Part III
THE MEDITERRANEAN
CHAPTER VII
The Middle East Countries
Brigadier General Crawford F. Sams, MC, USA (Ret.)
HISTORICAL NOTE
Prewar Planning
President Franklin D. Roosevelt signed a memorandum toSecretary of War Henry L. Stimson on 13 September 1941, requesting thatarrangements be made as soon as possible for the establishment and operation ofsupply and maintenance depots in the Middle East. The facilities were to serviceAmerican aircraft and all types of ordnance furnished to the British in thatarea. The President also directed that British authorities be consulted on alldetails as to location, size, and character of the depot and transportfacilities.
Since the United States, at that time, was officially anonbelligerent, the War Department was required to contract with civiliancompanies to construct these depots. Planning and supervision of all activitieswere the responsibility of the Army.
The U.S. Military North African Mission, headed by Maj. Gen.Russell L. Maxwell, USA, was established immediately by the Secretary of War tomake plans to execute the presidential directive. The original plans called forprojects to include ordnance shops with tank and other heavy equipment repairshops, quartermaster motor repair, engineer repair, and locomotive repair shops,and signal repair installations-all to be located in Egypt. Similar activitieson a smaller scale were planned for Palestine. An Army Air Forces repair depot,ordnance repair shops, a naval base, and port facilities were to be establishedin Eritrea and at Port Sudan. All of these activities were to be carried outunder the principle of Lend-Lease. All construction was to be oftheater-of-operations type, which would permit use by military units shouldsubsequent events require it. If existing corporations could not be induced toconstruct and operate these activities, new corporations were to be establishedfor this purpose (map 6).
A special staff and a general staff were assembled to preparedetailed plans before the departure of the Mission for the Middle East. Theinitial plans provided for 12,940 U.S. civilians and 8,300 natives. The overallplans of the Mission provided tentatively for the rough grouping of theinstallations into a standard theater of operations-communications zoneorganization. An advance section was to be located near Cairo, Egypt; a secondadvance section, in the Palestine area. Within the Intermediate Zone,
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MAP6.-Service Command, U.S. Army Forces in the MiddleEast, 15 May 1943.
installations were to be located at Port Sudanand Asmara. The base section was to be at Port Elizabeth, Union of South Africa.
Since poor sanitation was a detriment to the successfuloperation of such a mission, and medical facilities for many thousand Americancivilian employees were considered to be either unavailable or inadequate, thechief of the Mission decided that a separate medical service would be requiredto support these installations.
The Surgeon, Maj. (later Brig. Gen.) Crawford F. Sams, MC,reported to the chief of the Mission in Washington on 16 October 1941 incompliance with War Department orders.
The original medical plan as approved by The Surgeon Generaland the Secretary of War, based upon the overall mission plan, provided fordispensary or ambulatory patient treatment and essential hospitalization forAmerican civilian personnel.
To provide this medical service, it was estimated that 1,942doctors,
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dentists, nurses, and other civilian personnel would berequired to staff the dispensaries and station hospitals to be locatedtentatively as indicated:
Area | Number of beds |
Cairo | 300 |
Palestine | 250 |
Port Sudan (Anglo-Egyptian Sudan) | 900 |
Asmara-Gura area (Eritrea) | 600 |
Port Elizabeth (Union of South Africa) | 100 |
The estimate was based upon (1) a probable hospital admission rate for disease and injuries selected from available data for civilians in a tropical zone under unfavorable conditions as four per 1,000 per day, and (2) a plan of evacuation to the Zone of Interior, established as 120 days as the maximum period for retention of white patients in the area.1
Medical supplies were to be procured at a level of 120 daysto allow time for shipping. Supplies were to be sent to Port Sudan, subject toconfirmation after the arrival of the Theater Surgeon in the theater.
Not much information was available in Washington, D.C.,concerning the medical and public health situation in the countries of theMiddle East. One report of the Rockefeller Foundation indicated that typhus andcholera, as well as the usual gastrointestinal diseases, were endemic in thesecountries. Therefore, the Surgeon planned to make sanitary surveys of the areaas soon as possible after his arrival in the Middle East; then, he would issuespecific instructions as to essential sanitary measures to be undertaken bycontractors to preserve the health of the civilian personnel in the designatedareas. However, it was believed justified at this stage of the planning torequire the usual immunizations against smallpox, typhoid, paratyphoid, tetanus,and yellow fever since the existence of yellow fever in the area was consideredprobable, at least in the Eritrea-Ethiopia area. After consultation with Col.(later Brig. Gen.) James S. Simmons, MC, Chief of the Preventive MedicineDivision of the Surgeon General's Office, and a special committee of theNational Research Council assembled for the purpose, the new Cox method typhusvaccine and cholera vaccine were considered of sufficient value to requireimmunization of all personnel before they departed for the Middle East.
In the overall planning, the Army Air Forces was to establishan air route across Central Africa to ferry aircraft from Accra to the MiddleEast under contract with Pan-American Airways. Under the directive from theSecretary of War to the chief of the Mission, General Maxwell was to assumeresponsibility for all American personnel, both civilian and military, withinthe Middle East theater of operations. This would necessitate the subsequentdevelopment of a plan for provision of medical service for personnel of therefueling and repair installations to be established along the Trans-African AirRoute into the Middle East.
1Annual Report, Medical Department, U.S. Army Forces in the Middle East, 1942.
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After the Army Air Forces Surgeon, Col. (laterMaj. Gen.) David N. W. Grant, MC, was asked for assistance, an informalagreement was reached, providing that three flight surgeons would be sent to theMiddle East, on request of the Mission Surgeon, for assignment to selected baseson the Trans-African Air Route.
At the direction of General Maxwell, the Surgeon negotiatedwith British representatives in Washington concerning Lend-Lease requirements ofmedical supplies for the Middle East area. An agreement was signed, andsubsequently approved, between Mr. Booth of the British Purchasing Commissionand the Surgeon, U.S. Military North African Mission, under which requirementsfor Lend-Lease supplies, specifically medical supplies and equipment for theMiddle East, would be prepared jointly by the British Middle Eastrepresentatives in Cairo and the Surgeon of the U.S. Military North AfricanMission. These requirements would then be accepted by the British PurchasingCommission in Washington for procurement, a timesaving procedure.
Mission Organization
The U.S. Military North African Mission was divided into twogroups. One group, which included the Surgeon, was to proceed to the Middle Easttheater. The second group was to establish a home office in Washington, throughwhich communications could be sent and followup action taken withrepresentatives in the General Staff and Technical Services of the WarDepartment. Col. Howard T. Wickert, MC, was designated by the Surgeon General ofthe Army as the individual to be contacted by the Mission home office concerningany medical communications and requirements.
Selection and Training of Personnel
The Mission Surgeon was authorized one first lieutenant andone enlisted man to accompany him to the Middle East; 1st Lt. (later Col.) DanCrozier, MC, and S. Sgt. (later Capt.) Charles L. Tackett were selected.Additional military medical personnel were to be furnished, as required, by theSurgeon General of the Army upon request of the Surgeon of U.S. Military NorthAfrican Mission through the home office.
The home office was to negotiate contracts with GeneralMotors Corp., Douglas Aircraft Corp., and various construction companies toprocure civilian doctors, male nurses, and other medical personnel required tostaff and operate the dispensaries, hospitals, and other medical units includedin the original plan.
The Surgeon of the Mission was designated as the firstofficer to depart from Washington for the Middle East via the Pacific. After hewas joined in Hawaii by the Chief of the Mission, his aides, the Mission SignalOfficer, and a Navy representative, the group proceeded via commercial airtrans-
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portation across the Pacific and India to the Middle East,arriving in Cairo on 22 November 1941. En route, the chief of the Missioninformed the Surgeon of a conference he had in Washington with Mr. HarryHopkins, the assistant to the President. Mr. Hopkins had indicated that, sincethe Axis powers had overrun Europe and penetrated deeply into Russia, the UnitedStates likely would be brought actively into the war early in the spring of1942. Fighting at that time was limited to the operations in Russia and to theWestern Desert in North Africa. The initial military activities of the UnitedStates against Germany and Italy probably would begin in the Middle East. Toprepare for such contingency as soon as possible, the movement of some militaryunits into the Middle East theater was considered desirable. The considerablecontroversy in the United States concerning our active intervention in the warin Europe might increase should combat units be moved to the Middle East at thisstage. However, the President and Mr. Hopkins believed that there would belittle or no opposition to sending military medical units to staff hospitals tothis area before any formal intervention in military operations. The chief ofthe Mission received verbal instructions from the White House to have theSurgeon dispatch a message to the War Department when he arrived in Egypt. Themessage was to request that theater-of-operations military units replace thecivilian teams programmed in the medical plan to operate dispensaries andhospitals for medical care of the American civilians.
Sanitary Surveys and Supply
The first concern of the initial group of five individualswho arrived in Cairo, Egypt (fig. 21), on 22 November 1941 was to meet with theauthorities at British Middle East Headquarters to revise the initial plansagreed to at numerous conferences with British officials and to select sites forthe establishment of the bases.
The Surgeon made sanitary surveys of Egypt, Eritrea, theAnglo-Egyptian Sudan, and Palestine. These surveys included informationconcerning the prevalence of diseases and the availability of medical facilitiesfor the civilian population since it was contemplated in the revised plans thatmany thousands of natives would be employed in both the construction and theoperation of bases. In each area, first aid was to be provided for injuriesincurred by natives on the job and their subsequent hospitalization in existingnative medical facilities, to relieve the burden on American medicalinstallations. Health officials in each area were contacted to determine thelocal legal regulations and the United States obligation under thoserequirements to provide medical service to any of their nationals who might beemployed by our contractors.
These medical surveys were invaluable to the Surgeon insubsequent developments. The firsthand knowledge obtained during the personalvisits and contacts served as a background for decisions to be made as the
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FIGURE21.-Cairo, Egypt, November 1941.
American representative on the Medical Advisory Council ofthe Middle East Supply Center. The countries of the Middle East were found to bealmost entirely dependent on imports of drugs and medical supplies for theircivilian populations. Since the Axis powers had overrun Europe, the only sourcesof such supplies were the United Kingdom and the United States. Although theLend-Lease agreement applied initially only to active belligerents against theAxis, it was later extended to include the non-belligerent countries of theMiddle East. Shipping was in short supply because of German submarineactivities. Therefore, a British Middle East Supply Center had been establishedin April 1941 to procure all imports, to coordinate requirements, and to insureequitable distribution and use of the supplies.2
For drugs and medical supplies, health officials of thevarious countries prepared their requirements for the civilian populations.These data were presented to the British Medical Advisory Council, where theywere screened, and hearings were held with the officials of these countries whenpossible. The consolidated requirements were recommended for approval andsubsequent procurement and shipment to the Middle East. This rigid controlsystem for the civil public health and medical care supplies for
2Motter, T. H. Vail: The Persian Corridor and Aid to Russia. United States Army in World War II. The Middle East Theater. Washington: U.S. Government Printing Office, 1952.
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some 10 nations, embracing approximately 200 million people,continued throughout the war. Despite its magnitude, the system proved verysuccessful.
Wartime Developments
Initial planning had been based on supporting two lines ofcommunications: one in support of combat forces through Egypt to the WesternDesert; the other based on a buildup of a line of communications throughPalestine and Syria into Turkey in support of the Australian, New Zealand, andother Allied troops stationed in Syria and Lebanon, where they formed a reservefor a possible invasion of the Balkans should Turkey enter the war on our side.
Changes in the military situation brought about several majorrevisions in the original plan. Port Sudan was entirely eliminated fromconsideration; its projects were moved to the Asmara-Massawa area in Eritrea andcombined with the proposed installations there. The proposed base section inPort Elizabeth was moved to Bombay, out of jurisdiction of the Mission. Underthe revised civilian plan for health and medical care of the civilian-operatedinstallations, it was considered necessary to take over and operate a 100-bedhospital at Massawa, to operate a dispensary at Asmara, a 250-bed stationhospital at Ghinda, and a 250-bed station hospital at Gura for support of thecivilian-operated air depot to be established there. In Egypt, a 150-bed stationhospital was planned for the depot to be established at Heliopolis, near Cairo.A 150-bed station hospital was to be built at the base selected at Tel Litwinskyin Palestine. After the operation of the medical units by civilians was changedto operation by military medical units, arrangements were made to hospitalizeU.S. civilians and military personnel in British military hospitals until U.S.Army hospitals were completed.
The Japanese attack on Pearl Harbor changed the outlook ofall U.S. Army activities in the Middle East. Considerable confusion occurredbecause of uncertainty as to the status and the future of numerous projectswhich were ready to be started. Nevertheless, civilians employed by contractorsbegan to arrive, and construction commenced. The 250-bed station hospital atGura, for the air depot to be operated by the Douglas Aircraft Corp., was one ofthe early units completed.3
Aircraft ferrying activities, then in operation byPan-American Airways, had medical problems. No organized medical service existedfor the African portion of the route, which was extended subsequently to Malayaand Australia. Many members of the aircrews and the civilians flying with themarrived in Cairo ill with dysentery and malaria acquired along the way. Thesepatients were cared for at the headquarters dispensary in Cairo and hospitalizedin nearby British military hospitals. A plan to establish a
3Vickery, Maj. E. L., MC: History of the Medical Section, Africa-Middle East Theater, September 1941 to September 1945, Volumes I and II.
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medical service along the African ferry routeswas prepared by the Mission Surgeon after consultation with the chief medicalofficer of Pan-American Airways. This plan was in accordance with previoustentative arrangements made with the Air Surgeon, Colonel Grant, before hisdeparture from Washington.
Militarization of all Mission projects subsequently wasdirected by the War Department in an order dated 15 February 1942.4Although 6 months were allowed for the conversion, militarization was completedafter only 2 months.
Arrangements were made with the British General Headquarters,Middle East Forces, to turn over the captured Italian 500-bed hospital at MaiHabar, between Asmara and Gura in Eritrea, for use in place of the proposed500-bed station hospital in Asmara.
In July 1942, directives were received from the WarDepartment to plan for an alternative line of communications across CentralAfrica, to be known as the Trans-African Road. This road was to replace the longsea supply route around South Africa up to Suez, and was to be used if theAllied Armies in the Middle East were driven out of Egypt. Capt. (later Lt.Col.) Thomas G. Ward, MC, who reported on 2 June 1942 for duty as MedicalInspector and Chief of Preventive Medicine, was assigned to the reconnaissanceparty which left Khartoum on 14 June 1942 and arrived 6 weeks later in Lagos,Nigeria, on the west coast of Africa. The usual sanitary and medicalintelligence information was obtained. Malaria, venereal diseases, sleepingsickness, filariasis, yellow fever, and gastrointestinal diseases weredetermined to be the major health hazards along the proposed line ofcommunications. Because civilian medical facilities were lacking for eitherAmerican military personnel or native construction workers needed to build theintermediate bases for operating such a trans-African supply route, the successor failure of the route would depend on a carefully planned and executed medicalservice. However, the change in the tactical situation after the battle of ElAlamein in October 1942 made implementation of this plan unnecessary. Militarymedical units subsequently arrived in the theater and provided medical servicesextending over this tremendous area, from the border of India on the east toTunis on the west, and from the Turkish border on the north to Kenya on thesouth.5 All of thesemilitary hospitals did provide medical service and medical care for the severalthousand civilian American personnel in the theater throughout the war.
During the course of operations in the Libyan campaign acrossthe Western Desert, British military hospitals in Eritrea had to be moved toEgypt to support their forces in this campaign. By agreement with the
4Memorandum, Maj. Gen. B. Somervell for The Adjutant General, 15 Feb. 1942, subject: Closing Out of Overseas Contracts and Militarization of Contract Activities.
5The locations and changes of locations of these units are discussed in Wiltse, Charles M.: The Medical Department: Medical Service in the Mediterranean and Minor Theaters. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1965.
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Director of Medical Service, Middle East theater, theAmerican hospitals in Eritrea took over the medical support of remaining Britishmilitary units and American and British civil personnel in that area; they alsoprovided emergency service for the care of natives and many thousand Italianprisoners of war who were working voluntarily for the Allied forces in Eritrea.However, after the surrender in Tunis in May 1943, the American military unitswere transferred from Eritrea, and responsibility again was gradually turnedover to the British.
The year 1943 witnessed the successful achievement of themajor Allied military objectives in Africa and the Middle East.6The mission of the U. S. Army Forces in the MiddleEast, which had changed to the concentrated support of the fighting in theWestern Desert toward Tunisia, contributed to the surrender of the Axis there on13 May
Theater Organization
Between 10 April and 19 June 1942, militarization of theNorth African Mission was accomplished. Three area commands were established:Eritrea, Heliopolis, and Palestine. Approximately 10,000 U. S. civilian andmilitary personnel were stationed in Eritrea. The size of the Heliopolis depotwas greatly expanded, and provision was made for approximately 10,000 U. S.personnel there. In Palestine, the planning figure was set at 5,000,to be housed in the depot at Tel Litwinsky; this number was later reduced.Surgeons were selected for the staffs of the three area commands. The TheaterSurgeon, in addition to his other duties, was the Acting Executive Officer forthe Mission and Acting Personnel and Supply Officer.
On 19 June 1942, orders received from the War Departmentdesignated the militarized mission as a theater of operations, USAFIME (U. S.Army Forces in the Middle East), under the command of Maj. Gen. Lewis H.Brereton, USA.
The Iranian Mission had been a separate enterprise, with themission of establishing a line of communications from the Persian Gulf to Russiato supply Lend-Lease military supplies to that ally. In 1942, this mission wasplaced under USAFIME command and was reorganized as the Iran-Iraq ServiceCommand.
The U. S. Army Middle East Air Force, established on 28 June1942, was placed under the jurisdiction of the theater commander. The fourservice commands-subsequently designated the Eritrea, Delta, Levant, andPersian Gulf Service Commands-together with the Army Ground Forces and U.S.Army Middle East Air Force, operated directly under USAFIME. On 12 November1942, the U.S. Army Middle East Air Force was redesignated the Ninth Air Force,with the mission of supporting the British
6Annual Report, Medical Department, U.S. Army Forces in the Middle East, 1943.
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and Allied Armies on the offensive across theWestern Desert.7 Ina later reorganization, Headquarters, SOS (Services of Supply), USAFIME, wasestablished and all of the service commands were placed under it. The surgeonwas the Theater Headquarters Surgeon and the SOS Command Surgeon.
On 7 December 1942, the Libyan Service Command withheadquarters at Bengasi was established. This included all of Libya, exclusiveof territory still occupied by the enemy.
The command of the theater was transferred on 10 September1943 from General Brereton to Maj. Gen. Ralph Royce, USA. On 12 September 1943,the SOS Headquarters was disbanded by General Order 63, Headquarters USAFIME.The same directive also brought the U.S. Army Forces in Central Africa underUSAFIME jurisdiction and established the West African Service Command, toinclude all former activities of U.S. Army Forces in Central Africa except thosein Liberia. The West African Service Command Headquarters was at Accra, GoldCoast.
The U.S. Army Forces in Liberia retained its name andactivities but was under jurisdiction of USAFIME Headquarters. The Tripoli BaseCommand was disbanded on 25 September 1943; the Bengasi Base Command, on 21November 1943. They had been formed from the Libyan Service Command. The DeltaService Command took over all of their activities in addition to theTripolitania activity.
Suez Canal Ports Command, which had operated separately sinceMarch 1943, was discontinued and reabsorbed into the Delta Service Command on 10October 1943. Persian Gulf Service Command was reorganized as the Persian GulfCommand on 10 December 1943, made independent of USAFIME, and remained so untilthe end of the war.
The Chief Surgeon in the Middle East theater, Colonel Sams,who had served in Sicily for the brief campaign there,returned to the Medical Field Service School in the UnitedStates, where he directed the Department of Military Art.Colonel Sams was replaced in the Middle East by Col. EugeneW. Billick, MC.
The number of Army personnel assigned to the theater reachedits peak in July 1943 when 66,203 troops were assigned, plus 6,984 air transportcommand personnel for whose medical service the Theater Surgeon was responsible.U.S. civilian personnel reached a peak of approximately 10,000 and graduallydecreased to 4,000. Their medical service and the preventive medicine activitiesprovided for them were carried out by the military medical installations.
RELATIONSHIPS WITH HEALTH AGENCIES
Relationships were first established with the variousMinistries of Health of the Middle East countries during the course of thesanitary
7Craven, Wesley Frank, and Cate, James Lea: The Army Air Forces in World War II. Volume II. Europe: Torch to Pointblank. Chicago: The University of Chicago Press, 1949.
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FIGURE 22.-Airview of the 2748th Station Hospital, Iran, 1943.
surveys. Contacts were maintained through theMedical Advisory Council of the Middle East Supply Center in reviewing therequirements presented by various ministries of health or their counterparts insuch areas as Palestine, which was under British control.
Relationships with the Egyptian Government pertaining toactivities undertaken by the typhus commission in that country, and activitiesconcerning the control of malaria moving northward into the Delta from theAnglo-Egyptian Sudan, are discussed in detail later in this chapter (p. 235).
Relationships with the Free French Military Forces and withthe Egyptian Military Forces for the procurement of military medical suppliesand equipment are properly a part of the history pertaining to military andmedical operations, rather than civilian health activities.
SPECIAL PROBLEMS AND THEIR MANAGEMENT
Although the American personnel were largely concentrated onthe military bases and field installations (fig. 22) in the Western Desert anddid not exceed some 75,000 men, the major preventive medicine problem in theMiddle East was created by the employment of an estimated 400,000 natives fromthe various countries included in this vast area. An accurate figure on thenumber of natives employed could not be obtained because of the continuousfluctuation in the numbers engaged, either in construction or in operation andmaintenance in all types of activities on bases and other installations. Thesecivilians included not only natives of West Africa,
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Egypt, Eritrea, Palestine, Syria, Sudan, Persia, and Iraq,but also many thousands of European derivation, such as Jewish people inPalestine, Poles in Iran, and Italian prisoners voluntarily working for theAmerican forces in Eritrea and in the Delta and Western Desert areas. Thesethousands of individuals, in close contact with U.S. military and civilianpersonnel during working hours and frequently living near or even on the bases,created the special problems inherent in the preventive medicine activities inthe Middle East.
Personnel
European and native personnel were employed not only by allof the other technical and combat services but also by the Medical Department.They were of great value in making it possible for a comparative handful ofAmerican military and civilian personnel to construct and operate such extensivemilitary and supply installations. Wherever possible, from clerks to technicalpersonnel in laboratories, or as cooks or maintenance personnel, they replacedmilitary personnel and saved on shipping and maintaining American personnel.
Medical Intelligence
Attempts made in Washington to collect information about themedical situation in the Middle East before the departure of the Surgeon werepractically fruitless. This area had been considered a sphere of Britishinfluence, and the U.S. intelligence agencies had almost no information orinterest in collecting information about this vast area. Only after the arrivalof the Surgeon in the Middle East and subsequent personal contacts with Alliedrepresentatives in the military services, and contacts with the civilianofficials in the health organizations of the various countries, could a clearerpicture of the health situation be obtained. This included the incidence ofdisease, the availability and quality of the doctors, nurses, and paramedicalpersonnel, and medical installations to serve this vast civil population.Continuing information was obtained both from the British and, after the arrivalof additional medical personnel, by personal reconnaissance of the small staffof the Theater Surgeon's office and that of the Service Command Surgeons andsubordinate post surgeons.
Medical Care and Hospitalization
The initial plan proposed in Washington was toprovide American hospitalization for U.S. civil personnel who were brought fromthe United States to build and operate the various bases. The number of civilpersonnel operating bases was reduced by approximately 50 percent from theoriginal planning figure, as shown by actual arrival of civil personnel and thealmost immediate militarization of the installations. Nevertheless, throughoutthe
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period of the war, several thousand American civiliansremained, for whose medical care and hospitalization the military medicalservices were responsible. Early in the activities of the theater, particularlyin the U.S. Military North African Mission phase, the civil contractors and theengineers exerted continuous pressure on the surgeon to include hospitalizationof native personnel. This was successfully resisted although the contractors,under the supervision of the engineers, desired to offer medical care to nativesas an incentive for employment.
In general, throughout the Middle East theater and, later,throughout the Africa-Middle East theater, the principle was followed thatmedical care and hospitalization of the hundreds of thousands of nativesemployed at Army and Army Air Forces installations would not be provided in U.S.Army hospitals. To protect the military personnel, preventive measures-such asimmunization, delousing, and malaria control-would be taken among the natives,who were the greatest hazard to Army personnel from a medical standpoint.Medical care for injuries incurred on the job or for illnesses usually wasprovided by dispensary service. Dispensaries, whenever possible, were staffedwith medical personnel recruited from the country in which the installation waslocated. Local medical personnel served as civil employees of the Army MedicalDepartment. The dispensaries were supervised as part of the overall medicalactivities of the installation by the responsible U.S. Army Medical Departmentpersonnel. With the exception of Liberia, where hospitalization was provided fornative personnel in a U.S. Army hospital, hospitalization for both injuries andillnesses, occurring among the civil population employed by the Army for eitherconstruction or operation of installations, was provided in native hospitalsoperated by the government of the host country. This was accomplished byarrangement with the civil health authorities of the various governments,depending upon the laws of the respective country regarding liability forhospitalization for injuries or illnesses on the job. Financial reimbursementalso depended on the laws of the country concerned.
Eritrea.-Hostilities in Eritrea between the Italianand the British forces terminated on 30 November 1941 with the surrender atGondar, Ethiopia. A small British Imperial Force of approximately 20,000 troopswas in occupation. These troops were transferred elsewhere, principally to theDelta area in Egypt. The country was administered by the Occupied EnemyTerritory Administration, which consisted of a skeleton British staff with anItalian subordinate staff of personnel taken over from the Italian ColonialAdministration. The British were experienced and adept in administering behindthe scenes a large native country, using only a few British personnel. Two typesof hospitals were available for the civil population. There were six provinces,divided into regions, and each province had a provincial medical officer.Medical officers had been assigned to the two principal cities of Asmara andMassawa. Two laboratories were located in
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Asmara: a diagnostic laboratory, and a serovaccine institutein which both medical and veterinary serum and vaccines were prepared. TheItalian doctors practicing in Asmara and Massawa were augmented later by Italiannaval and army officers. The British Royal Army Medical Corps and the IndianArmy Medical Corps provided medical care for the army of occupation. However, byagreement with the British Middle East Headquarters, these remaining garrisontroops were hospitalized in the U.S. Army hospitals subsequently established.The native civilian hospitals throughout the entire country of Eritrea containedapproximately 1,500 beds. Two radically different systems and standards ofhospitalization and medical care existed in the area: one was found inItalian-operated hospitals for Italian civil and military personnel; the secondwas found in either the native wards of these hospitals or separate nativehospitals. Food, the amenities, and standards of medical care for natives werefar below those provided for Europeans. Dispensaries were established atmilitary installations at Gura, Decamere, Asmara, Mai Habar, Ghinda, and Massawafor the civilian population other than American civilian personnel. Thesedispensaries, for the most part, were staffed by Italian doctors either formercivilian or military personnel, under the supervision of American medicalofficers. Dispensary service was provided for Italians and, in separatesections, for native personnel working for the American civil contractors and,subsequently, for American military units. Italians and native personnelrequiring hospitalization for either injury or illness incurred on the job werehospitalized at the Prince Umberto Hospital in Massawa, at the Ospedal CivileRegina Ellen in Asmara, or the Decamere Hospital in Decamere; the latter alsoprovided hospitalization for natives and Italians sent from Gura, approximately5 miles south of Decamere.8
Egypt.-The Ministry of Public Health of Egypt wasresponsible not only for preventive medicine activities but also for theoperation of the government-owned hospital system. The hospitals were controlleddirectly by the hospital section of that ministry. The hospital beds in Egypt,exclusive of British military hospitals, were 95 percent government owned andoperated; the remaining 5 percent constituted a few private hospitals in thelarge cities. There were several types of hospitals: general hospitals,ophthalmic hospitals, and skin and venereal disease hospitals. The EndemicDisease Section of the ministry had its own hospitals which treatedschistosomiasis, malaria, ancylostomiasis, and leprosy. The Infectious DiseaseSection of the ministry also had its own hospitals which treated entericdiseases, typhus, plague, smallpox, erysipelas, and other infectious diseases.The one exception to the above hospital system was a 2,500-bed hospital inCairo, operated by the faculty of medicine of the university, which accepted alltypes of cases for teaching purposes. The provincial hospital establishment,also operated by the Ministry of Public Health,
8Report, Surgeon, USMNA Mission, 15 Dec. 1941, subject: Sanitary and Medical Survey, Massawa-Asmara-Decamere-Gura, Eritrea.
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provided a hospital in each provincialcapital. In some provinces, there was a separate ophthalmologic hospital. Inthose capitals which did not have such a separate hospital, special wards wereestablished for ophthalmologic diseases, which were prevalent. The provincialhospitals usually contained about 200 beds. In the larger towns exclusive of thecapitals, 48 smaller hospitals were caring for all types of cases. They averagedabout 50 beds each. In the larger villages, there were 62 hospitals of a stillsmaller size. Each hospital had an outpatient department through which most ofthe native population received ambulant medical care. Initially, the Americancivilian and military personnel were hospitalized in British military hospitalsin the Cairo area, principally the British 63d, 9th, and 15th General Hospitals.After the establishment of the U.S. Army 38th General Hospital and militaryhospitals at Ataka, Devesoir, and Fayid which were serving American personnel inthe Ninth Air Force bases and at the Port of Ataka, American civil personnelwere also hospitalized in these military medical units. At dispensaries fornative personnel maintained in accordance with an agreement with the EgyptianGovernment, the thousands of natives employed in these areas were given firstaid for injuries or illnesses incurred on the job. Those who requiredhospitalization for injury or disease were sent to Egyptian hospitals atHeliopolis, Ismailia, Port Said, or Suez. Before the war, the Anglo-AmericanHospital in Cairo and the Anglo-Swiss Hospital in Alexandria were used byforeign nationals, principally American, Greek, Swiss, and British. However,after the United States entered the war, these hospitals were not used forAmerican civil personnel in view of the agreement reached with the Director ofMedical Service, British Middle East Forces, that our personnel would behospitalized in British military hospitals until our own were in operation.9
Palestine.-The Government of Palestine washeaded by a High Commissioner appointed by Great Britain since Palestine wasadministered as a mandate by the British Government. Under the HighCommissioner, the Secretariat included a Department of Health headed by aBritish medical officer, Col. G. W. Harron, assisted by Dr. J. MacQueen.Palestine was divided into 17 districts, each headed by a commissioner and aBritish senior medical officer. A Government hospital was located in eachdistrict. The British Medical Section Headquarters, Line of Communication, waslocated in Jerusalem. The hospitalization situation for civilians in Palestinewas unique. Because of the antagonism between Jews and Arabs, placing bothgroups in the same hospital was obviously impractical. The charity cases werepractically all Arabs because of the difference in economic status. Therefore,throughout Palestine, Government hospitals were established for the care of theArabs. The Jews cared for themselves in voluntary hospitals, which correspondedto private or endowed hospitals in the United States. There were 1,255 bedsmaintained in Government hospitals at
9Letter, Surgeon, USMNA Mission, to The Surgeon General, 2 Jan. 1941, subject: Sanitary and Medical Survey, Cairo-Heliopolis, Egypt.
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Haifa, in which a 220-bed hospital for natives was locatedand another at Tel Aviv, where a 234-bed hospital was located. For Jewishpersonnel in the same areas, three voluntary hospitals at Haifa had a combinedtotal of 153 beds. At Jaffa, there were four hospitals with 207 beds. There were20 Government and 39 voluntaryclinics distributed in all large communities. Military activities of the U.S.Forces were near Tel Aviv (fig. 23). A site at Tel Litwinsky had been selectedfor the base, about 5 miles west ofTel Aviv. Since civilian employees at Tel Litwinsky consisted of both Jewish andArab personnel, in addition to American civilians, arrangements were made toprovide dispensary service for those injured on the job. Hospitalization for theJewish personnel was in the nearest private hospital for Jews. The Arabpersonnel were sent to the nearest Government-owned hospitals at Tel Aviv andJaffa. The Jewish philanthropic organization, Hadassah, operated and maintainedan excellent university hospital in Jerusalem. This hospital was used for a fewAmericans before the establishment of the U.S. hospital at Tel Litwinsky. Duringthe short time that U.S. heavy bomber groups were maintained at airbases inPalestine and Syria, arrangements were made to hospitalize U.S. military andcivilian personnel in nearby British military hospitals or in the Frenchhospital in Damascus. Native personnel were hospitalized as previously stated.The dispensaries were staffed by Jewish doctors, of whom there were many becausethe refugee situation had caused hundreds of Jewish doctors to leave Europe forPalestine. These were under the supervision of American medical officers, andprovided dispensary service to Jewish and Arab civilian employees.10
Iran-The Iranian Mission, as a separatemission, was to establish a line of communications fromthe Persian Gulf to the Russians, who had moved into andoccupied northern Iran, including the terminus of the mountain road at Kazvin.Brig. Gen. Raymond A. Wheeler, USA, had been relieved from command of theIranian Mission and was succeeded, on 4 April 1942, by Col. Don G. Shingler. Lt. Col. (later Col.) Hall G. Van Vlack, MC, aMedical Reserve officer who had worked in missionary hospitals in Iran, hadarrived in Basra, Iraq, on 4 March1942; his mission was to supply medical service to the civilian personnel of theIranian Engineer District. A provisional 50-bed hospital was to be establishedfor this purpose. The Iranian Mission, originally located in Basra, was moved toUmm Qasr, 54 miles northeast ofBasra in Iran. The missionsubsequently moved to Ahwaz at the head of the navigable water of the KarunRiver, and a 50-bed hospital unit was established there.
In June 1942, whenthe Iranian Mission was taken over and reorganized as the Iran-Iraq Service Command of the Middle Easttheater,11 the Theater Surgeonmade a staffvisit to this area. Plans were made for the
10Letter, Surgeon, USMNA Mission, toThe Surgeon General, 14 Jan. 1942, subject: Sanitary and Medical Survey,Palestine.
11See footnote 2, p. 214.
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FIGURE23.-Tel Aviv, Palestine, amodern Jewish city near the U. S. base at Tel Litwinsky.
medical service of military medical units to support some27,000 service troops who were to operate two ports, the Iranian railroad toTeheran, the truck and air assembly plants, and the road for truck transport toKazvin. The thousands of natives who were to be employed were to be provided onlywith first aid for injuries or illnesses incurred on the job, by dispensariesunder supervision of American medical officers. The natives were hospitalized inthe nearest Iranian Government hospital. The Ministry of Health operated allIranian civil hospitals other than military and missionary hospitals. Of 76hospitals in Iran, 44 were Government operated, eight were for the military, andeight were small quarantine station hospitals. Five American missionary hospitalswere located in the northern part of the country, and four British missionaryhospitals were in the southwest section. Three hospitals were operated by theAnglo-Iranian Oil Co. Only about 5,251 beds were available for the entirepopulation of 15 million. A "Pasteur Institute" was located in Teheranwhich manufactured various kinds of serums, antitoxins, and vaccines. Of the1,500 medical practitioners in Teheran (fig. 24), approximately 200 hadreceived formal training in European or American medical schools or at theTeheran Government medical school. The Iranian Government-operated hospitals atTeheran, Khorramshahr, Ahwaz, Bandar-e Shāhpūr, and Hamadan were used for themedical care of the thousands of civilian natives employed by the U.S. Armyunits.12
12Medical Report, Intelligence Branch,Preventive Medicine Division, Office of the Surgeon General, 3 June 1943, subject: Medical and Sanitary Data on Iran.
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FIGURE24.-A street scene in Teheran, Iran, 1943.
West Africa.-A report on the bubonic plague epidemicindicates that the natives suffering from this disease were hospitalized inboth a French military hospital and a native hospital in Dakar.
Liberia-In this area, information is lacking as toavailable civilian hospitals for the care of natives employed by the U.S. Army.However, a free clinic was established at Roberts Field and operated by an Armymedical officer to treat native women with venereal disease. From May 1942 toMarch 1943, an advance detachment of the 25th Station Hospital provided medicalcare for military personnel and natives employed by the Army at Roberts Field.13
13(1) See footnote 3, p. 215. (2)Smith, Clarence McKittrick: The Medical Department: Hospitalization andEvacuation, Zone of Interior. United States Army in World War II. The TechnicalServices. Washington: U.S. Government Printing Office, 1956.
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Anglo-Egyptian Sudan-The native civilians employed at the airfield and base, including the U.S. Army hospital, at Wadi Seidna onthe Nile River north of Khartoum, were provided dispensary service at theinstallation for injuries incurred. Hospitalization was provided in Khartoum innative hospitals under control of the Anglo-Egyptian Government.
Psychological Problems
Psychological problems encountered in dealing with the civilpopulation in the countries of the Middle East and Africa can be grouped intotwo major categories. The first type was that presented by the Middle East orAfrican "old hand," represented by the European who had lived most, ifnot all, of his adult life in the Middle East or Africa. He may have served as acivil servant of the colonial powers, such as the British, French, or Belgian;as a European adviser to a native government, formerly a colony of one of theseEuropean nations; as a member of the armed forces of the colonial powerstationed there; or as a European commander or adviser to native militaryforces. These "old hands" were a valuable source of information. Inmany instances, it was through them-particularly when they held specialadvisory positions in governmental medical services-that contact was made toundertake joint measures to prevent disease and provide medical care for thethousands of natives employed on, and frequently living either on, or adjacentto, U.S. military installations. These Europeans had an attitude, developed as aprotective mechanism, which permitted their mental survival through many yearsof service in these unfavorable environments. The attitude was manifested by analmost complete detachment from the health problem of the natives who surroundedthem and who carried out the work in the countries. The diseases in the countrywere talked about in abstract terms as native diseases. The fact that theEuropean was exposed also to enteric, insectborne, or contact diseases wasconsidered one of the hazards of living in that part of the world. An occasionalbout with malaria or dysentery was looked upon as of no particular consequence.Standards of sanitation among the native populations in producing, distributing,and preparing food, for example, were of little concern to the European (fig.25).
In discussing the enteric disease hazard, particularly thebacillary dysentery problem, with a senior European medical officer while havingdinner in the beautifully appointed dining room of the elegant Shepheard'sHotel in Cairo, this officer expressed, perhaps for all of the Europeanpopulation, the psychological attitude which made mental survival possible forthem in these countries. He said that, "So long as the linen is of finequality and clean, and the servants are trained well in the proper serving ofthe meal, one does not dare to think beyond the kitchen door as to how the cooksprepare the food or as to the condition of the native markets from which theyprocure the food."
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FIGURE25.-Egyptian lemonadepeddler or "sherbulli" in Cairo, 1943, illustrates the unsanitary methods of food handlingencountered by the Allies.
The second type of psychological problem was that presentedby native populations who were the adult survivors of the enteric, insectborne,or contact diseases which they had all acquired early in childhood. The adultsrepresented that small portion of infants born who survived these diseasessince, in many of these countries, 50 to 90 percent of the children died beforereaching the age of 5 years.14 The natives, on the whole, wereilliterate
14See page 21 of footnote 12, p. 225.
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and were living in filthy surroundings. These conditions madethe problem of health education among these hundreds of thousands of nativesmore complex than that of the explanation and illustration of the relationshipof cause and effect in the control of communicable diseases.
The author's experience with the problem may best beillustrated by a situation at Heliopolis. As a member of the site selectionboard, the Chief Surgeon had selected a site for this base 15 kilometers fromthe nearest native community. This was done specifically to try to minimize thehazards of the diseases which might be transmitted from native populations toAmerican personnel who would be stationed there. The area was free from fliesand mosquitoes-a somewhat isolated piece of desert. When construction wasundertaken, thousands of native laborers moved in to live in temporary camps.Pit latrines were constructed and efforts were made through illustrations,lectures, and demonstrations to teach these people to use them. Althoughsquat-type latrines were used, each morning human feces were deposited on theground outside the latrines. The flies swarmed. Then, sweepers were employed toclean the ground each morning. However, they, in turn, contaminated the groundwhich they had just cleaned. Finally, another gang was employed whose solemission was, through the exercise of a long pole, to "elevate" anyother native, including the sweepers, found to be squatting on the desert. Eventhis was only partially successful.
If no other lesson is learned from this entire chapter oncivil public health, it should be this: that the problem of improving the healthstandards of underdeveloped nations is not so simple that it can be solved bysending a few teachers on the assumption that all people, if given the sameeducational opportunities, are equally capable of understanding or absorbingthat education.
Communicable Diseases
Yellow fever and quarantine.-The Trans-African AirRoute across Central Africa ferried not only personnel and supplies but also alltypes of combat aircraft, including fighter planes for use in the Western Desertwest of Egypt. The route was extended to India, from Khartoum through Gura,Eritrea, and along the southeast coast of Saudi Arabia. A serious problem wascreated in the enforcement of quarantine regulations, particularly in referenceto the possible spread of yellow fever. The route traversed by the air transportrefueling stations was within the yellow fever belt. Within the Middle Easttheater, portions of the Anglo-Egyptian Sudan and Eritrea were also in theendemic area. Combat aircraft arriving in the Middle East landed at airfields towhich they were to be assigned. These airfields extended from Ryak in Syria, andRamat David and Lydda in Palestine, to Ismailia, Devesoir, and Heliopolis inEgypt. There was no central location at which quarantine procedures could becarried out. The transportation in these aircraft of infected insect vectors, aswell as crews
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or passengers who might have become infected during stopoversin the yellow fever belt, made possible the introduction of yellow fever intoany of the Middle East countries and also into India, where the British reporteda large reservoir of potential insect vectors.
For reasons of military security, civil authorities were notpermitted to exercise their normal quarantine prerogatives under internationalagreement in inspecting or certifying either personnel or aircraft in themilitary services during the war. After numerous conferences, it was agreed: (1)that the British Middle East Theater Headquarters and their subordinate commandmedical services would carry out strict inspection of British aircraft withtheir military medical personnel; and (2) the Medical Department, USAFIME, wouldundertake similar responsibilities for American aircraft arriving in, or intransit through, the Middle East theater to India or the China-Burma-IndiaTheater. By agreement, these quarantine procedures involved the checking ofimmunization certificates for smallpox, typhus, cholera, and yellow fever.Immunization for yellow fever was to be completed at least 9 days before entryinto the yellow fever belt. Physical inspections were carried out and, ifnecessary, passengers were detained for observation by the military medicalservices. Of particular importance was the spraying of aircraft for insectvectors immediately upon arrival within the theater boundaries, at the firstairfield at which the aircraft landed after transit of the yellow fever zone.Technical instructions were issued through subordinate commands, particularlythe Ninth Air Force, placing responsibility for carrying out these quarantineregulations on our medical officers at the various airfields.
On 19 June 1944, the Egyptian Government reopened thequestion of their resumption of the enforcement of quarantine regulations,particularly for aircraft entering Egypt; they suggested the establishment of aquarantine station at Payne Air Field adjacent to the Heliopolis base, and onthe Upper Nile at Luxor. The second communication, received from the EgyptianGovernment on 28 July 1944, listed infected areas, including Casablanca on thewest coast of Africa, where a bubonic plague epidemic had occurred. Thiscommunication required immunization against plague for passengers in planesarriving in Egypt from Casablanca in Morocco, Haifa and Jaffa in Palestine, andNairobi and Mombasa in Kenya.
On 22 August 1944, conferences were held by Colonel Billick,Chief Surgeon, USAFIME, with Dr. M. Khalil Bey, Undersecretary of State forHealth in Egypt, and with Allied military and naval authorities, to preventcertain communicable diseases and disease vectors from entering Egypt throughU.S. civilian personnel. Agreements were reached for continuation of theprocedures pertaining to military, naval, and civilian personnel of the UnitedStates arriving in Egypt by air. The exercise of quarantine procedures was to becontinued by Egyptian quarantine officers on U.S. merchant marine vesselsdocking at Port Said, Suez, or Alexandria; U.S.
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civilian personnel found to be ill were to be hospitalized orexamined at the U.S. military general hospital at Camp Huckstep at Heliopolis.
Smallpox.-Among the native populations in the Middle East,protection of U.S. military and civilian personnel against smallpox was carriedout through repeated booster doses of vaccine. Native civilian populationsliving or working on bases were given smallpox immunization. An epidemic ofsmallpox in northern Iraq, Syria, and southeastern Turkey, which had been inprogress at the end of 1943, was a health hazard. Three deaths occurred fromsmallpox among U.S. personnel in the Persian Gulf Service Command in the summerof 1943. The vaccination of contacts, all other military and civil personnel inthe areas who had not been vaccinated within a year, was required to control thethreat to U.S. personnel.
Cholera.-The Middle East was historically an area in whichexplosive epidemics of cholera had spread from the endemic areas of India. Themovement of ships from ports in India and the projected establishment of the airtransport route through the Middle East to India provided the possibility ofreintroduction of cholera from India into the Middle East. This hazard was thebasis for the requirement that all military and civilian personnel being sentfrom the United States to the Middle East theater should be immunized againstcholera. A cholera epidemic was reported in May 1942 to have begun atKhorramshahr, a port on the Persian Gulf which was enlarged and rebuilt for usein the line of communications running north into Russia by civil contractorsunder supervision of military engineers. However, personal investigation of thisepidemic by the Surgeon revealed that cholera vibrio had not been isolated inthe feces of the supposed cholera victims. No cases of cholera occurred amongAmerican personnel in the theater during the war.
Malaria.-Initial sanitary surveys conducted by the Surgeonin Eritrea, Egypt, Palestine, and Syria had indicated that malaria wouldconstitute one of the major health hazards to U.S. civilian personnel and tonative personnel employed on bases in these countries. In Eritrea, the Britishhad malaria control units in operation on, and immediately around, theirinstallations at Massawa, Gura, and Asmara. Malaria was endemic in Egypt in theirrigated areas in the delta and extending southward along the Nile. InPalestine, the Jordan Valley was historically a highly malarious area, and onthe western slopes of the mountain range parallel to the coast in Palestine,malaria was prevalent along the streams draining this area into the sea.Irrigation in the coastal plain increased the problem of mosquito vectorcontrol. Extensive activities had been carried out under the British Mandate forcontrol of malaria in this area, particularly in the cities and communitiesinhabited by the Jewish population.
The west coast of Africa and intermediate stations along theCentral African air transport route were in the most highly malarious areas inthe entire theater. The first death from malaria among U.S. civilians in the
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Middle East resulted from an infection by a civilian who hadstopped over at Accra before arrival at an airfield at Devesoir. The onlysymptoms presented had been a mild gastrointestinal complaint for which thedispensary surgeon had given symptomatic treatment. The patient was found deadthe following morning. The autopsy revealed engorgement of all cerebral vesselswith malaria plasmodia.
Conferences were held with British medical authorities of theBritish Middle East theater. Fortunately, one of the foremost authorities inmalariology, Col. J. A. Sinton, RAMC, on the staff of the British medicaldirectorate, was a valuable consultant to the Surgeon, U.S. Military NorthAfrica Mission, and subsequently to USAFIME. After evaluating the situation, theChief Surgeon in the Middle East theater adopted a policy to control malaria byorganizing malaria control units and exercising malaria control discipline byboth military and civilian personnel of U.S. Forces. Suppressive quinine orAtabrine was to be used only by troops or civil personnel in areas in whichactivities to control malaria vectors and human reservoirs among the civilnative population were unsuccessful, or in which the military situation requiredthat troops carry out combat operations in situations in which antimalariacontrol could not, for operational reasons, be undertaken. This policy formalaria control at U.S. installations paralleled that which was in effect forall Allied forces under British control throughout the Middle East.
The policy was the subject of numerous conferences in thespring of 1943 when the British Eighth Army, supported by the Ninth Air Forceand U.S. Army service units, having successfully fought the Axis forces acrossthe desert to Tunisia, advanced northward into southern Tunisia and establishedliaison with the Allied North African Forces who had invaded Tunisia from thewest. The North African Forces had been on routine suppressive Atabrine; theMiddle East Forces were not. Although Ninth Air Force units were placed foroperational control under the Allied Force Headquarters in North Africa, thesupply, including medical services, remained the responsibility of U.S. ArmyForces in the Middle East. The medical authorities of the Allied North AfricanForces desired that all British, Free French, Polish, and American Forces inTunisia should conform to their regulations for the routine use of suppressiveAtabrine.
Conferences were held first at Tripoli, and subsequently atCairo, with representatives of the Allied Forces in North Africa Headquartersand the Director General of the British Medical Services from the United Kingdomon one side, and the British Director of Medical Services of Middle East Forcesand the Chief Surgeon, USAFIME, on the other side. Antimalaria units (p. 234)had accompanied British and American Forces in their long trek across thesouthern coast of the Mediterranean into Tunisia and had successfully controlledmalaria among those forces. It was finally agreed that the policy of the MiddleEast Forces would remain in effect so far as
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their personnel in Tunisia were concerned. Malaria did notdevelop there. However, agreement was reached that, for the projected operationsin Sicily, which was known to be highly malarious, suppressive Atabrine would beused by both invading forces-those from the Allied Force Headquarters based inTunisia striking the southern coast of Sicily; and the Middle East Forces,including the Ninth Air Force, who would invade the east coast of Sicily frombases in Tripolitania.
Carrying out the policy originally adopted, of relying onmalaria control through means other than suppressive quinine or Atabrine,involved extensive work with the native civilians living near, or employed on,U.S. military installations. This was also true for the never-ending and arduoustask of attempting to indoctrinate and enforce malaria discipline throughcommand and medical channels at all installations where U.S. military andcivilian personnel were stationed. Where possible, base sites were selected,such as Heliopolis and Tel Litwinsky, as far removed as possible from the humanreservoir of native civilian populated areas but which, at the same time, wouldpermit the satisfactory operation of the bases. However, in many instances suchas at ports and near major cities, military installations had to be located indensely inhabited native areas. At Heliopolis and Tel Litwinsky, the initialselection of a relatively isolated site was nullified partially by moving nativepersonnel into temporary habitations close to the military installations wherethey were employed.
The attempt to eradicate the human reservoir among thesethousands of native civilian laborers by extensive therapy was impracticable.The supply of quinine in the hands of Allied Forces was extremely limited andAtabrine production was still too low to permit such an effort. Even hadadequate supplies of drugs been available for such an extensive therapeuticprogram among the civil population, it was recognized that, although thereservoir of carriers could be reduced, it could not be completely eliminated.This had been shown by the Gorgas Memorial Laboratory in Panama during a 10-yearstudy before the war in some five isolated native villages by the use ofAtabrine or quinine. Therefore, control activities (other than health educationactivities of U.S. personnel pertaining to the use of screening, avoidingexposure after nightfall where possible, and routine spraying of quarters oninstallations) emphasized attack on the insect vector in the adult stage byusing sprays in adjacent native communities. An attack was also made on thelarvae through draining and oiling anopheline breeding areas within 1- to 2-mileperimeters of the inhabited areas of the military installations. This measurealso was only partially successful since only pyrethrum was used.
Pyrethrum was available in adequate quantities from KenyaColony for spraying adult mosquitoes, and paris green and oil were available forattacking the larvae. Not until early 1944, however, were adequate supplies ofDDT available in the Middle East theater for the control of insect vectors.
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To implement the policies as far as insect vector control wasconcerned, antimalaria units were organized in the Eritrea, Levant, Delta, andPersian Gulf Service Commands in accordance with General Order No. 19,Headquarters, USAFIME, dated 17 October 1942. Each organization consisted of oneofficer and five enlisted men, supplemented by a force of civilian laborerswhich varied in strength as the work required. Lt. Col. (later Col.) Daniel E.Wright, U.S. Public Health Service, who had many years of experience in malariacontrol in Sicily, Crete, and the Balkans, was attached to the Chief Surgeon'sOffice as Malariologist and was given technical supervision over the malariacontrol program in the theater. As the malaria rate among troops in the PersianGulf Service Command increased, two more units were sent to that area in July1943.
The Chief Surgeon was informed of the organization andtraining of standard antimalaria units by the Surgeon General's Office in theUnited States late in 1942. As soon as this information was received, theseorganized table-of-organization units were requested. Nevertheless, they did notarrive until a year later. Additional units were requested and moved into theCentral African and Liberian Commands when those areas were incorporated in thetheater. By 1944, all antimalaria units were placed under centralized control ofthe theater headquarters, largely as the result of a visit of the TheaterMedical Inspector and a Malaria Control Commission sent by the Surgeon General'sOffice to West Africa late in 1943.
Eritrea.-The British had antimalaria control units inoperation when U.S. personnel first arrived in Eritrea. As their forces weremoved to the combat areas, and the U.S. forces began to operate at the navalbase at Massawa, at Ghinda, Mihabar, Decamere, Gura, and Asmara, U.S.anti-malaria control units gradually took over the work in the immediatevicinity of U.S. Army installations. They were comparatively successful, andmalaria did not become a major problem, as far as a noneffective rate isconcerned, among American civil or military personnel in Eritrea.
Delta Service Command.-Although malaria was apotentially serious threat, against which much effort was expended by themalaria control units in the areas immediately adjacent to U.S. militaryinstallations in Egypt including airfields occupied by the Ninth Air Force, thedisease did not become a major cause of noneffectiveness among U.S. troops orU.S. civilians in the Delta area. Most hospitalized cases had become infectedwhile en route over the Trans-African Air Route. As military operations in theWestern Desert advanced toward Tunisia, malaria control units accompanied theNinth Air Force and carried out survey and control work at airfields and SOSinstallations as far west and north as Sfax in Tunisia.
However, in January 1943, malaria among the civil populationin Egypt became a major concern of the Director General, British Middle EastForces, and the Chief Surgeon, USAFIME. This concern pertained to the movementnorthward from the Sudan of the highly effective vector,
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Anopheles gambiae. Egyptian health authorities reportedmany deaths from malaria among the native population living in the irrigatedareas along the Nile River, and that A. gambiae had reached Luxor. Theymaintained that the spread was being caused by the use of the air, water, andrail supply routes by British and U.S. Forces from the Sudan into the Delta areaof Egypt. Should this movement continue and gain access into the Delta where themajority of Egypt's civil population lived, there would be grave danger of areal epidemic of malaria with high mortality caused by the comparativelydomestic breeding habits of A. gambiae.
The United States of America Typhus Commission FieldHeadquarters under the directorship of Rear Adm. Charles S. Stephenson, MC, USN,had arrived in Cairo in January 1943 and was attached to the Theater Surgeon'sOffice for administrative purposes. An outstanding member of this commission wasDr. Fred L. Soper of the International Health Division of the RockefellerFoundation. He had demonstrated the possibility of eradicating A. gambiaefrom a vast river valley in Brazil after the species had been introduced andhad spread widely from the west coast of Africa in the 1930's.
Conferences were held with the Egyptian Minister of Healthand with the Director of the Medical Services of British Middle EastHeadquarters. It was agreed that the movement of A. gambiae northwardinto Egypt posed a serious threat to military operations based in Egypt.Negotiations took place with the Egyptian Government, the RockefellerFoundation, and the Typhus Commission for Dr. Soper to survey the Anopheles invasionand make recommendations for its control. Since the Egyptian Government lackedthe technical personnel, insecticides, and transportation for carrying outcontrol measures, these were to be supplied jointly by British and U.S. ArmyForces. Initially, some British malariologists opposed this arrangement as aninfringement on their prerogatives in Egypt and the Sudan by U.S. forces and theRockefeller Foundation. The surveys by Dr. Soper confirmed the existence of theproblem. Equipment was furnished to the Egyptian Ministry of Health andtechnical advice and supervision were offered. However, the Egyptian Government,having appropriated 250,000 Egyptian pounds for this program, desired as amatter of national pride to undertake the control program without such technicalsupervision. Unfortunately, some dissension arose between Dr. Soper and Col.(later Brig. Gen.) Leon A. Fox, the new director of the Typhus Commission.Colonel Fox arrived in Cairo in March 1943 to replace Admiral Stephenson, whowas relieved because of illness. Dr. Soper was subsequently reassigned toAlgiers.
The failure of the Egyptian Government to control thenorthward progress of the A. gambiae after the first year resulted in anultimatum presented jointly by the Medical Director of theBritish Middle East Forces and the Chief Surgeon, USAFIME, that this continuingthreat to military
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operations could not be tolerated, and more activesupervision and greater effort would be required. Technical advice andsupervision by representatives of the International Health Division, RockefellerFoundation (chiefly Dr. Soper at the start) were then accepted; and the A.gambiae was not only stopped, but also in the next 2 years was forced backsouth of the Sudan-Egyptian border. This program was so successful that periodicdusting with paris green and DDT, when available, was finally suspended on 30August 1945.
By the end of 1943, three malaria survey units and fivemalaria control units were operating in the theater, in addition to those in thePersian Gulf Service Command, which had been made into an independent commandoutside of theater control. Units were stationed in Liberia, Accra, Dakar, theDelta, and Eritrea Service Command.
Malaria was the principal health problem at the stations ofthe Air Transport Command at Accra and across Central Africa. The Africanpopulation was shown in a survey to be positive for plasmodia in the first bloodsamples drawn in 68 percent of the native children.15 The mostimportant mosquito vector in that area was A. gambiae.
Persian Gulf Service Command.-The principal Anophelesvectors in Iran were found to be Anopheles elutus, stephansi, and superpictus.The work of the antimalaria units in the first malaria control season washandicapped by lack of sufficient personnel and specialized equipment. The workin the second malaria season was increasingly effective as indicated by thereduction in malaria rates among both military and civil personnel.
West African Service Command.-Joint control effortswere made between the U.S. Army, Liberian health authorities, British and-whereapplicable-French military medical authorities. These activities, over severalyears, succeeded in reducing the malaria incidence among American personnel tomanageable proportions, from the unenviable position of having the highestmalaria rate of any of our forces in the world.
Liberia.-In this command, malaria was the principaldisease problem, as indicated by the malaria rate of 2,000 cases per thousandper year. The arrival of the malaria control unit in October 1943 resulted ineffective reduction in malaria incidence. The use of malaria control in the WestAfrican Service Command and the Central African Command was continued under thesupervision of the Inter-Allied Malaria Control Group at Accra and the theatermalariologists of U.S. Army Forces in the Middle East, until the units weredeactivated after the end of the war.16 One of the most importantfactors in the improvement in this control program was the arrival of adequateDDT powder in 1944, to permit its large-scale use instead of the kerosene, oil,and paris green previously used.
15See page 126 of footnote 3, p. 215.
16Complete detailed reports ofmalaria and malaria control units are contained in (1) footnote 3, p. 215, and(2) Medical Department, U.S. Army. Preventive Medicine in World War II. VolumeVI. Communicable Diseases. Malaria. Washington: U.S. Government PrintingOffice, 1963.
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Levant Service Command.-After the medium and heavybomber groups of the Ninth Air Force were moved from bases in Syria andPalestine to the Delta area and, subsequently, into the Western Desert duringthe late fall of 1942 and early spring of 1943, the activities of the malariacontrol unit there were confined to control in and about the remaining Americanmilitary base at Tel Litwinsky, northeast of Tel Aviv.
Typhus.-One of the principal problems in the civilpopulation in the Middle East was typhus. Both endemic fleaborne and epidemiclouseborne forms were present. Louse infestation among the native population wascommon. In 1942, some 26,000 civilian cases of typhus with 3,000 deaths werereported in Egypt alone. Major outbreaks of typhus also occurred during thisperiod in Turkey, Syria, and Iran. How much of the outbreak in Iran could beattributed to the inflow of thousands of released Polish prisoners of war fromRussia into the Teheran-Kazvin area, for movement onto bases in Palestine,cannot be determined. These Polish men and women, captured by the Russians in1939 when eastern Poland was invaded, had been held in concentration camps untilagreements had been reached, among the Allied governments concerned, for theirrelease by the Russians and movement into the Middle East. The men were to beorganized and equipped as military units at bases in Palestine and Syria. Thesebases had been occupied previously by Australian divisions recently withdrawnfor use against the Japanese, after Japan entered the war. The Polish troopswere to augment the single Polish Brigade in the Western Desert. Theysubsequently served throughout the remainder of the African and Italiancampaigns against the Axis. Many Polish women, and some men not qualified formilitary service, remained in Iran and Palestine, of whom some were employed byeither British or American military installations.
From a visit to the staging areas near Teheran, the Surgeon,U.S. Military North African Mission, confirmed reports that these people notonly had smallpox and typhoid but also were heavily infected with typhus.Eradication of typhus, particularly among the military personnel who were to beorganized and equipped to become an effective fighting force, created a problemfor both the British Middle East Forces and U.S. Army Forces there.
Dr. Herald R. Cox had developed a method through theinoculation of chick embryos which, for the first time in medical history, madepossible the production of comparatively large quantities of vaccine againsttyphus. A question of the efficacy of this vaccine was raised in 1941 by amember of the Preventive Medicine Division of the Surgeon General's Office.The Surgeon, U.S. Military North African Mission, recommended that all U.S.military and civilian personnel sent to the Middle East should be inoculatedwith this new vaccine. This recommendation was sustained upon its concurrence bya committee of the National Research Council. The available stocks, other thanthose required in the United States to carry out this program,
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were shipped to the Middle East and stored at the Heliopolisdepot. Approximately 1 million doses of this vaccine were all that wereavailable in the Middle East. Military operations and political exigencies hadto be considered in determining the allocation of this limited stock of vaccineto the various governments urgently demanding that each of them receive all theavailable vaccine.
The British had doubts as to the efficacy of the vaccine; inconferences with Col. (later Brigadier) John S. K. Boyd, pathology consultant atBritish Middle East Headquarters, they decided not to use the vaccine for theirtroops other than on an experimental basis for voluntary inoculation of formerPolish prisoners of war in Palestine.
Turkey was being wooed diplomatically in an effort to bringthat nation into the war on the Allied side. This factor had to be considered inweighing that Government's request for typhus vaccine. In Egypt, not only werelocal pressures exerted through official channels, but Government officials alsotold the Egyptian populace that the vaccine which would protect them againstdeath from typhus was in the hands of the American Forces.
The decision was made (1) to allocate the vaccine on apriority basis; (2) to give some vaccine to each of the requesting countries;and (3), since the quantity was limited, to use it for police, medicalpersonnel, and others actively engaged in caring for typhus cases among thecivil population (fig. 26).
In Egypt, some 21,000 doses were allocated for typhus;however, much of it was diverted into black market channels. Certain Governmentofficials publicly implied that the Chief Surgeon was withholding additionalstocks of vaccine from the Egyptian civil population. This major politicalproblem was later solved by a public statement, authorized by the TheaterCommander, Lt. Gen. Frank M. Andrews, USA, that allocation had been made to theEgyptian Ministry of Health and no more vaccine was available from Americanstocks. After the Typhus Commission arrived in January 1943, a procedure was setup to submit the Commission's recommendations to the Medical AdvisoryCommittee of the Middle East Supply Center, of which the Theater Surgeon was theAmerican member. Allocations of typhus vaccine for the use of civil populationsin the Middle East would be made by the Middle East Supply Center, as were allother imported medical and pharmaceutical supplies and equipment.
It was hoped that laboratory personnel could be trained atthe beautiful, but almost unused, vaccine laboratory in Cairo and thatadditional vaccine could be produced at the Hadassah Hospital Laboratory inJerusalem, Palestine, and at the American University Medical School at Beirut,Lebanon. These projects were not successful, partly because of the limitationsof the untrained native laboratory personnel. Ultimately, some 3 million dosesof typhus vaccine imported from the United States were dis-
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FIGURE26.-U.S. Army medical personnel inoculateEgyptian civilians for typhus.
tributed for the control of typhus in the civil populationsin the Middle East.
The work of the Typhus Commission in the Middle East wasimportant in civil health programs in that area, where one of the severest ofthe known typhus epidemics of World War II occurred.17 Thecommission members, drawn from the Navy, the U.S. Public Health Service, and theInternational Health Division of the Rockefeller Foundation, were sent to theMiddle East, and were attached to the office of the Theater Surgeon, USAFIME,for administrative purposes. The field unit arrived in Cairo in January 1943.Negotiations were started immediately for use in Egypt of the laboratory at theSerum and Vaccine Institute, and of a clinical ward in the localgovernment-operated fever hospital for clinical cases. Field experiments wereundertaken also by agreement with the Egyptian Government. The comparativeeffectiveness of dusting with the new DDT delousing powder, the use of thetyphus vaccine, the use of the old steam disinfestation for
17A detailed report of the activitiesof the United States of America Typhus Commission in the Middle East may be found in (1) Medical Department, United StatesArmy. Organization and Administration in World War II. Washington: U.S. Government Printing Office,1963, ch. VI. (2) Medical Department, U.S. Army. Preventive Medicine in World War II. Volume VII.Arthropodborne Diseases Other Than Malaria. Washington: U.S. Government Printing Office, 1964, ch. X.
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delousing clothing, and the use of various combinations ofthese measures in controlling epidemics were carried out in three Egyptianvillages: M?t Riheina, El-Shimb?b, and El-Tarf?ya in the province of G?za. Long term studies were also made on the epidemiology of typhus.Experimental work was carried out at the Egyptian Fever Hospital on thecomparative effectiveness of various forms of treatment, including the use ofhyperimmune rabbit serum and para-aminobenzoic acid.
A small outbreak of typhus occurred at Aden at thesouthwestern tip of the Arabian Peninsula. Yemen natives, who werelouse-infected, were employed by the Army to work on the base, a station on theAir Transport Command route. Periodic delousing of the native employees wascarried out. Rigid control through reimmunization of American personnelprevented outbreaks of typhus among the American military and civil personnel,as well as the native civil personnel employed by them.
During the late summer and fall of 1945, General Fox madeextensive typhus surveys in North Africa, India, the China-Burma-India Theater,Iran, Iraq, and Turkey. The activities of the Commission from its base ofoperations in the Middle East were extended to assist in controlling an outbreakin Naples, Italy. Extensive dusting of civil populations was carried out in theMiddle East as well, and instructions were given for delousing personnel of theUnited Nations Relief and Rehabilitation Administration, which was planning tocarry its activities into the Balkans when military operations permitted. TheSurgeons General of the Egyptian and Iranian Armies agreed to a program ofvaccination for their troops under the supervision of the Typhus Commission; andin 1943, the entire Egyptian Army and a large part of the Iranian Army wereproperly vaccinated.
In 1943, 22 mild cases of typhus occurred among Americancivil and military personnel but fortunately none was fatal.18 Duringa comparable period, British forces exposed equally to the civil population andto the laborers working at the installations suffered many hundreds of typhuscases, with an appreciable number of deaths. This caused the British medicalauthorities in the Middle East to change their minds and to request procurementof U.S. typhus vaccine for inoculating their troops.
In August 1943, General Fox asked to be relieved as directorof the Commission and was appointed Field Director in Cairo. Col.(later Brig. Gen.) Stanhope Bayne-Jones, MC, was appointed director of theTyphus Commission, with headquarters in Washington, D.C. (fig. 27).
Enteric diseases.-Throughout the area, the lack of potablewater by U.S. military standards, the complete lack of hygiene as it pertainedto human waste disposal and the handling of native foods, and the universalinfection of the native civil population by one or more of the dysenterybacteria, together with the psychological problems previously discussed inrelation to this hazard, made the enteric diseases one of the major
18See footnote 5, p. 216.
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FIGURE27.-Brig. Gen. StanhopeBayne-Jones in 1944.
medical problems for American military and civilian personnelin the theater. The fly transferred enteric organisms to the food directly fromhuman feces commonly not disposed of. Although, after the first year, the foodfor American military and civilian personnel was imported from the UnitedStates, it was handled and largely prepared by native assistants to the cooks inthe messes. It would be difficult to duplicate the magnitude of the fly problemin any other part of the world. The fly swarms were such that, habitually,Europeans and, ultimately also, American military and civilian personnel carried"fly whisks" to prevent masses of these insects from clustering on theface about the eyes, nose, and mouth.
The efficacy of the typhoid and paratyphoid vaccines in theprotection of the military and civil personnel of the American forces was wellproven in preventing, with the exception of a few mild cases, the occurrence ofthese diseases even in the presence of environmental conditions favoringuniversal infection. Approximately 75 mild cases of typhoid and paratyphoidoccurred in the theater during the 15 months from July 1942 to October 1943.
However, in the dysenteries, for which no vaccine existed,educational and control measures were carried on continuously. Strictregulations required abstinence from local dairy products, thin-skinned unpeeledfruits,
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uncooked vegetables, and berries which were available. Localrestaurants were placed out of bounds. No food which might have beencontaminated while being grown, handled, or washed with Nile or canal water waspermitted to be eaten without cooking. Nevertheless, every group of newcomersyielded a large percent of its number to the temporary diarrheas or milddysentery acquired through violating these instructions. The curiosity fortasting native foods and the elegance of some of the dining rooms in majorEuropean-operated hotels in Iran, Palestine, Egypt, and Eritrea could not beresisted by the newcomer although the food served was obtained from nativesources. There was, therefore, always a major rise in the incidence of entericdiseases among both military and civil personnel until a lesson had beenlearned, and it was found advisable to adhere to the theater regulations.
The malaria control units initially organized in the theateron a provisional basis were, in fact, insect control units and were used notonly to control malaria but also to control flies. Where possible, the unitssupervised native workers in eradicating fly-breeding areas on or near militaryinstallations, by either removing organic waste materials or spraying. Thisspraying was carried out for both larvae and adult fly control.
Infectious hepatitis.-Infectious hepatitis was knownhistorically to be endemic in the Middle East, particularly in Palestine whereit was known as the Levant Disease since most of the immigrants who arrived inthat area acquired the disease sooner or later. Although the hepatitis was foundalso in Egypt, the Western Desert, and Iran, it was not a problem in Eritrea forsome unknown reason. An epidemic occurred among British Forces in the El Alameinposition in 1942. A similar epidemic appeared among German and Italian troops inNorth Africa during October and November 1942. During the sixth Libyan campaign,many prisoners who were suffering from jaundice were seen by the Chief Surgeon.A few cases appeared among U.S. Army troops and U.S. Army Air Force personnel;77 cases occurred among Americans in the Africa-Middle East Theater from Julythrough December 1942. Because of the prolonged noneffective period whichresults from hepatitis and its possible effect on military operations, theSurgeon, USAFIME, requested that a commission be sent to the theater to studythis disease.19
On 26 April 1943, a commission headed by Dr. John R. Paularrived in Cairo to study infectious hepatitis and sandfly fever. Laboratoryspace and ward space were made available to the commission at the 38th GeneralHospital at Heliopolis. Previous experimental work done by a Britishinvestigator who inoculated a number of British volunteers with blood from acase of infectious hepatitis had shown that the incubation period of thisdisease was exceptionally long. None of the British volunteers had come downwith clinical symptoms of the disease during a 3-month observation
19See page 37 of footnote 3, p. 215,and footnote 5, p. 216.
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period, but after they were returned to combat units, all ofthem came down with the disease. Fatigue, emotional strain, and other factorswere thought to have some effect in precipitating the clinical syndrome ininfected individuals. The method of transmission was unknown, but it was thoughtit might be an insectborne disease. The almost complete incapacitation of the 2dNew Zealand Division at El Alamein before the Battle of El Alamein in October1942, when they had been subjected to a windborne flight of mosquitoes from theDelta, resulted in efforts to determine whether or not mosquitoes were apossible insect vector. Although infectious hepatitis is now known to betransmitted as an enteric infection, this was not determined by the time thecommission ended its activities on 15 December 1943. The subsequent occurrenceof hepatitis as one of the major worldwide medical problems among American andother Allied Forces prompted extensive research in many theaters.
Sandfly fever.-Although sandfly, or pappataci, fever wasprevalent throughout the Delta area, the Levant, and Iran, its principalimportance was in the production of a significant noneffective rate rather thana high mortality rate. Symptoms, although of short duration, were frequentlyexceedingly severe for a number of days. Therefore, it was one of the problemsto be investigated by the virus disease commission. Since the sandfliesresponsible for the spread of this disease were most prevalent in adobebuildings, or in sandbagged or dug-in emplacements, the control of the sandfliesfinally became a matter of spraying the areas inhabited by both military andcivil personnel. No great effort was made to control sandflies among the nativepopulation.
Venereal diseases.-In the Middle East, venereal diseaseposed a serious problem because legalized prostitution could not besuppressed in sovereign countries by U.S. Army military authorities as wasattempted in the United States.20 Another factor was the absence ofnormal social contacts with white females of good character by both military andcivil Americans. Capt. Herbert L. Traenkle, MC, was assigned as Venereal DiseaseControl Officer for the theater on 24 November 1942. The usual educationalmethods, warnings, and establishment of prophylactic stations were put intoeffect in all areas. The high venereal disease rates for U.S. civilians may beexplained partly by the fact that the civil personnel were located almostentirely in base installations while approximately 40 percent of the militarypersonnel, assigned principally to the Air Force and to SOS, were in the WesternDesert in combat operations where possibilities of exposure were exceedinglylimited.
In Eritrea, former Italian brothels were operated by the British military medical authorities. Separate brothels were maintained for white officers, for white other ranks, and for nonwhite other ranks. Similar in-
20Medical Department, U.S. 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.
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stallations were in operation in the Sudan. All otherbrothels were placed off limits to military and civil personnel. In Egypt andPalestine, this approach to the problem was not practicable.
As the Allied Forces, including U.S. Army Air Forces andsupply personnel, moved westward through Bengasi and Tripoli to Tunisia, thevenereal disease rate among these people increased, particularly as the civilpopulation gradually returned after fighting had ceased.
In Iran, the legal brothels were placed out of bounds, and acontrolled house, again under British supervision, was permitted to operate inthe town of Basra in adjacent Iraq.
In the Liberian Command, the venereal disease rate amongnatives appeared to be exceedingly high. The infection rate among Negro troops,who composed the majority of military forces there, was correspondingly high. Afree clinic, established to examine and treat women, was run by an Army medicalofficer. If a woman was found to be free of disease, she was given a tag; ifnot, she was offered treatment. This did have an effect since, eventually, thesoldiers would not accept a woman who did not have the tag. This developmentappeared to be accompanied by a drop in the venereal disease rates."Tolerated women's villages" were established in Liberia as a resultof cooperative activities of the Liberian health authorities, the medicaldirector of the Firestone plantation, and U.S. Army medical personnel.Compulsory chemical prophylaxis was required of all men who visited the"tolerated women's villages" after 1 May 1943. The very highvenereal disease rate decreased markedly following a fourfold increase in theprophylactic rate.21
Although some methods used to control venereal disease amongAmerican civilian and military personnel employed in certain areas of the MiddleEast were unorthodox by U.S. standards, they were effective in reducing the ratewhere they were employed. No attempt was made to control venereal disease amongthe vast native population in the area other than to treat infected women.
Schistosomiasis.-While the native population in the Deltaarea of Egypt was almost universally infected with schistosomiasis, it was not ahazard to American civil or military personnel because bathing in the Nile or inthe irrigation canals was prohibited. A few cases occurred in a British RoyalEngineers battalion which violated the regulation shortly after arrival, but itwas not a hazard otherwise. However, in cooperation with the Director of MedicalServices of British Middle East Forces and at the request of the Minister ofHealth of Egypt, copper sulfate for the control of snails in the Delta area wasincluded in medical supplies procured from the United States, as recommended bythe Middle East Supply Center. Schistosomiasis was found to be present along tworivers in the western watershed of Palestine, but since this was not animmediate hazard to
21See footnote 5, p. 216.
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FIGURE 28.-A native youthsuffering from right cervical and submental plague, Jaffa, 1943.
American civil or military personnel, it was not a problemfor the medical service other than to prohibit bathing and swimming in theserivers.
Dengue.-Dengue, which was endemic in the coastal area ofEritrea, had produced a number of cases among British troops in 1941. However,after U.S. civil and military personnel took over the bases of Massawa, the workof the insect control units resulted apparently in successful control of themosquito vector of this disease. No outbreak occurred subsequently.
Plague.-In the initial survey in Palestine, the Surgeon,U.S. North African Mission, had seen cases of bubonic plague22in the native hospitals in Haifa. Additional cases werereported by British medical authorities as having been endemic in the port ofJaffa (fig. 28), which was a native city. Bubonic plague constituted a potentialhazard as coastwise shipping, bringing tungsten from Turkey along the coast ofthe Levant and through the Suez Canal, offered the possibility of spreadingplague through rat infestation on the ships which stopped in Haifa.
22For additional information on plague, see (1) footnote 17(2), p. 239, and (2) Medical Department, U.S. Army. Preventive Medicine in WorldWar II. Volume III. Personal Health Measures and Immunization. Washington: U.S.Government Printing Office, 1955.
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Such an outbreak did occur at Port Said in 1942. This was ofconcern to the Surgeon, USAFIME, because of the hazard of exposure to U.S.personnel operating ammunition depots which supplied bombers on airfields nearPort Said. In the course of this outbreak of bubonic plague, nine cases ofpneumonic plague were identified among the civil population of Port Said. PortSaid was placed out of bounds to all U.S. military and civilian personnel.Intensive efforts were made to influence the course of the epidemic through ratand flea control. Although pneumonic plague decreased markedly, the Egyptianauthorities never completely eradicated the rat population. Additional cases ofplague occurred at Port Said in April 1944. Military security required thesuppression of all information about the plague epidemic at Port Said lest theAxis know that this dangerous health hazard existed in the base of operations ofthe Allied Forces in the Middle East.
Sporadic cases of bubonic plague continued to occur andspread, probably through coastwise shipping, to Suez. A major outbreak occurredin Suez in November-December 1943. This was investigated by Colonel Ward,Medical Inspector of USAFIME. His extensive investigation on the epidemiologyand measures undertaken by the Ministry of Public Health in Egypt were describedin great detail in his report. He conferred repeatedly with Egyptian healthofficials and urged much more stringent control measures. During this epidemic,primary pneumonic plague was first discovered on 13 January 1944. Before this,the usual bubonic or septicemic forms had been in evidence. Fortunately, thenumber of cases of primary pneumonic plague declined very rapidly. For thisoutstanding piece of work, Colonel Ward was awarded the Legion of Merit on 22February 1944.
An outbreak of plague in Dakar in the West African ServiceCommand in April 1944 was not so extensive as the one in the Suez area. Whetherthis epidemic occurred from endemic sources or was introduced by ships from theMiddle East was never determined. British control of the port insured thatrodent control work was being done, but the French authorities preferred to relyon a vaccine prepared in the Pasteur Institutes. In the plague outbreak inDakar, native huts were treated by spraying with DDT powder for control of fleasand by attempting to reduce the rat population. Disinfestation of natives bydusting with DDT was also carried out. Vaccination of American personnel withAmerican vaccine was an additional protection for American military and civilpersonnel.
Both bubonic and septicemic plague appeared at Casablanca. Acivil employee of the French Government contracted plague and died on 20 July1945. The French and American authorities quickly collaborated in puttingcontrol measures into effect.
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HeatIn the Middle East theater, heat23 presented aproblem to all Americans rather than to the native population. This problem waslargely confined to the exceedingly high temperature areas of the Port ofMassawa, and in the Persian Gulf south of the mountains at Andīmeshk to theports at Khorramshahr and Bandar-e Shāhpūr. Heat was a health problem in threeclinical forms. The importance of the incidence of any one depended on acombination of the variables, temperature and humidity.
The first and most hazardous form, heat stroke, was a problemin the port of Massawa and in the Persian Gulf. Exceedingly high temperaturesin these localities were recorded; the maximum of 129? F. in the shade wasrecorded at Andīmeshk in Iran during one visit of the Chief Surgeon. Heatstroke, with a high mortality, had caused many deaths among British and othercivilian personnel working in that area.
Heat stroke had also been responsible for deaths amongItalian prisoners of war and some British troops working in Massawa after thecapture of that port from the Italians. The previous policy of the Italians hadbeen to rotate personnel from this port up to hill country for recuperation.However, after Massawa was captured by the British, prisoners and others wererequired to work almost continuously in the port, and heat stroke with its highmortality was the result. In American planning for civil personnel to take overthis work, provision was made for a rest area at Ghinda where Americanpersonnel, principally civilians, were sent to work on the salvage of some 70Italian ships scuttled in the harbor and to rehabilitate the naval base. Theengineers thought the use of air-conditioning units in living quarters,hospitals, and offices would protect the military and civil personnel from theravages of heat stroke. Finally, heat stroke centers had to be established inthe Persian Gulf desert area and at Massawa. Civil employees of the earlycontractors were required to call for assistance if they ceased to perspire whenworking out in the open sun and were immediately placed in the heat strokecenters for the therapeutic procedures which often were responsible for savingtheir lives.
The second clinical problem, heat exhaustion, was a potentialthreat throughout most of the Middle East, including the Western Desert.However, the use of salt tablets and adequate consumption of water weresufficient to prevent this from being a major health hazard. The maceration ofthe skin following heat rash, which occurred particularly in areas of highhumidity, was a source of noneffectiveness, particularly among the civilemployees. These people frequently had to be rotated from their stations to
23The subject of heat trauma is dealt with in (1) lecturedelivered by Col. Tom F. Whayne, MC, formerly Chief, Preventive MedicineDivision, Office of the Surgeon General, entitled "History of Heat TraumaAs a War Experience" in MilitaryMedicine Notes, Army Medical Service School, Walter Reed Army Medical Center,Volume II, 1951, Section 5, "Problems of Hot and Cold Climates," pp. 1-38;(2) Medical Department, U.S. Army. Preventive Medicine in World War II. Volume IX.Special Fields. Washington: U.S. Government Printing Office, 1969, ch. IV.
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rest areas in Palestine or into the mountains north of thePersian Gulf. In Eritrea, they were sent up into the mountains at Asmara orGhinda.
The third clinical problem, "heat syndrome," wasparticularly troublesome among civilian and naval personnel at Massawa as wellas among civilians who had stayed too long in the Persian Gulf desert and portareas. The syndrome is the result of combinations of high humidity andmoderately high temperatures, or of very high temperatures with moderatehumidity. It was insidious. There was a moderate apparent secondary anemia. Theclinical manifestations were basically those resulting from a chronic cerebralhypoxia. Forgetfulness, inability to concentrate mentally on the work to beperformed, and marked mental depression occurred. The Surgeon had found thissyndrome under similar conditions in Panama and was well aware of itsimplication on the usefulness of key personnel working in the areas mentionedabove. This became particularly serious in the Massawa area when civilianemployees used in diving and salvaging operations were not permitted restperiods in the hill areas by the officer in charge of this operation; theofficer himself subsequently had to be relieved. The recovery from this syndromeis a prolonged one and apparently can be effected only by complete removal fromthe unfavorable environment.
The high incidence of heat trauma in the deserts of thePersian Gulf Command in 1942 contrasted with the decrease in the yearlyadmission rates between 1943 and 1944 and was caused by several factors. Theconsensus of the Command was that, with the experience gained from U.S. troopsperforming in the hottest theater (Persian Gulf Command) in 1942, certain radical changes had to be made in the living conditions ofthe troops. Beginning in 1943, the living conditions were improved throughoutthe Command. Proper working hours were adhered to, and the troops were handledin a way most likely to protect them from heat injury. With these correctivemeasures instituted, even during the hot summer, heatstroke decreased markedly throughout the Middle East Theater.
Hygiene and Sanitation
The lack of hygiene and sanitation among the native personnelhas been adequately discussed. Water was a major problem in Eritrea, wherepotability and quantity were factors. The limited quantity of available waterrequired strict rationing for bathing and laundry. The Italians had relied onbottled water for drinking; however, an investigation by the Surgeon showed thatthe source of this bottled water was a highly contaminated surface spring. Thiswas, therefore, prohibited for use by Americans. Although an American watergeologist was brought to the theater, he was unable to increase appreciably theavailability of water for American installations or for the native population.
In other areas such as the Levant, the Delta, and the PersianGulf, water supplies were adequate for all purposes. However, since no source
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was found to be potable by military standards, watertreatment facilities were built at all U.S. bases.
In the Western Desert, water presented the greatest problemof warfare and was a controlling factor in the speed at which militaryoperations could be undertaken. Water was obtained largely from aqueducts leftfrom long vanished civilizations. When combat operations moved back and forthacross the desert during the various Libyan campaigns, the retreating side wouldcarefully salt the aqueducts to deny that water to the advancing enemy. Underconditions of great necessity, water consumption could be reduced toapproximately a quart a day, per man, but this was dangerous. Dehydrationoccurred and urination was often reduced to once daily of 4 or 5 cubiccentimeters of highly concentrated fluid.
Waste disposal, as far as the native civil population wasconcerned, consisted of defecation at any place at any time. Sewage treatment anddisposal plants were constructed for the use of U. S. personnel at all bases operatedthroughout the Middle East theater where semipermanentinstallations were built. In some areas, bucket latrines were used, and theaccumulated feces were collected for fertilizing by the natives.
The problem of insect control has been discussed undermalaria and other insectborne diseases.
Nutrition
Initially, the U.S. Military North African Mission had torely upon local sources for procuring food (fig. 29). Not until late in 1942 didAmerican rations become available. No one suffered from inadequate nutritionduring this period.
The American contractors found that giving wheat, andparticularly salt, was a greater incentive in terms of payment to nativeemployees than the local currency. The local civil population was usually bothundernourished and malnourished.
Veterinary Problems
Maj. Edgerton L. Watson, VC, arrived in the theater on 7 July1942 as a result of a request by the Surgeon, U. S. Military North African Mission.At that time, both U.S. military and civil personnel were subsisting on locallyprocured food as American rations imported from the United States were not yetavailable. Some canned corned beef imported from Argentina by the British wasavailable to U.S. personnel. Other than this, camel, donkey, or water buffalomeats could be obtained from local slaughterhouses. However, an inspectionshowed that the sanitary standards in these slaughterhouses were not acceptable.After the arrival of Major Watson, an adequate supply of cattle was found inEritrea, with cold storage plants available for freezing beef in Massawa andAsmara. No abattoir was found
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FIGURE 29.-Native vegetable market stall inCairo, 1943.
to be acceptable; however, a partially completed building wasfound on the outskirts of Decamere which, after remodeling, could be convertedinto a good slaughterhouse. This project was completed and, for the first timein the history of the Middle East, an abattoir was in operation undersupervision of U.S. Army veterinary personnel, producing beef under sanitaryconditions comparable to those in the United States. This beef was distributedto U.S. personnel in Eritrea and also shipped to the Delta area.
In the Delta Service Command, the Veterinary Service wasresponsible for establishing and supervising a poultry slaughterhouse operatedby a native contractor, from which poultry was made available for military andcivilian personnel. A dairy farm at Alexandria, Egypt, was approved as a sourceof milk for U.S. personnel at the 38th General Hospital on 21 December 1942. Theherd was tuberculin tested, and veterinary personnel were to superviseproduction of milk under an agreement with the dairy operator that he wouldcomply with their sanitary standards for a premium price paid for the milk. Thisproject was discontinued after a short period of operationbecause the native manager lacked an appreciation of the need forsanitation.
Fresh milk was obtained and pasteurized under the supervisionof the Veterinary Service in Palestine under a similar agreement, with the milkbeing available to Americans in the Tel Litwinsky hospital and rest camp.
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In the Central African Command, sanitary slaughterhouses werebuilt and operated under veterinary supervision at El Geneina, El Fāsher, andLagos. The bulk of the slaughtering for the Central African area division tookplace at the slaughterhouse at Lagos, Nigeria.
In March 1945, Maj. Walter A. Lawrence, VC, investigateddiseases of swine in Lebanon at the request of the commercial attach? of theAmerican Legation there. The high disease death rate of animals had seriouslyaffected the meat supply of the Lebanese. In cooperation with the LebaneseGovernment, Major Lawrence developed a tentative plan for animal diseasecontrol in areas where he found hog cholera, hemorrhagic septicemia, and swineerysipelas.
On 3 June 1945, the veterinarian discovered hoof-and-mouthdisease in a Cairo municipal abattoir and notified Egyptian officials. Within 48hours, the disease was identified in 13 other localities in Egypt.
In the course of inspecting locally procured poultry, meat,and eggs, and in training native personnel to assist in the operation of theabattoirs and poultry slaughterhouses, the Veterinary Service created severalnuclei among native civil personnel engaged in these activities, from whichknowledge might be spread to improve the standards of processing and handlingmeat, poultry, and dairy products.
Narcotics
Iran was one of the legitimate world sources of narcotics forworldwide medical use. Opium, morphine, and other products of opium could beobtained legally; it was readily procurable in bazaars and teahouses. Hashish,widely used as an aphrodisiac throughout the Middle East, was also freelyavailable. It was feared that U.S. personnel, through the usual Americancuriosity to try anything once, and particularly through boredom and lack ofrecreational activities, might be tempted to try the use of narcotics and becomeaddicted. This problem, which theoretically might have become a major healthproblem, did not materialize. Relatively few cases of addiction were found amongAmerican personnel.
SUMMARY
A Presidential directive issued on 13 September 1941 was the basis upon which the U.S. Military North African Mission wasorganized to provide effective aid to British and Allied Forces fighting in theMiddle East.
The initial plan was to provide this assistance through theconstruction and operation of military installations by U.S. civiliancontractors and native labor although these installations were to be locatedin an active theater of military operations. The entire operation was to beunder the control of a military staff-the U.S. Military North African Mission.
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Based on this concept, the initial medical plan provided forpreventive medicine and medical care services for U.S.civilian personnel and for limited emergency medical care and preventivemedicine services for the native labor to be employed at U.S. operatedinstallations. The medical problem, therefore, was essentially a civil publichealth and medical care program.
After the formal entry of the United States into the war, theWar Department directed the militarization of the entire operation. This wascompleted by 19 June 1942. The U.S. Army Forces in the Middle East wasestablished as a theater of operations and the planned support for civilianmedical personnel was replaced by theater-of-operations type military medicalunits.
Missions assigned to the USAFIME were changed during thesubsequent years of the war. The basic medical mission became that of providingpreventive medicine and medical care for U.S. Army personnel. However, thecontinuing mission was to provide preventive medicine services and medical carefor the several thousand American civilian personnel who remained in the theateras employees of the U.S. Army throughout the war.
In addition to this mission, the major civil public healthactivities increased because of the several hundred thousand natives employed bythe U.S. Army throughout the Middle East and Africa. As a policy, only limitedemergency medical care for injuriesand illnesses acquired on the job was provided, usually through theestablishment of dispensaries staffed by locally recruited civilian medicalpersonnel under the supervision of the U.S. Army Medical Corps. The majorpreventive medicine activities were centered on thesenative personnel who were in contact with U.S. military andcivil personnel, to control the spread of the enteric, insectborne, and contactdiseases with which these natives were almost universally infected. Thecomparative success or failure of these preventive medicine programs isreflected in the noneffective rate among U.S. military and U.S. civil personnelstationed in a most unfavorable environment.
It must be emphasized that in the Middle East theater onlyEritrea and Libya were occupied territories captured by Allied Forces from theenemy. Civil affairs/military government activities in these countries wereexercised by the British. In all other areas, U.S. Army installations werelocated in sovereign neutral nations or in areas under the political control ofAllied Nations other than the United States. Therefore, civil public healthactivities carried out by the U.S. Army Medical Department were confined to thatportion of the local native population working for, or living on or adjacent to,U.S. military installations. Such activities were carried out in cooperationwith native health organizations, if any existed. All preventive medicine wasfocused on the protection of U.S. military and civilian personnel from healthhazards presented by the native populations and the environment in which theywere working.
