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Chapter 4, Part 2

Medical Science Publication No. 4, Volume II

VENEREAL DISEASE PROBLEMS, U. S. ARMY FORCES, FAR EAST 1950-53*

COLONEL JOSEPH H. McNINCH, MC

Environmental Background

The principal factors contributing to the high incidence and spread of venereal disease in military forces in the Far East Command are poverty in civilian populations and widespread prostitution, the former contributing significantly to the latter. Although prostitution exists in the absence of poverty, economic conditions in Korea during the period 1950-53 undoubtedly drove many women into this profession who would otherwise have married, raised families, or found other occupations.

Prostitution itself has long been a socially and legally accepted profession in the Orient. Japan, Okinawa, and Korea are not exceptions. Prior to the end of World War II prostitutes were licensed, organized, segregated into districts, and some medical examinations were done. Women had few rights and girls were frequently sold for the purpose of prostitution by their fathers to augment meager family incomes.

Following the occupation of Japan and Okinawa and the liberation of Korea, reforms were initiated. In Korea a law was enacted that made all phases of prostitution illegal. In Japan a law was enacted outlawing prostitution as an organized business and the licensing of prostitutes, but which did not bar women as individuals from engaging in prostitution. In Okinawa the Military Government issued an order prohibiting prostitution with United States personnel, but not among the Okinawans. It is not known why Occupation authorities did not impose stricter prohibitory measures, but it is assumed that it was believed that there were limits to the degree and speed with which customs and tradition could be changed. In any event, prostitution has continued to flourish in Japan and in Okinawa. Even in Korea where all phases of prostitution are illegal, since the onset of the war in 1950, the Government has taken the position that enforcement of the law is impractical.

In discussing the problem of prostitution as it exists today, it must be remembered that Japan and Korea are now sovereign nations, and


*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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United States military authorities are limited to requesting cooperation in application of United States policies regarding the suppression of prostitution.

Living conditions in all three countries also have a bearing on the incidence and variety of venereal diseases. Few houses in Okinawa have piped water supplies, either hot or cold. Facilities for cleanliness of the prostitute or her clients are almost totally lacking. The situation in Japan is better, but many Japanese homes are without piped water, especially hot water.

Another factor having a bearing on the venereal disease problem in the Far East Command is the almost complete lack of moral, wholesome feminine companionship for American servicemen. Important in this situation is the language barrier. Few if any United States personnel learn more than a few words or sentences in Japanese or Korean. Few Japanese, Okinawans or Korean girls and women can speak English. The exception is the prostitute who has learned through the practice of her profession. The inability to communicate effectively blocks the more wholesome mingling of young persons of opposite sexes. On the other hand, the language of the bedroom, if not of love, is universal. In addition to the language barrier, Japanese, Okinawan and Korean parents are naturally fearful of permitting their daughters to associate with foreign males. The result is that with relatively few exceptions, the American soldier in Japan, Okinawa and Korea in his search for female companionship is limited to the prostitute.

Venereal Disease Situation Prior to the War in Korea

Since prostitution is perhaps the most important factor in the spread of venereal diseases and in view of the conditions in the Far East Command as they have been described here, it was inevitable that control of venereal disease presented a continuing and vexing problem prior to the onset of hostilities in Korea. Total venereal disease rates for United States Army personnel in the Far East ranged from 100-160/1,000 per year throughout the period 1947-50. Some individual units reported rates in excess of 500/1,000 per year.

Effect of the Korean War on Venereal Disease Problems

The principal manner in which the onset of hostilities in Korea affected the venereal disease problem was through the marked increase in the numbers and activities of prostitutes. The war resulted in the movement of large numbers of troops through Japan to Korea and from Korea to Japan. Prostitutes followed concentrations of troops wherever such concentrations occurred. Sasebo, Japan, which is a port on the southern tip of the southern island of Kyushu can be cited


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as an example. This port, during the first 2 years of the war, was a staging area for replacements en route to Korea. Normally these replacements entered the Port of Yokohama, processed at Camp Drake near Tokyo, and then were sent to Sasebo by rail for transshipment to Korea. Troops rotating to the United States from Korea were brought to Sasebo where they were processed for return to the United States. Sasebo also is a United States Navy base and the number of Navy personnel arriving and departing increased tremendously with the onset of the war.

In a letter dated 9 December 1950, the Commanding Officer of the Army Camp at Sasebo stated that the prostitute population had increased tremendously since the onset of the war and that the number was then estimated to be between six and ten thousand, most of whom were street walkers. To meet the moral and disease problems posed by these prostitutes on the streets of Sasebo, United States military representatives met with city officials in mid-November 1950 and demanded positive action to drive the prostitutes out, threatening to place the entire city off limits if the situation were not corrected. When a check on 29 November showed no evidence of corrective action the entire city was placed off limits the following day. This drastic action resulted in the passage of an ordinance prohibiting solicitation on 8 December.

This ordinance was not enacted without considerable protest from Japanese officials, business men, and others among whom were representatives from the White Lily Association, which was the local organization of prostitutes. Following the passage of this ordinance Sasebo was again placed on limits except for individual establishments which were previously off limits for various reasons. The enforcement of this ordinance has varied from time to time, depending on the degree of pressure brought on Japanese authorities. The effect of the ordinance does not extend beyond the city limits and there are many houses of prostitution in these outskirts. Similar problems have existed at Camp Drake, near Tokyo, which is another replacement depot.

Another activity in connection with the war which has increased the problem of prostitutes has been the Rest and Recreation (R & R) leave for troops in Korea. During the past 3 years thousands of men have been flown from Korea to Japan for 5 days R & R. To process these men, so-called R & R centers were established in Japan where the men were provided with baths, clean, correct uniforms, and 5 days leave. Special Services has provided hotels and other recreational facilities for the use of R & R personnel but servicemen are free to reject these facilities and find their own recreation. One thing desired by most men returning from Korea could not be provided by Special Services-namely, female companionship. However, in Ja-


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pan there are many prostitutes to provide such companionship and pimps and prostitutes flocked to R & R centers. Despite continued attempts to suppress their activities, sometimes with and sometimes without cooperation of local authorities, the problem has not been solved. In Korea the Government does not attempt to enforce the anti-prostitution law. In fact, legal recognition of prostitution has taken place through the licensing of prostitutes, the institution of periodic physical examinations and the issuance of so-called health cards. United States Army commanders of combat units through their unlimited authority in the combat area have been able, with varying degrees of success, to keep prostitutes out of areas under their control. In Korea particularly, the factors of poverty and hunger have served to increase the prostitute population tremendously.

FIGURE 1.

Figure 1 shows the reported incidence of venereal disease in the Army Forces Far East during the years 1951-53. It is evident that during 1951 and the first half of 1952 there was a continuing rise in reported incidences. The decline during the second half of 1952 will be discussed in a later section.

Figure 2 shows clearly the venereal disease problem created when new units arrived in the Far East from the United States and when combat units rotated to rear areas. The first half of this chart shows the venereal disease incidence in two divisions which arrived in Japan in the spring of 1951. As prostitutes discovered the camps in which regiments were stationed, venereal disease rates rose progressively. In December 1951 these two divisions were transferred to Korea and


148

FIGURE 2.

two combat-seasoned divisions rotated back to Japan. The second half of this chart shows the venereal disease incidence in the rotated divisions. This time the prostitutes were already in the locations and the result is indicated by the high rates in excess of 500-1,000 per year during the first month following their return.

Venereal Disease Control Measures in the Far East Command

At all times in the Far East Command, repression of prostitution in compliance with AR 600-900, has been the policy and has been enforced insofar as local conditions would permit. In education of personnel, continence has been presented as the best method of avoid-


149

ing venereal diseases and one that is consistent with American moral and religious concepts. To further this concept there have been character guidance programs, health education programs, promotion of organized sports, construction and provision of recreational and educational facilities, and the promotion of religious activities. For personnel not accepting continence as the method of choice, there has been free provision of chemical prophylaxis, both sale and free provision of mechanical prophylaxis, and at times under certain restrictions, penicillin prophylaxis has been available. In Korea local health officials have at times used penicillin for periodic mass treatment of known prostitutes, entertainers, and waitresses. Contact tracing as a program has been encouraged at all times, but presents great difficulties in an Oriental country.

With reference to prevention of exposure of the individual or use of prophylactic methods, there is little in the experience of the Far East Command that differs from experience elsewhere. Incidence of venereal disease in the Command has indicated a fairly high degree of failure in both approaches.

Since prostitution is a particularly important element in the venereal disease problem in the Far East Command more space will be devoted to a discussion of this subject. The status of prostitution in the Far East has already been indicated. The declared policy of the United States Army that all commanders will act vigorously to repress prostitution presents many grave difficulties in implementation in the Far East.

One approach in the repression of prostitution is the use of off limits posting. This method is in liberal use in both Japan and Korea. In Korea entire villages and large sections of cities and towns have been placed off limits, and early curfews enforced almost everywhere during the periods of combat. In Korea off limits areas can be and are indicated by appropriate signs. This program, however, does not prevent the practice of prostitution nor does it prevent constant movement of prostitutes from "off limits" areas to "on limits" areas, always one jump ahead of the Provost Marshal. In Japan individual establishments and even entire areas are also placed off limits as a venereal disease control measure. Before the end of the Occupation such houses and areas were plainly marked with signs. Since the end of the Occupation all signs have been removed and off limits posting can be accomplished only by publication of the name and address of the establishment or area. However, it is doubtful if at any one camp in Japan many persons except the military police know the exact location of all off limits establishments. Identification of areas or houses in an Oriental city by description is exceedingly difficult.


150

The threat of off limits posting has been tried to force towns and villages in Japan to eliminate prostitution. This has been fairly effective in some areas and totally ineffective in others. However, through efforts on the part of military authorities, a number of municipalities and prefectures in Japan have enacted anti-prostitution laws more restrictive than the national law. At the present time, Tokyo, 9 prefectures, 28 cities, 6 towns and 4 villages in Japan have anti-prostitution ordinances. However, many of these ordinances only prohibit solicitation on the street and do not prohibit operation of houses. Enforcement of these ordinances varies considerably from place to place and in the same place from time to time. Japanese officials are usually able to produce many reasons for lax enforcement which vary from an insufficient budget to difficulties in obtaining sufficient evidence for conviction under the present Japanese Constitution.

There are widely divergent views in Japan on the subject of prostitution. Many Japanese desire a return to the "old days" in which prostitution was a well organized and regulated business operating in segregated districts where it was hidden from the eyes of Japanese wives, mothers, and children. Other Japanese, recognizing the fundamental evils of prostitution and its debasement of womanhood, are vigorous in demanding reform and the enactment and enforcement of laws similar to those of the United States. It is not known which of these groups constitute a majority.

However, it is my belief that increasing numbers of Japanese committees are cooperating with United States authorities in at least partial suppression of prostitution. Okinawa, although not a war-torn country as is Korea, is a country of poverty. The greatest source of income to Okinawans is the United States Government and its military personnel. Of this income a significant share is derived through prostitution. Some attempts have been made to repress prostitution completely in Okinawa, but such attempts have usually succeeded in only scattering the prostitutes. Commanders are faced with the very real problem of choosing between prostitution under some sort of local government control or taking suppressive measures which would scatter the women so that they are under no control at all.

Physical Inspections and Contact Tracing

Identification and treatment of infected persons is an important element in the control of any disease. It is particularly important in the venereal diseases. In the control of venereal disease in the Army this involves the discovery of the infected soldier and identification of the female contact.

Current regulations provide for physical inspections only by specific order of the Commander on recommendation of his surgeon. It is


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my belief that the indications for such inspections are knowledge or reasonable suspicion that there are concealed cases of venereal disease in the unit. In units where an appreciable number of such cases are found, inspections should be frequent until men are convinced that concealment is not desirable. Whenever there is punitive action against commanders for high venereal disease rates, such commanders are loath to order physical inspections because discovery of cases will increase their rate. There have been indications that commanders of some units in the Far East Command have at times avoided ordering physical inspections for this reason. It is likely that in many areas lack of inspection of troops is a factor in maintaining the reservoir of venereal infection in the civilian community.

Contact tracing in the Orient presents many problems. Identification of persons and places is complicated by barriers of language and the use of Oriental symbols which have no resemblance to the Roman alphabet. In Tokyo, one person in describing the advantages of a certain shop will usually end by saying "I can't possibly tell you how to find it, I will have to take you there sometime." With the great movement of replacements into and rotatees out of the Far East Command during the war, the simple device of having the patient take the investigator to the place of exposure was impractical in a large percentage of cases. Despite these difficulties there has been a contact tracing program at all times in the Command. The effectiveness has varied usually with the personnel making the investigation. Some camps in Japan claim to find a large percentage of contacts, others find almost none. In Korea the National Police assist military authorities in this program. The use of the patient to hunt down the contact improves the chances of finding the contact. However, in each area it is necessary to determine whether the results justify the time lost from duty.

It is essential that the form used for the contact report in the Far East Command be bilingual. The United States Navy operates a school of contact tracers at Sasebo, Japan. Army personnel are permitted to attend this school and many have done so. We are grateful to the Navy for this assistance.

One almost universal complaint of post and unit surgeons in Japan is that after being located only a small percentage of contacts are found to have venereal disease when examined by local health agencies. Indigenous, local diagnostic facilities in Japan, Okinawa, and Korea are poor at best. Also, the accurate diagnosis of gonorrhea or chancroid in females in the absence of clinical manifestations may be difficult. A number of United States medical officers have rendered voluntary assistance to local health agencies in improving their diagnostic technics. In Japan this has a double hazzard: that of being


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accused of abetting prostitution by higher military authorities and also that of being accused in the press of coercing Japanese health authorities. Diagnosis of chancroid in women presents an especially difficult problem. In Okinawa at one time when the ratio of gonorrhea to chancroid in military personnel was 1 to 1 the ratio in routinely examined prostitutes was 22 to 1.

Chemical and mechanical prophylactics have been both free and freely available in the Far East Command. Many medical officers believe that chemical prophylaxis is useless or worse than useless. If that is the consensus throughout the Army, it is recommended that its use be discontinued, even though a replacement item is not available, and even if there is danger of "loss of face" on the part of the Medical Service. In view of the excessively high venereal disease rates in some units in the Far East it would appear that neither chemical nor mechanical prophylactics were ever used in those units. The reason for this is not known, but it seems most likely that modern treatment has resulted in lack of fear of these diseases.

Penicillin Prophylaxis

In July or August 1949 the Surgeon of the Eighth Army, then stationed in Japan, asked for authority to try out penicillin prophylaxis. This trial was authorized and in October 1949 the Surgeon rendered a preliminary report based on the administration of oral penicillin in two units, one stationed in Yokohama and the other in Kobe, Japan.

Table 1 shows the data contained in that report. The results are striking. From available records it appears that based on these results the experiment was broadened to include more units. The course of events afterward is not clear from available records, except that the use of penicillin prophylactically was discontinued.

Table 1. Results of Test of Oral Penicillin to Prevent Gonorrhea, Eighth U. S. Army in Japan, 1949-Rates per 1,000 per Year


Organization

Incidence prior to test

Incidence during test

Cases

Rate

Period

Cases

Rate

Period

Yokohama Command

18

376

8 weeks

0

0

8 weeks.

Kobe Base Command

67

1,228

6 weeks

3

55

6 weeks.

Early in 1952 a number of officers in the Far East Command, both medical and non-medical, requested authority to reinstitute oral penicillin prophylaxis. Since available records on this subject were meager a letter was dispatched on 4 February 1952 to the Office of


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The Surgeon General asking for a restatement of policy. The reply to the request stated current policy to be:

    1. Oral penicillin prophylaxis could be used:

      a. Only in overseas commands.
      b. Only in areas of high gonorrhea incidence.
      c. Only in selected units.
      d. Only when leave periods would be less than 24 hours.

    2. Oral penicillin tablets could be given:

      a. Only in medical facilities.
      b. Only on request of the individual.

    3. The tablets must be taken in the presence of the person dispensing them.

    4. The use of penicillin must be emphasized to the individuals as effective only against gonorrhea, and he should be told to apply other routine prophylactic measures.

After receipt of this letter, on the premise that all areas in the Far East Command had a high gonorrhea incidence, the surgeons of all subordinate commands were authorized to institute its use under the prescribed restrictions. Reactions of surgeons of subordinate commands varied. The surgeons of Japan Logistical Command and Eighth Army were opposed to its use and did not take advantage of the authority granted. The Surgeon, XVI Corps, which controlled combat units in Japan, instituted its use immediately.

Since that time, oral penicillin has been used periodically in many Army units in the Far East. The local policy has depended usually on the professional opinions of the current local surgeon. Records of the success or failure are generally not available. In units where the program has been pushed, a lowering of the gonorrhea rate has almost always resulted. However, there have been no magic results apparent in the Army Forces Far East. It is the belief of the writer that the Department of the Army restrictions, particularly the one that requires the tablets to be dispensed at a medical facility, effectively precludes the successful application of the method.

Evolution of Present Policy of Venereal Disease Control

It is apparent in figure 1 that there was a progressive increase in the venereal disease incidence throughout 1951 and the early months of 1952. This increase was especially marked in Japan because of the arrival of two divisions from the United States in 1951 and rotation of two combat experienced divisions from Korea in 1952. However, rates were also rising in Korea and in Okinawa. Commanders were showing increasing concern and this concern was stimulated by published reports in United States newspapers about narcotics, vice, prostitution and venereal disease in the Far East Command.


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In June 1952 a Command conference on the problem of venereal disease was held in Tokyo. Following this conference, strong letters were sent out directing commanders at all levels to intensify their efforts to repress prostitution and reduce the incidence of venereal disease.

To meet the demand for reduction in venereal disease rates all of the usual control measures were intensified. Punishment of the individual was included among these measures despite regulations to the contrary. Such punishment was usually covert, but occasionally overt. One commander devised a method in which he appointed all noncommissioned officers as venereal disease control officers, then if the noncommissioned officer contracted a venereal disease he was reduced in grade for "inefficiency" as a control officer. Some punishment was not so subtle. One Corps commander ordered passes withdrawn from all men in the company having the highest venereal disease rate in each large unit or each camp.

Figure 3 shows the trend of venereal disease following the command letter of 7 July 1952. In Japan the reported incidence, and I stress the word "reported," dropped 26 percent in July, 20 percent in August and 16 percent in September. A similar reduction occurred in Okinawa. In Korea, where opportunities for self-treatment or treatment by civilians were limited, the decline was much more gradual.

It is difficult to determine the exact or even relative weight of the various factors involved in this reduction of reported incidence of venereal disease. However, there was considerable evidence that concealment, self-treatment and treatment by civilians existed and was increasing.

At every opportunity the Chief Surgeon pointed out to the Army Headquarters Staff that lack of treatment and inadequate treatment were the real dangers of venereal infection and that the most important factor in causing concealment of infection was the threat of punishment.

When finally converted to this point of view, the staff recommended to the Commander that AFFE Circular 152 be published. There are some sentences in this new circular that are believed to be worthy of quotation as expressing a new approach to the venereal disease problem in the Army.

The first paragraph of this directive points out that the venereal disease rate is not necessarily identical with the true incidence of venereal disease and that the former may be lower by certain command actions without a reduction in the latter. It is also stated that the success of a commander in venereal disease control will be judged on the basis of his control program with due allowance for the environmental situation of his unit and the means at his disposal. It is em-


155

FIGURE 3.

phasized that the venereal disease rate of his unit is not an accurate index of the control activities of the commander and that there is no justification or authority for evaluating his efficiency solely on the basis of the "venereal disease rate." It is finally pointed out that the control of venereal disease is but one of a myriad of command responsibilities and in the evaluation of the total efficiency of a commander, the problem of venereal disease control will not be given more emphasis than it deserves.

These, we believe, are important principles in a military venereal disease control program. The publication of this directive has not resulted in the acceptance of these principles by all unit commanders in the Far East Command. There is evidence that there is a fear by many unit commanders that these principles will not be recognized in intermediate headquarters or that they will be rejected the next time a new directive is published. It is our hope that the passage of time will see acceptance of these principles at Department of Army level


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and that subordinate commanders will realize that there has been a permanent modification of former Army policy.

Before closing, there are several other problems concerning venereal disease as encountered in the Far East Command which should be mentioned.

From 1949 to 1952 the percentage of all venereal disease reported as chancroid increased and that reported as syphilis decreased. This changing picture is shown in figure 4.

FIGURE 4.

Two problems are suggested here. First, the large incidence of chancroid presents a difficult problem of control. Penicillin prophylaxis is not effective against this disease. Diagnosis of the disease in women is difficult and identification of the bacillus of Ducrey is not easy or certain. It has been pointed out that in Okinawa, at a time when the ratio of gonorrhea to chancroid in the military population was approximately 1 to 1, the ratio diagnosed in prostitutes at routine examinations was reported as 22 to 1. Some medical officers in the Far East Command have expressed the belief that clinical chancroid is caused not only by the bacillus of Ducrey but that other agents might


157

be implicated. Certainly there is reason for more study of the clinical manifestation, etiology and diagnosis of chancroid, particularly in the female.

The second problem concerns syphilis. The decrease in diagnosed cases of syphilis was both relative and absolute. In 1950 the rate in Japan was 13/1,000, in 1953 the rate was 3.2. In Okinawa the rate dropped from 2.4 to 1.0 during the same period. This has caused grave concern that diagnoses of primary lesions were being missed.

FIGURE 5.

A recent survey of place of treatment of cases of syphilis has increased our concern over this problem.

Figure 5 shows the percentage of cases of syphilis treated on a duty status compared with the percentage treated in hospital or quarters. It will be noted that the percentage treated in hospital and quarters is 52 percent and 64 percent in Japan and Okinawa respectively. We believe that the great majority of these patients were not hospitalized for treatment of syphilis per se, but were diagnosed while in hospital for treatment of other conditions. This, of course, leads to the question of why a diagnosis was not made at the time of admission. If the disease was contracted in the Far East Command and missed, there


158

is reason for much concern. It is planned to initiate a study of all cases routinely diagnosed in hospitals to determine the circumstances attending the diagnosis of the primary lesion. Until such study is made we can only speculate on the significance of the last two charts.

Recently we conducted a survey to determine how uncomplicated gonorrhea was being treated in the Army Forces Far East. It was discovered that although there were a great many variations in the dosage of penicillin used, the number of treatments and the length of treatment, in almost no instance did we find the treatment to follow that prescribed in TB MED 230, Management of Venereal Diseases. The Surgeon General has been informed of this fact. When a complete analysis of the result of this survey is completed it is contemplated that an AFFE policy on treatment will be formulated and published, pending revision of the current policy by The Surgeon General.