CHAPTER IX
Malaria and the Defense of Bataan
Maj. Gen. James 0.Gillespie, MC, USA (Ret.)
The surrender of the Filipino-American Forces at Bataan occurred, after 4 months of defensive operations, on 9 April 1942. Defeat was inevitable because of the limited resources in men and materiel and inability to replenish them, but malaria and lack of food also played a significant role in the tragedy.1 The will to fight was weakened and this hastened defeat. Complications of disease led to appalling death rates in prison camps.
A brief review of the epidemiology of malaria, problems of malaria control, medical war planning, and military operations may enable one to appreciate the devastating effects of disease and malnutrition on U.S. Forces, the enemy, civilian refugees, and Japanese-held prisoners of war during the long years of captivity.
EPIDEMIOLOGY OF MALARIA
The mountainous terrainand climate of Bataan provide ideal conditions for the propagation of thevector of malaria.2 From the two chief mountain masses on Bataan,numerous streams course in all directions toward Manila Bay and the ChinaSea. The transition from the higher altitudes to the flat and narrow coastalplain through the foothills insures a rapid flow of water in the streams.The rainfall is sufficiently adequate to maintain a large number of permanentstreams through the dry season, which extends from November through May.These provide adequate breeding grounds and support protective vegetationin which adult mosquitoes survive throughout the dry season.
The chief vector of malaria in the Philippines is Anopheles minimus flavirostris 3 This mosquito breeds most readily in the protected areas of rapidly flowing rivers, streams, and irrigation ditches, preferring shady places and clear, fresh water. Breeding does not normally occur in salt water, rice paddies, or in water above 2,000 feet altitude. Thus, malaria in Bataan, as throughout the Philippines, is a disease contracted in the foothills, especiallybetween the flat coastal plain and the higher ground below 2,000 feet altitude.Seasonal variations in the incidence of malaria are related to the effectsof the
1 Hewlett. F.: Troops on Bataan Routed by Malaria. New York Times, 18 Apr. 1942, p. 5.
2 Russell, P. F.: Epidemiology of Malaria in the Philippines. Am. J. Pub. Health 26: 1-7, January 1936.
3 Russell. P. F.: Malaria in the Philippine Islands. Am. J. Trop. Med. 13: 167-178, March1933.
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drying of the small tributaries of streamsand irrigation canals and to the flushing of the breeding grounds duringthe heaviest rainfall. Thus, Bataan constituted a potent hazard for malarialinfection during the season when military operations were feasible.
PRE-WORLD WAR II MALARIA CONTROL MEASURES
Before World War II, malaria control measures in Bataan had not been impressive, although surveys had identified the vector and determined the incidence of malaria in the native population.
In 1930, Headquarters, U.S. Army, Philippines, authorized malaria reconnaissance throughout the Islands to determine the location of maneuver areas of relative safety from malarial infection. Holt and Russell carried out a rather complete survey of Bataan during 1930 and 1931 and included Corregidor in their observations. 4 They collected mosquito larvae, made blood film examinations for malaria plasmodia, and determined splenic indices. Corregidor was found to be relatively free of malaria, but Bataan was found to harbor a large reservoir of disease. Splenic indices varied from 3 percent in the villages of the flateast coastal plain of Bataan to over 50 percent in the populated areas ofthe foothills in the vicinity of Limay. Lamao. Cabcaben, Mariveles. Sisiman, and Bagac.
After 1926, the MalariaControl Division, Philippine Health Service, had carried on demonstrations and local control programs throughout the Philippines including Bataan Province. 5 The excessive cost of this program had imposed an insoluble problem, and only moderate progress had been made in the eradication of breedingareas. Military maneuvers involving small forces had been carried out inBataan during the dry season for many years. The contracting of malaria hadbeen an annually recurring phenomenon of varying magnitude. In 1940, thesurgeon of the Philippine Division reported an appreciable lessening of theincidence of malaria in troops engaged in maneuvers in Bataan.6 He attributed this to proper use of mosquito bars and to a more careful selectionof campsites. He emphasized the importance of locating sites, preferablyon the beaches, in the coastal swamplands, or in rice paddies, and of avoidingthe higher ground in the vicinity of rapidly flowing streams. Quinine prophylaxiswas continued for 14 days after termination of the maneuver. The PhilippineDivision surgeon believed that it was impracticable to eradicate all ofthe potential breeding areas. Virtually no antimosquito control measureswere carried out by the Army in Bataan at any time.
4 Holt, R.L., and Russell, P. F.: Malaria and Anopheles Reconnaissance in the Philippines. Philippine J. Science 49: 305-371, November 1932.
5 See footnote 3, p. 497.
6 McMurdo, H. B.: Malaria, 1940 Maneuvers, Luzon, Philippine Islands. Mil. Surgeon 87: 252- 255, September 1940.
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MEDICAL WAR PLANNING
The developers of War Plan Orange-3 for the defense of Luzon envisioned an attack on the Philippines by a superior enemy force, withdrawal of U.S. Forces from central Luzon,fall of Manila, and delaying defensive action in Bataan to protect the keydefenses of Corregidor until the arrival of naval reinforcements from theUnited States. The plan called for a force of 40,000 men for the defenseof Bataan and the removal of the civilian population upon outbreak of war.
Prewar implementation of this plan in Bataan was meager indeed. This was due in part to the provisions of the National Defense Act passed by the Philippine National Assembly in 1935, which authorized the formation of a 400,000-man Filipino Army to assume the responsibility for defense in 1946 when Philippine independence wasto be achieved. Prewar preparation on Bataan included the storage of ammunition, fuel oils, and a limited quantity of canned food.7 Potentialdefense lines had been agreed upon, but no fortifications had been built.Reliance for the control of malaria was vested in quinine prophylaxis ratherthan on an antimosquito control program. This was considered the only feasible procedure in view of the size of the peninsula, which measured 25 milesby 18 miles, most of which was favorable to the breeding of malarial mosquitoes.
In May 1941, the Philippine Department surgeon appointed a board of officers at Steinberg General Hospital, Manila, to prepare estimates of the quantities of antimalarial drugs needed, based upon the April revision of War Plan Orange-3. Col. Rufus L. Holt, MC, the president of the board, had had extensive experience studying the incidence of malaria throughout the Philippine Islands. Guided by his advice, estimates were prepared and submitted at a level 100 percent above anticipated requirements.
Gen. Douglas MacArthur, in July 1941, expounded a more aggressive concept for the defense of the Philippines. One aspect of this concept was to defeat the enemy at the beaches rather than merely delay them to permit the withdrawal of troops to Bataan. Revision of medical plans during 1941 included requirements for the expansion of all Regular Army hospitals and plans for the construction of 10 station hospitals for the 10 Philippine Army divisions, the relocation of the Philippine Department Medical Supply Depot from the port area in Manila to a less vulnerable spot at Quezon City, and the construction of medical subdepots at Taríac, Los Baños, and Cebu. On the basis of these considerations, requisitions were made to The Surgeon General for drugs, medical supplies, and aid station and hospital equipment. During the fall of 1941, moderate quantities ofmedical supplies and the equipment of two general hospitals and five stationhospitals were received. One general hospital was stored at a battalionpost which had been constructed at Limay
7 United States Army in World War II. The War in the Pacific. The Fall of the Philippines. Washington: U.S. Government Printing Office, 1953.
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to house the troops guarding military stores on Bataan. This construction was planned so that the utilities would be suitable for operating rooms, laboratories, wards, and storage areas. Before the outbreak of war, a tentative site was selected in the Real River Valley at kilometer point 162.5, near Cabcaben, for the location of an additional general hospital. Plans were also formulated for the development of a medical center in Manila of approximately 3,000 beds as stabilized warfare was anticipated. 8
MILITARY OPERATIONS
There were 78,000 military and 6,000 civilian employees available in Luzon for defense when war began on 8 December 1941; a force more than twice as large as provided for by War Plan Orange-3. Also, there were approximately 25,000 civilians in Bataan whose feeding and medical care became the responsibility of the military.
The defense forces in Luzon consisted of the Philippine Division (composed chiefly of Philippine Scouts), a U.S. Army unit, nine partially mobilized Philippine Army Divisions, and miscellaneous U.S. Army troops. The Philippine Army Divisions varied from 4,000 to 6,000 men each and were organized into the North Luzon Force and the South Luzon Force with the mission of defeating the enemy at the beaches.The Philippine Division was immediately ordered into reserve in Bataan, andthe Luzon Forces were moved forward to previously chosen sectors. The JapaneseForces, supported by an overwhelming air force, succeeded in driving theFilipino-American Forces back from the beaches and prevented them from establishingany successful defense positions in central Luzon. By late December 1941,both of the Luzon Forces had been forced to withdraw from southern and centralLuzon and were entering Bataan preceded by several thousand civilians. 9 During this phase of military operations, the effects of malariaon the troops were negligible.
On 8 December 1941, the Philippine Department surgeon instructed the medical supply officerof the Philippine Department to purchase all available antimalarial drugs,hospital supplies, and equipment which could be procured in Manila, anda similar program was begun at Cebu. The amounts procured proved to be avaluable supplement to the limited stocks on hand. Remarkable progress wasmade in the establishment of a hospital center in Manila, but, in view ofthe rapid withdrawal of the Filipino-American Forces, War Plan Orange-3was placed in effect on 22 December 1941, and it became an urgent necessityto transfer all available medical resources to Bateau. On 22 December, amedical cadre was transferred to Limay to establish General Hospital Number1. On 25 December, a similar cadre was transferred to kilometer point 162.5,near Cabcaben, to establish General Hospital Number 2. The
8 Cooper, Wibb E. : Medical Department Activities in the Philippines from 1941 to 6May 1942, and Including Medical Activities in Japanese Prisoner of War Camps.[Official record.]
9 See footnote 7, p. 499.
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movement of medical supplies and equipment to Bataan was accomplished during the period 23 December to 31 December,inclusive. Approximately 100 truckloads of medical supplies were moved byroad, and many barges were sent both to Corregidor and Bataan.
Unfortunately, much equipment and some drugs and medical supplies were abandoned in Manila because of limited time, extreme congestion of the single road into Bataan, andlimited shipping facilities. The Philippine Army medical units lost muchof their medical equipment and supplies during the early contact with theenemy and in their precipitate withdrawal to Bataan.10 The PhilippineArmy soldier was not provided with a mosquito bar. Many of the U.S. soldierswho were. provided with this item discarded it as they considered it tobe a useless inconvenience.
When the withdrawing Filipino-American Forces arrived in Bataan, they assumed a defense line acrossthe northern part of the peninsula from Abucay on the east coast to Moronon the west coast (map 29). The central and western sectors of the defenseline were mountainous, and the jungle was extremely dense on the lower slopes.An all weather highway, located 15-20 kilometers to the rear, connected theeast and west roads at Pilar and Bagac and provided an excellent route forthe evacuation of casualties.
Elements of the Japanese14th Army carried on a sustained frontal attack beginning early inJanuary 1942, on the east side of the main line of resistance combined withpenetration of the mountainous center and infiltration to the rear of unitson the west coast (map 29). This caused the U.S. Forces to withdraw on 24-25January 1942 to a new line through the waist of the peninsula, parallel toand slightly below the east-west Pilar-Bagac road. Use of this road was thenprecluded, and the development of trails and roads became mandatory to provideegress to the main east and west roads. The transportation of casualtiesfrom forward units to the general hospitals in the rear then posed an almostinsoluble problem. General Hospital Number 1 at Limay was abandoned, havingcome within range of Japanese artillery, and personnel and equipment weremoved to Little Baguio, kilometer 167, in the general vicinity of Mariveles.
The Japanese made repeated attacks during February with several penetrations of the Filipino-American line and also attempted coastal landings to the south and rear. All of these efforts were defeated, and, by the latter part of February, the Japanese 14th Army had become ineffective from casualties and disease and waswithdrawn. Similarly, the Filipino-American Forces were now in dire straits from disease and malnutrition. During March,, the Japanese 14th Army was reinforced with fresh troops and resupplied while the Filipino-American Forces remained in position awaiting the final blow. This came early inApril and resulted in total collapse of the Bataan defense forces with surrender on 9 April 1942.
10 See footnote 8, p. 500.
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MAP 29.- Situation on Bataan, 8 January 1942, approximate U.S. battle positions.
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THE MALARIA PROBLEM
One estimate, which was probably conservative, judged the number of cases of malaria in Filipino-American Forces at the time of surrender, on 9 April 1942, to be 24,000.11 No estimate is available of the number of cases in civilian refugees or in the Japanese Forces on that date. In a survey of 1,252 U.S. patients at General Hospital Number 2, made 3 weeks after the surrender of Bataan, 817 (65 percent) gave a history of having been treated for malaria during the preceding 4 months.12 Early in March, the commanding officer of General Hospital Number 2, had reported an estimated 60 percent incidence of malaria in personnel assigned to the hospital. The appalling death rate in Japanese-held prisoners of war during the first 6 months of captivity isfurther evidence of the catastrophic effects of infection contracted in Bataan.A substantial number of these deaths is attributable to malaria.
Malaria reconnaissance of Bataan before World War II had clearly demonstrated that it was a formidable reservoir of malaria. The military situation required the placement of some 80,000 troops and several thousand displaced civilians in areas of highmalarial endemicity. Some of the military units were located on the flatcoastal plain, immediately adjacent to Manila Bay, which is relatively freeof malaria, but the majority were located on higher ground within flightrange of A. minimus flavirostris which preyed upon a heavily infectednative population.
The civilian health authorities before 1941 had not been able to carry out an effective control program in Bataan. The military personnel did not have the authority nor the resources to carry out an antimosquito campaign throughout the entire extent of Bataan and had planned to rely chiefly on prophylaxis and careful campsite selection for peacetime needs. Aside from a limited program of prophylaxis, no antimalaria control measures of any significance were carried out during the campaign.
Quinine prophylaxis consisting of .650 gm. once daily was instituted for the Philippine Scouts of the Philippine Department upon their arrival in Bataan early in December 1941 and for service units working in the rear areas. The application of quinine prophylaxis to the Philippine Army divisions was not authorized because of an insufficient supply of quinine. Approximately 4,500,000 five-grain (.325gm.) tablets of quinine sulfate were available in the Philippine Department Medical Supply Depot at the outbreak of war. This was only sufficient for 30 days' prophylaxis on the basis of 10 grains (.650 gm.) of quinine perman per day. In spite of the lack of a formal program of prophylaxis forthe Philippine Army, many of the officers and men procured sufficient quinine for their personal use. The limited program of prophylaxis was hamperedby inaccessibility of units, difficulty in medical supervision, and sus-
11 See footnote 8, p. 500.
12 Memorandum, Chief; Medical Service, to the Commanding Officer, Bataan General Hospital Number 2, Bataan. P.I., 7 May 1942.
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tained combat. Many breaks in quinine discipline occurred. After 15 February 1942, quinine prophylaxis had virtually ceased except for personnel of the general hospitals, certain rear service units, and division, corps, and force headquarters.13
The diagnosis of malaria in the general hospitals in Bataan was made by the demonstration of the plasmodia in stained blood films. Positive film diagnosis was based on the presence of standard, well-documented, identification characteristics of the individual species. Approximately 60 percent of the blood films were positive for Plasmodium vivax, 35 percent for Plasmodium falciparum, and 5 percent for both types of Plasmodia. An occasional caseof quartan malaria was diagnosed. It is likely that blood films taken earlier in the course of malaria and at frequently repeated intervals would haveresulted in the finding of a higher incidence of mixed infections. Limitedfacilities precluded more comprehensive studies but were sufficient for fairlyadequate screening until the final chaotic days preceding surrender. Thedegree of parasitemia in the falciparum cases was strikingly moreevident when contrasted with the number of plasmodial forms seen in positivevivax blood films.14 Microscopes were not available inthe forward medical units initially, but, for a limited period, a few wereprovided as the military operations stabilized. On the whole, in the forwardareas, reliance had to be placed on clinical acumen for diagnosis.
The treatment of malaria in vogue in 1941 consisted of 2 gm. of quinine sulfate daily bymonth for 5 days followed by .030 gm. of Plasmochin naphthoate (pamaquinenaphthoate) daily in three divided doses for 5 to 7 days. Atabrine was anacceptable substitute for quinine. The long quinine treatment calling for.650 gm. of quinine daily for 8 weeks, after the initial 5-day treatmentof the acute phase, was considered effective but difficult to supervise.The short quinine treatment consisting of 1 gm. to 1.3 gm, of quinine dailyfor 4 to 7 days, repeating for relapses, was considered to be acceptablein that it avoided the disadvantages of prolonged quinine therapy and wasfairly successful. As Plasmochin and Atabrine were available only in limitedamounts, a short quinine treatment was most commonly prescribed.
IMPACT ON DEFENSE FORCES
The deleterious effectsof malaria on the troops in Bataan became strikingly evident in February 1942 and were aggravated by the universal state of malnutrition. Withinless than 1 month after the outbreak of war, 8 December 1941, the defenseforces were confronted with an acute food shortage. On 5 January 1942, theentire force was placed on half rations. The basic ingredient, of necessity,was rice, mostly of a poor quality. This was supple-
13 Memorandum, Lt. Col. James O. Gillespie, MC, to Gen, George C. Marshall, 26 Jan. 1942, subject: Medical Supplies.
14 Personal communication, Maj. Harold W. Keschner, MC, AUS, formerly Chief, Laboratory Service, General Hospital No. 2, Bataan, P.I, to Col. James O. Gillespie, MC.
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mented by small amounts of white flour, canned goods (salmon, meat, tomatoes), evaporated milk, and irregular issues of fresh carabao. Tea, coffee, sugar, and butter were unavailable after1 month. The ration was grossly deficient in protein, fat, and vitamins.It provided a maximum of 2,000 calories in January, gradually diminishingto 1,000 calories by early March and almost to the vanishing point by 1April 1942.
The ill effects ofsemistarvation on the troops had become critical by late February 1942. TheSurgeon of the Advance Echelon of USAFFE (U.S. Army Forces in the Far East),Bataan, advised the Surgeon, USAFFE, on Corregidor, in a memorandum dated27 February 1942, that the diet of troops on Bataan was grossly deficient and urged increased allowances of beef, vegetables, milk and the procurement, if possible, of native fruits and vegetables, and in their absence the procurement of vitamin supplements.
By the third month of operations, weight loss in the range of 20 to 30 pounds was commonplace. Men complained of weakness, lassitude, lack of endurance, and shortness ofbreath. Moderate exertion caused tachycardia and palpitation. Those nominally listed as effective for combat could not engage in sustained exertion, so it became increasingly difficult to accomplish necessary work on airstrips, maintenance of roads, clearing of trails, hand carrying of supplies overmountainous terrain, and patrol activities. Gradually, the high morale andconfidence of January was replaced by a loss of spirit and apathy. Dire predictionsfor the future could be heard. To lessen the morale- further, the men beganto note swelling of the ankles with pitting on pressure which was particularly evident toward evening. The pangs of hunger became more insistent.
Beginning about mid-February1942, the sickness rate began to rise abruptly. The majority of patientswere medical cases suffering from malaria or dysentery and showing evidencesof malnutrition and avitaminosis. Some showed loss of subcutaneous fat andmuscle wasting. Others appeared with a considerable degree of edema of thelower extremities. A few patients from isolated units who had undergone moresevere deprivations showed marked peripheral neuritis with footdrop and wristdrop.Patients with wounds and fractures began to show a slower rate of healing. 15
Up to the first weekin March 1942, the evacuation of the sick and wounded had been accomplished in an orderly fashion. Certain patients who ordinarily would have been transferred to the general hospitals had been treated by medical units because of inaccessibility to motor vehicles. The general hospitals had expanded to meet the continually increasing demand for beds through the device of manufacturing bamboo cots and clearing larger areas of the jungle to provide space for them. Then,beginning approximately 7 March 1942, patients by the hundreds began to arrivedaily at the re-ar hospitals. Most of them appeared to be suffering frommalaria. Shortage of quinine
15 History of General Hospital No. 2, Bataan, P.I., 28 Dec. 1941 to 9 Apr. 1942, from personal papers of Maj. Gen. James O. Gillespie.
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then required the adoption of a modified short quinine therapy utilizing 15 gm. or less of quinine rather than the standard treatment of 35 or 40 gm.
Admissions for cerebral malaria became evident early in March 1942. These were chiefly men fromisolated units who were in unusually poor physical condition from stressand malnutrition and for whom medical attention was not available. The numberof these cases reaching the general hospitals was not large; in all theydid not exceed 100 cases. Cerebral manifestations of malaria were usuallyassociated with P. falciparum. The symptomatology was variable butfrequently appeared with coma and a shocklike state or with delirium, convulsions,and maniacal reactions. Responses to intravenous quinine was dramatic. Moreoften the lack of that item required the administration of 3 or 4 gm. ofquinine sulfate by stomach tube. Usually the mental component of the diseasewas relieved in 3 or 4 days.
Malarial patients who were severely depleted from diarrhea and malnutrition did not respond well to massive antimalaria therapy. Occasional patients receiving 2 gm. of quinine sulfate daily by mouth continued to have fever and positive blood films. Other individuals on suppressive therapy of .650 gm. of quinine daily developed chills and fever and positive blood films. The same phenomenawere noted frequently at prison camps during the summer of 1942. One caseof blackwater fever was seen at general Hospital Number 2 in a civilianwho lived in Bataan. Two cases in Japanese-held prisoners of war (one Britishand one Dutch) were seen during 1943 in a prison camp in Formosa.
Early in March 1942, Col. Arthur F. Fischer, USAR, while convalescing from malaria in Bataan,called the attention of Maj. Gen. Jonathan M. Wainwright's headquarters to100,000 kilograms of high-grade quinine bark available in Mindanao, fromwhich totaquine could be extracted.16 Dr. Fischer had pioneered the introduction of cinchona into the Philippines and had worked with that program for 18 years. He was flown to Mindanao for the purpose of beginning large-scale extraction of the quinine bark. Penetration of the area by JapaneseForces prevented completion of the project, and Dr. Fischer was flown toAustralia carrying seeds for the establishment of cinchona plantations inSouth America.
The catastrophic impact of disease and semistarvation on the combat effectiveness of the Filipino-AmericanForce in Bataan was recognized to be of the utmost gravity by all levelsof staff and command. On 10 March 1942, the commanding officer of GeneralHospital Number 2, directed a letter regarding malaria control to the Surgeon,Philippine Department, a portion of which is quoted.
I would like to pointout a grave problem pertaining to the Medical Department and the USAFFE. Malaria is rapidly increasing: some 350 cases were under treatment in this hospital as of March 5th. The admission rate is alarming, sonic 260 patients
16 Personal communication. Col. Arthur F. Fischer, USAR, to Maj. Gen. James O. Gillespie, 24 July 1956.
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arriving March 9th. Most of these are medical and a large proportion have malaria. * * *. Quinine prophylaxis having stopped we anticipate additional hundreds or even thousands of cases * * * . We are urgently in need of a tremendous stock of quinine for treatment arid prophylaxis. The General Staff should understand the extreme gravity of the malaria problem and give priority to quinine above that of any other critical item. If the malaria situation is not brought under control the efficiency of the whole Army will be greatly impaired; in fact it will he unable to perform its combat functions. It is my candid and conservative opinion that if we do not secure a sufficient supply of quinine for our troops from front to rear that all other supplies we may get, with the exception of rations, will be of little or no value.
The USAFFE Surgeon, Corregidor, in a memorandum to the Assistant Chief of Staff, G-4 (logistics), USAFFE, on 22 March 1942, stated that there were 3,000 cases of malaria inBataan and that the numbers were increasing at an alarming rate. He referred to the extremely high noneffective rate in combat units and recommendedthat 3 million quinine tablets be sent from Australia by air at once witha like quantity thereafter each month.
To deal with the overwhelming flood of patients in the forward units and to relieve pressure on the general hospitals, the Surgeon, Luzon Force, early in March, directed that battalion aid stations and clearing and collecting companies assume the responsibility for the treatment of all patients except those whose condition was of the utmost gravity.17 The aid stations were expanded to 200 to 300 beds (bamboo construction) while the clearing and collectingcompanies handled from 600 to 900 patients each.
The Surgeon, Luzon Force, reported on 23 March 1942, in a letter to the commanding general, that the daily admission rate for malaria had reached 500 to 700 cases and that the available supply of quinine at the medical depot in Bataan was sufficient, using a short course of treatment, only for approximately 10,000 cases of malaria. He anticipated exhaustion of the stock in 3 or 4 weeks and predicted a mortality rate of 7 to 10 percent in untreated cases. Extreme concernwas expressed regarding the sharply rising noneffective rate in relationto combat potentialities of the Force. Writing to the Chief of Staff, USFIP(U.S. Forces in the Philippines), on 31 March, the Chief of Staff, LuzonForce, referred to a malaria admission rate reaching 1,000 cases daily andto the imminent loss of combat effectiveness.
By the end of March, some 7,000 patients were hospitalized in the forward medical units, a mere mile or so behind the main line of resistance. These represented only those who were severely incapacitated. Actually, at least 80 percent of the troops had become unfit for duty. One regimental surgeon described the situation as follows:18
To give an accurate word-picture of conditions as they actually existed at the time immediately preceding the surrender of our forces on Bataan would tax the descriptive powers of a rhetorical genius, hut in simple language, almost every man inBataan was suffering, not only from the effects of prolonged starvation, butalso from one or both of the acute infections that plagued us throughout thecampaign, viz, dysentery and malaria. I
17 See footnote 8, p. 500.
18 See footnote 8, p. 500.
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have seen men brought into the battalion aid stations and die of an overwhelming infection of dysentery or cerebral malaria before they could he tagged and classified for evacuation. Of the supposedly well men in the field, all were thin and weak from starvation. Many were swollen with nutritional edema; a large percentage were pale and anemic from repeated attacks of malaria or dysentery.
As early as January 1942, General MacArthur had made urgent requests to the Chief of Staff, U.S.Army, for food and medical supplies to be sent through the Japanese blockadeby any possible means. General Wainwright in March reiterated the extremeurgency of his requirements for both items and, in response., Gen. (laterGeneral of the Army) George C. Marshall, Chief of Staff, requested that maximumamounts of quinine be sent from Australia by air. This could not be accomplished,but 1 million tablets of quinine sulfate were brought by air from the medicaldepot at Cebu to Bataan. This supplement proved to be sufficient to provideat least a short type of therapy, and no hospitalized patients were deniedquinine before surrender. The death rate from malaria before capitulationtherefore was extremely low.
When the final Japanese attack began on 3 April 1942, it became imperative to move all patientsfrom forward medical units to the rear hospitals. Approximately five thousandpatients were absorbed at General Hospital Number 2 between 5 April and 8April; other thousands were directed to a convalescent camp in its vicinity. 19 On 9 April 1942, all surviving members of the Filipino-Americandefense force, including patients and medical personnel, were categorizedas captives and thereafter were required to submit to the orders of the ImperialJapanese Army.
IMPACT ON CIVILIAN REFUGEES
The situation of the several thousand civilian refugees behind the Filipino-American lines became increasingly desperate during the period 7 January to 9 April 1942. Most of these refugees were located in the Limay Mariveles Cabcaben areas which previously had been established as regions of severe malarial infection. There they lived in refugee camps and were issued the same meager rations as the Army received. Medical attention was provided by refugee Philipino physicians in crudely improvised hospitals. These people were without protection from malarial mosquitoes, and they suffered severely from malaria havingno antimalarial drugs for treatment. These unfortunates were often threatened by bombing raids on nearby villages and military installations. Many were wounded and killed.
A mass evacuation from Bataan of refugees and Filipino military patients began immediately following capitulation on 9 April 1942. These individuals trudged along the east road leading out of Bataan. Many of them were ill with malaria and dysentery. Among them were old men, women, and children, carrying their total possessions in assorted bundles, bags, and cans. The pro-
19 See footnote 15, p. 505.
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cession continued for days. Often, theseriously ill would fall by the roadside to die, and after a few days severalhundred bodies could be counted along the road between Cabcaben and Limay.
The disruptions causedby war resulted in a considerable increase in the incidence of malaria inBataan and adjacent provinces after the conclusion of the campaign in 1942.This was brought about by the huge increase in the numbers of human carrierswho had become infected and for whom proper treatment was not available, and by the complete breakdown of control measures. Studies made on the civilian refugee population evacuated from Bataan in 1942 showed a large increasein the malaria rate, and it was noted that the disease was more difficultto treat with the higher death rate. Over 24,000 cases of malaria were diagnosed in civilian emergency hospitals in Bataan and surrounding provinces during the fall of 1942.20 The overall mortality rate was 2.2 percent. Before the war in 1941, the fatality rate in the same provinces had been0.64 percent. An intensive malaria control program was carried on in Bataanfrom 1942-44 by direction of the Japanese military command.
IMPACT ON THE JAPANESE FORCES
The impact of malaria on the Japanese Forces can only be partially documented. The Japanese Army had planned for a quick operation in Bataan, expecting to overcome the Filipino-American troops in a week or 10 days. When they met with firm resistance which continued during January and February, their troops began to suffer from some of the same deprivations and diseases which harassed the Filipino-American Forces. The Japanese ration for their troops on Bataan was meager, although it did not reach the low point of the Filipino-American ration. The Japanese were exposed to the same hazards from malaria, diarrhea, and dysentery. By mid-February, the Japanese 14th Army was definitely depleted, chiefly from malaria. 21 An interpreter who served with the Japanese 14th Army in Bataan stated to the senior Japanese-held U.S. medical officer in July 1942, that the Cabanatuan prison camp situation, where over 3,000 seriously ill Americans were incarcerated, reminded him of the illness suffered by theJapanese troops in Bataan. He asserted that in some units of the JapaneseArmy the noneffective rate from malaria and dysentery reached 90 percentand that the death rate from malaria was very high. He stated that the formerU.S. military hospital, Steinberg General Hospital, was packed to capacitywith Japanese soldiers who had become ill in Bataan.
On 10 April 1942, a Japanese guard of 20 men was assigned to General Hospital Number 2. Approximately 60 percent of these soldiers were acutely
20 Urbino, Cornelio M.: Epidemiology of Malaria in Bataan Before the War and During the Japanese Occupation, and Malaria Control From 1942 to 1944. Philippine Islands Health Service Monthly Bulletin 23: 297-344, 1947.
21 See footnote 7, p. 499.
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ill with malaria within 3 weeks. No medication was provided for them by the Japanese Army. They were treated however, by U.S. medical officers at the direction of the Japanese Army. Itwas estimated by Horiguchi, surgeon of the Japanese 14th Army, that10,000 to 12,000 Japanese soldiers were ill with malaria, dysentery, andberiberi in February 1942 and that less than 3,000 effective men remained. The Japanese 14th Army had begun their campaign with only 1 month's supply of quinine, and in January its use for prophylaxis was discontinued except for frontline troops; after 10 March, quinine was available to them only for therapy. Thus, it seems clear that the firm resistance of the Filipino-American Forces in Bataan, combined with extensive infestation of the Japanese troops with malaria, resulted in an upsetting of the Japanese timetable for the prosecutionof the war in the Philippines. This was a significant matter as Japanesetroops had to withdraw from Singapore to complete the campaign in Bataan.
IMPACT ON THE FILIPINO-AMERICAN PRISONERS OF WAR
The tragic story of the appalling loss of life in the Filipino-American Forces after the surrenderis directly related to malnutrition and disease experienced in Bataan. Malariacontributed significantly to the impressive mortality. Other significantfactors included prolonged marches to the prison camps in tropical heat,inadequate food, lack of potable water, lack of medical supplies, deplorable sanitary conditions, extreme overcrowding, and overwork. Twenty-nine thousand five hundred eighty-nine deaths occurred in 1942 at Camp O'Donnell in Japanese-held prisoners of war from Bataan. Six thousand one hundred twenty-nine (20.7percent) clinically were attributed to malaria.22 Four hundredninety-eight deaths occurred in U.S. prisoners at Cabanatuan Prisoner-of-WarCamp Number 1 during June 1942. One hundred twenty-eight were diagnosed ascaused by malaria. During July 1942 in the same camp 789 U.S. prisoners died.Beginning approximately 1 August 1942, sufficient quinine was provided bythe Japanese to treat 1,600 cases of active malaria, using 14 gin. of quininesulfate per patient.23 Deaths decreased to 240 during the monthof August. On 31 August 1942, the senior Japanese-held U.S. medical prisonerof war requested in a letter to the Japanese camp commander, Cabanatuan Prisoner-of-War Camp Number 1, that 750,000 3-gram tablets of quinine sulfate be furnished to treat an estimated 3,119 cases of malaria. The quantity desired was not obtained, and needless deaths continued. Two thousand four hundred deaths occurred in Japanese-held U.S. prisoners of war at Cabanatuan Prisoner-of-War Camp Number 1 from 1 June to 1 December 1942. Approximately 25 percent of these deaths clinically were attributed to malaria.
22 See footnote 20, p. 509.
23 Diary, Col. James O. Gillespie. MC, U.S. Army, Prisoner of War Camp No. 1, Cabanatuan, P.I., 31 May-31 Aug. 1942.
511
Japanese-held prisoners of war in the Philippines were subjected to an extreme degree of stressduring the first 6 months of captivity. Semistarvation, begun in Bataan,continued for many months after capture. Nutritional edema (wet beriberi),multiple avitaminosis, burning feet syndrome, and pellagra affected 95 percentof prisoners to a greater or less degree. Diarrheal conditions, includingspecific dysenteries, were commonplace. Two hundred twenty-three prisonerscontracted diphtheria between 10 June and 8 August 1942 at Cabanatuan Prisoner-of-WarCamp Number 1. Ninety-one of these died. Men depleted by such a variety ofconditions did not respond to antimalarial drugs in the manner observed inhealthy individuals. The failure to respond may have been due to poor absorptionof quinine from the gastrointestinal tract. When intravenous quinine wasgiven, response was satisfactory. Unfortunately, almost none was available.
The protean manifestations of malaria in the prison camps caused much confusion in the presence of dysenteryand malnutrition with avitaminosis. Gastrointestinal symptoms such as nausea,vomiting, and severe diarrhea were frequent in proved cases of malaria. Othersshowed symptoms of acute appendicitis or other acute abdominal crises. Thesewere soon recognized as manifestations of malaria requiring search of a bloodfilm for plasmodia as the most important laboratory procedure. Response toantimalaria therapy often was dramatic in these cases.
Throughout more than3 years of captivity, malaria recurrences were very frequent in prisoners in the Philippines, Formosa, Japan, and Manchuria. A few individuals had as many as 20 relapses. As a cause of death, malaria became less important during 1943-44 not only because of the better conditions of diet and improved therapy but also because of the tremendous death rate which had eliminated the most severely ill. As late as 1945, an appreciable number of prisoners of war were suffering from malaria relapses.
COMMENT
The defeat of the Filipino-American Forces in the Philippines undoubtedly was hastened bythe conditions resulting from a semistarvation ration with the additionaldeleterious effects from common diarrheas, dysentery, and malaria. The Surgeon,Luzon Force, expressed his opinion as follows:
The capitulation of Luzon Force represents in many respects a defeat due to disease and starvation rather than to military conditions. Malnutrition, malaria, and intestinal infections had reduced the combat efficiency of our forces more than 75percent. The Bataan campaign can best he described as a campaign of attrition,a campaign in which consumption without replenishment was the rule. Thephysical fitness of Our troops was so seriously impaired by 1 March thatit became a determining factor in tactical Operations. From that date onwardthe physical deterioration of our forces was so rapid that by 2 April asuccessful defensive stand was no longer possible.24
24 See footnote 8, p. 500.
