascension Island. In addition, medical consultation servicewas rendered outside the theater in Montevideo and Asunción.

Malaria detachments. The 57th Malaria Control Detachmentarrived at Belém in February 1944 and undertook malaria controlwork at that city as well as at Amapá and São Luís.Normally, two men were sufficient to handle routine antimalarial operationsat Amapá; the remainder worked at Belém. Only occasionallywas it necessary to send a malaria control specialist to São Luísbecause good control was effected there by the Brazilian ServiçoNacional de Málaria. The detachment received information daily fromthe Serviço Especial de Sáude Pública. The greaterpart of the work of this detachment was in temporary and semipermanentantimalarial measures, which occupied the efforts of 40 to 60 Brazilianworkers who were employed by the post engineer and supervised by this detachment.

Soon after the 202d Malaria Survey Detachment arrivedin Recife on 3 July 1944, it was assigned the mission of malarial surveywork for the entire South Atlantic theater in addition to malarial controlfor the Recife Military Area. The laboratory staff conducted mosquito identificationand blood surveys, routine larviciding, ditching, and ditch maintenance.The 202d Malaria Survey Detachment's primary theater function consistedof performing surveys at the Army airbases at Amapá and Fortaleza.Further, the personnel assisted in survey work at Natal and Belémand performed experimental work on DDT (dichlorodiphenyltrichloroethane)as a mosquito larvicide, using an Army A-24 aircraft equipped for sprayingDDT. Another function of this detachment included fly survey and controlwork on Ascension Island.

The U.S. Army preventive medicine program in civil publichealth in Brazil, the host nation, differed vastly from the comprehensivecivil affairs programs implemented in liberated or occupied countries duringWorld War II by the U.S. Government through its military government branches.

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In Brazil, the theater surgeon, his staff, and medicalpersonnel at the various airbases, station hospitals, and dispensariesdeveloped a close liaison with the Brazilian health agencies as the resultof various necessary services requested of the local Brazilian community;namely, their assistance in administrative and logistical support for theAmerican troops assigned to nearby military installations. The civil publichealth activities and subsequent programs, therefore, were oriented moretowards the particular needs of the U.S. Army than towards Brazilian civilianhealth problems.

Problems of clothing, housing, nutrition, personal hygiene,water, waste, and protection from insects and rodents, all of which affectedthe health and efficiency of military forces in Brazil, were challengingto the sanitary engineers and to the malaria control and laboratory officers.The efforts of the theater surgeon and his preventive medicine officer,Colonel Ryan, were aimed at protecting the troops against such specificconcerns as intestinal infections, respiratory infections, venereal diseases,nutritional diseases, environmental hazards, and arthropodborne infections.

The U.S. Army Medical Department's greatest professionalcontribution was in the assistance given to Brazilian health agencies intheir civil public health problems. Extensive liaison activities were carriedon with the many local, State, and Federal public health agencies throughoutnortheastern Brazil.

The Army Medical Department and Brazilian health authorities,working together, received assistance from other public health agenciesand from the civilian and regular commissioned staff of the U.S. PublicHealth Service, as well as the International Health Division of the RockefellerFoundation in Rio de Janeiro, the American National Red Cross, and theU.S. Navy.

The Army Medical Department in the South Atlantic theater,in turn, contributed to the improvement of civil public health of the Brazilianpopulation. It carried out the overall military preventive medicine programat each military facility of the South Atlantic Command, furnished hospitalizationand medical care to other than U.S. military personnel, cooperated withBrazilian public health authorities on all matters of foreign quarantine(disinsectization of military aircraft), and adopted excellent extra-militarysanitation measures.

To appreciate the Army Medical Department's efforts toassist the Brazilian public health authorities, it is helpful to examinethe civil public health activities of a representative city of northeastBrazil, the coastal city of Recife, the site of South Atlantic theaterheadquarters.

Civil public health authorities in Brazil were concernedwith tropical communicable diseases as well as those more familiar in temperateclimates. Throughout northeast Brazil, civilian public health problemswere fairly

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uniform except that, as one approached the south fromthe Amazon Valley region, the conditions became generally better, the diseaseincidence lower, medical care more readily available, and sanitation moremodern.

In October 1943, the city of Recife, including its suburbs,had an estimated population of 372,641; by 1945, this figure had grownto approximately 500,000. The population varied considerably with regardto race and color, being made up of Caucasians, Indians, Negroes, and variouscombinations of these three races. The Caucasians were generally of Portugueseor Dutch ancestry.

Recife contained modern conveniences such as water service,sewerage facilities, telephone service, and electricity which are usuallyfound in most progressive cities. However, these facilities were substandardwhen compared with those available in North American cities of correspondingsize. The better homes were constructed of stone, stucco, and tile; thepoorer dwellings, greatly overcrowded, were generally mud or straw-thatchedhuts, locally referred to as "mucambos." Sanitary facilities in the poorerquarters were virtually unknown.

Communicable diseases.-Among the more importantdiseases prevalent in Recife and throughout northeast Brazil were malaria,parasitic infestations, intestinal infections, venereal diseases, and tuberculosis.The common respiratory diseases were troublesome to the civilian populationbut were insignificant when compared with the much-dreaded tuberculosis.Epidemics of contagious diseases, such as typhoid fever and smallpox, occurredfrom time to time. The dysenteries usually showed a higher rate than wouldnormally be expected. Leprosy, tropical ulcers, leishmaniasis, scabies,and fungus infections were relatively common.

The statistics of disease in Recife and in the State ofPernambuco were more reliable than those from areas to the north, but evenhere, they were irregular and many diseases were never reported. The followingtabulation shows the incidence in a population of 372,000 of some of themore common diseases in Recife in 1942, based on the total number of caseswhich were diagnosed and reported. 

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Tuberculosis. As in most sections of Brazil, theincidence of tuberculosis in Recife and the State of Pernambuco was high.The disease seemed to flourish where standards of living and of educationwere low, where nutrition was inadequate, or where health facilities werepoor. Individuals with "open cases" of tuberculosis frequently refusedhospitalization, and little effort was made to urge them to accept it becausehospital facilities for treatment of tuberculosis were inadequate. Therewas no followup service for active cases. BCG (bacille Calmette Guérin)vaccine was given to many newborn infants despite considerable controversyon the subject among leading local practitioners. Diagnosis frequentlywas not made in early cases because a minimum number of X-rays were takenand tuberculin tests were rarely done. Casefinding and nursing care wereminimal. In 1945, 12.2 percent of all the deaths in Recife were causedby tuberculosis; as a cause of death to children under 2 years of age,it was second only to diarrhea. In 1944, from 26 to 51 new cases of tuberculosiswere reported each week. Fortunately, troop contacts were comparativelycasual and the influence of this disease on the health of troops was unimportant.There were 12 cases among U.S. military personnel during the entire historyof the South Atlantic Command. The admission rate per 1,000 was 1.5 for1943, 0 for 1944, and 1.0 for 1945.

Venereal disease. There were no accurate figuresconcerning the prevalence of venereal diseases⁸amongthe civilian population. The incidence was high and infected prostitutesabounded. In Recife as in the other principal cities of northeast Brazil,an attempt was made to segregate the prostitutes in certain sections ofthe city. However, opportunities for clandestine contacts were plentiful.All the venereal diseases were present. In 1940, 2.7 percent of all deathsin the State of Pernambuco were due to syphilis; it ranked ninth as a causeof death. The venereal disease service of city, State, and Federal healthdepartments included attempts to examine prostitutes, but there was seriousneed for expansion in this program. A survey conducted in 1944 by the TheaterLaboratory, 200th Station Hospital, among Brazilian civilian employeesof the U.S. Army in Brazil, revealed 14 percent to have positive Kahn reactions.A survey made by the Recife Health Department showed 30 percent positiveserological reactions in a general population group of more than 1,000.

Malaria. Malaria was rampant along the entire northeastcoast of Brazil where there were many marshes and swamps. In 1940, it rankedthird as a cause of death in Pernambuco, causing 4.5 percent of all deaths.The chief insect vector was Anopheles aquasalis. Malaria surveysmade by the U.S. Army in areas surrounding the various military establishmentsrevealed parasitemia indices of 0.26 to 8.4 percent. Both Plasmodiumvivax and Plasmodium falciparum were found. Preventive measureswere

⁸For additional information on venereal disease in the South Atlantic, see Medical Department, United States Army. Preventive Medicine in World War II. Volume V. Communicable Diseases Transmitted Through Contact or By Unknown Means. Washington: U.S. Government Printing Office, 1960, pp. 316-318.

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carried on by the Serviço Nacional de Málaria,the Serviço Nacional de Febre Amarela, and the sanitary servicesof the various city health and hygiene centers (fig. 15). Lack of fundshindered civilian efforts.

Other communicable diseases. Typhoid fever wasendemic throughout this area and occasional flareups reached mild epidemicproportions. In Recife, during February 1944, 20 to 50 new cases occurredeach week. The outbreak abated after about 6 weeks.

The incidence of bacillary dysentery among the civilianpopulation was not definitely known but was estimated to be very high.Diarrhea of unspecified cause in infants under 2 years of age was usuallythe leading single cause of death and was responsible for 25.4 percentof all deaths in the State of Pernambuco in 1940. It was six times as commona cause of death as tuberculosis, which ranked second. In 1940, in thegroup over 2 years of age, it was responsible for 1.5 percent of all deaths,ranking it as 15th. In Recife, during 2 weeks in June 1944, 105 of the411 deaths were reported to have been due to gastroenteritis, of undeterminedcause. In a majority of instances, the disease was spread through food,milk, or water; but poor

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sanitation was a strong contributing factor. The prevalanceof flies, combined with the absence of screening, aided in its transmission.

Grippe was a diagnosis which was given as a cause of illnessanddeath. The illness generally resembled influenza in symptomatology, buta number of febrile illnesses of unknown cause were diagnosed as grippe.It was the reported cause of four to 11 deaths each week during 1944 inRecife. Usually, four to 20 new cases were reported each week. During theepidemic of typhoid fever in February 1944, the prevalence of grippe accordingto the reports rose to 40 new cases each week.

Measles, mumps, diphtheria, smallpox, chickenpox, meningitis,and whooping cough occurred, sometimes in epidemic form. Epidemics of anyof these diseases could have serious potentialities. For example, in August1944, an epidemic of smallpox among the civilian population in Fortalezapresented an urgent epidemiological control problem for the Medical Departmentbecause of the importance of keeping the base open for air traffic.⁹Whenseven civilians working on the base contracted smallpox, all military aswell as civilian personnel using the base were vaccinated immediately.Because of the urgency of the situation, the U.S. Embassy in Rio de Janeiro,Brazilian national health authorities, commercial airlines using the base,and Fourth Fleet Headquarters, U.S. Navy, were notified. No smallpox casesoccurred among military personnel as a result of this epidemic.

Poliomyelitis, yellow fever, typhus fever, and encephalitisappeared infrequently. Plague, rabies, scarlet fever, tetanus, and erysipelaswere seen occasionally.

Intestinal infections. Intestinal parasites wereprevalent and caused much illness. Infestation with Schistosoma mansoniwas endemic throughout northeast Brazil, and hookworm was quite common.Because of soil pollution, vegetables frequently were contaminated withorganisms causing enteric infections and infestations. In 1944, the U.S.Army conducted a survey of the prevalence of intestinal parasites on 1,578Brazilian civilian employees at a number of its bases in Brazil. This studyrevealed that 71 percent were carriers of pathogenic organisms. Necatoramericanus was present in 47 percent of the individuals examined, Ascarislumbricoides in 40 percent, and Trichuris trichiura in 26 percent.This survey was conducted among civilians who had been selected previouslyas being alert and physically capable for the job at hand. Another study,made with the cooperation of a Brazilian physician in Recife, revealedthat, of 2,800 stool specimens examined, 26 percent contained S. mansoniand 11 percent Entamoeba histolytica.

Public health services.-The Central GovernmentAgency for Health in Brazil became the Federal PublicHealth Service which was immediately

⁹(1) Essential Technical Medical Data, U.S. Army Forces, South Atlantic, for August 1944, dated 4 Sept. 1944. (2) Smallpox in Civilians at an Air Field. Bull. U.S. Army M. Dept. 83: 27, December 1944.

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subordinate to the Minister of Education and Public Health.This arrangement, in theory, avoided the unwise expenditure of limitedfunds and made available to the public health authorities of each Stateof Brazil the supervision and consultation of experts of the Federal Government.Federal Public Health Districts were composed of one or more States, eachhaving its own public health organization under the supervision of a directorof health.

Public health services in the State of Pernambuco wereconducted by three groups; namely, the State Department of Health, theSchool Physical Education Service, and the Institute of Hospital Aid. Theseactivities were the responsibility of the Secretary of Interior. Waterand sewerage systems were under the Secretary of Transportation and PublicWorks. The State Health Department consisted of four health centers inRecife, 11 major hygiene posts (one itinerant) in the interior of the State,and 44 minor municipal hygiene posts.

For administrative purposes, the State Health Departmentcontrolled the supervision of civil public health in Recife. The Departmentwas divided into four sections: the directorate, or executive section;the administrative section; the professional section, which included supervisionof professional activities, sanitary propaganda and education, epidemiology,statistics, and sanitary engineering, to mention a few; and the field service,which included the health centers and hygiene posts.

The following unofficial organizations were working inthe interest of public health: The League Against Infant Mortality, TheLeague Against Tuberculosis, and The Society Against Leprosy.

A good hygiene service was included in each health centerin Recife and in each hygiene post in the interior of the State. The serviceswere responsible for the inspection of all food offered for sale, the cleanlinessof food establishments, and the health of those connected with the saleof food. There was also an inspection service for abattoirs, the ServiçoNacional de Defesa Animal and the Diretoria da Produção Animalde Estado, under the Secretary of Agriculture, Industry, and Commerce.Although abattoirs were maintained in most cities, there were no storagefacilities, and, consequently, meat products had to be sold for immediateconsumption.

Medical services.-The medical services consistedof the following categories:

Professional personnel. Medical service in Recifeand in larger cities and towns was satisfactory but in need of improvement.The number of physicians in the Recife area was estimated to be somewhatover 300. Conditions in the rural areas were unsatisfactory, and many sectionswere without the services of a physician. Usually four trained nurses wereemployed by the City Health Department in Recife; their number in the hospitalswas negligible. In addition to a medical school in Recife were a dentalschool and a pharmacy school.

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Hospitals. Eleven large hospitals in Recife weresupported by State, city, or private sources. They were used variouslyfor general medical and surgical cases; for neuropsychiatric, obstetric,and pediatric patients; and for treatment of contagious diseases. One wasused for free (charity) patients and as a teaching hospital; another, controlledby the City Health Department, was an emergency hospital and operated anambulance service.

X-ray and laboratory facilities. X-ray facilitieswere available in only a few of these hospitals; however, some privatephysicians had them. The various hospital laboratories were poorly equippedand understaffed. There were a number of privately owned laboratories aswell. The two largest laboratories were in the school of medicine and inthe State Health Department. The former laboratory performed all of thevarious examinations, including microbiologic, parasitologic, and histopathologic.The central laboratory of the State Health Department in Recife had sufficientequipment to accommodate all public health laboratory work for the city.Antirabies and smallpox vaccines were prepared there.

Persons other than U.S. military personnel were hospitalizedor given medical treatment in Army medical facilities in the South AtlanticCommand in accordance with the provisions of Change 6, Army RegulationsNo. 40-590, dated 4 March 1943, and other pertinent directives. The principalrecipients of medical care were civilian employees of the War Departmentand military personnel of cobelligerent nations. The only major problemthat arose was in the care of Brazilian civilian employees of the War Departmentwho were injured in the performance of their official duties. As many as9,500 Brazilians were employed by the Army at its bases in Brazil duringpeak operations.

To establish an orderly plan for the medical care of theseemployees, the theater surgeon, the staff judge advocate, the base surgeonsat Recife and Natal, and representatives of the Office of the Coordinatorof Inter-American Affairs conferred at South Atlantic Command headquartersin July 1943. They decided to provide hospitalization and medical carethrough local civilian facilities, and to process all claims for disabilityand payment of expenses for medical service or hospitalization throughthis headquarters rather than through the U.S. Employees' CompensationCommission. A plan was approved and, subsequently, a War Department circularwas published in which Armed Forces commanders overseas were authorizedto establish local procedures to settle claims of native employees withoutapplying to the U.S. Employees' Compensation Commission. This plan wasembodied in an unnumbered War Department circular, dated 4 September 1943,subject: Application of Workmen's Compensation Laws in Oversea Commands.

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Pursuant to this authority, a letter published by theatercommand headquarters directed that any Brazilian civilian employee sufferingtraumatic injury in the course of his employment be referred to the nearestmedical installation of the U.S. Army for first aid and examination. Iffurther care was required, he would be referred to designated Brazilianphysicians or hospitals in the vicinity, and all claims for injuries ordisability and bills for medical services furnished by civilian physiciansor hospitals would be processed through the Contract Claims Commissionat Headquarters, U.S. Army Forces, South Atlantic.

Although payment of claims through the Contract ClaimsCommission proved satisfactory, considerable savings probably would haveresulted had complete medical care, including hospitalization, been furnishedin U.S. Army hospitals and dispensaries. Accordingly, in August 1944, theArmy was directed to provide this medical service through the use of itsown facilities insofar as they were available. Medical officers were directedto maintain an outpatient index of all Brazilian employees treated in thedispensary and to complete hospital records for patients admitted to thehospital. The employee's immediate superior was required to prepare a requestfor treatment which was to be delivered to the medical installation beforeany treatment was instituted. Monthly reports showing total number of hospitalpatients, number of patient days, and total outpatient treatments wereto be forwarded to the theater surgeon. Also, for those patients whoseinjuries might result in permanent disability, or where circumstances indicatedthat a claim against the U.S. Government might arise, the medical officerwas required to furnish a report to the local claims officer and an informationcopy to the theater surgeon.

In conformance with an opinion of the Fiscal Director,U.S. Army Forces, South Atlantic, after 1 June 1945, bills for servicesrendered by Brazilian civilian physicians and hospitals in the care andtreatment of injured employees were paid from Maintenance and HospitalFunds rather than through the Contract Claims Commission. However, allclaims for injuries and disability resulting therefrom continued to beprocessed by the commission. On 1 June 1945, civilian personnel regulationswere published by theater headquarters. Earlier directives concerning medicalservice for injuries and claims of Brazilian employees were incorporatedin these same regulations. From September 1944 (when complete hospitalizationwas first provided for Brazilian civilian employees) to July 1945, a totalof 384 patients were admitted to U.S. Army hospitals, as shown in table2.

The decision to furnish complete medical care to Braziliansinjured in the performance of official duties and to process all such claimslocally, without applying to the U.S. Employees' Compensation Commission,was believed to have benefited the operation of medical service in thiscommand. Claims of injured persons and bills for medical service were settledpromptly, in lump sums. No claims were paid by protracted monthly pay-

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TABLE2.-Brazilian civilians employed by the U.S. Government and hospitalizedin U.S. Army hospitals, September 1944-July1945 

Period	Number of  hospital patients	Number of  patient days	Number of  outpatients
1944
September	19	64	1,347
October	38	330	1,166
November	33	327	1,191
December	22	292	1,724
1945
January	27	344	1,509
February	22	172	1,318
March	22	283	1,535
April	47	482	2,009
May	63	587	2,383
June	42	344	2,690
July	49	452	2,853
Total	384	3,677	19,725

Source: Medical History, World War II, U.S. Army Forces, South Atlantic, 24 Nov. 1942-31 Oct. 1945, pp. 126-127.

ments over an indefinite period. The benefits given tothe employees were in accordance with local laws and customs. The promptsettlement of claims by persons on the scene familiar with local conditionsresulted in a great saving to the U.S. Government. Furthermore, harmoniousrelations with the Brazilians had been strengthened.

It was rarely necessary to employ civilian physiciansand dentists or to obtain hospital facilities for the care of persons entitledto medical care at U.S. Government expense. The South Atlantic Commandpolicy was to furnish complete medical and dental care to those personsentitled to it in U.S. Army medical facilities. This policy was plainlystated in Memorandum No. 106, prepared by the Surgeon's office and publishedby Headquarters, U.S. Army Forces, South Atlantic, on 4 July 1945.

Extra-Military Sanitation and Liaison Activities

In the South Atlantic Command, certain civilian healthproblems were so potentially dangerous to U.S. military personnel thatconsiderable effort was expended on extra-military sanitation and liaisonactivities. The more important of these were venereal disease control (inneighboring native establishments), malaria control, elimination of fly-breedingareas, and other sanitary problems. These activities involved numerouscivilian health organizations as well as the armies and navies of bothcountries.

Interservice activities.-An excellent spirit ofcooperation in matters pertaining to health and sanitation always existedbetween the U.S. Army

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Medical Corps and the U.S. Navy Medical Corps. Cooperativeefforts were most important in control of venereal disease. Prophylacticstations were operated jointly in the cities. Where possible, the servicewhich required the greater use of the installation furnished the medicalpersonnel and equipment for all U.S. Armed Forces personnel present. Assistancein venereal disease control was rendered by Brazilian Federal, State andcity health agencies, principally at Belém, Natal, and Recife. TheBrazilian Army adopted some modifications of the method of treatment ofvenereal disease as prescribed by The Surgeon General, U.S. Army.

The Army Medical Department from the very onset furnishedmedical service to survivors of sea disasters, particularly at AscensionIsland. Medical service was provided from time to time to U.S. Navy andmerchant marine personnel and to Royal Air Force and other Allied servicespersonnel. In 1943, a group of German prisoners of war under U.S. Navyjurisdiction were quartered at the U.S. Army dispensary at Ibura Fieldbefore transfer to the United States. Also, medical service occasionallywas furnished to personnel of contract carriers-namely, Pan American WorldAirways, American Airlines, TransWorld Airlines, and American Export Lines-andto members of the U.S. Rubber Development Corp. at Belém.

Active cooperation was maintained with the Health andSanitation Division and the Food and Nutrition Division of the Office ofthe Coordinator of Inter-American Affairs. The U.S. Army was given considerableaid in extra-cantonment sanitation, particularly in malaria control.

Liaison was maintained with the Brazilian Port SanitaryService concerning importation and exportation of rodent pests. Fortunately,no serious problems were encountered.

Malaria control activities.-In 1945, in responseto an invitation from the Serviço Especial de Sáude Públicathe theater sanitary engineer inspected their facilities in the AmazonValley.

The Brazilian Serviço Nacional de Málariaassisted the U.S. Army in those areas where the Office of the Coordinatorof Inter-American Affairs did not operate. At São Luís, Fortaleza,Natal, Recife, and Bahia, data collected by that agency were made availableto base surgeons and malaria control officers. Control work in these areaswas coordinated with the Brazilian agencies concerned. At Recife, the 202dMalaria Survey Detachment with the able assistance of Dr. Durval T. Lucenaof the Serviço Nacional de Málaria carried out experimentalwork on DDT as a mosquito larvicide. In addition, the 202d Malaria SurveyDetachment performed blood survey work in the Recife area, with the aidof a "guarda" on loan from Dr. Lucena's agency to collect epidemiologicaldata. On the basis of data furnished by the 202d Malaria Survey Detachment,infected natives were treated by the Serviço Nacional de Málaria.This detachment also gave invaluable laboratory assistance to the Braziliansin planning malaria control experiments based on the use of DDT as a residualspray against adult mosquitoes.

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The SESP (Serviço Especial de Sáude Pública)at Belém contributed considerably to malaria control in and aroundVal de Caens Field and the Amapá Air Station. Before the arrivalof the 57th Malaria Control Detachment, the SESP set up a program of permanentand temporary control measures to be applied around Belém and tobarracks spraying at Amapá. After the arrival of the 57th MalariaControl Detachment, SESP continued to furnish important mosquito surveyinformation in the malaria control work carried on by this detachment.In addition, SESP malaria control officials visited Recife in October 1942to make a malaria survey of Ibura Field. Cooperative malaria control measureswere decided upon by these officials and the Office of the Surgeon, SouthAtlantic Ferrying Wing, Air Transport Command. However, malaria controlwork around the Ibura base and the environs of Natal was taken over laterby the Brazilian National Malaria Service and the SESP which confined itsactivities to Belém and Amapá. An SESP officer cooperatedin a later malaria survey of Ibura by assisting the theater malaria controlofficer in establishing an Army malaria control program.

The Brazilian Government was vitally concerned with thepossible entrance of A. gambiae mosquitoes into Brazil onaircraft flying from Africa. In January 1944, following coordination withBrazilian national health authorities, Brazilian port sanitary personnel,the International Health Division of the Rockefeller Foundation in Riode Janeiro, and the U.S. Army, an efficient system for disinsectizationof aircraft was placed in operation. This disinsectization system is discussedin volumes II and VI in this historical series¹⁰and in a subsequent section (p. 153).

Medical laboratories activities.-Liaison with Brazilianmedical authorities occupied an important place in the activities of thevarious medical laboratories. This was especially true at the principaltheater laboratory at the 200th Station Hospital in Recife. Cooperationbetween this laboratory and the Faculdade de Medicina de Recife, the CityHealth Department, and other hospital laboratories was mutually beneficial.Contact was also maintained with the Instituto Oswaldo Cruz, the Hospitalfor Tropical Diseases, and the laboratories of the International HealthDivision of the Rockefeller Foundation in Rio de Janeiro. The laboratoryat the 193d Station Hospital at Belém was active in liaison withthe SESP laboratory in Belém; the latter was part of the medicalactivity of the Office of the Coordinator of Inter-American Affairs.

The city, State, and Federal health authorities of Brazilaided the epidemiological work of the Army Medical Department by supplyingstatistical data on current diseases in Brazil and other similar information.Cooperation in this regard was limited only by the availability of data.The Medical Department in return performed special laboratory proceduresfor the city health departments when requested and informed local healthau-

¹⁰See pages 137-165 of footnote 3, p. 132, and pages 220-223 of footnote 5, p. 136.

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thorities of important contagious diseases among Americanmilitary personnel. It was necessary to notify Brazilian health authoritiesof the expected increase in the movement of aircraft from Africa to Brazilwhen provision was made to redeploy men and planes from Europe to the UnitedStates via the South Atlantic route. "The original purpose was to fly homefor rest leave troops whose services would shortly be required in the waragainst Japan."¹¹This notification enabled Brazilian health authorities to provide additionaldisinsectization personnel at the airfields.

Brazilian Expeditionary Force.-Training of theBrazilian Expeditionary Force in medical matters was coordinated throughthe Office of the Surgeon, U.S. Army Forces, South Atlantic, and supervisedby the Joint Military Commission in Rio de Janeiro. Maj. (later Lt. Col.)Raleigh H. Lackay, MC, was in charge of the medical training of the ExpeditionaryForce in southern Brazil, and the Office of the Surgeon was contacted directlyfor medical aid in northern Brazil.

At times, medical officers were assigned temporarily toassist in physical examinations of Brazilian Expeditionary Force personnel.The most important instance occurred during September 1944 when seven U.S.Army Medical Corps officers and one Dental Corps officer were sent to Riode Janeiro. The largest contingent of the Brazilian Expeditionary Forcewas examined by the Medical Department of the Brazilian Army, with theseofficers acting in an advisory capacity. Eight examining teams, with oneU.S. Army Medical Department officer on the reviewing board of each team,examined approximately 14,000 troops of the Brazilian Expeditionary Forcein less than a week. The appreciation of the Brazilian Army's Surgeon Generalwas conveyed in a letter from the Joint Brazil-U.S. Military Commissionin Rio de Janeiro to the theater surgeon in which the professional effortsof these officers were highly commended.

Liaison with the Brazilian Expeditionary Force continuedthroughout the active period of the South Atlantic Command. Participationincluded activities in connection with air and water evacuation of Brazilianmilitary personnel from Italy to Brazil. In February 1945, the Surgeon,U.S. Army Forces, South Atlantic, inspected the Brazilian ExpeditionaryForce in Italy.

Ascension Island.-Ascension Island is a dependencyof the British crown colony of Saint Helena. An airfield built there byU.S. Army engineers in 1942 was used as a refueling base for transatlanticflights. A heavy fly population on the island plagued the U.S. Army cantonmentdespite determined efforts to control fly breeding in pit latrines. Notonly were flies annoying and contributing to poor morale, but they werealso incriminated on several occasions as vectors of gastrointestinal disease.

In January 1945, a Sanitary Corps officer of Headquarters,U.S. Army Forces, South Atlantic, performed an extensive survey of flybreeding on

¹¹Craven, Wesley Frank, and Cate, James Lea: The Army Air Forces in World War II. Volume VII. Services Around the World. Chicago: The University of Chicago Press, 1958, pp. 216-227.

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Ascension Island. The problem was determined to be oneof extra-military sanitation. Fly breeding in huge manure heaps on theBritish Farm on Green Mountain was found to be responsible for the plagueof pests in the lower areas of the island, to which they were easily carriedby downdrafts off the crest of the mountain. The farm manager had to beconvinced that he was losing the value of the manure as fertilizer by lettingthe rains leach it. An agreement was made to spread the manure on the fields,and the U.S. Army furnished a detail of men and trucks to haul it. On furtherrecommendations, the post engineer built manure bins outside the barnsand stables for storing the manure until it could be spread. The farm managercooperated by setting up a composting heap for that portion of the manurewhich had to rot before use. The U.S. Army also furnished a detail of men,supplies, and equipment to spray the barns, stables, and pigpens with DDTresidual spray and to treat the compost heap with borax and DDT. As a result,flies ceased to be pests, and little diarrheal disease was attributed totransmission by flies after these control procedures were established.

Uruguay and Paraguay.-U.S. liaison activities wereextended to Uruguay and Paraguay in training and assisting in the reorganizationof their military forces. Generally, the service to these countries wasadvisory; specifically, it was a matter of tailoring the medical servicesto correlate them with a proposed reorganization of their armed forces.Technical assistance consisted of providing them with training manuals,tables of organization and equipment for medical units, and technical manualson sanitation and preventive medicine.

The theater surgeon and his representatives made numerousvisits to these countries. The theater surgeon accompanied the commandinggeneral to Uruguay in March 1945 on a liaison visit in which questionsof future hemispheric defense were discussed.

The account just described covers only the more importantliaison activities and problems. During the history of the theater, inmany other instances smooth liaison was essential to the accomplishmentnot only of extra-military sanitation but also of the theater mission itself.

FOREIGN QUARANTINE

Early in the history of the South Atlantic Command, nearlyall military traffic en route from the United States to Africa and Europewas accomplished with little consideration for quarantine¹²requirementsbecause of the exigencies of war. Before August 1942, the War Departmentmade little or no organized effort to require the Medical Department inthe South Atlantic Command to impose any stringent foreign quarantine measuresregarding military aircraft entering and leaving Brazil. Again, the objec-

¹²See footnote 5, p. 136.

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tive of getting the military aircraft to North Africaand critical supplies to certain war zones was paramount in the minds ofall commanders when the first contingent of U.S. military personnel arrivedin Brazil in July 1942. Actually, there was no organized medical serviceuntil that time.

Clearance of personnel.-InAugust 1943, Air TransportCommand authorities in Africa requested the South Atlantic Command to inoculateeastbound personnel against bubonic plague, especially those destined topass through Dakar, French West Africa, and Marrakech, Morocco. These immunizationswere discontinued in September 1943 on instructions from Air TransportCommand headquarters which stated that such immunization of personnel wouldbe accomplished upon their arrival in the endemic area.

In response to a War Department radiogram and to War DepartmentCircular No. 254, 15 October 1943, a command directive was published affectingthe requirements of troop movements through endemic yellow fever zones.On 19 October 1943, the War Department published the first directive onprocessing military personnel returning to the United States.¹³

Brazilian influenza control measures.-In December1943, upon the recommendation of its port health authorities, the BrazilianGovernment requested the South Atlantic Command to check all individualsarriving in Brazil by plane to prevent the possible spread of influenzafrom the United States and Great Britain. The Brazilian authorities appearedon the Natal field one day prepared to take the temperatures of all personnelarriving at that station. This obviously would have impeded Air TransportCommand activities. With the assistance of the U.S. Embassy in Rio de Janeiro,a compromise was reached whereby only those individuals destined to remainin Brazil would be examined. The Army Medical Department assumed the responsibilityof examining those individuals upon their arrival at U.S. Army bases inBrazil.

Implementation of foreign quarantine directives.-Whenrotation of personnel to the United States began, the problem of foreignquarantine added further responsibilities. In March 1943, all base surgeonswere instructed to fulfill these responsibilities by complying with existingdirectives on foreign quarantine requirements. Upon receipt of a letterfrom the Surgeon General's Office in March 1945, including directives,policies, and amendments, the base surgeons again were furnished additionalinformation.

South Atlantic Command policies and procedures with referencesto foreign quarantine gradually were put into operation. During May 1945,the quarantine liaison officer, Lt. Col. Phillip T. Knies, MC, visitedthe South Atlantic Command to study the problems and practices of foreignquarantine. He became particularly concerned with the plans for increasedtraffic in the redeployment of troops from the European and Mediterraneantheaters. The Brazilian Government, through Dr. Fabio Carneiro de

¹³War Department Memorandum No. W600-83-43, Assignment of Military Personnel Returned From Overseas, 19 Oct. 1943.

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Mendonça, director of the Port Health Service andthe Quarantine Service, indicated that it was satisfied with the quarantineprecautions carried out by the U.S. Army and would impose no further restrictionsif personnel had not been immunized against yellow fever. This policy wouldapply even though the passengers came from recognized yellow fever endemicareas.

Immunization for non-U.S. military personnel.-ASouthAtlantic Command directive was issued on 14 July 1945 regarding the writingof invitational travel orders for Brazilian, Uruguayan, and Paraguayannationals. This directive provided that such orders would contain specialinstructions outlining the requirements for smallpox and yellow fever immunizationsbefore departure for the United States.

In addition to non-U.S. nationals, the arrival of dependentsof military personnel in the theater presented a similar problem. Hence,all such personnel, including American civilian personnel and Braziliandependents of U.S. military personnel, were required to comply with SouthAtlantic Command headquarters Memorandum No. 97, dated 14 June 1945, regardingimmunization, freedom from vermin, and freedom from communicable diseaseor from recent exposure.

Disinsectization of U.S. military aircraft.-In1943, the Brazilian Government, through the persistent efforts of the directorof the Port Health Service in Rio de Janeiro, vigorously protested theimportation by U.S. military aircraft of the dreaded malaria vector, A.gambiae. Dr. Mendonça also claimed that by failing to disinsectizetheir aircraft properly U.S. Air Force crews were not cooperating fully.In 1938, Brazil had suffered very seriously from a malaria epidemic inwhich it was estimated that, of nearly 100,000 people who became infectedwith malaria, about 20,000 died. This epidemic had been eradicated throughthe assistance of the International Health Division of the RockefellerFoundation, Rio de Janeiro, at a cost of $2 million.¹⁴

The Brazilian Government maintained constant surveillanceover the airports at Belém, Fortaleza, Natal (both land and seaplanebases), and Recife. Brazilian crews were available for aircraft disinsectizationat each airport.

The U.S. Army quarantine program was based on the principlesof a generally accepted philosophy of quarantine. Within the limitationsof military expedience, the program adhered generally to the quarantineregulations of the director of the Brazilian Port Health Service. However,the Army quarantine procedure differed from the civilian internationalquarantine program in subscribing to the policy of disinsectization atthe point of departure of military traffic rather than at the point ofentry.

Despite the publication of an Army quarantine directive(Army Air Forces Regulations No. 61-3, 14 October 1941, subject: Flying,Foreign Quarantine: Quarantine Inspection and Treatment of Aircraft), thein-

¹⁴Soper, Fred L., and Wilson, D. Bruce: Anopheles gambiae in Brazil, 1930 to 1940. New York: The Rockefeller Foundation, 1943.

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herent problems of military expediency, and the resolutionof disinsectization policy with the Brazilian National Malaria Service,the American air-crews did fail to cooperate satisfactorily with Brazilianhealth authorities. This failure illustrated the timeworn problem thatfaces large organizations, the breaking down of communications; in thisinstance, between the War Department and the medical or operational personnelin the field. Although implementation of the new military quarantine programwas available to higher headquarters, including the Transportation Corps,Army Service Forces, and Air Transport Command, the military directivepertaining to quarantine was not distributed to the officers responsiblefor carrying out the program.

As a result of a sequence of events between October 1941and the revision of Army Air Forces Regulations No. 61-3 on 11 February1942, the Brazilian National Malaria Service, representatives of the InternationalHealth Division of the Rockefeller Foundation, the U.S. Embassy in Brazil,the Secretary of War, and the Army Surgeon General considered how aircraftcould be disinsectized rapidly. Under the provisions of the revised ArmyAir Forces regulations, all base commanders and base surgeons in the SouthAtlantic Command were directed to cooperate in every way possible withaccredited Brazilian health representatives who, with their own sprayingcrews, supervised the Port Health Service. The need for understanding theproblems involved active cooperation between the U.S. Army and Brazilianhealth authorities. This joint cooperation was necessary for effectiveaccomplishment of the War Department accelerated disinsectization program.The main difficulty was that the U.S. Army was striving for autonomy ina workable program for the sake of military security, and the Brazilianauthorities were not in accord with this point of view.

The director of the Brazilian Port Health Service continuedto be dissatisfied with the degree of cooperation received from the ArmyAir Forces crews in disinsectizing their planes, even after the regulationwas revised on 30 November 1942.

Brazil's disinsectization law.-On 11 January 1943,Brazil published Decree Law 5181, which placed totalresponsibility for disinsectization of aircraft with the Brazilian authorities.In addition to the procedures outlined for this program, punishment fordisregarding it would be meted out in the form of fines ranging from $500for the first offense to a minimum of $3,000 for the second offense. Thus,in February 1943, during the height of the U.S. Army's drive to airliftmen and materiel to Africa, the Brazilian health representatives took completeresponsibility for the "disinfestization of aircraft from Africa."

Interdepartmental Quarantine Commission study.-TheBrazilian representatives at Natal continued to submit reports on the failureof American crews to comply with Decree Law 5181 and on the finding ofA. gambiae

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mosquitoes on U.S. military aircraft arriving from Africa.Following a meeting of the commanding general of the South Atlantic Command,the U.S. Ambassador, and the Brazilian Foreign Minister, the commandinggeneral requested the War Department to send representatives to his headquartersto advise, coordinate, and consult with the Brazilian representative inan effort to reach a satisfactory solution of the problem. The War Departmentpromptly instructed the newly formed Interdepartmental Quarantine Commissionto investigate the matter. Two members of the commission flew to Brazil.As a result of conferences held in Recife and Rio de Janeiro in November1943, the following agreements were reached: (1) The Brazilian Port HealthService would participate in the disinsectization in Africa of aircraftcontrolled by the U.S. Army and destined for Brazil, (2) Brazilian publichealth representatives assigned in Africa would have responsibilities similarto those of the U.S. Army officers participating in disinsectization ofU.S. Army planes arriving at Natal and Fortaleza from Africa, and (3) theultimate objective was to render African ports of aerial embarkation forBrazil free of A. gambiae and the U.S. Army would continue its effortsto this end.

U.S. airbases in Brazil and West Africa were inspectedby Maj. Elliston Farrell, MC, a member of the Interdepartmental QuarantineCommission, and Col. William A. Hardenbergh, SnC, and Lt. Col. (later Col.)Karl R. Lundeberg, MC, of the Surgeon General's Office. They investigatedall the procedures, and Major Farrell studied the potential for the introductionof disease-bearing insects from Africa. He concluded that adequate measureswere in force to prevent the importation of A. gambiae. Major Farrellindicated that the identification of arthropods recovered from incomingaircraft was not adequately confirmed, that there were discrepancies betweenreports by Brazilian and American officers stationed at Natal, and thata standard method of reporting by both parties was desirable.

As an outcome of these meetings and studies, a disinsectizationand quarantine section was established in the office of the theater surgeon,and the theater malariologist, Capt. Jacob M. Benson, MC, was placed incharge. Disinsectization and quarantine squads were activated at Nataland Fortaleza. By January 1944, Captain Benson reported that, after conferenceswith Dr. Mendonça and others on the highly controversial reportingsystem and identification of insects, a method of capture and identificationacceptable to everyone concerned had been adopted. Undoubtedly, the mostsignificant change in the control and reporting of suspected A. gambiaewas the final identification of all captured insects. This responsibilitywould now be undertaken by the laboratories of the International HealthDivision of the Rockefeller Foundation in Rio de Janeiro.

Even under these new systems, insects were still occasionallyfound, but on the whole, the arrangements worked satisfactorily. By December

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1944, the Brazilian representatives were withdrawn fromthe airfields in Africa.

Redeployment of troops.-Plans for the anticipatedincrease of air traffic from Africa via Brazil to the United States (p.150) were discussed by Colonel Knies, the Army quarantine liaison officer;Lt. Col. Oliver R. McCoy, MC, Surgeon General's Office; the U.S. Ambassadorto Brazil; the U.S. medical military attaché, Brig. Gen. Hayes A.Kroner; and Dr. Mendonça. Dr. Mendonça's letter to GeneralKroner, dated 9 June 1945 (translated), shows his satisfaction with theplanned arrangements and with the United States-Brazil relationship:

Dear General:

The object of this is to reaffirm to you the agreementmade with Lt. Col. Phillip Knies about the position of the Health Serviceof the Ports, in relation to the troops that will pass in transit throughthe Bases of the North, proceeding from Europe, via Africa, and who, atthe bases referred to, will not have contact with the civilian populationof the cities:

1. Such service desires the most rigorous spraying ofthe airplanes, when they leave the African continent.

2. New and rigorous spraying will be done by our Serviceupon arrival in Brazil.

3. It would be highly desirable that airplanes landingat Ascension Island be rigorously sprayed, at this island, while they arebeing refueled.

4. No sanitary requirements will be demanded with respectto the American troops, since this Service has knowledge of the hygienicand prophylactic steps to which the same are submitted.

5. I take advantage to thank you for all the cooperationthat we have received on the part of the American authorities.

SUMMARY

During the period 1943 through 1945, more than 8,200 aircraftentering Brazil from Africa were disinsectized at major airbases in Brazilunder U.S. Army jurisdiction. Of this number, 118 harbored A. gambiae.In all, 320 of these arthropods were found, of which nine were alive.Table 3 shows the number of planes disinsectized, the number of planeson which these vectors were found, and the total numbers of living anddead A. gambiae that were recovered during each year. The one livingA. gambiae recovered in 1944 was from a British hydroplane whichhad landed at the Natal seaplane base, which was not under U.S. Army jurisdiction.Seventeen of the 29 dead A. gambiae shown as recovered in 1944 weretaken from one aircraft on 17 May 1944.

Before the disinsectization squad at Recife was organized,an occasional plane arrived directly from Africa. These planes were sprayedby the aircraft pilots with additional help from base operations personnel.Many of these planes transported very important individuals. Too often,the classification of their mission was such that it was not militarilyexpedient to notify the Brazilian Port Health Service authorities so thatthey could meet the aircraft upon their arrival at the airbases.

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TABLE 3.-Number of aircraft disinsectized and number of Anopheles gambiae recovered at major U.S. airbases upon arrival in Brazil from Africa, by year, 1943-45

Year	Aircraft				Aircraft from which A. gambiae were recovered	A. gambiae
	Natal	Fortaleza	Recife	Total		Living	Dead	Total
1943	746	73	0	819	100	8	273	281
1944	2,419	133	0	2,552	9	1	29	30
1945	4,453	375	13	4,841	9	0	9	9
Total	7,618	581	13	8,212	118	9	311	320

Source: Medical History, World War II, U.S. Army Forces, South Atlantic, 24 Nov. 1942-31 Oct. 1945, pp. 523-524.

All U.S. aircraft transporting troops via Africa and landingat U.S. airbases in Brazil en route to the United States during redeploymentof men and planes were met upon arrival, and each aircraft was thoroughlydisinsectized by the Brazilian disinsectization squads at the airfields(p. 150).

Daily reports of spraying of aircraft at each U.S. airbasewere received in the Office of the Surgeon, U.S. Army Forces, South Atlantic.Similar reports were furnished to the Rockefeller Foundation laboratoriesin Rio de Janeiro.

The officers and men of the U.S. Army teams who workedwith Brazilian representatives in accomplishing their mission of disinsectizingU.S. planes acted as consultants and advisers to that government. At theoperating level, the U.S. medical teams and the Brazilian health officersworked in close harmony. The Brazilian Foreign Office through the U.S.Embassy in Rio de Janeiro made a considerable issue of each incident inwhich A. gambiae were found on incoming planes from Africa. It isa fact, however, that there was close coordination between the U.S. andBrazilian public health authorities at the airport level.

Every effort was made by the U.S. Army to cooperate fullyand actively with Brazilian health officers operating on U.S. airbasesin Brazil. This assistance was later extended to Brazilian representativesin Africa. Militarization of the Brazilian agency responsible for enforcingdisinsectization and foreign quarantine measures would have brought thesematters under better control and supervision as far as the U.S. Army wasconcerned. The Joint American-Brazilian Conference in Recife in 1943 didmuch to improve the disinsectization and identification procedures andled to better understanding between representatives of both countries.It became evident that the best method to protect Brazil against A.gambiae was to eradicate this species from the airdromes in Africa.

Both American and Brazilian authorities shared the anxietyaroused by the threat of malaria. Both fully realized that not only tragicloss of life but also their good relationship and the successful outcomeof the war

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were intimately involved in protecting the great countryof Brazil frominvasion by this small enemy. That their combined precautionarymeasures were successful and that A. gambiae did not regain a footholdin Brazil were matters of deep satisfaction to both nations.

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