CHAPTER IX
Sicily and Italy
Thomas B. Turner, M.D.
Section I. The Italian Campaign
BACKGROUND
Within the worldwide scope of Army operations in liberated and occupied territory, the Mediterranean Theater has a special significance. It was in this theater that the U.S. Army first encountered major problems of civil affairs in military government (CA/MG); here it tested traditional doctrine against the realities of total warfare, made necessary modifications, and developed policies and techniques which were later applied in other areas.1
In July 1942, the Combined Chiefs of Staff decided to launchan invasion of French North Africa as a prelude to an attack on "the softunderbelly of Europe." An Anglo-American AFHQ (Allied Force Headquarters)was soon thereafter established in London under the command of Lt. Gen. DwightD. Eisenhower to plan the invasion. On 11 September, a group of officers,graduates of the first class of the School of Military Government atCharlottesville, Va., reported for duty at AFHQ, and the Civil Affairs Sectionof that headquarters was activated under the direction of Col. Charles W. Booth.
As originally planned, this section included, among others, aspecialist division designated "Public Health." It should be noted,however, that no medical officer was ever actually assigned to this duty beforethe invasion of North Africa on 8 November 1942.
While the invasion touched off a succession of highly complexpolitical questions, the French territories, after a few critical weeks in whichthe relations between the invading forces and the local governments were in anexceedingly fluid state, remained essentially self-governing units. GeneralEisenhower was confronted with many problems of a high level political nature.Mr. Robert D. Murphy, the senior American State Department officer then in thetheater, assisted him in making decisions to cope with them. However, problemspertaining to medicine and public health were more specific in nature, and werenot considered to any significant extent at this time because primaryconsideration had to be given to resolving the many broad problems necessary tothe successful prosecution of the war.
1Komer, R. W.: Civil Affairs, and Military Government in the Mediterranean Theater, undated. [On file in the Office of the Chief of Military History, Department of the Army.]
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The absence of a medical officer in the CivilAffairs Section, AFHQ, was not, therefore, a matter for concern at this period.The original branches of the Civil Affairs Section were replaced by threeSubsections designated "Military," "Political," and"Economic," respectively. Most of the civil affairs personnel duringthis period were civilians, functioning through the North African Economic Boardand the OFRRO (Office of Foreign Relief and Rehabilitation Operation) FieldMission; several physicians, officers of the U.S. Public Health Service wereassigned to North Africa by attachment to the OFRRO Field Mission.
Tactical Situation
The initial move in the campaign against Sicily and Italy wasthe invasion of the Island of Pantelleria, east of Cap Bon, Tunisia, by Alliedtroops on 11 June 1943. On 10 July, assault forces of the 15th Army Group, whichconsisted of elements of the Seventh U.S. Army and the British Eighth Army,landed on Sicily. The landings were made on the southern and eastern shores fromSyracuse to west of Licata. British troops were on the right and U.S. troops onthe left.
As the British Eighth Army moved northward along the easternportion of the island and encircled Mount Etna, the Seventh U.S. Army sweptthrough the center to the western tip of the island, then moved eastward alongthe north coast, joined the British Eighth Army at Messina, and thus completedthe conquest of Sicily on 17 August 1943. The Eighth Army crossed the Strait ofMessina onto the beaches of the Italian mainland at Reggio, Calabria, on 3September, and steadily moved eastward and northward. The British 1st AirborneDivision landed unopposed at Taranto and Brindisi following the unconditionalsurrender of Italy on 8 September. The next day, the Allied Fifth Army invadedthe beaches at Salerno, south of Naples.
The Pattern of Civil Affairs in Sicily and Italy
The initial planning for civil affairs activities in Sicilywas carried out by Force 141, the forerunner of the 15th Army Group, but, as thedate for the invasion of Italy approached, a Military Government Section wasestablished at AFHQ to serve as the staff section for civil affairs for GeneralEisenhower. Col. (later Brig. Gen.) Julius C. Holmes, an American, was appointedas the chief of this section, with Lt. Col. (later Col.) Arthur T. Maxwell, aBritish officer, as the deputy chief. Although this group was not established intime to contribute much to the planning for the invasion of Sicily, its role inpolicy formulation and in the higher direction of operations continuallyincreased once the invasion was launched.
As will be pointed out later, this staff section neverincluded a medical officer, nor was responsibility ever clearly fixed on any oneAFHQ medical officer to concern himself with civil affairs.
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In point of time, the group designated "AMGOT"(Allied Military Government of Occupied Territories), which was organized as acomponent of Headquarters, 15th Army Group, antedated the Military GovernmentSection, AFHQ. This group carried out the first civil affairs operations alongthe lines we know today.
AMGOT officers went ashore with assault troops in Sicily onD-day (10 July 1943) and, again, with the invasion of the Italian mainland on 3September 1943. Effective civil government was reestablished locally, and theadministration of military government was placed on a territorial basis asquickly as possible. The original plans provided for the division of Italy intoseven Regions, as follows: I-Sicily; II-Calabria, Lucania, and Apulia; III-Campania;IV-Abruzzi-Lazio; V-Umbria-Marche; VI-Sardinia; and VII-Rome (see maps 8and 9). Later, regions were sometimes reidentified or consolidated as areasreverted to the Italian Government. Umbria was rejoined to Marche in Region V.2
The fall of Mussolini on 25 July 1943 immediately altered therelationship of the Allied Powers to the Italian Government and people, and thischange was accentuated further by the opening of armistice negotiations a monthlater. This led to the concept of two instruments through which Allied directionof Italian civil affairs would be accomplished: one, limited largely to thecombat zone, would be carried out through the existing AMGOT organization of the15th Army Group; the other, to exercise jurisdiction overthe rear areas, would be in the form of an ACC (Allied Control Commission).
Creation of what in effect were two control bodies led tojurisdictional disputes which, while perhaps not of transcending importance,were at times acrimonious and involved medical personnel as well as otherofficers. Although the limits of authority and responsibilities of these twocivil affairs organizations were often not clearly defined, an idea of how eachfunctioned will be gleaned from the following accounts.
PLANNING FOR THE OCCUPATION OF ITALY
Policy Questions
In planning the invasion of Sicily, two policy questionswhich had far-reaching effects on subsequent civil affairs operations werewarmly debated. The first was whether civil affairs was to be a jointAnglo-American responsibility or if each country was to administer separateparts of Sicily; as is well known, the decision was to make this a jointundertaking.
The second major question was whether civil affairs should beor-
2(1) Munden, 1st Lt. Kenneth W., AGD, dated 26 Mar. 1948, subject: Analytical Guide to the Combined British-American Records of the Mediterranean Theater of Operations in World War II, p. 285. (2) Harris, C. R. S.: Allied Military Administration of Italy 1943-1945. History of the Second World War. United Kingdom Military Series. London: Her Majesty's Stationery Office, 1957, pp. 94, 124, 270 (map 12), and 456-457.
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MAP8.-Original division of Italy into Allied Military Government of OccupiedTerritories Regions, 1943.
ganized primarily on a civilian basis as in North Africa orshould be an integral part of military operations. The decision was to followthe latter pattern although satisfactory integration between civil affairs andmore traditional military activities was achieved only after several majorcampaigns, and involved many months of trial and error.
Civil affairs planning for the invasion of Sicily began withthe assignment of Lt. Col. (later Brig. Gen.) Charles M. Spofford, GSC, as thesenior American officer to Force 141. He was joined later by his oppositenumber, Maj. Gen., The Lord Rennel of Rodd, who, because of his rank, became thesenior civil affairs officer. By April 1943, preliminary plans had beenformulated and approved in broad outline in both London and Washington. On 2June, Brig. Gen. Frank J. McSherry succeeded Colonel Spofford.
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MAP9.-Allied Control Commission regional organization, Italy, 1 April 1944.
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The plan as formulated called for a singlecombined military administration, the Allied Military Government of OccupiedTerritory. The method of administration envisioned was to use both direct andindirect controls over the civilian population. The commander of the occupyingforces would also be the military governor of Sicily and would carry out hisresponsibilities through AMGOT. A Chief Civil Affairs Officer would be appointedto the commander's staff to serve as his principal civil affairs adviser asthe administrative head of AMGOT. This officer would be assisted by a deputychief and six specialist divisions-Legal, Finance and Accounting, CivilianSupply, Public Health, Enemy Property, and Public Safety.
Military government personnel in the field would be under twoSenior Civil Affairs Officers on the staffs of the two task forces slated forinvasion, the Seventh U.S. and the British Eighth Armies. Below them would bethe actual operating units headed by Civil Affairs Officers. It was decided thatcivil affairs officers would not be provided for communities below 12,000-15,000population except when special problems existed. The total personnel for Sicilywas estimated to be 390 officers and 469 enlisted men; if the number availablewas much smaller, civil affairs officers were to serve as staff officers totactical commanders who were to have final responsibility and authority forcivil affairs during military occupation. As soon as possible, the tacticalbasis of civil affairs was to be changed to a provincial organization under asenior civil affairs officer in each province.
Planning for Public Health Operations
A small nucleus of British and American planning officers,including medical officers, was assembled at Chr?a, Algeria, by the MilitaryGovernment Section, AFHQ, in Algiers. The first officers arrived in early May1943. Early in June, several hundred additional officers, including more medicalofficers, began to arrive. These men were placed in the training and holdingcenter until they were used as military government officers in Sicilian andItalian mainland operations. The planning and training groups, known asHeadquarters, AMGOT, were a part of the combined General Staff of Force 141.After the Italian surrender on 8 September, the words, "OccupiedTerritory," were omitted, and the organization became known asHeadquarters, AMG (Allied Military Government), 15th Army Group.3
No medical personnel were on the Military Government Section'sstaff, AFHQ, and officers of Headquarters, AMGOT, dealt directly with theDirector of Medical Services, AFHQ, Maj. Gen. Sir Ernest Cowell (British) duringthe planning period.
Medical and welfare functions were combined in HQ, AMGOT, andinitially were under Col. D. Gordon Cheyne, RAMC, assisted by Col. (later
3This section is based in part on material submitted by Lt. Col. Leonard A. Scheele, U.S. Public Health Service, formerly assigned to HQ, AMGOT, 15th Army Group, and, later, to the Allied Control Commission, Italy. [On file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]
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Brig. Gen.) Edgar E. Hume, MC, Lt. Col. James A. Tobey, SnC,and Maj. Leonard A. Scheele, USPHS. Later, Lt. Col. Donald C. MacDonald, RAMC,Maj. Gordon M. Frizelle, RAMC, and Lt. (later Maj.) Manlio A. Manzelli, SnC,served on this staff. Lt. (later Capt.) Henry S. Price, MC, was responsible formedical care of officers and troops of HQ, AMG. Welfare personnel were underMaj. (later Lt. Col.) Ernest F. Witte, GSC. All were subsequently transferred tothe Allied Control Commission except Colonels Cheyne and Tobey.
Sections were planned for public health administration,regional health services, medical education, maternity, infant and schoolhygiene, communicable disease control, sanitation, laboratory services, andcontrol of biologicals, but this organization was not accomplished during theAMGOT or AMG phases because of the shortage of public health officers. Thenumber of officers assigned to headquarters never exceeded eight, and wasusually less than this; in fact, it later fell to two when the Allied ControlCommission was activated and HQ, AMG, 15th Army Group, gave up responsibilityfor rear areas.
Planning was based on the policy that Italian public healthlaws and regulations in force at the time of the invasion would be continued andthat existing Italian public health personnel and organization would be used tothe maximum extent possible, except in those instances when officials were foundto be objectionable Fascists. At first, the plan was to deploy MilitaryGovernment public health personnel with tactical units, and then to deploy themalong territorial lines at the earliest possible opportunity after fighting hadceased.
Planning at Chr?a included the writing of an AMGOT handbook.Instructions were prepared on refugee camp health problems and their solution,the medical aspects of air raid precautions, surveys of housing, instructionsfor medical responsibilities and activities of regional, provincial, and localmilitary government-civil affairs officers and public health officers.
American public health officers who came to Chr?a had allbeen trained either at the Charlottesville School of Military Government or inone of the Civil Affairs Training Centers at Yale or elsewhere. Upon arrival atChr?a, they attended classes covering general military subjects and had a smallamount of specialized [instruction in] malaria control, typhus control, watersanitation, and related subjects. Following lectures on these subjects,roundtable discussions were held.
Initial planning for medical supplies for civilian use wasdone in Chr?a. Lists of essential drugs and dressings,prepared by the Technical Advisory Committee on MedicalSupplies and Services of the ARB (Allied PostwarRequirements Bureau), were provided to HQ, AMGOT, by the Directorof Medical Services, AFHQ. These were lists of minimum essential drugsrequired to sustain a population of 100,000 persons for 1 month. Basedon an estimate that seven-eighteenths of the population would re-
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quire supplies, 21 drug units and 21 dressingunits were requested for delivery in Sicily. These units were to be made up fromU.S. Army medical supplies from the United States. In addition, quantities oftyphoid and smallpox vaccine were to be shipped from the Pasteur Institute inAlgiers.
In midsummer, so-called CAD (Civil Affairs Division) UnitLists were received, which replaced the former ARB Unit Lists. Planning forlater Sicilian and Italian mainland operations was made on the basis of the newCAD Unit Lists, 150 U.S. drug and dressing units and 750,000 cubic centimetersof antitetanus, antityphus, and smallpox vaccines being requested.
In late August 1943, a new group of officers, who were tobecome the nucleus of the Allied Control Commission, arrived at Tizi Ouzou. Thisgroup did independent planning and later followed AMG to operate in occupiedareas behind the combat zone.
INVASION OF SICILY-REGION I
Personnel
Initially, two American medical officers (Maj. Edgar B.Johnwick, USPHS, and Capt. (later Maj.) Anthony Pino, MC), one British medicalofficer (Maj. Leslie G. Norman, RAMC), and one Canadian sanitary engineer (Capt.(later Maj.) Alexander S. O'Hara) accompanied the assault forces which landedon Sicily on D-day and on D+1. In addition, another American medical officer,Maj. (later Lt. Col.) Orpheus J. Bizzozero, MC, accompanied the MilitaryGovernment team with Seventh U.S. Army Headquarters.
The officers with Seventh U.S. Army Headquarters stayed withthat group until it established itself in Palermo; then, a Military Governmentteam was formed for that city and province, and Major Bizzozero became thePublic Health Officer of the team.
Major Johnwick was pressed into service in the very earlydays as the general administrative officer for three communes in AgrigentoProvince because of the small number of military government officers who landedon Sicily in the initial combat phase. His work was so "efficient"that it required several months to secure his return to public health work.Captain Pino accompanied the 45th Division as a member of its MilitaryGovernment detachment. When this division entered Messina and the MilitaryGovernment detachment began to operate territorially, he became the MilitaryGovernment Public Health Officer for the City and Province of Messina.
Major Norman and Captain O'Hara, who accompanied theBritish Army, were responsible for Military Government Public Health in theareas occupied by British troops in the initial period; namely, Syracuse andRagusa Provinces. Later, Captain O'Hara was moved to Caltanissetta to becomeProvincial Public Health Officer there.
Advance elements of HQ, AMGOT, 15th Army Group, including thePublic Health Division, moved to Syracuse, Sicily, during the period 18-25
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July 1943. When Palermo fell, the Headquarters moved thereand began functioning on 2 August.
Beginning in August, Military Government Public Health wasoperated on a territorial basis in Sicily. The province was selected as the bestlevel at which to place officers; at first, one medicalofficer and, in most instances, one sanitary engineer officer were placed ineach of the nine provinces in Sicily. Whenever a sanitary engineer was not onfull-time duty in a province, one was always available part time from anadjoining province. No Military Government Public Health Officers were witharmies or divisions in Sicily after mid-August 1943.
When the time arrived for the invasion of the mainland, itbecame necessary to consolidate provinces in Sicily and reduce public healthpersonnel to obtain additional officers to send with the assault forces and toman the new areas to be occupied.
Problems Encountered in Sicily
For Military Government, the campaign in Sicily was a newventure; plans had been made but had never been tested. What happened to onecivil affairs medical officer who landed with elements of the British EighthArmy in Sicily on D-day4is described below:
Mission-The mission of this [CivilAffairs] team was to land with the reinforcements on D-Day, 10 July 1943, atLicata, Sicily, and establish military government there, extending the scope ofits activities inland as the Division advanced.
Use of Intelligence-The team receivedinstructions concerning its target from a collection of publications issued bythe Office of Strategic Services and the Ministry of Economic Warfare [Br.].G-2, Third Division, furnished recent air reconnaissance photos and tacticalinformation concerning the target. The publications contained names and locationof important medical installations and gave the names and titles of physiciansand health authorities in Agrigento Province where Licata was located. A briefresume of the medical administration of Sicily and a short historical review ofhealth conditions were also covered. This information was found to be out ofdate in many respects since changes had taken place by the time the landings hadoccurred. Medical officers had been discharged, or had fled from their posts,one hospital in Licata had been abandoned because of damage (which was notvisible in air reconnaissance photos), and some civilian public healthactivities were being carried out by organizations not named in the intelligencesurveys. However, the basic information obtained was very useful in the sensethat it served as a starting point for interviews with civilian authorities. Insome details, particularly knowledge of the higher administrative channels inItalian government, the AMGOT officers proved to be better informed than theSicilian public servants who were questioned. This was a particularly useful andimpressive administrative advantage.
Plan of Operation-The original planwas, briefly, to have each AMGOT officer seek out his civilian opposite numberin Licata and establish the normal function of that particular public officefor the benefit of the civilians in order to keep civilian demands on theresources and time of the task force to a minimum. In this plan, the publichealth officer had the following immediate tasks:
4Report, Maj. Edgar B. Johnwick, USPHS, subject: Notes on AMGOT Public Health Activities in Sicily (Period covered: 10 July to 3 September 1943). [On file at The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]
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1. Locate the city health officer, the head ofeach hospital, the head of the local Red Cross, the leading physicians and thehead of the Air Raid Protective Organization for the purpose of giving these menauthority to continue their work under the Military Government, and to issuesuch orders from time to time, as were required to accomplish the task of theoccupation.
2. Visit and inspect all local hospitals andmedical installations in the company of the Italian administrative head of theinstitution to ensure that staffs realized that they were to continue theirduties and recognized that AMGOT has delegated responsibility to one specificindividual.
3. Search for medical supplies and ensure thatsuch supplies as were available were equally distributed.
4. Investigate the food situation and ensurethat food supplies continued to be delivered to the people, particularly tohospitals.
5. Investigate the water supply to the cityand ensure that this remained adequate. (Licata was furnished with an inadequatenumber of public fountains, supplemented by a small aqueduct ending in a storagetank from which distribution was effected by water carts.)
6. Insure that the mayor maintained inoperation the city refuse disposal system (which was primitive andunsatisfactory even in peace), and that he supplemented this with clean-updetails for removing rubble and debris from the streets.
During the three days that the writer remainedin Licata (to 13 July 43), the above activities were undertaken and someprogress was made toward accomplishment of the mission. Many difficulties wereencountered and most of them were surmounted through the ingenuity of officersand enlisted men and the cooperative attitude of other members of the task forcenot attached to AMGOT. During the first three days following the invasion,frequent surprise raids by single German fighter planes careening over housetopskept the civilian population in a constant state of alarm and confusion.
Later, in a comprehensive report ofHeadquarters, 15th Army Group, on 11 October 1943, Colonel Cheyne summarized theexperiences in Sicily up to that time.5The following excerpts are taken from that report:
A considerable amount of detailed informationhas now been coordinated and the machinery of health administration is workingmore smoothly than could ever have been thought possible in the short timeconcerned.
The organisation of the Public Health Divisionhas continued on the lines indicated in the planning programme an organisationwhich has now stood the test of actual working conditions for nearly threemonths. The various sections of the Division are now working much more as ateam, and any tendency to a diversion into water-tight sub division has beenrigorously discountenanced.
As regards the policy of the future, this isat present wrapt up in some degree of mystery especially with the advent of anArmistice Control Commission in which Public Health is strongly represented.
An effort has been made to reestablishreporting of communicable diseases as previously done under Italian healthregulations. The disruption of communications between individual physicians andcommunal health officers * * * led to a complete breakdown of the reportingsystem. Communications are improving gradually, and weekly and monthly reportsare beginning to flow to Provincial Health Officers and this Headquarters.
Reports from about one-third of the communesin Sicily for approximately a 3-week period listed 571 cases of typhoid fever,404 cases of
5Report, Col. D. Gordon Cheyne, RAMC, to Chief Civil Affairs Officer, AMGOT HQ, Sicily, 11 Oct. 1943, subject: Report on Health Conditions Prevailing in the Territories Administered by AMGOT.
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pulmonary tuberculosis, and 535 cases ofmalaria. Even these fragmentary data served to focus attention on typhoid fever,tuberculosis, and malaria as the most important communicable diseases. The totalpopulation of Sicily at this time was roughly 3.5 million. Colonel Cheyne'sreport continues:
The structural condition of Sicilian hospitalsis dependent upon their position as regards centres of most intense militaryoperations. * * * It is the policy of AMGOT to provide the funds necessary forre-building. * * * In the days immediately after the occupation, lack ofelectricity hampered the work of many hospitals and laboratories, but as soon aselectric power became available it was put at the disposal of the hospitals bythe military authorities.
The health of the people has been good beyondexpectation. * * * Typhoid fever alone has caused concern, * * * malaria is muchmore common than statistics indicate.
Medical stores are obtained from two sources-(1)Captured Italian material, (2) Drugs and dressings imported from the UnitedStates. Essential medical supplies are first distributed to hospitals and laterto selected pharmacies. A central medical store has been set up at Caltanissetta* * * from which all the Provinces draw their requirements. * * * A system ofaccounting is being prepared, by which each province draws its medical storesupon repayment. Each province has received initially a 20 ton brick containingsuch essentials as wool, gauze, iodine, bandages, anaesthetics, suture material,sera and vaccines, sulphanilamides, denatured alcohol, insulin and antiseptics.
INVASION OF THE MAINLAND-REGION II
On 3 September 1943, the British Eighth Armycrossed the Strait of Messina to Reggio and moved steadily eastward andnorthward, eventually joining the British X Corps, which had landed with theFifth U.S. Army at Salerno. Following the Italian surrender on 8 September, aBritish airborne division landed unopposed at Brindisi, and within a shortperiod, the whole of Region II, comprising the compartments of Calabria, Lucania,and most of Apulia, was firmly in Allied hands.
Major Johnwick and Capt. (later Maj.) William H. Ball, MC,accompanied the assault troops that captured Reggio di Calabria, and the formerbecame the first Military Government Public Health Officer for Region II. Thesetwo medical officers subsequently were joined by four others. The headquartersof this region was moved later to Matera. In November 1943, most of Region IIwas transferred (along with Region I-Sicily) from the control of MilitaryGovernment, 15th Army Group, to the Allied Control Commission, and Capt. (laterMaj.) Everett E. Carrier, MC, became the Regional Director of Public Health.
With the exception of the initial attack on Reggio, there wasvery little heavy fighting in Region II, which embraced all the extreme southernportion of Italy. On the whole, the public health problems were essentiallythose likely to have been encountered in that portion of Italy during peacetimeand consisted, for the most part, of endemic malaria, outbreaks of smallpox, andrecurring small outbreaks of typhoid fever and other intestinal diseases. Someshortages of medical supplies and soap occurred,
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but, again, this situation was scarcely more than anaggravation of previously existing conditions.
NAPLES AND REGION III
An epidemic of typhus fever served to focusattention on civil public health in Naples and Region III and emphasized thedeveloping administrative confusion. As so often happens, from this near-crisiscame a new understanding of the potential and the importance of an adequatepublic health program in civil affairs.
Troops of the Fifth U.S. Army stormed ashore at Salerno on 9September 1943. The situation was critical for a fortnight, but eventually theU.S. VI Corps and British X Corps broke out of thebeachhead and captured Naples on 1 October. Operating under Military Government,15th Army Group, Colonel Hume, a medical officer then serving as Senior CivilAffairs Officer for Region III, took over the direction of civil affairs inNaples City and Naples Province with Col. Emeric I. Dobos, USPHS, as chief ofPublic Health and Welfare. Colonel Dobos was replaced in December 1943 by aBritish officer, Col. Walter H. Crichton, formerly with the Indian MedicalService.
The early health problems encountered in Naples are describedby Colonel Dobos:6
With the Headquarters Staff of AMG Region III,we arrived in Naples on October first and established headquarters at theMunicipio. The capital city of Southern Italy, with a population of over 1million, was found in a state of utter confusion. All public services were outof commission. The Sereno Aqueduct, which provided the water supply of Naples,was blown up in several places, and the source in the hills of Benevento wasstill in the hands of the enemy. Potable water was obtainable only from thesixty shallow and deep wells scattered near the port area of the city. None ofthe wells were provided with pumps; the water had to be dipped by buckets.Thousands of people crowded the streets, congregating around the water points,carrying home water in bottles, jugs, crocks and small barrels. The inhabitantsof the most populous residential district, the Vomero, situated up on the hill,had to walk several miles to fetch water from the wells which were located nearthe water front. Water for drinking purposes was obtainable in sufficientquantities to satisfy minimum needs, but the most serious trouble was the lackof water for flushing toilets. * * * The water supply of Naples wasreestablished on 22 October, three weeks after our occupation of the city. TheCorps of Engineers [did] an outstanding job in the quick and efficient repair ofthe 55 mile long aqueduct.
* * * The lack of electricity created a numberof inconveniences, but from the public health standpoint the chief danger was inits effect on the sewer system [which required electrically operated pumps tomaintain the flow]. * * * The hospitals suffered much inconvenience as theresult of lack of electric power particularly since all the sterilizing unitswere operated by electric current, but that was only one of the many importantfactors that well-nigh paralyzed these institutions.
The food situation during the first weeks ofour occupation was critical, * * * The hardest hit were the inmates ofinstitutions who didn't have funds, nor access to
6Report, Lt. Col. Emeric I. Dobos, USPHS, undated, subject: Allied Military Government. Italy, Region III; Allied Control Commission, Sardinia, Region VI. [On file at The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]
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the surreptitious means of transport, of whichthe individual citizen could take advantage when it came to securing foodstuffsfor himself and his family. Claims of death from starvation were frequentlyexaggerated by the hospital authorities * * * As the supply organizationimproved we were able to establish priorities for inmates of institutions, whichled to considerable amelioration of the situation. * * *
One of the many urgent problems was thedisposal of the dead. Upon our arrival there was a back-log of 500 cadaversdecomposing in the homes, hospital morgues, and air raid shelters. For that thelack of transportation facilities was one of the main reasons. * * * Thepopulation revolted against the idea of burying the dead without caskets, butneither wood, nor manufacturing facilities were available to provide them. * * *
On our arrival we were confronted with a twoweeks' accumulation of garbage * * * with the heapsgetting bigger and more numerous daily. * * * Hundreds of pushcarts were alsomobilized in an endeavor to improve conditions.
Excerpts from the monthly report for December1943, prepared by Colonel Crichton, summarize the situation in Naples and RegionIII toward the end of its second month of military government.7
The weather in the Region had been exceptionally severe, withlow temperatures and unusually heavy rains. Lack of transport and communicationfacilities made it extremely difficult to obtain reliable data on vitalstatistics. The outbreak of typhus had been the main preoccupation of the civilpublic health staff. (This will be described in more detail later.) Otherimportant diseases affecting the Region were typhoid, venereal disease, andmalnutrition.
Typhoid fever was known to have been endemic and, because ofthe similarity of names, was probably responsible for the initial delay inrecognizing the presence of an incipient epidemic of typhus. A severe epidemicof typhoid occurred in Montesarchio, a suburb of Naples.
The food situation throughout December was grave. While nocases of avitaminosis had been recognized, undernutrition was rife, particularlyamong inmates of civil hospitals, where the lack of transport had severelycurtailed food supplies. The shortage of food was believed to be a contributingfactor in the high incidence of both typhus and the venereal diseases,presumably through the attendant social disruption. Olive oil, an important itemof the Italian dietary, was not available through food control sources and wasavailable in the black market at the exorbitant price of 200 lire per liter; yetit was reliably reported that oil was abundant in all of southern Italy. Thehumble bean, which for generations had been scorned by all but the lowestclasses, became a delicacy which could be afforded only by the rich. The milkcollecting and distributing system had collapsed. In brief, the food situationwas serious largely because of transportation problems.
Hospital facilities had been greatly reduced by destructionfrom air attacks, looting, and, finally, requisitioning for military use. Glassfor
7Monthly report, Col. W. H. Crichton, Director of Public Health and Welfare Department, AMG Region III, 30 Jan. 1944.
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rehabilitation of damaged structures wasvirtually unobtainable and beds, bed linen, and certain essential equipment wereexceedingly scarce.
Transport-In a city in which everymeans of public conveyance, except a few decrepit taxis and some flea infestedhorse drawn vehicles, is out of action, it is literally impossible for anyefficient work to be done by this staff * * * unless adequate transport is madeavailable. * * * Trucks for the haulage of important A.M.G. like medical storesand clothing are also extremely difficult to get. * * * The need for transporthowever should not extend to the private cars of civilians who are fulfilling auseful function-to requisition doctor's cars for instance is merely a caseof robbing Peter to pay Paul. Doctors should be specially privileged in thisrespect and should be furnished with markings which will protect them fromdepredations carried out by officers from the many formations established inthis city.
Medical Stores-Naples has been madethe receiving and distributing center for all A.M.G. medical stores. Lt. Light,R.A.M.C., has been appointed in charge of the stores. Here again the greatestdifficulty was experienced in providing Lt. Light with a means of conveyance toenable him to carry out his duties.
Venereal Disease-Next to typhus thisdisease provides the most serious problem affecting the health of the troops inthis Region. Major Lewis [Maj. John A. Lewis, USPHS] has been appointed asAdviser on Venereal Diseases and several important steps have been taken tocombat the disease.
Among these steps to combat venereal diseaseswere the following:
1. All houses of prostitution were placed out of bounds (31December).
2. The bed capacity of Pace Hospital (venereal disease, forwomen) was increased by 139 beds to 268.
3. The standard of inspection of prostitutes arrested by thepolice was improved.
4. Civilian venereal disease clinics were advertised in thepress and by posters in lavatories.
5. Steps were taken to provide the venereal disease hospitalswith more effective drugs than they had had in stock.
6. Italian standards of treatment and cure were reviewed andsuggestions for improvement made.
7. It was recommended that an edict be published prohibitingcivilian doctors from treating infected soldiers.
8. An effort was made to increase the stock of antivenerealdrugs in pharmacies in the hope of effecting a reduction in the exorbitant pricethen being charged for these drugs.
9. The campaign against pimps was intensified by the police.
Early in 1944, cases of smallpox began to occur in excessivenumbers in both the City and Province of Naples; the incidence continued highthroughout the year despite an active vaccination program in which more than300,000 persons, mostly children, in Naples City alone, were vaccinated by theend of June. The disease was mild in character and did not serve as a seriousthreat to the military forces in and around Naples.
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Typhus Fever
The outbreak of typhus fever in Naples was the most dramaticand the most widely publicized one of the war. Detailed accounts will be foundin another volume in this Preventive Medicine series8and in a monograph by Soper, Davis, Markham, and Riehl.9
Two facts, one administrative, the other scientific, must benoted as background material for the events to be described. The essentialadministrative fact was that responsibility for military government operationsin Naples was shared in some undefined way by the AMG 15th Army Group and theSenior Civil Affairs Officer and his deputies in Naples. While a number ofmedical officers of the military forces stationed in Naples were aware generallyof the situation in the civilian population, they had no direct responsibilityfor civil affairs activities in this area. Likewise, a number of medicalofficers attached to the forward headquarters of ACC in Naples could only adviseand exhort for they had, at that time, no direct operational responsibility inthe Naples area.
The scientific fact to be noted is that MYL powder, which wasthen a standard delousing agent for the Armed Forces, was in abundant supply inNaples. This agent differed from DDT in that the latter had residual killingpotential for lice while MYL did not. In any event, it was the use of MYL, notDDT, initially in the dusting program which effectively brought the typhusepidemic under control.
A seeding of typhus cases was known to have occurred duringthe German occupation. Frequent air raids before and after the liberation ofNaples by the Allied Armies on 1 October 1943 had led to great overcrowding inthe deep tunnels and cellars under the city, the ricoveros which servedas makeshift air raid shelters. Naples had a semipermanent air raid shelterpopulation estimated at 12,000, caused in part by fear of air raids and in partby destruction of housing. This situation was aggravated by the influx of largenumbers of refugees from the north. Prisoners released when the Germansevacuated Naples were known to have been exposed to typhus while in prison and,most likely, were the major source of spreading and seeding the diseasethroughout Naples.
In October, 25 typhus cases among civilians were reported; inNovember, 46 cases. Col. William S. Stone, MC, Chief of Preventive Medicine ofthe North African theater, called attention to this situation on 18 October, 9November, and 3 December 1943. By the first week of December, the incidence oftyphus cases had increased sharply.
The chief of the Public Health and Welfare Section of thecivil affairs group in Naples, Lt. Col. (later Col.) W. Carter Williams, MC,submitted
8Medical Department, United States Army. Preventive Medicine in World War II. Volume VII. Communicable Diseases: Arthropodborne Diseases Other Than Malaria. Washington: U.S. Government Printing Office, 1964, ch. X.
9Soper, F. L., Davis, W. A., Markham, F. S., and Riehl, L. A.: Typhus Fever in Italy, 1943-45, and Its Control With Louse Powder. Am. J. Hyg. 45: 305-334, May 1947.
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recommendations for a program to meet thethreat imposed by the rising attack rate. However, definitive steps were nottaken, either through lack of appreciation of its potential seriousness orthrough delay in implementing control measures. An interesting commentary onmilitary security is that, at this time, civil affairs medical officers and,indeed, most of the U.S. and British medical officers in Naples were not awareof the existence of DDT, probably because of the classified nature of theinformation. Military government officers had been briefed on the use of MYL andDDT powders during their training period at Tizi Ouzou. In retrospect, probablythe early use of DDT in the ricoveros would have cut short this epidemicbefore it was well under way. There was also initially too little appreciationof the effectiveness of the standard delousing powder (army MYL).
A cable request for diagnostic antigens on 3 December 1943from Colonel Hume to the Cairo office of the United States of America TyphusCommission alerted that organization to the occurrence of typhus in Naples; butwhen the services of the Commission were offered, they were declined by both the15th Army Group and the Senior Civil Affairs officer for the Naples area. Largequantities of DDT, nevertheless, were shipped by air to Naples, where the civilpublic health group assisted by Dr. Fred L. Soper and other civilian staffmembers of the International Health Division of the Rockefeller Foundationinitiated a control program. This program was carried out under great handicaps,particularly the almost total lack of transportation facilities, and a shortageof personnel.
Adequate transport and other facilities were made availabletoward the end of December as a result of the forceful representation of Brig.Gen. Leon A. Fox, Field Director of the Typhus Commission (fig. 39), to Brig.Gen. Arthur W. Pence, CE, Commanding Officer of the Peninsular Base Section, andto Gen. Everett S. Hughes, Deputy Theater Commander of the North Africantheater. Without these facilities, the control program could not have beenimplemented. This was done in accordance with the authorizations embodied inExecutive Order No. 9285, which established the Typhus Commission. On 1 January1944, responsibility for the control program was formally transferred from thecivil affairs group to the Typhus Commission.
In January 1944, the peak month, more than 1,000 new typhuscases were reported. The epidemic was quickly brought under control, however,and only 39 new cases were reported during the last week of February. Few casesoccurred among U.S. military personnel operating in this area while a somewhatlarger number occurred among British troops; the difference was attributedprimarily to the fact that all U.S. military personnel had received typhusvaccine while the British troops had not.
The actual organization and supervision of Italian civilianteams of doctors, nurses, and various technicians by Dr. Soper and theRockefeller Foundation staff formed the backbone of this epoch-the first timein con-
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FIGURE39.-Brig. Gen. Leon A. Fox, MC.
temporary history that a full-blown typhus epidemic wasbrought promptly and completely under control.
The principal features of the typhus control program ascarried out in Naples were as follows:
1. Protection of key personnel by immunization and frequentDDT dusting of all medical personnel engaged in the program, including civilianpersonnel in hospitals likely to receive typhus cases.
2. Establishment of DDT dusting stations at strategic pointsin the city, with particular coverage of the main air raid shelters and refugeecamps. More than 1.5 million civilians were dusted with hand dusters using5-percent DDT in talcum powder during a 6-week period in December and January.Since the objective was to dust each person once weekly, undoubtedly this figureincludes many repeat dustings; nevertheless, it is evident that a substantialproportion of the population of Naples had the benefit of this important controlmeasure.
3. Large scale immunization of civilian population.Immunization teams likewise were established at strategic points throughout thecity, and thousands of injections of typhus vaccine were given. Opinion differsconcerning the effectiveness of this control measure, but it probably did notplay a major role. The effort involved in securing even limited coverage of
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the general population was probably out of proportion to thebeneficial results.
4. "Flying sparks" control. Since the normalmovements of populations may carry infected persons to outlying districts, allphysicians and health authorities in adjacent communities were alerted for theoccurrence of typhus cases, and highly mobile teams ("FlyingSquadrons") were organized to carry DDT dusting powder and vaccine to thevicinity of any such reported cases. Not only the patient but also his familyand immediate neighbors were dusted, and the members of his family were giventyphus vaccine. This was the so-called block-dusting program, first used inNaples.
Administrative Perplexities
By mid-December 1943, Military Government personnel had beenthrough the fire of three major military operations. Individually, the work ofthe civil public health officers had been of a high order and these men wereaccepted as important components of Military Government operations.Administratively, however, the situation was becoming complex and, to put itmildly, somewhat confused, especially in the realm of public health activities.This became apparent when serious trouble threatened in Naples.
In mid-November 1943, the HQ, AMG, 15th Army Group moved toBari and relinquished control of Sicily and most of Region II to the AlliedControl Commission, which began operating officially on 10 November. Thiscommission was directly responsible to AFHQ, as was HQ, AMG (through theCommanding General, 15th Army Group). As a result of this separation, there wasrelatively little official public health liaison between HQ, AMG, and ACC duringthe period November-December 1943. There was no medical officer on the MilitaryGovernment Section staff of AFHQ to provide the coordination required betweenthe two major headquarters described. The situation was complicated further bythe fact that the AFHQ staff was at Algiers although, by mid-December, onenonmedical officer was present in Naples representing the Military GovernmentSection of AFHQ at advanced HQ, AFHQ.
At the time of activation of the ACC, its headquarters was inPalermo, Sicily. Its public health functions were moved to Naples between 15 and25 December 1943. At that time, Naples was part of Region III, which was underthe direction of HQ, AMG, 15th Army Group. The situation with respect tomilitary echelons present and having responsibility in and about Naples wasextremely complicated in December 1943 and early January 1944. HQ, AMG, 15thArmy Group, and HQ, AMG, Fifth U.S. Army, controlled the area with respect toMilitary Government; yet ACC had its Forward HQ there. The main Headquarters ofACC operated from Salerno. An American base section (Peninsular Base Section)and a Metropolitan District both had Headquarters in Naples at this time. ABritish Line of
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Communications (equivalent of an American base section) hadits Headquarters in Naples. In addition, AFHQ had an advanced Headquarters therewith the Director, Medical Services, and Surgeon's representatives, and boththe British and American Navies had District Headquarters in Naples. The reasonsfor this vast array of headquarters were logical since the Fifth U.S. Army frontwas stalled north of Caserta at the time, which gave that Army a real interestin maintaining security in its immediate rear area, including Naples. It becameimperative for the Base Section organizations to move in early to land and storethe supplies needed for the late winter drive because Naples was the firstsizable port on the west coast of the Italian mainland.
This multiplicity of commands in Naples is mentioned becauseundoubtedly it was one of the causes of the initial confusion in dealing withthe Naples typhus epidemic. The confusion was complicated further by the lack ofspecific directives as to areas of administrative and geographicresponsibilities. Appropriate liaison between officers at AFHQ, Army Group, andArmy levels, combined with the issuance of simple directives delineatingadministrative and functional responsibilities, would have reduced confusionconsiderably. Lack of specialist liaison personnel at all these levels posedmore problems. That the United States and the United Kingdom were engaged in ajoint operation, each with its own and often different conception of whatcontrols should be used, further aggravated the situation.
When, therefore, the growing typhus epidemic posed a seriousthreat to military operations through the Port of Naples, it was virtuallyimpossible to determine what military organization, and therefore what medicalofficer, had primary responsibility for control measures among civilians.Fortunately, General Fox assumed the initiative and took responsibility forpreventive measures after Dr. Soper's team had done some extremely effectiveblock dusting.
Toward the end of January 1944, when the epidemic was clearlysubsiding, there began the acrimonious but largely off-the-record debate as towhich group really had controlled typhus in Naples. The writer, who was inNaples at the time as a representative of the Surgeon General's Office, wasappointed a year and a half later to a high level joint British-AmericanCommission to adjudicate the issue, but fortunately, the war's end brought therealization that all concerned could properly share the credit for a job welldone. Special note should be made of the exemplary action of the American Navymedical components in Naples at the time of the epidemic, who, staying above thetempest, took the opportunity to make a documentary film of the typhus epidemicand the control measures initiated. The work of Dr. Soper and his staff was ofinestimable value. Considerable credit must also be given to Colonel Stone, MC,the Preventive Medicine Officer of AFHQ, who anticipated many of the problemsand made excellent recommendations to superior officers on ways to handle them.
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Also, in his capacity as Medical Supply Officer, AFHQ, heprepared and submitted requisitions for the vitally needed supplies andequipment.
The dissimilarity between U.S. and British policies on staffassignments in the Allied Control Commission created unusual and difficultsituations; for example, if a British lieutenant were assigned to a positioncalling for a lieutenant colonel, he immediately would be promoted to, andreceive the pay and allowances of, that grade. Of course, the reverse was alsotrue. Most U.S. officers, including qualified Public Health specialists, wereassigned to, and retained indefinitely in, positions calling for grades higherthan the ones they actually held, but, because of the U.S. promotion policy,they could not be promoted. Obviously, considerable maneuvering occurred asBritish officers sought to fill higher grade positions which actually called fora U.S. officer. That these situations did not become overwhelming is a tributeto Brigadier George S. Parkinson, RAMC, Director of the Public HealthSubcommission of ACC and former Dean of the London School of Tropical Medicine,whose sincerity and understanding inspired both the United States and Britishcomponents. He took a positive stand against favoritism which was mostcommendable.
These difficulties, magnified unduly at the time, reflect inpart the growing pains of a new venture, civil public health, as an integralpart of military operations. But it was clear then, as it is now, that theprimary difficulty arose from a failure at theater level to provide forcentralized technical responsibility for civil public health affairs. Acontemporary report made by a representative of the Surgeon General's Officepointed out some of the difficulties, and recommended corrective measures inpart as follows:10
While theoretically the responsibility of eachorganization may have been clearly defined, in actual operation confusionresulted. * * * Policies regarding technical matters and the utilization ofmedical personnel were being determined by two individuals instead of one, withno unifying influence at the top.
An attempt has been made to correct thissituation by the centralization of authority for both AMG and ACC in oneindividual, Lt. Gen. Mason MacFarlane, who is directly responsible to Gen.Alexander [Commanding General, 15th Army Group]. At the present writingresponsibility for the technical aspects of civil public health as administeredby both AMG and ACC seems to have been placed on the Director of the PublicHealth and Welfare Subcommission of ACC, Brigadier Parkinson, who is very wellqualified to assume that responsibility. Because of diverging chains of command,however, this too may fail to resolve certain civil public health difficultiesunless the technical leadership of Brig. Parkinson is recognized by allconcerned.
* * * Too little attention has been paidthroughout to the relative importance of a civil public health program in thewhole picture of military government. The most obvious defect in this respect isthe lack of any one medical officer at Allied Force Headquarters whose primaryconcern is with civil public health problems. An effort has been made to utilizethe resources available in the Medical Section of British headquarters
10Letter, 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 Health Activities in the North African Theater of Operations. [On file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]
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and in the office of the Surgeon, NATOUSA, butthis can be only a hit or miss proposition unless there is at least onequalified medical officer thoroughly familiar with AMG problems and projectedoperations who can maintain close liaison with the British and American medicalsections. This individual should be responsible for obtaining the best availableadvice on matters pertaining to public health objectives, medical supplies andpersonnel.
Although this and other recommendations wereconcurred in and some were implemented by AFHQ, this one was not, possiblybecause the beginning of the end of the Italian campaign was at hand.
THE ANZIO BEACHHEAD
The landings at Anzio just south of Rome took place on 22January 1944, and for several weeks, elements of the U.S. VI Corps were engagedin one of the bitterest actions of the Italian campaign in an area thatstretched for approximately 18 miles along the coast and 7 miles inland.11Military Government personnel accompanied thelanding forces, but no medical officer was among them.
Even in the severest engagements, however, civil healthproblems arise and must be handled by someone, which, in this instance, was themedical service of the combat forces. The following account is quoted from theannual report of the Fifth Army Medical Service for 1944:12
Though the medical care of civilians on thebeachhead was the responsibility of the Allied Military Government,representatives of the Fifth Army Surgeon were obliged through force ofcircumstances to take a hand in this matter. [It should be noted that the Chief,15th Army Group, AMGOT, had issued orders forbidding ACC medical personnel fromgoing into the beachhead.] The existing civilian hospital was a misnomer. It wasinadequately staffed and miserably equipped. Supplies were at once madeavailable to this hospital from Fifth Army medical depots on the beachhead. Butsupplies alone would not eliminate the handicap under which the civilianhospital operated. Many of its patients had sustained wounds which requiredextensive treatment and long periods of convalescence.
Beginning with the early days of thebeachhead, these cases were evacuated along with combat troops to baseinstallations. In the case of the civilian hospital humanitarian reasons alonedictated this action. The same action was taken in the case of civilians whowere brought direct to the evacuation hospitals operated by the Fifth Army forits troops. Bed space urgently needed for combat troops was being utilized forcivilian wounded. To free this space, the principle governing the evacuation ofcombat troops was extended to cover civilians as well.
In both instances, if the course of recoveryrequired fourteen days or less, the casualty remained in the evacuation hospitaland would not be removed from the beachhead. If the course of recovery requiredmore than fourteen days, the casualties-soldier and civilian alike-wereevacuated to base installations the moment they were strong enough for themovement. When the greater number of civilians living in the Anzio area wereevacuated from the beachhead to protect them against German artillery fire andbombing attacks, the medical care of civilians ceased to constitute a majorconcern of the medical department. There were a number of casualties whichoccurred
11United States Army in World War II. Special Studies. Chronology, 1941-1945. Washington: U.S. Government Printing Office, 1960, pp. 164-174.
12Annual Report, Surgeon, Fifth Army Medical Service, 1944, ch. III, p. 30.
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from day to day among civilians left behind onthe beachhead to guard property, but these were accommodated without strain onthe medical resources assigned specifically for troops.
From 6 to 10 February, the beachhead wasvisited by Mr. Donald E. Hagaman, Field Supervisor of War Relief for theAmerican National Red Cross, from whose report the following is extracted:13
Health conditions in the Campana region arereported to be good, and there are no appearances of epidemics or seriousconcentrations of illness. However, since the region is so close to the militaryoperations-it does seem logical to believe that more and more wounded willappear unless the military operations move forward.
At the present time there is one civilianhospital, of 35 beds, in Nettuno which is handled by a Dr. Donati and hisbrother. * * * The hospital is presently established in the home of Dr. Donati,and supplies have been given him by the Army Medical Corps and AMG. All beds arefilled and there are many walking wounded who are kept at this hospital.
Shortly thereafter, Major Norman, RAMC, wasassigned as the medical officer with AMG and, on 28 February, reported thatabout 7 tons of AMG supplies had been sent to the bridgehead 3 weeks previously.14These supplies were adequate for about another month.
The beachhead reached a degree of stability until thebreakout in the May offensive. In April, it was decided to evacuate compulsorilymost of the civilians in the area (fig. 40), with the exception of essentialfarmers and their families. This decision was made partly to reduce theincidence of malaria and other infectious diseases among troops. By 15 April,733 civilians had been evacuated by sea to Naples, with approximately 1,000persons remaining as permanent residents of the beachhead. All refugees weredusted with DDT and given medical attention, if needed, before embarkation.
FOGGIA AND REGION IV
Situation Under British Eighth Army Control
Region IV, which originally comprised the Compartments ofAbruzzi and Lazio, excluding Rome, when first activated was limited to theFoggia area in the northern part of Apulia. Foggia was captured by the BritishEighth Army in October 1943 and served also as a base for the Twelfth Air Force.
A report from the AMG medical officer assigned to the BritishEighth Army, Lt. Col. (later Col.) Charles J. Farinacci, MC, on 19 October 1943indicated that considerable damage had been done in the city.15Housing was a serious problem since most of the few remaining habitablehouses
13Report, Field Supervisor, American Red Cross War Relief, 9 Feb. 1944, subject: Visit to Beachhead Sector, Anzio, Nettuno and Campana Region, App. B.
14See footnote 13.
15Telegraphic report, Lt. Col. Charles J. Farinacci, MC, to Captain Benson, AMGOT, Eighth Army, Italy, 19 Oct. 1943, subject: Report of the Health and Sanitation of City of Foggia.
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FIGURE 40.-Acivilian girl, shot by Germans while trying to warn Americans of Germanpositions, is taken from an aid station and carried to an ambulance for furtherevacuation to the rear.
had been requisitioned by the military. Probably30,000 people were homeless. The main sewer was broken in 15 or 20 places. Therewas no civilian hospital in the city, and no one knew what diseases wereoccurring. Essential drugs, such as alcohol, iodine, sulfonamides, and insulin,were almost unobtainable. Soap was badly needed to contend with outbreaks ofscabies and impetigo.
Colonel Farinacci recommended the following program:
a. Anti-louse campaign by use of posters, public baths,routine examination by the panel doctors.16
16One may observe here that DDT, a month before its use in Naples, was not generally known, or available, to medical officers. The first DDT arrived in the Mediterranean theater in December 1943.
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b. Immediate supply of drugs and sera to the province forissue to the various hospitals and public health institutions.
c. Immediate establishment of both a surgical and medicalhospital for civilians of Foggia.
d. Return of all antimalarial clinics to the provincialauthorities * * *
e. Establishment of a refugee camp or camps in the vicinityof Foggia to care for the homeless.
Display of the public health posters that Colonel Farinaccimentioned began in 1944. Written in Italian, the posters were designed toencourage civilians to help the military combat disease vectors. Many of theposters were seasonal in character; for example, in the spring of 1944, posterswarned the populace about the fly and mosquito dangers, and in the fall, postersdepicted the dangers of typhus and warned the people to stamp out the bodylouse. Huge posters called attention to the three common enemies: the mosquito, the fly, and the Nazi soldier. Bold blackletters spelled out "Unite in a common cause-Destroy your enemies."These posters awakened in the people a consciousness for disease preventivemeasures and supplemented the disease control program effectively.
By 26 October, Colonel Cheyne noted in a visit to Foggia17that "* * * generalsanitation of town improving. Medical supplies discussed. I consider strongrepresentations should be made to Army to liberate some of the hospitalbuildings taken over. Called on A.D.M..S. 86 Sub Area who promised activecooperation."
On 8 November 1943, Colonel Cheyne notes, "Large numbersof refugees are returning to Foggia, a much bombed and damaged town. In additionlarge numbers of persons are coming through the lines. The responsibility ofredistribution is a joint Military and Civil one, the collection in the forwardarea is clearly a military one, the redistribution in back areas is clearly anItalian responsibility. This is accepted by all concerned."
Colonel Farinacci writes further on 19 Nov. 1943:18
Medical supplies for the Forward Areas are rapidly beingfurnished as quickly as transportation becomes available. Up to this date, boththe Provinces of Foggia and Campobasso have each been given approximately 10tons of Emergency Medical Supplies. The C.A.O.S. in the Forward Areas have beencooperating by taking back with them in their vehicles the Medical suppliesneeded for the communes they serve. * ** The supplies received thus far are adequate in quantity for the next severalmonths but unfortunately, the variety is too limited; for example there is greatneed for Sulphur Ointment for the Scabies which is very prevalent in bothCampobasso and Foggia; Insulin is non-existent in either of the two provincesand none has been received. The same deficiency exists with regards to SmallpoxVaccine and Diphtheria Antitoxin. Can there be a special request made of the15th Army Group, AMGOT for the above items, as well as for a supply of X-rayFilms and Sodium Hyposulphite for the X-ray Laboratory of the CampobassoCivilian Hospital? * * * Thegreatest obstacle to im-
17Tour notes, Col. D. GordonCheyne, MC, Director of Public Health, AMGOT, 15th Army Group, 26 Oct. 1943.
18Report, Lt. Col. Charles J. Farinacci, MC, Division ofPublic Health, AMGOT, to Group Capt. Benson, Commanding AMGOT, Eighth Army,Italy, 19 Nov. 1943, subject: Public Health.
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provement in Medical Care of the civilian population has beenthe lack of communication and transportation. * * *
In connection with the distribution of Medical Supplies Ihave given the Medico Provinciali permission to sell the medical supplieswholesale to Drug-houses and Pharmacies at the wholesale price established bythe Italian Minister of Interior and also have given permission to allow thesame Drug-houses and Pharmacies to sell retail at the same price standards. ** * These established prices are contained in [aBulletin published in 1935] with its amendments latest of which is dated 1939.
Reversion to Allied Control Commission
Foggia passed from AMG to ACC control in November 1943. Lt.Col. (later Col.) Thomas N. Page, MC, became the director of the Public Healthand Welfare Division of the newly created Region IV. While the situation inFoggia City was improving, difficulties were still being encountered in sewagedisposal, civilian hospitalization, and the handling of refugees.
Refugees from the North were averaging about 800 a day. Thesewere collected at railheads and transported to the south of Italy. No medicalscreening was possible because of a lack of trained personnel.
By February 1944, the major breaks in the sewage system hadbeen repaired, garbage and trash collection services had been reestablished, andone of the two medical laboratories in the city had been rehabilitated. Medicalsupplies were arriving in satisfactory quantities from Naples. DDT dusting ofrefugees had begun, the AMG, British Eighth Army, being responsible for thosecoming through the lines; the health authorities of Foggia City, then under thedirection of Lt. Col. Ewen G. Dalziel, RAMC, were responsible for other refugeesincluding those landing from Yugoslavia. One free soup kitchen feeding about1,160 persons per day was operating in Foggia, but hunger was not an acuteproblem. Infectious diseases did not seem to be unusually prevalent althoughreports were inadequate.
On 15 June 1944, the City of Rome passed from the control ofthe Fifth U.S. Army Allied Military Government and became a separate AlliedMilitary Government Region under ACC. A month later, Rome and the Provinces ofLittoria and Frosinone were added to the expanding Italian Government territory.19These provinces, particularly Littoria, had borne the brunt of thestalemate between the two opposing forces during the winter months up to andfollowing the offensive of 11 May 1944. Considerable destruction to building andwater and sewage facilities had occurred, but some balance had beenreestablished. There had been widespread disruption of civilian activities. Theditch system of the Pontine marshes had been completely disrupted by theGermans. Weed cutting barges had been sunk, motors of water pumps destroyed, andfalse connections between ditches made.
Nevertheless, the general health of the population seemed tobe good.
19See page 171 of footnote 2 (2), p. 295.
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Malaria was on the increase, but supplies of Atabrine wereadequate and an active malaria control program was in progress.20Hospitalization for civilians was, in general, adequate, but much equipment hadbeen looted or destroyed. Most of the medical practitioners were at their posts,but a shortage of gasoline restricted their activities. Medical supplies wereshort but not dangerously so, and civilian supplies had been supplemented bycaptured German military stocks as well as by CAD units from Naples.
Mine fields proved to be a serious handicap to theinauguration of malaria control programs as well as to ordinary agriculturalpursuits. The shortage of transportation influenced every phase of healthactivities.
On 1 August 1944, Rome Region combined with Region IV. Thisregion, which originally included Abruzzi and Lazio, was reconstituted as theLazio-Umbria Region, comprising the Provinces of Rome, Frosinone, Littoria,Viterbo, and Rieti in Lazio and the two Umbrian Provinces of Terni and Perugia."Region IV thus became a 'mixed' region, since in three of itsprovinces, Rome, Frosinone and Littoria, Military Government no longerprevailed, as they had been transferred to Italian Government territory, whereasthe four provinces to the north of Rome were still subject to Allied MilitaryGovernment."21 The staff of the Rome Region, whom General Humehad brought to Rome, took over administration of the combined region. The formerCommissioner for Region IV and his chiefs of sections were detached to organizeRegion XII which was eventually to encompass the northern Provinces of Venezia,Tridentina, and Veneto.
SARDINIA-REGION VI
The Germans spontaneously evacuated Sardinia and shortlyafterwards, on 4 November 1943, Company F of the 2675th Regiment arrived on theisland and established military government.22 No military engagementstook place on the island preceding our occupation, with the exception of a fewheavy bombing raids on the important seaports during May 1943, in which the Cityof Cagliari was severely damaged.
The AMG unit was under the command of Brigadier M. Carr(British), who served first as Senior Civil Affairs Officer and, later, asRegional Commissioner. Because of the housing shortage in Cagliari, the unitheadquarters was originally established in Sassari, an inland town of 60,000population. Besides the AMG unit, approximately 15,000 U.S. troops, consistingprincipally of the 42d Wing, Twelfth Air Force, operated bomber bases and otherairfields throughout the island.
In addition to the normal population of about 1 million,approximately 300,000 Italian troops were interned in Sardinia, thus addinggreatly to the
20Medical Department, United States Army. PreventiveMedicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington:U.S. Government Printing Office, 1963.
21See page 172 of footnote 2 (2), p. 295.
22This section is taken mainly from an account prepared byCol. Emeric I. Dobos, USPHS; see footnote 6, p. 304.
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problem of supplying food, which had to come mostly from themainland. No medical officer was assigned to the staff of Region VI until 1April 1944.
The most important public health problem was malaria, whichhad been made more acute by the suspension of virtually all preventive measuresduring the war and by the depletion of medical personnel by calls to duty withthe Italian Army. The chief medical officer of Region VI, Colonel Dobos, withthe advice of Col. Paul F. Russell, MC, Consultant in Malariology for ACC,instituted a malaria control program in the areas adjacent to Army bases.
NORTHERN ITALY
After the offensive in May 1944 and the occupation of Rome on4 June, the German forces retreated rapidly through central Italy, and foughtonly delaying actions for time to prepare a new stand on the Pisa-Rimini line.
The City of Rome was governed by AMG, Fifth U. S. Army, from 4to 15 June when it came under the jurisdiction of ACC as Rome Region. On 1August, it, together with the provinces of Frosinone and Littoria, was added toItalian Government territory. During this brief period, signs of jurisdictionalconflict developed between General Hume, the director of AMG, Fifth U.S. Army,and Brigadier Parkinson, the chief medical officer of the ACC. The swift advanceof Allied troops to the Arno brought province after province under AMG. Theliberated areas were damaged only slightly, and no serious civil health problemswere encountered.
Portions of Region V (Umbria and Marches) were taken over byACC from the British Eighth Army, and portions of Region VIII (Tuscany) from theFifth U.S. Army.
After the establishment of the Bonomi Government on 6 July1944 in Rome, progressively fewer supervisory functions were performed by theACC, and sharp reductions were made in personnel. A new policy was then adoptedto return to Italian control territory no longer in the operational area.Indeed, by the fall of 1944, a major reorientation of policy toward the Italianshad evolved, bringing with it an acceptance of the idea of long term objectivesincluding reconstruction and rehabilitation.
On 20 October 1944, the Italian Government assumedresponsibility for distribution of all civilian medical supplies in all ofliberated Italy through an organization named ENDIMEA (Ente NazionaleDistribuzione Medicinali degli Alleati). All payments were to be made centrallyrather than at regional level. AMG Fifth and Eighth Armies could use this agencyin territories under their jurisdiction if they so desired. Civilian medicalsupplies produced in Italy were to remain in the owners' hands for sale to thepublic, with only excess production going to regions other than the one in whichthey were produced.
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FIGURE 41.-Four Italians carry a civilian refugee wounded during the battle for Cassino to a nearby hospital.
Health Activities of AMG Fifth and Eighth Armies
The Allied Forces in Italy spent the winter and early springof 1944 in arduous combat before Cassino (fig. 41) and on the Anzio beachhead.There followed the rapid advances of May, June, and July to the Arno, wherethere was intense fighting during the last 2 weeks of August and the first 2weeks of September. The front was stabilized along the Gothic Line during thesucceeding winter. Finally, in the great forward movement of Allied troops inApril and May 1945, the rout of the Germans was so complete that the remainderof northern Italy was occupied within a few days.
With the reevaluation of the AMG-ACC relationship had come aclearer delineation of functions between the two organizations having to do withthe Italian civil population. In the area under Army control, AMG activitieswere to be primarily of an emergency nature and territory was to be turned overto ACC jurisdiction at the earliest possible moment. For example, during therapid advance northward, AMG medical and sanitary officers were attached to theArmies for the emergency phase, then dropped off for permanent assignment aspredesignated areas were captured and came
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under ACC control. Consequently, most of the AMG-ACC healthpersonnel acquired valuable field experience under combat conditions beforetaking over their more prosaic duties as area officials.
In December 1943, Headquarters, AMG, 15th Army Group, triedto create a permanent tactical public health organization with officers at eachCorps G-5 Section. It was never possible, however, to obtain the personnel tomeet these requirements; for the remainder of the Italian campaign, only twomedical officers were at Headquarters, AMG, 15th Army Group (Colonel Cheyne andMaj. (later Lt. Col.) Lendon Snedecker, MC) and one medical officer each atHeadquarters, Fifth U.S. Army, and Headquarters, British Eighth Army,respectively. Lt. Col. Thomas Parr, RAMC, the Senior Public Health Officer withAMG, Fifth U.S. Army, and Colonel Farinacci, who held a similar post with theBritish Eighth Army, had little more than a skeleton organization to deal withhealth problems in the Army areas.
From the reports for the period23whenthe Fifth U.S. and British Eighth Armies were making their major advances ofMay, June, and July 1944, it seems evident that AMG personnel were becoming moreproficient in using existing local governmental officials to the fullest extent.Furthermore, lessons had been learned concerning the vital importance oftransportation and communications. The medical supply situation was, on thewhole, immeasurably better than that encountered in southern Italy in respect toboth civil affairs medical supplies and those available in the newly occupiedterritory. Finally, it is evident that the American Red Cross personnel werebeing used in Army areas to a greater and greater extent.
Pisa, Florence, and other cities and towns, which were caughtin the heavy fighting along the Arno, had been heavily damaged, and in additionhad been subjected to a long siege (fig. 42). The pattern of events in Naples,Foggia, and other cities of southern Italy was being repeated. Hospitals werefound to be in bad condition, both from the standpoint of physical destructionand from that of pillaged equipment and supplies. In addition, the heavy rainsof September and October had aggravated the destruction of buildings andequipment exposed by shell-damaged roofs and walls. A major effort, in whichthe Red Cross took a leading role, was directed toward getting the remaininghospital, first aid, and social welfare facilities and equipment under cover.In some forward areas, especially in the mountain communities along the GothicLine, winter weather forced Allied troops into covered billets which, in a fewplaces, included hospital space, thereby increasing the problem ofreestablishing ambulatories and hospitals for civilian casualties.24
23Public Health Reports, Fifth U.S. Army. Allied MilitaryGovernment, City of Florence, 1944, with appendixes.
24Report, George H. Bickel, Supervisor, Red Cross WarRelief, 5th Army, AMG, to Lt. Col. T. Parr, RAMC, Senior Public Health Officer, AMG, 5th Army, and MasonH. Dobson, Director, Civilian War Relief ARC, subject: Red Cross War Relief Operation Report, 5th ArmyCombat Team, September 1 to November 1, App. D.
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FIGURE 42.-An Italian child, wounded in a forward war area, is treated at a Fifth U.S. Army Refugee Center aid station in the Florence area.
In Florence, particularly, the main aqueducts had beendamaged and the water supply remained crippled for weeks. The AMG sanitationofficer, on starting work there on 1 September 1944, described it succinctly:"The chief problems that constituted serious public health hazards were:(a) No water. (b) Broken sewers and heavy collection in the sewers of solidmaterial resulting from unsufficient water to properly flush them. (c) Anaccumulation of over 2000 cu. meters of garbage on the streets with practicallyno transportation to move it."25
The report for October showed that the sanitary situation hadimproved considerably although, in November, the two main aqueducts were stillnot functioning.
Despite the disruption of sanitary services, no diseaseoutbreaks of importance occurred. The incidence of typhoid fever was high, butit had been rather high in this area even in normal times so that the situationseemed to be only slightly worse because of the war damage.
25Monthly Report, Capt. Edmond A. Turner, SnC, Allied Military Government, Cityof Florence, to SPHO, Florence City, 19 Oct. 1944, subject: Monthly Report for September,App. G.
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Closing Phases of the Italian Campaign
With the rapid surrender of the Germans in the north duringMay 1945, large sections of northern Italy came under the jurisdiction of theFifth and Eighth Armies, quickly passed to the ACC, and, in turn, reverted tothe regularly constituted Italian Government.
Damage within the Po Valley was generally limited to largecity communications centers and to the Alpine areas along the Brenner Passrailroad line. In addition, limited but intense destruction in certain Alpinevillages had been done during reprisal raids on partisan forces.
Although few hospitals had been destroyed in the rout of theGermans, virtually all bed space was filled by German sick and wounded to theexclusion of the civilian population, a condition which had existed during thepast year. In Verona, for example, 1,000 general hospital beds and 800 beds fortuberculous patients had been in German hands. Despite damage to the two mainhospitals of the city during the last stand of the Germans along the Adige Riverat Verona, 1,800 beds were returned to civilian use by 1 June 1945 through theefforts of AMG, Fifth Army, and cooperating American Red Cross personnel.26
Liberation of northern Italy also brought the problem ofhandling large numbers of refugees and displaced persons who poured through theBrenner Pass from Austria. Typhoid fever, tuberculosis, and malnutrition werethe principal health problems encountered; an antityphus program was institutedand this disease presented no problem.
Section II. Problems and Lessons of the Italian Campaign
Military Government problems in the health field were morenumerous and extensive in the earlier months of the Italian campaign, when theAllied armies were successively invading and occupying Sicily and southernItaly, than they were in the latter half of the campaign when the area involvedwas mostly that part of Italy north of Rome.
Not only were health problems normally greater in southernItaly but also, at all levels, personnel concerned with civil public healthwere much less experienced than later in the course of the campaign.
In addition to the administrative difficulties to whichreference has already been made, the problem of transport, or rather the lack ofit, loomed larger than any other. Likewise, problems of medical supply andmedical and health personnel presented difficulties which, in turn, affected themanner in which other civil health problems were met.
26Memorandum, George L. Bickel,Supervisor, Civilian War Relief, ARC, Fifth Army, AMG, to Col. Thomas Parr, SPHO,AMG, Fifth Army, and S. John Crawley, Director, CWR-ARC Mediterranean Theatre, 7June 1945, subject: Civilian War Relief Operations May 1, 1945 to June 1, 1945.
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TRANSPORTATION
In report after report covering military government healthactivities in Sicily and Naples, mention is made of the lack of transportationfacilities for Allied Military Government personnel, for Italian physicians andothers engaged in health activities, and for essential medical supplies. Acontemporary report states:27
(Deficiencies in the civil health program may be attributedlargely to) inadequate transportation facilities for key public health personneland medical supplies. In the Italian operation AMG medical personnel wererepeatedly sent into an area to organize and direct a civil health programwithout any means of transportation whatsoever. This is extremely wasteful ofmedical manpower. In the early days of occupation it is not possible to mobilizecivilian physicians, organize hospitals, provide essential medical supplies, andobtain additional transportation facilities without the means of getting aroundthe community. While existing Tables of Equipment appear to be adequate, actualtransportation frequently is still not available for transport of directingmedical personnel and supplies.
It is scarcely possible to overemphasize the effects of thedeficiencies in transportation facilities and in medical supplies. Thissituation became particularly acute when Military Government officials in Napleswere confronted with a rising rate of typhus fever cases. With the assistance ofthe team of experts headed by Dr. Soper of the Rockefeller Foundation, a programof typhus control was developed, but this program could be only partiallyimplemented until army vehicles were made available through the Peninsula BaseCommand.
This episode not only dramatically showed the potentialitiesof preventive medicine, but also contributed to an understanding on the part ofArmy authorities of the importance of transportation in the civil healthprogram.
PERSONNEL
In general, the policy was to maintain to the maximum extenta numerical balance between American and British personnel in the public healthprogram.28 However, at no time were the British able to provide theirfull share of personnel (see pp. 34, 454).
A fact which led to a considerable disturbance of the moraleof the officers was that many of them lost their opportunities for promotionassignments when they were transferred to Military Government and assigned toCivil Affairs training centers in the United States. Many of these men hadexcellent public health specialist qualifications, yet they were servingoverseas as lieutenants and captains because tables of organization were notsufficiently liberal. Because promotion policies were quite rigid, it was notpossible to promote them during this campaign
27See footnote 10, p. 312.
28Starr, Lt. Col. Chester G.: From Salerno to the Alps, 1943-1945:A History of the Fifth Army. Washington: Infantry Journal Press, 1948, p. 486.
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although their training and experience in the United Statesand the positions of great responsibility which the average officer held inSicily and Italy warranted promotion for most of them.
The combined operation in Italy showed the excellent abilityof public health officers of Great Britain and the United States to work in theclosest harmony and fellowship.
While relationships at the personal level were usuallyexcellent, jurisdictional disputes plagued the early months of AMG-ACCoperations in Italy. This perhaps was largely due to the historical rigidity ofcommand patterns in which personnel assigned to one command pass from thecontrol of the assigning command. For example, medical and sanitary officers,held in the officers' pool of Tizi Ouzou, were eager to move into operationalareas under the control of AMG, 15th Army Group, for field experience. The 15thArmy Group, however, would accept these officers only on permanent assignment.Despite the need for such personnel on the one hand and the desire of theofficers on the other, AMG would not agree to accept the temporary assignment ofmedical personnel who later would be needed in the area operations under ACC.
One of the principal problems of the 15th Army Group was theinability to obtain sufficient officers, particularly specialists, to fill thetable of organization. This meant that Headquarters, AMG, was unable to give thevarious provincial region public health officers enough supervision andcoordination. The chief reason for this was the inability of the British tofurnish their quota.
The absence of trained nutrition officers on the staff ofHeadquarters, 15th Army Group, made it difficult to furnish the best advice tothe supply division regarding the nutritional status of the Italian people inthe conquered areas, during the period from 10 July to mid-November 1943, beforeACC was activated.
CivilianCasualties
The initial problem during the beach assaults and the pushinland was one of providing medical care and hospitalization for civiliancasualties. Modern warfare is extremely mobile and, frequently, the moving frontexposes large numbers of civilians to the hazards of bombing, strafing, andartillery and small arms fire. Italian air raid precautionary services werepoorly organized. Large underground, concrete shelters had been provided in manycommunities, especially in the larger cities, and the rocky terrain in parts ofSicily and southern Italy provided shelter in the form of caves, but all toooften raids came without adequate warning and large numbers of people werekilled or injured.
As our troops moved forward, the sick and injured frequentlybecame a severe burden on forward military hospitals. Military Government publichealth officers were helpful in transferring these patients to undamaged
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Italian hospitals which could care for them, but thisactivity was hampered by a shortage of civilian and military ambulances andgasoline.
In December, Headquarters, AMG, 15th Army Group, developed aplan to alleviate the forward medical problems. This consisted of establishing asmall pool of Italian doctors, usually three, at Army level, who could bedeployed as required when special problems arose in forward areas. As the smallpool was depleted, it was refilled. Subsequently, ACC "drafted"Italian doctors for assignment where civilian medical care and the services ofphysicians were required.
Local Health Administration
One of the first problems faced by the Military Governmentpublic health officer was the reestablishment of local health administration,including the use of existing public health personnel when they appeared to becompetent. In some instances, it was necessary to replace them with newpersonnel who were often untrained and without previous public healthexperience. These Italian health officers were instructed in their dutiesverbally and by written directives. The larger health departments in cities likePalermo, Messina, Catania, and Naples were all understaffed. Transport wasvital, particularly for the provincial officials and the heads of healthdepartments of larger towns and cities, but at first, there were almost novehicles. However, 1 to 2 months after an area was occupied, it was usuallypossible to requisition cars for these higher officials.
Hospitals
Contrary to expectations, relatively little damage was doneto most hospitals in Sicily and southern Italy although, when time permitted,the Germans methodically removed or destroyed all medical supplies andequipment. In most instances, patients with chronic diseases had left thehospitals because of the war, and, on many occasions, weekly bed occupancyreports in Sicily showed a high percentage of unoccupied beds. It should not beinferred from this that the number of beds per capita was ideal, but ordinarilythere were enough to satisfy demands.
A contemporary report of the situation in the Civil Hospitalof Campobasso, when it came under the supervision of AMG on 3 November 1943,illustrated some of the problems encountered in southern Italy. There were 73patients in a hospital with a capacity of 50 beds. There were no dressings andmost important drugs were in short supply. There was no method of workingautoclaves and no major surgery was being performed. Most of the patients in thehospital were battle casualties from mine or grenade accidents and phosphorus orpetrol burns; many of them were children. The only way to obtain food was forthe Mother Superior of the hospital to forage around the community each morning,but these efforts yielded progressively less as food became scarcer. Within 3days after the
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hospital came under AMG jurisdiction, essential drugs,dressings, and plaster for fractures had been made available, corpsmen had beenassigned to various administrative duties, and a surgical team from one of thetactical medical units had cleaned up the backlog of surgical cases.Supplementary rations were provided from military supplies.
The most frequent type of damage to hospitals was loss ofroof tiles and glass as the result of blast rather than from direct hits bybombs. Replacing the glass was virtually impossible and the tiles were replacedwith considerable difficulty. Hospitals were generally poorly equipped, fuel andother utility services were frequently badly disrupted, and often they eitherwere understaffed or were staffed with nurses and others whose work would beconsidered substandard in the United States. A shortage of hospital facilitiesin Palermo and Syracuse, Sicily, was brought about primarily by the occupancy ofbuildings by military medical services. For example, many buildings of thePalermo University Hospital which had not been destroyed by our bombing wereoccupied by one, and later by two, American evacuation hospitals. In December1943 when it became apparent that this was preventing the reopening of theUniversity of Palermo Medical School, upon representation by Colonel Williams ofACC, the Commanding Officer of the 59th Evacuation Hospital, Col. Oral B.Bolibaugh, MC, agreed to move it to another location.
In Syracuse, one of the few large mental hospitals on theisland was taken over progressively by British Eighth Army hospitals. It becamenecessary to double up already crowded patients and, later, to move a thousandto other places. Several provinces which had no facilities for hospitalizationof mental patients sent their cases to Syracuse on a contract basis. The onlyother institution available at the time to which Syracuse cases could beevacuated was in Agrigento, several provinces away. When movement was attemptedby train, great difficulty was encountered. Because the train was very slow,many patients died en route and some escaped. A deficiency in the whole MilitaryGovernment program was the failure to allocate early those civilian medicalfacilities not required by Allied medical units and which would be available forcivilian use.
Many hospitals had splendid facilities for isolating patientswith communicable diseases, but all too frequently little effort was made to usethem. A very definite shortage of beds for tuberculosis existed in both Sicilyand southern Italy.
Civilian Medical Personnel and Medical Schools
Although most physicians were well trained and of highcaliber, many of the older ones were quite primitive in their knowledge andmethods. There was relatively little specialization except in some of the largercities. The Italian Government had made some effort to improve medical care andhad stimulated the training of specialists. Dentists and technicians were
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sparsely scattered in the area, and the incidence of dentalcaries was high. Nursing standards generally were low in southern Italy andSicily. Midwives were used extensively although, despite the relatively rigidtraining required under the Italian public health code, many of them were poorlytrained.
In general, professional problems were considered to beItalian problems. Our forces were not in Sicily and Italy to improve the qualityof Italian medical care except when this helped to protect the health of ourtroops by preventing the spread of communicable diseases, or when improvementwas necessary in preventing civilian unrest, which might have interfered withthe total Allied military effort.
It must be said to the credit of the Italian medical andrelated professions that they cooperated wholeheartedly in carrying out the AMGand ACC-AC programs during this period.
A prominent defect in the professional program was the lackof a directive from AFHQ defining the status of captured Italian doctors andnurses. A timetable for their release should have been set up, but as it was,these doctors and nurses frequently sat in prisoner-of-war camps when they couldhave been used profitably in caring for civilians. Had such a program been ineffect, American and British medical personnel would have been relieved of muchof the burden of caring for civilians and could have devoted more time to thecare of Allied casualties and to other necessary duties.
COMMUNICABLE DISEASES
The most prevalent communicable diseases were malaria,venereal diseases, and tuberculosis. The first two were extremely importantbecause of the danger of their spreading to our troops. Tuberculosis undoubtedlywas important, too, in view of the extensive fraternization of our troops withItalian civilians, but its effect on the troops was not immediately apparent.Typhoid fever was a grave local problem, but the sanitary discipline of ourtroops was sufficiently good to prevent its becoming a serious cause of illness.Louseborne typhus fever first became a threat in the Naples area in the latefall of 1943, and by the end of the year, a considerable epidemic was raging inthat city. The effectiveness of immunization and louse control methods wasevident since troops were practically free from typhus. Sandfly fever and acutecatarrhal jaundice did not appear to be special problems in the civilianpopulation although they did cause trouble to our soldiers in Sicily.
Malaria
The greatest concentration of malaria in Italy was found inSicily and Calabria. In the early days after battle, getting accurate reports ofthe current incidence was difficult. In one commune, Teresa de Riva, at the east
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base of Mount Etna, 1,072 cases were reported in the month ofAugust 1943. Of this number, 342 were primary and 730 were recurrent; 1,000 weretertian, 37 were quartan, and 35 were estivo-autumnal malaria. The population ofthis community had been 8,300 and was estimated to have increased in August to11,000 with the influx of refugees.29
The terrain of the south, especially in coastal areas, andthe climate were especially conducive to mosquito breeding. Several narrowcoastal plains contained many irrigation ditches and much brackish water. Inaddition, our bombing and shelling had made many craters which were waterfilled, and these had frequently dammed up ditches which were part of irrigationand malaria drainage projects. In one instance, Army Engineers prepared anemergency landing strip on the north coast of Sicily, filling in severalimportant drainage channels. When the rains occurred, serious mosquito breedingproblems were created.
In prewar times and until 1943, tree quinine, furnished bythe Italian Government, was obtainable in tobacco shops. Most provinces ofSicily and Calabria had provincial malaria laboratories, but lack of personnelhad greatly reduced activities during the war. The Italian Red Cross ran anumber of ambulatory clinics, and many other agencies were involved in theoverall field control program. Unfortunately, the programs of the individualagencies lacked adequate coordination.
Provincial antimalaria committees did a measure ofcoordination by advising some of the malaria control agencies on the technicalaspects of control. However, they gave advice only when requested, and theactual control remained with the individual organization. Furthermore, lack ofcentral coordination for the whole of Sicily led to many undesirable situations.The Provincial Genio Civile did some ditching and dusting but frequently farmedout the antimalaria work to private contractors. This practice produced verypoor results in many areas for the amount of money spent. The organization forthe colonization of Sicily also did malaria control work as did the Consorzio diBonifica. The latter received some funds from the Ministry of Agriculture;however, practically all of the other organizations received the bulk of theirfunds from the Ministry of Interior.
A beginning was made by Military Government in 1943 towardthe creation of centralized control of malaria projects for the 1944 malariaseason in Sicily. This centralized control was vested in the ProvincialAntimalaria Committee. An Island antimalaria committee was planned to coordinatethe Provincial work.
By the end of 1943, more than 2,000 men were employed onvarious malaria control projects. During the fall of 1943, the greatest effortwas directed toward areas near our troop concentrations and airfields.
Large stocks of Atabrine were found in captured Italianmedical
29See page 19 of footnote 3, p. 298.
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FIGURE 43.-Col. Paul F. Russell, MC.
supplies, and an effort was made to start free distributionof this drug. However, its use for civilians was usually restricted to thosealready suffering from malaria. Stocks of quinine which were found were kept byour military supply authorities. Adequate quantities of paris green were on handin a few limited areas, and requisitions were prepared for oil and additionalparis green to be used in early 1944. DDT was not available for mosquito controluntil that summer. Paris green was favored because officials and workers hadbeen trained in its use and were more familiar with it than they were with theuse of oil. However, oil was more generally available for civilian programs.
Malaria control was considerably handicapped by the shortageof transportation for control workers and their required supplies. All malariacontrol activities during this early period were the responsibility ofLieutenant Manzelli. In view of the size of the problem and despite hisexcellent work, this was inadequate staffing.
In line with earlier recommendations30and upon request of ACC, the expert malariologist,Colonel Russell (fig. 43) was sent from the SGO and placed in charge of theMalaria Control Branch of the Public Health Sub-
30See footnote 10, p. 312.
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Commission, ACC, in April 1944. He had the assistance ofthree officers, including Lieutenant Manzelli as entomologist. Directcommunication on malaria control matters was authorized between the Chief ofthis branch and regional and Army civil public health officers; monthly reportscovering malaria surveys and control activities were required;and highest priority was given to control measures in thevicinity of Allied military establishments. An extensive control program basedon drainage, filling, oiling, and the proper treatment of civilian cases wasinaugurated. This program was timely since the onset of warm weatherforeshadowed a tremendous increase in the malaria problem.31
Venereal Diseases
No reliable statistics were available on the various venerealdiseases for Italy as a whole. However, the experience of individual venerealdiseases treatment clinics indicated that syphilis, gonorrhea, and chancroidincidence was high. The activities of detection and treatment clinics haddecreased during, and toward the end of, the war; hence, vigorous efforts byMilitary Government were required to stimulate the reopening and expansion ofthe clinic program.
Italy had a system of licensed prostitution and, in thelarger cities, had inadequate programs to control venereal diseases in thisgroup of women. As far as our troops were concerned, this disease problem wasconsiderably expanded with the enormous growth of clandestine prostitution.Italian police services had disintegrated considerably and their efforts tocontrol licensed and unlicensed prostitutes were feeble and ineffective. InSicily, and for a short time in Italy, some of the existing brothels were takenover for the exclusive use of U.S. troops.32
Shortage of qualified personnel in Military Governmentpublic health in the initial period prevented the assignment of an officer tofull-time venereal disease control activities before the arrival, in the fall of1943, of Maj. John A. Lewis, Jr., USPHS, a well-qualified venereal diseasecontrol officer. He attacked the problem with great vigor and was influential incausing the Italians to set up improved detection and treatment facilities, andin bringing about a system for examination, detention, and treatment of women inthe infectious stage of their disease.33
* * * In every city and large town in Italy the problem wasthe same; promiscuity and high venereal disease rates. Repeated conferences wereheld by the Venereal Disease Control Officer of the AC with medical and provostmarshal officers of the headquarters of both British and American troopsthroughout occupied Italy in an effort to
31For full details concerning the evolution of theoutstanding control program directed by Colonel Russell, see footnote 20, p.318.
32Medical Department, United States Army. PreventiveMedicine in World War II. Volume V. Communicable Diseases Transmitted ThroughContact or by Unknown Means. Washington: U.S. Government Printing Office, 1960.
33Report, Maj. John A. Lewis, Jr., USPHS, Surgeon, DistrictNo. 3, 7 Dec. 1945, subject: Report to the War Department-History of CivilAffairs in Italy, pp. 11-14, 22-26. [On file at The Historical Unit, USAMEDD,Fort Detrick, Frederick, Md.]
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decide on a definite policy directed towards reducingexposures by the suppression of clandestine prostitution. In January of 1944,the Director of the Public Health Sub-Commission agreed that the Allied Commissionshould take the initiative and coordinate a cooperative program with allheadquarters of troops in Italy. The Director of the Legal Sub-Commission agreedto publish the laws on venereal disease as it applied to the control ofprostitution and working through Italian government channels to obtain betterenforcement of Italian law directed against clandestine prostitution. Theprogram as it pertained to the AC consisted in (1) a repression of clandestineprostitution, and (2) the provision of medical diagnosis and treatment, forclandestine prostitutes suspected of infection. In addition, it was understoodthat the Venereal Disease Control Officer would request the various headquartersthroughout Italy to put all houses of prostitution off-limits to their troops,and to request that they enforce the order using military police. In order tocarry out the first part of the program, repression of clandestine prostitution,police action was required and this meant the close cooperation between MilitaryPolice, Italian police and AMG Public Safety Officers. It was not possible forthe Italian police to do the job alone; very often it would be necessary for anItalian police to arrest a prostitute in the company of an American or Britishsoldier. Unless there was an Allied Military Police along to protect the Italianpolice, a fight would be started between the soldier and the Italian policeman;this happened on several occasions. For this reason, early in the program it wasrealized that vice squads should be started consisting of Allied soldiers andItalian police. An Allied Military Policeman would accompany an Italianpoliceman and be present at the time of each arrest. Early in January, 1944, theVenereal Disease Control Officer of PBS (Peninsula Base Section), the Surgeon ofthe Metropolitan Area, the ADH of the 55th area of Naples for the British, andthe Surgeon of IBS (Island Base Section), arranged with their Provost Marshal tocreate vice squads. Later on vice squads were formed in other Italian cities.The vice squads consisted of an officer and of several enlisted men. ** * Italian police, or Carabinieri were assigned towork with the vice squad men. The actual arrests were made by the Italian policeusually but sometimes by the Military Police and then the girl was turned overto the Italian police. The arrest, charges, and results of examination were allrecorded at the Questura (the police station) and made available to the AMGPublic Safety Officer. The Public Safety Officers of AMG were repeatedly urgedby the Venereal Disease Control Officer of the Allied Commission to keep thenumber of arrests high in order to discourage clandestine prostitution. In turn,the Public Safety Officers applied pressure on the Italian Police Officials, whoin turn ordered the Italian Police to increase their activities in combattingclandestine prostitution. In addition, the Ministry of Interior was induced bythe Allied Commission to send to the Prefects, a decree calling for morevigorous enforcement of Italian laws with regard to clandestine prostitution.The net results of these activities were that a great many women were arrestedin the larger cities of Italy on suspicion of clandestine prostitution withAllied troops. * * * Followingintensive activity to repress clandestine prostitution it appeared that someheadway was being made. Both Italian and Military Police reported that there wasa decline in clandestine prostitution. * * *
The treatment of venereal diseases was the most profitable ofall the specialties of medicine in Italy. One could not but be impressed withthe large numbers of signs advertising Specialist in Venereal Diseases. When theAC moved into Naples about the middle of December, it was noted that some of theItalian venereal disease specialists were advertising venereal diseasetreatments to troops. It was learned that many American soldiers were reportingto Italian physicians for treatment of their venereal diseases instead ofreporting their infection to their unit commanders. A determined effort was madeby AMG to stop this practice. The Medico Provinciale was told by the RegionalPublic Health Officer that it was strictly prohibited for any physician to offeror to give treatment for venereal disease to either an American or Britishsoldier. A threat
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was made by the Regional Public Health Officer to suspend thelicense to practice of any Italian physician who did not comply with the order.In addition, Military Police were instructed by the Venereal Disease ControlOfficer of PBS to remove these signs wherever found. It was believed that thisaction was relatively successful in breaking up the practice of [Italian]physicians treating Allied soldiers infected with venereal diseases.
In January and February of 1944 visits were made to all ofthe larger towns in Italy, Sicily and Sardinia occupied at that time tocoordinate activities of AMG-ACC, Italian Health Organization and TroopActivities. These took the Venereal Disease Control Officer to Palermo, Catania,Syracuse, Messina, Trapani, Lecce, Taranto, Brindisi, Cagliari, Sassari, Caserta,and the towns neighboring to Naples as well as Salerno. In all of these placesemphasis was placed in getting hospital beds for venereal disease patients,creation by the Military Police of vice squads for the repression of clandestineprostitution, enforcement of the "off-limits" policy of houses ofprostitution, and of parts of cities where contacts were most frequent. * * *
When the houses of prostitution were put "offlimits," 31 December 1943, there was an immediate fall in the number ofprophylaxis given, but at the same time that the houses of prostitution were put"off limits," Naples itself was put "off limits" to visitingtroops, because of the typhus epidemic figures. Prophylaxis given by PBS inNaples December 1943, 49,052; January 1944, 14,787. As a result of numerousconferences with the various headquarters, 7th Army, IBS, Sardinia Garrison,PBS, Metropolitan Area, 15th Air Force, 12th Air Force Service Command, BritishDistricts 1, 2 and 3, and their areas and sub areas, it was agreed, that theagreed upon policy should be reduced to writing in the form of a directive andcirculated to all concerned and that this policy should contain specificinstructions for the Italian physicians as regards diagnosis and treatment.After discussion of the points with various sections of the Allied Commission itwas decided to produce a directive addressed to the Regional Commissioners ofthe Allied Commission relating to this subject. * * *
Prior to the issuance of this directive the Director of thePublic Health Sub-Commission arranged a conference with Doctor Vezzoso, theChief Physician of the Italian Government and his advisors and the Public HealthSub-Commission on the subject of venereal disease control. The program of thePublic Health Sub-Commission was explained by the Venereal Disease ControlOfficer and emphasis was placed on the fact that the Allies considered thevenereal disease problem of its troops serious enough to warrant more effectivemeasures for its control by the closest cooperation of all military andcivilian authorities was suggested (really ordered!). The outlines of policy wasdiscussed, which called for more strict enforcement of existing laws and theexpansion of the hospitalization program. Directives on subjects went out fromthe Italian Government to the various Provinces explaining that the allies hadrequested that more effective action be taken and called for strict enforcementof laws against clandestine prostitution and for the hospitalization ofinfected prostitutes. These directives made negotiation with Italian ProvincialOfficials much simpler. Venereal disease rates showed a decline in the earlymonths of 1944.
Typhoid and Paratyphoid Fevers
The enteric diseases were endemic among civilians in Sicilyand southern Italy. It was not uncommon for a small town of 5,000 to 10,000people to have 40 to 60 current cases of typhoid and paratyphoid fever duringthe summer and fall of 1943. Much of the disease was water-spread, although insome coastal areas, seafood infection and infection from vegetables fertilizedwith night soil were common. Poor home nursing and
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infrequent isolation of cases led to much contact spread. Theimportance of the innumerable flies in the area in spread of the disease isunknown.
Water was frequently drawn from unprotected wells. Latrinesof primitive construction were often placed near wells and, worse still, manypersons did not bother to use a latrine and were not particular about whereexcrement was spread.
Chlorination of water supplies, the collection of sewage inclosed systems, and sewage treatment were practically absent in southern Italyand Sicily, except in a few of the larger cities. Even then, only a smallportion of the population of these cities was served by piped systems. In manyinstances, Military Government sanitary engineers assisted communities to buildmakeshift chlorinating apparatus and supervised the chlorination of local watersupplies.
Much effort was made to bring about a better system ofisolation of typhoid patients in hospitals since control measures in the averageItalian home where typhoid cases existed were usually so primitive that most ofthe nonimmunes in the same home also contracted the disease.
Vaccine for immunization was made available by MilitaryGovernment, but extensive immunizations were undertaken in only a few townswhich had a continued high incidence of typhoid fever.
Tuberculosis
Tuberculosis was a considerable problem in the civilianpopulation. A number of provincial tuberculosis clinics had been established,and before the start of the war, the Italian Government had begun makingtuberculosis surveys. However, this work had lagged during the war, and the workof building facilities for the hospitalization of patients had not moved apacewith the casefinding program. The few tuberculosis sanatoriums that were foundin southern Italy were crowded with incurable cases while convalescent patientsoften were released too early.
In general, Military Government was too busy with acuteproblems which had an obvious bearing on the health of troops, and with theurgent day-to-day health problems of Italian civilians, to do very much abouttuberculosis in the early period when specialist personnel were scarce.
Acute Communicable Diseases of Childhood
The incidence of diphtheria and other acute communicablediseases of childhood was high throughout the area, and the Italian provincialhealth authorities were urged to improve their control. Efforts were made toreestablish immunization programs against smallpox and diphtheria, and thenecessary biologicals were furnished.
Because of the destruction of communications, a completebreakdown in reporting communicable diseases occurred. Military Governmentpublic
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health officers attempted to reestablish it and, by the endof January 1944, haphazard reporting was in progress.
Trachoma
Trachoma should be mentioned as an important civilian healthproblem, particularly in Sicily. Infection rates were extremely high and theItalian Government had established trachoma clinics in small provincial capitalsand in many of the smaller communes. In addition, an effort had been made in thelarger cities to segregate children in special schools for trachoma cases. Theantitrachoma work had virtually come to a standstill during the war and wasslowly being reestablished in the initial Military Government period.
Scabies and Impetigo
Scabies and impetigo deserve special mention since theincidence of these diseases was extremely high in the population of southernItaly and Sicily, especially in children. An effort was made to supply thematerial needed for treatment. It was difficult to provide sufficient sulfurointment for the treatment of scabies in the early period. Actually, Sicilyhad many large sulfur mines, but the lack of ointment base made it impossibleto use the local sulfur adequately; consequently, little progress was made inthe control of these two diseases. Overcrowding, the acute shortage of soap, andpoor habits of personal hygiene were factors in the continued high incidence.
CIVILIAN HEALTH ACTIVITIES
Laboratory Services
Virtually every province had a small laboratory to whichdoctors could send specimens for examination. Unfortunately, the lack oflaboratory supplies and, in many instances, the destruction, requisitioning, orlooting of laboratory equipment, especially microscopes, by civilians or Alliedtroops, made it almost impossible for many laboratories to functionsatisfactorily. Military Government public health officers tried to redistributeexisting supplies of materials to equalize and provide essential public healthlaboratory services to all.
Maternal and Child Health
Part of the Fascist plan was to build a healthy,childbearing, and prolific womanhood; hence, an extensive system ofmaternity and child health clinics had been created. These clinics had ceased tofunction during the latter part of the war and were reopened very slowly by theItalian
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authorities. In some areas, reestablishment of the programwas retarded by the lack of transportation and because this activity had beensupervised by the party rather than by local and provincial health officers.
Infant and maternal mortality rates in southern Italy werealways high. The rate in Sicily per 1,000 births in 1939 was 127, compared with97 for Italy as a whole and 48 in the United States.34 During thewar, rates are alleged to have gone considerably higher. Enteric diseases werethe commonest causes of infant deaths under a year, with respiratory diseasesrunning a close second.
Smallpox vaccination was compulsory within the first 6 monthsafter birth, with revaccination required later. To continue this program,smallpox vaccine was imported from the Pasteur Institute in Algiers.
Diphtheria immunization was made compulsory in 1939. However,when it was discovered that immunization had not been extensively carried out insouthern Italy and Sicily, efforts were begun to reestablish and improve thisprogram.
The Fascist Party operated the ONMI (Opera Nazionale per laProtezione della Maternit? e dell'Infanzia). This semiofficial agency wasextensive and did much work for indigent mothers and young children bysupervising foster homes, caring for orphans, and operating prenatal clinics,day nurseries, and child and maternity feeding stations.
The Fascist youth movement organization, GIL (Giovent?Italiana del Littorio), operated a number of dispensaries for children andconducted antituberculosis, malaria, and trachoma programs. These programs werefinanced by the National Government and by individual taxes and contributions.They were abolished by the Military Government, and their programs ceased tofunction in Sicily. In cooperation with the welfare officer of HQ, AMG, 15thArmy Group, Major Witte, a partially successful effort was made to reestablishmany of the activities described. The local and provincial public health andwelfare heads were made responsible for these programs and given moreresponsibility than ever before. Thus, the establishment of an integrated publichealth program was begun.
A plan was made to avoid closing all ONMI and GIL activitieson the mainland when these Fascist organizations were abolished. This workedsuccessfully in Naples.
Sanitation
The primitive sanitation in Sicily has been mentioned. Atfirst, because of an expectation of inadequate water in Sicily to supply bothcivilian and military needs, large quantities of water were taken by the assaultforces for use as ballast in the ships. This proved unnecessary because an amplesupply of water was found in Sicily. In general, the supply was from wells
34War Department Technical Bulletin (TB MED) 178, July 1945,subject: Medical and Sanitary Data on Italy.
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and springs; and in the average town, the water was dippedfrom wells in buckets. In the larger cities, there was a piped supply althoughfew people had water piped to their houses. The typical method of collectingwater in some larger cities was to open a submerged tap in the sidewalk or inthe street and, with a small container, to dip water out of this hole into alarger container.
On the whole, the water was fairly pure at the sourcealthough occasional instances of contamination by sewage were found. In Naplesand several larger cities, water was piped from the nearby mountains throughaqueducts. A number of these were broken in the course of the fighting, but theywere repaired by the Italians and Army Engineers with very little difficulty.
In general, little treatment of sewage was carried out inSicily and southern Italy. A few cities of 50,000 population or over did havepipe sewage from a portion of the city to various inadequate disposal plants.Sewage and water mains often were found side by side, ruptured by bombing orshelling, thus contaminating the water.
Kitchen and other household refuse usually was dumped intothe street or road in front of the houses in the various cities because of thebreakdown in transportation. Then, the Military Government Public Health officerhad to reorganize the disposal of refuse; this was done by arranging for pickupby mule carts and dumping outside the town.
Refugees, Displaced Persons, and Housing
Refugee problems were always acute in the areas through whichthe moving battlefront passed. The civilians tended to move laterally from theareas of the principal thrusts, and then to return to their homes after thefront moved on. Occasionally, as occurred on the east side of the Apenninesnorth of Foggia, tens of thousands of refugees moved back as the German lineswithdrew; then, when the fighting became static, they began to move both throughthe lines and up onto the Apennine ranges lateral to the lines and, finally,south and into the British Eighth Army area. These refugees constituted adifficult problem because often more than 1,000 a day came through the lines,interfering with Allied operations. Arrangements were made to receive them atforward interrogation points, and to move them by truck to entraining pointswhere they began their long journey south on empty supply trains or specialpassenger trains. A limited number of Italian doctors with kits of medicalsupplies accompanied them. The Italian Government in Brindisi arranged with theprefects of the various Provinces of southern Italy to absorb the refugees inthe southern area by communes. The practice of moving them so far from theirhomes may be questioned, but this was entirely the responsibility of the ItalianGovernment.
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Bombing of houses had created another serious refugeeproblem; thousands of people were homeless and were living in caves and air raidshelters. The town of Augusta, Sicily, which was an Italian naval base, washeavily bombed and completely destroyed. Its approximately 20,000 inhabitantswere living in a series of caves north of the city. Fewer than 100 civilians,mostly the aged and infirm, remained in the town. The problem of organizing therefugees in the caves and caring for them proved to be difficult. Fortunately,many doctors who had practiced in the community remained with them and workedheroically to provide medical care. Later, many of these people were distributedto other eastern Sicilian communities.
It was always difficult to disperse refugees through anysystem of billeting in the homes of others for the simple reason that theaverage Italian household was already overcrowded. Censuses showed the averageroom in an Italian house already accommodated three to four individuals. Cookingwas frequently done out of doors on small wood and charcoal stoves, and bothrooms of the average dwelling were used for sleeping.
Few displaced persons were recovered until the Calabria areawas occupied, and then a large concentration camp was found at Cosenza. Thishoused several thousand people of approximately 20 nationalities, including alarge number of Italian Jews. Approximately 200 Yugoslavs were found at Palermo.After Cosenza, the next large displaced person population were Yugoslav refugeeswho were brought by ship to the east coast of the peninsula to escape thefighting and the destruction along the western Yugoslav coast. The Yugoslavsbegan to arrive in January 1944, and although the numbers which reached Italyduring that month were relatively small, their continued influx in everincreasing numbers later became a serious problem.
Housing surveys performed in Sicily revealed that only a fewcommunes presented acute housing problems. Trapani reported 15,000 homeless inan area then having less than half its normal population. Marsala reported14,000 homeless, but most of the damaged buildings there could be repaired in 1month if labor and materials were available. Unfortunately, they were notreadily available. Messina also had a serious housing shortage, as did Foggia onthe mainland. Glass and roofing tiles were in especially short supply, and itwas impossible to import building materials to make repairs. Fortunately, thewinter of 1943 was relatively mild, and there was little suffering.
It was feared that epidemics might occur on a large scaleamong the packed dwellers of air raid shelters. These people were dirty,louse-infested, and had little medical care; sanitation in the air raid shelterswas poor; and numerous cases of enteric disease developed in them. Shelterdwelling was a considerable factor in the spread of typhus fever in Naples.Whenever there was a reasonable possibility that these people could find otherhousing, the mayors and police officials of the towns were ordered to close theshelters at all times except during air raids.
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Clothing the population was a problem in southern Italy.Good, serviceable shoes were especially scarce although many people hadimprovised wooden shoes or leather shoes with wooden soles. Most people werewearing the last of their usable clothing, frequently patched, and obviouslythey badly needed additional clothing for the winter. Supplies could not beobtained through military channels, but the American National Red Cross agreedto provide surplus clothing from England and the United States. This clothingbegan to arrive in Naples during the first week of January 1944.
Nutrition
The general state of nutrition of the population of Sicily,which was primarily agricultural, was fairly good. However, it became obviousthat the dislocation of distribution and of the trade in grain between Africa,Sicily, and the mainland of Italy were creating a serious situation,requiring that wheat be imported from elsewhere. This problem had beenanticipated in planning for Sicily. Unfortunately, no transportation wasavailable to bring in 30,000 tons of grain which had been stored in Algeria forMilitary Government use in Italy.
"Black Marketing," which had prospered underFascist auspices during the war, was an extremely important factor in preventingequitable distribution of existing foodstuffs both before and after thearrival of Allied troops.
Because there were no nutrition experts in the MilitaryGovernment organization during this period, no adequate studies of thenutritional states of the people could be undertaken. In general, nutritionappeared to be less adequate in Naples itself than in the surrounding area,partly because of the inability to bring food in from the surroundingcountryside. Fortunately, southern Italy and, particularly, Sicily had goodsupplies of grapes, olives, pistachios, filberts, and citrus fruits whichnormally would have been distributed to the whole country or exported. Thesewere available for the occupied area alone and furnished much required food.
The general opinion of the public health authorities ofMilitary Government and the Allied Control Commission was that the state ofnutrition in southern Italy and Sicily during the first 6 months was good. Amoderate amount of undernutrition probably always existed in the economicallydepressed groups who formed the bulk of the population of these areas. As usual,the farmers did not fare badly. Hoarding, which was common among them, was foundto be extremely difficult, if not impossible, to stop even though vigorousmeans, such as sneak raids, were used.
Grain production in the area had fallen considerably becauseof the shortage of manpower and the lack of fertilizer during the war years. Allgrain reserves had been used up, and living was more or less on a day-to-
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day basis in most communities. Hospitals especially requiredextra and special foods which were difficult to provide.
Veterinary Medicine
Because Allied Military Government had no veterinaryofficers, its ability to ascertain and cope with veterinary problems was greatlylimited. In some instances, a sanitary engineer dealt with problems of milksupply. In general, only raw milk was sold; it was delivered from door to door.Usually, the herd of cows or goats was milked at the door so that the consumercould see that he was obtaining undiluted milk. In the larger cities were storesselling only milk and, generally, they sold skimmed and watered milk.
The Allied Control Commission included a veterinary medicalofficer from the beginning of its operations. On Sicily, he reestablished meatinspection. Farmers tended to sell directly to the consumer because of thescarcity of meat and the exorbitantly high prices. Thus, meat bypassed the oldslaughterhouses where inspection had been carried on in prewar days. Thisofficer also was able to assist the Zoo-Prophylactic Institute in Palermo tobegin production of human biological products, such as smallpox vaccine,diphtheria antitoxin, and other biologicals for human use.
Beginning in early January, fairly comprehensive data onveterinary problems became available. It is clear that the ACC veterinaryofficer, Major Rushmore, played an influential role in reestablishing Italianmeat production.
Medical Supplies
The 21 Allied Post-War Requirements Bureau drugs and 21Allied Post-War Requirements Bureau dressing units were delivered to Palermo ina series of shipments and were moved to Caltanisetta, where a former Italianmilitary medical supply depot had been taken over by HQ, AMG, 15th Army Group.Initially, the Seventh U.S. Army had captured this depot which containedapproximately 125 tons of Italian supplies. These supplies were turned over toHQ, AMG, which distributed them to the provinces (Provincial Health Officers)for redistribution to hospitals within their area in the form of balanced"bricks" or units. Allied Post-War Requirement Bureau unit supplieswere then issued on an item requisition basis.
The Allied Military Government made an effort to work outaccounting procedures in Sicily and started to develop price lists. This workwas continued and finished by the Allied Control Commission in 1944. At first,supplies were issued to the Italians on memo receipt, with the understandingthat they would pay later.
Assault parties landing on Sicily carried with them nomedical supplies for civilian use. Although they managed without them in Sicily,it developed later that such supplies should be brought in within a few daysof an
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assault. At the time of the Salerno landings, smallquantities of emergency supplies accompanied the troops. The value ofmaintaining small dumps of emergency civilian supplies in forward combat areasin Army depots became apparent and such a program was instituted by the FifthU.S. Army in December 1943.
Colonel Farinacci set up a highly successful program forhandling medical supplies in the British Eighth Army area. Captured Italianmedical stores, supplemented by some U.S. Army medical supplies, were made upinto Spearhead Medical Kits and Spearhead Civilian Hospital Kits. The formerconsisted of such emergency medical supplies as cotton, bandage rolls, aspirin,sulfathiazole, gauze, alcohol, iodine, ether, sulfanilamide, and adhesiveplaster, and were used by Civil Affairs officers when they first enteredliberated villages. The latter were used to provide for the basic needs ofcivilian hospitals after liberation on the basis of one kit per 100 beds. Thehospital kits were furnished gratis to the hospital only until thereestablishment of civilian government and the sale of medical supplies (CADunits) had become established in the area. Refugee Medical Kits were also madeup, and were issued gratis to the refugee camp dispensaries. This wasessentially a Spearhead Medical Kit, supplemented by various drugs.
In November 1943, Region III Military Government Headquartersset up a second central medical supply depot in a Red Cross warehouse in Naples.This was later taken over and operated by ACC under the direct supervision ofCol. Martin E. Griffin, MC. Colonel Griffin, assigned by The Surgeon General onrequest of ACC, succeeded in reorganizing the entire ACC civilian supplyprogram. Because of Colonel Griffin's wide knowledge of Army medical supplyproblems, the civil affairs supply program was, for the first time, efficientlycoordinated with that of the combat forces.
As the Allied troops moved forward, the principal items incritically short supply were cotton, iodine, bandages, anesthetics, suturematerial, serums, vaccines, sulfanilamide drugs, alcohol, insulin, andantiseptics. There was never a shortage of drugs for the population of Sicily.However, considerable hardship was experienced in Region IX because of thefailure both to plan sufficiently far in advance and to accept the initialsupply requisitions; as a result, 15th Army Group did not receive instructionschanging the method of requisitioning. This was corrected later and emergencysupplies were furnished directly from the Naples warehouse.
The period under discussion was hardly long enough to enableone to draw any final conclusions on the adequacy of distribution of items andquantities within the ARB and CAD unit lists. The Italians always wanted moredrugs in ampoule form for injection, but this was not considered to beessential. Most Italian physicians were accustomed to using drugs with tradenames and were unaccustomed to using drugs marked with drug names as were oursupplies. This pointed to a need for a booklet which
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would describe, in the language of the country, the items andindications for their use, and doses, but AMG was too busy and too understaffedto undertake such a project.
During the period under discussion, there was no formalagreement between Military Government public health authorities and the Surgeonsat any level regarding the distribution that was to be made of captured medicalsupplies, and there was no theater directive on this subject. The authorconsiders such a directive to be important.
Volunteer Organizations
The Italian Red Cross was the largest volunteer organizationoperating in the medical field. In prewar times, many of the Italian Red Crossactivities were in the field of service programs and were quite similar to thoseof the American Red Cross. However, during the war, after the Italian Red Crosswas reorganized, they established many hospitals throughout Italy in whichcivilian air raid casualties were cared for. The personnel of these hospitalswore military uniforms and held grades and ratings similar to those of medicalpersonnel in the Italian Army.
Allied Military Government began the reorganization of theItalian Red Cross on Sicily and appointed a new director with power to carry outthe program throughout the entire island. The principal change in the neworganization was the elimination of the pseudomilitary aspect of hospitaloperation and the system of rank and ratings. Hospitals built by the Red Crosswere turned over to municipalities for operation under local governmentauspices. Fascists who were involved in the program were removed, and morestress was laid on service programs for the homeless and needy and those ondisaster relief. This reorganization appeared to be highly successful andsimilar reorganizational measures were begun on the mainland.
Much help was given to AMG authorities by British andAmerican Red Cross personnel serving with the AMG. Another volunteer agency inthe field of medicine was the tuberculosis association, which had provincialbranches and, in Sicily, had a coordinating organization in Palermo. The work ofthis group was not interfered with, although it should be stated that they wererelatively ineffective. They had derived most of their funds from the ItalianGovernment in the past, and official support was withdrawn when they wereseparated from Rome by the battleline.
Activities of the many insurance associations, several ofwhich provided medical benefits, ceased. The new welfare program instituted byHQ, AMG, 15th Army Group, provided medical assistance to the indigent by paymentof necessary medical and hospital charges for its relief clients.
