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Chapter 4, Part 1

Medical Science Publication No. 4, Volume II

TUESDAY AFTERNOON SESSION
27 April 1954

MODERATOR
COLONEL CHARLES L. LEEDHAM, MC


TUBERCULOSIS*

COLONEL CHARLES L. LEEDHAM, MC

Introduction

The theme of this discussion might well be stated to be: That in spite of widespread exposure to tuberculosis in the Far East, American troops came away practically unscathed. This statement becomes all the more amazing when one considers the extent of tuberculosis to which these troops were exposed. In fact, consideration of the problem of tuberculosis in United States Forces in the Far East is inextricably bound with the problem of tuberculosis of the indigenous populations of Korea and Japan. A brief background discussion, therefore, of the Oriental problem must necessarily be given in order to realize the full implications of the theme as it has been stated. Let us turn our attention immediately to this background information. Let us consider the worst problem first-the Korean problem-then the Japanese problem and finally, as a pleasant comparison, the American experience.

The Problem in Korea

Every authority consulted in the preparation of this paper unequivocally stated that tuberculosis was and is the greatest health problem in Korea. Yet the problem of tuberculosis in Korea differs in no material sense from the problem of tuberculosis throughout the Orient. The problem of tuberculosis in the Orient differs from the problem in the Western countries only in degree and in the existence of certain adverse factors which exert a marked influence on the extent of the disease. These factors are poor sanitation, lowered resistance of the individual, the sociological reaction of the individual to his disease and the effectiveness of therapy. Since in Korea these factors are all demonstrably adverse, let us examine each factor briefly.

Only one who has spent time in Korea can be fully aware of the extremely low level of sanitation which exists in that country. By Western concepts, sanitation is shockingly absent. Paucity of sanitation inevitably results in high overall disease rates, or inversely translated, in very low levels of general health. This of course has a marked influence on the general susceptibility to tuberculosis.


*Presented 27 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


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To carry the point further, a low level of health in the population as a whole when broken down to the intimate individual case means basically a lowered individual resistance. This already low individual resistance was aggravated in Korea by the inadequate diet and malnutrition created by the war years. The multiple worm infestations, the avitaminoses and the chronic upper respiratory infections existent in the general population compounded the problem. Add to this the starvation, exposure and hovel-type existence of the vast refugee group and one has built up a background remarkably conducive to the spread of tuberculosis.

Another contributing factor is the attitude of the individual concerned. This attitude is in general based on ignorance of the condition, an indifference to the problem, and an all-pervading fatalism. These states of mind are present in varying degrees in all levels of the population, in all strata of society and in all echelons of authority. In fact, it is a rare individual and one unusually well educated-almost invariably one exposed to Western thinking-who has any real concept of the threat of the disease. As a result, families tend to ignore or even conceal cases of tuberculosis. This concealment combined with communal living in small, poorly heated and ventilated buildings-where as many as 20 persons may sleep in one room-further enhances the spread of the disease. This attitude of indifference or ignorance or fatalism-whatever name you give it-adds to the problem tremendously.

Medical measures and management are in general much below Western standards. Case finding effectiveness is definitely hampered by indifference, neglect, lack of knowledge, lack of proper equipment, and family concealment. When cases are found hospital facilities for the patients are at best poor. Institution sanitation is negligible, while isolation facilities are practically nonexistent. Knowledge of therapy is apt to be inadequate and based on antiquated concepts. When medical knowledge is good it is usually hampered by a woeful dearth of medication. Poor facilities, the distressing lack of drugs, and an inadequacy of professional knowledge contribute to the poor outlook of the individual with tuberculosis and thus to the high overall rates.*

There has been delineated thus, in a few short paragraphs, some of the background of the tuberculosis problem in the Orient, which, I re-emphasize, has been compounded in Korea by the vicissitudes and hardships of the war years. I might add anticlimactically that


*Dr. Yu Sun Yun (1) in his excellent report to the Pan Pacific Tuberculosis Conference in Manila in 1953 has emphasized the points made above most succinctly. In fact, in comparison I have been most diplomatic. His report should be required reading for any one more deeply interested in the problem.


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where progress has been made against the tremendous odds noted it has been made with the help, impetus and stimulus of Western civilization and medicine. It is here that hope for the future lies insofar as tuberculosis in the Orient is concerned.

But before delving into what is being done to alleviate these conditions, let us turn to some more or less specific statistics to illustrate the magnitude of the problem. Statistics concerning the disease in Korea are desperately inaccurate-partly due to the facts previously noted and partly due to the fact that as late as 1953 the disease has not been reportable. Dr. Bowditch (2) states that in 1950 mass radiographic surveys show 2 percent active tuberculosis in the general population. Another authority (3) states that in 1952 there were 800,000 cases (4 percent) in a population of 20 million. An estimate of 60,000 deaths per year or a rate of 200 per 100,000 population per annum is given by Dr. In Ho Chu (4) in a report to the UN in 1951.

Even more dramatic figures are furnished by Dr. Yu Sun Yun (1) in his presentation before the Pan Pacific Tuberculosis Conference in Manila in 1953. Dr. Yun estimates 1,300,000 cases or a 6.5 percent prevalence of whom 500,000 (2.5 percent of the population) need sanatorium care. He also reports that an x-ray study of 21,701 school-age children revealed 7.7 percent active tuberculosis. Dr. Yun estimates 100,000 deaths per year and a rate of 300 to 400 per 100,000 per annum. Somewhere in the range of these figures lies the real incidence of the disease.

In an effort to make comparisons with the extent of tuberculosis in the United States one encounters two difficulties. First, Korean figures are at best educated guesses and comparisons are thereby invalid. Secondly, Korean reports are given as prevalence figures whereas United States statistics are given as incidence rates. However, by using death rates one can make a somewhat reasonable comparison. Accepting the median figure of 300/100,000 per annum as the Korean death rate, and 16.1/100,000 per annum as the United States figure, one finds the Korean death rate almost 20 times that of the United States. The comparison, to say the least, is startling.

And what is being done to alleviate this situation? The first faltering steps have been taken principally by the Korean relief agencies, limited by a woeful lack of funds and lack of trained personnel. X-ray screening has been ambitiously planned for, but because of many difficulties has made a slow start. Using CRIK supplies KCAC (5) in 1952 administered 533,976 tuberculin tests, while 292,174 negative reactors received BCG vaccine. Tuberculosis hospital facilities have been expanded from 300 beds in 1950 to 1,536 in 1953. Fifteen ambulatory treatment centers have been established, and handled 15,000 cases


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in 1953. Remembering that 1,300,000 patients need care-500,000 of these sanatorium care-do you wonder I used the adjective "faltering"?

Private agencies and private charities are assisting in many ways. The American Korean Foundation presented $10,000 to the Ministry of Health to support personnel for a tuberculosis control program, which is now headed by a competent Korean physician who has had 4 years' training in the United States. The official and unofficial contributions of U. S. Army personnel in funds and medical assistance are extremely noteworthy. All in all, as you can see, a start is being made to sweep back the tide. When one considers the extent of the problem and the start delineated above, future needs stagger the imagination.

The Problem Concerning Communist POW's

Let us turn now to another and more practical facet of the tuberculosis problem as faced by the Military in the Korean campaign; the problem of tuberculosis in Communist Korean and Chinese POW's held by the U. N. In this group tuberculosis also ran rampant. The incidence rate for tuberculosis among the captured Communists for the calendar year 1 September 1951-31 August 1952 was 43 per 1,000 per annum (6). The incidence rate for U. S. Troops in Korea for a comparable period, the calendar year 1952, was 0.8 per 1,000 per annum (7). The rate, therefore, in Communist troops on whom we were able to collect data was 53 times that of U. S. Army troops. You may draw any conclusions from these figures that you desire.

The problem of care which this mass of tuberculosis placed on the U. S. Army Medical Service was tremendous. The problem was met with characteristically aggressive fashion in the POW camp hospitals. Tuberculosis patients were segregated as soon as detected, classified as to type and severity, and appropriate well-ordered plans of therapy were soon in operation. There were few U. S. Army professional personnel, physicians, nurses and paramedics, so in order to handle the problem captured medical personnel as well as friendly Korean civilians were employed. All therapy was carried out under the direction and guidance of the U. S. Army Medical Service. In order to give you a sketchy picture of such an operation, I shall go into a bit of detail about one such hospital of which I have considerable personal knowledge. I am indebted to Dr. Robert W. Briggs (8) of Indianapolis for much of the material contained in the next few paragraphs.

Imagine my surprise on my first visit as FEC Medical Consultant to POW Camp Number 1 to find a field hospital of 10,000-bed capacity. This 10,000-bed unit was actually operated by a combination of two field hospital units working under a single commanding officer. The total patient load, all Koreans, ranged between 7,200 and 8,000. The


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hospital itself was divided into compounds accommodating from 1,500 to 2,000 patients each. The medical service consisted of Compounds Number 3, Number 5 and Number 6, and averaged at all times between 4,500 and 5,000 total patients. Compound Number 3 was primarily for general medical problems and cared for 800 to 1,200 patients. The other two compounds treated primarily tuberculosis.

Since we are dealing specifically with tuberculosis, let us look into the operation of Compound Number 6. Here the average patient load varied from 1,800 to 2,000 patients. Five hundred of the patients had pleural effusions, the remainder had other types of tuberculosis. Approximately 300 of the latter represented minimal disease and the remainder moderately advanced and far advanced tuberculosis. There were 30 to 40 seriously ill patients at all times.

Physically, the compound occupied considerably more than an acre. Within the inclosing walls of barbed wire were rows of ward tents with appropriate areas for exercise, sanitary facilities and food preparation. A frame headquarters building served as an American doctor's office and a nurse's station, as well as a records center. As time passed and material became available, the tents were replaced by long low buildings of mud, adobe, rock and lumber with thick walls and small windows high under the wide overhanging eaves. This type of structure, characteristic of the colder rural Orient, is surprisingly warm and adequately suited for the purposes intended. Throughout the entire period one tent, later a frame building, was set aside as a therapy center and assembly building for indigenous physicians. Here too, medical meetings were held. Under these conditions and with the able assistance of the Korean nurses and POW hospital attendants, patients were given surprisingly good care. The fact that medical nursing and dietary care of these prisoners was so good and, in fact, better than that available to the civilian population was the source of much adverse comment among the South Korean population.

As previously mentioned, the bulk of the work was done by indigenous personnel. Compound Number 6 had a staff of three American physicians and three American nurses. There were 17 North Korean POW physicians, and two South Korean civilian physicians. South Korean civilians were employed as nurses. Daily medical clinics were held and literature was reviewed on current problems of interest. Once weekly a CPC was held. The Chest Surgery Department collaborated in medical-surgical conferences twice weekly. The results of this training activity not only were evidenced in maintaining good patient care, but also in raising markedly the level of medical education of the Korean doctors. Cooperation among the various nationality groups was excellent. Even during prison riots, when American medical personnel were not permitted within compound limits, the Americans


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continued their supervision of medical care from stations outside the compound fence. It is interesting to note two facts. To my knowledge no American medical personnel were ever injured by POW's and to my knowledge never has a propaganda barrage been released against American medical personnel in the tuberculosis compounds. The young American doctors and nurses used the opportunity presented to them to demonstrate to the enemy in their care the great principles of our American democracy, both by means of good medical care and by personal example.

Therapy was based on the accepted American therapeutic regimen directed and supervised by the American physicians. Bed rest, nourishing diet, medication and supplemental therapeutic procedures were the basis of medical care. Progress was followed by periodic laboratory work and chest x-rays. Bed rest schedules followed American sanatoria planning as much as possible. The Communist-indoctrinated Oriental mind of the patient frequently limited cooperation. Diet was a minimum of 3,000 calories per day and consisted principally of rice, barley, vegetables, various types of meat stews, supplemented with milk shakes and vitamins. Streptomycin was used at first, later supplemented by para-amino-salicylic acid as it became available. Selected patients were given pneumoperitoneum therapy, even pneumothorax when warranted. When indications were present, excisional surgery was done. Results of therapy compared quite favorably with those in the earlier phases of United States regimens, and were startingly good when one considers the handicaps of the poor physical and nutritional status of the patient, the numerous inherent infections and infestations, and the gross inability or indoctrinated unwillingness of the patient to cooperate. Specifically, it is interesting to note that approximately one-third of the patients receiving pneumoperitoneum converted from a positive to negative sputum in from 3 to 4 months.

The 500 cases of pleural effusions presented a problem of some magnitude. Many were simple effusions having the cytological appearance of an exudate in which even after assiduous search acid-fast bacilli were rarely found. Many were massive effusions with marked mediastinal shift, a few were mixed infections due to bronchopleural fistula. Miliary tuberculosis and tuberculosis meningitis were much more frequent end results in this group than in similar groups seen in the Western Hemisphere. Likewise, there were more mixed infection empyemas. The patients, because of their initial state of nutrition, low resistance and advanced disease, usually died in spite of surgical procedures. Some of the most successful surgery in the effusion group was decortication for the end results of massive effusions of long standing.


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Tuberculous peritonitis was seen in its most severe form. Mesenteric lymph nodes were matted together in such a way that intestinal structures in almost all of these cases could not be dissected at autopsy. In searching for a possible explanation, it is interesting to note that even the peritoneum of "healthy" Koreans is thick and fibrous. The mesenteric lymph nodes in these people were also enlarged, quite possibly because of the intestinal parasites which are the normal inhabitants of the intestines of Koreans. When one states that not infrequently an Ascaris lumbricoides passed through the walls of the intestine to produce an acute condition in the abdomen, one realizes the magnitude of related problems.

Even though not tuberculosis, paragonimiasis must be mentioned. About 5 percent of the POW's coming from coastal areas gave a 5- to 20-year history of non-distressing hemoptosis. Sputum was anchovy paste in type and microscopic examination invariably revealed paragonimiasis. Therapy was never successful, although emetine HCI and other measures were given extensive trial. Much work was done and many interesting x-rays of the chest resulted but the disease was never conquered. However, the problem is not quite as severe as it might seem. The only direct death from paragonimiasis I have knowledge of was that of a patient with a brain abscess, an unusually rare finding.

Of more than passing interest to those who in the future may be interested in the problem is a tuberculosis case-finding project undertaken by the Far East Command. All prisoner-of-war camps were to be surveyed ultimately. This project was operating well in its initial phases until abruptly ended by prisoner-of-war riots. Among the difficulties encountered was a distinct lack of cooperation on the part of the examinees. The only explanation I can offer is that either they were carrying out party-line instructions or in their ignorance regarded the project as an evil scheme. The results of this survey may someday be released from present security restrictions.

The Problem in Japan

But to move back to the broader aspects of tuberculosis in the Orient, the tuberculosis problem in Japan is very similar to that in Korea, although lesser in degree and severity. The country, although densely populated, is almost on its feet economically and has recovered to a large degree from its war damage. The U. S. Occupation gave great impetus to Japan's recovery both in the economic and health fields, with great strides made between 1945 and 1952.

In spite of all of this, the same background factors noted in the Korean problem exist in Japan in varying degrees. Although sanitation in Japan is much better than in Korea, it is still far below that


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of Western countries. Nutritional levels are higher; in fact, considering the Orient, they are very high indeed. The attitude of the Japanese people toward the diseases is much the same as that of the Korean people, and it is still regarded as somewhat of a disgrace to the family, in spite of much enlightenment generated by the Occupation Forces. Families still tend to minimize, if not actually conceal, cases. This, combined with a somewhat similar type of communal living, where the average family of 8 to 12 all sleep in one room, effectively sealed off in winter because of lack of heating, adds appreciably to the spread of the disease. However, case finding, immunization and therapy are all excellent as a result of the efforts initiated by the PH & W Section, GHQ, SCAP. So, all in all, the background factors contribute much less to case incidence than in Korea.

During the period 1932 to 1951, tuberculosis was the leading cause of death in Japan. In 1945 the death rate had reached a peak of 282.2/100,000 (9). A gradual decline brought the rate down to 82.1/100,000 in 1952, in which year it was at last no longer the leading cause of death. Although there are many other factors involved in this accomplishment, full credit must be given to the part played by the occupation leadership.

During the occupation, the PH & W Section of SCAP, under the leadership of Brigadier General Crawford Sams, took aggressive action in the Japanese tuberculosis problem. Under SCAP guidance a tuberculosis control law was enacted (9), a case-finding campaign organized, 800 health centers established, tuberculin testing carried out en masse and BCG vaccination given to negative reactors. Three million vaccinations were given in 1945, and eight million in 1948. Three hundred eighty thousand new active cases of tuberculosis were discovered in the first year of the work, and an increasing number yearly thereafter. Five hundred ninety thousand cases were reported in the year 1951. Tuberculosis beds were increased from 25,000 in 1945 to 101,000 in 1951. Modern therapy on an ambulatory basis is presently carried out in the 800 health centers, while nutritional campaigns are an effective accompaniment. In 1951 the therapy program carried 1,300,000 active cases uncovered in 25,500,000 persons surveyed under the age of 30.

Compare these figures with those given above for Korea; 500,000 tuberculin tests, 1,500 tuberculosis beds, 15 treatment centers, 15,000 patients under treatment. Remembering that the Japanese population is a bit more than four times that of Korea, the comparisons indicate what aggressive leadership, absolute control of the population healthwise, and the passage of time will do.

To get back to a more specific type of problem, there is a factor in the exposure of American troops to tuberculosis in Japan that existed


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to a much lesser degree in Korea. That factor is the experience of the American Army with war brides. In 1952 (10), approximately 5,200 non-quota visas for dependents of American servicemen were issued. It can reasonably be assumed that the majority of these were wives of Japanese extraction. The number of others rejected for entry is not available to the author at present, but is undoubtedly large. Only the future will tell how many cases of tuberculosis were contracted in the marital bond which might otherwise not have occurred. If one adds to this the extramarital adventure in both Japan and Korea, one realizes the seriousness of the tuberculosis exposure problem when American troops are billeted amongst a friendly, receptive population harboring a high tuberculosis incidence. As will be seen later, there has been little immediate effect. However, only the future will tell. It is safe to conjecture at this time that only the magnificent physical resistance of the American soldier kept the problem from becoming a real tragedy.

But to get to the more practical aspects of the problem for future guidance; one aspect of this is the screening of Japanese wives for entry into the United States. The USPHS acting for the Immigration Service has absolute and final decision on the physical fitness of any non-citizen applicant for entry into the United States. Tuberculosis in any form or evidence of past tuberculosis is a bar to such entrance. During the early phases of the occupation, United States medical authorities permitted Japanese physicians to certify to freedom from disease for those Japanese nationals desiring admission to the United States. It soon became apparent from this was an unsatisfactory procedure. The work then fell on the shoulders of the Medical Services of the Armed Forces. Even here, too frequent errors were made and only when the greatest emphasis was placed on the problem by higher authority did the proper adjustments take place. What I should like to recommend for future generations is that only those well or thoroughly trained in tuberculosis be permitted to give entry clearances in questionable cases, and that a high index of suspicion be maintained, not only in regard to the tuberculosis itself, but also in regard to the identity of the individuals being examined. More need not be said.

The End Results in American Troops

In spite of all the dire things said about tuberculosis in the Orient to which American troops, because of their gregarious nature, were more than exposed, the tuberculosis incidence rates (all types) in American troops in Korea and Japan are surprisingly low. In fact, there is no really significant difference between rates in U. S. troops in the Orient, in the Army as a whole, or in the U. S. civilian popula-


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tion. As an example (11), in the year 1952, the incidence rate for all forms of tuberculosis for U. S. troops in Korea was 0.8 per 1,000 per annum; for U. S. troops in Japan 1.0; for all overseas commands 1.0; for the Army as a whole 1.0; and for the civilian U. S. population 0.7 per 1,000 per annum (12). The rates for previous years are entirely comparable. As an example, the all-types tuberculosis rate for American troops in Korea for 1950 (13) was 0.90 per 1,000 per annum; for 1951, 0.98; for 1952, 0.79; and for 1953, 0.68.

Another point to be noted is that neither the type nor the severity of tuberculosis seen in American troops in the Orient has varied significantly from that seen in previous years, or from that seen in the Army as a whole, or in the Continental United States. In fact, except for tuberculosis in returned American POW's, the disease was no more a problem in the Orient than it is normally a problem in the Army as a whole. Only the passage of time will tell whether the statements just made are valid.

It must be acknowledged that tuberculosis contracted by exposure in the Far East may not develop to clinically recognizable severity until long after the return of the victim to the United States. When then discovered, if the victim has returned to civilian life, the case will presumably be lost in the mass of U. S. statistics and its source be unrecognized. With this thought in mind, the Department of Defense, through Dr. Frank Berry, Assistant Secretary (Health and Medical) is seriously considering a case-finding project for Far East Command returnees.

The Problem in American POW'S

Tuberculosis among Americans imprisoned by Communists is another story entirely. We will perhaps never know the true morbidity and mortality rates of the disease. Suffice it to say we can infer that the rates were very high, that the care given was negligible, and that many deaths were contributed to or caused by tuberculosis. The only statistics available are on Americans recovered in Operations Big and Little Switch (14). In these instances, 4.1 percent either had tuberculosis or were under observation for it. Breakdown of these figures at once dissipates their apparent importance. Of the 4.1 percent mentioned, only 17 percent of those had demonstrable pulmonary tuberculosis, 4.1 percent had tuberculosis unspecified, and the remaining 78.9 percent were under observation. Further follow-up studies are not available at this time. However, because of the factors stated in the opening of this paragraph, no significance can be attached to these figures in attempting to assess the extent and severity of tuberculosis in Americans north of the combat line. As time goes on, perhaps more adequate data will be published which may shed some additional light on the problem.

Conclusions

If conclusions are warranted, I should like to repeat as a preface my initial statement: That in spite of widespread exposure to tuberculosis in the Far East, no significant increase in the incidence of the disease has occurred among American troops. If the future supports that statement, and there is much doubt among authorities, the conclusion I should like to draw is that this miracle is in large part due to the magnificent physiques, the exceptionally high state of nutrition, and the inherited and acquired resistance of the American soldier.

May the American soldier always be that fortunate.

References

1. Yu Sun Yun: Tuberculosis Problem in the Republic of Korea. Presented at the Pan Pacific Tuberculosis Conference, Manila PI, 13-19 April 1953.

2. Bowditch, Sarah H.: South Korea Tuberculosis. Medical Intelligence Branch, Preventive Medicine Division, OTSG, 18 June 1953.

3. FEC Surgeons Circular Letter, January 1952, Volume VII, No. 1.

4. In Ho Chu: Public Health Reports in Korea for the UN, 1951.

5. Extracts from Monthly Civil Affairs, Summary for Korea by HQ Korean Civil Assistance Command, July 1953.

6. Unpublished data from Medical Statistics Division. OTSG.

7. Korea-A summary of Medical Experience, July '50-December '52. Reprinted from Health of the Army, Jan., Feb., Mar. 1953.

8. Briggs, R.W.: Personal communication.

9. Sams, Crawford F.: Experiences in Immunization against Tuberculosis with BCG Vaccine in Japan. (To be published)

10. Data from Preventive Medicine Division, OTSG.

11. Health of the Army, May 1953.

12. Public Health Reports, November 1953.

13. Data furnished by Preventive Medicine Division, OTSG.

14. Data furnished by Preventive Medicine Division, OTSG.