History

CHAPTER II

Army Medical Service in Africa and the Middle East

(from The Medical Department: Medical Service in the Mediterranean and Minor Theaters)

The U.S. Army entered the scene of conflict in the Middle East on a limited scale in 1941 as a result of the urgent need of the British and Russian Armies for military supplies and equipment. Aid to the British in the Middle East began with the first deliveries of American planes to the Royal Air Force in the spring of that year, and the arrival of U.S. Army Signal Corps and Ordnance Department technicians during the summer to instruct the British in the use and maintenance of American equipment. Aid to Russia by way of the Persian Corridor began in November, but was held to a minimum pending the enlargement of port and rail facilities and the construction of roads in Iran. Military planes were ferried from the United States to the Middle East by way of Brazil and central Africa before the end of 1941. Transport planes following the same route carried both American civilian and military personnel.

The Beginnings of Medical Service in the Middle East

The U.S. Military North African Mission

The expanding needs of the British forces in the Middle East were met by the creation in September 1941 of the United States Military North African Mission, with Brig. Gen. Russell L. Maxwell as its chief. The mission surgeon, Maj.(later Col.) Crawford F. Sams, joined the group in October and prepared a medical plan based on information available in Washington before personnel of the mission went overseas. The group traveled by air across the Pacific, arriving in Cairo on 22 November. Major Sams was joined there on the 27thby his assistant surgeon, 1st Lt. (later Maj.) Dan Crozier.¹

Projects to be carried out under control of the U.S. Military North African Mission included construction of port facilities and establishment of shops for the repair and maintenance of aircraft, tanks, locomotives, and signal equipment. Because the United States was not a belligerent, the work was to be done

¹Principal sources for this section are: (1) Hist, Med Sec, Africa- Middle East Theater, Sep 41- Sep 45; (2) Annual Rpt, Med Dept Activities, USAFIME,1942; (3) Annual Rpt, Med Dept Activities, Eritrea Serv Comd, USAFIME,1942; (4) Hist of AMET to 1 Jan 46, Summary Outline, MS, OCMH files; (5) Matloff and Snell, Strategic Planning for Coalition Warfare, 1941-42,pp.250--55; (6) Edward R. Stettinius, Jr., Lend-Lease: Weapon for Victory (New York: Macmillan Company, 1944), pp. 89-98 (7) Ltr, Brig Gen Crawford F. Sams (Ret) to Col Coates, 12 Mar 59 commenting on preliminary draft of this chapter.

under lend-lease by civilian contractors, but the mission surgeon was responsible for the medical care of all civilians employed, as well as for the health of American military personnel in thearea.²

Within a few weeks, Major Sams had completed sanitary surveys of Egypt, Eritrea, Anglo-Egyptian Sudan, and Palestine, using local civilian, British, and captured Italian records as well as personal reconnaissance. The information so developed was used to locate bases for medical operations and to modify preliminary plans in terms of actual conditions. Port Sudan was eliminated as a hospital location, and plans to establish a 100-bed unit at Port Elizabeth, near Capetown on the long Cape of Good Hope route to India and the Far East, were indefinitely deferred. For the time being the British supplied hospitalization of all U.S. personnel, both civilian and military, although 2,150 U.S. beds were scheduled for the area. Medical supplies from the United States reached the area through three different channels: the various contractors were responsible for procuring supplies needed by civilians employed by them; medical supplies for American civilian and military personnel under military control were requisitioned by the mission surgeon; British forces in the area were supplied under the Lend-Lease Act. Entry of the United States into the war resulted in some interruption to deliveries until the future status of the various construction projects about to get under way could be determined, but no immediate change of medical plans was required.

In Egypt, a headquarters dispensary was set up in Cairo in mid-December 1941 with Lieutenant Crozier as attending physician. Another dispensary in Heliopolis, a Cairo suburb where repair and maintenance shops were under construction, was established in February 1942. Hospitalization for all U.S. personnel continued to be provided in British hospitals, while native workers were cared for in Egyptian hospitals.

In Eritrea, where a naval base at Massaua, an air depot at Gura, and an arsenal and signal installations at Asmara were the principal projects, medical service began early in February 1942 with the arrival of Capt. (later Maj.) Thomas C. Brandon. With a male nurse, an X-ray technician, and six hospital attendants--all civilians--Captain Brandon established dispensaries at Asmara and Gura in February and, the following month, at Massaua and at Ghinda, where a large housing project for Massaua personnel was under development. Until additional medical officers arrived late in April, Brandon made the rounds of all four stations himself, covering a circuit of about 120 miles of mountainous country. American personnel were hospitalized in British hospitals, while Italian hospitals cared for Italian and native workers under insurance carried by the contractors.

The War Department, meanwhile, had directed on 18 February that all proj-

² Military personnel, although not yet engaged in actual combat, were not immune to combat wounds. The first U.S. battle casualty in the Middle East occurred less than a week after Major Sams`s arrival. S. Sgt. Delmar E. Park, a Signal Corps observer and instructor with a British combat unit, was killed by German machine-gun fire near Sidi Omar, Libya, on 27 November 1941, ten days before the United States entered the war. The Signal Corps has erected a plaque to Sergeant Parks memory at Fort Monmouth, N.J. Annual Rpt, Med Dept Activities, USAFIME, 1942, with confirmation from a Signal Corps historian.

COLONEL SAMS

ects sponsored by the U.S. Military North African Mission be converted from civilian to military status within six months. Two months proved sufficient. The mission was completely militarized by 10 April. By special arrangement, some 2,500 civilian employees of the Douglas Aircraft Corporation were to continue operating the Gura depot for another six months, and about 2,000 employees of engineer contractors were to remain on civilian status, but all projects were brought under military control.

Following militarization, three area commands were organized to supervise construction work in the three main centers of activity. These were the Heliopolis Area; the Eritrea Area, with headquarters at Asmara; and the Palestine Area, with headquarters at Tel Aviv. Medical plans under the new organization called for military hospitals in these areas with an aggregate capacity of 2,450 beds. Since work had not yet been started in Palestine and medical personnel was at a premium, surgeons were named only for Eritrea and Heliopolis.

In Eritrea, Captain Brandon was succeeded as area surgeon on 1 May by Maj. (later Lt. Col.)William A. Hutchinson, who had arrived with two other medical officers a few days earlier. The area was organized at that time into four districts--Gura, Massaua, Asmara, and Ghinda--each with its own dispensary. The first U.S. hospital in Eritrea was a 250-bed unit established at Gura by the Douglas Aircraft Corporation on 17 June 1942. Although all personnel were civilians, the Army furnished the supplies and equipment, and the hospital functioned under control of the area surgeon. Its services were available to all Americans in Eritrea. In addition to this unit, plans called for a 500-bed station hospital at Asmara, 250 beds at Ghinda, and 100 beds at Massaua.

The Heliopolis Area medical section was set up by Crozier, now a captain, on 12 May. Captain Brandon succeeded Captain Crozier as Heliopolis Area surgeon on 22 May. Dispensary and outpatient service was provided for Americans and for native workmen, but hospitalization continued to be provided by the British, pending construction of a 900-bed station hospital planned for the Heliopolis depot. The Palestine area was to be served by a 450-bed station hospital in the vicinity of Camp Tel Litwinsky, near Tel Aviv, whenever it should be required.

In his capacity as Surgeon, U.S. Military North African Mission, Crawford F. Sams, by then lieutenant colonel, took

COLONEL VAN VLACK

part as American observer in the fourth and fifth Libyan campaigns, in March, May, and June 1942. Particularly concerned with the problem of forward evacuation from rapidly moving armored units, Colonel Sams was attached to the British 7th Armoured Division.³

The U.S. Military Iranian Mission

While the North African mission was operating in Egypt and Eritrea and was preparing to move into Palestine, another prewar mission, formed in October 1941 to help the British deliver supplies to Russia through the Persian Corridor, was laying the groundwork for extensive port and rail construction work in Iran and Iraq. The chief of the U.S. Military Iranian Mission, Brig. Gen. Raymond A. Wheeler, arrived in Basra, Iraq, with the first contingent of officers late in November. The mission surgeon, Lt. Col. (later Col.)Hall G. Van Vlack, did not reach the area until March 1942, after militarization had been ordered. Every effort was made to select medical personnel who had some familiarity with the area, and Colonel Van Vlack was no exception. He had directed missionary hospitals in the Persian Gulf area for several years before serving in World War I and knew well both the language and the people. The medical staff was soon augmented by the arrival of a dental officer, and by a few medical officers and enlisted men sent from the United States or transferred from the Russian mission, which dissolved in May.⁴

The surgeon`s office was located with the mission headquarters near Basra at the head of the Persian Gulf, but headquarters of the Iranian Engineer District was some 30 miles south at Umm Qasr, Iraq. The surgeon made the round trip across the desert each day to hold sick call at the mission headquarters, at the encampment of Goo men at Umm Qasr, and at a motor and equipment assembly plant at Rafidiyah. In addition to a headquarters dispensary at Basra, a small dispensary was maintained at Umm Qasr for emergency patients. The British 61st Combined General Hospital at Shu`aybah, 10 miles southwest of Basra, was available to all U.S. personnel.

The first U.S. hospital in the Persian Gulf area was a 50-bed unnumbered sta-

³ Ltr, Col Sams to TSG, so Jun 42, sub: Armored Forces Med Servs in the Western Desert.
⁴ Principal sources for this section are: (1) Narrative Hist of Med Activities in the PGC; (2) Annual Rpt, Med Dept Activities, PGSC, 1942; (3) Hist, Med Sec. AMET, Sep 41-Sep 45; (4) T. H. Vail Motter, The Persian corridor and Aid to Russia, UNITED STATES ARMY IN WORLD WARII (Washington, 1952); (5) Ltr, Hall G. Van Vlack, to Col Coates,23 Mar 59, commenting on preliminary draft of this chapter.

tion hospital (later designated the256th Station Hospital), originally destined for Umm Qasr but diverted to Ahwaz, Iran, where it opened on 6 June 1942. Under command of Colonel Van Vlack, the hospital was staffed by U.S. Army medical officers, civilian male nurses from the construction companies, Polish refugee nurses, and a few first aid men borrowed from their regular construction jobs.

Air Routes to Africa and the Middle East

Late in June 1941Pan American Airways, at the request of the United States Government, took over the task of ferrying lend-lease planes to British forces in the Middle East. The route followed ran from Florida across the Caribbean to Natal, Brazil, and thence over the narrowest point of the South Atlantic to Bathurst in the British colony of Gambia in West Africa. From Gambia the planes were flown to Khartoum in Anglo-Egyptian Sudan by way of Nigeria and French Equatorial Africa. A regular transport service over this route and on to Cairo was opened in mid-November at the request of tile U.S. Military North African Mission.⁵

After Pearl Harbor, the AAF took over operation of the ferrying and transport services. Roberts Field, Liberia, became the west African terminus of the route, which was extended east to Karachi, India, over alternative courses. One route ran from Khartoum to Cairo, Palestine, and Basra; the other was by way of Eritrea and Aden. Before medical service along the route was established, aircrews and passengers were treated for malaria, dysentery, and other ills at the headquarters dispensary of the U.S. Military North African Mission in Cairo.

The Middle East as an Active Theater of Operations, 1942-43

Both the North African and the Iranian missions passed out of existence late in June 1942.They were replaced by the United States Army Forces in the Middle East(USAFIME), organized as a theater of operations under command of General Maxwell. Headquarters was in Cairo. Under USAFIME, the North African Service Command took over operations in Egypt and Palestine, while the Iran-Iraq Service Command supplanted the existing organization in the Persian Gulf area, now commanded by Col. Don G. Shingler, without change of functions. At the same time, a newly organized U.S. Army Middle East Air Force, commanded by Maj. Gen. Lewis H. Brereton, former commander of the Tenth Air Force in India, was brought under theater control.⁶

Coincident with activation of USAFIME, Generalfeldmarschall Erwin Rommel`s Afrika Korps broke through British positions in Libya and drove to within 70 miles of Alexandria. Work was hastily suspended on all U.S. Army projects in Egypt and Palestine. Civilian construction workers and many military personnel were moved to relative safety in Eritrea. The North African Service Command shifted its headquarters to Gura early in July, and the theater head-

⁵Craven and Cate, eds., Plans and Early Operations, pp. 320-27.
⁶The chief sources for this section are: (1) Hist, Med Sec, AMET; (2) Hist of AMET to 1 Jan 46, Summary Outline; (3) Motter, Persian Corridor and Aid to Russia, pp. 85-93; (4) Craven and Gate, eds., Plans and Early Operations, pp. 341-42.

AIR TRANSPORT COMMAND DC-3 OVER PYRAMIDS

quarters staff began burning its files in preparation for the evacuation of Egypt. By August, however, Rommel had been contained at El `Alamein and work was resumed in the Cairo and Palestine Areas.

After the resumption of activities in Egypt, the theater was reorganized to simplify the command structure. The North African Service Command was abolished, and the three existing areas formerly under its jurisdiction became service commands responsible directly to the theater headquarters. The Heliopolis Area became the Delta Service Command, including all of Egypt. The Palestine Area, with boundaries enlarged to include the Levant States, Transjordan, and a wedge-shaped segment of western Arabia, became the Levant Service Command. Boundaries of the Eritrea Service Command were drawn to include Anglo-Egyptian Sudan, Eritrea, French Somaliland, Aden, and all of Arabia south of the Persian Gulf. The Iran-Iraq Service Command was renamed the Persian Gulf Service Command, with jurisdiction over Iran, Iraq, Kuwait, and that portion of

Arabia not included in other command areas. A short-lived and never important Army Ground Forces Command was also added to the theater organization in August to provide administrative supervision over U.S. tank crews operating with the British Eighth Army. Plans to move an American armored corps into the theater were dropped when invasion of Morocco and Algeria received priority, and the Army Ground Forces Command was eventually inactivated. That portion of Libya reconquered from the Axis forces was set up as the Libyan Service Command in December1942.

Organization at the theater level was completed early in November with the creation of a Services of Supply headquarters, to which the service commands were thereafter responsible. General Maxwell became commanding general of the theater Services of Supply (SOS), being replaced briefly as USAFIME commander by Lt. Gen. Frank M. Andrews. In January 1943 Andrews was succeeded by General Brereton, who also retained his command of the Ninth U.S. Air Force into which the Middle East Air Force had been merged. As in the European theater at this time, the air mission was the primary combat function of USAFIME between May 1942 and September 1943.

Organization of the Medical Service

Theater Headquarters-The surgeon of the North African Mission, Crawford F. Sams--promoted to the rank of lieutenant colonel in February and colonel in August 1942--became USAFIME surgeon on the creation of the theater. In November he was also made Services of Supply surgeon, carrying out both assignments with a single staff. The dual assignment favored centralized control of the medical service, but the distance of some of the service commands from Cairo, and the lack of good rail and road communications put obstacles in the way. The surgeon was forced in large measures to rely on air travel as a means of co-ordinating the medical affairs of the widely dispersed commands.⁷

Contact with health department representatives of the various countries of the Middle East, and particularly with the Egyptian Ministry of Health, was an essential part of the medical sections activities. The theater surgeon was a member of a medical advisory committee of the Middle East Supply Council (and of its executive committee), which controlled the requisitions of medical supplies for the civilian populations of the countries within the theater. He kept in close touch with the medical authorities of the various Allied armies, especially with the Medical Directorate at General Headquarters, British Army Middle East Forces, and the Surgeon General, Egyptian Army.

The theater surgeon`s office supervised the provision of medical services, the operation of the medical supply system, and the program for prevention of disease. The staff provided professional information to the theater commander; prepared medical records and reports, co-ordinating those sent in by the service commands; and inspected medical installations. It assigned personnel to the

⁷Principal sources for this Section are: (1) Hist, Med Sec, AMET; (2)Annual Rpts, Med Dept Activities, USAFIME, 1942 and 1943; (3) Interv, W.K. Daum, Historian, with Col Eugene W. Billick; 11 Jul 52; (4) Intervs, Blanche B. Armfield, Historian, with Gen Sams, 18 Jan and 30 Jan50.

offices of service command surgeons and the Ninth Air Force and advised them on local medical problems. It also supervised the medical service supporting the Ninth Air Force in its movement across the Western Desert. As U.S. Army troops engaged in little fighting in the Middle East theater, many of the activities undertaken by the theater surgeons office were those directed at prevention of disease. The provision of a supply of pure food and water and the establishment and maintenance of good facilities for disposal of waste were two important undertakings.

The Service Commands- The service commands set up under the U.S. Army Forces in the Middle East remained relatively stable until near the end of 1943,when the mission of the theater underwent considerable change. The headquarters of each service command had a medical section in charge of a surgeon who was under the direction of Colonel Sams in his Services of Supply capacity.⁸

The administrative center of medical service in Delta Service Command was at the command`s headquarters in Heliopolis, where a medical staff section operated an office patterned on the theater headquarters medical section. It also controlled an antimalaria unit and a general dispensary. A few miles from Heliopolis, at Camp Russell B. Huckstep, the site of a large quartermaster depot, was a small medical section consisting of a post surgeon, a veterinarian, and a dental officer. Three dispensaries operated by unit surgeons, a dental dispensary, and a medical subdepot were located there. When the surgeons office of Delta Service Command moved from Heliopolis to Camp Huckstep in May 1943, it absorbed the post surgeons office. The 38th General Hospital, which was to be the leading hospital of the theater, was established at Camp Huckstep in late 1942.

Delta Service Command served a number of other areas in some phase or other of its medical programs. The medical subdepot at Camp Huckstep frequently furnished medical supplies to the whole Middle East area. American air forces battle casualties occurring over Libya, Tunisia, Sicily, Italy, and southeastern Europe were cared for in the commands hospitals. Medical care for U.S. Army personnel stationed in the vicinity of the Suez Canal ports was provided by Delta Service Command, except for a brief period from March to October 1943 when an independent Suez Port Command was active. A port surgeon`s office, a general dispensary, and the platoons of a field hospital served troops in the canal area.

A medical staff section of Eritrea Service Command was located at the command headquarters, which was established in August 1942 at Asmara, the capital city of Eritrea. A surgeon placed in each of four districts of the command maintained the health and sanitation of his particular area. Medical Department personnel stationed throughout the command were responsible for the health of Army personnel, American civilians, and

⁸This section is based primarily on the following documents: (1) Hist, Med Sec, AMET; (2) Annual Rpt, Med Dept Activities, USAFIME, 1942; (3) Med Hist, Delta Serv Comd, 1942; (4) Annual Rpts, Med Dept Activities, Eritrea Serv Comd, 1942, 1943; (5) Annual Rpt, Med Dept Activities, Levant ServC omd, 1942; (6) Narrative Hist, Med Activities, PGC; (7) Annual Rpt, Med Dept Activities, PGC, 1943; (8) Ltr, Gen Sams to Col Coates,12 Mar 59; (9) Ltr, Van Vlack to Col Coates, 23 May 59; (10) Ltr, Lt Col James J. Adams to Col Coates, 7 Apr 59. Last three letters comment on preliminary draft of this chapter.

Italian laborers working for the U.S. Army. By the end of 1942 about 150 American military hospital beds were available to troops of the command; the civilian hospital of the Douglas Aircraft Corporation relieved the Army of the necessity of caring for civilians. With the decrease in construction of port and air base facilities in 1943,personnel strength in Eritrea was cut back to the minimum necessary for servicing bases and fuel dumps of the Air Transport Command, and for operating extensive radio installations. The need for medical service diminished proportionately.

In Levant Service Command, a medical staff section was set up in August 1942 at Tel Aviv, Palestine. The section included the surgeon of the command and a staff of veterinary, sanitary, and administrative officers, assisted by several enlisted men. Because of the lack of supplies and incomplete construction of American hospital facilities in 1942, British military hospitals in the area furnished most of the hospitalization of U.S. Army patients. For a time Levant Service Command was important as a base for the operation of American Air Forces units, but activities never developed to the extent originally anticipated, and by June 1943 the command was on the decline. The headquarters of the command moved from Tel Aviv to Camp Tel Litwinsky, some eight miles away, the site of a repair depot for engineer and ordnance equipment and of a steel container manufacturing plant. At this time the members of the medical section were relieved from duty with the exception of the veterinarian, and the commanding officer of the 24th Station Hospital(a unit that had arrived in February 1943) assumed the additional assignment as service command surgeon.

Libyan Service Command, established in early December 1942, did not have a medical staff section until March 1943. The surgeons office was composed of a surgeon, a medical inspector, a veterinary officer, a Medical Administrative Corps officer, and a medical officer in charge of the headquarters general dispensary. This command functioned only until the end of active operations against the Axis in North Africa. In late May it was divided into Tripoli Base Command and Benghasi Base Command.⁹The new commands were disbanded in the fall of 1943, and their areas and installations were absorbed by Delta Service Command.

The medical section of the Persian Gulf Service Command (PGSC) was inherited with little change from the Iranian mission. Headquarters remained at Basra, Iraq, until January1943, then moved to Tehran, Iran, pending completion of permanent headquarters at Camp Amirabad two miles from that city. A surgeon`s office, responsible to Colonel Van Vlack, the command surgeon, was maintained in each of the three districts into which the gulf area was divided. The command surgeons office instituted the medical policies for the whole command, but the emphasis was on the operating agencies--the hospital units. The headquarters medical section consisted only of the surgeon, a small staff, and a minimum of enlisted personnel to handle reports and records. The district headquarters also operated

⁹ In the Middle East theater a base command was normally one step below a service command. Since Libyan Service Command no longer existed, Tripoli and Benghasi Base Commands dealt directly with their next highest echelon, SOS USAFIME.

with minimum staffs. In April 1943Colonel Van Vlack was succeeded as PGSC surgeon by Col. Forrest R. Ostrander, former commanding officer of the 38th General Hospital.

Although it was administratively bound to the Middle East theater, the first major step toward autonomy came for the command in January 1943 when Cairo head quarters gave PGSC permission to requisition supplies directly upon the War Department, handle its own personnel procurement, assignments, and promotions; and deal with the British and Iranians without reference to theater headquarters. While the command still remained in the Middle East theater organization, this decisive action gave it a very independent status. Complete autonomy came with an order from Washington on 10 December 1943, which redesignated the command the Persian Gulf Command and made it directly responsible to the War Department through the Operations Division of the General Staff. With a simplified command relationship solidly established, the Persian Gulf Command was better able to carry on its mission of aid to the Soviet Union.

The Ninth Air Force- The Ninth Air Force, which at its peak had about 25,000 troops, was the major American combat force in the Middle East theater. It was organized in August 1942 by General Brereton, at which time the head quarters of U.S. Army Middle East Air Force was discontinued. During 1942 and 1943the Ninth Air Force operated against enemy targets in Libya, Tunisia, Sicily, Italy, Greece, and Rumania. Under supervision of the theater surgeon, Col. Edward J. Kendricks, Jr., who had served as surgeon of the U.S. Army Middle East Air Force became General Brereton`s Ninth Air Force surgeon. At the Cairo headquarters of the air force, Colonel Kendricks organized an office containing an assistant surgeon, a dental officer, a plans and training officer, a sanitation team, an adjutant, and some enlisted men. At first Colonel Kendricks doubled as Ninth Air Force Service Command surgeon, but a separate surgeon was later appointed to that element of the air force. The bomber and fighter commands had their own surgeons from the outset. Colonel Kendricks and his staff left the Middle East for England with the Ninth Air Force in October 1943.¹⁰

The Air Transport Command- In July 1942 a headquarters to administer Army activities in the vast reaches of central Africa was organized at Accra, Gold Coast, and named United States Army Forces in Central Africa (USAFICA). Its major mission was to maintain bases for the Air Transport Command. Although it never had a large number of troops, the command was originally organized like a theater. Under the theater headquarters was SOS USAFICA, an organization that furnished supplies and services needed for the operation of Air Transport Command units throughout Africa.¹¹

¹⁰ (1) Hist, Med Sec, AMET. (2) Annual Rpts, Med Dept Activities, USAFIME, 1942, 1943.See also p. 80, below.
¹¹ Major sources for this section are: (1) Hist, Med Sec, AMET; (2) Annual Rpt, Office of Surg, USAFICA, 1942; (3) Hist of the ATC in Central Africa and the Middle East, pt. 2, Hist of the AMEW, ATC (30 Jun-14 Dec43), vol. III, Hist of Supply and Servs, Files of Hist Br, MATS; (4) Annual Rpt, Med Sec. West African Serv Comd, USAFIME, 1943; (5) Annual Rpt, Sta Surgs Office, Roberts Field, Liberia, Hq, USAFIL, 1943;(6) Interv, Blanche B. Armfield with Lt Col Stephen D. Berardinelli; (7) Ltr, Col Berardinelli to Col Coates, 24 Mar 59 commenting on preliminary draft of this chapter.

As in other areas where transportation was the Army`s primary mission, command of the theater was given to the AAF, in this case to the Commanding General, Africa-Middle East Wing, Air Transport Command, Brig. Gen. Shepler W. Fitzgerald. The Army retained control of the supply function through Col. James F. C. Hyde, commanding the SOS USAFICA, and for the time being of the medical function, which was in the hands of Lt. Col. (later Col.) Don. G. Hilldrup, simultaneously surgeon of the theater, the SOS headquarters, and the Africa- Middle East Wing of ATC. By December 1942, however, activities had grown to a point that made this triple duty no longer feasible. Following an inspection by Brig. Gen. (later Maj. Gen.) David N. W. Grant, the air surgeon, Lt. Col. (later Col.) James G. Moore was made surgeon, AMEW, relieving Hilldrup of all responsibility for Air Transport Command medical service except for furnishing hospitalization and medical supplies, both included among his SOS functions. Colonel Hilldrup was relieved in mid-1943 by Col. Thomas E. Patton, Jr.

Later in the year the central African command was dissolved and its territory absorbed by the Middle East theater. In its place theater headquarters established the West African Service Command, with headquarters at Accra. The commanding officers of the 67th Station Hospital at Accra, Maj. George F. Piltz and, from early 1944, Maj. (later Lt. Col.) Leslie E. Knapp, served also as surgeons of the West African Service Command. At the end of 1943 the Africa-Middle East Wing of the Air Transport Command was split into Central African and North African wings, with Maj. (later Lt. Col.) James W. Brown and Lt. Col. (later Col.) Clarence A. Tinsman, the respective surgeons.

Another important base in the West African Service Command was the city of Dakar, in French West Africa.¹²Soon after control of the area passed to the Allies with the invasion of North Africa, a complete airport had been constructed that could handle up to 100 planes a day, and a camp for all permanent personnel had been built and fully equipped. It was later necessary to move the airport to a new site because the swampy mosquito-infested surroundings contributed to an excessively high malaria rate.

The command, known as U.S. Army Forces in Liberia, which established its headquarters in mid-1942,was to provide services along the ATC route through Liberia, defend the U.S. Army installations as well as the facilities of the Firestone Tire and Rubber Co. plantation, and carry out certain diplomatic commitments for training Liberian military forces and for the construction of roads. The presence of a force of about 2,000 men in Liberia in this early period had the added advantage of posing some threat to the pro-Vichy French around Dakar and in French Guinea and the Ivory Coast.

Medical activities in Liberia were administered at the station surgeons office at Roberts Field, some thirty miles east

¹²Dakar was actually within the boundaries of the North African theater, but the city and a small area around it came under control of U.S. Army Forces in Central Africa and later of the West African Service Command.

of Monrovia, where central control over medical matters was maintained and medical reports on the Liberian force were completed. The 25th Station Hospital (250 beds) near the field cared for the medical needs of the entire command. From June 1942 until April 1943, Lt. Col. (later Col.) Loren D. Moore served as station surgeon. Under the experienced direction of Lt. Col. (later Col.) Justin M. Andrews, Colonel Moore carried out extensive malaria survey and control work. When the entire Liberian Task Force, commanded by Brig. Gen. Percy L. Sadler, arrived in the spring of 1943, both Moore and Andrews were transferred to the new North African theater. Lt. Col. Stephen D. Berardinelli, commanding officer of the 25th Station Hospital, succeeded Moore as station surgeon. Medical department personnel in Liberia were responsible for the medical care of a large force of construction engineers during the period when the base was being built, and later gave support to all elements of the defense forces in Liberia. Air Transport Command personnel, some members of the Royal Air Force, and natives working for the Army also received medical care. In September 1943, the Liberian command was subordinated to the Middle East theater, but this action did not change its basic mission.

Hospitalization and Evacuation

The extreme heat of the Africa-Middle East area, originally thought to be one of the greatest problems in planning for hospitalization, proved to be less important than anticipated. Except in the Persian Gulf, the experience of the Medical Department demonstrated that adverse climatic factors were overrated as to their effect on the general health of troops. Excessive heat lasting for 24 hours of the day during the long summer season occurred in only a few locations, but the appalling list of diseases endemic in the population of the area caused great concern on the part of medical officers. Malaria, yellow fever, typhus, smallpox, dysentery, all forms of venereal diseases, and many other diseases represented a serious danger to troops working in close contact with the inhabitants of the region. In the face of centuries of ignorance, maintaining good sanitation was a major task.¹³

Medical officers tried to create "isolated foci of cleanliness" in and around the immediate areas of hospital plants and other U.S. Army installations. This method proved to be the only practical way to handle the sanitation problem, since troops were concentrated in places widely separated from each other, making a comprehensive program impossible. Hospitalization in the Middle East theater was almost entirely associated with the service commands, and rear-area-type hospitals predominated throughout the theater. No mobile hospitals operated in the Middle East, although platoons of the field hospitals supporting the Ninth Air Force during its operations over Libya and Tunisia moved about more frequently than most other hospitals.

¹³ General sources for hospitalization and evacuation in the theater as a whole are: (1) Hist, Med Sec, AMET; (2) Annual Rpts, USAFIME, 1942, 1943; (3) Hist of Preventive Medicine in the Middle East, 19 Oct 41-23 Jun 44,by Lt Col Thomas G. Ward; (4) Hist of AMET to 1 Jan 46, Summary Outline.

Delta Service Command-Delta Service Command occupied a central position in the theater. The most important U.S. Army medical installation in the theater, the 38thGeneral Hospital (1,000 beds), arrived in the command in late October 1942 and moved into partially completed buildings in the desert near Heliopolis, adjacent to a large Quartermaster depot. It began admitting patients on 11 November, and by early 1943 was the focal point for fixed hospitalization in the Middle East. (Map 4) Until September 1943, when a general hospital was set up in the Persian Gulf Service Command, there was no other hospital with comparable resources in the theater. The chiefs of the medical, surgical, and neuropsychiatric Services of the 38th also acted as consultants in their respective specialties to the theater surgeon.¹⁴

Beginning in the spring of 1943, platoons of the 16th Field Hospital were set up as small hospitals along the route of the Suez Canal, to give medical care to U.S. troops stationed there. (See Map 4.) Another hospital unit served the Ninth Air Force for a short time at an airfield near Alexandria. The command also established dispensaries in scattered places having only small garrisons. A medical supply depot operating as the medical section of the quarter master depot at Heliopolis served as the main distribution point for medical supplies and equipment for all parts of the theater except the Persian Gulf area.

Medical Department facilities in Delta Service Command used permanent buildings, with the exception of the field hospital platoons, which were under canvas. The Egyptian climate on the whole did not hinder operations, but spells of extreme heat and dust storms caused some difficulties. An adequate supply of pure water was often lacking, except in large cities such as Cairo and Alexandria. To avoid using the contaminated and heavily silted water of the Nile, the command had sunk deep wells and extended pipelines. A water purification plant was installed at Camp Huckstep.

The general line of evacuation for the command, as well as for the whole theater, pointed toward the 38th General Hospital, whether a patient was an Ordnance Department soldier from the Suez Canal region sick with malaria, or an Air Force pilot wounded over Libya. Patients journeyed by ambulance from nearby places such as the Suez Canal, but if coming from Libya, Syria, Eritrea, or Iran, they traveled by air to Cairo and then by ambulance to the 38th General. Delta Service Command also served as the focal point for shipment of patients to the zone of interior by ship and plane, the latter method being employed most of the time.

Eritrea Service Command- Most of the U.S. Army medical installations in Eritrea Service Command were within Eritrea itself, although the boundaries of the command embraced the Anglo-Egyptian Sudan and the southern half of Arabia as well. In addition to the civilian hospital operated by the Douglas Aircraft Corporation at Gura, two hospitals were established in Eritrea. The 21st Station Hospital (500 beds), the first complete Army unit to arrive, debarked at Massaua on 13 November 1942. It was

¹⁴ (1) Annual Rpts, Med Dept Activities, Delta Serv Comd, 1942, 1943. (2) Annual Rpts,38th Gen Hosp, 1942, 1943. (3) Annual Rpt, 16th Field Hosp, 1943. (4) Ltr, Gen Sams to Col Coates, is Mar 59, commenting on preliminary draft of this chapter.

MAP 4-- U.S. Army Hospitals in USAFIME, 1 July 1943

sited the following day at Mai Habar, a town in the mountains between Asmara and Gura, and took over hospital buildings formerly occupied by the medical services of the Italian and British Armies. Some of the personnel of the 21st were detached to operate dispensaries at Asmara, Decamere, Ghinda, and Massaua. The second U.S. Army hospital to be established in Eritrea was the 104th Station Hospital, which arrived in late January 1943. It relieved the detachment of the 21stStation Hospital at Massaua, setting up a 100-bed unit there.¹⁵

By the spring of 1943 U.S. Army activities in Eritrea had diminished to the point where there was little need for a 500-bed hospital. Consequently, the 21st Station Hospital moved on to the Persian Gulf area in May 1943. During the previous month the 104th had turned over to the British Navy the hospital that the unit had been operating at Massaua and moved to the Gura air depot to share in the operation of the Douglas Aircraft hospital there. The depot finallyc losed in November, resulting in the disbanding of the Douglas hospital and the ship-

¹⁵ (1) Annual Rpts, Med Dept Activities, Eritrea Serv Comd, 1942, 5943. (2) Annual Rpt, 21st Sta Hosp, 1943. (3) Annual Rpt. 104th Sta Hosp, 1943. (4)Annual Rpt, 15th Field Hosp, 1943. (5) Annual Rpt, 16th Field Hosp, 1943.

KING GEORGE OF GREECE, COLONEL VAN VLACK, AND GENERAL ROYCE at 38th General Hospital, Camp Huckstep, Egypt.

ment of the 104th to Asmara (the location of the headquarters of Eritrea Service Command), where it established a 25-bed hospital. This small installation remained in operation for sometime as the only U.S. Army hospital in Eritrea. A 50-bed hospital at Wadi Seidna, an important junction near Khartoum along the Air Transport Commands central African route, cared for the ATC personnel stationed there, as well as for the transients who passed through on their way to and from the Middle East and India. It was operated by a platoon of the 15th Field Hospital beginning in June 1943, and taken over by a platoon of the 16thField Hospital in September. (See Map 4.)

Aside from the town of Massaua, which is one of the hottest and most humid seaports in the world, hospitals in Eritrea operated installations at places with fairly moderate climates due to elevations of 5,000 to 7,500 feet. The scarcity of potable water caused some trouble for these hospitals, and the task of maintaining good sanitary standards proved to be a constant battle, as in most other parts of the theater. The command was fortunate enough to secure permanent buildings for all its hospitals. It evacuated almost all of its patients by air.

HOSPITAL TRAIN IMPROVISED FROM PASSENGER CARS, BENGHASI AREA

Levant Service Command- U.S. hospital facilities were available in the Levant Service Command until February 1943, nearly eight months after the command was activated. General dispensaries at Tel Aviv and at Camp Tel Litwinsky, both in Palestine, served the area from July 1942. In mid-November the4th Field Hospital arrived at the camp, took over operation of the dispensary there, and established a small infirmary. Lack of equipment prevented it from operating as a hospital, but many medical officers from its staff worked for short periods at two British general hospitals in Jerusalem. The 24th Station Hospital (250 beds) relieved the remaining elements of the 4th Field Hospital in February 1943. The latter then joined the parent unit, which had been assigned a few weeks earlier to the Ninth Air Force-Libya.¹⁶

The buildings of the 24th Station Hospital at Camp Tel Litwinsky were ideally situated on a small hill with a beautiful view of the countryside. The water supply was adequate and the drainage good. The equable Mediterranean climate and the fresh air and sunshine made the 24th a perfect place for convalescing patients, and it operated as such for men who had received treatment else where in the theater. It also performed the usual functions of a station hospital for Levant Service Command personnel. Most patients arrived at the hospital by air, but some of those from Delta Serv-

¹⁶ (1) Annual Rpts, Med Dept Activities, Levant Serv Comd, 1942, 1943. (2) Annual Rpt, 4th Field Hosp, 1942. (3) Annual Rpt, 24th Sta Hosp, 1943.

PARTIALLY DUG-IN HOSPITAL TENTS of the 3d Platoon, 4th Field Hospital, near Tripoli, May 1943.

ice Command came in by rail. (See Map 4.)

Military activities in the command began declining by mid-1943. The command headquarters moved from Tel Aviv to Camp Tel Litwinsky, and the commanding officer of the24th Station Hospital started serving as surgeon of the command in addition to his duties at the hospital. By October, the 24th Station Hospital closed, evacuated its patients to the 38th General Hospital in Egypt, and made ready to depart for the China-Burma-India Theater.

Libyan Service Command- By the time that the British Eighth Army had passed Benghasi in its advance through the Western Desert, a new service command was added to the original five. A short-lived command--formed on 7 December 1942and disbanded on 26 May 1943--the Libyan Service Command included the area within the territorial boundaries of Libya not occupied by enemy forces. At first comprising only eastern Libya, the command grew in area as the Eighth Army advanced westward. The major American participants in the sixth Libyan campaign were members of the U.S. Ninth Army Air Force. Hospital care for the personnel of the force was provided first by British Army hospitals and later by hospitals of the Middle East theater.¹⁷

Beginning in January1943 the pla-

¹⁷(1) Annual Rpt, 4th Field Hosp, 1943. (2) Annual Rpt, 15th Field Hosp, 1943.

toons of the 4th Field Hospital, assigned to the Libyan Service Command, had the job of receiving Ninth Air Force patients from their squadron aid stations and evacuating them back to Egypt. The 4th Field also cared for Services of Supply troops stationed in the Libyan Service Command. The first unit of the 4th Field Hospital to begin work in Libya was the 1st Platoon, which arrived at Gambut on 26 January 1943 and began receiving patients three days later. It relieved pressure on the British hospitals in the area by taking American patients of the IX Bomber Command and Services of Supply personnel in the vicinity. It changed location on 28 February, moving forward to Benghasi where it established another hospital.

The 3d Platoon and the headquarters section of the 4th Field Hospital arrived in Tripoli on 26 March 1943 and set up a hospital for units of the Ninth Air Force and Services of Supply troops in western Libya and southeastern Tunisia. The 2d Platoon entered the field last, opening on 9 April at Sfax, Tunisia, where it supported two bombardment groups. Soon after the surrender of the Axis forces in Africa in mid-May, it moved back to Benghasi. Another field hospital, the 15th, arrived in Libya on 13 May and relieved the 1stPlatoon of the 4th Field Hospital at Benghasi. (See Map 4.)

The most characteristic feature of field hospital operations in Libya was the independent functioning of the platoons, often separated by hundreds of miles. Except for buildings obtained by one of the platoons of the 4th Field Hospital, all hospital installations used tents. British tropical-type tents supplemented the regular ward tents with good results. The extreme heat of the desert was15^o to 20^o F. less inside the British tent. During the period of active fighting, the platoons of the 4th Field Hospital habitually dispersed and dug their tents in for maximum protection from bomb fragments. Life in the desert under field conditions made it necessary to get along with what was on hand--nothing was wasted that could be turned into a useful item for the hospital. Water, though fairly adequate in quantity, had to be hauled for considerable distances.

Evacuation from southern Tunisia and Libya was generally by ambulance or plane from squadron aid stations of the Ninth Air Force and dispensaries of Services of Supply units to the platoons of the field hospitals, where planes picked up patients for delivery to the 38th General Hospital in Egypt. A curiosity of the situation was the parallel existence of an evacuation system under the control of the North African theater moving casualties from Tunisia westward to Algiers, so that two supply and evacuation routes ran at an angle of180^o to each other. A similar situation prevailed during the invasion of Sicily when the Ninth Air Force again supported the British Eighth Army. The Middle East theater ran its chain of evacuation from Sicily by way of Tripoli to Egypt, while the North African Theater evacuated from Sicily to Bizerte and thence westward.

Persian Gulf Service Command- In the Persian Gulf area the first substantial shipment of U.S. troops arrived at Khorramshahr, Iran, on 11 December 1942. With them came the personnel of 2 station hospitals, the first major increment of Medical Department troops

113 TH GENERAL HOSPITAL AT AHWAZ, IRAN, laid out in radial pattern with connecting wings.

to arrive in the command. The 2 hospitals, the 19th and 30th Station Hospitals, both 250-bed units, began operating in early January 1943, the 19th at Khorramshahr and the 30th at Tehran. Later in January the temporary 50-bed hospital at Ahwaz was designated the 256th Station Hospital. Between January and the end of June, 3 more station hospitals (the 21st, 113th, and 154th) and 3 field hospitals (the18th, 19th, and 26th) were established in Iran. No additional hospital units arrived there during the existence of the command¹⁸(Map5)

The 113th Station Hospital (750 beds), the largest American hospital in Iran, began acting as a general hospital for the command soon after it arrived at Ahwaz in May. It offered complete treatment for all diseases and injuries and served as a clearinghouse for patients being evacuated to the zone of interior through the 38th General Hospital in Egypt. It also provided station hospital care for nearby troops. In September the unit was reorganized as the 113thGeneral Hospital and was given personnel to operate a 1,000-bed plant. Another

¹⁸ (1) Hist, Med Activities, PGC. (2) Annual Rpts, Med Dept Activities, PGSC,1942, 1943. (3) Annual Rpt, 113th Gen Hosp, 1943. (4) Annual Rpts, 19th, 21st, 30th, 154th, 256th Sta Hosps, 1943. (5) Annual Rpts, 18th, 19th, 26th Field Hosps, 1943.

MAP 5-- U.S. Army Hospitals in the Persian Gulf Service Command, 1 July 1943

of the larger units in the command, the 21st Station Hospital (500 beds), began functioning at Khorramshahr in mid-May, replacing the 19th Station Hospital, which moved to Tehran. The 154th Station Hospital, a smaller unit of 150 beds, first established a tented hospital at Ahwaz in February, but moved north to its permanent station at Hainadan in June. The 50-bed 256th Station Hospital, displaced at Ahwaz by the 113th General, moved late in August to Abadan on the Shatt-al-Arabnear the Persian Gulf.

With one exception--the19th Field Hospital at Andimeshk--the field hospitals in Iran dispersed their platoons to scattered locations where each was able to run a hospital of at least 100 beds. Installations operated by field hospital platoons were, in effect, small station hospitals and were usually housed in permanent buildings. They shifted from place to place much more frequently than the commands station hospitals. During 1943 the 18th and 26th Field Hospitals used all their platoons separately most of the time, the 18th operating hospitals at Sultanabad, Ahwaz, and Bandar Shahpur, and the 26th functioning at Abadan, Kazvin, and Khorramabad.

By early December 1943 almost 2,700 beds, provided by one general, four station, and three field hospitals, were in operation in the Persian Gulf Command. Provisional dispensaries and aid stations had also been set up as they were needed at road camps, railway installations, and other work sites along the supply routes to the Soviet Union. These small units supplemented those maintained by the Ordnance Department and the Engineer, Quartermaster, and Signal Corps for their own personnel. Where the installation was large enough to justify it, a medical officer was placed in charge. Where the installation was no more than an aid station, it was generally in charge of a trained enlisted man, sharing with other such stations the supervision of one medical officer. In the southern part of the command, dispensaries operated heatstroke centers consisting of air-conditioned rooms with beds and special facilities for heat cases.

Few hospitals in the Persian Gulf area operated under conditions that approached those prevailing in the United States or even in some overseas theaters. All of the locations were deplorable as far as sanitation was concerned, and many were at the mercy of the sweltering heat for a good part of the year. Dust storms, combined with temperatures of 150^oand 160^oF. in the sun (one station reported a reading of 183^oF. ), made service in some parts of Iran an ordeal to bear. To make matters worse Iran was a land of pestilence, the population being a reservoir of malaria, typhus, venereal diseases, intestinal infections, smallpox, and a variety of other diseases. Scarcely a place could be found where the water supply was not heavily contaminated. Water had to be filtered and then either boiled or chlorinated before it was safe to drink. Because of the practice of fertilizing with human feces, most of the locally grown vegetables and thin-skinned fruits required thorough cooking or dipping in boiling water before they could be safely eaten. Flies, mosquitoes, and other insects provided another source of disease as well as a constant annoyance.

Housing for hospitals posed a serious problem. Tented hospitals functioned briefly, but eventually almost all hospi-

tal construction rose from the ground up, using native mud, brick, and stone. Window ramps and doors fashioned from cratings of automobiles and trucks sent to the USSR, and plastic for glass windowpanes put the finishing touches on many hospital buildings. Men of the hospital detachments made many of their own items of equipment such as tables, chairs, and desks. The buildings themselves were always one storied and frequently were built in a rosette pattern with central rotundas from which five wards radiated. In the southern part of Iran, hospitals had air conditioning units in some of their buildings, making the heat of summer more endurable for both patients and hospital personnel.

By the fall of1943 the Persian Gulf Command had reached a strength of some 29,500, a figure that varied no more than 2,000 during the following year. Although the command had hospital beds available for 10 percent of the strength during most of 1943, at no time was it necessary to use the full bed capacity. The average of hospitalization varied from 4.5 to 6.5 percent of the total strength. From the time the command was formed until 1 October 1943, total admissions numbered 24,889. The average rates per 1,000 per annum for disease and injury admissions in 1943 were 1,172 and 155 respectively. During the first nine months of 1943 the three main communicable diseases treated in PGSC hospitals were common diarrhea, which accounted for 4,348 admissions with a rate of 293 per 1,000 per annum; common respiratory disease, with2,511 admissions and a rate of 169; and venereal disease, accounting for1,563 admissions with a rate of 104. Specific dysentery, amebic dysentery, and pappataci fever were three other important causes for admission to hospitals.

Evacuation within the command was by rail, motor, and air transport, the more serious cases being sent from the station and field hospitals to the 113th Station Hospital at Ahwaz. Patients needing prolonged treatment traveled to Cairo by air for care at the 38th General Hospital. Soon after the 113th officially became a general hospital in mid-September 1943, it cared for many more serious and complicated cases. Here a board of medical officers examined patients and their records, and if it decided that an individual could not be successfully treated in the Persian Gulf Service Command, he would be shipped directly to the zone of interior by the air transport route across Africa. Although patients from the Persian Gulf area would frequently stop at the 38th General Hospital while waiting for a plane, their status was strictly transient, and the 38th could not change the decision made by the 113th General Hospital in Iran.

Central and West Africa- Except for a few dispensary beds at places along the route of the Air Transport Command, there were no U.S. Army hospital facilities under the U.S. Army Forces in Central Africa until early December 1942,when the 67th Station Hospital (250 beds) arrived at Accra.¹⁹

The following month another medical unit, the 93d Station Hospital (150

¹⁹ The 23dStation Hospital had been set up in Léopoldville, Belgian Congo, in September 1942 to provide medical care for a southern branch route of the ATC, but it never got into full operation because the proposed route was abandoned by the end of the year. The idle 23d was finally sent to the North African theater in April 1943.

67TH STATION HOSPITAL AT ACCRA, GOLD COAST

beds) debarked at Dakar, French West Africa. The major function of both hospitals was to give medical support to the bases of the Air Transport Command. Between Dakar and Accra a third hospital, the 25th Station (250 beds), had been operating since June 1942near Roberts Field, Liberia, a major airfield of the Air Transport Command.²⁰

The three major points of U.S. Army hospitalization remained at Accra, Dakar, and Roberts Field throughout the war. Since all three station hospitals were well within the tropics, their personnel were subject to high temperatures, malaria, venereal disease, and a host of tropical diseases. Malaria in particular took its toll in thousands of man-days lost. The hospital buildings built or acquired for these units followed a simple one-storied hospital plant layout. The dispensaries at the stations of the Air Transport Command sent patients needing hospital care by air to the hospital nearest their landing fields. During 1943 west African hospitals evacuated some 300 patients to the United States, most of them by air transport. Since all those evacuated were general-hospital cases, shipment west to the United States on

²⁰ (1) Annual Rpt, Med Dept Activities, USAFICA, 1942. (2) Annual Rpt, Med Dept Activities, West African Serv Comd, 1943. (3) Annual Rpts, Med Dept Activities, USAFIL, 1942, 1943. (4) Annual Rpt, Med Dept Activities, Central African Wing, ATC, 1943. (5) ETMD Rpt, USAFICA, Aug 1943. (6) Mae Mills Link and Hubert A. Coleman, Medical Support of the Army Air Forces in World War II(Washington, 1955), pp. 588-90.

the return air route was preferable to sending patients farther away from the zone of interior by going east across Africa to the nearest general hospital in Egypt.

Summary- From the beginning of the theater, the medical service in the Middle East was one that had served widely dispersed troop concentrations. The prevailing pattern of small station hospitals and field hospital platoons operating in the same capacity was the most logical approach to supplying medical service to one of the largest U.S. Army theaters in the world in terms of land area. In physical plant the hospitals of the Middle East theater compared favorably with many cantonment-type hospitals in the United States, considering the difficulties imposed by unfavorable climate, poor sanitary standards, and endemic diseases. All these factors caused extra work that would be largely unnecessary in some theaters. Hospital plants often took the additional precaution of enclosing their areas with barbed wire fences to prevent pilfering.

The theater reached its peak strength in July 1943, when it had 66,483 troops. Maximum hospital bed strength was reached at the same time, with 6,600 fixed beds scattered from Liberia to Tehran.²¹ Approximately half of the total, or3,200, were in the Persian Gulf Service Command. Delta Service Command had 1,000; Eritrea Service Command had 450, including those in the civilian hospital of the Douglas Aircraft Corporation; and U.S. Forces in Central Africa were served by 400 beds. There were 400 beds under jurisdiction of the short-lived Suez Port Command; 400 in the Libyan Base Command; 500in the Tripoli Base Command; and 250 each in the Levant Service Command and in Liberia.

Although the ratio of fixed beds to troop strength was high--9.9 in the peak month--the general average of beds occupied at any one time rarely exceeded 5 percent of theater strength.

Admissions to fixed hospitals in the Middle East theater during the period of greatest activity--1 July 1942 through 30 September 1943--totaled 53,863. of which24,889 were in the Persian Gulf Service Command. The five leading causes of admissions were intestinal disease, respiratory disease, injury (exclusive of battle casualties), cutaneous disease, and venereal disease. The 120-dayevacuation policy originally planned for the medical service of the theater proved adequate. Evacuation within the theater emphasized the use of airplanes because of the wide dispersal and lack of other adequate facilities. No special ambulance planes operated for this purpose, but regular transport planes were used when available. During the period under consideration most evacuees to the zone of interior traveled by Air Transport Command plane from Cairo. By October 1943, approximately 1,000 patients had made the trip to the United States.

At no time were U.S. hospital ships available for evacuation from the Middle East. In the early period, a few patients were sent to the zone of interior from the Persian Gulf on cargo ships by way of the Cape of Good Hope. Space on British hospital ships in the eastern Mediterranean was sometimes available. The British hospital ships, however, generally excluded psychotics, and the ATC planes would carry patients of this class only when accompanied by a medi-

²¹ See app. A-2

cal officer or nurse. As a result, some psychotics were held at the 38th General Hospital for more than a year. In other instances a medical officer who could not easily be spared was nevertheless detailed for this service.²²

The Middle East as a Supply and Service Theater, 1944-45

The United States Army Forces in the Middle East reached a peak strength of more than 65,000in midsummer of 1943, but combat activities in the area were rapidly coming to a close. Ground Forces headquarters was discontinued during the summer because no American ground combat troops remained in the Middle East. The Ninth Air Force supported the British Eighth Army in the invasion of Sicily early in July, and later that month participated in the bombing of Rome, but the successful raid on the Ploesti oil fields of Rumania in August was the last combat mission for the Ninth Air Force in the Middle East. Transfer of personnel to the Twelfth Air Force in North Africa began in July, and headquarters moved to the United Kingdom in October.

After departure of the Ninth Air Force, operations in the Middle East were those characteristic of a large communications zone, consisting almost exclusively of maintaining supply lines and transporting supplies and personnel.

Organizational Changes

Theater Headquarters-With the departure of General Brereton in September 1943, Maj. Gen. Ralph Royce assumed command of the United States Army Forces in the Middle East. The separate services of supply headquarters was discontinued at this time, but without in any way affecting the work of the Medical Department in the theater. Colonel Sams, who had returned to the United States in August, was succeeded as theater surgeon by Col. Eugene W. Billick.

While activity declined in the eastern Mediterranean in the fall of 1943, activity in the Persian Gulf area was still increasing. The independent mission of the Persian Gulf Service Command was recognized early in December when its administrative tie with Cairo was cut and the command was made directly responsible to the War Department. In effect, the redesignated Persian Gulf Command remained an independent theater until March 1945, when it was merged with USAFIME and the Mediterranean Base Section from the Mediterranean theater to form the Africa-Middle East Theater of Operations.

The staff of the theater surgeon`s office in Cairo underwent numerous changes during 1944and 1945. Many of the original officers on Colonel Billicks staff returned to the United States, their duties being carried on either by newly appointed officers (of lower rank than their predecessors), absorbed by other subsections of the office, or handled by officers assigned to Medical Department installations. The head of the dental section, for example, had a triple assignment, since he was also dental surgeon of a service command and of a general hospital. The preventive medicine section, the one element where expansion occurred, had a malariologist (stationed in

²² Ltr, Van Vlack to Col Coates, 23 Mar 59, commenting on preliminary draft of this chapter

West Africa) assigned to it, as well as a nutrition officer.

A contingent of the Women`s Army Corps, which arrived in the middle of 1944, replaced practically all the enlisted men in the theater surgeon`s office. The turnover in commissioned personnel was heavy in 1945, and the loss acutely felt, especially since the theater had experienced a substantial expansion in territory. A new development during early 1945 was the appointment of medical, surgical, dental, and neuropsychiatric consultants. They worked not only as members of the theater surgeon`s staff but also as chiefs of services in the 38thGeneral Hospital. During the course of the year many sections of the surgeons office were merged, and it was common to find medical staff officers combining two or more assignments.

The Service Commands- With the Persian Gulf Command autonomous by the beginning of 1944, the remaining service commands in Africa and the Middle East were regrouped into two major commands. The Middle East Service Command was established in February, merging the Delta, Levant, and Eritrea Service Commands. The Levant Service Command was disbanded, while Eritrea became a base command subordinate to the new headquarters. The West African Service Command remained substantially as it had been organized in the fall of 1943.²³

The medical service in the Middle East Service Command was responsible for the care of all American troops and associated personnel in Egypt, the Anglo-Egyptian Sudan, Eritrea, Libya, Palestine, Syria, and Arabia. When formed, the commanding officer of the 38th General Hospital at Camp Huckstep, Egypt, assumed the additional job of service command surgeon. Various other officers of the command surgeons office also had primary assignments with Medical Department units and installations. The surgeons office was located at the 38th General Hospital. Eritrea Base Command was a subcommand of the Middle East Service Command during most of 1944, but was established as a separate command directly under theater headquarters in December. The commander of the 104thStation Hospital at Asmara served as the base command surgeon throughout the year. Activities in the West African Service Command centered around the command headquarters in Accra and the base command at Dakar. The medical service, primarily for the benefit of Air Transport Command personnel, continued to provide hospitalization, medical supplies, sanitary services, and malaria control. The command surgeon was also the commanding officer of the 67th Station Hospital at Accra. The Medical Department in Liberia experienced some difficulties in carrying on medical and administrative measures for controlling malaria and venereal disease because of reductions in medical personnel.

Coincident with the territorial expansion of 1 March 1945, French Morocco, Algeria, and Tunisia were organized into a new command, the North African Service Command, under the Africa-Middle

²³The main sources for this section include: (1) Hist, Med Sec, AMET; (2) Hist of AMET, Summary Outline; (3) Annual Rpt, Med Dept Activities, Middle East Serv Comd, 1944; (4) Annual Rpt, Med Dept Activities, west African Serv Comd, 1944; (5) Annual Rpt, Sta Surg, Roberts Field, Liberia, 1944; (6) Hist, Med Activities, Persian Gulf Comd; (7) Annual Rpt, Med Dept Activities, PGC, 1944.

East theater. The offices of the Mediterranean Base Section at Casablanca became the new commands headquarters, and the commanding officer of the 56th Station Hospital in that city received the additional assignment of North African Service Command surgeon. By the end of June 1945, all U.S. Army activities in the West African Service Command were placed under the control of the North African Service Command. Medical Department units in West Africa were thereafter administered by the Southern Town Command, a subcommand whose function it was to handle the liquidation of U.S. Army installations in that area. Southern Town Command, with headquarters at Accra, was one of four subdivisions under North African Service Command, the others being Eastern Town Command, Center Town Command, and Western Town Command, with headquarters at Tunis, Algiers, and Oran, respectively. After the Central African Wing of the Air Transport Command had been inactivated in July, installations along its route through the Southern Town Command and the Middle East Service Command were either closed or greatly reduced. The bulk of air traffic passed through the northern part of Africa for the remainder of the year.

The Persian Gulf Command reached the peak of deliveries of war materials to the USSR during1944. The separation of the command from the Middle East theater in December1943 had no effect upon the medical service other than the forwarding of reports, which no longer required routing through Cairo. The Medical Department of the command continued to provide the best possible care for troops and carried on its never-ending task of refining preventive measures to combat the numerous diseases of Iran. Col. John E. McDill became PGC surgeon in January 1944. In the summer of that year, when the command was near its greatest strength, Colonel McDill exercised staff supervision over more than 2,400 Medical Department officers and enlisted men.

By the end of1944 the motor transport routes to the Soviet Union started closing down, narrowing the major supply activities to the more confined route of the railroad from Khorramshahr to Tehran. Progressive reductions in tonnage through the first half of 1945 completed the primary mission of the Persian Gulf Command by 1 June, after which it packed and shipped excess supplies, turned over surpluses to a liquidation commission, provided security detachments for remaining fixed installations until they could be disposed of, and continued to supply the Air Transport Command. These residual duties required fewer troops and many soon began moving out of the command. The Medical Departments responsibility was to reduce its own personnel and installations to conform with the commands program without impairing the efficiency of its services to the remaining troops.

Air Transport Command- During 1943 the Africa-Middle East Wing of the Air Transport Command had developed stations at many towns and cities in northern, central, and eastern Africa, and in countries of the Middle East, which lay along the ATC routes to Karachi, India. The northern arm of its system stretched across French West Africa, French Morocco, Algeria,

Tunisia, and through the Middle East to India, the most important stations being within the North African theater. All the airfields of the central route lay within the boundaries of the Middle East theater, passing through the countries of west, central, and eastern Africa, across southern Arabia, and on to India. By the end of 1943 the Africa-Middle East Wing had been split in two--the North African Wing with headquarters at Marrakech, French Morocco, and the Central African Wing with headquarters at Accra, Gold Coast. Since the latter was most closely associated with the Middle East theater, it is discussed here in more detail than the northern route. ²⁴

The primary objective of the Central African Wing was the delivery of high-priority freight and of military and civilian personnel, mail, and military aircraft across Africa. It transferred its cargoes to the North African Wing at Dakar and Cairo and to the India-China Wing at Karachi. The Central African Wing surgeons medical responsibilities were limited to preventive medicine measures and the maintenance of dispensaries at the stations, including stations at which theater service command hospitals were located. The territorial command within which the wing operated furnished medical supplies as well as hospitalization. Near the end of 1943 the Central African Wing was relieved of the major medical problem of malaria control, which was placed under the direction of the theater command. Nineteen officers and seventy-one enlisted men of the Medical Department served at the thirteen stations of the wing in December 1943. At some of the smaller stations a medical officer could be on duty only part of the time, but Medical Department enlisted men served at all the dispensaries. Some dispensaries had facilities to handle personnel with minor illnesses and injuries, but serious cases were evacuated by air to the nearest U.S. Army hospital.

Transportation of patients homeward from the Middle East along the route of the Central African Wing was handled by detachments of the 805th and 808th Medical Air Evacuation Transport Squadrons. Each air evacuation flight was composed of a medical officer, six nurses, and eight enlisted men. From March 1943to August 1944, 2,500 patients traveled westward across mid-Africa, the non to Brazil and the United States. Beginning in September 1944, however, air evacuation activities were transferred to the North African Wing.

Preventive medical problems constituted the chief concern of medical men stationed at the bases of the Central African Wing. Many of its stations were in highly malarious areas and on the edge of jungles and bush country, both insect ridden. Despite the presence of a large variety of tropical and other diseases(yaws, yellow fever, filariasis, typhus, dysentery, bubonic plague, small pox, and so forth), malaria caused more illness among wing personnel than any other disease. Aircraft accidents resulted in the death of more wing person-

²⁴(1) Hist, Med Sec, AMET. (2) Hist of AMET, Summary Outline. (3) Rpt of Med Dept Activities in the Africa-Middle East Wing, ATC, for 1943, Office of Surg, Sta #1. (4) Med Hist, Central African Div, ATC, 22 Sep 44,by Maj. Ralph N. Green, Jr., Div Med Historian, Air Staff files. ( 5) Hist of Central African Wing, ATC, AAF, by Capt John W. Dienhart, Wing Historian, on file at Hist Br, MATS. ( 6) Hist of the Med Dept, ATC May 1944, Cpl Celia M. Servareid, editor, Off of Surg, Hq, ATC, Air Staff files.

nel than any other cause, and the medical care of pilots flying the Central African route was an important matter to the medical service. Flight surgeons required that pilots take a semiannual flight physical examination to determine the flyers fitness for duty. All airports had emergency plans in readiness in the event of crashes, including specially equipped ambulances and other crash vehicles. Near the coast, air-sea rescue teams used motor launches and amphibious planes when an aircraft fell into the sea. Trained Medical Department enlisted men extricated patients from downed planes and gave first aid treatment to the crash victims.

As the much shorter trans-African route across North Africa developed, the importance of the more southern route under the Central African Wing diminished. However, the latter was still thought to be a military necessity since it provided a sure contact with India, and it continued in operation until July 1945.Its dispensaries were inactivated as the wing closed its stations during June and early July, and the dispensary equipment was shipped to the nearest hospital or medical supply depot. The medical service provided along the northerly route, under the North African Wing, now lay within the boundaries of the Middle East theater since the theater had absorbed all of northern Africa in March. The North African Wing operated dispensaries from Dakar and Casablanca in the west, across the coast of northern Africa to Egypt, and on through the Persian Gulf Command to India. During 1945 it was responsible for evacuating a large number of patients from the Mediterranean, India-Burma, and China theaters to the United States.

Hospitalization and Evacuation

The need for hospitalization in the Middle East declined with the changing mission of the theater. Toward the end of 1943 the 4th and 15th Field Hospitals were shifted to the Mediterranean theater. In January 1944 the 24th Station Hospital left Palestine for Jorhat, India; and the following month the 16th Field was transferred to the European theater. In other hospitals, bed strength was reduced as patient loads became minimal.²⁵

In Eritrea the104th Station Hospital continued to operate a 25-bed unit at Asmara through1944. Late in 1943 personnel not needed by this hospital were detached to form the 367th Station Hospital, activated as a 50-bed unit in January1944 and sent to Wadi Seidna, near Khartoum, Anglo-Egyptian Sudan, where it relieved a platoon of the 16th Field Hospital. In Egypt, the 38th General Hospital at Camp Huckstep was reduced from 1,000 to 750 beds early in 1944.In West Africa the 67th Station Hospital (250 beds) at Accra, the 93d Station(150 beds) at Dakar, and the 25th Station at Roberts Field, Liberia, remained in place throughout 1944. The 25th Station was reduced from 250 to 50 beds in January 1944, then increased to 75 beds in September.

The acquisition of Northwest Africa from the Mediterranean theater on 1 March 1945 brought three additional

²⁵ (1) Hist, Med Sec, AMET. (2) Annual Rpt, Med Dept Activities. Middle East Serv Comd, 1944. (3) Annual Rpt, West African Serv Comd, 1944. (4) Hist, Med Activities, PGC. (5) Annual Rpt, Med Dept Activities, PGC,1944. (6) Unit Rpts of hospitals mentioned in the text. (7) ETMD`s for 1944, 1945.

FORK-LIFTING A PATIENT aboard a transport plane, Casablanca, May 1945.

hospitals under jurisdiction of the Middle East theater, and offered an opportunity to relocate some of the hospitals already serving in the command. Those acquired were the 56th Station (250 beds) at Casablanca; the 57th Station (150 beds) at Tunis; and the 370th Station (25 beds) at Marrakech. At this time the 150-bed 93d Station was transferred from Dakar to Tripoli, being replaced at Dakar by the 50-bed 367th Station from the Khartoum area. The 25-bed 104th Station from Asmara replaced the 367th at Khartoum, leaving a medical composite platoon in charge of the hospital at Asmara.

The end of the war in Europe brought a further reduction of activity in the Middle East, but air traffic through the theater increased, both from the Far East byway of India and from Europe by way of North Africa. In order to provide medical care for thousands of transient patients en route from India and Burma to the zone of interior, the 38th General Hospital--a 500-bed unit since June 1945--was moved to Casablanca in August. The 56th Station, which had been more than two years at Casablanca, took over the Camp Huckstep site of the 38th General near Cairo. Also in August, the 53d Station Hospital was reactivated as a 50-bed unit and was established at Oran.26

The evacuation of patients to the zone of interior rose considerably during 1944, due primarily to the inauguration in August of an evacuation service through the Africa-Middle East theater for patients from the China-Burma-India theater. The Persian Gulf Command also sent many homeward-bound patients through the theater. While these transient cases were not formally admitted to a hospital, they put a strain upon the theaters small number of medical installations because in some instances they had to be held several days while awaiting a plane. Total evacuations to the United States including patients from the China-Burma-India theater, the Persian Gulf Command, and the Africa-Middle East theater itself, numbered well over 3,000 during 1944. This figure rose to more than 5,000 for 1945, the transient patients constituting most of the total. The evacuation policy changed from 120 days to 60 days in August 1945 in order to filter patients back to the United States more rapidly.

In the Persian Gulf Command a general reduction in bed strength, based on

²⁶ See pp.497-98, below

the experience of a year and a half of operation, began before the end of 1943, while activity in the area was still increasing. The 30th Station Hospital, with 250 beds, left the Persian Gulf area for the China-Burma-India theater in November 1943. In January 1944 the 150-bed 154th Station was transferred to the Mediterranean theater, and the following month the 113th General Hospital was reduced from 1,000 to 750 beds. The 18th Field Hospital left the command in July1944, and the 26th Field in December.

By the beginning of 1944, practically all hospital construction in the Persian Gulf area had been completed. The need for air-conditioned wards was recognized early, especially for hospitals located in the gulf and desert areas, but only a limited number of cooling units were available during the first year of operation. Installation of additional equipment in hospitals was begun in March 1944 and completed by the first of July, resulting in many completely air-conditioned wards at five hospitals. Approximately 1,248 beds in hospitals located at Andimeshk, Ahwaz, Khorramshahr, Bandar Shahpur, and Abadan had the benefits of air conditioning readily available.

The year 1944 saw a progressive reduction of illness in the command. At no time during the year did disease rates approach the peak rates of 1943. After July 1944 all the curves followed a steady downward trend. This decline, in a country rife with diseases, was a direct result of the effectiveness of the Medical Departments preventive medicine program.

By the beginning of 1945 there were 1.850 T/O beds remaining in the Persian Gulf Command, or a ratio of 6.9 to troop strength. Hospitals still operating at this time were the 113th General (750 beds) at Ahwaz, the 21st Station (500 beds) at Khorramshahr, the 19th Station (250 beds) at Tehran, and the 256th Station ( 50 beds) at Arak. The 19th Field Hospital had 200 beds in operation at Andimeshk and 100 beds at Bandar Shahpur.

Early in February the 21st Station was transferred to Italy, being replaced at Khorramshahr by the 113th General. A platoon of the 19th Field took over the Ahwaz site. At the beginning of April the 113th General was further reduced to 500 beds and was closed for movement out of the theater later that month. The end of June 1945 found only the 19th and 256th Station Hospitals and one platoon of the 19th Field Hospital still active in the command, with an aggregate of 400 beds.

Patients were evacuated from the Persian Gulf Command to the zone of interior on a 180-day policy, moving through the 113th General Hospital. For the period January 1943-September 1945, 1,168 patients were returned to the zone of interior. All patients were transported by air to Cairo and from there by air or water to the United States. Up to September 1944 the Persian Gulf Command furnished attendants for patients being evacuated to Cairo, but after that date Air Transport Command planes had one flight nurse and one enlisted man as attendants. A flight surgeon examined all patients before departure from Iran. The four leading causes for evacuation were neuropsychiatric diseases, injuries, cardiovascular diseases, and respiratory diseases. Most of the evacuation within the command,

that is from the station and field hospitals to the general hospital, was by a weekly railroad ambulance car, motor ambulance, or a combination of the two. The command used air evacuation for emergency cases occurring within its boundaries.

Medical Supplies and Equipment

When early in the war, American units arrived in the Middle East short of medical equipment the British furnished the necessary supplies, sometimes from lend-lease stores. Occasionally difficulties developed in the use of British supplies since American medical officers did not always regard British standards as equal to those of the U.S. Army. During the latter part of 1942, supplies in larger quantities began arriving from the United States, having been shipped by automatic issue of medical maintenance units. The supply situation was one of general disorder in the early period, as it was in most new theaters. Thousands of unlabeled boxes had to be opened to discover what had been received. To make matters worse, many Medical Department hospital units arrived without any supplies and equipment, their assemblies having been shipped separately. Fortunately, acquisitions from the British, improvisations from materials on hand, and a small number of local purchases enabled hospitals to operate without waiting for all their equipment to arrive.²⁷

The theater experienced some shortages during 1942 and the early part of 1943, but medical supply conditions improved after the middle of the year. The 4th Medical Depot Company, which had arrived on 1 November 1942, established three medical supply subdepots in the Middle East theater--at Camp Huckstep, Egypt; Decamere, Eritrea; and Tel Litwinsky, Palestine. By February 1943 the military situation in the theater had so changed.. that the subdepots in Eritrea and Palestine were closed. All medical supply depot work was then concentrated at Camp Huckstep, where the 4th Medical Depot Company became the medical section of the theaters quartermaster general depot. Automatic supply from the zone of interior was discontinued in October 1943 and thereafter the theater ordered medical supplies by quarterly requisitions on the United States.

The medical supply authorities in the Middle East theater found that the experience gained during the theaters most active period indicated that a better plan to equip medical troops would have been to establish an assembly depot well stocked with all types of medical supplies at or near the port of debarkation. Such a depot could have assembled equipment for each unit after notification of its embarkation from the United States had been received. In effect, the Middle East theater used this plan for all medical units arriving after February 1943, and the units so equipped were better able to perform their duties than those equipped with assemblies sent them from the zone of interior. The action taken within the theater helped medical units begin efficient operation sooner, since otherwise some units would have

²⁷The chief sources for this section are: (1) Hist, Med Sec, AMET; (2) Annual Rpts, Med Dept Activities, USAFIME, 1942, 1943; (3) Hist of Med Activities, PGC; (4) Annual Rpts, Med Dept Activities, PGC, 1943, 1944, 1945; (5) ETMD.USAFIME, Jan 1944.

had to wait many months before certain essential items arrived. Furthermore, unit assemblies from theater supplies had fewer shortages because the element of loss through handling was reduced to the minimum. Only items actually required by the unit to perform its mission were issued, thereby saving both equipment and transportation from depot to station.

Medical supply presented no serious problems in the Persian Gulf Service Command. Although the flow of supplies was slow in 1942 and early 1943, this situation improved by the middle of 1943, and adequate quantities of supplies were on hand after this time. A great deal of breakage and spoiling of perishable items occurred because of improper packing, poor handling, and exposure to the terrific heat of the Persian Gulf climate. Stock levels that had been built up during 1943 were reduced by 50 percent in January 1944, and the final reserve (a 90-day level of supplies set aside for emergency use) was abolished. About this time the automatic shipment of selected medical supplies was discontinued. Supplies were thereafter requisitioned on the basis of Table of Organization and Equipment (TOE) authorization and consumption. The overstockage that resulted was corrected by declaring excesses, which were eventually shipped back to the United States. Vaccines, which had previously been shipped by water, arrived in the Persian Gulf Command by air beginning in 1944, thus eliminating considerable loss in spoilage of vaccine before it could be used. In 1945 all surplus supplies and equipment not in use by medical installations were reported to an Army-Navy Liquidation Commission for disposition.

Professional Services

Major Medical Problems

The relatively limited combat activity, the difficult climatic conditions, and the low health and sanitary standards of the native populations all combined to channel the activities of the Medical Department in the direction of preventive medicine. In Central and West Africa the most serious problem was malaria; in the Persian Gulf area, respiratory diseases were common. Gastrointestinal disorders, venereal disease, and neuropsychiatric problems swelled the non-effective rates throughout the theater. Disease patterns in the Middle East were observed by medical officers with the original North African and Iranian military missions and the problems that would be encountered were fully appreciated from the start.

Malaria- American medical officers in the Middle East had first hand experience with malaria and other insect-borne diseases months before the standard malaria control and survey units developed by the Surgeon Generals Office were available for overseas duty. Based on this experience, an antimalaria unit consisting of one Sanitary Corps officer and five enlisted men was developed in the theater late in 1942. One such unit, supplemented by civilian laborers, worked in each service command.²⁸

²⁸ (1) Hist, Med Sec. AMET. (2) Rpt of Gambiae Control and Malaria Prevention at U.S. Army Bases in West Africa, by Maj Elliston Farrell, 1944. (3) Rpt of Malaria Control at U.S. Army Installations in West Africa, 1941-44,Hq, West African Serv Comd, USAFIME, to CG, USAFIME, attn Chief Surg. (4) Malaria: Its Prevalence, Control, and Prevention in the Africa-Middle East Area, by J. W. H. Rehn.

In March 1943the standard, more specialized units developed by the Surgeon General`s Office for the purpose of malaria control were requested after the theater was informed of their existence. The one survey unit and two control units asked for did not reach the theater, however, until September 1943 because of shipping delays. About that date malaria became the most important disease in terms of man-days lost in this theater where disease problems were now paramount and combat injuries nonexistent. This was the date when two highly malarious areas, those of the Central African and Liberian commands, were included in the theaters boundaries. In October the malaria rate at Dakar reached almost 2,000 per thousand men per year; in Accra it reached 580 and in Liberia over 800. Half of all hospital admissions in West Africa were caused by malaria. In Dakar 50 percent of the enlisted men of the 93d Station Hospital came down with the disease at the height of the 1943malaria season.

Efforts to control malaria were concentrated in western Africa, particularly at Dakar, in Liberia, and at Accra, the three worst areas. At the end of 1943 a malaria survey unit was at work in each of the three locations. In addition, Liberia and Accra each had a malaria control unit, two control units were assigned to Dakar, and a fifth one was assigned to Delta Service Command. Early in 1944 all these units were placed under more centralized control at theater headquarters, largely as a result of a visit to the theater by a group of officers from the Surgeon General`s Office and the Medical Inspector, USAFIME. This malaria control commission made its investigation in West Africa in November and December 1943.²⁹ It was primarily concerned with ridding the West African coastal airports of anopheles gambiae mosquitoes in order to prevent the introduction of this malaria vector by plane intoBrazil.³⁰A secondary purpose was to check on the accuracy of reports of excessively high malaria rates among Eighth Air Force combat crews who passed through Air Transport Command installations in Africa on the way to England. A third matter for investigation was the appalling malaria rates among U.S. military personnel stationed on the West African coast. These were among the highest in the entire Army, not excepting the rates for combat troops in New Guinea, Guadalcanal, and Sicily. The fact that the troops were living in relatively permanent installations made the theater medical inspector, Lt. Col. Thomas G. Ward, term the situation "a disgrace to the U.S. Army."

The causes were pointed out by Colonel Ward in a report to the Chief Surgeon, USAFIME. The Central African command had failed to organize and maintain malaria control even after high rates had developed. The Africa-Middle East Wing, ATC, had similarly failed to provide a sound malaria control organization and policy after it had agreed with the Central African command to takeover malaria prevention measures at the West African airfields. Shortages of personnel and equipment had prevented the wing from carrying out effective control measures. The Corps of

²⁹ Members of the commission were Col. William A. Hardenbergh, SnC, SGO, Washington, D.C.; Col. Paul F. Russell, Malariologist, NATOUSA; Lt. Col. Karl R. Lundeberg, MC, SGO, Washington, D.C.; and Maj. Elliston Farrell, MC, Office of the Air Surgeon, Washington, D.C.
³⁰ Seepp. 53-54, above.

Engineers and those charged with the maintenance of post utilities were in part responsible because of their failure to make the buildings mosquito proof where the permanent personnel lived and where combat aircrews and passengers stayed while in transit. Finally, the medical and line officers at the West African posts had not developed an effective educational program to acquaint permanent and transient personnel with the dangers of malaria.³¹

The commission concluded in its report to The Surgeon General that malaria control in the theater was the responsibility of the theater commander and that personnel engaged in it should be part of the theater organization. The commission pointed out that, with available air transportation, one malariologist could maintain close supervision over malaria control work in the widely separated malarious areas around Dakar, Roberts Field, and Accra.³²

The special malaria control organization that developed was headed by Maj. Elliston Farrell, the Army Air Forces representative on the visiting commission. He was assigned in February 1944 to the Medical Section, USAFIME, as theater malariologist, succeeding Lt. Col. Daniel Wright who had held that post since early 1942. Major Farrell was stationed in Accra, where he could direct operations on the coast of West Africa. He also acted as disinsectization officer for the South Atlantic, North African, and Central African Wings of the Air Transport Command and as liaison officer with the Brazilian Port Health Service. Two doctors of the Brazilian Department of Public Health were stationed at Dakar and Accra as liaison officers with the U.S. Army authorities. They were permitted to visit other Army airports in Africa that routed planes to Brazil, all in the interest of keeping Brazil free of gambiae.33

Working with the theater malariologist at the Accra, Liberia, and Dakar bases were assistant malariologists, entomologists, engineers, and the enlisted personnel of the control and survey units. Malaria control measures were usually restricted to a perimeter or protected area around a U.S. military installation. In some areas the U.S. Army and the British and French carried out successful co-operative schemes. The interallied scheme for, malaria control developed by the British and American forces stationed in and around Accra was one of the larger efforts along these lines. It achieved integration of British and American direction, engineering, survey, and control activities.

Although the theater malariologist was responsible for co-ordinating and supervising malaria control activities in West Africa, he had no power of command. Consequently he found it difficult to deal with station commanders. Major Farrell revealed some of the trouble he had in Accra when he stated:

Directives were not followed and as example the station commander was interested in building an officers` club and we

³¹ Memo, Col Ward, Med Insp, USAFIME, to Chief Surgeon, USAFIME, 21 Dec 43, sub: Malaria in West Africa.
³² Memo, Col Hardenbergh, Col Lundeberg, and Maj Farrell for The Surgeon General,4 Dec 43, sub: Mosquito and Malaria Control at West African Airfields.
³³ Elliston Farrell, "The Anopheles Gambiae Problem in Brazil and West Africa, 1941-44,"Bulletin,U S. Army Medical Department, vol. VIII, (February 1948), pp. 110-24.

were interested in having screened buildings in the camp. . . . The officers club was opened for general use the 5th of October [1944]. It was started the 29th of May and was built by men working m 2 hours a day, 7 days a week, during the height of our[malaria] season. It was built at a time when lumber was not available for essential screening work. When the officers club was finished the screening was done and by that time it was September and we didn`t need it. . . .

We are educating the soldiers in the malaria program, but we are not sufficiently educating the Generals and Colonels. I am actually convinced, from the reaction of the station commander, that he had no idea that malaria could be eliminated from the base. I had breakfast with him a few days before he was reassigned and he asked me how many cases of malaria we had last week. I told him two and that in the same time in 1943 there were forty or fifty. He was so obviously astonished that I realized for the first time that he had thought we were just pestering him. He had thought that when he had put in a good system of malaria discipline, nothing further could be done about it. He didn`t know that by attacking malaria at its Source it could beeliminated.³⁴

Major Farrell also believed that the efficacy of the malaria program could have been greatly increased if there had been a single battalion attached to theater headquarters under the direction of the theater malariologist in lieu of a larger number of scattered malaria units. In his opinion a theater battalion for malaria control would have provided a much better system of centralized control over the movement of units. Such a battalion could have had a commander responsible for the flow of orders. Major Farrell found it a disadvantage to be 3,000 miles from the theater headquarters in Cairo and thus out of touch with the top command. It would have been better, he thought, if he had had someone else to do the supervisory work on the West African coast and had himself remained in Cairo nearer the source of authority. He concluded that the effectiveness of a malaria control program "depends on the success with which you attain the support of the highest authority in the theater. The only way to reach lower commanders is to get action from above." ³⁵

The 1944 malaria control program in West Africa followed traditional lines (insecticiding, larviciding, and malaria discipline) except for the use of DDT, which was introduced during the spring and summer months. By the close of 1944 the rates for Army personnel at Accra and Dakar were reduced to the lowest ever known at those stations. Although they dropped in Liberia too, a reasonably low rate was not attained at Roberts Field until late the following year. By 1945 malaria incidence throughout the entire theater had decreased greatly, the highest theater-wide rate being only about 15 per 1,000 per annum in January. The majority of cases continued to occur in Liberia.

The program went on to the close of the war, the malaria control organization assisting, as in other theaters, with the control of various insect-borne diseases besides malaria--bubonic plague, sleeping sickness, filariasis, and yellow fever. By the end of the war it had become evident that the small number of U.S. Army installations remaining in the the-

³⁴ Interv, Oprs Serv, SGO, with Maj Farrell, Dec 44, Rpt of Med Dept Activities in Accra, Gold Coast. West Africa. See also, Ltr, Van Vlack, to Col Coates,25 Mar 59, commenting on preliminary draft of this chapter
³⁵ Farrell Interv.

ater would no longer require a malaria control organization of the size that had developed. After the surrender of Japan, most of the survey and control units were scheduled for inactivation with the exception of a survey unit located in Casablanca at the headquarters of the North African Service Command and a control unit at Roberts Field.

Venereal Diseases-The control of venereal disease was one of the most important medical problems in the Middle East theater. No reliable statistics existed as to the local incidence of venereal diseases, but Medical Department officers knew that the populations of all of the Middle Eastern countries were heavily infected. It was believed that in some areas almost 100 percent of the women with whom American soldiers came in contact had one or more venereal diseases. The Medical Department warned U.S. personnel of the danger through lectures, demonstrations, motion pictures, and other educational devices. It established prophylactic stations, used special investigation teams, and co-operated with civil public health authorities in finding the sources of infection.36

From an average of about 40 per 1,000 per annum for the period July-December 1942, the rate increased in 1943, exceeding 80 per 1,000 per annum in September, October, and November. Many factors other than the heavily infected population contributed to the high rate in the Middle East theater, among them being a general moral laxness common among men in overseas stations, and carelessness, forgetfulness, and refusal to accept advice. The Army was further handicapped because it was unable to command the aid of governments that were independent or were under the jurisdiction of another power.

In Delta Service Command, troops during the first part of 1942 were allowed to patronize houses of prostitution regulated by the Egyptian Government. The careless supervision of the houses and the cursory periodic medical examination given the inmates could hardly be classed as a controlled system according to officers of the U.S. Army Medical Department. The Egyptian Government next eliminated the houses of prostitution by law, but this action actually worsened the situation since "undercover houses," streetwalkers, and "taxicab prostitutes" increased in number. Venereal disease control activities were for the most part confined to U.S. Army troops, the commanders of units enforcing such measures as were practicable. Through an improved system of prophylactic treatment the venereal disease rate dropped from an average of 44.2 per 1,000 per year for the period January-July 1943 to a low of33.75 in December.

Control of venereal disease was one of the most vexing problems facing the Medical Department in the Persian Gulf Service Command. During 1943 rates averaged 105 per1,000 per annum, with a peak of more than 120 in September.

³⁶ General sources for this section are: (1) Annual Rpts, Med Dept Activities, USAFIME,1942, 1943; (2) Annual Rpt, Med Dept Activities, Levant Serv Comd,1942; (3) Hist of Med Activities, Persia,, Gulf Comd; (4) Annual Rpts, Med Dept Activities, PGC, 1943, 1944, 1945; (5) Annual Rpts, Med Dept Activities, Eritrea Serv Comd, 1942, 1943, 1944; (6) Annual Rpts, Med Dept Activities, West African Serv Comd, 1943, 1944; (7) Annual Rpt, Med Dept Activities, Task Force 5889 (Liberia), 1942; (8) Annual Rpts, Med Dept Activities, USAFIL, 1943, 1944, 1945; (9) Annual Rpts of Venereal Disease Control Activities, USAFIL, 1942-45; (10) Med Stat Div, SGO, Morbidity and Mortality in the United States Army, 1940-45.

Control was very difficult since a system of publicly countenanced prostitution prevailed throughout Iran. Medical Department officers believed that over 95 percent of Iranian prostitutes were infected. Rates during 1944 showed some improvement, chiefly because of more satisfactory housing, better recreational facilities, and increased activities in delivery of supplies to the USSR. With the slackening of activities in the fall of 1944, rates again assumed an upward movement. The venereal disease control program was intensified, and in addition to providing convenient prophylactic stations and supplying ample stocks of mechanical and chemical prophylactic devices, it employed educational measures on a large scale. Venereal disease films were shown regularly in conjunction with talks by medical officers.

In one district in late 1944 three badly infected prostitutes agreed to participate in a demonstration for which they received medical treatment in return. Their lesions were shown to the troops in that area in combination with the usual talk on venereal disease. Controversial though it was, the idea of using diseased prostitutes for demonstrations spread to other parts of the command, but no appreciable lowering of the rates resulted.³⁷ In spite of energetic efforts to reduce the incidence of these diseases, rates continued undesirably high. No significant lowering of the rate occurred until the summer of 1945.

In the Levant, Eritrea, and West African Service Commands, the venereal disease problem was not as serious, but when the U.S. forces in Liberia came under the jurisdiction of the theater in September 1943, a command having an extremely high incidence of venereal disease added its excessive rates to the theater totals. The situation in Liberia was bad from the start. The venereal disease rate among personnel stationed there averaged 650 per 1,000 per year for the period August-November 1942. A plan to control venereal disease among troops and the native population was formulated in September 1942 by the U.S. Army with the Liberian health authorities. It resulted in the establishment of areas known as "tolerated women`s villages" conveniently located near the barracks of the troops, but just outside the military reservation of Roberts Field. A health center for treatment of women in the villages was also established. Once begun, the command venereal disease officer and his assistant carried out the control program.

By December 1942,with the controlled native women`s villages in full operation, the rate for Army personnel in Liberia had decreased to 470 per 1,000 per annum for the last month of the year. During 1943 control measures were intensified by giving more frequent instructions to all enlisted men, issuing prophylactic packets and giving sulfathiazole tablets to men going on pass, establishing more prophylactic stations, and making chemical prophylaxis compulsory for all men visiting the tolerated women`s villages. The incidence of venereal disease decreased to an average rate of 180 per 1,000 per annum for the last seven months of 1943.

Venereal disease rates continued to decrease during the early part of 1944, a low of 63.2per 1,000 per annum being recorded for February 1944, but later in the year a rise developed which reached

³⁷ Ltr, Abram J. Abeloff to Col Coates, 16 Mar 59, commenting on preliminary draft of this chapter.

658.8 during November. One of the main reasons for the increase was that troops had started making contact with women in ten "off limits" villages near the military area. The refusal to accept advice and the failure to use available mechanical and chemical prophylaxis also contributed to the increase. The command thereupon undertook a more comprehensive control program that included treatment for women outside the tolerated villages. This extended coverage helped reduce the rate temporarily, but during 1945 venereal disease became so serious that it displaced malaria as the outstanding medical problem in Liberia. The elimination of the tolerated women`s villages in June, low morale, general indifference, and constant turnover in personnel all contributed to a marked rise in the venereal disease rate. In 1945, monthly rates ranged from about400 to almost 1,200 per 1,000 per annum.

As in other theaters, the use of sulfa drugs, and, from early 1944, of penicillin, greatly reduced the number of man-days lost because of venereal disease.

Typhus-Medical officers in the Middle East regarded typhus fever as one of the major problems of preventive medicine in the theater. During 1943 in Egypt alone over 25,000 cases occurred in the civilian population. Protective measures such as frequent inspections of immunization records to be certain that all personnel received a booster inoculation every three months, provision of bathing and delousing facilities, and the placing of native sections out of bounds contributed to the small number of cases that occurred among members of the U.S. Army and American civilians. Only 22 cases were found during 1943, none of them proving fatal.³⁸

In recognition of the threat of typhus in many areas of the world, the USA Typhus Commission was created in Washington in December 1942, and its work was an important phase of the medical program in the Middle East theater in 1943 and 1944.A forward echelon of the commission arrived in Cairo in January 1943 and established the field headquarters of the commission. The field staff was made up of U.S. Army, Navy, Public Health Service, and Rockefeller Foundation personnel, all under the administrative control of the Middle East theater headquarters but not a part of the theater organization. Experts of the commission worked in various theaters, but the Cairo group was the most active, as typhus posed a greater threat in the Middle East and the adjacent North African theater than elsewhere.

The Typhus Commission group worked closely with the theater surgeon and also with medical officers of the British Army Middle East Forces and with officials in the Egyptian Ministry of Public Health. The commission had the use of a laboratory at a government serum and vaccine institute and a clinical ward in a local fever hospital, and soon began testing vaccine and louse powders in field experiments. During the first months of 1943 members of the commission made surveys of the typhus

³⁸ (1) Hist, Med Sec, AMET. (2) Stanhope Bayne-Jones, "The United States of America Typhus Commission," Bulletin, U.S. Army Medical Department(July1943), pp. 4-15. (3) Folder Typhus Mission, 1943-46, in Maj Gen LeRoy Lutes`s personal files. (4) Interv, Blanche B. Armfield with Gen Sams, 30 Jan 50.(5) Condensed Rpts of the U.S.A. Typhus Commission.

situation in many areas of the Middle East and North Africa, visiting Syria, Lebanon, Palestine, Iran, Iraq, Libya, Algeria, Morocco, and Tunisia.

The field director of the commission during most of its existence was Brig. Gen. Leon A. Fox.³⁹The Cairo field headquarter was well situated so as to move easily to Europe, other African and Middle East locations, and the Far East. General Fox traveled during the late summer and fall of 1943 to North Africa, India, Burma, China, Iran, Iraq, and Turkey, making typhus surveys. His reports on the typhus situation in these areas were forwarded to the commission headquarters in Washington, and copies given to the Middle East theater surgeon and to U.S. Army surgeons of the North African and China-Burma-India theaters.

Activities of the Typhus Commission benefitting the population in Middle East countries consisted of the distribution of about 3,000,000 individual doses of typhus vaccine, repeated typhus surveys, and extensive dusting of populations with louse powders. The commission also handled a large-scale program to instruct personnel of the United Nations Relief and Rehabilitation Administration in modern and effective delousing methods. UNRRA was planning relief work in the Balkans, an area with a well-known history of typhus epidemics.

The commission maintained contact with French scientists at several of the Pasteur Institutes in North Africa and the Middle East. It also kept in touch with the Egyptian Ministry of Public Health, and co-operated with it in various projects. The surgeons general of the Egyptian and Iranian Armies agreed to a vaccination program administered by the Typhus Commission. The allocation of typhus vaccine to the various Middle East countries was handled by the Allied organization that governed the flow of lend-lease supplies, the Middle East Supply Council. As both the theater surgeon and the field director of the Typhus Commission were members of the council they were able to control the allocation, a point vital to the success of the program, as otherwise typhus vaccine could easily have become a monopoly of the privileged or have found its way into the black market.

The Typhus Commission participated in control activities at Naples during the outbreak of typhus in that city during the winter of 1943-44. The work of the commission was continued throughout the Middle East and Africa during 1944, and in 1945it put into effect a typhus control program in the Balkans. The possibility of dissolving the commissions field headquarters at Cairo was brought up during the summer of 1944, but this did not take place until mid summer of 1945, when it was closed and its facilities and equipment transferred to a U.S. Navy epidemiology unit.

³⁹ The first director of the Typhus Commission was Rear Adm. Charles S. Stephenson, MC, USN. On a survey trip to Lebanon and Palestine during January 1943,Admiral Stephenson became ill and later returned to the United States. In February 1943 Colonel Fox relieved Admiral Stephenson of the directorship of the commission and arrived in Cairo late the following month to assume control of the overseas program, having been promoted to brigadier general en route. He served as director until August 1943 when his title was changed to field director, and another Army officer, Col. (later Brig. Gen.) Stanhope Bayne-Jones, became director of the commission with headquarters in Washington, D.C.

GENERAL FOX

Neuropsychiatric Disorders- American soldiers in the Middle East theater had to accommodate themselves to widely divergent environments and cultural patterns. They also were exposed to climates completely dissimilar to those in their homeland. While the difficulty of adjustment in an overseas station in itself presented some problems stemming from separation from loved ones, familiar work, and the relative freedom of civilian life, long periods of exposure to the tropical climate imposed psychological and physiological stresses that frequently resulted in neuropsychiatric disorders.40

In the Persian Gulf area, for example,

⁴⁰(1) Maj John M. Flumerfelt, Hist of Neuropsychiatry in the Middle East. (2) Ltr, Lt Col Baldwin L. Keyes to Chief Surgeon, USAFIME, sub: Mental Fixtures in Tropics, 18 Feb 44, in ETMD Rpt, Feb 44. (3) Ltr, Maj Flumerfelt and Capt John T. Delehanty to Surg, Delta Serv Comd, sub: Discussion of (a) Effect of Climate upon Personnel (b) Neuropsychiatric Diseases, 9 Aug 44, in ETMD Rpt, USAFIME, Aug 44. (4) ETMD Rpts, USAFIME, May 44,Jan-Apr 45. (5) ETMD Rpm, West African Serv Comd, USAFIME, Aug 43. (6) ETMD Rpt, Central African Wing, ATC, Feb 44. (7) Hist of Med Activities, PGC.

the difficult climate and the initially poor living conditions troops endured resulted in neuropsychiatric casualties. The rate per 1,000 per annum was above 40 for most of 1943, but with the completion of semipermanent barracks, mess halls, and recreational facilities, the rate dropped to 16 in October 1943. Medical officers of the command considered it remarkable that in the early days the rate was not higher. At first many of these cases were repeatedly hospitalized in an attempt to salvage them for further duty, but it soon became apparent that a more liberal policy was needed in caring for them. More neuropsychiatric patients were evacuated to the zone of interior during the last half of 1943 and the first half of 1944.

The chief psychiatrist of the Middle East theater and the chief of the psychiatric section of the 38th General Hospital studied the effect of climate upon personnel and found that a definite tropical syndrome developed among many individuals assigned to tropical areas. The time required to develop the more severe syndromes varied with the individual and the area. Service in small isolated units in the desert or the jungles of central Africa produced some breakdowns in 3 months. In larger units stationed closer to centers of population and the more varied environments along the coast, the breaking point was reached in 6 months to a year or longer. After 18 to 24 months under tropical conditions the efficiency of almost anyone was greatly reduced. Characteristically, an individual affected with a tropical syndrome showed evidence of listlessness, slow speech, defective memory, poor thought content, and narrowed perspective. Although no obvious loss of intelligence occurred, the ability to use one`s faculties was considerably impaired.

Col. Baldwin L. Keyes, head of the neuropsychiatric service in theater headquarters, after investigating cases of mental deterioration caused by lengthy tropical service, recommended that personnel be returned to the United States on rotation after not more than two years service in the Middle East, and also advised that a rotation policy be established within the theater. The 2-year-rotation plan was favorably considered by the theater commander in the spring of 1944, but a new commanding general of the theater who arrived soon afterward did not back the recommendation of the chief neuropsychiatrist.

The depressing effect of having the 2-year-rotation plan scrapped was reflected in the rise in the hospital admission rates for neuropsychiatric diseases, which reached a peak of 31 per 1,000 per annum for July, 1944. The increased admissions were mostly personnel who had been making borderline adjustments, building up hope for return on the proposed rotation policy. Rotation was again considered later in 1944, but the difficulty of getting replacements for those eligible for return precluded any effective application of the policy. Intra theater rotation finally began in 1945 when many were shifted from the more undesirable stations in the theater to places having a comparatively favorable climate.

Evacuation of mental patients to the United States was a serious problem in the early days of the theater, since no American hospital ships were available. Psychotics and severe psychoneurotics whose return to the zone of interior had been recommended clogged the theaters hospital wards for periods up to six

months before they could be evacuated by infrequently departing American troop transports equipped with sickbays and medical personnel. The more numerous British hospital ships were also used, when they could be induced to accept this class of patient, but carried U.S. personnel only to North Africa or England for transshipment on U.S. vessels. In 1944, when the Air Transport Command routes through the Middle East to the China-Burma-India theater were well established, returning aircraft could be used for patients en route to the United States. Air evacuation worked admirably, and mental patients were responsible for no serious accidents to patients or personnel. From July 1942 to the end of 1944 neuropsychiatric disease led the list of causes for return of patients from the Middle East to the United States, and constituted over 35 percent of the total number returned. About a third of the neuropsychiatric cases evacuated had some history of psychiatric disorder before military service, the stresses present in the theater causing recurrences.

Beginning in the latter part of 1944, as many psychiatric cases as possible--including alcoholics--were treated on an outpatient basis, with only those wholly unable to perform their duties being admitted to the hospitals. It was felt that long periods of hospitalization tended to intensify symptoms rather than effect cures. The result of this policy was reflected in a substantial reduction in psychoneurotic patients presented to disposition boards for evacuation to the zone of interior.

Other Diseases-Gastrointestinal diseases constituted one of the greatest sources of lost manpower in the Middle East theater. Nonspecific diarrheas, bacillary and amebic dysentery, bacterial food poisoning, and the typhoid-paratyphoid group of infections were found in all areas. The factors contributing to the high incidence of these infections among natives of the Middle East were contaminated water supplies, lack of sewage disposal systems, generally insanitary conditions that promoted extensive fly breeding, and the personal habits of the individuals. These diseases, however, need not have been nearly as prevalent as they were. Men continued to arrive in the theater without proper training or discipline in hygiene and sanitation and continued to suffer a high diarrhea rate until the defects were made good. On the calendar-year average, this group of diseases accounted for more man-days lost than any other, and constituted 20 percent of hospital admissions for the period 1 July 1942 to 1 October 1943. The rates for intestinal diseases declined from year to year, owing in part to the intensive program of education in preventive medicine instituted in the theater by the Medical Department and in part to the use of sulfanilamide and later of sulfaguanidine.⁴¹

Contrary to most of the intelligence reports, which had indicated that respiratory diseases in the Middle East were of minor importance, this group of diseases constituted15 percent of hospital admissions during the period 1 July 1942 to 1 October1943. Infectious hepatitis

⁴¹ (1) Annual Rpts, MD Activities, USAFIME, 1942, 1943. (2) Col Ward, Hist of Preventive Medicine in the Middle East, 19 Oct 41-23 Jun 44. (3) Hist, Med Sec, AMET.(4) Hist, Med Activities, PGC. (5) Ltr, Gen Sams to Col Coates, 12 Mar59, commenting on preliminary draft of this chapter.

caused some difficulty in late 1942and early 1943, particularly among Ninth Air Force personnel stationed in the Western Desert of Egypt and Libya. Smallpox and bubonic plague, the former being widespread among the population, and the latter causing epidemics among the natives of Dakar, French West Africa, and the people living along the Suez Canal, were potential hazards to American troops. Immunization and control measures instituted by the Medical Department protected American troops so that the two diseases were of little military consequence.

A group of diseases that puzzled medical authorities in the Middle East resulted in a request by the theater surgeon to The Surgeon General for special assistance. A small organization known informally as the Virus Commission stemming from the Army Epidemiological Board arrived in Cairo in April 1943, and soon set to work collecting information about sandfly (pappataci) fever, poliomyelitis, and infectious hepatitis--three epidemic diseases, presumably of virus origin, prevalent in the Middle East. Members of the commission set up a laboratory and office in the 38th General Hospital, where they conducted experiments on the transmission of the various virus diseases. Members of the commission made field trips to nearby Egyptian areas as well as to more distant places during the year. By mid-December 1943 the commission closed its Middle East laboratory after making valuable contributions to the literature of the diseases they studied.

The intense heat of the Persian Gulf area was responsible for various forms of discomfort, including heatstroke, heat exhaustion, and prickly heat. Medical Department officers fought the effects of heat in a variety of ways. A liberal daily intake of water and fruit juices was recommended, and the men were advised to take a salt tablet with each glass of water. Alcohol, recognized as one of the greatest contributory factors, could not be entirely eliminated, but the danger was constantly emphasized in the slogan "If you want to live, don`t drink." Intravenous injections of normal salines were used in treatment of heatstroke and heat exhaustion. In the summer of 1942,before the U.S. medical authorities had learned the use of salines, icepacks, wrapped in toweling and soaked in ice water, together with electric fans adjusted to blow across the beds, served to reduce body temperatures by two or three degrees.⁴²

To make living conditions more bearable, the Engineer Corps installed air conditioning equipment when available, but most of the time "desert coolers" were used. These improvised devices consisted of crates filled with straw, camel thorn, or excelsior, which were set in windows. They operated by having a fan blow air through them while water trickled down through the filler material. This equipment reduced temperatures of rooms from twenty to thirty degrees. The adoption of special morning working hours for the summer months also helped reduce casualties. Heatstroke centers, where men could go at the first signs of heatstroke or heat exhaustion, cured many potentially serious cases.

Another problem that was common to the whole Middle East area early in the period was that of chronic vitamin deficiency. Detailed plans for the Persian

⁴² Ltr, van Vlack to Col Coates, 23 Mar 59, commenting on preliminary draft of this chapter.

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Gulf included vegetable gardens for which land and water rights had already been obtained, but these were canceled when the troops arrived because the normal ration was supposed to contain an adequate supply of vitamins. Many men, however, did not eat all of the rations issued. Very few uncontaminated green vegetables were obtainable locally, and the effects of vitamin deficiency were clearly observable. This situation was remedied in 1943, after a nutritional officer had been sent to the theater and had testified to the need for vitamins.⁴³

Still another disease problem peculiar to the area was leishmaniasis, or Bagdad sore. The disease was classified as exotic and so the drug required to cure it could be had only by special order "as required," and then only in small quantities, so that it was impossible to combat the condition effectively.⁴⁴

Dental Service

The dental service of the Middle East theater began with the formation of the theater in 1942, but it was not until well into 1943 that the service could be considered adequate. A high noneffective rate because of adverse climatic conditions reduced the number of dental officers available at any one time, and the wide dispersal of units made it necessary to place dentists with units too small for the most economical functioning. To compensate, certain dentists were frequently moved from one small station to another. During the period of growth in the Middle East theater there was a strong tendency to overburden dental officers with work not connected with their professional training. Dentists usually received such nonprofessional assignments when they were not able to work full time because of lack of equipment. Once this practice started, it became difficult to get dentists relieved of such jobs even when the burden of dental treatment increased. ⁴⁵

In the Persian Gulf area, dental officers arrived with the first major shipment of troops in December 1942, although one Dental Corps officer had been in Iran with the Iranian Mission since March. About eleven dental officers were in the area in December 1942, but eventually their number in proportion to the troop strength of the command became large compared to other overseas areas. More were needed because in addition to those stationed with hospitals and dispensaries, others had to minister to the needs of units strung along the transportation routes to the Soviet Union.

Although the British allowed U.S. Army dentists to use dental facilities in British Army hospital spending completion of American installations, a serious problem in the early days was the lack of facilities. The shortage of dental equipment, which lasted until mid-1943, seriously handicapped the dental service

⁴³ lbid.
⁴⁴ Ltr, Col Adams to Col Coates, 7 Apr 59, commenting on preliminary draft of this chapter
⁴⁵ (1)Annual Rpt, Med Dept, USAFIME, 1942 and 1943. (2) Hist, Med Sec, AMET. (3) Ltr, Maj George F. Jeffcott, Dental Surg, USAFIME, to Brig Gen Robert H. Mills, Asst to the SG, 29 Sep 42. (4) Hist of Med Activities, PGC. (5) Dental Hist of PGC, Dec 42-Aug 44, and 1 Jan-31 Mar 45.(6) Dental supplement to Annual Rpt, Surg, PGC, 1943. (7) Annual Rpt, Med Dept Activities, PGC, 1944. (8) Annual Rpts, Med Dept Activities, Delta, Eritrea, and Levant Serv Comds, 1942 and 1943. (9) Annual Rpt, Med Dept Activities, Middle East Serv Comd, 1944. (10) Annual Rpt, Med Dept Activities, Central African Wing, ATC, 1943.

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POST DENTAL CLINIC, KHORRAMSHAHR. IRAN

of the theater. In December 1942the thirty-nine dental officers then in the theater had a total of 6 field sets, 2 units and chairs, 1 incomplete laboratory, and a few miscellaneous items purchased locally. The British loaned field chests to U.S. Army units arriving in the Middle East without dental equipment. During 1943 adequate facilities were established and enough equipment arrived so that the dentists could establish a program of improving the dental health of the soldiers in the theater.

Dental service throughout the Central African Wing of the Air Transport Command was provided by ATC dental officers and local station hospitals. A dental officer and an enlisted man with portable equipment flew to stations that did not have resident dentists.

The greatest difficulty experienced by the dental service related not to hardships or shortages in equipment, but to the lack of promotions. The Dental Corps suffered from Table of Organization troubles about which very little could be done within the theater. Dental officers found themselves passed at regular intervals by men of other branches who often had less experience and ability. Enlisted assistants had similar morale-destroying problems, for many of

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them served on detached service to dental clinics that had no Tables of Organization.

The chief dental officer of the U.S. Army Forces in the Middle East was Lt. Col. George F. Jeffcott, who was succeeded at the beginning of 1944 by Lt. Col. Thomas A. McFall, already dental surgeon of the Delta Service Command and chief of the dental service for the 38th General Hospital. The dental activities of the Persian Gulf Command, during the period of its autonomy, were directed by Lt. Col. Herbert L. Gullickson, who came to the theater as dental surgeon of the 21st Station Hospital.

Veterinary Service

Except for a small number of horses used for recreational and military police purposes, the Middle East theater did not use animals for carrying on its duties. Consequently, members of the U.S. Army Veterinary Corps were chiefly concerned with meat and food inspection and supervision over animals and other food products raised for consumption of theater troops. The veterinary service conducted meat and dairy hygiene activities at various stations in the commands of the theater. Because of the low sanitary standards prevailing throughout the Middle East, veterinary officers experienced considerable difficulty in obtaining suitable food products of local origin. All meat, dairy, and other food products had to be inspected with great care to ensure strict compliance with U.S. Army standards. Whenever establishments maintaining satisfactory standards were located, the veterinary service recommended them as sources of supply. Products most commonly obtained in this way were poultry, eggs, and seafood. However, the majority of food products came in by ship from the United States, and large quantities of beef were secured through the British Government from Australia and New Zealand.

Various enterprises for the production of food for American troops were supervised by the veterinary service. A Cairo chicken dealer built a sanitary poultry-killing and dressing establishment with the advice and suggestions of the Delta Service Command veterinary officer. The U.S. Army obtained fresh milk that was pasteurized under the supervision of the veterinary service in Palestine. In Eritrea, the veterinary service of the Eritrea Service Command and the theater veterinarian put into operation a small but modern slaughterhouse, constructed especially for U.S. military use. In the opinion of Veterinary Corps officers in the theater, it was superior to any abattoir found anywhere in the Middle East. In Eritrea and Palestine the veterinary service operated pig farms, and in Egypt a veterinary officer rendered assistance in the operation of a piggery. These pig-raising projects helped dispose of garbage and provided a source of reliable pork. At the various stops along the Central African Wing, ATC, route two veterinary officers and an enlisted man inspected the food supplies of the personnel.

Veterinary officers arrived in the Persian Gulf area late in 1942 and quickly began the tasks of inspecting the food supplies of the troops. They also made surveys and recommendations regarding storage, refrigeration, and slaughterhouses. By the end of 1943, the veterinary strength of the command had reached its peak of 8 Veterinary Corps

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officers and 12 enlisted men, distributed in the northern, central, and southern areas of Iran. The veterinarians were of the opinion that an oversupply of their profession existed in the command and that 2 officers and 15 enlisted men would have been sufficient. Although Veterinary Corps officers were officially charged only with the inspection of meat, eggs, and other food products, the command authorized them to establish several animal clinics to care for pets acquired by members of the Army. Veterinary care was provided for these animals whenever time could be spared from food inspection.

Decline of Medical Activities in the Demobilization Period

Immediately after the surrender of Japan on 14 August 1945, the medical service of the Africa-Middle East theater began a program designed to keep up with the demobilization instructions issued by the War Department. The theater surgeon carried out a policy of reducing or reorganizing all medical installations in proportion to reductions in theater strength. Most medical units were either inactivated or transferred from the theater between September and December 1945. By the end of the year only the 38th General Hospital at Casablanca, the 25thStation Hospital at Roberts Field, the 56th Station Hospital at Camp Huckstep, and the 367th at Wadi Seidna in the Sudan remained in the theater. During this period the Persian Gulf Command completed its mission, and its liquidation was entrusted to the Africa-Middle East theater. The theater disposed of the Persian Gulfs surplus personnel and equipment and inactivated the command the last day of December. ⁴⁶

Although most of the theaters commands were still in existence at the end of 1945, they were working toward an early close-out date. Where station hospitals had formerly served, medical detachments operated to handle the diminishing military population of the commands. The two largest commands of the theater, the North African and the Middle East Service Commands, as well as the minor command in Liberia, were inactivated during the first quarter of1946, and the theater itself disbanded on 31 May 1946. The 56th Station Hospital, the last remaining theater hospital, closed its doors the day the theater was inactivated. The personnel of the service commands were assigned to 26 residual teams established to act as custodians of U.S. Government property awaiting sale by the Foreign Liquidation Commission. Some of the teams had one medical or surgical technician assigned, and every team had either Air Transport Command, British, or local civilian hospital facilities available for the medical care of its personnel. The remaining responsibility of the Medical Department was simply to provide sufficient medical attendance for the few remaining troops.

⁴⁶(1) Med Hist, AMET, vol. II, pp. 319-23. (2) Final Rpt, Med Sec, AMET, Oct45-Mar 46. (3) Hist of AMET, Supplement, Tab, Med Sec, AMET, separate rpts for following periods: Oct-Dec 45, 1 Jan-10 Mar 46, 11 Mar-30 Apr46, MS, OCMH. (4) An. C, Chief Surgeon, Final Hist Rpt, Hq, AMET, through 31 May 1946, in ETMD Rpt, May 46.

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