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Chapter 11

Contents

Part IV

EUROPE


CHAPTER XI

The United Kingdom

Pauline B. Vivette

* * * it must be recognized that the health of a military force is vitally affected by the health of the civil community in which it is stationed, whether stationed on a belligerent or a friendly basis. In many respects, the friendly basis favors closer contact with the civil population than does the belligerent so that the health problems of the civil community may be more readily reflected in military experiences.1

HISTORICAL NOTE

American citizens, including the President of the United States, had long been apprehensive about the state of affairs in Europe; but, when Adolf Hitler's forces invaded Poland on 1 September 1939, and France and the United Kingdom of Great Britain and Northern Ireland2 declared war on Germany 2 days later, American apprehension changed to simultaneous planning and action in many directions. The history of public health activities in Civil Affairs/Military Government in the United Kingdom demonstrates again and again the value of careful planning and action as it also demonstrates the power of negotiations and agreements at the conference table.

Foreign policy in the United States from 1933 to 1939 had remained in a subordinate position to the reforms of President Franklin D. Roosevelt's New Deal. Neutrality legislation from 1935 to 1939 fulfilled the overwhelming desire of the American people to stay out of war. President Roosevelt called a special session of the 76th Congress, in July 1939, to rescind the binding provisions of the neutrality acts, but the Senate declined by marginal vote to consider any revision of the acts. It was not until after war came to Europe that President Roosevelt persuaded the Congress to lift the embargo on arms to make possible giving aid to the United Kingdom and other countries fighting the Axis powers. By mid-1941, the United States

1This statement represents one of the basic principles underlying prewar planning for effective military and civilian health in areas where it was thought troops might be stationed; it is recorded in (1) the early working papers of Col. (later Brig. Gen.) James S. Simmons, MC, and published in (2) Simmons, James Stevens, Whayne, Tom F., Anderson, Gaylord West, Horack, Harold MacLachlan, and collaborators: Global Epidemiology; A Geography of Disease and Sanitation. Vol. 1. Philadelphia, London, Montreal: J. B. Lippincott Co., 1944, pp. vii-viii, x.
2Since 1927, the official name of this country has been the United Kingdom of Great Britain and Northern Ireland. The territory includes England, Scotland, Wales, and Northern Ireland. Popular terms used in this chapter (United Kingdom, Great Britain and Northern Ireland, Great Britain, and the British Isles) are used interchangeably. Formerly, from 1801, the official name of the country was the United Kingdom of Great Britain and Ireland.


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had become an "arsenal of democracy," and ties between this country and the United Kingdom were greatly strengthened.

The coalition between the United States and Great Britain in World War II, naturally attended by some controversy and differences of opinion, is generally agreed to have been "the closest and most effective partnership in war that two great powers have ever achieved." In an unbroken series of talks and agreements, both nations decided jointly what was necessary and desirable to do next to gain the maximum military advantage from any future situation.3

Lend-Lease and American-British Staff Conversations

Early in 1941, two important developments strengthened and drew the United States and the United Kingdom closer. The U.S. 77th Congress enacted the Lend-Lease Act on 11 March, initially allotting a fund of $7 billion to provide war materials for the democracies whose security was vital to that of the United States. Before the Lend-Lease measure passed, military leaders of both countries met in Washington in the first of several conferences which were to have far-reaching effects on the future conduct of the war and to influence all of the affairs of the two countries. Representatives of these conferences initiated a series of meetings called the American-British Staff Conversations; a joint planning staff was established in each of the other's capital; and the decision was made to concentrate the principal effort in Europe should the United States be forced into a war with both Japan and Germany.4

Passage of the Lend-Lease Act resulted in Winston Churchill's famous and inspiring words:5

These two great organizations of the English-speaking democracies, the British Empire and the United States, will have to be somewhat mixed up together in some of their affairs for mutual and general advantage. For my own part looking out upon the future, I do not view the process with any misgivings. I could not stop it if I wished. No one could stop it. Like the Mississippi it just keeps rolling along. Let it roll. Let it roll on full flood.

The agreement to collaborate continuously and the passage of Lend-Lease had a tremendous impact on all joint affairs. Within the framework of this design, the tone and style were set for Anglo-American public health activities in Civil Affairs/Military Government made necessary by the presence of U.S. forces in the United Kingdom.

3Greenfield, Kent Roberts: American Strategy in World War II; A Reconsideration. Baltimore: The Johns Hopkins Press, 1963, p. 24.
4Ruppenthal, Roland G.: United States Army in World War II. The European Theater of Operations. Logistical Support of the Armies. Volume I: May 1941-September 1944. Washington: U.S. Government Printing Office, 1953, pp. 13-14.
5Reprinted in The Times, Times Publishing Co., London, England, 11 June 1942, p. 5b. These moving words of Mr. Churchill foretold in certain terms the intimacy developing between two nations joining their strengths to defeat a common enemy: he captured the spirit of the day and prophesied the tolerance with which either nation would accept inevitable impingements from the other in this unavoidable mixture of civil and military affairs. Desire to win the war outweighed cultural differences.


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Those actions taken by our military in the United Kingdom to protect the health of troops and civilians were tempered by joint aims.

General Characteristics of Civil-Military Public Health Activities

Operating a military base in a foreign sovereign country is a complicated affair, but the British Government made every overture to the American guests to reduce the disadvantages to a minimum.6 The U.S. Army's preventive medicine service and command surgeons at all echelons struggled hard to avoid any impingement on British public health domains, but quite naturally, some problems and difficulties did occur.

Public health decisions in civil affairs and military government were reached by negotiation and agreement between the United States and United Kingdom military and civilian medical authorities. Their close association from local to higher levels fostered the intimate exchange of ideas and information for the control of disease. Thus, military preventive medicine did not function separately but was closely concerned and associated with the problems of the civilian population where the Army was stationed.

This chapter describes public health activities in Civil Affairs and Military Government that arose because of the presence of U.S. troops,7 staging and training, in the United Kingdom; it also deals with the preliminary public health planning leading up to the landings of the troops on the Continent. The general story is told in some detail, and each pertinent problem or entity is discussed with some thought toward revealing how American troops in the United Kingdom might have impinged on the British rights, conveniences, resources, customs, practices, and requirements.8,9

Beginnings of World War II Civil Affairs

At the onset of World War II, the civil affairs program in the War Department was a comparatively new development, and the civilian health phases there underwent a natural growth process of organization (see p. 12). The formal program in the United Kingdom, after the United States entered World War II, evolved slowly from its inception at Belfast, Northern Ireland, in May 1942 until mid-1944. On the larger scale of ETOUSA (European Theater of Operations, U.S. Army), this civil affairs activity attained success only when it came to be recognized by Supreme

6Ross, William F., and Romanus, Charles F.: The Quartermaster Corps: Operations in the War Against Germany. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1965, pp. 294 and 318.
7The terms "U.S. forces," "U.S. troops," and "American troops" refer to U.S. ground, air, and services of supply components.
8Conference on entire procedure for chapter with Dr. Stanhope Bayne-Jones (Brigadier General, Ret.), and Lt. Col. Frederick Bell, Jr., MSC, Chief, Special Projects Branch, The Historical Unit, U.S. Army Medical Service, 3 Aug. 1965.
9For civil affairs/military government activities on the Continent of Europe, see chapters XII and XIII, pp. 405, 431.


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FIGURE 44.-Col. John E. Gordon, MC.

Headquarters, Allied Expeditionary Force, as a General Staff function and an integral part of operational plans and command responsibility.10

In the combat zones, the General Board, U.S. Forces, ETOUSA, reported: "Military necessity is the determining factor in the execution of Civil Affairs operations and the practice of Military Government control."11 Early and continuous developments in the United Kingdom influenced the evolution of public health activity of Civil Affairs/Military Government designed to restore and maintain order in the wake of advancing troops in Europe.

The ultimate bearing of the program on the management of civilian and military health problems occurred as a result of the presence of U.S. troops in the United Kingdom. According to Lt. Col. (later Col.) John E. Gordon, MC (fig. 44), who, throughout the war, was chief of the Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, and who had close and continuous association with British public health officials: "The tactical problems incident to contact of a home population and a foreign

10Bailey, John Wendell: An Outline Administrative History of Civil Affairs in the ETO, G-5, Appendix: Public Health, First U.S. Army, to July 1, 1944, pp. 175-199. [Official record.]
11Report, The General Board, United States Forces, European Theater. Civil Affairs and Military Government Organizations and Operations. Study Number 32, subject: The Organization and Operation of Civil Affairs and Military Government in the European Theater of Operations [1946], p. 3.


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army provided all manner of interesting and sometimes distressing and trying situations."12

During staging of U.S. troops in the United Kingdom, the public health element of Civil Affairs and Military Government was seldom more than a fragmentary and confusing attempt to clarify its position with respect to the Office of the Chief Surgeon, ETOUSA, a factor not unusual, for "during the initial stages of military action there is usually no Civil Affairs Division, as such; it develops gradually, and under Army guidance, as the troops advance."13 However, formal relationships between the public health element of Civil Affairs and Military Government and the Office of the Chief Surgeon, ETOUSA, known to have been unsatisfactory, will not be explored here.14

Buildup in the United Kingdom

By D-day, 6 June 1944, the United Kingdom of Great Britain and Northern Ireland, smaller in area than the State of Oregon, was literally teeming with Allied troops, refugees, displaced persons, and the hardware of war; each was so much in evidence that one reporter was led to say, "The island would sink if the barrage balloons were cut."

The buildup of U.S. forces in the United Kingdom had been gradual and steady, with strength figures interrupted briefly by the flow of troops to North Africa for the TORCH operation in November 1942. From the beginning of the buildup in January 1942 to its height in June 1944, contingent after contingent of American troops arrived, day after day and month after month, until a total of more than 1.5 million Americans were present by D-day. In addition to the British population of nearly 50 million, troops from most of the dominions and colonies of the British Commonwealth had been present almost since the beginning of the war. Each successive defeat on the Continent brought in waves of Poles, Free French, Norwegians, and other refugees in uniform.

In the beginning, threats of the spread of communicable diseases in the 94,279 square miles of the territories of England, Scotland, Wales, and Northern Ireland were sources of great anxiety. Despite risks, however, not a single epidemic disease got out of hand and the death toll from infectious diseases was surprisingly low.15 Except for small and controlled outbreaks

12Letter, John E. Gordon, M.D., Senior Lecturer, Massachusetts Institute of Technology, Department of Nutrition and Food Science, Clinical Research Center, Cambridge, Mass., to Brig. Gen. Stanhope Bayne-Jones (Ret.), Chairman, Advisory Editorial Board, History of Preventive Medicine in World War II, 28 Apr. 1966, subject: Civil Affairs Public Health Activities in World War II.
13See page 3 of footnote 10, p. 366.
14(1) Report, Col. Thomas B. Turner, MC, to The Surgeon General, U.S. Army, 9 Mar. 1944, subject: Report on Plans for Civil Affairs Public Health in the European Theater of Operations. (2) Bell, Lt. Col. Frederick, Jr., MSC, Memorandum for Record, 1 May 1964, subject: Conference With Dr. John E. Gordon on Chapter XI, The United Kingdom, History of Preventive Medicine in World War II, Volume VIII.
15Medical Department, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts. Washington: U. S. Government Printing Office, 1958, pp. 14, 25.


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of common infectious diseases, a troublesome incidence of scabies, high venereal disease rates at intervals, sporadic occurrences of infectious hepatitis and postvaccinal serum hepatitis in situations where differential diagnosis was especially difficult, the wartime health of civilians and military personnel in the United Kingdom was good.16 The record is even more remarkable when one considers the housing shortages, overcrowding, tremendous ebb and flow of the civil and military populations, sanitation problems, water shortages, food restrictions, nutritional problems, and, in general, the contingencies of war.

Among these contingencies that had considerable bearing on the health of civilians were a number of conditions and problems which occurred among the population irrespective of the presence of U.S. troops. Gordon17 has listed four main examples:

1. The evacuation of young children to the country from bombed and threatened cities, and the attendant hazards of communicable and other diseases in the communities to which they went.

2. The unknown and unevaluated threat of biological warfare and necessary surveillance.

3. The health hazards of crowded air-raid shelters.

4. The infections and other aftereffects of traumatic injury after bombing.

After deliberate analysis, one may say with conviction that the joint activities of the Ministry of Health, the preventive medicine services of the military forces, and the good sense and cooperation of the British population were enough to establish reasonable control of the environment and to have been a real force in the prevention and control of communicable diseases.

Prewar Planning and Activities in America

The United States became sharply interested in the problems of civil health activities under war conditions shortly after the beginning of World War II. When the United Kingdom declared war on Germany in 1939, the probability of war for the United States became increasingly evident. American effort to study public health in Europe's war zone developed simultaneously in many directions.

On the military side, this effort represented an orderly development of the long term planning and preparation in OTSG (Office of the Surgeon General), U.S. Army. Col. (later Brig. Gen.) James S. Simmons, MC, appointed chief of the Preventive Medicine Subdivision in early 1940, initiated many new developments in the public health civil affairs function

16(1) MacNalty, Sir Arthur Salusbury, Editor-in-Chief: History of the Second World War. The Civilian Health and Medical Services. Volume I. London: Her Majesty's Stationery Office, 1953, pp. ix-x. (2) Medical Department, United States Army. Preventive Medicine in World War II. Volume V. Communicable Diseases Transmitted Through Contact or by Unknown Means. Washington: U.S. Government Printing Office, 1960, foreword, p. xi.
17See footnote 12, p. 367.


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and recognized it as something more than military government.18 Under his intelligent and inspiring influence, civil public health, sanitation, sociology, economics, and other cultural elements gained prominence and became integral constituents of the military preventive medicine program. General Simmons recognized medical intelligence as an important part of public health activities of Civil Affairs and Military Government and was an exponent of the scheme for reconnaissance surveys and analyses. To assist in the preparation of firsthand surveys, in early 1940, he arranged for three Sanitary Corps officers to report for active duty in the Preventive Medicine Subdivision. Lt. Col. (later Col.) Ira V. Hiscock, SnC, Lt. Col. (later Col.) William A. Hardenbergh, SnC, and Lt. Col. Albert W. Sweet, SnC, reported in May 1940 and began the preparation of advance surveys on health and sanitary conditions in countries where U.S. troops might eventually be stationed. These officers also assisted in the preparation of the section on health and sanitation in the Manual of Military Government, Field Manual 27-5, 30 July 1940, issued by the Office of the Chief of Staff.

In the Preventive Medicine Service, OTSG, a comprehensive and extraordinarily effective Division of Medical Intelligence was developed through the vision and initiative of General Simmons, and supported by able assistants: Capt. (later Col.) Tom F. Whayne, MC, from June 1941 to March 1943, and Maj. (later Col.) Gaylord W. Anderson, MC, from 27 March 1943 to the end of the war. This division was highly serviceable to civil affairs and military government.19

Before his departure to serve as Military Attaché for Medicine at the American Embassy in London, Colonel Whayne had initiated an expansion of the Medical Intelligence Division. After the establishment of his office at the embassy in March 1943, he provided much valuable information and service. Of particular value to public health activities were the relationships between representatives of the U.S. National Research Council and the British Medical Research Council, of the U.S. Public Health Service and other agencies, which contributed greatly toward the development of fruitful scientific medical and administrative associations with the British. In addition, joint activities of the Military Attaché for Medicine and representatives of the National Research Council, the U.S. Navy, and others who were engaged in exchanging information with the British, helped in every way possible the development of pubic health activities of Civil Affairs/Military Government.

On the civilian side, authorities in preventive medicine and public health administration directed their attention both to a systematic correlation with efforts of medicomilitary authorities and to the means by

18(1) See footnote 1 (2), p. 363. (2) Diary (unpublished), Brig. Gen. James S. Simmons, USA, entry of 20 May 1940 (verified by Dr. Stanhope Bayne-Jones). (3) Medical Department, United States Army. Organization and Administration in World War II. Washington: U.S. Government Printing Office, 1963, pp. 30-31. (4) See ch. I, pp. 4, 7.
19For a full account of the organization, operations, and accomplishments of medical intelligence, see Colonel Anderson's chapter VI in Medical Department, United States Army. Preventive Medicine in World War II. Volume IX. Special Fields. Washington: U.S. Government Printing Office, 1969.


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which civilian staffs, equipment, and experience could be converted to a wartime military organization.20

Prewar Planning and Activities in the United Kingdom

The United Kingdom, much closer geographically to Germany and Italy than to the United States, and far more vulnerable to attack, began serious planning and preparation at least 2 years before the autumn of 1939. Results of this planning were of significance to the United States when Dr. Gordon sailed for England in August 1940 to begin the earliest American civil affairs public health activity in the United Kingdom; and they were equally important when American troops landed and staged there.

One of the first steps to be taken by the Ministry of Health and local authorities was the organization of the Emergency Medical Service for the treatment of casualties, the sick and wounded. During the spring of 1938, 16 months before war was declared, plans were made to evacuate school children, expectant mothers, young children, incurables, cripples, and blind persons from urban centers to hundreds of towns and villages less likely to be subjected to enemy air raids. A grave fear expressed by Great Britain at the outset of the war was the possibility that the national health would be affected.21

By the time war was declared, all of Great Britain had become one gigantic placement agency. Evacuation went off smoothly; in less than 4 days, more than 600,000 children and mothers were moved from London, and a similar number from other large cities, to reception areas in small communities. Some movement of the evacuees between the reception centers and the cities was experienced, but the bulk of the evacuees remained in the centers. The next mass evacuation took place after the fall of the Low Countries in May 1940. By then, satisfactory arrangements had been made to absorb the evacuees in village communities.22

Thus, Great Britain's special arrangements for war emergencies and the evacuation of those who could not contribute to the war effort represented important factors in the maintenance of civilian and military public health and eased the burden for the reception of American troops.

PROGRESSION OF EVENTS

Reconnaissance Survey and Public Health

The Emergency Period, 1940-41, marked the actual beginning of American participation in civilian and military public health activities in

20Gordon, John E.: A History of Preventive Medicine in the European Theater of Operations, U.S. Army, 1941-1945. Volume I, Part I, p. 1. [Official record.]
21See footnote 16 (1). p. 368.
22(1) Jameson, Sir Wilson: War and Health in Britain. Am. J. Pub. Health 31: 1253-1262, December 1941. (2) Eliot, M. M.: Protection of Children in Great Britain in Wartime. Am. J. Pub. Health 31: 1128-1134, November 1941.


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the United Kingdom. These were formative years for America, investigative years, years of accomplishment, years in which this Nation not only studied seriously the effects of war on the health of civilian and military personnel alike in the United Kingdom, but also lent skills to the British in building an imposing record in civil and military public health activity. Success in the prevention and control of diseases in the United Kingdom was so overpowering, it almost completely obliterated the misfortune of what might have happened. One factor remains outstanding. The excellent public health and military preventive medicine record made in the United Kingdom stands in sharp contrast to the frustrating experiences encountered in the North African-Mediterranean theater where public health facilities were not functioning until 8 months after the landings there.

In summing up, the concurrent actions which evolved from many parts of the United States among civilian and military health authorities, in 1940 and 1941, arose from a genuine desire of Americans to aid Great Britain in the prevention and control of diseases, and an urgent need23 to acquire knowledge about the nature of civilian public health in a nation at war; to learn of the policies of military preventive medicine from the British services; and to correlate the two in this kind of war. The British, long at war, had handled this well.

Early observers.-A few Army and Navy medical officers, together with medical representatives of the U.S. Public Health Service, went to the United Kingdom in 1940 to observe British public health conditions. One of the Army officers, Col. (later Brig. Gen.) Raymond W. Bliss, MC, visited England briefly and reported his findings to The Surgeon General. Other military and civilian medical representatives set up headquarters at the American Embassy in 1940 and collected information for later dissemination to the U.S. Army, Navy, Public Health Service, and the National Research Council. These officers developed liaison with the British Ministry of Health and the Medical Departments of both the British and Canadian armies, navies, and air forces.24

National Research Council.-In the early months of 1940, the National Research Council organized a large number of committees at the request of The Surgeon General of the Army to advise on problems of medical research. His request was concurred in by the Surgeons General of the U.S. Navy and the U.S. Public Health Service. The committees played an important role in developing new methods to be used in the control of wartime diseases. One of the most important steps taken by the council was the establishment of close and intimate liaison with the Medical Research Council of Great Britain and the National Research Council of Canada. This resulted in the

23Letter, John E. Gordon, M.D., Department of Epidemiology, School of Public Health, Harvard University, Boston, Mass., to Brig. Gen. Stanhope Bayne-Jones (Ret.), Chairman, Advisory Editorial Board, History of Preventive Medicine in World War II, 7 Nov. 1963, subject: Civil Affairs Public Health Activities in World War II.
24Larkey, Sanford H.: Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, Vol. I. 1945, pp. 1, 11, 20. [Official record.]


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mutual pooling of all scientific medical knowledge. In addition to the exchange of information between the councils, there were many visits back and forth between the countries by military and civilian medical experts.

U.S. Public Health Service.-In February 1941, Surgeon General Thomas Parran of the U.S. Public Health Service spent 6 weeks in the United Kingdom. With a group of five observers, he collected information on infant and maternal welfare, air raid precautions, problems of evacuation, and other features of war which involved total military and civilian populations.

The American Red Cross-Harvard Field Hospital Unit-At the onset of World War II, a wave of sympathy for the welfare of the British people swept over the Harvard University community.25 Harvard's attention naturally turned to the distinguished service rendered the Allies, under similar circumstances, in the First World War. Dr. Harvey Cushing, under the university's sponsorship, had headed the first American medical service unit to enter the fighting zone of France in April 1915; this unit, supported by voluntary contributions, became the nucleus of the famous Base Hospital No. 5, served with the British, and was later transferred to the United States Army when this country entered the war.

During the remainder of 1939 and the first half of 1940, Dr. James B. Conant, president of Harvard University, Dean C. Sidney Burwell, Dr. John E. Gordon, Charles Wilder, Professor of Preventive Medicine and Epidemiology, Medical School and School of Public Health, and other members of the faculty conferred among themselves concerning what could be done to help Great Britain in the fields of nutrition, sanitation, epidemic prevention, or the psychological treatment of shellshock and related war casualties.

After an exchange of views between the representatives of Harvard University and the British Ministry of Health, the services of medical and public health experts were offered to Great Britain. However, the practical difficulties of fitting United States medical and ancillary personnel into the British public health organization became evident. The concept of sending medical experts broadened to include plans to send a fully equipped epidemiologic unit including a small hospital to study communicable diseases and to assist British authorities, both military and civilian, in the control of disease.

After the unexpected swiftness of the German successes in 1940, the fall of France, and the evacuation of Dunkirk, Harvard officials cabled the British Ministry of Health:

25(1) An excellent account of the activities of the unit appears in Dunn, Lt. Col. C. L.: The Emergency Medical Services. Volume I: England and Wales. London: Her Majesty's Stationery Office, 1952, pp. 435-437. (2) All of the quoted matter under this heading is published in The American Red Cross-Harvard Field Hospital Unit. Cambridge: Harvard University Printing Office, 1943, pp. 12, 13, 36-40. (3) In addition, copies of the letters from Sir Wilson Jameson to Dean C. Sidney Burwell are also on file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.


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Harvard ready to send small advance group of expert field and laboratory workers including Gordon to lend technical assistance looking toward organization of comprehensive unit. Ready to finance these men for one year. If this offer acceptable, hope to enlarge group, lengthen period of service, and expand work along lines of your cablegram provided we can raise necessary funds. Have given careful study hospital project and find it involves considerable delay. Therefore believe if need urgent quicker features should be initiated at once. Fund raising for any purpose increasingly difficult at this time; therefore assurances from British authorities on two points would be of greatest assistance: First, urgency of need of entire project; second, actual extent of contribution British ready to make to support of larger plan.

The British Ministry of Health replied: "Gratefully accept your generous offer. Consultation desirable as to answers to your questions and development of future plans with support from this government. Therefore cordially invite Dr. Gordon to visit us immediately and report to you."

Three steps were now before the university:

1. Making arrangements to send Dr. Gordon and an associate to England as the advance guard of the Harvard Public Health Unit.

2. Securing financial support for the Harvard part of the venture.

3 Finding an organization which might undertake the planning, construction, and staffing of a portable field hospital, stressed by the British as of vital importance to their plans as a citadel in state of siege.

With the invitation of the British Government and the cooperation of the U.S. State Department, Dr. Gordon sailed for England in August 1940 to negotiate with the British Ministry of Health. He was accompanied by Dr. John R. Mote, Good Samaritan Hospital and Assistant in Preventive Medicine and Epidemiology, Harvard Medical School and School of Public Health. They landed in Liverpool on 14 August, proceeded directly to London, and arrived there 15 minutes before the raid of the Luftwaffe signaled the opening of the Battle of Britain. Dr. Gordon returned to the United States briefly in September 1940 and began detailed planning of the hospital and selection of its equipment and staff. In the meantime, meetings were arranged by President Conant and Dean Burwell with Mr. Norman H. Davis, chairman of the American Red Cross, who gave his enthusiastic cooperation and financial support to the building of a 125-bed hospital for shipment to England. Dr. Gordon returned to England after these meetings, empowered with the authority to discuss the proposed plan with the British.

In March 1941, the first shipment of the hospital was made from the United States to Salisbury in southern England, a site selected by Dr. Gordon and Dr. J. R. Hutchinson, Ministry of Health, at Combe Road on the city's border, and offered by the British Government for the building of the hospital.

The American Red Cross-Harvard Field Hospital Unit was formally opened on 22 September 1941 and eventually numbered 85 physicians, nurses, and technicians; the installation included 22 prefabricated buildings,


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FIGURE 45.-The American Red Cross-Harvard Field Hospital Unit, assembled in Salisbury, England, from 66,000 pieces of prefabricated building material shipped from the United States. The hospital was used to study wartime epidemics. (Photograph, courtesy American Red Cross.)

housed 125 beds for communicable diseases, an epidemiologic field unit, and several well-equipped laboratories (fig. 45).

Dr. Gordon headed the unit and, in addition, acted as adviser to the British Ministry of Health upon the epidemiologic aspects of public health and hospital care. He was also Liaison Officer of the Ministry of Health. Dr. Gordon was given an office in the Ministry of Health and placed as an extra member of the principal committees of that office. From the point of view of the organization, this proved to be advantageous since this liaison provided information as to the current public health problems and activities throughout Britain, and increased the possible fields of activity of the organization tremendously. Dr. Gordon often referred to the Harvard Unit as a "freelance" group, mobile enough to move wherever an epidemic might strike, and based as a hospital for clinical study.

During the 13 months between Dr. Gordon's arrival in London and the final completion of the hospital, he and other American medical authorities worked with British military and civilian health authorities dedicated to the study and control of epidemic disease in the British Isles. The incidence of communicable diseases in the first winter of war proved far


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less than anticipated. Nonetheless, there were the unusual conditions to be watched in air raid shelters, minor outbreaks in distant communities to attend before they became major ones, and a variety of services to be rendered. The unit, a particular American contribution, played an active part in planning preventive medicine measures generally, particularly in the shelters, as well as on staffs of various emergency medical service hospitals.

The account of this fully organized American institution in Great Britain before the United States entered the war, with its availability for instant use by U.S. troops as they began to mass for the offensive against Germany and Italy, is an intensely interesting record of American volunteer effort in the war.

For nearly 2 years, epidemiologic experts from Harvard and the Field Hospital Unit formed an important part of the Emergency Medical Service. Sir Wilson Jameson, Chief Medical Officer of the British Ministry of Health, was so highly pleased with the work of these experts and the field hospital unit that he wrote the following two letters of praise to Dean Burwell, Harvard Medical School:

New York, N.Y.
November 5, 1941

Dear Dr. Burwell:

I was indeed privileged to have the opportunity of delivering the Cutter Lecture at Harvard Medical School on the twenty-second of October, and of paying public tribute to the work of the American Red Cross-Harvard Field Hospital Unit, so ably directed by Dr. John Gordon.

I leave New York in a day or two on my return journey to England and I should like before then to elaborate just a little what I said in my Cutter Lecture. As you know, the Unit consists of three essential elements never before brought together, in my own country at all events, as they have been in this instance. First of all, the hospital of some one hundred thirty beds provides us with the means of studying special groups of cases in a manner we should find it impossible to do with our present shortage of beds for communicable diseases. The hospital is so situated that it can admit either civilian or service patients, and Dr. Gordon has the complete confidence of all the civilian and the service medical officers of the area. We expect that the research work undertaken in the wards of the hospital will contribute materially to our knowledge of the origin and spread of communicable disease. Indeed, some of the staff have already, elsewhere in England, thrown new light on such a prevalent condition as scabies-a disease about which many people thought no new work remained to be done. I should like to make it clear that the hospital is not meant to supplement our ordinarily existing hospital accommodations. It is an integral part of a well-conceived scheme for the carrying out of research.

A hospital of this kind without a laboratory would be bereft of its usefulness, so a first-class laboratory has been included. This laboratory will not only do the work required of it in relation to the patients in the hospital; it will also form one of the units of our own emergency public health laboratory service. It is not the intention that it should be used for ordinary routine work, but that special problems involving laboratory research should be referred to it. This is readily accomplished, as it is situated at no great distance from Oxford, which is the headquarters of our own laboratory service, and already a close relationship has been established between the two places.


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Associated with the laboratory is a group of mobile teams of field workers, consisting of medical officers, public health nurses, and, when necessary, laboratory technicians. These teams have already proved themselves of the greatest value to us. They have carried out field studies on trichinosis, on paratyphoid fever, and on epidemic respiratory disease, to mention only a few subjects, and have not only done their work in the most competent manner but have at the same time really endeared themselves to the health staffs and to the public with whom they have been associated. Let me tell you what happened in Bristol a few weeks ago. That city, which has suffered severely from air raids and whose health department has been seriously overworked, was visited by a widespread epidemic of paratyphoid fever. The resources of the city proved inadequate to the occasion, and Dr. Gordon was asked to help. He sent six of his nurses to the local isolation hospital to lend a hand there. Another six public health nurses, together with a doctor, took charge of the field work and two laboratory technicians undertook all the necessary laboratory work. As a result, the situation was brought rapidly under control, and Dr. Gordon earned the gratitude of the whole city. Indeed, the Health Commissioner, whom I saw the last week I was in England, was unwilling to let the mobile team depart, as he insisted he had other problems he wished investigated but was quite unable to tackle with his own depleted staff.

Again, we dread the possible appearance of typhus fever in England. Dr. Gordon, who has had special experience in this disease, is providing us with our Number One mobile team which will proceed at once to any area where an outbreak of the disease is thought probable. And not only so; Dr. Gordon himself has been of great help in assisting us to draw up a set of rules for the guidance of our health commissioners in relation to this disease.

I could go on multiplying instances of the manner in which this excellent unit is rendering us invaluable help, but I think I must by this time have indicated sufficiently clearly to you how much we appreciate all it stands for. I regard the unit as most original in its conception and likely to modify our own general epidemiological practice in Britain. Even the type of hospital construction is novel and may well be the type we would do well to adopt more generally after the war. There seems to me to have been no extravagance in the planning of the unit and I can vouch for the efficiency of all the members of the staff.

Finally, I should like to remind you once again of the service Dr. Gordon has given us in the Ministry of Health by acting, with your permission, as official U.S.A. Liaison Medical Officer. He attends all our confidential staff meetings, and his opinions and advice have been wholly for good. I personally owe him a real debt of gratitude.

I hope it will be possible to maintain the whole unit on its present lines. You may rest assured that the American Red Cross, the Harvard Medical School, and all the foundations that have so generously assisted in the formation and maintenance of the unit, are making a contribution of the utmost value to us in our war effort.

Yours very sincerely,
WILSON JAMESON

Whitehall, S.W.1.
16th September, 1942

My Dear Dr. Burwell,

Now that the American Red Cross-Harvard Field Hospital Unit has been taken over by the United States Army authorities I feel I must send you a letter of appreciation for all you and the Red Cross have done for us through this admirable Unit.

You may remember that, when I was in the United States last October, I was privileged to give you some account of the early work of the Unit before the hospital had really begun to receive patients in any number. I was able to tell you of the great help we had received from the mobile teams that were sent out to districts where epidemic


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disease of one sort or another was prevalent, as well as of the interesting studies that various members of the staff had been conducting. During this year the demands on the Unit's bed accommodation grew steadily until the hospital had its full complement of patients. At the same time a large amount of field work was being undertaken. The field investigations covered epidemic myalgia at Salisbury, mumps, meningitis "follow-ups" in London and Wales, typhoid fever in Devonshire, paratyphoid fever in Weston-super-Mare, jaundice in a number of areas, notably in Northern Ireland, as well as other subjects of epidemiological interest. The staff of the Unit sometimes worked side by side with members of the staff of the Ministry of Health; at other times they carried out independent investigations with the aid of the staff of the local public health departments. I have a list of nearly forty important field studies made by the Unit's mobile teams between October, 1941 and July, 1942, activities which carried them through England, Wales, Scotland, and Northern Ireland.

The staff of the Unit have come to be regarded not as a group of workers from America but more as part of the general public health staff of the country. Many of them have attended our meetings and contributed in most helpful fashion to discussions on technical matters. Some of them have published papers in our medical journals and all of them have made the numerous visitors to the Unit feel welcome guests. Indeed the Unit, whether from the point of view of the interesting nature of its design and construction or of the quality and specialized character of the staff, is looked upon as a model for the postwar development of epidemiological studies in this country. The importance of this can be realised in view of the announcement recently made of the generous intention of sponsors of the Unit-The American Red Cross and Harvard University-to present the buildings and equipment to the Ministry of Health after the termination of the war

Of Dr. Gordon's special services I cannot speak too highly. He has kept in the closest touch with this Ministry and his advice and criticism have been sought on numerous occasions by officers of the department-and indeed by persons and bodies quite unrelated to the Government. All these associations, so firmly established prior to July 15th, 1942, we hope will remain even though the Unit is now under military control. Indeed, we have the assurance of Colonel Hawley, Chief Surgeon, United States Army Medical Corps, that it is the intention that the Unit should continue to give service to the civilian population so long as the exigencies of the war permit.

I hope I have succeeded in giving you some idea of the great contribution the Unit has made to British public health during its comparatively short life as a civilian organisation. It has created an impression that will long remain after the staff have returned to the United States. Your generous conception of making a gift of the premises to the Ministry of Health when the war is over enables me to believe that we shall be in a position to carry on the tradition of good work that has been so firmly established by this joint Red Cross-Harvard venture.

Please accept my grateful thanks for your own personal efforts to make a success of the scheme.

Yours very sincerely,
WILSON JAMESON

On 15 July 1942, the American Red Cross-Harvard Field Hospital Unit was transferred, with its personnel, to the U.S. Army to function as the central laboratory of the theater in support of preventive medicine and hospital activities. The Secretary of War, Henry L. Stimson, accepted the unit with these words of acknowledgment:26

The transfer to the United States Army of the American Red Cross-Harvard Field Hospital Unit at Salisbury, England, brings to the Army the valuable services of an

26See page 11 of footnote 24, p. 371.


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FIGURE 46.-Brig. Gen. Paul R. Hawley, MC.

establishment which is especially equipped in the field of preventive medicine. Much effort and money have gone into the founding of the Unit, and that the Army will be privileged to benefit from it during the present emergency provides a source of great satisfaction to all who are concerned with the maintaining of the health of our Forces. The War Department extends its appreciation to those whose generous and voluntary contributions have made the Unit possible.

The Harvard Unit was renamed "General Medical Laboratory A" and functioned thereafter as the central laboratory for the theater, rendering the same efficient service to military and civilian populations.27 The First Medical General Laboratory arrived from the Zone of Interior in June 1943, and the two units joined forces under the title of that organization. The combined facilities met the demands of an increasing troop strength and the approaching cross-channel operations.

When Col. (later Maj. Gen.) Paul R. Hawley, MC (fig. 46), began to set up headquarters for the Office of the Chief Surgeon, ETOUSA, he naturally turned to Dr. Gordon to serve as chief of the Preventive Medicine Division. When Dr. Gordon indicated that he believed his work was done, Colonel Hawley replied, "Where else can I find a man who has had two years' experience in the particular problems we are going to face?"

27Report, 1st Medical General Laboratory, 23 Aug. 1942-21 May 1943.


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Dr. Gordon was commissioned lieutenant colonel, MC, on 7 July 1942 and appointed Chief, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, the same day. He began immediately to build up his organization to provide the best possible preventive medicine service for air, ground, and service troops.

The American Red Cross-Harvard Hospital Field Unit, in retrospect, was an exceedingly important epidemiologic control unit for the British civil and military public health service for the British had indicated that they were weak in this one specialty of medicine. In serving the British, the unit served the best purposes of the United States in reconnaissance, survey, study, control, and reporting of communicable diseases.

Special Observers Group.-Foreseeing the possible future involvement of the United States in the war in Europe, the War Department established a military SPOBS (Special Observers Group), under the command of Maj. Gen. James E. Chaney, USA, in London, on 19 May 1941. Previously, General Chaney had been in England, from 12 October to 23 November 1940, to observe the Battle of Britain, and had predicted that Britain would not lose the war. The Special Observers Group was more than an assemblage of observers. It was, in fact, a miniature theater headquarters, and was one of the predecessor commands of the European theater.28 Although SPOBS had a number of sections in its organization, none was specifically designated "civil affairs/military government." Nevertheless, the group was interested in these matters and in public health activities, as evidenced by the presence among its staff officers of, first, Maj. (later Col.) Arthur B. Welsh, MC, and, after September 1941, Colonel Hawley, who became Chief Surgeon of the European theater. Colonel Hawley was the only officer of this group who remained throughout the span of the ETOUSA period to continue the work he had started as a Special Observer.

Early in January 1942, after the United States had become a belligerent, the name "Special Observers Group" was changed to USAFBI (U.S. Army Forces in the British Isles). The organization, still under the command of General Chaney, was now able to work openly as an ally of Great Britain instead of being in the delicate position of representing a professed neutral nation with a government that was engaged in a life and death struggle. In other ways, however, according to reports, the path of this force was rugged; its personnel was limited and its directives were both limited and contradictory. "In the hectic days that followed America's entry into the war they were forced to revise their plans again and again as one new crisis after another forced the War Department to redeploy its troops again and again."29 Although USAFBI operated until 8 June 1942, when

28Sprague, W. F., and Elliott, H. G.: The Administrative and Logistical History of the European Theater of Operations. Part I: The Predecessor Commands. The Special Observers Group and the U.S. Army Forces in the British Isles. [On file in The Historical Unit, USAMEDD, Fort Detrick, Frederick, Md.]
29See footnote 28; comment by a reviewer of the cited document.


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the European theater was activated, it never included a special section for civil affairs.

Colonel Hawley continued his work of reconnaissance, inspection, and medical intelligence reporting to The Surgeon General, U.S. Army. Colonel Hawley was particularly interested in preventive medicine. With his refreshing wit and optimism, he established excellent rapport and liaison with British health authorities. On the morning after Pearl Harbor was attacked, he said:

I was going down to Southern Command and I had to catch a train out of Waterloo Station, in London, about six o'clock in the morning. And so I got up at five o'clock that Monday morning-it was in London-I walked over to Baker Street tube station to take a train down to Waterloo Station, and * * * headlines this high on the newsstand. I picked it up there-Pearl Harbor has been attacked. I went right back to my apartment-was about a block away from the Baker Street tube station,-got into a uniform. That morning, Monday morning, was always conference in the [British] Surgeon General's office-all of his department heads. * * * And I walked into that conference room in uniform and they all got up and yelled and cheered.30

U.S. Army Forces in the British Isles and Subsequent Commands

The Special Observers Group was discontinued in January 1942, shortly after the United States entered the war. The U.S. Army Forces in the British Isles, created the same month, absorbed the staff of the Observers Group and became the top U.S. command in the area. The same excellent liaison relations, established with the British, continued under the new command and under the subsequent commands.

The term "U.S. Army Forces in the British Isles" endured for about 5 months and was superseded on 8 June 1942 by "European Theater of Operations, U.S. Army."

Landings of the Troops

The landings of large numbers of U.S. troops in rapid succession in the United Kingdom in 1942, 1943, and 1944 created sizable problems for British military and civilian public health officials as well as for their American military counterparts. Problems included traffic, transportation, housing, food, milk pasteurization, supplies, sanitary engineering, and communicable diseases. Lend-Lease and Reverse Lend-Lease, inaugurated as early as June 1941 for the construction of bases in Northern Ireland and Scotland, became an important part of the public health picture and, like the buildup, reached their height just before the continental invasion.31

When the first contingent of troops arrived in Northern Ireland on 24 January 1942, hard on the heels of President Roosevelt's announcement that a U.S. force was to be sent to Britain, the United Kingdom was hardly

30lnterview, Col. John Boyd Coates, Jr., MC, and others, with Maj. Gen. Paul R. Hawley (Ret.), at The Historical Unit, USAMEDS, Forest Glen, Md., 16 and 18 June 1962.
31See pages 20 and 257 of footnote 4, p. 364.


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in order to receive so many guests. A German invasion was expected any minute, the British Isles were already "crowded to the attic," and the British economy was hard pressed by shortages imposed by almost 2½ years of war.

Nevertheless, no nation in history ever appeared happier to see the vanguard of friendly and grinning "Yanks" as they swarmed down the gangplanks onto the quay at Belfast from each of the four successive ferrying tenders. The tenders, Canterbury, Maid of Orleans, Royal Daffodil, and Princess Maud, had gone out early in the morning of 26 January to meet the anchored transports, the Strathaird and the Chateau Thierry, which were too large to negotiate the Victoria Channel into the harbor. The transports, escorted across the Atlantic by British and American warships (and, much of the way, by air patrols), had made the journey safely and lay off the Irish Coast throughout the night at Belfast Lough.

General Chaney, Commanding General, USAFBI, and Maj. Gen. Russell P. Hartle, Acting Commanding General, U.S. Army Northern Ireland Force, stepped ashore first, while the band of the Royal Ulster Rifles played "The Star-Spangled Banner." It was a great and festive day in Northern Ireland; the docks were gaily decorated, and the Stars and Stripes and the Union Jack floated overhead. On hand to greet the generals were the Duke of Abercorn, Governor of Northern Ireland, Mr. J. M. Andrews, Prime Minister of Northern Ireland, and a number of other officials from the Northern Ireland Government. The Times, London, reported the arrival of the first contingent with lively and joyful interest as it did each consecutive contingent thereafter.32 It noted that "by contrast with its historic import, the occasion seemed curiously subdued in its mechanical efficiency."

After the first landings in Northern Ireland, U.S. troops landed in every major port in the United Kingdom. The cumulative buildup of U.S. troops, beginning with the first contingent of 4,058, had reached 241,839 by December 1942, 918,347 by December 1943, and 1,671,010 by May 1944.33

By the end of 1943, five base sections were in operation in Northern Ireland, Wales, Scotland, and England. The base sections, having undergone several changes in name and boundary during 1942 and 1943, were Northern Ireland Base Section, Western Base Section, Eastern Base Section, Southern Base Section, and Central Base Section (map 11).

Maintenance of the health of the U.S. Army in the United Kingdom, in consultation with British authorities, was under the jurisdiction of the Office of the Chief Surgeon, ETOUSA, supported by components of his office including chiefly the preventive medicine service. Responsibility was further delegated to the base section surgeons who had staffs resembling those of the parent organization. As health of the command involved civilians, or

32The Times, Times Publishing Co., London, England, 27 Jan. 1942, p. 4b, and other issues, 1942, 1943, and 1944.
33See pages 100 and 232 of footnote 4, p. 364.


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MAP 11.-United Kingdom base sections and surgeons' offices, December 1943.


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required joint negotiations and agreements, the Office of the Chief Surgeon and its components down the line arrived at appropriate decisions with the comparable British military and civilian authorities.

PROBLEMS OF THE CIVIL-MILITARY PUBLIC HEALTH
ACTIVITY

The cordial and cooperative relationships enjoyed with the Ministry of Health and other civilian and military organizations, while the U.S. Army staged in the United Kingdom, had tremendous impact on solutions to problems affecting military units and civilians. These relationships, having begun in August 1940 when Dr. Gordon and other civilian experts worked on the control of epidemic disease throughout the United Kingdom, were continued during the existence of SPOBS, USAFBI, and the European theater.

Weekly meetings of the executive committee of the British Ministry of Health, headed by Sir Wilson Jameson, were of prime importance in the civil and military public health activity. Colonel Gordon, then chief of the Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, and other American medicomilitary authorities were invited to attend these meetings as representatives of the U.S. Army. Health problems affecting civilians and the staging of military forces were thrashed out, and decisions were made on methods of handling them.

From the Zone of Interior, General Simmons and his deputy chief, Col. (later Brig. Gen.) Stanhope Bayne-Jones, charged with the responsibility for almost global military preventive medicine, participated in making decisions affecting the excellent record of preventive medicine service in the United Kingdom. In 1943, General Simmons made inspection tours of medical facilities in the theater and promoted further the spirit of good will between British and American medical officials. On completion of one of the tours of British and American medical installations in 1943, General Simmons praised the effective medical service and "excellent cooperation of British military and civilian medical authorities." "Working together," he said, "British and American medical authorities have developed many improvements in military medicine."34

Health and Public Health Arrangements for U.S. Troops in

Northern Ireland

The following account consists essentially of excerpts from Sir Arthur S. MacNalty's published summary,35 which he based mainly on notes supplied by Col. Joseph H. McNinch, MC, USA. Colonel McNinch held various

34The New York Times, 5 Sept. 1943, p. 9:5.
35
MacNalty, Sir Arthur Salusbury, Editor-in-Chief: History of the Second World War. The Civilian Health and Medical Services. Volume II. Part IV: Public Health in Northern Ireland. London: Her Majesty's Stationery Office, 1955, pp. 399-402.


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positions in the Office of the Chief Surgeon, ETOUSA, from 1942 to 1945, including the posts of Deputy and Assistant Surgeon of the theater.

The first contingent of U.S. troops, the V Corps consisting of the 34th Infantry Division and the First Armoured Division, arrived in Ulster, Northern Ireland, on 24 January 1942. From the beginning, invaluable assistance was furnished by the British authorities, both military and civilian. Liaison was established with British military commanders and their Royal Army Medical Corps representatives; with local health officers and Emergency Medical Service representatives; with leading local health authorities and surgical practitioners through the Ulster Medical Society and the Northern Ireland Branch of the British Medical Association; and with the heads of local British relief and hospital aid associations.

The Ministry of Home Affairs extended to members of the U.S. Forces stationed in Northern Ireland the same facilities for treatment as were available to members of His Majesty's Forces.

The assistance of the Ministry of Home Affairs did not appear to have been sought by U.S. military authorities at any time in regard to scavenging of camps, water supplies, et cetera. The U.S. authorities approached the local authorities directly on these matters and obtained from them such assistance as was possible. In many instances, water supplies sufficient for small rural communities were inadequate for large camps. As a result, the U.S. military authorities had to make their own provisions. The engineering work entailed was done on behalf of the American Forces by the Royal Engineers.

Camp Accommodation. Upon arrival, American troops were quartered in various districts. Nissen huts accommodated most of the troops although other types of shelter were utilised in some instances. Arrangements for occupancy of camps and installations were made through British Army Authorities. Their Barracks Engineer Officer was charged with the responsibility for the care and issue of movable equipment such as furniture, light-bulbs, coal and straw, and for conservancy service.

Each camp commander appointed a utility officer, who worked in close liaison with the local British Garrison Officer. The utility officer was the American agent; it was his duty to see that rules and regulations on camp maintenance were carried out, and that needed fuel, camp equipment, and waste disposal services were available.

Hygiene. Hygienic precautions received early and careful consideration by the surgeon, U.S. Army, North Ireland Forces. Following a survey of the situation, detailed and comprehensive sanitary regulations were published. These related to water supply, food, milk, disposal of waste, garbage and rubbish, personal hygiene, venereal diseases, and control of rats and other vermin. Commanding officers of all grades were responsible for initiating and enforcing sanitary measures within their organisations and the boundaries of areas occupied by them. In all cases where questions of jurisdiction arose, the appropriate British medical officer or local health officer was consulted.

All existing water supplies were non-potable according to U.S. standards, and therefore all cooking and drinking water in Northern Ireland had to be chlorinated. If community-chlorinated water was tested and found potable further chlorination was not practised.

Sewage disposal in the camps presented no problems. Bucket latrines were used and were emptied daily by civilian contractors.

Rat control was important. Units were directed to carry out a rat destruction campaign and were instructed as to the availability of poisons and traps.

Health of the Command. This was supervised by the Preventive Medicine Section, Office of the Surgeon, North Ireland Base Section. In this work liaison was maintained with the British military and civilian medical authorities. There was free and complete exchange of information as to the prevalence of communicable diseases in the U.S. personnel and civilians in the environment of troops. The Assistant Director of Hygiene


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of the Royal Army Medical Corps gave advice through personal visits and by telephone on the problems that might affect Allied military personnel. Civilian authorities also furnished useful information on disease that might affect U.S. Army personnel.

Venereal diseases. A Venereal Disease Control Officer was assigned to North Ireland Base Section on 22 February 1944. A number of existing VD control agencies and treatment clinics in Belfast and at other locations strengthened the efforts of the U.S. military to restrain venereal infections. On 11 April 1944, two nurses were attached to the Base Section headquarters as investigators of venereal disease contacts. The approval and cooperation of the Northern Ireland health officials was obtained before these nurses were sent out to interview contacts.

Health and the V.D. rate for U.S. Army troops in Northern Ireland compared very favourably with other sections of the British Isles, while the number of cases of respiratory diseases was slightly less than in England.

U.S. Army operations in Northern Ireland were completed in August 1945.

Housing

Provision of housing taxed the joint efforts of the United States and the United Kingdom as soon as war appeared inevitable for this country. The housing shortage in the United Kingdom was acute because of the heavy loss of buildings to enemy bombing, the cessation of building during the war, the influx of Dominion forces and refugees from the Continent, and an increasing population. Provision of. adequate housing, which affected the civil and military government public health activity in the United Kingdom, was, after food, the most pressing need.

Preventive health measures on transports presented a difficulty which had to be overcome; housing for troops arriving in the United Kingdom involved further the same problems of overcrowding, proper spacing arrangements, heating, ventilation, and other factors which might affect health.36

Public health and military preventive medicine considerations for housing began in mid-1941, along with other facets connected with the provision of housing. This country at that time, as stated previously, "walked a tightrope to avoid violating U.S. neutrality" with Great Britain in developing a housing program for the reception of U.S. troops. In June 1941, negotiation with the British Government had resulted in contracts signed by that government and an American firm for the construction of bases in Northern Ireland and Scotland. The Special Observers Group made reconnaissance tours of Northern Ireland and Scotland to determine housing requirements and environmental factors (fig. 47). Since American volunteers in the United States were not restricted from offering their services to a nation at war, several hundred skilled technicians did so in June 1941, went to the United Kingdom, and, under the direction of the British Government, began the construction of bases in Northern Ireland and Scotland.37

36Whayne, Tom F.: Housing. In Medical Department, United States Army. Preventive Medicine in World War II. Volume II. Environmental Hygiene. Washington: U.S. Government Printing Office, 1955, pp. 27-74.
37See pages 20-21 of footnote 4, p. 364.


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FIGURE 47.-An old mansion served as quarters for the 2d Infantry Regiment, 5th Infantry Division, at Warren Point, County Down, Northern Ireland.

The speed with which forces were built up in the United Kingdom and the shortages of materials necessitated the waiving of customary American building standards and also required the building services of the U.S. Army.

Housing consisted of hutments, barracks, billets, and tents. Hutments were of various types, from double-walled Nissen to tarred paper. These made satisfactory, although overcrowded, quarters. Ventilation became worse in the huts as nights grew longer and colder. Vertical walled huts were constructed of brick, concrete blocks, asbestos, wood, and tarred paper. Barracks loaned to Americans by the British varied greatly. Billets consisted of castles and manor houses, theaters, stores, armories, schools, churches, and any building having walls and a roof.38

Inherent in the housing of U.S. Army troops was the unavoidable problem of the Army's nearness to the civilian population.

Food and Nutrition

"In a dim steamy hut in Northern Ireland, a U.S. Army cook stirring a 40-gal. beef stew roared: 'We've gone back 20 years. No refrigerators, no electricity, no mixing machines. No bread slicers even. Gee, what a backward

38Annual Report, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, 1942, pp. 21-24.


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FIGURE 48.-The "kitchen" during the routine preparation of a meal at the 10th Station Hospital in Musgrave Park, Belfast, Northern Ireland.

country.' But generally the Yanks moving into Ulster have been so well behaved that they are a puzzle if not a disappointment to everybody but their officers"39 (fig. 48).

Troop rations-The first American convoy arrived in Northern Ireland ahead of its rations. British rations were issued by the Royal Service Corps until the supply system, Navy Army Air Force Institute, was placed in operation under reciprocal Lend-Lease. British Army cooks were lent to the U.S. messes to familiarize American cooks with the stoves and other mess equipment.

The British ration was found to be unsatisfactory largely because of the differences in national tastes. American soldiers griped; they preferred beef over the staple British meat, mutton.

By March 1942, American inventories mounted in Northern Ireland, and troops were changed over from the strict British ration to an American-British ration. The incorporation of British food in the American ration permitted a considerable saving of shipping space.

The Nutrition Section-The program of the Nutrition Section, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, operated throughout the war on five constituent factors: (1) collaboration with British military and civilian agencies concerned with nutritional problems,

39Welsh, M.: U.S. Troops Set Up Housekeeping. Life 12: 39, 23 Feb. 1942.


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(2) collaboration with the Subsistence Division, Office of the Chief Quartermaster, in developing all possible improvements of the ration, (3) participation in studies of the relation of the ration to the morale and the physical efficiency of the troops, (4) participation in the instruction of military personnel in matters pertaining to nutrition and mess sanitation, and (5) observation and study of the composition and methods of issue, storage, preparation, and serving of the prescribed ration to recommend design improvements in its nutritional adequacy and to minimize waste of foodstuff and nutrients.40

Food wastes-During November 1942, an extensive survey of American units in the United Kingdom was made by representatives of the Nutrition Section, the Quartermaster Subsistence Division, and the British Army Catering Corps. This investigation demonstrated that the issue of excess food was resulting in widespread wastage because of failure to use the ration economically and failure to return unused items to depots. The situation was distressing, not only because it represented financial loss and the futile transportation of supplies across the Atlantic, but also because of the unfortunate effect it had on the British who were campaigning for the maximum prevention of waste. As a result of the investigation, the chief of the Nutrition Section was ordered to recommend changes in the current directives on rations. A directive was issued on 14 January 1943 with adequate changes in the troop-ration scale.

Gardening-To obtain some of the fresh fruits and vegetables desired, arrangements were made for American and British troops to cultivate gardens. About 8,000 acres were cultivated by U.S. troops in 1942, and more than 15,000 acres in 1943. During 1944, the combined British and American military agriculture was estimated at 50,000 ship tons.41

Food poisoning from powdered eggs.-Eggs were scarce in the British market. The United States supplied powdered eggs to the Army and to British civilians. From May to September 1943, 78 British civilians from seven different districts in the United Kingdom contracted food poisoning which was traceable to infected powdered eggs and to the consumption of uncooked powder.42 The largest outbreak involved 26 civilians at a hotel, while the rest involved civilian families. Similar outbreaks occurred in the U.S. Army.

The strain of Salmonella causing the food poisoning was not prevalent in Great Britain and Northern Ireland but did occur in the United States. British authorities concluded that bacteria belonging to the Salmonella group would be found in powdered eggs imported from America because of the frequency of Salmonella infection among poultry in the United States and the ineffectiveness of the drying process used to manufacture the product.

40See footnote 38, p. 386.
41See footnote 6, p. 365.
42See Part III, Sec. 2, No. 2, pages 15-20 of footnote 20, p. 370.


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The problem was investigated thoroughly by British and American health officials. Supporting evidence from these investigations led to the belief that powdered eggs were a pertinent factor in the food poisoning outbreaks. The difficulties related to powdered eggs were attributed to unsatisfactory processing, badly infected birds, and contamination by food handlers. Sir Wilson Jameson, however, decided to continue the import of the vital product and to suffer the risk of food poisoning.43

Milk pasteurization-According to Sir Wilson Jameson, one of the finest examples of civilian public health activities to emerge from the joint British-American military and civilian efforts resulted from the order initiated by Colonel Gordon through the Office of the Chief Surgeon, ETOUSA, prescribing a standard of milk which did not exist in England to any appreciable extent.44 One day in mid-August 1942, Colonel Gordon observed American soldiers obtaining milk from carts in the street. Since British milk was not pasteurized nor cattle tested for tuberculosis in accordance with U.S. standards, Colonel Gordon relayed this information to General Hawley. He obtained General Hawley's approval to initiate an order prohibiting the purchase of British milk in bulk and authorizing the purchase of whole milk only when delivered in bottles and pasteurized under the provisions of Army Regulations No. 40-2230 from herds inspected and approved in accordance with the regulation. The result was a main dependence by troops on imported powdered milk. This was a doubly daring order, with shipping space from the United States so limited at that time, but it was accepted. The day before the order was issued, Colonel Gordon visited Sir Wilson Jameson to inform him of its contents. The next day British newspapers, according to Colonel Gordon, carried headlines- "British Milk Unfit for American Soldiers." Sir Wilson Jameson was most pleased for this action marked the start of a general pasteurization of milk in Great Britain. He had the weapon that had long been needed. If British milk was not good enough for American soldiers, it was not good enough for the British either. Full-scale pasteurization was not realized until the end of the war, but this important event had set the wheels in motion.

Sanitary Engineering

During the staging period of U.S. troops in Great Britain and Northern Ireland, sanitary engineering was an intricate responsibility, involving mutual agreements between British officials concerned with the problem and U.S. counterparts of the Office of the Chief Surgeon, the Corps of Engineers, and the Quartermaster Corps, ETOUSA. As the problem concerned the Chief Surgeon's office, sanitary engineering policy and procedure for the theater were established in the Preventive Medicine Division, Sanitation Branch, through coordination with other branches as necessary.

43See footnote 14 (2), p. 367.
44(1) See footnote 14 (2), p. 367. (2) Circular No. 40, Headquarters, ETOUSA, 5 Sept. 1942, section II, Use of Whole Milk for U.S. Army in ETO.


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A major function of Col. Ralph R. Cleland, SnC, Chief, Sanitation Branch, was the responsibility for effecting liaison with British and civilian military personnel and organizations in allied fields on sanitary engineering problems. Colonel Cleland also inspected sanitary conditions at all U.S. facilities, gave technical advice, and made recommendations on problems. The actual practice of sanitation was done in the unit area by unit commanders who, with the assistance of the unit surgeon, performed the necessary tasks. Water supply occupied first place in the field of sanitation, with waste disposal and water purification running a close second and third.45

Water supply and purification.-Water had never been abundant in the United Kingdom, but it had generally been adequate for the needs of the civilian population. The British public was not accustomed to the amounts of water supplied to the comparable American public. Increases in population and the drought in England from 1942 to 1944 contributed to water shortages. When U.S. troops arrived, with their notoriously high requirements for water, the situation became acute.

In the United Kingdom, water was drawn principally from old established water supplies and from municipal sources that had existed for years. The sanitary qualities of this water were well known.

Obtaining sufficient water for troops and civilians strained existing facilities so acutely that the United States and Great Britain developed new sources and improved and enlarged old systems. Despite these innovations, General Hawley's office had to issue numerous directives and memorandums to surgeons of base sections, hospitals, and hospital centers, urging them to practice water conservation and water discipline (fig. 49). The water shortage was so serious in late 1943 and in 1944 that General Hawley threatened a complete shutoff of water supply during certain hours each day if water consumption were not reduced.

Scales of allowance for water supply were established through mutual agreement and published in British Army Council Instruction No. 227 on 10 February 1943, as follows:

For sanitary purposes, the amounts allowed were ample

Scale of allowance

Imperial gallons1 
per person per day

Where waterborne sewage systems existed:

 

For all establishments except as stated

20

For hospital patients

50

Where no waterborne sewage systems existed:

 

For all establishments except as stated

10

For hospital patients

40

For temporary tented camps

5

11.20 U.S. gallons.

For sanitary purposes, the amounts allowed were ample.

43Unless otherwise indicated, material on sanitary engineering is based on (1) Cleland, R. R.: Sanitary Engineering in the European Theater of Operations. Mil. Surgeon 101: 36-40, July 1947. (2) Correspondence, reports, and directives, Office of the Chief Surgeon, ETOUSA, concerning Civil Affairs-Public Health, water supply and purification, sanitation, and sewerage and sewage disposal, 1942-44.


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FIGURE 49.-A field demonstration of pump and filter units of portable water purification apparatus in England, 1943.

Bacteriologic analyses were made by sanitary engineers from American and British facilities at monthly intervals to determine the potability of the water. Many of the analyses were made at the 1st Medical General Laboratory.

Water was seldom chlorinated by British municipal authorities to the extent required by U.S. Army standards. Consequently, the British War Office agreed to the application of chlorine alone as the type of purification to be furnished U.S. camps.

Damage to water mains by enemy bombs was extensive, and the typhoid hazard was a real fear.46 Some instances of diarrheas and dysentery during 1943 were traced to impure water.

Hardness of water was encountered in all areas of the United Kingdom except certain parts of Wales, Northwest England, and Scotland. Washing, cleaning, and dishwashing became a serious problem not only because of this condition but also because of the shortage of soap and lye. Water softening, as practiced in the United States, was relatively uncommon. Where hardness exceeded 100 per million, and especially at specialized hospitals, zeolite softeners were installed.

Waste disposal.-Food consumed by U.S. troops in the United Kingdom consisted largely of dehydrated foods and boned meats, materially lessening the quantity of garbage and residual wastes. Conservation of food was also a

46See page 1256 of footnote 22 (1), p. 370.


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contributing factor. Garbage was sold to civilian contractors for use as animal food.

Disposal of human wastes was an aggravating problem because the use of pit latrines was not feasible in this country. Many sections of the land had chalk formation underneath, which, because of its fissured character, allowed direct connection with nearby water supply sources. Bucket or pail latrines were used in some areas and were emptied by civilian contract. U.S. troops considered this method highly unsatisfactory, and it was a source of ridicule. Because of the unsanitary conditions encountered in the use of bucket latrines, the Corps of Engineers, on the recommendation of the Office of the Chief Surgeon, installed sewerage systems whenever possible.

Requirements for large volumes of water for flushing and sewerage frequently exceeded amounts available in certain towns and cities. These requirements often raised the problem of either increasing available water supply or decreasing installations to adjust to British capacity.

Sanitary Control at Ports

The closest liaison and cooperation were exercised at all times by U.S. port surgeons with British port medical officials. Procedure provided for the examination of military personnel and for the distribution to port surgeons of weekly memorandums on ports of origin involved in ships coming to the principal ports of the United Kingdom.

Early varying interests of the military and civilian organizations of British and American origin were correlated, with joint endorsement, by a directive on the sanitary control of ports. British quarantine differed from that in the United States, where the control of maritime traffic is at the Federal rather than the local level. Similar arrangements were made to inspect incoming and outgoing air traffic.47 Established policy provided for the inspection of the crew as well as for disinsectization of planes landing from areas where typhus, malaria, and other diseases were present.

Hospitalization

Through mutual Lend-Lease arrangements early in the war, provisions were made between the Medical Department of the U.S. Army and the British Emergency Medical Service for the emergency medical care of certain U.S. troops. Some Americans reported for sick call in British military and civilian hospitals. Later, British and Canadian Army, Navy, and Air Force personnel, in return, were accorded the privilege of medical service in U.S. military hospitals. For many reasons, the U.S. hospital program for its own forces lagged considerably behind the arrival of troops, but General Hawley did everything within his power to push the

47(1) Minutes, Eleventh Conference of the Chief Surgeon, ETOUSA, with base section surgeons, 20 Dec. 1943, p. 2. (2) See pages 240-247 of footnote 35, p. 383.


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FIGURE 50.-A medical ward in the 110th Station Hospital at Warrington, England, in July 1943.

rate of expansion of the American hospital service (fig. 50). As a result of the lag, many more U.S. troops were treated in British facilities than British in U.S. facilities.48 Records substantiate the fact that, as late as 1944, some U.S. troops were still being treated in British hospitals.

Several incidents occurred which provoked General Hawley's censure. For example: Two patients suffering from cerebrospinal meningitis were inadvertently admitted to the Royal Masonic Hospital, a hospital which prohibited the admission of those with communicable diseases. General Hawley directed that the commanding officer of the U.S. admitting installation visit the Honorary Secretary of the Royal Masonic Hospital to promote better relations through the prevention of misunderstandings "This office," General Hawley wrote, "has been embarrassed upon several occasions by blunders in the admission of patients and other infractions of the rules of the Royal Masonic Hospital." Several reprimands, explanations, and apologies took place.

General Hawley also made it very clear that patients who were under the care of British physicians at the Royal Masonic Hospital were not to be seen by American medical officers unless they were asked to do so by the British physician in charge of the case. "Naturally," Col. Elliott C. Cutler, MC, Chief Consultant in Surgery, Office of the Chief Surgeon, ETOUSA, wrote for General Hawley, "if the British physician in charge of the case

48(1) See pages 187-189 of footnote 25 (1), p. 372. (2) Hawley, Maj. Gen. Paul R., Chronological Files, 1942-44, passim.


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asks a consultant to see his patient, the consultant group should respond, but under no other circumstances."49

Infectious Diseases

Malaria.-Because of the military seriousness of malaria, the disease had been made officially reportable in U.S. troops in the United Kingdom since January 1942.50 Although indigenous malarial infections had been either entirely absent or comparatively rare in the United Kingdom for most of the twentieth century, four species of anopheline mosquitoes were native to the island. Only one of these, Anopheles labranchiae atroparvus, was classified as a dangerous vector of malaria. This species was considered especially dangerous because the adult habitually lives in close association with man, either in his dwellings or in animal houses.

British troops, returning home from the Middle East in World War I, had introduced malaria in sufficient proportions in the population to be described by the term "outbreak" by the Ministry of Health. Alert after this experience, the Ministry of Health was also concerned because malaria had been introduced from time to time before and after World War I by individuals returning from colonies where they had contracted the disease.

From 1942 forward, the following factors, experienced previously in the spread of malaria in the United Kingdom, engaged the attention of British and U.S. military and civilian health authorities: (1) the presence of susceptible populations, (2) the presence of a suitable mosquito vector, and (3) the possible importation of malaria by returning and incoming troops and airmen.

During 1942, Dr. Gordon recorded 20 cases of malaria in U.S. troops and 51 cases of fever of undetermined origin, the clinical investigations for which showed the original infections to have been acquired in the United States.

An important development in malaria incidence in American forces occurred in October 1943 when 10 B-24 aircraft destined for the Eighth Air Force arrived in England; 17 of 100 members of the crews subsequently developed malignant tertian malaria, caused by Plasmodium falciparum. The crews had flown the South Atlantic route from Florida to Puerto Rico, to British Guiana, and to Natal, Brazil. A few planes flew from Natal to Ascension Island and on to Roberts Field, Liberia; but most of the planes flew directly from Natal to Dakar, French West Africa, and then to Marrakech, French Morocco. Whether they flew directly or indirectly, all planes landed in Dakar and Marrakech, where living conditions offered a fertile source for infection. Only one of the aircraft crews escaped infection completely. Members of this crew had been thoroughly indoctrinated in malaria prevention and practiced it fully.

49Letters and memorandums, Royal Masonic Hospital, 1942-43.
50See Part III, Sec. 5, No. 2, pages 1-21, of footnote 20, p. 370.


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In November and December 1943, recurrent malaria in U.S. troops returning to the United Kingdom from malarial regions in North Africa posed a problem of medical importance. The 1st and 9th Infantry Divisions, the 2d Armored and 82d Airborne Divisions, and the 1st Engineer Brigade, with well-established histories of primary vivax malaria, were responsible for the sharp rise in malaria rates in the United Kingdom in late 1943 and 1944. Recurrent rates reached the highest peak in the spring of 1944 and declined sharply only after the four divisions and one brigade departed for the Continent.

A four-measure Anglo-American control program, intensified in late 1943, included (1) prompt treatment of malaria patients to render them noninfective to mosquitoes as quickly as possible, (2) use of Atabrine as a suppressive, (3) protection of patients in hospitals and troops of nearby regions from contact with malaria-transmitting mosquitoes when patients with malarial infection were under treatment, and (4) control of mosquitoes in the general military area.

Scabies.-Scabies was a troublesome problem in the United Kingdom because of the proximity of military and civilian populations. By 1942, scabies was found frequently among civilians and troops. Rates rose sharply in 1943, and by D-day, the European theater had one of the highest rates among theaters.

Scabies paralleled venereal diseases in several ways. Transmission depended on opportunities for contact and fraternization, and both were controlled to some degree (scabies to a lesser degree) by casefinding and contact investigation at the base-section level.51 In fact, Dr. (formerly Major, MC) Theodore H. Ingalls pointed out that the most significant deficiency in the control program for civilians and military personnel was the failure to recognize scabies as essentially a contact disease, in large part a venereal disease.52 Not enough attention was devoted to civilian contacts of infected soldiers. Indoctrination of the soldier lagged, and the realization that scabies was a joint command responsibility was somewhat lacking. Too much effort was expended in searching for a perfect scabicide when basic remedies on hand were already satisfactory.

Homologous serum hepatitis (yellow fever vaccine).-The "old and ugly camp follower," hepatitis, caused some strain on civil public health activity in Great Britain and Northern Ireland. British health officials, having encountered the disease earlier in the war, were far more concerned than Americans who gave little thought to a disease that had given little trouble during the last war, or since. Up to 1942, there had been no general realization, in America, of the dual character of hepatitis.53

The first real scare in the United Kingdom came on 13 May 1942, when Dr. Andrew Davidson, Chief Medical Officer of Health for Scotland,

51Diary, Col. John E. Gordon, MC, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, 1942-45.
52See footnote 16 (2), p. 368.
53See footnote 16 (2), p. 368.


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informed Dr. Gordon, at that time in Wales on a field investigation, that 26 cases of jaundice had been found aboard ship among incoming U.S. soldiers. The troop transport had stopped briefly at Glasgow and then proceeded to its destination in Northern Ireland. Concurrently, information concerning the event was relayed to Colonel Hawley by Dr. Hugh H. Smith of the Rockefeller Foundation, who had also been called by Dr. Davidson. On 14 May, Colonel Hawley called Dr. Gordon and asked him to begin an investigation with the American Red Cross-Harvard Field Hospital Unit (later 1st Medical General Laboratory). Dr. Gordon immediately dispatched 1st Lt. (later Lt. Col.) Dean Fleming, MC, and two nurses from the Salisbury unit to Northern Ireland, and joined them next day by plane. By this time, there were 83 American patients with jaundice in hospitals. The Northern Ireland command placed full facilities at the disposal of the Harvard Unit. It was entirely evident, by now, that the disease had started in the United States, that a number of the cases had occurred aboard ship, and that more occurred after arrival. From extensive and conclusive field studies, Dr. Gordon decided that the disease was not contagious and that it had been caused by icterogenic lots of yellow fever vaccine administered in the United States. Lot distribution indicated that the cause was probably related to human serum diluent used in the preparation of certain lots of the vaccine. Simultaneously, outbreaks that were occurring in other theaters furnished further proof of the cause.54

Once the British recognized that the disease was homologous serum hepatitis and not infectious hepatitis, they were greatly relieved. By September, when the outbreak ended, 1,591 cases were recorded by Dr. Gordon for U.S. troops in Northern Ireland.55

Colonel Gordon made the following statement concerning the outbreak of postvaccinal hepatitis: "Although the cause of this outbreak of jaundice was already known in the United States, such information had not yet reached U.S. Forces in Great Britain, here the cause was ascertained independently."56

Venereal diseases.-A high venereal disease57 rate among U.S. troops, with consequent increases in the rate within the British civilian population, was one of the most taxing joint civil-military public health problems encountered in the United Kingdom in World War II. No other public health problem threatened or disturbed Anglo-American relations more; yet, no other problem received closer cooperation and collaboration between health officials and agencies of the two countries in a genuine effort, on the part of each, to control venereal disease rates.

One distressing paradox was apparent from the beginning. Although

54Reports, Lt. Col. John E. Gordon, MC, subject: Homologous Serum Jaundice Arising From the Use of Yellow Fever Vaccine, European Theater of Operations, 1942. [Official record.]
55See page 452 of footnote 16 (2), p. 368.
56See Part I, page 5 of footnote 20, p. 370.
57The venereal disease situation in the United Kingdom is dealt with fully on pages 226-242 of footnote 16 (2), p. 368.


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the United States and Great Britain enjoyed cultural similarities in many respects, and consequently were a contributing factor to troop-civilian fraternization and increased rates, each country had a distinctly different attitude toward methods to be used in handling and solving the venereal disease problem. From the beginning, joint civilian and military experience showed the futility of American effort to impose certain restrictive public health methods, which had been successful in the United States, in a country which had traditionally considered sex behavior a personal matter and not subject to legislation or regulation.58 Also, any effort to effect restriction might have been misunderstood as reflecting an inclination on the part of Americans to meddle in affairs which the British considered strictly their own.

At the outset, the British were somewhat impressed with the usefulness of American venereal disease control methods including contact investigation and casefinding; but nothing of the sort had ever been practiced in Great Britain where very stringent libel laws rendered exceedingly precarious any action which might be interpreted as designating a woman as a source of venereal infection. The entire British approach to the control of venereal disease, at the time of the arrival of the first U.S. troops, was based on the provision of adequate free treatment facilities and voluntary application for treatment of infection. The provisions of the Venereal Disease Act of 1916 guaranteed the privacy of the individual by prohibiting physicians and clinics in the United Kingdom from reporting the disease.

The existence of different racial and socioeconomic groups within each of the civilian and military populations of the two countries, with further differences in their understanding and attitude toward venereal diseases, added fuel to an inflamed situation. These factors-coupled with the lack of educational materials, supplies, critical housing shortages for prophylactic stations, British sensibilities about the display of prominent signs (fig. 51), and the rigid requirements of the total blackout-made venereal disease the touchiest and knottiest of all medical problems. The influence which large amounts of money in the pockets of U.S. troops had in promoting promiscuity among some women was a source of bitterness in British circles.

For the purposes of this section on venereal diseases, circumstances may be divided into two phases: (1) the early problems in the United Kingdom when the United States was preparing for, and creating, a military base of operations; and (2) the later situation in the European theater when, with the building of a base well underway, major problems were caused by the tremendous concentration of troops in the overcrowded British Isles.

During the first phase, 1940 to mid-1942, excellent cooperative relationships were established with British health officials by Dr. Gordon, first as a

58Gordon, John E.: A History of Preventive Medicine in the European Theater of Operations, U.S. Army 1941-1945. Volume II, Part V, p. 6. [Official record.]


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FIGURE 51.-Two Army posters warning of the danger of venereal disease infection.

civilian expert in epidemiology on loan from Harvard University, and, in time, head of the American Red Cross-Harvard University Field Hospital Unit and Liaison Officer to the British Ministry of Health. Later, when the Special Observers Group and the subsequent command, USAFBI, came into existence, Dr. Gordon introduced incoming medical officers to the proper persons in the Ministry of Health, to other health officials, and to members of military organizations. Sir Wilson Jameson proved from the beginning to be interested in venereal disease problems and was most helpful. His interest assured easy access to all local medical officers of health, the level at which it eventually becomes necessary to control disease.

During the second phase, mid-1942 to mid-1944, Colonel Gordon was chief of Preventive Medicine, Office of the Chief Surgeon, ETOUSA, with the prime responsibility for venereal disease control. When U.S. troops began to buildup in increasing numbers, many effective measures to control venereal diseases began to take shape under the auspices of the Chief Surgeon and the British Ministry of Health; but venereal diseases were difficult to control from these top level offices before the base section surgeons' offices came into being. Many meetings took place between Colonel


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Gordon, other members of his staff including Maj. (later Col.) Paul Padget, MC, chief of the Venereal Disease Control Branch, and the British Ministry of Health. Because of the basic differences in attitudes, some of these discussions were rather heated, but moderators were both intelligent and deft. British officials were highly concerned about public opinion among their own people and feared that the techniques of contact investigation were unsuitable for them and even dangerous.

By April 1943, the high venereal disease rates among troops and civilians in the United Kingdom had aroused so much feeling that, under the auspices of the British Home Office and the Ministry of Health, the Joint Committee on Venereal Diseases was established. Large numbers of representatives of the British, American, and Canadian forces held a series of 11 meetings, from 25 June until 29 October, to discuss policies and procedures for resolving the venereal disease problem.

In July 1943, upon the invitation of the British Ministry of Health, and with the authority of The Surgeon General, U.S. Army, Dr. Joseph Earle Moore, chairman of the Subcommittee on Venereal Diseases, National Research Council, made an extensive tour of Great Britain and Northern Ireland to study the problem firsthand and to gain a better understanding of the interrelationships between military and civilian health officials. The survey, based on the advice of military and civilian authorities in preventive medicine and public health in the United Kingdom, was made in July and August 1943; and a written report was submitted on 19 August 1943 to the Chief Surgeon, ETOUSA, The Surgeon General, U.S. Army, and the Secretary of War. Substantial quotations and excerpts from Dr. Moore's report follow.59

Unfortunately, there is a tendency on the part of many English people to whom I have talked, professional as well as lay, some of whom are of national prominence, to attribute the increased incidence of syphilis in their own population to the influx of "foreign" troops and merchant seamen, rather than to the relaxation of public morals which, by experience, occurs in every country in wartime. Prominent, perhaps most prominent among the "foreign" troops are said to be those of the U.S. Army. English complaints from many sources (similar complaints were not heard in Scotland) cover several points:

1. That in general the attitude of American troops toward English women is undesirably loose.

2. That personnel with already existing infectious venereal disease are being sent from the United States to England, and that such men spread these diseases among the civilian population.

3. That Negro troops, because of their excessive sexual urge and the unfamiliarity of a certain small group of women with their social status, are a particularly potent source not only of venereal disease but of illegitimate pregnancies.

4. That the rate of pay of American troops is excessively high in proportion to British Army pay, and that the American soldier's excess funds leads him into increased sexual contacts.

59Report, Dr. Joseph Earle Moore, Consultant, Committee on Medical Research, National Research Council, to Brig. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, 19 Aug. 1943, subject: Comments and Recommendations on Venereal Disease in the U.S. Army, ETOUSA. [Official record.]


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There are, however, similar complaints from U.S. Army sources, fully as justified as the British complaints, as follows:

1. The British are so far unwilling or unable to take any steps to deal with the flagrant and blatant display of prostitution by street-walkers, which exists in the centers of all large cities, especially London.

2. The attitude of the British public in respect of venereal disease control, largely led by the Church, is far behind modern public health practice, even as exemplified by the desires and tentative future programs of responsible British Health Officers.

3. The attitude of U.S. soldiers toward women is at least in part attributable to the provocative and receptive attitude of some of the women themselves.

4. Entirely justifiable American efforts at newspaper publicity concerning the local venereal disease situation in our own troops have occasioned such a storm of British protest as to have led to an unpleasant international incident.

These complaints from British and American sources are offered sometimes soberly, sometimes with genuine bitterness. They seem to me to raise an issue far more important than the incidence of venereal disease in the U.S. Army, namely the maintenance of amicable Anglo-American relations.

In my opinion, the most important feature of the venereal disease situation in the ETO is its impact on Anglo-American relations. * * * It is agreed by thoughtful Americans and British that the winning of this war is overshadowed by the necessity of winning the peace to follow; and that to accomplish this aim, the maintenance not only of friendly relations, but of active cooperation between our two countries is essential. Many factors tend to disturb those relations, most of them economic and not readily obvious to the great bulk of our two peoples. In the public health and medical fields, however, there is no other factor so disturbing to Anglo-American relations as the venereal disease problem. The relations between the sexes which initiate these diseases are readily visible for all to see. Social and sexual behavior, and the consequences of the latter, can provoke, indeed already have provoked, serious differences of opinion in each group.

* * * Every effort should be made by both countries to remedy, so far as possible, defects in their own venereal disease programs which tend to contribute to international misunderstanding.

In respect to the British program, two encouraging factors are already visible. These are: (1) the interest of capable and powerful Medical Officers of Health in England and Scotland, Sir Wilson Jameson and Dr. Andrew Davidson; (2) the Joint Committee on Venereal Diseases sponsored by the Ministry of Health and the Home Office.60

I recommend, therefore, that-

1. U.S. Army participation in membership on the Joint Committee on Venereal Disease be continued.

2. The U.S. Army program of epidemiologic case finding be expanded.

3. A system of education of U.S. troops in British social customs, Anglo-American relations, and so forth, be inaugurated in the U.S. Army at home and continued in the ETO.

4. The policy of sending infectious venereal disease patients from the United States to the ETO be discontinued.

5. Negro troops in the ETO should be transferred to other theaters of operation, or alternately, their number held at its present level.

60The chairman of the committee was Sir Weldon Dalrymple-Champneys, Bart., Ministry of Health, and the members were Brigadier T. E. Osmond, RAMC, War Office; Air Commodore T. McGlurkin, RAF, Air Ministry; Lt. Col. M. H. Brown, RCAMC, Canadian Army; Col. John E. Gordon, MC, U.S. Army; Mr. H. R. Hartwell, Secretary, and Mr. T. Lindsay, Ministry of Health; Mr. T. Mathew, Home Office; Chief Constable E. A. Cole, Metropolitan Police; Dr. M. M. Goodman and Mr. E. A. Hogan, Department of Health for Scotland; Mr. J. S. Munro, Scottish Home Department; and Surgeon Cdr. D. Duncan, RN, Admiralty.


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6. The responsibility for public health and clinical measures as to venereal disease be centered in the Venereal Disease Branch of the Division of Preventive Medicine.

7. Additional venereal disease control officers should be immediately secured to a maximum of 9 for present strength, with continued expansion as strength increases.

8. The intensive treatment of early syphilis should be adopted as routine.

9. ETOUSAMD Form 313 (reporting form) should be adopted for use by the entire U.S. Army.

10. All punitive measures, official and unofficial, for the acquisition of venereal disease should be discontinued.

11. Laboratory service with respect of serological tests for syphilis should be brought to the highest possible standard.

12. Venereal disease control program among the W.A.C. should be instituted.

I should like particularly to commend the venereal disease control activities of Col. John Gordon, MC, Chief of the Division of Preventive Medicine, and of his venereal disease control officer, Lt. Col. Paul Padget, MC; also of the Dermatologic Consultant, Lt. Col. Don Pillsbury, MC.

Dr. Moore's report received the overwhelming support, with some restrictions and recommendations, of the War Department, General Simmons in the Surgeon General's Office, U.S. Army, and General Hawley, Chief Surgeon, ETOUSA.

Concurrently, the Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA, was delegating more and more responsibility for control to the now well-organized base sections throughout the United Kingdom. During the course of 1943, the Venereal Disease Control Branch became primarily a collection agency for the coordination and dissemination of information to the base section level, where disease was ultimately controlled.

The diligent efforts of both countries resulted in (1) easing of restrictions in British law, (2) changes in the organization of administration of the program, (3) intensification of education, (4) provision of prophylactic facilities and materials, (5) continued cooperation between military and civilian agencies, (6) epidemiology study and reports, and (7) strengthening of the highly effective program of casefinding and contact investigation.

British and Americans were now better able to appreciate each other's problems and, with better understanding, were in a position to develop and carry out the improved mutually supported program of venereal disease control.

Contact investigation was by far the most effective measure. During the height of the buildup, eight U. S. nurses were engaged in the investigation. These nurses worked under the base section surgeons and maintained liaison with the Chief Surgeon's Office. With the British law eased, the Ministry of Health influenced the organization of British contact investigation teams for full support of the program, and both countries appreciated the rewarding results.

SUMMARY

The Anglo-American coalition in World War II, one of the closest and most effective in the history of wars, served as a solid basis from which


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the successful public health activity of Civil Affairs and Military Government grew from its early beginnings in 1940 to the end of the war in 1945. Prevention and control of diseases in the United Kingdom were so successful, they almost completely eliminated the chances of epidemics. To prove a point in context, one has only to compare the record made in the United Kingdom with the frustrating experiences encountered in North Africa where public health facilities were not functioning until 8 months after the landings there.

The inherent desire of the United States and Great Britain to win the war by close alliance took precedence over any impingement which might be imposed upon either the British or American right of conveniences, resources, customs, practices, and requirements. That impingement did occur is evident in the vast collection of published and unpublished writings of military and civilian authorities. That impingement is inevitable in an alliance of nations, even in the face of relatively minor cultural differences, is reasonable and understandable.

The health of a military force is vitally dependent upon the health of the civil community where it is stationed, whether the force is in belligerent or friendly territory. The friendly nation favors closer contact between civilian and military populations than does the belligerent one. Friendly nations with a common heritage, such as that shared by the United States and Great Britain, enjoy one asset which offsets the peril of much else. This asset is obviously the ability of representatives of each country to negotiate with understanding and, in a series of talks and agreements, decide jointly what is necessary and desirable to do next to gain the maximum advantage from any future situation; success in the prevention and control of disease may be attributed measurably to this very great advantage.

A published example, picked at random and representative of the feeling existing on both sides, is readily evident in the vivid and objective account written by John W. Blake. Dr. Blake, a World War II historian for Northern Ireland, described brilliantly and concisely the dramatic and perplexing effects of large numbers of military guests descending upon a nation and staging among its residents; his statement follows.61

The influx of so many Americans * * * spread over nearly four years, naturally created problems as difficult as they were numerous. From the moment, in 1941, when a handful of technicians arrived in Northern Ireland, until the end of the war, the number and variety of these problems steadily grew. No bare record now can do justice to the effort entailed in solving them, smoothing over differences and ensuring friendly relations between the visitors and their hosts. The very intimacy which language permitted between American servicemen, British troops and Ulster civilians tended to multiply the opportunities of misunderstanding. All this the authorities foresaw, and it led them to apprehend some embarrassment. It was scarcely to be expected that scores of thousands of servicemen, including coloured troops, drawn from every quarter of the U.S.A.,

61Blake, John W.: Northern Ireland in the Second World War. Belfast: Her Majesty's Stationery Office, 1956, pp. 289-290.


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could be suddenly brought into Northern Ireland and as suddenly removed without repercussions upon the Americans themselves, upon the British troops in Northern Ireland, and especially upon the life of the province. Much of this was imponderable. If some of the external and more concrete results might be foreseen, the inward surge, the excitement and the stimulation could not be measured. Whatever the authorities might try to do, and whether they looked backwards or forwards, they would be moving in deep and unknown waters. The impact would certainly be great, yet who could gauge its strength, still less its effect?

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