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ACCESS TO CARE
The Philippines and Okinawa
Thomas B. Turner, M.D.
Section I. The Philippine Islands
Preparation for the Invasion
In June 1942, Gen. Douglas MacArthur's forces began the long push back to the Philippines. Landings were made at Buna in New Guinea, followed by landings, usually with relatively small forces, on numerous islands of the Solomons group, on New Britain, on the Admiralty Islands, and along the northern coast of New Guinea.1
In none of these areas were civil affairs activities, as such, carried out. Military forces had little contact with native populations, and the medical and health problems were largely ones of survival in malaria-ridden territory. Captured Japanese medical supplies were sorted and classified, many of the more useful drugs and equipment being issued to the military medical units, while the bulk of the supplies were turned over to the civil authorities.2
Detailed planning for the invasion of the Philippines was begun by General MacArthur's headquarters on 12 March 1944.3 The principal forces to be concerned with the invasion were the Sixth U.S. Army under the command of Lt. Gen. Walter Krueger, the newly activated Eighth U.S. Army under the command of Lt. Gen. Robert L. Eichelberger, USASOS (the U.S. Army Services of Supply), and the XIV Corps under the command of Maj. Gen. Oscar W. Griswold.
During most of 1943 and 1944, General MacArthur had, in effect, two headquarters groups: The one designated "GHQ, Southwest Pacific Area" was the headquarters of the Allied Commander in Chief, from which he directed all Allied Ground, Air, and Naval Forces; the other designated "Headquarters, USAFFE (U.S. Army Forces in the Far East)," was reactivated on 26 February 1943 and served as administrative headquarters
for all U.S. Army forces in the Southwest Pacific theater. Although assigned to USAFFE, both the Sixth U.S. Army and the Eighth U.S. Army, after its activation in September 1944, were attached to GHQ, SWPA (General Headquarters, Southwest Pacific Area), which, therefore, exercised operational control over them while USAFFE merely provided administrative support.4
The chief surgeon of the Southwest Pacific theater, Maj. Gen. Guy B. Denit (fig. 76), and his staff organizationally belonged to USASOS and were not a part of either General Headquarters or USAFFE. Indeed, for many months, the only physician attached to General Headquarters was Col. Howard F. Smith, a commissioned officer in the U.S. Public Health Service, who for a number of years had been responsible for quarantine duties in the Philippines; Colonel Smith was officially designated Chief Malariologist. On 26 September 1942, Col. George W. Rice, MC, was designated Surgeon, GHQ,5 but he was not allowed supporting personnel other than a secretary, and no reports were channeled through his office. Likewise, only a small medical group was attached to HQ, USAFFE. In January 1944, the Chief Surgeon, USASOS, was also designated Chief Surgeon, USAFFE.
Thus, the principal staff concentration of competent medical personnel was organizationally in a poor position to be effective in overall planning or in the supervision of operational activities as they affected medical and health matters. Until late in the war, the Surgeons of the component field armies functioned in a largely independent manner without much consultation with the Chief Surgeon of the theater. These organizational arrangements imposed handicaps upon the medical activities in this theater. In particular, much of the early planning for civil affairs health activities in the Philippines was carried on without benefit of professional advice from the principal medical headquarters in the theater.
Planning for Civil Affairs Health Activities
As plans for the invasion of the Philippines developed in the summer of 1944, a Civil Affairs Section was established in General Headquarters. The section was initially under the direction of Brig. Gen. Bonner F. Fellers; the only medical officer attached to the group was Colonel Smith.6
During the planning period, scant liaison was maintained with the Civil Affairs Division, War Department General Staff, and essentially no liaison with the Chief Surgeon of the U.S. forces in the theater.7
On 22 September 1944, Lt. Col. Isaiah A. Wiles, MC, was appointed the surgeon of Civil Affairs Service, ASCOM (Army Service Command), with the mission of planning medical activities for civil affairs. A plan was submitted and approved by higher authorities on 29 September 1944. Colonel
Wiles was joined by Lt. Col. Lorenzo L. Parks, MC, on 9 October 1944. Further planning, however, was carried on at General Headquarters, and ASCOM seems to have had no further mission in respect to civil affairs.8
On 28 September 1944, an important revision of a previous staff memorandum was issued by General MacArthur's Headquarters.9 The underlying philosophy of the memorandum was that the responsibility and authority of the Commander in Chief for civil administration and relief were to be exercised as far as possible through the Philippine Commonwealth Government, with the ultimate and primary objective of restoring the orderly and free democratic processes to the Filipino people.
Plans for civil administration and relief during the period of military reoccupation anticipated two phases, combat and noncombat. During the combat phase, civil affairs were to be handled through U.S. military detachments recruited from available Philippine and U.S. Army personnel. They were to be known as PCAU's (Philippine Civil Affairs Units) and were to be under the direct command of Task Force Commanders.10 Their
duty was to execute plans and policies formed by General Headquarters in cooperation with the Philippine Government. Local governmental organizations were to be used as far as possible to avoid further dislocation of the lives of the people when they should become self-sufficient.
After the cessation of hostilities in an area, the Commonwealth Government, under the supreme authority of the Commander in Chief, would administer civil government and relief. The seat of the Commonwealth Government would be established at General Headquarters, Southwest Pacific Area. As rapidly as was consistent with military operations, relief supplies were to be provided to maintain health and working capacity and to alleviate the effects of malnutrition. Stimulation of food production, fishing, and transportation would, hopefully, hasten self-sufficiency of the people.
Financial and economic matters were to be handled so that wage and price structures which could not be supported after the military period would not be established. Labor requirements of task forces and bases were to be recruited on a civilian basis. Punishment of Filipino collaborators with the enemy was to be carried out by the Commonwealth Government.
The particular responsibilities for civil administration and relief assigned to the Assistant Chief of Staff, G-5 (Civil Affairs), included the primary one of assisting the Philippine Government to carry out its tasks. The G-5 Section would (1) disseminate information to civilians and handle legal and financial matters, (2) prepare plans for recruiting, training, and assigning PCAU's as well as plan and supervise health and sanitation measures, and (3) prepare technical and policy instructions for the task forces and units.
The Assistant Chief of Staff, G-4 (Logistics), would estimate requirements for civilian relief and prepare directives for procuring, transporting, storing, and issuing relief requirements. He would make plans and implement directives to effect Philippine self-sufficiency as rapidly as possible. These plans would include procurement and storage of supplies and equipment. This section, in collaboration with the Chief Signal Officer and Chief Engineer, would prepare plans and directives for the restoration of transportation, communications, and utilities in furtherance of the military effort.
The Commanding General, USAFFE, was to be responsible for the recruiting and training of the PCAU's, for counterintelligence activities, and for censorship of civilian mail.
The basic philosophy was embodied more explicitly in Standing Operating Procedure Instructions.11 Army or Area commanders were responsible for administration and relief work in their areas as consistent with the military situation. Coordination of Civil Affairs policies was to be effected by General Headquarters in close cooperation with Army or Area commanders and the Philippine Commonwealth Government. From the medical point of view, in addition to general health and sanitation measures, these duties
would include the control and isolation of communicable diseases among the civil population and the provision of hospitals and dispensaries for civilians not employed on military projects.
PHILIPPINE CIVIL AFFAIRS UNITS
These specially trained units were to be moved into the combat areas as soon as the tactical situation permitted civil relief work to begin (fig. 77). Each unit normally contained 10 officers and 39 enlisted men. The number of units to be attached to an area command would depend on the population and needs of the people; hopefully, each unit would be self-contained and would possess the necessary transportation and facilities for distributing relief supplies.
While these units were not to be used as labor recruiting agencies, they were to be permitted to recruit labor for combat units and for their own use in carrying out their normal duties. Otherwise, they would notify the people of needs for civilian laborers and direct them to recruiting offices.
The War Department had already procured relief supplies in the United States. These consisted of food (mainly rice), fuel, clothing, emergency shelter, and medical and sanitary supplies sufficient to preserve lines of communication, to maintain health and working capacity, and to preserve order. Procurement of these supplies for Army and Area commanders according to General Headquarters estimates was a USASOS responsibility. The supplies furnished by the War Department for Philippine relief would be supplemented from excess military supplies, captured enemy material, and local produce. Army rations and medical supplies might be used until the relief supplies were available although troops were forbidden to issue them to civilians unless specifically authorized. Wherever practicable, PCAU supplies would be segregated by Services of Supply from other supplies and would be specially marked.
Maximum use was to be made of local products, for which a fair price would be paid; wholesale ceiling prices were to be announced from time to time. Emergency free relief was to be provided as necessary, but as soon as possible, stores were to be opened to sell relief supplies to the public.
If necessary, a rationing system would be established, with each family receiving one ration book. To stimulate local production of food, farm tools, fishing equipment, and seeds would be distributed. Since imported rice and corn will not grow in the Philippines, plans were made to distribute seed rice by a system of exchanging Philippine palay (unhusked rice) for husked imported rice.
Personnel.-Initial personnel requirements of 100
officers and 400 enlisted men were estimated for civil affairs activities.
Maximum use was to be made of qualified Filipinos; in addition, 240 officers
and 386 enlisted men trained in civil affairs were to be supplied by the
War Department. A limited number of officers were to be flown from the
United States. Early plans of the estimated requirements for Medical Department
personnel are not
clear, but each PCAU was to include one medical officer and four enlisted medical assistants among the 10 officers and 39 enlisted men assigned (table 4).
Although PCAU's were to accompany the Task Forces, under the direct command of the commanding general of each task force, they were assigned to various tactical units for administration.12
Training.-Training of civil affairs personnel for the Far East had been instituted under War Department direction as early as 27 June 1944, when a Civil Affairs Staging Area was established at Fort Ord, Calif. This staging area was moved to the Presidio of Monterey, Calif., on 10 February 1945, and was known as CASA (Civil Affairs Holding and Staging Area). It served as the final advanced training center where teams of civil affairs personnel were organized and given instruction just before shipment to the Far East. Students came from other civil affairs schools, directly from civilian life, or from other Army assignments.13
Coordination.-The General Headquarters Civil Affairs Section was to coordinate plans with the Civil Affairs Section, Sixth U.S. Army, and with representatives of the Philippine Commonwealth Government. Technical supervision and coordination of PCAU's were to be responsibilities of G-1, General Headquarters; on matters pertaining to Civil Affairs, direct communication between G-1, General Headquarters, and PCAU's was authorized. The PCAU Medical Affairs Officers were to collaborate with the Task Force Surgeon on matters relating to communicable diseases in occupied areas, and were to inform the PCAU commander and G-1, General Headquarters, of the medical situation among civilians, of the status of medical supplies and equipment, and of other relevant matters.14 In practice, these channels of communication were not particularly effective, partly because of the great distances involved and the difficulties of communication.
Supplies.-For the Leyte operation, a food requirement of 20,000 tons was estimated for a population of 1.6 million with additional tonnage for textiles, medical supplies, and transportation of equipment.
Transportation.-Profiting by the experience in the Italian campaign, in which civil affairs personnel were severely handicapped by lack of organic transport, it was planned that, whenever possible, PCAU's would be self-contained as regards transportation. That these plans were successful is indicated by there being virtually no reference to a lack of transportation in reports of civil affairs operations in Leyte and Luzon.
THE LEYTE CAMPAIGN
The Leyte Operation, which began the campaigns for the liberation of the Philippine Islands, was divided into three tactical phases: first, an amphibious operation to secure the entrance to Leyte Gulf; second, major amphibious assaults to seize the eastern coastal strip from Tacloban to Dulag
and the Carigara Bay area on the north central coast, and to open the San Juanico and Panaon Straits; and third, the destruction of hostile forces remaining on the island and the clearing of the enemy from southern Samar (map 18).
Phase One, begun on 17 October 1944, was completed with relatively small forces within a few days. On 20 October, the X and XXIV Corps of the Sixth U.S. Army landed abreast on the east coast of Leyte, and occupied Tacloban, Dulag, and the intervening area; simultaneously, elements of the 24th Infantry Division seized Panaon Island off the southeastern tip of Leyte and quickly gained control of Panaon Strait.
These forces rapidly moved inland and northwestward and captured Carigara on the north coast within a fortnight. Other elements moved southwestward to occupy Baybay on the west coast.
Despite heavy losses in the naval battle of Leyte Gulf, substantial Japanese reinforcements were landed. This fact, together with the onset of the rainy season, led to a protracted Phase Three; and it was not until 25 December 1944 that organized enemy resistance ceased and the occupation of Leyte was given over to the Eighth Army, while the Sixth Army readied itself for the invasion of Luzon.15Meanwhile, elements of the 1st Cavalry Division landed on the Island of Samar on 24 October, securing it toward the middle of December.
Organization for Civil Affairs
Coincident with the establishment of a Civil Affairs Section GHQ, SWPA, the Sixth U.S. Army improvised a G-5 section, with the Army Judge Advocate General temporarily assigned as G-5 in addition to his other duties; on 8 October 1944, an officer was assigned to this duty full time. Apparently, no medical officer was assigned to this section.
PCAU's Nos. 1 to 8, which had been organized and trained under GHQ, were attached to the Sixth U.S. Army for the Leyte Operation. PCAU's Nos. 5 and 6 were to be attached to X Corps, comprising the 24th Infantry Division and the 1st Cavalry Division; PCAU's Nos. 7 and 8 to XXIV Corps, comprising the 7th and 96th Infantry Divisions; and PCAU's Nos. 3 and 4 to ASCOM. PCAU's Nos. 1 and 2 were to be kept in reserve under the Sixth U.S. Army. In addition, naval civil affairs units would accompany XXIV Corps in the landing phase.
The Combat Phase
Because of his familiarity with advance planning, the Sixth U.S. Army Judge Advocate General, Col. William P. Connally, Jr., JAGD, landed with an advance civil affairs detachment on A+2 to coordinate the activities of the civil affairs units.16PCAU's Nos. 3 and 4 landed on Red Beach,
the X Corps Area, on A + 4. PCAU's Nos. 1 and 2, while beaching on A + 5, sustained a direct bomb hit on their landing craft and suffered casualties. PCAU's Nos. 7 and 8 landed on A-day on X Corps beach but, because of the absence of land communications, were unable to reach XXIV Corps beaches until A + 5; in the meantime, naval civil affairs units were carrying out the civil affairs functions in that area.
Naval bombardment of the beach areas had been heavy and there were many civilian casualties. It was inevitable that the regular medical installations would be called upon to render medical aid to wounded Filipino civilians. By A + 4, station hospitals were ready to receive patients on the beachhead. Because the large number of civilian wounded presented a serious problem to the regular medical installations, the Surgeon of the XXIV Corps decided to assign the Corps clearing company as a civilian hospital.17 By A + 5, this unit was able to relieve other military hospitals of all civilians. As fast as possible, civilian patients were moved for convalescence to civilian medical facilities established under the supervision of PCAU.
A somewhat similar situation prevailed in respect to the medical units supporting the X Corps. On A + 2, the 36th Evacuation Hospital was on the beach treating mainly civilian casualties in an aid station, while Army battle casualties were evacuated to Navy vessels.18 It should be noted, however, that PCAU's Nos. 5 and 6 went ashore with the assault forces; but in view of the limited size of the medical section of a PCAU, they could do little more during the actual assault phase than work with the combat medical units in trying to provide some care for wounded civilians.
The organizational medical supplies of PCAU's which were exhausted in the early beachhead phase were augmented by captured Japanese medical supplies. Generally, Army medical units provided necessary medical supplies as well as hospitalization for the civilians. The Civil Affairs Section of the Sixth Army recommended that PCAU's go ashore with at least a 10-day supply of medical items.
The Chief Surgeon, USAF Western Pacific, described the situation as follows:
On Leyte troops faced a serious civil public health problem. Civil affairs became the responsibility of tactical commanders and as no special medical facilities were provided for treatment and hospitalization of civilians, their care placed a considerable burden upon the army medical facilities. The problem was not only one of personnel, but also one of supply. Not only did civilian wounded need care during the active combat phase but also large numbers of civilians required medical attention for acute and minor diseases. The combat division was specially hampered by the presence of civilian casualties. The need was keenly felt for special medical civil affairs unit to be set up and operated by D-1 and capable of forward displacement in order to handle civilian casualties as they might occur. The civil affairs problems on Leyte permitted a preview of conditions later faced on Luzon. It was expected that in future operations it could be taken for
granted that civilian sanitation would be inadequate and that civil affairs units would have to be provided by army medical personnel and equipment.19
As the tactical forces advanced across Leyte towards the western and northern coasts, PCAU's attached to divisions continued to carry out their assigned functions. Resistance varied from area to area, but in essence, the civil affairs problems were those of the combat phase-dealing with civilian wounded, attempting to reestablish civilian health services, which were rudimentary at best, and furnishing medical supplies to hospitals and dispensaries. In this operation, PCAU's frequently were transferred as some units dropped off to join the occupational phase of the operation, while others remained with their divisions. Some idea of these changes are contained in the following comments:
On 26 December , Philippine Civil Affairs Units (PCAU) Numbers 14, 15, 17, 26 and 27 took over responsibility for civil affairs * * *. These PCAUs relieved Numbers 4, 7, and 8 which had been with the Corps for some time but were relieved from their duties on Leyte in order to make them available for duty on Luzon. Although the change in units resulted in some unavoidable confusion, the generally excellent service performed by the PCAUs was continued.
At this time, civil conditions on the east side of the island had become stable. On the west coast, however, thousands of civilians had been driven from their homes by our advance. The town of ORMOC-the largest in the area-and numerous smaller barrios had been destroyed. In addition, an estimated 2,000 natives of the Camotes Islands had left their homes due to the atrocities committed by the Japs and were living along the beaches north of Baybay. The shortage of food and medical supplies had resulted in seriously hazardous health conditions throughout the west coastal plain, with the exception of the Baybay area which had been restored to a reasonably normal condition.
The PCAUs operated directly under the Corps Commander with the mission of assisting the division commanders charged with tactical control of the particular area concerned. PCAU supplies of food, medicine, clothing and sundries were brought to the west coast as rapidly as space in the convoys could be made available. An organized effort to reap the unharvested rice crop produced an appreciable addition to the imported food supplies.20
The PCAU medical officer was instructed to "establish and operate hospitals and mobile and fixed dispensaries for the treatment of civilians in liberated areas, prior to the establishment of facilities for such medical care by the Philippine Commonwealth Government."21 Accordingly, immediately upon arriving in Leyte in October 1944, the U.S. Army, principally through the PCAU Medical Sections, began restoration and operation of several previously used Filipino medical installations and the establishment of many new ones to provide for the civilian population.
During the next 4 months, many of these original emergency medical
installations were continued and expanded, and a few new installations were established. Simultaneously, a public health and sanitation program was being conducted by army agencies.
The Occupation Phase
On 26 December 1944, 11 PCAU's arrived in Leyte to take over the responsibilities formerly discharged by PCAU's attached to the Sixth Army. Organizationally, the former, which had been attached to the Eighth Army, became a part of the SOS base on Leyte, Base K. Previously, various hospitals and dispensaries had been established for civilians, but were equipped to carry out only the most elementary medical care. In this area, Filipino physicians were scarce and much of the medical work was performed by Filipino nurses. The only source of competent major surgery and X-ray facilities for civilians on the east coast of Leyte was a station hospital in Dulag which, shortly after the invasion, had been allocated to civilians.
Following a well-defined policy,22 assistance by U.S. agencies gradually diminished until the Commonwealth Government assumed complete responsibility for all dispensaries and hospitals. Early in January 1945, the Medical Office of the Civil Affairs Section, USAFFE, recommended that all PCAU hospitals, clinics, and dispensaries be turned over to the Philippine Government. Certain unit commanders recommended that the changeover should not be abrupt, and that installations might operate without supervision if provisions were made for necessary supplies and transportation. It was also suggested that supervision of sanitation and control of communicable diseases should not yet be relinquished.
Before the end of February 1945, most of the medical installations which had been established and operated by PCAU's were either discontinued or handed over to the Philippine Government through Dr. Arturo B. Rotor, Secretary of the Department of Health and Welfare. It was explained in each instance that the U.S. Army accepted no more responsibility for their operation except to assist in securing relief medical supplies. Although technically the Army had no further responsibility, it continued to assist civilian medical installations in every way possible. Until the end of March 1945, eight hospitals, 25 dispensaries, and seven subdispensaries were maintained in the Base K area by PCAU's.
Despite all the directives issued before the occupation that military responsibility was to be limited to furnishing minimum emergency assistance and supplies, many other, well-meant activities were carried on which, in the long run, caused the Philippine Government problems which were at the time insoluble. The initial task of the PCAU's was to establish medical installations rather than to set up a health organization. In retrospect, it is clear that the units were not given sufficient medical personnel to carry out their assigned tasks and, further, that the Philippine Government was not
able to support the number of hospitals, clinics, and dispensaries which were established and which were considerably more numerous than those which had existed before the war. The problem raised by this situation began to appear as soon as control of the hospitals and dispensaries was assumed by the Philippine Government. Personnel, transportation, and financial support were all lacking.
Before the war, 11 hospital-type medical installations had been in operation in the Province of Leyte; seven of them were classed as maternity houses. During the occupation phase, 10 hospital-type dispensaries for civilians had been in operation in Base K area. When the Philippine Director of Health assumed responsibility, he was able to include in his budget for fiscal year 1945 only four hospitals-the Leyte Provincial Hospital, Tacloban Maternity Hospital, and the San José and Baybay hospitals.
Before the war, dispensaries were operating in all 47 municipalities of Leyte; during the military period, 25 dispensaries were in use. On 1 May 1945, all dispensaries which had been under the control of the Supervisor of Hospitals were placed under the care of the District Health Officer; by 1 July 1945, only 10 were in operation in the Base K area.
Congested conditions.-Three main factors contributed to overcrowding in the hospitals: (1) patients stayed longer in the hospitals because the physicians had no transportation to make followup calls in patients' homes; (2) chronic and incurable cases were accepted in hospitals where, with the very limited facilities, space and effort should have been concentrated on doing the greatest good for the greatest number; and (3) the Filipino "companion" system was extended to the hospitals. Shelter and food had to be provided for one or more members of a patient's family. Sometimes these companions would be helpful in an understaffed hospital in doing menial work, but the disadvantages of the system are clear, particularly when companions would sleep at night with a patient suffering from a communicable disease.
Overcrowded conditions prevented the practice of ideal patient segregation according to age, sex, surgical and nonsurgical cases, and even communicable diseases; for example, the Supervisor of Hospitals found a case of diphtheria in a general ward. With the cooperation of the Preventive Medicine Section Officer, Base K, isolation wards were provided in the Tacloban Hospital, and a gradual improvement was seen.
Lack of mobile medical units.-Although the establishment of mobile medical units was authorized and equipment, including transportation, had been available since the landing in October 1944, none was actually provided. Maj. Charles W. Hall, Inf, Civil Affairs Officer, stated in his report23 that mobile units could have served a very useful purpose in satisfying the needs of small villages, thus eliminating some of the small dispensaries. Their use would have extended the scope of the limited medical personnel and would have facilitated the work of the sanitation and public health sec-
tions of Civil Affairs. At the time this report was prepared, the establishment of the units was still desirable and had been recommended to the Leyte health authorities.
Personnel.-Difficulties inherent in the situation on Leyte were increased by friction between those who were in charge of the civilian medical installations and the Supervisor of Hospitals. The individuals in authority lacked tact and good leadership. Since the salaries paid to professional medical personnel were low and they could obtain more lucrative work elsewhere, they would not accept arbitrary treatment. Relations between the installations and local authorities and citizenry were often poor and uncooperative. Lack of administrative ability among those in charge of hospitals led to confusion and general laxity. In one hospital, for instance, operations were performed without the permission of the physician in charge, and even a "black market" in medical services, operations, and treatment was reported. These factors, together with the overcrowding, inadequate facilities, and the fear that the Commonwealth Government would be unable to give proper support to the installations, may have contributed to a lowering of morale among medical personnel. Nevertheless, despite these problems, medical care was generally satisfactory. The majority of the personnel were loyal, devoted, conscientious workers.
Liaison between U.S. Army and Civil Government.-Coordination between Army and civilian medical authorities after the installations were turned over to the Commonwealth Government was not on an official basis except possibly in the supply phase. Major Hall, in his report, stressed the need for a definite official liaison to secure proper supervision of civilian medical installations for both civilian and military interest.
MEDICAL CARE OF CIVILIANS IN U.S. ARMY INSTALLATIONS
The presence of the Army and, particularly, its use of many civilian laborers greatly taxed the normal civilian medical facilities. Furthermore, traffic casualties were numerous, and many civilians, including children, were killed or injured by exploding ordnance materiel thought to be "duds."
Military hospitals were reluctant to accept civilian cases because our facilities were already overtaxed in caring for military personnel, and also because of the directive which stated that civilians would be admitted to U.S. Army hospitals "only to save life or to prevent undue suffering."24 They were to be transferred to civilian hospitals or otherwise released as soon as movement was no longer a hazard to their condition.
There were instances where admission to an Army hospital was necessary to save life or prevent grave suffering (where civilian facilities were unable to handle the cases) and yet admission was refused. On the other hand, some civilian hospitals turned away cases for lack of proper facilities without attempting to secure admission to a military hospital. Transfers from U.S. Army hospitals to civilian hospitals rarely occurred, in spite of
the directives. The unusually high death rate among the civilian population seems to indicate that all that could have been done to aid those requiring medical attention fell short of what might have been expected.
Major Hall believed that the various instructions regarding civilians, both those who were employed by the Army and others, would have been carried out more satisfactorily and effectively if they had been published in one all-inclusive directive to the military.25
Health and Sanitation
Local organization.-The legal provision for health and sanitation in the Philippines was based on the Administrative Code of 1917. A system of municipal boards within the Health Bureau provided an excellent organization which would have accomplished a great deal had it been adequately supported with funds and personnel. This system was in operation at the time of the invasion and until 1946 when the Commonwealth Government achieved the independence which had been promised for that year since 1935. The Province of Leyte was designated as a Health District with a District Health Officer appointed by the Commonwealth Director of Health. The District was subdivided into 17 Sanitary Divisions, each supervised by a president, usually a physician, who functioned as Health Officer and Sanitary Inspector. Some sanitary divisions had Assistant Sanitary Inspectors. Securing satisfactory personnel for these positions was difficult because of the low wages.
When the U.S. Army landed on Leyte, investigation revealed that household cleanliness, personal hygiene, and community sanitation, in most areas, generally did not meet the standards existing before the Japanese invasion. The Japanese occupation had seriously disrupted an already inadequate system of public health supervision.
By July 1945, after 7 months of Allied occupation, little had been accomplished in Leyte by the District Health Officer, and the municipal boards of health were almost inactive. Transportation, funds, and qualified personnel were all inadequate. Cooperation between the local political leaders and the District Health Officer was poor and, although the health officer's work was purely professional and advisory, he was also confronted with the operational problems referred to him by the municipalities. These problems were solely the responsibility of the local government, but they refused to act on them, either through lack of ability or unwillingness, or through both.
Under PCAU supervision, each municipality in the Base K area had a sanitary inspector and an assistant sanitary inspector. Their principal function was to supervise the construction of public latrines and wells and to instruct the people in their use. These inspectors generally were un-
trained and unqualified, having been selected principally on the basis of their previous doubtful experience as sanitary inspectors.
The responsibility for health and sanitation was not turned over to the Commonwealth Government concurrently with the turnover of hospitals and dispensaries. Since the chief concern of the PCAU's in this area was the establishment of hospitals and dispensaries, they achieved little in sanitation.
The Base K Surgeon and his staff assisted local civilian medical agencies wherever and whenever military exigencies permitted. Acting on the principle that the health of an army parallels the health of the surrounding civilian population, the Base Surgeon incorporated a Preventive Medicine Section in his staff. Through this section, unofficial liaison was maintained with the District Health Office.
Activities of malaria control units.-The MCU's (Malaria Control Units) might well be described as the backbone of the Army public health projects among the civilian population after the reoccupation of Leyte (fig. 78). These units had certain advantages over the Philippine Civil Affairs Units' medical sections: they were larger, having a trained sanitation engineer and 11 enlisted men, and they were provided with eight vehicles of their own while the PCAU medical section had to share the vehicles assigned to the whole team. As a general rule, the PCAU medical team established hospitals and dispensaries, and the MCU teams engaged in public health rehabilitation.
Because of the absence of the malaria vector in Leyte, the MCU's operating in the area were able to concentrate on other phases of health control and disease prevention. These included fly control measures, garbage collection and disposal, latrine construction, drainage, sanitary surveys, cemetery rehabilitation, military camp installation inspections, operation of a mobile schistosomiasis laboratory and plague and rodent control schools, setting up a model home exhibit, and assisting in the survey of sites and construction of civilian hospitals and dispensaries.
One of the finest health projects was carried out by the 90th MCU in their public health inspection of Tanauan municipality using civilian public health workers. A checksheet including instruction was furnished to each worker in addition to an orientation lecture before inspecting the house and grounds, toilets, and water sources. The object of the program was to get the people of the community to do as many things as possible by themselves to improve their own homes and surroundings and thus to raise the level of health and hygiene of both the home and the whole community.
A survey conducted by the 32d Malaria Survey Unit of the
school children in Julita, Burauen, and Dagami revealed that, in Dagami,
schistosomiasis had a high incidence rate (23 percent) which not only was
a serious local health problem but also threatened the troops. Julita (1.3
percent) and Burauen (1.8 percent) had a relatively low incidence. Parasitic
infections and worms were found in the children. No record is available
on any follow-
up work; however, one report stated that no Fuadin (stibophen) was available for early treatment.
During February, the 98th MCU began an intensive sanitary campaign covering Carigara and Capoocan, and Barrio Balud. Sanitary conditions improved markedly and an interested cooperative spirit was aroused in the people. On 12 February, following a conference with the community civic leaders of Capoocan, a mass meeting was attended by approximately 3,000 civilians. Instructive talks were given and details of the coming sanitary campaign were outlined by the mayor, the school supervisor, and the commanding officer of the 98th MCU. Interestingly, the program provided for long range civic planning. Twenty-five female sanitary inspectors and 100 civilian laborers assisted in carrying out the sanitation program.
A general program of sanitation was carried out in the
Tacloban area during March by the 97th and 92d Malaria Control Units. The
program started with a mass meeting attended by more than 3,000 people
which was addressed by municipal authorities and Commonwealth Government
officials as well as the base surgeon and base malariologist. Next, a truck
with a mounted public address system carried the word to all sections of
and 500 posters, the results of a contest in the schools, were displayed. A model home was used as headquarters of the campaign. Posters and exhibits on schistosomiasis and rodent control were shown. A meeting of local doctors, nurses, teachers, sanitary inspectors, and community leaders was held in the high school to plan for the details of the cleanup campaign. This included daily collection and removal of garbage from the city proper to an authorized dump for burning; weekly spraying of all latrines, public and private; daily distribution of garbage collection cans until a sufficient number were in use; construction of public latrines; cleaning of vacant areas within the city; and daily inspection of homes by a group of trained civilian employees. Neighborhood inspections were carried out periodically by the local officials accompanied by MCU members. They visited homes and inspected yards, latrines, and adjacent areas. Wherever a dirty area was discovered, an order was issued from the Mayor's Office and delivered by the Chief of Police, forcing the owner to clean the area. These measures stimulated property owners, especially since fines were imposed upon a few lax individuals. A house-to-house canvass of the town was conducted by 12 girls who had been trained as inspectors. They reported all delinquencies to Unit Headquarters, and complaints were turned over to the local Sanitary Division. These girls also instructed each household in sanitation and hygiene. By 31 March 1945, 1,974 homes had been visited.
In the town of Carigara, the 90th MCU found a similar health and sanitation program was necessary to control gastrointestinal diseases among troops in that area. In collaboration with PCAU No. 5, a corps of 21 girls was hired and trained and, under joint supervision, conducted a complete public health survey. The training of the girls and their work were carried on simultaneously. They were given mimeographed instructions, written in Visayan, which included directions on the construction of flyproof latrines, and a copy of the PCAU Sanitary Bulletin No. 1.26 The girls also attended a series of lectures outlining the general problem. Conferences were held and further instructions were given after they had made several visits. All persons who were employed on the project were required to build flyproof latrines and to maintain their homes and grounds in a sanitary manner, as an example to others. Data were obtained on past and existing practices in public health matters and on the habits of the people.
Latrines.-Insanitary excreta disposal and disease vectors were undoubtedly the fundamental causes of the high mortality and morbidity rates in Leyte. The Commonwealth Government officially required every house to have a sanitary toilet. Before the war, Government sanitary inspectors told the people to build latrines; some complied, but mostly they were not used, being kept only for inspection purposes. Flyproof latrines were scarce in many areas of Leyte. The complacency of the Filipinos in this respect presented a serious obstacle to the Army's efforts to educate them in proper excreta disposal. Filth and disease were accepted as part of a normal existence.
An energetic educational program by Army units stimulated the construction of latrines in the area. After 7 months, the use of latrines by civilians in Base K was estimated to have risen from 10 percent to more than 30 percent. The Preventive Medicine Officer of the Base recommended a further program of instruction in building and using proper latrines, regular inspection by the local health officer, and enforcement of ordinances. An adequate and steady supply of disinfectants, especially diesel oil and chlorinated lime, was still needed.
Diseases.-A survey of the reports on disease prevalence showed that schistosomiasis, one of the special hazards in the Philippines,27was occurring among both civilians and Army personnel with some fatal cases.28 Dengue- and malaria-transmitting mosquitoes were prevalent, the latter among the foothills rather than in the coastal areas. In the Tacloban region, the high incidence of both yaws and influenza declined steadily with prompt medical attention and greater precautionary measures. Malnutrition was universal and, of course, aggravated all diseases. Many sick people refused proper medical care, preferring the home treatment given by "Dr. Laway," the Visayan equivalent of the quack or "faith" doctor. Some of the more outstanding disease problems warrant attention here.29
Mental illness. No provision was made to care for the mentally ill. For a time, cases of acute dementia were cared for in local military installations; however, the Provincial Supervisor of Hospitals advised that mental cases should not be accepted by military installations, but should be turned over to the local jail keepers for safekeeping. Later investigations revealed that most mental patients did not remain in jail long, either conveniently breaking away with no attempt at pursuit being made or actually being released by the jailer.
Tuberculosis. Tuberculosis was a major cause of death in Leyte. One report estimated that 90 percent of the population was infected, and that pulmonary tuberculosis was still increasing. Until July 1945, no arrangements were made for the examination, treatment, and care of these patients. Those who reported to Army dispensaries were given sedative treatment and returned to their homes. Sanitariums and diagnostic facilities were seriously needed as well as an educational campaign to teach the people the elements of personal hygiene in relation to the transmittal of the disease.
Leprosy. Before the war, lepers were isolated in a barbed wire enclosure behind the Provincial Capitol. During the war, they escaped to their homes and remained scattered throughout the province. When the U.S. forces arrived in Tacloban, seven lepers were discovered living under a school building in the swamp area behind the Capitol building. They made
painful excursions late at night in search of food. To isolate and provide care for lepers, a leprosarium was established by Army medical authorities in a reconditioned building about 4 kilometers from Tacloban. All lepers brought to the attention of the Army were transferred there. PCAU No. 25 furnished the necessary food and supplies and, later, the District Health Office assumed operation and control. Plans were made to transfer all the patients to the Culion leper colony on Palavan Island.
Gastrointestinal diseases and parasitic worms.Infestation was widespread throughout the area. People of nearly all ages had some degree of anemia due to persistent infestation of parasitic worms. Those who were not acutely ill or recovering from illness were probably carriers of the various forms of gastrointestinal diseases-bacillary dysentery, amebic dysentery, and typhoid fever. Flies, contaminated water, neglect of hand-washing with soap and water, unsanitary preparation of food, lack of shoes, and direct fecal transfer between individuals were the chief causes of infestation.
Infant mortality. In some villages, the infant mortality rate rose as high as 40 percent. Causes of death, based on reports by canvassers and by questioning the mothers, were the diarrheas of infancy, premature births, and obstetrical complications. The babies usually were delivered in homes under unsanitary conditions with the assistance of neighbors and untrained midwives. Very few Filipino babies were delivered in hospitals even when maternity care was provided.
Venereal diseases. Realizing the inevitability of a high venereal disease rate among military personnel on duty near populous civilian areas unless drastic control measures were exercised, Army venereal disease control officers conferred with the Tacloban Municipal Council. On the advice of these Army representatives, the council amended local communicable disease ordinances to include, under penalty of fine and confinement, isolation and treatment of venereal disease cases among civilians. Although prostitution was suppressed by Provincial law, the council, though not in agreement, judiciously elected to overlook the nuisance of a local "redlight district." The district, established on the fringe of the business sections, flourished. As many as 40 women solicited, and Army visitors numbered up to 500 daily. Army representatives rigorously enforced venereal disease control measures and cooperated in laboratory tests and treatment. The Provincial health representative examined prostitutes weekly at the local civilian hospital. When the district proved to be offensive to neighbors, a hessian screen was erected.
Without warning, the Municipal Council directed the mayor to order the chief of police to arrest all prostitutes. Before this could be done, the "madame" closed her brothels and vacated the district, leaving the Army with the task of locating the prostitutes and rendering treatment.
The Municipal Council, under pressure of some unenlightened
individuals, voted to repeal the ordinance making venereal disease a communicable
disease, subject to confinement. The matter was taken to the Provincial Governor who adjudged that the Municipality had no authority to repeal ordinances without approval from his office. This ordinance was the only instrument that could be used by the Army to control venereal diseases among civilians.
The Public Health Service and the local police system were woefully inadequate to cope with the civilian contact problem. The Army formed a vice squad, composed of Army and Navy personnel, and acted on information supplied by military personnel who contracted a venereal disease from civilian sources. Prostitutes were found in foodshops, empty buildings, seashore shacks, and other places. After the "district" was closed, the military venereal rate rose more than 100 percent over the previous month's rate. There was no method of determining the increase in the civilian rate.
Although venereal disease flourished, the Tacloban civilian government showed its disinterest in the problem by suddenly closing a controlled district and attempting to repeal the only instrument by which control was possible. It was unwilling to bring prostitutes and solicitors quickly to trial, and did not provide sufficient jail space with sanitary appointment for prisoners detained under the venereal disease and prostitute ordinances. Little cooperation existed among members of the local government in carrying out planned venereal disease control. A strong educational program was needed to explain the importance of treatment in the prevention of these diseases.
In summarizing the situation in Leyte with regard to communicable diseases, Major Hall emphasized the need for stricter observance of the existing civil laws on the subject. Reporting was inadequate, almost nonexistent. Quarantine and isolation measures were not enforced. In outlying villages where medical care was inadequate, diagnoses for official reports in cases of death were made by ministers or civilian Public Health Department appointees. In many instances, no diagnosis was made; the corpse was simply buried.
Water supply.-In most areas, the water supply was dependent upon shallow open wells. The water was undoubtedly contaminated since the ground water table had been subjected to massive deposits of feces for years. The people carried water from the wells in receptacles which varied from bamboo rods to salvaged tin cans. These containers, of doubtful cleanliness to begin with, often were set down in the muck, then used to dip water from the wells, thus adding to the pollution of the water. Many homes had rainwater cisterns which were never clean since they remained open all the time and were contaminated by dirty dippers and passing animals. Several towns on Leyte had public water systems with pipeline service which required rehabilitation before potable water could be made available to the residents.
Disposal of garbage and refuse.-Under Philippine
law, garbage and refuse collection and disposal were municipal functions.
To protect the
health of U.S. troops and to support the civilian public health program, however, Malaria Control Units provided cans for garbage and refuse and collection and disposal service for several municipalities. The Civil Affairs Section provided two trucks for Tacloban. Local officials were expected to take over these duties eventually. In the more populated areas, the only feasible method of disposal was by municipal collection. In less congested areas, disposal by burying or burning was feasible and adequate.
Restaurants and public food vendors.-Two purposes decided the commanding officer of Base K to place all foodshops off limits to military personnel-to reduce venereal diseases and to reduce gastrointestinal diseases. The Preventive Medicine Officer of the Surgeon's Office had reported that foodshops were being used as introduction points for military personnel and prostitutes. Not only were the prices exorbitant, but also there seemed to be no public awareness of cleanliness and no effective method of sanitary control. As an example, dirty dishes and a dirty baby were seen being washed in the same water used in one of the foodshops. The order, placing all foodshops off limits, while clearly displeasing to civilian authorities, did reduce the incidence of gastrointestinal diseases among military personnel.
Marketplaces and slaughterhouses.-Since U.S. Army forces had commandeered the marketplace and slaughterhouse in Tacloban for their own use during the early phase of the liberation, the civilian authorities could not maintain even minimal sanitary standards for food products in the makeshift locations they had to use. With no other accommodations available, they slaughtered animals in backyards and empty lots, leaving entrails and other odorous remnants where they fell. When Base K returned the slaughterhouse to the municipality, the Civil Affairs Section provided trucks to bring the meat to market and to carry away the refuse. Trucks of the Civil Affairs Section also carried livestock to the slaughterhouse.
Although representatives of the civil government requested
U.S. military authorities several times to return the marketplace to municipal
control, their requests were denied on the grounds of continuing military
necessity. In the meantime, another marketplace would spring up next to
the municipal building. The municipal authorities and tradesmen disregarded
sanitary codes, and the new, unplanned, and disorganized marketplace became
a festering sore of indescribable filth-a breeding ground for diseases
and disease vectors. Over the objections of the Provincial Health Officer,
members of the town council closed their eyes to the alarming threat to
the health of the people. Representatives of the Base Surgeon informed
the councilmen that they must either close the marketplace or have it kept
clean. The mayor then prevailed upon the vendors to clean it, and the U.S.
Army command provided trucks for hauling away and disposing of the rotting
refuse. The municipal marketplace, which had concrete floors, adequate
drainage, latrines, and other sanitary facilities, was returned to municipal
control on 15 June 1945, thereby greatly alleviating this deplorable situation.
Other municipalities in the area operated relatively clean marketplaces, having been instructed by the Malaria Control Units and the Philippine Civil Affairs Units.
Comments and recommendations.-Summarizing the situation in the Province of Leyte, Major Hall wrote as follows:
Health propaganda by civilian agencies is almost completely lacking. Little or no effort by any government agency except the feeble attempts of the schools has been made to pursue a regular course of civilian education in health and sanitation matters. Like the father who insists on fixing his son's broken toy rather than telling him how or letting him do it himself, so the army continues to do many things for the civilian-individually and collectively-rather than to show him how or let him do it for himself. This is an example of typical American impatience. One must not get the impression that little or nothing has been accomplished in the line of health improvement and health education here in Leyte-facts elsewhere in this report prove otherwise. The army has done much to promote the feeling of need for "good health" and the desire for better living conditions among the people-the seed is planted-the Commonwealth Government must carry on where we have left off.* * *
In many cases the interest and cooperation of municipal officers is evident, however their activity is generally unenergetic because they feel that in many cases the organization and funds for carrying on health work will cease almost simultaneously with the departure of the army. They know well that the number of army personnel and those employed by the army in addition to the almost unlimited equipment is impossible to duplicate by the municipality and provincial governments to carry on the work started. This condition is just as disheartening to the army personnel engaged in civilian medical activities as it is to the civilians who can realize what is happening. Many have felt that it is actually cruel to carry the health and medical work to such a high pitch and then have conditions revert to their former status. It is evident that certain supplies and equipment must be provided by the United States if the Filipinos are to be expected to carry on. Unless these tools are provided, we must not be too prone to condemn them, because neither could we accomplish our mission without the facilities at our disposal. To be honest we must admit that we have placed the government in an embarrassing position.
Ability and willingness are interdependent factors in health control and activities. A community may be very willing to support an activity but lack the ability because of inadequate personnel, supplies and funds. On the other hand the community may have the personnel, supplies and finance enabling them to support the project but it isn't the nature of the people of that locality to be willing to expend the time and energy required to secure the necessary results. Examples of both cases are found within the Base K area.30
Instructions on distribution of civilian relief medical and sanitation supplies were issued on 11 January 1945.31 The furnishing of these supplies was limited to "emergency shelter, medical, sanitary and other essential supplies necessary to preserve lines of communication, to maintain the health and working capacity of the population, and to preserve public order."32
As has been mentioned previously, when medical installations were turned over to the Government of the Commonwealth of the Philippines, the Civil Affairs Section, USAFFE, had no further responsibility than that of assisting the Government to secure relief medical supplies.33 Accordingly, the Supervisor of Hospitals of the province was granted authority by Dr. Rotor, as of 3 February 1945, to requisition, receive, and sign for medical supplies and equipment turned over by the U.S. Army for use in hospitals and dispensaries. After 18 April, the Supervisor of Hospitals continued to requisition supplies for hospitals, and the District Health Officer, for the municipal dispensaries.
Procedure.-In January, a letter from Advanced Headquarters, USASOS, indicated that thereafter civilian relief supplies were to be stored separately by the respective services concerned until they were issued, and that separate stock records for relief supplies were to be kept by the Depot Commander concerned.34 Medical stocks, therefore, were transferred from the Base K quartermaster to the medical supply service, 34th Medical Supply Depot Company.
Up to this time, no provision had been made to resupply civilian medical relief supplies for Base K, and the original supplies were so drained by continual PCAU requisition that the stock levels became critically low. Arrangements for replenishment were made eventually through the Eighth U.S. Army Civil Affairs Section.
Summary.-It is impossible to determine the actual quantity of civilian relief medical supplies distributed in the Base K area. Accurate accounting of issue was maintained by the 34th Medical Supply Depot Company, but this does not give a breakdown of supplies issued for use in the Base K area alone. From certain available records which indicate the quantity of medical supplies issued to civilian medical installations in Base K by PCAU's and through the Base Civil Affairs Section, it is clear that a large tonnage of medical supplies was distributed for civilian use in Base K.
The problem of civilian medical supplies was not generally understood or handled satisfactorily by the U.S. Army. Advance planning did not consider the whole civilian medical problem. The original intention was to inaugurate a program which would be supported adequately by a continuous flow of medical supplies until such time as the Commonwealth Government would have access to normal commercial resupply agencies. The intricacies of supply and resupply mechanisms required closer official liaison between the Commonwealth Government and the U.S. Army.
Disposition of Civilian Patients
Civilian patients, other than U.S. Government employees, in military hospitals who required extended hospitalization were moved to civilian hos-
pitals as soon as possible. Arrangements for their transfer were made with the base commander concerned.35
During the first few months after the liberation of Leyte, commanders of U.S. military hospitals experienced considerable difficulty in disposing of discharged civilian patients. Provisions for their disposition proved to be inadequate, and some lingered in hospitals for as long as a month after their discharge before they were returned to their homes.
This problem was solved eventually but would have been simplified by the issuance of a clear-cut statement authorizing bases to return, by the first available military transportation, civilians (nonmilitary, employees, and nonemployees) to the bases from which they had been originally received. Undue hardships were imposed on released patients by the delay in securing transportation to their home areas.
Civilian Medical Personnel
Employment by the U.S. Army.-One of the duties of the PCAU medical officer was to obtain information as to the availability of local physicians, nurses, school teachers, midwives, pharmacists, and qualified assistants. He was further directed to allocate and coordinate the activities of local physicians and nurses employed by PCAU's for the care of the civilian population. Physicians, dentists, nurses, and pharmacists were employed by the U.S. Army only if they were licensed to practice in the Philippine Islands. In the Province of Leyte, no local agency, military or provincial, was able to compile a list of available civilian medical personnel.
During February 1945, a plan, requested by the Commonwealth Secretary of Health and approved by the Chief Surgeon, USAFFE, was developed for employing civilian physicians as "residents" in Base K general hospitals. Several young Filipino physicians enrolled for the 4-month refresher course in general surgery and were most enthusiastic about it. Although they asked that the course be extended, it was decided to place them at once in positions where they could serve the overwhelming civilian medical needs.
Private practice.-On occasion, it was found necessary to draw attention to the regulations of the Commonwealth and of the PCAU's which forbade the private practice of physicians employed by these agencies. Patients were sometimes neglected because of the time the physicians were expending for private fees. This situation developed because of the low salary scale for doctors. The rates were based on the actual salaries paid by the Commonwealth Government,36 but, even allowing for their limited professional training and local economic conditions, the salaries were inadequate. These low rates of pay tended to attract only less qualified personnel to Govern-
ment positions and encouraged them to look for additional sources of income.
Private practice by physicians, except for consultation and administration of homemade remedies, was almost entirely prevented by the lack of drugs and other medical supplies and equipment.
Technicians.-Few civilians were trained and qualified as medical technicians by Army standards. A plan was developed, therefore, to train selected personnel in local U.S. Army medical installations (fig. 79). Individuals with high school training were selected for both their enthusiasm and previous training and were placed in military installations as laborers. When they could be spared from their regular work, they were given special opportunity to receive instruction in technical subjects. A dental laboratory technician, several medical laboratory technicians, and an X-ray technician were trained efficiently by this method. Under such special instruction, it was found that civilians spent many extra hours at work, did not shirk, and showed special interest which would not otherwise have been aroused.
Nurse's aides.-To establish a coordinated civilian service in military hospitals and afford an opportunity for civilian women to receive training in basic nursing techniques, a "Nurse's Aide Training Course" was organized in five major hospitals of the base. The course was started at the 73d Field Hospital on 28 February 1945. Enrollees were given a thorough physical examination, including blood tests. In the five hospitals, 110 young women were accepted for training in classes of 20-25 students. In one hospital, the aides were provided with both quarters and subsistence; in the other four, they were provided only with subsistence. They were given a minimum of 34 hours of class instruction followed by a written examination. Those who successfully passed the 3-month training period were awarded a certificate. The first class graduated on 28 May 1945. From both a training and assistance standpoint, this program was successful. Not only did these young women render valuable service, but also they learned basic nursing techniques and standards of cleanliness and efficiency. Unfortunately, the plan received a serious blow when the GPA (General Purchasing Agency), USAFFE, announced a wage scale so low that the course offered little attraction other than the certificate of efficiency awarded upon completion of the course. The nurse's aides were an integral part of a hospital personnel plan; to attract a high type of civilian personnel, the wage rate should have been at least equivalent to the average rate being paid for similar work in allied services. The base surgeon recommended that the wage rate for trained nurse's aides be equivalent to the skilled clerical rate or to a rate paid to skilled laborers in a semihazardous occupation.
Drugs, Pharmacies, and Pharmacists
A few civilian pharmacists were employed through PCAU's
in the hospital dispensaries and some of them were retained in the same
service by the Commonwealth Government. By July 1945, however, 15 to 20
cists still were unemployed. Since the sale of relief medical supplies and equipment to individuals was prohibited, the absence of pharmacies for civilian use precluded private practice by both pharmacists and physicians. It was feared that the remaining stock of relief medical supplies allotted to the area which was to be turned over the Commonwealth Government would be inadequate until the normal commercial flow of drugs and medical equipment could be resumed.
Occasionally, drugs intended for the use of the Commonwealth Government were sold for the treatment of patients by private practitioners, or for commercial resale. Some civilians also "begged" drugs from the Army medical units on the basis of urgent need. Some of these drugs also reached the black market. The Supervisor of Hospitals and Dispensaries warned all physicians that these were punishable, felonious acts. All medical units were notified to refuse unauthorized requests for drugs.
Occupation of Cebu, Samar, Mindanao, and Mindoro, 1945
Resisted landings were made on Cebu, Samar, Mindanao,
and Mindoro. The pattern of civil affairs activities was much the same
as on Leyte.
PCAU's went in with the invasion forces; medical units supporting tactical forces were responsible mainly for the care of civilian casualties during the early combat phase, and malaria survey and control units assisted in developing civilian health service for the occupied areas, particularly those with large concentrations of occupation troops.
PCAU No. 9, for example, was located at San José, Mindoro, and was administratively responsible for the entire island and also the nearby small islands of Marinduque, Tablas, Romblon, and Cuyo. Sanitary regulations were promulgated and put into effect through inspections by appointed civilians. Atabrine prophylaxis was administered to several thousand civilians, and approximately 4,500 civilians were inoculated with typhoid, dysentery, and cholera vaccines. Ten civilian dispensaries and three hospitals were organized and kept fairly well supplied with medicines and other items. Nearly 40,000 civilians received treatment in these facilities during the 3-month period from April to June 1945. The hospitals and dispensaries were staffed entirely by Filipino physicians and nurses appointed by the PCAU.37
Cebu.-As with other units, the mission of the medical section of PCAU No. 15 on Cebu was to organize medical installations for civilian care to relieve Army medical units of that burden. Immediately after landing, they set up an emergency civilian hospital at Pardo, adjacent to one of the field hospitals attached to the Americal Division. Civilian casualties, cared for initially in the military hospital, were transferred promptly to the emergency civilian installation. A few days after the invasion, the civilian hospital was moved to Cebu City and installed in one of the dormitories of San Carlos College; it ultimately became a 250-bed hospital, and preliminary steps were taken to organize it as a permanent government hospital. Eventually, an extensive system of dispensaries and civilian hospitals was established with a Filipino staff.
The Eversley Childs Leprosarium located at Mandawe was given prompt PCAU relief, which led to the return of many of the lepers who had wandered off during the Japanese occupation.
Sufficient medical supplies to carry out the civilian program for 10 days accompanied the unit during the invasion; it was unnecessary to call on the Medical Supply Officer of the Americal Division during this period. Later, there was some delay in obtaining medical supplies since the original plan was to obtain them from the Division Medical Supply Officer, but this procedure was altered by an Eighth Army directive which required that all PCAU medical supplies be requisitioned from Base K in Leyte. The scarcity of medical supplies was alleviated by the use of captured Japanese medical materials.38
Samar.-Mopping up operations were conducted by elements of the
Americal Division (X Corps). The civilian population was found to be fairly well cared for by small civilian hospitals adequately staffed by Filipino doctors and nurses.
Mindanao.-The 24th and 31st Infantry Division (X Corps) invaded the island of Mindanao near Parang on 17 April 1945. At first, military casualties were light and civilian casualties offered no problem. Later, however, both the 24th and 31st Divisions suffered heavy casualties.
PCAU No. 29 went ashore with the initial task force of the 24th Division on 17 April. Since civilian casualties were few, the medical section of the unit began its program by opening a dispensary in Santa Cruz, staffed with Filipino personnel, to care for civilians who had returned from the hills and who were in need of food and medical attention. Later, the unit entered Davao and found that all four civilian hospitals had been destroyed by heavy shelling. Within 2 weeks, one of these hospitals, with the aid of the Engineer section, had been repaired to the extent that some patients could be accepted. To cope with a continuing influx of liberated Filipinos from the surrounding areas, a second hospital, the Davao General Hospital, with a bed capacity of 120 patients, was opened in an old constabulary barracks. A third hospital, with a bed capacity of 500, was opened in the city of Davao by 1 July 1945. In addition, 10 dispensaries, each with an inpatient capacity of eight to 20 beds, were established in various parts of the island, mainly for the treatment of ambulatory patients.
Within 2 weeks after PCAU No. 29 reached Davao, the former city health personnel had been located and the health services reestablished. Army Engineers established water points for civilians. The unit also began a venereal disease control program in an effort to stem the rising venereal disease rates in military personnel. No epidemic of infectious diseases occurred. The total population under this PCAU's medical supervision was approximately 100,000, living in an area of 2,000 square miles. Approximately 10,000 patients were treated weekly in dispensaries and 1,200 were in hospitals.
PCAU No. 23 was attached to the 41st Infantry Division which invaded Mindanao in the vicinity of Zamboanga on 10 March 1945. Headquarters of the medical detachment of the unit was established on the grounds of the Zamboanga General Hospital. Civilian medical personnel were plentiful in the area, and altogether 42 dispensaries and four hospitals for civilians were maintained under supervision of the unit. The City Health Department continued to function with its regular personnel under the same supervision.39
Comments on the Leyte Operation
The principal need of the people was for clothing, shoes, and useful household articles. Some deficiencies in the items brought to Leyte became apparent. The sizes were too large, many shoes being sizes 10 and 11,
and there were not enough women's and children's garments. Some items were superfluous or were not adapted to normal civilian use. For instance, the people could not buy or use the 4,000 rattraps or the rolls of toilet paper; nor would they accept canned or powdered milk. The meat items came packed in 6-pound cans, a quantity that could not be used at one time by the average Filipino family. In addition, the Filipinos preferred dried or canned fish to beef, so that canned meat was rarely purchased. These items were frequently substitutes dictated by necessity; however, every effort should have been made to afford a basic ration and minimum clothing better suited to customs of the Filipino people.40
A tabulation shows that 10,000 tons of relief supply items were landed and 6,830 tons were distributed. A total of 1,102 tons of rice alone was sold or given away. More than 400,000 refugees were fed gratis, and 287,000 needy were cared for. By late December, the relief rolls were reduced to the aged, the infirm, and those families without a breadwinner-some 2,500 families.
The relieving civil affairs units of the Eighth U.S. Army did not land until 26 December 1944. By informal agreement with the Eighth U.S. Army, the Sixth U.S. Army PCAU's remained in place and continued their missions under Eighth U.S. Army's operational direction. To attain the continuity of effort and to orient the relieving units, PCAU's Nos. 1 to 8 remained under Eighth Army direction until the last possible moment before leaving for the Luzon operation. PCAU's Nos. 1 and 2 were relieved on 28 December 1944, and the remaining six units 2 days later. The units thus had only the minimum of time in which to draw supplies and equipment and to move to their loading positions.
The relief went off smoothly. More than adequate stores were left to the Eighth U.S. Army. Its civil affairs staff was fully informed as to the situation and the methods developed by Headquarters, Sixth U.S. Army.
The success of civil affairs activities during the Leyte operation proved that the original plans were basically sound and that PCAU training was adequate. The performance of all units was good, and that of PCAU's Nos. 5, 7, and 8 was outstanding.
At the close of the period (25 December 1944), all areas within reach of the Sixth U.S. Army, with the exception of Ormoc-Palompon, were functioning normally in all civic activities. Order was excellent; health service and health conditions were probably above prewar levels; and the trade of the people, always limited, was substantially restored.
No person is believed to have starved or died for want of medical assistance during the period of our operations. Adequate civilian labor was at all times secured for the troops. The local government and schools were restored, and commerce was started on its way to normal activity. Tested by these standards, it can be said that the civil affairs units in the Sixth U.S. Army performed the mission given them by GHQ instructions.
Experience in the Leyte operation showed that PCAU's attached to assault divisions should go ashore early, and definitely not later than D + 2. At Dulag, for example, the populace, in seeking to escape the enemy, concentrated behind our lines and seriously interfered with the military effort. This could have been prevented had the PCAU's been landed earlier.
The landing of civil relief supplies should have been assigned a higher priority than was assigned in the Leyte Campaign. Merchandise had practically disappeared from the open market, and the civilian laborer was unable to purchase anything with his wages. This condition destroyed the civilian's incentive to work and created a difficulty in securing an adequate supply of labor for the military units. Delayed landing of civilian supplies also caused an excessive demand on quartermaster supplies to prevent actual suffering among the friendly inhabitants.
Prescribed medical supplies of the PCAU's proved inadequate. Several of these units exhausted their supplies within 2 days after coming ashore, and thus unduly burdened the medical units and facilities of all echelons of the Sixth U.S. Army. A minimum of 10-days' supply for the estimated caseload should have been prescribed for each PCAU.
The organic vehicles of the PCAU's proved insufficient to distribute supplies promptly from the base warehouses and dumps. Because of the demands of the tactical situation, it was rarely possible to supplement this transportation from other sources. Provision should have been made for establishing a pool of vehicles under Army control to transport supplies from the base to supply points in the respective areas assigned to PCAU's; a platoon of a quartermaster truck company could have been used for this purpose.
Training of PCAU's was completed only a short time before their loading dates. PCAU's Nos. 4 to 8 were shipped directly from Oro Bay to the objective area. Their first contact with the units they were supporting was made when they landed on Leyte. This situation did not contribute to smooth functioning for the combat units had little appreciation of the duties, capabilities, and limitations of the PCAU's. Ideally, PCAU's should have staged with the units to which they were attached, and orientation conferences on civil affairs should have been held in the corps and divisions.
THE LUZON CAMPAIGN
Civil Affairs planning for the Luzon Campaign41 involved four separate operations with landings at the following points (map 19): Lingayen Gulf-9 January 1945; Subic Bay-29 January; Nasugbu Bay-31 January; and Legaspi-1 April. Two of these operations, the landings at Lin-
gayen Gulf and Legaspi, were mounted by the Sixth U.S. Army, and the other two by the Eighth U.S. Army.
The Civil Affairs Section of Headquarters, Sixth U.S. Army, consisted of 10 officers, organized in three main branches-medical, operations, and supply-under a chief of section and his executive officer. Initially, 13 PCAU's were attached to the Sixth Army for the Lingayen landing; one additional PCAU was made available for the Legaspi landing.
Planning for the Luzon Campaign began early in November 1944. Many of the PCAU's earmarked for Luzon were still on duty in Leyte as late as 31 December 1944, so that little detailed planning with these units was possible. Standing Operating Procedure No. 27, dated 15 November 1944, was used as the basis of planning.42
Throughout the entire campaign, civil affairs administration was to be of the operational (combat) rather than the territorial type. Supply planning for Luzon was for an estimated population of 8 million; 50 percent of the population were expected to require assistance for 90 days. Class I supplies aggregated 55,470 tons, the medical supplies being a part of 7,000 tons which included clothing, shoes, cloth, soap, kitchen utensils, and hardware. Each PCAU was to land on Luzon with 10 tons of relief supplies, of which 1 ton was to be medical supplies.
The operational plans were essentially the same as those used for the invasion of Leyte; and in the combat phases, conditions encountered on Luzon were similar to those encountered on Leyte. Except during the first few days, there was a shortage of PCAU's throughout the campaign. Despite the fact that PCAU coverage was entirely lacking for only brief periods in any area, the total coverage nevertheless was inadequate because of the density of the population. A total of 61 PCAU's attempted to administer an island of 6.5 million people; the average population served by each PCAU on Luzon was nearly seven times as large as those served on Leyte.
As in most campaigns, the tactical situation differed from one unit to another and from one time to another in the same unit. For example, I Corps encountered stubborn enemy resistance in northwestern Pangasinan Province and moved slowly while XIV Corps moved rapidly through the central plain toward Manila, thus bringing large areas of Luzon under nominal control of PCAU's.
Because of the rapidly shifting tactical situation, Corps boundaries changed quickly, necessitating frequent movement of PCAU's to maintain coverage. With the rapid advance of XIV Corps through the central plain, the liberated areas became too large for three PCAU's; three additional units (Nos. 6, 20, and 21) from Army reserve were assigned so that the original units (Nos. 1, 2, and 8) might keep up with their divisions.
Plans for the administration of Greater Manila called for its division
into eight zones with the assignment of one PCAU to each; these units were PCAU's Nos. 1 and 8 (of the XIV Corps); Nos. 4, 5, 6, 20, and 21 (from Sixth Army reserve), and No. 27, which landed with XI Corps at Subic Bay.
The systematic razing of towns and villages by the Japanese south of Manila created an unprecedented refugee problem and necessitated the shift of PCAU No. 2 to Laguna de Bay section. No PCAU had been attached to the 11th Airborne Division for its operation at Nasugbu, and not until sometime after the initial landing was PCAU No. 11 made available from Mindoro. Protracted fighting east and northeast of Manila made necessary the detachment of PCAU No. 19 from I Corps and its reassignment to XI Corps.
These changes give some idea of the organizational and liaison problems confronting these civil affairs units. It is not surprising that, in the health field, liaison was inadequate and often ineffective between the PCAU's and the surgeons of the tactical forces on the one hand, and the surgeons of the communication or base commands on the other.
Health and Medical Problems
After 3 years of Japanese occupation, much of Luzon's public health service had ceased to exist. Acute and chronic malaria, tropical ulcers, malnutrition, dysenteries, and tuberculosis were prevalent. By the time of liberation, many hospitals had been destroyed or looted of their supplies and equipment.
Civilian combat casualties added to the heavy medical load normally present in most communities. Although the majority of civilians had fled the path of some combat operations in response to our airdropped warnings, the rapid advance in other sectors produced many civilian battle casualties. These casualties were in addition to those resulting from tampering with explosive projectiles and hand grenades, and bayonet wounds inflicted by the Japanese.
Throughout the campaign, all major surgery and, in the initial phase of liberation, other types of health and medical services were carried out by Army medical units. The first civilian medical services were usually those afforded through dispensaries established and sponsored by PCAU's. Immediately upon arrival in an area, a PCAU selected a location, hired medically trained personnel, provided medical supplies, and opened a dispensary for the treatment of the sick and wounded. Altogether, 185 such dispensaries, operated under the supervision of PCAU's, gave approximately 1,674,000 individual treatments.
The reopening of the former government hospitals and often
the opening of new hospitals followed closely upon the establishment of
dispensaries. Under PCAU supervision, buildings were repaired, beds were
constructed, staffs were reassembled, and supplies and equipment were furnished.
Considerable difficulty was experienced in providing a satisfactory hospital
diet as there was a shortage of relief supplies. Military hospital rations could not be drawn for civilian hospitals. In the areas administered by PCAU's, in addition to the military hospitals, there were 45 civilian public hospitals where there had been only 15 before the war.
Measures to reestablish sanitary facilities were inaugurated with the assistance of Engineer officers and Malaria Survey and Control Units. Latrines were constructed, wells repaired, garbage disposal provided, and programs of mosquito control (fig. 80) and health education instituted. To the extent that the supplies were available, vaccinations against smallpox and typhoid were given. The government Serum and Vaccine Laboratory was reopened under PCAU supervision, and a unit for clinical and public health laboratory services was established.
The medical supplies initially available were those mobile-loaded on PCAU transportation. Included for each PCAU was approximately 1 ton of dressings, sulfonamides, human plasma, and morphine. Despite procurement of some emergency supplies from medical supply stocks, there were serious shortages of many items, especially anesthetics and tetanus antitoxin.
Civil Affairs basic medical units did not arrive until about 3 months after the landings on Luzon. Many items in the basic medical units were not well adapted to the needs of the Philippine population.
A serious shortage of organic transportation increased the difficulties of delivering medical supplies and of supervising the widely spaced dispensaries. No satisfactory means of evacuation of civilian casualties to civilian medical installations was available until early in February when one ambulance was issued to each of seven PCAU's.
The general lack of electric power, running water, gas, and sewerage systems added to the difficulties in operating civilian hospitals during the early phases of liberation. Many surgical operations were performed by candlelight and flashlight.
Special problems were created by large numbers of refugees who streamed out of combat areas, and it was frequently necessary to establish refugee camps and to provide essential medical services and hospitalization.
In Manila, there was confusion as to the responsibility for civil administration both before and after liberation. Sixth Army had this responsibility initially, but it was supposed to revert promptly to General Headquarters; Civil Affairs officers had no authority to appoint officials. PCAU No. 5 was designated to assist in the care of internees at Santo Tomas University. The other seven PCAU's moved into the cleared portion of the city at an early date but waited until such time as they could take over their specific assignments.
In the early phase of the liberation of Manila, PCAU's
handled more than 20,000 refugees a day; as many as 45,000 were fed in
soup kitchens in 1 day. During February, when the PCAU's were under the
Sixth Army, more than 5,000 individual bed patients were handled in civilian
and about 99,000 treatments were given in dispensaries. Before relief ships were unloaded in Manila Bay in March, all relief supplies were brought by truck from Lingayen Gulf; fortunately, a considerable amount of captured Japanese medical supplies was available for the civilian medical services.
On 2 March 1945, USAFFE relieved the Sixth U.S. Army and assumed full responsibility for administration of both civil affairs in Manila and for PCAU's Nos. 1, 4, 5, 6, 8, 20, 21, and 27.
Assault Phase in the Lingayen Gulf
The initial assault waves of the U.S. I Corps and XIV Corps encountered little enemy resistance as they went ashore on 9 January 1945, following heavy naval and air bombardment of the beaches and their land approaches. Since our own military casualties were light, the evacuation, field, and portable surgical hospitals in support of our troops could handle the many civilian casualties without difficulty. The Surgeon of the XIV Corps reported as follows:
Several hundred civilian Filipinos were wounded as the
result of the three day preliminary bombardment of the beaches and adjacent
areas prior to the landing. The ma-
jority of the large buildings were destroyed or badly damaged. What few medical supplies that had been in the hands of civilian physicians were also destroyed.
Because of the few Army admissions to clearing stations, it was possible to provide hospitalization and emergency medical care to civilians, in division and shore party clearing stations. Civilian physicians and nurses were hired through PCAU to assist Army personnel in the care of civilian casualties.
On the afternoon of 10 January 1945, civilian casualties were evacuated from division clearing stations to companies A and C, 264th Medical Battalion, in order to free them for possible movement inland.
During 11 and 12 January, civilian casualties were transferred to the 24th Field Hospital from Company A, 264th Medical Battalion, and to the 894th Clearing Company by Company C, 264th Medical Battalion. The 24th Field Hospital thereafter received civilian casualties in the 37th Division sector, and the 894th Clearing Company received those in the 40th Division sector, until such time as improvised civilian hospitals under PCAU control were able to assume such hospitalization responsibilities.43
The XIV Corps moved rapidly toward Manila, but I Corps encountered stiff resistance on the northern flank. Typical was the experience of PCAU No. 18, which landed on S + 2 in support of I Corps. Its first mission was in the town of Mangaldan, about a mile inland from the beaches; here, with the help of Army medical units, it dealt with a large number of civilian casualties. A 100-bed civilian hospital was established within 48 hours and staffed with Filipino doctors and nurses; this hospital handled the less severely wounded civilians and received patients from Army hospitals immediately after major surgery. Within a few days, dispensaries were organized in neighboring villages to relieve pressure on the hospital in Mangaldan.
A 75-bed hospital was established in the vicinity of Villasis to care for civilian casualties; major surgery for civilians was carried out in Army hospitals. Cooperation between Army and civilian hospitals was close; by 31 March, PCAU No 18 was supervising eight hospitals and 20 dispensaries which, together, were caring for about 3,500 civilians daily.44
Civil Affairs Plan
The Civil Affairs plan for the city of Manila and its suburbs was contained in a letter of instruction from General Krueger, Commanding General of the Sixth U. S. Army, to the Commanding General of the 37th Infantry Division; the 37th, upon the occupation of Manila, was to be detached from XIV Corps and become responsible directly under Sixth U. S. Army Headquarters for the civil government of greater Manila.45
Eight PCAU's were to be made available, together with certain spe-
cial headquarters personnel. Lt. Col. Albert M. Dashiell, MC, of Headquarters, Sixth U.S. Army, and one other officer, with two enlisted men, were detailed to the 37th Division as Surgeons and were immediately responsible for medical affairs in the city. Also available were one section of the 26th Medical Laboratory, two malaria control units, one malaria survey unit, one medical clearing company, and one medical supply platoon. Medical care and sanitation were to be the responsibility of these units and personnel. Civilian hospitals were to be opened and civilian doctors and nurses were to be employed as early as possible. Initial medical supplies were to move forward with the attached units and resupplies were to be obtained from Army Medical Supply points and from captured stocks. A separate detachment was detailed to give prompt attention to the 3,800 internees at Santo Tomas University.
Civil relief.-Although the nature and full extent of civilian distress in Manila would depend upon the final enemy action, in the light of known conditions, approximately 200,000 inhabitants were estimated to need immediate relief, and many others would be near starvation. During the initial phase, immediate objectives would be to provide direct relief in food, medical care, and shelter; to obtain labor, clerical, and professional assistance to aid the military and to develop civilian groups to further relief; to maintain order, in conjunction with The Provost Marshal; and, with the Engineers, to restore emergency public utilities.
To accomplish these tasks, the Civil Affairs Officer was to act as Director of Civilian Relief, and the eight PCAU's were assigned responsibility for specific districts in which they would set up their own headquarters and establish subdistricts as required. They were to follow their normal operating procedure and employ all necessary doctors, nurses, medical technicians, relief workers, clerks, messengers, and laborers. Cooperation was expected from the civilians. PCAU No. 5 would act as Headquarters for the units. Two quartermaster truck companies, under control of the Transportation Officer, would haul supplies for civilian relief into Manila.
With a view to the early assumption of responsibility by the appropriate agencies of the city of Manila and the Philippine Commonwealth, the Director of Relief was to form an Advisory Council. This council, composed entirely of civilians, would represent the following activities: Health and Sanitation, Labor, Food and Shelter, American Red Cross, Philippine Red Cross, Utilities, Commerce, and Finance. Full use would thus be made of the knowledge and experience of these residents of Manila. They would be consulted and kept informed of developments. Their function was to be purely advisory; the Sixth Army was responsible for administration of Civil Affairs in the city.
Supply.-Each PCAU was prepared to enter Manila
with its prescribed load of 10 tons of relief supplies. The Fred Galbraith,
a relief supply ship, was waiting in the Lingayen Gulf with 7,000 tons
aboard; and two
other ships with 1,500 tons each were expected shortly in the Luzon area. Additional supply ships were loading or were en route to the Southwest Pacific area. Supply dumps would be established in the city of Manila as directed by Transportation and Civil Affairs representatives; one of these would probably be near the depot of the Manila Railroad Co.
Hospitalization.-Three 400-bed Evacuation Hospitals (the 71st, 29th, and 54th) were to be moved to Manila by the Sixth U S Army to support the XIV Corps, and to be established in suitable areas for the prompt care of battle casualties. It was anticipated that they would be able to care for a limited number of internees requiring hospitalization, but not for civilian casualties.
All possible assistance was ordered to be given to civilian hospitals to enable them to continue to operate and to increase their capacity. Every effort was also to be made to help inoperative civilian hospitals to reopen. Evacuation routes to Army hospitals at Fort Stotsenburg, Tarlac, and Guimba were planned.
Care of liberated internees.-The 893d Medical Clearing Company was ordered to Santo Tomas to classify the internees. Those who required hospitalization were to be cared for in Army hospitals. If the number of insane was high, such cases were to be treated in civilian hospitals using Army medical officers and civilian nurses secured through the Manila Health Department. Those who needed home care with outpatient medical attention were to be released to the Civil Affairs Section with the request that they be housed where medical care could easily be provided. Those who required only domiciliary care were to be released to Civil Affairs for this care.
Rehabilitation of health and sanitary facilities.-On
1 March 1945, the Chief Surgeon, HQ, USASOS, assigned Col. Maurice C. Pincoffs,
MC, as director of the Manila Department of Health. He was instructed to
coordinate civilian health activities. These included the reestablishment
of the Manila Health Department so that sanitary inspections, health clinics,
visiting public health nursing, and municipal hospitals might resume activity
without delay; the provision of laboratory examination of water, milk,
and foodstuffs, and serum agglutination for the diagnosis of infectious
diseases; arrangement for the continued functioning of private and church-supported
hospitals for the care of civilian patients and for the opening of such
hospitals as were inoperative;
of quarantine proceedings for the control of contagious disease and immunizations
necessary for epidemic control; and the resumption of collection and preservation
of vital statistics. Also, he was to advise the Commanding General, 37th
Division, as to sanitary and communicable disease hazards within the city
as they were likely to affect American troops.
The Combat Phase
The plan for the city of Manila and its suburbs to be administered by eight PCAU's was put into effect during the initial period of occupation. While each PCAU had a medical officer on its staff, there was no coordinating Surgeon to whom these officers could look for an overall plan. Medically, each unit was on its own during the initial phase, which lasted from 3 February until the control of health matters among the civilian population became the responsibility of USAFFE on 2 March 1945. The fanatical Japanese defense of Manila led to great destruction of the city.
Colonel Dashiell and Capt. Huron L. Vaughan, SnC, were detached from Sixth Army Headquarters as part of a special staff assigned to XIV Corps for the emergency rehabilitation of Manila. While their duties were not clearly defined, their primary mission was to rehabilitate the health department and governmental hospitals to restore a public health system. The PCAU's, meanwhile, were to provide medical care for the sick and wounded. Civilian medical facilities were believed to be adequate for the civilian population, provided the Army issued medical supplies to PCAU Surgeons for distribution to their districts as needed. Since no Army hospitals could be spared, none was detailed specifically to care for civilians in Manila. Civilian internees liberated from Santo Tomas University and Bilibid Prison and needing hospital care were sent to one of three evacuation hospitals. The 29th, 54th, and 71st Evacuation Hospitals were supporting XIV Corps, and they played no other role in caring for civilians.
The medical units assigned to assist the civilian medical program were selected to provide technical service or transportation to cover anticipated civilian deficiencies. The units included the 26th Medical Laboratory (Army), the 55th Medical Supply Platoon (Avn) (later replaced by the 15th Medical Supply Platoon on 16 February 1945), the 7th and 10th Malaria Control Units, and the 26th Malaria Survey Unit.
On 6 February 1945, Colonel Dashiell, accompanied by the G-4 and Transportation representatives, opened an office at 1955 Rizal Street, from which to administer a civilian health program. The following day, the medical supply depot was established in an abandoned twine factory on Aragon Street and began to issue medical supplies. The two malaria control units and the malaria survey unit were quartered in the same factory. On 7 February, the 26th Medical Laboratory took over the laboratory at the San Lazaro Hospital and opened for business the next day.
The civil affairs health problems of this early phase are well described in a report by Colonel Dashiell:46
Due to the Japanese policy of destruction of Manila and atrocities committed against civilians by Japanese troops the civilian medical facilities were unable to function in the manner that had been expected. Many hospitals were destroyed and civilian casualties were heavy, particularly from the destroyed area south of the Pasig River. Inas-
much as the major surgical facilities were in the south area, particularly in the Philippine General Hospital, it was necessary to convert various institutions in north Manila into surgical hospitals although they were originally intended for other purposes. As an example the San Lazaro Hospital, the city communicable disease hospital, was loaded with 1,300 civilian battle casualties. This institution, like all hospitals in the occupied area, had been taken over by the PCAU unit in whose district it was located. The staff had been placed on the PCAU payroll and the institution was furnished medical supplies by the Surgeon of PCAU 20. However, the staff of this institution was untrained in surgery and by 15 February it was apparent that this staff was overwhelmed by the magnitude of the surgical load thrown upon it. Meddlesome surgery was being done such as sewing up old infected wounds; thus increasing the risk to the patient. It was apparent that a reorganization of this hospital was imperative. I requested of Lt. Colonel Meader, commanding officer of PCAU 20, authority to place Major W. D. Tigertt, MC, commanding officer of the 26th Medical Laboratory, in complete control of the San Lazaro Hospital. This was done at once. Major Tigertt accepted the responsibility and began the reorganization. Trained Filipino surgeons were brought in from the outside and two U.S. Army surgical teams were secured upon application to the Surgeon Sixth Army. The improvement in the institution from that time up to the present has been spectacular. Principles of war surgery were inculcated in the staff and the level of cleanliness and efficiency in the care and feeding of the patients improved beyond all expectations. The service rendered by Major Tigertt has been superior and was carried out in addition to his regular duties as laboratory commander and Manila epidemiologist. A somewhat similar measure was carried out at the Psychopathic Hospital at Mandaluyong, this institution being converted into a surgical hospital for the care of patients evacuated from the Philippine General Hospital and other casualties from south of the Pasig. Major Grounds from XIV Corps Surgeon's Office assumed supervision over the institution and surgical teams were procured from the 54th Evacuation Hospital. Personnel of the 26th Malaria Survey Unit assisted in sanitation work in the area. Surgical personnel from the Philippine General Hospital were concentrated in this hospital with the idea of taking over from the American surgical teams.
Regarding the critical medical supply situation for civilians in Manila, Colonel Dashiell had this to say:
Medical Supply for civilians was taken from Army stocks
and issued to PCAU Surgeons at the same depot from which army units were
supplied. No large stock level has been accumulated due to the heavy civilian
demands and the increasing number of army units which have drawn from the
depot. It was necessary to assure that army units were supplied and to
distribute supplies to PCAU units on the basis of actual needs on a day
to day basis. This office kept the depot informed as to areas of casualty
density in order that the PCAU units serving those areas should have special
allowances of medical supplies within the limits of depot stocks. It soon
became apparent that the Commanding Officer of the 55th Medical Supply
Platoon was unequal to this complex task. This unit was relieved by the
15th Medical Supply Platoon commanded by Captain Messina, MAC. This officer
has displayed remarkable ability to "stay on top" of the situation and
make an equable distribution of available medical supplies. It should be
pointed out that no "civil relief" medical supplies have yet reached Manila
and all supplies have come from stocks allotted to support Sixth Army's
operation. One hundred and fifty boxes of Red Cross supplies intended for
internees at Bilibid Prison were taken into the medical supply depot for
issue to civilians through PCAU. Medical supplies for civilian internees
have been furnished on the same high priority as for U.S. Army units. At
various times many items of medical supply have been critical but Tetanus
Antitoxin has been the outstanding shortage. Lack of this material has
resulted in the loss of a good many civilian lives that might otherwise
have been saved. This shortage persists up till the time of this
report. Several small increments of Tetanus Antitoxin have arrived at the depot, but the supply has never been enough to meet the demand.47
Discussing preventive medicine activities in Manila during the period of Japanese occupation, Colonel Dashiell reported:
Early in the course of the Mission the various civilian health authorities were interviewed as rapidly as they could be located. No evidence of any epidemic could be discovered. The consensus was that the enteric infections had been rather infrequent during the Japanese regime, the record in this respect being better than during the pre-war years. This was probably due to heavy chlorination of the city water supply by the Japanese coupled with a city wide immunization program against cholera, typhoid, and dysentery (bacillary-polyvalent vaccine) carried out in the Fall of 1943. This immunization program was compulsory and the city was said to be over 98% immunized. Smallpox, plague, and cholera were said to be completely absent during the Japanese regime. Diphtheria has been moderately prevalent. Gonorrhea and syphilis have increased apace during the Japanese period, many of the latter cases, particularly among prostitutes, being "serologically fast" due to inadequate treatment. Tuberculosis, always a serious problem in the Philippines, was almost completely neglected by the Japanese due in part to shortages of X-ray film and facilities for the care of the patients. Crowding and malnutrition have undoubtedly greatly increased this problem which will be the major health hazard of Manila and the Philippines for years to come. Sanitation suffered during the latter part of the Japanese occupation due to lack of transportation for garbage and refuse although efforts were made to effect disposal through the medium of the "neighborhood associations." In general it seems that the Japanese first approached Manila with a view toward permanent occupancy. They made reasonable efforts to maintain health standards and even effected some improvements. One of the few bright spots in the functioning of totalitarian governments is their ability to achieve success in preventive measures such as immunizations, sanitary handling of foodstuffs, etc. A man will readily submit to immunization rather than lose his rice card and a food processer will conform with sanitary laws rather than lose his license to engage in that or any other business. It will be observed that the Japanese effort was directed toward controlling those diseases immediately hazardous to Japanese troops. Tuberculosis was neglected and the insane were gradually starved, particularly during 1944. The Japanese gradually encroached upon the output of sera and vaccines prepared and distributed by the Institute of Hygiene of the Philippine Commonwealth. In September 1944 the facilities of the serological laboratories of the Institute of Hygiene at Alabang (Rizal Pr.) were completely taken over and the civilian supplies of antisera against diphtheria, tetanus, and gas gangrene were cut off. The Japanese removed much of the technical equipment of this institution and the herds were not fed. The building and much equipment of this vital institution are preserved and the nucleus of the herds remain.
In a discussion of the reorganization and resuscitation of Manila's health department, Colonel Dashiell noted that:
In the early days of February it was decided that in view of the urgent need of medical care both in hospitals and in outpatient clinics it was not advisable to attempt to build a medical and nursing staff for purely preventive services. Former health department medical personnel were directed to the various PCAU units as the districts were organized and were employed on the staff of these units. By informal agreement with Lt. Colonel Faust, Surgeon of PCAU 20, the director of health centers, Dr. [Lucerio] Ve-
lasquez, and the chief nurse, Mrs [Vicenta C.] Ponce, were employed in that unit but were permitted to work over all of north Manila in reorganizing the health centers. These health centers when reorganized, were absorbed by the PCAU in whose district they fell and served as general outpatient dispensaries. This program met with varying success depending upon the understanding of the PCAU Surgeon of the program attempted. In this matter, as in medical supply and many others, the lack of an overall PCAU Surgeon was keenly felt. It was necessary to hunt up each unit surgeon and explain to him the program attempted due to the lack of a responsible head with whom policy could be determined. By another informal arrangement with PCAU 20 Dr. [Jose] Navarro, the former venereal disease control officer, began to examine prostitutes in the various houses in north Manila, submitting his specimens to the 26th Medical Laboratory. Dr Navarro was permitted to work anywhere in north Manila without reference to PCAU districts.
The sanitation personnel of the health department were more readily available than the medical personnel since their headquarters was in north Manila. The staff of Mr. Emelio Ejercito, the former city Sanitary Engineer, functioned under the control of Captain Vaughan. This staff, which consisted of approximately 140 employees, was authorized to work anywhere in Manila that Captain Vaughan should direct. Malaria Control and Survey Units provided trucks and supervisory personnel and Capt. Henry M. Jones, SnC, the Commanding Officer of the 10th Malaria Control Unit, also furnished the sanitary group with technical supervision. Between 10 February and 30 June, sanitation personnel accomplished the following:
a. Burial of 1,604 bodies from the city streets and hospital
morgues-all buried in north cemetery.
Colonel Dashiell concluded with a discussion of the water situation and of the shortage of housing as follows:
The rehabilitation of the water system was carried out by the army engineers. Water was furnished to civilians first by the use of army water points and later through the regular water mains. At the time of this writing the water supply was partially restored. The water in the mains carried residual chlorine indicating its safety. Numerous examinations were conducted by us on the water points and private wells in the city. The sanitary quality of the water supplied to civilians by the army water points was satisfactory whereas practically all of the private wells, including the so called "artesian" ones, showed bacteriological evidence of fecal contamination. This was an uncontrollable health factor since there was too great a shortage of firewood to permit boiling of this polluted water even had the people been willing to go to the trouble to do so. In spite of this pollution of the private wells there is as yet no evidence of epidemic outbreaks of enteric diseases resulting from drinking polluted water.
The critical housing shortage due to the large numbers
of destroyed dwellings has resulted in overcrowding in most of the remaining
residential area, and the construction of many shanties and temporary quarters
in the ruins of former buildings. These latter establishments have not
even the most rudimentary sanitary facilities and are fast in-
creasing the disease hazard. It is recommended that action be taken to remove the populace from the ruined areas in order that the wreckage may be cleared away to permit of adequate new construction.
Supplementary and supporting observations were recorded by numerous other medical and civil affairs personnel. For example, the Surgeon, XIV Corps, Col. Robert E. Allen, MC, noted various items of interest:48
During February and March, there was a critical shortage of tetanus antitoxin which was urgently needed for the care of wounded Filipino civilians, internees, and guerrillas. The venereal disease rate among troops increased precipitously during February even though active fighting was in progress in the city; prostitution was widespread and, for many troops, this was the first contact with an urban civilization for 2 years.
Several thousand bodies of Filipino and Japanese dead were scattered among the ruins throughout the city. The 37th Division employed a full-time civilian burial detail under the immediate supervision of their medical inspector, whose duty it was to follow the troops through the city and dispose of the dead. The Manila Department of Sanitation under the supervision of Civil Affairs disposed of the dead from civilian hospitals and rear areas of the city.
The city water system, which had been seriously damaged by the enemy as well as by high explosives, was not in operation during February. Two Engineer Water Supply Companies and the portable water purification units of the Division served both Army troops and civilians. The only water sources available were sluggish and heavily polluted rivers and streams traversing the city. Chlorine residuals were maintained at 2-4 ppm and the water from all but three waterpoints satisfactorily passed bacteriologic tests.
While Army troops disposed of kitchen wastes by burial and human excreta in slit trenches, civilians indiscriminately disposed of garbage and human wastes onto sidewalks, gutters, streets, and backyards. By the end of February, the resulting filth and fly breeding had increased alarmingly and presented a serious menace to the health of both the command and the civilians.
Specialized Functions in Relation to Civil Health
It will be instructive at this point to review briefly the activities of certain specialized units which were assigned to civil health duties in Manila in March. None of these units had been designed primarily for these activities, and indeed none had had special briefing for the tasks ahead. Nevertheless, the evidence indicates that their assigned duties were carried out with imagination and timely improvisation.
The 26th Medical Laboratory (Army).-On 22 January 1945, the 26th
Medical Laboratory (Army)49 debarked at San Fabian and moved to a bivouac area at Calasiao. The unit was alerted to proceed to Manila and establish its laboratory there in February. The advance section arrived on 6 February and, the next day, set up in a laboratory building at San Lazaro Hospital, where it continued to function for several months. It operated as a stopgap public health laboratory for the city of Manila and also provided laboratory services for various Army units in the area. The unit was quartered in the attic above the laboratory itself because the concrete ceiling offered protection from shell fragments, shrapnel, and stray bullets. Original plans were for the laboratory to provide only limited service, but it rapidly became evident that full laboratory facilities would be required. By 20 February, when full laboratory facilities were available, it was necessary to supplement the staff with civilian technicians. Considerable equipment, much of which was American make, was salvaged from captured Japanese supplies.
On 25 February, Headquarters, USAFFE, directed the Laboratory to establish a Manila Public Health Department laboratory, which was to remain and continue to provide laboratory services for the civilian populace after the 26th Medical Laboratory left the area. The Public Health laboratory was organized and almost completely set up by 20 March. The staff consisted of seven Filipino officers and 18 technicians.
Providing diagnostic tests for venereal diseases constituted about 50 percent of the work of the 26th Medical Laboratory. Water bacteriology and analysis of alcoholic beverages also consumed much time and effort.
On 15 February, the unit was assigned the full responsibility for the care of the sick and wounded at San Lazaro Hospital, a civilian institution intended to care for contagious diseases, with an estimated bed capacity of 1,200. At the time this assignment was made, no surgeon was on the hospital staff; all public utilities were off; no sanitary measures were enforced; and patients had had no food and little water for more than 48 hours. The total number of patients in the hospital was about 1,750, of whom some 1,300 were battle casualties. Two Sixth Army surgical teams were assigned to care for these casualties. An additional 500 PCAU employees were used to supplement the hospital personnel and to institute the much needed cleaning required for sanitary purposes. An operating room was set up using supplies found in the storeroom of the Bureau of Health. Necessary temporary latrine facilities were constructed and the civilians were forced to use them. Minimum food supplies were procured through PCAU. An auxiliary water system was constructed using an artesian well on the grounds.
By 31 March 1945, when the laboratory was relieved of the responsibility for San Lazaro Hospital, an estimated 4,000 civilian war casualties and an ever-increasing number of medical cases had been cared for.
The quarterly report of the unit for the period 1 April to 30 June 1945 indicates that, by 1 April, the work of the laboratory had settled into a grinding routine. The laboratory was covering all types of medical installations, both military and civilian. Venereal disease diagnosis accounted for about 55 percent of the work of the laboratory with the daily average being about 500 Kahn tests, 110 dark field examinations, and 100 smears for gonococci. Enteric diseases accounted for the second largest amount of work, with a daily average of 70 stool cultures and 110 stool examinations for ova and parasites. During April and May, the unit performed laboratory work for some 10 large hospitals which were in the process of setting up in the Manila area and had received patients before their own laboratories were in operation.
The supplies authorized for a medical laboratory of this type were entirely inadequate to meet the demands made upon it. Only by supplementing them with captured supplies and supplies given by the authorities of Santo Tomas University was the laboratory able to function. Fortunately, the section operating the Public Health laboratory in Manila was located in a preexisting laboratory building containing some of the necessary nonexpendable equipment.
The equipment authorization for this laboratory was based on the assumption that it would function primarily for epidemiologic investigation. Actually, this was only a small part of the work, and the main function of the laboratory was to carry out a large volume of routine work until such time as the hospitals could establish their own laboratories. Furthermore, the laboratory was divided into three separate sections stationed in various parts of Luzon, each functioning more or less as a complete laboratory. This situation demonstrated some of the deficiencies in the table of equipment. For example, some 8,000 test tubes were required whereas only 1,440 were authorized. Many other deficiencies of supplies were accounted for, in part, by the division of the laboratory into three sections. One of the greatest deficiencies was in the provision of power for the electrical instruments which hampered work until Manila's municipal power was restored.
It is interesting again that this laboratory underwent many administrative changes although, throughout this period, it was carrying out the principal function of providing laboratory services for almost the entire armed forces and civilian population of Luzon. This unit was functioning in an entirely different manner from any other such laboratory unit in the SWPA; its duties were neither anticipated nor planned. During the training period, no official information of any kind could be obtained as to the method of operation of any similar unit either in the European theater or SWPA, nor did any training program, as such, exist.
The 26th Malaria Survey Unit.-The 26th Malaria Survey Unit50 departed from Sansapor in the SWPA on 8 January 1945, disembarked at
Lingayen Gulf, Luzon, on 27 January, and moved to Calasiao on 1 February; left Calasiao on 5 February and arrived in Manila on 6 February. After several changes in assignment, including attachment to Sixth Army, I Corps, and USASOS, on 12 March, the unit was placed under control of Luzon Base Section; and on 17 March, it was attached for duty with the Department of Health, Manila, which was then functioning under USAFFE.
The first duty assigned to the unit during this period was as a part of the Manila command, where it functioned as a general sanitation survey unit and not as a malaria survey unit since the area in which the mission was assigned was nonmalarious.
The principal duties consisted of a survey of the water supply, including the gathering of water samples for bacteriologic analysis, spotting of broken water mains and pipes, general surveys of mosquito breeding, fly population densities, human waste disposal, and garbage disposal in the devastated areas of the city. During this period, the unit was housed in a well-lighted and well-ventilated school building which provided adequate laboratory workspace, as well as office and storage space. Enlisted men of the unit were quartered in this same structure.
In a report dated 4 July 1945,51 the commanding officer of this unit, Capt. Walter J. La Casse, SnC, stated that the unit had been functioning under the direction of the health department and had conducted several entomologic and parasitologic surveys. In addition, studies continued for several months to determine the effects of DDT spray on fly population densities. Similar surveys were conducted on the larval and adult mosquito population to determine the effect of larviciding programs and dengue control measures. Also, surveys were made on the incidence of intestinal parasites in certain groups, including children, civilian food handlers, employees of civilian establishments, and civilians employed in Army messes. Systematic collection of water samples throughout the city for bacteriologic examination had also continued. An average of about 30 civilians had been employed on the various projects during the previous months.
The 10th Malaria Control Unit.-The 10th Malaria Control Unit52 arrived in Base M on the Lingayen Gulf on 28 January 1945. On 10 February, the unit was assigned the mission of supporting the Department of Health in Manila. It performed a variety of duties while on this mission; such as, procuring civilian trucks for the disposal of accumulated garbage, procuring civilian crews to man these vehicles, installing and supervising city garbage dumps, installing a motor pool for the Division of Sanitation, installing public latrines, pail systems collecting and disposing facilities for these latrines, establishing a proposed budget for the Division of Sanitation of the Manila Health Department, and establishing garbage routes for night and day crews.
During the succeeding 3 months, the unit functions were extended to include sanitary inspections; installation and repair of public plumbing facilities; disinfection and disinfestation of public markets and garbage dumps, and of private homes where communicable diseases had been reported; and supervision over all abattoirs. Some of the problems encountered by the unit were the following: since the unit was permitted to pay garbage collectors only 1.45 pesos per day, it was difficult to obtain laborers for this job since they could make higher wages elsewhere. The unit experienced certain difficulties with the labor it did employ. For example, several crews had to be discharged for such offenses as hauling wood to their own homes, stopping work, and loitering around outside their routes. Despite these difficulties, however, from 10 February to 30 June 1945, the unit had been responsible for collecting and burying 1,796 enemy dead; collecting and burying 2,058 civilian dead, most of whom were casualties; and burying 3,073 civilian paupers. In addition, the unit had collected and properly disposed of 11,981 truckloads of garbage and disposed of 19,464 truckloads of garbage that originated in Army and Navy organizations. The garbage was distributed in three dumps and a system of sanitary fill was developed. This was operated so that no odor or fly nuisance occurred and, in addition, certain low-lying land had been reclaimed for buildings.
The 893d Medical Clearing Company.-The activities of the 893d Medical Clearing Company fell into three phases:53 a period of preparation, including travel; a period of operation in Manila; and a period of operation at San Miguel, Tarlac Province, Luzon. The first period ended and the second began when the company arrived at Santo Tomas University on 6 February 1945 to operate a hospital for liberated civilian internees.
The unit, which had been operating a hospital of 125 beds on Leyte for American soldiers, boarded an LST on 21 January 1945, and sailed for Luzon. It arrived in the Lingayen Gulf on 27 January, and went ashore on 29 January (D+20).
Shortly after landing, it was learned that the 893d had been selected to provide medical and surgical attention for the civilian internees held by the Japanese at Santo Tomas University. Expensive additional equipment and supplies were obtained to carry out this special assignment, particularly vitamins, vermifuges, calcium, extra food, and extra clothing such as bathrobes and pajamas. The Company traveled in convoy with PCAU No. 5 which was also destined to go to Santo Tomas University. The hospital was established in the three-story education building on the hospital grounds. Hungry-looking liberated internees were wandering about aimlessly. The rooms assigned for the hospital were deplorably untidy. Quantities of paper, debris, and plaster lay all over the floors and furniture.
The operation at Santo Tomas lasted only 18 days, but this was a very active period. On the first night, 320 people were fed at the kitchen, and by
midnight, 97 patients had been admitted. Street fighting was still going on just outside the compound, and many Filipinos and Americans were brought into the hospital for surgery. No other station was prepared to treat these battle casualties; the surgical theater was in use day and night almost continuously for the first week. PCAU No. 5, located in the adjacent main building of the University, had the job of feeding all the internees and scores of news reporters, Red Cross workers, airmen, Filipino doctors and nurses, and visiting military personnel. Approximately 3,800 liberated internees were in the Santo Tomas Camp.
A problem of the first magnitude was sanitation. The building contained six latrines, each with seven toilets, most of which did not work. Moreover, the city water supply failed and the latrines could only be flushed with water brought from a brackish well by the Philippine laborers. This created a bad situation for the first week. Later, 6,000 gallons of water were hauled daily from scattered waterpoints, but even this supply was dangerously small. Twenty-six 2½-ton truckloads of garbage, rubbish, and debris were hauled away from the education building during the first 3 days of operation.
Two factors influenced the activities of the unit during this period: the Japanese artillery shelling and the severe malnutrition of the liberated internees. Intermittently throughout the day of 7 February, shells hit many buildings on the University grounds. On that day, approximately 100 Filipino laborers were hired by PCAU and placed on duty with the hospital unit; but 3 hours later, four-fifths of them had disappeared.
The majority of the internees suffered from severe malnutrition, principally from a severe hypoproteinemia and avitaminosis. Most of them had edema of the lower extremities and a few had wrist- and foot-drop. Many showed obvious signs of scurvy. Altogether, 544 civilian internees were hospitalized. In addition, 332 Filipino civilians and 49 American soldiers were hospitalized. Six Filipino patients had tetanus, two of whom died.
The 55th Medical Supply Platoon (Avn).-The 55th Medical Supply Platoon (Avn)54 was among the Sixth U.S. Army forces which invaded Luzon. The unit arrived off Lingayen Gulf on 13 January 1945, disembarked near San Fabian on the morning of 20 January, and moved the next morning to San Carlos, leaving supplies under the guard of a truck company. From 24 January to 6 February, the unit stayed in Tarlac, in an area occupied by the 21st Medical Supply Platoon (Avn), and the personnel assisted in establishing a supply depot.
On 6 February, the 55th Medical Supply Platoon (Avn) entered Manila, unloading equipment and five truckloads of medical supplies on the grounds of Santo Tomas University. The next day, the unit moved to the George Washington School on Aragon Street near the Jockey Club and remained there until 18 February. The main units supplied were the 1st Cav-
alry and the 37th and 40th Infantry Divisions. In addition, the unit was responsible for supplying agencies treating civilian casualties although initial supplies were inadequate to meet these demands. Later, it was possible to make supplies available to civilian hospitals.
The Occupation Phase
On 1 March 1945, the administrative control of Civil Affairs in Manila came under USAFFE, with Brig. Gen. Courtney Whitney in charge of the Civil Affairs Section. Lieutenant Colonel Dy (a native of the Philippines) and Lt. Col. Gottlieb L. Orth, MC, were also assigned to the Civil Affairs Section, Manila.
While some progress had been made during the combat phase towards reestablishment of the Manila Health Department-the water system had been partially restored and most of the civilian dead had been buried-the new Civil Affairs health personnel were confronted with tremendous problems. Among the more serious were the procurement and assignment of qualified civilian personnel, the development of a system of garbage and sewage disposal including fly control measures, and the reopening of civilian hospitals.
The Department was organized into the following divisions: Communicable Disease Control, Medical Care (including hospitalization), Sanitation, and Supply and Procurement. In addition, eight Malaria Control Units and two Malaria Survey Units were attached to the Manila Department of Health for epidemiologic activities as well as malaria control.
By 20 April, 113 motor vehicles, including 74 U.S. Army trucks and weapons carriers, and 25 bicycles were at the disposal of the Health Department. During the period 1-20 April, the Sanitary Engineering Section reported 542 blocks initially cleaned and 925 blocks recleaned, 4,665 truckloads of garbage hauled to dumps, 7,408 pails of night soil collected, and 1,270 human bodies buried. Seventeen markets were under supervision and all had been recleaned and sprayed. Five abattoirs were being maintained in which 1,482 animals were slaughtered during this 3-week period. More than 7,000 restaurants and other eating establishments had been inspected, 130 ordered closed, and 623 approved for license. Of 177 water samples tested, 14 were found nonpotable.55
On 14 April, a conference of representatives of the Department of Health, the Engineer Command, and the Commonwealth Government agreed upon the prompt provision of 10,000 pails for the collection of night soil.
The diarrheas and dysenteries were among the most prevalent diseases among civilians and a sharp rise in the number of typhoid fever cases was reported; it was believed that this reflected an actual increase. Typhoid vaccination teams were organized and their activities concentrated in the dis-
tricts of greatest prevalence. Active casefinding programs for infectious venereal disease and tuberculosis were put into operation. In the 3-week period, 1,013 civilian patients were treated for syphilis; of approximately 3,661 persons examined for tuberculosis, 614 were found to be positive with an additional 319 suspected cases; and 75,550 typhoid and 3,461 smallpox immunizations were given.56
During this period, the Division of Medical Care inspected 14 hospitals and attempted to correct some of the major deficiencies arising from lack of supplies, equipment, food, and water. The excellent work being carried out in the former Children's Hospital under the direction of PCAU No. 5 General Hospital was noted.
The procurement section of the Health Department distributed fresh vegetables to all hospitals and arranged for the requisition on an emergency basis of milk, eggs, butter, lard, and coffee from U.S. Army stocks. These were sufficient to supplement each civilian hospital ration for 60 days with 4 oz. of milk, and 1.5 oz. each of eggs, butter, lard, and coffee. In addition, 4,000 bundles of firewood (for hot water and sterilization of instruments) were procured for hospitals.
Two 40-bed hospital assemblies were delivered to the Provisional Philippine General Hospital, two 40-bed assemblies to the Emergency Hospital (Psychopathic Hospital), and one 40-bed hospital assembly to the Children's Hospital (PCAU No. 5 General Hospital).
During this period, the most serious health hazard to civilians and, indirectly through them, to the military forces, arose from the severely limited supply of water for both drinking and cleaning. Colonel Pincoffs forcefully pointed out to command echelons the serious threat to the fighting forces because of a rise in enteric diseases from nonpotable drinking water, lack of cleanliness in restaurants, and inability to dispose of sewage.
By 1 May, considerable progress had been made in reestablishing water supplies, electric services to hospitals, and satisfactory sewage disposal. Typhoid fever and tuberculosis continued at a high endemic level, but otherwise the health situation improved generally.57
Civilian hospital rations.-No special provision had been made for feeding civilian patients in civil hospitals in Manila upon the entry of our troops.58 Distribution of relief food was under the supervision of the PCAU's. Since most patients admitted to these hospitals showed evidence of malnutrition, it became clear that special food allowances would be needed.
Colonel Pincoffs requested a survey of the situation by a nutrition officer. Accordingly, Maj. William R. Bergren, SnC, spent several weeks during March and April visiting hospitals and food supply installations, observing conditions, and gathering data for a definitive study of the subject.
He found that conditions varied considerably from area to area as each was administered by an independent PCAU. In all instances, the PCAU's had taken some measures to improve the patient ration; and in some instances, they furnished a limited amount of fresh vegetables. Action had been taken to reserve available milk stocks for young children and pregnant and lactating women. Despite the efforts made, however, the dietary was found to be inadequate for complete recovery.
The patient ration improved considerably during the period of PCAU administration. One step was the establishment of a centralized procurement agency for larger amounts of fresh fruits and vegetables for distribution to all the PCAU districts. The most important factor, however, was the addition of a supplement to the hospital ration from stocks obtained from the U.S. Army. Fats, milk products, and sources of ascorbic acid were added to bring the average dietary to an adequate standard and to furnish sufficient balance in the meals to encourage consumption over a continued period. In the early stages of the liberation of Manila, variety and palatability in meals were of little importance for the preceding months under the Japanese regime had been meager, sometimes almost to the point of starvation. As the weeks went by after liberation, however, the monotonous character of the relief ration made it distasteful. The supplementary ration obtained by the director of Public Health was a big improvement.
During April, Col. John B. Youmans, MC, Chief of the Nutrition Division of the Office of the Surgeon General, visited this theater. The primary purpose of his visit was to make observations in connection with the occurrence of atypical lichen planus, especially with respect to the possibility of nutrition as a cause. He had the opportunity also to visit most of the bases and to discuss current problems with the base nutrition officers. Colonel Youmans also conferred with the Chief Nutrition Officer and other nutrition officers in the Manila area. Current problems were discussed and various ways were outlined in which cooperation could be maintained between the Office of the Surgeon General and the Nutrition Officers in this theater.
Release of control to the Philippine Government.-By the middle of May, the PCA units, which had been mainly responsible for the supervision of various hospitals and dispensaries, both public and private, were being withdrawn; and on 19 May, Colonel Pincoffs was succeeded as Director of Health by Lt. Col. Lorenzo L. Parks, MC.
On 1 July, all privately owned hospitals reverted to their
owners; arrangements were made to purchase drugs and supplies through wholesale
dealers, and food through the PCA. One basic medical unit was sold to the
Philippine American Drug Co., wholesaler, for resale to private hospitals,
and the plan called for two such basic units a month to be put into private
supply channels for resale to hospitals and reputable drugstores. Public
hospitals reverted to control of the Commonwealth Government. The last
two PCAU's (Nos. 5 and 27) turned over their responsibility on 19 June.
main administrative responsibility was assumed increasingly by Filipino personnel. On 1 August, administration of the Health Department became the responsibility of civilian authorities except for an Advisory Health Board consisting of Colonel Parks, Maj. Ray E. Trussell, MC, and Capt. Emil F. Vogt, SnC.
Summary of achievements to July 1945.-The weekly report of PCAU No. 27 for 31 July 1945 provides certain summary figures for the period, 2 March to 27 July. In all, 2,075 city blocks had been initially cleaned and 4,644 recleaned; 52,931 truckloads of garbage had been hauled to the city dump; 88,615 pails of night soil had been collected; and 20,544 animals had been slaughtered in supervised abattoirs. More than 16,000 restaurants had been inspected, 1,000 closed, and more than 8,000 approved for license. Because of the abundance of "poison liquor," 650 specimens had been analyzed for the presence of methyl alcohol. More than 700 water specimens had been studied bacteriologically; and a total of 68,000 gallons of DDT in oil had been sprayed for fly and mosquito control. More than 8,000 bodies had been buried.59
Diarrheal diseases had steadily declined over the 5-month period, with typhoid falling to its previous low level. The high rate of syphilis and chancroid among prostitutes was reflected in excessively high rates in military personnel. Tuberculosis continued at a high endemic level.
During March through July, eight Army Medical Department officers (of whom two were native Filipinos) headed by Colonel Pincoffs, one USPHS officer, and 10 Malaria Control and Survey Units had been assigned to Civil Affairs Health activities in the vital city of Manila, and military personnel were assisted by many Filipino doctors and nurses. These men and women succeeded in bringing order out of chaos and starting Manila back along the road toward being a modern city with all the health and sanitary safeguards that this implies. It should be noted that virtually all the Medical Department personnel upon whom these responsibilities fell came to their assignments unexpectedly and without the benefit of prior planning.
Little imagination, it seems fair to say, would have been needed to foresee the problems likely to be encountered in a city like Manila when the battle for liberation had rolled over it.
Within the limitation of their concept and organization, the PCAU's and their medical officers served adequately, some of them with distinction. Always too few in number for the enormous job at hand, most of them also lacked adequate training to cope with so many varied and complex problems. Planning, organization, and manpower of a totally different order of magnitude were required to rehabilitate a metropolitan area of 2 million people. Moreover, restoration of health and sanitation in Manila in the shortest possible time was essential.
Later Occupation Phase
From 1 August 1945 until late in the fall of that year, the Health Department of Manila operated under the direct supervision of civilian government personnel. The Advisory Health Board for Manila, consisting of three Medical Department officers, continued to serve in an advisory capacity and to submit weekly reports to the Commanding General, AFWESPAC, concerning health matters in Manila. Venereal disease among prostitutes presented the most serious health problems confronting the Armed Forces.
On 18 September, Colonel Parks, the Chairman of the Advisory Health Board for Manila, recommended that the Board be dissolved about 15 October, and that its function be assumed by a liaison officer from the Army to the Manila Health Department. This action was taken in November.
Comments on the Luzon Campaign
The following comments and suggestions arising from the experiences of the Sixth U.S. Army in the Luzon campaign are derived from the operational report of 9 January-30 June 1945. While all the comments are not directly pertinent to health and medical concerns, they are, nevertheless, significantly related.
Policies and instructions from higher headquarters should have been distributed earlier, in time for planning rather than after the initial landings, as they were at Luzon.
A more adequate number of PCAU's should have been provided. For efficient operation, the units should have been displaced as little as possible from their initial areas. Reserve units should have been at hand to advance with the tactical units and replace those which were detached. Operations planning should have included sufficient medical units and transportation to enable Civil Affairs activities to be independent of tactical commands.
In an area which is evenly populated, such as the Central Plain, the need for Civil Affairs units is normally related to the size of the operations. For operations in such an area, holding a large reserve of units under Army control is advisable. These units are then available for subattachment to Corps, based upon the extent of their zones of action. All forces for the Lingayen operation were landed in the same general area. This permitted free movement of PCAU's to any Corps at an early date. Where landings are made at more than one point and the forces may not join for a period of time, a much higher proportion of units should be subattached initially.
Regarding responsibility for civil administration, the Sixth Army report recommended that, whenever an exception to directives is made, the decision should be both early and final to prevent such uncertainty as occurred in Manila.
Experience proved the importance of establishing definite,
clear-cut wage scales and charges for rations as well as the amount of
supplies allowed to be sold. The supplementing of authorized wages or supplies
to obtain laborers should be prohibited. Especially, service troops should
permitted to use these means to induce laborers to leave combat troops as was done in areas near Manila. It was believed that, if established wages are related to the ceiling prices of foodstuffs, a sufficient supply must be available to civilians to permit them to support their families.
Supplies should be impartially allocated on the basis of the size, needs, and self-sufficiency of the population. The warehousing and issuing of PCAU supplies should be handled by trained service troops, not, as in Luzon, by the Civil Affairs Section, which had no personnel trained for the purpose. There were some difficulties with the supplies themselves: the sizes of the clothing had been planned for normal U. S. sizes instead of the smaller Filipino sizes; the food for civilian use did not include the common items of the national diet, and, moreover, it was issued in large containers more suitable for army than for family units.
The report included some criticism of the CAD Basic Medical Unit and the comment that, if these units are to be used in the future, their composition should be governed by the needs of the area where they are to be used. The units received in Luzon were poorly balanced, with excesses of certain items and omission of such important ones as intravenous fluids, plasma, iodine, and hydrogen peroxide. Powders were furnished without means of converting them into sterile solutions or making them into capsules or ointment. A system whereby requisitions may be submitted for required items, rather than for fixed units only, is believed preferable.
Trained Civil Affairs staffs should be made available for assignment rather than for temporary duty. Officers who have demonstrated abilities above the average, and whose status is other than that of assignment, subject the staff to which they are assigned to the inroads of higher headquarters, as was the experience of the Civil Affairs Section, Sixth Army.
Section II. Okinawa
Okinawa, the principal island of the Ryukyu group, is some 400 miles south of the southern tip of Japan itself. Conquest of Okinawa (map 20) was regarded as an essential step in the invasion of the Japanese homeland. Under the overall command of Adm. Raymond A. Spruance, the Tenth U. S. Army, under command of Lt. Gen. Simon B. Buckner, was given the mission of the capture of Okinawa, with, of course, close support of Navy and Army Air Forces. The Tenth U.S. Army consisted mainly of the XXIV Corps which staged on Leyte and the III Amphibious Corps, U.S. Marines, which staged on Guadalcanal and the Russell Islands.
The offensive on the Ryukyus was launched on 26 March
1945 with the landing of the 77th Infantry Division on the small approach
islands of Kerama-retto. Within 3 days, the entire Kerama chain had been
and artillery commanded the western shores of Okinawa.
Preceded by a realistic feint toward the southern tip of Okinawa and by
intensive naval bombardment of the western beaches, landings were made
by the III Amphibious Corps and the XXIV Corps on 1 April. The Japanese
forces had been drawn toward the southern tip and offered little initial
resistance to the landings. The Marines turned north and, against light
opposition, secured the northern portion of the island. The XXIV Corps,
moving inland and southward, soon encountered the main Japanese force which
was elaborately entrenched. Enemy resistance was fanatical both in fighting
ground and in air attacks on our shipping. Eventually, the III Corps, U.S. Marines, and XXIV Corps pressed slowly southward and occupied the two principal cities, Naha and Shuri, in mid-June; within a few more days, organized resistance ceased. Our casualties both among ground forces and naval personnel had been among the heaviest of the war; General Buckner himself was killed.
Planning for Military Government
It should be noted that the Okinawa operation was planned and staged under CINCPOA (Commander in Chief, Pacific Ocean Areas) (Fleet Admiral Chester W. Nimitz), whose headquarters was on Guam. Headquarters Tenth U.S. Army was originally in Hawaii so that, from the beginning, two factors influenced the evolution of military government developments: (1) joint planning with the Navy, whose outlook had been influenced by military government problems encountered in the Marianas; and (2) much closer liaison with the Civil Affairs Division of the War Department, with the result that the Okinawa planning group readily availed themselves of the experiences of military government activities in the Italian campaign and the planning for northwest Europe.
A staff memorandum,60 dated 21 August 1944, pointed out the need for adequate planning, personnel, equipment, and supplies for military government in Okinawa. The staff section of the Tenth Army was augmented, on 15 August 1944, by the addition of a Civil Affairs Section. Later, pursuant to a directive from CINCPOA that henceforth the term "Military Government" would be used in lieu of "Civil Affairs" in all future Pacific operations, the name of the planning unit was changed to Military Government Section, Headquarters Tenth U.S. Army.61
The basic responsibility for military government in the Japanese Outlying Islands was placed on the Navy. Thereafter, CINCPOA requested that the Army assume this responsibility inasmuch as Army units would constitute the larger portion of the expeditionary force and garrison troops.62
Planning for military government for Okinawa was made a responsibility of the Tenth U.S. Army, and Brig. Gen. William E. Crist was assigned as head of the Military Government Section (G-5) on 3 November 1944. Among the plans and directives prepared by this Section were the following:
1. Operational Directive No. 7 for Military Government of the Commanding General Tenth Army, 6 January 1945 (Short title: Gopher). This
document outlined the basic concepts and principles for the control of enemy population in the area of the Tenth Army.
2. Tenth Army Technical Bulletin on Military Government, 25 February 1945. This bulletin contained detailed instructions for the conduct of military government operations within the framework established by Gopher to the Okinawa operation, and presented the attachment of military ment operations.
3. Annex 15 to Operations Plan 1-45. This applied the principles of Gopher to the Okinawa operation, and presented the attachment of military government units and the boundaries of military government districts.
It was contemplated that the Commander in Chief of the Pacific Ocean Area would retain the title of Military Governor and proclamations would be issued in his name. The Operations Plan provided that the Military Government Section, Tenth U.S. Army, would function as Military Government Headquarters under the Island Commander; the Chief Military Government Officer would become Deputy Commander for Military Government.
As a result of military government experiences in other operations, four types of Civil Affairs units were organized:
A Teams, consisting of four officers and 11 enlisted men, were organized to accompany assault divisions and to conduct preliminary reconnaissance as the troops advanced.
B Teams, consisting of eight officers and 19 enlisted men, were designed to be attached to both corps and divisions, and their mission was to organize military government activities behind the fighting front.
C Teams, consisting of 10 officers and 26 enlisted men, were organized primarily to administer refugee camps.
D Teams, consisting of 22 officers and 60 enlisted men, were designed to administer the six districts into which Okinawa was divided.
Only D Teams included medical officers, although, in the Okinawa operation (see p. 629), many G-10 Navy dispensaries were attached to all B and C teams to provide for emergency medical care.
For the Okinawa operation, there were to be six A Teams, eight B Teams, 13 C Teams, and six D Teams. In addition, regularly constituted Army and Navy units such as an MP battalion, a QM truck company, 20 Navy G-10 dispensaries (one officer and six enlisted men each), six Navy G-6 hospitals (15 officers and 158 enlisted men each), and certain camp components (N-lA, N-4C, and N-5C) were assigned to military government.
Since the War Department was unable at this time to furnish the necessary Military Government personnel for this operation, a plan was devised under which 182 Army officers, including a general officer (General Crist) would be made available for Military Government in Okinawa; the remaining officer personnel and all the enlisted personnel were to be supplied by the Navy.
Personnel for Military Government headquarters were assembled
Tenth U.S. Army Headquarters, Schofield Barracks, Hawaii, while personnel for the detachments were staged and, to the extent permitted by the logistical timetable, trained at the Civil Affairs Staging and Holding Area, which was located first at Fort Ord and later at the Presidio of Monterey, Calif. It was most difficult to find Japanese interpreters, who were in short supply.
Military government detachments attached to XXIV Corps and the 7th, 77th, and 96th Infantry Divisions staged with those units on Leyte; those attached to the III Amphibious Corps and 1st Marine Division to units on Guadalcanal; and those attached to the 6th Marine Division to units on the Russell Islands. The teams attached to the two divisions in the Army floating reserve staged with their respective divisions, the 2d Marine Division on Saipan and the 27th Infantry Division on Espíritu Santo. Some military government units, however, arrived on Okinawa directly from the United States.
Special Planning for Military Government Health Activities
Special military government health plans for the invasion of Okinawa were contained in the Technical Bulletin of Military Government, dated 25 February 1945, prepared under the direction of General Crist.
The medical plans were prepared by the Chief Civil Affairs Medical Officer, Lt. Col. Glen W. McDonald. While these instructions followed in general outline those promulgated previously for other operations, the evolution of the whole concept of the role of military government can be recognized in these instructions, which were becoming more complete with each new operation. The essential features of the medical plans were as follows:
Medical officers of detachments, teams, and districts were to make medical reconnaissance at such intervals as were necessary to keep them informed of the situation in their areas. During the assault, MG (Military Government) medical officers were to maintain continuous liaison with the Surgeons of the tactical units to which they were attached while, during the garrison phase, they were to maintain liaison with the Surgeons of the Island Command medical units. Wounded and sick civilians were to be evacuated from MG dispensaries to MG hospitals wherever possible. Appropriate tags to identify patients as civilians were to be used.
Maximum use was to be made of native medical personnel and facilities. As soon as possible, native physicians, dentists, pharmacists, midwives, veterinarians, and other related technical personnel were to be registered and assigned appropriate duties. Civilian hospitals and other medical facilities were to be rehabilitated if at all possible and provided with sufficient supplies to operate. The qualifications of native practitioners were to be investigated by MG medical officers, and licenses issued by native government agencies were to be continued in effect as long as the licensees performed their work satisfactorily.
Certain basic reports and records which are essential
for planning, op-
eration, and technical direction of the Public Health Program were to be kept and submitted to the proper authority. Among these were Communicable Disease Reports, Birth and Death Certificates, Daily Record of Civilian Deaths, Vital Statistics and Treatment Summaries from all MG hospitals, dispensaries, and camps which were to be submitted on a weekly basis. In addition, reconnaissance reports were to be submitted covering the following subjects: (1) general health and nutritional status of the population; (2) prevention and control of communicable diseases; (3) extent of civilian casualties; (4) information concerning native medical facilities, such as hospitals, laboratories, sanitariums, and others; and (5) the number, qualifications, and distribution of civilian medical personnel. All these reports were to be submitted to MG Headquarters, with copies furnished to the tactical units to which the medical unit was attached.
Concerning communicable disease control, military necessity dictated that priority should be assigned to the control of those diseases or conditions which endanger the health of the occupying troops. Maintenance of health and welfare of the civil population was assigned secondary attention. Attempts to raise the standards of public health above prewar levels were not regarded as feasible because of the limitations of personnel and supplies.
Military government public health officers were to act in an advisory capacity to other MG officers who were responsible for providing and distributing food to civilians. A survey of local food supplies and of the nutritional level of the civilian population was to be undertaken as early as possible.
It was recognized that the extent and nature of the initial program for civilian medical care would depend upon the extent of hostilities, the number of civilian casualties, the amount of destruction of local medical facilities, the previous state of health in the area, and the availability of local medical facilities, supplies, and personnel.
The laboratories of the large MG hospitals were to be made available to dispensaries and to the MG medical personnel located in civilian camps and communities. These laboratories were to be prepared to perform blood counts; bleeding and clotting time; blood-smear examinations for malaria; urinalysis; examination of stools for blood, parasites, and ova; bacteriologic smears and cultures for common disease-producing organisms; tests for the serological diagnosis of syphilis; and appropriate agglutination tests and post mortem examinations. Local facilities for producing biologicals were to be appraised promptly and the manufacture of all biologicals essential to epidemic control restored as promptly as possible. A special effort was to be made to secure all antivenom serum and the facilities for its production; if found, priority was to be granted to the use of such serum by troops.
Water supply for civilians, whether in collection points,
temporary enclosures, or organized camps, was to be procured through the
of local resources wherever possible. If local sources were unavailable, troop waterpoints could be used, but arrangements for their use were to be made through the appropriate Engineer officer. All water from local wells, streams, ponds, or other surface sources was assumed to be contaminated with pathogenic bacteria and amebic cysts. The usual instructions were given for the treatment of water for unit personnel.
Technical instructions were also issued for disposal of sewage, for collection and disposal of garbage, and for control of flies, rodents, and mosquitoes.
It was recognized that the whole military government operation would be influenced to a considerable extent by the supply situation, and it was pointed out that all military government personnel must be prepared to act in a supply capacity if the situation so demanded, particularly during the initial stages of the operation. Maximum use of local supply resources would be made so that importation of supplies for civilians might be held to a minimum. The general scheme of supply was to be essentially that used by the line forces. Unloading, delivery, and storage of military government supplies were to be functions of the Army Supply service charged with handling comparable types of military supply. Liaison officers from military government were to be sent to appropriate supply installations. In general, MG units were to draw civilian supplies from the regular military depots or dumps.
During the assault phase, MG supply requirements were
to be confined to a few essentials, such as food, water, tools, and medical
supplies. Military government units, while attached to tactical units,
were to draw all supplies, civilian or military, through the tactical units'
supply channels. Captured stocks of food and clothing were to be reserved
for the use of military government unless urgently required by the military
forces. Amounts, types, and location of captured supplies were to be included
in a daily MG report. In emergencies, water for civilians might be drawn
from corps or division water distributing points by MG personnel. During
the early stages of the assault phase, no formal requisitions were to be
required, but proper stock control and other records would be established
at the earliest possible date. The distribution of MG supplies was to follow
formal accounting procedures during the latest stages of the assault phase
and in the garrison phase. During these phases, a closely controlled supply
system for military government would be in effect. Military Government
Headquarters was to have responsibility for (1) planning the requirements
for future overall MG supplies necessary to maintain area stocks at established
levels; (2) arranging for the delivery of supplies and their storage at
proper depots or dumps; (3) establishment of necessary stock control and
other records; and (4) allocation of supplies to MG units or installations
in accordance with availability and necessary priorities. Responsibilities
were similarly fixed for district headquarters, camp headquarters, MG hospitals
and dispensaries, and Army and Navy units assigned to military government.
Captured vehicles were to be turned over to MG units to reinforce organic transportation unless urgently required for combat operations.
All MG personnel were urged to report usable supplies and equipment from civilian and captured enemy sources. The types of salvageable material regarded of greatest value were food, clothing, medical supplies, fishing gear and equipment, motor or animal transport, hand tools and agricultural equipment, building material, and livestock and poultry. Guards were stationed to prevent looting or damage to dumps and other supply installations.
Tactical operations proceeded swiftly against light resistance, uncovering thousands of dazed civilians much more rapidly than had been anticipated (fig. 81). Many villages were left in a relatively habitable condition. Many civilians were really displaced persons who had fled north in advance of the invasion. However, thousands of civilians had to be assembled in large camps for security reasons.
An ample supply of food was available locally, although much of it was unnecessarily destroyed or dissipated because of the inability of Military Government to store and protect it for future use. Similar losses were sustained in clothing, blankets, furniture, household utensils, farm implements, and building materials.
The medical situation was much more favorable than had been anticipated. By and large, Okinawa has a healthful and equable climate, the incidence of malaria was low, and, with the exception of filariasis, no serious epidemics were encountered. Moreover, the number of civilian casualties had been low and, with some assistance from a naval mobile surgical unit which had no military patients, the MG medical units were adequate to meet all needs.
Many civilians had fled into the hillside caves where they led a crowded and unsanitary existence. The incidence of impetigo, scabies, and lice infestation was high, as was the incidence of pulmonary tuberculosis.
In the villages, the typical arrangement for sewage disposal was an open pit a few feet deep close by or inside the native dwellings. Often the pit overflowed into a pool of feces and contaminated water in the yard. Flies were numerous. Drinking water was obtained principally from shallow wells, cisterns for the collection of rainwater, and springs; the widespread practice of tea drinking for which water is boiled probably reduced the incidence of enteric disease.
In general, therefore, the medical facilities of Military Government were adequate in this operation. It was observed, however, that the Navy G-6 and G-10 medical units were not sufficiently mobile to be well adapted to field conditions.
The principal medical problem arose from the large refugee
(fig. 82). On 30 April (D + 29), approximately 125,000 civilians were under Military Government care. For security reasons, these civilians were made to congregate in villages well to the rear of the combat zone, or were sealed off in wire enclosures. All of this necessitated large mass movements of refugees. On the Katchin peninsula, 31,825 Okinawans were in one wire-enclosed camp. By native standards, health in these camps was good and no epidemics were encountered, but scabies and louse infestation were common.
The Japanese had deported, apparently for labor crews, a high proportion of the young adult population, both male and female, so that the camps were filled with elderly people and children There was a curious absence of infants under 1 year and it was suspected that infanticide was being practiced, possibly because of Japanese terror propaganda which spread the notion that Americans were cruel to crying children
Despite the fact that the original plans called for the
collection of civilians in barbed wire enclosures, this proved impractical
because of the shortage of labor to construct the enclosures. For the most
part, displaced Okinawans were relocated in villages and kept within them
by Military Police with the aid of war dogs.
XXIV Corps Activities
To examine some of the military government activities in more detail, the experiences of the XXIV Corps will be discussed briefly.63
This Corps, which was commanded by Lt. Gen. John R. Hodge, USA, completed its mission in the conquest of Leyte in February 1945, and began staging for the Ryukyus operation with the 7th, 96th, and 77th Infantry Divisions as its principal component units. The landing on Okinawa was made on 1 April; by the following day, the 7th Division reached the east coast to cut the island in two. Both the 7th and 96th Divisions turned southward to meet fanatical Japanese resistance. On 9 April, the 27th Infantry Division landed to reinforce the Corps; and on 30 April, the 1st Marine Division moved in to relieve the 27th Infantry Division.
In the mounting area, the following number of MG units were attached to the Corps: three A, five B, and two C detachments, one G-6 hospital, and nine G-10 dispensaries. The A detachments were assigned to divisions; their duties included posting proclamations, locating civilian food and medi-
cal supplies, establishing collecting centers, and evacuating civilians, with the assistance of Military Police.
Each division was also assigned one B Team to assume control of collection centers established by A Teams, so that the latter could move forward closely behind the assault units. Corps B detachments were prepared either to relieve the division B detachments or to leapfrog them, whichever the tactical and civilian situation might require.
The function of the C Teams, each with equipment to set up a 10,000-capacity camp, was to select and establish campsites to which B Teams could evacuate civilians.
The G-6 hospital was prepared to operate a 500-bed hospital, and the G-10 dispensaries were equipped to operate 25-bed aid stations. The latter were attached to B and C detachments to provide emergency medical care. D Teams were to arrive on later echelons and take over in the rear areas.
A study of the activities of B and C Teams as given in the Operational Report XXIV Corps shows that they were concerned almost exclusively with handling refugees on Okinawa. There was much movement of refugees from the combat areas to collecting stations and, thence, to more permanent camps. For example, through 30 April, 32,098 civilians were processed, of whom 363 died. On the whole, however, medical problems seemed not to have loomed large in the overall picture. Four rear area camps housed more than 32,000 civilians; these reverted from Corps to Island Command on 30 April. It was estimated that 10 percent were old men, 6 percent able-bodied men, 40 percent women, and 44 percent children. First aid and clinical care were given to approximately 13,500 persons by G-10 dispensaries, and approximately 950 were hospitalized, mostly in the one G-6 installation located at Koza. The incidence of communicable diseases was surprisingly low. A continuing educational program was directed toward the improvement of sanitation and personal hygiene.
When the final breakthrough into the southern peninsula occurred during the early days of June, 13,285 civilians were evacuated, many by water because of the almost impassable roads. These civilians were in much poorer physical condition than those encountered elsewhere on the island. At least 30 percent required some medical care, and there were hundreds of stretcher cases. The regular B Teams were further augmented by G-10 dispensaries and by medical officers and medical corpsmen from the D detachments under Island Command. More than 28,000 civilians were evacuated from 10 to 30 June, most of them to camps on the Chinen Peninsula, Okinawa.
By using captured Japanese medical supplies and those
supplies available to the G-10 and G-6 units, minimum standards of civilian
care were met without calling on the stocks of tactical units.
Comments on the Okinawa Campaign
It seems clear that the Military Government activities of the Okinawa operation were handled very satisfactorily, and few criticisms were reported. The primary mission of Military Government, which was that of relieving the fighting forces of responsibilities to civilians, was certainly adequately accomplished. Moreover, there seems to have been better rapport or, at least, less friction between the tactical forces and Military Government detachments than had existed in many other operations.
This result probably stemmed mainly from two considerations: adequate planning well in advance of the operation by each headquarters of forces engaged in the operation, and due regard for the experience of Military Government in other theaters.
It must be recognized, however, that in this operation our forces were in contact with a civilian population which was not only our enemy, but which was also on a low cultural and economic level. It was comparatively easy, therefore, to handle the Okinawan natives in a summary manner without evoking surprise or lasting hatred from them.
From a medical standpoint, several conclusions seem justified:
First, the large refugee operation must have been handled in such a manner as to avoid the development of serious epidemics or exceedingly poor sanitary situations; the absence of evidence to the contrary is significant. This, in itself, indicates that the elements of good preventive medicine were practiced.
Second, civilian sick and wounded were handled by the organic medical facilities of military government and the hard-pressed Army medical units were not burdened with this aspect.
Third, these results were accomplished by what appears to have been the most economical use of scarce medical personnel by Military Government up to that time. The assignment of regularly constituted medical units to work with Military Government detachments apparently was an eminently sound development.