CHAPTER II
War Department Provisions for Malaria Control
Oliver R. McCoy, M.D.
ORGANIZATION INTHE OFFICE OF THE SURGEON GENERAL
Although malaria and other tropical diseases had long been of concern to the Army in relation to posts in Panama, Puerto Rico, and the Philippines, the military importance of these diseases increased in the fall of 1940 with the acquisitionand development of new bases in the Caribbean region. At this time, formulation of tropical disease control policies was included among the functionsof the Preventive Medicine Subdivision, although no organizational unitfor tropical disease control was established until the creation, in April1941, of the Subdivision on Medical Intelligence and Tropical Medicine ofthe Preventive Medicine Division.1 This new subdivision wasto (1) collect and coordinate data concerning problems in tropical preventivemedicine and sanitation, (2) coordinate the malaria control program of theArmy in the United States and abroad, and (3) maintain flies of reportson the incidence and prevention of the diseases indigenous to tropicalpossessions and bases.
The unit for tropical disease control continued in the same organizational status until 26March 1942, when Preventive Medicine was reorganized as a service. Atthis time, the unit was transferred to the Epidemiology Division andremained there until 1 January 1944, when it separated to become an independentdivision. 2 This status was maintained until the end ofthe war.
Before 1 January 1944, the unit had no official internal organization. Upon becoming adivision, the following organization and functions were authorized: 3
Tropical Disease Control Division * * * * Directs the activities of the Control Policies Branch, the Education Branch, the Field Survey Branch, and the Malaria Control Branch.
Control Policies Branch * * * Establishes policies and procedures forthe prevention and control of tropical diseases in the Army in this country and overseas. Maintains liaison with governmental and civilian agenciesconcerned with tropical disease control; analyzes data and reports dealingwith the morbidity and mortality from tropical diseases in the Army; recommendsinvestigations of special tropical disease situations when indicated.
1 Office Order No. 87, Office of The Surgeon General, U. S. Army, 18 Apr. 1941.
2 Office Order No. 4, Office of The Surgeon General, U.S. Army, 1 Jan. 1944.
3 Manual of Organization and Standard Practices, Office of The Surgeon General, U.S. Army, 15 Mar. 1944.
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Education Branch * * * Initiates informative circulars, posters, pamphlets, and other material; arranges programs of special training for selectedpersonnel needed in tropical disease control.
Field SurveyBranch * * * Maintains contact with field investigationsand field conditions; participates in special field investigations dealingwith tropical diseases.
Malaria Control Branch * * * Exercises general advisory supervision over activities related to malaria control in the Army; advises on investigations of new drugs, materials, and equipment applicable to the control of malaria, and makes recommendations as to their use.
In November 1944, after the Preventive Medicine Service moved to integrate the educational functions of the Service im a single Health Education Unit, the Tropical Disease Control Division was unofficially reorganized as follows:4
Tropical Disease Control Division * * * Deals with procedures and policies bearing on the prevention and control of tropical diseases and maintains liaison with governmental and civilian agencies concerned with the health of the Army in tropical theaters of operation.
Field SurveyBranch * * * Studies and disseminates information andmakes recommendations on reports from research laboratories and field experiencesin new methods for the control of insect-borne and other tropical diseases.
Disease Analysis Branch * * * Analyzes and acts upon reports concerning the incidence of tropical diseases and initiates informative materialsconcerning tropical diseases for indoctrination and refresher trainingof troops.
Malaria Control Branch * * * Assists in the formulation of policy formalaria control, maintains liaison with other divisions of the SGO inmatters relating to the training and operational use of malaria controlpersonnel, and selects and arranges for special training of such personnel.
No personnel were specifically assigned to tropical disease control until 18 May 1942,when Lt. Col. (later Col.) Paul F. Russell, MC, reported for duty aschief of the Tropical Disease Control Section within the Epidemiology Branch.Personnel of the unit always remained a small group, never enlarging beyondfour officers.
ORGANIZATION FOR MALARIA CONTROL
Control of malaria first became a problem when, in the fall of 1940, the mobilization program, involving the training of large numbers of troops in Southern Stateswhere malaria was endemic, was instituted. Planning of the organization,personnel, and finances necessary for malaria control at installationsin the continental United States became a function of the Sanitary EngineeringDivision, Preventive Medicine Service, OTSG (Office of The Surgeon General).Early in the year, steps were taken to obtain the cooperation of the U.S.Public Health Service in carrying out measures of sanitation in
4 Annual Report, Tropical Disease Control Division, Preventive Medicine Service, Office of The Surgeon General, 1944.
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extramilitary areas.5 Cooperation of this agency, which was first utilized in maneuver areas, was soonextended to include extracantonment zones at Regular Army stations.6 The malaria control program in the continental UnitedStates was thus a cooperative effort, mosquito control within militaryreservations being carried out by the Army and in extramilitary zones bythe U.S. Public Health Service.
During 1941, the sum of $1,500,000 for the Army's mosquito control program was obtained through a special allocation of funds by the budget officer of the WarDepartment. 7 The work was carried out by post surgeonsunder the general direction of the corps area surgeons, utilizing theadvice and assistance of entomologists and sanitary engineers. In December1941, the Corps of Engineers took over the responsibility for mosquitocontrol work which was previously a function of the Quartermaster Corps.Post engineers were authorized to employ civilian laborers and supervisorsto perform the control work. Beginning in July 1943, insect and rodent controlsections were established in the Office of the Chief of Engineers and inthe offices of service command engineers to promote and coordinate the variousaspects of the mosquito control program. The Medical Department retainedresponsibility for surveying the malaria problem, recommending measures neededfor control, and exercising technical supervision over the execution of thesemeasures.8
As a result of the cooperative antimosquito program of the Army and the U.S. Public Health Service, the malaria rate among troops in the continental United States was maintained at satisfactorily low levels in 1941 and 1942 and dropped to almost negligible figures in the succeeding years. The rates per 1,000 per annum during the war period were as follows: For 1941, 1.7; 1942, 0.6; 1943, 0.2; 1944, 0.2; and 1945, 0.1.9 The effectiveness of the program may be judged by comparison with the average annual rate during the10 preceding peacetime years, 1931 to 1940 inclusive, which was approximately 2.3 (chart 1).
The situation was quite different, however, in oversea theaters, especially where conditions of combat prevailed. By the time the Tropical Disease Control Sectionwas established in May 1942, malaria had become a disease of crucial military importance. A definite organization was needed to furnish the experttechnical guidance required for effective control among troops operatingin the field in highly endemic regions. Experience in other armies andin civilian malaria control programs had repeatedly demonstrated that,to obtain
5 Letter, The Secretary of War, to Administrator, Federal Security Agency, 30 Jan. 1940, and reply dated 12 Feb. 1940.
6 Letter. The Adjutant General, War Department, to Commanding Generals, First, Second, Third, and Fourth Armies, and Commanding General of each Corps Area, 4May 1940, subject: Extension of Present Utilization of the U.S. PublicHealth Service.
7 Letter, Lt. Col. F. C. Tyng, Chief, Finance and Supply Division, to the BudgetOfficer of the War Department, 10 Feb. 1941, subject: Mosquito Control,and reply thereto, Maj. Gen. H. K. Loughry, Budget Officer for the WarDepartment, 20 Mar. 1941.
8 Army Regulations No. 40-205, 31 Dec. 1942; Army Regulations No. 40-210, 15 Sept. 1942.
9 Statistical Health Reports, Medical statistics Division, Surgeon General's Office.
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successful results, technically trained personnel must be organized and designated to do the work. In September 1942, it was therefore recommended that a special malaria control organization be authorized within the Medical Department to function in the malarious areas in oversea theaters:10
Experience has taught that an antimalaria organization in an army must be responsible not only for reconnaissance and plans but also for carrying out the actual control operations. It has proved impossible to obtain adequate protection when a malaria unit functions merely in a consulting or advisory capacity. The normal demands on the medical and sanitary personnel in nonmalarious areas continue to exist in very malarious areas--in fact, they are usually intensified. Therefore, the addition of specialist personnel for malaria control is advisable, logical and urgent. Without adequate control it is certain that malaria in many areas will immobilize large numbers of troops and will cause more casualties than the enemy.
It is recommended that in those areas where malaria is a special problem, certain selected specialist personnel be added to the existing medical and sanitary establishment of the Army to deal primarily with malaria control * * *
War Department General Staff, G-1 (Personnel), endorsed this request favorably on 9 October 1942 and recommended immediate action. The Assistant Chief of Staff, G-3 (Operations and Training), requested the com-
10 Letter, The Surgeon General, to The Adjutant General, War Department, 21 Sept. 1942, subject: Malaria Control.
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manding general of Services of Supply to determine the opinions of the several theater commanders on theirrequirements for special antimalaria personnel and authorized directcommunication for the purpose.11 Accordingly, The Surgeon General,on 24 October 1942, addressed letters to the Commander in Chief, SouthwestPacific Area, and to the commanding generals of U.S. Army Forces in theMiddle East, Central Africa, China-Burma-India, South Pacific Area, theCaribbean Defense Command, and, in view of the landing in north Africa,the European Theater of Operations. These letters recommended that selectedspecialist personnel be added to existing medical and sanitary establishmentsto deal primarily with malaria control and asked that appropriate requisitionsbe submitted.
The malaria control organization was recommended to include:
1. A malariologist, and one or more assistant malariologists as needed; medical officerstrained in large-scale malaria control methods.
2. Malaria survey unit.--An entomologist, a parasitologist, 11 technically trained enlisted personnel, and necessary laboratory and transportation equipment.
3. Malaria control unit.--A sanitary engineer, 11 enlisted men trained in field methods for malaria control, and equipment necessary for drainage, mosquito larvicidal work, and transportation.
4. Antimalaria labor gangs.--Laborers recruited locally as required to work under the supervision of a malaria control unit.
5. Antimalaria squads.--Military personnel assigned to conduct minor measures for mosquito control within their unit areas.
The basic functions of the malariacontrol organization were described to include:
1. Evaluation of the malaria problem by surveys to determine the amount and distribution of malaria and the species and habits of mosquito vectors in the area.
2. Institution and supervision of malaria control measures.
3. Trainingof troops in general control measures and methods of individual protection against malaria.
4. Assistance in the control of other insect-borne diseases when indicated.
The malaria survey and control units were new and untested organizations. War Departmentapproval of them was contingent upon a favorable response from overseatheaters, which were just beginning to experience the impact of malariacasualties. The building up of the organization was slow because units couldnot be activated until requests for them had been received by the War Department. A major proportion of the activities of the Tropical Disease Control Division was devoted to promoting the development of the malaria control organization by encouraging use of the units overseas and through supervision of theselection and training of personnel in this country. It was
11 Letter, Assistant Chief of Staff, G-3 (Operations Division), War Department General Staff, to Commanding General, Services of Supply, 14 Oct. 1942, subject: Malaria Control.
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only after the organization had proved its worth in the field that malaria units were regularly included inthe planning of future operations.
The first replyto the letters sent to the oversea theaters in October 1942 was receivedfrom the South Pacific Area on 26 November. Three malariologists, three assistant malariologists, three survey units, and three control units were requested. On 1 December 1942, a reply was received from the Southwest Pacific Area requesting 1 malariologist, 6 assistant malariologists, 3 survey units, and 12 control units. Transportation by air was authorized for certain of the officers and enlisted personnel. On the basis of these requests, the preliminary plans for tables of organization and equipment, which had been made in cooperation with the Laboratory and Sanitary Engineering Divisions, were completed in conjunction with the Plans and Operations Division, OTSG. In coordination with Operations Division, War Department General Staff, an administrative mechanism was adopted whereby the survey and control unitswere to be formally activated and each given a number.12
During December1942 and January 1943, additional requests for malaria control personnelwere received from Central Africa, China-Burma-India, the Middle East, NorthAfrica, and the Caribbean Defense Command. Although certain of the malariologists and advance echelons of units were sent overseas by air early in 1943, the majority of the first units were not activated until 25 January 1943. Included in the first group of units which were activated at the Services of Supply Unit Training Center, New Orleans Port of Embarkation, were 6 survey and 15 control units. During January and February 1943, authorization was granted for the activation of an additional 10 survey and 12 control units. Officers for these units were obtained from a list of specially qualifiedpersonnel furnished by the Tropical Disease Control Section.
The programmed malaria control organization in the oversea theaters on 13 February 1943 is shown in table 1. The figures given are the numbers of malariologists and malaria survey and control units then projected for these theaters. Actually, only a portion of the malariologists and advance echelons of a few units were on duty or were en route to the theaters at that time.
Activation of Malaria Control and Survey Units
In March 1943, The Surgeon General sent a letter to the commanders of all theaters and service commands, describing the new malaria control organization and its functions. Authorization was granted for The Surgeon General's recommendation of 15 March that 10 survey and 15 control units be activated in anticipation of future requests. By 7 June, all these units, except one survey and one control unit, had been committed to oversea theaters. Meanwhile, on 30 May, theChina-Burma-India theater had activated four control units within the theater.The status of the malaria control organization in the oversea theaters asof 15 July 1943 is shown in table 2.
12 Memorandum, Tropical Disease Control Section, for Colonel Simmons, chief, Preventive Medicine Division, Professional Services, 13 Feb. 1943, subject: ArmyAntimalaria Organization
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TABLE 1.- Projected status of malaria control organization for the overseatheaters, 13 February 1943
TABLE 2.- Status of malaria control organization in the oversea theaters,15 July 1943
Requests for malaria units during the first half of 1943 had indicated that the medical malaria control organization was essential and was suited to perform a highlyimportant function in the oversea theaters in malarious areas. As projectedtroop strengths in tropical areas increased, it became necessary to planadditional units to take care of anticipated requisitions. Accordingly,an estimate was made of requirements for units during the remainder of 1943,and, on 30 July, recommendation was made for the activation of 15 surveyunits and
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25 control units. Authorization was granted for the activation of the 15 survey units and 23 of the control units. By the time these were activated, and personnel assigned and trained, all were committed to fulfill requests from oversea theaters.
In order in thefuture to avoid undue delay in shipment of units requested by oversea theaters,an estimate was made by the Tropical Disease Control Section in September1943 of the number of units needed for the first 6 months of 1944. A requirement of 58 survey and 116 control units was projected, based upon past experience in the theaters and probability of future needs as troop strengths increased. Using this estimate, The Surgeon General, on 25 October 1943, recommended to the Commanding General, ASF (Army Service Forces), that 50 surveyand 105 control units be activated during the remainder of 1943 and inearly 1944.
In November 1943, the Tropical Disease Control Section was informed that the activations scheduled for that month were to be postponed a month and that the enlisted personnel for the units were to be assigned directly from induction centers without basic training. The addition of 4 months time required to givebasic training to the month necessary for unit training would thus resultin prolonged delay in meeting the requirements of the oversea theatersduring the first half of 1944. It was recommended that no further postponementsin activating units be allowed and that consideration be given to thetransfer of men who had already received basic training from establishedMedical Department organizations.
After a series of conferences with the Plans Division, OTSG, it was agreed that the policy of supplying men without basic training to the malaria units would result in failure to meet theater requirements on schedule. In view, however,of the personnel situation then current, no practical solution of the problem was evolved. Because highest priority for personnel was given to oversea replacements, great difficulty and delay were experienced in obtainingenlisted men for 16 survey and 36 control units activated in December 1943at Camp Ellis, Ill. This situation was called to the attention of higherheadquarters, 13 but only slow improvement resulted. Thefinal complement of this group of units did not reach Camp Plauche, La.,for unit training until 20 March 1944. For a later group of 14 units (7survey and 7 control) activated at Camp Grant, Ill., in February and Marchof that year, only 114 enlisted men out of a required complement of 154had been assigned by 1 June 1944.
A summary of the status of malaria units in the oversea theaters as of 15 February 1944 is presented in table 3. A total of 35 survey and 65 control units, with a complement of 1,235 officers and enlisted men, were present in the oversea theaters. An additional 7 survey and 8 control units were en route, and 17 survey and 37 control units were activated and scheduled for shipment.
13 Memorandum, Brig. Gen. R. W. Bliss, Chief, Operations Service, OTSG, to Commanding General, ASF, attention: Mobilization Division, Troops Unit Branch, Col. Henry C. Harrison, Jr., 27 Jan. 1944, subject: Enlisted Personnel for Malaria Survey and Control Units.
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Beginning in June 1944, a program for the preactivation training of malaria units was inaugurated. 14 Personnel for malaria units scheduled for activation were given basic military and technical training (totaling 16 to 17 weeks) aspart of medical training battalions at Camp Grant before assignment tothe units. The schedule for activation of units for the remainder of 1944was fixed according to the Six Months Projection List revised monthly byOperations Division, War Department General Staff. Heretofore, shipment of malaria units had been authorized, for the most part, on the basis of individual requests for units from theater commanders. According to the 15threvision (May 1944) of the Six Months Projection List, 4 survey and 32control units were planned for activation during the remainder of 1944. The authorized number of units fluctuated during subsequent revisions; actually,38 control and 11 survey units were activated in this period. The statusof the malaria control organization in the oversea theaters in malariousregions as of 30 September 1944 is shown in table 4.
Based upon experience in the use of malaria units in the malarious theaters, the War Department, in December 1944, addressed a letter to the commanders of the Pacificand Asiatic theaters recommending a standard for provision of units infuture operations. In highly malarious territory, or in areas where othermosquitoborne diseases were a serious hazard, it was recommended that:(1) One survey and one control unit be attached to each division; (2) forother troops, one control unit be provided in an approximate ratio of oneunit per 20,000 men; and (3) at least one control unit be provided for each
TABLE3.- Status of malaria units in oversea theaters, 15 February 1944
14 Letter, The Adjutant General, War Department, to Commanding Generals, Sixth and Eighth Service Commands, 29 May 1944, subject; Preactivation Training for Medical Units Beginning June 1944.
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important post or station, at large installations in an approximate ratio of one unit per 7,500 men.
TABLE4.- Status of malaria control organization in oversea theaters, 30September 1944
Using this basis, it was computed that by the fourth quarter of 1945, a total of 278 control units and 130 survey units would be required in the Pacific theaters(assuming the prior defeat of Germany).15 Because the WarDepartment Troop Basis then current authorized only 166 control and 77survey units, it was recommended that in addition a minimum of 30 controland 15 survey units be activated from units then undergoing preactivationtraining. This recommendation was rejected by G-3, War Department GeneralStaff, on the ground that a shortage of personnel existed for meeting currentrequirements.
The status of the malaria control organization overseas at the end of the war was essentially as shown in table 5. Eight additional control and three additional survey units were sent to the Pacific after 1 April 1945. At the end of thewar in Europe, plans were made to redeploy malaria units from the Mediterranean theater to the Far East. The abrupt ending of the war with Japan permitted cancellation of these plans before more than a few of the control units had been directly redeployed.
Tables of Organization and Equipment
When the first malaria units were organized, tables of organization and equipment for both the survey and the control units were published as enclosures to the activation order. Various changes were made in the tables
15 Memorandum, Brig. Gen. R. W. Bliss, Operations Service, OTSG, to commanding General, ASF (attention: Mobilization Division, Troop Units Branch, Colonel Harrison), 20 Dec. 1944, subject: Projected Requirements for Malaria Control andsurvey Units for Overseas Theaters for 1945.
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of equipment (which included special lists of technical supplies and equipment authorized for issue to theunits as Medical Department items) as the units accumulated experiencein the field, but the tables of organization, except for certain adjustmentsin rank of personnel, remained unchanged throughout the war. First officialpublication of these tables was made on 23 April 1944.
TABLE5.- Status of malaria control organization in oversea theaters, 1 April1945
In January 1944, tables of organization and equipment had been proposed for theater and battalion headquarters organizations for malaria control. Plans were made for a battalion headquarters organization to supervise the activities of a group of malaria survey and control units and to serve as an intermediate echelon between the units and theater headquarters. The plan was included in a proposed revision of TOE (tables of organization and equipment) 8-500, but it was not approved by G-3, War Department General Staff, which hadpreviously disapproved a similar proposal from the North African theater.A compromise arrangement was then agreed upon, whereby the table of organizationfor a medical battalion headquarters was made applicable to malaria units,and this was published in January 1945. This action was too late to be ofhelp in most of the theaters of operations, although such a malaria controlorganization was established in a battalion headquarters on Okinawa in May1945.
Special Personnel and Units
A few medical malaria control organizations consisted of specially selected personnel. In February 1943, when plans were made to transfer malaria con-
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trol personnel from Liberia to North Africa, the surgeon at Roberts Field, Liberia, requested that malariaunits (one survey and one control) consisting of Negro personnel be sentas replacements. Since the command was predominantly Negro, it was believed that morale and malaria discipline would be improved by having Negro units. These units were activated on 15 April 1943, completed their trainingin August, and arrived in Liberia in September. Two other Negro units(one survey and one control) were activated on 24 January 1944 to servewith a Negro division in the South Pacific.
The China-Burma-India theater in August 1943 requested two units with Chinese-American personnel. The request was made because of difficulties in obtaining cooperationand malaria discipline in Chinese troops deployed in the highly malariousregions of northern Burma. Because it was difficult to locate qualifiedChinese-American personnel, such units were not formed.
In July 1944, the War Department, without prior consultation with The Surgeon General, ordered activation of 30 malaria control units in the Antilles Department, the units to consist of Puerto Rican personnel. Because of the supervisory dutiesperformed by malaria units and the uncertainty of obtaining properly qualifiedmen, The Surgeon General recommended that this order be amended and thatinsular troops not be used in malaria units. Action on the order was latermodified so that only two Puerto Rican control units remained activated.These units were trained at the Army School of Malariology in Panama, remainedfor some months on temporary duty there, and were en route to the India-Burmatheater when the war ended.
Training of Malariologist Officers and Units
Tropical disease control was intimately connected with the development of programs andprocedures for the training of malariologists and malaria units. The selectionand training of officer personnel for the malaria control organization wasa responsibility of the Tropical Disease Control Division in cooperationwith the Laboratories and Sanitary Engineering Divisions, Preventive MedicineService, and the Training Division, OTSG. Because few Medical Departmentofficers had had practical experience in malariology, it was necessary toarrange training programs for most of the personnel who were to be assignedas malariologists or as officers for the malaria units. Medical Corps officerswho had successfully completed the 8-week course in tropical medicine atthe Army Medical School, Army Medical Center. were usually selected for suchtraining.
Entomologists and parasitologists for malaria survey units were obtained at first mainly from the teaching and research staffs of educational institutions and from such governmental agencies as the U.S. Department of Agriculture and the U.S. Public Health Service. Later, commissions were granted to graduate students in these specialties who had been inducted into the Army as enlisted men. Sanitary engineers to command malaria control units were
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obtained at first principally fromState and city health departments. In the later stages of the war, studentsfrom the Army Specialized Training Program who had studied engineering werecommissioned in the Sanitary Corps and assigned to malaria control unitsafter special training.
The first fieldtraining courses in malaria control were arranged in the summer of 1942 throughcooperation of the Tennessee Valley Authority. The 2-week courses were conductedat Wilson Dam, Ala. Instruction consisted principally of field trips in orderto enable students to observe and participate in the various procedures employedfor malaria surveys and mosquito control. Six courses were held during August, September, and October 1942 and were attended by a total of 67 Medical and Sanitary Corps officers.16
As the locationat Wilson Dam was not favorable for malaria control training during the winter season, arrangements were made with the Rockefeller Foundation and the Florida State Board of Health to conduct similar field courses in Florida. The length of the course was increased to 3 weeks, and instruction in mosquito dissection and further experience in the identification of malarial parasites were added. Fourteen courses were given between November 1942 and December 1943, and a total of 140 Medical Corps and Sanitary Corps officers were trained. 17 The Navy also took advantage of this facility; 32 Navy officers attended the classes.
To supplement the Florida field course in malaria control, arrangements were made in December 1942 with the Corps of Engineers whereby medical officers who had taken this course could be sent to Costa Rica for several months of duty with the field headquarters of the Pan American Highway project in order to gain practical experience in the control of tropical diseases. The first group of 4 officers arrived in Costa Rica in March 1943, and by September a total of 10 Medical Corps officers had received from 2 to 3 months of field experience in Central America.18 When the Pan American Highway project began to close in the fall of 1943, no additional officers were sent to this location for training.
At about this time, the Army planned to establish a school of malariology at Fort Clayton, C.Z. This school was intended to provide more satisfactory applicatory training in malaria control than was possible in the Florida field training course and on the Pan American Highway project. Exigencies of the military situation and of transportation had prevented the previous establishment of sucha school in Panama. Authorization for the Army School of Malariology inthe Canal Zone was granted in September 1943.19 In conjunction with the Sanitary Engineering Division and the Training Division, a program
16 Annual Report Preventive Medicine Division, Office of The Surgeon General, U.S. Army, 1942.
17 Annual Report, Preventive Medicine Division, Office of The Surgeon General, U.S. Army, 1943.
18 Annual Report, Tropical Disease Control Section, Epidemiology Branch, Preventive Medicine Division, Office of The Surgeon General, U.S. Army, 1943.
19 War Department General Staff Disposition Form, Maj. Gen. Thomas T. Handy, Assistant Chief of Staff, G-3, to Commanding General. ASF, 29 Sept. 1943, subject: Army School of Malariology (Canal Zone), and first endorsement thereto,dated 29 Sept. 1943.
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was developed for a 4-week course,and a qualified staff of seven instructors was selected. Several men withexperience in malaria control in the oversea theaters were brought back forthis assignment. The course was designed to emphasize field work under tropicalconditions, and opportunity was afforded the students to make surveys inhighly malarious native communities (figs. 1, 2, and 3).
Between 7 February 1944 and 1 September 1945, 14 classes were held, and 107 Medical Corps and 153 Sanitary Corps officers successfully completed the course. In addition, 24 officers from Allied countries attended classes at the School, andtraining was given to 2 officers of the U.S. Public Health Service andto 9 civilians (mainly employees of the Panama Canal Department).
Throughout the war, the unit training of malaria survey and control units was carried out at the Unit Training Center, Camp Plauche. In cooperation with the Training Division, a 4-week training program was arranged and published officially in May 1943. 20 The climate and terrain at Camp Plauche were suitable for the training of units throughout the year, although conditions were most favorable during the spring, summer, and fall. Since most units after completing the 4-week training program had to wait some weeks for oversea movement orders, opportunity was afforded for practice field bivouacs and other additional training exercises (figs. 4 and 5).
When the Army School of Malariology was established, it was planned to send units to Panama for training; however, difficulties in transportation and the necessity for meeting oversea commitments of units prevented this plan from being carriedthrough. Only two control units, with Puerto Rican personnel, were trainedat the Army School of Malariology in July 1944.
Antimalaria details
Although Army regulations clearly defined the responsibility of commanders of all organizations to institute and enforce the measures necessary to control malaria within their units and unit areas,21 no definite means were prescribed tocarry out this responsibility. In the summer of 1943, when the full impact of malaria on military operations in the Pacific area became apparent, stepswere taken to designate antimalaria details in each unit of company size.In War Department Circular No. 223, published on 21 September 1943, theseunits were defined and their duties described as follows:
Antimalaria details. - In order to assist unit commanders In the control of malaria there will be formed in each company, battery, or similar unit, an antimalaria detail to consist of a minimum of two enlisted men, including one noncommissioned officer. In nonmedical units this detail will be made up of nonmedical personnel. This detail will be specially selected by the commander andwill be given immediate training in use and minor maintenance of repairsof screening and bed nets; hand-killing and spray-killing adult
20 War Department Mobilization Training Program No. 8-21, 4 May 1943.
21 See footnote 8, p. 13.
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FIGURE 1.- Army School of Malariology, Fort Clayton, C.Z.
FIGURE 2.- Parasitology classroom, Army School of Malariology, Fort Clayton, C.Z.
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mosquitoes; larvicidal oiling of puddles and minor collections of water; minor ditching; minor water tidiness around a company encampment; and individual measures of malaria control in rear areas and in combat. These antimalaria details will carry out ordinary antimalaria housekeeping measures, such as those listed above, in and immediatelyaround the company encampment.
This circular reiterated responsibilities of commanders for malaria control and also contained provision for a special 4-hour period of training in malaria control which is discussed later under "Educational Activities."
The unit antimalaria details, when properly trained and employed, performed an important function in the overall malaria control program in endemic areas.
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Growth and Achievements of the Malaria Control Organization
The success of the special medical malaria control organization in the oversea combat theaters was attested by the rapid growth of the organization as the war progressed and by its accomplishments in bringing malaria and other insect-borne diseases under control. The situation in regard to malaria improved vastly during the last 2 years of the war in spite of the fact that operations continued in highly malarious territory and involved increasing numbers of troops. Malaria rates dropped dramatically after their peak in 1943. Casualtiesdue to the disease were reduced to a point where they were not a significantinfluence on military operations. The decisive factor in bringing about thisreduction was the activities of the special medical malaria control
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organization;22 in mosttheaters the drop in malaria rates paralleled closely the building up ofthat organization (chart 2).
By the end of the war, a total of 159 control units and 68 survey units had served overseas. Of this number, 133 control and 66 survey units were activated and trained in the United States; 26 control and 2 survey units were activated inthe oversea theaters with personnel locally available. More than 60 malariologists had been assigned in oversea theaters. The total personnel specifically designated for malaria control overseas was thus approximately 350 officers and 2,500 enlisted men. In addition, many thousands of troops and native laborers were employed under their direction.
The organization played the major role in the training of troops in malaria control and supervised the work of unit antimalaria details. The mission of the organization included prevention of other insect-borne diseases as well as malaria;in particular, dengue, scrub typhus, typhus, and filariasis. Because oftheir special training, malaria units were also used to assist in the control
22 Denit, G. B.: Message from the Chief Surgeon in the Far East. Bull. U.S. Army M. Dept. No. 86: 53, March 1945.
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CHART2.- Admission rates for malaria, U.S. Army, by year, 1941-45
of certain other diseases, such asschistosomiasis and those spread by rodents.
Since malaria control and survey units were new and untested organizations, proper planning for their inclusion in projected troop requirements overseas was not attained until the later stages of the war. During 1943 and the first half of1944, units were activated only after specific request for them had beenmade by oversea commanders. Since considerable time was needed to locatethe technically trained personnel and to conduct unit training, long delaysoften occurred between theater requests and their fulfillment. Usually,from 6 to 8 months elapsed between the receipt of a request and the arrivalof units at their oversea destination. For example, request was made fora large number of units in the Southwest Pacific on 23 August 1943. Activationwas recommended on 25 October and accomplished on 10 December. Because ofthe personnel shortage, 3 months elapsed before the units were broughtto full strength. In March 1944, they were finally transferred to CampPlauche for unit training, and in the following June, 10 months after therequest was made, they were scheduled for shipment.23
At no time was it possible to build up a reserve of malaria units in anticipation of requests. As a result, additional demands for units brought about by changes inthe military situation sometimes could not be met. For example,
23 Memorandum, Capt. Nils W. Bolduan, MC, Chief, Malaria Control Branch, Tropical Disease Control Division, Preventive Medicine Service, for Brig. Gen. Simmons (through: Col. Karl R. Lundeberg, 8 June 1944), subject: Status of Malaria Units as of 30 May 1944.
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in January 1944, a request for seven control units to set up a malaria control program for the Twelfth AirForce in the Mediterranean theater could not be filled promptly, and laterthe units had to be activated within the theater with personnel locallyavailable.
Experience during the war demonstrated that an organization specially trained and equipped for malaria control and specifically assigned to this duty was essential for effective control of this disease in the oversea theaters.
DRUGS FOR SUPPRESSIVE TREATMENT OF MALARIA
Throughout the war, the Preventive Medicine Service recommended policy in regard to the suppressive drug treatment of malaria and encouraged and guided the search for new and better agents for this purpose. Directives emphasized that suppressive treatment did not prevent infection and was an emergency measure to enable troops to operate in highly malarious territory despite infection which wouldotherwise incapacitate them.24
The dosage for suppressive treatment recommended in June 1941 was Atabrine 0.2 gm. twice a week at intervals of 3 or 4 days, or quinine 0.3 gm.. (5 gr.) daily. In 1942, when conservation of quinine became imperative, it was directed that quinine be used for suppressive treatment only when Atabrine was not available. Thedosage of quinine recommended for this purpose was increased to 0.64 gm.(10 gr.) daily.
Previous experience with Atabrine for the suppression of malaria in military forces was not very extensive. At the beginning of the war, little was known about absorption, blood concentration, or excretion of Atabrine, nor was it known whether prolonged use would lead either to transient toxicity or to permanent injury. The drug had heretofore been completely synthesized only in Germany. After American industry took over the manufacture of Atabrine, question was raised as to whether the American product was equal to the German, because ofthe frequency with which gastrointestinal disturbances were noted whennew supplies of the drug were administered for suppressive treatment. Thisproblem was referred to the National Research Council. After thorough studyby a committee of the Division of Chemistry and Chemical Technology ofthe Council, it was concluded that there was no significant differencebetween Atabrine of domestic and German manufacture and that whatever toxicitywas manifested by commercial preparations of Atabrine was due to the inherentproperties of the drug. 25
Conference on Atabrine
A conference was called in November 1942 by the National Research Council to organizea thorough investigation of the pharmacology of Atabrine and
24 (1) Circular Letter No. 56, Office of The Surgeon General, U.S. Army, 9 June 1941.(2) Circular Letter No. 135, Office of The Surgeon General, U.S. Army,21 Oct. 1942.
25 Report, Committee on the Toxicity of Commercial Atabrine, Division of Chemistry and Chemical Technology, National Research Council, 3 Oct. 1942.
31
to obtain more precise knowledge of the relation of dosage schedules to efficient therapeutic use of the drug. 26 Results of these studies were reported during the ensuing months at meetings of the Subcommittee on Coordination of Malarial Studies which was organized under the Division of Medical Sciences acting for theCommittee on Medical Research of the National Research Council on 20 January1943. 27 Investigation of the relationship of different schedulesof suppressive doses of Atabrine to plasma concentration of the drug ledto recommendation of a change in the routine method of administration.This action was taken in July 1943 at a joint meeting of the Subcommitteeon Coordination of Malarial Studies and the Subcommittee on Tropical Diseases of the National Research Council.28 Based on these recommendations, the following schedules for Atabrine suppressive treatment were adopted by the Army in August 1943:
1. Recommended method.- 0.1gm. of Atabrine once daily, 6 days a week (total 0.6 gm. per week).
2. Alternative method satisfactory in certain areas.- 0.05 gm. of Atabrine, once daily 6 days a week, and 0.1 gm. on the seventh day (total 0.4 gm. a week).
More extensive and precise information concerning the relation of plasma concentration of Atabrine to weekly dosage was obtained through a cooperative study conducted by the Commission on Tropical Diseases, the Board for the Investigation and Control of Influenza and Other Epidemic Diseases in the Army, the Office of The Surgeon General, and the Armored Medical Research Laboratory, Fort Knox, Ky., in the fall of 1943.29 Upon the basis of these studies and reports from the field which were then becoming available in increasing numbers, in July 1944, the recommended dose of Atabrine for suppressive treatment was raised to 0.1 gm. once daily (total 0.7 gm. per week). 30 No further change in the recommended dosage was made during the remainderof the war.
Conservation and Production of Atabrine and Quinine
Conservation ofquinine and production of Atabrine were problems of considerable concernto the Tropical Disease Control Division. When early in 1942 the Japanesecaptured the Netherlands East Indies, the world's principal source of cinchonaalkaloids, it became imperative to conserve the stocks of quinine which hadbeen accumulated in this country. In February 1942, The Surgeon General addresseda memorandum to the Army-Navy Munitions Board advising that use of quininein the United States be limited to treatment
26 Minutes, Atabrine Conference, Committee on Medical Research, National ResearchCouncil, 2 Nov. 1942.
27 Minutes, First Meeting, Subcommittee on Coordination of Malarial Studies, Committee on Medical Research, National Research council, 20 Jan. 1943. In Bulletin of Malaria Research, pp. 50-55.
28 Minutes, Joint Meeting of Subcommittees on Tropical Diseases and the Coordination of Malarial Studies, Committee on Medical Research, National Researchcouncil, 20 July 1943. In Bulletin of Malaria Research,pp. 106-112.
29 Report, Armored Medical Research Laboratory, Fort Knox, Ky., 23 Dec. 1943, subject: Final Report on Investigation of the Effects of Activity and Environment on Atabrine Therapy.
30 War Department Technical Bulletin (TB MED) 65, 3 July 1944.
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of malaria. On 2 March 1942, the Army-Navy Munitions Board forwarded this to the War Production Board and added a further recommendation that cultivation of cinchona be undertaken in South America. This action led to issuance by the War Production Board of Conservation Order M-131 in April 1942, which established control over the supply and distribution of quinine in the United States and permitted sale of the drug only for use as an antimalarial agent.
The Surgeon General supported a project for the establishment of cinchona plantations intropical America sponsored by Col. Arthur F. Fischer, MI, who had broughtcinchona seeds to this country from the Philippines after the fall ofBataan. 31 With these seeds, it was planned to establisha permanent source of high quality cinchona bark in the Western Hemisphere.The initial phases of this project were carried through under the auspicesof the Board of Economic Warfare (later a division of the Foreign EconomicAdministration) with support from the War Department, and cultivation wasstarted in several Central and South American locations. Because of thenatural slow growth of the trees, this project did not influence quininesupplies during the war period.
Estimates, prepared in the spring of 1942 by Preventive Medicine Service of requirementsfor antimalarial drugs, were based on the assumption that quinine wouldbe needed to supply at least 50 percent of antimalarial medication. Atthat time, uncertainty prevailed as to possible toxic effects from long-continueduse of Atabrine. By the fall of 1942, further positive steps by the Armywere needed to conserve stocks of quinine. At the meeting of a board appointed by The Surgeon General to consider this question, it was stated that atthe current rate of consumption quinine stocks would probably be exhaustedby the end of 1943.32 The board decided upon a policy whereby Atabrine would be utilized as extensively as possible in the suppressive and clinical treatment of malaria. Upon recommendation of the board, letters were sent to commanders in the field to advise them of this policy andof the necessity to conserve quinine. The board also recommended that Atabrine production in this country be expanded and urged the purchase of certain supplies of quinine known to be in South America.33 Circular Letter No. 179 was issued on 21 December 1942 by The Surgeon General tostress further the necessity of conservation of quinine by utilization ofAtabrine to the fullest possible extent.
As the fightingfronts were extended in tropical regions during 1942 and 1943, more and moremen were placed on regular suppressive medication for malaria, and the demand for Atabrine increased enormously. Domestic pro-
31 Letter, The Surgeon General, U.S. Army, to the Secretary of War (through theCommanding General, Services of Supply), 22 Sept. 1942, subject: QuininePlantations.
32 Memorandum, Lt. Col. K. R. Lundeberg, Chief, Epidemiology Branch, Preventive Medicine Division, Professional Services, Office of The Surgeon General, to The Surgeon General, U.S. Army, 16 Oct. 1942, subject: Proceedings of a Board of Officers Appointed to Consider the Present Status of Antimalarial Drugs.
33 Letter, The Surgeon General, U.S. Army, to Commanding General, Services of Supply, 17 Oct. 1942, subject: Bolivian Quinine
33
duction of the drug already had been increased severalfold during 1941 and early 1942. Foreseeing future increased requirements for Atabrine, The Surgeon General, in October 1942, recommended further expansion of production. Despite this effort, the supply of Atabrine was critical during the first quarter of 1943, and allocations were necessary to meet the needs of the U.S. military forces and lend-lease requirements. The War Production Board expedited the construction of new facilitiesfor the production of Atabrine, and, after the first 6 months of 1943,supplies of the drug were adequate.
Throughout the war, the Tropical Disease Control organization of the Office of The Surgeon General, U.S. Army, assisted in preparing estimates of requirements for antimalarial drugs. Based upon probable exposure to malaria, calculations were made of the amounts of drugs required per 10,000 men per year in different geographic areas. Because of uncertainty about the possible toxicity of Atabrine, calculation of quinine requirements was at first made on the assumptionthat 25 percent of men receiving suppressive medication might require quinine;in December 1943, this figure was dropped to 15 percent; and, in May 1944,to 3 percent. 34
Since actual issue of quinine fell far below the estimated requirements, by May 1944 Army stockpiles had accumulated so that they could he expected to last untilearly 1947. The War Production Board was apprised of this fact.35 After V-E Day, it was recommended that the War Production Board releaseamounts of quinine sufficient for domestic civilian medicinal use. This modification of Conservation Order M-131 was put into effect 18 August 1945.
Ample supplies of quinine were available for military needs throughout the war. Because of the superiority of Atabrine, consumption of quinine was far less than was anticipated early in the war period. As a result of experience, Atabrine became the preferred drug for the suppression of malaria.
Cooperation With the National Research Council
The Tropical Disease Control unit served as liaison between The Surgeon General and thoseagencies involved in the development and trial of new drugs for suppressionand treatment of malaria. The wartime program for the development of newantimalarial drugs had its inception in the Subcommittee on Tropical Diseaseswhich was organized in May 1940 by the Division of
34 (1) Memorandum, Lt. Col. Paul P. Russell, MC, Tropical Disease Control Section, Epidemiology Branch, Preventive Medicine Division, Professional Services, OTSG, for Lt. Col. H. E. Coder, Chief, Requirements Branch, Distribution and Requirements Division, Supply Service, OTSG, 3 July 1943, subject: Estimated Atabrine, Quinine, and Plasmochin Requirements of the Army. (2) Memorandum, Maj. O. R. McCoy, MC, Tropical Disease Control Section, Epidemiology Branch,Preventive Medicine Division, Professional Services, OTSG, for Chief, Requirements Branch, attention: Lt. Col. Martin A. Compton, 17 Dec. 1943, subject: Estimated Atabrine, Quinine, and Plasmochin Requirements of the Army. (3) Memorandum, Maj. O. R. McCoy, MC, Director, Tropical Disease Control Division, Preventive Medicine Service, OTSG, for Chief, Supply Service, 6 May 1944, subject: Requirements of Quinine for Suppressive Treatments of Malaria.
35 Memorandum, Brig. Gen. Albert J. Browning, GSC, Director, Purchases Division, ASE, for The Surgeon General, 17 May 1944, subject: Quinine Procurement, and 1st Endorsement thereto, dated 20 May 1944.
34
Medical Sciences of the National Research Council upon recommendation by The Surgeon General. From its first meeting in June 1940 until the summer of 1941, the Subcommittee dealt with various recommendations covering the prevention, chemoprophylaxis, and chemotherapy of malaria, and promotion of research in this field.36 In the summer of 1941, this Subcommittee instituted a series of conferences on malaria research, the first of which was held on 8 July.37 In September 1941, research projects were initiated which were recommended bythe Subcommittee on Tropical Diseases and were financed through the Committee on Medical Research of the OSRD (Office of Scientific Research and Development) 38
Early in 1943, the Conference on Malaria Research was replaced by a Subcommittee on Coordination of Malarial Studies, organized under the Division of Medical Sciencesacting for the Committee on Medical Research of the National ResearchCouncil. This Subcommittee coordinated the research projects on the synthesisand biochemistry of antimalarial drugs, carried out under the auspices ofthe Division of Chemistry, and the studies on the pharmacology and clinicaltesting of antimalarials sponsored by the Division of Medicine. Throughoutthe history of these conferences and committees, representatives of the PreventiveMedicine Service attended the meetings and acted in a liaison capacity tothe research program on problems encountered by the Army. In November 1943,the Subcommittee on the Coordination of Malarial Studies was superseded bya Board for the Coordination of Malarial Studies which included officersfrom the military services.39 The director of the Tropical DiseaseControl Division served on this Board which functioned through the remainderof the war.
When, in the spring of 1943, the clinical testing of new antimalarial drugs was expandedunder enlarged OSRD contracts, 3 Medical Corps officers under a specialallotment to the Preventive Medicine Service were assigned to assistin the drug research program, and, in the winter of 1944, this group wasenlarged by The Surgeon General to 15 officers. The group actively participatedin the clinical studies made during the remainder of the war.
Clinical Testing of New Antimalarial Drugs
The first new drug recommended to the Armed Forces for trial was sulfamerazine. Field tests of sulfamerazine as a causal or true prophylactic were proposed by the Subcommittee on Coordination of Malarial Studies at its meeting on 20 January 1943.The recommendation was based upon the prophy-
36 Report, Owsei Temkin, M.D., and Elizabeth M. Ramsey, M.D., Antimalarial Drugs--Summary of Classified Material File, Office of Medical Information, Divisionof Medical Sciences, National Research Council, August 1944, p. 1.
37 Minutes, Conference on Chemotherapy of Malaria, 8 July 1941.
38 Minutes, Subcommittee on Tropical Diseases, Division of Medical Sciences, National Research Council, 4 Sept. 1941.
39 Minutes, Board for the Coordination of Malarial Studies, Division of Medical Sciences, National Research Council, 10 Nov. 1943. In Bulletin of Malaria Research, pp. 162-166.
35
lactic action of sulfadiazine in bird malaria and in falciparum malaria in human beings and upon the demonstration of sulfamerazine's superiority over sulfadiazine from the standpoint of physiologic disposition and toxic hazard.40
In accordance with this advice from the National Research Council, permission was obtained from the War Department to conduct field tests of sulfamerazine in oversea theaters where men were exposed to malaria, in order to determine whether this drug could act as a causal prophylactic in human malaria; that is, actually prevent infection. Direct correspondence from The Surgeon General to the oversea commands was authorized, and, early in March, letters were sent to the commanding generals in the Southwest Pacific, South Pacific, China-Burma-India,and the Caribbean Defense Command to ask that tests be arranged. A suggestedprotocol was enclosed, and 4,800 tablets (0.5 gm.) of sulfamerazine wereshipped to the surgeons concerned. The protocol suggested that approximately200 uninfected men proceeding to a highly malarious area be used for thetests. One-half of the group was to be given one 0.5 gm. tablet of sulfamerazinedaily; the other half, the usual suppressive treatment with Atabrine. Thedrugs were to be given 2 days before exposure to malaria and were to be continuedfor 10 days thereafter. The period of exposure was to be at least 30 days,and the period of observation at least 30 days after the last dose of thedrug.
Trials which conformed in general to the aforementioned protocol were carried out during thespring of 1943 in New Guinea, the Solomon Islands, India, and Panama.Final reports of these studies were summarized for the National ResearchCouncil. 41
Sulfamerazine, in doses of 0.5 gm. daily, was not a causal prophylactic against malaria. Although this dosage showed a fairly high degree of suppressive action against vivax and falciparum infections, its effectiveness wasnot equal to that of Atabrine in doses totaling 0.4 or 0.6 gm. per week. Significant toxic effects from sulfamerazine were noted only in India where the men were living under harassing conditions; however, in no instance didthe drug have to he stopped because of toxic reactions.
The report of the New Guinea trial was of particular interest because this study included a control group of 51 men who did not receive any antimalarial drug and because it was impossible to continue the followup observations for a period of 98 days.42 Although 3 percent of the group receiving sulfamerazine and 22 percent of the control subjects acquired Plasmodium falciparum infections, no cases of malaria caused by P. falciparum occurred among the 107 men who received Atabrine (0.6 gm.. per week). None of the 33 cases of vivax
40 See footnote 36. p. 34.
41 Malaria Report No. 94, Office of The Surgeon General, U.S. Army, to Division of Medical Sciences acting for Committee on Medical Research, Office of Scientific Research and Development, National Research Council, 4 Mar. 1944.
42 Report, Col. Maurice C. Pincoffs, MC, Chief Consultant in Medicine, United States Army, Services of Supply, Southwest Pacific Area, to The Surgeon General, ASF (through: Chief Surgeon, United States Army, Services of Supply, Southwest Pacific Area), 6 Jan. 1944, subject: Summary of Field Test of Sulfamerazine.
36
malaria which ultimately developedin the latter group appeared while Atabrine was being administered. Theseobservations were highly significant because they afforded well-controlledevidence obtained under field conditions that Atabrine in a total dosageof 0.6 gm. per week was completely effective in suppressing Plasmodiumvivax infections and in preventing the subsequent development of P.falciparum infections, a fact borne out by subsequent experience.
No additional drugs for suppressive treatment of malaria were recommended for field trial until chloroquine diphosphate (SN 7618), hereafter referred to as chloroquine, was investigated late in 1944. The first recommendation that this drugwas suitable for field tests was made at a meeting of the Board for theCoordination of Malarial Studies in September 1944.43 It was agreed that a protocol would be prepared to include suggested fieldtrials of the drug as a suppressive agent. This protocol was subsequentlygiven restricted publication. 44 At that time, however, reportsof toxic reactions began to be received, and consequently, it was recommendedat the next meeting of the Board that current studies with chloroquinein Army and Navy installations be discontinued until the uniformity andhomogeneity of the various batches be established. 45 Later,it was found that no chemical differences existed between the differentlots and that toxic effects could be minimized by employing smaller doses.
Early in 1945, arrangements were made at the Army Medical School for a study of plasma levels of chloroquine in groups of volunteers who were given suppressive doses of 0.3 gm. or 0.5 gm. once a week. This investigation showed that although there were wide individual variations, plasma levels presumably effective for suppression were generally maintained by a single dose (0.3 gm.) of the drug taken once a week. Equilibrium in the level was apparently reached after the thirdweek of administration. 46 Similar studies productive of essentially the same results were carried out at Moore General Hospital on a groupof patients who had relapsing tertian malaria. No relapses occurred during8 weeks of suppression with 0.3 gm. of chloroquine once a week, and toxiceffects from this dosage were extremely mild.47
The Board for the Coordination of Malarial Studies reviewed the status of the researches on chloroquine in March 1945 and again recommended that the suppressive action of the drug be investigated in the military forces in hy-
43 Minutes, Board for the Coordination of Malarial Studies, National Research Council, 21 Sept. 1944. In Bulletin of Malaria Research, pp. 472-515.
44 Malaria Report No. 239, Board for the Coordination of Malarial Studies, 29 Sept. 1944.
45 Minutes. Board for the Coordination of Malarial Studies, National Research Council, 6 Nov. 1944.
46 Malaria Report No. 417, Capt. John M. Mason, SnC. Division of Chemistry and Physics, Army Medical School, Army Medical Center, to Board for the Coordination of Malaria Studies, May 1945.
47 (1) Malaria Report No. 407, Medical Division, Office of the Surgeon General, U.S. Army, to Board for the Coordination of Malarial Studies, 1 May 1945. (2) Malaria Report No. 440, Moore General Hospital (through the Tropical Disease Treatment Branch, OTSG) to Board for the Coordination of Malarial Studies, 1 June 1945.
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perendemic areas. A protocol of a suggested plan of study was written.48 In April 1945, The Surgeon General sent letters to the surgeons in four oversea theaters to suggest that trials of chloroquine for suppressive treatment be undertaken. The chief advantages of this drug over Atabrine at that time were as follows:
1. A single weekly doseof 0.3 gm. was apparently sufficient to maintain a suppressive plasmalevel of the drug.
2. This dosage did not cause gastrointestinal irritation or other significant toxic effects.
3. The drug did not discolor the skin. Experiments in civilian hospitals had already demonstrated that chloroquine was not a causal prophylactic against malaria or a curative drug for malaria caused by P. vivax.
Redeployment after V-E Day and later demobilization after V-J Day interfered with conducting suitable trials overseas. Tests with chloroquine for suppression of malaria were, however, carried out in India and in the Philippines during thesummer and fall of 1945.49 These studies showed thata single dose of 0.3 gm. of the drug per week was effective in suppressingrelapses in the field of malaria caused by P. vivax. Only a few significant untoward effects, mainly gastrointestinal disturbances, were noted in approximately 700 men who took the drug for a period of from 3 to 4 months.
SUPPLIES AND EQUIPMENT FOR INSECT CONTROL
Repellents
A research program to develop improved methods of insect control was instituted by the Subcommittee on Tropical Diseases. At the first meeting of this Subcommittee, it was suggested that chemical repellents against mosquitoes be studied and the cooperation of civilian industry be sought.50 In the fall of 1941, after funds became available through establishment of OSRD, a contract was approved with the Bureau of Entomology and Plant Quarantine of the U.S. Department of Agriculture for investigation of new insect repellents. 51 This contract later was extended to include investigation of other
48 (1) Minutes, Board for the Coordination of Malarial Studies, 16 Mar. 1945. In Bulletin of Malaria Research, vol. 2, pp. 831-857. (2) Letter, Robert F. Loeb, M.D., Chairman, Board for the Coordination of Malarial Studies, to Maj. Gen. Norman T. Kirk, Surgeon General, U.S. Army, 20 Mar. 1945. (3) Malaria Report No. 353, James A. Shannon, M.D., Chairman, Panel on Clinical Testing, to Board for the Coordination of Malarial Studies, 16Mar. 1945.
49 (1) Malaria Report No. 536, 20th General Hospital, India-Burma theater, submitted by Tropical Disease Control Branch, OTSG, to Board for the Coordination of Malarial Studies, 7 Nov. 1945. (2) Malaria Report No. 637, Tropical Disease Control Branch, OTSG, to Board for the Coordination of Malarial Studies, 11 Feb. 1946.
50 (1) Minutes, Committee on Tropical Diseases, National Research Council, 19 June 1940. (2) Minutes, Subcommittee on Tropical Diseases, Division of Medical Sciences, National Research Council, 30 July 1940.
51 Minutes, Subcommittee on Tropical Diseases, Committee on Medical Research, National Research Council, 13 Oct. 1941.
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phases of insect control.52 Contracts with other governmental agencies and civilian laboratories were made as the scope of the program increased after the beginning of the war. Studies of the toxicity of new compounds by the U.S. Food andDrug Administration were included as an essential phase of the researchprogram. In June 1942, the U.S. Department of Agriculture was asked bythe War Department to undertake investigation of new mosquito larvicidesin addition to studies which already were being conducted on insecticidesfor lice and insect repellents.
The first fieldstudies on repellents were conducted in the fall of 1941 at the Gorgas MemorialLaboratory in Panama. Later, as it became apparent that field studies inthe tropics were necessary to supplement laboratory investigations in thiscountry, four Sanitary Corps entomologists were assigned to the Gorgas MemorialLaboratory to conduct such studies on the new repellents and insecticides.They began work in the spring of 1943 and during the course of the war madea number of notable contributions to the research program.53
To coordinate and evaluate the investigations, conferences were called from time to time under the auspices of the National Research Council at which recommendations were made to the armed services. At the first of these conferences, held in August 1942, it was recommended that Indalone (butopyronoxyl) be adopted immediately by the Armed Forces as a repellent against flying insects and that Rutgers 612 (2-ethyl-l, 3-hexanediol) be substituted as soon as it could be produced in sufficient quantity.54 At a subsequent meeting in November 1942, dimethyl phthalate was also recommended foruse as a standard repellent. 55 Dimethyl phthalate and Rutgers612 gave protection against bites of mosquitoes for several hours and werefar more effective than insect repellents heretofore available. At first,these repellents were issued separately for individual use. Later, aftera recommendation of the National Research Council in September 1943, a mixtureof the three repellents, referred to as "6-2-2," (6 parts of dimethyl phthalate,2 parts of 612, and 2 parts of Indalone) was adopted.56
These repellents were developed primarily for use against mosquitoes. Investigations in the field soon disclosed that they were also of value in protection against other insect vectors of disease. Studies in Egypt by the Neurotropic Virus Disease Commission of the Army Epidemiological Board showed that dimethyl phthalate was effective against Phlebotomus papatasii,
52 Minutes, Subcommittee on Tropical Diseases, Committee on Medical Research, National Research Council, 9 May 1942.
53 Hertig, Marshall: Chronological History 1943 to 1945, Unit of Sanitary Corps Officers, Gorgas Memorial Laboratory, Panama, 1 Nov. 1945. [Official record.]
54 Minutes, First Conference on Insect Repellents, Committee on Medical Research,National Research Council, 18 Aug. 1942.
55 Minutes, Conference on Insect Repellents, Committee on Medical Research, National Research Council, 12 Nov. 1942.
56 Minutes, Fifth Conference, Insect Repellents and Insecticides, Office of Scientific Research and Development, National Research Council, 28 Sept. 1943.
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the vector of sandfly fever, for a periodof from 5 to 7 hours.57 Tests in Peru by investigators of theGorgas Memorial Laboratory demonstrated the effectiveness of both dimethyl phthalate and Rutgers 612 against local species of Phlebotomus which were vectors of verruga peruana (bartonellosis).58
As part of the investigation of mosquito repellents at the Orlando Laboratory of the Bureau of Entomology and Plant Quarantine, tests were also made on larval mites (chiggers). It was found that Indalone, Rutgers 612, and dimethyl phthalate were all effective in protection against larval mites, especially when applied around the openings in clothing.59 These substances were thus of value as a preventive measure against scrub typhus which is transmitted by certain species of larval mites in the Orient. Australian workers reported that dimethyl phthalate acted as a lethal agent against larval mites rather than as a repellent. Members of the United States of America Typhus Commission working in New Guinea developed a field method for the impregnation of clothing with dimethyl phthalate, utilizing a soapy water emulsion.60 This was found more practicable than previously used methods of applying repellents to clothing and was widely employed as a preventive measure to protect troops from scrub typhus in the western Pacific.61 Bulk supply of dimethyl phthalate in gallon containers for application to clothing was recommended in the fall of 1943 for certain of the oversea theaters. In December 1944, it was recommended that an emulsifier be incorporated with the dimethyl phthalate to facilitate the preparation of emulsions in the field.
As investigations of repellents continued, a number of substances were discovered whichwere superior to dimethyl phthalate for impregnation of clothing to protect against larval mites. Benzyl benzoate was selected because of its rapidaction against mites and its persistence in clothing after laundering. InMarch 1945, recommendation was made to the Office of the Quartermaster General that benzyl benzoate, together with an emulsifier, be substituted for dimethyl phthalate in the bulk issue of insect repellent. Because of difficulties in procurement, however, supplies of benzyl benzoate did not reach thefield in time to be of use before the end of the war.
Insecticides
Coincident withplans for the deployment of increasing numbers of troops in tropical regions,need was foreseen for greatly increased amounts of insecti-
57 Report, Maj. Albert B. Sabin, MC. "U.S. Army Virus Commission," U.S. Army Forces in the Middle East, to Commission on Neurotropic Virus Diseases of theBoard for the Investigation and Control of Influenza and Other EpidemicDiseases of the Army, Office of The Surgeon General, U.S. Army, May 1943,subject: Preliminary Observations on the Effectiveness of Certain RepellentsAgainst Phlebotomus papatasii.
58 Office of Scientific Research and Development Monthly Progress Report No. 4,15 Feb. 1944, subject: Studies on Repellents, Sprays and Other ControlMeasures Against Phlebotomus Carried Out in the Rimac Valley, Peru,December 1943 to January 1944.
59 A Summary of Investigations on the Development of Insect Repellents and Lousicides, OSRD Projects M-723, M-920, and M-631, 4 Mar. 1943.
60 Letter, Lt. Col. Joseph F. Sadusk, Jr., MC, United States of America Typhus Commission, to Dr. W. E. Dove, Bureau of Entomology, Department of Agriculture, 7July 1944, inclosure thereto.
61War Department Technical Bulletin (TB MED) 121, December 1944.
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cides to control insect pests and disease vectors. Pyrethrum was the active ingredient of most of the insecticides employed for spray killing and also of some of the preparations used as mosquito larvicides, and was widely used in this country as an agricultural insecticide. After the beginning of the war, Kenya, British East Africa, became almost the sole source of pyrethrum. Increased military demand,crop failure in Kenya, and shipping difficulties resulted in a criticalshortage in the spring of 1942. At a conference held in the U.S. Departmentof Agriculture on 22 May 1942, it was agreed that priorities should be establishedto control stocks of pyrethrum and that cultivation of the plant shouldbe developed in the United States. By action of the War Production Board,supplies of pyrethrum in the United States were "frozen" on 11 June, andthereafter allocations were made primarily upon the basis of militaryneeds.
In the spring of 1943, a joint United States-United Kingdom committee was established under the International Aid Division, ASF, to consider technical aspects of the use and conservation of pyrethrum and to determine policies to govern allocations of pyrethrum flowers by the Combined Raw Materials Board. 62 It was agreed that the amount of pyrethrum allocated for military useshould be in proportion to the number of troops exposed to the risk ofinsect-borne disease, and, so far as practical, American and British standardsof issue of pyrethrum preparations should be identical for similar conditions.Although stocks of pyrethrum remained critical during 1943 and allocationscontinued through 1944, supplies were always sufficient to meet essentialmilitary needs.
Aerosol Dispensers
Economy and efficiency in the use of pyrethrum by the Army was accomplished by the adoptionof the Aerosol insecticide dispenser as the principal means for spray killing adult mosquitoes. In 1941, scientists of the U.S. Department of Agriculture discovered the principle of using a propellent gas to disperse an insecticidal mixture into a fine mist, or Aerosol. With the advice and assistance ofofficers of the Preventive Medicine Service, manufacturers, during thesummer of 1942, developed a suitable small container utilizing Freon-12as the propellent. One pound of the pyrethrum mixture contained in thiscylinder was sufficient to treat 150,000 cubic feet of space and was morethan equivalent to 1 gallon of pyrethrum oil spray in insecticidal efficiency.Because of their small size, Aerosol insecticide dispensers, popularlyknown as mosquito bombs, effected a saving of approximately 85 percent inshipping space and could conveniently be carried into forward areas (fig.6). They were also highly valuable for disinsectization of aircraft. Specificationsand requirements were submitted in October 1942; and production began inNovember. By 1 March 1943, approximately 600,000 dispensers had been manufactured.
62 Minutes, Joint United States-United Kingdom Committee on Pyrethrum, 15 and 18May 1943.
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As Aerosol insecticide dispensers proved their worth in the field, recommended allowances for use in malarious areas in oversea theaters were increased by 50 percentin March 1943. By summer, difficulty was experienced in obtaining sufficient Freon-l2 to permit manufacture of the number of dispensers needed to meet oversea requirements. Strong support was given by The Surgeon General toincreased allocation of Freon-12 for insecticide use 63 As a result,War Production Board Order M-28 was immediately amended further to conserveFreon-12 by prohibiting its use for comfort cooling installations, and stepswere taken to increase its production. A proposal to mix methyl chloridewith the Freon-12 used in insecticide dispensers was rejected because ofthe toxicity of the compound and because the gain from the use of methylchloride would not compensate for the loss of production due to requiredalteration of manufacturing facilities. 64 Supplies of Freon-12for Aerosol dispensers remained critical until new plant facilities for itsmanufacture were completed in the summer of 1944.
63 Letter, Maj. Gen. Norman T. Kirk, The Surgeon General, U.S. Army, to the Commanding General ASF, 10 July 1943, subject Freon-12 for Insecticide Use.
64 See footnote 56, p. 38.
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DDT
The principal advance in insect control during the war was the discovery and application of the various insecticidal actions of DDT against the vectors of disease. InFebruary 1943, the Orlando Laboratory of the U.S. Department of Agriculture first reported the remarkable effectiveness of DDT as an anopheline larvicide. Further field studies during the summer of 1943, including a series of carefully controlled experiments, confirmed the value of DDT oil solutions and dust preparations as mosquito larvicides. Production during 1943 was limited, and all the DDT was used for louse powder because other noncritical materials were available as effective larvicides. Small amounts, however, (approximately 50 pounds) were shipped to each of five oversea theaters in September in order that the usefulness of DDT as a mosquito larvicide might be tested underthe varying conditions prevailing in the field.
In the meantime, studies of the toxicity of DDT were being conducted to determine thesafety of the different preparations of DDT for various insecticidaluses. By September 1943, these investigations had progressed to the pointwhere the National Research Council Conference on Insecticides and Repellentsrecommended use of the following preparations:
1. Commercially pure DDT for use (a) in a 5-percent solution in kerosene as residual-type spray. to control mosquitoes, flies, and bedbugs, and (b) in concentration of notmore than 10 percent in petroleum oil solutions as an anopheline larvicide.
2. DDT in powder form for use (a) in dilution not exceeding 10 percent with inert diluents for application as anopheline larvicide dusts, and (b) in water suspension with a suitable wetting agent as residual-type spray to control mosquitoes and flies.
3. DDT in concentrated (20 percent) solution for dilution with water and use in emulsion form as a residual-type spray and as a mosquito larvicide (figs. 7. and 8).
The first estimate of requirements for DDT for use as a mosquito larvicide was submittedin December 1943; however, except for small amounts employed for experimental purposes. DDT was not available for mosquito control until the springof 1944. Directions for its use as a mosquito larvicide were publishedin March 1944. 65 Fifty thousand pounds were allocated fromproduction in April, and recommendation was made for this amount to bedistributed among the various theaters in malarious areas. Automatic shipmentof this supply was ordered. Regular allowances of DDT for mosquito controlwere first authorized in April 1944, but because expanding production didnot keep pace with the increase in authorized allowances. allocation ofsupplies to the theaters was necessary through the remainder of l944.66
65 War Department Technical Bulletin (TB MED) 14, 3 Mar. 1944.
66 (1) War Department Circular No. 151, 17 Apr. 1944. (2) Memorandum, Col. Edward V. Macatee, OMC, [Chief, General Supplies Branch, Storage and Distribution Division], for Office of The Surgeon General, Preventive Medicine Section, attention Major McCoy, 23 June 1944, subject: Larvicide, DDT, Powder. Dissolving.
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FIGURE 7.- Mixing DDT in the field.
Even before allowances of DDT mosquito control items were published, it became apparent thatlarger amounts of this agent would be required, especially for area controlof mosquitoes by airplane application. In March 1944, estimated requirements for DDT were approximately quadrupled, and, in May 1944, this amount was doubled as a basis for calculation of Army procurement. in 1945.
Airplane Spraying
First studies of airplane application of DDT to kill mosquitoes were conducted during the fall of 1943 at the Orlando Laboratory. In January 1944, a conference was held in the Office of The Surgeon General at which liaison was established between the various agencies concerned with the development of methods for aerial dispersion of insecticides. Cooperation of the Army Air Forces was obtained to facilitate development of equipment and for further trials of DDT airplane spraying at Orlando. A project was established under the Army Air Forces Board in April 1944 to determine the practicability of employing standard aircraft and equipment for this purpose.
In order to confirm in a tropical jungle location the promising results obtained in Florida, arrangements were made for representatives of the U.S. Department. ofAgriculture to conduct a field trial against anopheline mosquitoes inPanama (fig. 9). The spraying of DDT oil solution over jungle forest at
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FIGURE 8.- Preparation of DDT oil solution for use as a mosquito larvicide.
the rate of 0.4 pound of DDT per acre reduced the number of adult anophelines by more than 90 percent and killed practically all anopheline larvae.67
Upon the basis of favorable results obtained in Florida and in Panama, a summary of information then available concerning airplane spraying of DDT was sent in April1944 to the surgeons of theaters in malarious areas, and further trialof this method of insect control was encouraged. Also, the possibilityof DDT airplane spraying for mosquito control in combat areas was emphasized.During the summer, airplane spraying projects were carried out in all thetheaters where mosquitoborne diseases were important, in many instances,with equipment improvised in the field. This method of control was
67 Interim Report No. 0-76: Studies on the Application of DDT from the Air and on the Ground for Control of Mosquitoes in Panama, Arthur W. Lindquist, U.S. Department of Agriculture, Agricultural Research Administration, Bureauof Entomology and Plant Quarantine, Orlando, Fla., and Capt. W. C. McDuffie, SnC, Army of the United States, to Committee on Medical Research of theOffice of Scientific Research and Development, 20 Apr. 1944, subject: InsectRepellents, Contract No. M-723.
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FIGURE 9.- B-25 airplane spraying DDT oil solution over jungle area in Panama.
especially valuable in newly occupied territory before ground control measures could be established. In order that aerial spraying might be performed most efficiently, it was proposed that special squadrons be authorized for this purpose. In May 1945, certain of the oversea theaters were questioned concerning the extent to whichsuch units could be utilized. The war ended, however, before special AirForces units were organized and trained in this country.
Further experimentation in the development and trial of apparatus for dissemination of DDT from aircraft was conducted throughout the war, both in this country and overseas. Much of this work was carried out by the Army Air Forces Board in closecooperation with Division 10 of the National Defense Research Committee,OSRD, and other Government agencies. Important information was acquiredconcerning the principles and practical applications involved in the dissemination of insecticides from aircraft.68
Because DDT notonly kills disease vectors but also may destroy fish and wildlife and certainspecies of insects beneficial to agriculture, consideration was given toprecautions to be observed in large-scale use of DDT in this country. A conferencewas held between representatives of the Army and the U.S. Public Health Service in March 1945, and it was agreed that certain safeguards should be adopted to prevent indiscriminate application from air-
68 Andrus, E. C.. Keefer, C. S., Bronk, D. W., Lockwood, J. S., Carden, G. A., Jr., Wearn, J. T., and Winternitz. M. C. (editors) Advances in Military Medicine. Boston: Little, Brown & Company, 1948. vol. II, pp. 643-644.
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craft in the United States.69 War Department Circular No. 207, published on 10 July 1945, prescribed that projects for airplane spraying of DDT at military installations in the continental United States must first be approved by the Army Committee for Insect and Rodent Control. Nine such projects were approved in 1945. 70
Army Committee for Insect and Rodent Control
When problems in the supply and use of DDT assumed increasing importance early in 1944, the Commanding General, ASF, at the suggestion of the director of OSRD requested The Surgeon General to form a committee to coordinate the activities ofvarious agencies concerned with this new insecticide and to make recommendations regarding production, allocation of current supplies, and new applications for use in the field. This committee, known as The Surgeon General's DDT Committee, consisted of representatives of the Navy, U.S. Public HealthService, U.S. Department of Agriculture, and OSRD, as well as various branchesof the War Department. The committee served as a valuable channel for theinterchange of information and the correlation of various phases of research,production, distribution, and field uses of DDT. 71
By the fall of 1944, the scope of research aspects and civilian applications of DDT had become so extensive that the OSRD created an Insect Control Committee to correlate the diverse and expanding research projects involved in this program and to act as an information bureau for the collection and dissemination of information on DDT. The Surgeon General's DDT Committee became the Army Committee for Insect and Rodent Control which continued to deal with the military aspects of DDT and also considered other measures for the control of insects and rodents. 72 Close liaison was maintained between the two committees. Reports from Army sources were submitted to the OSRD Committee for abstracting and distribution to the various U.S. and Allied agencies interested in DDT.
The Subcommittee on Field Uses of the Army Committee for Insect and Rodent Control dealt with matters of immediate concern to the Army's tropical disease control program. The field testing of new repellents, the dissemination of DDT from aircraft, and the development of Aerosol methods of dispersal were the most important subjects of consideration. Although experiments were conductedwith smoke generators and explosive charges as means of dissemi-
69 (1) Letter, Brig. Gen. James S. Simmons, U.S. Army, Chief. Preventive Medicine Service OTSG, to Dr. Thomas Parran, The Surgeon General, U.S. Public Health Service, 12 Apr. 1945, inclosure thereto, subject: Use of DDT for Mosquito Control in the United States--A Joint Statement of Policy by the U.S. Army and the U.S. Public Health Service. (2) Letter, C. L. Williams, Assistant Surgeon General, U.S. Public Health Service, to The Surgeon General, U.S. Army, 20 Apr. 1945.
70 Minutes, Ninth Meeting, Army Committee for Insect and Rodent Control, 28 Aug.1945. Appendix II: Report of Subcommittee on Field Uses, 28 Aug. 1945.
71 Minutes, The Surgeon General's DDT Committee, 16 June 1944.
72 War Department Memorandum No. 40-44, 8 Nov. 1944.
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nating DDT, these methods had not been adopted for field use by the end of the war.
Dissemination of Information to Field Workers
The circulationof information concerning new developments in insect control to workers inthe field was an important phase of the tropical disease control program.Minutes of meetings of The Surgeon General's DDT Committee and later of theArmy Committee for Insect, and Rodent Control and the "Abstract Bulletin"of the Insect Control Committee, OSRD, were sent directly to key personsin this country and overseas. As new insecticides were adopted, directionsfor their use were published in War Department technical medical bulletins 73 Arrangements were made, through cooperation of the U.S. Department of Agriculture, for selected Medical Department officers to observe demonstrations of the field uses of DDT insecticides and the new repellents at the Orlando Laboratory of the Bureau of Entomology and Plant Quarantine. These 4-day demonstrations were held at intervals of approximately 6 weeks, beginning in November 1943 and continuing through July 1945. They were extremelyvaluable for the instruction of preventive medicine officers, especiallythose assigned to oversea service.
Distribution ofSupplies and Equipment
Because supplies of insecticides and other items for control of insects were often limited, it. was necessary to distribute what was available. among the varioustheaters in accordance with the estimated needs. Accordingly, the PreventiveMedicine Service usually recommended allowances of insecticides and pestcontrol equipment in terms of so much per thousand men per month in specifiedgeographic areas. These allowances served as a basis both for the Army supplyprogram and for the requisitions from oversea theaters. The first publishedtable of allowances was issued in March 1943 and was revised as suppliesincreased. Since some, items were supplied by the Quartermaster Corps andothers by the Corps of Engineers, it proved convenient to publish subsequenttables of allowances in the form of War Department. circulars.74
Issuance of insect control supplies was a constant problem, not only because of frequentmateriel shortages in this country and the necessity for allocations butalso because of inadequate distribution in the oversea theaters. Whenthe Aerosol insecticide dispenser and the new repellents were adopted,establishment of adequate supplies overseas was particularly difficult.Automatic supply of these items was therefore ordered in March 1943. Becausetroops often arrived in malarious localities without provision for adequateinsect control supplies and equipment, it was ordered that a 30-day supplyof essen-
73 (1) See footnote 65, p. 42. (2) War Department Technical Bulletin (TB MED) 110, 25 Oct. 1944. (3) War Department Technical Bulletin (TB MED) 194, 17 Aug. 1945.
74 (1) War Department Circular No. 289, 1 Oct. 1943. (2) See footnote 66 (1), p.. 42. (3) War Department Circular No. 163, 4 June 1945.
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tial antimalarial drugs, insecticides, and repellents accompany troops embarking in this country and that they be so stored aboard ship as to be immediately available upon landing. 75 Provision also was made that troops carry a mosquito barand a bottle of insect repellent as part. of their individual equipment. 76
EDUCATIONAL ACTIVITIES
Instruction for Medical Officers
Development of special courses and programs of instruction formed part of Tropical Disease Control activities at intervals throughout the war. As the Medical Department began to expand in the prewar period, physicians who were being recruited from civil life had little or no practical experience with tropical diseases. Teaching of tropical medicine in U.S. medical schools was generally either inadequate or altogether lacking. To meet this deficiency, a special 8-week Course in Military and Tropical Medicine was organized at the Army Medical School for medical officers coming into the service. The instruction emphasized the preventive and control aspects of tropical infections as well as the methods for their diagnosis and treatment. The first course began in August 1941. During the war, 28 courses were held, attended by 1,797 Medical Department officers who completed the course and by 48 others who received part of the instruction. As approximately 55,000 doctors were mobilized into the Army, this program of courses met only a small fraction of the need for special instruction in tropical medicine.77
As a longer range program, steps were taken through the Subcommittee on Tropical Diseases of the National Research Council, in the summer of 1942, to improve undergraduate teaching of tropical medicine in medical schools which were then largely given over to the training of future medical officers for the Army andNavy. 78 Grants from the John and Mary R. Markle Foundation,totaling $170,000, in the years 1942, 1943, and 1944 enabled medical schoolsto send one or two staff members to the 8-week course in tropical medicineat the Army Medical School and to Central America for a month of practical field experience in the tropics. Of the 77 medical schools in time United States, 63 took advantage of these opportunities.79 With the support of the foundation grants, specially qualified lecturers and parasitologic specimens and other teaching materials also were furnished to medical schools.
75 (1) Letter. Brig. Gen. L. S. Ostrander, USA, Adjutant General, U.S. Army Forces in the Far East, to The Adjutant General, War Department, 1 Oct. 1943, subject: Malaria Control. (2) Letter, Maj. Gen. J. A. File, Adjutant General, War Department, to the Commanding Generals, Ports of Embarkation the Commanding Officers, Ports and Subports of Embarkation; the Quartermaster GeneralThe Surgeon General, and Chief of Transportation, 30 Dec. 1943, subject:Antimalaria Supplies for Troops Moving Overseas.
76 Preparation for Overseas Movement (Short Title: POM), 2d edition, 1 Aug. 1943.
77 Data were obtained from the Resources Analysis Division, Office of The Surgeon General.
78 Minutes, Eleventh Meeting, Subcommittee on Tropical Diseases, Committee on Medical Research, National Research Council, 8 July 1942.
79 Annual Report, The John and Mary R. Markle Foundation, 1944.
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When the war inEurope ended and the redeployment of large forces to the Pacific was scheduled,arrangements were made for refresher training in tropical medicine for medicalofficers during redeployment. A 2-week program of instruction, known as theCourse in Diseases of the Pacific Area, was established at Carlisle Barracks,Pa., and a group of 12 specially qualified officers was selected to giverefresher instruction on the prevention, control, diagnosis, and treatmentof these diseases. The course was intended for Medical Corps officers assignedas unit surgeons, as medical inspectors, or as chiefs of hospital medicalservices. The first course began on 20 August 1945, but, because the warended, only four courses were given. A total of 66 officers attended.
The issuance ofinformational bulletins and other educational materials was an importantactivity, because Medical Department officers, in general, lacked knowledgeand experience relating to tropical diseases. The first digest of essentialinformation concerning tropical infections was distributed in June 1941 asa circular letter for medical officers.80 It was republished inan expanded form early in 1943.81 The prevention and control ofmalaria was discussed at more length in a separate publication.82 Later, as more information was accumulated from the Army's field experience,individual bulletins were issued dealing with specific diseases which hadproved to be of military importance. As a rule, these described diagnosisand treatment, as well as prevention and control, and were prepared in collaborationwith other interested divisions of the Preventive Medicine Service and theMedical Consultants Division, OTSG. Because of the outstanding militaryimportance of malaria, War Department technical medical bulletins were preparedfrom time to time in order to summarize latest field experiences with thedisease and give information concerning the development of new control measures. These bulletins were 8 of 24 War Department technical medical bulletins on tropical diseases which were prepared primarily or in part by the Tropical Disease Control Division during the war.
Eleven articlesrelating to the control of tropical diseases were printed in medical andscientific journals. The most significant of these publications were a keyto the anopheline mosquitoes of the world and a mosquito atlas which summarizedimportant information concerning the vectors of malaria and other mosquitobornedisease.83 These were issued in the spring of 1943 and werehighly valuable to entomologists and other members of the worldwide malariacontrol organization.
80 See footnote 24 (1), p. 30.
81 Circular Letter No. 33, Office of The Surgeon General, U.S. Army, 2 Feb. 1943.
82 Circular Letter No. 22, Office of The Surgeon General, U.S. Army, 16 Jan. 1943.
83 (1) Russell, Paul P., Rozeboom, Lloyd E., and Stone, Alan: Keys to the Anopheline Mosquitoes of the World, with Notes on Their Identification, Distribution, Biology, and Relation to Malaria. Philadelphia: The American Entomological Society, The Academy of Natural Sciences, 1943. (2) Ross, Edward S., and Roberts, H. Radclyffe: Mosquito Atlas. Philadelphia: The American Entomological society, The Academy of Natural Sciences, pt. 1, 1943.
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The Division ofMedical Sciences of the National Research Council developed a series of compactand practical textbooks designed particularly for use by Army and Navy medical forces. Two of the volumes had special value in malaria control and were prepared by staff members of the Army Medical School.84
Troop Training in Malaria Control
During the summer of 1943, efforts were made to strengthen the training and indoctrination of troops in malaria control measures. In September 1943, War Department Circular No. 223 was published which prescribed a special 4-hour coursein malaria control and discipline for everyone in the Army. For future officers and inductees, it was ordered that this instruction be included duringtheir training in the continental United States. For personnel alreadyin the Army, both in the United States and overseas, the instruction wasto be completed at the earliest date possible. Details of the instruction,including an outline of the material to be presented during the 4-hour course,were published in War Department Training Circular No. 108, 21 September1943. These provisions for special training in malaria control were keptin effect by a subsequent War Department circular published in April 1945,at which time a revision of the training circular including new developmentsin preventive measures was also issued.85
Training Aids
Throughout the war, the Tropical Disease Control unit promoted and gave consultative technical assistance in the preparation of various training aids for the instruction of troops in the prevention and control of malaria and other tropicaldiseases.
Informative material to serve as a basis for lectures on malaria control was published incircular letters from the OTSG and in War Department training circulars.86 Portfolios, measuring 30 by 40 inches, of mounted illustrationswith suggested texts for the lecturer printed on the reverse side weredesigned to assist instructors in presenting lectures on prevention oftropical diseases in such a manner that they could be understood readilyby troops. 87
A number of motion picture films were produced under the auspices of the Army PictorialService or were adapted from those produced by other agencies to supplementbasic instruction. The first of these on malaria control (TF 8-953, Malaria--Cause and Control), issued early in 1943, showed the life
84 (1) Mackie. Thomas T., Hunter, George W., and Worth, C. Brooks: A Manual of Tropical Medicine. Philadelphia: W. B. Saunders Co., 1945. (2) Russell, Paul F., West, Luther S., and Manwell, Reginald D.: Practical Malariology. Philadelphia: W. B. Saunders Co., 1946.
85 (I) War Department Circular No. 117, 14 Apr. 1945. (2) War Department Training Circular No. 16, 14 Apr. 1945.
86 (1) Circular Letter No. 44, Office of The Surgeon General, U.S. Army, 15 Feb. 1943. (2) War Department Training Circular No. 108, 21 Sept. 1943.
87 (1) War Department Graphic Training Aid 8-4: Malaria (Graphic Portfolio), 1944. (2) War Department Graphic Training Aid 8-17: Personal Health (Graphic Portfolio), 1945.
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cycle of the malaria parasite and emphasized environmental control measures. In 1944, another film (TF 1-3343, Malaria Discipline), produced primarily under the auspices of the Army Air Forces, stressed individual protective measures and malaria discipline. Later, films were issued which portrayed experiences in the field and served as a background for refresher training; for example:
Miscellaneous Film 1046, Silent Battle, a portrayal of Australian Army experience with malaria.
Film Bulletin 195, DDT--Weapon against Disease, an account of the development and early Army uses of DDT insecticides.
Film Bulletin 200, Malaria Control on Corsica, a picture of field application of recommended control measures.
Miscellaneous Film 1230, Schistosomiasis, a brief portrayal of the geographic distribution, epidemiology, clinical aspects, and control of schistosomiasis, most of which was photographed on Leyte where this disease was a military problem during the early stages of the campaign to reoccupy the Philippines.
Educational Propaganda
In order to supplement instruction given during formal training periods, advantage was takenof every opportunity to issue reminders or educational propaganda concerning tropical disease preventive measures, especially those which the individual had to apply himself. Various media were employed for this purpose, including posters, pamphlets, cartoon moving picture films, recordings for broadcasts, signs, and printed warnings on match covers and ration containers. Because of the prime military importance of malaria, most of these reminders were designed to promote malaria discipline and the use of individual protective measures against mosquitoes.
In the summer of 1943, a booklet entitled "This is Ann," prepared by Maj. Munro Leaf and the cartoonist Theodor S. Giesel (Dr. Seuss), was published and distributed to troops proceeding to tropical theaters. The booklet presented in humorous style the essential facts about malaria and the protective measures which the soldier himself should apply (fig. 10). It was well received andwidely publicized and distributed. Several million copies were printedbefore the end of the war. Material from the booklet also was printed onthe back of oversea news maps which were given wide distribution throughoutthe Army.
During the summer of 1943, the cooperation of the Special Services Division (later Morale Services Division), ASF, was secured to promote an educational propaganda program in malaria prevention among troops in the field. Through this cooperative effort, 15 posters, 3 cartoon motion picture films, and recording were produced which utilized the facilities and specially qualified talent of the Special Services Division. The posters emphasized personal
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protective measures against malaria (figs. 11 and 12). Twenty-five thousand copies of each were printed and distributed to the oversea theaters in malarious areas early in 1944.
Cartoon motion pictures were produced as part of the Snafu Series which was regularly included in the Army-Navy Screen Magazine. These cartoons, each with a running time of about 4 minutes, depicted in humorous fashion the difficulties experienced by Private Snafu when he neglected antimalaria precautions. They were entitled and released as follows:
"Private Snafu vs. Malaria Mike," released in Army-Navy Screen Magazine No. 23, March 1944, and later issued as Miscellaneous Film No. 1035.
"Target Snafu," released in Army-Navy Screen Magazine No. 38, October 1944.
"Its Murder, She Says," released in Army-Navy Screen Magazine No. 52, May 1945.
One hundred copies of a recording entitled "Know Your Enemy--Malaria" were produced anddistributed in the spring of 1944. About 20 minutes in length, this recordingwas suitable for broadcasting over local radio networks and loudspeakersystems and was intended for use in orientation programs and for refresherinstruction. It stressed the hazards of malaria in the tropical theatersand the individual means of malaria prevention.
Experience had shown that short cartoon trailers attached at the beginning of feature motion pictures shown in the oversea theaters were effective
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FIGURE 11.- Antimalaria poster.
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FIGURE 12.- Antimalaria poster.
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reminders in promoting malaria discipline. Arrangements were made with the Army Pictorial Service for the production of 50 appropriate cartoon trailers, each of which stressed an aspectof personal measures for prevention of malaria.
Other reminderswere issued in the form of stickers for vehicle windshields displaying antimalaria slogans such as "Prevent Malaria--Shorten the War," and an admonition to "Stay on Authorized Roads--Malaria Mosquitoes Breed in Road Ruts--Do Your Part to Stop It." Reminders to observe malaria precautions also were printed on ration box containers and on matchbook covers sold by Army Post Exchanges.
In connection with plans for redeployment in the Pacific, a series of posters on tropical diseases was prepared in conjunction with the Health Education Unit. Release was postponed because of the sudden end of the war with Japan. However, threeposters dealing with schistosomiasis and four relating to scrub typhus wereissued in December 1945. Other posters on plague, filariasis, and malaria were still in the process of publication at that time. The importance of health education as a program separate from didactic training in disease preventionwas not appreciated early enough nor its value widely recognized. Experienceindicated that the propaganda phase of preventive medicine warranted morethorough and systematic exploitation.
From time to time, members of the staff of the Tropical Disease Control unit were calledupon to lecture at meetings of various medical and public health societies. In these lectures, opportunity was afforded to present accounts of thetropical disease problems faced by the Army and the steps taken by TheSurgeon General to meet them. Attendance and discussion at such meetingsserved as a valuable liaison between the Office of The Surgeon Generaland the medical and public health professions in the country at large.In addition to these lectures, members of the staff lectured on numerousoccasions at Army training centers including the Army Medical School;the Medical Field Service School, Carlisle Barracks; the Unit TrainingCenter, Camp Plauche; and the Schools of Military Government at Charlottesville,Va., and New Haven, Conn.
PRECAUTIONS AGAINST THE INTRODUCTION OF TROPICAL DISEASES INTO THE UNITED STATES
General Policies
As the zones ofmilitary operations were extended and large numbers of men were deployedin tropical regions, it became apparent that the possible introduction ofexotic diseases into this country by returning service personnel would bea serious problem. At the request of the armed services, this matter wasconsidered at a meeting of the Subcommittee on Tropical Diseases in
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January 1943, and a report of its recommendations was circulated to representatives of the armed services in March 1943. 88 As then visualized, the risks especially to be guarded against were:
1. Introduction of diseases not then existent in the United States.
2. Introduction of new strains or types of disease organisms which might be more dangerous than thosealready in the country.
3. Admission of large numbers of persons infected with diseases them existent in the United States,with the result of wider distribution and increased incidence.
4. Introduction of the vectors of certain diseases which were presumably then absent because of the lack of those vectors.
The recommendations contained in this report were discussed at conferences of representatives of the Army, Navy, and U.S. Public Health Service held in the OTSG on13 and 27 April. At the latter conference, agreement was reached regarding general recommendations on the introduction of tropical diseases into the United States and also specific recommendations on certain diseases which presented the greatest military problem; namely, malaria, filariasis, amid schistosomiasis. 89 In substance, it was decided that: (1) control of the mosquito vectors in known endemic areas in the United States was the most practical solution to the problem of preventing postwar malaria epidemics; (2) the presence of microfilariae in the blood without symptoms should not warrant restriction of the location or movement of infected persons in this country; and (3) studies should be undertaken to determine whether local species of snails could act as vectors of schistosomiasisand to develop more satisfactory drugs for treatment.
The recommendations made at this conference were adopted by the Subcommittee on TropicalDiseases in July 1943 and served as the basis for Army policy. Questionson measures to prevent the introduction of disease vectors into the UnitedStates were handled by the Interdepartmental Quarantine Commission ofthe Army, Navy, and the U.S. Public Health Service. Subsequent conferencesof representatives of the Army, Navy, and the U.S. Public Health Serviceto discuss problems in connection with the introduction of exotic diseaseswere held on 13 March 1944 and on 8 June 1945. Although a number of additionalrecommendations were made, chiefly to encourage better diagnosis and reportingof tropical diseases by civilian agencies, no important changes affectingthe policies of the armed services were adopted.
88 (1) Minutes, Thirteenth Meeting, Subcommittee on Tropical Diseases, Committee on Medical Research, National Research Council, 12 Jan. 1943. (2) Minutes, Fourteenth Meeting, Subcommittee on Tropical Diseases, Committee on Medical Research, National Research Council, 20 July 1943, and Appendix A thereto, dated 28 Apr. 1943, subject: Conference on Precautions Against the Introduction of Tropical Diseases into the United States by Returning Military Personnel.
89 See footnote 88 (2).
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Program for Returning Soldiers and Prisoners of War
As more and more men returned from tropical areas, many of whom were infected with malaria, further steps were taken to minimize the hazard of possible spread ofthe disease in this country. In June 1943, Circular Letter No. 111, Office of The Surgeon General, U.S. Army, was published on the management of malaria cases; it emphasized antimosquito precautions and prescribed thick-blood film examination of all patients who had had recent duty in an overseaarea where malaria was endemic. Adequate control of anopheline mosquitoeswas maintained at military installations, including hospitals, throughoutthe country. In accordance with the agreement between the Secretary of Warand the Federal Security Administrator, the U.S. Public Health Service carried out mosquito control, when needed, in extramilitary zones adjacent to reservations. This program was originally instituted to protect troops from acquiringmalaria from civilians, but it also served equally well to help preventspread of malaria from soldiers to civilians.
In the spring of 1943, large numbers of prisoners of war from the North African campaign, many of whom were infected with malaria, were brought to this country.The same antimosquito measures were employed at prisoner-of -war campsas at regular military installations to prevent possible spread of malariaamong the prisoners and to surrounding civilian communities.90 In the 1944 season, the problem of malaria control was made moredifficult because prisoners were widely dispersed in branch camps to workon farms and other scattered labor projects. In camps which were to be occupiedfor comparatively short periods, emphasis was placed on screening, on theuse of bed nets, and on the employment of insecticidal sprays, rather thanon drainage and larvicidal programs.91
Cooperation With the U.S. Public Health Service and State Health Offices
As the, prospect of demobilization approached, support was given to extend the programof Malaria Control in War Areas, U.S. Public Health Service, to includeselected locations in Southern States where the risk of transmission wasconsidered greatest. 92 Evidence of the effectiveness of thiscoordinated mosquito control program was afforded by the extremely lowmalaria rate which prevailed among troops permanently stationed in thiscountry after 1941 and also because, so far as was known, only an insignificantnumber of secondary cases of malaria were traced to oversea veterans.
During the summer of 1944, the number of malaria relapses occurring among veterans caused concern on the part of civilian public health authorities.
90 ArmyService Forces Memorandum No. S40-10-43, 19 June 1943. [Malaria Among Prisonersof War.]
91 Army Service Forces Circular No. 206, 5 July 1944.
92 Letter, Maj. Gen. Norman T. Kirk, The Surgeon General, U.S. Army, to Dr. Thomas Parran, The Surgeon General, U.S. Public Health Service, 11 Oct. 1944.
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This was manifested in a series of letters to The Surgeon General from State health officials asking that the Army furnish the names and addresses of all persons discharged from the service who had had malaria. The question was brought beforea meeting of the Subcommittee on Tropical Diseases in September.93 After discussion by representatives of the services and the Association of State and Territorial Health Officers, a resolution was adopted to the effect. that no essential public health purpose would be accomplished by reporting to civil health authorities the names and addresses of personswho had had malaria or had been exposed to it during the course of theirmilitary experience. The consensus was that malaria control in the UnitedStates should be based upon antimosquito measures in endemic and potentiallyendemic areas rather than upon control of individual cases.
Special MedicalProcessing for Returning Troops
In order to lessen the risk of possible introduction of tropical infections, a, supplement to the usual quarantine, procedures was adopted, which required specialmedical processing of troops returning from foreign duty.94 During this medical processing, special effort was to be made to identifyand hospitalize or treat individuals who, while on furlough, were likelyto suffer from a recrudescence of a chronic infection, especially malariaor other tropical disease. Thick-blood film examinations were prescribedroutinely for those who had discontinued taking suppressive antimalarialdrugs within the previous 30 days. All persons who had had malaria overseasor had served in a hyperendemic area and had had suppressive treatmentwere to be warned that. they might suffer a relapse or an initial clinicalattack while on furlough. They were instructed to seek prompt medical attentionand to have a blood examination in case of a febrile illness. This warningand instruction was also printed in War Department Pamphlet No. 21-16,1944, which was distributed to soldiers about to go on furlough after oversea service. With the prospect of extensive redeployment and demobilization, the procedures relating to the medical processing of troops returned from foreign duty were later revised and emphasized in TB MED 180, publishedin July 1945.
Another measurewhich helped to prevent spread of malaria in civilian communities was thepolicy on discontinuance of malaria suppressive treatment in returnees whichwas established in November 1944.95 In order that. personnel whowere still taking suppressive medication upon arrival in the United Statesmight be protected from malarial attacks during travel and furlough and alsoto insure that medication was given for at least. 4 weeks after last exposure in an oversea malarious area, it was ordered that. suppressive treatment should be
93 Minutes, Seventeenth Meeting. Subcommittee on Tropical Diseases, Committee onMedical Research, National Research Council, 28 Sept. 1944.
94 War Department Technical Bulletin (TB MED) 2, 3 Jan. 1944.
95 War Department Circular No. 449, 25 Nov. 1944.
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given to such personnel for at least 28 days after their arrival. This measure not only was beneficial tothe individual, by preventing an attack of malaria at an inconvenienttime, but it also reduced the chance of spread of the disease to othersduring the furlough.
The protection of the public from tropical diseases was stressed in performing the terminal physical examination on separation of soldiers from the service.96 Special examinations were prescribed for those who had a recenthistory of malaria, dysentery, filariasis, schistosomiasis, leishmaniasis,or hookworm infection. It was directed that persons carrying organismsof these diseases, even though asymptomatic, should be treated before discharge,except those individuals who had microfilariae in the blood but showedno signs or symptoms of filariasis.
SUMMARY
From the beginning of the war, it was universally recognized that troops deployed in thetropical theaters of operations would be exposed to a variety of diseaseswhich either do not occur or are not widely prevalent in the United States.There was much speculation as to the disease problems which might arise whenthe Army was demobilized and soldiers returned to civil life, In retrospect,the dangers were overemphasized. Except for malaria early in the war, tropical disease rates, in general, were low. At times, dengue, sandly fever, scrub typhus, filariasis, schistosomiasis, and hookworm infection constituteddisease problems military significance in certain areas; however, many ofthe tropical and parasitic diseases which are commonly a scourge of nativepopulations proved little or no problem to the military forces. This wastrue of such diseases as yellow fever, cholera, plague, yaws, leprosy, trypanosomiasis, and leishmaniasis as well as many of the minor tropical afflictions. Deaths from tropical diseases were amazingly few. The majority of men who served in the tropics returned with unimpaired health. From experience to the end of 1945, it would appear that no serious tropical disease problems havebeen created in this country as a. result of the worldwide deployment, ofthe military forces.
96 War Department Technical Manual 8-255, 10 Sept. 1945.
