CHAPTER XII
Estimating and Meeting Requirements of Theaters for Hospital Beds
Although estimates of beds required for theaters weregenerally made separately from those for the zone of interior, developmentsattending the estimation of requirements for both areas were in some respectssimilar. Such similarities occurred despite the fact that co-ordination betweeninterested divisions of the Surgeon General's Office was incomplete.
Until the late summer of 1943 the Plans Division of theSurgeon General's Office continued to plan hospitalization for active overseastheaters on the basis of a 10-to 15-percent ratio of fixed beds to troopstrength.1 One reason for this high ratio wasthat the director of the Division, aware of public criticism which the MedicalDepartment would incur if it ever failed to have enough beds, desired to have asufficient number to meet promptly a greatly accelerated build-up of troopsoverseas and still have enough left to constitute a safety factor.2Another reason of equal cogency was that sufficient information aboutvarious factors that affected bed requirements during World War II was not yetavailable to justify the establishment of lower ratios than those derived fromWorld War I experience.
Factors Influencing Bed Requirements
Among the factors that influenced bed requirements were: (1)overseas troop strengths, both actual and projected; (2) disease and nonbattle-injuryhospital-admission rates; (3) battle-casualty hospital-admission rates; (4) theaverage length of time patients stayed in hospitals; and (5) evacuationpolicies. While troop strengths and admission rates for disease and nonbattle-injurycases could be determined with reasonable accuracy, admission rates for battlecasualties could be estimated only roughly and were therefore uncertain at best.The average length of time that patients stayed in hospitals depended upon somefactors that were uncontrollable, such as the severity of wounds and theseriousness of illnesses, and upon others, such as evacuation poli-
1For example, see Ltr, SG to CG ASF, 13 Jul 43, sub: Trp Basis for Pacific Area. SG: 320.2.
2Interv, MD Historian with Col Arthur B. Welsh, MC, 27 Dec 50. HD: 000.71. According to Colonel Welsh the safety factor was an undeployed reserve within the United States for use in case the enemy employed atomic, chemical, or biological weapons effectively.
215
cies, that could be determined by the War Department.
Evacuation policies governed the numbers and types ofpatients to be transferred from theaters to the zone of interior and wereexpressed in terms of days. For example, a theater which evacuated all patientsrequiring 120 or more days of hospitalization was said to have a "120-daypolicy." Under such a policy a theater would retain for treatment in itsown hospitals all patients who, it was expected, could be returned to dutywithin 120 days and would evacuate the balance, not at the end of the 120-dayperiod, but as soon as they were able to travel and conveyances were available.Under a 120-day policy the average length of stay of patients in theaterhospitals was shorter than under a 180-day policy and more patients wereevacuated to the zone of interior. It was estimated, for example, that 30percent of all battle-casualty patients were returned to the United States underthe former, while only 20 percent were returned under the latter. Thus theevacuation policy affected the number of hospital beds required in theaters. Italso affected the number needed in the United States to hospitalize evacuees,the amount of transportation required for patients, and the number ofreplacements needed by theaters. From a theater commander's viewpoint, theideal arrangement was to hospitalize in theaters those patients who could bereturned to duty within a "reasonable" period of time, thus reducingthe number of replacements needed, and to evacuate the rest as soon as possible,thus reducing the number of hospital units and the amount of equipment shippedinto and used in the theater. The Surgeon General believed that a 120-day policymore nearly approached the ideal than did any other.3
Establishment of Official Evacuation Policies
Although the Surgeon General's Office and ASFheadquarters had tried to get official evacuation policies established in thespring of 1943, final action was delayed until August. Being of vital concern totheaters, evacuation policies were normally established by the War Departmentonly after consultation with theater headquarters, and several months wererequired to get comments on a proposal of The Surgeon General in May 1943 that a120-day policy be officially adopted.4 Thesereplies revealed that all theaters except the European and Asiatic(China-Burma-India) agreed upon the desirability of that policy. Having enoughbeds to operate under a 180-day policy, both the European and Asiatic theaterspreferred the latter. It permitted them to return to duty a greater proportionof experienced personnel. It also enabled them to save shipping required both toevacuate patients to the United States and to return replacements to theaters.In addition, the European theater favored a 180-day policy because it lackedhospital ships for evacuation and its chief surgeon opposed returning patientsto the United States in transports. Although the South Pacific, SouthwestPacific, and North African theaters preferred a 120-day policy, they requestedpermission to continue operations under a 90-day policy because of short-
3(1) ASF Monthly Progress Rpt, Sec 7, Health, 31 Dec 44, pp. 29-34. HD. (2) Memo SPOPP 370.05, Dir Planning Div ASF for Dir Plans and Oprs ASF, 24 Jan 45, sub: Review of "Elements of an Evac Policy." HRS: ASF Hq Planning Div File, 370.05 "Hosp and Evac."
4WD Memo W40-12-43, Evac Policy for Overseas Comds, 8 May 43. HD: Wilson files, 008 "Policy re Evac for Overseas." See p. 165.
216
ages of beds. After analysis of these replies, the WarDepartment announced on 28 August 1943 that it was establishing a 180-day policyfor the European and Asiatic theaters and a 120-day policy for all others tobecome effective as soon as required hospital and transportation facilities wereavailable.5
Establishment of Bed Ratios for Theaters of Operations
A few days before theater evacuation policies were announced,official bed ratios had been authorized for theaters for the first time in WorldWar II. Early in August 1943, when the Surgeon General's Office and theGeneral Staff were concerned about means of meeting the needs of the Army withthe number of physicians authorized, The Inspector General reported that membersof his staff, including General Snyder, had found in a survey of North Africanoperations that battle-casualty rates had been lower than anticipated and thathospitalization requirements had been met during the first two campaigns withless than half the number of beds originally considered essential.6In view of this report the Deputy Chief of Staff of the Army directed OPD tosurvey bed requirements of all theaters "in the light of experience todate." Meanwhile, OPD was to limit the total number of beds shippedoverseas, whether in fixed or mobile hospitals, to 8 percent of theater troopstrengths.7
In the study that followed, both OPD and the Surgeon General'sOffice agreed that fixed and mobile beds should be estimated and authorizedseparately because they served different purposes. Designed to support divisionsin combat, mobile hospitals cared for patients requiring only short-durationtreatment before return to duty and prepared others for evacuation to the rear.Thus sufficient numbers of fixed hospital beds were needed in the rear to takeover patients whom mobile hospitals could not return to duty. Both officesagreed also that theaters should be supplied with "50-percent expansionequipment"-that is, with enough equipment to permit each fixed hospitalto expand its bed capacity for short periods of time by 50 percent, without anyincrease in its authorized personnel. This would provide a safety factor foremergencies. Both offices further agreed that combat operations up to that timefurnished an insufficient basis for estimating future rates of battle-casualtyadmissions, but they differed as to how this should affect the establishment offixed-bed ratios. A computation by the Surgeon General's Office of beds neededin each theater for disease and nonbattle-injury cases, based on experiencebetween the last of 1941 and the early part of 1943, did not alter its opinionthat the 10- to 15-percent ratio should still be adhered to. It thereforerecommended that this ratio be officially authorized. Believing that fewer bedswould suffice, OPD used The Surgeon General's rates for disease and nonbattleinjuries along with limited information available about World War IIbattle-casualty rates to develop
5WD Memo W40-19-43, Policy on Evac of S&W from Overseas Comds, 28 Aug 43. HD: Wilson files, 008 "Policy re Evac from Overseas Comds." Replies of theaters to the War Department memorandum of 8 May 43 are found in SG: 705-1.
6(1) Memo, IG for DepCofSA, 10 Aug 43, sub: Ests of Battle Casualties as Affecting Repls and Plans for Evac and Hosp. HRS: OPD, 700 "ETO." (2) Memo, IG for DepCofSA, 10 Aug 43, sub: Surv of the Orgn and Opr of the MD Fac in NATOUSA and Sicily. Same file.
7Memo WDCSA 333 (10 Aug 43), DepCofSA for ACofS OPD WDGS, 13 Aug 43, sub: Surv of the Orgn and Opr of the MD. HRS: OPD, 700 "ETO."
217
other ratios of fixed beds that ranged from a low of 4percent for one theater to a high of 10 percent for others. Abandoning itsformer position because of the limited number of physicians now available, theSurgeon General's Office concurred in recommending these ratios.
As a result, on 24 August 1943, the Deputy Chief of Staffapproved the proposal to authorize fixed and mobile beds separately, agreed tosupply all theaters with 50-percent expansion equipment, and authorized ratiosof fixed beds as follows: 8 percent for the European and Asiatic(China-Burma-India) theaters, 10 percent for the South and Southwest Pacifictheaters, 6.6 percent for the North African theater, 6 percent for the MiddleEast-Central-African theater, and 4 percent for the American (the WesternHemisphere, exclusive of the United States) theater.8A short time later a ratio of 7 percent was established for the CentralPacific,9 and the 8 percent ratiofor the Asiatic theater, which at first applied only to American troop strength,was revised in February 1944 to provide 8 percent each for the American forcesand the Chinese Army in India.10 Inestablishing such ratios the Deputy Chief of Staff announced that he was notthereby authorizing additions to the troop basis. It remained to be seen whetherquotas of beds authorized for various theaters could be met with units alreadyincluded in the troop basis.
Mobile bed requirements were agreed upon in a conferencewhich OPD held with representatives of G-3, G-4, ASF headquarters, the GroundSurgeon, and The Surgeon General, and were approved on 23 August 1943 by theDeputy Chief of Staff. For planning purposes, beds were authorized in evacuationhospitals for 3 percent, and in convalescent hospitals for 1 percent, of thetroops in combat zones. Although there was misunderstanding about what thismeant in terms of units, it was generally considered that one 400-bed evacuationhospital would be supplied for every division (except airborne divisions, whichwere not authorized evacuation hospitals) and for each group of army or corpstroops equivalent in number to a division; that one 3,000-bed convalescenthospital would be supplied for each group of nine divisions; and that threeportable surgical hospitals would be supplied, whenever theaters used them, foreach division. If 750-bed evacuation hospitals were used, they were to besupplied in numbers sufficient to give a quantity of beds equal to thatauthorized in 400-bed hospitals. It was expected that portable surgicalhospitals would be used only in the Pacific and Asiatic theaters and thatconvalescent hospitals would be used as mobile units chiefly in the European andNorth African theaters.11 In addition, spe-
8(1) Memo, SG for ACofS OPD WDGS, 17 Aug 43, sub: Fixed Hosp, Overseas. SG: 701.-1. (2) Memo, Act ACofS OPD for DepCofSA, 20 Aug 43, sub: Surv of Orgn and Opr of the MD, with notation: "Approved as amended," by order of SecWar, by Col W. A. Schulgren, Asst Sec WDGS, 24 Aug 43. HRS: OPD, 700 "ETO."
9This ratio was established before April 1944. See Memo, CG ASF for CofSA thru ACofS G-4 WDGS, 10 Apr 44, sub: Overseas Hosp. HRS: ASF Planning Div Program Br file, "Hosp, Apr 44."
10(1) Memo OPD 632 (19 Sep 43), ACofS OPD WDGS for DepCofSA, 24 Sep 43, sub: Hosp-Asiatic Theater. HRS: WDCSA 632. (2) DF OPD 632 (22 Oct 43), ACofS OPD WDGS to TAG, 1 Feb 44, sub: Hosp in the Asiatic Theater (Beds). HRS: G-4 file, "Hosp and Evac Policy."
11(1) Memo, [Col] R[obert] B. S[kinnerl for Record, 26 Aug 43. Ground Med files: Chronological file (Col Skinner). (2) Memo, Act ACofS OPD WDGS for DepCofSA, 28 Aug 43, sub: Surv of the Orgn and Opr of the MD. HRS: OPD, 700 "ETO." (3) Memo, Col A[rthur] B. Welsh for Record, 7 Sep 43. SG: 632.-2.
218
cial provision had to be made for the hospitalization ofChinese troops in the Asiatic theater. For the Chinese Army in India (which hadan authorized strength of 57,000) beds were authorized in evacuation hospitalson a 2-percent ratio; and for the Chinese Army in China, beds were authorized inportable surgical hospitals at the rate of one such unit for each oftwenty-seven divisions.12
Ratios of mobile beds authorized at this time remainedunchanged during the war;13 but some theatersnever received full quotas and therefore had to improvise mobile hospitals,while others found it desirable to use, in addition to authorized mobilehospital units, some fixed hospital units (field hospitals) as mobile hospitals.14
Efforts to Provide Theaters With Authorized Quotas ofBeds
After bed ratios and evacuation policies were established,adjustments had to be made in hospital facilities in each theater. Some, notablythe South Pacific, Central Pacific, and European theaters, had less than theirauthorized quotas of mobile beds. Others, the Southwest Pacific, Asiatic, andNorth African, had more.15 A few areas, forexample Alaska and the Middle East, had more fixed beds than authorized, whileothers-the European, North African, Pacific and Asiatic theaters-had fewer.16Theaters that had too many mobile and too few fixed beds were permittedeither to convert excess mobile hospital units into fixed hospital units, as wasdone in the Southwest Pacific area,17 or to usemobile units as fixed units, without conversion or reorganization, as was donein the Asiatic and North African theaters.18
When these changes did not erase deficits of fixed beds,other methods of increasing capacities were employed. The most obvious was tosend additional hospital units to theaters. Between September and December 1943,24 general hospital units, 10 field hospital units, and 39 station hospitalunits were shipped from the United States,19but they were insufficient to supply all theaters with authorized bedcapacities.
Another method was to enlarge hospitals already in theatersby increasing capacities authorized various units by tables of organization andequipment. This was economical of personnel. In the fall of 1943 a 750-bedstation hospital, for example, required 40 officers (of whom 24 were MedicalCorps officers), 75 nurses, and 392 enlisted men, while three 250-bed
12(1) Memo OPD 632 (19 Sep 43), ACofS OPD WDGS for DepCofSA, 24 Sep 43, sub: Hosp-Asiatic Theater. HRS: WDGSA 632. (2) DF OPD 632 (22 Oct 43), ACofS OPD WDGS to TAG, 1 Feb 44, sub: Hosp in the Asiatic Theater (Beds). HRS: G-4 file, "Hosp and Evac Policy."
13Memo SPMDA 322.05, SG for SecWar, 10 Jan 45, sub: The Med Mission Reappraised. HRS: G-4 file, "Hosp and Evac, vol. II."
14These developments will be discussed fully in a volume planned for this series on hospitalization and evacuation in theaters of operations.
15Table Showing Mobile Hosp Units in Theaters, Tab X to Memo, Act ACofS OPD WDGS for DepCofSA, 28 Aug 43, sub: Surv of Orgn and Opr of the MD. HRS: OPD, 700 "ETO."
16See Chart 11.
17(1) Memo OPD 320.2 (5 Oct 43), ACofS OPD WDGS for CG ASF, 9 Oct 43, sub: Evac Policy for Overseas Comds (Hosp Units). SG: 320.2. (2) Ltr AG 322 (14 Oct 43) OB-I-SPMOU-M, TAG to Comdr-In-Chief SWPA, 18 Oct 43, sub: Reorgn and Redesignation of Certain Hosp Units, SWPA. SG: 320.3-1.
18(1) DF OPD 632 (22 Oct 43), ACofS OPD WDGS to TAG, 1 Feb 44, sub: Hosp-Asiatic Theater (Beds). HRS: G-4 file, "Hosp and Evac Policy." (2) Rpt, Asst Comdt MFSS, Carlisle Bks to SG, 29 Nov 43, sub: Visit to ETO and NATO, 1 Sep-24 Oct 43. SG: 333.1.
19An Rpt, MOOD SGO, FY 1944. HD.
219
station hospitals required 63 officers (of whom 39 wereMedical Corps officers), 90 nurses, and 450 enlisted men.20For this reason the Surgeon General's Office had proposed as early as thesummer of 1943 that from 662/3 to 80 percent ofall fixed beds should be in general hospitals (1,000-bed capacity) and theremainder in smaller units.21 In the fall of1943 the Central Pacific theater enlarged the table-of-organization capacitiesof some of its hospitals in order to provide additional fixed beds with aminimum of additional personnel,22 andin December 1943 The Surgeon General asked other theaters to do likewise.23
A third method of increasing numbers of fixed beds was toexpand hospitals beyond table-of-organization capacities-that is, to have a1,000-bed general hospital, for example, set up beds and temporarily care formore than 1,000 patients without any increase in personnel. Anticipated in theprovision that theaters be authorized 50-percent expansion equipment, thismethod was used in many instances, particularly in the Southwest Pacific andNorth African theaters, in the fall and winter of 1943.24
If bed capacities were not increased sufficiently by thesemeans, theaters were permitted temporary "reductions" in officialevacuation policies to enable them to transfer more patients to the UnitedStates. The South Pacific theater, for example, operated under a 60-dayevacuation policy until January 1944 and changed to a 90-day policy in February,while the North African theater followed a 90-day policy until May 1944.25
Although some theaters objected to using the expedientsdiscussed above,26 all succeeded inmeeting hospitalization needs during the winter of 1943-44. While none having adeficit of fixed beds in the fall of 1943 reached its authorized quota by theend of the year, only one-the North African theater-had more patients thanit did table-of-organization beds.27
While efforts were being made to supply theaters withauthorized quotas of fixed beds, the Surgeon General's Plans Division waslooking toward the future. As theaters built up troop strengths and plannedcombat operations, they called upon the War Department for specific types andnumbers of units to meet anticipated needs. The OPD and G-3 Divisions of theGeneral Staff, attempting to meet theater requests if possible, periodicallyissued a "Six Months Forecast"-a document showing units needed andthe time
20See T/O 8-560, Sta Hosp, 22 Jul 42 with C 1, 5 Sep 42, and C 2, 18 Sep 42.
21(1) Draft Rad, CG ASF to CGs NATO, SWPA, USAF CBI, SPA, and ETO, 21 Jun 43. HD: Wilson files, "Day File, Jun 43." (2) Memo for Record on Draft Memo, Asst to CofS ASF for ACofS OPD WDGS, 23 Jun 43, sub: Proposed Rad for Certain Overseas Theaters Concerning Fixed Hosp Policy. Same file. It is not readily apparent how such a percentage could be applied generally, unless the essential difference between functions of general and station hospitals were to be ignored.
22Ltr AG 322 (24 Sep 43)OB-I-SPMOU-M, TAG to CG USAFCPA, SG, and Chiefs of Tec Servs, 28 Sep 43, sub: Reorgn of Sta and Gen Hosps in CPA. SG: 320.3-1.
23(1) Diary, MOOB SGO, 4-10 Dec 43. HD: 024.7-5, "MOOB Diary." (2) Rad CM-OUT-8738 (23 Dec 43), CG ASF to theater commanders. SG: 322.15-1.
24(1) Notes atchd to Memo, Col William L. Wilson, MC for Chief Control Div [SGO], 1 Nov 43, sub: Visit to SWPA. SG: 333.1-1 (Aust)F. (2) Rad CM-IN-9494 (15 Jan 44), Algiers to AGWAR, 14 Jan 44. SG: 322.15-1.
25(1) Rad CM-IN-18720 (25 May 44), CG NATO to WD, 24 May 44. HRS: G-4 file, "Hosp and Evac Policy." (2) Rad CM-OUT-42858 (28 May 44), WD to CG NATO, 27 May 44. Same file.
26Theater objections will be discussed in a volume planned for this series on hospitalization and evacuation in theaters of operations.
27See Chart 11.
220-221
CHART 11-FIXED HOSPITAL BED CAPACITY, ANDOCCUPANCY IN OVERSEAS THEATERS: MARCH 1943-DECEMBER 1945
222
of their shipment.28 Hospitalunits listed in the "Forecast" did not always exist in this country,and it was sometimes necessary to make adjustments among units alreadyactivated. The Surgeon General's Plans Division proposed such action. Forexample, in November 1943 the Mobilization and Overseas Operations Branch made astudy of units required by the eighth revision of the "Forecast" andfound that more station hospital units of 750-, 250-, 200-, 150-, 100-, and25-bed capacities had been activated than were needed but that fewer general andfield hospital units had been activated than were required. The Surgeon General'sOffice then recommended the inactivation and reorganization of certain stationhospital units in order to supply personnel for the required number of generaland field hospitals.29 ASF headquartersapproved this recommendation and orders were issued to make it effective. Atsuccessive times later, as for example in September 1944, the Surgeon General'sOffice suggested similar action to insure the availability of units in the typesand sizes desired by theaters.30
In addition to recommending adjustments among types ofhospital units being prepared for overseas service, the Surgeon General'sOffice took other actions in the fall of 1943 to meet future needs. After theDeputy Chief of Staff authorized 50-percent expansion equipment for fixedhospitals in theaters, the Mobilization and Overseas Operations Branchco-operated with the Supply Service of the Surgeon General's Office insecuring authority to procure the equipment thus authorized.31In addition, the troop basis of 1944 was reviewed and G-3 agreed to increase thenumber of fixed hospital units included in it to provide 20,000 additional beds.Even so, the troop basis did not list enough units to supply all theaters withquotas authorized by the Deputy Chief of Staff in August 1943.32Finally, and not of least importance, under a system of telegraphic reportinginitiated in July 1943, the Surgeon General's Office began to receive fromtheaters fuller, more accurate, and more current data on which to base studiesof admission rates.33
Problems encountered in the fall and winter of 1943 inproviding theaters with authorized quotas of fixed beds were merely a preview of1944. The increasing scope and intensity of combat operations created morepressing needs for hospitalization and at the same time, by using up morepersonnel in the form of replacements, accentuated the shortage of men forassignment to hospital units. From the early part of 1944 this shortage was sogreat that it became one of the controlling factors in planning overseashospitalization. Early in February 1944 the Surgeon General's Office warnedASF headquar-
28An example of this document, Twentieth Revision of the Six Months Forecast, Units and Availability, Data as of 20 Oct 44, Based on OPD Reqmts 5 Oct 44, G-3 Div WDGS is on file HD: 370.5.
29(1) An Rpt, MOOD SGO, FY 1944. HD. (2) Diary, MOOB, 27 Nov-3 Dec 43. HD: 024.7-5, "MOOB Diary." (3) Ltr, SG to CG ASF, 5 Nov 43, sub: Activations, Reorgns and Inactivations of Non-Div Med Units. SG: 322.3-1.
30Ltr, SG to CG ASF, 8 Sep 44, sub: Reorgn of Med Units. SG: 320.3-1.
31(1) Memo, SG for ACofS OPD WDGS, thru CG ASF, 9 Dec 43, sub: Recommended Changes in Victory Program Trp Basis, Revision of 22 Nov 43, with ind. SG: 322.15-1. (2) Memo, Act Chief Sup Serv SGO for SG, 28 Dec 43, sub: Fixed Beds Overseas in Army Sup Program. SG: 632.-2. (3) Memo, Dep Chief Oprs Serv SGO for SG, 30 Dec 43. SG: 632.-2.
32Memo for Record on DF, ACofS G-3 WDGS to ACofS OPD WDGS, 26 Jan 44. HRS: G-3 file, 700-800.
33Memo WDGDS 6442, Act ACofS G-4 WDGS for CG ASF, 7 Sep 43, sub: Hosp in Overseas Theaters, with 1st ind, SG to ACofS G-4 WDGS, 17 Sep 43. SG: 701.-1.
223
ters that it would be impossible to meet theater requirementsunless enlisted men were supplied in sufficient numbers to activate and trainthe units authorized.34 Soon afterward ASFheadquarters informed G-3 that the Service Forces had 72,813 fewer men than wereneeded to activate units according to schedule and that 27,160 men were neededfor Medical Department units alone.35 Urgentrequests from ASF headquarters for more men were of little avail, and during thefirst four months of 1944 only 12 general, 1 station, and 11 field hospitalunits were activated. In May the Medical Department received its firstsubstantial allotment of personnel for numbered hospitals during 1944 andactivated that month 11 general and 3 field hospital units. Then, duringsubsequent months, as a result of the policy of releasing from zone of interiorinstallations men who were qualified for overseas service, additional men becameavailable, and during the five months beginning with June and ending withOctober 98 general, 8 station, and 43 field hospital units were activated.36Thus few hospital units were activated during 1944 until the latter halfof the year.
The Medical Department also had difficulty in procuringenough Medical Corps officers to man the units activated. As early as February1944 the director of the Surgeon General's Military Personnel Division statedthat there would not be enough Medical Corps specialists to staff hospitalsbeing sent overseas and that some units would have to be shipped withoutspecialists.37 A month later theSurgeon General's Office reported to ASF headquarters that physicians to staffforty general hospital units then in training could not be procured until Juneand that full officer strength for nine of the general hospitals activated inMarch would not be available until August.38
Use of Negro Hospital Units
The use of Negro personnel-doctors, nurses, and enlistedmen-to help relieve the general personnel shortage and meet theater needs forhospital units was complicated by existing policies and practices and by theattitude of theater commanders and surgeons.39Following a practice adopted early in the war-the organization of all-Negrounits to provide opportunities for the use of Negro doctors and nurses-the WarDepartment activated a third Negro hospital unit-the 335th Station Hospital-inAugust 1943. Meanwhile the 268th Station Hospital unit, which had been activatedfive months earlier, completed its training and in October 1943 embarked for theSouthwest Pacific.40
34(1) Ltr, SG to CG ASF, 15 Feb 44, sub: Projection of Non-Div Med Units. SG: 322.3-1. (2) An Rpt, MOOD SGO, FY 1944. HD.
35(1) Memo, CG ASF for ACofS G-3 WDGS thru ACofS OPD WDGS, 18 Mar 44, sub: Projection of Non-Div Med Units, with incls. HRS: Hq ASF, Lt Gen LeR. Lutes' file, "Hosp and Evac, Jun 43 thru Dec 46." (2) Memo, CG ASF for ACofS G-3 WDGS, 26 Mar 44, sub: Med Units. Same file.
36An Rpt, MOOD SGO, FY 1944. HD.
37Memo, Dir Mil Pers SGO for Chief Oprs Serv SGO, 12 Feb 44, sub: Staffing of Gen Hosp Destined for Shipment to ETO. SG: 320.3-1.
38Memo, Dir Mob Div ASF for Dir Plans and Oprs ASF, 25 Mar 44, sub: Status of Med Units. HRS: Hq ASF, Lt Gen LeR. Lutes' file, "Hosp and Evac, Jun 43 thru Dec 46."
39These questions will be discussed fully in John H. McMinn and Max Levin, Personnel (MS for companion vol. in Medical Dept. series), HD. Also see Ulysses Lee, The Employment of Negro Troops, forthcoming volume in UNITED STATES ARMY IN WORLD WAR II.
40(1) An Rpt, 335th Sta Hosp, 1944. HD. (2) Quarterly Rpt, 268th Sta Hosp, Jul 44. HD.
224
With the need to use Negro personnel increasing asdifficulties in meeting theater requirements mounted, the War Department inJanuary 1944 requested all theaters to state whether or not they would useall-Negro hospital units. Most replied negatively. Fearing loss of the servicesof the 335th Station Hospital unit, The Surgeon General in May 1944 appealed toASF headquarters for "efforts [to] be made to obtain an appropriateassignment" for it.41 The same month he appealed personally tothe chief surgeon of the European theater to use Negro nurses in at least onehospital.42 The chief surgeonagreed, and in July 1944 sixty-three Negro nurses, among whom were some who hadformerly served with the 25th Station Hospital in Africa and had been returnedto the United States at the end of 1943, arrived in the European theater. Aftera period of training they were assigned in September to replace white nurses inthe 168th Station Hospital.43
Meanwhile an assignment for the 335th Station Hospital hadbeen found. In June 1944 the chief surgeon of the China-Burma-India theater madea trip to Washington to explain in person his desperate need for additionalhospital units. Among the means of meeting the need, in view of the generalshortage of units for shipment overseas, the low priority of theChina-Burma-India theater, and the demands of other theaters, the use of the335th Station Hospital was proposed. The theater surgeon agreed to accept thisunit with an overstrength of sufficient size to permit the organization of anadditional hospital in the theater.44 Asa result the 335th Station Hospital embarked in August 1944 and was stationed onthe Stillwell Road after its arrival in Asia. According to plan, it wasreorganized in December 1944 and its capacity was reduced from 150 to 100 beds.The personnel thus made surplus, along with that carried as overstrength, wasused to form another 100-bed all-Negro hospital unit-the 383d StationHospital. Both units continued to serve together as one hospital until the 383dwas sent to the Philippines in August 1945.45
Thus, although Negroes served in the Medical Departmentoverseas in organic medical units of divisions and in such other units assanitary companies, the use of Negro professional personnel in hospital unitswas limited to the 25th Station Hospital (a Negro unit with four white officersin command and supervisory positions), the 268th, 335th, and 383d StationHospitals (all-Negro units), and the 168th Station Hospital (a white unit withNegro nurses).
Estimating Requirements for Major Combat Operations
Before the full impact of personnel shortages was felt, theSurgeon General's Office began early in 1944 to estimate hospitalization andevacuation requirements for full-scale combat operations. In November andDecember 1943 the Com-
41Memo, SG for Dir Planning Div ASF, 17 May 44, sub: Overseas Employment of 335th Sta Hosp (Colored). AG: 370.05 (335th Sta Hosp)1944-I.
42Ltr, SG to Chief Surg, ETOUSA, 16 May 44. HD: ETO file, "Kirk-Hawley Corresp."
43An Rpt, 168th Sta Hosp, 1944. HD.
44(1) Memo for Record, 30 Jun 44, sub: Hosp in CBI, by Chief Theater Br MOOD SGO. HD: 024 "MOOD (CBI)." (2) Ltr, Col Robert P. Williams, Theater Surg USAF in CBI to Col George E. Armstrong, Dep Theater Surg USAF in CBI, 30 Jun 44. Same file. (3) Interv, MD Historian with Brig Gen Robert P. Williams, 13 and 15 Feb 50. HD: 000.71.
45(1) An Rpt, 335th Sta Hosp, 1944. HD. (2) Final Rpt, 383d Sta Hosp, Jul 45. HD. (3) AG Unit Card, 383d Sta Hosp. Orgn and Directory Sec, Oprs Br, Admin Servs Div, AGO.
225
bined Chiefs of Staff met with President Roosevelt and PrimeMinister Churchill at the SEXTANT conference in Cairo and then with thePresident, the Prime Minister, and Marshal Stalin at Teheran.46The decision of these conferences to mount both OVERLORD (the invasion of Europefrom England) and ANVIL (the invasion of Southern France from bases in theMediterranean) during May 1944 focused attention on the European and NorthAfrican theaters,47 and twice during the winterof 1943-44 the Surgeon General's Office made studies of their need forhospital beds. On the basis of the first, made by the Mobilization and OverseasOperations Branch,48 The SurgeonGeneral recommended to ASF headquarters that North Africa be supplied withadditional hospital units and with additional personnel for existing units toraise its bed capacity to its authorized quota, and to G-4 that the current bedratios of both the European and North African theaters be raised.49Both recommendations were disapproved. OPD was handling requests fromNorth Africa for additional personnel and hospital units. Because of theshortage of personnel in the United States, it proposed that the North Africantheater increase is fixed-bed capacity by using personnel already in the theaterto expand existing hospitals.50 G-4 disapprovedraising current bed ratios because it believed hospital units supplied underthem would provide sufficient beds for the early phases of operations on theEuropean continent. If additional beds should then be needed, they could be sentlater. Meanwhile, both theaters could use expansion equipment to increasecapacities of existing hospitals for emergencies, and the European theater, ifit should have a shortage of beds, could reduce its evacuation policy from 180to 120 days and thus send a larger proportion of patients to the United States.51
The Surgeon General "strongly urged" that thedecision not to send additional personnel and units to North Africa bereconsidered. He concurred in the decision not to raise bed ratios, butrecommended that it be considered temporary, pending accumulation of moredefinite information about needs. Furthermore, he warned that evacuationfacilities (ships and planes) would have to be adequate to remove patients fromtheaters if they were not given additional beds.52Meanwhile, his office had begun another study of the needs of overseastheaters.
The second study, made by the Facilities Utilization Branchof the Hospital Administration Division in connection with its attempt toestimate the number of beds that would be needed in the United States, coveredestimated requirements of
46Biennial Report . . . Chief of Staff, 1943-45, p. 27.
47Memo SPOPP 337, Dir Plans and Oprs ASF for Dir Sup and Mat ASF; Chiefs of TC et al., 15 Dec 43, sub: Sextant Decisions. HRS: Hq ASF Planning Div Program Br file, "Gen, vol. 2, 17 Jul 44." The invasions actually occurred later than planned.
48(1) Diary, MOOB SGO, 11-17 Dec 43. HD: 024.7-5, "MOOB Diary." (2) DF WDGDS 9381, ACofS G-4 WDGS to ACofS OPD WDGS and CG ASF, 11 Jan 44, sub: Fixed Bed Hosps, NATO and ETO. HRS: G-4 file, "Hosp and Evac Policy."
49Memo, SG for Dir Planning Div ASF, 17 Jan 44, sub: Serv Units for NA Forces. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3."
50Rad CM-OUT-8230 (21 Jan 44), ACofS OPD WDGS to CG NATO, 20 Jan 44. SG: 322.15-1.
51DF WDGDS 9381, ACofS G-4 WDGS to ACofS OPD WDGS and CG ASF, 11 Jan 44, sub: Fixed Bed Hosps, NATO and ETO. HRS: G-4 file, "Hosp and Evac Policy."
52(1) Memo, SG for CG ASF, 17 Feb 44, sub: Serv Units for NA forces. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3." (2) T/S, SG to ACofS G-4 WDGS thru CG ASF Planning Div, 9 Feb 44, sub: Fixed Bed Hosps, NATO and ETO. SG: 632.2.
226
all theaters as well as of the United States forhospitalization and evacuation facilities. Among the general conclusions drawnfrom this study were the following: under existing plans there would be ashortage of beds in both the European and North African theaters after themounting of OVERLORD and ANVIL; the number of patients that would be broughtback to the United States each month would rise to 40,000, of whom 60 to 70percent would be in the "helpless" category; there would be a shortageof space on transports and hospital ships for evacuation from the European andNorth African theaters; using only the evacuation facilities planned, not morethan 20 percent of all patients would be returned on hospital ships; and airevacuation offered little promise of supplementing ships in view of pastaccomplishments.53 Ultimately actionwas taken upon each of these problems, but only those pertaining to theaterhospitalization will be discussed at this point.
Decisions concerning overseas hospitalization were made at aconference on 28 March 1944. At that time General Somervell directed (1) thatthe number of beds supplied to Europe and North Africa under existing ratiosshould be increased, (2) that the General Staff should be requested to raise theauthorized ratio for North Africa from 6.6 to 8.5 percent, and (3) that bedrequirements for all theaters should be reviewed.54Plans to supply additional beds to Europe and North Africa were colored bythe shortage of personnel and of trained hospital units in the United States. Tofurnish the European theater with a total of ninety-one general hospitals by theend of July, some had to be shipped before completion of training.55The shortage of fixed beds in North Africa was alleviated, as OPD had suggestedearlier, by expanding table-of-organization capacities of existing hospitalswith personnel available in the theater. With War Department approval, thattheater inactivated six 250-bed station hospitals and with personnel formerlyassigned to them expanded twelve 1,000-bed general hospitals to 1,500-bedcapacities and five to 2,000-bed capacities. This increased the fixed-bedcapacity by 9,500 beds and brought the ratio of available beds to troops up to6.4 percent.56
The question of raising the ratio for North Africa becameinvolved in a general review of bed requirements for all theaters because theGeneral Staff refused to consider the former before completion of the latter.57Prepared by the ASF Planning Division and the Strategic Logistics PlanningUnit of the Surgeon General's
53(1) Hosp and Evac: A Re-estimate of the Pnt Load and Facilities, Feb 44. HD: 705.-1. (2) Memo, SG for CG ASF, 22 Feb 44, sub: Hosp and Evac. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3."
54(1) Memo, CG ASF for Dir Planning Div ASF, 28 Mar 44, sub: Hosp. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3." (2) Memo, CG ASF for Dir Plans and Oprs ASF, 28 Mar 44, sub: Conf on Hosp and Evac. Same file.
55Memo, Chief Program Br Planning Div ASF for Col Bogart, ASF, 4 Apr 44, sub: ETO Hosp. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3."
56(1) Rad CM-IN-16542 (23 Mar 44), CG USAF NATO to WD, 23 Mar 44, sub: Expansion of Hosp. SG: 322.15-1. (2) Rad CM-OUT-20160 (7 Apr 44), War (OPD) to CG USAF NATO, 7 Apr 44. Same file. (3) Memo SPOPI 632, Dir Plans and Oprs ASF for ACofS G-3 WDGS, 29 Mar 44, sub: Expansion of Gen Hosps in NATO. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3."
57(1) Memo, CG ASF for CofSA, 30 Mar 44, sub: Deficiency of Fixed Hosp Units in NATO. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, Apr 44." (2) Memo WDGSA/371 NATO (31 Mar 44), CofSA for CG ASF thru ACofS OPD WDGS, 4 Apr 44, sub: Deficiency of Fixed Hosp Units in NATO. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3."
227
Office, the general review was presented to the General Staffon 10 April 1944.58 It was based uponrecommendations of theaters, the average occupancy of beds in theaters duringthe previous six months, and the number of hospital units included in the troopbasis. It represented an attempt to balance bed requirements against the numberof hospital units already authorized.
Most of its proposals were accepted by G-4: that the bedratio of the Southwest Pacific should be reduced from 10 to 8 percent, and ofthe Central Pacific from 7 to 5 percent, and that ratios for the European,Middle East, and American theaters should remain unchanged. G-4 rejected theproposal to raise the North African bed ratio above 6.6 percent, stating thatthe theater had gotten along satisfactorily on it and that the invasion ofSouthern France was uncertain. North Africa's later request (in May 1944) tochange its evacuation policy from 90 to 120 days indicates that this decisionwas justified. G-4 also believed that the South Pacific ratio should be reducedfrom 10 to 6 percent (since the theater itself had recommended only 5 percent)instead of to 7 percent as ASF headquarters and the Surgeon General's Officeproposed. While the two latter authorities recommended that theChina-Burma-India ratio be reduced from 8 to 7 percent, G-4 thought that bedsfor the Chinese Army in India should remain at 8 percent and that the ratio forAmerican troops only should be reduced to 7 percent.
The Deputy Chief of Staff approved G-4's findings. Thismeant that 351,528 of the 370,500 beds in units in the troop basis would bedistributed among theaters, but that the remainder (18,972 beds) would be heldin the United States as an undeployed reserve to meet unforeseen contingencies.59
Movement To Reduce Authorized Bed Ratios
Continuing Difficulty in Providing Authorized Quotas of Beds
Although beds authorized for theaters in the spring of 1944 didnot exceed the number in hospital units in the troop basis, personnel shortagesmade it difficult to supply theaters with authorized quotas. A method formerlyused-expansion of the table-of-organization capacities of the hospitalsalready in theaters-was applied again, particularly in the Southwest Pacific,where the closure of small hospitals released enough officers to expandcapacities of larger hospitals by 7,250 beds and to permit the assignmentelsewhere of 259 Medical Corps officers.60Occasionally, reductions in bed ratios and in troop
58(1) Memo, Dep Dir Plans and Oprs ASF for CG ASF, 4 Apr 44, sub: Overseas Hosp. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, vol. 3." (2) Memo, Dir Strategic Logistics Planning Unit SGO for Chief Oprs Serv SGO, 6 Jun 44, sub: Rpt of Accomplishments of SGO. HD: 319.1-2 (MOOD Oprs Serv SGO).
59(1) Memo, CG ASF for CofSA thru ACofS G-4 WDGS, 10 Apr 44, sub: Overseas Hosp, with Tabs A-F. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac, Apr 44." (2) Memo WDGS 13077, ACofS G-4 WDGS for CG ASF, 27 Apr 44, sub: Overseas Hosp. HRS: Hq ASF Planning Div Program Br file, "Staybacks, 14 Apr-8 Aug 44." (3) Memo, Dep Dir Plans and Oprs ASF for SG, 29 Apr 44, sub: Overseas Hosp. Same file. (4) Rad CM-OUT-42858 (28 Mar 44), Marshall to CG USAF NATO, 27 May 44. HRS: G-4 file, "Hosp and Evac Policy."
60(1) Memo for Record, by Lt Col Lamar C. Bevil, SGO, 4 Jul 44, sub: Conf with Surg SOS SWPA. SG: MOOD "Pacific." (2) Memo, Dep Chief Oprs Serv SGO for SG, 5 Sep 44, sub: Anal of CM-IN-2287 (3 Sep 44) for SWPA. Same file. (3) An Rpt, MOOD SGO, FY 1945. HD.
228
strengths of one theater released hospital units for transferelsewhere. In the summer of 1944, for example, units no longer needed in theSouth Pacific area were transferred to the China-Burma-India, Central Pacific,and Southwest Pacific theaters.61 Moreover, changes in the zone ofinterior hospital system were expected not only to use personnel moreefficiently at home but also to release some physicians for assignment to unitsearmarked for theaters. In addition, ratios of doctors, nurses, and enlisted mento beds were decreased in numbered hospital units as well as in zone of interiorhospitals.62 Furthermore, hospitals were "short-shipped" tothe European theater-that is, before completion of training and withoutbalanced or full staffs of physicians. In such cases, the theater was expectedto complete the training of units and to supply missing specialists and otherMedical Corps officers. Such personnel was believed to be available from severalsources: from affiliated hospital units overstaffed with specialistsand already in the theater, from hospital units in the theater that were beingreorganized under revised tables of organization; and from infantry regimentswhere Medical Administrative Corps officers were replacing Medical Corpsofficers as battalion surgeons' assistants.63Finally, it wasrecognized that authorized bed quotas of theaters in some instances could not bemet even by expedients just discussed, and that a theater would then have"to take care of its own requirements."64
Review of Requirements of European Theater
As difficulties were encountered in the summer and early fall of 1944 in meetingauthorized fixed-bed quotas, The Surgeon General'sMobilization and Overseas Operations Division began to review the needs oftheaters to see if estimates had been too high and if authorized bed ratiosmight therefore be lowered. As early as July 1944 there were "preliminaryindications" that ratios authorized for both the European and the SouthwestPacific theaters could be lowered,65 but a directive of the DeputyChief of Staff that requirements of the European theater be reviewed 30 daysafter the initial landing in France (or the mounting of OVERLORD)
61(1) Rad WARX 62981, Marshall to Comdr-in-Chief SWPA;CG USAF CPA; CG USAF SPA; CG USAF CBI, 10 Jul 44, sub: Movement of Ptbl Surg Hosp in Pacific. (2) Rad WARX 72125, Marshall to CG USAF CBI, 26 Jul 44, sub: Departure of 18th and 142d Gen Hosps from SPA. (3) Rad CM-IN-25976, CG USAF SPA to WD and CG USAF CPA, 31 Jul 44. All in SG: 322 "Hosp Misc 1944."
62See below, pp. 181-99, 248-50.
63(1) Mins, Mtg of Staff Conf ASF, 13 Jul 44, incl 4 to Memo SPOPP 320.2, Act Dir Plans and Oprs ASF for ActCofS ASF, 21 Jul 44, sub: Status of Hosp units. HRS: Hq ASF Planning Div ProgramBr file, "Hosp and Evac, vol. 3." (2) Rad CM-OUT-34789 (10 May 44),Marshall (OPD) to Eisenhower, 10 May 44. SG: 320.3. (3) Rad CM-IN-11147(15May 44), CG USF ETO to WD, 15 May 44. Same file. (4) Memo, Dep SG for CG ASF, 27 Jul 44. HD: MOOD "ETO." (5) Rad CM-OUT-77546 (8 Aug 44), Marshallto Eisenhower, 8 Aug 44. Same file. (6) Rad CM-IN-2778 (30 Aug 44),Eisenhower to WD, 29 Aug 44. Same file. (7) Memo, SG for ACofS OPD WDGS thru CGASF, 31 Aug 44, sub: Hosp in ETO. Same file. (8) Memo, SG for CG ASF, 5 Oct 44. SG: 322 "Hosp Misc 1944."
64(1) Memo with Memo for Record, Dir Plans and OprsASF for Joint Logistics Plans Cmtee, 6 May 44, sub: Med Reqmts-Twentieth AF.HRS: Hq ASF Planning Div file, "Hosp and Evac." (2) Memo, Lt Col LamarC. Bevil for Col Arthur B. Welsh, 18 Aug 44, sub: Est of Med Situation in CBI.HD: MOOD "CBI." (3) Draft rad, ACofS OPD WDGS to CG USAF NATO, 12 Jul44, with Memo for Record. HRS: OPD, 632 "Security Sec I."
65Memo, Act Dir Plans and Oprs ASF for Act CofS ASF, 25 Jul44, sub: Hosp Reqmts, ETO. HRS: Hq ASF Planning Div Program Br file, "Staybacks, 15 Apr 44-8 Aug 44."
229
focused attention upon that theater.66
During July 1944 the Surgeon General's Office analyzedreports of hospital admissions for the first 32 days of operations in France andcomputed actual hospital admission rates for that period. This analysis showedthat the average battle-casualty rate had been lower than anticipated-51 per1,000 per month instead of 60-although during one week it had been as high as89 per 1,000. Other studies showed that the average length of time that patientsstayed in hospitals in the North African theater between the fall of 1942 andthe middle of 1944 was 23.7 days. This was shorter than the average in Europeduring World War I-27.29 days. If admission rates in the future shouldapproximate those of the 32-day period of operations in France and if theaverage number of days patients stayed in hospitals should be as low as in theNorth African theater, the European theater would need fewer beds than at firstanticipated. The Surgeon General's Office computed the number that would berequired under a variety of combinations of admission rates, lengths of stay,and evacuation policies, and then calculated bed ratios that might be requiredunder different sets of circumstances. It appeared that, under a 180-dayevacuation policy, the highest ratio that would be needed under the mostunfavorable circumstances was 12.05 percent and the lowest, under more favorablecircumstances, was 5.46. Under a 120-day policy, the highest would be 8.06 andthe lowest, 3.90 percent. It was thought that such ratios would providesufficient beds not only for all patients hospitalized by the Army, includingcivilians and prisoners of war, but also for their dispersion in wards. TheSurgeon General therefore considered it safe to reduce the bed ratio of the European theater from 8 to 7 percent if at the sametime the evacuation policy should be reduced from 180 to 120 days.67
ASF headquarters arrived at the same conclusion after takinginto consideration certain additional facts. General and convalescent hospitalsin the United States had about half of their beds empty during the first half of1944.68 At the same time, the European theater was not sending to the UnitedStates as many patients as it could on returning troop transports.69Presumably a reduction in the evacuation policy would require the theater toreturn a great number of patients to the zone of interior and would thereforeresult in fuller use of available evacuation space on transports and of hospitalbeds in the United States. It would also make possible a reduction in the bedratio of the European theater and, consequently, in the number of hospital unitsthat would have to be sent there. In view of these considerations, ASFheadquarters recommended on 11 August 1944 that the authorized bed ratio for theEuropean theater be reduced from 8 to 7 percent and that its evacuation policybe lowered from 180 to 120 days.70 The Deputy Chief of Staffap-
66Memowith Memo for Record SPOPP 337, Plans and Oprs ASF for ACofS OPD WDGS, 1 Jul 44, sub: Fixed Hosp Data, with incls. HRS: Hq ASF Planning Div,"Hosp and Evac."
67(1) Ltr, SG to CG ASF, 1 Aug 44, sub: Overseas Hosp, with 2incls. HRS: Hq ASF Planning Div Program Br file, "Hosp and Evac." (2)An Rpt, MOOD SGO, FY 1945. HD.
68See above, pp. 202-07.
69Memo, SG for ACofS OPD WDGS thru CG ASF, 31 Aug 44, sub:Hosp in ETO. HD: 705 (MRO Fitzpatrick Staybacks, 1 May 44-29 Oct 44).
703d ind SPOPP 370.05 (8 Aug 44), Plans and Oprs ASF to ACofSG-4 WDGS, 11 Aug 44, with Memo for Record, on Ltr, SG to CG ASF, 1 Aug 44, sub:Overseas Hosp. HRS: Hq ASF Planning Div, "Hosp and Evac."
230
proved this recommendation and the War Department informedthe theater of the changes on 5 October 1944.71
Shift of Attention to the Pacific
The review of fixed-bed requirements of the European theaterhad hardly been completed when the Chief of Staff of the Army Service Forces,returning from a visit to the Pacific, turned attention in that direction.72He reported that increased operations against islands nearer the Japanesehomeland and the necessity of caring for civilians on such islands might requiremore hospitals than those already planned for the Pacific. ASF headquarters thendirected The Surgeon General on 8 September 1944 to re-examine plans forhospitalization and evacuation in that area.73
In complying with this directive The Surgeon General'sMobilization and Overseas Operations Division computed bed ratios by a differentmethod from that used for the European theater. From statistical reports itdetermined the actual ratio of occupied beds to troop strength during 1943 and1944 and to this ratio it added estimated ratios of beds to troop strength toprovide for casualties from increased combat operations, for dispersion withinhospitals, for dispersion of hospitals within theaters (that is, to permit somebeds to be vacant or unused either because hospitals were situated in placeswith little or no combat or because they were being moved from one place toanother), for soldiers of Allied armies, for prisoners of war, and for patientsevacuated from mobile hospitals to permit such units to move. For example, inthe Southwest Pacific area the ratio of occupied beds had been 3.75 percent; tothis ratio were added the following: 1.00 percent for increased operational requirements, .90 percent for hospital dispersion, .45percent for theater dispersion, .45 percent for Allied soldiers and prisoners ofwar, and .45 percent for patients from mobile hospitals.74 Thesum of these ratios was 7.00 percent and was considered the ratio of fixed bedsto troop strength that would be required for the Southwest Pacific area. Ratiosfor other areas of the Pacific were also computed according to this method andon 14 September 1944 The Surgeon General recommended a reduction in the ratiofor the Southwest Pacific from 8 to 7 percent and an increase in that for thePacific Ocean areas (a theater formed in August 1944 by the combination of theCentral and South Pacific areas) from 6 percent in the South Pacific and 5percent in the Central Pacific to 7 percent for the entire area. At the sametime he recommended that the 120-day evacuation policy should remain in effectand that the Army Medical Department should continue free of responsibility forthe care of civilians in occupied islands.75
71Memo AG 704 (30 Sep 44) OB-S-SPOPP, TAG for CG ETO,5 Oct 44, sub: Hosp and Evac Policy for the ETO. HD: MOOD "ETO."
72Memo, CofS ASF for SG, 27 Aug 44. HRS: Hq ASF PlanningDiv, "Hosp and Evac."
73Memo SPOPP 632.2, CG ASF for SG, 8 Sep 44, sub: Hosp and Evac,POA and SWPA. HRS: Hq ASF Planning Div, "Hosp and Evac."
74The reason for adding in the ratio of beds totroop strength to provide beds for patients evacuated from mobile hospital unitsto permit them to move is not clear. Actually, one of the chief functions offixed hospitals was to receive patients evacuated from mobile hospitals toinsure mobility. This had been pointed out by the Surgeon General's Office inAugust 1943, and as a result the General Staff had agreed that fixed- andmobile-bed requirements would be computed separately.
751st ind, SG to Dir Plans and Oprs ASF, 14 Sep 44, on Memo SPOPP 632.2, Dir Plans and Oprs ASFfor SG, 8 Sep 44, sub: Hosp and Evac, POA and SWPA. HRS: Hq ASF Planning Div, "Hosp andEvac."
231
ASF headquarters approved these recommendations, with minor modifications,but the General Staff took no final action upon them because a new study ofhospital bed requirements for all theaters soon superseded the study ofrequirements for the Pacific.76
The Manpower BoardEstimates Requirements
The drive of the War Department Manpower Board to save personnel by reducingthe number of hospitals in the Army-a drive which threatened the closure ofsome hospitals in the United States in the fall of 1944-extended tooverseas areas also.77 The method which the Board used to computetheater bed requirements differed from The Surgeon General's. The Boardproposed that the average noneffective rate (that is, the number of persons per1,000 per day unfit for duty because of sickness or other disability) beconverted into a ratio for authorizing fixed beds. Thus the number of authorizedfixed beds would equal but not exceed the number of noneffectives. The Boardcontended that this method would provide sufficient hospitalization for alltheaters, since beds were not actually needed for all noneffectives (some beingtreated in quarters) and since all hospitals could expand authorized capacitiesby 50 percent. If any theater should by chance accumulate more patients thanbeds, the Board stated, it could transfer greater numbers of patients to theUnited States, because in the Board's opinion evacuation facilities and zoneof interior hospital capacities already exceeded requirements. Arriving on thebasis of statistics published by the Surgeon General's Office at an averagenoneffective rate of 50, the Board concluded that not more than 250,000 beds were needed for the 5,000,000 troops in alltheaters of operations. It therefore advocated deleting from the troop basisfixed hospital units containing 120,000 beds in excess of this number.78
On the basis of this study, G-3 recommended on 29 September 1944 that allinactive general, station, and field hospital units (having authorizedcapacities totaling 44,000 beds) should be deleted from the troop basis; that nofurther fixed hospital units be sent to theaters of operations; that the activeunits in training in the United States, with a total authorized capacity of20,000 beds, be kept in this country in the strategic reserve; and that the bedrequirements of all theaters be restudied by 1 November 1944.79
Although OPD believed that these recommendations were "premature,"80 G-4 directed ASF headquarters on 11 October 1944 to make an immediatereview of fixed-bed requirements of all theaters on the basis of "thelatest and most complete current experience data available to The SurgeonGeneral" and warned that it was "particularly desired that no attemptbe made in this study to arbitrarily justify
76(1) Memo with Memo for Record SPOPP 370.05, CG ASF for ACofS OPD WDGS, 16Sep 44, sub: Hosp and Evac, POA and SWPA. HRS: Hq ASF Planning Div, "Hosp and Evac."(2) Memo WDGDS 3710, ACofS G-4 WDGS for DepCofSA, 5 Oct 44, sub: Hosps forSWPA and POA. HRS: OPD, 632 "Security Sec I."
77See above, pp. 203-05.
78Memo WDSMB 323.3 (Hosp) (25 Sep 44), WDMB for ACofS G-3 WDGS, 25 Sep 44,sub: Fixed Hosp Reqmts for Overseas Theaters. HRS: G-4 file, "Hosp andEvac Policy."
79Memo WDGCT 705.1 (29 Sep 44), ACofS G-3 WDGS for CofSA, 29 Sep 44, sub:Fixed Bed Reqmts. HRS: G-4 file, "Hosp and Evac Policy."
80DF, Act ACofS OPD WDGS to ACofS G-4 WDGS, 7 Oct 44, sub: Fixed BedReqmts, with Memo for Record. HRS: OPD, 632 "Security Sec I."
232
present figures on fixed bed hospitalization fortheaters."81
General Review of Bed Requirements
The study which the Surgeon General's Office prepared incompliance with the G-4 directive was impressive. It included estimates ofrequirements of all theaters arrived at by two methods-the "admissionrate" method used earlier for the European theater and the "bedsoccupied" method used earlier for the Pacific. Each was supposed to serveas a check on the other. All estimates were based upon certain principles orassumptions which the Mobilization and Overseas Operations Division consideredimportant. First, hospitals could operate with 50 percent more patients thanauthorized beds for only short emergency periods and hence expansion capacitiescould not be considered available for normal needs. Second, beds for dispersionwould be needed within hospitals and within theaters. Vacant beds in contagiouswards could not be used for surgical patients, for example, and some hospitalswould always be only partially filled because the shifting fortunes of wartemporarily left them on quiet fronts. Finally, though evacuation policies mightbe changed in emergencies to permit theaters to transfer larger proportions ofpatients to the United States, the maintenance of policies already establishedwas desirable.
As much as possible this study was based upon World War IIstatistics, but in some instances rates and ratios still had to be estimatedwithout the benefit of such data. For estimates by the "admissionrate" method the Mobilization and Overseas Operations Division used actualadmission rates for disease and nonbattle injury patients for the period fromJuly 1943 to June 1944 formost theaters. In some instances, these rates had to be adjusted. For example,the daily admission rate (the number of patients admitted to hospitals per 1,000men per day) for disease and nonbattle injuries for the Pacific Ocean area hadbeen 1.7, but in anticipation of higher disease incidence in future operationsnearer Japan an admission rate of 2 was used. While the length of stay inhospitals-also used in this method-differed from one theater and from onetime to another, ranging from 18 to 21 days, the actual average length of stayin hospitals in all theaters during World War II was used. In estimates ofrequirements by the "beds occupied" method the ratio of occupied bedsto theater troop strength during 1943 and 1944 was considered as a base to whichwere added ratios of beds for patients resulting from increased operations;those needed for transient, Navy, Allied, and prisoner-of-war patients; andthose required for dispersion. The ratio of occupied beds was actual, based onstatistical reports, but the other ratios were estimated.
Different ratios of beds for the same theater resulted fromthe use of the two methods of estimating requirements. For the European theaterunder a 120-day evacuation policy, for example, a ratio of 7.73 percent wasneeded according to estimates made by the "admission rate" method andof 7 percent according to the "beds occupied" method. Lower ratios ofbeds would be needed with 90-, 60-, or 30-day evacuation policies. Because zoneof interior hospitalization and evacuation
81DF WDGDS 3918, ACofS G-4 WDGS to CG ASF, 11 Oct 44, sub: Fixed Bed Reqmts for Overseas Theaters, with 1 incl. HRS: Hq ASF Planning Div, "Hosp and Evac." Also, SG: 632.2 "Bed Reqmts."
233
facilities had been planned on the basis of a 120-day evacuation policy andbecause such a policy seemed more economical of personnel and shipping thanlower ones, The Surgeon General recommended that the 120-day policy be continuedand that estimated ratios of beds required under it be approved. Those ratioswere the same as the ones already authorized for all theaters except theAmerican, China-Burma-India, Southwest Pacific, and Central Pacific. For thefirst three of these, The Surgeon General proposed reductions in ratios from 4,7, and 8 percent to 3, 6, and 7 percent respectively. For the last, he proposedan increase from 5 to 6 percent. In addition, he recommended that beds beprovided in hospital units in the strategic reserve for 4 percent of the troopsin that reserve. He proposed further that theaters be asked what evacuationpolicies and bed ratios they wanted and that, until their answers were received,no reduction should be made in the number of units in the troop basis, nopersonnel should be diverted from training for those units, and hospital unitsshould continue to be shipped overseas as planned. ASF headquarters approvedthis study and its recommendations.82
Faced with varying estimates of bed requirements made by the War DepartmentManpower Board and G-3 on the one hand and by the Surgeon General's Officeand ASF headquarters on the other, G-4 had the problem of considering both andof arriving at recommendations that could be presented to the Deputy Chief ofStaff for approval. As a result of conferences with representatives of TheSurgeon General and G-3,83 and of analyses of the differentstudies, G-4 arrived at a compromise which favored The Surgeon General and on2 November 1944 sent the following recommendations to the Deputy Chief of Staff: (1) thatthe bed ratios recommended by The Surgeon General be approved, with minorexceptions; (2) that the evacuation policies already authorized remain ineffect; (3) that the shipment of hospital units to the European theater beslowed down in order to permit them to be better staffed and trained and to seeif they were actually needed; and (4) that the four general hospital units andthe four field hospital units that were in the troop basis but were notscheduled by OPD for shipment to any theater be deleted. On 22 November 1944,the Deputy Chief of Staff approved G-4's recommendations. The bed ratiosthus authorized were as follows: for the European and Southwest Pacifictheaters, 7 percent; for the Mediterranean theater (formerly North African), 6.6percent; for the Pacific Ocean areas (formerly the Central and South Pacific), 6percent; for the Middle Eastern theater, 6 percent; for the China andIndia-Burma theaters, 6 percent for all American troops and for 102,000 Chinesetroops in India; and for the American theater, 3 percent.84
82(1) 1st ind, SG to CG ASF, 18 Oct 44, with Tabs A through D,on Memo SPOPP 370.05, CG ASF for SG, 13 Oct 44, sub: Fixed Bed Reqmts forOverseas Theaters, with 1 incl. (2) 1st ind SPOPP 705, CG ASF to ACofS G-4 WDGS,24 Oct 44, with Memo for Record, on DF WDGDS 3918, ACofS G-4 WDGS to CG ASF, 11Oct 44, sub: Fixed Bed Reqmts for Overseas Theaters. Both in HRS: Hq ASFPlanning div file, "Hosp and Evac."
83DF WDGDS 4602, Act ACofS G-4 WDGS to ACofS G-3 WDGS, 1 Nov44, sub: Fixed Bed Reqmts, with Memo for Record. HRS: G-4 file, "Hosp andEvac Policy."
84(1) Memo WDGDS 4434, Act ACofS G-4 WDGS for DepCofSA, 2 Nov 44, sub: Fixed Hosp Bed Allowances for Overseas Theaters, with Tab A. HRS: Hq ASF Planning Div, "Hosp and Evac." (2) Memo WDGDS 4477, ACofS G-4 WDGS for CG ASF, 22 Nov 44, sub as above. Same file.
234
This re-examination of the needs of theaters for fixed bedsachieved in part the desired end-saving of personnel through a reduction inthe number of hospital units the Army would have. While it was being made, theGeneral Staff deleted six general hospital units from the troop basis. Afterwardit deleted four more general and four field hospitals.85 These wereunits which OPD had not scheduled for shipment but which the Surgeon General'sOffice wished to hold in the United States as an undeployed reserve. Theshipment of hospital units to the European theater was also slowed down. Withthe concurrence of that theater, the General Staff planned to send 11 generalhospital units to Europe during the last two months of 1944, instead of 30 thatwere scheduled, and to send the remaining 19 early in 1945.86 Although theseactions may have helped the Medical Department, they did not solve all problemscaused by personnel shortages and it was still necessary to ship hospital unitswith less than full complements of personnel. For example, eleven of the generalhospitals sent to Europe during the winter of 1944-45 had no nurses assignedto them upon departure from the United States.87
Experiences of theaters in hospitalization from November 1944to May 1945 showed that enough fixed beds were supplied to meet actualrequirements. During this period only two theaters, the Southwest Pacific andthe Asiatic, failed to receive enough beds to fill authorized quotas. The othershad numbers that either exceeded quotas consistently or reached them and thenwavered slightly above or below. Even during periods when theaters had fewerbeds than authorized, they also had fewer patients than the number of fixed bedspresent, with one exception-the European theater. (See Chart 11.) In thewinter of 1944-45, its patient load increased rapidly and by January andFebruary 1945 the number of patients occupying fixed beds was greater than thenumber of normal beds present in the theater.88 For a short time,then, attention was centered upon this problem. (Table 14.)
The Problem of the European Theater in the Winter of 1944-45The situation in which there were more patients than normalfixed beds in the European theater arose from a variety of causes. DuringNovember and December 1944 hospital admissions increased rapidly. In addition,stoppage by the War Department in the fall of 1944 of the transfer (with fewexceptions) of prisoner-of-war patients to the United States resulted in theaccumulation of 14,000 German patients in theater hospitals by the end ofDecember. Furthermore, failure of the European theater to follow evacuationpolicies set by the War Department (because of a shortage of hospital ships andthe chief surgeon's opposition to the use of transports for evacuation)created a backlog of Army patients awaiting
85(1) Memo SPMDA 322.05, SG for SecWar, 10 Jan 45, sub:Med Mission Reappraised. HRS: G-4 file, "Hosp, vol. II." (2) Memo forRecord on Memo, CG ASF (SG) for CofSA, 17 Dec 44, sub: Adequacy of Hosp and Evac,ETO. HRS: Hq ASF Planning Div file, "Hosp and Evac."
86(1) Memo WDGDS 4434, Act ACofS G-4 WDGS for DepCofSA, 2 Nov 44, sub: Fixed HospBed Allowances for Overseas Theaters. HRS: Hq ASF Planning Div file, "Hosp and Evac." (2)MRS, Col Durward G. Hall (SGO) to Gen [George F.] Lull then Col A[rthur] B. Welsh then Col Carl [C.] Sox,14 Nov (1944?). SG: 322 "Hosp Misc."
87Memo, Chief Atlantic Sec Theater Br MOOD SGO for Record, 8Mar 45, sub: Substitution of Enlisted Technicians for Nurses in ETO Hosps. HD: MOOD "ETO."
88An Rpt, SG, FY 1945, pp. 53-54. HD.
235
TABLE 14-EVACUATION POLICIES AND AUTHORIZEDBED RATIOS, MAJOR THEATERS OF OPERATIONS
236
transfer to the zone of interior. Meanwhile, the theateractually had fewer fixed beds than it was credited with, because many of itsfield hospitals (normally counted as fixed hospitals) were being used asforward-area surgical hospitals and evacuation holding units.89 Informedof this situation early in December 1944,90 the General Staff, ASFheadquarters, and the Surgeon General's Office turned their attention to asolution of some of the theater's problems.
Difficulties of the War Department in meeting authorizedquotas of fixed beds for all theaters precluded shipment to Europe of morehospitals than already scheduled. Therefore, G-4 decided that the Europeantheater would have to care for prisoner-of-war patients in hospitals that weremanned primarily by captured German medical personnel. On 28 December 1944 theWar Department informed the theater of this decision,91 and byFebruary 145 it had in operation or in the process of organizationprisoner-of-war hospitals containing 13,000 beds.92
Failure of the theater to use vacant evacuation space ontroop transports threatened not only to continue to contribute to a shortage ofbeds in Europe and insufficient use of those in the United States but also tocreate a serious evacuation problem. If patients were not evacuated as theyaccumulated it would be difficult to get them out of the theater after thedefeat of Germany, because transports would then be diverted to the Pacific andhospital ships would be unable to move the patient load as rapidly as desirable.On 3 December 1944, therefore, the Chief of Staff of the Army ordered thecommanding general of the European theater to use all evacuation space ontransports, even if it required the theater to lower its evacuation policy to 90 days or less.93 As aresult, the theater evacuated patients under a 120-day policy in January, a90-day policy in February, and a 60-day policy in March and April.94 Bythus transferring a larger proportion of its patient load to the zone ofinterior, the European theater reduced its requirements for additional beds andcontributed at the same time to the more effective use of beds in generalhospitals in the United States.
To enable the theater to establish as many fixed beds as itwas credited with having, The Surgeon General proposed that it be authorizedadditional fixed beds to replace those in field hospitals being used as mobileunits.95 The General Staff approved this proposal, and on 25 December1944 the War Department authorized both the European and Mediterranean theatersto subtract from fixed-bed totals the beds in field hospitals being used asmobile units and to replace them by expanding table-of-organization capacitiesof station and general hospitals already present.96 Later, ASFheadquarters pro-
89(1) An Rpt, MOOD SGO, FY 1945. HD. (2) Interv MDHistorian with [Maj] Gen [Paul R.] Hawley, 18 Apr 50. HD: 000.71.
90Ltr SHAEF 704-3 Med, SHAEF to CofSA thru ACofS G-4 WDGS,4 Dec 44. SG: 632.2.
91Rad, ACofS OPD WDGS to CG ComZ ETO and CG USAF MTO, 28 Dec44. HRS: Hq ASF Planning Div, "Hosp and Evac."
92An Rpt, MOOD SGO, FY 1945. HD.
93(1) Memo, Col William B. Higgins (G-4) for ACofS G-4 WDGS, 4 Dec 44, sub: Evac from ETO. HRS: G-4 file, "Hosp and Evac Policy." (2) Rad CM-OUT-72113 (3 Dec 44), CofSA to CG ComZ ETO and CG UK Base Sec, 3 Dec 44. SG: 560.2.
94Administrative and Logistical History of the Medical Service, Communication Zone-ETO, Ch 13, "Evacuation," pp. 32-34. HD.
95Memo, SG for CG ASF, 13 Dec 44. HRS: Hq ASF Somervell file, "SG 1944."
96Rad OPD 632 (26 Dec 44), ACofS OPD WDGS to CG ComZ ETO and CG USAF MTO, 26 Dec 44, sub: Hosp. HRS: Hq ASF Planning Div, "Hosp and Evac."
237
posed that other theaters be given similar authority.97
In addition to the measures just discussed, at the suggestion of the Chief ofStaff G-4 sent to Europe one of its representatives, Col. (later Brig. Gen.)Crawford F. Sams, a Medical Corps officer, to discuss with the chief surgeon ofthe theater and the chief medical officer of SHAEF the most effective use of thebeds present.98 The situation in Europe was thereby so alleviatedthat by March it was possible to divert to the Pacific six of the generalhospitals scheduled earlier for shipment to Europe.99
Meeting the needs of theaters for hospitalization in the latter part of thewar was characterized by efforts to estimate requirements as realistically aspossible and by the necessity of using a variety of expedients to provide quotasof beds actually authorized. Establishment in the second half of 1943 ofofficial evacuation policies and bed ratios for various theaters placed planningon a sounder basis than formerly. The first ratios established were based onlypartially upon World War II experience; but as statistics of casualty anddisease incidence accumulated they were studied repeatedly to determine whetheror not ratios could be lowered. Though a reduction was at times possible, shortages of personnelcontinued to require some theaters to meet their quotas partially by expandingthe table-of-organization capacities of some units, using the emergencyexpansion of others, and employing units shipped from the zone of interiorincompletely trained and staffed. Toward the end of 1944 it was necessary toforce the European theater to observe War Department policies on evacuation inorder to relieve the load on theater hospitals by transferring part of it to theUnited States. That theater also had to use other expedients, such as theemployment of captured enemy personnel in the the treatment of prisoners of war,in order to have sufficient fixed beds for American Army patients.
97Memo SPOPP 705, Act Dir Plans and Oprs ASF for ACofS OPD WDGS, 5 Jan 43, sub: Adequacy of Hosp in TofOpns-Deletion of Fld Hosps from Auth Fixed Beds, with Memo for Record. HRS: Hq ASF Planning Div, "Hosp and Evac."
98(1) Memo, G. C. M[arshall] (CofSA) for [Lt] Gen [ThomasT.] Handy, 26 Dec 44. WDCSA: 632 A 414. (2) Interv, MD Historian with Brig GenCrawford F. Sams, 18 Jan 50. HD: 000.71.
99(1) Memo, Act CofS ASF for Dir Plans and Oprs ASF, 24 Mar 45, sub: Hosps in ETO. HRS: Hq ASF Control Div files, 323.3 "Hosps." (2) An Rpt, MOOD SGO, FY 1945. (3) Memo, Chief Planning Br G-4 WDGS for ACofS G-4 WDGS, 3 Apr 45, sub: Diversion of Hosps.HRS: G-4 files, "Hosp, vol. III."
