History

CHAPTER VIII

French North Africa (1942-44)

First Lieutenant Raymond E. Finocchiaro, MSC

THE CIVIL AFFAIRS PROBLEM

Decision to invade French North Africa-To relievethe hard-pressed Russians, to deny the oil-rich Middle East to the Germans andpreclude their linking up with the Japanese, as well as to reopen theMediterranean to Allied shipping, Prime Minister Winston Churchill, PresidentFranklin D. Roosevelt, and the Combined Chiefs of Staff decided on 24 July 1942that French North Africa would be the target of a major Allied invasion. Inaddition, President Roosevelt was very anxious for American ground forces to becommitted to action against the Germans during 1942. An invasion of French NorthAfrica might well enable comparatively small forces to achieve significantresults without being forced to engage battle-hardened German troops in theinitial stages. It appeared probable also that sizable French forces wouldrejoin the Allies if Operation TORCH, as the invasion was code-named, weresuccessful.

In early August 1942, by a Combined Chiefs of Staffdirective, Lt. Gen. (later General of the Army) Dwight D. Eisenhower wasappointed Commander in Chief of the Allied Expeditionary Force that would invadeFrench Morocco, Algeria, and Tunisia (map 7). Although the directive wasapproved 3 weeks after the decision to invade North Africa had been made,General Eisenhower had already assumed leadership on a provisional basis. Theactual plans were developed by Maj. Gen. Mark W. Clark, Eisenhower's deputycommander who had landed in North Africa from a submarine and conferred secretlywith sympathetic French officers in October 1942. The objective of OperationTORCH was to gain complete control of North Africa from French Morocco toTunisia. Thus, by joining with the British Eighth Army, then fighting in Egyptand Libya, the Allies would control Africa from the Atlantic Ocean to the RedSea.

Both the United States and British Governments had agreedthat, although British troops would complement the American forces, the invasionshould have a predominantly American tone since the French, whose military andcivilian population in North Africa numbered more than a million, were stilldecidedly hostile toward the British after their naval clashes at Oran and Dakarin September 1940 and the military campaign in Syria in June 1941.

President Roosevelt and, to a lesser extent, Prime MinisterChurchill hoped and believed that the French would receive the invaders withonly

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M AP7.-French North Africa areas.

token resistance if the invasion was advertised as a purelyAmerican operation. This hope prevailed despite the fact that the Eastern TaskForce, which was mainly British, was to be used in the capture of Algiers.

The general policy was that the French inhabitants were to beregarded as friendly and as allies to be gained in the fight against Germany. Toachieve this end, enough troops would have to be provided so that local Frenchofficials and military leaders could logically use the excuse of unavoidablesurrender to "an overwhelming force" when explaining their actions tothe Nazi-controlled Vichy Government under which they ruled.

While the invasion plans included provisions to meet and overcome any French resistance, the prevailing idea was that the Allied Forces were not to act as if they were conquering a hostile territory unless continued French resistance was encountered.¹

These attitudes determined the character of civil affairs public health activities in these areas. There would be no imposition of military government. This would be not only the first American blow against Germany on

¹(1) Komer, R. W.: Civil Affairs and Military Government in the Mediterranean Theater. On file, Office of the Chief of Military History, Department of the Army, undated, ch. 1. (2) Wiltse, Charles M.: United States Army in World War II. The Technical Services. The Medical Department: Medical Service in the Mediterranean and Minor Theaters. Washington: U.S. Government Printing Office, 1965.

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the ground but also one of the earliest American experiences with civil affairs public health activities in an occupied country with a liberated population. The British, who had already gained civil affairs experience in Libya and Italian East Africa, could be of little aid because of their unpopularity with the French. It was, therefore, agreed that the United States would assume complete civil affairs responsibility in the occupied area. This included the provision of the necessary staff personnel and the establishment of the actual government.

It is important to note that certain conclusions concerning American civil affairs policy, which were arrived at following the TORCH operation, affected all later civil affairs planning. Although the ordinary administration of civil affairs in French North Africa was left to the Government of Adm. Jean Francois Darlan, the senior Vichy French official, the Allies were responsible for the economic and political support of the regime which, in turn, involved many problems best characterized as civil affairs. The Allies encountered great difficulties not only in meshing the activities of the many civilian agencies concerned but also in integrating civilian and military efforts in such a manner that the principle of the ultimate responsibility of the theater commander was not violated.

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It is true that the North African experience, although notspecifically designated civil affairs/military government, resulted inconclusions which affected all later civil affairs planning. On the other hand,by tradition and practices of the U.S. Army, activities of preventive medicineand public health carried out when troops were in intimate contact with civilianpopulations, contained the chief elements of civil affairs.

Medical and military organizations-With respect tocivil affairs public health activities in the U.S. forces in French NorthAfrica, two organizations were directly concerned. The first was composed of theunits and officers of the Medical Department of the U.S. Army attached to thetask forces at the beginning and later to the theater forces after theestablishment of NATOUSA (North African Theater of Operations, U.S. Army) on 4February 1943. More will be said about them later. The second organization wasAFHQ (Allied Force Headquarters) with its Medical Section headed by BritishBrigadier (later Maj. Gen.) Ernest M. Cowell, RAMC, Director of MedicalServices. His deputy was Col. John F. Corby, MC, USA, and the executive officerwas Lt. Col. (later Col.) Earle G. G. Standlee, MC, USA.

Allied Force Headquarters was officially activated in Londonon 12 August 1942. Its Civil Affairs Section, which was organized 3 days later,was concerned with political, diplomatic, and economic matters, as well as withpublic health. About 11 September 1942, its staff was increased by the arrivalof a group of officers from the United States, graduates of the first class ofthe School of Military Government of Charlottesville, Va.

The Civil Affairs Section, AFHQ, included, among otherbranches, a Public Health Subsection. However, no medical officer was assignedto this subsection before the invasion of French North Africa, and medicalplanning of the assault Task Forces was conducted almost completelyindependently of AFHQ, and, indeed, independently of each other. Allied ForceHeadquarters did not accompany the landing forces but arrived in Algiers 2 weeksafter the invasion; its Medical Subsection personnel reached the city in lateDecember 1942 and January 1943.²

The invasion.-In the predawn hours of 8 November 1942, U.S.shock troops lowered themselves from amphibious assault boats into the coldMediterranean waters on either side of Algiers and began wading ashore. AtCasablanca and Oran, American and British forces were also moving to seize theirobjectives. The invasion of Vichy-controlled French North Africa had begun.

²(1) Letter, Col. Thomas B. Turner, MC,Director, Civil Public Health Division, Preventive Medicine Service, Headquarters, North African Theater of Operations,Office of the Surgeon, to The Surgeon General, 21 Feb. 1944, subject: Report of Civil Affairs Public HealthActivities in the North African Theater of Operations. Additional general sources for this chapter are:(2) Howe, George F.: United States Army in World War II. The Mediterranean Theater of Operations.Northwest Africa: Seizing the Initiative in the West. Washington: U.S. Government Printing Office, 1957. (3)Meyer, Leo J.: The Decision to Invade North Africa (TORCH). In Command Decisions, KentRoberts Greenfield, editor. Washington: U.S. Government Printing Office, 1960. Number 7, pp. 173-198.(4) In Medical Department, United States Army. Organization and Administration in World War II. Washington:U.S. Government Printing Office, 1963.

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The Western Task Force, composed of approximately 34,000troops under the command of Maj. Gen. (later Gen.) George S. Patton, Jr., landedin the Safi-Casablanca-Rabat-Port Lyautey area of the Atlantic coast. The TaskForce Surgeon was Col. (later Maj. Gen.) Albert W. Kenner, MC. When the AtlanticBase Section was activated on 30 December 1942, General Kenner was relieved byCol. Daniel Franklin, MC, and assumed the position of Medical Inspector of AFHQ.

The Center Task Force, composed of 40,000 American troops ofthe II Corps under command of Maj. Gen. Lloyd R. Fredendall, USA, was assembledin the United Kingdom with Col. Richard T. Arnest, MC, the II Corps Surgeon, asits Surgeon. The Eastern Task Force, which consisted of 23,000 British and10,000 U.S. troops commanded by Lt. Gen. K. A. N. Anderson of the British FirstArmy, landed in the Algerian area, with Tunis as its ultimate objective.

French resistance and attitude.-Althoughthe Allies achieved strategic surprise, the French in every instance but onefought back at the invasion beaches. The effectiveness of their defense, however,was reduced by dissidence among the officers and enlisted men. On 11 November1942, an armistice agreement was signed and, 2 days later, Admiral Darlan wasrecognized as de facto head of the French Government in North Africa.

In the weeks and months that followed, American and Britishforcesadvanced eastward toward Tunisia, forming the western half of a gigantic visedesigned to crush the Axis Afrika Korps. To the east was the BritishEighth Army, commanded by Lt. Gen. (later Field Marshal) Bernard L. Montgomery,which was moving westward after its important victory at El Alamein.

In Tunisia, German Field Marshal Erwin Rommel occupied strongdefenses, the supposedly impenetrable Mareth Line, which Montgomery succeeded inbreaking, and by 13 May 1943, Allied Forces had seized Tunis, Mateur, and theport of Bizerte. The Afrika Korps had collapsed and the Axis powers weresqueezed out of North Africa.

THE ROLE OF CIVIL PUBLIC HEALTH

The problem in North Africa-Except foroutright military occupation, civil public health is predicated on aninterrelationship between armed forces operating in a friendly country and thecivil population and government of that country. In North America and NorthernEurope, these relationships presented few extraordinary medical problems; inAfrica, as in other underdeveloped areas, the problem was monumental. Poverty,disease, and vice were rife throughout the areas through which Allied troopsmarched. The situation was complicated further by the breakdown of Frenchcontrol and the anomalous position of the Vichy Government regarding theEuropean and native populations of French North Africa. The defeat of France in1940, followed by the German occupation, had greatly

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F IGURE30.-An Arab hut for sorting tobacco in theAlgiers area, 1943.

weakened French colonial authority. The FrenchResident-Generals had been reduced to mere puppets.

In these countries where venereal diseases were endemic andothers, such as malaria and typhus fever, were constant dangers, the efforts ofboth French physicians and Allied medical officers to enforce public healthmeasures were often frustrated by the incoherent and disorganized governmentsystems.

Before the war, the Governments of Morocco, Algeria, andTunisia had made great strides in safeguarding the health of the Europeanpopulations. Despite their efforts, however intense, to do likewise for theindigenous inhabitants, the native populations continued to live amidindescribable filth. The French found it impossible to alter the ingrainedhabits of the predominantly Moslem population. Generally, the Moslems were toopoor to change their living conditions, unwilling to develop habits of personalcleanliness and community sanitation, or untutored in the advantages of asanitary environment (fig. 30). Poverty and filth, together with the nativepopulation's suspicions of French motives, prevented any real progress. Lowmoral standards, combined with the unsanitary surroundings, pre-

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sented a serious threat to the health of the American troopsthat arrived in the invasion.³

The Pasteur Institute of Algeria-The foremost researchinstitute in North Africa was the internationally important Pasteur Institute ofAlgeria. Subsidized by the Algerian Government, it functioned closely with theDirection de la Sant? Publique et de la Famille, systematically attacking allthe principal problems of contagious disease rampant throughout Algeria. Itsdirector was Dr. Edmond Sergent who was assisted by six chiefs of service, sevenlaboratory chiefs, and others. One of the most important activities carried onthere was the constant fight against malaria and, more specifically, the actualplanning for control of the disease.

The Institute also carried on research in bacteriology,parasitology, mycology, immunology, and entomology. Public health surveys werefrequently undertaken and routine bacteriologic analyses were performed.Postgraduate instruction was also a function of the Institute staff.

One of the Institute's major efforts was a program tocombat tuberculosis in Algeria. After extensive investigations by means of thevon Pirquet test, Institute members found that tuberculosis was more prevalentin the larger centers with European inhabitants, and concluded that much of thetuberculosis resulted from contact with natives who had returned to Algeriaafter contracting the disease in France. The Pasteur Institute then successfullyvaccinated large numbers of natives, especially children, with the BCG (bacilleCalmette Gu?rin) live vaccine. A 50-percent reduction in the infant mortalityrate was soon evident, and this was attributed to the Institute's vaccinationprogram.⁴

The Institute's main laboratories were in Algiers and itsfacilities were frequently used by U.S. medical personnel while the AlliedForces were in North Africa.

Plans for Public Health

Since U.S. forces had had relatively little experience withcivil affairs at the time of the North African invasion in November 1942, plansfor a public health program in the French protectorates were sketchy. Many U.S.medical officers arriving in North Africa were not fully aware of the healthproblems that American troops would face there and, consequently, manyemergencies and problems that arose were solved by improvisation.

As was later proved in French North Africa, public health isa major component of civil affairs because of certain considerations, the mostobvious of which is that widespread disease among the civilians of an area canseriously affect military operations, whether by direct troop infection or bydisruption of activities in support of military operations.

³Simmons, James Stevens, Whayne, Tom F., Anderson, Gaylord W., Horack, Harold Machlachlan, Thomas, Ruth Alida, and collaborators: Global Epidemiology: A Geography of Disease and Sanitation. Philadelphia: J. B. Lippincott Co., 1951. Volume II. Africa and the Adjacent Islands, pp. 530-547, 558-594.
⁴War Department Technical Bulletin (TB MED) 90, 6 Sept. 1944, subject: Medical and Sanitary Data on Algeria.

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As a result, the governing authority of an area-be itcivilian or military-must assume responsibility for the public health of thatarea, and must include programs for disease prevention and facilities forgeneral medical care.

The AFHQ Medical Section-Although the Eastern TaskForce's landings in the Algiers area were accomplished initially by U.S. andBritish troops, the British First Army landed as soon as hostilities ceased andbegan to proceed eastward toward Tunisia. Algiers remained a Britishresponsibility and, consequently, no U.S. base section was initially establishedin the area. Unfortunately, the U.S. public health planning for the invasion washurried and incomplete. When the U.S. component of the AFHQ Medical Sectionarrived in Africa in December 1942, the U.S. officers immediately realized thattheir previous expectations of merely a planning role had been inaccurate andthat the section would have to become involved in operations from the standpointof hospitalization and evacuation, as their British counterparts already were.

As plans were instituted for the activation of base sections,it soon became apparent that a certain amount of administrative and operationalsupervision would be required of the AFHQ Medical Section.

The Medical Section was maintained at theater level, givingits Surgeon direct access to the theater commander, the chief of staff, and thechiefs of the general and special staff sections. This also facilitated theSurgeon's entry into all subordinate theater commands. Had the Medical Sectionbeen placed at communications zone or services of supply level, coordination ofthe professional aspects of medicine and surgery by the Consultants Divisionthroughout the various echelons of command would have been increasinglydifficult. As it was, since advice on all technical matters came from thehighest theater level, it was accepted in subordinate echelons without muchdifficulty. The coordination and correlation of technical subjects betweenvarious commands were also simplified.

The Medical Section originally was a completely integratedstaff section since early Anglo-American interests in the North African campaignwere closely interrelated in both tactics and logistics. The Chief Surgeon, AFHQ,was British, with an American Deputy Surgeon. Within the Medical Section wereseparate British and American branches within the theater.⁵

Upon arrival in Algiers 2 days before Christmas 1942, theAmerican component had been authorized only five officers and five enlisted men,but additional officer personnel had been assigned as overstrength. ColonelCorby, the senior American officer, took command of the U.S. personnel.

Four subsections were quickly established for Hospitalizationand Evacuation, Medical Records, Dental, and Veterinary activities. Lt. Col.

⁵A more detailed study of theorganization of Allied Force Headquarters at its inception can be found inMedical Department, United States Army. InternalMedicine in World War II. Volume I. Activities of Medical Consultants.Washington: U.S. Government Printing Office, 1961, pp. 150-154.

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(later Col.) Perrin H. Long, MC, the AFHQ Medical Consultant,also served as adviser on preventive medicine and neuropsychiatry.

Since centralized administrative control over the basesections had not been provided for in the preliminary planning, the basesections proceeded somewhat in accordance with their own desires, and adivergence of development and activity soon resulted. It became increasinglyapparent that some form of centralized control was essential and that anaugmentation of personnel would also be necessary.

Therefore, on 26 April 1943, a new table of organization forthe base section, providing for 22 officers and 30 enlisted men, was approved.The assignment of additional personnel to the medical sections necessitated achange of location to a larger building, which, although somewhat removed fromthe other section staffs, still provided working space for both the British andAmerican staffs. Before the move, both staffs had worked side by side in thesame office although separate files had been maintained. In the new location,the British and American officers were completely separated, occupying differentfloors, but close liaison was constantly maintained and regular weekly jointconferences were held.

The creation of NATOUSA-On 4 February 1943, the NorthAfrican Theater of Operations was established. With its creation, the control ofall troops, material, and installations in the newly defined NATOUSA area passedfrom the commanding general of the European Theater of Operations to the NATOUSAcommander, General Eisenhower.

The headquarters was similar to the usual communications zonesetup, with general and special staff sections. However, as a personnel economymeasure, NATOUSA's sections were to be staffed with the corresponding U.S.Army personnel in AFHQ general and special staff sections, and the seniorAmerican officer in each would become chief of the section. The NATOUSA MedicalSection officers, therefore, served in dual capacities. When dealing withstrictly American operations within the theater, they acted as NATOUSA staffofficers. All joint operations with the British, however, were carried out intheir capacities as AFHQ members.

Thus, NATOUSA and Allied Force Headquarters were operatedwith the same personnel, although AFHQ, as the combined Allied command, retainedoperational and tactical control. The NATOUSA Surgeon was given administrativeand operational supervision over the U.S. base sections but no direct control ofthe subordinate commands. This diffuse overall medical organization directlycontrasted with the British system, in which operational control reached fromthe highest to the lowest echelon throughout the British Army. Of the twosystems, the British method was producing better medical results and creatingfewer problems.

On the day NATOUSA was activated, Colonel Corby, AFHQ DeputySurgeon, was relieved from duty and returned to the United States. GeneralKenner then became NATOUSA Surgeon with Colonel Standlee, AFHQ

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Executive Officer, as Deputy Surgeon. General Kenner alsoacted as AFHQ Medical Inspector until April 1943, when he returned to the UnitedStates. Brig. Gen. Frederick A. Bless?, MC, former Fifth Army Surgeon, wasofficially assigned as his successor on 16 April, although he had been ontemporary duty at NATOUSA Headquarters since March.⁶

Lt. Col. (later Col.) William S. Stone, MC (fig. 31), who wasassigned to the NATOUSA Surgeon's office as Theater Preventive MedicineOfficer in July 1943, arrived in Algiers on 5 August 1943. He remained in thatrole until 1 November 1944, when NATOUSA became MTOUSA (Mediterranean Theater ofOperations, U.S. Army), at which time he assumed the same functions for MTOUSA.From February 1944 to September 1945, he also served as Chief of AFHQ'sPreventive Medicine Division.

The Base Sections

Atlantic Base Section.-The Medical Section, Headquarters,ABS (Atlantic Base Section), was activated in Casablanca on 30 December 1942,with Col. (later Maj. Gen.) Guy B. Denit, MC, as its Surgeon.

Before the arrival of the base section, all medicalactivities in the area had been carried on by the Western Task Force. The ABSMedical Section conducted immediate surveys and inspections of the area whichrevealed a deplorable native situation with poor public health supervision. Thewater was nonpotable and plumbing was inadequate. Malaria control was but agesture. Time-consuming alterations would be necessary to transform the existingfacilities into adequate hospital and housing installations. Furniture,communications, transportation, and space seemed to be eternal problems. Inshort, the tremendous problems of safe troop sanitation, eradication of healthhazards, and proper public health control became the primary tasks of the ABSmedical personnel.⁷

The Surgeon's Office operated primarily as anadministrative unit, although a few medical officers performed some professionalduties before the arrival of the Fifth General Dispensary. Thereafter, theMedical Section devoted itself entirely to administrative supervision, plans andtraining, and other duties pursuant to the administration of subordinate units.

The Base Section Surgeon was responsible for prescribing andcontrolling the policies established by the Medical Department to safeguard thehealth of the troops and the indigenous population. Since this responsibilityhad many implications and ramifications, it was essential that the Surgeon beassisted by specially qualified subordinates whose individual efforts could bechanneled into a highly efficient, well-coordinated unit.

To achieve this goal in the Atlantic Base Section, ColonelDenit acted as the deciding authority in all matters of policy and procedurewhile the Deputy Surgeon and Executive Officer supervised the routine affairs ofall

⁶For a description of the organization of NATOUSA, seefootnotes 2 (4), p. 256 and 5, p. 260.
⁷Annual Report, Atlantic Base Section,1943.

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F IGURE 31.-Col. William S. Stone, MC, Preventive Medicine Officer, North African theater, inspects a louse-infested native in Algeria in 1943. Colonel Stone found more than 50,000 lice and eggs in the folds of these rags, enough to keep this native chronically anemic. Thousands of tiny bites and almost constant scratching made his body one large area of irritated, broken skin, with the ever-present danger of serious infection.

subsections, Matters which also concerned nonmedicalspecialties, such as the Transportation Corps' role in evacuation and theEngineer's cooperation in malaria control activities, were also aresponsibility of the Surgeon's Office, which collaborated with other SectionStaffs whenever such action was necessary.

In general, although the overall medical policy for theentire area was set by the Theater Surgeon, routine matters were handleddirectly between the Surgeons of the various base sections.

Mediterranean Base Section.-The advance echelon of the MBS(Mediterranean Base Section) medical unit arrived in Oran on 11 November 1942 aspart of TORCH's G-3 Section. The Medical Section remained attached to theCenter Task Force Surgeon for duty until the activation of the base section inOran on 8 December, a month after the invasion began. Most of the section'spersonnel had arrived on convoys by that date, and the final contingent wasexpected shortly. Col. Howard J. Hutter, MC (fig. 32),became the first MBS Surgeon.

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F IGURE 32.-Col. Howard J. Hutter, MC, Surgeon, Mediterranean Base Section, at his desk in Oran, Algeria, in 1943.

Operating in the Mediterranean Base Section were the medicalservices for the port of Oran and the replacement depots, a medical supply depotwith many widespread warehouses, a general dispensary, an Army medicallaboratory, a sanitary company, a medical battalion for evacuation, dispensariesand minor hospitalization, and malaria control and survey units. Also inoperation was a French civilian malaria control agency.

French and Arab civilian employees, both men and women,professional and laborers, were hired for specific tasks in medicalinstallations from time to time. These civilians were used in addition to manythousands of U.S. medical personnel who were rotated through the base sectionand were utilized wherever possible as rotation relief and medical inspectors.⁸

The MBS Medical Inspector, noting that cooperation with theFrench civil and military population was necessary if adequate disease controlamong U.S. personnel was to be achieved, arranged for a weekly meeting withFrench officials. Sanitation, venereal disease, and epidemiology were discussedat these meetings and great strides were made toward prophylactic measures forthe control of certain endemic communicable diseases. Other subjects includedpreventive measures for typhus and malaria, which were prevalent in the area.The result of these discussions was that conferences on malaria, typhus, andvenereal diseases were arranged later for area medical officers.

⁸Hutter, H. J.: Medical Service of theMediterranean Base Section. Mil. Surgeon 96: 41-51, 1945.

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Eastern Base Section-The last of the threesections to be established was EBS (Eastern Base Section), which was activatedin Constantine, on the northeastern coast of Algeria (in MBS territory) on 21February 1943, by its own order.

One officer and seven enlisted men from the Mediterranean Base Section andfour ABS officers comprised the EBS Surgeon's staff which gathered at MBSHeadquarters in Oran on 22 February. From there, an advance echelon, consistingof the Surgeon, another officer, and three enlisted men, left for Constantine,arriving 4 days later and establishing the EBS Medical Section. The remainder ofthe section arrived on 5 March. Lt. Col. (later Col.) William L. Spaulding, MC,was the first Surgeon, although he was succeeded on 21 July by Col. Myron P.Rudolph, MC. Colonel Spaulding was then reassigned as the EBS MedicalInspector.

Originally organized with a strength of five officers and seven enlisted men,the EBS Medical Section was by necessity augmented by the attachment of officersfrom other units under the Surgeon's control and from higher headquarters. Aveterinarian, venereal disease control officer, dental surgeon, and medical andsurgical consultants were obtained in that way.

The immediate missions of the EBS Medical Section were supply and thehospitalization and evacuation of battle and local casualties. Only one hospitalwas operating at the time and no other medical installations or facilities wereavailable.⁹

Various diseases were prevalent among the civil inhabitants of the area,endemic malaria and typhus being the most widespread. Smallpox was found mainlyamong the native population in rural areas where successful vaccination programswere difficult. The incidence of other diseases, including dysentery, plague,and rickets, was also widespread and threatened to affect the U.S. troops in thebase section.

Civil Affairs Division, War Department Special Staff

The medical supervision of the civil health programs was to become more andmore dependent on the base sections since most of the liaison on publichealth matters in North Africa was carried on by medical officers on the staffsof the Chief Surgeon, NATOUSA, and Surgeons of the base sections.

Not until 1 March 1943, almost 4 months after the invasion and more than 15months after the attack on Pearl Harbor, was a Civil Affairs Division createdand added to the War Department's Special Staff in Washington. Maj. Gen. JohnH. Hilldring, GS, became the first director on 7 April 1943. By the time thisnew division (which originally was created to handle the mounting civil affairsproblems in North Africa) had actually established any definite policies, mostof the major problems in NATOUSA had been met and resolved by trial and error.

⁹Annual Report, Eastern Base Section, 1943.

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PUBLIC HEALTH AND SANITATION

Of the three base sections established, the MediterraneanBase Section assumed the most important role since it eventually became thestaging area for the Sicilian and Italian campaigns and the subsequent invasionof Southern France. Although the problems that confronted the MBS Surgeon andhis staff were essentially the same as those that arose in the other two basesections, they were magnified many times. This section of the history,therefore, will deal primarily with the public health efforts of theMediterranean Base Section, which can be considered as representative of theNorth African theater.

The situation in Algeria-Before the fall of France in1940, Algeria had been by far the most advanced protectorate in publichealth. Overall administration of the program, as pointed out earlier,rested with the Central Service of Public Hygiene and Preventive Medicine,headed by an Inspector General of Hygiene. Nominally, this organization wasresponsible for all public health activities, which included the battle againstdisease, the control of epidemic outbreaks, the management of serums andvaccines, and port sanitation. The Inspector General was assisted by a colonialphysician and the Director of the Anti-Malaria Service. Assistant medicalhygienists, who were designated by the Governor General to take charge ofspecial hygienic and epidemiologic missions, also provided some assistance.

For the purposes of local public health administration,Algeria was divided into 112 zones or "circumscriptions," each ofwhich was supervised by an overworked French physician whose duties includedvisits to native communities, consultations, vaccinations, and supervision oflocal hospitals and dispensaries. U.S. military commanders and medical officers,confronted with problems of public health and sanitation, usually had to workthrough these harried doctors. Liaison was often poor and led to less thanoptimum results.

The colonial physicians were assisted by "nativetechnical adjuncts" who were trained in a 3-year course and accompanied thephysician on his visits, applying bandages, giving injections, and even actingas interpreters. Colonial visiting nurses often were on hand to carry out theduties for which the native adjuncts were unsuited, such as care of femalepatients. In 1940, there were 108 technical adjuncts, 80 colonial visitingnurses, and an undetermined number of native visiting nurses in Algeria.¹⁰

The German occupation and subsequent Allied military actionsseverely crippled the comprehensive and generally progressive sanitaryorganization that France had established in her North African protectorates. Inaddition, centuries of living in filth made it difficult for the natives toadjust to requirements of cleanliness. All this was complicated by the natives'suspicion and distrust of their French rulers, which was transferred to theBritish and American forces allied with France.

¹⁰See footnote 4, p. 259.

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F IGURE33.-An Arab family sit on the doorstep oftheir home near Algiers, 1943.

Sanitary problems in the MBS.-Although the sewage disposalfacilities in the larger cities of North Africa had been adequate before theinvading Anglo-American armies arrived, they were overloaded by the wasteproducts of the influx of troops.

Sanitation was virtually nonexistent in the smaller townsthroughout the protectorates (fig. 33). It was common to see the streets andsidewalks littered with human and animal feces; sewage was thrown onto thestreets and left to rot. In addition, the natives were not averse to urinatingpublicly in the streets.

The natives rarely bothered to remove dead animals from theroads, preferring instead to let them decompose where they lay. The task ofnotifying the local French authorities upon discovery of a decaying animalusually fell to U.S. Army personnel, who in turn instructed their subordinateunits to report all such discoveries so that the local civilian authorities,once notified, would be forced to act.

Even in the larger cities, such as Oran, empty lots becamecollecting stations for piles of garbage which, left in the sun, soon becamemajor breeding grounds for swarms of flies and mosquitoes, thus creating one ofthe major health problems.

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The task of remedying the sanitary ills that afflicted thenatives in Algeria fell to the medical personnel of the Mediterranean BaseSection. Work began immediately. Upon his arrival in Oran, the MBS MedicalInspector, realizing that French cooperation was necessary for the adequatecontrol of disease for the protection of American personnel, consulted with theFrench public health and city administrative officials and arranged a series ofweekly meetings on sanitation which began in December 1942 and continued until15 November 1943.

A wide range of problems was discussed: the incidence ofcommunicable diseases among the civilian population; sanitary projects for thecity of Oran, which served as a gathering place for swarms of breedingmosquitoes and unbathed natives; methods for the control of prostitutes whoopenly roamed the streets; and sanitary procedures for disposal of garbage andfecal wastes.

In the early months of 1943, little cooperation wasforthcoming from the French civilian authorities who, being elected officials,were often not trained medical personnel. As a result, many recommendations madeto them were given lipservice and then ignored. The mayor of Oran, inparticular, had been generally indifferent to public health problems, but hissuccessor tried in every way possible to help the Army's medical personnel inpromoting new sanitary procedures among the civilian population. The new mayorregularly visited the MBS Surgeon's office, thereby improving liaison andcoordination between military and civilian officials. Since a lack of materials,transportation, and labor often hampered his efforts, Army supplies were turnedover to civilian health agencies in Oran whenever possible.¹¹

To get the job done, U.S. medical officers and sanitariansoften made unofficial surveys and tried to work as closely as possible withFrench medical personnel. These medical officers were restricted by theprevailing policy that nothing could be done without the approval of the Frenchofficials, and great care was taken not to offend the French population who, itmust be remembered, were regarded as allies and not as a conquered people.

Some progress on minor matters was made in Oran, but vitalprojects, such as the extension of sewers and the covering of hitherto opensewage ditches, were unsuccessful because of a lack of such supplies as cementand steel. Medical Section representatives consulted with the MBS Engineer onthe problem of open drainage, but the situation was never satisfactorilyresolved although laborers did clean out the drainage ditches on occasion. For abrief time, Colonel Hutter was able to hire a crew of approximately 60 Arablaborers who, supervised by an Army sergeant and operating with two 2?-tontrucks, were dispatched to clean some of the debris and open sewers around thetown.

¹¹Annual Report, North African Theater of Operations,U.S. Army, Medical Section, 1943.

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Farms and piggeries on the outskirts of Oran were ofteninspected and the owners of those found to be filthy, which was the greatmajority, were offered the services of the Arab work force to clean the farmsand bring them up to U.S. standards. Some accepted and others refused. No directaction was possible against those who refused to clean their property since themedical inspectors could only solicit the cooperation of local farmers and hadno means of compelling them to accept the proffered services. Most farmers,however, quickly consented to the suggestion that their piggeries be cleaned.

Local civilian health officials were virtually powerless toenforce their own regulations concerning sanitation, such as they were, becausethey lacked money and manpower. Consequently, they were seldom consulted in thelatter stages of the Army's cleanup campaign, as the U.S. medical officerscarried their program directly to the people.¹²

A lack of funds forced the disbanding of the native laborforce in mid-1943. Medical personnel were then faced with the nearly impossibleproblem of getting the native population to clean their own living areas andpublic places. Individuals who consistently refused to clean fly-breeding areaswere reported to the civil authorities which, by yearend, had begun toreestablish their control and were thus able to enforce public health measuresmore effectively. Although much of the filth was removed, the natives still hadlittle appreciation of sanitation, and only a prolonged educational program atall levels of their society would really solve the problem.

In general, there was little rapport between U.S. militarypersonnel and French military and civilian authorities on matters of sanitation.There was no official French agency within the Mediterranean Base Section withthe responsibility of disseminating to the civilian population information oncommunicable diseases, water pollution, areas of endemic diseases, and the like.As a result, most of the efforts to protect the U.S. forces had to be channeledinto a program of educating the U.S. troops on what places to avoid and whatgeneral sanitary measures to practice.

Water problems-Water presented a twofold problem in FrenchNorth Africa. Obtaining an adequate amount of water for the U.S.personnel stationed throughout the base sections caused enough difficulty, but,once obtained, the water was found to be nonpotable. This was surprising sincemany North African cities had adequate, and fairly modern, water supply systems.

In Algeria, water was usually found to be contaminated, evenin the large cities. Bacteriologic and chemical examinations were made regularlyin the public health laboratories and the Pasteur Institute of Algeria, butthese tests failed to remedy the situation. In general, the French and native

¹²Interview, Lt. Col. Douglas Hesford,MSC, with Dr. (formerly Major, MC) Louis B. Simard, 26 Aug. 1962.

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populations showed little concern over the purity of theirwater since their main beverage was wine. Whatever water they purchased fordrinking was bottled and rarely contaminated. The American troops, however,whose daily consumption of water was great, were faced with problems.

Oran's civilian water supply, which also serviced thehotels and apartments housing U.S. officers, came from a hilltop reservoir thatoverlooked the city. Here, too, the water was nonpotable, mainly because it wasunchlorinated. This, explained the French city officials, was caused by theirinability to buy the necessary chlorinating materials. They pointed to achlorination plant that had been built but was lying idle. To solve the problem,the MBS Staff Engineer agreed to supply the needed chlorine.¹³ Oncechlorinated, the water had to be checked constantly to maintain its potabilitystandard; however, French laboratories in Oran were inadequate to perform thenecessary analyses and, once again, help was provided by the MBS laboratories.As a result, a close check was kept on the city water supply for both civiliansand military personnel.

Water also proved to be a problem for troop recreationalactivity in Algeria. American troops were not permitted to swim in fresh waterbecause of the presence of schistosome-carrying snails. Swimming was permitted,however, at the beach of Ain-el-Turk, 10 miles west of Oran, where a large numberof Army installations had been established. A water analysis showed that theMediterranean was polluted for a radius of almost 1 mile from a sewage outlet inthe vicinity, but that, past this restricted area, the water was uncontaminatedand, therefore, safe for swimming.

Civilian establishments-By American standards, most ofthe civilian establishments frequented by U.S. troops in French North Africa,from bars to barbershops, were unsuitable for use because their cleaning methodswere unsanitary.

Restaurants proved to be a particular problem. Except for theHotel Continental, which the Army immediately occupied after the landings inOran, the city's restaurants were particularly filthy. Initially, allrestaurants were placed "off limits" for U.S. military personnelbecause the water used for washing dishes, glassware, and eating utensils wascold untreated tap-water. Screening was virtually nonexistent in theserestaurants and flies swarmed throughout their kitchens. The bars, too, were putoff limits because of the fear that diseases would be contracted from drinkingglasses rinsed with unchlorinated water. At first, the restaurant and bar ownersresisted any suggestions that their sanitary conditions be improved,disregarding such requests as "crazy" demands. When the Army began totake action by declaring their establishments off limits, the protests began.The typical complaints that necessary chlorine and screening materials wereunavailable soon followed.

¹³See footnote 12, p. 269.

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To alleviate the problems and answer the complaints, the Armydistributed chlorinating materials in sufficient quantities to restaurant andbar owners on an individual basis so that all eating and drinking apparatuscould be sterilized. Screening materials, always scarce, were obtained inlimited quantities with the assistance of the Staff Quartermaster and were givento the restaurant owners.

Restaurants were not placed "on limits" again untiltheir owners complied with Army regulations and used chlorine in their washwater. Those not meeting acceptable standards retained their undesirable offlimits status. Needless to say, owners were quick to respond, and most of therestaurants were on limits by the end of 1943. Periodic checks were made on thecooks, food handlers, and eating facilities to insure that some sort of sanitarystandards were being maintained. Stool cultures of the food handlers of somerestaurants were taken to see if they were carriers of disease, and thesecultures were examined in hospital laboratories and in the 15th MedicalLaboratory in Oran.

The French civilian authorities did relatively little to aidthe restaurant inspection program, remaining apathetic towards the project andleaving most of the work to the U.S. Army. After a time, the Army, finallyrealizing that the civil officials would do nothing, no longer bothered tocontact them and just did the work themselves.¹⁴

As with the restaurants, sanitation in the civilianbarbershops was poor. As a rule, barbers did not sterilize their instruments andused feather dusters to brush away hair after cutting. U.S. Army medicalinspectors were especially critical of these practices and tried to persuade thebarbers to discontinue use of the dusters and begin sterilization of theirinstruments. Once again, resistance was met. Establishments owned byuncooperative barbers were placed off limits, but even this measure provedsomewhat unsuccessful. American troops, especially combat troops in the basesections for rehabilitation leave, ignored the restrictions. Consequently, thenumber of Military Police had to be increased to keep the U.S. soldiers out ofthe barbershops designated as unsanitary. Finally convinced that the U.S. Armymeant to enforce its regulations, most of the barbers began to comply with theArmy's demands, and their shops were again placed on limits.

Sanitary training of troops.-Despite the continuing effortsto improve the sanitary environment for American troops, the same problems ofsanitation remained throughout the war. But it was not only the French andnative civilians who opposed the medical protective measures. Lack ofcooperation among the American troops themselves contributed significantly tothe problem. The troops continually managed to ignore the directives designed toprotect their health. It was especially difficult to indoctrinate them in theperils they faced if they ate certain foods or frequented unsanitary hotels andrestaurants.

¹⁴See footnote 12, p. 269.

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F IGURE 34.-An Arab laborer distributes fertilizeron a potato crop on a farm near Algiers, in November 1943.

An example of how the troops were told to do one thing butdid another occurred in 1943 and concerned the raw vegetables that grew in thegardens around Oran. Because of the North Africans' habit of using humanexcrement for fertilizer (fig. 34), amebiasis was quite prevalent among thenative population. French reports indicated that 3,000 to 4,000 cases weretreated each month. As a consequence, American troops were instructed not to eatfresh fruit and vegetables, especially lettuce, since chlorine did not kill theinfecting amebae. Many soldiers, however, ignored all directives and ate theproscribed fruit and vegetables, and suffered the inevitable results.

The situation deteriorated to such a degree that even the MBSSurgeon's office had little influence upon troops directly under its advisorycontrol in matters of enforcing sanitation. The Surgeon had little or noauthority over the combat troops and even the Communications Zone soldiers, withwhom his office dealt primarily, paid little heed to his warn-

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ings. The few public health measures that had any effectwhatsoever were usually instituted at lower echelons by the battalion surgeonswho had direct contact with the troops.¹⁵

In many instances, Command did not give sufficient support tothe sanitation program and, at other times, training in health and sanitationwas too infrequent to be of any real value. This spirit of noncooperation wasnot limited solely to U.S. troops; French and British soldiers were alsocharacterized by a similar nonchalance in matters of sanitation and personalhygiene.

Recognizing these obstacles to public health, Colonel Hutterarranged for an international symposium on public health for American, British,and French participants. This symposium was held in Oran on 6 November 1943,almost a year after the North African invasion.

An outcome of the meeting was the establishment of sanitarydisplays in various large cities and in centers of troop population. Althoughthese displays were intended primarily for the training of the troops of thethree nations, civilians were permitted, and actually encouraged, to see them.Among the exhibits were field sanitary devices, many of which could have beenused to good advantage by the indigenous population had they been able to securethem or the materials to construct them. But, as was the situation throughoutNorth Africa, these devices were casually ignored.

Supplies for civilian public health.-It is unlikelythat much preinvasion planning was done to determine how essential medicalsupplies for the civilian population would be obtained and dispensed by thevarious base sections once ashore. Originally, medical supplies were expected toreach the operational areas in prepacked supply units directly from the Zone ofInterior or from the base of operations. This never fully materialized, and,consequently, the burden fell largely on AFHQ.¹⁶

A major supply system, which was established in December 1942and revised in early 1943 with Allied membership, was the NAEB (North AfricanEconomic Board) which eventually became the North African Joint Economic Missionon 1 June 1944. The board was responsible for importing all supplies that weredeemed necessary for civilian use by the French Provisional Government. The NAEBalso initiated, formulated, and established policies, plans, and programs forcivilian economic matters in North Africa. Later, the board's duties wereexpanded to include the actual purchase and distribution of necessarycommodities for civilian use in matters of public health and relief underLend-Lease.

On 26 February 1943, Drs. Dudley A. Reekie, Dorland J. Davis,and Michael L. Furculow (officers of the U.S. Public Health Service with thegrade of colonel) were assigned to serve as medical officers with the Military

¹⁵lnterview, Lt. Col. DouglasHesford, MSC, with Dr. (formerly Major, MC) Mortimer M. Cohn, 6 May 1962.
¹⁶Medical Department, United StatesArmy. Medical Supply in World War II. Washington: U.S. Government PrintingOffice, 1968.

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North African Mission. Their duties included assistance inthe procurement and distribution of medical supplies for the civilian populationand service as medical advisers in relief and rehabilitation activities.

These officers arrived in Algiers in late March and wereassigned as the medical section for the NAEB's Division of Public Welfare andRelief under Allied Force Headquarters. Dr. Davis immediately began apreliminary survey of the need for medical supplies among Morocco's civilianpopulation, and later conducted a similar survey of Oran upon request of cityofficials.¹⁷

In the Mediterranean Base Section, the Medical Section'soperating instructions specifically stated that civil authorities would beassisted "wherever possible by directing their efforts through the properchannels to secure allotted funds and materials from the NAEB."¹⁸

In 1944, the MBS Supply Section became extremely active,assuming the responsibility of maintaining the theater reserve while activelyparticipating in the collection of medical supplies for operations in Italy andsouthern France. During the year, more than $300,000 worth of supplies wereissued to the French while the equivalent of little more than $52,000 insupplies and service was received in return.¹⁹

COMMUNICABLE DISEASES

The planning for the preventive medicine program to beundertaken by the AFHQ and NATOUSA Medical Section concentrated on four majorareas: respiratory diseases, intestinal diseases, malaria, and venerealdiseases. Also considered was the possibility that serious outbreaks of typhus,epidemic hepatitis, plague, and cholera might arise to threaten the health ofthe Allied troops in the area, consequently impairing the Allied war effort inNorth Africa.

With these general considerations in mind, policies andprograms were formulated to obtain the necessary personnel and equipment tocombat these conditions, with emphasis being given to the training of medicalpersonnel at all levels.

From 1943 to 1945, five outbreaks of epidemic proportionswere experienced, all of which produced high noneffective rates. Intestinaldiseases and malaria were prevalent in the summer of 1943. These were followedby epidemics of infectious hepatitis and trenchfoot in the winter of 1943-44with a recurrence of hepatitis during the following winter. Venereal disease,which became prevalent almost as soon as the troops arrived, remained a problemthroughout the campaign.²⁰

¹⁷Williams, Ralph Chester: The United StatesPublic Health Service, 1798-1950. Washington: Commissioned OfficersAssociation of the United States Public Health Service, 1951, pp. 695-697.
¹⁸Standing Operating Procedures,Medical Section, Headquarters, Mediterranean Base Section, Office of theSurgeon, dated 19 May 1943.
¹⁹Medical History of the MedicalSection, Headquarters, Mediterranean Base Section, 1944.
²⁰Report, Preventive Medicine Officer,Office of the Surgeon, MTOUSA, 1945.

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Of the communicable diseases in the theater, malaria provedto be the most serious although hepatitis was not far behind. Their importanceresulted not only from the number of days lost but also from the fact that, whenkey personnel were afflicted, the resulting long periods of disabilityfrequently disrupted organization and operations.

Respiratory, intestinal, and venereal diseases were lessimportant. However, from 1943 to 1945, the incidence of venereal disease stillcreated a problem of major proportions.

Intestinal Diseases

Dysentery and diarrhea.-The North African theater comprisedan area in which the filth diseases of man had been prevalent for generations.The poor sanitary habits of the local population combined with inadequate, andsometimes nonexistent, sanitary facilities to make outbreaks of dysentery anddiarrhea commonplace. Waste disposal was seldom practiced, flies abounded, andscreening was scarce in even the most modern buildings. These conditions werecomplicated by the fact that unit and individual troop training in sanitationwas usually deficient. As a consequence, serious outbreaks of these intestinaldiseases occurred in 1943 from May to July, particularly among the newly arrivedunits and in the replacement depots. In the more seasoned units, the letdownfollowing the Tunisian campaign and the onset of the fly-breeding season wereundoubtedly responsible for some outbreaks.

Initially, the local French health authorities, both civiland military, did not consider that bacillary dysentery would constitute athreat to the U.S. troops in North Africa. However, when Colonel Long, U.S.Consultant in Medicine (fig. 35), and the British consulting physician andsurgeon inspected British hospitals in January 1943, numerous bacillarydysentery cases involving American patients were noted. In general, the diseasewas found to be a direct result of highly unsanitary practices. Colonel Longrecommended to the Deputy Surgeon of the Allied Force that rigid sanitarydiscipline be maintained in all units. This could be done, he noted, by makingevery effort to prevent officers and enlisted men from purchasing raw vegetablesand certain fruit from unauthorized sources. He further suggested that allcivilian mess attendants, cooks, food handlers, and other food service personnelbe subjected to three bacteriologic and urine examinations to rule out thepossibility that they could be carriers of typhoid, paratyphoid, or bacillarydysentery.²¹

From 24 to 26 March 1943, the prevalence of bacillarydysentery was discussed by the Committee on Hygiene and Epidemiology of theTechnical Section for Public Health in the French High Commissioner's Office.

²¹Long, Col. Perrin H., MC: AHistorical Survey of the Activities of the Section of Preventive Medicine,Office of the Surgeon, MTOUSA, 3 January to 15 August 1943.

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F IGURE 35.-Col. Perrin H. Long, MC, Consultant in Medicine, Allied Force Headquarters. (Photograph, courtesy of National Library of Medicine.)

Dr. Gaud, the Commissioner for Health in Morocco, commentedthat bacillary dysentery did not seem to be very common in the civil populationin Morocco, with but 10 to 106 cases being reported per month, the low being inFebruary and the peak in October. Colonel Jame, the departmental surgeon ofMorocco, concurred with Dr. Gaud, reporting that the disease was similarlyuncommon in French troops and occurred mainly in new recruits.

Dr. J. Grenoilleau, Director of Public Health in Algeria,noted that there appeared to be little amebic or bacillary dysentery in Algeria.General Gauthier, 19th French Corps Surgeon, stated that his corps had not beentroubled much with dysentery for 4 years. Chef de M?decin Chitron of the FrenchNavy noted that "dysentery was practically nonexistent in navalpersonnel."²²

Despite such reassuring statements from the French healthofficials, Colonel Long believed that bacillary dysentery would become a problemas soon as fly breeding commenced since the sanitation throughout the area wasso inadequate. Preventive measures were taken wherever possible, but be-

²²See footnote 21, p. 275.

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cause of equipment shortages, outbreaks of bacillarydysentery among U.S. troops occurred simultaneously throughout North Africa inearly May when the flies multiplied. Diarrhea and dysentery became prevalent inthe Eastern Base Section on 17 May, 2 days later in the Atlantic Base Section,and by 24 May in the Mediterranean Base Section. In all, 57,000 cases werereported throughout French North Africa in 1943.

In Oran, an attempt to locate all possible sources of fliesamong the civilians or within the city itself was started with the 60-man Arabwork force that had been assembled by the MBS Surgeon. However, this attemptsoon failed because of lack of funds. All street cleaning and washing stoppedalthough an MBS engineer inspected any reported areas of fly breeding.

An attempt to persuade the civilian population to clean theirown areas was once again unsuccessful although some of the uncooperativeindividuals were reported to civilian authorities who tried to aid the U.S.health officials.²³

Typhoid and paratyphoid fevers-During 1943, the 62typhoid cases and 45 paratyphoid cases which occurred among NATOUSA militarypersonnel were traceable to food handlers or to unapproved water sources.

Because typhoid fever was prevalent in the indigenouspopulation of North Africa and there were many suspected carriers of thedisease, it was considered advisable to give stimulating doses of 0.5 cubiccentimeter of typhoid-paratyphoid vaccine every 6 months to the U.S. forces inNorth Africa.²⁴

In the Mediterranean Base Section, the incidence of typhoidfever among the civilian population was reduced gradually from 747 cases in 1942to 641 in 1943, and to 520 by November 1944. In October 1944, typhoid feverthreatened to assume epidemic proportions, with 242 reported cases. However, theflurry was short-lived.²⁵U.S. troops were completely protected byextraordinary precautions, such as declaring all bars and restaurants offlimits, prohibiting eating in private homes, and close surveillance of allcivilian employees. Few typhoid vaccinations were given to civilians by localhealth agencies throughout 1944, but all U.S. civilian employees were immunizedagainst the disease, as well as against typhus and smallpox.

In general, intestinal disease declined sharply afterintensive sanitary training and discipline were imposed. Training in propersanitary methods was included in all unit training programs and in receptiondepots. New units arriving in the theater were contacted soon after landing andwere advised on the disease situation and the importance of institutingpreventive measures.

As screening became available, it became possible to encloseall kitchens, latrines, most messhalls, and contagious wards of hospitalsthroughout the

²³See footnote 12, p. 269.
²⁴NATOUSA Circular No. 59, dated 13Apr. 1943, Section II.
²⁵See page 13 of footnote 19, p. 274.

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theater. In 1944 and 1945, screening and other suppliesbecame more readily available, and the rates of intestinal disorders sharplydeclined.

Circumstances often forced U.S. units to bivouac nearcivilian centers or French military installations with native colonial troopswhose sanitary standards were extremely low. Allied Military Governmentpersonnel (and later the Allied Military Control Commission) in coordinationwith French officials were able to get cooperation from the civil population.Eventually, a semblance of proper sanitary disposal was developed in most areaswhere U.S. troops were operating. Direct liaison with commanders and medicalpersonnel in foreign military units then resulted in a general uplifting ofsanitary standards among their soldiers.

Insectborne Diseases

Malaria.-Although malaria was prevalent in French NorthAfrica, the seasonal distribution was not the same throughout the North Africantheater. Generally, probably as a result of relapsing cases, the clinicalincidence began to increase slightly in April 1943. The upswing from newinfections appeared in May and continued to rise steeply in June and July,reaching a peak in late July or in August. The rate usually declined inSeptember-in some areas, there was a modest secondary peak in October-anddropped abruptly to its lowest point in March.²⁶

The malaria control program was one of the largestundertakings of the NATOUSA Medical Section. From the beginning of 1943 to latespring, malaria control progressed through various stages of planning, liaison,and general development which necessarily preceded the physical organizationphase.²⁷

A Malaria Advisory Board was established in 1943 by Brigadier(later Maj. Gen.) Ernest M. Cowell, RAMC, Director of Medical Services, AFHQ,under Brigadier E. R. Boland, the British consulting physician. American,British, and French malariologists and major combat command representativescomprised the board. The U.S. representative was Colonel Long, the NATOUSAMedical Consultant and, later, NATOUSA Preventive Medicine Officer andMalariologist.

Colonel Long laid the groundwork for the malaria controlprogram by arranging conferences with British and French malaria controlrepresentatives. These representatives agreed on an arrangement with civilianhealth agencies whereby the local agencies would assume responsibility for thebulk of the environmental malaria sanitation in extra-military areas.

On 9 June 1943, Col. Loren D. Moore, MC, commander of the 2655th Malaria Control Detachment, was attached to NATOUSA's Medical Section Headquarters for duty as theater malariologist. However, he was soon in-

²⁶Russell, P. F.: A Note on the Epidemiology of Malaria in NATOUSA. M. Bull. North African Theater of Operations 1: 29-30, 1944.
²⁷Medical Department, United StatesArmy. Preventive Medicine in World War II. Volume VI. Communicable Diseases:Malaria. Washington: U.S. Government Printing Office, 1963, pp. 249-302.

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capacitated through illness and was replaced on 24 July byCol. Louis L. Williams, Jr., of the U.S. Public Health Service. A week later,Colonel Williams was stricken with coronary disease. On 21 September, Col. PaulF. Russell, MC, became theater malariologist, a post he held until 4 March 1944, when he left to become chief of the Malaria Control Branch of the AlliedControl Commission. His replacement was Lt. Col. Justin M. Andrews, also of theU.S. Public Health Service, who originally had been appointed assistantmalariologist to Colonel Moore on 9 June 1943.

On 23 February 1943, the Deputy Theater Commander requested ajoint conference of British and American military and French military and civilmalaria authorities so that the needs of the French could be ascertained while,at the same time, obtaining their cooperation in malaria control. Afterconsiderable discussion, which accomplished little, a small committee wasappointed to determine what supplies the French actually needed.

A letter was issued by the NATOUSA Surgeon on 7 May 1943,which authorized certain U.S. commanders to issue supplies to the FrenchDirector of Public Health and to expend up to 500,000 francs (approximately$11,400) per month for malaria control work. This policy was dictated by thepresence of large numbers of troops, many under bivouac conditions, scatteredthroughout the country, and by the offer from civilian health agencies, who wereacquainted with the terrain and the malaria problem, to assist in malariacontrol if provided with the necessary measures and equipment. Theresponsibility of the local civilian agencies was to encompass all anophelinebreeding areas outside the limits of U.S. military installations. In most areas,excellent results, benefiting both civilian and military personnel, wereachieved by the arrangement.

A French antimalaria program was launched in Oran in April1943, with Dr. Georges Rehm as its director. This civilian agency had beenauthorized a maximum monthly expenditure of $500,000, but actual expenses neverexceeded $70,000 in a single month. Nevertheless, problems were omnipresent. Dr.Rehm was rarely able to resolve mounting labor troubles and was able to employan adequate work force in relatively few areas. A satisfactory drug supply forthe treatment of malaria was difficult to arrange, and drugs for suppressivemedication were never available. The NAEB supplied the only available drugs. Inseveral localities, mosquito control projects were either seriously impeded orstubbornly opposed by municipal officials or certain influential colonials. As aresult, the Army was forced to assume full responsibility for such operations inand around areas where American troops were stationed.

A shortage of military malaria control vehicles added to thedifficulties. Even in some places where ample labor was available, there was notransportation to the job site. The civilian health agencies, faced withdifficulties in labor procurement, found themselves with a lack of sufficientlytrained personnel to supervise work operations. Some of the agencies were

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plagued by indirect and time-consuming methods of operation.In other instances, military malaria control groups had to take over civiliancontrol work to protect the troops.

Committees composed of representatives from variousinterested agencies met regularly in the base sections for a mutual exchange ofinformation on antidisease activities, with particular emphasis on malaria, andto coordinate plans for future work.

A lack of trained malariologists in the theater during muchof 1943 hampered the effectiveness of the antimalaria program. This deficiencyalso contributed to a disabling lack of cooperation and unification of purposebetween special antimalaria units, between military and civil organizations andprograms, and between Allied Forces agencies.

Experience indicated that, had a trained malariologist beenassigned to each base section who was permitted to devote his entire time to thesupervision of the malaria control program and who could establish and maintainliaison between all agencies involved in the program, many of the difficultiesencountered would have been minimized and more effective results would have beenachieved.

Casual native labor, recruited through either civil healthagencies or military active labor organizations, performed most of the physicallabor in North Africa. Italian POW's (prisoners of war) were also used in thetheater (fig. 36), except in the Atlantic Base Section. Soldier labor from asanitary company was used in the Mediterranean Base Section. Of all laborsources, POW's were found to be most satisfactory.

As the danger to the Mediterranean lifeline diminished in thesummer and fall of 1943, emphasis shifted northward and the Mediterranean BaseSection became the major staging area for the invasion of Sicily and the Italiancampaign. Several ABS malaria control and survey units were soon transferred tothe Mediterranean and Eastern Base Sections and, later, to the newly activatedPeninsula Base Section in Italy.

Therefore, by agreement with French authorities, on 27 August1943, all control work previously done by U.S. Army units was assumed by theFrench Malaria Control Service, with particular emphasis being placed on thework in areas where U.S. personnel were still stationed. These areas were thecities of Casablanca and Fedala and the airports at Marrakech, Ras E. Mar (F?s),and Sal?.

On 1 November 1943, all American subsidies for French malariacontrol work were discontinued, and the difficult and apparently never-endingtask of malaria control was left in the hands of the French civilian healthagencies. Thereafter, all malaria supplies needed by the agencies were obtainedthrough Lend-Lease channels.

Typhus fever.-The months of planning and preparation thatpreceded Operation TORCH included the consideration that French North Africawould be the first typhus-infected area invaded by U.S. troops in World

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F IGURE 36.-A work party of Italian prisoners of war digs a drainage ditch for malaria control in the Mediterranean Base Section, 1943.

War II. The lack of adequate medical intelligence on typhusfever in North Africa was, in part, responsible for the establishment of theUnited States of America Typhus Commission by Executive order of PresidentFranklin D. Roosevelt on 24 December 1942.²⁸

Unfortunately, the medical intelligence information receivedby AFHQ's Medical Section concerning the occurrence of typhus fever was soonfound to be incomplete. Based on a report of only 4,000 typhus fever casesduring the winter of 1941-42, when in reality there had been more than 64,000cases by the end of 1942, the British decided not to vaccinate their troopsagainst the disease. This decision was to become a source of great anxiety. AFHQ'sAmerican component, on the other hand, had been immunized before going overseas.²⁹

²⁸Medical Department, United States Army. Preventive Medicinein World War II. Volume VII. Communicable Diseases: Arthropodborne DiseasesOther Than Malaria. Washington: U.S. Government Printing Office, 1964.
²⁹See page 24 of footnote 21, p. 275.

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Upon the arrival of Allied Forces in North Africa in November1942, the typhus situation did notseem too disturbing. A few hundred cases existed in Morocco and a somewhatlarger number in Algeria; but, because of a lack of medical liaison between theAllied Forces and a partial disruption of liaison between the various Frenchhealth facilities as a result of the invasion, indications that a major epidemicof typhus fever among the civilian population was mounting in North Africaescaped attention until January 1943.³⁰ At that time, the correlation ofreports from Morocco, Algeria, and Western Tunisia clearly showed that theincidence of typhus fever was rapidly rising. At the same time, reports oftyphus fever breaking out among the unvaccinated British troops began to reachAFHQ's Medical Section.

The local situation was disturbing. The native population wasriddled with typhus as were native troops serving in the French Army. Thesesoldiers were in isolated wards in French military hospitals. Their high rate ofincidence was attributable in part to their custom of carrying their wives,family, and livestock with them as they traveled, thereby creating unusuallyclose and congested living conditions which consequently permitted the easytransmission of lice.

In the Mediterranean Base Section, which encompassed most ofAlgeria and was headquartered in Oran, the French Board of Health, from Januaryto March 1943, gave live typhus vaccine to approximately 37,000 Arabs among whomthe disease was especially prevalent, with further inoculations starting inDecember. Live vaccine was used because of the difficulty in giving more thanone inoculation. MYL powder, a louse powder consisting of pyrethrins as atoxicant, mixed with a synergist, an ovicide, an antioxidant, and a pyrophyllitepowder, was also available for delousing Arab typhus contacts, and the Frenchset up centers for delousing Europeans.

In 1942, 1,064 cases of typhus fever were reported amongcivilians. This number dropped to 298 the following year, and then fell to aminimum of seven cases for January through November 1944.

Since typhus was endemic to the area, French civiliandoctors, working out of the MBS Surgeon's office, inspected bars, restaurants,and barber-shops, resulting in a marked improvement in their general cleanlinessand sanitation. However, personal hygiene among the natives had made few, ifany, forward strides since the arrival of U.S. troops.

During 1943, six cases of typhus fever were reported in MBStroops. These cases were mild, atypical, and nonfatal. All of the men had beenimmunized, but two of them had not received booster shots.

In September 1943, a louse survey was made, and louse countswere made in three representative MBS units. No lice were found, but eggs werepresent on the clothes of one man. During bimonthly inspections, few men

³⁰See page 25 of footnote 21, p.275.

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were found to be infested. In fact, the problem of lousecontrol among MBS troops was minimal, mainly because of adequate facilities forgood personal hygiene.³¹

It is appropriate to include here a brief account of thedevelopment and use of a new method to eliminate louse infestation and theconsequent control of epidemic typhus fever by dusting individual members ofcivilian and military populations with lousicidal powder. The basic method andits variations were devised, tested, and proved effective in North Africa in1943 largely by American military and civilian personnel, with the support ofmedical and sanitary establishments of the Allied Forces of the United Statesand Great Britain. Personnel from the Offices of the Chief Surgeons fostered thenecessary relationships and arrangements with military units and nativegovernments, communities, and institutions. Elements related to Civil Affairsand Military Government in Egypt and Algeria also collaborated in the work.

Application of the results was not so much needed in NorthAfrica but was urgently needed in Italy in the winter of 1943-44, when adangerous epidemic of louseborne typhus in devastated, overcrowded Naplesthreatened the advance of the U.S. and British Armies in the Italian campaignagainst the Germans. The prompt eradication of that epidemic was as spectacularas it was protective, and this achievement is regarded as one of the mostbrilliant and important triumphs of preventive medicine.

The final experimental work in North Africa was done duringthe period from March to December 1943 by members of the staff of the TyphusCommission in Cairo and by the Typhus Team of the Rockefeller Foundation HealthCommission. This work was directed by Dr. Fred L. Soper (formerly attached tothe Typhus Commission), with the constant support of Colonel Stone, ChiefPreventive Medicine Officer of NATOUSA, in Algeria. In addition, invaluableassistance was given by Dr. Sergent, director of the Pasteur Institute ofAlgeria.

Both groups showed that the application of the louse powders,MYL and DDT, to the garments and skin of persons fully clothed killed adult liceand all stages of the instar. As the insecticide remained in the fabric of theclothing, it exerted a persistent louse-inhibiting action for more than 2 weeks.The powder was applied by blowing it with garden rose dusters underneath theclothing, upon the skin, into whatever underclothing was worn, and into bedding,hats, and hair (fig. 37).

In Algeria, Dr. Soper's team, which also included Drs.William A. Davis, Floyd S. Markham, and Louis A. Riehl, dusted thousands oflouse-infested Arabs in the village and commune of L'Arba, at the Maison Carree,which was a large civil prison near Algiers, and at a prisoner-of-war camp inthe vicinity of Algiers. Careful counts of lice in the clothing and on thesubjects' bodies were made at various intervals before and after the dusting.

³¹Annual Report, Office of theSurgeon, Mediterranean Base Section, 1943.

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F IGURE 37.-Medical Section personnel of the Mediterranean Base Section in Algiers treat Arab children with new insecticide powder designed to kill typhus lice.

The results showed that, in a closed population group whereeveryone is treated and then protected from reinfestation, two treatments ofeither MYL or DDT (preferably 10-percent DDT, a chlorinated phenolic compound,in pyrophyllite powder) at 2-week intervals could be expected to immediatelyreduce lousiness and prevent a dangerous degree of infestation during a 3-monthperiod.³²

Venereal Disease

There is no indication that much advance theater-levelplanning for VD (venereal disease) control was considered before the invasion ofNorth Africa. While a preventive medicine officer was included on the AFHQstaff, there is no mention in the official records of any VD control policy.

³²(1) Soper, F. L., Davis, W. A.,Markham, F. S., Riehl, L. A., and Buck, P.: Louse Powder Studies in North Africa(1943). Arch. Inst. Pasteur d'Algerie. 23: 183-223, September 1945. (2)Soper, F. L., Davis, W. A., Markham, F. S., and Riehl, L. A.: Typhus Fever inItaly, 1943-1945, and Its Control With LousePowder. Am. J. Hyg. 45: 305-334, May 1947. (3) Wheeler, C. M.: Control ofTyphus in Italy 1943-1944 by the Use of DDT. Am. J. Pub. Health. 36: 119-129,February 1946. (4) See footnote 27, p. 278.

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F IGURE 38.-Military Police patrol an "off limits" area ofAlgiers.

Apparently the only decision made was to make no decisionuntil after the landings. At such time, actual experience would be the guide.³³

Once ashore, the various units instituted and carried outtheir own control measures in their particular areas, a system which continueduntil January 1943. On 3 January 1943, Colonel Long, AFHQ's Consultant inMedicine, and Lt. Col. John W. R. Norton, MC, Preventive Medicine Officer, beganto coordinate the various aspects of the VD control program. At a jointconference with British and American health officers in Algiers in January, local French representatives statedthat the incidence of venereal disease in the native population was very greatand that clandestine prostitutes, of whom there were many, were almost alwaysinfected. The health officials contended that the police and medicalsurveillance (fig. 38) then in effect rendered most of the"registered" prostitutes, both on the streets and in brothels,relatively free from the disease. This fact, they concluded, should convince theAllied medical officers to support and maintain a system of controlledprostitution.³⁴

³³See footnote 11, p. 268.
³⁴Report, Lt. Col. Perrin H. Long, MC, 28 Sept. 1945,subject: Historical Report Upon Activities for the Control of Venereal Diseasein the North African Theater of Operations From 3 January to 8 March 1943.

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On 8 March 1943, Lt.Col. (later Col.) Leonard A. Dewey, MC, was assigned as full-time theater VDControl Officer with responsibility for control and treatment. Six additionalofficers were assigned later that month for duty on the various base sectionstaffs. All major theater organizations and major cities (with the exception ofAlgiers, which was under British control) were thus provided with the servicesof a trained and experienced VD control officer. This principle, inaugurated inNATOUSA, was to become an integral part of the Preventive Medicine programthrough the Sicilian and Italian campaigns.

Control by U.S. authorities.-Because of the high rate ofinfection among the indigenous population, venereal disease soon became thechief problem among U.S. troops, especially those stationed in the MediterraneanBase Section. Although estimates of the rate of venereal infection amongEuropean and native prostitutes varied, this rate reached extraordinaryproportions throughout the theater. In Oran, a French physician, who handled theexaminations daily, estimated that probably 95 percent of the women he inspectedwere infected at the time they were examined. Another 3 percent were justrecovering from infection, and the remaining 2 percent would probably contract avenereal disease within the week before the next examination. Apparently, therate of infection remained constant whether the prostitute was a pandererwalking the streets or a woman operating in a brothel.

U.S. officials estimated that the average prostitute in abrothel would usually accommodate six soldiers per hour and about 50 or 60 per8-hour period. This situation made disease control almost impossible. Althoughprostitutes in the larger cities insisted that U.S. troops wash themselves anduse prophylactics, those in smaller towns were not so demanding. Generally, themadams of brothels urged their girls to conduct a cursory visual examination ofeach customer, looking for chancres, syphilitic lesions, and venerealdischarges. If any were found, the man was refused. Of course, the visualexamination was useless in the chronic stages of gonorrhea or syphilis so thespread of infection was rampant.

These circumstances cast considerable doubt on the value ofthe French examination program, which called for a cursory skin inspection atlocal health centers. A prostitute servicing 50 men a day would haveaccommodated approximately 350 men between her weekly examinations.Consequently, if she contracted a venereal disease immediately after anexamination, she could infect 350 men in the interval before her nextexamination, at which time hopefully the disease would be discovered.

MBS control measures-Shortly after the activation ofMediterranean Base Section, the VD Control Officer, Capt. (later Maj.) MortimerM. Cohn, MC, inspected Oran and its surrounding environs. His majorrecommendation, which he continually repeated in letters to the MBS Surgeon, wasto place all brothels off limits because of control difficulties. Cohn reasonedthat declaring them off limits would reduce a prostitute's clientele

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from six men to one man an hour since she would have tosolicit her trade. Reducing opportunities of contact, Cohn argued, wouldcorrespondingly reduce rates of infection.

Invariably, these reports were returned, with the remarkthat the prohibition could not be put into effect. The common reason given wasthat, if prostitution was outlawed, the French women in the theater might bemolested by U.S. troops, a situation which could adversely affectFranco-Americanrelations. Since France was considered an ally, U.S. military policy dictatedagainst any action which might strain relations or weaken the joint war effort.Nevertheless, some instances of molestation did occur despite the controlledprostitution program.

To reduce contagion among U.S. troops, Colonel Hutter, theMBS Surgeon, had established prophylactic stations throughout his base section.Set up at the entrance to each red light district, these stations were manned byMedical Section aidmen, sometimes with local civilian assistance. However, astroop strength grew, the incidence of venereal disease increasedproportionately.

The VD control program in the Mediterranean Base Section wasintensified in 1944 and received good cooperation from the French civilauthorities. A VD clinic operated by civilian doctors employed by the MBSSurgeon continued to function and gradually improved its procedures. Allprostitutes picked up by the vice squads were examined, and those found infectedwere isolated at a French State Board of Health dispensary until cured.Beginning in October 1944, the French police arranged to have infectedprostitutes from brothels included in the isolation policy.

Cooperation with civil agencies-Opinion on thetypeand spirit of cooperation received from local public health agencies in NorthAfrica varies. On one hand are those who feel that the civil agencies did aswell as they could with what they had; on the other are those who decry analmost complete lack of cooperation between the local French authorities andU.S. medical units.

Colonel Long reported favorably on the work with civilauthorities, noting that the civil police departments had been cooperative incarrying out any program requested by Army authorities, including an effectivecampaign against clandestine prostitution which aided the enforcement of offlimits policies. The civilian health authorities were willing to cooperate, buttheir efforts actually proved of little value because of their "completelack of understanding of modern methods." In a few areas, local agencieswere willing to adopt some American methods and had instituted the beginningsof scientific VD control programs.³⁵

A dimmer view of civilian-military cooperation was taken byCaptain Cohn, who reported, "Rapport and cooperation with the Frenchcivilian medical authorities are notable only by their absence." As VDControl

³⁵Annual Report, PreventiveMedicine Division, NATOUSA, 1943.

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Officer, he contacted local physicians in towns outside Oran,and this process constituted the total exchange of information between hisoffice and the local French doctors. Cohn reported that he knew of no officialArmy or civilian agency in any city he visited where there existed adissemination of information concerning the contagious disease within that verycommunity.³⁶

As can easily be seen, two schools of thought existed in theVD control problem. Those who felt that the prevention of contacts was mostimportant urged the off limits classification of all brothels. The othersbelieved that contacts were unavoidable and that a regulated system of"approved" brothels with adjoining prophylactic facilities wasnecessary to reduce contacts in less desirable locations.

In November 1943, a survey of VD rates throughout NorthAfrica revealed that organizations maintaining an off limits and repressionpolicy had consistently lower rates by 15 to 40 percent than those units withsupervised and regulated prostitution. The survey also indicated that the chiefeffect of the regulated prostitution was to produce a larger number of sexualcontacts within the houses without materially reducing contacts on the outside.

All the blame for the chaos that engulfed the venerealdisease control program cannot be placed upon the theater prostitution policies,however. Once again, the incomplete planning that characterized most of the U.S.medical operations in North Africa arose to plague this already complicatedsituation. As a result, any beneficial medical developments that arose from theNorth African experience resulted more from trial and error than from priorplanning. Many man-hours were lost, especially in the early stages, which couldhave been saved by comprehensive and detailed planning and immediateimplementation upon arrival. While many of the control programs succeeded, toooften the problems of little cooperation, no coordination, and inadequate supplydoomed many worthwhile efforts that otherwise could have done much to check thevenereal disease problem and considerably reduce the casualties it created.

Respiratory Diseases and Tuberculosis

Respiratory diseases never reached epidemic proportions inNorth Africa. Generally, only mild infections occurred which followed thenonepidemic seasonal trends. Common respiratory diseases accounted for almost 90percent of the total respiratory diseases in NATOUSA in 1943, but since no trueepidemic, even of a localized nature, occurred, they never seriously affectedmilitary efficiency.

Tuberculosis had a high morbidity rate among the nativeinhabitants of Algeria, with glandular and skeletal forms especially common. Thehighest incidence was among Moslems and the lowest occurred in the

³⁶See footnote 15, p. 273.

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European population. Investigation by the Pasteur Instituteindicated that rates were higher in larger centers than in nearby villagesinhabited exclusively by natives.

To reduce its spread, the Pasteur Institute began vaccinatinglarge numbers of natives, especially children, with the BCG live vaccine, withgreat success. The use of the BCG vaccine was credited with a 50-percentreduction in the infant mortality rate in one series of 1,667 vaccinations, andsimilar results occurred thereafter.³⁷

Use of the BCG vaccine among U.S. troops was also considered,but The Surgeon General decided that, since its value was not fully established,it would be unwise to add an uncertain vaccine to a list of inoculations alreadyin use which had fully demonstrated their value.

Thus, the tuberculosis preventive program in NATOUSA remainedbasically the same as that in all theaters of operation; namely, early diagnosisof the disease through casefindings and hospitalization for isolation andtreatment in known cases.

Plague

Before the invasion of North Africa, plague was classified asa disease of potential military importance, but actual experience later revealedrelatively few cases. A total of 373 cases among the native population wasreported in March 1943 in Algeria alone, including 17 in Algiers. A rat survey ofthat city showed that the most common species of flea was the dangerous vector Xenopsyllacheopis, and that the number of fleas per rat varied from two to five. Thesestatistics, though inadequate for a complete picture of the situation, indicatedthat plague would be a constant threat to MBS armed forces.³⁸

Only a few cases of bubonic and pneumonic plague appeared inthe port area of Oran, however. U.S. military authorities were constantly tryingto convince the French to enforce rat control policies and to fumigate allincoming ships. This program, generally haphazard at best, proved to be ineffective.

SUMMARY

The concept of civil affairs was still relatively new at thetime of the North African invasion in November 1942. As a result, plans for apublic health program in the French possessions were sketchy at best. Despiteinnumerable health studies conducted by the Pasteur Institute of Algeria andextensive reports issued by the Algerian Government before World War II onprevailing health problems, U.S. medical officers were not fully apprised of thehealth problems that American troops would face in

³⁷See page 11 of footnote 4, p. 259.
³⁸See page 9 of footnote 4, p. 259.

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North Africa. Consequently, they were forced to meet byimprovisation the many emergencies and difficulties that soon arose.

Little high-level liaison was ever established with Frenchcivil authorities, and civil affairs public health activities could have endedin disaster had it not been for the work of Medical Department officers on thevarious base section staffs of NATOUSA as well as personnel from local Armymedical units and hospitals. Since the headquarters surgeons were limited tobroad policymaking and technical supervision, the lack of operational controlover subordinate commands left the preventive medicine program in the hands ofthe lower echelon medical officers.

As can be expected, this situation allowed the program'seffectiveness to vary from command to command, and thus much of the early workwas haphazard. Often the medical officers of lower commands were not trained inpreventive medicine and had to proceed on a trial-and-error basis. In someinstances, an unfamiliarity with the French civil and public health systems leftthe Army officers with no one with whom to effect liaison on health matters.

It was not until 1 March 1943, too late for the North Africanoperation, that the Secretary of War created a Civil Affairs Division as a partof the War Department Special Staff. Before the Civil Affairs Division everbegan to establish definite policies, the major problems in North Africa hadbeen met and partially resolved by trial and error.

At the lower levels, the conduct of civil affairs influencedthe health and welfare of the individual civilian and, in turn, determined thecooperation and assistance which the Allied Armies received from the civilianpopulation. It must be remembered that the Allied Forces recognized thesovereignty of France in North Africa, exerting less control over the indigenouspopulation than they would under a typical military government setup. The term"civil affairs" better represents the manifold and complex activitiesinvolving the Free French Government and the civilian inhabitants in NorthAfrica, and public health remained a major component of civil affairsactivities.

Perhaps the most significant point of the North Africanpreventive medicine campaign was that new methods were tried to meet unexpectedsituations. Despite the difficulties created by poor planning and inadequatesupervision, important lessons were learned, and those policies and proceduresthat proved successful formed the basis of the preventive medicine programslater used in Italy, France, and Germany.

Certain important points stand out:

First, the planning for any campaign must include well-laidpreventive medicine plans. Of course, such planning would be wasted unless theimportance of these plans could be impressed upon command. All unit commanders,from the highest to the lowest levels, must realize the importance of carryingout the recommended preventive medicine measures if the pro-

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grams are to succeed. Included in such planning should be theprovision to secure detailed analyses of the areas into which troops are goingand information on control measures.

Second, to carry out preventive medicine measures, suppliesmust reach troops promptly. These supplies include screening, sprays andsprayers, diesel oil, all current insecticides and rodenticides, and insectrepellents. This need was demonstrated by the high diarrhea and malaria rates in1943, which resulted from the failure to provide troops with fly and mosquitocontrol supplies.

Finally, provision must be made for immediate liaison withlocal government and local public health officials. Such coordination andcooperation are essential to a successful civil affairs public health program inan occupied area.

Of course, a civil affairs program is as dependent on men asit is on methods and materials. Well-trained medical personnel, acquainted withpreventive medicine procedures, are necessary for useful public healthactivities.

These points were demonstrated and proven in North Africa.Adequate preventive medicine programs were created, many for the first time,often through the ingenuity of the officers and men in overcoming the recurringhandicap that plagued their early efforts.

As the date of the Sicilian invasion drew near, planning forcivil affairs in Sicily and Italy was stepped up by Allied Force Headquarters.In May 1943, a small group of British and American officers assembled at Chr?a,Algeria, to prepare for the coming invasion on 10 July, undergoing training forthe Italian campaign. These planning and training groups originally were knownas Headquarters, Allied Military Government of Occupied Territory. After theItalian surrender on 8 September, the words "Occupied Territory" weredropped from the name. This group carried out the first civil affairs operationsas we know them today.

In late August 1943, a new group of officers arrived at TiziOuzou, a mountainous resort near the coast, east of Algiers. These men formedthe nucleus of the Allied Control Commission and later followed teams of theAllied Military Government into Italy to operate in occupied areas behind thecombat zone. The work of both groups on the Sicilian and Italian mainlands isincluded in chapter IX of this volume.

As attention shifted northward to Italy and Western Europe,the importance of French North Africa began to wane. With North Africa securelyin Allied hands, little more than a holding action was left for the troops whoremained behind. On 1 November 1944, NATOUSA itself passed out of existence,becoming the Mediterranean Theater of Operations.

In March 1945, the Mediterranean Base Section, which hadabsorbed the Atlantic and Eastern Base Sections 5 months before, was itselftransferred to the expanded Africa-Middle East Theater, and Headquarters,

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MTOUSA, was relieved of its responsibility in northern Africa. But by thattime, the fighting in North Africa was over and the concept of civil affairspublic health-which had had its inception there-was at last a workablereality.

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