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Maj. Gen. James 0. Gillespie, MC, USA (Ret.)
The surrender of the Filipino-American Forces at Bataan occurred, after 4 months of defensive operations, on 9 April 1942. Defeat was inevitable because of the limited resources in men and materiel and inability to replenish them, but malaria and lack of food also played a significant role in the tragedy.1 The will to fight was weakened and this hastened defeat. Complications of disease led to appalling death rates in prison camps.
A brief review of the epidemiology of malaria, problems of malaria control, medical war planning, and military operations may enable one to appreciate the devastating effects of disease and malnutrition on U.S. Forces, the enemy, civilian refugees, and Japanese-held prisoners of war during the long years of captivity.
EPIDEMIOLOGY OF MALARIA
The mountainous terrain and climate of Bataan provide ideal conditions for the propagation of the vector of malaria.2 From the two chief mountain masses on Bataan, numerous streams course in all directions toward Manila Bay and the China Sea. The transition from the higher altitudes to the flat and narrow coastal plain through the foothills insures a rapid flow of water in the streams. The rainfall is sufficiently adequate to maintain a large number of permanent streams through the dry season, which extends from November through May. These provide adequate breeding grounds and support protective vegetation in which adult mosquitoes survive throughout the dry season.
The chief vector of malaria in the Philippines is Anopheles minimus flavirostris 3 This mosquito breeds most readily in the protected areas of rapidly flowing rivers, streams, and irrigation ditches, preferring shady places and clear, fresh water. Breeding does not normally occur in salt water, rice paddies, or in water above 2,000 feet altitude. Thus, malaria in Bataan, as throughout the Philippines, is a disease contracted in the foothills, especially between the flat coastal plain and the higher ground below 2,000 feet altitude. Seasonal variations in the incidence of malaria are related to the effects of the
F.: Troops on Bataan Routed by Malaria. New York Times, 18 Apr. 1942, p.
drying of the small tributaries of streams and irrigation canals and to the flushing of the breeding grounds during the heaviest rainfall. Thus, Bataan constituted a potent hazard for malarial infection during the season when military operations were feasible.
PRE-WORLD WAR II MALARIA CONTROL MEASURES
Before World War II, malaria control measures in Bataan had not been impressive, although surveys had identified the vector and determined the incidence of malaria in the native population.
In 1930, Headquarters, U.S. Army, Philippines, authorized malaria reconnaissance throughout the Islands to determine the location of maneuver areas of relative safety from malarial infection. Holt and Russell carried out a rather complete survey of Bataan during 1930 and 1931 and included Corregidor in their observations. 4 They collected mosquito larvae, made blood film examinations for malaria plasmodia, and determined splenic indices. Corregidor was found to be relatively free of malaria, but Bataan was found to harbor a large reservoir of disease. Splenic indices varied from 3 percent in the villages of the flat east coastal plain of Bataan to over 50 percent in the populated areas of the foothills in the vicinity of Limay. Lamao. Cabcaben, Mariveles. Sisiman, and Bagac.
After 1926, the Malaria Control Division, Philippine Health Service, had carried on demonstrations and local control programs throughout the Philippines including Bataan Province. 5 The excessive cost of this program had imposed an insoluble problem, and only moderate progress had been made in the eradication of breeding areas. Military maneuvers involving small forces had been carried out in Bataan during the dry season for many years. The contracting of malaria had been an annually recurring phenomenon of varying magnitude. In 1940, the surgeon of the Philippine Division reported an appreciable lessening of the incidence of malaria in troops engaged in maneuvers in Bataan.6 He attributed this to proper use of mosquito bars and to a more careful selection of campsites. He emphasized the importance of locating sites, preferably on the beaches, in the coastal swamplands, or in rice paddies, and of avoiding the higher ground in the vicinity of rapidly flowing streams. Quinine prophylaxis was continued for 14 days after termination of the maneuver. The Philippine Division surgeon believed that it was impracticable to eradicate all of the potential breeding areas. Virtually no antimosquito control measures were carried out by the Army in Bataan at any time.
4 Holt, R.
L., and Russell, P. F.: Malaria and Anopheles Reconnaissance in the Philippines.
Philippine J. Science 49: 305-371, November 1932.
MEDICAL WAR PLANNING
The developers of War Plan Orange-3 for the defense of Luzon envisioned an attack on the Philippines by a superior enemy force, withdrawal of U.S. Forces from central Luzon, fall of Manila, and delaying defensive action in Bataan to protect the key defenses of Corregidor until the arrival of naval reinforcements from the United States. The plan called for a force of 40,000 men for the defense of Bataan and the removal of the civilian population upon outbreak of war.
Prewar implementation of this plan in Bataan was meager indeed. This was due in part to the provisions of the National Defense Act passed by the Philippine National Assembly in 1935, which authorized the formation of a 400,000-man Filipino Army to assume the responsibility for defense in 1946 when Philippine independence was to be achieved. Prewar preparation on Bataan included the storage of ammunition, fuel oils, and a limited quantity of canned food.7 Potential defense lines had been agreed upon, but no fortifications had been built. Reliance for the control of malaria was vested in quinine prophylaxis rather than on an antimosquito control program. This was considered the only feasible procedure in view of the size of the peninsula, which measured 25 miles by 18 miles, most of which was favorable to the breeding of malarial mosquitoes.
In May 1941, the Philippine Department surgeon appointed a board of officers at Steinberg General Hospital, Manila, to prepare estimates of the quantities of antimalarial drugs needed, based upon the April revision of War Plan Orange-3. Col. Rufus L. Holt, MC, the president of the board, had had extensive experience studying the incidence of malaria throughout the Philippine Islands. Guided by his advice, estimates were prepared and submitted at a level 100 percent above anticipated requirements.
Gen. Douglas MacArthur, in July 1941, expounded a more aggressive concept for the defense of the Philippines. One aspect of this concept was to defeat the enemy at the beaches rather than merely delay them to permit the withdrawal of troops to Bataan. Revision of medical plans during 1941 included requirements for the expansion of all Regular Army hospitals and plans for the construction of 10 station hospitals for the 10 Philippine Army divisions, the relocation of the Philippine Department Medical Supply Depot from the port area in Manila to a less vulnerable spot at Quezon City, and the construction of medical subdepots at Taríac, Los Baños, and Cebu. On the basis of these considerations, requisitions were made to The Surgeon General for drugs, medical supplies, and aid station and hospital equipment. During the fall of 1941, moderate quantities of medical supplies and the equipment of two general hospitals and five station hospitals were received. One general hospital was stored at a battalion post which had been constructed at Limay
7 United States Army in World War II. The War in the Pacific. The Fall of the Philippines. Washington: U.S. Government Printing Office, 1953.
to house the troops guarding military stores on Bataan. This construction was planned so that the utilities would be suitable for operating rooms, laboratories, wards, and storage areas. Before the outbreak of war, a tentative site was selected in the Real River Valley at kilometer point 162.5, near Cabcaben, for the location of an additional general hospital. Plans were also formulated for the development of a medical center in Manila of approximately 3,000 beds as stabilized warfare was anticipated. 8
There were 78,000 military and 6,000 civilian employees available in Luzon for defense when war began on 8 December 1941; a force more than twice as large as provided for by War Plan Orange-3. Also, there were approximately 25,000 civilians in Bataan whose feeding and medical care became the responsibility of the military.
The defense forces in Luzon consisted of the Philippine Division (composed chiefly of Philippine Scouts), a U.S. Army unit, nine partially mobilized Philippine Army Divisions, and miscellaneous U.S. Army troops. The Philippine Army Divisions varied from 4,000 to 6,000 men each and were organized into the North Luzon Force and the South Luzon Force with the mission of defeating the enemy at the beaches. The Philippine Division was immediately ordered into reserve in Bataan, and the Luzon Forces were moved forward to previously chosen sectors. The Japanese Forces, supported by an overwhelming air force, succeeded in driving the Filipino-American Forces back from the beaches and prevented them from establishing any successful defense positions in central Luzon. By late December 1941, both of the Luzon Forces had been forced to withdraw from southern and central Luzon and were entering Bataan preceded by several thousand civilians. 9 During this phase of military operations, the effects of malaria on the troops were negligible.
On 8 December 1941, the Philippine Department surgeon instructed the medical supply officer of the Philippine Department to purchase all available antimalarial drugs, hospital supplies, and equipment which could be procured in Manila, and a similar program was begun at Cebu. The amounts procured proved to be a valuable supplement to the limited stocks on hand. Remarkable progress was made in the establishment of a hospital center in Manila, but, in view of the rapid withdrawal of the Filipino-American Forces, War Plan Orange-3 was placed in effect on 22 December 1941, and it became an urgent necessity to transfer all available medical resources to Bateau. On 22 December, a medical cadre was transferred to Limay to establish General Hospital Number 1. On 25 December, a similar cadre was transferred to kilometer point 162.5, near Cabcaben, to establish General Hospital Number 2. The
Wibb E. : Medical Department Activities in the Philippines from 1941 to 6
May 1942, and Including Medical Activities in Japanese Prisoner of War Camps.
movement of medical supplies and equipment to Bataan was accomplished during the period 23 December to 31 December, inclusive. Approximately 100 truckloads of medical supplies were moved by road, and many barges were sent both to Corregidor and Bataan.
Unfortunately, much equipment and some drugs and medical supplies were abandoned in Manila because of limited time, extreme congestion of the single road into Bataan, and limited shipping facilities. The Philippine Army medical units lost much of their medical equipment and supplies during the early contact with the enemy and in their precipitate withdrawal to Bataan.10 The Philippine Army soldier was not provided with a mosquito bar. Many of the U.S. soldiers who were. provided with this item discarded it as they considered it to be a useless inconvenience.
When the withdrawing Filipino-American Forces arrived in Bataan, they assumed a defense line across the northern part of the peninsula from Abucay on the east coast to Moron on the west coast (map 29). The central and western sectors of the defense line were mountainous, and the jungle was extremely dense on the lower slopes. An all weather highway, located 15-20 kilometers to the rear, connected the east and west roads at Pilar and Bagac and provided an excellent route for the evacuation of casualties.
Elements of the Japanese 14th Army carried on a sustained frontal attack beginning early in January 1942, on the east side of the main line of resistance combined with penetration of the mountainous center and infiltration to the rear of units on the west coast (map 29). This caused the U.S. Forces to withdraw on 24-25 January 1942 to a new line through the waist of the peninsula, parallel to and slightly below the east-west Pilar-Bagac road. Use of this road was then precluded, and the development of trails and roads became mandatory to provide egress to the main east and west roads. The transportation of casualties from forward units to the general hospitals in the rear then posed an almost insoluble problem. General Hospital Number 1 at Limay was abandoned, having come within range of Japanese artillery, and personnel and equipment were moved to Little Baguio, kilometer 167, in the general vicinity of Mariveles.
The Japanese made repeated attacks during February with several penetrations of the Filipino-American line and also attempted coastal landings to the south and rear. All of these efforts were defeated, and, by the latter part of February, the Japanese 14th Army had become ineffective from casualties and disease and was withdrawn. Similarly, the Filipino-American Forces were now in dire straits from disease and malnutrition. During March,, the Japanese 14th Army was reinforced with fresh troops and resupplied while the Filipino-American Forces remained in position awaiting the final blow. This came early in April and resulted in total collapse of the Bataan defense forces with surrender on 9 April 1942.
10 See footnote 8, p. 500.
THE MALARIA PROBLEM
One estimate, which was probably conservative, judged the number of cases of malaria in Filipino-American Forces at the time of surrender, on 9 April 1942, to be 24,000.11 No estimate is available of the number of cases in civilian refugees or in the Japanese Forces on that date. In a survey of 1,252 U.S. patients at General Hospital Number 2, made 3 weeks after the surrender of Bataan, 817 (65 percent) gave a history of having been treated for malaria during the preceding 4 months.12 Early in March, the commanding officer of General Hospital Number 2, had reported an estimated 60 percent incidence of malaria in personnel assigned to the hospital. The appalling death rate in Japanese-held prisoners of war during the first 6 months of captivity is further evidence of the catastrophic effects of infection contracted in Bataan. A substantial number of these deaths is attributable to malaria.
Malaria reconnaissance of Bataan before World War II had clearly demonstrated that it was a formidable reservoir of malaria. The military situation required the placement of some 80,000 troops and several thousand displaced civilians in areas of high malarial endemicity. Some of the military units were located on the flat coastal plain, immediately adjacent to Manila Bay, which is relatively free of malaria, but the majority were located on higher ground within flight range of A. minimus flavirostris which preyed upon a heavily infected native population.
The civilian health authorities before 1941 had not been able to carry out an effective control program in Bataan. The military personnel did not have the authority nor the resources to carry out an antimosquito campaign throughout the entire extent of Bataan and had planned to rely chiefly on prophylaxis and careful campsite selection for peacetime needs. Aside from a limited program of prophylaxis, no antimalaria control measures of any significance were carried out during the campaign.
Quinine prophylaxis consisting of .650 gm. once daily was instituted for the Philippine Scouts of the Philippine Department upon their arrival in Bataan early in December 1941 and for service units working in the rear areas. The application of quinine prophylaxis to the Philippine Army divisions was not authorized because of an insufficient supply of quinine. Approximately 4,500,000 five-grain (.325 gm.) tablets of quinine sulfate were available in the Philippine Department Medical Supply Depot at the outbreak of war. This was only sufficient for 30 days' prophylaxis on the basis of 10 grains (.650 gm.) of quinine per man per day. In spite of the lack of a formal program of prophylaxis for the Philippine Army, many of the officers and men procured sufficient quinine for their personal use. The limited program of prophylaxis was hampered by inaccessibility of units, difficulty in medical supervision, and sus-
11 See footnote
8, p. 500.
tained combat. Many breaks in quinine discipline occurred. After 15 February 1942, quinine prophylaxis had virtually ceased except for personnel of the general hospitals, certain rear service units, and division, corps, and force headquarters.13
The diagnosis of malaria in the general hospitals in Bataan was made by the demonstration of the plasmodia in stained blood films. Positive film diagnosis was based on the presence of standard, well-documented, identification characteristics of the individual species. Approximately 60 percent of the blood films were positive for Plasmodium vivax, 35 percent for Plasmodium falciparum, and 5 percent for both types of Plasmodia. An occasional case of quartan malaria was diagnosed. It is likely that blood films taken earlier in the course of malaria and at frequently repeated intervals would have resulted in the finding of a higher incidence of mixed infections. Limited facilities precluded more comprehensive studies but were sufficient for fairly adequate screening until the final chaotic days preceding surrender. The degree of parasitemia in the falciparum cases was strikingly more evident when contrasted with the number of plasmodial forms seen in positive vivax blood films.14 Microscopes were not available in the forward medical units initially, but, for a limited period, a few were provided as the military operations stabilized. On the whole, in the forward areas, reliance had to be placed on clinical acumen for diagnosis.
The treatment of malaria in vogue in 1941 consisted of 2 gm. of quinine sulfate daily by month for 5 days followed by .030 gm. of Plasmochin naphthoate (pamaquine naphthoate) daily in three divided doses for 5 to 7 days. Atabrine was an acceptable substitute for quinine. The long quinine treatment calling for .650 gm. of quinine daily for 8 weeks, after the initial 5-day treatment of the acute phase, was considered effective but difficult to supervise. The short quinine treatment consisting of 1 gm. to 1.3 gm, of quinine daily for 4 to 7 days, repeating for relapses, was considered to be acceptable in that it avoided the disadvantages of prolonged quinine therapy and was fairly successful. As Plasmochin and Atabrine were available only in limited amounts, a short quinine treatment was most commonly prescribed.
IMPACT ON DEFENSE FORCES
The deleterious effects of malaria on the troops in Bataan became strikingly evident in February 1942 and were aggravated by the universal state of malnutrition. Within less than 1 month after the outbreak of war, 8 December 1941, the defense forces were confronted with an acute food shortage. On 5 January 1942, the entire force was placed on half rations. The basic ingredient, of necessity, was rice, mostly of a poor quality. This was supple-
Lt. Col. James O. Gillespie, MC, to Gen, George C. Marshall, 26 Jan. 1942,
subject: Medical Supplies.
mented by small amounts of white flour, canned goods (salmon, meat, tomatoes), evaporated milk, and irregular issues of fresh carabao. Tea, coffee, sugar, and butter were unavailable after 1 month. The ration was grossly deficient in protein, fat, and vitamins. It provided a maximum of 2,000 calories in January, gradually diminishing to 1,000 calories by early March and almost to the vanishing point by 1 April 1942.
The ill effects of semistarvation on the troops had become critical by late February 1942. The Surgeon of the Advance Echelon of USAFFE (U.S. Army Forces in the Far East), Bataan, advised the Surgeon, USAFFE, on Corregidor, in a memorandum dated 27 February 1942, that the diet of troops on Bataan was grossly deficient and urged increased allowances of beef, vegetables, milk and the procurement, if possible, of native fruits and vegetables, and in their absence the procurement of vitamin supplements.
By the third month of operations, weight loss in the range of 20 to 30 pounds was commonplace. Men complained of weakness, lassitude, lack of endurance, and shortness of breath. Moderate exertion caused tachycardia and palpitation. Those nominally listed as effective for combat could not engage in sustained exertion, so it became increasingly difficult to accomplish necessary work on airstrips, maintenance of roads, clearing of trails, hand carrying of supplies over mountainous terrain, and patrol activities. Gradually, the high morale and confidence of January was replaced by a loss of spirit and apathy. Dire predictions for the future could be heard. To lessen the morale- further, the men began to note swelling of the ankles with pitting on pressure which was particularly evident toward evening. The pangs of hunger became more insistent.
Beginning about mid-February 1942, the sickness rate began to rise abruptly. The majority of patients were medical cases suffering from malaria or dysentery and showing evidences of malnutrition and avitaminosis. Some showed loss of subcutaneous fat and muscle wasting. Others appeared with a considerable degree of edema of the lower extremities. A few patients from isolated units who had undergone more severe deprivations showed marked peripheral neuritis with footdrop and wristdrop. Patients with wounds and fractures began to show a slower rate of healing. 15
Up to the first week in March 1942, the evacuation of the sick and wounded had been accomplished in an orderly fashion. Certain patients who ordinarily would have been transferred to the general hospitals had been treated by medical units because of inaccessibility to motor vehicles. The general hospitals had expanded to meet the continually increasing demand for beds through the device of manufacturing bamboo cots and clearing larger areas of the jungle to provide space for them. Then, beginning approximately 7 March 1942, patients by the hundreds began to arrive daily at the re-ar hospitals. Most of them appeared to be suffering from malaria. Shortage of quinine
15 History of General Hospital No. 2, Bataan, P.I., 28 Dec. 1941 to 9 Apr. 1942, from personal papers of Maj. Gen. James O. Gillespie.
then required the adoption of a modified short quinine therapy utilizing 15 gm. or less of quinine rather than the standard treatment of 35 or 40 gm.
Admissions for cerebral malaria became evident early in March 1942. These were chiefly men from isolated units who were in unusually poor physical condition from stress and malnutrition and for whom medical attention was not available. The number of these cases reaching the general hospitals was not large; in all they did not exceed 100 cases. Cerebral manifestations of malaria were usually associated with P. falciparum. The symptomatology was variable but frequently appeared with coma and a shocklike state or with delirium, convulsions, and maniacal reactions. Responses to intravenous quinine was dramatic. More often the lack of that item required the administration of 3 or 4 gm. of quinine sulfate by stomach tube. Usually the mental component of the disease was relieved in 3 or 4 days.
Malarial patients who were severely depleted from diarrhea and malnutrition did not respond well to massive antimalaria therapy. Occasional patients receiving 2 gm. of quinine sulfate daily by mouth continued to have fever and positive blood films. Other individuals on suppressive therapy of .650 gm. of quinine daily developed chills and fever and positive blood films. The same phenomena were noted frequently at prison camps during the summer of 1942. One case of blackwater fever was seen at general Hospital Number 2 in a civilian who lived in Bataan. Two cases in Japanese-held prisoners of war (one British and one Dutch) were seen during 1943 in a prison camp in Formosa.
Early in March 1942, Col. Arthur F. Fischer, USAR, while convalescing from malaria in Bataan, called the attention of Maj. Gen. Jonathan M. Wainwright's headquarters to 100,000 kilograms of high-grade quinine bark available in Mindanao, from which totaquine could be extracted.16 Dr. Fischer had pioneered the introduction of cinchona into the Philippines and had worked with that program for 18 years. He was flown to Mindanao for the purpose of beginning large-scale extraction of the quinine bark. Penetration of the area by Japanese Forces prevented completion of the project, and Dr. Fischer was flown to Australia carrying seeds for the establishment of cinchona plantations in South America.
The catastrophic impact of disease and semistarvation on the combat effectiveness of the Filipino-American Force in Bataan was recognized to be of the utmost gravity by all levels of staff and command. On 10 March 1942, the commanding officer of General Hospital Number 2, directed a letter regarding malaria control to the Surgeon, Philippine Department, a portion of which is quoted.
I would like to point out a grave problem pertaining to the Medical Department and the USAFFE. Malaria is rapidly increasing: some 350 cases were under treatment in this hospital as of March 5th. The admission rate is alarming, sonic 260 patients
16 Personal communication. Col. Arthur F. Fischer, USAR, to Maj. Gen. James O. Gillespie, 24 July 1956.
arriving March 9th. Most of these are medical and a large proportion have malaria. * * *. Quinine prophylaxis having stopped we anticipate additional hundreds or even thousands of cases * * * . We are urgently in need of a tremendous stock of quinine for treatment arid prophylaxis. The General Staff should understand the extreme gravity of the malaria problem and give priority to quinine above that of any other critical item. If the malaria situation is not brought under control the efficiency of the whole Army will be greatly impaired; in fact it will he unable to perform its combat functions. It is my candid and conservative opinion that if we do not secure a sufficient supply of quinine for our troops from front to rear that all other supplies we may get, with the exception of rations, will be of little or no value.
The USAFFE Surgeon, Corregidor, in a memorandum to the Assistant Chief of Staff, G-4 (logistics), USAFFE, on 22 March 1942, stated that there were 3,000 cases of malaria in Bataan and that the numbers were increasing at an alarming rate. He referred to the extremely high noneffective rate in combat units and recommended that 3 million quinine tablets be sent from Australia by air at once with a like quantity thereafter each month.
To deal with the overwhelming flood of patients in the forward units and to relieve pressure on the general hospitals, the Surgeon, Luzon Force, early in March, directed that battalion aid stations and clearing and collecting companies assume the responsibility for the treatment of all patients except those whose condition was of the utmost gravity.17 The aid stations were expanded to 200 to 300 beds (bamboo construction) while the clearing and collecting companies handled from 600 to 900 patients each.
The Surgeon, Luzon Force, reported on 23 March 1942, in a letter to the commanding general, that the daily admission rate for malaria had reached 500 to 700 cases and that the available supply of quinine at the medical depot in Bataan was sufficient, using a short course of treatment, only for approximately 10,000 cases of malaria. He anticipated exhaustion of the stock in 3 or 4 weeks and predicted a mortality rate of 7 to 10 percent in untreated cases. Extreme concern was expressed regarding the sharply rising noneffective rate in relation to combat potentialities of the Force. Writing to the Chief of Staff, USFIP (U.S. Forces in the Philippines), on 31 March, the Chief of Staff, Luzon Force, referred to a malaria admission rate reaching 1,000 cases daily and to the imminent loss of combat effectiveness.
By the end of March, some 7,000 patients were hospitalized in the forward medical units, a mere mile or so behind the main line of resistance. These represented only those who were severely incapacitated. Actually, at least 80 percent of the troops had become unfit for duty. One regimental surgeon described the situation as follows:18
To give an accurate word-picture of conditions as they actually existed at the time immediately preceding the surrender of our forces on Bataan would tax the descriptive powers of a rhetorical genius, hut in simple language, almost every man in Bataan was suffering, not only from the effects of prolonged starvation, but also from one or both of the acute infections that plagued us throughout the campaign, viz, dysentery and malaria. I
17 See footnote
8, p. 500.
have seen men brought into the battalion aid stations and die of an overwhelming infection of dysentery or cerebral malaria before they could he tagged and classified for evacuation. Of the supposedly well men in the field, all were thin and weak from starvation. Many were swollen with nutritional edema; a large percentage were pale and anemic from repeated attacks of malaria or dysentery.
As early as January 1942, General MacArthur had made urgent requests to the Chief of Staff, U.S. Army, for food and medical supplies to be sent through the Japanese blockade by any possible means. General Wainwright in March reiterated the extreme urgency of his requirements for both items and, in response., Gen. (later General of the Army) George C. Marshall, Chief of Staff, requested that maximum amounts of quinine be sent from Australia by air. This could not be accomplished, but 1 million tablets of quinine sulfate were brought by air from the medical depot at Cebu to Bataan. This supplement proved to be sufficient to provide at least a short type of therapy, and no hospitalized patients were denied quinine before surrender. The death rate from malaria before capitulation therefore was extremely low.
When the final Japanese attack began on 3 April 1942, it became imperative to move all patients from forward medical units to the rear hospitals. Approximately five thousand patients were absorbed at General Hospital Number 2 between 5 April and 8 April; other thousands were directed to a convalescent camp in its vicinity. 19 On 9 April 1942, all surviving members of the Filipino-American defense force, including patients and medical personnel, were categorized as captives and thereafter were required to submit to the orders of the Imperial Japanese Army.
IMPACT ON CIVILIAN REFUGEES
The situation of the several thousand civilian refugees behind the Filipino-American lines became increasingly desperate during the period 7 January to 9 April 1942. Most of these refugees were located in the Limay Mariveles Cabcaben areas which previously had been established as regions of severe malarial infection. There they lived in refugee camps and were issued the same meager rations as the Army received. Medical attention was provided by refugee Philipino physicians in crudely improvised hospitals. These people were without protection from malarial mosquitoes, and they suffered severely from malaria having no antimalarial drugs for treatment. These unfortunates were often threatened by bombing raids on nearby villages and military installations. Many were wounded and killed.
A mass evacuation from Bataan of refugees and Filipino military patients began immediately following capitulation on 9 April 1942. These individuals trudged along the east road leading out of Bataan. Many of them were ill with malaria and dysentery. Among them were old men, women, and children, carrying their total possessions in assorted bundles, bags, and cans. The pro-
19 See footnote 15, p. 505.
cession continued for days. Often, the seriously ill would fall by the roadside to die, and after a few days several hundred bodies could be counted along the road between Cabcaben and Limay.
The disruptions caused by war resulted in a considerable increase in the incidence of malaria in Bataan and adjacent provinces after the conclusion of the campaign in 1942. This was brought about by the huge increase in the numbers of human carriers who had become infected and for whom proper treatment was not available, and by the complete breakdown of control measures. Studies made on the civilian refugee population evacuated from Bataan in 1942 showed a large increase in the malaria rate, and it was noted that the disease was more difficult to treat with the higher death rate. Over 24,000 cases of malaria were diagnosed in civilian emergency hospitals in Bataan and surrounding provinces during the fall of 1942.20 The overall mortality rate was 2.2 percent. Before the war in 1941, the fatality rate in the same provinces had been 0.64 percent. An intensive malaria control program was carried on in Bataan from 1942-44 by direction of the Japanese military command.
IMPACT ON THE JAPANESE FORCES
The impact of malaria on the Japanese Forces can only be partially documented. The Japanese Army had planned for a quick operation in Bataan, expecting to overcome the Filipino-American troops in a week or 10 days. When they met with firm resistance which continued during January and February, their troops began to suffer from some of the same deprivations and diseases which harassed the Filipino-American Forces. The Japanese ration for their troops on Bataan was meager, although it did not reach the low point of the Filipino-American ration. The Japanese were exposed to the same hazards from malaria, diarrhea, and dysentery. By mid-February, the Japanese 14th Army was definitely depleted, chiefly from malaria. 21 An interpreter who served with the Japanese 14th Army in Bataan stated to the senior Japanese-held U.S. medical officer in July 1942, that the Cabanatuan prison camp situation, where over 3,000 seriously ill Americans were incarcerated, reminded him of the illness suffered by the Japanese troops in Bataan. He asserted that in some units of the Japanese Army the noneffective rate from malaria and dysentery reached 90 percent and that the death rate from malaria was very high. He stated that the former U.S. military hospital, Steinberg General Hospital, was packed to capacity with Japanese soldiers who had become ill in Bataan.
On 10 April 1942, a Japanese guard of 20 men was assigned to General Hospital Number 2. Approximately 60 percent of these soldiers were acutely
Cornelio M.: Epidemiology of Malaria in Bataan Before the War and During
the Japanese Occupation, and Malaria Control From 1942 to 1944. Philippine
Islands Health Service Monthly Bulletin 23: 297-344, 1947.
ill with malaria within 3 weeks. No medication was provided for them by the Japanese Army. They were treated however, by U.S. medical officers at the direction of the Japanese Army. It was estimated by Horiguchi, surgeon of the Japanese 14th Army, that 10,000 to 12,000 Japanese soldiers were ill with malaria, dysentery, and beriberi in February 1942 and that less than 3,000 effective men remained. The Japanese 14th Army had begun their campaign with only 1 month's supply of quinine, and in January its use for prophylaxis was discontinued except for frontline troops; after 10 March, quinine was available to them only for therapy. Thus, it seems clear that the firm resistance of the Filipino-American Forces in Bataan, combined with extensive infestation of the Japanese troops with malaria, resulted in an upsetting of the Japanese timetable for the prosecution of the war in the Philippines. This was a significant matter as Japanese troops had to withdraw from Singapore to complete the campaign in Bataan.
IMPACT ON THE FILIPINO-AMERICAN PRISONERS OF WAR
The tragic story of the appalling loss of life in the Filipino-American Forces after the surrender is directly related to malnutrition and disease experienced in Bataan. Malaria contributed significantly to the impressive mortality. Other significant factors included prolonged marches to the prison camps in tropical heat, inadequate food, lack of potable water, lack of medical supplies, deplorable sanitary conditions, extreme overcrowding, and overwork. Twenty-nine thousand five hundred eighty-nine deaths occurred in 1942 at Camp O'Donnell in Japanese-held prisoners of war from Bataan. Six thousand one hundred twenty-nine (20.7 percent) clinically were attributed to malaria.22 Four hundred ninety-eight deaths occurred in U.S. prisoners at Cabanatuan Prisoner-of-War Camp Number 1 during June 1942. One hundred twenty-eight were diagnosed as caused by malaria. During July 1942 in the same camp 789 U.S. prisoners died. Beginning approximately 1 August 1942, sufficient quinine was provided by the Japanese to treat 1,600 cases of active malaria, using 14 gin. of quinine sulfate per patient.23 Deaths decreased to 240 during the month of August. On 31 August 1942, the senior Japanese-held U.S. medical prisoner of war requested in a letter to the Japanese camp commander, Cabanatuan Prisoner-of-War Camp Number 1, that 750,000 3-gram tablets of quinine sulfate be furnished to treat an estimated 3,119 cases of malaria. The quantity desired was not obtained, and needless deaths continued. Two thousand four hundred deaths occurred in Japanese-held U.S. prisoners of war at Cabanatuan Prisoner-of-War Camp Number 1 from 1 June to 1 December 1942. Approximately 25 percent of these deaths clinically were attributed to malaria.
22 See footnote
20, p. 509.
Japanese-held prisoners of war in the Philippines were subjected to an extreme degree of stress during the first 6 months of captivity. Semistarvation, begun in Bataan, continued for many months after capture. Nutritional edema (wet beriberi), multiple avitaminosis, burning feet syndrome, and pellagra affected 95 percent of prisoners to a greater or less degree. Diarrheal conditions, including specific dysenteries, were commonplace. Two hundred twenty-three prisoners contracted diphtheria between 10 June and 8 August 1942 at Cabanatuan Prisoner-of-War Camp Number 1. Ninety-one of these died. Men depleted by such a variety of conditions did not respond to antimalarial drugs in the manner observed in healthy individuals. The failure to respond may have been due to poor absorption of quinine from the gastrointestinal tract. When intravenous quinine was given, response was satisfactory. Unfortunately, almost none was available.
The protean manifestations of malaria in the prison camps caused much confusion in the presence of dysentery and malnutrition with avitaminosis. Gastrointestinal symptoms such as nausea, vomiting, and severe diarrhea were frequent in proved cases of malaria. Others showed symptoms of acute appendicitis or other acute abdominal crises. These were soon recognized as manifestations of malaria requiring search of a blood film for plasmodia as the most important laboratory procedure. Response to antimalaria therapy often was dramatic in these cases.
Throughout more than 3 years of captivity, malaria recurrences were very frequent in prisoners in the Philippines, Formosa, Japan, and Manchuria. A few individuals had as many as 20 relapses. As a cause of death, malaria became less important during 1943-44 not only because of the better conditions of diet and improved therapy but also because of the tremendous death rate which had eliminated the most severely ill. As late as 1945, an appreciable number of prisoners of war were suffering from malaria relapses.
The defeat of the Filipino-American Forces in the Philippines undoubtedly was hastened by the conditions resulting from a semistarvation ration with the additional deleterious effects from common diarrheas, dysentery, and malaria. The Surgeon, Luzon Force, expressed his opinion as follows:
The capitulation of Luzon Force represents in many respects a defeat due to disease and starvation rather than to military conditions. Malnutrition, malaria, and intestinal infections had reduced the combat efficiency of our forces more than 75 percent. The Bataan campaign can best he described as a campaign of attrition, a campaign in which consumption without replenishment was the rule. The physical fitness of Our troops was so seriously impaired by 1 March that it became a determining factor in tactical Operations. From that date onward the physical deterioration of our forces was so rapid that by 2 April a successful defensive stand was no longer possible.24
24 See footnote 8, p. 500.