|OFFICE OF MEDICAL HISTORY AMEDD REGIMENT AMEDD MUSEUM|
HISTORY OF THE OFFICE OF MEDICAL HISTORY
The European Theater of Operations (1944-45)
Stanhope Bayne-Jones, M.D., and Colonel Edward J. Dehné, MC, USA
THE CAMPAIGN IN NORTHWEST EUROPE
Of necessity, a successful assault by the Allied Expeditionary Force upon Normandy would ultimately involve both the United States and British Armies in CA/MG (civil affairs/military government) in the countries to be liberated and during the occupation of Germany.
Before the invasion and throughout the campaign in Europe, four main centers of plans and operations dealt with public health in connection with the civil affairs/military government and with the medical services of the field forces. These were SHAEF (Supreme Headquarters, Allied Expeditionary Force); Headquarters, 21 Army Group for the British Zone; the SHAEF Missions, connected chiefly with Headquarters, 21 Army Group; and Headquarters, ETOUSA (European Theater of Operations, U.S. Army), representing the military medical service of the American Zone. Various degrees of liaison and collaboration prevailed among these groups, but there was no single overall professional or military authority over public health activities.
The medical services of the United States and British Armies conducted public health operations as part of their programs of preventive medicine for troops. The fulfillment of this obligation meant participation in the prevention and control of diseases in civilian populations in contact with troops. Referring specifically to U. S. components, not only was the civil affairs organization at all levels an integral part of the Army but also in many health activities directed to the civilian populations, both friendly and enemy, the theater medical service made significant contributions, some of which at critical times were essential in accomplishing the overall mission. On the whole, the operational relationship between the two major U.S. public health organizations-Office of the Chief Surgeon, ETOUSA, and the Public Health Branch, G-5 SHAEF-was such that the narrative of events cannot always separate accounts of the activities of each element engaged in the campaign.1
Invasion of Normandy
The great invasion over the beaches of Normandy extended 20 miles inland by the end of June. A brief report to G-5 SHAEF by a Civil Affairs officer, Maj. E. J. Boulton, on his initial visit to the FUSA (First U.S. Army) zone of operations, on 10-11 June, indicated that the health of civilians was generally good and there were no epidemics. There was no civilian hospital in the liberated area and the civilian casualties who could not be treated by indigenous physicians were cared for by the military medical services. From the V Corps area, civilian casualties were evacuated to Bayeux. No Civil Affairs medical officers were on the ground. Medical supplies, especially those for treating wounds of civilians, were urgently needed. Reports covering the early days of the invasion are rather fragmentary, but apparently no serious civil health problems were encountered.
Small communities.-In the U.S. area, the rapid liberation of French towns-Grandcamp, Carentan, Montebourg, Valognes, Barfleur, Saint-Vaast-la-Hougue, Sainte-Mère-Église, Bricquebec, and Saint-Pierre-Église-by assault troops was closely followed by Civil Affairs Detachments, called forward by the First U.S. Army. Sixteen detachments were in operation by 15 June. On 24 June, two forward echelon public health teams arrived to give public health guidance. These were sent from the 1st ECA (European Civil Affairs) Medical Detachment of the 1st ECA Regiment, which was still in England. They were under the command, respectively, of Capt. (later Col.) John D. Winebrenner, MC, and Capt. (later Maj.) Fred H. Burley, SnC. These teams were severely handicapped by lack of transportation and shortage of personnel, deficiencies which were alleviated by the rear echelon of the 1st ECA Medical Detachment when it debarked on Omaha Beach on 30 June with vehicles and trained medical enlisted men.
Operations of CA Detachments followed a common pattern although no towns presented the same conditions. Immediate actions were the reestablishment of local government, emergency treatment and evacuation of wounded, organization of auxiliary police, care of refugees, provision of emergency water and food supplies for the needy, public health and sanitary surveys, issuance of civilian travel passes, procurement of labor for Army support, assistance to the Army in relations with the civilian population, and early restoration of community services and facilities. In the early phase, military progress was aided by the administration of triage and emergency treatment of wounded civilians, by the provision of water, food,
and shelter, and by the procurement of laborers for work on the beaches and ports. For the Civil Affairs officer, medical as well as nonmedical, it was always essential first to make a quick estimate of the situation, arrive at conclusions, and then take simple, clear-cut lines of action.
Cherbourg and vicinity.-Cherbourg, the first large city liberated in France, was administered by the first major Civil Affairs Detachment, CAD A1A1, which included among its members one CAPHO (Civil Affairs Public Health Officer), Capt. Juan Basora-Defillo, MC. This detachment landed at Utah Beach on the evening of 14 June 1944 and reported to VII Corps, First U.S. Army. Its strength of 22, later increased to 44, included Civil Affairs personnel of various categories. On 27 June, the day the city was captured, the detachment moved into Cherbourg, together with the combat troops to which it was attached. Its headquarters was set up in the chamber of commerce, and its officers and specialists met with the major, the health officials, and other principal officials of the city. The CAPHO and each specialist established communication with their counterparts in the municipal government.2
General conditions. Although damage to the city, about 25 percent, was less than expected, the population had been reduced, chiefly by forced evacuation, from about 40,000 to about 5,000. The remaining inhabitants were patriots who, evading German evacuation orders, had stayed to witness the liberation. Civilian casualties were light, and most of the wounded could be cared for in civilian hospitals. Food for 30 days was available. Some looting occurred during the first few days after the surrender, but police were functioning and law and order were maintained. Public health administration as well as most civilian community functions and services suffered from lack of transportation and poor communications. Early restoration of newspapers, movies, radio, and courts was achieved. The first newspaper to be published in Liberated France was distributed on 3 July; and on 4 July, the Cherbourg Continental Edition of the Stars and Stripes was issued. Eight changes in command within a short space of time resulted in repeated changes in military policy and orders.
The CAPHO concentrated on organizing and establishing civilian health services as rapidly as possible. He assisted the detachment commander in dealing with the medical and public health aspects of liaison between military and civilian parties. The damaged water supply system was repaired by 3 July. Of a large stock of food captured in the arsenal part was turned over to the 4th Division, and the remainder to civilian authorities. Efforts were made to prevent overcrowding of accommodations, but, because large numbers of troops had moved into the city and many civilians had returned, considerable overcrowding occurred. Problems of the control of prostitution were dealt with by city health officials assisted by the local
CAPHO who made available medical supplies and arsenicals for the treatment of syphilis.
Early in July, the initial work in Cherbourg having been completed, CAD A1A1 minus its Public Health officer moved to a temporary location outside that city to deal with various problems in the First U.S. Army area and to prepare for an eventual move to Paris. One of its first duties was to defend its own personnel. The CAPHO was missing because he had been retained by the military commander at Cherbourg. This "cannibalizing" was reported to the Surgeon of the Forward Echelon, ECAD, Capt. (later Lt. Col.) Edward J. Dehné, MC (fig. 56), at Chateau-Epinquet. He succeeded in securing the return of Captain Basora-Defillo to the unit in time for him to enter Paris with the division. During the campaign, other instances of tactical commands' appropriating personnel and vehicles from CA detachments occurred but were usually resolved by the Division and Regimental Surgeons of ECAD (European Civil Affairs Division).
Displaced persons and refugees. The first camps for displaced persons and refugees were opened in the vicinity of Sainte Mère-Église and Cherbourg in the First U.S. Army area. PHO 1st Lt. Samuel J. Ravitch, MC, of one of the Public Health teams of the Forward Echelon, ECAD, and Maj.
Frank J. Laverty, SnC, of the 1st ECA Medical Detachment, supervised the public health activities in these camps.3 As combat lines advanced, additional camps were opened. Most of the refugees from the immediate combat area were dispersed among the civilian population; the wounded and sick were sent to temporary, improvised shelters. After the capture of Caen on 9 July, refugee camps at Amblie and Bussy were expanded and more than a thousand refugees were evacuated to the FUSA area.
Medical supplies. During this early phase, a medical supply problem was caused by the large size of the ARB (Allied Requisition Board-British) and Civil Affairs Division-U.S. units. These had been designed for the long term needs of large cities and were not suited to the short term needs of smaller towns and camps. The consequent problem of their accessibility was solved in a manner that set a pattern for dealing with similar situations in the future. These units were broken down into emergency panniers that could be carried in jeeps or in 1½-ton trucks. In addition, 14 truckloads of German and French medical supplies uncovered at Cherbourg were removed to a medical dump at Utah Beach, where they were inventoried and immediately made available through Civil Affairs channels.
Communicable disease control. A civilian laboratory for testing water samples from localities on the Normandy peninsula was established at Cherbourg, and some confirmatory testing was done by Army medical laboratories. Health reports from newly recovered areas were always fragmentary because of the disruption of communications, transportation, medical services, and public health administration. Communicable diseases were seldom reported by civilian physicians, who paid little attention to them in the face of the overwhelming immediate tragedies of warfare. Furthermore, reports often were inaccurate or exaggerated, causing CAPHO's to be sent on hasty trips only to find mistaken diagnoses. For example, reported louse infestation often proved to be scabies. Language barriers and unreliable reports and rumors brought in by nonmedical persons aggravated this problem. Reports of typhus fever led repeatedly to undue alarm since the French terms for typhus fever and typhoid fever were easily confused. To prevent this, the term "epidemic louseborne typhus fever" replaced the term "typhus fever." Despite the low endemicity of malaria in Normandy and Brittany, reports of lapses occurring in troops caused concern which was allayed when surveys revealed too few Anopheles mosquitoes in the area to warrant sanitary engineering controls. The French venereal disease control law was of assistance as it provided for the detention and treatment of patients. Sporadic cases of diphtheria occurred, and there were a few instances of small epidemics of this disease. Outbreaks of diarrhea at refugee camps were successfully managed.
General and nutritional problems. At first, Civil Affairs Public Health Officers performed detailed operations rather than supervising the civilians
in conducting them because the area was crowded with troops and civilian activities and travel were restricted. Experience soon indicated that the CAD's required only minimal supervision by public health specialists. A full-time CAPHO was seldom needed by a CAD as guidance was given by the Public Health Officer traveling from detachment to detachment. The contact and communication system of the Civil Affairs company was used also by CAPHO's to give advice and receive reports. Medical enlisted men with the CAD's assisted in following up recommended sanitary measures, helped to maintain a journal of public health actions, and received and dispatched reports.
The distasteful task of burying the dead after heavy fighting was often initiated by the CAPHO since, in many instances, shovels were not available from civilian sources. The survivors, dazed and helpless, often existed amidst destruction and desolation but usually responded well to guidance and leadership and showed a remarkable capacity for recovery when given only minimal assistance.
The mild season, the ample agricultural resources of Normandy, and a rather widely dispersed population reduced the gravity of the civil affairs situation. A large portion of the dietary needs was provided from local resources. Malnutrition was limited to low-grade forms in children. The liberated population was composed predominantly of women, children, and the aged, few of whom were capable of much labor, but most could care for the infirm and manage for themselves. The Civil Affairs effort was aided greatly by the stalwart, impassive character of French peasants who accepted the situation as it existed, imbued with the will to survive despite the catastrophe that had swept over them. Fortunately, the people of this region lived close to the soil, were hard workers, and could supply most of their basic needs. Had this been a highly industrialized area, problems might have been more numerous.
Breakthrough at Saint-Lô and Advance Across France
General conditions.-The breakthrough at Saint-Lô on 25 July 1944 was followed by severe combat and the rapid advance of the Allied armies across the northern half of France. Falaise was enveloped and Coutances, Avranches, Brest, Rennes, Vire, Mortain, and Caurmont were captured. The battlefield at Falaise was called by Gen. Dwight D. Eisenhower "unquestionably one of the greatest 'killing grounds' of any of the war areas."4 While many towns escaped damage, some were destroyed. Saint-Lô, for example, a road center, had hardly a habitable structure standing after the bombardment and, as it could not be rehabilitated, its inhabitants were evacuated (fig. 57).
By mid-September, all of northern France, Belgium, and Luxembourg had been liberated, and the Dutch border and the western border of Ger-
many as far south as the Saar had been reached and crossed in a number of places (map 12).
Civil Affairs Detachments followed closely behind the advancing columns to control the civilian population and refugees, to evacuate civilian casualties to civilian treatment facilities, and to reestablish governmental organization and procedures as quickly as possible. Portions of the public health section of the CAD remained in place, after the combat troops had moved forward, to supervise the carrying out of required health measures. Within slightly more than 6 weeks after the breakthrough at Saint-Lô, Civil Affairs control extended over many villages, towns, and cities in France, Belgium, and Luxembourg.
In the United States Sector, the Civil Affairs Medical Detachments with public health functions frequently were called into action by the field forces to which they were attached (the First and Third U.S. Armies, the 12th Army Group, and Advance Section, Communications Zone). Increasingly, they provided guidance, supervision, and direct services in public health to civilians and occasionally, to military units. Through experience in this region, it became clear that civil public health operations under existing conditions required close collaboration between the theater Medical Service and Civil Affairs, as represented by the G-5 Public Health Branch and the ECAD Medical Detachments. Indeed, as the restoration of civil government was basic to the restoration of public health administration, this primary objective of Civil Affairs was, in large measure, a part of the program of public health. Consequently, accounts of public health activities include a great deal about the so-called nonmedical aspects of Civil Affairs.
Communicable diseases.-The chief communicable diseases of civilians during this period were diphtheria, tuberculosis, enteric infections (diarrheas, dysentery, and typhoid fever), venereal diseases, and scabies.5
Diarrheas and dysentery were prevalent, at times, in the large camps for displaced persons and refugees. An outbreak of 104 cases of typhoid fever occurred in the civilian population in Greater Liège, Belgium, from 1 August to 18 November 1944.
Throughout northwest Europe, the venereal disease rate rose in the civilian population. Army Surgeons and Civil Public Health Officers were equally aware of the problem thus presented to the military forces; many conferences were held, many staff papers were written, and civilian health authorities were prodded to act. With the scarcity of penicillin, the unusual conditions posed by two huge foreign armies in France and Belgium in succession, and the inherent difficulty of effective venereal disease control, the accomplishments in this area were not great and all concerned felt a degree of frustration in dealing with the problem.
The incidence of diphtheria had also been mounting in northwest Europe during the German occupation and continued to be relatively high after the invasion. Immunization programs, mainly for children, were already in effect and were developed further as diphtheria toxoid became more readily available through local production facilities and through the Civil Affairs supply units. While no large-scale epidemic occurred, the overall incidence was far above the prewar level.
Some anxiety arose over a possible spread of epidemic louseborne typhus fever in Normandy. Reports indicated that, during May 1944, typhus had occurred among Russian and Polish workers who had been brought into
Cherbourg by the Germans to work on coastal fortifications. This anxiety was allayed by a report by Maj. Theodore E. Woodward, MC, of the United States of America Typhus Commission,6 who made an inspection trip to Cherbourg and other places in the liberated area and found no evidence of typhus among the civilian population. He estimated, however, that about 30 percent of persons whose homes had been destroyed and about 5 percent of the general population were infested with lice. In view of the potential hazard, he believed it was imperative that a DDT dusting program be instituted at once.7
French physicians and other personnel were organized into dusting teams, DDT powder and necessary equipment which had not then reached the liberated area were brought in from London, and a dusting program was inaugurated. The program was carried out in this area, and elsewhere later, under the direction of representatives of the Typhus Commission, of the G-5 SHAEF Public Health Branch, and of the Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA.
General and nutritional problems-The higher regional and departmental public health organizations in northwest France and Belgium, which were not seriously dislocated by the war, were soon able to deal with the current problems. Water supplies, disposal of wastes and sewage, laboratory service, and related matters were put in order and functioned well. In all of these undertakings, CAPHO's were influential in guiding and supervising civilian officials. Food supplies and nutritional problems in these countries were subjects of serious consideration and investigation, at times requiring remedial measures (p. 444).
Displaced persons and refugees-Large numbers of refugees and ambulatory civilian casualties attempted to return to their homes unaided. It was necessary to clear them out of the way of military operations and to supervise and control their movements. For these purposes, CAD's C112 and D212 became "refugee control detachments" in August 1944, with the special mission of establishing routes over which a quarter of a million refugees and thousands of wounded and sick were kept away from military lines. Groups of refugees were brought under control in the French communities, and were cared for through the Maires, the Secours National, and the Croix Rouge Francaise, under guidance and supervision of CAD's, which billeted and fed them without military assistance. In only two
instances was it necessary for the G-5 Section of the Third U.S. Army to furnish relief supplies.8
One of these situations occurred at Brest:
A special problem developed in the vicinity of Brest when the Germans expelled the city's civilian population in the probable hope of embarrassing the American forces. [Civil Affairs] Detachment C112 was dispatched to this area and the G-5 Refugee officer, together with a French liaison officer, surveyed the area. Instructions were issued to the Maires and the Chief of Gendarmes of each community to clear the main highways and route individuals to communities where billeting facilities still existed. Six thousand refugees were entrained from Landerneau to Morlaix. The refugees which came through the German lines were excellently handled by the French Authorities, with the assistance of four women of the Military Liaison for Administrative Matters, through dispersal and billeting in nearby communities. Detachment C112 provided emergency hard rations, which included soap, codfish, pulses, biscuits, meat, milk, and chocolate. Its officers coordinated the work of the Maires. The Secours National established emergency feeding stations where necessary and a total of 24,000 refugees were cared for without interference to military operations or supply, and without suffering to the individual.9
Along the battlelines, control routes were established for moving refugees to nearby transit camps, where they were kept for a few days before being moved to more permanent camps. These camps were operated by Free French volunteers, at first under the jurisdiction of CAD's or military authorities. As the combat lines advanced, the camps were transferred to civil authorities as temporary places for refugees until more permanent homes could be found for them. Military transport was used to move medical and sanitary supplies from civilian and Civil Affairs sources. In crowded situations, the refugees slept on floors or on straw for a day or two, but cots and tents were provided later. In addition, during this period, Civil Affairs Detachments became responsible for the civilians in the internment camps which were uncovered as the troops moved forward.
Camps for displaced persons and refugees, which usually operated under Army control, included dispensaries. The ARB and CAD public health and medical supply units proved too large for meeting emergency medical needs. Therefore, a drug unit was augmented by dressings and other items and small "dispensary units" were set up. These were the Civil Affairs medical kits, which were found to be particularly convenient and useful. Likewise, refugee camps were managed satisfactorily largely by local physicians under the general supervision of Civil Affairs officers.
Invasion of Southern France
The Seventh U.S. Army landed on the coast of southern France, near Toulon and Marseille, on 15 August 1944, commencing Operation ANVIL.
This force moved swiftly northward up the Rhone Valley and reached the Swiss border by 1 September. With the First French Army, it formed a part of the 6th Army Group. On 11 September, just 27 days after the landing, the Seventh U.S. Army joined the Third U.S. Army in the vicinity of Dijon, and this junction of forces caused the disintegration of all German units in southwestern France.
Fortunately, in this vast and populous region of southern France, no conditions or situations among the civilians demanded unusual or extensive operations by CAD Medical Detachments. There were no serious health problems and no epidemics, and the civilian public health administration was satisfactory.10
Communicable disease control.-There was no serious prevalence of communicable diseases, but there was a threat of typhus, which in the winter of 1943-44 had been epidemic in Naples. Typhus control teams, composed of French civilians, were organized and trained in methods of delousing with DDT. Sufficient DDT was provided for a program of disinfestation of inmates of prisons in Nice and Marseille, which were regarded as potentially the most dangerous sources.
The only serious disruption of sanitary services occurred at Toulon and Arles, where the damage to water supply systems caused shortages of water for drinking, household uses, and flushing out sewers. These systems were repaired.11
Care of wounded civilians; hospital services-The treatment of wounded civilians by the Seventh U.S. Army Medical Service presented problems to the combat forces in this campaign as in other campaigns in Europe. The problems involved both military medical services and Civil Affairs. A lack of aggressive action by Civil Affairs to make maximum use of civilian resources is revealed by the following excerpt from a report:
During the advances wounded civilians from the forward areas were being evacuated out of the area to Army Evacuation Hospitals. This overtaxed the medical, surgical, and bed facilities of these installations, and interfered with the proper handling of U.S. patients.
Except in extreme emergencies and for immediate life-saving treatment, civilians will not be evacuated to Army Evacuation Hospitals, but will be hospitalized in available civilian institutions provided for that purpose.12
From the time of the invasion of Normandy in June 1944 until at least 2 months after the fighting ended in Germany in May 1945, the military medical services were confronted with the problem of the medical and surgical care of wounded civilians (fig. 58). Wounded civilians were first cared for at military aid stations or at posts of CAD Medical Detachments. Some were evacuated from these field stations to civilian facilities in the
rear; others were admitted to military hospitals for surgical operations or medical treatment. The records of the First, Third, Seventh, and Ninth U.S. Armies show that the numbers of civilians admitted to such hospitals in each Army ranged from 150 to 650 per month. Although the total number of cases was relatively small compared with the large number of military casualties handled, this extra load constituted an added burden on the military medical service. During 1944, French civilian casualties were held in the Army area until they became convalescent. Later, to reduce these burdens, efforts were made to find suitably equipped and staffed French civilian hospitals as soon as possible and to transfer wounded civilians to them. Civil Affairs medical personnel through liaison aided in the operation of this system of evacuation.
The Liberation of Paris
The SHAEF authorities had hoped that Paris might be captured without making it a battleground. Bombing of the French capital had been
avoided and plans had been made to surround the area, thus forcing the surrender of the German garrison. Fighting in Paris, however, was precipitated on 19 August 1944 by an uprising of French resistance forces who seized the Ministries and Prefectures. To support these forces, two Allied divisions-the French 2d Armored and the U.S. 4th Infantry Divisions-entered Paris on 25 August, quickly subdued the Germans, and restored order. On this day, the German commander surrendered formally to Gen. Jacques LeClerc, commanding the French 2d Armored Division, and Gen. Charles de Gaulle arrived in Paris and announced the composition of the Provisional Government of the French Republic, with himself as President of the Council. On 28 August, Maj. Gen. Leonard T. Gerow, commanding officer of V Corps, in a letter to Gen. Pierre Joseph Koenig, Military Governor of Paris, turned the city over to the French. Fortunately, no great material damage had been caused by the fighting.13
Civil affairs-public health activities in Paris began on 26 August when a combined Civil Affairs "A" Detachment, containing both American and British personnel, with the same CAPHO who had served in Cherbourg (Captain Basora-Defillo), entered the city. This CAD, bringing in relief food, assumed administration over an area encompassing the departments of Seine-et-Marne, Seine-et-Oise, and Loiret; Civil Affairs support came from the 12th U.S. Army Group and the U.S. Communications Zone.
Public health activities included a survey of the nutritional status of the population; investigation of the water supplies, sewage and garbage disposal; analysis of hospital beds; and a study of the extensive medical supply resources and requirements. Close liaison was maintained with civilian public health authorities. Assistance was rendered through 21 CAD's, one for each arrondissement. At the governmental level, these functions were performed by the SHAEF Mission to France.
Immediate problems were caused by limited stocks of coal, limited electrical lighting, inadequate pumping of water and sewage, and lack of fuel for the gas plant. Flour and other foods were critically short and, although there were surplus foods in the liberated areas, there was no way of moving them to Paris. On 26 August, the first convoys moved from the Sommervieu Civil Affairs Base Port Depot; the next day, the trucks carried the Union Jack and a chalked legend: "Churchill Keeps His Promises."14 By 1 September, 2,800 tons from the 21 Army Group had been delivered, and by 6 September, 2,336 tons were airlifted.
Other immediate tasks were caring for civilian casualties, safeguarding food supplies, and maintaining order.
In general, by October 1944 the health situation in the liberated areas of France, which included Paris, had stabilized and no acute problems were
being encountered. No critical shortages of medical and surgical supplies and equipment existed, serums for emergencies were being obtained from the Pasteur Institute in Paris, and other shortages were being met from stocks of Civil Affairs medical supplies. Reports from the 12th Army Group indicated that civilian departments of health were becoming more active, according to Lt. Col. James T. Cullyford, MC, CAPHO, who coordinated with Col. Tom F. Whayne, MC.
The Parisian situation was similar to the general situation regarding health. By October, the health situation in Paris was good. Although the supply of whole milk continued to improve, it was still irregular because of a lack of transportation and a lack of coal for pasteurization. Distribution of milk was largely limited to children under 14 years of age.15
During the period from 26 August 1944 to 31 July 1945, a number of detachments of the 1st European Civil Affairs Regiment were stationed in Paris. At first, some were attached to the 12th Army Group and the U.S. Communications Zone; finally, all were attached to the Communications Zone.
PUBLIC HEALTH ORGANIZATIONS
Two Civil Affairs public health organizations were established in the European theater during the period July-September 1944: the Civil Affairs Branch, Office of the Chief Surgeon, ETOUSA; and the European Civil Affairs Medical Group, ECAD, connected with G-5 SHAEF Public Health Branch. Although some information about them has been given (p. 431), it is desirable here to focus on them. Both were engaged in continuous operations, and both were involved in the nebulous assignments of public health responsibilities and were concerned with the obvious need for collaboration between the regular theater medical service and the public health activities of SHAEF.
Civil Affairs Branch, Office of the Chief Surgeon, ETOUSA
On 23 May 1944, a theater directive16 raised Civil Affairs from special staff level to general staff level in the ETOUSA organization. The same directive placed upon the Office of the Chief Surgeon (Maj. Gen. Paul R. Hawley) the following duties in connection with the medical and public health program for civilians in liberated and occupied countries: "f. Medical Service: (1) Requisitioning, procurement, storage and issue of medical supplies for civilian use. (2) Supervision of public health and sanitation, including supervision of the rehabilitation of civilian hospitals."
Predicated upon this directive, the Civil Affairs Branch of Operations Division, Office of the Chief Surgeon, ETOUSA, was established as of 1
July 1944 with Lt. Col. Walter L. Tatum, MC, as chief of the branch.17 Colonel Tatum was a Civil Affairs medical officer who had been attached to the Office of the Chief Surgeon on 1 May 1944 by the Assistant Chief of Staff, G-5, Communications Zone, ETOUSA.
After the establishment of this Branch, but not entirely as a result of its establishment and activities, there ensued a long period of difficulties, confusion, and considerable accomplishment nevertheless, most of which are described and discussed by Tatum18and Armfield,19 among others.
The Chief Surgeon, ETOUSA, was unable to carry out all of the duties imposed by the directive of 23 May 1944 because, as previously explained, he had not been provided with the means and personnel for civil affairs public health operations. Furthermore, the directive conflicted with other directives from Headquarters, ETOUSA, and from SHAEF. In addition, policies and procedures of the G-5 Section, Headquarters, Communications Zone, were also at variance with the plans and requirements stated in the directive. Confusion was increased by Civil Affairs Administrative Memorandums Nos. 8 and 9 from Headquarters, ETOUSA, dated 8 August 1944, which placed certain responsibilities for medical and public health services for civilians upon commanders of Communications Zone Sections. Finally this directive was interpreted differently at different echelons.
In September 1944, a new directive was issued which partially clarified the situation.20 The Chief Surgeon was made responsible for (1) requisitioning, storage, and bulk issue of medical supplies (complete ARB and CAD units) for civilian use; (2) supervising public health and sanitation, and issuing such regulations regarding the control of sanitation and communicable diseases among civilians as were necessary for the proper safeguarding of the health of the military command; and (3) furnishing technical advice and necessary assistance to Civil Affairs personnel.
Reports indicate that the directive of 25 September 1944 did not settle the issues. Nevertheless, the staff surgeons and medical officers assigned to G-5 Sections cooperated closely with each other. There was also considerable collaboration between the Chief Surgeon's Civil Affairs Branch and the G-5 SHAEF Public Health Branch and the European Civil Affairs Medical Group, and with the European Civil Affairs Division itself. Some examples of this are to be found in the accounts of the rehabilitation of water supplies in Cherbourg, Liège, and other cities, and in the control of outbreaks of typhoid fever in Belgium.
In all matters relating to communicable disease control, this Civil Affairs Branch closely coordinated its activities with the Preventive Medicine Division, Office of the Chief Surgeon. Reports from civilian and military sources were made available immediately to all interested sections, and reports were made, as required, to the Public Health Branch, G-5 SHAEF.
A close and highly beneficial liaison was maintained between the Civil Affairs Branch of the Office of the Chief Surgeon and the Field Headquarters of the Typhus Commission, chiefly when it was located first in London and later in Paris, under the command of the Field Director, Brig. Gen. Leon A. Fox, MC, USA, during 1944-45.
Although there was, in fact, extensive collaboration between officers of the medical service of the field forces and officers of the G-5 SHAEF medical and public health organizations, important underlying conflicts of interests and basic theories remained. On the one hand, the representatives of Civil Affairs who were concerned primarily with problems among the civilian population believed, on the basis of expressed opinions and actions, that officers of the regular medical service were only secondarily interested in such problems. On the other hand, officers of the regular medical service, even some senior ones, believed firmly that public health officers assigned to G-5 SHAEF, in general, would not be able to function according to plans and directives in combat areas. They believed that the public health activities of G-5 SHAEF should begin at the rear boundaries of the field armies. Among the reasons for this opinion, aside from questions of competence, two appear to have been most influential: (1) "the conviction, fairly widespread among medical officers, that the staff (command) surgeon should control all medical programs, whether for military personnel or for civilians, in which the command engaged," and (2) "the fact that the staff surgeon controlled the so-called 'medical means' of the command; that is, the medical supplies, personnel, transport, and other facilities on which those assigned to the public health program with the field armies had to depend whenever their own means became scarce."21As the campaign progressed and the armies advanced across France and into western Germany, events and experience confirmed these theories and opinions. The regular medical service of the theater, including the Civil Affairs Branch of the Office of the Chief Surgeon, had to assume increasing responsibilities for dealing with public health problems among civilian populations.
European Civil Affairs Medical Group
As a result of months of thoughtful and imaginative planning which was forced to a conclusion by the necessities of the campaign, the ECA
Medical Group22was established and activated within ECAD at headquarters of the Division at Chateau Rochefort, Rochefort-en-Yvelines, Seine-et-Oise, France, on 14 September 1944. This was one of the principal changes in the reorganization of ECAD. Col. James P. Pappas, MC (fig. 59), assumed command while retaining his staff assignment as ECAD chief surgeon. A headquarters was opened at Chateau Rochefort on the same date and the 1st, 2d, 3d and 4th (Special) Medical Detachments were formed. The initial commissioned strength was approximately 95 Medical Department officers with varied training and experience in public health, Army doctrine, and staff procedures. A staff for the headquarters detachment of the Medical Group was appointed between 26 and 29 September. On this staff, Captain Dehné served as Executive Officer. The ECA Medical Group became the medical organization designed to supervise the public health activities of SHAEF in liberated and occupied territory in the U.S. area of responsibility in northwest Europe. By this action, all ECAD medical
personnel were brought under centralized administrative direction. Also included in the Group were some of the attached officers of the U.S. Public Health Service, certain medical personnel of UNRRA (United Nations Relief and Rehabilitation Administration), branch immaterial officers with training in public health, and other Allied medical officers previously under G-5 public health sections of tactical commands. The organization did not include all CA/MG medical (public health) personnel in northwest Europe, but only those available at the time. Civil Affairs medical staff personnel assigned to G-5 sections in tactical commands, armies, and Army Groups were not included. The organization was shaped by a compromise between actual needs and personnel expected to be available to ECAD during combat. An analysis in December 1944 showed shortages of 16 Medical Corps officers, three sanitary engineers and two nutrition officers. It was assumed that, after the cessation of hostilities, medical personnel would become available from the medical service of the armies.
The proposed organization of the ECA Medical Group underwent a number of changes before staff approval. Planning in detail for the static military government of Germany was impossible because the areas to be occupied by the respective Allied armies were not known.
Movements into France-Civil affairs-public health personnel of the European Civil Affairs Division moved into France with the division and its regiments, companies, and detachments. A forward echelon of Headquarters, ECAD, established on 8 June 1944 at Shrivenham, England, proceeded to Omaha Beach on 21 July to administer ECAD elements in the field and to inspect, advise, and assist in Civil Affairs operations, supply, administration, and personnel problems. The Assistant Division Surgeon and six enlisted men, who operated from Chateau Epinquet until 4 September, comprised the Medical Department component of the Forward Echelon until headquarters was set up at Rochefort-en-Yvelines to accommodate Headquarters, ECAD, when it arrived on 9 September. An advance echelon of the 1st ECA Medical Detachment, 1st ECA Regiment, with two auxiliary public health teams, arrived in France on 24 June, and the remainder of the detachment, commanded by Lt. Col. (later Col.) William H. Riheldaffer, MC, debarked at Omaha Beach on 30 June. The 2d ECA Medical Detachment, 2d ECA Regiment, commanded by Lt. Col. Roswell K. Brown, MC, arrived at Utah Beach on 13 July, and the 4th and 3d ECA Medical Detachments arrived at Rochefort-en-Yvelines on 17 and 19 September, respectively.
Personnel.-The Civil Affairs Center at Shrivenham had no table of organization or table of distribution for personnel spaces and grades. Therefore, there were no position vacancies, and no promotions could be made. Activation of ECAD with a table of distribution on 6 February 1944 was followed by only four promotions. Theoretically, promotions were possible, but more personnel were assigned without proportionate increases in
authorizations for grades and ratings. Medical personnel were promoted after activation of the ECA Medical Group.
Use of enlisted personnel.-The evolution and development of the use of Medical Department enlisted personnel in Civil Affairs, to supplement activities of officers, were important factors in civil affairs-public health activities in northwest Europe; no medical enlisted personnel were used in the Italian campaign. A wider coverage was obtained by having, on each CA/MG detachment, a Medical Department enlisted man who rendered first aid and collected and assembled data for the officer responsible for the detachment's area. Frequently these enlisted men were not used sufficiently, primarily because an understanding of their capabilities was lacking.
Functions.-Specific functions of the ECA Medical Group included giving technical public health advice in planning, organizing, and supervising the territorial application of principles of public health in liberated and occupied lands from frontlines to rear areas and zones. The ECA Medical Group enabled SHAEF to provide personnel, units, and teams to operate with CA/MG regional detachments or teams in reestablishing civil public health and in preventing the development of hazardous health conditions that might interfere with military operations. The Group provided personnel for technical supervision of public health operations, prepared technical directives to implement public health functions, and furnished qualified personnel to supervise and review results in the field and to obtain and interpret information on prevention and control of disease. The Group also provided personnel for consultations and conferences with responsible civilian health authorities, and assisted in coordinating the similar public health programs and activities of the Allied armies.
In carrying out these functions, many difficulties had to be overcome. Coordination of efforts and supervision of personnel were especially difficult because of poor communication and limited contact among personnel of the Civil Affairs Detachments. Rapid movement, fluid combat situations, and limited communications demanded individual reconnaissance and direct contact if the job were to be done.
During the period between the liberation of Paris on 25-28 August 1944 and the middle of December, the Allied armies advanced to the northern and eastern borders of Belgium and France and were in the early stages of the planned alinement along the western bank of the Rhine. In this interval, extensive civil affairs-public health operations had been carried out by both the regular medical service of the field armies and by the public health organizations of G-5 SHAEF (p. 444).
THE GERMAN COUNTEROFFENSIVE IN THE ARDENNES
On 16 December 1944, the Germans, with the combined strength of three armies, struck suddenly in the Ardennes in a region held relatively lightly by elements of the 12th Army Group. This fierce attack soon became
known as the Battle of the Bulge because of the shape of its penetration between Saint-Vith and Bastogne, almost to Dinant on the Meuse River. The drive was contained in about 6 weeks, the enemy was forced out of the salient by 25 January 1945, and his defeat set the stage for the final Allied victory the following May.
The eruption of the Germans into Luxembourg and Belgium during the bitterly cold winter forced hordes of refugees and displaced persons into liberated areas full of Allied troops adjacent to the battleground. Cities lying just beyond the area of greatest penetration, such as Liège, were packed with refugees who, because of the repeated bombings, were crowded into underground air raid shelters. Many food stores and sources were lost and food, clothing, and shelter became scarce. Local officials, ordered by the Belgian Government to stand fast, understandably refused to do so, fearing retaliation from returning Germans and Belgian collaborators. Many new and complex problems called for vigorous efforts of all the military and Civil Affairs medical and public health agencies in the region. While the most vivid available descriptions of conditions and detailed reports on "Civil Affairs-Military Government Operations-Public Health" are from FUSA units, it is known from various sources that members of the ECA Medical Group were participants in the activities, assisting with advice, supervision, and supplies.
Examples of the activities, extracted from FUSA reports, follows:23
1. A survey of available hospital facilities for the care of civilian casualties, made early in December, provided information that was highly useful during the battle.
2. The emergency hospital set up in Verviers in November was used and emergency facilities were established at Liège. Less seriously injured civilians and convalescents were moved into private dwellings and convalescent homes.
3. Extensive damage to hospitals by enemy action further taxed facilities in the First U.S. Army area. Six of eleven hospitals in Liège were severely damaged and one civilian and one field hospital at Verviers were badly damaged.
4. German civilian patients in the hospital at Eupen were transferred to their homes in Monschau; other civilian casualties in Eupen were evacuated to Verviers.
5. When the German onslaught resulted in a large increase in civilian casualties, Civil Affairs detachments supervised rescue work and saw to it that medical care was provided.
6. In the VIII Corps area, providing hospitalization for civilian casualties was a constant problem. In such towns as Diekirch and Eitel, detachments assisted by attached American Red Cross personnel rendered service in transporting serious casualties and providing emergency care.
7. An adequate number of civilian medical personnel remained at their posts except in the extreme forward areas, where some doctors were among the first to get out.
8. The need for emergency medical supplies was met with captured enemy supplies from the stockpile at the G-5 depot at Liège and by ARB units from First U.S. Army allocations. Two ARB units were placed in Luxembourg City by mid-December, and were available for distribution in the entire Grand Duchy. Another ARB unit was placed at Libramont, Belgium, for use in the Province of Luxembourg. Large stores of supplies
were turned over to the Belgian Red Cross at Liège, and emergency drugs and dressings were shipped to Verviers. Late in December a Liège-type "Pannier" was provided for the Weywertz area.
9. Enemy shelling and bombing damaged water supply systems in cities and towns, breaking water mains and causing leaks. One bomb which fell near the Verviers refugee center demolished the water main, completely disrupting the water supply of the center. Repairs were made by civilian agencies with some assistance from Civil Affairs.
10. In the last days of December, after the situation had become better stabilized in the Eupen-Malmédy area, a formidable task was maintaining sanitation among refugees. Most of the population was living in extremely crowded underground shelters, in which sanitary measures had completely broken down. A public health specialist of the G-5 section made a thorough survey of the situation. His recommendations, including chlorination of the water supply, rigorous sanitary discipline in the use of latrines, and better dishwashing because of the threat of dysentery, were immediately put into effect by the Military Government Staff of the 30th Infantry Division. Congestion in the air-raid shelters was relieved. By evacuating more than 1,500 persons in Belgian Red Cross and Army trucks, and by the voluntary departure of more than 2,000 the special police enforced an order for cleaning all public shelters.
11. Antitoxin was provided from Civil Affairs sources for the treatment of five cases of diphtheria among the refugees.
12. With the retreat of the Germans, rehabilitation of civilian hospitals and sanitary facilities and services proceeded, with the aid of the Belgian Red Cross, which provided doctors, nurses, and related personnel. A team of public health workers, equipped with trucks, ambulances, drugs, dressings, and other materials from the Belgian Military Mission (SHAEF Mission) worked in areas most acutely in need of help, from La Roche-en-Ardenne to Vielsalm. Medical supplies were also received from the Civil Affairs Supply Depot, and from civilian sources, at Liège.24
The German counteroffensive in the Ardennes dislocated many Civil Affairs Detachments and caused considerable movement of public health personnel. When the U.S. Armies resumed their advance after 25 January 1945, Civil Affairs officers and public health officers were drawn from Military Government Centers and placed on duty in Belgium and Luxembourg. The advance into Germany called for Military Government Detachments to be deployed in local provincial headquarters under CAD command rather than under the tactical commands to which they had been attached.
THE SHAEF MISSIONS
For the sake of brevity, chronological continuity will be broken at this point by the insertion of a condensed account of the public health activities of the SHAEF Missions in the European theater (Northwest Europe) from the time of their establishment in 1944 to their disbandment in 1945, when SHAEF was dissolved. To do this, it is necessary to pass over for the moment the tremendous military operations of the Allied Forces immediately west of the Rhine and onward into Germany and Austria. The overpowering of Germany will be discussed after the account of the Missions has been completed.
Intelligence, Medical, and Public Health functions-The collection and analysis of intelligence on many subjects to obtain and use the most up-to-date and precise information about conditions in the countries of Northwest Europe were normal and important functions of the G-2 sections of SHAEF, ETO Headquarters, Army Headquarters, and, indeed, of all the major military units. A similar intelligence organization existed, of course, in the War Department and the Army Service Forces, and in their policymaking, operational, and technical components. With respect to activities concerning medical and public health intelligence in the European theater, it is known that the "country houses" and the headquarters of the SHAEF missions made constant and extensive efforts to ascertain the conditions in the countries of Northwest Europe as they existed from 1939 to 1944, and throughout the campaign into 1945. There were similar activities in the G-5 Public Health Branch, SHAEF, especially through the ECA Medical Detachments. A Medical Intelligence Section was established in the Office of the Chief Surgeon, ETOUSA, to which a Medical Intelligence Officer from the Office of the Surgeon General had been attached in August 1943.
The degree of liaison and exchange of information between these various agencies and offices is not clear from available records; it appears to have been relatively small.
During the period 1942-44, a strong and active Medical Intelligence Division had been developed in Preventive Medicine Service in the Office of the Surgeon General under the direction, first, of Colonel Whayne and, later, Col. Gaylord W. Anderson, MC. This division collected and issued a vast amount of medical and sanitary data about many countries throughout the world, including those in Northwest Europe. As the lines of communication of this division with the European theater were almost entirely through the G-2 intelligence system of ASF, few, if any, of its publications, circulars, and bulletins (TB MED's) reached either the Office of the Chief Surgeon, ETOUSA, or the G-5 SHAEF Public Health Branch offices or agencies. There are several reasons for this. One is an indication that the medical intelligence reports of the Office of the Surgeon General, based largely on previously published reports, were not sufficiently up to date for use in preparing to meet the urgent situations that the invading forces would encounter. For this purpose, on-the-spot current information was essential. Another reason was the effect of an added procedural hindrance. In 1944, as recorded by Colonel Anderson,25 these reports could not be sent directly to the Office of the Chief Surgeon, ETOUSA, because a theater Publications Screening Board had ruled against direct shipment or transmission of these and other types of medical reports. For some time, a ruling prevailed that only such material as might be issued over the signature of the Chief
Surgeon could be disseminated in the theater. In Colonel Anderson's chapter, there is no mention of either G-2 ETO or G-2 SHAEF.
Organization and functions-At various times in the latter half of 1944, the "country houses" or "state houses" which had been formed in England in 1943 were designated Military Missions of Supreme Headquarters, Allied Expeditionary Force, or briefly, SHAEF Missions. Substantial accounts of their organization, functions, and activities, including public health, have been presented in their own reports, in a special report by Draper,26 and in books by Donnison and Friedrich.27
The purpose of the Missions was to serve as liaison agencies between the governments of the liberated countries and the Allied military authorities for mutual assistance in prosecuting the war and in rehabilitation (p. 427). The liberated countries in northwest Europe with which the Missions were concerned were France, Belgium, Luxembourg, the Netherlands, Denmark, and Norway. Each Mission was directed by an American or British officer, especially selected; the personnel of the Mission included American, British, and Canadian officers and enlisted men. The SHAEF Mission to France, and the Mission to Luxembourg in the first phase of its deployment, were under the immediate command of ETOUSA; the others were under the British 21 Army Group.
The Missions were of different sizes but were generally similar in structure, comprising a headquarters and divisions, branches, and sections representing the main governmental and political subdivisions of these European states. Among the branches was a Public Health and Welfare Branch, with an experienced public health officer at its head. Capable public health personnel were selected with the assistance of Lt. Col. Leonard A. Scheele, MC, USPHS, who served as an adviser to the ECAD personnel board. Because the British had insufficient medical and public health personnel and were unable to fill their quota of officers for civil affairs-public health activities, the Public Health Branch of G-5 SHAEF had to lend U.S. personnel to Missions serving under the 21 Army Group (see pp. 32, 324).
The following additional comments on personnel problems and general evaluation of service rendered by the Missions are quoted from Draper's report (see above).
In general each Mission was provided with one or two medical officers and a Sanitary Corps officer. To these might be added various specialists for temporary duty from time to time as the need arose. The Netherlands Mission, for example, required the temporary services of nutrition consultants and teams; also sanitary engineers and a veterinarian. The Belgian Mission requested nutrition consultants and venereal disease consultants. The French Mission has especial need for advice in venereal disease control, veterinary problems, and narcotic drug control.
The public health personnel of the Missions established a close working relationship
with the health authorities of the national governments and their activities were of great value both to the civilian and military agencies. They assisted in working out the kinds and quantities of medical, sanitary, and food supplies required by the national governments from military sources. They aided in the recruitment of medical personnel for that part of the displaced persons program for which the national governments were responsible. They investigated sanitary conditions and outbreaks of disease. They were especially helpful in securing the cooperation of the liberated countries in the carrying out of anti-typhus measures. They assisted in the reporting of communicable diseases and in the establishment of measures for the control of venereal diseases. They were instrumental in securing data in regard to the nutritional status of the civil population. In short they were the liaison officers from whom both the military and civil authorities might obtain information on matters of concern to both, and to whom each might turn for proper representation of its interests to the other. * * *
One of the difficulties was in furnishing temporary personnel to the Missions of the type and for the length of time required. As previously stated, only two or three public health officials were on the permanent Table of Organization of the Missions. While a large number, including especially venereologists, sanitary engineers and nutritionists could have been used to advantage on a full time basis their services were not at all times vitally necessary and it would probably have been felt that they were more urgently needed elsewhere. However, when acute necessity arose it was difficult and sometimes impossible to supply the need or to permit such temporary personnel to remain as long as their services were required. We were frequently placed in the position of having to ask the Missions to make provision for additional public health personnel in their Tables of Organization in order that we might endeavor to secure them from sources outside the ETO. Such suggestion, however, was seldom if ever accepted and we were obliged to tide the emergencies over as best we could.
It is my opinion that the plan of the Missions was extremely well conceived and afforded a means whereby the health and other problems of the liberated countries could be understood and handled with the least possible demand upon the time of the personnel of SHAEF. Certain minor difficulties were encountered but these were due either to shortage of personnel or to honest differences of opinion between administrative officers rather than to defects of the plan itself.
Nutrition.-Except in rare emergencies which required the Army to participate in the relief of groups of people in distress, interest had been centered on the troops, and not much thought had been given to the steps that the Army would have to take to supply and distribute food to remedy deficiencies, and to restore and maintain the nutrition of large populations in foreign countries liberated and occupied by victorious forces of the United States and its allies. For this new concept, new organizations and new procedures were needed. These were developed and put into effect by Civil Affairs, chiefly by those divisions and sections that were concerned with preventive medicine and public health.
In the Surgeon General's Office, from 1941 to the end of the war, the Preventive Medicine Service had a special concern in these matters because of the foresight and energy of its Chief, Brig. Gen. James S. Simmons, MC. One of his chief assistants, Col. Thomas B. Turner, MC, who became chief of the Civil Public Health Division, dealt with the practicalities of selection and supply of materials in his early collaborative work on devising the CAD (Civil Affairs Division) Units. Following him, Col. John B.
Youmans, MC, as Director of the Nutrition Division, influenced further developments, some of which led for the first time to the offering of advice, suggestions, and recommendations by the Surgeon General's Office to commanders (and surgeons) of forces in theaters of operations.28
In the European theater, a Nutrition Branch was established in the Division of Preventive Medicine of the Office of the Chief Surgeon, ETOUSA, following the arrival late in August 1942 of the Nutrition Officer, Col. Wendell H. Griffith, MC, who served as chief of the Branch for the ensuing 3 years. "The Nutrition Branch was not directly concerned with civilian feeding in Europe inasmuch as this problem was assigned to the Public Health Branch of SHAEF. Prior to the organization of that Branch, the Nutrition Branch had participated in early plans for this phase of the Army's general task on the continent. It continued to cooperate with the Public Health officers and assisted the latter in the preliminary surveys in Germany."29
When the Public Health Branch of G-5 SHAEF was established in London on 8 May 1944, the importance of nutrition was recognized. Col. Paul E. Howe, SnC, was appointed to the staff as Chief Consultant in Nutrition. He had been a nutrition officer with the American Expeditionary Forces in France in World War I. Reports filtering through the Netherlands in October 1944 indicated to Colonel Howe that serious malnutrition existed among the civilians.30
In London on 25 May 1944, the foundation of the nutrition program for Civil Affairs in the European theater was laid by the Deputy Chief of the Public Health Branch, G-5 SHAEF, Brigadier Thomas F. Kennedy, RAMC, and the Chief Nutrition Consultant, Colonel Howe, USA. "The task confronting them involved the development of a basis for solutions of a problem which was then of unknown proportions. Its anticipated magnitude was difficult to convey to those in command positions, who at that time were concerned with actual combat activities and did not visualize the extremely vital role nutrition was to play in the overall allied operations in the near future."31
Mission to France
History and functions-After more than a year spent in planning in the French "Country House" in London, the SHAEF Mission to France opened its headquarters at the Trianon Hotel in Paris on 25 August 1944, immediately after the city was liberated and the Provisional Government was proclaimed by General de Gaulle. From here, the Mission operated throughout France until 14 July 1945, when it was replaced by separate
U.S. and British Military Missions. This was the largest of the Missions but, like the others, had only a small staff of medical, sanitary, and public health officers.
The guidelines for the Mission to France were the same as those for the other Missions and Civil Affairs Detachments, in general. These were set forth in two basic directives32which contain both broad principles and many technical details, and in a handbook.33
In France, Civil Affairs Officers, including Public Health Officers, were governed by the order of the Supreme Commander that "Civil Administration in all areas will be normally controlled by the French themselves." The Field Historian of the Third U.S. Army has stated the point of view and attitude of the authorities of that Army in terms applicable to each U.S. Army in France, namely: "The Third Army went into action with the understanding that 'any semblance of military government in France was to be scrupulously avoided, and that the French would resume full civil activity as fast as conditions permitted.' * * * In all echelons the spirit and letter of the Supreme Commander's order were felt as corresponding to the use of the official designation 'Civil Affairs' rather than that of 'Military Government,' which was to obtain in Germany."34
Refugees, repatriations, and nutrition-The unexpectedly large number of refugees from Paris embarrassed the First and Third U.S. Armies. In late August 1944, there were 100,000 Parisians outside Paris in the area of the Third U.S. Army, and on 31 August, a Civil Affairs Officer estimated 500,000 refugees were in the various army zones of operation in France. Severe conditions in Alsace-Lorraine during September and the Battle of the Bulge in December 1944 forced many thousands of displaced persons and refugees to flee to the rear. Their problems of feeding, clothing, shelter, and sanitation were worked out, in part, by Civil Affairs Officers of various specialties, in collaboration with the French and the Medical Service of the armies. During all of 1945, repatriating about 350,000 persons through France to their own countries involved medical and sanitary problems of the types previously described. Fortunately, no outbreak of disease occurred in France at any time during the campaign on a scale to threaten the armies or to cause serious disturbance among the civilians. Although there was a great increase in tuberculosis and venereal disease among the French during the war, and some malnutrition in the large cities, public health in general was satisfactory. Contributing to this favorable situation were the high standards of the Allied armies, the "standfast policy" in handling refugees, and the sanitary precautions of the French and U.S. authorities
in handling displaced persons. Another factor was the stock of biologicals at the Pasteur Institute in Paris for distribution through civilian channels. In addition, there was never any serious shortage in the medical supplies which the Army Medical Supply Depot furnished on civilian requisition. Considerable use was made by Civil Affairs public health agencies of the CAD and ARB supply units, and the "pannier" system of packaging in smaller lots.
A dramatic incident of relief took place at Sarreguemines and Welferding in December 1944 when public health officers took first aid and medical supplies to several thousand refugees in caves in no man's land.
The personnel of the French Provisional Government were understandably concerned with a forthcoming campaign for office, with almost overwhelming administrative problems, and with securing the recognition of the Provisional Government itself, before the general elections. On 11 November 1944, formal recognition of this Government by the United States, the United Kingdom, and Soviet Russia made France a member of the European Advisory Commission.
In 1948, 3 years after the end of the war, historians reviewing the events concluded that the SHAEF Mission to France did much good in carrying out every responsibility, "and in the direction given to (French) authorities in reorganizing their police and fire brigades, their public health and hospital services * * * a substantial contribution was made."35
Mission to Belgium
On 15 September 1944, the SHAEF Mission to Belgium was established under the command of the 21 Army Group with Maj. Gen. G. W. E. Erskine of the British Army at its head. This Mission became responsible also for civil affairs-public health activities in Luxembourg in October 1944.
During most of the first 5 months of the Mission's operations, the civil affairs-public health problems in Belgium were severe because of several factors. Belgium was a battlefield. Overcrowding of buildings and underground shelters in the chief cities, destruction of water supplies and sanitary facilities by enemy bombing and shelling, and occasional shortages of food and medical supplies were some of the situations requiring public health action. Camps for displaced persons and refugees presented similar distressing problems. The Battle of the Bulge drove destitute people westward into central Belgium. Enteric disorders were prevalent, and in the summer and autumn of 1944, there was an outbreak of typhoid fever in the Liège area. The presence of two enormous armies in the country added greatly to the overcrowding and created conditions in which venereal diseases flourished.
The Mission to Belgium especially needed nutrition consultants and
venereal disease consultants. These were furnished from time to time through the Public Health Branch, G-5 SHAEF.
During December 1944 and January 1945, at the request of the Mission, a thorough and helpful sampling survey of the public water supply in Belgium was made by a team of public health personnel of the 1st European Civil Affairs Regiment. Recommendations from this study were carried out with good results by Belgian officials acting with advice and assistance from civil affairs-public health officers.36
The care of sick and wounded civilians in the fall and winter of 1944 called for extensive exertions, with or without success, by personnel of the Ninth, First, and Third U.S. Armies, in collaboration with medical and public health personnel of Civil Affairs.
Mission to the Netherlands
The Netherlands were invaded by Germany on 10 May 1940 and the center of Rotterdam, which had been declared an open city, was destroyed in a German air raid on 14 May. Queen Wilhelmina and officials of her government fled to London. A period of ruthless terrorism was instituted in Holland under the Reichskommissar Seyss-Inquart. Large quantities of food were removed to Germany and thousands of men were deported to work in German factories. For 5 years, the Netherlands suffered the ravages of the occupying Germans. During the final year of the war, the country was a battleground over which the 21 Army Group and the Ninth U.S. Army fought a destructive campaign against German forces; at the same time, the Allied armies crowded cities, towns, and rural areas and, of necessity, made severe demands upon the civilians for billets and other facilities.
In London in 1943, representatives of Civil Affairs in COSSAC (Chief of Staff to the Supreme Allied Commander) collaborated with the Netherlands Government in exile to establish the Netherlands "Country House." Between March and September 1944, the handbook for Civil Affairs in the Netherlands was developed, and the Public Health Branch estimated the kinds and quantities of medical and sanitary supplies and equipment which would be required under various conditions which might arise following an Allied invasion by both land and sea. Projected analyses dealt with the health problems which might be caused by extensive inundation of the low country and the consequent displacement of the population. In September 1944, the Country House became the SHAEF Mission to the Netherlands and moved into Brussels, Belgium, shortly after the liberation of that city on 3 September.
The Mission's headquarters was established first at the University of Brussels, where Maj. Guy V. Rice, Jr., MC, coordinated activities with the
21 Army Group. Lt. Col. Harold R. Sandstead, MC, USPHS, a specialist in nutrition, who headed the Public Health Branch of the Mission, and Lt. Col. Harry A. Gorman, VC, set up advance headquarters at Eindhoven, Holland. The Branch then became operational. Colonel Sandstead conferred frequently with Maj. (later Col.) Leonid S. Snegireff, MC, who was the Civil Affairs Public Health. Officer in the G-5 Division at Ninth U.S. Army Headquarters.37
Southern Holland-The period under consideration begins in September 1944 with the liberation of Eindhoven and Nijmegen by the 82d Airborne Division, the push north by the First Canadian Army on the left, the British Second Army in the center, and the Ninth U.S. Army on the right, and continues to the Rhine crossing in the vicinity of Wesel on 22 March 1945. All during the winter, these three Armies were deployed in Southern Holland, in the provinces of Limburg and Brabant. At times, the Allied troops outnumbered the 2 million Dutch inhabitants. During the early phases of the fighting, extreme crowding occurred because of the influx of refugees. Factories and monasteries were used as centers for refugees and displaced persons and, to the great discomfiture of the Dutch people, the Armies requisitioned all sorts of buildings, including private dwellings, for headquarters, billets, and supply depots. Civilian hospitals were overcrowded; the Armies had taken over several which had been occupied by the Germans. There was an extreme shortage of fuel during the entire period, and until December, rail, water, motor transport, and gasoline were limited to military use. Government and commerce were disrupted because of the breakdown of all civilian communications. Only Army transportation was available for moving civilian supplies.
Southern Holland was not prepared for reinstitution of civil administration at the time of liberation because the country had a highly centralized form of government, and local officials looked to The Hague and to Amsterdam for direction and decision. Only a few well-qualified men in government and commerce were liberated. The result was confusion, fear, and, in a few instances, a lack of cooperation with Allied authorities. This last was understandable considering the fact that most of the Dutch had friends and relatives in the area under German occupation, even in concentration camps.
The first priority in public health was the reorganization of civilian health and medical services. Weekly conferences were held by the Public Health Branch with health inspectors and public health officers of the three Allied armies, who settled problems affecting both the civilian and military groups. Although a number of practicing physicians were appointed as deputy inspectors, the Public Health Branch did not succeed in forming an effective civilian health service.
After October 1944, Civil Affairs met all essential and emergency demands for medical supplies. Through Civil Affairs guidance, a State-
controlled bureau for all medical and hospital supplies and equipment, including Red Cross materials, was organized and transport was made available. Physicians, hospitals, and pharmacists were required to place requisitions through the local health inspectors for approval at the depots. Requirements for medical supplies and control of their release were under the jurisdiction of the Public Health Branch. This system worked well and prevented hoarding, inflation, and black marketing. One need that could not be fully satisfied by Civil Affairs was that for scabicidal drugs. In some groups of refugees and displaced persons, scabies infestation was as high as 85 percent. The use of DDT powder for delousing was limited to refugees and displaced persons, and civilian delousing teams were organized and trained under the health inspectors.
In November 1944, Major Snegireff reported succinctly on the situation, in substance as follows: Public health problems in South Limburg Province were closely linked with the state of nutrition of the populace. The diet had steadily deteriorated, and had dropped from the 1,600 calories permitted by the Germans to 980 calories per person per day in the first week of November 1944. The complicated rationing system of the Dutch Military Administration did not permit the immediate alleviation through increase in caloric allocation for several days after food had been delivered through G-5, Civilian Supply, Ninth U.S. Army. He found that tuberculosis was the most serious communicable disease problem. Scabies was also prevalent.38
In December 1944, Civil Affairs food supplies could not be brought in because Antwerp harbor and the Scheldt River basin had not been cleared. The reduced civilian ration of 1,200 calories per day added to the confusion, apathy, and doubt in the minds of the Dutch. The incidence of diphtheria and scarlet fever was high. There were few isolation facilities and the limited supply of drugs was exhausted. Fortunately, there were only sporadic cases of typhoid fever. Through urging by the Public Health Branch of the Mission, the Dutch began a sizable diphtheria immunization program, about the first evidence that their health services were recovering.
By the time eastern and northern Holland were liberated, southern Holland had recovered sufficiently to permit civilian authorities to handle most problems with little Civil Affairs assistance other than supplies. A large Dutch pharmaceutical manufacturing firm produced most of the needed biologicals (except vaccines) and substantial quantities of the sulfonamides.
The eastern provinces.-The eastern provinces of Friesland, Drenthe, Overijssel, and Gelderland were liberated in a few days during late March 1945, without much material destruction or dislocation of the population. These provinces were well supplied with food and other essentials, were well organized, and required only minor assistance from the Mission.
Developments affecting public health activities.-The work of the Public Health Branch of the Mission was affected indirectly by a number of important events, particularly the following:
1. In August 1945, the four medical schools at Groningen, Utrecht, Amsterdam, and Leiden (with which the Public Health Branch had an informal relationship) were reopened, and the veterinary school at Utrecht was scheduled to reopen in the fall.
2. Circulation of all except German medical journals had been prohibited. Arrangements were made through the Office of War Information, the American Library Association, and the Rockefeller Foundation to import medical books and journals.
3. The State Department of Health in the Netherlands had never been strong because the prewar high economic level of the population, statewide compulsory medical insurance, a high ratio of physicians to population, good hospitals, and the cleanliness of the people made it unnecessary to have a vigorous state health service. A lay Director of Health served under the Minister of Social Affairs; under him were four bureau chiefs and inspectors under each bureau for each of the provinces. These officials, although able and courageous, could not cope with the numerous daily problems. The Head of the Public Health Branch of the Mission conferred several times with a committee of Dutch physicians about plans for a larger and stronger State health service, including public health.
4. Two important laws affecting public health were decreed by the Government while the Mission was in Holland. One amended the narcotics control laws to secure greater protection for the troops. The other was a new law requiring reporting of cases of venereal disease.
Displaced persons and refugees.-The medical and public health officers of the Armies and the Mission were responsible for supervision of health and sanitation among displaced persons and refugees. Centers for displaced persons were established at strategic locations along the eastern border of the country from Maastricht in the south to Groningen in the north. Civilian medical officials were on full-time duty. Through the Mission, arrangements were made for emergency hospital accommodations or civilian hospitals were supplied with additional beds. Some of the larger centers, particularly those handling non-Dutch persons, were manned and operated by the Armies. Lt. Col. Harold Ansley, RCAMC, Public Health Officer of the First Canadian Army, and Major Snegireff dealt with all health problems arising among displaced persons and refugees passing through their areas.
Between 400,000 and 500,000 displaced persons of Dutch origin returned to Holland from February through June 1945, with the peak influx in March and April. During the early days, up to 95 percent of those returning from certain areas were infested with body lice; however, after the centers in Germany became better organized, the louse infestation rate declined to less than 10 percent.
A total of 55 cases of typhus occurred among Dutch displaced persons after their arrival at border stations in Holland. Presumably, these people were in the incubation stage of the disease when they entered the country. As a result of casefinding efforts, quarantine of the sick and their contacts, immunization of contacts, and dusting with DDT of families and groups, not a single case of typhus developed in the local civilian population which was not displaced. Health officers made louse counts in groups of civilians and, when the incidence of infestation rose to 10 percent or greater, DDT powder was issued for use.
The western Netherlands.-Even before the liberation of the western Netherlands, steps were taken to assemble food supplies for this stricken area and to arrange for medical care of the victims of malnutrition and starvation. These plans were put into effect immediately after the liberation of the region in May 1945. Simultaneously, the survey teams carried out studies and collected an immense amount of clinical, biochemical, and dietary-nutritional information. To assemble and analyze the data would have taken a considerable amount of time under normal conditions. To do this in the immediate postwar period required even more time. By 1948, however, the Government of the Netherlands was able to publish the report of the expert committee, with recommendations applicable to future conditions should similar situations occur.39
During the last months of the German occupation, from October 1944 to 5 May 1945, the people in the western area of Holland were afflicted with a famine produced by the ruthless removal of foodstuffs and the restriction of production and importation imposed by the Germans. The experience of western Netherlands in 1945 was almost a vast catastrophe. If the German occupying forces had held out another 2 or 3 weeks against the Allied attack, nothing could have saved hundreds of thousands from starvation. How many died will never be known, but probably at least 10,000 lost their lives because the occupying power failed in its obligation to sustain the civilian population under its authority.
Some of the events, descriptions of activities, clinical observations and opinions, and recommendations in the 1948 report of the committee follow:
(a) Lt. Col. H. R. Sandstead, in the words of the Minister of
Social Affairs, "as head of the Health Section of the SHAEF mission to the
Netherlands contributed much to the recovery of the health of the population of
our country and who was a great support of the relief action."
ment of individuals suffering from grave starvation * * * none of the experts who were consulted could say with assurance how such a famine should be met."
(d) The report gives a clear picture of a condition caused by a serious deficiency of energy (calories), inevitably involving lack of protein. Specific disorders due to deficiencies of vitamins and minerals did not complicate the situation to any significant extent because the people were able to get some vegetable produce from their fields.
(e) It was found that predigested foods of the type of protein hydrolysates for oral or intravenous administration were not essential or effective for resuscitating patients in the late stages of exhaustion from starvation. The gastrointestinal tracts of such persons could digest foods such as milk and even large amounts of butterfat. "Only in the very last stage of starvation, when the patient is almost moribund, was direct feeding of no value; indeed, experience in the western Netherlands indicated that there is no available treatment that will resuscitate such cases * * * it is important to emphasize that what the starving person needs is food and plenty of it. The experience in western Netherlands did not support the popular view that they need careful nursing back to a condition in which they can take a full diet." The importance of putting a starving person as quickly as possible on a diet of high energy value and high protein content could not be overemphasized.
(f) "The psychological condition of an underfed population constituted one of the greatest difficulties the teams encountered. The peculiar psychological state of individuals suffering from severe and prolonged calorie-shortage makes it necessary to pay the utmost attention to methods of approach, imparting of information, and understanding of mental states. Apathy and irritability are the outstanding features of such a situation, which calls for special attention not only in regard to the relation between doctors and patients, but to the difficulties of dealing with civilian authorities. Good understanding will avoid delay in action and therefore be of life-saving importance."
(g) "Food stocks were exhausted when the Allied forces entered in the western area. For a few days before actual liberation came, food in considerable quantities had been reaching the area by air and by road. Notwithstanding every effort on the part of all concerned in food distribution, delays caused by sorting, stockpiling, and allocating supplies resulted in large numbers of people going without any food at all for the best part of a week. This was a period of acute danger for those who were already in a severe nutritional state at the time of liberation. In future emergencies every possible measure should be taken to avoid such a delay."
(h) Finally, the Editorial Committee recorded its considered opinion that "there is no justification for the ruthless sacrifice of a civilian population in such circumstances and that the United Nations should devise a Convention of international scope of which the object would be to protect civilians subjected to an occupying power from suffering grave injury to health as a result of inadequate nourishment."
Mission to Denmark
The Danish "Country House" was established in London on 7 February 1944; in mid-October of that year, at Norfolk House, St. James's Square, it became the SHAEF Mission to Denmark. The Mission moved to Copenhagen, Denmark, on 7 May 1945, 2 days after all the German forces in northwest Germany, Holland, and Denmark had surrendered unconditionally to the 21 Army Group.
The Mission, composed of 20 British and 17 American civil affairs officers, had distinguished leadership. Its organization contained a Public Health Section, of which Col. John P. Hubbard, MC, was Head from September 1944 until the unit was disbanded in July 1945.
The following account of general and health conditions in Denmark, and of some of the public health activities, is condensed from Colonel Hubbard's reports for May and June 1945.40
On arrival in Copenhagen on 7 May 1945, the Mission was greeted by a jubilant and healthy-looking, well-dressed people. It was evident that the population and the country had suffered less from the war than had any of the other belligerent states of northwest Europe. Food appeared to be abundant and of excellent quality, especially dairy products.
During the months before the liberation, refugees, displaced persons, and German military wounded had been swarming into Denmark. This placed a heavy burden upon the National Health Service. The displaced persons and refugees were in poor condition and presented a danger of the spread of epidemic diseases. In other respects, the National Health Service was in a favorable position. The functioning of the Service and related institutions, such as the Serum Institute, had been but slightly affected by the German occupation.
Control of displaced persons-The chief concern of the Public Health Section of the Mission during May and June 1945 was the control and management of the 200,000 to 300,000 displaced persons and refugees estimated to be in Denmark. Several thousand DP's (displaced persons) were in Danish hospitals and German military hospitals, mingled with sick and wounded German military personnel. The consequent overcrowding put a strain on the hospital facilities, and the mingling of the Danes and Germans, both patients and civilian doctors, caused serious problems. As it was found unwise to mix German military and civilian medical personnel in the hospitals and camps, an arrangement was made for German military medical personnel to leave Denmark as soon as they were no longer needed for the medical care of Wehrmacht personnel.
Ships crowded with displaced persons and refugees from Germany, and crowded harbor shacks, produced dangerously unsanitary conditions in Copenhagen Free Port. Many of these persons slept on straw spread on cement floors. There was a high degree of louse infestation. Sanitary facilities were inadequate and not often used. During May, under the supervision of the Public Health Section of the Mission, all DP's and refugees were removed and the whole port area was cleaned up.
During May and June, all Allied displaced persons were inspected medically by Danish doctors to determine the presence of communicable disease or other obvious illness. An extensive immunization program was undertaken to administer two injections of diphtheria toxoid and three injections of triple typhoid vaccine to each of approximately 200,000 DP's and refugees. Teams of Danish medical students assisted by visiting all DP
centers. The Public Health Section of the Mission was aware of this work but did not take a direct part in it.
Communicable diseases.-No serious epidemic of infectious disease occurred in Denmark during May and June 1945. During the occupation, venereal diseases, scarlet fever, and diphtheria increased above the normal incidence but not to an alarming degree. Tuberculosis showed an insignificant increase. Statistics on the occurrence of diseases were collected from Danish sources by Colonel Hubbard and were included in his reports.
Typhus fever.-From 1 May to 9 June 1945, a total of 60 cases of typhus fever were reported in Denmark. The control measures applied by the Danish health authorities, with some advice and assistance from the Public Health Section of the Mission, were (a) isolation of cases in the Copenhagen Communicable Disease Hospital, (b) a thorough and effective disinfestation program by delousing with 5-percent DDT powder, and (c) limited use of typhus vaccine and a booster dose of this vaccine to all military personnel of the Mission. Most Danish doctors previously had been immunized with typhus vaccine prepared in Denmark.41
The outbreak declined in the latter part of June and did not spread among the Danish civilian population at any time.
Typhoid fever.-During June 1945, there was an outbreak of 478 cases of typhoid fever among German displaced persons, without spreading to the civilian population of the country.42 The typhoid immunization program was continued. In addition to the usual control measures, swimming along the coast of Zealand was prohibited by the Danish authorities because many DP's among whom typhoid was occurring were living in boats lying off Copenhagen.
Nutrition.-Supplies of meat and milk were sufficient, but fresh fruits and green vegetables were scarce. The people had maintained an average daily caloric intake of 2,900 to 3,000 calories per person and there were no significant nutritional deficiencies.
Danish medical personnel for service outside Denmark-As one of its final acts, the Mission and its Public Health Section served in an advisory capacity to a committee representing the National Health Service and the Ministry of Social Affairs which was concerned with the possibility of making Danish medical personnel available for service outside Denmark. In view of the anticipated urgent needs for medical and public health assistance in Germany, the Danish health authorities were advised to prepare a plan for submission to UNRRA, which had authority over any nonmilitary organization that might contribute medical or other aid to Germany.
Mission to Norway
Planning for Civil Affairs activities, including public health, in Norway began in August 1943 when the Norwegian "Country House" was formed in London by representatives of the Norwegian Government in exile and British and American Civil Affairs Officers under COSSAC. This organization was designated the SHAEF Mission to Norway in February 1945 but did not become operational as a Mission until 8 May 1945, when Norway was liberated from the Germans. A month later, on 7 June, the Mission was discontinued when King Haakon VII returned to Norway and the responsibility for civil administration was restored to the Norwegian Government.
Nutrition was the main problem. During the German occupation, food supplies for the Norwegians had been progressively reduced and, according to a Nutrition Consultant to the Office of the Surgeon General who visited Norway in June 1945, there was still a severe food shortage. Norwegian observers reported that early famine edema had been seen just before liberation. Loss of weight of adults in Oslo amounted to 10 to 15 kg. Although school children did not show any serious loss of weight, they had failed to continue to increase in height and weight as was normal for children during the period 1920-40. Food relief, which was put into effect immediately following liberation, using supplies shipped into Norway from Denmark and Sweden, apparently averted more serious consequences and conditions rapidly improved.
In summary, the more important Civil Affairs responsibilities were those of rendering assistance to the Royal Norwegian Government in providing medical and other supplies for the civil population, managing displaced persons and refugees, and establishing military courts for trials of Germans.
THE RHINELAND CAMPAIGN
Advance across the Rhine.-During the period from 11 September to 16 December 1944, the Ninth, First, and Third U.S. Armies conquered three small areas of the western fringe of Germany, lying along the Belgian, Luxembourg, and French frontiers. Military Government was inaugurated in this territory and U.S. Military Government detachments gained their first experience in the European theater in dealing with enemy populations.43
The advance was interrupted by the German counteroffensive in the Ardennes on 16 December 1944, which created severe public health problems with which the staffs and units of Civil Affairs and the medical services of the three U.S. Armies had to contend through a long month of the bitterly cold and wet winter (p. 451).
The advance was resumed shortly after 25 January 1945. By 8
February, the Germans along the Roer River were forced to withdraw to the west. Within the next month, the entire Rhineland was conquered. A bridgehead on the Rhine was established by the 9th Armored Division at Remagen on 7 March by the capture of the Ludendorff Bridge. The Third U.S. Army drove to the south, cleared the Saar, made the first assault crossing of the Rhine in modern history on 22 March, and broke into the cities of Mainz and Koblenz. Later, after the surrender of Germany, the Saar-Palatinate became parts of the British and French Zones of Occupation.
First Military Government in Germany.-Superseding an interim directive of 10 September 1944, SHAEF issued a directive on 9 November covering the situation that would be developed by Allied conquest and occupation of territory before the defeat or surrender of Germany.44 As future operations were governed extensively by this directive, space will be given here to an abstract of parts of it, with special reference to specifications of public health activities.
The SCAEF (Supreme Commander, Allied Expeditionary Force) was announced as initially and fully responsible for establishing and maintaining Military Government in areas of Germany occupied by forces under his command. At some time following the occupation of Germany, this responsibility would be assumed by a tripartite Control Commission. Each commander addressed was made responsible for the execution of SCAEF's policies in the establishment and operation of Military Government in the areas occupied by his Group of Armies. During hostilities in Germany, the Supreme Commander was given the legislative, executive, and judicial rights of an occupying power, and his authority and power were delegated to the Army Group Commanders, who in turn were authorized to redelegate powers to subordinate commanders. The Army Group Commanders were directed to establish Military Government immediately upon the occupation by their forces of any part of German territory.
Seven primary objectives were specified: (1) Imposition of the will of the Allies upon Germany; (2) Care, control, and repatriation of displaced United Nations nationals, and minimum care necessary to control enemy refugees and displaced persons; (3) Apprehension of war criminals; (4) Elimination of Nazism and German militarism, and related matters and individuals; (5) Restoration and maintenance of law and order; (6) Protection and control of United Nations property and assets; and (7) Preservation and establishment of suitable civil administration.
Five restrictions were to be observed in the attainment of these objectives: (1) No steps to rehabilitate the German economy except as necessary to support military operations; (2) Importation of only minimum relief supplies to prevent disease and disorder; (3) Removal from administrative office of Nazis or ardent Nazi sympathizers; (4) Temporary use of
Nazi administrative machinery of certain dissolved organizations when necessary to provide relief, health, and sanitation; and (5) Germany to be treated as a defeated country and not as a liberated one.
The directive pointed out that the conduct of Military Government operations was a command responsibility and that the discharge of this responsibility might require the use of all resources at the disposal of commanders. By specific reference, this included Military Government staffs and detachments, and functional experts, with retention as needed of Civil Affairs staffs already assigned to Army Group Headquarters.
Public health specifications.-Public health policy of the Supreme Commander was stated in section IX of this directive, as follows: (a) Control of communicable diseases among civilians in Germany; (b) Prevention of the spread of dangerous diseases across German boundaries; (c) Removal of Nazis and ardent Nazi sympathizers in German public health services and their replacement by acceptable personnel; (d) Provision of medical care necessary to protect the health of United Nations nationals in Germany; (e) Use of medical and public health resources and productive capacity of Germany to the extent needed to supply urgent needs of the United Nations, and sanction of the use of the balance for maintenance of public health in Germany; (f) Importation, if German resources proved to be inadequate, of limited medical supplies for use of German nationals as might be necessary to prevent disease and disorder, such as might endanger or impede military operations; and (g) Discovery and dissemination of any new advances by Germans in the fields of public health and medical science. In succeeding paragraphs of this directive, many particulars were specified to give effect to this policy.
Health conditions.-During the Rhineland Campaign, there were no serious epidemics and no great public health problems. No major problem of preventive medicine arose until typhus fever appeared in February and became a dangerous threat in the Rhineland and Inner Reich in March 1945.
THE DEFEAT OF GERMANY
Military situation.-Between 24 March and 1 April 1945, the Rhine barrier was breached in many places by all of the Armies of the Allied Expeditionary Force. The assault crossings of the river were made near Wesel in the north and all along the river to the vicinity of Karlsruhe in the south. According to General Eisenhower, "the March 24 [northern] operation sealed the fate of Germany."45
In the 45 days following 24 March 1945, Germany was overrun by the victorious forces of the Allies. From the long list of advances and conquests of this period, the following achievements deserve mention to summarize the final stage of the vast campaign. The Ruhr was enveloped and reduced by the First and Ninth U.S. Armies between 24 March and 18 April. The 21
Army Group cleared Holland and northwest Germany and received the surrender of all German armed forces in those areas and in Denmark, on 4 May. Bremen and Hamburg fell to the British Second Army. The Ninth U.S. Army reached Magdeburg, and elements of the First U.S. Army met the advancing Russians at Torgau on the Elbe River, on 25 April. The Third U.S. Army was as far east as Chemnitz, Pilsen, Regensberg, and Linz on the Danube in Austria. The Seventh U.S. Army took Munich, the capital of Bavaria, on 30 April, and advanced through Salzburg, Austria, to Berchtesgaden, Bavaria, without opposition. The French First Army had advanced from Strasbourg to the Swiss border near Basel and on to Lake Constance, completely encircling the enemy in the Black Forest. On 2 May, Berlin surrendered to the Russian forces; on the same day, the German armies in Italy surrendered completely. On 7 May, the German High Comman surrendered all the land, sea, and air forces unconditionally to the Allied Forces, effective at 1 minute after midnight on 8-9 May. Upon receipt of this news in the field, all offensive operations were immediately halted.
Phases and plans of Military Government in Germany-The first phase of Military Government in Germany began about 11 September 1944 when the First, Third, and Ninth U.S. Armies occupied small areas in the Saar-Palatinate of the Rhineland. This phase (Phase I) of the occupation continued until the surrender of Germany when it was succeeded by a so-called Static Phase (Phase II) of the U.S. military occupation of Germany, extending from the surrender until 2 July 1949, when the Hon. John Jay McCloy as High Commissioner succeeded Gen. Lucius D. Clay, who had been United States Military Governor in Germany since shortly after the fall of Berlin. On that date, as former Brig. Gen. Frank L. Howley put it: "Military rule was out; civil rule was in."46
In dealing with the two phases of Military Government and associated public health activities, the plan of this section is to describe and discuss rather fully the major events of the early phase (Phase I) and to present a relatively brief account of activities of the static phase (Phase II). The conclusion will be 31 December 1945, the closing date for this history, but some projections beyond that date will be necessary.47
Civil public health problems during the ebb and flow of military operations in the Ardennes were merely a prelude to those encountered in western Germany, where disruption of the people, facilities, and government was extensive, and where most of the cities had been destroyed by shelling or by bombing.48 Pictures of Cologne in March 1945 are graphic examples of the destruction (figs. 60 and 61).
The swiftly moving events following the capture of the Remagen bridge on 7 March 1945 brought the greatest tests of Civil Affairs activities, including those of public health. That the health aspects of the advance into Germany were met is a tribute to the combined medical and public health efforts of the Allied armies and justified the long and often frustrating planning by a handful of public health personnel. The civil health responsibilities of SHAEF and of the Army Groups were substantial. They differed more in quantity than in kind from those previously encountered in France, Belgium, and Luxembourg: emergency medical care of civilian sick and wounded, rehabilitation of sanitary services, reestablishment of civilian medical services and medical supply facilities, care and control of displaced persons and refugees, and the prevention and control of communicable diseases. But in sheer magnitude, nothing equaled the control and movement of vast numbers of refugees and displaced persons, and the problems posed in the protection of Northwest Europe against the threat of louseborne typhus fever, which occurred in epidemic form in the Rhineland and Inner Reich. Another problem unique in modern medicine was presented by starvation conditions in German concentration camps as well as among some civilians outside these camps. The account of how these problems were met is, to a great extent, the history of CA/MG public health activities carried out by many types of regular and special units during the last phase of the European War.
Plans, personnel, and dispositions.-In October 1944, plans to use Civil Affairs public health personnel were integrated with the overall CA/MG plans. Under "Plan 1186 South," the 3d ECA Medical Detachment and the 3d ECA Regiment were earmarked for Military Government public health in Germany; Companies E, F, G, and H, 2d ECA Regiment, with 2d ECA Medical Detachment were reorganized for German occupation; and the reorganized 1st ECA Regiment and the 1st ECA Medical Detachment were assigned to Civil Affairs public health in France and Belgium in support of communications lines. Thus, the already insufficient strength was spread more thinly than ever by the deployment of one-third of it to cover rear areas, leaving but two-thirds to cover the increasingly large areas of occupied Germany.
The CARPET PLAN envisioned specific Military Government Detachments for duties in German governmental subdivisions for which they were trained. In theory the MG (Military Government) fabric would be unrolled like a carpet as territory was occupied in Rhine Province, Hessen-Nassau, and parts of Westphalia. The CARPET PLAN, drawn up before there were any U.S. forces in Germany, suffered from great uncertainty as to which element of an Army Group would "lay" a particular portion of the carpet. Pinpointing of units or personnel for specific localities, regardless of their company affiliations, required placement of detachments with the armies which were to uncover their ultimate destinations. The entity of an MG company meant little under such conditions. Actual situations made it necessary for commanders sometimes to disregard deployments according to plan, which also affected the deployment of MG public health personnel. In addition, uncertainties caused by the frequent shifting of boundaries between armies and the transferring of detachments persisted in the operations of PLAN TALISMAN, later named "PLAN ECLIPSE," the plan for
the final penetration of Germany, withdrawal into the final U.S. Zone of Germany, and the full establishment of Military Government.
Public Health activities to 28 March 1945.-Public Health officers of ECA Medical Detachments, then serving in Germany under Military Government, continued to exercise the advisory and supervisory functions that they had performed in France and Belgium. The problems with which these officers were concerned were complex and extensive and called for vigorous and sustained activity, as indicated by the scope and requirements set forth in a special SHAEF G-5 manual.49
The territory in which the problems arose was so large, and the mass of civilians involved was so great, that the tasks proved to be beyond the resources and competence of the relatively small group that constituted the Public Health Branch of G-5 SHAEF and the ECA Medical Group. The situation became so urgent that the great resources of the regular medical service of the field armies were called upon to meet it on 28 March 1945.
The events of the period ending on 8 May 1945 are obviously interrelated and cannot be treated in isolation. It is possible, however, to examine them separately and this will be done in succeeding sections dealing with (1) the epidemic of typhus in 1944-45 and the "cordon sanitaire," (2) the Nazi concentration camps, (3) the care and control of displaced persons and refugees, (4) nutritional problems among civilians, and, finally, (5) the relation of the operations of the medical and public health units and officers of G-5 SHAEF Civil Affairs/Military Government to those of the regular Medical Service of the Armies and Army Groups.
Typhus in Occupied Germany, 1944-45
As the history of epidemic louseborne typhus fever in the European theater during World War II has been presented elsewhere in considerable detail, only a relatively brief account will be given here.50
At the outset, it must be remembered that numerous Army and civilian medical, public health, and research organizations, and many individuals were engaged in the fight against typhus during the war. Although this chapter focuses upon the activities of SHAEF G-5, Public Health Branch and its related units, such as the ECA Medical Group, many other military-medical elements in the field and at various headquarters participated effectively in the antityphus operations. In describing the extensive typhus control activities in northwest Europe, it is often difficult to identify
exactly which group should be credited with the success, or judged responsible for the failure, of a given aspect of the overall effort.
Major policies, plans, and activities were developed and carried out by the following organizations, working sometimes alone, but usually in collaboration: (1) SHAEF G-5 Division and the Public Health Branch, SHAEF G-5; (2) Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA; (3) Chief of Preventive Medicine, Office of the Surgeon, 12th Army Group; (4) G-5 Divisions of armies, corps, and Communications Zone, Advance Section; (5) innumerable surgeons of armies, corps, and divisions, and their staffs; (6) Preventive Medicine Service, Office of the Surgeon General, War Department; (7) the United States of America Typhus Commission; (8) Civil Affairs Division, War Department Special Staff; and (9) representatives of the Medical Service of the British 21 Army Group. This list, though incomplete, is indicative of the large forces that were engaged in one of the most extensive, intense, and successful public health operations in history. Key individuals in this enterprise were Col. John E. Gordon, MC, Chief, Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA; Colonel Scheele, Preventive Medicine Officer, Public Health Branch, G-5 SHAEF; Colonel Whayne, Chief of Preventive Medicine, Office of the Surgeon, Headquarters, 12th Army Group; and Brigadier General Fox, MC, Field Director, United States of America Typhus Commission.
Awareness and preparations.-Knowledge of the ravages of louseborne typhus fever under conditions of war coupled with destitution and malnutrition among civilians created in the minds of all medical and public health authorities concerned an awareness of the potential threat of typhus. As some of the main foci of typhus were in eastern Europe, that area was marked for particular attention. Preparations to protect troops, and to prevent and control typhus, were intensified in the years immediately preceding the entry of the United States into World War II. Improvements of chemical lousicides, of typhus vaccine, and of methods for using these agents were well underway as early as 1939. The possibility of encountering typhus in northwest Europe became apparent in reports showing that typhus had become established in eastern Germany in 1939, and had been spread throughout the country by German soldiers returning from the eastern front, by prisoners of war, and by slave laborers brought in from infected areas.
Information concerning the prevalence of typhus in Germany until near the end of 1943 was available from reports issued by German health authorities. Then, in January 1944, the Germans stopped the general issuance of these reports. Consequently, uncertainty ensued.
In July 1942, Brigadier General Simmons, Chief of the Preventive Medicine Service, Office of the Surgeon General, realized that there was a disquieting lack of information about the occurrence of epidemic typhus in parts of Europe, including Germany, and in North Africa and other areas
into which U.S. troops might be sent. One consequence of his concern in these matters was the establishment of the United States of America Typhus Commission on 24 December 1942 by Executive Order No. 9285.
During 1943, stocks of DDT and typhus vaccine were accumulated in London, and the Division of Preventive Medicine, Office of the Chief Surgeon, ETOUSA, increased activities in planning, training, and various precautionary measures. Typhus had been encountered in North Africa after the landings in 1942. The outbreak of typhus at Naples, Italy, was brought under control during the period December 1943 through February 1944. The extraordinary lethality of DDT powder for the body louse and its prolonged effect from residual amounts in clothing were well established in 1943. The use of DDT powder applied by dusting individuals fully clothed greatly strengthened the effects of delousing, thus preventing the spread of typhus.
Lack of definite information about the prevalence of typhus in Germany in early 1944 and for several months after the invasion of Normandy reduced in the minds of some authorities remote from the scene of action the need to prepare for the control of typhus in the European theater. This opinion, of course, was not shared by either the Division of Preventive Medicine, Office of the Chief Surgeon, ETOUSA, or the Public Health Branch, G-5 SHAEF, represented by Lieutenant Colonel Scheele, who urged the shipment of increased amounts of DDT and other antityphus supplies to the theater, starting in September 1944.
Some 20 years later, Dr. Scheele, at the request of the chairman of the Advisory Editorial Board of the Preventive Medicine series, recorded some of the details of this episode in a reminiscent letter, from which the following portions are quoted.51
My recollections of some dates in 1944 is somewhat hazy but I will try to reproduce some of the happenings of that time. The Germans in Paris surrendered on August 25, 1944, and shortly thereafter I had an opportunity to visit Dr. Robert Pierret, Director-General of Office Internationale d'Hygiene Publique, 195 Bd. St. Germaine, Paris. The International Office of Public Health was a precursor of World Health Organization. It came into existence in 1907 and survived through the period of the Health Organization of the League of Nations which had fewer members.* * * * * * *
Most of the U.S. people who were working in UNRRA assumed that the International Office of Public Health had been destroyed by the Germans and had gone out of existence. However, I found when I visited Pierret that the worst treatment he had had from the Germans was the rifling of his files. They attempted to replace him with a German but finally gave up when he "sat in" his office and said that only the nations which elected him could discharge him. He continued to collect communicable disease reports and continued to publish the Office's Bulletins. He took duplicate sets of these, wrapped and addressed to the USPHS, along with sets for Latin American and other countries not under German control, who were members, to a farm for burial under a
haystack against the day when the Germans would be defeated and the back issues could be mailed.
I told Dr. Pierret of our great interest in getting early intelligence on the possible occurrence of typhus fever in areas still under German control, and he offered to contact the man in Switzerland who was principal representative of that country to the meetings of the Office, to ask him to contact his German counterpart in Berlin to obtain information. As a result of this there were mailed to Paris via Switzerland, the German Ministry of Health's summaries covering the period of 23 weeks January 1 through June 6, 1944, and weekly reports #31 through 34 covering July 30 through August 26, 1944. These showed a slow increase in reported weekly cases of typhus in the civilian population, especially in July and August 1944. They did not, as I recall, distinguish between the German civilian and slave laborer cases. It was on the basis of these reports that SHAEF sent a substantial request for DDT and power dusting equipment to the War Department through the Combined Chiefs of Staff in Washington, its normal channel to the U.S. Military Services. You will recall that you sent Joe Sadusk [Col. Joseph F. Sadusk, MC, Executive Officer, United States of America Typhus Commission] to Paris to visit us in mid-September, 1944, in order to explore more fully the basis for our very substantial DDT requirement. I believe that Joe went home satisfied with the request and recommended it to you. I supported it further when I talked with you in the USA on my trip home during the period November 1 to 14 (1944).
United States of American Typhus Commission.-On 26 February 1944, Brigadier General Fox and Colonel Turner conferred in London with Major General Hawley, Colonel Whayne, MC, Assistant Military Attaché for Medicine, American Embassy, London, and with British officials concerning the participation of the Typhus Commission in typhus control in the European theater. As a result of agreements and approvals, on 17 May 1944, the Commission, attached to the Public Health Branch, Civil Affairs Division, G-5 SHAEF, established its Field Headquarters in London at 44 Grosvenor Square, and later acquired two refrigerated warehouses for storage of typhus vaccine. Thereafter, most of the typhus vaccine used in ETOUSA was issued by the Commission. DDT concentrate and powder were procured, stored, and issued by appropriate authorities of ETOUSA and SHAEF, with the constant support of the Commission. The Field Headquarters of the Typhus Commission in the European theater moved to Paris on 9 November 1944, and personnel of the Commission continued to collaborate with personnel of SHAEF, the 12th Army Group, and 21 Army Group, throughout the remainder of the campaign in Germany and until 27 August 1945, when this field headquarters was closed. After that date, the Commission was attached to the Headquarters, USFET (U.S. Forces European Theater), at Frankfurt, Germany, working in various areas, including Poland, under Lt. Col. David M. Greeley, MC, until 22 April 1946.
Typhus in the Rhineland.-Typhus was first reported at Aachen, in the Rhineland, in February 1945. Several Italian conscript laborers traveling from Holland to Aachen had fallen into the hands of a Ninth U.S. Army unit. A tentative diagnosis of typhoid or typhus fever was made by a Military Government medical officer, and the serological diagnosis of typhus was made by the 10th Medical Laboratory. On 5 March 1945, five more cases were discovered in Mönchen-Gladbach. Almost at the same time, an out-
break of typhus was uncovered in the city of Cologne by elements of the First U.S. Army and the Cologne Military Government detachment. By 1 June 1945, 183 cases had been reported in Mönchen-Gladbach and 199 in Cologne. Russian and Polish laborers and native Germans mostly living in air raid shelters and prisons were principally affected. An explosive outbreak occurred at Hermülheim in the last week of March. In the Rhine Province, the Saarland, and the Palatinate, about 400 cases of typhus had occurred in the weeks preceding the entry of American troops. The region of the Rhineland from north to south was heavily seeded with infection and the potential for spreading was strong. Colonel Gordon has vividly described the conditions in this area in March 1945 as follows:52
The whole area seethed with foreign peoples, conscript laborers moving this way and that and in all directions, hoping to reach their homes, in search of food, seeking shelter. Most of the typhus was within this group and they carried the disease with them. They moved along the highways and in country lanes-now a dozen Roumanians pulling a cart loaded with their remaining belongings; here a little band of Frenchmen working their way toward France, there some Netherlanders, or perhaps Belgians; and everywhere, the varied nationalities of the East-Ukrainians, Poles, Czechs, Russians. They moved mostly on foot, halted, then gathered in great camps of sometimes 15,000 or more, extemporized, of primitive sanitation, crowded, and with all too little sense of order or cleanliness.
These were the people where typhus predominated, more than half a million of them in the Rhineland, wearied with the war, undernourished, poorly clothed and long inured to sanitary underprivilege and low level hygiene. Add to this shifting population the hundreds of released political prisoners, often heavily infected with typhus but happily far fewer in numbers; the German refugees, first moving ahead of our troops and then sifting back to their homes through the American lines. Rarely if ever has a situation existed so conducive to the spread of typhus.
Typhus fever in a stable population is bad enough. It has demonstrated its potentialities in both war and peace. The Rhineland in those days of March, 1945, could scarcely be believed by those who saw it-it is beyond the appreciation of those who did not. It was Wild West, the hordes of Genghis Khan, the Klondike gold rush, and Napoleon's retreat from Moscow all rolled up into one. Such was the typhus problem in the Rhineland.
By the intensive efforts of typhus teams and medical and sanitary personnel of military (Army) medical units and CA/MG detachments, having adequate supplies and applying methods of casefinding, isolation of cases, and delousing with DDT powder, the main centers of infection at Mönchen-Gladbach and Cologne were brought under control during March. From March to June 1945, 693 cases were reported from 65 localities in the Rhineland.
Typhus in the Inner Reich.-According to Colonel Gordon, the Inner Reich was defined as "that part of Germany east of the Rhine and north of Switzerland which fell under the influence of the United States Army. It included not only a major part of Germany, but also the westernmost part of Czechoslovakia and the greater part of Austria."53
The epidemic of typhus in the Inner Reich lasted about 3 months, from the last week in March to the end of June 1945. About 15,800 cases were reported from 518 localities in the environment of troops. Among these localities were the typhus-infested German concentration camps. Once the disease was suppressed, it did not recur in epidemic proportions.
The cordon sanitaire.-Shortly after the breaching of the Rhine barrier and the start of the rapid eastward advance of the Allied Forces, a stream of displaced persons, refugees, prisoners, and others began to move west. To protect regions west of the Rhine, including France, Luxembourg, Belgium, and the Netherlands, special arrangements had to be made for typhus control measures at the river crossings. Accordingly, there was erected a sanitary border, called the "cordon sanitaire." This was done officially by a SHAEF directive on 31 March, implemented by an order from Headquarters, ETOUSA, on 12 April 1945.54 Before this, however, both the First and Ninth U.S. Armies had established cordons in their areas.
The cordon extended from the junction of the Swiss border and the Rhine River along the course of that river to the junction of the Rhine and Waal Rivers and, thence, along the north bank of the Waal to the North Sea. All existing or future crossings of the rivers were designated either as ports of entry or as guard stations, and all civilians and liberated prisoners of war traveling from east to west were deloused at ports of entry before crossing the cordon sanitaire. Delousing stations at ports of entry, with adequate personnel and supplies of 10-percent DDT powder and hand- or power-dusters, were located near bridges, usually in a displaced persons center. Guard stations were established and staffed with sufficient personnel at intermediate points between the ports of entry to prevent crossing the cordon at places other than ports of entry. Transportation by river or canal boats along the line of the cordon was suspended except when persons under military control moved to a port of entry. Delousing stations were maintained at entraining points and airfields for persons crossing the Rhine by train or plane. Each treated person was given an endorsement on his identification papers showing the date and method of delousing, and no person was permitted to cross the cordon without such evidence. Persons giving evidence or suggestion of illness were placed under observation until either their illness was diagnosed or proper disposition was determined.
At some of the large stations, approximately 2,500 persons were deloused daily. The six-gun power-duster could handle 425 to 500 persons per hour. Dusting teams were organized from Quartermaster Bath and Dusting Units. These had a normal capacity of treating 1,600 persons per team per day, but in actual operations using power-dusters, this figure was considerably exceeded.
The concept of the cordon sanitaire was an old one, having been included in the report of the Committee of Experts in 1937. By the fall of 1943, the original plan for such a cordon, according to Colonel Gordon,55 was prepared in his Preventive Medicine Division, Office of the Chief Surgeon, ETOUSA. At about the same time, it became a basis for planning in the Public Health Branch, G-5, COSSAC. Direct supervision over the cordon sanitaire was a function of the Surgeon of the 12th Army Group, performed by his Chief of Preventive Medicine, Colonel Whayne.
Before the establishment of the cordon sanitaire, and complementary to it, there was a program of rapidly searching out foci of typhus (casefinding) and, following the pattern developed in Italy, a program for seeking out and extinguishing the "flying sparks" made up of secondary as well as primary cases which had escaped into unaffected territory.
The following excerpts from reports from Military Government medical and public health detachments attached to units of the First U.S. Army in March 1945 present typical indications of experiences.
Fifteen hundred pounds of DDT, 75 spray guns, 990 cc. of typhus vaccine and other supplies have been received. Bunkers and other shelters have been assigned to disinfestors who will each appoint deputies and spraying the bunkers will begin today.
Tactical forces have been advised to issue directives prohibiting troops from entering civilian shelters which are the chief foci of typhus. The shelters are being posted "Off Limits."
Arrangements were made for the evacuation of 11 cases of typhus from the Couteyard plant and 25 sick persons from the Ford plant where they are a menace to the health of troops. They will be sent to St. Vincent's Hospital.56
All typhus cases in Cologne have been isolated in hospitals, all contacts have been deloused with DDT powder, and personnel continuously exposed to diseased persons have been inoculated with anti-typhus vaccine. A case-finding program was instituted, involving a search for all areas of the city where focal points of louse infestations and typhus fever might be found. Based on previous experience, the portion of the population in which ninety percent (90%) of infestation might be anticipated has been thoroughly investigated. Over 10% of the total population have been dusted, and no new cases have been reported since 9 March '45.
A medical officer from SHAEF has been sent to Bad Godesberg, Ahrweiler, Euskirchen, and Bonn to investigate reported cases of typhus and to brief detachments on typhus control.
Three medical officers, two (2) Sanitary Corps officers and one Veterinary Corps officer were obtained and attached to E1H2 for public health operations in Cologne, Bonn and the surrounding territory.57
Army Security Guards are in control to prevent displaced persons from crossing the Rhine except at designated crossing points. Displaced persons in organized convoys only will be allowed to cross, and these are to be dusted under Army Medical Corps supervision with DDT powder on the east bank just before crossing.58
Twenty-nine sick persons, including 6 typhus cases were evacuated from the Gestapo
Prison. * * * All the remaining inmates have been dusted with DDT and can be sent to a DP Center * * * A partial list of locations of typhus cases was obtained from the 104th Infantry Division.59
Administrative change and summary-Colonel Gordon60 has recorded that:
From the first discovery of typhus in the Rhineland, it became increasingly evident that active typhus control in the field was beyond the scope of the numbers of Military Government personnel then available. On 4 March 1944 an altered plan of organization for typhus control in respect to continental operations was recommended by the Division of Preventive Medicine to the Chief Surgeon [ETOUSA]. Consideration was given to four groups of people: troops in the field, casualties returned to the United Kingdom or to the Zone of the Interior, prisoners of war, and the civilian populations in operational areas.
Control of typhus in the first three population groups had always been a responsibility of the Medical Department, United States Army. With regard to civilians [with respect to whom the G-5 Division of SHAEF had primary responsibilities] the following recommendations were made: (1) That the responsibility for immediate control measures among civilians rest with the Chief Surgeon, ETOUSA, (2) That the necessary pool of supplies be authorized and obtained by the Medical Department, United States Army, (3) That joint plans be initiated with the Civil Affairs Division, UNRRA, or other agency, to the end that responsibility for typhus control in relation to civilian populations be assumed by such organization within a thirty day period.
On 28 March 1945, the Supreme Headquarters Allied Expeditionary Forces (SHAEF) issued the following order: "To protect this command it is necessary that public health functions in enemy occupied territory be a responsibility of Command and under the direction of unit medical officers in all echelons." Within a brief period this action was brought about; with medical officers of all echelons responsible for typhus fever within their areas of responsibility, irrespective of its occurrence in civilian or military personnel; and with technical supervision of the program of control by the Chief Surgeon of ETOUSA. Unified and intensified effort led to an increased level of accomplishment.
During the epidemic of typhus fever within German territory occupied by U.S. forces from March to the end of June 1945, 16,506 civilian cases of typhus were reported from 518 localities. Of these cases, 15,810 occurred in the Inner Reich and 696 in the Rhineland. By the middle of July 1945, Western Europe had returned to a satisfactory low level of typhus endemicity.
Finally, with respect to CA/MG, G-5 Public Health activities in the invasion of Germany, Colonel Gordon's comment was, in substance, as follows (and this is confirmed by comments of other high authorities): The Public Health Section at SHAEF prepared and issued the technical directives for the control of typhus fever among civilians. They assured the provision of adequate supplies.
Through various echelons of command of G-5, and through constituted health officers and teams, active control in the field was contributed both initially when the responsibility rested in Military Government, and
later when Public Health sections joined with the Medical Department to serve under the direction of Surgeons of corresponding echelons.
The Nazi Concentration Camps
By 1939, the Nazi Government had established six concentration camps in Germany and Austria at Buchenwald, Dachau, Flossenbürg, Mauthausen, Ravensbrück, and Sachsenhausen. From 1940 to 1945, more were added, some of which were in Poland. These included Arbeitsdorf, Auschwitz, Belsen, Gross Rosen, Güsen, Lublin, Natzweiler, Neuengamme, Niederhagen, and Nordhausen. Among the inmates, there was much sickness and almost universal louse infestation, typhus fever became rampant, and from them, especially in April 1945, it was spread through large portions of the Inner Reich.
The following fragmentary extracts of contemporary reports and a published account convey some idea of the magnitude of the effort which had to be made by public health and medical personnel of Military Government, Army organizations, and the Typhus Commission to cope with the situation. These examples relate to conditions and experiences at the concentration camps at Belsen, Buchenwald, Dachau, and Mauthausen.61
Belsen.-Among the concentration camps, Belsen, in the area of 21 Army Group, became especially notorious because of the starvation of its inmates, the horror of the conditions imposed by the Nazis, and the epidemic of typhus fever.62
This camp was taken by the British Second Army on 15 April 1945, at which time typhus had been prevalent for 4 months, and there were about 3,500 cases among the 45,000 inhabitants of Camp 1. Nearly all of the internees were heavily infested with lice. The deplorable situation was described as follows:
Camp 1 contained 40,000 political prisoners. There are unknown numbers of cases of typhus fever. The disease is quite wild but definitely diagnosed and confirmed. There are generalized gastroenteritic diseases, which in the early observations are considered to be all types, particularly typhoid and dysenteries. Malnutrition is advanced in practically all occupants; 50 percent of the 40,000 occupants are estimated to be unable to consume any food by mouth, that is of the normally available foods which could be furnished from Army stocks. There are 1,000 to 1,500 in advanced or acute stages of starvation who will require intravenous feedings. For these arrangements have been made to fly in 7,200 lbs. of protein hydrolysate from London. The handling of typhus has been placed under the direction of Captain William A. Davis, MC, Consultant from the United
States of America Typhus Commission. The personnel of a British Field Hygiene Section are employed in delousing all individuals. There are adequate supplies at this time for handling the typhus situation.
Camp 2 at Belsen has approximately 15,000 individuals, 2,000 of whom are westbound Europeans. The remaining are individuals who should head east.-Camp 2 is typhus free.63
Buchenwald.-Describing the medical situation at Buchenwald, a Civil Affairs Public Health Officer wrote:
Of the approximately 21,000 inmates, there are 5,000 who need medical attention. Of these, 2,400 are already (15 April) cared for in the prison hospital, 1,500 are invalids or old people who cannot fend for themselves, and 1,000 are severely ill of dysentery, tuberculosis, severe malnutrition, and skin infections. These 1,500 invalids and 1,000 other ill are in various barracks in the so-called "Little Camp." They exist there under indescribable conditions, living as many as sixteen in one compartment. On the day of inspection, in one barrack alone, twenty-four died. There are sixty cases of typhus fever in a special barrack which was very clean and well equipped. It was also well isolated and served as an experimental station using prisoners as guinea pigs. * * * There is no epidemic of typhus in the camp. Most of the sixty cases were from Ohrdruf.64
Dachau.-The situation at the Dachau concentration camp was described as follows:
It was stated that the camp was constructed to house between 10,000 and 12,000 people whereas the census on 1 May '45 was 31,404, all male except for 300 females. It is evident that the camp is overcrowded. Wooden shelves three tiers high serve as beds with practically no mattresses padding and a few blankets for covering. In one block visited it was reported that four people take turns sleeping on a single bed space. Crowding and dirt was predominant. Within the living quarters bathing facilities were apparently not used.
From the standpoint of physical condition the inmates may be divided into two groups. About one-half are up and around the camp and appeared to be in a fair state of nourishment, the remainder and [those] who were reported as new arrivals, were in an extremely poor state of malnutrition. These people were extremely emaciated and represented advanced stages of malnutrition. Muscle wasting was extreme and many so weak they were unable to walk. Practically all gave the appearance of indifference and apathy indicative of mental changes. It is extremely doubtful if these people will ever recover. Malnutrition in many is so far advanced that irrespective of treatment many will go on and die.
Within this camp there are approximately 800 open cases of tuberculosis and in an adjacent camp about 300 others. There unquestionally are many more unrecognized at this time. It is estimated that there are 1,200 cases of typhus in the camp, with the possibility of others not being recognized. Other conditions that have caused considerable difficulty from a health standpoint are erysipelas and skin diseases of which there are great numbers.65
Mauthausen.-Similar conditions were found at the concentration camp at Mauthausen, Austria, as described in the following account:
The maximum capacity of the camp was from 35,000 to 40,000. The 11 Armoured Division found 18,000 residents, of whom 3,000 were women. * * * At the time of uncovering, the Camp could be described as utterly without sanitation. Water power had been off for weeks, and conditions were indescribable. Triple-decker beds accommodated 16 persons-five or six to a bed. Thousands slept on the floor and on the ground. The dead-700 unburied bodies in all-were piled up in corners of the barracks * * * Army doctors arrived at the camp within two days of its uncovering * * * The 130th U.S. Army Field Hospital now have full control over all medical and sanitary matters in the camp.66
It was necessary to continue to operate these camps since many of the inmates were too ill to be moved. As the acute emergency phase passed, the character of the medical problems changed. The following note was made in early July 1945 concerning current problems at that time in the Mauthausen and Güsen concentration camps:
Pulmonary tuberculosis is now the biggest medical problem in the camps. Probably more than half of all the patients have advanced pulmonary tuberculosis and approximately 80 percent of present autopsies show advanced pulmonary tuberculosis. * * * Malnutrition is the other great medical problem in the camps. * * * Deaths with malnutrition as a complication are still occurring. This is a result of conditions existing before the camps were taken over, the correction of which were, in part, complicated by the difficult tactical and supply situation.67
Displaced Persons and Refugees in U.S. Occupied Germany, September 1944-July 1945
Planning.-In preparing for Civil Affairs/Military Government in northwest Europe, in London during 1943 and 1944, SHAEF was to assume initial responsibility for the care, control, and repatriation of United Nations displaced persons and refugees, and some groups of enemy (German) civilians. It was intended that these responsibilities would later be transferred to UNRRA.
In June 1944, it was estimated that there would be 11,361,000 displaced persons and refugees in France, Belgium, Luxembourg, the Netherlands, Denmark, Norway, and Germany (exclusive of German refugees.). Of these, 2,501,000 would be refugees within their own countries and 8,860,000 would be displaced persons in foreign countries. With regard to Germany, Nazi slave labor policies and practices resulted in the existence of some 4.2 million displaced persons in the U.S. Zone of Germany. The release of these millions of individuals, coincident with combat operations, posed the gravest problems of care and control, confirming the understanding by the planners that care and disposition of DP's and refugees would present not
only technical (medical and public health) and administrative problems of great magnitude but also complex political problems.68
Commanding Generals of the field armies were directed to prepare plans for dealing with displaced persons and refugees in their areas of responsibility.69 The objectives were to prevent hindrance of military operations, to prevent and control outbreaks of disease among refugees and displaced persons that might threaten the health of military forces, and to handle the repatriation of these persons.
As a result of plans discussed in 1943, a Displaced Persons Branch was established in the G-5 Division of SHAEF in June 1944, or somewhat earlier. This Branch had a close association with the Public Health Branch, G-5 SHAEF. In future operations, planning and activities of all groups concerned with the care and handling of displaced persons and refugees proceeded in various degrees of collaboration, and with some changes of responsibilities to meet the unexpected exigencies that emerged during the overrunning of Germany.
Details have been given of typical conditions that existed among displaced persons and refugees and of the activities of the CA/MG Public Health Branch to correct and improve them. These conditions included malnutrition and starvation, communicable diseases, louse infestation and the epidemic of typhus fever related to the German concentration camps, general neglect of even primitive sanitary measures, and pitiable destitution. In dealing with these situations, CA/MG personnel rendered valuable assistance to the field armies, thereby gaining invaluable experience which was applied later in occupied areas of Germany. Joint activities of the G-5 SHAEF Public Health personnel with personnel of armies were the rule. Examples of this can be found in many reports, of which several from the Third U.S. Army and the 6th Army Group are illustrative.70
Early phase.-The first deployment of MG public health personnel and units in German territory began in September 1944 and, by the end of October, 25 MG detachments in German cities and towns in the area of the First U.S. Army were served by MG Public Health Officers. These officers coordinated activities regarding public health measures and communicable disease control, and maintained close supervision of sanitation in the camps and assembly centers for displaced persons and refugees. The health of DP's and refugees at large, outside the pest-ridden Nazi concentration camps, was generally fair. The diet had been reasonably adequate and
hygienic conditions, except in severely bombed areas, were on the whole satisfactory. Substantially similar conditions prevailed among German civilians.
The rapid advance.-Relatively manageable conditions continued until the period of the rapid advance of Allied Forces east of the Rhine, from March to May 1945. Hordes of displaced persons and refugees migrated westward, knowing from the attitude of the Russians that there would be no haven for them in the east. The number of DP's and refugees overrun by the 6th and 12th Army Groups had reached 500,000 by 15 March 1945, 1 million by 1 April, and 2.8 million by 9 May. Within the next few weeks, the number rose to more than 4 million. The problems of medical care and public health for these masses of people did not differ in principle or in detail from problems previously described. They differed in magnitude-in such magnitude, in fact, that the MG units and the Public Health Branch personnel which had been provided according to plans were swamped. One aspect of this was the demand for treatment of the sick and injured. Concerning CA/MG officers, Colonel Turner stated clearly at a meeting in 1944: "The function of civil public health officers is to appraise a given situation, outline a few clear and practical objectives, organize and direct local health and medical personnel, and assist in obtaining medical supplies essential to the program. Except under unusual circumstances, for the public health officer to attempt to treat patients or to operate a clinic would be misdirection of energy."71
Use of Army Medical Department and combat troops.-The large numbers to be controlled, and the woefully small organization provided to handle DP work exclusively, presented commanders, as they did the Public Health Branch, G-5 SHAEF, with a trying dilemma. Troops and services could not be diverted to the care and control of displaced persons and refugees without risks. A turning point, however, was reached on 12 April 1945 when SHAEF declared that "Partial Eclipse Conditions" existed. Authority was given to put into effect applicable portions of Operation ECLIPSE, where defeat of the enemy had become a fact. Operation ECLIPSE was a general plan for taking over the administration of Germany upon its sudden collapse or surrender, dealing primarily with armistice terms, displaced persons, prisoners of war, and German courts.72 Commanders were enjoined to use all resources to accomplish the displaced persons mission. This enabled them to detail officers and men as well as supplies of combat and service units to assist MG Detachments and to carry out MG policies.
At this time also, on 14 April 1945, SHAEF directed that G-5 Divisions would have general staff supervision over public health and that the Sur-
geons of Army Groups and Armies would direct the functions, as will be discussed later.
At their peak, approximately 50,000 combat and service troops were employed in the care, control, and repatriation of displaced persons in the 6th and 12th Army Groups. This number rapidly diminished in late June as repatriations were accomplished. Repatriation of western European DP's began as soon as U.S. Armies entered Germany. By 10 July 1945, when responsibility for DP's passed from the 12th Army Group to Headquarters, USFET, 2.7 million United Nations DP's had been repatriated from the U.S. Zone of Germany.
Brief mention has been made of the SHAEF directives issued in March and April 1945, which changed the relationship between the public health organizations under G-5 and the regular medical services of the combatant Armies and Communications Zone in the European theater. Now that sufficient background has been provided by indications of differing conceptions and opinions, and by accounts of events, with citations of difficulties, failures, and achievements, it is appropriate to explore the matter in greater depth.
The two separate military public health organizations operating in the European theater were (1) the medical units and personnel of the Medical Department of the Army which were connected with the Office of the Chief Surgeon of the theater, and (2) the CA/MG units and personnel in SHAEF which were connected with the Office of the Assistant Chief of Staff, G-5, and were components of the Public Health Branch of G-5 Division, SHAEF. In addition to the G-5 SHAEF personnel, there were G-5 sections or officers in all field units down to corps, and in the Communications Zone. Civil Affairs/Military Government in all of its aspects became a major objective of the Supreme Commander. In theory, the SHAEF public health and medical groups were to be concerned with conditions among civilians, the strictly military medical groups with preventive medicine among the troops. Both groups, however, were concerned with sanitary problems and many other problems among civilians in countries liberated or conquered and occupied by the armies. The attempted separation of the two was unrealistic and, until March and April 1945, the respective responsibilities were not clearly drawn and, even then, were not fully specified.
In reviewing early deliberations on this subject, the Surgeon of the 12th Army Group, Col. (later Maj. Gen.) Alvin L. Gorby, MC, USA, referred to an important conference, attended by high-ranking officers, at Princess Gardens in London in June 1944, shortly before the invasion of Normandy.73 He reported that, at this conference, the main subjects of dis-
cussion were the contemplated parallel functions of the Public Health Branch, G-5 SHAEF, and the Office of the Chief Surgeon, ETOUSA, in public health and medical operations in Northwest Europe. He wrote:
It was pointed out by the Surgeon of the 12th Army Group that the concept of a separate Civil Affairs and later Military Government Public Health Service would be a duplication of effort, personnel and supplies, and that overall economy could be effected by establishing the G-5 medical personnel in the Office of the Surgeon in all echelons of the field forces. It was especially pointed out that the Surgeons of Armies and lower echelons had the means, organization and experience to assume this responsibility.
At this conference, the decision was confirmed and supported by command that CA/MG Public Health should function as a separate medical organization in the field forces. This was regarded as final. Actions of Surgeons in accordance with this were determined also by SHAEF directives to the effect that G-5 personnel would be attached to field units when called for and, then, would come under the administrative control of the local field commander. All concerned were urged to maintain the closest liaison.
During the campaign in Europe, the Surgeon of the 12th Army Group, as did Surgeons at all echelons, maintained only a liaison with the Public Health Section, G-5. However, because of the necessity for working together to solve common problems, the Surgeon, 12th Army Group, and the Chief Public Health Officer, G-5, at that headquarters collaborated constantly and exchanged medical information fully.
Commenting further upon developments during the campaign, Colonel Gorby wrote: "As the rigors of combat increased and the demands upon the medical service for purely medical support became great, it is understandable that Surgeons of Armies found little time to concern themselves with civil public health problems, especially since they had been given no specific responsibility in these matters, were not concerned except where the health of troops was involved, and no greatly important epidemic diseases had presented themselves."
This remark has a bearing on the statement made repeatedly by officers of the Public Health Branch, SHAEF, that Surgeons of the field forces were only secondarily interested in civilian health, and would have made only minimal exertions along the lines of Civil Affairs mission and policy. The records show that there is truth in both statements.
Colonel Gorby pointed out, also, that:
Another complicating factor was the dissimilarity of the chain of command between military medical services and the public health services, G-5. Whereas the Surgeon looked through proper channels to the Office of the Chief Surgeon, European Theater of Operations, United States Army, for support, G-5 Public Health Section channeled directly back to the Chief Public Health Officer, G-5, SHAEF, from the field forces, and did not go through Theater headquarters echelons. Since the SHAEF echelon was an overall policy making headquarters and not an operations headquarters, innumerable difficulties in the solving of field problems which required Communications Zone and European Theater of Operations support, and which under the circumstances only could
be obtained by liaison, became apparent. Not the least of these was the provision of adequate personnel, of which there was only a handful in the Armies to cope with the overall public health problem.
In view of these conditions, 12th Army Group Headquarters, through its Surgeon and its Assistant Chief of Staff, G-5, began to transfer responsibility for public health activities from the G-5 group to the Surgeons of all echelons so that all available medical resources could be mobilized to meet the tremendous task.
Almost from the start of the invasion of Normandy, there had been a tendency toward shifting responsibility for the public health program in the European theater from G-5 organizations to the regular medical service, represented, for example, by the Office of the Chief Surgeon and by Surgeons of Army Groups, Armies, and the Communications Zone. This resulted from (1) the conviction held by many that all medical and public health activities in the combat zone should be under the control of the regular theater medical service; and (2) the severe shortage of G-5 medical and public health personnel and, in some instances, their lack of fitness for the work. After the Allied Forces had crossed the Rhine and were advancing rapidly eastward through Germany in March and April 1945, the large epidemic of typhus which had to be combated, and the mass of displaced persons and refugees who had to be controlled and cared for, underscored these critical deficiencies and called for a vigorous reorganization of the program.
On an inspection trip in late March 1945, Maj. Gen. Albert W. Kenner, the Chief Medical Officer of SHAEF, became convinced that the G-5 organization, short of personnel and lacking supplies and transportation, would be unable to meet its commitments. Incidentally, this confirmed General Kenner's predictions in March 1944, when he objected to the separate establishment of the Public Health Branch, G-5 SHAEF.
After a conference with Maj. Gen. Warren F. Draper, Chief, Public Health Branch, G-5 SHAEF, and his deputy, Col. William L. Wilson, MC, and other G-5 officers, the Surgeon and the Preventive Medicine Officer, 12th Army Group (Colonels Gorby and Whayne), General Kenner arranged for the Supreme Commander to issue directives which turned over to the Army Group and Communications Zone Commanders and their medical staffs total responsibility for public health in occupied enemy territory.74
The first of these directives was a SHAEF cable (TWX FWD 18271) to Commanding Generals of Army Groups, Armies, and Communications Zone, dated 28 March 1945. This consisted of one sentence which stated: "Public health in occupied enemy territory is a responsibility of command."
Directive of 14 April 1945.-On 14 April 1945, the above statement concerning command responsibility was amplified, and orders were issued
in an "immediate action" directive, from which the main parts are abstracted or quoted here (omitting British terminology).75
1. Reference is made to cable, SHAEF,
FWD-18271, dated 28 March 1945.
a. Supreme Headquarters, AEF:
(1) Supreme Commander-Establishes
policies for conduct of Civil Affairs operations, including public health
b. U.S. Army Groups and Communications Zone (and 21 Army Group):
(1) Commanders-The conduct of Civil
Affairs operations in accordance with policies established by the Supreme
Commander is a responsibility of Commanders.
By direction of the Supreme Commander:
As this directive was not entirely clear, a supplementary directive was issued by SHAEF on 15 April 1945, clarifying the relationship between the Public Health Branch, G-5 SHAEF, and the regular medical service. It allowed the Public Health Branch to continue to be concerned with certain aspects of the health of civilians.76
In these deliberations and rearrangements in the 12th Army Group and in the forces as a whole, an influential role was played by Colonel Whayne, who had been assigned to the headquarters of this Army Group as Chief of the Preventive Medicine Branch on 19 April 1944.
Actions taken by the Surgeon, 12th Army Group, to implement the SHAEF directive of 14 April 1945 may be regarded as typical of similar actions taken by the other Surgeons in the European theater. On 26 April 1945, the medical personnel assigned or attached to the Public Health
Branch, G-5 Section of Headquarters, 12th Army Group, were attached to the Medical Section, and a Public Health Branch was established in the Preventive Medicine Section on 1 May 1945, all under the direction of the Army Group Surgeon. All activities formerly carried on in the Public Health Branch of the G-5, 12th Army Group, were integrated with related sections of the Surgeon's office. By these actions, the G-5 Public Health Sections and the Army Medical Services were "amalgamated" in the field forces. Unified and centralized direction and control of public health activities in the combat zone, under unit Surgeons, resulted in increased efficiency and smoother administration.
The foregoing section has dealt with a controversial matter which is still subject to debate. As Colonel Gordon put it:
The Public Health Section of the Civil Affairs Division was the preventive medicine organization for that part of Army activities directed toward the maintenance of health among civilians of liberated countries. As the Public Health Section of Military Government, it served a similar purpose for the civilians of conquered countries. No inconsiderable discussion arose in the course of operations, and again after the war was over, on the nature of a health organization to accomplish the obligations associated with military occupation of conquered countries. There is serious reason for combining into a single organization two activities-preventive medicine for troops and public health for civilians who become the wards of the army-which are identical in their aims and differ only in the populations to which they apply. When this is not done, however, the closest cooperation between the two activities is necessary. The obligation to troops of protection from typhus fever cannot be accomplished satisfactorily if an epidemic among the civilians who surround the army is disregarded. Venereal disease is not a problem of an army but of a complete population. The army and civilians live in the same area and the environmental hygiene of that area is as closely related to the one as to the other.77
In his summary report to The Surgeon General of the Army, General Draper, covering the period May 1944-June 1945, analyzed at length the pros and cons, and "honest differences of opinion" as to whether CA/MG Public Health should be a separate organization or a function of the Surgeons of the field forces.78
Views of Chief, Public Health Branch, G-5 SHAEF-General Draper's opinion was expressed as follows: "There is no doubt in my mind that the G-5 public health organization and relationship to the Army Medical Services at SHAEF [italics added] were in the best interest of military operations as a whole and I do not know how they could be improved upon." With regard to relations with the Field Forces at Army Group level, General Draper compared the G-5 plan of operation with his understanding of the plan that the Surgeon and G-5 Public Health Officer at headquarters of the 12th Army Group considered preferable. After consideration of the comparison, General Draper wrote:
My personal opinion in regard to the foregoing is that the Surgeon at the larger formation levels is fully occupied with the manifold and exacting duties of his position.
In order to become qualified for such responsibility an officer must have had long and intensive training and experience in that particular field. It would be seldom indeed that such an officer could have received training in public health sufficient to enable him to assume complete responsibility for civilian public health administration in addition to his other duties. I believe that the best results are obtainable by means of the present G-5 type of organization, but that success can be assured only by full compliance with the following measures:
1. That all personnel assigned as public health members of Formation staffs be fully trained and competent to perform the duties expected of them.
2. That the number of public health staff positions at the several Formations which are necessary to insure proper public health administration be determined and specified in a manner that will insure the presence of such personnel without relation to the number and grades of personnel in the rest of the Formation.
Concerning relations between the Public Health Branch, G-5 SHAEF, and the Office of the Chief Surgeon, ETOUSA, General Draper analyzed the respective functions and recited numerous examples of cooperation that existed, not because of an organic relationship but because of the extremely generous attitude and helpful actions of the Chief Surgeon, General Hawley. In General Draper's opinion: "The two organizations worked together to maximum efficiency to attain the objectives of each," and "no finer demonstration of cooperation between two medical organizations had ever been afforded."
Thus, the Chief of the Public Health Branch, G-5 SHAEF, found that experience demonstrated the correctness of the policies, type of organization, and activities that were specified in the recommendations made by Colonel Turner on 9 March 1944, which resulted in the establishment of the Public Health Branch, and the appointment of its Chief, in SHAEF (p. 413).
Views of Surgeons of Field Forces.-The views of Surgeons of the Field Forces, the Chief Surgeon, and Surgeons and Preventive Medicine Officers in all echelons strongly favored placing all civil public health activities in army areas during the combat phase entirely under the control of commanders of Armies and Army Groups, for administration through staffs of the regular medical services, under the Chief Surgeon of the theater of operations.
One of the first to formulate this concept, and to take the lead in securing its adoption as policy, was Colonel Whayne, who in 1944-45 was Chief of Preventive Medicine in the Office of the Surgeon, Headquarters, 12th Army Group. Colonel Whayne's immediate contact with the operational difficulties permitted an early insight into what was needed. To supplement the records, about 20 years after the events, Dr. Stanhope Bayne-Jones asked Colonel Whayne to confirm the opinions he had expressed in 1945. This Colonel Whayne then did in a forceful letter to Dr. Bayne-Jones dated 7 February 1964, from which the following is quoted:
It is a matter of history that it was a military necessity for Surgeons of large commands in combat areas in Europe in World War II to take over civil affairs and military government activities in their areas. Prior to this action the dual activities and dual
commands concerning civilian health problems and military health affairs had failed and especially broke down under the impact of the vast refugee and displaced persons problems in combat areas during the latter part of the war. Under these circumstances from Army areas [rear boundaries] forward, civil affairs military government organizations and officers were put under the command of the Army and all medical and health activities under the supervision of the surgeon of the command concerned. This was a situation almost entirely comparable to the management of civilian health affairs in the maneuver areas in the United States in the early 1940's [described in chapter IV, section 1 in this volume] * * * We have to face with courage at the present time the necessary decision that civil affairs-military government can apply in its present sense only to territory which has been liberated or captured and passed over. In the combat areas, there is no alternative except to combine health activities concerned with the civilian populations under one health authority, namely, the surgeon of the responsible command.
Col. John Boyd Coates, Jr., MC, who served in the Office of the Surgeon, Third U.S. Army, was convinced that the organizational and operational necessity outlined by Colonel Whayne was proved decisively in the European theater. This was also the consensus of a number of senior medical officers who were Chief Surgeons of Theaters of Operations, of Army Groups and of Armies, and of some of their assistants in administration and preventive medicine.79
Public Health teams in forward areas.-Another example of the revised arrangements which followed the SHAEF directive of 14 April 1945 is provided by action taken in the Third U.S Army. The Surgeon of the Third U.S. Army assumed direct control over all public health personnel attached to that Army and established in his office a separate Public Health Sub-Section. After observing the value of having public health personnel continuously present in forward areas, the Surgeon organized three Public Health Teams, one to be attached to each corps. Each team consisted of one Medical Corps officer, one Sanitary Corps officer, three Army Nurse Corps officers with public health training, two drivers, and two vehicles. These teams were placed under the operational direction of Corps Surgeons. They kept in constant touch with civilian public health problems through Military Government officers and Army Surgeons, and could take immediate action. Their chief functions were (a) to organize and supervise medical and sanitation services of displaced persons camps, with particular reference to delousing activities; (b) to reestablish German medical and health
organizations in the larger German cities and towns, and in districts uncovered by Corps, with special reference to the care of displaced persons; (c) to act as specialist consultant groups on medical and sanitation problems encountered by Corps, with special reference to civilian public health; and (d) to act on divisional and regimental problems of public health and sanitation upon call by forward echelons.
When the Third U.S. Army entered the static phase of occupation of Germany, public health teams attached to Corps were no longer needed. These teams were dissolved and their personnel were attached to Military Government Detachments at Regierungsbezirk (county) level in accordance with anticipated plans of higher authority.80
THE OCCUPATION OF GERMANY
Military Government Public Health in the U.S. Zone in 1945
The records of public health activities of Military Government in the United States Occupation Zone of Germany, including the Berlin District, are voluminous and complex. To understand what was done by whom and for what reason, and to assess the results, a knowledge of military, political, governmental, economic, demographic, and broadly conceived epidemiologic factors affecting the situation is required. Only a limited account for the year 1945 will be given here, stressing points of particular significance.
Conditions in Germany.-Following its surrender on 8 May 1945, Germany was in a state of utter confusion. Thousands were homeless, and many had fled. Displaced persons and refugees numbered in the millions. Transportation was crippled by the destruction of railways, highways, and bridges, and by the lack of motor vehicles and fuel. Food stocks were almost exhausted in the cities, many of which had been leveled.81 The movement of essential supplies was extremely difficult.
At first, there was little semblance of civil government as most officeholders, who were Nazis or Nazi-sympathizers, had fled before the advancing armies. The people, stunned by defeat, were concerned with immediate needs-food and shelter. The German public health system was practically nonexistent.
Planning and directives.-During the months before the collapse of Germany and immediately thereafter, plans to deal with expected situations were drawn up and directives were issued by SHAEF, Headquarters, 12th Army Group, and by Headquarters, USFET. The chief early plans were known as the ECLIPSE PLAN and the STATIC PLAN. All plans contained statements regarding Military Government Public Health. The chief documents are listed below. With minor variations, public health activities in
the U.S. Zone of Occupation in Germany during 1945 proceeded according to these plans and directives.
(1) The SHAEF, G-5, Technical Manual for Public Health Officers,82 revised in February 1945, was broad in scope and covered procedures in detail. A mimeographed copy of the first issue of November 1944 was used faithfully by Colonel Wilson, who was Deputy Chief successively of Public Health Branches in SHAEF, USFET, and OMGUS (Office of Military Government of Germany, U.S.), from 1944 to 1947.
(2) The Surgeon of the 12th Army Group, which was designated as the U.S. military occupation force, recognized that the early planning, while based upon the best information available at the time, did not have the benefit of firsthand field observation and study. Therefore, he arranged to have two expert public health officers, Lt. Col. Joseph A. Bell, MC, USPHS, and Maj. Edward B. Johnwick, MC, USPHS, attached to 12th Army Group Headquarters and sent into U.S. occupied areas of Germany to make a survey and report, with recommendations. This was done in the first half of June 1945. Their report83 influenced intermediate and final plans for public health in the early static phase. An important element of the plan was the provision for control of medical and health affairs in the U.S. Zone by the U.S. Zone Surgeon.
(3) On 24 May 1945, Lt. Gen. Walter Bedell Smith, Chief of Staff of ETOUSA, issued, by direction of General Eisenhower, a comprehensive organizational directive for Military Government of the United States Zone and areas in which U.S. forces were deployed in Germany, "to be implemented when combined command is terminated." Until that time, it was to be made effective insofar as practicable without violation of existing AEF policies. Combined command was terminated on 14 July 1945 when SHAEF was dissolved. Matters relating to the administration of public health are dealt with in rather general terms in par. 8,c,(1) and (4) of this directive.84
(4) On 26 July 1945, Headquarters, USFET, issued an important directive85 which rescinded the SHAEF letter of 14 April 1945 (p. 489), and specified certain new lines of responsibility and jurisdiction.
Public Health policy and arrangements.-The MG policy made civil government in Germany a civilian responsibility. At first, existing civil laws continued in force, except for amendments by which members of the Nazi Party and ardent sympathizers were excluded from public office. Nearly all officials of the Nazi regime had to be replaced; unfortunately, many German
persons placed in office by the Allied military authorities were inexperienced. Finally, essentially the laws of the Weimar Republic were reinstituted. Military detachments were trained to deal with resistance, but this never developed.86
The main objectives of Military Government after hostilities ceased were to insure that German health services and facilities were reestablished and maintained by the Germans, to prevent and control communicable diseases, and to eliminate health hazards that might interfere with the military administration of Germany, threaten occupation forces, or create hazards to other countries. To accomplish these purposes, great pressure was put on the Germans, technical guidance was given, and necessary supplies were provided by the U.S. forces when indigenous sources were insufficient.87
An effective reporting system was instituted immediately for the rapid collection, analysis, publication, and distribution of biostatistical data. Weekly reports were exchanged with the other occupying powers and with the League of Nations.
Civil government was reestablished first at the Kreis or local level (composed of Stadtkreise or urban communities) and Landkreise or rural areas (comparable to U.S. townships); next, at the Regierungsbezirke (comparable to counties); and finally at the Land or state level.
The U.S. Zone of Occupation in Germany.-Effective on 12 July 1945, the United States, British, French, and Soviet areas of occupation in Germany were delineated. The U.S. Zone (map 13) comprised the following:
a. The U.S. Zone comprised the Land Bavaria, excluding the Landkreis Lindau; the Land Hessen, east of the Rhine River; the Province Hessen-Nassau (existing before July 1938), less the Landkreise Oberwesterwald, Unterwesterwald, Unterlahn, and Sankt Goarshausen; the northern parts of the Länder Baden, Württemberg south to and including the Landkreise Ulm, Nürtingen, Böblingen, Leonberg, Pforzheim and Karlsruhe, and the Bremen Enclave.
b. The Land Bavaria, excluding the Landkreis Lindau, was designated the Eastern Military District under the immediate MG control of the Third U.S. Army, with headquarters at Munich.
The remaining area in the final U.S. Zone was designated as the Western Military District under the immediate MG control of the Seventh U.S. Army, with headquarters at Heidelberg.88
Withdrawal to final occupation zones involved two phases. In the first phase, U.S. Military Government personnel were withdrawn from areas slated for eventual occupation by France, Great Britain, or the Soviet Union. In the second phase, MG detachments served at each governmental
level from province on down. The redeployment of MG Public Health Officers from initial tactical sites to final locations in accordance with the revised plan took place rapidly. The 286 U.S. Army MG detachments in Germany, Austria, and Czechoslovakia on 20 June 1945 increased to 346 by 14 July. The five U.S. Armies in Germany on 9 May 1945 were reduced to two by mid-July; namely, the Seventh and Third.
Organizational changes and redeployment of personnel.-In view of changes in the situation and the need to have closer relationships between MG detachments and the command of the Military Districts, the ECAR's (European Civil Affairs Regiments) were detached from the European Civil Affairs Division and attached to the Army Military Districts Headquarters. The 2d ECAR, with its ECA Medical Group, was assigned to the Western Military District (Seventh U.S. Army) and the 3d ECAR, with its ECA Medical Group, was assigned to the Eastern Military District (Third
U.S. Army). The regiments were to continue to serve the detachments but were entirely under Military District control; the ECA Medical Group had been disbanded by 1 September 1945.89
The 2d ECA Medical Detachment, commanded by Colonel Riheldaffer (fig. 62), was reorganized as the 2d Military Government Detachment, and the 3d ECA Medical Detachment, commanded by Lt. Col. Charles D. Shields, MC (fig. 63), was reorganized as the 3d MG Medical Detachment. After the disbandment of the ECA Medical Group Headquarters on 27 August 1945, the Commanding Officer, Colonel Pappas, and the Executive Officer, Colonel Dehné, with staff and equipment, were transferred to the Public Health Branch, G-5, USFET. At that time, the chief of this branch was General Draper, and Colonel Wilson was deputy chief. Later, when this branch became the Public Health Branch, OMGUS, Maj. Gen. Morrison C. Stayer, MC, USA, served as its chief, and Colonel Wilson was its deputy chief.
Each Group's elements were deployed as Public Health staffs with the MG detachments, and the medical detachment headquarters constituted com-
plete administrative staffs for MG Public Health personnel under the MG Regiment to which they were attached. The Senior Public Health Officer had authority to direct travel of his personnel within the district and to transfer personnel as necessary. Again, there were personnel shortages because of the redeployment of some to the Pacific and the return to continental United States of those with long overseas service. The plan called for 233 officers and 569 enlisted men, but the number assigned never exceeded 150 officers and 478 enlisted men.
The 1st ECA Medical Detachment of the ECA Medical Group, active in France and the Communications Zone, was disbanded after it moved to Germany. Its commanding officer, Lt. Col. John T. Morrison, MC (fig. 64), and staff became the Public Health staff in Hessen.
The organizational-deployment-technical channels of the 2d MG Medical Group in the Western Military District comprised a Headquarters (District Public Health Staff), three subordinate headquarters (Hessen-Nassau, Hessen, and Württemberg-W. Baden), one Medical Supply Team, and 32 Public Health Teams, of which one (No. 101) was deployed in the Bremen Enclave. The 3d MG Medical Group had a similar organization, with a main Headquarters (District Public Health Staff), five subordinate
headquarters (Franconia, Upper and Central Franconia, Lower Bavaria, and Upper Palatinate, Swabia, and Upper Swabia), one Medical Supply Team, two Nutrition Teams, and 26 Public Health Teams.
Command responsibility.-The SHAEF letter, dated 14 April 1945 (p. 489) was rescinded by a new USFET directive on 26 July 1945.90
Tactical and administrative changes led to rescinding those portions of the original directive which no longer applied, but the policy that public health was a responsibility of command was not rescinded. The main statements in the USFET letter of 26 July 1945 may be summarized as follows:
1. Rescission of the SHAEF letter of 14 April 1945.
2. The establishment or reconstitution of indigenous public health medical services in the U.S. Zone of Germany under direction of the Military Government is essential.
3. a. The organization to accomplish public health functions will be in accordance with the directive of 24 May 1945 (p. 495).
b. The SHAEF manual "Military Government of Germany. Technical Manual for Public Health Officers," dated February 1945 (p. 495), will continue to govern operations in the U.S. Zone, pending publication of a European theater technical manual.
4. Responsibilities and relationships for military government public health operations in Germany were specified with respect to:
a. Headquarters, United States Forces, European Theater:
(1) The Commanding General, USFET, establishes policies for conduct of Military Government operations in Germany, including public health functions.
(2) The General Staff G-5 Division is responsible for plans, policies, and directives related to public health and exercises general staff supervision.
(3) The Special Staff-Under the Commanding General, USFET, the Chief Surgeon exercises overall technical supervision of military medical and military government public health functions.
b. Deals with Military Districts and Berlin District.
(1) Commanders-The conduct of Military Government public health operations in accordance with policies established by the CG, USFET, is the responsibility of commanders.
(2) General Staff G-5 Division of the staff of each commander is responsible for plans, policies, and directives related to public health and exercises general staff supervision.
(3) Special Staff-Under district commanders, military government public health functions in the U.S. Zone of Germany are under the direction of the commanding officers of the attached European civil affairs medical detachments in the Eastern and Western Military Districts and in the Berlin District under the direction of the Senior military government medical officer of the Military Government Detachment A1A1. In implementing public health plans, policies, and directives, in accordance with the foregoing, military government-medical personnel are placed by commanders at the disposal of military government medical officers for assignment, attachment, relief, or detachment as considered necessary. All authorized equipment and supplies required for military government public health operations will be made available through appropriate general staff divisions.
(a) When necessary, assistance will be obtained from the army medical service by coordination with the district surgeon concerned.
(b) Under district commanders the commanding officers of the attached European civil affairs medical detachments in the Eastern and Western Military Districts and the senior military government medical officer of the Military Government Detachment
FIGURE 65.-American and German health officials meet in Wiesbaden, Germany, to discuss health conditions in the American Zone. Here, Dr. von Drigalsky, German Public Health Officer, reports on conditions in his area.
A1A1 in the Berlin District will be responsible for coordination, where necessary, of the military government public health activities in their respective districts with the military medical services.
(c) Under district commanders, district surgeons will exercise overall technical supervision of military medical and military government public health functions.
By Command of General Eisenhower:
Disciplines of Military Government Public Health.-In the U.S. Zone in Germany from 1945 on, MG Public Health and the restored German civilian public health organizations had objectives, procedures, and technical problems very similar to those of Federal, State, municipal, and local public health departments in the United States. Indeed, they were similar to those in all advanced countries, and included the following:
(1) The prevention of epidemics and the provision of food, shelter, fuel, and safe water supplies were the foremost concerns of the German civil public health authorities, with whom many conferences were held (fig. 65).
(2) Control of communicable diseases: diarrheas and dysentery, typhoid fever, diphtheria, scarlet fever, tuberculosis, and typhus.
(3) Venereal disease control: a huge and difficult problem of great concern to both civilian and military public health and preventive medicine. (The general methods of dealing with the problem, and the results achieved in Germany, are summarized in vol. V of footnote 5 (1), p. 439).
(4) Sanitation: supervision of environmental sanitation; repair of disrupted water supply systems, sewers, and sewage treatment facilities; garbage and refuse collection and disposal.
(5) Insect and rodent control.
(6) Nutrition: surveys and information derived from nutritional surveys for the improvement of the food supply, and increase of the vitamin and caloric content of diets, especially in cities and in the former prison camps (fig. 66).
(7) Reestablishment of public health laboratory service.
(8) Reestablishment of pharmacy services.
(9) The introduction of Public Health Nurses into the operations of MG public health and into the German health services.
(10) Use of veterinary services in connection with food supply and the diseases of animals, both those transmissible from animals to man and those limited to animals.91
Relations with Preventive Medicine Service, Office of the Surgeon General.-In many places in this chapter and chapter XII, which deal with CA/MG public health activities in the European theater, mention has been made of the direct and indirect participation of the Preventive Medicine Service of the Office of the Surgeon General in these matters. Overtly, the relationship between the Service and the Theater was unusually close; spiritually and inconspicuously, it was even closer. The following example illustrates the close relation between policy and public health considerations. In July 1945, General Simmons, Chief of the Preventive Medicine Division, Office of the Surgeon General, and Colonel Turner, director of the Civil Public Health Division, visited the European theater. They had an important conference at Dachau on 20 July with Col. Paul A. Roy, Commanding Officer of Dachau Camp, Colonel Gordon, Chief of Preventive Medicine, O.C., TSFET (Rear), and Colonel Scheele. After this visit, General Simmons reported to Maj. Gen. John H. Hilldring, Chief, Civil Affairs Division, War Department Special Staff, and the Honorable John Jay McCloy, Assistant Secretary of War. He reemphasized the importance of the development of a program of public health for Germany, free from the repressive and punitive measures that had been advocated in the Morgenthau proposals to reduce Germany to a pastoral state.92
After the surrender, the problems of care and control of displaced persons and refugees in Germany were enormous. Guidelines were provided by a SHAEF manual.93 Public health activities concerning the handling of displaced persons and refugees in Germany were essentially the same as those already described with regard to civil affairs in other countries of northwest Europe during 1944-45.
By 10 July 1945 when responsibilties for displaced persons passed from the 12th Army Group to Headquarters USFET, 2.7 million United Nations displaced persons had been repatriated from the U.S. occupied areas of Germany.
As time passed, the problems became fewer. Their dimensions toward the end of the year 1945 have been described by Floyd as follows:94
The Displaced Population Becomes Stabilized. Mass repatriation of displaced persons, which had attained a record rate during the late spring and summer of 1945, was terminating in September. Primary emphasis immediately after V-E Day had rested on the importance of getting the largest possible number home before winter, while the program of care and maintenance was in the nature of a temporary expedient. The essential needs of displaced persons were in every case satisfied; they were fed, clothed, and sheltered, and adequate provisions were made for medical care. It was recognized that there would be a nonrepatriatable group remaining after the momentum of mass repatriation had spent itself. During the month of October, 113,000 displaced persons were repatriated from the United States Zone of Germany. There remained 474,000 displaced persons in the United States Zone, of whom 224,000 or 47 percent, were considered probably nonrepatriatable. At the end of October, the over-all level of repatriation was 85 percent complete. It was apparent that some half million displaced persons in the United States Zone would remain as a continuing responsibility through the winter and that primary emphasis would shift from repatriation to a program of care and maintenance adequate for a longer period.
The objectives of Civil Affairs/Military Government Public Health should be as follows:
1. Restoration of war-torn, devastated communities. The basic needs are for water, food, clothing, shelter, police forces, and restitution of civil government and health services.
2. Assignment of public health officers trained and experienced in civil public health administration, capable of adapting the best public health practices to the military situations. These officers must be provided with adequate assistance, supplies, and transportation.
3. Prevention and control of communicable diseases, including insect and rodent control; delousing to prevent the spread of typhus fever; and other well-known and proven control methods.
4. Good surveys to determine the nutritional state of the people, and arrangements for feeding civilians an adequate diet with foodstuffs from indigenous sources or from military sources if the former are insufficient.
5. Emergency medical care and treatment of civilian casualties.
6. Psychiatric and mental hygiene problems to be sensed and adjusted among civilians who have been exposed to bombing, shelling, disrupted families, lost children, wounded and dead relatives, and conditions produced by prolonged combat.
7. Provision of veterinary services.
Plans for Civil Affairs/Military Government public health activities in the European Theater of Operations (northwest Europe) in World War II, formed in times of travail, confusion, and uncertainty, were well carried
out with modifications enforced by circumstances. The task was prodigious and unprecedented, and the difficulties that were overcome were enormous. In the opinion of General Grasett and General Draper, at SHAEF, and of General Clay, surveying affairs from Berlin, the accomplishments far outweighed the deficiencies. The relationships between the G-5 groups and the regular medical services of the theater and the field armies had to be adjusted to make it plain that, in the combat zone (from the rear boundaries of armies forward) and in the zone of occupation, public health was a responsibility of command, and that unit surgeons should have charge of all the medical and public health activities in the areas of the armies in which they were serving. Although it was not intended to do away with the public health groups of the G-5 type, regular military jurisdiction was essential. When centralization of responsibility, direction, and control was effected under command, the operations in public health became more efficient and beneficial. The two groups, working together under one type of command in the combat and occupied areas, attained great success.95